Speech & Language Therapy in Practice, Winter 2006

ISSN 1368-2105
Winter 2006
www.speechmag.com
SOLUTION FOCUSED
How I use multi-media tools The long and short of interactive whiteboards Software that helps compensate Research A can do attitude And featuring A speech and language therapy Utopia
Some hae meat:

An aphasia-friendly menu
A special education Training for teaching staff Volunteer conversation partners Acute Connections
PLUSWinning Ways Winter growthHeres one I made earliermore great reader offersand My Top Resources for early group work
Reader oers Win the Phoneme Factory Phonology Screener

Speech & Language Therapy in Practice has teamed up with assessment specialists nferNelson to offer the new Phoneme Factory Phonology Screener - a digital screening tool that helps detect phonological difficulties in children from 47 years. Developed in partnership with the Speech and Language Therapy Research Unit at Bristol, the Screener prompts a child to say a target word in relation to a given picture. It analyses initial and final sounds, consonant clusters and number of syllables, then provides a report detailing the childs phonological development stage and recommending appropriate action. And thats not all! nferNelson will also include a FREE copy of the companion Phoneme Factory Sound Sorter CD-ROM, to help you address the problems identified by the Screener. To enter, simply send your name, job title and contact details to danielle.morgan@granadamedia.com by 25th January. The winner will be notified by 1st February 2007. The Phoneme Factory Phonology Screener costs 85 for the initial annual licence. The Phoneme Factory Sound Sorter has a range of pricing options, starting from 64 for a single user licence. For further details, visit www. nfer-nelson.co.uk/phoneme.
We had a great offer for React2 software in our Autumn 06 issue, and the lucky winner is Ashleigh Denman. We also had a copy of Taskmasters Collaborating for Communication, which went to Karen Powell, while Plural Publishings Singing and Teaching Singing was won by Louise Tweedie. Congratulations to you all and keep those entries coming!
WIN Photosymbols 2!
Photosymbols are photographs on a CD / DVD that you can use to make easy-to-read information. Designed to be used like symbols, they feature positive images of disabled people, everyday items, and things that help us make sense of information. Photosymbols Ltd were so pleased with the response to our reader offer for the original product that they are giving you all another chance to win version 2! This includes over 800 new photographs of a more diverse range of people, and it can now be installed onto your hard drive for easy access. Photosymbols 2 normally costs from 470.00, but you can win a single user pack FREE simply by e-mailing your name and address to pete@ photosymbols.com. Entries must be received by 25th January and the winner will be notified by 1st February 2007. Photosymbols Ltd was previously known as worth1000words. You can find more information about Photosymbols 2 on www.photosymbols.com.
Winter06speechmag
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REPRINTED ARTICLE VIEW FOR FREE!

Crocker, A. (2004) Personalised place mats, Speech & Language Therapy in Practice Winter, pp. 16-17. Online at www.speechmag.com/archives/angela crocker.pdf.
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WINTER 06 (publication date 27/11/06) ISSN 1368-2105
contentswinter06
4 COVER STORY SOME HAE MEAT
The picture menu became a vehicle for allowing James to make a choice but also reintroduced the social aspect of choosing. It motivated the staff to interact with him and to learn more about him as a person although he was unable to express himself verbally. Karen Rodger develops and pilots an aphasia-friendly alternative to a printed hospital menu.
Published by: Avril Nicoll, 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com
Cover photo of Theresa with speech and language therapist Karen Rodger by Paul Reid.
INSIDE COVER READER OFFERS, WINTER 06 SPEECHMAG

Win Photosymbols 2 and the Phoneme Factory Phonology Screener. See also special offer for Metaphon Games Boxes on p17.
18 REVIEWS
Computer use, Asperger syndrome, group work, student education, phonetics, ethics, communication, narrative, autistic spectrum disorder, language, transcription, speech difficulties.
20 WINNING WAYS WINTER GROWTH

While nature is generally a source of inspiration for me, I always dread the arrival of the winter seasonThis year, Im doing something differentThis winter is going to be honoured and enjoyed Life coach Jo Middlemiss offers a self-coaching strategy to help you G.R.O.W. this winter.
2 NEWS / COMMENT 7 CONNECTING IN THE ACUTE SETTING

Design & Production: Fiona Reid, Fiona Reid Design Straitbraes Farm, St. Cyrus, Montrose Angus DD10 0DS Imagine a world where conversation was denied to you not because you lacked the will, but because you lacked the opportunity. In response to the challenges imposed by the acute hospital environment, I decided to pilot the use of the techniques and principles of supported conversation. Barbara Hegarty, Leanne Matheson and Sally McVicker show that, even in the current NHS financial climate, it is possible to introduce a volunteer conversation partner scheme in an acute setting, with benefits for clients, volunteers and services.
22 HOW I USE MULTI-MEDIA TOOLS

Our contributors work makes it clear that speech and language therapists have a significant role to play in exploring and exploiting the potential of technology as a therapy tool. (1) INTERACTIVE WHITEBOARDS: THE LONG AND THE SHORT OF IT Leona Cook and Kerry Trim demonstrate how interactive whiteboard technology and the associated software together with strong collaboration, a focus on effectiveness, and excellent technical support - have helped secure the future of their language provision. (2) RESEARCH THAT HAD ITS COMPENSATIONS Hannah Kay researched the impact of Clicker 4 software on the expressive language skills of children with epilepsy and learning and communication needs. Her experience suggests such tools can help children compensate for their difficulties.
Printing: Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT Editor: Avril Nicoll, Speech and Language Therapist Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2006 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.
10 A SPECIAL EDUCATION
When therapists offer training to teachers, it is often perceived as an attempt to address the shortfall in speech and language therapy provision. However I was fortunate that the head recognised and promoted the understanding that training was being offered in spite of a shortfall in speech and language therapy provision, not because of it. How can you get commitment and involvement from teachers in special education to make joint working more effective and rewarding? Gillian Bolton and Susan Kidd offer practical suggestions.
28 CONFERENCE CALLS A CAN DO ATTITUDE TO RESEARCH

Joan Murphy, Lois Cameron and Mary Turnbull got across that speech and language therapists have the skills to do research, can be involved at different levels, and can even have fun doing it! Editor Avril Nicoll looks back on a recent conference organised by the Royal College of Speech & Language Therapists, and considers what practical steps we can all take to increase the professions evidence base.
14 FEATURE I BELIEVE IN MIRACLES

By all accounts, speech and language therapists, particularly in the NHS in England, are experiencing high levels of stress due to stringent budget cutsThe temptation to give in to despondency and despair and to react with anger or apathy is great. Editor Avril Nicoll asks therapists Kidge Burns, Sally Byng, Deborah Green, Kim Mears, Amanda Medhurst, Janet OKeefe, Jacki Pearce and Emily Williams what resources we have that will enable us to continue to practise in a way true to our vocation.
BACK COVER MY TOP RESOURCES

Carpet squaresare useful in helping the child to establish their own space and that of othersThe mats provide a controlled method of bringing children into a structured circle. They also help to reinforce sitting activities in contrast to moving around tasks. Karen Shuttleworth and Alison Taylor share their top resources for early group work.
17 HERES ONE I MADE EARLIER

Alison Roberts with more low-cost therapy activities: Map game / Rally navigator; Self-awareness beads; Body idioms.
IN FUTURE ISSUES: NURSING HOMES...STAMMERING...NASENDOSCOPY...APHASIA...BULLYING...SOCIAL COMMUNICATION...WRITING FOR PUBLICATION

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006
NEWS
Price increase
Speech & Language Therapy in Practice has gone up in price as, for several years now, costs have been increasing faster than turnover - and this situation is set to worsen following recent changes to postal charges. Publisher Avril Nicoll says, Feedback from readers is that the magazine is a top quality, highly regarded publication and, following a successful promotion supported by Speechmark Publishing, the last issue went to over 1900 subscribers, our highest ever. However, while the magazines strength is that it serves a very specific, niche market, the flip side is that this offers very limited opportunities for further expansion, or for income from advertising. This is only the second price increase in the 10 years since I took over the magazine, and the first one was purely to offset some of the cost of introducing colour. I hope I can count on the support of our loyal readers to ensure that the magazine and speechmag website can continue to offer the readable, up-to-date and practical information for which they are renowned.
In The Picture
Scope is running a three year campaign to promote the inclusion of disabled children in early years picture books. In the Pictures guiding principles include showing images of disability as the norm, in the same way as images of different ethnicities are now the norm, and portraying disabled children as equals, giving as well as receiving. Project manager Susan Clow would like to hear from any speech and language therapists who know of other images, including photos, which the campaign could use. She is also keen to find out how children with a communication impairment respond to seeing themselves represented in pictures and books and, in particular, if this has a positive impact on their self-esteem. To sign up to the campaign or to download lesson plans for use with children when they are drawing, see www.childreninthepicture.org.uk.
Right: London Bridge is falling down Childs Play International Ltd. See-Saw Nursery Songs. Illustrated by Annie Kubler. Reproduced by kind permission. Below: Dianne Lorriman
Travel scholarship deadline

Earlier this year, Aberdeen based speech and language therapist Karen Yuill headed off to Belfast on a travel scholarship to gather ideas for improving her service to people with aphasia. Karen has written an article based on her experience, which will feature in our Spring 07 issue (published end February). Meanwhile, readers in Scotland with five or more years of experience who want to apply for an NHS Scotland travel scholarship should note that the closing date is 1 February 2007. www.sehd.scot.nhs. uk/ahp/dev_support_ scheme.htm
Every Disabled Child Matters

Four leading organisations working with disabled children and their families are looking for 10,000 people to sign up to their Every Disabled Child Matters Campaign. Contact a Family, the Council for Disabled Children, Mencap and the Special Education Consortium want all disabled children and their families to have the right to the services and support they need to live ordinary lives. The campaign urges the government to ensure that every family who wants one is entitled to a key worker on diagnosis, and for all education and childcare professionals to receive training to ensure that they have the skills and competencies to meet the needs of disabled children. All Primary Care Trusts working with children would be required to have a comprehensive strategy to meet the health needs of disabled children and their families, and multi-agency adolescent services in every local area would ensure the transition to adult services is planned and delivered. The campaign is also urging all agencies to fully involve disabled children and their families in the planning, commissioning and delivery of services. To find out more and register your support for the Every Disabled Child Matters campaign, see www.edcm.org.uk.
Aphasia funding plea

Speakability has launched a fundraising drive to ensure it can continue its work for people with aphasia. With sufficient funds, it aims to increase its network of self-help groups, create a network of experts at living with aphasia, complete its Communication Passport work and improve its website and training materials. www.speakability.org.uk
Is two better than one?

Deafness Research UK is raising funds for a study to find out whether the NHS should fund children to have two cochlear implants rather than one. Two implants, although more invasive, could potentially improve a childs ability to locate the sources of sounds and to track their movements. In practical terms, this would enable them to know where to look to see the person who is talking, and to know where to move to avoid hazards outdoors. The research will use ring of sound equipment to track how sound location abilities develop in children with normal hearing, and compare this with children with two implants and children with one implant and a hearing aid. www.deafnessresearch.org.uk
Hospital Food Watch

A national survey of user views on hospital food paints a worrying picture of the timing and quality of meals and the support available to patients. Although no data is specific to people with dysphagia, a key finding of the Patient and Public Involvement Forum Food Watch survey of over 2,200 patients was that over a quarter were not receiving the help they needed to eat their meals, and this went up to almost a third in general hospitals. Lack of choice was also an issue, as was food being served at the wrong temperature. Forty per cent of those surveyed had their hospital meals supplemented by food brought in by visitors. Comments from patients included, Not enough time given or liquids, given two spoonfuls of food and then left; Get the impression you should eat as quickly as possible; Sometimes not enough staff for amount of patients who need help; I am nearly blind and cannot see the menu easily and do not receive help; Patients do not get to see a menu, it is read by the housekeeper. However, some positive comments were received such as, Plenty of time given to eat your meal. If you want to keep a sandwich for later the staff cover it up for you and Protected mealtimes seem to be working. A spokesperson said, Patients have every right to expect food that is nutritious, served at the appropriate temperature, meets their dietary needs and help to eat if they need it. Proper nutrition is essential to recovery both physically and psychologically. She continued, The findings do show that some Trusts can get it right or at least almost right. The Trusts that are getting it very badly wrong need to learn from those who are succeeding in meeting patients needs. www.cppih.org
NEWS AND COMMENT
OT works
A Cochrane systematic review has found that occupational therapy benefits people who have had a stroke. People with strokes who get help from an occupational therapist have higher levels of independence than those with strokes who do not see an occupational therapist. They are better at feeding themselves, dressing, bathing, using the toilet and moving around. The Review drew data from ten studies involving 1348 participants. It showed that occupational therapy significantly reduced the chance of a person having a poor outcome and that it significantly increased peoples ability to look after themselves. Legg, L.A., Drummond, A.E. & Langhorne, P. (2006) Occupational therapy for patients with problems in activities of daily living after stroke, Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003585. DOI: 10.1002 /14651858.CD003585.pub2.
comment
Solution Focused
There is no doubt that, for many of you, times are tough. Take the specialist therapist paid as a grade 5 because thats all the employer could afford. The member of staff arriving at work one week to be informed their post is no more as of the next. The department which won a Trust prize but weeks later had its budget slashed. The many newly qualified therapists who have yet to find a job. Caseloads in the hundreds. And a consultancy model that could work, but doesnt, because it is driven by resource rather than need. Yet, at the same time, we see phoenixes rising from the ashes, like Leona Cook and Kerry Trims Evergreen Centre (p.22) which until recently was in special measures. How are they managing to do that? Our Utopia feature (p.14) suggests it is by focusing on solutions, having a passion for their work and keeping clients at the centre. Karen Rodger (p.4) was driven to develop an aphasia-friendly menu, recognising that that one step would provide solutions to issues of choice, control, nutrition and social communication. Gillian Bolton and Susan Kidd (p.10) are passionate about finding the best way to share skills with teachers so that interaction with children throughout their education is at the optimum level. And Barbara Hegarty (p.7) worked to extend the opportunities offered by a volunteer communication partner scheme to her clients in an acute setting. One way of coping in cash-strapped times is through being especially creative with our resources and, like Alison Roberts (p.17), whose Heres one I made earlier never lets us down, Alison Taylor and Karen Shuttleworth (back page) have original suggestions that wont break the bank. This can do attitude is also developing in the professions approach to research (conference calls, p.28) At the same time, Hannah Kay (p.25) calls for more inclusion in research, and recognition of the value of the compensatory strategies offered by multi-media tools. When things are tough, a bit of encouragement can make all the difference to us retaining our focus and passion. Jo Middlemiss (p.20) spotted the unprecedented praise for the profession from Lord Ramsbotham, the former chief inspector of prisons, and I received this e-mail from a reader: I shall not be renewing my subscription as I have just left the profession and do not anticipate returning. I would like to thank you and your contributers, however, for producing such an excellent publication. This has been far and away the most helpful material available to me, and I would congratulate you on keeping the emphasis on what we should really be about when much of the organisation of the profession and the NHS seems to have lost sight of this. Keep up the good work. We will.
Funding crisis highlighted

The National Literacy Trust has highlighted the funding crisis in speech and language therapy early years services and called for greater investment. Liz Attenborough, manager of the Trusts Talk To Your Baby initiative, was speaking as presentations at a Working Together to Get Talking conference showed that speech and language services are key in a multi-agency approach. She said, Early years professionals are being encouraged to identify young children with communication difficulties. But in too many places there are long waiting lists for therapy, as health budget cuts are not in step with educational needs. This means too many vulnerable children are not getting the help they need at the start of their educational career. The Royal College of Speech and Language Therapists says that local NHS cutbacks are threatening vital speech and language therapy services and that, though the government predicts it will be over ten years until there are enough speech and language therapists to meet the needs of local communities, funding cuts at a local level mean that eight out of ten newly qualified therapists cannot find jobs. www.literacytrust.org.uk www.talktoyourbaby.org.uk www.rcslt.org
RCSLT honours
The Royal College of Speech & Language Therapists has recognised the work of the founder and first chair of the Association for Speech and Language Therapists in Independent Practice. Maria Farry received the RCSLT honour at a ceremony in Edinburgh attended by Scottish Health and Community Care Minister Andy Kerr. She commented, My two main motivations in starting ASLTIP were in order to form a group dedicated to the highest possible standards and for such a group to give advice and support to therapists who wished to work independently and who were prepared to sign up to the standards required of its members. She continued, When we launched in 1991 we had 20 people at our first AGM, including the wonderful Liz Clarke, the then Chairman of RCSLT. Since then we have come a long way and now have over 500 members. I was proud to accept the Honours of the Royal College for founding ASLTIP and I consider it a tribute to all those who have helped to make it the force for good it is today. Other RCSLT award recipients included Janet Scott of the Scottish Centre of Technology for the Communication Impaired and Sally Millar of the CALL Centre, Carole Pound, co-founder of the communication disability network Connect, Fiona Robinson, Shelagh Brumfitt, Bernadette Boyle, Kath Williamson, Ray Michie and Joy Stackhouse. www.rcslt.org www.helpwithtalking.com
Speaking and listening skills

I CAN has teamed up with a private sector education services provider to develop a speaking and listening tool for teachers. The childrens communication charity has worked with Serco on Targeting Talk. This initiative aims to enable teachers to assess pupils speaking and listening skills in key stages one and two with accuracy, to use classroom strategies to help children improve their skills and to share best practice through a virtual online learning environment. www.ican.org.uk
Avril Nicoll, Editor 33 Kinnear Square, Laurencekirk AB30 1UL tel/ansa/fax 01561 377415 e-mail avrilnicoll@speechmag.com
COVER STORY: CREATIVE SHORTS
Some hae meat and canna eat, and some wad eat that want it, but we hae meat and we can eat, and sae the Lord be thankit. (The Selkirk Grace) Concerned that people with aphasia in hospital miss out on choice-making, social contact and nutrition through not understanding the menu on offer, Karen Rodger secured funding to develop and pilot an aphasia-friendly alternative.
Karen Rodger and Theresa demonstrate the pictorial menu. Photo by Paul Reid.
ublications concerning nutritional standards in hospital and care settings (for example Scottish Office, 1993; 1996; ACHCEW, 1997) have all concluded that many people in care settings are undernourished for a variety of reasons, including lack of meal choice. The Clinical Resource and Audit Group (CRAG) audit on nutrition investigated the quality of nutritional care for elderly people (Walker & Higginson, 2000). By stimulating improvements in this area, the report aimed to impact on overall quality of life. One aspect under scrutiny involved the recording of patients food and drink preferences. The authors highlighted that people who had difficulties with communication had no single way of expressing their choices. This factor was something I had already observed during my work with in-patients with aphasia or cognitive impairment, and was the starting point for the development of a pictorial version of our hospital menu. It is interesting to note that advice issued recently by NHS Quality Improvement Scotland regarding nutrition in hospitals is still emphasising the need for recording of an individuals food preferences (QIS, 2006). In order to choose their meals, in-patients in our hospital select from a printed menu by reading a list of choices and ticking the relevant selection (see figure 1). People who are
Some hae meat

unable to read the menu because of literacy or visual problems can have the selections read to them by a member of staff. However, patients who have limited understanding of spoken or written English for example, those with moderate or severe aphasic or cognitive difficulties, or nonEnglish speakers - are unable to make a choice by either of these methods. Food for these patients is chosen by the nursing staff or ward clerk and may not be acceptable to the patient. This can result in poor oral intake and weight loss as well as low self-esteem and frustration.
Positive effect
I felt that, if these patients were provided with a nonlanguage based menu, they should be able to make a choice with assistance from staff and this should have a positive effect on not only their nutritional status but also their mental wellbeing. Picture and symbol based menus have been used in other settings, especially with people with learning difficulties, for example Vaughn & Horner (1995). However, published articles on picture or symbol menus with other patient groups are lacking. The aims of this project therefore were firstly to establish a means to enable communication-impaired people to choose their meals with some assistance, and secondly to evaluate its effectiveness.
Initial analysis of the three-week menu cycle showed that some items were repeated - for example, ice-cream appeared on 20 occasions over the three week cycle. When I listed each different item on the menu once, this made a total of 123 pictures to be included in a picture menu. Having obtained a small amount of funding from the hospitals League of Friends, I used this to have photographs of the menu items taken by Medical Illustration staff. With the help and co-operation of the hospital Catering Department, a sample of each item was delivered to the Medical Illustration department, where it was photographed. Some items on the menu (for example soup and sandwiches) were photographed once but a symbol was added to the picture to differentiate between flavours or fillings. When all items had been photographed I divided them into categories such as vegetables or breakfast items. These were set out two to a page with a colour-coded border to indicate category, to allow for easier location by the assisting staff member (page examples in figure 2). The whole A5-sized book was indexed and laminated. Because of the limited funding, only one copy of the menu was made. In addition to the picture menu book, I developed a profile of food likes and dislikes so that carers could give some insight into the types of food preferred and the pattern of eating which the individual favoured (see figure 3).
Figure 1 Printed menu
Figure 3 Relatives profile of patients food likes and dislikes (For use in conjunction with standard menu) 1. Breakfast What kind of breakfast cereal does your relative / friend like to eat? Do they take a roll or bread? Do they like jam or marmalade? Would they choose fruit, a yoghurt, scrambled egg or bacon as well? 2. Lunch / Tea Does your relative /friend like soup or fruit juice? Are they a traditional type of eater, preferring mince and tatties etc., or do they like more adventurous types of foods such as curries or stir-fries? Do they eat meat or are they vegetarian? Do they prefer soup and pudding at lunchtime and their main meal at night? Do they like vegetables? Do they like sandwiches? What kind of pudding do they like? Do they like tea breads and cakes? Is there anything else you can think of that they might choose to eat?
Figure 2 Page examples
I carried out a single case study of the pictorial menu in the Stroke Rehabilitation Unit of Perth Royal Infirmary. The participant, James, was a single man aged 61 years, who had suffered a cerebrovascular accident (CVA) resulting in severe aphasia. Immediately following his CVA, James was very unwell with a collapsed lung and required care in the intensive care unit. As a result he had nasogastric feeding in situ. As his medical condition improved, assessment of swallowing revealed considerable difficulties and he required a texture-modified diet and thickened fluids, supplemented by the nasogastric feeding then subsequently percutaneous endoscopic gastrostomy feeding until four months after admission. After this time, nutrition needs were met by oral feeding alone. Both auditory and reading comprehension were inconsistent at single word level, and verbal expression and writing were non-functional at the time of this study. Despite a prolonged period of therapy, James had made limited progress in his language abilities and, although happy to attend for therapy sessions, refused to use any alternative means of communication. Because both he and the staff were familiar with the daily routine, this did not present too many difficulties in the ward, and James was usually able to express himself with varying intonations of single sounds (ah,ah,ah).
Not what he thought

Nursing staff were concerned about Jamess poor oral intake and weight loss. They explained that he preferred to select from the standard menu without their help but when the chosen item arrived at mealtime he refused to
Food is chosen by the nursing staff or ward clerk and may not be acceptable to the patient. This can result in poor oral intake and weight loss as well as low self-esteem and frustration.
eat it because it was not something that he liked. Further discussion revealed that due to Jamess auditory and reading comprehension difficulties, the items that he chose from the menu were not what he thought they were. I sought permission from James to use the picture menu and he agreed to take part in a small study. Consent was gained by demonstrating the picture menu to him and, because of his good situational understanding, James man-
aged to convey that he would like to try using it. Prior to using the picture menu, nursing staff recorded weekly weights and details of quantity of oral intake. I gave a short informal training session to selected staff members on how to use the menu and they were allowed time to familiarise themselves with the layout. Unfortunately, James had no family members who could complete the food likes / dislikes profile, therefore this could not be used as part of the study. The picture menu was then used with James for six weeks while nursing staff continued to record his weight and quantity of oral intake. A member of ward staff (usually the ward clerk) would take responsibility for completing the next days menu with James. Each meal was discussed, with the staff member reading the menu choices aloud while showing him the appropriate picture, then allowing him to point to the chosen picture item. Nursing staff reported that it took approximately three days for James to become familiarised with the pictures and that, after an initial period of use, he no longer needed the picture prompt but could identify menu items by the written and verbal stimuli alone. It is likely that staff also became more familiar with Jamess usual choices and were able to anticipate which items he wanted to order. Jamess overall quantity of oral intake improved (see table 1, p.6), though his weight fluctuated slightly. A subSPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006
sequent medical investigation into his weight loss was carried out as further larger fluctuations in weight occurred after the study concluded, despite much improved oral intake.
Table 1 Weight changes during period of picture menu use Date Weight 2nd May 67.6kg 9th May 67.6kg 11th May 67.8kg 24th May 67.8kg 1st June 66.9kg 6th June 66.9kg 14th June 66.0kg
Figure 5 Questionnaire for ward staff [Staff had 4 scaled options to tick for each question] a) Did you find the pictures clear and easy to identify? b) Did you find the pictures easy to select? c) Did you find the picture menu quick to use? d) Did you find the picture menu easy to explain to and use with patients? e) How did you find the quality of the picture menu package? f) How adequate was the training you received in using the menu? g) How useful overall did you find the picture menu? Figure 4 Visual analogue card
case study could be carried over to all patients whose ability to choose their own food is compromised. I am seeking further sources of funding to continue the work and hope that current interest in the need for aphasiafriendly information might mean that this is a starting point for further projects within the hospital. Karen Rodger is a speech and language therapist at Perth Royal Infirmary, tel. 01738 473714, e-mail karenrodger@nhs.net.
References
Association of Community Health Councils for England and Wales (1997) Hungry in Hospital? London: ACHCEW. Quality Improvement Scotland (2006) Food, Fluid and Nutritional Care in Hospitals National Overview. Available at: http://www.nhshealthquality.org/nhsqis/files/FFNCH_NOV_AUG06.pdf (Accessed: 21 September 2006). The Scottish Office (1993) The Scottish Diet Report of a Working Party to Chief Medical Officer in Scotland. Edinburgh: HMSO. The Scottish Office (1996) Eating for Health A Diet Action Plan for Scotland. http://www.scotland.gov.uk/library/ documents/diet-exe.htm (Accessed: 21 September 2006). Vaughn, B. & Horner, R.H. (1995) Effects of Concrete Versus Verbal Choice Systems on Problem Behaviour, Augmentative and Alternative Communication 11(2), pp. 89-92. Walker, J. & Higginson, C. (2000) The Nutrition of Elderly People and Nutritional Aspects of their Care in Long-Term Care Settings. Final Audit Report. Available at: http://www. show.scot.nhs.uk/crag/topics/nutrition/report.PDF (Accessed: 21 September 2006).
I also used a simple visual analogue smiley and sad face card with James to find out how useful he had found the picture menu (figure 4). He was able to indicate by pointing that he had found this helpful. Nursing staff who also used the picture menu were questioned on their opinions of it (figure 5). Although they found it helpful and easy to use, they also found it slow and time-consuming.
Control
The use of the picture menu with James allowed him to take some control over an activity which most of us take for granted as part of everyday life. Before using the pictures, his average intake was, at most, half a portion of food, and he frequently refused all of it. He demonstrated obvious frustration at mealtimes and his overall weight loss in the three-week period before using the menu was 11kg. During the study period, he consistently took three-quarters or all of his food and his overall weight loss slowed to 1.6kg. Nursing staff were also happier during and after the study period as they felt that they were giving James a genuine choice rather than choosing for him. They could see that he was less frustrated and obviously happier to eat the foods chosen. Because James had no family members who could complete the food preferences profile, no information about his likes and dislikes was available, so staff had no prior knowledge when choosing with him. Because of this they had to rely solely on the picture book, but this shows that it can be successfully used as a standalone tool. Standard menus are normally completed by the patient if they are able to do so. Those who physically cannot tick their choices or cannot read the menu are assisted by the staff, but are still able to express a choice themselves. When James was unable to do this at all, staff made the choice for him, so the choosing process and its subsequent social interaction were taken away. The picture menu became a vehicle for allowing James to make a choice but also reintroduced the social aspect of choosing. It motivated the staff to interact with him and to learn more about him as a person although he was unable to express himself verbally. Ideally the picture menu package should be available to all patients within the hospital who require it. Any changes to the hospital menu obviously mean the pictures have to be updated, and this has practical and cost implications. However it would be a valuable resource to have on each ward if the positive results of this single
Acknowledgements
With grateful thanks to the Departments of Medical Illustration and Catering especially Ian Bow, Catering Manager, and to the League of Friends of Perth Royal Infirmary for the original funding. Also to my speech and language therapy colleagues, especially Linda Armstrong, to James and the other patients and nursing staff in the Stroke Rehabilitation Unit who took part in this study, and to Theresa for the photograph. SLTP
news extra
Educational psychology rethink
A review of educational psychology provision in England and Wales commissioned by the government has recommended a fundamental rethink of the way services are delivered. The researchers analysed data from over 1,000 respondents including teachers, local authority officers, parents, pupils, mental health professionals and youth offending teams. While 88% of parents rated the contribution made by the educational psychologist who assessed their child to be helpful or very helpful, the overwhelming view was that heavy involvement of educational psychologists in statutory assessment of children with special educational needs has not been a good use of their time. Professor Peter Farrell, who led the project, said the reviews key recommendations include the need for educational psychologists to clarify whether an alternative provider might be available to carry out some of their work with the same impact. He added We also thought educational psychologists should take advantage of the reduction in statutory work to expand and develop their activities in different areas where their skills and knowledge can be used to greater effect. The researchers suggest that educational and clinical psychologists who work with children should develop closer working relationships, and begin discussions about a possible future merger of the two professions. The report (RR92) is 4.95, tel. 0845 602 2260
Standards consultation
The Health Professions Council has launched a three month consultation about revisions to its Standards of Proficiency, which play a central role in how someone becomes and remains registered. Speech and language therapy Alternate Council member Jacki Pearce was involved in the group that led the revision process for the 2003 document. Suggested changes include clarification of legal issues, confidentiality, informed consent and scope of practice. The consultation will run until Friday 12 January, 2007. To participate, visit www.hpc-uk.org.
Communication aid stories

Scope is looking for personal stories from people trying to access communication equipment. In particular, the organisation is seeking volunteers who would be willing to talk to the media about their problems getting communication aids. Contact Abigail Lock on 020 7619 7253 or email abigail.lock@scope.org.uk
ENVIRONMENT
Connecting in the acute setting

Part 1: The therapists story
Little did Barbara Hegarty know when she became a volunteer conversation partner with the communication disabilities network Connect that the experience would inspire her to become an agent for change for people with aphasia in an acute environment.
phasia is a life altering condition that can strike suddenly, leaving the person with aphasia confused, depressed and unable to express their fears and sense of loss. Kagan (1995) observed that the skills and competencies of the person with aphasia were often hidden by their communication difficulties. These observations led Kagan to develop a supported conversation approach to aphasia therapy. Kagan advocated the concept and use of communication ramps and suggested that the environment be adapted to meet the needs of the person with aphasia. These environmental adaptations included the training of skilled communication partners and the development of conversation resources to allow the person with aphasia to contribute to daily decision making and improve their psychosocial well being and the quality of their lives.
REPRODUCED BY KIND PERMISSION OF CONNECT
READ THIS IF YOU WANT TO UNCOVER THE SKILLS AND COMPETENCIES OF CLIENTS INCREASE CLIENTS COMMUNICATION OPPORTUNITIES HARNESS THE COMMITMENT OF VOLUNTEERS
On commencing work as a speech and language therapist in the acute stroke unit of a large inner city teaching hospital, I was struck by the constraints of the environment on the communication opportunities for people with aphasia. Imagine a world where conversation was denied to you - not because you lacked the will, but because you lacked the opportunity. In response to the challenges imposed by the acute hospital environment, I decided to pilot the use of the techniques and principles of supported conversation. The results illustrate the rich possibilities to clients of this type of approach at an early stage in their treatment. Most importantly, our experience shows that it can be done in spite of staff shortages and the current NHS financial climate, and that there are benefits to both clients and speech and language therapy services.
This pilot project was inspired primarily by my experience as a volunteer conversation partner on an outreach project with Connect the communication disabilities network. In 2002, Sally McVicker from Connect had introduced the idea of volunteers visiting people with aphasia in their own homes, with the aim of using conversation to increase their confidence and participation in social activities. At that time I was a newly qualified speech and language therapist looking for practical experience working with adults before deciding which direction to take in my new career. The other volunteers came from diverse backgrounds and were asked to commit to a six month period of weekly visits to the home of their conversation partner. We attended six hours of training at Connect that included information on disability equality, health and safety and aphasia. The training also covered the skills and personal attributes that are helpful when communicating with a person with aphasia such as reflecting back behaviours and information to check you are both on the same lines, having props to hand to help out and being natural in your conversation at all times. Following the training, we were introduced to our conversation partner by the community speech and language therapist. Boundaries were discussed and agreed, and then we began our journey into the world of supported conversation together.
ENVIRONMENT
Table 1 Features of conversation partner scheme across settings Connect - Community Model Differences Home based Mainly 1-2 years post-onset Medically stable No formal therapy Potential participation in functional activities Potential to access community and social activities Similarities Isolation due to physical and / or communication impairment Depression and low mood Reduced confidence and sense of self Feeling of loss of control over ones life Training Six hours of training Contract signed with agreement to visit the client at a set time weekly for an hour for a 6 month period Training covered disability equality, health and safety and general conversation skills Paired with a local speech and language therapist and a person with dysphasia Initial introduction with speech and language therapist and client to set boundaries and set goals Written feedback forms and monthly meeting with project manager at Connect
Adaptations for Acute Service Delivery Acute ward based - mostly acute stroke unit Immediately post-onset Often acutely unwell Intensive multidisciplinary team involvement Severely reduced opportunities to participate in functional tasks Limited access to social activities
Isolation due to physical and / or communication impairment Depression and low mood Reduced confidence and sense of self Feeling of loss of control over ones life
Initial one hour meeting including video and discussion of total communication techniques Flexibility in session timing and length required to accommodate clients medical instability; aim was for a weekly visit Home study of the training pack, including overview of aphasia and conversation techniques Paired the volunteer with 3-4 clients Speech and language therapist modelled conversation with client in the acute ward setting and volunteer observed supported conversation techniques Diaries, email and text messaging used for feedback and support. Written feedback forms placed in folder in speech and language therapy department weekly.
A lot of laughter
According to Zeldin (1998), Dostoyevsky claimed that it doesnt matter what people say, only how they laugh. My experience of being a conversation partner did indeed involve a lot of laughter and reminded me that conversation is much more than just sending and receiving information. Real conversation brings people and ideas together and can change the way we see the world. However, a conversation for a person with aphasia in the period immediately following a stroke can be a very demanding and frightening experience. I was interested in exploring whether the positive communication experience of partnering a person with aphasia at home could be translated into the very different world of an acute hospital setting. So, I set about adapting the Connect conversation partner model into a pilot program that would accommodate the demands of an acute stroke unit. The similarities and differences between the home and acute hospital models and the adaptations we had to make to the training of our conversation partners are in table 1. Firstly, we needed to train appropriate volunteers. Being a large department in an inner city teaching hospital, we are frequently contacted by prospective speech and language therapy students seeking work experience. We are also fortunate in having access to a volunteers bureau which registers and police checks all our voluntary applicants. The conversation partners scheme seemed to provide us with an ideal opportunity to utilise the time and enthusiasm of our long list of volunteers whilst simultaneously providing experience for people interested in pursuing a career in speech and language therapy. Training our volunteers had to be time and cost-effective. We therefore decided to develop a training pack. The training pack included an overview of the aims of the scheme, a basic description of what is involved in a conversation and a copy of an evidence based study (Kagan et al., 2001) describing the benefits of supported conversation. The training pack also included a summary of the effects of stroke on communication, communication strategies and a short video modelling total communication techniques. A starter pack with an alphabet chart, a communication board, maps, paper and pencils and conversation topic suggestions were provided. In addition, we compiled an aphasia friendly letter to enable the person with aphasia to give informed consent for participation in the scheme; none turned the opportunity down. A feedback form allowed the volunteer to give written feedback on helpful resources and the successes and difficulties experienced in their conversation sessions. Following an introductory meeting and reading of the training pack, Leanne, our volunteer for the pilot project, accompanied me onto the acute stroke unit and observed a supported communication session with a person with aphasia. As our case load was extremely fluid, with rapid transfers and discharges, Leanne contacted me at the start of each week thereafter to arrange a list of clients and visiting times. Each week she conversed with one to three conversation partners for ten minutes to an hour. She worked independently and we communicated primarily via feedback forms, e-mail and text messaging. When Leanne asked Tom, one of her conversation partners, Has it been helpful? When I come and talk to you, do you think it helps?, he said: ....yes....because the people I know........youre different, youre friendly...... youre different, I know. Like yesterday, I got....... people just didnt like me .... and I didnt like them! I tell it all straight. I said, Look, I like people. Especially theres [pointing to conversation partner]. Youre /bek...r/ at talking to people. And thats what I love. I love that..... I hope to God that you.... that you still look after me... you or somebody like that. Only sometimes, speech..... wacky stuff! Six months later, and inspired by her experience, Leanne began work as a speech and language therapy assistant. The pilot conversation partner scheme had enabled eight people with aphasia to participate in real life conversations with an unfamiliar listener. This opportunity had given them the confidence to know they could make themselves understood, express their opinions and be themselves in the dark and early days post stroke. There was positive feedback from members of the multidisciplinary team regarding the participants improved self-esteem and confidence. Members of the multidisciplinary team also reported increased use of total communication techniques such as gesturing, writing and drawing in therapy sessions. Most importantly, I felt that our conversation partner scheme enabled our clients with aphasia to participate in real and meaningful conversations for at least a part of their hospital admission. Following the successful pilot we are hoping to extend the scheme into the community by developing a pool of local trained volunteers who can work between our service and the local community. Barbara Hegarty is a speech and language therapist at Charing Cross Hospital, Fulham Palace Road, London W6 8RF, tel. 0208 846 1761. Further information about the conversation partners scheme / Reaching Out project from Connect, tel. 020 7367 0840, www.ukconnect.org.
Acknowledgement
Thanks to the Friends of Charing Cross who have now provided full funding so this project can continue.
References
Kagan, A. (1995) Revealing the competence of aphasic adults through conversation: A challenge to health professionals, Topics in Stroke Rehabilitation 2, pp.15-28. Kagan, A., Black, S., Duchan, J., Simmons-Mackie, N., & Square, P. (2001) Training volunteers as conversation partners using supported conversation for adults with aphasia (SCA): A controlled trial, Journal of Speech, Language and Hearing Research 44, pp. 624-638. Zeldin, T. (1998) Conversation: How Talk Can Change Your Life. London: The Harvill Press.
ENVIRONMENT
Part 2: The volunteers perspective

Reflecting with Barbara Hegarty on her experience as the volunteer conversation partner for the Charing Cross pilot, Leanne Matheson finds that the real motivation for her is helping people to feel like themselves.
enerally speaking, everyone benefited in some way from the conversation partner scheme. The people with aphasia I was paired with seemed to enjoy having someone spending time with them who was not testing or assessing them in any way. Conversations were generally fairly lighthearted and relaxed. I think having someone who had time to try things out with them to let them practise things - made them more confident. And it gave them something to do, instead of perhaps being a bit bored and looking at the wall all day. I learnt a lot from both the clients and the speech and language therapists. The experience has also made me feel a lot more confident in my ability to communicate with people who have problems with their speech or understanding what is being said to them. And hopefully the speech and language therapists benefited too maybe it freed up a bit of time for them and at the same time also helped improve the communication of their clients. The training pack was good as preparation and gave me some idea of what to expect. The communication guidelines were helpful and gave me some useful tips such as keeping sentences short, using pictures and photographs, and writing down key words - but nothing really prepares you until you are there doing it for yourself. Every conversation I had was so different. Each person was also so different and each person was different on different days, even at different times in the day depending on when I saw them. The time I spent with each partner was unpredictable sometimes only a few minutes if they were unwell or tired was good to be introduced to them by the speech and language therapist and to have the chance to share in that first conversation, or sometimes just to observe and get the measure of the person. I remember for example meeting a man who had had a massive stroke that had left him with no speech other than some sounds. I felt a bit overwhelmed at first but after two or three sessions with the speech and language therapist I had enough confidence (and knew to take in a copy of The Guardian!) to talk to him on my own. We had our ups and downs but, when he transferred to a local nursing home, I continued seeing him once a week. It was over the Christmas period. He died three weeks after the transfer and I was so glad that he had had someone who knew him and that the staff at the nursing home had seen that he could have a good conversation and laugh and enjoy himself. I do wish I had been able to listen to a recording or watch myself on a video having a conversation with one of the partners earlier on. I really learned a lot about how I interact in conversation when I eventually heard myself. There were things I heard myself say that I could have made so much clearer or easier to understand. Listening to our conversation highlighted things I could have developed - and times when I wished I had stopped speaking. I would like to continue being a conversation partner because it makes me feel I can help people to feel like themselves, as shown in this excerpt from a transcript of a conversation I had with a man who was really missing being able to talk to his family, especially his granddaughter, following his stroke: T: Always be the.Always be me, always CP: Thats really what youre missing, isnt it? T: Yeah
or needing to see a doctor or nurse. At other times the session would last much longer, up to an hour or so. I would definitely say that, although its great having a plan for possible conversation topics and resources to support conversation, it doesnt always work out the way you think it will! I did find it easier if I could find a quiet corner as it was generally less busy off the ward and it was easier for my conversation partner to concentrate on the conversation if there was less going on to distract them. But not all of the people with aphasia I talked to were able to leave the ward, or indeed wanted to, and sometimes it was useful to have their things about them such as photographs and cards - as a stimulus or to help us out. I remember one lovely lady who was very distressed when I arrived for our session. The nurses had not been able to find out why. We talked and drew and she kept gesturing towards her handbag and drawing a house and scribbling odd numbers. We eventually communicated the problem successfully - that she was worried her rent was not being paid whilst she was in hospital. I was able to let the speech and language therapist know and she contacted the family and got it sorted out.
Levels of support
I always felt that I could ask anything of the speech and language therapist even really basic things and get good answers and explanations. I felt I needed different levels of support at different times. It was really useful having some background information about a new partner before I met them: what they liked / disliked, names of close family members, a brief medical history. And it
Reaching Out
Sally McVicker of the communication disability network Connect outlines the development of the conversation partner scheme and the subsequent Reaching Out project.
he Connect Conversation Partner Scheme began in 2001, based on inspiration from Jon Lyon, Aura Kagan, Nina Simmons-Mackie and the Life Participation Approach to Aphasia (LPAA) group. The idea of the scheme was to train, support and supervise volunteers to visit people with aphasia in their own homes for the purpose of having supported conversation. The scheme began in 2001 and ran from the Connect London Centre for four years. During this time over one hundred volunteers, including Barbara Hegarty, were trained and supported to visit over one hundred people with aphasia. Feedback from people with aphasia, referrers and volunteers (each followed up by questionnaire)
REFLECTIONS DO I ACTIVELY SEEK TO ADDRESS A CLIENTS AND MY OWN - NEED FOR LAUGHTER? DO I APPRECIATE THE POTENTIAL BENEFITS OF ENGAGING WITH VOLUNTEERS? DO I ENSURE CLIENTS HAVE OPPORTUNITIES TO LEARN AND THEN USE TOTAL COMMUNICATION TECHNIQUES?
Interest in the scheme grew, and in 2003 we launched the Reaching Out project which aimed to work in partnership with other organisations to enable them to deliver a conversation partner scheme in their area. The University of East Anglia was the first partner incorporating the scheme into first year practice. Partners have grown in number across the NHS and Universities within the UK and Eire and now include Bedfordshire Heartlands NHS Trust; Plymouth PCT; Exeter PCT; North Bristol NHS Trust; West Cornwall PCT; the University of Ireland, Galway; Trinity College, Dublin; Manchester Metropolitan University; and recently Canterbury Christ Church University. SLTP
was overwhelmingly positive: For people with aphasia, it gave them a chance to talk (90 per cent) and feel more confident (80 per cent). Service providers reported that the service offered a good extension and enhancement to current practice: No question that it does offer long term support and it helps to build confidence that we couldnt otherwise do. Volunteers seemed to learn from and enjoy (90 per cent) the visits: Expected more changes for my partner, but actually changed ME more than my conversation partner: a bit more understanding; just being there asking less.
TRAINING
How can you get the necessary commitment and involvement from teachers in special education to make joint working more effective and rewarding? Gillian Bolton reflects on the drivers for her APEC2 training package and, together with Susan Kidd, offers inspiration and practical suggestions.
READ THIS IF YOU WANT TO MAKE YOUR CHANGES SUSTAINABLE OFFER TRAINING THAT MAKES A DIFFERENCE GET COMMITMENT TO JOINT WORKING
Susan Kidd offers training
A special ed
W
hen I talk to therapists working in special education, a picture often emerges of large, complex caseloads and an annual review commitment which absorbs most - sometimes all - of their allocated sessions. I found myself in the same position when I took responsibility for speech and language therapy provision at Brooke Special School in 1996 and decided, after my first year with them, that it was time to make significant changes in service provision. I distributed a questionnaire inviting staff to give their views on the service. It provided a shared perspective on the problems, and justification for some radical changes. It also confirmed what I suspected about my review reports - they were detailed and comprehensive but not particularly useful to someone outside our profession. For a year I stopped writing reviews in order to get other projects up and running. Each new initiative was discussed and agreed at a termly meeting with the head, senior teachers, myself, the speech and language therapy assistant and the head of the speech and language therapy service, giving a sense of joint ownership to each project. One change was to dramatically increase staff training. When therapists offer training to teachers, it is often perceived as an attempt to address the shortfall in speech and language therapy provision. However I was fortunate that the head recognised and promoted the understanding that training was being offered in spite of a shortfall in speech and language therapy provision, not because of it. I had worked with Clare Latham and Ann Miles while they were developing a communication framework for The Redway School (1997; 2001). Brooke School agreed to adopt this framework and it became the foundation for communication environment assessments, staff training, lesson planning, staff / student interaction therapy sessions and so on. In future years my annual review reports were based on a framework and terminology staff now understood. There were challenges - as there are in any work environment - but I was able to feel my work was effective and that the changes I influenced might stay in place after I had moved on. I have since developed a package which is now being used by other speech and language therapists to train teachers, classroom assistants and speech and language therapy assistants. Assessing and Promoting Effective Communication (APEC), revised in 2004 (APEC2), has been very well received by speech and language therapists and participants. Some therapists are now looking at using it with staff working with children with special needs in mainstream education and with staff who work with adults with learning disabilities. I have designed APEC2 to be a comprehensive and user-friendly course. It includes a training video made with the support of the technician, Ann Miles (teacher), Rachel Key (speech and language therapist) and other staff and students of different ages at The Redway School. The package also includes a trainers manual, handouts, a written assessment and certificates.
Gillian Bolton
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Figure 1 Communication, Curriculum and Classroom Practice - The Assessment Framework Band One Developmental Language Stage Pre-level One Indicators QCA* Method of Communication For students who are pre-verbal i.e. those who are not yet using a formal means of communication (signs, symbols, words) including those who are: 0 to five months P1 P2 Pre-intentional: those students who are not communicating deliberately - they rely on us interpreting their needs from their facial expressions, their actions and the sounds they make such as crying or giggling Intentional: students who communicate purposefully (deliberately) For students who are beginning to use formal methods of communication, e.g. words, symbols and signs that they have learnt For students who have an increasing vocabulary and are linking words/signs/symbols into simple phrases or sentences For students with increasingly complex language skills
Five to nine months
P3
Two
Nine to 18 months
P4
Three
18 to 36 months
P5 P6 P7 P8
Four
Three to five years
*Qualifications and Curriculum Authoritys Pre-level One Indicators, DfEE, 1998
ducation
Clear framework
On completing the course, participants have a clear framework for assessing communication skills, and understand the approaches to teaching and intervention set out in Latham & Miles (2001). In addition they have developed or revised their knowledge of normal development of play and communication and communication breakdowns and difficulties, and further developed their skills in effective interaction with students. Participants have the opportunity to observe and assess students in each band (figure 1) and to differentiate their approach, teaching style, and classroom activities. I first met speech and language therapist Susan Kidd when I delivered a training day in Preston. She has now run the APEC course three times, training 32 staff in Peartree School, Kirkham. When we reflected on the process of implementation, four main themes emerged: 1. The unexpected learning outcomes for trainers 2. The role of staff training in promoting shared understanding and joint working 3. The advantages of extended training 4. Gaining commitment to training and joint working. 1. The unexpected learning outcomes for trainers My original questionnaire highlighted the erratic, hurried and irregular nature of discussions between myself and staff. In contrast, I have since found that weekly training sessions provide planned, focused and comprehensive discussion. An ongoing dialogue develops over ten weeks with information passing both ways. When I wrote APEC, I had a clear idea about what I wanted participants to learn, but had not anticipated how much I would learn. I learn about their previous training experiences, their perspective on their role, their professional challenges, and their level of understanding of communication development, breakdown, assessment and intervention. During training sessions, special education assistants frequently describe: Lack of involvement in assessments despite having useful and unique observations to contribute Varying levels of involvement in setting individual education plans. Some discuss and agree individual education plans, while others never see them. Lack of explanation of the purpose of activities they are given to carry out with students Feeling empowered by what they learn during training sessions. For example, one special education assistant realised that a students challenging behaviour at snack time had occurred when the class moved on to using symbols. The student was becoming distressed and sometimes throwing her drink. Recognising that the student was unable to understand and use symbols, the assistant suggested they allow her to continue indicating her preference by pointing to the bottles of juice - and the problem was solved. Teachers and special education assistants frequently describe: A wide variety in the type of in service training they have received with previous courses often not relevant to special needs.
The teaching style and approach suitable to a students level of ability was rarely discussed unless AAC equipment was being introduced or reviewed. During APEC courses, participants spontaneously and openly begin the process of critically evaluating their current approach and teaching style. Uncertainty over what level of language to use with different students. For example, one participant said, When all staff were able to get together to think of the language level of each pupil in the class it then helped us to plan all curriculum activities, as communication is the foundation of all we do. Classroom environments, language levels and curriculum based activities not addressing the needs of students at the earliest levels of development (Redway bands one and two). One participant commented that APEC has given me the confidence to follow my instincts, not just follow the curriculum blindly without thinking of the childs level of communication. Limited opportunities and lack of a suitable environment for child led, play based interaction. One school responded by developing unused rooms as playrooms and making more play materials accessible. Different assessments and record forms being used across the school, with subsequent difficulties sharing information when students change class. Staff then spend a long time getting to know their students, identifying their level of functioning and filling in record forms. Reservations about the appropriateness of play for older students. My opinion was that anxiety over age appropriateness was a problem for the onlooker not for the student, and should not prevent someone exploring and learning at their true developmental level. However, while filming the APEC2 training video I had many opportunities to observe sessions in which student led, play based interaction was achieved with older students using interesting, age appropriate materials. 2. The role of staff training in promoting shared understanding and joint working In APEC2, participants look at the advantages of The Redway framework. Communication, Curriculum and Classroom Practice (Latham & Miles, 2001) advocates a shared framework and underlying knowledge base, shared responsibility and integrated working: The development of communication is valued, not just as a vehicle for teaching the curriculum but as the core of the curriculum. For children with severe and profound learning difficulties this is crucial for their happiness and quality of life as well as their education. This framework facilitates joint assessment and planning involving teachers, speech and language therapists, assistants and parents, and encourages users to ensure students become active communicators, generalising skills across different contexts. It is appropriate right across the age and ability range in a special school, so completed assessments are passed on and continuity of approach from one class to the next is facilitated. It emphasises the teaching styles and interactive techniques that are most effective and highlights the importance of play and cognitive development and the link between these and language development. The Redway framework addresses communication skills, cognitive skills, and literacy skills and shows clearly how these are interrelated. Sample lesson plans and suggested activities are included.
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TRAINING
I have used APEC in three special schools and receive feedback via other therapists who use it. This has been overwhelmingly positive, even from staff who have worked in special education for many years. They say they welcome training which: a) is specifically relevant to children with special needs b) addresses the very wide range of ability within a special school. As one participant commented, Its great so good to receive something that reminds us that Special Ed is different not just trying to keep up with mainstream. Feedback also shows that teachers and assistants appreciate information on the normal development of play and language skills and the link between play, cognitive development and language. Teachers enjoy and benefit from the opportunity to revisit, reflect on and revise their professional knowledge and opinions. Special education assistants particularly welcome certificated training.
Time well spent

Speech and language therapist Susan Kidd writes: I have been working in schools for children with severe learning disabilities and profound and multiple learning disabilities for seven years with a great belief in the importance of training and joint working. However, over the years I have just been able to grab the odd slot on inset days or twilight sessions, and have always felt that these were not enough and devalued my role in the schools. As the APEC package is set over a ten-week period with weekly follow-up activities, the staff and management have to be committed to investing time and effort into learning more about communication. Of all the courses I have run, the feedback was the most positive and all participants felt their time was well spent. The APEC course is extremely easy to use and as a busy therapist this is essential. Each of the ten sessions is planned in detail and participants build up their own folder of over 60 handouts. The course guide is very clearly written and the sessions flow well with practical activities, videos, discussion topics and information giving. Each week a follow-up activity, linked with the topics covered, gives staff the chance to relate information to the children in their class. They also give weekly feedback to their class team about what they have learnt. Staff commented that taking time to observe their pupils communication, with a clear assessment structure, was invaluable as before they had felt it was not their role. The course provided sufficient time to allow them to do this confidently. Assessing the children in this way then informs their target writing as they have a clearer understanding of levels of communication. The main benefit for me as a school based therapist is that I now find joint working much easier as we all have a shared understanding of communication levels and the style of teaching we should adopt to bring the most out of our pupils. Staff now have a greater understanding of issues such as intentionality, language concepts, play skills and how we can assess and promote these in the classroom. 3. The advantages of extended training The APEC course is delivered through ten one-and-ahalf hour sessions over a term giving a total of 15 hours of training, with additional time spent on follow-up activities and feedback to class bases. In contrast, an inset day does not provide anywhere near this level of contact or continuity and does not guarantee carryover of information into classroom practice. Feedback has been consistently positive, for example, The homework activities
have really helped. Theyve made me really think about the children in my group and to carry out more observations during the weeks between classes. The homework activities have also made the work sink in a lot more. In each session participants discuss their follow-up activities, and this acknowledges and values their commitment and shows the course leader how well information has been understood and integrated into classroom practice. Discussion about individual students levels of ability and needs is actively encouraged. Course leaders bring sessions to life with their own examples and experience and can relate the course work to students and situations that participants know. Course leaders have found that: Through focused observation of students and better understanding of normal development, participants often re-evaluate a students level of ability. Initially staff were overestimating the language ability of some students with autistic spectrum disorder due to the length and clarity of their echolalic utterances, and underestimating the ability of preverbal students because of a lack of understanding of non verbal communication: (I have learnt that) non-verbal communication could be respected as a growing, developing skill too. Participants demonstrate and report increased confidence, increased awareness of students levels of comprehension, and better understanding of why their students have communication difficulties. Participants are keen to alter their approach/teaching style/language level and find the results very rewarding: It has made me more aware that each of the pupils in my class may be at a different band level and different teaching styles/approaches need to be used.
The course has really made me take a look not only at the children, but at myself. It has made me change my approach in certain areas (using more simple language, letting the children take the lead more, etc). Ive also found it useful to talk to others on the course and discuss similar situations. Jo Emery-King, a speech and language therapist in Bedfordshire, gave pre and post course questionnaires in addition to the course feedback form. Two points highlighted were: a) Before the course, participants focused on AAC devices and the use of formal signing when asked how they can help students who have difficulties with comprehension and expressive language. After the course they responded to the same question with comments about adapting their language level, the role of the communication environment, positioning / eye contact / eye level, slowing their rate of speech etc. b) When asked about their role, special education assistants made very general comments about helping and supporting students. After the course they identified themselves as having a role in the observation, recording and joint assessment of students communication skills. They described themselves as working jointly with other professionals and acknowledged the need to adapt their own approach and teaching style to meet the needs of each student they work with. 4. Gaining commitment to training and joint working Many therapists recognise training as a route towards shared understanding and better joint working but can find that schools are not keen to invest the time. Compromising on the length and content of training sessions may then seem a practical option but there are significant risks: Devaluing our role and the importance of communication. Omitting relevant information. Even as an experienced trainer I am still amazed to find that the concepts, terminology, and developmental norms which are familiar to speech and language therapists are frequently not understood by staff working in special school classrooms. Reducing the standard and efficacy of training provided.
Teachers and assistants appreciate information on the normal development of play and language skills and the link between play, cognitive development and language.
Susan Kidd with Harriette
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TRAINING
Doing a disservice to the schools and education staff who do make the commitment to adequate staff training and real joint working. Susan Kidd notes that, at Peartree School, the head felt so strongly that communication is the foundation to all learning that she made a poster for the staff room detailing all the communication bands and which band the pupils belong in, to remind staff at which level to teach. One of the key things to remember is that a school needs to see that a training opportunity is being offered to them in spite of any shortfall in speech and language therapy provision, not because of it. We have to be able to convince them of their own vital role in understanding and facilitating communication development. A number of years ago a headteacher decided to sit in on the first session of an interaction therapy course we were running for her staff. She was not happy that her staff were having to undergo training so that they could do your job as well as their own, but by the end she said it was the best course shed seen and that all her staff must be trained. Interestingly, an I CAN conference survey (RCSLT, 2006) found 70 per cent of the teachers polled felt there was insufficient in-service training to help them meet the needs of children with communication disability. The link between communication difficulties and behaviour was clearly identified at the conference - in itself good motivation for schools to invest time and energy in communication training. We hope this article inspires you to consider, review, or maintain staff training as one very rewarding and effective part of the service you provide. If you are working to set up in-service training and to achieve the necessary commitment, Susan and I hope the following suggestions will be helpful:
a. If you cover several schools, start with those who will be most supportive and receptive. b. Find out if there are issues or pressures affecting staff which may overshadow your course. Communication training might not be the schools current priority. c. Identify staff who are particularly supportive and involve them in selling your idea to the whole school. Support from the head teacher seems crucial. d. Try a staff questionnaire. Let them tell you where the current service falls short - then explain how regular training sessions will help. e. Talk directly to as many staff as possible explaining the remit, aims and benefits of the course. In week ten of one course we learnt that all the information we had given to the head had been presented in a staff meeting as a speech therapy course. f. Circulate written information. g. Use a training day or one-off training session to explain the purpose, aims and benefits of your course. h. Highlight the potential benefits of the framework you would like them to adopt. Ensure they can see clearly how it will make their job easier. Show how it links in with frameworks they already use, such as P-levels. (If they view the new framework as yet more paperwork or at a tangent from existing ones they will find it hard to feel positive!) i. Make clear your expectations re attendance, time commitment, and follow-up work before the course starts. j. Identify staff who are receptive to training. When participants volunteer, their motivation is excellent. One head, who knew her staff extremely well, recommended suitable candidates.
k. For joint ownership, invite a teacher to be co-leader. Gillian Bolton is a self-employed speech and language therapist living in Rugby, e-mail gillian@apectraining. co.uk, tel. 01788 576488, www.apectraining.co.uk. Susan Kidd is a speech and language therapist employed by Central Lancashire PCT and working at Peartree School, Station Road, Kirkham, Preston PR4 2HA, e-mail susan.kidd@ centrallancashire.nhs.uk.
References
Latham, C. & Miles, A. (1997) Assessing Communication. London: David Fulton. Latham, C. & Miles, A. (2001) Communication, Curriculum and Classroom Practice. London: David Fulton. RCSLT (2006) More school communication disability training needed, Bulletin of the Royal College of Speech & Language Therapists 650 (June), p.6.
APEC2 costs 260 + p&p. See www.apectraining.co.uk for more details. SLTP
Resource
REFLECTIONS DO I SYNCHRONISE WHAT PEOPLE WANT TO LEARN WITH WHAT I WANT TO TEACH? DO I START A CHANGE PROCESS WITH PEOPLE WHO WILL BE GENERALLY POSITIVE ABOUT IT? DO I TRULY VALUE WHAT I HAVE TO OFFER?
The Fourth Afasic International Symposium 2 5 April 2007 Warwick University Understanding developmental disorders: From theory to practice
Confirmed keynote speakers: Cathy Adams, Gillian Baird, Dorothy Bishop, Gina Conti-Ramsden, Fred Dick, Julie Dockrell, Anthony Monaco, Kate Nation, Michael Rutter, Margaret Snowling, Bruce Tomblin and Maggie Vance. Seminar presenters include: Nicola Botting, Shula Chiat, Maggie Johnson, James Law, Heather van der Lely, Wendy Rinaldi, Kate Ripley, Penny Roy, Judy Roux, Joy Stackhouse, and many more.
Poster sessions including evening wine reception. An exhibition will run for two days during the Symposium. Discounted rates for booking before 31 December 2006.
For more information and details of booking and fees, please contact Carol Lingwood on 01273 381009 or e mail carol@lingwoods.demon.co.uk or log on to www.afasic.org.uk/sympsite/
13
FEATURE
I Believe in
When you wake up READ THIS IF YOU ARE WEARY OF CHANGE tomorrow to life in * * FEELING TRAPPED Utopia, with the * LOOKING FOR SOLUTIONS problems you face as a speech and language therapist solved, what will be different? And what ideas will that give you for changing and coping today? Editor Avril Nicoll hears practical suggestions from resourceful therapists.
On a daily basis, our clients and their carers get on with their lives in spite of a communication disability, be it aphasia, stammering, language disorder or autism. We are often humbled by their great resilience in the face of seemingly insurmountable life-changing events, frustration and despair. As therapists we are familiar with strategies to help clients develop their resilience and uncover their own solutions. For example Kidge Burns finds that, The more you ask questions about the future, and discover how clients are able to describe and enjoy thinking about things in life other than the problem, the less you become fearful of using clients imagination in order to facilitate change (2005, p.23). By all accounts, speech and language therapists, particularly in the NHS in England, are experiencing high levels of stress due to stringent budget cuts, frozen posts, the prospect of redundancy and no recruitment of newly qualified therapists. The temptation to give in to despondency and despair and to react with anger or apathy is great. But, to continue to care for others, we have to care for ourselves too. Doing what we can and drawing on all the sources of support available to us, internal or external, thus ensuring we continue to practise in a way true to our vocation. The miracle question of Solution Focused Brief Therapy as described by Kidge Burns (2005) asks clients to consider how life will be different when they wake up
Illustration by Graeme Howard
tomorrow and their problem is solved. This approach can lead people to find their own solutions, and to recognise the many things they are already doing that they can build on to make life better. I decided to ask eight therapists the miracle question to see if their Utopia of tomorrow would offer practical ideas for coping and making changes today, whatever circumstances we find ourselves in. Our therapists are clear that Utopia will involve more staff, with manageable, equitable caseloads and no waiting. Our service will offer a mix of direct therapy and a consultative approach on the basis of need. The bigger political picture will be calm and stable. Therapists, organised in small, supportive teams, will be trusted to
make more day to day decisions and to assume budgetary control, however limited that budget might be. Our service will be valued as much as, say, treatment for a broken leg - and clients voices will be heard. In our Utopia, there will be a much greater strategic focus on prevention and collaborative work. While the intention is to reduce the need for our service, its interesting that our ideal doesnt quite extend to there being no communication and swallowing needs. Kim Mears, a therapist for 9 years, started down that route but concluded that children with profound and multiple learning disabilities are so special I cant imagine a world without them! She believes our strength is the caring element. We are in this for the intrinsic rewards.
14
FEATURE
miracles...
We have the tools to help, and can make a big difference. Deborah Green manages a service in Kingston for people with learning disabilities. She finds hands-on, face-to-face contact with clients and person-centred development projects vital to her job satisfaction as they are the nuggets of treasure - what its all about. Meanwhile, newly qualified therapist Emily Williams has been surprised to discover that she most enjoys working with challenging and complex cases as the grittier ones give you more of a chance to test your skills.
Negotiation
When we recognise the interdependence of our relationship with clients, we open up a whole new set of possibilities. Instead of feeling the pressure (and the illusion of control) that comes from thinking Im the only person who can provide this, we share responsibility and delegate more. Realistically, there will always be resource issues, but Sally Byng, co-founder of the communication disability network Connect, believes learning negotiation skills can help us come to a shared thinking about the best use of limited funds and personnel. Because an apparent solution is not workable you need to negotiate something that is different from where you both started. We need to listen below the surface and not take things at face value. Only then can we think imaginatively of other ways to meet the underlying need. For example, Sally described a neat solution that she had recently heard about elsewhere. People living with stroke said they wanted more physiotherapy in fact, further probing showed they wanted regular exercise delivered in a way appropriate to stroke. The negotiated settlement was for the physiotherapist to work with community centre staff so this could be offered. This belief in the resourcefulness and reasonableness of others is central to the process of solution focused brief therapy. Kidge Burns says its beauty is that it moves you away from feeling stuck. Kidge has authored a book on the subject and completed a diploma but a solution focus has had an impact beyond her work. It has completely changed my life and helped me enormously. Its that thing of doing something different, knowing that things wont always work and that you will keep on thinking of new ways. In family relationships a solution focus helps you look for what is working rather than what isnt, and to hold your tongue and listen so that the other person can finish what they are saying. Importantly, this lets you understand why they have chosen to tell you their story, and gives you opportunities to help them notice what they have done well and what they have identified as ways to sort things out for themselves. Deborah Green uses a solution focus in supervision sessions. Asking the miracle question, she notices staff moving from despair to hope as they gain insight into the problem. There is just a change in demeanour the person sees they can have some control, and they go away having chosen at least one thing they can do tomorrow to make a change. Deborah believes strongly that speech and language therapists are good agents of
change, and that we need to take more control over the organisation of our working day so we become more responsive to the needs of clients and carers. While feeling fortunate in having a rewarding job in her chosen field, Emily Williams would also like to make changes where she sees a need. I would like to be trusted with more independence to try things myself. We do need checks, but they sometimes seem like barriers to change. Kim Mears has found a freedom in working as an independent therapist - and previously as a therapist in New Zealand where, as part of a small team in a school, she was encouraged to try different approaches in collaboration with teaching staff. She says, Fairness and justice are important to me. I want to be able to do things or withdraw my services as necessary. I revel in being able to choose packages of care on the basis of need. Locum service manager Jacki Pearce has some sympathy for therapists who are keen to implement new ideas, and recognises staff need to have exciting projects and feel empowered to tackle things in a different way and evaluate the results. However, it is important that therapists are committed to their department and that managers show strong leadership, so change is sustainable and skills are used appropriately. Training in project management skills supported by regular debriefing can help. As a speech and language therapy representative on the regulatory body the Health Professions Council, Jacki has additional insight into the importance of working within your scope of practice and maintaining standards. She is particularly keen on maintaining case notes so that at any time a history and diagnosis will be immediately apparent.
means we are not just helping people but working with them through a therapy process using tools such as self-rating outcome scales. Kidge values herself and her team more now, and says supporting and complimenting each other is essential.
Compliments
In Utopia we give and receive compliments, in whatever form they appear, as they make us feel valued. Jacki Pearces team won a primary care trust Improving working lives award recently, having been nominated by social work, education and NHS professionals in recognition of their efforts to work in a collaborative way in very difficult circumstances. And, in spite of current uncertainty about the future and being snowed under, Amanda Medhurst is enjoying her work as there are good things going on. She is offering more training and, as an Elklan tutor, has received a lot of positive feedback, both verbally and practically. When you see people putting into practice what you have taught them it is very rewarding. Amanda adds, I feel valued when people ask my opinion, when we make joint decisions in the multidisciplinary team and when I have been able to get my message across and been appreciated. Emily Williams knows she has had a good day when she has been out into the community, felt the support of parents and liaised with teaching staff who are open to discussing a childs needs in a positive way. Listening to the interviewees, I sense that Utopia is smaller but bigger. Smaller in terms of team size to enable more focus, control and practicality, but bigger in its ambition, networking and impact. Deborah Green talks about the need for creative thinking about professional development when heads of department, funding for multiple cross-disciplinary services and access to courses are being eroded. We need a good, diverse critical mass for professional development, so we need to look at things like a voucher trading system for training, more work shadowing and access to courses outside health. Kidge Burns finds that, using solution focused brief therapy, such creative thinking can be done even when time is short. During study for her BRIEF Diploma she engaged in 10 minute co-coaching sessions once a month: It was enormously helpful and supportive although we knew nothing about each others work. Sally Byng finds people dont realise that, wherever they are working, they have permission to think radically, adding often the most radical ideas are the most obvious and simple but so much stuff gets in the way, and assumptions and status cloud the picture. We need to ask: 1. What difference do I want to make, and to whom? 2. Whats my rationale for making that difference? 3. Do the beneficiaries also think that its a good idea, or is it just a professional concept? 4. What is the most effective way of using available resources to make that difference? 5. How am I going to sustain making that difference?
Learning negotiation skills can help us come to a shared thinking about the best use of limited funds and personnel.
There is clearly a tension between how therapists want to use their time and how they are required to use it in a big organisation such as the NHS. Independent therapist Janet OKeefe thinks we have to be creative if the profession is going to continue. Emily Williams believes speech and language therapy is evolving quickly, but we cannot move with the times, and Deborah Green has come to understand that the NHS is bigger than carers and clients. Kidge Burns notes that with every crisis comes an opportunity. She believes that, as we have to produce figures and talk about outcomes, we are now more focused on what we can and cannot do. Rather than spreading ourselves too thin and being divided by specialisation we are getting back to commonalities and really using our communication skills. The notion of clinical effectiveness
15
FEATURE
Thinking radically means stopping doing something and putting something else in its place. Sally gives the example of services for people with aphasia in the acute setting. From listening to people with aphasia it seems that in the early stages what is needed is not necessarily hours of assessment, as you can very quickly get to know how the person communicates, and the picture is probably changing rapidly anyway. Instead, look at offering reassurance, explanation to the family, advice on immediate ways of managing and supporting transition from hospital to home. Direct a percentage of your budget to developing a small number of people with aphasia who can befriend, support and give information, and another percentage to training the staff who spend most time with people with aphasia, using trained trainers with aphasia. Another portion should go on getting and maintaining the most relevant and up-todate information about local support resources.
Manage risk
If thinking radically takes you out of your comfort zone and feels risky, Sally suggests that putting the risk in context makes it easier to take action. She senses that public services are no longer a comfortable place for the risk averse person, but by not doing anything you are still taking a decision - and running the risk that things will be unsatisfying and unrewarding. She adds, We have to think about how to manage risk. For me, not following my vision was a bigger risk than staying put in the public sector. Sallys Utopia was a values based organisation that would function as an innovator and influencer rather than a provider of services. Six years on, while the reality includes the challenge of being very principled and the constant pressure to keep the show on the road while looking to the future, she describes Connect as incredibly exciting and rewarding at the same time. She is in no doubt that the key ingredient for any entrepreneurial endeavour is passion a belief in what you are doing and the passion to get other people to recognise and understand. The Connect team, the standard of the building where they are based and the feedback from people with aphasia and service providers prove to Sally that Connect is making the difference it wants to make. This can come to light in unexpected ways; a book club meets monthly in Norway to discuss the chapters in Beyond Aphasia (Pound et al., 1999), and the University of West Michigan was heavily influenced by a visit to Connect, and has radically changed its clinic, involving people with aphasia in running it. But being proud of our achievements does not seem to come naturally, and Jacki Pearce thinks we are not good at blowing our own trumpet. She recommends you write up your projects for magazines and journals but, at the very least, send audit results to your chief executive officer. Even if the audit shows problems, you can demonstrate you have closed the loop, tackled things to make the situation better and will be re-auditing. In Emily Williamss Utopia we would see more positive stories about speech and language therapy in the general press so we dont feel we need to cover our backs, and that we can follow our instincts more. Part of blowing our own trumpet involves us being clear and focused about our message, and we have the communication skills to get better at doing this. Sally Byng has learned a lot from marketing professionals about the importance of brand and of being able to explain succinctly and quickly what you are about
to people with no prior knowledge of the profession or communication disability. Importantly, this also helps you clarify ideas to yourself. Janet OKeefe is similarly impressed by what she has learnt from people outwith the profession since she took the decision in 1997 to integrate her life by working independently from home, planning work time around the needs of her children. While she had the speech and language therapy skills, the biggest stress was running a business, and she says working with people from other professions is brilliant the local enterprise agency, Business Link and my business adviser whom I meet every eight weeks. For some people, then, the time might be right to leave the NHS. Deborah Green says partnership agencies are crying out for our skills, and she has seen an increasing number of colleagues going out to see what the big wide world holds. She believes being adaptable, good communicators puts us in a strong position to manage ourselves outside a big organisation.
I sense that Utopia is smaller but bigger. Smaller in terms of team size to enable more focus, control and practicality, but bigger in its ambition, networking and impact. Support
Wherever we are working, Janet OKeefe is clear that we need to take more control and responsibility for seeking out our own opportunities for supervision and support, right from the time we are students. Janet is a member of the Association of Speech & Language Therapists in Independent Practice, and of one of their local groups which meets once a term to exchange ideas. Janet also goes to group supervision once every eight weeks, run on a neurolinguistic programming (NLP) model. This helps people to link apparently work-based issues to their personal life and to work out what choices they have for handling the situation. Kim Mears went independent two years ago and is impressed by the amount of reading and networking that independent therapists do to keep up-to-date and their enthusiastic participation in special interest groups. She also takes inspiration from some fabulous therapists and has appreciated emotional support from her mum. Emily Williams was fortunate to start work with two other new graduates from her degree course, who were already her friends. While she would like protected time to stop and think, she makes the most of shared car journeys to talk over ideas, and is always pleased to know she is not alone. And, tellingly, for staff concerned about the services ability to deliver enough therapy to a huge waiting list, service manager Jacki Pearce always has a box of tissues in her office! Readers who have worked with Speech & Language Therapy in Practice life coach Jo Middlemiss praise the way she helps them think of things differently - and it
is worth remembering she offers a complimentary session for the cost only of your call. She is keen to promote the theme of balance, and for us to avoid looking at our working life in isolation. Janet OKeefe realises more and more that things evolve according to personal and work circumstances and that You have to do what is right for you at different times. As well as her family, Janet finds balance from choir practice and, like Kim, yoga. Amanda, whose manager actively encourages staff to seek balance, finds tennis does the job. Emilys work package included discounted gym membership and doing a workout means that even on a bad day I come home on a positive note. This is important because, as Janet OKeefe says, If you are not happy you will not be giving a good service, and people will become more dissatisfied with the profession. Personal qualities count too. Amanda is down to earth, friendly and approachable. Emily tries to have the humility to laugh at myself, to look on the lighter side of life and accept that things happen - its not my fault as such. Kim takes every opportunity to learn from situations such as becoming a mother and to pause and reflect on what this means for the way she works. A lot of it is great, and I have to remind myself of that. What is important is that I can go to sleep feeling Ive done a good job. Jacki Pearce recognises that I do enjoy a challenge, and want to continue to make things work better. In the end, we are resourceful people, and we cope. Kidge Burns asks, Suppose things dont get worse? We have already learnt to cope better we are more skilled than we were. But if circumstances dont change, if you feel like you are rearranging deckchairs on the Titanic, if you are a new graduate who has yet to find a speech and language therapy post - it can help to suppose that in six months time you have everything you want. Now ask yourself: of all those things, which one feels like something I could be doing now, and what difference will it have made? Speech and Language Therapy in Practice feature articles are intended to get people thinking and talking in different ways. Editor Avril Nicoll would be interested to hear how this article has affected you - for example, any change you have initiated, and the difference that has made (e-mail @p g avrilnicoll@speechmag.com / tel. 01561 377415).
References
Burns, K. (2005) Focus on Solutions A health professionals guide. London: Whurr. Pound, C., Parr, S., Lindsay, J. & Woolf, C. (1999) Beyond Aphasia. Bicester: Speechmark.
Resources
BRIEF Diploma in Solution Focused Practice, www.brieftherapy.org.uk. Connect, the disability network, www.ukconnect.org. Elklan training, www.elklan.co.uk. Life coach Jo Middlemiss, tel. 01356 648329.
Acknowledgements
My thanks to all the speech and language therapists who gave me time and the benefit of their experience: Kidge Burns, Sally Byng, Deborah Green, Kim Mears, Amanda Medhurst, Janet OKeefe, Jacki Pearce and Emily Williams. SLTP
16
HERES ONE I MADE EARLIER....
Heres one I made earlier...

ALISON ROBERTS WITH MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONS SUITABLE FOR A VARIETY OF CLIENT GROUPS.
BODY IDIOMS SELF-AWARENESS BEADS MAP GAME / is a group activity finishing up with an This is a good way for a group of children or teenagers to RALLY NAVIGATOR improve their self-awareness but in a private or semi-private way. This image that is made with your clients actually
This is good for listening skills, concentration, organising and prioritising sentences, and incidentally for getting to know the locality. Girls particularly like this activity, but some boys seem to be quite happy to do it too, especially if the beads are brownish, or edged in a dark colour.
MATERIALS IN PRACTICE Thin knitting needles, or 1. Cut long narrow triangles strong wire about 10cms long and 2cms White or coloured paper wide, tapering to a point. (You Small beads from a craft shop may need to do this yourself if Paste your clients have trouble with Felt tips their fine motor skills.) Varnish 2. Colour the very outermost Scissors edges of the tapered point of Narrow elastic (craft shops each triangle. sell elastic especially 3. Write along the triangle designed for threading anything of interest about beads) yourself. If you want to keep the information a secret you write it at the fatter end of the triangle, but if you are prepared to share a little of your disclosure you put it towards the thinner end. You will need to use very small writing! 4. Turn the triangles writing side down and apply paste along the length. 5. Place the knitting needle or wire across the fat end of the triangle and roll up from the fat end. You should end up with a bead that is oval and ridged like a croissant because that is exactly how they roll up croissants. You should be able to make several beads on one needle. 6. A few trials are advisable first you will soon see how much of the writing is visible. 7. Now you must leave the beads to dry until your next session. 8. Ideally you would varnish the beads before use but that means you will have to repeat the drying process. (You might be able to do this between sessions for the clients.) 9. Now comes the interesting bit threading the beads onto the elastic, interspersing the made ones with the ready-made variety that you have bought. 10. The clients should find that they have something they can actually wear.
there with you. It is designed to promote understanding of idiom, and is good fun to do, but you need to have a brave (and still) soul who is prepared to be drawn around!
MATERIALS Large piece of paper (or a large blackboard would do if it is the right height from the floor and large enough to contain the template person) Wide and narrow water-based felt tips or board chalk IN PRACTICE (I) 1. Draw around your person, (or you could just draw a person shape if participants are too shy). 2. Together think of all the sayings you can, that are connected with the body. You will probably come up with sayings such as: head for heights; made my hair stand on end; making eyes at...; Im all ears; dont bite my head off; lend a hand; green fingers; pain in the neck; heart in the right place; butterflies in my tummy; hes got guts; sitting on his bottom all day; legless; feet on the floor; treading on his toes. There must be dozens more of these and the best ones will be those they think of themselves. 3. Write them on the relevant part. 4. Now have your discussion on how these are used, and request that they use them in a sentence, so that they become familiar. IN PRACTICE (II) You can add a wardrobe its amazing how many expressions are based on these. Examples include: pull your socks up; down at heel; bore the pants off; to pocket something; to skirt round; cloak and dagger; keep it under your hat.
MATERIALS A large-scale map of the local area, photocopied for each group member Pencils, paper, envelope
IN PRACTICE Take it in turns to be the navigator, but its probably best if you go first, so that you can convey the general idea. Decide on the destination and secretly write it down on paper, which is then placed in the envelope. State the starting point (such as a school) and have in mind a route towards the secret end point. Make sure everyone has their finger on the start, and begins by going the right way. Now simply direct the group members to turn left or right at various landmarks en route to the destination. When someone reaches the correct point you can congratulate them and show the paper in the envelope to prove that you have not changed the destination. Now the play passes to that winner. They think of a new destination, write it down and place it in the envelope as before, and state the new starting point.
Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.
Offer Metaphon Games Boxes

Do you work with children who have phonological delay / disorder? And are you looking for activities that will help them consolidate progress? Metaphon Games Boxes were designed for just this purpose. They consist of coloured pictures on cards and boards which can be used to play lotto, snap, matching and memory type games. As Langlearn Communications has only 100 each of Games Boxes 1 and 2 remaining, now is your chance to benefit and to help Afasic and I CAN at the same time! Games Box 1 contains two sets of boards and pictures representing Fricative / Stop and Cluster / Single Phoneme contrasts. Games Box 2 covers Alveolar / Velar and Voice / Voiceless contrasts. The pictures have been chosen to give children the opportunity to use and listen to the phonemes in a wide range of words, and in all word positions, but particularly word initially. Order Metaphon Games Box 1 and 2 for just 5.00 each or 9.00 for both (UK only), and all profits, once postage and packing has been deducted, will go to these two charities. Send your order to: Janet Howell, Langlearn Communications, 8 Traquair Park East, Edinburgh EH12 7AW. Please make your cheque payable to J. HOWELL, and remember to enclose your name and address and state which box you are ordering. You can find out more about Metaphon in the book Treating Phonological Disorders in Children (Metaphon Theory to Practice), 2nd edn, by Janet Howell and Liz Dean, published by Whurr.
17
REVIEWS
reviews
COMPUTER USE
The Very Best CD of Office Sense AbilityNet Reviewed as a CD, now available as an elearning course called Office Sense for Windows XP, and costing from 40.00 (single user licence) see www.abilitynet. org.uk. to be of at least secondary age with no language or social communication difficulties. Expensive, but the first few chapters are useful if you want some new ideas. There are other better, more specific speech and language therapy resources on the market. Claire Madeira is an independent paediatric speech and language therapist in Kent. pathology students. DVD clips, sample scripts and workshop forms provide a structured (although somewhat idealistic) way of learning and applying skills such as enthusiasm and behavioural management. Useful sections include the implications of learning theories and developmental disorders for speech-language pathology. (NB As the author is from Alabama, legal references are to US laws and organisations.) Overall this book is more useful for students preparing for placements, though clinical supervisors may like to dip into it to help students develop specific skills. Sarah Woodhams is a 4th year BSc Speech and Language Therapy student at Reading University. legal background defending his fathers reputation. Add a heavy dash of journalistic overstatement and a heap of post-hoc justification. As speech and language therapy textbooks go, this is quite a mix. And yes, there is already a novel on the case too! The case study at the heart of the book is a 1939 project on stuttering first brought to the attention of the wider speech and language therapy audience by Silverman in 1988, and more recently given the tabloid journalist treatment in 2001. This book explores the ethics of the original study within the context of its time and also applies current day ethical principles to the same study, as well as considering the ethics of journalism. The theoretical content is comprehensive, as expected in a volume with contributions from such eminent authors as Bloodstein and Yairi, and it offers insight into changes in ethical thinking and current (US based) speech and language therapy ethics. Each chapter stands alone, which leads to some repetition of content and themes, but overall this is a useful text, although perhaps better suited to the departmental library than the bedside table. Jois Stansfield teaches speech and language therapy students at Manchester Metropolitan University.
A simple-to-use gem
This CD is a very simple-to-use gem of illustrated information regarding computer use. It covers topics ranging from the legal obligations of both employee and employer, through to practical illustrations of good and bad posture and desk space. It also contains appropriate information for our clients on how to adapt computers, for example for voice activation or single handed use. It is easy to navigate and has a wealth of resources in 24 skillsheets and 30 factsheets on topics ranging from how to adjust your computer settings to communication aids and advice on epilepsy and computing. Overall, a very functional and practical tool to dip in and out of as necessary. Hilary Armstrong is a speech and language therapist with Maldon & South Chelmsford PCT.
ASPERGER SYNDROME
Group Treatment for Asperger Syndrome A Social Skill Curriculum Lynn Adams Plural Publishing ISBN 1-59756-022-7 25.00
Carefully thought out PHONETICS This book of practical ideas to encourage

communication and interaction is primarily aimed at speech and language therapists and teachers within specialist educational environments. It has an excellent introductory chapter with theoretical information about Asperger syndrome. It is quick and easy to read and would be a useful resource for any therapist running social skills groups. It has clear session plans for different age groups and the activities have been carefully thought out to provide children with opportunities to communicate and co-operate with each other. Generalisation of skills is not mentioned; however the activities can easily be transferred to other contexts such as classroom settings. The accompanying DVD illustrates activities described in the book. Alison Hunter is a specialist speech and language therapist working within the Child and Adolescent Mental Health Service in Manchester.
Phonetics Principles and Practices Sadanand Singh Plural Publishing 28.50 ISBN 1-59756-020-0
An ideal book
This is an ideal book for first year students to introduce the principles of phonetics and is a good reference guide for other students and clinicians. Each chapter begins with objectives and ends with exercises to test knowledge and understanding of the topic. Further reading material is also recommended. The transcription exercises, although good practice for transcribing skills, are in American English and consequently subtle differences are evident. This easy to read, enjoyable book is very beneficial for students, as the application of phonetics in a clinical setting is discussed throughout. It is also excellent value for money. Gemma Rafferty is a 3rd year speech and language therapy student at the University of Ulster, Jordanstown.
GROUP WORK
Group games - Building Relationships Thorsten Boehner Speechmark ISBN 0-86388-546-2 15.95
NARRATIVE
StoryBoards Felicity Durham Speechmark ISBN 0 86388 553 5 39.95 + VAT
Activities quite complex

This easy to read, well laid out book contains 148 activities in 6 areas: Facilitating group bonding Warm-up Building trust and awareness Imagination and improvisation Closing Special exercises and tips for Amateur Dramatics Groups. Written by Thorsten Boehner, an industrial trader with a long-standing interest in Amateur Dramatics Groups, the book has recently been translated from German. The first two sections and some of the closing exercises could be useful in working with most groups of schoolaged children. However the rest of the book is really for Amateur Dramatic groups. Most of the activities are quite complex and would require the children
Caught childrens interest

This resource is fun, colourful and well illustrated. It caught the childrens interest and was easy to use. It has a game-like feel with hand-sized cards, dice and story boards. StoryBoards uses six story elements location (such as the beach), objects (related to each location eg. shells for beach), transport, feelings, weather and time, but it omits a key component by not including characters. While it helps to identify story components and build basic story vocabulary, the children I work with had difficulty with the move from collecting cards to then sequencing them and creating a story; using the story boards seemed to further constrain them. The colour-coded cards unfortunately use a
STUDENT EDUCATION
Heres How To Do Therapy - Hands-On Core Skills in Speech-Language Pathology Debra M. Dwight Plural Publishing ISBN 1-59756-002-2 42.50
ETHICS
Ethics: A Case Study from Fluency Robert Goldfarb (ed.) Plural Publishing ISBN 1-59856-010-3 28.50
Structured learning
This easy to read book focuses on 28 therapeutic-specific core skills, not explicitly taught to speech-language
Insight into changes in thinking

Take one small masters degree study, three large speech pathology egos and a number of smaller ones, and a son with a
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REVIEWS
news
different colour-coding system to other already familiar narrative therapy packages, which led to some confusion. A good resource, though, with helpful suggestions for extension and generalisation activities. I found it most useful in one-to-one and small group work. Teresa Egan is a specialist speech and language therapist working with schoolaged children with specific language impairment, Hillingdon PCT. recording sheets and modifiable files in MSN word format. The theory is relevant to everyday practice, but to incorporate this very structured protocol in everyday clinical settings would be problematic. The main difficulty is that no pictures are provided to support the many target phrases, and busy therapists would find it time consuming to put together the dozens of pictures required. Also, although there is no indication of an appropriate age level, we feel it would be unrealistic to implement this treatment strategy with preschool children. The books have a comprehensive glossary to explain the many complex terms, some having an American bias. We generally would not recommend these treatment protocols, as we feel other language schemes on the market are more useful in the clinical situation. Karen Shuttleworth and Alison Taylor are speech and language therapists with Cumbria PCT.
TRANSCRIPTION
Multi-layered Transcription Nicole Mller (ed.) Plural Publishing ISBN 1-59756-024-3 29.95
Web exchange
A partnership board which has produced an accessible website to support communication for adults with learning disabilities is looking for people to visit the site and exchange ideas. The Burnley Pendle and Rossendale Partnership Board site includes information about its Communication Plan, and gives training on how to support communication in different situations. www.clear2us.org
Useful to all
This book provides an incredibly detailed overview of how to analyse all levels in an interaction. It helps pull together the familiar and the less familiar for transcription. It supplies clear descriptions and transcribing conventions and has an add-on section to the International Phonetic Alphabet with symbols for disordered speech. Whilst the full process is not suitable for day to day use, it does provide a lot of useful techniques for helping answer the What are they doing? factor. The user can select part of the processes described to help focus on details they are interested in. This makes it useful to all users from students to experienced clinicians. Laura MacDonald is a speech and language therapist working with children in south-east Glasgow.
AUTISTIC SPECTRUM DISORDER

Engaging Autism Stanley I. Greenspan & Serena Wieder The Perseus Books Group ISBN 0 7382 1028 5 15.99
Nice Warm Socks

A new CD (with freely downloadable website resources) is proving a hit with children who have learning disabilities, including those who use AAC. Speech and language therapist Shan Graebe collaborated on the development of Nice Warm Socks with a community musician and a music specialist. Integration and inclusion were the guiding principles for the project, which aims to create a sensory space where songs can be sung and enjoyed by all children. Shan says, It is important for leaders and teachers to take a creative role in constantly re-working and re-making songs, perhaps substituting lyrics or changing bits of tune. As an example, out of the 17 songs on the CD, 10 are specially written while the remaining 7 are adaptations. Attention has been paid to pacing and pitch, and including time dependent lines which feature repeatedly at predictable points. The Widgit website has ready-made symbol resources to go with the songs on the CD, available free via Communicate: In Print software. www.nicewarmsocks.org.uk www.widgit.com
Upbeat and accessible

This book describes the D.I.R or Floortime approach to teaching children with autistic spectrum disorder to relate to other people, communicate and think logically. Floortime involves harnessing the childs interests, giving emotional motivation, then providing challenges in a developmental way, taking account of an individuals sensory and motor profiles. It contains practical advice on how best to develop childrens potential, with individual case examples. The model can also be extended to teenagers and adults. The tone is upbeat and the style accessible; caregivers, professionals and students would find the book useful, but plenty of time is needed to read it thoroughly. Mary Jennings is a specialist speech and language therapist at Moor House School.
COMMUNICATION
Talking Mats: A Resource to Enhance Communication Joan Murphy & Lois Cameron AAC Research Unit, University of Stirling, www.talkingmats.com ISBN 1 85769 2144 14.99
SPEECH DIFFICULTIES
Persisting Speech Difficulties in Children Michelle Pascoe, Joy Stackhouse & Bill Wells John Wiley ISBN 0-470-02744-4 29.99
Clear and easy guidance

This extremely readable and comprehensive booklet provides clear and easy to read guidance on how to set up and start using Talking Mats for anyone working with clients presenting with communication difficulties. Its most likely to be of interest to therapists new to the profession or working with clients relying on augmentative methods of communication. For those more experienced, however, it may provide some new ideas to enhance their own or their multidisciplinary teams existing interventions. A number of uses are highlighted such as looking at outcome measures and gaining client views for planning meetings involving their care or education. Talking Mats may only be appropriate for clients whose symbolic understanding is at a two word level, but beyond this its uses appear flexible. Hannah Kay is a locum speech and language therapist whose special interests include working with children with complex needs including autistic spectrum disorder and challenging behaviour.
A positive way forward

Therapists and teachers feel despondent when faced with a child of school age with persisting and significant speech difficulties which do not respond to our therapeutic approaches. This book provides a positive way forward based on a psycholinguistic framework but with many dynamic approaches to management. It is an academic book providing useful case histories and is firmly grounded in evidence-based practice. Suitable for speech and language therapists in language units, teachers, students and researchers, there are good summaries after each chapter and activities to keep the reader focused. A useful book which addresses the needs of a challenging client group. Ann Gosman is a senior speech and language therapist in Orkney.
LANGUAGE
Treatment Protocols for Language Disorders in Children Vol I Essential Morphologic Skills Vol II Social Communication (inc CD Roms) M N Hegde Plural Publishing ISBN 1-59756-045-6 59.95
Early intervention
The British Stammering Association has started the final phase of its three year early intervention project. The Association will be working with a few NHS trusts to help speech and language therapy departments improve the service they offer to preschool children who stammer, with the aim of spreading good practice and enabling far more children to benefit from therapy. www.stammering.org
Prescriptive and formal

These volumes provide very detailed assessment and treatment plans in a prescriptive and formal way. They also incorporate CDs which include the
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WINNING WAYS
Winter growth
READ THIS IF YOU HAVE THE WINTER BLUES TEND TO ARGUE WITH NATURES WAY THINK THERE MUST BE MORE TO LIFE
travelled to The Eden Project in Cornwall recently (www.edenproject.com), and was impressed with the sheer audacity of the materialisation of the dream: to transform an old, china clay mine to a dramatic tribute to Nature in all her glory. Although it is still in development, the evolution of the idea is a perfect example of a work in progress. It reminded me that, before anything becomes material, it has to be thought of or imagined. Dreams really can come true if we are prepared to use our imagination, but also our intelligence and then our backbone. While Nature is generally a source of inspiration for me, I always dread the arrival of the winter season, and wish it away. But, as we bid farewell to what has been a spectacular autumn, I cant help noticing the grandeur and splendour of winter; the amazing architecture of a denuded tree, the seeming stillness of the solid soil and the spectacular light show that the night sky offers when the temperature drops. Perhaps it is time for me to see winter differently? Speech and language therapists help people to see things differently, as former chief inspector of prisons Lord Ramsbotham expressed so eloquently in a House of Lords debate on the future of youth justice (heard on the Radio 4 Today programme, 28 October, 2006). He said, In all the years Ive been looking at prisons and the treatment of offenders, I have never found anything so capable of doing so much, for so many people, at so little cost, as the work that speech and language therapists can carry out. Lord Ramsbotham explained that, following the introduction of speech and language therapy at one institution, It was fascinating to me that immediately - the governors of the prison, the education staff, the healthcare staff and the discipline officers realised that they had been given a tool without price which they had never had before. And this was reflected most clearly to me in the discussion I had with a hardbitten prison officer who said that, until the therapist appeared, he reckoned that he and his colleagues had been damaging many young people, because they had not understood how to communicate with them, and they were putting everything down to bad behaviour which they were punishing - which was not the right answer. Now he knew where to get help.
Life coach Jo Middlemiss has always dreaded winter but, this year, through a spot of self-coaching, she is going to be inspired by it. So, whats your Goal, your Reality and your Options and what Will you do about it?
the point is that, as Nature knows, it is never too late to make changes and to do a spot of reinventing. Sandra is a therapist who wishes to specialise with children with severe learning difficulties. However, she has taken up an appointment in a field that is not her specialty because it has a slight financial advantage. She also has a great and creative talent which is not used because the job she has taken on is busy, stressful and unsatisfying. What should she do? For Sandra, all the fears are rearing their heads: Fear of failure Fear of starting again Fear of not being good enough, or of not knowing enough. Fay is wondering if she has the nerve to be an independent practitioner. She could develop a practice, working according to her own timescale and quite complicated family set-up, but again fear is rearing its ugly head: Fear of change Fear of the unknown Fear of giving up the old familiar ways. Ruth works in an inner city area where there are many immigrant families. She has a long held Teaching English as Second Language qualification, which she has rarely used. She sees this as a way to supplement her speech and language therapy work, but cant get an entry into this world. She has also done some staff training as part of her professional development. She really enjoyed this opportunity and received enough positive feedback to know that she had delivered it effectively. Where can she go with this new discovery? What is the next step, and how can a spot of coaching help? Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk. Jo offers readers a complimentary half-hour telephone coaching session (for the cost only of your call). You may want to phone Jo if you are going through a major change (such as coping with being a student, starting a first job, promotion or returning to work after a career break), or if you find yourself in circumstances which make it difficult for you to do your job in the way you want to. While all Jos work informs Winning Ways, your contact is confidential, and no personal or identifying details will be given. without being too intrusive. The vehicle I used was the TGROW method (attributed to Sir John Whitmore). I offer it to you now as a way of self-coaching. (This is entirely possible; people always have more resources than they know.) T stands for Topic or theme. G stands for the Goal. What is it you really want? R stands for Reality. With all the honesty that you can muster, state how things are at this precise moment. O stands for Options and Opportunities. This is the chance to brainstorm and really look at what could be possible if time, money and YOU were not in the way. W stands for Way forward or Way ahead - or I Will. This is the action to be taken in the light of all the thinking that has been done. To work through the GROW model, smart questions are helpful. There are many, but I will highlight a few effective ones for each stage.
Seeing things differently

Of course, while we are busy facilitating change in other people, it is easy to forget that we too benefit from help to see things differently. Following my Grey(ish) power article, in the Autumn 06 edition of this magazine, many readers picked up the phone for some coaching. My callers were all of a certain age, but the recurring theme was, There must be more to life than this. As usual, the stories I tell are a bit of an amalgam - but
Self-coaching
Recently I was asked to run an Introduction to Coaching workshop for a range of health professionals including doctors and receptionists. The idea was to show, over the course of two hours, that it really is possible to do a little coaching
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WINNING WAYS
GOAL What would you like to achieve? What would you like to be different? What outcome would you like from this coaching / thinking session? REALITY What is happening at the moment? How do you know that this is true? What other factors are relevant? Is anything else relevant? What obstacles would need to be overcome on the way? What resources do you already have? What other resources will you need? OPTIONS What could you do to change the situation? What alternatives are there to the present situation? Who might be able to help? What options do you like the best? What are the pros and cons of these options? How committed are you, on a scale of 1 to 10, to your favourite option? WAY FORWARD What are the next steps? Precisely when will you take them? What might get in your way? What support do you need? How will you get this support? How committed are you to taking these steps? (Scale of 1 to 10) What prevents your commitment from being a 10 if it is not? I work on the principle that there is no such thing as a problem without a solution. Looking honestly at the situation in an unemotional way really does help solutions to emerge. On reading Caroline Mysss most recent book (2005), I came across a quote from M Scott Pecks book The Road Less Travelled: The truth is that our finest moments are most likely to occur when we are at our most uncomfortable, unhappy or unfulfilled. For it is only in these moments, propelled by our discomfort, that we are likely to step out of our ruts and start searching for different ways or truer answers. (p.205) This really does sum up what we need to grasp hold of so that we can make the changes we need to make, if we want our lives to bring us satisfaction and fulfilment. There is something in our modern life that wants to argue with the normal way of things. In our climate of non-stop economic growth, it rarely gets to be truly dark, and the slow-down that the winter season offers us is not really convenient. But doesnt Mother Nature deserve a break, just like the rest of us? So, this year, Im doing something different, and making a winter resolution to GROW. This winter is going to be honoured and enjoyed - and I am going to allow it to inspire me.
resources
Returning to practice
The Health Professions Council has produced a guide for professionals who have not been practising, are considering a break from practice or are intending to supervise or employ someone returning to practice. Downloadable from www.hpc-uk.org
Let s sign
The Lets Sign series of British Sign Language teaching and learning resources is available from a new online shopping site. The site also includes interactive ebooks, a signing merit chart and sticker set and free download sheets. www.DeafBooks.co.uk
Education Maintenance Allowance

The charity Contact a Family has published a new factsheet on the Education Maintenance Allowance. This looks at how to get a weekly payment for a child if they stay on at school, college or training after compulsory schooling. www.cafamily.org.uk/ema.html
Exploring Elizabeth I
The National Portrait Gallerys Learning & Access Department has worked with pupils at I CANs Meath School, all of whom have severe and complex communication disabilities, to produce a resource for teachers of pupils with special educational needs. The venture has been funded by the Vodafone UK Foundation. The National Portrait Gallerys Education department also hosts one-day workshops for pupils with special educational needs, tel. 020 7312 2483 for information. Exploring Elizabeth I, see www.npg.org.uk/exploreelizabeth
Developing voice
The Vocal Process website includes two free downloads written by Jenevora Williams which may be relevant to therapists working with children and adolescents with voice problems. http://www.vocalprocess.co.uk/resources/FAQ_Developing_Voice.pdf http://www.vocalprocess.co.uk/resources/Developing_Voice_presentation.pdf
Parkinson s questionnaire
A questionnaire to help medical professionals identify and therefore treat - non-motor symptoms of Parkinsons Disease is available from the Parkinsons Disease Society. Such symptoms include sleep problems, depression, fatigue, blurred vision and sweating. The questionnaire also asks about dribbling and swallowing. www.parkinsons.org.uk
Dementia lm
Ex Memoria is a 15 minute film about one womans experience of dementia. A copy is available free of charge to anyone working in dementia education, training or practice by sending a sturdy stamped addressed envelope (big enough to accommodate a DVD case 14x19cm) to Bradford Dementia Group, School of Health Studies, University of Bradford, 25 Trinity Road, Bradford, BD5 0BB. www.exmemoriafilm.co.uk www.bradford.ac.uk/acad/health/dementia
Encephalitis explained
Gilley the Giraffewho changed is written by a mother for the siblings of her child recovering from encephalitis. 8.50 to professionals, see www.encephalitis.info
Communication Disability Prole

The Communication Disability Profile, by Kate Swinburn with Sally Byng, is a new tool to enable people with aphasia to express their views and experiences of what life with aphasia is like for them. 125 from Connect, www.ukconnect.org
Lidcombe story
The Australian Stuttering Research Centre has released Toms Story, a DVD about the Lidcombe Program of Early Stuttering Intervention to convey a feel for what the treatment is really like. It looks at the programme from three perspectives: the therapist, the childs mother and researcher Mark Onslow. Toms Story costs AUD 35, details on www.fhs.usyd.edu. au/asrc.
Multi-sensory stories
Bag Books is a not-for-profit organisation that creates, produces and distributes multi-sensory stories for children, young people and adults who cannot access regular printed books. www.bagbooks.org
Big Talk Triple Play

The company Enabling Devices has combined its Big Talk and Press Your Luck products into a communicator called the Big Talk Triple Play. It has four levels and three message capabilities: single message, sequential and random. www.enablingdevices.com
Something s not Right...

A parent-led project has resulted in the production of a DVD and web-based video which provides information about autism in an accessible way. (NB This will be reviewed in a future issue of Speech & Language Therapy in Practice.) Somethings not Rightthe clues that might mean autism is downloadable free from www.kids-first.org.uk
References
Middlemiss, J. (2006) Grey(ish) power, Speech & Language Therapy in Practice Autumn, pp. 22-23. Myss, C. (2005) Invisible Acts of Power. London: Simon & Schuster. SLTP
Patients Talking
A new website invites people who use NHS services to write a confidential diary and find support through sharing their medical experiences. Patients Talking, www.patientstalking.com
Autism update
Contact a Family has updated its directory entry for autism spectrum disorders. www.cafamily.org.uk/Direct/a84.html
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HOW I
HOW I USE MULTI-MEDIA T

READ THIS IF YOU ARE A TECHNOPHILE OR A TECHNOPHOBE NEED MORE OPTIONS FOR VISUAL LEARNING WANT TO ADD A MOTIVATING TOOL TO YOUR BOX
RESEARCH EVIDENCE GATHERED BY THE BRITISH EDUCATIONAL COMMUNICATIONS AND TECHNOLOGY AGENCY (BECTA, 2003) SUGGESTS THAT INFORMATION AND COMMUNICATION TECHNOLOGY (ICT) ENABLES GREATER LEARNER CUSTOMISATION, INDEPENDENCE AND AUTONOMY, UNLOCKS HIDDEN POTENTIAL FOR THOSE WITH COMMUNICATION DIFFICULTIES, AND PROVIDES A WAY OF DEMONSTRATING ACHIEVEMENT THAT MAY NOT OTHERWISE BE POSSIBLE. IT IS PERHAPS SURPRISING, THEREFORE, THAT COMMUNICATING QUALITY 3 (RCSLT, 2006) HAS LITTLE TO SAY ON THE SUBJECT BUT THE WORK REPORTED BY OUR CONTRIBUTORS HERE MAKES IT CLEAR THAT SPEECH AND LANGUAGE THERAPISTS HAVE A SIGNIFICANT ROLE TO PLAY IN EXPLORING AND EXPLOITING THE POTENTIAL OF TECHNOLOGY AS A THERAPY AND TEACHING TOOL.
References Becta (2003) What the research says about ICT supporting special educational needs (SEN) and inclusion. Available at: www.becta. org.uk/page_documents/research/wtrs_ictsupport.pdf (Accessed: 12 October 2006). RCSLT (2006) Communicating Quality 3. London: Royal College of Speech & Language Therapists.
Interactive whiteboards: the long and the short of it
HOW I (1):
IN DESCRIBING THEIR USE OF INTERACTIVE WHITEBOARD TECHNOLOGY AND SOFTWARE AS A TOOL FOR TEACHING ADJECTIVES, LEONA COOK AND KERRY TRIM DEMONSTRATE HOW STRONG COLLABORATION, A FOCUS ON EFFECTIVENESS AND EXCELLENT TECHNICAL SUPPORT HAVE HELPED ENSURE THEIR LANGUAGE PROVISION IS EVERGREEN.
e have frequently heard interactive whiteboards hailed as the future of teaching, but how far has their potential really been explored within speech and language therapy? With this in mind, our team at the Evergreen Centre set out to develop a project that would investigate the benefits of whiteboard technology as one of the teaching tools in the development of childrens understanding and use of adjectives. Our three-stage project involved: 1. pre-testing nine children on our assessment of adjectives, 2. teaching and therapeutic input, then 3. post-testing on the same assessment three months later. The results were promising as most children improved in their ability to match a spoken adjective to a picture and use it at single word level.
From little acorns

The Evergreen Centre opened in February 2006 in purpose-built accommodation at the heart of a mainstream primary school. The centre has an allocation of 32 places for children with statements for speech and language disorder. The centre is staffed by a dedicated team consisting of a centre manager, two speech and language therapists, three specialist teachers, ten specialist learning support assistants and a part-time personal assistant. A provision for language needs has existed on the school site since the 1980s. The provision has a turbulent history, having been dogged by high staff turnover, inap-
MULTI-MEDIA TOOLS (1) INTERACTIVE WHITEBOARDS: THE LONG AND THE SHORT OF IT MULTI-MEDIA TOOLS (2) RESEARCH THAT HAD ITS COMPENSATIONS
propriate placements and a two year period of special measures. Inadequate accommodation in dilapidated wooden huts further contributed to a growing malaise. From this crisis point emerged a joint determination to turn the provision into a centre of excellence. Collaborative working between the newly appointed headteacher, speech and language therapy manager, school governors and the local education authority led to the formation of a detailed action plan supported by substantial financial backing. In addition to funding for new accommodation, the school was included in an authority-wide project involving interactive whiteboard technology. (Connected to a digital projector and a computer, an interactive whiteboard functions like a high-tech, touch-sensitive blackboard. The difference is that it can be used to show video clips, software and resources from the internet to groups, whose members can all contribute to what is on the screen.) We were furnished with three interactive whiteboards and associated software for the new classrooms, and asked to devise a relevant research project, as this technology is still relatively new and its effectiveness under-researched (Becta, 2003). We decided to investigate the potential impact of whiteboard use on the childrens adjectival development.
Sowing the seed

Armed with the financial and advisory backing of Medway Local Education Authority, we met with our Medway Information and Communications Technology (ICT) consultant to decide on a focus for the project. A clear action plan with timescales and resources was agreed, with the whole project to run for an academic year. It was important to us that our focus for the project was relevant across the year groups and could eventually be made accessible to other schools in the area. Initial training was provided by our ICT consultant in using our interactive whiteboards with ACTIVprimary and Clicker 5 software. ACTIVprimary software is used in conjunction with the Promethean ACTIVboard, offering users a wide range of functions. For this article, we are only referring to those features we generally applied. Essentially these included:
PRACTICAL POINTS: MULTI-MEDIA TOOLS

1. HAVE A COLLABORATIVE APPROACH AND SHARED VISION 2. INVEST TIME IN FAMILIARISATION AND PREPARATION 3. STRUCTURE ASSESSMENT TO ENSURE FUNCTIONAL PROGRESS CAN BE REFLECTED 4. INCLUDE COLOUR CODING, SYMBOLS AND ANIMATIONS AS APPROPRIATE 5. ENSURE INTERVENTION IS OF SUFFICIENT INTENSITY AND DURATION TO BE EFFECTIVE 6. CONSIDER BOTH SKILL LEARNING AND ANY COMPENSATORY VALUE 7. OFFER IN ADDITION TO TRADITIONAL APPROACHES THAT WORK 8. ENJOY!
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HOW I
TOOLS
Figure 1 Pupil Assessment Grid Pupil Name: Date of Birth: Date of initial assessment: Date of end assessment: Level 1 Big Happy Noisy Heavy Cold Empty Small Fast
Leona Cook and Kerry Trim
Class: N.C. Year Group: Target set: Target met? pre EXPRESSIVE post PHRASE pre post pre SENTENCE post
RECEPTIVE pre post
Tall Thin Frightened Long Assessment Stages: 1 RECEPTIVE LEVEL 2 EXPRESSIVE LEVEL 3 NOUN PHRASE LEVEL 4 SENTENCE LEVEL
Child is given a choice of 3 pictures. Show me.. Verbal sentence completion. The dress is .. Adjective followed by noun, eg. Dirty shirt Noun-verb-adjective-noun, eg. The man is riding the big bike.
N.B. Phrase level and sentence level assessments can both be supported with colour coded prompt cards. Warren Wood Community Primary School and Inclusive Provision Interactive Whiteboard Project. Based on Ann Lockes Living Language
customised activities which could be saved drag and drop for sorting pictures (big / not big activities, for example) spotlight tool for slowly revealing pictures attachment of sounds to pictures writing tool, and insertion of complex pictures and story characters. Clicker 5 is a writing-support tool that allows writing with whole words, phrases or pictures. Users are able to hear words in spoken form, illustrate words using pictures, attach sounds to words / pictures and animate writing for story-work.
The saplings
Although all our children at the provision were included in the project, due to time constraints we have selected one class for analysis of the results. These nine children were aged between 5 and 7 years at the time of pre-testing (April 2006) and post-testing (July 2006). All these children have a variety of speech and language disorders, including impoverished use of descriptive language. We feel adjectives are particularly vital for language and learning as they provide more specific information in a sentence. Further, within an educational context, children are expected to understand and use many adjectival concepts, for example those of quantity and size.
The project grows

For assessment design, we began with identification of core adjectival vocabulary that could be clearly represented by pictures. Our choices were based on the
concept levels as identified in Concept Consolidation (Woods, 1992). We organised words into three levels according to developmental acquisition: Level One big, happy, noisy, heavy; Level Two cold, empty, small, fast; Level Three tall, thin, frightened, long. We then designed a computer-based assessment using the Clicker 5 programme, selecting pictures from Clicker 5 or open sites on the internet. Our assessment comprised of four aspects: 1. receptive (single word in carrier phrase) 2. expressive (single word) 3. phrase level 4. sentence level. The paper-based pupil assessment grid was constructed with regard to these levels and aspects (figure 1). For the receptive subtest, children were shown three visual presentations of a concept on the computer screen (for example, a picture of an elephant, ant and man for the concept of big). They were asked to select the correct picture from the three visual presentations whilst the standard carrier phrase Find the was given verbally. For assessing single word use, a sentence starter was given verbally with a picture prompt (such as, The man is ). If the child was unable to generate the target adjective then a verbal prompt was given (for example, I want you to use the word frightened. The man is ). If the word was self-generated it was marked on the grid with a tick. However, if a prompt was used a small p was also entered. For phrase level testing, the child was shown a picture (such as a dirty shirt) and prompted verbally with
the sentence-starter, Its a.... Visual support was also provided using a colour-coding system (a green card for adjectives and an orange card for the noun). The colourcoding system is based on an amalgamation of semantic / grammatical colour-coding approaches that are used widely in speech and language provisions. At sentence level the child was shown a picture to describe. The Noun phrase-verb-adjective-noun structure was prompted by colour-coded cards to denote each syntactical part of the sentence [pink-yellow-green-orange]. The children were familiar with this colour-coding system as it has been used extensively throughout the provision classes and therapy. To make the screening more robust, we tested each concept three times (for a total of 36 trials). In retrospect, however, this should have been six trials of each concept to reduce the chance factor. To ensure consistency and reliability, one tester presented the assessment to all the children in a quiet room. The results of our pre-tests prior to the therapy / teaching input are presented in figure 2. We discontinued testing when it was evident that the child would not achieve any correct responses at that level. For example, child B was able to use many of the adjectives at single word level, but not within phrases.
Figure 2 Results of pre-testing Child Receptive - Expressive No. 3 over single word 36 trials No. 3 over 36 trials 28 33 16 32 36 31 0 30 0 9 33 27 0 27 0 Expressive phrase No. 3 over 36 trials 0 Sentence No.3 over 36 trials
A B C D E F G H I
6
18 36
0
0 31 0
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HOW I
The fruits of our labour

Over the term from April to July 2006, one of the main focuses for the class teacher and speech and language therapists was development of adjectives. This included the twelve adjectives selected for the assessment, but also expansion of general adjectival use. Where possible, this work was incorporated into curriculum planning, for example within literacy. As signing is used within the provision to support spoken language, adjectives were consistently signed throughout therapy and teaching. The class teachers and speech and language therapists met together to design several activities that were then stored in the central school database. This allowed all teachers to access the resources. We found the Clicker 5 programme extremely useful during our assessment phases for receptive and single word expressive subtests. Initially, the collation of pictures and design of activities was time intensive. Our choice of pictures was restricting at phrase and sentence levels where video clips would have perhaps been more fruitful. It was difficult locating the pictures for the level three concepts: tall, thin, frightened, and long. These pictures were also not as successful during testing where some clarification was needed (for example, reference was made to comparatives such as tallest). On occasions children made literal responses within the receptive subtest as a result of picture size, such as pointing to baby for big as it was the biggest picture rather than having internalised the concept. The ACTIVprimary software enabled us to design fun interactive activities such as: Sorting pictures of big / not big items by placing not big items into a visual box - children could move pictures around the screen; Spotlight tool for revealing a picture slowly for the children to describe, for example happy boy; Attaching noisy / not noisy sounds to pictures of items such as a fire engine - children could click onto the picture, listen to the noise and then describe it; Selecting a story background scene and characters like the Three Little Pigs. Tasks included brainstorming adjectives and writing them over the scene in colourcoded green, then writing on phrases and sentences. Teachers within the provision became proficient users of these programmes enabling them to use the interactive whiteboard regularly during lessons. Speech and language therapists were timetabled to work within the classroom, for example during literacy. This allowed joint teaching around the interactive whiteboard, with therapists using supporting techniques like signing and language simplification. During therapy sessions, the therapists carried
A teacher using an interactive board
out more traditional activities that included tactile experience of concepts like heavy and cold.
Thorny issues?
This project was not carried out as a rigid scientific study with a control group and formal statistical analysis, and all staff acknowledged the need for traditional approaches to the teaching of adjectives as well, using other multisensory techniques. Nevertheless, this project has borne fruit and provided support for using interactive whiteboard technologies as an effective teaching tool for the development of specific aspects of language. The provision and school have continued to move forwards through this and other collaborative projects, and it was with tremendous relief that we were taken out of special measures early in 2006. Leona Cook is a speech and language therapist / dyslexia teacher with Medway PCT, e-mail cookl023@medway.org. uk and Kerry Trim is the Evergreen Centre Manager / Assistant Headteacher at Warren Wood County Primary School, Rochester, Kent, tel. 01634 337227.
Reaping the benefits

The children were re-tested in July 2006 on our assessment of adjectives (figure 3).
Figure 3 Results of pre- and post-testing Child Rec. Rec. Expr Expr Expr Expr Expr Expr single single phrase phrase sent. sent. Pre Post Pre Post Pre Post Pre Post A B C D E F G H I 28 33 16 32 36 31 6 18 36 35 36 28 36 36 36 14 29 36 0 30 0 9 33 27 0 0 31 7 34 0 12 36 33 0 0 36 0 7 0 27 0 0 34 7 0 0 8 0 0 0 0 0
References
Becta (2003) What the research says about interactive whiteboards, http://www.becta.org.uk/page_documents/research/wtrs_whiteboards.pdf (Accessed 13 October 2006) Woods, G. (2002) Concept Consolidation. Romford: Cheerful Publications.
Two of the nine children were already confident in matching a spoken adjective to a picture, and the results show the other seven improved. Of the nine children, six improved in their use of adjectives at single word level. For the other three, the nature of their speech and language disorders meant that single word production was very difficult. It was disappointing that, of the six children who potentially could have used adjectives within phrases after the teaching / therapy intervention, only three were. However, anecdotally, the older children within the provision were using the adjectives readily at phrase and sentence levels after the intervention. They also became more confident in their use of adjectives in their written work. This suggests that the issue for the younger children can be addressed through time and continued work.
Resources
Clicker 5 details at www.cricksoftware.com ACTIVboard and ACTIVprimary software see www.prometheanworld.com/uk
Acknowledgements
Our thanks to all the staff and pupils at the Evergreen Centre, to Chris Blow for tirelessly searching for the pictures and to Andrew Webster, Medway ICT consultant, for his invaluable support and advice. SLTP
24
HOW I
Research that had its compensations

DO INTERACTIVE MULTI-MEDIA DEVICES HAVE A PLACE IN THE SPEECH AND LANGUAGE THERAPY TOOLBOX? TO FIND OUT, HANNAH KAY RESEARCHED THE IMPACT OF CLICKER 4 ON THE EXPRESSIVE LANGUAGE SKILLS OF CHILDREN WITH EPILEPSY AND LEARNING AND COMMUNICATION NEEDS. WHILE NO EFFECTS OF THE TREATMENT WERE SHOWN, HER EXPERIENCE SUGGESTS SUCH TOOLS CAN HELP CHILDREN COMPENSATE FOR THEIR DIFFICULTIES.
echnology has created opportunities for greater access across the national curriculum, particularly for those with special educational needs (Stevens, 2004), and the government is clear that Information and Communication Technology (ICT) should be a significant part of every childs experience of learning (DfES, 2003). It is therefore important that speech and language therapists take advantage of the opportunities of ICT, and can offer appropriate advice on its use with our clients. ICT enables educators to combine speech, pictures, words and animation in a flexible, interactive and dynamic format, so concepts are structured in a way that suits the learners level of understanding (Blamires, 1999). For those with learning difficulties, appropriately selected technology is likely to provide more control over the learning process, increase opportunities for practice and be more suited to individual learning styles and needs. Anecdotal evidence suggests that the majority of school aged children have been exposed to interactive television, gaming devices, computers and mobile phones, and are confident in using and generalising these skills. Classroom computers are favoured during reward time, suggesting technology is motivating to children and may be better able to maintain their attention and concentration for longer periods of time. In my research I used a multi-media tool, Clicker 4, with children with epilepsy, learning and communication difficulties. I was aiming to find out if controlled practice using a visually based intervention programme resulted in skill development in spoken language (clause and sentence structure). The 10 secondary school aged participants attend The National Centre for Young People with Epilepsy, which is the UKs major provider of specialist services for children and young people with complex epilepsy. Epilepsy is the second most common neurological condition to migraine and may cause, or co-exist with, a number of language, speech or communication impairments. Characterised by transitory but recurrent disturbance of the electrical activity of the brain (Lebrun & Fabbro, 2002), there are many types of epilepsy and seizures. Children with epilepsy frequently underachieve at school, and 50 per cent achieve less than would be predicted from their IQ (Epilepsy Task Force, 1999). More than one in five people with epilepsy have a learning or intellectual disability (Sander, 2004). Educators and therapists need to consider the specific learning and language impairments associated with an individuals epilepsy and seizure activity. Cognitive impairment is frequently seen in children with epilepsy. At least 20 per
Figure 1 Clicker Grids
HOW I (2):
cent of patients with epilepsy present with features of Attention Deficit Hyperactivity Disorder (Gucuyener et al., 2003) compared to the general population, where the prevalence is reported to be approximately 5 per cent (Dunn et al., 2003). Memory function and its potential impact on academic achievement are vital considerations when managing children with epilepsy (Nolan et al., 2004) and, as such, careful consideration needs to be given to individual learning styles and therapeutic approaches. This group may also present with adverse side effects from their anti-epileptic medications, which can include motor slowing, ataxia, dysarthria, hypotonia, word finding problems, increased levels of activity, attention difficulties, memory impairment, poor concentration, delayed speed of processing and fatigue.
Context and structure

For many children with epilepsy a visual approach to learning is essential - particularly in terms of teaching key skills such as speaking and listening. While learners with learning disabilities and sensory impairments often benefit from a kinaesthetic / hands-on approach to learning, not all academic skills can easily be taught in this way. The advantage of a visual approach is that strategies adopted remain static, allowing the learner with processing difficulties to understand and internalise the information at a pace which best suits them. Visually presented information allows for revision, and can provide a context and a structure to a child with poor or variable attention. I used colour coding as a way of visually supporting language development in my therapy. The idea was driven from established schemes such as Language Through Reading and work described by Bryan (1997) called colourful semantics. I used a colour code based on the modified Fitzgerald Key, which forms the basis of the system used by commercially written language programmes and software such as Clicker. While different colour coding systems have evolved, I have found that it is the consistency for the individual or education setting which is important. Clicker 4 is a powerful multi-media tool that enables children to write with whole words, phrases or pictures. A talking word processor, you can type into it directly using the keyboard, or by clicking the mouse on items such as words or pictures which are presented within the Grid. It comes with high-quality speech software so learners can hear words before they write. It includes a large picture library plus the option of using your own
pictures, enabling written words to be supported with an additional visual aid (see figure 1). For my study, I developed a resource of 36 individual Clicker Grids presenting vocabulary needed to describe each of the 36 ColorCards selected from the Familiar Verbs pack (Speechmark, 2004) to promote the use of the relative, coordinate and subordinate clause and to stimulate the subject to provide information about every possible aspect of the picture presented. If spontaneously generated by subjects, it was also possible to insert additional vocabulary during the session. Vocabulary was supported by symbols or photographs where possible. I selected symbols from the traditional Clicker library, Mayer Johnsons PCS set and Clicker animations add-on library. Clicker animations allow moving pictures to be inserted into the grid. The animation provides additional visual cues and further supports the meaning of action words and the correct use of the present participle.
Colour coded
I colour coded each cell to support the selection of appropriate vocabulary and sequence, and presented a basic visual key using prompt cards prior to each training item, to remind subjects of a possible word order and the questions that may need to be answered when describing the ColorCard. Subjects were also shown cards of sentence starters, little words and the common auxiliary verb (is) required for the planning frame being developed. The card system was used to facilitate independent use of the Clicker grids on the screen (figure 2, p.26). The cards also prompted the subjects to find the appropriate content word from the grid.
25
HOW I
Figure 2 Prompt cards
Figure 4 Change in two subjects (Renfrew, 1997)
Subjects were reminded as necessary that the answer to the question would be found by looking for a button of the same colour from the grid. At this point, if more than one option was available and the subjects were still unsure of the word they wanted to select, they were encouraged to look at the symbol and / or right click on the mouse to receive an auditory cue. The basic colour coding system used is in figure 3.
Figure 3 Colour Coding System Colour Yellow Red Green Blue Tan Referent People/animals Noun Verb Adjectives Prepositions Question Who? What? Doing? What is it like? Where is it?
Item 3 Prompt question: What HAS been done to the dog? Subject 3 5 Before Therapy Tied up (1,1) Tied on a string (2,1) After Therapy He put on the dog (0,0) Hes been tied on wood (2,5)
Item 5 Prompt question: What has the cat just done? Subject 3 5 Before Therapy Got some rats (1,3) Catching mice (2,2) After Therapy Hes caught the mice (2,4) Catching the mouses (2,1)
Item 6 Prompt question : What has happened to the girl? Subject 3 5 Before Therapy Fallen over the stairs and shes broken her glass (4,5) Broken glasses (2,0) After Therapy Shes fallen down the stairs and broken her glasses (5,6) She fell down the stairs and hurt her glasses (4,1)
Item 10 Prompt question: Now, look at this picture (Take your time!) Tell me what is happening. Subject Before Therapy Ladys dropping her apples and the boy is picking them up (5,4) Lady dropping fruit (3,1) After Therapy The woman is the apples are all falling out of the bag and the boys picking them up (6,5) The lady dropped her apples inside the hole..boys picking them up (6,2) 3
At the beginning of the intervention all subjects were tested on the Renfrew Action Picture Test (Renfrew, 1995) and ColorCards training items. Subjects from both groups were tested in the same weeks to account for variables such as maturation. Half of the sample population were randomly selected and placed into the experimental group. The experimental group were seen during the first block of intervention, while the remaining subjects were the control group and received intervention during stage two. Intervention was 12 individual sessions, twice a week for a period of six weeks (one half term).
Prompts
Individual sessions involved 3-4 pre-planned tasks using Clicker 4. Subjects were presented with ColorCards and a question, and asked to generate a visual response (words with keyword symbolisation), using the Clicker Grid. Support and prompts were provided to promote language and sentence building as needed. Subjects were taught to activate auditory feedback after each sentence had been completed and then asked to generate a verbal response based on the sentence they had formulated, using the grid as a prompt. Following the completion of intervention by the experimental group, all subjects were re-tested. The control group were then seen in the same way. All subjects were again re-tested, and training items and assessment record sheets from the each stage of the intervention were scored. Unfortunately, an effect of treatment was not shown. There are many possible reasons for this, including:
1. The therapy was not effective. 2. The timescale was too short and / or the amount of therapy too little for it to be effective. 3. The assessment tools were not sensitive enough to change, particularly in those who were already achieving scores approaching ceiling level. It would have been useful to assess more functional situations such as sharing of weekend news with staff and peers, and to question parents and staff. 4. The individuals involved were just too different for effectiveness to be shown. (The standard deviations, calculated at each stage of testing, confirm that there were considerable subject differences within groups, and considerable variation in test performance and response over time to intervention.) However, two subjects did show general functional improvement over time (see examples in figure 4). Some variables, such as a fluctuating word finding difficulty, were difficult to control. My observation was that such difficulties were better supported during sessions, when the therapy tool providing visual cues in the form of symbols and colour coding was available. Although not generalised to the post-intervention assessment, this may be possible given more time. Five additional test items randomly selected from the original set of 36 training items appeared three times during
Compensatory strategies
In addition to the subjects own positive attitude, this research gives some indication of the potential benefits of using a multi-media tool with our clients in individual and group work. Firstly, they can support childrens receptive skills and give them a way to demonstrate their comprehension and evidence their development. Secondly, they can enable our clients to use compensatory strategies independently in the classroom. Over the six week intervention period, my subjects became more independent in the use of the Clicker Grids, and the majority required no additional input from the therapist to complete the task after two to three weeks.
26
Photo by Paul Reid - a liveACTIVE Makaton group
intervention as well as once during each assessment phase. Figure 5 shows pre- and post- intervention responses as well as one of the sentences generated by the pupil during the intervention using the Clicker Grid. I asked all subjects to answer a symbolised questionnaire, supported by staff independent of the research, to comment on their performance and effectiveness of the intervention (figure 6). I also recorded their willingness to attend, distinguishing unable to attend from did not attend, as an indication of how motivating they found the therapy (figure 7). Both suggest that multi-media tools can be a useful way of making therapy more stimulating and exciting.
HOW I
Figure 5 Intervention responses Item 13 Prompt question: What is the little boy doing? Subject 3 Before therapy Assessment Paying for a drink and theres a man behind the stall Intervention The big boy is giving some coke to the little boy. The little boy is giving the big boy some money to buy some coke The boy is giving the money to the man and buying a coke After therapy Assessment Paying for his drink
Buying a coke
Paying money for man buys coke
Item 15 Prompt question: What is the boy doing? Subject 3 Before therapy Assessment Intervention After therapy Assessment The boys grating the cheese, hes gonna put it on the jacket potato Scraping the cheese
Figure 7 Attendance Figure 7 Attendance
Hes grating some cheese The boy is grating the cheese and putting it on the potato Scraping cheese The boy is grating the cheese and putting cheese on the potato
Figure 6 Questionnaires responses
You could say that similar studies in the future may do best to focus on those whose epilepsy is better controlled, and on groups without additional complex learning, language or behavioural difficulties. Historically, many of the children included in my study may have been excluded from therapeutic interventions - never mind research - on medical grounds, due to the complexity of their needs. Yet is this right? The question I would ask is whether the goal of intervention should always be something that is measured in terms of a child learning or developing a new skill. Should we not, for some children, be focusing more on functional progress, for example by reporting on when and how a child has learnt to apply a compensatory strategy? This is of particular importance when those strategies may result in them having better access to the curriculum.
The National Centre for Young People with Epilepsy (NCYPE) is the UKs major provider of specialist services for children and young people with complex epilepsy. A national charity, The NCYPE works in partnership with Great Ormond Street Hospital for Children NHS Trust and the Institute of Child Health. Located in Lingfield, Surrey, The NCYPEs 200-acre campus includes St Piers School, St Piers Further Education College and a range of epilepsy diagnostic, assessment and rehabilitation services. www.ncype.org.uk
References
Blamires, M. (Ed) (1999) Enabling Technology for inclusion. London: Paul Chapman Bryan, A. (1997) Colourful semantics, in Chiat, S., Law, J. and Marshall, J. (eds.) Language Disorder in children and adults; Psycholinguistic Approaches to Therapy. London: Whurr Publishers Ltd. Department for Education and Skills (2003) The National Literacy Strategy, ICT in the literacy hour: Whole class teaching. Date of issue 04/03 Ref: DfES 0296/2003. London: Dfes Publications. Dunn, D.W., Austin, J.K., Harezlak, J. & Ambrosius, W.T. (2003) ADHD and epilepsy in childhood, Dev Med Child Neurology 45(1), pp.50-4.
Epilepsy Task Force (1999) Burden of Epilepsy; a health economics perspective. Leeds: Joint Epilepsy Council. Gucuyener, K., Erdemoglu, A.K., Senol, S., Serdaloglu, A., Soysal, S. & Kockar, A.I. (2003) Use of methylphenidate for attention-deficit hyperactivity disorder in patients with epilepsy or electroencephalographic abnormalities, J Child Neurol 18(2), pp.109-12. Lebrun, Y. and Fabbro, F. (2002) Language and Epilepsy. London: Whurr Publishers Ltd. Nolan, M.A., Redoblado, M.A., Lah, S., Sabaz, M., Lawson, J.A., Cunningham, A.M., Bleasel, A.F. & Bye, A.M. (2004) Memory function in childhood epilepsy syndromes, Journal of Paediatric and Child Health 40(1-2), pp. 20-27. Renfrew. C. E. (1997) The Renfrew Language Scales: ACTION PICTURE TEST. Bicester: Speechmark Publishing Ltd. Sander, J.W. (2004) The use of Antiepileptic Drugs Principles and Practice, Epilepsia 45 (Suppl 6), pp. 28-34. Stevens, C. (2004) Information and Communications Technology, Special Educational needs and school; A historical perspective of UK government initiatives, in Florian, L. and Hegarty, J. (eds.) ICT and Special Educational Needs; A tool for inclusion. Maidenhead: Open University Press
Resources
Clicker software, see www.cricksoft.com/uk/ ColorCards Familiar Verbs in context, from Speechmark Publishing, ISBN 0 86388 519 5 Language Through Reading 1/2/3, contact John Horniman School, 2 Park Road, Worthing, West Sussex, BN11 2AS PCS Metafiles UK version from Mayer Johnson is available through various suppliers. SLTP
Hannah Kay is currently working as a locum speech and language therapist at The National Centre for Young People with Epilepsy Assessment and Rehabilitation Unit, Lingfield, and The Childrens Trust, Tadworth, e-mail hkay@ homechoice.co.uk. This article is based on a dissertation submitted in partial fulfilment of the MSc in Speech and Language Therapy, City University London, Department of Language and Communication Science (December 2005).
27
CONFERENCE CALLS
Research: Getting that can do attitude
uring parts of this conference I felt I was being beaten with a stick. A constant voice in my head asked, What exactly is the point of being a speech and language therapist if nothing that we do works? Scenes from past clinics floated before my eyes and set me wondering. Where are these clients now? How are they coping? Even with all the effort and self-questioning poured into every session, did anything I had to offer actually make a difference? But, while Paul Carding was fairly scathing about the professions fitness for the evidence race, he was also keen to stress that no evidence is not the same as no use. In our favour, we are a young profession, we are willing to act and we are far from being the only discipline facing tough questions about its very existence. By the end, Rosalind Rogers, incoming chair of the Royal College of Speech & Language Therapists, sensed delegates were leaving with a much more can do attitude. So, what are we going to do differently? Matthew Hallsworth from the UK Clinical Research Collaboration said there will be no new money, so we need to be creative with what we have. Some practical suggestions and recommended reading from presenters and participants are in table 1, but I also wanted to find out what impact contributors thought their sessions had. Paula Leslie hopes those attending realised that real, onthe-job clinicians are capable of instituting evidence based practice and that they have a responsibility to do so, even if its just making an informed decision about an aspect of received wisdom intervention by critically reading a paper, or writing an objective case report. Joan Murphy, Lois Cameron and Mary Turnbull got across that speech and language therapists have the skills to do research, can be involved at different levels, and can even have fun doing it! Importantly, they say we need to build our confidence in partnership with academic institutions as therapists have pertinent clinical questions to ask and the academic institutions need us as much as we need them. While Elspeth McCartney is happy that participants understood we have some good ways of evaluating practice, and that we can show some practice is effective, she was aware of anxieties about the process that we will have to address. I think some participants in my session were concerned that measuring intervention and trying to pin down best practice might impede a therapists flexibility, and impair on line clinical responsiveness. But, as one attendee remarked, when the East Kent Outcomes system was introduced to her area, there was an initial resistance because you dont want to lose the creative buzz. This turned to a more positive attitude when people realised the benefits: After all, why would you want to keep doing something that doesnt work? Looking to the future, Elspeth McCartney has a vision of phased clinical trials of many aspects of therapy intervention, moving as far as evaluation of real therapy practice in a variety of centres and contexts, with results showing very good effects for clients. While action is needed on many levels to bring this about, individual clinicians are key to this vision becoming a reality. For James Law, this starts with people being driven by the right questions about their practice, a skill that has to be embedded in speech and language therapy training. He would like people to have relatively easy access to research support, whether that is through a university or other body, and to be realistic about what research entails in terms of the time and support needed. He wants managers to be creative about encouraging practitioners to see research as a career option
How is the profession going to increase its evidence base? Looking back on a recent conference organised by the Royal College of Speech & Language Therapists, editor Avril Nicoll considers what practical steps we can all take.
THE ROYAL COLLEGE OF SPEECH & LANGUAGE THERAPISTS HELD A CONFERENCE IN EDINBURGH ON 28 SEPTEMBER 2006 TO CONSIDER THE THEME PLUGGING THE EVIDENCE BASE GAP: IMPORTANT RESEARCH IN SPEECH AND LANGUAGE THERAPY. SPEAKERS INCLUDED PROFESSOR PAUL CARDING AND DR PAULA LESLIE FROM THE UNIVERSITY OF NEWCASTLE, PROFESSOR JAMES LAW, QUEEN MARGARET UNIVERSITY COLLEGE, ELSPETH MCCARTNEY, UNIVERSITY OF STRATHCLYDE, AND JOAN MURPHY (UNIVERSITY OF STIRLING) WITH MARY TURNBULL AND LOIS CAMERON (FORTH VALLEY PCT).
Table 1 Developing an evidence base: What can we do? All Familiarise yourself with the UK Clinical Research Collaboration (www.ukcrc.org) Read: Lewison, G. & Carding, P. (2003) Evaluating UK research in speech and language therapy, International Journal of Language & Communication Disorders 38(1), pp. 65-84. Pring, T. (2004) Ask a silly question: two decades of troublesome trials, International Journal of Language & Communication Disorders 39(3), pp. 285-302. Reilly, S., Oates, J. & Douglas, J. (2003) Evidence Based Practice in Speech Pathology. London: Whurr. Student Learn to ask the right questions Therapist Provide RCSLT with basic evidence to lobby Parliament Judge the quality of papers, and read more widely before you accept the evidence Develop critical appraisal through journal clubs / networks / special interest groups / peer support opportunities Get formal training in research skills, eg. systematic decision-making Keep a reflective diary Join local research and audit committees Academic Address pay differentials to encourage more clinician researchers Build partnerships with clinicians Management Make research as much of a priority as number of level contacts Give senior clinicians protected time for clinical research as part of their career structure, expect them to publish, and actively support them through individual performance review Maintain new graduates enthusiasm for research by protecting time and limiting caseloads Recognise that time is needed even more than funding Seek out and take advantage of funding opportunities (investment in Scotland means the next 3 years is the time to act; regional funding has been reintroduced in England) Research Build strong collaborations leaders Focus on quality Ensure a locus of responsibility to see the project through Start from a thorough understanding of professional knowledge Encourage applications and publicise schemes, eg. those designed for small scale developmental research Improve IT systems Streamline form filling Increase part-time opportunities Help the Allied Health Professions find a unified voice Broaden the medical evidence hierarchy to include qualitative research Give extra support to proposals for relatively under-researched fields Royal College Develop a research strategy that facilitates a of Speech & research attitude, sets priorities and promotes our Language involvement in multidisciplinary research Therapists Outline research competencies Facilitate better support for postgraduate education Support research applications Provide extra input to areas that dont have natural links with universities Build on the advice offered in Communicating Quality 3
L-R Jan Broomfield, Elspeth McCartney, Jen Reid and Mary Turnbull have much to offer as the profession plans a research strategy.
that they can support in practice, rather than assuming that people will disappear off into universities. Paula Leslie is passionate about the need for more clinician researchers to build a robust evidence base. The clinician researcher is sometimes more clinician: evaluating practice with a researchers robust and beady eye. And sometimes more researcher: with a clinicians understanding of the frailty of the human situation and the questions that need answering to more directly improve patient care. Joan Murphy, Lois Cameron and Mary Turnbull know from experience that this can only happen if research time is seen as an essential part of our career, rather than an added extra, with protected time given. There is clearly a fair level of agreement on the way forward, and many small things we can all do to get things moving, whether we are individual clinicians or in a leadership role. It seems that opportunities have been missed for example, one delegate commented that Agenda for Change could have been used to build a research attitude into job descriptions. And, though the conference largely chose to pass over this, we must not underestimate the challenge of building research capacity, particularly in parts of the NHS in England at the moment. The point, however, is that we want to make a real difference to people with communication and swallowing needs, now and in the future. We need to have confidence in our clinical decision-making and information giving. We have to develop the professions resilience. Cant do is simply not an option. SLTP
28
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4) PARENTAL INVOLVEMENT We have found that parents are the key to any successful group. They are a means to support activities, and their understanding of the aims and objectives of the group is always an important focus of our strategy. Parents are sometimes reluctant to join in with activities and it is important to gauge their confidence levels. We would never force parents to participate but their involvement is always encouraged and supported, as is that of other family members; for example we have had some very active grandparents willing to be birds, rabbits etc. Children always benefit more from the group if there is full parental participation and support to repeat activities at home. Parents are also important in providing feedback so we can develop and improve our service (see no. 8). 5) GROUP ACTIVITIES Here are three of our favourites: a) Bubble wrap This provides a wealth of activities focusing on verbs. Hop, skip, jump and crawl to pop the bubbles. (Remove socks and shoes to prevent slipping.) b) Puppets These help to encourage the children in a nonthreatening way. c) Cardboard tube We paint a long cardboard tube (for example the inside of a roll of carpet). We post objects down the tube and get the child to name them when they re-appear. If you would like a copy of the programme, contact us at the The Fairfield Centre (01229) 841315. 6) FIRST HUNDRED WORDS LIST This has been a very valuable resource and we have found it useful when targeting vocabulary in our young children. The list helps us to focus on appropriate topics which allows us to theme each day - for example food, transport, me. The checklist is also useful in providing a baseline and post-group assessment. We adapted our list from Bill Gillhams The First Hundred Words (available in Gillham, B. (1979) The First Words Language Programme. London: George Allen & Unwin). If you would like a copy of our list, please e-mail Alison.Taylor@mbpct.nhs.uk. 7) CARPET SQUARES These are useful in helping the child to establish their own space and that of others. In our experience, squares should be all the same colour to avoid arguments over colour preference. We also find that children enjoy the responsibility of putting the mats out and stacking them away at the end of the group. The mats provide a controlled method of bringing children into a structured circle. They also help to reinforce sitting activities in contrast to moving around tasks. A local carpet shop donated our squares. (A good scrounging ability is definitely a core competency for a speech and language therapist!) 8) FEEDBACK FORM These should be an essential part of every group to make practice relevant and appropriate and to help in planning future groups. Our feedback form consists of some specific but mostly open-ended questions. Forms are anonymous and everyone has been willing to complete them. We asked about the timing of the group, the location, what they would like to see changed and if their child had enjoyed the group. As a result, we lengthened the group time from one hour to one and a half to allow more flexibility in activities and more natural communication at snack time. We also allowed sibling participation so all members of the family could get involved in speech ideas and targets. 9) TEAM WORK We have good secretarial support to carry out the many administration tasks - for example letters, booklets for parents, feedback forms and the daily plan. Colleagues are very supportive in mentioning children who would benefit from the group approach. We are also fortunate in having support from the rest of the clinic staff when activities become noisy and mobile! 10) SENSE OF HUMOUR AND FLEXIBILITY This is very important and helped us especially when we were piloting the musical group with no musical talent! The ability to laugh with the children makes everyone more willing to have a go, regardless of skill. When working with children so young, flexibility is also essential as they can be unpredictable and need lots of short activities to reflect their concentration levels.
AT THE END OF EVERY GROUP, KAREN SHUTTLEWORTH AND ALISON TAYLOR SAY THEY ASK THEMSELVES IN EXHAUSTION, WHY GROUPS?! BUT THEY HASTEN TO ADD THAT, IN ALL HONESTY, GROUP WORK PROVIDES A GOOD NATURAL ENVIRONMENT FOR CHILDREN TO COMMUNICATE. IT ALLOWS THERAPISTS TO TARGET ACTIVITIES FOR A CERTAIN GROUP OF CHILDREN, FOR EXAMPLE THOSE WITH PHONOLOGY OR LANGUAGE NEEDS. AND MORE RECENTLY ALISON AND KAREN HAVE PILOTED A MUSICAL LANGUAGE GROUP TO PROMOTE LANGUAGE DEVELOPMENT IN VERY YOUNG CHILDREN, AGED 18MTHS+. HERE, THE SPEECH AND LANGUAGE THERAPISTS WITH CUMBRIA PRIMARY CARE TRUST SHARE THEIR TOP RESOURCES FOR EARLY GROUP WORK.
1) LYCRA SHEETS This may seem very bizarre, but lycra sheets have been one of our most successful tools in any of the groups. This inexpensive resource can be used in a variety of ways. It helps to teach children co-operation and involvement as they sit in a circle, each holding the sheet. The children can pull the sheet and then release it, and bounce objects or photographs (of themselves) indeed, it can stimulate them to attempt any target word. Lycra is a brand name for the synthetic fibre known as elastane or spandex. It is relatively strong and allows material to be stretched without breaking, then to return to its original size. 2) LONG CONTAINERS Pringles potato chips 200g cans are ideal for this purpose. We put a few lentils, beans or rice grains inside and then wrap the pot in colourful plastic. This provides an inexpensive instant shaker to bang / tap / roll / shake. The shakers can be used for listening, tapping out easy rhythms, follow my leader and copying activities. They are easy for children to handle, robust, virtually indestructible and have a wonderful resonance when banged on the floor. Language associated with position (up / down), concepts such as noisy / quiet and verbs can be taught. 3) INFORMATION FROM TRAINING COURSE ON EARLY YEARS MOVEMENT AND MUSIC An inspirational Early Years Educational Course we attended linked early language to music. It was reassuring to hear that, in spite of our total lack of musical skills, it was possible to help children acquire early language through incorporating tutor Gay Wickerss excellent ideas. This helped us to encourage parents. It also gave us the confidence to try in the clinic situation. The course helped us to build up an understanding of childrens musical development which occurs in several different but related areas: rhythm, singing, physical responses to music, and instrumental awareness. The course we attended was offered locally through the Cumbria Early Years Development and Childcare Partnership, but there is also useful information on the Music One 2 One project at http://education.ex.ac.uk/music-one2one/. Music specialist and speech and language therapist Wendy Prevezer also runs a course through I CAN called Developing Communication Through Music, details on www.ican.org.uk.

Speech &amp; Language Therapy in Practice, Winter 2006

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WINTER 06 (publication date 27/11/06) ISSN 1368-2105

INSIDE COVER READER OFFERS, WINTER 06 SPEECHMAG

20 WINNING WAYS WINTER GROWTH

2 NEWS / COMMENT 7 CONNECTING IN THE ACUTE SETTING

22 HOW I USE MULTI-MEDIA TOOLS

28 CONFERENCE CALLS A CAN DO ATTITUDE TO RESEARCH

14 FEATURE I BELIEVE IN MIRACLES

BACK COVER MY TOP RESOURCES

17 HERES ONE I MADE EARLIER

IN FUTURE ISSUES: NURSING HOMES...STAMMERING...NASENDOSCOPY...APHASIA...BULLYING...SOCIAL COMMUNICATION...WRITING FOR PUBLICATION

Travel scholarship deadline

Every Disabled Child Matters

Aphasia funding plea

Is two better than one?

Hospital Food Watch

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

NEWS AND COMMENT

Funding crisis highlighted

Speaking and listening skills

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

COVER STORY: CREATIVE SHORTS

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

COVER STORY: CREATIVE SHORTS

Figure 1 Printed menu

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Not what he thought

COVER STORY: CREATIVE SHORTS

Communication aid stories

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

Connecting in the acute setting

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

Part 2: The volunteers perspective

Susan Kidd offers training

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

Five to nine months

Three to five years

*Qualifications and Curriculum Authoritys Pre-level One Indicators, DfEE, 1998

Time well spent

Susan Kidd with Harriette

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

Illustration by Graeme Howard

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

HERES ONE I MADE EARLIER....

Heres one I made earlier...

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

Carefully thought out PHONETICS This book of practical ideas to encourage

Activities quite complex

Caught childrens interest

Insight into changes in thinking

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

AUTISTIC SPECTRUM DISORDER

Nice Warm Socks

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Speech & Language Therapy in Practice, Winter 2006

Speech & Language Therapy in Practice, Winter 2006