ISSN 1368-1205

Winter 2008

How I use EPG

Children and adults
Service delivery A flying start in nurseries User involvement People with dementia Teaching and therapy The best of both Transitions From primary to secondary Happy birthday To PECS, Talking Mats and Afasic My Top Resources Childrens Centres PLUSMy Top AssessmentHeres one I made earlierreviewsgreat reader offersand concluding our series on supervision Pieces of the jigsaw www.speechmag.com

Reader offer

Win the Signalong Basic Vocabulary Dictionary!

The Signalong Group has come a long way since its first manual of signs was published in 1992. A recent release is the Signalong Basic Vocabulary Dictionary and one copy is going FREE to a lucky reader of Speech & Language Therapy in Practice. The Dictionary contains all the signs in the Basic Vocabulary Phases 1-4 manuals arranged alphabetically in three A5 books complete with slipcase. Every sign is fully described and illustrated. There are additional sections on days of the week, months, numbers and name signing. The Dictionary retails for 75 but you have a chance to win one FREE simply by e-mailing your name and address by 25th January 2009 to mkennard@signalong.org.uk, putting SLTIP Dictionary Offer in the subject line. The winner will be notified by 1st February. Details of this and the full catalogue of Signalong resources are at www.signalong.org.uk. See also reader offer on p.21.

Reader Offer Winners

The lucky winners of the Speech Sounds Cards from Speaking Matters in our Autumn 08 issue are Grianne Dorian and Elizabeth Gadsden. The Black Sheep Press Copycat DVD goes to Jean Kennedy, Christine Hobden and Barbara Kendray. Congratulations to you all and please keep your entries coming.

Winter 08 speechmag
Forum For discussion of articles in Speech & Language Therapy in Practice. Anyone can read the forum messages but only registered subscribers can post. Register at http://members.speechmag. com/forum/ with a user name and password of your own choosing. Members area For a reminder of your user name and password, e-mail avrilnicoll@speechmag. com. The members area includes: Extra online only articles Material complementary to articles Back issues from 2000-2006

NEW! Only online articles added for Winter 08!

www.speechmag.com/Members/ Editor Avril Nicoll reports from a Symposium held to celebrate 10 years of the low tech communication framework Talking Mats (www.talkingmats.com). www.speechmag.com/Resources/ Originals Avril Nicoll reflects on the Afasic Scotland 40th Anniversary Conference Growing up with a speech and language impairment. Speakers included James Law, Marysia Nash and Amanda Kirby.

www.speechmag.com/Members/

Winter 2008 (publication date 30 November 2008) ISSN 1368-2105

Winter08contents
22 COVER STORY: HOW I USE ELECTROPALATOGRAPHY (1) In his [Gabriels] case treatment needs to address respiration and phonation instead of articulation to try to improve his intelligibility. We didnt know this before his speech was evaluated by EPG When traditional therapy techniques were not proving effective with two boys who have dysarthria due to dyskinetic cerebral palsy, Ann Nordberg, Elvira Berg, Goran Carlsson and Anette Lohmander offered real-time visual feedback through EPG. (2) for a person whose intelligibility is severely reduced and who for whatever reason cannot use AAC, EPG could be worth pursuing even for small gains. A stroke at the age of 33 left Lesley Anne Smiths client with impairments which affected his ability to return to work and his motivation to socialise. She explains how EPG had a small but important impact on his articulatory dyspraxia and intelligibility.

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

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

INSIDE FRONT Win the Signalong Basic Vocabulary Dictionary. (See also reader offer for CLEAR Phonological Screening Assessment on p.21.) 4 SERVICE DELIVERY They [nursery staff] were keen to build on the skills they already had, and make their interactions with children more positive rather than repeatedly asking them questions Collaborative working with early childhood educators can be challenging but, with commitment and support, newly qualified therapist Esther Black gets off to a Flying Start. 7 USER INVOLVEMENT Collecting the feedback was a small part of the process but, in retrospect, it has taught us more about how to take the group forward than our own reflections did. Charly Harveys success in enabling people with dementia to express their views on a therapy group run jointly with a clinical psychologist has inspired her to continue making user involvement a priority. 10 COLLABORATION On reflection, I feel I gave myself quite a hard time as a teacher and had potentially unrealistic expectations of how well and how quickly I could help the children learn to listen. Drawing on her dual training and experience as a teacher and speech and language therapist, StoryPhones consultant Kirstie Page explores what she has learnt from sitting on both sides of the fence. 13 HERES ONE I MADE EARLIER Alison Roberts with the low-cost seasonal activities Save your cracker jokes, Interaction paper chains for Christmas and Gift list.

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

14 TRANSITIONS The activity that had the biggest impact over all the years audited was practice using and understanding the timetable. Other activities that consistently scored highly were subject vocabulary, homework planning and making friends. Nadine Arditti and Debbie Swifts annual group aims to reduce anxiety and ease the process of transition from primary to secondary school for pupils with communication difficulties. 16 CONFERENCE CALLS The defining feature of PECS is that it teaches spontaneous requesting as the first skill. If a child who uses PECS is prompt dependent or is not acting spontaneously, Lori argues this is because they have never been taught or taught properly to request spontaneously. Editor Avril Nicoll reports from a day spent with Lori Frost, Andrew Bondy and Julia Biere as they celebrated the 10th birthday in the UK of the low tech AAC tool PECS (Picture Exchange Communication System).

18 SUPERVISION (4) FROM SUPERVISEE TO SUPERVISOR there are inherent assumptions and expectations that the therapist simply steps up to the next level and by osmosis develops the requisite skill set to take on the role of supervisor. Sam Simpson and Cathy Sparkes conclude their popular series on supervision practice. 20 REVIEWS Aphasia goal setting, family and care givers, foreign accent, head and neck, music in therapy, social interaction. 21 MY TOP ASSESSMENT Simon Henderson recommends the CLEAR Phonological Screening Assessment while Alyson Eggett praises the basic principles of Teaching Spontaneous Communication to Autistic and Developmentally Handicapped Children. BACK COVER MY TOP RESOURCES Its great when parents move from being on the periphery of groups to joining in, becoming involved and even leading sessions! Speech and language therapists in the Waltham Forest Childrens Centre Team list the people, approaches and tools that are most important to their work.

Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2008 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site. Speech & Language Therapy in Practice can be found on EBSCOhost research databases

AUTUMN 08s e-article at www.speechmag.com/Members/ E1 TALK & PLAY Talk & Play has now been accepted as one of the pathways within our community service. Staff see it as a very positive way to help many of our families and tackle parent-child interaction in a non-confrontational way. Penny Best looks back on the development of a new type of care package offered for preschool children with language difficulties. IN FUTURE ISSUES: DYSPHAGIASTORY TELLINGADVOCACYBILINGUAL INSIGHTSGROUP LEARNINGSYMBOLSPHONOLOGYDOWNS SYNDROMEMOTOR NEURONE DISEASE

news

Year of Care
The Motor Neurone Disease Association has launched a pathway tool to help professionals involved in the care of people with the condition understand and meet their needs more effectively. In recognition that Motor Neurone Disease is a complex and often rapidly progressing neurological condition, the Year of Care pathway lists all the possible care and equipment needs that a person with the disease may have over a 12 month period. Each has a cost attached to help commissioners and health and social care professionals plan and deliver services in a proactive and timely way. The pathway takes the form of a spreadsheet, with one axis listing the various stages in loss of function and the other listing the services and personnel involved in the care of people with Motor Neurone Disease. It relates the individuals need for health and social care services to the progression of their disease, where they are likely to experience increasing difficulty with speech, swallowing, walking and breathing.

The tool is a result of collaboration between Wandsworth PCT, Leeds PCT and Leeds Adult Social Care. Professor of Palliative Medicine Baroness Finlay commented, Its beauty is in its simplicity. This is one of the most important documents for patient care I have seen. To demonstrate the need for the pathway, the Motor Neurone Disease Association highlighted the case of Stan Oleson from Leeds. Some months before his death at the end of August, he spoke about the delays he had had to endure since receiving his diagnosis five years ago: You require certain pieces of equipment to help you but by the time you receive them you cant use them anymore as your needs have since changed. Im hoping that this new pathway will help me in the future. I dont know how long Ive got to live but I hope to enjoy the bit I have left. For a copy of the pathway, contact the professional support service MND Connect, e-mail mndconnect@mndassociation.org.

Chatterbox weather challenge

ICANs 2009 Chatterbox Challenge will go ahead - whatever the weather. Come rain or shine, 2-8 February will see young children across the UK performing their favourite weather song to raise funds to support the charity in its work to help children with communication difficulties. The event, supported by BT Openreach, has the dual purpose of highlighting the importance of childrens communication as the foundation for learning and development. Activity packs are available for event organisers at www.chatterboxchallenge.co.uk. In a separate fund-raising venture I CAN is encouraging Christmas shoppers to do something different and Adopt a Word. www.adoptaword.com

Story writers rewarded

Three winners of a story writing competition for AAC users were invited by the charity Communication Matters to read their work at Downing Street. Sean Lucas (7) professed himself full of joy and excited at having won not only the UK under-11 award but also the ISAAC (the International Society for Augmentative and Alternative Communication) International Youth Award. Beth Moulam (14) won the 12-16 category and said I cannot believe it, I just wrote my story Just Talking based on me. The 17 and over category Alan Martin receives his award from went to actor Alan Martin. All Chancellor of the Exchequer, Alistair Darling the entries had to have reference to AAC and the three winners were selected on the basis of content, originality and structure. All entries from the UK are at http://www.symbolworld.org/stories/cm_stories/index.htm.

SWORD unleashed

A new software therapy program designed to treat speech apraxia following a stroke is undergoing a major trial after showing significant results in early studies. SWORD was developed by researchers at the University of Sheffield and has been exclusively licensed to Propeller Multimedia, a company which specialises in rehabilitation software for people with communication difficulties. In initial studies, 20 clients showed significant improvements in the speed and accuracy of their word production after six weeks of use and maintained this improvement up to 18 weeks after the end of the therapy. The research began eight years ago, when speech scientist Dr. Sandra Whiteside and clinician and neuro scientist Professor Rosemary Varley gained funding from The Health Foundation to evaluate new ways to understand and treat apraxia. Professor Varley said, The opportunities offered by the IT revolution could be exploited, allowing patients to self administer complete therapy regimes at convenient times and locations. The result is SWORD which, through the licensing deal with Propeller, we now hope will make a real difference to many people with speech apraxia. Gordon Russell from Propeller added, SWORD will be available in a variety of flexible licenses for home and professional users, with multi-user licenses and subscriptions being made available, on CD ROM, USB Pen drive and via download. www.propeller.net/sword

Praise for Health Professions Council

The Health Professions Council has received a very positive annual performance review from the Council for Healthcare Regulatory Excellence. The report says that the HPC is an effective, publicly accountable regulator which has good communications with registrants and the public, in spite of dealing with a larger and wider range of health professions than the other regulators. The CHRE report covers nine health professions regulators including the Health Professions Council, the General Medical Council and the General Dental Council. The CHRE was able to draw attention to good practice ideas in areas such as standards and guidance documents, registration, managing fitness to practise processes and communication. While eight regulators were found to be performing well in their duties, extremely serious concerns were raised about the Nursing and Midwifery Council. http://www.chre.org.uk/_img/pics/Perf_Rev_Report_1.pdf

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

NEWS & COMMENT

Johansen update

As a result of an international agreement, Johansen Sound Therapy is now known as Johansen IAS (Individualised Auditory Stimulation). Registered providers are required to ensure they attend an Update or Refresher course at least every two years, or they will no longer be able to continue to order the programmes CDs. For information on courses in 2009, contact UK National Director Camilla Leslie, e-mail Camilla.Leslie@johansensoundtherapy.com.

Comment:

Talking Mats Symposium

Talking Mats, the low-tech framework successfully used to help people with a variety of difficulties to communicate, is 10 years old. Originally developed by speech and language therapist Joan Murphy in 1998 for people with Motor Neurone Disease, research and practice has extended its use to people with learning disabilities, aphasia and dementia. To mark the 10th anniversary and as a particular tribute to Joan NHS Forth Valley Research and Development Committee funded a Symposium day. Editor Avril Nicoll attended - more information at www. speechmag.com/Members/. www.talkingmats.com

Pieces of the jigsaw

My older son was very attached to his jigsaws when he was little, with a line of Bob the Builder puzzles repeatedly stretching from one end of the house to the other. Our authors tackle their professional puzzles with similar enthusiasm, determination and vision of the completed picture. Charly Harvey (p.7) provides the corners and edges to support people with dementia to locate their views - and finds their insights invaluable for planning future provision. Esther Black (p.4) had a clear picture of collaborative working but fitting the pieces together was harder than it looked and needed a strategic approach with guidance from experienced colleagues. Meanwhile, in reporting from both a teaching and a speech and language therapy background, Kirstie Page (p.10) helps us understand how to bring the different pieces together more effectively. Lifes transition points present us with new puzzles. Nadine Arditti and Debbie Swift (p.14) guide pupils with communication difficulties from the end of primary to secondary school, while Sam Simpson and Cathy Sparkes (p.18) help speech and language therapists make the links from supervisee to supervisor. Sometimes the difference in the cut and appearance of pieces is very subtle. (I remember giving up on a jigsaw puzzle of baked beans.) Both Ann Nordberg (p.22) with two boys with cerebral palsy and Lesley Anne Smith (p.27) with a man with a brain injury found that EPG identified fine but clinically significant distinctions. In other situations, a single piece appears to be the key. The turning point in the development of PECS (p.16) was spotting the need for exchange rather than pointing. As the Waltham Forest Childrens Centre Team (back page) show, effective therapy is about people, approaches and tools and how they interlock. A conference organiser also needs to bring the right pieces together so that those attending see the whole picture, as at the recent Afasic Scotland 40th anniversary conference (see new online article at www.speechmag.com/Resources/Originals). Putting a magazine together brings a similar sense of satisfaction as well as relief! when apparently disparate pieces of information come together and complement each other beautifully. There would be no final whole without the fantastic input from readers, not just of full-length articles, but reviews and snippets too. Please consider submitting a 300 word My Top Assessment (p.21) it wont take you long, will count for your continuing professional development, and will be of use to your colleagues.

Charity cycle

Christina Barnes, a speech and language therapist in Wiltshire, is pictured outside Moscow State University at the end of a 608km cycle between St Petersburg and Moscow in aid of the National Deaf Childrens Society. Anyone who wishes to make a donation should contact Christina at the Speech and Language Therapy Department, The Health Centre, The Halve, Trowbridge, Wiltshire BA14 8SAor e-mail christina. barnes@wiltshire-pct.nhs.uk. Meanwhile another speech and language therapist, Louise Tweedie, has entered the 2009 Mac 4 x 4 challenge with her Land Rover Discovery to raise money for Macmillan Cancer Support details at www.justgiving. com/mac4x4teamtnt.

Can we talk about it?

A creative arts project has enabled members of a self-help group to make a DVD to raise awareness of aphasia. The ST/ART Project has been providing Creative Rehabilitation Programming across Tayside for 4 years and worked on the DVD with the Speakeasy Tayside Group. Project Co-ordinator Chris Kelly explains, The content and structure of the film (and some of the filming itself ) have been very much in the control of the participants who all have personal experience of this communication impairment. Copies of Aphasiacan we talk about it? from Chris Kelly, ST/ART Project Coordinator, THAT, Trust Offices, Royal Dundee Liff Hospital, Dundee DD2 5NF. Please make cheques for 5 payable to Tayside Healthcare Arts Trust.

Stroke trial invitation

The Virtual International Stroke Trials Archive (VISTA) has been expanded to include trials of rehabilitation, including speech and language therapy. The resource is a collection of anonymised patient data from previous acute stroke clinical trials, which investigators can access to carry out novel analyses. It was set up to aid the design and planning of future clinical trials. The organisers are inviting trialists to contribute anonymised rehabilitation trial data from the last 10 years for the benefit of the wider research community. The trials need to have been randomised to at least 20 patients and have recognised measures of stroke impairment and outcomes measured within a defined follow-up period. www.vista.gla.ac.uk / e-mail Myzoon.ali@gcla.ac.uk

PS Winning Ways with Jo Middlemiss will return in 2009.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

Service delivery

Getting off to a flying start

The transition from student to newly qualified therapist can be frustrating when there are barriers to putting ideals into practice. With support from her colleagues and manager, as well as the Scottish Governments Flying Start programme, Esther Black finds that the biggest challenges in this case collaborative working with early childhood educators - can inspire the most radical changes and opportunities for professional development.
READ THIS IF YOU ARE INTERESTED IN ENVISIONING THE BEST SERVICE EVER CHANGING THINKING AND BEHAVIOUR TRANS DISCIPLINARY WORKING

s a new graduate I was looking forward to the challenge of working in an environmentally deprived area and to collaborating with early childhood educators (nursery teachers, early years officers and auxiliaries) to improve the communication skills of local children. My service provision involved working with individual children in the nursery, working with staff, joint sessions with staff and occasional short training sessions for staff. In the event, service delivery in the nurseries was particularly demanding. This was due to multiple factors including: the lack of language stimulation that can exist in some families, particularly in environmentally deprived areas high non-attendance rates at appointments

a varying degree of commitment from parents and early childhood educators to supporting my recommendations a lack of shared agreement with some nursery staff about my role and about their role within speech and language therapy aims. The aims for episodes of care for children on my caseload (Malcomess, 2001) were therefore not always met, and I experienced growing frustration.

Build capacity

Partly as a result of this, my manager set up a departmental working party to consider service provision to environmentally deprived areas, which I was invited to join. A further consideration was the potential health promotion role of speech and language therapists (RCSLT, 2006), in particular

when working in environmentally deprived areas. The other driver for change was ongoing discussion within the department regarding a model of service delivery which would build capacity in schools in line with legislation (Scottish Government, 2008) and good practice in education (Learning & Teaching Scotland, 2008). We hoped to build the capacity of early childhood educators in their interaction with children particularly those with language delay which may or may not be the result of a lack of stimulation. We reasoned that this would have an effect on the ability of staff to support children with additional support needs, facilitate their contribution to speech and language therapy goals, and help children develop towards being successful learners, confident individuals, responsible citizens and effective contributors (Learning and Teaching Scotland, 2008). As part of the working party, I was involved in carrying out a literature search into training that is effective and changes thinking and behaviour. Hulme (2005) outlines a pilot scheme offering training for childcare staff using a simple self-rating tool to analyse staff-child interaction. This involved a one-day in-service plus four weekly small group tutorial sessions. Staff members were asked to identify one target for developing their interaction. This method led to staff reducing their use of questions and directions, allowing the children more time to initiate. Staff feedback was positive. Sutton & Sedgemore (2005) describe their strategic, coordinated response to the increase of nursery aged children with a speech and language delay. This involved identifying a key
Figure 2 The best nursery ever Appropriate accommodation and resources A genuinely collaborative approach based on shared understanding, knowledge, skills, roles, enthusiasm, training An enabling environment eg. visual timetables, symbolised environment.

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Service delivery
Figure 3 Domainal map of change in service delivery to nurseries

worker from each nursery to attend a weekly one-day training session. The key worker then cascaded the information to other members of staff. This approach intended to address the communication needs of all the children in the nursery, not just those on the speech and language therapy caseload. As figure 1 shows, we took these articles into account when planning training. Our working party then considered the potential features of providing a speech and language therapy service in the best nursery ever (activity adapted from Duffy & Griffin, 2000). Our ideals are in figure 2. We discussed as a group how this could be facilitated and agreed that a change in service delivery was required. We then used a domainal map (a visual tool devised by Spiegal et al., 1992). This enables judgement of whether a change is feasible by examining the costs, benefits, implications and potential problems for those involved (figure 3).

A positive experience

With the support of the head teacher and educational psychologist, I took forward some of these principles in my service provision to a nursery in an environmentally deprived area. This was facilitated by the head teacher, who approached me to set up a joint initiative for building on staff-child interaction. I had several meetings with the head teacher to discuss offering intensive workshops on

staff-child interaction to all the nursery staff. The head spoke with the nursery staff and identified what they hoped to gain from the training. They were keen to build on the skills they already had, and make their interactions with children more positive rather than repeatedly asking them questions such as What colour is that? They were also looking for the training to be a positive experience to boost their own confidence. I met with a more experienced speech and language therapy colleague to plan and implement training. We then gave the nursery staff a whole day inservice on staff-child interaction and a series of three follow-up workshops. We also offered members of staff the opportunity to have a video made of their staff-child interaction and to receive individual and group feedback on this. Our workshop presentations were influenced by the Hanen Centres Four P Cycle (Prepare, Present, Practise, Personalise) for facilitating learning (Pepper et al., 2004). We included: educator and child styles, balancing questions with comments, listening, waiting and observing during interaction, adding routines to interaction, and interaction with groups of children. Service delivery also changed in that I spent increased amounts of time with individual members of staff discussing their views on the training. I also spent more time with one member of staff who was the key worker for a child on my caseload, modelling strategies and enabling her to evaluate her performance.

Not all members of staff agreed to be videoed and initially none, including the head teacher, were keen on the idea (although they have since purchased their own video camera). Following the whole day training we videoed eight early childhood educators with groups of children. Three agreed to be videoed on a further occasion, this time on a one-to-one with different children. One agreed to do a third video. We analysed the videos of staff who did more than one in terms of how many questions and comments were made by the adult, and the balance of turns (verbal / gesture / vocalisation) in conversation between the adult and the child. As we didnt have a baseline or look at the same adult-child dyads over time the quantitative results provide limited information but, overall, the videos showed us a positive difference in the interaction styles of the adults following the training and feedback. This led to children being able to take more turns in the conversation and thus having increased opportunity to develop their language and communication skills.

Dramatic effect

We measured one childs responses, initiations and use of language in a video made by one member of staff. The child, who was on my caseload, was aged three and had a very limited vocabulary of two or three words. Although her understanding of language was also delayed, it was significantly better than her use of language, but she was often 5

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

Service delivery unable to express even her basic needs and wants. I modelled strategies for the early childhood educator, including the use of signing and symbols. During the video, the educator significantly reduced the complexity of her language, waited for longer periods of time than before, imitated what the child was saying and mainly used three different key words throughout the interaction. I heard the child imitate and spontaneously use two of these words on many occasions as well as the Signalong sign for the word MORE. The educators use of new strategies appeared to have a dramatic effect on the childs communicative abilities. We got formal feedback from staff who attended the training using a questionnaire at the end of each session and a more detailed Final Reflections one at the end of the final session. We based the questionnaire content on material produced by The Hanen Centre (Pepper et al., 2004). Staff feedback was mainly positive. Nine of the ten members of staff completed the final reflections questionnaire (one was off sick). Five said they did not know anything new about themselves or the children following the workshops. However, seven stated that they had changed the way they interacted with children, for example by asking fewer questions and waiting longer for children to respond and initiate. Three noted a difference in the way children communicated with them following the training. Most members of staff found the training helpful, some found it very helpful and one person found it less than helpful. Some staff did not enjoy the role play, while others found it helpful. Eight said they would recommend the workshops to other nursery staff. Less positive comments included: The training about routines was patronising; Hated having to be [role play] a child, what was I meant to say / do? Positive comments included: Feel we learned a lot from each other and we feel more confident in what we can do to support SLT and our own targets; Daunting but worthwhile; Proud of myself and the child; Youre never too old to learn. Informally, several members of staff approached me individually and stated that they found the training helpful and interesting. One of them told staff at a different nursery that the training had been helpful, and they have now requested it for themselves. The staff who had less positive comments also felt able to speak to me about this personally and some issues appeared to be resolved in this way. The head teacher wrote a letter of thanks to my line manager recording her appreciation that we were able to adapt the sessions to the needs of the education team. The early childhood educator who I was working most closely with appeared to be empowered by the training and more able to suggest strategies to be used with the child who was on my caseload. She independently suggested the use of Signalong signs and Boardmaker symbols (which were very appropriate for the child) and, along with other members of staff, also played a significant role in preparing materials and implementing this. Previously, the suggestion and preparation would have come from the speech and language therapist and working collaboratively to follow this through was a challenge. This particular member of staff also developed in her ability to explain and recommend the use of these strategies to the childs parents, and helped them to problem solve in using them at home. As this was done alongside me, it reinforced and supported my recommendations. Following the workshops, the nursery staff made further requests for training in the use of Signalong and Boardmaker, and have also suggested that interaction training be given to parents whose children attend the nursery. I plan to take this forward with a speech and language therapy colleague, in collaboration with the education staff. The differences between the video sessions taught me a lot which will be useful in planning future training. Firstly, staff reported that individual feedback was a lot more helpful and less daunting than group feedback. Secondly, staff found it more beneficial to have time spent discussing their interaction goals in detail before making the video. Discussion around interaction goals within a routine included: 1. Identifying how the routine would start 2. How the educator would plan for the child to take a turn 3. How the routine could be changed to enable the child to take a turn 4. The actions, sounds and words that the educator would repeat during the routine 5. How the routine would end. These points (adapted from Pepper et al., 2004) can be filled in on a worksheet before the video is made. I have learned that a significant change to service delivery can be necessary to achieve positive outcomes for children, and that implementing it is both rewarding and challenging. My confidence has developed and I look forward to building on the changes and taking them further in other nurseries and schools. I have seen the positive effects of taking into account the evidence in the literature when providing training and have booked a place on a three day course that goes into more detail about providing training. I now feel more able to contribute to change in service delivery, and to work more collaboratively with education colleagues. The nursery at the heart of it has become a more enabling environment, the relationship between the speech and language therapist and the education staff has become more genuine and collaborative, and outcomes for children are encouraging. Esther Black is a speech and language therapist with NHS Fife, e-mail estherblack@nhs.net.

Key learning

As a year 2 Flying Start NHS speech and language therapist, I completed a reflective essay for the Scottish Government on the key areas of my learning from this change in service delivery. The Flying Start initiative for newly qualified allied health professionals is intended to promote effective practice and encourage us to remain in NHS Scotland. I noted that through the experience my knowledge and skills increased in several different areas including negotiation, flexibility, and planning and delivering presentations. I also developed in my ability to model strategies, give other people positive feedback on their performance and to enable and facilitate their learning by allowing them to come up with answers themselves.

Acknowlegement

With thanks to Roma More, speech and language therapist, for her support in planning and implementing the training, and to the nursery staff for the opportunity to take forward the change in service delivery, and develop my own SLTP practice through this.
REFLECTIONS DO I SEEK SUPPORT AT A DEPARTMENTAL LEVEL WHEN MY JOB IS CHALLENGING? DO I ASK FOR AND RESPOND TO FEEDBACK TO ENSURE THE TRAINING I OFFER MEETS THE NEEDS OF THE PARTICIPANTS? DO I MODEL THE STRATEGIES I AM ASKING OTHER PEOPLE TO USE? How have you gone about making changes in service delivery? How do you support new graduates to be involved in this process? Let us know via the Winter 08 forum at http://members.speechmag. com/forum/.

References

Duffy, M. & Griffin, E. (2000) Facilitating Organisational Change in Primary Care. Oxon: Radcliffe Medical Press. Hulme, S. (2005) ACT!: Innovative training for childcare staff, Bulletin of the Royal College of Speech and Language Therapists December, pp.12-13. Learning and Teaching Scotland (2008) Curriculum for Excellence Aims, purposes and principles. Available at: http://www. ltscotland.org.uk/curriculumforexcellence/ (Accessed 8 October 2008). Malcomess, K. (2001) The Reason for Care, Bulletin of the Royal College of Speech & Language Therapists November 595, pp.12-14. Pepper, J., Weitzman, E. & McDade, A. (2004) Making Hanen Happen, Leaders Guide for Hanen Certified Speech-Language Pathologists. It Takes Two to Talk, The Hanen Program for Parents. Toronto: The Hanen Centre. Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Scottish Executive (2008) Additional Support for Learning website. Available at: http://www.scotland.gov.uk/Topics/Education/ Schools/welfare/ASL (Accessed 8 October 2008). Spiegal, N., Murphy, E., Kinmoth, A-L., Ross, F., Bain, J. & Coates, R. (1992) Managing change in general practice: a step by step guide, BMJ 304, pp. 231-4. Available at: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1881432&blobtype=pdf (Accessed 8 October 2008). Sutton, C. & Sedgemore, J. (2005) Enriching the early years, Speech and Language Therapy in Practice Summer, pp.10-12.

Resources
6

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

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

user Involvement (3)

Its to have a laugh and be with others

Charly Harvey discovers it is not only possible to support clients with dementia to express their views on services, but that their feedback can give more valuable pointers to future improvements than health professionals reflections.
User involvement whats your experience? Let us know at the Winter 08 forum, http://members.speechmag.com/forum/.

ccessing the views of our users has been an integral part of the way we work in Medway for the last decade. This has informed changes in service delivery and assisted in service development. Each member of the team is encouraged to continue this process on an annual basis to ensure we meet clients needs and develop as a service. When I started working with people with dementia three years ago, I was keen to find a way to enable this client group to express views themselves, rather than by proxy. In the past most consultations in dementia care have been with carers, but there is a growing recognition that we need to involve people with dementia - and that they can, and want to, express their views on services (DH, 2005). I decided it might be easiest to start by accessing views about a specific event rather than the service in general to overcome the inevitable difficulties with short-term memory that are characteristic of the condition. In March 2008 I ran a 5-week group with the team clinical psychologist and her trainee for people with mild-moderate dementia. We invited five men, all of whom had had input from me focusing on compensatory strategies to overcome word-finding difficulties of varying degrees. One of the invited clients declined as he had recently been admitted to a nursing home following deterioration in his condition. One client attended the first two sessions but then decided to withdraw. His wife, the psychologist and I all agreed that his communication skills had declined below the level of the group. The other three attended all sessions except for two clients missing a session each due to holidays. The structure of the group was loosely based on
Figure 1 Session ratings Week 1 Week 2 Week 3 Week 4 Week 5 Client A 4.4 On holiday 6.1 5.4 4.5 Client B 6.2 6.9 6.7 7.9 On holiday

Cognitive Stimulation Therapy (Spector et al., 2006). The psychology trainee was an observer in all sessions and evaluated each clients communication skills. She rated clients on listening / comprehension, expressive skills and turn-taking, prosody, group involvement and eye contact, on a scale of 1 to 5 which all three staff agreed beforehand. We gathered feedback in three ways: 1. Sessional feedback To gain the views of clients about each session, we modified parts of the VASES (Brumfitt & Sheeran, 1999) and asked them to evaluate the session in terms of a) how cheerful, b) how mixed up, c) how angry, and d) how outgoing they felt during the session. We presented the pictures in this order so that the feedback session started and ended on a question with a positive focus. We offered a range of options in an attempt to gather more qualitative information from people who were less fluent and to allow for the variety and complexity of negative feelings people might have about the group. We were acutely aware that the group situation was a new one for all the clients and as such might be daunting for them, especially as people with dementia often report group conversations to be more challenging. We gave each client one-to-one support to rate the four items and asked them to place a sticker on a line under the pictures to indicate where they rated themselves. The sheets were left anonymous but we noted individual responses so that we could later compare them with how successfully each person had communicated in the group, and analyse any relationship. We gave feedback a numerical rating between 1 and 2, to one decimal place. We then totalled this to give an overall feedback score the higher the overall score, the greater the satisfaction Client C Client D with the session. The maximum possible 5.7 0.9 score was 8. Results 7.6 Left Early are in figure 1. 7.2 / All clients had 8 / their lowest satisfac7.7 / tion score in the first

OUR SERIES AIMS TO SHOW THAT USER INVOLVEMENT CAN BE TRANSFORMATIONAL FOR CLIENTS, THERAPISTS AND SERVICES PUT INTO PRACTICE AT MANY DIFFERENT LEVELS A POWERFUL TOOL FOR INFLUENCING COMMISSIONERS

week. All had expressed some degree of anxiety or nervousness about attending the group and the first weeks scores may reflect this. Client As score dropped again in the final week. This may have been because there were only two clients in that session, which affected the dynamic. As comment, make it bigger six people seems to confirm this. Interestingly, the ratings also correlated positively with observer ratings of each clients communication skills. So, those clients who had higher observed communication scores tended to say that they had enjoyed the session more. The client who stopped coming to sessions had given very low enjoyment ratings and his communication skills were noted to be quite significantly more impaired than other group members. The system used for gaining feedback felt successful, although each client did need oneto-one support to remind them how to complete their ratings. It is therefore important to be mindful of not leading the client to place their sticker nearer to one end of the scale! By the final week, all remaining clients were more competent with the system and were starting to use it more independently. This might suggest that, once a simple system is implemented for accessing the views of people with dementia, it should be used more widely within the service to offer consistency. Future projects could look into the practicalities of setting up such a system in a multidisciplinary team setting. 2. End of group feedback At the end of the final session we asked each client six questions in a one-to-one discussion. We employed symbols previously used to represent different sessions as visual reminders. The psychologist and I also had a list of topics / options to go through as a prompt to ensure that our 7

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USER INVOLVEMENT (3)

Figure 2 End of group feedback Client A 1. What did you like about Useful. Informative. Enjoyed itgives you interest. Morning is the best time of day. There was the group? the right number of staff. The group was better than 1-1 but you need some 1-1. 2. What did you not like about the group?

Client B Everyone tried to help everyone. Going straight into it and chatting about. Got on with the others. About the right length and right amount of staff. Right number of weeks and a good time of day.

Client C Have a laugh with the others. Just the right number of sessions, time of day good, happy with the people running the group, liked the venue, dont mind if wife is there or not.

Not enough oomph [Psychology trainee] was Maybe 5 people would be better. Would To be with misery bags people who going like the clappers. (The client was referring to have liked a cup of tea. dont laugh. Nothing else to say that I the fact that the trainee was keeping notes from her did not like. observations throughout and therefore could not join in much). Sessions should have been longer. Make sure all the people are willing candidates. Newspaper article. Discussing holidays. Comparing All of them. Liked sharing photos. prices of different objects. It takes too long to look at everyones photos. Too much going on for one person to manage. Yes. It gives an insight into what you can pass over people. Make it bigger 6 people, 3 of each gender, perhaps a couple of teams.Try to get people who know each other. Make a coffee as an opener and do the newspaper then. Make it harder as it goes on. Mustnt make it too paper oriented. I was worried about the person who sat at the back. Id like to do it again help each other out. Tea. A weekly routine. Discussing jobs and hobbies, showing photos and talking about Korea and the war. Nothing that I did not like. I came and saw and did with whatever is going on. Yes. Its to have a laugh and be with others. It could be a mixed group. That would be nice. Increase number of people in the group 5 instead of 3.

3. Which activity did you like the most? 4. Which activity did you like the least? 5. Would you recommend the group to other people? 6. What could we do to make the group better?

Figure 3 Carers feedback 1. The time of the group was convenient for me and my husband.

All agreed that the time of the sessions was convenient. One person added that times were convenient as long as they had no prior appointments on the dates of the group. Another said that Wednesday would not normally be a good day but the time of the sessions meant that it was convenient.

2. The dates of the group were All agreed that the dates of the sessions were convenient. convenient for me and my husband. 3. I didnt like my husband 3/4 people disagreed, one of these adding that her husband was fine as attending the group without me long as his mood was fine . or a carer. 1/4 strongly disagreed and said that her husband was happy on his own and gave him the confidence he needs . 4. It has been easy to make 2/4 agreed. arrangements to allow my 1/4 neither agreed nor disagreed and said that Wednesday was husband to attend the group. convenient, another day may have not been . 1/4 strongly agreed saying, Its important to put everything else aside for the good of communication . 5. I would not recommend the group to other carers. 6. What did your partner say it was like attending the group? 2/3 people disagreed. 1/3 strongly disagreed and said it was a very useful group . Client As wife He found it helpful. Client Bs wife He enjoyed everyone.

Client Cs wife When he came out and I asked him what it was like he always saidalright, we had a laugh. 7. What was your husbands mood or Happy. Very bright He always seemed to be in a good mood behaviour like following the group? and cheerful. following the group. Especially as he never wanted to go in the morning. No. More Always go shopping on a Wednesday 8. Did you notice any changes confidence, after the group. We went into town, had in your husbands mood or which he needs. coffee, where C speaks to everyone communication after the group? especially the children. He would like to Im sure your Cannot think of anything to improve the 9. Have you any suggestions have had some sort experience is group. C seems happy with the things on how we could improve the of refreshment. enough. youve done. group? A said he enjoyed I was happy For some reason, C always seemed to 10. Any other comments? listening and to bring B and think it was a meeting of the RNA [Royal taking part in he enjoyed Naval Association] and wanted to wear current situations meeting other his blazer and naval tie, and got annoyed and memories people. I feel when I told him it wasnt necessary. of all the other he needs to people and be without me himself. sometimes.

References Brumfitt, S. & Sheeran, P . (1999) VASES (Visual Analogue Self-Esteem Scale). Milton Keynes: Speechmark Publishing Ltd. Department of Health (2005) User and Carer Involvement in Dementia Care. National Institute for Mental Health in England. Available at www.changeagentteam.org.uk/_library/DEMENTIA%20FINAL.doc (Accessed 28 October 2008). Spector, A., Thorgrimsen, L., Woods, B. & Orrell, M. (2006) Making a difference: An evidence-based group programme to offer Cognitive Stimulation therapy (CST) to people with dementia. London: Hawker Publications. Resources www.cstdementia.com - for more information on Spector et al.s Cognitive Stimulation Therapy programme. www.alzheimersforum.org - views of people with dementia on a section of the Alzheimers Society website written by and for people with dementia.

supported conversation was comparable. Responses from the three clients who had attended regularly are in figure 2. Verbatim quotes are in quotation marks, while other information is paraphrased from clients responses. On the whole the feedback was positive and, gratifyingly, each client felt comfortable enough to provide constructive feedback as well. All seemed to pick up on the fact that Client D had not been coping with the group and were sensitive to that. There was a general feeling that the group should be bigger, but also an understanding that too many people would be harder for staff to manage. The statement by one client that the right number of staff ran the group may be evidence of the need to have two members of staff, even for such a small group. This particular client also felt that it could be quite hard work to manage each persons stories and reminiscences. There was general agreement that the scheduling of the group was good, and that we should have offered tea and coffee at the start of the group. With hindsight, this is an obvious rapport-building icebreaker and its a shame that we didnt think of it. 3. Carers feedback After the final session, we also sent the four carers a questionnaire. All four were returned, although one person was unaware of the back page so only answered questions 1-4. The questionnaire contained a combination of fairly closed and more open questions. We phrased some questions negatively (Q3 and Q5) to ensure balance and consistency, and to avoid a scenario where respondents just ticked yes for everything. The carers responses are in figure 3. Again, all respondents felt that the timing of the sessions was appropriate. All felt that their partners had enjoyed the group and it was nice that one of the carers used the opportunity to provide more social stimulation after the group by going into town for a coffee. In future, we could recommend this to other carers as an idea for extending the benefits of the group. The comment about one client always enjoying the group despite never wanting to come in the

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

USER INVOLVEMENT (3) morning is interesting. It may be that he became anxious each week about going somewhere without his carer, having forgotten where he was going and who would be there, and then relaxed on seeing the familiar setting, staff and clients from the previous week. In future it might be useful to send home a visual diary / timetable, staff or group photograph (if consent is given) or another object that acts for the individual as a meaningful reminder of the group.

resources

Talking Keyboard

TextSpeak has released the TS-04 wireless Talking Keyboard. Speech is generated as you type in male or female voices. www.textspeak.com/news/tts-04.htm

MS Talent

Taking the group forward

When we initially decided to run this group, most of our thought and preparation related to the content of the sessions. Collecting the feedback was a small part of the process but, in retrospect, it has taught us more about how to take the group forward than our own reflections did. Next time we run the group we will: Extend the time of the session to offer refreshments at the start. Remove some of the monitoring and assessment, which would not only make it easier to run but would also reduce the likelihood of people feeling uncomfortable through the presence of an observer. Make sure we indicate that the carers questionnaire continues on the back page. Offer a visual timetable featuring something meaningful to the client, for use by carers as a reminder before each session. Ensure similar levels of impairment to reduce dropping out rates. Finally, as these clients enjoyed the group, we feel it would be appropriate to invite them again. By doing this, the group can also serve as a support network for the clients as well as a therapy process. The success of the methods used to access views was incredibly rewarding, particularly as the clients were so motivated to give their opinions. By using supported conversation techniques and offering a range of methods for giving feedback, the clients were empowered to comment on their care, something people with dementia are not often given opportunities to do. The techniques we used can work just as well following individual sessions so that clients can comment on therapy as they go through it. The success we had with this group has motivated me to keep adapting my approach to try and access the views of more seSLTP verely impaired clients in the future. Charly Harvey is a Highly Specialist Speech and Language Therapist with Medway PCTs Adult Service, St Bartholomews Hospital, New Road, Rochester, Kent, ME1 1DS, e-mail charlyharvey@ nhs.net. The questionnaires used for end of group and carer feedback are available at http://www. speechmag.com/Members/Extras.

Here to Learn

A DVD due for release by the National Deaf Childrens Society aimed at helping mainstream school staff with little experience of working with deaf children. Further information Freephone 0808 800 8880.

An anthology of original short stories, poetry and personal accounts, MS Talent Volume 2 aims to benefit four charities supporting people with Multiple Sclerosis and raise awareness. MS Talent Volume 2 is 8.95 from www. mstalent.org

Contact a Family Directory offer

Signing Time

Singing Hands have released a new DVD. Its Signing Time features 25 songs with Makaton signs and symbols. www.singinghands.co.uk

The paperback version of the Contact a Family Directory (a guide to medical conditions, disabilities and support) comes with a free copy of the Disability Rights Handbook. www.cafamily.org.uk/medicalinformation/ subscribe.html

Disability swimming

Parent2Parent

A new online service from the National Deaf Childrens Society and the NHS Newborn Hearing Screening Programme to help parents contact similar families with deaf children. www.parentsnetwork.org.uk

British Disability Swimming has released a DVD to encourage the next generation of athletes to take the plunge. E-mail wcpdisability@swimming.org

Hate crime

Gardening for recovery

Thrive has produced a self-management programme to support the recovery through gardening of people affected by heart disease or stroke. Gardening for Hearts and Minds, 8.99, www. thrive.org.uk

A report from Scope, Disability Now magazine and the United Kingdoms Disabled Peoples Council examines disability hate crime and calls for greater awareness training for police and prosecutors. www.timetogetequal.org.uk/page.asp?section=90& sectionTitle=Hate+crime

Bullying signs

Dream-Toys

AbilityNet hopes to capture the Christmas market with a collection of specially adapted toys for children whose disabilities limit their motor skills and dexterity. www.abilitynet.org.uk/newsarticle73

Dont put up with it aims to ensure deaf children and young people are equipped with the information they need to spot the signs of bullying and how to cope with it if it happens to them. Order from NDCS Freephone Helpline 0808 800 8880 or e-mail helpline@ndcs.org.uk.

Cochlear impants

Sense and The Ear Foundation have published a guide for both families and professionals on cochlear implantation for congenitally deafblind children. Deafblindness and Cochlear Implantation, 8.00, www.earfoundation.org.uk/shop/items/102

Spanish stimuli

MaUSECat is a Windows computer-based system for selecting and presenting audio-visual stimuli in English and Spanish to people with communication disorders. http://computerizedprofiling.org/MaUSECat/ index.php

Developmental Journals

Early Support in England has produced Developmental Journals to help families track, record and share their childs progress through the early years. Versions include a generic Early Support Developmental Journal and those for use by families with a child who is deaf, who has Down syndrome, or who has a visual impairment. www.earlysupport.org.uk

Couple Connection

Relationship research organisation One Plus Ones interactive, self-help website for couples includes sections for those who have a child with additional support needs. http://thecoupleconnection.net/

Autism pod

Acknowledgements

Active Designs

Thanks to Nerisha Singh, Clinical Psychologist, for her help in setting up and running the group, and collecting the feedback. Special thanks to all the clients and their carers who took part in the group for giving us such honest and helpful feedback, and for giving me permission to share the information.

Active Designs fabric resources are designed to approach learning in a tactile and hands on way. www.activedesigns.co.uk

Contact a Family has produced a podcast on autism, featuring an interview with one mum and highlighting additional sources of support. www.cafamily.org.uk/news/podcasts.html

SEN standards

Stroke Matters

New quarterly e-publication for professionals in health and social care. Subscribe free e-mail strokematters@stroke.org.uk

Quality Standards for SEN Support and Outreach Services offer suggested markers against which services provided can be evaluated. Download free from www.teachernet.gov.uk 9

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collaboration

Sitting on both sides of the fence

While speech and language therapists and teachers both want the best for every child, our overlapping worlds have differences that create barriers to effective working. Drawing on her dual training and recent experience as a consultant on the StoryPhones project, Kirstie Page explores what she has learnt from sitting on both sides of the fence.
Once upon a time there was a speech and language therapist who worked with young children. One day she had the bright idea of becoming a teacher This therapist was me, and I would like to share with you the reality of this experience and look at what we, as speech and language therapists, can gain from an increased understanding of the other side of the fence. Although teachers can learn much from the world of speech and language therapy, we can also learn a lot from the world of education. to learn. If Im honest, I thought that it would be a relatively easy transition and that the learning curve would not be too difficult. The reality was somewhat different
READ THIS IF YOU WANT TO UNDERSTAND A DIFFERENT CULTURE IMPROVE COMMUNICATION ENVIRONMENTS HAVE YOUR ADVICE PUT INTO PRACTICE

The reality

The idea

The learning curve I experienced was steep in many ways. From a theoretical point of view a background in speech and language therapy stood me in very good stead. However, becoming more familiar with the curriculum, educational theories and the planning procedure were all hurdles I had to jump.

As a speech and language therapist I worked mainly within the educational environment. Like many others, I felt I had good working relationships with teachers. Although things were never perfect, I tried wherever possible to make any advice I gave as applicable to what was going on in the classroom as I could. (With hindsight I realise there are many things I could have done differently and more effectively, but we will come back to that later.) My role at Sure Start Stanley allowed me to spend more time in fewer settings than before. As a result, I became increasingly interested in the impact childrens speech and language skills have on their education and learning as a whole. I also began to look at how good Early Years practice strongly overlaps with speech and language therapy advice. I felt many childrens needs could be met more fully and effectively by advising teachers and practitioners on: the layout of the setting interacting and talking to children at the right level incorporating activities and resources to promote speech and language development specific resources such as Beat Baby, Lola and Storyboxes. Advising on some of these issues can be tricky as a speech and language therapist, so this is where the idea to become a teacher came from. The initial aim was to widen my perspective, to make me more aware of educational issues and 10

The hardest things centred around the practical issues of being a teacher and the level of preparation and organisation this involves
The hardest things I had to learn centred around the practical issues of being a teacher and the level of preparation and organisation this involves. I thought that I was aware of a teachers workload before, but I now realise I wasnt. In the past I also didnt properly understand that, when a teacher said they had no time, it was the truth. By raising these issues I am not saying that teaching is harder or more stressful than speech and language therapy or vice versa. If asked to choose I couldnt answer, as they are just different. I would say, however, that my days as a teacher in a Foundation Unit were physically very busy and demanding. Along with the learning opportunities I wanted to create and language experiences I wanted the children to have, there was an endless stream of running noses (excuse the pun!) and behavioural issues that needed sorting out as well as accidents of both kinds. (Trying to

change a boy with a language disorder who was highly distracted and interested in anything but socks and shoes, whilst wondering what the other twelve little darlings were doing, was interesting.) Experience of working with children and knowing how to interact with them obviously helped. Many of these skills can be transferred when you work with larger groups of children, but that does not make it easy. On reflection, I feel I gave myself quite a hard time as a teacher and had potentially unrealistic expectations of how well and how quickly I could help the children learn to listen. This was compounded by my awareness of the expectations of some other people, who liked the idea that I had a magic wand which would sort out all of the listening, speech and language problems. Although a strong grounding in child development allowed me observe and think about the children at a different level and in a different way to many newly qualified teachers, it was often a cause for frustration when teaching. Being very aware that a child does not understand or is not ready to learn something was often very difficult to cope with if there were limits to what I could do about it. As therapists we think of the child first and what he or she needs second. The world of education, however, encourages teachers to think curriculum first, child second. In reality, this can mean that differentiation involves the teacher watering down what they are teaching rather than focusing on what the individual child needs.

The other side of the fence

People on both sides of the fence want the same thing. Therapists and teachers want a child to be safe, happy, to learn and to develop to their potential. Although the worlds we inhabit strongly overlap, they are also very different. These differences can create barriers to effective working, and make us forget that we want the same thing.

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collaboration
StoryPhones in action

From our side of the fence

In an ideal world, advice and targets for an individual child from a speech and language therapist should be taken on board and implemented and embedded by the childs teacher and school. Sometimes this happens, but often it does not. When things dont go as well as they could, we are often quick to look to the other side of the fence for reasons. Lack of knowledge, understanding and motivation on the teachers behalf are all common reasons why we feel our advice has not been as effective as it could have been. Although these thoughts are sometimes valid, they are rarely the only reasons for breakdown. Looking closely and critically at our own side of the fence can also give us a lot of reasons and solutions. We need to consider some of the following: a) Do I ask the education practitioner for their thoughts and observations on a child? Although the practitioner may focus on different strengths and needs, and although they may use different terminology, they are usually a great source of information. b) If the practitioner doesnt understand the childs difficulty and how this will impact on their learning, do I support the practitioner with this through discussion, training, report writing and so on? c) Does the practitioner know how to support the child in the give and take of daily conversations? Strategies such as talking to children at the right level or modelling speech sounds and grammar are not part of teacher training. Just because it is so instinctive to us, we cannot assume that other people know what they have not been told. d)Does the practitioner have a toolbox of strategies which they can support the child with during stories, group time, and adult-led activities? Strategies such as sitting the child who finds it hard to listen opposite and gaining their attention visually and / or kinaesthetically can be easily integrated into general practice. These strategies will also support many of the other children in the class who may not be known to speech and language therapy, but who cause educational concern. e) Can our ideas for activities be easily incorporated into the activities which are going on already? Although some activities are very specific to an individual child, most will support many childrens learning within the class. Embedding advice in this way will also make it easier to carry out as it will no longer have the same implications for adult time and support. f) Could we use more educational terminology to make our advice more effective? If we can link our advice to the curriculum where possible, even if the link is just to an area of learning or subject area, a teacher will see how the advice fits in. Speech and language therapy advice, therefore, is not robbing time from the curriculum and what the practitioner should be doing. 11

The world of education places many demands on teachers. Just as therapists have legally binding elements to their work, so do teachers. As a therapist, I feel that understanding the culture within which teachers work can make us more effective: 1. Value added as a teacher I am under huge pressure to demonstrate that the children in my class are making progress. My competence as a teacher, the schools Ofsted inspection and potentially my pay and promotion prospects will depend on this. Progress will be judged on a childs assessment results and levels. The world of education creates an environment where progress can be encouraged by pushing children on towards their target. The world of speech and language therapy believes that the best way to encourage progress is to go in at the childs level and to build them up from there. If we are advising the latter, we need to support teachers and help them realise that they will be encouraging long-term progress, even if this is at the expense of short-term gains. 2. Curriculum The National Curriculum and the Foundation Stage Curriculum (the Early Years Foundation Stage from September 2008) are legally binding documents in England. As a teacher, it is my duty to deliver these. If speech and language therapy advice is portrayed as separate, I may see it as an extra thing which is taking time away from what I should be doing. Contrary to popular belief, the National Numeracy and Literacy Strategies (which have now become the Primary Frameworks) are optional and are not legally binding. In reality they will often be followed to a greater or lesser extent in most schools. If a school is to opt-out, they will need to prove to Ofsted that what they are teaching instead is just as good if not better. This is scary, but an increasing number of creative and innovative schools are opting out. 3. Early Years Foundation Stage the new early years curriculum extends from birth to five years and has received some bad press for formalising education too quickly. In reality, it may make

the lives of speech and language therapists easier. It offers a lot more scope for targeting earlier stages of development to meet a childs needs. Although this is often what therapists advise already, the fact that this is part of the curriculum will make it easier for a teacher to incorporate advice, and to see it as part of the childs education rather than their therapy. 4. Literacy an awareness of the links between speech and language and literacy is becoming more commonplace within the world of education. Phonological awareness, however, will still

Differences can create barriers to effective working, and make us forget that we want the same thing.
be confused with phonics, and many teachers continue to feel difficulties with literacy are due to the fact that the child doesnt say words properly. The depth of the links may not be fully appreciated by some teachers. Although the new Primary Framework for Literacy embeds speaking and listening throughout, a closer inspection reveals that this is often speaking and listening for literacy rather than for communication. It is a great improvement though, and therapists can potentially support teachers with how they could use this time and create opportunities to meet more fully the needs of those children with speech and language delay / disorder. 5. Groups versus individuals As a teacher I work with groups and rarely individuals. I will need you, as a therapist, to understand that this is my world. For your advice, I want you to tell me what I can do which will fit into the way that I work. Giving me ideas for one-toone activities which you would do with that child on a one-to-one will be less meaningful.

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The best of both

At the moment I work as a freelance trainer on issues relating to speech and language development and early literacy. For this training I try to combine the theoretical knowledge and experience I gained as a therapist with the practical insight and curriculum knowledge I gained as a teacher. As a teacher I became increasingly concerned that many of the advances within educational ICT (Information & Communication Technology) focused mainly on childrens visual skills rather than their auditory and verbal skills. Visual ICT has many benefits but is often overused due to the fact that teachers are encouraged to embed ICT across the curriculum wherever possible. As concerns about childrens listening and language skills increase, the amount of audio work being done with children is in reality decreasing. I am therefore also working as Educational Consultant for StoryPhones, a new digital audio system for the Foundation Stage and Key Stage 1. StoryPhones have been specifically designed to promote listening, language and literacy skills. The MP3 headsets have no wires so can be used to listen to stories, music, songs and rhymes or to carry out listen-and-do activities throughout the environment, both indoors and outdoors. Although they are a resource for all children, there are many applications for children with speech and language delay / difficulties and could easily be utilised by therapists as they start to appear in schools. Many of the listenand-do activities which will be available to download and use on the StoryPhones have

in-built differentiation within the audio track. This will allow teachers and therapists to select different levels to target the individual needs of different children. The record facility will also allow speech and language therapists to record and make their own resources. These could then be left at the school or nursery, allowing the child to carry out the activity many times with or without adult support. In an ideal world, these could also be sent home and shared with parents. This facility can also be used by the children to record their own thoughts, stories, ideas and songs. As this saves digitally, there are many opportunities for assessment and monitoring childrens progress. The Education Team at StoryPhones would like to hear from therapists and teachers who are keen to develop and publish good quality resources for use on StoryPhones. We would also like to hear about how people have used SLTP them in different ways. Kirstie Page is a speech and language consultant with StoryPhones, e-mail educationteam@ameeca.co.uk, www.storyphones.co.uk.

TEN STEPS TO BETTER PRACTICE WORKING WITH TEACHERS: 1. ASK FOR AND LEARN FROM THEIR EXPERIENCE AND OBSERVATIONS 2. ACKNOWLEDGE THEIR CULTURAL CONTEXT AND WORKLOAD 3. LINK RECOMMENDATIONS WITH THE CURRICULUM AT EVERY OPPORTUNITY 4. USE EDUCATION TERMINOLOGY 5. EMBED ADVICE WITHIN WHAT THE TEACHER IS ALREADY PLANNING 6. OFFER SUGGESTIONS THAT ARE SUITABLE FOR GROUPS 7. PROMOTE LISTENING FOR COMMUNICATION ACTIVITIES / ICT 8. EXPLAIN YOUR PLAN IN TERMS OF THE IMPACT ON LEARNING 9. SPELL OUT STRATEGIES NEVER ASSUME THEY ALREADY KNOW 10. MAKE IT CLEAR HOW SUPPORT COULD BENEFIT OTHER CHILDREN TOO What issues has this article raised for you? What has helped you collaborate more effectively with teachers? Let us know via the Winter 08 forum at http://members. speechmag.com/forum/.

Resources (Foundation Stage / KS1)

Beat Baby - by Ros Bayley and Lynn Broadbent, Lawrence Educational Publications, www.educationalpublications.com Lola by Ros Bayley and Lynn Broadbent, Lawrence Educational Publications, www.educationalpublications.com  Storyboxes (50 exciting ideas) by Helen Bromley, Lawrence Educational Publications, www.educationalpublications.com StoryPhones www.storyphones.co.uk

news extra
SENDIST petition
An online petition is urging the Prime Minister to stop government plans to change Special Educational Needs Tribunals (SENDIST). This appeal system is available to parents who disagree with Local Education Authority provision for their child with special needs. Regulations have been amended so that from November 2008, SENDIST is to be part of a unified tribunal system called the Health, Education and Social Care Chamber with the Care Standards Tribunal and the Mental Health Review Tribunal. Some parents of children with special needs are expressing concern that the detail of the changes could lead to their children being assessed against their wishes and at their expense. They also believe that it will now be impossible for parents to attend a Tribunal without the expense of hiring a barrister. The petition is available at http://petitions.number10.gov.uk/SENDISTtribunals/.

Self-referral welcomed

The Parkinsons Disease Society has welcomed the health secretarys announcement that confirms and extends the right to self-refer to allied health professionals. Self-referral is not a new concept in speech and language therapy, but awareness and access is not universal. Although the announcement applies to all allied health professions, it has been prompted by research with the Chartered Society of Physiotherapy which showed that people who self-refer access services more quickly and are also more likely to complete their treatment. The Parkinsons Disease Society hopes that self-referral will enable more people with the condition to access physio, occupational and speech and language therapy. www.parkinsons.org.uk

Cochlear implant ruling The National Institute for Health and Clinical Excellence (NICE) has ruled

Write on

that the NHS should offer cochlear implants to all profoundly deaf children where this is the preferred option of the family. A number of deaf charities who have lobbied for an end to the previous postcode lottery have welcomed this development, along with a ruling that all profoundly deaf children should also be offered the option of cochlear implants in both ears, providing this is done at the same time. The National Deaf Childrens Society website has a summary of the guidance and further information on cochlear implants, www.ndcs.org.uk.

WriteOnline, an online word processor, has won the English Speaking Unions Presidents Award 2008 for being interactive, empowering and educationally useful. The Award is given annually for innovation in the use of new technologies to enhance English teaching and learning worldwide. The tool aims to provide users of all ages and abilities with a consistent level of writing support on any computer with an internet connection. The word processor has an integrated Wordbar to give easy access to words and phrases. Predictive text and speech functions are available along with switch access if necessary. Preferences are saved online, so are automatically applied wherever the student logs in. www.cricksoft.com

12

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

heres One I made earlier

Heres one I made earlier...

Save your cracker jokes
Most cracker jokes are based on puns and idioms - forms of ambiguity that are sometimes difficult for people on the Autism Spectrum to understand. I have found it possible to dismantle these simple jokes, explain them step-by-step, and then put them back together again, thereby making them accessible and enjoyable for all. Many youngsters with Aspergers Syndrome are motivated by this activity. Its best not to introduce this though until some preparation has taken place through work on visual ambiguity and idiom. The idea is that as you examine more and more pun-type jokes the clients will begin to understand the system, and start to enjoy them on their own. The additional benefits are that a) they should then have a few jokes up their sleeves for social occasions, b) be more open to understanding other peoples puns that crop up in conversation and c) may also have widened their vocabulary and knowledge of idiom. But beware: the most groan-making jokes are the ones that seem to be most easily remembered, and will be re-quoted at you long afterwards!
MATERIALS As many cracker jokes as you can possibly get. Within a brand of cracker they tend to repeat the same jokes, so it is a good idea to ask all your acquaintances to save theirs so you have the best chance of acquiring many different jokes. IN PRACTICE (I) Carefully pick out the jokes you are going to work with; you are looking for the ones with obvious puns and idioms. Stick the jokes, well spacedout, on pieces of A4, and make photocopies for each group member. The core of the work is to find the word or idiomatic phrase that means two things, the double entendre, for example: Patient: Doctor, Doctor, I feel like a pair of curtains. Doctor: Well pull yourself together then! The key words are pull yourself together. You will have to explain the idiomatic meaning as take control of your behaviour, recap the literal meaning, and then retell the joke. With this other old joke, the pun on smell is an easier one to explain as no idioms are involved, just two meanings of the one word: Boy: My dogs got no nose. Girl: How does he smell then? Boy: Terrible! Once you have explained the procedure about finding the pun word using a few of the jokes, you can ask one of the other group members to pick out the next pun in the same way. IN PRACTICE (II) This work was so popular with our group that they decided to collate their favourites into a little book (just six folded A4 sheets), which we photocopied and sold at our Christmas market in aid of our local branch of the National Autistic Society, the Stroud Autistic Support Group. They sent us a lovely thank-you letter which in turn raised the self-esteem of the group members.

Alison Roberts brings a Christmas theme to these low cost, flexible therapy suggestions suitable for a variety of client groups.

Interaction paper chains for Christmas

This is a simple and festive idea to recap on work done in the pre-Christmas period, and a way to link all your various clients and groups together. You are aiming to create festive decorations on which the clients have written down ways in which communication benefits us, or prerequisites for achieving good communication. Friendship and social skills, and conversation tips, can be included as well.
MATERIALS Packs of coloured paper strips sold for Christmas decorations (already glued at one end) Pens IN PRACTICE 1. Each client writes one aspect of communication on a strip. Ideally the aspect they would choose would be something on their personal target list for the term. 2. Curl one strip round, and stick it to itself to form a paper circle, then loop another through it, and so on until you have a long chain which can be added to, by other groups or individuals. Dont hang it too high, because you need to be able to see the words written on the loops. 3. Ask everyone how they feel about the chain, and which targets belonging to other clients might also apply to them.

Gift list
This is an awareness-of-others game particularly suitable for group or individual sessions leading up to Christmas. It can be done as a group exercise, or as an individual task. It is a useful exercise for learning to appreciate other peoples interests and preferences, and helps with friendship building.
MATERIALS Semi-official looking forms which you will have made (see below) Pens PREPARATION You need to make a form, in a list style, and head it with the words A gift for Then put these person types down one side (you will probably think of many more). Leave space for two price ranges; one is a small gift, costing a little pocket money, and the other is a more expensive gift, pretending you are very rich: an elderly granny or grandpa who like gardening and going for short country walks a friend who is the same age as you, and has similar interests a baby a six year old girl a ten year old boy a teenage girl who loves clothes a friend who is keen on art a business man who is stressed out a friend who is keen on sport IN PRACTICE No matter what the ability level of your group, it would be wise to begin by discussing the list and filling in one set of ideas together. Next, the clients might like to work in pairs, which will offer an opportunity to discuss and try to agree on ideas. If they prefer to work individually they can share the ideas after they have finished.

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HEALTH PROMOTION

Dead good transitions

The move from primary to secondary school can be a daunting prospect, particularly for pupils with communication difficulties. Nadine Arditti and Debbie Swift have been involved since 2003 in projects which seek to reduce anxiety and ease the process.
READ THIS IF YOU ARE INTERESTED IN GROUP WORK FACILITATING PEER SUPPORT MULTI-AGENCY COLLABORATION

hether or not they have communication difficulties, many children find moving from primary to secondary school difficult. Anderson et al. (2000) found that when children make this transition they have considerable anxieties but positive anticipations about the new opportunities. The move is also commonly accompanied by a dip in attainment as some children engage less well with class teaching and school work (Galton & Morrison, 2000). A study undertaken by Graham & Hill (2003) looked at the transition process. It took the form of a questionnaire survey in Glasgow in May / June 2002, supplemented by focus group discussions with children and data from teachers. Nearly all children reported looking forward to making new friends (89%), learning new things (82%) and doing practical subjects (79%). Their concerns included getting lost (77%), not knowing anyone (55%), getting picked on (53%) and more homework (53%). Most children had taken part in some sort of induction to their new school through visits or meetings. The nature of language and communication difficulties means that affected children need extra support and preparation to enable a smooth transfer to secondary school. As a result of looking at the needs of Year 6 children and talking to colleagues in neighbouring speech and language therapy departments, we decided to set up a transition group and programme for children in their final year at primary school (Year 6). Before the transition group was established we kept children on speech and language therapy caseloads, with the anticipation that they would need more intervention at secondary school. When we set up the group we hoped it would act as a preventative therapy which would enable many pupils to be discharged. The group has been running since 2003. All the invited children are on community clinic, specific language impairment, autism spectrum disorder, special school or mainstream school caseloads in Trafford. We ask speech and language therapists in the department for names in the November and invite pupils in the Easter. The group is held over three days in a secondary school during the summer holidays. We have a ratio of two adults to eight pupils. We are often supported by speech and language 14

therapy students from the two Manchester universities. In 2007, we invited 27 pupils - 20 responded and 19 attended. In 2008, we invited 36 pupils, with 25 responding and 21 attending. The aim of the group is to teach children specific skills that they will need at secondary school. This supplements the work already done by their own primary schools, such as visits and open days, to prepare them for the move. One of the first things we do with the children is a group activity to explore what they are looking forward to at secondary school and also what concerns and worries they may have. This helps them to prepare for the course and to begin to problem solve. Sometimes the children say that they are not worried about anything which, in our experience, is partly due to the nature of their communication difficulty. We find this activity helps them to be more realistic and to understand the aims of the group.

l-r Nadine and Debbie

Themes

The themes that have been generated by this process form the basis of the transition programme. These include: How do I read a timetable? How does the school canteen work? What can I choose to eat and how much will it cost? What do I do if I get lost? What do I do if I forget my homework? What do all these new words (biology, geography etc.) mean? How do I get organised for school? Making friends. The programme looks at these aspects in more detail and concentrates on teaching specific skills to address the childrens anxieties. We use a solution focused Pupil Passport activity to encourage the children to think about both how to deal with their anxieties and strategies that might help. We practise following a timetable, problem solving, organisation skills, using a canteen, secondary school vocabulary and making friends. We ask the children to find their way around the school by following clues and working as a team. This activity is particularly diagnostic as it relies on inferential understanding. They have to learn, for example, that just because

there is a computer in the room does not make it a maths room. On the last day of the course, we organise a parents session to discuss the course content. Support is also offered by the Educational Welfare Service and Parent Partnership Officer. They discuss issues such as Statements and attendance and support the parents in preventing problems. Every October, following their childs transition, we audit the success of the group by sending home a parent questionnaire. We have carried out a retrospective audit of the last three years. In 2005, 74% said that activities covered in the group helped their childs transition to secondary school. In 2006, the score was 87% and in 2007 it was 90%. This is probably due to the development of the programme and how the content has evolved. The activity that had the biggest impact over all the years audited was practice using and understanding the timetable (100% each year). Other activities that consistently scored highly were subject vocabulary, homework planning and making friends. We asked parents if the group had supported their childs transfer to secondary school on a scale of 1 (not very much) to 5 (very much). Over the three years no-one used the 1 or 2 ratings, 5.5% rated the success as 3, 44.5% rated the success as 4, while 50% rated the success as 5. This suggests that parents see the group as a beneficial support for transition. We now run a group every year for approximately 16-25 children. Although other professionals have run transition programmes / groups, there were no published resources to standardise therapeutic practice. As a result of this, we decided to develop our transition programme as a resource pack which has been published by Winslow (Arditti & Swift, 2008). The pack is intended for speech and language therapists, Year 6 teachers / Year 7 form tutors and SENCos (Special Educational Needs Coordinators) who want to organise a transition group for pupils transferring from Year 6 to Year 7. It consists of a set of photocopiable resources with full instructions on how to plan and organise a three day course.

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Health promotion

Welcome to Secondary School Trafford CYPS

Project group

Following the success of the Transition Programme, we were invited to join the Traffords CYPS (Children and Young Peoples Service) project group, Welcome to Secondary School! Transfer support for young people with statements from young people with statements (2007). The group consisted of the Positive Contribution Strategy Manager, Special Educational Needs Parent Partnership Officer, School Improvement Service Inclusion Officer and three speech and language therapists. The aim of the project was to promote the value of partnership working, and in particular the benefits of enabling children and young people to design and develop services for their peer group in line with government policy. In its Special Educational Needs Toolkit, the Department for Education and Skills (2001, p.2) says, Children should be enabled and encouraged to participate in all decision-making processes that occur in education including being involved in transition planning. The Department of Health (2006, p.14) states that, Health care is provided in partnership with patients, their carers and relatives, respecting their diverse needs, preferences and choices, and in partnership with other organisations (especially social care organisations) whose services impact on patient well-being. In addition, the

policy is reflected in the 2004 National Service Framework which states that health promotion and early intervention improve outcomes for children and young people. Standard 2 around Supporting Parenting encourages strengthening awareness of safety and emotional well-being, including tackling bullying. Primary Care Trusts and schools are urged to engage parents to support children in learning and the development of life-skills. It adds, Schools provide information to parents at times of transition in their childrens lives, such as the move from primary to secondary school. This includes information about child development and learning and behaviour, and where to obtain further help if needed. (p.75) The project group decided to ask statemented Year 7 pupils if they would like to work with us to produce a booklet for Year 6 pupils with SEN (Statements of Educational Needs), to help allay their real or perceived worries about secondary schools. We hoped that the booklet would provide pupils, parents and teachers with increased knowledge and understanding of how to ensure that transition would be as smooth as possible. We worked in focus groups with Year 7 pupils from a range of secondary schools. The discussions were guided by the concerns that the Year 6 children had raised at

our Speech and Language Therapy Transition Group, such as getting lost and understanding in class. The discussions were mainly led by the SENCo or teacher in the resource centre and responses were recorded. The children had to complete a questionnaire following the discussion, for example, I ask for help when I need it always / sometimes / not very often / never. The children from a chosen secondary school designed and edited the content of the booklet. The children really valued having editorial control over the content, graphics and overall look and, for example, a child with visual impairment chose the colours that were easier to see. As the booklet is a resource for parents and children to use to support the transition process, funding was successfully sought from Traffords Demonstration Project Fund (TIS Transition Information Sessions). The booklet is now given to all Year 5 pupils with a statement and the children who attend the Speech and Language Therapy Transition Group. It will be available on www.cyps.org.uk . The transition programme has alleviated some of the concerns and difficulties children face when they transfer to secondary school and has indeed met our aim of enabling many children to be discharged following the group, having completed their episode of care. Some examples of parents comments include: It gave him confidence and took away some of the fears and worries; He showed the pupil passport to his maths teacher and he explained his worries and the teacher was understanding; Js very organised with packing his bag and following his timetable and homework. It can only be because of attending the group. Finally, one from a pupil - Youve sorted us out dead good for secondary school! Nadine Arditti and Debbie Swift are Specialist Speech and Language Therapists with Trafford PCT, e-mail nadine.arditti@trafford.nhs.uk and SLTP debbie.swift@trafford.nhs.uk.
REFLECTIONS DO I RECOGNISE THAT TRANSITION POINTS REPRESENT BOTH A RISK AND AN OPPORTUNITY FOR INDIVIDUALS AND SERVICES? DO I OFFER SOLUTION FOCUSED ACTIVITIES SO CLIENTS CAN FIND THEIR OWN WAY FORWARD? DO I USE ONGOING AUDIT TO MONITOR THE SUCCESS OF A DEVELOPING INITIATIVE? What have you done to support clients through transitions? Let us know via the Winter 08 forum at http://members. speechmag.com/forum/.

References

Anderson, L.W., Jacobs, J., Schramm, S. & Splittgerber, F. (2000) School transitions: Beginning of the end or a new beginning? International Journal of Educational Research 33, pp.325-339. Arditti, N. & Swift, D. (2008) Transition Programme. Chesterfield: Winslow Press. Children & Young Peoples Service: Participation Team (2007) Welcome to Secondary School! Transfer for young people with statements from young people with statements. Trafford: CYPS. Available at: http://www.cyps.org. uk/2008/03/11/VTEH0171%20June07%20July%23510A1A.doc.pdf (Accessed 30 October 2008). Department for Education & Skills (2001) SEN Toolkit. (Product number: 0558 2001). Available via: http:// publications.teachernet.gov.uk (Accessed 30 October 2008). Department of Health (2006) Standards for better health (updated). (Product number: 40366.) Available via: www.dh.gov.uk (Accessed 30 October 2008). Department of Health & Department for Education and Skills (2004) National service framework for children, young people and maternity services. Available at: http://www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks/Children/DH_4089111 (Accessed 30 October 2008). Galton, M. & Morrison, I. (2000) Concluding comments. Transfer and Transition: The next steps. International Journal of Educational Research 33, pp. 443-449. Graham, C. & Hill, M. (2003) Negotiating the transition to secondary school, University of Glasgow Spotlight September. Available via: www.eric.ed.gov (Accessed 30 October 2008).

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Conference calls

Ripples in a pond
Editor Avril Nicoll reports from a day celebrating 10 years of the Picture Exchange Communication System (PECS) in the UK.
Lori Frost, co-developer of the Picture Exchange Communication System, says she likes not being able to identify the profession of people in the classroom. This ethos of shared responsibility and commitment was evident in the mix of people attending the 10th birthday celebrations of PECS in the UK. The Edinburgh event had parents, teachers, nursery nurses, a foster carer and speech and language therapists participating. PECS is a low-tech AAC tool designed to encourage initiation of communication (see figure 1). It was developed by Lori Frost and Andrew Bondy in the United States while Lori was working with children aged from 2-6 years with autism, many of them not talking. She reflects that when she graduated she knew a lot about what to teach but was woefully unprepared how to teach. As is often the case, a particular client inspired the thinking that led to the development of PECS. This boy was 4 years old, nonspeaking, hadnt learnt sign language or speech imitation, didnt want to be touched, couldnt isolate his pointer finger and - not surprisingly - was very frustrated and aggressive. Although he would tap a communication board, he wasnt doing this communicatively. Lori describes being kept awake thinking, I dont know what to do with this boy because nothing is working. Re-examining the definition of communication was key to finding a solution. Loris definition is that: Not all behaviours are communicative Communication must occur between two people The speaker directs behaviour to the listener The listener mediates access to the reinforcer (what the speaker wants). Rather than encouraging her client to indicate a picture on a communication board, Lori recognised that as the speaker he actually needed to take the picture to someone. This forced social interaction and brought a focus on the person (listener) rather than the board. Lori says there are no prerequisites for PECS other than that the client needs to want something and the picture that is used in phase I is merely their ticket for getting it. of an 8 year old boy called Conall, describes herself as very stubborn in ensuring PECS is done properly. In talking about how Pictures mean the world to her son, Julies own role in ensuring the success of PECS through encouraging this spontaneity is clear. When Conall used his PECS folder in a caf, for example, Julie explained he had to show the lady rather than her. Parents stories are vital in raising awareness among professionals about the real, day in day out experience of living with autism and other developmental disorders. Their stories also demonstrate how essential it is to acknowledge, appreciate and support parents coping strategies and expertise. Conall was successfully introduced to PECS at his special school when he was 7 by a teacher trained in the approach. His mother was funded and encouraged by the school to attend a 2 day course so that Conall could bring his form of communication home. It was fascinating to hear how this has led to him being a happier child who improvises a lot with his symbols (eg. used chips as didnt have carrot sticks), becomes excited over his achievements and instigates taking his PECS folder with him wherever he goes even when thats stomping off to his room in the huff. He maintains his own PECS folder, expresses emotions and tastes and makes informed choices (out of two) independently. Although life for the family remains challenging given Conalls dietary preferences, sensory intolerances and erratic sleep pattern, Julie describes the reduction in stress and increase in family cohesion as being like ripples in a pond. She adds that PECS is about helping a child develop into the adult they should be. PECS is administered in the UK by Pyramid Educational Consultants (www.pecs.org.uk). Discussion with Lori, Julia Biere (Pyramid Consultant) and delegates confirmed that one of the major challenges with PECS, as with many other approaches, is ensuring it is offered in a way that is true to its philosophy and therefore in a way that will work. Its fairly normal practice for one person from a team to attend training and then to cascade what they have learnt to colleagues, which can lead to a Chinese Whispers effect and a focus on the symbols rather than the spontaneous communication. For this reason, both Lori and Julia are very positive about the role of Pyramid Consultants in supporting UK trainees with PECS implementation. Pyramid is an approach to education which runs from wake up to bedtime. It recognises that developmental disorders impact on the whole day, not just communication, and is heavily influenced by Applied Behaviour Analysis (ABA)
Figure 1 PECS at a glance Reproduced from http://www.pecs.org.uk/general/ what.htm (Accessed 5 November 2008)

Phase I Teaches students to initiate communication right from the start by exchanging a single picture for a highly desired item. Phase II Teaches students to be persistent communicators- to actively seek out their pictures and to travel to someone to make a request. Phase III Teaches students to discriminate pictures and to select the picture that represents the item they want. Phase IV Teaches students to use sentence structure to make a request in the form of I want _____. Phase V Teaches students to respond to the question What do you want? Phase VI Teaches students to comment about things in their environment both spontaneously and in response to a question. Expanding Vocabulary Teaches students to use attributes such as colours, shapes and sizes within their requests.

learning theory. Lori describes herself as on a mission to teach Speech-Language Pathologists about ABA, which is somewhat controversial in the speech and language therapy world. She cautions people not to be put off by the most commonly held beliefs about ABA / the Lovaas Method as being in your face and requiring lots of repetition, as this is such a small part. Loris early experience involved collaboration with occupational therapists and teachers, and included tying shoelaces and changing diapers. Language and communication was integrated in the whole day. She has asked herself what makes certain classrooms, homes and people take off with such an approach, and believes a flat hierarchy can help as well as each individual being smart, enthusiastic, motivated and willing to share. Her special contribution to the team as a speech-language pathologist has included knowledge of the developmental sequence and of pragmatics.

Name the feelings

Spontaneous requesting

The defining feature of PECS is that it teaches spontaneous requesting as the first skill. If a child who uses PECS is prompt dependent or is not acting spontaneously, Lori argues this is because they have never been taught or taught properly to request spontaneously. Julie McGhee, the mother 16

Loris husband and PECS co-developer is behaviour analyst Andrew Bondy. He presented his most recent thinking on how we help children with autism develop the language of emotions. When typically developing children fall, we might see the bleeding, but they also cry. When they eat ice cream, we notice they eat quickly, but they also smile. They show pain and pleasure, so we comment on this and name the feelings. Typically

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

news extra
HPC updates
Speech and language therapists can now update their details with the Health Professions Council online. All registrants should have received a letter with details of how they can activate their account. Each registration certificate and authentication card are valid for two years. The authentication card is needed to update details online or over the phone (0845 3004 472, Monday-Friday, 8am-6pm). www.hpc-uk.org/registrants/yourdetails/

Conference calls

Communication support needs discussed

What About Us?

l-r Andrew Bondy, Sue Baker (Clinical Director of Pyramid UK) and Lori Frost cutting the cake at a celebration in London

developing children therefore have many natural opportunities to learn the language that matches how they feel. Andrew says what may be different with children with autism is that they are less likely to show the pain or pleasure so we deal with the situation without giving sufficient feedback on the feelings. As Andrew says we have strange conversations about how a child doesnt feel pain while the real issue is around the lost opportunity for language acquisition that will help keep them healthy, safe and secure in future. Children need to have the language for how they feel before they can understand that language applied to other people. Andrew therefore suggests we generate a list of emotions a child needs to be able to talk about and ask ourselves how we can get the child to feel this way. Contrast is all important, so there need to be opportunities to experience emotions we dont like so much such as anger and pain. While ethically this presents challenges, he argues that it is important for teams and parents to have these conversations and agree on a plan appropriate to each individual. As well as celebrating the present, birthdays give us the chance to reflect on the past and look to the future. PECS started in the United States over 20 years ago and the ripples have spread worldwide. But, while speech-language pathologists in the United States are very involved with it, my impression is that in the UK it is mainly driven by teachers. One experienced speech and language therapist told me that she has found many people mistakenly believe PECS is about pointing. While this may benefit some non-verbal children, it is unlikely to help those who need the exchange to develop their spontaneous communication skills. I would be interested to hear how readers have contributed to the successful implementation of PECS please either e-mail me directly (avrilnicoll@speechmag.com) or go to the forum http://members.speechmag.com/forum/. SLTP Talking Mats has also celebrated its 10th birthday. See editor Avril Nicolls report from a Symposium held to mark the event at www.speechmag.com/Members/.

What about us, the report from a participative action research project, is recommending a number of improvements to promote the emotional wellbeing of young people with learning difficulties in inclusive secondary schools and colleges. In terms of communication, the collaboration between Cambridge Universitys Faculty of Education and the Foundation for People with Learning Disabilities notes that the young people lacked experience in being asked for their views but that their confidence grew with support and practice. The report says (p.42), Some of the young people we spoke to were not really sure, at first, what their views were. This might have been either because they had not considered what they thought, because they were unsure how to express these ideas or because they had never been asked. A particular difficulty with transition periods moving between lessons and during breaks was highlighted and the young people asked for access to safe areas such as libraries or learning centres or to have access to support, supervision or an activity they enjoy. What About Us? www.learningdisabilities.org.uk/ information/news/?EntryId17=31340&p=2

Communication aids manufacturer Toby Churchill has asked John Bercow MP to press the government to address the communication support needs of the post-19 population. The MP recently completed the eponymous Review of Services for Children and Young People (0-19) with Speech, Language and Communication Needs. Toby Churchill Chairman David Collison invited Mr Bercow to the companys headquarters to see their latest products and to offer support for the Reviews findings. Discussion included examples of good practice in funding communication aids. www.toby-churchill.com

Teachers want ADHD training

Seventy six per cent of the teachers responding to an online survey said they would benefit from some form of communication with qualified healthcare professionals about ADHD. Tickbox.net conducted the survey of 1050 primary and secondary school teachers in the UK on behalf of drugs company Janssen-Cilag. While 83 per cent of those surveyed said they could recognise the symptoms, they did not feel that they were suitably equipped or supported to deal with a child with ADHD in the classroom and would welcome more training. Attention Deficit Hyperactivity Disorder is characterised by general inattention and impulsivity which also impacts on communication. There is a National Attention Deficit Disorder Information and Support Service at www.addiss.co.uk.

Down syndrome Spreading the word research

Speech and language therapists have until the 31st January to take advantage of Early Bird rates for the Royal College of Speech & Language Therapists Scientific Conference. Partners in Practice Spreading the Word aims to provide an interactive forum for practitioners, researchers and educationalists within the profession and in related fields. The two day programme will cross all client groups and include oral and poster presentations, plenary sessions with keynote speakers, workshops and symposia. The conference takes place at the Queen Elizabeth II Conference Centre, Westminster, London from 17-18 March 2009. The EarlyBird rate for RCSLT members is 299.63, rising to 329 from February. For more information and to book, visit www. rcslt.org.

Down Syndrome Education International has been awarded a grant by the Big Lottery Fund to test a structured language and reading teaching programme in UK primary schools. The four year randomised controlled trial will be delivered by the pupils teaching assistants. Professor Charles Hulme at the Centre for Reading and Language at the University of York is collaborating in the research. He said, Existing evidence suggests that an integrated approach to teaching reading and language skills might be particularly effective for children with Down syndrome. We will trial a teaching approach that combines a structured reading instruction programme with an oral language programme.We expect this approach to be highly beneficial to these childrens reading skills, and to also directly benefit their oral language skills. www.downsed.org

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SUPERVISION PRACTICE

Are you getting enough? (4) From supervisee to supervisor

Sam Simpson and Cathy Sparkes conclude their supervision series by exploring how you develop the integral skills to successfully make the transition from supervisee to supervisor.
l-r: Cathy and Sam

Supervision are you getting enough? Let us know at the WINTER 08 forum, http://members. speechmag.com/ forum/.

n this article we first aim to explore how therapists gain the relevant experience and develop the requisite skills in order to make the transition from supervisee to supervisor. We then aim to reflect on current supervisory practices and consider some possible training options to achieve necessary skill development. Finally we conclude by sharing our ideas on ways of developing a more robust network of supervisors throughout the profession.

Developing requisite skills: current practice

Discussions in both focus groups held to inform this series of articles highlighted a typical developmental cycle for supervisors within the profession. This cycle consists of the following transition points: newly qualified therapist becomes a junior therapist who, with increasing experience, takes on the additional role of student supervision; as each therapist gains in seniority s/he is expected to start supervising more junior therapists; if s/he moves up to management level there is an inherent expectation that s/he will then supervise staff at all levels and possibly across a range of disciplines. In view of this progression, the question that we would like to pose is do we expect therapists to develop these increased supervisory skills implicitly or are there a series of training opportunities through which therapists can learn the skills more explicitly? It is true that as a profession speech and language therapists possess excellent communication skills including counselling skills (empathy, higher level listening skills, an awareness of different questioning styles) to varying degrees as well as higher level clinical knowledge. However, we are of the opinion that at each of the transition points described above there are inherent assumptions and expectations that the therapist simply steps up to the next level and by osmosis develops the requisite skill set to take on the role of supervisor. We would strongly argue that the transition from supervisee to supervisor parallels the tran18

sition from, for example, clinical specialist to manager. Both signify not just an extension of a role, but a change significant enough to incorporate new skills and roles in their own right. Using the example of clinical specialist to manager, it is generally acknowledged that, in order to make this step up, the individual requires additional training, support and on-going supervision into that role. Equally, it is generally anticipated that a new manager will experience self-doubt in the face of new challenges which could test their skills, competencies and work / life balance. We would suggest that the same could equally apply to a newly-appointed supervisor.

Developing requisite skills: key dimensions

We believe becoming a skilled supervisor involves a combination of factors. According to the members of the two focus groups and reflections on our own experiences, the primary factor is the personal experience of good quality supervision. The reasons for this are two fold the lived experience of a positive role model provides observational learning opportunities, which are further reinforced by being on the receiving end of the process and experiencing firsthand the impact supervision can have on both personal and professional development. Those of you wanting to make the transition or who are already supervising people may well be asking the question, how do I know if I have received good quality supervision? In many respects the answer to this is personally defined in that each individual has their own particular preferences - and what works well for one person might not work for another. However, to identify what works best for you as an individual, we believe it is important to experiment. We would advocate a trial and error approach in order to gain multiple experiences of different supervision styles and to then reflect on what worked best at a particular moment, in the knowledge that this may well change over time. The key dimensions raised in both focus groups and in the literature can be broadly

divided into the two categories of skills and qualities. a) Key skills Essentially the three key skills integral to the role of supervisor detailed in the literature are: listening facilitation feedback. However, discussions during the focus groups highlighted others including: a clear knowledge of the role of a supervisor and boundaries reflexivity [the process of applying to yourself the constructs or frameworks you apply to others] detachment and an ability to stand back from the issue the capacity to make sense of a persons reality confidentiality. b) Key qualities According to the two focus groups held for this series of articles, the key qualities of a supervisor change over time and vary at different stages of the supervisees development / career. They placed emphasis on the importance of the supervisors understanding of supervision as a process that evolves over time; flexibility in terms of their style and skills; confidence; trust; safety; a commitment to the time; integrity and honesty as well as natural talent. In the literature a number of additional qualities are also documented as follows: empathy and understanding; unconditional positive regard; sense of humour; warmth and self-disclosure; flexibility in styles, roles, structures and interventions; attention and concern; investment and commitment; openness and curiosity; an awareness of cross-cultural issues and the ability to enable each supervisee to find their own ways.

Training and development options

Rather than elaborating or defining each of the areas identified, we want to consider how these skills and qualities can be developed and finetuned in the context of supervision. There are a

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

SUPERVISION PRACTICE range of training courses available within Trusts and via Specific Interest Groups and certain educational establishment such as the City Lit that focus on the development of skills such as listening, facilitation and feedback. Additionally, integrated supervision courses are available, for example through the Royal College of Speech & Language Therapists and the UCL short course programme. Furthermore, over the last year there has been a growth in such courses being offered in house, where Trusts are employing outside facilitators. As intandem, we are increasingly being involved in trust-wide training projects to look at supporting a cultural shift and establishing new supervision infrastructures within a given service. Supervision involves knowledge, skills and techniques. Above all it involves attitudes and feelings of a supervisor in a relationship with another person. It is thus important that supervision training includes not only the relevant knowledge, skills and training to equip a competent technical supervisor, but concentrates on exploring the attitudes and assumptions of the trainees (Marchant, cited in Marken & Payne, 1989) This citation highlights that the transition from supervisee to supervisor is not solely about knowledge and skill acquisition, but is also about achieving a way of being and a state of mind in that relationship. We believe this attitude evolves over time and is nurtured via on-going supervision providing opportunities to reflect on ones own practice as a supervisor coupled with ongoing experiences as a supervisee.
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Box 1 Practical activities 1. Reflect on the training you have received / would like to receive whilst making the transition into the supervisor role. Consider your current training needs and wants. 2. Discuss this article within your team and consider who is supervising whom within the department / service. What particular skills, qualities and styles do each of these supervisors bring to the department, and what choices do people have in terms of accessing them or outside supervision?
2. A national database of supervisors (both independent and within the NHS) which would enable therapists to experiment more easily with different styles and have access to a greater choice of supervisor; 3. Creative ideas in terms of access to and payment for outside supervision. For example, there could be a supervisor swap across neighbouring trusts; a therapist could exchange 3 hours work within a department in return for 1 hour of supervision; a therapists Continuing Professional Development money or course allocation could be freed up for the purchase of supervision with someone external to the organisation. We look forward to hearing any comments you have in relation to this article and the practical activities in box 1. This is our final article but we have been invited to comment on any ideas and points raised by the readership in the next edition. We look forward to hearing from you. Sam Simpson and Cathy Sparkes are specialist speech and language therapists. Cathy is also a trained counsellor and Sam in currently in training. Together they are www.intandem.co.uk. SLTP Marken, M. & Payne, M. (1989) Enabling and Ensuring, in Hawkins, P. & Shohet, R. (eds.) Supervision in the Helping Professions. Maidenhead: Open University Press, p.80. Editors note: I would like to thank Sam and Cathy for the supervision series, which I know from reader feedback has proved both thoughtprovoking and useful. I would also like to thank the members of the focus groups who helped Sam and Cathy plan the content. If you would like to offer other perspectives on supervision, explain the impact the series has had on you or ask Sam and Cathy any questions, please e-mail avrilnicoll@ speechmag.com as soon as possible so we can put together a follow-up feature.

ASLTIP provides information and a contact point for people searching for an Independent Speech and Language Therapist. For its members, it provides professional support and information about working independently in the UK. ASLTIP is led by an Executive Committee, which also advises RCSLT and HPC on issues relating to independent practice. The ASLTIP Executive Committee members also facilitate discussion around specific issues or cases involving ASLTIP members. ASLTIP members: Have set standards and guidelines for working in independent practice. Are listed on the only national online database of independent speech and language therapists. Receive regular copies of the newsletter, Independent Talking Points. Access a network of local groups, supervision groups and an online support network. Receive discounted places on training days and a national annual study day. Have access to professional, clinical and business support. To find out more, visit our website or attend the next

Supervision: looking to the future

It is interesting to compare recent developments in counselling supervision with the field of speech and language therapy. Increasing Continuing Professional Development requirements and membership of the Health Professions Council has brought about a growth in post-qualification supervision training courses for counsellors and psychotherapists with nationally recognised qualifications. We invite you to consider whether this would also be a welcome development within field of speech and language therapy? Imagine a level 1 supervision training course available for junior therapists which, similar to an obligatory dysphagia course, would be a prerequisite prior to embarking on the supervision of students and newly-qualified therapists. A level 2 supervision training course could be available to more experienced therapists and clinical specialists making the transition into the supervisor role with less experienced speech and language therapists; finally a level 3 course could be open to all managers or senior therapists required to supervise staff from multiple professional backgrounds and levels of experience. Other ideas that we have been entertaining recently include: 1. A supervision SIG, which could co-ordinate a range of study days to support on-going skill development and understanding of the supervision process;

References

www.helpwithtalking.com Setting up in Independent Practice Course

on 16th January 2009 More information about this course can be found on the website. 19

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

reviews

reviews
APHASIA GOALS Goal Setting Symbol Resource Set / Talking Mats & Aphasia Joan Murphy and Sally Boa University of Stirling, Dept of Psychology ISBN 1 85769 216 0 99.95 (joint package)
This is a valuable and value-formoney resource for those wanting to promote person focused collaborative working. It is particularly useful for multidisciplinary team and rehabilitation settings. Clinical skill is required to facilitate a persons use of the framework. However, well written supporting booklets are provided together with a Goal Setting Topic Poster and excellent DVD demonstrating Talking Mats in action. Further training / information is available from the AAC Research Team at Stirling. The CD symbol disk is easily downloaded (you need Acrobat Reader, PC and colour printer), but we needed to enlarge and laminate the symbols for use. Recommended. Karen Bonham is Lead Speech and Language Therapist for Brain Injury at Rookwood NeuroRehabilitation Unit, Cardiff and Vale NHS Trust. illustrated. The author hopes the book will help change attitudes around death, dying and living well. Certainly the messages contained within it will stay with the reader long after finishing the book. Despite the tragic context, the book is a totally uplifting read. I would definitely recommend it to all. Part of the proceeds of this book will go to Marie Curie Cancer Care. Linda Richards is an independent speech and language therapist working in the Leicestershire area.

FOREIGN ACCENT Foreign Accent Management Mythri S. Menon Plural Publishing ISBN 1-59756-068-5 57.00

American English Drawback

Valuable and valuefor-money

Person centred, collaborative goal setting is crucial to effective rehabilitation, but it can be challenging to engage those with complex communication needs. Talking Mats aim to provide people with a means of expressing their views more easily via an interactive framework using picture symbols (Mayer-Johnson, Boardmaker). It uses 3 sets of symbols - topics, options, visual scale - and a textured mat upon which to display them. The authors use the WHO-ICF 2001 domains of Activity and Participation such as mobility and self-care to inform the selection of topics / symbols. By placing relevant symbols under the visual scale the person produces an initial mat isolating target areas for goal setting. Goals are refined through use of option or individualised symbols within sub-mats. You can photograph the mats to create an accessible documentation of goals. We trialled this resource in our Neuro-Rehabilitation Unit. Some individuals with severe cognitive and comprehension difficulties (under the level of 2 information carrying words) were unable to benefit. However, the majority of individuals grasped the concept, understood the symbols and responded positively to goal mapping with it. They appreciated ownership of their mat and demonstrated greater awareness of the rehabilitation process. Mats were used in meetings to illustrate the individuals viewpoint / priorities and to track progress. In some cases the documentation was adapted to support rehabilitation contracts. The Talking Mat process appealed to the multidisciplinary team and promoted inter-disciplinary working. Targeting the WHOICF domains supported holistic management.

MUSIC IN THERAPY Lets all listen - Songs for Group Work in Settings that Include Students with Learning Difficulties and Autism Pat Lloyd Jessica Kingsley ISBN 9781843105831 24.99

FAMILY AND CARE GIVERS What should I tell you? A Mothers final words to her infant son Jo Middlemiss Printmatters ISBN 978 0 9559153 0 7 9.95

Some good ideas

Moving and uplifting

This is an extremely moving book. It tells the story of Maggie, who died from cancer aged 31. The book has been compiled by her sister. The way Maggie and her family support each other through her illness, death and beyond is inspirational. During her final 8 weeks of life, Maggie made a tape recording for her son (then aged two) to listen to when he was 21. The transcript of this recording forms the core of the book. Her story is expanded by notes, letters, illustrations and photos of Maggie and her family. An accompanying CD allows the reader to hear Maggies own voice as her health fails. This adds great poignancy for the reader. The book should appeal to a wide audience. Anyone in a caring and supportive role could benefit from the themes of love and honesty that are powerfully

This resource of 46 songs is based on the growing body of evidence that music can be a powerful means of promoting early communication skills such as cause and effect, initiating interaction, anticipation, joint attention and turn taking. The option of accompanying your singing with an instrument such as a guitar or piano is useful and, for some songs, I felt it to be essential. If - like me - you are unable to play an instrument, this could therefore restrict the use you can get from this publication, however the CD helps you learn the melodies. The book gives ideas on how songs can be used and adapted if required, and it would be most useful in the context of the educational curriculum. It provides some good ideas of how concepts such as fast and slow and up and down can be taught through the medium of song. It also provides ideas on how the beginnings and endings of sessions can be structured using music by means of hello and goodbye songs. Sarah Heneker is a speech and language therapist and Lead Clinician working with Adults and Children with Learning Disabilities in Surrey PCT.

This book with accompanying CDs is written mainly for students of English as a second language rather than clinicians. The style is therefore informal and easy to read. However the author is very thorough in addressing different aspects of good communication, eg. useful chapters on prosodic features, listening skills and nonverbal aspects of communication. Each chapter contains worksheets in addition to a CD. Learning the phonetic symbols is inherent in this kind of training so this book has a major drawback unless the student or clinician wants American English. This affects vowels rather than consonants but the different symbols and aural examples mean this book, especially the worksheets, could only be used selectively by a UK audience. Although containing many useful exercises and ideas, people may well feel the book is too expensive given that much would have to be adapted. Annabel Bosanquet is an independent speech and language therapist in London.

SOCIAL INTERACTION Promoting Social Interaction for Individuals with Communicative Impairments M. Suzanne Seedyk (ed.) Jessica Kingsley ISBN 9781843105398 16.99

Useful source

This is essentially a collection of research papers and essays by a variety of researchers and multidisciplinary practitioners. Useful for those interested in the use and benefits of Intensive Interaction and similar approaches and inspiring if youre thinking about conducting research into this area but not a daily dip in and out book. Rather, it is a useful source of up-to-date evidence, theory and references to use

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My Top Assessment
whilst preparing training for staff / parents and carers. As each chapter has a different author, the style and accessibility of information varies. Most make for interesting reading. However, theres a fair amount of repetition for example, each chapter detailing what Intensive Interaction / Imitation means and where it has developed from. On a whole, the book reminded me of the importance of advocating this type of approach. Im sometimes guilty of striving to establish a symbolic communication system before first making sure that staff / parents and carers are establishing a trusting relationship with the person based on valuing, imitating and responding to their current communication repertoire. Non Thwaite is a highly specialist speech and language therapist and Regional Makaton Tutor, Learning Disability Team, North West Wales NHS Trust.

assessments

Simon Henderson recommends a comprehensive and child-friendly phonology screen, while Alyson Eggett praises the basic principles of an approach to identifying and developing social communication targets.
PHONOLOGY CLEAR Phonology Screening Assessment Clear Resources, www.clear-resources.co.uk 50 + VAT + p&p SOCIAL COMMUNICATION Teaching Spontaneous Communication to Autistic and Developmentally Handicapped Children Linda R.Watson, Catherine Lord, Bruce Schaffer & Eric Schopler (1989) ISBN 9780890795286 $62.00 www.proedinc.com

A CLEAR favourite

HEAD AND NECK Head and Neck Cancer (Treatment, Rehabilitation, and Outcomes) Elizabeth C. Ward & Corina J. van As Brooks Plural Publishing ISBN 1-59756-061-8 94.00

Comprehensive

This book and accompanying CD will be useful for speech and language therapists of all levels of experience working in head and neck cancer. The number and scope of topics included make it an invaluable clinical and educational resource for any specialist centre. It is easy to read with high quality images, illustrations, and tables. The CD supplements the text with audio, video and radiological examples. While there is an interesting summary of international perspectives, it is disappointing that none of the authors are from the UK, but this is a minor detraction from a comprehensive textbook. Ruth Best, Jodie Bumster and Eryl Evans are specialist speech and language therapists with Abertawe Bro Morgannwg University NHS Trust at Singleton Hospital in Swansea.

I have recently discovered the CLEAR Phonology Screening Assessment (CLEAR PSA) to be an invaluable assessment tool in my own clinical practice. Interestingly - and somewhat surprisingly - the CLEAR PSA appears to be relatively underused. I therefore wanted to share the practical and diagnostic benefits of this assessment for the clinician working with children with speech sound difficulties. Each page of this compact assessment focuses on a specific speech sound in all word positions. The picture stimuli cover all of the singleton phonemes and consonant cluster sounds. The pictures are bright, unambiguous and very child-friendly. As with the picture stimuli, the assessment record sheet is conveniently structured according to the developmental acquisition of speech sounds. Personally I found this a real help, especially when explaining results, age norms and therapy management decisions to parents and other professionals. In the case of more complex speech disorders, the concise and structured layout of the results form effectively allows progress to be profiled between repeat administrations with ease and without the need for copious amounts of paper. I first discovered this assessment whilst working in a mainstream speech and language unit for children with persistent speech difficulties. Generally all of the children responded very well to the clear and colourful pictures. I also found that it was easy to start talking around the pictures with the children, thus allowing me to assess the childs intelligibility informally in connected speech. Overall, this assessment is a cost-effective, portable and user-friendly tool. For the child, it is a fun and quick alternative to some of the more traditional phonological assessment batteries. For the enthusiastic speech scientist, the CLEAR PSA provides a comprehensive overview of the childs speech skills and needs in a logical and coherent fashion. Simon Henderson is a speech and language therapist with NHS South of Tyne and Wear: Gateshead PCT.

Good overall approach

This spontaneous communication curriculum includes an observational assessment tool and ideas for setting functional communication targets in a social setting. It enables the observer to record: the number of communicative turns used within a measured time period the context in which communication takes place (eg. at school / home, with adults / peers) the form of communication used (eg. gestural, pictorial, verbal) its function (eg. gaining attention, requesting, rejecting, commenting, giving information, seeking information, social routines) the semantic categories used for spoken or signed communication. Ideas for identifying communication goals and teaching strategies are provided. Although the text and photocopiable forms look a little uninspiring, the basic principles described are extremely useful. I have redesigned the forms to be more user-friendly within my own clinical context but believe that the resource provides a good overall approach to identifying and developing social communication targets.

Case example Billy is 10 years old with a diagnosis of autism. I observed him during a home-based activity, on a trip to the shops and at school and analysed and compared the results from the three settings. The main findings were that Billy was much more communicative in the home setting (as shown by the reduced number of communicative turns observed in the community and at school). His communication was always directed to an adult. There were significantly more attempts to give information / answer questions, request and reject with other communicative functions rarely or never observed. Parents and professionals were able to identify new communicative functions to introduce within the home setting (seeking information / asking questions). Communicative functions already in use at home were introduced into new contexts (in the community / school; with peers) to help generalise their use into other social settings.

Alyson Eggett is Clinical Lead (ASD / Special Needs) in South Shields. Clear Resources is offering a copy of the CLEAR Phonology Screening Assessment in a FREE prize draw for Speech & Language Therapy in Practice readers. For your chance to win, e-mail your name and address to info@clear-resources.co.uk by 25th January, putting SLTiP offer in the subject line. The winner will be notified by 1st February 2009. Further information about the Clear Resources product range is at www.clear-resources.co.uk.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

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COVER STORY / HOW I USE EPG (1)

How I use electropala

Ann and Gabriel, www.sergiojoselovsky.se

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COVER STORY / HOW I USE EPG (1)

atography
When articulation difficulties seem intractable, a visual feedback system called Electropalatography (EPG) may be of benefit - but its availability is still mainly limited to specialist centres and networks. Our two case based articles consider the practicalities and scope of using EPG, the first for two boys with dysarthria as a result of cerebral palsy and the second for a man in his thirties with articulatory dyspraxia following a stroke.

Moving forward with EPG

Ann Nordberg

How I use electropalatography (1)

When traditional therapy techniques were not proving effective with two boys who have dysarthria due to dyskinetic cerebral palsy, Ann Nordberg, Elvira Berg, Goran Carlsson and Anette Lohmander offered them the chance to try real-time visual feedback through Electropalatography, with promising results.

he exact prevalence of communication disorders associated with cerebral palsy is not known, but many children with this Elvira Berg diagnosis experience difficulties ranging from a mild motor speech disorder to being fully non-verbal (Pennington et al., 2005). In children with dyskinetic (also known as athetoid) and spastic cerebral palsy, omission errors tend to exceed substitutions of phonemes, a feature that typically developing children normally do not show in their speech development. Children with dyskinetic dysarthria may also experience respiratory problems, such as paradoxical or reverse breathing and air rushes through the vocal tract that result in no phonation (Hardy, 1983), which may have negative effects on speech performance. Limitations in pitch and loudness due to increased subglottal pressure are common as is velopharyngeal dysfunction. In traditional speech and language therapy approaches for children with cerebral palsy, clinicians have used a variety of techniques to help establish a particular articulation placement (Strand, 1995). Such techniques include mirrors for visual feedback, providing verbal descriptions of target placements, and using fingers to manipulate the articulators. These techniques may help the children to move on to imitation or responding to auditory stimulation, which can be a starting point for many conventional treatment regimes. However, effectiveness has not been Figure 1 Palatal plate proven.

We were working with two Swedish boys aged 7;4 and 10;1 years who both presented with moderate to severe motor speech disorders including deviant articulation of /t/ due to dyskinetic cerebral palsy. They had received lots of speech and oral motor therapy without significant improvement, and we were looking for an alterative. Electropalatography (EPG) is a technique which records the location and the timing of tongue contacts with the hard palate during continuous speech. In Europe, the EPG system was originally developed at Reading University, UK. It consists

of 62 electrodes in an individually designed palatal plate (figure 1) connected to either a computer or a Portable Training Unit (figure 2) (Hardcastle et al., 1991). On the screen the participant is presented with real time visual feedback on tongue palate contacts (figure 3, p.24). The use of visual feedback through EPG represents a relatively new approach to clinical management of speech disorders. Results have suggested positive outcomes for at least some clinical populations, especially those who have failed to respond to other treatment approaches and those who, having received speech and language therapy for some time, have reached a plateau where no progress is being made (Hardcastle et al.,1991). One previous case study reported outcomes using EPG in therapy for velar fronting for a

READ THIS IF YOU WANT TO EXPLORE ALTERNATIVES TO TRADITIONAL TECHNIQUES CARRY OUT CLINICAL CASE STUDIES GET INSIDE A CLIENTS MOUTH

Figure 2 Portable Training Unit

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COVER STORY / HOW I USE EPG (1)

Figure 3 Real time visual feedback

child with articulation disorders associated with mild cerebral palsy (Gibbon & Wood, 2003). In their study successful outcomes as well as important diagnostic features of the childs articulation disorder were revealed. We therefore felt it would be worth trying visual feedback of tongue positions through EPG with the two boys. We met with them and their parents to discuss our plans for a clinical study, and they gave their informed consent.

Bjorn

Our first participant has a mild dyskinetic cerebral palsy due to severe perinatal asphyxia. By the time of the study he was 10;1 years old, had been assessed by an educational psychologist to be of average intelligence and was successfully integrated into a mainstream school. He presented with a mild general motor coordination disorder and walked without aids. There was no documented visual or hearing impairment. Using a screening test (Hellquist, 1982) we found his comprehension to be at an average level. Pre-school, between 4;0-6;0 years, Bjorn had received regular speech and language therapy once a week. At the end of this he produced phonemes with a retracted oral articulation, so that dental phonemes were articulated at a posterior oral place, often velar. At school between 7;0-9;10 years he received speech training from 24

one of his teachers supervised by a speech and language pathologist. The training included different oral non-speech exercises. Multiple auditory-visual stimulation was also used - Bjorn looked and listened to the teacher who produced a sound or a word which he then tried to imitate. The sessions often took place in front of a mirror to try to get more awareness of the speech movement patterns. At the start of the study an impressionistic auditory analysis by Ann Nordberg showed that Bjorn had a generally retracted oral place of articulation in production of some phonemes, for example /t/. Intelligibility in spontaneous speech was significantly reduced and he had difficulty sustaining intensity when he was tired.

Gabriel

Our second participant, Gabriel, has a moderate dyskinetic cerebral palsy due to severe asphyxia. He walks with a walker and with high braces. At the start of the study he was 7;4. Like Bjorn, he had been assessed by an educational psychologist to be of average intelligence and was successfully integrated in a mainstream school. There was no documented visual or hearing impairment and we found his comprehension to be at an average level on a screening test (Hellquist, 1982). From the age of 4;0-6;2 years Gabriel had lots of speech training, often once a week with a

speech and language pathologist. After starting school at the age 6;5 years his personal assistant and teacher were supervised by a speech and language therapist and, until the beginning of our study, he had had short periods of oral motor and speech training up to three times a week. The speech exercises were very much the same as the ones described for Bjorn. At the start of our study an impressionistic auditory analysis by Ann Nordberg showed that Gabriel had a severe motor speech disorder and, according to his parents and teachers, the intelligibility of his speech in spontaneous speech / conversation was poor. His speech rate was slow and he had difficulty coordinating breathing and speech production. His speech errors varied in different words. He had both omissions (such as the initial phoneme /t/ for the Swedish word /ti:gr/) and substitutions of the same phoneme. The initial /t/ in another Swedish word /to:/ sounded more like a velar plosive. He also reduced consonant clusters. The movement of his articulators varied a lot, causing many types of speech errors.

The study

For the study, Bjorn and Gabriel each had a personal individual EPG palatal plate made in cooperation with the Department of Odontology, Gteborg University, Sweden and Incidental Ltd in Newcastle, UK.

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COVER STORY / HOW I USE EPG (1)

Figure 4 Exercises and goals Week Exercises 1 Learn to place the EPG palate correctly. Test different tongue-palate patterns. Goal Discover the relation between the movements of the tongue and different tongue palate patterns on the display of the Portable Training Unit. To reach an anterior place of articulation when producing /t/, /d/, /n/ and /s/. Manage to create a horseshoe shape for /t/, /d/, /n/ and /s/. Stabilise an anterior production of /t/, /d/, /n/ and /s/. To reach an anterior place of articulation when producing /t/, /d/, /n/ and /s/. To reach an anterior place of articulation when producing /t/, /d/, /n/ and /s/.

Production of syllables with the sound initial /t/, /d/, /n/ and /s/ followed by a vowel and look at the display; vary between anterior and posterior place of articulation. Production of words containing /t/, /d/, /n/ and /s/ in an initial position. Production of /t/, /d/, /n/ and /s/ (all positions) in words. The boys were told to do this a) looking at the EPG display and b) not looking at it. Production of two word phrases containing /t/, /d/, /n/ and /s/ (initial position).

3 4

5 6 7 8

Production of two word phrases containing /t/, /d/, /n/ and /s/ (all positions).

Production of three and four word sentences containing To generalise the anterior place of /t/, /d/, /n/ and /s/. articulation for /t/, /d/, /n/ and /s/ in single words to sentences. Short stories containing words and sentences with /t/, /d/, /n/ and /s/ (all positions). To generalise the anterior place of articulation for /t/, /d/, /n/ and /s/ in words and sentences to a more complex short story.

word, were presented with the first seven words from the pre-treatment recording, the following seven from the post-treatment recording, alternating in this way until the end of the test. We instructed the listeners simply to write down what they perceived the participants said. We inserted a five second pause between each word to ensure that the listeners would have enough time to write down their answers. Out of the three judgments for each boy, we are reporting the median (where two correct and one incorrect answer is considered as correct, while two incorrect and one correct answer is considered incorrect). We calculated agreement between the listeners point by point as a percentage. The agreement between listeners, including all words and both participants, was 75 per cent. Agreement in words without the target sound was 72 per cent (Bjorn) and 59 per cent (Gabriel).

Bjorns results
Before EPG therapy Bjorn consistently produced the target /t/ with retracted tongue-palate contact, mostly at the palatal (figure 5) and velar place of articulation. The contact pattern varied, even for words with the same vowel context. Fricative pronunciation of the targeted initial /t/ was noticed, for example in the word /to:g/.
Figure 5 Bjorn saying Swedish word /to:/ before EPG therapy

We assessed them with EPG on two occasions, once before EPG therapy and then again after 8 weeks of therapy. For Bjorn we made a third registration with EPG at a follow-up after 11 weeks, when he asked for additional training. The boys articulation was assessed with the palatal plate using EPG (computer-based), and without it, through recording the same words on an audio tape. All recordings took place at the Institute of Neuroscience and Physiology, Division of Speech and Language Pathology, Sahlgrenska Academy at Gteborg University. In the assessment with the EPG palatal plate, we encouraged Bjorn and Gabriel to name 35 pictures from the Swedish Articulation and Nasality TEst (SVANTE) (Lohmander et al., 2005) and another 35 which we added to increase the number of test words. There were five words with initial /t/ (teve, t, tg, tng, trta) and three with final /t/ (vit, hatt, katt) among the 70. As each was repeated three times, the total number of words containing /t/ was 15 with an initial /t/ and 9 words with a final /t/. To assess intelligibility 35 of the single words in SVANTE (Lohmander et al., 2005) were audio recorded without the EPG palatal plate before the treatment and 35 after. We used a digital tape recorder (Sony Digital audio Recorder PCMR300) and a microphone (Sony Microphone ECM-M3957). The word lists contained different consonants but nine with initial or final /t/. We lent each family a Portable Training Unit, and the therapy took place primarily at home where the boys practised with the unit 15 minutes each day, five days a week over eight weeks, supervised by their parents. Bjorn followed this instruction, but for Gabriel and his family this intensity was too high because he also had a physiotherapy program to complete. He therefore practised approximately 15 minutes a day for three days a week. Once a week the boys and one of their parents met their speech and language

pathologist for advice on how to practise during the coming week. All other speech training was cancelled during this period. As both boys had a retracted oral articulation of the targeted /t/ before therapy, the exercises contained syllables and words with /t/. However, the exercises also contained material with the other Swedish dental phonemes based on our belief that this would facilitate establishment of the target place of articulation. The phonemes were placed in initial, medial and final positions followed by a vowel. At the beginning of the training period there were syllables and words containing the phonemes and later on in sentences and at last in a short story (figure 4). The participants constantly had visual feedback from the Portable Training Unit in the training phase. We located the EPG frame of maximum contact between tongue and palate for each /t/ in the test words and, in order to find differences in production before and after therapy, we calculated values for Centre of Gravity and Alveolar Total. Low Centre of Gravity values correspond to posterior tongue palate contact and high values to anterior tongue palate contact. The Alveolar Total value ranges from 0 to 14 where 14 indicates that all the14 contacts in the first two anterior rows of the EPG palatal plate are activated (Hardcastle et al., 1991). We compared the measures before and after therapy using the Wilcoxon matched pair test. We engaged three adults with no experience of deviant speech for each participant to evaluate any change in the intelligibility of the boys speech. To avoid a learning effect, we only allowed the listeners to listen to the speech material once. During the recordings we suspected that the performance of the boys differed across the test due to loss of concentration and tiredness, especially towards the end. We therefore split the 70 words of the test into ten parts and the listeners, who were blinded as to the timing of the recording of the

After EPG therapy Bjorn showed a more correct anterior placement for his tongue palate contacts for the targeted initial /t/. In 10 of the 15 words with initial /t/ he had full alveolar contact from row 1 as is illustrated in figure 6, which is similar to the adult target in figure 7. Figure 6 also highlights an unusually long stop closure duration which we would not have been aware of without EPG. After EPG therapy Bjorn no longer had fricative pronunciation of initial /t/.
Figure 6 Bjorn saying Swedish word /to:/ after EPG therapy

Figure 7 Adult target of Swedish word /to:/

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

25

COVER STORY / HOW I USE EPG (1) For the targeted final /t/ the placement of the tongue varied before therapy. Out of the nine words five showed some alveolar contact. After therapy there was a stable anterior placement of the tongue, with full alveolar contact, for all words with final /t/. The number of alveolar contacts increased from 1.33 to 11.27 and the measure of the greatest concentration contact (Centre of Gravity) changed significantly from 2.88 to 4.18. A similar change was seen for final /t/. Bjorns extra follow-up showed no change in the values of Centre of Gravity and Alveolar Total for either initial or final /t/. The perceptual evaluation indicated that the intelligibility of single word utterances for Bjorn increased from 22/35 words from the pre-treatment recording to 29/35 words from the post-treatment recording (63 per cent to 83 per cent accuracy) including all words, that is both with and without /t/. However, the agreement between listeners was only 72 per cent. The perceptual evaluation showed that Gabriel had generally very low intelligibility scores before therapy and showed no improvement after therapy. His intelligibility score for single word utterances was constant at 9/35 words, that is, 26 per cent accuracy. However, the agreement between listeners was only 59 per cent. production of different phonemes are so subtle and automatic. EPG therefore seems to be a very useful tool in providing the feedback and awareness required to remediate speech errors even in relatively severe motor speech disorders. Another advantage is the fact that the feedback provided through EPG is objective and offered in real time (Hardcastle et al., 1991). Before any generalisation can be made further evaluation with an amended study design is needed. In future we would want to explore the ecological validity of the treatment to find out whether it can improve intelligibility in a social context (WHO, 2001). What we can say is that it seems to us a promising tool for individuals with speech disorders due to cerebral palsy. Ann Nordberg is a speech and language pathologist with the Disability Administration, Region Vastra Gotaland, Sweden, e-mail ann.nordberg@ vgregion.se. Elvira Berg is a speech and language pathologist with Habiliteket AB, Taby, Stockholm, Sweden, Goran Carlsson is a psychologist at the Department of Pediatrics, University of Schleswig-Holstein/Campus Kiel, Germany and Anette Lohmander is Professor at the Department of Clinical Neuroscience and Rehabilitation, Division of Speech and Language Pathology, Sahlgrenska Academy at Gteborg University, Sweden.

Overall aim

Rating of intelligibility in connected speech may have been more revealing. Gabriels results
Before EPG therapy Gabriel had varying tongue-palate contacts for the target /t/. Initial /t/ showed no tongue-palate contact at all because the plosive /t/ was omitted. At other times there was a little lateral velar contact. After EPG therapy the tongue-palate contact patterns for the target initial /t/ were more stabilised at the correct alveolar place of articulation. He also succeeded in producing closure in all the targeted initial /t/, which he did not before EPG therapy, and initial /t/ was not omitted in any of the words. The number of alveolar contacts increased from 2.43 before therapy to 13.33 after and the Centre of Gravity values significantly from 2.43 to 13.33.

The overall aim of this clinical study was to find out if Electropalatography could be at all useful in treating and diagnosing speech errors related to dyskinetic cerebral palsy. Both boys had changes in EPG patterns which demonstrated a more stable anterior place of articulation. The EPG also highlighted Bjorns unusually long stop closure duration. A merit of EPG in the therapeutic work with Gabriel was that the visual feedback made it possible to see that he reached the dental place of articulation for the target /t/. In his case treatment needs to address respiration and phonation instead of articulation to try to improve his intelligibility. We didnt know this before his speech was evaluated by EPG, so it gave a secondary diagnostic benefit. Only Bjorn showed improvement in intelligibility in the perceptual evaluation. Perhaps Gabriels severe motor speech disorder made it difficult for the listeners to understand him? Low agreement between listeners was a problem, however, and it was interesting to note that the parents of both the boys said they understood them better following the EPG. Rating of intelligibility in connected speech may have been more revealing. As EPG records and displays details of the tongue-palate contact during continuous speech, it provides new insight into articulatory patterns. This is important for a range of clients where traditional treatment techniques have failed. It also enabled our participants to learn where to place their tongues, something that other speech and language therapy had failed to achieve. Many parts of speech and articulation can be difficult for therapists to explain or raise awareness about, as the differences in

Acknowledgments

We express our thanks to the parents, who gave consent for publication of their childrens case reports. We also want to express our gratitude to Professor Fiona Gibbon, Queen Margaret University College, Edinburgh, UK and Per Lindblad, Senior Lecturer at the University of Lund, Sweden, for exquisite advice and guidance. The present research was financially supported by grants from the Research Council of Disability Administration, Region Vastra SLTP Gotaland, Sweden.

References

Gibbon, F. & Wood, S. (2003) Using electropalatography (EPG) to diagnose and treat articulation disorders associated with mild cerebral palsy: a case study, Clinical Linguistics and Phonetics 17, pp.365-374. Hardcastle, W., Gibbon, F. & Jones W. (1991) Visual display of tongue-palate contact: electropalatography in the assessment and remediation of speech disorders, British Journal of Disorders of Speech Communication 26, pp.41-74. Hardy, J.C. (1983) Cerebral Palsy. Englewood cliffs, NJ: Prentice-Hall. Hellquist, B. (1982) SIT- Sprkligt Impressivt Test fr barn (Language Comprehension Test for Children) (Malm: Tryckeriteknik). World Health Organisation (2001) International Classification of Functioning, Disability and Health (ICF). Geneva: WHO. Lohmander, A., Borell, E., Henningsson, G., Havstam, C,. Lundeborg, I. and Persson, C. (2005) Swedish Articulation and Nasality Test. Pedagogisk Design, www.dop.se Pennington, L., Goldbart, J. and Marshall J. (2005) Direct speech and language therapy for children with cerebral palsy: findings from a systematic review, Developmental Medicine and Child Neurology, 47, pp.57-63. Strand, E.A., (1995) Treatment of motor speech disorders in children, Seminars in Speech and language, 2, pp.126-139. 26
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

REFLECTIONS DO I FACILITATE AND REACH AGREEMENT ON REALISTIC LEVELS OF HOME PRACTICE? DO I SEEK WAYS OF CAPTURING SMALL CHANGES IN THE DIRECTION OF A TARGET? DO I USE A VARIETY OF METHODS TO ASSESS THE IMPACT OF THERAPY ON INTELLIGIBILITY?
What questions does this article raise for you? Have you been able to access Electropalatography for any of your clients? Let us know via the Winter 08 forum at http://members.speechmag. com/forum/

COVER STORY / HOW I USE EPG (2)

How I use electropalatography (2)

Therapy on a plate
had however moved into a flat of his own again and seemed to be spending more time with a couple of close friends, albeit to play computer games. Perhaps as a result of this he seemed more relaxed and was feeling motivated for therapy. On assessment, the consonants that were either disordered, absent or highly variable in production were sh (realised as s), r, l, ch, j. The aims of the treatment were to improve overall tongue control, increase understanding of articulation, make a clear distinction between production of sh and s, and to achieve production of target sounds l and r with evidence of carry-over into single word production. Chris received six weeks of therapy, with three sessions each week. Ideally he would have taken the equipment home but in the past he had not taken good care of aids and also failed to complete work independently. The solution was to offer as much time as we could afford to make maximum impact. One session per week was with a speech and language therapist with two repetitions of that session each week with a technical instructor. Chris used a portable visual feedback device borrowed from the paediatric service, through which his tongue-palate contact patterns were displayed. The therapist did not have a palate but instead used static images of articulatory positions. Static images were ideal for Chris because he could look at them for as long as he needed in order to replicate the position. Meanwhile the therapist could provide verbal prompts to support him.
READ THIS IF YOU WANT TO INTRODUCE A NEW TECHNIQUE BOOST MOTIVATION HELP A CLIENT FIND OUT HOW TO HELP THEMSELVES

A stroke at the age of 33 left Lesley Anne Smiths client with impairments which affected his ability to return to work and his motivation to socialise. With the help of colleagues, she introduced Electropalatography, which had a small but important impact on his articulatory dyspraxia and intelligibility.

yspraxia of speech has been described as a disorder impairing the volitional movement of the vocal organs in speech production in the absence of any impairment to muscle tone or speed, range and strength of the articulators as is present in dysarthria (Miller, 1989; Howard & Varley, 1995). It can further be distinguished from dysarthria by characteristic groping or searching for articulatory placements. Chronic articulatory dyspraxia following head injury is notoriously difficult to remediate and traditional therapeutic methods can often be limited once the client reaches a plateau. Electropalatography (EPG) provides a dynamic visual display of lingual palatal contact and can be used as a visual biofeedback system (Hardcastle et al., 1985). Although much of the literature on EPG describes its potential to improve the speech of children with repaired cleft palates or functional articulation disorders, EPG has also been used to analyse dyspraxic speech (eg. Hardcastle et al., 1985) and also as a treatment method (eg. Howard & Varley, 1995). It has been identified as a useful method of providing speakers with dyspraxia with crucial visual feedback on their attempts at speech production and thus facilitating the gradual modification of abnormal articulatory patterns (Howard & Varley, 1995). Hartelius et al. (2005) also found that EPG therapy improved sentence and word intelligibility in an adult with disordered articulation by 10 per cent.

speech. Speech in conversation was estimated to be 60 per cent intelligible with a familiar listener and was heavily dependent upon contextual cues. Treatment involved a variety of traditional methods, including: using a listen and watch me approach (Rosenbek et al., 1984) describing how sounds are made using articulatory diagrams to reinforce these imitation of sounds in isolation then CV, VC, CVC combinations. Chris was always unwilling to use aided communication, likely due to embarrassment. He would only use writing when prompted and had difficulty with word selection and spelling. Following discharge from the Centre he received two blocks of therapy as an outpatient but made minimal improvement in intelligibility. His motivation for therapy was low at this point. Additionally, Chris did not recover functional

Chronic articulatory dyspraxia following head injury is notoriously difficult to remediate

movement of his right arm and could therefore not return to work as a plasterer. He was spending less time with his friends and had moved home to his mothers house. Although his social life was already quite limited before his stroke, Chris was becoming more and more socially isolated as a result of his embarrassment about his impairments. At this point my colleague and I began to consider the benefits of using an alternative to traditional therapeutic methods and the potential of electropalatography (EPG). With a significant amount of help from a specialist colleague from the Dundee paediatric service, I designed a plan of assessment and treatment using EPG for Chris. We deemed the Edinburgh Articulation Test (Anthony et al., 1971) to be the most useful method of identifying target sounds. Although traditionally a paediatric assessment, the simple vocabulary meant that word-retrieval errors were not an issue. I discussed the method and requirements with Chris and his mother who supported him to attend therapy. The Dundee adult speech and language therapy department agreed to fund the cost of the palatal plate at 325. Arranging and making dental impressions followed by production of the specialist palate took six months. During this time Chris received no therapy. When I met Chris again his speech had not changed. He

Chris

One of my clients well call him Chris - had a stroke in 2005 at 33 years old and has physical, cognitive and communication impairments as a result. Initially Chris presented with severe articulatory dyspraxia and mild dysarthria, which made his speech completely unintelligible out of context. He was unable to use any consonants in spontaneous speech and used writing when prompted as his primary method of communication. Language assessment indicated mildmoderate impairment resulting in difficulties with spelling, verb selection and sentence construction. Comprehension was sufficient for everyday conversation although neuropsychological assessment highlighted difficulty learning new information. Chris was also found to have impaired reading and spelling, but this may reflect his pre-morbid performance. Chris received intensive in-patient treatment at the Centre for Brain Injury Rehabilitation in Dundee for two months after which he was able to imitate 60-70 per cent of all consonant sounds with some generalisation into everyday

Warm-ups

In week one, Chris practised a number of nonspeech articulatory exercises to familiarise himself with the palate and the Portable Training Unit. From this we devised a set of warm-up exercises which he carried out at the beginning of each session. These included: Making full contact, achieved initially by asking Chris to swallow Making lateral contact by producing ee Alveolar and lateral contact by producing eat but delaying the release of the plosive Lateral and velar contact by producing eek and delaying the release of the plosive Minimal alveolar contact with prompts Velar contact only with production of egg Running the tip of the tongue from front to back and vice-versa. Chris quickly achieved most of these articulatory positions and showed that he could use the visual feedback to modify his tongue movements. During the first week we were able to discuss some speech sounds and the contrast 27

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

COVER STORY / HOW I USE EPG (2) between front and back sounds, adding these labels to the feedback device. In weeks two and three, the aim was to increase awareness of articulatory movements for speech sounds established as present in assessment. Starting with alveolar sounds, the visual feedback highlighted lateral air escape on the plosives t and d and incomplete closure on the nasal n. Chris achieved complete closure in t and d using visual feedback and practised this with and without the palate. He was unable to achieve lateral contact in production of n, however the sound produced was satisfactory in isolation. With velar sounds, he achieved optimum articulation when the consonant was preceded by a close vowel. It was difficult for Chris to modify production of velar consonants preceded by an open vowel and they continued to be produced too far back. At this point, Chris came to the realisation independently that his articulation improved if he reduced his rate of speech. Weeks four and five concentrated on production of target sounds. The fricative s was present veolar contact but by week five he was able to produce l accurately in isolation and in wordinitial position with modelling. We got Chris to practise production of l both with and without the palate. There was continuing variation in production and l was still vulnerable to distortion depending on the adjacent vowel but Chris was having more success in attempts to correct his errors in simple words. sounds but became more difficult to interpret for some of his target sounds. He made some significant gains but was limited in terms of how well he could apply his newly acquired knowledge to improve his output. In saying that, for a person whose intelligibility is severely reduced and who - for whatever reason - cannot use AAC, EPG could be worth pursuing even for small gains. It certainly seems likely that a person with strong cognitive abilities could make even more progress with this method. In terms of cost, Chris had a palate while the therapist used static images and verbal prompts to support him. Ideally both would have their own palate, particularly if there were a larger number of sounds being targeted, or for connected speech. This has cost implications but, at 325 each, the combined cost would still not equal that of a basic communication aid. Of course I couldnt even have attempted this therapy without the help of senior colleagues and specialists from other areas. This really demonstrates the importance of being aware of professional resources on your doorstep that you can tap into. My experience suggests that EPG has a place as a therapy tool as well as a method of analysis for acquired motor speech disorders, particularly those that are chronic and where traditional methods have failed to have an impact. Lesley Anne Smith is a speech and language therapist at the Centre for Brain Injury Rehabilitation, Royal Victoria Hospital, Dundee, e-mail lesleyannesmith@nhs.net.

Gains maintained

Chris was able to achieve a satisfactory s both with and then also without the palate.
in assessment but production was variable in conversational speech. Using visual feedback and with prompts to increase air pressure, Chris was able to achieve a satisfactory s both with and then also without the palate. However, he was unable to achieve the fricative sh in isolation or in CV/VC syllables using visual feedback. This prompted us to try to make a contrast between s and sh by emphasising lip rounding on sh. However, this technique had been unsuccessful in previous attempts and was again difficult for Chris to master. Similarly, we had little impact on Chriss production of r. He was initially able to achieve in r in word-final position and in some VC syllables and this was unchanged following treatment. However, Chris achieved better results with l, which he previously tended to produce in an interdental position with audible air escape. Initially he required lots of prompts to make al-

By the end of week six there were no further improvements in production of target sounds and it seemed as if Chris was again nearing plateau. His motivation again appeared reduced and he failed to attend two appointments. Although Chris had shown increased awareness of the benefits of reducing his rate of speech, he was finding it difficult to modify this in real conversations. After a break of four weeks I reassessed Chris using the Edinburgh Articulation Test, which suggested that some of the gains had been maintained. Chris seemed to have better control in s-clusters, more successful corrections of l with some variability, but no change in production of r or sh, which continued to be produced as s in all positions. There appeared to be an overall improvement in tongue control and Chris reported he felt increased confidence in his speech, although I am not sure of the social impact of this. In conversation Chriss intelligibility was now approximately 70 per cent. It is difficult to know whether my perception of this was due to increased familiarity with his speech but there certainly seemed to be a qualitative change and perhaps the assessment measures I used were too limited to show measurable changes. I felt as if Chris had a much better understanding of articulation in general and was now in a position to attempt to correct some of his errors. However, further benefits of EPG appeared unlikely due to limited progress with target sounds. It is therefore even less likely that Chris would achieve the more complex affricates that were not addressed. It is clear that there are limitations with this treatment. Given that learning and retaining new skills may be problematic for a person with a brain injury, so it may be difficult to achieve the desired results with this method. For Chris, the visual feedback really worked for simple

Acknowledgements

I would like to thank my client for agreeing to me sharing this work, as well as Laorag Hunter, Senior Speech and Language Therapist, CBIR, Dundee, Jan Wilson, Senior Speech and Language Therapist, Centre for Child Health, Dundee and Jan Brodie, Chief Speech and Language Therapist, Ninewells Hospital for their support SLTP and guidance.

References

Anthony, A., Bogle, D., Ingram, T.T.S. & McIsaac, M.W. (1971) The Edinburgh Articulation Test. Edinburgh: Churchill Livingston. Hardcastle, W.J., Morgan Barry, R.A. & Clark, C.J. (1985) Articulatory and voicing characteristics of adult dysartric and verbal dyspraxic speakers: an instrumental study, British Journal of Disorders of Communication 20, pp.249-270. Hartelius, L., Theodoros, D. & Murdoch, B. (2005) Use of electropalatography in the treatment of disordered articulation following traumatic brain injury: a case study, Journal of Medical SpeechLanguage Pathology 13(3), pp.189-204. Howard, S. & Varley, R. (1995) EPG in therapy: Using electropalatography to treat severe acquired apraxia of speech, European Journal of Disorders of Communication 30, pp.246-255. Miller, N. (1989) Apraxia of Speech, in Leahy, M.M. (ed.) Disorders of Communication: The Science of Intervention. London: Taylor & Francis. Rosenbek, J.C., McNeil, M.R. & Aronson, A.E. (1984) Apraxia of Speech: Physiology, Acoustics, Linguistics, Management. California: College Hill Press. 28
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

REFLECTIONS DO I CONSIDER THE SOCIAL IMPACT THAT EVEN SMALL GAINS WOULD HAVE FOR A CLIENT? DO I TAKE SUFFICIENT ADVANTAGE OF SUPPORT FROM LOCAL EXPERTS? DO I HAVE A REALISTIC EXPECTATION OF INDEPENDENT HOME PRACTICE FOR EACH INDIVIDUAL AND OFFER THERAPY ACCORDINGLY?
What has this article got you thinking about? How have local experts from different specialties helped you in your work? Let us know via the Winter 08 forum at http://members.speechmag.com/forum/.

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My Top Resources

SPEECH AND LANGUAGE THERAPISTS IN THE WALTHAM FOREST CHILDRENS CENTRE TEAM LIST THE PEOPLE, APPROACHES AND TOOLS THAT ARE MOST IMPORTANT TO THEIR WORK.
1. Bubbles The number one early years tool and a great motivator for babies and young children. You can use bubbles with a wide range of children at different developmental levels. They are great for facilitating early communication skills eye contact, attention, requesting more, pointing to different parts of the body (eg. bubbles on fingers or feet), ready, steady, go games, up or down concepts, and also for encouraging lip closure, which is needed to blow successfully. Bubbles work as a motivator and reward, so you can build them into the structure of a session for older children as part of a choosing activity. As bubbles are cheap and widely available, they are an affordable and accessible toy. If parents only take one idea away from a group, its often how to use bubbles to promote early communication skills! Balloons offer a great alternative you can buy a cheap pump, which children can often use if they cant manage to blow bubbles. 2. Home made items Home made shakers are cheap and practical. Fill an empty plastic drink bottle with rice or pasta then glue the top shut. This makes a great musical instrument for use during singing groups. As the children participating in the group have a sense of ownership over their musical instrument, this encourages them to join in with the activities. To make a sensory tube, add water or oil and glitter to the rice or pasta, then glue the top shut (tightly!) Home made playdough is a cheap activity for encouraging messy play and developing imaginative play and colour concepts. There are many recipes on the internet, for example http://becomingdomestic.co.uk/2006/10/28/how-tomake-playdough-no-cook-recipe/. 3. Carer-child interaction Carer-child interaction approaches such as Hanen and the Camden & Islington model (1994) are invaluable when you are working with carers and early years practitioners to help develop childrens communication skills. Often, helping them to reflect on their own communication style and then think about the children around them can bring about significant changes. Using a camcorder enables carers and staff to see and reflect on their interactions and the impact they have on children and so to do more of what works well. The Hanen Centre www.hanen.org Kelman, E. & Schneider, C. (1994) Parent-child interaction: an alternative approach to the management of childrens language difficulties, Child Language Teaching and Therapy 10(1). 4. Key word signing Using key word signs with nursery rhymes and action songs either during baby groups or rhyme time groups enables babies to copy actions and encourages vocalisation. Such systems also help

maintain childrens attention in a group and encourage eye contact. They help make our groups more inclusive as a wide range of families can access them, for example those from diverse ethnic backgrounds who speak English as another language and those with children with additional needs. Key word signs also form the basis of our baby signing groups which are available in childrens centres on a rolling programme. UK signing systems include Makaton and Signalong. Baby signing programmes which have featured in Speech & Language Therapy in Practice include Talking Hands, Makaton Signing for Babies and Accelerating Babies Communication (search http://www.speechmag.com/Abstracts/). Something special, a CBeebies programme, has also raised families awareness of key word signing (http://www.bbc.co.uk/cbeebies/somethingspecial/). 5. Parental involvement One of our aims as childrens centre therapists is to encourage and empower parents to feel confident to try out language stimulation activities and join in groups. Using the Family Partnership Model (http://www.cpcs.org.uk/about.php) has developed our skills in working with parents, enabling us to scaffold our approaches and work at the parents level. Its great when parents move from being on the periphery of groups to joining in, becoming involved and even leading sessions! They also give us valuable feedback on our groups and activities, enabling us to change our services to suit them and their childrens needs. 6. Other professionals While speech and language therapy colleagues provide support and valuable ideas to maintain and develop our services, colleagues from other backgrounds bring a different approach which complements our own and provides continuing professional development opportunities. The knowledge and skills of early years practitioners is vital to collaborative working and to ensuring carryover of our programmes in childrens centres. We have learned a huge amount from working with early years practitioners in education, seeing how we both support children from slightly different perspectives. Colleagues from the Early Years Advisory team have been invaluable on sharing practice about the Early Years Foundation Stage curriculum and supporting our work with early years practitioners on language development and enrichment. Running groups with nutritionists and dietitians has developed our skills supporting children in the community with food aversions, delays in developing eating and drinking skills and sensory difficulties. Outreach workers and family support workers have extended and broadened the scope of our practice, ensuring a holistic approach to working with families which will achieve the best outcomes.

7. Props Props provide great objects of reference for songs and stories, such as a duck to signify Five Little Ducks, animals for Old MacDonalds Farm, and a mouse for Hickory Dickory Dock. As children learn to associate objects with a song they can begin to make choices. Older children may be able to make choices from pictures or Boardmaker symbols, but props give early access to choice making. They also help to make songs more interesting and to hold childrens visual attention (along with key word signing). Also they are usually cheap and readily available at the supermarket or pound shops. Boardmaker symbols see http://www.mayerjohnson.com/. 8. Tots Talk Time Tots Talk Time was developed in Waltham Forest to support early years practitioners and develop their practice. This resource includes information about all aspects of early communication development and activities to stimulate and promote language development at all levels. It is currently being updated to integrate with the Early Years Foundation Stage to ensure that we have a common resource that reflects and develops current practice. 9. Talk Time Bags These bags were produced as part of a project initially funded to promote play and provide language stimulation activities for families referred to a Childrens Centre. They contain selected play items (such as sensory and pretend play objects) and a leaflet outlining play activities at different levels. Each childrens centre has a link worker who has been trained to work with families to promote play using these bags. This project is now being rolled out so that other early years professionals can use the bags to help parents develop their childs play and communication skills and also provide toys for families in need. 10. Nursery Rhymes Nursery rhymes are useful with groups and individuals as they help create rapport and develop early communication skills. They are also good for informal assessment as often the childrens eye contact increases and they copy gestures or words. Symbolic gestures and key word signs make nursery rhymes accessible for families who speak English as a second language, and nursery rhymes in additional community languages are a useful language resource. We download and provide parents with song sheets so they can offer continuity between the group and home. h t t p : / / w w w. s o n g s f o r t e a c h i n g . c o m / nurseryrhymes.htm http://www.mes-english.com/worksheets/ music.php http://www.bbc.co.uk/cbeebies/stories/ What other resources have you found useful in childrens centres? Let us know via the Winter 08 forum at http://members.speechmag.com/forum/.