resource reviews / TRAINING

Opening doors
LANGUAGE
Talking Dice Starter Pack ISBN 1-84795-083-3 25.52 + VAT Teachers Notes and Student Workbook 0-9550429-0-9 14.99 + VAT Linguascope www.talkingdice.co.uk

A fun way to learn

Talking Dice is a practical resource which aims to get children talking. It is targeted at children with English as an Additional Language, but could also be used with children on the speech and Language therapy caseload. The resource is clear and easy to use and, as most children enjoy playing with dice, is a fun way to learn and practise language structures in expressive speech. The starter pack consists of 25 dice, each covering a different topic such as clothes, hobbies, countries, parts of the body. Each dice therefore has six pictures per topic and more than one dice can be used at any time. Accompanying the dice there is a Teachers Notes book and a Student Workbook. The workbook contains 40 photocopiable sheets (copyright permission must be applied for) and the teachers book explains how to use each worksheet and expand it. Each worksheet shows which dice to use for a particular language structure. These include: use of why-because; opposites; question and answers; comparing things; connecting ideas; vocabulary; verbs and tenses. I found it very useful to look up in the index what I wanted to work on with a child and have a game and worksheet provided. I think this resource would work well in language groups where certain language areas are being targeted. The Talking Dice website contains useful information including E-Talking Dice, an interactive software version for school whiteboards. The worksheets encourage writing of sentences. As a speech and language therapist I would be more interested in the verbal expression of the target, but in a school setting this dimension could be utilised. Also there is only one worksheet for each target area so the therapist or teaching staff need to use their imagination to expand the ideas. The resource is easily portable, value for money and I would recommend it as a useful tool, particularly in schools. Faith Lewis is a speech and language therapist working in clinic and mainstream schools for NHS Leeds Community Healthcare.

Using the results of her practice-based research, Kit Clewley made a successful case for carer communication training groups to be provided as an essential element of aphasia intervention. She now finds a 3 stage model, which includes joint client / carer groups, offers the best outcome and use of resources.
ollowing his stroke, Mr Williams received 7 months of individual speech and language therapy, focusing on dyspraxia, gesture, inconsistent yes / no, drawing and using a communication book. Despite this input, he used no communication strategies besides facial expression and intonation. He relied on Mrs Williams to ask him yes / no questions, to which his answers were inconsistent. He responded to his wife but did not tend to initiate communication beyond his basic needs. Mrs Williams did not encourage her husband to use any communication strategies and never used any - such as drawing or gesture - herself. She did use strategies to help Mr Williamss comprehension but tended to rely on yes / no questions and guessing to understand him. Mr Williams attended a social club with wellknown friends and hospital appointments, but was not confident enough to leave the house for any other reason. This scenario will be a familiar frustration to many of you, as will the question what can we do about it? In Wrexham and Flintshire we have for several years offered communication therapy groups to people with aphasia. These were based on the Supported Conversation for Adults with Aphasia approach (SCA) (Kagan et al., 1996 a; b) and provided the opportunity to engage in functional communication. Clients tended to join at the point where they required consolidation of identified functional communication strategies. Although the clients improved in using their communication strategies in the group, we found they were not generalising into the home environment or other functional settings. Similarly, carers were not using the communication strategies we advised them to try. Although this could be partly a result of limited liaison, we felt it was primarily due to the carers needing hands-on communication skills training (Hoen et al., 1997; Rice et al., 1987). We recognised that the client cannot be seen in isolation. To achieve optimal return of

READ THIS IF YOU WANT TO MAKE EFFICIENT USE OF RESOURCES AN IMPACT ON REAL LIFE COMMUNICATION DISCHARGE A BEGINNING RATHER THAN AN END

function and well-being, they must be treated alongside those with whom they communicate on a daily basis. At this point, evidence in the literature suggested that untrained conversation partners can pose a barrier to effective communication (Kagan et al., 2001). In addition, research studies firmly established the value of training partners, usually on a 1:1 basis in the home setting. (Cunningham & Ward, 2003; Simmons et al., 1987). Training carers on a 1:1 basis was not considered feasible, as we had limited resources and such an approach would not explore the potential benefits of peer support. I therefore undertook a research project in 2005 which looked at the advantages of providing tailored communication training in a group setting to carers of clients who presented with aphasia (Barber, 2006; 2007). The research was supported by the then North East Wales NHS Trust, and carried out in accordance with its Ethics requirements and consent procedures. The project

Kit Clewley (nee Barber) (right) is a specialist speech and language therapist at Maelor Hospital in Wrexham, email kit.clewley@ wales.nhs.uk. Technical instructors Jill Roberts (left) and Berne Roberts (centre) are key members of the communication training programme team.

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2011

23

TRAINING
demonstrated that improvements occurred not only in the carers interaction skills following the training, but also in the clients. My conclusions were that: 1. Carer training should be available automatically alongside direct client intervention for those who need it. 2. Training the partners of communication therapy group clients in a group format benefits both carer and client and has the potential to reduce 1:1 and group therapy time. 3. Most carers, including those with longstanding experience of cerebral vascular accident, valued peer support highly. They indicated that the group reduced feelings of isolation, promoted problem-solving, helped them to share experiences, and gave greater understanding and the opportunity to learn from one another. 4. Speech and language therapists routinely advise carers how to achieve effective, natural interaction with their partners. However, for carers to modify communication strategies consistently, they also need designated, ongoing training sessions where they can practise in a supportive environment with their peers. These research recommendations were accepted by the Trust (now Betsi Cadwaladr University Health Board). After discussion with speech and language therapy management, we provided 10 weeks of communication training as set out in the research to five groups of carers over the period 2005-2009. The training incorporated handouts primarily from Supporting Partners of People with Aphasia in Relationships and Conversation (SPPARC) (Lock et al., 2001) and video footage from SPPARC, SCA and our communication therapy groups. Sessions included roleplay exercises, personalised video analysis, feedback and discussion to provide the carers with as much hands-on experience and support as possible.
Figure 1 The three stages Stage 1

Carer communication training group 10 week training programme comprising principles from SPPARC (Lock et al., 2001) and SCA (Kagan et al., 1996 a; b; 2001) Feedback Stage 2

Client communication strategies group 10 weeks practising communication strategies at a functional level

Client and carer training consolidation group 10 week consolidation of carer communication with clients and carers working together Feedback Stage 3

Client and carer functional goals group Flexible number of weeks where clients and carers work together to identify and achieve functional goals before discharge Feedback Discharge

with moderate-severe dyspraxia. Most were 6-11 months post onset, and one was 1 year 10 months post onset. Stage 1 Carer communication training group and client communication strategies group Five carers received weekly training of 1.5 hours for 10 weeks. (The sixth had to withdraw two weeks before the start due to her partner being taken ill.) The training was revised slightly from the programme provided previously, but continued to be based on the SPPARC and SCA approaches. This group was run by a speech and language therapist, a technical instructor and a volunteer. At the same time as the carer training, the five clients attended a communication strategies group where they worked on their strategies at a functional level. This was run by a technical instructor and a volunteer. Stage 2 Client and carer training consolidation group In this group, the carers and clients worked together on the principles of SCA and SPPARC. The principal aims were to ensure that: 1. the carers increased their confidence to put

Convinced

Although the carers and clients demonstrated improvements in their interaction skills, there was still a problem with generalisation into the functional setting. The carers remained convinced that their partners required further speech and language therapy, despite the fact that they now possessed the skills necessary to support their partners to communicate well. They frequently expressed the opinion that their partner communicated better with the speech and language therapist and technical instructor, and would not communicate in the same way with them at home. To address this, in September 2009 we devised and offered a 3-stage Communication Training Programme to a maximum of six clients and their carers (figure 1). All the clients presented with moderate-severe receptive and expressive aphasia, and five presented

training into practice. We asked them to use the training with their own partner and with the other clients in the group. This gave them the opportunity to use their skills in situations where knowledge could not be assumed. It also enabled them to observe how well their partner could communicate when adequately supported by a peer rather than a therapist or technical instructor. 2. the clients began to accept that their partners were changing long-standing interaction patterns by implementing the training. They were encouraged by their partners to comply with requests to use alternative communication strategies, rather than to expect their partners to engage in habitual interaction patterns such as guessing the word. The carers and clients were also expected to carry out work at home between sessions to help generalise the training and acceptance of its usage outside the clinical setting. This group took place each week for 1.5 hours for 10 weeks. It was run by two technical instructors and two volunteers, one from the Association of Voluntary Organisations in Wrexham and the other from the Communication Support Service. Both had

24

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2011

training
received the carer communication training. The speech and language therapist attended sessions at the beginning, middle and near the end of stage 2 to provide guidance and support to the technical instructors. Attendance was variable due to bad weather and ill health. This resulted in three couples no longer attending by week 5, leaving only two couples to complete stage 2 and move on to stage 3. Stage 3 Client and carer functional goals group Here, clients and carers set functional goals to achieve up to and following discharge. They worked as a group to establish how these goals could be met through a process of problemsolving, suggestion and support. We gave each couple a toolkit to provide them with the means to achieve functional goals identified in the group and future goals. The tools were specific to each couple. They comprised supported conversation techniques, updated communication books, I have difficulty communicating cards and practical tips derived from peer support. This 1.5 hour weekly group only ran for two weeks as there were only two remaining couples and their confidence to achieve the set goals with the tools provided was high. The duration of stage 3 in future groups is expected to be flexible, as factors such as number of members and confidence levels are significant. The group at stage 3 was run by one technical instructor and one volunteer due to the reduction in numbers. The speech and language therapist attended the first session to provide guidance and support to the technical instructors. There was a break of three weeks between each of the three stages, and the group members were discharged from the speech and language therapy service at the end of stage 3. making more comments versus asking questions no longer demanding the correct target from their partners reducing test questions following their partners lead encouraging their partner to express an opinion. Feedback from partners following stage 1 indicated that they placed great value in seeing and hearing how others cope with similar conditions, not being alone and receiving useful hints. In feedback after stage 2, the carers thought it was good to work with their own partner but also with someone elses. When asked if stage 2 had made a difference to the way they communicate at home the answer was Yes completely. Comments included: We can discuss things better It gave me more confidence with him He does more using his communication book. He writes more in his book and started saying more words because of this. The carers felt there had been a complete change in their confidence levels when communicating with their partners: I am more relaxed I understand him more and we both dont get as frustrated as we used to do and he has a lot more confidence doing things himself. They also indicated that their partners had enjoyed the group. One client was at first not sure but enjoyed the weekly group meetings as the weeks went on. Also nice group of people he made friends with. In future I propose to obtain feedback after all three stages, as shown in figure 1. completely. In future programmes we will give the carers greater control in carrying out supported conversation techniques earlier in stage 2 by reducing the amount of direct intervention provided by the technical instructor at the outset. Client reluctance to use communication strategies with partners is however always likely to be a problem, and could be due to a number of factors including personalities, expectations and relationships. The breaks between the stages will be reduced given the length of the programme and the need to keep momentum and motivation going. I propose to use a one week break in the next programme. The videoed communication sessions had a tendency to turn into a therapeutic session as opposed to a functional conversation. To obtain as accurate a measure a possible of natural interaction patterns, future videoed sessions will be based on an activity such as those used in the communication strategies group, which are more successful in terms of achieving functional communication.

Stepping stone

Goals and outcomes

Prior to stage 1, a technical instructor videoed clients and their partners having a conversation at home. This procedure was repeated with the two remaining couples following stage 2. Using principally the SPPARC approach, I analysed the interaction patterns of the client and partner to: establish communication goals for each couple set a baseline measurement provide an outcome measure. Improvements were clearly shown in the interaction patterns of both the clients and the carers. The clients demonstrated improvements with comprehension, yes / no confusion, and use of drawing and writing to communicate. The carers showed improvements by: encouraging their partners to use communication strategies versus guessing the word using these strategies themselves giving their partners more time to communicate

We have found that clients bond faster if they are joining a group which is already established
In stage 1, the carers bonded immediately but the clients took four weeks before they began to interact with one another. We expect this process to take longer for the clients because of the level of aphasia. However, we have found that clients bond more quickly if they are joining a group which is already established, as new members see communication strategies being used straightaway, and this encourages them to use these strategies faster. In future it may be possible to establish a client communication strategies group from which appropriate members can access the communication training programme. In stage 2, He wont do it with me at home was still a common feeling beyond the midpoint. We attempted to address this by asking carers to work with different clients to improve confidence levels. Although this worked well, it did not solve the problem

I invited the Communication Support Service (CSS) organiser for the local area to the last session in stage 3. The larger CSS group based in the community setting forms a natural stepping stone from the safe, contained and clinical environment of the communication training programme, and offers the clients the opportunity to maintain their communicative strategies and increase their communicative confidence. Inviting the organiser worked well as the clients were able to: 1. ask questions about the group 2. meet the organiser, which made the idea of attending for the first time less daunting 3. support each other by agreeing to attend together. Because they were present, the carers also improved their understanding of CSS objectives. Carers do not usually attend the CSS group and therefore do not have the same opportunities to maintain their skills in this setting. However, the CSS is planning the introduction of supported conversation groups in the local area and it may be possible to work with them in developing these groups so that the carers are also included. Within the communication training programme, clients and partners practise their communication strategies and therefore build communicative confidence in a supportive environment with their peers. We found that it engenders a sense of empowerment in both the client and partner enabling: the carer to reduce their protection of the client and increase their support the client to demonstrate their full communicative potential to the carer the client and carer to improve acceptance of their new life context and how it can be optimised both parties to open doors to functional life goals which have been closed until now.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011

25

training
Whilst the initiative is still at an early stage, we are convinced that the communication training programme exhibits significant benefits for client care and is cost-effective (figure 2). Present arrangements require six clients and carers to trigger stage 1 for optimum use of resources. There may be reduced participant numbers in stages 2 and 3, for example due to ill health, but this can be offset by reducing the technical instructor resource in these later stages. We believe these findings demonstrate that carer communication training is an essential consideration in aphasia intervention and should be provided as a matter of routine to those who require it. Mr and Mrs Williams agree. After the Communication Training Programme, Mrs Williams encouraged her husband to use drawing, gesture, writing and a communication book. She also used these strategies herself and Mr Williams successfully used them with her support. He was also able to gesture and draw spontaneously on occasion. He still relied on Mrs Williams to lead the conversation but his participation in it was greater. Mr and Mrs Williams goals on discharge included attending the CSS group, planning a journey on a bus to visit nearby towns, and working towards returning to drive. Both indicated that they felt very positive about the future: This is the start of SLTP the rest of our lives now.
References Barber, K. (2006) Pilot study to investigate the benefits of providing tailored communication training in a group format to family members/partners of clients who present with aphasia. Unpublished. Barber, K. (2007) Group communication, RCSLT Bulletin 660, pp.16-17. Cunningham, R. & Ward, D. (2003) Evaluation of a training programme to facilitate conversation Stage 1 Carer group Potential no. of clients Staff resource 6 1 SLT 1 TI 1 Volunteer Client group 6 1 TI 1 Volunteer 6 2 TIs 2 Volunteers SLT supervision Stage 2 Joint group 6 2 TIs 2 Volunteers SLT supervision Stage 3

Figure 2 Staff resource between people with aphasia and their partners, Aphasiology 17 (8), pp.687-707. Hoen, B., Thelander, M. & Worsley, J. (1997) Improvement in psychological well-being of people with aphasia and their families: Evaluation of a community-based programme, Aphasiology 11(7), pp.681-691. Kagan, A., Winckel, J. & Shumway, E. (1996a) Pictographic communication resources. North York, Canada: Pat Arato Aphasia Centre. Kagan, A., Winckel, J. & Shumway, E. (1996b) Supported conversation for aphasic adults: Enhancing communicative access (Video). North York, Canada: Pat Arato Aphasia Centre. Kagan, A., Black, S.E., Duchan, J.F., SimmonsMackie, N. & Square, P. (2001) Training volunteers as conversation partners using Supported Conversation for Adults with Aphasia (SCA): A Controlled Trial, Journal of Speech, Language and Hearing Research 44, pp.624-638. Lock, S., Wilkinson, R. & Bryan, K. (2001) Supporting Partners of People with Aphasia in Relationships & Conversation (SPPARC). Milton Keynes: Speechmark. Rice, B., Paull, A. & Muller, D.J. (1987) An evaluation of a social support group for spouses of aphasic partners, Aphasiology 1(3), pp.247-256. Simmons, N.N., Kearns, K.P. & Potechin, G. (1987) Treatment of Aphasia Through Family Member Training, in Brookshire, R. (ed.) Clinical Aphasiology Conference Proceedings. Minneapolis, MI:BRK, pp.106-115. Resource The Communication Support Service is run by the Stroke Association in a number of local areas across the UK, see www.stroke.org.uk

Kit Clewley (nee Barber) is a specialist speech and language therapist at Maelor Hospital in Wrexham, email kit.clewley@wales.nhs.uk.

REFLECTIONS DO I OFFER THERAPY IN THE CONTEXT OF PEOPLES LIVES? DO I HELP COMMUNICATION PARTNERS BREAK OUT OF HABITUAL AND LIMITING PATTERNS OF INTERACTION? DO I PRACTISE IN A WAY THAT PROMOTES INDEPENDENCE AND SELF-BELIEF?
How can you apply this article to your own practice? Let us know via Speech & Language Therapy in Practices Critical Friends at www. speechmag.com/About/Friends.

Resources

The Frenchay Screening Tool for AAC is now available as a first step in assessment (80). www.ennovations.co.uk/product_info. php?cPath=42&products_id=228 AuKids magazine for parents of children with autism is co-edited by speech and language therapist Tori Houghton. 10 for 4 quarterly issues, www.aukids.co.uk Interactive version of Avril Websters Going to the Hairdresser now free online. www.offwego.ie A website aimed at getting the public involved in clinical research. http://www.peopleinresearch.org/ Scope has introduced Meeting Point, a closed online forum for young disabled people living in England and Wales. www.scope.org.uk/help-and-information/ young-people/meeting-point

Brook has revised its sex education and personal development modular resource for young people with learning disabilities. Living Your Life, 120, www.brook.org.uk/shop Stuttering Stan Takes a Stand is now available as a free flash-animated storybook. www.mightybook.com/MightyBook_free/ books/stuttering_stan/stuttering_stan.html UEA (University of East Anglia) has updated its undergraduate degree course profile. www.uea.ac.uk/ahp/courses/bsc-speechand-language-therapy The seven documents that make up the Language Support Model for Teachers resource are freely accessible at w w w.strath.ac.uk/humanities/ speechlanguagetherapy/resources/lsm/ Reading for Life is the National Literacy Trusts social marketing campaign to reach people who are least likely to read. www.readingforlife.org.uk/

The Contact a Family Directory summarisies 430 disabilities and health conditions and details UK support groups. Available online and in print, tel. 020 7608 8700. Messages from the National Literacy Trusts Face to Face project might help therapists to promote good communication between parents and babies. www.literacytrust.org.uk/talk_to_your_ baby/policy_research/2612 An online dungarees firm says a major part of its client base is people with disabilities. www.dungarees-online.com The Meningitis Trust has posters and leaflets to support its Dont wait for a rash campaign. www.meningitis-trust.org Downloadable publications from the disability campaigning network RADAR by and for people living with injury, ill health or disability cover work, money and IT. www.radar.org.uk/doinglifedifferently/

26

SPEECH & LANGUAGE THERAPY IN PRACTICe SPRING 2011