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ISSN 1368-2105 (print) ISSN 2045-6174 (online)

Autumn 2011

Training Plan, Do, Study, Act New Pathways Working with parents Research into practice Graphic symbols

How I manage acquired brain injury


Journal Club Observational studies Goal negotiation Readiness to change PLUS...heres one...reviews...ethics... in brief... top resource... reader offers www.speechmag.com

Reader offers

Sea Words giveaway!

Win books - Plural!


If you enjoy reading to discover ways to improve your practice, dont miss this opportunity to win one of the latest textbooks FREE courtesy of Plural Publishing. Simply send an email with SLTIP Plural offer in the subject line to avrilnicoll@speechmag.com stating which book(s) from the following list you would like to receive. All entries must be received by 25 October and the winners will be notified by 1 November 2011. Science of Successful Supervision and Mentorship by Linda Carozza Professional Writing in Speech-Language Pathology and Audiology Workbook by Robert Goldfarb & Yula C. Serpanos Psycholinguistics - Introduction and Applications by Lise Menn Handbook of Acquired Communication Disorders in Childhood by Bruce E. Murdoch Mild Traumatic Brain Injury - Episodic Symptoms and Treatment by Richard J. Roberts & Mary Ann Roberts Velo-Cardio-Facial Syndrome Vol. II - Treatment of Communication Disorders by Karen J. Golding-Kushner & Robert J. Shprintzen

Grow Words publishes a range of practical resources that contain photocopiable games, activities and worksheets that target a range of language and literacy skills. This issue, Grow Words is offering THREE readers of Speech & Language Therapy in Practice a CD containing three titles from their Sea Word Series: Vocabulary, Phonological Awareness & Learning Concepts, and Following Directions. Each set is worth approximately 70, but you can enter the draw to win one FREE by emailing info@growwords.com.au with Speechmag Autumn Grow Words Offer in the subject line by 25 October. The winners will be notified by 1 November 2011.

Explore the full range of Plural books at www.pluralpublishing.com, Grow Words is run by two Australian speech pathologists. where you can also pay to download individual chapters of the most Information about all Grow Words resources, including sample popular titles. pages and how to order, is at www. growwords.com.au. See also the review The lucky winners of our fantastic Summer 11 offers are: Patricia Watson, Sara Knox and Suzanne Foster of the companys (Grow Words Regular and Irregular Plurals CD), Kirsty McLaughlan (Photosymbols 4) and Linda Robinson, Food Words on p.7. Janice Maughan and Jean Kennedy (I CAN Secondary Talk Narrative Resources from Black Sheep Press). Congratulations to you all, and thanks to the three companies for their generous prizes. Special thanks to Pete Le Grys at Photosymbols who also sent complimentary packs to two entrants working in Kenya, where resources are particularly scarce.

Previous winners

Win the New Reynell Developmental Language Scales!


The New Reynell Developmental Language Scales is out now and GL Assessment is giving a lucky Speech & Language Therapy in Practice reader the opportunity to win a FREE copy of this revised and newly standardised fourth edition. NRDLS has two scales, one for comprehension and one for production, of selected vocabulary and grammatical features. This edition keeps the play-based format but reduces the amount of stimulus material so it is quicker to administer. The authors Susan Edwards, Carolyn Letts and Indra Sinka selected the key features based on robust evidence, and it has been standardised on over 1200 UK children aged from 2 to 7 years 5 months who have English as their first language. In recognition of increasing diversity, the additional Multilingual Toolkit gives guidance on how to adapt and use the assessment with children who have English as an additional language. The NRDLS would normally cost you 499 + VAT. For your chance to win a copy, email your name and address with SLTIP NRDLS offer in the subject line to danielle.morgan@gl-assessment.co.uk. Entries must be received by 25 October and the winner will be notified by 1 November 2011. Further information about the NRDLS, please visit http://reynell.gl-assessment.co.uk/.

Autumn 2011 (publication date 31 August 2011) ISSN 1368-2105 (Print) ISSN 2045-6174 (Online)

Autumn 11contents
Cover photo of Dan at the Spotted Cow cafe by Charlie Hedley, www.charliehedley.com

Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 email: avrilnicoll@speechmag.com Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor Avril Nicoll, Speech and Language Therapist

27 COVER STORY: HOW I MANAGE ACQUIRED BRAIN INJURY (1) TUNING IN A NEW AUDIENCE ...it is important to note that the supplementary and consequential changes in Dans level of confidence, appearance, growing circle of friends and social activities has occurred over the last year since commencing Melodic Intonation Therapy and between the third and fourth years post injury. Inspired by a presentation at an aphasia special interest group, Lindsay King decided to revisit Melodic Intonation Therapy with 19 year old Dan. (2) THE LOCAL DIMENSION: IN MEMORY OF ZANNAH Overall, Suzannahs outcomes from intervention at the local ICU were positive, as the tracheostomy wean was commenced and baselines were established with respect to swallowing and communication before her transfer. Her case shows why it is important to have a degree of knowledge at local level and also the invaluable role for specialist units in supporting local teams. Laura Flynn on providing the best possible service to a minimally conscious patient in a local hospital pending transfer to a specialist facility.

INSIDE FRONT READER OFFERS Fantastic offers for you in the Autumn 11 issue! A Grow Words resource set, books from Plural Publishing and the New Reynell Developmental Language Scales. 4 TRAINING The [questionnaire] responses... suggest that both Rhys and staff may be using more signs in conversation and understanding each other more successfully. Karen Leadbitter monitors the impact of empowering Rhys - a man in his thirties with Downs syndrome - to participate in training his own support staff.

14 WORKING WITH PARENTS As New Pathways is not a branded package, we have flexibility over which parents can attend and the content...One family wanted to come even though it has been five years since their son was diagnosed, as they now feel that they are ready to take on the information. Lynsey Paterson explains how her service used a literature review to develop parent training following an autism diagnosis. 17 IN BRIEF Diana James uses Paget Gorman Signed Speech to support pupils with specific language impairment; Nicola Groves granddaughters talk about talking. 18 JOURNAL CLUB (5) OBSERVATIONAL STUDIES There are a number of observational research designs, and not all provide robust evidence of causality...The goal of observational studies is usually to identify factors which may be causally related, and thus may be incorporated into interventions which then produce better outcomes in the future. Jennifer Reids series takes the mystery out of critically appraising different types of journal articles. 22 HERES ONE I MADE EARLIER Fortune tellers promote choicemaking, encourage conversation, can be designed for different abilities... Alison Roberts with another low cost, fun suggestion for groups.

23 RESEARCH INTO PRACTICE Regardless of attitudes towards the use of symbols and beliefs about their appropriate usage, the implementation of symbol use in schools is a complex reality. Practitioners in each of the three professional groups considered a range of factors - and their reasons for using symbols with one child may be very different to using them with another. Louise Greenstocks final findings on the use of graphic symbols in schools offer insights into clinical reasoning and professional roles. 26 BOUNDARY ISSUES (6) The department you lead has a recruitment freeze and you are struggling to keep up standards of service, including waiting times. A referral comes in from a GP, and you realise the child concerned is the son of the Trusts Chief Executive Officer. Jan Broomfield responds to the sixth scenario of our ethics series. 34 MY TOP RESOURCE While most clinicians would agree that the concepts and vocabulary of maths present a challenge to both clinician and student, there is not a lot of agreement as to how we can mediate this to our children...[Stern Maths] has given me an innovative and developmentally sound way to teach the language of maths as well as providing a wonderful tool to use in small group work... Cynthia Pelman recommends Stern Structural Arithmetic.

Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2011 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.

7 REVIEWS Software, childhood apraxia of speech, developmental delay, autism, narrative, leadership, using music, stammering, sociolinguistics, wellbeing, AAC, interaction, bilingualism. 9 EDITORS CHOICE 10 GOAL NEGOTIATION (3) ...we would invite you to start a conversation about goals with a blank sheet of paper. This signifies that, as the therapist, you do not have a fixed preset agenda and that the client can bring their own wants, hopes and aspirations to the discussion. In the third of our series of four articles, Sam Simpson and Cathy Sparkes explore readiness to change and framing and supporting goal negotiation conversations.

Speech & Language Therapy in Practice can be found on EBSCOhost research databases.

IN THE REMAINING ISSUE: WINNING WAYS...TRAINING...ANIMATION...CRITICAL APPRAISAL... TRANSCRIPTION...STUDENTS TOP RESOURCES...MAKATON APP...GOAL NEGOTIATION

news

Ripple effect

Politicians give voice

An MP has explained his strong personal reasons for supporting a campaign to raise awareness of the economic and social case for speech and language therapy. Ed Davey was attending an event organised by the not-for-profit social enterprise community provider Your Healthcare as part of the Royal College of Speech & Language Therapists Giving Voice campaign. The MP for Kingston & Surbiton talked about the problems experienced by his family in accessing services for his son. He said, I am also the father of a young boy of 3 who cannot speak and we are trying to access services for him. He cannot say a word we have taught him some Makaton signs but his hands are a little bit wobbly. We have been trying to get speech and language services but he is not entitled to them because he is no longer choking on his food and drink. The MP added that he understands there are about 100 preschool children in Kingston in a similar position. Having watched a Your Healthcare video featuring service users and parents he commented, As we heard on your video, early intervention is key...but we just do not have enough of you. Fellow MP Zac Goldsmith admitted that, while This is about real lives - its also about the crude figures at a time when there is a battle for funds. Using the example of the high percentage of communication difficulties among young offenders, he said it is easy to dismiss speech and language therapy as fluffy and indulgent but in fact it is absolutely central and we have to invest in peoples ability to communicate. The MPs plan to work together to support speech and language provision in Kingston, while Your Healthcare intends to continue to address financial constraints through partnership working and collaboration. The photo by Emma Cattell shows Zac Goldsmith, Ed Davey and Your Healthcare managing director Siobhan Clarke demonstrating the use of picture cards to order at the events cafe. www.givingvoiceuk.org www.yourhealthcare.org

Speech and language therapist Gemma Morgan has received an award from the Stroke Association in recognition of her tireless commitment to raising quality of care. Stroke survivor Christine Welburn nominated Gemma for the Life After Stroke Award for Excellence in Stroke Care. Christine participated in and now volunteers with Gemmas Communication Partners project. This trains speech and language therapy students and volunteers in supported conversation with people with aphasia. She is impressed by the ripple effect of Gemmas enthusiasm, commitment to the team and empathy with clients. Gemma, who is based in Rotherham, is keen to address the social impact of aphasia and has forged partnerships with the University of Sheffield, The Stroke Association and the North Trent Stroke Strategy Project. In the first year of Communication Partners, all participants reported that the scheme had improved their communication. Six months into it, 71 per cent showed significant improvements in mood, feeling more understood, calm and optimistic. Gemma hopes these findings will lead to Communication Partners being commissioned as a new service. Nominations for the 2012 Life After Stroke Awards open in December. For information visit www.stroke.org.uk/lasa.

Secondary struggles

The speech, language and communication needs of pupils at secondary school was a major focus of the imagine life for those who struggle month of the National Year of Communication. Following a three day Lost for Words conference co-hosted by City University, I CAN and Afasic, I CAN produced a report Speech, Language and Communication in Secondary Aged Pupils. This stressed that early intervention means before the communication difficulty has an impact - whatever the age of the client. The paper suggests whole school models which suit the changing and different needs of adolescents, and which position speech and language therapists as having workloads rather than caseloads. www.ican.org.uk/~/media/Ican2/Whats%20 the%20Issue/Evidence/ICAN_TalkSeries10.ashx

Involved in research

INVOLVE, which supports public involvement in NHS, public health and social care research in England, is looking for new members for its working groups. The three working groups each have a responsibility for leading on a strategic objective of the main group. They are Strategic Alliances, Empowerment, and Evidence, Knowledge & Learning. The organisation would particularly welcome applications from members of the public who have experience and understanding of public involvement in research. If they are not employed full-time in the public sector, such members may be able to claim a committee fee in addition to expenses. Applications close on 31 October 2011. www.invo.org.uk/Membership.asp

Making a difference

Two innovative library projects for adults with learning disabilities have been recognised in the CILIP Libraries Change Lives Awards 2011. The Kent Libraries and Archives service winner Making a Difference (pictured) aimed to provide new opportunities, experiences and skills to encourage independence and fun. It has created an information library staffed by adults with learning disabilities who are employed as paid librarians. It has also developed Easy Access collections of books and DVDs chosen by adults with learning disabilities, as well as providing volunteering and work experience opportunities and holding dedicated Biblio Hour and Coffee and Chat sessions. Finalist The History Club from Tyneside started as a 12 week partnership programme of activities including research, photography, creative writing, music and crafts along with guided tours and talks. Due to its success, Newcastle Libraries launched The History Club for adults with learning difficulties. They have looked at topics including The Great Fire of Newcastle, The Ghosts of Newcastle and Newcastle United and report that it has become a vital part of participants and staffs lives, with 100 per cent of participants reporting that they find it fun. The Chartered Institute of Library and Information Professionals Changing Lives Awards are open to projects which change lives, bring people together, involve user communities, demonstrate innovation and creativity and develop staff and services. In addition to celebrating success, they aim to contribute to equality of access, enrich the lives of individuals and strengthen local communities. www.cilip.org.uk/about-us/medalsandawards/libraries-change-lives/pages/lclawardintro.aspx

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

NEWS & COMMENT

Resources
REPoD (Rotarians Easing Problems of Dementia) is a UK wide Rotary Club initiative to provide practical online and local support to families living with dementia. www.repod.org.uk/ Developmental psychology researcher and early years campaigner Suzanne Zeedyk interprets the evidence and shares her views via a blog and newsletter. www.suzannezeedyk.com New Standards of Care for Dementia in Scotland are being tested and consulted on over the next 6 months. A guide for people with dementia and their carers is available. www.alzscot.org/pages/info/standards-of-care.htm The Speech, Sign and Song Club, run by Wendy Prevezer, caters for children from 2 years old with communication difficulties. www.speechsignsong.co.uk/page_2407251.html With its newly overhauled website, Black Sheep Press can now offer downloads of over 120 products on purchase. www.blacksheeppress.co.uk The Motor Neurone Disease Association has a new dedicated campaigns website. You can sign up as part of a network to take action and spread the word, contributing as much or as little time as you want to. www.mndcampaigns.org KIDS has published a book for play, leisure and childcare providers to help them include disabled children under 8 years old. The dip in resource is the culmination of the 10 year Playwork Inclusion Project. Everybodys Business , see www.kids.org.uk The Lifelites charity provides adapted computer and gaming equipment and digital cameras to all UK childrens hospices. It won the accessibility award at the UK Technology 4 Good Awards 2011. www.lifelites.org; www.technology4goodawards.org.uk Following a pilot with Odeon on 11 August, not-for-profit organisation Dimensions hopes Autism Friendly Film Screenings will become a regular event. www.dimensions-uk.org/what-we-do/autism/autism-friendly-films/ The 2011 Cycle Show at the NEC, Birmingham will include an Inclusive Cycling Hub, dedicated to technologies and opportunities to enable elderly people and disabled children and adults to get cycling. www.cycleshow.co.uk The Meningitis Research Foundation has developed a website to support families living with after effects to access equipment and benefits. http://drb.meningitis.org The latest edition of free digital magazine Stroke Matters includes a contribution from Professor Pam Enderby on community rehabilitation and a study on psychological treatment for low mood in people with aphasia. www.stroke.org.uk/strokematters The SLI Handbook, which aims to be a comprehensive guide for parents and practitioners, has been launched by I CAN and Afasic. It was commissioned by the Communication Trust as part of the Hello campaign. www.ican.org.uk/slihandbook

Comment:

Rien ne vaut lexprience


aving had difficulty accessing speech and language therapy for his son, Ed Davey MP has a very personal reason for supporting the Royal College of Speech & Language Therapists Giving Voice campaign (p.2). While Jan Broomfield (p.26) has some thoughts on the ethical dimensions of referrals associated with people in positions of power, there is no doubt that we understand the implications of a communication need much more powerfully when we experience it for ourselves. Like me, you have probably used the analogy of landing in a foreign country to explain how aphasia or specific language impairment might feel. I can only provide anecdote and not an observational study (Jennifer Reid, p.18) but, having just been to Paris on my first foreign holiday, I realise even more how language and communication are central to our sense of competence and confidence. Nicola Groves granddaughter Adelaide believes the best word is please. Because when you say please, people give you things (p.17). However, sil vous plat and phrase books only take you so far when what you actually want is to engage with people and broaden your horizons. Our most rewarding conversation in France was with a man who, on realising we were Scottish, hit us with a rapid stream of enthusiastic French within which the words golf, whisky, chteau in Highlander and Glasgow mtro were discernable. Having found the kind of common ground referred to by Cynthia Pelman (p.34), my feeble offering of orange (the colour of the Glasgow underground) established much more rapport than I deserved. Lindsay Kings client Dan (p.27) found Melodic Information Therapy provided a platform for talking. The resultant selfexpression, particularly through the use of humour, allows him to compensate for his difficulties and reduces his social isolation. Working in a complex and diverse field, speech and language therapists like Laura Flynn (p.30) are also well used to making the best of their available skills and resources, and developing them through reflective practice. Although I only had long-dormant schoolgirl French, I found the signage in Paris an ideal way to reconnect with it, and a powerful reminder of the value of graphic symbols in supporting comprehension (Louise Greenstock, p.23). Im still not sure why, when I asked for brie, the boulangerie assistant held up some kind of sausage. Thankfully basic pointing got us out of that sticky situation, and I didnt have to attempt more sophisticated gestures. Karen Leadbitters project with her client Rhys and his support workers (p.4) helped them understand his Makaton signing, and this appeared to improve the communication competence and confidence of both parties. Being stronger with reading than listening, I was interested to discover how much more easily I deciphered formal, written French in museums compared to the spoken word. Although Lynsey Paterson (p.14) has co-produced a parent training programme based on evidence, she reminds us that different strategies work with different people, and at different times. It is interesting to consider this in light of Sam Simpson & Cathy Sparkess exploration of a model of readiness for change (p.10) which might also provide an explanation for why it has taken me 44 years to get a passport... Au revoir,

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

training

Understanding Rhys

Rhys is a young man with Downs syndrome. When he was referred to speech and language therapy, Karen Leadbitter followed a plan, do, study, act cycle to monitor the impact of her episode of care. Empowering her client to participate in training his own support staff in the use of Makaton appeared to improve the communicative confidence and competence of both parties.

READ THIS IF YOU WANT TO REDUCE FRUSTRATION, INCREASE FUN BRING CLIENTS AND CARERS TOGETHER PROMOTE TEAMWORK

hys is a young man in his thirties who has Downs syndrome. He lives with two other men, who also have learning disabilities, and they are supported in their home by a team of around eight members of staff. Rhys works in a local caf throughout the week, participates in a range of social activities in the evenings, and enjoys seeing his family at weekends. Rhys lives in a bilingual community in North Wales and his first language is Welsh, but he also understands and uses some English words depending on the message he is trying to communicate and the people he is communicating with. Rhys receives support from the Integrated Learning Disabilities Service. He was referred to speech and language therapy in November 2009 by his social worker following a review. Support staff had reported his speech clarity was poor, and that Rhys was becoming increasingly frustrated by his difficulty communicating basic messages successfully. I used a Plan-Do-Study-Act cycle (NHS Institute for Innovation and Improvement, 2008) to structure and monitor the impact of my episode of care:

Detailed Test of Comprehension (Masidlover & Knowles, 1982), which I translated into Welsh. Language comprehension Rhys was able to process information at a 3 key word level within a quiet environment with limited distractions. However, it was evident that his understanding of language was significantly reduced within conversation and he often relied on contextual information to support his understanding of what was being said. Language expression Rhys was able to express himself at a 1 to 2 word level. His expression was characterised by a large amount of jargon, with Rhys frequently linking words with jargon. I noted that he was often able to pronounce words related to his favourite topics very clearly. Non-verbal communication Rhys used appropriate tone of voice and intonation within the jargon to help apply meaning to his conversation. He also used a range of gestures and personal signs to communicate topics that are important to him. Within assessment, he showed an ability to copy signs successfully with little prompting needed. Although staff were unaware whether Rhys had used Makaton in the past, it is likely that he would have encountered it while at school. Social communication I saw that Rhys is a very sociable young man who enjoys the company of others. He also

enjoys jokes and used his tone of voice and gestures to have a laugh with staff. Finally, I asked staff to complete a questionnaire (figures 1-7) to provide information in relation to their perception of Rhyss communication abilities and their own communication skills.

2. DO (intervention)
Training session 1 Goal setting I held an initial meeting to gain information from the staff group, and to encourage them to identify the goals they wanted to achieve. Kelly (2000, p.240) cites Clements & Zarkowska (1994) as saying, the more actively that the learner is involved in the training process the more likely that learning will occur, and I guided staff to lead the session to maximise learner involvement. I gathered information in relation to Rhyss Means, Reasons and Opportunities for communicating (Money & Thurman, 1994). This was also an opportunity for staff to share their experiences, observations and the strategies they use to support Rhyss communication. The staff then selected vocabulary that corresponded to Rhyss interests and motivators (reasons and opportunities) and I demonstrated and practised the corresponding Makaton signs or appropriate gestures with them. I wrote up the information gathered from this session and shared it with the support staff and Rhyss social worker.

1. PLAN (assessment)

I gathered information about Rhyss communication through discussion with his key worker and informal observations of him interacting with staff at his home. I then assessed Rhyss language comprehension levels using the non-standardised Derbyshire

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

training
Figure 2 Faint o hyderus ydych chi yn teimlo wrth sgwrsio hefo Rhys? / How confident do you feel when chatting with Rhys? Pre-training Ddim yn hyderus / Not confident Yn hyderus weithiau / Confident sometimes Yn weddol hyderus / Fairly confident Yn hyderus rhan amlaf / Usually confident Yn hyderus iawn / Very Confident 0 2 1 2 3 Post-training 0 1 0 4 3

Figure 1 Pa arwyddion mae Rhys yn ddefnyddio yn aml o fewn sgwrs hefo chi? / Which signs/gestures does Rhys use regularly within conversations with you? Pre-training TV Cinema Popcorn Post-training Hello (5) Drink (2) Cinema (2) Food Good (3) Xbox (2) TV (2) Bye (3) Work Cocopops Bad Shower Bowling

Figure 3 Faint o hyderus ydych chi yn teimlo am arwyddo hefo Rhys o fewn sgwrs? / How confident do you feel about signing while chatting with Rhys? Pre-training Dim Ymateb/No Response Ddim yn hyderus / Not confident Yn hyderus weithiau / Confident sometimes Yn weddol hyderus / Fairly confident Yn hyderus rhan amlaf / Usually confident Yn hyderus iawn / Very Confident 2 1 0 2 3 0 Post-training 0 0 0 4 1 3

Figure 5 Beth fydd Rhys yn gwneud pan maen cael trafferth rhoi neges drosodd i chi? / What does Rhys do when he has difficulty getting his message across? Pre-training Walk away Anger Frustration Gestures Post-training Gesture Repeat Slow down Anger Forget it

Figure 4 Faint o lwyddiannus ydi Rhys i gael ei neges drosodd? / How successful is Rhys at getting his message across? Pre-training Ddim yn llwyddiannus / Not successful Yn llwyddiannus weithiau / Successful sometimes Yn weddol lwyddiannus / Fairly successful Yn llwyddiannus rhan amlaf / Usually successful Yn llwyddiannus iawn / Very successful 0 6 2 0 0 Post-training 0 4 1 2 1

Figure 6 Pa strategaethau ydych chin defnyddio pan fyddwch yn cael trafferth deall Rhys? / Which strategies do you use when you are having difficulty understanding Rhys? Pre-training Repeat Patience Slow down Start again Gestures Point Post-training Wait Repeat Yes/no Use gestures Use Makaton Slow down Body language Eye contact Try 5 top topics

Figure 7 Faint o weithiau'r dydd ar gyfartaledd fyddwch chin defnyddio arwyddion neu ystumiau wrth siarad hefo Rhys? / On average, how often do you use signs or gestures while talking with Rhys in the day? Pre-training Dim Ymateb/No Response Dim o gwbwl / Not at all Weithiau / Sometimes Yn weddol aml / Fairly often Rhan amlaf / Usually Pob tro / Every time 1 0 4 1 2 0 Post-training 0 0 1 2 4 1

In preparation for the second training session, I gathered photographs of Rhys taking part in daily tasks at his workplace, and identified PCS symbols that corresponded to Rhyss leisure activities. Training session 2 In this session with Rhys and his support workers I aimed to teach the identified signs and gestures to Rhys and to staff. I also wanted to provide an opportunity for Rhys to take part in training his staff, and for the staff to practise their own signing skills and develop their understanding of Rhyss signs. I revised the signs and gestures for the vocabulary identified in the previous training session with the group by showing the photograph or symbol to the group demonstrating the sign / gesture that corresponded to the photo / symbol

Figure 8 The second training session game Staff were split into two groups. Both groups were provided with a set of photos and symbols that corresponded with the signs learnt. Rhys and the therapist were seated at the front of the room, facing the groups, with an identical set of photos and symbols out of view of the groups. A card was selected at random and Rhys and the therapist signed what was in the picture without speech. Staff identified the corresponding picture / symbol, and then repeated the sign and said the word. One point was given to the team that was first to identify the picture and make the correct sign. The team with the highest score won.

encouraging the group to make the sign / gesture while saying the word. Some signs were new to Rhys and he required support to copy these. I used physical prompting to help him form the sign - or an approximation of it - independently.

I devised a game (figure 8) to target Rhyss signing skills, the staffs comprehension of Rhyss signs and the staffs own signing skills. To ensure the game would be suitable, I referred to Browns (1992) checklist referenced by Kelly (2000) for advice in planning the

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

TRAINING
activity. The game provided an opportunity for Rhys to play an active role in training his staff, and also gave them the chance to see him using signs successfully. The staff team also had a large collection of photos of Rhys and leaflets for places they had visited, but these were kept in a photo album on a shelf, and were not used functionally. I provided a talking photo album so Rhys could collect his pictures and leaflets, thus enabling him to communicate about novel events that were not part of his usual daily routine. I also created a photo diary for Rhys using the photographs from the training to help Rhys show people what he has been doing during the week. I hoped these resources would reduce his frustration. own communication skills. They were also a useful tool to measure changes in opinion following the intervention. On reflection, the questionnaires provided lots of qualitative information but did not show whether there was an actual increase in staff signing or in Rhyss use of signs and gestures. It could be argued that a chart to measure the use of signs would help to focus staff on practising their new signing skills, and provide more accurate information about the frequency of signing. I felt this would add pressure to the team, who also had two other gentlemen to care for in the house but, if carrying out this type of training again, I would certainly consider using quantitative measures. I feel the training process was extremely successful. The initial session with the staff provided a rare opportunity for staff to meet, with allocated time to discuss one service user in particular. It also provided staff with an opportunity to share ideas and strategies, as well as to gain a clearer understanding of Rhyss language levels and to learn some useful signs. The second session with Rhys and his staff provided a fun environment for learning. Rhys responded well - he enjoyed being in the company of the staff, and his role in the game. It was also evident that Rhys enjoyed sharing the pictures of him at work. Previously staff could only guess the tasks that Rhys took part in at the caf, so the photos provided him with an opportunity to share new information with the group. The signs and gestures selected by the staff included many signs that Rhys already used with some of them, and was therefore confident in demonstrating. The new signs taught were simple and related to photographs, therefore Rhys quickly understood and was able to copy each sign with little support. Within the game Rhys was able to form the sign for most of the photographs independently. Where photos were not available we used symbols, and it became evident early on that Rhys needed more support to understand these. He also required those signs to be modelled by the therapist. Putting staff into two groups for the game created an element of competition which encouraged teamwork. I encouraged them to observe Rhyss signs and interpret their meaning in order to practise their comprehension of signs, and to recognise approximations if Rhys was unable to form the exact sign. I then encouraged staff to repeat and model the sign back to practise their expressive signing skills. and Makaton signs with Rhys, and that they are adopting new signs in relation to his new interests such as current films. The manager of the house also said that Rhys continues to use the photographic diary and that this has been very useful in supporting conversation. Rhyss parents have been providing additional family photos for the talking photo album, for example when a new baby arrived and following family days out. Rhyss parents and house manager said they have noticed that communication is now more successful and staff report fewer incidents of Rhys becoming frustrated. The next step for the staff team would be for them to attend a certified Makaton course to maintain and develop their current signing skills. It would also be beneficial to have further research into individual service user participation in training their own staff. SLTP Karen Leadbitter is a speech and language therapist with the learning disabilities teams across Gwynedd, email Karen.Leadbitter@ wales.nhs.uk. References Kelly, A. (2000) Working With Adults with a Learning Disability. Milton Keynes: Speechmark. Masidlover, M. & Knowles, D. (1982) Derbyshire Language Scheme. Derby: Derbyshire County Council. Money, D. & Thurman, S. (1994) Talkabout Communication, Bulletin of the College of Speech and Language Therapists 504, pp.12-13. NHS Institute for Innovation and Improvement (2008) Plan, Do, Study, Act (PDSA). Available at: http://www.institute.nhs.uk/quality_and_ service_improvement_tools/quality_and_ service_improvement_tools/plan_do_study_ act.html (Accessed: 10 July 2011). Resource PCS symbols, www.mayer-johnson.co.uk

3. STUDY (evaluation)

Following the training sessions I asked the eight staff to complete the questionnaire again, so I could compare their perceptions before and after the intervention (figures 1-7, p.5). The responses imply that staff increased their understanding of the signs that Rhys uses, and have greater confidence in communicating with him. They also suggest that both Rhys and staff may be using more signs in conversation and understanding each other more successfully. Post training, staff showed a better awareness of the strategies that Rhys uses to try to get his message across, and of the communication strategies they can use with him. The questionnaire also asked Unrhyw sylwadau pellach? Any other comments? Although there were no responses before the training, six staff provided comments after it, and their feedback was very positive. It included: I enjoyed both courses. It was great to see Rhys and staff interacting and learning whilst having fun. The course has definitely been of benefit to me and to Rhys. I understand Rhys much easier when he does use the signs / gestures and it must be better for Rhys to see staff understanding what hes got to say quicker and easier by using the signs. I thoroughly enjoyed both training sessions, especially having Rhys participating and learning with all of the staff. The course has given me an understanding of how to communicate through using hand gestures/signs and will be of benefit to myself and Rhys and others. I have enjoyed this course very much. It was great to do the card game using Makaton with the service user. I now can use Makaton with the service user which has made conversation more fun. Also the service user and myself like his new activity picture book. Rhys has fun when staff are doing Makaton with him. He tries his best to help staff. Communication has improved with Rhys since attending both training sessions has developed basic Makaton with staff. From my own perspective, the questionnaires were a useful way of gaining insight into staff opinions of both Rhyss and their

4. ACT (what next?)

REFLECTIONS DO I USE MEANS, REASONS AND OPPORTUNITIES TO INFORM ASSESSMENT AND INTERVENTION? DO I HAVE THE RESOURCES TO OFFER INTERVENTION IN A CLIENTS FIRST LANGUAGE? DO I MONITOR CHANGE THROUGH PLAN, DO, STUDY, ACT CYCLES?
To comment on the impact this article has had on you, see guidance for Speech & Language Therapy in Practices Critical Friends at www. speechmag.com/About/Friends.

In November 2010, 12 months from when I received the referral, a review was held with Rhyss parents, staff within the home and his social worker, with a written report from the staff at Rhyss workplace. The support staff stated that they continue to use gestures

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

SOFTWARE SOLUTIONS / REVIEWS

reviews
SOFTWARE SOLUTIONS
As technology becomes more accessible, our reviews help you decide whats hot and whats not... Food Words: Vocabulary / Phonological Awareness (UK edns) Sharon Crosbie & Shannon Wandschneider; illus. Scott McIntosh Grow Words, www.growwords.com.au $40 + $2.50 shipping to UK (Australian dollars approximately 25 + 1.60) you to scan for the information you require. The book is written by a therapist in America, so some of the diacritics and terminology apply to American English. The chapter on intensity of services is probably the least useful, especially as the examples seem very unrealistic. The final chapters discuss topics which may influence therapy including literacy, AAC, social language skills, books and music, autism spectrum disorder, individual education plans and involving parents. These, and the strong emphasis on functional communication throughout, add to already available resources. Some of the forms and lists of resources may be of benefit, especially to recently qualified therapists. This book is one to dip into for ideas and inspiration. Although priced at 51.00, its practicality and functionality mean that, for some, it will have a good cost per use value. Abi Longland is a speech and language therapist for Hertfordshire Community NHS Trust.

AUTISM

Social Enjoyment Groups for Children, Teens and Young Adults with Autism Spectrum Disorders (ASD) John Merges Jessica Kingsley ISBN 9781849058346 14.99

Refreshing focus

Plenty of activities

This useful resource is on a CD-ROM, but it has a comprehensive contents page so you can pick and choose the activities you want to download and print off. It has two parts, one focusing on developing childrens vocabulary and the other on developing phonological awareness skills within the theme Food. The disc contains plenty of games and activities for groups or individual children. There are also record sheets should you wish to track progress. The activities have clear, step-by-step instructions and would be a valuable addition to resources in an educational setting. I tried and tested some of the syllable awareness games with positive results. Although it is a UK version, some of the vocabulary is Australian, and knowledge of international food would be useful to help recognise some of the food illustrations! If I could change one thing, it would be to have the option of colour, as Im not a great fan of black and white worksheets. One final request...please could Grow Words do a minibeast version? Lisa Harding is a speech and language therapist in a Speech and Language Class, Spalding, Lincolnshire.

DEVELOPMENTAL DELAY

How to Detect Developmental Delay and What to Do Next Practical Interventions for Home and School Mary Mountstephen Jessica Kingsley ISBN 978-1-84905-022-7 12.99

This book is structured well and easily accessible. The refreshing focus throughout is on supporting young people with autism spectrum disorders to develop the skills needed to enjoy interaction. There is also an emphasis on supporting young people to develop skills that will allow them to function better within the workplace. The information provided would allow an experienced practitioner to set up and run the groups described. This book would be very useful for speech and language therapists working with children with autism spectrum disorders within educational and community settings. Alison Hunter is the clinical lead speech and language therapist for ASD, working within Child and Adolescent Mental Health Services in Manchester.

Easy to read

NARRATIVE

CAS

Heres How to Treat Childhood Apraxia of Speech Margaret Fish Plural ISBN 978-1-59756-589-9 51.00

Good cost per use

Therapists and students will find this easy to read book very useful. After discussion of the definition of Childhood Apraxia of Speech and assessment, a series of chapters suggests approaches to treatment and, most usefully, practical ideas for planning and implementation of therapy. Each chapter ends with a helpful in a nutshell section, allowing

This book is aimed at parents and teachers of primary school aged children who have concerns about their childs development. The author writes from a background in teaching and special educational needs. She gives an overview of child development, looking at reflexes, developmental milestones and special educational needs. She describes three main developmental disorders dyslexia, dyspraxia and attention deficit/hyperactivity disorder, giving checklists of possible symptoms and advice on where concerned parents can seek help. She goes on to look at movement, vision and hearing in relation to learning, and how programmes devised to develop these skills can improve learning outcomes. The author touches briefly on language needs and the role of the speech and language therapist. Throughout, she includes case examples, helpful checklists and strategies on ways to help children in the classroom and at home. Easy to read and understand, this would be a useful tool for parents and teachers of children with a range of developmental difficulties. For a speech and language therapist working within a multidisciplinary team, it gives a helpful framework for some of the work undertaken by colleagues from other disciplines. Debbie Hughes is a speech and language therapist working with a charity for preschool children with physical needs in the Watford area.

Getting the Picture: Inference and Narrative for Young People with Communication Difficulties David Nash, illus. Oliver Allchin Jessica Kingsley ISBN 978-1-84905-127-9 17.99

Clear aims

This is a really cost-effective resource for anyone working with teenagers in either mainstream or specialist settings. It provides coherent explanations of inference and narrative skills and explains their importance in the context of educational policy. The clear aims for each chapter and differentiation of worksheet levels make this resource useful for inclusion in language programmes set by therapists for young people or for parents / caregivers and other professionals to follow. The illustrations are representative of a variety of daily life situations and age appropriate. Despite its ease of application to this client group, a software alternative would have made this resource more functional and motivating for educational use. Cheryl Hanson is a specialist speech and language therapist working with young people with a broad range of learning disabilities aged 11-19 years across specialist and mainstream resourced provision in Stockport.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

REVIEWS

reviews
LEADERSHIP
Clinical Leadership from A-Z Dickon Weir-Hughes Pearson ISBN 978-0-237-75156-4 16.99

Successful and concise

In the current climate, developing leaders is a priority. Understanding how leaders can ultimately influence the success or failure of any venture is relevant to most areas of clinical practice and all levels of practitioner. This little book serves both as a starting point and refresher. Having been in a leadership role for many years I found it useful to reflect on my own style, as well as our ever changing context and networks, and the approaches adopted by my multidisciplinary colleagues. Unlike many books on this topic, it is a practical, easy read that allows the reader to dip in at any point. The 26 short chapters follow an alphabet theme from Authenticity to Zenith, through Influence, Knowledge and Networking, to explain key leadership concepts successfully and concisely. Each chapter concludes with useful reflective comments and suggestions for developing your own knowledge and skills. This could be used to inform your personal development plan or, as the author suggests, as part of a 360 degree appraisal process. The book has useful checklists and is well referenced. A quick and easy read on the subject of clinical leadership, I have already offered to lend it to a colleague. Sue Newman is head of childrens speech and language therapy at Cornwall Partnership Foundation Trust.

what to do through easy to follow, well defined steps. Photographs illustrate the instruments to be used and also act as picture cues for the layout of materials. The use of syllables such as dumdum, dada to replace words helps to avoid an overload for some speakers who may struggle with nursery rhymes. More importantly, it can be used to help speech sound production. Perhaps the only negative is the title, which does not reflect that the book is suitable for all children, and we question the term special kids. Alison Taylor and Karen Shuttleworth are speech and language therapists with Cumbria Partnership NHS Foundation Trust.

STAMMERING

Recovery From Stuttering Peter Howell Psychology Press ISBN 978-1-84872-916-2 50.00

Thorough job

USING MUSIC

Music for Special Kids (Musical Activities, Songs, Instruments and Resources) Pamela Ott Jessica Kingsley ISBN 978-1-84905-858-2 14.99

Parents often have lots of questions about the origin of their childs stammer and clinicians need to decide whether and when to treat. This books author does an extremely thorough job of interpreting and evaluating the current evidence about the factors associated with stuttering in its early stages and those which contribute to recovery. The book is a rather heavy theoretical read, but it is clearly laid out with concise introductions and summaries. Therefore, the busy clinician could just refer to relevant sections in response to specific queries. I would recommend this book to students and any therapist with a special interest in stammering. Alison Westwood is an independent speech and language therapist, working mainly with dysfluent children and their families in West Hertfordshire.

These issues are heavily underscored by the reluctance of society to speak about how these body breakdowns impact upon everyday life. Ramanathan addresses how women with breast cancer linguistically engage in typically male dominated discourses, and how those with type-1 diabetes or epilepsy are prevented from open articulations by the language of the biomedical world. She then examines how general language skills are rendered problematic as a result of partial hearing loss, autism and Alzheimers disease. The book skilfully brings together the parallel strands of illness and impairments of the mind and body and how they are languaged by society and the medical profession. Throughout, the author emphasises the importance of researchers keeping their practices honest and transparent. All 136 pages are crammed full of applied sociolinguistic terminology and discourse, critically analysing current narratives on models of disability and normalcy, which makes for a thought-provoking and fascinating read. The 7 short chapters can be dipped into, however, the book is heavy going and complex owing to the challenging terminology. It lacks wider application in a busy clinical setting but would be useful for a researcher or those interested in applied sociolinguistics. Margaret Davis is a speech and language therapist with Derbyshire Community Health Services.

WELL-BEING

Promoting Psychological Well-Being in Children with Acute and Chronic Illness Melinda Edwards & Penny Titman Jessica Kingsley ISBN 978-1-84310-967-9 19.99

Up-to-date and relevant

SOCIOLINGUISTICS

Suitable for all children

This excellent resource is full of practical ideas for anyone working with children and offers good value for money. The author aims to develop a childs self-esteem, confidence, motor skills and communication through musical tasks. There is a wide range of topics such as song games, using music to identify feelings and emotions, and quiet time activities. Many can be used by parents and professionals regardless of musical ability. The book clearly sets out the aims of the activity, lists the materials needed and explains

Bodies and Language - Health, Ailments, Disabilities Vaidehi Ramanathan Multilingual Matters ISBN 978-1-84769-235-1 17.95

Complex and challenging

Vaidehi Ramanathan is a Professor of Applied Sociolinguistics in California. This book follows a series by her in the rapidly developing field of the body, language and health. She fuses personal narratives with critical theories to explore issues surrounding linguistic interactions related to the physical and cognitive breakdowns of the human body.

It is refreshing to read a book that contains up-to-date information and is written for a UK audience. The book incorporates an overview of psychological techniques and assessments, plus a wide range of issues affecting those involved with a child with a psychological illness. It is relevant for all speech and language therapists regardless of their place of work and at any stage of their career, as the inclusion of children with chronic illness covers issues that are pertinent to children with developmental disabilities. It is an easy to read text that you can also dip in and out of as need be, although I would recommend getting through the whole book if you can. It also includes an excellent resource section and is good value for money. Rebecca Howarth is a senior specialist speech and language therapist at Royal Manchester Childrens Hospital.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

REVIEWS

AAC 

Rising to New Heights of Communication and Learning for Children with Autism (The Definitive Guide to Using AlternativeAugmentative Communication, Visual Strategies and Learning Supports at Home and School) Carol L. Spears and Vicki L. Turner Jessica Kingsley ISBN 9781849058377 13.99

Jenny Treen-smith is a speech and language therapist working in Wiltshire with children who have learning difficulties and complex additional needs.

Editors choice

BILINGUALISM

Language Disabilities in Cultural and Linguistic Diversity Deirdre Martin Multilingual Matters ISBN 978-1-84769-159-0 29.95

Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.
The title I cant sleep at night with discharging this lady: The personal impact of ending therapy on speech-language pathologists catches the eye. With termination of therapy a complex negotiation which involves a great deal of emotional energy (p.283) it is not surprising that therapists report feelings such as self doubt, failure, guilt and sadness. Concentrating on people with aphasia, Hersch suggests we raise our awareness of reluctance to discharge, improve our handling of transitions, question our reliance on a plateau and use the success of the ending as a test of how effective that intervention has been (p.286). International Journal of Speech-Language Pathology (2010) 12(4), pp.283-291 I only appreciate how impenetrable my own professions jargon must be when I try to access something from a different perspective. I read Whites A sociocultural understanding of mediated learning, peer cooperation and emotional well-being to find out more about dynamic assessment and helping people communicate more effectively in groups. The study involved self-selected students and no blinding, but the theoretical argument was thought-provoking, as it integrates educational and developmental assumptions in ways that other current models of education do not (p.21). It also made me think how disadvantaged pupils with language and social communication disorders must be when it comes to cooperation and self-regulation. Emotional and Behavioural Difficulties (2011) 16(1), pp.15-33 This interview with the pioneer of the Family Partnership Model gives a fascinating insight into what makes an individual passionate and successful. Hilton Davis says all aspects of my life are highly interrelated (p.1), with one of the biggest influences when his first wife became ill with multiple sclerosis and died aged 20. While this taught him about resilience and adaptation, he also became aware that conventional services were not related in any way to psychological needs (p.3). Ironically homeopathy provided a package that included listening and respect for her body and person (p.4). Hilton believes every single practitioner has a duty to care for and promote the psychological wellbeing of everyone with whom they work (p.5), and offers helpful suggestions for influencing the health service culture. An interview with Professor Hilton Davis, ed. Peter Limbrick (2011) interconnections

Introductory guidance

This easy to read book provides practical guidance into visual methods of supporting communication and learning for children with autism. It contains several useful diagrams and the layout is consistent. Key approaches addressed include speech generating devices, TEACCH, PECS, symbolic language systems and social stories. There are useful reminders of the significant factors to consider in each case. The authors are both speech and language therapists and appear to be drawing on their own experiences, which makes their suggestions practical and easy to follow. Although by no means the definitive guide suggested in the title, this is a good value, informative book. It would be a useful introductory resource for speech and language therapists and students, and would also be beneficial for families and other professionals. Carol Parry is a speech and language therapist at Grange Park School, a specialist secondary school for students with Autism Spectrum Condition in Kent.

Worth the effort

This book uses Vygotskian and Sociocultural perspectives to explore issues related to Cultural and Linguistic Diversity and language disabilities, and considers a wide range of client groups. It is a very thought-provoking and interesting read which is high on theory and low on practicality. (If you want a how to book, this is definitely not for you!) Overall the book is complex to read, but well worth the effort if your caseload includes clients with cultural and linguistic diversity and you have a need for a good grounding in the issues that may arise. It will appeal to therapists already working in this specialist field or those wishing to develop a specialism in this area. Linda Robinson is a highly specialist speech and language therapist with Barnsley Primary Care Trust.

AUTISM

INTERACTION

My Child Has Autism, Now What? Susan Larson Kidd Jessica Kingsley ISBN 9781849058414 9.99

Analysing Interactions in Childhood (Insights from Conversation Analysis) Hilary Gardner & Michael Forrester Wiley-Blackwell ISBN 978-0-470-76034-5 34.99

Handy little book

In-depth

This in-depth analysis of conversation is split into three sections: typically developing children with their main carers, childhood interactions with the wider social world, and atypical child interactions. The key theme is the mutual understanding between speakers. Each section examines the production, recognition, repair and / or maintance within a conversation. With lengthy chapters and quality evaluations, this is a thought-provoking book but one not for the faint hearted! It is aimed at academics and students who want up-to-date information. Although a little over priced for the limited new information I can use for my client group, I have revised my own performance and interactions as a consequence of this book.

As a generalist speech and language therapist working in community clinic I found this slim book to be clear and structured with a friendly tone throughout. It is specifically aimed at empowering parents and carers with knowledge and skills about how to support their child. I have no doubts that many parents will find this a good starting point for early reading without being overwhelmed by jargon and theory. Undergraduate students and practising therapists may also find it a handy little book for immediate reference. The advice given is grounded within commonly known approaches. I found the sections on visual support, creating routines and simplifying areas in the home particularly useful. Each chapter or step has a helpful to learn more section at the end with references for further reading. At 9.99 this book is good value for money. Kim Foster is a speech and language therapist in Bury.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

GOAL NEGOTIATION (3)

Whose goal is it anyway?


Part 3: The wheel in motion
In the third of a four part series, Sam Simpson and Cathy Sparkes focus on the clients voice by exploring readiness to change and discussing practical ideas to frame and support goal negotiation conversations.
aving described a process of goal negotiation that underpins clientcentred interdisciplinary rehabilitation (Simpson & Sparkes, 2011b), we will now consider some of the factors that influence how this process can be shaped for a given individual to promote flexible service delivery. One key consideration often at the forefront of a therapists mind relates to the clients readiness for change and the timing of intervention. Why is it that some people glide easily through the goal negotiation process whilst others get stuck at one or several stages? We consider it crucial that healthcare professionals have a solid understanding of theories of readiness for change and the timing of intervention as a means of supporting their goal negotiation practice. Following research and analysis of factors influencing the achievement of change by people with addictive behaviours, Prochaska & DiClemente (1986) developed a model explaining how and why people achieve change with or without rehabilitation. This model (figure 1) views motivation as a state of readiness for change, which fluctuates over time and across situations. Readiness for change is construed as existing along a continuum and is a state that can be influenced by external factors. The six stages of the model are: 1. PRE-CONTEMPLATION At this entry point to the process of change the client does not yet acknowledge there is a problem and is therefore not considering the possibility of change. This may be a result of not being aware that a problem exists, or due to a lack of acceptance that a situation is problematic. Generally at this stage it is not the client who thinks they have a problem, but rather significant others such as healthcare professionals, family, teachers or work colleagues. In fact the person may demonstrate surprise or defensiveness if confronted about the problem. Realistically the individual is unlikely to present for therapy voluntarily at this stage and therefore often enters a service under coercion. READ THIS IF YOU WANT THERAPY TO BE MORE CLIENT-CENTRED MEANINGFUL FOCUSED

normal and characteristic of change, although it is all too often misattributed to pathological personality traits or defense mechanisms by healthcare professionals. Therapists role Once again the therapist needs to focus on the development of the prerequisite skills for goal negotiation through evoking reasons for change and decreasing the perceived desirability of a problem behaviour. One way is to help the client step into other peoples shoes and begin to understand the implications and consequences of their behaviour from different perspectives. It is vital that the pros and cons of change are considered as well as the pros and cons of the problem behaviour. Contemplation is not a commitment to change. This is an important distinction as, all too often, failure to engage a client in therapy results from the therapist misinterpreting an interest in changing as a decision to change. The client also needs to understand and own their strengths to develop their self-efficacy. The therapist can support each client to identify and overcome barriers to change by means of practical problem solving and offering access to positive role models through group opportunities. 3. DETERMINATION / PREPARATION FOR ACTION Early descriptions of this model referred to stage 3 as determination and described it as being characterised by the decision to change. However, subsequently this stage has been referred to as preparation for action, which intrinsically implies a decision. Essentially, this is where the balance tips in favour of change and increased statements of motivation will be made by the client. This represents a window of opportunity, which opens for a short period of time. If a person moves from this stage to the next (action) the change process continues, but, if not, they will slip back into contemplation. At this stage it is very common for people to come for therapy. Therapists role It is the therapists role to reinforce this window of opportunity and help the client

Cathy and Sam

Therapists role If a client is not considering change due to lack of knowledge or interest, the therapists role is to raise knowledge, awareness and concern. However if the client feels overwhelmed by their problem, does not want to think about it, or feels it is too late to do anything about it, then the therapists role is to instil hope and promote feelings of self-efficacy by exploring the barriers to change. The therapist can help the client develop the prerequisite skills for goal negotiation by providing information about their difficulties and giving feedback to raise their awareness of problem(s) and the possibility of change (for example using assessment results, video feedback). They can also involve family and friends to establish a clear knowledge of the present situation and the clients strengths, needs, wants and issues. Finally the therapist can ensure that the client has an increased awareness of the risks and problems associated with their current behaviour. 2. CONTEMPLATION In this stage the client is willing to consider their problem(s) and the possibility that change may be desirable and beneficial. They are consequently more likely to present for therapy of their own accord. However, whilst they are developing some awareness of their problem(s), the contemplation stage is characterised by ambivalence - considering the possibility of change and then rejecting it. They will alternate between reasons for concern and justifications to continue unchanged. It is important to note that this oscillation process is

10

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2011

GOAL NEGOTIATION (3)


Figure 1 Model of Change (Prochaska & DiClemente, 1986)

Figure 2 Practical exercise 1. Personal reflection: Consider a change that you have tried to make in your life. Can you identify your position on the wheel (figure 1) at different points in time? How many times have you been round the wheel? What has enabled you to finally make a sustainable change? Pre-contemplation 2. Clinical reflection: Think of a current or past client. Can you locate them and their family on the model as well as yourself and the therapy team? How does the model presented support your understanding of this clients rehabilitation process?

Permanent exit Maintenance Relapse

Contemplation Action Preparation for Action

move forward to the action phase. At the determination or preparation for action stage the therapist will support the information gathering process to enable the client to develop a menu of choices for moving forward. In relation to goal negotiation, it is at this point that the therapist will explain the concept of goals in more depth, outline the goal planning process and engage the client in goal exploration (pp.12-13). Through this process, the therapist will help the client determine their preferred course of action and arrive at a possible plan, through eliciting commitment and immediate steps for action. It is also important to prepare the client for the possibility of relapse. Commitment and enthusiasm for change cannot compensate for lack of ability or knowledge, so it is important to consider the clients resources for achieving change and the support available to them. A strong commitment alone does not guarantee change. 4. ACTION This is the stage most akin to therapy. The person engages in actions intended to bring about a change in behaviour and goals negotiated at this stage aim to produce a direct change in the problem behaviour. We invite the reader to note the amount of preparation involved in the lead up to action to ensure the clients readiness for change. Therapists role This stage is characterised by further goal negotiation and elicitation. The therapist supports the client to take steps towards change and develop skills and strategies to accomplish change through the ongoing process of goal negotiation. The therapist also helps the client produce and measure change in the problem area(s), which can be achieved through regular goal review opportunities. However, as with all changes in life, individuals are prone to minor slips or major relapses. Consequently, it is important that there is a clear understanding by the client and their family of attainment / non-attainment of goals. If a client does not achieve a goal or partially achieves it this can provide valuable

information with which to renegotiate and set new goals. We encourage clients to avoid viewing the non-achievement of a goal as a failure, but alternatively to construe it as a useful opportunity to achieve greater understanding of their potential for change and the approach that needs to be adopted. 5. MAINTENANCE The length of time that a client is involved in the action stage varies considerably. During the action stage new patterns of behaviour are developed and consolidated. However, making a change does not guarantee that the change will be maintained. Good intentions and initial changes are often followed by minor or major steps backward. The challenge is to sustain the newly-accomplished change and to prevent relapse. Maintaining change requires a different set of skills and strategies to those involved in making the change in the first place. We only have to think of our own attempts to lose weight, get to the gym regularly or give up smoking to notice that the initial flurry of excitement is very different from the longerterm continuation of these changes. It is also evident that some changes are more difficult to maintain than others. A key factor in this is the support network that an individual creates for themselves around a particular skill (friends, family, professionals and / or peer support groups). Clients who are able to sustain their desired change will exit the process of change here, whilst others will continue round the wheel as they need more time or experience to achieve sustainable change. Therapists role The therapist at this stage needs to support the development of the specific skills and strategies required to maintain change and establish new behaviours. Once again goal review meetings are a useful way to renegotiate and review goals, thereby keeping rehabilitation on track. The therapist needs to assist the client in identifying and using strategies and support networks to prevent relapse. Additionally the specific active support of the therapist needs to be withdrawn gradually. If the client has

established the new behaviours and is coming to the end of the package of care, the final goal meeting may take place with the potential transfer to another service. 6. RELAPSE This stage completes the model and reflects the reality that, even when change is achieved and sustained, the possibility of relapse always exists. Indeed, minor slips or major relapses are considered a normal part of the change process and are to be expected. Prochaska & DiClemente (1986) claim that people go round the change cycle between three and seven times before achieving stable change. This is an important consideration when planning rehabilitation services, and calls into question whether a realistic perspective is often taken regarding intervention time frames and reentry into services. As and when relapse occurs, the client needs to move around the wheel again as opposed to getting stuck at this stage and becoming demoralised. Therapists role The therapist needs to help the client renew the process of change without becoming stuck or discouraged, to identify intrinsic and / or extrinsic factors influencing the relapse and assist the continued contemplation of change. The therapists role will therefore encompass the renewal of determination in addition to the resuming of action and maintenance efforts. Hopefully it is evident how this theoretical model of change can usefully frame the proposed goal negotiation process and inform clinical practice in terms of the nature and timing of service delivery. We now invite you to consider the practical excercise in figure 2. We anticipate that readers will immediately be able to relate to the model both personally in terms of any change they have tried to bring about and professionally in terms of past or present clients. Indeed, its breadth of application is one of the models intrinsic strengths. We encourage use of this model as an integral part of a clients assessment process and as a means of informing the therapy team of their

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GOAL NEGOTIATION (3)


required roles, the recommended approach and management options for a client at any point in time. The model is particularly helpful for enabling therapy teams to re-frame clients as well as family members frequently labelled as unmotivated or difficult. The emphasis on building the prerequisite skills for therapy and tackling the realities of relapse also supports the development of flexible service delivery in terms of entry into and exit from any service. Finally, the model provides a useful communication tool to explore any synchrony or mismatch between the client, their family and the therapy team. In this way the model can serve as a prioritisation tool in keeping with the remit and boundaries of any specific work context. We have established that gauging a clients ability to engage in the goal negotiation process as well as establishing their readiness for change is integral to the information gathering and assessment process. However, as Catherine Williamson says (2007, p.12), All my years of experience, supposed wisdom and knowledge count for nothing unless the client comes to their own conclusions. This quote has particular resonance for both of us, as it has been repeatedly borne out through our clinical work, but how in practice do we ensure that the clients voice remains central to the rehabilitation process? Where and how do you begin? Starting out Initial goal exploration (Step A4, Simpson & Sparkes, 2011b) Assuming that the client has a shared understanding of goal negotiation in the context of your service and is clear as to the purpose it serves, we would invite you to start a conversation about goals with a blank sheet of paper. This signifies that, as the therapist, you do not have a fixed preset agenda and that the client can bring their own wants, hopes and aspirations to the discussion. The sheet represents an opportunity space for the individual where there is a broad life focus. In our experience people like to have their personal story witnessed and want someone to listen to their hopes and dreams even if they may seem unrealistic to us as healthcare professionals. We can listen openly and record these aspirations without false promise and collusion (figure 3). The sheet of paper can be a useful reference point both during the initial session and across subsequent sessions with all members of the team always keeping the door open to discuss and renegotiate goals. The time needed for this initial exploration process varies according to someones cognitive and communicative abilities. However, we strongly believe that, by making the time for this conversation, you will ultimately save time by establishing what has meaning for the client and what they want to focus on in therapy. How often have we set off on our professional agenda and written goals for our clients only to find out several sessions later that we are off on our track and not
Adult relationships * Do more Tiredness with children Managing things that I ( responsibility) frustration want to do Educate family / friends Understanding (aphasia) films/TV more Goals * Have Change family more equal expectations re conversations money as not *Knowledge of working aphasia and * Confidence how to manage (people / situations) Assertiveness Figure 3 Mind map from an initial goal exploration conversation 5 3 Downsizing the house More leisure time, 1 - time-consuming eg. concerts - stressful Less parent 3 focused Change my social life Less housework - take stock of / domestic my friends Changes Life duties - redefine friendships 2 Change - meet new people work 4 1 I have more in pattern More Meet a new holidays common with partner Figure 4 Mind map showing prioritisation of goal areas

Now getting there slowly - not clear enough - I have to repeat myself lots - cant sing - voice cuts out - cant talk fast - cant talk rhyming slang - get tired (start yawning) - have to concentrate more 2 3 4 5 Speech 6 7

Pre-injury talked properly - people could understand me - talk whatever speed - people found it easy to listen to me - could sing - people didnt ask me to repeat myself Settle for 8 9 Ideal 10

Immediately after couldnt talk no voice 0 1

Figure 5 Rating scale for Speech

theirs? This early open conversation serves to make therapy personally meaningful, timely and focused. For those readers working in a multidisciplinary team, this initial exploratory conversation can be carried out by one team member for and on behalf of the wider team, with the understanding that the information gathered will be shared with others, as appropriate. This process can often help clients who are feeling quite fragmented by what has happened to them to begin to feel more integrated and whole again. Pulling together Goal negotiation and elicitation (Step B7, Simpson & Sparkes, 2011b) Initial ideas need to be translated into tangible multi/uni disciplinary goals relevant to the particular therapy context and timeframe available. Thus, having listened openly to the clients hopes and aspirations the real negotiation begins by entering into discussions with the client and their family about priorities and what is possible within the timeframe and remit of your service. This can be done jointly as a team or in individual sessions prior to coming together as a team. The following considerations can help ensure goal negotiation conversations remain client-centred: a) Overarching principles Continuous process of loosening and tightening Clear time frame boundaries

Respect the process - avoid rushing to the outcome Acknowledge and reveal competence Goal negotiation and therapy are interdependent - avoid viewing them as mutually exclusive! b) Listening skills and styles Give the client time Listen openly and support without colluding Listen to whats meaningful and not just to what is professionally safe Use the clients own vocabulary Do not be afraid of silence Park your own prejudices c) Questioning / facilitation styles Hierarchy of questions (initially open and gradually becoming more closed) Repeat back/summarise - keep the focus Probe - avoid superficiality Follow the clients lead Clarification (Let me just check Ive got this right) - assume at your peril! d) Supporting / total communication Use writing or drawing as a reference point (in and across sessions) Consider other relevant visual stimuli such as photos Be sensitive to non-verbal signs and follow these up Use visual frameworks such as mind maps, rating scales, ladders.

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Settle for - not so slurred - can sing (wouldnt cut out way through) - people can understand me 10 - no more repeating myself (4-5 reps in 10 mins 9 conversation) 8 Think it will be a bit Now 7 slurred for life 6 Figure 6 Ladder example

Group with other people with Look at 1 brain injury materials Try on own with Sam - self help

Read a 2 Assertiveness Wait and book see - do nothing Role play / Adult Watch video practice education examples and course discuss Figure 7 Mind map showing option appraisal

The mind map in figure 7 shows an option appraisal which led to the following goal being drawn up: John will read a book on assertiveness and evaluate the impact on talking about his feelings, wants and priorities since his stroke with his close family and friends in 4 weeks, and then decide if he wants to work more on this in therapy sessions or attend an assertiveness course. To take your learning forward, we invite you to identify a client you are about to start working with in the next two or three weeks. Reflect on the approaches and ideas to negotiate, elicit and develop goals we have presented. Try out one approach or idea and then reflect on how helpful it has been in supporting the goal negotiation process. Ask your client for feedback. We hope that this article has provided you with a useful theoretical model of change and some practical pointers to enable you to return to your workplace more confident in ensuring that your client truly remains at the centre of your goal negotiation service and SLTP intervention. Sam Simpson (email sam@intandem.co.uk) is a specialist speech and language therapist and trainee counsellor. Cathy Sparkes is a specialist speech and language therapist and counsellor. Together they are intandem (www.intandem.co.uk). References Prochaska, J.O. & DiClemente C.C. (1986) Towards a comprehensive model of change, in Miller, W.R. & Heather, N. (eds.) Treating Addictive Behaviours. New York: Plenum Press, pp.3-27. Simpson, S. & Sparkes, C. (2011b) Whose goal is it anyway? Part 2: Getting the process right, Speech & Language Therapy in Practice Summer, pp.10-12. Williamson, C. (2007) Life coaching: the missing link?, Speech and Language Therapy in Practice Spring, pp.12-14. Resources Elton Wilson, J. (1996) Time-Conscious Psychological Therapy. London: Routledge. Miller, W.R. & Rollnick, S. (1991) Motivational Interviewing: Preparing People to Change Addictive Behaviour. Hove: Guilford Press.

In a more structured way the following tools can facilitate this process: 1. Prioritisation of goal areas Using the initial goal exploration mind map as a starting point, the client is asked to rank the identified goal areas in order of importance. Collaboration can be promoted by involving family members and therapists. Healthcare professionals may often be surprised by what the client sees as their highest priority, however this can help the team determine how their service can be delivered in terms of format and timing. Sometimes certain professional groups may need to take a back seat while others come to the fore. Rehabilitation can work best at times in series rather than all professionals in parallel. The clients themselves may usefully remind of us of this fact. The prioritisation mind map in figure 4 led to the following goals being negotiated: Steve will have discussed the changes he is experiencing following his stroke (physical, communication, emotional) with his children and negotiated new house rules (cleaning rota, shopping rota, financial contributions) in 2 months Steve will plan and organise a trip abroad with a friend or relative x 1 in 4 months. 2. Rating scales and ladders Again using the initial goal exploration mind map as a starting point, the client is asked to select a particular goal area such as speech or confidence to explore in more depth. The client is subsequently asked to rate themselves on a scale of 1 to 10 across time and/or situations such as before their injury,

immediately after their injury, now, and where they would like to be in the future (ideal vs. where they would settle for). You can then ask them to elaborate on specific points on the scale to establish in behavioural terms how they would recognise any movement along the scale. (What does a 5 look like? How would I know if you got to a 6? What would you be doing at a 6 that would be different from a 5? ) Involvement of family members and therapists can enable increased access to multiple perspectives during this process. The rating scale and ladder examples in figures 5 and 6 led to the following goal agreement: Pete will be able to hold a 10 minute conversation with an unfamiliar person, speaking sufficiently clearly in order to be asked to repeat himself a maximum of 5 times (as demonstrated by video feedback) within 6 weeks. 3. Mind maps and option appraisals The client identifies a particular goal area of personal relevance from the initial goal exploration mind map. They are then invited to draw up a menu of different ways of working on this chosen goal area prior to carrying out an option appraisal to explore the advantages and disadvantages of each option. From this discussion the client prioritises his preferred options and agrees on a specific goal. It is key to really listen to the clients preferred choice and to be open to the fact that, at times, this does not involve therapy. Thus, having reviewed and appraised their menu of options, a client may decide that a self-help group, a day facility, education sessions, or working through friends and family are preferable in the first instance.

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WORKING WITH PARENTS

New Pathways
Lynsey Paterson reviews the literature on parent training which follows a diagnosis of autism, then explains how this has informed the design and implementation of a consistent, evidence based programme across Tayside. A. LITERATURE REVIEW
of non-disabled children or children with other disabilities. Lecavalier et al. (2006) added that having a child with conduct problems was a particularly significant predictor of stress (C4). Keen et al. (2010) identified that mothers are more typically affected by eating, sleeping and emotional dysregulation than fathers, who are more typically affected by a childs externalising behaviours than mothers (R7; R8). Whitman (2004) discusses the impact of stress depending on family challenges versus protective, moderating factors (C5). He states, the healing process is facilitated through gaining knowledge and, if parents are given the opportunity, they can start out as students and end up as teachers (p.244/5) (R9). 3. What is the evidence for long and short term benefits of parent training? McConachie & Diggle (2006) conducted a comprehensive review but excluded many studies due to weak methodology. The 12 included studies showed parent training can improve childrens social communication skills and have positive effects on parentchild interactions and maternal knowledge of autism. Solomon et al. (2007) reported that, of the 68 children who engaged in their parent mediated intervention, 45.5 per cent made good functional developmental progress, 52 per cent made very good clinical progress and 70 per cent of parents were very satisfied with the approach (R10). Engwall & MacPherson (2003) concluded that parents were less stressed as they had acquired relevant information and learnt new practical skills in supporting their child (R11). On evaluating the EarlyBird parent programme, Shields & Simpson (2004) noted moreover that parents perceived their child more positively. All these programmes provided written information, which parents found helpful (R12). Sofronoff et al. (2004) compared parent training in a one day workshop to individual sessions and found similar results. Keen et al. (2010) compared professionally supported workshops and home visits with self directed video based intervention. The professionally supported intervention was more effective in reducing parenting stress (R13). Rickards et al. (2009) followed up 54 families one year after they had completed a home based programme. Improvements were sustained, and children from highly When NHS Tayside developed a new autism diagnostic service for children and young people in line with national guidelines (SIGN, 2007), it identified inequity in provision of parent information sessions following a diagnosis. To ensure our resultant new panTayside parent training programme would be consistent and reflect research evidence, I undertook a literature review as part of an MSc in Autism. I had four key questions, and linked findings with recommendations (R) if the evidence was strong and with considerations (C) if less clear-cut (figure 1). 1. What have parents found supportive and helpful when their child has been diagnosed with autism? There are considerable emotional and practical demands on parents at the time of diagnosis. Keen et al. (2010) concluded that parental access to information about evidence based strategies alleviated some of the stress and increased self efficacy, most notably when it was individualised (R1). In Mansell & Morriss (2004) postal survey, 89 per cent of the fifty respondents found the most useful support from a family support worker, the local parent support group and the parent support course (R2; R3). Over 50 per cent had accessed the internet with variable levels of usefulness, 70 per cent books and 30 per cent academic journals (R4). Dunn et al. (2001) found from 58 survey returns that parents were more likely to cope by maintaining social supports, having good self esteem and psychological stability (R5). In a longitudinal survey, Gray (2006) concluded that coping strategies change over time. Ten years on fewer parents relied on service providers, and parents used fewer strategies (C3). Appreciating the childs good qualities and achievements can help parents cope (R6). 2. What happens if parents are not supported following their childs diagnosis? Whitaker (2002) found parents did not find mainstream supports overly useful and needed more specialised, autism specific input. Dunn et al. (2001) and Keen et al. (2010) reported that parents with children with autism spectrum disorders experience more stress than parents

READ THIS IF YOU WANT TO DO MORE OF WHAT WORKS OFFER AN EQUITABLE SERVICE HELP FAMILIES COPE WITH DISABILITY

stressed families and families with limited social support appeared to benefit the most. When Seung et al. (2005) trained fathers, they showed increased feelings of parental competence, marital satisfaction and self worth compared to fathers who were not involved (R7; R8). As less cohesive models exist for older children, Matson et al. (2009) state that, further programs need to be developed that help the child with ASD (and their parents) cope with new life challenges over time (p.873) (R14). McConachie et al. (2005) noted that some families turned down training, citing stress (C6). Matson et al. (2009) say the drop out rate from parent training in general is high and parents who perceive the treatment to be ineffective are more likely to drop out (C7). Whittingham et al. (2009) found a minority reported a negative experience, stating that they were uncomfortable in group situations and found discussions too focused on just one member (R15). Andrews & Brock (2004) outlined challenges in organising parent training including finding a suitable venue, making information easy and accessible, ensuring equity of access, protecting professional time and identifying support after the training (C8; C9). 4. What areas should be covered in parent training sessions? Whitaker (2002) found the most frequent unmet parental need after diagnosis was information about autism spectrum disorder, how it manifests itself in their child and options for support (C1). Shields (2001) identified four key components: to increase confidence, understand the nature of autism and the causes for behaviour, and provide an opportunity to learn from other parents. Andrews & Brock (2004) included understanding autism, communication, behaviour, education, sharing diagnosis, managing stress and accessing help. In addition Keen et al. (2010) covered play, sensory issues and strategies to facilitate communication such as alternative communication and following the childs lead. Whittingham et al. (2009) say many parents found social stories and comic strip conversations helpful. Parents in Sofronoff et al. (2004) found information on autism and management of behaviours most useful (R16).

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WORKING WITH PARENTS


Figure 2 Course structure Week 1 Introducing your child. What is autism and social communication difficulties? What is behind the behaviour? (including sensory processing difficulties and an introduction to cognitive theories) Strategies to promote social communication development (visuals, PECS, The Incredible 5 Point Scale and language strategies) Strategies to promote social communication development (comic strip conversations, social stories and communication passports) A summary and problem solving night for extended family and friends

Figure 1 Recommendations and Considerations Recommendations 1. Parents should receive information about strategies that are relevant to their child. 2. Parent training should be seen as part of the package of support a family receives. 3. Close liaison with family support workers is essential to ensure they are aware of what is included so they can support families who are attending. 4. Families should receive information about accessing books, websites and academic papers. 5. The format should allow for parents to learn from each other and share experiences and knowledge. 6. The skills and strengths of the children should be emphasised and a balanced view of living with autism portrayed. 7. Fathers and mothers may react in different ways to having a child with autism and may need different types of support. 8. Trainers should encourage fathers to attend. 9. Experienced parents should be included in the training sessions if they are willing. 10. All parents should be offered parent training with clear aims following their childs diagnosis. They should be made aware of the benefits of parent training that have been found in the research literature. 11. Training must have a balance of information giving and learning practical skills. 12. Training should be reinforced with written handouts summarising the information covered. 13. The training should be delivered by a professional who is knowledgeable in autism to groups or in individual sessions depending on the needs of the families. 14. Different training programmes should be developed for children of different ages that parents can attend as their child develops. 15. Group leaders should ensure the sessions are facilitated for all families to have equal discussion time. 16. The content should include topics such as: understanding autism, communication (and strategies like social stories and comic strip conversations), understanding and managing behaviour, sensory issues, play, sharing diagnosis, managing stress, how to access help, information from other agencies including education. Considerations 1. Parents should be helped to understand how autism affects their child. 2. Training and information should be made available for other family members to access. Consideration should be given to a member of school staff attending with the parents for children of school age. 3. Training should continue to be available as the child develops to ensure parents have up-todate knowledge and parents should be able to access booster sessions. 4. Leaders should have an understanding of the stress having a child with autism can place on a family and appreciate this may limit their ability to learn and retain new information and strategies. 5. Families should be encouraged to become aware of what acts as a stressor for them and what they can do to help themselves. 6. The timing of when parents attend should be flexible so that they feel able to engage with the information. 7. When parents drop out of parent training, information should be gathered as to why. 8. Possible venues should be investigated and this information held centrally. 9. Parent training should be scheduled across the locality ensuring equity and to protect professionals time. 10. Evaluation of outcomes should be built into the training. Pre and post checklists to measure parental stress and other forms should be considered.

Week 2

Week 3

Week 4

Week 5

It is difficult to compare different studies and identify significant factors because robust methodologies are lacking, and evaluation was carried out in many ways (C10). However, the research base we have shows training is one of the tools that can empower parents and the wider family, including siblings, to cope with a child who has autism (C2). Future research should evidence the impact of investing in families at this early stage. It is important to remember that, as the impact of autism is diverse, each family also requires an individual approach. Most crucially, as Le Couteur (2003) reminds us,

information provision is a two way process and families must be listened to (R5; R15).

B. APPLICATION

As a team of speech and language therapists working with families going through a specific autism assessment, we were interested in putting the research findings about parent training into practice. We audited the parent sessions we were already running in some areas against the recommendations from the literature review. This highlighted several areas that were not being met, including written

information. We were also aware that delivery was not consistent across Tayside. In conjunction with speech and language therapy and education colleagues from Perth & Kinross, Dundee and Angus, we designed New Pathways, a five session course (figure 2) for parents or main carers of children who have a diagnosis of autism or social communication difficulties. Each session lasts two and a half hours and is normally run weekly in the evening. The course aims to: provide information and understanding about autism and social communication signpost parents to more information enable parents to gain support from each other highlight strategies that can promote social communication development. We recommend both parents come along where possible for all five sessions. New Pathways can be run for preschool and primary school age children. The content is the same except we select relevant strategies for the group of children the parents represent. All sessions include a mixture of teaching, small group work, paired discussion and reflection and practical tasks. Two main themes run throughout: 1. Multiagency working Each course is run by a speech and language therapist plus a colleague from education (autism outreach teacher, educational psychologist or preschool home visiting teacher). The second session has a presentation from an occupational therapist who specialises in working with children with sensory issues. In the other sessions we have workers from Parent to Parent, a voluntary organisation. We also give out information about local supports and services that parents and carers have found helpful. 2. Parent involvement We want parents to recognise all the expertise and skills they already have and to develop a

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working with parents


further support network with each other. We invite other parents to do a short presentation on using strategies at home, and have set up a group email so people can easily keep in touch after the group has finished. The parents of all children who have a specific assessment and a diagnosis of autism or social communication difficulties are offered a place on a New Pathways course. So far we have run two preschool and two primary school age courses across two of the three areas of Tayside in a mixture of health and education premises. Catering facilities are essential to creating a relaxed atmosphere. Uptake has been variable but is better if the course happens shortly after a child has completed their assessment. We have had really positive feedback; for example, The topics covered and the knowledge gained are an invaluable resource for times ahead with our precious kids. It was lovely to meet the other parents and to share our stories. We now know that we are not as isolated as we thought. Evaluation forms show a resounding benefit is parents meeting others in a similar position. Many have gone on to meet up after the course and some have also requested a follow-up session six months later. comfortable participating, this should only be one of several different ways we have of working with and supporting families. SLTP Lynsey Paterson is a speech and language therapist with the Autism Assessment Team, NHS Tayside, email lynseypaterson@nhs.net. Acknowledgements
Thanks to Julie Murray, Principal Speech and Language Therapist, and Fiona Young, Highly Specialist Speech and Language Therapist, who developed New Pathways with me. Thanks also to those who are also involved in its delivery: Donna Officer, ASD Outreach Teacher, Perth & Kinross; Penny Forsyth, Educational Psychologist, Dundee; the Occupational Therapy Service, Tayside; Moira Wares, Principal Speech and Language Therapist; and Rebecca Richardson, Highly Specialist Speech and Language Therapist.

Evaluation forms show a resounding benefit is parents meeting others in a similar position. Many have gone on to meet up after the course
From our perspective, planning and development was time-consuming but we are seeing the benefit in having a standardised package. We have also found the courses very rewarding to deliver. Through them we have developed a consistent vocabulary to work with parents, which has in turn added to the good multiagency working across Tayside. As New Pathways is not a branded package, we have flexibility over which parents can attend and the content. One parent asked if we could discuss issues with telling their son about his diagnosis, so we included this the following week. We have also been open to referrals from other professionals. One family wanted to come even though it has been five years since their son was diagnosed, as they now feel that they are ready to take on the information. In future, we would like to deliver a regular rotation of New Pathways courses across all three areas of NHS Tayside and consider developing a six month follow-up session. We might need to write an adapted version for teenagers and their parents to attend as we appreciate there can be issues particular to this age group and a late diagnosis. We also have to remember that, as not all parents feel

References Andrews, A. & Brock, C. (2004) A project to develop parent programmes in ASD: building support and enabling families, Good Autism Practice 5(2), pp.14-18. Dunn, M. E., Burbine, T., Bowers, C.A. & TantleffDunn, S. (2001) Moderators of stress in parents of children with autism, Community Mental Health Journal 37(1), pp.39-52. Engwall, P. & MacPherson, E. (2003) An evaluation of the NAS EarlyBird programme, Good Autism Practice 4(1), pp.13-19. Gray, D.E. (2006) Coping overtime: the parents of children with autism, Journal of Intellectual Disability Research 50(12), pp.970-976. Keen, D., Couzens, D., Muspratt, S. & Rodger, S. (2010) The effect of a parent focused intervention for children with a recent diagnosis of ASD on parenting stress and competence, Research in Autism Spectrum Disorders 4(2), pp.229-241. Lecavalier, L., Leone, S. & Wiltz, J. (2006) The impact of behavioural problems on caregiver stress in young people with autism spectrum disorders, Journal of Intellectual Disability Research 50(3), pp.172-183. Le Couteur, A. (2003) National Autism Plan for Children. London: National Autistic Society. Mansell, W. & Morris, K. (2004) A survey of parents reactions to the diagnosis of ASD by a local service, Autism 8(4), pp.387-407. Matson, M.L., Mahan, S. & Matson, J.L. (2009) Parent training: A review of method for children with ASD, Research in ASD 3(4), pp.868-875. McConachie, H. & Diggle, T. (2006) Parent implemented early intervention for younger children with ASD: a systematic review, Journal of Evaluation in Clinical Practice 13(1), pp.120-129. McConachie, H., Randle, V., Hammal, D. & Le Couteur, A. (2005) A controlled trial of a training course for parents of children with suspected autism spectrum disorder, Journal of Pediatrics 147(3), pp.335-340. Rickards, A.L., Walstab, J.E; Wright-Rossi, R.A., Simpson, J. & Reddihough, D.S. (2009) Oneyear follow-up of the outcome of a randomized controlled trial of a home-based intervention programme for children with autism and developmental delay and their families, Child: Care, Health and Development 35(5), pp.593-602.

Scottish Intercollegiate Guidelines Network (SIGN) (2007) Assessment, diagnosis and clinical interventions for children and young people with autism spectrum disorders. Edinburgh: Scottish Intercollegiate Guidelines Network. Seung, H.K., Ashwell, S., Elder, J.H. & Valcante, G. (2005) Verbal communication outcomes in children with autism after in-home father training, Journal of Intellectual Disability Research 50(2), pp.139-150. Shields, J. (2001) The NAS EarlyBird Programme: partnerships with parents in early intervention, Autism 5(1), pp.49-56. Shields, J. & Simpson, A. (2004) The NAS EarlyBird Programme: preschool support for parents of children with ASD, Good Autism Practice 5(2), pp.48-60. Sofronoff, K., Leslie, A. & Brown, W. (2004) Parent management training with Asperger Syndrome, Autism 8(3), pp.301-317. Solomon, R., Necheles, J., Ferch, C. & Bruckman, D. (2007) Pilot study of a parent training program for young children with autism, Autism 11(3), pp.205-224. Whitaker, P. (2002) Supporting families of pre-school children with autism, Autism 6(4), pp.411-426. Whitman, T.L. (2004) The Development of Autism: A self Regulatory Perspective. London: Jessica Kingsley. Whittingham, K., Sofronoff, K., Sheffield, J. & Sanders, M.R. (2009) Behavioural family intervention with parents of children with ASD: What do they find useful in the parenting program stepping stones triple P?, Research in Autism Spectrum Disorders 3(3), pp.702-713. Resources Parent to Parent - www.parent-to-parent. org/index.html PECS (Picture Exchange Communication System) - www.pecs.org.uk/ The Incredible 5-Point Scale www.5pointscale.com/

REFLECTIONS FOR SERVICES DO WE SEE INFORMATION PROVISION AS A TWO WAY PROCESS? DO WE CONSIDER THE POTENTIAL HARM OF NOT PROVIDING AN INTERVENTION AS WELL AS THE BENEFITS OF OFFERING IT? DO WE PLAY AN INTEGRAL ROLE IN WIDER STRATEGIC DEVELOPMENTS?
How has this article changed your thinking? Let us know - see information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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IN BRIEF

In Brief...
Supporting Communication with Signed Speech
Diana James summarises her case study of the effects of the use of Paget Gorman Signed Speech in supporting the communication of four pupils with specific language impairment at a Special School. aget Gorman Signed Speech (PGSS) is a method of augmentative and alternative communication (AAC) that uses both signing and the spoken word to support a persons ability to communicate. The system is most commonly used in specialist language units and schools as a learning tool for children with specific language impairments. There have been very few recent studies of the effect of PGSS upon the communicative development of children with specific language impairment. This case study took place in Meadowbank Special School in Cardiff, which caters for children aged five to eleven whose primary difficulty is a severe/profound speech, language and communication disorder. The speech and language therapists based at the school provide the high level of therapy appropriate to meet the complex speech and language needs of the children. They are employed by the Local Health Authority but work in close collaboration with the class teacher and teaching assistant in a high adult / pupil ratio of 3:8. I examined the effectiveness of the PGSS system in supporting receptive and expressive language before and after using a teaching programme that involved learning new vocabulary with and without the use of PGSS. I evaluated the opinions of a focus group of professionals who work with pupils with specific language impairment, together with the results of questionnaires presented to the pupils themselves and their parents. I assessed levels of attention using structured observations during a story session that incorporated PGSS and one that did not. Analysis of the data indicated that, when PGSS is used with pupils with specific language impairment, it can have a positive effect on scaffolding both receptive and expressive language skills. As a learning tool it supports the understanding, learning and use of new concept vocabulary at a single word level. My recommendation was that further assessment be carried out into the effectiveness of PGSS in supporting language at a higher level of complexity such as in a phrase, in a sentence or in a narrative. Finally, data relating to the use of PGSS in improving attention levels revealed a clear differ-

supported by

One lucky contributor in each issue receives 50 in vouchers from Speechmark, which publishes a wide range of practical resources for health and education professionals (www.speechmark.net).
ence between those who found or considered it effective in supporting different styles of learning and those for whom it was a distraction. As a class teacher I conducted the research primarily from an educational perspective. However, I have a PGCE in Speech and Language Difficulties from Birmingham University, coupled with ten years experience of working collaboratively with the speech and language therapists based at the school. My initial motivation for undertaking this case study was that I had been using PGSS as an AAC tool with pupils with specific language impairment for over ten years, but had never questioned how and why the system supports their language development. Furthermore, I do not consider my position in my educational setting to be unique. This case study examines and outlines the efficacy of PGSS as a successful learning tool in helping children with specific language impairment understand, learn and be able to use new vocabulary. What was enlightening to me as a practitioner was to analyse in detail how the PGSS system works as a supportive strategy, and to consider its use in other less specialist educational settings. This can inform the practice of other professionals and parents, not only when working with children with specific language impairment, but also those with wider communication difficulties. Diana James is a specialist teacher at Meadowbank Special School in Cardiff. For further information about the case study, email diana-james@meadowbanksp.cardiff.sch.uk. Resource Further information on Paget Gorman Signed Speech is at www.pgss.org Grandma: How do you think they learn to talk? Hester: They learn from other people. By their speaking. They try to say it and they listen to what people talk about for when theyre bigger. When they was just babies they didnt know anything. People talk about things they dont know about. You tell them what to say. Like this: Say duvet. Adelaide: u-ay Hester: Thats right. First words are blah blah blah, just bubbly noises. Adelaide, talk. (Adelaide ignores her) Hester: TALK!! Have you lost your voice? (to Grandma) When she says, Hester come, she doesnt say the things in between. You have to work it out. (to Adelaide) Whats this? (pointing to a picture of a puppy) Adelaide: ph Hester: Whats this? Adelaide: /i/ (inaudibly) Hester: Say it clearly. Adelaide: tee Hester: Thats not tea, its a puppy. Adelaide: tee Hester: puppy Adelaide: tee Hester: puppy Adelaide: puppy Hester: (triumphantly) See! Hesters instructive role was continued in a conversation about a year later, however by now her sister was distinctly less cooperative. Adelaide, charmingly, misarticulates a few words (as a retired speech and language therapist, I have no motivation whatsoever to correct her t/k d/g substitutions, which are adorable). Hester: Adelaide, why do you always say bollom instead of bottom? Adelaide: Because I want to. Hester: Well, when you grow up you will just have the wrong word in your head. And then you wont be able to say bottom. The most recent conversation on the nature of language took place as they walked to school. Hester is now 6 and Adelaide 4. Hester: I think the best word is AND. The best word is and, because it joins sentences together. Adelaide: (thoughtfully) I think the best word is please. Because when you say please, people give you things. Clearly words, for my granddaughters, are performatives. Nicola Grove is a retired speech and language therapist, best known in recent years for her work on storytelling and sharing, email drnicolagrove@ fastmail.net, www.openstorytellers.org.uk.

Out of the mouths of babes


Nicola Grove is amused to observe the changing course of her granddaughters talking about talking over a two year period. ow do young children view the process of language acquisition? If my experience is anything to go by, they start out as inveterate behaviourists. This is a verbatim conversation between Hester (4), Adelaide (20 months) and Grandma (myself, aged 60). We are sitting in bed companionably in the early morning, reading books and chatting. Hester: When babies are little, they cant say anything, but they hear people talking about what they dont know about.

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journal club (5)

Journal club 5: observational studies


Jennifer Reids series aims to help you access the speech and language therapy literature, assess its credibility and decide how to act on your findings. Each instalment takes the mystery out of critically appraising a different type of journal article. Here, she looks at observational studies.

READ THIS SERIES IF YOU WANT TO yy BE MORE EVIDENCEBASED IN YOUR PRACTICE yy FEEL MOTIVATED TO READ JOURNAL ARTICLES yy INFLUENCE DEVELOPMENT OF YOUR SERVICE

esearch is fundamentally a quest for explanations. Explanations go beyond simple description in order to provide an account of causal relationships, for example, between events, human beliefs, behaviour, experiences and ill-health. It is really important to keep the notion of causality in mind as we try to get our heads round the observational designs used in health-related research. Causal reasoning, in a nutshell, requires us to: know what conditions preceded the phenomenon of interest, assess which of these antecedent conditions are candidates as causal agents, and then organise this knowledge into a plausible, causal chain of events. There are a number of observational research designs, and not all provide robust evidence of causality. It is not enough to demonstrate that there is an association between two factors. If you find that children living in high flats have poorer health, this is not good evidence that living in a flat causes ill-health. The two factors may be related, with economic or social circumstances perhaps much better candidates for an underlying cause.

NHS Fifes Dunfermline cluster Journal Club. Author Jen Reid has her back to the camera.

Experimental or observational?

When an article talks about an intervention, how do I know if this is an experimental study or an observational one? Group intervention studies, especially those using randomisation to groups, are considered superior to observational designs for answering causal questions about healthcare interventions, since there is better control of the effects of any unforeseen (confounding) factors. However, such an experimental design is not always practical or possible, especially where the participants common characteristic cannot be manipulated (such as having a genetic condition) or would not be ethical because of likely negative effects (for example, not talking to your baby). Observational studies examine aspects of peoples past and/or present life in order to identify relevant information through observation rather than experimental man-

ipulation. They do not offer a particular intervention and measure directly its effect. However, information may be collected about intervention(s) the participants have received. The goal of observational studies is usually to identify factors which may be causally related, and thus may be incorporated into interventions which then produce better outcomes in the future. Sometimes people who have received a particular intervention are followed up and their outcomes compared to the outcomes of others who did not receive the intervention. An observational study appraisal tool is likely to be the one to choose for such a study. The exception is if the intervention was offered as a core part of the research design and participants were allocated or selected to receive one intervention or another according to some preset criteria.

Observational designs

There are a number of observational designs and some jargon to deal with. 1. Cohort study A cohort study follows over time of a group of people who have something in common. (The term cohort was also used to refer to a group of Roman soldiers, which could be a

useful aide-mmoire.) The group may have a common characteristic, such as where the participants were born, how they were educated or an aspect of their health or wellbeing. Alternatively they may have all been exposed to a risk or challenging circumstance of some kind, or have received a particular health intervention. The comparison group for cohort studies may be the general population from which the cohort is drawn, or another cohort of persons thought to be similar except for the common characteristic under investigation. Alternatively, subgroups within the cohort may be compared with each other. This is commonly the case in birth cohort studies, where all children born in particular years in one geographical area are studied. Results are analysed to detect a cohort effect. This means finding out whether membership of the cohort, and therefore having the common characteristic, appears to make a difference to the outcome. In research designed to investigate risks of adverse health outcomes, a cohort is identified before the appearance of the condition(s) under investigation. For example, Conti-Ramsden & Botting (2007), in a study of emotional health in adolescents, describe their young people with specific language impairment as, originally recruited at 7 years of age as part of a wider study The original

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Figure 1 Criteria for Causation, from Bradford Hill (1965) Temporal relationship: Cause always precedes the outcome. Strength: The stronger the association, the more likely it is that the relationship is causal. (NB Look at the significance of those correlation coefficients!) Consistency: The association is consistent across different studies. Dose-response relationship: An increasing amount of the proposed cause increases the outcomes severity or risk of occurrence. Sense: The causal explanation is theoretically plausible and compatible with current knowledge. Alternate explanations: Other plausible explanations have been ruled out. Experiment: The outcome can be influenced by an appropriate intervention. Specificity: A single putative cause produces a specific effect. This one is probably less important for our purposes, especially given the multi-factorial nature of most of the behaviours speech and language therapists are dealing with.

Critical appraisal for speech and language therapists (CASLT) Download the observational study and survey questionnaire frameworks from www.speechmag. com/Members/CASLT for your own use or with colleagues in a journal club.
Spearmans rho only indicates the presence or absence and direction of any association between the variables being measured. Hills (1965) criteria for causation (figure 1) were originally designed for epidemiological studies but have been widely quoted and so may pop up in authors discussion of the results of their observational studies. Here is an appropriately cautious conclusion about causality from the Conti-Ramsden & Botting (2007) study: Our data show a clear increased risk for this population as they near adulthood compared to peers, even when concurrent language and cognition are accounted for. This finding replicates other studies that have shown raised prevalence of psychiatric difficulties in those with communication impairments or increased language impairment in children referred psychiatrically However, the association has often been assumed to be causal in that either long-term language impairment may lead to (or exacerbate) wider difficulties or psychiatric impairment may constrain communication skill. Nonetheless, it needs to be noted that the majority of adolescents with SLI in our study did not appear to suffer from emotional problems (p. 522).

cohort of 242 children represented a random 50% sample of all children attending year 2 (age 7) in language units across England. The emotional mental health of this cohort is the health outcome of interest. It is compared with a matched group of young people without a history of specific language impairment to explore whether there may be a greater risk of negative mental health outcomes for young people who have the condition. Cohort designs are particularly useful for studying developmental changes across the lifespan, such as to identify the influence of early circumstances, or the negative longterm effects of a condition, on life outcomes. An example might be language and literacy outcomes for children born very prematurely. However, they are expensive to do: outcomes may take a long time to occur so you need to follow up the same group over a long period of time, it is hard to prevent loss of participants (attrition) which is bad for the integrity of your results and, unless your cohort is very large indeed, it may be impossible to pick up enough people with a rare outcome to gain evidence for prognosis. 2. Case-controlled study In a case-controlled (or case-control) study, on the other hand, people who have the outcome of interest (cases) are identified and matched with people who do not (controls). For example, a case-controlled design for ContiRamsden & Bottings outcome of interest emotional mental health in adolescence might be to recruit participants with poor emotional mental health. They would then investigate their current language skills and / or their developmental language history in comparison with a matched group with good emotional mental health. Case-controlled studies may be the only practical design for researching rare conditions or outcomes, but on their own they provide much weaker evidence of a causal relationship because there is much more risk of systematic bias affecting the results. You need to ensure every participant is allocated correctly as a case or not, as any misallocation can profoundly influence the results. The measures used to

determine who is a case therefore need to be pretty bullet-proof. This can be particularly tricky with complex human behaviour such as communication or emotional mental health. At a recent conference I attended, speech and language therapists debated whether they would identify the same children as languagedelayed as the team studying a large Australian preschool birth cohort. The study was using a cut-off of 1.25 standard deviations below the mean for their age on language testing. We concluded its cases might include quite a few of our non-cases. 3. Cross-sectional survey The third main observational design is the cross-sectional survey. A representative sample of the population of interest (clients, practitioners, relatives) is interviewed, examined or otherwise studied to gain information on a question, such as, How many children entering primary school have poor vocabulary? or, What influences speech and language therapy intervention for adults with autism and learning disability? or, What do care staff in residential homes know about aphasia? The data for crosssectional studies are collected at a single point in time. However, the study may include retrospective information. An example would be, in a survey of knowledge and skills for making information accessible for people with learning disability, asking support staff whether they had ever received any formal training on making information accessible. Surveys can be relatively cheap and easy to do, but there are even more potential challenges to the integrity of the data, so it is not an appropriate design for answering causal questions. I have prepared a separate framework tool for surveys that use questionnaires, which is available at www. speechmag.com/Members/CASLT. For observational study results, there are ways to evaluate how robust the evidence is for inferring causality. Remember, just because you have established an association between two factors, this does not allow you to assume a causal relationship. In terms of the numbers, a correlation coefficient such as Pearsons r or

Appraisal

The reporting of observational studies in peerreviewed journals has been influenced by the STROBE statement (von Elm et al., 2008). Like the Bradford Hill criteria (figure 1), this was originally devised to improve reporting of epidemiological research but it has been extended to other areas. Although designed for authors, it may provide some guidance for readers too. Observational studies are perhaps less common in speech and language therapy literature, so I have found it helpful to have a tool that encapsulates all the main observational designs rather than trying to match separate tools to cohort, case-controlled and cross-sectional studies. I developed the following appraisal framework for speech and language therapists from relevant CASP tools (PHRU, 2006) and the STROBE statement (combined checklist).

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Question 1: Did the study address a clearly focused issue? In general, you are looking for selection bias which might compromise the extent to which the findings can be generalised (external validity). Were participants representative of a clearly defined and clinically relevant population? Appraise the eligibility (inclusion and exclusion) criteria, the sources and methods of selection of participants and how cohorts were followed up. The selection method should be systematic explicit, reliable and replicable - especially for a casecontrolled study, where it is crucial that there is no misallocation of cases. Scrutinise also the way that controls have been selected. Are they matched, populationbased or randomly selected, and is the rationale justified? If controls were matched, were the matching criteria appropriate? Authors should also provide information to allow you to assess whether those who were invited to participate but declined could be different in any important way from the study participants. Potential controls are perhaps more likely to decline or ignore invitations to participate, so this may be even more important for this group. How many participants were there, was there a rationale for this and were the numbers sufficient to support generalisation of the findings? If the study is asking, How many people have you need to think whether the sampling is of newly identified (incidence) or of cases across the whole population (prevalence) (see figure 2), and which would provide a more appropriate answer to the research question.
Figure 2 Incidence or Prevalence? iNCidence is the number of New Cases in a given time span Prevalence is the Proportion of cases in the Population

Which population was studied? Which risk factors or outcomes were investigated? Did the study try to detect a beneficial or harmful effect? Is the underlying issue one of causation? Try formulating the reviewers stated aims into a research question if they have not done so explicitly in the article. Is this question important for your clinical practice? Question 2: Was the choice of design appropriate? Is an observational design an appropriate way of answering the research question under the circumstances? Remember that a group intervention study is a more powerful design for demonstrating causality. Try to work out whether this is a cohort, case-controlled or cross-sectional study. For a cohort study, the participants should have been recruited before the outcome of interest has occurred, and the cohort should have something in common (though this can be a very general characteristic, such as being born in Scotland in 2005, or a more specific one like being a sibling of a child with autism spectrum disorder). For a case-controlled study, cases and controls are identified at the outset of the study, criteria for caseness are crucial for quality control, and the outcome of interest should be rare or harmful. Crosssectional surveys are probably the easiest to spot, since we meet them regularly in everyday life. For surveys, sampling methods which ensure that the participants represent adequately the population of interest are very important for quality control. Question 3: Were participants recruited in an acceptable way?

objective, and do they measure what they are supposed to measure? Externally validated measures, like formal tests, need less supporting information than measures developed for the purposes of the study. Some outcomes may take a long time to occur, so was the timeframe of the study long enough to assess this accurately for all participants? Moreover, the participants who are lost to follow-up may have different outcomes from those who were available, so attrition rates need to be given and their potential impact discussed. A flowchart of recruitment and follow-up schedule, indicating attrition numbers, can be really helpful for long-term studies. As in intervention trials, the study method should minimise the possibility of performance bias by employing similar measurement methods for both cases and controls, and by blinding those undertaking the assessments to participants status wherever feasible. Question 5: Has there been adequate attention to confounding?

Question 4: Were phenomena measured enough to minimise bias?

accurately

Confounding is the influence of unforeseen factors. Check which factors have been considered and list any you think might be important that the authors seem to have overlooked. How, if at all, have the researchers taken account of the confounding factors in the design and/or analysis? Have a look in the data analysis section for evidence they have used statistical techniques such as modelling, regression or sensitivity analysis to make adjustments for confounding factors. Here is some relevant wording from the Conti-Ramsden & Botting (2007) article: all the analyses above comparing those with SLI and those with NLD [no language disorder] remained unchanged after controlling for gender Question 6: What are the results of this study? As for intervention studies, it helps to try to sum up the bottom-line result of the study in one sentence this also helps to

You should be given enough information to assess how well all the phenomena involved have been assessed or otherwise measured, both factors (cohort characteristics or caseness criteria) and outcomes. Are definitions clear enough? Were measurements subjective or

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ensure youve got it straight enough in your own head to be able to communicate the gist of your appraisal to others. Consider whether the analysis appears appropriate to the design. Bear in mind that an observational study can only demonstrate associations: the presence or absence of an association, its strength (weak/strong correlation) and direction (positive = one goes up, so does the other; negative = one goes up, the other goes down). How are the results expressed? Begin by having a look at their descriptive statistics such as the numbers or proportion of participants with a given outcome, or tables of average differences. Inferential statistics draw conclusions rather than simply describing. These may include analysis of tables of correlations or of measures of difference (between groups, as in a randomised controlled trial), such as analysis of variance (ANOVA), modelling, regression or sensitivity analysis. It might help to think of the study variance as all the measured differences amongst the participants. You then use your statistical analysis to try to make sense of this variance. The more of the variance accounted for in the end, the better the evidence is that the study has captured the strongest - and therefore potentially causal - factors. You have already had a look for evidence that confounding factors were considered. Are the numerical results adjusted for confounding? Take into account the list you made of overlooked confounding factors and consider if confounding could still explain an important part of the results? How did they evaluate the effect of individuals refusing to participate and did they adjust the overall results accordingly? Did this make much difference? For the phenomena of interest, how large and how meaningful is this size of result? (Continue your practice in NOT glossing over the sections with the p-values and confidence intervals!) And, of course, do the results answer the studys questions? Question 7: Are the findings plausible? To what extent can we generalise these findings? As in other appraisal frameworks you need to examine the detail of the study to determine whether there are important differences between the context of the research study and your own context. Do you bias, confounding, or even chance (especially if the numbers of participants was small). For studies drawing causal conclusions, run them through the causality criteria in figure 1 (p.19). Question 8: Do the results of this study fit with other available evidence? think that the study participants and setting may be very different from your own caseload? Can you quantify the potential local benefits and / or harms? Question 10: Should policy or practice change as a result of the evidence contained in this study?

Consider evidence from other studies, of all types, for consistency of findings. A wellconducted systematic review would be particularly helpful. You may need to conduct (or even commission) a literature review and appraise the quantity and quality of the available evidence before you are able to assess this. Bear in mind costs and benefits; the issue in question will have to be particularly important (specific, relevant, timely, and with resource implications) for your service before you decide to invest resources in a more comprehensive review of the evidence base in this area. Question 9: Can the results be applied to the local population?

As with the other appraisal tools, we should evaluate the studys contribution to the evidence base for local service provision. Does this study have implications for my practice, for that of my colleagues or more widely? Is there a further question to be asked, or more evidence needed, before I can answer this question? Always bear in mind that an individual observational study rarely provides sufficiently robust evidence to recommend changes to clinical practice or decisionmaking. However, for certain questions, observational studies provide the only evidence we can access. Recommendations from observational studies are always stronger when supported by other evidence. In a local journal club report on the ContiRamsden & Botting study (2007), the group concluded that the study added weight to a growing body of evidence showing a raised risk of negative mental health in young people with specific language impairment. However, since the majority of the group with specific language impairment did not have negative mental health symptoms, there is no simple, causal relationship between specific language impairment and mental health. There must be other factors at play. So, speech and language therapists need to be alert to the raised risk in young people with specific language impairment of anxiety and depression, either of which would have an impact on our clinical decision-making or on SLTP the success of our interventions. Jennifer Reid is a consultant speech and language therapist with NHS Fife, email jenniferreid@nhs.net. Cartoons are by Fran, www.francartoons.co.uk.

Do you believe the findings? As with any research, a big effect is hard to ignore, but this is only true if the study design and methods were of a high enough standard, so any flaws you have identified need to be borne in mind. The sorts of things to consider are whether the results could have been unduly influenced by

References Bradford Hill, A. (1965) The Environment and Disease: Association or Causation?, Proceedings of the Royal Society of Medicine 58, pp.295-300. Conti-Ramsden, G. & Botting, N. (2008) Emotional health in adolescents with and without a history of specific language impairment (SLI), Journal of Child Psychology and Psychiatry 49(5), pp.516525. Public Health Research Unit (2006) Critical Appraisal Skills Programme. Available at: http://www. phru.nhs.uk/Pages/PHD/CASP.htm (Accessed 29 July 2011). von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gtzsche, P.C., Vandenbroucke, J.P. (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies, Journal of Clinical Epidemiology 61(4), pp.344-349.
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HERES ONE

Heres one I made earlier...


Alison Roberts with another low cost, flexible and fun therapy suggestion for groups Paper fortune tellers
happens they will either have two nice or two nasty things to choose between. c. Now open the fortune teller up even more, to expose the inner part and write 3 choices for each theme... Holiday Disasters could include: It will rain solidly for two days. You will forget to bring your picnic on a day out. The cinema will close due to a flood. Nice Surprises could be: You will find a fiver in your pocket. Some excellent musicians will perform in the street. A beautiful butterfly will settle on your hand. Lovely Foods might be: You will have sausages and chips. You will have crisps and a fizzy drink. You will have a huge ice cream. Wrong Clothes could include: You have to wear a plastic bag hat because of the rain. Your shoelace breaks, so you have to use hairy string. You thought it was a casual bonfire party and put on old clothes, everyone else wears smart gear. The above is only an example; you can have whatever subjects enthuse your group. You might try a Talking Situations version with the following scenarios and predictions: The Waiting Room: The only other person there will think they know you. You will be confronted with a beautiful girl. Everyone will be sitting down and the only spare chair has a bag on it. The Youth Club: The only activity available tonight will be table tennis, and you feel awkward trying that It will be disco night and all your favourite music will be played It will be snooker night but someone will have stolen the cues. The School Reunion: The person who bullied you at school will be there. Your favourite teacher will be delighted to see you. A friend you lost touch with will come up and say hello. Fortune tellers promote choice-making, encourage conversation, can be designed for different abilities, cost almost nothing and are good fun! Do you remember making these at school? If not, your own or a neighbours children may be able to help with folding the prototype. If you already know how to fold these things the first bit will seem very long-winded, so pass swiftly on to Writing. MATERIALS Sheets of A3 paper - cut square Scissors and pens BRAWN 1. Folding Its best to do all the folding first, and then begin the writing in the areas formed. If you are managing a group on your own, a few trial runs beforehand of folding the fortune teller would be a wise idea. It is easy really, though; you will soon be able to demonstrate making one at the same time as watching everybody elses progress. a. Fold the square in half and half again, to find the middle. Open out so that you now have a flat piece of paper with a cross in the middle. b. Fold the corners to the middle neatly, and flatten down so that you now have a new, smaller sized square with folds along all the outer edges and all the corner points meeting. c. Turn the whole thing over so that the side with the corner points is face down. Now fold the newly formed corners to the middle as before. d. Turn it over again and youll see that you have made four little pockets for your index fingers and thumbs to poke into. Now pinch the whole thing together. This will be quite easy to do if you have done the folding neatly. You should now have a three dimensional object ready to write on. You will probably want to open it out a bit, to make the writing easier. 2. Writing a. On the outer 4 squares, formed on the back of the fortune teller, write the numbers 1-8. b. On the next part, the 8 triangles within, write 4 themes or situations, such as Holiday Disasters, Nice Surprises, Lovely Foods, and Wrong Clothes. Place the desirable themes opposite each other in this way when the choosing part

The Birthday Party: There will be great fireworks at the end. It will be a beach party and you will have a barbecue. There will be good music and great food. Once you have shown your examples of fortunes written in this device then you can encourage your clients to devise their own; take care, though, that nothing too disastrous is written. Note: You can write 8 situations if you can fit them onto the paper, and have enough ideas. You would then have to think of 8 sets of choices. IN PRACTICE i. One person pokes their fingers into the fortune teller and becomes the clairvoyant. ii. This person gives the instructions / asks the questions, while the other person, the fortune seeker, responds. This could be by pointing. iii. The first instruction is Choose a number between 1 and 8. Depending on the response, the clairvoyant opens and closes the fortune teller that number of times, in opposite directions. iv. The next instruction is to choose between the situations revealed. v. Once this is done, ask the fortune seeker to pick a number between 1 and 3, then the clairvoyant will read out the fortune.

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RESEARCH INTO PRACTICE

Symbolic voices (2): a complex reality


In 2009, Louise Greenstock gave us an interim report on her qualitative research into the use of graphic symbols in schools. The final findings presented here offer insights into clinical reasoning and ambiguity around professional roles that could also be helpful for other interventions and settings.
hould symbols be used with all children? Are children in the Foundation Stage too young for symbols? And should symbol terminology be more consistent? In Greenstock (2009), I wrote about the progress of my PhD research project into the use of graphic symbols in schools, and how my experience as a teaching assistant had influenced the focus and conduct of my research. Having completed in December 2009, I am now a fulltime researcher in Australia. As well as applying my knowledge on the other side of the world, I wanted to share my final findings with you and consider the implications for practitioners, policy makers and researchers. My research project had the central objective of exploring practitioners experiences of using graphic symbols in Foundation Stage school settings in a geographical region of the East Midlands. I focused on three groups thought to be most likely to use symbols in school settings: teachers, teaching assistants / nursery nurses and speech and language therapists (Abbott & Lucey, 2005). Given the context, I felt it was also important to explore their experiences of working with other practitioners in ways that might be considered inter-professional. The concept of inter-professional working is an important theme in government policy influencing health and education, where practitioners are increasingly expected to foster a culture of collaboration. I considered school settings to be a pertinent example of practitioners working together across different disciplinary and training backgrounds, and was curious about how inter-professional working develops in schools. The ever-increasing use of symbols gave me a very specific and topical context in which to explore the reality. Having received ethical approval from De Montfort University and one of the local NHS Research Ethics Committees, I recruited a sample of 53 participants (9 for the pilot READ THIS IF YOU WANT TO DEVELOP CLARITY AROUND INTERPROFESSIONAL WORKING DECISION MAKING INCLUSIVE COMMUNICATION

Major themes Theme 1: Practitioners beliefs about which children to use symbols with Theme 2: Practitioners thoughts about childrens understanding of symbols and representation Theme 3: Practitioners accounts of the ways in which symbols are used

First layer subthemes a. Specific children b. All children a. Developmental progression b. Modality a. Developmentally appropriate b. Production and introduction of symbols c. Consistency of symbol use d. Using symbols for specific purposes (see second layer subthemes)

Second layer subthemes

i. Visual timetables ii. Expressing choices and exchange systems iii. Learning to read / literacy skills iv. Rules and expectations of behaviour

Theme 4: Practitioners experiences of implementing symbols in schools

a. The setting b. Roles c. Collaborative working

Figure 1 Major themes and subthemes

study and 44 for the main study) with support from two Primary Care Trusts and four Local Education Authorities. After giving their informed consent, participants took part in a face-to-face interview with me. Interviews took place at schools and health centres. I transcribed the interviews and analysed the data using a form of thematic analysis (Braun & Clarke, 2006). The analysis led me to develop a theoretical framework consisting of a series of themes and subthemes, as well as two original theoretical constructs. I presented my preliminary findings in Greenstock (2009). The analysis of data continued after the article was published, and the findings

presented here represent the final version in my PhD thesis. The findings consisted of a thematic framework and a theoretical model which describe the overarching observations of the data. The major themes and subthemes are in figure 1. When they considered using symbols in school settings, each interviewee followed a unique and subjective process of reasoning around questions of how, why, when and with whom. Their decision making processes incorporated each of the four major themes: which children to use symbols with, the childs needs and developmental capabilities, how symbols could be used and how the strategy

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RESEARCH INTO PRACTICE


could be implemented. I developed a model of reasoning to reflect this (figure 2). The practitioner may consider any or all four of the components identified in any order, with any starting point. The model can be applied to individual practitioners accounts of thinking about how to use symbols. For example, figure 3 shows how a speech and language therapist considered a client who has physical difficulties and expressive communication needs and decided to introduce a choice board to facilitate the child in expressing choices at singing time on the carpet. Figures 4 and 5 also come from the original dataset, and show how the model can be applied to an individual teacher and a teaching assistant. The interview data reflected practitioners beliefs and ideas about each of the four major themes. There were areas of consistency and agreement, as well as discrepancies and tensions in their accounts. Theme 1: Practitioners beliefs about which children to use symbols with This theme directly addresses the question about whether symbols should be used with all children or specific children. In general, the practitioners were divided in their opinions. This reflected a tension in the data, and both sides of this debate were represented by practitioners in each of the three professional groups. Many expressed the belief that symbols should only be used with children with a specific need for them, and these needs were often related to their difficulties in certain areas of learning and communication. In contrast, a number argued that they could potentially benefit the full range of children but the reasons given varied among the professional groups. Educational practitioners tended to suggest this approach because they felt symbols could support all children in the setting. In contrast, speech and language therapists often suggested using symbols with all children as a way of ensuring communication opportunities and partners are made available to individual children using symbols to participate. The disparity between professional groups reflected some overarching differences in professional roles and disciplinary background. Theme 2: Practitioners thoughts about childrens understanding of symbols and representation Practitioners accounts of using symbols were frequently related to their perceptions of childrens understanding of representation and their ability to understand the referential nature of symbols. This aspect of cognitive understanding was seen as a developmental process. Many practitioners referred to childrens development in understanding representation, and gave accounts of assessing their development in this area and differentiating their use of symbols accordingly. Many practitioners suggested that childrens symbolic development occurred in stages, which could be related
Figure 2 When to use symbols Who which children Figure 3 Singing time on carpet Schoolbased speech and language therapist Why childrens needs Choice boards express choice through pointing Expressive communication needs Child with physical difficulties

Practitioner

How to use symbols

to the appropriate use of symbols and other representational items. Childrens understanding of symbols was often related to the modality of various forms of representation. Practitioners referred to objects of reference, photographs and symbols as possible modes used to represent ideas and information to children. Many times in the data practitioners referred to the use of multi-modal or multi-channel approaches. Using more than one mode (for example, text and symbols), and/or more than one channel (for example, auditory and visual), was believed to increase the accessibility of the message to a range of children. These findings did not appear to suggest that practitioners felt children were too young for the use of symbols, but did indicate that age and developmental stage were a consideration when using various modes of representation. Theme 3: Practitioners accounts of the ways in which symbols are used The practitioners interviewed appeared to have some firm ideas about how symbols should be used, incorporating developmental differentiation, how to produce and introduce symbols, the consistency of symbol use, and specific purposes to use symbols for. Relating to their beliefs about childrens developmental understanding of symbols, many gave accounts of the ways in which they would differentiate activities so they were developmentally appropriate. These practitioners frequently referred to the need to assess childrens level of symbolic development before making decisions about which mode of representation to use. Most were in agreement that objects of reference would be most suitable for use with children at an earlier stage of development. Photographs were considered the next stage in this hierarchy, and symbols and text to be more advanced. The hierarchy of understanding these modes of representation was referred to by practitioners in each of the three professional groups, and there was agreement across the data about the need to differentiate for different developmental abilities. Many practitioners expressed clear views about the need to produce and introduce symbols in certain ways to children in this age group. The production of symbols was usually

supported by software, and practitioners were in agreement that they should be introduced to children in small numbers so as not to overwhelm. There was some level of agreement about the need to use symbols consistently. Practitioners appeared to believe that symbols used throughout the school environment should be visually similar to support children at times of transition by providing something familiar in other environments. This finding was believed to be related to the level of anxiety experienced by children in the Foundation Stage age group. In contrast, some practitioners argued that individualised strategies were more important when symbols were being used to enable individual children to communicate and participate. Practitioners gave accounts of using symbols for a number of specific purposes. The most frequent were visual timetables, choices and exchange systems, developing literacy skills and representing rules and expectations of behaviour. The most dominant way of using symbols across all three professional groups was as part of symbol-supported visual timetables. Visual timetables were used to represent sections of time, and activities within the session and symbols were displayed in a vertical or horizontal line. Practitioners gave accounts of going through the visual timetable each day with the children and removing symbols to show time passing. This was seen as a tool to support children who experience anxiety about separating from caregivers or have difficulties in attention and staying on-task. Symbol-supported choice boards, the Picture Exchange Communication System (PECS), literacy and representing rules were all mentioned as additional ways of using symbols. Using symbols to support literacy in particular for word recognition - was unique to the educational practitioners. However, using symbols to represent rules and expectations was referred to by practitioners across all three professional groups. Theme 4: Practitioners experiences of implementing symbols in schools This theme was the most relevant to practitioners experiences of working interprofessionally in schools. Most of those

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RESEARCH INTO PRACTICE


Figure 4 Accessible throughout the session All children Figure 5 Accessible when choosing activities Teaching assistant Child with English as an additional language

Teacher

Visual timetable

Separation anxiety

Symbolised activities in book

Struggles to comprehend instructions

interviewed gave accounts of their experiences of the actual implementation of symbols in schools. The implementation process appeared to be influenced by contextual factors relating to ways of working in the school setting. Some practitioners highlighted that speech and language therapists were visitors in the school and this appeared to affect the amount of influence they felt they had. A number of speech and language therapists expressed frustration with the way symbols were implemented in schools, mainly related to symbols not being used enough. The practitioners accounts of their use of symbols in schools appeared to suggest that in some settings there were specific roles associated with each professional group. Speech and language therapists were frequently seen as experts and expected to deliver training and support in the ongoing implementation of symbols. Early years practitioners were frequently seen as responsible for carrying out the strategy or programme suggested by the speech and language therapist and maintaining resources. The role of the teacher was the most ambiguous in the data and it was not clear if teachers had any consistent role in this area of practice. These findings reflected a number of tensions in the data relating to discrepancies in interpretations of the roles of various practitioners. In some cases there appeared to be resistance and conflict between practitioners and their colleagues. The most dominant factors influencing collaborative working were time and availability, communication and perceptions of professional roles. Many practitioners commented on the lack of time available to discuss the use of symbols with colleagues and many highlighted the difficulty of releasing educational practitioners from duties to talk face-to-face. Communication and interpersonal skills were frequently mentioned as a factor in the success of collaborative working, and speech and language therapists in particular referred to the need for diplomacy. My findings led to the development of a suggested series of practical strategies for improving childrens experiences of using symbols, many of which applied to all of the professional groups:

When using symbols, consider which children the intervention is targeted at. Consider whether it is just a specific child, or group, or more designed to support all children. Always consider the developmental ability of the child in terms of their understanding of representation. Speech and language therapists are skilled in identifying this. Differentiate the use of symbols or other modes of representation to the childs level of understanding (for example, objects of reference, photos or symbols). Introduce symbols in small quantities and explain or teach their meaning. Discuss as a team whether to use one symbol set consistently or differentiate use depending on the child or the purpose. Consider the objectives and professional role of all colleagues involved in the implementation of symbol use. Define roles where necessary and make use of any opportunity to communicate and share ideas and reasoning.

of representation and this gave some interviews a rather abstract dimension. This is of great interest in considering the cognitive processes in everyday practice, an aspect which could be explored further in the future. Regardless of attitudes towards the use of symbols and beliefs about their appropriate usage, the implementation of symbol use in schools is a complex reality. Practitioners in each of the three professional groups considered a range of factors - and their reasons for using symbols with one child may be very different to using them with another. Practitioners in all three professional groups called for more training and more time to discuss and plan the symbol strategies collaboratively. The practitioners who expressed the most satisfaction with their experiences of using symbols referred to respectful, supportive and mutually advantageous experiences of working with other professionals. This suggests that there is value in the move towards increasing inter-professional practice. It also confirms that examples of good practice can be recorded and shared as a result of conducting research which places the practitioners voice SLTP at its heart. Dr Louise Greenstock, formerly at De Montfort University, is now a Research Fellow at the Australian Health Workforce Institute, University of Melbourne, email lgreens@unimelb.edu.au. References Abbott, C. & Lucey, H. (2005) Symbol communication in special schools in England: the current position and some key issues, British Journal of Special Education 32(4), pp.196-201. Braun, V. & Clarke, V. (2006) Using thematic analysis in psychology, Qualitative Research in Psychology 3(2), pp.77-101. Greenstock, L. (2009) Symbolic voices, Speech & Language Therapy in Practice Summer, pp.12-14.

Think deeply

Practitioners think deeply about the ways in which they use symbols and base their reasoning on the needs of the children they work with. Using symbols does seem to frequently involve working with one or more other practitioners who may or may not have contrasting disciplinary and training backgrounds. While practitioners may be expected to work inter-professionally, it must be recognised that every practitioner is a unique individual with their own reasoning and decision making processes. There may be trends in professional reasoning across and within professional groups, but there may also be personal differences which are hard to make explicit in day to day practice. There were discrepancies and inconsistencies in the terminology used to describe and discuss symbols, but there was no indication that this caused any major problems in daily practice. This issue was part of a more philosophical conversation with some participants about the meaning

REFLECTIONS DO I TAKE AN EVIDENCE BASED APPROACH TO COLLABORATIVE WORKING? DO I UNDERSTAND MY OWN REASONING PROCESSES AND SEEK TO UNDERSTAND THOSE OF OTHERS? DO I GIVE SUFFICIENT PRIORITY TO DEVELOPING SKILLS AROUND NETWORKING AND DIPLOMACY?
What ideas has this article given you? Let us know! See Speech & Language Therapy in Practices Critical Friends information at www.speechmag.com/About/Friends.

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BOUNDARY ISSUES (6)

An exceptional case?
Jan Broomfield considers the following scenario:
n these times of austerity, we are increasingly faced with limited resources to meet the needs of our clients. This means we must make challenging decisions. Do we offer less to all clients? Do we prioritise those requiring specialist services rather than targeted and universal, as per the triangle of need (Gascoigne, 2006)? Do we respond to demands to keep initial assessment waiting lists short, thereby opening up a duty of care for those cases requiring intervention (RCSLT, 2006, p.25) and being cognisant of the nature and needs of the caseload? Or do we instead prefer to remain nave about what awaits us and defer the initial appointments? We face these issues of prioritisation every day, whether managing a whole service, a specialist team or a personal caseload. We determine the acceptable standards for our service, including waiting lists, both from referral to initial assessment, and from assessment - which identifies a need for intervention - to the point at which that intervention can be offered. Whenever we have a staffing issue, whether covering annual leave, long term sickness, maternity leave or career break, there is juggling of resources to maximise the provision available. When this situation is short-term, it is demanding yet somehow achievable but, when it is longer term or even permanent, such as through a recruitment freeze or cuts, this is likely to result in a reduction of service standards and availability. We have a duty to conduct the assessment, as the only person who can identify a speech and language therapy clinical risk is a Speech and Language Therapist . Whether or not an individual can be helped by SLT will determine the existence of a clinical risk (RCSLT, 2006, p.25). There is a growing evidence-base which, in some cases, indicates that direct input from our services is required for effective interventions (Law et al., 2003). Further, there is emerging evidence suggesting that lengthy waiting lists may lead to less overall progress than offering intervention soon after referral and initial assessment (Broomfield & Dodd, in press). What then are the consequences of deferring initial assessment, or of delegating our directed intervention to others? These may be strategies we employ to enable us to manage increasing caseload demands within tightening resources. Where does that sit within an evidence based practice framework (RCSLT, 2009)? The Royal College of Speech & Language Therapists states that we must act in the best interests of individuals using speech and language therapy services and carry out all duties in a professional and ethical way. Further, it reminds us that we must recognise the eth-

The department you lead has a recruitment freeze and you are struggling to keep up standards of service, including waiting times. A referral comes in from a GP, and you realise the child concerned is the son of the Trusts Chief Executive Officer.
BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics (2008) require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this series we think through everyday events which receive much less attention but also need to be on our ethical radar. So, when you recognise a referral as being the son of your organisations Chief Executive Officer, and you have vacancies and are therefore not able to meet your contracts agreed waiting times from referral to assessment, what do you do? Have you already informed the Trust Board of the difficulties you are facing and the economic case for your service (Marsh et al., 2010)? You could take the view that the CEO ought to be treated like everyone else and made aware on a personal level of the impact your waiting list has on families in which case you simply add the name to the lengthy waiting list and they receive an assessment as time permits. Alternatively, perhaps falling outside of the contractual time may place the future of your service at risk. Is it ethical to prioritise this case over all others, in order to appear to be meeting the demands of the contract and the agreed service standards? As with all such ethical issues, there is not necessarily a right answer, but rather an argument to be had, and the best possible decision made, taking account of all the supporting evidence and pitfalls. Whatever you decide, it is an opportunity to raise the profile of your service in a positive way. For this reason you will wish to ensure you communicate well about the waiting time and send the appointment with lots of notice. You may also offer a short-notice cancellation, consider the likely urgency of the clients needs, or hand pick the therapist who will see the child. Any therapist who becomes aware of such a referral should consult their manager in the first instance. In the end the manager, as leader of the team, needs to be able to provide support, if challenged, to justify the decision SLTP you have jointly made. Jan Broomfield (jan@speechtherapy4kids.co.uk) is a consultant speech and language therapist and the RCSLT Councillor for Research & Development.
References Broomfield, J. & Dodd, B. (in press) Is speech and language therapy effective for children with primary speech and language impairment?, IJLCD. Gascoigne, M. (2006) Supporting children with speech, language and communication needs within integrated children's services. Position Paper. London: RCSLT. Law, J., Garrett, Z. & Nye, C. (2003) The effect of treatment for children with primary speech and language delay or disorder, The Cochrane Database of Systematic Reviews, 3. Marsh, K., Bertranou, E., Suominen, H. & Venkatachalam, M. (2010) An economic evaluation of speech and language therapy. London: Matrix Evidence. Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Royal College of Speech & Language Therapists (2009) Research Strategy. London: RCSLT.

ical dimension that exists within every clinical decision taken (RCSLT, 2006, p.10). Much of the time we can adhere to our services protocols about length of waiting list and prioritisation, even though we may believe this is not ideal. Periodically, perhaps where we have a personal connection or a professional interest in a particular client, we will be faced with a dilemma do we adhere to the standard service provision, or do we make an exception? RCSLT (2006) recommends response times from referral to assessment for different client groups and clinical presentations. These go from 2 working days (extremely high risk of choking, inhaling food or inadequate nutritional intake), through 10 working days (individuals at risk of the above, or those at high psychosocial risk due to newly acquired communication difficulties or deteriorating communication skills), to within 13 weeks (at psychosocial or educational risk due to speech, language, communication difficulties) (p.199). Our contracts with funders, purchasers, commissioners and others who buy our services may stipulate different waiting times, usually shorter. When fully staffed we may manage to meet these demands but, when resources become limited, this may have to give to best meet the needs of the whole caseload.

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COVER STORY: HOW I

How I manage acquired brain injury (1):

Tuning in a new audience

Daniel was only 16 when he sustained a severe head injury. Three years later he was in supported accommodation and receiving regular therapy, but Lindsay King wondered if he could achieve more. Inspired by a presentation at an aphasia special interest group, she decided to revisit Melodic Intonation Therapy, an intervention she had assumed was out of date. Lindsay says this appeared to give Dan a platform for speech and, in turn, for greater social participation and independence.
here are many potentially useful treatments around, which we may have heard of but know very little about. Even for a relatively young profession such as ours, these treatments can seem old, so we assume they are outdated. One such intervention is Melodic Intonation Therapy, first published in 1973 by Albert et al. I was inspired to try it out after attending an Aphasia Special Interest Group where I heard recent evidence directly from the researcher, music psychologist Katie Overy. Benson et al. (1994) say that as far back as 1953 singing was recommended for the rehabilitation of expressive deficits, as it had long been observed that many people with aphasia could sing better than they could speak. Melodic Intonation Therapy was introduced by Albert et al. (1973) with a report of its successful use with three people with chronic nonfluent aphasia. Melodic Intonation Therapy provides a hierarchically structured intense treatment programme divided into three levels. At the first two levels, multisyllabic words like /tel-evis-ion/ and short high probability phrases such as /a- cup- of -tea/ are musically intoned (sung) in a prescribed graduated course. The third level introduces longer or more phonologically complex sentences or both. At each level the material is first intoned (sung with the therapist) accompanied by tapping the rhythm on the clients hand. This is followed by tapping accompanied by exaggerated speech prosody before being spoken normally without any tapping. (For a detailed explanation, see HelmEstabrooks et al., 1989). Strict use is recommended by the original authors, who also prescribe that Melodic Intonation Therapy is used in a controlled and measured time frame such as 1.5 hours per day, 5 days per week over 8 weeks for success to be achieved (Schlaug et al., 2008). Helm-Estabrooks et al. (1989) recommend suitable candidates have: 1. Left hemisphere lesion with the right hemisphere intact 2. Severely restricted non-fluent poorly articulated speech

3. Poor repetition even at single word level 4. Good auditory comprehension 5. Good motivation, emotional stability and attention span. Katie Overy (2009) verbally described her recent research using fMRI (functional magnetic resonance imaging). Following Melodic Intonation Therapy, she discovered that more neural activation occurred in the participants right superior temporal gyrus than pre-therapy. In addition there was increasing activation in the region surrounding the participants lesion, including Wernickes area and the left frontal temporal gyrus. Katie also told us about a 2009 study where Gottfried Schlaug and colleagues used diffusion tensor imaging following Melodic Intonation Therapy. This revealed an increase in the number of white matter fibres (neurones) in the right hemisphere arcuate fasciculus, which connects structurally Wernickes and Brocas area and the adjacent pre-motor cortex. Both of these recorded changes may suggest some long-term positive effect on brain function recovery following Melodic Intonation Therapy. Not only do pathways in the right hemisphere become more active but other areas of the left hemisphere become active also. In addition, evidence for plasticity has occurred in the brains white matter.

Dan and Lindsay

READ THIS IF YOU WANT IDEAS FOR DIRECT THERAPY TO LEARN FROM HISTORICAL APPROACHES CLIENTS TO BE ABLE TO EXPRESS THEIR PERSONALITY required at home. Sadly, Dans home life was in upheaval as his parents were divorcing. Dan was referred to Cumbria Community Acquired Brain Injury Rehabilitation Team in May 2008, 17 months after his accident. At that time he was unable to match single written words to pictures. His auditory comprehension was reliable at one information carrying word such as point to your nose. Dan could copy letters but, other than his first name, he was unable to write letters independently. Speech production was severely restricted to single word naming with considerable dyspraxic groping and many word finding errors such as [ti:ef ] for toothbrush. Dan tried hard to repeat single sounds and simple words but the effort was considerable, and his working memory was severely impaired too. Our team includes a neuropsychologist, occupational therapist, physiotherapist and rehabilitation assistant. We all found it very difficult to progress from work set in our therapeutic surroundings due to the fluctuating levels of support in Dans home environment. Eventually, funding was secured jointly through adult social care and the primary care trust for a place in a supported house run by the Brain

Client in mind

Armed with this inspiring contemporary information, I had one 19 year old client in mind with whom I had been working therapeutically for 18 months. In January 2007, when he was 16, Dan had sustained a severe head injury whilst riding pillion on a motor scooter. He spent ten months in hospital and was discharged home in October 2007 with little follow-up community support from the allied health professions. After a brief spell being visited for 15 hours per week by a local care agency, direct payments were made to the family to enable them to provide all the support Dan

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cover story: how i


Injury Rehabilitation Trust. Dan moved into Thornton Road in July 2009. Thornton Road has individual bedrooms for three residents at any one time, all of whom have suffered an acquired brain injury. As a visiting therapist, I had previously observed that the staff team was in an ideal position to provide targeted Supported Conversation (Kagan, 1998). All staff members have therefore been trained and, on recruiting new staff to the house, we have re-run the programme. The techniques are now absorbed so naturally into everyday conversation that its a given standard expected of the staff in the house. Dan was therefore now in an environment where Supported Conversation techniques were the norm and in use by trained staff throughout the entire day. He responded well to phonemic cueing and encouragement to use total communication. He attended college to address his numeracy and literacy skills. We used writing and reading materials to supplement repetitive dyspraxic-type drilling exercises, attempting at all times to make the speech meaningful and relevant to him. However, he painfully expressed his isolation from his friends and his frustration with his continued limited verbal expression. Speech targets now expanded to include adjectives in specific exercises. In addition, rather than staff responding with a series of closed informed questions where they retained the burden of the communication, they would ask Dan for supplementary information. For example if Dan said, Car?, staff would previously have said, What about your car Dan? Is it parked outside? Short of petrol? Now they would say, Car? Tell me more.

Flow of conversation

Cover photo of Dan at the Spotted Cow cafe by Charlie Hedley, www.charliehedley.com

He painfully expressed his isolation from his friends and his frustration with his continued limited verbal expression
In January 2010, three years post-injury and six months after Dan moved into Thornton Road, we held a goal review meeting where I set out my plans to introduce daily practice of an adaptation of strict Melodic Intonation Therapy. I trained the Brain Injury Rehabilitation Trust staff at Thornton Road in the intoning and syllabic tapping techniques, and gave an overview of the theory I had gleaned from the Aphasia Special Interest Group two months earlier. We began singing together familiar songs with a regular rhythm and tempo such as Ten green bottles, Happy birthday, For hes a jolly good fellow and Shell be coming round the mountain. Dan, the other two residents and the staff at Thornton Road shed their inhibitions, and karaoke nights became a regular activity. We then progressed to singing and tapping sets of 12 short written sentences on cards accompanied by the picture, such as A slice of toast, A pinch of salt and A can of coke. Trained staff at Thornton Road worked with Dan for a minimum of 15 minutes a day using the cards. I visited weekly to supplement their sessions. When Dan became 100 per cent fluent, we gradually withdrew accompanied singing and tapping and replaced the singing with

accompanied exaggerated prosody of speech, known as sprechgesang. When Dan was 100 per cent fluent at this level, we withdrew our speech and he spoke in sprechgesang alone. When 100 per cent fluent with this, he reverted to natural prosody, initially reading the phrase. Finally, simply in response to the picture, he spoke the phrase with no text. Sentence structure then progressed in syntactic and phonemic complexity but retained a regular rhythm. I made another set of 12 cards with pictures and text depicting for example A walk in the park, A swim in the pool, A key for the door. Following exactly the same pattern above, the sentences progressed to a further set of 12 cards depicting sentences such as Im cleaning the bath, Im ironing my clothes and Im walking to college. Dan spontaneously started to combine the cards to produce longer and longer sentences. For example he said, Im walking to college and then Im going to the Spar. In January 2010, Dans spontaneous speech was 19 syllables spoken in 58 seconds, which converts to 19.6 syllables per minute (table 1, sample I). By July 2010, Daniel was speaking with cards and no text at a rate of 18 syllables in 22 seconds (49.1 syllables per minute). On the basis of this speed, we set the ambitious target of both cued (using props / pictures) and free spontaneous speech (no props / pictures) at a 50-54 syllables per minute speaking rate. Andrews & Ingham (1971) state the normative rates of adult speech are between 162-230 syllables per minute. Even allowing for a large variation of speed between speakers, this means that Dan would at best be speaking three times slower than his peer group.

By November 2010, Dan was using sophisticated social skills in order to maintain his flow of conversation. Spontaneously, he began to: 1. Introduce his turn with a dramatic Well (pause). This alerted the listener that he had something to say and was adding processing time to find words and sequence sounds. 2. Incorporate well-rehearsed phrases into his new conversations. For example, when describing which venues he had visited recently, Dan responded, ..walked past MacDonalds but then well you have to, you have to, you just doI know I know we went in and I ordered. This has the effect of him holding the conversational floor for longer periods. 3. Use facial expressions, particularly smiling, eye-rolling, smirking and eyebrow-raising, to supplement his conversations and make banter and gentle teasing possible. For example, when staff were pulling his leg about his unwillingness to spend money on non-essential items such as a daily newspaper, Dan responded wittily, well, wait, wait, next day I can read it for free while smiling and gesturing to another residents paper which had been placed in the recycling bin. This level of humour was completely absent in earlier interactions, but it injects his identity, personality and growing confidence.

This level of humour was completely absent in earlier interactions, but it injects his identity, personality and growing confidence
4. Use all available channels of communication to resume contact with old friends. With support, he emails and texts friends and is planning to set up his own facebook profile. He uses the internet to enjoy online crosswords, games and puzzles. He also uses his mobile phone to arrange meetings and then writes the details in his diary.

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Overy & Molnar-Szakacs (2009, p.499) argue that singing and rhythmic syllabic tapping are effective in supporting language skills. They add that the method of Melodic Intonation Therapy is also highly imitative, synchronised and an intensely shared experience using physical hand contact and close eye contact. They believe this may be central to its effectiveness as a tool. Though we did not reproduce exactly the strict levels stipulated by Helm-Estabrooks et al. (1989), our moderate adaptation still appears to have contributed to some effective changes, and I am grateful for the support and enthusiasm offered by the Brain Injury Rehabilitation Trust staff. My limited experience of Melodic Intonation Therapy with Dan suggests his enjoyment of the initial singing sessions and early intoning sessions (sprechgesang) with sets of pictures gave him a platform for speech which earlier therapy had failed to provide. Once he had mastered the regular rhythms of speech from the well rehearsed practice sentences he was able to generalise this spontaneously to his own self-generated sentences, albeit at a slower processing rate and speed. As his sentence flow improved, we saw an accompanying growth in his levels of confidence.
Table 1 Spontaneous speech samples as spoken syllables per minute NB Early speech samples did not last for one minute. I therefore made calculations on the basis of the number of syllables spoken divided by the speed in seconds multiplied by 6o to give syllables per minute. Date of spontaneous speech sample June 2008 (on referral, 18 months post brain injury) June 2009 (Moves into Thornton Road) January 2010 (Melodic Intonation Therapy introduced) May 2010 July 2010 August 2010 November 2010 Syllables per minute with props 4 8.8 22.3 45.3 49.1 No data (Sample II) 51.7 Syllables per minute, no props 1-2 7 (Sample I) 19.6 26.4 No data 31.7 (Sample III) 35.8

Stable environment

Speech samples I. me.walking.no problem. Tired, butfine. Winter..walking..I..fall over.hey II. Am having cereal then am making a cup of tea. Firstly I need to drop the sugar in the cup, then, well am pouring milk over the cereal and cup. Later am making a sarni-bacon. III. Firstly I need a plate then am making toast in the - kettle - no toaster. In. Fair enough. Then waiting. Waiting - ready. So fridge, open it to find butter. Take it out, spread it, knife of course! Then put the butter in the fridge. Enjoy!

Simultaneously, Dan was living in a stable environment with staff not only trained in Melodic Intonation Therapy but also Supported Conversation. He was also maturing and coming to terms with the impact of his injury. I regret not measuring Dans language recovery more closely and accurately using regular formal testing. It would have been interesting to understand this evolving picture phonemically, semantically and syntactically. In addition, had I had access to fMRI scanning equipment, I would have enjoyed exploring hypothesised parallel changes in this medium. However, this technique is realistically only available in a strict research environment and Nicoll (2007, p.1) reported from a conference, Its easy to get excited about the potential of technology but what I hadnt appreciated was the many drawbacks associated with its use. Although it is not possible to isolate the contribution of Melodic Intonation Therapy to Dans overall progress, it is important to note that the supplementary and consequential changes in Dans level of confidence, appearance, growing circle of friends and social activities has occurred over the last year since commencing Melodic Intonation Therapy and between the third and fourth years post injury. In light of his improved communication skills reducing his vulnerability, it is now possible to support Dan to work towards one of his goals, to have my own home. His social worker and case manager are exploring social housing options with some carer support, where Dan may live independently in his own space. As Dan put it, where old fella [Dad] can come. SLTP stay.but its MY mine.house.

Lindsay King is a specialist speech and language therapist with the Cumbria Community Acquired Brain Injury Rehabilitation Team email Lindsay. King@cumbria.nhs.uk. References Albert, M.L., Sparks, R.W. & Helm, N.A. (1973) Melodic Intonation Therapy for Aphasia, Archives of Neurology 29, pp.130-131. Andrews, G. & Ingham, R.J. (1971) Stuttering: considerations in the evaluation of treatment, British Journal of Disorders of Communication 6(2), pp.129-138. Benson, D.F., Dobkin, B.H., Gonzalez Rothi, L.J., Helm-Estabrooks, N. & Kertesz, A. (1994) Assessment: melodic intonation therapy. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, Neurology 44(3 Pt1), pp.566-568. Helm-Estabrooks, N., Nicholas, M. & Morgan, A.R. (1989) Melodic Intonation Therapy. Austin, TX: Pro-ed. Kagan, A. (1998) Supported conversation for adults with aphasia: methods and resources for training conversation partners, Aphasiology 12(9), pp.816-830. Nicoll, A. (2007) BAS Conference 2007. Available at http://www.speechmag.com/content/files/ BASSep07.pdf (Accessed 15 July 2011). Overy, K. (2009) Handout from the Aphasia SIG, 9 October. Overy K., & Molnar-Szakacs I. (2009) Being Together in Time: Musical Experience and the

Mirror Neuron System, Music Perception 26(5), pp.489-504. Schlaug, G., Marchina, S. & Norton, A. (2008) From singing to speaking: Why Singing May Lead to Recovery of Expressive Language Function in Patients with Brocas Aphasia, Music Perception 25(4), pp.315-323.

REFLECTIONS DO I CAPITALISE ON OPPORTUNITIES TO PROVIDE BETTER COMMUNICATION ENVIRONMENTS? DO I RECOGNISE THE VALUE OF SPECIAL INTEREST GROUPS FOR CONTINUING PROFESSIONAL DEVELOPMENT? DO I TAKE SUFFICIENT MEASURES TO MONITOR THE DIFFERENCE A NEW INTERVENTION MAY BE MAKING?
How has this article changed your thinking? Let us know see information about Speech & Language Therapy in Practices Critical Friends at www. speechmag.com/About/Friends.

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HOW I

How I manage acquired brain injury (2):

The local dimension


Laura Flynn reflects on the challenges and rewards of providing the best possible service to a minimally conscious patient in the intensive care unit of a local hospital pending transfer to a specialist facility.

hen Suzannah Pemberton was 20, she suffered a severe head injury as the result of a rollerblading accident. After surgery she spent 18 weeks in our local Intensive Care Unit (ICU) before transferring to a specialist unit. Caring for Suzannah was a valuable experience for us all, and led to us developing links with and learning from a specialist team. This article reflects on the options available to our multidisciplinary team and the decisions we made. I hope it may benefit other local teams who face similar challenges in establishing baselines and forming initial hypotheses before their clients are discharged to specialist units. The incidence of severe brain injury in the UK is approximately 8 per 100,000 of the population (Andrews, 2001), and is thought to be increasing given advances in medicine and survival rates. ICUs care for patients whose conditions are so life-threatening they need constant close monitoring and support from equipment to avoid organ failure. Severely brain injured patients are likely to require level 3 care initially, which is advanced respiratory support alone or basic respiratory support together with support for at least two organs. Although numbers remain small, local hospital ICUs are therefore likely to face an increase in admissions of vegetative or minimally conscious patients who require highly specialist care and early rehabilitation for improved outcomes (Elliott & Walker, 2005). Local hospitals may not have the level of expertise or staffing to provide intensive specialist programmes before patients can be transferred to regional specialist units as recommended by NICE (2003). Following her accident, Suzannah was initially transferred to a regional neurological centre for emergency brain surgery. She returned sedated and ventilated to our ICU two weeks later when she was medically stable. She remained in a likely persistent vegetative state for approximately nine weeks and was additionally suffering paroxysmal autonomic instability. (Clinical manifestations of this include a temperature of 38.5 C, hypertension, a pulse rate of at least 130 beats per minute, a respiratory rate of at least 140 breaths per minute and intermittent agitation.) Suzannah was referred to speech and language therapy 10 weeks post injury for

advice regarding cuff deflation, swallowing and communication. She was managed by the local service for a further 10 weeks before being transferred to a specialist unit once she was medically stable and funding had been secured. On referral, Suzannah appeared to track to voice and moving environmental stimuli. She was in definite sleep wake cycles. Some inconsistent purposeful motor behaviour had been observed. As a multidisciplinary team we felt we could discriminate these movements from reflexive responses, which may suggest Suzannah was emerging into a minimally conscious state, but we needed objective evidence.

1. Communication

The Royal College of Physicians (2003) state that differential diagnosis of minimally conscious state from persistent vegetative state can be made if a patient demonstrates awareness, responds to noxious stimuli, localises pain and demonstrates some consistent or inconsistent verbal or purposeful motor behaviour (p.6). These responses must be distinguishable from reflexive behaviour. The literature supports the use of formalised programmes to establish responses and consequently form an accurate diagnosis (Giacino et al. 2002). The Sensory Modality & Assessment Rehabilitation Technique (SMART) (Gill-Thwaites & Munday, 2001) examines the response of a patient in a persistent vegetative or minimally conscious state to a sensory programme including vision, hearing, taste, touch and smell. Two therapy staff had undertaken training and used SMART previously, and it is also used at the specialist unit where Suzannah was later discharged. Because of limited resources, the team was unable to offer the daily sessions a specialist unit would provide. We therefore developed a simplified assessment programme based on the principles of SMART with observation forms kept in the nursing notes at Suzannahs bedside. These were completed by members of the team and her family. We graded responses from 1-5 as outlined in SMART (1 being no response to 5 a differentiating response such as following auditory or visual commands), and repeated the same measures during each planned team

session to observe for consistent responses. Our observation forms are downloadable from the members area of www.speechmag.com. Suzannahs responses to sensory stimuli were inconsistent across sessions. For example, she would inconsistently look towards the controlled sounds presented and to voice (SMART level 3 and 4), and she appeared to dislike the taste stimuli (change in facial expression), possibly secondary to being hypersensitive. There were no obvious responses to the controlled visual or olfactory stimuli. She did, however, appear to respond to familiar people by staring at them more intently (SMART level 4). She moved her leg and head to command but did not repeat these movements consistently across the sessions. No consistent yes/no response was established at this time. This all meant that Suzannah fitted the criteria for a diagnosis of minimally conscious state (Royal College of Physicians, 2003; Giacino et al., 2002). The team, however, acknowledged that the intensity of assessment was much less than that used in SMART, making it difficult to draw firm conclusions.

2. Dysphagia and tracheostomy management

On referral Suzannah was nil by mouth and fed via a percutaneous endoscopic gastrostomy (PEG). She had a 7.5mm portex unfenestrated cuffed tracheostomy tube in situ. Her sedation was being reduced and she was no longer ventilated; at this point she was unable to manage secretions and required frequent suctioning. The teams management of Suzannahs tracheostomy followed the graded approach recommended across the literature (for example Frank et al., 2007). The Intensive Care Society (2008) states that a longer wean is expected from patients with neurological deficits, and recommends working with cuff deflation as the safest option. During the first session, Suzannah tolerated cuff deflation for up to 15 minutes. The medical and multidisciplinary team agreed to trial longer periods of deflation over the next ten weeks (eventually up to 24 hours cuff deflation). This helped to promote sensation and encouraged dry swallows, although

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HOW I

READ THIS IF YOU WANT TO OFFER THE BEST SERVICE THAT CIRCUMSTANCES ALLOW MAKE DECISIONS BASED ON EVIDENCE UNDERSTAND YOUR CONTRIBUTION TO LONG-TERM OUTCOMES episodes of paroxysmal autonomic instability caused delays in the process. During cuff deflation Suzannah achieved some voice with the speech and language therapist using digital finger occlusion to normalise the airflow. In the following session the inner cannula was changed to fenestrated to allow for maximum air to pass supraglotically, and a Passy Muir speaking valve was trialled. We could now assess laryngeal competencies. Involuntary voice was achieved, mainly crying, with some pitch variation noted, but no phonation to command. Achieving vocal cord closure indicated that airway protection for swallowing was possibly intact, and Suzannah spontaneously gave a strong cough when suctioned by the physiotherapist. Given evidence of laryngeal competencies and tolerance for periods of cuff deflation we felt it was appropriate to commence oral trials. Logemann (1998) details the advantages to swallowing trials and therapy while the tracheostomy is in situ because aspiration can be observed more directly, and the team has the ability to easily suction (p.164). On bedside assessment Suzannah was unable to achieve oro-motor movements to command. At this stage it was difficult to confirm whether this was secondary to a language or cognitive impairment, apraxia, or anarthria. It was hard to gain evidence of lip, tongue or palatal movements. Spontaneous oro-motor movements included a degree of ability to open her mouth when she cried. She triggered spontaneous dry swallows. She required regular suctioning of oral secretions and deep suctioning below her tracheostomy. She would cough reflexively to clear secretions but was unable to cough voluntarily to command. Suzannah appeared hypersensitive; she was biting her lips severely, had an abnormal bite reflex to oral hygiene procedures and appeared to react negatively to facial touch, particularly of the lower half. The literature indicates people with severe head injuries often experience hypersensitivity (Logemann, 1998). We wanted to get objective information on the pharyngeal stage of Suzannahs swallow (RCSLT, 2005). Sherlock (2007) says that FEES is a useful tool for assessment of swallowing in ICU, but we did not have access to it. Videofluoroscopy was available, and a small study by ONeil-Pirozzi et al. (2003) supports its use with this population. However, it was not indicated at this point because it was so difficult for Suzannah to open her mouth and control a bolus. Physical positioning in

In memory of Zannah

Suzannah Pemberton died in February 2009, three years after a severe head injury. The Zannah Pemberton Gaze Control Project was set up by her parents in her memory to enable other people with severe disabilities in Jersey to trial gaze controlled technology for personal, email and text communication as well as surfing the internet and controlling the environment. The two year project in association with Dr Mick Donegan began in September 2010 and includes vital specialist training and support for carers and local professionals.

the radiography suite would also have been challenging due to her hyperextension. In the absence of empirically supported assessments, we used the Modified Evans Blue Dye Test along with cervical auscultation and pulse oximetry. The controversy in the research over the reliability and validity of these approaches (see for example ONeilPirozzi et al., 2003; Leslie et al., 2007) meant we had to be cautious in our interpretation of the results, particularly as they were not clear-cut. The physiotherapist monitored Suzannahs chest sounds using bronchial auscultation during the Modified Evans Blue Dye Test. Shaw et al. (2004) found this approach to be 88 per cent accurate in confirming the absence of aspiration. There was no change, but we were aware this did not take account of potentially delayed aspiration or the effect of fatigue if further boluses were given. The results of the Modified Evans Blue Dye Test, bronchial auscultation and monitoring of pulse oximetry might indicate that Suzannah had not aspirated. However, given her severe oro-pharyngeal impairment at bedside assessment, difficulties with secretion management, abnormal bite reflex, changes in breath sounds on cervical auscultation post swallow, change in voice quality post swallow, inability to cough to command to clear any possible aspirated or penetrated

materials, low awareness levels and inability to follow commands, we hypothesised that she presented as a high aspiration risk and that oral trials were not safe at this time. Suzannahs initial portex size 7.5 unfenestrated cuffed tracheostomy was downsized to a portex size 4.0 uncuffed fenestrated tracheostomy before her discharge to the specialist unit. This downsizing reduced the chances of stenosis, the speaking valve allowed for voice, and it commenced the weaning from the tracheostomy.

3. Therapy

RCSLT (2005) state that oral hypersensitivity should be treated as part of dysphagia management. We chose Facial Oral Tract Therapy (FOTT) (Coombes, date not stated; Davies, 1994) as the clinical intervention because it can be used with patients in low levels of consciousness who would not be able to engage in postures, manoeuvres or exercises. I hypothesised that FOTT may contribute to desensitisation, promote oral movements and stimulate sensation by introducing taste. Although the research is limited, it may also contribute to reducing time to decannulation and promote functional long term oral intake in patients with traumatic brain injury (Hansen et al., 2008; Frank et al., 2007).

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HOW I
FOTT can be administered alongside SMART because FOTT involves repeated activity and reactions can be monitored. The goals we set were i. de-sensitisation of the lower half of Suzannahs face ii. improved oral movements. Our FOTT programme was guided by the specialist unit. It involved facial massage, supported mouth and jaw opening, passive tongue movement, oral hygiene, introducing items in gauze, and tastes. We used the observation sheets to monitor progress, and saw the intensity of Suzannahs bite reflex during oral hygiene and the frequency of negative responses to facial touch reduce.
Phys Med Rehabil 89(8), pp.1556-1562. Leslie, P., Drinnan, M.J., Zammit-Maempel, I., Coyle, J.L., Ford, G.A. & Wilson, J.A. (2007) Cervical auscultation synchronized with images from endoscopy swallow evaluations, Dysphagia 22(4), pp.290-298. Logemann, J.A. (1998) Evaluation and Treatment of Swallowing Disorders. 2nd edn. Austin, TX: PRO-ED. NICE (2003) Clinical Guideline 56 - Head Injury. Latest update available at: http://www.nice.org.uk/CG56. (Accessed: 6 July 2011). ONeil-Pirozzi, T.M., Lisiecki, D.J., Jack Momose, K., Connors, J.J. & Milliner, M.P. (2003) Simultaneous modified barium swallow and blue dye tests: A determination of the accuracy of blue dye test aspiration findings, Dysphagia 18(1), pp.32-38. Royal College of Physicians (2003) The Vegetative State. London: RCP. Royal College of Speech and Language Therapists (2005) RCSLT Clinical Guidelines. London: RCSLT. Shaw, J.L., Sharpe, S., Dyson, S.E., Pownall, S., Walters, S., Saul, C., Enderby, P., Healy, K. & OSullivan, H. (2004) Bronchial auscultation: An effective adjunct to speech and language therapy bedside assessment when detecting dysphagia and aspiration?, Dysphagia 19(4), pp.211-218. Sherlock, Z. (2007) The use of instrumental swallow assessment in critical care, RCSLT Bulletin Feb, p16. The Intensive Care Society (2008) Standards for the care of adult patients with a temporary tracheostomy. Available at: http://www.ics.ac.uk/intensive_ care_professional/standards_and_guidelines/ care_of_the_adult_patient_with_a_temporary_ tracheostomy_2008 (Accessed 6 July 2011). Resource Tracheostomy and tube choices - http://www. patient.co.uk/doctor/Tracheostomy.htm

4. Long term outcomes

Suzannah was transferred to a specialist unit at 20 weeks post injury and remained there for 12 months. Here she moved into a fully conscious state, and a reliable yes / no was quickly established. Oral trials of food and diet were not commenced on a daily basis until approximately 9 months post injury and the tracheostomy wean was slow and decannulation complicated. During this period the team kept in touch with monthly updates, which helped us reflect on treatment options and time commitments. Suzannah was not fully weaned until approximately 11 months post injury. She was diagnosed with anarthria and remained dependent on low tech AAC and high tech AAC (via a my tobbii eye gaze.)

Laura Flynn is a lead speech and language therapist at the Jersey General Hospital, St Helier, Jersey, email L.Flynn@health.gov.je.

5. Reflection

The approach followed by our team was guided by the literature on managing patients with dysphagia, and national guidelines on the management of a patient in ICU emerging from a vegetative state. It was also guided by informal input from a specialist unit via the telephone. We have the relative advantage of being a small, well-gelled team with consistent staffing, and this is important when working with patients with neurodisability. We were also fortunate to have a local speech and language therapist who had worked on a brain injury unit in the UK, as well as members of the multidisciplinary team trained in SMART. However, maintaining skills is an issue given the limited numbers of such admissions. In addition, medication must be managed optimally for patients in low awareness states to rule out any adverse affects on arousal. This may be difficult for local medical teams who do not specialise with such complex patients. We had difficulty adhering to the intensity of involvement required, which limits the outcome and raises the question of how confident we were in the diagnosis. Fortunately, liaising closely with the specialist unit meant access to expert advice and guidance. Overall, Suzannahs outcomes from intervention at the local ICU were positive, as the tracheostomy wean was commenced and baselines were established with respect to swallowing and communication before her transfer. Her case shows why it is important to have a degree of knowledge at local level and

also the invaluable role for specialist units in supporting local teams. On reflection, an earlier referral to speech and language therapy would have been of benefit for Suzannah in terms of working with her family and commencing the SMART observations as early as possible. Since this case, referrals have become more timely. Suzannahs condition is rare, but clearly some skills I learnt are transferable, such as close observation with respect to communication and dysphagia assessment. I gained increased confidence in understanding and using SMART techniques, both for intervention and observing exact repeated measures, and have been far more confident with subsequent clients. SLTP
References Andrews, K. (2001) Memorandum to Parliament. Available at: http://www.publications.parliament. uk/pa/cm200001/cmselect/cmhealth/307/1031508. htm (Accessed 6 July 2011). Coombes, K. (not stated) Facial Oral Tract Therapy. http://www.arcos.org.uk/index.php?option=com_ content&view=article&id=60&Itemid=66 (Accessed 6 July 2011). Davies, P. (1994) Starting Again: Early Rehabilitation After Traumatic Brain Injury or Other Severe Brain Lesion. New York: Springer. Elliott, L. & Walker, L. (2005) Rehabilitation interventions for vegetative and minimally conscious patients, Neuropsychological Rehabilitation 15(3-4), pp.480-493. Frank, U., Mader, M. & Sticher, H. (2007) Dysphagic patients with tracheotomies: a multidisciplinary approach to treatment and decannulation management, Dysphagia 22(1), pp.20-29. Giacino, J.T., Ashwal, S., Childs, N., Cranford, R., Jennett, B., Katz, D.I., Kelly, J.P., Rosenberg, J.H., Whyte, J., Zafonte, R.D. & Zasler N.D. (2002) The minimally conscious state - definition and diagnostic criteria, Neurology 58(3), pp.349-353. Gill-Thwaites H. and Munday R. (2001) Sensory Modality Assessment and Rehabilitation Technique. London: Royal Hospital for Neuro-disability. Hansen, T.S., Engberg, A.W. & Larsen, K. (2008) Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury, Arch

Learning Points for local teams 1. Look for the specialist skills you already have within your team. 2. Be prepared to re-prioritise your workload to give complex patients more of your time. 3. Contact specialist centres and explain what you do or dont know. Build a relationship with these teams early on. 4. Encourage early referral for complex cases; even if a patient is heavily sedated you can build relationships with their families. 5. Dont be frightened to adapt assessment or therapy into what is manageable for your team. All baseline information is helpful for the receiving specialist centres, even if it has not followed the intensity or depth to the letter.
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Well beyond the basics (Summer 11 online only, pp.E1-E3) Speech & Language Therapy in Practice editor Avril Nicoll reflects on a challenging but invigorating two days spent immersed in speech sound disorder assessment, diagnosis and intervention with international expert Caroline Bowen.

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CYNTHIA PELMAN (WWW.CYNTHIAPELMAN.COM) IS A SPEECH AND LANGUAGE THERAPIST IN LONDON. SHE HAS OVER 20 YEARS EXPERIENCE OF WORKING WITH CHILDREN OF ALL AGES, A MASTERS DEGREE IN TEACHING CHILDREN WHOSE FIRST LANGUAGE IS NOT ENGLISH, AND A PARTICULAR INTEREST IN WORKING WITH TEACHERS AND TEACHING ASSISTANTS. A REGULAR CONTRIBUTOR TO SPEECH & LANGUAGE THERAPY IN PRACTICE, SHE RECOMMENDS STERN STRUCTURAL ARITHMETIC AS AN APPROACH THAT GOES FAR BEYOND MATHS. PICTURES ARE COURTESY OF VIKKI HORNER.

Maths vocabulary The vocabulary of maths is complex and abstract and presents a real challenge for school children with language delay. For example, under, which in the early years of language development usually refers to under the table, must be re-learned to signify the number which is lower down on a page and below a little line. Take away, when taught with number lines, means move to the left. How is the child to make sense of such ambiguous and abstract vocabulary? While most clinicians would agree that the concepts and vocabulary of maths present a challenge to both clinician and student, there is not a lot of agreement as to how we can mediate this to our children. Teaching method Over the past few months, after an inspiring one day training course, I have been using Stern Maths, or Structural Arithmetic, a maths teaching method used with children with special educational needs. It has given me an innovative and developmentally sound way to teach the language of maths, as well as providing a wonderful tool to use in small group work to develop attention, listening and turn-taking. The method was developed from the 1920s by Catherine Stern and is grounded in Piagets developmental theory, and Gestalt psychology. It therefore works to promote a wide range of cognitive functions: attention, comparison, spatial perception, inter-sensory organisation, sequencing, and visual and auditory processing. The kit and handbooks have now been re-issued in the UK. Multi-sensory The method works through very concrete and tactile materials which provide the child with multisensory experiences of the operations of mathematics. The equipment consists of a series of beautifully constructed wooden blocks and puzzle boards which can be fitted together in a range of combinations. I can therefore show a child in a very visual and concrete way that the 8 block and the 2 block can join together

to fill up a certain space, and whether we put the 2 block or the 8 block on the left or right makes no difference; they still fit into the same space (a space into which I can also fit a 10 block or two 5 blocks). In this way we have shown the child that 8+2 = 2+8 (commutativity) as well as 8+2= 5+5, without having mentioned the linguistically and cognitively complex concepts of plus, add, or equals. Take away (often used by teachers as a synonym for subtract) is easily understood when the child actually takes away an 8 block and sees how the 10-slot is almost empty. Concrete before abstract In the initial stages I do not refer to the numerals at all but call them the grey block and the blue block. The number names and their written symbols - in themselves abstract and difficult to grasp - are only introduced once the child has experimented successfully, and understood, the various concrete combinations. Similarly, the formal names for mathematical operations are introduced only after the child has had ample time and success in experimenting with different combinations and comparisons. Concepts of comparison (same, nearly the same, bigger, smaller) and of categorisation (all the blue ones, all the big ones, all those which fit into the 9 box) are thus easily demonstrated through attractive, sturdy and enjoyable materials. It makes a real change from working with pictures! Group skills The added bonus of working in a way which engages childrens attention so thoroughly is that we can have some very extensive conversations about different ways to solve the problems. The handbook includes some really good ideas for using the materials in small groups to work on attention, conversation skills and turn-taking. The kit includes an outstandingly wellprepared booklet which gives step by step

practical guidance (including very clear photographs of the equipment being used), as well as suggestions for additional games which can be played to develop these cognitive functions and their associated language still further.

Common ground I often find that teachers see what they do and what speech and language therapists do as two completely different things. Working on maths, which is traditionally the teachers area, is a good way to give both groups common ground for discussion and understanding. AVAILABILITY I have found this kit an excellent tool to add to my basic kit for development of abstract concepts and vocabulary, and it has become one of the most popular games in my groups. The materials can be bought and viewed online at www.mathsextra.com, and the developer and trainer, Vikki, can be contacted on 01747 861503 or vikki.horner@mathsextra.com.

Maths Extra would like to offer a special 10% discount to Speech & Language Therapy in Practice readers who order Stern Structural Arithmetic products online at www.mathsextra.com. To receive this discount please quote: SLTPSA11.