Speech & Language Therapy in Practice, Spring 2001

ISSN 1368-2105
SPRING 2001
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Equity of service
A team consensus
Integration
Removing language barriers
Outcome measures
The power of groups
In my experience
Transferable skills
How I manage mild/moderate adult learning disability My Top Resources

Management
Sense and sensitivity

Working with occupational therapists
C L A S S S E R V I C E
F I R S T
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Spring 2001 speechmag
Now with a search facility! Key in any word(s) and very quickly you will be guided to relevant areas of the site. New article A report on an Estill Voice Training Systems introductory day. Courtesy of The Music Room, Aberdeen, editor Avril Nicoll experiences this in-depth overview with tutors Gillyanne Kayes and Jeremy Fisher.
Reprinted articles
Clinical Focus - Pragmatics: Assessing pragmatic skills of people with learning disabilities. (May 1992, 1 (3))** Only when skills and opportunities are brought together can we hope to see someone with learning disabilities achieve a real ordinary life say Robert Spence and Alex Hitchings. This philosophy shapes the thinking behind their service for this client group. Focus on Management: How secretaries can save you time and money. (November 1992, 2 (1))** Many clinicians spend over their time on administrative or clerical tasks which could be carried out more efficiently and for less cost by secretaries. Susan Brown has carried out a comprehensive study of how speech and language therapists spend their time. Her findings should give us pause for thought. Therapy for real life. (Summer 1999)*** For pupils with language disorders, making friends - or even coping in social situations - can be a long, challenging process. Barbara Paulger reports on a pilot project where a group of 11 to 13 year olds with poor social communication skills were given strategies and opportunities for integration at a youth club.
From Speech Therapy in Practice* / Human Communication**, courtesy of Hexagon Publishing, or from Speech & Language Therapy in Practice***
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Speech & Language Therapy in Practice has a complete PIPA kit to give away FREE to lucky readers, courtesy of The Psychological Corporation. Intended for use by teachers, psychologists and speech and language therapists, this new assessment, with UK norms, has six subtests that aim to identify difficulties in the knowledge and manipulation of sound structure in children from 3.0 to 6.11 years. The normal retail price is 79.38. To enter, simply send your name and address marked Speech & Language Therapy in Practice - PIPA offer to Sarah Bleazard, The Psychological Corporation, Harcourt Place, 32 Jamestown Road, London NW1 1YA. The closing date for receipt of entries is 21st April, 2001. The winners will be drawn randomly from all valid entries and be notified by 30th April.
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Contents
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SPRING 2001
(publication date 26th February) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Website design and maintenance: Nick Bowles Webcraft UK Ltd www.webcraft.co.uk Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2001 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines Internet site.
Spring 2001
16 A first class team
Inside cover Spring 01 speechmag Reader offers 2 News / Comment

4 COVER STORY
Through peer observation and discussion it appeared that, in some cases, decision making on these issues varied between therapists and between clinics. The Win PIPA and Reasons & Remedies plus Checklist. team response to these observations was to examine whether this was really the case. If so, then perhaps we had something to learn from each other by comparing and discussing our practices and guiding principles. In their search for a team consensus on intervention for phonological Although vestibular, tactile and proprioceptive sensory systems have traditionally been delay, Rosalind the interest of occupational therapists, it is useful for speech and language therapists Owen and treating children or adults with an immature or damaged central nervous system to have colleagues shared an understanding of these systems to appreciate how they relate to the auditory and visual their practice systems, and how all interact to influence looking, listening, communication and feeding. and took some Sarah Barnes explains how being alert to oral sensory problems and working closely with tough decisions. occupational therapists can help speech and language therapists identify and understand the implications of a more general underlying sensory processing disorder.
Sensory integration
8 Collaboration with teachers

Initially pupils also attended the resource for support and specialised language teaching in science. Towards the end of the first year, as relationships developed within the resource and school, a new model was proposed. This model aimed to utilise the specialist knowledge of the science co-ordinator, the Science National Curriculum and the skills and language focus of the resource team. Whatever the subject, language difficulties are a barrier to accessing the curriculum. Barbara Paulger and Jude Bowens language focused science curriculum is increasing integration and benefiting everyone.
21 News 22 In my experience
As our work in speech and language therapy is little understood in the wider world, so is the work of specialists in palliative medicine/care...Thus public relations is important and my own role as an ambassador for speech and language therapy in the Highlands has helped me in promoting the care the Hospice provides. Joan Munro, Chief Executive of Highland Hospice, is proof that speech and language therapists have transferable skills and shouldnt be afraid to capitalise on them.
24 Further reading
Hearing impairment, child language, dysphagia, multiple sclerosis.
11 Reviews
Speech difficulties, child language, voice, education, AAC.
25 How I manage mild/ moderate learning disability

By sharing and dramatising parts of our own lives, by hearing each other with respect and no judgement, we affirm that everyones story is unique and worth telling. Given caseload pressures, how can we meet the needs of this neglected client group? Sue Doncaster with Kath Brooke, Alison Matthews and Mary Newman have positive suggestions.
12 Groups
Working off site with no distractions or time pressures enabled the team to think more clearly. As part of this exercise, we reviewed the current status regarding speech and language therapy group interventions, generated a list of all the speech and language therapy skills available, created a list of identified client needs, matched the lists, and devised a whole new range of groups that could be offered. Inge Berrie tells us how an away day opportunity led to improvements in the Royal Hospital for Neurodisability speech and language therapy groups for adults with severe communication impairments.
Cover picture by Paul Reid. Thanks to models Maria, Molly and Sally. See page 4 Sense and Sensitivity: Part 1.
30 My Top Resources
Readers will understand that some of the techniques described are ones I aspire to use - or to use more often - rather than purely those I may have mastered. Joe Reynolds is speech and language therapy manager, Leeds Community and Mental Health Trust. Find out why he believes GSOH is a key resource.
IN FUTURE ISSUES
ADULT LEARNING DISABILITY VOICE LANGUAGE THERAPY SPECIAL NEEDS INDEPENDENT PRACTICE SOCIOLOGY
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2001
news
Common pathway for professional development

A national initiative is to identify a common pathway for the professional development of qualified teachers and therapists, to benefit children with communication difficulties. The 12-18 month project from I CAN, the national educational charity for children with speech and language difficulties, is funded by a DfEE grant and led by Dr Ruth Paradice, an educational psychologist with special interest in language development. The original proposal for the Joint Professional Development Framework was produced by a Steering Group incorporating teachers, therapists, educational psychologists, researchers and public and voluntary organisations (including parents). The political climate is also favourable, with inclusion, integration and training high on the agenda. In a separate move, I CAN has joined forces with Tesco Baby Club to raise money to support I CANs Early Years Programme, a national initiative to provide integrated speech, language and education services to preschool children. Tescos loyalty club magazine goes to over 500,000 parents and offers support and advice on a range of issues to families with young children. I CAN, tel. 0870 010 44 66, www.ican.org.uk
Pioneering services
Acknowledgement
Speech & Language Therapy in Practice is happy to include this acknowledgement as requested by Jane Cantwell, author of Pressures, priorities and pre-emptive practice in the Winter 2000 issue (pp16-19). The following information was omitted from the article Collaboration in the Community:The author wishes to thank Lucie Spurway for all her work in initiating the project, Vicky Woods for her help and advice, and Joyce Waters for her typing and administration skills. She would also like to acknowledge the help of the District Nurses in the Trust who participated in the project. She apologises for any distress that this may have caused.
Disability rights in education

Leading disability charities and education organisations have welcomed the governments commitment to introduce new rights for disabled children in education. RNID has welcomed the SEN and Disability Rights in Education Bill and the additional funding awarded to the Schools Access Initiative to back it up. Chief Executive James Strachan said, For the first time deaf and disabled children will have legislation to protect their rights and give them full access to mainstream education. The disability charity Scope believes this legislation will make a significant move forward towards an inclusive education system. It means that disabled children can expect equal treatment at school and places a new duty on schools and LEAs to plan strategically to increase accessibility for disabled children. Scope has been campaigning for disability rights in education legislation since the Disability Discrimination Act, 1995, which gave disabled people protection from discrimination when using shops, cafes and other services - but excluded education. The Special Educational Needs Consortium - made up of over 250 organisations and individuals with a key interest in special education - also applauds the move, but adds that it hopes the government will move even closer towards an inclusive education system by removing the remaining condition in Section 316 of the Education Act that limits the duty on an LEA to provide a mainstream place for children whose parents want it. RNID tel. 020 7296 8137, www.rnid.org.uk Scope tel. 020 7619 7100, www.scope.org.uk SEC, tel. 020 7843 6318.
SPRING 2001
A child development centre team has been rewarded for producing a template for better working practices that benefit children, their families and staff. The winners of the BUPA Foundation Clinical Excellence Award have moved away from a traditional medical model of working. They now provide more broad based family support, involving parents more rather than taking control away from them, and have therapy groups based on need and ability rather than age. They believe the changes could easily be made in other centres, as no advanced expertise or resources were needed. The team - which includes nurses, social workers, paediatricians, occupational therapists, speech and language therapists, physiotherapists and teachers - is donating the prize money towards an appeal fund for a larger, more advanced centre at the Diana, Princess of Wales Hospital in Grimsby. Meanwhile, a pioneering occupational therapy service is being held up as a model
of how to streamline services and ensure continuity of care for the patient. Over the past two years, a range of jointly managed services have been developed so that a new centre at St Marys Hospital in the Isle of Wight can provide equipment, adaptations, a mobile service, a mobility clinic, a wheelchair service, outreach rehabilitation and mental health services. Patients are referred to just one occupational therapist as health and social services have been integrated, and there are partnerships with local voluntary organisations, businesses and Parkhurst Prison. The development was kick-started by a survey of what was actually happening to patients. It discovered that some were seeing up to five occupational therapists with multiple assessments and little time for treatment. This has been addressed through a central referral system, sharing of resources, more training for assistants and working in teams.
Aim is social inclusion

The Schools Minister has launched the working group report on the provision of speech and language therapy services to children with special educational needs in England with an emphasis on social inclusion. Jacqui Smith said, We are not talking solely about ensuring that children with communication difficulties achieve the same exam or test results as other pupils, important as that is. We are also talking about helping them to overcome - or at least minimise - very real difficulties and establish good relationships with their peers and with adults. In short, we want them to be happy in school and outside it. The working group was established against a background of widespread concern over the significant difficulties encountered in making appropriate provision for children. The minister wants all children with significant communication difficulties to be covered by the arrangements, not just those with statements of SEN, and effective joint working arrangements to be agreed between education and health and between parents and carers, and the children themselves. The Department has responded by making extra support available to LEAs to help them enhance speech and language therapy services in partnership with the NHS and the voluntary sector. Ten million pounds will be available under the Standards Fund 2001-2002. DFEE document ref. 0319/2000 www.doh.gov.uk/slt/slt.pdf
SPEECH & LANGUAGE THERAPY IN PRACTICE
news & comment
Dementia research
A fellowship in memory of Dame Iris Murdoch is intended to promote new research into communication by and with people with dementia. Her husband, Professor John Bayley, announced the setting up of the Alzheimers Society - Iris Murdoch Research Fellowship, expected to be for three years with funding up to 150,000. The Societys director of research, Dr Richard Harvey, said People with dementia should be encouraged to communicate in whatever way seems most appropriate in order to help them preserve their own sense of identity and improve their quality of life...This research fellowship will therefore play an invaluable role in furthering our understanding in this field and in helping us to better communicate with people with dementia in the future. There are over 700,000 people with dementia in the UK. Alzheimers Helpline, tel. 0845 300 0036.
...comment...
Avril Nicoll, Editor
Getting things moving

33 Kinnear Square Laurencekirk AB30 1UL
Hearing loss simulated

Live speech can now be used in the UK to measure the performance of a hearing aid system in situ. Independent hearing aid audiologist Cubex has installed OtoWizard, a PC based system which includes video otoscopy, audiometry, real ear measurements, master hearing aid, loudness scaling, test box, real time HIPRO programming and speech mapping. It also has a hearing loss simulator which demonstrates the hearing impairment and allows the whole family to understand and be involved. Cubex Hearing Centre, tel. 020 7935 5511, e-mail appointments@cubex.co.uk.
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e-mail
avrilnicoll@speechmag.com
Winslow moves
A leading education, special needs, health and rehabilitation publisher has sold its mail order catalogue business and changed the name of its publishing division. Winslows mail order catalogues are now owned by Rompa, but will continue to be marketed under the Winslow brand. The Winslow publishing division is now known as Speechmark. All its current and future titles including the ColorCards range and Winslow Editions will continue to be available through the Winslow catalogues. Ian Franklin, former Chairman of Winslow and now Publisher with Speechmark, hopes this move will provide clarity for customers. Speechmark Publishing, tel. 01869 244644 Rompa (and Winslow catalogues), tel. 0845 9211777.
Trekking fundraiser
The National Autistic Society is looking for people to take part in a challenge of a lifetime to raise funds. An arduous trek through Inner Mongolia from 9-18 September will include the Yellow River, canyons, deserts and grasslands and finish at Ghengis Khans mausoleum which few westerners have seen. Details: Melanie Jaques, tel. 020 7903 3522, e-mail mjaques@nas.org.uk.
Scottish slant
Afasic Scotland is being funded by the Scottish Executive education department under its SEN Innovation Grants Scheme to adapt the Afasic Glossary Sheets to reflect Scottish processes and legislation, and to place a copy in every school and college in Scotland. Afasic Scotland, tel.01382 666560.
Individual therapists and service managers who can see where change is needed are often stymied by constraints such as their working environment and lack of finance. How do we get things moving? Involvement in the local acute services review (as a user of maternity services) has shown me just how difficult it is to bring about evidence-based change, even when the opportunity arises. It would appear that intransigent, male-dominated medical opinions hold sway. The public seems convinced by media scare stories that an acute medical model (on their doorstep) is the only one that will save them from disaster. Equity of service is difficult to bring about because it means diverting resources - people tend to perceive what they have as being the best, and do not wish to lose it. Yet, at the same time, there are positive signs. The push from the top is away from a medical model. Many staff willingly accept having their practice and decisions questioned and analysed in a way I doubt I could handle. Top level personnel are surprisingly accessible. Newer communication methods such as e-mail make it much easier for like-minded people across the country to share ideas and information, and to support one another. Rosalind Owen and colleagues (p16) took a big step towards service equity by examining clinical decision making . What is good is that the result is not a prescription or a rule, but a process based on the evidence and available finance. Inge Berries (p12) department also took time out to re-shape their groups . Not only did this benefit clients but ensured the range of therapists skills was fully exploited. Sue Doncaster and Kath Brooke (p26) are also planning changes to groups based on experience. Barbara Paulger and Jude Bowen (p8) found that, as relationships developed, they were able to see where more integration could take place and take steps to facilitate this. Though their working environment at an I CAN school - with its ethos of inclusion - undoubtedly helped, individuals still have to be quite persistent for collaboration to be successful. Other professionals have so much to offer us if we are prepared to take it on board, as Sarah Barness (p4) work with occupational therapists demonstrates. By studying counselling, Mary Newman (p28) is extending the possibilities of her speech and language therapy work with adults with learning disabilities. Speaking Out, Making Changes was the apt title chosen by this client group for a workshop facilitated by Alison Matthews (p27) and professionals from other disciplines - user involvement at its most inspiring! In the end, we can cope with what appear to be big changes when we find some familiarity. After many years in speech and language therapy, Joan Munro (p22) now runs a hospice - but she never forgets her roots and uses her new position to continue to promote the profession which gave her the skills for the job. Change means being open to new ideas and putting your money where your mouth is. It means being positive, reasonable and tenacious, even when you feel fed-up and emotional. It means taking time to build relationships and mutual trust, collaborating and accepting that you cant always have everything you want. And, as Joe Reynolds (p30) so rightly says, a WPB, GSOH and fully-functioning waffle, rhubarb, and gobbledygook detector also come in handy.
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Problems integrating sensation can have a profound effect on feeding and communication. In the first of two articles, Sarah Barnes explains how being alert to oral sensory problems and working closely with occupational therapists can help speech and language therapists identify and understand the implications of a more general underlying sensory processing disorder.
Read this if you prefer to address underlying problems work with anyone with oral sensitivity want to improve your observation skills
Sense and sensitivity: Part 1

A
ny therapist working with children with central nervous system immaturity or damage will, at some time, come across oral sensory problems. A problem with sensation in and around the mouth may be an isolated one which impinges on efficient feeding and increased drooling, but - if it is part of a general sensory processing problem across several sensory systems including the vestibular, proprioceptive and tactile systems - it may not only affect eating and drinking, but also attention, speech and language and the ability to play. Close joint working with occupational therapists can help speech and language therapists understanding of feeding and drooling by looking not just at the motor difficulties involved in the process of eating and drinking but understanding sensory processing theory and how problems in integrating all sensation can have a profound effect on our area of clinical interest: feeding and communication. The ideas outlined in this treatment method are a combination of Bobath theory as applied to children with cerebral palsy (Bobath, 1980) and sensory integration theory as applied to children with an immature or damaged central nervous system (CNS) (Ayres, 1979).
Questions
When presented with a child who has oral sensitivity problems, several questions need to be asked. How do I know its a sensory problem and not a motor problem, or is it a combination of both? How much is it impinging on other areas of the childs life; for example, behaviour, play, how they move? Is it an isolated problem around the mouth or is it a part of a bigger sensory processing problem? In children with an immature or damaged CNS there can be a deficiency in the bodys neural processing of sensory information. The only way we can ascertain this is by observing behaviours such as those listed in figure 1 (CaseSmith, 1989). Children with cerebral palsy have a primary motor disorder giving them abnormal tone and
Close joint working with occupational therapists can help speech and language therapists understanding of feeding and drooling
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Figure 2 Sensory processing model
Higher cortical functioning Attention control Language and reasoning Emotional stability Self-control & self esteem Kieran receiving increased vestibular input through bouncing on the ball to increase his level of arousal Figure 1 Signs of sensory processing problems A child with problems in processing sensory information may do any of the following: mouth all objects given to them bite down hard on objects select a narrow range of toys with a similar texture resist having face washed or teeth brushed dislike getting dressed and refuse to wear certain fabrics avoid getting hands dirty have an intolerance to loud noises seen by covering ears constantly put hands in mouth rock body excessively tolerate only a very limited range of foods, or gag on lumpy food not tolerate very hot or cold food fuss or cry in response to handling. SENSORY INTEGRATION gravity & movement body position BRAIN STEM touch vision hearing spinal cord Behavioural organisation Gross & fine motor movement
SENSORYMOTOR CORTEX
patterns of movement but they may also have additional sensory processing deficits. These deficits may either be primary or secondary (Blanche et al, 1995). When the original insult is caused to the brain, the damage that results in the movement disorder can also cause a sensory processing disorder. A secondary sensory processing deficit occurs as a result of movement limitations. For example, the child with cerebral palsy who is unable to bring their hands towards the midline cannot actively explore their own body through hand-to-hand, hand-to-feet and handto-mouth play. If oral motor function is abnormal - such as poor lingual movement and delayed swallow reflex - and there are also additional problems processing sensory information, then a feeding problem could be quite severe. Children with cerebral palsy can also suffer from chronic illnesses, especially in the first year of life. When chronically ill they are at the mercy of their physiologic-status with all the resources focused on survival (Wolf & Glass, 1992). In this state, the slightest increase in sensory stimuli may prove overwhelming. The oral area is particularly vulnerable because of the large number of tactile receptors there and their relative maturity at birth. Invasive procedures like intubation and placing of nasogastric tubes, together with the lack of oral feeding, cause an aversive reaction to
anything coming near or into the mouth. This group of children have very few pleasant oral experiences. Although my work is exclusively with children with cerebral palsy, there are other groups of children with an immature or damaged CNS who may have sensory processing problems for whom the principles of therapy are also applicable. These include children on the autistic spectrum (Blanche at al, 1995), children and adults with learning difficulties (Green & Chu, 2000), premature infants (Anderson, 1986) and children with developmental coordination disorder (Goodard, 1996).
Coping
Invasive procedures... cause an aversive reaction to anything coming near or into the mouth. This group of children have very few pleasant oral experiences.
From birth, the child is coping with sorting out and interpreting all the incoming stimuli that bombard them constantly. They are coping with sensations coming from the environment (auditory, visual, tactile, gustatory) and from within their own body (proprioceptive, vestibular). Jean Ayers, an occupational therapist working with people with learning difficulties in the 1960s and 1970s, had a theory about how the child integrated all these senses, processed them and made an adaptive response. She hypothesised that the development of basic sensory systems
and their information occurs in the brainstem area and thalamus, and this is necessary before higher level skills like attention control, emotional well being and speech and language can develop normally. She called this sensory integration and defined it as the brains ability to interpret and organise information from the senses for use in a goal directed activity. Sensory integration occurs automatically and is the process through which the CNS matures and all the senses (vision, hearing, touch, balance, proprioception) are not fully integrated until about 8 years. During her years of research she carried out many studies on children with and without learning difficulties and identified dysfunctions in the tactile, vestibular, proprioceptive and visual systems (Ayers, 1979). These interfered with the development of motor planning, language, behaviour and emotional well being (see figure 2).
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Figure 3 Signs of hypersensitivity
Symptoms associated with feeding and the mouth include: a) turning head away when lips are touched with spoon b) autonomic changes (such as an increase in rate of breathing, flushing or sweating) when touched intra or extra orally c) an over-active gag reflex d) difficulty transferring from breast or bottle to solids e) tone increases when spoon placed in mouth f) very particular about nipple shape g) facial grimacing h) crying while being fed i) vomiting while being fed (needs differential diagnosis from gastroesophageal reflux) j) increase in involuntary movements locally (tonic bite reflex or excessive tongue thrust) or throughout body k) blinking and eye rolling l) will only eat one consistency of food and avoids certain food textures such as mashed food or multiple textured food (which cannot be explained in terms of oral motor control). A detailed sensory history may reveal symptoms of hypersensitivity in other areas: a. avoids tooth brushing b. avoids having hair brushed c. avoids certain textures of clothing d. doesnt like having face washed e. dislikes being touched by other people f. dislikes finger paints, play dough, sand on skin and even just looking g. dislikes clothes being pulled over head h. dislikes any dental work i. gags when food or certain textures get on hands.
Although vestibular, tactile and proprioceptive sensory systems have traditionally been the interest of occupational therapists, it is useful for speech and language therapists treating children or adults with an immature or damaged CNS to have an understanding of these systems to appreciate how they relate to the auditory and visual systems, and how all interact to influence looking, listening, communication and feeding:
have difficulty sitting still become irritable when moved (Green & Chu, 2000). Sensory integration theory would argue that, if you first work on improving the vestibular system, this might be a way to tap into higher cognitive skills of attention and listening.
2. The proprioceptive system

This enables us to know where parts of our body are at any time and what they are doing. It allows us to be able to make postural adjustments. Proprioceptors are located throughout the body in joints, tendons and muscles. Behavioural indicators of proprioceptive processing dysfunction include: rigid posturing of arms and legs grinds teeth; bites self, objects, others bangs head/hits self has difficulty in sitting down - may overshoot or sit down too hard on seat clumsy, and falls frequently.
1. The vestibular system

This is responsible for interpreting gravity and movement and making it possible to develop a sense of place in space. It is also critical in providing the muscle tone necessary to maintain an upright posture. Specialists have often viewed the vestibular and the auditory systems separately when in fact they share a common chamber, fluid, and the transmission of information via the VIII cranial nerve (Goodard, 1996). Goodard argues that hearing is bound to be influenced by information passing through the vestibular system and it, in turn, is bound to be influenced by sound. This is worth remembering when treating a child with listening problems with or without obvious neurological impairment. A detailed case history may also reveal symptoms which might indicate difficulties processing vestibular information; for example, the child may have weak muscles crave for movement stimulation such as rocking or swinging
indicators of tactile processing problems are: may not be able to register when their mouth is full so the child piles large amounts of food in their mouth without clearing each bolus and swallowing it before biting off more food. This can lead to choking. may have tactile hypo sensitivity intra and extra orally and may drool excessively, unaware when drool spills over onto their chin (WeissLambrou et al, 1989). if their hands are touched, you see excessive mouthing, tongue thrusting or gagging.
Relevance
Working with children with cerebral palsy, often the motor disorder is more apparent and, as a result, is most often addressed in treatment. But a sensory processing problem may impact just as much as the movement deficit on a childs ability to function (Blanche et al, 1995). This fact has relevance for speech and language therapists working with a cerebral palsied child with a feeding or communication deficit. For example, the cerebral palsied child who gags on lumps or whose tone increases whenever the spoon touches their lips is not experiencing any pleasure at mealtimes and may actually be losing weight. The child who mouths all objects handed to them is not developing eye hand coordination, playing functionally with that toy or developing an expressive vocabulary. We cannot address the feeding or communicative deficit until we address the underlying
3. The tactile system

This is the infants first source of contact with the outer world and it is the mouth - through rooting, sucking and exploring with the lips and tongue - that provides them with their primary source of tactile information. As speech and language therapists, we are often the first professionals to be alerted to a problem in tactile processing manifested in feeding difficulties. It is generally easier to identify an oral motor difficulty of the muscles but certain
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processing deficits at brain stem level. Many children with cerebral palsy have problems with the fine tuning of sensory input. This is known as a sensory modulation deficit and means they cannot regulate sensory input either from their own bodies or from the environment; they either under react or overreact to it (Blanche et al, 1995). This process occurs in the midbrain and brainstem as we register information. Modulation disorders may be seen as occurring along a continuum. At one end is the child who under reacts or who is known as hyporeactive. Their sensory system is under aroused and they may seek stimulation around the mouth. The mouth is one of the most sensitive parts of the body and, if you bite hard on an object in your mouth, it gives you a lot of tactile and proprioceptive information about where your jaw is. It also heightens a childs arousal level or can help them calm down (Richter & Oetter, 1995). A hyporeactive child may lack the inner drive to be involved in sensory motor activity. This is the child who is happy lying on the floor or sitting well supported. They do not actively explore their environment. They appear to ignore or reject objects given to them or seek out an activity and perseverate with it. This could be through the tactile system (biting either on their own hand or on objects), proprioceptive (stomping, pushing up against something) or movement (rocking of the head or the whole body) (Dunn, 1991). You may see significant drooling in a child without a motor disorder such as cerebral palsy, who can achieve mouth closure and can swallow safely, and wonder why drooling is so bad. In this case, consider hyposensitivity. At the other end of the continuum is the child who is hypersensitive or hyper reactive. This child has an aversive or defensive reaction to nonthreatening or normal sensory input. It can occur in one modality or across sensory modalities. Symptoms associated with feeding and the mouth, and those with other areas, are in figure 3. Within this continuum these children can fluctuate between hypo and hyper sensitivity. Their responses are variable from day to day (Richter & Oetter, 1995; Blanche et al, 1995) and parents may report that he has good and bad days. For these children who have difficulty regulating their level of arousal, biting down hard on an object may help calm them and give them a point of reference. If it is rewarding they will do it repeatedly as it gives them lots of feedback, but they cannot move forward from this to look and listen - and therefore this self stimulation is a block to learning. Older children and adults use strategies to
Only when their arousal level is ready do you work directly on the most threatened system. This can then have a knock-on effect on higher cortical functions such as listening, eye contact and verbal expression
regulate state, especially if stressed, such as biting down on pens, chewing gum, sucking sleeves or biting nails. The difference is that we also have internalised higher level strategies such as inner language, problem solving and consciously changing our breathing pattern to regulate state.
palsy in the Bobath Centre for children in Wales, based in Cardif, tel 029 20405689 or e mail video.inset@ntlworld.com
Acknowledgement
Thanks to Annie Broziatis and Diddo Green, occupational therapists, for advice.
References
Anderson, J. (1986) Sensory Intervention with the pre term infant in the neonatal intensive care unit. American Journal of Occupational Therapy 40 (1). Ayers J. (1979/82) Sensory integration and the child. Western Psychological services, Los Angeles, CA. Bobath, K. (1980) A neurophysiological basis for treatment of cerebral palsy. Heinmann, London. Blanche, E., Botteceli, M. & Hallway, M. (1995) Combining Neuro developmental Treatment & Sensory Integration Principles. An Approach to Pediatric Therapy. Therapy Skill Builders. Case-Smith, J. (1989) Intervention strategies for promoting feeding skills in infants with sensory defects. Occupational Therapy in Health Care 6. Dunn, W. (1991) The sensorimotor systems: A framework for assessment and intervention. In Orelove, F.P. & Sobsey, D. (eds) Educating children with multiple disabilities: A transdisciplinary approach (2nd ed.). Baltimore: Paul H. Brookes. Green, D. & Chu, S. (2000) Application of Sensory Processing Theory in the Treatment of Individuals with Learning Disabilities. Course notes. Goodard, S. (1996) A teachers guide into a childs mind. Fern Ridge Press. Parham & Mailloux (1996) Sensory Integration. In
Receptive
If you suspect from your assessment that the childs oral sensory problem is part of a general sensory processing problem, then Sensory Integration theory would say you have to look at lower levels of development occurring in the brainstem and midbrain (processing of vestibular, tactile, visual, auditory and proprioceptive input) as these contribute to higher levels of functioning. It involves a bottom up approach in brain terms (see figure 2). If the child is having problems processing information at a brain stem level then the information transferred up to a cortical level is not useful and effective functioning is skewed. In therapy you try and influence the processes occurring at brain stem and mid brain level first to calm the whole CNS so that the childs regulatory state is at the right level of arousal to be receptive to a functional activity. For example, if a child has an aversive reaction to touch around the mouth, rather than stimulating them in the sensory system that has the most aversive Do I recognise when practising one skill that it may response (the tacactually be inhibiting the development of another? tile system), you try Do I accept that underlying, general skills may need first to influence other sensory sysattention before a change will be seen in more obvious, tems that are less specific ones? threatening for Do I appreciate when it is appropriate to build up them, such as the proprioceptive tolerance gradually? and/or vestibular system. This could Occupational Therapy for Children. Edited by involve rocking the infant in your arms or, for an Case-Smith, J., Allen, A. Pratt, P. N., 3rd ed. Mosby. older child, swinging them on a swing or bouncing Times Mirror Co. them on a ball. Only when their arousal level is Richter, E. & Oetter, P. (1995) M.O.R.E. Integrating ready do you work directly on the most threatmouth with sensory and postural functions. 2nd ened system. This can then have a knock-on effect ed. PDP Press. on higher cortical functions such as listening, eye Weiss-Lambrou, Tetreult & Dudley (1989) The contact and verbal expression (Parham & Mailloux, Relationship between Oral Sensation and 1996). Drooling in persons with Cerebral Palsy. American In a follow-up article in the Summer 01 issue, I Journal of Occupational Therapy 43. will outline the principles of treatment and give Wolf, L. & Glass, R. (1992) Feeding and Swallowing some practical tips and illustrative case studies. Sarah Barnes is a specialist speech and language Disorders in Infancy: Assessment and therapist working with children with cerebral Management. Therapy Skills Builders.
Reflections
collaboration
Experimenting with language

Whatever the subject, language difficulties are a barrier to accessing the curriculum. As knowledge and staff relationships developed in their school, Barbara Paulger and Jude Bowen recognised that pooling specialist resources to create a language focused science curriculum would increase integration and benefit everyone.
Read this if you believe integration is important are looking for a model of working together want your planning to be more focused
CAN at The Park is a Secondary Language Resource based at The Park School. The school caters for pupils with learning difficulties and the resource, which opened in September 1996, for those with additional speech and language difficulties. Six pupils in each year group attend the language resource for extra support and specialised language teaching in English, maths, geography and history. The resource has two full time speech and language therapists. Initially pupils also attended the resource for support and specialised language teaching in science. Towards the end of the first year, as relationships developed within the resource and school, a new model was proposed. This model aimed to utilise the specialist knowledge of the
It raised the profile of speech and language therapy in the school and enabled us to focus on the language aspect of the curriculum areas.
science co-ordinator, the Science National Curriculum and the skills and language focus of the resource team.
Effective
The staff in the resource had been using Wendy Rinaldis Language Concepts to Access Learning in maths and geography and found the principles and teaching approach very effective. The speech and language therapist from the resource and the science specialist from the school worked together to produce a language focused science curriculum that used the Language Concepts to Access Learning as its foundation. Setting up this curriculum involved an initial planning meeting to outline the curriculum and to decide on how the pupils would be taught (that is, the group structures) and who would be
collaboration
Figure 1 Example of pairs
Figure 3 Examples of right or wrong (digestion)
Pairs: Digestion: Body part and function
The blood digests food. Food is chewed in the mouth. The stomach carries food around the body.
Food is chewed
Figure 4 Example of board game questions (saliva)
Mouth
Figure 2 Example of sequencing (cards for digestion)
What does saliva do? True or false? - Saliva is found in the stomach. What is the name of the wet liquid in the mouth?
Food is put in the mouth
Food is chewed in the mouth
Saliva makes food easier to swallow
Food is squeezed down the oesophagus
Figure 6 An example of learning objectives and activities
Figure 5 States of Matter Assessment Sheet
can identify the 3 states of matter: SOLID LIQUID GAS can describe / explain
arrangement of atoms (model used: yes / no)
Photo: Assessing knowledge of internal organs!
3.2.2d (part) 3.2.2e
SOLID
N/A
LIQUID
N/A
GAS
N/A
movement of atoms shape
Each topic starts with the big picture; Each subsequent lesson begins with a recap of teaching objectives of previous lessons.
volume change from ice / solid to water / liquid change from water / liquid to steam / gas change from steam / gas to water / liquid change from water / liquid to ice / solid * responses given by pupil
in a warm place it melts* if you boil water it evaporates* in a cold place it condenses* you freeze it*
4. Nutrition. to be able to say that digestion is the word we use when we talk about how we take what our bodies need from food to be able to name the parts of the digestive system to be able to sequence the path of digestion to be able to say what each part of the digestive system does to be able to say that the substances needed by the body are absorbed by the blood to be able to say that waste food is passed out through the anus
introduction : the big picture - use large diagram and sequencing cards to explain what happens during digestion pupils to sequence cards in turn - can be timed to make it a competitive game pairs : parts of digestive system / function worksheet - stick pre-written functions onto diagram action game :- walk through digestive system on large floor diagram describing process as you go; useful substances go into red bucket (blood) to be carried round edge of diagram; waste food (brown cubes) go into different bucket. Demonstrate first, then let each pupil have a turn right or wrong round game: ask a question
large diagram of digestive system
sequencing cards / timer
cards for pairs game worksheets / Pritt / scissors floor diagram multi-link cubes (food) red bucket brown bucket
right or wrong statements yes / no cards blindfold / ruler
teaching. This was followed by weekly planning meetings to develop lesson plans, produce resources and identify key language concepts and vocabulary, and other meetings to identify and develop objectives for the language curriculum as a whole. Initially we concentrated on years seven and eight. We decided that the pupils in each year group would be divided into two groups according to ability. The groups would be taught at the same time; one group by the science specialist and the other by a member of the resource team, initially the senior specialist speech and language therapist. The pupils have two double science lessons per week, one double lesson taught by the science specialist and the other by the speech and language therapist. There were several advantages to this. It raised the profile of speech and language therapy in the school and enabled us to focus on the language aspect of the curriculum areas. It also merged expertise from two areas and allowed us to target key vocabulary
together. And, at the same time as it enabled the pupils to be fully integrated, all the pupils in years 7 & 8 benefited from the language approach. The main principles employed in the language focused approach are: 1. To begin with the big picture. 2. To work on comprehension before expression. 3. To identify key concepts and vocabulary and teach these explicitly. 4. To work on vocabulary and concepts in categories. 5. To build on previously learnt concepts and vocabulary. 6. To recap skills previously learnt at the beginning of each lesson.
Recap
Each topic starts with the big picture; for example, This lesson is Science. We are learning about The Body. Each subsequent lesson begins with a recap of teaching objectives of previous lessons.
This means that, once a topic is halfway through or more, the recap can take up a large part of the lesson. This constant revisiting consolidates memory before new words and knowledge are added. The activities we use are based on those described in Dr Wendy Rinaldis Language Concepts to Access Learning. They include: pairs (figure 1) sorting sequencing (figure 2) right or wrong (pupils are read statements and they have to say whether they are right or wrong; can also use yes/no, tick/cross cards) (figure 3) board games (figure 4) guess what / who. Pupils are assessed on their knowledge of concepts and vocabulary when they enter the resource. Ongoing assessment is carried out through the learning objectives. Formal assessment of the main concepts and vocabulary is carried out at the end of each topic. This assessment is oral and
collaboration
individual, which allows pupils to demonstrate their knowledge without limitations set by poor literacy skills. An example of an assessment carried out on a year 8 pupil (age 12.5 years) at the end of the States of Matter topic is in figure 5. At this time he had a vocabulary age of 7.8 years as assessed by the British Picture Vocabulary Scales (Dunn et al, 1997). The Park School now has a language based science curriculum with clearly stated language objectives for years seven and eight (see example
in figure 6). This provides a solid foundation for the accredited science course in year nine. It has also provided a model for science teaching in years ten and eleven and the junior part of the school. Due to the success of the approach and the raised interest in and awareness of language this produced, Jude Bowen the science co-ordinator for the main school has now joined the resource as a teacher but still remains as co-ordinator for science for the whole school.
Reference
Dunn, L., Dunn, L., Whetton, C. & Burley, J. (1997) British Picture Vocabulary Scale: Second Edition. NFER-Nelson.
Resource
A catalogue including Language Concepts to Access Learning and other items by Wendy Rinaldi is available from Child Communication & Learning, 18 Dorking Rd, Chilworth, Surrey GU4 8NR, tel 01483 458411.
Reflections
Do we use enough repetition through a variety of activities? Do we understand that collaboration develops over time? Do we have the most effective mix of assessment, planning and contact time?
Barbara Paulger is a specialist speech and language therapist and Jude Bowen the science co-ordinator and a teacher at I CAN at The Park.
news extra..news extra..news extra..news extra..news extra..news extra..
Dementia signposts
A major report has condemned the lack of care services for people with dementia in Scotland. The report from Alzheimer Scotland Action on Dementia pulls together research to inform policy makers and planners about the range and volume of services necessary to meet the needs of people with dementia and their carers. These facts and figures are applied to a model population of 100,000, where you would expect to find about 1120 people with dementia. By indicating how many of these people are likely to be in the community, care homes or hospitals, and how many will have mild, moderate or severe dementia, it is possible to map out the amount of services needed, ranging from emotional support and memory training to constant care and supervision. Authorities can then see where there are gaps. For example, very few areas have specialist counselling and advocacy services, or services for the under 65s, and, in many areas, people have difficulty accessing new drugs which delay the onset of symptoms of Alzheimers disease. Alzheimer Scotland is demanding that high quality services be available from the first signs and throughout the illness, regardless of where people with dementia and their carers live. It believes the introduction of free health and personal care services at the point of need, paid for by some form of taxation or compulsory insurance, would remove a major barrier to the planning and provision of comprehensive services. Planning Signposts for Dementia Care Services, from Alzheimer Scotland Action on Dementia, tel. 0131 243 1453, www.alzcot.org
Management course exploits web
A new management course for the health and social care sector encourages students to take full advantage of the Internet. The Open University Business Schools Professional Certificate in Management comprises four modules, each studied over three months. The course has its own website with specific health and care links, articles and conferences for the tutor groups. A local tutor can offer help via e-mail and tutorials can be held online. A substantial part of the course material has been developed in consultation with the Department of Health and the Institute of Healthcare Management. Areas covered include modernising health and care services; understanding the agenda of different stakeholders; considering who the customers are and how they can shape health and social care services; working with colleagues, boards and volunteers. Dr Vivien Martin, one of the architects of the programme, says it is designed to help managers become more entrepreneurial, accountable and business minded. She suggests the certificate course is a starting point for long-term career development, followed by the Diploma in Management and possibly a full MBA. Details: OUBS Information Line 08700 100311 / www.oubs.open.ac.uk.
...RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES..
Predicting and drafting

Co:Writer 4000, an updated version of the word prediction program, has new features including an ability to predict on phonetic spelling and a different method of managing and creating dictionaries. From 149; upgrade from 71. Draft:Builder is an organisational tool to assist pupils with special needs gather, organise and synthesise information to produce a first draft where it can be exported to a regular or specialised word processing program. From 99. Don Johnston Special Needs, tel. 01925 256500.
Personality traits
A reproducible version of Patricia Sims Personality Checklist is now available to be used in conjunction with her Reasons & Remedies book. For completion by the professional or an informant, it aims to bring out any relationship between a childs speech, language, literacy and other developmental difficulties and tension or anxiety. From bookshops of direct from Mortimore Books, PO Box 156, Barnstaple, EX33 1YN (p+p free). Personality Checklist ISBN 0 9536209, 8. Reasons & Remedies ISBN 0 9536209 0 5, 12.95.
Resources online
To buy Black Sheep Press resources online, go to www.blacksheepepress.com
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reviews
r e v i e w s REVIEWS. . . . . . . . . .
Beautifully produced
SPEECH DIFFICULTIES
Speech Sounds on Cue CD-ROM Carol Bishop Supplied by Propeller Multimedia Ltd., P.O. Box 27028, Edinburgh, EH10 6WD, tel. 0131 446 0820 www.propeller.net/react Price : 90 + VAT + 5 delivery [Requires : PC with Windows 95 or higher/Mac Power PC with system 8 or higher, Quick Time 4 (supplied), 16 bit true colour display, minimum 32mb ram, 16 x CD-ROM drive, 640 x 480 resolution.] Designed by an Australian speech & language pathologist, this is beautifully produced and allows for practice of 19 consonant sounds in isolation, in initial position and in short phrases. Having chosen the sound you wish to work on, a video clip clearly shows how to produce it, while the technique is explained verbally. A colour picture then illustrates a phrase, the crucial word being cued by another video clip of the initial sound. It is also possible to print out photos of the sound positions and word lists. The author intends the CD to be used with either adults or children with speech difficulties. This shows in the material; some of the words and phrases are not very child-friendly; for example, credit or cash. However, it is very easy to skip over these items. The CD is simple to use and was greatly enjoyed by my victims in the language unit (aged 4 - 7 years). They found it easier to concentrate on the face on the computer screen than on their therapist (!) and could operate the programme themselves. This is an excellent resource for working on complex speech difficulties. It has a fairly limited function (similar programmes to develop consonants in other word positions or vowels would be useful, for example), and is quite expensive, but what it does, it does well. Enid McCracken is a speech and language therapist working for Cheshire Community Healthcare Trust, mainly within an infant language unit. She won Speech Sounds on Cue in a reader offer in the Autumn 00 issue.
Useful and interesting

CHILD LANGUAGE
StoryCards - Prepositions Sue Duggleby & Ross Duggleby Winslow ISBN 0 86388 2668 34.95 This attractive resource targets prepositions but could also be used for a range of expressive language tasks. There are four stories in the set, each covering three prepositions (ranging in difficulty from in to between). The stories are scripted and each picture covers at least one preposition. The pictures clearly depict each target word, making it easy for children to retell the stories. There is also a finger puppet for the central character of each story, adding another dimension to the picture description activity. The colour pictures are simple but attractive and would appeal to children of about 4 years upwards. In addition, the photocopiable line drawings on the back of each picture provide a useful basis for homework activities. It would be most useful for children needing extra work to consolidate their learning of concepts which have already been introduced at a simpler level. It is good value and would be an interesting addition to any therapists resource cupboard. Sue Stegeman is a speech and language therapist working in mainstream paediatrics for Tees and North East Yorkshire NHS Trust.
Constructive advice
VOICE
Evaluating voice therapy: measuring the effectiveness of treatment Paul Carding Whurr ISBN 186156 162 8 24.50 This is the book that many therapists will have been waiting for. It sets out clearly the need for evidence of clinical effectiveness and evidence-based practice. It confronts therapists with important questions they need to consider when measuring and evaluating the impact of therapy on patients. All therapists and students about to embark on research (not just in voice) will find the opening chapters a useful reference source. For voice therapists the book offers constructive, easy to follow advice on how to undertake research and provides an overview of techniques for measuring improvement in voice. It encourages therapists to look to the future and, in doing so, consider what is required to prove the effectiveness and value of therapy and maintain the integrity of the profession. Giulia Campbell is a speech and language therapist at City Hospital, Birmingham.
Wealth of experience
EDUCATION
Language Difficulties in an Educational Context Wendy Rinaldi Whurr ISBN 186156 1563 19.50 This book is written for practitioners and students across the professions involved with language impaired children. It reflects Rinaldis wealth of experience working collaboratively in education. The book is easy to read and well researched. One of the key issues concerns accurate early identification of language impairment, which has implications not only for the childs early learning experience but as s/he enters school. The chapters include Perspectives on children with language difficulties, The pre-school years (James Law) and Pragmatic disorder in the context of autism. This focuses upon the grey area between language and autism. The final chapter, Information technology for children with language difficulties (Janet Larcher) is comprehensive and informative. Ann Gosman is a speech and language therapist with Orkney Health Board.
Good value
AAC
Its My Life Kay Meinertzhagen, Gill Kennard and Linda Hall Signalong ISBN 1 902317 11 X 25.00 This dictionary of approximately 1050 signs is another addition to the Signalong range. The vocabulary includes body parts, clothes, personal care, relationships, professionals, social interaction, sexuality, independent living, bereavement and crime. It is easy to use as the book is arranged in colour coded sections. The signs are presented alphabetically within each section and there is a complete index at the back. Signs are illustrated with supporting written descriptions. The signs are intended for people who have learning disabilities and the vocabulary reflects their needs. However, some of the actual signs selected from BSL may be conceptually difficult for that client group. This resource is useful for therapists working in learning disability. Prior signing knowledge is essential to use it effectively. At 25, it represents good value for money. Sarah Chandler is a specialist speech and language therapist with the New Possibilities NHS Trust in Colchester. She works with adults and children who have severe learning disabilities, and is a Makaton Regional Tutor.
A book you can rely on

VOICE
Working with Voice Disorders. Stephanie Martin and Myra Lockhart Winslow ISBN 0 86388 243 9 29.95 This book is a valuable resource for any speech and language therapy department. Its in-depth informative content offers valid current information on all issues related to voice from theory / assessment through to service management. It is especially useful for students and newly qualified clinicians or those not working full-time with voice disorders; however, it may also give useful ideas to service managers. It is a lengthy book for a practising clinician to read entirely, but its well organised layout guides you to specific issues instantly. The practical photocopiable handouts are most useful and particularly client friendly. The books practical application ensures consideration of all issues while managing different voice disorders. Perhaps not a resource that you would use on a daily basis, but definitely one you can rely on and refer to regularly. Barbara Birrane is a speech and language therapist with the Western Health Board, Mayo Community Care, Co.Mayo, Ireland.
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groups
Invigorating the Wheel

Read this if you are looking for meaningful outcome measures have clients with severe difficulties want to offer group therapy to a wider variety of clients
Speech and language therapists at the Royal Hospital for Neurodisability took an away day opportunity to re-shape their group service for adults with severe communication impairments. As a result, meaningful outcome measures are used routinely, therapists are exploiting more of their skills and groups are addressing a wider range of client needs. Inge Berrie tells us how.
organised two half-day away day sessions. Working off site with no distractions or time pressures enabled the team to think more clearly. As part of this exercise, we reviewed the current status regarding speech and language therapy group interventions, generated a list of all the speech and language therapy skills available, created a list of identified client needs, matched the lists, and devised a whole new range of groups that could be offered. The final outcome was positive and we decided we needed to: Evaluate the time structure of the groups. How frequently would they be run, and for how long? (That is, length of each group session and of the total group programme in weeks.) Further develop the types of groups that could be run with the unique client group at the Royal Hospital. For each group devised, develop clear objectives, criteria for referral and criteria for discharge. Clarify the roles of the referring speech and language therapist versus the speech and language therapist running the groups. Develop outcome measures for each group. These outcome measures have continued to evolve and we envisage making further changes so we can meet the needs of the client group more closely. Develop ways to improve carry-over of client skills outside the groups. It was agreed that each group could take place weekly for a ten-week block, with a break between each block. This break would allow time for evaluating the groups, deciding if any members were ready for discharge or deemed inappropriate for further group intervention, and to work on new developments. We decided on a set time period for each group programme so that clients from the continuing care wards did not become dependent on the speech and language therapy groups. This also gave us an opportunity to become more goal directed within this period, which we hoped would help focus the clients to their individual goals within their group. The types of groups devised were aimed at meeting the needs of clients on continuing care as well as rehabilitation wards in the hospital (figure 1).
roup therapy in the speech and language therapy department at the Royal Hospital for Neuro-disability provides a service to a unique client group which may not fit into a traditional group therapy model. The clients seen are adults with severe neuro-disability stemming from disorders such as traumatic brain injury, severe stroke, anoxic brain damage and multiple sclerosis. Some clients attending the speech and language therapy groups also receive active and regular individual intervention, whereas others are from our continuing care wards where speech and language therapy management is on a review / monitor basis only. The types of groups therefore vary to accommodate the needs of this mixed client group. They create an environment that aims to facilitate and develop communication skills and provide clients with an opportunity to interact, with and without facilitation. In the current climate of clinical governance, more emphasis is being placed on outcome measures and demonstration of the efficacy of treatment. This focus has provided an ideal opportunity for us to review our service at the Royal Hospital in terms of the development of our group therapy structure and clear measurement of clients performance within groups. Historically the groups were loosely goal directed, with no formal outcome measures. The main types tended to focus on intelligibility work and supporting the use of alternative/augmentative communication (AAC) equipment. The groups on offer did not reflect the extensive range of speech and language therapy skills available. We felt our skills as therapists were not being utilised to their full potential, nor were we using our resources as effectively as possible. There was also little evidence of carry-over of clients skills to ward/unit level.
Guide
The aims and objectives for each group were clearly defined, as were the referral and discharge criteria to guide the therapists decision when making a referral. This information also clarified the purpose of the group for all involved including volunteers and speech and language therapy students. As an example, figure 2 shows the aims, objectives, referral criteria and discharge criteria of the low level social communication skills group. The groups were to be run by one qualified therapist assisted by a volunteer or speech and language therapy assistant. For some groups, where the clients were highly dependent, more than two staff members were required to assist. The assistants have often been prospective students or volunteers. A second person has been essential for the more severely impaired clients, in terms of providing physical support and allowing the lead speech and language therapist to model skills. Activities were aimed at providing each group with a framework within which the clients individual goals could be developed. The therapists running the groups were acutely aware of tailoring activities to suit an adult client group. This concept proved to be more difficult than anticipated when the responses of severely disabled clients were considered. Activities included quizzes, card games, discussing themes such as countries, seasonal topics, the outdoors and types of food. Some groups focused on themes that incorporated smell and touch, not just auditory and visual senses. The Royal Hospital is a registered charity which, by its nature, relies on external funding for clients, for example from Health Authorities. As a direct result, it is important that we clearly
Off site
To advance the structure and content of the groups, and to shift the focus to measuring outcomes, the speech and language therapy team
12
groups
The groups on offer did not reflect the extensive range of speech and language therapy skills available. We felt our skills as therapists were not being utilised to their full potential, nor were we using our resources as effectively as possible.
Inge Berrie
Figure 1 Types of groups devised
demonstrate the benefits and outcomes of our interventions. The speech and language therapists therefore devised an outcome measure appropriate to group intervention with this client group.
Social Communication Skills Group low level high level AAC Group Language Stimulation Group Cognitive Communication Group new users low level high level high level
Baseline
The first step was for the referring ward therapist to select a number of goals for their client. The goals were selected from subsets of skills or behaviours deemed relevant to that type of group so, for example, the social communication skills group would have a different focus and different goals from the language stimulation group. Both groups would have elements of working on impairment and handicap. The concept of rating clients performance and representing that diagrammatically on a wheel as per the Personal Communication Profile (PCP) (Moir & Spence, 1997) was adapted and set up with five layers, each of which measured a particular level of performance of the client (figure 3). Each layer represented a number from 1-5 and each number had a definition of what was required to achieve that score (see figure 4 for an example). The referring ward speech and language therapist would complete this wheel before the groups first session so that the therapist running the group had a baseline measure of the clients performance. This task would then be repeated at the end of the group programmes. Therefore, two wheels are completed - one prior to the treatment programme and one post group intervention. The specific goals selected by the ward therapist were incorporated into the group sessions and translated into laymans terms for the clients in the group (for example; Aim to begin working on starting conversations, Aim to look at one other group member when speaking to them). Some goals - for example, initiation - may not have been previously brought to the clients attention during individual intervention, as they were intrinsic to the therapy and not a separate component. If clients were cognitively able to participate in joint goal setting
Functional Communication Group low level high level Intelligibility Group Confidence Group Conversation Group low level high level high level high level
Figure 2 Example of group definitions LOW LEVEL SOCIAL COMMUNICATION SKILLS GROUP AIM To enable the client to use appropriate social communication skills in a functional setting. OBJECTIVES To be able to initiate more appropriate social greetings and topics. To be able to participate in more appropriate turn-taking tasks. REFERRAL CRITERIA Potential members should fulfil all of the following criteria: Have functional expressive skills Have functional receptive skills Demonstrate the ability to learn Have ineffective social skills Be motivated to attend the group and carry over skills developed Have a therapist/carer able and motivated to carry out practice exercises with the group member (if this is not possible please discuss with therapist running the group). DISCHARGE CRITERIA Group members will be discharged when one or more of the following apply: Therapist is satisfied that goals have been achieved Group member is satisfied that goals have been achieved There is no improvement noted There is no change in status There is a deterioration in general status affecting the skills required to attend the group.
Figure 3 The Wheel demonstrating the scoring system for the Low Level Social Skills Group. Figure 4 Example of one of the definitions of a measurement category Initiation 1. Never initiates with indirect prompting. 2. Occasionally initiates with indirect prompting. 3. Consistently initiates with indirect prompting. 4. Occasionally initiates with no indirect prompting. 5. Consistently initiates with no indirect prompting.
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groups
Figure 5 Score sheet for client JS (low level Social Communication Skills Group) GOALS INITIATION EYE CONTACT TURN-TAKING PARTICIPATION MOTIVATION CLIENTS SPECIFIC GOAL CLIENTS SPECIFIC GOAL CLIENTS SPECIFIC GOAL 1.3.2000 2 3 1 3 1 3 2 3 7.3.2000 14.3.2000 21.3.2000
Figure 6 Observation sheet for client JS (low level Social Communication Skills Group) DATE 1.3.2000 OBSERVATIONS / COMMENTS JS interacted with PN in the group and showed more tolerance of other group members.
7.3.2000 14.3.2000 21.3.2000 Figure 7 An example of a wheel completed prior to group therapy
If clients were cognitively able to participate in joint goal setting then, together with the referring ward therapist and group therapist, they set their goals.
Figure 8 An example of a wheel completed after group therapy
then, together with the referring ward therapist and group therapist, they set their goals. Each week the speech and language therapist running the group completed two recording forms for each client. One score sheet (case example in figure 5) was numerical and the therapist selected a number from 1-5 to describe the clients performance related to a specific goal or skill (figure 4). The other score sheet (case example in figure 6) allowed for a limited amount of subjective reporting; for example the mood of the patient or interaction between group members. At the end of the 10 session block of weekly group intervention, the speech and language therapist running the group then averaged out the scores of each group session for each client, and compared this to the baseline score on their wheel (figure 7). The therapist then completed the wheel with the new scores (figure 8) and a before and after record could be seen. The resulting picture of scores clearly demonstrated outcome and could be incorporated, if necessary, into progress reports to funding authorities. Results also served to assist in evaluating whether the patient would benefit from further group intervention, a different type of group intervention, no group intervention, or whether individual intervention was more appropriate.
Reflections
Do we recognise the value of away days for shaping and improving services? Can carry-over be successful in a hospital environment? Could we make more use of groups for assessment purposes?
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Sensitive
We have found that the wheel concept of the PCP profile (Moir & Spence, 1997) as a method of measuring performance has been sensitive with this client group as it measures small gains made by the clients. Health care assistants, nurses and relatives/carers were invited to attend the groups, but regular attendance was difficult to achieve for a variety of reasons. This meant that the carry-over of skills for clients was not as successful as anticipated. The onus fell onto the referring ward speech and language therapist to talk to staff and relatives/carers about carry-over. This proved difficult as staff and relatives/carers had often not seen the client in the group, and therefore could not accurately relate to the concept. The groups have unexpectedly become an education medium for various professionals and students. Prospective speech and language therapy students and students from other disciplines have frequently observed and participated. In addition, speech and language therapy students have been given the opportunity to observe and run some of the groups. Recent changes have been made to the structure of the groups and the outcome measures. The structure has been changed from a purely closed group format to a more flexible one where therapists can refer patients even after the groups have commenced the 10-week programme. The groups that focus on maintenance of continuing care clients are now run by volunteers and the speech and language therapy assistant, with guidance/supervision from a qualified therapist. This means that the qualified speech and language therapy resource is freed up to focus on the groups that require it.
groups
...RESOURCES...RESOURCES...RESOURCES...RESOURCES...
Naturalistic
A new assessment group has been developed for clients who are minimally responsive or in the vegetative state. The outcomes for this group are measured differently. Clients can be rotated into the group for 1-3 sessions. The group environment provides these clients with the opportunity to show responses in a structured naturalistic environment. This group has proved invaluable, as different responses are often noticed compared to individual speech and language therapy sessions. The description of outcome measures for the groups has become more precise and consistent over time, so reflecting the performance of the client more accurately. A glossary of all the measurement categories has been devised so that referring speech and language therapists have some flexibility. They are guided by the categories related to a specific group but have the option of choosing a scoring category from another group. For example, the referring speech and language therapist will select measurement categories associated with the low level social communication skills group, but may feel that one category from the language stimulation group is also an appropriate measurement.
Computer basics
The first pan-European Union qualification in personal computing skills aims to help people with computing for their job or general interest. The European Computer Driving Licence is not designed specifically for IT professionals, but for those who wish to gain a basic qualification in computing. It is open to anyone regardless of age, education, experience or background. Details: The British Computer Society, tel. 01793 417417, www.bcs.org.uk
Strengths and weaknesses

The Verbal Reasoning Skills Assessment is an informal procedure covering the 3-14 year age range. Collated by Maggie Johnson, it is particularly useful for helping to identify strengths and weaknesses in the language skills of children with semantic and pragmatic disorders. 12 (inc. p&p) from Sally Gresham, Speech and Language Therapy Service, Kent and Canterbury Hospital, Ethelbert Road, Canterbury CT1 3NG tel. 01227 766877 ext 74762. Cheques payable to East Kent Community NHS Trust.
Symbols Now
This book has been written to demonstrate the variety of ways symbols are being used to support people with learning difficulties. It includes examples of good practice in the school, day centre or home, and has contributions from people working with symbol users and symbol users themselves. Ed. By Chris Abbott 10 + p&p from Widgit Software, tel. 01926 885303, www .widgit.com.
Opportunity
Speech and language group therapy at the Royal Hospital has proved to be a successful medium through which clients have been given the opportunity to develop aspects of their communication skills difficult to target in individual sessions. It complements individual therapy programmes and provides the referring speech and language therapist with an opportunity to view their clients skills in a different setting. Our experience has led us to question some of our aims and further develop our group programme. We plan to: > continue to review the types of groups being offered and develop new groups to meet the changing needs of the client group. > devise scoring categories for new groups. > continue to develop group activities appropriate to an adult client group with severe neuro-disability. > develop innovative ways to assist carry-over of skills acquired in the group environment. Inge Berrie is a Senior Speech and Language Therapist at the Royal Hospital for Neuro-disability, Putney.
Jargon initiative
The Communications Forum website has an initiative to translate professional jargon into plain English. To take part in this discussion group, e-mail cf@communicationsforum.org.uk for a password. Formed in 1994, the Forum brings together organisations in the field of human communication and communication disability, to break down barriers to equal participation in society faced by those with communication problems. The website also includes legal pages and information on therapy and access to employment. Communications Forum, tel. 020 7482 9200, www.communicationsforum.org.uk.
Stroke in other languages

Information leaflets about stroke prevention in Bengali, Gujerati and Urdu will soon be available from the Stroke Association. People of Asian origin are at higher risk of stroke than many other ethnic groups. The leaflets have been developed in partnership with Oldham NHS Trust Ethnic Health Team. Communication problems after stroke is one of many of the Associations leaflets which are also available in Welsh. Stroke Association, tel. 020 7566 0300.
References
Moir, D. & Spence, R. (1997) Inventing the Wheel. Bulletin. Royal College of Speech & Language Therapists.
Stammering for teachers

A video pack for teachers gives practical advice and guidance on how they can help their stammering pupils. The 12 minute drama documentary tells the story of a boy and the problems he faces during a normal school day as a result of his stammer. The accompanying booklet gives background information, guidance on how to help and notes about such aspects as covert stammering, talking in school, oral examinations, teasing and bullying and teachers attitudes. A Chance to Speak, 11.95 (inc. p&p) from BSA tel. 0208 1983 1003.
Acknowlegements
I would like to thank Ann-Marie OConnor ( Head of Speech and Language Therapy Service) and all the team members in the Speech and Language Therapy Service who assisted me with the article for their advice and support and Gary Derwent, Head of Technology Clinic, for assisting with the drawings of the wheels.
15
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A first class team

To make a real difference, speech and language therapy has to be provided to the right people, at the right time, in the right way and in sufficient quantity. We want to offer an equitable service but large caseloads and different methods of prioritisation interfere. In their search for a team consensus on intervention for phonological delay, Rosalind Owen and colleagues shared their practice and took some tough decisions.
Read this if you like to take decisions as a team want to make the best use of therapy time are interested in the process of clinical judgement
s speech and language therapists, we aim to give to all our clients a level of service that is appropriate, effective and efficient. Our shared professional knowledge and expertise regarding development, assessment, diagnosis and intervention forms the basis for clinical judgements. At the heart of our work should be an objectivity that results in a first class equitable service (Department of Health, 1998). The art of our profession is to combine such objectivity with sensitivity to the needs of the individual, and flexibility to adapt to the demands of the situation. Prioritisation follows an initial assessment session and is based on information the therapist gains about the clients speech and language skills. Other factors are also relevant and taken into account, such as information about the
Figure 1 Case descriptions and management

1: Male 2;6 Referred by health visitor as Cant understand what he is saying. Poor language acquisition and restricted expressive language. Mostly uses single words but has the occasional 2 word phrase. 2: Male 3;3 Referred by health visitor. Supportive parents. Can imitate all sounds within system. Has established p, b, t, d, f. Does not have k, s, , g, t, d .
;; ;; ;;
3: Male 4;0 Referred by nursery school. Supportive parents although a little anxious. Older school age sister. Has recently started attending nursery a few times per week. Stops fricatives. Reduces clusters.
;; ;; ;;
4: Female full-time. A of problem Normal m Fronting v
; ;
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Figure 2 Types of management strategies: definitions Regular 2-8 (usually 6) individual/group treatment therapy sessions at weekly intervals carried out by the speech and language therapist. Programme and review Advice and or review Discharge Activities/strategies relating to specific targets provided in written form to the parent/ carer or other keyworker at home/school/nursery. A review appointment planned after 2-6 months (usually 3). General advice provided to the parent/carer other keyworker at home/school/nursery. This may include a printed leaflet/handout. No further speech and language therapy intervention planned. The child is discharged, with the option to re-refer should further concerns arise.
Figure 3 Criteria for offering therapy Childs speech The childs speech skills for their age; type and severity of impairment; whether delayed or disordered; rate of progress over time; ability to imitate sounds; phonological awareness. Support and commitment General development Anxiety Intelligibility From parents or other key worker to attend therapy and carry out activities or advice. Motivation of the child, in the case of older children. How the childs speech compares with other aspects of their development (cognitive, linguistic, general maturity, academic progress), and how the speech problem impacts on these areas. The extent of concern and anxiety expressed by the parent/teacher regarding the problem, and any anxiety or self consciousness on the part of the child. How intelligible the childs speech is in context, and levels of frustration experienced by the child or the listener.
Caseload pressures Numbers on the caseload; schedules for group therapy sessions. Environmental factors Extent of playgroup attendance; date for school entry; number of siblings.
clients other abilities, needs, background, and carers and their attitudes (RCSLT, 1996, p.272). In community clinics, decisions regarding prioritisation following an initial assessment include: Does the child need therapy? Will it be enough to give advice and review progress in time? Is discharge appropriate already? Through peer observation and discussion it appeared that, in some cases, decision making on these issues varied between therapists and between clinics. The team response to these observations was to examine whether this was really the case. If so, then perhaps we had something to learn from each other by comparing and dis-
At the heart of our work should be an objectivity that results in a first class equitable service
cussing our practices and guiding principles. Through this audit process we sought to come to some agreement that would assure us of provision that was consistent, appropriate and fair. Our aim was to examine current practice for a client group with specific difficulties, with a view to devising a pathway protocol. We decided to look at the level of consistency across therapists in the way we make decisions about initial management of children with phonological delay. We focused on this client group because of the high prevalence in community clinics, and because typical cases could be summarised more concisely than for some other types of disorder.
Six descriptions of cases as they might present at initial assessment were drawn up (figure 1). These vignettes were all imaginary, and designed to give a spread of ages and range of sound system problems. There were also a variety of external factors that needed to be considered. Each therapist in the team was interviewed by another member of the team. The case descriptions were given in random order, and two questions asked about each: 1. What would be your management of this child? 2. What would be your criteria for offering therapy to this child? Both questions were open, without predetermined options to choose from. Question 1 (What would be your management of this child?) elicited a range of responses which, when analysed retrospectively, fell into four categories (figure 2).
;;; ;;;
4;0 Only child with both parents working Attends nursery full-time. Child is conscious m. Parents feel its not their problem. ilestones and appropriate language skills. velars. Stopping fricatives.
5: Male 6;0 Referred by anxious schoolteacher. Poor spelling skills and emergent writing doesnt show phoneme-grapheme correspondences. Unable to say l, r, .
;;; ;;;
;;; ;;; ;; ;;; ;; ;;;

Advice & review Discharge Regular therapy
6: Male 6;0 Referred by small village school who are very concerned and would like to know how to help. Previously discharged for non-attendance aged 3 years and again at reception age. History of hearing problems now resolved. At stage 3 of Code of Practice. Moderate problem affecting social and emotional well-being and academic progress. Language skills delayed. Stopping s and (has f). Reducing clusters.
KEY
Programme & review
17
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Figure 4 Proportion of times each therapy criterion mentioned
25 20 15 10 5 0
The charts in figure 1 show the type of management strategies chosen by therapists for each case. All therapists chose to review in at least some of the cases. This was a frequent choice, with a 68 per cent preference overall for review with advice/programme, showing some consistency between therapists. For three of the six cases, however, the range of responses also included the apparently opposite strategies of discharge and regular therapy, illustrating the degree of disparity which we sought to explore and address. Question 2 (What are your criteria for offering therapy to this child?) shed light on the reasons behind the responses given to the first question. Therapists mentioned a whole range of factors that they take into account when deciding whether to give
; ;; ;; ; ;;;;; ; ;;;; ;;; ;

Figure 5 Therapists criteria for therapy
;; ;;;; ;;;; ;; ;; ;; ;; ;; ; ;; ; ;; ;;;; ;; ;; ;;;; ;; ;; ;; ;;;; ;; ;; ;; ;; ;; ; ; ; ; ;; ;; ; ; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;; ;;; ;;; ;; ;; ;;;

;; ;; ;; ;;;
;; ;; ;;
;; ; ;;; ;; ;; ;; ;;; ;; ;;; ;; ;;; ;;
; ;; ; ;
;; ;;
;;
To solve this, we selected a single chart that seemed to be the best summary of a number of studies (Grunwell, 1981), and circulated this among therapists
therapy. When analysed retrospectively, they broadly fell into seven categories which are listed and exemplified in figure 3, p.17. We counted the frequency with which each of these factors was mentioned by therapists in the questionnaire (figure 4). Features relating to the childs speech patterns and age were mentioned most frequently, but the graph shows how a spread of other factors was also acknowledged. The spread of factors was not acknowledged with equal weighting by all therapists. Figure 5 shows the way in which individual therapists in response to Question 2 emphasised different factors, relative to their colleagues. Therapists are randomly numbered 1-14 on the chart. While 0 per cent indicates the average for the group, bars above the line show factors that were mentioned more than average by an individual and bars below the line indicate factors that were mentioned less than average by that individual. The chart illustrates the degree of variation of all individuals from the mean.
Results promoted discussion and debate amongst the team about the role that each of these factors had to play in making clinical judgements. At the end of the discussion, we made decisions about what needed to happen to standardise and improve our practice (figure 6, p.20). The six vignettes were imaginary and the descriptions brief. It is possible that, in real life cases, decisions and the criteria behind them would differ. Some therapists said they found it difficult to answer the questions without further information available. Other factors are also recognised as influential such as a therapists personal level of experience, confidence, stress or areas of specialist interest. Our findings nevertheless formed a useful starting point. From these discussions and decisions we were able to design a protocol which will be tested during the next few months. This is for use with children with phonological delay or disorder and takes the form of a flowchart (figure 7). From information gained at the initial interview, the therapist will follow the flowchart through to a decision regarding management of the case: direct or indirect intervention, or discharge. Our
18
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Figure 7 Phonology flowchart
19
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Figure 6 Discussion and decisions

Our discussion Age norms The most significant factor in determining clinical management was, predictably, the childs speech. Therapists were looking at the phonological processes relative to the childs age. One reason for variability between us, however, was discrepancy in what was expected at a particular age. Research into published norms revealed differing findings depending on the methods of data collection and analysis. Delay/disorder All the example children in our questionnaire were showing error patterns that were delayed rather than disordered (or deviant). Such a way of differentiating error patterns has been found to be of diagnostic value (Dodd, 1995). Some therapists look carefully at this distinction, and prioritise children whose speech contains non-developmental processes. In many cases, children with delayed speech can be seen to make spontaneous progress with maturity. There was some debate as to whether it is worth giving therapy as a catalyst, or whether these children can progress in time without intervention. Literacy Case 5 introduced the question of whether literacy difficulties fall within our domain. Over that case there was greatest inconsistency, perhaps because of the mention of the boys literacy difficulties. Recent literature has highlighted links between speech and literacy difficulties (Stackhouse & Wells, 1999), and it is clear that speech and language therapists have a potential role here. The extent of speech and language therapists involvement in literacy problems is a matter of debate (Wren, 2000). Issue of support Some therapists prioritised treatment for those children who were highly motivated, or who had a supportive adult, such as a parent or school support assistant, to carry out activities and back up the work in the clinic. They argued that best use is made of therapy time in these cases where consolidation is available outside the clinic. Others felt that in the absence of this type of support, the therapists role was perhaps even more significant in effecting any change for the child. Parental anxiety Some therapists treated the parents, childs or teachers anxiety as part of the problem, and included this as a reason to give therapy. Others referred only to more objective measures. Some therapists felt more confident than others in offering reassurance and reducing anxiety. Our decision To solve this, we selected a single chart that seemed to be the best summary of a number of studies (Grunwell, 1981), and circulated this among therapists as a common reference point. We also represented the same data in an accessible form as a handout resource for parents.
We agreed to direct our treatment towards children with disordered phonology. Our protocol would recommend discharging children whose speech is delayed. Exceptions to this were children with poor intelligibility, or cases where there was anxiety about the problem on the part of the child or parent.
In order to manage effectively the large number of children seen in clinics with oral speech difficulties, our team agreed to exclude from treatment those children whose problems were affecting written skills in the context of resolved oral difficulties. (This could change should specific money become available for such a development.)
We agreed that the issue of support should be a factor not in the decision of whether the child receives therapy, but in how the therapy, if needed, is delivered. A clinic session including demonstration and provision of activities for consolidation at home or school is seen as an effective way of working in many cases. A block of direct therapy sessions remains an option, however, where indirect practice is not possible or available. Indicators of a severe problem include disordered phonology, poor speech in comparison with other abilities, and poor intelligibility. If, however, there is anxiety on the part of the carer and/or the child that appears symptomatic of the speech problem, then it is appropriate to offer a short course of therapy, even in the absence of these indicators. This is seen as worthwhile, to provide reassurance and prevent any secondary communication difficulties developing.
new protocol takes into account all the criteria outlined in our results with the exception of caseload pressures. We excluded this because, when looking at the process of clinical judgement, we felt this issue should be a subordinate one, and dealt with separately. Staff have therefore been advised to have waiting lists. We are in the process of piloting the new phonology care pathway in our clinics, and look
level of service, with more either being discharged or receiving therapy and fewer being kept under review. Less intervention will be provided for those children who are likely to make spontaneous progress, and more therapy time will be made available for those with significant problems such as speech disorder and poor intelligibility. We have collated all therapeutic materials in our clinic and have classified them into packages
by the demands and pressures of the situation. And, once caseload pressures are analysed and balanced, equity of service will be achievable. Rosalind Owen, Heather de la Croix, Jennifer Lewin, Elma Lawer and Stella Davies are speech and language therapists with Wiltshire & Swindon Health Care NHS Trust, W.Wiltshire and N. Wiltshire and Devizes PCG.
References
Reflections
Do we work as a team to provide some standardisation of clinical decisions? Do we have the best combination of responsiveness and evidence-based practice? Do we need initially to remove caseload pressures as a variable when agreeing on priorities?
forward to sharing our findings at the Royal College of Speech & Language Therapists Conference Sharing Communication in April 2001. We hope it will make a difference to our management of children with speech difficulties. Firstly, children will receive a more appropriate of care available to all therapists, so there will be equity throughout North Wilts & Devizes and West Wilts PCG. Secondly, clinical judgements will be made with more confidence and consistency. Therapists will remain sensitive to individuals needs and attitudes without being unduly swayed
Department of Health (1998) A First Class Service, Quality in the New NHS. Consultation document. Dodd, B. (1995) Differential diagnosis & treatment of children with speech disorder. Whurr: London. Grunwell, P. (1981) The development of phonology. First language iii 161-191. Royal College of Speech and Language Therapists (1996) Communicating Quality 2: Professional standards for speech and language therapists Stackhouse, J. & Wells, B. (1997) Childrens speech and literacy difficulties: A psycholinguistic framework. Whurr: London. Wren, Y. (2000) Spelling it out: Should speech and language therapists be involved in working with children with literary impairment? RCSLT Bulletin 577 (May) 8-9.
20
news
Collaboration is essential
Parents of children with speech and language needs are most satisfied with provision when they perceive health and education agencies to be collaborating effectively, according to a research report. The study aimed to provide an overview of the nature and extent of speech and language therapy provision across England and Wales and to identify factors which promote effective provision of education and health services in this area. The researchers warn that parents, teachers, teaching assistants and therapists may approach the needs of children from a radically different perspective. And that these understandings are rarely explicit. The five key recommendations for improvement focus on developments at a service level and through funding, training and research. The authors say that more is generally known about collaboration at a practitioner level than at a managerial one. For example, professionals should have a clear understanding of their respective roles; therapists should take account of the educational context; teachers should understand the importance of language to the whole curriculum; school systems should support the involvement of therapists. Other discussions are around appropriate speech and language therapy caseloads, methods of service delivery for rural communities, and areas of unmet need - namely provision for children in secondary schools, those with emotional and behavioural difficulties and those for whom English is an additional language. Provision for children with speech and language needs in England and Wales: Facilitating communication between education and health services by Law, Lindsay, Peacey, Gascoigne, Soloff, Radford, Band and Fitzgerald, ISBN 1 84185 398 4. Research Brief RB239, www.dfee.gov.uk/research, tel. 0845 6022260 Full report RR239 4.95 from DfEE Publications, PO Box 5050, Sherwood Park, Annesley, Nottingham NG15 0DJ.
Programme to match needs in AD/HD

Guidelines for professionals working with AD/HD aim to help the wide variety of professionals involved provide a multi-modal response to a multi-dimensional problem. The report, produced by a British Psychological Society working party, suggests that professionals should look at behavioural management and educational practice in the first instance, rather than trying to change the child, and that a clear programme should be developed to match the precise nature of the needs identified. Attention Deficit/Hyperactivity Disorder (AD/HD): Guidelines and principles for successful multiagency working, 10 from The British Psychological Society, tel. 0116 254 9568.
Computing and disability together

The leading provider of expertise on computing and disability is opening a new regional centre in London. AbilityNet helps individuals with disabilities of all types to use a computer, at work, in education or at home. This eighth centre is to be based at one of BTs key operational buildings, the Angel Centre in Islington, and will be funded by them over the next three years. www.abilitynet.co.uk Freephone helpline, tel. 0800 269545.
Complaint system fails to please

The NHS complaints system has been condemned as failing older people. An Age Concern report quotes older people in their own words on how they have battled against secrecy, intransigence, incompetence and time-wasting which can last for three years or more - and in many cases still do not get satisfactory answers or outcomes. A specific example is of a stroke ward where The patients were treated discourteously and without respect. Many were in tears. The complainer says a social worker had listened to complaints but patients were too intimidated to let her do anything about it, and continues, She made her family promise never to allow her to enter the ward if she had a stroke. The charity has eight recommendations for reforming the complaints system: 1.Listen and act promptly on patients concerns, including showing evidence of change following a complaint. 2.Improve communication with patients - taking their views into account, addressing concerns as they arise, and apologising when things go wrong. 3.Provide information relevant to a patients case, promptly and with less resistance. 4.Adopt a more open approach to complaints, ending the closing of ranks which some patients encounter. 5.Reassure patients, through their policies and practice on complaints, that there will be no recriminations. 6.Keep the person informed over progress made as a result of their complaint, making this information more publicly available. 7.Show particular sensitivity when dealing with complaints about the care and treatment of those at the end of their lives. 8.Ensure there is an accessible and independent service to provide advice and advocacy if it is needed.
Black Sheep Press on the move

Black Sheep Press has moved to 67 Middleton, Cowling, Keighley, West Yorkshire, BD22 0DQ, tel. 01535 631 346, e-mail alan@blacksheeppress.co.uk. To buy Black Sheep Press resources online, go to www.blacksheep-epress.com.
Votes for all

Pilots of a wireless interactive voting system designed specifically for educational purposes have seen previously passive students become active participants. ACTIVote works via a two-way radio communication between the voting units and the ACTIVboard, an interactive whiteboard. Peter Lambert, product manager at Promethean which developed the technology, says, The system allows you to gauge the comprehension of specific lessons and tutorials, instantly identifying areas of concern or difficulty within the class thus enabling the teacher to focus and act accordingly. The system can be used for 100 per cent participation in opinion gathering, quizzes and testing. www.promethean.co.uk
Speaking out - Older people and complaints against the NHS, from Age Concern, tel. 020 8765 7200, www.ace.org.uk.
MY TOP RESOURCES
References from My Top Resources on back page: (1) See www.aptcentral.org (website of the Association for Psychological Type) for more information. (2) Enderby, P. & Emerson, J. (1995) Does Speech and Language Therapy Work? Whurr. ISBN 1897635389, 24.50 (3) Royal College of Speech & Language Therapists (1996) Communicating Quality 2 (4) An example is STEP in the BMJ: see www.bmj.com for Glogowska, M., Roulstone, S., Enderby, P. & Peters, T. (2000) Randomised controlled trial of community based speech and language therapy in preschool children. BMJ. 321;923; the website also includes electronic correspondence about the article. (5) Mays, N. & Pope, C. (1997) Speech and Language Therapy Services and Management in the Internal Market. Kings Fund. ISBN 1 857 17 159 4, 7.99 (6) Department of Health (1997) Providing therapists expertise in the new NHS; Developing a strategic framework for good patient care. Practices Made Perfect. Details on www.doh.gov.uk/publications - see POINT (publications on the internet) and COIN (circulars on the internet).
21
in my experience
In her role as Chief
Executive of a Hospice,
Joan Munro draws heavily on her professional background, and continues
to promote speech and
language therapy from this wider platform. She is
proof that speech and language therapists have transferable skills and
shouldnt be afraid to capitalise on them.

Read this if you are looking for a fresh challenge interested in quality of life - and death wondering what the point of it all is...
You only live once

S
peech and language therapy abandoned? Wasted years of training and experience gained in the profession?..Apart from a few years of time out to have my children (no maternity leave encouraged over 30 years ago), I worked in the NHS as a speech and language therapist from 1966 until 1999. My title and grade changed a few times on the way as did my responsibilities and my last post in the NHS was as Head of Professions Allied to Medicine. Until 1999 I still had a clinical caseload, albeit very small by then. Since September 1999 I have been Chief Executive of Highland Hospice. I never forget my roots and continue to promote the profession which provided me with the skills and experience to do my current job from a wider platform. But speech and language training is not just for the one job - we do have transferable skills and we should use and build on them. Skills gained in my various posts in the NHS have been invaluable in supporting the management of the multi-disciplinary clinical, fund-raising, finance, personnel and volunteer teams for Highland Hospice. This independent voluntary organisation receives only 27 per cent of its annual running costs from the NHS, the rest coming from charitable sources and the local community.
Everyone
suffering from an incurable progressive receive
illness should
palliative care.
Joan Munro pictured with some of the main characters of the BBC drama, Monarch of the Glen: Dawn Steele (Lexie), Alistair MacKenzie (Archie) and Richard Briers (Hector), who took time out from filming the new series to attend the Monarch of the Glen Ball, a Highland Hospice fundraising event.
Fund-raising is thus very important for our survival as an organisation, as is good financial management. I have overall responsibly for both as well as for the care provided for our patients and their families and friends. Our running costs are currently just over 1.6 million per year. The NHS gave me experience of managing a larger budget, but I was always supported by a big finance department. Cash releasing savings were an annual challenge, but fund-raising to keep the show on the road is completely new to me. We have a beautiful building which originated as the Royal Northern Infirmarys Medical Superintendents House (a listed building by the banks of the river Ness in Inverness), and has been added to on two occasions providing us with a 10 bedded in-patient unit, a day Hospice with up to 12 places a day and an education suite with a 50 seated lecture theatre plus tutorial/meeting rooms and a library. I have overall responsibility for the running and maintenance of the building also, but nothing in my training or experience as a speech and language therapist prepared me for the management of air handling units, complex boiler systems, security alarms and maintenance contracts!
22
in my experience
It can help at all stages of the

Thirty thousand pounds per year of our income comes from profits from our eight charity shops located in towns throughout the 10,000 square miles of the Highlands. There is a large store in one of the Inverness industrial estates where black bags are emptied and the contents sorted and prepared for sale in our shops. Special events, raffles, door-to door collections, charitable grants, in memorial donations and bequests form the bulk of the rest of our funding each year. We have a huge band of volunteers registered with the Hospice, 200 of whom work within the main complex and 300 or so in the community, either in the shops or fund-raising. Each volunteer is interviewed, trained and managed as appropriate for their chosen role.
illness, from diagnosis
stages of the illness, from diagnosis onwards, while treatment is in progress, and at the end of life.
onwards, while treatment is in the end of life. progress, and at
Enabling
Hospice care is aimed at enabling individuals to remain as independent as possible, replacing only what they are unable to carry out for themselves. Support for the patients family and friends is of paramount importance and the patient, family and friends receive encouragement to take an active part in setting and achieving realistic goals. So how - specifically - has my speech and language therapy training been of help in this new, sometimes awesome, responsibility I have? I recall speaking at a speech and language therapy student conference in Birmingham some six or so years ago, listing the qualities required of speech and language therapists, and the skills that we develop over the years. 1. Being an expert juggler was one. That is certainly a necessary attribute for my current job. 2. Effective communication is as fundamental to hospice care as it is in speech and language therapy, and is aimed at developing relationships based upon mutual understanding and trust. 3. Hospice care initiates and encourages a multiprofessional and holistic approach in order to meet physical, psychological, spiritual and social needs. As a profession, speech and language therapists are well practised in multi-disciplinary and multi-agency working. 4. Speech and language therapists have long recognised the role family, carers and volunteers have in supporting patients. My past experience has stood me in good stead for working with the army of volunteers who assist in direct, as well as indirect, patient care. 5. As specialists in palliative care in the Hospice, our clinical staff - doctors, nurses and professionals allied to medicine - have a responsibility to maintain and continuously update their own professional knowledge and to act as a resource of skill and expertise to colleagues and other health care workers to encourage a wider understanding of the principles of palliative and hospice care. Our current focus is our out reach service which must be through the education of others - health care professionals as well as carers and volunteers in the areas outside Inverness throughout 10,000 square miles. Speech and language therapists have long recognised the importance of continuing professional development and developing others knowledge through education and training. In the Highlands, the complexities of rurality have always been present.
6. As our work in speech and language therapy is little understood in the wider world, so is the work of specialists in palliative medicine/care. Both are comparatively young professions. Thus public relations is important and my own role as an ambassador for speech and language therapy in the Highlands has helped me in promoting the care the Hospice provides. I also recall one grim Christmas and New year when I was the sole speech and language therapist working in the hospital in Inverness. The only in-patients requiring speech and language therapy had cancer or motor neurone disease and were too unwell to be at home. It was difficult coming home to family celebrations of Christmas and New Year. It is hard for us all at times in the Hospice, but there is good mutual s u p p o r t . .
Satisfaction
Reflections
Special
Our permanent staff number about 70. The majority are based in the Hospice in Inverness but we now fund two palliative care nurses who work in the community in Caithness and Sutherland, the two most northerly counties of Highland. There is also a bank of nurses and nursing assistants. We use the bank frequently to supplement our permanent staff who may be called on to provide a rapid response service to patients in their own homes; currently, this service operates within a 25 mile radius of Inverness. Four shop managers are based outwith the Hospice building. All who work for the Hospice are very special - it is tough, emotionally. One in three people in Scotland will develop cancer. One in four people in Scotland will die from cancer. Two people in every three with cancer will experience severe symptoms such as pain in their last year of life. Six hundred people in Highland die per year of cancer. Despite improvements in treatment, survival prospects for the more common cancers remain poor. Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Everyone suffering from an incurable progressive illness should receive palliative care. Palliative care has been developed mainly for people with cancer but can also help those with, for example, advanced heart failure, AIDS, motor neurone disease and Parkinsons disease. People of all ages can benefit from palliative care. It can help at all
There is great
satisfaction when discharged home of symptom
some patients are
following a period management, to period of quality living.
enjoy an extended
However, not all is Do I get gloom. There is a lot of sufficiently laughter as well as tears. involved in the We have weddings as well as funerals in our work of my Hospice. There is great professional satisfaction when some patients are discharged body? home following a peri Do I realise I od of symptom managemay have a role ment, to enjoy an extended period of in palliative quality living. There is care? also satisfaction when a patient has a peaceful, Do I try to pain-free death. I speak understand the at many meetings and bigger picture? address small as well as large audiences. We enjoy ourselves at fundraising events; I am grateful for the experiences I had meeting the famous during my time as Chair of Council of the Royal College of Speech & Language Therapists. So, speech and language therapy abandoned? Never! Wasted years of training and experience gained in the profession? Certainly not. My advice to readers is to store up all your experiences and try to develop as many of your skills as you can - our profession allows us the opportunity to travel many avenues in the course of our work, and you never know what is just around the corner. Get involved in the business of the Royal College; join your local group, volunteer to be a member of your regional or special interest group committee, and then consider standing for the RCSLT Council. It is all hard work, but rewarding - and fun! Speech & language therapist Joan Munro is Chief Executive of Highland Hospice. In 1993/4 she was Chair of Council for the Royal College of Speech & Language Therapists.
23
further reading
further reading further reading further reading further reading further
This regular feature aims to provide information about articles in other journals which may be of interest to readers. The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire YO7 4PP, tel. 01765 640283, fax 01765 640556. Annual rates are Disks (for Windows 95): Institution 90 Individual 60 Printed version: Institution 60 Individual 45. Cheques are payable to Biomedical Research Indexing.
further reading...
HEARING IMPAIRMENT
Moeller, M.P. (2000) Early intervention and language development in children who are deaf and hard of hearing. Pediatrics 106 (3) E43. OBJECTIVE: The primary purpose of this study was to examine the relationship between age of enrolment in intervention and language outcomes at 5 years of age in a group of deaf and hard-of-hearing children. METHOD: Vocabulary skills at 5 years of age were examined in a group of 112 children with hearing loss who were enrolled at various ages in a comprehensive intervention program. Verbal reasoning skills were explored in a subgroup of 80 of these children. Participants were evaluated using the Peabody Picture Vocabulary Test and a criterion-referenced measure, the Preschool Language Assessment Instrument, administered individually by professionals skilled in assessing children with hearing loss. A rating scale was developed to characterise the level of family involvement in the intervention program for children in the study. RESULTS: A statistically significant negative correlation was found between age of enrolment and language outcomes at 5 years of age. Children who were enrolled earliest (eg. by 11 months of age) demonstrated significantly better vocabulary and verbal reasoning skills at 5 years of age than did later-enrolled children. Regardless of degree of hearing loss, early-enrolled children achieved scores on these measures that approximated those of their hearing peers. In an attempt to understand the relationships among performance and factors, such as age of enrolment, family involvement, degree of hearing loss, and nonverbal intelligence, multiple regression models were applied to the data. The analyses revealed that only 2 of these factors explained a significant amount of the variance in language scores obtained at 5 years of age: family involvement and age of enrolment. Surprisingly, family involvement explained the most variance after controlling for the influence of the other factors (r =.615; F change = 58.70), underscoring the importance of this variable. Age of enrolment also contributed significantly to explained variance after accounting for the other variables in the regression (r = -.452; F change = 19.24). Importantly, there were interactions between the factors of family involvement and age of enrolment that influenced outcomes. Early enrolment was of benefit to children across all levels of family involvement. However, the most successful children in this study were those with high levels of family involvement who were enrolled early in intervention services. Late-identified children whose families were described as limited or average in involvement scored >2 standard deviations below their hearing peers at 5 years of age. Even in the best of circumstances (eg, early enrolment paired with high levels of family involvement), the children in this study scored within the low average range in abstract verbal reasoning compared with hearing peers, reflecting qualitative language differences in these groups of children. CONCLUSIONS: Consistent with the findings of Yoshinaga-Itano et al, significantly better language scores were associated with early enrolment in intervention. High levels of family involvement correlated with positive language outcomes, and, conversely, limited family involvement was associated with significant child language delays at 5 years of age, especially when enrolment in intervention was late. The results suggest that success is achieved when early identification is paired with early interventions that actively involve families.
CHILD LANGUAGE
Trauner, D., Wulfeck, B., Tallal, P., Hesselink, J. (2000) Neurological and MRI profiles of children with developmental language impairment. Dev Med Child Neurol 42 (7) 470-5. Children with developmental language impairment (LI) are defined partly by the absence of other identifiable neurological diagnoses. Such children are generally considered to be neurologically normal, but no systematic studies of neurological function have been reported. We obtained detailed medical histories and conducted neurological examinations for 72 children aged 5 to 14 years with LI and 82 typically developing age-matched control children. All the children took a standardised test of language, and those who were at least 8 years old and were willing to have brain MRI scans (35 children with LI and 27 control children) had scans. Analysis of developmental milestones from the medical histories revealed that children with LI were not only significantly later in speaking, but also mildly but significantly delayed in motor milestones, particularly walking. On neurological examination, abnormalities were found in 70% of the children with LI and only 22% of the control children. The most common abnormalities in the LI group included obligatory synkinesis, fine motor impairments, and hyperreflexia. The children with LI with the most abnormal neurological findings had the lowest language scores. Finally, 12 of 35 children with LI had abnormalities on their MRI scan, while none of the 27 control children had abnormal scans. Abnormal findings included ventricular enlargement (in five), central volume loss (in three), and white matter abnormalities (in four). These findings suggest that developmental LI is not an isolated finding but is indicative of more widespread nervous system dysfunction. Children with LI may need more comprehensive intervention programs than language therapy alone, depending on their other areas of dysfunction. Early identification of such problems may allow for more successful remediation.
DYSPHAGIA
Okada, S., Ouchi, Y., Teramoto, S. (2000) Nasal continuous positive airway pressure and weight loss improve swallowing reflex in patients with obstructive sleep apnea syndrome. Respiration 67 (4) 464-6. The swallowing reflex is impaired in patients with obstructive sleep apnea syndrome (OSAS). Two cases of OSAS are presented in whom the impaired swallowing reflex before the start of treatment was improved by nasal continuous positive airway pressure (NCPAP). The improvement remained improved 1 year after NCPAP indicating that impaired swallowing reflex may be reversible by OSAS treatment. Improved swallowing reflex by NCPAP treatment of OSAS has not been reported previously.
MULTIPLE SCLEROSIS
Friend, K.B., Rabin, B.M., Groninger, L., Deluty, R.H., Bever, C., Grattan, L. (1999) Language functions in patients with multiple sclerosis. Clin Neuropsychol 13 (1) 78-94. Few studies have demonstrated language impairment in patients with multiple sclerosis (MS) compared to healthy controls. The purpose of this investigation was to examine language functions, specifically naming, comprehension, and verbal fluency, in patients with MS and healthy controls to (1) determine if patients with MS demonstrate language impairment, and (2) provide clarification of MS-related language disturbance, particularly in patients with MS of differing courses. Results showed that both chronic-progressive and relapsing-remitting patients with MS performed significantly more poorly than controls on naming, aural comprehension, letter fluency, and category fluency, as well as other language-based cognitive measures. Chronic-progressive patients obtained significantly lower scores than relapsing-remitting patients on the latter three tests. The language disturbance in this MS sample may be partly explained by impairment in other verbal cognitive functions. These findings highlight the importance of assessing language abilities in patients with MS.
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Read this if you are: planning any groups keen to empower clients interested in extending your role
Sue Doncaster is a speech and language therapist with Community Health Sheffield and the Adult Learning Disabilities Team. The group she describes was run jointly with Kath Brooke, a Sheffield speech and language therapist working in paediatric special needs who is on secondment with the adult learning disability team.
manage adults with
mild-moderate
learning disabilities
All speech and language therapy services have caseload pressures - and the adult learning disability field is no exception. Arguably, those at the milder end have the greatest potential to benefit, yet the way prioritisation works often means they dont receive any speech and language therapy input. It is widely accepted that a multidisciplinary, environmental approach which reduces barriers should have the biggest impact, but does this take sufficient account of individual need? For adults with mild-moderate learning disabilities, there are many issues around employment, relationships, bereavement and accessing services which our three contributors are working to address.
Alison Matthews is a specialist speech and language therapist within the Oldham Learning Disability Service.
Mary Newman is a Chief speech and language therapist with Leicestershire & Rutland Healthcare NHS Trust and is working towards a Diploma in Counselling. She would be interested in hearing from others who have experience of counselling within speech and language therapy, particularly with adults with learning disabilities.
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how I
A
practice
Grouping adults with mild/moderate learning disability to work on social communication skills is not a straightforward process, as Sue Doncaster and Kath Brooke discovered. They argue that, before a client is considered for a group, a full profile including formal linguistic and pragmatic assessment is essential.
Group
fter discussion with speech and language therapy colleagues in the learning disability team, it became apparent that we all had several clients with mild/moderate learning disabilities who had been referred with communication difficulties. They presented as being more verbally and cognitively able than the clients usually seen within the team, with no identifiable speech or language problems that required one-to-one intervention. These clients were diverse; three of them were in current employment and one had been employed but had had difficulties in the area of social interaction. Three were on the autistic spectrum. All had a degree of functional independence and, on the surface, they all had relatively good social skills. However, they all had difficulties with the social use of language. This led to a decision to run a group for developing social interaction skills. During the first session, when we outlined the general aim of the group, the members all said that they found social interaction difficult, although these difficulties varied according to the individual. Knowing the rules of language does not necessarily mean that a successful interaction is achieved (Kernan & Shabsay, 1989). The aim of the group was to improve social communication. We followed an assessment procedure to confirm suitability of individuals for the group. For a baseline measure of each clients communication skills we used the following Talkabout (Kelly, 1996) worksheets .... what am I like at it?: body language the way we talk conversation assertiveness. The group was originally planned as eight early evening sessions but owing to circumstances only six sessions were achieved. We ended up with five group members out of a potential seven. Of these, four were male and one female. Four of the five attended all or most of the sessions, while one group member was only able to make two of the sessions.
phasic clients had strict referral criteria that necessitated detailed individual assessments prior to attending the group. We had no specific referral criteria and created the group from the identified needs of clients with mild/moderate learning disability. We did not carry out detailed linguistic assessment; instead we used the Talkabout assessment to create a baseline of social interaction skills. Over the period of the group it became apparent that one client found difficulty following the instructions, role-play and discussions, and we realised we needed to have more detailed referral criteria in relation to linguistic and cognitive skills. We had not carried out formal linguistic assessment because - at an informal level - we felt these clients would cope with the demands of the group. To enable all the clients to have fully benefited from the group we needed to have individual profiles of levels of ability. In retrospect, we realise a combination of assessments covering both comprehension and expressive language skills could have been useful to achieve this end, for example TROG (Bishop, 1982) and CELF (Semel et al, 1987).
Inferences
We know that, after carrying out linguistic assessments, it will not be straightforward to create a baseline for inclusion into future groups. The clients still have a learning disability and so will display uneven performance in the assessment. However, a combination of assessments will give a clear profile that will allow us to make inferences about cognitive functioning and to choose clients who will be able to cope with the demands of this type of group. Two potential clients displayed limited motivation and we noted that motivation levels varied from one group member to another. Although everybody enjoyed the sessions, one client - despite good attendance and participation - stated that he did not need to change; it was his parents who wanted him to develop his interaction skills. However, we noted that he adapted his behaviour appropriately to accommodate the expectations of the group. (We suggest that this was due to peer pressure rather than our intervention!) The questions we are asking as a result of this experience are: Does this client group need the time allowed in an assessment group to gel together prior to working in a group with specific aims? Do we carry out formal assessment to find out if clients can cope with the group then run the therapy group? Or, do we carry out the formal assessment followed by a group to create social interaction aims before running the therapy group? Do we allow ourselves time to carry out an assessment group in order to formulate productive individual and group aims? If a client is not motivated should s/he be invited to a future group? Should we offer a place to a client who shows they are able to adapt but does not feel the need to change?
Flexible
We presented the session plans visually. The following framework was used as a basic session plan each week, although it was sufficiently flexible to change according to need: * Greetings * Setting the session aims * Recap of previous week * Main activity * Social time, including drinks and snacks * Short activity, which was a leader to the main activity the following week * Recap of session/session aims * Goodbyes. We used the various Talkabout self-assessments to help us plan the areas of social interaction to target in the sessions and they gave us an individual client profile for each of the self-assessments. We also used the relevant Talkabout pages as therapy materials. We felt that the clients benefited from the visual presentation of the sessions, self-assessments and the therapy materials, but it became clear that our group was an assessment group that had created both group and individual aims for a subsequent therapy group. The six week timescale for this group was exceedingly short. This led to us thinking about what sort of group we had run and various models for group work which target social communication/interaction. We compared our group with a couple which had been run by adult community therapists for dysphasic clients and/or their carers. We felt that this comparison was relevant because these groups also addressed social communication/interaction issues. The groups for dys-
Sue Doncaster
References
Bishop, D. (1982) Test for Reception of Grammar. Medical Research Council. Kelly, A. (1996) Talkabout: A Social Communication Skills Package. Winslow Press, Bicester, UK. Kernan, K.T. & Shabsay, S. (1989) Communication in Social Interactions: Aspects of an Ethnography of Communication of Mildly Mentally Handicapped Adults. In Beveridge, M., ContiRamsden, G. & Leudar, I. (eds.) Language and Communication in People with Learning Disabilities. Routledge, London. Semel, E., Wiig, E. & Secord, W. (1987) Clinical Evaluation of Language Fundamentals. Psychological Corporation.
Kath Brooke
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rioritisation systems invariably mean that adults with mild to moderate learning disabilities are at the end of lengthy waiting lists. Our approach in Oldham has been to focus input both into work with individuals and work with the environment. This is often a difficult process in itself and achieving a balance often seems impossible. Our approach has been to adopt a Total Communication philosophy. Our definition is: Total Communication is about communicating in any way you can. It is not just about talking its about signing, pointing to pictures, objects or photographs. It is also about using gestures or body movements. Facial expressions tell people how you feel. Writing, drawing, miming and drama and other art forms are also ways of communicating. Through communication we build relationships with other people, we let others know how we feel and what we think. Being able to communicate and knowing that you are being listened to is important. People who dont use speech can communicate, its just a matter of being more creative. Oldham Learning Disability Service Total Communication Project hopes to begin to find ways of enabling everyone to communicate and to provide ways for people to tell us if they want to be involved, how they are to be included and what they want to be included in. (Matthews & Dean, 1997) Our Total Communication project focuses resources into three main areas, each overlapping the other: 1. the service users world or communication environment (usually staff or family members) 2. the world of the service and 3. the community at large. In the 1990s, services were emphasising inclusion and in Oldham a commitment to the values of inclusion is still prevalent. However, a shift in service culture towards consultation and person centred planning has taken place. Speech and language therapists and creative arts therapists are ideally placed to facilitate consultation and to prepare the groundwork for effective person centred planning.
Aims of the workshop were to: explore the questions what is your life like now? and what would you like to change? speak out and be heard plan change make a collage and use drama. On the first day of the conference, people in the workshop made two collages, one to show what their life is like now and one to show what they would like to change. The group worked with an artist, a person centred planning worker and one of our total communication co-ordinators. Total communication co-ordinators are members of staff on secondment to the communication therapy team one and a half days a month to undertake development work. On the second day, group members worked with our two dramatherapists and the Big Issue Drama Group. The Big Issue group was set up as an advocacy group following experimentation at a previous conference with a technique known as playback theatre. Playback was developed in the mid 1970s by an American actor and psychodramatist, Jonathan Fox.
Big
issues
Respect
Playback Theatre Manchester took part in the earlier experiments with this technique. It was the first time the group had worked specifically with people with learning disabilities. They describe Playback Theatre as a form of improvisation where the stories told come from personal experiences. The storytellers are assisted by a conductor to tell their story and, in the case of the workshop, by the collages. The story is then spontaneously acted out. The storyteller is then the playwright and director of their own autobiographical drama. By sharing and dramatising parts of our own lives, by hearing each other with respect and no judgement, we affirm that everyones story is unique and worth telling. We make connections, bridging the gaps between us, and our sense of isolation diminishes, while our sense of ourselves both as individuals and as members of a wider group increases. This is why Playback is sometimes referred to as Therapeutic Theatre. Dramatherapist Jayne Liddy has worked with her colleague Julie Williams to develop this technique in combination with a total communication approach. During this process the drama group brought the collages to life, each person having the chance to see their own story and to comment on the changes they imagined on the final day. The common themes from the collages were then brought together; these included: getting an education pets getting your own house music and hobbies choosing what you want to eat making decisions about your future going on holiday transport romance and having a relationship being responsible for your own money. The biggest issue of all seemed to be that people did not feel they were being listened to. In an attempt to address this, service managers were asked to a final presentation incorporating art work, sign and drama and were invited to respond. Since the workshop, People First commissioned a student from the Human Communication Course at Manchester University to produce a report summarising their work*. The report is produced in an accessible format using pictures. It is also available on tape in English, Bangla and Punjabi. An interesting aspect of the workshop was the commitment shown by People First to advocate for other service users with greater communication support needs. Part of the therapists role is therefore to encourage the use of all forms of communication in order to successfully achieve this.
The service culture in Oldham has shifted towards consultation and person centred planning. Alison Matthews explains how speech and language therapists and creative arts therapists can facilitate this.
Successful
One approach to improving the individuals environment has been to provide training for communication partners. One of the most successful ways we have found has been through a Total Communication Conference. This is a large three-day event with a variety of workshops, all exploring different forms of communication. Over the last five years we have run over 40 workshops ranging from symbols bingo, drama, signing and dance, through to samba, gardening and fashion. The conference aims to: provide positive experience of communication by involving people in workshops improve access issues across the community give people opportunities to have fun, explore their creativity and meet old and new friends promote community awareness of total communication look at how total communication is used. The initial idea to hold a conference stemmed from the desire to raise awareness about communication across the service and to increase levels of motivation to implement change. Many services are devised to provide input for those people who are at the action stage of change (Procaska & Di Clemente, 1986). The conferences provide opportunities for information to be given to people who may not actively be contemplating changing their approach to communication. For those people at the contemplating stage it provides a boost for motivation, increases their knowledge base and hopefully tips the balance towards change. In 1999, People First (an advocacy group run by people with learning disabilities) approached the communication therapy team with an idea for a workshop about advocacy. I met with them once a month to begin planning. The workshop gradually began to take shape, the group chose the title Speaking Out Making Changes, and designed their own symbol.
Alison Matthews
* Available from: People First, c/o Alison Matthews, Communication Therapy, Oldham Learning Disability Service, Broadway House, Broadway, Chadderton, Oldham, Lancs OL9 8RW.
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References
Matthews, A. & Dean, A. (1997) Total Communication - An approach. Unpublished.
Procaska, J.O. & Di Clemente, C.C., (1986) Towards a comprehensive model in change. In: Miller, W.R. & Heather, N. (Eds) Treating addictive behaviours: processes of change. Plenum, New York.
I
holistic
A
approach
How can speech and language therapists attempt to address this gap? Is counselling of adults with learning disabilities a specialism within speech and language therapy? Within counselling? Or both? I would argue that it has the potential to cross both professions; for example, it might be possible to have speech and language therapists who are also qualified counsellors to act in an advisory / consultative capacity to agencies who offer counselling to adults with learning disabilities. Speech and language therapists have an in-depth knowledge of communication disorders, and counsellors an in-depth knowledge of therapeutic theories and processes. There is much to be learned and gained from each other in addressing this issue for adults with learning disabilities. During my career as a speech and language therapist working Mary Newman with adults with learning disabilities, I have encountered many situations where awareness of counselling skills has been required and indeed necessary, including: working with parents / 1. Adults with learning disabilities have the same needs as us all. carers / families 2. Service culture should be around inclusion, consultation and person bereavement issues such centred planning. as death of a parent / 3. It is important for our clients to feel they are being listened to. family member / friend, 4. Individual clients have unique stories and should have the opportunity moving home, loss of to tell them. function 5. A balance is needed between work with a client on their own or as part of a group and approaches that target environmental change. young adults; for 6. A full client profile including formal assessment leads to more effective grouping. example, transition 7. A collaborative approach works best - with clients themselves and with issues, changing colleges, other professionals such as creative arts therapists. starting work 8. We should consider how best to develop and target our advisory work relationships to benefit more people. abuse.
Mary Newmans interest in counselling has begun to merge with her work with adults with learning disabilities. Here, she examines how this might best be done.
t is so important to take a holistic approach when working with clients. This cannot be emphasised enough. Communicative, interpersonal skills are at the core of speech and language therapy and are also at the heart of the counselling process. The nature of our profession is interpersonal - it is no longer (and, indeed, never has been) enough to only treat the disorder. For some time I have had an interest in counselling and, over the years, have attended many courses and gained several counselling qualifications. Currently, I am in my second year of a three year Diploma in Counselling, person-centred therapy. Gradually this interest has begun to merge with my work with adults with learning disabilities. How can I best use my counselling skills in my work with this client group? Inevitably, this poses many more questions and challenges! To look more closely at this question, I needed to take a retrospective view of my training and experience to date. Looking back to when I qualified as a speech and language therapist, an introduction to counselling theories and skills was taken in the final year of my degree. Is this sufficient? Is this consistent across courses? As speech and language therapy, by its very nature, is interpersonal, I feel a stronger emphasis may need to be placed on a students interpersonal abilities, alongside their academic performance. Once qualified, speech and language therapists may need to use any counselling skills gained; for example, in their work with parents/carers, terminally ill clients, clients who have undergone laryngectomies, or people with voice disorders. Issues such as loss, bereavement, illness and relationships are also experienced by and apply to adults with learning disabilities - a client group whose needs in this area would appear to have been neglected, even avoided.
There may also be emotional difficulties attached to having an increasing awareness of their disabilities. Low self-esteem may be related to experience of loss of autonomy, with others making decisions for them regarding their lives. Adults with learning disabilities may feel / experience that others are more powerful than they are, that the control of their lives is outside of themselves, creating dependency on others for many things. This is the external locus of control. Some of us may also have experienced this feeling at some point in our lives, and adults with learning disabilities have needs that are no different to those of any of us. In the second year of the Diploma in Counselling students are required to obtain and attend counselling placements. Qualification and accreditation with the British Association of Counsellors requires 450 hours of counselling practice and 250 hours of supervision over the three year course. I have recently obtained a placement with a charity organisation called DISCERN. This organisation is for counselling people with disabilities, including adults with learning disabilities. My counselling practice, experience and regular, ongoing supervision began in January 2001. DISCERN offer training to student counsellors who have a placement with them. At present, this consists of six individual training days on the following topics:- Disability Awareness; Sexuality; Learning Disabilities; Sexual Abuse; Brief and Focal Counselling (x2). Training opportunities may also include students attending British Sign Language courses.
Insight
Through my placement with DISCERN, I hope to gain experience, knowledge and insight into counselling adults with learning disabilities. I hope to combine this and integrate it all into my work, my role as a counsellor and my self. After the three year diploma, there may be the possibility of continuing to an MA in Psychotherapy. If so, an MA may offer research opportunities, the chance to consider any consistency in counselling skills training of speech and language therapy students and / or postgraduate counselling training for speech and language therapists. I hope to continue to assist DISCERN, welcoming a chance to be supportive, influential and useful in setting up and extending any plans they may have for expansion in their service with adults with learning disabilities. Also, I would like to be in a position to have the chance to extend speech and language therapy services. This could be through an advisory / consultative and supportive role to agencies offering counselling services to adults with learning disabilities.
Potential
PRACTICAL POINTS
Recommended reading
Luterman, D. (1984) Counselling the Communicatively Disordered and their Families. Little, Brown & Co, Boston / Toronto. Rollin, W.J. (1987) The Psychology of Communication Disorders in Individuals and their Families. Prentice-Hall, New Jersey. Shewell, C. & Brumfitt, S. (1994) Teaching interpersonal and counselling skills to speech and language therapy students. Bulletin. February 6-8. Royal College of Speech & Language Therapists. Syder, D. (1998) Wanting to Talk - Counselling Case Studies in Communication Disorders. Whurr Publishers Ltd, London. To find out more about DISCERN, write to them at Chadburn House, Weighbridge Rd., Littleworth, Mansefield, Notts NG18 1AH, tel / fax 01623 623732.
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E V E N T S
Talking About Dyspraxia 10 March, 2001 Glasgow Afasic Scotland in collaboration with the Dyspraxia Foundation Scotland Details: Afasic Scotland, tel. 01382 666560. Voice Care Network UK 31 August - 2 September 2001 Annual Study Meeting Winchester Speakers include Prof David Crystal, John Rubin and Lesley Mathieson. 26-27 March 2001 with July follow-up Vocal Profile Analysis With Christina Shewell UCL (London) 24-25 September and 9 October 2001 Voice: Anatomy & Physiology Meredith Bunch Ealing, London Details: Voice Care Network, 29 Southbank Road, Kenilworth, Warwicks, CV8 1LA. BS 7799 - the Current Issues as they affect the Health Sector London 3rd April, 2001 Leeds 5th April, 2001 Following and individualising the BS 7799 code of recommendations to produce a successful and sustainable security system. Implications of the Data Protection and Human Rights Acts will also be covered. Free Information Day, tel. Pauline Dowson, SGS 01388 776677. Naidex 15-17 May, 2001 NEC Birmingham, Hall 1 Events for healthcare professionals, disbled and elderly people and their carers. Co-located with Medtrade, event for home healthcare and rehabilitation equipment. www.naidex.com Speak About Aphasia Week June 4-10, 2001 Speakability, tel. 020 7261 9572. British Aphasiology Society Biennial International Conference 2001 University of Exeter, 13-15 September Details: Chris Code, e-mail C.F.S.Code@exeter.ac.uk Work in Progress Research Meeting - Ins and Outs of Phonological Processing 15th May 2001 University College London Details: Elaine Funnell, e.funnell@rhbnc.ac.uk.
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MY TOP RESOURCES
Joe Reynolds
1. Taking the long view
My strategic objectives in broad terms havent changed greatly over the last few years (getting extra resources where needed, providing increasingly high-quality service, achieving good external relations and understanding of our work), but the context around us changes all the time, and its essential to keep up or ahead. The best telescope might be made up as follows: well-informed colleagues (managers and well-networked field staff) a quality daily paper; the Health Service Journal; other education and social care journalism (and time to read them) web-pages (DoH, DfEE etc) (and time...) experience (your own or other peoples) of previous NHS reorganisations a small dose of healthy scepticism.
8. Focus
Like any human situation, speech and language therapy services and their operations are very complicated. Its essential to be on good terms with that complexity and indeterminacy. Equally, to get anything done you have to find focus points. Try these: SWOT analysis (strengths-weaknessesopportunities-threats), to review whether action is relevant and worthwhile PEST analysis (political-economic-socialtechnological pressures) to define the major action force-field analysis (what are the factors promoting change, and those promoting no-change? If the balance is against you, can you influence it?) agendas which say what the meeting or discussion is for minutes which define agreed action and say who will do it filters; for example, if I take this problem to the boss, will s/he: 1. take it away from me 2. contribute but leave it with me 3. note it for information and leave it with me 4. do nothing and prefer not to know?
5. Clinical Work
I maintain a small clinical caseload, as another way of getting out and keeping in touch. I also try to have a nodding acquaintance with clinical developments and the evidence base, particularly in fields where I dont now practise. For this, specialist colleagues, the Royal College of Speech and Language Therapists and Speech & Language Therapy in Practice and many other publications are all useful. Its also helpful to be involved in student clinical training; I learn a lot from students familiarity with more up-to-date sources, but Im also relieved to find that I still know things about clinical practice that the students havent yet learned.
2. Time
Unless you squeeze short-term issues into only part of the time, theres never a moment to take that long view. Everyone has their own preferences in time management; some of mine are: WPB file - buy a bigger waste-paper basket and use it decisively pending files (that is, WPB file if not raised within three months) to-do list, distinguishing urgent/ important long-term/pending items for which there may realistically never be time; ideally also asterisking key items related to your key overall objectives diary - especially keep-free blocks to catch up, and some floating time to deal with unplanned tasks (those from the general manager, for example). And you dont always have to tell people when a meetings been cancelled...
6. Paper
I am supported by a tireless secretariat and a justifiably notorious photocopier, and contribute my share to the bumf which lands in staff intrays. But Im an inconsistent advocate of less abundant but more effective paper: bullet points if its that type of document covering the key issues in one side of A4 (admittedly it might take longer to compose) yes/no answers to yes/no questions executive summaries avoiding repetition prose (sentences, paragraphs, subordinate clauses etc) where a problem / dilemma has to be explained, described, argued out, or to show the justification for proposed action succinct curriculum vitaes and job applications, with prose for explanatory power, but other styles where easier for the reader.
3. Numbers
Managers dont have to be highly numerate, but we have to have ways of dealing with people who are (often accountants or information managers). I try to carry around (partly in my head and partly in my briefcase): budget summary figures; staffing breakdown and allocation to different service agreements and areas; current salary scales (and a crude formula for costing out new posts on the hoof) ; activity returns summaries for broad service areas. I get lots of help from my finance manager, as long as I know my way round the reports. But I also borrow the secretariats calculator when a rounded-up figure wont do.
7. Management training
Very varied. Many specific skills covered relate to general clinical practice (listening, assessing, planning, priority-setting, running meetings) but its useful to cover some areas more particularly (in-tray management, how budgets work, performance management). Its important to have a view of your own implicit theory and style of management. One possibility is the Myers-Briggs Type Indicator. Im usually agnostic about psychometrics, but I found this a quite human and helpful tool in thinking about how I work. It can be administered only by trained and accredited people but, if you get a chance to take part in a training course involving this, I would recommend it. (1)
4. Authors and documents

We all have lists of contacts and phone numbers; but it takes time to find out who wrote what, and which people you can trust. I add constantly to my box-filed collection of documents but mainly refer to a selected few policies and procedures, including: Trust Business Plan, and Strategic Direction; Management Unit Annual Report and Business Plan; LEA SEN Funding Matrix, Criteria for Statutory Assessment, and agreed levels of speech and language therapy support; Primary Care Group plans and strategies; our own service policies and procedures briefing. I aspire to use the contacts to influence the policies and plans, and to produce papers which might develop the contacts.
is speech and language therapy manager, Leeds Community and Mental Health Trust. He says... Speech and language therapy managers spend very little time on standard codified procedures using standard instruments. However, when I sat down to consider my resources, I found a range of objects, techniques and concepts which may be interesting or provocative. Some might be relevant to everyone, but some might be of particular interest to colleagues in management roles or supporting management processes. Readers will also understand that some of the techniques described are ones I aspire to use - or to use more often - rather than purely those I may have mastered.
9. Evidence
Speech and language therapists need evidence to inform developing practice. Speech and language therapy managers need some of the same evidence, but particularly selected for the purpose of responding to the old chestnut that theres no decent evidence of the effectiveness of speech and language therapy services. For these purposes, prominently displayed copies of Does Speech and Language Therapy Work (2) and Communicating Quality (3) are often a useful starting-point; very few planners and commissioners have taken up the offer to borrow them. The debate about evidence tends also to be provoked by reports of projects in the medical or general press (4) and its important to be up-to-date with the significance of emerging findings. Wider use of IT systems will greatly affect how such projects are disseminated and debated in Trusts and areas. There is very little evidence about the specific challenges of speech and language therapy management, but I have two reports on my shelf which are sometimes useful (5) (6).
10. GSOH
We shouldnt take ourselves too seriously. Clients and management tasks in our services deserve our honest best efforts and best understanding, and we should look for actions and solutions which are reasonable and practical, though some may be simply the best that can be achieved in the circumstances. That might mean compromising between two key objectives, or compromising between my key objectives and someone elses key objectives. To avoid taking myself too seriously - and to avoid being taken for a ride by other people who take themselves too seriously - I aspire to have: a fully-functioning waffle, rhubarb, and gobbledygook detector the ability to ask Whose needs are being met by this idea/proposal/initiative? (acknowledgements to more experienced and senior colleagues for this) recognition of the times when lifes too short an occasional minute to remember the clients, who we are trying to serve.
NOTE: For references (1) - (6) please see page 21.

Speech &amp; Language Therapy in Practice, Spring 2001

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Speech & Language Therapy in Practice, Spring 2001

Speech & Language Therapy in Practice, Spring 2001