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ISSN 1368-2105

vlNTER oo
Competency in
head and neck
When is good enough?
Long-term care
Training with SOAP
Clinics and
Out of the
frying pan...
How I
My top resources
Music in therapy
And introducing
Winning Ways
a climbing frame
not a cage
Peter 8
The at
No scary wolf for Peter this time, but still a
story to capture the interest of young
school-aged children. Black Sheep Press is
offering copies of this narrative re-tell
assessment to THREE lucky Speech &
Language Therapy in Practice readers - FREE!
Peter and the Cat can be used with children from 5 to 9 years, pri-
marily those with language delay / disorder, but also for more
general screening. The task is not norm-referenced, but gives a
descriptive profile of the childs development of key narrative
competencies which can be linked directly to intervention goals.
For your chance to win, send your name and address to Speech &
Language Therapy in Practice - P&C offer, Alan Henson, Black
Sheep Press, 67 Middleton, Cowling, Keighley, W. Yorks BD22 0DQ
by 25th January. The winners will be notified by 1st February, and
are asked to let Black Sheep Press know what they think of the
Peter & the Cat consists of an A5 booklet illustrating the story in 9
full colour pictures, an instruction booklet and photocopiable
cards for transcription and analysis. It is available from Black
Sheep Press, see, or telephone 01535
631346 for a free catalogue.
Karen Phillips was the lucky winner of Pip the puppet in the Autumn 03
issue, courtesy of LDA. Speechmarks Basic Verbs colorcards go to Joanne
Sheldon, Margaret Purcell, Joanna Hardman, Irene Dobbin and Ms
Caulfield. Congratulations to you all!
WINTER 03 speechmag
In need of inspiration?
Doing a literature review?
Looking to update your practice?
Or simply wanting to locate an article you
read recently?
Our cumulative index facility is there to help.
The speechmag website enables you to:
View the contents pages of the last four
Search the cumulative index for abstracts of
previous articles by author name and subject
Order a copy of a back article online.
The editor has selected some previous articles you
might particularly want to look at if you liked the arti-
cles in the Winter 03 issue of Speech & Language
Therapy in Practice. If you dont have previous issues of
the magazine, check out the abstracts on this website
and take advantage of our new article ordering service.
New! Conference report
The CPLOL / RCSLT conference on evidence based prac-
tice left Frances Harris (p.20) wanting to continue to
climb; read editor Avril Nicolls report on the web.
If you liked...
Wendy Prevezer, see (176) Finlay, C.: Be brave and sing
up!, (177) Bruce, H.: A healing force, (178) Magee, W.:
Creating opportunities. All from Winter 2001, How I
use music in therapy.
Linda Armstrong & Alison Bain, look at (160) Talbot, K.
& Stinchcombe, J. (Autumn 2001) A question of taste.
Lorna Gamberini, what about (084) Robinson, F.
(Autumn 1999) Setting the standard, or (162) Harris, C.
(Autumn 2001) Ahead-and-neck of the field.
Jo Middlemiss, you might be interested in (031)
Shewell, C. (Summer 1998) The Counsellor as Travelling
Karen Heins, check out (174) Rinaldi, W. (Winter 2001)
Access all areas.
Alyson Portch, try (128) Millard, S., Cook, F. & Fry, J.
(Autumn 2000) Homebase - but not DIY.
How I augment AAC, consider (pre-dates abstracts)
Cameron, C. & Murphy, J. (Human Communication, 5
(2), 1996) Skill sharing - training in the use of low tech
communication systems, or (pre-dates abstracts) Grist,
E., Davies, A. & Bradburn, J. (Human Communication, 5
(4), 1996) High spec, low tech.
Also on the site - news about future issues, reprinted
articles from previous issues, links to other sites of
practical value and information about writing for the
magazine. Pay us a visit soon.
Remember - you can also subscribe
or renew online via a secure server!
vn TROG-
Is your TROG a bit dog-eared? Not to worry,
author Dorothy Bishop also felt it was
time for an update, and has revised and
extended the format to include:
All new items
New national UK norms
Upward age extension
More scope for qualitative
List of TROG research studies with different client groups.
The Test for Reception of Grammar - Version 2 normally retails
at 147.77 (manual, stimulus book and 25 record forms) but the
Psychological Corporation is offering a FREE copy to a lucky
reader of Speech & Language Therapy in Practice.
For your chance to win, simply write your name and address on a
postcard with the title TROG-2 Reader Offer and post to: Liz
Akers, The Psychological Corporation, 32 Jamestown Road,
London NW1 7BY.
The Test for Reception of Grammar - Version 2 is available along
with a free catalogue from The Psychological Corporation, tel.
020 7424 4512,
lnsde cover
vnter o speechmag
Reader oers
Win TROG-2 and Peter & The Cat.
News / omment
( vhen s good enough'
While there is a wealth of literature on the effects of
surgery and radiotherapy on the swallowing process,
there is relatively little about speech and language
therapy intervention and even less on the level of
expertise or experience on which that intervention
should be based.
Lorna Gamberini explores the concept of sufficient
competency when working with people with dysphagia
associated with head and neck cancer.
; lurther readng
Child language, articulation, voice, head injury,
Huntingtons disease.
8 The need or SOAP
Swallowing......on a plate
(OLoughlin & Shanley, 1996) is an
Australian dysphagia
management (training)
programme designed for use in
nursing homes so that, following
training, nursing home staff
would be able to provide basic
assessment and management
strategies for their patients.
When Linda Armstrong and
Alison Bain found out they were piloting the same
off-the-shelf package (SOAP), they were interested to
compare methods and results.
++ oaboratng or ommuncaton
Teaching assistants participated fully in the sessions by
preparing materials, observing my demonstration of
activities, then implementing the activities with the
children themselves, and taking notes on the childrens
abilities in the different tasks.
In the Collaborating for Communication project,
Karen Heins and colleagues found an efficient and
effective way of managing clients with speech and
language difficulties in mainstream schools.
+( vnnng vays seres (+)
lrom caterpar to buttery
People come to coaching because they want to make
changes in their lives. If people just want to wander
round the mulberry bush a few times, only to be
reassured that their problem really does have no
solution, then Im not the coach for them.
Life Coach Jo Middlemiss believes that every
challenge has a solution and that, ultimately, the only
person you can change is yourself.
+ Heres one l made earer...
Alison Roberts continues to generate low-cost
ideas for flexible therapy activities: Car logo
pelmanism, How I help people poster and
Cooperation tin.
+ Out o the ryng pan, nto the
The combined effect of a therapist considering the
individual childs speech and language need, who is
the main focus of intervention and the reason for
the proposed intervention should enable therapists
to decide where it is best carried out.
Alyson Portch argues that, instead of pulling out of
clinics and concentrating on schools, we should be
grilling ourselves about what combination is right
for each individual.
+, 8 Revews
Downs Syndrome, learning disabilities, working
with education, early intervention,
social communication, life skills,
multi-professional working and
word finding.
+ e-mas to the edtor
Writing for people with dementia;
raising awareness of DownsEd.
How l augment AA
The many different types of
communication book meet different
needs. In an ideal environment,
people with communication
difficulties can use not just one but as many as they
find helpful. (Sally Millar)
Janet Scott on choosing a graphic symbol system,
Sally Millar on communication books and Cheryl
Davies on AAC (alternative and augmentative
communication) service development.
Back over Ny top resources
Contrary to popular belief, even musical people need
to practise. On my early morning walks I rehearse songs
(internally, not usually out loud!) and make up or
adapt words, to the steady beat of my footsteps.
Wendy Prevezer brings her dual role of speech and
language therapist and musician to her work.
(publication date 24th November)
ISSN 1368-2105
Published by:
Avril Nicoll
33 Kinnear Square
AB30 1UL
Tel/fax 01561 377415
Design & Production:
Fiona Reid
Fiona Reid Design
Straitbraes Farm
St. Cyrus
Website design and
Nick Bowles
Webcraft UK Ltd
Manor Creative
7 & 8, Edison Road
East Sussex
BN23 6PT
Avril Nicoll RegMRCSLT
Subscriptions and advertising:
Tel / fax 01561 377415
Avril Nicoll 2003
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.
Cover picture by Paul Reid (posed by
model). See p.20
In future issues...
Evdence based practce: a
chaenge or speech and
anguage therapsts
The sound bite of the weekend goes
to Kath Williamson: Evidence based
practice should be a climbing frame
and not a cage. I want to continue to
Frances Harris dissects the
proceedings of CPLOLs 5th European
Manager is disheartened
A speech and language therapy manager is disheartened that more than nine months
of negotiation has failed to solve a Dysphasia Support Service funding crisis.
In the Autumn 03 issue, we reported on the campaign by volunteer and speech and lan-
guage therapy student Louise Walters to have cuts to the Dysphasia Support Service in
Stockport reversed. Karen Davies, head of speech and language therapy in Trafford, says
that the situation across the north west of England is far more complex than Stroke
Association volunteers have been led to believe, and that it is too simplistic to blame
Trusts. She explains, The Stroke Association told all the Trusts commissioning services in
the north west that the amount of money they were receiving was no longer sufficient
to cover the costs of running the service and maintaining the support from the Stroke
Association charity. They therefore told the Trusts that, unless they increased the budget
allocated to the Dysphasia Support Service by 10,000, their services would be cut.
Karen continues, The 10,000 that is being requested is additional money. I am in the
unusual situation of holding the budget for the Trafford Dysphasia Support Service,
which means I can track back the funding provided by our Trust - and I can assure volun-
teers it has always been increased in line with inflation. She says her concern is that it is
not at all clear what the additional money is for and, at a time when most Trusts are
struggling financially and juggling priorities, it seems reasonable to expect to influence
the way a service is delivered or, at the very least, have detailed information about how
public money is being used.
Karen believes that, while reconfiguration of Trusts and regionalisation by the Stroke
Association have contributed to the complexity of the situation, the Stroke Association
needs to show more commitment to working in partnership with the Trusts, and to rais-
ing funds by other means. She comments, If the Stroke Association had match funded
the original budget provided by my Trust we would have a Rolls Royce service. Sadly,
instead we have a reduced service, and many disheartened users and volunteers.
Team leaders
Clinical teams in England can now access a leadership programme aimed at developing
the leadership qualities of all team members to improve client care.
Participating teams will work with facilitators over a 12 month period using techniques
such as action learning, patient stories, observations of care and 360 degree feedback.
The NHS Leadership Centre also recently held a conference to look at ways of increasing
diversity at a senior level, so that skilled leaders from ethnic communities are fairly rep-
resented at all levels.
Further information: The Clinical Teams Programme, NHS Leadership Centre, tel. 0207 647
3847 or e-mail
From assumptions to hard evidence
The people behind a new national Stroke Rehabilitation Research
Centre hope their work will provide the NHS with evidence that
stroke services are worth developing.
The Stroke Association is providing funding of 500,000 to the
University of Southampton where researchers will be focusing on long-
term recovery of movement. The effects of mental rehearsal of activ-
ity and functional electrical stimulation will be examined, along with
the reasons for poor balance and frequent falls experienced by some
people following a stroke. Quality of life interviews with stroke sur-
vivors and carers will also inform therapy developments.
Head of the research Professor Ann Ashburn says, There is a kind of
accepted wisdom amongst therapists that certain things work. We
think that we can do better for our patients and get things on a much
more scientific footing. Instead of basing therapy on myths and
assumptions, we need hard evidence about what works best so that
everyone who has had a stroke can reach their full potential. She
concludes, The aim ultimately is to benefit patients directly and to
ensure we are developing sound value for money therapies.
Art Works in Mental Health
Following a period at Londons Royal College of Art, the Art Works
in Mental Health exhibition is to tour Cardiff, Manchester,
Edinburgh and Birmingham.
One hundred and twenty works were selected by a distinguished review
panel from open submission including two and three dimensional pieces
and creative writing. Organisers recognise that creative expression can
help people to tolerate mental distress and increase understanding
about how important acceptance by other people is to recovery.
On average, one in four people experiences a mental health prob-
lem in the course of a year.
Entries can be viewed on
Talking Point
The website developed as a one-
stop shop for information and sup-
port relating to children with speech,
language and communication difficul-
ties is reporting early success.
Officially launched by Sophie Wessex
on 8th September, Talking Point wel-
comes the involvement of parents and professionals in time-limited
online discussion groups. Topics have included The new school year -
sharing concerns and solutions and Enabling children with speech,
language and communication difficulties to access the curriculum. To
contribute or read the postings you need to register as a user of the
website by supplying your e-mail and a password.
Talking Point is a collaborative venture between I CAN, Afasic and
the Royal College of Speech & Language Therapists, with finance
from BT and Lloyds TSB Foundation for England and Wales.
Stroke progress criticised
Health Which? has drawn attention to the poor progress on stroke
units being made in England and Wales.
The government has set a target for all people with a stroke to be treat-
ed in stroke units by 2004. Scotland is now estimated to have between
60 and 70 per cent of the beds needed to provide people with a stroke
unit place for their entire hospital stay, and a strategy requiring patients
to be admitted to a unit within 24 hours of hospital admission. In
England and Wales only 36 per cent of stroke patients are able to spend
any time in a stroke unit. Acting Editor Sue Freeman says, The
Government must ensure that proper provision of acute stroke beds for
patients immediately following a stroke is addressed and equally it must
address the provision of rehabilitation beds for longer term recovery to
improve the UKs unenviable record in survival after a stroke.
The Consumers Association publishes Health Which? six times a
year, tel. 0845 924 5000 for details.
Following the
success of the
2 0 0 3
C h a t t e r b o x
C h a l l e n g e ,
organising chari-
ty I CAN is bringing it back bigger, better
and LOUDER in 2004.
This years event involved an estimated
75,000 preschool children learning songs,
nursery rhymes and stories. Sponsorship
from parents raised over 100,000 for
children with speech, language and com-
munication difficulties at I CANs Early
Years Centres. Encouraging nursery work-
ers, teachers and other staff who work
with young children to register for the
2004 challenge, Chief Executive Gill
Edelman says, Chatterbox Challenge is a
fun event with educational value that will
also raise awareness and vitally needed
funds to help us achieve our goals.
Chatterbox Challenge hotline, tel. 0870
350 0095, or see
box for a free fundraising ChatterPack.
On the move
The Fragile X Society is now
Rood End House
6 Stortford Road
Great Dunmow
Essex CM6 1DA
tel. 01371 875100
family phone line 01424
Lets talk about sex
Finding information and practical advice on
growing up, puberty and sex for disabled
young people is almost impossible, accord-
ing to the UK wide charity for families with
disabled children.
Contact a Family has therefore joined forces
with the Arthrogryposis Group to produce a
comprehensive, cartoon-illustrated pack
containing a series of publications offering
advice for the teenager, the parent, the
social worker and the health professional. A
pack for teachers will follow. Areas covered
include self-esteem, making and keeping
friends, personal relationships, body image,
sex and relationship education at school and
at home, and there are tips for young dis-
abled teenagers from their peers.
The pack, Growing up, sexuality and the young
disabled person, has been funded by the
Department for Education and Skills and will
be available from the end of January 2004, free
of charge to parents and professionals. The
Arthrogryposis Group is a charity supporting
families affected by multiple joint contractures.
Contact a Family freephone helpline 0808
808 3555, e-mail
news 8 comment
Onwards and upwards
Frances Harris (p.20) likes Kath Williamsons description of evidence based
practice as a climbing frame not a cage. Watching young children on a
climbing frame, you get a sense of the different ways speech and language
therapists might approach evidence based practice: some attack fearlessly
while others are wary and careful; some are methodical and purposeful, and
others imaginative and daring.
The level of supervision a child needs on a climbing frame varies according to
their age and stage and the level of difficulty of the particular frame.
Younger children need the reassuring presence of an adult who can step in if
they get into difficulties. Lorna Gamberini (p.4) is clear that part of being
competent as a therapist is knowing when we need help. Jo Middlemiss (p.14)
would agree: a winner is someone who willingly shares what they do know
and acknowledges what they dont. Life coaching can provide the support
you need to make a climb, and I hope readers will benefit from the
opportunity of working with a coach who is taking a particular interest in the
challenges of our profession.
One day a familiar climbing frame can be a pirate ship, the next a jungle -
but the structure itself remains the same. Karen Heins (p.11) has used this
principle to great effect when planning programmes for teaching assistants
to carry out. Linda Armstrong & Alison Bain (p.8) borrowed structure from a
dysphagia management programme and applied it to their different
situations - comparing and contrasting outcomes.
Our local park hasnt held the same appeal since the roundabout was closed
off - reducing choice reduces opportunities for children to get what they
need at a particular time. Alyson Portch (p.16) cautions against going down
that road in speech and language therapy, believing we need to tailor a
combination of clinic and school services to the needs of individuals.
I suspect the contributors to How I augment AAC (p.23) would do rather
well if they were asked to design a climbing frame, as the decision making
process must be similar to introducing a graphic symbol system, a
communication book or even a new service. It wouldnt surprise me if Alison
Roberts (p.15) - who surely missed her vocation as a Blue Peter presenter -
could find a cheaper way of constructing it. And who better than Wendy
Prevezer (back page) to devise a climbing song to help us on our way?
A climbing frame offers challenge, variety and social interaction. And,
however many people are on it, theres always room for more to go onwards
and upwards.
Avr Nco,
Knnear Square
ABo +Ul
o++ ;;(+
Help for self-harm
Are you aware of levels of self-harm and suicide among
adolescents, and would you know where to find help?
The British Association for Counselling and
Psychotherapy has launched a website for teachers in
secondary schools as part of World Mental Health Day
2003 which focused on emotional and behavioural dis-
orders of children and adolescents. The Association is
concerned that there has been an increase of 75 per
cent in suicide by young men in 10 years, and that
research suggests 1 in 17 adolescents may be self-harm-
ing. As mental health problems in young people are a
clear predictor of difficulties in adulthood, they have
worked with teaching unions to provide a web resource
where teachers can get more information and help.
Bookstart update
A report from Bookstart Australia discusses how
speech pathologists are working in conjunction with
librarians and child health nurses to promote reading
and book sharing with very young children, and how
it can help speech and language development.
Meanwhile, Bookstart in the UK has rolled out
Booktouch nationwide through health visitors, parents
and visual impairment teachers.
Residential development
A specialist college for disabled young people from
throughout the UK has opened a purpose-built resi-
dential development for its students.
Campbell Court at Treloar College in Hampshire has
seven new state-of-the-art studio flats to be used as part
of the Colleges Independence Training Programme.
High tech equipment in the open-plan one-bedroom
flat enables the student to self-manage home activities
such as cooking, washing, shopping and leisure.
D/deaf forum
A forum under development in Somerset aims to give
deaf and hard of hearing people a collective voice.
The D/deaf Forum will provide an opportunity for
people who have something in common to get
together and share experiences, and to identify barri-
ers and service improvements. Community Worker
Claire Crowley also points out that such a group can
provide good practice information, for example if
approached by a theatre for advice on improving their
facilities for deaf people.
Bath & Wells Diocesan Council of D/deaf People,
Phone/fax 01761 239272, minicom 01761 239273, e-
Post-grad in Asperger syndrome
Professionals working in the field of autistic spectrum
disorders now have the opportunity to study for a
post-graduate certificate in Asperger syndrome.
The result of a collaboration between the National
Autistic Society and Sheffield Hallam University, cours-
es will be held in Leicester, Leeds and Cheltenham.
Module 1 provides an introduction including social
behaviour and skills and sensory and perceptual
issues. Module 2 is a work-based independent study
unit. Speakers and advisors include Dr Tony Attwood
and Dr Simon Baron-Cohen.
Further information and application forms from The
National Autistic Society Training & Consultancy
Department, tel. 0115 911 3363 or e-mail
ollowing the Calman-Hine Reports
standards for patient-centred deliv-
ery of cancer services (1994), we have
seen a shift in organisation and deliv-
ery, including centralisation to cancer
centres or units. This allows patients
to have access to multidisciplinary
teams with knowledge, expertise and experience
in specific cancers. The downside
is that patients may have to travel
considerable distances, especially
where there is a need for ongoing
Head and neck cancer patients
often need to attend speech and
language therapy for communica-
tion and swallowing difficulties
resulting from their treatments.
Because of the distances involved,
responsibility is often devolved to
the local community therapist.
All speech and language thera-
pists working with adults with
dysphagia are required to have
post-graduate training. For the majority this is at
a post-registration level, as relatively few go on to
the Advanced level (RCSLT, 1999). It is likely that
their training is largely neurologically based,
reflecting most caseloads, but to what extent
does this prepare them to treat dysphagia in head
and neck cancer patients?
In 1999 the RCSLT Education Committee
Dysphagia Working Group published recommen-
dations as to the necessary knowledge base and
skills level for pre-registration, post-registration
and advanced level dysphagia education. Figure 1
shows my interpretation of how this applies to
patients with head and neck cancer.
Figure 1 Expected competence
No. of speech Level of Expected competence
and language training (dysphagia associated with
therapists head and neck cancer)
All Pre- Good knowledge of normal
registration anatomy and physiology
of the head and neck,
and of the normal swallow.
All of those Post- Knowledge of the needs of
working with registration clients with complex with
adult dysphagia conditions.
Relatively few Advanced Ability to manage clients
of those post- with complex conditions.
working with registration
adults with
While there is a wealth of literature on the
effects of surgery and radiotherapy on the swal-
lowing process, there is relatively little about
speech and language therapy intervention and
even less on the level of expertise or experience
on which that intervention should be based. The
BAO-HNS Consensus Document (2000), for exam-
ple, in its chapter on speech and swallowing reha-
bilitation talks of team members having suffi-
cient post-qualification experience (as well as a
major clinical component in this field). The case
example in figure 2 (p.5) shows why it is impor-
tant that the therapist dealing with people with
head and neck cancer has knowledge of:
1) Staging of tumours
The first time I encountered the staging classifica-
tion of tumours (BAO-HNS, 2000) in medical
notes, it was a complete mystery. Although the
speech and language therapist is not involved in
the staging progress it is important
to have a clear understanding of the
implications in terms of the likely
surgery and prognosis, and of the
nature of cancer generally.
2) Pre-operative counselling
The head and neck client group is
unique in that the patient is seen first-
ly with a normal / functional (albeit
diseased) swallowing process, before
the sudden onset of dysphagia
brought about by surgery and / or
radiotherapy and / or chemotherapy.
Doyle (1999) states that pre-operative
counselling provides the single most
important dimension in patient care, therefore
therapists working with this client group need to
ensure they have the necessary skills.
Doyle (1999) talks about using the process of
When does a speech and
language therapist have
sufficient competency to
manage a client whose
difficulties fall outside the
remit of standard training?
Lorna Gamberini explores
this in relation to people
with dysphagia associated
with head and neck
cancer and finds that, as a
profession, we have much
to ponder.
you are nterested n
how tranng and
experence combne to
mprove competency
provdng servces to a
arge geographca area
mprovng the journey
rom acute to
communty servces
Read ths
When is good
training should
give a therapist
the tools, but
they may need
to be applied a
little differently
to this group than
to neurological

Figure 2 Case example
Mary (64), retired, married
A social drinker and ex-smoker. Year-long history sore throats (initial tonsil biopsy -
no significant abnormality)
New investigations found
- poorly differentiated squamous cell carcinoma
- a lesion within the left tonsillar fossa, extending anteriorly to the anterior pillar
and floor of mouth, and posteriorly to the posterior tonsillar pillar
- Classification: T2 N1 M0
Combined clinic (ENT surgeon, maxillo-facial surgeon, oncologist, speech and
language therapist, head and neck nurse)
Consented to extensive surgery with adjuvant radiotherapy
Pre-operative counselling with speech and language therapist and head and neck nurse.
left selective neck dissection: level I-III
resection of tonsillar tumour, involving posterior pharyngeal wall and soft palate
radical forearm free flap
skin graft
Post-operatively (acute)
transferred to Intensive Treatment Unit with naso-gastric tube in situ, and cuffed no8
Shiley tracheostomy tube.
24 hours: ENT ward on intravenous fluids, cuff deflated on tracheostomy tube (speech and
language therapist contact for support; communicating effectively by writing and mouthing)
2 days: naso-gastric feeds
4 days: tracheostomy tube removed by surgeon
speech and language therapy assessment: left sided tongue weakness and loss of
sensation to the left side of tongue, lip and jaw. Trial swallows with fluids triggered
effectively; no obvious pharyngeal stage problems but some pooling of fluid on the
left. Recommended trial of free fluids, with postural modification to aid transit of bolus.
5 days: managing fluids well. Assessed on smooth, semi-solid consistency, some
pocketing in the left sulcus, remedied by postural modification. Oral transit slow, but no
pharyngeal stage problems. Naso-gastric tube removed; started on liquidised diet.
6 days: managing fluids well and tolerating liquidised diet
8 days: discharged home into care of local therapist.
Post-operatively (community)
Week 2: Coping with free fluids (including fortified drinks) and smooth semi-solids.
Complying well with postural modifications.
After clearance from the surgeon, range of motion exercises introduced. Reiterated advice
re- range of motion exercises, particularly in lessening build up of fibrotic
tissue and discussed possible deterioration in swallow during radiotherapy.
Week 3: Radiotherapy started, continuing with range of motion exercises, oral intake
increased substantially.
Week 4: Tolerating radiotherapy. Some discomfort, but not interfering with oral intake.
Continuing exercises - managing without postural modification.
Week 5: Struggling with range of motion exercises - very painful. Fluids easiest (relying
heavily on dietary supplements). After discussion with head and neck nurse and
oncologist, prescribed Oromorph to help with pain and advised on strategies for coping
with dry mouth (xerostemia).
Weeks 6/7: Mary rather disheartened. Very particular about appearance and, although
oedema and suture lines as a result of the surgery tolerated, added disfigurement from
radiotherapy skin changes is proving difficult.
Some difficulty triggering swallow, fibrotic tissue in tongue base. Losing weight as oral
intake decreases. Candida and taste changes affecting appetite. Very tired from
radiotherapy. Reassured should see improvement in 2-3 weeks. Dietitian to contact again
to advise about food choices.
Week 8: Pain and oedema reduced. Candida cleared. Oral intake easier. Coping with
xerostemia well. Feels able to start range of motion exercises again - encouraged.
Week 10: Less pain. Appetite returning, despite continuing taste changes. Swallow
triggering faster. Does not need postural modification. Mary trialling new textures herself
and feeling much more optimistic about returning to pre-operative diet.
Four months post-operatively: Good progress. Range of motion exercises regularly, rapidly
putting weight back on. Able to eat most foods, even if modified form. Xerostemia and
taste changes persist.
pre-operative counselling for the therapist and
patient to set common goals for rehabilitation.
Logemann (1983) discusses the difficulty of initiating
therapy post-operatively with a patient who has
been unprepared for the problems of swallowing.
Although consent for surgery or radiotherapy is
obtained primarily by medical and surgical members
of the team, the speech and language therapist has
an important role in ensuring that the patient is
fully aware of the consequences for speech and
3) Tracheostomy tubes and their effect on
Knowledge of the needs of clients with tra-
cheostomy is included in the Dysphagia Working
Groups recommendations for inclusion in post-
registration courses. Any patient who presents
with a compromised airway because of a head
and neck tumour may require a tracheostomy
(Ridley, 1999) Additionally, a tracheostomy may
be performed as a temporary measure until soft
tissue swelling has resolved post-operatively.
4) Swallowing assessment
Skill in selection and interpretation of swallowing
assessment procedures such as videofluoroscopy
and FEES (Fiberoptic Endoscopic Evaluation of
Swallowing) covers all client groups (RCSLT,
1999b). Here, however, to interpret the results of
any assessment accurately, the therapist must
have a very good understanding of the nature of
cancer, of the structural changes that have taken
place after surgery and of the effects of any con-
comitant treatment (Ridley, 1999).
5) Management of swallowing problems
Ability to use appropriate compensatory tech-
niques, exercises, positioning and change in consis-
tencies is a desired outcome of post-registration
training. Sullivan (1999) states that, for people with
head and neck cancer, therapy goals typically focus
on compensation rather than long-term improve-
ment of swallowing function. Post-registration
training should give a therapist the tools, but they
may need to be applied a little differently to this
group than to neurological patients.
6) Multidisciplinary team working
Post-registration courses aim to give speech and
language therapists knowledge of multidisciplinary
team working. The therapist is very much a core
member of the team providing an integrated service
to people with head and neck cancer, and has an
important role in raising awareness of swallowing
problems with the other team members.
7) Radiotherapy and its effects
Any therapist working with this client group needs to
be aware of potential treatment induced swallowing
problems, and prevention and therapy strategies.
The speech and language therapist has the best
knowledge of a patients swallowing status post-
operatively. She can therefore advise the team

With thanks to Linda Slack, Macmillan speech and
language therapist for North Cumbria who
looked after Mary at the acute stage.
British Association of Otolaryngologists - Head
and Neck Surgeons (2000) Effective Head and
Neck Management - Second Consensus
Burgess, L. (1994) Facing the reality of head and
neck cancer. Nursing Standard 8 (23): 30-34.
Calman, K. & Hine, D. (1995) A Policy Framework
for Commissioning Cancer Services. London:
Department of Health.
Doyle, P. (1999) Postlaryngectomy speech rehabil-
itation: contemporary considerations in clinical
care. Journal of Speech-Language Pathology and
Audiology 23 (3): 109-115.
Harris, C. (2001) Ahead and neck of the field.
Speech & Language Therapy in Practice. Autumn:
Logemann, J. (1983) Evaluation and Treatment of
Swallowing Disorders. Pro-ed, Austin, Texas.
Ridley, M. (1999) Effects of surgery for head and
neck cancer. In Sullivan, P. & Guildford, A. (Eds)
Swallowing Intervention in Oncology. Singular
Publishing Group: San Diego/London.
Robinson, H.F. (1999) How I manage head and
neck cancer: Setting the standard. Speech &
Language Therapy in Practice. Autumn: 23-24.
Royal College of Speech & Language Therapists
(1996) Communicating Quality 2. RCSLT: London.
Royal College of Speech & Language Therapists
(1999a) Dysphagia Working Group:
Recommendations for Pre and Post-registration
Education and Training. RCSLT: London.
Royal College of Speech & Language Therapists
(1999b) Invasive Procedures Guidelines. RCSLT:
Sullivan, P. (1999) Clinical Dysphagia Intervention.
In Sullivan, P. & Guildford, A. (Eds) Swallowing
Intervention in Oncology. Singular Publishing
Group: San Diego/London.
Williamson, K. (2000) The best things for the best
reasons. Bulletin of the Royal College of Speech &
Language Therapists. October.
before the onset of radiotherapy or
chemotherapy as to any need for non-oral
nutrition once the treatment effects are
added to the effects of surgery. It is unlikely
that this specialised and highly important
knowledge would be included in general
8) Body image
Both head and neck cancer and the treat-
ments for it can affect an individuals
appearance. Burgess (1994) includes not only phys-
ical change but also change in bodily function or
control of the bodys activities, and the speech and
language therapist needs to have an awareness of
the possible psychological implications.
Writing about the background to the RCSLT
Competencies Project, Williamson (2000) states
that: Although some skills and knowledge are
core to speech and language therapy profession-
alism, their profile and depth will vary according
to particular clients demands, contexts and ther-
apists responsibilities. On its own, attendance at
a dysphagia course does not make a therapist
competent. A therapist who has attended a post-
registration course, and has much clinical experi-
ence, can easily be as competent to treat dyspha-
gia in a head and neck patient as someone like me
who attended an Advanced course, but had rela-
tively little clinical experience. Experience may
come about by direct patient contact, or simply
from working with the multidisciplinary team. In
attending the Combined Clinic each week, I
learned a significant amount about the whole
spectrum of head and neck care - prevention,
recurrence, palliative care, carotid blow out for
example - all of which informed my practice.
Communicating Quality 2 (RCSLT, 1996) states that
therapists working with this client group tend to
learn by experience.
In outlining the content of dysphagia courses,
the Dysphagia Working Group makes it clear that,
while a therapist completing the course would be
expected to be able to work without supervision,
the ability to know when to ask for support
would mean the therapist is working competent-
ly. What may be problematic is ensuring that that
support is available.
The literature suggests that speech and lan-
guage therapy intervention for this client group is
optimally delivered by therapists with specific
responsibilities for head and neck cancer (RCSLT,
1996; Ridley, 1999; BAO-HNS, 2000), who will be
part of multidisciplinary teams working in cancer
centres. If the therapist linked to a particular centre
has the ability to be peripatetic, this may not be a
problem. However, if geographical or time con-
straints prevent this, there is a dilemma as to
whether the patient will travel for rehabilitation, or
be seen by the local speech and language therapist.
Would a local therapist, without specialist training
or specific clinical experience be appropriately
qualified, and would they be able to deliver high
quality, safe and effective treat-
ment (Calman & Hine, 1994)? I
believe the answer is possi-
bly. I cannot be more positive
due to uncertainty over the
amount of support the thera-
pist would receive. Issues of
competence and asking for sup-
port do not take account of fac-
tors such as Trust boundaries,
geography and politics, which
can hamper communication between therapists
and the contact that is needed to provide appro-
priate support. Harris (2001) describes a clinical
liaison group set up to improve communication
between professionals, vital when patients are
travelling across Trusts.
At the acute stage, there should be support from
the other members of the multidisciplinary team,
whereas a community therapist may be working in
isolation, and dealing with the head and neck can-
cer patient at what is often the most traumatic
time. Discharge home can bring about a stark reali-
sation of problems they have to overcome. The
swallowing problem may take on more significance
when the choice is no longer from a hospital menu
and the social aspect of eating comes to the fore,
and all this at a time when further treatment may
start and worsen the dysphagia.
General dysphagia training gives therapists a
good basic grounding in managing dysphagia in
head and neck cancer patients. If there are very
good support systems in place, it is possible that a
generally trained therapist could successfully
manage the dysphagia. However, there are still
aspects of care, such as pre-operative counselling,
that are so important to the outcome of the reha-
bilitation that they should remain within the
remit of a therapist with specific responsibilities
to this client group.
Robinson (1999) reports on the drawing up of the
Head and Neck Oncology Consensus document,
and the fact that some of the objectives were
unachievable in certain areas because of issues such
as geography. Despite this, they were included
because, ultimately, they were good practice, and
could be used to help highlight deficiencies in local
service provision. This process needs to continue to
ensure parity of service for head and neck cancer
patients, no matter where they live.
I am not sure if it is possible to quantify the level
of expertise and training required to work with this
client group, but it is an area that the profession
needs to explore. For the sake of career progression,
continuing professional development and ultimate-
ly patient care, it would be helpful to have some
way of gauging when ones experience is sufficient.
Lorna Gamberini is a speech and language thera-
pist who works with ENT clients for Morecambe
Bay Primary Care Trust. This article is based on the
essay component of the Advanced Dysphagia
Course (Head & Neck Module) which was written
while Lorna worked for West Cumbria Primary
Care Trust.

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Laccourreye, O., Papon, J-F., Kania, R., Crevier-
Buchman, L., Brasnu, D. & Hans, S. (2003)
Intracordal injection of autologous fat in patients
with unilateral laryngeal nerve paralysis: long-
term results from the patients perspective
(review). Laryngoscope 113 (3): 541-5.
OBJECTIVE: Based on 80 patients with a previously
nonsurgically treated unilateral laryngeal nerve
paralysis (ULNP) and according to the patients self-
assessment, the authors document the long-term
results achieved with the intracordal injection of
autologous fat. STUDY DESIGN: Retrospective series,
inception cohort. METHODS: Kaplan-Meier actuarial
life table method and univariate analysis. RESULTS:
None of the 80 patients died in the immediate post-
operative period. Morbidity included haematoma at
the donor site (in three patients), development of an
intracordal cyst at the injection site (in three
patients), fat extrusion at the injection site (in one
patient), and temporary tracheotomy (in one
patient). The initial and ultimate overall success rates
were 96.2% and 77.2%, respectively. In univariate
analysis, none of the variables under analysis (gender,
age, associated neurological lesions, associated pneu-
monectomy, associated neoplasia, cause of the ULNP,
side of the ULNP, nerve involved, delay between the
onset of the ULNP and the intracordal injection,
severity of the symptoms, mode of harvesting the
autologous fat, and surgeon who performed the
injection) was statistically related to the ultimate
outcome after the intracordal injection of autologous
fat. Among the group of 45 patients in whom the
intracordal injection was initially considered to be
successful with no further recovery of motion of the
true vocal cord and a minimum survival of 12
months, the ultimate overall success rate was 62.2%,
and the 3-month, 6-month, and 12-month Kaplan-
Meier actuarial estimates for success were 91.1%,
72.8%, and 63.1%, respectively. CONCLUSIONS: In
the present study, data confirm that the intracordal
injection of autologous fat is a useful and safe procedure
in patients with ULNP. However, the impossibility of
exactly predicting the amount of resorption of the
injected fat and the lack of predictability of the duration
of the results, together with the good and stable results
achieved at the authors department with the medi-
alization thyroplasty led the authors to reduce its
current use. (23 References)
Widen, S.C. & Russell, J.A. (2003) A closer look
at preschoolers freely produced labels for
facial expressions. Dev Psychol 39 (1): 114-28.
Childrens performance on free labelling of proto-
typical facial expressions of basic emotions is modest
and improves only gradually. In 3 data sets (N = 80,
ages 4 or 5 years; N = 160, ages 2 to 5 years; N = 80,
ages 3 to 4 years), errors remained even when
method factors (poor stimuli, unavailability of an
appropriate label, or the difficulty of a production
task) were controlled. Childrens use of emotion
labels increased with age in a systematic order:
Happy, angry, and sad emerged early and in that
order, were more accessible, and were applied
broadly (overgeneralised) but systematically. Scared,
surprised, and disgusted emerged later and often in
that order, were less accessible, and were applied
Hohoff, A., Seifert, E., Fillion, D., Stamm, T., Heinecke, A. & Ehmer,
U. (2003) Speech performance in lingual orthodontic patients
measured by sonagraphy and auditive analysis. Am J Orthod
Dentofacial Orthop 123 (2): 146-52.
Aesthetically appealing, externally invisible, lingually applied orthodontic
brackets are in increasing demand. Because the brackets are placed lin-
gually, however, they appear to cause some problems with respect to
speech. This study is the first to present a prospective evaluation of the
articulation of 23 patients with lingual brackets by means of an innovative
combination of test methods. An acoustic, objective evaluation of articulation
measured by digital sonagraphy was related to a semiobjective auditive
evaluation by 10 speech professionals, to a semiobjective auditive evaluation
by close contacts of the patients, and to a subjective auditive evaluation by
the patients themselves, the latter 2 using standardised questionnaires.
The tests were performed before (T1), within 24 hours after (T2), and 3
months (+/- 1 week) after (T3) the start of therapy. In comparison with
the initial findings, a significant deterioration in articulation was recorded
with all test methods at T2 and T3. Using a new combination of methods,
our investigations show the need for detailed briefing of patients about
the extent and duration of changes in speech resulting from lingual
Dunn, L.T., Fitzpatrick, M.O., Beard, D. & Henry, J.M. (2003) Patients with
a head injury who talk and die in the 1990s. J Trauma 54 (3): 497-502.
BACKGROUND: Patients who talk and die after head injury may repre-
sent a group who suffer delayed and therefore potentially preventable
complications after injury. We have compared the clinical and pathologic
features of patients who talk and die with those who talk and live after
head injury. METHODS: Data collected prospectively by the Scottish
Trauma Audit Group were used to identify patients with a head injury
and classify them according to verbal response at admission to hospital.
All talking patients in the catchment area of a regional neurosurgical
centre were selected and those who died were compared with those who
survived. RESULTS: Seven hundred eighty-nine talking patients were identified.
Seven hundred twenty-seven patients survived and 62 died. Patients who
talked and died were older, had more severe extracranial injuries, had
lower consciousness levels, and reached theatre more quickly than those
who talked and lived. Thirty-one of the patients that died had extra-axial
haematomas. CONCLUSION: Even with increased availability of computed
tomographic scanning, some patients still talk and die after head injury.
Bilney, B., Morris, M.E. & Perry, A. (2003) Effectiveness of physio-
therapy, occupational therapy, and speech pathology for people
with Huntingtons disease: a systematic review. Neurorehabil
Neural Repair 17 (1): 12-24.
This review provides a summary of the current literature examining the
outcomes of physiotherapy, occupational therapy, and speech pathology
interventions for people with Huntingtons disease. The literature was
retrieved via a systematic search using a combination of key words that
included Huntingtons disease, physiotherapy, occupational therapy, and
speech pathology. The electronic databases for Medline, Embase, CINAHL,
Cochrane Controlled Trials Register, and PEDro were searched up to May
2002. Articles meeting the review criteria were graded for study type and
rated for quality using checklists to assess study validity and methodology.
The majority of articles that examined therapy outcomes for people with
Huntingtons disease were derived from observational studies of low
methodological quality. A low level of evidence exists to support the use
of physiotherapy for addressing impairments of balance, muscle strength,
and flexibility. There was a small amount of evidence to support the use
of speech pathology for the management of eating and swallowing dis-
orders. The current evidence is insufficient to make strong recommendations
regarding the usefulness of physiotherapy, occupational therapy, or
speech pathology for people with Huntingtons disease. There is further
need for therapy outcomes research in Huntingtons disease so that clinicians
may use evidence-based practice to assist clinical decision making. (80
Basic strategies
Swallowing......on a plate (OLoughlin & Shanley, 1996)
is an Australian dysphagiamanagement (training) pro-
gramme designed for use in nursing homes so that,
following training, nursing home staff would be able
to provide basic assessment and management strate-
gies for their patients. It provides information about
swallowing problems and their management in
user-friendly handouts and information sheets. It
introduces specific forms and protocols that provide
a model to help implementation of the package
within the home. Five modules cover the following
topics: understanding the swallowing process; the
assessment and management of swallowing prob-
lems; implementation of the SOAP programme in
the nursing home; supplementary information and
resources. The modules are designed to be taught
to other staff by an experienced registered nurse.
SOAP includes four instruments:
1. a prefeeding checklist (swallowing screening tool);
2. swallowing assessment checklist (observation at
mealtime, noting consistency of food and drink,
position of client, level of dependence and
obviously presence of swallowing problems);
3. swallowing management index (details of possible
problems and related strategies such as feeding
techniques to aid lip closure) and
4. swallowing care plan. Importantly the care plan
provides details of supervision required, special
procedures necessary, positioning - location and
posture, equipment required and client-specific
advice gained from the swallowing management
index (see figure 1, p.9).
A pilot SOAP project within a Renfrewshire NHS
continuing care hospital is reported fully else-
where (Bain, 2003) so we will summarise it here
before we compare it to one
undertaken in Tayside.
Renfrewshire is a mixed urban and
rural community situated southwest
of Glasgow with approximately
30,000 people over the age of 65
years. A very limited specialist com-
munity / domiciliary speech and
language therapy service of assess-
ment and advice (with no review)
for clients over 65 years with swal-
lowing problems is available. It is
therefore necessary to consider
any model of care that will max-
imise the effectiveness of this limited service.
The essential features of the Renfrewshire project
were the introduction of a new model of care which
ensured that, following the training and implemen-
tation period, regular speech and language therapy
review of clients could be achieved. Rather than
relying on self-directed study, all nursing staff
(including auxiliaries / nursing assistants) in a long
you want to
ncrease knowedge
and change workng
provde cear and
supported care
prove ong-term
Read ths
his article is not about infection con-
trol, but a training package called
Swallowing......on a plate (SOAP for
short). Our two Scottish speech and
language therapy services coinciden-
tally and simultaneously piloted this
package in markedly different ways and we thought
it would be useful to compare them. Importantly, we
found that, even though it is slow and difficult to
achieve successful new multidisciplinary working,
this model of care can be used and adapted to dif-
ferent environments.
So, why is such a package needed? Dysphagia is
recognised in the literature and in clinical experi-
ence as a widespread problem in the long-term
care settings of residential and (especially) nursing
homes as well as in continuing care wards for
older people (Smithard, 1996; Steele et al, 1997;
Kayser-Jones & Pengilly, 1999). Management of
swallowing difficulties may however not be part of
the training or knowledge-base of staff
in these institutions and so residents
and clients with dysphagia may be
experiencing unnecessary malnutrition,
dehydration, chest infections and
problems taking medication among
other side-effects of inadequately
managed dysphagia, including acute
hospital admissions.
Specialist speech and language
therapy and dietetic services to these
locations are often restricted by
resource limitations. One solution to
this problem has been to provide
training to staff in swallowing and dysphagia
management. Speech and language therapy
training programmes however have been devel-
oped locally and mainly for hospital settings
(acute wards and stroke units), without validity
and reliability being established (Gravill, 1999;
Magnus, 2001). Long-term effectiveness is rarely
We included a
control home so
that measures
devised for the
project could be
assessed for
The need
When Linda Armstrong and
Alison Bain found out they were
piloting the same off-the-shelf
package, they were naturally
interested to compare methods
and results. Swallowing......on a
plate (SOAP) may benefit people
with dysphagia, but the principles
are relevant to any client group
where the aim is to train other
professionals in basic assessment
and management.
Linda Armstrong
stay hospital received training (either one or two
sessions) over eight consecutive days. Link nurses
were identified to screen clients for swallowing
problems and develop care plans for managing their
dysphagia. The speech and language therapist
assessed the appropriateness of each care plan and
monitored each identified client fortnightly over the
six month pilot period. Assessment of the effective-
ness of the training was measured in terms of
increased staff knowledge and more appropriate
feeding behaviour (as deemed by observation of
mealtimes by the speech and language therapist).
Effects of training
The aim of the project undertaken in rural Tayside
was to evaluate the short- and longer-term effects
of in-service training on acquired dysphagia with
residential and nursing home staff using a published
training package. The project objectives were:
to evaluate SOAP as a training package for local use
to evaluate the effectiveness of SOAP in increasing
knowledge and changing working practices
and so to improve the quality of care for people
with acquired neurological swallowing problems.
The project focused on the two residential and two
nursing homes in the catchment area for GPs based
in one of the five geographical localities of Perth
and Kinross Local Health and Social Care Co-opera-
tive (LHSCC). The local community hospital was also
initially included, as there was an identified training
need which had not been met as part of the rolling
community hospital training programme (because
of staff shortage in the hospital). Its client popula-
tion is more transient than that of the homes and it
has a different balance of trained and untrained
staff. However, the SOAP training package and its
protocols appeared possibly to be applicable also in
the hospital setting. In addition we reckoned that, if
both the community hospital and the homes in the
locality were using the same method of identifying
and managing swallowing problems, transfer of
information about individual people in either direc-
tion would be expedited. We also included a control
home in another locality, so that measures devised
for the project could be assessed for test-retest reli-
ability. For this home, the initial day-long training
was offered following two baseline assessments.
We used a number of outcome measures pre- and
post-training to examine the short- and long-term
effectiveness of the programme. These were: com-
parison of referral / re-referral rate and quality of
referral (speech and language therapy and dietetics);
resident profiles and swallowing environment obser-
vations (nutrition checklist, swallowing environment
checklist); a food / fluid customer satisfaction ques-
tionnaire; SOAP knowledge quiz and training day
evaluation sheets. At the end of the project, we sent
a short questionnaire to home managers / matrons.
for SOAP
Figure 1 Sample Care Plan
Step 1: Prefeeding Assessment Checklist
May lead to either Nil-by-mouth / onward referral or Step 2: Swallowing Assessment Checklist
Refer to solutions in Swallowing Management Index and develop Step 4: Swallowing Care Plan
Case history:
This case history is taken from the SOAP Manual (p48)
Mrs White had a right CVA three years ago. She has a left facial droop, slurred speech and has no dentures. She sometimes
coughs with thin fluids, takes a long time to eat her meals, is losing weight and has difficulty swallowing her medication.
She often slips down in her chair, and pockets food in her mouth.
SOAP step 4:
Swallowing Care Plan (See SOAP Manual, p51)
Devised by Grainne OLoughlin & Chris Shanley 1996
USE: To be filled out by a registered nurse and reviewed as necessary. To be used by all persons feeding or super-
vising a resident at mealtimes, as a guideline for safe swallowing.
Residents Name: .
(Please tick any boxes that apply)
Diet consistency:
Minced & Mashed
Diabetic Diet: Yes No Other Special Diet:
Needs to be fed
Needs to be supervised
Doesnt need supervision
Location for mealtime:
Upright in bed
Upright in chair
At dining table
Adapted cutlery Plate guard Cut-out cup
Straw for drinks Spouted cup Clothing protection
Other equipment
Please insert specific instructions needed to assist this resident.
(Use the information from the Swallowing Management Index)
. , , ,
, . ,
, . , ,
' . , ,

STOP FEEDING if resident is drowsy, coughing, choking or aspirating.
Staff to be aware of procedure in event of choking.


1996 Centre for Education & Research on Ageing and Inner West Geriatrics & Rehabilitation Service. Reproduced with permission.
Fluid Consistency:
Very thick
Administration of Medications:
Give as normal
Liquid form only
Crush and mix with puree
Special Instructions
Additional requirements:
Hearing Aid
Special procedures:
Suction on standby
To be fed by specified staff only
Posture for feeding:
Keep head in midline
Cushion/pillow for support:
- behind head
- behind back
- under arm L / R

Do l seek out exstng o-the-
she packages beore spendng
tme deveopng my own'
Do l network wth other speech
and anguage therapsts to
compare methods and resuts'
Do l pan how l w assess
reabty, vadty and ong-term
eectveness o a project'
Response to the project varied among the care
homes and the hospital (see table 1). Two baseline
measures were taken at the control home but two
planned training days were cancelled by this home
because of staffing problems; staff shortage was
given as the reason at the community hospital too.
The referral rate to speech and language thera-
py and dietetics did not increase post-training.
Resident profiles (describing swallowing prob-
lems and their management) pre- and post-train-
ing depended on the member of staff reporting -
there was little reliability. Swallowing environ-
ments in the residential homes were very positive.
In the nursing homes, post-training improvement
was seen in one (NH1) but not the other (NH2,
whose commitment to the project appeared to
peter out). In the control home, no change was
noted from the first baseline measure to the sec-
ond. Satisfaction among a sample of residents
varied among the homes. Participants at the
training day showed a significant improvement in
knowledge immediately post-training. This
improvement was sustained over six months by
the staff who attended the follow-up half-day
(several of the participants had left by then).
There are several implications for the use of
SOAP in care homes:
This package can promote increased knowledge
about dysphagia and change in working practice
and should be rolled out on an ongoing basis to
other homes in the Local Health and Social Care
Small changes are needed to reflect UK
circumstances (for example, food items and
Responses among the homes varied. Perhaps in
future homes that are willing to commit to change
(if necessary) and able to give staff protected
time should be targeted.
Another way forward would be the development
of a dedicated team of allied health professionals
for residential and nursing homes. The remit of
this team would include both ongoing training
and assessment / management of residents
chronic problems. A model for this exists in
Glasgow (Scott, 1999).
Used quite differently
SOAP was used quite differently in the two pro-
jects (see summary in table 2). The composition of
project staff in the two areas shows that either
one person or a team can run a training project.
There was also variation in planning time, with
protracted discussions required in Renfrewshire
and a much shorter lead-in time in Tayside. In
both projects we trained staff looking after older
people in institutions where turnover of clients /
residents is likely to be slow, but where the same
cannot necessarily be said for staff turnover. The
number of staff trained was very different. The
model used in Renfrewshire is our preferred one,
in which all staff received training. In Tayside the
range of staff grades and experience was prob-
lematic in terms of generalisation of the training
to the homes. Training time was longer in Tayside
than in Renfrewshire but the model of care in
Renfrewshire was introduced in the continuing
care hospital rather than in any care homes.
The Tayside project included a wider range of
outcome measures, most of which were developed
specifically, for example customer satisfaction ratings
and quality and rate of referrals. Three of the
homes changed working practice after their train-
ing as measured by observation of swallowing
environment and feeding practices at mealtimes;
however the changes were much less widespread
than those achieved by the blanket training in the
continuing care hospital. There it was noted that
length and quality of mealtimes had improved,
and that appropriateness of feeding strategies had
improved significantly. Importantly, the speech and
language therapist was able to monitor clients reg-
ularly and thus, we feel, provided a more effective
speech and language therapy service as a result of
implementing the SOAP model.
So, would we use the SOAP training package
again? YES.
And do we recommend it for use either in care
homes or long stay hospitals? YES.
Linda Armstrong is a speech and language therapist
working for Perth & Kinross LHSCC, NHS Tayside,
e-mail and Alison
Bain a speech and language therapist with NHS Argyll
and Clyde at New Sneddon Street, Paisley (contact via
Bain, A. (2003) Swallowing on a plate. Bulletin of
the Royal College of Speech and Language
Therapists. May.

Table 2 Comparing our use of SOAP

Renfrewshire Tayside
Project team 1 speech and language therapist 3 speech and language therapists and 1 dietitian
Project length 6 months 1 year
Time in planning 18 months 3 months
Locations involved 1 continuing care hospital 5 care homes and a community hospital
Staff trained 82 trained nursing staff and auxiliaries18 care home staff
Length of training One day (repeated x8) One and a half days
Outcome measures Knowledge and feeding environment Knowledge, referral rate, swallowing
environment, resident profiles, customer
satisfaction, manager questionnaire
SOAP model of care introduced yes no
Difficulties Huge speech and language Control home training
therapy commitment Community hospital could not send staff
Limited funding Range of levels of staff trained
Changes as an outcome of Speech and language therapy Individual to homes
the project service offered in different way
SOAP documentation in place
Table 1 Response to the Tayside project
RH1 RH2 NH1 NH2 Hospital
Interested in participating Yes Yes Yes Yes Yes
Able to send staff Yes Yes Yes Yes No
to training
Pre-training measures Yes Yes Yes Yes N/A
Post-training measures Yes Yes Yes Yes N/A
Changes in working Yes Yes Yes No N/A
practice observed
Staff sent to 6-month Yes Yes Yes No N/A
Manager questionnaire Yes Yes Yes No N/A
RH= residential home, NH = nursing home
Gravill, P. (1999) SIGNs of progress in dysphagia.
Speech & Language Therapy in Practice Spring: 12-15.
Kayser-Jones, J. & Pengilly, K. (1999) Dysphagia among
nursing home residents. Geriatric Nursing 20: 77-82.
Magnus, V. (2001) Dysphagia training for nurses in
an acute hospital - a pragmatic approach.
International Journal of Language &
Communication Disorders 36 (supplement): 375-378.
OLoughlin, G. & Shanley, C. (1996)
Swallowing......on a Plate: A Training Package for
Nursing Home Staff Caring for Residents with
Swallowing Problems. The Centre for Education
and Research on Ageing: Concord, Australia.
Scott, D. (1999) Communication and swallowing
training for care home staff. Nursing &
Residential Care 1: 318-321.
Smithard, D.G. (1996) Feeding and swallowing
problems in the institutionalized elderly. Clinical
Rehabilitation 10: 153-54.
Steele, C.M., Greenwood, C., Ens, I., Robertson, C.
& Seidman-Carlson, R. (1997) Mealtime difficulties
in a home for the aged: not just dysphagia.
Dysphagia 12: 43-50.
Further information about SOAP and other training
resources is at
Alison Pendlowski and Alison Cuthbertson were the
speech and language therapists also involved in the
Tayside SOAP project and Alison Gibb the dietitian.
Funding for the Renfrewshire project was received
from the Directorate of Continuing Care and Old
Age Psychiatry and in Tayside from the Initiatives
Fund of Tayside Primary Care NHS Trust.
In common with other
therapists, Karen Heins
and colleagues were
looking for an efficient
and effective way of
managing clients with
speech and language
difficulties in mainstream
schools. The result was
the development of the
Collaborating for
Communication project,
which combines practical
workshop training for
teaching assistants with
supervised practice
involving groups of real
ollaboration is the key to effective
speech and language therapy within
mainstream schools (RCSLT, 1996;
Manz, 2000; Pritchard Dodge et al,
2000). In practice, collaboration
often involves assessment of the
child, discussion with parents and teachers, fol-
lowed by a written programme to be carried out
by parents and education staff (Portch & Harrison,
2002). Initially, speech and language therapists in
the local mainstream school service in Kent were
also using this model of service delivery. However,
in a survey carried out to evaluate the service,
special educational needs co-ordinators emphasised
the need for more help from speech and language
therapy to train staff and implement therapy pro-
Speech and language therapists had often
worked together with individual teaching assis-
tants to demonstrate how to provide therapy for
specific children, yet this kind of hands-on supervi-
sion was not always possible. The department
also offered workshops to teaching assistants on
working with children with speech and language
difficulties but, despite a very practical focus, it
was not feasible for the teaching assistants to
immediately practise the ideas with real children
under the supervision of a speech and language
therapist. The Collaborating for Communication
project was developed in 2001 - 2002 to combine
practical workshop training with supervised practice
in using the therapy techniques with real children.
This training supplemented the assessments,
reviews and programmes which we continued to
I developed and piloted the project while work-
ing half time in the schools team with a caseload
of ten primary schools. Instead of visiting each
school two to three times a
term, I targeted two
schools at a time, and visit-
ed each school for one full
day each week for five
weeks (roughly a half -term
period). The schools not
involved in the project dur-
ing that term continued to
receive one visit per term
for assessments and
reviews. Eight out of the ten schools chose to
participate in the project which was structured as
1. Assessment and planning day
The first visit involved carrying out three to four
assessments / reviews and planning with the special

educational needs co-ordinator for the therapy

groups to be run over the next four visits.
Students with language difficulties were placed
together in groups of three to five children of
roughly similar ages. Students needing phonolo-
gy therapy were seen individually or in a small
group. One or two teaching assistants were allo-
cated to run each group with me.
2. Language groups
Therapy is much more effective if education staff
can see the immediate relevance of language
goals to current class work and the broader cur-
riculum (RCSLT, 1996). Each language group
therefore focused on a current class topic such as
history (for example, Ancient Egypt; Florence
Nightingale), geography (Kenya), English
(fables) or a time of year (Christmas).
A different language area was targeted each
Week 1 - Understanding stories: Role play
helped students understand a story related to
the class topic (adapted from Withey, 2000).
Week 2 - Building vocabulary: Students
described the meaning of words related to the
class topic. This area was chosen as many children
had semantic difficulties.
Week 3 - Listening and following instructions:
Activities focused on listening and following
instructions while reinforcing vocabulary relevant
to the class topic (adapted from Johnson, 1998).
Week 4 - Telling stories: Students learned to
use a story plan, develop their own story, act it
out and retell it in their own words (story plan
adapted from Liverpool Speech Pathology
Service, Sydney).
These particular language areas were chosen as
they were relevant for most students with lan-
guage difficulties, and they fitted
easily into current class work.
The groups were designed so
that teaching assistants could
later re-run the same four ses-
sions with the same group of
children, but each time they
would choose a new topic that
the children were currently
studying in class. In this way the
material was new and relevant
to the children, yet the teaching assistants could
use the same session plan each time. Each group
session ran for 30 minutes, but 45 minutes were
allocated to give time to explain the session to
the teaching assistants, collect children from class,
return them and demonstrate writing up notes. A
sample session plan and homework sheet are in
particular language areas
were chosen as they were
relevant for most students
with language difficulties,
and they fitted easily into
current class work
you want to
Be more ecent
wthout compromsng
on eectveness
lmprove coaboraton
wth other proessonas
ombne tranng wth
supervsed practce
Read ths
Collaborating for

Figure 1 Sample session plan and homework sheet
Session 4: Telling Stories
You will need pictures of scenes (such as a family at the beach; children going shopping) and
problems (for example a child who has lost something or fallen over). You will also need the
picture cues for the different stages in the story plan.
Session Plan:
Revise Homework: Ask students what are the three things they need to remember to follow
instructions (look, listen, repeat). (1 min)
Setting/Beginning: Revise that when questions are about time (have a picture of a clock),
who questions are about people (have a picture of people) and, where questions are about
place (have a picture of a house). Show the pictures of different scenes, and ask the children
to make up when, who and where (for example, One hot day, mum, dad and Sam were
at the beach.) If when is not clear, then just use One day. For the first 1-2 pictures, think
up the setting as a group. Then give each child a picture of a scene, and ask them to make
up the setting (when, who and where). (5 mins)
Problem and Ending: Show the children pictures of different problems, and ask them to
explain what the problem is, think how the characters would feel in these situations, and two
or three things that they could do to solve the problem. For younger children it is fine if they
can only think of one solution, but older children should be able to think of at least two
possible solutions. As above, do the first 1-2 pictures as a group, and then give each of the
children a different picture to discuss the problem. If the child can only think of one solution
to the problem, ask the rest of the group if they can think of any other ideas. Once a number
of solutions have been suggested, ask the child to choose one as the ending, and then
explain how the characters would have felt in the end. (8 mins).
Children make up a story to do with the class topic: Ask the children to think of a story that
fits in with the class topic. Use the same prompts as above to generate a setting, problem
and ending. For example, if the topic is Ancient Egypt, the setting could be Thousands of
years ago, a pharaoh and his slaves were living in Egypt, and then the children can continue
the story by thinking of a problem that the pharaoh could have. Sometimes the children
need to be led through the different solutions by the adult saying First the pharaoh tried....,
but...., then the pharaoh tried ....., but ..... In the end...... (6 mins).
Children act out the story: Give each child a different role in the story, and they can act it
out. If there is time, you can switch the roles over and act it out again. (5 mins)
Children retell the story in their own words: Use the picture cues to help them remember all
the important stages in the story; perhaps each child could take a section (e.g. first child
setting, second child problem etc.). (5 mins)
(Note: Story plan is adapted from Speech Pathology, Liverpool Health Service, Sydney).

figure 1.
Teaching assistants participated fully in the ses-
sions by preparing materials, observing my
demonstration of activities, then implementing
the activities with the children themselves, and
taking notes on the childrens abilities in the dif-
ferent tasks. All schools were provided with a
written information package so that they could
run the same groups independently in the future.
3. Speech sounds
Children needing phonology therapy were seen
either in small groups or individually. A teaching
assistant jointly ran each session with me, and
brought toys and activities available in school to
provide motivation.
4. Workshops for teachers, teaching
assistants and parents
School staff and parents were invited to attend a
one hour workshop on working with children with
speech and language difficulties. Five out of the
eight schools chose to hold workshops. Some schools
preferred joint parent and staff training, while the oth-
ers decided to have separate sessions for parents and
staff. The number of participants in each workshop
ranged from about six to more than twenty.
5. Providing experience for more recently
qualified therapists
The mainstream school team was keen to encour-
age more recently qualified therapists to consider
working in schools. Therapists were therefore invit-
ed to spend five days working on the project in one
school, and three chose to participate. An infor-
mation package included advice on assessing
school-aged children, writing reports and prepar-
ing programmes. A resource file contained infor-
mation on expected speech and language develop-
ment in school-aged children, programmes for dif-
ferent areas of language, speech and fluency, and
pre-prepared training packages for delivering
workshops to school staff and parents.
6. Reports
At the end of the weekly visits, each child received
a report using a standard format to explain the
group sessions and provide further ideas for
helping children at home and in school.
At the end of the programme, special educa-
tional needs co-ordinators and the more recently
qualified therapists completed a questionnaire to
provide feedback about the project. Their com-
ments are summarised in figure 2.
One day hands-on workshop
After the success of the first two terms of the pilot
project, we decided to extend the training to
other schools in the area. To involve as many
schools as possible, the training was condensed to
a one day hands-on workshop held at each par-
ticipating school. Ten schools chose to be involved.
All schools identified at least one teaching assistant
who would attend all day, so that they could under-
stand how the programme worked as a whole.
Some schools then chose to send different teaching
assistants to each session, or else to have three to
four teaching assistants who attended all sessions.
After initially observing the therapist, the teaching
Language Group Homework
Session 4: Telling Stories
Today we have been working on telling stories. Here is a story plan to help your child tell stories
with you at home, or if they have to prepare a story in class.
If your child has difficulty with writing stories, then they can start by just putting 1-2 key words in
each of the boxes. If necessary, later they can expand these key words to make full sentences.
WHEN did the story happen?
WHO was in the story?
WHERE were they?
What was the PROBLEM?
How did they FEEL?
How did they try to FIX the problem?
(Think of 2-3 possible solutions)
How did the story END?
How did they FEEL?
Manchester Metropolitan University: Manchester.
Manz, J. (2000) Positive teamwork. Bulletin of the Royal
College of Speech and Language Therapists, March.
Portch, A. & Harrison, P. (2002) Clarifying priorities.
Bulletin of the Royal College of Speech and
Language Therapists, March.
Pritchard Dodge, E., Andrews, M. & Andrews, J. (2000)
Communication and collaboration. In: Pritchard
Dodge, E. (Ed) The survival guide for school-based
speech-language pathologists. Singular: San Diego.
Withey, C. (2000) Developing language skills
through playscripts training course. Riverside
Community Health Care, London, 29 June 2000.
assistants were actively involved in carrying out the
activities themselves with the children and taking
notes. Each session ran with different children from
the school, as using the same group of children all
day would have been too tiring for them. One
topic was used for all sessions (school), but teach-
ing assistants were encouraged to think how to
adapt the activities for current topics in their own
classes. A sample timetable is in figure 3, although
specific times were adapted for individual schools.
Four recently qualified therapists and a speech
and language therapy student participated in the
training days. The therapists were provided with
the session plans beforehand, and chose to run
two of the group sessions. It was easier for them
to get time away from their regular work for just
one day rather than five days.
After the training days in the ten schools, 64
questionnaires with completed confidence ratings
were returned. Of these, 79 per cent reported
increased confidence in working with at least one
area of speech or language, while 47 per cent
reported increased confidence in three or more
areas. One of the speech and language therapists
involved volunteered to take on a caseload of
mainstream schools, while the others were planning
to incorporate the ideas into their current work.
The comments were generally very positive, and
the perceived benefits were similar to those reported
by the schools in the weekly version of the project.
The main criticism was from teaching assistants who
were only able to attend for one group session;
they would have liked to see how the other groups
worked, and to have had more practice with the
children. Another suggestion was having more
advice on other areas of communication, such as
social skills development. On a one day training
workshop, the special educational needs co-ordina-
tors had to make compromises in deciding how
many teaching assistants could be released from
classes during the day, and not all areas of speech
and language therapy could be covered.
Effective method
The Collaborating for Communication project has
been a very effective method of providing hands-
on training with real children so that teaching
assistants can run groups for students with speech
and language difficulties. It would be valuable to
extend the training to other schools in the area,
and follow up the schools involved to find out if
the groups are still running and if the strategies
are being used in class work. A second training
programme could also be developed to target
other areas of communication difficulty, such as
focusing further on speech sounds and phonemic
awareness, grammar, voice care for staff and stu-
dents, and social communication skills. Continuing
to develop our collaboration with teachers, teach-
ing assistants and parents will enable us to be
much more effective in implementing therapy for
students with speech and language difficulties.
Karen Heins is a speech and language therapist.
Copies of the Collaborating for Communication
training manual are available, with all the materials
needed to run the project, including notes for
presenters, strategies for getting teaching assis-
Figure 3 Sample timetable
9.10 Introduction: Expectations, confidence rating scale for working with speech and language
difficulties. Explanation of the days sessions, and how to run the groups with weekly sessions.
9.30 Language Group 1: Understanding stories
10.15 Break
10.30 Language Group 2: Building vocabulary
11.15 Language Group 3: Listening and following instructions
12.00 Lunch
1.00 Language Group 4: Telling stories
1.45 Working with speech sounds: Therapy activities for one child with a phonology programme.
2.15 Question and answer session: Adapting groups for future use, confidence ratings
after the day, feedback.
tants actively involved, session plans for language
groups, visual cue sheets, homework, and stan-
dard report and letter formats. Please contact
Karen at 34 Op der Sterz, Fentange L-5823,
Luxembourg, e-mail
Many thanks to all the speech and language therapists
and schools who participated in the project for
their enthusiasm, commitment, advice and sugges-
tions. Thanks in particular to Kat McKeown,
speech and language therapist, for her sugges-
tions in the initial development of the project, to
Louise Ring, speech and language therapist, for
the child report format, to Jackie Charlton, speech
and language therapist, for the confidence rating
scale, and to Rachel Meinertzhagen, teacher, who
developed the story plan bookmark.
RCSLT (1996) Communicating Quality 2. Professional
standards for speech and language therapists. Royal
College of Speech and Language Therapists: London.
Johnson, M. (1998) Functional Language in the
Classroom. Clinical Communication Material,
Do l try to act on eedback
receved about my servce'
Do l provde programmes that are
meanngu both to those
mpementng them and to my
Do l encourage recenty quaed
sta nto my partcuar ed'
Figure 2 Comments about Collaborating for Communication
Key benefits reported by schools:
Practical demonstrations and participation
made more sense than on paper.
Improved confidence and skills in supporting
students with speech and language needs.
Children enjoyed sessions and groups allowed
all children on the caseload to be included.
Closer links with the speech and language
therapy department.
Strategies used in groups were extended to
the classroom.
Main disadvantages and suggested improvements
from the schools:
Timetabling and grouping children, withdrawing
teaching assistant support from classrooms and
finding space in the school to run the groups.
Teachers would have liked to be more
Less time for assessments of children, and the
concentrated support of a day a week over a
five week period reduced visits from speech
and language therapy for the rest of the year.
Perhaps children could attend language groups
during the holidays as they had in the past.
Future plans of the schools:
6/8 schools plan to continue the language
groups, as well as incorporating the ideas
into class work.
The other schools plan to use the strategies
within existing class work.
One school was creating an advice file for
working with speech and language difficulties.
A bookmark with the story plan was devised for
all students to keep with their reading books.
Key benefits reported by the more recently
qualified therapists:
Developed confidence in training teaching
Many therapy ideas and useful resources.
Seeing how language therapy can encompass
National Curriculum areas, and be adapted
for future use by schools.
Useful for coping with large numbers on
the caseload.
Main disadvantages and suggested improvements
from the more recently qualified therapists:
Reduced time for therapists usual area of work,
and stretched them in another direction.
Project was general, with limited opportunity
to focus on more specific issues.
Teaching assistants would benefit from a
briefing meeting before the groups and then
another meeting in the last week for questions
and adapting the project for their own use.
A rating scale could measure the teaching
assistants confidence in working with children
with speech and language difficulties before
and after the project.
Future plans of the more recently qualified
One therapist has decided to increase the
amount of school-based work in her caseload.
Another therapist was planning to run similar
groups in the schools she visits.
The third therapist will use the programmes
and advice when preparing reports for
school-aged students.
wnnng ways seres (+)
Susan came to me in a terrible
state, crying most of the time.
She had a job, which she had
applied for with great enthusi-
asm. Everything about it
appealed to her, and she
thought she would be able to
work to her strengths.
Unfortunately, the stress of
staying ahead of the job, juggling a busy home life
and operating alongside someone with a very dif-
ferent working style meant Susan had totally lost
sight of herself. Her self-esteem and self-confidence
were rock bottom. Interestingly enough, she didnt
look like she wasnt coping - but, although she
looked fabulous, she was falling apart inside.
When we are overwhelmed everything becomes a
challenge. My tactic with Susan was to get her to
tease out the big tangle of problems. To write them
all down and look at ways of tackling them one at a
time. We called solving the problems a project.
Suddenly our work had a purpose, with a beginning
and an end. Each challenge was graded with a level
of difficulty rating - 10 is unbearable, 1 isnt a prob-
lem at all. Then we set to, picking the challenges off
one at a time. One of the main things causing Susan
to be so frustrated was that her very best qualities
were not being put to good use. With time spent on
building her self-esteem she was able to approach
her boss and explain in a calm way that she was
unable to give of her best because of poor commu-
nication and poor organisation in the workplace.
Susan also reviewed how she looked on her work
colleague. We explored the reasons why this other
person behaved the way she did, and looked to
changing Susans attitude rather than expecting the
colleague to change. Eventually, Susan decided to
change her job but by that time was sure enough of
herself to go for the kind of workplace where she
would be able to contribute according to her skills.
Life Coaching is about transformation, from caterpillar
to butterfly. This might sound fanciful, but hold your
opinion just for a minute. People come to coaching
because they want to make changes in their lives. If peo-
ple just want to wander round the mulberry bush a few
times, only to be reassured that their problem really
does have no solution, then Im not the coach for them.
I always assume that the only person you can
change is yourself. When Viktor Frankl was impris-
oned in a concentration camp and had literally every-
thing taken away from him, he states that the only
thing he had any control over was his own attitude.
Managing director
I also believe that every challenge has a solution. It
might not be the obvious one but there will be one
and, through coaching, the client will find it. Through
coaching, people can discover the rules and values
that govern their lives. We all live by rules and values
but, if you dont actually know what they are, then
someone else is running your life. Coaching helps you
to be the managing director of your own life.
Sadly, we live in a competitive world. Our society
values those who win the race, get to the top of the
slippery pole of promotion, and elbow all difficulties
out of the way in order to gain that elusive thing -
success. However, the winning ways that this column
will be dedicated to are not necessarily those valued
by the vast majority of society. In my work, both in the
coaching and the counselling field, I endlessly meet
people who would seem to be successful but are
deeply unhappy because they eventually realise that,
if success means living in a state of stress and pretence,
staying ahead and not being themselves then,
although it might look like winning, it feels like losing.
Winners are people who recognise the boundless
potential in themselves and others. They see them-
selves and anyone that they deal with as wonderfully
unique. The most important thing to them is not
achievement, but being honest enough to be yourself
in all situations. As Shakespeare said in Hamlet,
This above all: to thine own self be true, And it
must follow, as the night the day, Thou canst not
then be false to any man.
From caterpillar to
you want to
work to your strengths
make changes n your e
nd soutons
Read ths
Life Coach Jo Middlemiss
believes that every challenge
has a solution and that,
ultimately, the only person
you can change is yourself.
If you feel ready for a
transformation, read on...
Once you decide to be a winner you can give up the
energy loss that goes into putting on a performance.
Winners need not fret about what other people are
thinking about them. They know the difference
between acting caring and being caring, acting the
fool and being a fool. If they know something, they
helpfully share it; if they dont know something, they
are not afraid to acknowledge that fact. Not hiding
behind a mask frees up a winner to step into their
own confidence. They have realistic views of their
own strengths and weaknesses. They are prepared to
listen to the opinions of others, but generally come
up with their own considered judgement about how
to behave. Winners do not play the victim role, nor
do they blame others for the situation in which they
find themselves. Wherever they are, they know deep
down that they are their own bosses. Winners get
their timing right. Their responses are appropriate.
They know about and acknowledge their emotions
as helpful signals. They love life and rejoice in their
own and others achievements. They are brave in the
face of setbacks and joyful about ordinary things.
Even when the world seems a terrible place, winners
do not see themselves as powerless. When Mother
Teresa was challenged that her work was but a drop
in the ocean, she quoted Armand Marquiset in reply:
The ocean is made up of drops. A winner works to
make the world a better place.
My guiding principles when working with a client are
firstly to believe in their unique magnificence, no matter
who they are, and secondly to get them to believe that
they only have to be better at being themselves. They
are already fine and good enough, but limiting beliefs
and behaviours may be holding them back.
How can we apply these two ideas to this winning
ways column?
To apply coaching techniques directly and specifically
to the speech and language situation.
To recognise that speech and language therapists
are people like everyone else.
Issues around promotions, interpersonal relationships,
work / life balance, physical / mental / spiritual
health can all be included plus a sharing of the trials
which seem to be unique to the profession.
I am learning about the huge range of your work
through preliminary discussions with speech and
language therapists. Your charges range from
preschool infants to elderly people who have had a
stroke. Your profession is sometimes misunderstood
as just about speaking when in fact it is about effec-
tive communication. Other challenges you face
include juggling caseloads, balancing work and life
and even seemingly minor ones such as carrying
equipment around.
As I go through back issues of Speech & Language
Therapy in Practice to read myself into the challenge
of writing for it, I am impressed with the high level of
ongoing professional development, not to mention
the wide range of situations in which therapists might
find themselves. Common to many of the articles is an
emphasis on inclusion for all and Valuing People,
but frustration can build when you feel your
employers dont value you as much as you value
your clients. In Unlocking the voice (Steven et al,
2002), I also saw many parallels with coaching. In
coaching we might say we are unlocking the voice
and also the heart. As Dr Bernie Segal says in his
wonderful book Love Medicine and Miracles,
...when you live in your heart magic happens.
Would you tell me, please, which way I ought to go
from here? That depends a good deal on where
you want to get to, said the Cat. I dont much care
where - said Alice. Then it doesnt matter which
way you go, said the Cat. - so long as I get some-
where Alice added as an explanation.
(From Alice in Wonderland by Lewis Carroll.)
Jo Middlemiss is a qualified Life Coach with a back-
ground in education and relationship counselling,
tel. 01356 648329,
Frankl, V. (1997) Mans Search for Meaning. Simon &
Schuster Inc.
Siegel, B.S. (1998) Love, Medicine and Miracles:
Lessons Learned about Self-Healing from a Surgeons
Experience with Exceptional Patients. Perennial.
Steven, L., Thompson, J. & Brown, D. (2002)
Unlocking the voice. Speech & Language Therapy in
Practice Autumn: 14-17.
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Jo is therefore offering readers a confidential and
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heres one l made earer
Alison Roberts continues to generate low-cost ideas
for flexible therapy activities.
Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.
Do l know the rues and vaues governng
my e'
Do l share what l know and acknowedge
what l dont'
Do l aow mtng bees and behavours
to hod me back'
Card. Index cards, or half-size index cards.
Taskmasters blank cards would give a superior
effect (5.75 for 200, see
As many pictures of car logos as you can get your
hands on. (Weekend newspaper colour supplements,
or other car magazines are good sources.)
Instead of car logos, you could use clothing logos
(Nike, Adidas and so on), or small pictures of
cosmetic items like nail varnish and shampoo, or
the ever popular chocolate bars. In fact you can
use anything that fits on your cards. Some
supermarkets produce good photos of food and
other items in their leaflet handouts, so this can
provide another source of free pictures.
Learn or make a note of the car manufacturer
corresponding to each logo, or write on the cards.
Stick one logo on each card. Note: you can vary the
level of difficulty in picture pairing, choosing to show
either identical images, or perhaps the logo on one
card and an image of the car itself on the other.
In practice (I)
1. Place the cards face up on the table. The number
presented at a time is up to you, but I have found
it best to start with three pairs to convey the idea,
and then build up. (For some clients you may end
up with as many as 15 pairs on the table.) Turn
the cards over and muddle them up.
2. Turn two cards over. If they are a pair, the player
keeps them. If not, turn them over again.
3. Play passes to the next person. The winner is the
one with the most pairs.
In practice (II) (a version of Kims Game)
1. Place just one of each of the card pairs (so that all
the cards are different) face up on the table. The
number presented at a time is up to you. I have
found it best to start with three to convey the
idea, and then build up.
2. Turn the cards over and muddle them up. Take
away one card, hide it, and turn the others face up
again. The client must guess which one has gone.
3. You could of course take away more than one
card at a time.
one round biscuit tin, approximately 20cm
in diameter
three 2-metre lengths of strong nylon cord.
six rubber grommets, large enough for the
cord to pass through
1. Drill six equally spaced holes around the side of
the tin, about halfway down the side, the diameter
of the inner core of the grommets.
2. Fit the grommets on the holes in the tin.
3. Tie the cords together in the middle, and thread
the ends through the grommets.
4. Tie knots in the ends of the cords to form handles.
In practice
1. Sit the participants in a circle on the floor, or
around a table, with the tin in the centre.
2. Each person should hold a rope.
3. Place six treats in the tin - in a bag is a hygienic
idea - and state that they may only take one treat,
and that they may only do so when the tin touches
them. (If your group has challenging behaviour, you
may need to restrict the number to one treat at a
time, and then top up after each turn.)
4. They are now allowed to pull on the ropes, but
they will soon find that the tin will only touch some-
one if everyone allows it to - that is, five people must
slacken their ropes while one person pulls.
Car logo pelmanism
, , , ,
Place your, or your clients, hand on the platen of the
photocopier; close the lid and preferably cover with
a white cloth to exclude daylight. Take a photocopy
and then copy this several times once you are satisfied
with the image. Older teenagers seem to like to
photocopy their own hands. (If you have any Health
& Safety qualms about photocopying clients hands
then you can draw around their hands instead.)
In practice
Use the hand image to make an insightful and
esteem raising poster. Head the poster How I
help or As a friend I ...
Fill in a quality or two in each finger, or the
palm. You may need to add white stickers if
the palm is too dark on the photocopy.
Consider using the other copies for similar
posters, such as My strengths, My hobbies,
My favourite sports.
For a group setting you could cut out the hands
and stick them onto a larger sheet as if reaching
for each other.
How I help people poster
, , , ' ,
Cooperation tin
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, , ' ,
Heres one
I made earlier...
he report Provision of speech and lan-
guage therapy services to children with
special educational needs (England)
(2000) advocated that the greater part of
the provision for school age children with speech
and language needs should be embedded within
the curriculum and take the childs education con-
text into consideration. Since then many speech
and language therapy services have reorganised to
work within schools, and no longer provide a clinic
based service to school age children.
I have worked in schools most of my career, am a
strong advocate of working collaboratively with
teachers, and now manage a large diverse service. I
believe it is vital to consider a number of basic principles
and, indeed, the purpose of and process for provid-
ing a service within schools to avoid leaping from the
frying pan into the fire - and inappropriately reor-
ganising services to the detriment of all children.
Does working in schools ensure that provision is
embedded within the curriculum or takes the edu-
cation context into consideration? I would argue
that it may not, and may even be less effective if a
therapist does not have relevant training and / or
experience, or consider a few basic principles.
My other concern is what happens to preschool
children? Given that all speech and language thera-
py services suffer a shortfall in resources and that
provision into school adds increased demand to a
service, are these children getting the intervention
they need early enough and at a frequency sufficient
to reduce the possibility of severe long-term prob-
Principle 1 What is the individual need?
First, therapists should always carefully consider the
individual childs speech and language needs and
whether they have an impact on the childs ability to
learn. Difficulties which have the most implications
for learning are:
Significant language delay
Language disorder
Some general learning difficulties where there is a
verbal / non-verbal skill discrepancy and the aim is
to reduce the discrepancy.
It may therefore be more effective to work with
these children in schools rather than in a clinic.
Sometimes a combined approach may be best initially.
For example, a child with an expressive language
disorder and developmental verbal dyspraxia may
be initially best treated by a block of intervention in
a clinic setting, followed by a period of consolida-
tion when the therapist could take the opportunity
to visit and advise the school. Similarly, if a childs
primary presenting problem is a speech difficulty,
direct therapy within a clinic can be highly effective,
although sound generalisation and phonological
awareness may be best achieved at school. School
visits may also be necessary to complete assessments
in some cases, for example assessment of a child
with a possible pragmatic language disorder.
Principle 2 Who is the main focus?
It is important to then consider who should be the main
focus of input. If it is the parents, then a clinic or home
setting is likely to be the most effective environment to
facilitate change. If the child is the main focus and their
needs have implications for learning (for example con-
cept work), then the school is the best place to inter-
vene. If the difficulties have little impact on learning,
then clinic may be the most appropriate setting.
Principle 3 Why are we intervening?
Why we are intervening at all is an essential question
as this establishes the primary purpose, and enables
therapists to look ahead to the predicted outcome
for the client. Kate Malcomess developed eight care
aims, which give us a framework for considering
these important questions prior to intervention:
Assessment - to determine the nature and
impact of the condition
Enabling - to maximise use of existing function
Supportive - to support the client to cope optimally
with their present condition
Curative - to facilitate lasting change in function,
to within normal limits (chronological
age / pre-morbid state)
Rehabilitative - to facilitate improvement / lasting
change in function
Maintaining - to stabilise / maintain / preserve
Palliative - to reduce pain and / or increase
comfort when no other change is
possible or appropriate
Anticipatory - to prevent the development of, or
reduce the risk of difficulty
These care aims relate to the child not the environ-
ment and, once the reason for intervening is estab-
lished, therapists can then decide not only what to
do but where to do it. School visits must therefore be
considered in this context, and should be provided
when it is important that the school has a key role in
the development of the childs skills because of the
impact the childs difficulties have on their learning.
The combined effect of a therapist considering the
individual childs speech and language need, who is
Out of the
frying pan,
servce management
make decsons about
where therapy shoud
take pace
work wth / through
other proessonas
have to prortse
Read ths
Discussions about clinic
or school based therapy
can get quite heated.
Alyson Portch warns
that, by pulling out
of clinics and
concentrating on
schools, the profession
is in danger of getting
its fingers burned.
Instead she argues we
should be grilling
ourselves about what
combination is right for
each individual, and
what will enable us to
continue giving an
appropriate service to
all children, irrespective
of their age.
A big part of the success of working in schools must
therefore be not only selecting the right children but
also learning to value the specific differences in the
roles of teachers and therapists and sharing skills to
enable us to work together to help children. From the
therapists point of view, this involves learning and
understanding the educational context, and a sound
knowledge of the curriculum and staged approach to
managing special educational needs via the new Code
of Practice (2001). It is therefore essential that joint /
shared training takes place in local areas to ensure this
knowledge base is established and skills developed.
On the job training is also highly beneficial as a
study by Jannet Wright (1994) highlighted; therapists
and teachers who worked together grew to really
appreciate what they learnt from each other and
increased their knowledge of what
each had to offer. This ultimately
must influence the successful out-
come for children with school based
speech and language therapy provi-
Our service is piloting a new ser-
vice for delivering speech and lan-
guage therapy to non-statemented
school aged children whose needs
would be best met through a col-
laborative approach with school
staff. The children are identified by
speech and language therapists
who complete a referral form
including current support in school
and the rationale for school based
input. We have assigned a named therapist to each
school for these children, and ensured the school
also provides a named contact with protected time
for discussion and carrying out activities. Via the
Special Educational Needs Co-ordinator (SENCO), we
ask the teaching staff to complete a two page ques-
tionnaire on each child which covers skills in listen-
ing / attention (1:1 and class group), understanding
of language (following instructions, answering ques-
tions, gleaning information from stories and class
discussions), expressive language (telling news,
vocabulary, sentences), pronunciation, use of lan-
guage (interaction with adults and peers), general
academic progress (reading, number work, writing
and spelling) and anything else they think is rele-
vant. In the questionnaire we also ask for feedback
about how useful the school has found our input. In
preparing programmes, speech and language therapy
staff draw on a list of useful assessments and therapy
materials (figure 1).
the main focus of intervention and the reason for
the proposed intervention should therefore enable
therapists to decide where it is best carried out.
Principle 4 Proper procedures
The procedure you follow is also crucial to your success.
My experience suggests that before arranging a
school visit it may be helpful to:
Send a questionnaire to the school requesting further
On receipt, either telephone the school to discuss the
information, or discuss it during the school visit.
Arrange a visit and confirm it in writing. This letter
should clearly explain the purpose of the
visit and the format your visit will take, such
as staff you need to see, or observation in
class. The letter should also make it explicit
that parents will be invited to attend for
part of the session if they so wish.
A letter should also be written to the parents
to inform them of this.
During the visit:
Make any observations / assessments of the
child within class
Share findings with staff
Listen carefully to teachers concerns and
priorities (and if possible the parents / carers)
Develop shared / agreed curriculum focused
targets with the teacher and discuss and agree
ways in which these targets can be
implemented at school and monitored
Agree roles - therapist, teacher and parent.
If it is essential that specific work is undertaken
with a child, it is important that school identifies a
named adult who will be responsible for working
with the child and therapist and implementing the
targets. This is more likely to ensure a positive out-
come. If this is not available but you consider it to
be essential, school visiting may not be beneficial.
After the school visit, provide a written record for
staff, parents and other professionals which summarises
your observations and assessment, your discussion and
any agreed plan of action, and identifies agreed targets,
strategies for achieving these and how you have agreed
these should be implemented and monitored.
Principle 5 Collaborate and learn
SENDA (2001) has strengthened the rights of children
with special educational needs to be educated in
mainstream school. This inclusive agenda means more
children with difficulties will be educated in mainstream,
creating a challenge for teachers and therapists alike.
Figure 1 Resources for school-aged children
Bracken (1998) Bracken Test of Concepts
Bracken Basic Concept Scale - Revised.
Psychological Corporation.
Dunn, Dunn, Whetton & Pintilie (1982)
British Picture Vocabulary Scales. NFER-
Harrison & Portch (in preparation) School
age screen (SAS).
Renfrew (Renfrew Action Picture Test, Test
of Word Finding, Bus Story) available from
Semel, Wiig & Secord (2000) Clinical
Evaluation of Language Fundamentals
). Psychological Corporation.
Wiig & Secord (1992) Test of Word
Knowledge. Psychological Corporation.
Therapy materials
From Learning Materials ltd, tel. 01902 454026:
Looking and Thinking (books 1-5)
Reading for Meaning (books 1-4)
Reading for Meaning More (books 1a-4a)
Reading and Thinking (books 1-5)
New Reading and Thinking (books 1-6)
From Winslow, tel. 0845 921 1777
Think it - Say it - improving reasoning and
organization skills, by Luanne Martin
(1995), 32.95
From Speechmark,
Working with pragmatics, Lucie Andersen-
Wood & Benita Rae Smith
From Black Sheep Press
First / Last / Next
Before / After
Parts of the Day
Why / because
Facial Expressions
Speaking and Listening Through Narrative
From The Psychological Corporation,
Describe it - games to build descriptive lan-
guage skills, by Thomas-Kersting,
McCormack & Satin (1998)
CLIP Worksheets: Semel & Wiig (1991)
1. Syntax
2. Morphology
3. Pragmatics
4. Semantics
From LDA,
Socially Speaking - a pragmatic social skills
programme for pupils with mild to moderate
learning difficulties, by Alison Shroeder, ISBN
1 85503 252 X
From STASS, tel. 01661 822316
Cambridge Language Activity File
From ECL
Practical Language Activities - Materials for
Clinicians and Teachers by JoAnn H. Jeffries
& Roger D. Jeffries
Auditory Processing Activities - Materials
for Clinicians and Teachers by JoAnn H.
Jeffries & Roger D. Jeffries
From Manchester Metropolitan University,
tel. 0161 247 2535
Functional Communication in the
Classroom by Maggie Johnson
into the fire?
servce management

A big part of the

success of working
in schools must
therefore be not
only selecting the
right children but
also learning to
value the specific
differences in the
roles of teachers
and therapists
and sharing skills
servce management
Figure 2a) Case example
Cameron has
moderate bilateral sensori-neural hearing impairment (aided)
severely disordered expressive skills, profoundly delayed language skills and
moderate speech difficulties (some associated with hearing impairment)
Early therapy
- Clinic based, speech and language intervention with some written
correspondence and telephone contact with school.
Year 4
- No additional funding.
Year 4 Spring term:
- Therapist works with school, parents and other professionals to get LEA
funding for extra support (at that time 15 minutes per week for 1:1 or small
group work with SENCO)
- Cameron attends clinic sessions; liaison with school for advice / strategies
Year 4 Summer term / Year 4 Autumn term:
- Extra funding granted on hearing impairment needs. Prioritised by school and
parents for specific hearing impairment resources to support Cameron within
- General classroom assistant support, continuation of 1:1 / groups with SENCO
for 15 minutes per week.
- SENCO becomes named contact
- Cameron and parents still attend clinic sessions
- Clinic input focuses on speech skills and language work / vocabulary,
especially verbs.
- Copies of advice / targets given to school via parents after each clinic session.
- Input at school limited, focusing on general advice / strategies and support
for SENCO and school staff.
- SENCO has regular meetings with staff, who then try to support / reinforce
advice given, wherever possible within the classroom environment.
Figure 2b) School visiting example
Write up of visit

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Figure 2c) Update to programme
Target 1
Cameron will consistently choose the correct multiple-choice questions / answers,
targeting his development of inferencing skills in Looking and Thinking Book 1 activities
Cameron finds it difficult to look at visual material and make an inference from the
information he can see. This is due to the fact that the skill requires more abstract thinking.
Strategies / activities
Please use materials enclosed and answer the appropriate corresponding A/B questions
from Looking and Thinking Book 1. In the materials provided, multiple-choice
answers are given but Cameron may still require adult prompting to complete the
task. In particular give prompts to encourage him to think outside the immediate context
and not just how it relates to himself.
Encourage Cameron to make his reasoning process explicit eg. prompt with how do
you know? type questions. This will help him understand the steps he needs to go
through to make an inference / prediction. Continue to encourage Cameron to identify
when and what he has not understood.
Target 2
Cameron will consistently use a voiced loud regular past ending during structured
Cameron has difficulty using regular past tense endings (-ed) because of his hearing
There are two forms of regular past tense endings
a) -ed - spoken with a d sound (eg. served)
b) -ed - spoken with a t sound (eg. walked)
d is a loud sound and t a quiet sound. Due to Camerons hearing impairment, the loud
regular past tense endings will be worked on initially as they are easier for him to hear.
Strategies / activities
Please use materials enclosed from Yesterdays Verbs and follow instructions on
each page. Identify and group words with -ed endings (into loud and quiet) and
practise in writing tasks.
Target 3
Cameron will learn 80 per cent of class topic vocabulary
Cameron has a specific problem learning new vocabulary and relating it to previous
Strategies / activities
Cameron to develop my little book of words noting key vocabulary items and new
words which he comes across. Prior to introduction of the topic, new vocabulary will
be rehearsed with Cameron and then revised after the lesson.
Use topic webs, linking words by association where possible. When explaining what
new words mean try to put them into categories and link them to words which he
already knows. Rehearse the vocabulary through action, activities and experience at
school and at home. Throughout tasks, encourage Cameron to identify any words he
has not understood.
Year 5 Spring term
- 1 hour per day learning support assistant time allocated from
funding. Used mainly for general support within classroom
(hearing aid maintenance, repeating instructions, explaining
tasks / vocabulary meanings, completion of work etc.)
- Therapist continues to work with named contact / SENCO and
occasionally with class teacher / learning support assistant.
- SENCO has regular meetings with learning support assistant
and class teacher to plan and discuss action / progress.
- Clinic therapy ends, as only language needs remain and all
parties feel these needs best met within school environment.
- Speech and language therapy school visits 1 per term.
- Frequent written correspondence and telephone contact
between all parties.
Year 5 Summer term
- 1 hour per week support not meeting all Camerons hearing
impairment needs and only some of speech and language
therapy needs.
- SENCO and parents feel greatest area of need is speech and
language so 1:1 hour per day with learning support assistant
focuses on speech and language therapy strategies.
- Frequency of speech and language therapy visits to school
increases to three per term.
- Focus of school visits becomes more specific and target based.
- SENCO remains named contact, having regular meetings with
class teacher and learning support assistant.
- Liaison and support for learning support assistant become
primary aim; high level of input demonstrating and advising
on tasks and approaches to use during specific 1:1 slots and
classroom support.
- SENCO continues to meet therapist at each visit to clarify
outcomes and maintain overall responsibility.
- Statement applied for and finalised to commence in Year 6.
We must not let speech and language therapy
become just another task that teachers cannot
possibly undertake. We dont need another black
mark against our profession. If services and each
individual therapist consider the principles and
procedures listed, then appropriate decisions can
be made about where we should be targeting our
resources based on what the individual child
requires (see case example in figure 2a) - c), p.18).
This, coupled with effective training and collabo-
ration with school staff, should mean preschool
children do not suffer because of inadequate
resources and that the greater part (not all) of the
provision for school age children ... is really
embedded within the curriculum and takes the
childs education context into consideration.
Alyson Portch is Head of Childrens Speech and
Language Therapy Services for Hertfordshire
Partnership NHS Trust at St Peters House, 2 Bricket
Road, St Albans AL1 3JW, tel. 01727 829415.
Thanks to Cathy Goodbun and Lisa Cookson,
speech and language therapists.
DfEE (2000) Provision of speech and language
therapy services to children with special educa-
tional needs (England): report of the working
group (DfEE 0319/2000). Online at
DfES (2001) SEN Code of Practice. Department for
Education & Skills. (tel publications centre on
0845 602 2260, quoting ref. 581/2001).
Malcomess, K. (2001) The reason for care. Bulletin
of the Royal College of Speech & Language
Therapists 595: 13-14.
Portch, A. & Harrison, P. (2002) Clarifying priori-
ties. Bulletin of The Royal College of Speech &
Language Therapists 599: 7-8.
Special Educational Needs & Disability Act (2001)
From The Stationery Office or online from the
Queens Printer of Acts of Parliament at
htm). Crown Copyright 2001.
Wright, J.A. (1994) Collaboration between speech
and language therapists and teachers.
Unpublished PhD thesis, University of London.
servce management / revews
Themed Activities for People
with Learning Difficulties
Melinda Hutchinson
ISBN 0 86388 307 9 34.95
This resource manual has 20 objects as
the basis of activities to use with people
with profound and complex learning
difficulties. It has a very clear, straight-
forward layout, is well organised and
the activity sheets can be photocopied.
Its very easy to read. It provides ideas
for group work, using readily available,
low cost items (for example, take a
Whilst the book contains some creative
ideas, we found some suggestions sim-
plistic. It is therefore of limited value to
the experienced clinician and not partic-
ularly good value for money. It would be
a useful tool for teachers or generic sup-
port workers who work with people with
more moderate learning disabilities.
Rafaella Peerutin, Debbie Charles and
Louise McMillan are speech and language
therapists for adults with learning disabil-
ities in Newham Primary Care Trust.
Skills for Daily Living:
Personal Safety
ISBN 086388 474 1 26.95
These cards come with a booklet that
lists each situation clearly. Each card is
numbered so can be easily cross-refer-
enced to the list. The cards are well
drawn in colour and would be appro-
priate for use with adults, older chil-
dren, and adults with mild learning
disabilities. Both newly qualified and
experienced therapists could use the
cards. The basic themes - such as immi-
nent danger and everyday situations -
are good. However, some of the cards
are quite abstract or have complex
themes. This may be confusing
depending on the individuals own
experiences of everyday situations.
A useful tool to stimulate discussion,
highlighting an individuals level of
insight within different situations, the
cards could be used with both individ-
uals and groups. Overall, my col-
leagues and I felt they would be of
most use in a group setting.
Sue Martin is a speech and language
therapist in London.
The Social Toddler (Promoting Positive
Helen & Clive Dorman
The Childrens Project
ISBN 1 903275 38 5 15.99
This is a useful and enjoyable read for both experienced and
inexperienced therapists working with toddlers and their par-
ents. The authors believe that by showing why children of 2-4
years behave the way they do, their parents and carers will be
better able to understand them and respond appropriately.
The attractive use of photo pictures showing sequences of toddler
behaviour in contexts helps the reader absorb and relate the ideas
to real situations, while avoiding telling the parent what to do.
The many examples of young childrens behaviour and development
at different stages provide the therapist with a real opportunity to
generate discussion when used together with parents. At the very
least this is a useful reference for parents and therapists seeking to
gain insight into the mysteries of toddler thinking.
Grainne Hampson is a senior speech and language therapist at the
Department of Child and Family Psychiatry, Mater Hospital, Dublin.
Teamwork. A Guide to Successful
Collaboration in Health & Social Care
Sue Hutchings, Judy Hall & Barbara Loveday
ISBN 0 86388 276 5 25.95
This book covers the basic concepts of collaboration, prerequi-
sites for success, benefits, barriers and pitfalls. Each chapter
ends with a summary of the key points discussed, and many
with an opportunity to reflect, and formulate an action plan of
personal or service level goals. The authors are from health
backgrounds (occupational therapy, physiotherapy and nursing)
although all now work in professional education. Hence some
speech and language therapy settings may find it easier to
relate to this book than others. However the general principles
of collaboration apply to all. This is a useful and practical refer-
ence for those embarking on multi-professional working.
Judith Anderson is the speech and language therapy coordi-
nator (mainstream services), Cotswold and Vale PCT.
Find the Link (game)
Diana Williams
ISBN 0 86388 421 0 48.75
This resource does what it says on the box in that it provides an
attractive word finding and category game. The 200 good quality
Colorcard pictures are useful in themselves and ideas are given
for a number of different games. My secondary aged students
generally gave it a thumbs up but some of the materials, partic-
ularly the clothes category pictures, are aimed at much younger
children. Also the insects category includes an earthworm and
snail which would upset a lot of science teachers! However this
resource will not be staying in the back of my cupboard as it is
regularly requested by my students as a fun activity.
Karen Kelly is a specialist speech and language therapist at
the secondary speech and language base, Twynham School,
Christchurch, Dorset.
Do l have gudng prncpes
to hep me pan and dever
my servce'
Do l ensure a partes agree
on each persons roe'
Do l back up conversatons
n wrtng'

Were you at the conference in Edinburgh? I won-

der what challenges you came away with.
I felt there were four key messages:
1. Evidence based practice is a
process of different actions
2. There are different levels of evidence
3. The researcher may be a different person to the
consumer of evidence
4. Real evidence based practice requires collaborative
networks across our profession.
But what do they mean in practice?
1. The process
Evidence based practice for me includes the fol-
lowing steps:
The question Should I use therapy x?
How can I measure y?
Finding the Literature search
evidence Critical appraisal techniques
Summary of findings
from the literature
Generating the Design and execute a
evidence therapy trial / test an
assessment tool
Dissemination Discussing findings
Apply validated Decision making informed
ideas by evidence as well as
by clinical insights
A question is always the beginning for an
enquiry into the literature. Typically it takes the
form should I use therapy X (or Y)? or How can
I measure (change in) X? Then either the litera-
ture addressing that question can be scrutinised,
or some new evidence needs to be generated. The
conference papers were often about therapy or
assessment evaluations. Some papers instead
were about the critical appraisal process. (Here we
can commend Hanneke Kalf of the Netherlands
for a whistle stop tutorial in summary statistics
and critical appraisal techniques; I imagine only a
few understood all of her notation.) Others
spoke about the need to integrate the literature
with clinical judgement and insights: memorably
noting that what makes the speech and lan-
guage therapist wise is not just expert knowledge
of their domains but an understanding of the
issues of the human condition. There were also
poster presentations dealing with clinical decision
making. Yet none of the papers I attended actu-
ally talked about case studies or examples of the
application of evidenced-based ideas.
2. The levels
The concept came through that there are different
levels of evidence which have acceptability for
practice. Not just the randomised controlled trials,
but treatment delay / withdrawal group trials,
experimental group studies, individual case studies,
case reviews and expert opinion. Sylvia Taylor-
Goh of the Royal College of Speech & Language
Therapists gave a helpful overview of an evidence
hierarchy for evaluating literature. Different lev-
els of evidence address different types of ques-
tions. It is not simply a case of sighing over our
fields lack of randomised controlled trials, and
then saying that we cannot do evidence based
practice as a result. One level of evidence may be
a stepping stone towards developing practice
even if it is not top-notch evidence. The face
validity and clinical acceptability of some more
recent therapy innovations has as much to do
with their take up as the supporting evidence
with which they were launched.
3. The people
Given the several steps within the evidence based
practice process, and the many different ways of
gathering or demonstrating evidence, it is clear
that not every speech and language therapist can
carry all these roles. Some are born to it, and
some achieve it, but others object to being thrust
into all of it. Why not let the Thinkers pose the
questions, the Methodical gather the data, the
Clinically Wise introduce a debate and process of
Continuing to
cover story
change? With this concept some people are the
researchers and others are the consumers of
research. What is needed is not more polymaths
but more networking between teams. Then the
practitioners will be enabled to have a practice
based on evidence.
4. The collaboration
The issue of who does what can only really be
addressed at the highest levels. We have excellent
training centres, strong researchers and research
centres, many teams of practitioners and even
funding opportunities awaiting us. The next
stage for the profession has to be integrating
these sometimes remote corners of our field into
collaborative networks. These ideas can be
extended not just nationally but internationally:
otherwise what is the point of having CPLOL and
the Royal College of Speech & Language
Therapists meet together?
In terms of strengths, the most obvious character-
istic of the conference was its diversity. There were
delegates from all over Europe and some from
further afield as well. Simultaneous translation
into French or English was professional and
CPLOL is the Comit Permanent de Liaison des Orthophonistes-Logop` edes de lUnion
Europenne, in other words the organisation for speech and language therapists across
Europe. Its 5th European Congress, entitled Evidence-based Practice: a challenge for speech
and language therapists, was held in conjunction with the UK professional body the Royal
College of Speech & Language Therapists in Edinburgh from 5-7 September, 2003, .
Delegates at a European Congress were asked to consider
the challenge of evidence based practice for the speech
and language therapy profession. Frances Harris dissects
the proceedings, and suggests where we go from here.
e-mas to the edtor
cover story/ e-mas to the edtor
impressive, taking into its stride all sorts of jargon.
The diversity of people and languages was seen
also in the range of poster presentations and
speakers. The posters were generally of a high
standard; not only well displayed, but also show-
ing clear thinking. The conference benefited from
a strong foundation of good organisation and
clear communication. The room allocations
worked well, with advance selection of seminars
by the delegates proving very helpful.
When not in the conference centre, Edinburgh
provided well for social possibilities, even when a
major rugby match with Ireland seemed to take
over many restaurants capacities. Informal discus-
sions and meeting old colleagues were a real
bonus of the weekend for me.
As well as the three keynote speakers, there
were numerous presentations to smaller groups,
with parallel sessions running concurrently. Here
the range of topics was wide, but so also was the
quality. The unfortunate Frenchman with only a
one per cent return rate on his questionnaire
struggled to maintain credibility as he went into
detailed analysis of his results. Audiences were
provided with a CD file of the presentations. In
practice this meant (without my laptop) that I
could not read abstracts or texts in advance, and
audiences could only think of discussion questions
at the time of the presentation.
Over the refreshments and meal times, interna-
tional huddles were rare; my impression was that
delegates tended to stay in their cultural groups.
I also felt that there was insufficient time or
opportunity to draw together the ideas from the
conference. The concluding round table discussion
(in fact an oblong dias for the keynote speakers) for
me should have been at the beginning of the
weekend: it worked well to open up debate and
could have been used to draw out key messages
to a much greater extent.
I came away with these challenges:
Who takes the lead at different points in the
evidence based practice process?
How can we promote collaboration between
therapists and research teams?
How can we be more transparent about applying
evidenced-based ideas to practice?
How can we achieve cross-national discussion of
ideas, evidence and practice?
The sound bite of the weekend, however, goes
to Kath Williamson: Evidence based practice
should be a climbing frame and not a cage. I
want to continue to climb.
Frances Harris is a speech and language therapist
with the Sure Start speech and language
development project at City University, London.
Further thoughts on the conference from editor
Avril Nicoll at
21 October 2003
Dear Avril,
One of the many ways of communicating with people is through the written word.
Professional posters at conferences are one form of communication for which guidelines
may be drawn up. These give advice on how to catch the eyes and interest of the
passing audience. At another level of communication, instructions may need to be given
in writing to someone with a learning difficulty or with dementia. Mencap has already
produced very helpful guidelines for accessible writing, available as a pdf file through its
website ( This is clearly directed at a specific audience, although
interestingly contains some good advice for poster presenters!
At the Dementia Services Development Centre, University of Stirling, we are
considering a similar production but geared to people with dementia. Lest duplicating
work already done, does anyone know of an existing text that provides guidance for
those needing to communicate in writing with people with dementia? Or should we
develop guidelines on writing in a way that is clearly understood by this group of
Responses would be welcome by staff at the Centre and to Marion Munro in the first
Marion Munro
Publications Coordinator
Dementia Services Development Centre
University of Stirling
Stirling FK9 4LA
Tel: 01786 467740
Fax: 01786 466846
15 October, 2003
Dear Avril,
I was interested to find your website, and wondered if you are aware of the ground
breaking research conducted by Professor Sue Buckley at The Down Syndrome
Educational Trust ( in Portsmouth?
They have established, through peer reviewed research, the enormous benefit of early
reading (preschool reading, as young as 2 or 3 years) in helping develop speech and
language in children with Down syndrome. (Some preschool children are demonstrating
a capable level of reading and comprehension before they can even speak.)
DownsEd are recognised worldwide as a Centre of Excellence and regularly have people
travel from overseas to attend their workshops and training days for parents and
professionals. (They also conduct workshops specifically for speech and language therapists).
They publish a wide range of information booklets in their Issues and Information Series,
and they produce speech and language resource materials which, in the early years, we have
found invaluable in developing our daughters speech and language.
With their help, through training workshops and also by having our daughter attend
their Early Development Classes, our daughter was reading before she started school
aged 4
/2 years, and now aged 7 she is still reading at a level one year ahead of the level
expected for typically developing children of her age. (I know of several other children
with Down syndrome who have also excelled in reading.) Along with the sound card
resources, early reading has had an enormous benefit on the development of speech
and language for our daughter.
I am a grateful parent and, looking through your website, I hoped that our experiences
may be of interest to speech and language therapists generally.
Kind Regards,
Greg Sneath
Speech and Language
Difficulties in the Classroom
Deirdre Martin & Carol Miller
David Fulton Publishers
ISBN 1 85346 845 2 17.00
This book discusses childrens language
development and language difficulties in
the context of the classroom. It is written
primarily for teachers and other educational
professionals. The text is relevant and easy
to read, including chapters on speech and
language difficulties, difficulties in reading,
writing and spelling, comprehension diffi-
culties and working in a team. The authors
emphasise the need for good collaborative
practice in assessment, planning, interven-
tion and outcome measures. Timetabled
sessions for joint working being the key to
There is useful discussion on the strong links
between communication difficulties and
emotional and behavioural difficulties. The
book has been well researched with refer-
ences at the end of each chapter. A useful
book to share with colleagues in education.
Ann Gosman is a speech and language
therapist with NHS Orkney, based at the
Health Centre in Kirkwall.
Supporting Communication
Disorders (A Handbook for
Teachers and Teaching
Ed. Gill Thompson
David Fulton Publishers
ISBN 1 84312 030 5 15.00
This is a helpful guide for identifying and
evaluating communication disorders in the
classroom setting. It advocates early inter-
vention and continued work alongside a
speech and language therapist. Easy and
enjoyable to use, particularly for someone
with limited experience of communication
disorders. Empowers the reader by provid-
ing useful and practical information along-
side clear guidelines as to if and when
referrals should be made.
Good value for money, introducing a wide
range of relevant topics in simple and
coherent terms, without overloading the
reader. The practical activities and work-
sheets are useful both for identifying diffi-
culties and overcoming them. All of these
are clearly explained and easy to use.
Alice Burton is a teaching assistant in a
school for children with Autistic Spectrum
Disorders and Complex Learning
Disabilities in Manchester.
Education Support Pack for Schools
(Mainstream: Primary and Secondary)
Downs Syndrome Association
Limited free availability (also downloadable
free from
I found the Education Pack for schools
from the Downs Syndrome Association
Concise yet
Extensive in content.
Well documented
Easy to read and
User friendly with
Snappy bullet points.
Full of ideas and
The type of resource that everyone working
with Downs children in mainstream schools
should have.
Shona Barclay is a nursery teacher with Howe o
the Mearns Nursery, Kincardineshire, Scotland.
Speech & Language Intervention in
Down Syndrome
Jean Rondal & Sue Buckley (Eds)
ISBN 1-86156-296-9 35.00
This book contains eleven chapters written by dif-
ferent authors. It covers all aspects of speech and
language development in individuals with Down
Syndrome from prelinguistic development
through to maintenance training in older ages.
Each chapter contains current research and guide-
lines for intervention. At a time when therapists
are being asked to provide evidence based therapy,
this is a valuable resource.
The organisation of the book means it is possible
to read just the chapter that is relevant to you at
the time or the whole book. I think it would be
useful to therapists new to working with this
client group and to those with more experience in
the field. It is a book that I will refer back to and
it would be a useful addition to any departments
Carolyn Alvis is a speech and language therapist
with Salisbury Healthcare NHS Trust.
Talkabout Activities
Alex Kelly
ISBN 0 86388 404 0 32.50
As with Alex Kellys Talkabout, this is a well-
designed manual that provides useful information
presented in a clear, concise and humorous manner.
It comprises activities aimed at developing social
communication and is organised into the same levels/
chapters. Activities are cross-referenced to relevant
worksheets in the original book and worksheets can
be photocopied.
This would be a very useful resource even without
reference to the original. It could be used for many
social skills groups or for useful activities alongside
other published approaches. Suitable for adults and
children, variations are suggested to alter task com-
With its guidelines on running groups and bibliography,
Talkabout Activities would be informative for stu-
dents and their supervisors, but also practical for
more experienced therapists who would appreciate
ideas or who wish to give advice to teachers / carers.
Can be used by therapists with differing levels of
experience and with a range of clients. Well worth
the price.
Clare Beasley is a speech and language therapist with
the North Durham Learning Disability Team, working
with adults who have learning disabilities.
Social Skills Programmes (An
Integrated Approach from Early
Years to Adolescence)
Maureen Aarons & Tessa Gittens
ISBN 0 86388 310 9 29.95
This programme upholds the clinical rationale for the
overt teaching of social skills for children with specif-
ic social communication difficulties (with or without
diagnosis). Based on extensive clinical experience, the
authors offer an extremely practical and user-friendly
resource with clear handouts and invaluable advice.
The book provides a programme of 10 group ses-
sions for children with average cognitive ability
within four age-bands: 3-5, 5-7, 7-11 and 11-16 years.
The authors directly address issues such as joint lead-
ership with teachers, evaluation and record keeping.
The programmes are detailed and use everyday
materials. Consistent with autistic spectrum disorder
learning style, sessions are highly structured with
repetitive elements and use visual support extensively.
Generalisation is addressed through parent work-
shops, detailed handouts, weekly homework tasks
and ongoing evaluation after the group has ended.
A very welcome practical resource for therapists of
all levels of experience.
Ali Kennett-Brown is the Clinical Lead for Autism,
South Birmingham PCT.
how l...
In the past, alternative and augmentative
communication was perhaps seen as a rather exclusive
field - but this is changing.
A small number of service users will always need
specialist input using high tech equipment and it is
important that we have therapists who keep up with the
breathtaking pace of improvements in the capacity and
flexibility of technology. At the same time, however, we
have greater awareness of the fundamental importance
of all therapists developing an inclusive and enabling
communication environment for everyone.
Whether high tech, low tech or a combination of
methods, our three contributors demonstrate why the
implementation of AAC needs strategic thinking,
practical skills and a strong focus on the needs of users.
How I
Read ths
coud make more use o AA
nd ads are not used by cents
have dcuty accessng specast
Practical points: AAC
1. Respond to long-term and
changing needs
2. Focus on building opportunities for
3. Take time to reflect
4. Understand why AAC is used - and
why it is not
5. Network to share skills and secure
6. Work from the clients level but
leave room for growth
7. Be as consistent as possible
8. Check that meaning is shared
9. Provide an appropriate range of tools
10. Involve users, families and carers
at every stage.
To find out more about AAC, check out CASC Road Shows. They...
Provide an overview and an update of specialised communication aid technology for use by people
with complex communication needs.
Are sponsored by the UK Trade Association of Communication Aid Suppliers (a sub-group of
Communication Matters)
Include mini-master classes on latest products presented by their manufacturers and suppliers
Have a full day programme including time for browsing, hands-on and discussion, and workshop sessions
They are intended for...
People new to the field of AAC and voice output technology
Professionals specialising in this field who want to keep up-to-date
Everyone with an interest in communication technology
Anyone who works with children or adults with complex communication needs
Presenting companies can include...
Cambridge Adaptive Communication, Don Johnston, Liberator, Prentke Romich International, QED 2000,
Sensory Software International, Sunrise Medical / Dynavox, Crick software and Widgit.
They are FREE.
A list of CASC Road Show dates is at
Janet Scott is a speech and language therapist
at SCTCI, Westmarc, Southern General Hospital,
1345 Govan Road, Glasgow G51 4TF,
tel. (0141) 201 2619, e-mail
Please note:
Janet Scott does not endorse any particular
graphic (or other) symbol system or approach,
and the views expressed are her own.
Sally Millar is a speech and language therapist
at the Communication Aids for Language and
Learning (CALL) Centre, University of
Edinburgh, Holyrood Road, Edinburgh EH8
8AQ, e-mail
Cheryl Davies is a specialist speech and
language therapist at Denewood Centre,
Denewood Crescent, Bilborough, Nottingham
NG4 2FT,
tel. 0115 915 9619,
simple line drawing. Unless the photograph is
carefully set up with good lighting on a non-dis-
tracting background selected to provide a good
contrast to the target item, the end product may
well pose an interesting figure-ground quandary -
the opposite of what was intended. For others,
three-dimensional, tangible symbols (or objects of
reference) may be more appropriate - perhaps as a
stepping stone to more abstract levels of represen-
tation (Rowland & Schweigert, 1989; 2000).
How genuinely guessable / transparent is
the symbol?
Graphic symbols can be graded along a spectrum
of iconicity (the visual relationship between the
symbol and its referent). At one end are transparent
symbols; at the other, the relationship between the
graphic symbol and the referent is opaque or
arbitrary. Translucent symbols fall somewhere in
the middle - the meaning may not be immediately
apparent but becomes obvious once it is explained.
Most symbols are accompanied by text (the gloss).
For people who can read, this tends to disguise
how opaque even a fairly pictorial symbol actually
is. Test out your friends with a selection of symbols
with the gloss removed. How many can they
understand? How far from the accepted meaning
are they? Even the most pictorial symbol systems
involve a degree of lateral thinking, of metaphor,
of life experience and simply of remembering what
the particular symbol means.
Culture has a huge impact on peoples understand-
ing of what they see and hear. The further away
our clients life experiences are from our own, the
less we should assume that we share a common
meaning. Perception of symbol meanings varies as
a function of culture / ethnicity (Huer, 2000).
However, cultural differences can be very subtle
indeed. Phillips (2001) identified distinct differ-
ences in the understanding of the phrase play
with your child. Life experience is so important in
shaping our understanding. Early in my career I
realised a client thought there were five types of
people: girls and boys, women and men - and
wheelchairs. Given the language he heard around
him every day and his extremely limited life experi-
ence, this was an obvious link to have made: Line
the wheelchairs up at the door, The wheelchairs
go in the bus first, and even Wheelchairs have
their dinner first - they take longer to eat.
3. Flexibility:
Shades of meaning can be hard to convey, and mor-
phological and syntactical markers may be lacking
in a graphic communication system. Where the
emphasis is on a functional means of communica-
tion, full grammatical sentences can seem a luxury.
However the use of graphic symbols to represent
higher level linguistic concepts may influence how
language is acquired, understood and produced
(Sutton et al, 2002). One of my clients demonstrated
how l...
Figure 1 Comparison of picture producing versus non-picture producing symbols across four different symbol systems
Blissymbol Makaton PCS Rebus
MacDonald (1998) suggests you consider three
main aspects of a graphic symbol system:
1. Construction:
Ease of reproduction?
Computers, scanners, photocopiers have made it
much easier to create good, high quality images
time after time.
Visual abilities?
We need to be aware of our clients visual skills -
their field of vision, their acuity, whether they are
sensitive to contrasting levels of brightness between
different surfaces, their colour vision and so on
(Aitken & Buultjens, 1992). A significant percentage
of people with cerebral palsy have a cognitive visual
impairment; they may also have problems with visual
acuity and motor dysfunction affecting their ability
to coordinate their eye movements. Some of the
more pictorial symbol sets have detail, which may be
distracting for some. We might need to think about
whether colour or black and white symbols would
be easier. It might be helpful to accentuate or high-
light the salient part of the symbol with glitter, a
bright colour or a different texture. We might need
to think about the background for the symbol dis-
play (to make the figure ground contrast more
effective), or the spacing of the symbols, and even
whether to laminate the displays (and if so, whether
to use matt laminate rather than the standard,
cheaper shiny variety).
2. Level of symbolic representation:
Are graphic symbols appropriate?
For some people photographs and other more con-
crete referents will be easier to understand than
even the most pictographic symbol. However for
others they can be more visually confusing than a
Of the confusing number of
graphic symbol systems, how
do you choose which one to
use? The best? The one you
know? Whats been used in the
past? Or, like me, the easy
option (one with a computer
package which creates high quality materials)?
Before computers, I recall hours at the photocopier
then cutting and sticking, and the laborious tracing
or drawing of symbols. I remember scouring mag-
azines and catalogues for pictorial material to
make up communication charts. That still goes
on, but usually it is to supplement a more stan-
dardised symbol set - then it was the symbol set!
Perhaps, though, we actually thought more about
how and why we used graphic symbols? Maybe it
is time to re-evaluate our choices?
Sadly, there is no perfect graphic symbol system;
each has its strengths and weaknesses, each its fer-
vent proponents. Choice of one over another should
be based on the needs and abilities of the client. UK
mainstream graphic symbol systems include
Blissymbols, Makaton, Picture Communication
Symbols and Rebus. Symbol systems associated with
particular high-tech communication aids include
DynaSyms (also known as PicSyms in their low-tech
life), mainly used in the DynaVox family of communi-
cation aids, and Minsymbols (or multi-meaning icons)
used in the Minspeak family of communication aids.
Finally, a number of other graphic symbol systems
have been developed to meet a local need or a spe-
cific client group such as the Bonnington Symbol
System designed to help communication, informa-
tion and access, and a set from Speakability to help
people in the early days of aphasia.
Every symbol system has to be taught to its users,
some are more pictorial than others, some symbols
are fairly easy to guess the meaning of, others are
not. Abstract language is always difficult to convey in
a pictorial way (compare the more concrete mental
image generated by the spoken word house or tree
with the feeling / association of happy and with the
idea / concept of under or this - see figure 1).
Get out there and use it!
There are many things to
think about when choosing
a graphic symbol system.
Janet Scott takes us through
the decision-making process.
Blissymbols are reproduced
from Bliss for Windows -
Export Program, Pub.
Handicom, The Netherlands,
Makaton symbols are
reproduced from The
Makaton Core Vocabulary
Data Base Pub. Makaton
Vocabulary Development
Project, Camberley, Surrey,
Rebus Symbols are
reproduced from Symbols for
Windows 2000, Pub. Widgit
Software Ltd., 124 Cambridge
Science Park, Milton Road,
Cambridge, 2003.
PCS are reproduced from
Picture Communication
Symbols, 1981-2002,
Mayer-Johnson Co., PO Box
1579, Solana Beach, CA 92075,
a cookery session), dinner place mats (for
lunchtime chat), hard backed folding boards, cred-
it card sized symbol wallets, keyring / chain on a
belt clip, stuck inside a plastic lunchbox with carry
handle, on an apron or vest (Goossens & Crain,
1992) or mounted on an eye gaze (ETRAN) frame.
In its most complete form, a communication book
is a full-scale formal communication system, consist-
ing of a large bank of symbols and words, providing
the user with access to a comprehensive vocabulary
covering any and every situation. To produce an
efficient communication book, consider:
1. Design
First consider the basics - size, shape, weight,
style. A4 ring binders are often too unwieldy and
- importantly - uncool. A5 size display folders or
FiloFax style (from office supply catalogues, sta-
tioners and photo shops) are better, with pages in
plastic pockets or laminated.
For people using the Picture Exchange
Communication System (PECS), the communica-
tion book is organised very specifically using
Velcro strips on each page, with each individual
symbol Velcro-backed, so that it can be easily
how l...

A communication book is a
simple, low-tech aid to commu-
nication either on its own or as
part of a range of augmenta-
tive communication methods.
Communication books are on a
At one end of the continuum are resources
whose primary purpose is to provide listeners and
potential communication partners with back-
ground and day-to-day information about the
person (which might or might not be accessible to
the client). These include Personal
Communication Passports (Millar, 2003) and home
school / centre diaries.
In the middle ground are resources such as a sym-
bol diary, which provide some element of back-
ground information, and also a shared context for
conversation using text, photos, pictures and sym-
bols. Other examples are:
a scrapbook or Clue Book in which the writer
attaches objects of significance, such as a birthday
candle, shop receipt or cinema ticket, plus a
prompt to launch an appropriate conversation
path (Guess where we went on Saturday).
a more structured Conversation Book which
scripts exact questions for the communication
partner (Ask me where I went at the weekend;
Ask me where I like to go best) alongside the
symbols which will provide the answers.
a photograph album to stimulate conversation.
Captions or accompanying stories can be written
in symbols if that helps. (The easy-to-use new
Talking Photo Album (Liberator, 32) is a cheap
and cheerful way to turn photo albums into
communication aids.)
Towards the other end of the continuum are
resources used more independently for day-to-day
interactive communication. Displays can be of a
limited amount of vocabulary linked to one specific
setting or topic, or a full-scale vocabulary bank.
Symbols can be displayed in all sorts of ways,
including: laminated topic sheets (such as for use in
the importance of not neglecting these grammatical
features when he spontaneously generated this
novel message: Grandpa sore leg get (then he
selected the past participle key) got bandage. I
was so excited to hear this as he had only been pro-
vided with a symbol based electronic communica-
tion aid three months previously, when he was 3;11.
Abbot (2000) provides a useful overview of the
main reasons for using graphic symbols, such as
for accessing information, to support inclusion, to
aid comprehension, to develop literacy skills. It
can be helpful to ask yourself:
Why do I want to use the symbols?
What am I hoping to achieve?
Why am I introducing symbols in the first place?
In addition, you should consider:
What other graphic symbols systems are in use?
Look not just at the clients current school or
resource centre, but also at what is used in the
local environment and wider community.
What support is available?
Symbols become more functional if they are not
the preserve of the therapy cupboard! Look for
computer packages for writing, symbol games,
books with symbol support, using symbols in
email, symbolised websites.
Symbols are becoming more mainstream in our
increasingly visual, pictographic world. Graphic
symbols are on crisp packets, our computer
screens, clothes labels, by the side of roads, at air-
ports. Symbols can make a real difference for the
people we work with (see Walker & Keating
2000a and b; Trapnell & Chapman, 2002).
However, remember that the graphic symbol set
used is the language encoding system for its user -
how they think, how they work out what the world
means. Dont change or introduce a new system with-
out a lot of thought. Try to be consistent across all the
different things the person uses - computer program
for writing, the symbol set in their high-tech aid and
in their low-tech display. Apart from that, dont worry
too much about which symbol system to use. Just
choose one, and get out there and use it!
Abbott, C. (ed) (2000) Symbols Now. Widgit
Software Ltd.
Aitken, S. & Buultjens. M. (1992) Vision for Doing:
Assessing Functional Vision of Learners who are
Multiply Disabled. Moray House Publications,
Sensory Series No. 2.
Huer, M.B. (2000) Examining Perceptions of
Graphic Symbols Across Cultures: Preliminary Study
of the Impact of Culture/Ethnicity. Augmentative
and Alternative Communication 16 (3): 180-185.
MacDonald, A. (1998) Symbol Systems, in Wilson,
A. (ed.): Augmentative Communication in
Practice: an Introduction - revised edition. CALL
Centre, University of Edinburgh.
Phillips, J. (2001) The Culture of Community: Do par-
ents and speech and language therapists mean the
same thing when they talk about play? Paper pre-
sented at the XXV IALP World Congress, Montreal.
Rowland, C. & Schweigert, P. (1989) Tangible
Symbols: Symbolic Communication for Individuals
with Multisensory Impairments. Augmentative
and Alternative Communication 16 (2): 61-78.
Rowland, C. & Schweigert, P. (2000) Tangible
Symbols, Tangible Outcomes. Augmentative and
Alternative Communication 5 (4): 226-234.
Sutton, A., Soto, G. & Blockberger, S. (2002)
Grammatical Issues in Graphic Symbol
Communication. Augmentative and Alternative
Communication 18 (3): 192-204.
Trapnell, N. & Chapman, J. (2002) Reading with
Symbols at Frederick Holmes School.
Communication Matters 16 (1): 29-31.
Walker, L. & Keating, F. (2000a) Being Arrested.
Grampian Primary Care NHS Trust (for more infor-
mation contact Lynn Walker, Speech and Language
Therapy Department, Woodlands Hospital,
Craigton Road, Cults, Aberdeen AB15 9PR).
Walker, L. & Keating, F. (2000b) Being a Witness.
Grampian Primary Care NHS Trust (see 2002a).
Blissymbols (Blissymbolics UK c/o the ACE Centre,
92 Windmill Road, Headington, Oxford OX3 7DR)
Makaton (The Makaton Vocabulary Development
Project, 31 Firwood Drive, Camberley, Surrey GU15 3QD)
Picture Communication Symbols (Mayer-Johnson
Co., Box 1579, Solana Beach, CA92075-1579, USA)
Rebus (Widgit Software Ltd., 124 Cambridge
Science Park, Milton Road, Cambridge CB4 0ZS)
DynaSyms (Sunrise Medical Ltd., AAC Department,
Sunrise Business Park, High Street, Wollaston,
West Midlands DY8 4PS)
Minspeak (Prentke Romich International,
Minerva House, Minerva Business Park,
Lynchwood, Peterborough, Cambs PE2 6FT)
Bonnington Symbol System (Bonnington Resource
Centre, 200 Bonnington Road, Edinburgh EH6 5NL)
Speakability, 1 Royal Street, London SE1 7LL.
Communication - by the book
Sally Millar explains how
different communication
books match different
clients abilities and
Look, stop, come, like, help
I (me, mine), you/yours, Mum, Dad,
More, not
(I need the) toilet: I feel bad;
Ive finished; more please; I like it; I dont like it; I
want; I need
Whats happening?; When?
Youve got that a bit wrong, Im going to start
again; its something like; opposite; sounds like
(Yes & No unless they can be indicated clearly in
some other, unaided, way.)
I like to mount this frequently used vocabulary
on the inside covers of the book, around the out-
side of the symbol pages that are cut smaller than
the total area of the binder. Another strategy is to
have the core vocabulary on a separate page
attached to the inside cover of the front of the
book that unfolds out to the left hand side, to be
permanently visible and accessible whilst the user
turns to different vocabulary pages of the book to
the right. With smaller books, the actions and sen-
tence starters might be down the left hand side of
each page, with descriptors across the top of the
page, each colour-coded.
3. Symbol books and language development
To develop a users linguistic ability, the book
needs to reflect the users actual level of language
and cognition ability, plus room for growth.
Latham (2003) has developed a prototype com-
munication book design based on her earlier work
at the Redway School (Latham & Miles, 1997) in
which vocabulary is not only divided up into core
and fringe vocabulary but also into developmental
stages 1-5 (matching the bands outlined in the
book). A Stage 1 left-hand core page has a few key
words and phrases, while a Stage 5 core page has
fold-outs with a full set of core chat words,
questions, pronouns, and starters.
It is important, however, not to overlook low
tech, simple options. One of my most successful
AAC solutions consisted of a piece of white paper
with the letters of the alphabet on it (in QWERTY
rather than alphabetic layout, to link with com-
puter use) cut to size and inserted into a clear

detached and exchanged with the communi-

cation partner either on its own or attached
to the sentence strip.
Full-scale communication books can con-
tain photos, pictures, symbols or words, or a
mixture of some or all of these. The layout
has to be both logical and intuitive to navi-
gate around and find the symbol required,
and physically possible for the user to indi-
cate. The organisation, layout, style and cho-
sen size and number of symbols per page has
to take into consideration a range of factors,
Vision and visual perception, visual processing,
visual scanning
Developmental, cognitive and linguistic
Motor planning
Accessing method (direct pointing (range?
accuracy?) or indirect, such as eye pointing,
However the book is organised, it should
include explicit guidance for communication
partners and helpers about what to do and
what not to do to help the user, what they
should expect the user to do, and ideas for
when and how to use the book. This will
include clear instructions about how the
partner is expected to model book use by
pointing to symbols themselves as they chat
with the user.
It is usually helpful to have an index page,
and coloured dividers and staggered tags
(with colour or symbol on them) to help part-
ner and user alike to locate sections of the
vocabulary quickly. Typical sections for a child
might include home, people, places, activities,
body parts, feelings, food & drink, clothes, ani-
mals, transport, school (weather, colours, num-
bers, money, time, reading book characters.)
On vocabulary pages, colour coding can be
used to make it easier for users to scan
through and visually locate specific symbols.
Unless some other specific colour code is in
operation, I suggest the Fitzgerald Key
scheme (verbs in green, people in yellow, descriptors
in blue, determiners, prepositions etc. in white or
grey, objects, places and other nouns in orange (and
sometimes red), social phrases in pink.) (If coloured
backgrounds are used, symbols may need to be
black and white / transparent, rather than coloured,
to make the page less visually busy overall.)
2. Vocabulary selection and organisation
Selection of vocabulary will be coordinated by
one person, often the speech and language ther-
apist, but input will be sought from everybody
with whom the book user is in contact, especially
parents and family. Once everyone has been
informed about the plan to develop the book, cir-
culate an ordinary exercise book with vocabulary
page headings on it, leaving people to fill in the
words and phrases that they feel are important to
the user in various contexts. This will ensure firstly
that vocabulary is relevant and motivating, and
secondly that family and team members feel
involved and have a sense of ownership, making
them more likely to use the book constructively.
Mechanisms will be put in place to update vocab-
ulary regularly.
We have to ensure that books contain a full
range of communication functions (not just lists
of nouns, I want requests, and one-word
answers to questions). Include vocabulary for
attention grabbers, questions, conversation main-
tenance, interjections, and comments and so on,
and a mixture of different parts of speech.
Once collected, vocabulary will commonly be
divided up into frequently used and highly func-
tional core vocabulary and specific but vital
fringe vocabulary which keeps conversation
going. (Nobody says I had food - they say I had
a ham and tomato toasted sandwich and a coke,
at the Silver Spoon.)
Users may need some of the core vocabulary so
often that it needs to be displayed all the time.
Depending on developmental level, these might
include frequently used key vocabulary, social
phrases, sentence starters, and vocabulary expan-
sion strategies, for example:
Figure 1 Communication Books Continuum
How much involvement does the person have in the communication?
How independent is communication?
not at all little some, with support more even more, most
much wider range
Varying degrees of
input from person
possible; lots of input
from family.
Diary written in
symbols, Photo
album, Personal
scrapbook, Clue
book, Conversation
Simple topic related
display, eg. topic chart,
daily lunch menu,
storyboard, activity
choice cards.
Input from person is
often prompted. Use
may be modelled by
partner as aided
language stimulation.
Full scale
communication book;
word board, letter
Full vocabulary
available: input from
person is largely
independent but
output is mediated
- sometimes
developed and
expanded, always
spoken out loud and
/ or scribed - by
Voice output aid
Input is fully
(though introduction
and learning process
may be long).
documentation and
records, assessments,
reports etc.
No input from
how l...
diaries, scrapbooks, and so on, which may all be
drawn in at some point in the conversation to fill
an information gap, prevent or untangle misun-
derstandings, or illustrate a point.
The strengths and advantages of low tech com-
munication books are many. A book is cheaper than
a voice output communication aid, though we must
not forget the hidden - and recurring - costs which
include loads of staff time, and also software,
colour printer cartridges, laminator and laminate. A
book is sometimes also simpler and quicker to use,
and is accessible to all sorts of people in the widest
range of day-to-day contexts.
Goossens, C. & Crain, S. (1992) Engineering the
preschool environment for interactive symbol
communication. Birmingham Al. SouthEast
Augmentative Communication Conference
Proceedings, available in UK from Cambridge
Adaptive Communication.
Latham, C. & Miles, A. (1997) Assessing
Communication. David Fulton Publishers: ISBN:
Latham, C. (2003) personal communication.
Millar, S. (2003) Personal Communication
Passports: Guidelines to good practice. CALL
Centre, ISBN 1 898042 21 1.
Pound, C. & Hewitt, A. (2003) Conversation
Partners and Communication Access: a roadmap
to inclusion. Presentation at Communication
Matters Symposium, Lancaster, September 2003
Sahian, D. (2002) Fitzgerald Key
ACE Centre North - Developing and Introducing
Communication Books,
CALL Centre website (Passports Section &
Resources) (also downloadable Clicker grids and
BoardMaker topic charts)
Cambridge Adaptive Communication (Mayer
Johnson communication folders and symbol
resources books, BoardMaker and Handicom
Symbols for Windows (software)
Clicker 4 (software): information from
Liberator Ltd. (talking photo albums)
Mayer Johnson (communication folders and
Speaking Dynamically Pro (software))
Pyramid Educational Consultants UK Ltd. (PECS
communication books & other materials)
The Grid (software): information from
Widgit Software (Writing with Symbols 2000,
ideas and resources, link to Symbol World site)
(A fuller version of this article with accompanying
pictures will be on the magazines website from publication of the
Spring 04 issue at the end of February.)
how l...
college with a voice output device received limited
support from non-specialist therapists. The aim of
the AAC service was to dovetail with the childrens
service to include young adults with physical dis-
ability and adults with a learning disability who
needed a communication aid. The bid included 0.5
whole time equivalent therapist time for assess-
ment and ongoing support, assistant time and a
budget for communication equipment.
I was appointed with several years experience
working in AAC. One of my first jobs was to review
all the people known to the service. At the back of
my mind was the knowledge that several AAC
users no longer used their device, and I wanted to
get an overview of why this was. Maybe the aid
was no longer suitable? Perhaps insufficient speech
and language therapy support had led to a lessening
of skills? In fact problems included broken devices,
a Minspeak system only used in spell mode plus
the client felt it was too heavy, and expired war-
ranties. Some families had received no training in
AAC or the communication aid, and others were no
longer physically able to use an aid.
I assessed that the adults with learning and / or
physical disabilities population fell into broadly
three groups of clients:
Groups of clients Speech and language
therapy time needed
1. Those who have never
used a voice output
communication aid
2. Those who have been
introduced to AAC at
school or college and
have ongoing needs
3. Proficient users
In her Keynote Speech at
Communication Matters 2002,
Dr Pam Enderby stated that peo-
ple with alternative and aug-
mentative communication
needs require long-term speech
and language therapy support
for review of their physical status and to keep up
with evolutions in technology. Specialist AAC speech
and language therapists for adults are nonetheless
thin on the ground. I have had the opportunity to
develop this kind of service in Nottingham and hope
my experience will contribute towards our under-
standing of good practice in this field.
The post of specialist speech and language ther-
apist for AAC to work with adults with learning
and / or physical disabilities was realised in
January 2002 after a five year campaign by Sue
Thurman, the manager for speech and language
therapy services to adults with learning disabili-
ties in Nottingham. She had made a case of need
and submitted bids to the Health Commissioners
for Learning Disabilities. Initially funds became
available for equipment - but Sue declined this
until there was someone in post who knew how
to use it. Prior to this, people leaving school or
A case of need
It took five years for
Nottingham to get a specialist
AAC post for adults.
Cheryl Davies charts the
initiatives, successes and
ongoing challenges of the
first 18 months.

plastic zip pencil case bought in Woolworths for

49p! This could be folded into a pocket or bag and
brought out on any occasion when oral speech
attempts ran into trouble and backup was called for.
Trials have shown that the intelligibility of someone
with indistinct dysarthric speech, such as that of
many people with cerebral palsy, can be massively
increased if the user points out even just the first let-
ter to help listeners decode what they are hearing.
While Passports, diaries, photo albums, conver-
sation books and letter boards may be hand-
made, a computer is necessary to produce an
acceptable-looking full-scale symbol communica-
tion book. Key software will probably be either
BoardMaker (with Mayer Johnson Picture
Communication Symbols (PCS) only, printout
only); or Writing with Symbols 2000 (Widgit
Rebus, PCS, or Makaton symbols, printout and / or
onscreen use). But remember that high tech voice
output communication aid software such as The
Grid, Symbols for Windows, Speaking Dynamically
Pro, Clicker 4 will also offer printout options, so if
your client is using a computer-based voice output
system, you could use the same software for both
the high and the low tech version.
The many different types of communication
book meet different needs (figure 1). In an ideal
environment, people with communication diffi-
culties can use not just one but as many as they
find helpful. Pound & Hewitt (2003) refer to such
resources as communication ramps providing
access to social conversation, and show videos of
people with aphasia sitting with their listeners at
tables covered with several different albums,
familiarisation with
the aid
staff training
training new staff
identifying and
supporting new
environments and
communication needs
updating vocabulary
on the aid
staff training
I set out to establish baselines, to audit and
review, identify equipment needs and liaise with
all parties who would potentially have contact
with the service. I visited speech and language
therapists in hospital and childrens services with
AAC roles, Disabled Persons Act Workers, the
Independent Living Team, the local Further
Education college, Day Services for people with
physical and learning disabilities, SCOPE and
Disabilities services. I also linked with communica-
tion aid services in the region and nationally to
network and gain support for current and good
practice. I was already secretary of the Trent
Region AAC SIG.
I have now been in post for 18 months and
would like to give examples of initiatives, ongo-
ing issues and some successes:
1. User group
I was very keen for all AAC users and their parents /
carers in the area to get together and we have now
met three times. I am supported in this by speech
and language therapy technical instructors. My ini-
tial aims were for the communication aid users to
meet other users, have a social communication
opportunity and have fun. We have generally split
into two groups so that we can:
share experiences of supporting a person using
a communication aid
develop resources that can help new carers
focus on the positive aspects of AAC and
potentially have an advocacy role for AAC services
in the area.
At the last meeting Stuart Meredith, a proficient
communication aid user and excellent role model,
came to talk to the group. The best part has
been seeing the users having conversations.
2. Funding
In AAC this is always a major issue and in all ser-
vices there is no one funding agency that will pay
for equipment. For further information refer to
CAP and ICES websites (see resources). I am taking
part in a pilot study with ACE-North to look at
extending the CAP model into adult services,
which will help raise the issue of the continuing
difficulties in funding for communication aids. A
way forward has to be for funds to be ringfenced
for communication aids.
how l...
The AAC service receives a budget from health
for equipment and resources. This was spent ini-
tially on assessment tools, a device for one client
and equipment for a loan bank. I have also
accessed funds through the Learning and Skills
Council for a student in full-time education,
secured funds from an Further Education college
towards a mounting system and social services
have agreed to part fund one aid using Direct
payments. An ongoing issue will be the replace-
ment of older devices balanced against the needs
of people with no aids. This year we have paid for
warranties and funding or part-funding four aids.
3. The first new communication aid user
My first new communication aid user was Brian
(40). His day centre has provided a high level of
support to help the introduction of the aid. He
has used it to clarify and repair communication
breakdown. Everyone is pleased with that and
there is potential for more skills development.
This was also my first opportunity to co-work with
another speech and language therapist in the
team who had previously provided a communica-
tion book. We have looked closely at our roles
and how to complement each others skills.
4. The speech and language therapy team for
adults with learning disabilities
The team has a high level of expertise in signs and
symbols. They support clients and their communica-
tion environments. My role within the team is clearly
for high tech equipment. We are developing joint
working practices to utilise skills including those of
technical instructors. There are similarities between
the roles - people with high tech needs also need a
communication book and Personal Communication
Passport. I feel it is part of my role to field the frus-
trations of working with technology!
Things that have helped me tackle this new post
effectively include:
Having knowledge of a wide range of
communication aids from Minspeak systems,
Windows based set ups to less complex devices
with digitised speech. (At the last count the
client group use twelve different aids supplied
by six communication aid companies.)
The support of the Communication Aid Suppliers
Consortium (CASC). They have loaned devices to
help me become more familiar with them and are
always available to demonstrate to users and
their families / carers. The phone support is essential.
Communication Matters conference held at
Lancaster University in September each year.
Websites such as The ACE Centre, CALL Centre,
AAC Intervention, Communication Matters (see
Knowing the geographical area and some of the
resources available.
Apart from the usual joys of working with technology
and not having the time and funds to do as much as
youd like, some of the things I find difficult are:
Working in a community post. It is a real challenge
to support people in a wide range of environments
and to try and meet the training needs of
support staff.
Knowing that best practice is for a multidisciplinary
team approach while working in a fairly
unidisciplinary way. We are working towards
involving other disciplines.
Limited local support for technology and
integrated systems.
Whether its programming an aid, staff training,
helping a user write guidelines for new staff on how
she likes people to communicate with her, liaising
with a counsellor who was working with a client but
had never previously talked to someone using a
communication aid, writing service specifications
and guidelines for budgetary spending or introduc-
ing a new aid to a client, I really enjoy the scope of
my job and the variety of tasks I can undertake.
Ace Centre (
Ace Centre-North
AAC Intervention (
Call Centre (
Communication Aids Project (CAP)
Communication Matters
( (also includes
information about CASC - Communication Aids
Suppliers Consortium - roadshows)
Integrating Community Equipment Services
(ICES) (
Learning and Skills Council (
Minspeak( (
Black Sheep Press
New items in the Winter 2003/4 catalogue
from Black Sheep Press are a narrative
assessment Peter & the Cat (see reader
offer), Story Starter pack to complement
existing Narrative packs, concept packs
(Either / Or and All / Except), two sets of
barrier games and, in Phonology Resources,
revised s clusters.
See, or
telephone 01535 631346 for a free catalogue.
Fragile X
Speech and language therapy features in a multi-profes-
sional book about educating children with Fragile X.
Contributors include Jeremy Turk, Kim Cornish , Cathy Taylor
and Vicki Sudhalter, with each chapter suggesting intervention
strategies based on sound educational principles. Members of
the Fragile X Society are entitled to a reduced rate.
Educating Children with Fragile X is published by
RoutledgeFalmer and costs 22.50
Group Action
Contact a Family, the national charity
for families with disabled children,
has produced an updated pack for
parents who would like to set up a
local or national support group with
other parents in a similar situation.
For a free Group Action Pack,
freephone 0808 808 3555, e-mail, or see
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CASC Road Show
5 December 2003
Durham County Cricket Club, Chester-le-Street
Free to anyone with a personal or professional interest in
communication aids.
Details: Communication Matters, tel. 0845 456 8211.
Connect - the communication disability network
9 December 2003
Collaborating for Change: Practical ideas for how to involve ser-
vice users in designing, developing and delivering services
Centre for Contemporary Arts, Glasgow
Details: Carole Cross, 020 7367 0846, e-mail:,
28-30 January 2004
Lindamood Phoneme Sequencing
(for phonemic awareness, reading and spelling)
18-19 February 2004
Seeing Stars Symbol Imagery
(for phonemic awareness, orthographic processing, reading
and spelling)
20-21 February 2004
Visualizing and Verbalizing
(for language comprehension and thinking)
Details tel. 0207 727 0660,
Afasic Scotland
18 February 2004
Language and literacy in the early years
Details: tel. 01382 561891.
NAPLIC (National Association of Professionals concerned
with Language Impairment in Children)
3 April 2004
Aston University, Birmingham
The Maths and Science Curriculum
Speakers include Chris Donlan, Wendy Wellington, Fiona
Whyte, Sally Eveleigh and Cathy Watson.
Prices from 95-125
Details: NAPLIC, c/o Ann Ellis, Meadow J&I Language Unit, Bristol
Road South, Northfield, Birmingham B3 1SW.
A DEAF Conference
7-8 May 2004
For professionals, clergy, non-professionals, Deaf, Hard of
Hearing, Deafened and Hearing people.
The Brewhouse Theatre, Taunton
Details: e-mail
British Aphasiology Society
13-14 September 2004
Therapy Symposium
University Hospital Aintree, Liverpool
Details: Sarah Ross, e-mail
25 personal UK
21 part-time (5 or fewer sessions) (UK only)
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Note: Cheque and direct payment only. Credit card payments can only be deducted in sterling at the rates advertised above.
vendy Prevezer s
both a speech and
anguage therapst
and a muscan.
She works as a
musc specast at
Sutherand House
Schoo n
Nottngham or
chdren wth
autsm, and runs
musca paytme
sessons or babes
and todders n her
oca communty.
She aso gves
courses and
workshops on
usng musc
to actate
soca and
1. The actual process of
Childrens spontaneous movements,
sounds and words are valued and incorpo-
rated into individual and group sessions.
Interactive games and songs therefore
develop in diverse and often unexpected
ways. These developments give me ideas
to keep up my sleeve and offer as sug-
gestions to others.
By observing and experiencing exactly
what happens when two people share a
song, Ive learned strategies that enable
children to take an active part, such as
using both subtle and dramatic pauses at
key points. Ive seen new life brought to
old favourites... Have you tried Head and
Shoulders slowly and fast, quietly and
loudly, forwards and backwards? Such
contrasts often surprise and delight the
children, and tempt them to communicate
their preferences.
2. One decent drum
Following a childs lead as he explores a
drum often leads to shared play and turn
taking: drum conversations can be addictive!
Quiet children may express themselves
confidently with hands or beaters, and
many are fascinated to hear their own
sounds, movements and words reflected
back to them in drumbeats.
In a group, a drum provides a powerful
joint focus, and can be used in songs and
games to facilitate interaction. A hand-held
one (for example, a bodhran, tambour or
lollipop drum) may be passed round or
offered to individuals and pairs; a bigger
one can stand centrally to draw children
in together.
If you cannot invest in one quality drum,
do explore the sounds you can make with
boxes and tins - you may be surprised.
3. Fabrics
A simple piece of material can be a brilliant
aid to shared play. Chiffon scarves,
thrown and blown, scrunched and hidden
or put over faces, often engage a child. A
sheet provides a place to hide for peek-a-
boo, making eye contact fun and worth-
while for its own sake. Two people under
a sheet often gaze at each other in a
more sustained way, leading to face and
voice play. A Go to sleep song is often a
first step into imaginative play, but
coloured fabrics can be houses, rivers,
tents, grass and so on as well as blankets.
Groups also have great fun with pieces of
fabric. Shaking and stopping together,
raising it above heads, or stretching it
and letting go, can lead to play routines
and songs which act as frameworks for
4. Rosanna Rib Xylophone
This simple wooden instrument is ideal for
sharing, and is attractive, versatile, portable
and sturdy. It can be held vertically and
played from both sides; you can even see
each other between the bars. Its great for
non-verbal musical conversations. Not
being tuned to specific notes, you cant
play a tune on it, which can help people
to lose their inhibitions. It often stimu-
lates exploration, and reinforces learning
about up and down in space and pitch.
Available in kit form, to sand, decorate
and string up. 13.00 plus p&p, from Kate
Baxter, tel. 0115 9609528 or e-mail (Note: A beater is
included, though not the one pictured, as
shorter, sturdier beaters are needed for
young children. Sanded, painted and var-
nished dolly pegs work well.)
5. The Autoharp
If youve never played an instrument and
would like to strum as you sing, this could
be your starting-point. Its a zither with
chord buttons: you simply press a button
with one hand and sweep across the
strings with the other, to produce a rich
harp-like sound. The buttons are labelled,
so you can follow guitar chords from
I use mine mainly to accompany songs for
groups, and its worked wonders for my
singing confidence. Children and adults
are drawn to it, and its hardy enough to
put on the floor for toddlers to explore
with supervision.
Information and courses:
6. Game-Songs with Prof
Doggs Troupe
Generally I try to avoid recommending
just one songbook, but this was my inspi-
ration for flexible songs in the 1980s,
when I was discovering non-directive
techniques. Its definitely stood the test of
time: Ive used Say hello and We can do
anything several times a week for years,
and am not yet bored. The songs are
catchy, easy to learn and very popular,
with opportunities to sing about whatever
a child does or says. When a dinosaurs
feeling hungry and Walking through
the Jungle can also provide frameworks
for more complex verbal conversations.
By Harriet Powell (1983; 2001 with CD),
pub. A.&C. Black.
7. One small dog
Quite apart from the well-known physical
and mental health benefits, having a dog
means daily walking, which gives vital
space and time for creative thinking. Ive
even been known to use non-directive
techniques on my four-legged friend by
singing a commentary on her activity, to
practise fitting words to a tune.
Contrary to popular belief, even musical
people need to practise. On my early
morning walks I rehearse songs (internally,
not usually out loud!) and make up or
adapt words, to the steady beat of my
footsteps. A new song may take one or
several dog walks to compose, depending
on complexity.
8. Informed Intuition
Phil Christie at Sutherland House coined
this phrase, to describe how staff work
interactively. Our instinctive, playful
responses to the children are backed up
by knowledge of their individual needs
and personalities, as well as early commu-
nication skills, autism and interactive
approaches. Knowledge gained from
reflecting on our own practice by thinking
about, discussing and watching video of
sessions also informs how we implement
our intuitive skills.
9. Video facilities
The benefits of having sessions on video
far outweigh the discomfort. We find the
least intrusive way is to put the camcorder
on a high shelf, wedged at an angle to
cover most of the room.
Videos can show progress in communication
skills, including subtle qualities of interaction
that may not have been recorded otherwise.
When watching, we sometimes see and
hear communication that we missed at
the time, and revise our own evaluation.
We can share developments with parents
and other staff, and some children love
watching and commenting on their own
sessions. Edited tapes of extracts are also
invaluable for training, to illustrate tech-
niques and responses.
10. Ourselves
I learned from Dave Hewett many years
ago that a responsive adult is the most
wonderful and flexible piece of equipment
in interactive work. The way you use your
face, voice and body can enhance the
quality of interaction and relationships,
whether or not you incorporate fancy
props and instruments. I spend much of
my working life helping others to see
that their human ability to be sensitive
and flexible, to behave contingently, and
to enter into an interweaving of behaviour
with the pupil is the most valuable
resource of all.
Quotations from Hewett, D. (1989) The
most severe learning difficulties: Does
your curriculum go back far enough? In:
Ainscow, M. (Ed.) Special Education in
Change. David Fulton Publishers.
I also highly recommend: Nind, M. &
Hewett, D. (2001) A Practical Guide to
Intensive Interaction. BILD Publications.
Top: Wendy
with her
Rosanna Rib
One small dog