STRATEGY

Enriching the early years

With increasing numbers of nursery aged children being referred with speech and language delay, managers from the service, a local education authority and a university college joined forces to ensure a strategic, coordinated response. Team speech and language therapists Carol Sutton and Joanna Sedgemore report.
READ THIS IF YOU WANT TO TRY TO REDUCE REFERRALS PLAN A TRAINING PROGRAMME IMPROVE YOUR COLLABORATIVE PRACTICE

Carol Sutton

Joanna Sedgemore

n increasing number of referrals to speech and language therapy seemed to indicate to us that a significant number of children in Wolverhampton now enter nursery with delayed communication skills. To address this, Wolverhampton speech and language therapy department, Wolverhampton local education authority and University College Worcester set up a one year project (April 2002 to April 2003). A high level of training from speech and language therapy was an integral part of this project. Two members of the speech and language therapy team made up one whole time equivalent. University College Worcester also appointed a member of staff to oversee the research part of the project and to provide training on language enrichment within the nursery environment. Our objectives were to: 1. Increase early years practitioners knowledge of normal, delayed and disordered communication development 2. Increase early years practitioners skills in facilitating communication through a language rich environment 3. Develop a screening tool to promote appropriate and timely referral to speech and language therapy. The local education authority approached a number of early years settings that had not previously been involved in Sure Start or Education Action Zone initiatives and asked them if they wanted to commit to the project. Eight of the respondents, with children aged 3 and 4 years, were selected to take part. They consisted of two local education authority nursery schools and six local education authority nurseries attached to mainstream primary schools. The nurseries varied in size from 15 to 40 children per session, and from 2 to 6 members of staff. Three of the nurseries included children from ethnically diverse cultures. Each setting needed to commit one member of staff to the project for one year. These project early years practitioners needed to be available during our weekly visits to discuss the communication needs of individual children, and appropriate modifications to the language environment, such as visual timetables or labelling objects. These visits were intended to address the communication needs of all children within the

nursery, not just those already known to the speech and language therapy department. We sent a letter addressing the issue of consent to parents from each nursery and none refused permission. The eight project early years practitioners, a mixture of teachers and nursery nurses, were also required to attend a whole days training session on a fortnightly basis and then cascade the information to all other members of their setting. The training sessions were split into three terms and included a mixture of direct teaching, small group work, and whole group discussions. Topics covered in term 1 were: What is communication? Speech development Receptive language Expressive language Social communication Dysfluency. Each topic addressed normal versus delayed / disordered development. We aimed to make the sessions as interactive as possible, encouraging and valuing contributions from each practitioner. Tips to encourage the development of each of these topics - and therefore help create a language rich environment - were provided. This included strategy posters for display in the nurseries and to give to parents. As the project progressed, sharing ideas and experiences became an invaluable aspect of the training (figure 1). We set time aside for this, and developed a booklet of the ideas. Relationship building was an important aspect of the training sessions. The group valued sharing ideas and good practice, and became very supportive of each other. As an example, practitioners arranged informal visits to each others nurseries throughout the year. Participants also visited an Early Years Centre of Excellence. This gave them the opportunity to discuss how such a centre addresses the communication needs of children.

An active role
The knowledge gained during term one meant that participants could play an active role in developing the screening tool with us. We ran a trial of the draft screen on six children from each nursery. All of these children had been in nursery for one term. This gave them the chance to settle in, and for staff to get to know them, to reduce the need for one-to-one assessment by withdrawal - something the early years inspector particularly wanted to avoid. We suggested the nurseries should trial the screen on two higher, two medium and two lower ability children. We made adjustments following the trial and presented the final screen to the early years inspector. This input, and comments from practitioners involved, led to us developing two levels of screening, the first a quick screen (figure 2), to be administered to all children following one term in nursery. This would identify those in need of the more detailed screen to be

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

STRATEGY
Figure 1 Examples of ideas generated during training sessions

Strategies for language development

Planned opportunities for speaking and listening Engage child by talking about their interests Role play / using play situations Circle time for choices / turn taking etc, singing nursery rhymes Using key words, rather than complex language Bilingual support as appropriate Visual timetables / displays Working with parents, toy and book loan

Strategies to develop listening skills

Use visual aids Use of puppets with stories Small group work In groups, sit child close to speaker Use music and sound effects (rhymes / songs) Use rewards eg. stickers / charts Listening games (guess the instrument) Attention boxes

used at the beginning of the second term to indicate which children to refer to speech and language therapy. We did, however, say not to delay referral if the child had glaringly obvious communication needs. The early years inspector suggested that, for the more detailed screen, we build on the Early Profile used in Wolverhampton. This was first developed in 1999, and has since been revised following the introduction in 2000 of the Foundation Key Stage and in 2002/3 of the National Foundation Stage Profile. The profile aims to encourage a coherent and consistent approach to the profiling of children, from birth to five, in all settings within the city of Wolverhampton. (Wolverhampton Early Years Development and Childcare Partnership, 2003). Once a child has been in nursery for approximately one term, the quick screen is completed. Scores indicate whether a child requires the more detailed screen, would benefit from language enrichment, or is progressing within normal limits. We hoped that the more detailed screen would only need to be carried out on a small number of children, and trials indeed indicated that the majority of children would benefit from language enrichment rather than specialist input from the speech and language therapy department.

Figure 2 The quick screen Name: Age: years months

QUICK SCREEN
Listening and Understanding
Understands a large number of objects by name Responds to simple instructions Shows understanding of simple stories (comments made and response to questions) ___ ___ ___ Total /3

Vocabulary and Expressive Language

Indicates needs and wants by gesture, word or sound Has a wide vocabulary of basic words Uses short phrases of 3 to 5 words ___ ___ ___ Total /3

Social Communication
Uses eye contact appropriately (i.e. not fleeting/absent/excessive) Interacts appropriately with other children Responds appropriately to questions and requests ___ ___ ___ Total /3

Observations
We developed the detailed screen so it could be done via observations within the nursery during child initiated and / or adult focused activities. This would save time and reduce the need for one-to-one assessment. The early years practitioners came up with a list of ideas / activities to extract this information. This included role-play activities, counting activities, and circle time. Practitioners completed questionnaires throughout the project. These were distributed pre- and post-project, and at the end of each term. Before and after the project, they were asked to rate how confident they felt in identifying children with speech sound difficulties and language difficulties (figure 3). Practitioners felt more confident in identifying speech difficulties than they did language difficulties before the project started. However, post-project, confidence levels in both areas increased, with a notable increase in identifying language difficulties. We also collected a large amount of qualitative data via questionnaires. Participants were asked how they had personally benefited from being involved in the project. They said: Knowledge of speech and language difficulties has increased. New ideas / strategies to use in the nursery to support children with communication difficulties. Good professional development. Working with others as a team and exchanging ideas. Knowledge of assessing children increased. Easier to identify children having problems with speech sounds and so better able to understand them.

Speech Sounds
Speech can be understood by a variety of people ___ Total /1

Figure 3 Pre- and post- confidence levels

Speech:

Confidence level Very confident Fairly confident Not confident Very unsure

Pre 0 5 2 0

Post 1 6 0 0 (One participant did not return the postproject questionnaire so was not used in this analysis)

Language:

Confidence level Very confident Fairly confident Not confident Very unsure

Pre 0 2 4 1

Post 1 6 0 0

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

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STRATEGY
Figure 4 Programme of training day

Morning session
Introduction: history of the screen, outline of the day, and expectations Icebreaker - as a group gelling activity to encourage interaction between participants I CAN video An overview of communication in young children covering: - areas of communication development / factors involved in language delay - receptive language - expressive language - speech - social communication - dysfluency

been a lot of very hard work put into this project. Schools need this type of tool. Congratulations (November 2003). The project has reinforced some of our beliefs and given us pointers for the future direction of the speech and language therapy service. It confirms that collaborative work is essential if the childs communication needs are to be supported effectively. We have become more aware of time pressures on nursery staff and more able to give advice on supporting childrens communication needs through everyday and group activities.

Key worker
We felt the support for children was more effective when all staff, not just those involved in the project, took on board advice and ideas. However, the project experience also suggests that nurseries need to provide an identified key worker who is able to attend training, liaise with the speech and language therapist, and carry out specific activities with children with communications needs. This key worker should endeavour to involve parents / carers as much as possible as, for a variety of reasons, it is not always possible for a speech and language therapist to meet parents directly. A high proportion of children enter early years settings in Wolverhampton with delayed communication skills. This has significant implications in terms of nurseries providing a communication rich environment and indicates a specific training need for all practitioners in early years settings. This is being addressed via the local education authority. Although not specifically targeted in the project, many of the children were also identified as having limited attention and listening skills. This can often have a negative impact on the development of communication skills. Early years practitioners would therefore benefit from training and advice in this area, and this suggestion has been highlighted with the early years inspector. Finally, given that high numbers of children are entering nursery education with speech and language delay, parents / carers would benefit from support and advice in developing their childs communication skills from birth. This is happening in small pockets but not as yet on a larger scale. We have also done some separate training for health visitors who refer to our service. Our three project objectives were met and those involved have judged the project a success. Training is still ongoing, so any effect on referral rates will be assessed at a later date. Carol Sutton and Joanna Sedgemore are speech and language therapists with Wolverhampton City Primary Care Trust, Red Hill Street Health Centre, Red Hill Street, Wolverhampton WV1 1NR, e-mail carol.sutton@wolvespct.nhs.uk or joanna.sedgemore@wolvespct.nhs.uk.

Afternoon session
Overview of speech and language therapy service in Wolverhampton Screening tool - information pack and how to administer screen - quick screen - each section explained, followed by practical application on fictitious child - detailed screen - each section explained, followed by practical application on fictitious child Strategy pack distributed and explained Evaluation

NURSERIES NEED TO PROVIDE AN IDENTIFIED KEY WORKER WHO IS ABLE TO ATTEND TRAINING, LIAISE WITH THE SPEECH AND LANGUAGE THERAPIST, AND CARRY OUT SPECIFIC ACTIVITIES WITH CHILDREN WITH COMMUNICATIONS NEEDS.

Able to discuss individual children directly with the speech and language therapist. Becoming more aware of the different needs and approaches to individual children. Participants were also asked how they felt their nursery had benefited from the project. They said: Speech and language therapists coming into the setting and working with children. Noticed a difference in the children involved in the project. Other staff benefited from feedback of the sessions. Working directly with the speech and language therapist. Greater awareness of problems leads to earlier detection. Children more comfortable in their own environment. Regular joint goal setting. Speech and language therapist provides support for the whole team. Parents feel comfortable and happy to see the speech and language therapist in the nursery. More confident in speaking to parents about individual childrens communication needs. Following this positive feedback on the project, the local education authority was keen to introduce the screen to all early years settings in Wolverhampton. The organisers envisaged that one member of staff from each setting would receive a days training, and three such days were scheduled for 2003/4 (see programme in figure 4). To date, approximately 75 settings have received the training, and are using the screening tool to refer to speech and language therapy. We have now been asked to provide an additional two days of training to ensure that all remaining settings have been covered. Further evaluation will be carried out following these dates, but the majority of comments received to date have been positive and encouraging: Fantastic day - its nice to go back to school with something useful that has the potential in the long term to reduce the work load. Obviously there has

Acknowledgements
Many thanks to all the project early years practitioners for their constant support, ideas and enthusiasm.

References
Wolverhampton Early Years Development and Childcare Partnership (2003) Early Profile. I CAN (2003) Helping Childrens Speech and Language Development in the Early Years. Video.

DO I MAKE SUFFICIENT EFFORT TO UNDERSTAND THE PRESSURES ON OTHER WORKERS AND TO TAILOR ADVICE TO THEIR SETTING? DO I BUILD IN OPPORTUNITIES FOR RELATIONSHIP FORMING AMONG COURSE PARTICIPANTS DURING TRAINING? DO I CLARIFY LEVELS OF CLINICAL NEED AND WHERE THESE NEEDS ARE BEST MET?

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