ISSN 1368-1205

Summer 2009

Inclusion Adapting to complexity Caseload management Group funology

Empower point
How I put learning into practice

Symbolic voices Exploratory research Role models A care pathway Bilingual issues What does this house believe? Our Top Resources Placement tips

PLUSwinning waysheres one I made earliersoftware solutionscourse commentin briefreviews.great reader offersand introducing editors choice www.speechmag.com

Reader offers

Win Fidget Bins!

Do you work with children who find strong tactile feedback helps them to sit down, pay attention and focus? Fidget toys are known to adults as stress toys. They can be squeezable, heavy or pliable in our hands. In addition to their reported calming properties, they provide different visual stimulation under UV light and open up opportunities for interaction. The Novelty Warehouse has gathered together 13 of these toys in a grab and go Fidget Bin for therapists. The medium Fidget Bin retails on the Novelty Warehouse website at 24.99, but the company is offering it FREE to TWO lucky readers. To enter, all you have to do is e-mail your name and address with SLTiP Fidget offer in the subject line to info@thenoveltywarehouse.com. Your entry needs to be in by 25th July 2009 and the winner will be notified by 1st August. To see The Novelty Warehouses extensive range of sensory products, visit www.thenoveltywarehouse.com.

Win Photosymbols 3!
Do you make easy read information? Do you find it hard to find the right pictures? One lucky reader will win a free copy of Photosymbols 3, with 3000 pictures specially designed for easy read information. Pictures include objects, places and concepts, as well as hundreds of pictures of children and adults with learning disabilities. Photosymbols 3 comes on a USB flashdrive. The pictures are royalty free, so you can use them as often as you like in different types of publications. Photosymbols 3 is usually priced from 400 + VAT for a single user pack, but you can win a FREE copy courtesy of Photosymbols Ltd. All you have to do is e-mail your name and address with SLTiP Photosymbols offer in the subject line to ask@ photosymbols.com. Your entry must be received by 25th July 2009 and the winner will be notified by 1st August. Further details are at www.photosymbols.com.

Reader Offer Winners

The winners of Bambas First Comforts in the Spring 09 issue courtesy of The Baby Sign Factory Limited were Danielle Thomas and Su Wheeler. Meanwhile Alyson Eggett was the lucky recipient of Stass Publications Memory Magic. Congratulations to you all, and good luck to everyone with our new offers.

Summer 09 speechmag
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Extras See sample slides and instructions for making the PowerPoint slides detailed in Munro, L., Hunter, L., Smith, L. & Johnson, V. (2009) Empower point, Speech & Language Therapy in Practice Summer, pp.26-28. Also extended reviews from p.22 Back issues www.speechmag.com/ Members/ Spring, Summer, Autumn and Winter 2007 issues now available as pdfs!

Articles now freely available online at www.speechmag.com/Resources/ Reprints More on PowerPoint, this time to bring a phonology assessment and therapy activities to life: McBarnet, E. (2006) More Power to you, Speech & Language Therapy in Practice Autumn, p.17. The Portsmouth adult team article referenced by Peter Jones in Role models, pp.15-17: Clark, N. & Nineham, S. (2008) A driving force, Speech & Language Therapy in Practice Spring, pp.11-13.

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.

Summer 2009 (publication date 31 May 2009) ISSN 1368-2105

Summer09contents
26 COVER STORY: HOW I PUT LEARNING INTO PRACTICE (2) There was a sense of satisfaction that we had developed skills and produced resources that were transferable to other clients for both language and cognitive rehabilitation. For Douglas, noticing his use of practice words in real situations along with the steep rise in assessment scores engendered feelings of achievement and optimism. Lesley Munro, Laorag Hunter, Lesley Smith and Vicky Johnson report on a highly structured impairment based aphasia therapy using PowerPoint.

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

Thanks to Douglas for our cover photo of him at home working with his PowerPoint therapy programme. By Paul Reid, www.anguspictures.com

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 INCLUSION An interesting observation from a parent of a young adult using a Visual Diary underlined the value of empowering an individual he began to use the tiles to choose and plan his weekend activities in advance, as well as to talk about them afterwards. Liz Dean charts the progress of independent practice Langlearn in supporting children and young adults with complex needs to access the curriculum. 8 GROUP THERAPY Even quite early on in treatment we gave the child time to work out his or her own solution to the problem of being misunderstood. Feedback might be something like I heard you say car, youve got a car but more usually we would provide a model by adding, You need a scar and scarf. Gwen Lancaster, Shelagh Benford, Gerry Buckley, Alison Langshaw and Emma McCormack find fun phonology groups motivate and support children to change their speech. 11 HERES ONE I MADE EARLIER Alison Roberts with three low cost therapy suggestions Storyteller, Friendship consequences and So thats how that happened! 12 GRAPHIC SYMBOLS My previous experience in particular working in schools has influenced the focus and conduct of my research. I hope by reflecting on this and on my early findings to encourage more effective use of graphic symbols and greater collaboration between speech and language therapists and education practitioners. Louise Greenstock conducts exploratory research into how graphic symbols are used in schools.

15 CARE PATHWAYS In what at the time felt like a fairly innovative approach, speech and language therapy input in relation to dysphagia would now focus on the communication aspects of dysphagia management. Peter Jones discusses how roles are shifting as the multidisciplinary service for people with a learning disability and dysphagia in North West Wales evolves. 18 COURSE COMMENT Rebecca Joseph reviews a course on Using Music to Support Inclusion. 18 SOFTWARE SOLUTIONS Linda Preston tests out a head and neck DVD-ROM. 19 WINNING WAYS By valuing yourself and then turning that appreciation outwardsyou start to turn round whole departments. Life coach Jo Middlemiss addresses readers concerns about feeling valued and raising the profile of the profession. 20 THIS HOUSE BELIEVES IN ONE LANGUAGE The evidence available in the literature encourages clinical intervention to emphasise learning the concepts of language rather than the number of languages used or which language (such as English) to use in therapy. Rhona Galera and Paula Leslie debate the motion that speech and language therapists should encourage linguistically diverse families to use only one language for preschoolers with language delay.

22 REVIEWS Singing and signing, social communication, voice, Asperger syndrome, adult neurology, autism, language and reading, child language, Parkinsons Disease, brain injury, dyslexia, dysphagia. 24 EDITORS CHOICE 25 CRITICAL FRIENDS Valerie Dean, Alyson Eggett, Sheila Robson and Claire Smallman on the impact of Sitting on both sides of the fence by Kirstie Page (Winter 08). 25 IN BRIEF Tips on articulation, language and resources from Gillian Hayes. 30 OUR TOP RESOURCES Its useful to come to placement with equipment in the shape of a box of tricks which is familiar and can be used as an all encompassing informal assessment and therapy resource. This neednt be expensive and can consist of everyday items Alison Taylor, Karen Shuttleworth, Julie Leavett and colleagues observe what helps students get the most out of their placement.

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

IN FUTURE ISSUES: DYSPHAGIASTORYTELLINGMOTOR NEURONE DISEASEBRAIN INJURYTRAININGPLACEMENTSOUTCOMES ASSESSMENTDECISION MAKING

news

Call for investment now

Afasic Scotlands campaign for a Bercow-type review of services stepped up a gear with a reception and stand in the Garden Lobby of the Scottish Parliament. Introducing the speakers, Jeremy Purvis MSP said that, Across all different parties there is a strong interest and rightly so. He emphasised it was important to recognise the implications both for individuals and for Scotland as a whole, and that parental pressure on health, education and social work is crucial to making a difference. Professor James Law noted communication needs have only become a popular story in the past few years, with expert reports increasingly pointing out the importance of communication skills as a way out of poverty and for mental health and employment prospects. As a researcher, he sees there is strong evidence that intervention for expressive language can be effective preschool, but this is less clear at primary school age, while the biggest gap in evidence is at secondary school. As the parent of a 13 year old boy with significant and ongoing language difficulties, Patricia Atkinsons passionate address gave those attending food for thought. By the time Ian was 5 years old the family had had contact with 20 different professionals, as people went on maternity leave, moved or left. She emphasised the intrusiveness of having professionals in your life as the only way to access help. The impact was also felt by her daughter, as participation in community and social life was disrupted. Patricia says the main thing that has helped Ian become a contributor to society is key committed individuals. She considers herself fortunate to be full of hope and positivity for his future, and wonders if parents of children with less severe difficulties are as able to access support? Patricia is disappointed that, 10 years on from the launch of Afasic Scotland, parents are still reporting the same stories lack of coordination, duplication of assessments and long waiting lists. Ann Auchterlonie, who will shortly retire as Director, asked if the rhetoric of the Parliament was reflected in the reality. She pulled no punches in outlining the postcode lottery of services, the closure of specialist services, the inadequate training of mainstream staff, the frustration of time spent waiting following a diagnosis, and the cost of not responding to communication needs. She asked, Do you want to spend money picking up the pieces, or do we want to invest now? www.afasicscotland.org.uk/

Diverse Talking

Success in a Dragons Den-type competition at Birmingham City University has enabled senior lecturer Amanda Howett to develop action and object picture cards related to Asian Culture. In recognition of the limited resources available for working with bilingual clients, the Enterprising Staff, Enterprising Students scheme awarded Amanda business training and a budget of 5000. It also assigned her a Master of Business Administration student to help market the cards under theDiverse Talking banner. Further products are planned. The 50 cards are 45 plus 2.50 p+p. For further information e-mail diversetalking@bcu.ac.uk.

Action plan for NI

The Northern Ireland Assembly has heard that a new speech and language therapy action plan for the area will be consulted on and implemented by the end of September 2009. Michael McGimpsey, Minister of Health, Social Services and Public Safety, says the number of speech and language therapists in Northern Ireland has increased from 228 in 2007 to 412 in 2009, with 66 support staff. He also pointed to a reduction in waiting times from 26 weeks in 2008 to 13 in 2009. The action plan, being developed in conjunction with the Department of Education, will be ready for a brief consultation in June. The Minister added, One of its key thrusts will be to make better use of existing speech and language therapists. It is not always a matter of simply recruiting more therapists. Instead, we must think strategically and carefully about the best way to use them. www.theyworkforyou.com/ni/?id=2009-05-11.6.3 3&s=speech+and+language+therapy#g6.39

Regulatory developments

Vocalise
2

A project which establishes singing and signing choirs in special schools and for adults with learning disabilities was shortlisted for a 2009 Royal Philharmonic Society Music Education Award. The Live Music Now Vocalise initiative included the creation of a resource pack to assist special schools in the UK to set up their own singing and signing choirs. The photo shows a teacher and pupil at a participating school, the Cedar Special School in Doncaster. www.livemusicnow.org.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

Legislation is before Parliament and the Scottish Parliament that will bring practitioner psychologists into statutory regulation by the Health Professions Council. Until now educational and clinical psychologists and their colleagues in fields such as occupation and sport and exercise have had voluntary registration with one of two professional associations. The Health Professions Council anticipates opening its register to practitioner psychologists in the summer of 2009. While practitioner psychologists applied for regulation on a voluntary basis, the governments wish to extend this to applied psychotherapists and counsellors is proving more contentious. Organisations such as the British Association for Counselling & Psychotherapy are participating in the Health Professions Council Public Liaison Group, while the Alliance for Counselling and Psychotherapy Against State Regulation has been formed to oppose the plans. The arguments it advances - on the individual, medicalisation, evidence based practice, risk and control - may be of interest to speech and language therapists who wish to reflect on their role. www.hpc-uk.org; www.bacp.co.uk; http://www. allianceforcandp.org/

Photo by Tony Bartholomew

NEWS & COMMENT

Comment:

Influencing
Photo by Tim Morozzo

the profession

Outspoken

It used to be that I was the only person who stammered in the whole school. This was before Cameron showed up and ruined everything. Before he crash-landed on my patch and started breaking all the rules. Before Sandra turned on me. Before I entered into a dirty deal with big Graham and wee Jamesy. Before that incident by the pond... Outspoken is the story of Dannys journey through school as he battles against negative attitudes towards stammering including his own. The new play is the culmination of a two year collaboration between the TAG theatre group and the British Stammering Association Scotland. It follows an extensive drama workshop programme with young people who stammer, aged 16-30, to improve their confidence and self-esteem. Playwright Davey Anderson took inspiration from the workshop participants when writing about confidence, identity and the struggles faced when trying to fit in. In addition to a tour of secondary schools in central Scotland, sponsorship from ScottishPower has enabled support materials to be produced, such as a DVD and online resources for schools about stammering. Jan Anderson of the British Stammering Association Scotland is clear that the partnership with TAG has been a huge success. She says, Outspoken will do more to challenge the stigma associated with stammering than any information leaflet we could ever produce. Its spine-tingling drama that will transform attitudes in its intended teenaged audiences. www.tag-theatre.co.uk; www.stammering.org/scotland/index.html

Private concerns

Physiotherapists are continuing their efforts to challenge private health care insurer Bupas imminent Approved Physiotherapy Network plans. Independent physiotherapists who wish to work with clients funded via Bupa have had to submit to a blind tender process. Although Bupa has made concessions, such as ditching the plan to reduce drastically the number of approved providers and giving assurances that quality as well as price will be taken into consideration, there are ongoing concerns about the impact on commercial autonomy and client choice. The Chartered Society of Physiotherapists and Physio First, the Societys recognised occupational group for private practitioners, have mounted a legal challenge via the Office of Fair Trading. Max Sharp, of the esph practice in London, comments that private physiotherapy is largely made up of sole practitioners or small businesses who are gravely concerned at the prospect of losing a significant proportion of their income. He adds, Bupas attempt to try and impose onerous, one-sided contracts on vulnerable practitioners will inevitably disenfranchise patients. The tough contractual terms being proposed will require a substantial increase in time spent on unproductive, unpaid administration on Bupas behalf. www.csp.org.uk; www.esph.co.uk

Who or what influences you? And where does your influence reach? Gwen Lancaster and colleagues (p.8) refer to an influential theoretical framework behind their phonology groups. As a teaching assistant Louise Greenstock (p.12) felt her knowledge was limited, but the experience had a profound impact on how she has chosen to focus, conduct and disseminate findings from her PhD research. Personal experience of being a first generation immigrant to the United States is as important an influence on Rhona Galeras practice as her efforts (p.20 with Paula Leslie) to be evidence-based. Previous Speech & Language Therapy in Practice articles influenced a multidisciplinary group in North Wales to reflect on the evolution of their service and share it with others (Peter Jones, p.15). Meanwhile, for Laorag Hunter and colleagues (p.26), the arrival of a block student and a new client together with ideas and skills gleaned from a clinical network drove development of an efficient and effective therapy approach. Rather than reinventing the wheel, it makes sense to support new approaches with the best of existing ones and acknowledge sources and influences, as Liz Dean (p.4) has done. It isnt always possible to track back to the source of our inspiration, though, especially when - as Alison Taylor and Karen Shuttleworth say (back page) all therapists and students love sharing ideas, and small things like a word here or a glimpse there can be enough to set ideas in motion. Feedback from readers makes it clear they are appreciative of and influenced by articles, reviews, resource recommendations and therapy and assessment tips. The evolving Critical Friends (p.25) is an effort to track that influence and see where it takes the profession. While we have our own life coach (Jo Middlemiss, p.19), it was personal development guru Stephen Covey who coined the phrase Circle of Influence. He describes people who focus their efforts on this, rather than their Circle of Concern as proactive. Significantly, the nature of their energy is positive, englarging and magnifying, causing their Circle of Influence to increase (p.83). I hope you will join with me in enlarging the Speech & Language Therapy in Practice Circle of Influence do get in touch if you would like to participate in Critical Friends or contribute to our In Brief section.
Reference Covey, S.R. (1989) The 7 Habits of Highly Effective People. London: Simon & Schuster UK Ltd.

Brain donors wanted

The Parkinsons Disease Society has launched a nationwide appeal for people to donate their brains to help in the search for a cure. Anyone, whether or not they have Parkinsons, can sign up to the Parkinsons Brain Donor Register. Celebrities leading the way include Jane Asher, Jeremy Paxman and John Stapleton. www.parkinsons.org.uk/brainbank
SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

inclusion

Adapting to complexity
Liz Dean charts the progress of independent practice Langlearn in supporting children and young adults with complex needs to access the curriculum with the aid of tools such as Carrier Boards, Visual Diaries and Choice Boards.
READ THIS IF YOU WANT TO PROMOTE PARTICIPATION SELF ADVOCACY INDEPENDENCE THROUGH COMMUNICATION

anglearn is an independent speech and language therapy practice which specialises in supporting individuals with complex disabilities. This article features a selection of ways in which we have promoted inclusion and participation for individuals who: have limited spoken language skills have intentional communication skills can recognise two dimensional visual cues such as photos and symbols cannot complete written worksheets can indicate a choice by touching, picking up, or eye pointing. The examples show how published programmes and initiatives can be adapted to meet the needs of specific individuals and client groups. Langlearn services are delivered in varying ways (by a speech and language therapist, or by a speech and language therapist supported by a speech and language therapy assistant) depending on the needs of the client. We see our role as promoting participation, independence and self advocacy (DH, 2001; DH, 2009; www.everychildmatters.gov. uk). To achieve this end, we place an emphasis on working closely with families, teachers and support staff so that the speech and language therapy input achieves maximum benefit. While there is no final answer to the way in which children and adults with communication and literacy difficulties can be empowered to become independent self advocates, this article represents our efforts to put these principles into practice. We offer both direct and indirect speech and language therapy programmes but, unless the circumstances are exceptional, only offer a direct programme with the participation of a person central to the childs life. The programmes vary in their delivery and in their emphasis. They can, in partnership, focus on residential services (Dean, 2009a) or, to take an opposing example, centre around IT resources (Dean, 2009b).

symbol / photo books which are personalised for individual clients. These symbol books are available in A5, A6 and credit card wallet sizes. The A5 and A6 symbol books follow the principles established by Latham (2004/5). However, for clients with more complex disabilities, we have found that compact choice-based wallets have been most successful in enabling individuals to see the value of using symbols to make daily choices (figure 1). The symbol books / wallets all link to the individuals communication passports (Millar, 2003) and person centred planning documents. For some clients with more profound disabilities, the most successful symbol wallets have included some elements of the communication passport such as an added short explanatory sentence under a choice. For example, under personal belongings, a phrase such as I will be upset if I cannot find these can be added as a mnemonic for less familiar carers.
Figure 1 Choice-based communication wallet

been equally interesting whether the educational setting is mainstream or specialist, and we have worked to promote included access to the National Curriculum, as well as to accredited learning such as NVQ and NPTC qualifications.

Access

Maximising access to the curriculum can be achieved through two main routes, with a combination of the two probably being most successful: 1. The individual can be skilled up, and resourced, to participate as fully as possible 2. The curriculum and environment can be differentiated to allow it to become accessible for the child / adolescent with communication difficulties. Here, I will firstly consider strategies to support children with communication impairments who attend mainstream school, then look at how young adults with communication impairments can be supported through curriculum adaptation and help with social communication skills. (A) SUPPORTING A CHILD WHO ATTENDS MAINSTREAM SCHOOL: Carrier Boards and Visual Diaries Langlearn has developed the concept of topic based Carrier Boards to have symbols readily available and to provide a more efficient way of storing symbol / photo sets than small boxes. The choice of the symbol / photo sets is very important and great care should be taken to make it as comprehensive as possible whilst still being usable. The symbol / photo sets are placed on an A4 page, printed in black and white and laminated (figure 2a). The same page is printed in colour, laminated and then the squares are cut up into tiles. The tiles are then Velcro-ed or blu-tacked onto the Carrier Board depending on the use (for example a Talking Mat will require Velcro, while a laminated Choice Board can have blu-tack or

Daily choices

The speech and language therapy programmes devised are supported by Langlearns technical staff who, in addition to providing the resources illustrated in figures 1-5, also produce a range of

Whilst Langlearn, in common with many other NHS and independent services, addresses the need for alternative and augmentative communication systems, other areas have to be tackled if full participation and inclusion are to be achieved. One of our biggest challenges has been enabling children, adolescents and young adults with communication disorders to access their educational curriculum. This has

SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

Inclusion
Figures 2a - 2c Carrier Boards Figure 2a Black and white Carrier Board Figures 4a-b Visual Diary Figure 4a Blank diary sheet Figure 4b Completed diary sheet

Figure 2b Carrier board with coloured tiles

Figure 2c Selecting a tile from a Carrier Board

Figure 3 Tile formats

Velcro). When ready to be used, the tiles can be lifted from the Carrier Board and placed on the Visual Diary Sheet or Choice Board (figures 2b-c). The tiles on the Carriers Boards can be adapted to meet a clients individual requirements. For example, the format can be (figure 3): Large photo / small symbol / word Large symbol / small photo / word Word alone (if things like family names can be sight read).

Carrier Boards can be stored in personal Visual Diary, timeline or rota files. As the position of the tiles on the Boards is clearly marked, the tiles can easily be replaced after use, and clients can take responsibility for this. The visual resources described may either support spoken and / or written language skills or replace them. If the child has a symbol book or uses a high tech AAC device it is important that the symbols provided are also on the Voice Output Communication Aid (VOCA), and / or that the vocabulary is placed in the symbol book. Using a symbol book / wallet with plastic inserts allows vocabulary to be added temporarily, and then reviewed for permanent inclusion. The Langlearn therapist works with the teacher and learning support assistant to gather together topic vocabulary before a new topic is introduced to the class. This vocabulary is then put onto a Carrier Board by the Langlearn resource technician and removable tiles are made. The vocabulary may be represented by symbols, photos from the internet, or photos taken in the childs own environment. These resources are prepared by the Langlearn technical support using Boardmaker (Colour PCS symbols) and PowerPoint. This system of Carrier Boards and tiles allows the child to: become familiar with the vocabulary that the teacher will use recognise the symbols / photos and link them with the vocabulary use the symbols / photos as an aid to understanding when the teacher is talking use the removable tiles to plan and retain an answer use a tile in place of a spoken answer. This system has worked well within a mainstream classroom and the feedback from other children has highlighted the extent to which children find visual clues valuable in understanding, processing and retaining information. The fact that other children in the

class were keen to work alongside the child using the Carrier Boards naturally facilitated paired and group working and therefore inclusion and participation. These findings are similar to those presented by Widgit (2005). For children unable to write, the tiles are also used to complete worksheets. Whilst some worksheets are set up in advance by the Langlearn team, others need to be prepared by the teacher / learning support assistant at short notice. It is obviously important that the worksheets themselves are accessible to the child with emerging literacy skills, and we support the teacher to use Widgit software to prepare these in the classroom.

Thinking and talking

Another area in which the child with communication disorders may have difficulty is in retelling, and evaluating, the events of the day. Langlearn has developed the Visual Diary system to give children a way of thinking and talking about their school day. The child has a diary sheet (figure 4a) which includes personalised questions covering what the child did, who they were with and where they went. The concept of Narrative Frameworks (Shanks, 2001) has informed much of this work. For the diary sheet illustrated in figure 4b, the clients Carrier Board would be organised in the following topics: People Places in the community Places in school Feelings Weather Carrier Boards are prepared individually so that the fullest possible range of answers to the questions is provided and the tiles on the Carrier Boards are produced in a format that is appropriate for the individual. The Carrier Boards are updated regularly to include new answers that the child may wish to give and are stored in a Visual Diary file. Completed diary sheets are photocopied to record the work before the tiles are replaced on the Carrier Board.

SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

inclusion
The diary is also produced in a home / school version so that the child can bring news in to tell at school. Children using a VOCA can plan the news they want to tell using the Visual Diary system and then the news can be programmed into and given using the AAC device. For symbol book / wallet users, the Visual Diary can act as a catalyst to suggest new symbols / photos a child might like to add to their system. A review of previous diary sheets will indicate symbols / photos that are selected regularly and which should be added to the wallet / VOCA. We have extended this Visual Diary system to offer a way of preparing for review; that is, to allow the child to reflect upon the activities that they enjoy, work they do well, and topics they would like to focus on in future. The Visual Diary system can be used in conjunction with Talking Mats (Murphy & Cameron, 2004) or Choice Boards (see section Bi)) if more exploration is required to enable the child to reflect and choose the appropriate tiles. The success of the Visual Diary system has lain not just in the fact that children with limited spoken language have used this resource to support, or replace, spoken language so that they can tell their news alongside their classmates, but also in the fact that the system can be adapted to allow reflection and evaluation through visual channels. The Visual Diary system can be customised to suit the requirements of a range of individuals using AAC. An interesting observation from a parent of a young adult using a Visual Diary underlined the value of empowering an individual he began to use the tiles to choose and plan his weekend activities in advance, as well as to talk about them afterwards. B. SUPPORTING YOUNG ADULTS: Choice Boards and Social Communication Some areas of the curriculum are particularly problematic for students with learning disabilities who also have limited communication and literacy skills. These areas are those that traditionally require discussion and reflection. Whilst the first step to addressing these issues is to provide the best possible low / high tech AAC support, other initiatives can be central in developing independence and self advocacy. The person centered planning process has to be implemented through joint working. Achieving a discussion of views or developing self advocacy skills such as choice making can be difficult when individuals have limited communication skills. i) Choice Boards For young adults with more complex disorders, Langlearn has supported a system of Choice Boards (figure 5). These are based on a principle similar to Talking Mats, but are pre-prepared to cover a set range of choices that an individual commonly has to make. For example, there are symbol sets supporting Choice Boards focusing on Activities, Sessions, Tasks, Places and Foods. The Choice Boards may be headed up in different ways such as, Like / Dont Like or Yes / No and can be easily personalised to suit different subjects. The symbol sets supporting the Choice Boards can be produced and used in a variety of formats. Some people use Carrier Boards but, as all resources are saved on the web server, others prefer to print them out and then let students cut and paste the printed symbols on to the Choice Board.
Figure 5 Food Choice Board

The Choice Boards are taught using a symbol set reflecting a set of choices that appear to be known and understood by the carer, for example drinks. This allows the student to be supported to learn to use a set of visual prompts to convey a choice. The Choice Boards are only as good as the symbol / photo sets supporting them and care is taken to update and revise these whenever possible. The usual practice is to complete a Choice Board, photocopy it if removable tiles have been used, and complete it again after a short break to try to ensure that the choice process has been reliable. For some clients with more advanced choice making skills the Choice Boards are adapted, for example to include a column headed I dont know. ii) Social communication skills Another area in which we have found that students with limited spoken and written language skills find it difficult to join in is in specific practice of social communication skills. There are many excellent programmes which cover the pragmatic aspects of communication, such as the Talkabout series by REFLECTIONS DO I HAVE TECHNICAL SUPPORT AS AN INTEGRAL PART OF MY SERVICE? DO I BALANCE WHAT I OFFER INDIVIDUAL CLIENTS WITH WORK TO PROMOTE ACCESSIBILITY? DO I MAKE FULL USE OF PUBLISHED RESOURCES AS WELL AS DEVELOPING MY OWN?

Dean, E. (2009a) Supporting Independence, Do you wish to comment on the impact this SEN 38, pp.96-97. article has had on you? Please see the inforDean, E. (2009b) Using Lexion to Promote mation about Speech & Language Therapy Emerging Literacy Skills, SEN 39, pp.34-37. in Practices Critical Friends at www.speechDepartment of Health (2001) Valuing People: A mag.com/About/Friends. New Strategy for Learning Disability for the 21st Century. Available at: http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007429 (Accessed: 29 April 2009). Department of Health (2009) Valuing People Now: A new three year strategy for learning disabilities. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093377 (Accessed: 29 April 2009). Kelly, A. (1997) Talkabout. A Social Skills Package. Milton Keynes: Speechmark. Latham, C. (2004/5) Developing and Using a Communication Book. Oxford: ACE Centre Advisory Trust. Millar, S. (2003) Personal Communication Passports. Guidelines for Good Practice. Edinburgh: CALL Centre. Murphy, J. & Cameron, L. (2004) Talking Mats: A resource to enhance communication. Stirling: Stirling University. Shanks, B. (2001) Speaking and Listening Through Narrative. Keighley: Black Sheep Press. Widgit Software (2005) Symbols Supporting Inclusion In Mainstream Education. Cambridge: Widgit Software. Available at: http://www.symbolsinclusionproject.org/symbols/SIP_Project.pdf (Accessed: 29 April 2009).

References

Resources

Adult Literacy Core Curriculum latest information at www.excellencegateway.org.uk and www.talent.ac.uk Boardmaker see www.mayer-johnson.com National Vocational Qualifications, see www.qca.org.uk/qca_6640.aspx National Proficiency Tests Council, see www.nptc.org.uk/

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inclusion
Alex Kelly (1997), but such programmes often require the individuals to have a certain level of spoken and written language skills. In order to meet the needs of students with more complex disorders who are working at Entry Levels 1-3 (Adult Literacy Core Curriculum), Langlearn has developed the Independence Through Communication programme (Barnes & Dean, forthcoming). This is based on the authors individual and joint experience of teaching communication groups over the last six years as a teacher specialising in communication and a speech and language therapist respectively. The IndependenceThrough Communication programme has five strands which target key areas underpinning communication and independence: 1. Listening 2. Expressing yourself 3. Explaining your ideas 4. Making choices 5. Making friends. The specific emphasis of the Independence Through Communication programme is its use of accessible resources to promote the inclusion of individuals who: use an inclusive communication strategy; and need to process / answer using a combination of modalities such as vocalisation / symbols / photos / signs / body language have emerging literacy skills and cannot access the written word, or write, readily have memory limitations and require support to retain ideas participate / learn more readily if their session is structured, for example by the use of strategies to scaffold heard information or responses (Shanks, 2001). Whilst offering a new approach to the teaching of social communication skills, the authors recognised that selected parts of published resources have a place in such a programme, and so provide links to these in extension activities which supplement the main programme. We are now extending this work within a second programme Developing Communication Skills, designed for people using an inclusive communication strategy and working at Milestone 5 to Milestone 8/E1 (Adult Literacy Core Curriculum). SLTP Dr Liz Dean, e-mail lltraining788@btinternet. com, is a specialist speech and language therapist who leads the Langlearn team. Langlearn offers technical support to other speech and language therapists and schools. It is also a Widgit Centre. See www.langlearn.co.uk for further information. Acknowledgement I would like to acknowledge Anne Edmonstones role in developing my enthusiasm for this specialist area of speech and language therapy, and to thank her.

Independence Through Communication Pilot

Langlearn is offering the exciting opportunity to be involved in the pilot of the Independence Through Communication Programme (ITC), which is primarily designed for people using an inclusive communication strategy and working at Entry Levels 13 (Adult Literacy Core Curriculum). We have a limited number of copies of the ITC programme available on CD at a pre publication cost of 35 each to cover preparation and postage. We would like therapists and teachers to use, review and provide feedback for the programme. The ITC programme is divided into modules (split into core activities and extension tasks) which can be followed at the groups own pace. We estimate that the whole programme will take an average of 20 sessions (including extension activities) depending on the individual learners interests and abilities. The ITC Modules are: 1. Introducing Communication and Establishing Group Rules 2. Meeting People 3. Body Language 4. Listening Skills 5. Asking and Answering Questions 6. Staying on Topic and Paying Attention 7. Interruption and Turn Taking 8. Rules of Conversation. Langlearn is now working on a second programme Developing Communication Skills (DCS). The DCS programme is primarily designed for people using an inclusive communication strategy and working at Milestone 5 to Milestone 8/ E1 (Adult Literacy Core Curriculum). Please contact Liz Dean on lltraining788@btinternet.com if 1. you would like to purchase a pilot copy of the Independence through Communication CD 2. you would like to be notified when the Developing Communication Skills programme is ready for piloting 3. you would like more information about commissioning technical support for resource preparation.

news extra
Strengthening SEND
The chair of a review of special educational needs and disability information has urged the government to strengthen its approach to local authorities which fail to comply with their duties. The Lamb Enquiry was established to investigate how parental confidence in the special educational needs system of assessment and provision in England could be improved. Brian Lamb said, We need to shift the onus from parents having to find out for themselves, to schools and services finding out what parents need. The review recognises that the nature of the relationship between parents and professionals has changed. The previous relationship model of expert professional and ignorant lay person is no longer relevant. Professionals have one sort of knowledge, the patient, client or parent has expert knowledge of their situation (p.8). The Lamb recommendations, which have been accepted by Childrens Secretary Ed Balls, include improvements in training, policy and monitoring. www.dcsf.gov.uk/lambinquiry/

Dementia UK Awards

The closing date for nominations in the Dementia UK Awards 2009 is 3 July. The awards recognise those who improve quality of life for people with dementia. Categories include Best innovation in practice, Outstanding contribution to the field of dementia and Team of the year. www.dementia.stir.ac.uk/conference

AAC funding

The speech, language and communication needs action plan for England is progressing, with funding announced to support AAC. Better Communication, which followed the Bercow Review, recognised that initial funding was needed to ensure a vibrant AAC community is in place while a longer-term commissioning framework is developed through pathfinders. Becta has announced up to 1.5 million is available over three years through two separate streams. The first is designed to support the voluntary and community service sector to develop strong, sustainable services that meet the needs of commissioners and young people with AAC needs. The second is for specific innovative projects which will improve the knowledge base for high quality AAC provision. Becta was formerly known as the British Educational Communications and Technology Agency. It is a non-departmental public body of the Department for Children, Schools and Families. www.dcsf.gov.uk/slcnaction/aacgrants.shtml

SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

caseload management

Group funology
Over five years of running phonology groups, Gwen Lancaster, Shelagh Benford, Gerry Buckley, Alison Langshaw and Emma McCormack have found that a high level of fun motivates and supports children to change their speech.
Gwen

READ THIS IF YOU WANT TO IMPROVE INTELLIGIBILITY RUN GROUPS SUPPORT CLIENTS TO FIND SOLUTIONS

ur primary aim as speech and language therapists who work with children with phonological impairments is to increase intelligibility. In most cases our objective is to help the child become aware of the need to change their speech output in order to be understood - and for that change to become part of their phonological system so that they become more intelligible to everyone they know. It is common practice for children with phonological impairments to be treated in groups as it is efficient and can be enjoyable for clinicians and clients. These groups are sometimes referred to as sound awareness groups (eg. Allen et al., 2008). This implies that phonological awareness tasks such as sorting words by sound are explicity included in the therapy. This makes sense in the light of research such as Gillon (2000; 2002), who found that children with phonological impairments and also problems with attaining literacy benefited more when given explicit phonological awareness training than those given a traditional approach to therapy. This finding, however, was not replicated by Hesketh et al. (2000) when they studied children with phonological impairments in which the control group was given a more eclectic approach. Here we are going to present a way of working with children with speech impairments that is theoretically grounded but entails a quite direct approach to helping children change their speech output in order to be more easily understood. We will describe our treatment of children referred to phonological therapy groups in North Bristol over a five year period. These could be termed sound unawareness groups or, put more positively, meaning and motivation groups. We did not explicitly include phonological awareness tasks except at times with older children who also had literacy difficulties. However, many of the activities we included such as auditory discrimination and minimal pairs are also used to help children develop phonological awareness.

Explanatory model

Stackhouse and Wells (1997) provide a useful psycholinguistic assessment framework but, in our dynamic work of helping children to overcome

their speech impairments, Hewlett (1990) has been more influential as an explanatory model. The Hewlett model includes four boxes. The first, Auditory input, is essential and begins to form in infants aged 6 to 12 months. Phonological output is where the child (or adult aquiring a new phonological system for a new language) stores auditory information. Motor programming links the two. The other box is motor processing, or praxis. We view the links he describes between the boxes as crucial to providing therapy that helps our clients change. Hewlett describes a slow and fast route between the boxes. The fast route is the direct link from the auditory input store to the already stored form of a word in phonological output. A child with a phonological impairment might therefore access his outdated phonological representation for the word he wants to say. The slow route means the child needs to revisit the link between the auditory input store and motor programming. This can then influence the phonological store so the child can access their updated phonological representation. Even when this happens the child still has to work on praxis. It is like any new physical skill such as learning to play tennis. The child needs opportunities to try out and practise his new speech sound frequently for it to become automatised and part of his motor praxis. Children were referred to our groups from all clinics in North Bristol. Two clinicians (or one clinician and a speech and language therapy assistant) ran groups intensively. These were for three hours in a week during most school holidays for all age groups and from 4-5pm weekly for a term for the 6+ age range. When practicable groups were also run in schools or nurseries. The groups included up to 8 children (although we once had 15!) Many children attended for more than one goup. We included parents in some of the groups with younger children. Teaching assistants also attended some of the after school groups and saw a different side to the children they worked with. We gave all children homework tasks tailored to their needs and level and also varied the amount of support and challenge provided to each child. When carrying out the intensive three times a week groups, we found

that many children were already beginning to attempt to make changes in their speech output in the second session. Here we will describe the main approach used in group work with children aged 5 and above. With younger children we carried out auditory input work, and then discrimination of sets of words. However, as soon as they were able, we encouraged children to say the words. Rates of progress are different in all groups, so clinicians modified their input accordingly.

Error patterns

Referring clinicans provided information about the phonological error patterns of the children. The clinicians who ran the groups were able to include children with any degree of severity and any types of error patterns. This is because we focused on selected sets of words that included target and non target speech sounds for all the children referred. The idea of using both minimal (such as sea and tea) and maximal (such as me and tea) pairs has been discussed in the literature (Gierut,1990; Williams, 2003) as effective for children with moderate / severe phonological impairments. It has the additional advantage that a group of children with a range of error patterns can benefit from being in a single group. Using this approach we could sometimes work in schools and nurseries with all the children in the setting who were on our caseload. This brought the additional advantage that school staff were able to participate in sessions and acquire skills to help the child improve intelligibility in daily interactions. When planning the sessions we aimed to include both maximal and minimal pairs for each child in the group. A word set such as /ee/, key, tea, sea, seat, ski, tea, teak could address the patterns of fronting, backing, final consonant deletion and /s/ cluster reduction as well as the unusual pattern of initial consonant deletion. Meanwhile, a set such as air, bear, care, fair, pear, prayer, tear, scare, spare, stare (see p.9) could address fronting, stopping, voicing, approximant cluster reduction and /s/ cluster reduction and the unusual patterns of glottalisation and initial consonant deletion.

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caseload management

Picture set (clockwise): spare, fair, scare, air, bear, stare, care, pear.

Supportive atmosphere

Children with speech disorders are often confronted with their difficulty when they realise they dont understand me! In the groups we confronted children often and deliberately with their difficulty to help them begin to become aware of how to change their speech output and to give them a very good reason to do so. This strategy requires a therapeutic and supportive atmosphere that includes a good deal of fun, energy, and a high level of participation. The child might have to take a risk, make an effort and then perhaps fail but still needs to feel supported and motivated enough to try again. An additional benefit was that the children could express their problems with peers and we were able to contain these in the atmosphere of fun. We always had a theme for the session. This included topics like the fair, going on holiday, the zoo, cafs, motor racing, pirates, magic land, kings and queens and bees. We also included topical or seasonal themes like the Olympics, the World Cup, Crufts, Easter, Halloween and bonfire night. At the end of the session we would tell the parents and children what the theme for the next session would be. This worked very well particularly for the children attending after school, who might prefer to go to football practice instead. However if they remembered we were doing pirates or magic land they were immediately enthused, and also reminded that the groups were actually nearly as much fun as football. Most sessions included making something to take home on which the children would glue pictures of the items in the word set. For example they might make a ferris wheel where the pictures were revealed one by one, a magic wand with pictures stuck on streamers, a pirate hat, steering wheel, or a suitcase. This creative activity was often the first task and provided clinicians with many occasions to name the target words. We encouraged discussion of the topic and used the opportunity to transcribe the spontaneous speech of the children and note any changes. We found the discussions about the theme helped children develop relationships with their peers and become more confident. In addition we learnt a lot from them. For example we found out that one boy knew a lot more than we did

about dog obedience training during a Crufts topic. Similarly one quite shy little girl gave us a lot more information about bees because they were also a topic in school. In every session we introduced the words through the creative craft activity and then played a game that involved further familiarisation and discrimination of the word set. When possible we included a set of objects to represent the words as well as pictures. Pictures were made using Boardmaker and were coloured and laminated. We also used black and white pictures in varying sizes for the craft activities. We then encouraged articulation of single target consonants with the aim of familiarising the children with non-verbal cues to each sound (Passy, 1993). In later sessions we no longer needed to include this. We then carried out three or four activities that required the children to say the words. In these tasks we responded to what we heard the child say, not what they might have meant. Even quite early on in treatment we gave the child time to work out his or her own solution to the problem of being misunderstood. Feedback might be something like I heard you say car, youve got a car but more usually we would provide a model by adding, You need a scar and scarf. We might provide a lengthening of the target sound depending on the needs of the child. In any case we would give the child time to work out what changes were needed before we provided verbal and nonverbal cues. The way we responded to the child who was searching for a solution was important and obviously depended on their level of impairment. We aimed to keep verbal cues to a minimum so the child had to access his own phonological representation of the word he wanted to say. We encouraged a high level of participation. The best activities were those in which all the children were talking at once (figure 1). Some activities involved turn taking, but we aimed to have at least two or three children actively involved in each turn (figure 2).

Figure 1 Activities for participation Collect a set. Objects representing a word set were placed in a bag, with one item for each child (for example, accents allowing, the set could be scarves, toy cars, toy calves, plastic tarts, tar (bits from the car park!), star stickers and a red face paint stick with which we could draw a scar on the child). The children had to collect a set of these items as fast as possible, by asking us for the items. This was obviously frenetic but all children were motivated to be the first to get the set. We supported the children by giving cues if they were having difficulty naming an item. The therapist might hide one of the set of objects and pictures. Objects could be hidden in a sock, so the children could see or feel the shape , or in a tin that the therapist shook. All the children said what they thought the item was. We made a note of what each child said, and gave points if they were right. In groups with older children we indicated that often the hidden object would be one of the difficult words in order to encourage them to have a go at revising their speech patterns and get more points. Another way to make sure all children participated was to provide them with a prop. For example in magic land they would wave their magic wands during activities and in Crufts they all had a toy dog who took part in all the games.

Thanks to Black Sheep Press for providing the illustrations. The company is publishing a number of new phonological packs see www.blacksheeppress.co.uk for details (Avril Nicoll, Editor). Figure 2 Turn-taking activities A shopping game could include one child in the shop with the set of objects or pictures, one child phoning the shop on behalf of a puppet, and requesting an item and one child driving the item to the puppet. In larger groups we also incorporated a lift (box on string) in which the item was placed and one child would send the lift up and down to the puppet in his top floor flat. Each role was rotated around the group. A throwing game such as knocking items off a table by throwing a beanbag could include two children throwing at a time (or even all of them!) The children named the items they wanted to hit before they threw.

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caseload management
We included movement and motor skills during the sessions. This is one way to motivate children and keep energy levels high. In addition clinicians would make mistakes, pretend to be upset, make funny faces, and be overly dramatic so that children and clinicans would often be laughing or waiting in anticipation for what could happen next. With older children we might include gentle teasing - do you wear a tap on your head? - to encourage reflection on the meaning of what they were heard to say, and cause general amusement. Most games and toys can be adapted for use in activities to address speech disorders. Similarly, many of our stock of activiites
Figure 3 Adapating to the theme 1. Magic land Magic castle scene board, general discussion. Make a magic sock (older children) or magic wand. Magic Sock game - the sock has three compartments to make pictures disappear (Lancaster & Pope, 1989). The children call out for the picture to return which it magically does if they say the target word. Brewing a potion - the children all suggest which items from the set go into the brew. The potion then turns into a prince by the clinicians sleight of hand. Rescuing a princess - a ladder leads to the princess locked in the tower. The children name pictures as they go up the ladder and rescue the princess if they get to the top. Kims game - the children wave their wands as the object or picture disappears and then say which one has gone. Magic show- older children present a magic trick. 2. Crufts Discussion about dogs and dog shows with pictures of Crufts. Each child chooses a plastic toy dog which takes part in the show. Make a kennel from a box. Find the scent. Pictures are screwed up, and the children try to remember which is which. The clinician names the one the dog must find. If wrong it is screwed up again. Agility. Two teams. One member from each team either names the set of words, or tries to get their dog round the agility course as many times as possible before the other team have named all the words in the set. Best in show. Under the set of pictures are rosettes. The children name a picture and the one who finds best in show is the winning dog. 3. Pirates Toy pirates and boat for discussion about pirates. Make a pirate hat on which the children stick pictures of the word set. Find the treasure/ avoid the poison. Under a set of pictures are hidden one treasure and one poison. On top of each picture are raisins. The children name a picture and can eat the raisin if it is not poisonous. If they get the treasure they have extra raisins. If they get poison they cant eat the raisin and we start the game again. Stepping stones across the crocodile infested river. The word set is glued onto stepping stones. One or two children at a time name the picture they want to get to next. The other children act as scary crocodiles snapping at their feet. If they make a mistake they get eaten by the crocodiles. Cannon practice. A toy cannon that shoots plastic balls is used to try and hit a picture that the child has named. Stick / tick / kick / sick. Four chairs, one covered in sticky tape with sticky side up so that children stick to it, one with a toy crocodile who ticks, one with a soft ball to kick and one with a sick bag. Children say which one they want to sit on, and direct each other and the clinicians. 4. Motor sport Make a steering wheel with a set of pictures stuck to it. Discuss cars and motor racing. Car racing. Pictures are stuck on toy cars and are raced off a sloping board. Children guess which car will win. Car stunt course (see agility above). Car race track. Children name pictures as they go round the track. 5. Bees The bee family (Lancaster, 2007) are introduced and bees are discussed. Make a house for the masonry bees by sticking each bee into a window on the house. Find the nectar (similar to find the scent above). Guess the bee. The clinician describes a bee and children suggest its name. Beehive. Different bees need to go to different homes. The children suggest the bee that would be most happy in the home described by the clinician. Bees find nectar or a predator. (See treasure/ poison above in pirates.)

could be adapted to comply with the theme. Some examples are in figure 3. Although the activities are similar, using themes encouraged our creativity and we think was a motivating factor for the children we worked with. We hope other speech and language therapists are doing the same and, if not, we recommend it. Gwen Lancaster is a speech and language therapist with Merton Local Authority, Shelagh Benford with Salisbury Foundation NHS Trust, Gerry Buckley with The Mater Child and Adolescent Mental Health Service in Dublin, Alison Langshaw with North Bristol NHS Trust and Emma McCormack with Tower Hamlets NHS Trust.

Allen, S., Hirst, E. & Jones, R. (2008) Better by redesign, Bulletin of the Royal College of Speech & Language Therapists, 676 (August), pp.2223. Gierut, J. (1990) Differential learning of phonological oppositions, Journal of Speech and Hearing Research, 33, pp.540-549. Gillon, G.T. ( 2000) The efficacy of phonological awareness intervention for children with spoken language impairment, Language, Speech and Hearing Services in Schools, 31, pp.126-141. Gillon, G.T. (2002) Follow-up study investigating the benefits of phonological awareness intervention for children with spoken language impairment, International Journal of Language and Communication Disorders, 37, pp.381-400. Hesketh, A., Adams, C., Nightingale, C. & Hall, R. (2000) Phonological awareness therapy and articulatory training approaches for children with phonological disorders: a comparative outcome study, International Journal of Language and Communication Disorders, 35, pp.337-354. Hewlett, N (1990) Processes of development and production in Grunwell, P. (ed.) Developmental Speech Disorders. Edinburgh: Churchill Livingstone, pp.15-38. Lancaster, G. & Pope, L. (1989) Working with childrens phonology. Milton Keynes: Speechmark. Lancaster, G. (2007) Developing speech and language skills: Phoneme Factory. London: David Fulton. Passy, J. (1993) Cued Articulation. Ponteland: STASS Publications. Stackhouse, J. & Wells, B. (1997) Childrens speech and literacy difficulties: a psycholinguistic framework. London: WileyBlackwell. Williams, A.L. (2003) Speech Disorders Resource Guide for Preschool Children. NY: Thomson Delmar Learning.

References

Resources

Boardmaker see www.mayer-johnson.com

REFLECTIONS DO I OFFER THERAPY THAT IS DYNAMIC, ENERGETIC, PARTICIPATIVE AND FUN? DO I RELATE PRACTICE TO THEORETICAL FRAMEWORKS? DO I LOOK FOR INNOVATIVE WAYS TO GROUP 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.

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Heres one I made earlier

Heres one I made earlier...

Alison Roberts with three more low cost, flexible and fun therapy suggestions for groups. Storyteller Friendship consequences So thats how that happened!

To help clients improve their narrative skills. MATERIALS Magazine pictures of people doing different activities, the more varied the better. Words printed on cards: a) Story starters such as There was a sudden bang as my tyre went flat or We had just won 100 so or We had run out of money while we were on holiday. b) Atmospheric descriptors such as The pub was full and the music played loudly, or It was a wintry night with snow swirling around the door, or The lake was peaceful. c) Story finishers such as So eventually we were allowed to leave the caf, or I was so pleased to get back home, or I will never go to that place again, or What would you have done? d) Single words / word phrases graded to the ability of your client group: easier ones could include lawnmower, fizzy pop, fridge, while harder ones can include adjectives and adverbs such as cheerful, popular, despondently. e) Random extras such as nonsense words from Roald Dahl, or Edward Lear - frobscottle , gimble - or you (or they) can invent some. For able groups, any unusual or advanced vocabulary should also be included here, perhaps cookery or other technical terms such as carders, roux, trepanning, osmosis, or sphygmomanometer. IN PRACTICE Give each participant four pictures and a card from each section. They must make up a story linking the pictures and cards, and tell it to the group. They should be given a time limit, such as 5 minutes, to invent the story. It is worth advising them that it is often easier to establish the story ending first!

This is like the Consequences game played at parties. It helps to develop awareness of others, and can be very funny when mismatches occur. MATERIALS Paper and pens IN PRACTICE 1. At the top of the paper each participant writes about a friend (real or imaginary) who they will entertain and feed for a day, and regale with a gift. They should give the name and the age of the person, and indicate their preferences and dislikes for food, activities, and interests (for example Tyrone, aged 28, likes roast meals, hates fish, loves watching and playing football, is interested in motorbikes, is allergic to pet hair). 2. This information is concealed by folding the paper over twice. The paper is then passed on to the next player. 3. The next player, not knowing whom they are catering for, must write down a suggested activity for the morning, fold the paper over, and pass to the next. 4. This player adds their idea for lunch, and folds and passes as before. 5. Add an afternoon activity, an idea for supper, and a gift, folding and passing on after each new addition. 6. Now open up the paper and read the order of events for the day. You may end up with an oddly incompatible series of suggestions; for Tyrone, the morning activity might be to join the over 60s coffee morning, then eat baby food, then attend a ballet class, then have a prawn salad, and be given a hamster. 7. Discuss his reactions to all of the unfortunate suggestions, and then devise the perfect alternatives.

This is a lateral thinking activity for a group of fairly able clients. It is based on the idea of explaining how something improbable could have come about, and is great fun. MATERIALS List of unlikely circumstances written on small pieces of paper, folded, and put in a hat. Suggestions include: 1. so that is how I came to arrive at my interview for the office job, wearing muddy boots. 2. so that is how our college came to be used as an animal shelter for the weekend. 3. so that is how I realised I had dyed my friends hair purple. 4. so that is how I found myself under the table at a strangers wedding reception wearing my swimming trunks / costume. 5. so that is how the inspector came to be sitting on a plate of ice cream. 6. so that is how I found myself on a rocket to the moon. 7. so that is how I found myself having to spend the night in an empty multi-storey car park. 8. so that is how it was my fault that the Prime Minister came to rip his trousers. 9. so that is how I came to be shopping in my pyjamas and a tall hat. 10.so that is how four of us got our elbows stuck together with superglue. IN PRACTICE Ask clients to make up a story, the end point of which is the unlikely circumstance written on their piece of paper. They are allowed a few minutes to think of their story, perhaps while teabreak is going on.

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exploratory research

Symbolic voices
Louise Greenstocks previous experience as a teaching assistant brings a very practical focus to her research into how graphic symbols are used in schools and her associated observations on collaborative working.

READ THIS IF YOU ARE INTERESTED IN GRAPHIC SYMBOLS WORKING COLLABORATIVELY THE PERSPECTIVE OF SUPPORT STAFF

ow can we understand the ways symbols are used in schools without any research documenting this? And how can we learn from good practice in the use of symbols when practitioners experiences are not shared? I am halfway through my PhD research journey, where I have the exciting opportunity of investigating the use of graphic symbols in schools in a small geographical region. My previous experience in particular working in schools has influenced the focus and conduct of my research. I hope by reflecting on this and on my early findings to encourage more effective use of graphic symbols and greater collaboration between speech and language therapists and education practitioners. As a psychology graduate, one of my first jobs was working as a teaching assistant in a mainstream inner-city Infant and Nursery School. I worked in the same foundation stage setting for three to five year olds for two years. My role was class-based, supporting the teacher and all the children in that class. While working in school, I used Makaton manual signs and graphic symbols. (Please note I will use the term symbols to refer to all graphic symbols.) In this school, signs and symbols were used to label the environment and resources, help children learn signs for songs and rhymes, symbolise displays and text, and encourage children to sign greetings and requests. The school also promoted the use of symbol-supported visual timetables. Children were expected to plan their day and select the activities they intended to do during the session by placing symbolised cards representing activities on planning boards. As a teaching assistant I used Makaton signs and symbols in these ways because this was what I was instructed to do. When I look back, I am surprised I didnt ask more questions and even request some training, but I didnt. At no point was training offered to me. Although there seemed to be an implied school policy about the signs and symbols used and how these were presented, this was never explained to me. At the time I was unaware of alternative representational systems or the reasoning and rationale behind selecting from the various sets. I was oblivious to the arguments for and against using one symbol set consistently. In this particular school strict adherence to the preferred symbol set was

enforced. Software was used to retrieve new symbols when they were needed. There was no clear definition of whose role it was to plan and prepare for the use of symbols. While the use of symbols in schools with children in the Foundation Stage later became the primary focus of my research, one of my secondary research questions is concerned with the related collaborative working that occurs when practitioners use symbols in schools. As a teaching assistant, I was aware of a number of practitioners from outside agencies such as speech and language therapy and educational psychology coming in to observe and work with individual children and small groups. It was frequently the case that practitioners would arrive in the unit without introduction or warning from anyone. This made collaborative working between myself and the practitioner concerned very problematic. Opportunity for discussion with them was non-existent and I was not informed of their objectives. I was unable to learn about symbols from the speech and language therapist who visited the school.

Curious

I felt a considerable amount of empathy for the practitioners coming in from external agencies because they were not introduced to school staff, nor given the opportunity to share their professional opinion about how best to support the children. Their expertise was not utilised to full effect. I had no understanding of the experiences of speech and language therapists working in schools and began to be curious about this. After two years of working as a teaching assistant, I found a faculty funded PhD opportunity addressing symbol use in schools. I was overjoyed to be offered the studentship by my two experienced supervisors. I spent the first six months exploring what I saw as the research areas surrounding symbol use: augmentative and alternative communication (AAC), symbolic and cognitive development, collaborative working, inclusion, speech, language and communication difficulties, and early years education. I found only one example of a piece of research conducted in the last five years in which the use of symbols in schools was explored (Abbott & Lucey, 2005). I realised that this was an under-researched area in

need of a well-designed piece of exploratory research. I felt that the best way to explore the current situation was to approach and interview practitioners in schools and to attempt to empower them by incorporating their experiences into the findings. I was influenced by Schratz (1993) who argued that the voices of practitioners in the field are not utilised enough in research. I knew from my own experience that there was a gap between research and practice for practitioners in schools and that research literature was often inaccessible. As a researcher I want to bridge this gap by generating accessible findings and disseminating these where possible. Having explored the research areas and identified a gap, I went on to define my research questions and outline my objectives. From an understanding of the literature and building on my own experiences, I felt these needed to address a number of aspects of symbol use: Who uses symbols in schools and in what ways? What experiences have these practitioners had of using symbols? What guides them in their use of symbols? How do they decide which children might benefit from symbols? Is their use of symbols planned? Do they liaise with other practitioners about the use of symbols? During my investigation of the literature relating to symbols, I encountered several areas of difficult terminology, for example, symbols / signs / pictures, and interprofessional / multi-professional / collaborative / inter-agency working. I began to recognise the challenges faced by practitioners in schools with so little consistency in the terms used.

Function

Graphic symbols are often defined as a graphical representation of a referent (Greenstock, 2007). The referent is the concept that is being represented. Although there is some debate about which referents can and cannot be effectively represented by a graphic symbol, most symbol sets range from concrete to abstract

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exploratory research

referents and transparent to opaque symbols. Most recognised symbol sets have a communicative function although symbol use is developing and spreading to other inter-related areas of learning and participation, including visual timetables, English as an additional language support and literacy. The majority of the existing literature around the use of symbols is in the field of AAC. It discusses their use in high and low tech systems. Symbols are a well-recognised way of supporting people with communication difficulties related to physical disabilities, learning difficulties and developmental disorders. Symbols are also recommended by the National Autistic Society as a way of making information clearer for people with autism spectrum disorder. Symbol-supported software (see figure 1 for examples) is developing fast.
Figure 1 Symbol software examples

Software Supplier Communicate: in Print Widgit Software Communicate: SymWriter Boardmaker Mayer Johnson Clicker 5 Crick Software The Grid 2 Sensory Software International Ltd When AAC systems are used in schools, this obviously requires the involvement of teachers and a range of support staff as well as speech and language therapists. There is guidance for practitioners working with AAC users on how to select communication aids and the symbols to go with them (Clarke et al., 2001; McCurtin & Murray, 2000; Millikin, 1997; von Tetzchner & Martinsen, 1992). Literature about use of symbols other than for AAC is rarer. In the context of existing knowledge about symbol use, I decided to explore the experiences and attitudes of a range of practitioners about the use of symbols in schools (mainstream and special) with children in the Foundation Stage. As I had an interest in the ways these practitioners worked collaboratively when they used symbols, I decided to interview three groups who work together: teachers, speech and language therapists and early years practitioners. I felt the term early years practitioner (Letts & Hall, 2003) would encompass the diversity of job titles for support staff in school settings.

My preparatory work demonstrated that very little is known about how symbols are being used in schools. For this reason I designed a piece of exploratory research, hoping to increase understanding of symbol use in its current condition. Due to my location, I selected a sample from a region within the East Midlands. After a rigorous and lengthy process of scrutiny for ethical approval from the University and the NHS, I recruited a sample of practitioners who worked in schools and had experience of using symbols. I conducted semi-structured interviews individually with 15 teachers, 22 early years practitioners (teaching assistants, nursery nurses), and 16 speech and language therapists. I transcribed and coded these interviews one by one individually. I used QSR NVivo2 qualitative data management software during the initial coding, and built models and frameworks representing the themes on which my theoretical outcomes are based. The analysis gradually moved to conceptual linking, during which I looked for relationships between the transcripts. I then began to gather evidence for the themes that were emerging. Although the analysis is not complete and any early findings will not necessarily represent the final themes resulting from the full analysis, there is already a considerable amount of interesting data to refer to: 1. Purpose Symbols are being used for a wide range of purposes. I have ordered these loosely from the most frequently mentioned: Visual timetables Supporting children with speech and language needs Focused work with specific children (including those with special educational needs, autism and English as an additional language) Helping children understand rules, choices and following instructions Labelling the environment and resources PECS (Picture Exchange Communication System) and developing exchange routines Supporting children with social, emotional and behavioural needs Literacy activities and creative work As part of various games. 2. Consistency Interviewees in all of the professional groups expressed opinions about the importance of

PCS (Picture Communication Symbols) used for illustrative purposes by kind permission of Mayer Johnson Inc (www.mayerjohnson.com). Clockwise: communication, team, listening, talk, teacher, speech therapy.

consistency in symbol use, some suggesting this was important and referring to consistent symbol use within the school. 3. Progression Interviewees in all of the professional groups expressed ideas about progression in the use of symbols, referring to childrens understanding of symbols and appropriate use of symbolic items, objects, photos and symbols. 4. Needs Interviewees in all of the professional groups expressed reasons for and against using symbols and often spoke about their decision to use them in isolation or with other resources, depending on the needs of the child(ren). 5. Training Many interviewees had not had any specific formal symbol training and many said they would like some. Those who had had training said it was brief. 6. Collaboration Some interviewees from all of the professional groups had experienced working collaboratively with other professionals when they had used symbols. Time was often given as a factor supporting or challenging this. 7. Relationships Working relationships between teachers, early years practitioners and speech and language therapists were largely positive 8. Recognition Teachers and early years practitioners supported the view that speech and language therapists have knowledge about symbols and bring this knowledge into school. Again, sufficient time is needed to maximise this.

Good practice

There were some encouraging accounts of good practice in the use of symbols and related collaborative working. Many interviewees were able to discuss their rationale for using or not using symbols with confidence. Many had an understanding of developmental progression objects,

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exploratory research

resources
The National Deaf Childrens Society freephone helpline now has extended hours: Monday 9.30-19.30, TuesdayThursday 9.30-17.00, Friday-Saturday 9.3012.00. Calls can be translated into over 100 languages. 0808 800 8880; www.ndcs.org.uk Crick Software has added SoundsLike technology to its WriteOnline software, so that students with very poor spelling can benefit from word prediction. www.cricksoft.com/uk/products/ WriteOnline/ For details of the Bristol Speech & Language Therapy Research Units latest projects, see www.speech-therapy.org.uk The Challenging Behaviour Foundation has produced an information sheet on Difficult sexual behaviour amongst men and boys with learning disabilities. www.thecbf.org.uk/chall-behaviour/more/ Difficultsexualbehaviour.htm ITV is making childrens stories available in British Sign Language and in text, pictures and sound, with the aim of improving the literacy of deaf children. www.signedstories.com/page/index.cfm Jeremy Fisher of Vocal Process has now produced a film to help you Build Your Own Tilting Larynx. A free template is available. www.youtube.com/watch?v=H1UEzPc3I2g The Novelty Warehouse sells sensory toys for children with special needs. www.thenoveltywarehouse.com Speakability has produced a Communication Board to assist people with severe aphasia and a Medical Passport to enable a person with aphasia to discuss their needs with their doctor on an equal basis. The charity also sells the ICOON wordless picture dictionary. www.speakability.org.uk A new guide from the Foundation for People with Learning Disabilities details how person centred planning and selfdirected support can be used by young people with autism and their carers when making the transition from school or college to adult life. We Can Dream, free from www. learningdisabilities.org.uk The Work Wise UK initiative supports organisations to adopt smarter working practices such as flexible working / condensed hours / mobile and remote working. www.workwiseuk.org

photos, symbols, words and ideas about the appropriateness of symbols for certain age groups and developmental levels. Some interviewees were also looking for evidence that children were benefiting from symbols, for example, the children knew what they should be doing, or developed symbolexchange skills. Many participants referred to effective collaborative working. There were some clear consistencies between the working conditions given in their examples: Good communication and support Team working Time to talk Sharing information two way feedback Speech and language therapists in school regularly Same speech and language therapist each visit Speech and language therapists available to give guidance Educational practitioners feeling able to ask speech and language therapists questions Speech and language therapists feeling respected and welcomed into schools Speech and language therapists given the opportunity to share knowledge about symbols with staff teams many therapists were involved in delivering training and this was frequently in schools. During the analysis several contradictions and debates emerged which I shall explore further in the full analysis: a) Should symbols be used with all children? b) Are children in the Foundation Stage too young for symbols? c) Should terminology be more consistent (symbols, signs, pictures)? There is currently very little documentation of how symbols are being used in schools. This means that it is difficult to learn from each other and develop good practice. It also means that resources, ideas and suggestions are not

being shared as much as they could be. My research to date suggests that symbols are widely used for various purposes. Some practitioners are using symbols without training and there are issues around their consistent use, even within the same school. There is confusion over terminology and lack of time causes a strain on all services. On the positive side, we can learn from examples of good collaborative practice. Speech and language therapists would like to spend more time in school and education practitioners would like to see them more. From my research, I have developed the strong impression that practitioners working in schools would like to know more about how others are using symbols and would welcome the opportunity to share ideas. There is a reasonable amount of information about symbols available on the web, in research literature, text books, and from the symbol developers themselves. Practitioners need to be signposted to this information and given the opportunity to browse and explore these sources themselves. I believe in empowering practitioners by documenting their experiences and enabling their professional development by sharing information as widely as possible. The ultimate goal is more informed and evidence-based use of symbols in schools and better access to symbols for children. Louise Greenstock is a PhD research student at De Montfort University, e-mail lgreenstock@dmu. ac.uk. Louise will be happy to share her final research findings when they are available. SLTP

Abbott, C. & Lucey, H. (2005) Symbol communiDo you wish to comment on the impact cation in special schools in England: the current this article has had on you? Please see the position and some key issues, British Journal of information about Speech & Language Special Education, 32 (4), pp.196-201. Therapy in Practices Critical Friends at Clarke, M., Price, K. & Jolleff, N. (2001) Augmentawww.speechmag.com/About/Friends. tive and alternative communication, in Kersner, M. & Wright, J. (eds.) Speech and Language Therapy: the decision making process when working with children. London: David Fulton, pp. 268-282. Greenstock, L. (2007) MPhil to PhD Transfer Report. Unpublished. Leicester: De Montfort University. Letts, C. & Hall, E. (2003) Exploring early years professionals knowledge about speech and language and development and impairment, Child Language Teaching and Therapy, 19, pp.211-229. McCurtin, A. & Murray, G. (2000) The manual of AAC assessment. Bicester: Winslow Press Ltd. Millikin, C. (1997) Symbols systems and vocabulary selection strategies, in Glennen, S. & DeCoste, D. (eds.) The Handbook of AAC. San Diego: Singular Publishing Group Inc., p.97. Schratz, M. (ed.) (1993) Qualitative voices in educational research. Buckingham: The Falmer Press. von Tetzchner, S. & Martinsen, H. (1992) Introduction to sign teaching and the use of communication aids. London: Whurr Publishers Ltd.

References

REFLECTIONS DO I SEEK TO INCLUDE SUPPORT STAFF IN TRAINING AND LIAISON SESSIONS? DO I ENCOURAGE OTHER PROFESSIONALS TO ASK ME ABOUT MY PRACTICE? DO I AUDIT CURRENT PRACTICE BEFORE INTRODUCING NEW DEVELOPMENTS?

Resources

Makaton see www.makaton.org/ National Autistic Society see www.nas.org.uk/ PECS see www.pecs.org.uk/

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care pathways

Role models
People with a learning disability and dysphagia need specialist support and advice to ensure safe eating and drinking and optimal communication but who is best placed to provide what? Peter Jones discusses how roles are shifting as the multidisciplinary service in North West Wales evolves.
READ THIS IF YOU ARE INTERESTED IN RE-FOCUSING ON COMMUNICATION PATIENT SAFETY ISSUES MULTIDISCIPLINARY WORKING

ysphagia is more common in people with learning disabilities than in the general population. Poor management can lead to a host of other health problems including respiratory tract infection, which is a leading cause of death for this group of citizens (National Patient Safety Agency, 2004). The changing demographics of the population of people who have learning disabilities means there are many people - and an increasing number of children - with complex health needs including dysphagia. They require specialist support and advice to ensure eating and drinking is safe and that they receive adequate nutrition in a manner acceptable to them. In their supervision series, Sam Simpson and Cathy Sparkes (2008) mentioned the importance of creating space for reflection. With this in mind, several colleagues suggested we might briefly reflect upon the setting up of a local service for adults with learning disabilities who also have dysphagia. During this process we looked at the issues that presented themselves and how we have supported our dysphagia service to evolve over nine or so years. Whilst striving to ensure that our service develops further, we hope that sharing our experience might encourage others who are attempting to tackle what is an important and potentially life-threatening condition within a very vulnerable group of citizens. North West Wales NHS Trust provides a service for the counties of Gwynedd and Ynys Mn (Anglesey). It serves a population of about 187,200 people, approximately 64 per cent of whom are Welsh speakers, encompassing a geographical area of 3,268 square kilometres. The Trust is located in an area of outstanding natural beauty, combining the mountains of Snowdonia and a vast coastline. The learning disability service is provided by two community teams integrated with our local authority colleagues in Gwynedd and Ynys Mn. Due to the size of the region, these teams work from five different bases. There is also a former learning disability hospital site offering small-scale inpatient services for individuals with complex health needs and challenging behaviour. The hospital recently completed a programme of resettlement with

L-R Deirdre and Jill

L-R Peter Jones, Wendy Williams, Stephen Hughes, Gwenan Roberts previous long-stay residents moving to smallscale accommodation across North Wales. Our service used to have a Professional Advisory Group, a multidisciplinary committee tasked with looking at service development. During December 1999 the group considered the management of dysphagia across North West Wales. The inconsistency of the service being provided and absence of clear service standards at this time was a cause for concern - much as, we suspect, the Portsmouth adult team experienced in terms of their aphasia service (Clark & Nineham, 2008). At the time we did not have a clear policy or identified pathway of care for individuals. There was inconsistency in assessment and a general lack of coordination of the management of care. therapist, senior physiotherapist, GP, learning disability nurses and a dietician. The group was keen to advance a multidisciplinary and holistic ethos in relation to dysphagia management. Gwenan Roberts, our consultant speech and language therapist, led work to develop an integrated care pathway. The initial stages of our project involved an open reflection upon the service we were providing. This forced us to admit that the quality of that service varied enormously and we needed a framework for improving it. The development of the integrated care pathway involved the whole range of disciplines concerned in the management of dysphagia. In addition to the input of clinicians, secretarial support was vital to the creation and administration of relevant documents. During the initial development of the pathway we considered the roles and responsibilities of all involved in the delivery of care. Rather than allocating responsibilities according to traditional job boundaries and specific professionals, we wanted to respond

Holistic ethos

During 2000, the Trust put together a multidisciplinary dysphagia team with a view to developing our dysphagia service. The group consisted of our senior speech and language

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care pathways
to the needs of the service. We therefore considered who from our available resources was best placed to carry out each role. In many areas across the UK, the role of arranging and coordinating the multidisciplinary team with regards to dysphagia has traditionally been adopted by speech and language therapy. Within our service, we reached the consensus that this role lay comfortably with learning disability nursing. As the learning disability nurse has a significant role in the initial assessment of dysphagia we agreed that a nurse, having received specialist training in dysphagia management, would be the most appropriate professional to coordinate the management process.

Innovative approach

In what at the time felt like a fairly innovative approach, speech and language therapy input in relation to dysphagia would now focus on the communication aspects of dysphagia management: Assessment of individual communication skills (including the efficiency of oral structures). The formulation of strategies to promote communication, including the development of accessible information and supporting individuals to make choices and to participate in their dysphagia plan. Provision of advice and training on the communicative environment and the factors affecting communication at meal times and how best to communicate with the individual. Supporting and supervising dysphagia practitioners. One of the issues that arose from the decision to develop the nursing role was that access to appropriate training was initially difficult. One concern was how one professional group (speech and language therapy) could assure the competencies of another (nursing).The very positive working relationship that had been formed between local nursing and speech and language therapy services proved crucial in accessing information on relevant training opportunities. Wendy Williams was supported to undertake dysphagia training provided by the School of Nursing at Bangor University.Wendy is a learning disability nurse with a particular interest in and experience of dysphagia management. She had previously come into contact with the stroke team based at the local district general hospital as a result of supporting people with learning disabilities and complex health needs during acute admissions to the hospital. As part of the integrated care pathway, the dysphagia team put together guidelines on the management of dysphagia. The guidelines defined dysphagia and outlined potential risks to individuals with this condition. They emphasised the need for a coordinated and multidisciplinary approach. We piloted the pathway during 2000. It became apparent that the coordination and management of the dysphagia service was fairly

intensive in terms of time and effort. Wendy had to combine this role with that of a community learning disability nurse with an existing caseload of individuals. She also continued to liaise closely with the stroke team. The geographical area covered by the service is large and mainly rural. Given the extent of Wendys workload, a nurse was identified within each of the five locality-based community support teams to champion and coordinate dysphagia issues and to develop knowledge and expertise in this area. Offering clinical advice and more formal teaching sessions to direct carers from the health service and other providers as well as family carers has become a regular feature of the dysphagia teams service. Wendy has developed her role as dysphagia service coordinator, providing additional support to locality coordinators, including advice and involvement with people who have more complex needs.

In the period between 2000 and 2007 the dysphagia service has continued to develop with any resulting changes made to our pathway documentation as work progresses. Work undertaken by the National Patient Safety Agency during 2004 highlighted dysphagia as a particular risk to our client group, which gave us added encouragement to develop our service further. At this time Wendy and Gwenan liaised with representatives of the Agency as they gathered information on dysphagia management on a UK-wide basis. A dysphagia coordination group involving the Head of Service Stephen Hughes, consultant speech and language therapist Gwenan Roberts, clinical governance coordinator Peter Jones and Wendy was set up to monitor and evaluate the service. The central work of this group is to look at variations from records of individual pathways of care, any operational issues raised by Wendy and any

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care pathways
matters arising from implementation of the pathway. The clinical management process is summarised in figure1. therefore need to consider issues such as succession planning. We now have clear guidelines around the management of dysphagia for adults who have a learning disability and a formal recognition of the role of the specialist dysphagia nurse. We are in the process of developing our local training package from a diploma to a degree level module which will be available to all professions working with people who have dysphagia. Awareness of dysphagia issues throughout the service has been raised since the project began and this, we feel, can only benefit the individuals whom we support. We have now been asked to take a lead on modernising the dysphagia service in the acute hospital and the paediatric service. The development of our dysphagia service has demonstrated that we need: To work in a mutually supportive and multidisciplinary fashion. To be open and honest about the services that we provide and be prepared to accept that we do not always provide the best service possible. To think creatively and, at times, outside of traditional professional roles. Explicit service standards - in this case through the development of an integrated care pathway. A supportive learning environment. Involvement of all relevant individuals in the development of integrated care pathways. Peter Jones is a Learning Disability Nurse and Clinical Governance Co-ordinator. Further information is available from Gwenan Roberts, Consultant Speech and Language Therapist, e-mail gwenan.roberts@ nww-tr.wales.nhs.uk or Wendy Williams, Specialist Dysphagia Nurse, e-mail wendy.williams@nwwtr.wales.nhs.uk. All work with Learning Disability Services, North West Wales NHS Trust. SLTP REFLECTIONS DO WE OFFER A SERVICE THAT RESPONDS TO THE NEEDS OF CLIENTS RATHER THAN TRADITIONAL PROVIDER ROLES? DO WE INCLUDE ADMINISTRATIVE SUPPORT WHEN PLANNING A PROJECT? DO WE HAVE A SAFE PRACTICE INFRASTRUCTURE THAT IS INDEPENDENT OF SPECIFIC CLINICIANS? Do you wish to comment on the impact this article has had on you? Please see guidance for Speech & Language Therapy in Practices Critical Friends at www. speechmag.com/About/Friends.

resources
HeadsUp is a Hansard Society web forum for under 18s to debate political issues and learn about the political process. www.headsup.org.uk The Management Consultancies Association has awarded Atos Consulting for it lean principles work with NHS South Central to redesign patient treatment pathways and change practice among front-line staff. Waiting times have been reduced by an average of 14 weeks. www.mca.org.uk A Family Companion to the ACT Care Pathway for children with life-limiting and lifethreatening conditions aims to help families and carers understand what will happen following the childs diagnosis. Free to families, tel. 0117 916 6422 / e-mail Susannah@act.org.uk Listen. Hear! is a campaign designed to make people think twice about the way they listen to music, including suggestions for safer listening, guidelines on volume, recommended listening time limits and maintaining ear health. www.deafnessresearch.org.uk/ Listen%20Hear%21+4955.twl Games for Life is a not-for-profit Community Interest Company which seeks technological solutions for attention difficulties. www.gamesforlife.co.uk The POPS Reading Programme supports an integrated approach to learning to read, designed with advice from Down Syndrome Education International. www.downsed.org/ Planetree is a non-profit organisation which aims to promote patient centred care in environments focused on healing and nurturing body, mind and spirit. www.planetree.org/about.html The British Voice Association has expanded its range of information about voice conditions and care. www.british-voice-association.com/voice-care. htm NUK baby care manufacturers have relaunched their product range free of the chemical Bisphenol A (BPA). www.nukbaby.co.uk A Skills Passport for Maternity Care Assistants in Scotland uses a traffic light system to support achievement of competencies. It shows what the assistant should not be undertaking (red), what requires further training (amber) and what is ideal for them (green). www.nes. scot.nhs.uk/documents/publications/classa/ 010808MCA_Skills_Passport.pdf

Evidence base

Wendy has spent time monitoring the evidence base in relation to dysphagia management, linking up with colleagues in other areas around the UK. In March 2007 Wendy began the process of trying to find a screening tool for dysphagia. Having come across work being undertaken in the USA by Justine Joan Sheppherd of Columbia University, New Jersey, Wendy made contact and met up with Joan at an event in Holland in late 2007. Joan introduced Wendy to the Dysphagia Disorder Survey (DDS), Dysphagia Management Staging Scale (DMSS), and pneumonia and choking risk assessment tools. The Dysphagia Disorder Survey (Sheppard, 2002) was developed specifically to screen adults and children with learning disabilities for dysphagia and related eating disorders. It is intended to identify risk factors associated with dysphagia. The tool also provides a raw score that indicates an individuals functional eating competency as well as a percentile ranking of swallowing competency. The Dysphagia Management Staging Scale (DMSS) is a five level staging scale that indicates the level of severity of an individuals eating disorder. This tool may be used on its own or in conjunction with the Dysphgia Disorder Survey to give a more comprehensive screening of an individuals needs. Wendy has incorporated these tools in her everyday practice and is in the process of ensuring that colleagues within the wider dysphagia team have the skills to use them also. We have begun the process of sharing our structures and guidelines with other health services via the current North Wales Health Trusts Learning Disability Network group. We are hopeful that we will be able to develop our service across the region with the impending merger of NHS Trusts across North Wales into one organisation. The whole process of developing the service has been a learning curve for all involved and it has become apparent that the service continues to evolve as we learn from everyday practice.

Distinct service

One of the things we have learnt is the importance of having a distinct dysphagia service that does not use limited resources from either nursing or speech and language therapy. Safe practice has to have infrastructures that override the skills of specific clinicians and we

Clark, N. & Nineham, S. (2008) A driving force, Speech & Language Therapy in Practice Spring, pp. 11-13. N.P.S.A. (2004) Understanding the patient safety needs of people with learning disabilities. London: National Patient Safety Agency, NHS. Sheppard, J.J. (2002) Dysphagia Disorders Survey and Dysphagia Management Staging Scale User manual and Test forms. NJ, USA: Nutritional Management Associates. Simpson, S. & Sparkes, C. (2008) Supervision in context, Speech & Language Therapy in Practice Spring, back page.

References

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course comment / Software solutions

COURSE COMMENT

This occasional column aims to help you make priorities when planning your training schedule. Here, Rebecca Joseph finds a course on using music to support inclusion enjoyable, relevant and practical.

Software solutions
With technology becoming ever more sophisticated and accessible for therapy, our in-depth reviews will help you decide whats hot and whats not.
HEAD AND NECK 3D Head and Neck Anatomy with Special Senses and Basic Neuroanatomy DVD-ROM Barry Berkovitz, Claudia Kirsch, Bernard J. Moxham, Ghassan Alusi & Tony Cheeseman Primal Pictures ISBN 978-1-904369-69-1 Single user licence 180 + VAT

Using Music to Support Inclusion

Sarah Carling, Music for Starters www.musicforstarters.com 9 February, 2009, Birmingham

I was recently fortunate to have the opportunity to attend a course titled Using Music to Support Inclusion, which was pitched to suit a range of early years practitioners: anyone with an interest in using music to develop language, communication and interaction with children with any form of speech and language difficulty, Autism, learning and behavioural difficulties and children new to the English Language. Although Sarah, the course leader, introduced herself as a musician (not a music therapist), who would not be able to provide technical details, she clearly has many years experience of working with children with a range of needs and levels of ability and has thought through how best to encourage communication and interaction skills through a variety of visual modelling as well as auditory methods. No prior musical skills were necessary and the activities strengths often lay in their repetition and simplicity although there were more challenging and complex tasks if needed. Sarah has found that, sometimes, music can reach those children who can otherwise be unresponsive to experiences provided. The course was very practical right from the start and immediately called for hands on audience participation in the singing games and rhymes demonstrated. This is usually the clearest (and most entertaining!) way to experience a new approach, in order to retain it and then feel confident to use it yourself with others. The range of resources (props) used within the tasks were a variety of simple but very engaging puppets, instruments, scarves, lycra material and activity bands. These were used to good effect to encourage even the most selective of participants to interact and feel their contribution as valued on some level, whether verbally or non-verbally. Sarah was also open to dialogue, actively seeking opinions and discussion on the information she was providing. Currently working in a child development centre, health centre clinic and mainstream schools, I was particularly interested in activities that could be directly applicable for supporting the client groups in these settings - and there were plenty. This course uses content that encourages positive parent child interactions (imaginative play through music). It also demonstrates a fresh approach to interdisciplinary working, using music to develop early communication skills such as listening and attention / following instructions / shared interactions / turn-taking / copying and matching / anticipation / imaginative play. As well as working on rhythms and sound patterns, it could also be adapted to focus on specific vocabulary and concepts such as high, low, fast, slow. Many of the activities could easily be incorporated into language or other intervention groups. Although also applicable to children with normally developing speech and language skills, this course proved to equip practitioners with practical therapy ideas, directly relevant to our areas of work.
Rebecca Joseph is a speech and language therapist at Park House Child Development Centre, Birmingham. Music for Starters will run this course again on 6 October in London and 24 November in Birmingham.

A wow factor

After a couple of initial hiccups in the installation process, this interactive DVD has provided a fascinating technological experience with a real wow factor, and was fairly easy for a novice to navigate. The DVD-ROM is packed with different features which give opportunities to explore the anatomy and function of the head and neck in depth, plus examples of lesions in clinical slides. The anatomy is presented in 20 layers, revealing new structures within each layer. This multi-layered format enables a clear view of the position and inter-relationship of muscles and their innervation more fully and easily than 2D book illustrations. The 3D image can be rotated in both directions, revealing structures from different perspectives, with clear labels when highlighted. Concise text descriptions of their composition and function contain links to additional slides and brief movies. These include illustration of the specific muscle groups and their role and activity, in live film and through animated diagrams. Magnetic Resonance Imaging slides are shown alongside corresponding anatomical sections, offering a useful training exercise in identification and clarification. There is an interactive laryngoscopic view through to the trachea, taking you through six layers from the mucosa via muscle to the underlying cartilage, and zoom and rotation facilities bring the anatomy vividly to life. At 180 for a single user licence, this software is not cheap, and I needed help twice from my IT department, first in installing it, and then enabling the use of the movie function: this required use of the most recent QuickTime player available. This would be a valuable resource for a speech and language therapy service, with so many features and applications presented clearly in an eye-catching and engaging way. Its day to day use in the clinic appears limited in terms of direct therapy, though non-squeamish clients may well find it fascinating to see what is going on under their skin, but it is a useful, innovative tool in education, training and presentation. The illustrations can be saved and printed, and some animations can be exported for use in PowerPoint presentations. Overall an enjoyable and enlightening piece of kit! Linda Preston is Principal Speech and Language Therapist, ENT department, Royal Sussex County Hospital, Brighton.

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WINNING WAYS

Valuing Us
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 second article suggests that feeling valued and raising the profile of the profession are inextricably linked.

hen work is going really well and we are on a roll, it doesnt feel like work at all. Then, as the song Oh what a lovely war jokingly goes, its a shame to take the pay! But, if we are honest with ourselves, perhaps all of us are beset with questions from time to time: When did this profession become just a job for me? What happened to my passion for making a difference? If only I didnt have so much bureaucracy and ignorance to deal with! Ah, then my life would be a better, purer, more productive thing! So what drew you to being a speech and language professional? What sustained you during the hard years of study and the initial tentative months while you were turning from student to competent professional? What is your driver when other professionals dont seem to understand what you do or when the public seems to think that speech and language is confined to stammers and lisps? What keeps you going when the going gets tough? These are the questions which only you can answer. Some will be easy, I am sure, while others will make you stop and ponder. But if you are looking to educate both lay people and professionals as to the value and importance of your work, consider whether any or all of these four interweaving threads are key for you: 1. Passion I was surprised and delighted to hear that bluff old Army Officer, Lord Ramsbotham, talking excitedly in the House of Lords about the incredible value of speech and language professionals in HM Prisons. An unlikely champion you might think, but he was passionate about recidivism and knew that the way out of reoffending for young offenders was the ability to communicate effectively. Once they realise there are other ways to get their message across than violence and crime, life takes on a whole new vista. Suddenly speech and language therapy seems very, very important on many different levels. Bringing the qualities of passion, enthusiasm, love and determination to your work not only shows colleagues from other professions what you are about but demonstrates to you and your clients that it is important. 2. Efficiency Whether working in a multidisciplinary team or by yourself, inefficiency and disorganisation is a drain on your energy. This in turn affects your levels of passion and impact and is therefore counter-productive. Its easier said than done to become more efficient - how I would love that trait to come naturally to me! But changing your mindset is

READ THIS IF YOU WANT TO FEEL VALUED APPRECIATE OTHERS INFORM AND EDUCATE

what changes things. I was working with a client only yesterday who said she was a great starter but a hopeless finisher. This is one of the limiting beliefs that can confuse and control. Nothing is ever truly finished but every second starts and finishes, so we cannot help but be in the paradox of an endless open loop and thousands of little beginnings, middles and endings. A little quote often attributed to Goethe runs, Whatever you can do, or dream you can do, begin it now. Boldness has beauty, power and magic in it. 3. Interest I used to be part of a business organisation and the purpose of it was to help other businesses to grow. We had to organise one-to-one meetings, lasting no longer that an hour, designed specifically to find out about what the others did. This is such a fun way to educate and inform and to get other people working on your behalf. By showing an interest in the other disciplines, you begin to understand where you fit into the picture. This involves making time to find out what other members of the team do and also to explain to them what you do and how you can help each other. If busy people think this time might lighten their load then interest is soon sparked. 4. Being valued If you believe in yourself and your work, it doesnt really matter what other people think. Being valued always starts with how much you value yourself: this can never be replaced by targets or appraisals. Of course we all long for approval and appreciation but these things have to start at home base. Not with big-headedness or boastful chat, but the inner calm that comes with self belief. Dr Wayne Dyer, a writer of note, often quotes Abraham Maslow, that great inventor of the hierarchy of needs. When someone reaches the peak of self-actualisation, they become independent of the good opinion of others.

By valuing yourself and then turning that appreciation outwards, noticing the value of others and commenting on their contribution rather than their lack of it, you start to turn round whole departments. Its a challenge I know, but one that everyone is able for. The Goethe Society of North America website has a fascinating discussion about the little quote I mentioned earlier. A suggested context for it goes like this: Until one is committed, there is hesitancy, the chance to draw back. Concerning all acts of initiative (and creation), there is one elementary truth that ignorance of which kills countless ideas and splendid plans: that the moment one definitely commits oneself, then Providence moves too. All sorts of things occur to help one that would never otherwise have occurred. A whole stream of events issues from the decision, raising in ones favour all manner of unforeseen incidents and meetings and material assistance, which no man could have dreamed would have come his way. Whatever you can do, or dream you can do, begin it. Boldness has genius, power, and magic in it. Begin it now.
Sources Dr Wayne Dyer, visit www.drwaynedyer.com/ The Goethe Society of North America, see www.goethesociety.org/pages/quotescom.html

Jo Middlemiss is a qualified Life Coach who offers readers a confidential complimentary half hour coaching session (for the cost only of your call), tel. 01356 648329. Her book with CD What should I tell you? A Mothers final words to her infant son is now available.

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THIS HOUSE BELIEVES

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

This House Belie

The Proposition case: One language is beneficial
Defining the topic
An individual speaking more than one language defines linguistic diversity or bilingualism. The literature reports bilingualism to stimulate verbal and linguistic abilities, general reasoning, concept formation, divergent thinking, and metalinguistic skills (Bhatia & Ritchie, 2004). Children raised in linguistically diverse homes have an advantage for bilingual or multilingual development. Bilingual children may learn languages either simultaneously or sequentially depending on their natural environment. A home environment that alternates between two languages fosters simultaneous bilingualism. A child taught to speak a minority language at home (such as Spanish or Mandarin) who then learns a majority language (English) in school represents sequential bilingualism. Children who demonstrate receptive and / or expressive language delay(s), with no other sensory-motor, social, cognitive or neurological developmental concerns are diagnosed with language impairment. This definition holds true for children exposed to a linguistically diverse environment. In the United States many Speech Language Pathologists are encouraged to reinforce English as the language of choice in their clinical programs for preschool children with language delays who are raised in linguistically diverse homes. In 1998 a national movement in the United States swept the educational system, and a constitutional amendment to make English the official language was implemented (Riley, 1998). That year, early in my clinical education in the state of California, voters passed proposition 227 that worked towards eliminating bilingual education and many other states soon followed. The influence of this proposition changed many educational programs for students with Limited English Proficiency. As a result of this law, my clinical training - and that of many of my peers and other clinical professionals such as paediatricians - was based on a premise that, if these families chose to become residents of the United States, the children would be strongly encouraged to learn only one language: English. So how does the evidence for and against this approach to clinical services relate to ethical practice as Speech Language Pathologists? languages in the home environment. Cheuk and colleagues (2003) in Hong Kong, China compared bilingual Chinese-English children and monolingual Chinese children referred for behavioral problems. The results of this study found an association between language impairment and exposure to multiple languages in the home. POINT OF INFORMATION: This association was based solely upon chart reviews of standardised test results on the children sampled in this study. Tests were administered by attending physicians. Subject selection bias also played a role in this retrospective cohort study. 2) Reduce stuttering risk There is evidence of an association between stuttering and bilingual acquisition. Karniol (1992) hypothesises that stuttering may occur during bilingual acquisition as a reaction to momentary instability in a multi-loop system. According to this model, a load of two languages leads to an unstable system because of extra processing time required for either the outer loop (formulation of ideas and linguistic programming), inner loop (motor programming and control of vocal mechanism), or both. Karniol (1992) conducted a longitudinal study of a child from one to three years of age. This child was raised in a linguistically diverse family home environment (English, Hebrew). The author hypothesised that this child developed stuttering as a result of acquiring two languages simultaneously. Karniol observed this child prior to the onset of stuttering and the transition when the stuttering began in formulation of grammatical sentences. Onset of severe stuttering was evident a month after the child was aware of the two languages. When the dominant language became the only language used with the child, the non-dominant language as well as stuttering ceased. POINT OF INFORMATION: This was a single case study and a larger sample is needed before any findings can be generalised. Such studies also need to consider language load rather than bilingual acquisition to understand other reasons why this might have happened.

Rhona Galera and Paula Leslie debate the motion that speech and language therapists should encourage linguistically diverse families to use only one language for preschoolers with language delay.
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.

Rhona

Paula

Rhona Galera is a Speech Language Pathologist in the Department of Communication Sciences and Disorders at Childrens Hospital of Pittsburgh and a clinical fellow in the medical speech-language pathology clinical doctoral program at the University of Pittsburgh, USA, e-mail rig8+@ pitt.edu. 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.

Possible benefits

The proposition case is that Speech Language Pathologists should encourage linguistically diverse families to use only one language for preschoolers with language delays. Possible benefits include: 1) prevention of any language confusion or delays in development and 2) avoiding the increased risk of stuttering that occurs in bilingual acquisition. 1) Prevent language confusion A child with language delay tends to confuse language when s/he is exposed to two or more

Summing up the case for the proposition

Encouraging linguistically diverse families to use one language with preschoolers with language delays prevents language confusion and reduces the risk of stuttering.

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THIS HOUSE BELIEVES

eves in one language

The Opposition case: supporting language
Speech Language Pathologists should reinforce the concepts of language for children with language impairment who are raised in linguistically diverse homes. There is evidence that suggests this approach supports development of both languages and nurtures traditional family cultures. Anecdotal reports suggest that children confuse the acquisition of more than one language. Yet evidence supports an interdependence hypothesis in acquisition of more than one language for both normally developing bilingual individuals and children with language impairment (Cummins, 1979). There is an interdependence between the native language and learning another language. By developing the childs native language to a certain level (threshold), the knowledge of the native language helps, rather than hinders, the development of the new language. Perozzi & Sanchez (1992) studied 38 native Spanish-speaking 1st grade children (mean age 6 years 8 months) with language delays. This cohort group design study tested a monolingual and bilingual treatment approach to receptive acquisition of pronouns and prepositions. The investigators randomly separated the children into two groups. Group A received a bilingual approach and Group B received English only instruction. The bilingual approach involved initial instruction in Spanish until receptive acquisition was attained, and then English instruction was provided. The children acquired prepositions and pronouns with bilingual instruction faster than children with English-only instruction. POINT OF INFORMATION: The authors neither described the randomisation process nor blinding of investigators, and failed to specify the age range of the participants.

Self-confidence

Judgement:

Despite political controversy in the United States over immigration, parents who are first generation immigrants want the best for their children: theAmerican Dream. Children want to excel and do well for their parents and themselves, and to fit in. If we deny the value of a persons native language then cultural traditions and beliefs are also sacrificed. Commentators such as Schiff-Myers (1992) and Portes & Hao (1998) - who completed a qualitative study through surveys - argue that subtractive bilingualism (loss of the first language) results for most of these families. The parents do not necessarily serve as good models for speaking English. In addition to providing the solid grounding in their native language that will allow English to develop at a later stage, maintaining the home language encourages parents to communicate to children their cultural values, beliefs, and wisdom about coping with their experiences (Wong Fillmore, 1991). This creates cultural identity and self-confidence in children and their families.

The motion is defeated

Since my initial clinical training and as a growing clinician, I have learned to question anecdotal practices and see the value in reviewing primary resources. The evidence available in the literature encourages clinical intervention to emphasise learning the concepts of language rather than the number of languages used or which language (such as English) to use in therapy. I implement evidenced-based practice from my review in order to do no harm (the ethical principle of nonmaleficence) and to make certain that the clients with their families benefit from the services provided (the ethical principle of beneficence). My own experience is in line with the evidence. As a first generation immigrant to the United States, I have naturally incorporated culturally sensitive communication and clinical practices with clients and families different than my own. With the personal experience of subtractive bilingualism of my parents language, I see how this loss of the native language fades other traditions, beliefs and wisdom of the family culture in efforts to be an American. Clinicians should be encouraged to educate and reinforce the concepts of language with parents of children with linguistically diverse backgrounds so that the family unit and cultural heritage remains secure. If a monolingual clinician is the only one available to provide services, then a professional language interpreter should be used to reinforce language concepts. Such professionals also reduce cultural barriers in clinical services. Learning about language and communication characteristic of the culture can increase our clinical understanding of the child and family to differentiate normal bilingual development versus a true language disorder in planning treatment. This approach will also improve the quality of services between the clinician and the family unit to serve the child holistically. Language has a political influence in the United States. To serve our growing linguistically diverse young population ethically, Speech Language Pathologists need more research evidence. Involving the family in clinical services is a step further to explore in clinical research and supports collaborative care between the family and clinician.
SLTP

Summing up the opposition case

Nurturing traditional family cultures and native language is supported by the available evidence on bilingual intervention for preschoolers from a linguistically diverse background even when they have language impairment. The concept of language is independent of mono or bilingualism.
References Bhatia, T.K. & Ritchie, W.C. (2004) A Handbook of Bilingualism and Multiculturalism. Malden, MA: Blackwell Publishing. Cheuk, D.K., Wong, V. & Leung, G.M. (2003) Multilingual home environment and specific language impairment a case-control study in Chinese children, Paediatric and Perinatal Epidemiology, 19, pp.303-314. Cummins, J. (1979) Linguistic interdependence and the educational development of bilingual children, Review of Educational Research, 49, pp.222-251. Karniol, R. (1992) Stuttering out of bilingualism, First Language, 12, pp.255-283. Paradis, J., Crago, M., Genesee, F., & Rice, M. (2003) FrenchEnglish bilingual children with SLI: How do they compare with their monolingual peers?, Journal of Speech, Language, Hearing Research, 46, pp.113-127. Perozzi, J.A. & Sanchez, M.L. (1992) The effect of instruction in L1 on receptive acquisition of L2 for bilingual children with language delay, Language, Speech, and Hearing Services in Schools, 23, pp.348-352. Portes, A. & Hao, L. (1998)E Pluribus Unum: Bilingualism and loss of language in the second generation, Sociology of Education, 71, pp.269-294. Rice, M., Wexler, K. & Hershberger, S. (1998)Tense over time: The longitudinal course of tense acquisition in children with specific language impairment, Journal of Speech, Language, and Hearing Research, 41, pp.1412-1431. Riley, R.W. (1998) Statement by Secretary of Education Richard W. Riley on California Proposition 227. April 27. Washington, DC: U.S. Department of Education. Schiff-Myers, N.B. (1992) Considering arrested language development and language loss in the assessment of second language learners, Language, Speech, and Hearing Services in Schools, 23, pp.28-33. Wong Fillmore, L. (1991) When learning a second language means losing the first, Early Childhood Research Quarterly, 6, pp.323-346.

No greater difficulty

There is evidence that children with language impairment from multilingual homes have no greater difficulty than monolingual children with language impairment. Grammatical morphemes are the most difficult for children with language impairment (Rice et al., 1998). This characteristic feature was studied by Paradis et al. (2003) who sampled and compared 39 bilingual, monolingual French, and monolingual English children. They wanted to determine if both monolingual and bilingual children with language impairment exhibit similar difficulties on morphosytactic structures such as tense-marking. Across both groups there was a similar accuracy for tense morphemes based upon language samples from both age-matched monolingual and bilingual children with language impairment. POINT OF INFORMATION: Subject selection bias occurred because the child participants were all recruited or referred specifically for this study.

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reviews

reviews

SINGING AND SIGNING

Its Signing Time with MAKATON DVD Singing Hands, www.singinghands.co.uk 15.00

VOICE (I)

Exercises for Voice Therapy Alison Behrman & John Haskell (eds.) Plural Publishing ISBN 978-1-59756-231-7 51.00

Interactive experience

Having had an introduction to Singing Hands throughSomething Special(CBeebies), this DVD proved an enjoyable way to see more of their range and add new songs to my repertoire. Produced for anyone interested in signing with babies and children, with or without additional needs, it takes you through a typical Singing Hands session demonstrating 25 songs. These range from old favourites like Incy Wincy Spider to new, catchy songs that have already stuck in my head. You see babies, young children and parents signing and singing in a range of settings. Suzanne and Tracy (Singing Hands) make singing a fun, interactive experience, demonstrating the use of object and symbol props to embed a multisensory approach. An informative booklet explains the benefits, details key signs in each song and gives useful tips. Suitable for parents, early years settings and special needs groups, it is a favourite at home too with my 10 month and 4 year old. Alex Nancollis is a speech and language therapist with NHS Cumbria.

A welcome addition

SOCIAL COMMUNICATION
Social Skills Games for Children Deborah M. Plummer Jessica Kingsley ISBN 978-1-84310-617-3 15.99

This highly practical book is clearly organised into 11 chapters covering different parameters of the voice production system, with a very useful accompanying CD. Although many techniques would be familiar to experienced voice therapists, most would find something of interest. Its good for dipping in and out of, and is particularly helpful for therapists new to voice, or for fresh inspiration. The exercises are graded from straightforward tasks, through to more difficult exercises, appropriate for the elite vocal performer. Whilst professing to be international, it is a minor disappointment that the 28 eminent authors are American/Australasian with no European contributors. The purpose of the book is to assist therapists in developing treatment plans for voice clients by sharing therapy ideas, and I believe it does just that. An excellent resource for the symptomatic treatment of voice disorders, and a welcome addition to any speech and language therapy service. Lynn Armstrong is a senior specialist speech and language therapist (voice) with Cheshire East Community Health, and is a former senior lecturer in voice and aphasia at Birmingham City University. The full version of this review is at www. speechmag.com/Members/Extras.

This text is value for money, easy to dip into and a comprehensive resource for any level of experience. Penny Anne ODonnell works in paediatric and adult voice and fluency. She provides speech and language therapy input for the Professional Voice Users Voice Clinic in Worcester, and consults in private practice in Warwickshire and the West Midlands.

ASPERGER SYNDROME (I)

Asperger Syndrome and Employment What People with Asperger Syndrome Really Really Want Sarah Hendrickx Jessica Kingsley ISBN 978-1-84310-677-7 13.99

True picture

Treasure trove

VOICE (II)

This practical and accessible resource is split into two parts, the first offering up-to-date, relevant theoretical information and practical suggestions for facilitating groups, and the second detailing 80+ games which target specific skills. The games clearly show information such as: the target age, the size of group needed, the time it takes to play and the specific skills being targeted. At the end of each game description are questions for reflection, and space for additional notes. The book provides ideas for working with older children, and how to encourage transference of skills. It is likely to become a staple resource for departments running social communication groups as it is a treasure trove of ideas. Sarah Eitel-Smith (nee Gielty) is a specialist speech and language therapist with Liverpool PCT, working primarily with children who have social communication difficulties, Autistic Spectrum Disorder or Aspergers Syndrome. The full version of this review is at www.speechmag.com/ Members/Extras.

Understanding and Treating Psychogenic Voice Disorder: A CBT Framework Peter Butcher, Annie Elias and Lesley Cavilli WileyBlackwell ISBN 978-0-470-06122-0 39.99

Comprehensive

This easy to read book gives a very good insight into Asperger Syndrome. It is specifically related to the working environment and investigates why unemployment is disproportionately high. The anecdotal examples are excellent and give a true picture of how varied people are. There is helpful advice for employers and employees, although many tell of working for many years without disclosing their Asperger Syndrome to their employer. The book talks about successes and when things can go wrong. Unfortunately, things that help employment to be successful are not available to all, and not all employers are aware of Asperger Syndrome or the available help. I will use this book to help put together tips for prospective employers who take our Year 11 students on work experience. I would recommend it to people who work with young people who will soon be out in the working world. It reminded me of many aspects of Asperger Syndrome that we dont see the effects of in the more safe and familiar school environment. Laura Richards is a speech and language therapist working at Baycroft School (a secondary special school with an autism provision) for Hampshire LEA.

Highly relevant for voice departments, this text analyses the issues concerned with the diagnosis and treatment of psychogenic voice disorders combining specialist speech and language therapy and Cognitive Behaviour Therapy. It addresses specialised roles, possible crossover, and potential development. Its style is accessible and it is widely referenced with an invaluable summary at the end of each chapter. The working model of psychogenic voice disorder is clear and concise, and discussion regarding the overlap between muscle tension dysphonia and psychogenic voice disorders thought-provoking. Ideas on extended case history taking and treatment of lowered mood and anxiety are most constructive.

ASPERGER SYNDROME (II)

Social Skills for Teenagers and Adults with Asperger Syndrome Nancy J. Patrick Jessica Kingsley ISBN 978-1-84310-876-4 12.99

New ideas

Aimed at people working with older students and adults with social skills difficulties, this interesting book is beneficial to newly qualified and more experienced therapists. I work with secondary and college age students and, while it has reassured me about my practice, I have also learnt new ideas.

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reviews

Sections cover social world, friends and family, health and medical, living arrangements, education, training and employment, plus adaptive strategies. I particularly like the way the author explains social skills consist of three basic elements: social intake, social processing and social output. She describes areas to assess and target and the social rules that should be explained to cope with everyday life. There are also many case stories. Sometimes I find it difficult to motivate myself to read anything related to work in my spare time but this was easy. You do have to extract the information, so it is not a resource you can quickly start using. However, it is very good value for money and I would highly recommend it. Joanna Davis is a speech and language therapist in London.

gives insight into the familys experience of getting to know and understand Kim and her autism, enabling them to see the world through her eyes, and the impact this had on their daily life. One can also see examples of the application of theory into practice such as communication approaches and sensory processing issues. I would recommend this book to any person working with people with autism and their families and carers. Kate Evans is a principal speech and language therapist and RCSLT advisor working in two inpatient units for adults with learning disabilities whose behaviours challenge services. This includes those with Autistic Spectrum Disorder and mental health issues.

ADULT NEUROLOGY

LANGUAGE AND READING

Neurogenic communication disorders: Life stories and the narrative self Barbara B. Shadden, Fran Hagstrom & Patricia R. Koski Plural Publishing ISBN 978-1-59756-136-5 46.00

Brain, Behaviour and Learning in Language and Reading Disorders Maria Mody & Elaine R. Silliman (eds.) The Guilford Press ISBN 978-1-59385-831-5 33.00

Big and beefy

Lack of practical advice

This book explores the theory and practice of developing narrative self and life stories in therapy. It focuses on four disorders: motor neurone disease, Parkinsons disease, stroke and dementia. The book is not easy to read or dip in and out of. It is not written for a specific professional group and contains a mixture of some in-depth psychological and sociological theory alongside information on the disorders, which some speech and language therapists may find basic. The clinical case studies and life stories are of most use and interest, and provide insights into living with the disorders. Disappointingly there is a lack of practical advice about converting theory into practice, and its place alongside conventional therapy. At 46, this is not an essential text for clinicians, but is well referenced and may be of use to students and anyone with an interest in psychology, sociology or social model theory. Natalie Yeaman is a speech and language therapist (Clinical Lead for Voice) with Somerset Community Health.

AUTISM

This big, beefy collection of extended essays and research papers by prominent academics, mainly American, is hard work to read, but there are useful snippets throughout. It is organised into three parts: new frameworks for understanding language impairment and reading disorders, brain-behaviour relationships and the role of experience; the old nature-nurture debates with a modern twist. Aimed at academics, students, psychologists, speech and language therapists and specialist teachers with particular interest in language impairment and reading disorders, it will be of particular use to academics and students who need an up-to-date review of research. Chapters are generally written by different authors with resultant differences in style and approach. There is some repetition of information, a high level of assumed specialist knowledge and a lack of practical activities. I was reminded of the complexity of human cognition and why I find language and reading disorders so fascinating. Leona Cook is a highly specialist speech and language therapist and qualified Dyslexia Teacher for NHS Medway.

In children. Original presentation and arrangement of information makes it very readable, albeit intellectually demanding. The rich source of contributing authors brings something extra, such as Joanne Gerensers chapter on Language Disorders in Children with Autism. This is enlightening and practically informative on the bases and contexts of specific language impairments on the autistic spectrum. Specific disorders examined are: specific language impairment, autism, genetic syndromes, dyslexia and hearing impairment. The sections (not as complicated as they sound) are Typology of Childhood Language Disorders; Language Contexts of Child Language Disorders; Deficits, Assessment and Intervention in Child Language; and Research methods in Child Language Disorders. This is a must for everyone involved with children who have a language disorder, clinicians, researchers, students or teachers. A comprehensive resource which has successfully brought state of the art, contemporary information together in one compact handbook. Briege McClean is an independent speech and language therapist in Omagh.

PARKINSONS DISEASE

Neurorehabilitation in Parkinsons Disease Marilyn Trail, Elizabeth J. Protas & Eugene C. Lai (eds.) Slack Inc. ISBN 9781556427718 35.50

Examines evidence

The Girl Who Spoke With Pictures Eileen Miller, illus. Kim Miller Jessica Kingsley ISBN 978-1-84310-889-4 16.99

CHILD LANGUAGE

Insight

Handbook of Child Language Disorders Richard G. Schwartz (ed.) Psychology Press ISBN 978-1-84169-433-7 50.00

This book is both easy and enjoyable to read. It describes how Kim, a young woman with autism, developed her ability to communicate her thoughts and emotions through her art, examples of which are used throughout the text. It

Exceptional

This handbook is exceptional! It creatively examines issues intrinsic to the nature, assessment and remediation of language disorders

Useful for therapists both new to and already working with people with Parkinsons Disease, this book gives an overview, good information on the variants within Parkisonism and detail on the pathophysiology of the disease. Further chapters consider cognitive and psychosocial effects as well as physical symptoms, and encourage the reader to consider the impact of being diagnosed. Other chapters cover occupational and physiotherapy input. The book is well referenced, and examines evidence in relation to surgical and pharmacological treatment, showing the limited pros and many cons of these interventions. Intervention, in relation to speech and language therapy, is based wholly on the Lee Silverman Voice Therapy approach; this appears to have the most evidence surrounding its effectiveness on both speech and swallowing difficulties. Whilst it is easy to become bogged down in the detail, and the majority of the information is based in the USA, the book is an excellent summary of current knowledge and research. Alyson Cartwright is head of speech and language therapy and Caroline Gale a highly specialist speech and language therapist with Burton Hospitals NHS Foundation Trust.

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reviews

Editors choice

BRAIN INJURY (I)

reviews

So many Journals, so little time! Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.
Most therapists have sampled a thickened drink or done a bit of voluntary stammering, but to give up the power of speech for a week to find out what it is like to be an AAC user takes empathy to a whole new level. While many of the communication aspects of An AAC Challenge were anticipated by Katrina Moore and Lucy Dobson, there is fascinating insight into the unexpected emotional toll, exhaustion, identification with the device and difficulties of transition back to speaking. (Communication Matters, 23(1), April 2009, pp.32-35) Have you tried to talk about questions, display question forms and ask questions all in the same therapy activity? Having seen a real-life example in Dariel Merrills article Staying on the same wavelength, I will hold my hands up! The nature of our work means when we are with a client we talk, we talk about talking, and we also introduce talk about something else so the client can practise new talking skills. Dariel recommends we bring our awareness to these different Layers to help ourselves and our clients be clear about what we are doing. (Clinical Linguistics & Phonetics, 23(1), January 2009, pp.70-91) Should television be a passive leisure activity to fill free time or a stimulating and socially motivating activity? Jade Cartwright and Kym Elliott argue that Promoting strategic television viewing in the context of progressive language impairment is an example of the kind of innovative ecologically based intervention technique we should be engaging with. I was impressed by the effort that went into the planning of the pilot project to remove bias and increase the validity of results, the aphasia-friendly modifications and the recognition of the differing support needs of participants. (Aphasiology, 23(2), 2009, pp.266-285)

The Behavioural and Emotional Complications of Traumatic Brain Injury Simon F. Crowe Taylor & Francis ISBN 978-1-84169-441-2 44.99

DYSLEXIA

Phonological Core Dyslexia in Secondary School Students: Identification and Intervention Julie V. Marinac Plural Publishing 978-1-59756-090-0 35.00

Not essential

This book is written as a resource principally for psychologists. It includes an excellent discussion of the definitions, classifications and neuropathology of traumatic brain injury. The book discusses personality change, affective disorder, abnormal illness behaviour and psychotic states, detailing the impact on an individuals everyday functioning. It does not address the emotional effects of communication breakdown and social isolation, topics which speech and language therapists would find pertinent to their work. A discussion of neurorehabilitation is also not included. This is an informative, well-written book but not an essential text as it fails to address the issues most relevant to speech and language therapists in the clinical setting. Jean Bebb is a specialist speech and language therapist with the Traumatic Brain Injury Service, Abertawe Bro Morgannwg University NHS Trust, Swansea.

A starting point

BRAIN INJURY (II)

Music Therapy& Traumatic Brain Injury A Light on a Dark Night Simon Gilbertson & David Aldridge Jessica Kingsley ISBN 9781843106654 19.99

As the title suggests this book discusses issues around presentation, identification and remediation of difficulties in secondary school students with phonological core dyslexia. It is written in a style that is easily accessible and interesting as some of the sections are presented as PowerPoint slides and others as bullet points or questions and answers. At the end of each chapter, there is a useful summary of the main points discussed. However, as Julie Marinac is Australian, a large part is spent discussing assessment and remediation tools that are not widely used in this country. There is also some overlap between chapters (especially 5 and 6). Overall, this book can be used as a starting point but requires readers to have a more indepth knowledge of the difficulties students present with to make a differential diagnosis and suggest relevant support strategies. Korina Tavridou is a speech and language therapist and SpLD (Specific Language and Learning Difficulties) teacher.

DYSPHAGIA

Too technical

I approached this with great anticipation, but struggled to read it and quickly lost interest. It deals with the role of music therapy in the rehabilitation of individuals with severe Traumatic Brain Injury, particularly those initially thought to be in vegetative or low awareness states. The introductory section offers nothing new to those already working in this field. The second section is a comprehensive review of literature on the use of music therapy in the neurorehab setting. Chapter 3 onwards deals with Therapeutic Narrative Analysis (an assessment method used by music therapists) and its application. The narrative style becomes gradually more abstract and at times difficult to follow, with pages of technical musical transcription. The wider multidisciplinary team, so necessary when working with this client group, does not figure in the narrative at all, and it appears that music therapy is done in isolation. Aimed at qualified musicians/music therapists who are unfamiliar with traumatic brain injury, this book is too technical to be useful to other disciplines. Not recommended. Nia Came is lead speech and language therapist (Brain & Spinal Injury ) with Cardiff & Vale NHS Trust.

Dysphagia following stroke Stephanie K. Daniels & Maggie-Lee Huckabee Plural Publishing ISBN 978-1-59756-196-9 57.00

Valuable and up-to-date

This small, densely packed book proposes a neuroanatomical model of swallowing and moves through bedside and instrumental assessment onto management, strategies and therapy. The well-respected authors have peppered the book with critically appraised current research that is relevant to anyone working in dysphagia. The style of writing and detail in places do not always make it an easy-to-use handbook - the chapter on neural control contains forty word plus sentences that required reading three times even before reaching for the neurology textbook! Despite this, it is a valuable up-to-date resource that improved my understanding and management of dysphagia. Jackie Davies is a senior specialist speech and language therapist and Lead Clinician for Acute Admissions at the University Hospital of Wales, Cardiff.

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SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

critical friends / in brief

Critical Friends pilot

Readers have suggested that Speech & Language Therapy in Practice should pilot a form of supportive peer review. Valerie Dean, Alyson Eggett, Sheila Robson and Claire Smallman are the Special Needs Speech and Language Therapy Team with South Tyneside Primary Care Trust. They offer a retrospective critical friends appraisal of Sitting on both sides of the fence by Kirstie Page (Winter 08, pp.10-12).
As a team, we were interested to read this article on collaboration as we are moving towards more class-based therapeutic intervention within our special schools. The article gave us greater insight into the world of teaching and education and the similarities and differences between their world and ours. It was balanced in its presentation of the priorities and approaches adopted by therapists and teachers, and encouraged us to think about the assumptions we make. In particular, it made us aware that we cannot take shared knowledge as given and the Ten steps to better practice working with teachers made us reconsider how we present information about childrens speech, language and communication needs and how we can relate our recommendations to group-based activities and the curriculum. Several members of our team have just returned from the Royal College of Speech & Language Therapists Scientific Conference in London and felt this article was interesting in light of some of the findings presented by Victoria Joffe relating to her work with teaching assistants. She talked enthusiastically about how to work more collaboratively with this important group of staff and the implications for our profession in terms of our changing role and methods of service delivery. One of the challenges we face is the changing nature of the NHS. Whilst recognising the need to think about assessing a childs communicative environment and the barriers to effective communication, building mutually respectful relationships with teaching staff and working with them to modify the environment and the curriculum, we are under increasing pressure to improve activity levels and provide outcome measures. We feel that we need to think carefully about how we measure success and provide evidence of the effectiveness of class-based interventions. Perhaps this is something we can learn from teachers? Are there tools used within educational settings that we can apply to our work? It is worth remembering, however, that we are expected to work collaboratively, not just with teachers, but with other medical professionals, social care workers and parents/carers, all of whom have different priorities again. Although teachers also have this expectation on them, we felt that the article was limited in its consideration of the pressures facing therapists and the legal framework in which we work. For a more complete picture, we would welcome some top tips on what we can do to encourage teachers to see things from our point of view and to accommodate some of our priorities into their world too. Readers could then use this article alongside the top tips to share this helpful insight into our interlinked worlds with teachers and other educational professionals. Generally, we found this a very thought-provoking article. Our only criticism is in relation to the editing, as Kirsties work as a consultant for StoryPhones was included in the body of the article rather than presented separately alongside it. Whilst acknowledging that she is developing this approach to marry together work on listening, language and literacy, we felt that it did not fit with the rest of the article in which the focus was on team working and professional collaboration. Alternatively, perhaps a follow-up article focusing on shared approaches and resources would have been a more appropriate introduction to her work? If you or your team would like to comment on the impact an article has had on you, please contact editor Avril Nicoll for more information, e-mail avrilnicoll@speechmag.com, or see www.speechmag.com/About/Friends.

In Brief
`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.
Gillian Hayes is a speech and language therapist at the Centre dAudio Phonologie in Luxembourg. Working single-handedly, and with only 20 minutes allocated to screen each child, she has had to develop simple and efficient methods of informal assessment and parent-and-child group therapy. She offers these tips to readers: Articulation How to sort out lateralised articulation of / ,t , d/: ask the client to say the word <tie> slowly, then with lip rounding, then faster. The resultant approximation to /t / is very workable and tends to spontaneously become /t / before long. Language If a child says one word, repeat it back using two. If he says two words together, repeat them back using three. This can often be the only bit of advice parents remember but, by following it, they manage to do quite a lot of the suggestions in Hanen (www.hanen.org) automatically: slowing down, repeating, reducing, talking about childs interest, no pressure of questions. Useful resources Colourful bag to pull toys out of Mr Potato Head (www.mrpotatohead.com) Early Learning Centre post box (www.elc.co.uk) Black Sheep Press picture sheets (www.blacksheeppress. co.uk) My own Teddy stories for symbolic play
In Brief is supported by

SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

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HOW I PUT LEARNING INTO PRACTICE (2)

How I put learning into practice (2):

Empower point
Leoni, D. (2009) How I put learning into practice (1): View from a Welsh mountain, Speech & Language Therapy in Practice Spring, pp.26-27. In our first article about putting learning into practice, Dawn Leoni reflected on what immersion in Welsh has taught her about the experience of adults with communication difficulties and how we can best support their rehabilitation. Our second article focuses on a specific therapy approach.

Lesley Munro, Laorag Hunter, Lesley Smith and Vicky Johnson discover that highly structured impairment based aphasia therapy which exploits the features of dynamic PowerPoint presentations can be efficient, effective and enjoyable.

Vicky Johnson

n January 2008, Lesley Munro, a third year student from Birmingham City University, joined our team for her clinical placement. The placement was four days per week until May. This was the second year we had accommodated a Birmingham student on this long block. From our previous experience we were optimistic that the main stakeholders student, therapists and clients - could all gain benefits during these five months. Four things came together in the first few weeks of January that triggered a piece of work which contributed to the satisfying outcomes we had hoped for: 1. Our student induction period included a review of key theories and recommendations around aphasia management. This was useful revision for both therapists and student, and principles of good practice were in the front of our minds. 2. The student was required to complete an N of 1 experimental single case study for her degree. Objective evaluation of therapy outcomes was a motivating pressure. 3. Douglas, a new client with aphasia, was admitted to our rehabilitation centre. Our early therapy methods were not successful and we felt the need to do something different. 4. The therapists had new skills and ideas in using dynamic PowerPoint (Microsoft Office, 2003) as a therapy tool, learned from our colleagues in electronic assistive technology, learning difficulties and paediatrics who we meet through the Tayside AAC clinical network. We wanted to use and teach these skills.

L-R Lesley Smith, Douglas, Laorag Hunter cular accident and the onset of his aphasia. His speech was fluent but severely lacking in content. Douglass output consisted mainly of social greetings and phrases used repetitively, such as Im forgetting and Im confused. He had severe difficulty retrieving words both in conversation and naming, a pattern typical of anomia (Goodglass & Wingfield, 1997, cited by Nickels, 2002a). Douglas was emotional, withdrawn from interactions with other clients and constantly sought reassurance that he would get better. He became distressed and despondent at any difficulties or failures in therapy. With reference to a single word model of word production (Nickels, 2000) we identified a central semantic deficit and a severe difficulty accessing spoken or written noun forms along with good ability to produce nouns. As an example, Douglas was unable to name a picture of socks and could not draw socks if he was given only the spoken or written word. However, given a picture of socks to copy he could make a recognisable drawing. He could also sometimes read the written word socks aloud and could always repeat the word clearly if the therapist said it. The assessments and observations leading to this description of Douglass underlying processing strengths and weaknesses are summarised below: Score below chance on Pyramids and Palm Trees 3 picture version (Howard & Patterson, 1992) Inability to draw common objects No use of gesture in structured tasks or real situations Inability to name any common objects in informal assessment Single word reading aloud was impaired but

Lesley Munro better than naming READ THIS IF YOU Good ability to repeat ARE INTERESTED object names IN GETTING THE Inability to write MOST OUT OF names of common STUDENT objects PLACEMENTS PALPA 47 Spoken COMPUTER Word to Picture TECHNOLOGY Matching (Kay et al., IMPAIRMENT1992) score 28/40. BASED THERAPY Nickels (2002a) suggests that tasks which combine semantic and phonological activation may hold more promise for naming disorders than separating therapy (somewhat artificially) into semantic or phonological tasks. Target words are more likely to reach their activation threshold if combined semantic, phonological and orthographic information is provided. Dynamic PowerPoint is ideally suited to presenting progressive, multi-component cues. We designed slides with a photograph of an object (such as a bed, microwave, money) with hidden semantic, orthographic and phonological cues revealed on each mouse click in a step-by-step method. The photograph, which engages semantic processing, is presented first. Next, a semantic cue in the form of a written statement of the objects function is provided and read by the therapist, followed by the written word. Finally a recording of the target word is heard. The addition of the student to our staffing levels helped us to make the therapy tool. With a little practice we all got faster at making slides. Sample slides and instructions are available at www.speechmag.com/Members/Extras.

Douglas

Douglas is a 54 year old man who sustained a left middle cerebral artery infarct resulting in right hemiparesis, aphasia and dysphagia. It was three months since Douglass cerebrovas-

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SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

HOW I PUT LEARNING INTO PRACTICE (2)

Figure 2 Timelines for therapy

Errorless learning

Errorless learning principles aim to reduce or eliminate errors (Fillingham et al., 2005). Errorful approaches, where mistakes are part of therapy, may strengthen inaccurate associations and the likelihood of repeating an error. Furthermore, clients report a preference for errorless therapy methods (Fillingham et al., 2005). Douglas was supported to progress through the cues and to attempt naming once he was confident of success. This reduced the chance of errors. As Douglas had good repetition skills we knew that he would name the object from the final cue if earlier cues were not effective. Success was especially important for Douglas who responded with negativity to any failures and withdrew from challenging tasks. All cues were revealed to Douglas, even if he named the item early in the cue sequence in order to reinforce the item through multiple levels of processing. Nickels (2002b) highlights the benefits of practice. Once an item has been retrieved at a lexical level, its level of activation increases. Repeated practice further increases activation of the target and the likelihood that it will be triggered. McGrane & Armstrong (2008) in their investigation of new linguistic learning in aphasia also state that adequate time for repetition and consolidation of therapy stimuli is an essential component of therapy. The paperless nature of PowerPoint makes for slick presentation of each slide which helps to increase the number of items practised in each session. It is also easy to present different photographic representations of the same object.

This could encourage generalisation of lexical representations and also simply makes the task more interesting and relieves boredom. Having a student also increased the number of therapy sessions Douglas received. Each therapy set was practised three times a day for eight days (no treatment at weekends) with sessions lasting approximately 15 minutes. The therapy was mainly delivered by the student but there was no advantage of consistency of therapist and different staff also supported Douglas with the practice. The addition of assessment and no treatment phases meant the whole episode was completed in 32 days. The structure of the study and timeline for the stages are detailed in figures 1 and 2.

Reinforce capability

Our Community Health Partnership* has fully supported the acquisition of laptop and personal computers for therapeutic use, and donations to endowment funds have complemented these resources. We know that many of our clients engage much more readily with repetitive tasks presented by computer than on paper. In addition, computer delivered therapy has a professional and adult feel to it which can reinforce feelings of capability in patients. Communicating Quality (RCSLT, 2006) also proposes that computer tasks can lead to clients working independently with subsequent feelings of autonomy as dependency on therapists is reduced. Douglas showed no interest in manipulating the computer mouse. To avoid any feelings of pressure the therapist made mouse clicks to reveal the cues, with Douglas indicating when he wanted the next cue revealed. Despite the highly structured nature of the task, delivery of therapy was relaxed and had an informal feel to it. Douglas enjoyed commenting on the objects and some conversation around the images evolved naturally. This aspect of the

treatment was clearly enjoyable to Douglas. Therapists most frequently report time constraints as a barrier to outcome measurement (Webster, 2007) and yet speech and language therapy guidelines state outcomes of therapy should be routinely measured (RCSLT, 2005, p.18). The addition of student time made us more able to design a treatment method which could be measured objectively. We hypothesised that Douglass ability to name a self-selected set of ten nouns would improve through practice with the multicomponent treatment method delivered by PowerPoint. Due to the severity of Douglass anomia we used a small number of object names (10). The items were selected by Douglas choosing Colour Library cards (Franklin et al., 1992) that he felt would be useful, such as drink, toilet, razor. We used four photographic representations of each object. This had multiple advantages. There were sufficient items to make practice interesting, different photographs might facilitate generalisation of naming, and the larger number enabled us to collect data which could be objectively measured. Furthermore, in assessment phases Douglas had four opportunities to name an item. Variability is typical in aphasia and our baseline with four opportunities to name each object could show improvements in a severe client more sensitively than assessment which only allows one naming attempt. Douglas was assessed on a control task, written picture naming, which we did not expect to change as a result of the treatment. Baseline naming of the full set of 40 object photographs was collected over four sessions in two days. Each set of ten photographs contained one photo of each object. Baseline scores were then used to split the ten target words into two treatment sets of equal level of difficulty. Each treatment set had four different photographs of each target object, giving a total of 20 slides in each set. That is, Douglas practised five object names four times in each session. The slides were randomly organised. Each slide show was put on a continuous loop so that each practice session started with a different slide. Douglas practised the current set with a therapist three times a day for eight days in total, and there was no practice at weekends. At the end of the treatment for set one, the baseline naming assessment was repeated for

* Community Health Partnerships in Scotland are tasked with delivering local population health improvement through increased joint working between primary care, specialist NHS services and social care.
SPEECH & LANGUAGE THERAPY IN PRACTICE summer 2009

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HOW I PUT LEARNING INTO PRACTICE (2)

all 40 items and crossover occurred with set two delivered in therapy. Baseline assessment of naming was again repeated at the end of this therapy. Raw scores from the repeated assessment are in figure 3 and presented graphically in figure 4. Douglass naming of practice items clearly improved following therapy. The improvement can be attributed to the therapy, as it occurred only after treatment of each set. The improvement in naming was maintained after the therapy had ended. There was no change in performance in the control task, suggesting that improvement was not the result of general progress associated with spontaneous recovery. During the study Douglas started to use vocabulary from the practice sets in real interactions, for example to request to use the toilet or to go to bed. This was an encouraging indicator that impairment focused therapy was improving Douglass ability to function in day-to-day life.

good effect. We have also found that clients with computers at home can easily access the method through PowerPoint Viewer. This can be freely downloaded and enables viewing, but not construction or modification, of PowerPoint presentations. We have developed further PowerPoint presentations for Douglas. These include vocabulary to support conversation about topics of interest to him. Douglass enthusiasm for this approach contributed to his decision to purchase a laptop on his discharge home. He has advanced to working independently, exploiting two different dynamic PowerPoint designs to improve his retrieval of verbs. In the newer presentations we have added the option of hearing as well as reading the semantic cue to facilitate independent practice. As therapists we felt we had worked efficiently and effectively. There was a sense of satisfaction that we had developed skills and produced resources that were transferable to other clients for both language

and cognitive rehabilitation. For Douglas, noticing his use of practice words in real situations along with the steep rise in assessment scores engendered SLTP feelings of achievement and optimism. Lesley K. Munro is now a speech and language therapist at Delamere Forest School, Cheshire. Laorag Hunter and Lesley A. Smith are speech and language therapists at the Centre for Brain Injury Rehabilitation, Royal Victoria Hospital, Dundee. Vicky A. Johnson is a clinical engineer at the Assistive Technology Service, TORT Centre, Ninewells Hospital, Dundee. ACKNOWLEDGEMENT We would like to thank Douglas for his willingness to work intensively and try new things, and for his generosity in allowing us to share his story. REFLECTIONS DO I APPLY WHAT I HAVE READ IN THE LITERATURE TO MY PRACTICE? DO I LOOK FOR THERAPY METHODS WHICH FOSTER CLIENTS OPTIMISM AND HOPE? DO I ENSURE CLIENTS HAVE SUFFICIENT OPPORTUNITIES FOR PRACTICE, REPETITION AND CONSOLIDATION?

Highly engaged

Douglas was highly engaged in every session and did not show frustration or despondency. We invited him to give feedback on the value of each session using visual rating scales. Douglas consistently rated the sessions as useful and frequently indicated that he felt a sense of achievement. For Douglas, multi-component cues delivered via PowerPoint were an effective method of improving naming for a small set of items over the period of one month. The complex nature of aphasia research does not allow us to establish which specific aspect of the therapy caused the improvement. Changes in semantic representations, strengthening of mapping between semantics and phonological output representations and alteration of output representation thresholds are all possible. Reflection on the actual sessions identified that conversation about the objects naturally arose. This unplanned aspect may also have contributed to the outcome. A limitation of single case studies is that generalisation cannot be made to others (Edmundson & McIntosh, 1995). However, we have gone on to use this method and the same practice sets with other clients to

References Edmundson, A. & McIntosh, J. (1995) Cognitive neuropsychology and aphasia therapy: putting theory into practice, in Code, C. & Muller, D. Treatment of Aphasia: From Theory to Practice. London: Whurr Publishers. Fillingham, J., Sage, K. & Lambon Ralph, M. (2005) TreatDo you wish to comment on the impact ment of anomia using errorless versus errorful learning: this article has had on you? Please see the are frontal executive skills and feedback important?, information about Speech & Language International Journal of Language & Communication Therapy in Practices Critical Friends at Disorders 40 (4), pp.505-523. www.speechmag.com/About/Friends. Franklin, I., McCallister, C, & Whitton, J. (1992) Colour Library Cards. Oxford: Winslow. Howard, D. and Patterson, K. (1992) The Pyramids and Palm Trees Test. Bury St Edmunds: Thames Valley Test Company. Kay, J., Coltheart, M. & Lesser, R. (1992) Psycholinguistic Assessments of Language Processing in Aphasia. Hove: Psychology Press. McGrane, H. & Armstrong, L. (2008) The Maytor, the Shorpine and the Traigol, Speech and Language Therapy in Practice, Summer, pp.8-10. Nickels, L.A. (2000) A sketch of the cognitive processes involved in the comprehension and production of single words. Retrieved on 05/12/08 from http://www.maccs.mq.edu.au/~lyndsey/model.doc. Nickels, L. (2002a) Therapy for naming disorders: Revisiting, revising, and reviewing, Aphasiology 16(10/11), pp.935-979. Nickels, L. (2002b)Improving word finding: Practice makes (closer to) perfect?, Aphasiology 16(10/11), pp.10471060. Pring, T. (2005) Research Methods in Communication Disorders. London: Whurr Publishers. Royal College of Speech & Language Therapists (2005) Clinical Guidelines. Milton Keynes: Speechmark Publishing Ltd. Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Webster, D. (2007) Measuring Up, Speech and Language Therapy in Practice Winter, pp.8-9. Resources PowerPoint software is a brand product of the Microsoft Corporation, www.microsoft.com/powerpoint.

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Our Top Resources

Success in a block placement is not just down to theoretical knowledge and clinical skills. Over the years of supervising students, Alison Taylor and Karen Shuttleworth have observed the extra elements that help students settle in and get the most out of their placement. Based on their experience they have put these top tips together with Julie Leavett and other colleagues in the speech and language therapy department at Cumbria Teaching Primary Care Trust.
5. Be prepared Its useful to come to placement with equipment in the shape of a box of tricks which is familiar and can be used as an all encompassing informal assessment and therapy resource. This neednt be expensive and can consist of everyday items which can be collected easily such as small soft toys, play food, a magazine, old photos, books - the list is endless! Include things which are enjoyable to use for both client and therapist. This will hopefully enhance the interaction and demonstrate to clients / parents that therapy tools need not be expensive or specialised. 7. Manage your time A good start to the placement is arriving on time. An apology is appreciated for any lateness and it is always useful to exchange telephone numbers for any unexpected circumstances. Allow adequate time between and during client sessions for such things as preparation and feedback. It can be useful to think of a session as a pie chart so you can allocate a proportion of the time for each activity, allowing for meeting and greeting and finishing off the session. 8. Show initiative At the initial meeting with the therapist show willing to take on responsibilities such as answering the telephone or making appointments in addition to clinical work. Peer placements enable students to negotiate responsibility and to work as part of a team. Make the most of opportunities to demonstrate initiative but keep a balance between this and accepting direction. 9. People first, clients second When meeting with families offer a relaxed and friendly but professional manner. See beyond the issue to build a comfortable working relationship, being aware and respectful of different cultural backgrounds. Dont worry about completing a full assessment or finding out all the information in the first five minutes of a session. Even in your practical exam, remember that the session is most importantly the clients therapy time. 10. Reflect Allow time for a final session to reflect on the positive aspects of the placement and areas for further improvement. Consider also practical tasks such as returning equipment, finding references for resources and information required for case studies / coursework. It is useful to have collected evidence to include in a portfolio even if it is not immediately required for placement coursework.

Alison

Karen

1. Do your research To get the most out of your placement it may be useful to have carried out some pre-placement research. This neednt be difficult but relates to finding out about the local area in terms of facilities and geography, and considering any features which may be apparent such as accent or social issues. A useful starting point could be the local council website which often has some of these details. 2. Make an impression First impressions count - perhaps they shouldnt, but they do! Weve all made judgements or formed opinions of people via telephone calls, e-mails and letters. Be aware of the importance of your initial contact with clinicians and think about what information is required from the conversation. Plan ahead just in case the clinician is not available and you need to leave a message on an answering machine or with one of their colleagues. Many people now take advantage of e-mail because it allows us to convey more information easily and quickly. Unfortunately it also has the potential to cause confusion and misinterpretation, for example if an e-mail which makes a request appears to have a demanding tone. So check tone as well as content before you send. 3. Be sensitive Placements often provide the clinician and student with scope to negotiate a way to fit the demands of the placement with the needs of the student. However, by the nature of the job, some placements allow less flexibility. The student needs to be sensitive to this as well as to other aspects of the placement such as dress code. (Bare midriffs and skimpy garments are not advisable in any circumstances.) It is also important to learn and understand the role of other professionals in a positive and friendly way. We have noticed that these sorts of skills turn an average student into a good student. 4. Tune into the client group Think about the placement profile. If young children are to be seen, consider their interests. What will motivate and connect with them? Why not watch some TV programmes, get a couple of comics or visit toy shops such as the Early Learning Centre to find out current popular characters / games / toys and the way children engage with them? For adults, read the local papers and watch local news so you have a conversation starting point. Clients may relate better to the student who has demonstrated a real interest in them and their locality.

6. Be open Therapists want students to succeed. Start by discussing your previous experience with the therapist and jointly setting targets for this placement. Make your goals realistic and achievable within the setting / client group. Communicate clearly with the therapist or placement coordinator about your achievements and clinical improvements. There may be more practical issues which are affecting the placement such as long travelling distances, access to resources or health / personal issues, and it is important that your therapist is aware of these. Accept praise and constructive criticism and use this to develop your skills further. Also remember that all therapists and students love sharing ideas, so the placement provides an ideal opportunity for exchange of information between therapist and student regarding new resources.