Speech & Language Therapy in Practice, Summer 2001

ISSN 1368-2105
SUMMER 2001
http://www.speechmag.com
Storytelling
A multidisciplinary plot
Sensory integration
Ready for therapy
Peer support
A journey with chronic fatigue
In my experience
Sociology
How (and why) I work independently RCSLT Conference

Key messages
In the spotlight
A multisensory approach
Y O U R I M A G I N A T I O N
D E V E L O P
www.speechmag.com
www.speechmag.com
Summer 2001 speechmag
Now with a search facility! Key in any word(s) and very quickly you will be guided to relevant areas of the site. New article In the Summer 2001 issue, Keith Park discusses the value of storytelling for clients and for building multidisciplinary teams. See www.speechmag.com for an example from Marie Savill of this approach in practice with a student called Natasha. Humbug, ghosts, partying and nuts all feature...
..READER OFFER..READER OFFER..READER OFFER..READER OFFER..READER OFFER..
READER OFFER
Win Working with Adults with a Learning Disability
A comprehensive and practical resource, Working with Adults with a Learning Disability covers all aspects of working with this client group.
Written by Alex Kelly, author of Talkabout, it includes An introduction to learning disability Assessment of clients and their environment Augmentative and alternative communication Social skills Dysphagia. Each section gives the reader a theoretical background, practical suggestions and formats for assessment and a guide to intervention, as well as a clear and worked-out example. In addition, the author addresses staff training, group therapy, accessing the criminal justice system and working with a multidisciplinary team. A useful inclusion is a revised version of The Personal Communication Plan, as well as a users manual. The normal retail price is 34.95 but Speech & Language Therapy in Practice has FIVE copies to give away FREE to lucky readers, courtesy of Speechmark Publishing Ltd. To enter, simply send your name and address marked Speech & Language Therapy in Practice - ww learning disabilities offer to Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ. The closing date for receipt of entries is 25th July, 2001, and the winners will be notified by 31st July. Working with Adults with a Learning Disability is available, along with a free catalogue, from Speechmark, tel. 01869 244644, fax 01869 320040, e-mail info@speechmark.net.
Reprinted articles to complement the Summer 2001 issue of Speech & Language Therapy in Practice
Child dysphonia - harmony and balance. (Aug/Sept 1996, 5 (4))** In the light of their voice care programme, Jenny Hunt and Alyson Slater ask if therapists should be afraid of working with dysphonic children. Building an internal framework. (Feb/Mar 1997, 6 (2))** Barbara Larkham and Elaine Jeffers evaluate a contrastive metasyntactic approach to developing knowledge of English syntactic rules in a group of profoundly deaf teenagers. Assessment and therapy with adults. (Sept 1987, 3 (2))* Joan Murphy found herself devising an assessment programme for adults with mental handicap when she was asked to advise on their speech.
From Speech Therapy in Practice* / Human Communication**, courtesy of Hexagon Publishing, or from Speech & Language Therapy in Practice***
Also on the site - contents of back issues and news about the next one, links to other sites of practical value and information about writing for the magazine. Pay us a visit soon and try out our new search facility.
READER OFFER
Previous winners...
The winners of Reasons and Remedies and accompanying Personality Checklist in the Spring 00 reader offer are Katie Parrott, Jean Lindsay, Margaret Lines, Clare Attrill and Siobhan Young. In the same issue, the Psychological Corporation offered a copy of the Preschool and Primary Inventory of Phonological Awareness (PIPA) - this was won by Jean Lindsay. Congratulations to you all, and especially to Jean who can no longer say But I never win anything...
Remember - you can also subscribe or renew online via a secure server!
http://www.speechmag.com
Contents
www.speechmag.com
SUMMER 2001
(publication date 28th May) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Website design and maintenance: Nick Bowles Webcraft UK Ltd www.webcraft.co.uk Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2001 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.
Summer 2001
16 Sensory integration
Claire was a very agitated little girl who was usually over aroused, constantly on full alert and difficult to calm. The aim of treatment was to get her into an optimal state of arousal for a functional activity: taking food off the spoon without distress. In the first of two articles (Spring 2001 issue), Sarah Barnes explained how to recognise sensory deficits in children. In this second article, she demonstrates why helping a child to achieve an optimal level of arousal is crucial to the success of intervention.
Inside cover Spring 01 speechmag Reader offer

Win Working with adults with a learning disability.
2 News / Comment 4 A multidisciplinary plot

Storytelling, it seems, is a vital ingredient of human experience. But if this is so, how can we do storytelling with people who have sensory impairments and additional disabilities? Why should we bother? As a uniquely human and social experience enjoyed by all, Keith Park suggests storytelling is an ideal vehicle for promoting multidisciplinary collaboration.
19 Conference Call
Know your values; involve users; think differently; develop partnerships; have evidence-based vision. Avril Nicoll reports on five of the key messages for practice she took away from the Royal College of Speech & Language Therapists Sharing Communication conference.
20 A journey with chronic fatigue

We received a variety of therapeutic advice from a number of reputable sources but eventually had to feel our own way forward...this article is not prescriptive and certainly does not hold all the answers, but is intended to lend you the kind of support which we greatly valued from each other. Jane Patrick and Madeline Atherden on their work with two teenage girls with aphonia associated with chronic fatigue syndrome.
8 Reviews
Assessment, speech difficulties, psycholinguistics, progressive neuro, voice, hearing impairment, AAC, child language.
10 COVER STORY
Spotlight on language
The idea behind the Spotlight stems from using different coloured beams in a special torchlight as if it were a spotlight on part of a scene in a theatre, but instead used on pictures or actions. SPOTS-ON, a multisensory approach to language intervention, is relevant to any client with a language difficulty. Carole Kaldor, Janet Tanner and Pat Robinson highlight its benefits and applications.
24 Further reading
Child language, dysarthria, AAC, education, dysphagia.
14 In My Experience
Becoming a speech and language therapist does not solely concern the acquisition of clinical knowledge and the test of clinical competence; the adoption of a holistic approach marks a shift towards a more humanistic concern with communication. Sarah Earle argues that sociology is essential if students are to become reflective practitioners with an appreciation of the value of research and an understanding that successful communication is influenced by social factors and access to services.
25 How (and why) I work independently
I remain committed to the independent sector despite the enormous challenge it has posed and continues to pose - or maybe because of it? Heres to the next one - Accreditation! Janet Farrugia, Julie Andrews and Maria Farry discuss what working independently means to them and their clients.
IN FUTURE ISSUES
Cover picture by Paul Reid. The spotlight is on squeezing. Thanks to models Joanna and Connor and Inverbrothock Primary School, Arbroath. See page 10 Spotlight on Language
LARYNGECTOMY NEURO-DISABILITY INFANT FEEDING EARLY YEARS INTERVENTION DEMENTIA LEARNING DISABILITY
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001
news
Stroke units welcomed

The Stroke Association is estimating that 2500 lives will be saved each year and 3500 stroke patients will suffer less disability with the introduction of stroke units across England. The National Service Framework for Older People expects all general hospitals to have a specialist stroke service by April 2004. It sets out standards for stroke care for all ages at all stages from prevention to long-term support, with the development of intermediate care services a priority. Research has shown that patients who go into stroke units spend less time in hospital and are 25 per cent more likely to survive their stroke and suffer less disability; they also have a reduced risk of needing long-term institutional care. Chief Executive of the Stroke Association, Margaret Goose, says, The provision of stroke services across the country has been haphazard for far too long. We now have a real opportunity to organise and improve the care patients and carers receive both in hospital and in the community. However, the charity is concerned that the shortage of trained therapists may mean that some stroke patients miss out. National Service Framework, see www.doh.gov.uk The Stroke Association, tel. 020 7566 0317, www.stroke.org.uk.
Carry on gardening
Therapy for deaf children
A new booklet informs parents about speech and language therapy for deaf children in England and Wales. The 16 page publication from the National Deaf Childrens Society emphasises that speech and language therapy is part of an individuals communication development programme and is as relevant for children who are signing as for those who are not. Speech and language therapy is recommended for children with a cochlear implant and for deaf children with communication problems, including those associated with glue ear. It goes into some detail about how parents can ensure their child gets the therapy they need - and what to do if they do not - but reminds parents that speech and language therapy is about more than just time spent with the therapist. Speech and Language Therapy for Deaf Children in England and Wales from NDCS, tel. 020 7490 8656, www.ndcs.org.uk. A new website is designed to make gardening easier for everyone. Created by Thrive, the national charity that promotes the use of gardening and horticulture to improve lives, the site includes information on special tools, easy access and maintenance tips, a text-only facility and a feedback section. Meanwhile, a speech and language therapy assistant who is a Thrive supporter has spent an afternoon bringing the joys of an indoor sensory garden to people with learning difficulties who rely on AAC to communicate. Sheila Samson used Boardmaker software to make very clear and explicit symbols about sensory gardening and stages of growth, as well as the five senses. The 15-strong Hot Gossip group also received donations of plant samples from the Dundee University Botanic Gardens, and were able to smell, touch, see and hear such plants as coffee, cacti, trumpet tree, thyme, bay, rosemary, lipstick, orange, lily, hellebore, jasmine and prickly pear. To stimulate their sense of taste they sampled fruit and vegetables including lychees, mango, physallis, strawberries, tomatoes, mushy peas and prunes. Sheila says, The afternoons activities were great fun and stimulated lots of interesting conversation. We rounded up the day by signing and singing the sound track from the film The Jungle Book which we felt was suitably green! Thrive, tel. 0118 988 5688, www.thrive.org.uk; www.carryongardening.org.uk Sheila Samson, tel. 01382 346005.
Encephalitis appeal
Complete the jigsaw is an appeal for a National Encephalitis Resource Centre. The design has been broken into 1000 pieces to represent the difficult and complex task of trying to piece ones life together following the illness. One piece will be placed in the jigsaw for every 100 donated, with the contributors name appearing on the completed jigsaw which will be framed and displayed in the new resource centre. Encephalitis means inflammation of the brain and occurs in people of any age, usually as a result of a viral infection. The Encephalitis Support Group, tel. 01653 699599, http://glaxocentre.merseyside.org/enceph.html
SPEECH & LANGUAGE THERAPY IN PRACTICE
SUMMER 2001
news & comment
Asperger awareness
The introduction of a new character to a television programme is increasing childrens awareness of Asperger syndrome and how they can help. Grange Hill is CBBCs longest-running drama. Martin is a Year 7 pupil whose social communication difficulties make him a target for bullying. The National Autistic Society has produced a fact sheet aimed at young people aged 11-14 years to complement the programme. It is designed to raise awareness, give advice and inform pupils who may want to help a classmate with Asperger syndrome. It can also be used as part of a lesson plan or with youth groups such as scouts or guides. The suggestion Be a buddy is included with advice about where to go for further information. Resources such as websites, books and videos are also recommended. The National Autistic Society website now features a section dedicated to young people. NAS tel. 0207 833 2299, www.nas.org.uk.
...comment...
Avril Nicoll, Editor 33 Kinnear Square Laurencekirk AB30 1UL
Just imagine
Sarah Earle (p.14) exhorts us to find our sociological imagination so we can understand where other people are coming from and facilitate access to services. At the Royal College of Speech & Language Therapists Conference (p.19), Sally Byng argued that addressing mismatches between personal values and those of a service should lessen the professions retention problem. She recommended we work in a more holistic way, drawing on disciplines such as sociology. A more holistic and imaginative approach allows Sarah Barnes (p.16) to take a step back from a clients immediate communication and feeding difficulty. Working closely with occupational therapists, she ensures clients are first at the optimal level of arousal to enable them to benefit from more specific therapy. Is imagination our most powerful yet often latent skill? Louise Coigley believes so. She held participants spellbound at her storytelling workshop at the RCSLT conference with her book of invisible stories and her demonstration of the importance of role, ritual, rhythm, rhyme and repetition for slowing, calming and healing. Although it seems an impossible task for something so participative, Keith Park (p.4) succeeds in conveying the enormous sense of fun a storytelling workshop produces among people of all abilities, and the potential it has to improve multidisciplinary working. An example of this approach in action is on www.speechmag.com, the magazines complementary website. A link to the speechmag website appears on a new Internet portal under development at http://www.nelh.nhs.uk/speechtherapist/portal.htm. The Internet is proving invaluable to the Association of Speech & Language Therapists in Independent Practice in directing clients towards an appropriate therapist. At the start of their careers, Janet Farrugia, Julie Andrews and Maria Farry didnt necessarily imagine they would move into the private sector, but in How (and why) I work independently (p.25) they give us some insight into the variety of ways speech and language therapists can develop as independent practitioners. It is easier to find peer support in the NHS than in independent practice but, for more unusual and long-term cases, you may actively have to seek it out. Although they received a variety of advice on appropriate management, Jane Patrick and Madeline Atherden (p.20) eventually had to feel their way with two teenage girls who had aphonia associated with chronic fatigue, peer support stimulating the imagination. Inspiration can strike anywhere, anytime if you have an open mind. Carole Kaldors SPOTS-ON communication system (p.10) is a flexible, multisensory tool which uses the attractions of a theatre spotlight to draw attention to aspects of language. Carole talks about the life in the shared communication between therapist and client and how this can benefit from the therapist coming up with their own activities. At the conference, Claire Topping quoted four forces for maintaining the status quo: established practice; fear of change; confidence in well-learned skills; complacency. By unleashing our imagination, we have a powerful opposing force for change.
tel/ansa/fax 01561 377415
Evidence-based practice
Advice is available to help health care professionals make full use of research to ensure their practice is evidence-based. A bulletin from the NHS Centre for Reviews and Dissemination addresses the problem of busy clinicians accessing the best available sources of research evidence on clinical effectiveness. It recommends searching key focused resources such as the Cochrane Library and summaries of research evidence along with using libraries and search services and seeking training in search skills. Effectiveness Matters 5 (1), February 2001, tel. 01904 433648. Cochrane Library www.update-software.com/cochrane Clinical Evidence www.evidence.org Effective Health Care bulletins www.york.ac.uk/inst.crd.
e-mail
avrilnicoll@speechmag.co m
Access improves attitudes

Investment in access to education for disabled children is paying dividends. A report from the National Union of Teachers and the charity Scope found that, in 90 per cent of schools covered by the Schools Access Initiative, pupils have improved attitudes to those with disabilities. It also showed that schools and education authorities feel more positive about the inclusion of disabled children than they did in 1992 when the first survey on access was published. It recommends continuing Government investment in the initiative which is credited with improving access to the curriculum and providing opportunities for long-term friendships. Within Reach 3 15 organisations / 5 individuals from Scope, tel. 020 7619 7341 or see www.teachers.org.uk.
Toy libraries funded

Around 150 new toy libraries are to be created for young children in deprived areas in England. Parents will be able to borrow toys and play equipment and many libraries will offer onsite play facilities and care support for young children, including those with special needs. The libraries will be run by a mixture of volunteers and paid staff. Some will be mobile for families who have difficulties travelling. The project is supported through the European Social Fund and is to cover set-up costs.
multidisciplinary work
T
Interactive storytelling:
A multidisciplinary plot
Storytelling is a uniquely human and social experience enjoyed by all, including people with severe and profound learning disabilities. As such, Keith Park suggests it is an ideal vehicle for promoting multidisciplinary collaboration.
Read this if you believe in the therapeutic value of laughter are seeking ideas for inclusion want to promote multidisciplinary working
his article describes a one day course which aimed firstly to present some ideas on interactive storytelling for individuals with severe and profound learning disabilities, and, secondly, to explore how this activity might serve as a basis for multidisciplinary collaboration. There were about 45 participants who were from a wide range of professions who work with children and adults with severe and profound learning disabilities: speech and language therapists, teachers, support workers, audiologists, physiotherapists, and so on. The reason for the first aim is illustrated by Meat of the Tongue, a Swahili story from Angela Carters collection of fairy tales (Carter, 1991), which tells of a sultan whose unhappy wife grows leaner and more listless every day. The sultan sees a poor man whose wife is healthy and happy, and he asks the poor man his secret. Very simple answers the poor man, I feed her meat of the tongue. The sultan immediately orders the butcher to buy the tongues of all the slaughtered animals of the town, and feeds them to his wife. The queen gets even more thin and poorly. The sultan then orders the poor man to exchange wives. Once in the palace, the poor mans wife grows thin and pale. The final part of the story goes as follows: The poor man, after coming home at night, would greet his new (royal) wife, tell her about the things he had seen, especially the funny things, and then told her stories which made her shriek with laughter. Next he would take his banjo and sing her songs, of which he knew a great many. Until late at night he would play with her and amuse her. And lo! the queen grew fat in a few weeks, beautiful to look at, and her skin was shining and taut, like a young girls skin. And she was smiling all day, remembering the many funny things her new husband had told her. When the sultan called her back she refused to come. So the sultan came to fetch her, and found her all changed and happy. He asked her what the poor man had done to her, and she told him. Then he understood the meaning of meat of the tongue (Carter, 1991, p 215).
Uniquely human
Storytelling, it seems, is a vital ingredient of human experience. But if this is so, how can we do storytelling with people who have sensory impairments and additional disabilities? Why should we bother? Jean Ware provides an answer when she suggests that, in choosing activities for people with profound and multiple learning difficulties, our aim should be to enable the child to participate in those experiences which are uniquely human (Ware, 1994, p.72). Storytelling may be one of these uniquely human experiences. Whether it is legend, myth, folk tale, fairy story, poem, novel, film or play, the principle is the same: everyone everywhere enjoys stories. According to the story Meat of the Tongue, we all need them. Angela Carter suggests that For most of human history, literature, both fiction and poetry, has been narrated, not written - heard, not read (Carter, 1991, p.215).
The literature of fiction and poetry from around the world has existed in oral form for many thousands of years, long before the development of comparatively recent forms: writing, printing, radio, TV, cinema and Internet. The oral narration of stories was, and often still is, a social event where the story is sung, spoken or chanted, or in other words, performed. Storytelling may be far more important than reading and writing; our starting point for literature may therefore be in the performing of stories. The reason for the second aim is simply that multidisciplinary collaboration can be seen not as a luxury but as a necessity. Interactive storytelling is just one forum that can encourage the development of multidisciplinary collaboration. Imagine a group of clients with complex needs children or adults - seated in a semi-circle for a storytelling activity. The speech and language therapist may provide the communication aims for the activity, the physiotherapist might advise on the best positioning, an occupational therapist might advise on the positioning of switches, a teacher of the deaf and an audiologist skilled in the use of British Sign Language can advise on appropriate sign use, and so on. In theory it seems easy, so we decided to put the theory to the test. The day was opened by Alison Keens, the Therapies Team Manager for Lewisham adults with learning disabilities who welcomed the participants and explained the aims for the day. As an introduction to interactive storytelling, everyone then participated in a version of the Cinderella story by the brothers Grimm (adapted from Zipes, 1992), a version without the Fairy Godmother and Buttons, and with more than a hint of violence. This story is done using three main ingredients: rhythm, response and repetition. Most of the lines are in eight beat, and this helps to build a powerful momentum to the storytelling. In almost every case, there is a group response in alternate lines (as indicated in brackets) and so the participants are drawn into the rhythm of the storytelling. Thirdly, there is lots of repetition, which is of course a basic ingredient of folk tales where something bad, or good, or different, usually happens on the third visit or the third day. This story is done in pantomime style, and is intended to be colourful, exuberant, and with lots of participation. Someone is chosen as Cinderella to give direction to the verbal abuse she receives! It is easier to try it out with your colleagues than just to read the words on the page (figure 1).
Figure 1 - Cinderella Say hello to Cinderella (hello Cinderella!) Cinderellas ugly sisters (Boooo!) They were off to a Three Day Party (Oooooh!) Where the prince might find a bride (Aaaah!) Can I go? said Cinderella The ugly sisters said: You cant go cos you cant dance. (You cant go cos you cant dance) You cant go youve got no clothes. (You cant go youve got no clothes) Cinderella went to the hazel tree. She said: Shake and shiver little tree. (Shake and shiver, little tree) Let gold and silver fall on me. (Let gold and silver fall on me) She had a gold and silver dress She had golden slippers. Cinderella went to the ball Cinderella danced with the prince. And then she ran back home (Phew!) Day two: the sisters got dressed up They were off to the Three Day Party (Ooooh!) Where the prince might find a bride (Aaaah!) Can I go? said Cinderella The ugly sisters said: You cant go cos you cant dance. (You cant go cos you cant dance) You cant go youve got no clothes. (You cant go youve got no clothes) Cinderella went to the hazel tree. She said: Shake and shiver little tree. (Shake and shiver, little tree) Let gold and silver fall on me. (Let gold and silver fall on me) She had a gold and silver dress She had golden slippers. Cinderella went to the ball Cinderella danced with the prince. And then she ran back home (Phew!) Day three: the sisters got dressed up They were off to the Three Day Party (Ooooh!) Where the prince might find a bride (Aaaah!) Can I go? said Cinderella The ugly sisters said: You cant go cos you cant dance. (You cant go cos you cant dance) You cant go youve got no clothes. (You cant go youve got no clothes) Cinderella went to the hazel tree. She said: Shake and shiver little tree. (Shake and shiver, little tree) Let gold and silver fall on me. (Let gold and silver fall on me) She had a gold and silver dress She had golden slippers. Cinderella went to the ball Cinderella danced with the prince. And then she ran back home. (Phew!) But she had lost her slipper! (Oh No! or Oh Yeah? if you want the cynical version!) The prince picked up the shoe and said: Ill find the girl whose foot fits this shoe, And I will marry her (Aaaahhh!) He came to Cinderellas house. He said: Whose shoe is this? The sisters said its mine its mine. (Oh no it isnt!) Oh yes it is!! (and repeat for as long as you can stand it) One sister tried the shoe on; Her foots too big, it doesnt fit (Ouch!) Her mother said Cut your toe off (Cut your toe off!) You wont need it when youre queen The two white pigeons said: Looky look look at the shoe that she took (Looky look look, At the shoe that she took) Theres blood all over. (Yuk!) And the shoes too small. (Ow!) Shes not the bride you met at the ball. (Oooops!) The other sister tried the shoe on. Her foots too big, it doesnt fit (Ouch!) Her mother said Cut your toe off! (Cut your toe off!) You wont need it when youre queen The two white pigeons said: Looky look look at the shoe that she took (Looky looky look at the shoe that she took) Theres blood all over. (Yuk!) And the shoes too small (Ow!) Shes not the bride you met at the ball. (Oooops!) Cinderella tried the shoe on (a long, expectant pause here) The two white pigeons said: Looky look look at the shoe that she took. (Looky looky look at the shoe that she took) The shoes just right. And theres no blood at all. Shes truly the bride you met at the ball. (Yes!!) So Cinderella married the prince (Hooray!) They lived happily ever after (everyone says the final line together).
Easy to do
In this introductory session, several other examples of interactive storytelling were described and demonstrated (Park, 1998; 1999; 2000). Margaret Charlesworth, a speech and language therapist from Nash College, Bromley, gave a presentation on switch use. She brought a variety of switches and VOCAs (Voice Output Communication Aids), explained their uses, and demonstrated how they could be used in storytelling and other activities. Pam Davis, from the Intensive Support Resource based at Leemore Day Centre then described some of her innovative storytelling activities at
Figure 2 - A Guyanese Folk Song
Helena an she muma goh ah grung What? Helena an she muma goh ah grung Ooh! Helena start cry feh she belly What? Helena start cry feh she belly Aah! Go home Helena Go home Helena Go bwoil serose fi yuh belly Go bwoil serose fi yuh belly Gal ah wah dis yuh bwoil fi yuh belly What Gal ah wah dis yuh bwoil fi yuh belly Ooh? Gal ah poison yuh bwoil fi yuh belly What? Gal ah poison yuh bwoil fi yuh belly Oh no! Muma stir de pot Muma stir de pot An de nite sage ah cum by di bungle An de nite sage ah cum by di bungle De muma she tek some serose What? De muma she tek some serose Ooh! An she bwoil it an gi it to Helena What? An she bwoil it an gi it to Helena
Left: The Guyanese Folk Song group Below: The Dr Who group Bottom: The Elmer the Elephant group: Elmer is multi-coloured, But his friends are grey. Right: Neptunia - The Goddess of the Lake group: I command the wind to blow!
Figure 3 - Dr Who
Look at the Box!
What box That box there What box where That box there Its the Tardis - oh yeah! Shall we go in Yes well go in Shall we go in Yes well go in Whos going in? (name) going in Whos going in? (name) going in Whos in the box Hes in the box Who, who? Im doctor Who Who Who Im Doctor Who Were all in the box Close the door Countdown commencing Off with a roar 5, 4, 3, 2, 1 (everyone stamps feet getting louder and louder) WHOOOSH! Everyone calls out Dr Who theme music, which of course is as follows: dum di dum dum di dum, dum di dum dum dum dum di dum dum di dum, dum di dum dum dum dum di dum dum di dum, dum di dum dum dum dum di dum dum di dum, dum di dum dum dum Woo-oooooooooooooooooooooooooooh!!!!!!!
Leemore Day Centre for adults with learning disabilities and showed some video to illustrate these sessions. Two main points of all the morning presentations was that, firstly, interactive storytelling is easy to do, and that, secondly, communication devices are essential in encouraging the participation of those individuals with the most complex needs. The afternoon session was a practical workshop. Participants divided themselves into groups, took a story or poem of their choice and had 45 minutes to re-work it into an interactive storytelling activity. In the final part of the day each group presented their story to the rest of the participants; each story was photocopied and so at the end of the day everyone left with a copy of all the stories for immediate use in their workplace. Two of the stories that were made that day, in just 45 minutes and using no equipment (other than the communication aids which would of course be used in the workplace) are in figure 2 (a Guyanese
folk song) and figure 3 (a version of Dr Who). Both of these stories are very simple to tell and were greatly enjoyed by everyone, as were all the others: an extemporary story about not wanting to get up in the morning, a version of Elmer The Elephant, a send-up of Lewis Carrolls poem Jabberwocky, and an adult version of the Enormous Turnip. All of these storytelling activities were very cleverly made, and provide many opportunities for individuals with the most complex needs to participate in the storytelling process. They are easier to perform than to read, so try them out - and then, better still, try arranging your own storytelling workshop, and grow your own stories. Since the workshop, there have been several storytelling developments in Lewisham. The secondary school for children with severe learning disabilities is about to start a regular storytelling project that will, over the year, involve all of the pupils at the school, and several professionals
from a number of disciplines. Speech and language therapists in the adults with learning disabilities team are meeting with their colleagues to plan similar activities in a variety of community settings. We plan to hold another storytelling workshop next September to review the activities that have taken place and to plan for future developments. Keith Park is based at the Sense Family Centre, 86 Cleveland Road, Ealing W13 0HE, tel. 0771-502-6354, e-mail: keith@busheyhillrd.demon.co.uk. The course interactive storytelling - a multidisciplinary plot took place at Lewisham Town Hall on September 23, 2000.
References
Carter, A. (ed) (1991) The Virago Book of Fairy Tales. London: Virago Press. Park, K. (1998) Dickens For All: Inclusive Approaches to Literature and Communication for People with Severe and Profound Learning
news extra..news extra..news extra..news extra..
Childrens brain injury needs

Improved links between services for children with acquired brain injury and access to a speech and language therapist with specific experience are key recommendations of a report into the condition. The Childrens Acquired Brain Injury Interest Group report also focuses on the need to speed up the implementation of more community-based provision and for accurate information to enable people to access services and benefits at the right time. The long-term nature of the impact of acquired brain injury is emphasised and information for children and young people is described as a specialist skill that cannot be achieved by simplifying material targeted at adults. Many of the recommendations concern the need to raise awareness and skills among school staff. The Group was established in 1999 as an umbrella organisation to represent and improve the quality of life of all children with acquired brain injury, their families and carers. One of its goals is to foster collaboration between health, education and social services. Missing Out - The lifelong impact of childrens acquired brain injury, prepared by Sophie Petit-Zeman, tel. 0115 941 0006 (Secretariat).
Communication skills through music

Reflections
Do I use storytelling as a device to improve communication and social skills? Do I ensure clients have the necessary communication aids to enable them to participate? Are
Preschool music and singing lessons are proving popular with parents and children as a means of developing confidence and communication skills. The Jo Jingles franchise starts children as young as one year old with percussion instruments, doing simple action songs and simple music and movement. Between two and three years children begin to learn to play the instruments without too much help and concepts of loud/soft and fast/slow are introduced. By three to five years, they often play the instruments in time to the music and are introduced to simple music concepts such as duration, orchestral instruments, pitch, dynamics and tempo. While packages are available for preschool groups such as nurseries, the other classes are attended by children with their parents and the emphasis is on informality and fun. www.jojingles.co.uk, tel. 01494 676575.
New deal for computers
we having fun yet?
Surplus Jobcentre computers are being refurbished by people with cerebral palsy for use within the community. With the Employment Service undergoing a modernisation of its IT, supplier Electronic Data Systems is giving the old computers to the charity Paces which aims to create jobs and training opportunities for people with disabilities to help them achieve economic and social inclusion. Paces will train disabled New Dealers to recondition the machines which will then be given to schools and charities. Paces was set up in by parents in 1997 in support of conductive education for children with cerebral palsy. www.paces.org.uk
Disabilities. The British Journal of Special Education 25 (3) 114-118. Park, K. (1999) Storytelling with people with sensory impairments and additional disabilities. The SLD Experience 23, 13-16. Park, K. (2000) Riverrun and Pricking Thumbs. The SLD Experience 25, 11-13. Ware, J. (1994) The Education of Children with Profound and Multiple Learning Difficulties. London: David Fulton. Zipes, J.(ed) (1992) The Complete Fairy Tales of the Brothers Grimm. London: Bantam Books.
Training framework
The author of a research report into continuing professional development hopes her work will be the catalyst for multidisciplinary local initiatives. Dr Eve Pringle found that, while there is a broad consensus about its importance, strategic, organisational and individual barriers remain. The project in Kent and Sussex explored the education and training needs of speech and language therapy, radiography, physiotherapy, occupational therapy, dietetics, chiropody and clinical psychology. The resulting multidisciplinary framework for continuing professional development sets out the need for underpinning structures which facilitate it, better coordination, development of work based opportunities and dissemination of funding information. Training for managers in assessing the needs of their staff and closer working between the professions are also key elements. Dr Pringle does not underestimate the difficulties associated with achieving change in attitude and working patterns established over many years, but notes that by simply creating an opportunity for practitioners and managers from the separate professions to sit down together and discuss the projects findings and CPD issues more generally, ideas began to develop and local initiatives were beginning to be forged. Pushing an open door (A stakeholder approach to developing CPD initiatives for professions allied to medicine and clinical psychology) by Eve Pringle, ISBN 1901177262, published by the University of Brighton is 15, tel. 01273 643647.
See www.speechmag.com for an example of this approach in practice with a student called Natasha. Humbug, ghosts, partying and nuts all feature...
reviews
REVIEWS. . . . . . . . . .
Clinically useful
ASSESSMENT
SOMA: Schedule for Oral Motor Assessment Sheena Reilly, David Skuse, Dieter Wolke Whurr ISBN 1 86156 134 2 75.00 The SOMA has been developed as a standardised procedure for the assessment of oral motor skills in infancy. It is used to identify clinically significant oral motor dysfunction in children with or without an identified neurological disorder. The assessment pack is well presented, and includes detailed administration and scoring manuals, published articles, and photocopiable scoring sheets. The background details regarding the development of the assessment are interesting and provide relevant information about validation and reliability. The assessment itself aims to rate discrete oral motor behaviours during the presentation of graded textures of food. At first glance the score sheet looks complex, but in practice it is relatively easy to complete and score. There are a few minor errors in the score sheet but these should not cause confusion. At 75 the SOMA is not cheap. However, for therapists working in paediatric dysphagia, it is a clinically useful tool. With familiarity the schedule can be administered and scored in around 30 minutes, and the detailed assessment of specific behaviours with a range of food textures can be helpful in planning intervention and measuring outcomes. Marian Johnson is head of paediatric speech and language therapy with North Tees and Hartlepool NHS Trust.
reviews
Excellent value
HEARING IMPAIRMENT
Guidelines for Mainstream teachers with deaf pupils in their class Effective inclusion of deaf pupils into Mainstream Schools Using residual hearing effectively RNID ISBN 0 900634 76 6 ; 0 900634 74 X ; 0 900634 75 8 5.99 each These 3 booklets form part of a series written for education staff (mainstream teachers, learning support assistants, Special Educational Needs Coordinators and Teachers of the Deaf) who support deaf children in mainstream schools. They provide clear, well presented and photocopiable material on: different types of hearing loss strategies for classroom management technology used to support deaf children different communication approaches examples of good practice including sample worksheets, Individual Education Plans and modified texts. All would be valuable for a specialist speech and language therapist working with hearing impaired children in educational settings. For non-specialists I would thoroughly recommend Using Residual Hearing Effectively which contains jargon-free and easy to read information. The sections on glue ear are suitable for sharing with parents and preschool staff and should be essential reading for anyone working with children. Excellent value. Rowena Fellingham is a speech and language therapist at a Child Development Centre for Harrogate NHS Trust.
A cracking book
AAC
Introduction to Augmentative & Alternative Communication (2nd Edition) Stephen Von Tetzchner & Harald Martinsen Whurr ISBN 1 86156 187 3 29.50 A cracking book; relevant to new and experienced alike. Prior knowledge is not assumed so it is relevant for a wide variety of readers, not just speech and language therapists. Clear definitions and explanations are provided throughout. It is practical but thought provoking and takes you through the whole process of providing an AAC system for an individual from describing and defining low and high tech AAC (eg. manual and graphic sign systems; voice output devices) through to the choice and implementation of the system. It also discusses the role of the conversation partner, and conversation skills of the user. Its focus is on potential AAC users with developmental language and communication disorders only, and it provides information on the most common groups (eg. motor impairment and autism.) One criticism: it is unclear as to which manual sign system is being depicted throughout the book, which may be a little confusing for those less familiar with particular systems. Excellent value for money! Penny Williams is a speech and language therapist at John Chilton School (a school for children with physical & medical needs.)
New ideas
PSYCHOLINGUISTICS
Childrens Speech and Literacy Difficulties (2) Identification and Intervention Joy Stackhouse and Bill Wells Whurr ISBN 1 86156 131 8 19.50 This book extends the psycholinguistic principles of assessment outlined in Book 1. It examines the identification of speech processing strengths and weaknesses in children and how this can inform the planning and implementation of therapy programmes. The framework can also be used to measure progress. It takes a while to read and digest, but it is well worth the time if you are working in paediatrics, particularly in an educational setting. At 19.50 it represents good value for money. I certainly now have some new ideas for my own therapy but the more traditional activities can still be part of a psycholinguistic programme. The chapter on word finding difficulties was particularly useful but, as the book indicates, there are many more potential areas of work including dysfluency and intonation. Karen Kelly is a specialist speech and language therapist for Bournemouth Primary Care Trust working in a secondary speech and language Base.
Detailed exercises
VOICE
Voice and Self Ingeburg Stengel & Theo Strauch Free Association Books ISBN 1 85343 500 7 15.95 This book looks at integrating and developing each individuals vocal potential and identity. Allowing the client control of their therapy, it looks at the relationship between vocal function and personality. It explores this relationship, encouraging the therapist and client to acknowledge the link to achieve optimum voice. The chapter on anatomical and physiological links in voice production could be a useful resource to share with the voice client. Very detailed exercises and their implementation follow. Overall, a useful book for the therapist starting out in the field of voice, stressing, as it does, the importance of bringing together voice and self. The more experienced therapist will find old favourites as well as new vocal and physical exercises to add to their repertoire. Mary Price is a specialist speech and language therapist working for NHS Tayside.
Message does not ring true

SPEECH DIFFICULTIES
The Pebble in the Shoe John P. Streicher Winepress ISBN 1-57921-266-2 $24.95 This book succeeds in drawing attention to the need to address causes rather than symptoms and in directing therapists to consider the effects of oral habits (for example, finger or blanket sucking) on physical structure and speech. However, the authors boastful style and alleged guidance from God do not inspire confidence in his many assertions. He states that, in order to eliminate most speech problems, an oral habit must be identified and eliminated and then correct functioning re-conditioned and internalised with the help of thumb-sucking. This message of one universal method did not ring true for me. Admirably, the book seeks to challenge the status quo, but one is expected to take a great deal on trust. Patricia Sims is a speech and language therapist in North Devon. She specialises in special needs and literacy problems.
reviews
Useful for discussion and reflection

PROGRESSIVE NEURO
As Long As Possible: An Encounter with Motor Neurone Disease Linda Mowatt (proceeds to MNDA/Sir Michael Sobell House hospice charity) Quince, Oxford ISBN 0-9539228-0-4 9.99 This is hard to start reading because it is not an academic, or How to .. book, and is not going to be a comfortable holiday novel - so why read it? Billed as a love story, there are some delicate and poignant glimpses of the individuals beneath the text, but the passion is subsumed by the increasingly complicated and protracted practicalities of everyday life with a severe disability. It is a largely matter of fact account of the authors journey, with her lover, through the progression of his motor neurone disease, a journey that is harrowing but, for her, an inevitable choice. It is valuable for students and for those new to progressive neurological disorders as a personalised case history. It catalogues the progression of symptoms and services on offer, the use, or not, of communication aids, IT and other equipment, and the rejection or acceptance of help. It does not dictate or pretend to be a definitive account. Instead, it challenges us to reflect more carefully on issues such as resistance, over-protection and potentially abusive relationships. Clinicians at all levels will find it useful to use parts to trigger discussion and reflection on issues we encounter daily. It could, also, inform our process of assessment, decision making and goal setting, as it highlights how important the personal relationship and knowledge of the home situation is for clinicians. Most importantly, perhaps, anyone who works with people facing increasing difficulty and loss of communication cannot help but be touched by the grief (plus all the other emotions) that that person and their family and friends are suffering. This book will remind the experienced among us and warn the inexperienced that supervision, reflecting on our own views of loss and disability, and finding a way of managing our own grief are essential for our work and health. Gwyneth Evans-Patel is a specialist speech and language therapist with Croydon and Surrey Downs Community NHS Trust.
Comprehensive, effective, time effiCHILD LANGUAGE

CELF-3UK The Psychological Corporation 345.20 The CELF-3UK is a comprehensive assessment tool which displays the potential to provide valuable information in the diagnosis and intervention of communication skills across various individuals, including people with learning disabilities. This colourful and attractive test is standardised and representative to the UK population. It examines various communication skills using a combination of core and supplementary subtests which can be analysed and used for: screening assessment/qualification for service/placement extension testing establishing objectives and interventions assessment progression. The CELF-3UK displays political terminology when referring to age groups (children, adolescents and young adults) and has attempted to reduce any bias of race/ethnicity, gender and ability/disability. Formatting of the Record Form provides accessible verbal scripts required by the examiner in many of the subtests and an accessible and easy scoring format, whereby quick addition of the raw scores can be established after each subtest. Additionally, the starting point and discontinuation rules are clearly outlined on the Record Form and have the potential to avoid frustration and wasting of time during testing. Initially the CELF-3UK can be quite time consuming but - once the examiner is confident and experienced in the administration, scoring and interpretation of all the subtests within the various age groups - it has the potential to be a comprehensive, effective and time efficient assessment tool. Difficulties may arise when using it with people who have a learning disability. This client group may find the subtle clues difficult to detect. However, the stimulus manuals provide a variety of materials upon which assessment and intervention can be based for this population. Helen Aguirre is a speech and language therapist with Lifespan Healthcare in Cambridge. She won this assessment in the Autumn 2000 issue of Speech & Language Therapy in Practice.
..news extra..news extra..news
Valuing people
A major new strategy aims to improve radically the life chances of people with learning disabilities in England. The principles of civil rights, independence, choice and inclusion are behind key initiatives in the Governments white paper which was developed in consultation with people with learning disabilities. Designed to tackle the social exclusion and discrimination experienced by many people with learning disabilities and their families, the strategy will affect the work of many agencies - social services, health, education, housing, employment, the Benefits Agency, and the independent and voluntary sectors. The key initiatives include a new fund of up to 100m over the next two years, improvements in community accommodation, council day services and advocacy services, the creation of a Task Force, more research and specialist local services for people with severe challenging behaviour. Valuing People: A new strategy for learning disability for the 21st Century is at www.doh.gov.uk/learningdisabilities (or 15.95 from The Stationery Office.)
AAC shift
The concept of personal equipment marks a shift in government attitude to communication aids in England that has been welcomed by a disability charity. Schools Minister Jacqui Smith has announced 10m to provide hi-tech communication aids to children with special educational needs and disabilities and back this up with appropriate training for teachers and users. Working with specialist centres and the voluntary sector, she says that As well as helping young people to access the curriculum and learn alongside their peers, this project will aim to ease their transition from school into employment or further or higher education. In some cases this may mean that a particular piece of equipment goes with the young person, and the concept of personal equipment will be at the heart of this work. The announcement follows a visit by communication aid users Nikola Rennie and Jenna Jones, who attend Scopes Beaumont College in Lancaster, to the House of Commons. They helped launch a Scope report which showed some people were being denied a voice, with funding for communication aids a postcode lottery dependent on the policies of education, social services and health authorities. Speak for Yourself from Scope, 3 for individuals and aid users, 12.50 to professionals and organisations, tel. 020 7619 7341.
Free personal care in dementia

A dementia charity has welcomed the Scottish Executives commitment to legislate for free personal and nursing care for people with dementia. Legislation is to be introduced by 2002 which will enable people with dementia and other chronic illnesses in Scotland to receive free nursing and personal care on the basis of assessed need. However, Alzheimer Scotland - Action on Dementia has also called for immediate action to end postcode prescribing of dementia drugs in Scotland now that the National Institute of Clinical Excellence has ended the practice in England. Alzheimer Scotland - Action on Dementia, tel. 0131 243 1453, telephone helpline 0808 808 3000, www.alzscot.org (The Editor apologises for putting an incorrect website address in the last issue of Speech & Language Therapy in Practice.)
cover story
In 1984, Carole Kaldor devised a multisensory approach to language intervention, now known as the Spotlights on Language Communication System. Although it has been modified for children with various difficulties, it was initially used to meet the functional communication needs of adults with dysphasia. Here, Carole and her colleagues, Janet Tanner and Pat Robinson, highlight its benefits and applications. Although they focus on children with specific language impairment, the principles and methods are just as relevant for adult neurological and adult learning disability client groups.
Read this if you work with anyone with language impairment want to bridge the gap between the nonverbal and the verbal like to use a flexible, individually responsive approach
he Spotlights on Language Communication System [SPOTS-ON] has gradually developed over a 16year period to meet the functional needs of giving and receiving messages. It was first used to assist dysphasic adult clients and then children with mild learning difficulties and language impairments. The idea behind the Spotlight stems from using different coloured beams in a special torchlight as if it were a spotlight on part of a scene in a theatre, but instead used on pictures or actions. Central to the approach is the use of basic shapes (figure 1). For the adults, shape outlines only were displayed on a page in which information could be collated, for example; who was referred to? what were they doing? where were they? For the children, the shapes in a line on a page were used as a clue to organise their memories into verbal communication. The instruction for 10-12 year olds was to think of pictures in your mind and relay them by drawing and / or using spoken words. The torch proved too interesting to the children, so they were provided with something to hold that was relevant to the task. For several years the system has been further modified for use with 4-7 year olds within a school for children who have speech, language and communication impairments, some of whom may have characteristics associated with the autistic spectrum. This has involved making use of the knowledge gained from the work of authors in different disciplines to devise, support or confirm aspects in the system.
10
cover story
Left: A child draws herself and her birthday cake. Although she speaks mainly in single words, using SPOTS-ON we can produce a sentence together - I have 6 candles on my birthday cake. See back page for colour illustration of this and other photographs.
Figure 1 - SPOTS-ON shapes There are three basic shapes for giving clues to language structures triangle circle arrow
names, labels, pronouns (the subject); and attribute or number (an adjective)
actions (the verb)
places (the prepositional phrase of location)
Figure 2 SPOTS-ON colours (after Conn, 1973) Figure 3 - modifications of basic shapes These basic shapes can be modified - if and when appropriate for your aims - to represent elements in language, for example:
pink for a name orange for a label yellow for an action blue for a preposition (place)
small triangle (such as for plural)
1/4 of a circle (such as for is)
1/4 of a circle (for -ing)
verb + morpheme = verb...ing
folded circle = simple past tense
green for an attribute.
Responsive
Aims are within an overall approach that is responsive to the child from moment to moment, and therefore highly flexible in its rules. In general, the system aims to: make it possible for children with specific language impairment to make use of their various and successful modes of communication and of their creativity and encourage the children to use their memory, mainly through their five senses - and especially through their actions and sense of touch. More specifically, it aims to enable young children to become proficient in understanding and using verbal language in its early stages of development for their own thinking, learning and communication provide a link between their process of pre-verbal thinking - which is highly personal and can be pictorially based - and adult verbal language used around them provide a consistent method to help children become aware of verbal language structures as a means of communication. These colours to indicate different linguistic information (figure 2) were developed by Philip Conn (1973) and, because this was the system used at Meath School in 1988/9, these colours have been superimposed onto the shapes. The coloured shapes are presented in three forms: see-through acetate; card; outlines. The different coloured acetate shapes are used as hand-held overlays to act as spotlights. These can capture a childs invol-
untary visual attention to create a potential shared focus. The focus could be an actual object or action, a pictured event or, later, written language. The acetates can be used anywhere as spotlights; for example, a yellow circle a) held over a childs hand as they stir cake mixture so they focus on their action b) used as an overlay on part of a childs drawing, or c) on a video of the child at play. The overlay can be used to create a sense of anticipation and the use of a specific coloured shape can provide a clue for the child to map meaning onto a visual scene. The coloured acetate shapes provide a primary linking device in the system, making it possible to make connections between the event and the verbal language.
Concrete and practical

The coloured card shapes are used in tasks to assemble (construct) the verbal message in a linear form from left to right. They also act as a clue, when the card is blank, that information is needed for the formation of their verbal utterance. This information can be supplied by using an actual object stuck onto the card, a symbol, a photo, a drawing or the written word. In this way, the child can practise abstract verbal tasks in highly concrete and practical ways using the words on the different card-shapes. Outlines of the shapes can be drawn with coloured pencils as non-verbal clues indicating to the child where on the paper to place or stick the words. A further stage in the process could be
for the child to draw or write their word within the outline. The outlines for a sentence or phrase indicate the number of different elements that make up the verbal utterance. It is not expected in the early stages that a child will be able to recall or work on the whole of the utterance and its morphemes (figure 3). From the adults knowledge of the childs abilities, it is possible to indicate in a non-verbal way the number of elements he should attempt, and Paget Gorman Signing supports the words and the grammatical morphemes. The childs holophrases can be set out in the elements of a sentence so they can begin to see the separate words, or that their words may be combined. The materials provide links for the question/answer situation in a social setting where the answers are unknown. The question is formed initially so that the answer is in the picture and therefore easily accessible. The activities involved in the SPOTS-ON system are also designed to assist a child in understanding the passing of time in a repeating weekly cycle. Within the week events are also linked so, for example, on Thursday we revisit Wednesdays play activities as together we watch the video of them at play. This also provides the child with an opportunity to see their moving image and relate the action to a verbal label. These are just examples of what we do in class 1, and users of the system should make use of the materials, at a level of presentation appropriate to their particular client. Further, the life in the shared communication between therapist and client benefits from the therapist thinking up their own activities.
11
cover story
Curiosity is key.
From the childs own impetus, through the adults responses, communication is established. Together they work towards sharing a verbal world. The work of Lowenfeld and Winnicott and others in early infant and childhood development has confirmed and informed the approach, especially in the early tasks of SPOTS-ON. The children have a tenuous connection with our communications and our language system so we need to be flexible in our responses in order to keep life continuously linked together and meaningful for the children. Initial interaction may be of very short duration.
We work on building it and then hope to facilitate the childs own creativity, curiosity and responsibility in the learning process.
the importance of a childs multisensory experience, actions and, in particular, the sense of touch and movement, useful to the child at their stage in development, are acknowledged by visiting an adventure playground. During the sequence of tasks, we give the children materials to touch objects sent in from home as a reminder of events at the weekend. Power is given to the child in their efforts to find the power of words through their creativity. The desire to be looked at is satisfied in the one-to-one sessions and video viewing of each child at play. Lowenfeld includes in her hypothesis on emotional development that A child thinks with his hands. Therese Woodcock (tutor, Lowenfeld project) suggests that the child touching their words as they assemble them may be an important factor in their engagement in the task. Actual objects may be used to represent a word; for example, the train ticket from a recent journey stuck onto the relevant noun triangle. Spensley (1995), referring to children with autism, writes of a disjunction of looking and listening. She believes that these are the two principle receptive modes, which, coming together, produce the big bang of recognition and response. Keen et al (2000) refer to impairments in the use of eye gaze in children with autism, and difficulties in the scenario where pointing is a communicative act. These matters are addressed using the seethrough acetate in an attempt to gain attention perhaps holding it at eye level to capture gaze and lead on to shared communication. In the individual tasks of SPOTS-ON, the adults need to sit and listen to the children one-to-one as they communicate about the pictures they are creating. This provides the notion that listening exists. The preparation of the childs picture, their record of experience, is all-important in the effort to reach words. It is possible that the experience of the childs involvement in creating their own visual memory of an event (a picture) triggers their own words. It has meaning to them. The picture is a memory of their multisensory experience, transformed in the process of producing their own drawing. In using SPOTS-ON with children, it has been noted in more than one childs effort that the memory of their own movement often appears to have been the motivation for their drawing. One child returned to class with the wooden spoon he had used in cooking and spontaneously produced a picture resembling a circle scribble - his picture of stirring. He first touched the relevant object which aided his memories of it. He provided a visual record of the action in memory, and the drawing then provided the focus for verbal communication to take place. In the subsequent task, the child used his sense of touch to assemble the sentence.
Readiness
Goleman (1996) refers to readiness for school which he says depends on the most basic of all knowledge, how to learn. He quotes a report from the National Center for Clinical Infant Programs and lists seven key ingredients of this crucial capacity. They are: 1. confidence 2. curiosity 3. intentionality 4. self-control 5. relatedness 6. capacity to communicate 7. co-operativeness. In our management and general approach we accept these ingredients are vital if the child with speech and language impairment is to access our curriculum. As staff we all acknowledge all of the time, as others do, that the children need to develop this school readiness and reach the emotional maturity that will help make the curriculum accessible to them. SPOTS-ON has two key phases: I. Noticing words (pre-verbal to verbal experiences) II. Using words (combining, slicing and dicing).
II. Using words

Once the child has begun to make links from his idiosyncratic, pre-verbal world across into our social, verbal world, work on combining words and slicing and dicing (Tomasello & Brooks, 1999) language can begin in earnest. SPOTS-ON provides the language-impaired child with help to analyse and synthesise language from the first words and holophrases to complex spoken or signed utterances, including the morphemes and, later, written sentences. Starting as SPOTS-ON does with the childs impetus, it is possible to share the scene from the childs viewpoint. The materials with symbols or words on are used to create shared reference points. The scene can then be shared from different viewpoints, at first on separate occasions. The Construction Grammar approach, as outlined by Tomasello & Brooks, moves from this analysis of scenes and describes a developmental process in which the child uses specific and concrete linguistic phrases to partition their scenes. With practice and experience children are able to generalise discovered patterns in novel utterances. It is believed that the SPOTS-ON system provides the extra multisensory support and clues that speech and language impaired children need to discover for themselves the patterns in verbal language and then to make their own use of this knowledge in communication. The aim is that verbal language becomes the childs preferred and spontaneous means of communication.
I. Noticing words
Trevarthen (1993) states that emotions... are necessary in the process of qualifying, creating and connecting meanings. Lowenfeld (1934) discusses the emotions, which lie behind any successful education. Among the emotions she suggests are curiosity the desire for power...and control (in the sense of mastery of self and of all that surrounds the child) an interest in sensuous experience (by which she refers to an interest in and understanding of sensorial experience, processing that which comes through the five senses, and through this, the relationship with the environment) a desire to be looked at (and every child passes through a stage where they might be saying watch me, look, I can do this). The SPOTS-ON approach attempts to incorporate recognition of these areas for development. Curiosity is key. We work on building it and then hope to facilitate the childs own creativity, curiosity and responsibility in the learning process. So,
12
cover story
adults need to sit

Future focus
There are three main avenues to explore further when using the SPOTS-ON approach with our children: 1) The Verb Island Theory 2) Discovery, creativity and play 3) School readiness and the National Curriculum.
and listen to the children one-toone as they communicate about the pictures they are creating. This provides the notion that listening exists.
1) The Verb Island Theory
This theory may have some impact upon the current linear order, left to right, in which we present SPOTS-ON to the children. As soon as the child shows interest in his actions, is it better to first present the verb on the page and then work on what comes before and after it? Lowenfelds view on personal experience - preverbally - is that all in an event is fused together. Children have often focused on their own movement in producing a drawing, perhaps beginning to tease apart this fusion in memory. These factors may suggest reaching the linear form of language through the verb first.
ing meanings. Another aspect to investigate further would be Winnicotts description of the capacity to be alone in the presence of another (1990) which presumably, if developed sufficiently, could make it more swiftly possible for a child to participate in classroom activity since, in the classroom, one is required constantly to work alone in the presence of others and then to slide from absorbed individual thought back into receiving mode in order to listen.
In Barrett, M. (ed) The Development of Language, 161-190. Hove: Psychology Press. Tomasello, M. (2000) Acquiring Syntax is not what you think. In Bishop, D.V.M & Leonard, L.B. (ed) Speech and Language Impairments in Children, 115. Hove: Psychology Press. Trevarthen, C. (1993) Playing into reality. Winnicott Studies 7, 67-84. London: Kamac. Winnicott, D.W. (1974) Playing and Reality, 63. Middlesex: Pelican. Winnicott, D.W. (1990) The Maturational Processes and the Facilitating Environment, 29-36. London: Karnac Books.
Resources
1. Carole Kaldor and Pat Robinson are planning a workshop on the SPOTS-ON system. Details from I CAN, e-mail: training@ican.org.uk, tel. 0870 010 7088. 2. John Lea (1970) The Colour Pattern Scheme - A Method of Remedial Language Teaching from Moor House School, Oxted, Surrey. Do I base 3. The Lowenfeld language work Projective Play Therapy part-time on actions MSc program is run and sensory jointly by The Dr. experience to Margaret Lowenfeld Trust and Middlesex build memory? University. For a Do I make prospectus, contact Sue Barnard, sufficient use 52 Barton Road, of video as a Haslingfield, method of Cambridge CB3 7LL, tel. 01223 872291. reinforcing For further learning? information, contact Do I have Susie Summers, Course Coordinator methods for and speech and capturing the language therapist, tel. 0207 267 7439. dynamic 4. Paget Gorman nature of Signed Speech language, (1994) - Details from Paget Gorman particularly Society, 2 Dowlands verbs? Bungalows, Dowlands Lane, Smallfield, Surrey RH6 9SD. 5. Transparent paper in many colours from Lee Filters, Central Way, Walworth Industrial Estate, Andover, Hampshire SP10 5AN, tel. 01264 366245, fax 01264 355058, e-mail sales@leefilters.com. 6. The Squiggle Foundation exists to study and cultivate the tradition of D. W. Winnicott F.R.C.P. Administrator: 33 Amberley Road, London N13 4BH, tel. 0208 882 9744, fax 0208 886 2418.
2) Discovery, creativity and play

Tomasello & Brooks (1999) refer to the child needing to discover the syntactically relevant semantic features of the verb. They also refer to the fact that the childs own generalisations across verbs in creating constructions is a central question in the study of childrens syntactic development. It is in the nature of play that you are discovering and creating. In play, a child is also thinking, reasoning, problem solving and organising. Lowenfeld (1991) states that play is to a child, work, thought, art, and relaxation, and cannot be pressed into any single formula. It expresses a childs relation to himself and his environment, and, without adequate opportunity for play, normal and satisfactory emotional development is not possible. Winnicott (1974) states that it is in playing and only in playing that the individual.., is able to be creative. Perhaps these acts of creativity and discovery in one mode, play, can be transferred to another: discovering and creating verbal language. This may suggest more activities where the childs multisensory play actions are the focus.
Carole Kaldor is a speech and language therapist at I CANs Meath School in Surrey, e-mail meath@meath-ican.org.uk, or pkaldor@yahoo.com, tel. 01932 872302. Pat Robinson is the Curriculum and Assessment Leader at Meath. Janet Tanner, formerly a speech and language therapist at Meath, is now employed by Portsmouth City Primary Care Trust, e-mail thetanners@talk21.com, tel. 01329 828706.
Reflections
Acknowledgements
Thanks are given for the support and advice in preparing this paper to: Therese Woodcock; Ann Farquhar, Head of Speech and Language Therapy Service and staff involved at Meath School, and those working in Class 1 (Toni Beynon, Linda Daniel, Melanie Hanks, Jeannie Kent, Maureen Laidlaw, Maureen Rymill, Karen Davis). Graphics by Sheila Shanks. Special thanks to the children in Class 1 for their work. Also thanks to Pat Le Prvost, then Head of Services for Learning Disability in Oxfordshire, for inspiring me with her management strategy with a group of 18 month old children in 1980.
References
Conn, P. (1973) Language Therapy. London: Invalid Childrens Aid Association. Goleman, D. (1996) Emotional Intelligence, 193-4. London: Bloomsbury. Kaldor, C. (1999) unpublished presentation, Afasic Conference, York. Keen, D., Sigafoos, J. & Woodyat, G. (2000) Functional Communication Training and Prelinguistic Communication Behaviour of Children With Autism. Advances in Speech & Language Pathology 2, 107-117. Lowenfeld, M. (1934) What is meant by emotional development? Parents and Children 1 (1) Jan. London: New Era. Lowenfeld, M. (1991) Play in Childhood, 232. London: Mac Keith Press. Spensley, S. (1995) Frances Tustin, 125. London: Routledge. Tomasello, M. & Brooks, P.J. (1999) Early syntactic development: A Construction Grammar approach.
3) School readiness and the National Curriculum

At the same time as attempting to make good use of the National Curriculum for school-aged children, we also often need to respond to a child whose emotional maturity does not yet fully meet descriptions for school-readiness. This is not to say that school readiness is not within the childrens grasp, especially if we concentrate further on those ingredients related to emotional intelligence and referred to by Goleman (1996), Lowenfelds thoughts on successful education, and Trevarthens ideas of creating and connect-
13
in my experience
Sociology: a sure start

But why do we have to do sociology? - This lament may be familiar to those involved in teaching the subject, but Sarah Earle argues that sociology is essential if students are to become reflective practitioners with an appreciation of the value of research and an understanding that successful communication is influenced by social factors and access to services.
Read this if you want to take a holistic approach believe the profession needs a stronger research base could develop your
ithin everyday practice, speech and language therapists deal with individual communication difficulties. However, to assess, treat and prevent such difficulties it is important for the therapist to appreciate the wider social structures and the social processes which influence the ability of each client to deal with his or her difficulty. One of Sure Starts six key targets is the improvement of childrens speech and language; as part of the Governments social exclusion programme it recognises the relationship between poverty, deprivation and communication problems in young children and later life (Sheridan, 1999). Although the study of sociology has been explored in the context of other health professions such as nursing (for example, Cooke, 1993), my experience of teaching speech and language therapy students has prompted me to reflect on the role of sociology in their education. Becoming a speech and language therapist does not solely concern the acquisition of clinical knowledge and the test of clinical competence; the adoption of a holistic approach marks a shift towards a more humanistic concern with communication. Within this shift, sociology should be seen as central in enabling the therapist to deal with the whole client. The question But what is sociology? is notoriously difficult because there is no one answer. Sociology is multiparadigmatic; it consists of a variety of competing paradigms (Kuhn, 1962) which exist to explain any number of phenomena.
sociology should be seen as central in enabling the therapist to deal with the whole client
Or, as Giddens (1986, p.2) points out, sociology does not come neatly gift wrapped. Sociology is concerned with both social structure and social action. Theories of social structure are concerned with the way in which social and economic structures influence social behaviour. Examples of these macro-sociological theories include functionalism, Marxism and, to some extent, feminism. In contrast, theories of social action are concerned with the way in which individuals can help to shape society. An example of this approach is symbolic interactionism, a micro-sociological theory. Each of these theories are correct in themselves, although not in relation to each other. This is why sociology is described as multiparadigmatic.
Deeper understanding
In 1959, C. Wright Mills coined the now well-known phrase, the sociological imagination. This is a good way to understand sociology, as it refers to the way in which sociologists question familiar expectations and assumptions (Cooke, 1993), taking the everyday and the taken-for-granted and looking beyond obvious explanations to gain a deeper understanding of contemporary social issues. The sociological imagination also refers to the way in which the personal is seen to be influenced by the social, the political and the economic. Mills (1959) explains this with reference to what he calls private troubles and public issues. For example, stammering is both a private problem for the individual and a public issue because of the disabling attitudes of society towards people with
14
in my experience
communication difficulties. Thus, by engaging with sociology and developing a sociological imagination, students can learn to understand and make better sense of society. Sociology comprises of a range of competing paradigms which enable us to make sense of the social world. However, whilst there is no one dominant theoretical paradigm to provide a blueprint for understanding social behaviour, sociology does help us to see the individual within their wider social context. The development of a sociological imagination enables us to consider the ways in which personal issues are influenced by social, economic and political factors. This is an important aspect of holistic therapy, fundamental to the care of clients with communication difficulties. The classic sociological study of suicide conducted by Emile Durkheim in 1897, is an example of the way sociology can demonstrate that the personal is political. Suicide is one of the most apparently individual and personal of acts; however, by using quantitative official statistics, Durkheim demonstrated a positive correlation between high suicide rates and indicators of low social integration, such as living in urban areas and being unmarried. He argues (1979, p.47), If...the suicides committed in a given society during a given period of time are taken as a whole, it appears that this total is not simply a sum of independent units, a collective total, but is itself a new fact sui generis, with its own unity, individuality and consequently its own nature a nature, furthermore, dominantly social. Durkheims overall conclusion is that an understanding of suicide can be achieved without reference to the individual motivations of people who have committed suicide. For Durkheim, and other sociologists like him, social structure acts as a determinant of human thought and activity (Billington et al, 1998, p.18).
The implicit reflexivity within sociology can inspire speech and language therapists to question commonly held assumptions about their everyday practice.
Implicit reflexivity
The multi-paradigmatic nature of sociology creates an inherent reflexivity within the discipline which entails a continual reflection on its own grounds (Sharp, 1994, p.394). Although by no means consensual, the past few years has seen a shift towards a more reflective practice within speech and language therapy whereby therapists are encouraged to question the validity of therapies (Enderby & Emerson, 1996) and have acknowledged the more tacit aspects of dealing with communication difficulties (Mobley, 2000). The implicit reflexivity within sociology can inspire speech and language therapists to question commonly held assumptions about their everyday practice. Evidence-based practice is becoming increasingly significant within speech and language therapy. The Position Statement on research and development in the therapies stresses the increasing role
of research as a means of improving the nations health and quality of life (DoH 1995, p.1). However, whilst newly qualified students will have some basic grounding in research skills, the professions recognise the importance of developing a much stronger research base, arguing that, Therapists, like nurses, are in the best position to generate their own research questions and to investigate their own practice...This early exposure to research aims to foster critical consumers of research who are capable of evaluating their own practices against reliable up to date evidence. (DoH, 1995, p.4) The study of sociology makes a unique contribution to evidence-based practice in two distinct ways. Firstly, it provides the speech and language therapist with a wealth of both qualitative and quantitative methodologies with which to conduct research, enabling them to formulate research questions and investigate their own practice. As Mobley (2000) has suggested, speech and language therapists have traditionally employed a very limited range of methodologies, many of which are not wholly suited to the study of adults and children with communication difficulties (see also Code, 2000 and Greener et al, 2000). The study of sociology and sociological research methods can be used to help speech and language therapy students understand and interpret research findings. Secondly, sociology provides the therapist with a broad range of research findings that can be applied to the needs of speech and language therapy. The collection of empirical data can be used to make more rational judgements about practical issues, a significant aspect of evidence-based practice. Empirical data can also be used to make reasonable predictions; this can be helpful in the planning and delivery of therapy services. In addition, it is possible to use empirical data to explain social phenomena; that is, to subsume statements about them under more general statements (Bottomore, 1962, p.55). This, too, is helpful as it enables speech and language therapists to understand their clients needs more holistically and within a wider socio-economic framework. Sociology therefore contributes in three fundamental ways to the education of speech and language therapy students: 1. it helps students understand that successful communication is influenced by wider social factors such as gender, age, ethnicity and (dis)ability, as well as by differences in access to health care services; 2. its multi-paradigmatic and inherently reflexive nature encourages students to recognise the tacit nature of their practice, thus allowing them to become more effective, reflective practitioners; 3. it assists students to understand and engage in research; a transferable skill that they will find invaluable throughout their working lives.
Dr Sarah Earle is Lecturer in Health Studies at University College Northampton. Address for Correspondence: Centre for Healthcare Education, Boughton Green Road, Northampton, NN2 7AL, e-mail: sarah.earle@northampton.ac.uk, tel. 01604 735 500.
Acknowledgements
I would like to thank Mike Filby, who encouraged me to write this article, Oonagh Reilly and Angela Hurd for their encouragement; and the speech and language therapy students at the University of Central England, Birmingham.
References
Billington, R., Hockey, J. and Strawbridge, S. (1998) Exploring Self and Society. London: Macmillan. Bottomore, T.B. (1962) Sociology: a guide to problems and litera Does my work ture. London: reflect the nature of Unwin University communication Books. Code, C. (2000) disorders as both The problem private issues and with RCTs. RCSLT public troubles? Bulletin March Do I question (574) 14-15. Cooke, H. (1993) commonly held Why teach sociassumptions about Nurse ology? my everyday Education Today practice? 13 (3) 210-217. DoH (1995) Do I have a Research & sociological Development in imagination? Occupational T h e r a p y , Physiotherapy and Speech and Language Therapy: A Position Statement. London: DoH. Durkheim, E. (1979) [1897] Suicide: A Study in Sociology. London: Routledge & Kegan Paul. Enderby, P. and Emerson, J. (1996) Speech and language therapy: does it work? British Medical Journal 312, 1655-1658 (29 June) http://www.bmj.com/cgi/content/full/312/7047/1655. Giddens, A. (1986) Sociology: A Brief but Critical Introduction. 2nd Edition, London: Macmillan. Greener, J., Enderby, P., Whurr, R. & Grant, A. (2000) On trial. RCSLT Bulletin February (574) 1314. Kuhn (1962) The Structure of Scientific Revolutions. Chicago: University of Chicago Press. Mills, C. Wright (1970) [1959] The Sociological Imagination. London: Pelican. Mobley, P. (2000) Research renaissance. RCSLT Bulletin April (577) 7. Sharp, K. (1994) Sociology and the nursing curriculum: a note of caution. Journal of Advanced Nursing 20, 391-395. Sheridan, J. (1999) Children Need a Sure Start. RCSLT Bulletin September (569) 1-2.
Reflections
15
sensory integration
Read this if you work with anyone with oral sensitivity want to provide a multidisciplinary service need reminded of the value of patience...
Sense and sensitivity: Part 2

CASE STUDY 1
Assessment Claire is a three year old with spastic quadriplegia. She is registered blind. She has epilepsy and her fits are not entirely controlled with medication. She has scoliosis, recurrent chest infections and is underweight. She has repeated hospitalisations and the medical team have recommended a gastrostomy, but her parents are resistant to this. From analysing her behavioural responses, it appears she has problems processing sensory information. She becomes fearful when moved. Her tone increases and she cries and cannot self calm. Claire likes to be held tightly and rocked in her parents arms, suggesting vestibular and proprioceptive input help. She has a limited range of movement, either pulling her whole body into flexion or pushing into extension. Her communication is pre-verbal and pre-intentional. She cries when upset and becomes stiffer. While being fed, as the spoon touches her lips, her whole body increases in tone, suggesting hypersensitivity to touch. Other signs of an aversive reaction to being fed include facial grimacing, an increased rate of breathing, an attempt to push away from the spoon with hyperextension of the neck and gagging on lumpy food. She does not like to be touched around the face and there is no hand to mouth play, indicating more signs of an aversive reaction to tactile input. Claire is a very agitated little girl who is usually over aroused, constantly on full alert and difficult to calm. The aim of treatment was to get her into an optimal state of arousal for a functional activity: taking food off the spoon without distress.
Many children, including those with cerebral palsy, can benefit from Bobath and sensory integrative techniques used by a multidisciplinary team. In part 1 (Spring 2001 issue), Sarah Barnes focused on the identification of sensory deficits in children. Here she goes on to explain why helping a child achieve an optimal level of arousal is crucial to the success of intervention.
Management We saw Claire for a six week block for three sessions every week of approximately one hour. The physiotherapist or occupational therapist or speech and language therapist were present for every session. The aim was to calm her through influencing her vestibular and proprioceptive systems. She was placed securely on her mothers lap. Her mother then sat on an office chair on wheels. We rocked her forwards and backwards in a horizontal plane for 15 minutes at the beginning of each session. When she was calm I was able to come in front and apply deep pressure symmetrically with my hands on both sides of her trunk and then symmetrically on her arms and legs. When she could tolerate this, I introduced a Nuk toothbrush to the back of her hands and, as the hand began to un-fist, I placed it in the palm of her hand. When she could tolerate this, I guided her hand to her face while holding the brush, and firmly pressed it along her cheeks and then lips, constantly looking for a possible aversive reaction. We were then able to vary the textures that approached around and inside her mouth, progressing from the Nuk brush to an index finger inside a teat and finally tastes of food on the therapists finger. When this was achieved in the fifth week without any concomitant aversive reactions we were finally able to move onto food on the spoon. In the last week we could add small lumps in the form of crumbled biscuit in yoghurt. When she was able to take a full tub of yoghurt without distress, we had achieved our aim. (The debate continues about whether or not Claire should have a gastrostomy as, realistically, she will not thrive through oral feeding.)
Kieran receiving increased vestibular input through bouncing on the ball to increase his level of arousal
16
sensory integration
hen treating the neurologically impaired child I have found it helpful to view their communication and feeding problems in a systemic way, where how a child moves and integrates all sensory input can influence other elements of functioning that we as speech and language therapists are interested in - interacting, talking, eating. Through close collaborative work with other professionals involved with the disabled child, I have learned that, if the child has a sensory modulation problem, I must address this fundamental difficulty first for a specific feeding or communication treatment programme to work. When the child achieves an optimal level of arousal, then our therapy is more specific and more effective. At the Bobath Centre, we work mainly with children with cerebral palsy. If a child is assessed as having - and their behavioural responses are suggestive of - a sensory as well as a motor deficit, principles of Bobath (1980) and the use of sensory integrative techniques form the basis of the intervention programme. If the child has problems with communication at either the receptive, expressive or pragmatic level, or has problems with eating or drinking, the speech and language therapist is involved. Working jointly with the occupational therapist and physiotherapist, we take a bottom-up approach in brain terms, working to influence processes at brain stem level before looking for a functional response at a higher cognitive level -
such as bringing a spoon to his mouth without gagging, or looking at a toy without mouthing it.
Carefully graded
For the child who has problems integrating all their senses, bombarding them with stimuli is generally not indicated (Arvedson & Brodsky, 1997). Begin by presenting a level of stimulation that the child can comfortably tolerate, and then gradually alter the level of stimulation to enable the child to accommodate at a threshold nearer to normal. We need to grade the stimulus carefully, maybe only applying one sensory stimulus at a time; for example, just vestibular input through bouncing gently on a ball without talking or singing to the child so they dont experience sensory overload. During the treatment session the therapist carefully monitors the childs responses to input. Signs of overstimulation include crying, eye aversion, increased agitation, an increase in tone, pulling into flexion, pushing into extension or falling asleep. When these signs occur the intervention is stopped until the child has time to reorganise and be calm before starting again. When treating these children the therapist has to remember that s/he is providing sensory information to an already abnormal/disordered sensory-motor system. Oral stimulation is a dangerous thing which - unless it
For the child who has problems integrating all their senses, bombarding them with stimuli is generally not indicated
is carefully graded - very easily can and does lead to increasing hypersensitivity and increased hypertonus (Mueller, 1991). Four basic principles of intervention apply: 1. time Working closely with the physiotherapist, make sure the childs posture is aligned and symmetrical. Allow the child lots of time to adjust so that they can benefit from the experience.
2. control If the child is physically able, allow them to control the amount of tactile input they receive rather than imposing it on them. For example, if using intra-oral stimulation with a Nuk toothbrush, let them hold the brush in their hand and facilitate bringing it to their mouth by themselves. Introduce the stimulation in a playful way. For example, if using a vibratory toy, hide it and encourage the child to look for it. 3. deep pressure When touching the child, avoid light touch and maintain deep, firm pressure using your two hands symmetrically on the childs shoulders, hips or trunk. It is best to introduce oral stimulation outside of mealtimes so it doesnt interfere with nutritional intake (Arvedson & Brodsky, 1997). 4. hand play before face When giving tactile stimulation we encourage hand play before face. This is because, in the somatosensory cortex, the representation of the
CASE STUDY 2
Assessment Eileen is a 3 year 6 month old girl diagnosed as having cerebral palsy of prematurity. She is floppy in her trunk with spasticity in all four limbs. She is happiest close to the floor and does not crawl. She speaks in two and three word sentences but her expression is stereotyped and echolalic. She does not take turns in conversation or show good developing reciprocal interactions. Eye contact is poor and language often irrelevant to the context. There are no problems with feeding. Her sensory problems appear to be those of hyporesponsiveness. She drools intermittently and mouths all objects handed to her. From this we deduced that she is seeking out increased proprioceptive and tactile stimulation in the mouth - but this is preventing her from developing eye/ hand coordination as a precursor to visually examining toys and labelling them. She drifts in and out of attention and has problems maintaining sufficient levels of arousal to function and learn. Management Eileen had daily therapy for two weeks. The goals of therapy were to reduce mouthing and to increase more appropriate verbal initiatives rather than her resorting to stereotyped phrases. Making the assumption that we had to increase her level of arousal for her to start attending, we introduced vestibular and proprioceptive stimulation by bouncing her vigorously on the ball with one therapist giving downward pres-
sure through her shoulders and the other in front holding her legs. We modelled an appropriate request - more bouncing - for her to imitate by stopping the activity mid flow. In the first week, her sitting posture on the ball improved. (In neurological terms, it is hypothesised that the stimulation to her vestibular system activated her vestibulospinal tract which runs down the spinal cord and increases muscle tone in the trunk.) With this improved posture, social communication improved with increased eye contact and listening and, by the end of the first week, an increased number of appropriate verbal requests for more bouncing or more singing. We then took her off the ball and sat her at a table introducing a Nuk toothbrush for her to chew. She was allowed to chew on this while visually attending to a toy or listening to her music tape. Parents took the brush home and for a week after she chewed vigorously on the brush which seemed to calm her when her arousal levels were high. However, she then stopped this and also her mouthing of all toys. By the end of the second week we could introduce single toys which she would visually examine and play with - for example, shaking the bells or pressing the button on a pop-up toy. Her parents took on some of these ideas, continuing to bounce her on the ball and swing her on a swing. Reviewed six weeks later, the main change they observed was an increase in sentence length and more appropriate requests and labelling of objects.
17
sensory integration
Figure 1 Messy play textures coloured water smash potato with food colouring dried lentils, pasta, split peas baby lotion yogurt jelly shaving foam sticking pictures with jam using cheese slices chocolate pudding
Reflections
hand and mouth are very close. At birth the differentiation between hands and mouth is not well defined, and it is only through active exploration that the neural connections are separated. In children with damaged CNS (central nervous system) who do not actively bring their hands to their mouths these neural connections do not become differentiated and there is still a strong neural link between them. If you stimulate the hands you may see a strong reaction around the mouth such as jaw thrust, increased tongue thrust or a change in colour around the lips. Starting stimulation at the hands is less invasive, nothing can be swallowed and there are fewer sensory receptors in the hands than in the mouth, so the child who is hypersensitive to touch will more likely tolerate stimulation here first (Davies, 1997). Messy play is another way to give experience to hands and is a good way to introduce different textures of food without the child having to eat them. Suggestions of different messy play textures are in figure 1. Introducing the soft textures onto a hard texture such as a mirror, a large physiotherapy roll (which the child can stand up against and which has a smooth surface) or a doll, giving deep pressure through the hand onto the hard surface, can help reduce the unpleasant sensation caused by soft Do I have consistencies. sufficient Five specific techniques general are useful: knowledge
drooling, get them to hold a flannel/Nuk toothbrush firmly between the biting surfaces of their teeth and have a tug of war or the dog has a bone, with the therapist pulling strongly on the end of the object while the child actively resists. 5. Food textures For the child who cannot tolerate lumps and only eats pureed food, start with a taste that the child is familiar with and add a new texture to eat; for example, crumbled biscuit in a yoghurt, strained carrots in baby rice, or stewed apple stirred through breakfast cereal. If you dont make the changes too dramatic they will be less likely to reject it. Then, when they can tolerate this, you can move on to thicker uniform consistency such as cottage cheese or apple sauce and drinks of different temperatures - iced water, warmer water, fizzy drinks. For the child who will not bite off and chew foods, try chips dunked in ketchup, sponge biscuits dipped in chocolate sauce and bread soldiers dipped in egg to suck. Some applications of these techniques are described in the two case studies of children I have called Claire and Eileen (pages 16 - 17). Sarah Barnes is a specialist speech and language therapist working with children with cerebral palsy in the Bobath Centre for children in Wales, based in Cardiff, tel 029 2040 5689 or e-mail video.inset@ntlworld.com
Starting stimulation at the hands is less invasive, so the child who is hypersensitive to touch will more likely tolerate stimulation here first
used it as a preliminary to doing dental work on children with learning difficulties (Dennison, 1992). Vibration can be extremely integrating helping a child to adapt and adjust, but the child could alternatively have an aversive response. Do not continue with it if they are not enjoying it. Use an electric toothbrush or vibratory toy applying the principle of stimulating hands before approaching the face. When the child can tolerate stimulation around the mouth you can progress intra-orally along the surface of the gums and along the tongue moving in an anterior to posterior direction. For the child who mouths all objects given to them or is constantly mouthing or biting their own hands, short bursts of vibration can sometimes be enough stimulation to satisfy them, and overall mouthing and biting reduces over time. 3. Proprioceptive feedback is very calming for the child, which is why swaddling premature babies is now used extensively in special care baby units. If treating infants or severely physically disabled children, lay the child on their back propped up on a wedge and apply deep pressure with both hands symmetrically through both sides of the trunk, limbs, and hands first and then - when the child can tolerate it move to the head, the face, the lips and only finally intra-orally. 4. Tactile stimulation Closely associated with tactile system is the proprioceptive system, but it is the tactile system which speech and language therapists most often stimulate in oral motor therapy. Following on from giving strong tactile and proprioceptive stimulation for the whole body, as you approach the lips wear latex gloves or put your finger in a moistened teat or use a warm damp flannel. Rub your teat/finger/Nuk toothbrush along the gums going from the midline back on either side, then along the surface of the tongue from anterior to posterior, along the hard palate. For stimulation around the face and lips I also use vibratory toys, an electric toothbrush and chewy toys such as a Nuk giraffe. For a child who has low arousal levels and is hyporeactive, possibly with associated
of a client to reach a conclusion about underlying problems? Do I monitor clients for signs of over or under stimulation and react accordingly? Do I take a bottom-up, gradual, patient approach - and encourage clients and relatives to do the same?
1. Vestibular stimulation can be very calming and integrating. Place the child on a ball or trampoline while being supported by the therapist (if they lack sitting balance) and gently or vigorously bounce the child, depending on their level of arousal. For a child who is very flexed in their trunk and does not make eye contact as their head is habitually bent forward, vestibular input can lead to better trunk and head control so that eye contact and therefore interaction is possible. Place the child in a hammock or on a platform swing both standard equipment in occupational therapy departments - and swing them. We have also improvised using an swivelling office chair. 2. Vibration has been used with great success in some children with oral hypersensitivity. Specialist dentists have
Acknowledgement
Thanks to Annie Broziatis and Diddo Green, occupational therapists, for advice.
References
Arvedson, J. & Brodsky, L. (1997) Pediatric Swallowing and Feeding: Assessment and Management. Singular. Bobath, K. (1980) A neurophysiological basis for treatment of cerebral palsy. Heinmann, London. Davies, C. (1997) The Bobath Approach to hypersensitivity and its relevance to feeding difficulties in the child with cerebral palsy. Unpublished essay. Dennison, P. (1992) The use of vibration to modify the gag and bite reflexes and tactile defensiveness. Workshop. Mueller, H. (1991) Ch.9, Feeding. In Finnie, N. (ed) Handling the young cerebral palsied child. 3rd ed.
Recommended reading
Baraneck, G., Foster, L., Berkson, G. (1997) Sensory Defensiveness in Persons with Learning Disabilities. Occupational Therapy Journal of Research 17 (3). Evans Morris, S. & Dunn Klein, M. (1987) PreFeeding Skills. Therapy Skill Builders. Scheerer, C. (1992) Perspectives on an Oral Motor Activity: The use of rubber tubing as a chewy. The American Journal of Occupational Therapy 46. Winstock, A. (1994) Eating and Drinking Difficulties in Children. Winslow.
18
report
1. Know your values
Would addressing the mismatch between your values and those of your service make you want to stay in your job longer? Sally Byng and her colleagues at CONNECT have addressed values as a team. Although time consuming and not easy to do, this has led to a decision about 8 core values as aspirations which influence their practice: respect; communication; responsiveness; participation; The RCSLT Sharing Communication Conference was in Birmingham from 17-19 April, 2001. equality; creativity; health; excellence. Most solutions have practical rather than financial implications, as they are to do with working in a more holistic way, being explicit, and avoiding jargon. 4. Develop partnerships Sally suggests asking - What values are conveyed by your current practices? What Having been asked to cost a range of speech and language therapy packages for values do you aspire to? Can you prioritise values to make practice decisions? Can nurseries, Olwen Pate and Ann Harvey put their ethos into action through The you use values to evaluate the quality of your service? Consult with clients about Nursery Project. This included valuing and building on the experience people what matters to them, set up discussions with colleagues, imagine the ideal seralready have and giving up the role of expert. vice, identify the barriers to delivering on this and identify small steps towards The department was keen not to dump programmes on nursery staff, or take a practices that meet these core values. clinic service into a nursery - the idea was to offer something different. Six conwww.connect.org.uk sultations with cluster groups of schools found that teachers were keen to work 2. Involve users in partnership, particularly for reviews and running groups, and to have more The government agenda is that we must seek the views of service users, and use involvement with parents. Regular onsite visits from a known speech and lanthem to bring about meaningful change. guage therapist were very important. Lindy Peacey interviewed mothers of children with specific language impairment. Five packages were developed with a focus on training based on information How the mother sees the power balance between herself and professionals sharing and problem solving. Little time was needed to prepare materials, as affects the way she seeks help. Mothers who do not have English as their first lancourse participants brought videos of themselves with a child, there were no guage generally feel less confident than those who do in helping their child. It is OHPs, and the only handouts were a reflection of participants views. easier for mothers to describe speech than language, formal activities are easier The LEA agreed to fund all five packages - which are cumulative - but individual to carry out than informal ones, the demands of going to meetings are huge, and schools had to fund their own staff release. Package 5 included group intervenprofessionals rarely offer a clear prognosis. tion by nursery staff and a speech and language therapy assistant; by the second Julia Ritchies department has a rolling programme of user involvement and a year the training had been so successful that many nurseries started groups themvariety of tools: selves and no longer needed the speech and language therapy assistant. questionnaires telephone interviews focus groups user profiles This project should meet with the approval of James Law and Nick Peacey, who led a provider-led user-led discussion on the provision for speech and language therapy between education and quantitative qualitative professional agenda user agenda health. Part of being a consultant is that you have hands-on involvement, something audit tools user forums structured interviews that is frequently misunderstood. Individual practitioners can work in a collaborative Users have views on what makes a good service and there is a lot of consensus. It way, but they need the support of joined-up thinking at a strategic level. is useful to compare a therapists self-scoring on these measures with a clients score - and to address the perception gap. Supervision and reflective practice 5. Have evidence-based vision ensure users views change services. It is important to think of ways of engaging The debate on inclusion suggested that, while there are many examples of good with groups you wouldnt normally reach, and to be honest about the dilemmas practice, in general, the policy is insufficiently researched, not properly impleyou face. Always under-promise and over-deliver. mented and inadequately resourced.
Conference call
Avril Nicoll reports on some of the key messages for practice she took away from the Royal College of Speech & Language Therapists Conference.
3. Think differently
Tom Morris pointed out that, when we get more money, waiting lists initially go down but creep up again because we change our criteria. He calls on us to review the whole basis on which we provide our services, moving towards a community development model. The ability to transfer our skills is an essential part of this, but is not required on any undergraduate speech and language therapy course. Sure Start is a programme which uses a community development model, and the value added benefits of speech and language therapist involvement are being researched. Addressing social exclusion, poverty and disadvantage in innovative ways, it looks to empower and improve access, and emphasises strategies. But how do we use Western-based, parent-child interaction strategies to address different cultures? In Southwark, over 30 languages are used and a new approach is needed to reach families who have a negative perception of professionals. Three speech and language therapists are doing home visiting and outreach, play, learning and development with voluntary agencies, training, supporting parents and early surveillance. As art and music are part of any culture, collaboration with artists and musicians has included video making, photography and the production of a book on language development incorporating photos of the local community. Sean Pert and Carol Stow never forget that bilingualism is an advantage. As many children are multilingual, and as English words become lexicalised in other languages, they emphasise the need to look at the total language profile of children, and to ask - what can they do in what language? www.speechtherapy.co.uk
The cost of training teachers, speech and language therapists and learning support assistants needs to be built in to the cost of inclusion. The planned joint professional development framework for teachers and speech and language therapists should be of benefit, and we must be much more open to sharing our skills. Brigid Clifton feels the inclusion policy is failing, particularly at secondary school level, and that the culture promises everything but delivers too little, too late. She regularly gets reports on speech and language therapy from parents of promises not kept, meetings not attended, reports not available, children lost in changeovers and no support for Learning Support Assistants. Claire Topping emphasised that inclusion is about practice, not placement. Monica Uden added that it provides a child with special educational needs with as ordinary an experience as possible - underpinned by an extraordinary amount of understanding, skill, expertise and technology. It means social inclusion, in the end being able to take our place in society as adults. Society needs to remove barriers, and attitudes of staff and cultures of institutions need to change. James Law cautioned that we need to define what inclusion is and gather evidence for it; at the moment it is an evidence-free zone. It is hard not to like the idea of inclusion, but we need to be objective - or we might end up with an inclusion we dont want. Sue Roulstone is also a firm believer in the need for the speech and language therapy profession to build its evidence through a variety of methods. Her vision is of
targeted intervention delivered intensively by a team in context in a world where we know our limits and everyone knows our role.
19
peer support
In the course of their work with two teenage girls with aphonia associated with chronic fatigue syndrome, Jane Patrick and Madeline Atherden greatly valued the support they had from each other. In telling their story, they aim to help others embarking on a similar journey.
Read this if you are dealing with a long-term case want to work in a multidisciplinary way tend to keep troubles to yourself...
Patient, persistent and positive: a journey with chronic fatigue

ted the Carter & Marshall (1995) and Boger & Spirer (1995) descriptions for CFS (figure 1) almost to the letter and returned eventually to using good healthy voices. Although both clients could be recognised as typical children with CFS, deeper analysis revealed some interesting differences in the course of their illness (see client pathways, figure 2). When both girls attempted to speak there seemed to be no signs of external laryngeal tension. They were seemingly unable to put any effort into speaking, as all their energy was being channelled into staying awake. However, both complained of neck discomfort which could have been the result of internal laryngeal tensions compounded by the frustration of being unable to speak. Both girls also exhibited some shortness of breath which was probably due to inefficient transient adduction of the vocal folds allowing a lot of air escape during phonation. Voice therapy was intermittent during the first
C
20
hronic fatigue syndrome (CFS) in the paediatric population - which has received only recent attention - presents a host of diagnostic and treatment challenges. As aphonia can be one of the associated symptoms, speech and language therapists need to be aware of the complex nature of CFS and the course it takes, and to consider management of the aphonia within the context of the illness. As speech and language therapists working in neighbouring districts, we were both referred teenage girls with persistent aphonia and associated CFS. We received a variety of therapeutic advice from a number of reputable sources but eventually had to feel our own way forward. If you are embarking on a similar journey, this article is not prescriptive and certainly does not hold all the answers, but is intended to lend you the kind of support which we
greatly valued from each other. A multidisciplinary team approach is needed to optimise function and minimise the impact of this usually self limited illness on the childs social, academic and psychological development. The speech and language therapist is an important member of the team managing the client as a whole - each professional having a more active part to play at different times. More effective treatments and clarification of the pathogenesis of this perplexing illness await the findings of future studies. In the meantime, the course of CFS can often span over a whole year and the client may initially need to be supported and reassured, with formal intervention coming at a later stage when the CFS is beginning to relent. Maintaining contact is important, and support from a colleague invaluable.
Interesting differences
Both our girls, whom we will call Sarah and Faye, fit-
peer support
Figure 1 CFS descriptions Chronic Fatigue Syndrome (CFS) consists of profound, debilitating fatigue associated with low grade or subjective fever, sore throat, weakness, myalgia, headache, confusion, sleep disturbance or other constitutional complaints... Symptom onset in CFS is typically abrupt, often after an apparent mononucleosis - like illness, and fatigue can persist from weeks to years. The impact of these symptoms on the social and extra curricular activities of school age children can be considerable. In many cases school attendance is disrupted with a substantial number of patients receiving lengthy homebound instruction (Carter & Marshall, 1995). The typical children referred for evaluation of persistent fatigue are previously ambitious, athletic and in their early teens (Boger & Spirer, 1995).
Figure 2 Pathway of client management
SARAH
(symptoms = flu, severe sore throat, lethargy, swollen glands, voice loss)
FAYE GP appointment
paediatric referral
diagnosis of CFS
referral to ENT additional symptoms recognised: sleep disturbance mild depression slow motor movements general low mood aphonia no organic origin
referral to homeopath homeopathic tablets prescribed
speech and language therapy referral
diagnosis of CFS anti-depressants prescribed
ENT referral (Joint consultation - speech & language therapist / ENT consultant) vocal cords NAD no organic origin paediatric referral NAD psychiatric referral NAD
speech and language therapy referral
speech and language therapy recommended
four to five months due to the limitations of the CFS. It took the form of a limited number of sessions working on relaxation (body self-awareness using visualisation techniques; lying on a mat on the floor) and laryngeal palpation to reduce tension and aching along the sides of the larynx. Breath control was good at abdominal and diaphragmatic level but therapy focused on increasing control and support with voice which was lacking. We aimed to produce voice initially using Coblenzcer (rsted, 1986) and Accent Method (Thyme - Frkjaer & Frkjaer Jensen, 2001) techniques which incorporate physical body movement and intention: i) rocking - sat on edge of seat ii) exhalation - rock forwards iii) deep sighs - cough iv) hum with different intonation v) vowel production vi) bending body forwards in standing position,
allowing weight of body to facilitate exhalation and spontaneous vocalisation such as grunts - no voice / vocalisation. Relaxation therapy was very difficult at first as it made Sarah feel dizzy and tired and her muscles tended to festinate. However, by using visualisation to focus her attention, this began to get better and the relaxation greatly improved her sleeping pattern. Unfortunately, discomfort in the neck could not allow massage to be used with either girl. This raised the question of whether the muscles were tense or just tender due to the virus remaining within their systems. The sore throats continued to persist, relieved at times with antibiotics.
It soon became evident that both had a very good breath support system producing good scores for any voiceless sounds but quickly running out of air Periodic exacerbations if they tried to produce any voice; this would immediately are common with produce a lot of discomfort.
CFS; however, the natural history is favourable in children
Sarah was able to elicit a noise if she produced a very relaxed imploded sound such as [ ] or [ ]. It soon became apparent that she could only produce a sound if her throat was not feeling sore and she was not too tired. The moments of success were always short-lived and very much controlled by how fatigued Sarah was at the time whereas, with Faye, no voice was elicited with techniques, and attempting to achieve voice seemed to increase feeling of depression. After 8 - 10 sessions of therapy, treat-
21
peer support
When reviewing our involvement it was evident that we had both found them particularly difficult to treat and manage.
Figure 3 Chronic Fatigue Syndrome diagnosis 1. Clinically evaluated, unexplained, persistent or relapsing fatigue for six or more months that is of new or definite onset: not the result of ongoing exertion not substantially alleviated by rest resulting in substantial reduction in previous activity. AND 2. Concurrent occurrence of four or more of the following symptoms during at least six consecutive months and not predating the fatigue: impairment in memory or concentration sore throat tender lymph nodes multi-joint paint without arthritis new headaches unrefreshing sleep postexertional malaise.
ment goals were not being achieved and there were no obvious vocal improvements.
Reassurance
Sarahs treatment was suspended as her level of fatigue increased, but regular contact was maintained to provide reassurance and support. (Periodic exacerbations are common with CFS; however, the natural history is favourable in children.) This continued for three months until Sarah was re-referred to therapy following an ENT review. The consultant was concerned that there was evidence of muscle wasting within the voice box and asked if therapy could be re-aimed to provide muscle strengthening exercises. Faye was referred to a specialist voice clinic attended by a speech and language therapist for a second viewing of her vocal cords. The nasendoscopic view showed no vocal cord adduction, which may have indicated some vocalis muscle wasting. No organic aetiology could be found within the larynx, and the ENT consultant recommended both a psychiatric and paediatric opinion to establish whether any other psychosocial or medical factors were maintaining the aphonia. Neither consultation revealed any alternative diagnoses. Both girls resumed a voice therapy programme on a weekly basis but the focus shifted towards using more cognitive behavioural therapy techniques, alongside specific vocalis muscle exercises. The cognitive behavioural therapy approach (Butcher et al, 1993) involved brainstorming sessions to discuss CFS and its impact on their lives. Adjustments were being made which needed support and guidance to enable an element of normality to be gradually resumed. Adopting a positive mind set, which accepted CFS and its limitations but sought to accommodate them accordingly, ensured that activity was not totally avoided but reduced to a level which could be achieved. Weekly goals were set and a daily diary sheet was kept, focusing on both vocal exercise regimes and the physical activities achieved. Vocalis muscle exercises incorporated the use of forced adduction of the vocal cords during nonvoicing activities such as breath holding, and air flow control exercises such as blowing a ping pong ball and candles.
EXCLUSIONS:
active or unresolved medical conditions that may explain fatigue current or past diagnosis of major depressive disorder with psychotic or melancholic features; bipolar affective disorder; schizophrenia; delusional disorder; dementia; anorexia nervosa; bulimia nervosa substance abuse within two years before onset or any time afterward severe obesity.
INCLUSIONS:
conditions that cannot be defined by laboratory tests (for example fibromyalgia; anxiety disorder; multiple chemical sensitivity disorder) conditions documented to be under adequate treatment conditions definitively treated before development of chronic sequelae isolated findings insufficient to suggest an exclusionary diagnosis (for example, weakly positive antinuclear antibodies without other signs of lupus). (adapted from Fukada et al, 1994)
Change
This process continued for approximately four weeks towards the end of a twelve month period of voice loss. Both girls were beginning to experience less fatigue and noted a change in their physical activity. Sarah felt able to increase her school attendance and could take more exercise. Her general affect improved and she experienced less soreness around her throat. Faye had a slow increase in school attendance but a dramatic change in appearance, from a seemingly helpless childlike state to a more confident teenager. Both girls began to experience more voice, the improvements occurring rapidly, with normal
voice returning after a month. One further review was required to ensure voice maintenance, but both were then able to be discharged. Through detailed discussion of our clients following discharge, it became evident that their psycho-social backgrounds were very different and may have contributed to the cause of their CFS. Sarah was raised by a supportive single parent, who worked full-time and also had another teenage daughter. Previously Sarah had been very athletic, being involved in several sport societies in and out of school. Although she changed completely during her CFS episode, the attitude of those around her, particularly her mother, was very positive and focused on activity and getting back to school. Faye was from a very supportive family and the eldest of three children. The support from the family was perhaps too sympathetic, as Faye took on an increasing sick role during the treatment. As behavioural changes became evident with the fatigue, Faye regressed back to a young child. Previously she had been very academic and musical, with considerable pressure from school and home to be a high achiever. The change in her condition resulted in family behaviour changes and reduced any expectation of her completely, thereby almost allowing the lack of voice to be rewarding. According to Carter and Marshall (1995) no one model fully explains the pathogenesis of CFS. However, these two cases seem to Do I maintain fit Sarah into a more complex medical contact when model and Faye into therapy is a more dynamic psychological model. postponed In the more combecause the plex medical model, client is ill? it is proposed that CFS is the result of Do I help immune system dysclients take a regulation due to, positive attitude for example, infections or stress, thus within the producing fatigue context of symptoms. The more dynamic psytheir illness? chological model Do I seek peer proposes that an support when acute infection or immunological managing a event produces a challenging state of fatigue and case? invites a cyclical mind set in which avoidant behaviours can be accommodated. The fatigue symptoms are associated with the virus giving the patient permission to retreat from a previously active lifestyle into a state of learned helplessness.
Reflections
22
peer support
news extra..news extra..news extra..news extra..

Ongoing relationship
When reviewing our involvement with these clients it was evident that we had both found them particularly difficult to treat and manage. The recurrent and protracted nature of the illness leaves you feeling helpless and frustrated along with the other professionals involved. However, the general approach to the paediatric patient with CFS should be sensitive, understanding and supportive (Boger & Spirer, 1995), and it is imperative that you maintain an active and ongoing relationship with the client to confirm your understanding and acceptance of their illness and to prevent them feeling abandoned. Ideally, management should involve a multidisciplinary approach designed to meet the specific needs of the case. This team might include a paediatrician, GP, paediatric psychologist and psychiatrist, physiotherapist, occupational therapist, educational specialist, nutritionist and speech and language therapist. It is important that the team members are established from the beginning to avoid raising anxieties if they are needed at a later stage. The speech and language therapist should work with the team to try and apply the following set of principles when managing someone with CFS: 1. it is imperative that clients symptoms are heard and acknowledged by the therapist and subsequently a clear diagnosis is made in conjunction with a comprehensive medical evaluation (figure 3). 2. psychosocial evaluation is required to determine any underlying aetiology or the presence of - for example - depression in conjunction with CFS, as identification and treatment is essential. 3. a gradual return to school and other social activities needs to be encouraged and supported by the team, to reduce feelings of isolation and increase self-esteem. 4. alternative therapies may provide complementary input which can help to promote improved health.
Holistic Holidays a success

A charity which helps families living in desperate circumstances to take a holiday break now offers extended support to those most in need. The Family Holiday Association (FHA) has pioneered Holistic Holidays for families where stress levels are particularly high and a traditional break would not be enough. These are held in interesting locations in an atmosphere of relaxation and peace. Therapists, facilitators and creche workers organise activities for children including music, dancing, storytelling and exploring the countryside, while adults can have counselling, massage, reflexology, relaxation and workshops in parenting skills and community building, drama, music and dance. The FHA finds the holidays offer a high return in terms of improved health and wellbeing, better relationships within the family, enhanced social skills and a greater sense of community. FHA, tel. 0207 436 3304, www.fhaonline.org.uk.
Research opportunity
Are you a practising clinician interested in research? An opportunity has arisen for clinicians to participate in an international research study into software effectiveness using the interactive speech and language therapy program React. Details from Gordon Russell, Propeller Multimedia, tel. 0131 446 0820, e-mail gordon@propeller.net.
Learning difficulties tackled

The government has announced a package of measures to identify and tackle learning difficulties in young children in England. A government-sponsored working group will - in close collaboration with the Special Educational Consortium and other interest groups - develop practical guidance on best practice on identifying the special educational needs of children under two and providing multi-agency support to the children and families. In addition, nursery education grants will be conditional on the establishment having an SEN policy and 25m is being allocated to fund SEN training and service developments. SEC, tel. 020 7843 6318.
References
Arav-Boger, R. & Spirer, Z. (1995) Chronic fatigue syndrome: paediatric aspects (Review) (41 refs) Israel Journal of Medical Sciences 31(5): 330-4 (May). Butcher, P., Elias, A. & Raven, R. (1993) Psychogenic voice disorders and cognitive behaviour therapy. Whurr. Carter, B.D. & Marshall, G.S. (1995) New developments: diagnosis and management of chronic fatigue in children and adolescents. Current Problems in Paediatrics 25 (9):2281-93 (October). Fukuda, K., Straus, S.E., Hickie, I., Sharpe, M. C., Dobbins, J. G. & Komaroff, A. (1994) The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med 121; 953-9. rsted, . (1986) Authors seminar notes.
Telling tales
Storytellers in Newcastle have inspired the local service to look at incorporating storytelling techniques into speech and language therapists training. As Year of the Artist residencies in health care settings draw to a close, Newcastle storytellers have secured funding for another year. Chris Bostock, described as a yarn spinner extraordinaire holds tea parties where he tells a story and encourages others to do the same. Jane Young of the speech and language therapy service commented that his presence helped parents to relax. The project is part of a national scheme sponsored by the Kings Fund looking at the effect of the arts in health settings. A residency is an artist or group of artists, in any art form, working in, or responding to, a particular place and context. Residencies aim to develop or challenge familiar ideas. Year of the Artist takes artists and performers from all disciplines out of the usual spaces associated with the arts and places them in everyday or unexpected situations. Storytelling has also been the focus of a speech and language therapy project for children in Stockport. Speech and language therapist Becky Shanks worked in collaboration with education services to set up a narrative therapy project which takes a structured approach to storytelling to develop childrens attention, listening and speaking skills. Specially adapted flash cards so children can identify who / what / when / what happened / the ending are used along with puppets, role play, story books and video and tape recorders. Becky comments, The children feel much more confident when speaking and asking questions in the classroom. Once they know how to tell stories, they can learn how to plan written stories and apply these skills to other classwork. www.yearoftheartist.com, tel. 0114 279 6511 Stockport NHS Trust, tel. 0161 483 1010.
Thyme - Frkjaer, K. & Frkjaer - Jensen, B. (2001) The Accent Method. Winslow.
23
further reading
further reading further reading further reading further reading further reading
This regular feature aims to provide information about articles in other journals which may be of interest to readers. The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire YO7 4PP, tel. 01765 640283, fax 01765 640556. Annual rates are Disks (for Windows 95): Institution 90 Individual 60 Printed version: Institution 60 Individual 45. Cheques are payable to Biomedical Research Indexing.
further reading...
DYSARTHRIA
DePaul, R., Kent, R.D. (2000) A longitudinal case study of ALS: effects of listener familiarity and proficiency on intelligibility judgements. Am J Speech Lang Pathol 9 (3) 230-40. This study describes the effects of listener proficiency and familiarisation on judgements of speech intelligibility and speech severity associated with a progressive dysarthria. Speech performance was followed longitudinally for 39 months post diagnosis for a man with ALS. The subjects spouse served as a highly familiar listener whose speech severity and intelligibility judgements were compared to those of 24 unfamiliar listenerjudges. The expected superior ratings of the spouse over the unfamiliar listeners became especially evident at 20 months post diagnosis when the speech disorder was moderately severe. That is, the advantage of familiarity evolved over time and reached its maximum when the speech impairment was marked. Results for the unfamiliar listener group illustrated that differences among judges represented large individual variations in listener proficiency. These results have clinical significance in that they suggest the use of a practice standard for progressive dysarthria that includes speech intelligibility measures, listener proficiency indices, and familiarisation training.
EDUCATION
Eriks-Brophy, A., Ayukawa, H. (2000) The benefits of sound field amplification in classrooms of Inuit students of Nunavik: a pilot project. Lang Speech Hear Serv Schools 31 (4) 324-35. Purpose: This pilot study investigated the potential benefits of sound field amplification for Inuit first and second language learners in a remote community of Nunavik, Northern Quebec. Hearing screening results showed that 26 per cent of students attending the local school had hearing loss due to otitis media. The study used speech intelligibility and attending behaviour measures, as well as interviews, to examine the appropriateness of sound field amplification in the multilingual and multilevel instructional contexts found in the classrooms of Nunavik. Method: Sound field amplification systems were installed in three representative classrooms for a period of three months. Speech intelligibility of Inuttitut syllables was compared in amplified versus non-amplified conditions for 10 students with hearing loss and 10 age-matched normal hearing peers. Observations of four categories of attending behaviours for a separate set of seven students were carried out prior to the installation of the systems and with the systems in place. Teacher and student comments were collected during the study and after the study was completed. Results: Results showed significant improvements in speech intelligibility scores for students with hearing impairment and normal hearing in the amplified condition. Total scores for on-task behaviour improvement for six of the seven students observed; all students demonstrated improvement in at least one category of attending behaviour. Teacher and student comments identified numerous advantages of the amplification systems. Implications: Results point to the potential benefits of sound field amplification for multicultural populations that are similarly challenged by high rates of hearing loss, as well as for second language learners.
CHILD LANGUAGE
Ovadia,R. Hemphill, L., Winner, K., Bellinger, D. (2000) Just pretend: participation in symbolic talk by children with histories of early corrective heart surgery. Appl Psycholinguist 21 (3) 321-40. Children with histories of early corrective heart surgery (ECHS) are at risk for language, cognitive, and motor delays. This study examined parent-child play in 30 4-year-old children with ECHS and 30 typically developing children. Children were compared on basic language measures and on proportions of symbolic and nonsymbolic talk. Children with ECHS focused on concrete here-and- now talk and produced less symbolic talk than normative children. Only a third of the children with ECHS were able to produce story episodes. These findings reflect the ECHS childrens relatively immature participation in joint pretence and their over-reliance on earlier acquired strategies for pretend play. This style of participation may result from difficulty coordinating more complex social intentions with appropriate language forms.
AAC
Scott, J. (2000) How reliable is the evidence? The role of AAC in legal situations. Commun Matters 14 (3) 33-4. This paper provides a summary of a consultation exercise carried out by the Communications Forum on behalf of the Home Office. The survey was to gather information to develop guidance and identify training needs for intermediaries working in Crown Courts, and to hear about existing good practice. This provided an opportunity to highlight the specific needs of people with severe communication difficulties and of people who use an AAC system. AAC systems which support communication in everyday environments may not be sufficient for the very specific communication requirements of the legal process. The main problems appear to be lack of relevant vocabulary, the stress and fatigue of the situation, and the rate of message production. The consultation produced information about assistance given before legal proceedings, but also indicated a huge area of need, and little communication and sharing of knowledge. Two websites have been set up to address the issue. The article provides short lists of training materials, accessible materials/texts, information leaflets and relevant organisations.
DYSPHAGIA
Crary, M.A., Groher, M.E. (2000) Basic concepts of surface electromyographic biofeedback in the treatment of dysphagia: a tutorial. Am J Speech Lang Pathol 9 (2) 116-25. Surface electromyographic (sEMG) biofeedback has been used to enhance behavioural treatment interventions in a variety of movement disorders involving the head and neck musculature. These include, but are not limited to, voice disorders (Andrews, Warner, & Stewart, 1986), dysarthria (Gentil, Aucouturier, Delong, & Sambuis, 1994), hemifacial spasm (Rubow, Rosenbek, Collins, & Celesia, 1984), mandibular closure (Nemec & Cohen, 1984), and dysphagia (Bryant, 1991; Crary, 1995). Despite the potential for widespread application of sEMG biofeedback-assisted treatments in motor disorders of the head and neck musculature, speech-language pathologists generally are not aware of these techniques or of their potential application to speech, voice, or swallowing disorders. The intent of this tutorial is to provide a general introduction to surface electromyographic biofeedback techniques as they may apply to the rehabilitation of dysphagia in adults. Specific examples are provided based on clinical management of patients with dysphagia following brainstem stroke. [20 refs.].
24
how I
(and why)
Read this if you want to: understand the pros and cons of private practice liaise more effectively with independent therapists consider other ways of offering a service
Janet Farrugia runs Say & Play, a group speech and language therapy practice in Surrey (www.speechandlanguagetherapy.com).
independently
The NHS is changing. Partnerships with education, social services and voluntary organisations are common. Collaboration with other professionals, continuing professional development, user involvement, new technology and equity of access on the basis of need are key themes. Although the number of speech and language therapists is set to rise, the profession still has a retention problem and dissatisfaction with pay and conditions persists. How does the independent sector fit into this picture? Does the freedom allow therapists to be more responsive to what people want? What are the positive and negative aspects? Is it possible to mix NHS and independent work successfully? How much of a challenge is running your own business? What are the implications for collaboration, training and resources? Our contributors discuss what working independently means to them and most importantly - to their clients.
I work
Julie Andrews (www.jaspeech.co.uk) mixes NHS and private speech and language therapy.
Maria Farry is the founder and a former Chairman of the Association of Speech & Language Therapists in Independent Practice (ASLTIP) from its launch in 1991 until 1996 and is a Consultant speech and language therapist at the Ravenscaur House Clinic, London.
ASLTIP
The Association of Speech & Language Therapists in Independent Practice (ASLTIP) is the body recognised by and affiliated to the Royal College of Speech & Language Therapists (RCSLT) as representing self-employed members. Founded in 1991 to provide representation for private practitioners and to give them support and advice, the Association also provides a point of contact and information for members of the public who wish to consult an independent therapist. Although ASLTIP has some part-time clerical help, it is still a small organisation which relies heavily on the work undertaken by members of its executive and policy group. All members have to be registered with both RCSLT and CPSM and to have had at least two years postgraduate experience. The ASLTIP website - www.helpwithtalking.com - has more information about membership benefits, starting your own business and an online database to help members of the public locate an independent therapist.
25
how I
M
ongoing
From occasional clients in a room in her house, Janet Farrugia now runs a thriving independent practice in a purposebuilt facility with 10 therapists, 4 assistants and an administrator all working on a part-time basis. Independent work allows her to be more responsive and to provide a service of which she feels professionally proud.
An
chal-
Janet Farrugia
y initial decision to work independently was not made in any conscious way but was dictated by circumstances. I had worked for five years on the NHS in a variety of settings and was working with a colleague in a unit for hearing impaired children. We had difficulty when the head of the unit changed as she wanted us to follow her prescribed therapy plan. Speech and language therapy was subsequently withdrawn and we decided we had nothing to lose by doing some independent work. We had young children and thought we would be able to control our working hours more easily around family commitments, so we set aside a room each in our homes, bought essential items and, before we knew it, we each had a small but increasing caseload. After a while we became slightly frustrated working in isolation and decided to work together for professional support. We began by running small groups in one of our homes with the help of another therapist. Within a few months we had rented a village hall for a couple of mornings to satisfy the increasing demand. However the need to have a permanent base for the groups quickly became apparent and I now have a small purpose-designed clinic with 10 therapists, 4 assistants and a clinic administrator who all work on a part-time basis. We run 10 pre-school groups each week, provide individual therapy throughout the week and intensive groups in the school holidays. On Saturdays we run groups and offer individual therapy for school aged children. At the outset I had no long term plan to remain in the independent sector but independent work was very rewarding. Some advantages and disadvantages from my perspective are in figures 1 and 2. Running the practice involves a number of considerations. Primarily there is the need to inform people of the service. I have a web page and regular adverts in local child-orientated free papers but most marketing is now by word of mouth, through schools, consultants and Educational Psychologists. I believe in comprehensive assessments with detailed reports as parents often cannot absorb everything we are telling them. Prior to the assessment we contact any other therapist who is involved to prevent reduplication. Attendance at case conferences, regular reports, initial contact with any therapists involved with children referred to us, school visits and so on all enable us to liaise as effectively as possible. I also regularly provide reports for SEN Tribunals for children whose speech and language therapy needs are not being adequately met as part of their Statement of special educational needs. Our groups are re-organised on a termly basis depending on the number and type of communication difficulties the children have. We currently run groups for phonology, language, dyspraxia and pragmatics. Most groups have two therapists
Figure 1 Rewards of independent work
and an assistant. As self -employed therapists, the staff are not contracted to work set hours but are free to choose the number of sessions they want to work depending on their family commitments, other work commitments (some also work on the NHS and others have their own practices) and also the number of children attending the clinic. This can be time consuming and a worry as it is not always easy to envisage how all the patients and therapists individual requirements will be met but - amazingly - it all come together in the end. We adhere to the same standards of professional development as our NHS colleagues. When a therapist attends a course she disseminates what she has learnt to other team members. We have various specialisms amongst the different therapists and between us we attend a variety of SIGs and Local Groups. The annual return of the student timetable to the two London Universities is quite a complex task, but generally we have students throughout most of the year and attend the courses that the Universities offer to support their placements. Having students helps to keep all the therapists in touch with the latest trends and all feel that explaining the rationale behind therapy helps keep them on their toes! Accounts are the bane of my life and administration is everincreasing, but time each week has to be allocated to this. The more therapists in the clinic, the better organised the systems need to be. We have seven filing cabinets in the clinic and a further five in our lock-up garage full of discharged case-notes. As a founder member of the Association of Speech & Language Therapists in Independent Practice (ASLTIP), being involved here is high on my list of priorities and we have a corporate membership. Although no longer a member of the committee, I help out when I can. It is an invaluable support association which has made an immeasurable difference to the profile of independent therapists. We are now as highly regarded as any other therapist and, as Dr Pam Enderby once pointed out, we are helping with the retention problem. I have therapists whose expertise would have been lost from the profession had they not joined my independent practice. I believe many therapists go into independent work because it gives the freedom to be more responsive to clients needs and ultimately to provide a service of which you feel professionally proud. Working in independent practice does not guarantee an immediate increase in salary. Independent therapists only get paid for contact time so, although this may appear to be significantly higher than the hourly rate paid on the NHS, it generally averages out to be relatively similar once administration time and expenses for equipment, stationery, overheads, attendance on courses and so on are taken into account. I remain committed to the independent sector despite the enormous challenge it has posed and continues to pose - or maybe because of it? Heres to the next one - Accreditation!
Figure 2 Disadvantages of independent work a) attendance on courses is doubly expensive as there is the outlay for the course and, when we cancel patients to attend courses, we are not earning. b) accounts can be very tedious and yet is as essential as the therapy if the business is to succeed. c) finding the space to store case-notes for up to 25 years is costly and inconvenient. d) as an independent therapist I am totally responsible for every aspect of my service, with no manager to fall back on - the buck stops with me. e) I work very long hours compared with the NHS where my day rarely went later than 6 oclock. Most days I do not clock off completely until after 9 p.m.
a) the opportunity to see the children for as long and as often as is clinically beneficial. I no longer had to limit my therapy to six weeks followed by a statutory break for consolidation. b) the attendance rate is extremely high. No more frustrating DNA sessions - even more so in clinics with an ever growing waiting list. c) parental support is very high as, when people pay, they tend to be better at carrying out ideas and suggestions. d) control over time management so I could devote more time to therapy and less on administration, politics and so on. e) financial control so I can spend as much of my budget as I would like to attend courses and buy the equipment I want. f) control over working hours. g) satisfaction of being in control of my own business. h) personal satisfaction of providing a worthwhile service. I know I must be providing a good service otherwise parents would not continue to pay.
26
how I
our of my five working days are spent working for the NHS; the other day is reserved for self-employed, private work. I started independent work after three full years of experience with the NHS. This is very important as you are working alone, even though the Association of Speech & Language Therapists in Independent Practice (ASLTIP) does offer peer support. In fact, ASLTIP specifies that you must have at least two years consecutive NHS experience before being accepted to practise as an independent ASLTIP approved therapist. This helps to maintain a quality service within the private sector. As well as developing as a therapist and widening my experience, one of the attractions - as a younger therapist - of crossing over into the private sector was the ability to enhance my income. After the years at university and three years in the NHS I was on spine point 21 and wanted to enhance the financial rewards for the experience I had gained and the time I had put in to date. One of the positive aspects of working independently involves managing your own financial affairs. You get paid for what you do, you decide on your own fee (with guidance from ASLTIP) and everything you buy that relates to speech and language therapy can be offset against tax. In my case, I choose to spend most of the initial money I earn while self-employed on resources, equipment and courses and am still left with my pro-rata NHS salary to live on. Other positive aspects include being able to choose when and if I want to work to suit my own plans and the convenience of clients. There are no artificial restrictions on time and amount of therapy provided, and you can discuss with clients from the start what the best option for them would be. This includes recommending when therapy is not required or when advice and allowing time for spontaneous maturation is more appropriate. The homework set for paediatric therapy is nearly always carried out (except for the occasional parent who think that paying for weekly sessions gets them off the hook completely!) The sessions last up to one hour and I dont have to rush people out to get ready for the next client. There are absolutely no DNAs and Im only restricted to certain client groups when my own lack of experience suggests I should not take them on, rather than being confined to work in one area by the structure of a particular job. Another very important aspect of doing both NHS and private work is that I am able to keep up with current trends and issues while being supported by colleagues within the NHS and am then able to carry over the new information to my independent work, thus providing a professional and up-to-date service. Equally, through my independent work I have been able to bring more experience to and offer even more initiatives within my NHS work. When I first decided to go private, I took some really good advice from my line manager, who said Dont see clients who
are on this Trusts speech and language therapy list - and I never do. The NHS department I work in has a really healthy attitude towards independent therapists, and we work together to provide the best service for the clients. There is a professional responsibility for both the NHS and independent therapists to work in close liaison in a complementary not competitive way, and to recognise that people have a right to purchase private therapy, perhaps because of long waiting lists. My perception is that clients are becoming disillusioned with the NHS in general, not just with speech and language therapy, and believe they get a better service when they pay privately. People are tending to realise that they have greater choice now, that there are different opinions and approaches, and that they dont have to rely on what the NHS offers. Parents are becoming less accepting, and will pursue all avenues to get the best for their children. There is hardly any extra work involved in independent practice that is not also required in an NHS post, particularly if you are doing it on a part-time basis in addition to an NHS post. The tax records at the end of the year are quite straightforward (unlike their forms). I just record all my income in one column and all my expenditure in an outgoing column. I dont have the worry of wondering where all my clients are going to come from, as membership of ASLTIP provides most of the referrals to fill my diary for one day per week. Work has also been generated from my website, where clients are invited to submit details via a simple enquiry form. This brief information enables me to respond effectively to them and discuss whether I am able to offer a service or refer them on to a more appropriately experienced therapist. As I see preschool clients in their own homes, I leave a list of names and addresses with my husband and contact him regularly during the day. I see older children in their own homes to begin with, then usually in school. If I have no clients I just treat is as a quiet time and take up the opportunity to relax and do something for my family and myself. Overall, there are many positive aspects to working in both independent and NHS practice. I can see that the opportunities for independent practice are increasing with the amount of freedom the purchasers of our service now have. I have, for example, been requested several times to do proposals for local fundholders. However, I cant see myself transferring over to the independent sector completely as the work is never guaranteed, there isnt a good enough pension scheme, and you just dont have the same level of peer support that you find within an NHS department. On the other hand, I wouldnt want to give up the independent work, as this allows me a little freedom and the opportunity to work in areas other than those I specialise in for the NHS.
A complementary service
For Julie Andrews, working in the NHS and the independent sector can be the best of both worlds for therapists and clients.
Julie Andrews
t is now over ten years since I decided to set up in independent practice. After several years of working within the NHS, which I believe is essential if one is to eventually work independently, I decided the time had come to take control of my future professional life. Since then I have developed the specialist clinical fields of dysfluency and psychogenic voice disorders which I decided to pursue even whilst an undergraduate, and have focused on these fields in terms of caseload, study and professional development. I am also working towards a counselling / psychotherapy qualification as I believe this is an integral part of all speech and language therapy but especially perhaps in the fields of dysfluency and voice. As an independent practitioner I have the freedom and autonomy to organise my life - both professional and personal - as I see fit. For me this far outweighs
Through a short course at UCL, Maria now helps other therapists reach decisions about whether to start out on their own.
Maria Farry
what some people consider to be the disadvantages - the isolation, financial uncertainty, having to run a business and so on. Becoming isolated does not happen provided you take steps to prevent it. The Association of Speech & Language Therapists in Independent Practice (ASLTIP), in addition to its role as a formal representative body for the independent therapist, provides a strong mutual support and advice network. In my own practice, I can be completely flexible as to how I organise my working day. I often have my first appointment at 8am so that, for example, I can see a child in school without disrupting their classwork. Equally, I might finish a day with a session at 7pm so that an adult patient doesnt have to take time off from work. All my sessions are with individual patients. Around my appointments my time is my own and usually includes one or
Writing
the script
Freedom and autonomy to organise her professional and personal life are the main advantages of independent practice for Maria Farry.
27
how I
more of the following: a daily workout at the gym, correspondence and reports, planning of treatment programmes and, unavoidably, a wrestling match with the computer! I have an advantage in that there is a strong market for fulltime independent practitioners in the London area, and my clinic is based in my house. I have built up my practice through word-of-mouth recommendation by parents, patients and schools to which I act as a consultant. In the past, GPs were able to purchase private therapy so people could be seen immediately whilst on an NHS waiting list, but this is no longer possible. I often liaise with NHS therapists, particularly if, for example, the patient has dysphasia and has gone beyond the acute stage where most NHS therapy is focused, to management on a more long-term basis. There are many advantages to independent therapy for the patient or client: they can have as much time as they need to discuss their own or their childs problems and to plan with their therapist the most suitable treatment programme; visits to homes, schools, nurseries, GPs, consultants, hospitals and nursing homes can be arranged at mutually convenient
times; advice and training, where necessary, can be given to all others involved with the patients welfare; appointments can be arranged at short notice and patients or parents know they can usually telephone at any time to discuss problems which arise or when they need immediate advice or information. Regular, comprehensive reports can be provided following assessment, during a programme and at the end of therapy, and immediate referral on to other professionals such as an audiologist or psychiatrist can be made when necessary. In my work at UCL (short courses, tel. 020 7679 4204) I try to address the many concerns and anxieties of therapists considering an independent practice. In general, it is essential that therapists going into independent practice are experienced and have positive reasons for wanting to do so. In the main it is fear of the unknown which causes them to wonder whether this is for them. Once they become aware of the support network, information and training which is available to them, many of their worries disappear and they become excited by the realisation that when you work independently you can write your own script and the sky really is the limit!
1. Experience is essential for therapists starting in independent practice. 2. Membership of ASLTIP is vital for personal support and quality assurance. 3. Working independently can enable a more responsive, personalised service. 4. Positive aspects of freedom and autonomy come with financial uncertainty and business commitments. 5. Taking students, continuing professional development and accreditation are as relevant to independent practice as to the NHS.
6. It is important to identify how you will access peer support (for example, through ASLTIP local groups.) 7. The Internet helps the public locate independent therapy appropriate to their needs. 8. Working hours can be flexible but you are only paid for the work you do. 9. Attendance and motivation can be higher with independent clients. 10. Group practices and combining NHS and independent work can offer flexibility to staff and clients.
...RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES..
PRACTICAL POINTS
Independent Living RNID website

The second manual in Signalongs self-advocacy project covers the skills needed to live in the family or group home and going out into society. Independent Living, 25, tel. 01634 819915, e-mail: mkennard@signalong.org.uk. The Royal National Institute for Deaf People website has been completely redesigned. It has over 450 pages and offers access to information and an opportunity to get involved. Disabled people using assistive technologies now have full access and you can search for products and shop online too. www.rnid.org.uk; www.rnidshop.com
GridClub
A new approach to learning in school and at home will combine the appeal of television and the web. GridClub is a free online community for 7 - 11 year olds with activities linked to the National Curriculum. Virtual clubs include animals, music and sport. Guidance for supportive adults is provided. In September 2001, a TV series supporting GridClub called What If? will launch on Channel 4.
www.gridclub.com.
Music program
Make your own music with a program providing melodies, riffs and rhythmic patterns which can be combined in thousands of ways. Described by the special needs software company behind it as music with different access methods turning cant into can. Music Factory, Widgit Software, www.widgit.com, tel. 01926 885303.
Propeller demo
A free demo disk shows seven products available from Propeller Multimedia: React (an interactive speech and language therapy program), Speech Sounds on Cue (for speech practice), SAILS (Speech Assessment and Interactive Learning System), IVANS (the Interactive Voice Analysis System), TFR (Time Frequency Response), EcoSWin (Defining and Implementing Listening Tests) and ListenHear, which facilitates auditory perception and language learning following cochlear implantation or hearing aid fitting. Propeller Multimedia, tel. 0131 446 0820, e-mail gordon@propeller.net.
CASP forms
Record forms for the Communication Assessment Profile for people with learning disabilities by Anna van der Gaag are available from Speech Profiles, 10 Heathfield Drive Milngavie Glasgow G62 8AZ, tel. 0141 563 9445.
Slow songs
A CD aims to help children with speech disorder learn the words to familiar songs. A collaboration between Pittsburgh Symphony and others including speech-language pathologist David Hammer has produced 26 songs including Five little monkeys and Twinkle twinkle little star at a slow tempo and with edited words. Time to Sing! $16.99+shipping, see www.center4creativeplay.org/sing.
Voice for older people

The leaflet Keeping a Young Voice describes what older people can do to keep their voice fit and working well. Send a 1st class stamp in payment to Voice Care Network UK, 29 Southbank Road, Kenilworth CV8 1LA, and enclose a stamped A5 envelope addressed to yourself.
Black Sheep Press

The Winter 2001 catalogue is now available. Samples of materials to download and print are on the website. www.blacksheep-epress.com, tel. 01535 631346.
28
IMPORTANT NOTICE
Subscribers should contact the publisher if they have not received their magazine(s) within two weeks of the publication date, or if there are any problems with the magazine itself. Tel: 01561 377415
Speech & Language Therapy in Practice is published on the last Monday of February (Spring), May (Summer), August (Autumn) and November (Winter).
25 personal UK 21 part time (5 or fewer sessions) UK 18 students / assistants / unpaid * UK 30 Eire & Europe personal 34 other overseas personal
* delete as applicable
45 authorities (single subscription) 50 other overseas authorities.
UK/Europe
Bulk orders (sent to any single work address): 2 for 52 3 for 72 4 for 88 5 or more for 20 each
Special offer for personal subscribers Introduce a colleague* to Speech & Language Therapy in Practice and you both get an extra issue - free!
The new subscriber fills up their details on the form and puts your name in the recommended by space. Once their payment has been received, they will get 5 copies for the price of 4 in their first years subscription, and you will be notified that your subscription period has been moved on by three months. So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in Practice. Remember - you will get an extra issue for every new subscriber you bring in. *Must be a NEW subscriber to the magazine.
E V E N T S
British Stammering Association 7th BSA National Conference 7-9 September, 2001 Hope University, Liverpool 85 www.stammering.org. tel. 020 8983 1003 CONNECT the communication disability network Courses for speech and language therapists; for speech and language therapists, physiotherapists, occupational therapists, social workers, nursing staff, psychologists and other rehabilitation team members; for public sector workers; for volunteers, assistants, health & social care workers; for people with aphasia and their families/friends. Also visitor days and open events. Details: Course Hotline, tel. 020 7367 0863, e-mail events@ukconnect.org, www.ukconnect.org ACiP:Scotland / Communication Matters AAC Study Day Giving Augmented Language to Individuals with Cognitive Disabilities Gail Van Tatenhove 13 September, 2001, Dunfermline, e-mail sctci@waacis.edex.co.uk, tel. 0141 201 2619 19 September, 2001, Lancaster, e-mail admin@communicationmatters.org.uk, tel. 0870 606 5463 From 65 for professionals.
Cheques payable to AVRIL NICOLL BUSINESS. OR Please debit my Visa / Mastercard / Switch card: (Card payments cannot be accepted without a signature.) Card number: Expiry date: Switch only: Issue No. OR Valid from date:
(if issue no. not available)
Signature:
NAME: RECOMMENDED BY: (if applicable) HOME ADDRESS:
POSTCODE:
HOME TEL. WORK ADDRESS:
POSTCODE:
WORK TEL. e-mail:
Contributions to Speech & Language Therapy in Practice:

Contact the Editor for more information and / or to discuss your plans. Please note: articles must be of practical use to clinicians use case examples and list useful resources length is generally around 2500 words supply copy on disk if possible keep statistical information and references to a minimum photographs will be returned
Please note acknowledgements and renewal notices are sent automatically. Return to: Avril Nicoll, From outside the UK, Speech & Language Therapy in Practice, the address is: FREEPOST SCO2255 Avril Nicoll LAURENCEKIRK 33 Kinnear Square Aberdeenshire Laurencekirk AB30 1ZL Tel/fax 01561 377415, e-mail avrilnicoll@speechmag.com Aberdeenshire www.speechmag.com AB30 1UL
It would be very helpful if you could complete the following information:
Job title(s): Name of employer / university: Topics you would like to see covered
Your personal details will only be used for the purposes of Speech & Language Therapy in Practice magazine and will not be passed to any third party.
UBSCRIPTION FORM SUBSCRIPTION FORM SUBSCRIPTION FORM SUBSCRIPTION FORM
! ONLINE D N A TCH BY SWI T N E M Y KING PA Subscription form for Speech & Language Therapy in Practice A T W O N PERSONAL RATES AUTHORITY/DEPARTMENTAL RATES
Spotlight on Language
see page 10 for more information
A child draws herself and her birthday cake. Although she speaks mainly in single words, using SPOTS-ON we can produce a sentence together - I have 6 candles on my birthday cake.
c
Sequence: a) Picture of activity - Alice riding a bike. b) Alice is writing about her picture of riding the bike, with the pink triangle for I. c) Alice has added the yellow circle for the verb riding. This has been folded over so that the picture of riding is hidden to denote the past tense rode.
A worksheet of What am I doing? Climbing up.

Speech &amp; Language Therapy in Practice, Summer 2001

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Speech &amp; Language Therapy in Practice, Summer 2001

Încărcat de

Drepturi de autor:

Formate disponibile

ISSN 1368-2105

How (and why) I work independently RCSLT Conference

..READER OFFER..READER OFFER..READER OFFER..READER OFFER..READER OFFER..

Inside cover Spring 01 speechmag Reader offer

2 News / Comment 4 A multidisciplinary plot

20 A journey with chronic fatigue

25 How (and why) I work independently

Stroke units welcomed

SPEECH & LANGUAGE THERAPY IN PRACTICE

news & comment

tel/ansa/fax 01561 377415

Access improves attitudes

Toy libraries funded

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

Figure 2 - A Guyanese Folk Song

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

news extra..news extra..news extra..news extra..

Childrens brain injury needs

Communication skills through music

New deal for computers

we having fun yet?

Message does not ring true

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

Useful for discussion and reflection

Comprehensive, effective, time effiCHILD LANGUAGE

..news extra..news extra..news

Free personal care in dementia

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

actions (the verb)

places (the prepositional phrase of location)

small triangle (such as for plural)

1/4 of a circle (such as for is)

1/4 of a circle (for -ing)

verb + morpheme = verb...ing

folded circle = simple past tense

green for an attribute.

Concrete and practical

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

II. Using words

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

adults need to sit

1) The Verb Island Theory

2) Discovery, creativity and play

3) School readiness and the National Curriculum

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

Sociology: a sure start

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

Sense and sensitivity: Part 2

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

1. Know your values

Patient, persistent and positive: a journey with chronic fatigue

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2001

Figure 2 Pathway of client management

referral to homeopath homeopathic tablets prescribed

speech and language therapy referral

diagnosis of CFS anti-depressants prescribed

speech and language therapy referral

speech and language therapy recommended

CFS; however, the natural history is favourable in children

Speech & Language Therapy in Practice, Summer 2001

Speech & Language Therapy in Practice, Summer 2001