INT J LANG COMMUN DISORD, NOVEMBERDECEMBER 2013,

VOL. 48, NO. 6, 689702

Research Report
Investigation of practices to support the complex communication needs
of children with hearing impairment and cerebral palsy in a rural district of
Kenya: a case series
Karen Bunning, Joseph K. Gona, Susan Buell, Charles R. Newton and Sally Hartley
School of Allied Health Professions, Faculty of Medicine & Health, University of East Anglia, Norwich, UK
Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya
Neuroscience Unit, Institute of Child Health, University College London, London, UK
Department of Psychiatry, University of Oxford, Oxford, UK
Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
(Received January 2013; accepted June 2013)

Abstract
Background: Rehabilitation services are scarce in low-income countries, where under-representation of some
specialist professions has led to the role extension of others. An example of this can be found in Kilifi in Kenya
where the role of speech and language therapy has been taken on by occupational therapists and teachers.
Aims: To investigate the communication practices used by these professional groups to support children with
complex communication needs in a rural part of Kenya and to explore the ways in which this might be seen to
facilitate or obstruct improved communication by asking the following questions: What are the critical features
of interactional discourse in practitionerchild dyads with caregiverchild dyads providing a natural comparison?
What communicative modalities and practice techniques are invoked? And how does this information relate to
extending professional roles?
Methods & Procedures: An in-depth, descriptive study of a case series was conducted in a school for deaf children
and the occupational therapy department of a district general hospital. A mixed methodology was used involving
naturalistic observation and applied linguistics analysis. A convenience sample was established comprising six
practitionerchild dyads assigned to partnership types: (A) three children with hearing impairment and their
teachers; and (B) three children with cerebral palsy and their occupational therapists. As a natural comparator, the
same three children in B were also observed with their mothers (partnership type C). Dyadic interaction was video
recorded on three occasions. The video data were sampled, transcribed into standard orthography and translated.
Codes were applied to determine turn structure, linguistic move types and communicative modalities. Sequential
analysis was conducted on the move types.
Outcomes & Results: Partnership type A dyads showed a fairly even turn distribution between teacher and child.
A common pattern was teacher-initiated Instruct and Model/Prompt, followed by child response in the form of an
Action. The most frequently used modality was Sound Production and Hands-on-Articulators, which corresponded
to articulation drill practice. Partnership type B dyads revealed a tendency towards adult domination of turns.
The majority of adult-initiated moves required no response from the child. The practice technique Hands-on-
Articulators involved manipulating the oral musculature of the child. Partnership type C dyads showed resonances
of type B dyads, although focused more on Motor-Action in relation to task performance.
Conclusions & Implications: The assignment of speech and language therapy duties to teachers and occupational
therapists has resulted in suboptimal practice for children with complex communication needs.

Keywords: communication, rehabilitation, developing country, interactional discourse.

Address correspondence to: Karen Bunning, School of Allied Health Professions, Faculty of Medicine & Health, University of East Anglia,
Norwich NR4 7TJ, UK; e-mail: k.bunning@uea.ac.uk
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online  C 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12042
690 Karen Bunning et al.

What this paper adds?

What is already known on the subject?
There is a scarcity of speech and language therapists in developing countries. Extending the roles of other, established
disciplines is a commonly applied strategy to circumvent gaps in multidisciplinary provision. However, there is
currently no published information on the nature and effectiveness of such practice.
What this paper adds?
This case series provides evidence of the way communication support activities were delivered to children as part
of a role extension by teachers in a special, residential school for the deaf and occupational therapists seeing
pre-school children at the district general hospital in a rural part of Kenya. Practice tackled surface-level features of
communication, i.e. speech production or else manipulation of the oral musculature for speech, with limited recourse
to language and symbolic development. The study concluded that the assignment of duties to circumvent gaps in the
multidisciplinary team runs the risk of suboptimal practice, and may lead to the consequential neglect of childrens
complex communication needs.

Introduction East African universities (Staley 2013). East Africa has an

The prevalence of communication disorder amongst the
full range of impairments experienced by children in
Sub-Saharan Africa has been reported at around 50% of
the disabled population, e.g. 49.5% in Uganda (Hartley
1998), over 50% in Zimbabwe (World Health Organi-
sation (WHO, 1997), and 52.5% in Kenya (Mungala-
Odera et al. 2006). Associated with cognitive impair-
ment, autistic spectrum disorders and sensory or motor
impairments, the nature of communication need may
be complex and have a pervasive impact on the develop-
ing child, variously affecting social inclusion and access
to education (Karangwa et al. 2010), classroom partic-
ipation (Ademokoya and Olujide 2007), and academic
attainment (Olusanya et al. 2006).
Despite the reported prevalence and impact of child-
hood disorders in Sub-Saharan Africa, there is a scarcity
of rehabilitation specialists (Mont 2007). Discrepan-
cies in rehabilitation personnel employed in countries
of low-income status compared with middle-income
ones have been reported. In high-income countries,
speech and language therapy is the acknowledged pro-
fession responsible for addressing communication dif-
ficulties. In low-income countries, however, there is
a dearth of appropriately qualified personnel (WHO
2011). In East Africa (Burundi, Kenya, Rwanda, Tanza-
nia and Uganda), speech and language therapy provision
has mainly been confined to Nairobi and Mombasa in
Kenya, Moshi in Tanzania, and Kampala in Uganda
(Jochmann 2006), and supplied by a small, expatri-
ate workforce from the organization Voluntary Service
Overseas (VSO). A more recent development is the es-
tablishment of a dedicated specialist training course at
Makerere University in Uganda. So far, two cohorts
have graduated successfully (n = 18), with destination
posts reported as Uganda, Tanzania, Rwanda and Kenya.
Three more regional programmes are also planned at
estimated population of 141.8 million (The World Bank
2011). Based on a 15% prevalence rate (WHO 2011:
29), 21.27 million will have a disability, of which 50%
are likely to have communication difficulties (Hartley
1998, WHO 1997, Mungala-Odera et al. 2006). This
indicates that 10.6 million may require speech and lan-
guage therapy. There are about 35 speech and language
therapists covering this region (18 Makerere graduates,
VSO volunteers and independent practitioners), which
gives an approximate ratio of one speech and language
therapist to 302 857 children and adults with commu-
nication difficulties.
Poor availability of speech and language therapy
has given rise to two main approaches. The first is
community-based initiatives as promoted by the WHO
through the Community Based Rehabilitation guide-
lines, which includes how to conduct a basic assess-
ment and implement communication strategies to over-
come difficulties (WHO 2010: 1218). In Kenya,
other community-based initiatives have included work-
ing with womens groups to mobilize local support for
disabled children and their families (Hartley et al. 2009).
The second approach involves the extension of existing
practice to carry out duties associated with the missing
profession; however, there has been no published re-
port of the effectiveness of this role reassignment strat-
egy or of the resultant practice. In Kilifi, occupational
therapists were one of two professions implicated by a
lack of speech and language therapy provision, where
their role extension required specific accommodation of
children with complex communication needs (Bunning
et al. 2007) in spite of reported workforce deficien-
cies (International World Federation of Occupational
Therapy 2012). Occupational therapy is a client-centred
health profession concerned with promoting health and
well-being through occupation. It employs interventions
Practices to support communication needs in Kenya
for physical and psychiatric conditions using specific,
purposeful activity to prevent disability and promote
independent function in all aspects of daily life (see
International World Federation of Occupational Ther-
apy). Occupational therapists in Africa have a key role
in addressing the needs of children with developmental
delay, providing information to caregivers, psychological
support through counselling, and setting up stimulation
programmes to promote physical, cognitive and social
development (Mwanjabe 2010). Sherry (2010) observes
that in spite of an underlying person-centred philosophy,
pressure to conform to a medical model characterized
by professional dominance may be present.
Teachers were the second profession with an ex-
tended remit for addressing communication needs. In-
formation on pedagogical practice in Kenyas special
education sector is largely undocumented, although
Muuya (2002) reported a major focus on pupil con-
trol, containment and care. A larger body of research
has examined practice in mainstream education. The
dominance of transmissional forms of teaching that re-
strict opportunities for pupil participation in classroom
discourse has been reported (Abd-Kadir and Hardman
2007, Ackers and Hardman 2001). Teacher-led recita-
tion involving rote and repetition has also been observed,
with limited attention to pupil understanding (Ponte-
fract and Hardman 2005). The introduction of a na-
tional, school-based, teacher development programme
at the primary education level in Kenya was found to
improve levels of teacherpupil interaction; however, the
absence of teacher follow-up, i.e. evaluation of the childs
response, reported in previous research (Abd-Kadir and
Hardman 2007, Pontefract and Hardman 2005) per-
sisted (Hardman et al. 2009).
As well as the setting, the presenting condition of
the child may affect practice. An apparent lack of re-
sponsiveness in a child with a developmental condition
may lead to the adult adopting more directive and in-
structional styles of communication. Pennington (2008)
observed that parental use of questions and action re-
quests with children with cerebral palsy helped to cir-
cumvent ambiguities of meaning by restricting the lin-
guistic context. A similar pattern has been identified in
children with profound cognitive impairment and com-
plex needs (Bunning et al. 2013). In a review of related
studies on adultchild interaction, Marfo et al. (1998)
identified two parameters affecting communication: (1)
the directiveness or the extent to which the adult directs
the actions of the child; and (2) the sensitivity to child
behaviour or the degree to which the adult is tuned-in
to the childs response repertoire. Intrusive directiveness
combined with a lack of sensitivity seems to inhibit child
responsivity; however, directiveness combined with sen-
sitive, contingent responses to child behaviour appears
to facilitate development (Marfo et al. 1998).
691
Cultural factors form another layer of influence on
interaction style. Oral communication may have partic-
ular importance in rural communities of Africa where
literacy levels are low (Hartley 1998). Tonsing et al.
(2005) observed that some cultures with a stronger oral
tradition might find aided forms of communication, e.g.
communication boards, less acceptable than unaided
forms, e.g. speech and sign. The importance of speech is
demonstrated in Hartley et al.s (2009) study involving
community groups, in which deafness was attributed to a
lack of speech, with hearing predicted to return once the
child had started speaking. Their study revealed a lack
of understanding and awareness of childhood disability
in the community. Speech has been included in the goal
of normality expressed by caregivers (Hartley et al.
2009). The culture of mainstream education in Sub-
Saharan Africa reflects the high value of speech in the
domination of teacher-led recitation, where classroom
discourse has been characterized as teacher explanations,
question and answer routines, and whole-group choral
responses (Hardman and Abd-Kadir 2007).
The current study aimed to investigate the commu-
nication practice used by occupational therapists and
teachers of the deaf to support children with complex
communication needs in Kilifi District, Kenya, and to
explore the ways in which this might be seen to facil-
itate or obstruct improved communication. Kilifi Dis-
trict is approximately 60 km north of Mombasa and
is the second poorest district in Kenya, with most of
the rural population living as subsistence farmers. There
were three main research questions: What are the critical
features of interactional discourse in practitionerchild
dyads with caregiverchild dyads providing a natural
comparison? What communicative modalities and prac-
tice techniques are invoked? How does this information
relate to extending professional roles?
Design, setting and sample
The study was a descriptive, in-depth investigation of the
interactional discourse occurring between children with
complex communication needs and the adults support-
ing them. The case series employed a mixed method-
ology involving naturalistic observation and application
of structuralfunctional linguistics.
A preliminary survey of rehabilitation for children
with developmental conditions identified two settings
where dedicated communication support activities were
provided (Bunning et al. 2007). The first setting was a
residential school for the deaf, which housed what was
referred to as a speech therapy department staffed by
teachers of the deaf. The school followed an oral ap-
proach to communication, although not exclusively
Kenyan Sign Language was also used in the class-
rooms and in peer interactions during free periods.
692 Karen Bunning et al.
Table 1. Practitioner characteristics

Professional Training receivedlast Experience

Practitioner Sex Languages Place of work qualification 5 years (years)
T1 Male Swahili; English; Kenyan Special School Diploma (Sp. Speech and languageemphasis 20
Sign Language for Deaf Needs Ed.) on phonetics and phonology;
audiometric testing; hearing aid
repair and maintenance
T2 Male Swahili; English; Kenyan Special School Diploma (Sp. As above 16
Sign Language for Deaf Needs Ed.)
OT1 Female Swahili; English; Giriama Kilifi District Diploma in OT Tricycle and designing; 19
Hospital community counselling;
HIV/AIDS peer education;
home care
OT2 Female Swahili; English; Giriama Kilifi District Diploma in OT General counselling; TB and 13
Hospital leprosy
Note: Teachers = T1/T2; and occupational therapists = OT1/OT2.

Children were drawn out of the classrooms for individ-
ual sessions of approximately 10-min duration in one of
the allocated rooms, twice weekly. In line with all educa-
tional provision in Kenya, Spoken English was the pre-
ferred language for the childrens education, which in-
cluded speech therapy. This was against a background
of the local languages used by families and communi-
ties being Giriama and Swahili. The second setting was
the occupational therapy department at Kilifi District
Hospital, where one day a week was dedicated to what
was termed speech work in the absence of a speech
and language therapy service. Their caseload comprised
children aged 05 years with a variety of developmental
conditions. Children were usually seen individually in
a small side room designated for this purpose. Ther-
apy was conducted in the language of the childs home,
which was usually Swahili or Giriama. In order to gain
insights into natural communication taking place in
contrast to professional practice, it was decided to in-
clude the primary caregiver interacting with the child.
A convenience sample was established comprising
three types of communication partnership: A, teachers
of the deaf and children with hearing impairment; B,
occupational therapists and children with cerebral palsy;
and C, caregivers and children with cerebral palsy. The
head of each of the two services nominated three chil-
dren who were currently in receipt of dedicated support.
Departmental nomination and familiarity with the child
were favoured over a more random sample because the
practitioners needed to feel confident about being ob-
served in their work. The sample comprised six children,
three with hearing impairment and three with cerebral
palsy; four service practitioners and three caregivers
all mothers (a total of 13 participants). Table 1 displays
the characteristics of the adults. Table 2 presents sum-
mary information on each child that was available at
the time of recruitment. Three children were observed
with teachers of the deaf. The remaining three children
were seen with the occupational therapists, and again
with their mothers making nine partnerships in total.
The two occupational therapists had received no spe-
cific training in speech, language and communication,
but had followed an interest in children presenting with
communication needs in their department. Both teach-
ers of the deaf had received training in audiology, hearing
aid management, Kenyan Sign Language, phonetics and
phonology.
Ethics
Ethical approval was given by the National Ethical Re-
view Committee of Kenya and at the University of East
Anglia in Norwich, UK. Informed consent was obtained
from all participants.
Methods
Data collection
Video recording was used to capture communication
taking place in the nine communication dyads. For
partnership types A (teacherchild) and B (occupa-
tional therapistchild), sessions designated specifically
for communication support activities were targeted. For
partnership type C (motherchild), video capture was
conducted during waiting time for an occupational ther-
apy appointment. To accommodate individual variabil-
ity across time, video capture for each dyad occurred on
three separate occasions in different weeks. By restricting
the temporal gaps between recording times, data stabil-
ity was considered more likely. The camera operators
research status was known to persons present, but no
part was taken in the ongoing activity. The adult was
asked to do what you usually do with the child and to
ignore the camera as far as possible. Filming followed
the usual amount of time allocated to the activity and
varied across partnerships accordingly. A typical speech
session in the school involved the teacher sitting with
the child, either at a desk or else on the floor. Using
everyday objects or paper-based materials, the teachers
Practices to support communication needs in Kenya 693
Table 3. Distribution of turns across dyads in different

0 = No usable speech; 1 = a few words and sounds only; 2 = conversation about familiar things with help from the listenerfrequent failures in communication still occur; 3 = conversation about familiar things with little or no assistancesome
(see table 2)
Practitioner

failures in communication still occurs; 4 = discussion about new ideas as well as familiar thingsa few failures in communication still occur; and 5 = communication is adequate for purposeminimal discernible communication difficulties.
partnership types

OT1

OT2

OT2
T2

T2
T1
Partnership type A
T1 C1 T2 C2 T2 C3

M1: mother; < 20;00; only

M3: mother; age unknown;

Mean 27 27.7 30.7 26.3 24.7 23.7

M2: mother; > 20; five

Range 2333 2032 2637 2435 2030 2029
Caregiver
summary

Partnership type B

the one child

only child
OT1 C4 OT2 C5 OT2 C6

children
Mean 36 30.7 14.7 0.3 9 0.3
Range 2646 2043 1020 01 712 01
Partnership type C
difficultya
Areas of

3, 5, 6

M1 C4 M2 C5 M3 C6
1, 4

3
1

Mean 18.6 12.3 13.6 4 0 0

Range 1622 716 718 09 0 0
Table 2. Child (C4, C5 and C6) characteristics and mothers (M1/M2/M3)

Distraction testresponse at 110

Imitates lip language; symbolic

Attempts speech; short syllables
Communication and hearing

R = better ear90 db; basic

use of objects; vocal play

performed articulation drill work or sound discrimina-

db (drum); no speech
7090 db; speech delay

tion tasks with the child. In occupational therapy, the

Summary

child was positioned in supported seating during ther-

apy activities, e.g. a chair with a high back, a wedge
Notes: a 1 = hearing impairment; 2 = visual impairment; 3 = physical/motor difficulties; 4 = attention problems; and 5 = behaviour problems.
Vocalizes, cries

between the legs and a fixed tray to front, with the

gestures

mother in attendance. Activities mainly involved word

repetition or therapist wiping warm cloths and large ice
blocks (dimensions of 4 by 8 by 2 inchesthe sort to
be found in picnic cooler bags) around the childs oral
b
Rating

musculature. Interactions between the mother and child

12
2
0

1
2

usually involved carrying out gross motor exercises, e.g.

flexing and extending childs legs in bicycle fashion, or
Years in
school

fine motor tasks, e.g. placing wooden pegs in a board.

1
1

0
1

0
School for the Deaf

Data sampling
OT Department

The video footage was uploaded to a computer using

Service

Adobe Premier software. Competing demands on trans-

As Above
As above

As above
As above

lator availability affected project capacity to achieve full

transcripts of all recorded material. In order to reduce
the video footage into more manageable units, a sam-
pling framework was applied. Preliminary observations
Languages Spoken

Giriama; Swahili

Giriama; (a little
Chonyi; Swahili

(Bunning et al. 2007) revealed that the therapy appoint-

in Home

ments in both settings tended to be brief, around 1012

Swahili)

min in length, and focused typically on one main activ-

Swahili
Swahili

Swahili

ity, which was repeated throughout the session. Whilst

the study of rare phenomena often requires denser sam-
ples (Tomasello and Stahl 2004), the repetitive nature
Age (years;
months)
10;00
06;00

11;00

of therapy activities meant that it was not likely to be

4;06

3;00

1;06

the case for the current study. The first 2 min of the ses-
sion were excluded to minimize any potential effects of
camera reactivity. One-minute-long segments were sam-
Female

Female
Male
Male

Male

Male
Sex

pled at 2-min intervals in order to maintain the stability

of the interaction samples as far as possible (Heilmann
Child

et al. 2010). A 15-s lead-in was inserted at the start of

C1
C2

C3

C4

C5

C6

each segment to enable observer orientation. Data anal-

b

ysis was applied to the first three segments sampled from

694
each session captured. This meant that each partnership
yielded a total of nine video segments (three segments
from each of three video recorded sessions).
Transcription and coding
The data were transcribed into standard orthography
through repeated viewings of the video footage using
conventions adapted from Crystal (1992). A transcrip-
tion template was used, which was divided into three
columns: the communication acts (vocal and non-vocal
aspects) of children, adults and contextual information,
respectively. Participant use of spoken language was
transcribed verbatim and translations inserted imme-
diately afterwards in square brackets. Any unintelligible
items were represented by asterisks in brackets with a
question mark. Descriptions of other vocal behaviour,
e.g. high-pitched prolongation of vowel as in a scream,
and non-vocal acts, e.g. manual sign (standard and id-
iosyncratic), body movement, handarm gesture, facial
expression, eye gaze, and manipulation of materials used
in the session, were placed in brackets to make it distinct
from spoken communication.
Turn boundaries were determined by pause length,
usually of a 2-s gap and terminal contour behaviours,
e.g. pitch change, and non-vocal signals such as a break
in eye gaze. A system-based approach to coding, guided
by the principles of structuralfunctional linguistics, was
used to determine the nature of the interaction. Based
on the work of Carletta et al. (1996), the framework
consisted of two categories of dialogue move: initia-
tion (I-) and response (R-). Additional codes were
added to cater for some of the childrens early stage
communication behaviours, e.g. Self/Shared Expression
(SSE); and to accommodate the teachinglearning as-
pects of therapy, e.g. the initiation move Model/Prompt
(I-MP) and the response move Feedback (R-F). Based
on preliminary observations completed (Bunning et al.
2007), a second framework was devised comprising
communicative modalities. For example, Spoken En-
glish/Swahili/Giriama were defined alongside other com-
munication forms, such as Kenyan Sign Language and
Gesture. Additional codes were included to capture the
use of certain practice techniques, e.g. Sound Production
and Hands-on-Articulators. Brief summaries of the cod-
ing frameworks are provided in Appendix A.The codes
were applied to the printed transcripts using the recom-
mended annotations. Communications directed outside
the adultchild dyad were excluded from the analysis.
Variability
A second researcher was trained in the use of the cod-
ing framework and to recognize any idiosyncratic be-
haviours emitted by the participants and any word ap-
Karen Bunning et al.
proximations in Swahili or Giriama. Repeat coding was
applied to a random sample representing 30% of the
data. Inter-coder agreement was estimated using the
Kappa statistic () and revealed Kappa values for lin-
guistic move types: = 0.79 and modes of communi-
cation: = 0.87 that were excellent according to Fleisss
(1981) interpretation.
Data analysis
To investigate the distribution of turns and linguistic
move types in dyads, the mean and range for adult and
child per dyad were calculated across the three sam-
pled sessions. The strength of association between adult
and child contributions and the recurrence of move type
patterns were established through event-sequential anal-
ysis within a time-lag framework. (Bakeman and Quera
2011, Bakeman and Gottman 1997, Pennington and
McConachie 1999). Firstly, the two- and three-event se-
quences were identified and marked on the transcripts.
Then the raw frequencies for each two-event sequence
were counted and entered into a prepared matrix, with
the coding categories aligned vertically on the left for lag
0, also termed the given move, and horizontally for lag
1, termed the target move. A similar matrix was pre-
pared for sequences from lag 1 to lag 2. When calculating
the total behaviours recorded, care was taken to avoid
counting the event at lag 1 twice. Because of the few in-
cidences of transitions from lag 1 to lag 2, the next stage
of the analysis focused only on those from lag 0 to lag
1. The simple probability with which each given event
occurred in a dyad was calculated initially, followed by
the transitional or conditional probabilities for each tar-
get event being coded in relation to a given event. The
probabilities were then converted to percentages.
Communicative modalities were identified and
marked on the transcripts. The frequency was calculated
for each category and the mean scores were displayed
in a table.
Results
Interactional discourse
The distribution of turns varied across dyads and part-
nership types as shown in table 3. Partnership type A
dyads showed a fairly balanced distribution of turns be-
tween teacher and child. A similarly even distribution
was seen in dyad OT1/C4; however, the other two dyads
in partnership type B revealed greater turn usage by
OT2 than the children (C5 and C6). In partnership
type C, the dyadic interaction between C4 and her
mother (M1) showed resonances of the interaction be-
tween C4 and OT1. There was lower turn occupation in
Practices to support communication needs in Kenya 695
Table 4. Matrices of transitional probabilities for two-event sequences (expressed as a percentage) in partnership type A dyads where
the teacher (T) is at lag 0; the child (C) is at lag 1

Lag 1: C1
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: T1
Initiation (I-)
I 40 76 15 9
ICE 10 22 78
MP 30 100
A 10 100
Q 10 25 25 25 25
SSE 0
Lag 1: C2
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: T2
Initiation (I-)
I 15 19 81
ICE 3.5 34 66
MP 76 80 15 5
A 4.5 25 75
Q 1 100
SSE 0
Lag 1: C3
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: T3
Initiation (I-)
I 20 78 6 16
ICE 5 25 75
MP 60 90 5 5
A 2.5 100
Q 2.5 70 10 20
SSE 0
Note: sp = simple probability expressed as a percentage for a given move per session.

dyads M1/C5 and M2/C6 compared with all the other
dyads, with M2/C6 occupying no turns at all.
Across all partnership types, the moves at lag 0 were
adult initiations and the moves at lag 1 were child re-
sponses. Moves at lag 2 were seen mainly in partnership
type A, and on two occasions by OT1/C4 (partnership
type B). Tables 46 display the dyad matrices according
to partnership type for the two-event sequences (lag 0
to lag 1). The column sp displays the simple probabili-
ties signifying the likelihood of the given move at lag
0 preceding any target moves during a session. Each
cell of the matrix shows the transitional probability for
each possible pairing of adult to child (lag 0 to lag 1)
move types, which indicates the probability of the tar-
get event occurring at lag 1 after the given event at
lag 0. Excerpts of dyadic dialogue are provided as exam-
ples. Non-vocal turns and contextual information are
given in the curved brackets. Where Swahili is used a
translation is provided immediately afterwards in square
brackets.
Partnership type A
The mean number of two-event sequences in partner-
ship type A dyads was generally high, showing little vari-
ation and with minimal presence of follow-up moves at
lag 2. For dyad T1/C1, the mean number of two-event
sequences was 25.3, of which six response moves at lag
1 were followed up at lag 2. Dyads T2/C2 and T2/C3
involved the same teacher. For dyad T2/C2, the mean
number of two-event sequences was 25, of which 1.3
moves were followed up at lag 2. For dyad T2/C3, the
mean number of two-event sequences was 28, of which
4.6 moves at lag 1 were followed up at lag 2.
696 Karen Bunning et al.
Table 5. Matrices of transitional probabilities for two-event sequences (expressed as a percentage) in partnership type B dyads where
the occupational therapist (OT) is at lag 0; the child (C) is at lag 1

Lag 1: C4
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: OT1
Initiation (I-)
I 20 7 30 3 56 4
ICE 10 6 6 82 6
MP 50 73 2 10 12 3
A 0
Q 20 29 13 25 8 25
SSE 0
Lag 1: C5
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: OT2
Initiation (I-)
I 28 5 86 9
ICE 28 1
MP 9 14 57.5 28.5
A 14 82 18
Q 0
SSE 20 6 94
Lag 1: C6
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: OT3
Initiation (I-)
I 10 100
ICE 40 100
MP 20 100
A 10 100
Q 10 100
SSE 10 100
Note: sp = simple probability expressed as a percentage for a given move per session.

As shown in table 4, the most common initiation In dyads T2/C2 and T2/C3, the given move I-MP
move in dyad T1/C1 was Instruct (I-I = 40%) and then had the highest probability of occurring in a session,
Model/Prompt (I-MP = 30%), which had the strongest with a transitional probability for the target move R-
likelihood of triggering a target response of Active (R- Act occurring at 80% and 90% of the time in each dyad.
Act) by C1. The first excerpt features T1 sitting behind Instruct moves (I-I) had a lower probability of occurrence
a desk with C1 seated to the side. They are looking at than for dyad T1/C1. In dyad T2/C2 there was a strong
each other during articulation drill work, which lasted association between the given Instruct move and No
on this occasion for 14 separate turns. Response Expected (NRE). In both dyads T2/C2 and
T2/C3, the given moves Alignment (I-A) and Query
1. T1 (turns head slightly away) ah (looks back at (I-Q), whilst having a lower chance of occurring in a
C1) ba session, were more likely to be associated with a target
2. C1 (makes vocal soundapproximating target of NRE.
with nasal quality) ba
3. T1 a-a-a (vowel sound is prolonged)
Partnership type B
4. C1 (makes vocal soundapproximating target)
a-a For dyad OT1/C4, the mean number of two-event se-
5. T1 ba-a-a quences was 42.7, of which less than 1 move at lag 1
Practices to support communication needs in Kenya 697
Table 6. Matrices showing transitional probabilities for two-event sequences (expressed as a percentage) in partnership type C dyads,
where the mother (M) is at lag 0; the child (C) is at lag 1

Lag 1: C4
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: M1
Initiation (I-)
I 75 5 36 5 40 14
ICE 14 9 18 73
MP 0
A 3.5 33 33 33
Q 6 20 20 20 40
SSE 2 50 50
Lag 1: C5
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: M2
Initiation (I-)
I 41 93 7
ICE 21 79 21
MP 25 18 12 70
A 5 25 50 25
Q 0
SSE 8 100
Note: sp = simple probability expressed as a percentage for a given move per session.

was followed up at lag 2 per session. For dyads OT2/C5 Expected (NRE). Whilst Query (I-Q) had a similar rate
and OT2/C6 the mean number of two-event sequences of occurrence, C4 was more likely to respond with a
was much lower, 25.3 and 14.6 respectively. No moves target move of Acknowledgement (R-A), Reply (R-R) or
at lag 1 were followed up at lag 2. Action (R-Act).
As indicated in table 5, dyad OT1/C4 had the high- In dyad OT2/C5, I-MP constituted a majority of
est occurrence of Model/Prompt (I-MP) as a given move given moves with R-Act as the most likely transitional
with a strong association to Action (R-Act) by C4. This is move at lag 1. No Response Expected (NRE) was a
shown in excerpt 2, which opens with OT1 holding up a highly probable target response to the given initia-
small toy and saying frog in Swahili, which C4 attempts tions of Instruct (I-I) and Inform/Comment/Explain (I-
to copy. The pattern shows OT1 modelling the spoken ICE). Excerpt 3 shows OT2 giving an explanation of
word and C4 responding with her own approximation, her actions. She addresses C5 in Swahili whilst sitting
which ran to 12 turns on this occasion. on the floor with her hands placed around the childs
jaw and mouth.
1. OT2 hii ni nini [what is this?] (points to detail
on toy frog) 1. OT2 mmmmmmmm (moves hands either
2. C4 (places hand on OT1s outstretched fore- side of C5s jaws and mouth, making for a
arm) nimee (looks towards OT1) repeated openclose movement)
3. OT1 ah? (looks up to C4) 2. OT2 fanya hivi useme vizuri sawa? [do this to
4. C4 (continues to make attempts at speech talk well, ok?]
sounds)
5. OT1 ulimi [tongue] Dyad OT2/C6 revealed an apparently one-sided di-
6. C4 (continues to make attempts at speech alogue where given event I-ICE was most likely to oc-
sounds) cur, followed by Model/Prompt (I-MP), but with a 100%
7. OT1 ulimi [tongue] probability of transition to No Response Expected (NRE).
8. C4 eh bimu (upper limb movement accom-
panies speech efforts)
Partnership type C
The use of Instruct (I-I) had a lower rate of occur- The mean number of two-event sequences recorded
rence with about half being associated with No Response for dyads in partnership type C were M1/C4 = 28.3;
698 Karen Bunning et al.
Table 7. Summary of communicative modalities and practice techniques across partnership type dyads: mean scores per session

Partnership type A Partnership type B Partnership type C

Modalities and practice
techniques T1 C1 T2 C2 T2 C3 OT1 C4 OT2 C5 OT2 C6 M1 C4 M2 C5 M3 C6
Swahili 7 1 29 0 18 7.7 22 0.3 17
Giriama 6
English 27 6 16 0.3 2
Kenyan Sign Language 1 1.3 0.7
Speech production 9 15 24 19 12 18 17 11 2 0.7 1.3
Oromotor practice 1.3 0.3 0.3 0 0.3
Gesture 21 11 4 11 3.3 8.3 9.3 2.3 4.3 1 5 4 4.7 0.7 6.7 0.5 1
Hands-on-Articulators 9.7 6 2.7 0.7 2.3 9.7 6.7 0.5
Sound input 2.3
Motor response 2 7.7 1 2 2.7 2 1.7 0.7 0.3 4.3 8.3 6 0.7

M2/C5 = 22.6 with no follow-up moves from lag 1 to
lag 2. No moves were recorded for dyad M3/C6, where
the mother engaged in extending and flexing the childs
limbs.
As shown in table 6, there was a high probabil-
ity of the mothers in dyads M1/C4 and M2/C5 using
the given Instruct (I-I) move. This was associated al-
most evenly with No Response Expected (NRE) and Ac-
tion (R-Act) in dyad M1/C4, and mainly with NRE
as the target in dyad M2/C5. Model/Prompt (I-MP)
as the next most likely given move, had a strong as-
sociation to NRE. The small presence of Query (I-Q)
as a given move was associated with Acknowledgement
(R-A), Action (R-Act) and Reply (R-R), although there
was a 40% probability of a No Response (NR). In dyad
M2/C5 Self/Shared Expression (SSE) was a likely target
move to the given I-MP particularly. NRE was majorly
associated with the given moves of I-I, I-ICE and I-
MP. This is illustrated in excerpt 3 where C5 is standing
against a therapy roll, with his mother holding onto his
shoulders whilst supporting the small of his back. The
mother talks to her child as she adjusts his position.
1. M2 C5 haya shika chini [hold down] (adjusts
C5s clothes and also his position)
2. C5 (continues in position)
3. M2 angalia chini. [look down] weka mikono
chini [put hands down] (moves roll forward
with child whilst holding onto the backs of
his legs)
4. C5 (continues in position)
5. M2 haya angalia [okay look] (tips roll forwards)
6. C5 (continues in position)
7. M2 shika chini. shika chini tena. [hold down.
hold down again] (holds onto C5s legs)
Communicative modalities and practice techniques
Table 7 summarizes the communicative modality usage.
Partnership type A dyads employed English as the spoken
medium during a session, whereas partnership type B
used Swahili mainly. Speech Production acts were preva-
lent in partnership type A dyads and in dyad OT1/C4
(partnership type B). Gesture was used mainly by the
teachers (T1 and T2) with a more balanced dyadic usage
in OT1/C4 (partnership type B.) The practice technique
Hands-on-Articulators was used by all the practitioners.
The mothers (partnership type C) spoke in Swahili
with some support from Gesture. The small presence of
Gesture and Hands-on-Articulators in dyad M3/C6 did
not constitute interactional turns, but were representa-
tive of small body behaviours.
Discussion
Turns were distributed fairly evenly between the teach-
ers and pupils in Partnership A and dyad OT1/C4 in
Partnership B. The remaining dyads in Partnerships B
and C revealed the dominant role of the adult. Initi-
ating moves were used exclusively by the adults across
all the partnership types with the child as the respon-
dent. Follow-up moves at lag 2 in the form of Feedback
and Reply were used mainly by the teachers in part-
nership type A, although not consistently. The teach-
ers variously favoured the Instruct and Model/Prompt
moves, which were similarly used by the occupational
therapist in dyad OT1/C4. In correspondence to the
adults in these dyads, the children mainly responded
with Action moves. In OT2/C5 and OT2/C6, there
was preferred use of Inform/Comment/Explain by the
occupational therapist with low levels of Action re-
sponses being recorded for the children. Partnership
type C (caregiverchild) revealed higher Instruct and
Inform/Comment/Explain moves by the adults, whereas
the children used more Self-Shared Expression. Com-
municative modalities and practice techniques revealed
reliance on speech generally amongst the adults across
all partnership types. Both Speech production and Hands-
on-Articulators featured in partnership types A and B.
The teachers execution of an instructional, speech
training approach with the children produced pat-
terns that were resonant of the transmissional forms of
Practices to support communication needs in Kenya
teaching identified by Abd-Kadir and Hardman (2007)
and Ackers and Hardman (2001). This may explain the
fairly even distribution of turns between adult and child
playing out an initiation-response sequence. The inter-
actional discourse in these dyads followed a recurring
sequence of Model/Prompt or Instruct to Action, similar
to the teacher-led recitation patterns found by Ponte-
fract and Hardman (2005). The teachers limited use
of Feedback moves at lag 2, echoed findings reported
by Hardman et al. (2009). It appears that the teaching
frames of the classroom were imported into the therapy
session in Partnership type A. dyads. The similarities
seen in dyad OT1/C4 (partnership type B.) may have
been affected by the therapists personal experience and
cultural knowledge of the teachinglearning process as
summarized by Hardman and Abd-Kadir (2010).
A quite different theoretical orientation was in-
dicated by the interactional discourse involving the
younger children (C5 and C6). Although the two-event
sequences were still adult-led, therapist initiation moves
were linked to No Response Expected (NRE). This may
be explained by the therapy activity of wiping ice blocks
and warm cloths around the childs face, which effec-
tively cast the child in a passive role with the discourse
proceeding as a therapist-delivered commentary. The
medical model in the hospital setting may have influ-
enced the use of special techniques and equipment and
could be seen to support the dominance of the health
professional (Sherry 2010). No formal label was used
by the occupational therapists to describe these activ-
ities; however, there appears to be parallels with two
particular intervention approaches. The first is a branch
of proprioceptive neuromuscular facilitation, which is
used by occupational therapists and physiotherapists to
promote muscle flexibility. Called pseudo neuromuscu-
lar facilitation, it was developed in the 1970s for the
treatment of acquired motor speech disorders (Langley
and Darvill 1979) and involved applying ice to the neu-
ral pathways of the oral musculature. The second is a
collection of exercises designed to increase strength, tone
and control of the oral musculature termed non-speech
oral motor treatments (Powell 2008). Both approaches
have been largely discredited due to a lack of evidence
supporting their efficacy (Ruscello 2008).
In addition to the underlying pedagogies of prac-
tice, factors concerning the childs age, condition and
developmental stage may have influenced the discourse
structure. The dyads OT2/C5 and OT2/C6 (partner-
ship type B.) featured younger children, for whom the
early stage communication behaviours seen in typically
developing children were compromised by the primary
condition of cerebral palsy. This affected their motor
skills for verbal and non-verbal representations of mean-
ing (Pennington 2008). Thus the likelihood of the adults
overlooking small or idiosyncratic, seemingly insignifi-
cant behaviours was a possibility (Bunning et al. 2013,
699
Pennington 2008, Pennington and McConachie 1999).
This might explain how the recorded Acknowledgements
emitted by C4 in response to Initiation-Query were not
recognized by the occupational therapist (OT1). This
suggests inadequate knowledge and understanding of
communication development, in particular at the earli-
est stages, underpinned by a lack of specialist training
associated with the new responsibilities. In addition, the
given moves at lag 0, i.e. Inform/Comment/Explain or
Instruct were mainly rhetorical and required no response
of the child, thereby indicating therapist control of the
discourse, which affected a reduction in communication
opportunities for the child similar to that observed by
Abd-Kadir and Hardman (2007). Whether this was a bi-
product of therapy that was about doing something to
the child, e.g. manipulation of oral-musculature, which
was not conducive to two-way interaction, or a lack
of sensitivity to early, non speech communication be-
haviours as described by Marfo et al. (1998) is debatable.
The similar control exerted by the mothers in part-
nership type C raises the question of contextual influ-
ences at work. Both partnership types C. and B. were
enacted in the hospital department where the mothers
were exposed to occupational therapy practice applied to
their children. What is notable is that the mothers relied
more on Instruct moves and less on Model/Prompt, com-
pared with partnership type B dyads. This was borne
out by the absence of the modalities/practice techniques
of Speech Production, Oral-motor Practice and Hands-on-
Articulators, although there was a greater concentration
of Motor Responses from the child during physical exer-
cises under the mothers instructions. However, Gesture
was used by both mother and child in dyads M1/C4
and M2/C5, which may reflect greater maternal sensi-
tivity to a child who has difficulties in the area of speech.
Alternatively, it could be that the mothers viewed ma-
nipulation and icing as a specialist activity requiring
the particular expertise of the therapists. Of course it
would most certainly have been the case that ice blocks
would not have been available at the homesteads.
In addition to activity selection, the setting cul-
ture appears to have influenced the choice of language.
Speech was the dominant communication modality
used by adults across all the partnerships, consistent with
its valued status in educational discourse (Abd-Kadir
and Hardman 2007) and the oral traditions associated
with African culture (Hartley et al. 1998). English as
the language of education also featured in the schools
therapy sessions (Pontefract and Hardman 2005). As the
school was residential the children were effectively de-
nied development opportunities in their mother tongue.
In addition, the school for the deaf followed an oral ap-
proach to communication, which likely governed the
goal of speech production. In contrast, the language of
the childs home was used in the occupational therapy
department, which indirectly acknowledged the role
700
of the home and the family in supporting the childs
development. Typical practice with children with de-
velopmental disorders affecting communication would
usually involve some combination of augmentative
and alternative communication strategies (Pennington
2008); however, partnership types A and B were charac-
terized by speech sound production and manipulation
of the oral musculature.
The extent to which the practitioners were prepared
for the additional responsibilities associated with the
missing profession, i.e. speech and language therapy,
must be questioned. Training in phonetics, phonology
and associated therapy techniques has likely influenced
the teachers use of multi-sensory techniques for mod-
elling sound production targets, which is resonant of
practice described by Beazley et al. (2001). However,
the lack of feedback following the instructional two-
event sequences reflected the learning by rote reported
by Pontefract and Hardman (2005), with a lack of spe-
cific techniques to facilitate target accuracy. Continu-
ing professional development recorded for the occupa-
tional therapists seemed to be about raising awareness
via knowledge exchange on matters such as HIV and
AIDS, and skills training in areas relevant to the profes-
sion, with no specialist training recorded for the extra
duties associated with speech, language and communica-
tion needs. It is possible that the occupational therapists
practice, with its focus on oral-motor skills and mo-
tor production of speech, stemmed from their original
diploma studies, where undoubtedly human anatomy
and physiology will have featured. The practice in both
partnership types A and B seem to tackle surface level
processes affecting speech production, with apparently
limited attention to pre-requisite competencies, such as
symbolic development, or indeed communication by
means other than speech. Thus it may be that staff prac-
tised what they had been trained for and not for the
additional responsibilities assumed.
Limitations
This was a small-scale study of children with complex
communication needs associated with either hearing
impairment or cerebral palsy, interacting with adults in
three types of communication partnership. The results,
therefore, are not representative, but nevertheless
serve to illustrate some of the features of interactional
discourse between teachers, occupational therapists and
mothers with such children. Nomination of the child
participants by the service heads was not ideal and
introduced bias to the sample, as they may have chosen
children more capable of producing speech. It was orig-
inally planned to recruit a purposive, stratified sample
covering key age ranges and underlying conditions
associated with communication disorders; however,
Karen Bunning et al.
the observational methodology meant that practitioner
confidence outweighed such considerations. During the
study period it was noted that one of the occupational
therapists changed her practice by ceasing the use
of icing and related techniques with the particular
participant, but was informally observed to continue
their use at other times. Capacity-building workshops
carried out as part of the large scale project may have
influenced the therapist in question to try out new
practices or to conceal usual practice due to raised
awareness. Inclusion of motherchild interaction was
originally planned as an informal comparator to the
practice in partnership types A and B. Video capture
during attendance of the occupational therapy depart-
ment was not ideal and likely influenced the choice of
physical activities carried out. The homestead, whilst
less convenient, would have been a more natural setting
for observing motherchild interactions; however, this
was not possible due to resource limitations.
Conclusions
In the absence of a speech and language therapy service
in this rural part of Kenya, there has been the assign-
ment of duties to teachers of the deaf and occupational
therapists. However, practice appears to be determined
by the pedagogies associated with the original profes-
sional training. The teachers had received some pre-
qualification training in phonetics and phonology, al-
though practice was reminiscent of classroom discourse
in Kenya. The occupational therapists had not un-
dertaken any specific training relevant to the support
of communication development. They used techniques
that demonstrated inadequate knowledge of communi-
cation. However, the mothers were present and therapy
was conducted in the language of the home. Speech
and sound production was emphasized with limited re-
course to language acquisition and the development of
concepts. The instrumental benefits of such practice
and the capacity for generalization into everyday life are
questionable.
Whilst communication between the mothers and
their children showed resonances of the communication
seen in occupational therapy sessions, their shared use
of gesture and the spontaneous self-/shared expression
by the children are possibly indicative of a more natural
and participative interaction style. Development of sup-
port for children with complex communication needs
and their families in low-income countries requires con-
sideration of the range of augmentative and alternative
communication strategies that might support a more
functional approach; the familys contribution as poten-
tial agents for change; and finally the training require-
ments for effective expansion of professional roles.
Practices to support communication needs in Kenya
Acknowledgements
The authors would like to thank the Director of the Kenya Medical
Research Institute for permission to publish the data. Gratitude is
expressed to the CP Charitable Trust for its generosity in funding the
project. Thanks must also go to the Wellcome Trust at KEMRI and
the services across the health and educational rehabilitation sectors of
Kilifi District. Professor Charles Newton is funded by the Wellcome
Trust. Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and writing
of the paper
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Appendix. Coding frameworks

Initiation move types

Instruct Commands or gives instruction, usually related to the current activity
Inform, comment or explain States information not solicited by another person; provides a commentary for their own actions; asks
self-directed, rhetorical question; explains or states a reason for a circumstance
Model or prompt Demonstrates a target response as a model for another person to copy; gives a prompt or a cue to other
person, which can take a vocal or a non-vocal form for completion by another person
Align Calls for other persons attention in the absence of clear instruction or gives a simple name call and
pause before the next move; attracts attention to detail
Query Asks other person a question that takes a yes/no answer; solicits information in an open-ended form;
solicits a response to a forced alternative; follows a proposition with a brief check on another persons
understanding/readiness/compliance
Response move types
Attend or acknowledge Aligns attention to an object or a person showing that something has been heard or seen, but it falls
short of a deliberate response like an action; use of back channels to indicate engagement
Feedback Evaluates a prior move by another person
Action Responds to an instruction given with or without a model, prompt or situational cue
Reply Replies as appropriate to various forms of query: gives a yes/no surface form meaning yes or no;
provides information solicited; completes the stem of a given phrase
No response Occurs when a turn change has been signalled in a previous turn, but no or little response is made.
There may be the intimation of confusion or insecurity in the persons gestures
Practice modalities and techniques
Speech Swahili Utterances spoken in Swahili
Speech Giriama Utterances spoken in Giriama
Speech English Utterances spoken in English
Kenyan Sign Language Hand shapes and movements derived from Kenyan Sign Language
Speechsound production Attempt at speechsound production
Oral production Attempt at oro-muscular production (lip closure, puffing cheeks, etc.)
Gesture Pointing, facial expression, handarm or body gestureincludes the use of materials for multisensory
feedback in speech production activities
Hands-on-Articulators Touch contact or approximation with oral-facial structures
Auditory input Sound input directed specifically around the ears and head
Motor response Execution of motor skills or action