JCPSLP Vol 21 No 1 2019

Journal of Clinical Practice in Speech-Language Pathology Journal of Clinical ractic i Spe ch-L l

Volume 13 , Number 1 2011 Volume 21 , Number 1 2019

The role of speech- language pathologists in the justice system

In this issue: Hearing loss and services available for people in the justice system The role of the speech-language pathologist in supporting young people in youth justice: A Queensland perspective Speech-language pathology service provision in English youth offending institutions: Findings from a survey Creating communication accessible frontline police services The role of speech-language pathology in supporting legal capacity Speech-language pathology intervention with young people in custody Reflections on ethical speech-language pathology practice in the justice system

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1 December 2019

The role of speech-language pathologists in the justice system

From the editor Jae-Hyun Kim


W elcome to the first JCPSLP issue of 2019. As a major clinical publication of Speech Pathology Australia, it is not by any chance that JCPSLP delivers this issue on the role of speech-language pathologists in the justice system. We are pioneers in practice and research focused on achieving communication access for all. We are proud to present this issue which does not only facilitate translating research into action but also celebrates ground-breaking work by speech-language pathologists in the justice system. This issue begins with an invited article from Samantha Harkus, a senior audiologist from Australian Hearing. We are grateful for her insightful contribution to this issue and for sharing an audiologist’s perspectives on working in the justice system. Her article reminds us of the pervasive

1 From the editor

2 Hearing loss and services available for people in the justice system – Samantha Harkus

6 The role of the speech-language pathologist in supporting young people in youth justice: A Queensland perspective – Stella Martin 11 Speech-language pathology service provision in English youth offending institutions: Findings from a survey – Kim Turner, Judy Clegg, and Sarah Spencer services – Georgia Burn, Hilary Johnson, Barb Solarsh, Denise West, Katie Lyon, and Mark Nichols 25 The role of speech-language pathology in supporting legal capacity – Jo Watson 29 What’s the evidence? Speech- language pathology intervention with young people in custody – Mary Woodward, Emina McLean, Nathaniel Swain and Pamela Snow 34 Ethical conversations: Putting on a new hat: Reflections on ethical speech-language pathology practice in the justice system – Mary Woodward and Suze Leitão 39 Viewpoints: Why do speech- language pathologists need to recognise the differences between Australian Aboriginal English and Standard Australian English? – Stella Martin 19 Creating communication accessible frontline police

impact of hearing loss in the justice system and “how hearing well empowers and throws open the possibilities again”. The second article in this issue is by Stella Martin who provides an informed literature review and shares clinical insights into the innovative and transformative clinical services she and her team provide for young people in the justice system in Queensland. The third article takes us from Queensland to the UK. Kim Turner, Sarah Spencer and Judy Clegg present a research article surveying the service provisions by the youth offending institutions. This article provides valuable insights into service provisions in the UK youth justice system, which give us an opportunity reflect on the Australian youth justice system. Returning to Australia, Georgia Burn, Hilary Johnson, Barb Solarsh, Denise West, Katie Lyon and Mark Nichols present a research article about creating communication accessible frontline police services. Jo Watson provides insightful clinical perspectives on the role of speech-language pathologists in supporting individuals with communication needs in legal capacity. It is inspiring to see international efforts by speech-language pathologists in ensuring communication access in the justice system. In this issue, “What’s the evidence?” article by Mary Woodward, Emina McLean, Nathaniel Swain and Pamela Snow focuses on speech-language pathology intervention with young people in custody. This is a great piece synthesising the existing evidence to map on to interventions for young people in the justice system. The JCPSLP issue would not be complete without the ethical conversations. Mary Woodward and Suze Leitão provide insightful discussions about ethical speech-language pathology practice in the justice system. Stella Martin then discusses the importance of recognising the differences between Australian Aboriginal English and Standard Australian English. Finally, “Around the journals” (by Lydia Timms, Sally Kedge and Julia Kania), “Resource review” (by Mary Woodward) and “Top 10” columns (by Fiona Taylor) contain helpful and practical information for speech-language pathologists working in the justice system. The editorial board thanks the contribution of all authors for this important issue, especially Mary Woodward, Speech Pathology Australia National Advisor, Justice and Mental Health. As we present this issue, we acknowledge and express our appreciation for Leigha Dark for her hard work as the Editor of JCPSLP for the past two years. We are committed to continue delivering high-quality clinical research focused on translating knowledge into action for speech-language pathologists. JCPSLP now has its own Twitter account (@JCPSLP). We will be posting updates on forthcoming issues and useful and practical information relevant to each issue. Our readers will also find Twitter handle of each author at the end of the article in this issue. Twitter provides a convenient and useful platform to learn from one another and share resources and clinical insights. Follow our authors and engage with them.

42 Around the journals

45 Resource review

47 Top 10 tips for working within justice – Fiona Tayor


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The role of speech-language pathologists in the justice system

Hearing loss and services available for people in the justice system Samantha Harkus

I am going to tell you a story about a woman whose name is not, in actual fact, Christine. I would like to acknowledge and pay respect to the real woman behind the name. Knowing and working with her briefly was personally touching, professionally transformative and very memorable. In the late 1990s I was regularly visiting an urban Aboriginal medical service providing rehabilitative hearing services through Australian Hearing’s outreach program: hearing and communication evaluation, hearing aid fitting and communication support. The visits ran concurrent to a visiting ear nose and throat (ENT) clinic. At the time, a GP from the medical service was providing services to Aboriginal women at a nearby women’s prison. During one of the hearing clinics, a prisoner was brought in to see the visiting ENT specialist, an unusual event. The woman, Christine, had large, almost total, perforations in both ear drums, suggesting that she had experienced chronic ear disease at some time in her life. Early onset, chronic ear disease and conductive hearing loss continue to be much more prevalent for Aboriginal and Torres Strait Islander people than for non-Indigenous Australians. The disparity is largely socially determined (Kong & Coates, 2009). According to self-report data, one in eight Aboriginal or Torres Strait Islander Australians report middle ear disease or hearing loss (Australian Bureau of Statistics, 2013); however, self-report is thought to underestimate actual prevalence rates as both ear disease and hearing trouble are often normalised (Burns & Thomson, 2013). Prevalence of hearing loss varies significantly, by remoteness and socioeconomic status (Australian Institute for Health and Welfare, 2017; Simpson, Enticott, & Douglas, 2017). Christine’s hearing results showed a flat, moderately severe mixed hearing loss in both ears: the maximum possible level of conductive hearing loss with an additional component of sensorineural hearing loss, likely to relate to cochlear damage caused by bacterial toxins that diffuse through the round window membrane (Kolo, Salisu, Yaro, & Nwaorgu, 2011). At 36 years of age, this was the first time she had been referred for both ENT consultation and hearing evaluation. With such a degree of loss, it was highly likely that most speech sounds were inaudible to Christine, yet her communication skills were very good: conversation was fluent, with few clarifications or repeats. Observing her, it was clear she was working hard to use all visual and auditory resources to achieve this: she was leaning forward, sitting at the front edge of her chair, straining to hear and

watching me so intently that she was frowning. Cognitively, she would have been using knowledge of context and language to supplement gaps in the auditory signal. When it is difficult to hear speech for any reason, because of hearing loss, environmental noise or the speaker’s voice is soft or unclear, the centres of the brain not normally engaged in the process of hearing and decoding language must come to the assistance of the centres whose role it is. When this happens, performance on these non-hearing related activities decreases. For example, verbal working memory performance decreases as level of listening difficulty increases. As listening difficulty increases, cognitive activity increases – to a certain point. Once it becomes too difficult, cognitive activity drops off sharply (Peelle, 2014). We know that for children in the classroom, it is important to hear easily, to have good acoustics and amplification when needed, so that students can spend more time thinking about what they are learning rather than trying to decode what it is they are hearing. Despite the listening effort required for daily communication, Christine was able to communicate well, indicating she was motivated to understand and communicate. Christine agreed to join the waiting list for surgical repair of one ear drum, and her GP approached the prison to request funding for one hearing aid. As for many adult prisoners, any eligibility Christine may have had for the Australian government’s Hearing Services program prior to imprisonment was likely to have been lost upon incarceration. For most adult prisoners, responsibility for funding services relating to hearing and ear health, including hearing devices, transfers to state and territory- based corrections health services. Currently, adults with age-based eligibility, for example, adolescents and young adults aged 25 years or younger and Aboriginal or Torres Strait Islander adults aged over 50 years, retain access to the Hearing Services program, provided that they were in receipt of services at the time of incarceration. Adults with a current Hearing Services Voucher may continue to receive services until it expires. When prison services are deciding whether to fund a hearing aid for a prisoner, factors such as severity and impact of hearing loss and length of time still to serve are often considered. Christine had significant hearing loss and one year remaining on her non-parole period, and one hearing aid was approved. I saw her at the prison to find out more about her hearing and communication needs and discuss amplification options with her. During the appointment, she told me more about herself. Christine


Samantha Harkus


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how to support or communicate with hearing impaired prisoners. Prisons rely on sound in order to run smoothly: loudspeaker systems, verbal directions from staff, bells and alarms are key in daily routines (Kelly, 2017). A study of English and Welsh prisons show that they are ill- equipped to meet the needs of hearing impaired prisoners: reasonable adjustments that would help make sound accessible to prisoners with hearing loss, including hearing aids, are often not provided (Kelly, 2017). Globally, prisoners with hearing loss report that difficulties communicating with guards is an additional detrimental and stressful element of prison life (Dahl, 1994; McCulloch, 2012; Quinn & Rance, 2009; Vanderpoll & Howard, 2011). Knowing that courtrooms can be difficult listening environments for people with hearing loss, I asked Christine how she managed in this environment. Unfamiliar, technical legal language is common, multiple speaking locations make it difficult to make use of visual cues, distances between the defendant and the person questioning them can be further than optimal, and long periods of listening concentration may be required, fatiguing defendants with hearing loss. Howard, Quinn, Blokland, and Flynn (1993) speculate on the extent to which the apparently withdrawn courtroom demeanour of a noticeable number of Aboriginal defendants relates to hearing loss: remaining silent, gazing out the window or looking down. Christine confirmed that courtrooms were not easy listening environments for her, and when she could not hear, she guessed what was being asked and answered accordingly. Hearing loss is certainly prevalent among the cohort of people who pass through courtrooms and then into prisons. The final report of the Royal Commission into Aboriginal Deaths in Custody first commented on the relationship for Aboriginal people between childhood ear disease and hearing loss, poor school performance and incarceration (Johnstone, 1991). Murray et al. (2004) examined the hearing of 640 people in New South Wales prisons. The hearing of all inmates was poorer than for the normative Australian population, and the hearing of Aboriginal people was poorer than non-Aboriginal inmates. At Bandyup Women’s Prison in Western Australia, 45% of Aboriginal women assessed did not pass hearing screening, compared with 12% of non-Indigenous women (Siewert, 2010). In the Northern Territory, 94% of Aboriginal men in Alice Springs and Darwin prisons had hearing outside the normal range (Vanderpoll & Howard, 2011). So what are the mechanisms that appear to lead to the apparent overrepresentation of people with hearing loss in prison? Hearing loss of any degree, unless identified and remediated early, causes language and communication problems. Australia’s Longitudinal Outcomes of Children with Hearing Impairment isolates the factors that are supportive of global language development in children with hearing loss requiring amplification: early device fitting, higher maternal education level, absence of additional disabilities and higher cognitive ability (Ching, Dillon, Leigh, & Cupples, 2018). Since the implementation of newborn hearing screening in Australia, hearing loss present at birth is often identified and remediated within the first few months of life. Prior to this, particularly for less severe loss, identification and remediation often occurred significantly later. Unremediated hearing loss is one cause of delay in listening and talking skills, a pre-requisite for transition to literacy in the early years of schooling and for academic success across the whole school curriculum (Snow & Powell, 2012).

had been in and out of prison annually since the age of 18 years. She had passed through police, court, prison and parole systems 18 times without attention being brought to her ear health or hearing problems. Was this because Christine had not been screened for it, had not reported it, no one had noticed the signs, or the signs had been misinterpreted? Multiple studies from Australia, the United Kingdom and North America evaluate prevalence of hearing loss among prisoners (Dahl, 1994; Holmes et al., 1996; McCulloch, 2012; Murray, Butler, & LePage, 2004; Quinn & Rance, 2009; Vanderpoll & Howard, 2011). All studies note higher prevalence among prisoners than in the general population and the particular risks associated with not hearing well in the prison environment. Most comment on the absence of objective hearing screening as part of routine health assessment processes, and make recommendations for audiometric hearing screening to be implemented. Currently, self-report is often relied upon, either through prisoners volunteering the information or prison staff soliciting the information: problematic for populations where hearing loss is normalised. As part of an unpublished 2015–16 trial carried out in the Northern Territory by Australian Hearing, Anyinginyi Aboriginal Health Service and the NT Corrections Barkly Work Camp, the response to “Do you have hearing trouble?” was compared with the results of hearing screening for 60 male Aboriginal volunteers. Twenty-two per cent of the men had moderate or greater hearing loss. Relative to the hearing screening results, self-report was found to be poor at correctly identifying people with hearing loss, confirming that asking about hearing status, the most common approach to detecting hearing loss in prisons, is unreliable. It is quite plausible that Christine had not commented on her ear and hearing trouble. Many members of the Aboriginal community perceive ear and hearing trouble to be inevitable and normal for Aboriginal people. Evidence suggests, however, that prior to colonisation, it was not (Bhutta, 2015; Stuart, 2007). An Elder interviewed as part of social research commissioned by the Australian government Department of Health and Ageing (2010) commented “I always associate ear problems with Aboriginal people ... it’s a blackfella thing … you can’t do much ... it’s just one of nature’s things that happens”. In addition, treatments for ear disease are often perceived as ineffective (Jeffries-Stokes et al., 2004) and ear specialist services as expensive and inaccessible (Department of Health and Ageing, 2010). When viewed in this way, hearing loss and ear trouble can easily become something not worth raising. When Aboriginal men in Darwin and Alice Springs prisons who indicated they experience hearing problems were asked whether they had notified the prison health service, 72% had not (Vanderpoll & Howard, 2011). It is also quite likely that most prison staff did not recognise any communication difficulties Christine had as hearing related. The guard who escorted me to the prison clinic to see Christine memorably commented “Christine, is she deaf? I just thought she was stupid”. This is not uncommon: a Canadian study showed that many prison staff are unable to recognise behavioural signs of hearing loss, and when those behaviours were described, staff were five times more likely to ascribe them to personality or behaviour disorders, resulting in adverse consequences for the prisoner (Dahl, 1994). Staff who do recognise the behaviour as an indicator of hearing loss often do not know


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and pre-existing hearing loss that increased over time. A recent data linkage study of just under 23,000 children in WA showed that the presence of one chronic illness in early childhood, the most common of which in the cohort was middle ear disease, is a risk factor for school readiness (Bell, Bayliss, Glauert et al, 2016). During our discussion, Christine talked about what had been her dream job as a child: a receptionist in a doctor’s surgery. She recalls the moment when she realised that, because of her poor hearing, this could not be a pathway for her. Patients in a clinic waiting room need to be able to talk discreetly at times to reception staff, but Christine always needed people to speak up. That she recalls this suggests it was a significant moment in her life. Following this first appointment in the prison, I visited again to fit Christine’s hearing aid and several weeks later I returned to follow up on her progress. I had no idea what to expect. This was the first time I had provided rehabilitative hearing services to a client in a prison environment. What I found was remarkable: Christine had been wearing the aid constantly. The most significant difference was the way she held herself. In contrast to the first time I saw her, Christine was relaxed, sitting back in her chair, conversing easily, with a relaxed expression. Her friends had been commenting positively about the change in her: the way she held herself, the way she communicated, and this seemed to be an additional positive reinforcer. Christine could now hear and contribute in rehabilitation group sessions. She loved that she could talk to her mum on the phone, something she had not previously raised, but unremediated hearing loss amplifying loneliness and separation in prison is a common theme in the literature (Dahl, 1994; McCulloch, 2012). I will never forget Christine saying “There is nothing better than being able to hear”. Today, no jurisdiction routinely screens for hearing loss in prisoners; however, anecdotally, there appear to be coincidental plans for a trial of hearing assessment and tele-otology services in two states, so momentum may be building. The inquiry into treatment of youths in NT detention centres has brought fresh attention to hearing loss as a causal factor in incarceration (Australian Medical Association, 2017). Access to rehabilitative hearing devices and services appears inconsistent across jurisdictions, but anecdotal reports suggests it is increasing. To speech-language colleagues working in the justice system, my request to you is to be vigilant for opportunities to raise awareness among prison staff of the high rates of hearing loss, the behaviours that signal it, and provide strategies on how to accommodate for it in daily communication. If you have the opportunity, please promote the need for routine hearing screening and onwards connection to appropriate services. Together we can work to improve hearing and communication outcomes. A few months later, when I was running a clinic at the Aboriginal medical service, the doctor who visited the prison caught my attention as I walked past her office to let me know that Christine had been moved to a lower security prison to serve out the remaining months of her term, and that she had just been elected Aboriginal women’s advocate. We both understood the significance of this, and we stood for a moment together feeling a bit emotional. This really spoke to how unrecognised and unremediated hearing loss disempowers and limits potential, and conversely, how hearing well empowers and throws open the possibilities again. Disclaimer: The views expressed in this paper are mine and not necessarily those of my organisation.

A longitudinal cohort study found a direct association between diagnosed language impairment at age 5 and late adolescent delinquency, after controlling for verbal IQ (Brownlie et al., 2004). For children with hearing loss that occurs early in the post-newborn period, including Aboriginal children experiencing early and chronic ear disease, risk of late diagnosis and remediation persists (Australian Hearing, 2018). Christine talked about having had ear trouble as a young child. She recalled not hearing well at school and leaving early. Although there may well have been other contributing factors leading to early disengagement from school, unremediated hearing loss was likely to have played an important role (Williams & Jacobs, 2009). Christine’s almost total ear drum perforations suggest that she had had chronic suppurative otitis media, with repeated episodes of pus discharging from the middle ears for extended periods, rupturing and re-rupturing the ear drums and eroding the middle ear bones. The age of onset was likely to have been early, during the critical language and communication-learning years, from birth to three and a half years (Leach et al., 1994). For most Australian children, otitis media, or middle ear infection is transitory, self-limiting, and chronic suppurative otitis media is rare (Kong and Coates, 2009). Early onset, recurrent or chronic otitis media and related hearing loss is less likely, for most children, to lead to poorer long-term language and communication outcomes if the child is from socioeconomically advantaged family, has no other delays or disabilities and the hearing loss is not significant and unremediated (Roberts, Rosenfeld, & Zeisel, 2004). It is likely that two of these factors were relevant to Christine: socioeconomic disadvantage and the late age of remediation of significant hearing loss. The relevant aspect of socioeconomic advantage is the quality of the home language environment. Globally, children growing up in socioeconomically disadvantaged households are more likely to experience poorer quality of communication and a smaller number and range of words daily compared, on average, to children in socioeconomically advantaged homes (Hirsh-Pasek et al., 2015). Today, socioeconomic circumstances are improving for a proportion of Aboriginal people. Although 1.8% of Aboriginal people are now in the most advantaged decile of the population, Aboriginal and Torres Strait Islander families are still overrepresented in the most disadvantaged decile. In the 1960s, there was an even stronger likelihood that Christine and her family grew up experiencing socioeconomic hardship. It cannot, however, be assumed that the quality of Christine’s home language environment was poor. Given her use of visual cues, context and language base to construct fluent conversation, she may have had a rich home language environment. We know already that Christine had significant and unremediated hearing loss. Today, the average age of first hearing aid fitting for Aboriginal and Torres Strait Islander children is 6 years (Australian Hearing, 2018). Given the early age of onset of chronic ear disease, this indicates delays in the identification – diagnosis – remediation pathway. In the past decade, the average age of first fitting for Aboriginal children has lowered by 2 years (Australian Hearing, 2018), but continues to be late when referenced to age of onset and the critical window for development of language and communication skills. When Christine was a child, in the early 1960s, the proportion of Aboriginal children with aidable hearing loss who successfully connected with government-funded hearing services was undoubtedly significantly lower. Christine is likely to have started school with language and communication delay


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References Australian Bureau of Statistics. (2013). Australian Aboriginal and Torres Strait Islander Health Survey: First results, Australia, 2012–13 . Cat. no. 4727.0.55.001. Canberra, ACT: ABS. Australian Government Department of Health and Ageing. (2010). Indigenous ear health developmental research to inform indigenous social marketing campaigns final report . Canberra, ACT: Cultural & Indigenous Research Centre Australia. Australian Hearing. (2018). Demographic details of young Australians aged less than 26 years with a hearing loss, who have been fitted with a hearing aid or cochlear implant at 31 December 2017 . Retrieved from https://www. research/Aided-Child-Demographics-2017/Aided-Child- Demographics-Dec-2017-FINAL2.pdf?lang=en-AU Australian Institute for Health and Welfare. (2017). Aboriginal and Torres Strait Islander health performance framework . Available from indigenous-health-welfare/health-performance-framework/ contents/summary Australian Medical Association. (2017). AMA Report Card on Indigenous Health: A national strategic approach to ending chronic otitis media and its lifelong impacts in Indigenous communities. Canberra, ACT: Australian Medical Association. Bell, M. F., Bayliss, D. M., Glauert, R., Harrison, A. and Ohan, J. L. (2016). Chronic illness and developmental vulnerability at school entry. Pediatrics , 137 (5), 1-9. Bhutta, M. (2015). Evolution and otitis media: A review, and a model to explain high prevalence in indigenous populations. H uman Biology , 87 (2), 92–108. Brownlie, E., Beitchman, J., Escobar, M., Young, A., Atkinson, L., Johnson, C., Wilson, B., & Douglas, L. (2004). Early language impairment and young adult delinquent and aggressive behaviour. Journal of Abnormal Child Psychology , 32 , 4, 453–467. Burns, J., & Thomson, N. (2013). Review of ear health and hearing among Indigenous Australians. Australian Indigenous Health Bulletin, 14(4), 1–23. Ching, T. Y. C., Dillon, H., Leigh, G. L., & Cupples, L. (2018). Learning from the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study: summary of 5-year findings and implications. International Journal of Audiology , 57 (sup2), S105–S111. Dahl, M. (1994). Hard-of-hearing inmates in penitentiaries. Journal of Speech-Language Pathology and Audiology, 18 , 271–277. Hirsh-Pasek, K., Adamson, L. B., Bakeman, R., Owen, M. T., Golinkoff, R. M., Pace, A., Yust, P. K. S., & Suma, K. (2015). The contribution of early communication quality to low-income children’s language success. Psychological Science , 26 (7), 1071–1083. Holmes, A. E., Kaplan, H. S., Nichols, S. W., Griffiths, S. K., Weber, T. F. and Isart, F. A. (1996). Screening for hearing loss in juvenile detention centers. Journal of the American Academy of Audiology , 7 , 332–338. Howard, D., Quinn, S., Blokland, J. & Flynn, M. (1993). Aboriginal hearing loss and the criminal justice system. Aboriginal and Islander Health Worker Journal , 18 (1), 9–11. Jeffries-Stokes, C., Lehmann, D., Johnston, J., Mason, A., Evans, J., Elsbury, D., & Wood, K. (2006) Aboriginal perspective on middle ear disease in the arid zone of Western Australia. Journal of Paediatrics and Child Health , 40 , 258–264. Johnstone, E. (1991). Royal Commission into Aboriginal Deaths in custody . National Report,volume 2. Canberra, ACT: Australian Government Publishing Service.

Kelly, L. (2017). Suffering in silence: The unmet needs of d/Deaf prisoners. Prison Service Journal , 234 , 3–15. Kolo, E. S., Salisu, A. D., Yaro, A. M., & Nwaorgu, O. G. B. (2011). Sensorineural hearing loss in patients with chronic suppurative otitis media. Indian Journal of Otolaryngology and Head & Neck Surgery , 64 (1), 59–62. Kong, K., & Coates, H. L. C. (2009). Natural history, definitions, risk factors and burden of otitis media. Medical Journal of Australia , 191, S39–S43. Leach, A., Boswell, J., Asche, V., Nienhuys, T. G., and Mathews, J. D. (1994). Bacterial colonisation of the nasopharynx predicts very early onset and persistence of otitis media in Australian Aboriginal infants. Paediatric Infectious Diseases Journal , 13 , 983–989. McCulloch, D. (2012). Not hearing us: An exploration of the experience of deaf prisoners in English and Welsh prisons . London: The Howard League for Penal Reform. Murray, N., Butler, T., & LePage, E. (2004). Hearing health of New South Wales prison inmates. Australian and New Zealand Journal of Public Health , 28 (6), 537–541. Peelle, J. E. (2014). Methodological challenges and solutions in auditory functional magnetic resonance imaging. Frontiers in Neuroscience , 8, Article 253. Quinn, S. & Rance, G. (2009) The extent of hearing impairment amongst Australian Indigenous prisoners in Victoria, and implications for the correctional system. International Journal of Audiology , 48 (3), 123–134. Roberts, J. E., Rosenfeld, R. M., & Zeisel, S. A. (2004). Otitis media and speech and language: a meta-analysis of prospective studies. Pediatrics , 1 13 (3), e238–e248. Siewert, R. (2010). New prison research a wake up call for hearing health . Retrieved from https://rachel-siewert. hearing-health Simpson, A., Enticott, J. C., & Douglas, J. (2017). Socioeconomic status as a factor in Indigenous and non- Indigenous children with hearing loss: analysis of national survey data. Australian Journal of Primary Health , 2 3 (2), 202–207. Snow, P., & Powell, M. (2012). Youth (in)justice: Oral language competence in early life and risk for engagement in antisocial behaviour in adolescence. Trends and Issues in Crime and Criminal Justice, 435 , 1–6. Stuart, J. E. (2007). The antiquity of chronic ear disease in Australian Aboriginal children. Health and History , 9 (2), 155–158. Vanderpoll, T., & Howard, D. (2011). Investigation into hearing impairment among Indigenous prisoners within the Northern Territory Correctional Services . Available from investigation-into-hearing-impairment-among-indigenous- prisoners-within-the-northern-territory-correctional-services/ Williams, C., & Jacobs, A. (2009). The impact of otitis media on cognitive and educational outcomes. Medical Journal of Australia , 191 , S69–S72.

Samantha Harkus , BA, DipAud, MPH (@SamHarkus) is an audiologist and program leader for Aboriginal and Torres Strait Islander Services at Australian Hearing.

Correspondence to: Samantha Harkus Australian Hearing


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The role of speech-language pathologists in the justice system

The role of the speech-language pathologist in supporting young people in youth justice A Queensland perspective Stella Martin

A significant body of research indicates the high level of (usually undiagnosed) language and communication disorders in young people in contact with youth justice. Emerging Australian research highlights the benefits of speech-language pathology (SLP) interventions for improving communication outcomes. Young people in the Queensland youth justice system now have direct access to SLPs. This is an important development for both SLP practice, and broader governmental agendas seeking to implement evidence- based reforms that reduce offending and reoffending. This article will provide an overview of how SLPs can make a difference to the communication of young people who come into contact with youth justice, including existing literature about their communication profiles and needs. Clinical insights will be discussed based on the learnings from the commencement of the SLP program in Queensland, Australia, the considerations for service provision, and the current gaps in service. T here is a substantial body of research demonstrating the correlation between the speech, language and communication needs (SLCN) of young people and youth offending (see Anderson, Hawes, & Snow, 2016 for a review). Statutory systems expect adolescents to function with a level of maturity expected of their chronological age, regardless of their developmental age (Baidawi, Mendes, & Snow, 2014). However, for a young person with SLCN, their ability to successfully interact and comply with a number of aspects of the youth justice system is limited. Recent research has identified that the prevalence of SLCN among young people admitted to young offender institutions is over 60%, with only 5% of these young people diagnosed with SLCN before they commenced offending (Bercow, 2008; Bryan, Freer, & Furlong, 2007). The 2015 NSW Young People in Custody Health Survey (Justice Health and Forensic Mental Health Network and Juvenile Justice, 2017) reflected the noteworthy findings indicating that 48.7% of young people in custody had

severe core language difficulties (2 or more standard deviations below the mean), 51.1% had severe single word reading difficulties, and 77.8% had severe reading comprehension difficulties. SLP interventions can be effective in improving these areas, highlighting the positive impact therapeutic engagement can have on young people in youth justice (Gregory & Bryan, 2011; Snow & Woodward, 2017). Links between SLCN and factors impacting a young person’s trajectory to offending The presence of SLCN is often found in combination with other characteristics that impact a young person’s path to offending. Selected risk factors are briefly summarised below. SLCN and neuro-disabilities At least one in five young people in youth justice have a neuro-disability (Farrer, Frost, & Hedges, 2013; Hughes, Williams, Chitseabesan, Davis, & Mounce, 2012). In particular, there is a high prevalence of fetal alcohol spectrum disorder in youth justice (Bower et al., 2018). SLCN in young people with neuro-disabilities can be a significant barrier in youth justice. For example, young people with intellectual disabilities relay fewer story grammar elements in narrative accounts (Murfett, Powell, & Snow, 2008). Such difficulties can make them vulnerable communicators when they are required to “tell their story”, which has implications for the quality of forensic interviewing, restorative justice conferencing, and other verbally mediated contexts. SLCN and exposure to traumatic experiences and attachment difficulties Prior traumatic experiences and attachment difficulties can be another risk factor in young people with SLCN. Children and adolescents who experienced complex trauma show higher levels of behaviour and emotional difficulties (Varese et al., 2012; Wamser-Nanney & Vandenberg, 2013). In addition, females with language disorders reported more incidences of sexual abuse as a child when compared to females without language disorders (Brownlie, Graham, Bao, Koyama, & Beitchman, 2017). Young people who have been exposed to abuse, neglect, or inconsistent responsiveness from primary caregivers were more likely to have difficulties in attachment which, in turn, impacted on their communication abilities (Lum, Powell, & Snow, 2018) and were at a higher risk of becoming bullies, attributable to


Stella Martin


JCPSLP Volume 21, Number 1 2019

Journal of Clinical Practice in Speech-Language Pathology

administrative or legal information (Nolan, 2018). In the past year, several objectives have been progressed by Youth Justice Services, Department of Child Safety, Youth and Women in Queensland, to raise awareness of SLCN in young people in youth justice and promote communication- accessible contexts. In this section, an overview of significant objectives and achievements is provided. Provision of training and information to staff A fundamental component was to raise awareness of the prevalence of SLCN in young people in youth justice. This was an ongoing priority and was conducted through group training and information sessions, particularly to the staff who had the most direct contact with young people, including youth workers, caseworkers, teachers, and restorative justice officers. Workshops were developed to address topics including modifying communication for young people with communication difficulties; and recognising the differences between Australian Aboriginal and Torres Strait Islander languages/dialects and Standard Australia English. A notable achievement was successfully lobbying to gain a full day in every youth worker induction and every caseworker induction to raise awareness of the young people’s communication needs, and discuss practical ways to support their communication. Other forums included executive leadership forums, communities of practice for court and psychology, lunchbox sessions, allied health training days, and via Youth Justice media releases and newsletters. Integration of SLP frameworks and services SLP frameworks and services have been integrated at a systemic level within Queensland’s Youth Justice practice frameworks, policies and procedures, practice manuals, executive leadership reports, and responses to the Review of Youth Detention Centres (available at Modifying written materials for young people The Queensland Youth Justice SLPs have modified written materials for young people with SLCN, including consent, confidentiality and privacy of information forms, court orders, incentives and rewards posters, factsheets, youth detention induction booklets, and individualised therapeutic strategies. There is a growing interest by youth justice staff in this area and the demand for modifications to written documents is increasing. Modifying current therapeutic interventions Currently, SLPs are involved in a working group to modify a cognitive-behaviour therapy program delivered by caseworkers so that language that is easy-to-understand by people with SLCN is used. It was found that 59% of young people completing custodial sentences had alexithymia (difficulty identifying and describing affective states) and 37% of young people had a language impairment (Snow, Sanger, Caire, Eadie, & Dinslage, 2015); thus there is a need to provide socioemotional interventions which include skills that develop the vocabulary of emotion and expression (Way, Yelsma, Van Meter, & Black-Pond, 2007). SLPs need to work alongside mental health workers who are providing services to young people. Scaffolding communication within restorative justice processes Restorative justice conferencing relies on young people to understand, admit and articulate the offence committed, accept responsibility and understand the impact on the

reduced modelling in resolving disagreements (Hughes, 2014). Children who had been exposed to domestic violence showed more difficulties in phonological awareness and reading than those who had not been exposed (Blackburn, 2008). SLCN and social, emotional, behavioural and relationship difficulties Young people with SLCN are more likely to demonstrate behavioural, emotional and social difficulties (Lindsay, Dockrell, & Strand, 2007). Boys and girls with poor receptive language were more likely to be physically aggressive and girls with poor expressive language were more likely to show higher levels of relational aggression (i.e., causing harm to others by damaging their relationships or social status) (Estrem, 2005). Other studies have shown that children diagnosed with conduct disorder frequently had pragmatic language impairments (Gilmour, Hill, Place, & Skuse, 2004) and that young people with depression reported difficulty with many pragmatic skills such as initiating and terminating conversations, changing topics and maintaining eye contact (Perrott, 2012). Young people with SLCN who offend are at increased risk of developing mental health disorders into adulthood (Botting, Durkin, Toseeb, Picles, & Cont-Ramsden, 2016), including significantly higher rates of anxiety disorders and antisocial personality disorders compared to their peers without SLCN (Beitchman et al., 2001; Hollo, Wehby, & Oliver, 2014). SLCN and the impact on engagement with education, employment and programs People with SLCNs are more likely to have difficulty in academic achievement and in gaining employment (Johnson, Beitchman, & Brownlie, 2010). Research has shown that a larger proportion of adolescents with developmental language disorders were employed in service and unskilled occupations whereas typically- developing adolescents were more likely to be involved in skilled and professional education and occupations (Conti-Ramsden & Durkin, 2012). SLCN is a risk factor for offending, and there is a need to advocate for the conceptualisation of language within a broader risk and protective framework (Snow & Powell, 2004). Such a framework may assist SLPs to support a young person’s success at school and contribution to the workforce. An Independent Review into Youth Detention in Queensland provided a unique opportunity to increase the therapeutic response to vulnerable young people in youth justice. In Queensland, Youth Justice employed six SLPs – a senior practitioner, four youth-detention centre-based SLPs (Brisbane and Townsville), and a regional SLP. In this section, key aspects of the current service provision for young people in youth justice are outlined. Ensuring accessible communication for all young people One of the key aspects of the current model is its focus on ensuring accessible communication for young people in youth justice. There is collective agreement that all young people who come into contact with youth justice need to have the skills to understand and express themselves effectively in addition to retaining and processing complex Current service provision for young people in youth justice


JCPSLP Volume 21, Number 1 2019

victim, answer verbally loaded and emotive questions, develop solutions to repair the harm, and use the conferencing process to change their future behaviour. This also requires sufficient executive functioning and metacognitive skills. The Youth Justice SLPs are becoming more involved in preparing young people for involvement in restorative justice conferencing. Collaborative practice Collaborative practice is key to the integration of therapeutic perspectives with educational, health, and youth justice priorities (Department of Education, 2018). In Queensland, it has been essential for youth justice SLPs to collaborate with multiple professionals to build connected and coordinated services for young people in custody that allow for smoother transitions back into the community. This includes within their own multidisciplinary teams, caseworkers, heads of curriculum, education, child safety services, Aboriginal and Torres Strait Islander cultural units, First Nations Action Board members and Indigenous reference groups, child and youth mental health services, and primary medical services. Language assessment and intervention The scope of SLP service provision is varied – services include 1:1 individualised assessments, interventions, and behaviour support, group work, consultation and building capacity within other professionals and programs, psychoeducation and training, and consultation with stakeholders. SLPs prepare comprehensive reports that may influence various outcomes for the young person – such as, to inform magistrates, judges and legal representatives in the children’s courts prior to sentencing; to medical professionals that may inform their care plans for young people, or to National Disability Insurance Agency planners to determine the level of support required. SLPs also engage in the dissemination of information to relevant stakeholders to ensure smooth transition into the community and access to support post-detention. Regardless of how service is delivered, there is a compelling need for language assessment and intervention for young people in youth justice. Improving communication skills, including reading comprehension, were predicted to reduce the likelihood of re-offending with one study suggesting that if reading comprehension scores improved by one standard deviation, the risk of young people reoffending would reduce by approximately 30% (Rucklidge, McLean, & Bateup, 2009). Young people with SLCN in youth justice will have difficulty receiving and practically applying services if they are not accompanied by intense language intervention (Linares-Orama, 2005). Working with young people with Standard Australian English as an additional language/dialect The Queensland Youth Justice system has a significant percentage of young people from diverse cultural backgrounds, specifically from Aboriginal and/or Torres Strait Islander backgrounds, with 87% and 56% of Aboriginal and/Torres Strait Islander young people at Cleveland Youth Detention Centre (Townsville) and Brisbane Youth Detention Centre respectively in 2016–17 (Youth Justice Annual Summary Statistics – Detention, 2017). Many of these young people have English as an additional language/dialect, which indicates the need for individualised support that draws upon culture-specific knowledge of communication. Young people may code-switch between

different dialects along the Australian Aboriginal English continuum. The majority of Australian Aboriginal languages use between 3 to 5 vowels (Butcher & Anderson, 2008), which requires SLPs to ensure they avoid “misidentification through over-identification of speech errors, or conversely through under-identification, where dialectal difference is held accountable for all errors” (Toohill, McLeod, & McCormack, 2012, p. 102). Standardised assessments are by their very nature culturally and linguistically specific, and therefore, standardised tests in isolation are diagnostically inadequate and inappropriate for bilingual young people (SPA, 2016; ASHA, 2004). However, standardised assessments used in conjunction with non-standardised methods can be appropriate measures of performance, as long as the SLP has adequate understanding of the language differences (Miller, Webster, Knight, & Comino, 2013), and the skills to compare cross-linguistic clinical markers between the two languages (Bedore & Peña, 2008), obtain carer reports of the young person’s abilities in both of their languages, and to understand context of what needs to be spoken and the manner in which it is to be spoken (Gould, 2008). Clinical support In Queensland, access to clinical support has been essential to the ongoing development of the experienced SLPs in youth justice. Supports have included individual clinical supervision, regular peer-group meetings, and specialised professional development which has included topics addressing trauma-informed practice, positive behaviour support, mental health interventions, evidence- based intervention frameworks when working with young people who sexually offend, and evidence-based communication interventions for young people with neuro-disabilities or English as an additional language/ dialect. Gaps in service As SLP services have only recently been implemented in youth justice in Queensland, there are several challenges that must be considered and/or addressed. High turnover The average daily number of young people held on remand in Queensland is 81%. The average stay of a young person on remand in Queensland is 34 days (Youth Justice Annual Summary Statistics – Detention, 2017), which impacts the ability to build rapport, assess and gather collateral information to inform the report and recommendations for treatment. Access to medical and education information There are three different government departments (Youth Justice, Education, Health) operating within the detention centres, with each having its own legislation and policies around information-sharing and confidentiality. There is a need for ongoing collaboration between departments to maximise the quality of service provision and avoid service duplication. Follow-up of health services by young people and their families upon release With the prevalence of dual diagnoses and other comorbidities in young people comes the need to be consistent with medical check-ups and treatment implementation. Examples include the identification and follow-up of young people with hearing and vision loss, accessing further services such as counselling, SLP,


JCPSLP Volume 21, Number 1 2019

Journal of Clinical Practice in Speech-Language Pathology

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