ISSN 1368-2105

Autumn 2009

Motor Neurone Disease

Scoping and scaling Dysphagia assessment

The cost of care

Walking with Dobermanns Brain injury rehabilitation Talking flats Evidencing competence Beep, beep! Steering the way home E-stim What does this house believe? Our top resources Specific language impairment PLUS...winning ways...heres one I made earlier... reviews...in brief...great reader offers...editors choice...and lets Talk Shop www.speechmag.com

Reader offers

Win Time for Sounds!

Are you looking to develop sound awareness skills such as syllable segmentation and onset and rime in children who need support to acquire phonics knowledge? Black Sheep Press is giving away TWO copies of Time for Sounds Reception, normally worth 70, to Speech & Language Therapy in Practice readers. This complete group programme was developed by speech and language therapist Sarah Parkin as part of a joint project between Stockport LEA and PCT. She says it has been extensively trialled over the past three years and has produced excellent outcomes in childrens literacy skills. The pack is aimed at children in Foundation Stage and Key Stage 1 (aged from 3-7 years). It includes 200 pages of session plans, colour pictures and black and white line drawings and is suitable for use by speech and language therapists, teachers and teaching assistants. To enter this FREE prize draw, all you have to do is e-mail your name and address with SLTiP Time for Sounds Offer in the subject line to Gillian@blacksheeppress.co.uk by 25th October 2009. The winners will be notified by 1st November. For more about this and other Black Sheep Press products, see www.blacksheeppress.co.uk.

Win Best Games for Groups!

Looking for warm-ups, ice breakers and quick ideas to make groups fun? Then Hinton House Publishers is offering a set of 8 pocket books FREE to THREE lucky readers. Aimed at young people from 5-16 years, each collection of the 50 Best Games addresses a specific area of development. The set comprises 50 Best Games for... Speech & Language Development, Building Self-Esteem, Relaxation & Concentration, Brain Exercise, Sensory Perception, Groups, Childrens Groups and Indoor Games for Groups. The books are usually sold as two sets totalling 71.98 but, for your chance to win them all, email your name and address with SLTiP Best Games offer in the subject line to info@hintonpublishers.com. Your entry must be received by 25th October 2009 and the winners will be notified by 1st November. Hinton House is a new company owned and run by Sarah Miles, formerly the Publisher at Speechmark, publishing in the fields of education, special needs, emotional literacy, classroom and behaviour management, literacy, storytelling and drama. For the full range of products and information about submitting your ideas for publication, see www.hintonpublishers.com.

Reader Offer Winners

The company behind Photosymbols 3 was so pleased with the response to its reader offer in our Summer 09 issue that it has decided to choose three winners across the globe instead of one! The UK winner is Fiona Soutar, for the Republic of Ireland its Sherley Birdthistle and the international recipient is Louise Frazer in Barbados. Fiona Soutar also struck lucky in the Novelty Warehouses Fidget Bin draw, as did Kirsty McLaughlan. Thanks to our sponsors, congratulations to our winners, and good luck with this issues offers!

Autumn09 speechmag
Members area
For a reminder of your user name and password, e-mail avrilnicoll@speechmag.com.

Extras

www.speechmag.com/Members/ See the endoscopic rating scale detailed in Hydes, K. & Leslie, P. (2009) Scoping and scaling, Speech & Language Therapy in Practice Autumn, pp.4-6. Find the adaptation of Coupe & Levys (1985) The Object Related Scheme Assessment Procedure as described in Martin, S. & Pearson, M. (2009) How I help people move on (1): Steering the way home, Speech & Language Therapy in Practice Autumn, pp.23-25.

Coming soon

www.speechmag. com/Resources/ Originals Report on a specific language impairment seminar at Queen Margaret University

Feedback

The forum has been replaced by more information about the Critical Friends form of peer review for the magazine. To get involved, see www.speechmag.com/About/ Friends.

Back issues
www.speechmag.com/Members/ 2006 - 2007 issues available as pdfs!

Autumn 2009 (publication date 31 August 2009) ISSN 1368-2105

Autumn09contents
8 COVER STORY: THE COST OF CARE With motor neurone disease being such a rapidly progressive disease with complex symptoms, there is a case for saying that, if practitioners can get it right here, then managing other long term neurological conditions will be simpler. Beverley Hopcutt assesses the potential impact of the Motor Neurone Disease Year of Care Pathway with Hal Bailey, and brings us up-to-date with other essential resources when working with this client group.

Published by: Avril Nicoll, 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com

Thanks to Hal and Margaret Bailey for our cover photo by Karen Wright, www.karenwrightphoto.co.uk

Design & Production: Fiona Reid, Fiona Reid Design Straitbraes Farm, St. Cyrus, Montrose Angus DD10 0DS Printing: Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT Editor: Avril Nicoll, Speech and Language Therapist

4 ASSESSMENT Our rationale for inviting comments on the rating scale was to check we had included the main features that can be seen during endoscopy and that the scoring systems were familiar, user friendly and had clinical relevance. Kirsty Hydes and Paula Leslie discuss why a standardised and reliable rating scale for the use of endoscopy with people with dysphagia is needed and how they have kick-started its development with an evidence-based pilot. 6 EDITORS CHOICE 7 HERES ONE I MADE EARLIER Alison Roberts with two low cost therapy suggestions The communication tree and What on earth..? 11 WINNING WAYS Collaborators listen and talk, they discuss and clarify and really do want to keep going until everyone can at least be aware of and acknowledge the positions of others. Life coach Jo Middlemiss addresses readers concerns about workplace conflicts. 12 PARTICIPATION ...the map became intrinsically motivational. This was evidenced by the many self-initiated changes in behaviour that accompanied and followed the actual construction of the map, including a reduction in drinking, increased physical exercise, a healthy eating programme and exploration of further study options with the support of his family. Sam Simpson, Emma Gale and Ashleigh Denman reflect on the impact the late Dr Mark Ylvisakers ideas have had on their practice with people with brain injury. In this first of two articles, Sam and her client PJ demonstrate why identity mapping is central to true rehabilitation.

16 THIS HOUSE BELIEVES IN E-STIM There have been no sufficiently well designed clinical trials to date that support this method as a valid treatment for dysphagia. Indeed, there is more evidence in the literature that finds either no effect or adverse effects. Christine Matthews and Paula Leslie examine the evidence around the effectiveness of transcutaneous neuromuscular electrical stimulation in treating people with dysphgia. 19 IN BRIEF Kirsty Forde joins a local network for newly qualified therapists and Beth Brewster evaluates two therapist assessment clinics for two-year-olds. 20 REVIEWS Resilience, language disorder, speech science, voice, laryngectomy, velo-cardio-facial syndrome, voice and speech, assessment, culture, stammering, head and neck. 22 IN-DEPTH REVIEWS Jois Stansfield considers the 3rd edition of the CASP and Bernie Brophy-Arnott appraises the Signalong Sexual Awareness Pack. 23 HOW I HELP PEOPLE MOVE ON (1) STEERING THE WAY HOME Our aim was that through acting out the tasks and the feelings of moving house, the group would have memories and experiences that they could relate back to during and after the move. Speech and language therapist Sue Martin and drama therapist Magda Pearson draw inspiration from Keith Park when supporting a group of people with severe and profound learning disabilities to move house.

(2) TALKING FLATS Moira was not demonising her family but recognising that there were some good times shared. However, for many reasons, both simple and complex, she was making an active choice not to return there and to move into her own home and onto the next chapter in her life. Maria Venditozzi found the Talking Mats framework ideal for gathering evidence of the competence of a lady with learning disabilities to make the decision about where she should live. 28 LETS TALK SHOP Five attendees at the 2009 National Speech and Language Therapy Fair choose their favourite resource. 30 OUR TOP RESOURCES The childs story allows us to gain information and insight into how the child is feeling in relation to their learning and emotional well-being and to support our clinical decision-making. We use a number of approaches to gather information social stories, our diary system, Talking Mats, communication passport, target sheets, personal learning plans and child centred plans. Sandra McKeen, Toddy Lawson, Bernadette Bannon and Ruth Wallace work in Fife with children with specific language impairment. IN FUTURE ISSUES: PLACEMENTS... VOICE...STORYTELLING...TRAINING... ASSESSMENT...BRAIN INJURY... MENTAL HEALTH...WORKING INDEPENDENTLY

Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2009 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site. Speech & Language Therapy in Practice can be found on EBSCOhost research databases

news

Fair Care for Parkinsons

The Parkinsons Disease Society is campaigning for Fair Care for Parkinsons following an All Party Parliamentary Group (APPG) for Parkinsons Disease report documenting severe inequalities in access to services, including speech and language therapy. Dr Nick Miller from the University of Newcastle was among over 350 people who gave evidence to the enquiry. His research identified that very few speech and language therapists have any involvement with people with Parkinsons disease and, even in major centres, the number of people with Parkinsons disease on speech and language therapists caseloads is tiny compared to the number that would be expected. He also highlighted gaps in early intervention, nursing homes and palliative care and called for a body of specialist speech and language therapists to be trained who are totally cognisant of the latest evidence basis and are able to deliver it in an expert fashion. www.parkinsons.org.uk/PDF/APPG_Report_ Please_Mind_the_Gap.pdf www.parkinsons.org.uk/faircare

AuKids in bloom
A regional not-for-profit parenting magazine aimed at families with young children on the autism spectrum is celebrating its first birthday with a drive to go national. AuKids began as a joint venture between parent Debby Elley, whose five year-old twin sons have autism, and speech and language therapist Tori Houghton. The quarterly publication is distributed free to families in Greater Manchester and Stockport. Debby says it is popular as, we dont talk about unproven cures. Our subject matter is down-to-earth, practical and fun information and advice. From 2010 there will be a small subscription charge for home delivery to help with efforts to expand. To date the magazine has survived through voluntary effort, sponsorship and advertising. Tori says, Every issue we have to sit down and think where the money is coming from. We desperately need sponsors to help us continue with this magazine, which we know is so needed. Any contribution, however big or small, is welcomed. Download AuKids magazine at www.aukids.co.uk

Vice-President of The Childrens Trust, Richard Hammond, with Calvin, who is on a brain injury rehabilitation programme.

A can do attitude
Broadcaster Richard Hammond, who sustained a serious brain injury in an accident while filming for BBCs Top Gear in 2006, has opened a 7 million residential centre for children from across the UK with acquired brain injuries. The Childrens Trust rehabilitation centre in Tadworth, Surrey has been funded entirely by voluntary donations. Chief Executive Andrew Ross said, Our challenge was to design a facility for the nursing and care of children with the most complex physical, psychological and social needs without losing sight of our main purpose: to give the children a road back to normality, marrying expert care with a can do attitude to disability. Meanwhile another charity, The National Centre for Young People with Epilepsy, is also preparing to open the doors of a new facility in the Autumn. The Neville Childhood Epilepsy Centre replaces a 1960s building which is no longer fit for purpose. It will be a base for the international study and treatment of epilepsy and other neurological conditions in under-18s as well as offering a wide range of diagnostic, assessment and rehabilitation services including speech and language therapy. www.thechildrenstrust.org.uk; www.ncype.org.uk

Faithful companions
Seven year old Sam Daly, who has muscular dystrophy, and his assistance dog, Josie, are celebrating after completing their training period with a successful compatibility assessment. Josie is one of four dogs whose training to work with children by the charity Dogs for the Disabled was made possible by grants from the Kennel Club Charitable Trust. An 18 month old yellow Labrador Retriever, Josie can help wheelchair user Sam with everyday tasks such as removing socks and undoing zips, opening doors, and taking notes between Sam and his parents. Sams mum Sarah said, Josie has completely changed Sams life.For the first time ever, he can have his own independence.Sam can now play on his own in the garden thanks to Josie, something we would never had dreamed he would do, before she came along.We cant believe the change already in Sam. Dogs for the Disabled has around 200 assistance dogs working with disabled clients in England and Wales. www.dogsforthedisabled.org/; www.justgiving.com/kennelclub/.

On the buses

Delaying dementia
The Alzheimers Society and The Stroke Association have joined forces to fund research to try to prevent or delay dementia developing in people who have had a stroke. The charities say that thirty per cent of stroke survivors develop dementia. Over eight years, the new PODCAST study will consider whether intensive treatment to lower blood pressure and cholesterol makes a difference. www.alzheimers.org.uk; www.stroke. org.uk

Therapists looking for ways to improve access to transport for people with communication support needs can take inspiration from a bus supervisor in Gateshead. John Gordon (50) found himself unable to help when a deaf passenger approached him for information at Gateshead Interchange last year. To make sure this couldnt happen again, he signed up for a 12 week Deaf and Blind Awareness course with the local council, followed by the Learn to Sign NVQ level 1. As well as enrolling for the next level, John has encouraged 11 of his colleagues to go on the course, and has become a volunteer with Gateshead Deaf Club. He has also worked

John Gordon helps a deaf passenger

closely with the Nexus Bridge Card scheme, which helps anyone with special communication needs travel independently on public transport by alerting drivers. www.gateshead.gov.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

NEWS & COMMENT

Stroke Matters
The UK Stroke Forum in December 2008 saw the launch of Stroke Matters, The Stroke Associations free quarterly e-publication for professionals in health and social care. Editor Joanne Murphy says it covers interesting and accurate news on stroke issues, carefully selected by an expert multidisciplinary editorial board comprising of leading stroke specialists. The latest issue includes updates on stem cells in stroke, childhood stroke, the use of telemedicine and skills training for stroke care, along with research updates across the stroke care pathway. Subscribers can also access archived issues. Joanne is encouraging speech and language therapists both to subscribe to the service and contribute relevant articles. You can subscribe for free by completing a form at www.stroke.org.uk/ strokematters.

Comment:

Reason

with passion

Protect your title

The Health Professions Council is urging all speech and language therapists to sign and return their renewal declaration with payment by the deadline of 30th September. To continue to practise using the title speech and language therapist or speech therapist all members of the profession must renew their registration every two years. The annual renewal fee is 76. Registrants must sign and return their declaration even if they pay by direct debit. The renewal form confirms that the registrant is undertaking continuing professional development. Straightforward guidance on the Councils requirements is available in an online DVD at www.hpc-uk.tv/flash.html. Further information is also at www. hpc-uk.org/registrants/renew/.

Recognising fathers

A national survey of fathers who have children with learning disabilities has found that people working in health and social care could do more to acknowledge and include fathers. Good practice guidance in the report from the Foundation for People with Learning Disabilities stresses the importance of giving fathers the opportunity to attend meetings and contribute towards decision-making. Professionals can help by planning meetings in advance at convenient times, possibly outwith normal working hours, and giving sufficient information in advance for parents to plan whether one or both will attend. If fathers cannot attend a meeting, the guidance recommends they are kept informed via telephone or e-mail. It concludes by noting that for cultural reasons some fathers may not be comfortable discussing sensitive topics with female members of staff. www.learningdisabilities.org.uk/publications/?entryid5=32902

Mobility rights

UK charity Contact a Family and the Every Disabled Child Matters campaign have welcomed a court ruling to grant a judicial review of mobility benefits for disabled children under the age of three. Stephen and Wendy Meek, whose son Justin cant walk and is oxygen dependent, argued that the non-payment of mobility benefits contravened their sons human rights. The Court of Session ruled that the Department of Work and Pensions may indeed be breaching Justins rights under European law. The charity says some disabled children need to travel with bulky equipment while others need to be close to a car to enable prompt access to medical attention. Current rules mean that families cannot claim high rate mobility Disability Living Allowance until a child is three. Contact a Family estimates that the review could benefit up to 10,000 families in the UK at any one time. www.caf.org.uk

One of the best things about being in a book group is reading things I wouldnt necessarily choose myself and finding them surprisingly resonant. Touching Distance by Rebecca Abrams is a fictionalised account of a true story. Set in 1790, it follows a young doctor who is committed to using reason to determine what we now call evidence based practice, even in the face of powerful vested interests and other peoples fear of change. ...there are persuasive arguments on both sides... You must weigh the existing evidence, then gather new evidence. Only when you have sufficient facts in front of you, can you make a proper assessment. Above all you must never forget...Authority without facts is nothing but opinion and opinion without authority is worth less than a barleycorn. (Abrams, 2008, p.109) Dr Alexander Gordons methodical and logical approach would certainly find favour with Paula Leslie and her collaborators Christine Matthews (p.16) and Kirsty Hydes (p.4). I suspect he may well have benefited from Jo Middlemisss thoughts (p.11) on resolving workplace conflict - and would no doubt have welcomed the positive response from the authorities that Maria Venditozzi (p.26) encountered when she presented evidence of a clients wishes using Talking Mats. Weve come a long way from healthcare being funded privately and through charitable donations as it was in 1790 but arguments about the best way of funding the health service are unlikely to go away. With its Year of Care Pathway (Beverley Hopcutt with Hal Bailey, p.8), however, the Motor Neurone Disease Association has opened up discussion about the true cost of care and how improving funding mechanisms can make that care more effective. Sadly, the groundbreaking story telling work by Sue Martin and Magda Pearson (p.23) is hampered by difficulties accessing funding for drama therapy. Dr Gordon had to retire through ill health and died aged 46, with his pioneering work on puerperal fever only properly recognised after his death. In contrast another pioneer, the late Dr Mark Ylvisaker, could have been in no doubt about the value of his contribution to brain injury rehabilitation. By highlighting the impact his work has had on their practice, Sam Simpson, Emma Gale and Ashleigh Denman (p.12) hope that readers will consider how it can be applied to other client groups. Alec Gordon thought that reason was his one and only driver. It took some time for him to appreciate that passion for his work played as big a part. The blend of reason with passion is evident in the Fife specific language impairment teams choice of top resources (p.30) and indeed, as always, throughout this issue of Speech & Language Therapy in Practice. Would he, Alexander Gordon of Miltown of Drum, have done all that he has without passion, without faith in something far beyond mere provable facts?...Reason is not everything. Reason is only a part of everything. Without passion, reason is as cold and dead as the fire at his feet. (Abrams, 2008, p.285)

Reference Abrams, R. (2008) Touching Distance. London: Pan Macmillan.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

assessment

Scoping and scaling

Speech and language therapists use endoscopy to assess the needs of people with dysphagia - but clinical effectiveness is hampered by the lack of a standardised and reliable rating scale. Kirsty Hydes and Paula Leslie discuss why such a scale is needed and how they have kick-started its development with an evidence-based pilot.
hile the endoscopy swallow assessment is within the scope of practice for speech and language therapists with expertise and specialist training in dysphagia (Kelly et al., 2007), the profession lacks an evidence based endoscopy rating scale. Kirstys research study as part of an MPhil degree (Newcastle University) was designed to look at inter-rater reliability of anatomical and swallowing features observed during endoscopy. The first part of the study involved developing a rating form for endoscopic swallow studies, based on clinical practice and robust evidence. This article focuses on why the endoscopic rating scale was needed and how we created it. The scale is available at http://www.speechmag. com/Members/Extras. Swallowing impairment affects eating and drinking safety by increasing the risk of aspiration: material entering the airway below the level of the vocal folds. Complications associated with dysphagia include pneumonia, malnutrition, dehydration, longer hospital stay, and increased health service dependency (Smithard et al., 1996). Clinical practice requires efficient and accurate assessments to plan management. The main instrumental assessment tools are videofluoroscopy and endoscopy (Fibreoptic Examination of Swallowing: FEES). Literature describes the endoscopic procedure and which features of anatomy and physiology should be assessed, but this is based on limited robust evidence and often uses subjective descriptors. Any evidence borrowed from videofluoroscopic assessment should be used with caution because the structures and features seen differ between the two procedures. Videofluoroscopy uses radiographic imaging to track food/liquid from the oral cavity, through the pharynx and into the oesophagus. Patients must be physically stable and able to be transported to the X-ray suite. Patients are exposed to radiation although this can be kept to a minimum (Zammit-Maempel et al., 2007). Endoscopy gives a clear view of the pharynx
Kirsty and Paula

READ THIS IF YOUR ARE INTERESTED IN DEVELOPING A CLINICALLY USEFUL ASSESSMENT TOOL EVIDENCE-BASED OBJECTIVE MEASURES INTER-RATER RELIABILITY

and larynx before and after the swallow but not the oesophagus or the period of whiteout the moment of swallow (Langmore et al., 1988). A fibreoptic camera is passed along the nose, beyond the velopharyngeal port and into the hypopharynx with a view of the tongue base and valleculae. Clinicians can assess anatomical and physiological deficits of the soft palate, pharynx and larynx. There is no radiation exposure and the patient can be examined at bedside or in the outpatient clinic.

Endoscopy gives a clear view of the pharynx and larynx before and after the swallow
Currently there are no standardised descriptors for anatomical and physiological features observed during endoscopic swallow studies and there is insufficient information on how reliable clinicians are at rating swallowing behaviours when using endoscopy. Inter-rater reliability in endoscopic swallow studies is reported to have acceptable levels (83 per cent agreement) for observing oral/pharyngeal transit, laryngeal elevation, laryngeal closure at the airway entrance, and epiglottic contact with the pharyngeal wall (Logemann et al., 1999). Colodny (2002) focused on inter-rater agreement (but not validity) in endoscopy using the Penetration-Aspiration Scale (Rosenbek et al., 1996), and the results showed an acceptable 65-75 per cent. This study only looked at agreement on the degree of laryngeal penetration and therefore results cannot be generalised to other swallow features. The use of the Penetration-Aspiration Scale is questionable because the landmarks used to score are not visible in real time when using endoscopy and timing of events sometimes

Insufficient information

has to be inferred. Recent work has shown that speech and language therapists do judge images of the same swallow differently depending on whether it is from endoscopy or videofluoroscopy (Kelly et al., 2006). Limited research on reliability during swallow endoscopy is partly because no rating form with published reliability and validity exists to measure rater agreement for anatomical and physiological swallow features. So, having been granted favourable ethical opinion by the Local Research Ethics Committee for this project, we started the process of designing an endoscopy rating scale. We searched for existing scoring procedures used with videofluoroscopy and endoscopy using terms: dysphagia, Fibreoptic Endoscopic Examination of Swallowing, videofluoroscopy, rating scales, and reliability. Databases included: AMED, CINAHL, Medline, Pubmed, and The Cochrane Library. We included videofluoroscopy to examine which features are measured, how they are scored and if a similar scoring method could be used with endoscopy. We designed an evidence based rating form using published reports of what could be seen during endoscopic swallow studies - which may not equate to what clinicians can reliably rate. Features included anatomical ratings of the pharynx and larynx, physiological events in the absence of a bolus, and physiological swallow features in the presence of a bolus. Features such as velopharyngeal motion, vocal cord closure during a tight breath hold, ratings of pharyngeal secretions, evidence of premature spillage in pharynx, penetration/ aspiration and residue were included (Langmore et al., 1988; Rosenbek et al., 1996; Bastian, 1991; Murray et al., 1996; Dua et al., 1997; Langmore & McCulloch, 1997; Murray, 1999; Hiss & Postma, 2003). Ordinal scales (normal/mild/moderate/severe) and nominal scales (present/absent) were used. Ordinal scales had descriptors so that raters could decide on feature severity. Nominal scales were used to rate movement of the velum in speech and swallowing, vocal

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

assessment
fold adduction during phonation, epiglottic retroflexion, laryngeal elevation, and nasoregurgitation. These types of scoring were based on endoscopy (Rosenbek et al., 1996; Langmore & McCulloch, 1997; Murray, 1999) and videofluoroscopy research (McCulloch et al., 2001). Clinical significance may be easier to identify with an ordinal scale (Brunier & Graydon, 1996). We created and discussed several versions of the scale with both academic (Newcastle University) and clinical tutors working in the field of dysphagia and voice and, after two months, a pilot form was ready. 5. The ratings of pharyngeal and laryngeal anatomy were altered to a simplified rating of normal versus abnormal anatomy. This was expanded to comment on presence or absence of a number of normal and abnormal anatomical features. 6. Vocal fold adduction during phonation was removed because this is related to speech and not directly to swallowing. Assessment of vocal fold movement during tight breath hold was kept to view vocal fold mobility and the potential for adduction. 7. Seven point ordinal scales were used to rate the overall swallow, inferred base of tongue movement, timing of swallow initiation, pooling and residue and swallow efficiency. Checklists of features relating to oropharyngeal transit and the location of residue were added. 8. One expert requested that an impression of laryngeal elevation should form part of the assessment. Epiglottic function was included in the checklist of features associated with laryngeal excursion. 9. The Penetration-Aspiration Scale (Rosenbek et al., 1996) was retained, together with a question on when penetration/aspiration occurred. tongue base retraction together with features which might indicate a problem with this movement, but did not include analysis in greater depth. After we had made the changes to the pilot form, we returned the revised version to one expert for further comments if needed.

Feedback from experts

As research clinicians developing skills in the area of endoscopy, we deemed it appropriate to seek feedback from experts in the field of dysphagia. We invited two international experts in dysphagia to comment individually on the pilot scale. Both are trained in endoscopy, and one also provides training and publishes work in this area. We asked them to advise on improvements regarding content of features, scoring, length, presentation and clinical relevance. Our rationale for inviting comments on the rating scale was to check we had included the main features that can be seen during endoscopy and that the scoring systems were familiar, user friendly and had clinical relevance. In addition, this consultation process helped to reduce author bias of scale content. Both experts were happy to make suggestions within an agreed time frame and their comments resulted in a number of improvements: 1. Anatomy/physiology features with and without a bolus trial were divided. Overall swallow rating was moved to the start of the bolus trial section so clinicians would report on the whole swallow before rating specific features in detail. 2. Ordinal scales were kept and one expert recommended that ordinal scales should contain 7 points to improve reliability. 3. Severity descriptors relating to the ordinal scales were removed except for the validated severity scales for tight breath hold, secretion severity and penetration/ aspiration. We decided to remove semantic descriptors - such as swallow frequency where a normal rating was described as swallowing frequently in response to a build up of saliva/residue and mildmoderate impairment was labelled as trace pooling of secretions/residue with delayed swallow response - because they set up artificial guidelines that are not uniformly agreed or evidence based. 4. Velar closure during speech was removed because it does not relate to movement during swallowing. Velar closure during the swallow was kept, changed to velopharyngeal closure on a dry swallow and scored on a 7 point ordinal scale of range of closure as opposed to strength of movement (Murray, 1999).

As would be expected in any collaborative exercise, the experts advice differed at times.
As would be expected in any collaborative exercise, the experts advice differed at times. One suggested that a detailed assessment of lateral pharyngeal wall movement and pharyngeal response to touch should be part of the assessment form. However, our other expert suggested removing the pharyngeal sensation rating because it is a crude measure of sensory impairment in the pharynx. We decided to retain a measure of sensory awareness via the rating of pharyngeal secretions using the Secretion Severity Scale (Murray et al., 1996) and a question on rating the presence/ absence of secretions within and around the pharynx and larynx, and the response or lack of response to secretions. One of the experts advised looking at base of tongue movement at rest, on post vocalic / l/, and on dry swallow. While we acknowledge that examinations using endoscopy may include a more in-depth assessment of the movement of base of tongue, the purpose of this assessment tool was to identify a) which features clinicians could see on FEES and b) how reliably they could rate visible features as a group. As a result, we kept in a general measure of

We found the experts comments relating to the scoring and layout useful in providing structure to the pilot version of the scale. Questions relating to the inference of base of tongue retraction and laryngeal elevation were added since both are vital components of the pharyngeal stage of swallowing. Scoring feature severity is no longer qualified with semantic descriptors, which are often highly subjective and not validated in the literature. Clinicians instead are asked to make a severity judgment on a feature, such as the amount of residue, and then to qualify this by answering a checklist of sub features relating to the overall feature, for example the location of residue. This type of scoring is clinically more useful because people qualify why they rated a particular feature as normal or abnormal. We didnt include all features recommended by the experts because the purpose of this form was to produce an initial clinical tool rather than to rate an entire endoscopic swallow assessment. Other researchers (Rosenbek et al., 1996) have already examined which features are difficult to rate in videofluoroscopy. As part of her MPhil research study, Kirsty has gone on to use the endoscopy rating scale to examine inter-rater reliability on anatomical and physiological features of swallowing, and this will be written up for publication at a later date. It is important to keep research focused and doable, so including questions on compensatory strategies and intervention techniques was beyond the remit of Kirstys study. Examining inter-rater reliability on decisions made following endoscopy assessment should form part of a follow-up. Also to be assessed in further work is the use of the 7 point rating scale. Although Likert scales have good psychometric properties (Brunier & Graydon, 1996), this may be too detailed for clinicians to use reliably. We are limited in our clinical and research assessment and intervention by the lack of published, validated scales and scoring systems for endoscopic swallow studies. We need to focus future research on whether the features identified in this preliminary work can be viewed consistently during endoscopy. Based on results of this type of follow-up study we will be in a better position to know which features should be incorporated on an endoscopic swallow assessment rating scale and how this should be applied in clinic. In the longer term we want to use this preliminary work to design research to develop a standardised tool.

Clinically useful

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

assessment

Editors choice

So many Journals, so little time! Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.

Our aim to devise a rating form based on clinical practice and supported by robust evidence was achieved. The expert peer review increased the clinical validity of the tool, and both speech and language therapists were happy to do this as part of their expert role. Clinicians should therefore consider the features reported in this rating scale when assessing swallowing. Kirsty Hydes is a consultant speech and language therapist at St Johns Hospital, Livingston, e-mail kirsty.hydes@wlt.scot.nhs.uk. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, e-mail pleslie@pitt.edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists. The endoscopic rating scale described is available at http://www. speechmag.com/Members/Extras.

Acknowledgements Our sincere appreciation to the expert clinicians who advised on this project and to Kirstys thesis tutors Nick Miller and Paul Carding. We also wish to thank Dr James L. Coyle for advice on the manuscript.

Our interest in Attachment Theory is increasing but, in Making Space for Positive Constructions of the Mother-Child Relationship, Natalia Cecelia Charles and Rachel C. Berman draw attention to its limitations. Critical of research methods that accentuate stress and difficulties, they use qualitative oral history interviews of mothers of children with autism. Their findings suggest we can and should foster resilience in such mothers and their relationship with their child. Answers to questions such as What aspects of your relationship with your child do you enjoy the most? help identify strategies that, over time, will support and strengthen it. Hopeful, thought-provoking and moving. (Journal of the Association for Research on Mothering (2009) 11(1), pp.180-198) Do people who stammer have impoverished language? Do they use less language to minimise stammering? In The effect of stuttering on communication: A preliminary investigation, Elizabeth Spencer, Ann Packman, Mark Onslow and Alison Ferguson tackle these questions through Systemic Functional Linguistics, which analyses how people communicate with language and the meanings they convey. It is possible that the extent to which modality (a lexicogrammatical resource that is used to indicate opportunities for verbal engagement) is employed will emerge as an area for therapy and outcome measurement in adults who stammer. (Clinical Linguistics & Phonetics (2009) 23(7), pp.473-488) I am coming to appreciate how systematic reviews focus attention on evidence, its strength, the gaps, and how research procedures can be improved. Effectiveness of Early Phonological Awareness Interventions for Students with Speech or Language Impairments by Stephanie Al Otaiba, Cynthia S. Puranik, Robyn A. Ziolkowski and Tricia M. Montgomery details 18 studies. A stand out recommendation for me is collaborative early intervention for children with speech impairment where speech-language pathologists deliver speech production and phonological training that is linked to explicit early literacy phonological awareness training provided by a classroom teacher in a small group setting. (The Journal of Special Education (2009) 43(2), pp.107-128)

REFLECTIONS DO I CONSIDER ASKING FOR PEER AND EXPERT OPINION TO MAKE MY INFORMAL ASSESSMENTS MORE ROBUST? DO I KEEP CLINICAL EXPLORATION FOCUSED AND ACHIEVABLE? DO I EXERCISE CAUTION WHEN APPLYING EVIDENCE FROM ONE TOOL TO ANOTHER?

Do you wish to comment on the impact Bastian, R. (1991) Videoendoscopic evaluation this article has had on you? Please see the of patients with dysphagia: An adjunct to the information about Speech & Language modified barium swallow, Otolaryngology Therapy in Practices Critical Friends at Head and Neck Surgery, 104, pp.339-350. www.speechmag.com/About/Friends Brunier, G. & Graydon, J. (1996) A comparison of two methods of measuring fatigue in patients on chronic haemodialysis: visual analogue versus Likert scale, International Journal of Nursing, 33, pp.338-348. Colodny, N. (2002) Interjudge and intrajudge reliabilities in Fibreoptic Endoscopic Evaluation of Swallowing (FEES) using the Penetration-Aspiration Scale: A replication study, Dysphagia, 17(4), pp.308-315. Dua, K., Ren, J., Bardan, E., Xie, P. & Shaker, R. (1997) Coordination of deglutitive function and pharyngeal transit during normal eating, Gastroenterology, 112, pp.73-83. Hiss, S. & Postma, G. (2003) Fibreoptic Endoscopic Evaluation of Swallowing, Laryngoscope, 113, pp.1386-1393. Kelly, A.M., Leslie, P., Beale, T., Payten, C. & Drinnan, M.J. (2006) Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal severity? Clinical Otolaryngology, 31(5), pp.425-432. Kelly A.M., Hydes K., McLaughlin C. & Wallace S. (2007) Fibreoptic Endoscopic Evaluation of Swallowing (FEES): The role of speech and language therapy. RCSLT Policy Statement 2007. London: Royal College of Speech & Language Therapists. Langmore, S. & McCulloch, T. (1997) Examination of the pharynx and larynx and endoscopic examination of pharyngeal swallowing, in Perlman, A. & Schulze-Delrieu, K. (ed.) Deglutition and Its Disorders. San Diego: Singular Publishing, pp.201-226. Langmore, S., Schatz, K. & Olsen, N. (1988) Fibreoptic Endoscopic Examination of Swallowing Safety: A new procedure, Dysphagia, 2, pp.216-219. Logemann, J., Rademaker, A., Pauloski, B., Ohmae, Y. & Kahrilas, P. (1999) Interobserver agreement on normal swallowing physiology as viewed by videoendoscopy, Folia Phoniatrica et Logopaedica, 51, pp.91-98. McCullough, G., Wertz, J., Rosenbek, J., Mills, R., Webb, W. & Ross, K. (2001) Inter- and Intrajudge reliability for videofluoroscopy swallowing evaluation measures, Dysphagia, 16, pp.110-118. Murray, J. (1999) Manual of Dysphagia Assessment in Adults. San Diego: Singular Publishing. Murray, J., Langmore, S., Ginsberg, S. & Dostie, A. (1996) The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration, Dysphagia, 11, pp.99-103. Rosenbek, J., Robbins, J., Roecker, E., Coyle, J. & Wood, J. (1996) A penetration-aspiration scale, Dysphagia, 11, pp.93-98. Smithard, D., ONeill, P., Park, C., Morris, J., Wyatt, R., Engand, R. & Martin, D. (1996) Complications and outcome after acute stroke: Does dysphagia matter?, Stroke, 27(7), pp.1200-1204. Zammit-Maempel, I., Chapple, C.L. & Leslie, P. (2007) Radiation Dose in Videofluoroscopic Studies, Dysphagia, 22(1), pp.13-15.

References

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

Heres one I made earlier

Heres one I made earlier...

Alison Roberts with two more low cost, flexible and fun therapy suggestions for groups. The communication tree What on earth?

This has been a really useful collage item to have on the wall of the clinic. It helps with motivation and understanding the interactive process. It is useful at the early stages of a social language group, where the clients are beginning to be aware of the skills they could improve in order to become better communicators, and is also a handy end-of-course recap. You are aiming to create an outline image of a tree, with roots and branches, to which the clients can attach leaf-shaped labels describing the ways in which communication benefits us, and clod-of-earth shaped labels stating prerequisites for achieving good communication. You will need to have constructed the base before your clients complete it. It is worth making the basic framework sturdily, because you can then use it again and again. Alternatively, you could make it out of paper as a quick illustrative exercise. It may take the group more than one session to complete the tree. MATERIALS A piece of board A2 size is about right. Fibreboard is ideal as you can stick pins into it. Its best to use it the portrait way round. Pale blue fabric to cover the whole board. Old polycotton sheeting is fine for this. Beige fabric to cover the lower third of the board representing the area under the ground where roots form. Thin strip of greenish fabric to form a grass level. Rough-textured brown fabric - we used hessian with success as it is textured enough to resemble tree bark and roots, yet lightweight enough to stay stuck on the backing. Glue (PVA is good as it doesnt show through the fabric). Leaf-green paper (several shades of green would be great). Earthy-brown paper. Pens, scissors, and pins. BRAWN Stick the blue fabric on the board to cover it completely and add the beige across the bottom third, forming the earth. SLTP Draw your tree on the textured brown fabric and cut it out. Its a good idea to make it a manybranched variety so that you will have lots of room for leaf- and clod- labels. Dont worry if you cant cut out the root part at the same time, you can cover the join with grass anyway. Stick your tree on, and stick the grass across where the roots meet the trunk, and the earth meets the sky. Write the word COMMUNICATION on or alongside the trunk. Now you have the basic form to which your clients can attach labels. IN PRACTICE Completing the board It is important that you discuss with your clients the reasons for making the board, and I have found that it is best to begin with the subject of the benefits of being able to communicate. The clients will tell you why it is important, but you should end up with a list including the following: chatting to people; making friends; using the phone; making appointments; asking for things in shops; telling people what you need; making jokes; having discussions; being part of a group; interview skills; getting a girl / boy friend; keeping in touch with old acquaintances. Write down all the suggestions as they are given, and then give everyone in the group some green paper and scissors to cut out leaves to stick on the tree. The tendency is for people to cut leaves that are too small to write on, so suggest to them that they write first, then cut out and pin on the tree. Now you need to tackle the roots of the tree in a similar way, first discussing the prerequisites for good communication and making a list, this time including skills such as listening; body language; speech clarity; eye contact; using the persons name; greetings and farewells; turn taking; being optimistic; staying on, and shifting the subject; having a few topics ready; prioritising and organising. It is likely that several of these areas will be unfamiliar to your clients, especially those that are not a problem to them, so you will need to give an outline description although you are not actually teaching these skills at this stage. Again make the suggestions into labels and pin them to the tree, this time using clod-shapes, at the roots. IN PRACTICE - Discussion Ask everyone how they feel about the tree, and which bits apply to them. Discuss how real trees use their roots to draw nourishment from the earth, and can therefore put out shoots. Try to make the point really clearly that if they work at the prerequisite skills they will be able to reap the benefits.

A handy addition to your materials for developing lateral thinking skills. The game is suitable for a group of 4-5. MATERIALS Strong (preferably fabric) bag - size depends on your choice of contents Funny objects - this is the main challenge in preparing for the game, in that ideally you will provide objects which no-one else will have seen before. You may find, as I did, that there are all sorts of peculiar items (often Aunties Christmas presents!) in your kitchen drawer such as honey scoops, ice-lolly moulds, parts of coffee-makers. A tool chest may also yield some weird things. My lovely friend and assistant Julia, a part-time upholsterer who also used to own a flock of sheep, provided some items whose original uses I found impossible to guess! Even broken items (but not sharp or otherwise hazardous) will be fine. IN PRACTICE In turns, each group member picks one item from the bag. Spend some time examining the item, and then describe one or more uses for it. Encourage miming to clarify the meaning. This game is good fun, and is comfortable for everyone, as there are no right answers. Often it can be hilarious too.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

CARE PATHWAYS

The cost of care

Beverley Hopcutt, with the help of Hal Bailey, considers how the Motor Neurone Disease Year of Care Pathway will help commissioners ensure interventions will be in place when needed so that the multidisciplinary team can spend more time with clients and plan to manage symptoms effectively.
Gwen

READ THIS IF YOU ARE INTERESTED IN LONG TERM CONDITIONS A MULTIDISCIPLINARY APPROACH INFLUENCING COMMISSIONERS

ffective symptom management in Motor Neurone Disease is challenging due to the rapid progression and number of problems people with the disease can present with over a short space of time. It is essential for speech and language therapists to work as part of a multidisciplinary team to ensure a holistic approach to management access to the right professional for advice, support and treatment at the right time. While the focus of this article is on a new Year of Care Pathway, this is just one of many useful resources now available to support the quality of life of people with motor neurone disease (figure 1). In its quality requirements, the National Service Framework for Long Term Conditions reinforces the consensus that multidisciplinary care is the right approach. However, in the world of commissioning, costs of service provision are coming under closer scrutiny. The current system in England of payment by results focuses on payment for procedures or outpatient attendance. It does not cover the ongoing health and social care costs of people with long term conditions, whose treatment does not fit neatly into an episode of care and where best practice is for ongoing contact with services. With motor neurone disease being such a rapidly progressive disease with complex symptoms, there is a case for saying that, if practitioners can get it right here, then managing other long term neurological conditions will be simpler. Ideally, commissioners (GP, Primary Care Trust, social care) need to ensure that a comprehensive package of care is commissioned over a period of time. This means current and anticipated healthcare needs are planned and budgeted for so care can be delivered in a timely manner as needs arise without having to constantly refer back to the commissioner for approval for funding. In future, these costings could be used to support the provision of a personal health budget to be held by the client, as direct payments and individual budgets for purchasing social care are currently. The concept of a year of a care was originally piloted in diabetes and, more

recently, in motor neurone disease by the MND Association in collaboration with Leeds PCT and Leeds Adult Social Care. The year of care pathway tool outlines the health and social care services that an individual with motor neurone disease will need to access dependent on the symptoms they develop and how these progress. The services are described for costing purposes in terms of staff time, equipment and other consumables such as medication. Having assessed current need and produced a care plan, an experienced practitioner should be able to predict likely disease progression. Using the tool, they can then create an anticipatory care plan with costings for the year ahead.

the professional is encouraged to plan ahead and raise issues with the person with motor neurone disease in a timely manner Applications
For speech and language therapists the Motor Neurone Disease Year of Care Pathway has a number of applications. Firstly it outlines all of the multidisciplinary inputs available for symptom management. This helps practitioners to understand others roles and contributions, and to notify and make timely referrals to the relevant services as new difficulties develop regardless of whether or not they are a designated keyworker or care coordinator. The pathway also describes the multifaceted speech and language therapy role, with our involvement in the management of communication, dysphagia and sialorrhea (excess salivation). It can also help with the prediction of symptom progression and what to expect in the future, so the professional is

encouraged to plan ahead and raise issues with the person with motor neurone disease in a timely manner. This ensures that services and equipment are in place in good time for when they will be needed. It means too that sensitive issues such as advance directives to refuse treatment such as gastrostomy insertion can be discussed at a time when the client is still readily able to communicate and make such decisions (figure 1, no.10). Speech and language therapy managers might also find the tool useful for benchmarking their local service costs. The Year of Care Pathway tool can act as an alert for symptoms which portend the need for other involvement. This might include onset of respiratory problems requiring non-invasive ventilation. There is a useful checklist from the MND Association outlining symptoms of respiratory failure, indicating possible need for non-invasive ventilation and for cough assist (figure 1, no.2) due to weak cough and secretion retention. While the tool highlights the importance of multidisciplinary team input, including multidisciplinary motor neurone disease clinics, it also demonstrates the high costs of such care. It is unlikely that an individual would need every health intervention in one year but, if this were the case, it would cost about 198,459 based on the year of care for an individual with advanced disease, with an additional 82,900 needed to fund equipment. So how much does a year of speech and language therapy input come to? a) Communication Many people present with bulbar motor neurone disease which is frequently misdiagnosed, often as a stroke. It is only as symptoms progress despite dysarthria therapy that a neurological opinion is sought and diagnosis confirmed. Only post-diagnosis speech and language therapy intervention is included but, at 39 per monthly session equating to 468 per year, it could be a challenge to meet all communication needs including the training of the individual and their key communication partners to use communication aids. However, the suggested costs of 8,200

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

Care pathways Figure 1 Motor neurone disease resources 1. Motor Neurone Disease Year of Care Pathway See main section of article. Available at http://www.mndassociation.org/for_professionals/sharing_good_practice/mnd_year_ of_care.html. Additional downloads include equipment costs, services and learning from the development of the tool in Leeds. 2. Cough assist This device, more frequently used in cystic fibrosis to assist secretion clearance, is being used to aid people with motor neurone disease to expectorate secretions. It can be particularly helpful for those individuals who are experiencing prolonged coughing episodes as they attempt to clear secretions, resulting in extreme breathlessness and often triggering an Accident & Emergency attendance and possible admission to hospital. Assessment for cough assist is usually provided by specialist respiratory centres who also offer non-invasive ventilation. 3. Swallow reminder badge This badge delivers a sound at a preselected time interval to remind the individual to swallow their saliva. With prolonged use, anticholinergic medications prescribed to reduce saliva production seem to become less effective, and the badge can be helpful in delaying the introduction of medication. www.winslow-cat.com 4. Professional Respiratory Checklist Cards This is a handy pocket-sized checklist to remind the practitioner about the symptoms suggestive of carbon dioxide retention (an indication of respiratory failure), and the need for referral for consideration of non-invasive ventilation. www.mndassociation.org 5. The Grid 2 This software package can be loaded onto standard desk and laptop computers. It enables switch users to easily access all of the functions they would normally use on their computer plus use it as a communication aid. www.sensorysoftware.com 6. Drinkup This new drinking device is designed to enable more physically dependent individuals to drink via a straw without the assistance of carers when seated or in bed. The system accepts any household cup, mug, glass or drinks can. For larger quantities of liquid, Drinkup has also been designed to take a standard NHS drinks jug, together with a modified lid. www.drinkup.uk.com 7. Sl drinks Hot and cold drinks are available in a variety of flavours in the three fluid consistencies recommended in the National Descriptor Guidelines for Texture Modification in Adults (syrup, custard and (cold only) pud8. Biotene Dry Mouth Toothpaste This non-foaming toothpaste can be helpful for people with bulbar motor neurone disease who are no longer able to rinse and spit out when cleaning their teeth. www.biotene.com 9. Botox There is an increasing research evidence base for the use of botulinum toxin injections into the salivary glands to reduce intractable excess salivation which is no longer responding to anticholinergic medication. Giess, R., Naumann, E. Werner, Riemann, R., Beck, M., Puls, I., Reiners, C. & Toyka, K. (2000) Injections of botulinum toxin A into the salivary glands improve sialorrhoea in amyotrophic lateral sclerosis, J Neurol Neurosurg Psychiatry 69(1), pp.121-123. 10. Advance decision to refuse treatment It is important that people living with motor neurone disease make informed decisions about future symptom management options (for example, their choice as to whether they would want to have a feeding gastrostomy in the face of increasing dysphagia, non-invasive ventilation if in respiratory failure, or invasive ventilation in the case of a respiratory arrest) and that they record these decisions in a way that their wishes can be carried out legally. Speech and language therapists can play a role in introducing these discussions, and facilitating communication. If there is evidence of early cognitive changes associated with the motor neurone disease, it is important that these discussions happen early on. The National Council for Palliative Care Guide for Health and Social Care Professionals is a useful resource. http://www.endoflifecareforadults.nhs.uk/eolc/files/NHS-EoLC_ ADRT_Sep2008.pdf 11. Understanding My Needs Booklet Many people with motor neurone disease report poor management of their neurological symptoms when admitted to hospital or other care settings such as respite due to professionals lack of knowledge about motor neurone disease and how the individual wishes to be cared for. By having this form completed and up-to-date, this information can be readily communicated to caregivers in the event of a planned or unplanned admission. Available from www.mndassociation.org 12. Computer Accessibility A number of adaptations can be made to any computer through the Windows accessibility programme and wizard to make it easier to use for those with a disability. These include changes to key responsiveness, keyboard shortcuts for those who have difficulty using a mouse and changes in cursor size/colour. The programme is accessed as follows: 1. Click on the START icon 2. Click on All Programmes 3. Click on Accessories 4. Click on Accessibility 5. Click on Accessibility Wizard 6. Activate the options that you think might make the keyboard and computer easier to use.

ding consistencies). The easy to prepare drinks are supplied as powder in a plastic cup to which hot or cold water is added and then stirred to achieve the desired consistency. Blackcurrant, lemon, orange, white coffee and chocolate are available on prescription in the community, and can be helpful in overcoming the issue of carers adding thickening

powders to drinks being viewed as administering medication. A standard consistency is achieved, eliminating variability. www.slodrinks.com

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

care pathways
for the purchase of a variety of communication aids for the duration of the disease could be argued to be overgenerous. b) Dysphagia With the onset of swallowing difficulties there is the need for regular review, advice on compensatory strategies and modified consistencies, and education of formal and informal carers. Objective assessments such as videofluoroscopy or FEES (fibreoptic endoscopic evaluation of swallowing) are not listed as routine, but may be needed in some cases. c) Sialorrhea Difficulty controlling saliva co-occurs with dysphagia, and the speech and language therapist is often involved in assessment and advice about symptom management, including use of medication and provision of equipment such as a swallow reminder badge (figure 1, no.3). These are not included in the core medication and equipment costings. This all suggests that, while the initial 281,359 might have sounded high, in reality it could prove challenging to meet all client needs within cost. The Motor Neurone Disease Year of Care Pathway is useful for practising speech and language therapists, speech and language therapy service managers and commissioners, but what about the client perspective? I asked Hal Bailey what difference it would have made had it been available to him. Bev: What problems have you experienced trying to access the appropriate services/ equipment using the current system? Hal: Although I am happy with the NHS provision of service, without the financial support of the MND Association for certain items of equipment I would be struggling. The provision of equipment tends to be basic with little choice or consideration of the individuals circumstances. There are two instances where the equipment I was offered wasnt ideal for my situation. The first was my communication aid. Having tested the one offered by the NHS it was large and bulky and not practicable for my current lifestyle. Because I use two sticks I was looking for a communication aid which I could easily carry in my pocket, and which was quick to use, the hand held unit from Possum answered my problems. The NHS solution was large and bulky and this alternative solution was funded by the MND Association. The second issue was the problem of getting out of bed. The option suggested by the NHS was a mattress lifter, which would be fine if I slept in a hospital bed, but as a couple we are determined to keep life as normal as possible. Again the MND Association came to my aid and contributed towards an electric adjustable bed. Bev: How would local implementation of a Year of Care have made a difference to you? Hal: If the funding of up to 7000 for a computer-based communication aid as per the year of care had been immediately available

Photos of Hal and Margaret Bailey by Karen Wright

then it would have been possible for the NHS to purchase my aid without having to wait for funding to be sought from various alternative sources, and without having to access charitable funding. Bev: What do you think about people holding their own budget for services and equipment? Hal: For me, the whole purpose of care is not who holds the budget, but trying to maintain life as normal as possible. If that means holding your own budget then I will take that route. I personally think that it is horses for courses in that it would not suit everyone. Plus there would have to be some form of control on how the budget is spent. If I had a personal health budget I probably would have spent a larger proportion on physiotherapy. Bev: Is there anything else you would like to share with the speech and language therapy readership? Hal: In September 2007 I started looking at what was available to assist me in communicating. I was fortunate enough to be able to research the market place through the internet. At this stage I had not mentioned this to my speech therapist. I found that there were several communication aids in the market place and, as in all walks of life, there is not one solution that suits all. I was lucky enough be able to test a number of the products mainly through a direct approach to the companies selling the products. I also tested the product on offer through the NHS. Had I not been in a position to research the market, I wonder whether I would have ended up with a device that was totally impracticable? I have since spoken to a number of people where the NHS solution is collecting dust and not being used! In my position, I undertake the research so that I can remain as independent as possible whilst try-

ing to maintain as normal a life as possible; not everyone is as fortunate as me to have access to a computer to do this. Beverley Hopcutt is Speech and Language Therapist at the Manchester MND Care Centre, and Therapy Service Manager (Stroke & Neuro) at Manchester Royal Infirmary, e-mail Beverley.Hopcutt@ cmft.nhs.uk. She is also the Department of Healths Clinical Advisor for the Long Term Neurological Conditions NSF. Hal Bailey retired in 2003 aged 57 as Managing Director of a software company, and was diagnosed with MND in 2004. He is newsletter and website editor for the Cheshire Branch of the MND Association, www.mndcheshire.org.

Resource

The National Service Framework for long term conditions is available at: http://www.dh.gov.uk/en/Healthcare/ Longtermconditions/Long-termNeurologic alConditionsNSF/DH_4128647. SLTP

REFLECTIONS DO I ADDRESS POSSIBLE FUTURE NEEDS IN A SENSITIVE AND TIMELY FASHION? DO I UNDERSTAND ENOUGH ABOUT WHAT OTHER SERVICES CAN OFFER TO MAKE APPROPRIATE REFERRALS? DO I KEEP UP-TO-DATE WITH CHARITIES RELEVANT TO MY CLIENT GROUP?
Do you wish to comment on the impact this article has had on you? Please see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

10

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

Winning ways

Conflicting ideas
A survey sent out to a sample of readers included an open question about which concerns they would most like life coach Jo Middlemiss to address in 2009. This third article suggests that, by taking a step back from workplace conflicts, you can find a creative and satisfactory solution.
The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed. Carl Jung Why cant they just get on?is a pretty universal question in families, schools, voluntary organisations, businesses, religions and countries. Is conflict just part of being human? If so, why is it so uncomfortable? Why does it leave us finished either high with excitement or low with the legacy of hurt feelings and minds racing with unresolved issues? When Speech & Language Therapy in Practice editor Avril Nicoll asked readers what problems they most often encounter as speech and language therapists, conflict figured highly. The frustration that conflict can provoke comes out in some of the language used readers want advice on dealing with demanding patients and difficult members of the multidisciplinary team. It is clear that conditions can engender conflict, be it the very antagonistic nature of SENDIST work, or being managed by someone from another agency with very different priorities and working culture. Readers understand they have responsibility for negotiation and resolving situations but want to succeed in assertiveness and still retaining enthusiasm. This suggests that, like me, you believe conflict is a part of being human and that until we are all raised to the levels of the great enlightened ones - we just have to deal with it. There are many different reasons as to why people argue but they can generally be boiled down to issues around values, needs and expectations and rights. People want to be right, and will defend their corner energetically if the ego-ruled position is threatened. There are healthy and not so healthy ways to deal with conflict. Everyone has their own conflict style and its my contention that your conflict style, and your ability to stand back from and change it, will largely determine the outcome. I was recently asked to evaluate a course which is in preparation for young people to help them develop healthy relationships (Training for Youth in Relating to Others). It defines the various conflict styles very usefully as follows: READ THIS IF YOU WANT TO BE AWARE OF CONFLICT STYLES EFFECTIVE IN CHALLENGING SITUATIONS CREATIVE IN RESOLVING DIFFERENCES

1. Avoidance - No Way 2. Accommodation - Your Way 3. Competition - My Way 4. Compromise - Half Way 5. Collaboration - Our Way. Avoidants simply wont engage and can drive others crazy by refusing to acknowledge the causes of the conflict. They hope that, if they ignore it, it will all go away. It often does, but will always come back in another form, maybe with a bigger kick. Those who accommodate give in, with an anything for a quiet life attitude. Again this is a slow burner and can cause deep seated resentment in the accommodator, leading to illness, sudden bursts of emotion or a severe case of victimitis. Competitors think that they need to be right more than they need to be happy. They feel good for a little while when the victory is theirs, but if that victory is at the expense of the relationship, where is the value? People who have a compromising style are into give and take. They need to be open to the opinion of others and are prepared to be partially satisfied and not overly attached to their own position. They do believe in win/ win and this is often a very effective style indeed. The slight downside is that they may be saving up their compromises and will use them at a later date to win a big battle. It is one to be a little wary of because there may be an unexpected payback! Collaborators are not those that deal with the enemy as the war time term would have you believe. No, they focus on working together

with the team to find a solution which meets the needs of all parties. Collaborators listen and talk, they discuss and clarify and really do want to keep going until everyone can at least be aware of and acknowledge the positions of others. This requires courage and honesty and really does lead to healthier relationships in all areas of life. No prizes for guessing which one I favour. The challenge now is to work out which style is yours, and which style operates in your workplace. How can you change and become more effective when conflict makes its appearance, as it most certainly will? Thinking about your conflict style and recognising the conflict style of others helps you to take a step back from the conflict and a step forward into the creative and satisfactory solution which is SLTP most assuredly available to you. Jo Middlemiss is a qualified Life Coach, who offers readers a complimentary half hour coaching session (for the cost only of your call). Please note that Jo moved in May 2009 and her new telephone number is 07803589959. Jos book with CD What should I tell you? A Mothers final words to her infant son is now available.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

11

participation

Walking with Dobermanns (part 1)

In this first of two articles inspired by the late Dr Mark Ylvisaker, Sam Simpson, Emma Gale and Ashleigh Denman reflect on the impact his ideas have had on their practice with people with brain injury, and the promise they hold for other difficult-to-serve client groups. With the help of her client PJ, Sam Simpson then goes on to demonstrate why Ylvisakers concept of identity mapping is central to true rehabilitation.
en years ago, speech and language therapists working with adults with acquired brain injury faced a dilemma. Intervention for this client group had a poor evidence base, with evidence on efficacy limited to speech and language diagnoses found more commonly in stroke (aphasia, dysarthria, right hemisphere language disorder, dysphagia) or learning disability (social skills), and there were few assessments tailored to the needs of people with brain injury. There was a paucity of evidence or discussion of the real issues clinicians in brain injury rehabilitation faced. As a result, many of us struggled with the legitimacy of our treatment approaches, in addition to difficulty engaging clients with a brain injury in a rehabilitation process designed for people who had had a stroke. The key clinical issues for us included communication difficulties falling under the umbrella of cognitive communication disorder, as well as more general social interaction impairments like reduced awareness of listener needs, reduced turn taking and poor inference and social inferencing skills. We also encountered impairments of insight and self-regulation, which often manifest as challenging behaviour and are more commonly seen as the province of clinical psychology. The models used by our multidisciplinary team colleagues - such as errorless learning theories, awareness and insight - also challenged us to find a firm theoretical basis for speech and language therapy intervention. It was in this context that we first came across the work of Mark Ylvisaker and his clinical psychologist colleague, Timothy Feeney, in a special brain injury edition of Aphasiology (Ylvisaker & Feeney, 2000a). For the three of us, these articles were a revelation. They told a story of dobermanns and poodles to differentiate between the two kinds of clients who typically access brain injury rehabilitation services. Poodles described clients who turn up on time, carry
READ THIS IF YOU WORK WITH CLIENTS WHO STRUGGLE WITH BEHAVIOURAL REGULATION IDENTITY RECONSTRUCTION IDENTIFYING MOTIVATING PERSONAL GOALS

Ashleigh, Sam and Emma

In memory of Mark Ylvisaker Dr. Mark Ylvisaker was Professor of Communication Sciences and Disorders, College of Saint Rose, Albany, New York, USA from 1990 until his death in May 2009. He worked with children and adults with cognitive, communication and behavioural disability for over 30 years in rehabilitation, special education, and community settings. He originally studied and taught philosophy before becoming a speech-language pathologist. He published extensively and served as consultant to a number of state, federal and international projects dealing with brain injury in children and adults. He also helped develop materials for educators, clinicians and parents, and was the primary contributor to the LEARNet web site www.bianys.org/learnet. Mark was delighted to hear about our forthcoming articles and had hoped to add his comments, but sadly this was not to be. out self-directed work and show gratitude for our hard work. In contrast, dobermanns are oppositional, unreliable, insightless and antiauthority, often exhibiting behaviour that is difficult to manage in rehabilitation settings and even less acceptable in the community. In short, the article described many of our clients, who often have a post-injury history of alcohol or drug misuse, with oppositional or anti-social behaviour, and who struggle to access traditional brain injury services. Ylvisaker and Feeney turned our traditional model of speech and language therapy intervention on its head. They highlighted the importance of engaging this difficult-to-serve group of clients, involving them in the goal setting process and finding out what motivates them. In addition to describing their programme, they were able to demonstrate how the outcomes improved the quality of life of their clients and reduced the cost to the state of their support longer-term. They proposed models

12

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

participation
of working which have helped to develop a practical, holistic, integrative approach to brain injury rehabilitation, based on sound theoretical models. They have since applied these to other adult and paediatric client groups who demonstrate self-regulatory impairments, such as those with attention deficit/hyperactivity disorder or autism, with significant success. In the intervening years, the work of Mark Ylvisaker and Tim Feeney has been adopted widely by speech and language therapists and clinical psychologists working in the field of brain injury. All three of us have attended conferences and study days Ylvisaker has run here in the UK on his many trips since he was first invited over by the Speech and Language Therapy Head Injury Specific Interest Group in 2003. Ylvisakers work highlights two competing models for rehabilitation (Ylvisaker et al.,1999). The traditional model is hierarchical, with a clear progression from work at the level of impairment, through activity, to a later focus on participation. The alternative model proposed by Ylvisaker reverses this traditional hierarchy (figure 1). Using this alternative model Ylvisaker has developed a range of interventions focusing on goal setting, group and individual project work, use of metaphor and identity mapping. Our second article in the Winter 09 issue will focus on project work, with Emma Gale detailing how she has applied this to groups in a rehabilitation setting and Ashleigh Denman describing some of the projects her individual clients have worked towards in the community. In the rest of this first article, Sam Simpson describes how she has put Ylvisakers ideas about identity reconstruction into practice with a recent client. been identified as a critical theme in outcome studies of severe brain injury and an obstacle to active engagement in rehabilitation. Ylvisaker thus positions identity reconstruction as central to rehabilitation. He argues that, unless there is a strong correlation between an individuals rehabilitation goals and sense of personal identity, rehabilitation efforts are at best likely to be ineffective and at worst counter-productive in that negative attitudes to disability and rehabilitation can be escalated. (Ylvisaker et al., 2008). With this in mind, Ylvisaker proposes a process of identity-oriented goal negotiation, which he terms identity mapping, as a means of coaching the development of a new life narrative. Identity mapping aims explicitly to assist individuals after a brain injury to construct an organised and compelling sense of personal identity through the use of metaphor. In brief the approach involves the use of a visual map (figure 2) and a central metaphorical figure or concept to elicit what is important to an individual. This acts as a platform to identify rehabilitation goals. Figure 2 Visual map The original literature gives a full account of the theoretical underpinnings of this approach (Yvisaker & Feeney, 2000b; Ylvisaker et al., 2008). For the purposes of this article, I aim to illustrate how I have recently applied the use of identity mapping and metaphor practically in my work with PJ, a 23 year-old man with a traumatic brain injury. In truth, my initial application of this approach was a somewhat chance event. I chose to experiment with identity mapping in direct response to metaphors PJ brought to therapy two weeks after my having attended an Ylvisaker study day. Little did I know the impact that identity mapping was to have on both my client and my subsequent clinical practice. PJ had his brain injury at the age of 18 when he was on the cusp of becoming a professional sportsman. Whilst in many respects his rehabilitation had been successful PJ was living back at home with his family, had a manual job and socialised regularly with old friends five years on, he was now grappling with questions about his future. He and his family had initiated access to independent speech and language therapy / counselling as PJ was reporting reduced confidence in group and novel social situations, which was impacting on his community access and social life. PJ reported significant feelings of despondency at this time, having no purpose and direction in life, feeling frequently bored and drinking heavily. The conversation that triggered the use of identity mapping related to PJs having re-watched the film Forrest Gump and having identified strongly with the character of Lieutenant Dan (see www.imdb.com/character/ ch0002105/bio for more information). The film had made such an impression on him that he was keen to explore why and so we constructed the identity map in figure 3 in response to this curiosity.

Identity reconstruction

Difficulty re-establishing an organised and compelling sense of personal identity has Figure 1 Models of rehabilitation Traditional model of rehabilitation Identify underlying impairments and disabilities, with less focus on participation. Focus on eliminating or reducing underlying impairments with restorative or training exercises. Compensatory strategies used if impairment persists. Later shift in focus to context and environmental compensations if activity and participation reduction persists. Ylvisaker model of rehabilitation Identify what is working/not working for the individual in everyday routines (that is, at a participation level). Identify potential to change negative routines into positive routines and build repertoires of successful behaviour, through changing activities, the environment, the support of others or the individuals own behaviour. Identify motivational sources for the individual. Facilitate intensive practice of positive routines in real-world contexts, to promote successful participation in meaningful activities, habituation of positive behaviours and the internalisation of strategic behaviours. Systematically withdraw supports. Ongoing review to consider re-introduction of supports according to fluctuation in life stressors.

Figure 3 PJs identity map

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

13

participation
The development of this identity map enabled PJ to talk openly for the first time about his struggle to re-construct a new robust personal identity since his injury. In addition it enabled him to reflect on and make sense of his drinking and increased anger dyscontrol at home. In relation to this, we constructed a second identity map capturing his fears about following the same path as an older relative this map has not been included here at PJs request. Whilst Ylvisaker tends to focus on positive identity maps, the process of isolating and elaborating particular features of this feared self enabled PJ to explore his fears openly. PJ subsequently chose to show these two maps to his family, thereby opening up discussions about the inner turmoil he was experiencing and the behaviours that he was very aware were impacting heavily on his family. PJ was enthusiastic about the process of identity mapping and reported specifically finding it helpful to organise muddled thoughts and get what was going on in my head down on paper in a clear way, as he felt that none of it had previously made any sense. He was also expressing his readiness for change (Prochaska & DiClemente, 1986), so we negotiated trialing identity mapping to elaborate specifically on his hoped-for self (figure 4). Whilst PJ was unable to identify an overarching metaphor (such as the original Lieutenant Dan one) that encapsulated all of the qualities and activities of his hoped-for self as recommended by Ylvisaker et al. (2008), he was nevertheless able to work with the concept of me as I would like to be as an integrated representation of the changes he would like to make. The very process of constructing this identity map served to give form, meaning, organisation and direction to his hopes and aspirations. The different dimensions were reported to be particularly helpful in breaking down the whole into more tangible and manageable parts - I could think about how I want to be, what I want to do and where I could find these things then I could pick what bit I wanted to look at and change. Writing the map down and having a permanent record also proved critical to the process everything became a reality once Id written it down something to aim for getting them written down made a valid point of me doing it. increased physical exercise, a healthy eating programme and exploration of further study options with the support of his family. PJs engagement in the rehabilitation process has increased considerably with him now taking a lead in directing the focus of therapy and accessing the support he wants as and when he determines it to be relevant and timely. PJ prioritised the overarching goal of returning to study. He consequently identified and signed up for a two year part-time National Diploma in Sport which commenced in September 2008. At the time of writing, he has just completed the second term of his first year. We recently reviewed the identity map in figure 4 as a means of tracking change. PJ reported finding it particularly helpful to have a clear, personally meaningful and selfdetermined mechanism to evaluate the many changes that have taken place over the past 12 months. It also enabled him to see the interconnections between the changes that he has made. For example, by starting college he now has a more natural structure to his week, has met many new people and made new friendships. This initial encounter with identity mapping has been highly formative for me. Having initially worked with PJ on developing his selfawareness, interaction skills and confidence in both one-to-one and group settings, identity mapping has enhanced goal negotiation and engagement to promote the generalisation of knowledge and skills into real-life meaningful contexts. Ylvisaker et al. (2008) propose a range of applications, as detailed in figure 5 below. I now regularly use identity maps as a means of better establishing rapport, getting a more integrated picture of my clients and negotiating personally meaningful goals. I also use more metaphors to assist clients to self-cue (for example, how would I approach this as Lieutenant Dan? As me as I would like to be?). Finally, as a trainee counsellor, I increasingly use it as a scaffold and springboard to exploring underlying feelings and emotional responses. We strongly believe identity mapping is an approach relevant to therapists working in many fields with clients of all ages. At the very least we hope this article inspires you to read

Intrinsically motivational

Thus the map became intrinsically motivational. This was evidenced by the many selfinitiated changes in behaviour that accompanied and followed the actual construction of the map, including a reduction in drinking,

Above: Figure 4 PJs hoped-for-self Right: Figure 5 Identity mapping and metaphors: a continuum (Ylvisaker et al., 2008)

14

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

participation
more about Ylvisakers work and at most that it promotes the cross-fertilisation of his ideas into other areas of clinical specialism through prompting you to consider how they might be applied to your work. Sam Simpson is a specialist speech and language therapist and trainee counsellor at intandem (www.intandem.co.uk), e-mail sam@intandem. co.uk. Ashleigh Denman is principal lead speech and language therapist with the Gloucestershire Brain Injury Team, e-mail Ashleigh.denman@glos. nhs.uk, while Emma Gale is clinical lead speech and language therapist at the Royal Hospital for Neurodisability in London, e-mail egale@rhn.org.uk. Part 2 of this article will be in the Winter 09 issue. Acknowledgement Our thanks to PJ for the courage he has shown and the teaching he has provided. SLTP References Prochaska, J.O. & DiClemente, C.C. (1986) Towards a comprehensive model of change, in Miller, W. & Heather N. Treating Addictive Behaviours. New York: Plenum Press, pp.3-27. Ylvisaker, M., Feeney, J. & Feeney, T. (1999) An everyday approach to long-term rehabilitation after traumatic brain injury, in Cornett, B. (ed.) Clinical practice management in speechlanguage pathology: Principles and practicalities. Gaithersburg, MD: Aspen Publishing Co., pp.117-162. Ylvisaker, M. & Feeney, T. (2000a) Reflections on Dobermanns, poodles and social rehabilitation for difficult-to-serve individuals with traumatic brain injury, Aphasiology 14(4), pp.407-431. Ylvisaker, M. & Feeney, T. (2000b) Construction of identity after traumatic brain injury, Brain Impairment, 1, pp.12-28. Ylvisaker, M., Mcpherson K., Kayes, N. & Pellet, E. (2008) Metaphoric identity mapping: Facilitating goal setting and engagement in rehabilitation after traumatic brain injury, Neuropsychological Rehabilitation, 18(5), pp.713-741.

Resources

Access Scottish Theatre lists forthcoming accessible performances in Scotland. An update service by e-bulletin is available. www.scottishtheatres.com/accessguide.php. The government has published revised guidance for practitioners and managers on sharing information legally and professionally with professionals working in different sectors such as education and health. www.everychildmatters.gov.uk/ informationsharing In What Makes My Family Stronger Contact a Family reports on the experiences of families in 2009 with disabled children. Over 60 per cent said they didnt feel listened to by professionals, and wanted their expertise to be acknowledged. www.cafamily.org.uk/pdfs/wmmfs.pdf Quality standards in vision care for deaf children and young people: Guidelines for professionals from Sense and the National Deaf Childrens Society seek to ensure that deaf children receive good vision care. Forty per cent of children who are born deaf also have eye problems. www.sense.org.uk The website of a multidisciplinary team of therapists in San Francisco includes photographs from a 10 day volunteer venture in the Dominican Republic. www.therapista.net/dominican/ Projects Abroad organises overseas volunteer work placements for gap years and career breaks in areas including healthcare and education. A recent scheme has focused on providing opportunities to out of work graduates. www.projects-abroad.co.uk/ A lecturer blogs about a 6 week project at an orphanage in Bethlehem teaching staff to use music with Palestinian children who suffer from extreme anxiety and abandonment issues. http://creativetherapiesnewport.blogspot.com/ Christian Heilmann has developed ways to make popular social networking tools You Tube, Flickr and SlideShare easier for children and people with learning disabilities to access. (Source: AbilityNet, www.abilitynet.org.uk.) http://icant.co.uk/easy-youtube/docs/index.html http://icant.co.uk/easy-flickr/ www.wait-till-i.com/2008/06/22/easy-slideshare/ Vocal Processs e-zine 37 includes front foot, back foot advice from Jeremy Fisher for changing the energy and emotional flow. Intended for performers, it may also be of interest to some speech and language therapy clients. www.vocalprocess.co.uk/resources_1.htm

CHANGE has developed accessible resources for parents who have difficulty reading and understanding information. www.changepeople.co.uk/catalogue. php?type=3 The latest research document in the I CAN Talk series is on Speech, Language and Communication Needs and the Early Years. The link also includes free resources to raise awareness of communication development and how to promote it. www.ican.org.uk/sitecore/content/Home/ Resources.aspx Scopes Campaigns Officer Jamie Robertson is the central figure in a Five News video investigating access to shops and transport in London for people who use a wheelchair. www.fivetvonline.tv/news. php?news=1840&dm_i=6J4,1HGJ,Q08EJ,4H8B,1 YoungMinds Very Important Kids (VIK) is a national panel of young people with mental health problems. Their manifesto with accompanying film and petition encourages change to improve young peoples mental health. www.youngminds.org.uk Crick Software has created free Clicker activities to support and reinforce messages about online safety for children with special needs as part of the Know IT All for Primary Schools project. www.LearningGrids.com; www.childnet-int. org/KIA/primary/ Connectors, a new reading scheme for 7-11 year olds from Scholastic, aims to develop comprehension strategies through speaking and listening. http://shop.scholastic.co.uk/series/599 The Social Market Foundation report From feast to famine: reforming the NHS for an age of austerity includes discussion around managing demand. www.smf.co.uk/assets/files/Health%20Report% 20From%20Feast%20to%20Famine.pdf New Local Government is a not-for-profit independent think tank which seeks to transform public services. Recent activities include lobbying the government to ensure people in their 20s and 30s think about saving now to cover their future health and social care needs. www.nlgn.org.uk A specialist dyslexia teacher and a teacher and mother of a boy with dyslexia have joined forces to produce a system of teaching and learning materials for adults to use with children who find reading, spelling and handwriting difficult. www.dyslexikit.co.uk (Source: www.wordswell.co.uk newsletter)

REFLECTIONS AM I READY TO TURN TRADITIONAL APPROACHES ON THEIR HEAD IF AN ALTERNATIVE BUT THEORETICALLY GROUNDED PRACTICE EMERGES? DO I CONSIDER THE ROLE OF PERSONAL IDENTITY IN GOAL SETTING AND OUTCOME? DO I SEEK WAYS TO GIVE FORM, MEANING, ORGANISATION AND DIRECTION TO THE HOPES AND ASPIRATIONS OF MY CLIENTS?
Do you wish to comment on the impact this article has had on you? Please see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

15

this house believes

This House Belie

OUR NEW SERIES AIMS TO DEVELOP YOUR SKILLS FOR CRITICAL APPRAISAL MAKING DECISIONS EVIDENCE BASED PRACTICE

Christine Matthews and Paula Leslie examine the evidence around the effectiveness of transcutaneous neuromuscular electrical stimulation in treating people with dysphagia.
Christine Matthews is a speech-language pathologist at the Veterans Administration Medical Center in Pittsburgh, USA, a clinical instructor at the University of Pittsburgh and a clinical fellow in the medical speech-language pathology clinical doctoral program at the University of Pittsburgh, USA, e-mail Christine.matthews@va.gov. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, e-mail pleslie@pitt.edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists.

This House Believes explained

In her teaching, Paula Leslie uses a debating idea from the British Medical Journal to get her students to critically review a controversial subject. By understanding the strengths and weaknesses of the arguments on both sides, the students are better prepared to develop their own views. Students are strictly limited in word count and number of references to foster concise and relevant writing. Their work is now being adapted for Speech & Language Therapy in Practice. The debating format means: the Proposition is required to prove its case, while the Opposition aims to show why the Proposition is wrong either side can interrupt with a point of information while the other side is speaking our authors reach a conclusion based on the evidence and readers can continue the floor debate via the Critical Friends process see www. speechmag.com/About/Friends.
Paula Christine

Defining the topic

Dysphagia is an impairment in swallowing function caused by neurological insults such as stroke, traumatic brain injury or tumours, progressive diseases such as Parkinsons Disease and motor neurone disease, or trauma to the oropharyngeal tract. Providing effective treatment is crucial because dysphagia affects nutritional status and overall health (Hudson et al., 2000). In 2007-8, there were almost 27,000 finished consultant inpatient cases of primary diagnosis dysphagia (ICD-10) in England and Wales (Hospital Episode Statistics, 2009). The traditional treatments for dysphagia are diet modification and/or compensatory postures, manoeuvres and swallowing exercises (Robbins et al., 2007). Transcutaneous neuromuscular electrical stimulation (shortened to and known as NMES, TES or e-stim) in dysphagia therapy has recently increased in popularity. Principles from NMES of limbs are being applied to swallowing musculature in the hope that this method is an effective treatment for people with acquired and

progressive dysphagia. The largest marketed system is VitalStim - currently the only company to license clinicians in the use of NMES. As with most novel treatment methods about which great claims are made, NMES is a hot topic, with polarised views on its effectiveness in print and under discussion. Our debate considers the evidence for and against the use of NMES in dysphagia treatment. For clarification, NMES is not: surface ElectroMyoGraphy (sEMG) which measures muscle activity and can be used in patient biofeedback and education Electrical Muscle Stimulation (EMS) / Trophic Electrical Stimulation (TES), used to retard muscle atrophy and to improve local blood flow Functional Electrical Stimulation (FES) used to promote functional activities such as gait therapy Transcutaneous Electrical Nerve Stimulation (TENS) used to manage pain. (Wijting & Freed, 2006)

References Blumenfeld, L., Hahn, Y., Lepage, A., Leonard, R. & Belafsky, P. (2006) Transcutaneous electrical stimulation versus traditional dysphagia therapy: a nonconcurrent cohort study, Otolaryngol Head Neck Surg, 135(5), pp.754-757. Carnaby-Mann, G. & Crary, M. (2007) Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis, Arch Otolaryngol Head Neck Surg, 133(6), pp.564-571. Hospital_Episode_Statistics (2009) Inpatient Primary diagnosis: 4 character 2007-8. Retrieved 12/06/09, from http://www.hesonline.nhs.uk. Hudson, H., Daubert, C. & Mills, R. (2000) The interdependency of protein-energy malnutrition, aging, and dysphagia, Dysphagia, 15(1), pp.31-38. Humbert, I., Poletto, C., Saxon, K., Kearney, P., Crujido, L., Wright-Harp, W., Payne, J., Jeffries, N., Sonies, B.C. & Ludlow, C.L. (2006) The effect of surface electrical stimulation on hyolaryngeal movement in normal individuals at rest and during swallowing, J Appl Physiol, 101(6), pp.1657-1063. Kiger, M., Brown, C. & Watkins, L. (2006) Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy, Dysphagia, 21(4), pp.243-253. Lim, K., Lee, H., Lim, S. & Choi, Y. (2009) Neuromuscular electrical and thermal-tactile stimulation for dysphagia caused by stroke: a randomized controlled trial, J Rehabil Med, 41(3), pp.174-178. Ludlow, C. (2008)Electrical stimulation and dysphagia:What we do and dont know , TheASHALeader, 13(3), pp.8-11.

16

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

this house believes

eves in e-stim
The Proposition case: Effective for dysphagia
The proposition case is that NMES is an effective treatment for dysphagia. In NMES, an electrical current is used to activate key swallowing muscles during swallowing activities, resulting in increased strength of these muscles. The effect of NMES is typically studied when used in conjunction with more traditional swallowing therapies such as the effortful swallow, Mendelsohn manoeuvre, and thermal-tactile stimulation. The VitalStim website (2009) information includes: The use of electrical stimulation seems to contribute significantly to the improvement in swallow function (Carnaby-Mann & Crary, 2007) NMES in conjunction with swallowing exercise seems to be more effective than traditional treatment techniques alone (Blumenfeld et al., 2006). POINT OF INFORMATION: The retrospective chart review study by Blumenfeld et al. (2006) did not compare traditional therapy with traditional therapy plus NMES only traditional therapy or NMES. The authors only postulate that traditional therapy plus NMES might be more effective than traditional therapy alone. They acknowledge weaknesses such as the study being retrospective, that treating clinicians were also the evaluating clinicians, and that clinicians may not have used NMES on patients with a poorer prognosis. NMES in combination with the effortful swallow demonstrated improvement in swallow function according to patient-reported change in functional oral intake (Permsirivanich et al., 2009). POINT OF INFORMATION: This study relied only on patient-reported measures to measure improvement in swallow function, not more objective measures using endoscopic or videofluoroscopic data. Hyolaryngeal elevation has been seen to increase when NMES was used in conjunction with the effortful swallow in healthy, non-dysphagic participants (Park et al., 2009). POINT OF INFORMATION: This study showed no statistically significant differences between the control and treatment groups, and any effects faded within two weeks of treatment. Patients post stroke who used NMES with thermal-tactile stimulation reported more benefits than a control group who used thermal-tactile stimulation only (Lim et al., 2009). POINT OF INFORMATION: The patients were not blinded to which treatment they received and no control was made to avoid bias from patients knowing which treatment they received. clearing the bolus from the pharynx, by increasing their sensitivity to its presence. Stronger evidence for the use of electrical stimulation in treating dysphagia comes from the results of a meta-analysis that summarised findings from 7 studies. The aetiologies of dysphagia in the studies were a mix of stroke, cancer, head trauma, and respiratory failure. The results of the metaanalysis demonstrated a significant summary effect size that supports the use of NMES to treat dysphagia. Improvements in swallowing function were measured by examining changes in swallowing scores and the metaanalysis revealed an overall twenty percent change in swallowing performance following the treatment (Carnaby-Mann & Crary, 2007). POINT OF INFORMATION: The meta-analysis findings should be interpreted cautiously due to the small number of studies included and their low methodological grading.

Summing up the case for the proposition

The evidence supports the use of NMES in conjunction with traditional swallowing treatment techniques to improve swallow function. Patient reports demonstrate clear support of the technique, and we owe it to them to try all options.

Sensory facilitation

There is some controversy about the placement of surface electrodes for stimulating muscles deep within the pharynx which are used in swallowing. Ludlow et al. (2007) hypothesised that low levels of electrical stimulation might improve swallow function as a result of sensory facilitation (stimulation great enough for the participants to feel a tingle but not to cause muscle activation). They concluded that sensory levels of stimulation may be useful for patients who have difficulty

Ludlow, C., Humbert, I., Saxon, K., Poletto, C., Sonies, B., & Crujido, L. (2007) Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia, Dysphagia, 22(1), pp.1-10. Park, J., Oh, J., Lee, H., Park, S., Yoon, T. & Kwon, B. (2009) Effortful swallowing training coupled with electrical stimulation leads to an increase in hyoid elevation during swallowing, Dysphagia. Published online 3 March 2009 at http://www.springerlink.com/content/r73610572875004x/. Permsirivanich, W., Tipchatyotin, S., Wongchai, M., Leelamanit, V., Setthawatcharawanich, S., Sathirapanya, P., Phabphal, K., Juntawises, U. & Boonmeprakob, A. (2009) Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study, J Med Assoc Thai, 92(2), pp.259-265. Robbins, J., Kays, S., Gangnon, R., Hind, J., Hewitt, A., Gentry, L. & Taylor, A.J. (2007) The effects of lingual exercise in stroke patients with dysphagia, Arch Phys Med Rehabil, 88(2), pp.150-158. VitalStim (2009) For Heath Professionals. Retrieved 06/12/09, from http://www.vitalstim.com/ health_professionals/detail.aspx?id=62 Wijting, Y., & Freed, M. (2006) VitalStim Therapy Training Manual. Hixson, TN: Chattanooga Group.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

17

This house believes

The Opposition case: Evidence is lacking

Speech and language therapists are using NMES without the publication of appropriate levels of evidence to support its use. There have been no sufficiently well designed clinical trials to date that support this method as a valid treatment for dysphagia. Indeed, there is more evidence in the literature that finds either no effect or adverse effects. Current electrical stimulation techniques, like those in VitalStim, claim to use surface electrodes to deliver the signal to target muscles. These muscles for laryngeal elevation are located deep within the neck and there is little evidence to suggest that the current reaches these muscles. Surface electrical stimulation is unlikely to reach the thyrohyoid, intrinsic or extrinsic tongue muscles, velopharyngeal muscles, buccinator, pharyngeal constrictors, and intrinsic laryngeal muscles. These all play a major role in oral and / or pharyngeal swallowing function. Movement of the hyolaryngeal complex anteriorly and superiorly protects the airway during swallowing; when this is inadequate the risk of aspiration increases. Traditional treatment for reduced hyolaryngeal elevation has involved exercises to improve the excursion of the complex. This may be combined with alterations in diet consistency, postures or swallowing manoeuvres (Humbert et al., 2006). It is of concern that one effect of NMES they report is increased depression of the hyoid bone while at rest. Similarly, while one of Ludlow et al.s hypotheses (2007) was that stimulation would produce motor movement, the consistent motor movement was limited to depression of the hyoid bone. POINT OF INFORMATION: While the hyoid movement was in the opposite direction of that required for swallowing, it did not adversely affect swallow function in either study (Humbert et al., 2006; Ludlow et al., 2007). Humbert et al. (2006) trialled several other electrode placements in the submental and laryngeal areas and found that, no matter where the electrodes were placed, stimulation resulted in decreased hyolaryngeal elevation during the swallow in healthy adults. They used the National Institutes of Health - Swallowing Safety Scale (NIH-SSS) as a measure of swallowing safety and blinded judges rated the stimulated swallowing trials as less safe. These authors suggest that surface electrical stimulation will result in reduced elevation during swallowing for people with dysphagia. POINT OF INFORMATION: The NIH-SSS is not currently standardised. talStim) and control (traditional approaches) groups. The traditional approaches were comprised of a variety of treatments based on findings from their baseline instrumental swallowing assessments. This aimed to ensure that the individual needs of the participants were met. The authors examined change scores in oral and pharyngeal swallowing function and diet advancement from pre and post treatment. The only statistically significant difference between the two groups was that the control group improved in the oral stage of swallowing. There was no true control group (i.e. with no intervention) so the effect of spontaneous recovery cannot be ruled out. Also, a greater proportion of the experimental group had conditions that were likely to improve. It is important to note that participants who underwent NMES received more treatment than those in the control group. Treatment intensity may have more to do with reported improvement in studies where NMES is used rather than the method itself.

Judgement:

The motion is defeated

We owe our patients the best standard of practice available. The best standard is a combination of what our patients tell us, what we think to be good based on our training and experience, and what the literature tells us. NMES has not been around long in the treatment of dysphagia, but there have still been ample opportunities for substantive rigorous investigations of its efficacy. So far, there is mainly anecdotal evidence declaring effectiveness with very little research to support the claims made by its proponents. The papers cited here are the best available in our opinion. Variables that confound the true effectiveness of this method include patient selection, treatment intensity, and the pairing of traditional treatments with the method, often with poor control conditions. In our opinion, NMES has not been demonstrated in the literature to be an effective treatment method for dysphagia. Before jumping onto this bandwagon, clinicians should demand solid studies for all groups and patient specific populations that: control for major threats to validity are randomised are double blinded are funded independently of companies who market NMES systems. Clinicians must read the evidence regarding the effectiveness of NMES and carefully consider the flaws in most of these studies. The ASHA (American Speech-Language-Hearing Association) Code of Ethics Principle IG states that: Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected. Although the Royal College of Speech & Language Therapists does not have such a clear statement, the sentiment of evidence based practice is the same for both organisations. We must consider if spending healthcare resources on such an intervention is appropriate? And if giving patients unfounded hope is ethical? Until there is more evidence citing the effectiveness of this method in wellcontrolled and well-designed studies, we propose that it would be unethical to support the use of NMES in dysphagia treatment. Clinicians should continue to use methods that they know to be effective through clinical practice, patient report, and published evidence.

Side effects

Treatment candidate selection is important when considering the use of NMES. While insufficient data exists regarding the efficacy in certain populations, there are some types of patients for whom NMES should not be used such as those with diseased motor and/or sensory nerves. NMES stimulates the axons that innervate the muscle fibres, not the muscles fibres themselves. Patients with motor neurone disease should not receive the electrical stimulation because of their existing motor neuron death (Ludlow, 2008). The same is true for patients with peripheral nerve injuries or those with Myasthenia Gravis (Ludlow, 2008). Reported possible side effects of NMES include laryngospasm, cardiac arrhythmias, hypotension, glottic closure, and burns (Lim et al., 2009).

Summing up the opposition case

Kiger et al. (2006) directly compared the effectiveness of VitalStim to traditional swallowing therapy techniques for improving dysphagia in 22 subjects with various aetiologies. The subjects were assigned to the treatment (Vi-

Treatment intensity

Due to the lack of quality evidence that NMES has positive effects on swallowing function, this should not be considered an effective treatment method for dysphagia. There is no evidence that the signal delivered reaches the majority of the deep neck muscles involved in swallowing. There is evidence that the muscles involved in hyolaryngeal elevation are adversely affected resulting in reduced movement. Worse than no effect, this may increase a patients risk of aspiration, which is unacceptable.

18

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

In brief

In Brief...
In Brief is supported by

`In Brief is a new section of Speech & Language Therapy in Practice for 2009 suggested by readers to showcase short, practical ideas. One lucky contributor in each issue will receive 50 in vouchers from Speechmark, a company which publishes a wide range of practical resources for health and education professionals working with people of all ages (visit www.speechmark.net for more information). Brief items (up to 500 words) may include therapy or assessment tips or a description of a resource you have developed. It may also be a reflection on the best piece of advice I have been given, or the things I wish theyd told me at University. Although what you write will be substantially your own work, please acknowledge any influences. E-mail your entries to avrilnicoll@speechmag.com.

Network for Two heads better newbies than one?

As a newly qualified therapist, Kirsty Forde welcomes the support of her peers.
A network for newly qualified speech and language therapists in Tayside has recently been established. There are ten therapists in the network with length of clinical experience ranging from a couple of months up to two years. We agreed that therapists should stay in the network for as long as they feel they need the support or can offer support to the newer therapists in the network. There is a good mix of paediatric and adult therapists and we have had two successful meetings so far with three more planned for this year. The meetings provide informal opportunity for ongoing support with Flying Start (www. flyingstart.scot.nhs.uk/), information sharing and case discussions as well as providing us with a safe forum for asking questions we may be hesitant to ask more senior therapists. So far we have discussed the positive and negative aspects of our departmental inductions to NHS Tayside and our next meeting will be looking at how to access the e-libraryeasily. We also look forward to up-coming speakers who have very kindly agreed to share their clinical experience or specialist knowledge with us. We would be delighted if anyone feels they would like to come and speak at one of our meetings next year! If you would like to know more about the network or what we do in it, please get in touch. Kirsty Forde is a speech and language therapist working with adults with learning disabilities for NHS Tayside, e-mail kirstyforde@nhs.net.

Beth Brewster evaluates two therapist assessment clinics for two-year-olds.

In summer 2008 the paediatric department in Dundee was going through a period of change. We were looking to improve our client pathway and streamline our service. The aim was to ensure each client received the appropriate, timely input required from referral to discharge. We also aimed to improve the quality of the client experience. One area we felt required changing was our assessment of two-year-olds. Therapists often found it difficult to spend time with parents to get an in-depth case history while keeping an active two-year-old child occupied. This could make it difficult to reach a decision following a first appointment. We decided to trial two therapist assessment clinics for these young children in our community clinics. During this same period I became involved in a project for the Speech and Language Therapists Clinical Effectiveness Programme run by the Tayside Audit Resource Centre. The project I chose was to compare case histories for two-year-old clients taken during single therapist clinics with those taken during the two therapist clinics. Twenty points of information were taken to compare how much we learned from parents at initial contact. These ranged from finding out about pregnancy and the postnatal period, through early communication, to family circumstances at present and nursery placements. Feedback from therapists involved in the trial was positive. Most felt they were able to get a clearer insight into any difficulties the child may be presenting with. They also felt parents were able to discuss issues and to listen to advice given when not distracted by their child. Therapists also commented they had more quality time with the children to gauge their communication abilities. Evaluation of the results obtained from three community clinics confirms more information has been gained from parents at two therapist clinics. Although not all twenty points demonstrated an increase in the amount of information obtained, more information was obtained overall and more detailed information was recorded. Therapists have indicated they can make decisions about onward referral and how to proceed with care without the need for a further appointment. The results of the survey carried out for the project would appear to support therapists feelings that two therapist assessment clinics for two-year-olds are worthwhile in terms of providing appropriate, timely input for this client group. Beth Brewster is a speech and language therapist in Dundee with NHS Tayside, e-mail bethbrewster@ nhs.net.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

19

reviews

reviews
RESILIENCE
Helping children with complex needs bounce back Resilient Therapy for Parents and Professionals Kim Aumann & Angie Hart Jessica Kingsley ISBN 978-1-84310-948-8 13.99

SPEECH SCIENCE

Preclinical Speech Science - Anatomy Physiology Acoustics Perception Thomas J. Hixon, Gary Weismer & Jeanette D. Holt Plural Publishing ISBN 978-1-59756-182-2 95

Numerous coping strategies

Ideal for students

This book allows a more exciting, experiential approach to working with voice clients, is great value for money, and a pleasure to read. A must for all voice practitioners. Alice Poulter is a speech and language therapist for the Heart of England NHS Foundation Trust, working with people with speech, voice and swallowing disorders.

Resilient Therapy helps you deal with the challenges faced in living / working with children with complex needs. This practical dip into book provides numerous coping strategies enabling parents and professionals to feel uplifted and energised. It provides a valuable insight into the challenges faced every day by the families we work with and makes us ask, How well would I do faced with the same job 24 hours a day? Easy to read and thought-provoking, Resilient Therapy is simple to apply and can provide a very positive outcome for the child. A recommended read guaranteed to give you that feel good factor. Sharon Simpson is a specialist speech and language therapist (Advisor in Learning Disability) with NHS Forth Valley.

LANGUAGE DISORDER

Understanding Developmental Language Disorders: From Theory to Practice Courtenay Frazier Norbury, J. Bruce Tomblin & Dorothy V.M. Bishop (eds.) Psychology Press ISBN 978-1-84169-667-6 22.50

This large reference book written specifically for the speech and language therapy audience is relatively easy to read. It covers breathing, laryngeal, velopharyngeal-nasal and pharyngeal-oral function, acoustic theory for speech, speech perception and swallowing. Each chapter follows a similar structure, with clear diagrams and photos, and ends with a useful summary (review) to check understanding. In additional to the fundamental theory it briefly introduces disorders and the professionals involved in these. It does, however, use American examples and terminology. It is an ideal, if expensive, text for pre-registration students and might serve departments as a reference to support students and newly qualified therapists. Despite summarising recent research there is little new content to justify its purchase for an experienced therapist. Claire Hartley is Head of Division for Speech and Language Therapy at Birmingham City University.

VOICE (2)

Constriction and Release the techniques (DVD) Gillyanne Kayes & Jeremy Fisher Vocal Process ISBN 9780955827617 47.00

Aimed at performers

VOICE (1)

Filled me with confidence

This overview of current research developments with this client group across their lifespan is good value and comprehensive, with each chapter written by well-known experts within their specific field. Some chapters were of greater interest and more relevant clinically than others due to the wide coverage of investigations spanning genetic, neurobiological and cognitive levels. It was fairly easy to dip into to gather relevant information from each area. Reading it filled me with confidence to understand current theory and which outcomes from ongoing research are still needed. It is well written and enables the reader to consider how the findings can be applied clinically. It will certainly support our care pathway and service development projects. This book will be useful for students, researchers and practising therapists of all levels of experience working with children and adolescents with developmental language disorders. I will also be sharing the findings in discussion with colleagues in education, psychology and health. Caroline Booth is a specialist speech and language therapist working with the Assessment and Intervention Team (Early Years and School Age) for Wandsworth PCT.

Voice Work Art and Science in Changing Voices Christina Shewell Wiley-Blackwell ISBN 978-0-470-01992-4 39.50

Exciting, motivational and practical

Although aimed at performers rather than therapists, this DVD may be of some support as a revision source for an experienced speech and language therapist. Students, clients and professional voice users could find some of it instructive. Gillyanne Kayes and Jeremy Fisher are experienced voice trainers and educational to observe, although the DVD was filmed during a workshop and comments from participants are difficult to hear. Chapters 48 and Bonus 2 are the most useful. The chapters show and train the technique and Bonus 2 (for the unsqueamish) shows Jeremys true and false cords releasing and constricting. Each section is easily accessed therefore can be repeatedly watched to your hearts content. However, the DVD is expensive and costs would rise if the accompanying book is obtained as advocated on the disc. Barbara Molteno is an independent speech and language therapist specialising in adult neurology and voice, www.vocalispartnership.co.uk.

If ever a book was written to re-ignite my passion as a voice practitioner, this is it. Christina Shewells wealth of experience and active approach jump off the pages of this motivational and practical book. Packed with ideas and exercises it will make even the most experienced voice practitioner reflect on current practice, consider new approaches and pump imagination into their work. Its content is common sense with a clear emphasis on problem-solving. Accurately described as a map for working on the voice in a logical order, Christina offers a voice skills framework focusing on 8 core aspects, letting one unpick the voice making it easier to work on, or a perceptual profile (VSPP) that allows both qualitative description and numerical evaluation. Half focuses on analysing a voice, and the rest includes endless practical ideas, voice exercises, extensive case studies, completed VSPPs, and outlined sessions and voice skill frameworks so you can see Christinas tools in action.

LARYNGECTOMY

Voice restoration after laryngectomy - Current science and future perspectives Umanath Nayak & Rehan Kazi (eds.) Byword Books (www.bywordbooks.in/) ISBN 978-81-8193-046-0 USD$128

All the basics covered

This book is intended as a reference for clinicians working in the field of head and neck cancer. It consists of thirteen chapters, each discussing aspects relating to voice restoration after laryngectomy. All the basics are covered and the simple page layout makes it an easy read. The pictures in the book will make it a useful tool when training students or other team members. The book unavoidably refers to products that are already outdated, but this does not affect its overall usefulness. The book ultimately achieves the goal of being a useful reference for any clinician in the field of head and neck cancer. Louise Pothier is a Macmillan speech and language therapist at Bath Royal United Hospital.

20

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

reviews

VELO-CARDIO-FACIAL SYNDROME

ASSESSMENT

Velo-Cardio-Facial Syndrome Volume 1 Robert J. Shprintzen & Karen J. Golding-Kushner Plural Publishing ISBN 9781-59756-071-9 57

Assessment of Communication Disorders in Children - Resources and Protocols M. N. Hegde & Frances Pomaville Plural Publishing ISBN 978-1-59756-291-1 62.00

This would not be a book that all speech and language therapists would immediately turn to, but it would be valuable further reading for those working with diverse, multicultural populations. Louise Carr is a specialist speech and language therapist working for NHS Warwickshire.

Comprehensive coverage

A reference guide to keep

STAMMERING

This is the first of a two volume comprehensive coverage of the study, diagnosis and treatment of individuals with Velo-Cardio-Facial Syndrome (VCFS). History is followed by a detailed description of the 190 anomalies that occur in VCFS. Associated speech and language disorders are described and there is a very helpful section on how and why children with VCFS develop compensatory articulation. Treatment is not in this volume. Further chapters cover genetics, the multiple specialties required and a chapter on growth, weight gain and feeding. An accompanying DVD of 19 video clips demonstrates what the text describes. This will most appeal to clinicians specialising in cleft palate and other craniofacial disorders requiring a greater understanding of VCFS. Its good index and clear layout and style make it quick and easy to refer to for specific information. The DVD could also be used as a resource for the clinician new to this area or cleft palate in general. Rosie Sleator is a speech and language therapist in Northern Ireland. She is recently returned from 8 years with a charity in Nepal where she developed services for children including those with cleft lip and palate.

This practical and accessible book with accompanying CD is split into seven parts. Part one covers assessment, including basic outlines, common protocols, standardised, alternative and integrated approaches and assessment of ethnoculturally diverse children. Parts two to seven cover the most common communication disorders in children: speech, language, fluency, voice disorders, nonverbal/minimally verbal children and literacy skills, each with research, resources and protocols (including interview questions and assessment formats). The CD has the same protocols to upload on computer to modify, individualise and print. Its an American publication, which impacts on the examples and assessments and cultures highlighted. However, the majority of the principles remain the same. For any clinician who wants to brush up on principles of assessment, communications disorders and developmental norms, or to access / develop assessment templates, this is a definitely a reference guide to keep. It is particularly useful for less experienced or less confident clinicians and students. Rating 4/5. Liz Tomlinson is a specialist speech and language therapist (special schools) in Bexley Care Trust.

Stuttering Stan Takes a Stand Artie Knapp Cincinnati Childrens Hospital Medical Centre ISBN 978-0-9821677-0-0 8.02

Worth having

VOICE AND SPEECH

CULTURE

This useful short childrens story is worth having if your caseload includes primary children who stammer or who are likely to encounter teasing / bullying. It is suitable for 5+ years to be read to or 8-10 years to read themselves. It is a good story with endearing animal characters, although it would have benefited from more illustrations, and the occasional American vocabulary needs explanation. The issues arising from the story are: learning to share, not to tease / bully, to stand up for yourself without being a bully yourself, being kind to others and accepting that others have difficulties with different things. It is appropriate for working with individual clients and groups as well as for lending to class teachers and parents to read to their children. Sandra Unsworth is an independent speech and language therapist. She reviewed this book with the help of two teenage clients at The Willy Russell Centre for Children and Adults Who Stammer in Liverpool and a class of primary children at Sunnymede School, Southport.

Voice Catcher an anthology Heather Kay (ed.) Voice Care Network UK ISBN 978-0-9524524-4-7 10.00 + p&p (www.voicecare.org.uk)

Being White in the Helping Professions Judy Ryde Jessica Kingsley ISBN 978-1-84310-936-5 19.99

HEAD AND NECK

Educational and entertaining

Produced by the Voice Care Network, this anthology contains stories, prose and poetry covering a wide range of speech related areas, such as voice, aphasia and dysfluency.The book would be ideal to use with professional voice users and clients with an interest in literature.The text could be used as an alternative source of therapy reading aloud material or to spark conversation about voice. It is certainly an educational and entertaining read, which I found thoroughly enjoyable.It is not expensive, however it is more of a luxury speech and language therapy resource than an essential. Angela Shimada is a speech and language therapist with adults for Lincolnshire Community Health Services.

Judy Ryde is a psychotherapist and this book describes her experience of being white (her inverted commas) in a healthcare profession. Whilst Ryde does not directly refer to speech and language therapy, her thoughts on working in a predominately white profession are very salient. The book is easy to read and makes frequent reference to the authors own practice. The final section is particularly practical. Here Ryde outlines her attempts to increase the diversity of staff and clients in her organisation and summarises the training package that she developed to raise awareness of being white and white culture. This thought-provoking book offers an alternative view supplementing traditional equality and diversity training. It stimulates the reader to consider what white culture is and how it implicitly and explicitly affects the thoughts and perceptions of not just the white person but also the people around them.

Valuable further reading

Meeting the Challenges of Oral and Head and Neck Cancer Nancy E Leupold & James J. Sciubba Plural Publishing ISBN 978-1-59756-239-3 16.00

Does not deliver for UK

This book, edited by a survivor of head and neck cancer, aims to give patients and their carers information and guidance through the journey from diagnosis to rehabilitation. Sadly, although it promises to be a useful text, it does not deliver for a UK audience. Its contributors and target audience are American and therefore a large amount of the information is only relevant to America. Many of the products / services referred to are either not available here or have a different name. The information leaflets produced by local trusts, cancer Bacup and cancer networks are likely to have better and more relevant information for UK clients. Gill Jolly is a speech and language therapist with Huddersfield and Calderdale NHS Trust. SLTP

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

21

in-depth reviews

Assessments Resource assessed review

CASP
Jois Stansfield finds the latest version of the CASP for adults with learning difficulties a very useful addition to the clinical tool kit.
Communication Assessment Profile 3rd edition Anna van der Gaag (2009) Speech Profiles www.speechprofiles.co.uk/index.html 145 + p&p
A welcome third edition of the Communication Assessment Profile (CASP) was published at the beginning of this year. The assessment, designed for use with adults with learning difficulties, retains the same format as the original, with updated presentation and new photographs and audio material. There are three sections. The carer assessment gathers information about the service users communication environment and their ability to understand and be understood. The therapist assessment follows the pattern of previous editions, considering comprehension and expressive language at single word and sentence level, and taking into account phonology and pragmatics (this latter arguably the most significant area for adults with learning difficulties, as community presence and involvement has increased dramatically since the first edition of CASP over 20 years ago). The most important element, however, is where these are drawn together into a joint assessment, combining the views of the carer, speech and language therapist and where possible also the service user, to identify communication strengths and needs. There are issues with any assessment and this is no exception. The author speaks of administering the assessment, which, while technically appropriate, detracts from the otherwise entirely person centred approach of the pack, and some of the references are rather dated. Also, as identified by the author herself, while the new materials have been reviewed, the assessment has not (yet?) been revalidated. While this is understandable, it does mean that validity relies on data and material from a very different era. That said, this is still the only published assessment explicitly designed to evaluate the communication skills and needs of adults with learning difficulties. Anna van der Gaag is clear that this is not intended to be an in-depth assessment, but a screening tool, which may be used to provide a baseline for measuring change. The sections for assessment are well supported in the manual by recommendations and suggestions for further action, depending upon the service users needs. It is person centred, sensitive to the needs of the individual service user and inclusive of carers. A very useful addition to the clinical tool kit. Jois Stansfield is Professor of Speech Pathology at the Research Institute for Health and Social Change at Manchester Metropolitan University. She wishes to declare that she offered comments on the new photos and layout of the 3rd edition of the CASP during its development but was not involved in deciding on content.

Designed to be used alongside currently available available sex education and awareness materials, Bernie BrophyArnott considers this a very useful package, as long as delivery of the information is by suitably trained professionals.
Signalong Sexual Awareness Pack Signalong / Widgit 153.19 + VAT
The Signalong Sexual Awareness Resource Pack is designed to support the teaching of vocabulary related to sex education and awareness. The pack contains 41 illustrations relevant to sexual awareness. These illustrations are provided on laminated A4 black and white sheets and cover topics from male and female genitals to couples on the sofa. The accompanying CDs are used for installing the line drawings of the signs and illustrations into Widgits symbols processors Symwriter and Communicate in Print. There is a manual of line drawings of the signs which gives detailed descriptions of how the hand signs should be produced along with a guide to installing the software and guidance on the use of its contents. The very clear illustrations provide much needed material for demonstrating topics that are difficult to get photos or images of. Some of the illustrations of body parts have a version with symbols and a version with signs. The symbols are clear and useful labels for the illustrations. The line drawings of the signs however are a little small, and perhaps a cross reference to the manual of signs might be helpful. The vocabulary of signs and illustrations can be printed through the Widgit packages and, when used this way, the user can access the Widgit literacy symbols to extend the range of materials that can be produced. The instructions for installing and accessing symbols and illustrations are clear and comprehensive. The package is designed to be used alongside currently available sex education and awareness materials including Signalongs self advocacy material Its my life. The guidance notes contain information on how to teach this sensitive subject, as well as how to teach signs. There is also a section called My body which includes explanations of aspects of sex (for example conception and contraception and my rights concerning sex). My only criticism of this very useful package would be that, although teaching sex education to people with learning disabilities should be no different to teaching other groups of people is probably true for many cases, there should have been more comment on the need to be trained and experienced in the delivery of this information and aware of the clients cognitive abilities to understand this often complex language. Bernadette Brophy-Arnott is a speech and language therapy manager with the adult learning disability service, NHS Tayside.

22

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

how i

How I help people move on (1):

Steering the way home

When a group of people with severe and profound learning disabilities were referred for support with preparing to move house, speech and language therapist Sue Martin and drama therapist Magda Pearson took inspiration from the ideas of Keith Park and responded in a creative and dynamic way.
READ THIS IF YOU WANT TO OFFER SUPPORT WITH TRANSITIONS A PHYSICAL AND CREATIVE EXPERIENCE NON-TRADITIONAL THERAPY IN A CONFIDENT WAY

s a speech and language therapist and drama therapist working in the Camden Learning Disabilities Service, we were asked by the manager of a local day service to develop a meaningful and interactive way to convey the concept of moving house to a group of people with severe and profound learning disabilities. Transition can be a key stressor for people with complex needs and typically they have limited opportunities to express their choices / wishes (May, 2000). We wanted to provide an alternative intervention that would prepare the group for their move to a new house by supporting them to have a physical and creative experience of what moving house involves. To do this we based our projects aims (figure 1) on the principles of Keith Parks Story Telling work (2002). Our aim was that through acting out the tasks and the feelings of moving house, the group would have memories and experiences that they could relate back to during and after the move. Our hope was that this would provide familiarity with an experience to help aid understanding and reduce anxiety during a difficult time of transition. The development of the project involved the creation of communication profiles, writing the story, developing objects of reference and switches.
Figure 1 Aims of the group 1. To support the group and individuals to understand the move 2. To develop understanding and use of objects of reference, and use these to initiate interactions 3. To develop use of switches to initiate interactions between group members 4. To engage service users to participate in a creative group activity 5. To encourage and develop interaction skills such as turn taking eye contact use of switches 6. To provide a safe and therapeutic space for expression of emotional responses to the move 7. To provide a tangible experience relating to the move.

l to r Magda and Sue Communication profiles were drawn up for each member of the group. Two profiles were completed for each service user, one by their key-worker at the day centre and the second by their key-worker at home. Once these were completed (example in figure 2) we compared the two; it was interesting to note that in each environment the service users way of expressing themselves was similar in terms of their likes and dislikes, their responses to objects and activities and their emotions. The consistency in the profiles from both environments enabled us to feel confident that we had a good understanding of each service users level of communication. The information provided by the communication profiles and the knowledge of the staff team demonstrated that the general understanding was at a one to two key idea level. The profiles also gave us a good understanding of how each service user communicated. There were nine group members. Three had some expressive language skills, mainly using learnt phrases and one-word phrases, while the other group members communicated non-verbally at an intentional level. The levels of motivation to interact with others varied.
Figure 2 Sample completed profile Object of Cup, plate, suitcase, sensory Reference visual stimulation/tactile objects Communication Vocalisations (vary according to mood), leads people to object Likes Open spaces, outside spaces, quiet, walking Change Has had negative experience in the past. When he goes on holiday takes a couple of days to orientate himself. Understanding Limited of Time

We identified six stages of the move (figure 3). Together we wrote a four line verse for each of these stages and set them to a call and response rhythm (Park, 1999). We kept the language simple and accessible, leaving the rhythm, gesture, signing and objects of reference to engage the service users and relay the meaning of the story (figure 4, p.24).
Figure 3 The six stages of moving. 1. Packing boxes 2. Packing suitcases 3. Packing things onto the van 4. Getting onto the bus 5. Arriving and opening the front door 6. Unpacking and settling in.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

23

how i
Figure 4 The story SWITCH; Phweeee Were all moving house today Lets get started; theres lots to do. Wrap our things up, pack our boxes. This is such hard work, phweeeee SWITCH: Clink, clink, clink Time to fold and pack our clothes now, Into the suitcases they must go. Push and squeeze to lock the suitcase, Sit on it, all push now, clink, clink, clink. SWITCH: Goodbye Time to get going, pack up the van, All of the boxes, the suitcases to, The van is packed, close the front door. Leaving [NAME OF HOUSE]. Lets all say goodbye! SWITCH: BEEP, BEEP! Now its our turn, get on the bus, Seat belts on, were ready to go. Through the streets and roads were driving Were all wondering Are we there yet? beep, beep SWITCH: Creak Turn in to the drive (road), we have arrived. [NAME OF NEW HOUSE] is our new Home Off the bus take a look around, Slowly, carefully open the door. creak SWITCH: Hurrah! So here we are, unpack the van, Boxes, suitcases into the house Find a place for all of our things Life at [NAME OF NEW HOUSE] begins. Hurrah! Figure 5 The Objects of Reference Verse Theme Object of reference Reason To represent the house The ribbons were attached to make the suitcase more tactile and engaging The front door of this house was blue To represent the bus Material captured attention because it reflected light and sparked; its tactile nature gave them something to engage with physically To represent the new house 1 Packing of non-personal items Large walk in box 2 Packing of personal items Suitcase with ribbons attached 3 Current home Large piece of silk blue cloth 4 The journey Steering wheel, long pieces of ribbon attached 5 Arriving at the new house Large textured gold cloth 6 Settling in Large walk in box, draped with gold cloth

Increase participation

The communication profiles informed our choice of the type of objects of reference that would be used to represent the key ideas of each verse (figure 5). By identifying objects and materials that would motivate and engage group members we hoped to increase their participation in the telling of the story. While the primary function of an Object of Reference is as a communication tool (Park,1999) that is usually developed for an individual service user, we developed the objects of reference for a group (Jones et al., 2002). Additionally, we made our objects of reference oversized to physically reflect the action held within the verse - for example we used a steering wheel with ribbons tied to it to represent the bus (figure 6). The wheel was held by a service user standing in the centre of the circle and the other service users took and moved the ribbons as the verse was sung. The objects had different therapeutic functions for the speech and language therapist and the drama therapist. We found that we had to spend some time defining how we would use them within the session. From the speech and language therapy perspective, objects of reference are viewed as a means to support an individuals understanding, and their ability to express themselves and make choices. Nominated objects are used to represent a person or an activity. In drama therapy objects are used more spontaneously. They aid interaction and give opportunities to

project feelings and act out expressions and emotions. The flexible exploration of objects exercises choice, independent improvisation and may lessen the stress produced by intensive direct interactions with another person (Chesner, 1994, p.143). From Magdas point of view it was felt that these opportunities might be lost in the structured use of nominated objects. After discussion we felt that focusing on improvisation could affect the group process and be intimidating for individuals, particularly in such a short-term piece of work. We agreed to use the objects primarily as objects of reference to develop an understanding of the concept of the move. In this sense some flexibility was lost but service users were still able to use the objects to exercise choice and they were actively used as props within the session. We pre-recorded sounds, such as phweeee (see figure 4, The Story), onto BIGMack switches to be used in conjunction with the objects and to accompany the opening and ending gesture of each verse. These were used to give individuals a voice and encourage them to start and finish the action.

Clear signal

The sessions were held in the main activity room so it was important to create a transformation from usual space to therapy space. We achieved this by simply moving the chairs away from the walls into a circle. The circle focused the attention into the therapy space and encouraged service users to observe and acknowledge each other. Changing the physical appearance of the space also gave service users a clear signal that the session was about to start. Service users with this level of disability are not always given the opportunity to express their choices and are often discouraged from choosing not to participate. Within our session we allowed space for movement within the circle and clear opportunities for leaving. It was important that service users were able to make a choice about whether or not to participate. A repetitive and rhythmical beginning and ending chant welcomed and acknowledged each participant to the group. This was an important time for everyone to be seen and

recognised. The calling of each person by name (including drama therapist, speech and language therapist and day centre staff) encouraged responses and participation even from those whose motivation to interact with others was very limited. For example, Robbie entered the room when we had been told he probably wouldnt join in, and Mary uncharacteristically came to the centre of the space to say hello. The sessions were well received, energetic and motivating. Many of the service users grew in confidence and we were able to observe increased levels of participation, such as engaging with and responding to the rhythm by dancing, rocking and clapping. responding to intonation of words and repeating back phrases and sounds. spontaneous use of objects of reference including individuals walking into the box without any prompting, and individuals getting up independently to join other people in the box. independent use of the BIGMack switches. (Although we dont feel that this indicated an anticipation of the beginning or ending of the section, the switches enabled service users to have a voice and initiate sounds within each specific section.) We used two methods to measure and record each individuals participation and responses: observation sheets and video. We chose to adapt The Object Related Scheme Assessment Procedure (ORSAP) (Coupe & Levy, 1985). The ORSAP uses a rating score that allows for a consistent, reliable way to measure how each individual responded, for example 1 = no response and 5 = great response/interaction. Our adapted form is available at www.speechmag.com/ Members/Extras. After training the intention was that weekly observation sheets would be completed by the same member of staff. Sue was to rate a different service user each week to allow for some inter-rater reliability. As well as completing the rating scores, any additional comments could also be recorded. Due to the demands and everyday practicalities of the day centre, it proved to be difficult for the members of staff to observe and record the responses of the same service user each week. These variations made it

24

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

how i
Figure 6 Steering wheel with ribbons

difficult to use the ratings as validated data, but the observation sheets did demonstrate that each service user made significant progress in their communication and interaction. Magda made her own observations and notes to guide her work. In addition the sessions were filmed and played back to the service users. This use of multi-media was usual practice within the day centre to support service users understanding of an activity. The process of gaining consent to use video as external professionals took a lot of effort but it was worthwhile because it also made it possible for us to observe and record progress made by individuals at a later date. We ran a weekly, hour long session over a period of 12 weeks at the day centre. Magda then carried out some transitional work based on the storytelling techniques. This was done at the service users home during and after the move. Techniques used to achieve a clear ending included continued use of the rhythm and song, adaptation and breaking down of the objects (for example each service user chose a ribbon from the wheel and this was cut off and then used in movement work), physical exploration of the new house (touching the walls, floor, furniture) and re-writing the story to incorporate and re-enforce good-bye.

a closed group, which would have only included service users who were involved in the move and not other members of the day centre. Although it was not possible to measure clinically the benefits of the story telling project, we believe that through participation in the sessions the service users were more familiar with the concept of the move. This was reflected in our observations that the service users enjoyed the sessions and developed their communication skills along with their sense of group and peer interactions. They were also energised and motivated, had reduced levels of anxiety and had fewer challenging behaviours than expected. During the three months after the move, staff at the day centre and home observed that the levels of anxiety were kept to a minimum. Some of the service users did present with challenging behaviours but the number of incidents thought to be directly connected to the move were less than anticipated. Overall the majority of service users coped well with the move. Encouragingly, the day centre staff were able to reflect on the success of this project and made a second referral to Magda to strengthen the service users understanding

of the changes and address any post-move anxiety and behavioural issues. By taking inspiration from Keith Park and his story telling framework we had the opportunity to extend and share the skills of our individual disciplines and to explore a more creative and dynamic way of approaching referrals. This was an innovative learning experience for us and the service users. We have found that developing a project like this has given us increased confidence to work using less traditional methods, for example, Magda continues to use drumming, call and response and voice work at the beginning of new projects as this supports the service users to gel and to become familiar with each other and the structure of the session. We developed this project in response to a unique referral which demanded an innovative approach; however service demands and limited opportunities for gaining funding for drama therapy have made it difficult for us to run further projects using these ideas. Sue Martin is a Highly Specialist Speech and Language Therapist, Camden Learning Disabilities Service (Speech & Language Therapy Service, Islington PCT), e-mail Sue.Martin@islington.gov.uk. Magda Pearson is an Independent Drama Therapist, e-mail magdap73@hotmail.com. The observation form based on Coupe & Levy (1985) is available at www.speechmag.com/Members/Extras.

Acknowledgements

We would like to extend our thanks to the service users who took part in this project and the staff team at Lilestone Street Day Service, Westminster City Council. Identifying details of clients have been removed. REFLECTIONS DO I ENSURE GROUPS HAVE A DEFINED THERAPY SPACE, CHOICE ABOUT PARTICIPATION AND CLEAR INTRODUCTIONS? DO I BRING DIFFERENT PROFESSIONAL PRIORITIES INTO THE OPEN AND NEGOTIATE A SHARED PATH? DO I USE THERAPY TO SOW THE SEED OF MEMORY IN PREPARATION FOR NEW EXPERIENCES?

Challenging

The wide range of levels of communication skills and motivation of the service users made this a challenging project to develop and run. We felt that the project was a success because: the aims and objectives (figure 1) were met we had joint planning with day services and other disciplines it was a creative alternative to regular intervention we had positive reactions from the service users we had positive feedback from staff. We also consider that the project would have benefited from: more than 12 sessions to run it a more flexible timeframe to enable us to work with colleagues in clinical psychology to develop outcome measures more planning time more staff training more consistent availability of staff

References

Chesner, A. (1994) Drama therapy for People with Learning Disabilities. London: Jessica Kingsley. Coupe, J. & Levy, D. (1985) The Object Related Do you wish to comment on the impact Scheme Assessment, Mental Handicap 13(1), this article has had on you? Please see pp.22-24. guidance for Speech & Language TherJones, F., Pring, T. & Grove, N. (2002) Developapy in Practices Critical Friends at www. ing communication in adults with profound speechmag.com/About/Friends. and multiple learning difficulties using objects of reference, International Journal of Language & Communication Disorders 37(2), pp.173-184. May, D. (2000) Transition and Change in the Lives of People with Intellectual Disabilities. London: Jessica Kingsley. Park, K. (1999) Whose needs come first?, Speech & Language Therapy in Practice Summer, pp.4-6. Park, K. (2002) Switching on to Shakespeare: A Midsummer Nights Dream, Speech & Language Therapy in Practice Spring, pp.4-6.

Resource

BIGMack switches are available from www.thesensorycompany.co.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

25

HOW I

How I help people move on (2):

Talking flats
M
oira had lived with a long history of neglect and physical abuse from her family. She was eventually given temporary supportive accommodation in the community as she was deemed to be capable of living independently of her mother with a support package in place. This move was supported by the Community Learning Disability Team and the staff team within her local resource centre, as both had been dealing with the consequences of her home situation for years. After living in temporary accommodation with other residents for some months, Moira was allocated her own home and was in the process of choosing the furnishings. She was looking forward to having her own tenancy. However, her brother was adamant that she should not live there but should be living with their mother. He wanted Moira to be registered under the Adults with Incapacity (Scotland) Act 2000, so that the family had guardianship over her and could decide where she should live. To achieve this, the family had hired a solicitor to take the case to court to prove that Moira could not make a decision for herself in terms of her own tenancy. The solicitor had contracted a private psychiatrist to meet with Moira and, after a short session, he had deemed her incapable of making decisions. This was in direct contrast to the professional opinion of both the Community Learning Disability Team psychiatrist and psychologist. Aware of my previous involvement with Moira, the teams clinical psychologist referred her to speech and language therapy. Her professional opinion was that Moira had the capacity and skills necessary to make appropriate choices for herself. However, she was aware that Moiras low level of confidence undermined these skills, and that she presented as a lady with very limited comprehension and expression. She was keen for this to be explored in more detail via speech and language therapy. Given the complex nature of the case, it was also necessary to evidence Moiras capacity clearly. This is one example of a gradual shift in the type of referral made by other team members

When the family of a lady with learning disabilities challenged her capacity to make decisions about where she should live, Maria Venditozzi found the Talking Mats framework ideal for gathering evidence of Moiras competence and ultimately for ensuring her wish to move into her own flat was respected.
to speech and language therapy over the 8 years I have worked within community teams. This change is mirrored in the referrals coming in from the community. In both cases, there is an appreciation of the role we offer in complex cases which involve the more subtle areas of language. This includes recognition of our input into high level social language dysfunction, such as in Aspergers syndrome, semantic/pragmatic language disorders and clients who can mask their language difficulties under a cloak of competence. In other cases, a clients reluctance to communicate verbally or within social norms such as with eye contact, has had a seriously detrimental effect in the way in which they have been managed generally and with regard to their communication. Speech and language therapy and training along with general improvements in social awareness have redressed this to some extent. As all these difficulties have far-reaching consequences, it is has been gratifying to note recognition and appreciation of this within the districts for whom I provide a service. My assessment found that there had been no change or deterioration in Moiras skills since the last speech and language therapy assessment some years previously. This confirmed that Moira was functioning at an approximately three word level, both in comprehension and in expression. Although she had these verbal communication skills, she was an extremely anxious lady and would only speak reluctantly and in a very quiet voice. Her eye contact was poor at times and she had closed body language. Overall, she presented as fearful and intimidated.

READ THIS IF YOU ARE INTERESTED IN OPPORTUNITIES FOR CHOICE ESTABLISHING CAPACITY THE LEGAL PROCESS

Time and space

To explore Moiras decision-making ability, I introduced Talking Mats at the next session. Talking Mats is a low tech communication framework involving a textured doormat and sets of symbols. It is designed to help people with communication difficulties reflect on their experiences and express their views. It was originally developed by the AAC Research Unit at the University of Stirling, and has since

been the subject of ongoing research with many different client groups (Nicoll, 2008). It was ideal for use with Moira as, Talking Mats can help people arrive at a decision by providing a structure where information is presented in small chunks supported by symbols. It gives people time and space to think about information, work out what it means and say what they feel in a visual way that can be easily recorded (AAC Research Unit, 2009). The session with Moira was video taped, audio taped and a photograph of each completed mat was taken. I felt such comprehensive recording was necessary due to the legal implications of the investigation. This session was carried out with the help of speech and language therapy students who were on placement at the time. Moira was co-operative and attentive throughout the session. She can get side tracked on a particular train of thought, so occasionally I had to re-focus her using the photographs or pictures as a prompt. This worked well and she would then continue with no difficulty. A trial of the Talking Mats was carried out with Moira using the topic food and Moira was able to quickly classify foods she liked (under happy face) or did not like (under sad face). She presented with very fearful behaviour as before and was reluctant to place the pictures

26

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

HOW I
onto the mat; she preferred me to place them on it where she indicated. We then discussed the subject of where she wanted to live. The key worker supported the session by providing photos of her mothers home, her new flat and the temporary residence where Moira was staying. Using a straightforward Talking Mat - Where I want to live - Moira confirmed that, from the three options, she wished to live in her own flat. We then explored the reasons for her choice in more detail through a number of sub mats. When asked about her current temporary residence, Moira was clear that she liked living there but complained that at times some of the other residents annoyed her. This was confirmed as true by her key worker, who explained that some new residents had challenging behaviours and could be difficult around Moira on occasion. We then addressed the subject of living in her new flat. Moira was very clear that she wanted to live there and why she wanted to live there. We explored this on a sub mat about feelings. This is pictured in figure 1, with the photograph of her flat removed. She considered that she would not (sad face / no) feel bad, cross or hurt, and she would not shout. She wondered if she might (maybe) cry and feel frightened. She thought that she would (happy face / yes) feel relaxed, safe, nervous, worried, angry and happy. She would have fun, be listened to, she would laugh and it would be quiet. Prior to the session I had had a long discussion with Moiras support worker in the Resource Centre. She reported that Moira was scared of her brother - and considered that there were ulterior motives for him wanting Moira back with their mother, who had now become infirm. Moira did have a few months of living with her brother prior to her temporary community accommodation, which was unsuccessful and, according to her key worker, caused Moira great distress. As it was important to get Moiras views directly on why she did not want to live with her mother, we completed a sub mat with the subject How I feel at mums house. Moira made a comprehensive picture list. Again using a happy face for yes and a sad face for no, she categorised how she felt (frightened, nervous, angry, in danger, tearful, shouting, a bad girl, worried, cross, happy, cheerful, hurt, sad) and how she didnt feel (safe, quiet, or that she laughed) at her mothers house. Shots of the two sections from this mat are in figure 2, with the photograph of her mothers house removed. When I asked Moira again if she wanted to live with mum she was adamant that she did not. She verbally stated that her mother and her brother hit her, and that her brother frightened her. She was able to indicate where on her body she had been hit. This video discussion was submitted along with the speech and language therapy report and photographs of the mats to the Chief Medical Officer. Figure 1 Moiras feelings about her new flat

Figure 2 a) Section of How I feel at mums house

Figure 2 b) How I dont feel at mums house

Complexity of emotion

Moiras responses to the mat How I feel at mums house were interesting and highlighted the complexity of emotion which Moira felt. Although the responses were negative overall and caused significant concerns for the teams involved in her wellbeing, she also acknowledged that at times she was happy and cheerful at home. This was an honest account of life there; Moira was not demonising her family but recognising that there were some good times shared. However, for many reasons, both simple and complex, she was making an active choice not to return there and to move into her own home and onto the next chapter in her life. The responses to how she would feel in her own flat were also realistic and there was evidence of sensible expectations of her future life there. She acknowledged that there would be times when she would be worried or angry. However, what was important was that she considered that she would feel safe and

relaxed there. She also realised that she would be able to seek support should she need it and that her concerns would be listened to. What was very poignant was the fact that she would not feel like a bad person or feel hurt any more. Moiras brother was advised by his solicitor to delay proceedings until the Chief Medical Officer had scrutinised the assessments from the Community Learning Disability Team. When it became evident that Moira was making allegations of harm and that she was very anxious about living in her mothers house, the Chief Medical Officer was understandably extremely concerned. The consequences of the assessment procedure - and particularly the video tape to evidence Moiras statement - resulted in the case being dropped by Moiras brother. Moira has since moved into her own accommodation where she has little contact with her family. The advantage of using Talking Mats as a therapeutic tool was twofold. Firstly, Moira was very timid and under-confident when

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

27

HOW I / Let's talk shop

speaking and often used nonverbal means of communication, such as nodding/shaking her head for yes/no, despite her verbal skill levels. Using the mat gave her the opportunity to answer direct, personal questions with no pressure on her to respond verbally. We were able to visually tackle the issues which caused her distress, such as living with her mother. As we were addressing these, she became more confident and felt able to offer some verbal responses to supplement the pictures. Secondly, we also gained visual evidence of Moiras opinions regarding her future home. She was able to evidence clearly her decisionmaking skills and her capacity to make informed choices for her future wellbeing. This satisfied the decision-making panel of professionals who were working to ensure that Moiras needs were appropriately met. It was very satisfying to be involved in supporting someone to assert their opinion in the face of adversity. Moira deserved to have her views listened to and respected. Thankfully, the community team and speech and language therapy with the use of Talking Mats were able to facilitate this process to a happy conclusion. Maria Venditozzi is Principal Speech and Language Therapist with the Joint Learning Disability Service, NHS Greater Glasgow and Clyde, e-mail mvenditozzi@hotmail.com.

Acknowledgement

Thank you to Moira for allowing me to share her case. Identifying detail has been minimised to respect the privacy of her family. SLTP REFLECTIONS DO I ALLOW CLIENTS SPACE, TIME AND SUPPORT TO EXPLORE COMPLEX FEELINGS? DO I KEEP SUFFICIENTLY COMPREHENSIVE RECORDS OF CLIENTS VIEWS? DO I GAIN RESPECT OVER TIME FOR WHAT I BRING TO MULTIDISCIPLINARY TEAMS?

References

AAC Research Unit (2009) Talking Mats: A communication tool designed to help people who suffer from communication disabilities or difficulties. Available at: http://www.talkingmats. com (Accessed: 12 July 2009). Do you wish to comment on the impact Adults with Incapacity (Scotland) Act 2000 asp this article has had on you? Please see 4. Available at: http://www.opsi.gov.uk/legislaguidance for Speech & Language Thertion/scotland/acts2000/asp_20000004_en_1 apy in Practices Critical Friends at www. (Accessed: 12 July 2009). speechmag.com/About/Friends. Nicoll, A. (2008) The third person in the room, Speech & Language Therapy in Practice Winter E1-E4. Available at: http://www.speechmag.com/Members/ (Accessed: 12 July 2009).

Lets talk shop

The second Talk Shop (National Speech and Language Therapy Fair) in June 2009 showcased resources for the speech and language therapy profession. Delegates were asked to say what their favourite resource was and why. Information about the 2010 Talk Shop is at www.talk-shop.org.
My favourite resource today is Language Garden (www. languagegarden.org/). I particularly loved the way you could use it to generate long, complicated sentences with visual demonstration of different grammatical functions. I feel it fills a gap in my resource bank. Geraldine Hindley Our Sound Pictures CD is flexible, practical and - best of all - cheap at 20. The CD is packed full of pictures of all speech sounds in all word positions. I use it daily to provide resources for targets set in school. I use the pictures in clinic for eliciting words, picture sorting and lotto boards. The pictures come in full colour and also black and white so the children can personalise them. Abigail Padgett (Sandwell Childrens Therapies, tel. 021 530 8035) Alex Kellys Talkabout for Teenagers (www.alexkelly.biz/) because I work with adults with learning disabilities and, looking through this resource, could see lots of instances when it would be easy and effective to use with these clients as well as teenagers. I have found that working on social skills with adults with learning disabilities is a growing field, and we dont always know where to go for ideas. Previously a lot of my therapy has focused on functional communication and now, as clients build their skills, social aspects are becoming more of a priority for them. Izzy Leighton

My favourite was the CLUE Magnifying Glass. I really like how such a simple tool, made to look like a magnifying glass, provides a new, imaginative approach to working on semantics and word finding. As I work with teenagers, I particularly like how it can be used across most age ranges. Young children will enjoy turning the wheel, and older children will appreciate its user friendly appearance, with some higher level language to develop their vocabulary. It provides many useful questions and prompts to develop language. Katy Harrison (Katy wins a years subscription to Speech & Language Therapy in Practice) For more information on the CLUE (Category, Location, Use, Extra special features) Magnifying Glass, e-mail Sue Dobson, susan.dobson@dudley.nhs.uk Speech and language therapists are now fully involved in an educational context, working with students with social language and self-esteem issues. Alex Kellys Talkabout DVD (www.alexkelly. biz/) is a resource I had not seen before. It combines video clip examples of appropriate and less good social language and interaction, featuring children, teenagers and adults. It will be very useful in training and working with groups, and will complement her new Talkabout for Teenagers which arrives later this year. Having used the original Talkabout books for years now, this DVD (30) will be an invaluable addition. Jane Oates

28

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2009

Subscribers should contact the publisher if they have not received their magazine(s) within two weeks of the publication date, or if there are any problems with the magazine itself. Tel: 01561 377415 Speech & Language Therapy in Practice is published at the end of February (Spring), May (Summer), August (Autumn) and November (Winter).

IMPORTANT NOTICE

Subscription form for Speech & Language Therapy in Practice

PERSONAL RATES

28 personal (UK) 24 part-time (5 or fewer sessions) (UK only) 21 student / unpaid / assistant (UK only) 33 personal (Europe) 37 personal (other overseas)

Bulk orders (sent to any single work address): 2 copies for 56 3 copies for 78 4 copies for 96 5 or more copies for 23 each. No: Total price

48 authorities (UK / Europe) 53 authorities (other overseas)

AUTHORITY/DEPARTMENTAL RATES

EUROZONE RATES
Note: Cheque and direct payment only. Credit card payments can only be deducted in sterling at the rates advertised above.

Web 2.0 Accessibility Conference 22 September 2009 www.abilitynet.org.uk/accessibility2 Phoneme Factory Sound Sorter Workshop 1 October 2009 For SENCOs, teachers and speech and language therapists With Yvonne Wren Wotton under Edge, Glos 55 E-mail sarah@speech-therapy.org.uk Working with Listening and Auditory Processing Difficulties 1-2 October 2009 With Diana Crewdson and Camilla Leslie Antrim, Northern Ireland 250 e-mail lslc@lismenary.com Down Syndrome Education Conference 1-2 October 2009 (professionals), 3 October (families) London (Heathrow) 414 (professionals) www.downsed.com/conferences/2009/london/?dm_ i=597396952 TES Education London 2-3 October 2009 Olympia, London https://secure.eventadv.com/tsl/step1.asp Special Needs London 16-17 October 2009 Programme includes a seminar with Maggie Johnson www.teachingexhibitions.co.uk/Exhibitions/TES+Special+Ne eds+Exhibition/London/2009/ Profound Education: a day conference centred on pupils with PMLD 24 October 2009 St Margarets School, Tadworth, Surrey 95 e-mail stmargarets@thechildrenstrust.org.uk Afasic Cymru Conference 5 November 2009 Keynote speakers Alex Kelly, Gina Conti-Ramsden. Chaired by Sue Roulstone & opened by Keith Towler, Childrens Commissioner for Wales. Village Hotel, Cardiff E-mail jeannette@afasiccymru.org.uk; www.afasiccymru. org.uk

37 personal 32 student / unpaid 54 authority / department

Bulk orders (sent to any single work address): 2 copies for 63 3 copies for 88 4 copies for 108 5 or more copies for 26 each. No: Total price
SWIFT BIC: BOFSGBSIEUG

IBAN NUMBER: IBAN GB44 BOFS 8020 0608 3990 01

The new subscriber fills up their details on the form and puts your name in the recommended by space. Once their payment has been received, they will get 5 copies for the price of 4 in their first years subscription, and you will be notified that your subscription period has been moved on by three months. So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in Practice. Remember - you will get an extra issue for every new subscriber you bring in. *Must be a NEW subscriber to the magazine.

Cheques payable to AVRIL NICOLL BUSINESS. OR Please debit my Visa / Mastercard / Switch card: (Card payments cannot be accepted without a signature.) Card number: Card security code Expiry date: Debit cards only: Issue No. ORValid from date:
(if issue no. not available)

(last 3 digits of number on signature strip) Signature:

NAME: RECOMMENDED BY: (if applicable) HOME ADDRESS:

POSTCODE:

HOME TEL. WORK ADDRESS:

POSTCODE:

WORK TEL. e-mail: Please note acknowledgements and renewal notices are sent automatically. From outside the UK, Return to: Avril Nicoll, the address is: Speech & Language Therapy in Practice, FREEPOST SCO2255 Avril Nicoll LAURENCEKIRK 33 Kinnear Square Aberdeenshire Laurencekirk AB30 1ZL Aberdeenshire Tel/fax +44 (0) 1561 377415, e-mail avrilnicoll@speechmag.com AB30 1UL www.speechmag.com
It would be very helpful if you could complete the following information:
Job title(s): Name of employer / university: Topics you would like to see covered:

Contact the Editor for more information and / or to discuss your plans. Please note: articles must be of practical use to clinicians use case examples and list useful resources length is generally around 2500 words supply copy by e-mail or on CD keep statistical information and references to a minimum

Contributions to Speech & Language Therapy in Practice:

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 SUBSCRIPTION FORM

Special offer for personal subscribers - Introduce a colleague* to Speech & Language Therapy in Practice and you both get an extra issue - free!

Our Top Resources

SANDRA MCKEEN (SANDRA.MCKEEN@FIFE.GOV.UK), TODDY LAWSON (TODDY. LAWSON@FIFE.GOV.UK), BERNADETTE BANNON (BERNADETTE.BANNON@FIFE. GOV.UK) AND RUTH WALLACE (RUTH.WALLACE@FIFE.GOV.UK) ARE SPEECH AND LANGUAGE THERAPISTS WORKING WITH CHILDREN WITH SPECIFIC LANGUAGE IMPAIRMENT IN TWO SPEECH AND LANGUAGE CLASSES AND THEIR LOCAL SCHOOLS IN FIFE. THEY ALSO PROVIDE ADVICE AND SUPPORT TO COMMUNITY THERAPISTS.
1. CUED ARTICULATION This set of hand cues, for 26 consonants and 23 vowel sounds, was developed by Jane Passy for teaching the individual sounds in a word. Each hand movement represents one sound and the cue gives clues as to how and wherethe sound is produced. Colour Coding is also used for the written letters that represent these sounds. It is an invaluable support for children with articulation and phonology difficulties as it provides additional visual and kinaesthetic feedback. It also supports teaching of phonics. Teachers find that using the cues not only helps children with specific language impairment, but it raises the sound awareness skills of everyone in the class. Passy, J. (1990) Cued Articulation. STASS Publications. 2. DE BONOS THINKING HATS The Six Thinking Hats is a quick, simple and powerful technique to improve thinking. It encourages pupils to recognise what type of thinking they are using, and to apply different types of thinking to the subject. We all use different types of thinking, usually without realising it. The White Hat is cold, neutral, and objective, so think about facts and figures. The Red Hat represents anger so listen to your emotions, your intuition. The Black Hat is gloomy and negative so think about why this will fail. The Yellow Hat is sunny and positive so be hopeful and optimistic. The Green Hat is grass, fertile and growing, so be creative and cultivate new ideas. The Blue Hat is the color of the sky. Take time to look from a higher and wider perspective. de Bono, E. (1985) Six Thinking Hats. See www.edwdebono.com/. 3. MENTAL PICTURES This strategy helps pupils to remember and sequence sounds correctly within words. It can also support word retrieval difficulties and vocabulary learning. It is particularly useful for pupils with poor auditory processing skills but strong visual skills. The pupil breaks the word up into syllables and creates either a mental picture or a drawing to represent each syllable for example, ass + kid for asked (picture of a donkey and a child!) 4. GRAMMATICAL COMPREHENSION AND USE We have found our modified Colourful Semantics approach (Colourful Grammar and Mr. Samich) extremely useful in developing the childrens oral and written use of grammar. We began at a very basic level to support the children to understand the concepts, using a coloured approach as a visual tool. We then developed the concept of a sandwich (nicknamed Mr Samich by the children), to visually illustrate and mark the components of a sentence. The two pieces of bread represent the beginning and end of a sentence. The filling represents each grammatical component (subject, verb, object, adverb, conjunction and preposition), as well as punctuation (commas, question marks and exclamation marks). We are now developing narrative using Mr. Samich and focusing on the use of conjunctions and prepositions in story writing. Bryan, A. (1997) Colourful Semantics. In Language Disorders in Children and adults: Psycholinguistic approaches to Therapy, ed. S. Chiat, J, Law & J. Marshall. London: Whurr. 5. INTERACTIVE WHITEBOARDS These phenomenal tools are used in many schools as replacements for traditional whiteboards or flipcharts. They provide ways to show our pupils anything that can be presented on a computers desktop (educational software, web sites). In addition, they allow us to create specific pupil / group lessons, which can provide an effective instructional strategy for pupils who benefit from repetition, who are visual learners and who are struggling with the mainstream curriculum. This fun and entertaining way of teaching allows the pupils to be active and successful participants in their learning. 6. ICT We use a wide range of computer programmes to support various aspects of the childrens learning. These include programmes to develop their phonological awareness and spelling skills (Earobics, Simon Sounds it Out), supports for writing (Write Out Loud, Co-Writer, Clicker 4), and maths (Number Shark). The children also have access to various internet based resources that can be used on the PCs or interactive whiteboards. We find Boardmaker invaluable as it allows us to produce everything from classroom signs and wall displays to visual timetables and symbols to support reading. The two classes have recently purchased Rapid Reading to support older children with their reading development and literacy skills. This uses speech recognition technology, so that the children can read the stories to the computer, which corrects them on their accuracy. Earobics www.earobics.com Simon Sounds it Out, Write Out Loud, Co-Writer www. donjohnston.com Clicker 4 www.cricksoft.com Number Shark www.wordshark.co.uk Boardmaker www.mayer-johnson.com/ Rapid Reading www.heinemann.co.uk 7. COMMUNICATION PASSPORTS Adapted from work by Sally Millar, we originally developed our communication passports for our Primary 7 children making the transition to secondary school. The purpose is to empower the child to explain to teachers and others about their language difficulties and the strategies and supports they need to learn. Having tried out a number of formats, we have found most children prefer a series of credit card sized cards, held together on a key ring. This is small and discreet and the individual pages can be easily changed and updated when necessary. Having received positive feedback from children, parents and teachers, we have started to develop them for all our children to use during the transition period from one primary school class to another and throughout the school year.

Millar, S. & Aitken, S. (2003) Personal Communication Passports Guidelines for Good Practice. Call Centre, Edinburgh. 8. THE CHILDS STORY The childs story allows us to gain information and insight into how the child is feeling in relation to their learning and emotional well-being and to support our clinical decision-making. We use a number of approaches to gather information social stories, our diary system, Talking Mats, communication passport, target sheets, personal learning plans and child centred plans. The Child Centred Plan focuses on gathering information in collaboration with our education colleagues and parents. We have several informal conversations with the child and ask them what they enjoy, what they find tricky and what social experiences they get pleasure from. This information is all linked to the childs home, class and their sending school. There are photographs of the child experiencing different aspects of their learning incorporated into the story, for example during art, maths, reading and drama. Every child within our classes receives a copy of their individual Story. The story is also shared with the sending school and parents at the childs review meetings and is used to set the childrens targets. Social Stories www.thegraycenter.org Talking Mats www.talkingmats.com 9. CARE AIMS The Malcomess Care Aims Model, designed to support practitioners to demonstrate evidence-based practice through systematic reflection, was adopted by our department in 2000. The main benefits are: a standardised way of capturing and communicating clinical reasoning a clear and comprehensive way of demonstrating clinical effectiveness a systematic way of supporting and demonstrating clinical reflection an ability to focus resources where they can make the most difference by being outcomes driven and not demand led a sound framework for managing caseloads and workloads a framework to support service design, planning and evaluation. This philosophy continually encourages us to ask the question WHY and to consider all aspects of the Clients story. www.careaims.com 10. INNOVATIVE PARTNERSHIP We use a partnership and collaborative approach across the two classes to standardise most of our practice. For example, we are up-dating a document for the childs sending school staff, educational psychology and parents. Contents include information on specific language impairment and the speech and language class, explaining the responsibilities and role of each professional, the parents and the child, outreach, review meetings, transition from nursery to the class and from the class back to the childs sending school, transition to secondary schools, transport, in-service day, swimming and terminology. In addition we are producing information sheets on speech and language difficulties and support strategies. The class teachers and therapists also run advisory sessions together to community speech and language therapists to provide support from a therapy and educational point of view. We are auditing this service across Fife to support evidence-based practice.