ISSN 1368-2105

summer 2004

http://www.speechmag.com

Total communication
Working with teachers

Clinical education
A strategic approach

Autism
Early intervention

Interactive training
A touchy subject?

How I am making a Sure Start

Winning Ways
Under pressure

My top resources
Cancer and palliative care

its all in the framework

Novel events:

RINGING THE CHANGES

READEROFFERSREADEROFFERREADEROFFERSREADEROFFERS

Summer 04 speechmag
In need of inspiration? Doing a literature review? Looking to update your practice? Or simply wanting to locate an article you read recently? Our cumulative index facility is there to help. The speechmag website enables you to: View the contents pages of the last four issues Search the cumulative index for abstracts of previous articles by author name and subject Order copies of up to 5 back articles online.
New! Angela Hunters article on using Talking Mats to assist with National Care Standards Inspections. (See also review on p.20 - Low tech AAC.) Plus The editor has selected some previous articles you might particularly want to look at if you liked the articles in the Summer 04 issue of Speech & Language Therapy in Practice. If you dont have previous issues of the magazine, check out the abstracts on this website and take advantage of our article ordering service. If you liked... Charlotte Child, see (255) Heins, K. (Winter 2003) Collaborating for Communication. Sue Dobson, look at (170) Dobson, S. (Winter 2001) When effectiveness is hard to prove. Myra Kersner & Ann Parker, what about (207) Kersner, M. & Wright, J. (Autumn 2002) Getting comfortable with collaboration. Rachel Baker, you might be interested in (181) Hall, A. (Spring 2002) The early intervention gap - can we fix it? (Yes, I CAN!) Hilary Cowan, check out (060) Leonard, A. (Spring 1999) Right From The Start: The end of the (bad) beginning? and (104) Shields, J. (Spring 2000) Offering hope (but not a cure). Linda Slack, try (162) Harris, C. (Autumn 2001) A-head and neck of the field. How I am making a Sure Start, consider (201) Marsh, T. & Brookes, C. (Summer 2002) My Top Resources.

Win the BNVR: The Butt Non-Verbal Reasoning Test

Looking for a non-linguistic way of identifying cognitive problems in people with aphasia? Speech and language therapist Pam Butt and clinical psychologist Romola Bucks have developed this quick and easy assessment of problemsolving abilities to help clinicians with goal setting, management and appropriate therapeutic intervention. Speechmark Publishing ltd is offering a FREE copy to THREE fortunate Speech & Language Therapy in Practice readers (normal price 64.95). To enter, send your name and address to Speech & Language Therapy in Practice - BNVR offer, Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ by 25th July. The winners will be notified by 1st August. BNVR: The Butt Non-Verbal Reasoning Test is available along with a free catalogue from Speechmark, tel. 01869 244644.

Expression, Reception and Recall of Narrative Instrument (ERRNI)

The wait for a narrative assessment with national UK norms is over - and whats more we have a copy of ERRNI to give away FREE to a lucky reader, courtesy of Harcourt Assessment (normal price 101.39). For your chance to win, simply write your name and address on a postcard with the title ERRNI Reader Offer and post to Liz Akers, Harcourt Assessment, 32 Jamestown Road, London NW1 7BY by 25th July. The winner will be notified by 1st August. Dorothy Bishops latest offering is a quick (8-10 minute) assessment of the ability to relate, comprehend and remember a story after a delay. It is suitable from age 6 years to adult and norms are available from 4 years. The Expression, Reception and Recall of Narrative Instrument (ERRNI) is available along with a free catalogue from Harcourt Assessment, tel. 020 7424 4512, see www.trog-2.co.uk.

Also on the site - news about future issues, reprinted articles from previous issues, links to other sites of practical value and information about writing for the magazine. Pay us a visit soon. Remember - you can also subscribe or renew online via a secure server!

www.speechmag.com

The lucky winners of Speechmarks Indoor Sounds in the Spring 04 issue were Lorna Meech, Cath Valentine, Lynn Dyson, Angela Abell and Linda Robinson. Linda Robinson ALSO won the APEC (Assessing and Promoting Effective Communication) package courtesy of Gillian Bolton, who has just had a baby. Congratulations to you all!

SUMMER 2004
(publication date 31st May) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Design & Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Website design and maintenance: Nick Bowles Webcraft UK Ltd www.webcraft.co.uk Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2004 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.

Inside cover Summer 04 speechmag Reader offers

Win the BNVR and ERRNI.

14 COVER STORY
It aint what you say, its the way that you say it
Once the booklet was done I used it as the basis of my sessions with the families and staff. This meant that we could work from a shared text, I was able to discuss and explain the information, and we could make decisions from it. How do we improve collaboration with parents and teachers of children with special needs? For Charlotte Child, Choices, Changes & Challenges is proof that its all in the framework.

2 News / Comment 4 Pulling in the same direction

All of the teaching staff commented that time spent with the speech and language therapists raised their awareness of the childrens communication needs and enabled them to interpret the childrens communication responses. To achieve a total communication environment in a special nursery class, Rachel Baker & colleagues introduced a collaborative approach.

17 Interactive training: a touchy subject?

Overall the use of the training package was considered to be useful in raising levels of awareness, but of limited value in improving knowledge. The use of information technology in staff training may be successfully utilised in skills training but have more limited applications in altering the qualitative aspects of care. Sue Dobson & clinical liaison team colleagues reflect on the pilot of an interactive training package on CD about the use of touch with people with profound and complex needs.

7 Further reading
Paediatric dysphagia, Laurence-Moon-Biedle syndrome, oral cancer, phonology, crossing cultures, dysphonia.

8 Change: an educational experience

On placement students need to be encouraged to think like a therapist. Diversity and difference are to be encouraged so long as students are able to become active learners contributing to real work as members of the speech and language therapy team. A lack of clinical placements has created a critical time for speech and language therapy education. Myra Kersner & Ann Parker have seen the wider, longterm benefits of adopting a strategic approach to change.

20 Reviews
Dysphagia, aphasia, pragmatics, AAC, learning disability, evidence based practice, clinical education, low tech AAC, motor neurone disease, dyslexia, autistic spectrum disorder. (Also head injury and passports on p.11.)

22 Winning Ways series (3) Diamonds are made under pressure

By visualising the work completed and submitted for marking, Andrea was able to feel what it would be like to get over that hump of uncertainty. By imagining the feelings of joy, excitement, relief and satisfaction, she was able to motivate herself enough to complete the task. Recognising the fear that underlies resistance to change is essential if we are to realise our potential, as examples from the casebook of life coach Jo Middlemiss demonstrate.

11 Heres one I made earlier...

Alison Taylor with more low-cost ideas for flexible therapy activities: scream jars, wild journeys and spots for the dogs.

12 A holistic approach - from the outset

Because the session is highly structured, as free as possible from extraneous distractions and uses a high proportion of visual strategies, the children settle into the sessions within a very short space of time, and begin to generalise the strategies being taught. Hilary Cowan explains why a specialist multidisciplinary early intervention team is good news for preschool children with autistic spectrum disorder.

24 How I am making a Sure Start

The Sure Start programme focuses on prevention. It works with parents and children to provide services that are tailored to individual needs and designed to encourage access. It places high value on outcomes, and on ways of working which are customer and community driven and professionally coordinated. So, how does this focus alter practice? To mark National Sure Start month (June 2004), Alex Jack, Tom Morris & Beryl Downing share their experiences.

In future issues...
antenatal education adult learning disability hearing impairment collaboration student training getting organised dysphagia voice baby signing

Back Cover My top resources

It wasnt until I was appointed that I appreciated how much support Macmillan provides to post holders, particularly in terms of training and equipment grants, which are a tremendous help when starting up a new post. Linda Slack is a Macmillan specialist speech and language therapist who works full-time with head and neck cancer patients and also those with palliative care needs in North Cumbria.

Cover picture by Paul Reid (posed by models). See p.14

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

news

Flexible Enough?
While the year old law on flexible working is bringing benefits to some parents of disabled children, more needs to be done to raise awareness of a parents right to ask. A survey of over 900 parents of disabled children by the charity Contact a Family found that those who have asked for more flexible employment patterns have found it a positive experience, which has decreased their stress. However, only half knew that the provisions apply equally to men and women and that the law does not only apply to families with children under the age of six, and respondents highlighted the need for more publicity and information about rights. The survey also asked wider questions about balancing employment and caring for a disabled child, and one chapter of the report is devoted to the experiences of fathers. Childcare and taking time off for hospital visits and appointments emerge as significant issues. Flexible Enough? See www.cafamily.org.uk/campaigns Family Freephone Helpline 0808 808 3555

Storytelling grant
People in Somerset with learning disabilities are to have the opportunity to join a company of storytellers, thanks to a Community Fund grant to the British Institute of Learning Difficulties (BILD). The three year project, from 2004-2007, will involve participants in developing their narrative skills, compiling portfolios of stories to tell, and learning to work together as a group. As their skills develop, they will be running workshops in the community and training staff and families in ways of effectively sharing stories. The project will be directed by Nicola Grove, senior lecturer in speech and language therapy at City University, building on work done during a sabbatical year funded by the Health Foundation*, and supported by a steering group at BILD which included Professor John Harris, Chief Executive, Dr David Middleton, Loughborough University and Dr Helen Hewitt, Nottingham University. Nicola said, I am thrilled to have this opportunity to focus on storytelling - the new post combines everything I enjoy in speech and language therapy. There are some wonderful service users in Somerset, and I am really looking forward to working with them and with local staff and families. There is great support from the community team for people with learning disabilities, including the speech and language therapists in the area. BILD have been enthusiastic about the project throughout the development of the application, and we could not have got this far without them. * See Speech & Language Therapy in Practice, Spring 2004, A year of storytelling, pp7-9.

Call to join the Big Conversation

Readers of Speech & Language Therapy in Practice are being asked to support efforts by the charity I CAN to ensure the needs of children with speech, language and communication difficulties are considered in a new public consultation exercise. A letter from Alex Hall, Director of Policy and Practice at I CAN, responds to the chapter How do we give every child an excellent education? in the governments consultation exercise, the Big Conversation, and asks readers for their help in getting this subject high up the political agenda. She says, I CAN would like to highlight the needs of the one in ten children who have speech, language and communication difficulties. Many children are not starting school with the skills they need for learning, putting them at risk of educational, emotional, behavioural and social difficulties. She adds, We strongly promote the provision of training for all early years staff in speech and language development, the identification of difficulties and the strategies to support children who have these problems. We would also welcome specialist integrated teaching and speech and language therapy for those children with the most severe and complex difficulties. Alex goes on to mention I CANs work in establishing integrated Early Years Centres across the UK, an early years accreditation programme, the I CAN TALK! training pack and www.talkingpoint.org.uk developed in partnership with the Royal College of Speech & Language Therapists and Afasic. She urges anyone who shares I CANs views to log on to the website and submit a letter to government. www.talkingpoint.org.uk

More autism research needed

The first-ever comprehensive overview of the UK autism research field concludes that there needs to be more exploration of the causes of autism, successful interventions, how families cope and support services. Mapping Autism Research has been published by The Institute of Child Health, The National Autistic Society and The Parents Autism Campaign for Education, as part of a unified campaign to help identify and reach a consensus on future research priorities. It combines the views of scientists and people with autism and their families, and presents a comprehensive picture of the state of science and funding across the country. Recommendations include establishing an electronic network of scientists in the autism field to disseminate research findings, collaborate with parent organisations and publicise research opportunities. www.gosh.nhs.uk

Deaf study Coalition to improve carers lot funded

The Equal Opportunities Commission has set up a coalition of charities and trade unions to influence government policy on the rights of parents and carers, and to change attitudes of society and employers. Member organisations represent parents, carers and paid care workers as well as older and disabled people. They are seeking to ensure that people are able to choose whether or not to combine caring with paid work, and that they will be supported in their choice with a range of measures including access to flexible working, good quality childcare and a pensions framework that doesnt penalise people for the time they spend caring. The coalition includes the National Autistic Society, the Multiple Sclerosis Society, Contact a Family, Age Concern and Amicus, the union representing speech and language therapists. In a recent survey by the National Autistic Society, 70 per cent of carers said they were prevented from returning to work due to lack of appropriate care facilities, and only 15 per cent had received any support from social services in their caring role. www.eoc.org.uk/parentsandcarers; www.nas.org.uk A four year study aims to show how the use of technology, as well as support from professionals and parenting style, can impact on language and communication development for deaf babies and their families. The Community Fund grant of 500,000 to Defeating Deafness and The National Deaf Childrens Society is seen as vital to supporting social inclusion of deaf children. According to Susan Daniels, chief executive of NDCS, To be able to track the development of deaf children from such an early age and assess the impact that different choices and models of professional and parental support have on their lives is vital. This will help parents make more informed choices, assist us to provide more appropriate support for services working with families and hopefully result in more deaf children reaching their full potential. www.defeatingdeafness.org.uk; www.ndcs.org.uk

Shameless in Swindon!

The speech and language therapy service in Swindon is appealing urgently for new staff so they can meet increased demand for their unique two week residential course after it featured on Channel 4s Shameless programme. Already so popular that it had a years waiting list, managers have been overwhelmed with enquiries since Carl revealed that the course had enabled him to develop his hovercraft building skills. Service manager Louise Campion says applicants should have a wide variety of interests and talents, in addition to being enthusiastic team players looking for a new challenge: We are looking to fill some important gaps, and would particularly like to recruit therapists who are experts in macram, belly dancing, tree felling and water polo. In light of this development, the Royal College of Speech & Language Therapists is understood to be consulting insurers with a view to extending cover for its members...

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

news & comment

Play Talks at Scope

The disability organisation Scope is launching a pack to help preschool children with communication difficulties enhance their skills and have fun with professionals and parents at the same time. Play Talks is an early years training pack which contains practical ideas to promote communication skills through play and includes tips on how to adapt toys and make them accessible. It will be available as colour-coded fact sheets that can be used together or separately alongside a CDROM. Jackie Logue, Scopes Early Years coordinator, developed the pack. She says, All children need to have fun and play but that can be lost when a child has additional needs. We hope the Play Talks pack will inspire parents and hands-on early years professionals to give play and communication a bigger voice. www.scope.org.uk/earlyyears

comment
Avril Nicoll, Editor 33 Kinnear Square Laurencekirk AB30 1UL

Ringing the changes

Early stroke surgery call

The Stroke Association is calling for carotid endarterectomy to be provided within two weeks of an initial transient ischaemic attack to reduce the risk of subsequent, more serious strokes. Carotid endarterectomy is a common surgical procedure that is routinely used to remove the build up of fatty deposits in the main artery between the heart and brain. These deposits could cause blood clots that block the blood supply to the brain, leading to ischaemic strokes. Dr Peter Rothwell - coordinator of a research project funded by the Stroke Association and published in medical journal The Lancet - said, At the moment, many patients in the UK wait for months for this particular treatment, by which time the benefits are very much reduced or absent. www.stroke.org.uk

Alzheimers drug ban

A decision to stop the prescription of two neuroleptic drugs to people with dementia has been hailed as an important opportunity to improve treatment. In welcoming the Committee on Safety of Medicines decision that the drugs risperidone and olanzapine should not be used by people with dementia because of the increased risk of stroke, the Alzheimers Society points out that overuse of sedative and antipsychotic drugs, particularly in residential and nursing homes, is no substitute for assessment and support from trained staff. www.alzheimers.org.uk, Helpline 0845 300 0336

tel/ansa/fax The band Rush have been around for thirty years with a constantly evolving yet unique 01561 377415 musical and lyrical style. OK, I admit Im biased, but Jo Middlemisss observation (p.22) that we need to recognise the fear that underlies resistance to change recalls the lines: e-mail Ignorance and prejudice avrilnicoll@speechmag.com And fear walk hand in hand...1 We need to remind ourselves that this fear is not only present in ourselves but in everyone else - clients, parents, children, other professionals. That we need to tackle our own and others ignorance, prejudice and fear if we are to overcome the collective anxiety that can stymie new plans and creative ideas. But how to go about it? The authors in this issue suggest a variety of strategies. Rachel Baker and colleagues (p.4) found that spending time with teaching staff, and really making an effort to understand and acknowledge where they were coming from, made a big difference to the total communication environment provided. Charlotte Child (p.14) asked why teaching staff made changes after attendance at certain courses rather than through her day-to-day advice. She came to the conclusion that frameworks provide the basis for the explanations and negotiations that underlie commitment to change. Similarly, now that Hilary Cowan and colleagues (p.12) have developed a clear care pathway with services provided in line with clinical need and national standards, young children with autism are making progress more quickly. Sue Dobson and colleagues (p.17) researched how well an interactive training tool promoted change in practice. Importantly for others considering such a venture, they discovered that, while it had some effect on raising awareness, it had limited effect on the quality of care provided. Permanent audit is proving useful to Myra Kersner & Ann Parker (p.8) as part of a long-term, strategic approach to changing the way clinical placements prepare students for the reality of life as a therapist. Meanwhile, for Linda Slack (back page), clinical supervision from a non-speech and language therapist gives a fresh perspective that helps her improve her practice. How I am making a sure start (p.24) celebrates National Sure Start month with a three-part look at some of the changes stemming from speech and language therapy involvement. The variety of community initiatives do much to reduce the ignorance, prejudice and fear of all parties, and the commitment to mainstreaming services is clear and welcome. In the end, we have to ask if we get more out of resisting or ringing the changes? After all, He knows changes arent permanent But change is.2

From Witch Hunt (part III of Fear) by Neil Peart From Tom Sawyer by Neil Peart Both songs feature on the 1981 Rush album, Moving Pictures.
1 2

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

collaboration

Pulling in the same

Read this
if you want to initiate a collaborative approach allocate more time to joint planning and evaluation introduce total communication environments

To achieve a total communication environment in a special nursery class, Rachel Baker and colleagues introduced a collaborative approach. Importantly, new skills which developed as a result of everyone pulling in the same direction can now be used to benefit other projects.

right (1996) suggests collaboration is an active, evolving process that requires commitment, energy and effort, to succeed. I discovered this for myself when we initiated a collaborative approach into a nursery class at a local special school. Although not a process that can be entered into lightly, the result has been rewarding clinically, professionally and personally. As speech and language therapists we work with numerous professionals from different backgrounds and services on a day-to-day basis, with varying degrees of success. Collaborative working has become ever more widespread as service provision moves from a withdrawal model, where the clinician is the expert, towards a more holistic one, with the professionals working in partnership. There are several levels of collaborative working and terms vary from multidisciplinary through interdisciplinary to transdisciplinary and collaboration. Whichever model may be used, we are constantly striving for a successful partnership. Collaborative working has been described by Kersner & Wright (1996) as, absolutely essential for teachers and therapists to establish reliable and effective working practices. This is recognised also by the Code of Practice (DoE, 1994). Our Community Team Learning Disability speech and language therapy service used to begin work with reception age children as they entered school. The level of involvement depended on the needs of the children, and varied from initial advice and monitoring to running language groups in the classroom. Generally we had initiated input, as the children were transferred from the preschool team in the summer holiday.

The principles of total communication were incorporated into the communication sessions and it was intended that teaching staff would...continue to implement these principles throughout the school day.

Reorganisation
In 1999, following reorganisation of special educational needs provision in Newcastle upon Tyne, a large number of children (15) from two years old attended a new nursery class. Given their younger age and more complex problems, the nursery staff requested more speech and language therapy time

as they felt our specialist input was needed from the outset. After discussion with the nursery staff we decided that the speech and language therapy service would see the children in class on a weekly basis for a whole morning (covering two school sessions). What evolved was a collaborative approach, with the clinicians and teachers identifying and working on joint rather than discipline specific goals, with the aim of creating an educationally inclusive communication environment. This approach went beyond team working where individuals only perform tasks that are specific to their respective disciplines into a successful partnership whereby all staff involved were pulling in the same direction. In 2002, following two years of this approach, two final year students from Newcastle upon Tyne undertook a review of service provision in the form of a face-to-face questionnaire as part of their professional context placement. The report brief was to evaluate the service provided over the two years. The aim of the questionnaire was to discover the differing attitudes of staff towards the approach taken, and their perception of the benefits or disadvantages to the children and to professional relationships. Research has shown that effective collaboration between teachers and speech and language therapists has advantages for the children involved, as they benefit from the more holistic approach to their needs. There are also advantages for the professionals themselves, as they are able to provide each other with support, exchange knowledge and skills, and develop a greater awareness of each others roles (Wright, 1996). However, McCartney (1999a; 1999b) described potential barriers to effective collaboration between teachers and speech and language therapists as occurring at several levels, including service policy and curriculum related. The ultimate aim of the nursery sessions was to establish a total communication environment that would meet all the childrens individual communication needs, and that would last throughout the week. This involved making both physical changes to the classroom environment (for example multisensory experiences including objects of reference) and the adaptation of current communication rou-

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

collaboration

direction
tines (such as intensive interaction techniques and manual signing). The principles of total communication were incorporated into the communication sessions and it was intended that teaching staff would acquire the knowledge and skills and be able to continue to implement these principles throughout the school day. Given the high physical dependency of the children and diversity of needs, the communication session allowed for a mixture of individual and small group work, with a staffing ratio that was not available at any other time throughout the week. The students interviewed the two speech and language therapists, including me, and the nursery staff (three learning support assistants and one teacher) individually. All the responses indicated a positive learning experience, as this summary of outcomes shows:

1. Relationships

The teaching staff described their relationship with the speech and language therapists as being open, friendly, co-operative, a partnership and lastly a lot of mutual respect, while the speech and language therapists described it as educational, rewarding, two way, and enjoyable. All of the teaching staff commented that time spent with the speech and language therapists raised their awareness of the childrens communication needs and enabled them to interpret the childrens communication responses. The teaching staff also felt that the activities they did with the children during the communication sessions gave them ideas for activities at other times of the week which encouraged repetition and the development of the skills of both the staff and children. The speech and language therapists felt that they were able to get to know the children and their environment better and could use this information to set more appropriate targets. The target setting gradually became a joint activity; however this tended to be speech and language therapist / teacher rather than assistant led.

I built up many skills clinically, professionally and personally which I now endeavour to take into other teams.

clear understanding of each others roles. The teaching staff all had previous experience of working with speech and language therapy, and therefore views of the clinicians role. This experience had been of the speech and language therapist visiting to assess and advise about individual children or to run a group. Over time the speech and language therapists felt that the teaching staff were able to play an increasing role in planning and problem solving. We gradually began to discuss situations from outside the specific communication session and how ideas could be adapted and incorporated. The interviewees repeatedly referred to the value of the group discussions. After each session thirty minutes was spent reviewing and planning. Staff had to give up their lunch break for this. The majority of staff thought that there was sufficient time, however it was also suggested that more time for discussion would have provided further benefits. The responsibility for record keeping and monitoring progress was taken entirely by speech and language therapists. Despite targets being set in the childrens Individual Education Plans, they were not mentioned by any of the teaching staff in the interviews.

essary for speech and language therapists to remain directly involved. All felt there would be a negative impact and loss of focus for the sessions if speech and language therapy input was withdrawn. However, Kersner & Wright (1994) suggest that, following collaborative projects, teaching staff often develop new skills that they are then able to use when speech and language therapists are unavailable. In the year following the interviews the numbers in the nursery halved. Staff had acquired much knowledge and skill, so we decided that only one therapist should facilitate the communication session. This was a different therapist from the previous years. As 2003 has seen the smallest intake of children, we agreed that a speech and language therapy assistant should facilitate the session, with the teacher taking the lead on planning. A speech and language therapist has been available in a consultant role. The staff have kept up the planning / review sessions, including the speech and language therapy assistant who has increasingly become involved in making resources such as picture symbols as the education staff have limited time. This time factor has a significant influence on the maintenance of the total communication environment.

Commitment
The nursery teacher continues to show commitment to the collaborative approach due to the specific benefits which have been identified (see also case examples in figure 1). This commitment is mirrored by the Community Team Learning Disability speech and language therapy service. Following the interviews I had hoped to take this approach to other classes in the school as the children moved on. Despite school management support for this to happen, it has occurred with varying levels of success. This level of collaboration cannot be achieved overnight. It is an active process that requires all involved to be equally committed - with personality issues being a strong influencing factor. The findings of the interviews provide evidence of a positive experience, with insight into how a collaborative approach can work. During the two years working in the nursery I built up many skills clinically, professionally and personally which I now endeavour to take into other teams. The most important is developing flexible problem solving strategies which enable staff to meet a diversity of complex needs in the classroom environment. This approach allows us to deal with issues there and then, with shared responsibility and respect.

3. Disadvantages
None of the staff thought there had been any major difficulties but there had been a challenge initially as the speech and language therapists took a developmental approach while the teacher came from a curriculum background. However the teaching staff were very open to the developmental approach and, as the children were nursery age, curriculum restraints were less of an issue than they might have been. A study of this type has limitations. Although effort was made to ensure non-bias, all the participants were aware that the researchers were students from the speech and language therapy service, and the speech and language therapist continued to provide input at school. Over the two years the partnership had strengthened and the total communication environment had developed in the classroom. In the interviews the teaching staff were asked if they felt it was nec-

2. Role boundaries
Wright (1996) warns that it cannot be assumed that collaborative partnerships will occur because teachers and therapists spend time in the classroom together. McCartney (2001) asserts that one of the hallmarks of good practice in working together is a

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

collaboration

Rachel Baker is a speech and language therapist with the Community Team Learning Disability in Newcastle upon Tyne.

References
Enderby, P. & John, A. (1997) Therapy Outcome Measures - Speech and Language Therapy. Singular. Kersner, M. & Wright, J. (1996) Collaboration between teachers and speech and language therapists working with children with severe learning disabilities. British Journal of Learning Disabilities 26 (1), 33-37. McCartney, E. (1999a) Barriers to communication: an
Figure 1 Case examples

analysis of systematic barriers to collaboration between teachers and speech and language therapists. International Journal of Language and Communication Disorders 34 (4), 431-440. McCartney, E. (1999b) Scoping and Hoping: the provision of speech and language therapy services for children with special educational needs. British

Journal of Special Education 26 (4), 196-200. McCartney, E. (2001) ICAN Seminar Snapshot: Teachers and Therapists working together. ICAN Publications. Wright, J. (1996) Teachers and Therapists: the evolution of a partnership. Child Language Teaching and Therapy 21 (1), 3-16.

Reflections
Do I understand that collaboration is an active, evolving process? Do I engage students in practical projects to review therapy and services? Do I recognise new skills as they develop - and purposely apply them in new situations?

1. Jess Jess joined the nursery class in October 2000 (aged 3;4 years) with multiple and profound learning difficulties. When she first started, Jesss communication skills were at a preintentional stage. She was not reported as being able to point. Her hearing was assessed as normal, although her vision was causing concern. Her physical skills were also developmentally delayed. Objects of reference for Jesss routine were introduced and a multisensory approach taken throughout sessions alongside intensive interaction style communication. Jesss eating / drinking skills were also addressed, with work done on increasing her tolerance to drinking from a cup rather than a bottle.
Therapy Outcome Measures (Enderby & John, 1997) 12 February 2001
Diagnosis: 5.9 Pre-verbal skills Severe, multiple areas. No intent consistent but present on variable basis. Inconsistent attempts at communications. Cannot make basic needs known consistently. No effective understanding established. Basic and limited decisions. Shows preferences inconsistently by a smile versus passive response. Does not achieve potential.

2. Lucy Lucy joined the nursery class aged 3;7 years. She has cerebral palsy with severe visual impairment. Lucy was taking medication to control her epilepsy. However, she continued to have frequent absence seizures and periods of tiredness with drop fits on waking. There was concern that she was missing out on activities as a result of the time she spent sleeping during the day. Objects of reference alongside picture communication symbols were introduced for the daily timetable and choice making. A developmental approach including early pretend play and cause and effect was taken. Communication and eating/ drinking aims were also integrated into her individual education plan after collaboration between the speech and language therapist and class teacher.
Therapy Outcome Measures (Enderby & John, 1997) 12 February 2001
Diagnosis: Impairment: Disability: 5.2-3 AAC - Low Tech 2 1 Developmental dysarthria - related to over-riding disability. Able to make basic needs known - more and finished, points and vocalises to request object. Vocalises for attention, uses photographs for choice making - developing understanding of symbols. Better with trained listener and family. Needs contextual cues. Not consistently doing all above. Communicates in familiar and supported situations. Clearly communicates that she has finished or doesnt want song, and will request more and gain attention. Needs encouragement to achieve potential.

3. Jack Jack attended the nursery from 3;2 years until he was 5 years old. He has spastic tetraplegia and feeding difficulties. Long-term communication session aims: To develop consistent, intentional communication To develop true turn-taking with an adult (activities and vocalisations) To explore objects independently To develop protoimperative communication (use an adult to obtain an object / action) To develop protodeclarative communication (use an object to attain joint attention with adult) To develop purposeful means-end understanding through cause and effect and switch toys. Activities used to achieve aims: Intensive interaction to develop response, anticipation, intentionality Sensory stimulation Facial massage, smells, tastes Visual tracking, horizontal and vertical Object permanence Cause and effect Objects of reference Referral to Communicate (the Communication Aids Centre, Newcastle upon Tyne). Feeding: Main source of nutrition = gastrostomy Some oral feeding Feeding plan implemented March 2001
Therapy Outcome Measures (Enderby & John, 1997)

Impairment: 0.5

Disability:

0.5

Handicap:

Handicap:

30 June 2001
Diagnosis: 5.2-3 AAC - Low Tec 2 2 As before. Interested and alert in everyday environment. Able to direct attention to herself, request for example food, her turn, protoimperative and declarative communication, intentionally ends communication and chooses when / when not to participate. More consistent communication attempts. Communicates basic needs and relies on context and familiarity. As before - needs adult support. Impairment:

12 February 2001
Diagnosis: 5.9 Pre-verbal skills Profound and multiple learning difficulties (cognitive, communication and motor). Basic recognition at object level. Intentionality of communication is inconsistent. Limited functional communication developing greeting and reoccurrence. Relies heavily on carer and context.

18 May 2001
Diagnosis: 5.9 Pre-verbal skills Now showing some slight ability in anticipation of familiar routines, for example peek-a-boo scarf, opens mouth when sees spoon. Inconsistency still very evident. Can sometimes make basic needs known by some action such as smile / reach versus passive withdrawal. Hand-over-hand initiation at eating/drinking time.

Impairment: 1.0

Disability:

Impairment: 1

Disability: Handicap:

1.0 2.0

Disability:

Handicap:

18 May 2001
Diagnosis: 5.9 Pre-verbal skills Impairment: 1.5 Basic switch skills emerging (physically limited). Responding to basic stage 1 verbal language eg. chocolate / drink. Disability: Handicap: 1.5 Consistently vocalises for more, expresses preferences objects / toy. 3.0 Greeting activity - consistently able to vocalise as his turn - in response to name. Switch-control equipment.

Handicap: 1.5 Goes to favoured things, reaches for them. Can be variable. Passive when doesnt like. Occasional vocalisations for more / happy etc.

Lucy was able to communicate at a higher level than Jess, and her aims for this period of intervention reflected this. Despite the differences in their individual aims, both pupils made progress as a result of participating in the communication sessions. The nature of the sessions allowed individual aims to be targeted in individual and small group work, in addition to more general aims being targeted during work done in larger groups.

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further reading

Chen, C-L., Chung, C-Y., Cheng, P-T., Chen, C-H. & Chen, M-H. (2004) Linguistic and gait disturbance in a child with Laurence-Moon-Biedl syndrome: left temporal and parietal lobe hypoplasia. Am J Phys Med Rehabil 83 (1): 69-74. Laurence-Moon-Biedl syndrome is an autosomal recessive disorder characterized by retinitis pigmentosa, obesity, polydactyly, hypogenitalism, mental retardation, and renal abnormalities. We report the linguistic and gait disorders in a child with Laurence-Moon-Biedl syndrome associated with left temporal and parietal hypoplasia as determined by magnetic resonance imaging. Our patient was mildly mentally retarded, scoring better on the performance subtest than on the verbal subtest. He received serial assessments for developmental, language, speech, and gait functions, before and after rehabilitation, at age 4.5 and 6 yr, respectively. After comprehensive rehabilitation, the boy achieved improvement in speech, language, fine motor, and gait functions. Early comprehensive rehabilitation programs seem beneficial for improving functional development for children with Laurence-Moon-Biedl syndrome.

Nelson, R. & Ball, M.J. (2003) Models of phonology in the education of speech-language pathologists. Clin Linguist Phonet 17 (4-5): 403-9. We discuss developments in theoretical phonology and, in particular, at the divide between theories aiming to be adequate accounts of the data, as opposed to those claiming psycholinguistic validity. It would seem that the latter might have greater utility for the speech-language pathologist. However, we need to know the dominant models of clinical phonology, in both clinical education and practice, before we can promote other theoretical approaches. This article describes preliminary results from a questionnaire designed to discover what models of phonology are taught in institutions training speech-language pathologists in the United States. Results support anecdotal evidence that only a limited number of approaches (phonemic, distinctive features, and processes) are taught in many instances. They also demonstrate that some correspondents were unable to distinguish aspects of theoretical phonology from similar sounding (but radically different) models of intervention. This ties in with the results showing that some instructors of phonology courses have little or no background in the subject.

Paediatric dysphagia
Hiorns, M.P., Patwardhan, N. & Spitz, L. (2003) Dysphagia caused by a foreign body. Arch Dis Child 88 (11): 1017-8. A boy with a long history of dysphagia attributed to neurological impairment was shown to have a large oesophageal foreign body. It had remained undetected for five years as a central lumen allowed the passage of liquids and semisolids. Foreign bodies must be excluded in children with dysphagia.

Oral cancer
Nicoletti, G., Soutar, D.S., Jackson, M.S., Wrench, A.A., Robertson, G. & Robertson, C. (2004) Objective assessment of speech after surgical treatment for oral cancer: experience from 196 selected cases. Plast Reconstr Surg 113 (1): 114-25. In 1992, a personal computer-based workstation for speech-digitized analysis was developed in conjunction with Canniesburn Hospital and Edinburgh University to measure all dispersion in speech after surgery for oral cancer. The voices of 196 patients with tumour of the oral cavity were recorded preoperatively and postoperatively. Surgical resection was carefully mapped out on standard diagrams of the oral cavity. Patients recordings were assessed for conversational understandability by two referees. Patients also self-scored their speech using the Functional Intraoral Glasgow Scale self-questionnaire. Many patients had similar if not identical resections; therefore, 12 homogeneous groups were identified. Functional outcome for speech was correlated with the site and size of resected tissue and with the reconstruction modalities. The original association of an objective, computerbased tool and two subjective assessment tools proved to be the most suitable investigation method for speech. The general pattern was for consistently better speech quality with smaller excisions. The reconstruction modalities did not seem to influence the overall speech quality, as it was related mainly to the extent of surgical demolition. The authors present a detailed correlation between site and size of excision and functional outcome using colour multiple-view diagrams for immediate appreciation. Positive and negative prognostic factors were identified in surgery for oral cancer.

Crossing cultures
Marshall, J. (2003) International and cross-cultural issues: six key challenges for our professions. Folia Phoniatr Logopaed 55 (6): 329-36. A number of key challenges that face professionals who work with clients with communication disabilities are examined. The challenges, which relate to working internationally and in a cross-culturally competent way, are discussed, drawing on material from a range of sources, including the papers in the final 2003 edition of Folia Phoniatrica et Logopaedica. Experiences from majority world countries that can be used to benefit services elsewhere, mainstreaming commitment to cross-cultural competence, learning from relationships with other professionals, influencing research practice, responding to requests to work internationally and dealing with cultural differences that challenge working practices are discussed. Some solutions are suggested and additional questions posed.

This regular feature aims to provide information about articles in other journals which may be of interest to readers. The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire YO7 4PP, tel. 01765 640283, fax 01765 640556. Annual rates are CDs (for Windows 95): Institution 90 Individual 70 Printed version: Institution 72 Individual 50. Cheques are payable to Biomedical Research Indexing.

Dysphonia
Tilles, S.A. (2003) Vocal cord dysfunction in children and adolescents [review]. Curr Allergy Asthma Rep 3 (6): 467-72. Vocal cord dysfunction (VCD) is a nonorganic disorder of the larynx that involves unintentional paradoxical adduction of the vocal cords while breathing. The resultant symptoms can include dyspnea, chest tightness, cough, throat tightness, wheezing, or voice change. Most patients with VCD are female, and among adolescents and children, VCD tends to be triggered by exercise and is typically confused with exercise-induced asthma. Both gastroesophageal reflux disease (GERD) and psychiatric illness have been reported as having strong associations with VCD, although, to date, there is no evidence that either causes VCD. VCD often coexists with asthma, and should be suspected in any patient in whom asthma treatment fails. Confirming the diagnosis involves direct visualization of abnormal vocal cord motion, and this usually only occurs during symptoms. Adolescent athletes often require free running exercise challenge to reproduce their symptoms and confirm abnormal vocal cord motion laryngoscopically. The primary treatment for VCD involves a combination of patient education and speech therapy, and, in most cases, patients may resume their activities without significant limitation. (20 References)

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

further reading further reading further reading further reading

Laurence-Moon-Biedle Syndrome

Phonology

FURTHER READING

education

I Change: an educational experience

Read this
if you want to feel more positive about change understand models of learning help students think like therapists
Ann Parker and Myra Kersner

n the mid 1990s speech and language therapy courses around Britain reported increasing difficulties in securing the necessary clinical placements for their students (Morris & Parker, 1998). Change in the old system of acquisition was clearly needed. In many instances the situation required crisis management using short-term solutions such as increasing the amount of time spent procuring places. However, managing change is a complex process as change in one part of a system is inextricably linked not only to other parts of the internal system but also to external forces. Recognition therefore that change was occurring at that time in the NHS and in higher education led to the acknowledgement that, to effect real change, longer-term solutions would be needed. Individual colleges developed their own innovative approaches to clinical placements and professional learning (Grundy, 1994) and this paper describes some of the changes made at the Department of Human Communication Science at University College London.

Consultation
Initially a consultation process was undertaken with the local speech and language therapy services, supervising therapists, and past and present students in order to establish the departments strengths as well as to solicit suggestions for improvement. The joint involvement of University College London staff with clinic based supervisors from the different clinical contexts and services within which the students were placed enabled the development of a longterm strategic plan for professional studies (Kersner & Parker, 2001). This included plans for the management of clinical placements, changing aspects of the approach to teaching and learning and making changes in the curriculum of the two speech and language therapy programmes run by the department. Discussions revealed that some of the problems of placement acquisition were linked to assumptions that were being made about the type of learning experience needed for students and the level of supervision required from the clinicians. Speech and language therapy students traditionally have received comparatively close, direct, individual supervision. However, different professions have equally successful models and approaches to supervision involving less frequent and less direct supervision (Barnet et al, 1987). While there are advantages to close supervision, such as instant access to feedback and opportunities for close management of risk, there are also disadvantages. For example, there is the possibility of de-skilling the learner and encouraging overdependency on the supervisor so reducing the students confidence in their own abilities. There is also the implication of correct practice - as in the total quality management aspiration of getting it right first time (Collard, 1993). However speech and language therapy students need to develop the ability to test hypotheses, try different therapy options, and to adjust quickly when a change of direction is needed as described by Parker & Kersner (2001) in what is referred to as a navigation model.

A lack of clinical placements has created a critical time for speech and language therapy education. However, while reactive crisis management has its place, Myra Kersner and Ann Parker have seen the wider, long-term benefits of adopting a strategic approach to change.

Strengths
The consultation resulted in much positive feedback about existing strengths in the departments system and it was agreed that these should be maintained and developed. It also became apparent that there was a need to be more explicit about some of the positive aspects of existing clinical practice that were working well. There were suggestions for change in three main areas relating to students clinical learning on placement. These required: further development of the departments external relationships with the clinical supervisors; internal development to optimise college-based learning within the course curriculum; the development of evidence-based research into professional learning. A strategic plan for professional studies was developed to incorporate different approaches to learning aiming to integrate practice and theory more effectively; to encourage greater team work between University College London tutors, placement supervisors, and the students (Kersner & Parker, 2001), and to develop a professional research strategy.

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education

Assumption
In many professional courses including speech and language therapy there has traditionally been an assumption that students professional development will follow a linear approach (Bines & Watson, 1992) often involving front loading of theory (Eraut, 1994) preceding closely supervised individual workexperience placements. Such placements often include long periods of observation before active involvement in practical work and will typically conclude with a summative examination at the end of the process. While there may be advantages to this technocratic approach (Stengelhofen, 1993; Parker & Kersner, 1998) there are some serious limitations for students professional learning such as the counterproductive risk avoidance described by Morris (2001). The sequence of theory observation supervised practice may oversimplify the acquisition of complex skills and ignores the fact that in many instances theory may be more easily assimilated after some active involvement in practical work. Such a model does not reflect real life work where therapists need to be innovative, adjusting to feedback from constantly changing circumstances and new information rather than following prescribed, correct routines (Parker & Kersner, 1998). In addition, there is the potential for students overdependency on feedback from the experts - placement supervisors and tutors - rather than from other sources such as clients and peers and this may hinder their abilities to develop confidence in their professional work (Parker & Kersner, 2001). This may then result in newly qualified therapists experiencing a giant step in the transition from final year student to newly qualified therapist as shown in Figure 1.
Figure 1 Student development in a dependency model: a giant step from final year student to newly qualified therapist.

Involvement
Normally speech and language therapy students are selected for their effective communication skills, and many have relevant prior work experience. Involvement in action and practice at an early stage of the course enables effective use to be made of students pre-existing skills, so that they do not feel de-skilled but are able to build confidence in their work by taking some level of professional responsibility from the start. The importance of active involvement in the learning process while on placement was underlined during the consultation process by many of the students supervisors. These practising clinicians reported their own studentdays experiences of falling asleep during protracted observation placements - not through lack of interest, but rather through lack of involvement. Often they were kept awake only through fear of not knowing what to observe and trying to guess what they might be required to report. Of course, opportunities to observe an experienced speech and language therapist at work are valuable at any stage of students training but it may often be even more valuable for final year students who, having experienced practical work, have a clearer idea of what to learn from their observations. The students themselves reported that they had gained more confidence and learned more effectively through active task participation from the earliest stages of the course and through opportunities to observe experienced therapists at all stages of their learning. Students also reported they learned more when they had opportunities to take part in the whole range of the speech and language therapists work, including administration, timetable construction, staff meetings and case conferences as well as client contact. Then the giant step shown in figure one became just another step as shown in figure 3. This was endorsed by supervising clinicians who agreed that students worked better and learned more quickly when they were integrated and involved in all aspects of the speech and language therapy teams work from the outset.
Figure 3 Active learning: reducing the step between student and qualified therapist NEW THERAPIST STUDENT Lifelong THERAPIST learning continues... Integrated STUDENT practice, THERAPIST theory, observation, STUDENT Integrated reflection ACTIVELY practice, INVOLVED theory, observation, Integrated reflection practice, theory, observation, reflection

NEW THERAPIST

STUDENT THERAPIST OBSERVER THEORY

Of course there are situations when adult learners will benefit from learning the theory prior to their work experience. For example, phonetic transcription in clinical work requires pre-existing knowledge. However, in many cases, it is important to consider alternative models such as the learning cycle based on Kolb (1984) shown in figure 2.
Figure 2 Learning cycle An alternative model of professional learning: integrating theory and practice

different professions have equally successful models and approaches to supervision involving less frequent and less direct supervision

Practice

Rehearsal

Reflection

Theory
In this model the student may enter at any point of the cycle so that practical learning, rehearsal and reflection may precede theoretical learning (Parker & Kersner, 2001). For example, a student having interacted and conversed with a person with neurological problems may then find it easier to learn neurological theory. Such a model reflects the real work of speech and language therapy as reported during the consultation by managers responsible for appointing therapists to first posts. They commented on the importance of students developing the ability to investigate, problem solve, devise creative ways of working in new situations and take responsibility for clinical management decisions.

Curriculum changes were made within the University College London courses, aiming to: encourage peer learning and reduce dependence on supervisors; encourage students to use feedback from a variety of sources not only their supervisors and tutors; ensure that observation was embedded at all stages of clinical practice; change the nature of observation in placements; consider and encourage concurrent practice and theory; develop even closer links between university tutors and placement supervisors; focus more on reflection in the learning process; encourage risk assessment and management, rather than risk avoidance; develop a hypothesis-testing approach and problem-solving skills; seek placements where students could be involved in more real work in teams; give more feedback to students by developing new formative assessments; establish an evidence base for the philosophy and practice of the learning process; change the assessment process in order to examine aspects of clinical practice students have not directly experienced as well as those they have; involve the supervisors more in the assessment process.
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education

Workshops were run for the students in addition to those already being provided for supervising clinicians. The workshops emphasised the teaching philosophy and the development of practical skills with tutors taking more of a facilitating role aiming for more independent learning for the students. Thus for example students were enabled to manage their own tutorials, taking responsibility for planning, time management, problem solving and feedback and developing other group skills. Wherever possible within the curriculum, theory and practice were further integrated so that there was an even closer link between the type of clients seen and the content of students concurrent college-based learning. Students discussed approaches to a diversity of placements, including paired and group placements and special team projects, as well as individual ones in a variety of settings (Parker & Cummins, 1997; Parker & Emanuel, 2001).

as students are able to become active learners contributing to real work as members of the speech and language therapy team. In addition, it also seems important for students to have time to reflect on the models and processes underlying their own professional learning. This is reflected by the action research described here which embraces the continuous learning cycle of action - reflection - theory - rehearsal. Within University College London, as with any speech and language therapy department responding to its internal and external environment, there is the need for an ongoing monitoring and feedback process to highlight current strengths and identify areas for change. Myra Kersner and Ann Parker are at University College London, Department of Human Communication Science, 2 Wakefield Street, London WC1N 1PF, e-mail m.kersner@ucl.ac.uk or a.parker@ucl.ac.uk.

Outcomes
Changes made as a result of the strategic plan were regularly monitored and specific outcomes noted. Placement offers increased with significantly more paired and group placements; supervising clinicians reported favourably on their closer involvement in the assessment process, and new and innovative placement projects continue to be offered each year. Recognising the importance of the constant need for monitoring and change, a permanent audit was put into place to facilitate the regular gathering of qualitative data from the students and placement supervisors. Some examples of student comments are given in Figure 4. This type of feedback, showing advantages to paired and individual placements, supported the decision to maintain a diversity of placement experience so preparing them for the diversity of real work.
Figure 4 Examples of Students Feedback

Acknowledgements
We would like to acknowledge and thank the students for their involvement and feedback, as well as our colleagues in University College London and the South East speech and language therapy services. Special thanks also to Clare Morris and Heather Anderson.

References
Barnet, R.A., Becher, R.A. & Cork, N.M. (1987) Models of professional preparation: Pharmacy, nursing and teacher education. Studies in Higher Education 12 (1) 51-63. Bines, H. & Watson, D. (1992) Developing Professional Education. Buckingham: Society for Research into Higher Education and Open University Press. Collard, R. (1993) Total Quality: Success Through People (2nd edition). London: Institute of Personnel Management. Eraut, M. (1994) Developing Professional Knowledge and Competence. London: The Falmer Press. Grundy, K. (1994) Peer Placements: Its easier with two. College of Speech and Language Therapists Bulletin (October) 10-11. Kersner, M. & Parker, A. (2001) A strategic approach to clinical placement learning. International Journal of Language and Communication Disorders 36 (Supplement) 150-155. Kolb, D. (1984) Experiential Learning. Englewood Cliffs: Prentice Hall. Morris, C. (2001) Student Supervision: Risky Business? International Journal of Language and Communication Disorders 36 (Supplement) 156-161. Morris, C. & Parker, A. (1998) Exploring the crisis in clinical training: looking to the future. International Journal of Language and Communication Disorders 33 (Supplement) 244-248. Parker, A. & Cummins, K. (1997) Group placements and student practice: a project in under fives centres. Speech and Language Therapy in Practice (Winter) 13-14. Parker, A. & Emanuel, R. (2001) Active Learning in service delivery an approach to initial clinical placements. International Journal of Language and Communication Disorders 36 (Supplement) 162-166 Parker, A. and Kersner, M. (2001) Developing as a speech and language therapist. In M. Kersner and J.A. Wright (eds) Speech and Language Therapy: The decisionmaking process when working with children. London: David Fulton Publishers. Parker, A. and Kersner, M. (1998) New approaches to learning on clinical placement. International Journal of Language and Communication Disorders 33 (Supplement) 255-260. Stengelhofen, J. (1993) Teaching Students in Clinical Settings. London: Chapman and Hall.

Some Learning Advantages of Paired Placements Theres someone at your own level to discuss things with. You get more support and backup from a colleague. One comes up with information the other hasnt thought of. A peer is very honest in the feedback they give. More responsibility given to a pair than individual. Sometimes you achieve more with another person. You become more adept at negotiation and teamwork. Its not so scary, therefore its fun.

Some Learning Advantages of Individual Placements Not able to rely on peer so had to work independently. Had more individual time with the therapist. You see more of what the therapist does. It feels more like reality - on your own in the team. More feedback from the therapist. Get to do everything yourself, dont have to negotiate so much. Gives you a different type of confidence, no peer to lean on. More secure to work closely with the therapist.

A permanent process
Change is a permanent process, small changes leading to bigger ones. As changes are made so they need to be constantly monitored and further changes made in the light of the feedback received. However, when assessing such a process it is always important for strengths to be acknowledged as well as identifying areas for improvement. There needs to be strong communication links between the students, the college-based tutors and the supervising clinicians within the speech and language therapy services, and an explicit openness about actions taken, so enabling feedback and facilitating links between philosophy and practice. The variety and diversity of learning opportunities and experiences facilitates students in their confident development in the real world of speech and language therapy. On placement students need to be encouraged to think like a therapist. Diversity and difference are to be encouraged so long

5 steps to effective change

1. Consult widely, maintaining strong and transparent communication links. 2. Challenge assumptions! 3. Develop a strategic plan. 4. Audit outcomes and acknowledge strengths. 5. Put in place an ongoing monitoring and feedback process to identify areas requiring change.

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heres one I made earlier

Heres one I made earlier...

Alison Taylor with some low-cost, flexible therapy suggestions.

Reviews
PASSPORTS Personal Communication Passports Guidelines for Good Practice Sally Millar with Stuart Aitken The CALL Centre, University of Edinburgh ISBN 1 898042 217 14.00

Scream jars

Definitely for you!

My brief for this review said, This magazine is for practising therapists and students who have too much to do and insufficient time in which to do it. This book then is definitely for you! Clearly set out and easy to dip into, it is essentially a time-saving, very practical guide for clinicians involved in creating Personal Communication Passports with their clients, taking you through each stage with clear illustrations and many practical examples. The authors consider who benefits from Passports, when where and why they are needed, through to the software and hardware necessary to create them and the practicalities involved in their making. A lot of consideration is given to the Passport content and evaluation of its usefulness. Good value for money, a lot of information is presented in an easy to read style and there are many references to resources available on the internet. Karen Phillips is a specialist speech and language therapist at Bell Lane School, Buckinghamshire.

Useful for listening work for individuals or group - the idea is adapted from Disney / Pixars Monsters, Inc., where monsters collect screams / laughs to make electricity work. Materials
4 jars (glass sweet jars are useful) with lids Megaphone

In practice I
1. Put a sound picture on each jar. 2. The child listens to a sound then makes a noise / blows into the correct jar. 3. Quickly put the lid back on so the scream doesnt escape, and see how many screams you can collect (you can use ping pong balls to represent the screams).

In practice II
You can use the jars for categories eg. child screams into the jar for furniture if they turn up a picture with a chair on it.

Wild journeys

A way of motivating children to practise sounds or language work, this was inspired by the popular SEGA console game Crazy Taxi. Materials
coloured dice 4 coloured cars / buses / trains people (small pictures) waiting to get on board plastic money the board itself which will probably be A3 size and laminated - made up of squares, with a starting point and colour coded routes to six possible destinations (eg the supermarket, a school, a burger bar).

In practice
1. Choose a vehicle and stick a passenger on it with blu-tac. 2. Roll the dice - the first roll tells the child which colour of destination they are heading for (give them a coloured sticker to remind them). 3. For each part of the road / track, give the child a word or sentence to say. If the child gets it wrong they miss a go or go back one square (what they are told to do will depend on their age). If the child gets it right, they move to the next square. When the destination is reached the child removes the person from the car and collects their fare. 4. The child then blu-tacs a new passenger to the vehicle and rolls the dice to find out the next destination. 5. The game can continue for as long as you wish, or until the child has a certain amount of money. The more money, the better the child will have done with their speech or language task.

HEAD INJURY The Brain Injury Workbook - Exercises for Cognitive Rehabilitation Trevor Powell & Kit Malia Speechmark Publishing ISBN 0 86388 318 4 33.95

Comprehensive, clear and valuable

Spots for the dogs

Excellent for sound production, listening, language work or rewards, individually or in a group. Materials
photocopied pictures of Dalmatian puppies (no spots) lots of black spots OR rich tea biscuits icing sugar chocolate dots (from a supermarket)

In practice I
Each dog has a sound and the child has to put a spot on the right dog. A version of this is to have one large dog every time the child says a sound / word correctly, a spot is put on the dog. You can adapt this for language work (eg. opposites).

In practice II
1. Put icing sugar on a biscuit when child says a sound correctly. Then put one chocolate dot for each sound on the icing. 2. You could use this as a listening game - the child picks a chocolate dot from the correct picture.

Over 140 cognitive rehabilitation exercises together with information sheets, questionnaires and quizzes. Appropriate for clients with moderate or higher level difficulties. Most exercises lend themselves easily to group or individual work. A useful initial chapter on brain injury education is followed by sections on memory, thinking skills, executive function, awareness and emotional adjustment. The latter sections are particularly welcome since they are rarely found in traditional speech and language therapy resources. Activities provided encourage the development of adaptive compensatory strategies. Caution and sensitivity should be used with regards to the timing and appropriateness of individual tasks. A comprehensive, clearly written and valuable workbook. Mary Henretty is a speech and language therapist with South Glasgow University Hospitals NHS Trust.

Alison Taylor is a speech and language therapist with Morecambe Bay Primary Care Trust.
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care pathways

A holistic approachfrom the outset

Read this
if you are interested in multidisciplinary working the generalist / specialist interface easing access to services

Hilary Cowan explains why offering intensive initial support from a multidisciplinary team, promoting functional communication at an early age and giving parents the opportunity to have a better understanding of their child is good news for preschool children with autistic spectrum disorder.

aird et al (2003) discuss the wishes of parents when they are going through the process of assessment and diagnosis of autistic spectrum disorder. Three of these wishes are to have : Equality of access and a prompt response to concerns Prompt provision of educational and therapeutic interventions The streamlining of assessment by a multidisciplinary team. In West Lancashire, parents and children with a suspected autistic spectrum disorder used to be seen separately by the educational psychologist, paediatrician and speech and language therapist and, although each individual professional offered a comprehensive service, communication between them wasnt always coordinated and cohesive. This occasionally left parents feeling as though they were receiving a slightly piecemeal service - and not always aware that professionals were communicating with each other. In May 2002, the three of us - Val Cumine, senior educational psychologist and specialist in autism, the consultant community paediatrician and me decided to streamline the preschool assessment, diagnosis and therapy offered. The changes we made in the coordination of our services came about at the same time as the United Kingdom working party National Initiative for Autism: Screening and Assessment (NIASA) - published as the National autism plan for children - was released in draft form. This document proposes best practice in the assessment and diagnosis of autism in preschool children with a suspected autistic spectrum disorder, and we have submitted a proposal to audit our service against the standards it sets out.

Contacted immediately
Children are referred to the multidisciplinary team by a variety of different professionals such as speech and language therapists, health visitors, community paediatricians and GPs. Parents are immediately contacted by a member of the team to discuss the

purpose of referral and what they can expect from us. Parents are also sent a preschool communication questionnaire to complete and return prior to the initial assessment. This gives not only an indication of the childs communication abilities but also the parents perception of their childs communication difficulties. Examples of these questions are: How does your child tell you what they want? Does your child point in order to a) Get something b) Show you something? Will your child join in with social games eg. peeka-boo? Does your child always respond to his/her name? Does your child use natural gestures to get his/her message across? Several questions are also included regarding the childs receptive and expressive language abilities. Parents and children are then sent an appointment to be seen in the child development centre, usually within four weeks of referral. The assessment usually takes place over a number of weeks in a variety of settings such as the child development centre, the childs own home and a nursery or preschool setting if the child is attending one. This gives the clinicians the opportunity to observe the childs communication and social interaction skills in different situations and with different people and allows me to assess the childs functional communication within these settings. The educational psychologist and I carry out most of the initial assessment sessions jointly. During the assessment process a variety of assessment techniques are used by each professional. Initially we carry out a parental interview, which can take up to two hours. However this is an invaluable time as it allows professionals and parents to form a relationship of trust, essential for future working relations. I use informal observation of the childs play, communication and interaction skills. If appropriate the childs receptive and expressive language will be formally assessed. We always carry out the POKIT (Mogford-Bevan, 2002). This is a qualitative assessment in which the child and parent/carer are videoed interacting and playing with specific toys. The educational psychologist and I then observe the video and complete a checklist which records social interaction skills and communication. The POKIT also includes a checklist for diagnostic indicators in play and interaction of autistic children. This has proven to be an extremely useful tool as it allows us to re-examine the childs play, social interaction and communication skills several times. It is not, however, a diagnostic tool to be used in isolation but part of an array of tools and observations to be used to aid the diagnosis of an autistic spectrum disorder. The child will also have a cognitive assessment by the educational psychologist if appropriate, and medical assessment carried out by the paediatrician.

Tremendous success
Communication therapy begins almost immediately the child is referred to our team. Parents are

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care pathways

offered weekly therapy involving work on joint attention and joint action routines, turn taking, imitation and the Picture Exchange Communication System (Frost & Bondy, 1994). Throughout the session the children are introduced to the concept of using visual symbols, photographs or objects of reference to help them understand what they are doing now and what they are expected to do next. Parents then use these strategies during the week at home and in nursery. Therapy sessions are based around an object or activity that engages the child which, according to Schopler & Mesibov (1988), is essential when working with children and adults on the autistic spectrum. Because the session is highly structured, as free as possible from extraneous distractions and uses a high proportion of visual strategies, the children settle into the sessions within a very short space of time, and begin to generalise the strategies being taught. We have had a tremendous amount of success since starting this type of therapy, not only with the children but also with the parents and nursery support assistants who are then able to go away with an idea of where to move the child onto during the week. Once a diagnosis of an autistic spectrum disorder has been reached, parents are offered a place on the EarlyBird course (Shields, 2001) which I run with one other speech and language therapist and the specialist educational psychologist in autism. This course lasts for thirteen weeks and gives parents the opportunity to learn about what an autistic spectrum disorder is, communication and autism, and managing behaviours. Groups vary in size from four to six sets of parents. This not only gives them the opportunity to gain a better understanding of their childs differences and difficulties but also allows parents in a similar situation to meet up and share ideas. Several have recently discussed starting up a local support group for parents and siblings of children with an autistic spectrum disorder. Once every half term parents and support assistants working with individual children are invited along to a Picture Exchange Communication System (PECS) training session. During the morning we discuss why PECS was devised, the importance of functional communication, phases 1 to 3 of PECS and how to implement PECS at home and in the nursery setting. This, together with the weekly therapy sessions and the EarlyBird training (which covers augmentative types of communication, specifically PECS), enables most parents to implement PECS at home. The early introduction of this type of communication system is of enormous benefit to the child as it gives them a successful means of communicating and their parents a structured positive approach to teaching communication which also often results in an improvement in their joint attention.

The three members of the multidisciplinary team meet monthly to discuss and collate the evidence and observations of each child.

As part of this initiative we felt that health visitor training was essential. We arranged a full day training session, which was well attended, and discussed several behaviours seen in young children presenting with a possible autistic spectrum disorder. We also discussed the use of the Checklist for Autism in Toddlers (CHAT) as a screening tool in addition to their general 18 month developmental screen. The CHAT was developed by Baron-Cohen et al in 1992 as a screening device to be used around the age of 18 months by GPs and health visitors; however, it is not meant as a diagnostic tool for autism. Baron-Cohen et al suggested that, although at this age there may not be specific behaviours that can be used to denote autism, the lack of certain behaviours at an expected time in their development may be indicative of an autistic spectrum disorder. The five key behaviours are:1. Protodeclarative pointing (pointing that is used to comment on something rather than to request something) 2. Joint attention 3. Interest in, and emotional engagement with, other people 4. Social play 5. Pretend play. Further training for Health Visitors and GPs is planned. The three members of the multidisciplinary team meet monthly to discuss and collate the evidence and observations of each child. Once all members of the team have reached an agreement, a diagnosis will be given to parents. The time taken to reach a diagnosis - or not varies with each child. Parents are asked to attend a meeting with the team members, but not to bring their child with them, to give them time to absorb the information being given and to ask questions. If the child does not have an autistic spectrum disorder we arrange a referral to a more appropriate speech and language therapist. I asked my eleven speech and language therapy colleagues what they think of our specialist service, and the impact it has had on them. Ten feel it is an excellent service and are very happy to transfer children at an early stage to a therapist with expertise in the area of autistic spectrum disorder. One is happy to transfer due to caseload pressure but is concerned at the potential deskilling of generalist therapists over time.

ents the information and support that is required to help them come to terms with such a diagnosis. When suggesting a referral to the specialist team to parents, most therapists say they would like the parents to have a second opinion from a speech and language therapist and educational psychologist who specialise in working with children with complex communication difficulties. If parents then ask if they suspect an autistic spectrum disorder, they say that is something the team will be looking at. The feedback from parents has been extremely positive. They feel that there is a clear pathway of care from the outset that is holistic and meets the needs of the whole family during a time that, for most families, is very traumatic. Offering intensive support initially, promoting the implementation of a functional communication system at an early age and giving parents the opportunity to have a better understanding of their child will hopefully equip them to deal with the differences and difficulties of their child as they grow up. In West Lancashire we are meeting the needs and wishes of most parents, and strive continually to improve the service to the children and their parents. Not every family however feels able to accept this amount of input from the outset. Some take longer than others to accept the diagnosis and its implications. We offer these parents as much support and therapy as they feel they can cope with. Hilary Cowan is a speech and Language therapist with West Lancashire NHS Trust, Child Development Centre, Ormskirk District General Hospital, Wigan Road, Ormskirk, West Lancashire.

References
Baird, G., Cass H. & Slonims, V. (2003) Diagnosis of autism. BMJ 327: 488-93. Frost, L.A. & Bondy, A.S. (1994) PECS The Picture Exchange Communication System Training Manual. Le Couteur, A. & Baird, G. (2003) National Initiative for Autism: screening and Assessment (NIASA). National autism plan for children. London: National Autistic Society. Mogford-Bevan, K. (2002) Play Observation Kit (POKIT). Egghead Publishing. Schopler, E. & Mezibov, G.B. (eds.) (1988) Diagnosis and assessment in autism. New York: Plenum Press. Shields, J. (2001) The NAS EarlyBird programme: partnership with parents in early intervention. Autism: Int J Res Pract 5: 49-56.

Training need
As key referrers to our service, the majority of the speech and language therapists are confident in recognising the signs of autism, and some feel it depends on the severity of the presenting signs. New graduates are less confident in recognising the signs, which is a clear training need, and some of the more experienced therapists commented that they dont feel they have the expertise to give par-

Reflections
Do I recognise the need for onward referral for specialist opinion? Do I allocate enough time to initial interviews? Do I help clients prepare for their first contact with our service? 13

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cover story

It aint what you say, its the way that you

H
Read this
if you want to create a positive communication environment share knowledge and your decision-making process break goals down into logical steps
ow many times have you come away from a productive meeting having agreed some very clear aims and ideas only to find three weeks down the line that these plans are faltering or abandoned? Or the other situation when you have been going on and on about developing looking, listening and turn taking skills - only to be greeted one morning by a teacher fresh off a course telling you enthusiastically how she will be implementing this new approach in her class. Familiar? Well it certainly brings back painful memories to me. So why were my suggestions failing to get going and yet similar suggestions, when delivered through a package, were firing peoples enthusiasm? What was I doing wrong? I believe that its all in the framework. Thats why these approaches such as the Social Use of Language Programme (Rinaldi, 1992), Intensive Interaction (Nind & Hewett, 1994) and the Picture Exchange Communication System (Frost & Bondy, 1994) have been so successful and so important in helping us to develop and establish these ideas in the places where we work. They all provide a clear framework of why, what, how and when that enables the user to understand the underlying principles and therefore effect real change within their practice. I decided therefore to apply this principle to my joint work with the teachers at Bidwell Brook Special School in our quest to create a positive communication environment throughout the school. This task, from bitter experience, can feel like trying to get the pot of gold at the end of the rainbow; depending on where you stand your perspective of the end point - and therefore the route - is very different. And, most significantly in our jobs, what do we do if the teacher goes off in a totally different direction?

How do we improve collaboration with parents and teachers of children with special needs? For Charlotte Child, the experience of conceiving and piloting Choices, Changes & Challenges is proof that its all in the framework.

Responsibility
It seems that we often voice frustration that our ideas and recommendations have not been taken on board. It could be argued that the responsibility for ensuring that a child is provided with a suitable communication environment lies with the person in charge of that environment: the teacher or the parents. How they choose to run their classroom or home is clearly their choice and ultimately their risk (Malcomess, 2001). However Kate Malcomess challenges us, through the use of Care Aims, to reflect upon our practice, to identify both the strengths and weaknesses in our intervention, and to make changes. It then becomes clear that the responsibility lies with us to get our practice right. If our aim is that a child is provided with lots of real reasons to communicate, then one of our underlying tasks, as well as direct intervention, is to ensure that we get the information over to the teachers, families or carers in a clear accessible way that enables them to understand fully: where the child is where you want to get to why you want to get there and how youre going to do it, so that they can take an active role in decision making and developing their own ideas. For us, these ideas came together in a booklet Choices, Changes & Challenges that encapsulates the way I work through the school and follows a broadly developmental hierarchy.

Charlottes daughters choose to be photographed with her!

A Bidwell Brook leaver group

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cover story

, u say it
Fundamental step
Being able to make Choices, or being perceived as able to make a choice, is the most fundamental step for a child to being viewed and treated as a communicator. Once children have begun to develop their language skills, we need to focus on extending these skills through their use, rather than on tasks that teach vocabulary. Changes provides a structure that is based on making small changes within well-known routine situations that create a communicative need. Finally Challenges focuses on a more reasoned use of communication and includes clarification and repair skills. Once the booklet was done I used it as the basis of my sessions with the families and staff. This meant that we could work from a shared text, I was able to discuss and explain the information, and we could make decisions from it. Crucially they could take the booklet home and re-read it, which helped the families in particular to remember certain strategies and helpful hints. However I am always very careful to point out that it provides a framework and not a formula (see practical examples). 1. Choices I realised very quickly in my work with families and staff that such a simple concept as offering choices was indeed far from simple in achieving, and the whole area needed to broken down into logical steps (see figure 1 for examples).
Figure 1 Examples from Choices

Practical example I: using Choices.

Paul is a 5 year old boy with Downs Syndrome. He lives with his parents David and Sue, and older brother Matthew. When I first met Paul and his parents, they described him as using a couple of signs (for more and biscuit) and some sounds and words. They felt he understood most of what they said, but didnt necessarily always choose to respond. Targets had been set to further his understanding and use of signs and words but it was becoming clear that Paul wasnt very motivated by this work and it was becoming frustrating all round. Paul, who had fleeting attention, was wandering around the television fiddling, and began to get cross and agitated, occasionally banging his hands together and using a grumpy cry. Sue explained this meant that Paul was after something, and that he was using his version of the more sign to tell her. After Paul settled we talked more about the way that he communicated and we came up with a list of behaviours and a need for his parents to both notice and interpret. Paul had never yet indicated what he specifically wanted. My overall feeling was that Paul actually had little functional use of his signs, sounds or words in order to communicate a message. The earlier behaviours I had observed had not been directed at the adults; he had simply been reacting with frustration at the television not coming on with the right programme and, although his use of the more sign was really positive, indicating that he knew the context in which to use a sign, it wasnt actually providing any real information. Take control The introduction of choice-making is a critical part of enabling a child to use whatever communication behaviours they have to begin to take control and lead an interaction. Its also easy to set up across the childs different environments, and allows people to feel that they are helping and respecting the childs own wishes. It may be the first time that people have actually experienced the child indicating a preference. David and Sue felt their experiences of offering any sort of choice to Paul hadnt worked and that he simply wasnt interested. Paul usually ignored any attempt by an adult to direct him and make suggestions. I reassured them that this was just part of where he was in his development rather than a specific problem, and that it would be a very good idea to look at choice-making again, but this time in a more structured way. I introduced the ideas about making choices using the booklet. Immediately David and Sue could see that making choices was a starting point and was based on previously published work that had been tried and tested, rather than just an off-the-cuff suggestion. We discussed how the skill of making choices develops, and ideas to try out. I left the booklet with them and they knew they could contact me before our next appointment in two weeks time. I would love to report that that was it and that on my next visit Paul was making clear choices. It wasnt, and that isnt my message. It took an enormous amount of hard work, with lengthy and challenging discussions and quite often that feeling for me of being in free fall not knowing what the outcome would be. However, what clearly helped was the use of the joint framework so that David and Sue were able to follow up the ideas, try them out and make informed choices themselves about what they felt their son needed and the kind of support they wanted from me. It helped us to get through the issues about how do you know he is making a choice if you offer two things that he quite likes? What do you do if he turns and runs off? Where do you stand? How do you hold the items? Why do you hold the items and whats this choice-making business anyway - he can help himself to most things and makes choices that way! I can happily report though that, through their hard persistence, Paul is indeed now making clear choices, reaching towards what he wants and beginning to use his sounds, signs and words at the same time.

Practical example II: using Changes to structure a classroom interaction environment

I had been running groups using the Social Use of Language Programme (Rinaldi, 1992) in a class of nine children for some time, working together with both the teacher and learning support assistant. Over time the ideas had become absorbed into the everyday activities and I had got to the point where I felt that I needed to introduce another new idea. The children were aged 6-7, all with severe learning difficulties, including two with autism using Picture Exchange Communication System (PECS) books. We started to look at how we could create spontaneous reasons for the children to communicate during the day, prompted by in part by the development of the PECS approach, and agreed that it was equally important for all the children in the class. However as I sat there with the staff suggesting the old favourites such as just a drop of paint, no pencil, things out of reach, I didnt need their bemused faces to know that such hotchpotch planning wasnt terribly practical. It also became very clear that we were viewing the whole thing rather differently; I could see all my disruptions creating motivating reasons to communicate - they could foresee behavioural meltdowns and not being ready for playtime. Quite honestly they had a point, and so this was the beginning of drawing up the framework. The process of organising exactly what I meant by Changes and trying out ways of creating them helped me to gain a lot more confidence in target setting and evaluating outcomes and I became a lot more realistic in my expectations. Having the framework meant the teaching staff could see where my ideas had stemmed from and then adapt them to their own style and needs within the class. It also enabled us to see a clear progression over the school year, identify any particularly tricky areas for individuals and essentially create a naturally communicative environment that extended beyond the snack routine and beyond the speech and language therapy slot.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

Start with choices that your child can see If your child doesnt reach and make a choice... How will you know if your child is making a real choice?

(Child, 2004) Very often I found that people hadnt perceived their child as being able to make a choice or to communicate - so they either anticipated their preferences and needs, or their experiences of offering choices were frustrating and disheartening. A really important step for some families was recognising the judgements that they were already making about whether their child liked or disliked something - and realising that choicemaking starts with these reactions. More proactive choice-making will be whether or not they reach towards the item that you are holding in front of them and eventually, for some children, making a choice between two offered items.

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cover story

Common situations and questions that I addressed in this section included: How do I know if my child is really making a choice? What do I do if they dont react? and Clear ideas to try when things dont go to plan.

3. Challenges
In spite of the name, challenges should focus on a gentle extension of changes with a problem solving element, rather than creating significant disruption (examples in figure 3).
Figure 3 Examples from Challenges

2. Changes
For some time in schools I had been using Joint Action Routines (J.A.R.) (Coupe OKane & Goldbart, 1998), which focuses on creating changes within everyday routines that prompt communication and interaction. This had worked well but, in trying to recreate the same approach with families, I realised that I ended up structuring it so much that the suggestions were rather rigid and, if the families didnt agree with them or the suggestions didnt immediately work, they were quickly dropped or discounted. With the written structure the families were able to develop their own ideas in keeping with their belief systems and environments. It also provided the opportunity for us to evaluate jointly how things had gone and to plan the next step. Changes is organised into three areas: a. new events - includes new choices. b. errors - making mistakes. c. omissions - missing things out. I also split errors and omissions into person / action / item in order to prompt a range of different ideas when planning (see figure 2 for examples).
Figure 2 Examples from Changes

Challenges 1. Opportunities to ask for more Providing small amounts of something they want - food, paint, glue. 2. Opportunities to ask for help Not always anticipating the things your child needs help with - leave jars done up, leave a door closed, remove some thing from the place they always expect to find it. 3. Active listening targets Described by Maggie Johnson (1996) as making listening an active process so that the child takes responsibility for understanding a message - so that rather than guessing or opting out, they acknowledge the difficulty and ask for repetition, or seek clarification.

phase. Colleagues within my department are just beginning to try out the structure in their schools and clinics and I am constantly rewriting bits of the booklet as I go. So, no, it hasnt revolutionised my work or the lives of the teachers at Bidwell Brook Special school - but it feels like a really positive step forward. I am convinced that frameworks have got to be an essential part of the way we work with other people. Creating a shared knowledge base from which you can all work and plan proves that its not what you say, but how you say it. Charlotte Child (e-mail chaos@hgf.eclipse.co.uk) is a speech and language therapist with South Devon Healthcare NHS Trust.

References
Child, C. (2004) Choices, Changes & Challenges. South Devon Healthcare NHS Trust. Available on disk for 6.00, e-mail chaos@hgf.eclipse.co.uk for more information. Coupe OKane, J. & Goldbart, J. (1998) Communication Before Speech. David Fulton: London. Frost, L.A. & Bondy, A.S. (1994) The Picture Exchange Communication System. Training Manual. Pyramid Educational Consultants UK Ltd. Johnson, M. (1996) [2001] Functional Communication in the Classroom [and at home]. Contact the Commercial Office, Dept of Psychology and Speech Pathology, The Manchester Metropolitan University, Elizabeth Gaskell Site, Hathersage Rd, Manchester M13 0JA, tel. 0161 247 2535. Malcomess, K. (2001) The Reason for Care. Bulletin of the Royal College of Speech & Language Therapists. November. Nind, M. & Hewett, D. (1994) Access To Communication: Developing The Basics Of Communication With People With Severe Learning Difficulties Through Intensive Interaction. David Fulton: London. Rinaldi, W. (1992) The Social Use of Language Programme. NFER Nelson.

(Child, 2004) Again I had been working with Active Listening Targets (Johnson, 1996; 2001) in school with good results and had found them to be a natural progression from Joint Action Routines (Coupe OKane & Goldbart, 1998), further developing the students confidence in using their communication skills. There were some initial concerns that teaching the students to communicate the message I dont know would encourage them to use it to opt out. However it actually allowed them to opt in, because they were able to replace their embarrassed silence and bowed head with a question or comment that meant they continued to take part. Any real opt out was tackled separately. The outcome was a far more confident group of young people who were only too keen to correct us and became very assertive in ensuring they were understood. I also included requesting more and help in this section. I commonly found people would introduce these quite early to children but, in fact, by their abstract nature - you cant see a more or a help - they are actually quite tricky to communicate. By placing these concepts in this section it helped people to focus on the earlier, more concrete requesting skills first. Using the framework Choices, Changes & Challenges has begun to make a difference to the way we set up communication programmes in Bidwell Brook School and to the expectations we have of the children.

Changes a. New Event New Choices - a different biscuit / drink / video / game Novel Events - something weird thats worth a strange look, if not a comment: boots in the bath / sparkly wig on the dog. b. Omissions Missing out an ITEM - no spoon, no cup, an empty jug. Missing out an ACTION - put them on the swing but dont push; put on their trousers but dont pull them up. Missing out a PERSON - one person doesnt get a biscuit. c. Errors - making mistakes Incorrect ITEM - when the child asks for an apple, you give them a banana. Incorrect ACTION - when they tell you to brush dolly, you wash her. Incorrect PERSON - when they tell you its Daisys, you give it to Molly.

Acknowledgement
An enormous thank you to the staff at Bidwell Brook Special School, Dartington, who have let me try out so many new ideas on them and with the children. They have smiled (or gritted their teeth) as Ive created chaos, and even encouraged me to try again next week. Guess what guys - Ive thought of our next project already.

(Child, 2004) I gave illustrations that people could work from, but this still needed careful discussion to make sure that the families or staff took on the principle and didnt get hung up on the example. For example I would commonly hear, Oh, but Jamie wouldnt bother at all if you only put one shoe on him. I had to be ready to say, OK, the principle is that you make a mistake with an item. What could you do that would cause a response with their favourite toy?

Reflections
Do I yearn for revolution - or focus on a positive evolution? Do my plans make the why, what, how and when clear? Do I provide a framework rather than a formula?

Shared partnership
Planning around communication use has become far more of a shared partnership. Through sharing my knowledge and decision making process I am able to work far more constructively with the teachers and families. However it is important to stress that this is all still very much in a developmental

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training

Interactive training: a touchy subject?

Read this
if you want to set standards or monitor compliance explore new methods of offering training implement change
L R: Louisa Carey, Ian Conyers and Sue Dobson

Computer based training can be used during staff induction to raise awareness of protocols and general issues such as health and safety. But can it improve the actual quality of care provided? Sue Dobson and colleagues reflect on the pilot of an interactive training package on CD about the use of touch with people with profound and complex needs.
and social care workers who also need to know about styles and types of touch. The literature seems to indicate that, due to the unique nature of people with learning disabilities who may have diverse needs, care staff require considerable time in post in a new unit to learn about the individual service users need for touch.

ouch is a common practice in care for people with learning disabilities; there are strong arguments for it to be taught as part of induction and for methods to be established for the maintenance of standards relating to its use. Touch is a more complicated process than just the physical act of contact with another person. It has an essential role in emotional and physical well-being. It sends unwritten messages which convey a wide variety of positive meanings: value, affection and helpfulness. Alternatively, the withholding of touch can transmit negative messages such as rejection, worthlessness and lack of attractiveness (Carter, 1995). These complex processes have several dimensions, all of which rest upon the conceptual structures and attributions of the carers. The teaching of touch therefore needs to be approached in a holistic way. McCann & McKenna (1993) suggest that, to improve quality, interpersonal training for nurses has to include an awareness of the effects of touch in care (see case examples in figure 1). This must be equally - if not more - important for unqualified health
Figure 1 Case examples

Distinct and different cultures

A staff consultation undertaken by a project team (Dobson et al, in press) also indicated that different units may develop a distinct culture about the use of touch. This seems to lead to different focuses of attention to various aspects of touch in care in different care settings. This in turn affects the likely attributions which staff apply to service users own use of touch and their responses to it. However, staff new to a unit tend to adopt the prevalent style of touch and the philosophy about touch in care within the first two weeks of their new post (Estabrook & Morse, 1992). Also, new staff tend to rely on guidelines written by fellow staff within their unit rather than district policies and

Susie
Susie has no sight, and also has autistic spectrum disorder. She enjoys the comfort that the touch of a familiar person gives to her, sometimes actively seeking this out, but she is also wary of being touched by strangers or unfamiliar people. Susie sometimes needs to change her clothes but does not like this to be done by anyone she is not comfortable with. Providing supportive touch through linked arms helps Susie find her way around. This is a good way of allowing Susie to get to know you and for her to become familiar with your touch. New staff are encouraged to help Susie move around the unit; she then eventually understands and learns their touch and lets them change her clothes when necessary.

David
David, who is a non-verbal communicator, has developed his own system of hand shapes to make requests. He reaches out to people who are seated next to him and lays the back of his hand on their forearm. A slight change of hand shape or angle of the fingers or degree of touch can mean different types of requests about food and drink items. His mother explained to his care staff what each type of touch meant. The speech and language therapist took photographs of Davids special hand shapes and touch style, and included these in a communication passport to explain his use of touch and communication.

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guidelines. This is because unit-specific notes give more practical information about the frequency, timing and pace of the use of touch (Carnaby & Cambridge, 2002). This means that, within a district, each care setting tends to develop and maintain distinct and different cultures about their use of touch. This project used an options appraisal approach to develop a training package about the use of touch for people with profound and complex needs. The process followed the principles for implementing change (consult, compare, compete, challenge and change). The development and piloting of the training package is the final stage of the process: establishing the learning needs of the individual staff catering for the particular environments in which care is delivered taking account of organisational issues determining the expected learning outcomes. The analysis of the discussions in the staff focus groups had demonstrated that any training about touch would have to cover: a. developmental aspects of touch b. touch in personal care c. communication and touch d. touch in therapeutic interventions e. the use of touch in supporting activities. Competing pressures with the amount of information that has to be presented to new staff on induction courses meant the training would have to occur on site soon after appointment to a post. The original plan had been to make the training package available on the employers intranet system so staff could access it at their work site within the first three months of their appointment. This system already existed in the matching local acute service to teach the use of blood testing, health and safety issues and the use of electronic thermometers. We felt an investigation of the use of the same technology in teaching qualitative issues might be successful. Eventually, we decided instead to produce the training package and pilot it using interactive software on a CD. The CDs were circulated to the four day centres who participated in the original focus groups. Twenty people with various lengths of service were invited. They were required to complete pre- and post- questionnaires to determine their level of awareness of touch in the workplace and to attend a discussion on the content and format of the course. Each of the five sections of the training package followed a similar pattern of presentation about aspects of touch for both staff and service users. It included some theory about the perceptions and use of touch, together with pictorial illustrations accompanied by explanations. Each section followed the same presentation pattern:

The reasons for touch in terms of socio-emotional issues, communication, therapy and activities The function of touch in relation to the aspect of care and its conscious and unconscious use Touch and disability in contrast to the general population Permission to touch, and perceptions of both parties The benefits of touch in each aspect of care Contra-indications of touch which includes risks, misinterpretation and the perceptions of others. An individualised certificate was included, which could be printed on completion of the training. The original consultations and comparison stages of the project had indicated that using a computer training package would present several difficulties. A named person in each unit was therefore identified to support those staff who volunteered to take part in the pilot study. Several themes emerged from our analysis of the pre- and post- training questionnaires:

After training, staff were more concerned about the misinterpretation or misunderstandings of touch that could occur between staff, service users and others.

3. Reasons for touch

At first, staff mainly mentioned touch in relation to comfort and affection, or specific disabilities such as visual impairment or deafness. However they also used it to get service user attention to themselves or objects. After training they expressed similar intentions, but also included the use of touch to demonstrate lack of threat and as a support for communication.

4. The effect of service users disabilities on staffs use of touch

Staff initially felt that the main factors were the size of the person, their specific condition, the complexity of their problems and their need for help during movement. After the training experience they made additions to this list in terms of individuality and personality factors, the individuals communication needs, therapeutic needs and the persons pain threshold.

5. Other specific factors about the individual

Prior to training the main statements related to the individuals like or dislike of touch or if they were visually and hearing impaired, with infrequent consideration of gender, age or culture. These response levels remained similar even after the training.

1. Awareness, confidence and anxieties

There was an initial difference in levels of confidence and anxiety about the use of touch in care between less experienced staff and staff who had been in post for five years or more. The experienced staff showed greater awareness of the limitations of their knowledge of touch in care and more anxiety about its use, while less experienced staff felt fully confident and expressed little anxiety about touch. After both sets completed the training this situation was reversed. The more experienced staff expressed more confidence and less anxiety, while less experienced staff were more cautious about expressing confidence and showed more awareness of the level of risk involved.

The teaching of touch needs to be approached in a holistic way.

6. When touch is not used

Staff did not use touch when people were distressed or having epileptic fits, when they received negative responses to touch or felt people needed their own space, or when the persons condition meant touch was contraindicated. Touch was also not used when the person refused permission for touch or demonstrated that it was disliked. The only additional statements after participating in the training were about guidelines for clinical procedures or relating to specific individuals being particularly important.

7. When permission to touch is sought 2. Staffs personal concerns about touch

The most frequent response prior to engaging in the training package was that there were few concerns because staff knew they were following the proper policies and guidelines. However, none of the units had formal policies or guidelines about touch to follow. The other concerns were about knowing which individuals were vulnerable to injury during procedures involving touch, improper use of touch by the service users, and hygiene issues. After completing the training package, staff were more concerned about the misinterpretation or misunderstandings of touch that could occur between staff, service users and others. There was also more awareness about ensuring both of us are happy with touch and unease about procedures which were considered too medical. Before training this was considered to be approximately all the time and in most activities. However, baseline observations prior to starting the project had not shown this to be the case. While some continued to maintain this view after training, others had revised their response to hardly ever or rarely with a more limited range of descriptions of the types of touch this covered and with fewer activities.

8. Recording service users initiation of touch

Prior to the training package, all staff were consistent in stating they rarely or never recorded the service users use of touch unless the service user goals required it. Most of these recordings related to the aggressive use of touch by those in their care. There were, however, infrequent examples

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training

..resources...
Visual feedback at home
of staff stating that they did sometimes record touch by service users which demonstrated their enjoyment of a situation, or those which were new examples of communication. Affection or communicative touch was not recorded. After using the training package the staff were more specific in their comments in that they felt they were more likely to record service users initiation of touch during clinical settings or when in activities which they particularly enjoyed. However, they felt actions involving distress or aggression remained the most frequent recordings about touch. They also recognised that they recorded inappropriate touch or their reactions to touch that had sexual connotations. Participation in the training seemed to give permission for staff to discuss concerns about the use of touch, its positive and negative aspects and the potential risks. This led to an increased awareness of the limited recording of touch in current practice. However, staff continued to refer to the use of district policies and guidelines as determining their day-to-day practice, although these documents did not exist. The initial aim had been to increase staffs awareness of the use of touch in care. This seems to have been successful. A secondary aim of the training had been to try to establish a shared vocabulary about how to record and discuss touch in care. The responses to the pre- and post- questionnaire showed little change in use of vocabulary about touch. There was also little or no evidence of an alteration in awareness of gender, age or cultural issues and the use of touch. It would seem that these factors cannot be addressed by a short course approach. Overall the use of the training package was considered to be useful in raising levels of awareness, but of limited value in improving knowledge. The use of information technology in staff training may be successfully utilised in skills training but have more limited applications in altering the qualitative aspects of care. Sue Dobson is a specialist speech and language therapist, Louisa Carey a speech and language therapist, Ian Conyers, head occupational therapist, Liz Whitaker the team leader of physiotherapy and Shripatti Upadhyaya the consultant clinical psychologist with Bradford District Care Trust, Clinical Liaison Team, Leeds Road Hospital, Maudsley Street, Bradford BD3 9LH, tel. 01274 363666, e-mail sue.dobson@bdct.nhs.uk. A system for use on home desktop or laptop computers has been designed to supplement speech and language therapy where the client requires visual feedback of pitch and nasality. Speech Tutor, see www.glottal.com

Moveable larynx
Struggling to explain the larynx to the uninitiated? Jeremy Fisher of Vocal Process has put together step-by-step instructions for building a moveable larynx, and a wordsearch containing the names of the laryngeal cartilages. See www.vocalprocess.net

Autism help streamlined

The National Autistic Society has streamlined its helpline and information services for people with autism, their families and professionals with a one point phone number and e-mail. All calls, including minicom access for deaf and hard of hearing enquiries, will now be at a local rate. The society is also launching Language Line, a three way phone conference service which allows non-English speaking callers to access helpline support through interpreters in over 120 languages. The helpline is supported by Barclays community investment programme. Helpline 0845 070 4004 (Mon-Fri, 10am4pm), minicom 0845 070 4003, e-mail autismhelpline@nas.org.uk

9. Recording service users responses to touch

Initially, records of service users positive or negative responses to touch were stated to be about increases in their frequency of use of touch, their trust of staff or their reactions to intervention, or if their touch resulted in some form of injury to the staff. This remained the same after the training.

10. The advantages of using touch in care

Before accessing the training package the advantages of using touch in care were seen mainly in terms of the advantages for staff, for example the demonstration of support, friendship, its calming and soothing effects and giving staff the reward of gaining increased trust from the service users. Its use in communication was only briefly mentioned in terms of gaining attention. Afterwards there was still an emphasis on the development of relationships but also a new demonstration of awareness about the role of touch in developing service users skills and an identification and focus on the benefits of touch for service users social and emotional well-being.

Smoking advice
Smoking is a major cause of mouth cancer a disease that kills 1,700 every year. The British Dental Health Foundation produces leaflets Tell Me About Smoking and Oral Health and Tell Me About Mouth Cancer (12.50 per pack of 100), a Mouth Cancer CD-ROM (3.99), and books Tobacco and Your Oral Health (16) and Oral Cancer (56). All these can be used by health professionals to encourage smoking cessation and promote better oral health. Tel. 0870 770 4015 for a catalogue. Prices exclude p&p and VAT.

References
Carnaby, S. & Cambridge P. (2002) Getting Personal: an exploratory study of intimate care provision for people with profound and multiple intellectual disabilities. Journal of Intellectual Disability Research 46 (2): 120-132. Carter, A. (1995) The use of touch in nursing practice. Nursing Standard 9 (16): 31-35. Dobson, S., Carey, L., Conyers, I., Upadhyaya, S. & Raghavan, R. (in press) Learning about Touch. Journal of Learning Disabilities. McCann, K. & McKenna, P. (1993) An examination of touch between nurses and elderly patients in a continuing care setting in Northern Ireland. Journal of Advanced Nursing 18 (5): 838-846.

11. The disadvantages of using touch in care

There was little difference in comments either before or after participating in training. The possibility of misinterpretation and misunderstanding of touch, improper use of touch and rejection of touch to the detriment of therapeutic intervention were similar. However, there was an apparent increased willingness to voice concerns about issues of hygiene or worries about causing distress or damage to service users by their own use of touch.

Voice clips
An internet review in ENT News recommends the visually rich, useful and interesting image gallery on the Voice and Swallowing Website which includes still and video clips of a range of pathologies and procedures including nodules, papilloma and bowing, and functional endoscopic evaluation of swallowing (FEES). (Tunde Odutoye, ENT News, March/April 2004) www.voiceandswallowing.com

Reflections
Do I attempt to establish a shared vocabulary with other professionals for recording and discussing clients? Do I undertake baseline real-life observations prior to offering training? Do I strike a healthy balance between the confidence of inexperience and the knowledge of limits that comes with experience?

Sign up to get fit

At The Leisure Centre is the latest manual from Signalong. It includes sport and fitness activities and equipment and a section of coaching sentences with key words highlighted to help people with communication difficulties to understand instructions. www.signalong.org.uk, tel. 0870 774 3752

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reviews

Reviews
DYSPHAGIA Stickerpack: Safe Eating and Swallowing Vanessa Crowe University of Stirling Dementia Services Development Centre ISBN 185769 1SS5 50.00 PRAGMATICS Merrimaps Sally Merrison & Andrew John Merrison STASS Publications ISBN 1 874534 35 7 45.00+VAT

Eye catching
This practical resource for adults with acquired neurological dysphagia provides eye-catching visual and written advice in sticker form. The stickers can be used flexibly to allow complex dysphagia strategies to be presented pictorially. The 44 sticker sheets range from advice regarding texture modifications to specific strategies to aid safe swallowing. A clear rationale emphasises the importance of providing written information alongside pictures to ensure advice is carried out. The picture form means miscommunication is more likely to be avoided, and it is also a useful visual aid for patients who struggle to remember or understand recommendations. One section gives advice on medication. We have an essential role in highlighting to the multidisciplinary team that a patient is dysphagic and may have difficulty with certain oral medications. However, whilst this is an area of long-standing difficulty in dysphagia management, surely recommendations to make medication unlicensed - as in crushing tablets - need to be made by the medical team? The pack provides a limited number of stickers and some, such as pured diet, are more likely to be used than others. Although individual sticker sheets can be purchased, it may be expensive at a cost of 7 for 10 sheets of your choice. Karen Hawley and Laura OShea are specialist speech and language therapists working with adults with acquired neurological disorders at Hope Hospital, Salford.

A joy
This short, easy test consists of a number of street maps. The child is given a number of ambiguous / unclear directions to follow and is required to take turns, request clarity, repair broken down communication and make inferences. The materials are clear and well marked and provide a very relaxed environment for natural communication to take place. It is useful to video record the session for subsequent analysis. The assessment provides a good profile of a childs pragmatic skills and the therapy resource materials in particular are hugely beneficial for building on these. A re-assessment map is provided to monitor progress. I would find it useful to have more information about how much help to offer children without a direct request for it and examples of asking questions / making repairs on the trial maps. I would also love to see Merrimaps normed on a variety of children, and reliability and validity tests. It is a joy to have this excellent assessment and therapy resource tool for children over seven with pragmatic difficulties and I recommend it for every department. Sinead Monaghan is a speech and language therapist in Castlebar, Co. Mayo.

APHASIA Aphasia Inside Out - Reflections on communication disability Eds. Susie Parr, Judy Duchan & Carole Pound Open University Press ISBN 0 335 21144 5 17.99

AAC Communicating with Pictures and Symbols Ed. Allan Wilson The CALL Centre, University of Edinburgh ISBN 1 898042 25X 9.00

Incredibly easy to read

A collection of papers presented at an Annual Study Day for AAC in Scotland in 2003, this covers the basic considerations when creating communication boards (purpose; format; presentation; vocabulary selection) and also offers advice for accessing pictures and vocabulary on the net and using computer packages. There are a couple of case-study papers on helping teaching professionals to symbolise the school environment, and introducing symbols to extend access to stories. There are also details regarding a project to improve communication between service users and providers. This would be a useful starting point for therapists or students who have not had experience in this field but who have client/s who may benefit from AAC. This publication is incredibly easy to read and does not need to be read from cover to cover. Very good value for the price and advice within it. Sarah Jones is a newly qualified speech and language therapist with Pontypridd and Rhondda NHS trust.

A stimulating insight
This 13 chapters in this very readable and moderately priced book each present a different aspect of the experience of living with aphasia from the perspectives of aphasic individual, carer, speech and language therapist, linguist, counsellor and researcher. As a result, it provides a stimulating insight into the personal and psychological impact of living with a communication disability as well as current thinking on appropriate therapy and support. The editors have attempted to make the content more accessible to people with aphasia by including a summary of key points at the beginning of each chapter. A much-welcomed addition to the existing resources that explore the social model of aphasia, this will be useful to students, speech and language therapists at all levels of experience and other interested professionals as well as individuals and families living with communication disability. Alison Moss is a speech and language therapist working for speechmatters Northern Ireland.

CLINICAL EDUCATION Innovations in Professional Education for Speech and Language Therapy Shelagh Brumfitt Whurr ISBN 1 86156 385 X 20.00

LOW TECH AAC Talking Mats and Frail Older People Joan Murphy Psychology Department, University of Stirling ISBN 1 85769 192 X 50.00 (e-mail joan.murphy@stir.ac.uk)

Thought-provoking and inspiring

This is a book for all practising therapists who are offering student placements as part of their continuing professional development. Well organised, with useful introductions and conclusions to most chapters, it offers varied topics, contributors and writing styles making for an easy read that can be dipped into as needed. Examples include peer placement, teaching dysphagia and PATsy. I found it thought-provoking and inspiring. As clinical educators we are expected to be the clinical expert, teacher, supervisor and supporter. For this vital role a text of this high standard is required reading. Every department library should hold a copy. Cathy Hones is a speech and language therapist and clinical co-ordinator for Cheshire West PCT.

Beautifully simple
This package describes how picture symbols attached by Velcro to textured mats can be used to help people express their views and feelings more easily. Primarily designed for use with frail order people, it can easily be adapted for a much wider age and range of disabilities, for example children or people with learning difficulties. Talking Mats consists of a clearly presented and easily understood manual, together with a video which demonstrates how it has been used with four frail elderly people in nursing or residential homes. A beautifully simple idea. Any therapist can quickly make this resource without breaking any speech and language therapy budget! Its low tech, cheap and effective. Angie Bird is a speech and language therapist in Finchley, London.

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reviews

LEARNING DISABILITY The Dorset Assessment of Syntactic Structures (DASS) Belinda Howell STASS Publications ISBN 1 874534 36 5 60.00

MOTOR NEURONE DISEASE Talking Together (Communication Strategies of people with MND and their partners) Joan Murphy Scottish Motor Neurone Disease Association 20.00

Strengths and limitations

Strengths... a more formal expressive language assessment specifically for adults with learning disabilities light, portable, transparent quick and easy (approx 20 mins) format and position of questions and picture reflect the position of the client and clinician nature, purpose and use described clearly in simple language large, clear and relatively age appropriate pictures target sentence sheet helpful for analysing structures eg. word levels, grammar - prepositions, pronouns, negatives ...Limitations familiarity with LARSP/STASS assumed - and needed - for scoring no instructions for Rapid Assessment Score Sheet (a worked example would be very beneficial) needs a key to explain the abbreviations eg. cX, AAXY structure does not follow a hierarchy eg. of easy to increasingly difficult sentence structures some of the questions rely on the persons ability to reason, so are at risk of being unanswerable we are unsure why such an in depth assessment of expressive language skills would be necessary given that, typically, an individual with learning disabilities has disordered language structure. Vinny Raval is a student, and Sue Giles & Sue Martin speech and language therapists, with Camden Learning Disabilities Service, London NW1 7JR.

A missed opportunity
Based on a 3 year research project, this video describes some of the difficulties people with motor neurone disease face communicating with the general public, using telephones and interacting with carers in the early stages, and illustrates communication strategies and some dos and donts. It has clear subject headings and voice-overs and is set in the community so avoids looking clinical, however it is unclear who the target audience is. It could possibly be used as part of a training package for support staff and might be of some help to carers of the newly-diagnosed, but would have to be handled sensitively. Surprisingly, there is no mention of introducing AAC in the early stages. The accompanying leaflets contain some useful advice but the typeface is small and difficult to read. Value for money? Probably not. A missed opportunity. Heather Campbell, Charlotte Ogilvie & Sam Livingston are speech and language therapists with Southwark Adult Therapy Team, a domiciliary multidisciplinary team, and part of Southwark Primary Care Trust.

DYSLEXIA English Reading Pen Text-to-Speech Technology WizCom Technologies Ltd 198.99 from www.scanningpens.co.uk or tel. 0800 1 613 713

Could help carefully selected users

This small, portable device sounds like the answer to every dyslexics prayer. It scans and reads aloud words and whole phrases. It will also supply word definitions. I tested the pen on both children and adults. All were eager (indeed desperate) to try it but most reported that it was fiddly to use and said they could not always understand the robotic speech. On the positive side, some reluctant young readers immediately grabbed a book to try the pen out. Teenagers were better than primary pupils at handling the pen and enjoyed exploring its many features. These include: choice of earphones or speaker, adjustment for left- or right-handed use, reading multiple font types and sizes, and breaking words down into syllables. The pen could help carefully selected users to read and study independently. It would be a helpful tool for specialist therapists working with more able upper primary, secondary age and adult clients. Its use takes practice and it is unsuitable for those with visual or motor problems but it certainly increases motivation. The pen is easily damaged, making it an expensive option to recommend to schools. Zohra Jibb is a specialist speech and language therapist, working in mainstream schools in East Lothian.

AUTISTIC SPECTRUM DISORDER Writing & Developing Social Stories (Practical Interventions in Autism) Caroline Smith Speechmark ISBN 0 86388 432 6 24.95

Will save hours of work

A parents view... Rightly labelled a practical resource manual this clearly formatted book benefits everyone interested in social stories. Reasoning how comfortable adults feel when using a story form to effect behavioural change and indicating that if a story is right... changes...occur quite quickly, the social story presents as a highly effective tool. The text complements Carol Grays studies and is enhanced by excellent (photocopiable) examples. Commentary on visuals and continuing the creativity open amazing horizons on the basic format. The section on the deliverance of training is apt; this book will suit the specialist, and could be usefully shared with others. Beth McDonough is a parent of a preschool child with autistic spectrum disorder. ...A therapists view The introduction clearly describes how the theoretical underpinning of social stories integrates into their practical use. Early on, the author takes care to point out this is not an off the peg resource for readers to lift examples for their own use. While it provides clear guidelines for writing social stories, the examples are wordy at times which may be disappointing if clients have limited verbal comprehension abilities. (The section creating the creativity does however provide suggestions to address this.) This would be of benefit to parents, education staff and carers of youngsters with autistic spectrum disorder and as a reference for speech and language therapists, as the handouts and activities form a clear and comprehensive training package which will save hours of work. Fiona Young is a senior speech and language therapist in Dundee.

EVIDENCE BASED PRACTICE Evidence Based Practice in Speech Pathology Sheena Reilly, Jenni Oates & Jacinta Douglas Whurr ISBN 1 86 156 320 5 25.00

A must for every department

This helpful book is a must for every department. For therapists qualified more than 5 years it provides an excellent overview of the components of evidence-based practice. It presents a summary of the evidence base for 10 areas and what current research is telling the practising therapist. This includes what we dont know (eg. what defines normal in dysphagia) as well as what we do (eg. early intervention with late talkers is superior to wait and see). For those sceptical about the limitations and lack of clinical relevance of the randomised controlled trial the authors acknowledge that this may not be the gold standard for speech pathologists that it is for medicine. This book is a challenge to all therapists. Do we have Sackett et als (p317) essential characteristics of clinical skill mastery, the practice of continuing professional development, humility, enthusiasm and irreverence to be evidence-based practitioners? I hope Reilly and colleagues are working on volume 2. Magda Moorey is a speech and language therapist in London.

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winning ways series (3)

are made under pressure

ANDREA has done many things in her life but has always been drawn to working with people. After an interesting variety of jobs, including being a speech and language therapy assistant, she decided to go the whole hog and embark on full speech and language therapy training. This is where Andrea met her challenge. Although she was accepted on to the course and was therefore thought capable of completing it, Andreas own personal gremlins are persuading her that everyone on the course is brighter, sharper, and more organised and confident than she is. She studies effectively but has difficulty putting her thoughts together in a fluent and readable way. She has received good constructive feedback for previous efforts although, in her present state of mind, she interprets that as criticism. Because Andrea is afraid of failing the essay she has been set, she endlessly puts off making the plan and the draft. Because she is afraid that others on the course will sense her inadequacy, she holds back from seeking help and advice and friendship. Because she wants to hide her difficulties, she does not approach tutors and lecturers and, because she has persuaded the family to commit some of their hard earned funds to her course, she cannot admit to not enjoying herself and worrying herself half to death as a consequence. So she spirals into a pattern of anxiety, procrastination and helplessness. She feels she has no options open to her other than resigning from the course and cutting her losses. This was Andreas state of mind when she called for a series of coaching sessions. As ever, when things are at this stage, the feeling above all the other feelings is that of being overwhelmed. She was stuck in the mire of anxiety, worry, helplessness and procrastination. Even when she took the time to retreat to her study table she was sitting gazing at the work and doing nothing, thus exacerbating the problem. Know the feeling? Well, diamonds are made under pressure, and I knew that she was a woman of great qualities because of all the previous achievements in her life. When a pot is boiling hot on the stove you can only pick it up by its handle - and that is what I proposed to do with Andrea. Firstly we had to tackle the thing which was upsetting her the most and that was the unfinished assignment. So, we imagined that it was on the top of the pile, and looked at it all by itself. There were a few layers

Diamonds
Recognising the fear that underlies resistance to change is essential if we are to realise our potential, as these examples from the casebook of life coach Jo Middlemiss demonstrate.

Read this

if you are afraid of failure believe you are undeserving wear defensive armour

to the problem which by now had been renamed The Project: Motivation Plan Draft Advice Confidence Completion Reward By visualising the work completed and submitted for marking, Andrea was able to feel what it would be like to get over that hump of uncertainty. By imagining the feelings of joy, excitement, relief and satisfaction, she was able to motivate herself enough to complete the task. We talked about times when she had felt these things before and she was able to come up with quite a few peak moments in her life. So Andrea knew

how to feel these emotions and I got her to use this knowledge for working on the essay. The way she was feeling I should think it would be hard to get out of a chair never mind complete a challenging professional assignment - but by 4pm the draft was done. Appointments had been made with her tutor for some advice and by the following week the work was completed. However, the procrastination of the essay was just a symptom of an underlying issue. Somehow Andrea believed that she did not deserve to be on the course. She had decided, without any basis, that everyone else on the course was cleverer than she was and that, if she asked for help, they would all realise her subterfuge. This is what I call Stinking Thinking! It is useless, energy zapping, ego-driven and always untrue. This thinking has many disguises. It poses as excuses, beliefs (inherited and adopted), behaviours and assumptions. Everyone reading this article will know what I mean: no time, no money, too old, too young, too fat, too thin, not clever enough, dont know the right people, people like me just dont..., people like me always..., other people might think... And on it goes until stasis sets in. Raising our awareness to our resistance to change is the key to making the changes which allow us to jettison the limiting beliefs which stop us from reaching our potential. One client shared his favourite metaphor with me. Imagine that, when you are a small child, your mind is like a glorious castle filled with hundreds of wonderful rooms just there for exploring and enjoying. Gradually, as the child grows, rooms get shut down or go unvisited and the vista shrinks to a room and kitchen with the grand castle just a distant memory. Sad, but true. What rooms are there in your mind left unexplored? ANGELA is an experienced speech and language therapist. She is an expert in her speciality and enjoys being involved in a multidisciplinary team. She loves her work and became quite emotional when recalling some of the high points of her career with me. At the moment Angela is experiencing difficulties not with the job but with the system. Due to changes within the NHS Angela finds herself under new management. The pay structure is not clear and she is unsure as to who is her boss from the point of view of appraisal. The lack of security of tenure and uncertainty about things beyond her control has caused Angela to experience a deep sense of frustration in her work, which is having an impact on her home life. Because she has always been the problem solver in the family Angela has been unwill-

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winning ways series (3)

ing to bring her problems home, although the family is well aware that she is not her usual self. The coaching challenge here was to tease out all the various strands of what was happening in Angelas world so that she could return to functioning at the level she was used to. We started on a positive note. What was really working for Angela? She agreed that, at the basic level, she still loved her job, and that interacting with her clients and their families still gave her as much satisfaction as ever. Secondly, being involved with professionals from other fields gave her a sense of being part of the bigger picture and also helped her to educate the wider world about the variety of work carried out by speech and language therapists. Thirdly, she was pleased to be making a valued contribution to the family coffers and was well supported by a loving family. All that was going well. On the negative side, Angela was beginning to feel undervalued by her employers. The shortage of speech and language therapists and the large caseload was also a long-term concern for Angela as it was often difficult to give the care and attention she wanted to individuals and their families. When we looked at Angelas work situation there were definitely more plusses than minuses, however she recognised that there were two main blocks to her peace of mind. The first was that she was resistant to a changing circumstance reference her employers. Secondly, she was allowing her fear of appearing weak to stop her from reaching out to her family. I asked Angela which of theses areas she would like to tackle first and she opted for the family. She called a family meeting and explained to them why she had been tetchy and uncommunicative. Her teenage children were surprised to realise their mum could be vulnerable but were delighted that she was treating them as equals giving them respect by asking them for help and support. The atmosphere in the house brightened, giving Angela the impetus to take her worries to her colleagues. She discovered that many of those from other disciplines were also working under the same restraints and they all decided to stay effective within their sphere of influence rather than be frustrated about what was happening outwith it. So, by splitting up the problem and recognising the emotions she was attaching to each area, Angela was able to step into the parts of her life that she could enjoy and influence. She took her focus off what she could not influence, and peace of mind was returned for the time being.

Would you like to: Identify and achieve your dreams Unlock your potential Confront difficult decisions Shake off restrictive behaviours and limiting beliefs Gain and maintain mental and spiritual balance Be aware of and use your talent? Our series Winning Ways with Personal Life Coach Jo Middlemiss aims to help you find out how you can be better at what you do, and better at being you. To gather material to make the issues - and their potential solutions - as realistic and relevant as possible for readers, Jo offers readers a confidential and complimentary half-hour telephone coaching session (for the cost only of your call). Although Winning Ways will be based on what is raised in the calls, you can be reassured that details will be altered so that it will not be possible to identify individuals.

We apologise for the poor printing quality of this figure in the Spring 04 issue. Physical Environment Fun and recreation Career Money

Personal growth Significant other/ Romance

Health Friends and family

The eight sections represent balance. The centre is 0, the outer edge is 10. Rate your level of satisfaction with each section, then draw a new outer edge (example below). How bumpy is your Wheel of Life now?

The Wheel of Life him and the department flourishing. Drawing on The Fish Philosophy (Lundin et al, 2000), he started in small ways to make their day: Small notes of positive feedback Treats for the coffee break Offers of time release to allow notes to be written up. He did not make a big song and dance about this, just gradual almost imperceptible changes. The benefits for him in doing this were: A sense of relief A feeling of confidence A feeling of being in control A feeling of satisfaction Better team relations. These feelings were infinitely preferable to what he had had before. In deciding to take FEAR out of the equation he has released himself from slow burning levels of anxiety, and his department is gradually becoming a great place to work. Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk.

CALL JO ON 01356 648329 (www.dreamzwork.co.uk).

My final case concerns JAMES, who was appointed to a position of responsibility and was delighted to receive the promotion. Sadly, not all of his colleagues were pleased for him and it seemed to James that they were deliberately trying to thwart his authority. From the outset James thought this was a problem with his colleagues. However it was actually about FEAR: his own fear of not being able to handle the situation, and of everything getting out of control. He exaggerated the situation until he actually imagined himself being sacked as a hopeless leader. As you can imagine this led to a very unhealthy atmosphere in the workplace. As James became more authoritarian and aggressive his colleagues became more defensive and secretive. James wanted to help them but he was the last person they would come to. He was unhappy, they were unhappy. Firstly I discussed with James what it was he really wanted. He wanted a happy working environment where the work got done according to professional guidelines. Taking it as read that you can only change yourself, I asked James to look at the areas of his behaviour he could change. He opted for asking his colleagues how and where they needed help. He decided to have interviews that were not appraisals. And he decided to change his own internal representation of his colleagues. He realised that he had been visualising them as working against him. As he closed his car door he put on his defensive armour ready to do battle. He decided to change his attitude. We used the slamming of the car door as the trigger for creating a new picture. As he approached his office he pictured the day going well, his team responding to

Reference
Lundin, S., Paul, H. & Christensen, J. (2000) Fish!: A remarkable way to boost morale and improve results. Hyperion Books.

Recommended reading
Hay, L.L. (2003) You can heal your life. Full Circle Publishing Ltd.

Reflections
Do I stay effective within my sphere of influence? Do I look at changing my internal representations of other people? Do I explore all the rooms in the castle or just stay in the kitchen?

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how I...

Read this

if you want to tackle non-attendance raise awareness of speech, language and communication needs share skills more effectively with other professionals Alex Jack is a specialist speech and language therapist - Sure Start Scunthorpe, with North Lincolnshire PCT. Further information from Alex on 01724 298100. Tom Morris is a speech and language therapist with Sure Start West Green & Chestnuts, Haringey Teaching PCT. Beryl Hylton Downing is speech and language therapy coordinator for Gateshead Sure Start Partnership.

How I am makin
Alex Jack outlines how Sure Start in Scunthorpe is raising awareness of speech and language development in the wider community, and making core speech and language therapy services more accessible.
The nursery staff were asked to identify children they felt would benefit from small group work (6-8 children in each group), and to provide a member of staff to help with each group. This was to develop joint working and sharing of skills. The nurseries were keen to be involved but disappointed that some children missed out, as the groups were initially limited to one afternoon or morning per week due to restrictions on therapists time. In October 2002 we were lucky enough to employ a speech and language therapy student having a year out from her course. She eventually took over the running of the groups with supervision from the therapists, and was able to spend a whole day in each of the nurseries. This meant that more children had the opportunity to be part of the groups, and she also provided invaluable feedback about the programme, which has since been amended. As a result of the success of these groups, we have obtained funding for a full-time assistant to carry on this work, which has been well received by staff, children and parents. 2. Home visits To access hard to reach families who generally dont attend clinic appointments, I have developed a home visiting service to screen children for speech and language difficulties, offer advice to parents, and refer on to the main speech and language therapy department where necessary. These visits help to demystify the role of the therapist, and can also be used to encourage parents to attend Sure Start groups and events. Joint visits can be arranged with other members of the Sure Start team such as health visitors. Children are usually referred to this service by the Sure Start family link workers who visit all two year olds to carry out the Sure Start Language Measure. If appropriate, I can also offer the family a course of parent-child interaction therapy (Kelman & Schneider, 1994). 3. Drop-in sessions There are several one oclock clubs run by Sure Start staff in various venues and these are generally well attended by parents and children. During the holidays, play schemes provide parents with a place to take their children while the schools are shut. I provide a drop-in service at these sessions to give parents information about speech and language development and discuss any concerns. 4. Booklets The previous therapist began a series of Time to Talk booklets, which provide advice about language stimulation from birth to 9 months and 9 to 18 months. I have updated and extended the series to include 18 to 36 months and 36 months plus. They are designed to be parent friendly, have proved extremely useful during home visits and drop-in sessions, and give parents something concrete to take away. I have also developed a Dump the Dummy leaflet, which is promoted at Sure Start events such as Fun Days. Children are invited to throw away their dummies in exchange for a bottle of bubbles, and the parents are given a leaflet. Although we know many children who use dummies have more than one, this process helps to raise awareness about the sensible use of dummies and the conse-

Nationally, approximately 10 per cent of young children suffer communication difficulties but, in areas of high socio-economic ne clinically significant (Locke et al 2002). Communication difficulty in social adjustment in adolescence and adult life (Clegg et al, 1999). and children to provide services that are tailored to individual nee and on ways of working which are customer and community driv So, how does this focus alter speech and language therapy practic their experiences. Further information on www.surestart.gov.uk a

Turning the future around

While, as with any post, it takes time to understand the politics and to develop the relationships necessary for effective multidisciplinary working, Sure Start gives you a tremendous opportunity to learn about different working cultures and to try new things. We are fortunate that the Sure Start Programme Manager in Scunthorpe is committed to supporting and funding speech and language therapy input, and we value the opportunity to work flexibly and innovatively in this exciting new area. This is the story so far... 1. Nursery Programme When the Sure Start programme for Scunthorpe Old Town was initially set up, a speech and language therapist was employed on a part-time basis. She carried out baseline assessments of all the children in the four nurseries in the area, and found that 30 per cent had a speech and / or language delay. She then ran listening and attention groups in the nurseries with a member of staff. When she left in May 2002, two therapists from the main speech and language therapy department took over these groups on a part-time basis as an interim measure. I joined the team on a full-time basis in September 2002 and, in consultation with the local nurseries, we decided to develop and pilot a programme for the whole academic year to include other areas of speech and language development: Term 1: Ten weeks promoting vocabulary development Term 2: Five weeks of listening and attention activities Five weeks of language activities based around the senses Term 3: Five weeks of phonological awareness / Jolly Phonics (Lloyd, 2001) Five weeks of Story Sacks (Griffiths, 1995).

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ng a Sure Start
Clegg, J., Hollis, C. & Rutter, M. (1999) Life sentence: what happens to children with developmental language disorders later in life? Bulletin of the Royal College of Speech & Language Therapists 571: 16-18. Locke, A., Ginsborg, J. & Peers, I. (2002) Development and Disadvantage International Journal of Language & Communication Disorders 37 (1): 3-15.

eed, around 50 per cent of children have communication needs which are n early childhood is positively correlated with poor mental health and The Sure Start programme focuses on prevention. It works with parents eds and designed to encourage access. It places high value on outcomes, en and professionally coordinated. ce? To mark National Sure Start month (June 2004), three therapists share and www.nationalsurestartmonth.com.

Practical points: making a Sure Start (whatever your client group)

quences of overuse. As preventative measures, the Sure Start midwife distributes the birth to 9 months booklet during her antenatal visits, and the dummy leaflet is given to parents by the family link workers as part of the 18-month book bag visits. 5. Training I have developed a training package for all members of the Sure Start team, which broadly aims to: inform about the role of the speech and language therapist give an overview of speech and language development and how to identify children with potential speech and language difficulties provide ideas about early language stimulation. The package is divided into two sessions, the first of which is available to all members of the team (including office staff), and the second more practical session is aimed at team members who have direct contact with children. I have found it difficult to pitch this training at a level suitable for everyone due to the variety of backgrounds and experience, but overall feedback has been very positive. Although not all Sure Start team members have provided formal training, my knowledge of diverse issues such as welfare rights, breastfeeding and personal safety has increased as a result of working alongside a welfare rights advisor, midwife and community policeman. 6. Joint assessment sessions In conjunction with the main speech and language therapy department, we have developed joint screening sessions with health visitors for all children under four identified as having speech and language difficulties. We are currently piloting this scheme, and early indications are that it has improved attendance. The general consensus is that the sessions provide parents with a less

1. Capitalise on the expertise, resources and community penetration of other organisations. 2. Consult with service users to understand where they are coming from. 3. Establish baselines so you can monitor change. 4. Make and take opportunities to try new things. 5. Recognise when you are in a position to fulfil mutual objectives. 6. Consider a variety of changes to make your service more accessible. 7. Use a least effort approach to maximise uptake. 8. Ease entry to specialist services for those in need.

intimidating, more holistic approach. In addition, we have jointly produced a health visitor induction pack, which was distributed at a training session with information about speech and language development and the referral process. We plan to invite all new health visitors to shadow a speech and language therapist for a session to observe how we work and discuss the induction pack. So, what next? The two part-time therapists returned to the main speech and language therapy department at the end of April 2003, leaving one full-time therapist and an assistant working in the Old Town programme. A second Sure Start programme has recently been launched in Scunthorpe (the Cloverleaf Patch) and we have recruited a part-time therapist and two more assistants for this area. We continue to develop new ways of working which include: 1. Training for preschool staff in conjunction with the main speech and language therapy department. 2.Dump the Dummy days in nurseries and preschools. 3. Meet the Parents days in the nurseries to keep them informed about the group sessions and discuss any individual concerns. 4. Involvement at the antenatal stage through

multi-agency parent classes called Ready Steady Baby, which start in June. 5. Sing and Sign sessions (Felix, 2001). 6. Joint working with the main speech and language therapy department to develop early intervention including parent workshops, early language groups, early sound awareness groups, and further parent-child interaction sessions. 7. A multi-agency project to develop early rhyme bags. Our next major challenge is to look at mainstreaming services, and I am working in close collaboration with the main speech and language therapy department to plan future early years services which build on the preventative work piloted within Sure Start.

References
Felix, S. (2001) Sing and Sign. www.singandsign.com Griffiths, N. (1995) Story Sacks. www.storysack.com Kelman, E. & Schneider, C. (1994) Parent-child interaction: an alternative approach to the management of childrens language difficulties. Child Language Teaching & Therapy 10 (1): 81-94. Lloyd, S. (2001) The Phonics Handbook. Jolly Learning Ltd: Essex.

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how I...

Turning up or turning off?

ne of the primary difficulties facing the childrens speech and language therapy service in Haringey has been the poor rate of attendance. Data collected by Sure Start from the community service found that, of children under four discharged from clinic caseloads, 62 per cent had been due to a failure to attend. A subsequent survey found that over 30 per cent of initial appointments were not attended, rising to 50 per cent in some clinics. This had significant implications. First, the cost of the time and resources allocated and subsequent financial justification for the use of the service in this format. Second, the problems arising for children and relevant services when recurring communication difficulties begin to be picked up at a later stage, for example the increased resources required to meet the childs educational needs. A common attitude from therapists has been both frustration and relief; the first for the time wasted on non-attendees, the second for justifying discharge from the caseload, so reducing the waiting time for others, as well as giving extra time to carry out the administrative and non-clinical duties that have become increasingly demanding. However, one of the key principles of Sure Start is to take a client-focused approach to service development. This meant looking beyond the immediate results of non-attendance, instead focusing on some of the potential causal factors, and giving potential users of the service the opportunity to express their own ideas on any changes that could increase accessibility and reduce the likelihood of families missing appointments in the future. Our study was largely qualitative, intended to reflect the views and experiences of parents. The interviews were broken into two sections. The first was semi-structured with open questions, such as: I see that that you had an appointment on _________ but you didnt attend. Why was that? Where would be the best place for their initial assessment and then therapy if s/he needed it? What else might make it easier for you and your child to access the service? These were gradually pared down, taking into account relevance, redundancy, or adaptation needed as core themes emerged. The second included closed questions to gain relevant background information on the families. The telephone was used for purely practical convenience, although home visits were made for those with no phone line or for families who required an interpreter (figure 1).

Non-attendance is frustrating and wasteful. Working with a community clinic service, Sure Start therapist Tom Morris identifies why it is so common and what can be done to address it.
community of diverse linguistic, cultural, and social backgrounds. At least half, including the area covered by West Green & Chestnuts, has a population with significant socio-economic needs, such as a high rate of unemployment, temporary accommodation, and one of the largest numbers of refugees and asylum seekers in the country. This has implications for attendance, where many residents are unaware of the range of services available. As a family in temporary accommodation has a higher likelihood of moving between referral and initial appointment than someone in permanent accommodation, this may also present the possibility of failure to receive appointments, resulting in non-attendance and subsequent discharge, although this could not be confirmed. The low economic status of both those attending and not attending reflected high rates of unemployment, but also suggested that this may not significantly affect a familys likelihood to attend. However, there were signs of a potential influence on attendance from the familys primary home language (figure 2).
Figure 2 Background details

We therefore decided to look more closely at the views from both sets of users on the way the service as a whole is delivered, and key themes emerged: 1. Waiting Times Waiting times had sometimes reached up to 21 weeks and beyond for initial assessment due to the high referral rate and subsequent large caseloads. Both attendees and non-attendees identified this as being unsatisfactory. For example: [I was] quite annoyed it would take so long...I felt it was quite urgent so it made me uncomfortable knowing itd be months away. [The service was] very good, but we were very unhappy at the wait between therapy sessions. [He] could have done with going back sooner as he definitely benefited from speech and language therapy. One parent just expressed disillusionment with the service as a whole after having waited so long. In a further community clinic review, an audit showed that 26 per cent of children on the caseload were being monitored rather than discharged. As this increased the number of children on the caseload, it had a direct affect on the waiting time for both assessment and therapy, which could have had a subsequent affect on attendance. It also may have led to an increased likelihood of non-attendance at review appointments due to a lack of parental concern or a spontaneous resolution without intervention.

3. Location For initial appointments, the most popBlack A-C 4, Somali 1, ular location for non-attendees was the White UK 2, Mixed clients home, not only for convenience, White UK/Black A-C 1, Black African 1, Irish 1 but also due to factors such as other Black UK 4, Somali 1, siblings, and parents views on the White UK 1, Mixed importance of making clinical judgeWhite UK/Black A-C 2, ments in a more natural environment. Mixed White UK/Irish 1, Black African 1 [The best place would be] at home because I cant speak English and I have English 9, Somali 1 Primary language English 15, Arabic 1, three other children. Turkish 1, Kurdish 1, Twi 1, used at home In the Health Centre he wasnt acting Lingala 1, Fanti 1, Punjabi 2 normally because of the environment. Interpreter needed 1 Turkish, 1 Kurdish 1 Somali Not in a strange place, better to have 10/23 Car owners 4/10 home visits... more natural for a child...get At least one parent 9/23 3/10 Figure 1 Interviews a better example of what theyre like. employed For attendees, a clinic setting was preNumber No. Non- No. Interviewer Interviewer Telephone Clients Clinic ferred, emphasising recognition of different needs Interviewed Attendees Attendees 1 2 Home for different families. 33 23 10 29 4 24 6 3 For therapy, most parents said that both clinic and / or From the initial interviews, the need for the service and Samples of both attendees and non-attendees nursery settings were appropriate, although many its overall quality was, in general, appreciated. Ninety under the age of four were taken from lists of those stated a preference for an environment promotnine per cent could remember the actions to be taken given appointments by the community clinic team. ing interaction with peers. after initial assessment, with 76 per cent happy with While effort was made to choose the participants Its best to mix with people...now I think therapy the advice given. Even for non-attendees, 87 per cent randomly, this proved difficult due to the high rate would be better in nursery to get the benefit of thought the referral had been appropriate. of mobility within the population. Haringey has a other children.

Non-Attendees Parent Interviewed 21 Mothers, 1 Mother & Father, 1 Stepmother Childs Gender 14 Male, 9 Female No. of children at Average 2.25 home Black A-C 6, White UK 6, Parents/Carers Black African 4, Asian 2, interviewed Kurdish 2, Sikh 1, Irish 1, Ethnic/Cultural Moroccan 1 Group Black African 4, White Childrens UK 4, Mixed Black/White Ethnic/Cultural UK 4, Black A-C 3, Mixed Group (as defined White UK/Irish 1, Irish 1, by Parents) Asian 2, Kurdish 2, Sikh 1, British Muslim 1

2. Communication Some parents without English as a first language stated that appointment letters in their first language would have increased their likelihood to attend. The majority of families said that a Attendees reminder by phone nearer the time of 10 Mothers the appointment would be helpful as a prompt to attend.
7 Male, 3 Female Average 2.25

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...when he goes to nursery there are other children who talk really well. At speech and language therapy, the other children werent talking either. He needs to hear other children talk. Assessment at home to see how she interacts at home, or in a drop-in centre to see her with other children. Best place for therapy is the clinic. Again, this stresses the need for a variety of options depending on the clients wishes. 4. Flexibility The traditional times offered for appointments were seen by some parents, particularly those working, as being inconvenient, with either evenings or weekends preferred. Its not convenient for working families - outside working hours would be better. 5. Childcare For families with siblings, the provision of childcare facilities was suggested. Couldnt attend because have a younger son and no-one else to look after him. Maybe a cr` eche would be ideal. 6. Awareness Unfortunately, family awareness of the nature of the speech and language therapy service and what it could offer was poor, even though almost all the parents had identified communication difficulties in their children. This relates directly to the need

to raise the service profile through both publicity and the promotion of preventative approaches with key stakeholders.

Direct implications
One of the measures of the success of Sure Starts third objective, to increase achievements of children through play and learning opportunities, is to reduce the number of children in need of referral to speech and language therapy. However, this objective cannot be met until there is a clear recognition as to what this indefinite amount might be, given the number of potentially appropriate users who are not currently accessing the service. The interviews conducted have direct implications on the form and nature of future preschool speech and language therapy provision. Based on the information gathered and discussion between Sure Start and the community clinic coordinator, a number of adaptations are to be implemented by the Early Years and Community team therapists supported by us. These include: Asking the health visiting service to identify hard to reach families who may find it difficult to attend and note this on their referral form. This will then lead to a home visit rather than an initial assessment in clinic. Offering more individual family work through the Sure Start community team to address other social issues that can act as barriers to attendance.

Arranging a convenient time with the family before making an appointment for an initial assessment. Where possible, contacting the family by phone or text nearer to the day of the appointment to confirm attendance. Providing a telephone helpline for families unsure as to whether or not an appointment is necessary, or seeking advice on activities to continue while awaiting an appointment. Translating appointment letters into a variety of community languages. Working more closely on site with playgroups and nurseries, making joint decisions as to the appropriacy of referrals and subsequent actions to be taken by all parties. This emphasises the importance of close collaboration between Sure Start and core services, and other professionals involved in both referral and follow ups. Subsequent outcomes will be closely monitored and evaluated over the forthcoming year before any permanent changes are made to childrens speech and language therapy service delivery in the community.

Acknowledgements
With thanks to Jane Dixon, Sure Start speech and language therapist and Liz Stein, Early Years & Community speech and language therapy coordinator.

Turning out for Chatterkids

For two years I was in the fortunate position of working full-time within a single programme to achieve Sure Start objectives, particularly Improving the ability to learn, (No. 3), the proxy measure for which is a Target of A 5 per cent reduction in those children requiring specialised intervention at the age of 4 years. Whilst I did not quite have a carte blanche, I did have the opportunity to think creatively about how to achieve the objectives and overcome probable barriers. As speech and language therapists, it is incumbent upon us to ensure early and accurate identification of those with speech, language and communication needs. Given the scale of the problem, this has to be done indirectly through the people who have contact with children in their earliest years. Nevertheless, however good our training of parents and practitioners is, we have further obstacles to overcome. Training is a two-edged sword. Having established relationships with key people and taken steps to increase awareness of childrens language development amongst early years practitioners in the Sure Start area, there was an inevitable increase in referrals. Given that language delay / disorder was hith-

When needs are under-reported, families are hard to reach and professionals are overstretched, innovative methods are called for. Beryl Downing sets the context for the development of Chatterkids and considers why it has got everyone talking.
erto greatly under-reported, this was welcome. However, we then had the task of responding to the increased demand for over-stretched services. Furthermore, there was still the problem of engaging families sufficiently to work with their children. Despite a network of local speech and language therapy clinic bases, a high proportion of families in the Sure Start areas do not attend even for initial assessment and are discharged unseen. Some are referred and discharged several times - a familiar tale to many readers, and one that contributes further to waiting lists. It has become fashionable to call these hard-to-reach families, and Sure Start is meant to find out how to reach them. A further complication was that the local health visitors and associated community nursery nurses,

our main source of referrals, had in the last few years changed their patterns of contact with young children. Developmental checks, previously carried out at 18 months and three years, are presently offered by way of a home visit between 24 - 30 months of age. The highly variable nature of language development at this age had led to an increase in the number of children who, whilst exhibiting little language in the course of a home visit, when later seen at the speech and language therapy clinic had apparently caught up and did not require intervention. Even more alarming than this false positive rate, the paediatric service noted an increase in referrals of school-aged children who seemed to have slipped though the child surveillance net (false negatives). Clearly, there was scope for ongoing dialogue and training but, in the meantime, what was to be done? Chatterkids emerged as a means of dealing with the issues.

Challenged
Well, thats the official version, but theres always the personal story that runs in parallel. Shirley, manager of the local family centre, challenged me repeatedly: Whenre you going to do speech therapy at the centre then? Were sick of referring the bairns to the clinic and finding out months

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Figure 1 Equipment

Figure 2 Documentation

later theyve been discharged, cos their Mams never took them to the clinic, and we know they still need it. Whats the point? Its a waste of time for all of us. How true! Local health visitors had a similar lament. After consultation with colleagues, I told the family centre manager that, if she could find me a co-worker from the centre, I would run a language group there, where many of the hard-toreach families already attended. The family centres in the borough were undergoing a reorganisation and losing their childcare remit in favour of outreach to families. Their management was prepared to consider new ventures to support children in need. The centre workers themselves were very well aware of the prevalence of language needs and they were open to anything that might help. We were in a position to fulfil mutual objectives. I met my new collaborator, Andrea, and we decided upon a weekly group for up to eight prenursery children for six weeks. The main aim was to differentiate those who were simply somewhat delayed from those who had significant developmental language or other difficulties requiring specialist intervention. We hoped that the existing relationship with the family centre might help families to trust our judgement and bridge the gap to existing services where required. We ran the pilot course together in the family centre with children nominated by staff from amongst those referred to them by social services for a variety of reasons, all under the banner of children in need. I devised a least effort programme using adaptations of typical preschool practice in circle-work (figure 1), particularly musical activities and interactive narrative, which are thought to improve linguistic and social skills. The emphasis was upon facilitation and observation of communication skills, with minimal perturbation of normal practice, since I knew that - quite rightly I was unlikely to find a warm welcome for anything that appeared to be too technical. I developed documentation to facilitate observation, recording and family involvement (figure 2).

Sparkly cloths Glove puppets, esp. crocodile, monkey, mouse Finger puppets eg. IKEA pack Large doll with clothes Teddy & monsters Rainsack Sound-effects ball, bean-bag Bubbles & bubble wand Range of childrens texts Video camera & tapes

Waiting-list form Introductory letter Welcome letter Participation / emergency treatment consent Video-recording consent Session plans Weekly individual record Detailed individual record Parent feedback forms

Wonderful
Despite our doubts, the families brought their children, the children had a wonderful time and we all loved doing it. Of eight families invited to

bring a child, seven did so on a regular basis. Five of the families attended for the feedback session and another attended later. We felt that three of the children needed speech and language therapy intervention and they subsequently attended the local clinic for individual therapy. Of the others, one needed referral to the child development team and, although the parents disagreed initially, they did attend and the child was subsequently admitted to a specialist school unit. The remaining children made substantial progress during the course of Chatterkids and needed no more than recommendation to general Sure Start activities. The family centre staff felt that they were much more able to home in on the nature of the childrens problems and strengths. Encouraged by our success (the engagement figures were far better than wed hoped for), Andrea and I discussed ways of opening Chatterkids to a wider group in the Sure Start area, from amongst children referred by other agents. We began by presenting Chatterkids to family centre colleagues and they agreed to take Chatterkids forward with Andrea (a trained nursery nurse) taking over as group leader and working with another member of the centre staff. This freed me from weekly sessions, and I was then able to concentrate on other aspects of Chatterkids. I could now select children from those referred by health visitors with speech, language and communication needs. I saw all the families prior to the group to explain its purpose, discussed progress with the leaders and observed initial and final sessions to assess progress. I was responsible for verbal and written feedback to parents as well as referral and liaison to other agencies where required. The family centre provided psychological and practical backup support to families, for example by offering inclusion in a behaviour group where parents voiced concerns, or perhaps in assisting with siblings. Many of the families had social services

involvement and the family centre staff were ideally placed to deal with matters relating to this. As I write, Chatterkids has completed its sixth cycle and dealt with more than 40 families who might previously have been labelled hard-to-reach. In each group we have had at least one child with active social services involvement. The structure and content has gradually evolved and we feel that it provides the youngest children and their families with a high quality service, reducing inappropriate referrals to overstretched clinicians and enabling hard-to-reach parents to access specialist services such as the child development team and speech and language therapy clinic. The local health visitors now refer to Chatterkids as the standard response to apparent speech, language and communication needs in children under four. We are about to start three new Chatterkids rolling programmes across the borough, covering all four Sure Start areas. If we find that this works for this cohort, then we will proceed to mainstream Chatterkids as an entry to the service for the youngest children. Chatterkids is very much in harmony with current policy in relation to the kind of multi-agency working described in Every Child Matters (DfEE, 2003) and the Sure Start / Childrens Centres Guidance 2004-2006 (see www.surestart.gov.uk). Our local speech and language therapy department is looking to Chatterkids as a means of reshaping services to the youngest children referred. We feel that other speech and language therapy departments may well want to collaborate with colleagues in family support services, capitalising on the expertise, resources and community penetration of such organisations. I feel privileged to have worked with my family services colleagues who have added another dimension to the services we might otherwise have been offering to families in disadvantaged areas. I strongly commend exploration of the possibility of establishing similar collaborative relationships and would be happy to share details of our experience with others.

References
DfEE (2003) Every Child Matters. Green Paper. The Stationery Office.

..resources.....resources.....resources...
Leadership tool
The NHS Leadership Centre has launched a 360 assessment tool to support leadership development for individuals, teams and organisations in the health service. Anyone in the health service who is interested in participating should contact Anne-Marie Archard on 020 7592 1021, e-mail anne-marie.archard@doh.gsi.gov.uk. 45 plus VAT, www.nhsleadershipqualities.nhs.uk

SEN books
New books from David Fulton include a second edition of Planning the Curriculum for Pupils with Special Educational Needs (Richard Byers and Richard Rose, 17) and Moving On: Supporting Parents of Children with SEN by Alison Orphan (17.50). www.fultonpublishers.co.uk

Child brain tumour

Multimedia health information for children who have a brain tumour aims to help them find out more about their illness and cope with their treatment, thereby lessening their anxiety. The folder, magazine, CD-ROM and website have been heavily influenced by advice from children with brain tumours and their parents. Headstrong - see www.headstrongkids.org.uk

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

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events

MY TOP RESOURCES
1. Macmillan
I am one of a growing number of allied health professionals whose post is funded by the cancer charity Macmillan. It wasnt until I was appointed that I appreciated how much support Macmillan provides to post holders, particularly in terms of training and equipment grants, which are a tremendous help when starting up a new post. The charity also funds speech and language therapy advisors on surgical voice restoration, which Ive found helpful when Ive needed assistance sorting out valve problems. Not to mention the advice and information leaflets, evidence updates and various courses and seminars. So, Macmillan has to be my number one resource. www.macmillan.org.uk

4. Communicaton systems
North Cumbria is a big geographical patch encompassing three primary care trusts and one acute trust which is on two hospital sites. Though Im hospital based, Im out and about two or three days a week doing outpatient clinics or on home visits, and its important that I can be contacted easily. We have an ansaphone in our office in the hospital, but I carry a pager as well and have a mobile phone for when Im travelling around the countryside. As Im a lone worker, the mobile phone also gives me a bit more security - and its a great help when Im lost on home visits and have to ring up for directions!

8. My patients
I am learning such a lot from the people I work with in this post. Being involved with palliative care patients has certainly encouraged me to be more holistic in my approach. Also, Im constantly impressed at how patients who have had extensive surgery do manage to learn compensatory strategies for swallowing, often with a great deal of perseverance and fortitude it has to be said. Some of the laryngectomees are very inventive and develop ingenious systems for managing valves and Heat and Moisture Exchangers which I would never have thought of.

Linda Slack is a Macmillan specialist speech and language therapist who works full-time with head and neck cancer patients and also those with palliative care needs. The post is a relatively new one which Linda has been developing since she was appointed almost two years ago. She is based in Carlisle and covers all of North Cumbria, which includes some of the Lake District, the West Cumbrian coast and up as far as the Scottish border. She works in both hospital and community settings and will often see patients from the point of diagnosis onwards.

5. Jeri Logemann
I was first inspired by Jeri Logemann when I attended one of the early courses she held in this country, at which time dysphagia was a new and growing area for speech and language therapists. Ive attended several other of her courses since then and continue to be impressed not only by her breadth of knowledge and experience, but also her continued enthusiasm and dedication. Her book Evaluation and Treatment of Swallowing Disorders (Pro Ed, 1997) continues to be an invaluable resource as are the many articles she has written on dysphagia in head and neck cancer over the years. http://www.advancedrehab.org/courses/ Swallowing/swallowing.html

9. Clinical support and supervision

At times I can feel professionally isolated and so I value the contact I have with speech and language therapy colleagues from the north east of England who also work with head and neck cancer patients. We meet up from time to time to offer one another clinical support as well as looking at service issues. I also have individual clinical supervision which helps me reflect on my practice and talk through any specific problems I might have. My clinical supervisor works in head and neck cancer but is not a speech and language therapist, which I find can encourage me look at things from a different perspective.

2. Videos
Providing training to other professionals is a key aspect of my job. This can range from teaching sessions to increase awareness of my role in the management of communication and swallowing problems in cancer patients, to specific training on the management of valves in laryngectomees. My video collection is invaluable in helping illustrate such things as normal and abnormal swallowing, communication problems and aspects of laryngectomy. Favourites are Swallowing Matters (for the normal swallow sequence in particular), Dysphasia Matters, Talking it Through, and Nursing and Laryngectomee Care (some of which was filmed in our hospital). Dysphasia Matters (video alone 45, as part of complete training package 105) from Speakability, 1 Royal St, London SE1 7LL, tel. 020 7261 9572. Talking It Through / Nursing and Laryngectomee Care both from the National Association of Laryngecomy Clubs (NALC), tel. 0207 381 9993. Swallowing Matters from MNDA of Victoria, P.O.Box 23, 265 Canterbury Rd, Canterbury, Victoria, Australia, http://www.mnd.asn.au/information. html#Videos.

10. Multidisciplinary team clinic

The head and neck cancer team has a weekly clinic in which new patients are seen and others reviewed. Whilst the number of professionals present during patient consultations concerns me at times, being present to hear exactly what the doctors say has many advantages. It means that I can subsequently check out a patients understanding of what has been said, reinforce information and clarify any misunderstandings. The multidisciplinary team discussion - which takes place before each consultation - is invaluable as it provides me with information on diagnosis and treatment as well as an opportunity to address issues relating to communication or swallowing.

6. Diagrams and models

Providing information and explanation pre-operatively to patients and their relatives is a key aspect of my job. Its important that patients are prepared for the potential effects of surgery on communication and swallowing so that they are well informed when making decisions about their care. I use diagrams and models when explaining the anatomy and effects of surgery and patients seem to find them helpful. The Before and After Laryngectomy diagrams produced by In Health are very useful, particularly the tear off pads so patients can take copies home (from Forth Medical Ltd, tel. 01635 550100). I also like some of the models produced by Adam Rouilly (tel. 01795 471378), particularly the median section of the nose, mouth and throat which has a movable epiglottis - useful when explaining swallowing.

3. Books
I feel as if Ive been on a steep learning curve since starting this job and have needed to do lots of reading. The palliative care component has meant that Ive worked with patients who have had cancers which I had little experience of, such as lung and oesophageal cancers, and lymphomas. Two additions to my library which Ive found very helpful are Cancer and its Management by Robert Souhami & Jeffrey Tobias (Blackwell Science, 2002) and Swallowing and Communication Intervention in Oncology by Paula Sullivan & Arthur Guilford (Singular, 1998), which includes useful chapters on chemotherapy and radiotherapy as well as the impact of different cancer sites on swallowing. Another useful introductory book has been Supportive and Palliative Care in Cancer by Claud Regnard & Margaret Kindlen (Radcliffe Medical Press, 2002).

7. My tool box
This carries my tool kit for sorting out laryngectomees valve and stoma problems and it stays in the boot of my car for when Im on home visits. Its also useful when I do practical teaching sessions, such as for district nurses. Its a hobby box (mine was bought from a local Wilkinsons shop) which has lots of compartments for valves, Heat and Moisture Exchange systems, tape, brushes, catheters and all the other odds and ends I regularly use. Our head and neck ward now supply all new laryngectomees with similar boxes so that they have somewhere to keep all the items they are sent home with.

It wasnt until I was appointed that I appreciated how much support Macmillan provides to post holders, particularly in terms of training and equipment grants, which are a tremendous help when starting up a new post.