ISSN 1368-2105 WINTER

http://wwwspeechmagcom Competency in head and neck When is good enough? Long-term care Training with SOAP Collaborating for Communication Clinics and schools Out of the frying pan... How I augment AAC My top resources Music in therapy Evidence And introducing ‘Winning Ways’ based practice: a climbing frame not a cage

ONWARDS AND UPWARDS READEROFFERSREADEROFFERSREADEROFFERSREADEROFFERS WINTER 03 speechmag Peter & In need of inspiration? Doing a literature review? The Cat Looking to update your practice? No scary wolf for Peter this time, but still a story to capture the interest of young Or simply wanting to locate an article you school-aged children. Black Sheep Press is read recently? offering copies of this narrative re-tell Our cumulative index facility is there to help. assessment to THREE lucky Speech & Language Therapy in Practice readers - FREE! The speechmag website enables you to: Peter and the Cat can be used with children from 5 to 9 years, pri- marily those with language delay / disorder, but also for more View the contents pages of the last four general screening. The task is not norm-referenced, but gives a issues descriptive profile of the child’s development of key narrative Search the cumulative index for abstracts of competencies which can be linked directly to intervention goals. previous articles by author name and subject For your chance to win, send your name and address to Speech & Language Therapy in Practice - P&C offer, Alan Henson, Black Order a copy of a back article online. Sheep Press, 67 Middleton, Cowling, Keighley, W. Yorks BD22 0DQ Plus by 25th January. The winners will be notified by 1st February, and The editor has selected some previous articles you are asked to let Black Sheep Press know what they think of the might particularly want to look at if you liked the arti- resource. Peter & the Cat consists of an A5 booklet illustrating the story in 9 cles in the Winter 03 issue of Speech & Language full colour pictures, an instruction booklet and photocopiable Therapy in Practice. If you don’t have previous issues of cards for transcription and analysis. It is available from Black the magazine, check out the abstracts on this website Sheep Press, see www.blacksheep-epress.com, or telephone 01535 and take advantage of our new article ordering service. 631346 for a free catalogue. New! Conference report The CPLOL / RCSLT conference on evidence based prac- tice left Frances Harris (p.20) wanting to continue to climb; read editor Avril Nicoll’s report on the web. Win TROG If you liked... Wendy Prevezer, see (176) Finlay, C.: Be brave and sing up!, (177) Bruce, H.: A healing force, (178) Magee, W.: Creating opportunities. All from Winter 2001, How I use music in therapy. Linda Armstrong & Alison Bain, look at (160) Talbot, K. & Stinchcombe, J. (Autumn 2001) A question of taste. Lorna Gamberini, what about (084) Robinson, F. (Autumn 1999) Setting the standard, or (162) Harris, C. (Autumn 2001) Ahead-and-neck of the field.

Jo Middlemiss, you might be interested in (031) Is your TROG a bit dog-eared? Not to worry, Shewell, C. (Summer 1998) The Counsellor as Travelling author Dorothy Bishop also felt it was Companion. time for an update, and has revised and Karen Heins, check out (174) Rinaldi, W. (Winter 2001) extended the format to include: Access all areas. • All new items • New national UK norms Alyson Portch, try (128) Millard, S., Cook, F. & Fry, J. • Upward age extension (Autumn 2000) Homebase - but not DIY. • More scope for qualitative How I augment AAC, consider (pre-dates abstracts) analysis Cameron, C. & Murphy, J. (Human Communication, 5 • List of TROG research studies with different client groups. (2), 1996) Skill sharing - training in the use of low tech The Test for Reception of Grammar - Version 2 normally retails communication systems, or (pre-dates abstracts) Grist, at £147.77 (manual, stimulus book and 25 record forms) but the E., Davies, A. & Bradburn, J. (Human Communication, 5 Psychological Corporation is offering a FREE copy to a lucky (4), 1996) High spec, low tech. reader of Speech & Language Therapy in Practice. For your chance to win, simply write your name and address on a postcard with the title ‘TROG-2 Reader Offer’ and post to: Liz Also on the site - news about future issues, reprinted Akers, The Psychological Corporation, 32 Jamestown Road, articles from previous issues, links to other sites of London NW1 7BY. practical value and information about writing for the The Test for Reception of Grammar - Version 2 is available along magazine. Pay us a visit soon. with a free catalogue from The Psychological Corporation, tel. Remember - you can also subscribe 020 7424 4512, www.trog-2.co.uk. or renew online via a secure server! Karen Phillips was the lucky winner of Pip the puppet in the Autumn 03 issue, courtesy of LDA. Speechmark’s Basic Verbs colorcards go to Joanne Sheldon, Margaret Purcell, Joanna Hardman, Irene Dobbin and Ms www.speechmag.com Caulfield. Congratulations to you all! www.speechmag.com

WINTER 2003 Inside cover “Here’s one I made earlier” (publication date 24th November) Winter speechmag Alison Roberts continues to generate low-cost ISSN 1368-2105 Reader offers ideas for flexible therapy activities: Car logo Win TROG-2 and Peter & The Cat. pelmanism, ‘How I help people’ poster and Published by: Cooperation tin. Avril Nicoll 33 Kinnear Square News / Comment Laurencekirk Out of the frying pan into the AB30 1UL When is good enough? fire? Tel/fax 01561 377415 e-mail: “While there is a wealth of literature on the effects of “The combined effect of a therapist considering the [email protected] surgery and radiotherapy on the swallowing process, individual child’s speech and language need, who is there is relatively little about speech and language the main focus of intervention and the reason for Design & Production: Fiona Reid therapy intervention and even less on the level of the proposed intervention should enable therapists Fiona Reid Design expertise or experience on which that intervention to decide where it is best carried out.” Straitbraes Farm should be based.” Alyson Portch argues that, instead of pulling out of St. Cyrus Lorna Gamberini explores the concept of ‘sufficient’ clinics and concentrating on schools, we should be Montrose competency when working with people with dysphagia grilling ourselves about what combination is right Website design and associated with head and neck cancer. for each individual. maintenance: Nick Bowles Webcraft UK Ltd Further reading & Reviews www.webcraft.co.uk Child language, articulation, voice, head injury, Down’s Syndrome, learning disabilities, working Huntington’s disease. with education, early intervention, Printing: Manor Creative COVER STORY social communication, life skills, 7 & 8, Edison Road The need for SOAP multi-professional working and Eastbourne “‘Swallowing...... on a plate’ Evidence based practice: a word finding. East Sussex challenge for speech and BN23 6PT (O’Loughlin & Shanley, 1996) is an language therapists Australian dysphagia emails to the editor Editor: management (training) “The sound bite of the weekend goes Writing for people with dementia; Avril Nicoll RegMRCSLT programme designed for use in to Kath Williamson: ‘Evidence based raising awareness of DownsEd. practice should be a climbing frame Subscriptions and advertising: nursing homes so that, following and not a cage.’ I want to continue to Tel / fax 01561 377415 training, nursing home staff How I augment AAC climb.” would be able to provide basic “The many different types of ©Avril Nicoll 2003 Frances Harris dissects the assessment and management communication book meet different Contents of Speech & Language proceedings of CPLOL’s 5th European Therapy in Practice reflect the strategies for their patients.” Congress. needs. In an ideal environment, views of the individual authors When Linda Armstrong and people with communication and not necessarily the views of Alison Bain found out they were piloting the same difficulties can use not just one but as many as they the publisher. Publication of off-the-shelf package (SOAP), they were interested to find helpful.” (Sally Millar) advertisements is not an compare methods and results. Janet Scott on choosing a graphic symbol system, endorsement of the advertiser Sally Millar on communication books and Cheryl or product or service offered. Any contributions may also Collaborating for Communication Davies on AAC (alternative and augmentative appear on the magazine’s “Teaching assistants participated fully in the sessions by communication) service development. internet site. preparing materials, observing my demonstration of activities, then implementing the activities with the Back Cover My top resources children themselves, and taking notes on the children’s “Contrary to popular belief, even ‘musical’ people need abilities in the different tasks.” to practise. On my early morning walks I rehearse songs In the ‘Collaborating for Communication’ project, (internally, not usually out loud!) and make up or Karen Heins and colleagues found an efficient and adapt words, to the steady beat of my footsteps.” effective way of managing clients with speech and Wendy Prevezer brings her dual role of speech and language difficulties in mainstream schools. language therapist and musician to her work.

Winning Ways series () From caterpillar to butterfly In future issues... “People come to coaching because they want to make SURE START changes in their lives. If people just want to wander STORYTELLING round the mulberry bush a few times, only to be DYSARTHRIA DYSPHAGIA reassured that their problem really does have no ADOLESCENTS solution, then I’m not the coach for them.” CHILD VOICE Life Coach Jo Middlemiss believes that every COLLABORATION Cover picture by Paul Reid (posed by challenge has a solution and that, ultimately, the only model). See p.20 STUDENT TRAINING person you can change is yourself.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 news

From assumptions to hard evidence Chatter Let’s talk about sex The people behind a new national Stroke Rehabilitation Research Centre hope their work will provide the NHS with evidence that Matters Finding information and practical advice on stroke services are worth developing. Following the growing up, puberty and sex for disabled The Stroke Association is providing funding of £500,000 to the success of the young people is almost impossible, accord- University of Southampton where researchers will be focusing on long- 2003 ing to the UK wide charity for families with term recovery of movement. The effects of ‘mental rehearsal of activ- Chatterbox disabled children. ity’ and functional electrical stimulation will be examined, along with Challenge, Contact a Family has therefore joined forces the reasons for poor balance and frequent falls experienced by some organising chari- with the Arthrogryposis Group to produce a people following a stroke. Quality of life interviews with stroke sur- ty I CAN is bringing it back “bigger, better comprehensive, cartoon-illustrated pack vivors and carers will also inform therapy developments. and LOUDER” in 2004. containing a series of publications offering Head of the research Professor Ann Ashburn says, “There is a kind of This year’s event involved an estimated advice for the teenager, the parent, the accepted wisdom amongst therapists that certain things work. We 75,000 preschool children learning songs, social worker and the health professional. A think that we can do better for our patients and get things on a much nursery rhymes and stories. Sponsorship pack for teachers will follow. Areas covered more scientific footing. Instead of basing therapy on myths and from parents raised over £100,000 for include self-esteem, making and keeping assumptions, we need hard evidence about what works best so that children with speech, language and com- friends, personal relationships, body image, everyone who has had a stroke can reach their full potential.” She munication difficulties at I CAN’s Early sex and relationship education at school and concludes, “The aim ultimately is to benefit patients directly and to Years Centres. Encouraging nursery work- at home, and there are tips for young dis- ensure we are developing sound value for money therapies.” ers, teachers and other staff who work www.stroke.org.uk abled teenagers from their peers. with young children to register for the The pack, Growing up, sexuality and the young Art Works in Mental Health 2004 challenge, Chief Executive Gill disabled person, has been funded by the Following a period at London’s Royal College of Art, the Art Works Edelman says, “Chatterbox Challenge is a Department for Education and Skills and will in Mental Health exhibition is to tour Cardiff, Manchester, fun event with educational value that will be available from the end of January 2004, free Edinburgh and Birmingham. also raise awareness and vitally needed of charge to parents and professionals. The One hundred and twenty works were selected by a distinguished review funds to help us achieve our goals.” Arthrogryposis Group is a charity supporting panel from open submission including two and three dimensional pieces Chatterbox Challenge hotline, tel. 0870 families affected by multiple joint contractures. and creative writing. Organisers recognise that creative expression can 350 0095, or see www.ican.org.uk/chatter- Contact a Family freephone helpline 0808 help people to tolerate mental distress and increase understanding box for a free fundraising ‘ChatterPack’. 808 3555, e-mail [email protected]. about how important acceptance by other people is to recovery. On average, one in four people experiences a mental health prob- lem in the course of a year. Manager is “disheartened” Entries can be viewed on A speech and language therapy manager is “disheartened” that more than nine months www.artworksinmentalhealth.co.uk. of negotiation has failed to solve a Dysphasia Support Service funding crisis. On the move In the Autumn 03 issue, we reported on the campaign by volunteer and speech and lan- The Fragile X Society is now Talking Point at: guage therapy student Louise Walters to have cuts to the Dysphasia Support Service in The website developed as a ‘one- Rood End House Stockport reversed. Karen Davies, head of speech and language therapy in Trafford, says 6 Stortford Road that the situation across the north west of England is far more complex than Stroke stop shop’ for information and sup- Great Dunmow port relating to children with speech, Essex CM6 1DA Association volunteers have been led to believe, and that it is too simplistic to blame language and communication difficul- tel. 01371 875100 Trusts. She explains, “The Stroke Association told all the Trusts commissioning services in family phone line 01424 ties is reporting early success. 813147 the north west that the amount of money they were receiving was no longer sufficient Officially launched by Sophie Wessex www.fragilex.org.uk to cover the costs of running the service and maintaining the support from the Stroke on 8th September, Talking Point wel- Association charity. They therefore told the Trusts that, unless they increased the budget comes the involvement of parents and professionals in time-limited allocated to the Dysphasia Support Service by £10,000, their services would be cut.” online discussion groups. Topics have included ‘The new school year - Karen continues, “The £10,000 that is being requested is additional money. I am in the sharing concerns and solutions’ and ‘Enabling children with speech, unusual situation of holding the budget for the Trafford Dysphasia Support Service, language and communication difficulties to access the curriculum.’ To which means I can track back the funding provided by our Trust - and I can assure volun- contribute or read the postings you need to register as a user of the teers it has always been increased in line with inflation.” She says her concern is that it is website by supplying your e-mail and a password. not at all clear what the additional money is for and, at a time when most Trusts are Talking Point is a collaborative venture between I CAN, Afasic and struggling financially and juggling priorities, it seems reasonable to expect to influence the Royal College of Speech & Language Therapists, with finance the way a service is delivered or, at the very least, have detailed information about how from BT and Lloyds TSB Foundation for England and Wales. public money is being used. www.talkingpoint.org.uk Karen believes that, while reconfiguration of Trusts and regionalisation by the Stroke Association have contributed to the complexity of the situation, the Stroke Association Stroke progress criticised needs to show more commitment to working in partnership with the Trusts, and to rais- Health Which? has drawn attention to the poor progress on stroke ing funds by other means. She comments, “If the Stroke Association had match funded units being made in England and Wales. the original budget provided by my Trust we would have a Rolls Royce service. Sadly, The government has set a target for all people with a stroke to be treat- instead we have a reduced service, and many disheartened users and volunteers.” ed in stroke units by 2004. Scotland is now estimated to have between 60 and 70 per cent of the beds needed to provide people with a stroke unit place for their entire hospital stay, and a strategy requiring patients Team leaders to be admitted to a unit within 24 hours of hospital admission. In Clinical teams in England can now access a leadership programme aimed at developing England and Wales only 36 per cent of stroke patients are able to spend the leadership qualities of all team members to improve client care. any time in a stroke unit. Acting Editor Sue Freeman says, “The Participating teams will work with facilitators over a 12 month period using techniques Government must ensure that proper provision of acute stroke beds for such as action learning, patient stories, observations of care and 360 degree feedback. patients immediately following a stroke is addressed and equally it must The NHS Leadership Centre also recently held a conference to look at ways of increasing address the provision of rehabilitation beds for longer term recovery to diversity at a senior level, so that skilled leaders from ethnic communities are fairly rep- improve the UK’s unenviable record in survival after a stroke.” resented at all levels. The Consumers’ Association publishes Health Which? six times a Further information: The Clinical Teams Programme, NHS Leadership Centre, tel. 0207 647 year, tel. 0845 924 5000 for details. 3847 or e-mail [email protected].

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 news & comment

Help for self-harm Are you aware of levels of self-harm and suicide among adolescents, and would you know where to find help? The British Association for Counselling and Psychotherapy has launched a website for teachers in secondary schools as part of World Mental Health Day 2003 which focused on emotional and behavioural dis- orders of children and adolescents. The Association is concerned that there has been an increase of 75 per ...comment... cent in suicide by young men in 10 years, and that research suggests 1 in 17 adolescents may be self-harm- ing. As mental health problems in young people are a clear predictor of difficulties in adulthood, they have Onwards and upwards worked with teaching unions to provide a web resource Avril Nicoll where teachers can get more information and help. Editor www.bacp.co.uk/emotional Frances Harris (p.20) likes Kath Williamson’s description of evidence based practice as a climbing frame not a cage. Watching young children on a Bookstart update Kinnear Square climbing frame, you get a sense of the different ways speech and language A report from Bookstart Australia discusses how Laurencekirk speech pathologists are working in conjunction with therapists might approach evidence based practice: some attack fearlessly AB UL librarians and child health nurses to promote reading while others are wary and careful; some are methodical and purposeful, and and book sharing with very young children, and how it can help speech and language development. others imaginative and daring. tel/ansa/fax Meanwhile, Bookstart in the UK has rolled out The level of supervision a child needs on a climbing frame varies according to Booktouch nationwide through health visitors, parents their age and stage and the level of difficulty of the particular frame. and visual impairment teachers. www.booktrust.org.uk Younger children need the reassuring presence of an adult who can step in if email they get into difficulties. Lorna Gamberini (p.4) is clear that part of being Residential development avrilnicoll@speechmagcom A specialist college for disabled young people from competent as a therapist is knowing when we need help. Jo Middlemiss (p.14) throughout the UK has opened a purpose-built resi- would agree: a winner is someone who willingly shares what they do know dential development for its students. and acknowledges what they don’t. Life coaching can provide the support Campbell Court at Treloar College in Hampshire has seven new state-of-the-art studio flats to be used as part you need to make a climb, and I hope readers will benefit from the of the College’s Independence Training Programme. opportunity of working with a coach who is taking a particular interest in the High tech equipment in the open-plan one-bedroom challenges of our profession. flat enables the student to self-manage home activities such as cooking, washing, shopping and leisure. One day a familiar climbing frame can be a pirate ship, the next a jungle - but the structure itself remains the same. Karen Heins (p.11) has used this D/deaf forum principle to great effect when planning programmes for teaching assistants A forum under development in Somerset aims to give deaf and hard of hearing people a collective voice. to carry out. Linda Armstrong & Alison Bain (p.8) borrowed structure from a The D/deaf Forum will provide an opportunity for dysphagia management programme and applied it to their different people who have something in common to get together and share experiences, and to identify barri- situations - comparing and contrasting outcomes. ers and service improvements. Community Worker Our local park hasn’t held the same appeal since the roundabout was closed Claire Crowley also points out that such a group can off - reducing choice reduces opportunities for children to get what they provide ‘good practice’ information, for example if approached by a theatre for advice on improving their need at a particular time. Alyson Portch (p.16) cautions against going down facilities for deaf people. that road in speech and language therapy, believing we need to tailor a Bath & Wells Diocesan Council of D/deaf People, combination of clinic and school services to the needs of individuals. Phone/fax 01761 239272, minicom 01761 239273, e- mail [email protected]. I suspect the contributors to ‘How I augment AAC’ (p.23) would do rather well if they were asked to design a climbing frame, as the decision making Post-grad in Asperger syndrome process must be similar to introducing a graphic symbol system, a Professionals working in the field of autistic spectrum disorders now have the opportunity to study for a communication book or even a new service. It wouldn’t surprise me if Alison post-graduate certificate in Asperger syndrome. Roberts (p.15) - who surely missed her vocation as a Blue Peter presenter - The result of a collaboration between the National Autistic Society and Sheffield Hallam University, cours- could find a cheaper way of constructing it. And who better than Wendy es will be held in Leicester, Leeds and Cheltenham. Prevezer (back page) to devise a climbing song to help us on our way? Module 1 provides an introduction including social A climbing frame offers challenge, variety and social interaction. And, behaviour and skills and sensory and perceptual issues. Module 2 is a work-based independent study however many people are on it, there’s always room for more to go onwards unit. Speakers and advisors include Dr Tony Attwood and upwards. and Dr Simon Baron-Cohen. Further information and application forms from The National Autistic Society Training & Consultancy Department, tel. 0115 911 3363 or e-mail [email protected].

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 competencies

reflecting most caseloads, but to what extent does this prepare them to treat dysphagia in head and neck cancer patients? When is good In 1999 the RCSLT Education Committee Dysphagia Working Group published recommen- dations as to the necessary knowledge base and skills level for pre-registration, post-registration and advanced level dysphagia education. Figure 1 shows my interpretation of how this applies to patients with head and neck cancer. Figure 1 Expected competence No. of speech Level of Expected competence enough? and language training (dysphagia associated with therapists head and neck cancer) All Pre- Good knowledge of normal When does a speech and registration anatomy and physiology of the head and neck, language therapist have and of the normal swallow. All of those Post- Knowledge of the needs of ‘sufficient’ competency to working with registration clients with complex with manage a client whose adult dysphagia conditions. Relatively few Advanced Ability to manage clients difficulties fall outside the of those post- with complex conditions. working with registration remit of standard training? adults with dysphagia Lorna Gamberini explores While there is a wealth of literature on the this in relation to people effects of surgery and radiotherapy on the swal- lowing process, there is relatively little about with dysphagia associated speech and language therapy intervention and even less on the level of expertise or experience with head and neck on which that intervention should be based. The BAO-HNS Consensus Document (2000), for exam- cancer and finds that, as a ple, in its chapter on speech and swallowing reha- bilitation talks of team members having ‘suffi- profession, we have much cient’ post-qualification experience (as well as a to ponder. major clinical component in this field). The case example in figure 2 (p.5) shows why it is impor- ollowing the Calman-Hine Report’s tant that the therapist dealing with people with Read this standards for patient-centred deliv- head and neck cancer has knowledge of: if you are interested in ery of cancer services (1994), we have •how training and seen a shift in organisation and deliv- 1) Staging of tumours experience combine to ery, including centralisation to cancer The first time I encountered the staging classifica- improve competency centres or units. This allows patients tion of tumours (BAO-HNS, 2000) in medical •providing services to a to have access to multidisciplinary notes, it was a complete mystery. Although the large geographical area teams with knowledge, expertise and experience speech and language therapist is not involved in F the staging progress it is important •improving the journey in specific cancers. The downside from acute to is that patients may have to travel Post-registration to have a clear understanding of the community services considerable distances, especially implications in terms of the likely where there is a need for ongoing training should surgery and prognosis, and of the rehabilitation. give a therapist nature of cancer generally. Head and neck cancer patients often need to attend speech and the tools, but 2) Pre-operative counselling language therapy for communica- they may need The head and neck client group is tion and swallowing difficulties unique in that the patient is seen first- resulting from their treatments. to be applied a ly with a normal / functional (albeit Because of the distances involved, little differently diseased) swallowing process, before responsibility is often devolved to to this group than the sudden onset of dysphagia the local community therapist. brought about by surgery and / or All speech and language thera- to neurological radiotherapy and / or chemotherapy. pists working with adults with patients. Doyle (1999) states that pre-operative dysphagia are required to have counselling provides the single most post-graduate training. For the majority this is at important dimension in patient care, therefore a post-registration level, as relatively few go on to therapists working with this client group need to the Advanced level (RCSLT, 1999). It is likely that ensure they have the necessary skills. their training is largely neurologically based, Doyle (1999) talks about using the process of

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 competencies

Figure 2 Case example Pre-operatively Mary (64), retired, married pre-operative counselling for the therapist and A social drinker and ex-smoker. Year-long history sore throats (initial tonsil biopsy - patient to set common goals for rehabilitation. no significant abnormality) Logemann (1983) discusses the difficulty of initiating New investigations found therapy post-operatively with a patient who has - poorly differentiated squamous cell carcinoma been unprepared for the problems of swallowing. - a lesion within the left tonsillar fossa, extending anteriorly to the anterior pillar Although consent for surgery or radiotherapy is and floor of mouth, and posteriorly to the posterior tonsillar pillar obtained primarily by medical and surgical members - Classification: T2 N1 M0 of the team, the speech and language therapist has Combined clinic (ENT surgeon, maxillo-facial surgeon, oncologist, speech and an important role in ensuring that the patient is language therapist, head and neck nurse) fully aware of the consequences for speech and Consented to extensive surgery with adjuvant radiotherapy swallowing. Pre-operative counselling with speech and language therapist and head and neck nurse. Surgery 3) Tracheostomy tubes and their effect on left selective neck dissection: level I-III swallowing resection of tonsillar tumour, involving posterior pharyngeal wall and soft palate Knowledge of the needs of clients with tra- mandibulectomy cheostomy is included in the Dysphagia Working radical forearm free flap Group’s recommendations for inclusion in post- skin graft registration courses. Any patient who presents tracheostomy. with a compromised airway because of a head and neck tumour may require a tracheostomy Post-operatively (acute) (Ridley, 1999) Additionally, a tracheostomy may transferred to Intensive Treatment Unit with naso-gastric tube in situ, and cuffed no8 be performed as a temporary measure until soft Shiley tracheostomy tube. tissue swelling has resolved post-operatively. 24 hours: ENT ward on intravenous fluids, cuff deflated on tracheostomy tube (speech and language therapist contact for support; communicating effectively by writing and mouthing) 4) Swallowing assessment 2 days: naso-gastric feeds Skill in selection and interpretation of swallowing 4 days: tracheostomy tube removed by surgeon assessment procedures such as videofluoroscopy speech and language therapy assessment: left sided tongue weakness and loss of and FEES (Fiberoptic Endoscopic Evaluation of sensation to the left side of tongue, lip and jaw. Trial swallows with fluids triggered Swallowing) covers all client groups (RCSLT, effectively; no obvious pharyngeal stage problems but some pooling of fluid on the 1999b). Here, however, to interpret the results of left. Recommended trial of free fluids, with postural modification to aid transit of bolus. any assessment accurately, the therapist must 5 days: managing fluids well. Assessed on smooth, semi-solid consistency, some have a very good understanding of the nature of pocketing in the left sulcus, remedied by postural modification. Oral transit slow, but no cancer, of the structural changes that have taken pharyngeal stage problems. Naso-gastric tube removed; started on liquidised diet. place after surgery and of the effects of any con- 6 days: managing fluids well and tolerating liquidised diet comitant treatment (Ridley, 1999). 8 days: discharged home into care of local therapist. Post-operatively (community) 5) Management of swallowing problems Week 2: Coping with free fluids (including fortified drinks) and smooth semi-solids. Ability to use appropriate compensatory tech- Complying well with postural modifications. niques, exercises, positioning and change in consis- After clearance from the surgeon, range of motion exercises introduced. Reiterated advice tencies is a desired outcome of post-registration re- range of motion exercises, particularly in lessening build up of fibrotic training. Sullivan (1999) states that, for people with tissue and discussed possible deterioration in swallow during radiotherapy. head and neck cancer, therapy goals typically focus Week 3: Radiotherapy started, continuing with range of motion exercises, oral intake on compensation rather than long-term improve- increased substantially. ment of swallowing function. Post-registration Week 4: Tolerating radiotherapy. Some discomfort, but not interfering with oral intake. training should give a therapist the tools, but they Continuing exercises - managing without postural modification. may need to be applied a little differently to this Week 5: Struggling with range of motion exercises - very painful. Fluids easiest (relying group than to neurological patients. heavily on dietary supplements). After discussion with head and neck nurse and oncologist, prescribed Oromorph to help with pain and advised on strategies for coping 6) Multidisciplinary team working with dry mouth (xerostemia). Post-registration courses aim to give speech and Weeks 6/7: Mary rather disheartened. Very particular about appearance and, although language therapists knowledge of multidisciplinary oedema and suture lines as a result of the surgery tolerated, added disfigurement from team working. The therapist is very much a core radiotherapy skin changes is proving difficult. member of the team providing an integrated service Some difficulty triggering swallow, fibrotic tissue in tongue base. Losing weight as oral to people with head and neck cancer, and has an intake decreases. Candida and taste changes affecting appetite. Very tired from important role in raising awareness of swallowing radiotherapy. Reassured should see improvement in 2-3 weeks. Dietitian to contact again problems with the other team members. to advise about food choices. Week 8: Pain and oedema reduced. Candida cleared. Oral intake easier. Coping with 7) Radiotherapy and its effects xerostemia well. Feels able to start range of motion exercises again - encouraged. Any therapist working with this client group needs to Week 10: Less pain. Appetite returning, despite continuing taste changes. Swallow be aware of potential treatment induced swallowing triggering faster. Does not need postural modification. Mary trialling new textures herself problems, and prevention and therapy strategies. and feeling much more optimistic about returning to pre-operative diet. The speech and language therapist has the best Four months post-operatively: Good progress. Range of motion exercises regularly, rapidly knowledge of a patient’s swallowing status post- putting weight back on. Able to eat most foods, even if modified form. Xerostemia and operatively. She can therefore advise the team taste changes persist.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 competencies

Issues of

competence and asking for before the onset of radiotherapy or support do not quality, safe and effective treat- Acknowledgement chemotherapy as to any need for non-oral ment” (Calman & Hine, 1994)? I With thanks to Linda Slack, Macmillan speech and nutrition once the treatment effects are take account believe the answer is “possi- language therapist for North Cumbria who added to the effects of surgery. It is unlikely of factors such bly”. I cannot be more positive looked after Mary at the acute stage. that this specialised and highly important due to uncertainty over the knowledge would be included in general as Trust amount of support the thera- References training. boundaries, pist would receive. Issues of British Association of Otolaryngologists - Head geography competence and asking for sup- and Neck Surgeons (2000) Effective Head and 8) Body image port do not take account of fac- and politics Neck Management - Second Consensus Both head and neck cancer and the treat- tors such as Trust boundaries, Document. ments for it can affect an individual’s geography and politics, which Burgess, L. (1994) Facing the reality of head and appearance. Burgess (1994) includes not only phys- can hamper communication between therapists neck cancer. Nursing Standard 8 (23): 30-34. ical change but also change in bodily function or and the contact that is needed to provide appro- Calman, K. & Hine, D. (1995) A Policy Framework control of the body’s activities, and the speech and priate support. Harris (2001) describes a clinical for Commissioning Cancer Services. London: language therapist needs to have an awareness of liaison group set up to improve communication Department of Health. the possible psychological implications. between professionals, vital when patients are Doyle, P. (1999) Postlaryngectomy speech rehabil- travelling across Trusts. itation: contemporary considerations in clinical Writing about the background to the RCSLT At the acute stage, there should be support from care. Journal of Speech-Language Pathology and Competencies Project, Williamson (2000) states the other members of the multidisciplinary team, Audiology 23 (3): 109-115. that: “Although some skills and knowledge are whereas a community therapist may be working in Harris, C. (2001) Ahead and neck of the field. core to speech and language therapy profession- isolation, and dealing with the head and neck can- Speech & Language Therapy in Practice. Autumn: alism, their profile and depth will vary according cer patient at what is often the most traumatic 12-13. to particular clients’ demands, contexts and ther- time. Discharge home can bring about a stark reali- Logemann, J. (1983) Evaluation and Treatment of apists’ responsibilities.” On its own, attendance at sation of problems they have to overcome. The Swallowing Disorders. Pro-ed, Austin, Texas. a dysphagia course does not make a therapist swallowing problem may take on more significance Ridley, M. (1999) Effects of surgery for head and competent. A therapist who has attended a post- when the choice is no longer from a hospital menu neck cancer. In Sullivan, P. & Guildford, A. (Eds) registration course, and has much clinical experi- and the social aspect of eating comes to the fore, Swallowing Intervention in Oncology. Singular ence, can easily be as competent to treat dyspha- and all this at a time when further treatment may Publishing Group: San Diego/London. gia in a head and neck patient as someone like me start and worsen the dysphagia. Robinson, H.F. (1999) How I manage head and who attended an Advanced course, but had rela- General dysphagia training gives therapists a neck cancer: Setting the standard. Speech & tively little clinical experience. Experience may good basic grounding in managing dysphagia in Language Therapy in Practice. Autumn: 23-24. come about by direct patient contact, or simply head and neck cancer patients. If there are very Royal College of Speech & Language Therapists from working with the multidisciplinary team. In good support systems in place, it is possible that a (1996) Communicating Quality 2. RCSLT: London. attending the Combined Clinic each week, I generally trained therapist could successfully Royal College of Speech & Language Therapists learned a significant amount about the whole manage the dysphagia. However, there are still (1999a) Dysphagia Working Group: spectrum of head and neck care - prevention, aspects of care, such as pre-operative counselling, Recommendations for Pre and Post-registration recurrence, palliative care, carotid blow out for that are so important to the outcome of the reha- Education and Training. RCSLT: London. example - all of which informed my practice. bilitation that they should remain within the Royal College of Speech & Language Therapists Communicating Quality 2 (RCSLT, 1996) states that remit of a therapist with specific responsibilities (1999b) Invasive Procedures Guidelines. RCSLT: therapists working with this client group tend to to this client group. London. learn by experience. Robinson (1999) reports on the drawing up of the Sullivan, P. (1999) Clinical Dysphagia Intervention. In outlining the content of dysphagia courses, Head and Neck Oncology Consensus document, In Sullivan, P. & Guildford, A. (Eds) Swallowing the Dysphagia Working Group makes it clear that, and the fact that some of the objectives were Intervention in Oncology. Singular Publishing while a therapist completing the course would be unachievable in certain areas because of issues such Group: San Diego/London. expected to be able to work without supervision, as geography. Despite this, they were included Williamson, K. (2000) The best things for the best the ability to know when to ask for support because, ultimately, they were good practice, and reasons. Bulletin of the Royal College of Speech & would mean the therapist is working competent- could be used to help highlight deficiencies in local Language Therapists. October. ly. What may be problematic is ensuring that that service provision. This process needs to continue to support is available. ensure parity of service for head and neck cancer The literature suggests that speech and lan- patients, no matter where they live. Reflections guage therapy intervention for this client group is I am not sure if it is possible to quantify the level optimally delivered by therapists with specific of expertise and training required to work with this • Do I recognise when to ask for responsibilities for head and neck cancer (RCSLT, client group, but it is an area that the profession support and do I know where 1996; Ridley, 1999; BAO-HNS, 2000), who will be needs to explore. For the sake of career progression, to get it? part of multidisciplinary teams working in cancer continuing professional development and ultimate- centres. If the therapist linked to a particular centre ly patient care, it would be helpful to have some • Do I see myself as an has the ability to be peripatetic, this may not be a way of gauging when one’s experience is ‘sufficient’. individual or part of a network problem. However, if geographical or time con- Lorna Gamberini is a speech and language thera- of service provision? straints prevent this, there is a dilemma as to pist who works with ENT clients for Morecambe whether the patient will travel for rehabilitation, or Bay Primary Care Trust. This article is based on the • Do I expand my knowledge be seen by the local speech and language therapist. essay component of the Advanced Dysphagia through involvement in Would a local therapist, without specialist training Course (Head & Neck Module) which was written or specific clinical experience be appropriately while Lorna worked for West Cumbria Primary multidisciplinary ventures? qualified, and would they be able to deliver “high Care Trust.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 further reading

VOICE ARTICULATION FURTHER Laccourreye, O., Papon, J-F., Kania, R., Crevier- Hohoff, A., Seifert, E., Fillion, D., Stamm, T., Heinecke, A. & Ehmer, Buchman, L., Brasnu, D. & Hans, S. (2003) U. (2003) Speech performance in lingual orthodontic patients READING Intracordal injection of autologous fat in patients measured by sonagraphy and auditive analysis. Am J Orthod with unilateral laryngeal nerve paralysis: long- Dentofacial Orthop 123 (2): 146-52. This regular feature term results from the patient’s perspective Aesthetically appealing, externally invisible, lingually applied orthodontic (review). Laryngoscope 113 (3): 541-5. brackets are in increasing demand. Because the brackets are placed lin- aims to provide OBJECTIVE: Based on 80 patients with a previously gually, however, they appear to cause some problems with respect to information about nonsurgically treated unilateral laryngeal nerve speech. This study is the first to present a prospective evaluation of the articles in other paralysis (ULNP) and according to the patient’s self- articulation of 23 patients with lingual brackets by means of an innovative assessment, the authors document the long-term combination of test methods. An acoustic, objective evaluation of articulation journals which results achieved with the intracordal injection of measured by digital sonagraphy was related to a semiobjective auditive may be of interest autologous fat. STUDY DESIGN: Retrospective series, evaluation by 10 speech professionals, to a semiobjective auditive evaluation to readers inception cohort. METHODS: Kaplan-Meier actuarial by close contacts of the patients, and to a subjective auditive evaluation by The Editor has life table method and univariate analysis. RESULTS: the patients themselves, the latter 2 using standardised questionnaires. None of the 80 patients died in the immediate post- The tests were performed before (T1), within 24 hours after (T2), and 3 selected these operative period. Morbidity included haematoma at months (+/- 1 week) after (T3) the start of therapy. In comparison with summaries from a the donor site (in three patients), development of an the initial findings, a significant deterioration in articulation was recorded Speech & Language intracordal cyst at the injection site (in three with all test methods at T2 and T3. Using a new combination of methods, Database compiled patients), fat extrusion at the injection site (in one our investigations show the need for detailed briefing of patients about patient), and temporary tracheotomy (in one the extent and duration of changes in speech resulting from lingual by Biomedical patient). The initial and ultimate overall success rates brackets. Research Indexing were 96.2% and 77.2%, respectively. In univariate Every article in analysis, none of the variables under analysis (gender, HEAD INJURY over thirty journals age, associated neurological lesions, associated pneu- Dunn, L.T., Fitzpatrick, M.O., Beard, D. & Henry, J.M. (2003) Patients with monectomy, associated neoplasia, cause of the ULNP, a head injury who “talk and die” in the 1990s. J Trauma 54 (3): 497-502. is abstracted for side of the ULNP, nerve involved, delay between the BACKGROUND: Patients who “talk and die” after head injury may repre- this database onset of the ULNP and the intracordal injection, sent a group who suffer delayed and therefore potentially preventable supplemented by a severity of the symptoms, mode of harvesting the complications after injury. We have compared the clinical and pathologic monthly scan of autologous fat, and surgeon who performed the features of patients who talk and die with those who “talk and live” after injection) was statistically related to the ultimate head injury. METHODS: Data collected prospectively by the Scottish Medline to pick outcome after the intracordal injection of autologous Trauma Audit Group were used to identify patients with a head injury out relevant fat. Among the group of 45 patients in whom the and classify them according to verbal response at admission to hospital. articles from others intracordal injection was initially considered to be All “talking” patients in the catchment area of a regional neurosurgical successful with no further recovery of motion of the centre were selected and those who died were compared with those who true vocal cord and a minimum survival of 12 survived. RESULTS: Seven hundred eighty-nine talking patients were identified. To subscribe to the months, the ultimate overall success rate was 62.2%, Seven hundred twenty-seven patients survived and 62 died. Patients who Index to Recent and the 3-month, 6-month, and 12-month Kaplan- talked and died were older, had more severe extracranial injuries, had Literature on Meier actuarial estimates for success were 91.1%, lower consciousness levels, and reached theatre more quickly than those Speech & Language 72.8%, and 63.1%, respectively. CONCLUSIONS: In who talked and lived. Thirty-one of the patients that died had extra-axial the present study, data confirm that the intracordal haematomas. CONCLUSION: Even with increased availability of computed contact injection of autologous fat is a useful and safe procedure tomographic scanning, some patients still talk and die after head injury. Christopher Norris in patients with ULNP. However, the impossibility of Downe Baldersby exactly predicting the amount of resorption of the HUNTINGTON’S DISEASE Thirsk North injected fat and the lack of predictability of the duration Bilney, B., Morris, M.E. & Perry, A. (2003) Effectiveness of physio- of the results, together with the good and stable results therapy, occupational therapy, and speech pathology for people Yorkshire YO PP achieved at the authors’ department with the medi- with Huntington’s disease: a systematic review. Neurorehabil tel alization thyroplasty led the authors to reduce its Neural Repair 17 (1): 12-24. fax current use. (23 References) This review provides a summary of the current literature examining the outcomes of physiotherapy, occupational therapy, and speech pathology CHILD LANGUAGE interventions for people with Huntington’s disease. The literature was Annual rates are Widen, S.C. & Russell, J.A. (2003) A closer look retrieved via a systematic search using a combination of key words that CDs (for Windows at preschoolers’ freely produced labels for included Huntington’s disease, physiotherapy, occupational therapy, and ): facial expressions. Dev Psychol 39 (1): 114-28. speech pathology. The electronic databases for Medline, Embase, CINAHL, Children’s performance on free labelling of proto- Cochrane Controlled Trials Register, and PEDro were searched up to May Institution typical facial expressions of basic emotions is modest 2002. Articles meeting the review criteria were graded for study type and Individual and improves only gradually. In 3 data sets (N = 80, rated for quality using checklists to assess study validity and methodology. Printed version: ages 4 or 5 years; N = 160, ages 2 to 5 years; N = 80, The majority of articles that examined therapy outcomes for people with Institution ages 3 to 4 years), errors remained even when Huntington’s disease were derived from observational studies of low method factors (poor stimuli, unavailability of an methodological quality. A low level of evidence exists to support the use Individual appropriate label, or the difficulty of a production of physiotherapy for addressing impairments of balance, muscle strength, task) were controlled. Children’s use of emotion and flexibility. There was a small amount of evidence to support the use Cheques are labels increased with age in a systematic order: of speech pathology for the management of eating and swallowing dis- payable to Happy, angry, and sad emerged early and in that orders. The current evidence is insufficient to make strong recommendations order, were more accessible, and were applied regarding the usefulness of physiotherapy, occupational therapy, or Biomedical broadly (overgeneralised) but systematically. Scared, speech pathology for people with Huntington’s disease. There is further Research surprised, and disgusted emerged later and often in need for therapy outcomes research in Huntington’s disease so that clinicians Indexing. that order, were less accessible, and were applied may use evidence-based practice to assist clinical decision making. (80 narrowly. References). further reading

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 training The need When Linda Armstrong and Basic strategies Read this Alison Bain found out they were ‘Swallowing...... on a plate’ (O’Loughlin & Shanley, 1996) if you want to is an Australian dysphagia management (training) pro- •increase knowledge piloting the same off-the-shelf gramme designed for use in nursing homes so that, and change working package, they were naturally following training, nursing home staff would be able practices •provide clear and interested to compare methods to provide basic assessment and management strate- supported care and results. ‘Swallowing...... on a gies for their patients. It provides information about pathways swallowing problems and their management in •prove longterm plate’ (SOAP) may benefit people user-friendly handouts and information sheets. It effectiveness with dysphagia, but the principles introduces specific forms and protocols that provide Linda Armstrong a model to help implementation of the package are relevant to any client group within the home. Five modules cover the following where the aim is to train other topics: understanding the swallowing process; the professionals in basic assessment assessment and management of swallowing prob- lems; implementation of the SOAP programme in and management. the nursing home; supplementary information and his article is not about infection con- resources. The modules are designed to be taught trol, but a training package called to other staff by an experienced registered nurse. Swallowing...... on a plate (SOAP for SOAP includes four instruments: short). Our two Scottish speech and 1. a prefeeding checklist (swallowing screening tool); language therapy services coinciden- 2. swallowing assessment checklist (observation at tally and simultaneously piloted this mealtime, noting consistency of food and drink, package in markedly different ways and we thought position of client, level of dependence and Tit would be useful to compare them. Importantly, we obviously presence of swallowing problems); found that, even though it is slow and difficult to 3. swallowing management index (details of possible achieve successful new multidisciplinary working, problems and related strategies such as feeding this model of care can be used and adapted to dif- techniques to aid lip closure) and ferent environments. 4. swallowing care plan. Importantly the care plan So, why is such a package needed? Dysphagia is provides details of supervision required, special recognised in the literature and in clinical experi- procedures necessary, positioning - location and ence as a widespread problem in the long-term posture, equipment required and client-specific care settings of residential and (especially) nursing advice gained from the swallowing management homes as well as in continuing care wards for index (see figure 1, p.9). older people (Smithard, 1996; Steele et al, 1997; A pilot SOAP project within a Renfrewshire NHS Kayser-Jones & Pengilly, 1999). Management of continuing care hospital is reported fully else- swallowing difficulties may however not be part of where (Bain, 2003) so we will summarise it here the training or knowledge-base of staff before we compare it to one in these institutions and so residents We included a undertaken in Tayside. and clients with dysphagia may be Renfrewshire is a mixed urban and experiencing unnecessary malnutrition, control home so rural community situated southwest dehydration, chest infections and that measures of Glasgow with approximately problems taking medication among 30,000 people over the age of 65 other side-effects of inadequately devised for the years. A very limited specialist com- managed dysphagia, including acute project could be munity / domiciliary speech and hospital admissions. language therapy service of assess- Specialist speech and language assessed for ment and advice (with no review) therapy and dietetic services to these test-retest for clients over 65 years with swal- locations are often restricted by lowing problems is available. It is resource limitations. One solution to reliability. therefore necessary to consider this problem has been to provide any model of care that will max- training to staff in swallowing and dysphagia imise the effectiveness of this limited service. management. Speech and language therapy The essential features of the Renfrewshire project training programmes however have been devel- were the introduction of a new model of care which oped locally and mainly for hospital settings ensured that, following the training and implemen- (acute wards and stroke units), without validity tation period, regular speech and language therapy and reliability being established (Gravill, 1999; review of clients could be achieved. Rather than Magnus, 2001). Long-term effectiveness is rarely relying on self-directed study, all nursing staff reported. (including auxiliaries / nursing assistants) in a long

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 training for SOAP

stay hospital received training (either one or two Figure 1 Sample Care Plan sessions) over eight consecutive days. Link nurses Background: were identified to screen clients for swallowing Step 1: Prefeeding Assessment Checklist problems and develop care plans for managing their May lead to either Nil-by-mouth / onward referral or Step 2: Swallowing Assessment Checklist Refer to solutions in Swallowing Management Index and develop Step 4: Swallowing Care Plan dysphagia. The speech and language therapist Case history: assessed the appropriateness of each care plan and This case history is taken from the SOAP Manual (p48) Mrs White had a right CVA three years ago. She has a left facial droop, slurred speech and has no dentures. She sometimes monitored each identified client fortnightly over the coughs with thin fluids, takes a long time to eat her meals, is losing weight and has difficulty swallowing her medication. six month pilot period. Assessment of the effective- She often slips down in her chair, and pockets food in her mouth. ness of the training was measured in terms of SOAP step 4: Swallowing Care Plan (See SOAP Manual, p51) increased staff knowledge and more appropriate Devised by Grainne O’Loughlin & Chris Shanley 1996 feeding behaviour (as deemed by observation of USE: To be filled out by a registered nurse and reviewed as necessary. To be used by all persons feeding or super- vising a resident at mealtimes, as a guideline for safe swallowing. mealtimes by the speech and language therapist). Resident’s Name: Mrs White Effects of training (Please tick any boxes that apply) The aim of the project undertaken in rural Tayside DIET Fluid Consistency: Administration of Medications: Diet consistency: was to evaluate the short- and longer-term effects Thin ❑ Give as normal ❑ Normal ❑ ❑✓ ❑ of in-service training on acquired dysphagia with ❑ Thick Liquid form only ✓ residential and nursing home staff using a published Soft Very thick ❑ Crush and mix with puree ❑ Minced & Mashed ❑ Special Instructions training package. The project objectives were: Puree ❑✓ • to evaluate SOAP as a training package for local use • to evaluate the effectiveness of SOAP in increasing Diabetic Diet: Yes ❑ No ❑ Other Special Diet: knowledge and changing working practices • and so to improve the quality of care for people PREFEEDING Supervision: Additional requirements: Special procedures: with acquired neurological swallowing problems. Needs to be fed ❑ Dentures ❑ Suction on standby ❑ The project focused on the two residential and two Needs to be supervised ❑✓ Glasses ❑ To be fed by specified staff only ❑ nursing homes in the catchment area for GPs based Doesn’t need supervision ❑ Hearing Aid ❑ in one of the five geographical localities of Perth and Kinross Local Health and Social Care Co-opera- tive (LHSCC). The local community hospital was also Comments: initially included, as there was an identified training need which had not been met as part of the rolling POSITIONING community hospital training programme (because Location for mealtime: Posture for feeding: Upright in bed ❑ Keep head in midline ❑✓ of staff shortage in the hospital). Its client popula- Upright in chair ❑✓ Cushion/pillow for support: ✓ tion is more transient than that of the homes and it ❑ - behind head ❑ At dining table ❑ has a different balance of trained and untrained - behind back ✓ staff. However, the SOAP training package and its - under arm L / R ❑ protocols appeared possibly to be applicable also in Comments: the hospital setting. In addition we reckoned that, if both the community hospital and the homes in the EQUIPMENT Adapted cutlery ❑ Plate guard ❑✓ Cut-out cup ❑ locality were using the same method of identifying ❑ ❑ ❑✓ and managing swallowing problems, transfer of Straw for drinks Spouted cup Clothing protection Other equipment ❑ information about individual people in either direc- tion would be expedited. We also included a control Comments: home in another locality, so that measures devised for the project could be assessed for test-retest reli- SPECIFIC ASSISTANCE FOR RESIDENT ability. For this home, the initial day-long training Please insert specific instructions needed to assist this resident. was offered following two baseline assessments. (Use the information from the Swallowing Management Index) We used a number of outcome measures pre- and * Massage Mrs White’s left cheek to prevent pocketing post-training to examine the short- and long-term * Prompt Mrs White to clear residue from her cheek using her tongue * Reposition Mrs White if she slips down the chair effectiveness of the programme. These were: com- * Prevent drooling by getting Mrs White to hold her lips closed on the left side parison of referral / re-referral rate and quality of * Note change in diet to Puree and Thick Fluids referral (speech and language therapy and dietetics); * Note change to crushed medications resident profiles and swallowing environment obser- STOP FEEDING if resident is drowsy, coughing, choking or aspirating. vations (nutrition checklist, swallowing environment Staff to be aware of procedure in event of choking. checklist); a food / fluid ‘customer satisfaction’ ques- tionnaire; SOAP knowledge quiz and training day Signed M. Assessor Date 26/3/96

evaluation sheets. At the end of the project, we sent © 1996 Centre for Education & Research on Ageing and Inner West Geriatrics & Rehabilitation Service. Reproduced with permission. a short questionnaire to home managers / matrons.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 training

Table 1 Response to the Tayside project Table 2 Comparing our use of SOAP RH1 RH2 NH1 NH2 Hospital Renfrewshire Tayside Interested in participating Yes Yes Yes Yes Yes Project team 1 speech and language therapist 3 speech and language therapists and 1 dietitian Project length 6 months 1 year Able to send staff Yes Yes Yes Yes No to training Time in planning 18 months 3 months Pre-training measures Yes Yes Yes Yes N/A Locations involved 1 continuing care hospital 5 care homes and a community hospital Post-training measures Yes Yes Yes Yes N/A Staff trained 82 trained nursing staff and auxiliaries18 care home staff Changes in working Yes Yes Yes No N/A Length of training One day (repeated x8) One and a half days practice observed Outcome measures Knowledge and feeding environment Knowledge, referral rate, swallowing environment, resident profiles, customer Staff sent to 6-month Yes Yes Yes No N/A satisfaction, manager questionnaire follow-up SOAP model of care introduced yes no Manager questionnaire Yes Yes Yes No N/A returned Difficulties •Huge speech and language •Control home training therapy commitment •Community hospital could not send staff RH= residential home, NH = nursing home •Limited funding •Range of levels of staff trained

Changes as an outcome of •Speech and language therapy Individual to homes the project service offered in different way Response to the project varied among the care •SOAP documentation in place homes and the hospital (see table 1). Two baseline measures were taken at the control home but two planned training days were cancelled by this home There was also variation in planning time, with Gravill, P. (1999) ‘SIGNs’ of progress in dysphagia. because of staffing problems; staff shortage was protracted discussions required in Renfrewshire Speech & Language Therapy in Practice Spring: 12-15. given as the reason at the community hospital too. and a much shorter lead-in time in Tayside. In Kayser-Jones, J. & Pengilly, K. (1999) Dysphagia among The referral rate to speech and language thera- both projects we trained staff looking after older nursing home residents. Geriatric Nursing 20: 77-82. py and dietetics did not increase post-training. people in institutions where turnover of clients / Magnus, V. (2001) Dysphagia training for nurses in Resident profiles (describing swallowing prob- residents is likely to be slow, but where the same an acute hospital - a pragmatic approach. lems and their management) pre- and post-train- cannot necessarily be said for staff turnover. The International Journal of Language & ing depended on the member of staff reporting - number of staff trained was very different. The Communication Disorders 36 (supplement): 375-378. there was little reliability. Swallowing environ- model used in Renfrewshire is our preferred one, O’Loughlin, G. & Shanley, C. (1996) ments in the residential homes were very positive. in which all staff received training. In Tayside the Swallowing...... on a Plate: A Training Package for In the nursing homes, post-training improvement range of staff grades and experience was prob- Nursing Home Staff Caring for Residents with was seen in one (NH1) but not the other (NH2, lematic in terms of generalisation of the training Swallowing Problems. The Centre for Education whose commitment to the project appeared to to the homes. Training time was longer in Tayside and Research on Ageing: Concord, Australia. peter out). In the control home, no change was than in Renfrewshire but the model of care in Scott, D. (1999) Communication and swallowing noted from the first baseline measure to the sec- Renfrewshire was introduced in the continuing training for care home staff. Nursing & ond. Satisfaction among a sample of residents care hospital rather than in any care homes. Residential Care 1: 318-321. varied among the homes. Participants at the The Tayside project included a wider range of Smithard, D.G. (1996) Feeding and swallowing training day showed a significant improvement in outcome measures, most of which were developed problems in the institutionalized elderly. Clinical knowledge immediately post-training. This specifically, for example customer satisfaction ratings Rehabilitation 10: 153-54. improvement was sustained over six months by and quality and rate of referrals. Three of the Steele, C.M., Greenwood, C., Ens, I., Robertson, C. the staff who attended the follow-up half-day homes changed working practice after their train- & Seidman-Carlson, R. (1997) Mealtime difficulties (several of the participants had left by then). ing as measured by observation of swallowing in a home for the aged: not just dysphagia. There are several implications for the use of environment and feeding practices at mealtimes; Dysphagia 12: 43-50. SOAP in care homes: however the changes were much less widespread • This package can promote increased knowledge than those achieved by the blanket training in the Resources about dysphagia and change in working practice continuing care hospital. There it was noted that Further information about SOAP and other training and should be rolled out on an ongoing basis to length and quality of mealtimes had improved, resources is at www.cera.usyd.edu.au. other homes in the Local Health and Social Care and that appropriateness of feeding strategies had Co-operative. improved significantly. Importantly, the speech and Acknowledgements • Small changes are needed to reflect UK language therapist was able to monitor clients reg- Alison Pendlowski and Alison Cuthbertson were the circumstances (for example, food items and ularly and thus, we feel, provided a more effective speech and language therapists also involved in the vocabulary). speech and language therapy service as a result of Tayside SOAP project and Alison Gibb the dietitian. • Responses among the homes varied. Perhaps in implementing the SOAP model. Funding for the Renfrewshire project was received future homes that are willing to commit to change So, would we use the SOAP training package from the Directorate of Continuing Care and Old (if necessary) and able to give staff protected again? YES. Age Psychiatry and in Tayside from the Initiatives time should be targeted. And do we recommend it for use either in care Fund of Tayside Primary Care NHS Trust. • Another way forward would be the development homes or long stay hospitals? YES. of a dedicated team of allied health professionals for residential and nursing homes. The remit of Linda Armstrong is a speech and language therapist this team would include both ongoing training working for Perth & Kinross LHSCC, NHS Tayside, Reflections and assessment / management of residents’ e-mail [email protected] and Alison • Do I seek out existing offthe chronic problems. A model for this exists in Bain a speech and language therapist with NHS Argyll shelf packages before spending Glasgow (Scott, 1999). and Clyde at New Sneddon Street, Paisley (contact via time developing my own? e-mail [email protected]). • Do I network with other speech Used quite differently and language therapists to compare methods and results? SOAP was used quite differently in the two pro- References • Do I plan how I will assess jects (see summary in table 2). The composition of Bain, A. (2003) Swallowing on a plate. Bulletin of reliability validity and longterm project staff in the two areas shows that either the Royal College of Speech and Language effectiveness of a project? one person or a team can run a training project. Therapists. May.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 collaboration Collaborating for communication ollaboration is the key to effective educational needs co-ordinator for the therapy Read this speech and language therapy within groups to be run over the next four visits. mainstream schools (RCSLT, 1996; Students with language difficulties were placed if you want to • Be more efficient Manz, 2000; Pritchard Dodge et al, together in groups of three to five children of without compromising 2000). In practice, collaboration roughly similar ages. Students needing phonolo- on effectiveness often involves assessment of the gy therapy were seen individually or in a small • Improve collaboration Cchild, discussion with parents and teachers, fol- group. One or two teaching assistants were allo- with other professionals lowed by a written programme to be carried out cated to run each group with me. • Combine training with by parents and education staff (Portch & Harrison, supervised practice 2002). Initially, speech and language therapists in 2. Language groups the local mainstream school service in Kent were Therapy is much more effective if education staff also using this model of service delivery. However, can see the immediate relevance of language In common with other in a survey carried out to evaluate the service, goals to current class work and the broader cur- special educational needs co-ordinators emphasised riculum (RCSLT, 1996). Each language group therapists, Karen Heins the need for more help from speech and language therefore focused on a current class topic such as therapy to train staff and implement therapy pro- history (for example, ‘Ancient Egypt’; ‘Florence and colleagues were grammes. Nightingale’), geography (‘Kenya’), English looking for an efficient Speech and language therapists had often (‘fables’) or a time of year (‘Christmas’). worked together with individual teaching assis- A different language area was targeted each and effective way of tants to demonstrate how to provide therapy for week: specific children, yet this kind of hands-on supervi- • Week 1 - Understanding stories: Role play managing clients with sion was not always possible. The department helped students understand a story related to also offered workshops to teaching assistants on the class topic (adapted from Withey, 2000). speech and language working with children with speech and language • Week 2 - Building vocabulary: Students difficulties in mainstream difficulties but, despite a very practical focus, it described the meaning of words related to the was not feasible for the teaching assistants to class topic. This area was chosen as many children schools. The result was immediately practise the ideas with real children had semantic difficulties. under the supervision of a speech and language • Week 3 - Listening and following instructions: the development of the therapist. The Collaborating for Communication Activities focused on listening and following project was developed in 2001 - 2002 to combine instructions while reinforcing vocabulary relevant ‘Collaborating for practical workshop training with supervised practice to the class topic (adapted from Johnson, 1998). Communication’ project, in using the therapy techniques with real children. • Week 4 - Telling stories: Students learned to This training supplemented the assessments, use a story plan, develop their own story, act it which combines practical reviews and programmes which we continued to out and retell it in their own words (story plan provide. adapted from Liverpool Speech Pathology workshop training for I developed and piloted the project while work- Service, Sydney). teaching assistants with ing half time in the school’s team with a caseload These particular language areas were chosen as of ten primary schools. Instead of visiting each they were relevant for most students with lan- supervised practice school two to three times a guage difficulties, and they fitted term, I targeted two easily into current class work. involving groups of real schools at a time, and visit- particular language areas The groups were designed so ed each school for one full were chosen as they were that teaching assistants could children. day each week for five later re-run the same four ses- weeks (roughly a half -term relevant for most students sions with the same group of period). The schools not with language difficulties, children, but each time they involved in the project dur- and they fitted easily into would choose a new topic that ing that term continued to the children were currently receive one visit per term current class work studying in class. In this way the for assessments and material was new and relevant reviews. Eight out of the ten schools chose to to the children, yet the teaching assistants could participate in the project which was structured as use the same session plan each time. Each group follows: session ran for 30 minutes, but 45 minutes were allocated to give time to explain the session to 1. Assessment and planning day the teaching assistants, collect children from class, The first visit involved carrying out three to four return them and demonstrate writing up notes. A assessments / reviews and planning with the special sample session plan and homework sheet are in

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003

collaboration figure 1. Figure 1 Sample session plan and homework sheet Teaching assistants participated fully in the ses- sions by preparing materials, observing my Session 4: Telling Stories demonstration of activities, then implementing Preparation: the activities with the children themselves, and taking notes on the children’s abilities in the dif- You will need pictures of scenes (such as a family at the beach; children going shopping) and problems (for example a child who has lost something or fallen over). You will also need the ferent tasks. All schools were provided with a picture cues for the different stages in the story plan. written information package so that they could Session Plan: run the same groups independently in the future. Revise Homework: Ask students what are the three things they need to remember to follow 3. Speech sounds instructions (look, listen, repeat). (1 min) Children needing phonology therapy were seen Setting/Beginning: Revise that ‘when’ questions are about time (have a picture of a clock), either in small groups or individually. A teaching ‘who’ questions are about people (have a picture of people) and, ‘where’ questions are about assistant jointly ran each session with me, and place (have a picture of a house). Show the pictures of different scenes, and ask the children brought toys and activities available in school to to make up ‘when’, ‘who’ and ‘where’ (for example, ‘One hot day, mum, dad and Sam were at the beach.’) If ‘when’ is not clear, then just use ‘One day’. For the first 1-2 pictures, think provide motivation. up the setting as a group. Then give each child a picture of a scene, and ask them to make up the setting (‘when’, ‘who’ and ‘where’). (5 mins) 4. Workshops for teachers, teaching Problem and Ending: Show the children pictures of different problems, and ask them to assistants and parents explain what the problem is, think how the characters would feel in these situations, and two School staff and parents were invited to attend a or three things that they could do to solve the problem. For younger children it is fine if they one hour workshop on working with children with can only think of one solution, but older children should be able to think of at least two possible solutions. As above, do the first 1-2 pictures as a group, and then give each of the speech and language difficulties. Five out of the children a different picture to discuss the problem. If the child can only think of one solution eight schools chose to hold workshops. Some schools to the problem, ask the rest of the group if they can think of any other ideas. Once a number of solutions have been suggested, ask the child to choose one as the ending, and then preferred joint parent and staff training, while the oth- explain how the characters would have felt in the end. (8 mins). ers decided to have separate sessions for parents and staff. The number of participants in each workshop Children make up a story to do with the class topic: Ask the children to think of a story that fits in with the class topic. Use the same prompts as above to generate a setting, problem ranged from about six to more than twenty. and ending. For example, if the topic is ‘Ancient Egypt’, the setting could be ‘Thousands of years ago, a pharaoh and his slaves were living in Egypt’, and then the children can continue 5. Providing experience for more recently the story by thinking of a problem that the pharaoh could have. Sometimes the children need to be led through the different solutions by the adult saying ‘First the pharaoh tried...., qualified therapists but...., then the pharaoh tried ....., but ..... In the end.....’. (6 mins). The mainstream school team was keen to encour- Children act out the story: Give each child a different role in the story, and they can act it age more recently qualified therapists to consider out. If there is time, you can switch the roles over and act it out again. (5 mins) working in schools. Therapists were therefore invit- ed to spend five days working on the project in one Children retell the story in their own words: Use the picture cues to help them remember all the important stages in the story; perhaps each child could take a section (e.g. first child school, and three chose to participate. An infor- setting, second child problem etc.). (5 mins) mation package included advice on assessing school-aged children, writing reports and prepar- (Note: Story plan is adapted from Speech Pathology, Liverpool Health Service, Sydney). ing programmes. A resource file contained infor- mation on expected speech and language develop- Language Group Homework ment in school-aged children, programmes for dif- Session 4: Telling Stories ferent areas of language, speech and fluency, and pre-prepared training packages for delivering Today we have been working on telling stories. Here is a story plan to help your child tell stories with you at home, or if they have to prepare a story in class. workshops to school staff and parents. If your child has difficulty with writing stories, then they can start by just putting 1-2 key words in 6. Reports each of the boxes. If necessary, later they can expand these key words to make full sentences. At the end of the weekly visits, each child received WHEN did the story happen? a report using a standard format to explain the group sessions and provide further ideas for helping children at home and in school. WHO was in the story? At the end of the programme, special educa- tional needs co-ordinators and the more recently WHERE were they? qualified therapists completed a questionnaire to provide feedback about the project. Their com- ments are summarised in figure 2. What was the PROBLEM? One day hands-on workshop After the success of the first two terms of the pilot How did they FEEL? project, we decided to extend the training to other schools in the area. To involve as many How did they try to FIX the problem? schools as possible, the training was condensed to (Think of 2-3 possible solutions) a one day hands-on workshop held at each par- ticipating school. Ten schools chose to be involved. How did the story END? All schools identified at least one teaching assistant who would attend all day, so that they could under- How did they FEEL? stand how the programme worked as a whole. Some schools then chose to send different teaching assistants to each session, or else to have three to four teaching assistants who attended all sessions. After initially observing the therapist, the teaching

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 collaboration assistants were actively involved in carrying out the activities themselves with the children and taking Figure 2 Comments about ‘Collaborating for Communication’ notes. Each session ran with different children from Key benefits reported by schools: Key benefits reported by the more recently • Practical demonstrations and participation qualified therapists: the school, as using the same group of children all ‘made more sense than on paper’. • Developed confidence in training teaching day would have been too tiring for them. One • Improved confidence and skills in supporting assistants. topic was used for all sessions (‘school’), but teach- students with speech and language needs. • Many therapy ideas and useful resources. • Children enjoyed sessions and groups allowed • Seeing how language therapy can encompass ing assistants were encouraged to think how to all children on the caseload to be included. National Curriculum areas, and be adapted adapt the activities for current topics in their own • Closer links with the speech and language for future use by schools. classes. A sample timetable is in figure 3, although therapy department. • Useful for coping with large numbers on • Strategies used in groups were extended to the caseload. specific times were adapted for individual schools. the classroom. Four recently qualified therapists and a speech Main disadvantages and suggested improvements Main disadvantages and suggested improvements and language therapy student participated in the from the schools: from the more recently qualified therapists: training days. The therapists were provided with • Timetabling and grouping children, withdrawing • Reduced time for therapists’ usual area of work, the session plans beforehand, and chose to run teaching assistant support from classrooms and and stretched them in another direction. finding space in the school to run the groups. • Project was general, with limited opportunity two of the group sessions. It was easier for them • Teachers would have liked to be more to focus on more specific issues. to get time away from their regular work for just involved. • Teaching assistants would benefit from a • Less time for assessments of children, and the briefing meeting before the groups and then one day rather than five days. concentrated support of a day a week over a another meeting in the last week for questions After the training days in the ten schools, 64 five week period reduced visits from speech and adapting the project for their own use. questionnaires with completed confidence ratings and language therapy for the rest of the year. • A rating scale could measure the teaching • Perhaps children could attend language groups assistants’ confidence in working with children were returned. Of these, 79 per cent reported during the holidays as they had in the past. with speech and language difficulties before increased confidence in working with at least one and after the project. area of speech or language, while 47 per cent Future plans of the schools: Future plans of the more recently qualified reported increased confidence in three or more • 6/8 schools plan to continue the language therapists: areas. One of the speech and language therapists groups, as well as incorporating the ideas • One therapist has decided to increase the into class work. amount of school-based work in her caseload. involved volunteered to take on a caseload of • The other schools plan to use the strategies • Another therapist was planning to run similar mainstream schools, while the others were planning within existing class work. groups in the schools she visits. to incorporate the ideas into their current work. • One school was creating an advice file for • The third therapist will use the programmes working with speech and language difficulties. and advice when preparing reports for The comments were generally very positive, and • A bookmark with the story plan was devised for school-aged students. the perceived benefits were similar to those reported all students to keep with their reading books. by the schools in the weekly version of the project. The main criticism was from teaching assistants who Figure 3 Sample timetable were only able to attend for one group session; 9.10 Introduction: Expectations, confidence rating scale for working with speech and language they would have liked to see how the other groups difficulties. Explanation of the day’s sessions, and how to run the groups with weekly sessions. worked, and to have had more practice with the 9.30 Language Group 1: Understanding stories children. Another suggestion was having more 10.15 Break advice on other areas of communication, such as 10.30 Language Group 2: Building vocabulary social skills development. On a one day training 11.15 Language Group 3: Listening and following instructions workshop, the special educational needs co-ordina- 12.00 Lunch tors had to make compromises in deciding how 1.00 Language Group 4: Telling stories many teaching assistants could be released from 1.45 Working with speech sounds: Therapy activities for one child with a phonology programme. classes during the day, and not all areas of speech 2.15 Question and answer session: Adapting groups for future use, confidence ratings and language therapy could be covered. after the day, feedback. Effective method The Collaborating for Communication project has tants actively involved, session plans for language Manchester Metropolitan University: Manchester. been a very effective method of providing hands- groups, visual cue sheets, homework, and stan- Manz, J. (2000) Positive teamwork. Bulletin of the Royal on training with real children so that teaching dard report and letter formats. Please contact College of Speech and Language Therapists, March. assistants can run groups for students with speech Karen at 34 Op der Sterz, Fentange L-5823, Portch, A. & Harrison, P. (2002) Clarifying priorities. and language difficulties. It would be valuable to Luxembourg, e-mail [email protected]. Bulletin of the Royal College of Speech and extend the training to other schools in the area, Language Therapists, March. and follow up the schools involved to find out if Acknowledgements Pritchard Dodge, E., Andrews, M. & Andrews, J. (2000) Many thanks to all the speech and language therapists the groups are still running and if the strategies Communication and collaboration. In: Pritchard and schools who participated in the project for are being used in class work. A second training Dodge, E. (Ed) The survival guide for school-based their enthusiasm, commitment, advice and sugges- programme could also be developed to target speech-language pathologists. Singular: San Diego. tions. Thanks in particular to Kat McKeown, other areas of communication difficulty, such as Withey, C. (2000) Developing language skills speech and language therapist, for her sugges- focusing further on speech sounds and phonemic through playscripts training course. Riverside tions in the initial development of the project, to awareness, grammar, voice care for staff and stu- Community Health Care, London, 29 June 2000. Louise Ring, speech and language therapist, for dents, and social communication skills. Continuing the child report format, to Jackie Charlton, speech to develop our collaboration with teachers, teach- and language therapist, for the confidence rating ing assistants and parents will enable us to be scale, and to Rachel Meinertzhagen, teacher, who Reflections much more effective in implementing therapy for • Do I try to act on feedback developed the story plan bookmark. students with speech and language difficulties. received about my service? References • Do I provide programmes that are Karen Heins is a speech and language therapist. RCSLT (1996) Communicating Quality 2. Professional meaningful both to those Copies of the ‘Collaborating for Communication’ standards for speech and language therapists. Royal implementing them and to my clients? training manual are available, with all the materials College of Speech and Language Therapists: London. • Do I encourage recently qualified needed to run the project, including notes for Johnson, M. (1998) Functional Language in the staff into my particular field? presenters, strategies for getting teaching assis- Classroom. Clinical Communication Material,

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 winning ways series () From caterpillar to butterfly Susan came to me in a terrible Life Coach Jo Middlemiss Once you decide to be a winner you can give up the state, crying most of the time. believes that every challenge energy loss that goes into putting on a performance. She had a job, which she had Winners need not fret about what other people are applied for with great enthusi- has a solution and that, thinking about them. They know the difference asm. Everything about it between acting caring and being caring, acting the appealed to her, and she ultimately, the only person fool and being a fool. If they know something, they thought she would be able to helpfully share it; if they don’t know something, they work to her strengths. you can change is yourself. are not afraid to acknowledge that fact. Not hiding Unfortunately, the stress of behind a mask frees up a winner to step into their staying ahead of the job, juggling a busy home life If you feel ready for a own confidence. They have realistic views of their and operating alongside someone with a very dif- transformation, read on... own strengths and weaknesses. They are prepared to ferent working style meant Susan had totally lost listen to the opinions of others, but generally come sight of herself. Her self-esteem and self-confidence up with their own considered judgement about how were rock bottom. Interestingly enough, she didn’t to behave. Winners do not play the victim role, nor look like she wasn’t coping - but, although she do they blame others for the situation in which they looked fabulous, she was falling apart inside. find themselves. Wherever they are, they know deep When we are overwhelmed everything becomes a down that they are their own bosses. Winners get challenge. My tactic with Susan was to get her to their timing right. Their responses are appropriate. tease out the big tangle of problems. To write them They know about and acknowledge their emotions all down and look at ways of tackling them one at a as helpful signals. They love life and rejoice in their time. We called solving the problems a project. own and others’ achievements. They are brave in the Suddenly our work had a purpose, with a beginning face of setbacks and joyful about ordinary things. and an end. Each challenge was graded with a level Even when the world seems a terrible place, winners of difficulty rating - 10 is unbearable, 1 isn’t a prob- do not see themselves as powerless. When Mother lem at all. Then we set to, picking the challenges off Teresa was challenged that her work was but a drop one at a time. One of the main things causing Susan in the ocean, she quoted Armand Marquiset in reply: to be so frustrated was that her very best qualities “The ocean is made up of drops.” A winner works to were not being put to good use. With time spent on make the world a better place. building her self-esteem she was able to approach My guiding principles when working with a client are her boss and explain in a calm way that she was firstly to believe in their unique magnificence, no matter unable to give of her best because of poor commu- who they are, and secondly to get them to believe that nication and poor organisation in the workplace. they only have to be better at being themselves. They Susan also reviewed how she looked on her work are already fine and good enough, but limiting beliefs colleague. We explored the reasons why this other Read this and behaviours may be holding them back. person behaved the way she did, and looked to if you want to How can we apply these two ideas to this winning changing Susan’s attitude rather than expecting the •work to your strengths ways column? colleague to change. Eventually, Susan decided to •make changes in your life • To apply coaching techniques directly and specifically change her job but by that time was sure enough of •find solutions to the speech and language situation. herself to go for the kind of workplace where she • To recognise that speech and language therapists would be able to contribute according to her skills. are people like everyone else. Life Coaching is about transformation, from caterpillar Sadly, we live in a competitive world. Our society • Issues around promotions, interpersonal relationships, to butterfly. This might sound fanciful, but hold your values those who win the race, get to the top of the work / life balance, physical / mental / spiritual opinion just for a minute. People come to coaching slippery pole of promotion, and elbow all difficulties health can all be included plus a sharing of the trials because they want to make changes in their lives. If peo- out of the way in order to gain that elusive thing - which seem to be unique to the profession. ple just want to wander round the mulberry bush a few ‘success’. However, the winning ways that this column I am learning about the huge range of your work times, only to be reassured that their problem really will be dedicated to are not necessarily those valued through preliminary discussions with speech and does have no solution, then I’m not the coach for them. by the vast majority of society. In my work, both in the language therapists. Your charges range from I always assume that the only person you can coaching and the counselling field, I endlessly meet preschool infants to elderly people who have had a change is yourself. When Viktor Frankl was impris- people who would seem to be successful but are stroke. Your profession is sometimes misunderstood oned in a concentration camp and had literally every- deeply unhappy because they eventually realise that, as just about speaking when in fact it is about effec- thing taken away from him, he states that the only if success means living in a state of stress and pretence, tive communication. Other challenges you face thing he had any control over was his own attitude. staying ahead and not being themselves then, include juggling caseloads, balancing work and life although it might look like winning, it feels like losing. and even seemingly minor ones such as carrying Managing director Winners are people who recognise the boundless equipment around. I also believe that every challenge has a solution. It potential in themselves and others. They see them- As I go through back issues of Speech & Language might not be the obvious one but there will be one selves and anyone that they deal with as wonderfully Therapy in Practice to read myself into the challenge and, through coaching, the client will find it. Through unique. The most important thing to them is not of writing for it, I am impressed with the high level of coaching, people can discover the rules and values achievement, but being honest enough to be yourself ongoing professional development, not to mention that govern their lives. We all live by rules and values in all situations. As Shakespeare said in Hamlet, the wide range of situations in which therapists might but, if you don’t actually know what they are, then “This above all: to thine own self be true, And it find themselves. Common to many of the articles is an someone else is running your life. Coaching helps you must follow, as the night the day, Thou canst not emphasis on inclusion for all and “Valuing People”, to be the managing director of your own life. then be false to any man.” but frustration can build when you feel your

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 here’s one I made earlier

Alison Roberts continues to generate low-cost ideas for flexible therapy activities. “Here’s one I made earlier...” employers don’t value you as much as you value your clients. In ‘Unlocking the voice’ (Steven et al, Car logo pelmanism 2002), I also saw many parallels with coaching. In “A variation of the traditional memory game, useful particularly for clients keen on cars.” coaching we might say we are unlocking the voice Materials In practice (I) and also the heart. As Dr Bernie Segal says in his ✔ Card. Index cards, or half-size index cards. 1. Place the cards face up on the table. The number wonderful book Love Medicine and Miracles, Taskmaster’s blank cards would give a superior presented at a time is up to you, but I have found “...when you live in your heart magic happens.” effect (£5.75 for 200, see www.taskmasteronline.co.uk). it best to start with three pairs to convey the idea, ✔ As many pictures of car logos as you can get your and then build up. (For some clients you may end “Would you tell me, please, which way I ought to go hands on. (Weekend newspaper colour supplements, up with as many as 15 pairs on the table.) Turn from here?” “That depends a good deal on where or other car magazines are good sources.) the cards over and muddle them up. you want to get to,” said the Cat. “I don’t much care ✔ Instead of car logos, you could use clothing logos 2. Turn two cards over. If they are a pair, the player where -” said Alice. “Then it doesn’t matter which (Nike, Adidas and so on), or small pictures of keeps them. If not, turn them over again. way you go,” said the Cat. “ - so long as I get some- cosmetic items like nail varnish and shampoo, or 3. Play passes to the next person. The winner is the the ever popular chocolate bars. In fact you can one with the most pairs. where” Alice added as an explanation. use anything that fits on your cards. Some (From ‘Alice in Wonderland’ by Lewis Carroll.) supermarkets produce good photos of food and In practice (II) (a version of ‘Kim’s Game’) other items in their leaflet handouts, so this can 1. Place just one of each of the card pairs (so that all Jo Middlemiss is a qualified Life Coach with a back- provide another source of free pictures. the cards are different) face up on the table. The ground in education and relationship counselling, number presented at a time is up to you. I have tel. 01356 648329, www.dreamzwork.co.uk. Brawn found it best to start with three to convey the Learn or make a note of the car manufacturer idea, and then build up. References corresponding to each logo, or write on the cards. 2. Turn the cards over and muddle them up. Take Frankl, V. (1997) Man’s Search for Meaning. Simon & Stick one logo on each card. Note: you can vary the away one card, hide it, and turn the others face up Schuster Inc. level of difficulty in picture pairing, choosing to show again. The client must guess which one has gone. either identical images, or perhaps the logo on one 3. You could of course take away more than one Siegel, B.S. (1998) Love, Medicine and Miracles: card and an image of the car itself on the other. card at a time. Lessons Learned about Self-Healing from a Surgeon’s Experience with Exceptional Patients. Perennial. Steven, L., Thompson, J. & Brown, D. (2002) Unlocking the voice. Speech & Language Therapy in ‘How I help people’ poster Practice Autumn: 14-17. “Useful for self-esteem building, also self / other awareness.” Materials In practice ✔ Paper • Use the hand image to make an insightful and ✔ Photocopier esteem raising poster. Head the poster “How I Reflections help” or “As a friend I ... “ • Do I know the rules and values governing Artistry • Fill in a “quality” or two in each finger, or the my life? Place your, or your client’s, hand on the platen of the palm. You may need to add white stickers if • Do I share what I know and acknowledge photocopier; close the lid and preferably cover with the palm is too dark on the photocopy. what I don’t? a white cloth to exclude daylight. Take a photocopy • Consider using the other copies for similar • Do I allow limiting beliefs and behaviours and then copy this several times once you are satisfied posters, such as “My strengths”, “My hobbies”, to hold me back? with the image. Older teenagers seem to like to “My favourite sports”. photocopy their own hands. (If you have any Health • For a group setting you could cut out the hands & Safety qualms about photocopying client’s hands and stick them onto a larger sheet as if reaching then you can draw around their hands instead.) for each other. Would you like to: • Identify and achieve your dreams • Unlock your potential Cooperation tin • Confront difficult decisions “A useful activity early in the life of a speech and language therapy group for children. It illustrates the benefits • Shake off restrictive behaviours and limiting of working with rather than against each other. The participants need to be roughly of equal strengths. beliefs The making of this item seems fiddly, but it is worth taking the time to produce something sturdy.” • Gain and maintain mental and spiritual balance • Be aware of and use your talent? Materials In practice Our new series ‘Winning Ways’ with Personal Life ✔ one round biscuit tin, approximately 20cm 1. Sit the participants in a circle on the floor, or Coach Jo Middlemiss aims to help you find out how in diameter around a table, with the tin in the centre. ✔ three 2-metre lengths of strong nylon cord. 2. Each person should hold a rope. you can be better at what you do, and better at being ✔ six rubber grommets, large enough for the 3. Place six treats in the tin - in a bag is a hygienic you. However, we need your help to gather material cord to pass through idea - and state that they may only take one treat, to make the issues - and their potential solutions - as ✔ treats! and that they may only do so when the tin touches realistic and relevant as possible for readers. them. (If your group has challenging behaviour, you Jo is therefore offering readers a confidential and Brawn may need to restrict the number to one treat at a complimentary half-hour telephone coaching session 1. Drill six equally spaced holes around the side of time, and then top up after each turn.) (for the cost only of your call). Although Winning the tin, about halfway down the side, the diameter 4. They are now allowed to pull on the ropes, but of the inner core of the grommets. they will soon find that the tin will only touch some- Ways will be based on what is raised in the calls, you 2. Fit the grommets on the holes in the tin. one if everyone allows it to - that is, five people must can be reassured that details will be altered so that it 3. Tie the cords together in the middle, and thread slacken their ropes while one person pulls. will not be possible to identify individuals. the ends through the grommets. CALL JO ON 01356 648329 4. Tie knots in the ends of the cords to form ‘handles’. (www.dreamzwork.co.uk). Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 service management Out of the frying pan, Read this he report Provision of speech and lan- to visit and advise the school. Similarly, if a child’s if you guage therapy services to children with primary presenting problem is a speech difficulty, • make decisions about special educational needs (England) direct therapy within a clinic can be highly effective, where therapy should (2000) advocated ‘that the greater part of although sound generalisation and phonological take place T • work with / through the provision for school age children with speech awareness may be best achieved at school. School other professionals and language needs should be embedded within visits may also be necessary to complete assessments • have to prioritise the curriculum and take the child’s education con- in some cases, for example assessment of a child resources text into consideration’. Since then many speech with a possible pragmatic language disorder. and language therapy services have reorganised to work within schools, and no longer provide a clinic Principle 2 Who is the main focus? Discussions about clinic based service to school age children. It is important to then consider who should be the main I have worked in schools most of my career, am a focus of input. If it is the parents, then a clinic or home or school based therapy strong advocate of working collaboratively with setting is likely to be the most effective environment to teachers, and now manage a large diverse service. I facilitate change. If the child is the main focus and their can get quite heated. believe it is vital to consider a number of basic principles needs have implications for learning (for example con- and, indeed, the purpose of and process for provid- cept work), then the school is the best place to inter- Alyson Portch warns ing a service within schools to avoid leaping from the vene. If the difficulties have little impact on learning, that, by pulling out frying pan into the fire - and inappropriately reor- then clinic may be the most appropriate setting. ganising services to the detriment of all children. of clinics and Does working in schools ensure that provision is Principle 3 Why are we intervening? ‘embedded within the curriculum’ or takes the ‘edu- Why we are intervening at all is an essential question concentrating on cation context into consideration’? I would argue as this establishes the primary purpose, and enables schools, the profession that it may not, and may even be less effective if a therapists to look ahead to the predicted outcome therapist does not have relevant training and / or for the client. Kate Malcomess developed eight care is in danger of getting experience, or consider a few basic principles. aims, which give us a framework for considering My other concern is what happens to preschool these important questions prior to intervention: its fingers burned. children? Given that all speech and language thera- • Assessment - to determine the nature and py services suffer a shortfall in resources and that impact of the condition Instead she argues we provision into school adds increased demand to a • Enabling - to maximise use of existing function should be grilling service, are these children getting the intervention • Supportive - to support the client to cope optimally they need early enough and at a frequency sufficient with their present condition ourselves about what to reduce the possibility of severe long-term prob- • Curative - to facilitate lasting change in function, lems? to within normal limits (chronological combination is right for age / pre-morbid state) Principle 1 What is the individual need? • Rehabilitative - to facilitate improvement / lasting each individual, and First, therapists should always carefully consider the change in function what will enable us to individual child’s speech and language needs and • Maintaining - to stabilise / maintain / preserve whether they have an impact on the child’s ability to function continue giving an learn. Difficulties which have the most implications • Palliative - to reduce pain and / or increase for learning are: comfort when no other change is appropriate service to • Significant language delay possible or appropriate all children, irrespective • Language disorder • Anticipatory - to prevent the development of, or • Some general learning difficulties where there is a reduce the risk of difficulty of their age. verbal / non-verbal skill discrepancy and the aim is These care aims relate to the child not the environ- to reduce the discrepancy. ment and, once the reason for intervening is estab- It may therefore be more effective to work with lished, therapists can then decide not only what to these children in schools rather than in a clinic. do but where to do it. School visits must therefore be Sometimes a combined approach may be best initially. considered in this context, and should be provided For example, a child with an expressive language when it is important that the school has a key role in disorder and developmental verbal dyspraxia may the development of the child’s skills because of the be initially best treated by a block of intervention in impact the child’s difficulties have on their learning. a clinic setting, followed by a period of consolida- The combined effect of a therapist considering the tion when the therapist could take the opportunity individual child’s speech and language need, who is

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 service management into the fire? Figure 1 Resources for school-aged children the main focus of intervention and the reason for A big part of the success of working in schools must Assessments the proposed intervention should therefore enable therefore be not only selecting the right children but Bracken (1998) Bracken Test of Concepts Bracken Basic Concept Scale - Revised. therapists to decide where it is best carried out. also learning to value the specific differences in the Psychological Corporation. roles of teachers and therapists and sharing skills to Dunn, Dunn, Whetton & Pintilie (1982) Principle 4 Proper procedures enable us to work together to help children. From the British Picture Vocabulary Scales. NFER- Nelson. The procedure you follow is also crucial to your success. therapist’s point of view, this involves learning and Harrison & Portch (in preparation) School My experience suggests that before arranging a understanding the educational context, and a sound age screen (SAS). Renfrew (Renfrew Action Picture Test, Test school visit it may be helpful to: knowledge of the curriculum and staged approach to of Word Finding, Bus Story) available from • Send a questionnaire to the school requesting further managing special educational needs via the new Code Speechmark. Semel, Wiig & Secord (2000) Clinical information of Practice (2001). It is therefore essential that joint / Evaluation of Language Fundamentals • On receipt, either telephone the school to discuss the shared training takes place in local areas to ensure this (CELF-3UK). Psychological Corporation. Wiig & Secord (1992) Test of Word information, or discuss it during the school visit. knowledge base is established and skills developed. Knowledge. Psychological Corporation. Then: ‘On the job’ training is also highly beneficial as a Therapy materials • Arrange a visit and confirm it in writing. This letter study by Jannet Wright (1994) highlighted; therapists From Learning Materials ltd, tel. 01902 454026: should clearly explain the purpose of the and teachers who worked together grew to really Looking and Thinking (books 1-5) Reading for Meaning (books 1-4) visit and the format your visit will take, such appreciate what they learnt from each other and Reading for Meaning More (books 1a-4a) as staff you need to see, or observation in increased their knowledge of what Reading and Thinking (books 1-5) class. The letter should also make it explicit each had to offer. This ultimately New Reading and Thinking (books 1-6) that parents will be invited to attend for A big part of the must influence the successful out- From Winslow, tel. 0845 921 1777 Think it - Say it - improving reasoning and part of the session if they so wish. success of working come for children with school based organization skills, by Luanne Martin • A letter should also be written to the parents in schools must speech and language therapy provi- (1995), £32.95 to inform them of this. sion. From Speechmark, www.speechmark.net therefore be not Working with pragmatics, Lucie Andersen- During the visit: Our service is piloting a new ser- Wood & Benita Rae Smith • Make any observations / assessments of the only selecting the vice for delivering speech and lan- From Black Sheep Press child within class right children but guage therapy to non-statemented www.blacksheep-epress.com • Share findings with staff also learning to school aged children whose needs First / Last / Next Before / After • Listen carefully to teachers’ concerns and value the specific would be best met through a col- Time priorities (and if possible the parents’ / carers’) laborative approach with school Parts of the Day differences in the Days • Develop shared / agreed curriculum focused roles of teachers staff. The children are identified by Why / because targets with the teacher and discuss and agree speech and language therapists Facial Expressions ways in which these targets can be and therapists who complete a referral form Speaking and Listening Through Narrative implemented at school and monitored and sharing skills including current support in school From The Psychological Corporation, www.tpc-international.com • Agree roles - therapist, teacher and parent. and the rationale for school based Describe it - games to build descriptive lan- If it is essential that specific work is undertaken input. We have assigned a named therapist to each guage skills, by Thomas-Kersting, McCormack & Satin (1998) with a child, it is important that school identifies a school for these children, and ensured the school CLIP Worksheets: Semel & Wiig (1991) named adult who will be responsible for working also provides a named contact with protected time 1. Syntax 2. Morphology with the child and therapist and implementing the for discussion and carrying out activities. Via the 3. Pragmatics targets. This is more likely to ensure a positive out- Special Educational Needs Co-ordinator (SENCO), we 4. Semantics come. If this is not available but you consider it to ask the teaching staff to complete a two page ques- From LDA, www.LDAlearning.com be essential, school visiting may not be beneficial. tionnaire on each child which covers skills in listen- Socially Speaking - a pragmatic social skills programme for pupils with mild to moderate After the school visit, provide a written record for ing / attention (1:1 and class group), understanding learning difficulties, by Alison Shroeder, ISBN staff, parents and other professionals which summarises of language (following instructions, answering ques- 1 85503 252 X your observations and assessment, your discussion and tions, gleaning information from stories and class From STASS, tel. 01661 822316 any agreed plan of action, and identifies agreed targets, discussions), expressive language (telling news, Cambridge Language Activity File strategies for achieving these and how you have agreed vocabulary, sentences), pronunciation, use of lan- From ECL www.eclpublications.com Practical Language Activities - Materials for these should be implemented and monitored. guage (interaction with adults and peers), general Clinicians and Teachers by JoAnn H. Jeffries academic progress (reading, number work, writing & Roger D. Jeffries Auditory Processing Activities - Materials Principle 5 Collaborate and learn and spelling) and anything else they think is rele- for Clinicians and Teachers by JoAnn H. SENDA (2001) has strengthened the rights of children vant. In the questionnaire we also ask for feedback Jeffries & Roger D. Jeffries with special educational needs to be educated in about how useful the school has found our input. In From Manchester Metropolitan University, mainstream school. This inclusive agenda means more preparing programmes, speech and language therapy tel. 0161 247 2535 Functional Communication in the children with difficulties will be educated in mainstream, staff draw on a list of useful assessments and therapy Classroom by Maggie Johnson creating a challenge for teachers and therapists alike. materials (figure 1). p.19

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 service management

Figure 2a) Case example Cameron has Year 5 Spring term • moderate bilateral sensori-neural hearing impairment (aided) - 1 hour per day learning support assistant time allocated from • severely disordered expressive skills, profoundly delayed language skills and funding. Used mainly for general support within classroom moderate speech difficulties (some associated with hearing impairment) (hearing aid maintenance, repeating instructions, explaining tasks / vocabulary meanings, completion of work etc.) Early therapy - Therapist continues to work with named contact / SENCO and - Clinic based, speech and language intervention with some written occasionally with class teacher / learning support assistant. correspondence and telephone contact with school. - SENCO has regular meetings with learning support assistant and class teacher to plan and discuss action / progress. Year 4 - Clinic therapy ends, as only language needs remain and all - No additional funding. parties feel these needs best met within school environment. - Speech and language therapy school visits 1 per term. Year 4 Spring term: - Frequent written correspondence and telephone contact - Therapist works with school, parents and other professionals to get LEA between all parties. funding for extra support (at that time 15 minutes per week for 1:1 or small group work with SENCO) Year 5 Summer term - Cameron attends clinic sessions; liaison with school for advice / strategies - 1 hour per week support not meeting all Cameron’s hearing established. impairment needs and only some of speech and language therapy needs. Year 4 Summer term / Year 4 Autumn term: - SENCO and parents feel greatest area of need is speech and - Extra funding granted on hearing impairment needs. Prioritised by school and language so 1:1 hour per day with learning support assistant parents for specific hearing impairment resources to support Cameron within focuses on speech and language therapy strategies. classroom. - Frequency of speech and language therapy visits to school - General classroom assistant support, continuation of 1:1 / groups with SENCO increases to three per term. for 15 minutes per week. - Focus of school visits becomes more specific and target based. - SENCO becomes named contact - SENCO remains named contact, having regular meetings with - Cameron and parents still attend clinic sessions class teacher and learning support assistant. - Clinic input focuses on speech skills and language work / vocabulary, - Liaison and support for learning support assistant become especially verbs. primary aim; high level of input demonstrating and advising - Copies of advice / targets given to school via parents after each clinic session. on tasks and approaches to use during specific 1:1 slots and - Input at school limited, focusing on general advice / strategies and support classroom support. for SENCO and school staff. - SENCO continues to meet therapist at each visit to clarify - SENCO has regular meetings with staff, who then try to support / reinforce outcomes and maintain overall responsibility. advice given, wherever possible within the classroom environment. - Statement applied for and finalised to commence in Year 6.

Figure 2b) School visiting example Figure 2c) Update to programme Write up of visit Target 1 - Attended school and liaised with SENCO (30mins) Cameron will consistently choose the correct multiple-choice questions / answers, - worked alongside Cameron in class (l0mins) targeting his development of inferencing skills in “Looking and Thinking” Book 1 activities - 1:1 work outside the class (20mins). Rationale Cameron finds it difficult to look at visual material and make an inference from the Liaison with SENCO to review previous targets: information he can see. This is due to the fact that the skill requires more abstract thinking. 1) Cameron will now ask for repetition if not understood but not yet consistent, therefore keep as a target Strategies / activities 2) Cameron can now answer 5 concrete questions about a passage Please use materials enclosed and answer the appropriate corresponding A/B questions from “Looking and Thinking” Book 1. In the materials provided, multiple-choice he has read but he finds gleaning abstract information difficult i.e. answers are given but Cameron may still require adult prompting to complete the inferencing and prediction, therefore therapist to look at visual task. In particular give prompts to encourage him to think outside the immediate context information first before written/reading material and not just how it relates to himself. 3) Cameron has met his 10-vocabulary word target and SENCO Encourage Cameron to make his reasoning process explicit eg. prompt with “how do has sent more. Therapist stated this would be an ongoing process you know?” type questions. This will help him understand the steps he needs to go with new vocabulary but also needs to be filling in gaps of basic through to make an inference / prediction. Continue to encourage Cameron to identify vocabulary. Therapist discussed strategies such as word webs and when and what he has not understood. “my little book of words” to be sent home for discussion/practice Target 2 and also available to child in classroom to help self help skills and Cameron will consistently use a voiced loud regular past ending during structured increase independent learning. activities 4) Regular past tense still difficult for Cameron. Therapist discussed why this was with SENCO, as he has fairly good irregular Rationale Cameron has difficulty using regular past tense endings (“-ed”) because of his hearing forms. Due to Hearing Impairment “ed” quiet sounds at high frequency impairment. therefore doesn’t I didn’t hear as clearly as irregular forms where There are two forms of regular past tense endings whole word changes. Discussed two forms of “ed” past tense endings a) -ed - spoken with a “d” sound (eg. served) both spelt the same but pronounced “t” with quiet word endings and b) -ed - spoken with a “t” sound (eg. walked) with “d” in loud word ending e.g. quiet “t” = walked “d” is a loud sound and “t” a quiet sound. Due to Cameron’s hearing impairment, the loud loud “d” = heard regular past tense endings will be worked on initially as they are easier for him to hear. Therefore will send in picture material to work on loud “d” past Strategies / activities tense (reg) first then will target quiet ‘t” past tense (reg). Please use materials enclosed from “Yesterday’s Verbs” and follow instructions on Also advised school to have a recording system to document when each page. Identify and group words with “-ed” endings (into loud and quiet) and input given on each target and if any changes observed in that skill. practise in writing tasks. Agreed with SENCO school visit after half term. Therapist then took Target 3 Cameron out to try visual inferencing which he managed well with Cameron will learn 80 per cent of class topic vocabulary multichoice answers but found difficult with open ended questions B Rationale from “Looking and Thinking” book 1. This is when information is not Cameron has a specific problem learning new vocabulary and relating it to previous in the picture at all but high level of inference is to be made therefore knowledge. target questions B, but complete A as a preparatory activity. Strategies / activities Back in the classroom found some vocabulary difficulties therefore dis- Cameron to develop “my little book of words” noting key vocabulary items and new cussed with SENCO ways to introduce new vocabulary before and words which he comes across. Prior to introduction of the topic, new vocabulary will be rehearsed with Cameron and then revised after the lesson. review after a lesson so Cameron has more cues to comprehend les- Use topic webs, linking words by association where possible. When explaining what son and vocabulary. new words mean try to put them into categories and link them to words which he Therapist to write new targets and send new material to home and school. already knows. Rehearse the vocabulary through action, activities and experience at school and at home. Throughout tasks, encourage Cameron to identify any words he Therapist also to telephone mum. has not understood.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 service management / reviews

REVIEWS LEARNING DISABILITIES EARLY INTERVENTION We must not let speech and language therapy SOME SUGGESTIONS OPPORTUNITY TO GENERATE DISCUSSION become just another task that teachers cannot The Social Toddler (Promoting Positive possibly undertake. We don’t need another black SIMPLISTIC Themed Activities for People Behaviour) mark against our profession. If services and each Helen & Clive Dorman individual therapist consider the principles and with Learning Difficulties Melinda Hutchinson The Children’s Project procedures listed, then appropriate decisions can ISBN 1 903275 38 5 £15.99 be made about where we should be targeting our Speechmark This is a useful and enjoyable read for both experienced and resources based on what the individual child ISBN 0 86388 307 9 £ 34.95 inexperienced therapists working with toddlers and their par- requires (see case example in figure 2a) - c), p.18). This resource manual has 20 objects as ents. The authors believe that by showing why children of 2-4 This, coupled with effective training and collabo- the basis of activities to use with people years behave the way they do, their parents and carers will be ration with school staff, should mean preschool with ‘profound and complex learning better able to understand them and respond appropriately. children do not suffer because of inadequate difficulties’. It has a very clear, straight- The attractive use of photo pictures showing sequences of toddler resources and that ‘the greater part (not all) of the forward layout, is well organised and behaviour in contexts helps the reader absorb and relate the ideas provision for school age children ... is really the activity sheets can be photocopied. to real situations, while avoiding telling the parent what to do. ‘embedded within the curriculum and takes the It’s very easy to read. It provides ideas The many examples of young children’s behaviour and development child’s education context into consideration’. for group work, using readily available, low cost items (for example, ‘take a at different stages provide the therapist with a real opportunity to generate discussion when used together with parents. At the very Alyson Portch is Head of Children’s Speech and coconut’). least this is a useful reference for parents and therapists seeking to Language Therapy Services for Hertfordshire Whilst the book contains some creative gain insight into “the mysteries of toddler thinking”. Partnership NHS Trust at St Peters House, 2 Bricket ideas, we found some suggestions sim- Grainne Hampson is a senior speech and language therapist at the Road, St Albans AL1 3JW, tel. 01727 829415. plistic. It is therefore of limited value to the experienced clinician and not partic- Department of Child and Family Psychiatry, Mater Hospital, Dublin. ularly good value for money. It would be Acknowledgements a useful tool for teachers or generic sup- MULTI-PROFESSIONAL WORKING Thanks to Cathy Goodbun and Lisa Cookson, port workers who work with people with COVERS BASIC CONCEPTS speech and language therapists. more moderate learning disabilities. Teamwork. A Guide to Successful Rafaella Peerutin, Debbie Charles and Collaboration in Health & Social Care References Louise McMillan are speech and language Sue Hutchings, Judy Hall & Barbara Loveday DfEE (2000) Provision of speech and language therapists for adults with learning disabil- Speechmark therapy services to children with special educa- ities in Newham Primary Care Trust. ISBN 0 86388 276 5 £25.95 tional needs (England): report of the working This book covers the basic concepts of collaboration, prerequi- group (DfEE 0319/2000). Online at LIFE SKILLS sites for success, benefits, barriers and pitfalls. Each chapter www.dfee.gov.uk/sen. OF MOST USE IN A GROUP ends with a summary of the key points discussed, and many DfES (2001) SEN Code of Practice. Department for Skills for Daily Living: with an opportunity to reflect, and formulate an action plan of Education & Skills. (tel publications centre on Personal Safety personal or service level goals. The authors are from health 0845 602 2260, quoting ref. 581/2001). ColorCards backgrounds (occupational therapy, physiotherapy and nursing) Malcomess, K. (2001) The reason for care. Bulletin Speechmark although all now work in professional education. Hence some of the Royal College of Speech & Language ISBN 086388 474 1 £26.95 speech and language therapy settings may find it easier to Therapists 595: 13-14. These cards come with a booklet that relate to this book than others. However the general principles Portch, A. & Harrison, P. (2002) Clarifying priori- lists each situation clearly. Each card is of collaboration apply to all. This is a useful and practical refer- ties. Bulletin of The Royal College of Speech & numbered so can be easily cross-refer- ence for those embarking on multi-professional working. Language Therapists 599: 7-8. enced to the list. The cards are well Judith Anderson is the speech and language therapy coordi- Special Educational Needs & Disability Act (2001) drawn in colour and would be appro- nator (mainstream services), Cotswold and Vale PCT. From The Stationery Office or online from the priate for use with adults, older chil- Queen’s Printer of Acts of Parliament at dren, and adults with mild learning WORD FINDING http://www.hmso.gov.uk/acts/acts2001/20010010. disabilities. Both newly qualified and DOES WHAT IT SAYS ON THE BOX htm). Crown Copyright 2001. experienced therapists could use the Find the Link (game) Wright, J.A. (1994) Collaboration between speech cards. The basic themes - such as immi- Diana Williams and language therapists and teachers. nent danger and everyday situations - Speechmark Unpublished PhD thesis, University of London. are good. However, some of the cards ISBN 0 86388 421 0 £48.75 are quite abstract or have complex This resource does ‘what it says on the box’ in that it provides an Reflections themes. This may be confusing attractive word finding and category game. The 200 good quality depending on the individual’s own Colorcard pictures are useful in themselves and ideas are given • Do I have guiding principles experiences of everyday situations. for a number of different games. My secondary aged students to help me plan and deliver A useful tool to stimulate discussion, generally gave it a ‘thumbs up’ but some of the materials, partic- my service? highlighting an individual’s level of ularly the clothes category pictures, are aimed at much younger insight within different situations, the children. Also the ‘insects’ category includes an earthworm and cards could be used with both individ- • Do I ensure all parties agree snail which would upset a lot of science teachers! However this uals and groups. Overall, my col- resource will not be staying in the back of my cupboard as it is on each person’s role? leagues and I felt they would be of regularly requested by my students as a fun activity. most use in a group setting. Karen Kelly is a specialist speech and language therapist at • Do I back up conversations Sue Martin is a speech and language the secondary speech and language base, Twynham School, in writing? therapist in London. Christchurch, Dorset.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 cover story Continuing to Were you at the conference in Edinburgh? I won- Delegates at a European Congress were asked to consider der what challenges you came away with. I felt there were four key messages: the challenge of evidence based practice for the speech 1. Evidence based practice is a and language therapy profession. Frances Harris dissects process of different actions 2.There are different levels of evidence the proceedings, and suggests where we go from here. 3.The researcher may be a different person to the consumer of evidence 4. Real evidence based practice requires collaborative networks across our profession. But what do they mean in practice?

1. The process Evidence based practice for me includes the fol- lowing steps: The question Should I use therapy x? How can I measure y? Finding the Literature search evidence Critical appraisal techniques Summary of findings from the literature AND / OR Generating the Design and execute a evidence therapy trial / test an assessment tool

Dissemination Discussing findings CPLOL is the Comité Permanent de Liaison des Orthophonistes-Logop`edes de l’Union Apply validated Decision making informed ideas by evidence as well as Européenne, in other words the organisation for speech and language therapists across by clinical insights Europe. Its 5th European Congress, entitled Evidence-based Practice: a challenge for speech and language therapists, was held in conjunction with the UK professional body the Royal A question is always the beginning for an College of Speech & Language Therapists in Edinburgh from 5-7 September, 2003, . enquiry into the literature. Typically it takes the form should I use therapy X (or Y)? or How can I measure (change in) X? Then either the litera- ture addressing that question can be scrutinised, case reviews and expert opinion. Sylvia Taylor- change? With this concept some people are the or some new evidence needs to be generated. The Goh of the Royal College of Speech & Language researchers and others are the consumers of conference papers were often about therapy or Therapists gave a helpful overview of an evidence research. What is needed is not more polymaths assessment evaluations. Some papers instead hierarchy for evaluating literature. Different lev- but more networking between teams. Then the were about the critical appraisal process. (Here we els of evidence address different types of ques- practitioners will be enabled to have a practice can commend Hanneke Kalf of the Netherlands tions. It is not simply a case of sighing over our based on evidence. for a whistle stop tutorial in summary statistics field’s lack of randomised controlled trials, and and critical appraisal techniques; I imagine only a then saying that we cannot ‘do’ evidence based 4. The collaboration few understood all of her notation.) Others practice as a result. One level of evidence may be The issue of who does what can only really be spoke about the need to integrate the literature a stepping stone towards developing practice addressed at the highest levels. We have excellent with clinical judgement and insights: memorably even if it is not ‘top-notch’ evidence. The face training centres, strong researchers and research noting that ‘what makes the speech and lan- validity and clinical acceptability of some more centres, many teams of practitioners and even guage therapist wise is not just expert knowledge recent therapy innovations has as much to do funding opportunities awaiting us. The next of their domains but an understanding of the with their take up as the supporting evidence stage for the profession has to be integrating issues of the human condition.’ There were also with which they were launched. these sometimes remote corners of our field into poster presentations dealing with clinical decision collaborative networks. These ideas can be making. Yet none of the papers I attended actu- 3. The people extended not just nationally but internationally: ally talked about case studies or examples of the Given the several steps within the evidence based otherwise what is the point of having CPLOL and application of evidenced-based ideas. practice ‘process’, and the many different ways of the Royal College of Speech & Language gathering or demonstrating evidence, it is clear Therapists meet together? 2. The levels that not every speech and language therapist can The concept came through that there are different carry all these roles. Some are born to it, and In terms of strengths, the most obvious character- levels of evidence which have acceptability for some achieve it, but others object to being thrust istic of the conference was its diversity. There were practice. Not just the randomised controlled trials, into all of it. Why not let the Thinkers pose the delegates from all over Europe and some from but treatment delay / withdrawal group trials, questions, the Methodical gather the data, the further afield as well. Simultaneous translation experimental group studies, individual case studies, Clinically Wise introduce a debate and process of into French or English was professional and

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 cover story/ emails to the editor

emails to the editor climb 21 October 2003 Dear Avril, impressive, taking into its stride all sorts of jargon. The diversity of people and languages was seen One of the many ways of communicating with people is through the written word. also in the range of poster presentations and Professional posters at conferences are one form of communication for which guidelines speakers. The posters were generally of a high may be drawn up. These give advice on how to catch the eyes and interest of the standard; not only well displayed, but also show- passing audience. At another level of communication, instructions may need to be given ing clear thinking. The conference benefited from in writing to someone with a learning difficulty or with dementia. Mencap has already a strong foundation of good organisation and produced very helpful guidelines for accessible writing, available as a pdf file through its clear communication. The room allocations website (www.mencap.org.uk). This is clearly directed at a specific audience, although worked well, with advance selection of seminars interestingly contains some good advice for poster presenters! by the delegates proving very helpful. At the Dementia Services Development Centre, University of Stirling, we are When not in the conference centre, Edinburgh considering a similar production but geared to people with dementia. Lest duplicating provided well for social possibilities, even when a work already done, does anyone know of an existing text that provides guidance for major rugby match with Ireland seemed to take those needing to communicate in writing with people with dementia? Or should we over many restaurants’ capacities. Informal discus- develop guidelines on writing in a way that is clearly understood by this group of sions and meeting old colleagues were a real people? bonus of the weekend for me. Responses would be welcome by staff at the Centre and to Marion Munro in the first As well as the three keynote speakers, there instance. were numerous presentations to smaller groups, with parallel sessions running concurrently. Here Marion Munro the range of topics was wide, but so also was the Publications Coordinator quality. The unfortunate Frenchman with only a Dementia Services Development Centre one per cent return rate on his questionnaire University of Stirling struggled to maintain credibility as he went into Stirling FK9 4LA detailed analysis of his results. Audiences were Tel: 01786 467740 provided with a CD file of the presentations. In Fax: 01786 466846 practice this meant (without my laptop) that I Email: [email protected] could not read abstracts or texts in advance, and audiences could only think of discussion questions at the time of the presentation. 15 October, 2003 Over the refreshments and meal times, interna- tional huddles were rare; my impression was that Dear Avril, delegates tended to stay in their cultural groups. I also felt that there was insufficient time or I was interested to find your website, and wondered if you are aware of the ground opportunity to draw together the ideas from the breaking research conducted by Professor Sue Buckley at The Down Syndrome conference. The concluding ‘round table’ discussion Educational Trust (www.downsed.org) in Portsmouth? (in fact an oblong dias for the keynote speakers) for They have established, through peer reviewed research, the enormous benefit of early me should have been at the beginning of the reading (preschool reading, as young as 2 or 3 years) in helping develop speech and weekend: it worked well to open up debate and language in children with Down syndrome. (Some preschool children are demonstrating could have been used to draw out key messages a capable level of reading and comprehension before they can even speak.) to a much greater extent. DownsEd are recognised worldwide as a ‘Centre of Excellence’ and regularly have people I came away with these challenges: travel from overseas to attend their workshops and training days for parents and • Who takes the lead at different points in the professionals. (They also conduct workshops specifically for speech and language therapists). evidence based practice process? They publish a wide range of information booklets in their ‘Issues and Information Series’, • How can we promote collaboration between and they produce speech and language resource materials which, in the early years, we have therapists and research teams? found invaluable in developing our daughter’s speech and language. • How can we be more transparent about applying With their help, through training workshops and also by having our daughter attend evidenced-based ideas to practice? their ‘Early Development Classes’, our daughter was reading before she started school 1 • How can we achieve cross-national discussion of aged 4 /2 years, and now aged 7 she is still reading at a level one year ahead of the level ideas, evidence and practice? expected for ‘typically developing’ children of her age. (I know of several other children The sound bite of the weekend, however, goes with Down syndrome who have also excelled in reading.) Along with the sound card to Kath Williamson: ‘Evidence based practice resources, early reading has had an enormous benefit on the development of speech should be a climbing frame and not a cage.’ I and language for our daughter. want to continue to climb. I am a grateful parent and, looking through your website, I hoped that our experiences may be of interest to speech and language therapists generally. Frances Harris is a speech and language therapist with the Sure Start speech and language Kind Regards, development project at City University, London. Greg Sneath Further thoughts on the conference from editor Avril Nicoll at www.speechmag.com.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 reviews

REVIEWS SOCIAL COMMUNICATION DOWN’S SYNDROME WORKING WITH EDUCATION WELL WORTH THE PRICE EVERYONE SHOULD HAVE ONE USEFUL TO SHARE Talkabout Activities Education Support Pack for Schools Speech and Language Alex Kelly (Mainstream: Primary and Secondary) Difficulties in the Classroom Speechmark Down’s Syndrome Association Deirdre Martin & Carol Miller ISBN 0 86388 404 0 £32.50 Limited free availability (also downloadable (Eds) As with Alex Kelly’s ‘Talkabout’, this is a well- free from www.downs-syndrome.org.uk) David Fulton Publishers designed manual that provides useful information ISBN 1 85346 845 2 £17.00 presented in a clear, concise and humorous manner. I found the Education Pack for schools This book discusses children’s language It comprises activities aimed at developing social from the Down’s Syndrome Association development and language difficulties in communication and is organised into the same levels/ Clear the context of the classroom. It is written chapters. Activities are cross-referenced to relevant Concise yet primarily for teachers and other educational worksheets in the original book and worksheets can Extensive in content. professionals. The text is relevant and easy be photocopied. to read, including chapters on speech and This would be a very useful resource even without Well documented language difficulties, difficulties in reading, reference to the original. It could be used for many Easy to read and writing and spelling, comprehension diffi- social skills groups or for useful activities alongside User friendly with culties and working in a team. The authors other published approaches. Suitable for adults and Short emphasise the need for good collaborative children, variations are suggested to alter task com- Snappy bullet points. practice in assessment, planning, interven- plexity. tion and outcome measures. Timetabled With its guidelines on running groups and bibliography, Precise sessions for joint working being the key to ‘Talkabout Activities’ would be informative for stu- Specific success. dents and their supervisors, but also practical for Detailed There is useful discussion on the strong links more experienced therapists who would appreciate Thorough. between communication difficulties and ideas or who wish to give advice to teachers / carers. emotional and behavioural difficulties. The Can be used by therapists with differing levels of Comprehensive book has been well researched with refer- experience and with a range of clients. Well worth Relevant ences at the end of each chapter. A useful the price. Interesting book to share with colleagues in education. Clare Beasley is a speech and language therapist with Full of ideas and Ann Gosman is a speech and language the North Durham Learning Disability Team, working Enjoyable. therapist with NHS Orkney, based at the with adults who have learning disabilities. Health Centre in Kirkwall. The type of resource that everyone working with Down’s children in mainstream schools VERY WELCOME PRACTICAL should have. EMPOWERS THE READER RESOURCE Shona Barclay is a nursery teacher with Howe o’ Supporting Communication Social Skills Programmes (An the Mearns Nursery, Kincardineshire, Scotland. Disorders (A Handbook for Integrated Approach from Early Teachers and Teaching Years to Adolescence) Assistants) Maureen Aarons & Tessa Gittens COVERS ALL ASPECTS Ed. Gill Thompson Speechmark Speech & Language Intervention in David Fulton Publishers ISBN 0 86388 310 9 £29.95 Down Syndrome ISBN 1 84312 030 5 £15.00 This programme upholds the clinical rationale for the Jean Rondal & Sue Buckley (Eds) This is a helpful guide for identifying and overt teaching of social skills for children with specif- Whurr evaluating communication disorders in the ic social communication difficulties (with or without ISBN 1-86156-296-9 £35.00 classroom setting. It advocates early inter- diagnosis). Based on extensive clinical experience, the This book contains eleven chapters written by dif- vention and continued work alongside a authors offer an extremely practical and user-friendly ferent authors. It covers all aspects of speech and speech and language therapist. Easy and resource with clear handouts and invaluable advice. language development in individuals with Down enjoyable to use, particularly for someone The book provides a programme of 10 group ses- Syndrome from prelinguistic development with limited experience of communication sions for children with average cognitive ability through to maintenance training in older ages. disorders. Empowers the reader by provid- within four age-bands: 3-5, 5-7, 7-11 and 11-16 years. Each chapter contains current research and guide- ing useful and practical information along- The authors directly address issues such as joint lead- lines for intervention. At a time when therapists side clear guidelines as to if and when ership with teachers, evaluation and record keeping. are being asked to provide evidence based therapy, referrals should be made. The programmes are detailed and use everyday this is a valuable resource. Good value for money, introducing a wide materials. Consistent with autistic spectrum disorder The organisation of the book means it is possible range of relevant topics in simple and learning style, sessions are highly structured with to read just the chapter that is relevant to you at coherent terms, without overloading the repetitive elements and use visual support extensively. the time or the whole book. I think it would be reader. The practical activities and work- Generalisation is addressed through parent work- useful to therapists new to working with this sheets are useful both for identifying diffi- shops, detailed handouts, weekly homework tasks client group and to those with more experience in culties and overcoming them. All of these and ongoing evaluation after the group has ended. the field. It is a book that I will refer back to and are clearly explained and easy to use. A very welcome practical resource for therapists of it would be a useful addition to any department’s Alice Burton is a teaching assistant in a all levels of experience. bookshelf. school for children with Autistic Spectrum Ali Kennett-Brown is the Clinical Lead for Autism, Carolyn Alvis is a speech and language therapist Disorders and Complex Learning South Birmingham PCT. with Salisbury Healthcare NHS Trust. Disabilities in Manchester.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 how I How I augment Read this if you •could make more use of AAC •find aids are not used by clients •have difficulty accessing specialist support AAC Janet Scott is a speech and language therapist In the past, alternative and augmentative at SCTCI, Westmarc, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, communication was perhaps seen as a rather exclusive tel. (0141) 201 2619, e-mail field - but this is changing. [email protected]. Please note: A small number of service users will always need Janet Scott does not endorse any particular specialist input using high tech equipment and it is graphic (or other) symbol system or approach, and the views expressed are her own. important that we have therapists who keep up with the breathtaking pace of improvements in the capacity and Sally Millar is a speech and language therapist at the Communication Aids for Language and flexibility of technology. At the same time, however, we Learning (CALL) Centre, University of have greater awareness of the fundamental importance Edinburgh, Holyrood Road, Edinburgh EH8 8AQ, e-mail [email protected]. of all therapists developing an inclusive and enabling communication environment for everyone. Cheryl Davies is a specialist speech and language therapist at Denewood Centre, Whether high tech, low tech or a combination of Denewood Crescent, Bilborough, Nottingham methods, our three contributors demonstrate why the NG4 2FT, tel. 0115 915 9619, implementation of AAC needs strategic thinking, e-mail [email protected]. practical skills and a strong focus on the needs of users. Practical points: AAC To find out more about AAC, check out CASC Road Shows. They... 1. Respond to long-term and • Provide an overview and an update of specialised communication aid technology for use by people changing needs with complex communication needs. 2. Focus on building opportunities for • Are sponsored by the UK Trade Association of Communication Aid Suppliers (a sub-group of conversation Communication Matters) • Include mini-master classes on latest products presented by their manufacturers and suppliers 3. Take time to reflect • Have a full day programme including time for browsing, hands-on and discussion, and workshop sessions 4. Understand why AAC is used - and why it is not They are intended for... 5. Network to share skills and secure • People new to the field of AAC and voice output technology • Professionals specialising in this field who want to keep up-to-date funding • Everyone with an interest in communication technology 6. Work from the client’s level but • Anyone who works with children or adults with complex communication needs leave room for growth Presenting companies can include... 7. Be as consistent as possible Cambridge Adaptive Communication, Don Johnston, Liberator, Prentke Romich International, QED 2000, 8. Check that meaning is shared Sensory Software International, Sunrise Medical / Dynavox, Crick software and Widgit. 9. Provide an appropriate range of tools 10. Involve users, families and carers And... at every stage. They are FREE. A list of CASC Road Show dates is at www.communicationmatters.org.uk.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 how I Get out there and use it! There are many things to Of the confusing number of think about when choosing simple line drawing. Unless the photograph is graphic symbol systems, how carefully set up with good lighting on a non-dis- do you choose which one to a graphic symbol system. tracting background selected to provide a good use? The ‘best’? The one you Janet Scott takes us through contrast to the target item, the end product may know? What’s been used in the well pose an interesting figure-ground quandary - past? Or, like me, the easy the decision-making process. the opposite of what was intended. For others, option (one with a computer three-dimensional, tangible symbols (or objects of package which creates high quality materials)? MacDonald (1998) suggests you consider three reference) may be more appropriate - perhaps as a Before computers, I recall hours at the photocopier main aspects of a graphic symbol system: stepping stone to more abstract levels of represen- then cutting and sticking, and the laborious tracing tation (Rowland & Schweigert, 1989; 2000). 1. Construction: or drawing of symbols. I remember scouring mag- • Ease of reproduction? azines and catalogues for pictorial material to • How genuinely guessable / transparent is Computers, scanners, photocopiers have made it make up communication charts. That still goes the symbol? much easier to create good, high quality images on, but usually it is to supplement a more stan- Graphic symbols can be graded along a spectrum time after time. dardised symbol set - then it was the symbol set! of iconicity (the visual relationship between the symbol and its referent). At one end are transparent Perhaps, though, we actually thought more about • Visual abilities? symbols; at the other, the relationship between the how and why we used graphic symbols? Maybe it We need to be aware of our client’s visual skills - graphic symbol and the referent is opaque or is time to re-evaluate our choices? their field of vision, their acuity, whether they are arbitrary. Translucent symbols fall somewhere in Sadly, there is no perfect graphic symbol system; sensitive to contrasting levels of brightness between the middle - the meaning may not be immediately each has its strengths and weaknesses, each its fer- different surfaces, their colour vision and so on apparent but becomes obvious once it is explained. vent proponents. Choice of one over another should (Aitken & Buultjens, 1992). A significant percentage Most symbols are accompanied by text (the ‘gloss’). be based on the needs and abilities of the client. UK of people with cerebral palsy have a cognitive visual For people who can read, this tends to disguise ‘mainstream’ graphic symbol systems include impairment; they may also have problems with visual how opaque even a fairly pictorial symbol actually Blissymbols, Makaton, Picture Communication acuity and motor dysfunction affecting their ability is. Test out your friends with a selection of symbols Symbols and Rebus. Symbol systems associated with to coordinate their eye movements. Some of the with the gloss removed. How many can they particular high-tech communication aids include more pictorial symbol sets have detail, which may be understand? How far from the ‘accepted’ meaning DynaSyms (also known as PicSyms in their low-tech distracting for some. We might need to think about are they? Even the most pictorial symbol systems life), mainly used in the DynaVox family of communi- whether colour or black and white symbols would involve a degree of lateral thinking, of metaphor, cation aids, and Minsymbols (or multi-meaning icons) be easier. It might be helpful to accentuate or high- of life experience and simply of remembering what used in the Minspeak family of communication aids. light the salient part of the symbol with glitter, a the particular symbol means. Finally, a number of other graphic symbol systems bright colour or a different texture. We might need have been developed to meet a local need or a spe- to think about the background for the symbol dis- • Meaning? cific client group such as the Bonnington Symbol play (to make the figure ground contrast more Culture has a huge impact on people’s understand- System designed to help communication, informa- effective), or the spacing of the symbols, and even ing of what they see and hear. The further away tion and access, and a set from Speakability to help whether to laminate the displays (and if so, whether our clients’ life experiences are from our own, the people in the early days of aphasia. to use matt laminate rather than the standard, less we should assume that we share a common Every symbol system has to be taught to its users, cheaper shiny variety). meaning. Perception of symbol meanings varies as some are more pictorial than others, some symbols a function of culture / ethnicity (Huer, 2000). are fairly easy to guess the meaning of, others are 2. Level of symbolic representation: However, cultural differences can be very subtle not. Abstract language is always difficult to convey in • Are graphic symbols appropriate? indeed. Phillips (2001) identified distinct differ- a pictorial way (compare the more concrete mental For some people photographs and other more con- ences in the understanding of the phrase “play image generated by the spoken word ‘house’ or ‘tree’ crete referents will be easier to understand than with your child”. Life experience is so important in with the feeling / association of ‘happy’ and with the even the most pictographic symbol. However for shaping our understanding. Early in my career I idea / concept of ‘under’ or ‘this’ - see figure 1). others they can be more visually confusing than a realised a client thought there were five types of people: girls and boys, women and men - and Figure 1 Comparison of “picture producing” versus “non-picture” producing symbols across four different symbol systems Blissymbol Makaton PCS Rebus wheelchairs. Given the language he heard around Blissymbols are reproduced him every day and his extremely limited life experi- from “Bliss for Windows - ence, this was an obvious link to have made: “Line house Export Program”, Pub. Handicom, The Netherlands, the wheelchairs up at the door”, “The wheelchairs 1996. Makaton symbols are go in the bus first”, and even “Wheelchairs have reproduced from “The their dinner first - they take longer to eat”. Makaton Core Vocabulary tree Data Base” Pub. Makaton Vocabulary Development 3. Flexibility: Project, Camberley, Surrey, 1996. • Vocabulary? Rebus Symbols are Shades of meaning can be hard to convey, and mor- happy reproduced from “Symbols for Windows 2000”, Pub. Widgit phological and syntactical markers may be lacking Software Ltd., 124 Cambridge in a graphic communication system. Where the Science Park, Milton Road, Cambridge, 2003. emphasis is on a functional means of communica- under PCS are reproduced from tion, full grammatical sentences can seem a luxury. Picture Communication Symbols, 1981-2002, However the use of graphic symbols to represent Mayer-Johnson Co., PO Box higher level linguistic concepts may influence how 1579, Solana Beach, CA 92075, language is acquired, understood and produced this USA. (Sutton et al, 2002). One of my clients demonstrated

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 how I the importance of not neglecting these grammatical However, remember that the graphic symbol set Symbols, Tangible Outcomes. Augmentative and features when he spontaneously generated this used is the language encoding system for its user - Alternative Communication 5 (4): 226-234. novel message: “Grandpa sore leg get (then he how they think, how they work out what the world Sutton, A., Soto, G. & Blockberger, S. (2002) selected the past participle key) got bandage”. I means. Don’t change or introduce a new system with- Grammatical Issues in Graphic Symbol was so excited to hear this as he had only been pro- out a lot of thought. Try to be consistent across all the Communication. Augmentative and Alternative vided with a symbol based electronic communica- different things the person uses - computer program Communication 18 (3): 192-204. tion aid three months previously, when he was 3;11. for writing, the symbol set in their high-tech aid and Trapnell, N. & Chapman, J. (2002) Reading with Abbot (2000) provides a useful overview of the in their low-tech display. Apart from that, don’t worry Symbols at Frederick Holmes School. main reasons for using graphic symbols, such as too much about which symbol system to use. Just Communication Matters 16 (1): 29-31. for accessing information, to support inclusion, to choose one, and get out there and use it! Walker, L. & Keating, F. (2000a) Being Arrested. aid comprehension, to develop literacy skills. It Grampian Primary Care NHS Trust (for more infor- can be helpful to ask yourself: References mation contact Lynn Walker, Speech and Language • Why do I want to use the symbols? Abbott, C. (ed) (2000) Symbols Now. Widgit Therapy Department, Woodlands Hospital, • What am I hoping to achieve? Software Ltd. Craigton Road, Cults, Aberdeen AB15 9PR). • Why am I introducing symbols in the first place? Aitken, S. & Buultjens. M. (1992) Vision for Doing: Walker, L. & Keating, F. (2000b) Being a Witness. In addition, you should consider: Assessing Functional Vision of Learners who are Grampian Primary Care NHS Trust (see 2002a). Multiply Disabled. Moray House Publications, • What other graphic symbols systems are in use? Sensory Series No. 2. Resources Look not just at the client’s current school or Huer, M.B. (2000) Examining Perceptions of • Blissymbols (Blissymbolics UK c/o the ACE Centre, resource centre, but also at what is used in the Graphic Symbols Across Cultures: Preliminary Study 92 Windmill Road, Headington, Oxford OX3 7DR) local environment and wider community. of the Impact of Culture/Ethnicity. Augmentative • Makaton (The Makaton Vocabulary Development and Alternative Communication 16 (3): 180-185. Project, 31 Firwood Drive, Camberley, Surrey GU15 3QD) • What support is available? MacDonald, A. (1998) Symbol Systems, in Wilson, • Picture Communication Symbols (Mayer-Johnson Symbols become more functional if they are not A. (ed.): Augmentative Communication in Co., Box 1579, Solana Beach, CA92075-1579, USA) the preserve of the therapy cupboard! Look for Practice: an Introduction - revised edition. CALL • Rebus (Widgit Software Ltd., 124 Cambridge computer packages for writing, symbol games, Centre, University of Edinburgh. Science Park, Milton Road, Cambridge CB4 0ZS) books with symbol support, using symbols in Phillips, J. (2001) The Culture of Community: Do par- • DynaSyms (Sunrise Medical Ltd., AAC Department, email, symbolised websites. ents and speech and language therapists mean the Sunrise Business Park, High Street, Wollaston, Symbols are becoming more mainstream in our same thing when they talk about play? Paper pre- West Midlands DY8 4PS) increasingly visual, pictographic world. Graphic sented at the XXV IALP World Congress, Montreal. • Minspeak (Prentke Romich International, symbols are on crisp packets, our computer Rowland, C. & Schweigert, P. (1989) Tangible Minerva House, Minerva Business Park, screens, clothes labels, by the side of roads, at air- Symbols: Symbolic Communication for Individuals Lynchwood, Peterborough, Cambs PE2 6FT) ports. Symbols can make a real difference for the with Multisensory Impairments. Augmentative • Bonnington Symbol System (Bonnington Resource people we work with (see Walker & Keating and Alternative Communication 16 (2): 61-78. Centre, 200 Bonnington Road, Edinburgh EH6 5NL) 2000a and b; Trapnell & Chapman, 2002). Rowland, C. & Schweigert, P. (2000) Tangible • Speakability, 1 Royal Street, London SE1 7LL. Communication - by the book

A communication book is a Sally Millar explains how a cookery session), dinner place mats (for simple, low-tech aid to commu- different communication lunchtime chat), hard backed folding boards, cred- nication either on its own or as books match different it card sized symbol wallets, keyring / chain on a part of a range of augmenta- belt clip, stuck inside a plastic lunchbox with carry tive communication methods. clients’ abilities and handle, on an apron or ‘vest’ (Goossens & Crain, Communication books are on a situations. 1992) or mounted on an eye gaze (ETRAN) frame. continuum. In its most complete form, a communication book At one end of the continuum are resources • a more structured ‘Conversation Book’ which is a full-scale formal communication system, consist- whose primary purpose is to provide listeners and ‘scripts’ exact questions for the communication ing of a large bank of symbols and words, providing potential communication partners with back- partner (“Ask me where I went at the weekend”; the user with access to a comprehensive vocabulary ground and day-to-day information about the “Ask me where I like to go best”) alongside the covering any and every situation. To produce an person (which might or might not be accessible to symbols which will provide the answers. efficient communication book, consider: the client). These include Personal • a photograph album to stimulate conversation. Communication Passports (Millar, 2003) and home Captions or accompanying stories can be written 1. Design school / centre diaries. in symbols if that helps. (The easy-to-use new First consider the basics - size, shape, weight, In the middle ground are resources such as a sym- ‘Talking Photo Album’ (Liberator, £32) is a cheap style. A4 ring binders are often too unwieldy and bol diary, which provide some element of back- and cheerful way to turn photo albums into - importantly - ‘uncool’. A5 size display folders or ground information, and also a shared context for communication aids.) ‘FiloFax’ style (from office supply catalogues, sta- conversation using text, photos, pictures and sym- Towards the other end of the continuum are tioners and photo shops) are better, with pages in bols. Other examples are: resources used more independently for day-to-day plastic pockets or laminated. • a scrapbook or ‘Clue Book’ in which the writer interactive communication. Displays can be of a For people using the Picture Exchange attaches objects of significance, such as a birthday limited amount of vocabulary linked to one specific Communication System (PECS™), the communica- candle, shop receipt or cinema ticket, plus a setting or topic, or a full-scale vocabulary bank. tion book is organised very specifically using prompt to launch an appropriate conversation Symbols can be displayed in all sorts of ways, Velcro strips on each page, with each individual path (“Guess where we went on Saturday”). including: laminated topic sheets (such as for use in symbol Velcro-backed, so that it can be easily

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003

how I detached and exchanged with the communi- scheme (verbs in green, people in yellow, descriptors Look, stop, come, like, help cation partner either on its own or attached in blue, determiners, prepositions etc. in white or I (me, mine), you/yours, Mum, Dad, to the ‘sentence strip’. grey, objects, places and other nouns in orange (and More, not Full-scale communication books can con- sometimes red), social phrases in pink.) (If coloured (I need the) toilet: I feel bad; tain photos, pictures, symbols or words, or a backgrounds are used, symbols may need to be I’ve finished; more please; I like it; I don’t like it; I mixture of some or all of these. The layout black and white / transparent, rather than coloured, want; I need has to be both logical and intuitive to navi- to make the page less visually ‘busy’ overall.) What’s happening?; When? gate around and find the symbol required, You’ve got that a bit wrong, I’m going to start and physically possible for the user to indi- 2. Vocabulary selection and organisation again; it’s something like; opposite; sounds like cate. The organisation, layout, style and cho- Selection of vocabulary will be coordinated by (Yes & No unless they can be indicated clearly in sen size and number of symbols per page has one person, often the speech and language ther- some other, unaided, way.) to take into consideration a range of factors, apist, but input will be sought from everybody I like to mount this ‘frequently used’ vocabulary including: with whom the book user is in contact, especially on the inside covers of the book, around the out- • Vision and visual perception, visual processing, parents and family. Once everyone has been side of the symbol pages that are cut smaller than visual scanning informed about the plan to develop the book, cir- the total area of the binder. Another strategy is to • Developmental, cognitive and linguistic culate an ordinary exercise book with vocabulary have the core vocabulary on a separate page levels page headings on it, leaving people to fill in the attached to the inside cover of the front of the • Motor planning words and phrases that they feel are important to book that unfolds out to the left hand side, to be • Accessing method (direct pointing (range? the user in various contexts. This will ensure firstly permanently visible and accessible whilst the user accuracy?) or indirect, such as eye pointing, that vocabulary is relevant and motivating, and turns to different vocabulary pages of the book to coding). secondly that family and team members feel the right. With smaller books, the actions and sen- However the book is organised, it should involved and have a sense of ownership, making tence starters might be down the left hand side of include explicit guidance for communication them more likely to use the book constructively. each page, with descriptors across the top of the partners and helpers about what to do and Mechanisms will be put in place to update vocab- page, each colour-coded. what not to do to help the user, what they ulary regularly. should expect the user to do, and ideas for We have to ensure that books contain a full 3. Symbol books and language development when and how to use the book. This will range of communication functions (not just lists To develop a user’s linguistic ability, the book include clear instructions about how the of nouns, “I want” requests, and one-word needs to reflect the user’s actual level of language partner is expected to ‘model’ book use by answers to questions). Include vocabulary for and cognition ability, plus room for growth. pointing to symbols themselves as they chat attention grabbers, questions, conversation main- Latham (2003) has developed a prototype com- with the user. tenance, interjections, and comments and so on, munication book design based on her earlier work It is usually helpful to have an index page, and a mixture of different parts of speech. at the Redway School (Latham & Miles, 1997) in and coloured dividers and staggered ‘tags’ Once collected, vocabulary will commonly be which vocabulary is not only divided up into core (with colour or symbol on them) to help part- divided up into frequently used and highly func- and fringe vocabulary but also into developmental ner and user alike to locate sections of the tional ‘core’ vocabulary and specific but vital stages 1-5 (matching the ‘bands’ outlined in the vocabulary quickly. Typical sections for a child ‘fringe’ vocabulary which keeps conversation book). A Stage 1 left-hand core page has a few key might include home, people, places, activities, going. (Nobody says “I had food” - they say “I had words and phrases, while a Stage 5 core page has body parts, feelings, food & drink, clothes, ani- a ham and tomato toasted sandwich and a coke, ‘fold-outs’ with a full set of core ‘chat words’, mals, transport, school (weather, colours, num- at the Silver Spoon”.) questions, pronouns, and starters. bers, money, time, reading book characters.) Users may need some of the core vocabulary so It is important, however, not to overlook low On vocabulary pages, colour coding can be often that it needs to be displayed all the time. tech, simple options. One of my most successful used to make it easier for users to scan Depending on developmental level, these might AAC solutions consisted of a piece of white paper through and visually locate specific symbols. include frequently used key vocabulary, social with the letters of the alphabet on it (in QWERTY Unless some other specific colour code is in phrases, sentence starters, and vocabulary expan- rather than alphabetic layout, to link with com- operation, I suggest the Fitzgerald Key sion strategies, for example: puter use) cut to size and inserted into a clear

Figure 1 Communication Books Continuum How much involvement does the person have in the communication? How independent is communication?

not at all little some, with support more even more, most much wider range Traditional Passport Diary written in Simple topic related Full scale Voice output aid documentation and symbols, Photo communication communication book; records, assessments, Varying degrees of album, Personal display, eg. topic chart, word board, letter Input is fully reports etc. input from person scrapbook, Clue daily lunch menu, board. independent, possible; lots of input book, Conversation storyboard, activity (though introduction No input from from family. book. choice cards. Full vocabulary and learning process person. available: input from may be long). Input from person is person is largely often prompted. Use independent but may be ‘modelled’ by output is ‘mediated’ partner as ‘aided - sometimes language stimulation’. developed and expanded, always spoken out loud and / or scribed - by listener

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 how I plastic zip pencil case bought in Woolworth’s for diaries, scrapbooks, and so on, which may all be Resources 49p! This could be folded into a pocket or bag and drawn in at some point in the conversation to fill ACE Centre North - Developing and Introducing brought out on any occasion when oral speech an information gap, prevent or untangle misun- Communication Books, attempts ran into trouble and backup was called for. derstandings, or illustrate a point. www.ace-centre.org.uk/html/resources/Combooks/. Trials have shown that the intelligibility of someone The strengths and advantages of low tech com- CALL Centre website (Passports Section & with indistinct dysarthric speech, such as that of munication books are many. A book is cheaper than Resources) (also downloadable Clicker grids and many people with cerebral palsy, can be massively a voice output communication aid, though we must BoardMaker topic charts) increased if the user points out even just the first let- not forget the ‘hidden’ - and recurring - costs which www.callcentrescotland.org.uk. ter to help listeners ‘decode’ what they are hearing. include loads of staff time, and also software, Cambridge Adaptive Communication (Mayer While Passports, diaries, photo albums, conver- colour printer cartridges, laminator and laminate. A Johnson communication folders and symbol sation books and letter boards may be hand- book is sometimes also simpler and quicker to use, resources books, BoardMaker and Handicom made, a computer is necessary to produce an and is accessible to all sorts of people in the widest Symbols for Windows (software) acceptable-looking full-scale symbol communica- range of day-to-day contexts. www.possum.co.uk/Cambridge/Index.htm). tion book. Key software will probably be either Clicker 4 (software): information from BoardMaker (with Mayer Johnson Picture References www.cricksoft.co.uk/uk/clicker_products/. Communication Symbols (PCS) only, printout Goossens, C. & Crain, S. (1992) Engineering the Liberator Ltd. (talking photo albums) only); or Writing with Symbols 2000 (Widgit preschool environment for interactive symbol www.liberator.co.uk. Rebus, PCS, or Makaton symbols, printout and / or communication. Birmingham Al. SouthEast Mayer Johnson (communication folders and onscreen use). But remember that high tech voice Augmentative Communication Conference Speaking Dynamically Pro (software)) output communication aid software such as The Proceedings, available in UK from Cambridge www.mayerjohnson.com. Grid, Symbols for Windows, Speaking Dynamically Adaptive Communication. Pyramid Educational Consultants UK Ltd. (PECS Pro, Clicker 4 will also offer printout options, so if Latham, C. & Miles, A. (1997) Assessing communication books & other materials) your client is using a computer-based voice output Communication. David Fulton Publishers: ISBN: www.pecs.org.uk/. system, you could use the same software for both 1853465038. The Grid (software): information from the high and the low tech version. Latham, C. (2003) personal communication. www.sensory.com. The many different types of communication Millar, S. (2003) Personal Communication Widgit Software (Writing with Symbols 2000, book meet different needs (figure 1). In an ideal Passports: Guidelines to good practice. CALL ideas and resources, link to Symbol World site) environment, people with communication diffi- Centre, ISBN 1 898042 21 1. www.widgit.com. culties can use not just one but as many as they Pound, C. & Hewitt, A. (2003) Conversation find helpful. Pound & Hewitt (2003) refer to such Partners and Communication Access: a roadmap resources as ‘communication ramps’ providing to inclusion. Presentation at Communication (A fuller version of this article with accompanying access to social conversation, and show videos of Matters Symposium, Lancaster, September 2003 pictures will be on the magazine’s website people with aphasia sitting with their listeners at Sahian, D. (2002) Fitzgerald Key www.speechmag.com from publication of the tables covered with several different albums, www.bbbautism.com/pecs_fitzgerald_key.htm Spring 04 issue at the end of February.) A case of need

In her Keynote Speech at It took five years for and language therapy support had led to a lessening Communication Matters 2002, Nottingham to get a specialist of skills? In fact problems included broken devices, Dr Pam Enderby stated that peo- AAC post for adults. a Minspeak™ system only used in spell mode plus ple with alternative and aug- the client felt it was “too heavy”, and expired war- mentative communication Cheryl Davies charts the ranties. Some families had received no training in needs require long-term speech initiatives, successes and AAC or the communication aid, and others were no and language therapy support longer physically able to use an aid. for review of their physical status and to keep up ongoing challenges of the I assessed that the adults with learning and / or with evolutions in technology. Specialist AAC speech first 18 months. physical disabilities population fell into broadly and language therapists for adults are nonetheless three groups of clients: thin on the ground. I have had the opportunity to college with a voice output device received limited Groups of clients Speech and language develop this kind of service in Nottingham and hope support from non-specialist therapists. The aim of therapy time needed my experience will contribute towards our under- the AAC service was to dovetail with the children’s for standing of good practice in this field. service to include young adults with physical dis- 1. Those who have never • familiarisation with The post of specialist speech and language ther- ability and adults with a learning disability who used a voice output the aid apist for AAC to work with adults with learning needed a communication aid. The bid included 0.5 communication aid • staff training and / or physical disabilities was realised in whole time equivalent therapist time for assess- 2. Those who have been • training new staff January 2002 after a five year campaign by Sue ment and ongoing support, assistant time and a introduced to AAC at • identifying and Thurman, the manager for speech and language budget for communication equipment. school or college and supporting new therapy services to adults with learning disabili- I was appointed with several years’ experience have ongoing needs environments and ties in Nottingham. She had made a case of need working in AAC. One of my first jobs was to review communication needs and submitted bids to the Health Commissioners all the people known to the service. At the back of 3. Proficient users • updating vocabulary for Learning Disabilities. Initially funds became my mind was the knowledge that several AAC on the aid available for equipment - but Sue declined this users no longer used their device, and I wanted to • staff training until there was someone in post who knew how get an overview of why this was. Maybe the aid • re-assessment to use it. Prior to this, people leaving school or was no longer suitable? Perhaps insufficient speech

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 how I

I set out to establish baselines, to audit and The AAC service receives a budget from health help me become more familiar with them and are review, identify equipment needs and liaise with for equipment and resources. This was spent ini- always available to demonstrate to users and all parties who would potentially have contact tially on assessment tools, a device for one client their families / carers. The phone support is essential. with the service. I visited speech and language and equipment for a loan bank. I have also • Communication Matters conference held at therapists in hospital and children’s services with accessed funds through the Learning and Skills Lancaster University in September each year. AAC roles, Disabled Person’s Act Workers, the Council for a student in full-time education, • Websites such as The ACE Centre, CALL Centre, Independent Living Team, the local Further secured funds from an Further Education college AAC Intervention, Communication Matters (see Education college, Day Services for people with towards a mounting system and social services resources). physical and learning disabilities, SCOPE and have agreed to part fund one aid using Direct • Knowing the geographical area and some of the Disabilities services. I also linked with communica- payments. An ongoing issue will be the replace- resources available. tion aid services in the region and nationally to ment of older devices balanced against the needs Apart from the usual joys of working with technology network and gain support for current and good of people with no aids. This year we have paid for and not having the time and funds to do as much as practice. I was already secretary of the Trent warranties and funding or part-funding four aids. you’d like, some of the things I find difficult are: Region AAC SIG. • Working in a community post. It is a real challenge I have now been in post for 18 months and 3. The first new communication aid user to support people in a wide range of environments would like to give examples of initiatives, ongo- My first new communication aid user was Brian and to try and meet the training needs of ing issues and some successes: (40). His day centre has provided a high level of support staff. support to help the introduction of the aid. He • Knowing that best practice is for a multidisciplinary 1. User group has used it to clarify and repair communication team approach while working in a fairly I was very keen for all AAC users and their parents / breakdown. Everyone is pleased with that and unidisciplinary way. We are working towards carers in the area to get together and we have now there is potential for more skills development. involving other disciplines. met three times. I am supported in this by speech This was also my first opportunity to co-work with • Limited local support for technology and and language therapy technical instructors. My ini- another speech and language therapist in the integrated systems. tial aims were for the communication aid users to team who had previously provided a communica- Whether it’s programming an aid, staff training, meet other users, have a social communication tion book. We have looked closely at our roles helping a user write guidelines for new staff on how opportunity and have fun. We have generally split and how to complement each other’s skills. she likes people to communicate with her, liaising into two groups so that we can: with a counsellor who was working with a client but • share experiences of supporting a person using 4. The speech and language therapy team for had never previously talked to someone using a a communication aid adults with learning disabilities communication aid, writing service specifications • develop resources that can help new carers The team has a high level of expertise in signs and and guidelines for budgetary spending or introduc- • focus on the positive aspects of AAC and symbols. They support clients and their communica- ing a new aid to a client, I really enjoy the scope of • potentially have an advocacy role for AAC services tion environments. My role within the team is clearly my job and the variety of tasks I can undertake. in the area. for high tech equipment. We are developing joint At the last meeting Stuart Meredith, a proficient working practices to utilise skills including those of Resources communication aid user and excellent role model, technical instructors. There are similarities between • Ace Centre (www.ace-centre.org.uk) came to talk to the group. The best part has the roles - people with high tech needs also need a • Ace Centre-North www.ace-north.org.uk been seeing the users having conversations. communication book and Personal Communication • AAC Intervention (www.aacintervention.com) Passport. I feel it is part of my role to field the frus- • Call Centre (www.callcentrescotland.org.uk) 2. Funding trations of working with technology! • Communication Aids Project (CAP) In AAC this is always a major issue and in all ser- Things that have helped me tackle this new post (www.becta.org.uk/cap) vices there is no one funding agency that will pay effectively include: • Communication Matters for equipment. For further information refer to • Having knowledge of a wide range of (www.comunicationmatters.org.uk) (also includes CAP and ICES websites (see resources). I am taking communication aids from Minspeak systems, information about CASC - Communication Aids part in a pilot study with ACE-North to look at Windows based set ups to less complex devices Suppliers Consortium - roadshows) extending the CAP model into adult services, with digitised speech. (At the last count the • Integrating Community Equipment Services which will help raise the issue of the continuing client group use twelve different aids supplied (ICES) (www.icesdoh.org) difficulties in funding for communication aids. A by six communication aid companies.) • Learning and Skills Council (www.lsc.gov.uk) way forward has to be for funds to be ringfenced • The support of the Communication Aid Suppliers • Minspeak( (www.minspeak.com) for communication aids. Consortium (CASC). They have loaned devices to • SCOPE (www.scope.org.uk)

...resources...resources...resources... Fragile X Group Action Black Sheep Press Speech and language therapy features in a multi-profes- Contact a Family, the national charity New items in the Winter 2003/4 catalogue sional book about educating children with Fragile X. for families with disabled children, from Black Sheep Press are a narrative Contributors include Jeremy Turk, Kim Cornish , Cathy Taylor has produced an updated pack for assessment Peter & the Cat (see reader and Vicki Sudhalter, with each chapter suggesting intervention parents who would like to set up a offer), Story Starter pack to complement strategies based on sound educational principles. Members of local or national support group with existing Narrative packs, concept packs the Fragile X Society are entitled to a reduced rate. other parents in a similar situation. (Either / Or and All / Except), two sets of Educating Children with Fragile X is published by For a free Group Action Pack, barrier games and, in Phonology Resources, RoutledgeFalmer and costs £22.50 freephone 0808 808 3555, e-mail revised ‘s’ clusters. (www.routledgefalmer.com). [email protected], or see See www.blacksheep-epress.com, or www.fragilex.org.uk www.cafamily.org.uk. telephone 01535 631346 for a free catalogue.

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Your personal details will only be used for the purposes of Speech & Language Therapy in Practice magazine and will not be passed to any third party. SUBSCRIPTION FORM SUBSCRIPTION FORM MY TOP RESOURCES 1. The actual process of 4. ‘Rosanna Rib Xylophone’ 7. One small dog interaction This simple wooden instrument is ideal for Quite apart from the well-known physical Children’s spontaneous movements, sharing, and is attractive, versatile, portable and mental health benefits, having a dog sounds and words are valued and incorpo- and sturdy. It can be held vertically and means daily walking, which gives vital rated into individual and group sessions. played from both sides; you can even see space and time for creative thinking. I’ve Interactive games and songs therefore each other between the bars. It’s great for even been known to use non-directive develop in diverse and often unexpected non-verbal musical conversations. Not techniques on my four-legged friend by 5 ways. These developments give me ideas being tuned to specific notes, you can’t singing a commentary on her activity, to Top: Wendy to keep up my sleeve and offer as sug- play a tune on it, which can help people practise fitting words to a tune. with her gestions to others. to lose their inhibitions. It often stimu- Contrary to popular belief, even ‘musical’ autoharp By observing and experiencing exactly lates exploration, and reinforces learning people need to practise. On my early Right: what happens when two people share a about ‘up’ and ‘down’ in space and pitch. morning walks I rehearse songs (internally, ‘Rosanna Rib song, I’ve learned strategies that enable Available in kit form, to sand, decorate not usually out loud!) and make up or Xylophone’ children to take an active part, such as and string up. £13.00 plus p&p, from Kate adapt words, to the steady beat of my Below: using both subtle and dramatic pauses at Baxter, tel. 0115 9609528 or e-mail footsteps. A new song may take one or One small dog 4 key points. I’ve seen new life brought to [email protected]. (Note: A beater is several dog walks to compose, depending old favourites... Have you tried ‘Head and included, though not the one pictured, as on complexity. Shoulders’ slowly and fast, quietly and shorter, sturdier beaters are needed for loudly, forwards and backwards? Such young children. Sanded, painted and var- 8. Informed Intuition contrasts often surprise and delight the nished dolly pegs work well.) Phil Christie at Sutherland House coined children, and tempt them to communicate this phrase, to describe how staff work their preferences. 5. The Autoharp interactively. Our instinctive, playful If you’ve never played an instrument and responses to the children are backed up 7 2. One decent drum would like to strum as you sing, this could by knowledge of their individual needs Following a child’s lead as he explores a be your starting-point. It’s a zither with and personalities, as well as early commu- Wendy Prevezer is drum often leads to shared play and turn chord buttons: you simply press a button nication skills, autism and interactive taking: drum conversations can be addictive! with one hand and sweep across the approaches. Knowledge gained from both a speech and ‘Quiet’ children may express themselves strings with the other, to produce a rich reflecting on our own practice by thinking confidently with hands or beaters, and harp-like sound. The buttons are labelled, about, discussing and watching video of language therapist many are fascinated to hear their own so you can follow guitar chords from sessions also informs how we implement and a musician sounds, movements and words reflected songbooks. our intuitive skills. back to them in drumbeats. I use mine mainly to accompany songs for She works as a In a group, a drum provides a powerful groups, and it’s worked wonders for my 9. Video facilities joint focus, and can be used in songs and singing confidence. Children and adults The benefits of having sessions on video music specialist at games to facilitate interaction. A hand-held are drawn to it, and it’s hardy enough to far outweigh the discomfort. We find the Sutherland House one (for example, a bodhra´n, tambour or put on the floor for toddlers to explore least intrusive way is to put the camcorder ‘lollipop’ drum) may be passed round or with supervision. on a high shelf, wedged at an angle to School in offered to individuals and pairs; a bigger Information and courses: cover most of the room. Nottingham for one can stand centrally to draw children www.ukautoharps.org.uk. Videos can show progress in communication in together. skills, including subtle qualities of interaction children with If you cannot invest in one quality drum, 6. Game-Songs with Prof that may not have been recorded otherwise. do explore the sounds you can make with Dogg’s Troupe When watching, we sometimes see and autism and runs boxes and tins - you may be surprised. Generally I try to avoid recommending hear communication that we missed at musical playtime just one songbook, but this was my inspi- the time, and revise our own evaluation. 3. Fabrics ration for ‘flexible’ songs in the 1980s, We can share developments with parents sessions for babies A simple piece of material can be a brilliant when I was discovering non-directive and other staff, and some children love aid to shared play. Chiffon scarves, techniques. It’s definitely stood the test of watching and commenting on their own and toddlers in her thrown and blown, scrunched and hidden time: I’ve used ‘Say hello’ and ‘We can do sessions. Edited tapes of extracts are also local community or put over faces, often engage a child. A anything’ several times a week for years, invaluable for training, to illustrate tech- sheet provides a place to hide for ‘peek-a- and am not yet bored. The songs are niques and responses. She also gives boo’, making eye contact fun and worth- catchy, easy to learn and very popular, while for its own sake. Two people under with opportunities to sing about whatever 10. Ourselves courses and a sheet often gaze at each other in a a child does or says. ‘When a dinosaur’s I learned from Dave Hewett many years workshops on more sustained way, leading to face and feeling hungry’ and ‘Walking through ago that a responsive adult is ‘the most voice play. A ‘Go to sleep’ song is often a the Jungle’ can also provide frameworks wonderful and flexible piece of equipment’ using music first step into imaginative play, but for more complex verbal conversations. in interactive work. The way you use your coloured fabrics can be houses, rivers, By Harriet Powell (1983; 2001 with CD), face, voice and body can enhance the to facilitate tents, grass and so on as well as blankets. pub. A.&C. Black. quality of interaction and relationships, social and Groups also have great fun with pieces of whether or not you incorporate fancy fabric. Shaking and stopping together, props and instruments. I spend much of communication raising it above heads, or stretching it my working life helping others to see skills and letting go, can lead to play routines that their ‘human ability to be sensitive and songs which act as frameworks for and flexible, to behave contingently, and interaction. to enter into an interweaving of behaviour with the pupil’ is the most valuable resource of all. Quotations from Hewett, D. (1989) The most severe learning difficulties: Does your curriculum ‘go back far enough’? In: Ainscow, M. (Ed.) Special Education in Change. David Fulton Publishers. I also highly recommend: Nind, M. & Hewett, D. (2001) A Practical Guide to Intensive Interaction. BILD Publications.