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It aint what you say, its the way that you

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if you want to create a positive communication environment share knowledge and your decision-making process break goals down into logical steps
ow many times have you come away from a productive meeting having agreed some very clear aims and ideas only to find three weeks down the line that these plans are faltering or abandoned? Or the other situation when you have been going on and on about developing looking, listening and turn taking skills - only to be greeted one morning by a teacher fresh off a course telling you enthusiastically how she will be implementing this new approach in her class. Familiar? Well it certainly brings back painful memories to me. So why were my suggestions failing to get going and yet similar suggestions, when delivered through a package, were firing peoples enthusiasm? What was I doing wrong? I believe that its all in the framework. Thats why these approaches such as the Social Use of Language Programme (Rinaldi, 1992), Intensive Interaction (Nind & Hewett, 1994) and the Picture Exchange Communication System (Frost & Bondy, 1994) have been so successful and so important in helping us to develop and establish these ideas in the places where we work. They all provide a clear framework of why, what, how and when that enables the user to understand the underlying principles and therefore effect real change within their practice. I decided therefore to apply this principle to my joint work with the teachers at Bidwell Brook Special School in our quest to create a positive communication environment throughout the school. This task, from bitter experience, can feel like trying to get the pot of gold at the end of the rainbow; depending on where you stand your perspective of the end point - and therefore the route - is very different. And, most significantly in our jobs, what do we do if the teacher goes off in a totally different direction?

How do we improve collaboration with parents and teachers of children with special needs? For Charlotte Child, the experience of conceiving and piloting Choices, Changes & Challenges is proof that its all in the framework.

Responsibility
It seems that we often voice frustration that our ideas and recommendations have not been taken on board. It could be argued that the responsibility for ensuring that a child is provided with a suitable communication environment lies with the person in charge of that environment: the teacher or the parents. How they choose to run their classroom or home is clearly their choice and ultimately their risk (Malcomess, 2001). However Kate Malcomess challenges us, through the use of Care Aims, to reflect upon our practice, to identify both the strengths and weaknesses in our intervention, and to make changes. It then becomes clear that the responsibility lies with us to get our practice right. If our aim is that a child is provided with lots of real reasons to communicate, then one of our underlying tasks, as well as direct intervention, is to ensure that we get the information over to the teachers, families or carers in a clear accessible way that enables them to understand fully: where the child is where you want to get to why you want to get there and how youre going to do it, so that they can take an active role in decision making and developing their own ideas. For us, these ideas came together in a booklet Choices, Changes & Challenges that encapsulates the way I work through the school and follows a broadly developmental hierarchy.

Charlottes daughters choose to be photographed with her!

A Bidwell Brook leaver group

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, u say it
Fundamental step
Being able to make Choices, or being perceived as able to make a choice, is the most fundamental step for a child to being viewed and treated as a communicator. Once children have begun to develop their language skills, we need to focus on extending these skills through their use, rather than on tasks that teach vocabulary. Changes provides a structure that is based on making small changes within well-known routine situations that create a communicative need. Finally Challenges focuses on a more reasoned use of communication and includes clarification and repair skills. Once the booklet was done I used it as the basis of my sessions with the families and staff. This meant that we could work from a shared text, I was able to discuss and explain the information, and we could make decisions from it. Crucially they could take the booklet home and re-read it, which helped the families in particular to remember certain strategies and helpful hints. However I am always very careful to point out that it provides a framework and not a formula (see practical examples). 1. Choices I realised very quickly in my work with families and staff that such a simple concept as offering choices was indeed far from simple in achieving, and the whole area needed to broken down into logical steps (see figure 1 for examples).
Figure 1 Examples from Choices

Practical example I: using Choices.

Paul is a 5 year old boy with Downs Syndrome. He lives with his parents David and Sue, and older brother Matthew. When I first met Paul and his parents, they described him as using a couple of signs (for more and biscuit) and some sounds and words. They felt he understood most of what they said, but didnt necessarily always choose to respond. Targets had been set to further his understanding and use of signs and words but it was becoming clear that Paul wasnt very motivated by this work and it was becoming frustrating all round. Paul, who had fleeting attention, was wandering around the television fiddling, and began to get cross and agitated, occasionally banging his hands together and using a grumpy cry. Sue explained this meant that Paul was after something, and that he was using his version of the more sign to tell her. After Paul settled we talked more about the way that he communicated and we came up with a list of behaviours and a need for his parents to both notice and interpret. Paul had never yet indicated what he specifically wanted. My overall feeling was that Paul actually had little functional use of his signs, sounds or words in order to communicate a message. The earlier behaviours I had observed had not been directed at the adults; he had simply been reacting with frustration at the television not coming on with the right programme and, although his use of the more sign was really positive, indicating that he knew the context in which to use a sign, it wasnt actually providing any real information. Take control The introduction of choice-making is a critical part of enabling a child to use whatever communication behaviours they have to begin to take control and lead an interaction. Its also easy to set up across the childs different environments, and allows people to feel that they are helping and respecting the childs own wishes. It may be the first time that people have actually experienced the child indicating a preference. David and Sue felt their experiences of offering any sort of choice to Paul hadnt worked and that he simply wasnt interested. Paul usually ignored any attempt by an adult to direct him and make suggestions. I reassured them that this was just part of where he was in his development rather than a specific problem, and that it would be a very good idea to look at choice-making again, but this time in a more structured way. I introduced the ideas about making choices using the booklet. Immediately David and Sue could see that making choices was a starting point and was based on previously published work that had been tried and tested, rather than just an off-the-cuff suggestion. We discussed how the skill of making choices develops, and ideas to try out. I left the booklet with them and they knew they could contact me before our next appointment in two weeks time. I would love to report that that was it and that on my next visit Paul was making clear choices. It wasnt, and that isnt my message. It took an enormous amount of hard work, with lengthy and challenging discussions and quite often that feeling for me of being in free fall not knowing what the outcome would be. However, what clearly helped was the use of the joint framework so that David and Sue were able to follow up the ideas, try them out and make informed choices themselves about what they felt their son needed and the kind of support they wanted from me. It helped us to get through the issues about how do you know he is making a choice if you offer two things that he quite likes? What do you do if he turns and runs off? Where do you stand? How do you hold the items? Why do you hold the items and whats this choice-making business anyway - he can help himself to most things and makes choices that way! I can happily report though that, through their hard persistence, Paul is indeed now making clear choices, reaching towards what he wants and beginning to use his sounds, signs and words at the same time.

Practical example II: using Changes to structure a classroom interaction environment

I had been running groups using the Social Use of Language Programme (Rinaldi, 1992) in a class of nine children for some time, working together with both the teacher and learning support assistant. Over time the ideas had become absorbed into the everyday activities and I had got to the point where I felt that I needed to introduce another new idea. The children were aged 6-7, all with severe learning difficulties, including two with autism using Picture Exchange Communication System (PECS) books. We started to look at how we could create spontaneous reasons for the children to communicate during the day, prompted by in part by the development of the PECS approach, and agreed that it was equally important for all the children in the class. However as I sat there with the staff suggesting the old favourites such as just a drop of paint, no pencil, things out of reach, I didnt need their bemused faces to know that such hotchpotch planning wasnt terribly practical. It also became very clear that we were viewing the whole thing rather differently; I could see all my disruptions creating motivating reasons to communicate - they could foresee behavioural meltdowns and not being ready for playtime. Quite honestly they had a point, and so this was the beginning of drawing up the framework. The process of organising exactly what I meant by Changes and trying out ways of creating them helped me to gain a lot more confidence in target setting and evaluating outcomes and I became a lot more realistic in my expectations. Having the framework meant the teaching staff could see where my ideas had stemmed from and then adapt them to their own style and needs within the class. It also enabled us to see a clear progression over the school year, identify any particularly tricky areas for individuals and essentially create a naturally communicative environment that extended beyond the snack routine and beyond the speech and language therapy slot.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004

Start with choices that your child can see If your child doesnt reach and make a choice... How will you know if your child is making a real choice?

(Child, 2004) Very often I found that people hadnt perceived their child as being able to make a choice or to communicate - so they either anticipated their preferences and needs, or their experiences of offering choices were frustrating and disheartening. A really important step for some families was recognising the judgements that they were already making about whether their child liked or disliked something - and realising that choicemaking starts with these reactions. More proactive choice-making will be whether or not they reach towards the item that you are holding in front of them and eventually, for some children, making a choice between two offered items.

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Common situations and questions that I addressed in this section included: How do I know if my child is really making a choice? What do I do if they dont react? and Clear ideas to try when things dont go to plan.

3. Challenges
In spite of the name, challenges should focus on a gentle extension of changes with a problem solving element, rather than creating significant disruption (examples in figure 3).
Figure 3 Examples from Challenges

2. Changes
For some time in schools I had been using Joint Action Routines (J.A.R.) (Coupe OKane & Goldbart, 1998), which focuses on creating changes within everyday routines that prompt communication and interaction. This had worked well but, in trying to recreate the same approach with families, I realised that I ended up structuring it so much that the suggestions were rather rigid and, if the families didnt agree with them or the suggestions didnt immediately work, they were quickly dropped or discounted. With the written structure the families were able to develop their own ideas in keeping with their belief systems and environments. It also provided the opportunity for us to evaluate jointly how things had gone and to plan the next step. Changes is organised into three areas: a. new events - includes new choices. b. errors - making mistakes. c. omissions - missing things out. I also split errors and omissions into person / action / item in order to prompt a range of different ideas when planning (see figure 2 for examples).
Figure 2 Examples from Changes

Challenges 1. Opportunities to ask for more Providing small amounts of something they want - food, paint, glue. 2. Opportunities to ask for help Not always anticipating the things your child needs help with - leave jars done up, leave a door closed, remove some thing from the place they always expect to find it. 3. Active listening targets Described by Maggie Johnson (1996) as making listening an active process so that the child takes responsibility for understanding a message - so that rather than guessing or opting out, they acknowledge the difficulty and ask for repetition, or seek clarification.

phase. Colleagues within my department are just beginning to try out the structure in their schools and clinics and I am constantly rewriting bits of the booklet as I go. So, no, it hasnt revolutionised my work or the lives of the teachers at Bidwell Brook Special school - but it feels like a really positive step forward. I am convinced that frameworks have got to be an essential part of the way we work with other people. Creating a shared knowledge base from which you can all work and plan proves that its not what you say, but how you say it. Charlotte Child (e-mail chaos@hgf.eclipse.co.uk) is a speech and language therapist with South Devon Healthcare NHS Trust.

References
Child, C. (2004) Choices, Changes & Challenges. South Devon Healthcare NHS Trust. Available on disk for 6.00, e-mail chaos@hgf.eclipse.co.uk for more information. Coupe OKane, J. & Goldbart, J. (1998) Communication Before Speech. David Fulton: London. Frost, L.A. & Bondy, A.S. (1994) The Picture Exchange Communication System. Training Manual. Pyramid Educational Consultants UK Ltd. Johnson, M. (1996) [2001] Functional Communication in the Classroom [and at home]. Contact the Commercial Office, Dept of Psychology and Speech Pathology, The Manchester Metropolitan University, Elizabeth Gaskell Site, Hathersage Rd, Manchester M13 0JA, tel. 0161 247 2535. Malcomess, K. (2001) The Reason for Care. Bulletin of the Royal College of Speech & Language Therapists. November. Nind, M. & Hewett, D. (1994) Access To Communication: Developing The Basics Of Communication With People With Severe Learning Difficulties Through Intensive Interaction. David Fulton: London. Rinaldi, W. (1992) The Social Use of Language Programme. NFER Nelson.

(Child, 2004) Again I had been working with Active Listening Targets (Johnson, 1996; 2001) in school with good results and had found them to be a natural progression from Joint Action Routines (Coupe OKane & Goldbart, 1998), further developing the students confidence in using their communication skills. There were some initial concerns that teaching the students to communicate the message I dont know would encourage them to use it to opt out. However it actually allowed them to opt in, because they were able to replace their embarrassed silence and bowed head with a question or comment that meant they continued to take part. Any real opt out was tackled separately. The outcome was a far more confident group of young people who were only too keen to correct us and became very assertive in ensuring they were understood. I also included requesting more and help in this section. I commonly found people would introduce these quite early to children but, in fact, by their abstract nature - you cant see a more or a help - they are actually quite tricky to communicate. By placing these concepts in this section it helped people to focus on the earlier, more concrete requesting skills first. Using the framework Choices, Changes & Challenges has begun to make a difference to the way we set up communication programmes in Bidwell Brook School and to the expectations we have of the children.

Changes a. New Event New Choices - a different biscuit / drink / video / game Novel Events - something weird thats worth a strange look, if not a comment: boots in the bath / sparkly wig on the dog. b. Omissions Missing out an ITEM - no spoon, no cup, an empty jug. Missing out an ACTION - put them on the swing but dont push; put on their trousers but dont pull them up. Missing out a PERSON - one person doesnt get a biscuit. c. Errors - making mistakes Incorrect ITEM - when the child asks for an apple, you give them a banana. Incorrect ACTION - when they tell you to brush dolly, you wash her. Incorrect PERSON - when they tell you its Daisys, you give it to Molly.

Acknowledgement
An enormous thank you to the staff at Bidwell Brook Special School, Dartington, who have let me try out so many new ideas on them and with the children. They have smiled (or gritted their teeth) as Ive created chaos, and even encouraged me to try again next week. Guess what guys - Ive thought of our next project already.

(Child, 2004) I gave illustrations that people could work from, but this still needed careful discussion to make sure that the families or staff took on the principle and didnt get hung up on the example. For example I would commonly hear, Oh, but Jamie wouldnt bother at all if you only put one shoe on him. I had to be ready to say, OK, the principle is that you make a mistake with an item. What could you do that would cause a response with their favourite toy?

Reflections
Do I yearn for revolution - or focus on a positive evolution? Do my plans make the why, what, how and when clear? Do I provide a framework rather than a formula?

Shared partnership
Planning around communication use has become far more of a shared partnership. Through sharing my knowledge and decision making process I am able to work far more constructively with the teachers and families. However it is important to stress that this is all still very much in a developmental

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