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ISSN 1368-2105 (print) ISSN 2045-6174 (online)

Winter 2010

Best of PALS A parental programme Whos next? A prioritisation tool Winning ways Are we having fun yet?

How I encourage community participation

Journal Club Qualitative research Service development Lets CHAT My Top Resources Collaboration PLUS...heres one I made brief...reader offers

Reader offers

Win Talking About Conversation!

Do you work with secondary aged pupils who need support to become a good conversational partner? Black Sheep Press has released Talking About Conversation, a pack to illustrate common breakdowns in conversation and possible repair strategies, and is offering a FREE copy to a winning reader of Speech & Language Therapy in Practice. The pack depicts 14 common problems such as starting a conversation, turn taking and staying on topic. Each large scenario picture is accompanied by four associated smaller pictures showing a variety of repair strategies. Some are appropriate and some are not. Instructions, a suggested script for presenting each scenario, and role play extension activities are included. Talking about Conversation usually costs 24.00 + VAT but you can enter the draw for a free copy by emailing your name and address, with Speechmag Conversations offer in the subject line, by 25th January. The winner will be notified by 1st February 2011.

Its a Christmas cracker!

Singing Hands have released two new DVDs with Makaton signs and symbols in time for Christmas and are giving away a FREE set in the new year to a lucky reader of Speech & Language Therapy in Practice. Suzanne and Tracy of Singing Hands aim to introduce you to the world of signs through songs, rhymes, stories and games. Its Signing Time 2 is their second DVD of nursery rhymes and action songs. It features Singing Hands tutors and over 300 children performing songs for babies, toddlers and schoolchildren. These include Miss Polly had a Dolly, the Pirate Song and I Hear Thunder. The duo have also filmed the first Christmas DVD collection to feature Makaton signs and symbols. It has Christmas carols such as Away in a Manger and Silent Night, as well as festive songs like Frosty the Snowman and Christmas Alphabet. The DVDs retail at 12.99 each plus p&p. For your chance to win a free set, email info@ singinghands. with Speechmag Singing Hands DVDs offer in the subject line by 25th January. The winner will hear by 1st February 2011. For more information on Singing Hands and their online shop, see

Also win Friendship Terrace!

Fitzroy First, Bragging Bradley, Manisha Mine and Rough Ryan are among the 10 residents of Friendship Terrace. Black Sheep Press is also offering a FREE copy of this new series of sessions to reflect on and teach friendship skills (usual price 35.00 + VAT). The publisher says it is especially relevant for children who find making and keeping friendships difficult, and for children with an autistic spectrum disorder. Author Sue Nicholls has a particular interest in developing childrens emotional literacy, and intends this pack to help those aged from 4-12 years recognise friendship blockers and builders, either in individual or group settings. Each story has discussion questions, short of time and extra time alternatives and activity suggestions. To enter, email your name and address with Speechmag Friendship in the subject line to by 25th January. The winner will be notified by 1st February. For details of Black Sheep Press resources go to

Win NDP3 now in colour!

The Nuffield Centre Dyspraxia Programme, 3rd edition (NDP3) is a comprehensive assessment and therapy package for children with severe speech disorders. To mark the release of the NDP3 in colour, its publisher is offering a FREE copy to a lucky reader of Speech & Language Therapy in Practice. NDP3s aim is to provide therapists with the flexibility, strategies and activities they need to successfully manage any child with a severe speech disorder. The resource covers all stages from pre-speech motor skills to connected speech. In addition to a therapy manual, photocopiable therapy worksheets and a photocopiable assessment procedure, NDP3 now includes 1,912 colour Therapy cards and 6 colour Assessment flip-books. NDP3 Complete in colour normally costs 209, with extra sets of colour Therapy cards (79) and Assessment flip-books (69) available separately. For your chance to win a free copy of NDP3 Complete, email your name and address, with Speechmag NDP3 offer in the subject line, to by 25th January. The winner will be notified by 1st February 2011. For more information on NDP3 and the forthcoming NDP3 Speech Builder, visit

Winter 2010 (publication date 30 November 2010) ISSN 1368-2105 (Print) ISSN 2045-6174 (Online)

27 COVER STORY: HOW I ENCOURAGE COMMUNITY PARTICIPATION (1) ANY VOLUNTEERS? ...until recently, volunteering by people with aphasia has not been given great attention. It is not widely considered as an option either in rehabilitation or in living a more fulfilling life with aphasia . Following a pilot study of the Personal Development Programme, Gill Pearl and Gill Jackson ask us how we can engage and support people to do more with aphasia. (2) ACTIONS NOT WORDS We felt that a period of volunteer work would give Colin a good experience of what it would be like to return to regular work but would also allow him to be flexible with his hours and to build up his skills and confidence slowly. Speech and language therapist Rebecca Allwood and occupational therapist Jane Terry reflect on the factors that enabled Colin to embark on a journey back to work in spite of aphasia.

Published by: Avril Nicoll, 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 email: Printing: Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT Editor Avril Nicoll, Speech and Language Therapist

Photo of Joan Morris, Gill Pearl and David Morris by Martin Stembridge,

INSIDE FRONT READER OFFERS Lots of offers for you in the Winter 10 issue! NDP3 Complete in colour; Talking About Conversations; Friendship Terrace; Its Signing Time 2 / Its a Christmas Cracker DVDs. 4 TRAINING One of the aspects of the programme most valued by those attending was the opportunity to share experiences and support with other parents in similar circumstances. Judy Crow and Diana Finley explain why and how they developed the PALS (Parents, Aspergers/ Autism, Language and Social Skills) programme. 6 IN BRIEF Pat Brookes on the development of easier self-referral for people who stammer, and Amy Jensen on being a member of Communication Therapy International. 8 RESOURCES / SPEECHMAG 9 PRIORITISATION ...we feel it is a useful, practical process, based on professional guidelines, which will speed up and guide what can be a stressful and challenging aspect of our work. Nicola Allan and Claire Cahoon have developed a two stage tool to support prioritisation of new and existing clients with dysphagia on acute wards.

12 WINNING WAYS Many of the schools I have visited are excellent, but - perhaps because of paperwork, Ofsted inspections, or the demand to demonstrate progress things often seem very serious. In this exploration of the use of humour, Keith Park hopes to inspire you to spread a little happiness as you go by... 15 HERES ONE I MADE EARLIER Alison Roberts with a low cost therapy idea - Vocabulary workbook. 15 EDITORS CHOICE 16 REVIEWS Signing, games, emotion and behaviour, voice care, PSHE, special needs, challenging behaviour, language psychology, literacy, software solutions. 18 JOURNAL CLUB (2): QUALITATIVE RESEARCH Qualitative methods are the gold standard for exploring and creating meaning from participants subjective experiences, and for gaining insight into phenomena that are ill-defined or poorly understood. Jennifer Reids series aims to take the mystery out of critically appraising different types of journal articles. Here, she looks at qualitative research.

22 SERVICE DEVELOPMENT Our overall aim is to enable those involved with children in the early years to work together to maximise childrens language and social development in order to promote later literacy and communication skills. NHS Forth Valleys Communication Help and Awareness Team (CHAT) introduced and evaluated a Whole Nursery Narrative Approach in areas of disadvantage, with positive outcomes for language development, school readiness and curricular impact. 26 RESOURCE REVIEWS In-depth reviews of WellComm: A Speech and Language Toolkit for the Early Years; Lets Sign BSL 36 MY TOP RESOURCES I have been passionate about Practice Development throughout my career, and fascinated by how we transfer evidence into practice. Karen Krawczyks top resources and career path show her interest in collaborating with other colleagues and professions.

Subscriptions and advertising: Tel / fax 01561 377415

Avril Nicoll 2010 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site.

Speech & Language Therapy in Practice can be found on EBSCOhost research databases.



Lets dance
Niall Cullen, who runs a not-for-profit integrated physical theatre and contemporary dance company, is in line for an award that celebrates people who have taken steps to establish a sustainable business in spite of great personal challenges. Niall has been a theatre performer since the age of eight. He developed difficulties with motor functioning, communication, reading, writing and vision as a result of Moyamoya Disease. This inspired him to set up PrefaceMorn, whose work all involves ablebodied and disabled people.; P1242560619417

The government-backed National Year of Communication in 2011 has been launched as Hello. The year aims to make childrens communication skills a priority in homes and schools across England. The Communication Trust, a group of 39 voluntary and community sector organisations, is managing and delivering it in collaboration with Communication Champion Jean Gross. Speech & Language Therapy in Practice editor Avril Nicoll summarises the key messages for speech and language therapists from the launch reception at the House of Commons: Jean Gross asks us to concentrate on measuring and showing the impact of our intervention, for example by comparing two settings where that is the only difference. There are times when we just have to make it happen in spite of organisational and financial barriers. As an example, parent activist Amanda Ryalls praised speech and language therapists Lisa Smith and Debbie Turtle for seeing the possibilities and making it possible for her son to attend outreach communication classes. Minister Sarah Teather is keen for us to get involved in the progress of the Green Paper to ensure the SEN system becomes more transparent and family friendly, less adversarial and offers greater choice. Christopher Pike, an aspiring politician with a diagnosis of Asperger Syndrome, made clear we need to use fewer acronyms and less jargon to include people with speech, language and communication needs. We should encourage parents of children with speech, language and communication needs particularly those who, in their day jobs, are familiar with the system and campaigning to get involved as they can make a big difference to raising awareness at the right level of what needs to be done and how we can provide better services.

Hello to 2011

International Day of Persons with Disability

The chief executive of UK based charity World Emergency Relief is calling for the International Day of Persons with Disability on 3 December to act as a reminder of the particular difficulties faced by those living with disability in the developing world. Alex Haxton says, Living with disability is often a forgotten issue in overseas aid, but 75 per cent of people with disabilities are living in the developing world. Inadequate provision means that these people are often the poorest of the poor. World Emergency Relief wants to draw particular attention to Guatemala. Fourteen per cent of the population have a disability compared with a worldwide average of 10 per cent. This is believed to be due to a combination of a long-running civil war, high gun crime, toxins linked to diet and decreasing infant mortality. There is almost no government help, and many people with Picture courtesy of Fotokids, Guatemala disabilities live in isolation and severe poverty. Eight year old Dayri Santos (pictured) attends special education classes and receives physiotherapy through the Guatemalian non-governmental organistion Transitions. World Emergency Relief has supported this home-grown project since 2002, and commissioned a group of young photographers from the Guatemalan Foundation Fotokids to tell its story. As well as working to change prevailing negative attitudes towards disabled people, Transitions provides special education to children with mental disabilities and rehabilitation for both adults and children with physical disabilities.;

Reader offer winners

Hinton House Publishers has sent off copies of The Communication Toolkit: Assessing & Developing Social Communication Skills in Children & Adolescents to three readers of Speech & Language Therapy in Practice. The lucky winners of the Autumn 10 issue reader offer were Andrea Arnold, Catherine Byrne and Sarah Chandler. Sarah Miles of Hinton House would be happy to hear from any speech and language therapists who are interested in publishing resources related to autism spectrum disorder or education. Tel. 01280 822557, (See also the Winter 10 issues reader offers on the inside front cover.)

Award deadline

This CGI image is of the performance space in the new National Centre for Arts Access and Inclusion, due to open in Essex in May 2011. Run by Zinc, the social enterprise formerly known as Theatre Resource, the centre will be fully accessible and include accommodation, exhibition facilities and teaching spaces.

The deadline for entries to the Advancing Healthcare Awards is 7 January 2011. The awards are for allied health professionals and healthcare scientists across the UK to recognise innovative practice that makes a difference to clients lives. Each shortlisted project team is entitled to a free place on a GateHouse one day course. Winners in some categories will also receive a grant towards their personal and professional development. Categories relate to leadership, improving quality, integration and learning and development. Judging takes place on 23 February, with the awards ceremony and lunch on 8 April.



Text-to-speech aid gives wonderful feeling

A company which produces text-to-speech communication aids has donated its latest product to the founder of an online virtual reality nightclub for people with disabilities. Simon Stevens, who was born with cerebral palsy, received a Lightwriter SL40 Connect from Toby Churchill Ltd at the companys recent Open Day. Simon is a full-time disability consultant, trainer and activist, and founder of the Wheelies Nightclub in Second Life. In his presentation to the assembled users, families and speech and language therapists, he explained that he had been using a Lightwriter for the last year. He said, it is a wonderful feeling to realise for the first time in my life I can say whatever I want, to whoever I want, when I want, without being reliant on people. Simon is pictured with Toby Churchill chairman David Collison. David said, Not only do we manufacture here, we also have our own research and development team which works to design communication aids. We are particularly pleased to give one of our latest Lightwriters to Simon who already uses our technology, and look forward to receiving his feedback.;


Practical connections
ne of the most exciting aspects of editing this magazine is seeing shifts in thinking, evidence and policy come alive in practice. The advantage of Speech & Language Therapy in Practice articles is that authors can explain in some depth why and how they have gone about making changes, and what has happened as a result. Like critical appraisal of qualitative research (Journal Club, p.18), it is important to consider where you share circumstances with each author and can use their ideas, and where you can use their experience as inspiration to reflect on your situation and develop your own solutions. Nicola Allan & Claire Cahoon (p.9) used a previous article as a starting point, and adapted and customised a prioritisation tool for their own setting. Judy Crow & Diana Finley (p.4) were inspired by an existing and successful parent group programme to grow their own version for use as children get older and relationships change. The aspect most valued by the parents was the opportunity the group offered to spend time with others in a similar situation. Putting people in touch with each other so they can share experiences and knowledge is also the strength behind Communication Therapy International (p.7). Working with other professionals is a core part of what we do, and Karen Krawczyk (p.36) is passionate about the difference this synergy makes to the outcome for our clients. Pat Brookes (p.6) linked up with her IT department to use new technology to make it easier for clients who stammer to self-refer to speech and language therapy. As she shows, when we need help to get something done, it is extremely useful to know a (wo)man who can. Our professional networks and resources can be a valuable addition to a clients own for increasing their opportunities in spite of communication difficulties (Editors choice p.15). Using a goal setting approach, Rebecca Allwood & Jane Terry (p.30) worked with their client Colin to get him into a suitable voluntary position as a stepping stone back to paid employment. Gill Pearl & Gill Jackson (p.27) also enable clients with aphasia to be included in their communities as volunteers, and to experience the health and social benefits of increased activity and participation. The Communication Help and Awareness Team (CHAT) (p.22) get out into the community too, working in nursery settings in areas of social and economic deprivation to improve the life chances of hard to reach populations. As the pictures from one of the nurseries show, our job can be great fun - but do we enjoy it as much as we could? With his exploration of the use of humour Keith Park (p.12) encourages us to make having fun an integral part of our work rather than a chance by-product. Happy reading!

Stammering awareness appeal

The British Stammering Association has launched an appeal for 100,000 to run a stammering awareness campaign. Chair Leys Geddes says this is necessary because people who stammer are virtually invisible and inaudible. He wants to challenge the misconceptions, inequalities and bullying associated with the condition amd increase access to early intervention and speech and language therapy. To find out more about the appeal and how you can help raise awareness, see

Evidence based practice for head and neck

The leaders of a multidisciplinary masterclass-based module in head and neck cancer are encouraging speech and language therapists to apply. Macmillan head and neck cancer nurse specialist Libby Potter started the module in collaboration with Principal Lecturer in Cancer Care Pat Turton two years ago. She says, Participants have included cancer nurse specialists, speech and language therapists, occupational therapists, dietitians and community nurses. The course has enabled students to be supported to make safe and supervised changes in practice, and to have improved patient care. In our Autumn 10 issue (p.24-27), Morwenna White-Thomson investigated how the involvement of speech and language therapists might help to improve the success rate of tracheoesophageal puncture closure. Her article was based on a project undertaken as the Evidencing Work-Based Learning part of the University of the West of England course. This element aims to ensure that best practice is translated into good patient care. Examples of other assignments include developing tracheostomy competencies and a mouth care protocol. Further information from; see also Events p.35.

Post-registration consultation

Do you think post-registration qualifications should be annotated on the Health Professions Council Register? The Health Professions Council is consulting on five draft criteria. The consultation closes on 1 February 2011.


Best of PALS
Judy Crow and Diana Finley explain how they developed the PALS (Parents, Aspergers/Autism, Language and Social Skills) programme to meet a clinical need for better support, information and useful strategies for parents of older and more verbally competent children with social and communication difficulties.
READ THIS IF YOU WANT TO ADDRESS A GAP IN YOUR SERVICE OFFER GROUP TRAINING FACILITATE PEER SUPPORT or referred by colleagues in CAMHS (Child & Adolescent Mental Health Services). All children in the early programmes attended mainstream schools. Subsequently, colleagues working in special education have indicated that many families they encounter would also benefit. We do feel the structures and principles of PALS could be usefully adapted by those wishing to develop a programme for parents of children with a range of differing needs (such as moderate learning difficulties or specific language impairment) by altering the content and emphasis as appropriate. However, organisers should not be tempted to include families with younger children, or those with core autism, as the PALS programme does not meet their needs. We found that that the optimum number of participant families was 8 to 14 but it is perfectly possible to run a course with smaller numbers, for example in a rural area. The minimum number of families to make a viable group is probably four to six, taking into account occasional inevitable absences and the need for consistent members to build a group dynamic. Conversely, including too many families may result in insufficient time to give each the personal attention and support needed. Our programmes were initially presented by both of us as experienced therapists, but as time went on we found that one therapist with an assistant or student was equally effective. Our pilot programmes took place in the early evening to allow access to working parents, but location and times are flexible. We found a weekly session of two hours about right, with a 15 minute break. A Weekend Workshop format could work equally well.

Judy Crow

Diana Finley

s consultant speech and language therapists specialising in autism spectrum disorders, we have a background in delivering the Hanen More Than Words programme (Sussman, 1999) over many years. This has been successful in helping parents develop positive strategies to facilitate their young childrens development of play, communication and interaction skills. Parents also value the opportunity to meet other families experiencing similar difficulties. However it became clear to us that there was a need for more advanced strategies as the children grew. We did not feel More Than Words was suitable for parents of older and more recently identified children, as it is designed for pre-school children and teaches early communication and play strategies. The parents of older and more verbally competent children nevertheless needed some specific support and information. To meet this need we developed the PALS programme. It is specifically designed for parents of children between 6 and 12 years of age who have Asperger Syndrome, highfunctioning autism, semantic-pragmatic disorder, PDD-NOS (Pervasive Developmental disorder Not otherwise specified) or other complex social and communication difficulty. We wanted it to be equally suitable for those families who had previously attended an early

intervention course, or those whose child had been newly identified at a later stage. We offered two pilot programmes in Northumberland. These reached 28 families and were extremely well received. We therefore felt confident in offering this programme on a regular basis, and also encouraging other professionals to participate. We hope that any specialist speech and language therapist who has experience of working with parent programmes or wishes to develop this area of service delivery will find this new programme of interest. Equally, other professionals who have considerable experience both of autism and working with families may find it helpful and bring valuable insights of their own to the programme. The programme has three main aims: 1. To provide knowledge and insight for parents into their childs difficulties with language and social interaction 2. To provide strategies to help with these difficulties 3. To bring together groups of parents who are facing similar difficulties and facilitate their mutual exchange of experiences and support. The participating families all had a child who fulfilled our age and diagnostic criteria. Families were recruited from our own caseloads and communication clinics

Time for sharing

One of the aspects of the programme most valued by those attending was the opportunity to share experiences and support with other parents in similar circumstances, and it was important that we left time for this to occur. Similarly, parents often raised issues spontaneously during the course of these sessions, and we found it helpful to allow ourselves to respond to these naturally rather


Figure 1 Programme Content 1 Part 1 Introduction Autism, Aspergers and the range of the spectrum Part 2: Theory of Mind What is it, why and how do we use it, can we teach it? 2 Obsessions and Routines What do the children get out of them? We cant eliminate them all which can we live with; which are unacceptable? Strategies to Help 3 Language Language development in autism spectrum disorder, how does it differ from the norm? Specific language problems Strategies to help 4 Visual Supporters What are they, how and why do we all use them? Information on a range of visual supporters; how they can help Social Stories (Gray & White, 2001) 5 Making and Sustaining Friends (see figure 2) What is friendship? Why do we value it? What do our children need in terms of friendship? Strategies to help 6 Final Session Part 1 Discussion on topics of choice (issues parents have raised during the programme), for example: When to tell a child about his autism spectrum disorder What to tell other people, and when. Anxiety in Aspergers Syndrome Part 2 Guest Speaker, such as Consultant in Child and Adolescent Mental Health Child Clinical psychologist Educational psychologist Questions/Discussion Evaluation and Information Packs Figure 2 Sample Session Content Session 5 Making and Sustaining Friends What is friendship? What does it mean to us? Why do we value it? What does it mean to our special children? What do the children need in terms of friendship? Different ages different needs Different types of friendship Who needs what? How do adults make friends? And typically developing children? What makes us like our friends? How can we support our childrens need for friends? Strategies for different stages Turning obsessions into opportunities Special groups and clubs Parents groups Perhaps the most important lesson accepting the childs need to be sometimes alone and not to have friends. Loneliness is not always the same as wanting to be on your own. Figure 3 Which topics did parents find most helpful? 16 14 12 10 8 6 4 2 0 Autism and Obsessions theory of and mind routines Discussion Making Language Using with other friends development visual and use supporters parents

than sticking rigidly to a planned agenda. For example, we found that parents frequently raised concerns that their child might be vulnerable to bullying. We were able to explore the nature and perceptions of bullying and discuss as a group how to address it. As trainers we found it important to use sensitive listening skills and to be alert to the underlying anxieties that parents might be expressing. For the style of presentation, we took account of factors that are believed to make learning most effective for adults (Lieb, 1991). These include: Drawing on own experience Being prepared for the topic / building awareness Providing clear information Seeing the relevance and application of the information to own situation Providing practical strategies to help. For these reasons we used a Ready, Steady, Go approach: READY (being prepared for the topic and building awareness)

STEADY (giving clear information) GO (seeing the relevance and application, strategies to help). Each session therefore consisted of a mixture of personal experiences from parents, direct teaching and then discussion of strategies. The programme content covers six sessions (figure 1). We found session 5 on Making and Sustaining Friends (figure 2) particularly moving, as parents gained awareness of the differing types of friendship, and their childs need for personal space. Although the running order of the programme is generally flexible, we found it was important to have this particular session towards the end, when members of the group were beginning to build trust with each other and we knew them well. The dynamic of every group differs; some parents can be very vociferous, assertive or needy, whilst others require encouragement to contribute. Trainers again need to be flexible and alert to ensure that everyone has an equal opportunity to voice their concerns or views.

Usefulness evaluated

We evaluated the usefulness of the PALS programme by seeking the views of all parents who attended via a questionnaire. Twenty eight families attended our first two programmes and 22 questionnaires were returned. Overall average attendance was five out of the six sessions. The questionnaire included general and specific queries and the feedback was generally extremely positive. Questionnaires were anonymous and we had asked parents to be as honest and constructive as possible in their feedback. We explained that, as this was a pilot, their views would help to shape future content of the programme. All 22 of the respondents agreed they found the style of presentation helpful and said that they would recommend PALS to other families. Figure 3 shows the topics the responding parents said they found most helpful. We asked parents to indicate as many topics as they wished, without hierarchy. Specific feedback included:


It was great to meet other people who were going through similar problems. I cannot over emphasise how welcome it has been to hear discussion on practical and pragmatic things that are clearly relevant and which will help us. I think the course gave us time to take time out of our normal situation and focus on our daughter and things we could do to support her in her daily life. [In the past] We were given the diagnosis and told to read Tony Attwoods book [Attwood, 2006]. That is all the information we were given. This programme has been invaluable in helping us understand our child and his difficulties. I wish his teacher had the same level of knowledge and understanding. We have both recently left the NHS but offer training workshops to enable other staff and professionals to deliver the PALS programme. We have also had a book published (Crow & Finley, 2009) which provides detailed session plans and teaching materials to enable others to present the programme. We would like to follow up future programmes with more detailed assessment and evaluation of benefits to children, families and service providers. We would be interested to hear from others who would like SLTP to contribute to this. Judy Crow (email and Diana Finley (email diana.finley@virginmedia. com) are consultant speech and language therapists who developed the PALS programme while working for Northumberland NHS Care Trust. Both are now in the independent sector.
References Attwood, T. (2006) The Complete Guide to Aspergers Syndrome. London: Jessica Kingsley. Crow, J. & Finley, D. (2009) PALS. Parents Aspergers/ Autism, Language and Social Skills. Chesterfield: SHU (Sheffield Hallam University) / Winslow Press. Gray, C. & White, A.L. (2001) My Social Stories Book. London: Jessica Kingsley. Lieb, S. (1991) Principles of adult Learning. VISION. Available at: committees/FacDevCom/guidebk/teachtip/ adults-2.htm. (Accessed 6 October, 2010). Sussman, F. (1999) More than Words: Helping Parents Promote Communication and Social Skills in Children with Autism Spectrum Disorder. Toronto: The Hanen Centre.

In Brief...
Easier self-referral for people who stammer
Pat Brookes on how a speech and language therapy department is working with service users to become more stammer-friendly by developing web-based information and referral. have been working with adults who stammer since 2000. Sometimes clients would tell me about their experiences of difficulties in getting a referral for therapy. Most assumed that they needed to be referred by their GP. The process of phoning for an appointment or talking to the receptionist in a crowded waiting room and then explaining their difficulty to the doctor felt very daunting to many of them. Those who braved this process did not all find their GP very helpful. Some were given incorrect information, even that there was no provision, so we wondered how many potential clients are lost at this point. Although we offer open referral for fluency problems, potential clients had few ways of knowing this and, if they did, the normal option of making a phone call to a complete stranger, or answering machine, was far from stammer-friendly. The process was putting unnecessary barriers in the way of people who needed help and advice and failing to fulfil the Royal College of Speech & Language Therapists requirement: Referral procedures will ensure that all individuals have access to the service, irrespective of age, language, gender, race, presenting communication difficulty or location (RCSLT, 2006, p.190). In 2008 Anna Shepherd, a student speech and language therapist, undertook a serviceuser consultation about access to and value of speech and language therapy for adults who stammer. She interviewed nine people who had received speech and language therapy. The participants in her study valued the speech and language therapy that they had received, but thought that the speech and language therapy service did not inform the public about the help that was available, and that referral was difficult. Anna reported, All participants believed that the SLT department should advertise their services better including alternative ways to access SLT, such as an email service and a direct telephone number for the SLT department. We decided to put information about the fluency service on the PCT website, including alternative means of referral. The communications and IT department were enthusiastic about the idea. We linked up with Katie Pringle, Communications special project officer, who implemented our ideas.

supported by

We decided that the website needed to include information about the whole service for people who stammer from preschool to adult. The design consisted of a short introductory page with quotes from service users and four options aimed at the different age groups. On each page there is a brief description of the difficulties that stammering can cause for that age group, a description of what the speech and language therapy service can provide, and ways to self-refer. There are also links to other helpful organisations such as the British Stammering Association and the Michael Palin Centre. Two service users reviewed and agreed the wording and layout. The information package was approved by speech and language therapy managers, IT and information governance. We produced leaflets for adults and for teenagers with the same information as on the website to encourage self-referral. The website went live in the autumn of 2008. Adults on my current caseload who stammer looked at the website and confirmed that it was easy to access (by searching for North Tyneside stammering) and included the information that they thought was necessary. Comments included: Really liked the matter of fact approach... delighted to see it up and running and so easy to access, too has all the details for each age group. The leaflets for teenagers were sent to high schools and colleges in North Tyneside. The information about self-referral was publicised in an article in our local paper, the Newcastle Evening Chronicle, in March 2009. Its content was largely based on ideas from the adults who stammer who attended an evening therapy group.

To comment on the impact this article has had on you, see guidance for Speech & Language Therapy in Practices Critical Friends at www.

Unexpected bonus

I normally receive about 12 referrals a year for adults who stammer. This year 4 of the initial enquiries that I received were via email and text. An unexpected bonus for service users was that adults on my caseload have found it very useful to use text and email for arranging or changing appointments, sharing news about issues relating to stammering and discussing ideas. I plan to inform GPs about the website so that, if people come to them asking about speech and language therapy for stammering, they have easy access to accurate information for their patients. Pat Brookes is a speech and language therapist and specialist in stammering with NHS Newcastle and North Tyneside Community Health.



Email In Brief entries to One lucky contributor in each issue receives 50 in vouchers from Speechmark (, a company which publishes a wide range of practical resources for health and education professionals.
Resource You can access the website at: community-services/speech-and-languagetherapy/stammering Acknowledgements I am very grateful to the following people who have helped me in developing the service to adults who stammer in this area and in writing this article: adult clients; Rose Hilton, Speech and Language Therapy Lead, North Tyneside PCT; Katie Pringle, Communications special project officer NHS North of Tyne; Anna Shepherd, Speech and Language Therapist, Rotherham PCT. References Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Shepherd, A. (2008) The Views of Service Users and Potential Service Users of Speech and Language Therapy for Adults that Stammer. Unpublished student project.

Communication Therapy International - whats that?

Amy Jensen explains why she is an enthusiastic member of the networking organisation Communication Therapy International.

any low and middle income countries have limited services for people with communication disabilities. Often services are provided by people with very little training in the area and, where specialists exist, they are likely to be working in the main cities with the most affluent people. Large numbers of people with a communication disability receive no specialist support. Communication Therapy International does what it says on the tin: its an international network of people with an interest in communication therapy. It was set up in 1990 by a group of British speech and language therapists who had experience of working in developing countries. They recognised that speech and language therapists were not the only people who might help those with communication disabilities; in many places this work is carried out by interested and motivated teachers, doctors, nurses, community disability workers and others. Often they do a great job, with very limited resources and few opportunities to gain extra information and ideas about practical ways to help. Although many techniques and approaches used by speech and language therapists in well-resourced countries can be

applied effectively elsewhere, it often takes a bit of imagination and adaptability to be helpful in a different cultural context. So, Communication Therapy International acts as an information and support network. It serves as a forum for sharing knowledge, experience, resources and the low-tech, practical know-how which can make a difference to peoples lives. Particular emphasis is placed on countries where there is a shortage of resources for people with communication disabilities. We are keen not to restrict our membership to qualified specialists, and have a diverse list which includes speech and language therapists, doctors, teachers, community development workers, and people with a communication disability along with their parents and carers. Many of our members fall into one of two categories. Over half are people working in their own countries either for nongovernmental organisations (NGOs) or for government health or education services, providing services for disabled adults or children. They may have had related specialist training or learning on the job. For them it is useful to have contact with people in other regions who face similar challenges, and to receive information about new and useful approaches and resources. The other big membership group is people from well-resourced regions such as the UK, USA and Australia who are interested in helping to develop services outside their own country. Communication Therapy International can help them to think about how their specialist knowledge can best be used in other settings. Transferring skills and knowledge from one place to another is often more difficult and complicated than people first imagine! Sharing ideas and experiences is useful and saves people from repeating mistakes or reinventing the wheel.

Challenges and benefits

Most of the information exchange happens via individuals making links by email or letter. Communication Therapy International meets once a year in the UK. Members attend a study day and annual general meeting, and have the opportunity to network in person. Our 2009 study day focused on overseas projects, their inherent challenges and benefits, and how to address some of the issues that arise from shorter term projects. Melanie Adams examined the advantages and disadvantages of different models of project work, and these were explored in more detail by a number of speakers with experience of different overseas projects. Debbie Sell introduced the Sri Lankan multidisciplinary Cleft Lip and Palate Project,

set up to provide treatment, teaching and research. She explored some of the challenges of transferring skills to a team with no speech and language therapist, expanding speech and language therapy services in the context of a developing health field, and promoting self-sufficiency. Bethan Hope and Peter Smith from the Jack Tizard Special School reported on their visit to two special schools in Uganda, which offered them an understanding of how best to develop useful and rewarding links between the schools. The audience was also introduced to City Universitys ongoing project in Cambodia, which is visited annually for three months by a group of newly qualified speech and language therapists. The challenges of measuring effectiveness and increasing sustainability in the context of such short visits was discussed. This interesting and informative study day was rounded off with a lively debate for and against the motion, Short-term projects are no more than a glorified holiday. Our annual study days take place every November and are open to non-members, with members paying a reduced price. As Communication Therapy International is a non-profit making organisation, all membership fees are used to cover overheads, run study days and produce resources. If you are interested in joining, benefits include: access to the membership directory, and the ability to interact and collaborate with other members and share knowledge and experiences the opportunity to make a positive impact by letting other members profit from the challenges youve faced, the experience youve gained and the lessons youve learned the ability to support the publication of our newsletter and development of our website by writing an article about your work participation in our networking ideas such as the Buddy system information about international jobs or volunteer opportunities information about upcoming events and activities. We welcome contact from anyone interested in finding out more about Communication Therapy International, email Speech and language therapist Amy Jensen has volunteered and worked overseas and is currently a research assistant at Strathclyde University. Resource The Communication Therapy International website is at



Animal education charity the Society for Companion Animal Studies (SCAS) provides training for healthcare professionals about animal-assisted intervention therapy.

The November issue of online newsletter Stroke Matters includes an article on internet therapy. Talk to Your Baby Conference 2010 report resources/2747_talk_to_your_baby_2010_ conference_report_smile_talk_and_listen_ doing_our_best_for_babies The Talk about Autism campaign is one strand of TalkTalks sponsorship of TreeHouse, the natioanl charity for autism education. Black Sheep Press has released a new pack of picture resources for conjunctions (30). Products from the Sensory Toy Warehouse as they have never been seen before. Report by Dr Anne J. Hill on the potential application of telerehabilitation to adult rehabilitation services in Scotland (Source: Propeller Multimedia). Revivo, an online speech program aimed at people with aphasia. Ten day trial available. Connects ten top tips for talking to people with aphasia, free download at A non-profit website that creates captions for YouTube videos suitable for people who speak a different language or are deaf. The Authors Licensing and Collecting Society (ALCS) holds money in trust for people who have written books and journal articles which have then been photocopied or scanned by schools, universities, businesses or public sector bodies.

Members area
Back issues and exclusive extras. For a reminder of your user name and password, email New! Spidergram explained by Alison Roberts (p.15), Extras. New! Print off the qualitative research framework document by Jennifer Reid (p.18) from .

Original articles (

Go forth and influence (Winter 10, E1-E4) Speech & Language Therapy in Practice Editor Avril Nicoll reports on the innovative practice showcased at the RCSLT (Royal College of Speech & Language Therapists) Scotland Study Day in Perth on 26th August 2010, where delegates were also urged to give voice to people with speech, language,communication and swallowing needs. Coming very soon! (Winter 10, E5-E7) You have been asked to provide a second opinion for the parents of a five year old boy who has profound physical and cognitive disabilities... Jane Handley takes a case based approach to ethical reasoning inspired by a series of workshops in her final year as a speech and language therapy student.

Reprinted articles (

Matthews, C. & Leslie, P. (2009) This House Believes in e-stim, Speech & Language Therapy in Practice Autumn, pp.16-18. Newton, A, & Priestnall, L. (2008) Decision time, Speech & Language Therapy in Practice Spring, pp.E1-3. Park, K. (2009) How I create creativity (1): Extra! Extra! Read all about it!, Speech & Language Therapy in Practice Winter, pp.23-25.

Blog Keep up-to-date between issues by following editor Avril Nicolls blog. Recent highlights include Voice banking for people with degenerative diseases (10 September) and Making a succinct case for speech and language therapy (13 October)


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Whos next?
When you work in the acute dysphagia sector and demand for your service outstrips supply, you have to decide who needs to be seen first and who can wait longer without a negative impact on their recovery or condition. Inspired by a previous article about prioritising new referrals, Nicola Allan and Claire Cahoon have developed a two stage tool to support their teams decision making across new referrals and existing clients.
ts a scene no doubt familiar to us all: having to prioritise and fulfil a duty of care to those on our existing caseload, whilst taking into consideration the needs of the patients on the waiting list. This - combined with variable staffing levels, a high workload, and the need to support new graduates who are still developing their decision making skills - can make prioritisation a real challenge. We were inspired to delve deeper into prioritisation by Alison Newton and Linzie Priestnalls article Decision time (2008). Its publication coincided with an exceptionally busy period in our acute department, and we saw huge potential benefits in using such a tool. After contacting the wider speech and language therapy community for further ideas via the Bulletin of the Royal College of Speech & Language Therapists (RCSLT), we realised there were few prioritisation tools already in use, and those that were available did not match the requirements of our department. We therefore wanted to produce our own practical tool, based on RCSLT guidelines (2006), to speed up decision making and ensure objectivity. We also hoped it would be useful for more inexperienced members of staff, and reduce any stress or uncertainty they may feel when prioritising in-patients. READ THIS IF YOU HAVE MORE CLIENTS THAN CLINICAL TIME ARE KEEN TO MAKE FAIR DECISIONS WANT TO OFFER A CONSISTENT SERVICE

Photo (l-r) Nicola Allan, Jenny Pennington, Claire Cahoon, Terri Horton. Terri is head of adult speech and language therapy and Jenny is also a speech and language therapist.

Starting point

We used the Flow chart for new referrals (Newton & Priestnall, 2008) as our starting point and, following positive feedback from colleagues about the concept, produced our first draft. The tool gradually evolved and changed over the next ten months in light of real life prioritisation issues and comments from colleagues. The end result is a two stage Prioritisation Tool for Dysphagia Assessment. Stage 1 is an initial screen, and Stage 2 provides additional important factors to consider if further prioritisation is needed. We envisage the process will be most helpful when the number of patients requiring assessment exceeds the clinical time

available. We felt it was important that the tool could be used as a record of decision making. It therefore contains space for patient information, with a view to it being retained in the patients notes if considered necessary. The tool also reflects our teams requirement for a doctors signature on all dysphagia referrals. This is a local policy which is under frequent review. We feel it has benefits such as encouraging doctors to take an active role in a patients dysphagia management, which is particularly helpful with quality of life decisions. Discussions regarding eating and drinking as part of end of life care are often very challenging and we find that, when doctors have been involved from the point of referral, these discussions are much easier. A recent audit of our swallow screening procedure indicated that the need for a doctors signature did not delay referral time.

For us, the important elements are: The tool is not intended to be prescriptive or to provide all the answers, and cannot take into account all factors that influence clinical decision making. We have therefore incorporated a reference to the need to use clinical judgement when making prioritisation decisions. For example, the date of discharge may influence how quickly a patient is seen, or a patient referred for an urgent videofluroscopy may be considered a priority over some others. We have included consideration of our existing caseload to reflect good practice and duty of care. On trialling a pilot version with the case examples featured in Newton & Priestnall (2008), we realised that too many were evaluated as high priority


and therefore the usefulness of the tool was diminished. We developed Stage 2 (Additional factors to aid prioritisation) to help with further prioritisation of patients who fall into the high priority category. We also included factors such as distress and end of life issues, as the importance of these when evaluating priorities cannot be overestimated. of prioritisation, we feel it is a useful, practical process, based on professional guidelines, which will speed up and guide what can be a stressful SLTP and challenging aspect of our work. Nicola Allan (email is principal speech and language therapist and at the time of writing Claire Cahoon was a specialist speech and language therapist with NHS Medway Community Healthcare. Claire is now an advanced specialist at the Royal Hospital for Neurodisability (email Acknowledgements Our thanks to Alison Newton and Linzie Priestnall for inspiring this work and to Alison for providing feedback on the first draft of this article. References Newton, A. & Priestnall, L. (2008) Decision time, Speech and Language Therapy in Practice Spring, pp.E1-E3. Available at: Spr08SLTiPANewtonLPriestnall.pdf. Royal College of Speech and Language Therapists (2006) Communicating Quality 3. London: RCSLT.

Figure 1 Exercise used for evaluation

Using only this information, place these patients in the order that you would carry out an initial swallow assessment: Joan Complaining of food sticking in throat able to eat small amounts, slowly No difficulties managing fluids Is very anxious about her eating Family are keen for her to be seen by speech and language therapy as soon as possible Fred Lily Admitted yesterday with a broken hip Nursing staff report she is being seen by speech and language therapist in the community but are unsure of recommendations Has IV fluids Nil by mouth Jack COPD (chronic obstructive pulmonary disease) On 60% 02 via facemask Alert Nil by mouth Nursing staff concerned about aspiration No non-oral feeding Mabel End stage dementia Safest consistency / Risk feeding assessment requested Nil by mouth for 3 days No IV fluids as too agitated Calling out for water Parkinsons disease Nil by mouth for 2 days No non oral feeding IV (intravenous) fluids in situ Unable to receive medication


For evaluation, we asked two newly qualified members of our team and two experienced clinicians to use the tool to prioritise five hypothetical cases for initial dysphagia assessment (figure 1). The results, whilst only based on a small sample, showed almost complete consistency in prioritisation by the four speech and language therapists. The only minor discrepancy was between the two newly qualified therapists prioritisation of Fred and Mabel, with Therapist C choosing Mabel as number one priority, and Therapist D choosing Fred. This highlights that the tool is not prescriptive and should be used as guidance only, in conjunction with clinical judgement. Clinically we did not feel the discrepancy was significant, as both Fred and Mabel could justifiably be seen as the highest priority. Indeed, on any given day, it is very likely that both Fred and Mabel would be seen for assessment. Interestingly, Therapist C reported that she initially selected Fred as the highest priority, but altered her decision after using Stage 2. In our opinion this further highlights the usefulness and importance of this second stage in helping to refine judgement regarding prioritisation. The final version of our tool is in figure 3. Feedback has been very positive. Colleagues report that it is easy to follow and gives a good overview of factors to take into consideration when prioritising an in-patient caseload. Many colleagues have also commented on the tools usefulness for newly qualified therapists and speech and language therapy students. We now use the tool for daily prioritisation when patient numbers exceed the clinical time available, and also to guide newly qualified therapists in their decision making. While it is by no means the solution to the challenges

What difference has this article made to you? Please see the information about Speech & Language Therapy in Practices Critical Friends at and let us know.

Critical friends
Alison Newton and Linzie Priestnalls article Decision time inspired Nicola and Claire when they were looking for solutions to prioritisation. That article is available online at and includes interesting background on how members of the department were orientated to the task. As part of Speech & Language Therapy in Practices informal peer review process ( Friends), Alison agreed to look over Nicola and Claires article. Alison commented: The article is great and the flow chart looks excellent. It looks like Claire and Nicola have capitalised on the parts of our flow chart that would work best for their service and their team. Their flow chart looks smart and is easy to follow. Claire and Nicola have significantly improved upon the 'usability' of the flow chart compared with the one that Linzie and I put together for our prioritisation policy. Thanks for letting me have a look at the article. I have recently taken up a new post as Lecturer at Birmingham City University. I look forward to the publication of this article and teaching my speech and language therapy students about prioritisation. The decision making tasks are going to foster some interesting discussions!




Figure 2 Prioritisation for Dysphagia Assessment Patient Name NHS No. Date of birth Date Name of staff member spoken to Ward Speech and language therapist Medical diagnosis/reason for admission

STAGE 1 - Initial prioritisation screen (Remember that professional duty of care exists for patients on existing caseload) Existing caseload

New referral received

Check screening test and referral card completed (must be signed by doctor)

Phone review or indirect review

Has the patient passed the alertness screen? YES Is the patient able to receive essential medication? YES Is the patient nil by mouth? * NO Is there a concern about aspiration? NO LOWER PRIORITY


Unable to assess phone in 24 hours

If concerns raised...

If no concerns raised...




Does the patient have non-oral feeding? YES



*If nil by mouth for more than 3 days contact dietitians in line with local agreement between speech and language therapy and dietetic teams

STAGE 2 - Additional factors to aid prioritisation Length of time nil by mouth Distress expressed by patient / carer Ability to receive IV fluids / meds - yes / no Respiratory status Any current swallow recommendations from community? Has a safest and most comfortable consistencies whilst accepting high risk of aspiration assessment been requested? Other PLEASE NOTE: CLINICAL JUDGEMENT MUST ALWAYS BE USED WHEN MAKING PRIORITISATION DECISIONS




Are we having fun yet?

They say laughter is the best medicine, but how often in our working lives do we remember to take and to offer it? In this exploration of the use of humour, Keith Park hopes to inspire you to spread a little happiness as you go by
ome years ago, I used to visit a group in a special school where one of the teenagers was thought to be dying. He did not die, and is still alive and well, but at the time everyone was understandably in a state of extreme stress. The teenager lets call him John would be asleep in his beanbag with at least one member of staff looking for signs of life and of course no-one could fully concentrate on anything else. (Why this was happening in school is another story.) So, to cut a long story short, we tried an interactive version of the pantomime Sleeping Beauty. John, on his beanbag, was placed at the centre of the circle of staff and pupils and all the exchanges literally went over his head. The challenge we set ourselves was to laugh. We came up with the idea of doing the pantomime in the style of one of the games from the TV programme Whose Line Is It Anyway? where participants were challenged to perform Hamlet, for example, in the style of Philip Marlow, Julian Clary, Frank Sinatras My Way and so on. Every episode of Sleeping Beauty was done in a different character and changed from week to week: John Wayne, Del-boy (from Only Fools and Horses) and, quite memorably, Darth Vadar, which was just a series of heavy breathing. My favourite was in one of the later episodes when the castle gardener finally discovers Sleeping Beauty. The words we used are a parody of Humphrey Bogarts character Rick in the film Casablanca: Of all the gardens In all the castles In all the world And shes asleep in mine Heres looking at you kid Mmmwah! The sound effect of the final line was to accompany a kiss being blown across the circle. It was all extremely silly, which was of course the aim. At the end of the activity, one of the staff said, Thanks for that, I needed a laugh. Result! Although this situation was extreme, I think her comment is true for all work situations. Many of the schools I have visited are excellent, but - perhaps because of paperwork, Ofsted inspections, or the demand to demonstrate progress - things often seem very serious.


Interactive Storytelling Interactive storytelling began as a way of including people with severe and profound learning disabilities in drama, poetry and storytelling activities. It is based upon three principles. The first is that apprehension precedes comprehension. A character in Oscar Wildes An Ideal Husband says I never go to concerts by Strauss. The music is always in German. The joke is quite instructive: what do we mean by a proper understanding of something? When we listen to Beethovens Fifth, look at Leonardo da Vincis Mona Lisa or go to a Shakespeare play, are we understanding them? Nicola Grove and I have suggested (Grove & Park, 1996) that poetry and stories can be enjoyed by anyone, irrespective of whether they can translate them into contemporary prose to demonstrate understanding. One of my favourite examples is Jabberwocky its a very famous and popular poem but can anyone comprehend it? The second principle is that affect and engagement are central to responses to literature. One of the first times I did Macbeth in a school, we recited the famous witches spell Double double toil and trouble with the lights out. When we finished one of the pupils shivered, stood up, and said, Lights on. This

Knock knock...

was clearly a direct emotional response to the text. Similarly, there was much laughter when finishing a section of Twelfth Night when Sir Toby and the others are calling Malvolio rude names, the final one of which is sheep-biter followed by everyone bleating like a sheep. The head teacher walked into the room and was quickly surrounded by a group of pupils who repeated the litany of Shakespearean abuse, ending with the sheep noise, then followed by a lot of laughter (from the head too, fortunately!) The third principle is that recital and performance are valid means of experiencing stories, drama and poetry. Instead of trying to get people to look at a book, the primary focus can be on performing the story and by making it possible for everyone to participate in storytelling in some way. We, quite literally, do the book and enjoy the music of words in performance, and look for and encourage affective responses to the piece of work we are doing. So, having decided that exploring humour was an important project, I then came across the problem of appropriate texts, in particular for teenagers and adults with complex needs. Several years ago I visited a certain special school and joined a group of teenagers with profound and multiple learning disabilities. I watched in dismay as the teacher sang If youre happy and



you know it clap your hands followed by Five fat sausages sizzling in a pan. I should add that an Ofsted inspector was also observing the lesson and described it as outstanding. (I have a short poem about Ofsted inspections that cannot be performed in schools!) A discussion of age-appropriateness and literacy would take up too much space here, but surely it must be boring and unimaginative to be doing the same songs and poems throughout the school years. If I had a pound coin for every time I have seen Eric Carles The Very Hungry Caterpillar in a teenage classroom, I would be quite rich. So I decided to investigate literature and, where necessary, adapt it for use in schools. Here are a few examples of what I hope is the use of humour. and Canterbury Cathedral. On our last visit to Westminster Abbey in January we performed the story of The Calming Of The Waters one of the miracles of Jesus - which has a touch of Tommy Cooper to it. Jesus falls asleep on the boat and there is a great storm. The disciples are afraid and they wake up Jesus. He tells the winds and waters to calm down, which they immediately do. The last section goes One word from him And thats a fact It all went stumm We was gobsmacked! What is he like? We know hes a Really wicked Diamond geezer! This Jesus bloke Got up and spoke And the sea went flat Just like that! Many people of course would not know about Tommy Cooper, but it doesnt seem to matter. Those who did were quickly doing impersonations of him when repeating his catchphrase Just like that! It is quite surreal to witness a Bible story in cockney rhyming slang being performed in a cathedral in the style of Tommy Cooper. One of the clergy at Rochester Cathedral came up to me afterwards and said, Do you know, it is quite lovely to hear laughter in a cathedral. c) The Brothers Grimm Another recent topic has been Grimm Takes which consists of new versions of some of the famous stories. Here is the start of Rumpelstiltskin: A Case Study in Anger Management, which seemed an appropriate title given that, at the end of the story in some versions, he tears himself in half in anger. Psychiatry Thats what they said I had a bad place In my head Anger management My shrink told me I need Behaviour Therapy Cos mum and dad To their shame Gave me this Revolting name And I really Got the hump When we went out Dad called me Rump d) Shakespeare Most Shakespearean text is in iambic pentameter (a ten beat line, alternating long short long short), which is rather long to perform in call and response, but extracts can be easily divided into shorter sections. This can also give people a direct experience of a Shakespeare workshop. The Taming Of The Shrew is a difficult play. Petruchio, who tames Kate, says some very uncomfortable and unpleasant things about women, so I decided to match extracts of Shakespearean text with aphorisms and observations in contemporary feminist literature. Here is the first episode; Kates final two lines are her response to Petruchios patronising banter: You are called plain Kate Bonny Kate Kate the cursed Kate of Kate Hall Super-dainty Kate Therefore Kate Myself am moved To woo thee for my wife. A woman needs a man like A fish needs a bicycle! Finally, in the last episode, Kate appears to be tamed or is she? This episode is performed in a very over-obsequious way, culminating in the famous lines spoken by Bette Davis in the film All About Eve: Thy husband is thy lord Thy life Thy keeper Thy sovereign Place your hands Below your husbands foot And fasten your seatbelts Its going to be a bumpy night! e) Hans Christian Andersen Together with stories by the brothers Grimm, some schools are exploring new versions of stories by Hans Christian Andersen. Here is a new version of his story The Red Shoes where the little girls red shoes are touched by a mysterious stranger who says Dance, red shoes! All night, all day! Dance all London Come what may! So off she dances, all over London: First a boogaloo At Waterloo Then a saraband Along The Strand A quadrille At Notting Hill At Pimlico I stubbed my toe! And so on until she finds a shoe repair shop (Oh! Cobblers!) where her shoes are cut off (and not her feet as in the gruesome original), and, as they dance away, she says: But I dont care Just let them go Im going home For physio. f) Homer Some years ago Nicola Grove and I wrote Odyssey Now with Homers Odyssey as the basis for a series of drama games (Grove & Park, 1996). I decided to re-visit Homer and look at making a verse account of some of his adventures that happened on his long journey

Whos there?..

a) Pantomime Pantomime is a very popular art form and is perceived as being appropriate for people of all ages. It can contain song and dance, poetry, slapstick comedy, political satire, and of course terrible jokes and puns. Three years ago The Churchill Theatre in Bromley (south east London) was putting on Mother Goose for its Christmas pantomime season and the theatre staff kindly allowed us to use the stage and perform our interactive script in front of the spectacular scenery of the backdrop. In episode 2 of the script, Priscilla the goose lays a golden egg and Mother Goose is rich. This activity is easier to do than to describe. Everyone speaks the words together, and then from the second verse, the words are replaced by sound effects, until it is nothing more than a sequence of sound effects: Priscilla the goose has laid a golden egg (repeat this line 3 times) And Mother Goose can put it in her bank account! This is then repeated, but with bank account replaced by a sound effect of everyone shouting out dingalingaling! Priscilla the goose has laid a golden egg (repeat 3 times) And Mother Goose can put it in her dingalingaling! Then the word egg is replaced by a sound effect so it becomes Priscilla the goose has laid a golden squork! (repeat 3 times) And Mother Goose can put it in her dingalingaling! And so on until everything is sound effects: Oooh! Honk! Urgh! Ching! Squork! And Mother Goose can put it in her dingalingaling! This is of course totally frivolous but it is great fun to see people wiping tears of laughter from their eyes. b) Bible Stories in Cockney Rhyming Slang The Bible Stories in Cockney Rhyming Slang project continues to develop, and groups from various schools have now visited Westminster Abbey, St Pauls Cathedral, Rochester Cathedral



home from Troy to Ithaca. The Laestrygonians are a race of giant cannibals. Odysseus and his men land on their island and some of the sailors are eaten alive. The humour is rather ghoulish: Because we are So gigantic Our appetites Are elephantic So at the risk Of sounding louche Humans to us Are amuse-bouches Eating humans They are only an Hors doeuvre for a Laestrygonian g) Chaucer Geoffrey Chaucer is often referred to as the father of English poetry and The Canterbury Tales, written in the 1380s and 1390s, is his most famous work. It was written in Middle English and there is some debate as to how the words might have been pronounced 600 years ago, so I decided to try a version in contemporary English. The Wife of Baths Tale is the story of a knight accused of a terrible crime. In the original text it is rape, but I have omitted that word as it is difficult to use in school settings. However, an unspecified crime makes it more of a mystery. The knight is sentenced to death but the queen gives him a reprieve of one year and a day to find the answer to her question: what do women most desire? He travels the world and searches in vain for the answer until he finds an old woman in the woods who says she knows the answer and will tell him on condition that he promises to do what she asks of him. He appears before the queen on the appointed day and tells her: Women desire Generally To control their men Totally. This is followed by the verse in which the knight says what women want and it usually gets a laugh and a cheer from female staff: To be the boss The governor-wife To dominate In married life He gives the correct answer and then the old woman says that he must fulfill his promise to obey her, and this means they must be married. He grudgingly consents, and then she gives him a choice: she can be old, ugly and faithful, or young, beautiful and cheating. Which is it to be? The knight, now wiser, replies that he will abide by her decision. This is the correct answer that breaks the spell over the old woman who is transformed into a young and beautiful bride and, in true fairy tale style, they live happily ever after, following this important principle: Admit the truth Dont be a fool In a marriage Women rule!

Boom boom...

One of the most effective uses of humour I have ever seen was with Tim, who was seven at the time. Tim uses a step-by-step communication aid. His teacher Sheila, on her birthday, recorded a message on Tims BigMack: Hey! Listen Everyone! Its Sheilas birthday today. Shes 21 again! Then Tim, assisted by another member of staff, visited all the classrooms in the school, and played the message to everyone in the room. It was a great laugh, and was a brilliantly simple and effective use of humour. And of course it made Tim, a switch user, the centre of attention.

So maybe we could all try to raise a laugh occasionally or, even better, actively try to introduce laughter to the working day
Another example of humour that can be easily done is poetry ambush. I tried this with three teenagers in an excellent school that was nevertheless quite intense and serious. We practised a few very short poems by Ogden Nash, and then went around school ambushing members of staff. This consisted of rushing up to the target, surrounding them and then quickly reciting A curious bird/The Pelican/Whose beak holds more/ Than his belly can and then rushing off again, preferably with a snigger. The shortest and quickest poem was Ogden Nash again: Parsleyis gharsly. Another type of ambush involved knock knock jokes, which are consistently so awful they often get a laugh or at least a groan. (This must be one of the worst: Knock knock /Whos there? / Wurlitzer / Wurlitzer Who? / Wurlitzer one for the money, two for the show...) This is only a brief introduction to some of the work being done on the use of humour and the adaptations of classical literature. Anyone who would like to find out more detail, or to visit one of the workshops, is welcome to contact me. I have also listed some publications on aspects of storytelling. So maybe we could all try to raise a laugh occasionally or, even better, actively try to introduce laughter to the working day. Perhaps we could subvert the deadly earnest BBC Radio 4s Thought For The Day and have SLTP a Joke For The Day instead? Keith Park (email is an advisory teacher, poet and performer who works with children and adults with multi-sensory impairments in a variety of educational and community settings. His Winter 2009 article Extra! Extra! Read all about it! is now available at www.

Bibliography Grove, N. & Park, K. (1996) Odyssey Now. London: Jessica Kingsley Publishers. Grove, N. & Park, K. (2001) Macbeth In Mind. London: Jessica Kingsley Publishers. Park, K. (2001) Interactive Storytelling for Deafblind Children, Deafblind Perspectives 8(3), pp.5-9. Available at: dbp/pdf/may01.PDF. (Accessed: 11/11/10). Park, K. (2001) Interactive Storytelling: A Multidisciplinary Plot, Speech & Language Therapy in Practice Summer, pp.4-7. Park, K. (2002) Macbeth: a poetry workshop on stage at Shakespeares Globe Theatre, British Journal of Special Education 29(1), pp.14-19. Gallimore, A., Savill, M. & Park, K. (2002) Interactive Storytelling and AAC with People with High Support Needs, Communication Matters 16(3), pp.25-27. Park, K. (2002) Switching on to Shakespeare, Speech and Language Therapy in Practice Spring, pp.4-6. Park, K. (2003) The Tempest on stage at Shakespeares Globe Theatre, The SLD Experience 37, pp.27-31. Park, K. (2003) Shakespeares Twelfth Night on stage at the Globe Theatre, The SLD Experience 38, pp.3-7. Park, K. (2004) Interactive Storytelling in the art gallery and the theatre, The SLD Experience 39, pp.3-7. Gouda, N. & Park, K. (2004) Interactive Storytelling: Multicultural Perspectives, Communication Matters 18(3), pp.33-35. Park, K. (2004) Interactive Storytelling. Milton Keynes: Speechmark. Park, K. (2004) Interactive Storytelling: from the book of Genesis, British Journal of Special Education 31(1), pp.16-23. Park, K. (2004) Shakespeare goes to Harrow, The SLD Experience 41, pp.3-7. Gouda, N. & Park, K. (2005) One Night of Shakespeare, The SLD Experience 43, pp.9-12. Park, K. (2009) Bible Stories in Cockney Rhyming Slang. London: Jessica Kingsley Publishers.

To comment on the impact this article has had on you, see guidance for Speech & Language Therapy in Practices Critical Friends at www.




Heres one I made earlier...

Alison Roberts with another low cost, flexible and fun therapy suggestion, this time best done in a one-to-one session Vocabulary workbook
This is a way to work on vocabulary building in themes, with the extra value of being able to record idioms associated with each theme area. This is best done in a one-to-one session. MATERIALS Exercise book Coloured pens or felt tips IN PRACTICE Decide on some themes to be tackled. Its a good principle to go for the themes suggested by your client, usually a favourite pastime, or a school or college subject, adding some that you know they need to work on. You dont need to think of all possible themes at the start, just build them up gradually. You can also come back from time to time to add to themes already tackled. Allow four pages for each theme. On the first page draw a spidergram (see, or mind map, with the theme word in the middle. (Mind maps are really the same thing as spidergrams, but the central shape is not a spider.) This page is the place to put ideas associated with the theme. For example, if the theme happened to be HORSE RIDING you would put this in the centre, adding all the generally connected ideas such as ponies, fresh air, special clothes, group, teacher, Thursday afternoons, Willow Farm. Each of these can have further connections; for example, Willow Farm might spawn ideas such as view, tea break, barn shelter, top field. The second page is for all the extra, specialist vocabulary that you both can think of, connected with the theme, and presented in sub-themes. You can make more spidergrams for this if you like but, in this case, you would need to take more pages over each major theme. For either approach you will need to have a title and then a list of connected items; for example the title Tack would include halter, bridle, saddle. Parts of the Horse would include fetlock, withers and hoof. Then there would be Riding Gear, including jodhpurs, hardhat, boots. (I am not a horse rider myself, but this has been inspired by some of my clients!) Use different colours of pen for writing the title and content of each sub-theme, as it makes it easier to remember. The third page is for connected idioms. Continuing with the horse-riding theme, this could include: closing the stable door after the horse has bolted; getting up on your high horse; being saddled with; get the bit between your teeth. Beside each idiom the client should write the agreed meaning of each idiom. This will take you from the original theme to many other areas. The fourth page is for a quiz. You write one quiz question, for example What metal things do you put your feet into when you ride? The client adds the next question, which may be What is the name of my riding teacher? Building the quiz up together in this way helps the client to own their therapy. The quiz answers also call for a different kind of thinking. With the spidergram, we start from a central point and find many associated ideas (divergent thinking). With the quiz, we start from an associated idea and work towards the target word (convergent thinking).

Editors choice

Jonathan Rowson, Steve Broome and Alasdair Jones present a fascinating report on real world social network research. Here are just two of many examples from Connected Communities How social networks power and sustain the Big Society worth exploring for our practice. Firstly, they discuss the Six degrees of separation, three degrees of influence law of connectivity (p.25), and the relationship between bonding and bridging capital (p.27), which would add a potentially fruitful dimension to assessment and intervention. Secondly they point out (p.41) how merely participating in surveys has the effect of holding up a mirror and changing behaviour. RSA Project report, 74 pages, available at Its a shame that Social capital theory: A crosscutting analytic for teacher/therapist work in integrating childrens services is so jargony, because the thinking behind it is practical and useful. Joan Forbes and Elspeth McCartney are looking for a way to produce improved public services for the benefit of children and young people (p.331) through better integration. The article offers a different way to reflect on yourself and your service by considering the value and types of relationships and connections you have. If these are well balanced, it becomes more likely that professional problems are recognised as being shared and there is the potential to promote better collective action (p.331). Child Language Teaching & Therapy (2010), 26(3), pp.321-334 When we buy a fridge or a sofa, we are consumers exercising a choice (of sorts). We have played no part in the production process. In healthcare, the outcome is always coproduced by the client and the professional / service. In Co-Production and Health System Reform From Re-Imagining to Re-Making, Roger Dunston, Alison Lee, David Boud, Pat Brodie and Mary Chiarella argue that the level of success of the outcome is therefore inextricably linked to the strength of this co-production. Words like relationships, assets, capacity, capability and contribution are again much in evidence, and there is a thought-provoking section on the role of higher education. The Australian Journal of Public Administration (2009) 68(1), pp.39-52

So many journals, so little time! Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.



Lets Sign BSL Flashcards: House & Home Cath Smith Co-Sign Communications ( ISBN 978-1-905913-17-6 9.99

Flimsy but useful

This set contains 50 items found in the home, with the signs demonstrated by eight female and six male characters in bright, attractive pastel colours and backgrounds. Each sign is reinforced through demonstration, finger spelling and description. The front of each card shows the sign and written label while the finger spelling and a description of how to make the sign are on the back. Generally, key vocabulary has been selected, although items such as kettle, fridge and toaster are not present. The cards need to be reinforced and laminated as they can be easily bent or torn. Once they have been taken out, it is very difficult to put them back in the box without damaging it. Locating specific vocabulary would be easy if a list was provided or the rooms colour coded. The cards are suitable for older children and could be adapted for younger children if pictures of the household items were used rather than words. The set has not been reasonably priced, due to the poor quality of the cards and flimsy packaging. However, parents and support staff in mainstream settings working on supporting general vocabulary development would find it useful, and it is a useful resource to have in clinic. Inyang Adegbola is a specialist speech and language therapist (hearing impairment) in Essex.

require good literacy skills. Games would have to be used carefully when working with group members, especially those who could be emotionally vulnerable. Some activities may not be practically possible, as they suggest frequent division between boys and girls. In Sensory Perception, Andrea Erkhert focuses on each sense in turn, describing targeted games and necessary materials. As speech and language therapists we would concentrate on only two of the five sections looking and listening. The listening section is particularly interesting and also focuses on attention and auditory memory. The looking games focus on awareness and improvement of eye contact. Generally these games seem well suited for children aged 5-11. Relaxation and Concentration contains a range of games designed to create calm and quiet (often listening games). It includes a range of interesting activities which could be used with both younger children and adolescents. The games require some physical contact between group members which, as the author acknowledges, could be uncomfortable for some, especially adolescents. Overall, the books include some interesting ideas but would be most useful to school staff working through relevant topics with children. Raman Kaur and Gillian Gaskell are speech and language therapists with South Birmingham Community Health.


A Voice Fit for Teaching Caroline Cornish Southgate ( ISBN 978-1-85741-142-0 1.07-1.95 depending on number of copies

Good value for money

I reviewed this myself and sought comments from a teacher client and from my young colleague, who has less than two years experience of working with voice clients. It took fifteen minutes to read the book and do the exercises. It is about effective voice presentation (the author Caroline Cornish is a voice tutor) and is of limited relevance to speech and language therapy clients who already have a voice problem. It might be useful to lend to a teacher having problems with the effectiveness of their voice to extend their knowledge of what is possible vocally. The vocal care section is good, and it is good value for money at 1.95. Heather Taylor is a speech and language therapist and voice specialist with Bolton PCT.



Walking in the Shoes of Another - Stories for seeing life from different perspectives Lars Collmar Hinton House ( ISBN 978-1-906531-24-9 24.99


The 50 Best Games for Building Self-Esteem Rosemarie Portmann ISBN 978-1-906531-18-8 9.99 The 50 Best Games for Sensory Perception Andrea Erkert ISBN 978-1-906531-11-9 9.99 The 50 Best Games for Relaxation & Concentration Rosemarie Portmann ISBN 978-1-906531-17-1 9.99 All Hinton House,

Smasher: A story to help adolescents with anger and alienation Margot Sutherland, illus. Nicky Armstrong Hinton House ( ISBN 978-1-906531-10-2 9.99

Starting point

Cleverly written

Interesting ideas

These three small, well-packed books, full of ideas for group games, would sit nicely on your clinic shelf. Each book has a clear structure, being divided into sections according to the specialist area, and each game has a clear description of the activity. In Building Self-Esteem, each game is well described and is followed by clear examples and discussion points, including ideas for how the games could be extended. These games seem well suited for older children and adolescents as they have high language demands and

This short book is written for troubled adolescents (aged 10-16) who are struggling to come to terms with identity issues, peer pressure and problems with anger. A young teenager is guided by a mysterious dream-like figure to make life-changing decisions between a Smash-it-Up world and a Special world. It is colour illustrated on every facing page, with speech bubbles and text, cleverly written so the story can be followed using the speech bubbles alone. I asked one of my 15-year old clients with emotional and behavioural difficulties (and average reading abilities) to read it. He was totally absorbed from start to finish and at the end said he loved it. He also admired the pictures, which carry stark but appealing images. I might use this book to encourage reading in difficult-to-engage teenagers, but it is maybe more useful to psychologists and psychotherapists working in this field. Jinnie Goodlake is a speech and language therapist with the Novalis Trust.

This book contains 10 stories, told from two different perspectives. It sets out to highlight the differing viewpoints of individuals and the varying emotions felt. It is aimed at younger children (aged 8-12). Each story is followed by a selection of questions for the adult to focus any discussion. The author states that the book is ideal for use with individuals with brain injury and autism spectrum disorder, and within PSHE (Personal, Social & Health Education) sessions. It could be useful for teachers leading PSHE sessions, particularly within secondary mainstream settings. However for my caseload - many of whom have autism, and all of whom have language difficulties I feel the book uses language which is excessively complex, and refers to concepts and references that are overly abstract. Many of the students with whom I work would struggle to access the deeper messages referring to social understanding and emotions. It could provide a useful starting point for adaptation according to specific needs, and could be useful within a group setting. Fiona Smith is a specialist speech and language therapist working with primary and secondary children in mainstream and special school in North Wales for Betsi Cadwaladr University Health Board.





Grandparenting a Child with Special Needs Charlotte E. Thompson Jessica Kingsley ISBN 978-1-84310-906-8 12.99

and families would find useful if new to the field of autism spectrum disorder. Gillian Welsher is a speech and language therapist working with children with learning disabilities and their families in Newcastle upon Tyne.

setting and are closely involved in the development or teaching of the literacy curriculum. Katrina Chapman is a speech and language therapist working at an independent school for children with speech, language and communication difficulties in Wimbledon.

Different insights

This book covers a topic Ive not read about before, and contains many stories from the authors professional life as a paediatrician. It aims to provide practical advice on all aspects of grandparenting a child with special needs and as such could be useful to therapists working with multi-generational families. Much of the advice is relevant to parents as well as grandparents, such as a section on the need to support siblings whose needs can be overlooked when there is a child with additional needs in the family, and the advice if youre not good to yourself you wont be able to take care of your grandchild or yourself. The first chapter on coping with the diagnosis would be particularly helpful to therapists new to working with children with additional needs, as it gives information relating to family dynamics which is not often covered in professional training. The book is American and, though there are attempts to make it relevant to the UK audience, I skimmed over large sections. A mother, grandmother and great grandmother I work with commented that, although they didnt find the book particularly helpful, they would consider suggesting other families read it, as each family is different and would gain different insights. Margaret Greer is a speech and language therapist in Bradford.


Talking the Talk Language, Psychology and Science Trevor A. Harley Psychology Press ISBN 978-1-84169-340-8 17.50

As technology becomes more accessible, our in-depth reviews help you decide whats hot and whats not... S Homework Disc Leaps & Bounds Multimedia ISBN 0-9546521-2-6 18.00 (single user licence)

An enjoyable read

This book discusses major questions, such as how do we understand, use and acquire language? It presents the research carried out to investigate these topics along with major theories and models, for example Garretts model of speech production and the dual route model of reading. These are conveyed in a clear and accessible manner and broken down into smaller sections such as what is phonological awareness? or how do we retrieve words? This makes it easy to pick out particular sections of interest. It is an enjoyable read at a very good price. Whilst not particularly useful in day-today clinical practice, it would be perfect for individuals just starting a speech and language therapy course or those looking to brush up on some of the fundamental theories and approaches to speech and language. Catherine Cole is an MSc student currently completing her final year at Reading University.

Really good timesaver



Managing Family Meltdown The Low Arousal Approach and Autism Linda Woodcock and Andrea Page Jessica Kingsley ISBN 978-1-84905-009-8 12.99

Meaning, Morphemes and Literacy - Essays in the Morphology of Language and its Application to Literacy E. Neville Brown and Daryl J. Brown Book Guild Publishing ISBN 978-1-84624-337-0 17.99

One to suggest

Controversial but convincing

As a therapist working with children with autism and their families, you often have conversations with parents about how things are at home. Discussing challenging behaviour can make you feel useless as a professional if you arent able to offer any help. If the family are into reading self-help books, this is one you could definitely suggest. Its co-written by a parent with lots of insight and practical experience. Both authors are part of a team who train in the low arousal approach to managing challenging behaviour, something you and your team may want to look into further before using the book with families. It also lists further resources both professionals

This book summarises the research undertaken by the authors that led to the establishment of the Maple Hayes Dyslexia School and Research Centre in Staffordshire. In 12 chapters, the authors attempt to persuade the reader of the need to adopt a morphological approach in the teaching of literacy, flying in the face of the current trend for phonics. Though controversial, the authors certainly make a convincing argument. However, this is a heavy-duty read and definitely not a book you can dip in and out of between clients. Further reading or training would also be needed in order to apply the theory to a clinical setting. The price is pretty reasonable but this is a book only for therapists who work in an educational

This resource is useful for any clinician who works on the production of s with young children. The disc contains activities to help consolidate production and discrimination of s at single word and phrase level. It does not contain worksheets for practice of single sound s or s plus vowel. It is important to note that all the activities are designed to be printed off and completed on paper. The disc contains a good selection of black and white colouring activities, board games and lotto games. The instructions on the worksheets are short and easy to follow. There is also the option to create sheets of colour pictures in different sizes which could be used for your own games. The homework packs include a cover sheet; a progress tracking picture; worksheets and a certificate. The authors have included a useful Handy Hints page which contains advice for parents about modelling and praising correct production. The disc starts itself and opens in a separate window with its own navigation. It has clear, straightforward instructions and the navigation is intuitive. It is possible to create a homework pack and print it out within about five minutes. Homework packs can also be saved for future use which means you can just open up a saved pack and print it out in a couple of minutes. There were some frustrations with the discs usability: it was not possible to maximise the window; there was no way to enlarge the pictures of the worksheets when previewing them; it would be good to have the option to print the whole work pack at once rather than needing to print one worksheet at a time. Overall, this is a really good timesaver. The activities could be used in clinic and for homework. Fran Oakley is a pre-school speech and language therapist in Dudley.




Journal club 2: qualitative research

Jennifer Reids series aims to help you access the speech and language therapy literature, assess its credibility and decide how to act on your findings. Each instalment takes the mystery out of critically appraising a different type of journal article. Here, she looks at qualitative research. www.francart

rather like numbers. It seems obvious to me to count things to see if there is a pattern, evidence of progress or a useful comparison to be made. At this point, you will not be alone if you are thinking anorak! Many of you may feel that as soon as you convert something to numbers it loses any kind of real meaning. However, in research design, its all about horses for courses; using numbers (quantitative methods) works for studying some kinds of phenomena and sticking with words (qualitative methods) works for others. Here is a story to illustrate the different yet potentially complementary approaches of quantitative and qualitative methods. Amy leads a small team of speech and language therapists working in the community in quite a sparsely populated area, so she and her colleagues spend a lot of their time travelling, and timetabling can be quite a juggling act. She notices that referrals are rising quite rapidly in one part of their patch while elsewhere they remain pretty constant. As she may need to change how the service is deployed to make best use of the teams resources, she discusses this with her manager, and they agree they need to know a bit more about what might be going on. What background research would help them? Some sources of quantitative data that might be available are:

1. The local authority publishes regular bulletins on population trends within age bands in NHS areas, parliamentary constituencies, council wards, secondary school catchments areas and so on. 2. The speech and language therapy service has an electronic database of referrals and their sources going back over 12 years. 3. Most of the teams referrals come from practitioners in either primary/community care (40 per cent) or education (45 per cent). 4. Amys not sure but feels there may have been more inappropriate referrals over the past year, and she is certain they are seeing a lot more 2-3 year-olds than they used to. 5. Four of the biggest schools they cover have new headteachers and there have been quite a few meetings with them to discuss roles and responsibilities and to go through the procedures for referral. 6. Several health visitors in the area retired recently and Amy feels that the team has not yet had the opportunity to develop strong working relationships with their successors. Two community paediatrician posts have also been vacant for more than a year now, and the health board has been unable either to fill the posts or to secure locum cover.

The numerical sources 1 and 2 should give Amy and her manager an indication of whether the trends in referrals reflect (a) changes in the population demographics of the area, or (b) changes in the referral rate (the proportion of the population being referred). Items 3 and 4 provide figures for investigating whether increasing referral numbers appear to be associated with particular sources of referral rather than across the board. Items 5 and 6 probably reflect some of Amys hypotheses about potential sources of temporary fluctuation in referral rates. They could use their database to check numbers of referrals over time from these schools and healthcare practitioners to see if the pattern of fluctuations over time in referral numbers is associated with personnel change. However, knowing who is referring more, or fewer, clients than is typical for their practitioner group wont necessarily help Amy and her manager understand why this is happening. They need to elicit information on the perspectives of these referrers. Here is where the qualitative techniques of document study, observation and interview come into their own. In this case, exploring the content of referral forms (document study) and / or exploring referrers decisionmaking (using individual or group interview




Criticial appraisal for speech and language therapists (CASLT) Download the qualitative research framework document from Use it yourself or with colleagues in a journal club, and let us know how you get on (email
techniques) should help Amy and her manager understand, and subsequently manage, the reasons underlying the changes in their referral numbers. Qualitative methods are the gold standard (the method of choice) for exploring and creating meaning from participants subjective experiences, and for gaining insight into phenomena that are ill-defined or poorly understood. The strength of these methods rests in their ability to reveal the underlying truth of a phenomenon in research terms, its validity. It may be true only for a single individual at one point in time and in one particular context, but listening to or observing individuals is much more likely to elucidate their subjective experience as they perceive it than any amount of counting. As Greenhalgh puts it: The strength of qualitative research lies in validity (closeness to the truth) that is, good qualitative research, using a selection of data collection methods, really should touch the core of what is going on rather than just skimming the surface. The validity of qualitative methods is greatly improved by the use of more than one method in combination ( triangulation), by the researcher thinking carefully about what is going on and how their own perspective might be influencing the data ( reflexivity), (Greenhalgh, 2006, pp.168-9). However, you do need to bear in mind that the strength of qualitative methods may also be the source of a potential weakness. Generalisation of the findings of qualitative research to other contexts (people, setting) may not be justified, or at least not without appeal to a wider evidence base. It is the reliability of quantitative methods which give us confidence that the same study would produce roughly the same findings if it were to be repeated elsewhere with different participants. This reliability allows us to generalise with a degree of confidence beyond the immediate context in which a study has been conducted. Authors of qualitative studies may not help you much with this, so you do need to think carefully about the context of the research study and how this may differ from your own. From a service development point of view there is no point in searching for meaning in studies whose context or setting will not illuminate your own service issues. A fantastic research team and top-notch methods wont do you much good if you go looking in the wrong place. As the story goes: Late one evening, a passer-by notices someone searching about under a lamppost. Have you lost something, says the publicspirited passer-by, Can I help you? The searcher replies that he has dropped his car key and accepts the offer of assistance. Some time elapses while both search the ground all round the lamppost. Are you sure you dropped it here? queries the passerby, I cant see it anywhere. Eh, no, says the searcher, I dropped it down the road but its so dark down there I couldnt see properly so I came up here where its brighter. There is a plethora of literature on qualitative methods should you wish to read about this more widely (Barbour, 2008; Immy, 2010). I also recommend a useful short summary article that is a free download from the British Medical Journal (Kuper et al., 2008).


methods are expected to have their research question clearly formulated at the outset. In qualitative designs, however, it is acceptable for the aims to be influenced by the data analysis (the so-called iterative approach, in which results influence questions, which then influence results, and so on in a cyclic fashion). The authors should therefore explain if and how their aims have been shaped during the study. Question 2: Was the choice of qualitative approach appropriate?


Use the following questions adapted from Greenhalgh (2006) and CASP (PHRU, 2006) to assess the rigour, credibility and relevance of the study and whether there are implications for your service. This is set up at www/speechmag. com/Members/CASLT as a document for you to download, print off and use as an individual or with colleagues in a journal club. Question 1: Did the paper describe an important clinical problem addressed via a clearly formulated question?

Was a qualitative method appropriate in the first place? Look for evidence that the study sought to interpret or illuminate the actions and / or subjective experiences of the research participants. Was the research design appropriate to address its aims? Consider whether the authors discussed selection and justification of their methods. Question 3: How were the participants selected?

This may be broken down into whether the aims of the research were clearly stated, what the point of the study was, why the problem is important and how the issue is relevant for clinical practice. Studies that use quantitative

Have the authors explained how the participants were selected? You may be less familiar with qualitative sampling methods who you select to interview or observe, or which texts you choose to analyse as they are different from the representative sampling



(and variations thereof) used in quantitative designs. Kuper et al. (2008) have a helpful list of qualitative sampling methods for interviews or focus groups in healthcare settings. These include self-evident ones like: typical or deviant case sampling, to less familiar ones like: maximum-variation sampling sampling from a range of perspectives that is wide enough to include all the factors that might influence the nature and quality of peoples experiences, or snowball sampling each recruit to the study generates more participants through personal contact, often used for research with hard to reach or stigmatised groups. Have the authors explained why the participants they selected were the most appropriate to provide access to the type of knowledge sought by the study? Were there any discussions around recruitment, such as why some people chose not to take part? Question 4: Were the data generated in an appropriate way?
Qualitative design methods involve exploration and interpretation via data generation. They are stronger on validity (closeness to the truth). They are the preferred methods for poorly understood or relatively unexplored phenomena. Documents Passive observation Participantobservation Semistructured interview Narrative interview Study of documents produced by real people in real situations (for example, casenotes). Systematic recording of behaviour and talk in naturally occurring settings. The researcher takes part in the setting as well as observing. Face-to-face (or telephone) conversation with the purpose of exploring issues or topics in detail. Uses a pre-set list of questions or topics but is not restricted to these. Interview undertaken in a less structured fashion, with the purpose of getting a long story from the interviewee (typically a life story or the story of how a condition has unfolded over time). The interviewer uses only general prompts to tell me more. Method of group interview which explicitly includes and uses the group interactions to generate data.

Focus Groups

Table 1 Qualitative methods

Was the setting justified the right place to look rather than the easiest? (Not just looking under lampposts!) Peoples experiences of your service may be fresh in their mind on the way out of the door from their first appointment but perhaps they might provide more meaningful information once they have experienced some intervention. In my local setting, we recently conducted a series of focus groups with people with aphasia. The participants were all folk whose Samantha Paula stroke had occurred relatively recently but who were now discharged from speech and language therapy. We could be reasonably confident that: a. the groups views provided a unique perspective on their whole care pathway, which reflected our (and other healthcare practitioners) current practice, b. the impact of communication difficulties had been minimised, and c. there was no undue influence from a desire to maintain current therapeutic relationships. The findings are being used as an evidence base for our current service strategy - for example, that we invest effort and resources in raising awareness of aphasia and health promotion for people living with aphasia in our local community.

Is it clear how data were generated in the study, and have the researchers justified the methods chosen? Table 1 is extracted from the first article in this series to remind you of the most common sorts of qualitative methods. Authors should make their methods very explicit so that you can judge whether bias might have crept in. For example, for an interview method, is there an indication of how interviews were conducted? If different interviewers were involved, how did they minimise differences in personal interviewing style? Did they use a topic guide or a standard set of questions and / or prompts? A lot of qualitative research is exploratory and so researchers are expected to reflect on their data as it is being generated. This means that methods may be modified during the study. Check whether this happened in this study, and, if so, do the authors provide enough explanation of how and why? Is the form of data clear? A good test is whether you can you visualise what the data looks like (tape recordings, video material, notes)? Illustrations of field diaries, transcription frameworks and so on are helpful. Now we come to a bit of qualitative technospeak. Did they discuss data saturation? This is the point at which your method is generating no new information. Question 5: Was the study conducted within an appropriate ethical framework?

Participants in a research study need to understand what they are letting themselves in for, why the study is important and how their contribution will be used once the study is completed and disseminated. This is true of all research. However, in qualitative studies the ethical issues can be trickier, since the personal experiences of the participants will not necessarily be reduced to a set of anonymous numbers. There are potential consequences when peoples personal experiences are exposed both to themselves and to others. Have the authors discussed the ethical issues raised by the study, such as informed consent (and how they achieved this where children or participants with communication difficulties are concerned), confidentiality and how they have handled the effects of the study on the participants during and after the study? Its not enough just to know that approval was gained from a recognised ethics committee (but they should mention this as well). Question 6: What perspective is the researcher coming from, and how has this been built into the study? Another bit of qualitative technospeak is reflexivity the extent to which the researchers critically examined their own role, potential bias and influence during the course of the study. You need to look at reflexivity in the formulation of the research questions, in the data generation, including how they recruited their sample and in their choice of location. It is also critical that they explain how they responded to events during the study and considered the implications of any changes in the research design.



Question 7: How have the data been analysed? it one or two dangers of its own. Ignoring data that doesnt fit into any of your categories or themes is one of them. To what extent have contradictory data been taken into account? Question 8: How credible are the findings? Question 10: What impact does this study have? Do the study findings resonate with my own experiences (and / or those of my colleagues) and therefore have a potential impact: for my practice for my colleagues or care group for the service as a whole? Is there a further question to be asked, or a local study to be carried out, that would allow me to generalise the findings to my own context? And finally... In another recent journal club we used this framework to appraise an article on the perceptions of clinicians and parents on the outcomes of speech and language therapy with children aged 2-6 years (Thomas-Stonell et al., 2009). The study had been conducted in Canada but we looked very carefully at how they selected their participants and at the sorts of provider organisations included. We concluded that there seemed no reason to think that the participants were significantly different from the sorts of families we see in our own paediatric service. Their findings on the disparity between parents and therapists perceptions and perspectives of change also rang true for us, providing support for our current service-wide focus on outcome measures that are clientcentred, and related to impact rather than being impairment-based. Parents, apparently, are more aware than therapists of how speech, language and communication disorders are affecting their childrens social participation. SLTP Now theres a surprise! Jennifer Reid is a consultant speech and language therapist with NHS Fife, email
Barbour, R.S. (2008) Introducing qualitative research: a students guide to the craft of qualitative research. Los Angeles:Sage. Graves, J. (2007) Factors influencing indirect speech and language therapy interventions for adults with learning disabilities: the perceptions of carers and therapists, Int J Lang Comm Dis, 42(S1), pp.103-121. Greenhalgh, T. (2006) How to read a paper: the basics of evidence-based medicine (3rd edn). Oxford: Blackwell. Holloway, I. & Wheeler, S. (2010) Qualitative Research in Nursing and Healthcare. Chichester:Wiley-Blackwell. Kuper, A., Lingard, L. & Levinson, W. (2008) Critically appraising qualitative data, BMJ 337, pp. 687-90. Available at: a1035.full (Accessed: 8 November 2010.) Public Health Research Unit (2006) Critical Appraisal Skills Programme. Available at: CASP.htm (Accessed: 8 November 2010.) Skeat, J. & Perry, A. (2008) Grounded theory as a method for research in speech and language therapy, Int J Lang Comm Dis, 43(2), pp.95-109. Thomas-Stonell, N., Oddson, B., Robertson, B. & Rosenbaum, P. (2009) Predicted and observed outcomes in preschool children following speech and language treatment: Parent and clinician perspectives, J Comm Disorders 42, pp.29-42.

Did the authors critically examine their own role, potential bias and influence during analysis and selection of data for presentation? Remember that qualitative research often uses an iterative method where data generation and analysis proceed hand-inhand. Each may influence the other in a cyclic fashion during the course of the study. This means that it is essential that the report includes an in-depth description of the analysis process. Was thematic analysis used? If so, is it clear how the categories or themes were derived from the data? Bottom-up categories are derived from the raw data itself whereas some studies will start with some of their categories pre-set (top-down), perhaps derived from previous research. Horses for courses, but the authors should have described how they arrived at their categories. Beware of bland statements about use of, for example, grounded theory, without any kind of explanation. Do not take on the responsibility for not knowing exactly what they mean! In a journal club earlier this year we were reviewing an article on factors influencing indirect interventions for adults with learning disability (Graves, 2007), which we found helpful for supporting our current practice. The term grounded theory was new to most people in the group so we found her brief explanation invaluable its a bottom-up approach to building categories but I also found another article (Skeat & Perry, 2008) which actually explained the grounded theory approach in a speech and language therapy context. We could do with a few more accessible reviews of methods, illustrated from the speech and language therapy field, to help us with our appraisal of methods. Its common to include in the text of the article examples from the data set to illustrate categories and themes. Do they explain how the data presented were selected from the original sample to demonstrate the analysis process? Are sufficient data presented to support the findings? In qualitative research, the researcher is included as one of the study components, rather than being seen as some sort of objective, reliable, impartial and unbiased observer from the planet Zog. This brings with

First of all, consider whether the findings are explicit enough, then whether there is adequate discussion of the evidence both for and against the researchers arguments. Do they discuss how they have attempted to increase the credibility of their findings using methods such as triangulation (using different sources to elicit and compare information), respondent validation (using participants that are qualified to speak about the issue in question), more than one analyst? Do you believe the authors narrative? Finally, are the findings discussed in relation to the original research questions? Its important to know if their results did not in the end really illuminate the issue they set out to explore. After all, youre probably only appraising the article because you think the study aims were related to some aspect of your own clinical work. Question 9: How valuable are the findings? Do the authors discuss the contribution the study makes to existing knowledge or understanding? We have already established that its more difficult to generalise from qualitative studies so its important that the findings of this one study are plugged into the bigger picture, however fuzzy it might be. For example, do they consider the findings in relation to current practice or policy, to other relevant researchbased literature or to theory? A theoretical motivation is considered particularly appropriate for exploration of issues with no substantive research base. Qualitative findings sometimes provide at best an incomplete or inconclusive story. Do the authors identify new areas where research is necessary? Do they discuss whether or how the findings can be transferred to other populations or consider other ways the research may be used?







Getting speech and language therapy services to the most vulnerable and deprived children is a challenge. NHS Forth Valleys Communication Help and Awareness Team (CHAT) introduced and evaluated a Whole Nursery Narrative Approach in areas of disadvantage across three Scottish local authority areas. Here, they report on the projects positive outcomes for language development and for school readiness. Additional information on the curricular impact is provided by Diane Cairns, one of the senior early childhood educators involved.

s is widely appreciated in the world of speech and language therapy, language development for children living in areas of social-economic disadvantage is significantly depressed in comparison with their cognitive abilities (Locke et al., 2002, p.1). Communication difficulties are the most common neuro-developmental condition. It is vital that children with communication difficulties receive appropriate early intervention to give them the best chance of making progress during the optimum time for language acquisition. Within NHS Forth Valley (covering the three local authority areas of Stirling, Falkirk and Clackmannanshire) our head of service Mary Turnbull identified a gap in the speech and language therapy service for vulnerable families with children in the 0-5 years age group. To address this, she submitted an application in August 2002 to the Changing Childrens Services Fund for 4.5 whole time equivalent speech and language therapy posts. This fund was set up to provide transitional funding for integrated services and new approaches in Scotland that would deliver better outcomes for the most vulnerable and deprived children and young people. Funding was initially granted for two years for 3 whole time equivalent speech and language therapists, to be shared equally across the three areas. This small group began work in January 2003 as CHAT (Communication Help and Awareness Team). Funding beyond the initial period has so far been granted on a year-by-year basis from each Local Authority. Our overall aim is to enable those involved with children in the early years to work together to maximise childrens language and social development in order to promote later literacy and communication skills. We are achieving this through: 1. Prevention By raising awareness of normal language development, encouraging joint working and helping parents to enjoy developing their

childs language in a fun way, CHAT hopes to reduce the number of children who require specialist help. 2. Promotion By providing both formal and informal training in all aspects of communication to those involved with children in the early years (05), CHAT promotes best practice. Our 2 day training course Supporting and Identifying Children with Speech and Language Difficulties (adapted from Habgood et al., 1999) is delivered to nursery staff, with an adapted version for health visitors, childminders, GPs and relevant professionals from independent agencies. 3. Prioritisation By providing training, CHAT hopes to enable other professionals and parents to identify and prioritise the children who need specific intervention. 4. Provision By increasing the accessibility of the speech and language therapy service in local communities, we are able to target the hard to reach population and provide increased support for parents, families and other professionals such as health visitors, social workers and family support workers. We are proactive in offering group and one-to-one sessions at baby clinics, toddler / playgroups, young mothers groups and antenatal groups. The parents are usually very keen to ask questions, for example about dummy use, television viewing and their other children. 5. Production With funding for printing from the speech and language therapy budget, CHAT has produced relevant and easy to read leaflets, posters and information packs for community wide distribution through doctors surgeries, libraries, Bookstart packs (now the Scottish Book Trust), baby clinics, playgroups and nurseries. These five objectives formed the foundation of the work of CHAT, and its steering group also identified overarching aims of health promotion and raising language attainment.

This steering group of speech and language therapists, including manager Mary Turnbull and the CHAT team, meets at least once a term. We initially selected nurseries in areas of deprivation where we had the highest fail to attend rates for our service. Throughout the project, the CHAT team has worked with early years staff in these nurseries to deliver the Whole Nursery Narrative Approach, a 10 week programme adapted from Carey et al. (2007). The sessions: target attention, listening, turn taking, vocabulary and sequencing skills. follow a specific structure in that there is always a hello song, an activity, a story and a goodbye song to finish. Positive praise is given for good listening, good sitting, good turn taking and good looking. use visual materials from the pack. This primarily consists of picture material, however with younger children the use of real objects is recommended. cover different topics each week (figure 1). These focus on strengthening the childrens understanding of the elements that make up a simple story, namely who, where when and finally what happened. cover vocabulary reinforced by activities, songs, rhymes and Makaton signing. From August 2007 until March 2008 CHAT therapists investigated the effectiveness of this Whole Nursery Narrative Approach. We wanted to find out if it a. improved the narrative / language skills of the children b. enhanced these skills when combined with preschool nursery education c. could be replicated. If we were able to demonstrate effectiveness through comparing results from two different nurseries in each geographical area, we would be better placed to meet our objective of promoting the integration of the approach into the preschool curriculum. To prove that the study could be replicated with similar results, we matched two nurseries in each geographical area (Stirling, Falkirk and



Figure 1 Session topics WHO 1. 2. 3. 4. 5. me and my family animals insects jungle and zoo animals people who help us

WHERE 6. sound location 7. where would you find it? 8. animals and insects where they live WHEN 9. night and day 10. narrative session using 3 little pigs / little red riding hood

Figure 2 Session plan example (Session 5, People Who Help Us) ACTIVITIES Rules of good looking / listening / sitting sit children in a semi-circle MATERIALS good looking, good listening, good sitting cards (yellow) good looking, good listening, good sitting Makaton signs ball who sheet (pink) who Makaton sign

Hello Song, with names pass the ball to a child while saying the childs name sing the Hello song ask each child who to sing to next Who is in the box? give clues for each child to guess who is in the box

People Who Help Us pictures - people and associated items box who sheet (pink) who Makaton sign People Who Help Us pictures who sheet (pink) who Makaton sign objects of reference pictures from pack People Who Help Us pictures - people and associated items who sheet (pink) who Makaton sign People Who Help Us pictures lotto board of people who help us who sheet (pink) who Makaton sign

Clackmannanshire) as best as possible. For example, in Stirling, both selected nurseries were classes within primary schools in small former mining villages. We did not, however, match individual children for language ability.

Jump up if... give clues such as who works with animals? for each child to jump if it is their person Objects of reference Objects that different professionals use Card Game put people on the floor. Give each child two cards to put beside the right person. Who Lotto

Selection process

We had a total of 88 children involved, with up to 24 children in their preschool year in each participating nursery. These children were selected by the nursery staff with no criteria imposed on the selection process, and our results have to be interpreted with that in mind. As we anticipated, the staff selected some children with previously acknowledged language difficulties. Once the nursery identified the children, we provided a parental consent letter. This gave information about the group and specified that, although the children had been selected to participate, it did not mean that they had difficulties with speech and language. Although parents were given a chance to opt out, none did. CHAT therapists visited the designated nursery one day per week to see the selected children, running four language groups each day. The groups included a maximum of six children, one early years worker / early

Story The Tiger Who Came to Tea Goodbye Song sit children in a semi-circle pass the ball to a child while saying each childs name sing the Goodbye song ask each child to choose who to sing to next

Book by Judith Kerr, The Tiger Who Came to Tea ball who sheet (pink) who Makaton sign

childhood educator who had attended our 2 day training programme and one CHAT therapist. CHAT staff requested the use of a relatively quiet, distraction-free environment where possible. Groups ran for between 30 and 45 minutes. The early years worker / early childhood educator repeated the group plan with the same children on a day in the same week

when the CHAT therapist was not in nursery. An example of a session plan is in figure 2. CHAT therapists devised a set of four parent workshops which are made available during the Whole Nursery Narrative Approach. These cover early language and literacy development. We advertised them via posters and leaflets, and nursery staff invited the parents of participating children to attend.



We held them at the start of the nursery session (morning / afternoon) and they lasted around 40 minutes. Uptake differed between nurseries, with attendance ranging from 3075 per cent. We used two assessments, the Action Picture Test (Renfrew, 1997) and the Squirrel Story Narrative Assessment (Carey, 2006) with the children. We took a baseline measure before the groups started, then re-assessed following the 10 week programme (figure 3).
Figure 3 Assessment programme Pre screen nursery August September December January March 10 week narrative sessions Post screen nursery A Pre screen nursery B 10 week narrative sessions Post screen nursery B


We collected results from all three areas. In Clackmannanshire the narrative groups were unfortunately disrupted in Nursery B due to the therapists ill health. As only 6 out of the 10 weeks were completed, it was inappropriate to carry out post course assessment. Aim 1 To investigate whether the Whole Nursery Narrative Approach improves narrative/ language skills in pre-school children Across all three geographical areas, 100 per cent of the children who completed the programme had increased information and grammar raw scores on the Action Picture Test (Renfrew, 1997). On information scores, a significant majority achieved an age equivalent increase greater than their increase in chronological age. The childrens grammar scores highlight interesting results on post intervention assessment; more children had age equivalent scores that were above their chronological age. Grammar is not taught throughout the 10 week programme, so this suggests there may be a positive effect on grammar development when focusing on narrative skills. All except two children (total = 86) achieved substantially higher scores on the Squirrel Story Narrative Assessment. We therefore feel it is fair to conclude that the Whole Nursery Narrative Approach does improve narrative and language skills in preschool children. Although there was some variation in the amount of change, it is positive that children from each nursery improved on their pre-intervention scores. Aim 2 To investigate whether the Whole Nursery Narrative Approach enhances narrative / language skills when combined with preschool nursery education in comparison with preschool nursery education alone To do this, we compared assessment results from the second screening of Nursery A (after intervention) in relation to the scores from the initial screening of Nursery B (before intervention). All these assessments were administered during the same week in December 2007. The children in Nursery B were also in their pre-school year and therefore around the same age as the children in Nursery A. Both sets of children had been in nursery for the same amount of time and therefore the only difference between the groups was that

children from Nursery A had received the 10 week group programme of narrative input. In two of the three geographical areas (Falkirk and Stirling), children from Nursery A scored higher for both Information and Grammar on the Action Picture Test and were more capable with narrative (Squirrel Story) than their peers in Nursery B. Both groups of children had been in nursery for the same length of time. It would therefore appear that 10 weeks of the Whole Nursery Narrative Approach in addition to 10 weeks at nursery enhances language skills more than nursery education alone. This was not shown as clearly in Clackmannanshire where the nursery B scores pre-intervention were closer to those of Nursery A post-intervention. We felt this might reflect poorer matching, as the children from Nursery B were from an area of higher socio-economic status than those from Nursery A. We noted however, that, relative to themselves, most children at Nursery A improved their scores. Aim 3 To investigate whether the Whole Nursery Narrative Approach can be replicated in other establishments with similar results This has been clearly demonstrated by this project. We replicated results across all three geographical areas, with all three Nursery A groups showing improved language and narrative skills after the 10 week intervention period. Results were also replicated in two of the areas (Falkirk & Stirling) with Nursery B children. In Clackmannanshire, where we could not measure Nursery B due to the therapists illness, informal feedback suggests these children would have followed the same pattern, as nursery staff were already aware of the benefits: Groups have been so beneficial [The groups] tied in with needs we found in the nursery It provided an opportunity for children to have a quiet time to focus on their talking in an otherwise busy and noisy nursery Children who were otherwise quiet gained in confidence to contribute We would like to continue this approach next year. The second comment also suggests that,

although the groups were planned by speech and language therapists, the Whole Nursery Narrative Approach is relevant to the needs of nurseries. The approach is continuing to be popular and is used by some nurseries with only minimal support from us (figure 4).

Wider impact

Having completed one successful service evaluation using measures familiar to speech and language therapists, the CHAT team was keen in 2010 to investigate the wider impact of the Whole Nursery Narrative Approach. In particular, we wanted to find out if there was any impact on general school readiness. While there is no single specific measure of school readiness, for the purpose of this evaluation we considered language concepts needed for primary one as well as social communication skills as indicators. In addition to the assessments used in the 2007-2008 evaluation, we administered the Bracken School Readiness Composite (SRC) (in Bracken, 2006). We also decided that a measure of cognitive maturity would be useful, as we suspected there may be a correlation between cognitive ability and a childs capacity to improve their language skills. For this we used the GoodenoughHarris Drawing Test (1963). The methodology for this evaluation was consistent with the previous study, with the exception of the additional assessments and selection. We assessed the children before and after involvement in the 10 week programme. We used one nursery in each area (three in total) and concentrated on pre and post group assessment results for each. However, this time, we matched the nurseries in terms of their scoring on the Scottish Index of Deprivation, looking at the percentage of the population who are income deprived and the percentage of the working age population who are employment deprived. Following participation in the 10-week groups, between 77.7 per cent and 100 per cent of the children made improvements in their language and communication skills. They also made progress in their school readiness (Bracken, 2006). It appeared that, irrespective of cognitive maturity, the majority of children showed improvements in the concepts that parents and nurseries traditionally teach in preparation for primary one. While these



Figure 4 The curricular impact at Cornton Nursery Diane Cairns, senior early childhood educator, writes...

ornton Nursery is a standalone early years establishment serving a community situated in an area of urban deprivation. It assists 109 families on varying levels and accommodates children from three months to five years of age. It has a team of 16 early years professionals who work closely with many visiting specialists. Through collective professional observations it was noted that an increasing number of children had reduced and impaired language skills. Due to close partnership working with the speech and language therapist Hazel McKellar and lengthy professional discussions, it was concluded that many children would benefit from narrative language sessions. This would potentially raise achievements across the learning environment and help eradicate any further issues, while highlighting areas for further specialist language input. This proposal was put to the team, who collectively agreed that it would be an excellent way forward. A staff member was selected to deliver this narrative approach and worked jointly with the speech and language therapist on a weekly basis for ten weeks. Each staff member in the 3-5 play room was jointly trained by their colleague and the therapist on a rotational basis, and any staff member who had not accessed the CHAT training programme was promptly put forward to do so. The therapist was then approached to help with early language intervention for children aged 0-3, resulting in the enhancement of the Baby Chat programme. This was already being delivered but is now heavily assisted by Makaton signing, which helps staff reinforce the spoken word. On evaluation of the narrative sessions, a handful of children were then chosen to engage in a phonological awareness group. This was again developed jointly with the speech and language therapist to help with the childrens preparation for going to school. On further reflection and detailed observations, we soon realised that the fundamental principles of the narrative approach were assisting with our other programmes such as Fun Friends and transition, so we increased the weekly session to twice weekly. The nursery also arranged for the speech and language therapist to come along to the parent information evening, where the strong message of joint partnership working to provide positive outcomes for children was given. This also gave parents and carers the opportunity to find out from a professional specialist exactly what their children were involved in. The fundamental principles of the narrative approach are now fully embedded into daily practice. They mirror the nursery contexts for learning, thus enabling staff to use this approach to extend childrens natural dispositions and interests. Staff in the 3-5 room now own a box of narrative resources, ensuring its daily delivery. Due to limited space within the establishment the sessions are run in group areas. Although they are seldom free from distraction, we feel this helps the childrens concentration skills and their ability to filter out background noise, which again will be an expectation when they enter school. This holistic and whole nursery approach is proving invaluable and allows flexibility of learning. Differentiation can be taken into account, as it encapsulates the principles for design from the Scottish Curriculum for Excellence offering challenge and enjoyment; breadth; progression; depth; personalisation and choice; coherence and relevance. This early intervention approach is also assisting us to execute core areas from the Early Years Framework and displays multiprofessional working for children in a very positive and successful manner. To date childrens expressive language and listening skills have significantly increased and all staff have gained an increased awareness of language and its importance for communication and thought processes. All this said, the attitude of staff and their willingness to engage and work through difficult logistics and limited resources needs to be commended, as does the speech and language therapists commitment to our establishment. As she herself stated it was the true spirit of learning and trying things out together that made it all worthwhile.

All photos show children at Clackmannan Nursery enjoying a narrative group

concepts are not a focus of the 10 week Whole Nursery Narrative Approach, it would appear that targeting listening skills has a positive impact on childrens readiness to learn in the nursery environment. If funding allows, the CHAT team will continue the valued pre-referral work, training and involvement with children between the ages 0-5 and their families who live in vulnerable communities. The CHAT team would also consider carrying out some more formal research into tracking the children involved in this study throughout the early years of primary education. We anticipate that they will continue to make progress with SLTP language and narrative skills. Nicola Orr ( and Claire MacLean ( are speech and language therapists with the Forth Valley CHAT team. Liz Richie is a former member of the CHAT team, now retired.

Bracken, B.A. (2006) Bracken Basic Concept Scale Revised (BBCS-3:R). Oxford: Pearson. Carey, J. (2006) Squirrel Story. Keighley: Black Sheep Press. Carey, J. et al. (2007) Nursery Narrative (2nd edn). Keighley: Black Sheep Press. Harris, D.B. & Goodenough, F.L. (1963) Goodenough-Harris Drawing Test. Oxford: Pearson. Locke, A., Ginsborg, J. & Peers, I. (2002) Development and disadvantage: implications for the early years and beyond, International Journal of Language & Communication Disorders 37(1), pp.3-15. Habgood, L., Wheeler, K., Battye, A., Falkus, G., Hayon, K. & Typadi, E. (2003) The Community Early Years Training Pack (revised edn). London: Hammersmith & Fulham PCT, Kensington & Chelsea PCT, Westminster PCT. Renfrew, C. (1997) Action Picture Test. Milton Keynes: Speechmark.

To comment on the difference this article has made to you, see information about Speech & Language Therapy in Practices Critical Friends at




Resource reviews
WellComm: A Speech and Language Toolkit for the Early Years Sandwell Primary Care Trust GL Assessment ISNB 978 07087 19718 250.00 + VAT


An all-encompassing package

WellComm is a screening and intervention package designed for Early Years Practitioners to use with young children between the ages of 6 months and 6 years. It provides practitioners with a means to monitor the language development of youngsters in their educational settings. It also identifies those requiring additional support, as well as providing resources to enhance the skills of all children. We see it as an all-encompassing resource that may be used by mainstream, private and social work nurseries, childrens centres, school support bases and perhaps some mainstream schools. WellComm consists of: 1. a Handbook 2. Big Book of Ideas 3. The Picture Book 4. The Little Book of Rules 5. Resources CD/Training DVD. The Handbook was a pleasure to read. It is jargon-free, easily read and well laid out. It is an accessible resource for building the capacity of early years practitioners in relation to their understanding of speech and language development. According to one practitioner we approached, the information is easy to relate to, as it captures the theory covered in their training. It also documents clear links with Government policies. The Handbook is divided into clear sections, including how to use the resource, information on language development, policy and development and appendices / score sheets. The 10 question screening assessment is split into two parts; what the child understands and what the child uses. There is an individual assessment sheet for each age band (6-11 months; 1217 months and so on), and the accompanying DVD gives practitioners practical hints and tips on assessment. Every assessment follows a similar logical pattern and requires a combination of observation, parental discussion and picture / object based activities. The Little Book of Rules identifies the equipment required for each assessment sheet. Scoring is clear and plotted against a traffic light system. There is then easy identification of those children developing their language age appropriately (green), and those showing mild (amber) or significant (red) delays. Furthermore, it points the practitioner in the direction of the childs next steps. The Big Book of Ideas is a fantastic reproducible resource that provides practitioners with a comprehensive collection of activities to help further develop a childs pre-linguistic and expressive / receptive language skills. The activities are grouped into age intervals and encompass the early years learning through play philosophy. Activities are practical and easily absorbed into a nursery setting. We particularly liked the layout of the resource sheets, which took the format of rationale, activities, and step up / step down strategies in relation to a particular skill. The sensible wording throughout and eye catching format are further strengths. For interest we trialled the assessment. It crossed over nicely with our informal observations and taps into the familiar Reynell and Derbyshire Language Scheme tasks, but would not replace our usual assessment protocol. WellComm is not specifically for speech and language therapists, but still has a place in a busy community clinic. The Big Book of Ideas in particular supports our collaboration with parents and other professionals, and boosts their knowledge base in helping all children develop speech and language skills. We can see the general advice sheets being used to reinforce the strategies speech and language therapists frequently advise to both parents and professionals. The resource sheets are user-friendly for speech and language therapists of all levels of experience. They are a useful addition to support the development of pre-linguistic skills such as joint attention. Like other ring-bound resources, it is vulnerable to damage, but the resource CD makes up for this! WellComm is a quick and accessible way of refreshing your knowledge of language developmental milestones. Our current speech and language therapy students were positive in their feedback and acknowledge its usefulness as a resource to develop their clinical skills. For us, WellComm is not just an assessment or a paper resource, it is a tool that can facilitate collaborative working. WellComm is a surprisingly refreshing read and resource, and is well worth the one-off payment. Mairi Cowley and Mhairi Mullin reviewed WellComm with help from Liz Fairweather and Fiona Berry. All are paediatric speech and language therapists based in Glenrothes, Fife.

Lets Sign BSL Early Years Curriculum Tutor Book / CD ROM and Student Book Debra May & Alison Wells Co-Sign Communications ISBN 978-1-905913-15-2 20.00 ISBN 978-1-905913-16-9 10.00

Clear and well-structured

These resources have been developed primarily by Deaf Tutors for Deaf Tutors in education to deliver early years courses in British Sign Language (BSL). They are designed as a 10 week course of 1 hour per session or 5 weeks of 2 hours per session. The BSL training is aimed at nurseries, families and primary settings. The tutor book contains clear, wellstructured course outlines, plans and materials. The teaching covers basic BSL linguistics, topic based vocabulary sheets and single signs/ phrases for early years (greetings, people, family, colours, questions, animals, time, numbers, toys, weather, clothes, school and Christmas). It has excellent BSL sign graphics created by Cath Smith. They are organised into relevant categories for use with young children. This resource is not aimed at speech and language therapists. The course content and materials would however be relevant for a speech and language therapist new to working with young children using or developing BSL. I am not sure why the authors have seemingly limited this to a resource for Deaf people to deliver. I feel that teachers, speech and language therapists or experienced learning support assistants or speech and language therapy assistants qualified to BSL level stage II or above could also present this course. It would also be perfect to use in the running of a Sign Club for hearing children in primary schools where there is hearing resource base or Deaf children are integrated into mainstream classes. For speech and language therapists wanting a book of basic, early years BSL vocabulary, however, there are other Lets Sign dictionaries and guides that would be more useful. Ann Birch is a specialist speech and language therapist working with children with severe/ profound hearing loss for Cardiff & Vale University Health Board.




How I encourage community participation (1):

Any volunteers?

A pilot study of the Personal Development Programme suggests it promotes volunteering and increased activity among people with aphasia, bringing benefits to the individuals and their communities. Gill Pearl and Gill Jackson ask us to consider how we can engage and support people to do more with aphasia.


espite calls for many years now for increased focus on community participation by people who have aphasia (Sarno, 1993; Hirsch & Holland, 2000; Cruice et al., 2006), it appears their exclusion is still highly prevalent (Parr et al., 1997; Parr, 2004; Steel, 2005). As therapists we have a duty to work with people who have aphasia in a way that promotes more personally meaningful activity, and supports their re-integration and participation in their communities (Kagan, 1993). The great majority of research into access and inclusion for people with aphasia has happened within the last 10 years (SimmonsMackie & Damico, 2007) and the January 2007 issue of Aphasiology (21(1)) was devoted to the subject. Although it is not always clear what individuals consider as meaningful community participation, for some, volunteering is an appealing and appropriate way to spend their time. Volunteering has potential to re-engage people with their communities, to demonstrate and develop skills, and to enhance confidence, self-esteem and quality of life (IVR, 2004). Volunteering is defined as activity that involves spending time, unpaid, doing something that aims to benefit the environment or individuals or groups other than (or in addition to) close relatives (Compact, 2008, p.4). There is recognition that it is beneficial both for those who volunteer and for the organisations hosting the activity. However, until recently, volunteering by people with aphasia has not been given great attention. It is not widely considered as an option either in rehabilitation or in living a more fulfilling life with aphasia. It appears that the small amount of volunteering currently happening for people with aphasia is within or supported by stroke or aphasia specific organisations (Pearl et al., 2006). A recent research project hosted at Manchester University and funded by the Health Foundation explored both the effects of volunteering by people with aphasia

Gill Pearl (centre) with Joan Morris and David Myles. Joan and David are members of Speakeasy, and took part in the volunteering programme. Photo by Martin Stembridge.

(on themselves, on other people and on the organisations hosting the activity) and the influences on volunteering from the perspective of people with aphasia (Pearl et al., 2007). This research gave considerable insight into the perceived processes operating

around this activity and contributed to the development of a conceptual model. The research participants were clear that volunteering was more likely to be successful if there was consideration of the potential positive and negative effects, and forward




planning to maximise the positive and minimise the negative. As an example, one participant was asked to assist with running activities in a local stroke group. Although this activity itself was within the capabilities of the participant, it was at an inappropriate time (I was too close to the stroke really), of an overlong duration (I got so tired) and did not provide the required communication support. The whole experience left the volunteer reflecting, I felt I was in a mad house. Another participant commented that volunteering within his support group for an activity at the start of the session left him so tired that he was unable to join in with the rest of the day. There was wide recognition that appropriate support is essential and that thinking through the support in advance would have helped to prevent difficulties (next time I would stay overnight; They [the organisers] need to do it differently; it were good but get the support that need). People working with those who have aphasia are in a position to promote volunteering both as part of rehabilitation and as an aspect of community participation. To support these professionals in promoting more or more successful volunteering, we used the conceptual model which developed from the research as the basis of a resource for group discussions.

Figure 1 Activites identified by all members of the group Gardening at the local YMCA sports centre Teaching bowls to new members of the bowls club Helping at the local Citizens Advice Bureau Helping in a charity shop Taking on a new role in a Masonic club Volunteering at Dyscover Making tea in a residential home

A healthcare professional is routinely seen as a person of expertise. This designation gives them a position of power that derives in part from their ascribed knowledge and skills, but it can also derive from how they behave, communicate and engage with others. Professionals are trained to be aware of their power and its effects. In the context of group discussions that are led by a healthcare professional, there can be an element of compliance. Group members may be more prone to agreeing with suggestions unless the group leader employs strategies to manage

The resource, entitled the Personal Development Programme: Doing more with aphasia, is structured in three sections. The first considers the philosophical issues surrounding approaches to disability. We have included this because the underlying attitudes of those involved in the group undoubtedly affect the quality and content of the discussions. The medical model of disability, which focuses on the impairment, is often dominant amongst healthcare professionals. The philanthropic view is highly prevalent in the voluntary sector and in society at large, and views disability in terms of care and pity. The social model, which has grown from the views of disabled people themselves, offers an alternative. It considers the barriers in society which act to disable, and the identity of each individual as having a right to a unique, integral part of their society. Further reading around this topic would help to give greater insight and understanding of the effects of an individuals approach to disability (Jordan & Kaiser, 1996; Pound et al., 2000; Swain et al., 2004). The social model is concerned with issues of power and liberation from the constraints imposed by society and from those operating with a value base situated in other approaches to disability. The discussions in the Programme involve open and honest debate. It is important therefore to consider the values which drive the process and are manifested in the power relationship between those in the group, the environment and the communication of those involved.

Underlying attitudes

It is essential that attention is given to fine detail. What may seem a small issue to one person can seem an insurmountable barrier to another.
the power relations to maximise participation and minimise compliant responses. One way to achieve these empowerment effects is for the group leader to actively encourage people in the group to consider what is right for them, challenge assumptions, and progress in their own way. Engagement is participation which occurs at a deeper level with more commitment and ownership. Putting inclusive and empowering values into practice means giving consideration to the way barriers presented by the environment prevent participation and engagement. The venue for the group meetings, if selected carefully, can act specifically to support people both to attend and to engage in the meetings. Although some of the suggested adjustments may appear trivial, they are important elements in the bigger picture. It is essential that attention is given to fine detail. What may seem a small issue to one person can seem an insurmountable barrier to another. As would be expected for a group involving

people with aphasia, the provision of communication support is essential to foster discussion; this involves both materials to support communication exchange and the skills of the people providing the support (Kagan, 1998). The second section of the Personal Development Programme considers the practicalities of hosting group discussions where the members have aphasia. These considerations may include such aspects as the adoption of group rules for good conversations. Another example is the appropriate timing for meetings to take into account fatigue caused by the effort required to communicate in a group. The Programme contains information about how the principles of fostering participation and engagement can be put into practice. The third section provides structure for the discussions themselves, clustered into six sessions. Each session provides the background for the topic, quotes from the research participants to provide additional insight, complementary resources and finally a DVD which features people with aphasia talking about their experiences of volunteering. These resources can be used flexibly and creatively to stimulate in-depth discussions and assist with planning and decision making for activity for people with aphasia. In summer 2008, Dyscover (an aphasia support and therapy group in Surrey) piloted the Personal Development Programme. The purpose of the pilot study was to evaluate the Programme so we could refine and improve it. We also wanted to evaluate its usefulness from the perspective of the people with aphasia, the staff facilitating the group discussions and the manager of the aphasia centre. In addition we evaluated the outcome of activity changes which occurred as a result of participation in the group discussions. Initially eight people with aphasia as a result of stroke elected to take part in the pilot (five men and three women). Four were clear at the outset that they did not want to volunteer, only to take part in the pilot. All had attended Dyscover for between 18 months and 12 years and were 2.5 - 16 years post stroke. The discussions were facilitated by an experienced aphasia therapist with support




from two student speech and language therapists. It was necessary to allocate initial time for planning of the group work and evaluation following the discussions, and to schedule time after the end of the Programme to allow for follow-up and further support. Six people completed the course; one dropped out due to health issues, and one following discussion with the staff due to a combination of factors including continuity difficulties from a holiday break, competing interests and the need for more individualised one-to-one support for comprehension. We evaluated the process of taking part. Comments by the six members who completed the course suggest that the activity itself was of value: this is good, you might be surprised what it might lead to Why cant we do this all day? Completion of the course itself was seen to improve confidence, to help with focusing on ability rather than disability, and to demonstrate the ability to make decisions. Each individual chose an activity that they wished to pursue. The activities identified by all members of the group - including those who did not initially want to increase their activity - are in figure 1. that supported purposeful discussions on the theme of volunteering, and they intend to run the programme on a regular basis. The feedback from the pilot study suggests that the Personal Development Programme has potential to support therapists to promote volunteering and other activity as a way of increasing community participation for people with aphasia. After six months of volunteering as a result of attending the group discussions one member of Dyscover has taken on a part-time job, thus demonstrating that volunteering for people with aphasia can be a stepping stone back into employment. There is still much we dont know about the usefulness of the Programme. For example, can it fulfil its potential as part of rehabilitation, would an evaluation in a medical setting reveal different results, is the resource useful in one-to-one discussions, is there a minimum set of requirements before someone can engage in the discussions? However, the small scale pilot study at Dyscover suggests that the resource has potential to encourage volunteering and a wider range of life activities, as well as volunteering which is SLTP more likely to be successful. Speakeasy ( and Dyscover ( are specialist aphasia charities in Bury, Lancashire and in Surrey. Gill Pearl and Gill Jackson are their respective Chief Executives. aphasia: Living with the loss of language after stroke. Buckingham: Open University Press. Pearl, G., Young, A. & Sage, K. (2006) Volunteering and people with aphasia in North West England. Pearl, G., Young, A. & Sage, K. (2007) An exploration of the involvement of people with aphasia in service delivery activity. M Phil Thesis. University of Manchester. Pound, C., Parr, S., Lindsay, J. & Woolf, C. (2000) Beyond Aphasia: Therapies For Living With Communication Disability. Milton Keynes: Speechmark. Sarno, M.T. (1993) Aphasia rehabilitation: psychosocial and ethical considerations, Aphasiology 7(4), p.321. Simmons-Mackie, N.N. & Damico, J.S. (2007) Access and social inclusion in aphasia: Interactional principles and applications, Aphasiology 21(1) pp. 81-97. Steel, R. (2005) Actively involving marginalized and excluded people in research, in Lowes, L. & Hulatt, I. (eds.) Involving service users in health and social care research. Routledge: Oxford. Swain, S.F., Barnes, C. & Thomas, C. (2004) Disabling barriers - enabling environments. 2nd edn. London: Sage.

Increased activity

In addition the discussion promoted thought around increased activity not necessarily related to volunteering (it set my mind thinking about gardening), thus demonstrating the potential for the Programme to promote general activity. There appeared to be a perceived value in having structure to the discussions (if they do a course like this they may volunteer sooner; I didnt think of doing voluntary work before; ..focus the mind to think about things otherwise drift forever). The discussions helped staff to understand more fully the perspectives of the people in the group, even those whom they had known for many years. For example, the participants had had a tendency to put on a brave face about the challenges they regularly met and to present a more positive view of their lives to the world. Open discussion through the Programme promoted honesty and therefore the generation of more realistic and appropriate solutions. It assisted staff to structure discussions in a flexible way, and to support discussions to include activity which had not previously been considered, such as helping out in a local residential home. The pilot project resulted in considerable changes to the format of the Programme, condensing it from 10 down to 6 sessions whilst still allowing for expansion back to 10 sessions should time allow. The six participants suggestions for improving the resource were incorporated into the final version. In addition, we re-structured the content to allow simpler navigation around the support resources. All the staff at Dyscover valued the Personal Development Programme as a useful resource


Compact (2008) Volunteering: Compact Code of Good Practice. Crown Copyright. Available at: files/GFSR.asp?NodeID=100323 (Accessed: 2 November 2010). Cruice, M., Worrall, L. & Hickson, L. (2006) Perspectives of Quality of Life by People with Aphasia and Their Family: Suggestions for Successful Living, Topics in Stroke Rehabilitation 13, pp.14-24. Hirsch, F.M. & Holland, A.L. (2000) Beyond Activity: Measuring Participation in Society and Quality of Life, in Worrall, L.E. & Frattali, C.M. (eds.) Neurogenic Communication Disorders - A Functional Approach. Thieme: New York. Institute for Volunteering Research (2004) Volunteering for all? Exploring the link between volunteering and social exclusion. London: Institute for Volunteering Research. Jordan, K. & Kaiser, W. (1996) Aphasia - A social approach. London: Chapman and Hall. Kagan, A. (1993) Functional is not enough: Training conversation partners for aphasic adults, in Holland, A.L. & Forbes, M.M. (eds.) Aphasia treatment: World perspectives. San Diego: Singular. Kagan, A. (1998) Supported conversation for adults with aphasia - methods and resources for training conversation partners. Aphasiology 12(9), pp.816-830. Parr, S. (2004) Living with Severe Aphasia - The experience of communication impairment after stroke. Brighton: Pavilion. Parr, S., Byng, S. & Gilpin, S. (1997) Talking about

The Personal Development Programme is available to buy at cost from Speakeasy. For further information please contact Gill Pearl, tel. 01706 825802.

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How I encourage community participation (2):

Actions not words

Shortly after being made redundant from his job as a welder, Colin had a stroke which left him with mild motor difficulties and moderate aphasia. Speech and language therapist Rebecca Allwood and occupational therapist Jane Terry reflect on the factors that enabled him to embark on a journey back to work in spite of his communication difficulties.
eturning to work is often a long-term goal for younger people who have had a stroke. The National Stroke Strategy (DH, 2007, p.34) cites the finding of the Stroke Association and Different Strokes (2006) that three quarters of affected younger individuals want to return to work. It also recognises that employers and voluntary organisations require training so they can support the process. The National Clinical Guideline for Stroke (2008, p.103) gives advice on supporting people to return to activities or work: A. Every person should be asked about the vocational activities they undertook before the stroke. B. Patients who wish to return to work (paid or unpaid employment) should: have their work requirements established with their employer (provided the patient agrees) be assessed cognitively, linguistically and practically to establish their potential be advised on the most suitable time and way to return to work, if this is practical be referred to a specialist in employment for people with disability if extra assistance or advice is needed (a disability employment advisor, in England). The Community Stroke Team (Citihealth, NHS Nottingham) supports people to return to or undertake new activities, including paid or unpaid work if this appears to be realistic. The team provides multidisciplinary medium to long-term rehabilitation and advice for people with a stroke and their carers. It works alongside other agencies such as the YMCA, Stroke Association and Aphasia Nottingham (a local self help group), and also offers stroke awareness training. Alongside occupational therapy, speech and language therapy and physiotherapy, we have a mental health nurse who supports people and carers with the emotional side of having a stroke and rehabilitation. We also have generic assistant practitioners and rehabilitation support workers who carry out programmes of rehabilitation under the supervision of the


Figure 1 Colins Communication Profile

I had a stroke in April 2008. Due to the effects of the stroke: I sometimes have difficulty saying what I would like to say. I sometimes get stuck on words. I sometimes say words that I do not mean to say. I can mostly read single words but I have difficulty reading sentences. I can: Understand everything that is said. Think normally and make decisions. Ways to help: Give me time to find the words I want to say. Take things slowly. Do not pretend to understand what I am saying - check with me. Do not give me a lot of information to read.

health professionals. Rehabilitation centres on patient-led goals which are reviewed and updated regularly. Outcome measures are recorded using the East Kent Outcome System (EKOS) (Metcalfe, 2010).


One of our clients, Colin (now aged 63), had a left hemisphere stroke in April 2008, and was referred to us around four months later. His stroke caused a mild motor apraxia and right sided weakness. The main effect was a moderate expressive aphasia characterised by word retrieval difficulties. Colin initially required a lot of support to express himself in conversation, and had acquired reading and writing difficulties.

After a period of residential intermediate care, Colin returned to live on his own in a complex of flats near the city centre. The team worked with him to achieve his early goals, which related to important everyday activities such as shopping and using public transport. Speech and language therapy focused on 1. strategies for effective communication 2. impairment based work to improve word retrieval reading comprehension. Colin began to use communication strategies such as gesture and talking around the word. There was some improvement in conversational language but his aphasia remained a challenge when meeting new people. His




Colin working at Wheelbase. The top left photo shows him in discussion with Rebecca and Jane.

reading improved to comprehension at sentence level, and he was able to write important information such as his name and address. As Colin continued to improve we began to discuss longer term goals. Just prior to his stroke, Colin had been made redundant from his profession as a welder. In December 2008, as part of the goal setting discussion, he expressed an interest in returning to work. Following this we had a joint session with Colin to identify goals that would begin the process. These were to: a. attend an interview at a volunteer agency with the support of speech and language therapy and identify suitable volunteering opportunities b. identify the challenges of returning to a work environment c. be able to explain his communication difficulties and identify the support strategies that he finds useful d. begin the return to driving process e. sustain a regular commitment to a social activity. We felt that a period of volunteer work would give Colin a good experience of what it would be like to return to regular work but would also allow him to be flexible with his hours and to build up his skills and confidence

slowly. His main challenge to returning to work was his communication difficulties and it was important that whoever he was placed with had a good understanding. Returning to driving and sustaining a regular commitment to a social activity require routine, motivation, increasing independence and commitment, and these qualities are all important in working life.

Real life

We arranged an interview at the local Volunteer Agency in Nottingham. This was a challenge for Colin. Much of it was word based, for example he was required to search computer databases for work opportunities and to respond to direct questions from the interviewer. The experience also highlighted the jump between conversation in therapy sessions and in real life. Colin had been forthcoming in talking about his communication difficulties during therapy but had difficulty explaining them in this new situation. Having reflected on this, we developed a communication profile (figure 1). Colin could use this to help explain his communication difficulties to new acquaintances. It would also offer them strategies to support Colins communication. We explored the volunteer opportunities together and Colin chose Wheelbase, a motor

charity project supporting young people at risk of crime and social exclusion. His role was to work on old motor vehicles, initially breaking down parts and cleaning them, with the aim of restoring the vehicle. Colin started volunteering at Wheelbase once a week and was allocated a supervisor / mentor. Although Colin was working in a quiet workshop away from the main project, he was still required to interact with his colleagues. Around this time Colin was also assessed by the DVLA (Driver and Vehicle Licensing Agency) as able to return to driving. He got a car, which increased his general confidence and independence. After a few weeks of settling in, we met with Colin and his supervisor to set some workplace based goals. These were to: a. begin a graded return to a motor task (initially breaking down and cleaning parts from a car, progressing to reassembling and welding) b. be assessed for competency to weld c. access an email account and read a short email each week d. ask for support with reading when required e. update his CV and add the communication profile to inform potential employers




f. use the communication profile to explain communication difficulties to a colleague g. identify services to support return to paid work h. attend Work Directions / Pathways to Work interview with the speech and language therapist. These carefully structured targets enabled Colin to build his confidence and to experience success with each small step achieved. These goals integrated functional occupational and speech and language therapy rehabilitation as well as developing skills required for return to work. Colins mentor at Wheelbase described the difference in Colin from the beginning of his volunteer placement: The biggest thing for Colin was that he wanted to talk to people but he didnt think they would listen. When they did it gave him confidence. He added, The first time he turned up he had no car, it was difficult to engage in conversation and physically he seemed awkward. Now, what was it you said the other day [referring to Colin losing his temper about something not going right], you tried something, got irritated and used natural language; the words were just there. I was impressed at how natural the speech was. It may as well have been anyone else who worked here. One-to-one speech and language therapy continued, concentrating on question and answer scenarios and strategies such as having important information written down. Following discussion with Colin about his communication difficulty and helpful strategies, he began to interact more and we noticed a significant improvement in his conversational language. Colin also commented that, Its improved things because I can talk to people. Anything I want I know I can go and ask. I just get on with it. Our experience at the Volunteer Agency and at the Wheelbase Motor Project highlighted again a lack of awareness among the general population of the effects of stroke, especially aphasia. Colins communication profile helped to explain that he was not just forgetting words and that his speech difficulties did not affect his ability to think and make decisions. There is a need for specific training for employers and voluntary services to improve their awareness of the effects of stroke and to improve their confidence in supporting people in the workplace. In the Community Stroke Team, we recognise it is our responsibility to provide this training, and we have developed a training package that can be offered to potential employers and outside agencies. We aim to deliver this training 3-4 times a year and hope to link in with the volunteer agency. Although general training is important, this experience has also taught us the importance of specific support and training for places which are supporting a person back into work. As well as being valuable to Colin, the multi-agency and interdisciplinary approach means we have developed our skills and learnt from each other. For example, we have an increased awareness of the challenges of a communication difficulty in returning to an activity and also of the importance of making use of retained ability and working in a graded approach to build skills and confidence. The key learning outcomes for us are in figure 2. As Colin says, it is about actions not words. Although this article describes one clients journey, it encapsulates the philosophy of our team in offering a service that crosses professional boundaries to achieve patients goals and recognise their full potential. SLTP
References Department of Health (2007) National Stroke Strategy. Available at: consum_dh/groups/dh_digitalassets/documents/ digitalasset/dh_081059.pdf. (Accessed: 1 November 2010). Intercollegiate Stroke Working Party (2008) National clinical guideline for stroke (3rd edn). London: Royal College of Physicians. Available at: http:// (Accessed: 1 November 2010). Johnson, M. & Elias, A. (2002) East Kent Outcome System for speech and language therapy. Eastern and Coastal Kent Community Services. (Email Metcalfe, M. (2010) EKOS a SMART solution, Speech & Language Therapy in Practice Spring, pp.4-6. Resources Wheelbase Motor Project, Search for Pathways to Work, Disability Employment Advisers, and information about returning to driving at disability Acknowledgment With thanks to Sally Knapp, speech and language therapist.

Figure 2 Our key learning outcomes There is a need for lifelong access to stroke services as documented in the National Stroke Strategy (DH, 2007) to support long term goals. Teams must be aware of the need for support as peoples needs change and develop over time, and to have a robust system to enable people to re-access services. Services should be commissioned to reflect evidence based research for stroke rehabilitation. Aphasia is not just a speech and language issue. Involvement of occupational therapy and other agencies has been key in recognising Colins retained abilities and offering a graded approach to return to work. We need to provide stroke awareness training to services that may not be directly related to stroke.


Colin continues to set and achieve new goals. He has overcome the initial barriers in returning to the workplace and now sees that paid employment is a realistic option. Colin is becoming more independent in establishing his role and seeking out opportunities to develop himself further. This volunteering placement has benefited Wheelbase as well as Colin. Staff are more aware of the effects of stroke and how to support people with communication difficulties. Colins mentor says, Hes a nice bloke, good to have around and Ive learnt something from him being here. In helping Colin to learn things Ive had to find new ways to teach. We hope Wheelbase will offer similar opportunities to other people and share their experience with other voluntary groups and employers. There is a drive to support people with disability back into work. National services such as Pathways to Work and Disability Employment Advisers have been useful in giving us information about what is available for Colin in terms of opportunities and financial support.

Rebecca Allwood (left) (email rebecca.allwood@ was a speech and language therapist in the Nottingham Community Stroke Team until November 2009 and now works for Nottinghamshire Community Health. Jane Terry (email is an occupational therapist in the Nottingham Community Stroke Team.

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My Top Resources
KAREN KRAWCZYKS TOP RESOURCES AND CAREER PATH SHOW HER INTEREST IN COLLABORATING WITH OTHER COLLEAGUES AND PROFESSIONS. HAVING HELD CLINICAL AND MANAGERIAL POSTS IN ENGLAND AND SCOTLAND, KAREN NOW WORKS FOR NHS GREATER GLASGOW & CLYDE IN TWO COMMUNITY REHABILITATION TEAMS. SHE TAUGHT ON THE ADVANCED DYSPHAGIA COURSE AT MANCHESTER METROPOLITAN UNIVERSITY AND IS NOW EXTERNAL EXAMINER. KAREN WAS A SPECIALIST REVIEWER FOR THE SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK (SIGN) ON DYSPHAGIA AND CONTRIBUTED A CHAPTER DYSPHAGIA COMBINING CONFLICTING MODELS? TO THE BOOK SPEECH AND LANGUAGE THERAPY: ISSUES IN PROFESSIONAL PRACTICE (WILEY, 2005). SHE HAD A PARTTIME SECONDMENT TO NHS QUALITY IMPROVEMENT SCOTLAND IN 2008-9. KAREN ALSO HOLDS A LIFE COACHING DIPLOMA. 4. MODEL FOR INDIVIDUAL CHANGE Prochaska & Di Clementes Stages of Change model is widely available on the internet. I came across it a number of years ago and it had resonance. It outlines 5 stages to identify where a client is in relation to making changes in their lives. Identifying the stage they are at can help you provide appropriate intervention. There is a natural fit between Prochaska & Di Clementes model and Motivational Interviewing. This method to enhance motivation can increase our effectiveness and is recommended in recent SIGN Guidelines (118) for people who have had a stroke. Miller, W.R. & Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change. New York: Guilford Press. Scottish Intercollegiate Guidelines Network (2010) Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning. Available at: guidelines/fulltext/118/index.html (Accessed: 12 October 2010). 5. DYSPHAGIA RISK ASSESSMENT Developed in the field of adult learning disability, the National Patient Safety Agency risk assessment has relevance for adult neurological patients. It is invaluable in guiding explicit conversations with ward or care home managers about the risk for patients within their setting. This then allows for discussion of how you can work together to reduce that risk. The different formats for passing on mealtime information to care staff are also very useful. Documentation is in Word format, allowing you to personalise it for your own area. h t t p : / / w w w . n r l s . n p s a . n h s . u k / resources/?entryid45=59823 6. POSTER AND DVD I have been involved with other speech and language therapists and dietitians in the development of the Sndri First Steps to Easier Swallowing poster and an NHS Education for Scotland DVD (available end 2010) to provide support and advice for carers and relatives. They ensure that professionals, whether in the hospital or community, are all using the same language and providing a consistent message. The pictures, along with the National Descriptors A-E and accompanying words, ensure there is no ambiguity in the instructions that the patient / carer is given. FirstStepstoEasierSwallowing/swallow%20 poster.pdf 7. SELF-ASSESSMENT The Road to Recovery Easier to Swallow is a programme of Practice Development Support from NHS Quality Improvement Scotland. In it, speech and language therapist Sheena Borthwick and I include a conceptual wheel for allied health professionals to use as a team. You can consider and rate your effectiveness in 7 areas and develop an action plan. The areas are: Decision Making, Communication / Documentation, Risk management, Roles and Responsibilities, Concordance / Compliance, Training, Patient Involvement. Stroke_Dysphagia_Mar09.pdf 8. LISTENING SKILLS As speech and language therapists listening is or should be our bread and butter and a core function. When studying for a Life Coaching diploma I looked again at the 3 levels of listening (internal, focused, global), which are widely discussed on the internet. It reminded me how powerful it is to be truly listened to, and that you can always work harder at developing your listening skills. 9. THE 7 HABITS WORKSHOP I was fortunate to access this excellent course in 2005. Stephen Covey discusses 7 habits based on principles of effectiveness, paradigms that are aligned with the principles, and behaviours that produce effective results. He shows that we need to learn self mastery and self discipline the private victory - before reaping the public victory of deep, lasting and highly effective relationships with other people. As Covey says, Your life is a result of your own decisions not your conditions. 10. PLUS, MINUS AND INTERESTING POINTS In todays world there is a propensity to look at things as a dichotomy - mind/body, black/ white, good/bad. I have found De Bonos way of thinking about Plus, Minus and Interesting (PMI) points opens up peoples minds to see that there are different ways of viewing and seeing the world. PMI allows people to shift their way of thinking and to attain a different perspective. De Bono, E. (2009) Think! Before Its Too Late. London: Vermillion.
Photo: Geoff Wilson / RCSLT

1. COLLABORATION Our greatest resource has to be our colleagues. We all have blind spots, and a great strength is knowing you do not have all the answers. My most difficult times are when I think I need to go it alone. My most exciting and interesting are where the perspective of others really benefits the service for patients. Steven Covey refers to this as synergy, where 1+1 doesnt equal 2 but can equal 5, 10, even 100. The drive for efficiency and speed can sometimes force us into working in a less collaborative way, but in the end some crucial point or area will have been omitted and there can be a need to rework. 2. TRANSFERRING EVIDENCE INTO PRACTICE I have been passionate about Practice Development throughout my career, and fascinated by how we transfer evidence into practice. We can fool ourselves into thinking practice will be altered by circulating a guideline or some new way of working, but we really are deluding ourselves. Involvement in major projects - training nursing staff in dysphagia in Stockport and Easier to Swallow at NHS QIS (Quality Improvement Scotland) - has broadened my understanding of how you can assist in the transfer of evidence. Thompson et al. (2006) identify key roles. Thompson, G.N., Estabrooks, C.A. & Degner, L.F. (2006) Clarifying the concepts in knowledge transfer: a literature review, Journal of Advanced Nursing 53(6), pp.691-701. 3. TOOLS TO AID UNDERSTANDING I use rating scales a lot. They help me with prioritisation through understanding the concerns of patients, carers and other professionals. When life coaching I use rating scales to judge how committed someone is to achieving their goal. Less than 7 can be an indicator that the goal is not likely to be achieved or requires some adjustment. Wilsons The Tree of Life (2003) is also good for tapping into someones feelings about their communication difficulty. It allows you to open up a dialogue that can often surprise you. It can be used as an outcome measure by comparing the baseline and final measure. Wilson, P. (2003) The Tree of Life, in Powell, T. & Malia, K. (eds.) The Brain Injury Workbook: Exercises for Cognitive Rehabilitation. Milton Keynes: Speechmark, p.194.