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Putting in nails with a spanner: the potential effect of using false data from language-rich tests to assess dyslexic people

Gerald Hales

Consultant Psychologist and Clinical Hypnotherapist, Milton Keynes, England enquiry@drhales.co.uk

Abstract

Although there is a movement against the 'discrepancy' measure of disability, it is still frequently used as a defining pattern by education providers. It attempts to define scale of need by the size of the deficit of an individual's expected developmental rate. This is frequently described in terms of age measures, so a ten-year old with a reading age of eight years is considered to be two years 'behind' the norm for his age. This is only likely to be a valid measure for those for whom the individual's expectation is normal- in other words, that at ten years old his expected achievement on a particular measure would be equivalent to ten years. A more appropriate measure is to consider the discrepancy between an individual's level of achievement and his personal expectation from his own level of ability. Even this raises a difficulty for dyslexic people. Most test batteries designed to establish levels of ability or intelligence utilise material, concepts and procedures that are language based. So the methodology uses the very skills in which the person is deficient in order to establish how proficient they are - thereby introducing a strong possibility of profiles being established which relate to a false premise. This paper examines the pattern of differences between uses of conventional, language-rich test batteries and alternative language-fair test methodologies and shows how, for many dyslexic people, a significant error in conceptualisations of their ability may lead to inappropriate and unfair outcomes.

Introduction

In 1997 Martin Turner wrote a book called 'Psychological Assessment of Dyslexia'. The very first paragraph of the introduction said this:

"The nature of dyslexia is much clearer than it used to be. There may one day be hard, physical criteria for its detection, given, for example, that it is now possible using specimens of sweat or hair to test how much zinc has been absorbed by the body. But until then we must continue to use behavioural measures that are, by their very nature, imprecise, even slippery. For this reason it is necessary, in assessing individuals for dyslexia, to use measurement resources to their utmost."
(Turner 1997)

In this paper I shall discuss precisely that: using our measurement resources to the utmost. But I will extend the concept, by discussing how we can use the resources open to us in ways that help to prevent misleading results and in ways that are more representative of procedures that are fair to dyslexic people.

Dyslexia has been called many things. Some attempts to change nomenclature have come about because of a search for more clarity, some because of suspicions about why the term is used, others because of a belief that a new understanding has been born. However, the one thing that cannot be denied is that it is invisible. The symptoms are visible- often all too clearly so for the dyslexic person- but the actual functioning of the difficulty and the reasons why it happens cannot be seen by the external observer.

So, when trying to identify it, diagnose it, find it or specify the details, many different tests are used. These range from simple task tests for screening (eg. digit span) through tests of skill for comparison or monitoring (eg reading and spelling tests) to full IQ batteries used as part of a diagnostic assessment (eg. WISC or WAIS). But although these have regularly been used as tests for dyslexia, there never has been a definitive test of dyslexia. There is no definitive test that will categorically distinguish those who are dyslexic- and certainly no test that will specify type, variation or sub-group. The tests outline the profile of the individual in certain respects (those tested by the test) and leave us all to extrapolate what must have caused that profile. Hopefully we will also be able to match elements of the profile to the various techniques known to help dyslexic people and thereby establish a prescription of something that will help and give us a way forward.

Dyslexia and literacy

Dyslexia is frequently regarded as a 'literacy problem'; this, however, is not quite the case. Many dyslexic people do have difficulty with literacy-related tasks, but this is because they are dyslexic, it is not the cause of it. They have problems with sequencing even when the material is not linguistic. How, then, did dyslexia (the cause) and reading and writing problems (the outcome) become confused? How did 'literacy difficulties' and 'dyslexia' become almost synonymous in many people's minds?

One of the earliest papers discussing what we would nowadays call dyslexia was published by Hinshelwood in the December issue of The Lancet in 1895. It was called "Letter-, word- and mind-blindness" (Hinshelwood, 1895). I do not believe that this date was random coincidence. In 1833 parliament made its first limited grant to education. The grant was small and it went to religious bodies, which used it to build schools. It was significant because it was the first time that the government had accepted any financial responsibility for the education of 'the poor'.

In 1870 the government passed an Education Act drafted by William Forster; this divided the country into about 2500 school districts and in each district School Boards were to examine the provision of elementary education in their district and if there were not enough school places they were authorized to build and maintain schools. The Boards could charge fees or, if they wished, educate children free. The importance of this may be seen from a comment written by Philip Snowden in his autobiography.

'After the passing of Mr. Forster's Education Act, a few progressive persons in the village started an agitation for the adoption of the Act. The Act was adopted, and the school I attended was taken over by the newly formed School Board. Steps were taken at once to build new school premises. A trained master was appointed, and a new era in child education in the village was opened up. I was between ten and eleven years old when this change took place. It brought me into a new world of learning. We were taught in a new schoolroom, which by comparison with the dingy old place we left seemed like a palace to us. The walls were covered with maps and pictures. Our curriculum was extended to include grammar, geography, history, elementary mathematics, and the simple sciences.'
(Snowden, 1934)

The outcome of all this development was that many people were, mostly for the first time, offered an education. It was more comprehensive for some than others, but for all it included learning of the basic skills- reading, spelling, writing and arithmetic. And, naturally, once the teaching of large numbers of people how to do these things began, it became rapidly apparent that some had enormous difficulty. It did not matter if you were dyslexic when almost everyone could not do those things- but once most people began to learn them, the difficulty became both apparent and important.

No-one is good at everything, of course, and there are people who are not particularly good at skills such as reading, spelling and writing without having any specific condition at all- let alone dyslexia. It is, therefore, necessary to distinguish carefully between three groups of people

1. Those who are of low intelligence and cannot cope with literacy skills because they have difficulty with many things.
2. Those who have difficulty with literacy skills because these happen to be at the lower end of their personal spectrum of abilities.
3. Those who have literacy difficulties because they are dyslexic.

The difference may be identified by considering the ability at sequencing skills with material which is not linguistic. The dyslexic individual has difficulty with the sequential information even when it is not language-based, simply because it is sequential, whereas the person with poor literacy skills who is not dyslexic only has problems when using words and literacy components.

Identifying all this in particular individuals is a daunting task. We need to know several different things

1. What is the structure of their information-processing patterns?
2. What are the components that they handle less efficiently than others?
3. What are the components that they handle less well than they should from their own apparent ability?

The last point is particularly important. It is important to know if someone is doing less well than other comparable people as such an individual will be at a relative disadvantage. But it is vital to know if he is matching up to the expectation we should have for him in the light of his own level of ability and potential. In other words, we need to know how intelligent he is. And therein lies a substantial problem for us as psychologists.

In order to assess how an individual matches up to the expectation for the normal, average person like him (age, sex, and so on) we clearly need to test him on the same tests that would be used with all the others, to see how he fares. However, those tests were designed by- and for- non-dyslexic people. There is an implicit assumption that the dyslexic individual will react to the assessment situation- and demonstrate his ability through it- in the same way as everyone else. But why should he? He does everything else in a 'dyslexic' way, so what leads us to believe that he demonstrates his ability through testing in anything other than a dyslexic way? If this is true it gives us a substantial range of problems. Not least among these is that there is not a lot of data on what a 'dyslexic way' of taking tests is, plus (especially) that there is no way of knowing how any individual would have performed if he had been different (ie., not dyslexic), because he cannot go back in time and re-live his life without the dyslexia. We therefore run the risk of our evaluation of an individual relying heavily on extrapolation.

Differences and similarities

Everyone who undertakes an assessment naturally brings with him the outcome of his experience of the world to date. It is the dyslexic person's experience that makes him what he is at the moment when we see him- whether that is for assessment, teaching or anything else. However, his experience is of functioning as a dyslexic person in a non-dyslexic world, which gives us a difficulty when we try to work out what 'must have' been happening in the past. I have addressed this in my own practice by trying to test people in two ways, one using the methodologies which are commonly used for everyone and the other by trying to use methodologies that allow for dyslexia. This enables us to obtain an indication of how the individual performs by comparison with others and to gain some idea of what might have happened without it.

My starting point was the recognition that no-one makes steady progress in education. None of us moves at a constant rate from one piece of learning to the next. This is for two major reasons. One is that there are times when our learning moves on more efficiently and swiftly and other times when our progress is much slower. The second aspect is the more crucial for the dyslexic person- or indeed, anyone with a difficulty that affects education. It is that education is cumulative. What we learn in week one is need in order to learn properly what there is in week two, and so on. Let us consider how these two factors affect our dyslexic learners.

The overall pattern of moving through the educational experience is one of development- something which is as true of dyslexic people as it is of everyone else. However, the difficulties and inefficiencies with which the learning takes place means that although there is progress, the rate of that progress may be slower. We can therefore hypothesise that the trend over time is likely to be as represented in Figure 1:

Figure 1: Trend of progress over time

Comparisons

It is common for many testing procedures in psychology and education to rely on comparisons with the expectation for an average person of equivalent age. This leads to the 'discrepancy' model of ability, where the size of the difference between

1. performance observed or measured, and
2. performance expected

is taken as a valid indicator of the individual's position. Many test procedures utilise this, including measures of intelligence. An individual's performance on intelligence tests is customarily converted to a 'standard score', which is corrected for age. This means that a standard score of, say, ten at age eight years means the same as a standard score of ten at age twelve years. By comparison with the average at the time the individual is performing just the same. So, if we make normal progress from one age to another, our standard scores should stay the same. This does not mean that we are standing still, but that we are making progress at a normal rate.

However, it is clear from the projection of progress patterns for the dyslexic child that if we measure apparent ability by constant reference to the age-norm at the time of testing, the scores will become relatively lower and they will appear to be becoming less intelligent. This comes as a great shock to parents, but it is something that has been recognised for many years. In 1974 a report on dyslexia by the British Council stated

dyslexia can affect performance on standard IQ tests and produce misleading results.
(Kershaw, 1974)

We must also recognise that this situation takes no account of the factor, already mentioned, that education is a cumulative process. Most of the skills we learn are, once learned, required to be used in order to learn new skills. This is particularly true of basic skills such as reading, writing, spelling and number. For a dyslexic child it is likely that their pattern of progress may not be one of less progress, but actually one of diminishing progress. This is shown in Figure 2:

Figure 2: Modified trend of progress over time

So, as time progresses there is an increasing likelihood of dyslexic people producing low scores on tests of intelligence, suggesting lower levels of ability, understanding and comprehension. Actually, the low scores are produced because of a lack of knowledge. This lack of knowledge is created by an inability to acquire it, rather than an inability to understand it, so although the testing may be carried out perfectly properly and although the results might seem perfectly clear, in reality the dyslexic individual's situation is not truly represented by the results obtained.

Culture-Fair testing

For those who suffer from an information processing problem there is a risk that their pattern of difficulty may interfere with some aspects of conventional testing procedures and produce results which do not properly represent their real level of ability. Not only does this chain of events lead to an apparent picture of the individual's situation which is erroneous, but it is also highly likely to generate frustration in the individual. Indeed, the whole provision made for such a person may be inappropriate, since the underlying higher level of ability remains unknown and is not addressed.

I have approached this by the use of the Cattell Culture Fair Intelligence Test. The essential principles have been recognised for a long time and were originally described by Cattell many years ago (Cattell 1940, 1941). The Culture Fair testing procedure includes language only for the purpose of giving the instructions: no reading, no writing, no spelling and no words- not even speaking- are necessary in order to carry out the tasks required. The elements of the tasks involve the mental manipulation of concepts and answers are given by use of a visually representative multiple-choice format.

Such a methodology measures individual intelligence in a manner designed to reduce, as much as is humanly possible, the influence of aspects such as verbal fluency, cultural climate or educational level. The approach attempts to make a cleaner separation of natural ability from specific learning and thus permits a better analysis and prediction of the individual's ultimate potential.

Where there is a contrast between results using this approach and those obtained on conventional tests the difference is likely to be important. This is because the conventional battery uses the types of skills which are normally the ones regarded as representing 'intelligence' as well as being those most commonly forming part of normal education. A situation like this means that the individual's performance on a number of types of standardised test should be regarded as suspect in terms of how much they are able to produce a fair estimate of the true level of ability.

The results do show such a contrast between the Wechsler IQ figures and the Culture-Fair figure, with the Culture-Fair results being considerably higher. This is demonstrated by the diagram at figure 3, which plots the Wechsler Full-scale and Culture-Fair IQ figures for the first twenty people in this study.

Figure 3: Full Scale and Culture Fair IQ figures

This not only shows that the Culture Fair figures are higher than the Wechsler figures, but also demonstrates that in many cases the conventional testing result is below average, while the Culture Fair result is above average. This situation is especially critical for the dyslexic person, for it is important to recognise that while anyone's achievement can be lower than their ability, it is not possible the other way round. We all can perform at a lower level than that of which we are capable- and indeed we do, when we are unwell, for example, or under some extra stress. However, while it is possible not to use ability we have, we cannot artificially use ability we don't have. Therefore, where there are substantial discrepancies between scores when tested in different ways, it must be the highest scores that represent what is possible, at least when the circumstances are right. This demonstrates the risk associated with working on the basis of conventional Wechsler scores when they give an under-estimate of the capability of the dyslexic individual.

The data indicate that all scores fell as people enter the secondary age-range, as shown in figure 4:

Figure 4: Average IQ test scores by age group

The Culture-Fair scores perform in the same way as the Wechsler scores between Junior and Senior levels, but once it stabilises it remains at a consistent level. In the Wechsler test patterns we see that not only do the scores continue to change, rising somewhat as time passes, but it is noteworthy that the relative pattern differs as time passes as well. In the younger children it is the Verbal scores that are highest, but in the adults they are the lowest. The Performance scores do the opposite, starting as lower in the younger children and finishing as the highest for the adults.

In my earlier research I noted that the negative effect of the experience of dyslexia appears to be more serious for the girls, especially in the middle years of education (Hales, 1994). In the present instance we see that the discrepancy between the conventional Full-scale IQ and the Culture Fair IQ was 16.3 IQ points for the boys, but 35.25 for the girls. Among the adults the difference was much less pronounced, at 10.5 for the men and 8.67 for the women. This is graphically observed when plotted (figure 5).

Figure 5: Discrepancy between Full-scale and Culture Fair IQ scores

The Wechsler tests provide a verbal IQ score which gives us an indication of verbal comprehension, including the ability to use verbal skills in reasoning and solving problems, as well as the capacity to learn verbal material and apply knowledge in logical and structured ways. It is the verbal scores that correlate most closely with the majority of work which comprises normal education, including ability in conventional examinations. In making this comparison we see that the difference corrects itself to a large extent in later life, especially for the women.

Figure 6: Discrepancy between Verbal and Culture Fair IQ scores

The Dyslexia Index

It has always been considered that it is difficult to allocate a precise level to the effect of dyslexia, specifying exactly 'how much' someone is dyslexic. Many factors affect how we all learn and work including those which are highly individual and are different from person to person. However, an indication of severity is clearly very useful and parents often ask for such an indication. In 1997 Martin Turner developed a methodology for dealing with this, producing a 'Dyslexia Index' (Turner 1997). The Index places results on a scale running from 0 to 2 with the bands categorised as shown in table 1.

Table 1: Categorisations in the Dyslexia Index

We may consider this as a personal measure which indicates the level of severity of the practical effect of dyslexia for the particular individual. This is not the same as measuring the degree to which their dyslexia is 'bad', but provides more of an insight into the degree to which it interferes with what would have been their possible level of potential without it. The Index gives an indication of how severe the effect of dyslexia is in an individual's particular situation.

Of course, one of the major elements included in this calculation is the IQ figure, so it is possible that an erroneous IQ will also lead to the impression, through the Dyslexia Index, of the level of severity being less than it actually is. Some of the differences were quite pronounced, as may be seen on the following exemplars.

Example 1

Example 2

Example 3

Anyone with any sort of specific learning difficulty will find that during the years of learning the great amount of information involved in education, scores are likely to decrease. This is because performance gradually falls off as compared with peers and performance, as we have seen, is often the criterion for measurement. However, the effect is a matter of information load, not intelligence. Once the amount of information begins to decrease, the information can often be consolidated more and gradually performance returns to its true level. So it is possible to see a gradual falling-behind between the ages of about nine and sixteen, with a similar restoration between sixteen and the late twenties. Indeed, people in this position often find that by the time they are in their mid-twenties they are functioning at much the same level as others,- although frequently at the cost of a consistently higher mental effort.

The pattern of change can be seen on the diagram shown here. This effect is often especially pronounced where the first scores are obtained when an individual is very young, something which occurs for two reasons. One reason is that the younger the child the less acquired information there is to test and so overall scores are built up from relatively little data. The other reason concerns the fact that as we go below the age of around six years there is a decreasing amount of verbal skill to test and so scores are derived from largely non-verbal data. When the child begins to learn and use verbal skills, these may not be handled in the same way as the non-verbal ones.

As an individual reaches the point of GCSE studies the workload is higher and more complex than it has ever been so far. GCSE work involves a number of subjects, some of which appeal more than others and all work in different ways and require different skills at which everyone is supposed to be equally competent. Continuing to later studies such as 'A' levels the work requires a new degree of analytical and interpretative ability which involves manipulation of knowledge and data that may be particularly difficult for a dyslexic person. Although post-GCSE work is more likely to be in subjects which are more appealing to each individual and in which more aptitude is apparent, this is offset by the substantially greater depth demanded.

Scores often return to their earlier level as the individual's ability to utilise skills facilitates an improvement in knowledge and the scores begin once again to represent the likely true level of ability. However, the effects of workload and effort also affect examination performance, leading to the risk of results which may not properly represent the real level of understanding. It is for this reason that special arrangements have been developed for people with a wide range of difficulties, including dyslexia. This, of course, is a matter that should be based on evidence.

Understandings

I began by quoting Martin Tuner's comment:

it is necessary …… to use measurement resources to their utmost.
(Turner 1997)

It is also necessary to use the outcome of measurement properly, in ways that facilitate help for dyslexic people. It is surprisingly common to discover that dyslexic people (or parents) have not been provided with information in a way that informs them best. This is particularly illustrated in reports of psychological assessments by use of a level of conditional tense that renders the whole a very unclear message. Examples are:

"In verbal skills, Fred appears to be developing a reasonable foundation of competence although probably at a level which is somewhat below average for his age. He has, at best, a basic grasp of general knowledge."

It is extremely difficult to know what the writer of this gem actually intended the child's parents to discover from it.

"Freda presents as a pupil of reasonably high average intellectual abilities whose mastery of written language skills is likely to be affected by a moderate degree of dyslexic learning difficulties."

Here we see the phenomenon of the invented descriptor- 'dyslexic learning difficulties' is not a term likely to be understood as having a consistent and specific meaning.

It is also possible to see statements which may be perfectly accurate but are not especially informative.

"Boadicea is currently performing within the high average range of intellectual abilities. On the academic front it is clear that she is below expectations in the areas of spelling and reading comprehension."

This young lady's parents need to know what this situation means.

Schools are not always more informative or understanding when reporting to parents. The following extracts from recent school reports are interesting because the very situations they describe are exactly what happen to dyslexic people- but they are presented as if they were a deficiency in the children that they should put right.

"Progress and success in some areas is combined with inconsistency and poor attitude in others. A very determined and positive learning style is required."

It would be interesting to know what 'learning styles' this pupil has been taught.

"Marmaduke is not really prepared to put in the required effort to make the progress that is expected. He is not without ability, for his oral contributions show he has understood the skills being taught. He must develop a more mature attitude to his studies."

This shows no recognition of the oral/written discrepancy so often part of the dyslexic profile, but it clearly states that it is the child who is required to do something about it.

"Anastasia has had a positive year, disguised by a poor exam result."

This is as clear a definition of the effects of being dyslexic as anything.

As a final example, consider this more complete quotation:

"If anything positive has come out of this term it has been the realisation that something fundamental has to change if any degree of academic success is to be achieved.

Pandora's general level of blindness is so poor that I am amazed that she has been able to get as far and remain as positive. Daily she faces things that she cannot see, copy or comprehend and until she is able to operate at something close to normal vision for her age entrance into university must remain on the back-burner."

Actually, of course, it was not written like that. This would, naturally, be regarded as ridiculous. However, only five words have been changed: it originally read this way:

"If anything positive has come out of this term it has been the realisation that something fundamental has to change if any degree of academic success is to be achieved.

Pandora's general level of literacy is so poor that I am amazed that she has been able to get as far and remain as positive. Daily she faces things that she cannot read, spell or understand and until she is able to operate at something close to normal literacy for her age entrance into university must remain on the back-burner."

There are two routes which lead to support systems not being offered to dyslexic people. One is because f a lack of knowledge about the condition, involving those who either do not know how to provide help, or are unwilling to learn how to do it. The other is because of those who wish to pretend that dyslexic people do not have needs that are different to others- or at least, not much. This leads to concepts of artificial anti-discrimination procedures including concepts such as 'inclusion'. Everyone has his or her own views on the rightness or efficacy of such methodologies or policies, but it can carry over into areas that affect serious and important elements of provision. An example of this is seen in recent changes to the methods of applying for assistance in GCSE and 'A' level examinations.

Up to the early 1980s dyslexic candidates required a medical certificate for examination arrangements, called (in those days) 'concessions'. Then the BMA announced that the identification and specification of dyslexia was not within the realm of competence of medical professionals, so documentation was then required from psychologists. Before long I was being asked for copies of reports (remembering that this was before the Data Protection Act). It was at that point that I made my opinion known. In discussion with one of the examination Boards I stated that I was only prepared to supply technical documents if I could be assured that they would be read by a qualified person who would understand them. They couldn't, of course, and it was that discrepancy that led me to develop with them the 'extended certificate'. This contained a clear statement of the diagnosis, an outline of the data that gave rise to that and some recommendations.

The current arrangements require highly specific data, but they are as interesting for what they omit as what they include. They ask, as expected, for information on skills such as reading, spelling, writing and ability, However, they explicitly ask for scores on specified tests, including scores on 'timed test of reading'. This is not something for which tests have customarily been developed, especially at the age of GCSE and 'A' levels. Despite demanding this level of specificity, though, the new system does not require the psychologist to offer any diagnosis or recommendations. The data required relate entirely to literacy skills and the speed with which those skills are exercised. The new system is standardised and it is certainly bureaucratic. But it has led us back full circle to the late 1800s, for it relates entirely to literacy skills and nothing else, which is not an adequate methodology.

Conclusion

We still have to wait for the day when dyslexic people are supported and evaluated on the basis of what they are and what they can do, not what they are not and what they cannot do. "Accentuate the positive" should be our watchword. In this paper I have tried to show that we have begun to understand what this means and we have at least some of the tools to allow us to measure it. I hope we can continue to build on ever-expanding knowledge in a way that maximises the chances that our dyslexic children and colleagues have to show us what they can do. We will discover that our job is to give them wings- and when we do we shall find that they can fly!!

References

Cattell, R. B. (1940). A culture free intelligence test. I. Journal of Educational Psychology, 31, 161-180.

Cattell, R. B. (1941). A culture free intelligence test. II. Evaluation of cultural influences on test performance. Journal of Educational Psychology, 32, 81-100.

Déjerine, J. (1892). Contribution à l'étude anatomo-pathologique et clinique des différentes variétés de cécité verbale. Memo. Soc. Biol, 27 (February).

Hales, G. W. (1994). The human aspects of dyslexia. In G Hales (Ed) Dyslexia Matters. London: Whurr

Hinshelwood, J. (1895). Letter-, word- and mind-blindness. The Lancet, 21 (December).

Kershaw, J. (1974). People with Dyslexia. Report of a Working Party commissioned by the British Council for the Rehabilitation of the Disabled. London: British Council for the Rehabilitation of the Disabled.

Snowden, P, 1st Viscount. (1934). An Autobiography

Turner, M. (1997). Psychological Assessment of Dyslexia. London: Whurr.

Dr Gerald Hales is a Chartered Psychologist, a Clinical Hypnotherapist, a Master Practitioner of Neuro-Linguistic Programming and an Allergy Therapist. He has expertise in Educational, Health and Occupational areas of psychology, is a member of the American Psychological Association and the British Psychological Society- in which he is an Associate Fellow- and he is a member of Divisions of Educational, Health and Counselling Psychology as well as holding the Statements of Competence in Occupational Testing. He is a Fellow of the Counselling and Psychotherapy Society, a Fellow of the Hypnotherapy Society and a Member of the New York Academy of Sciences.

He is a qualified and experienced teacher and has taught at every level from Reception to PhD; he was for twenty-five years a Research Fellow of the Open University and is a consultant at university level. He is widely experienced in the assessment and diagnosis of learning difficulties and dyslexia, both with children and adults, seeing patients and carrying out training in many parts of the world. His books include Dyslexia Matters and Beyond Disability as well as contributions to Dyslexia- Successful Inclusion in the Secondary School and Dyslexia and Stress.

Dr Hales' Practice is a supporting Corporate Member of the British Dyslexia Association and he is a Department of Health Independent Provider 8FH07. Visit the web site at www.drhales.co.uk for the full range of professional services or call 01908 366221.

Disclaimer: all the abstracts presented here have satisfied the academic committee as appropriate for presentation at an international conference. However, the material reflects the views of the authors, not necessarily those of the academic committee or the BDA. No endorsement of any approach, product or service is intended or implied.

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