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

Spring 2011

How I get signing into practice Capacity Good moves

On TOPICC Pragmatic assessment

Patient safety Training My Top Resources Journal Club Reducing risk A joint model The adviser role Systematic reviews

PLUS...here’s one I made earlier...reviews...boundary issues...in brief...reader offers ...and introducing our new series, ‘Whose goal is it anyway?’ www.speechmag.com For more information on NDP3 and the forthcoming NDP3 Speech Builder, visit the product is launched. April. winnernotified The 2011, their May and willbe copy 1st forwardedby soon as as ‘SpeechmagSpeechBuilderoffer’ subject line, to the in withaddress, and name yourBuilder, emailSpeech of copy a win to chanceyour For prize draw. firstcopy enteringthe people by ofa one get beto you NDP3canandusers)this free - Readeron screen using a simple paintbrush tool. You can add text in a variety of styles,lettersounds including and phonetics. You – or the child youtitle, are includingworkingbyways, withof variety - can coloura searchedthemin in be canimages ofdatabaseentire The neme illustrations. pho PhonicsJolly of set full a as and 750 images from NDP3 as well templates70 over of libraryplete com BuilderincludesSpeechthe offers andgames.ers, activities stick cards, worksheets, therapy engaging and targeted colourful, new creating for a application software – Builder Speech NDP3 to touches finishing the putting are Programme Dyspraxia Centre Nuffield popular the behind pists thera- language and speech The Win NDP3® Speech Builder therapy software! Win Independence Through Communication! Press). Congratulations to you all, and thanks to the three companies for their prizes. (Talking About Conversation, Black Sheep Press) and Susan Fischgrund HandsDVD (Friendshipset), paediatric speech and language Terrace,therapy at WerringtonBlackSheepHealth Centre, Peterborough The lucky winners of our fantastic Winter 10 offers are: Sam Feldman (NDP3), SusanPrevious Bannatyne (Singing winners NDP3Speech Builder is£99 for existing NDP3 users (£139 to non- phonetics, in any colour. You can then work with the project on-screen, or print it, and share with the wider team by email.byteamwiderthe sharewithYounotes addalso can information to parents. providechild’sperformancetheorrecord to project the to h dvlpr sy ht atog Sec Bidr was Builder Speech although that, say developers The rae t spot h ue f D3 ih hlrn with children with NDP3 of use the support to created any level from oro-motor to connected speech. severespeechdisorders, usefulwillalsobeitfortherapy at Independence Through Communication is a modular social communication skills resource with a difference. Its main focus is the full participationnon-speakersfulllimitationsnon-readersofthe memoryhaveand andfocusiswho main Its need structure to learn. - - - Details of this and all other Black Sheep Press resources are at available at Liz’sarticle about the programme (‘Adapting tocomplexity’, Summer 09, pp.4-7) isnow offer’ in the subject line by 25th April. The winner will be notified by 1st May 2011. emailwin, chanceto your forbut, FREEtolucky a reader. Independence ThroughCommunication usually costs £80 + VAT readers. It has now been published by Black Sheep Press,SaraLander specialistat Colleges,which wellasbySpeech as Language is& Therapymaking Practicein a copy available those using AAC, by Dr Liz Dean. It was then piloted by Alison Barnes, Luan Harrold and Thematerial wasfirst developed with young adults with learning disabilities, including yourself, explaining your ideas, making choices and making friends. listening, expressingcover strands five pace.The own their programmeat thefollow strategiesof to ‘scaffold’ responses. designedis It for groups aroundof learners, 6 who The programme, delivered by a teacher and at least one support worker, teaches the use [email protected] www.speechmag.com/Resources/Reprints www.ndp3.org by 25thby [email protected] . and Alison Crosbie Holm, which Sharonexplains how to Dodd, deal with Barbara by CD Therapy Vocabulary speech Core the Australian distributes It two pathologists. by run is Words Grow winners will be notified by 1st May 2011.Words Offer’ in the subject line by 25th [email protected] The emailing by FREE one win to draw the enter can you but £70, approximately worth is set children,small groups and whole classes. Each includerecordingdataall individualsheetsfor LearningandConceptsFollowing & Directions Awareness, Phonological Vocabulary, Series. their‘Foodfrom Words’titles containingthree CD a Practice in Therapy Language & Speech GrowofferingWords readers is of lucky THREE language and literacy skills. of range worksheetstargetinga andactivities practical games, photocopiable contain of that resources range a publishes Words Grow Win a Grow Words resource set! . www.blacksheeppress.co.uk. with ‘Speechmag ITC n hw o re, s at is order,www.growwords.com.au . to how pages and sample including resources, Word Grow all about Information speech. children’s in inconsistency with ‘SpeechmagGrow Spring 2011 Spring 11 contents (publication date 28 February 2011) ISSN 1368-2105 (Print) 28 COVER STORY: HOW I GET SIGNING INTO PRACTICE ISSN 2045-6174 (Online) (1) IT’S SIGNSATIONAL! “If you are considering this kind of approach, it is worth noting that we have learned not to underestimate the amount of preparation time required each time to put on the week. This is especially from the speech and language therapy assistants...” The speech and language therapy team for people with learning disabilities at Yourhealthcare help parents, carers and staff find the confidence to use the signs they have learnt.

(2) LEARNING BY TEACHING “Too often I think that we as therapists have great ideas that, with some reins, thinking and planning, could be developed into valuable evaluation projects. The [Action Learning Set] group helped me think in a more systematic way Published by: and took the mystery out of research.” Avril Nicoll, Photo of (l-r) Ashlee, Non and Jieu Having discovered the potential of giving pupils the power to teach 33 Kinnear Square by Steve Ford, Makaton to staff, Non Thwaite carried out a promising peer tutor pilot Laurencekirk www.stephenfordphotography.co.uk project with the help of Ashlee and Jieu. AB30 1UL Tel/fax 01561 377415 email: [email protected] INSIDE FRONT 10 GOAL NEGOTIATION (1) 18 JOURNAL CLUB (3) READER OFFERS “We are very much of the opinion that SYSTEMATIC REVIEWS Printing: Fantastic offers for you in the Spring goal negotiation is not purely about “...we have found appraising Manor Creative, 11 issue! NDP3 Speech Builder the setting and writing of goals, and systematic reviews in our journal 7 & 8, Edison Road software application; a Grow in fact consider the actual writing of clubs really helpful (even if they do Eastbourne, East Sussex Words resource set; Independence the goal to represent the final part of a nip your head to begin with!)” BN23 6PT Through Communication. complex process.” Jennifer Reid’s series takes the In the first of our new series of four mystery out of critically appraising 4 CAPACITY articles on goal negotiation, Sam different types of journal articles. Editor “Tenancy agreements have been Simpson and Cathy Sparkes share Avril Nicoll, drawn up based on capacity their strategies to ensure the timing 22 RESOURCE REVIEWS Speech and Language Therapist assesment findings on an individual and tempo is driven by the client. In-depth reviews of EYBIC (Early Years basis (for example with vocabulary Based Information Carrying) Word used and specific pictures chosen 12 PATIENT SAFETY Pack; Speech Quest; Talking Dice. by the client). Many have been “The factors influencing choking succesfully approved and entered can be numerous and complex. 23 TRAINING into by landlords.” To explain and then attempt to “The carers remained convinced that Karen Bamford and Rachael Kasch’s prevent further incidents as a their partners required further speech process puts people with learning multidisciplinary team, we need to and language therapy, despite the disabilities in control of where they identify potential risk factors.” fact that they now possessed the skills live and with whom. Adults with learning disabilities necessary to support their partners to Subscriptions and or mental illness are at increased communicate well.” advertising: 6 IN BRIEF risk of choking. Susan Guthrie Kit Clewley has developed a three Tel / fax 01561 377415 Joan Murphy and Tracey Oliver on and Hazel Roddam explore the stage model of training to support ­ Talking Mats and dementia, and challenges, and the impact of people with aphasia and their Maggie Robinson with a simple enhanced electronic reporting. carers to communicate effectively phonology game. for the rest of their lives. ©Avril Nicoll 2011 14 EDITOR’S CHOICE Contents of Speech & Articles about stammering. 27 BOUNDARY ISSUES (4) Language Therapy in 7 RESEARCH INTO PRACTICE “...you recognise the family that has Practice reflect the views of “When we met Charlie it was evident 15 HERE’S ONE I MADE EARLIER moved in to the house next door. the individual authors and that he had significant difficulties with Alison Roberts has low cost They have a child with severe learning not necessarily the views of a range of pragmatic behaviours. The suggestions for groups: True story difficulties and have made several the publisher. Publication challenge for us was to profile these and Every cloud. complaints about the speech and of advertisements is not an in a naturalistic way using a valid language therapy service you provide.” endorsement of the advertiser method, [and] to use this information 15 REVIEWS or product or service offered. Joe Reynolds responds to the both to plan therapy and to show the Autism, writing problems, dyslexia fourth scenario of our ethics series. Any contributions may also outcome of intervention.” and bilingualism, speech sounds appear on the magazine’s Catherine Adams, Jacqueline and disorders, intensive interaction, 34 MY TOP RESOURCES internet site. Gaile, Elaine Lockton and Jenny communication disorders, Claire Butler shares the resources that Freed introduce TOPICC (Targeted dyspraxia, working with families, enable her to be a national adviser in Speech & Language Therapy Observation of Pragmatics in research, evidence-based practice, adult dysphagia for the Royal College in Practice can be found Children’s Conversations). Asperger syndrome. of Speech & Language Therapists. on EBSCOhost research databases. IN THE REMAINING ISSUES: SYMBOLS...DEMENTIA...TASTERS...ETHICS...EARLY YEARS...CRIMINAL JUSTICE... DOWN SYNDROME...MELODIC INTONATION THERAPY...TOTAL COMMUNICATION...CRITICAL APPRAISAL news

Talk 2 Baby The speech and language therapist behind a DVD to help teenagers talk to their babies says it has attracted interest from a much wider range of services than originally expected. Hannah Murtagh worked with a specialist midwife, community nursery nurse and pregnant teenagers in Swansea to produce the DVD. This format was chosen as pregnant teenagers are given a lot of printed leaflets Winter 11 to be final issue of magazine which are not necessarily suited to their level Speech & Language Therapy in Practice publisher and editor Avril Nicoll is to make Winter 2011 the of literacy. In the DVD the young women final issue of the long-running magazine. carry out a variety of activities to encourage Explaining the move Avril said, “I have edited the magazine since 1996 and owned it since language and communication development 1997. It has been a part of the speech and language therapy profession from its launch way back in their babies. They demonstrate the in 1985 and, indeed, some of today’s subscribers have been buying it since then! Every issue importance of early bonding and talking, and feels like the best one yet and I love working with authors to get their articles into print. So, as of good parent-child interaction as the basis you can imagine, this was by no means an easy decision.” for a positive, lifelong relationship. She continued, “The magazine is widely read and appreciated by practising therapists but has Hannah says, “The original objective was to always been a small, niche product run on a shoestring. There are now many different ‘platforms’ appeal to teenagers and use it as a learning tool for information exchange such as websites, blogs and facebook. While this can be positive, each for them but since its launch we have seen its platform increases the workload without a corresponding increase in subscribers. This will only value as a teaching tool for all parents.” Orders continue, which means the magazine as it is currently set up - in print and with space used for have come from people across the UK working in practical articles rather than advertising - is not sustainable.” early years, the probation service and with dads. Avril added, “This year’s articles are fantastic, so I am looking forward to working on the final The evaluation of the project is written up three magazines and going out on a high with the latest issue still being ‘the best one yet’!” in the December 2010 Bulletin of the Royal New subscribers will continue to be able to purchase ‘5 for 4’ starting with the Winter 10 issue, College of Speech & Language Therapists. while readers whose terms expire in March, June and September this year will be contacted with The Talk 2 Baby DVD costs £5.66 inc. p&p, a pro rata rate for renewal. As well as the remaining magazines, this will include access to the email [email protected]. You members’ area of the website until 29 February 2012. can also email Hannah (hannahrichards565@ hotmail.co.uk) for more information.

Talking Point I CAN has revamped Talking Point, “the first stop for information on children’s communication”. It includes a special section for speech and language therapists. www.talkingpoint.org.uk/SLTs.aspx

Giving Voice Tried and tested Fitness to practise The Royal College of Speech & Language The communication disability network The Health Professions Council has introduced Therapists has launched its media campaign to Connect says a “comprehensive and well- new information about its fitness to practise show how the profession transforms lives and researched” Care Quality Commission review of processes for registrants, their representatives, brings benefits to society and the economy. services for people with stroke and aphasia in complainants and witnesses. This includes an You can learn more about Giving Voice and England highlights an unacceptable variability audio-visual presentation about hearings. ways to get involved at www.givingvoiceuk.org. across the country. www.hpc-uk.org; www.hpc-uk.tv/ The review looked at progress against the 2007 National Stroke Strategy. It found that, Autism draft welcomed in 48 per cent of areas, people had to wait two Education Bill concerns Speech and language therapist Penny Williams weeks or more, on average, until they received The National Deaf Children’s Society (NDCS) was involved in the production of draft NICE community based speech and language and national deafblind charity Sense have guidelines on recognition, referral and diagnosis therapy. It also discovered that fewer than half expressed concern about the impact of the of children and young people with autism. of social services could signpost community- Education Bill on disabled children in England. The draft has been welcomed by the autism based services for people with aphasia. The Bill proposes an accelerated expansion education charity Treehouse. Chief Executive Connect’s Director of Services Sally of the academies programme, but the Jolanta Lasota said, “The focus of the guidance McVicker says it is clear that some areas are NDCS says it does not address essential on improving joint working across health, doing well: “We believe the disparity can be funding arrangements to safeguard support schools, social care and the voluntary sector overcome by implementing tried and tested from Teachers of the Deaf and specialist will make the world of difference to families service models. Our experience shows that equipment. Sense warns, “Schools form the who currently struggle to navigate their way training people with aphasia and volunteers building blocks of an inclusive society. But by through the maze of services.” to run their own support and activities, based ending local authority oversight of schools Consultation on the NICE (National Institute on what they themselves have designed and the government risks undermining parental for Health and Clinical Excellence) draft developed, is a cost-effective way to provide choice by making special education schools guideline ends on 25 March 2011. community-based services which successfully the only real option for deafblind and other http://guidance.nice.org.uk/CG/Wave15/78 meet their needs.” disabled children.” www.treehouse.org.uk www.cqc.org.uk; www.ukconnect.org www.ndcs.org.uk; www.sense.org.uk

2 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 NEWS & COMMENT

No Mind Left Behind Comment: Nine lucky speech and language therapists will be heading to the No Mind Left Behind Having a voice conference in Glasgow on bursary places. s the future George VI in the film The The international ev- King’s Speech, Colin Firth tells his speech ent, from 29-30 March Atherapist “Timing isn’t my strong suit”. It 2011, is organised by is however hard to imagine that the publicity the charity Mindroom surrounding the release of the film and Sophie Dow is pictured with her daughter in association with associated book could have come at a better Annie who has severe learning difficulties Professor Christopher time for the profession as it faces ever greater and is the inspiration behind Mindroom Gillberg and the pressures to prove its worth and to be heard. Swedish Child Neuro- Speech therapy has evolved considerably psychiatry Science Foundation. Over 50 speakers from a range of since the early days of Lionel Logue and his disciplines will present their latest thinking on autism, ADHD and other fellow pioneers. Until recently it would have early onset neurodevelopmental disorders. seemed as impossible to enable people Mindroom founder Sophie Dow was keen to see speech and language with learning disabilities to make choices over where they live therapy represented at the event. She initially offered 4 free places following and with whom as it was for ‘Bertie’ to change his job, but Karen a blog post by Avril Nicoll (www.speechmag.typepad.com) about pressures Bamford and Rachael Kasch (p.4) are finding it can be done. on training budgets. Having received 40 applications in the space of a few Although the film has a scene where a young client practises his days, Sophie upped the offer to 9 places. Each bursary place is worth over talking with Bertie, peer support and tutoring was not at that time £500 and includes access to the virtual conference proceedings for a year. a consideration. With the help of cover stars Ashlee and Jieu, Non Sophie says, “We also announced a further 16 places, 8 for parents or Thwaite (p.30) encourages us to investigate what it can offer. people affected by learning difficulties and 8 for teachers via the press, The film suggests the future Queen Mother was actively involved eNewsletter and facebook page and we were absolutely inundated with in helping Bertie apply fluency techniques, although the crucial applications. The need for information and support out there is huge.” importance of working with families and carers is a relatively The organisation of international conferences is part of Mindroom’s recent development. Kit Barber (p.23) has found a model of group strategy “to create such awareness, that by the year 2020 all children therapy which seems to offer clients with aphasia and their carers and adults in this country with learning difficulties will receive the the best chance of successful real life communication. recognition and help they need.” Kit’s model relies on technical instructors and volunteers, and www.mindroom.org Yourhealthcare’s community based Signsational programme (p.28) could not run without assistants. While it appears that Lionel Logue worked very much on his own, he was one of the founders Master Clinician Network of the College of Speech Therapists. Claire Butler (p.34) describes A pilot project The Master Clinician Network is designed to make peer the resources that help her to be a national adviser in dysphagia reviewed videos of clinical practice in speech-language pathology for what is now the Royal College. available for observation and critical discourse. Setting the boundaries of a client / therapist relationship may As the name suggests, it is set up to enable members to invite friends, be more challenging when the client is a King, but Joe Reynolds leave comments and submit their own videos. The site was created (p.27) finds that considering an unusual ethical dilemma can help by Martin Fischer, a professor in the Department of Communication us recognise and reflect on those that are more familiar. Sciences and Disorders at Oklahoma State University - Tulsa. Marbles in the mouth, apparently advocated by a contemporary http://masterclinician.ning.com/ of Logue, is one of many techniques imagined in the film which would not find favour today. Lionel Logue didn’t have the Making chatter matter advantage of tools to help him plan, prioritise and show the The 2011 ‘Hello’ campaign to make children’s outcome of intervention (Catherine Adams and colleagues, p.7). communication skills a priority is underway. Nor did he have journal clubs or systematic reviews to inform For January’s theme ‘don’t take communica- his practice (Jennifer Reid, p.18), although the film hints at his tion for granted’, the Communication Cham- influences coming from different disciplines as they still do today. pion Jean Gross said, “Public understanding Colin Firth perfectly conveys the terror Bertie must have felt of children’s communication difficulties re- over live radio broadcasting, a tradition his father had introduced mains worryingly low. The automatic response in 1932 as a way of connecting the Royal Family with the public. seems to be to blame parents or technology. New technology can be threatening for many reasons, but Susan Jean Gross (r) with Minister This just isn’t right. We need to clear up the Guthrie and Hazel Roddam (p.12) have succeeded in encouraging of State for children and staff to see a computerised database reporting system as a positive confusion and myths that exist around this families Sarah Teather at subject - 10% of children - that’s two to three in the Hello launch step for patient safety. every UK classroom - have some form of long Today’s goal negotiation hopefully does not include promises term communication difficulty that can affect them early, severely and for of a ‘cure’ but, in the first of a new series (p.10), Sam Simpson and life. Their brains don’t process language in quite the same way that other Cathy Sparkes emphasise our role is to ensure that the timing children’s brains do.” and tempo of discussions is driven by our clients. As Bertie said to Over February and March the campaign is focusing on ‘early chatter Lionel, “Because I have a voice.” matters - from bump to birth and beyond’. Resources to help you plan your involvement in Hello, the national year of communication are available in the ‘All Together Now’ toolkit. The government-backed national year is managed by The Communica- tion Trust, a group of 39 voluntary and community sector organisations. www.thecommunicationtrust.org.uk/hello.aspx

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 3 CAPACITY Relocation, relocation READ THIS IF YOU WANT TO In line with government policy of supporting people to live where HELP • REDUCE ANXIETY OVER and with whom they wish, Karen Bamford and Rachael Kasch have CHANGE developed accessible information and a speech and language • PEOPLE MAKE THEIR OWN MAJOR LIFE DECISIONS therapy process for screening, consultation and referral which puts • SHIFT THE CULTURE FROM CARED FOR TO people with learning disabilities in control. INDEPENDENCE

experience of alternatives, a reluctance to consider any kind of change or a genuine desire for this type of setting. Where the person’s current accommodation is indicated as their first choice, we are involved in supporting this decision; we either advocate for them to remain there or to relocate to a similar situation with their present level of support. Where the individual lacks experience of other housing options, we provide ideas to carers of how to support them to find out about different types of properties, for example through visiting friends, relatives and show homes. After an agreed period we Karen Rachael re-visit the Talking Mats to discuss whether the person’s preferences have changed. any people with learning disabilities to live in. We therefore consulted local do not choose where they live or with advocacy agencies, housing development Stage 2 Mwhom. Recent government directives officers and supported moves social workers The next stage is based on the person’s have focused on changing this situation and regarding how we could support people preferences, needs and financial circumstances. supporting people to live in their own homes as with learning disabilities to be actively and The individual is supported by the multi- owners or tenants, sharing with groups of friends meaningfully involved in the process of disciplinary team, including family and carers, or living in residential care (DH, 2009). As speech moving house. We developed a process map to make a decision regarding the types of and language therapists this has implications for change of accommodation which covered accommodation and support to be sought. for the focus of our intervention and areas in communication support from initiation of Supported living is defined as support which we can support these directives. the move through to the move itself, in three to help individuals to live independently in The kind of accommodation people have stages (see flowchart in the members’ area of their home and in the community. If this is influences how they view themselves and are www.speechmag.com). identified as appropriate, a further decision viewed by others. Research shows that people is required regarding the individual’s mental who are confident and happy with where they Stage 1 capacity to sign up to a tenancy (for renting live develop skills and independence and We work alongside other agencies, carrying a property) or mortgage agreement (for are motivated to seek links with their local out joint assessments with social workers, purchasing a property). If a person lacks community (McConkey, 2007). In 1969, 58,850 housing agencies, advocates and so on. the mental capacity to sign a tenancy or people with learning disabilities lived in long During the first stage, we establish the mortgage agreement, then an application stay institutions in England and Wales. Now individual’s understanding around change of must be made for them to be represented people are living in their own homes and taking accommodation (a flowchart is available in the financially by the Court of Protection. Tenancy responsibility for tenancy and ownership members’ area of www.speechmag.com), and has been a problematic issue for the agencies (Mathieson, 2004). However, in 2001, only 6 per their ability to use this information to make a involved in recent times (figure 2). cent of people with learning disabilities chose decision. We also frequently identify a lack of Because of the rigidity of mortgage who they lived with (DH, 2009). knowledge from individuals and their families agreements, there is considerably less Since the introduction of the Mental regarding the range of housing and support possibility of adapting these to meet the Capacity Act (MCA) in 2005, the speech and options available, due to their limited life needs of individuals with communication language therapy service in South Birmingham experience and expectations. difficulties; this could only carried out Community Health has been involved in an For people with communication difficulties, on an individual basis and has not been increasing number of capacity to consent we use a Talking Mats format (also favoured experienced in our area to date. We have assessments. In 2008 and early 2009 we were by Venditozzi, 2009) to gather information therefore concentrated our main resources on involved in a small number regarding change about an individual’s preference around where supporting the understanding of individual of accommodation on an individual basis. they currently live and what their ideal living tenancy agreements. Several social care homes and medium circumstances would be (figure 1). Where the Tenancy agreements are a new concept to sized residential campuses closed, and more mat for an individual’s current accommodation many people with learning disabilities due individuals were indicating a preference for and their ideal housing are the same, we to the tendency towards a ‘cared for’ culture the type of accommodation they wanted discuss whether this is due to their lack of that still resonates, whilst we move into a long

4 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 CAPACITY

Figure 1 Talking Mats Figure 2 Possible issues with tenancies

• No clarity about legal requirements of tenancy • Mental Capacity Act (2005) states that no-one else can sign tenancy on someone’s behalf • Court of Protection application can be a lengthy process • No legal precedent regarding requirements or responsibilities • Different messages from different agencies • Other people involved are invested in the results of a capacity assessment, making an unbiased assessment difficult (for example application to Court of Protection, if someone lacks capacity, would stall the process for a considerable time)

Figure 3 Object format option

awaited new generation of independence. capacity report outlining the client’s ability to 1. We need commitment from other pro- Pieces of work need to be carried out to understand, retain, weigh up and communicate fessionals to develop their competencies inform individuals of the constituent parts about the different aspects of a tenancy to carry out the basic screen effectively, but and implications of a tenancy agreement. We agreement. A multidisciplinary team decision is we did not always get managerial sign-up compiled an information booklet outlining then made alongside the landlord as to whether to allow individuals to follow this process the different aspects of tenancy (‘What is this is sufficient for the contract to be enforced. through appropriately. Meetings with Tenancy?’) for people with different levels Tenancy agreements have been drawn up managers of other services could be useful of symbolic understanding, using Widgit based on capacity assessment findings on an to discuss the time demands. Symbols, Picture Communication Symbols individual basis (for example with vocabulary 2. As speech and language therapists we (PCS) and photographs. We also have an used and specific pictures chosen by the client). are clear that communication starts at option to discuss a tenancy in object format Many have been successfully approved and the beginning of the process, but often where appropriate (figure 3). entered into by landlords. referrals were only made once properties Because of the large numbers of people had been found and decisions confirmed. requiring assessment, and a move towards Stage 3 At times we suggested delaying the more efficient ways of working, we developed Moving house is anecdotally one of the most process to allow the individual service a basic tenancy screen for other professionals stressful life events. Change is often associated user time to gain more experience and to use where our expert knowledge regarding with increased levels of anxiety due to lack of understand the options available to communication is not required. We support perceived control, painful past experience and them. Obviously this did not always this with the use of guidelines, tips and the fact that it is often imposed, particularly make us popular! A longer term solution modelling or consultancy. on those with learning disabilities. We want would be to express openly with all other Following this, three options are available: to ensure that we address this to provide as stakeholders when the optimum time for 1. Where a decision can be made by one smooth a transition as possible. referral to our service would be. of the professionals already supporting Once a property is identified for the client, 3. We found a large part of our time was the person, they complete appropriate we provide advice to carers about practical spent informing others about the Mental capacity documentation. ways of supporting clients through the move. Capacity Act and their roles in relation to 2. Where a capacity decision cannot be This advice is focused towards the individual it. Often family members are not familiar made by one of these people due to and their experience, ability and needs. For with the intricacies of the Act and on communication difficulties highlighted example, we support carers to develop visual frequent occasions have thought that, by the screen, they consult speech and timetables with the individual to record all the regardless of the assessment findings, language therapy. events related to moving, such as buying new they would have the final say. It is vital 3. Where the screen cannot be completed furniture, decorating, and visits. in the current climate that speech and due to complex communication needs, Having written the process map and utilised language therapists are knowledgeable they make a referral to speech and the pathway to support the moves of several regarding the Mental Capacity Act and the language therapy. service users, we came across some issues in role of communication. An internet search When we receive a referral, we compile a implementation: will highlight training courses available to

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 5 CAPACITY / IN BRIEF

you locally, and most areas have a policy to supported by support implementation of the Act. Notwithstanding these difficulties, having a process to follow around change of accom- In Brief... modation has been useful for consistency and to clarify expectations. Most importantly we have One lucky contributor in each issue receives £50 in vouchers from had some good feedback from service users Speechmark (www.speechmark.net), which publishes a wide range about how the process ensures that they are in control of where and how they want to live. of practical resources for health and education professionals. Whilst this is a small step towards implementing government directives (DH, 2009), we would like who repeatedly reported feeling ‘listened to continue to develop this work and encourage Talking Mats and dementia to’ by the person with dementia and felt others to do so too. SLTP that their loved one could actually ‘see’ Joan Murphy and Tracey Oliver on the use of Karen Bamford and Rachael Kasch are speech their point of view. One carer said: “It never Talking Mats in managing daily living discussions seems like he is listening to me. With this I and language therapists working for Birmingham for families affected by dementia. Community Health Care. For further information can make him sit down and look at symbols or to find out more about the resources they have and get him to understand what I am trying ecent guidance from the government to say.” developed, email [email protected] recommends that people with dementia and see www.speechmag.com/Members/Extras. The study concluded that Talking Mats helped Rshould have more involvement in improve communication between people with References decisions about their care options. Government dementia and their family carers, and this hope- Department of Health (2009) Valuing People policy also states that people with dementia fully could lead to improved relationships. Now. Available at: http://www.dh.gov.uk/ and their carers should influence how en/Publicationsandstatistics/Publications/ government strategies and targets are Joan Murphy and Tracey Oliver are researchers PublicationsPolicyAndGuidance/DH_093377 implemented. Most families try hard to include at the Talking Mats Research & Development (Accessed: 12/01/11). their relative who has dementia in discussions Centre, University of Stirling. Mathieson, A. (2004) ‘Valuing People: more around their care, but this is often difficult due evolution than revolution’, Learning Disability in to the communication and cognitive problems Resources Practice 7(2), pp.8-9. associated with the illness. This latest research, • a copy of the findings and the full report McConkey, R. (2007) ‘Variations in the social funded by the Joseph Rowntree Foundation on the project can be found at http:// inclusion of people with intellectual disabilities and carried out by the Talking Mats team at www.jrf.org.uk/publications/talking- in supported living schemes and residential the University of Stirling, has implications for mats-decision-making settings’, Journal of Intellectual Disability the improvement and delivery of services. It • further information about Talking Research 51(3), pp.207-217. could also be a significant help for people with Mats resources and training is at www. Mental Capacity Act (2005) Available at: dementia and their families talkingmats.com http://www.legislation.gov.uk/ukpga/2005/9/ The project explored if people with contents (Accessed: 12/01/11). dementia, living at home, and their family Venditozzi, M. (2009) ‘How I help people move carers can use Talking Mats together, to discuss on (2): Talking flats’,Speech & Language Therapy how they are managing daily living activities. Phonology by numbers in Practice Autumn, pp.26-28. Eighteen couples (a person with dementia and a family carer) were involved and were asked to Maggie Robinson suggests a simple, easy-to- Resources discuss the following topics using Talking Mats prepare game for working on phonology. • Picture Communication Symbols, www. and come to agreement together: Aim mayer-johnson.com 1. ‘Personal care’ (washing, dressing) To practise using a phoneme in words or • Talking Mats, www.talkingmats.com 2. ‘Getting Around’ (walking, using the stairs) sentences. • Widgit symbols, www.widgit.com/symbols/ 3. ‘Housework’ (cooking, making the bed) 4. ‘Activities’ (watching TV, listening to Materials music). REFLECTIONS You need approximately 10 picture cards Following analysis of video data the results which illustrate items with the target • DO I APPRECIATE THE WIDER showed that both the people with dementia phoneme in target position in their names (15 BENEFITS WHEN PEOPLE ARE and the family carers felt more involved in is the maximum I would suggest). Number the discussions about how they were managing pictures from 1-10, on the front. HAPPY WHERE THEY LIVE? their daily living when using Talking Mats, • DO I DEVELOP compared to simply having a conversation. Method PROCESSES TO PROVIDE They also felt more satisfied with the outcome Spread the cards out face down. Take turns to CONSISTENCY AND CLARIFY of those discussions. turn over a card and either say the word, or say Two of the key outcomes were: the word in a sentence. The numbers on the EXPECTATIONS? 1. People with dementia reported that Talking front of the cards have to be placed in order. • DO I GIVE SUFFICIENT Mats helped them to clarify their thoughts, The player who turns over number 1 can leave it SUPPORT SO OTHER express them to their family carers, and face uppermost on the table. Any other number PROFESSIONALS CAN FULFIL reach a decision in these discussions. One must be placed back face down. Once number person said: “It is so difficult to tell [my wife] 1 is face uppermost, the player who turns over THEIR ROLES? what I think when I can’t remember the number 2 can leave that face uppermost, beside words, the pictures could help me a lot.” the number 1. The game continues until all the To comment on the impact this article has had 2. Although people with dementia and their pictures are in a line face uppermost. on you, see guidance for Speech & Language family carers both felt more involved in Therapy in Practice’s Critical Friends at www. discussions when using Talking Mats, the Maggie Robinson is an advanced practitioner speech speechmag.com/About/Friends. increased feeling of involvement was and language therapist in Skelmersdale, email significantly higher for the family carers, [email protected].

6 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 RESEARCH INTO PRACTICE TOPICCal applications

READ THIS IF YOU WANT TO TOPICC (Targeted Observation of Pragmatics in Children’s • CAPTURE COMMUNICATION Conversations) is a new assessement procedure developed for an IN A NATURALISTIC intervention research project. Catherine Adams, Jacqueline Gaile, WAY • KNOW ABOUT A Elaine Lockton and Jenny Freed explain how it can help speech and TOOL’S VALIDITY AND RELIABILITY language therapists in clinical practice plan, prioritise and show the • USE ASSESSMENT outcome of intervention for a child with pragmatic difficulties. TO PLAN THERAPY AND MEASURE OUTCOME

hen we first met ‘Charlie’, he had been referred to us by his local speech and Figure 1 What is pragmatic language impairment (PLI)? language therapist as a potential W The literature describes children with pragmatic language impairment as verbose, fluent, over- participant in our research project. We were literal, with expression often in advance of comprehension and difficulty constructing coherent aiming to investigate the effects of intervention narratives. It is evident from our research and others (Botting & Conti-Ramsden, 1999) that a for children who have disproportionate proportion of children with pragmatic language impairment fit into traditional diagnostic difficulty with pragmatics (figure 1), and Charlie categories such as high-functioning autism or Asperger’s syndrome, but there remains some seemed to fit the bill well. controversy over diagnostic issues. Charlie was aged 8;4, attended a mainstream classroom and had a statement of special educational needs specifying twenty hours pragmatics profile-type assessment was the this analysis into a conversational coding of learning support every week. He received Children’s Communication Checklist-2 (CCC- system, the Analysis of Language Impaired a diagnosis of autism at age four, and some 2) (Bishop, 2003). This scale is derived from a Children’s Conversation (ALICC). In this the mild features such as inconsistent eye contact series of teacher / parent-rated behaviours, frequency and / or proportions of individual were still present. He also had difficulty and gives the practitioner a valid means pragmatic behaviours, such as speech acts, making friends and did not understand how – beyond that of professional opinion - of turn clashes and cohesive devices, could be to join in language-based play. His language confirming the presence of a communication counted within a controlled sample (Bishop et assessment revealed word-finding difficulties, impairment. This is especially useful where a al., 2000). ALICC has the benefit of providing significant problems of understanding and child functions at ceiling on language tests a concrete method of measurement within creating narratives, and difficulty in drawing or cannot cooperate with formal testing. controlled samples and is a potential tool for visual and verbal inferences. His teachers However, in addition to pragmatic behaviours evaluation of change, but it is prohibitively expressed concern about Charlie’s literacy, lengthy as a clinical measure. As it requires numeracy and lack of independence in class. at least 6 hours of transcription and skilled When we met Charlie it was evident that The range and number analysis of a 10 minute sample, it is not in any he had significant difficulties with a range of children who way a feasible procedure for the clinician. of pragmatic behaviours. The challenge for us was to profile these in a naturalistic way require an assessment using a valid method, to use this information Real time both to plan therapy input and to show the of pragmatics has To translate ALICC into a clinical tool, the outcome of intervention, and then to do the increased greatly assessment ideally needed to be completed in same sort of profiling for another 84 children real time. Realistically, coding of conversational like him who were participating in the project. turns needed to be simplified and guided The range and number of children who it profiles other communication difficulties, by clinical examples rather than by lengthy require an assessment of pragmatics has and is not focused on providing detailed training. increased greatly, with improved understanding information for intervention planning. In our research study, the Social of communication in autism spectrum The CCC-2 uses a reported observational Communication Intervention Project (SCIP), conditions and spiralling caseloads of such method. Direct observational methods are based at the University of Manchester, we children. The practitioner needs a practical usually felt to be more reliable but, with investigated the effects of an intensive speech format for observation or testing, which can be pragmatics, you generally find that the more and language intervention for 85 children used with a variety of children with pragmatic structured the context, the less naturalistic with pragmatic language impairment. We communication needs from pre-school to and representative the assessment will be. wanted to have a direct observational measure adolescence and is not too time-consuming. So, in 1989, Bishop & Adams tested a semi- of pragmatics in conversation to use as an There are tests of pragmatics (for a review structured task which sampled conversations outcome measure. There was a need, therefore, see Adams, 2002) and checklists of pragmatic between the child and the adult assessor. In to come up with a short analysis of pragmatics behaviours (such as Andersen-Wood & Smith, this task, the assessor conversed with the child in conversation. The new observation scheme, 1997) but most of these were not suitable about specific topics, supported by pictures. TOPICC (Targeted Observation of Pragmatics for the project. A strong contender for a Bishop and her colleagues further developed in Children’s Conversation), was based on

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 7 RESEARCH INTO PRACTICE

ALICC and the sound principles of its research, Figure 3 Examples of how TOPICC and CCC-2 items were matched in the concurrent validity study and used an identical sampling method. This allowed us to: TOPICC item Corresponding CCC-2 item (no. on CCC-2 form) • Incorporate the breadth of the ALICC Difficulties with topic maintenance 26 Moves the conversation to a favourite topic scheme, looking not just at speech acts but even if others don’t seem interested in it also at responsiveness and information Giving too much detail and information *42 Includes over-precise information • Use a short format observation scheme AND based on vulnerable areas of pragmatics 37 Tells people things they know already • Use an observational rather than transcription approach *note that some TOPICC items have alternative corresponding CCC-2 items, in which case rating • Embed aspects of interactional / of both CCC-2 items at 2 or above was required to show agreement with TOPICC interpersonal communication within the pragmatic categories. We piloted the new scale with preliminary intensive SCIP therapy or therapy as usual. Figure 2 TOPICC rating scale data from pre-intervention conversation All coding was completed blind to group assessments. Two experienced researchers status. In a sample of 50 children who have marked evidence of that behaviour independently coded recordings of our pragmatic language impairment, there was 3 across conversation; makes a participants ‘live’, and discussed areas of good agreement (80 per cent) between marked impact on the interaction agreement and difference. We then amended independent coders on opinion of change makes a moderate but still 2 categories in the scale and produced in conversational skills in TOPICC, showing significant impact on the descriptors for each aspect of pragmatic reasonable reliability of overall impression of interaction behaviour. We used this final revised version conversation change. is noticeable occasionally but of TOPICC (available for free download at Charlie entered into the intervention arm 1 makes only a slight impact on the www.psych-sci.manchester.ac.uk/scip/) to an- of SCIP (Adams et al., in preparation). At the interaction alyse all 85 children’s conversation data. beginning of therapy we used the TOPICC is never observed and the 0 TOPICC consists of a single observation profile as a planning tool for intervention (figure behaviour is typical of mature sheet with seven principal categories, some 4). He then received intensive intervention of interaction style of which are broken down into separate 20 specialist speech and language therapist items. Each item within the category is scored sessions plus usual Learning Support Assistant according to agreed observational guidelines, input over 12 weeks. This was aimed at: Having used TOPICC within SCIP and in our for which examples are available. The purpose • enhancing his understanding of own clinical practice, we feel it has potential of doing this is to derive a total score for interlocutors’ needs as a clinical observational instrument for TOPICC as well as sub-scores for separate • identifying topics and signalling topic profiling pragmatics and conversational skills categories. The rating scale is in figure 2. change in a wide range of children of school age who Content validity of TOPICC had already been • developing strategies to acknowledge have pragmatic communication difficulties. addressed by inclusion of categories from when he doesn’t understand and to ask Its main strengths seem to be that previous research found to be descriptive of for help 1. it prompts observation of key char- pragmatic communication needs. Concurrent • developing metapragmatic skills of acteristics of conversation likely to be validity was addressed by comparing children’s knowing how much to talk and when to significant in planning needs and support scores on TOPICC with their parents’ ratings on allow the interlocutor to contribute 2. it can be done in real time CCC-2. In advance of this analysis, we matched • understanding the thoughts and feelings 3. to the experienced observer it is relatively each TOPICC item to the CCC-2 item(s) which of others by reading social signals, and the easy to use the examples to guide coding. best matched its description before the validity importance of this in peer interactions It should be carefully noted that there are study started (figure 3). We then identified the • strengthening narrative ability via no normative data on TOPICC - and there 20 children in our participant group with the sequencing and narrative construction probably never will be, because pragmatics highest TOPICC scores – in other words, with practice to enhance language-based is not amenable to standardisation. Reliability the most notable difficulty with pragmatics in interactions in social situations and in the of observation and coding on TOPICC has yet this context. We compared the rating on each of classroom. to be tackled and may remain problematic their three highest scored TOPICC items, scored without substantial funding for research at 2 or above, with the parent ratings of the studies. In the meantime, TOPICC may be corresponding items on CCC-2. This yielded 60 Charlie showed a strong a useful aide memoire for the practitioner pragmatic behaviours in total. We then calculated attempting to profile pragmatics for individual the agreement between pragmatic behaviours response to therapy children from a naturalistic sample. SLTP observed as identifying need on TOPICC and the corresponding CCC-2 item. A CCC-2 item had to and at six months post- be rated at 2 or 3 to be considered problematic intervention his TOPICC Catherine Adams (email catherine.adams@ and in agreement with the observed TOPICC manchester.ac.uk), Jacqueline Gaile, Elaine item. Across the 60 behaviours, there was very profile had changed Lockton and Jenny Freed are researchers in the good agreement (88.3 per cent) between Human Communication and Deafness Group at pragmatic behaviours identified as problematic considerably the University of Manchester. on TOPICC and on CCC-2. As a secondary outcome measure in the Acknowledgements and ethics intervention project, we asked trained TOPICC In addition, making inferences from words SCIP was funded by the Nuffield Foundation raters to complete TOPICC coding and then and short texts, supported by self-cuing and sponsored by the University of Manchester. to do a further task to confirm reliability . We strategies, provided a platform for word Thanks to Kirsty McBean (Queen Margaret asked them to give their overall impressions learning that transferred readily to class-based University Edinburgh), Gillian Earl (NHS of change in conversation skills from the learning. Charlie showed a strong response to Lothian), Ruth Wadman and to all the children, beginning to the end of intervention for therapy and at six months post-intervention families and schools who participated. The those children who had received either his TOPICC profile had changed considerably. research was carried out in accordance with

8 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 RESEARCH INTO PRACTICE

Figure 4 TOPICC profile for Charlie pre-intervention showing indications for intervention TOPICC OBSERVATION SCALE © Adams, Gaile, Freed & Lockton 2010 CHILD ID: Charlie STIMULI USED: Picture set 3 ASSESSOR: Gaile AGE: 8;4 TOPICC protocol DATE: 2009 Time 1

Category Rating Link to intervention in SCIP* Reciprocity Difficulties initiating conversation 0  1 2 3 Relative strength Difficulties responding to questions 0 1  2 3 Child ignores speaker 0  1 2 3 Taking account of listener knowledge Giving too much detail and information 0 1 2 3  Understanding information requirements Understanding thoughts and feelings of others Giving too little information 0 1 2 3  Understanding information requirements Narrative construction Turn taking Interrupts speaker frequently 0  1 2 3 Relative strength Verbosity Child dominates conversation 0 1 2 3  Metapragmatics and monitoring quality of talk in interaction Child uses too many questions 0 1 2  3 Understanding information requirements Child provides unsolicited information 0 1 2 3  Understanding thoughts and feelings of others Topic management Obsessional topics 0 1  2 3 Topic management strategies Difficulties with topic maintenance 0 1 2 3  Stereotyped or unusual language 0 1 2  3 Monitoring information in talk; demonstrating effects of irrelevant language on conversation flow using sabotage methods Discourse style Proximity 0 1  2 3 Overly formal 0 1  2 3 Non verbal behaviours 0 1 2 3  Eye gaze and meaning in interaction Response problems Comprehension limitation 0 1 2 3  Comprehension monitoring Linguistic limitation 0  1 2 3 Relative strength * These are main headings for aspects of intervention in the SCIP manual, which then specifies aims, methods and activities for each aspect in turn. the NHS Research Governance Framework for Bishop, D.V.M. (2003) The Children’s Communi- Health and Social Care (NHS, 2005) and ethical cation Checklist – 2. Oxford: Pearson. REFLECTIONS permission was gained from the NHS Research Bishop, D.V.M., Chan, J., Adams, C., Hartley, J., • DO I CONTRIBUTE TO THE Ethics Committee. Informed consent was & Weir, F. (2000) ‘Conversational responsiveness DIALOGUE BETWEEN gained from all participants and schools. in specific language impairment: evidence of disproportionate pragmatic difficulty in a subset RESEARCHERS AND References of children’, Development and Psychopathology PRACTITIONERS? Adams, C. (2002) ‘Practitioner Review: The 12(2), pp.177-199. • DO I MONITOR AND Assessment of Language Pragmatics’, Journal of Botting, N. & Conti-Ramsden, G. (1999) RESPOND TO CHANGES Child Psychology and Psychiatry 36, pp.289-306. ‘Pragmatic language impairment without Adams, C., Gaile, J. & Aldred, C. (in preparation) autism: the children in question’, Autism 3(4), IN THE PROFILE OF MY Social Communication Intervention Programme pp.371-396. CASELOAD? (SCIP): manual and electronic resource. • DO I OFFER SUFFICIENT Andersen-Wood, L. & Smith, B.R. (1997) Working Resources HOURS OF THERAPY TO with Pragmatics. Milton Keynes: Speechmark. • NHS Research Governance Framework for Bishop, D. & Adams, C. (1989) ‘Conversational Health and Social Care, see www.dh.gov.uk/ BRING ABOUT CHANGE? characteristics of children with semantic- en/Publicationsandstatistics/Publications/ Tell us the difference this article has pragmatic disorder. 2: What features lead to a PublicationsPolicyAndGuidance/ made to you. See the information about judgement of inappropriacy?’, British Journal DH_4108962 Speech & Language Therapy in Practice’s of Disorders of Communication 24, pp.241-263. • Further information about SCIP and the full Critical Friends at www.speechmag. Available at: http://www.mugsy.org/spd2.htm TOPICC form (with definitions) are available com/About/Friends. (Accessed: 24 January 2011). free at www.psych-sci.manchester.ac.uk/scip/.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 9 GOAL NEGOTIATION (1)

READ THIS IF YOU WANT THERAPY TO BE MORE Whose goal is it anyway? • CLIENT-CENTRED • MEANINGFUL Part 1: A strong foundation • FOCUSED In the first of our new four part series,Sam Simpson and Cathy Sparkes unpack the terminology, different perspectives and key principles that underlie effective client-centred goal negotiation, and share their strategies to ensure the timing and tempo is driven by the client rather than external pressures.

e very much value the opportunity to bring the complex and diverse topic Task 1: What do you understand by the term ‘goal’? Wof client-centred goal negotiation Take 10 minutes to consider and write down your responses to the following questions: into the public arena for discussion and debate. • What do you understand by the term goal – both in and outside of work? We are two clinicians with long and varied • To what extent do you as an individual have hopes, dreams, goals…? careers in the fields of brain injury (both) and • In what ways do you try to achieve them? • Who / what do you turn to in order to move your life forward? stammering (Sam), for whom client-centred • When do you know the time is right to take the first step towards your hopes, dreams or aspirations? goal negotiation has played a central role at • Do you plan / negotiate / set yourself goals – either implicitly or explicitly? both unidisciplinary and interdisciplinary levels. Then, either on your own or with a colleague with whom you feel comfortable, discuss and reflect Having lectured and consulted clients, families, on your answers. professionals and students since 1993 in this field, it is highly apparent that the concept means different things to different people. likely to be quite specific and clearly articulated, a goal negotiation process which can be used In this first of four articles we will cover whilst others are likely to be more vague and flexibly and tailored individually offers a sense terminology, review different perspectives difficult to explain. Some will feel very possible of direction, particularly if the world is or has to goal negotiation, consider its relevance and easily achievable, whereas others will be become chaotic for the client and their family. to client-centred working, and introduce set year in year out, even in the knowledge that the four key principles. In the second we will they are unlikely ever to be achieved. C. Key principles present a goal negotiation process along with We also predict that different styles and personal preferences to goal negotiation will 1. Client involvement a theoretical model of change that further By ‘client’ we refer not only to the person with frames this process and delineates flexible goal become apparent. Some of you will enjoy the task of defining clear personal goals to work communication difficulties, but also to their negotiation practices across acute, rehabilita- relatives, friends and carers. Client involvement tion and community settings. In our third article towards, whereas for others the process and sense of direction will be more important at all stages and levels of goal negotiation is we will explore the actual goal ‘negotiation’ essential as, when the client remains central conversation, including case examples from a than whether or not you actually achieve the final goal. Some of you will also enjoy having to the process, they gain insight into therapy, range of contexts. Finally, we will consider goal their recovery or development, and the entire writing skills, represent the client voice and a focus and challenge to work towards over an extended period in anticipation of the feelings enablement process. It will also give them some reflect on clinicians’ service developments that control and choice at a time when they may we have supported in recent years. of achievement this will bring about. For others, the risk of failure and having to manage feel overwhelming powerlessness. In addition This first article includes two practical tasks, it provides opportunities for the review and which are suitable for you to do alone, with a potential disappointment will be enough to deter you from setting goals outside of demonstration of progress (or not). Goal colleague or as a team. Please now complete negotiation can therefore offer the therapist task 1 before continuing with the article. the day-to-day routine. All of this serves to highlight the diverse meanings, personal a vehicle for increasing client commitment to A. TERMINOLOGY styles and preferences people bring to the and engagement in their therapy, for preparing We anticipate your reflections will highlight goal negotiation table, and the importance of transitions between services, and ultimately the broad range of meanings that are readily exploring this from the very outset to ensure a for facilitating client autonomy. associated with the term ‘goal’ – from more shared language and understanding. 2. Identification of strengths and problems professional connotations such as a ‘target’, The assessment process enables each ‘something to work towards’ and ‘outcome’, to B. Perspectives and client-centredness discipline and the multidisciplinary team to include more of a layperson’s understanding Each person you work with, either as a client determine early on each client’s strengths, relating to the goals scored in football, where or family member, will have their own unique problems, hopes and aspirations. This provides there is a strong association with winning views and experiences of ‘goals’. It is vital to the team with information about potential and losing, success and failure. They will have this conversation early on, and to be areas of focus with the client. Involving the also hopefully have highlighted the many proactive in engaging clients in a dialogue client in identifying their strengths and areas different parameters of goals that people set around what is meant by the terms and of difficulty allows for assessment of their themselves – from the looser, more aspirational concepts that are going to be used. In this way, level of self-awareness and knowledge of and potentially unrealistic personal goals that right from the start, goal negotiation provides the implications of their condition. This is an may only go acknowledged privately, through a framework to develop a shared language that essential stepping stone in engaging the client to those that we are willing to go public with is embedded in the world of the client. Thus, in directing their own management. Once all and share, right to the more concrete, smaller, in essence, it is truly client-centred. This initial areas have been investigated and discussed, routine-based actions that we readily write and conversation helps to promote a balance of the next step is to ensure that appropriate re-write in a daily ‘to do’ list. Thus some goals are power in the therapeutic relationship. Having resources within the regular multidisciplinary

10 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 GOAL NEGOTIATION (1) team or the wider service are in place. This Task 2: helps the client to understand who they can To what extent do you embrace the core principles in your goal negotiation practice and service? turn to, and for what support. Take 10 minutes to consider and write down your responses to the following questions: 3. Multidisciplinary team involvement • To what extent do you truly involve clients in planning and evaluating the therapy you deliver? Working in the field of neurorehabilitation, • To what extent do you involve clients in the assessment process and determining what their there is an inherent complexity to each strengths, difficulties, wants and priorities are…? individual client’s needs. To work with this client • How interdisciplinary is your goal negotiation practice and service? • How proactive are you at making links with any professional or service a client becomes involved group to best effect, a true skill mix, excellent in (such as the voluntary sector) if you generally work in isolation? collaboration and respect for areas of overlap • How much time do you allocate to negotiating goals with your clients? and (in turn) carryover between professionals • Does the culture and philosophy of your service support client-centred goal negotiation? are needed. Such effective interdisciplinary • What terminology do you use in relation to goal negotiation? team work can be facilitated by efficient lines of • How consistently and transparently is this terminology used across clients and professionals? communication, including formal and informal Then, either on your own or with a colleague with whom you feel comfortable, discuss and reflect meetings, clear documentation, and a shared on your answers. understanding that goal negotiation is the very foundation of neurorehabilitation. Also, In many settings goals are typically divided regularly’. A preliminary goal area provides to ensure that the goals negotiated with each into two time frames, short and long. The the client and the team with a sense of overall client are personally meaningful and relevant, exact length of these time frames will vary direction under which short-term goals can be they need to be negotiated not only between according to the work context – with a written and worked on for an interim period the client and a single discipline, but with the short-term goal being achievable within one until a more specific long-term goal has been client and the entire multidisciplinary team. week to one month, and a long-term goal negotiated. This flexible process will ultimately We are aware that not all of you have potentially spanning four weeks, six months enable the formulation of a more meaningful, easy access to any or all multidisciplinary or longer in some contexts. client-centred long-term goal as the client team members in your respective settings. a) Long-term (discharge) goals gains an understanding of the therapy process, However, wherever you are based, it is always We define long-term goals as interdisciplinary their own priorities and potential for change. helpful to be linked or communicating goals which reflect the client’s potential c) Short-term goals with relevant professionals, whether in the lifestyle or level of participation (WHO, 2001) By contrast, short-term goals represent a NHS, voluntary sector or social services. on discharge. One or more of the following breakdown of a longer-term goal into smaller, This invariably requires a commitment to domains are often included in long-term goals: more manageable steps (for example, ‘John making contact with these services and being • Home will read the Stroke Association booklet on proactive in fostering ongoing relationships. • Leisure continence and discuss it with his named 4. Goals • Social relationships nurse and wife at least once in two weeks’). It is We are very much of the opinion that goal • Occupation / self-occupation. important that all short-term goals have a linear negotiation is not purely about the setting Often clients need reflection time to relationship with the long-term goal they relate and writing of goals, and in fact consider the identify meaningful long-term goals, and this to. Typically short-term goals are set at the level actual writing of the goal to represent the final requires sensitivity and patience on the part of of activity and impairment (WHO, 2001) and part of a complex process. It is also important healthcare professionals. Indeed, it is important are a combination of multidisciplinary team to remember that not all goals negotiated to remember that any discussion about and single discipline goals. have to be achieved – indeed, in life we rarely longer-term outcomes provides a platform d) Plan of action achieve everything we set out to do. It is for enhancing the client’s understanding of In addition to a client’s long-term and short- important, from the very outset, to ensure that their condition and potential for change, for term goals, other activities or roles are carried clients do not perceive goals purely in terms of managing their expectations, and for exploring out by healthcare professionals on behalf of success and failure, but can appreciate there is issues such as dependence, support needs or for the client in support of their goals, and potentially more to learn from not achieving and networks, role changes, losses and the re- can often go unnoticed. We call these ‘plans of and subsequently revising a goal than from writing of personal narratives. Consequently it is action’. Examples include ‘organise purchase achieving it the first time. In fact, research has important not to underestimate the emotional of bath board’ and ‘liaise with Social Services’. demonstrated that, in order to set goals at load of such discussions and the need to respect It is important to distinguish this professional an appropriate level of challenge for a client, and be sensitive to the client’s pace and process. activity from the goals carried out by the client optimally an 80 per cent success rate should be This is invariably in direct conflict with NHS and / or their family, and also to make sure aimed for (Johnson, 1997). time pressures, lean working principles, ever they are documented clearly and assigned to For the goals negotiated to be intrinsically increasing throughput targets and emphasis a particular member of the team. motivating they need to be client-centred. on data collection to demonstrate clinical Please now complete task 2. We hope your In addition, for a client to experience the full effectiveness. Such factors often result in reflections will form a strong foundation for impact of goal achievement the goals need therapists feeling the need to negotiate goals you to get the most out of this series. to relate to a change in behaviour. A useful very quickly in order to get on with the ‘actual conceptual framework for negotiating and therapy’. This rush to define a clear clinical Sam Simpson (email [email protected]) is a spe- writing goals is shown in figure 1. outcome frequently results in little time and cialist speech and language therapist and trainee attention being given to the client’s process. counsellor. Cathy Sparkes is a specialist speech and Figure 1 Framework for negotiating and True collaboration and negotiation are sidelined language therapist and counsellor. Together they writing goals and the actual writing of the goal becomes a are intandem (www.intandem.co.uk). SLTP • WHO professionally driven pen and paper exercise. Reference • Will be doing WHAT b) Preliminary goal area vs. long-term goals Johnson, M. (1997) ‘Outcome measurement: towards • Under what CONDITIONS an interdisciplinary approach’, British Journal of • To what DEGREE of success We strongly advocate against rushing to write Therapy and Rehabilitation 4, pp.472–479. • Within what period of TIME long-term goals for the sake of it. Instead we propose using a looser concept provisionally, Resources e.g. John will go to the cinema with a friend • An explanation of lean thinking is at www.lean.org/ (James or Susan) at least once a month for which we have termed a ‘preliminary goal • World Health Organisation (WHO, 2001) International the next three months area’. This might be to ‘return home’, ‘get out Classification of Functioning, Disability and Health and about’ or ‘meet up with friends more (ICF), www.who.int/classifications/icf/en/index.html

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 11 PATIENT SAFETY

Reducing the risk READ THIS IF YOU WANT TO • SUPPORT OTHER STAFF TO FULFIL Adults with learning disabilities or mental illness are at increased risk THEIR DUTIES of choking. Choking incidents are stressful for the individual involved • CONTRIBUTE TO A CULTURE OF and for anyone who has to recognise what is happening and assist. REPORTING AND Susan Guthrie and Hazel Roddam explore the challenges for speech LEARNING FROM MISTAKES and language therapists and the wider multidisciplinary team, and the • BUILD UP A DETAILED PICTURE impact of enhanced electronic reporting of incidents and training. OF CLINICAL INCIDENTS

“He looked anxious and like he was in a state of panic. He was unable to talk or cough. He was going red at first and his eyes were bulging and watering. He then dropped to his knees and he was going blue around the lips, his eyes were rolling to the back of his head. I felt shaken and anxious that I had to carry out this practice [abdominal thrusts], however I felt a sense of relief when the client resumed normal breathing.” (Account of a choking incident by a member of care staff)

ecent literature has highlighted asphyxiation from choking as an Rincreased risk for people with learning disabilities (Samuels & Chadwick, 2006; NPSA, 2008), and also those who have a mental illness (Corcoran & Walsh, 2003; Bazemore et al., 1991). Studies indicate that dysphagia may be under-diagnosed in this population (NPSA, 2004). The nature of the relationship between dysphagia and choking and the evidence base Susan Hazel needs further investigation. A choking incident can, however, act as a trigger. It can alert carers risk management procedure then feeds into further problem is that these reports often that an individual may be having difficulty at the national reporting and learning service lack information. Such absence of detailed mealtimes, prompting referral to speech and (NRLS) database coordinated by the National description is of concern, as possible causes language therapy for dysphagia assessment. Patient Safety Agency (NPSA) (figure 1). or influences for an incident may be lost. While the experience of a choking incident For speech and language therapists Accuracy may also be variable when reports is traumatic for the person concerned, the care the electronic system has provided a new are delayed, rushed or subjective. staff involved also experience considerable source of information when working with To address this, and with the help of the IT distress. Care staff need clear guidelines for dysphagia referrals. Although fatal incidents department, Susan added 10 further prompt when to be concerned, and for when and how are generally known about, in the past it questions to the standard open questions to document their concerns. For staff training, has been more difficult for us to access already in the electronic system. Supported finding a working definition of choking is a information on near miss incidents. As part of by speech and language therapy led staff priority. The literature tends to offer definitions the multidisciplinary team, we can now access training workshops, these new questions aim with medical jargon. Bazemore et al.’s definition all reports of suspected choking incidents for to promote greater detail in reporting. Susan includes more easily observable characteristics: each service user. derived the prompts from discussion with a choking incident is “an acute episode in The trust includes both small community nursing and care staff, then sought expert which the patient coughed incessantly or homes and on-site low and medium secure speech and language therapy consensus at experienced a colour change (with inability accommodation. In the last 7 years in the the ALD Dysphagia UK network forum. The to speak or cough effectively) while ingesting population of adults with mild – profound prompts are based on the need to be able food or drink. The solid or liquid had to be learning disabilities (approximately 400 to learn from incidents. They are designed expelled to terminate the event” (1991, p.3). people) there have been 4 deaths due to to elicit greater detail; for example, ‘describe Since 2005 Susan’s specialist trust for adults choking on food, and 2 sudden deaths related what you saw’ prompts staff to include a with learning disabilities has had a policy of to PICA (ingestion of non food items). description of clinical presentation at the time reporting patient safety incidents using an The number of reported choking incidents of the incident. Jargon is avoided for non- electronic system accessed directly by the staff is small; for example, in 2009 there were 40 clinical staff. involved. These range from ‘personal accident’ near miss choking incidents compared to Susan’s workshops also raised issues to a wide variety of ‘clinical incident’. This local over 9000 total patient safety incidents. A around Basic Life Support (BLS) training. This

12 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 PATIENT SAFETY

Figure 1 National reporting and learning a measuring scale which can be used and understood by all and – crucially - repeated The National Patient Safety Agency (NPSA) National Reporting and Learning Service (RLS) more reliably (figure 2). website states: “Information from reported incidents helps the NHS understand why things go wrong and how 2. Frequency to stop them happening again. The number of incidents appears similar Within a local NHS organisation, a serious event may be perceived as a one-off. Reporting to the between people in community houses (with RLS can reveal similar incidents in other parts of the NHS and can also help identify learning from incidents in different organisations. a more elderly population, more diagnoses The RLS helps NHS organisations understand why, what and how patient safety incidents of physical disability) and those in medium happen, learn from these experiences and take action to prevent future harm to patients.” / low secure provision (younger population with more diagnoses of mental illness, http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safety- personality disorder), with 7 per cent of the incidents/ (How reports are used) Accessed: 20 January 2011 total service users in this trust experiencing a choking incident. However, a noticeable difference is seen in the medium / low secure Figure 2 Measuring scale: Severity of choking incident (degree of first aid) and frequency of accommodation incident reports. They record occurrence over 12 month period more examples of service users who have experienced more than three repeat incidents Spontaneous Cough after Backslaps Abdominal Paramedic Details over a 12 month period. cough staff prompt thrusts unspecified 20% 10% 44% 5% 5% 16% 3. Location The majority of incidents take place in usual home settings, and many fewer are reported for Figure 3 Timing of choking incidents (Data over period mid 2005- end 2007) eating out. The proportion of meals eaten away from home is much smaller, but this statistic 4% may also be explained by staff comments such as “he eats much slower, more politely [sic] when out and about”. However feedback and 24% 20% screening would suggest that staff are also less breakfast likely to report incidents occurring off-site.

lunch 4. Timing evening meal (‘tea’) Unsurprisingly the majority of incidents (70 per cent) occur at mealtimes, with a strong 6% late snack (‘supper’) tendency (42 per cent) at evening meal (‘tea’) (figure 3). unknown The potential influencing factors for 4% incidents at this time of day are complex and not mealtime multiple. The literature generally refers to factors such as physical and mental health status, behaviours, fatigue and medication. 42% However discussion with nursing staff has suggested many environmental and social factors. There are many stresses for staff around producing and supervising a main Figure 4 Type of bolus meal at the end of a long shift. Self-induced or peer pressure for service users, such as Unspecified Unspecifed Bread/ ‘Sausage’ ‘Salad’ ‘Potato’ Medication feeling the need to rush to get finished, may ‘food’ ‘meat’ toast also contribute. In this trust immediately after 8 8 6 3 1 1 4 ‘tea’ is the opportunity for social club, phone calls home, free time or a cigarette. All are highly motivating but also a potential source is a mandatory requirement for health care The database now shows a steady increase of anxiety and tension, and incident reports in staff (Resuscitation Council UK guidelines) in reporting of choking incidents, although general show an increase at this time of day. but feedback from agency staff indicates it it is clear from discussion with care staff that We can attempt to untangle these complex is not always accessed before they start work some are still not being reported. We have influences via ward round discussions and with service users. Care staff also highlighted carried out an informal review of care staff multidisciplinary team intervention. However, practical problems in attempting the standard incident reports over a 12 month period and further research is needed to establish an recommended BLS procedures with people selected 6 themed comments which have evidence base, as we do not know what who are obese, in wheelchairs, or have severe implications for practice: influencing factors are significant and what physical disabilities. Susan referred this to the outcomes can be achieved in terms of BLS trainer who will now offer individualised 1. Severity intervention and risk mitigation. guidelines to ensure care staff are able to The majority of reports now describe the administer first aid in an emergency. This extent of first aid or intervention, which gives 5. Food types development made us re-evaluate how far a more objective measure of the severity of Seventy six per cent of incidents give some our role and professional responsibility as an incident. Such incidents are emotional and description of a solid food item causing speech and language therapists extends, and stressful for all concerned and, throughout this choking. The type of bolus described reflects led to a closer working relationship with the work, it has been difficult to achieve objective the frequency of evening meal incidents BLS trainer. reporting. It is therefore useful to try to create (figure 4).

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 13 EDITOR’S CHOICE / PATIENT SAFETY

The higher incidence of tougher, more Footnote chewy textures involved in these choking At the time of writing, the NPSA (National incidents would appear from this small sample Patient Safety Agency) is expected to be to match with the ‘High Risk foods’ attached to abolished as the overall coordinator of learning Editor’s the National descriptors (BDA, 2009). However from healthcare safety incidents. The transfer texture modification leading to changes in food of the NPSA’s different functions is being choices and tastes offered must take into account explored by the Department of Health. individual circumstances, capacity and quality of choice References So many journals, so little time! life issues around mealtimes. For example, some Bazemore, P., Tonkonogy, J. & Ananth, R.(1991) people are keen to avoid the foods they perceive Editor Avril Nicoll gives a brief ‘Dysphagia in psychiatric patients: clinical and as difficult to process but others are resistant to flavour of articles on stammering videofluoroscopic study’,Dysphagia 6(1), pp.2-5. change. As a multidisciplinary team we have to BDA (2009) National Descriptors for Texture that have got her thinking. consider the impact of changing food and drink Modification in Adults. Available at: http:// choices, balancing this with needs of palliative Many clients are so afraid of the reaction if a www.bda.uk.com/publications/statements/ care, mental illness and challenging behaviours listener realises they stammer that they go to NationalDescriptorsTextureModificationAdults. (Langmore, 1999). any lengths not to do it. In ‘Listener perceptions pdf (Accessed 21 January 2011). of stuttering, prolonged speech, and verbal Corcoran, E. & Walsh, D. (2003) ‘Obstructive 6. Clinical presentation of individual incident avoidance behaviors’, Von Tiling lays bare the asphyxia: a cause of excess mortality in It has become increasingly clear from care cost, as “excessive use of verbal avoidance psychiatric patients’, Irish Journal of Psychiatric staff comments that the signs of choking are behaviors like interjections, revisions, incom- Medicine 20(3), pp.88-89. Available at: http:// not always obvious or immediately visible. A plete phrases, and pauses make people who www.ijpm.org/content/pdf/193/Ostruct.pdf minority of the reports from care staff have stutter look more incompetent than the use (Accessed 21 January 2011). described experiencing a delay in recognising of stuttered speech or prolonged speech” Langmore, S.E. (1999) ‘Issues in the the onset of choking, and there are accounts (p.9). I found the process of this research management of dysphagia’, Folia Phoniatrica et of service users who become silent and inert and the concepts it discussed very thought- Logopaedica 51, pp.220-230. when choking. The lack of movement and provoking (core vs associated behaviours, NPSA (2004) Understanding the patient safety absence of agitated behaviour in these service emotional vs communicative competence, issues for people with learning disabilities. users may not attract the attention of the care entity vs incremental theory). Available at: http://www.nrls.npsa.nhs.uk/ staff. In addition, familiar staff are more able to J Commun Dis (2010), in press resources/?EntryId45=92328 (Accessed: 21 identify when an individual is not exhibiting January 2011). Plexico, Manning & DiLollo make a convincing normal behaviour, while agency or unfamiliar NPSA (2008) Resuscitation in mental health case in ‘Client perceptions of effective and inef- staff can miss subtle changes. and learning disability settings: Rapid response fective therapeutic alliances during treatment Full detailed recording of clinical presentation report. Available at: http://www.nrls.npsa.nhs. for stuttering’ for giving more attention to the (such as prompting ‘what did you see?’) is crucial uk/resources/?entryid45=59895 (Accessed: 21 effectiveness of a clinician rather than focusing to ensure quick identification and intervention January 2011). solely on the treatment. Citing Brown (2004), for further incidents. Given the transitory Samuels, R. & Chadwick, D. (2006) ‘Predictors they warn that failure to do so “limits the po- nature of care staff (NPSA, 2004) it is essential to of asphyxiation risk in adults with intellectual tential to improve outcomes and to lower document fully each suspected incident to allow disabilities and dysphagia’, Journal of Intellectual costs” (p.350). Their qualitative study investi- handover of potentially life saving information. Disability Research 50(5), pp.362-370. gated the characteristics associated with effec- However research is needed to establish tive and ineffective clinicians solely from the what information is relevant, influential and Resources point of view of the client. I’m not sure that the significant and then how this can be used to • ALD Dysphagia UK network forum, email clients were as diverse as the authors believed mitigate risk of future incidents. [email protected] (8 were speech pathologists!), but the findings • Resuscitation Council UK guidelines - www. ring true. The summary in table 3 could be Further analysis resus.org.uk/ used for reflection or team discussion. The factors influencing choking can be numerous Journal of Fluency Disorders (2010) 35, pp.333-354 and complex. To explain and then attempt to Clinical questions and challenges In ‘Stuttered and fluent speakers’ heart rate prevent further incidents as a multidisciplinary and skin conductance in response to fluent team, we need to identify potential risk factors. 1. Would you recognise if your and stuttered speech’, Zhang, Kalinowski, This may include aspects of a person’s diagnosis - patient was choking? Saltuklaroglu & Hudock replicate previous their physical skills and the presence of dysphagia, 2. Could you give standard findings that listening to someone with a mental illness, behaviours, medication history - basic life support or are moderate-severe stammer induces two sig- but may also include external influences such as there complicating factors? nificant negative physiological responses in environmental and social factors. We are trying to source funding for further 3. Do you know whether comparison to fluent speech.This study was choking has happened before? different in that one group were people who analysis of the nature of choking incidents stammer but, interestingly, they showed the and the influences present using the wealth 4. Is there an underlying same pattern of responses. The authors be- of information generated by the incident dysphagia? lieve that, “The results may provide a unique reports. With a stronger evidence base it will 5. Can we show that perspective for helping PWS to understand be possible to begin to research strategies to intervention reduces the SLTP the negative responses they encounter in reduce risk in this area. risk of further incidents? their daily interactions with others, and bolster the notion that stuttering therapists Susan Guthrie is a Specialist Speech and Language should put an emphasis on reducing the Therapist with East Lancashire Community aberrance and abnormality of primary and Health Services and Calderstones Partnership How has this article changed your thinking? secondary stuttering behaviours in the ini- NHS Foundation Trust, email susan.guthrie@ Let us know - see information about Speech & tial phases of stuttering treatment” (p.673). calderstones.nhs.uk. Dr Hazel Roddam is Principal Language Therapy in Practice’s Critical Friends IJLCD (2010) 45(6), pp.670-680 Lecturer in Research, University of Central at www.speechmag.com/About/Friends. Lancashire, email [email protected].

14 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 HERE’S ONE / reviews “Here’s one reviews AUTISM Foundation Role Plays for Autism I made earlier...” Andrew Nelson Jessica Kingsley Alison Roberts with more low cost, flexible ISBN 978-1-84905-063-0 £34.99 and fun therapy suggestions for groups An excellent resource This is a practical resource for anyone working True story with young people with autism spectrum “This memory activity helps clients to listen, and to learn something about disorder. It offers pre-prepared activities to each other. It could be something about their biography, or maybe an enable participants to make choices and event last weekend, such as a barbecue or a trip to a zoo. It also requires practise skills in a safe imaginary situation. the person telling their story to plan something reasonably coherent, for I particularly loved the sections aimed at which they may need some help. If your group of clients prefers, they can tell made-up stories. It siblings, parents and peers as there are very few is best for a group of four teenagers or adults.“ resources available for these groups. These role plays are most suited for older children or young IN PRACTICE adults as they require higher levels of language a. Person A tells their story, which should last approximately half a minute. ability and have a written feedback form for b. Person B repeats the story as exactly as possible, trying to use the same words and each activity. This is an excellent resource for inflections. therapists working with young people with c. Person C mimes it. high functioning autism. I will be passing it on to d. Person D tells it again, but as a character such as an old woman or a reporter might. our therapist dedicated to the secondary school e. Together think of some questions that would extend the information originally given. service and the Youth Offending Team. f. Now person B tells their story, and the procedure is repeated. Louisa Waters is Principal speech and language g. When everyone has told their story try to remember Person A’s story. therapist, Children’s Therapy Team, Medway h. The outcome should demonstrate that, if the clients really focus on other people’s Community Healthcare. news or biographies, they can remember and use them to form part of a conversation. The point can also be made that, if the story is remembered, it can be referred to at a later date, showing interest and therefore possibly helping to build a friendship. WRITING PROBLEMS Benjamin Writer-Messy / Jake Monkey-Tail Priya Desai Learning Cycle Ltd Every cloud ISBN 978-0-9565247-0-6 / 978-0-9565247-1-3 “This activity has two main purposes: lateral thinking practice, and how to be optimistic. £5.99 / £6.99 Clients who are working on idiom will also learn the meaning of the expression ‘Every cloud has a silver lining’.” Hard work to hold attention Both these beautifully illustrated books MATERIALS feature characters who have writing problems. • List of problems Benjamin Writer-Messy’s handwriting is • Paper and pens illegible and Jake Monkey-Tail cannot spell. IN PRACTICE Writing and spelling difficulties, perhaps even Write a problem at the top of the page, such as “Amy broke her ankle but…”. more than poor reading, can seriously affect Now, as a group, brainstorm some positive points about such a situation. These could be: confidence, self-esteem and motivation. she found that her true friends rallied round to help her; she found out different ways of Ms Desai, a speech and language therapist, doing things (like bouncing down the stairs on her bottom, and drinking her tea beside aims to encourage children to identify with the kettle rather than carry it to her table); she learnt to use crutches, and in so doing her the characters in her stories. Both Benjamin arms got stronger; people wrote funny things on her plaster; she was given lots of flowers. and Jake, with the help of a little magic, win through to conquer their difficulties and gain Other hypothetical problems and positive points might include: praise and respect. Both books also touch on • There was a power cut (but - we ate by candlelight; we had a log fire; we teamed up the need for hard work and practice. with others and had a bonfire; we saved a bit on electricity). I am not sure whether the stories are intended • We missed the train (but - while waiting we took the opportunity to have a coffee in for children with language impairment. Some the station café; we caught a later one which was a through train; we spent another of my own young clients (aged 7-9) enjoyed day on holiday). Benjamin Writer-Messy but I had to work hard • Our car broke down (but - at last we were able to benefit from all those years of paying to hold their attention. Jake Monkey-Tail proved in to the RAC; two of us could go and get everyone an ice cream; it made us decide too long and its language too advanced for this to buy a new car; it made us decide to sell the car and use public transport instead). particular group. As the stories are concerned • Faith failed her driving test (but - she was able to have a bit more practice before with writing and spelling, I consulted an driving alone so was a safer driver in the end; she didn’t need her own car yet; so could occupational therapist and a teacher. We all save on petrol money; one less driver means a bit less pollution; she shared a lift with felt that, as motivating tales, both stories could someone who became a friend). be valuable as a resource for pupils needing When you have tackled some hypothetical situations you might feel that the group is a multidisciplinary approach to literacy. They able to look at some actual problems of their own. It’s best to stick to fairly light problems would be less useful in a community clinic. that will pass in time rather than examining deeper difficulties. Zohra Jibb is a specialist speech and language therapist with NHS Lothian.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 15 REVIEWS reviews

compared. The sound is described together a young boy. This is a useful insight into a live DYSLEXIA AND BILINGUALISM with a photograph, diagram, ultrasound image intensive interaction session. Reading and Dyslexia in Different Orthographies and EPG frame. Older children and adults The DVD gives a powerful demonstration of Nicola Brunswick, Sine McDougall and Paul de would find the photo and diagram useful. intensive interaction which cannot be done Mornay Davies (eds) Unless they have experience of EPG, the frames as easily or clearly in a book. It will definitely Psychology Press are quite difficult to explain. encourage the watcher to put these ideas ISBN 978-1-84169-712-3 £39.95 So, useful to brush up on exactly how a sound into practice and will be extremely useful for is produced and possibly for training other therapists and teachers / support staff working Not a quick reference professionals, although we found day-to-day with children or adults with autism whose This account of current research on reading and clinical application more limited. communication is severely impaired. It would dyslexia in different languages is a theoretical Sarah Braithwaite is a speech and language also be a useful tool when training others or read. Although stated as being suitable for therapist with Language Resource Provisions for explaining intensive interaction. teachers, my teaching colleague found the NHS Tower Hamlets. Karen Large is a speech and language therapist technical language ‘a bit much’ and preferred with Hertfordshire Community Healthcare the summary I provided. Nevertheless, I look Services, working with children and young forward to sharing the information with my AUTISM people with learning difficulties. educational psychology colleagues. Autism and the Edges of the Known World – As a specific language impairment therapist Sensitivities, Language and Constructed Reality working bilingually I found the information Olga Bogdashina COMMUNICATION DISORDERS interesting and informative. It was pleasing Jessica Kingsley Perspectives on Individual Differences to read literature with regards to the Welsh ISBN 978-1-84905-042-5 £13.99 Affecting Therapeutic Change in language. Although I would refer to the book Communication Disorders again, I found I needed time to process the Theoretical insight Amy Weiss information and it could not be used as a quick This book gives an interesting and theoretical Psychology Press reference during a busy day. In the current insight into different sensory experiences of ISBN 978-1-84872-887-5 £40.00 climate a hardback book is quite expensive individuals with autism spectrum disorder. The when unlikely to be used on a regular basis and key points are about the difficulties individuals Summarises the research more suited to specialist clinical areas. have with ‘filtering’ stimuli, and how this leads The thirteen chapters written by different Lowri Jones is a specialist speech and language to sensory deprivation. authors focus mainly on research and therapist in specific language impairment The author links in experiences of individuals interventions for children with a range of working in bilingual (Welsh/English) mainstream with autism to reinforce the key points and communication disorders including specific primary schools for Betsi Cadwaladr University help make the information more accessible. language impairment, speech disorders, Health Board, North Wales. It is not quick to read, and will not provide literacy difficulties, bilingual clients, autistic you with practical ideas or easily accessible spectrum disorder, cochlear impants and cleft SPEECH SOUNDS information you could give to families. palate. Each chapter summarises the research Speech Sounds – A Pictorial Guide to Typical However it would be a good book if you want and evidence for intervention in these areas and Atypical Speech to look at theories behind sensory difficulties and how individual differences in clients ISBN 978-1-59756-106-8 £57.00 in autism. impact on success or failure in therapy. Seeing Speech – A Quick Guide to Speech Sounds Fiona Alexander is a speech and language The book is not easy to read and does not really ISBN 978-1-59756-322-2 £26.00 therapist with NHS Greater Glasgow & Clyde. tell us anything new. It was however useful as Sharynne McLeod and Sadanand Singh a reminder of evidence based practice, and Plural in arguing the importance of considering INTENSIVE INTERACTION differences in clients (such as personality types, Useful to brush up Autism and Intensive Interaction – Using social competency and family environment) body language to reach children on the as well as the clinician’s experience when This is two resources – a reference book and a autistic spectrum smaller flip book. deciding on therapy approaches. DVD It is expensive for what it offers, but may be Reference book: Phoebe Caldwell with Matt Houghton and useful as a departmental reference. Each English sound is described and pictured in Penny Myton Alison Muir is a speech and language therapist a photograph, schematic diagram, ultrasound Jessica Kingsley working with children with complex additional image and EPG (electropalatography) frame. ISBN 978-1-84905-088-3 £19.99 support needs in Stirling. The sequence of producing the sound, in a range of word positions, is discussed, as Powerful demonstration is the intra- and inter- speaker variability of Part 1 of this practical DVD is a discussion on DYSPRAXIA each sound. This varies in detail considerably, the significance of sensory information in Understanding Dyspraxia – A guide for sometimes covering a range of client groups young people with autism. This is backed up parents and teachers and languages. This detailed book would be by footage of Phoebe working with a number Maureen Boon useful for students, for clinicians building a of students and using their body language Jessica Kingsley clear picture of a target sound and therapists to begin to open channels of interaction and ISBN 9781849050692 £12.99 working with children with complex speech communication. Part 2 raises the issues of the sound disorders. appropriateness of touch when working with Jargon-free language Flip book: young people. I found this particularly useful as I reviewed this book myself and sought Each sound is represented on each side of some of the interactions observed use quite an comments from two sets of parents. the divided pages. Each side can be ‘flipped’ intimate level of contact. Part 3 is non edited The jargon-free language made the book independently so any two sounds can be video footage of a complete intervention with very concise and easy to read and the clearly

16 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 REVIEWS

defined chapters make it easy to find particular With 39 contributors from across the globe, it information. presents a wide range of interventions. Each EVIDENCE-BASED PRACTICE Embedding Evidence-Based Practice As a basic grade therapist I found it extremely is allocated its own chapter (which follows the in Speech and Language Therapy - interesting and informative, however it may same structure to enable critical comparison) International Examples be of limited benefit to specialists. Some of and the evidence base is considered in great Hazel Roddam and Jemma Skeat (eds) the excellent practical ideas are of more use to detail. It is well worth reading the introduction, Wiley-Blackwell physiotherapists and occupational therapists. and there are summary charts detailing the main ISBN 978-0-470-74329-4 £29.99 The descriptive case studies throughout were components of each intervention. Old favourites a particular highlight to both myself and the such as minimal pair, metaphonological and parents. Information is split into age groups, psycholinguistic intervention are included, A valuable resource which the parents felt was useful as they could along with newer ones such as family-friendly This book is the product of a UK / Australian go to specific sections. and complexity intervention. collaboration with worldwide contributors The book is excellent value for money but, as In an accompanying DVD, contributing including the editors. The 34 short chapters, the title says, is more targeted at parents and authors demonstrate key components for organised into six sections, clearly take the teachers than speech and language therapists. most interventions, generally bringing them reader from understanding what evidence- Lynsey McDowell is a community paediatric to life (who would have thought non-linear based practice is, through many salient therapist in Newry, Northern Ireland. phonology could prompt me to get the aspects of its application, to future directions. dressing up box out?) Overall, the reader One section includes chapters focusing on is provided with sufficient information to everyday and more unusual client groups WORKING WITH FAMILIES select appropriate intervention for individual and contexts, such as those with psychogenic Working with Families in Speech-Language children, and to try out new ones. dysphonia or in an adult stroke unit as well Pathology This detailed reference book for students and as prosody therapy, stroke dysphagia and Nicole Watts Pappas & Sharynne McLeod clinicians is a ‘must buy’ for any paediatric bilingual dysfluency in children. Plural speech and language therapy department. Although scholarly, it is mainly written ISBN 978-1-59756-241-6 £38.00 Oonagh Reilly is a Senior Lecturer at Birmingham by clinicians for clinicians. Because of the City University and Honorary speech and importance and immediate relevance of the A ‘one stop shop’ language therapist in South Staffs PCT. topic to current clinical practice as well as the This book links research to clinical practice transferable methods described, this book with studies of parents’ perceptions of their would be a valuable resource for a wide range involvement in their child’s intervention. RESEARCH of readers – students, newly qualified therapists, It explores families’ relationships with the Ethnographic Fieldwork - A Beginner’s Guide lecturers, experienced therapists and managers. therapist to inform us of the most effective Jan Blommaert & Jie Dong Linda Armstrong is a speech and language ways of interacting with and involving parents. Multilingual matters therapist working with adults in the Perth It is useful in all contexts of children’s speech ISBN 978-1-84769-294-8 £14.95 and Kinross community who have acquired and language therapy and for all ages and communication and/or swallowing disorders. stages of careers - as a student textbook, as an introduction for less experienced therapists to A wider perspective truly working ‘with’ families and as a refresher This title would not normally attract my ASPERGER SYNDROME Aspergirls – Empowering Females with of good practice. eye, and it received a few face pulls from Asperger Syndrome The style of this well-written book is informative colleagues. First impressions were not good Rudy Simone and accessible and its evidence base is strong. and the explanation of ethnography was quite Jessica Kingsley The research and practice is balanced and difficult to digest. However, once I waded ISBN 978-1-84905-826-1 £12.99 representative of work in the US, UK, Canada through the initial (short) chapters, I could see and Australia. the applicability to clinical practice. This book may appear quite expensive, Those embarking on research would find it Accessible and touching however its relevance, accessibility, resource useful as it gives a wider perspective of data In the accessible and relevant ‘Aspergirls’, Rudy base and evidence make it a one stop shop for collection: “... the target of scientific method is Simone takes the reader through the stages of therapists working in any context with children simplification and reduction of complexity ... life from childhood to old age, looking at issues and their families. ethnography is precisely the opposite”. It gives such as the Aspergirl’s ‘meltdowns’, ‘stims’ Helen Daly is service manager in Wakefield. a methodology on the sequence of collecting (self-stimulatory behaviour), literal thinking, and analysing ethnographical data, as reality socialising and sexuality. It is written in a is “kaleidoscopic, complex, complicated and touching, often humorous and very practical SPEECH SOUND DISORDERS often a patchwork of overlapping activities”. style, effectively providing a life manual Interventions for Speech Sound Disorders Language, communication and culture do for females with Asperger Syndrome. The in Children not occur in a vacuum, hence the importance anecdotes from Aspergirls she has interviewed A. Lynn Williams, Sharynne McLeod, Rebecca J. of a structured observation of the context in broaden the reader’s insight into what it must McCauley which they occur. be like to live with this syndrome. At the end Paul H. Brookes Although not necessarily a clinical companion, of each chapter Simone sums up key points for ISBN 978-1-59857-018-2 £62.50 it gives a view on how to look at the bigger her Aspergirl readers and their parents. Whilst picture and delve into individual narratives this can at times feel repetitive, we would A ‘must buy’ and stories, so as clinicians we may construct anticipate it being a helpful strategy for her This excellent book achieves its aim of our own learning process. target audience. “describing, analysing and exposing readers to Gwenan Roberts is a consultant speech Liz Phippen and Charmian Hewson-Ekornrød a broad spectrum of intervention approaches and language therapist in Conwy with Betsi are speech and language therapists working for for all types of child speech sound disorders.” Cadwaladr University Health Board. Symbol UK at Penn School, Buckinghamshire.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 17 journal club

READ THIS SERIES IF YOU WANT TO Journal club 3: yy BE MORE EVIDENCE- BASED IN YOUR systematic reviews PRACTICE yy FEEL MOTIVATED TO READ JOURNAL Jennifer Reid’s series aims to help you access the speech and language ARTICLES therapy literature, assess its credibility and decide how to act on your yy INFLUENCE THE findings. Each instalment takes the mystery out of critically appraising a DEVELOPMENT OF YOUR different type of journal article. Here, she looks at systematic reviews. SERVICE

www.francartoons.co.uk

here has been an explosion of literature very foreign to the uninitiated – my advice results of primary research studies. It can be relevant to speech and language therapy is to persevere, because well-conducted used for systematic reviews with or without Tover the course of my working life. An systematic reviews on areas of current meta-analysis (when the reviewers attempt to article which reviews the current state of concern for speech and language therapy combine the numerical results from various play in a relevant area may appeal to time- services are invaluable. In Fife, we have found studies). These methods are at the top level of pressed clinicians. Can we expect a review to appraising systematic reviews in our journal the ‘evidence hierarchy’, so authors often use be more comprehensive than an article on a clubs really helpful (even if they do nip your the actual terms, ‘systematic review’ or ‘meta- single piece of research? Should it avoid the head to begin with!) analysis’, in the title of the article. need to comb the literature for articles on The results of a systematic review rely original research? And may we assume that not only on the quantity and quality of the the scope of the review will be better than we primary studies included but also on how could do ourselves, the reviewers being more my advice is to persevere well the review and synthesis was conducted. knowledgeable than us? Well, the answer is However, a well-conducted systematic review probably both yes and no. because well-conducted should provide more definitive evidence than Reviews may indeed provide a ready-made systematic reviews on any other type of study, even if the results synthesis of the available research but they too relate only to a circumscribed area. are open to that enemy of science, bias. This areas of current concern The tool can also be used for other types of fact, along with the huge expansion, particularly review but, for a non-systematic or narrative in the medical literature, has led to the for speech and language review, you may wish to use selectively this development of a new type of review method. therapy services are and the ‘Expert Opinion’ tool presented in the The sorts of reviews many of us grew up with, first article in this series (Reid, 2010). As with like those presented in textbooks, have been invaluable other critical appraisal tools, the main themes reclassified variously as ‘overviews’, ‘narrative to be addressed revolve around the study reviews’, or simply ‘non-systematic reviews’. results, their validity (how ‘true’ they are) The systematic review has become one of and to what extent, if any, they might apply the core tools of evidence-based practice. If The critical appraisal tool for speech and to the appraiser’s own context. As previously, you can get your head round its principles and language therapists presented here has been magazine subscribers may download a methods, you will find you are much better developed primarily from CASP (PHRU, 2006). formatted version of the appraisal tool at www. equipped to deal with the current literature. It provides a structured framework for reading speechmag.com/Members/CASLT to use on The landscape of a systematic review may feel and appraising reports which summarise the their own or with colleagues in a journal club.

18 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 journal club

Question 1: or exclusion of particular designs. As you read Like other aspects of evidence-based What question was being asked, and is this an more systematic reviews, you will begin to get practice, appraisal ‘points’ are scored by important clinical question? a better feel for this. playing the game by the rules: systematic The prestigious Cochrane Collaboration reviews should provide an exhaustive (www.cochrane.org), along with other summary of the literature relevant to the authorities on evidence-based medicine, question in hand, so reviewers are expected will try to convince you that a respectable to have tried to identify all sources of review of an intervention should include evidence including those that are in the ‘grey’ only randomised controlled trials (RCTs). This literature (such as dissertations, unpublished may well be an attainable goal for medical studies or articles in obscure publications.) treatments. However, in many areas of For appraising exhaustiveness, the relevant speech and language therapy practice, the questions to ask are: only available evidence comes from small • Did they follow up reference lists? scale, exploratory studies. Moreover, the UK • Did they make personal contact with Medical Research Council’s Framework for experts? Development and Evaluation of RCTs for • Did they search for unpublished studies? Complex Interventions to Improve Health • Did they search for non-English-language Try formulating the reviewers’ stated aims into (2000) advocates the use of small-scale and studies? a research question if they have not done so exploratory designs in the early phases If they did, they will mention it, because explicitly in the article. Is the question clearly of development of evidence-informed they know this earns them credit towards focused in terms of the PICO framework, which interventions. publication in respected, peer-reviewed we discussed in the first article of the series Those engaged in systematic reviews may journals! If they failed to do so, is there a (Reid, 2010): need to take into account the level of maturity danger their review has been seriously • Population studied of the field of research before deciding where compromised? Hmm, I leave you to form your • Intervention given (if it is an intervention study) to draw the line. Inclusion criteria set too high own opinion… • Control / comparison (if applicable) up the evidence hierarchy increase the danger • Outcomes considered? of arriving at the ‘nil’ result of, for example, a Question 4: Is this question important for your clinical Cochrane review of treatment for acquired Did the reviewers assess the quality of the practice? If the reviewers’ question does not dysarthria (Sellars et al., 2005) – it found no included studies? quite fit the bill, what question(s) do you wish studies met its inclusion criteria. This result may they had asked instead? be a trigger for future research in this area, but it is distinctly unhelpful for clinicians looking Question 2: for clues to potentially promising treatments, Did the review include the right type of study? and by default promotes the ‘expert opinion’ route with all its potential biases.

Question 3: Did the reviewers try to identify all relevant studies?

The main consideration is whether a clear, pre-determined strategy was used to decide which studies were included. Look for a set of defined categories that together form the definition of quality the reviewers have The article should present clear inclusion adopted, plus a scoring system – there may and/or exclusion criteria, so home into this Which bibliographic databases were used? If be a table of the included studies showing the section of the article to consider whether the you are not yet familiar with the nomenclature, points awarded against each quality criterion. included studies address the review’s question. consider whether more than one database These sorts of tables often interfere with the Sometimes the primary studies have been was searched. Beware reviews that use only readability of an article but you should try designed to answer a different question, so it one database source – the field of speech and not to skip them. They really are crucial to is important to check that a study’s inclusion in language therapy is so cross-disciplinary that it understanding the results of the review – the review is justified. is impossible to predict which journals contain and you may find that one or more primary Do the included studies have an appropriate potentially useful articles. For example, my studies are worth following up. study design? In my experience, those who default setting for rapid literature searching is to It is also important that more than one are new to critical appraisal or research design search simultaneously MEDLINE®, PsychINFO® assessor has been involved in rating and may be inclined to feel that the views of the and possibly ERIC (www.eric.ed.gov) if the scoring the studies. This provides evidence reviewers are more valid than their own. Deal question involves school-aged children. This that the quality system is objective and with any feelings of inadequacy by reading produces some duplicates but also many reliable enough to support the credibility of carefully the reviewers’ rationale for inclusion unique references from only one database. the results.

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2011 19 JOURNAL CLUB

Question 5: How are the results presented and what is the Figure 1 A reminder about Confidence Intervals main result? Confidence intervals allow you to estimate the strength of the evidence and whether itis definitive (in other words, you don’t need further studies to check the result). A single study gives you only one example of the difference between two measures, two groups etc. If you repeated the same study several times, you would not get exactly the same result each time. You can’t know what the ‘real’ difference is, especially from one study. Calculating a 90 per cent confidence interval around your result allows you to say that there is a 90 per cent chance that the ’true’ result lies within this range. If an author is interpreting the confidence interval appropriately, you should see comments about both the extent to which their results support their original hypothesis as well as whether any further studies need to be done. Confidence intervals which straddle zero suggest that there may be no real difference or that your study used too few participants for you to detect the effect definitively.

crucial concept here is the notion of effect size. ensured that other influences on performance (Don’t panic! I’m going to talk about numbers were controlled. Calculation of percentage of now but stay with me…) non-overlapping data may be used to combine Calculating an effect size is a method the results of small-scale studies for a systematic for quantifying the effectiveness of an review with meta-analysis. The two components of this question are intervention, allowing you to compare or Meta-analysis of more robust studies, such as stated in this order for a reason: how results are combine the results of different studies. RCTs, is more likely to be reported using a forest expressed can have an important influence on Numerical calculations are used to produce a plot (figure 3) or blobbogram‘ ’ (see the logo of what you perceive as the main result. number (a statistic!) so you can then compare the Cochrane Collaboration). These provide a You need to consider: like-with-like across different studies. You can visual display of the effect sizes associated with • whether the reviewers’ interpretation of think of it as similar to converting raw scores the included studies, the confidence intervals numbers was sensible to standard scores in formal assessments – it of their results, a summary effect size and • how the results are expressed (for example, allows you to compare a client’s performance confidence interval. The convention is for them odds ratio; means and confidence intervals in different areas of functioning, for example to include an identifier for each study on the (figure 1)) and receptive vocabulary vs. comprehension of left (in order of year of publication), and some • how large and how meaningful this size of sentences. The value of a ‘Cohen’s d’ or other scary statistics on the right – though if you can result is. statistic tells you about how big a change deal with them, you will find they answer the Some systematic reviews provide an has been found in the outcome measure for question about how results are expressed. assessment of quality followed by a verbal the intervention. Whether changes can be Weighting is about how much each study synthesis in the form of one or more attributed wholly to the intervention is a moot contributed to the overall summary measure conclusions, with an indication of the strength point, but in general the bigger the average – the bigger the blob, the more influential the of the current evidence for each. change – the effect size – the more likely we are study. One of our adult acquired journal clubs In terms of the main result, it can be to believe it was caused by the intervention. appraised a review of treatments for dysphagia instructive trying to sum up the ‘bottom-line’ A weak effect does not equate to no effect, in neurological disorders (Ashford et al., 2009). result of the review in one sentence – it does but it may not show up conclusively in some We found the heavy weighting of a couple of help when trying to communicate the gist study designs. To detect weak effects, you large Logemann studies a concern, because of your appraisal to others. And your clinical usually need lots of study participants. This the participants in the Logemann studies bottom-line will certainly be needed if your may be where a meta-analysis comes into were skewed towards people with Parkinson’s appraisal is to be combined with the appraisal its own, as combining the data from lots of Disease and dementia, with very small of other evidence in order to produce a clinical smaller studies of a relatively weak effect can numbers of people with stroke – very different, guideline or a ‘best practice’ standard, whether provide much more definitive evidence that we thought, from the Fife caseload profile. for your local context or for a wider audience. the intervention really does have an effect. You will come across different methods Question 7: Question 6: for analysing effect sizes. Percentage of non- Can the results be applied to the local If theSamantha results of thePaula studies have been overlapping data (PND) provides a means of population? combined, was it reasonable to do so? translating the results of individual studies into a common currency so you can evaluate them side-by-side. It can be applied to research designs that are lower down the evidence hierarchy, such as single-subject designs (also known as n=1 studies). In figure 2, can you work out which intervention had the stronger effect? For both studies, there is an area of overlap (see arrows) where the relatively high pre-intervention scores of some participants are the same as those of the people with the lowest post-intervention scores. However, this area of overlap is much smaller for intervention B, which translates into a stronger effect size and, numerically, to a larger percentage of non-overlapping data. Some systematic reviews go beyond qualitative For study B, we can be more confident that Clinical recommendations may be offered synthesis and present a meta-analysis of the the changes in participants’ performance was by reviewers, but without an accumulation quantitative data from included studies. One indeed treatment effects and/or that the design of robust, scientific evidence, these are often

20 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 JOURNAL CLUB

Figure 2 Effect size Figure 3 Forest plot example (fictional) Key Intervention A Intervention B pre- post- pre- post- Measure of effect, and Black et al., 1999 therefore weighting, Connor, 2002 in meta- analysis

Drake et al., 2005 Confidence interval Scores in the overlapping area could either be from pre- or from post-testing Elder et al., 2005 Line of no effect Foukes, 2009 Summary fairly circumspect. You need to address measure of Summary effect - lateral the usual considerations about potential spread shows differences between the population covered confidence by the review and your own, and whether your interval local setting is different from that of the review to the extent that its results cannot reasonably be applied. You also need to consider whether Consider whether any reported benefit how to design and deliver training effectively. the intervention is practical and acceptable to outweighs any risk and/or additional cost. If Of course, what we really need to know is how clients in your own setting. this information is not reported, can it be filled to bring about long-term, sustained change in in from elsewhere? staff behaviour, but unfortunately this study Question 8: did not speak to that question. SLTP Were all important outcomes considered? And finally... A good example of a clinically helpful review, in Jennifer Reid is a consultant speech and my opinion, was one we reviewed last year in an language therapist with NHS Fife, email adult learning disability journal club. The study [email protected]. (van Oorsouw et al., 2009) posed a question the group felt was extremely important for them, regarding which aspects of staff training are related to improvements in staff behaviour. References Ashford, J., McCabe, D.M.A., Wheeler-Hegland, The authors included single-subject and small K., Frymark, T., Mullen, R., Musson, N., Schooling, sample studies and found 55 studies that met T. & Smith Hammond, C. (2009) ‘Evidence-based their criteria, which provided relevant data systematic review: Oropharyngeal dysphagia from over 500 participants. Meta-analysis behavioral treatments. Part III - Impact of dysphagia (using percentage non-overlapping data) was treatments on populations with neurological applied to the data from all the participants. disorders’, Journal of Rehabilitation Research & The results suggested that a combination Development 46(2), pp.195-204. of in-service (using multiple techniques) Medical Research Council (2000) A Framework for You should try to think whether the reviewers with coaching-on-the-job (featuring verbal development and evaluation of RCTs for Complex have considered the outcomes of the review Interventions to Improve Health. Available at http:// feedback) is the most powerful format. from all angles, that is from the point of view www.mrc.ac.uk/Utilities/Documentrecord/index. Even though these results did not really of clients, families and carers, and the wider htm?d=MRC003372 (Accessed 18 February 2011.) add to what the group already believed, community, as well as speech and language Public Health Research Unit (2006) Critical Appraisal it is important for us to have evidence to therapists and other professionals, service Skills Programme. Available at: www.phru.nhs.uk/ support what we are currently doing as well Pages/PHD/CASP.htm (Accessed: 18 February 2011.) managers and policy makers. as information to help us break new ground. Reid, J. (2010) ‘Journal Club: expert opinion’, Speech & The journal club session helped the staff feel Language Therapy in Practice Autumn, pp.17-21. Question 9: more confident in their practice and gave them Sellars, C., Hughes, T. & Langthorne, P. (2005) ‘Speech Should policy or practice change as a result of ammunition for resisting pressure to undertake and language therapy for dysarthria due to non- the evidence contained in this review? staff training that was unlikely to be effective. progressive brain damage’, Cochrane Database of Systematic Reviews Issue 3. Art. No: CD002088. DOI: The study results were also of great interest 10.1002/14651858.CD002088.pub2. to paediatric and adult acquired staff. These van Oorsouw, W.M.W.J., Embregts, P.J.C.M., Bosman, days pretty much every speech and language A.M.T. & Jahoda, A. (2009) ‘Training staff serving therapist has to do staff training, whether this clients with intellectual disabilities: a meta-analysis is with health, education or social care staff, so of aspects determining effectiveness’, Research in this review also spoke to their concerns about Developmental Disabilities 30(3), pp. 503-511.

Critical appraisal for speech and language therapists (CASLT) Download the ‘systematic review’ framework document from www.speechmag.com/Members/CASLT. Use it yourself or with colleagues in a journal club, and let us know how you get on (email [email protected]).

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 21 RESOURCE REVIEWS Resource reviews EMPOWERING PARENTS Speech Quest When budgets are tight, www.speechquest.net (subscription pricing - see details in review) our in-depth reviews by practising speech and Well thought out, thorough and educational language therapists Speech Quest is an independent website devised by speech and language therapists. It aims to enable parents/carers to assess their child’s communication between 6 months and 5 years, and help you find affordable to provide them with a communication profile and a tailored programme which they can carry out resources that are right for independently at home. If any area shows significant difficulties, parents are clearly signposted to see their GP or health visitor for a referral to a speech and language therapist. In addition to the you and your clients. website, there are links to YouTube tutorials which talk through the whole process from completing the assessment to filling in activity record sheets. The website is generally easy to navigate, with an appealing layout. Once a parent or carer has registered, they complete a ‘free test questionnaire’, in fact, a series of detailed online questionnaires that are presented in two sections. The Foundation section EARLY YEARS examines ‘Attention and Listening’, ‘Play’ and ‘Interaction’ skills, while the Language section EYBIC (Early Years Based Information looks at ‘Understanding Talk’, ‘Talking’ and ‘Making Speech Sounds’. Results are expressed as a Carrying) Word pack percentage score, and a traffic light colour coding system is used, with red, amber and green Henrietta McLachlan & Liz Elks, illus. Livi Rowe to indicate whether (a) the child needs referral on (red – scoring less than 25 per cent); (b) Elklan child would benefit from recommended activities tailored to results and parents are therefore www.elklan.co.uk encouraged to purchase the full assessment (amber - 26-75 per cent) or (c) child is progressing £35.00 well but they can still purchase the assessment if they would like (green – over 75 per cent). It may be worth noting that the term ‘assessment’ across the Speech Quest website seems to refer to the assessment results, rather than any actual assessment (which takes the form of questionnaires). This terminology may be confusing for parents or professionals using the site. Useful and affordable The questionnaire is not exhaustive: for example, articulation difficulties are not covered in EYBIC consists of a book and CD. It aims great detail, so it may fail to highlight less salient difficulties such as a 4 year old with a lateralised to develop children’s communication and or dentalised production of /s/. However, the same section provides good general identification language skills. and support for those with developmental speech delay and appropriately flags up those with a Suitable for pre-school children with more profound phonological disorder. language delay, older children with more Parents/carers then have the option of (1) paying £7.95 to view the full assessment results, or significant language difficulties and children (2) paying a one-off fee for the more extensive assessment breakdown and targeted activities who are learning English as a second (currently £19.95 for access for a year, or £34.95 for unlimited access). The second option also gives language, the pack includes training sessions the opportunity of retesting and monitoring progress. It provides new activities as the old ones for parents and education staff. It empowers are completed, as well as the useful feature of being able to adapt activities if they are found to parents to reinforce ideas at home and helps be too difficult. Parents are given attractive, easy to navigate sheets of activities and game ideas, education staff to understand and apply the as well as forms to record progress each month, and these can also be downloaded and printed principles within the classroom. out. Tips and advice are given along the way, based on everyday routines, activities and resources. EYBIC provides: Parents/carers are also given the opportunity to ‘ask the therapist a question’ at the cost • A PowerPoint workshop presentation of £9.95. This could present a difficulty if more of an ongoing dialogue is required, perhaps • Teaching notes becoming expensive? However, it might give a specific answer to any concern that was not • Parent Information Booklet identified by the questionnaire. • Home activities pack with easy to follow Speech Quest could be a useful resource to bridge the gap between referral and intervention explanations for parents for parents whose child is on a lengthy waiting list, as well as for parents who are concerned • Record form for recording progress about their child’s development and considering referral. The website effectively targets • Black & white and colour printable resources language delayed children and those with simple speech delay, and provides simple activities for use in clinic. that can be carried out at home. It highlights the importance of sharing assessment results, All speech and language therapists with a recommendations and activities to all the child’s caregivers. Speech Quest consistently knowledge of Information Carrying Words emphasises the importance of the foundation stages of language and it encourages parents / could use this resource as a therapy tool and carers to consider all aspects of communication by ensuring that all parts of the questionnaire training package. Each component is clearly are completed before results are given. Whilst this may be frustrating if a parent is only set out and requires minimal preparation. concerned about one aspect, for example speech sounds, it ensures that these other important The home activities pack and teaching re- aspects are highlighted to parents who may not be aware of them. sources are user friendly with straightforward The cost of viewing the assessment results and/or activities and the level of questioning does instructions and easy to use materials. limit the clientele who can afford to and are able to access and utilise the site, particularly those EYBIC would be a useful and affordable with more than one child. However, the degree of advice and information provided in such resource for any paediatric speech and an interactive and user friendly manner offers good value for money. The website covers an language therapy department. impressive breadth of information, empowering the parent/carer to affect positive changes in their child. Speech Quest is a well thought out, thorough and educational website which Julie Mackie and Kirsten Manson are paediatric provides appropriate signposting and functional, practical advice to its target client group. speech and language therapists at Glassgreen Centre, Elgin. Jo Cardy and Juliet Vale are speech and language therapists with Buckinghamshire Healthcare Trust.

22 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 resource reviews / TRAINING Opening doors LANGUAGE Talking Dice Starter Pack Using the results of her practice-based READ THIS IF YOU ISBN 1-84795-083-3 £25.52 + VAT research, Kit Clewley made a successful WANT TO MAKE Teacher’s Notes and Student Workbook • EFFICIENT USE OF 0-9550429-0-9 £14.99 + VAT case for carer communication training RESOURCES Linguascope groups to be provided as an essential • AN IMPACT www.talkingdice.co.uk ON REAL LIFE element of aphasia intervention. She COMMUNICATION A fun way to learn now finds a 3 stage model, which • ‘DISCHARGE’ Talking Dice is a practical resource which A BEGINNING aims to get children talking. It is targeted includes joint client / carer groups, offers RATHER THAN at children with English as an Additional the best outcome and use of resources. AN END Language, but could also be used with children on the speech and Language therapy caseload. ollowing his stroke, Mr Williams received function and well-being, they must be treated The resource is clear and easy to use 7 months of individual speech and alongside those with whom they communicate and, as most children enjoy playing with language therapy, focusing on dyspraxia, on a daily basis. At this point, evidence in dice, is a fun way to learn and practise F gesture, inconsistent yes / no, drawing and the literature suggested that untrained language structures in expressive speech. using a communication book. Despite this conversation partners can pose a barrier to The starter pack consists of 25 dice, each input, he used no communication strategies effective communication (Kagan et al., 2001). covering a different topic such as clothes, besides facial expression and intonation. In addition, research studies firmly established hobbies, countries, parts of the body. Each He relied on Mrs Williams to ask him yes / the value of training partners, usually on a 1:1 dice therefore has six pictures per topic and no questions, to which his answers were basis in the home setting. (Cunningham & more than one dice can be used at any time. inconsistent. He responded to his wife but Ward, 2003; Simmons et al., 1987). Accompanying the dice there is a did not tend to initiate communication Training carers on a 1:1 basis was not ‘Teachers’ Notes’ book and a ‘Student beyond his basic needs. Mrs Williams did considered feasible, as we had limited Workbook’. The workbook contains not encourage her husband to use any resources and such an approach would not 40 photocopiable sheets (copyright communication strategies and never used explore the potential benefits of peer support. permission must be applied for) and the any - such as drawing or gesture - herself. I therefore undertook a research project in teacher’s book explains how to use each She did use strategies to help Mr Williams’s 2005 which looked at the advantages of worksheet and expand it. Each worksheet comprehension but tended to rely on yes / no providing tailored communication training shows which dice to use for a particular questions and guessing to understand him. in a group setting to carers of clients who language structure. These include: use of Mr Williams attended a social club with well- presented with aphasia (Barber, 2006; 2007). why-because; opposites; question and known friends and hospital appointments, The research was supported by the then answers; comparing things; connecting but was not confident enough to leave the North East Wales NHS Trust, and carried out ideas; vocabulary; verbs and tenses. house for any other reason. in accordance with its Ethics requirements I found it very useful to look up in the This scenario will be a familiar frustration to and consent procedures. The project index what I wanted to work on with a child many of you, as will the question ‘what can we and have a game and worksheet provided. do about it?’ I think this resource would work well in In Wrexham and Flintshire we have for language groups where certain language several years offered communication therapy areas are being targeted. The Talking groups to people with aphasia. These were Dice website contains useful information based on the Supported Conversation for including E-Talking Dice, an interactive Adults with Aphasia approach (SCA) (Kagan et software version for school whiteboards. al., 1996 a; b) and provided the opportunity The worksheets encourage writing of to engage in functional communication. sentences. As a speech and language Clients tended to join at the point where they therapist I would be more interested in required consolidation of identified functional the verbal expression of the target, but in communication strategies. a school setting this dimension could be Although the clients improved in using utilised. Also there is only one worksheet their communication strategies in the group, for each target area so the therapist or we found they were not generalising into teaching staff need to use their imagination the home environment or other functional to expand the ideas. settings. Similarly, carers were not using the The resource is easily portable, value for Kit Clewley (nee Barber) (right) is a specialist communication strategies we advised them money and I would recommend it as a speech and language therapist at Maelor to try. Although this could be partly a result of useful tool, particularly in schools. Hospital in Wrexham, email kit.clewley@ limited liaison, we felt it was primarily due to the wales.nhs.uk. Technical instructors Jill Faith Lewis is a speech and language therapist carers needing ‘hands-on’ communication skills Roberts (left) and Berne Roberts (centre) are working in clinic and mainstream schools for training (Hoen et al., 1997; Rice et al., 1987). key members of the communication training NHS Leeds Community Healthcare. We recognised that the client cannot be programme team. seen in isolation. To achieve optimal return of

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2011 23 TRAINING demonstrated that improvements occurred Figure 1 The three stages not only in the carers’ interaction skills following the training, but also in the clients’. Stage 1 My conclusions were that: 1. Carer training should be available automatically alongside direct client intervention for those who need it. Carer communication training group Client communication strategies group 2. Training the partners of communication 10 week training programme comprising 10 weeks practising communication therapy group clients in a group format principles from SPPARC (Lock et al., 2001) strategies at a functional level benefits both carer and client and has the and SCA (Kagan et al., 1996 a; b; 2001) potential to reduce 1:1 and group therapy time. Feedback 3. Most carers, including those with longstanding experience of cerebral Stage 2 vascular accident, valued peer support highly. They indicated that the group reduced feelings of isolation, promoted Client and carer training consolidation problem-solving, helped them to group share experiences, and gave greater 10 week consolidation of carer understanding and the opportunity to communication with clients and carers learn from one another. working together 4. Speech and language therapists routinely advise carers how to achieve Feedback effective, natural interaction with their partners. However, for carers to modify Stage 3 communication strategies consistently, they also need designated, ongoing training sessions where they can practise in a supportive environment with their Client and carer functional goals group peers. Flexible number of weeks where clients These research recommendations were and carers work together to identify accepted by the Trust (now Betsi Cadwaladr and achieve functional goals before University Health Board). After discussion with discharge speech and language therapy management, we provided 10 weeks of communication Feedback training as set out in the research to five groups of carers over the period 2005-2009. The training incorporated handouts primarily Discharge 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 with moderate-severe dyspraxia. Most were training into practice. We asked them to therapy groups. Sessions included role- 6-11 months post onset, and one was 1 year use the training with their own partner and play exercises, personalised video analysis, 10 months post onset. with the other clients in the group. This gave feedback and discussion to provide the carers them the opportunity to use their skills in with as much hands-on experience and Stage 1 situations where knowledge could not be support as possible. Carer communication training group and client assumed. It also enabled them to observe communication strategies group how well their partner could communicate Five carers received weekly training of 1.5 when adequately supported by a peer rather Convinced hours for 10 weeks. (The sixth had to withdraw than a therapist or technical instructor. Although the carers and clients demonstrated two weeks before the start due to her partner 2. the clients began to accept that their improvements in their interaction skills, there being taken ill.) The training was revised slightly partners were changing long-standing was still a problem with generalisation into from the programme provided previously, but interaction patterns by implementing the the functional setting. The carers remained continued to be based on the SPPARC and SCA training. They were encouraged by their convinced that their partners required further approaches. This group was run by a speech partners to comply with requests to use speech and language therapy, despite the fact and language therapist, a technical instructor alternative communication strategies, that they now possessed the skills necessary to and a volunteer. rather than to expect their partners to support their partners to communicate well. At the same time as the carer training, engage in habitual interaction patterns They frequently expressed the opinion that the five clients attended a communication such as guessing the word. their partner communicated better with the strategies group where they worked on their The carers and clients were also expected to speech and language therapist and technical strategies at a functional level. This was run by carry out work at home between sessions to instructor, and would not communicate in the a technical instructor and a volunteer. help generalise the training and acceptance same way with them at home. of its usage outside the clinical setting. To address this, in September 2009 we Stage 2 This group took place each week for 1.5 devised and offered a 3-stage Communication Client and carer training consolidation group hours for 10 weeks. It was run by two technical Training Programme to a maximum of six In this group, the carers and clients worked instructors and two volunteers, one from clients and their carers (figure 1). All the clients together on the principles of SCA and SPPARC. the Association of Voluntary Organisations presented with moderate-severe receptive The principal aims were to ensure that: in Wrexham and the other from the and expressive aphasia, and five presented 1. the carers increased their confidence to put Communication Support Service. Both had

24 SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2011 training received the carer communication training. • making more comments versus asking completely. In future programmes we will The speech and language therapist attended questions give the carers greater control in carrying sessions at the beginning, middle and near the • no longer demanding the correct target out supported conversation techniques end of stage 2 to provide guidance and support from their partners earlier in stage 2 by reducing the amount of to the technical instructors. Attendance was • reducing test questions direct intervention provided by the technical variable due to bad weather and ill health. This • following their partner’s lead instructor at the outset. Client reluctance to resulted in three couples no longer attending • encouraging their partner to express an use communication strategies with partners by week 5, leaving only two couples to opinion. is however always likely to be a problem, and complete stage 2 and move on to stage 3. Feedback from partners following stage could be due to a number of factors including 1 indicated that they placed great value in personalities, expectations and relationships. Stage 3 seeing and hearing how others cope with The breaks between the stages will be Client and carer functional goals group similar conditions, not being alone and reduced given the length of the programme Here, clients and carers set functional goals to receiving useful hints. and the need to keep momentum and achieve up to and following discharge. They In feedback after stage 2, the carers thought motivation going. I propose to use a one week worked as a group to establish how these goals it was good to work with their own partner break in the next programme. could be met through a process of problem- but also with someone else’s. When asked if The videoed communication sessions had solving, suggestion and support. stage 2 had made a difference to the way they a tendency to turn into a therapeutic session We gave each couple a toolkit to provide communicate at home the answer was “Yes as opposed to a functional conversation. To them with the means to achieve functional completely”. Comments included: obtain as accurate a measure a possible of goals identified in the group and future • “We can discuss things better” natural interaction patterns, future videoed goals. The tools were specific to each couple. • “It gave me more confidence with him” sessions will be based on an activity such as They comprised supported conversation • “He does more using his communication those used in the communication strategies techniques, updated communication books, book. He writes more in his book and started group, which are more successful in terms of “I have difficulty communicating” cards and saying more words because of this.” achieving functional communication. practical tips derived from peer support. The carers felt there had been a complete This 1.5 hour weekly group only ran for change in their confidence levels when two weeks as there were only two remaining communicating with their partners: Stepping stone couples and their confidence to achieve the • “I am more relaxed” I invited the Communication Support Service set goals with the tools provided was high. • “I understand him more and we both don’t (CSS) organiser for the local area to the last The duration of stage 3 in future groups is get as frustrated as we used to do and he has session in stage 3. The larger CSS group based expected to be flexible, as factors such as a lot more confidence doing things himself.” in the community setting forms a natural number of members and confidence levels They also indicated that their partners had stepping stone from the safe, contained and are significant. enjoyed the group. One client was “at first not clinical environment of the communication The group at stage 3 was run by one sure but enjoyed the weekly group meetings training programme, and offers the clients the technical instructor and one volunteer due as the weeks went on. Also nice group of opportunity to maintain their communicative to the reduction in numbers. The speech people he made friends with.” strategies and increase their communicative and language therapist attended the first In future I propose to obtain feedback after confidence. Inviting the organiser worked well session to provide guidance and support all three stages, as shown in figure 1. as the clients were able to: to the technical instructors. There was a 1. ask questions about the group break of three weeks between each of the We have found that 2. meet the organiser, which made the idea of three stages, and the group members were attending for the first time less daunting discharged from the speech and language clients bond faster 3. support each other by agreeing to attend therapy service at the end of stage 3. if they are joining a together. Because they were present, the carers Goals and outcomes group which is already also improved their understanding of CSS Prior to stage 1, a technical instructor objectives. Carers do not usually attend the videoed clients and their partners having a established CSS group and therefore do not have the conversation at home. This procedure was same opportunities to maintain their skills repeated with the two remaining couples In stage 1, the carers bonded immediately in this setting. However, the CSS is planning following stage 2. Using principally the but the clients took four weeks before the introduction of supported conversation SPPARC approach, I analysed the interaction they began to interact with one another. groups in the local area and it may be possible patterns of the client and partner to: We expect this process to take longer for to work with them in developing these groups • establish communication goals for each the clients because of the level of aphasia. so that the carers are also included. couple However, we have found that clients bond Within the communication training pro- • set a baseline measurement more quickly if they are joining a group which gramme, clients and partners practise their • provide an outcome measure. is already established, as new members communication strategies and therefore build Improvements were clearly shown in see communication strategies being used communicative confidence in a supportive the interaction patterns of both the clients straightaway, and this encourages them to environment with their peers. We found that and the carers. The clients demonstrated use these strategies faster. In future it may be it engenders a sense of empowerment in both improvements with comprehension, yes possible to establish a client communication the client and partner enabling: / no confusion, and use of drawing and strategies group from which appropriate • the carer to reduce their protection of the writing to communicate. The carers showed members can access the communication client and increase their support improvements by: training programme. • the client to demonstrate their full • encouraging their partners to use In stage 2, “He won’t do it with me at home” communicative potential to the carer communication strategies versus guessing was still a common feeling beyond the mid- • the client and carer to improve acceptance the word point. We attempted to address this by of their new life context and how it can be • using these strategies themselves asking carers to work with different clients optimised • giving their partners more time to to improve confidence levels. Although this • both parties to open doors to functional life communicate worked well, it did not solve the problem 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, Stage 1 Stage 2 Stage 3 we are convinced that the communication training programme exhibits significant Carer group Client group Joint group benefits for client care and is cost-effective Potential no. 6 6 6 6 (figure 2). of clients Present arrangements require six clients and Staff 1 SLT 1 TI 2 TIs 2 TIs carers to trigger stage 1 for optimum use of resource 1 TI 1 Volunteer 2 Volunteers 2 Volunteers resources. There may be reduced participant 1 Volunteer SLT supervision SLT supervision numbers in stages 2 and 3, for example due to Figure 2 Staff resource ill health, but this can be offset by reducing the technical instructor resource in these later stages. We believe these findings demonstrate that between people with aphasia and their partners’, Kit Clewley (nee Barber) is a specialist speech Aphasiology 17 (8), pp.687-707. carer communication training is an essential and language therapist at Maelor Hospital in Hoen, B., Thelander, M. & Worsley, J. (1997) Wrexham, email [email protected]. consideration in aphasia intervention and ‘Improvement in psychological well-being of people should be provided as a matter of routine to with aphasia and their families: Evaluation of a those who require it. community-based programme’, Aphasiology 11(7), Mr and Mrs Williams agree. After the pp.681-691. Communication Training Programme, Kagan, A., Winckel, J. & Shumway, E. (1996a) REFLECTIONS Pictographic communication resources. North York, • DO I OFFER THERAPY Mrs Williams encouraged her husband Canada: Pat Arato Aphasia Centre. to use drawing, gesture, writing and a Kagan, A., Winckel, J. & Shumway, E. (1996b) IN THE CONTEXT OF communication book. She also used these Supported conversation for aphasic adults: Enhancing PEOPLE’S LIVES? strategies herself and Mr Williams successfully communicative access (Video). North York, Canada: used them with her support. He was also Pat Arato Aphasia Centre. • DO I HELP able to gesture and draw spontaneously on Kagan, A., Black, S.E., Duchan, J.F., Simmons- COMMUNICATION Mackie, N. & Square, P. (2001) ‘Training volunteers occasion. He still relied on Mrs Williams to as conversation partners using “Supported PARTNERS BREAK OUT lead the conversation but his participation Conversation for Adults with Aphasia” (SCA): A OF HABITUAL AND in it was greater. Mr and Mrs Williams’ goals Controlled Trial’, Journal of Speech, Language and on discharge included attending the CSS Hearing Research 44, pp.624-638. LIMITING PATTERNS OF group, planning a journey on a bus to visit Lock, S., Wilkinson, R. & Bryan, K. (2001) Supporting INTERACTION? nearby towns, and working towards returning Partners of People with Aphasia in Relationships & • DO I PRACTISE IN A to drive. Both indicated that they felt very Conversation (SPPARC). Milton Keynes: Speechmark. Rice, B., Paull, A. & Muller, D.J. (1987) ‘An evaluation WAY THAT PROMOTES positive about the future: “This is the start of of a social support group for spouses of aphasic the rest of our lives now.” SLTP partners’, Aphasiology 1(3), pp.247-256. INDEPENDENCE AND Simmons, N.N., Kearns, K.P. & Potechin, G. (1987) SELF-BELIEF? References ‘Treatment of Aphasia Through Family Member Barber, K. (2006) Pilot study to investigate the benefits Training’, in Brookshire, R. (ed.) Clinical Aphasiology of providing tailored communication training in a Conference Proceedings. Minneapolis, MI:BRK, How can you apply this article to your own group format to family members/partners of clients pp.106-115. who present with aphasia. Unpublished. practice? Let us know via Speech & Language Barber, K. (2007) ‘Group communication’, RCSLT Resource Therapy in Practice’s Critical Friends at www. Bulletin 660, pp.16-17. • The Communication Support Service is run by speechmag.com/About/Friends. Cunningham, R. & Ward, D. (2003) ‘Evaluation of the Stroke Association in a number of local areas a training programme to facilitate conversation across the UK, see www.stroke.org.uk

Brook has revised its sex education and The Contact a Family Directory summarisies personal development modular resource 430 disabilities and health conditions and Resources for young people with learning disabilities. details UK support groups. Available online The Frenchay Screening Tool for AAC is now Living Your Life, £120, www.brook.org.uk/shop and in print, tel. 020 7608 8700. available as a first step in assessment (£80). www.ennovations.co.uk/product_info. ‘Stuttering Stan Takes a Stand’ is now Messages from the National Literacy Trust’s php?cPath=42&products_id=228 available as a free flash-animated storybook. Face to Face project might help therapists www.mightybook.com/MightyBook_free/ to promote good communication between AuKids magazine for parents of children books/stuttering_stan/stuttering_stan.html parents and babies. with autism is co-edited by speech and www.literacytrust.org.uk/talk_to_your_ language therapist Tori Houghton. UEA (University of East Anglia) has updated baby/policy_research/2612 £10 for 4 quarterly issues, www.aukids.co.uk its undergraduate degree course profile. Interactive version of Avril Webster’s ‘Going www.uea.ac.uk/ahp/courses/bsc-speech- An online dungarees firm says a major part to the Hairdresser’ now free online. and-language-therapy of its client base is people with disabilities. www.offwego.ie www.dungarees-online.com The seven documents that make up the A website aimed at getting the public Language Support Model for Teachers The Meningitis Trust has posters and leaflets involved in clinical research. resource are freely accessible at to support its ‘Don’t wait for a rash’ campaign. http://www.peopleinresearch.org/ www.strath.ac.uk/humanities/ www.meningitis-trust.org speechlanguagetherapy/resources/lsm/ Scope has introduced Meeting Point, a Downloadable publications from the closed online forum for young disabled Reading for Life is the National Literacy disability campaigning network RADAR by people living in England and Wales. Trust’s social marketing campaign to reach and for people living with injury, ill health or www.scope.org.uk/help-and-information/ people who are least likely to read. disability cover work, money and IT. young-people/meeting-point www.readingforlife.org.uk/ www.radar.org.uk/doinglifedifferently/

26 SPEECH & LANGUAGE THERAPY IN PRACTICe SPRING 2011 boundary issues (4) Where work and home life meet Joe Reynolds considers the following scenario: You have just completed a house purchase. When you next visit the property, you recognise the family that has moved in to the house next door. They have a child with severe learning difficulties, and have made several complaints to the NHS body you work for about the speech and language therapy service you provide to the child... It hardly needs saying that buying a house service users themselves have strayed into and moving is a major life-event, in personal BOUNDARY ISSUES EXPLAINED personal comment in their complaints or in and emotional terms as well as practically and The Health Professions Council Standards local discussions. Occasionally there is no financially. Similarly, making a complaint - or of Conduct, Performance and Ethics (2008) prospect of restoring trust in the relationship, being complained about - can cause great require us to “behave with honesty and and the only option is to arrange for care to be anxiety for families and professionals, regardless integrity” at all times (p.14). We are reminded transferred to another therapist. In any case, it of whether the complaint is justified. This that “poor conduct outside of your is critical that therapists in this situation receive scenario brings together two stressful situations, professional life may still affect someone’s effective support from their manager and from where emotional responses can make it more confidence in you and your profession” (p.9). the other staff dealing with the complaint. difficult to maintain boundaries. Arguably, our clinical conversations and In the scenario we started with, there could The specific scenario where a new neighbour research literature do not focus sufficiently be many reasons why the family have pursued turns out to be a parent who has complained on moral principles, but they at least their dispute. Relations between the therapist about our clinical work may be rare. It is touch on the ethics around issues such as and the family may be quite open and however an extreme version of a much more prioritisation and evidence-based practice. positive, in which case the additional status as common experience. Though they may not In this new series we think through the sort new neighbours should not be problematic. A often be immediate neighbours, how often do of everyday events which – although they comprehensive complaints procedure should we and a service user and their family live in receive much less attention – also need to include whatever mediation and conciliation the same community, and come into contact be on our ethical radar screen. is needed to allow therapy to continue in in non-work settings? We could be members the future. Ideally, the complaint can be put of the same church, golf club, political party or little therapy time is provided to a particular behind us once it is resolved. amateur dramatics society. We could both be facility, or dissatisfaction with the model of Conversely, it may be difficult and parents of children attending the same school service provision. These matters are ultimately complicated to establish the new relationship or sports club. Or we could be colleagues in the about commissioning decisions at a strategic as neighbours, and for everyone to understand NHS or other services. level, and are not always amenable to simple that this is distinct from the relationship in In any of these cases, the challenge is to resolution by the therapist or their manager. the clinical setting. It may be necessary to maintain boundaries through clarity about Some complainants are also struggling with discuss the difference quite explicitly with the roles, while not damaging the therapeutic their own grief and bereavement over the parents. They also need to understand that our relationship. Professionals tend to be very disability of their family member, which can obligation to maintain confidentiality extends clear about this; away from work we are off- colour the way they voice their dissatisfaction. to off-duty hours, and that we would never duty, and not acting in a speech and language These instances need not have any comment on or discuss anything about our therapy role. Carers and service users often implications for continuing positive relations service users and internal NHS matters such understand this in a social context, but some between family and therapist, though it as complaints. This applies even when other find it difficult to avoid asking for speech is important to recognise if the complaint neighbours and our own family may be aware and language therapy advice or clarification. becomes an obstacle to progress in the that we are providing a clinical service to the It is essential to have ways to avoid getting therapeutic partnership. child in question. It would be regrettable if drawn into providing clinical advice in social In a smaller number of cases, the complaint the previous professional contacts were to and off-duty situations. At the same time, we is about the speech and language therapist’s prevent the establishment of neighbourly remain bound by professional obligations to assessment or management. Here there is relations, especially when these need not go preserve confidentiality and to maintain high some scope for the complaint to be handled beyond day-to-day practical matters. standards of personal conduct (HPC, 2008). informally by local action. Many such instances Where work and home life meet in a We are therefore never completely out of role. are settled through further discussion, review particularly complex and distressing way, it is Relations with neighbours may be cordial, meetings with other partners, or through a essential that our line manager is aware of the but they are not necessarily friends in the clinical second opinion. Service managers unusual pressures on professional boundaries. deeper sense. There are practical benefits to have to provide the right support to staff Non-managerial supervision from a suitably good neighbourly relations, to do with security, affected by complaints, as well as ensuring qualified and experienced person will also be local environmental problems or community that lessons are learnt if necessary, and that useful to make it easier to see the situation as networks, for example. But these can be quite complainants receive honest answers. The dispassionately as possible, and to continue consistent with clear boundaries, and most role of the Chief Executive in replying to effective care for the child. SLTP people are able to negotiate how far they want formal complaints adds a further pressure on to become closer friends with their neighbours. the people involved. Dr Joe Reynolds is a retired member of the Royal Boundaries can however become much These can be difficult processes for College of Speech & Language Therapists, email more complicated where there is a grievance therapists. It is vital to take a professional [email protected]. or dispute. approach, and to avoid personalising The substance of a complaint about NHS the disagreement. If we take the matter Reference Health Professions Council (2008) Standards of care can vary widely, and not all complaints are personally, it becomes difficult to return conduct, performance and ethics. Available at: http:// critical of clinicians or of service delivery. Many to the therapeutic partnership later on. www.hpc-uk.org/assets/documents/10002367FINAL are about waiting lists, waiting times, why so Particular problems arise where families or copyofSCPEJuly2008.pdf (Accessed: 26 January 2011).

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 27 how i How I get signing into practice (1):

It’s Signsational! READ THIS IF YOU WANT TO • PROMOTE TOTAL After completing training courses in signing, parents, carers and staff COMMUNICATION • DESIGN INTENSIVE may lack the confidence and skills to actually use the signs they have TRAINING FOR CLIENTS AND learnt. The speech and language therapy team for people with learning CARERS disabilities at Yourhealthcare describe the Signsational way they found • MAKE MORE USE OF MUSIC IN to address this. THERAPY

Deborah Denise Laura Nicky Radhika Roz Wendy

s a team of speech and language chatting and interaction. We wanted to users, booklets of signs and an accessible therapists working with adults with develop people’s enthusiasm, skills and story book. A speech and language therapist Alearning disabilities we constantly confidence to use signs in a natural way, and or assistant or students also made visits to the promote the use of signs in the everyday move people with basic signing skills on to homes before and after the group to conduct environment to support communication. being more confident and fluid. We adopted pre- and post-group measures. Despite a rolling programme of training a Total Communication approach, using The four days of the Signsational course encouraging people to use sign in the home photographs, and signing throughout. involved practical and fun activities with an environment, we were aware that many We circulated information to promote intensive approach to the use of signs (figure 1). parents and staff were coming away from Signsational, and invited referrals. We We used music to mark activities and provide signing courses having learnt the signs but considered anyone who used signing to structure. Every day the same piece of music was not the skills and confidence to put them into communicate, regardless of age or cognitive played at the beginning of an activity, for example use. We wanted to provide an effective way ability. Nine service users attended, each with ‘Everything stops for tea’ for the tea break and of overcoming the barriers and giving staff, a member of their family or care staff. The ‘Aquarium’ from ‘Carnival of the animals’ for the carers and family members the confidence participants ranged from a man in his mid 50s to relaxation activity. We used music throughout to to use signing as part of their everyday the youngest, a teenager. The most important provide mood and atmosphere and to engage communication with our service users. element for acceptance was commitment from the participants emotionally. Two of us had experience of working on staff / carers / family; we asked them to sign a We found music provided an opportunity intensive Kith and Kids 2:1 holiday projects with contract to attend for the whole week. for people to express themselves and interact children and adults with learning disabilities, The course was planned sufficiently in in a poignant way. There were many special and were impressed by the positive outcomes advance so that at least four of the six moments where groups members spontan- and success. This led to the idea of designing speech and language therapists and both eously expressed themselves through a an intensive signing course that included both our assistants could attend and facilitate. We performance of dance and movement. This has service users and their carers. also invited students from City and UCL to given us food for thought about the link between We chose a fun title that we hoped would join us as part of their placements, so it was a communication, music and movement. capture the spirit of the course. Signsational big, bubbly group! Other health professionals People began bringing in their favourite was a light-hearted and catchy name that we were also welcome to observe. music to play in break and lunch times. It thought would appeal to all participants. We Planning the activities was the most time in- created more opportunities and established chose a pleasant community facility in the tensive aspect of the project. We used a wide some common ground on which to form high street near to local amenities and shops range of activities previously developed in bonds and friendships. as the venue. other groups to facilitate skills such as turn tak- In terms of outcomes, the speech and We aimed to create an intensive signing / ing, anticipation, listening and participation. language therapy team observed throughout total communication focused environment The speech and language therapy assistants the Signsational week an increase in both that would illustrate to parents and carers gathered together and made resources includ- quantity and quality of signs (accuracy and how positively people respond to a signing ing costumes and props for the story activities, appropriateness) from the service users and environment, how successful and effective it materials for the craft sessions, refreshments, carers. There was also an increase in the level can be, and how easily it can be implemented music and sound effects compilation cds. of interaction and communication between in homes and day centres. It was important We prepared documentation such as an the service users, for example, initiating for us to demonstrate that signing is not just accessible information booklet for service communication, anticipation, turn taking and about giving instructions, but about everyday users, a contract for both carers and service participation in the activities. This is backed

28 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 how i

Figure 1 Structure of the week Key for figures 2-4:

DAY 1 An afternoon signing workshop for the people accompanying the service users. We taught pre-Signsational them a core vocabulary of signs in a functional and conversational way and covered the signs for the story telling activity. post-Signsational DAYS 2 - 5 10.00 Good morning activity. This provided an opportunity for sharing news and promoting conversational skills. 10.10-11.00 Morning signing activities: structured turn taking games and activities focusing on Figure 2 Number of signs observed specific topics for signs. Tea Break – opportunities to make choices, take responsibility for offering drinks and to sign in an informal, conversational way. 20 11.30–12.30 Community / practical activity. We recognised that for some of the carers using sign ‘out 15 and about’ was difficult, so this involved everyone going out into the community to shop for items to use in the following practical session. The practical sessions always linked in to the afternoon’s 10 story telling. An example was to buy decorations for party invitations, make the invitation to invite 5 another person from the group and then post the letter for the Friday afternoon party. of signs No. Lunch break – more opportunities to sign in an informal, conversational way and use signing in 0 the community. People were encouraged to go out and use the local cafés and shops. A B C D E 13.30–14.50 Afternoon story telling activity: A story was told over the four days – Alice in Service user Wonderland. This activity was based on Nicola Grove’s work where a story is told using a series of games and activities using a multi-sensory approach. 14.50-15.00 Relaxing time using a parachute, specific relaxing music and glowing balloons. Figure 3 Confidence using signs at home up by the change in pre- and post- measures This article was written by the speech and language 10 for clients’ use of sign (some are illustrated therapy team for people with learning disabilities 8 in figure 2) and carer’s reported confidence at Yourhealthcare. For further information on the 6 signing at home and ‘out and about’ following morning activities or copies of the Signsational their participation in Signsational (some accessible contract and information booklet 4 Deborah Denise Laura Nicky Radhika Roz Wendy shown in figure 3). Feedback from staff also and the general information pack for carers, 2 implies that service users and staff are signing contact Deborah Green (email deborah.green@ of confidence Level 0 more and can be more easily encouraged to yourhealthcare.org), Wendy Reed (email wendy. F G H I use signs when required: [email protected]) or Roz Angier (email Carers • “I didn’t know much about signing before [email protected]). the course but I learned a lot and feel very confident about signing now.” Acknowledgement • “It’s good she’s learnt signs otherwise she The PLD SLT team at Your healthcare would Figure 4 Confidence using signs out and about wouldn’t be able to communicate.” particularly like to thank Nicky Chibah – speech 10 and language therapy assistant extraordinaire • “Seeing other proficient signers makes me 8 realise how useful signing is and makes me – for her outstanding contribution to the want to learn it more...consistent signers Signsational project. 6 around her will help her learn.” Recommended reading 4 • [pre-Signsational] “Although I’d done the 2 Chadwick, D. and Joliffe, J. (2008) ‘A pilot 2 day course I still lacked confidence.” [post- investigation into the efficacy of a signing of confidence Level 0 Signsational] “Fabulous system to learn signs. training strategy for staff working with adults F G H I I’m more confident in working out signs on with intellectual disabilities’, British Journal of Carers bigger words.” Learning Disabilities 37(1), pp.34-42. • “Our service users are able to communicate Graves, J. (2000) ‘Vocabulary needs in better and are able to let us know what their augmentative and alternative communication: needs are by signing.” a sample of conversational topics between We have since run two further Signsational staff providing services to adults with learning REFLECTIONS ON GROUPS courses for service users and their carers difficulties and their service users’,British Journal • DO I PUT THOUGHT in November 2009 and May 2010 and held of Learning Disabilities 28(3), pp.113-119. Christmas parties in both 2009 and 2010 Grove, N. & Park, K. (1996) Odyssey Now. INTO CHOOSING AN to get together again and maintain the London. Jessica Kingsley Publishers. APPROPRIATE NAME? friendships that formed. Both courses have O’Callaghan, P. (2008) ‘Rise and sign’, Speech & • DO I MONITOR THE been as successful as the first, and had 100 Language Therapy in Practice Summer, pp.11-13. IMPACT USING SIMPLE per cent attendance. Powell, G. (1999) Current research findings Where there is a need we will continue to support the use of signs with adults PRE AND POST to support service users and their carers and children who have intellectual and MEASURES? for as long as possible to maintain a total communication difficulties. Available at:http:// • DO I FACTOR IN ENOUGH communication, signing environment. If www.makaton.org/research/powell99.htm you are considering this kind of approach, it (Accessed: 11 January 2011). TIME FOR PREPARATION? is worth noting that we have learned not to Volpato, D., Orton, D. & Blackburn, D. (1986) underestimate the amount of preparation ‘Making Progress with Makaton’, Nursing What difference has this article made time required each time to put on the Times 30 April, pp.33-35. Available at: http:// to you? Please see the information week. This is especially from the speech and www.makaton.org/research/research.htm about Speech & Language Therapy language therapy assistants, who are fantastic (Accessed: 11 January 2011). in Practice’s Critical Friends at www. at sourcing and making all the resources for speechmag.com/About/Friends, and the story groups. We clear their caseload Resource let us know. ahead of time so they can do it all! SLTP • www.kithandkids.org.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 29 COVER STORY: HOW I How I get signing into practice (2): Learning by teaching

As a Regional Makaton Tutor, Non Thwaite has a special interest in READ THIS IF YOU the transfer of training in the use of sign to everyday settings. Having WANT TO • EMPOWER CLIENTS discovered the potential of giving pupils the power to teach Makaton • MAKE TRAINING LESS INTIMIDATING to staff, Non carried out a promising Makaton peer tutor pilot project • IMPROVE with the support of an ‘Action Learning Set’ of other therapists, a clinical COMMUNICATION ENVIRONMENTS psychologist and a university lecturer.

ven though Makaton workshops are met with enthusiasm and receive great Efeedback, skills learnt aren’t always transferred to and used in the everyday settings of participants as much as they could be. Since qualifying as a Regional Makaton Tutor I’ve been exploring ways of addressing this, particularly at Ysgol Pendalar, a special needs school in Caernarfon, North Wales, because we are aiming for a Centre of Excellence Award from the Makaton Charity. To obtain – then keep - the award, a high standard of signing and symbol use by all staff has to be achieved. This would be a strong incentive for the school to maintain excellent standards of Makaton use, thereby having a positive impact on the communication environment for the pupils. I sent a questionnaire to school staff at Ysgol Pendalar to find out what helped and hindered them to use Makaton. One trend was that staff felt less confident signing in the presence of professionals such as me, and more confident when they were with children who signed. This set me thinking - why not reverse things and allow the children to adopt the role of a Makaton tutor? I set up a mini project in 2008 to introduce signing to fringe members of staff. I asked for volunteers amongst the older pupils to teach some basic Makaton signs to the taxi drivers and escorts whilst they waited for the school doors to open at the end of the day. I didn’t formally evaluate this, but could see the pupils and taxi staff enjoyed themselves. It seemed Cover photo of (l-r) Ashlee, Non and Jieu by Steve Ford, www.stephenfordphotgraphy.co.uk an effective way of introducing signing, and less intimidating than if I had done it myself. I had also been inspired by Tamsin Although there is research supporting the use Analysis course at Bangor University. This Crothers of 1Voice when she spoke about the of peer tutoring in mainstream and special group provided me with support and importance of AAC users having role models needs schools, I haven’t been able to find any encouragement to develop my ideas into a (Claxton & Crothers, 2007). I started thinking that specifically looks at AAC. pilot project. that, if some older pupils acted as peer tutors I discussed my ideas with my line manager If it hadn’t been for the group I probably to younger pupils, they could possibly teach who facilitated a meeting with Steve would have set up the project quickly and consolidate new skills, act as positive role Noone, Clinical Psychologist. Following this without much thought about formalising models, and maybe even encourage staff to an Action Learning Set was established data collection and evaluation. Too often I sign more. whose membership consisted of speech think that we as therapists have great ideas Topping (2005) states the benefits of peer and language therapists from the Learning that, with some reins, thinking and planning, tutoring are well documented and reciprocal; Disability Team, Steve Noone and Dr Carl could be developed into valuable evaluation this effect is described as ‘learning by teaching’. Hughes, Co-Director of the Applied Behaviour projects. The group helped me think in a

30 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 COVER STORY: HOW I

Figure 1 Number of times Jieu signed spontaneously while looking through the book

Pre intervention Immediately post 1 month post 2 months post intervention intervention intervention

2 22 18 20

more systematic way and took the mystery days. The sessions took place on beanbags confirm that signs which represent attractive out of research. I realised it doesn’t have to be in the reading room of Jieu’s classroom, a or motivating items are often picked up and complex - in fact, they encouraged me to slim quiet and familiar place. The sessions were used quicker. things down. I learnt that if the project was to videotaped by the classroom assistant and No significant effects were seen on the throw out more questions than it answered, lasted about ten minutes. Jieu sat on my knee multiple probe assessment when post and pre this would only be a good thing. I remember and, although I didn’t take an active part in intervention data was compared. However, being surprised when some completed the storytelling, I prompted Ashlee when she whilst watching the video clips, I observed questionnaires were labelled as “really made a very occasional mistake and praised many positive changes. It became apparent good data”. On discussion, I realised what and encouraged both Ashlee and Jieu. that the quality and accuracy of Jieu’s signs a fortunate position we are in as practising I looked at the effect of the intervention on for ‘look’ and ‘biscuit’ improved as the sessions clinicians. We have a rich source of data at our Jieu in several ways: went on. This is a very positive effect as it will fingertips and, because of the relationship we make Jieu’s communication easier for others have with school staff, it’s not a problem to Baseline Data to understand. Jieu communicated in a multi obtain it. 1. Multiple Probe testing a few weeks before modal way during the session, sometimes intervention and immediately before pointing to symbols then signing them, intervention: and quite often vocalising or saying close Creative • Asking Jieu to imitate my signs (can you approximations to words as he signed. As I enjoy creative writing I decided to write a do this?) Questionnaires from teaching staff short story that the peer tutor could read and • Asking Jieu to sign to a verbal command completed seven months post intervention sign to the younger pupil. I devised a simple (can you sign ‘biscuit’?) were positive. Jieu’s teacher felt that he had story about a mischievous teddy and dolly. The • Testing his comprehension of the signs benefited by learning new signs which he language was at a one to three key word level. (Where’s the biscuit?) still uses, thus suggesting that Jieu had I selected functional vocabulary that would • Testing his expressive signing in response generalised what he had learnt during the be useful in the everyday life of the classroom, to a visual prompt (show him a picture of storytelling sessions to other environments. I including teddy, dolly, sand, biscuit, yes, no, a biscuit / actual biscuit and ask ‘What’s asked staff if they would do anything different more, eat, look and bye. The left page included this?’) in future as a result of the project. Responses the script of the story along with matching 2. I asked Jieu’s teacher to keep data included a suggestion to leave a copy of the symbols on Velcro strips. The right hand page regarding the signs he used (spontaneous story book in class so that Jieu could become had a cartoon picture to match what was being and imitated) before intervention a peer tutor himself to other members of his said and signed. 3. I looked at the story book with Jieu to see class, and a new story book to develop the Teachers from the primary and secondary if / what he would spontaneously sign project further. areas identified Ashlee and Jieu as suitable before the intervention One teacher responded that he was going to candidates. Ashlee attends the Older Unit make more of an effort to use Makaton to aid where she receives her education as well Data collection during intervention pupils’ comprehension and communication as work experience opportunities. She is 1. Video of each of the five sessions skills. Another member of staff said she had a sociable young woman who has well 2. Jieu’s teacher to keep data on the signs learnt that repetition of a signed story was an developed expressive language, excellent used throughout the day during the effective way of teaching new signs. memory, well developed literacy skills and intervention period. Effects on self-esteem can be hard to a good level of comprehension of spoken quantify, but observations and comments language. Jieu is in the youngest class of the Data collection after intervention suggest that taking part in the project had a school. He expresses himself mostly with 1. Multiple Probe Testing repeated positive effect on the peer tutor’s self-esteem signs, symbols, some vocalisations / words 2. Teacher to continue to keep data and confidence. Both teachers reported and body language. He enjoys looking at 3. Looked at the story with Jieu to see that Ashlee’s self confidence had grown as a books, making jigsaws and singing, especially if / what he spontaneously signed result of being a peer tutor. On the first day, the Bob the Builder theme. Both Ashlee and immediately after the last session, and Ashlee was noticeably shy, walking down the Jieu’s parents gave written consent for their then a few months post intervention. corridor with tense shoulders. By day five, she children to be involved. skipped. Ashlee said that reading the story to The first part of the project involved Pre intervention, Jieu only signed twice Jieu made her feel good and happy and that teaching the story to Ashlee, the peer tutor, whilst looking at the story. Post intervention, her mum was proud of her. until she was fluent at reading and signing Jieu signed up to 22 times whilst looking Both Jieu and Ashlee seemed to enjoy the story. We met three times and followed at the book, and this effect seemed to be the sessions and the staff questionnaires a ‘Model, Teach, Test’ style of teaching. I maintained over time (figure 1). confirmed that they thought this too. Both modelled the story (Model) then we read According to Jieu’s teacher he also received a ‘star of the week’ badge in assembly and signed through the story together generalised some of the signs (such as ‘sand’) for their involvement in the project. Video clips (Teach) and then Ashlee read and signed the to the classroom setting. Of the ten signs used were shown during school assembly to share story by herself (Test). This gave a definite, in the story, Jieu signed seven of them, with their success with the rest of the school. predictable and safe shape to our sessions ‘sand’ and ‘biscuit’ being signed the most. The project had a nice ripple effect. More and was an effective way for her to learn. Interestingly, in one of the pre intervention than one teacher said to Ashlee that they Once Ashlee was fluent, we arranged for her assessments, Jieu was very interested in were impressed with and proud of her. One to read the story to Jieu once a day over five obtaining the sand and biscuit. This seems to day, on the way back to class after a session, a

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2011 31 COVER STORY: HOW I

teacher from another class asked Ashlee what e. encouraging school staff to repeat similar Acknowledgements she had been up to - and Ashlee walked in ideas and to make more of an effort to use I’d like to thank the many people who’ve been and spontaneously read and signed the story Makaton signing involved in this project: Gwenan Roberts and to that whole class. The teacher was amazed f. developing ideas within the school the learning disabilities speech and language that Ashlee knew all she did, and actually regarding integrating peer tutoring into therapy team for their support as well as learnt a few signs from watching her. the curriculum members of the Action Learning Set including Whilst teaching the story to Ashlee we both g. gathering evidence to help Ysgol Pendalar Steve Noone and Carl Hughes; Pete Jones who looked back at the video of our sessions. This gain a Centre of Excellence award drew the gorgeous cartoons to go with the worked as a powerful reinforcer for Ashlee as h. giving me huge job satisfaction! story; Val Jones, speech and language therapy I was able to point out the positive bits where assistant, for all the laminating and Velcro she did really well. So far three students from the Applied work; Wendi Evans (Assistant Head, Makaton Jieu also taught some signs to Ashlee, for Behaviour Analysis (ABA) Masters at Bangor Co-ordinator, Local Makaton Tutor and Jieu’s example from Old MacDonald, so the learning University have used my project as a basis for teacher); Clare (Jieu’s classroom assistant and was two-way. their research thesis. I’ve been involved with brilliant camera woman during the project); I hypothesised that Jieu would learn new the planning and procedure aspects of their Geraint Roberts (Ashlee’s classroom teacher) signs from Ashlee but I hadn’t considered that research, giving advice on clinical aspects and Ieuan Roberts (Headmaster) for all their he would take any notice of the sentence strips such as using Talking Mats as a measure of support, generous time and for allowing me and symbols included in the story book as a self-esteem with the peer tutors, and how to the opportunity to do the project at Ysgol prompt and reading support for Ashlee. Jieu pitch language. One aspect I advised on was Pendalar. I’d also like to thank Ashlee and Jieu’s was really interested in these, tearing off the involving the peer tutors’ classroom assistants parents for consenting to their involvement. Velcroed sentence strips, and often pointing rather than the ABA students in teaching the My biggest thanks go to Ashlee and Jieu, who to symbols above words before signing them. story book to the peer tutors. I wanted school were brilliant, taught me a lot, and whose This shows the potential positive effect on company I enjoyed very much. literacy skills. I think he was interested in I wanted school staff being able to physically handle the sentence References strips by tearing them off. to be empowered to Claxton, K. & Crothers, T. (2007) ‘Role Models: Who Needs ‘em?’, Communication Matters run similar sessions 21(1), pp. 2-4. Available at: http://www. Impact on behaviour independently in the communicationmatters.org.uk/page/cmj- The videos captured a clear link between 2007 (Accessed: 18 January 2011). language levels / visuals and behaviour. When future and also to make Hooper, H. & Walker, M. (2002) ‘Makaton peer I tested Jieu on his ability to sign to verbal tutoring evaluation: 10 years on’, British Journal command ‘can you sign biscuit?’ he withdrew sure that the whole of Learning Disabilities 30(1), pp.38-42(5). and became agitated. He was much more school was an integral Topping, K.J. (2005) ‘Trends in Peer Learning’, involved when the tests were visually supported Educational Psychology, 25(6), pp.631-645. (with signs and or symbols). I felt uncomfortable part of the research using verbal commands alone to communicate Resources with Jieu as it wasn’t fair on him, therefore staff to be empowered to run similar sessions • ABA Masters, Bangor - www.bangor.ac.uk/ discontinued this aspect of the multiple probe independently in the future and also to make psychology/postgraduate/masters/aba.php assessment. This type of video clip would be sure that the whole school was an integral • Action Learning Sets – see www. useful during training as an example to show part of the research. Research has shown that, actionlearningsets.com/php/news.php?id=4 that how we communicate has an impact where peer tutoring schemes using Makaton • ASDAN - www.asdan.org.uk/ on someone’s level of comprehension and, have been set up, they were only maintained • Makaton - www.makaton.org/ consequently, their behaviour. in establishments where a facilitator remained • 1Voice - www.1voice.info/ I also sent out a brief questionnaire to Jieu (Hooper & Walker, 2002). I therefore felt it was • Talking Mats - www.talkingmats.com/ and Ashlee’s parents asking them for feedback. imperative to have school staff as facilitators. Jieu’s parents wrote, “The project did help The project has been expanded and Jieu a lot to do Makaton signs. He’s been includes a number of peer tutors and tutees REFLECTIONS using them at home. He’s so brilliant at it. Well as well as a control group. Initial results • DO I APPRECIATE HOW done and thank you very much for your help.” appear positive and the students are writing Ashlee’s parents wrote, “Ashlee really enjoyed up their theses. From chatting to some of MUCH DATA IS POTENTIALLY the project and enjoyed the responsibility - it the peer tutors they seem very proud of the AVAILABLE TO ME THROUGH made her feel really grown up!” work they’ve done and are keen to do more. CLIENTS AND COLLEAGUES? The teacher of the secondary age pupils is A classroom assistant asked me when the considering including this peer tutoring work next story book would be coming out, so it’s • DO I LOOK FOR SUPPORT TO as part of the ASDAN accreditation scheme in good to know that this is an approach that TRY OUT NEW IDEAS MORE the future. generates enthusiasm amongst both pupils SYSTEMATICALLY? The peer tutoring project had many positive and staff. • DO I MAKE USE OF MY effects including I would encourage therapists to liaise and a. developing the frequency and accuracy of set up links with their local university. There OTHER TALENTS AND the tutee’s ability to sign whilst looking at is much to be learnt and - similar to peer HOBBIES IN MY WORK? a story book, with anecdotal evidence of tutoring - it’s not a one sided relationship as, generalisation to everyday situations during meetings, it felt as though the learning b. providing the tutee with a role model who occurring was reciprocal. SLTP Would you like to comment on the impact uses Makaton signing this article has had on you? See the c. an increase in the peer tutors’ self-esteem Non Thwaite is a Highly Specialist Speech and information about Speech & Language and confidence Language Therapist with Betsi Cadwaladr Therapy in Practice’s Critical Friends at www. d. an opportunity to show Makaton in action University Health Board, and a Regional Makaton speechmag.com/About/Friends. and its benefits to the whole school Tutor, email [email protected].

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1. THE ADVISER NETWORK 5. ORGANISATION SYSTEM Questions posed to RCSLT advisers are often Being an RCSLT Adviser can be very hit and sent out to all the advisers for the relevant miss. At times there will be weeks on end area. This means if I don’t know the answer to a with no contact from RCSLT, but at others query, or have nothing to add to the discussion, the queries and requests to participate come someone else invariably will. The adviser lead in thick and fast. It’s at these busier times in in RCSLT also monitors all responses (which particular that a system for organising the must be copied in to her) so that no query gets requests proves invaluable. forgotten. This is an extra backup to ensure My own preference is to make use of my that every individual remembers to respond Gmail account. I’ve set it up to incorporate a to everything they wish to, and that no person series of labels. These indicate whether items posing a query is left without an answer. require action, are waiting for someone else The advisers’ responses are often sent only to or are being kept purely for reference (both the person who posed the question, but I find short and long-term). There is also a specific it much more useful when responses are sent label indicating those items which relate to to all. If I haven’t given a reply myself, I often my adviser role. With Gmail allowing me to learn a lot from the response of others and, add multiple labels to each email, I can easily where I have been able to help, others may see when there are items which require my have a different viewpoint, which again I can attention, while keeping my inbox clear for learn from. new emails arriving. In addition, with Gmail difficult to achieve, such as those requiring automatically storing emails back and forth on 2. EMAIL regular travel to meetings. the same subject as a ‘conversation’, I have an For me, all adviser work is carried out via In terms of my own flexibility, I need to easy to follow reference source for each query email. When I first signed up, I chose not be able to respond well to the variations in I deal with. At regular intervals, each adviser is to provide phone or postal contact details, workload of the adviser role. I’ve also learnt asked to provide a breakdown of their recent mainly because I carry out the adviser work that I have a great resource of personal adviser activity and the Gmail system with its in my own time from home. As a result, email knowledge and experience, much of which is labelled emails allows me to pick out quickly is the key part of my toolkit. But it isn’t just a transferable. This enables me to give a useful the relevant items for this report. case of wanting to keep my phone number response to some queries that lie outside my private. Email has revolutionised the way immediate area of work. 6. COLLEAGUES we communicate, enabling therapists from It is just as important as an adviser to know anywhere in the UK to send a query which 4. RESEARCH TOOLS when you can’t be of help as to know when can be in the inbox of specialists around the Even the best adviser cannot have all you can, and it would be unrealistic to expect country within minutes. This allows for a more information about a given subject at their to answer every query. However, over the considered response while maintaining a fast fingertips. Although advisers need a strong years, I have built up a fantastic network of turnaround, without the pressure to answer basis of knowledge and experience in their colleagues in many specialisms. When I’m instantly which is inherent in a phone call. If chosen area, they also need to know how to unable to answer a query, it’s often a case of one or other party wishes to share items such research areas they may be less familiar with. ‘but I know someone who can’. as documentation, papers or references, these For me, research ranges from a simple Being an RCSLT adviser isn’t for everyone, can be sent immediately rather than waiting Google search (usually when I have a strong and many therapists with a great degree for the post. Finally, the use of email allows for a idea of the answer already but want to check of specialist knowledge and experience record of the ‘conversation’ to be kept for future some facts) to a full scan of the databases. choose not to or are not able to take on that reference and as an aide memoire. The Dysphagia Resource Center (http:// commitment. However, the majority of my dysphagia.com/) is a searchable American contacts in that category are happy for me 3. FLEXIBILITY site with a wealth of information including to put them in touch with someone who has This particular attribute is important as much discussion boards (where users support one posted a query if I feel they can be of more in the person acting as an adviser as in the another with clinical issues), articles about help than I can. In this way, my colleague network itself. Due to the flexibility of RCSLT, particular disorders or technical terminology, network becomes a fantastic resource, I have been able to continue as an adviser and links to useful websites. It’s not the prettiest allowing me to introduce individuals who can during two lots of maternity leave, and have of websites and it’s important to remember assist one another but who may otherwise fitted the role around a fluctuating caseload that the information represents the personal have never got in touch. when working. I am able to do as much or as view of the individual who has posted it, but I am also lucky enough to be a member little as I wish to fit the time I have available, there are some pearls of wisdom to be found. of an active local dysphagia support group. and there is no pressure to do more than I feel Databases, my favourite being MEDLINE, This helps to keep me focused on recent comfortable with. The flexibility of the role allow for detailed searching of everything developments in the world of dysphagia, and allows me to tailor it to my own circumstances, that’s been published about a particular topic. challenges my thinking in areas which I may choosing between the different aspects of the Once you learn to search a database properly otherwise take for granted. remit. This can include replying to individual (something most hospital libraries should be queries, sitting on working parties, responding able to teach you if you don’t already know), Members of RCSLT can find out more about to the media or commenting on future you can find everything from the oldest becoming an adviser at www.rcslt.org/ publications. I have been able to elect not to published works to cutting edge research in members/advisers/intro. take part in certain activities which would be your chosen subject.