Speech & Language Therapy in Practice, Winter 2008

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PLUSMy Top AssessmentHeres one I made earlierreviewsgreat readeroersand concluding our series on supervision

www.speechmag.comPieces o the jigsaw

How Iuse EPG

Childrenand adults

ISSN 1368

Service deliveryA ying start in nurseries

User involvementPeople with dementia

Teaching and therapyThe best o both

Transitions

From primary to secondary

Happy birthdayTo PECS, Talking Mats and Aasic

My Top ResourcesChildrens Centres

Winter 2008


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Readeroffer

Winter 08speechmagForum

For discussion o articles in Speech &Language Therapy in Practice.Anyone can read the orum messagesbut only registered subscribers can post.Register at http://members.speechmag.com/orum/ with a user name andpassword o your own choosing.

Members areaFor a reminder o your user name andpassword, email [email protected] members area includes:

Extra online only articlesMaterial complementary to articlesBack issues rom 20002006

Win the Signalong Basic Vocabulary Dictionary!The Signalong Group has come a long way since its rst

manual o signs was published in 1992. A recent release

is the Signalong Basic Vocabulary Dictionary and one

copy is going FREE to a lucky reader o Speech & Lan-

guage Therapy in Practice.The Dictionary contains all the signs in the Basic Vo-

cabulary Phases 1-4 manuals arranged alphabetically

in three A5 books complete with slipcase. Every sign

is ully described and illustrated. There are additional

sections on days o the week, months, numbers and

name signing. The Dictionary retails or 75 but you

have a chance to win one FREE simply by e-mail-

ing your name and address by 25th January 2009

to [email protected], putting SLTIP Dic-

tionary Oer in the subject line. The winner will be

notied by 1st February.

Details o this and the ull catalogue o Signalong

resources are at www.signalong.org.uk.

See also reader oer on p.21.

Reader Oer WinnersThe lucky winners o the Speech Sounds Cards rom Speaking Matters in our Autumn 08 issue are Grianne Dorian and

Elizabeth Gadsden. The Black Sheep Press Copycat DVD goes to Jean Kennedy, Christine Hobden and Barbara Kendray.

Congratulations to you all and please keep your entries coming.

NEW! Only online articlesadded or Winter 08!

www.speechmag.com/Members/

Editor Avril Nicoll reports rom

a Symposium held to celebrate

10 years o the low tech

communication ramework Talking

Mats (www.talkingmats.com).

www.speechmag.com/Resources/

Originals

Avril Nicoll reects on the Aasic

Scotland 40th Anniversary

Conerence Growing up with a

speech and language impairment.

Speakers included James Law,

Marysia Nash and Amanda Kirby.

www.speechmag.com/Members/


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INSIDE FRONTWin the Signalong Basic VocabularyDictionary. See also reader oeror CLEAR Phonological ScreeningAssessment on p.21.

4 SERVICE DELIVERYThey [nursery sta] were keen tobuild on the skills they already had,and make their interactions withchildren more positive rather thanrepeatedly asking them questionsCollaborative working with earlychildhood educators can bechallenging but, with commitmentand support, newly qualiedtherapist Esther Blackgets o to aFlying Start.

7 USER INVOLVEMENT

Collecting the eedback was a smallpart o the process but, in retrospect,it has taught us more about how totake the group orward than our ownreections did.Charly Harveys success in enablingpeople with dementia to expresstheir views on a therapy group runjointly with a clinical psychologisthas inspired her to continue makinguser involvement a priority.

10 COLLABORATIONOn reection, I eel I gave mysel quitea hard time as a teacher and had

potentially unrealistic expectations ohow well and how quickly I could helpthe children learn to listen.Drawing on her dual trainingand experience as a teacher andspeech and language therapist,StoryPhones consultant KirstiePage explores what she has learntrom sitting on both sides o theence.

13 HERES ONE I MADE EARLIERAlison Roberts with the low-costseasonal activities Save your cracker

jokes, Interaction paper chains orChristmas and Git list.

Winter08contentsWinter 2008publication date 30 November

2008ISSN 1368-2105

Published by:

Avril Nicoll,33 Kinnear SquareLaurencekirkAB30 1UL

Tel/ax 01561 377415e-mail:[email protected]

Design & Production:Fiona Reid,Fiona Reid DesignStraitbraes Farm,St. Cyrus, MontroseAngus DD10 0DS

Printing:Manor Creative,7 & 8, Edison RoadEastbourne,

East Sussex BN23 6PT

Editor:Avril Nicoll,Speech and Language

Therapist

Subscriptions andadvertising:

Tel / ax 01561 377415Avril Nicoll 2008Contents o Speech & Lan-

guage Therapy in Practice re-ect the views o the individualauthors and not necessarily theviews o the publisher. Publica-tion o advertisements is not anendorsement o the advertiseror product or service oered.Any contributions may alsoappear on the magazinesinternet site.

Speech & Language Therapyin Practice can be oundon EBSCOhost researchdatabases

14 TRANSITIONSThe activity that had the biggestimpact over all the years audited waspractice using and understandingthe timetable. Other activities thatconsistently scored highly were

subject vocabulary, homeworkplanning and making riends.Nadine Arditti and Debbie Switsannual group aims to reduceanxiety and ease the processo transition rom primary tosecondary school or pupils withcommunication difculties.

16 CONFERENCE CALLSThe dening eature o PECS is thatit teaches spontaneous requesting asthe rst skill. I a child who uses PECSis prompt dependent or is not acting

spontaneously, Lori argues this isbecause they have never been taught or taught properly to requestspontaneously.Editor Avril Nicoll reports rom aday spent with Lori Frost, AndrewBondy and Julia Biere as theycelebrated the 10th birthday in theUK o the low tech AAC tool PECSPicture Exchange CommunicationSystem.

18 SUPERVISION (4) FROMSUPERVISEE TO SUPERVISORthere are inherent assumptionsand expectations that the therapistsimply steps up to the next level and byosmosis develops the requisite skill set

to take on the role o supervisor.Sam Simpson andCathy Sparkesconclude their popular series onsupervision practice.

20 REVIEWSAphasia goal setting, amily and caregivers, oreign accent, head and neck,music in therapy, social interaction.

21 MY TOP ASSESSMENTSimon Henderson recommendsthe CLEAR Phonological ScreeningAssessment while Alyson Eggett

praises the basic principleso Teaching SpontaneousCommunication to Autistic andDevelopmentally HandicappedChildren.

BACK COVER MY TOPRESOURCESIts great when parents move rombeing on the periphery o groups tojoining in, becoming involved andeven leading sessions!Speech and language therapistsin the Waltham Forest ChildrensCentre Team list the people,

approaches and tools that are mostimportant to their work.

22 COVER STORY: HOW I USE ELECTROPALATOGRAPHY(1) In his [Gabriels] case treatment needs to address respiration and phonationinstead of articulation to try to improve his intelligibility. We didnt know thisbefore his speech was evaluated by EPGWhen traditional therapy techniques were not proving efective with twoboys who have dysarthria due to dyskinetic cerebral palsy, Ann Nordberg,Elvira Berg, Goran Carlsson and Anette Lohmander ofered real-timevisual eedback through EPG.(2) for a person whose intelligibility is severely reduced and who for whateverreason cannot use AAC, EPG could be worth pursuing even for small gains.A stroke at the age o 33 let Lesley Anne Smiths client with impairmentswhich aected his ability to return to work and his motivation to socialise.She explains how EPG had a small but important impact on his articulatorydyspraxia and intelligibility.

IN FUTURE ISSUES: DYSPHAGIASTORY TELLINGADVOCACYBILINGUAL

INSIGHTSGROUP LEARNINGSYMBOLSPHONOLOGYDOWNS SYN-DROMEMOTOR NEURONE DISEASE

AUTUMN 08s earticle at www.speechmag.com/Members/

E1 TALK & PLAYTalk & Play has now been accepted as one o the pathways within our commu-nity service. Sta see it as a very positive way to help many o our amilies andtackle parent-child interaction in a non-conrontational way.Penny Best looks back on the development o a new type o care packageoered or preschool children with language difculties.

Thanks to Gabriel and to Ann Nordbergfor our cover picture by Sergio Joselovsky,www.sergiojoselovsky.se


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NEWS

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20082

Story writers rewardedThree winners o a story writingcompetition or AAC users wereinvited by the charity Communi-cation Matters to read their workat Downing Street.

Sean Lucas 7 proessed him-sel ull o joy and excited athaving won not only the UK un-der-11 award but also the ISAAC

the International Society orAugmentative and AlternativeCommunication InternationalYouth Award. Beth Moulam 14won the 12-16 category and saidI cannot believe it, I just wrotemy story Just Talking based onme. The 17 and over categorywent to actor Alan Martin. Allthe entries had to have reerence to AAC and the three winners wereselected on the basis o content, originality and structure.All entries rom the UK are at http://www.symbolworld.org/stories/cm_sto-ries/index.htm.

Praise or Health Proessions CouncilThe Health Proessions Council has received a very positive annual per-ormance review rom the Council or Healthcare Regulatory Excellence.The report says that the HPC is an eective, publicly accountable regula-tor which has good communications with registrants and the public, inspite o dealing with a larger and wider range o health proessions thanthe other regulators.The CHRE report covers nine health proessions regulators including theHealth Proessions Council, the General Medical Council and the GeneralDental Council. The CHRE was able to draw attention to good practice ideasin areas such as standards and guidance documents, registration, manag-ing tness to practise processes and communication. While eight regulatorswere ound to be perorming well in their duties, extremely serious concerns

were raised about the Nursing and Midwiery Council.http://www.chre.org.uk/_img/pics/Per_Rev_Report_1.pd

The Motor Neurone Disease Association haslaunched a pathway tool to help proessionals in-volved in the care o people with the condition un-derstand and meet their needs more eectively.

In recognition that Motor Neurone Diseaseis a complex and oten rapidly progressing

neurological condition, the Year o Care path-way lists all the possible care and equipmentneeds that a person with the disease mayhave over a 12 month period. Each has a costattached to help commissioners and healthand social care proessionals plan and deliverservices in a proactive and timely way.

The pathway takes the orm o a spreadsheet,with one axis listing the various stages in loss ounction and the other listing the services andpersonnel involved in the care o people withMotor Neurone Disease. It relates the individu-als need or health and social care services tothe progression o their disease, where they arelikely to experience increasing difculty with

speech, swallowing, walking and breathing.

The tool is a result o collaboration betweenWandsworth PCT, Leeds PCT and Leeds AdultSocial Care. Proessor o Palliative MedicineBaroness Finlay commented, Its beauty is inits simplicity. This is one o the most importantdocuments or patient care I have seen.

To demonstrate the need or the pathway,the Motor Neurone Disease Association high-lighted the case o Stan Oleson rom Leeds.Some months beore his death at the end oAugust, he spoke about the delays he hadhad to endure since receiving his diagnosisve years ago: You require certain pieces oequipment to help you but by the time youreceive them you cant use them anymore asyour needs have since changed. Im hopingthat this new pathway will help me in the u-ture. I dont know how long Ive got to live butI hope to enjoy the bit I have let.For a copy o the pathway, contact the proession-al support service MND Connect, e-mail mndcon-

[email protected].

SWORD unleashedA new sotware therapy program designed to treat speech apraxia ol-lowing a stroke is undergoing a major trial ater showing signicant re-sults in early studies.

SWORD was developed by researchers at the University o Shefeld andhas been exclusively licensed to Propeller Multimedia, a company whichspecialises in rehabilitation sotware or people with communication di-culties. In initial studies, 20 clients showed signicant improvements in

the speed and accuracy o their word production ater six weeks o useand maintained this improvement up to 18 weeks ater the end o thetherapy.

The research began eight years ago, when speech scientist Dr. SandraWhiteside and clinician and neuro scientist Proessor Rosemary Varleygained unding rom The Health Foundation to evaluate new ways to un-derstand and treat apraxia.

Proessor Varley said, The opportunities oered by the IT revolutioncould be exploited, allowing patients to sel administer complete therapyregimes at convenient times and locations. The result is SWORD which,through the licensing deal with Propeller, we now hope will make a realdierence to many people with speech apraxia. Gordon Russell rom Pro-peller added, SWORD will be available in a variety o exible licenses orhome and proessional users, with multi-user licenses and subscriptions

being made available, on CD ROM, USB Pen drive and via download.www.propeller.net/sword

Year o Care

Alan Martin receives his award romChancellor o the Exchequer, Alistair Darling

ChatterboxweatherchallengeICANs 2009 Chatterbox Challenge will goahead - whatever the weather.

Come rain or shine, 2-8 February will see youngchildren across the UK perorming their avour-ite weather song to raise unds to support thecharity in its work to help children with com-munication difculties. The event, supportedby BT Openreach, has the dual purpose ohighlighting the importance o childrens com-munication as the oundation or learning anddevelopment.Activity packs are available or event organisersat www.chatterboxchallenge.co.uk.

In a separate und-raising venture I CAN isencouraging Christmas shoppers to do some-thing dierent and Adopt a Word.

www.adoptaword.com


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NEWS & COMMENT

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008 3

Comment:

Pieces ofthe jigsaw

My older son was very attached to his jigsaws

when he was little, with a line o Bob the Builder

puzzles repeatedly stretching rom one end o

the house to the other. Our authors tackle their

proessional puzzles with similar enthusiasm,

determination and vision o the completed

picture.

Charly Harvey p.7 provides the corners and

edges to support people with dementia to locate

their views - and nds their insights invaluable or planning uture

provision. Esther Black p.4 had a clear picture o collaborative

working but tting the pieces together was harder than it looked

and needed a strategic approach with guidance rom experiencedcolleagues. Meanwhile, in reporting rom both a teaching and a

speech and language therapy background, Kirstie Page p.10 helps

us understand how to bring the dierent pieces together more

eectively.

Lies transition points present us with new puzzles. Nadine Arditti

andDebbie Switp.14 guide pupils with communication difculties

rom the end o primary to secondary school, while Sam Simpson

and Cathy Sparkes p.18 help speech and language therapists make

the links rom supervisee to supervisor.

Sometimes the dierence in the cut and appearance o pieces

is very subtle. I remember giving up on a jigsaw puzzle o baked

beans. BothAnn Nordberg (p.22 with two boys with cerebral palsy

and Lesley Anne Smith p.27 with a man with a brain injury oundthat EPG identied ne but clinically signicant distinctions. In

other situations, a single piece appears to be the key. The turning

point in the development oPECS p.16 was spotting the need or

exchange rather than pointing.

As the Waltham Forest Childrens Centre Team back page show,

eective therapy is about people, approaches and tools and how

they interlock. A conerence organiser also needs to bring the right

pieces together so that those attending see the whole picture, as

at the recentAasic Scotland40th anniversary conerence see new

online article at www.speechmag.com/Resources/Originals.

Putting a magazine together brings a similar sense o satisaction

as well as relie! when apparently disparate pieces o inormation

come together and complement each other beautiully. There would

be no nal whole without the antastic input rom readers, not just

o ull-length articles, but reviews and snippets too. Please consider

submitting a 300 word My Top Assessment p.21 it wont take you

long, will count or your continuing proessional development, and

will be o use to your colleagues.

PS Winning Ways with Jo Middlemiss will return in 2009.

Johansen updateAs a result o an international agreement, Johansen Sound Therapy isnow known as Johansen IAS Individualised Auditory Stimulation.Registered providers are required to ensure they attend an Update orReresher course at least every two years, or they will no longer be ableto continue to order the programmes CDs.For inormation on courses in 2009, contact UK National Director CamillaLeslie, e-mail [email protected].

Talking Mats SymposiumTalking Mats, the low-tech ramework successully used to help peoplewith a variety o difculties to communicate, is 10 years old.Originally developed by speech and language therapist Joan Murphyin 1998 or people with Motor Neurone Disease, research and practicehas extended its use to people with learning disabilities, aphasia and de-mentia. To mark the 10th anniversary and as a particular tribute to Joan NHS Forth Valley Research and Development Committee unded aSymposium day. Editor Avril Nicoll attended - more inormation at www.speechmag.com/Members/.www.talkingmats.com

Charity cycleChristina Barnes, a speechand language therapist inWiltshire, is pictured outsideMoscow State University atthe end o a 608km cyclebetween St Petersburg andMoscow in aid o the Na-tional Dea Childrens Society.Anyone who wishes to makea donation should contactChristina at the Speech and Language Therapy Department, The HealthCentre, The Halve, Trowbridge, Wiltshire BA14 8SA or e-mail [email protected].

Meanwhile another speech and language therapist, Louise Tweedie,

has entered the 2009 Mac 4 x 4 challenge with her Land Rover Discoveryto raise money or Macmillan Cancer Support details at www.justgiving.com/mac4x4teamtnt.

Can we talk about it?A creative arts project has enabled members o a sel-help group tomake a DVD to raise awareness o aphasia.

The ST/ART Project has been providing Creative Rehabilitation Pro-gramming across Tayside or 4 years and worked on the DVD with theSpeakeasy Tayside Group. Project Co-ordinator Chris Kelly explains,The content and structure o the lm and some o the lming itselhave been very much in the control o the participants who all havepersonal experience o this communication impairment.Copies o Aphasiacan we talk about it? rom Chris Kelly, ST/ART ProjectCoordinator, THAT, Trust Ofces, Royal Dundee Li Hospital, Dundee DD25NF. Please make cheques or 5 payable to Tayside Healthcare Arts Trust.

Stroke trial invitationThe Virtual International Stroke Trials Archive VISTA has been expandedto include trials o rehabilitation, including speech and language therapy.

The resource is a collection o anonymised patient data rom previousacute stroke clinical trials, which investigators can access to carry outnovel analyses. It was set up to aid the design and planning o uture clin-ical trials. The organisers are inviting trialists to contribute anonymisedrehabilitation trial data rom the last 10 years or the benet o the widerresearch community. The trials need to have been randomised to at least20 patients and have recognised measures o stroke impairment and

outcomes measured within a dened ollow-up period.www.vista.gla.ac.uk / e-mail [email protected]


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SERVICE DELIVERY


when working in environmentally deprived areas.Te other driver or change was ongoing discus-sion within the department regarding a modelo service delivery which would build capacityin schools in line with legislation (Scottish Gov-ernment, 2008) and good practice in education(Learning & eaching Scotland, 2008). We hopedto build the capacity o early childhood educatorsin their interaction with children particularlythose with language delay which may or may notbe the result o a lack o stimulation. We reasonedthat this would have an eect on the ability o sta

to support children with additional support needs,acilitate their contribution to speech and languagetherapy goals, and help children develop towardsbeing successul learners, condent individuals,responsible citizens and eective contributors(Learning and eaching Scotland, 2008).As part o the working party, I was involved in

carrying out a literature search into training thatis eective and changes thinking and behaviour.Hulme (2005) outlines a pilot scheme oeringtraining or childcare sta using a simple sel-rat-ing tool to analyse sta-child interaction. Tis in-volved a one-day in-service plus our weekly smallgroup tutorial sessions. Sta members were askedto identiy one target or developing their interac-tion. Tis method led to sta reducing their useo questions and directions, allowing the childrenmore time to initiate. Sta eedback was positive.

Sutton & Sedgemore (2005) describe theirstrategic, coordinated response to the increaseo nursery aged children with a speech andlanguage delay. Tis involved identiying a key

Getting o to a

ying startThe transition rom student to newly qualied therapist can be rustratingwhen there are barriers to putting ideals into practice. With supportrom her colleagues and manager, as well as the ScottishGovernments Flying Start programme, Esther Blacknds thatthe biggest challenges in this case collaborative workingwith early childhood educators - can inspire the most radicalchanges and opportunities or proessional development.

a varying degree o commitment rom parentsand early childhood educators to supportingmy recommendationsa lack o shared agreement with some nurserysta about my role and about their role withinspeech and language therapy aims.Te aims or episodes o care or children on my

caseload (Malcomess, 2001) were thereore not al-ways met, and I experienced growing rustration.

Build capacityPartly as a result o this, my manager set up a de-partmental working party to consider service pro-vision to environmentally deprived areas, which I

was invited to join. A urther consideration wasthe potential health promotion role o speech andlanguage therapists (RCSL, 2006), in particular

As a new graduate I was looking or-

ward to the challenge o workingin an environmentally deprivedarea and to collaborating withearly childhood educators (nursery

teachers, early years ocers and auxiliaries) toimprove the communication skills o local chil-dren. My service provision involved working

with individual children in the nursery, workingwith sta, joint sessions with sta and occasionalshort training sessions or sta.

In the event, service delivery in the nurseries

was particularly demanding. Tis was due tomultiple actors including:the lack o language stimulation that can existin some amilies, particularly in environmen-tally deprived areashigh non-attendance rates at appointments

READ THIS IF YOUARE INTERESTEDIN ENVISIONING

THE BESTSERVICE EVER

CHANGINGTHINKING ANDBEHAVIOUR

TRANS-DISCIPLINARYWORKING

Figure 2 The best nursery ever Appropriate accommodation and resources A genuinely collaborative approach based

on shared understanding, knowledge,skills, roles, enthusiasm, training

An enabling environment eg. visual

timetables, symbolised environment.


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SERVICE DELIVERY


worker rom each nursery to attend a weekly

one-day training session. Te key worker thencascaded the inormation to other memberso sta. Tis approach intended to address thecommunication needs o all the children in thenursery, not just those on the speech and lan-guage therapy caseload.As gure 1 shows, we took these articles into

account when planning training.Our working party then considered the poten-

tial eatures o providing a speech and languagetherapy service in the best nursery ever (activityadapted rom Duy & Grin, 2000). Our ide-als are in gure 2.We discussed as a group how this could be a-

cilitated and agreed that a change in service deliv-

ery was required. We then used a domainal map(a visual tool devised by Spiegal et al., 1992). Tisenables judgement o whether a change is easibleby examining the costs, benets, implications andpotential problems or those involved (gure 3).

A positive experienceWith the support o the head teacher and educa-tional psychologist, I took orward some o theseprinciples in my service provision to a nursery inan environmentally deprived area. Tis was acili-tated by the head teacher, who approached me toset up a joint initiative or building on sta-child

interaction. I had several meetings with the headteacher to discuss oering intensive workshops on

sta-child interaction to all the nursery sta. Te

head spoke with the nursery sta and identiedwhat they hoped to gain rom the training. Teywere keen to build on the skills they already had,and make their interactions with children morepositive rather than repeatedly asking them ques-tions such as What colour is that? Tey werealso looking or the training to be a positive expe-rience to boost their own condence. I met witha more experienced speech and language therapycolleague to plan and implement training.We then gave the nursery sta a whole day in-

service on sta-child interaction and a series othree ollow-up workshops. We also oered mem-bers o sta the opportunity to have a video madeo their sta-child interaction and to receive indi-

vidual and group eedback on this.Our workshop presentations were infuenced

by the Hanen Centres Four P Cycle (Prepare,Present, Practise, Personalise) or acilitating learn-ing (Pepper et al., 2004). We included: educatorand child styles, balancing questions with com-ments, listening, waiting and observing duringinteraction, adding routines to interaction, andinteraction with groups o children.

Service delivery also changed in that I spent in-creased amounts o time with individual mem-bers o sta discussing their views on the train-ing. I also spent more time with one member osta who was the key worker or a child on my

caseload, modelling strategies and enabling herto evaluate her perormance.

Not all members o sta agreed to be videoed and

initially none, including the head teacher, were keenon the idea (although they have since purchasedtheir own video camera). Following the whole daytraining we videoed eight early childhood educators

with groups o children. Tree agreed to be videoedon a urther occasion, this time on a one-to-one

with dierent children. One agreed to do a thirdvideo. We analysed the videos o sta who did morethan one in terms o how many questions and com-ments were made by the adult, and the balance oturns (verbal / gesture / vocalisation) in conversationbetween the adult and the child.As we didnt have a baseline or look at the same

adult-child dyads over time the quantitative re-sults provide limited inormation but, overall,

the videos showed us a positive dierence in theinteraction styles o the adults ollowing the train-ing and eedback. Tis led to children being ableto take more turns in the conversation and thushaving increased opportunity to develop theirlanguage and communication skills.

Dramatic eectWe measured one childs responses, initiations anduse o language in a video made by one membero sta. Te child, who was on my caseload, wasaged three and had a very limited vocabulary otwo or three words. Although her understanding

o language was also delayed, it was signicantlybetter than her use o language, but she was oten

Figure 3 Domainal map o change in service deliveryto nurseries


8/32

Te dierences between the video sessionstaught me a lot which will be useul in plan-ning uture training. Firstly, sta reported thatindividual eedback was a lot more helpul andless daunting than group eedback. Secondly,sta ound it more benecial to have time spentdiscussing their interaction goals in detail beoremaking the video. Discussion around interac-tion goals within a routine included:

Identiying how the routine would startHow the educator would plan or the child totake a turnHow the routine could be changed to enablethe child to take a turnTe actions, sounds and words that the educa-tor would repeat during the routineHow the routine would end.Tese points (adapted rom Pepper et al.,

2004) can be lled in on a worksheet beore thevideo is made.

I have learned that a signicant change to serv-ice delivery can be necessary to achieve positiveoutcomes or children, and that implementing itis both rewarding and challenging. My condence

has developed and I look orward to building on thechanges and taking them urther in other nurseriesand schools. I have seen the positive eects o tak-ing into account the evidence in the literature whenproviding training and have booked a place on athree day course that goes into more detail aboutproviding training. I now eel more able to contrib-ute to change in service delivery, and to work morecollaboratively with education colleagues. Te nurs-ery at the heart o it has become a more enablingenvironment, the relationship between the speechand language therapist and the education sta hasbecome more genuine and collaborative, and out-comes or children are encouraging.

Esther Black is a speech and language therapistwith NHS Fie, e-mail [email protected].

AcknowlegementWith thanks to Roma More, speech and lan-guage therapist, or her support in planning andimplementing the training, and to the nurserysta or the opportunity to take orward thechange in service delivery, and develop my ownpractice through this.

1.2.

3.

4.

5.

SERVICE DELIVERY


How have you gone about makingchanges in service delivery? How do yousupport new graduates to be involved inthis process? Let us know via the Winter08 orum at http://members.speechmag.

com/orum/.

ReerencesDuy, M. & Grin, E. (2000) Facilitating Organisational Change in Primary Care. Oxon: Radclie Medical Press.Hulme, S. (2005) AC!: Innovative training or childcare sta, Bulletin o the Royal College o Speech and Language TerapistsDecember, pp.12-13.Learning and eaching Scotland (2008) Curriculum or Excellence Aims, purposes and principles. Available at: http://www.ltscotland.org.uk/curriculumorexcellence/ (Accessed 8 October 2008).Malcomess, K. (2001) Te Reason or Care, Bulletin o the Royal College o Speech & Language TerapistsNovember 595, pp.12-14.Pepper, J., Weitzman, E. & McDade, A. (2004)Making Hanen Happen, Leaders Guide or Hanen Certied Speech-Language Pathologists.It akes wo to alk, Te Hanen Program or Parents. oronto: Te Hanen Centre.Royal College o Speech & Language Terapists (2006) Communicating Quality3. London: RCSL.Scottish Executive (2008) Additional Support or Learning website. Available at: http://www.scotland.gov.uk/opics/Education/Schools/welare/ASL (Accessed 8 October 2008).Spiegal, N., Murphy, E., Kinmoth, A-L., Ross, F., Bain, J. & Coates, R. (1992) Managing change in general practice: a step bystep guide, BMJ304, pp. 231-4. Available at: http://www.pubmedcentral.nih.gov/picrender.cgi?artid=1881432&blobtype=pd(Accessed 8 October 2008).Sutton, C. & Sedgemore, J. (2005) Enriching the early years, Speech and Language Terapy in PracticeSummer, pp.10-12.

ResourcesBoardmaker - www.mayer-johnson.com/Signalong - www.signalong.org.uk

unable to express even her basic needs and wants.I modelled strategies or the early childhood edu-cator, including the use o signing and symbols.During the video, the educator signicantly re-duced the complexity o her language, waited orlonger periods o time than beore, imitated whatthe child was saying and mainly used three dier-ent key words throughout the interaction. I heardthe child imitate and spontaneously use two o

these words on many occasions as well as the Sig-nalong sign or the word MORE. Te educatorsuse o new strategies appeared to have a dramaticeect on the childs communicative abilities.We got ormal eedback rom sta who attend-

ed the training using a questionnaire at the endo each session and a more detailed Final Refec-tions one at the end o the nal session. We basedthe questionnaire content on material producedby Te Hanen Centre (Pepper et al., 2004).

Sta eedback was mainly positive. Nine o theten members o sta completed the nal refec-tions questionnaire (one was o sick). Five saidthey did not know anything new about them-selves or the children ollowing the workshops.

However, seven stated that they had changed theway they interacted with children, or exampleby asking ewer questions and waiting longer orchildren to respond and initiate. Tree noted adierence in the way children communicated

with them ollowing the training. Most memberso sta ound the training helpul, some oundit very helpul and one person ound it less thanhelpul. Some sta did not enjoy the role play,

while others ound it helpul.Eight said they would recommend the work-

shops to other nursery sta. Less positive com-ments included: Te training about routines

was patronising; Hated having to be [role play]

a child, what was I meant to say / do? Positivecomments included: Feel we learned a lot romeach other and we eel more condent in what

we can do to support SL and our own targets;Daunting but worthwhile; Proud o mysel andthe child; Youre never too old to learn.

Inormally, several members o sta ap-proached me individually and stated that theyound the training helpul and interesting. Oneo them told sta at a dierent nursery that thetraining had been helpul, and they have now re-

quested it or themselves. Te sta who had lesspositive comments also elt able to speak to meabout this personally and some issues appearedto be resolved in this way. Te head teacher wrotea letter o thanks to my line manager recordingher appreciation that we were able to adapt thesessions to the needs o the education team.

Te early childhood educator who I was work-ing most closely with appeared to be empowered

by the training and more able to suggest strategiesto be used with the child who was on my caseload.She independently suggested the use o Signalongsigns and Boardmaker symbols (which were veryappropriate or the child) and, along with othermembers o sta, also played a signicant role inpreparing materials and implementing this. Previ-ously, the suggestion and preparation would havecome rom the speech and language therapist and

working collaboratively to ollow this through wasa challenge. Tis particular member o sta alsodeveloped in her ability to explain and recommendthe use o these strategies to the childs parents, andhelped them to problem solve in using them athome. As this was done alongside me, it reinorced

and supported my recommendations.Following the workshops, the nursery sta made

urther requests or training in the use o Signalongand Boardmaker, and have also suggested that in-teraction training be given to parents whose chil-dren attend the nursery. I plan to take this orward

with a speech and language therapy colleague, incollaboration with the education sta.

Key learningAs a year 2 Flying Start NHS speech and lan-guage therapist, I completed a refective essay orthe Scottish Government on the key areas o mylearning rom this change in service delivery. Te

Flying Start initiative or newly qualied alliedhealth proessionals is intended to promote eec-tive practice and encourage us to remain in NHSScotland. I noted that through the experience myknowledge and skills increased in several dierentareas including negotiation, fexibility, and plan-ning and delivering presentations. I also developedin my ability to model strategies, give other peoplepositive eedback on their perormance and to en-able and acilitate their learning by allowing themto come up with answers themselves. SLTP

REFLECTIONSDO I SEEK SUPPORT AT ADEPARTMENTAL LEVEL WHEN MY JOB ISCHALLENGING?DO I ASK FOR AND RESPOND TOFEEDBACK TO ENSURE THE TRAININGI OFFER MEETS THE NEEDS OF THEPARTICIPANTS?DO I MODEL THE STRATEGIES I AMASKING OTHER PEOPLE TO USE?


9/32SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008 7

USER INVOLVEMENT (3)

Cognitive Stimulation Terapy (Spector et al.,2006). Te psychology trainee was an observer

in all sessions and evaluated each clients com-munication skills. She rated clients on listening/ comprehension, expressive skills and turn-tak-ing, prosody, group involvement and eye con-tact, on a scale o 1 to 5 which all three staagreed beorehand.We gathered eedback in three ways:

1. Sessional feedbacko gain the views o clients about each session,

we modied parts o the VASES (Brumtt &Sheeran, 1999) and asked them to evaluate thesession in terms o a) how cheerul, b) how mixedup, c) how angry, and d) how outgoing they eltduring the session. We presented the pictures in

this order so that the eedback session startedand ended on a question with a positive ocus.We oered a range o options in an attempt togather more qualitative inormation rom peo-ple who were less fuent and to allow or the va-riety and complexity o negative eelings peoplemight have about the group. We were acutelyaware that the group situation was a new one orall the clients and as such might be daunting orthem, especially as people with dementia otenreport group conversations to be more challeng-ing. We gave each client one-to-one support torate the our items and asked them to place asticker on a line under the pictures to indicate

where they rated themselves. Te sheets were letanonymous but we noted individual responsesso that we could later compare them with howsuccessully each person had communicated inthe group, and analyse any relationship.We gave eedback a numerical rating between

1 and 2, to one decimal place. We then totalledthis to give an overall eedback score the high-

er the overall score, thegreater the satisaction

with the session. Temaximum possiblescore was 8. Resultsare in gure 1.All clients had

their lowest satisac-tion score in the rst

Accessing the views o our users hasbeen an integral part o the way we

work in Medway or the last dec-ade. Tis has inormed changes inservice delivery and assisted in serv-

ice development. Each member o the team isencouraged to continue this process on an an-nual basis to ensure we meet clients needs anddevelop as a service.When I started working with people with de-

mentia three years ago, I was keen to nd a wayto enable this client group to express views them-selves, rather than by proxy. In the past mostconsultations in dementia care have been withcarers, but there is a growing recognition that

we need to involve people with dementia - and

that they can, and want to, express their viewson services (DH, 2005). I decided it might beeasiest to start by accessing views about a specicevent rather than the service in general to over-come the inevitable diculties with short-termmemory that are characteristic o the condition.

In March 2008 I ran a 5-week group withthe team clinical psychologist and her traineeor people with mild-moderate dementia. Weinvited ve men, all o whom had had inputrom me ocusing on compensatory strategiesto overcome word-nding diculties o varyingdegrees. One o the invited clients declined as hehad recently been admitted to a nursing homeollowing deterioration in his condition. Oneclient attended the rst two sessions but thendecided to withdraw. His wie, the psychologistand I all agreed that his communication skillshad declined below the level o the group. Teother three attended all sessions except or twoclients missing a session each due to holidays.Te structure o the group was loosely based on

week. All had expressed some degree o anxietyor nervousness about attending the group andthe rst weeks scores may refect this. Client Asscore dropped again in the nal week. Tis mayhave been because there were only two clientsin that session, which aected the dynamic. Ascomment, make it bigger six people seemsto conrm this.

Interestingly, the ratings also correlated

positively with observer ratings o each clientscommunication skills. So, those clients whohad higher observed communication scorestended to say that they had enjoyed the ses-sion more. Te client who stopped coming tosessions had given very low enjoyment ratingsand his communication skills were noted to bequite signicantly more impaired than othergroup members.

Te system used or gaining eedback eltsuccessul, although each client did need one-to-one support to remind them how to com-plete their ratings. It is thereore important tobe mindul o not leading the client to placetheir sticker nearer to one end o the scale! By

the nal week, all remaining clients were morecompetent with the system and were starting touse it more independently. Tis might suggestthat, once a simple system is implemented oraccessing the views o people with dementia, itshould be used more widely within the serviceto oer consistency. Future projects could lookinto the practicalities o setting up such a systemin a multidisciplinary team setting.2. End of group feedback

At the end o the nal session we asked each cli-ent six questions in a one-to-one discussion. Weemployed symbols previously used to representdierent sessions as visual reminders. Te psy-

chologist and I also had a list o topics / optionsto go through as a prompt to ensure that our

Charly Harveydiscovers it is not only possible to support clients withdementia to express their views on services, but that their eedbackcan give more valuable pointers to uture improvements than healthproessionals reections.

Its to have a laugh andbe with others

OUR SERIES AIMSTO SHOW THATUSER INVOLVE-MENT CAN BETRANSFORMA-TIONAL FORCLIENTS,THERAPISTSAND SERVICESPUT INTOPRACTICE ATMANY DIFFERENTLEVELSA POWERFUL

TOOL FORINFLUENCINGCOMMISSIONERS

User involvement whats your experience? Let us know at the Winter08 orum, http://members.speechmag.com/orum/.

Figure 1 Session ratings

Client A Client B Client C Client D

Week 1 4.4 6.2 5.7 0.9

Week 2 On holiday 6.9 7.6 Let Early

Week 3 6.1 6.7 7.2 /

Week 4 5.4 7.9 8 /

Week 5 4.5 On holiday 7.7 /


10/32



supported conversation was comparable. Respons-

es rom the three clients who had attended regu-larly are in gure 2. Verbatim quotes are in quota-tion marks, while other inormation is paraphrasedrom clients responses.

On the whole the eedback was positive and,gratiyingly, each client elt comortable enoughto provide constructive eedback as well. Allseemed to pick up on the act that Client D hadnot been coping with the group and were sen-sitive to that. Tere was a general eeling thatthe group should be bigger, but also an under-standing that too many people would be harderor sta to manage. Te statement by one clientthat the right number o sta ran the group may

be evidence o the need to have two members osta, even or such a small group. Tis particularclient also elt that it could be quite hard work tomanage each persons stories and reminiscences.

Tere was general agreement that the schedul-ing o the group was good, and that we shouldhave oered tea and coee at the start o thegroup. With hindsight, this is an obvious rap-port-building icebreaker and its a shame that

we didnt think o it.3. Carers feedback

Ater the nal session, we also sent the our carersa questionnaire. All our were returned, althoughone person was unaware o the back page soonly answered questions 1-4. Te questionnaire

contained a combination o airly closed andmore open questions. We phrased some ques-tions negatively (Q3 and Q5) to ensure balanceand consistency, and to avoid a scenario whererespondents just ticked yes or everything. Tecarers responses are in gure 3.Again, all respondents elt that the timing o

the sessions was appropriate. All elt that theirpartners had enjoyed the group and it was nicethat one o the carers used the opportunity toprovide more social stimulation ater the groupby going into town or a coee. In uture, wecould recommend this to other carers as anidea or extending the benets o the group.

Te comment about one client always enjoyingthe group despite never wanting to come in the

ReerencesBrumtt, S. & Sheeran, P. (1999) VASES (Visual Analogue Sel-Esteem Scale). Milton Keynes: Speechmark Publishing Ltd.Department o Health (2005) User and Carer Involvement in Dementia Care. National Institute or Mental Healthin England. Available at www.changeagentteam.org.uk/_library/DEMENIA%20FINAL.doc (Accessed 28 Oc-tober 2008).Spector, A., Torgrimsen, L., Woods, B. & Orrell, M. (2006)Making a diference: An evidence-based group pro-

gramme to ofer Cognitive Stimulation therapy (CS) to people with dementia. London: Hawker Publications.

Resourceswww.cstdementia.com - or more inormation on Spector et al.s Cognitive Stimulation Terapy programme.

www.alzheimersorum.org - views o people with dementia on a section o the Alzheimers Society website writtenby and or people with dementia.

Figure 3 Carers eedback

1. The time o the group wasconvenient or me and myhusband.

2. The dates o the group wereconvenient or me and my husband.

3. I didnt like my husbandattending the group without meor a carer.

4. It has been easy to makearrangements to allow myhusband to attend the group.

5. I would not recommend thegroup to other carers.

6. What did your partner say itwas like attending the group?

7. What was your husbands mood orbehaviour like ollowing the group?

8. Did you notice any changesin your husbands mood orcommunication ater the group?

9. Have you any suggestionson how we could improve thegroup?10. Any other comments?

All agreed that the time o the sessions was convenient. One person addedthat times were convenient as long as they had no prior appointments onthe dates o the group. Another said that Wednesday would not normallybe a good day but the time o the sessions meant that it was convenient.

All agreed that the dates o the sessions were convenient.

3/4 people disagreed, one o these adding that her husband was ne aslong as his mood was ne.1/4 strongly disagreed and said that her husband was happy on his ownand gave him the condence he needs.

2/4 agreed.1/4 neither agreed nor disagreed and said that Wednesday wasconvenient, another day may have not been.1/4 strongly agreed saying, Its important to put everything else aside orthe good o communication.

2/3 people disagreed.1/3 strongly disagreed and said it was a very useul group.

Client As wieHe ound ithelpul.

Happy.

No.

He would like tohave had some sorto rereshment.A said he enjoyedlistening and

taking part incurrent situationsand memorieso all the otherpeople andhimsel.

Client Bs wieHe enjoyedeveryone.

Very brightand cheerul.

Moreconidence,which he needs.

Im sure yourexperience isenough.I was happyto bring B and

he enjoyedmeeting otherpeople. I eelhe needs tobe without mesometimes.

Client Cs wieWhen he came out and I asked him whatit was like he always said alright, we hada laugh.He always seemed to be in a good moodollowing the group. Especially as henever wanted to go in the morning.Always go shopping on a Wednesdayater the group. We went into town, hadcofee, where Cspeaks to everyoneespecially the children.Cannot think o anything to improve thegroup. Cseems happy with the thingsyouve done.For some reason, Calways seemed tothink it was a meeting o the RNA [Royal

Naval Association] and wanted to wearhis blazer and naval tie, and got annoyedwhen I told him it wasnt necessary.

Figure 2 End o group eedback

Client A

Useul. Inormative. Enjoyed itgives youinterest. Morning is the best time o day. There wasthe right number o sta. The group was betterthan 11 but you need some 11.

Not enough oomph [Psychology trainee] wasgoing like the clappers. (The client was reerring tothe act that the trainee was keeping notes rom her

observations throughout and thereore could notjoin in much). Sessions should have been longer.Make sure all the people are willing candidates.

Newspaper article. Discussing holidays. Comparingprices o dierent objects.

It takes too long to look at everyones photos. Toomuch going on or one person to manage.

Yes. It gives an insight into what you can pass overpeople.

Make it bigger 6 people, 3 o each gender,perhaps a couple o teams. Try to get people whoknow each other. Make a coee as an opener anddo the newspaper then. Make it harder as it goeson. Mustnt make it too paper oriented.

Client B

Everyone tried to help everyone. Goingstraight into it and chatting about. Got onwith the others. About the right lengthand right amount o sta. Right numbero weeks and a good time o day.

Maybe 5 people would be better. Wouldhave liked a cup o tea.

All o them. Liked sharing photos.

I was worried about the person who satat the back.

Id like to do it again help each otherout.

Tea. A weekly routine.

Client C

Have a laugh with the others. Just theright number o sessions, time o daygood, happy with the people runningthe group, liked the venue, dont mindi wie is there or not.

To be with misery bags people whodont laugh. Nothing else to say that Idid not like.

Discussing jobs and hobbies, showingphotos and talking about Korea and the war.

Nothing that I did not like. I came andsaw and did with whatever is going on.

Yes. Its to have a laugh and be withothers.

It could be a mixed group. That wouldbe nice. Increase number o people inthe group 5 instead o 3.

1. What did you like aboutthe group?

2. What did you not likeabout the group?

3. Which activity did youlike the most?

4. Which activity did youlike the least?

5. Would you recommendthe group to other people?

6. What could we do tomake the group better?


11/32



SLTP

morning is interesting. It may be that he becameanxious each week about going somewhere

without his carer, having orgotten where he wasgoing and who would be there, and then relaxedon seeing the amiliar setting, sta and clientsrom the previous week. In uture it might beuseul to send home a visual diary / timetable,sta or group photograph (i consent is given)or another object that acts or the individual as a

meaningul reminder o the group.

Taking the group orwardWhen we initially decided to run this group, mosto our thought and preparation related to thecontent o the sessions. Collecting the eedback

was a small part o the process but, in retrospect,it has taught us more about how to take the grouporward than our own refections did.

Next time we run the group we will:Extend the time o the session to oer reresh-ments at the start.Remove some o the monitoring and assess-ment, which would not only make it easier to

run but would also reduce the likelihood o peo-ple eeling uncomortable through the presenceo an observer.Make sure we indicate that the carers question-naire continues on the back page.Oer a visual timetable eaturing somethingmeaningul to the client, or use by carers as areminder beore each session.Ensure similar levels o impairment to reducedropping out rates.Finally, as these clients enjoyed the group, weeel it would be appropriate to invite themagain. By doing this, the group can also serveas a support network or the clients as well as atherapy process.

Te success o the methods used to access viewswas incredibly rewarding, particularly as the cli-ents were so motivated to give their opinions.By using supported conversation techniques andoering a range o methods or giving eedback,the clients were empowered to comment on theircare, something people with dementia are not o-ten given opportunities to do. Te techniques weused can work just as well ollowing individualsessions so that clients can comment on therapyas they go through it. Te success we had withthis group has motivated me to keep adapting myapproach to try and access the views o more se-verely impaired clients in the uture.

Charly Harvey is a Highly Specialist Speech andLanguage Terapist with Medway PCs AdultService, St Bartholomews Hospital, New Road,Rochester, Kent, ME1 1DS, e-mail [email protected]. Te questionnaires used or end o groupand carer eedback are available at http://www.speechmag.com/Members/Extras.

AcknowledgementsTanks to Nerisha Singh, Clinical Psychologist, orher help in setting up and running the group, andcollecting the eedback. Special thanks to all the cli-ents and their carers who took part in the group or

giving us such honest and helpul eedback, and orgiving me permission to share the inormation.

resources

Here to LearnA DVD due or release by the National DeaChildrens Society aimed at helping mainstreamschool sta with little experience o working

with dea children.Further inormation Freephone 0808 800 8880.

Signing imeSinging Hands have released a new DVD. ItsSigning ime eatures 25 songs with Makatonsigns and symbols.www.singinghands.co.uk

Parent2ParentA new online service rom the National DeaChildrens Society and the NHS NewbornHearing Screening Programme to help parentscontact similar amilies with dea children.www.parentsnetwork.org.uk

Gardening or recoveryTrive has produced a sel-managementprogramme to support the recovery throughgardening o people aected by heart disease orstroke.Gardening or Hearts and Minds, 8.99, www.thrive.org.uk

Dream-oysAbilityNet hopes to capture the Christmasmarket with a collection o specially adaptedtoys or children whose disabilities limit theirmotor skills and dexterity.www.abilitynet.org.uk/newsarticle73

Cochlear impantsSense and Te Ear Foundation have publisheda guide or both amilies and proessionalson cochlear implantation or congenitallydeablind children.Deablindness and Cochlear Implantation, 8.00,www.earoundation.org.uk/shop/items/102

Developmental Journals

Early Support in England has producedDevelopmental Journals to help amilies track,record and share their childs progress throughthe early years. Versions include a generic EarlySupport Developmental Journal and those oruse by amilies with a child who is dea, who hasDown syndrome, or who has a visual impairment.www.earlysupport.org.uk

Active DesignsActive Designs abric resources are designed toapproach learning in a tactile and hands on way.www.activedesigns.co.uk

Stroke MattersNew quarterly e-publication or proessionals

in health and social care.Subscribe ree e-mail [email protected]

alking KeyboardextSpeak has released the S-04 wirelessalking Keyboard. Speech is generated as youtype in male or emale voices.www.textspeak.com/news/tts-04.htm

MS alentAn anthology o original short stories, poetryand personal accounts, MS alent Volume 2aims to benet our charities supporting people

with Multiple Sclerosis and raise awareness.MS alent Volume 2 is 8.95 rom www.mstalent.org

Contact a Family Directory oerTe paperback version o the Contact a FamilyDirectory (a guide to medical conditions,disabilities and support) comes with a ree copyo the Disability Rights Handbook.www.caamily.org.uk/medicalinormation/subscribe.html

Disability swimmingBritish Disability Swimming has released aDVD to encourage the next generation oathletes to take the plunge.E-mail [email protected]

Hate crimeA report rom Scope, Disability Now magazineand the United Kingdoms Disabled PeoplesCouncil examines disability hate crime andcalls or greater awareness training or policeand prosecutors.www.timetogetequal.org.uk/page.asp?section=90&sectionitle=Hate+crime

Bullying signsDont put up with it aims to ensure deachildren and young people are equipped withthe inormation they need to spot the signs obullying and how to cope with it i it happensto them.Order rom NDCS Freephone Helpline 0808 8008880 or e-mail [email protected].

Spanish stimuliMaUSECat is a Windows computer-basedsystem or selecting and presenting audio-visualstimuli in English and Spanish to people withcommunication disorders.http://computerizedproling.org/MaUSECat/index.php

Couple Connection

Relationship research organisation One PlusOnes interactive, sel-help website or couplesincludes sections or those who have a child

with additional support needs.http://thecoupleconnection.net/

Autism podContact a Family has produced a podcast onautism, eaturing an interview with one mumand highlighting additional sources o support.www.caamily.org.uk/news/podcasts.html

SEN standardsQuality Standards or SEN Support andOutreach Services oer suggested markersagainst which services provided can be

evaluated.Download ree rom www.teachernet.gov.uk


12/32SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 200810

COLLABORATION

change a boy with a language disorder who washighly distracted and interested in anything butsocks and shoes, whilst wondering what the othertwelve little darlings were doing, was interesting.)

Experience o working with children andknowing how to interact with them obviouslyhelped. Many o these skills can be transerred

when you work with larger groups o children,but that does not make it easy.

On refection, I eel I gave mysel quite a hardtime as a teacher and had potentially unrealisticexpectations o how well and how quickly I couldhelp the children learn to listen. Tis was com-

pounded by my awareness o the expectations osome other people, who liked the idea that I hada magic wand which would sort out all o the lis-tening, speech and language problems.Although a strong grounding in child devel-

opment allowed me observe and think aboutthe children at a dierent level and in a dierent

way to many newly qualied teachers, it was o-ten a cause or rustration when teaching. Beingvery aware that a child does not understand oris not ready to learn something was oten verydicult to cope with i there were limits to whatI could do about it.As therapists we think o the child rst and

what he or she needs second. Te world o

education, however, encourages teachers tothink curriculum rst, child second. In reality,this can mean that dierentiation involves theteacher watering down what they are teachingrather than ocusing on what the individualchild needs.

The other side o the encePeople on both sides o the ence want the samething. Terapists and teachers want a child to besae, happy, to learn and to develop to their po-tential. Although the worlds we inhabit stronglyoverlap, they are also very dierent. Tese dier-

ences can create barriers to eective working, andmake us orget that we want the same thing.

While speech and language therapists and teachers both want the bestor every child, our overlapping worlds have dierencesthat create barriers to eective working. Drawing on herdual training and recent experience as a consultant on theStoryPhones project, Kirstie Page explores what she haslearnt rom sitting on both sides o the ence.

Once upon a time there was a speech and languagetherapist who worked with young children. One dayshe had the bright idea o becoming a teacherTis therapist was me, and I would like to share

with you the reality o this experience and lookat what we, as speech and language therapists,can gain rom an increased understanding o theother side o the ence. Although teachers canlearn much rom the world o speech and lan-guage therapy, we can also learn a lot rom the

world o education.

The ideaAs a speech and language therapist I worked

mainly within the educational environment.Like many others, I elt I had good working re-lationships with teachers. Although things werenever perect, I tried wherever possible to makeany advice I gave as applicable to what was goingon in the classroom as I could. (With hindsightI realise there are many things I could have donedierently and more eectively, but we willcome back to that later.)

My role at Sure Start Stanley allowed me tospend more time in ewer settings than beore.

As a result, I became increasingly interestedin the impact childrens speech and languageskills have on their education and learning as a

whole. I also began to look at how good Early

Years practice strongly overlaps with speech andlanguage therapy advice. I elt many childrensneeds could be met more ully and eectively byadvising teachers and practitioners on:

the layout o the settinginteracting and talking to children at the rightlevelincorporating activities and resources to pro-mote speech and language developmentspecic resources such as Beat Baby, Lola andStoryboxes.Advising on some o these issues can be tricky

as a speech and language therapist, so this iswhere the idea to become a teacher came rom.

Te initial aim was to widen my perspective, tomake me more aware o educational issues and

to learn. I Im honest, I thought that it wouldbe a relatively easy transition and that the learn-ing curve would not be too dicult. Te reality

was somewhat dierent

The realityTe learning curve I experienced was steep inmany ways. From a theoretical point o viewa background in speech and language therapystood me in very good stead. However, becom-ing more amiliar with the curriculum, educa-tional theories and the planning procedure wereall hurdles I had to jump.

Te hardest things I had to learn centredaround the practical issues o being a teacher andthe level o preparation and organisation this in-volves. I thought that I was aware o a teachers

workload beore, but I now realise I wasnt. Inthe past I also didnt properly understand that,

when a teacher said they had no time, it wasthe truth.

By raising these issues I am not saying that teach-ing is harder or more stressul than speech and lan-guage therapy or vice versa. I asked to choose Icouldnt answer, as they are just dierent.

I would say, however, that my days as a teacherin a Foundation Unit were physically very busyand demanding. Along with the learning oppor-tunities I wanted to create and language experi-ences I wanted the children to have, there wasan endless stream o running noses (excuse the

pun!) and behavioural issues that needed sortingout as well as accidents o both kinds. (rying to

Sitting on both

sides o the ence READ THIS IF YOUWANT TOUNDERSTANDA DIFFERENTCULTUREIMPROVECOMMUNICATIONENVIRONMENTSHAVE YOURADVICE PUT INTOPRACTICE

The hardest thingscentred around thepractical issues obeing a teacher andthe level o preparationand organisation thisinvolves


13/32

COLLABORATION


Te world o education places many demandson teachers. Just as therapists have legally bindingelements to their work, so do teachers. As a thera-pist, I eel that understanding the culture within

which teachers work can make us more eective:Value added as a teacher I am under hugepressure to demonstrate that the children inmy class are making progress. My competenceas a teacher, the schools Osted inspection andpotentially my pay and promotion prospects

will depend on this. Progress will be judgedon a childs assessment results and levels. Te

world o education creates an environment

where progress can be encouraged by pushingchildren on towards their target. Te world ospeech and language therapy believes that thebest way to encourage progress is to go in at thechilds level and to build them up rom there.I we are advising the latter, we need to supportteachers and help them realise that they will beencouraging long-term progress, even i this isat the expense o short-term gains.Curriculum Te National Curriculum andthe Foundation Stage Curriculum (the Early

Years Foundation Stage rom September 2008)are legally binding documents in England. As ateacher, it is my duty to deliver these. I speechand language therapy advice is portrayed as

separate, I may see it as an extra thing whichis taking time away rom what I should bedoing. Contrary to popular belie, the NationalNumeracy and Literacy Strategies (which havenow become the Primary Frameworks) are op-tional and are not legally binding. In reality they

will oten be ollowed to a greater or lesser extentin most schools. I a school is to opt-out, they

will need to prove to Osted that what they areteaching instead is just as good i not better. Tisis scary, but an increasing number o creativeand innovative schools are opting out.Early Years Foundation Stage the new earlyyears curriculum extends rom birth to ve years

and has received some bad press or ormalisingeducation too quickly. In reality, it may make

1.

2.

3.

the lives o speech and language therapists easi-er. It oers a lot more scope or targeting earlierstages o development to meet a childs needs.

Although this is oten what therapists advise al-ready, the act that this is part o the curriculum

will make it easier or a teacher to incorporateadvice, and to see it as part o the childs edu-cation rather than their therapy.Literacy an awareness o the links betweenspeech and language and literacy is becomingmore commonplace within the world o educa-tion. Phonological awareness, however, will still

be conused with phonics, and many teacherscontinue to eel diculties with literacy are dueto the act that the child doesnt say words prop-erly. Te depth o the links may not be ullyappreciated by some teachers. Although the newPrimary Framework or Literacy embeds speak-

ing and listening throughout, a closer inspectionreveals that this is oten speaking and listeningor literacy rather than or communication. Itis a great improvement though, and therapistscan potentially support teachers with how theycould use this time and create opportunities tomeet more ully the needs o those children withspeech and language delay / disorder.Groups versus individuals As a teacher I

work with groups and rarely individuals. I willneed you, as a therapist, to understand thatthis is my world. For your advice, I want youto tell me what I can do which will t into the

way that I work. Giving me ideas or one-to-

one activities which you would do with thatchild on a one-to-one will be less meaningul.

4.

5.

From our side o the enceIn an ideal world, advice and targets or anindividual child rom a speech and languagetherapist should be taken on board and imple-mented and embedded by the childs teacherand school. Sometimes this happens, but otenit does not.When things dont go as well as they could,

we are oten quick to look to the other side othe ence or reasons. Lack o knowledge, un-derstanding and motivation on the teachersbehal are all common reasons why we eel ouradvice has not been as eective as it could havebeen. Although these thoughts are sometimesvalid, they are rarely the only reasons or break-down.

Looking closely and critically at our own sideo the ence can also give us a lot o reasonsand solutions. We need to consider some o theollowing:

Do I ask the education practitioner or theirthoughts and observations on a child? Al-though the practitioner may ocus on dier-

ent strengths and needs, and although theymay use dierent terminology, they are usu-ally a great source o inormation.I the practitioner doesnt understand thechilds diculty and how this will impact ontheir learning, do I support the practitioner

with this through discussion, training, reportwriting and so on?Does the practitioner know how to supportthe child in the give and take o daily conver-sations? Strategies such as talking to childrenat the right level or modelling speech soundsand grammar are not part o teacher train-ing. Just because it is so instinctive to us, we

cannot assume that other people know whatthey have not been told.Does the practitioner have a toolbox o strat-egies which they can support the child withduring stories, group time, and adult-ledactivities? Strategies such as sitting the child

who nds it hard to listen opposite and gain-ing their attention visually and / or kinaes-thetically can be easily integrated into gener-al practice. Tese strategies will also supportmany o the other children in the class whomay not be known to speech and languagetherapy, but who cause educational concern.Can our ideas or activities be easily incor-porated into the activities which are going

on already? Although some activities are veryspecic to an individual child, most willsupport many childrens learning within theclass. Embedding advice in this way will alsomake it easier to carry out as it will no longerhave the same implications or adult timeand support.Could we use more educational terminol-ogy to make our advice more eective? I wecan link our advice to the curriculum wherepossible, even i the link is just to an areao learning or subject area, a teacher will seehow the advice ts in. Speech and languagetherapy advice, thereore, is not robbing

time rom the curriculum and what the prac-titioner should be doing.

a)

b)

c)

d)

e)

)

Dierences can createbarriers to eectiveworking, and make usorget that we wantthe same thing.

StoryPhones in action


14/32

COLLABORATION


The best o bothAt the moment I work as a reelance trainer onissues relating to speech and language develop-ment and early literacy. For this training I tryto combine the theoretical knowledge and ex-perience I gained as a therapist with the practi-cal insight and curriculum knowledge I gainedas a teacher.As a teacher I became increasingly concerned

that many o the advances within educationalIC (Inormation & Communication ech-nology) ocused mainly on childrens visualskills rather than their auditory and verbalskills. Visual IC has many benets but is o-ten overused due to the act that teachers areencouraged to embed IC across the curricu-lum wherever possible. As concerns about chil-drens listening and language skills increase, theamount o audio work being done with chil-dren is in reality decreasing.

I am thereore also working as EducationalConsultant or StoryPhones, a new digital au-dio system or the Foundation Stage and Key

Stage 1. StoryPhones have been specicallydesigned to promote listening, language andliteracy skills. Te MP3 headsets have no wiresso can be used to listen to stories, music, songsand rhymes or to carry out listen-and-do ac-tivities throughout the environment, both in-doors and outdoors.

Although they are a resource or all children,there are many applications or children withspeech and language delay / diculties andcould easily be utilised by therapists as theystart to appear in schools. Many o the listen-and-do activities which will be available todownload and use on the StoryPhones have

TEN STEPS TO BETTER PRACTICEWORKING WITH TEACHERS:

ASK FOR AND LEARN FROM THEIREXPERIENCE AND OBSERVATIONSACKNOWLEDGE THEIR CULTURALCONTEXT AND WORKLOADLINK RECOMMENDATIONS WITHTHE CURRICULUM AT EVERYOPPORTUNITY

USE EDUCATION TERMINOLOGYEMBED ADVICE WITHIN WHAT THETEACHER IS ALREADY PLANNINGOFFER SUGGESTIONS THAT ARESUITABLE FOR GROUPSPROMOTE LISTENING FORCOMMUNICATION ACTIVITIES / ICTEXPLAIN YOUR PLAN IN TERMS OF THEIMPACT ON LEARNINGSPELL OUT STRATEGIES NEVERASSUME THEY ALREADY KNOWMAKE IT CLEAR HOW SUPPORT COULDBENEFIT OTHER CHILDREN TOO

1.

2.

3.

4.5.

6.

7.

8.

9.

10.

What issues has this article raised or you?What has helped you collaborate moreeectively with teachers? Let us know viathe Winter 08 orum at http://members.speechmag.com/orum/.

Resources Foundation Stage / KS1Beat Baby - by Ros Bayley and Lynn Broadbent, Lawrence Educational Publications,

www.educationalpublications.comLola by Ros Bayley and Lynn Broadbent, Lawrence Educational Publications,

www.educationalpublications.comStoryboxes (50 exciting ideas) by Helen Bromley, Lawrence Educational Publications,

www.educationalpublications.comStoryPhones www.storyphones.co.uk

in-built dierentiation within the audio track.Tis will allow teachers and therapists to selectdierent levels to target the individual needs odierent children.

Te record acility will also allow speech andlanguage therapists to record and make theirown resources. Tese could then be let at theschool or nursery, allowing the child to carry

out the activity many times with or withoutadult support. In an ideal world, these couldalso be sent home and shared with parents.

Tis acility can also be used by the childrento record their own thoughts, stories, ideas andsongs. As this saves digitally, there are manyopportunities or assessment and monitoringchildrens progress.

Te Education eam at StoryPhones wouldlike to hear rom therapists and teachers whoare keen to develop and publish good qualityresources or use on StoryPhones. We wouldalso like to hear about how people have usedthem in dierent ways.

Kirstie Page is a speech and language consultantwith StoryPhones, e-mail [email protected], www.storyphones.co.uk.

SLTP

Selreerral welcomedThe Parkinsons Disease Society has welcomed the health secretarys an-nouncement that conrms and extends the right to sel-reer to alliedhealth proessionals.Sel-reerral is not a new concept in speech and language therapy, but aware-ness and access is not universal. Although the announcement applies to allallied health proessions, it has been prompted by research with the CharteredSociety o Physiotherapy which showed that people who sel-reer accessservices more quickly and are also more likely to complete their treatment.The Parkinsons Disease Society hopes that sel-reerral will enable more

people with the condition to access physio, occupational and speechand language therapy.www.parkinsons.org.uk

Write onWriteOnline, an online word processor, has won the English SpeakingUnions Presidents Award 2008 or being interactive, empowering andeducationally useul.The Award is given annually or innovation in the use o new technologies toenhance English teaching and learning worldwide. The tool aims to provideusers o all ages and abilities with a consistent level o writing support on anycomputer with an internet connection. The word processor has an integratedWordbar to give easy access to words and phrases. Predictive text and speechunctions are available along with switch access i necessary. Preerences are

saved online, so are automatically applied wherever the student logs in.www.cricksot.com

news extraSENDIST petitionAn online petition is urging the Prime Minister to stop government plansto change Special Educational Needs Tribunals SENDIST.This appeal system is available to parents who disagree with Local EducationAuthority provision or their child with special needs. Regulations have beenamended so that rom November 2008, SENDIST is to be part o a uniedtribunal system called the Health, Education and Social Care Chamber withthe Care Standards Tribunal and the Mental Health Review Tribunal.Some parents o children with special needs are expressing concern thatthe detail o the changes could lead to their children being assessed

against their wishes and at their expense. They also believe that it willnow be impossible or parents to attend a Tribunal without the expenseo hiring a barrister.The petition is available at http://petitions.number10.gov.uk/SENDISTtribunals/.

Cochlear implant rulingThe National Institute or Health and Clinical Excellence NICE has ruledthat the NHS should oer cochlear implants to all prooundly dea chil-dren where this is the preerred option o the amily.A number o dea charities who have lobbied or an end to the previouspostcode lottery have welcomed this development, along with a rulingthat all prooundly dea children should also be oered the option ocochlear implants in both ears, providing this is done at the same time.

The National Dea Childrens Society website has a summary o the guidanceand urther inormation on cochlear implants, www.ndcs.org.uk.


15/32

Heres one I made earlier...Alison Roberts brings a Christmas theme to these low cost, exibletherapy suggestions suitable or a variety o client groups.

Save your cracker jokesMost cracker jokes are based on puns and idioms ormso ambiguity that are sometimes difcult or people on theAutism Spectrum to understand. I have ound it possible todismantle these simple jokes, explain them stepbystep,and then put them back together again, thereby makingthem accessible and enjoyable or all. Many youngsters withAspergers Syndrome are motivated by this activity. Its bestnot to introduce this though until some preparation has tak

en place through work on visual ambiguity and idiom.The idea is that as you examine more and more puntypejokes the clients will begin to understand the system, andstart to enjoy them on their own. The additional benets arethat a) they should then have a ew jokes up their sleeves orsocial occasions, b) be more open to understanding otherpeoples puns that crop up in conversation and c) may alsohave widened their vocabulary and knowledge o idiom.But beware: the most groanmaking jokes are the ones thatseem to be most easily remembered, and will be requotedat you long aterwards!

Interaction paper chainsor ChristmasThis is a simple and estive idea to recap on work done inthe preChristmas period, and a way to link all your variousclients and groups together. You are aiming to create estivedecorations on which the clients have written down waysin which communication benets us, or prerequisites orachieving good communication. Friendship and social skills,and conversation tips, can be included as well.

MATERIALSPacks o coloured paper stripssold or Christmas decorationsalready glued at one endPens

IN PRACTICE1. Each client writes one aspecto communication on a strip.Ideally the aspect they wouldchoose would be something ontheir personal target list or theterm.

2. Curl one strip round, and stickit to itsel to orm a paper circle,then loop another through it, andso on until you have a long chainwhich can be added to, by othergroups or individuals. Dont hangit too high, because you need tobe able to see the words writtenon the loops.3. Ask everyone how they eelabout the chain, and which tar-gets belonging to other clientsmight also apply to them.

MATERIALSSemi-ofcial looking ormswhich you will have made seebelowPens

PREPARATION

You need to make a orm, in a liststyle, and head it with the wordsA git or Then put these per-son types down one side you willprobably think o many more.Leave space or two price ranges;one is a small git, costing a littlepocket money, and the other is amore expensive git, pretendingyou are very rich:

an elderly granny or grandpawho like gardening and goingor short country walksa riend who is the same age as

you, and has similar interests

a babya six year old girla ten year old boya teenage girl who lovesclothesa riend who is keen on art

a business man who is stressedouta riend who is keen on sport

IN PRACTICENo matter what the ability levelo your group, it would be wiseto begin by discussing the listand lling in one set o ideas to-gether. Next, the clients mightlike to work in pairs, which willoer an opportunity to discussand try to agree on ideas. I theypreer to work individually theycan share the ideas ater they

have nished.

MATERIALSAs many cracker jokes as you can

possibly get. Within a brand ocracker they tend to repeat thesame jokes, so it is a good ideato ask all your acquaintancesto save theirs so you have thebest chance o acquiring manydierent jokes.IN PRACTICE ICareully pick out the jokes youare going to work with; you arelooking or the ones with obvi-ous puns and idioms.Stick the jokes, well spaced-out, on pieces o A4, and makephotocopies or each group

member.The core o the work is to nd theword or idiomatic phrase thatmeans two things, the doubleentendre, or example:Patient: Doctor, Doctor, I eellike a pair o curtains.Doctor: Well pull yourseltogether then!The key words are pull yourseltogether. You will have to explainthe idiomatic meaning as takecontrol o your behaviour, recapthe literal meaning, and then

retell the joke.

With this other old joke, the punon smell is an easier one to ex-

plain as no idioms are involved,just two meanings o the oneword:Boy: My dogs got no nose.Girl: How does he smell then?Boy: Terrible!Once you have explained theprocedure about nding thepun word using a ew o thejokes, you can ask one o theother group members to pickout the next pun in the sameway.

IN PRACTICE II

This work was so popular withour group that they decidedto collate their avourites intoa little book just six olded A4sheets, which we photocopiedand sold at our Christmas mar-ket in aid o our local brancho the National Autistic Soci-ety, the Stroud Autistic SupportGroup. They sent us a lovelythank-you letter which in turnraised the sel-esteem o thegroup members.

HERES ONE I MADE EARLIER

Git listThis is an awarenessoothers game particularly suitableor group or individual sessions leading up to Christmas. Itcan be done as a group exercise, or as an individual task. It isa useul exercise or learning to appreciate other peoples interests and preerences, and helps with riendship building.



16/32SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 200814

HEALTH PROMOTION

The move rom primary to secondary school can be a daunting prospect,particularly or pupils with communication difculties. Nadine Ardittiand Debbie Swithave been involved since2003 in projects which seek to reduceanxiety and ease the process.

Dead good transitionsREAD THIS IF YOUARE INTERESTEDIN

GROUP WORKFACILITATINGPEER SUPPORTMULTI-AGENCYCOLLABORATION

Whether or not they have commu-nication diculties, many chil-dren nd moving rom primaryto secondary school dicult. An-

derson et al. (2000) ound that when childrenmake this transition they have considerableanxieties but positive anticipations about thenew opportunities. Te move is also common-

ly accompanied by a dip in attainment as somechildren engage less well with class teachingand school work (Galton & Morrison, 2000).A study undertaken by Graham & Hill

(2003) looked at the transition process. It tookthe orm o a questionnaire survey in Glasgowin May / June 2002, supplemented by ocusgroup discussions with children and data romteachers. Nearly all children reported lookingorward to making new riends (89%), learn-ing new things (82%) and doing practicalsubjects (79%). Teir concerns included get-ting lost (77%), not knowing anyone (55%),getting picked on (53%) and more homework

(53%). Most children had taken part in somesort o induction to their new school throughvisits or meetings.

Te nature o language and communica-tion diculties means that aected childrenneed extra support and preparation to enable asmooth transer to secondary school. As a resulto looking at the needs o Year 6 children andtalking to colleagues in neighbouring speechand language therapy departments, we decidedto set up a transition group and programme orchildren in their nal year at primary school(Year 6).

Beore the transition group was establishedwe kept children on speech and language ther-

apy caseloads, with the anticipation that theywould need more intervention at secondaryschool. When we set up the group we hopedit would act as a preventative therapy which

would enable many pupils to be discharged.Te group has been running since 2003. All

the invited children are on community clinic,specic language impairment, autism spectrumdisorder, special school or mainstream schoolcaseloads in raord. We ask speech and lan-guage therapists in the department or namesin the November and invite pupils in the East-er. Te group is held over three days in a sec-ondary school during the summer holidays.

We have a ratio o two adults to eight pupils.We are oten supported by speech and language

therapy students romthe two Manchesteruniversities. In 2007,

we invited 27 pupils - 20 responded and 19 at-tended. In 2008, we invited 36 pupils, with 25responding and 21 attending.

Te aim o the group is to teach childrenspecic skills that they will need at secondary

school. Tis supplements the work already doneby their own primary schools, such as visits andopen days, to prepare them or the move.

One o the rst things we do with the chil-dren is a group activity to explore what they arelooking orward to at secondary school and also

what concerns and worries they may have. Tishelps them to prepare or the course and to be-gin to problem solve. Sometimes the childrensay that they are not worried about anything

which, in our experience, is partly due to thenature o their communication diculty. Wend this activity helps them to be more realisticand to understand the aims o the group.

ThemesTe themes that have been generated by thisprocess orm the basis o the transition pro-gramme. Tese include:

How do I read a timetable?How does the school canteen work?

What can I choose to eat and how much willit cost?

What do I do i I get lost?What do I do i I orget my homework?What do all these new words (biology,geography etc.) mean?How do I get organised or school?

Making riends.Te programme looks at these aspects in

more detail and concentrates on teaching spe-cic skills to address the childrens anxieties. Weuse a solution ocused Pupil Passport activityto encourage the children to think about bothhow to

Speech & Language Therapy in Practice, Winter 2008

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