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

Spring 2011

How I get signing into practice

Capacity Good moves On TOPICC Pragmatic assessment Patient safety Reducing risk Training A joint model My Top Resources The adviser role Journal Club Systematic reviews

PLUS...heres one I made brief...reader offers ...and introducing our new series, Whose goal is it anyway?

Reader offers

Win NDP3 Speech Builder therapy software!

Win a Grow Words resource set!

The speech and language therapists behind the popular Nuffield Centre Dyspraxia Programme are putting the finishing touches to NDP3 Speech Builder a new software application for creating colourful, targeted and engaging therapy worksheets, cards, stickers, activities and games. Speech Builder includes the complete library of over 70 templates and 750 images from NDP3 as well as a full set of Jolly Phonics phoneme illustrations. The entire database of images can be searched in a variety of ways, including by title, lettersounds and phonetics. You or the child you are working with - can colour them in on screen using a simple paintbrush tool. You can add text in a variety of styles, including phonetics, in any colour. You can then work with the project on-screen, or print it, and share with the wider team by email. You can also add notes to the project to record the childs performance or provide information to parents. The developers say that, although Speech Builder was created to support the use of NDP3 with children with severe speech disorders, it will also be useful for therapy at any level from oro-motor to connected speech. NDP3 Speech Builder is 99 for existing NDP3 users (139 to nonNDP3 users) - and you can be one of the first people to get a copy by entering this free prize draw. For your chance to win a copy of Speech Builder, email your name and address, with Speechmag Speech Builder offer in the subject line, to by 25th April. The winner will be notified by 1st May 2011, and their copy forwarded as soon as the product is launched.

Grow Words publishes a range of practical resources that contain photocopiable games, activities and worksheets targeting a range of language and literacy skills. Grow Words is offering THREE lucky readers of Speech & Language Therapy in Practice a CD containing three titles from their Food Words Series. Vocabulary, Phonological Awareness, and Learning Concepts & Following Directions all include data recording sheets for individual children, small groups and whole classes. Each set is worth approximately 70, but you can enter the draw to win one FREE by emailing with Speechmag Grow Words Offer in the subject line by 25th April. The winners will be notified by 1st May 2011.

Grow Words is run by two Australian speech pathologists. It distributes the Core Vocabulary Therapy CD by Barbara Dodd, Sharon Crosbie For more information on NDP3 and the forthcoming NDP3 Speech Builder, visit and Alison Holm, which explains how to deal with inconsistency in childrens speech. Information about all Grow Word resources, including sample pages The lucky winners of our fantastic Winter 10 offers are: Sam Feldman (NDP3), Susan Bannatyne (Singing and how to order, is at Hands DVD set), paediatric speech and language therapy at Werrington Health Centre, Peterborough (Talking About Conversation, Black Sheep Press) and Susan Fischgrund (Friendship Terrace, BlackSheep Press). Congratulations to you all, and thanks to the three companies for their prizes.

Previous winners

Win Independence Through Communication!

Independence Through Communication is a modular social communication skills resource with a difference. Its main focus is the full participation of non-speakers and non-readers who have memory limitations and need structure to learn. The programme, delivered by a teacher and at least one support worker, teaches the use of strategies to scaffold responses. It is designed for groups of around 6 learners, who follow the programme at their own pace. The five strands cover listening, expressing yourself, explaining your ideas, making choices and making friends. The material was first developed with young adults with learning disabilities, including those using AAC, by Dr Liz Dean. It was then piloted by Alison Barnes, Luan Harrold and Sara Lander at specialist Colleges, as well as by Speech & Language Therapy in Practice readers. It has now been published by Black Sheep Press, which is making a copy available FREE to a lucky reader. Independence Through Communication usually costs 80 + VAT but, for your chance to win, email with Speechmag ITC offer in the subject line by 25th April. The winner will be notified by 1st May 2011. Lizs article about the programme (Adapting to complexity, Summer 09, pp.4-7) is now available at Details of this and all other Black Sheep Press resources are at

Spring 2011 (publication date 28 February 2011) ISSN 1368-2105 (Print) ISSN 2045-6174 (Online)

Spring 11contents
28 COVER STORY: HOW I GET SIGNING INTO PRACTICE (1) ITS SIGNSATIONAL! If you are considering this kind of approach, it is worth noting that we have learned not to underestimate the amount of preparation time required each time to put on the week. This is especially from the speech and language therapy assistants... The speech and language therapy team for people with learning disabilities at Yourhealthcare help parents, carers and staff find the confidence to use the signs they have learnt. (2) LEARNING BY TEACHING Too often I think that we as therapists have great ideas that, with some reins, thinking and planning, could be developed into valuable evaluation projects. The [Action Learning Set] group helped me think in a more systematic way and took the mystery out of research. Having discovered the potential of giving pupils the power to teach Makaton to staff, Non Thwaite carried out a promising peer tutor pilot project with the help of Ashlee and Jieu.

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

Photo of (l-r) Ashlee, Non and Jieu by Steve Ford,

INSIDE FRONT READER OFFERS Fantastic offers for you in the Spring 11 issue! NDP3 Speech Builder software application; a Grow Words resource set; Independence Through Communication. 4 CAPACITY Tenancy agreements have been drawn up based on capacity assesment findings on an individual basis (for example with vocabulary used and specific pictures chosen by the client). Many have been succesfully approved and entered into by landlords. Karen Bamford and Rachael Kaschs process puts people with learning disabilities in control of where they live and with whom. 6 IN BRIEF Joan Murphy and Tracey Oliver on Talking Mats and dementia, and Maggie Robinson with a simple phonology game. 7 RESEARCH INTO PRACTICE When we met Charlie it was evident that he had significant difficulties with a range of pragmatic behaviours. The challenge for us was to profile these in a naturalistic way using a valid method, [and] to use this information both to plan therapy and to show the outcome of intervention. Catherine Adams, Jacqueline Gaile, Elaine Lockton and Jenny Freed introduce TOPICC (Targeted Observation of Pragmatics in Childrens Conversations).

10 GOAL NEGOTIATION (1) We are very much of the opinion that goal negotiation is not purely about the setting and writing of goals, and in fact consider the actual writing of the goal to represent the final part of a complex process. In the first of our new series of four articles on goal negotiation, Sam Simpson and Cathy Sparkes share their strategies to ensure the timing and tempo is driven by the client. 12 PATIENT SAFETY The factors influencing choking can be numerous and complex. To explain and then attempt to prevent further incidents as a multidisciplinary team, we need to identify potential risk factors. Adults with learning disabilities or mental illness are at increased risk of choking. Susan Guthrie and Hazel Roddam explore the challenges, and the impact of enhanced electronic reporting. 14 EDITORS CHOICE Articles about stammering. 15 HERES ONE I MADE EARLIER Alison Roberts has low cost suggestions for groups: True story and Every cloud. 15 REVIEWS Autism, writing problems, dyslexia and bilingualism, speech sounds and disorders, intensive interaction, communication disorders, dyspraxia, working with families, research, evidence-based practice, Asperger syndrome.

18 JOURNAL CLUB (3) SYSTEMATIC REVIEWS ...we have found appraising systematic reviews in our journal clubs really helpful (even if they do nip your head to begin with!) Jennifer Reids series takes the mystery out of critically appraising different types of journal articles. 22 RESOURCE REVIEWS In-depth reviews of EYBIC (Early Years Based Information Carrying) Word Pack; Speech Quest; Talking Dice. 23 TRAINING The carers remained convinced that their partners required further speech and language therapy, despite the fact that they now possessed the skills necessary to support their partners to communicate well. Kit Clewley has developed a three stage model of training to support people with aphasia and their carers to communicate effectively for the rest of their lives. 27 BOUNDARY ISSUES (4) recognise the family that has moved in to the house next door. They have a child with severe learning difficulties and have made several complaints about the speech and language therapy service you provide. Joe Reynolds responds to the fourth scenario of our ethics series. 34 MY TOP RESOURCES Claire Butler shares the resources that enable her to be a national adviser in adult dysphagia for the Royal College of Speech & Language Therapists.

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.

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



Talk 2 Baby

Winter 11 to be final issue of magazine

Speech & Language Therapy in Practice publisher and editor Avril Nicoll is to make Winter 2011 the final issue of the long-running magazine. Explaining the move Avril said, I have edited the magazine since 1996 and owned it since 1997. It has been a part of the speech and language therapy profession from its launch way back in 1985 and, indeed, some of todays subscribers have been buying it since then! Every issue feels like the best one yet and I love working with authors to get their articles into print. So, as you can imagine, this was by no means an easy decision. She continued, The magazine is widely read and appreciated by practising therapists but has always been a small, niche product run on a shoestring. There are now many different platforms for information exchange such as websites, blogs and facebook. While this can be positive, each platform increases the workload without a corresponding increase in subscribers. This will only continue, which means the magazine as it is currently set up - in print and with space used for practical articles rather than advertising - is not sustainable. Avril added, This years articles are fantastic, so I am looking forward to working on the final three magazines and going out on a high with the latest issue still being the best one yet! New subscribers will continue to be able to purchase 5 for 4 starting with the Winter 10 issue, while readers whose terms expire in March, June and September this year will be contacted with a pro rata rate for renewal. As well as the remaining magazines, this will include access to the members area of the website until 29 February 2012.

The speech and language therapist behind a DVD to help teenagers talk to their babies says it has attracted interest from a much wider range of services than originally expected. Hannah Murtagh worked with a specialist midwife, community nursery nurse and pregnant teenagers in Swansea to produce the DVD. This format was chosen as pregnant teenagers are given a lot of printed leaflets which are not necessarily suited to their level of literacy. In the DVD the young women carry out a variety of activities to encourage language and communication development in their babies. They demonstrate the importance of early bonding and talking, and of good parent-child interaction as the basis for a positive, lifelong relationship. Hannah says, The original objective was to appeal to teenagers and use it as a learning tool for them but since its launch we have seen its value as a teaching tool for all parents. Orders have come from people across the UK working in early years, the probation service and with dads. The evaluation of the project is written up in the December 2010 Bulletin of the Royal College of Speech & Language Therapists. The Talk 2 Baby DVD costs 5.66 inc. p&p, email You can also email Hannah (hannahrichards565@ for more information.

Talking Point

I CAN has revamped Talking Point, the first stop for information on childrens communication. It includes a special section for speech and language therapists.

Giving Voice

The Royal College of Speech & Language Therapists has launched its media campaign to show how the profession transforms lives and brings benefits to society and the economy. You can learn more about Giving Voice and ways to get involved at

Tried and tested

Autism draft welcomed

Speech and language therapist Penny Williams was involved in the production of draft NICE guidelines on recognition, referral and diagnosis of children and young people with autism. The draft has been welcomed by the autism education charity Treehouse. Chief Executive Jolanta Lasota said, The focus of the guidance on improving joint working across health, schools, social care and the voluntary sector will make the world of difference to families who currently struggle to navigate their way through the maze of services. Consultation on the NICE (National Institute for Health and Clinical Excellence) draft guideline ends on 25 March 2011.

The communication disability network Connect says a comprehensive and wellresearched Care Quality Commission review of services for people with stroke and aphasia in England highlights an unacceptable variability across the country. The review looked at progress against the 2007 National Stroke Strategy. It found that, in 48 per cent of areas, people had to wait two weeks or more, on average, until they received community based speech and language therapy. It also discovered that fewer than half of social services could signpost communitybased services for people with aphasia. Connects Director of Services Sally McVicker says it is clear that some areas are doing well: We believe the disparity can be overcome by implementing tried and tested service models. Our experience shows that training people with aphasia and volunteers to run their own support and activities, based on what they themselves have designed and developed, is a cost-effective way to provide community-based services which successfully meet their needs.;

Fitness to practise

The Health Professions Council has introduced new information about its fitness to practise processes for registrants, their representatives, complainants and witnesses. This includes an audio-visual presentation about hearings.;

Education Bill concerns

The National Deaf Childrens Society (NDCS) and national deafblind charity Sense have expressed concern about the impact of the Education Bill on disabled children in England. The Bill proposes an accelerated expansion of the academies programme, but the NDCS says it does not address essential funding arrangements to safeguard support from Teachers of the Deaf and specialist equipment. Sense warns, Schools form the building blocks of an inclusive society. But by ending local authority oversight of schools the government risks undermining parental choice by making special education schools the only real option for deafblind and other disabled children.;



Nine lucky speech and language therapists will be heading to the No Mind Left Behind conference in Glasgow on bursary places. The international event, from 29-30 March 2011, is organised by the charity Mindroom in association with Sophie Dow is pictured with her daughter Professor Christopher Annie who has severe learning difficulties and is the inspiration behind Mindroom Gillberg and the Swedish Child Neuropsychiatry Science Foundation. Over 50 speakers from a range of disciplines will present their latest thinking on autism, ADHD and other early onset neurodevelopmental disorders. Mindroom founder Sophie Dow was keen to see speech and language therapy represented at the event. She initially offered 4 free places following a blog post by Avril Nicoll ( about pressures on training budgets. Having received 40 applications in the space of a few days, Sophie upped the offer to 9 places. Each bursary place is worth over 500 and includes access to the virtual conference proceedings for a year. Sophie says, We also announced a further 16 places, 8 for parents or people affected by learning difficulties and 8 for teachers via the press, eNewsletter and facebook page and we were absolutely inundated with applications. The need for information and support out there is huge. The organisation of international conferences is part of Mindrooms strategy to create such awareness, that by the year 2020 all children and adults in this country with learning difficulties will receive the recognition and help they need.

No Mind Left Behind


Master Clinician Network

A pilot project The Master Clinician Network is designed to make peer reviewed videos of clinical practice in speech-language pathology available for observation and critical discourse. As the name suggests, it is set up to enable members to invite friends, leave comments and submit their own videos. The site was created by Martin Fischer, a professor in the Department of Communication Sciences and Disorders at Oklahoma State University - Tulsa.

Making chatter matter

The 2011 Hello campaign to make childrens communication skills a priority is underway. For Januarys theme dont take communication for granted, the Communication Champion Jean Gross said, Public understanding of childrens communication difficulties remains worryingly low. The automatic response seems to be to blame parents or technology. Jean Gross (r) with Minister This just isnt right. We need to clear up the of State for children and confusion and myths that exist around this families Sarah Teather at subject - 10% of children - thats two to three in the Hello launch every UK classroom - have some form of long term communication difficulty that can affect them early, severely and for life. Their brains dont process language in quite the same way that other childrens brains do. Over February and March the campaign is focusing on early chatter matters - from bump to birth and beyond. Resources to help you plan your involvement in Hello, the national year of communication are available in the All Together Now toolkit. The government-backed national year is managed by The Communication Trust, a group of 39 voluntary and community sector organisations.

s the future George VI in the film The Kings Speech, Colin Firth tells his speech therapist Timing isnt my strong suit. It is however hard to imagine that the publicity surrounding the release of the film and associated book could have come at a better time for the profession as it faces ever greater pressures to prove its worth and to be heard. Speech therapy has evolved considerably since the early days of Lionel Logue and his fellow pioneers. Until recently it would have seemed as impossible to enable people with learning disabilities to make choices over where they live and with whom as it was for Bertie to change his job, but Karen Bamford and Rachael Kasch (p.4) are finding it can be done. Although the film has a scene where a young client practises his talking with Bertie, peer support and tutoring was not at that time a consideration. With the help of cover stars Ashlee and Jieu, Non Thwaite (p.30) encourages us to investigate what it can offer. The film suggests the future Queen Mother was actively involved in helping Bertie apply fluency techniques, although the crucial importance of working with families and carers is a relatively recent development. Kit Barber (p.23) has found a model of group therapy which seems to offer clients with aphasia and their carers the best chance of successful real life communication. Kits model relies on technical instructors and volunteers, and Yourhealthcares community based Signsational programme (p.28) could not run without assistants. While it appears that Lionel Logue worked very much on his own, he was one of the founders of the College of Speech Therapists. Claire Butler (p.34) describes the resources that help her to be a national adviser in dysphagia for what is now the Royal College. Setting the boundaries of a client / therapist relationship may be more challenging when the client is a King, but Joe Reynolds (p.27) finds that considering an unusual ethical dilemma can help us recognise and reflect on those that are more familiar. Marbles in the mouth, apparently advocated by a contemporary of Logue, is one of many techniques imagined in the film which would not find favour today. Lionel Logue didnt have the advantage of tools to help him plan, prioritise and show the outcome of intervention (Catherine Adams and colleagues, p.7). Nor did he have journal clubs or systematic reviews to inform his practice (Jennifer Reid, p.18), although the film hints at his influences coming from different disciplines as they still do today. Colin Firth perfectly conveys the terror Bertie must have felt over live radio broadcasting, a tradition his father had introduced in 1932 as a way of connecting the Royal Family with the public. New technology can be threatening for many reasons, but Susan Guthrie and Hazel Roddam (p.12) have succeeded in encouraging staff to see a computerised database reporting system as a positive step for patient safety. Todays goal negotiation hopefully does not include promises of a cure but, in the first of a new series (p.10), Sam Simpson and Cathy Sparkes emphasise our role is to ensure that the timing and tempo of discussions is driven by our clients. As Bertie said to Lionel, Because I have a voice.

Having a voice A



Relocation, relocation
In line with government policy of supporting people to live where and with whom they wish, Karen Bamford and Rachael Kasch have developed accessible information and a speech and language therapy process for screening, consultation and referral which puts people with learning disabilities in control.
READ THIS IF YOU WANT TO HELP REDUCE ANXIETY OVER CHANGE PEOPLE MAKE THEIR OWN MAJOR LIFE DECISIONS SHIFT THE CULTURE FROM CARED FOR TO INDEPENDENCE experience of alternatives, a reluctance to consider any kind of change or a genuine desire for this type of setting. Where the persons current accommodation is indicated as their first choice, we are involved in supporting this decision; we either advocate for them to remain there or to relocate to a similar situation with their present level of support. Where the individual lacks experience of other housing options, we provide ideas to carers of how to support them to find out about different types of properties, for example through visiting friends, relatives and show homes. After an agreed period we re-visit the Talking Mats to discuss whether the persons preferences have changed.



any people with learning disabilities do not choose where they live or with whom. Recent government directives have focused on changing this situation and supporting people to live in their own homes as owners or tenants, sharing with groups of friends or living in residential care (DH, 2009). As speech and language therapists this has implications for the focus of our intervention and areas in which we can support these directives. The kind of accommodation people have influences how they view themselves and are viewed by others. Research shows that people who are confident and happy with where they live develop skills and independence and are motivated to seek links with their local community (McConkey, 2007). In 1969, 58,850 people with learning disabilities lived in long stay institutions in England and Wales. Now people are living in their own homes and taking responsibility for tenancy and ownership (Mathieson, 2004). However, in 2001, only 6 per cent of people with learning disabilities chose who they lived with (DH, 2009). Since the introduction of the Mental Capacity Act (MCA) in 2005, the speech and language therapy service in South Birmingham Community Health has been involved in an increasing number of capacity to consent assessments. In 2008 and early 2009 we were involved in a small number regarding change of accommodation on an individual basis. Several social care homes and medium sized residential campuses closed, and more individuals were indicating a preference for the type of accommodation they wanted

to live in. We therefore consulted local advocacy agencies, housing development officers and supported moves social workers regarding how we could support people with learning disabilities to be actively and meaningfully involved in the process of moving house. We developed a process map for change of accommodation which covered communication support from initiation of the move through to the move itself, in three stages (see flowchart in the members area of

Stage 2

Stage 1

We work alongside other agencies, carrying out joint assessments with social workers, housing agencies, advocates and so on. During the first stage, we establish the individuals understanding around change of accommodation (a flowchart is available in the members area of, and their ability to use this information to make a decision. We also frequently identify a lack of knowledge from individuals and their families regarding the range of housing and support options available, due to their limited life experience and expectations. For people with communication difficulties, we use a Talking Mats format (also favoured by Venditozzi, 2009) to gather information about an individuals preference around where they currently live and what their ideal living circumstances would be (figure 1). Where the mat for an individuals current accommodation and their ideal housing are the same, we discuss whether this is due to their lack of

The next stage is based on the persons preferences, needs and financial circumstances. The individual is supported by the multidisciplinary team, including family and carers, to make a decision regarding the types of accommodation and support to be sought. Supported living is defined as support to help individuals to live independently in their home and in the community. If this is identified as appropriate, a further decision is required regarding the individuals mental capacity to sign up to a tenancy (for renting a property) or mortgage agreement (for purchasing a property). If a person lacks the mental capacity to sign a tenancy or mortgage agreement, then an application must be made for them to be represented financially by the Court of Protection. Tenancy has been a problematic issue for the agencies involved in recent times (figure 2). Because of the rigidity of mortgage agreements, there is considerably less possibility of adapting these to meet the needs of individuals with communication difficulties; this could only carried out on an individual basis and has not been experienced in our area to date. We have therefore concentrated our main resources on supporting the understanding of individual tenancy agreements. Tenancy agreements are a new concept to many people with learning disabilities due to the tendency towards a cared for culture that still resonates, whilst we move into a long


Figure 1 Talking Mats Figure 2 Possible issues with tenancies No clarity about legal requirements of tenancy Mental Capacity Act (2005) states that no-one else can sign tenancy on someones behalf Court of Protection application can be a lengthy process No legal precedent regarding requirements or responsibilities Different messages from different agencies Other people involved are invested in the results of a capacity assessment, making an unbiased assessment difficult (for example application to Court of Protection, if someone lacks capacity, would stall the process for a considerable time)

Figure 3 Object format option

awaited new generation of independence. Pieces of work need to be carried out to inform individuals of the constituent parts and implications of a tenancy agreement. We compiled an information booklet outlining the different aspects of tenancy (What is Tenancy?) for people with different levels of symbolic understanding, using Widgit Symbols, Picture Communication Symbols (PCS) and photographs. We also have an option to discuss a tenancy in object format where appropriate (figure 3). Because of the large numbers of people requiring assessment, and a move towards more efficient ways of working, we developed a basic tenancy screen for other professionals to use where our expert knowledge regarding communication is not required. We support this with the use of guidelines, tips and modelling or consultancy. Following this, three options are available: 1. Where a decision can be made by one of the professionals already supporting the person, they complete appropriate capacity documentation. 2. Where a capacity decision cannot be made by one of these people due to communication difficulties highlighted by the screen, they consult speech and language therapy. 3. Where the screen cannot be completed due to complex communication needs, they make a referral to speech and language therapy. When we receive a referral, we compile a

capacity report outlining the clients ability to understand, retain, weigh up and communicate about the different aspects of a tenancy agreement. A multidisciplinary team decision is then made alongside the landlord as to whether this is sufficient for the contract to be enforced. Tenancy agreements have been drawn up based on capacity assessment findings on an individual basis (for example with vocabulary used and specific pictures chosen by the client). Many have been successfully approved and entered into by landlords.

Stage 3

Moving house is anecdotally one of the most stressful life events. Change is often associated with increased levels of anxiety due to lack of perceived control, painful past experience and the fact that it is often imposed, particularly on those with learning disabilities. We want to ensure that we address this to provide as smooth a transition as possible. Once a property is identified for the client, we provide advice to carers about practical ways of supporting clients through the move. This advice is focused towards the individual and their experience, ability and needs. For example, we support carers to develop visual timetables with the individual to record all the events related to moving, such as buying new furniture, decorating, and visits. Having written the process map and utilised the pathway to support the moves of several service users, we came across some issues in implementation:

1. We need commitment from other professionals to develop their competencies to carry out the basic screen effectively, but we did not always get managerial sign-up to allow individuals to follow this process through appropriately. Meetings with managers of other services could be useful to discuss the time demands. 2. As speech and language therapists we are clear that communication starts at the beginning of the process, but often referrals were only made once properties had been found and decisions confirmed. At times we suggested delaying the process to allow the individual service user time to gain more experience and understand the options available to them. Obviously this did not always make us popular! A longer term solution would be to express openly with all other stakeholders when the optimum time for referral to our service would be. 3. We found a large part of our time was spent informing others about the Mental Capacity Act and their roles in relation to it. Often family members are not familiar with the intricacies of the Act and on frequent occasions have thought that, regardless of the assessment findings, they would have the final say. It is vital in the current climate that speech and language therapists are knowledgeable regarding the Mental Capacity Act and the role of communication. An internet search will highlight training courses available to


you locally, and most areas have a policy to support implementation of the Act. Notwithstanding these difficulties, having a process to follow around change of accommodation has been useful for consistency and to clarify expectations. Most importantly we have had some good feedback from service users about how the process ensures that they are in control of where and how they want to live. Whilst this is a small step towards implementing government directives (DH, 2009), we would like to continue to develop this work and encourage SLTP others to do so too. Karen Bamford and Rachael Kasch are speech and language therapists working for Birmingham Community Health Care. For further information or to find out more about the resources they have developed, email and see References Department of Health (2009) Valuing People Now. Available at: en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_093377 (Accessed: 12/01/11). Mathieson, A. (2004) Valuing People: more evolution than revolution, Learning Disability in Practice 7(2), pp.8-9. McConkey, R. (2007) Variations in the social inclusion of people with intellectual disabilities in supported living schemes and residential settings, Journal of Intellectual Disability Research 51(3), pp.207-217. Mental Capacity Act (2005) Available at: contents (Accessed: 12/01/11). Venditozzi, M. (2009) How I help people move on (2): Talking flats, Speech & Language Therapy in Practice Autumn, pp.26-28. Resources Picture Communication Symbols, www. Talking Mats, Widgit symbols,

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.

In Brief...

supported by

Talking Mats and dementia

Joan Murphy and Tracey Oliver on the use of Talking Mats in managing daily living discussions for families affected by dementia.

To comment on the impact this article has had on you, see guidance for Speech & Language Therapy in Practices Critical Friends at www.

ecent guidance from the government recommends that people with dementia should have more involvement in decisions about their care options. Government policy also states that people with dementia and their carers should influence how government strategies and targets are implemented. Most families try hard to include their relative who has dementia in discussions around their care, but this is often difficult due to the communication and cognitive problems associated with the illness. This latest research, funded by the Joseph Rowntree Foundation and carried out by the Talking Mats team at the University of Stirling, has implications for the improvement and delivery of services. It could also be a significant help for people with dementia and their families The project explored if people with dementia, living at home, and their family carers can use Talking Mats together, to discuss how they are managing daily living activities. Eighteen couples (a person with dementia and a family carer) were involved and were asked to discuss the following topics using Talking Mats and come to agreement together: 1. Personal care (washing, dressing) 2. Getting Around (walking, using the stairs) 3. Housework (cooking, making the bed) 4. Activities (watching TV, listening to music). Following analysis of video data the results showed that both the people with dementia and the family carers felt more involved in discussions about how they were managing their daily living when using Talking Mats, compared to simply having a conversation. They also felt more satisfied with the outcome of those discussions. Two of the key outcomes were: 1. People with dementia reported that Talking Mats helped them to clarify their thoughts, express them to their family carers, and reach a decision in these discussions. One person said: It is so difficult to tell [my wife] what I think when I cant remember the words, the pictures could help me a lot. 2. Although people with dementia and their family carers both felt more involved in discussions when using Talking Mats, the increased feeling of involvement was significantly higher for the family carers,

who repeatedly reported feeling listened to by the person with dementia and felt that their loved one could actually see their point of view. One carer said: It never seems like he is listening to me. With this I can make him sit down and look at symbols and get him to understand what I am trying to say. The study concluded that Talking Mats helped improve communication between people with dementia and their family carers, and this hopefully could lead to improved relationships. Joan Murphy and Tracey Oliver are researchers at the Talking Mats Research & Development Centre, University of Stirling. Resources a copy of the findings and the full report on the project can be found at http:// further information about Talking Mats resources and training is at www.

Phonology by numbers
Maggie Robinson suggests a simple, easy-toprepare game for working on phonology. Aim To practise using a phoneme in words or sentences. Materials You need approximately 10 picture cards which illustrate items with the target phoneme in target position in their names (15 is the maximum I would suggest). Number the pictures from 1-10, on the front. Method Spread the cards out face down. Take turns to turn over a card and either say the word, or say the word in a sentence. The numbers on the front of the cards have to be placed in order. The player who turns over number 1 can leave it face uppermost on the table. Any other number must be placed back face down. Once number 1 is face uppermost, the player who turns over number 2 can leave that face uppermost, beside the number 1. The game continues until all the pictures are in a line face uppermost. Maggie Robinson is an advanced practitioner speech and language therapist in Skelmersdale, email



TOPICCal applications
TOPICC (Targeted Observation of Pragmatics in Childrens Conversations) is a new assessement procedure developed for an intervention research project. Catherine Adams, Jacqueline Gaile, Elaine Lockton and Jenny Freed explain how it can help speech and language therapists in clinical practice plan, prioritise and show the outcome of intervention for a child with pragmatic difficulties.

hen we first met Charlie, he had been referred to us by his local speech and language therapist as a potential participant in our research project. We were aiming to investigate the effects of intervention for children who have disproportionate difficulty with pragmatics (figure 1), and Charlie seemed to fit the bill well. Charlie was aged 8;4, attended a mainstream classroom and had a statement of special educational needs specifying twenty hours of learning support every week. He received a diagnosis of autism at age four, and some mild features such as inconsistent eye contact were still present. He also had difficulty making friends and did not understand how to join in language-based play. His language assessment revealed word-finding difficulties, significant problems of understanding and creating narratives, and difficulty in drawing visual and verbal inferences. His teachers expressed concern about Charlies literacy, numeracy and lack of independence in class. When we met Charlie it was evident that he had significant difficulties with a range of pragmatic behaviours. The challenge for us was to profile these in a naturalistic way using a valid method, to use this information both to plan therapy input and to show the outcome of intervention, and then to do the same sort of profiling for another 84 children like him who were participating in the project. The range and number of children who require an assessment of pragmatics has increased greatly, with improved understanding of communication in autism spectrum conditions and spiralling caseloads of such children. The practitioner needs a practical format for observation or testing, which can be used with a variety of children with pragmatic communication needs from pre-school to adolescence and is not too time-consuming. There are tests of pragmatics (for a review see Adams, 2002) and checklists of pragmatic behaviours (such as Andersen-Wood & Smith, 1997) but most of these were not suitable for the project. A strong contender for a

Figure 1 What is pragmatic language impairment (PLI)? The literature describes children with pragmatic language impairment as verbose, fluent, overliteral, with expression often in advance of comprehension and difficulty constructing coherent narratives. It is evident from our research and others (Botting & Conti-Ramsden, 1999) that a proportion of children with pragmatic language impairment fit into traditional diagnostic categories such as high-functioning autism or Aspergers syndrome, but there remains some controversy over diagnostic issues.

pragmatics profile-type assessment was the Childrens Communication Checklist-2 (CCC2) (Bishop, 2003). This scale is derived from a series of teacher / parent-rated behaviours, and gives the practitioner a valid means beyond that of professional opinion - of confirming the presence of a communication impairment. This is especially useful where a child functions at ceiling on language tests or cannot cooperate with formal testing. However, in addition to pragmatic behaviours

The range and number of children who require an assessment of pragmatics has increased greatly
it profiles other communication difficulties, and is not focused on providing detailed information for intervention planning. The CCC-2 uses a reported observational method. Direct observational methods are usually felt to be more reliable but, with pragmatics, you generally find that the more structured the context, the less naturalistic and representative the assessment will be. So, in 1989, Bishop & Adams tested a semistructured task which sampled conversations between the child and the adult assessor. In this task, the assessor conversed with the child about specific topics, supported by pictures. Bishop and her colleagues further developed

this analysis into a conversational coding system, the Analysis of Language Impaired Childrens Conversation (ALICC). In this the frequency and / or proportions of individual pragmatic behaviours, such as speech acts, turn clashes and cohesive devices, could be counted within a controlled sample (Bishop et al., 2000). ALICC has the benefit of providing a concrete method of measurement within controlled samples and is a potential tool for evaluation of change, but it is prohibitively lengthy as a clinical measure. As it requires at least 6 hours of transcription and skilled analysis of a 10 minute sample, it is not in any way a feasible procedure for the clinician.

Real time

To translate ALICC into a clinical tool, the assessment ideally needed to be completed in real time. Realistically, coding of conversational turns needed to be simplified and guided by clinical examples rather than by lengthy training. In our research study, the Social Communication Intervention Project (SCIP), based at the University of Manchester, we investigated the effects of an intensive speech and language intervention for 85 children with pragmatic language impairment. We wanted to have a direct observational measure of pragmatics in conversation to use as an outcome measure. There was a need, therefore, to come up with a short analysis of pragmatics in conversation. The new observation scheme, TOPICC (Targeted Observation of Pragmatics in Childrens Conversation), was based on



ALICC and the sound principles of its research, and used an identical sampling method. This allowed us to: Incorporate the breadth of the ALICC scheme, looking not just at speech acts but also at responsiveness and information Use a short format observation scheme based on vulnerable areas of pragmatics Use an observational rather than transcription approach Embed aspects of interactional / interpersonal communication within the pragmatic categories. We piloted the new scale with preliminary data from pre-intervention conversation assessments. Two experienced researchers independently coded recordings of our participants live, and discussed areas of agreement and difference. We then amended categories in the scale and produced descriptors for each aspect of pragmatic behaviour. We used this final revised version of TOPICC (available for free download at to analyse all 85 childrens conversation data. TOPICC consists of a single observation sheet with seven principal categories, some of which are broken down into separate items. Each item within the category is scored according to agreed observational guidelines, for which examples are available. The purpose of doing this is to derive a total score for TOPICC as well as sub-scores for separate categories. The rating scale is in figure 2. Content validity of TOPICC had already been addressed by inclusion of categories from previous research found to be descriptive of pragmatic communication needs. Concurrent validity was addressed by comparing childrens scores on TOPICC with their parents ratings on CCC-2. In advance of this analysis, we matched each TOPICC item to the CCC-2 item(s) which best matched its description before the validity study started (figure 3). We then identified the 20 children in our participant group with the highest TOPICC scores in other words, with the most notable difficulty with pragmatics in this context. We compared the rating on each of their three highest scored TOPICC items, scored at 2 or above, with the parent ratings of the corresponding items on CCC-2. This yielded 60 pragmatic behaviours in total. We then calculated the agreement between pragmatic behaviours observed as identifying need on TOPICC and the corresponding CCC-2 item. A CCC-2 item had to be rated at 2 or 3 to be considered problematic and in agreement with the observed TOPICC item. Across the 60 behaviours, there was very good agreement (88.3 per cent) between pragmatic behaviours identified as problematic on TOPICC and on CCC-2. As a secondary outcome measure in the intervention project, we asked trained TOPICC raters to complete TOPICC coding and then to do a further task to confirm reliability . We asked them to give their overall impressions of change in conversation skills from the beginning to the end of intervention for those children who had received either
Figure 3 Examples of how TOPICC and CCC-2 items were matched in the concurrent validity study TOPICC item Difficulties with topic maintenance Giving too much detail and information Corresponding CCC-2 item (no. on CCC-2 form) 26 Moves the conversation to a favourite topic even if others dont seem interested in it *42 Includes over-precise information AND 37 Tells people things they know already

*note that some TOPICC items have alternative corresponding CCC-2 items, in which case rating of both CCC-2 items at 2 or above was required to show agreement with TOPICC

intensive SCIP therapy or therapy as usual. All coding was completed blind to group status. In a sample of 50 children who have pragmatic language impairment, there was good agreement (80 per cent) between independent coders on opinion of change in conversational skills in TOPICC, showing reasonable reliability of overall impression of conversation change. Charlie entered into the intervention arm of SCIP (Adams et al., in preparation). At the beginning of therapy we used the TOPICC profile as a planning tool for intervention (figure 4). He then received intensive intervention of 20 specialist speech and language therapist sessions plus usual Learning Support Assistant input over 12 weeks. This was aimed at: enhancing his understanding of interlocutors needs identifying topics and signalling topic change developing strategies to acknowledge when he doesnt understand and to ask for help developing metapragmatic skills of knowing how much to talk and when to allow the interlocutor to contribute understanding the thoughts and feelings of others by reading social signals, and the importance of this in peer interactions strengthening narrative ability via sequencing and narrative construction practice to enhance language-based interactions in social situations and in the classroom.

Figure 2 TOPICC rating scale marked evidence of that behaviour across conversation; makes a marked impact on the interaction makes a moderate but still significant impact on the interaction is noticeable occasionally but makes only a slight impact on the interaction is never observed and the behaviour is typical of mature interaction style

3 2

1 0

Charlie showed a strong response to therapy and at six months postintervention his TOPICC profile had changed considerably
In addition, making inferences from words and short texts, supported by self-cuing strategies, provided a platform for word learning that transferred readily to class-based learning. Charlie showed a strong response to therapy and at six months post-intervention his TOPICC profile had changed considerably.

Having used TOPICC within SCIP and in our own clinical practice, we feel it has potential as a clinical observational instrument for profiling pragmatics and conversational skills in a wide range of children of school age who have pragmatic communication difficulties. Its main strengths seem to be that 1. it prompts observation of key characteristics of conversation likely to be significant in planning needs and support 2. it can be done in real time 3. to the experienced observer it is relatively easy to use the examples to guide coding. It should be carefully noted that there are no normative data on TOPICC - and there probably never will be, because pragmatics is not amenable to standardisation. Reliability of observation and coding on TOPICC has yet to be tackled and may remain problematic without substantial funding for research studies. In the meantime, TOPICC may be a useful aide memoire for the practitioner attempting to profile pragmatics for individual SLTP children from a naturalistic sample. Catherine Adams (email catherine.adams@, Jacqueline Gaile, Elaine Lockton and Jenny Freed are researchers in the Human Communication and Deafness Group at the University of Manchester. Acknowledgements and ethics SCIP was funded by the Nuffield Foundation and sponsored by the University of Manchester. Thanks to Kirsty McBean (Queen Margaret University Edinburgh), Gillian Earl (NHS Lothian), Ruth Wadman and to all the children, families and schools who participated. The research was carried out in accordance with



Figure 4 TOPICC profile for Charlie pre-intervention showing indications for intervention TOPICC OBSERVATION SCALE Adams, Gaile, Freed & Lockton 2010 CHILD ID: Charlie AGE: 8;4 Category Reciprocity Difficulties initiating conversation Difficulties responding to questions Child ignores speaker Taking account of listener knowledge Giving too much detail and information Giving too little information Turn taking Interrupts speaker frequently Verbosity Child dominates conversation Child uses too many questions Child provides unsolicited information Topic management Obsessional topics Difficulties with topic maintenance Stereotyped or unusual language 0 0 0 1 1 1 2 2 2 3 3 3 Monitoring information in talk; demonstrating effects of irrelevant language on conversation flow using sabotage methods Topic management strategies 0 0 0 1 1 1 2 2 2 3 3 3 Metapragmatics and monitoring quality of talk in interaction Understanding information requirements Understanding thoughts and feelings of others 0 1 2 3 Relative strength 0 0 1 1 2 2 3 3 Understanding information requirements Understanding thoughts and feelings of others Understanding information requirements Narrative construction 0 0 0 1 1 1 2 2 2 3 3 3 Relative strength STIMULI USED: Picture set 3 TOPICC protocol Rating ASSESSOR: Gaile DATE: 2009 Time 1 Link to intervention in SCIP*

Discourse style Proximity Overly formal Non verbal behaviours Response problems Comprehension limitation Linguistic limitation 0 0 1 1 2 2 3 3 Comprehension monitoring Relative strength 0 0 0 1 1 1 2 2 2 3 3 3 Eye gaze and meaning in interaction

* These are main headings for aspects of intervention in the SCIP manual, which then specifies aims, methods and activities for each aspect in turn.

the NHS Research Governance Framework for Health and Social Care (NHS, 2005) and ethical permission was gained from the NHS Research Ethics Committee. Informed consent was gained from all participants and schools. References Adams, C. (2002) Practitioner Review: The Assessment of Language Pragmatics, Journal of Child Psychology and Psychiatry 36, pp.289-306. Adams, C., Gaile, J. & Aldred, C. (in preparation) Social Communication Intervention Programme (SCIP): manual and electronic resource. Andersen-Wood, L. & Smith, B.R. (1997) Working with Pragmatics. Milton Keynes: Speechmark. Bishop, D. & Adams, C. (1989) Conversational characteristics of children with semanticpragmatic disorder. 2: What features lead to a judgement of inappropriacy?, British Journal of Disorders of Communication 24, pp.241-263. Available at: (Accessed: 24 January 2011).

Bishop, D.V.M. (2003) The Childrens Communication Checklist 2. Oxford: Pearson. Bishop, D.V.M., Chan, J., Adams, C., Hartley, J., & Weir, F. (2000) Conversational responsiveness in specific language impairment: evidence of disproportionate pragmatic difficulty in a subset of children, Development and Psychopathology 12(2), pp.177-199. Botting, N. & Conti-Ramsden, G. (1999) Pragmatic language impairment without autism: the children in question, Autism 3(4), pp.371-396. Resources NHS Research Governance Framework for Health and Social Care, see en/Publicationsandstatistics/Publications/ PublicationsPolic yAndGuidance/ DH_4108962 Further information about SCIP and the full TOPICC form (with definitions) are available free at

Tell us the difference this article has made to you. See the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag. com/About/Friends.



Whose goal is it anyway?

Part 1: A strong foundation


In the first of our new four part series, Sam Simpson and Cathy Sparkes unpack the terminology, different perspectives and key principles that underlie effective client-centred goal negotiation, and share their strategies to ensure the timing and tempo is driven by the client rather than external pressures.

e very much value the opportunity to bring the complex and diverse topic of client-centred goal negotiation into the public arena for discussion and debate. We are two clinicians with long and varied careers in the fields of brain injury (both) and stammering (Sam), for whom client-centred goal negotiation has played a central role at both unidisciplinary and interdisciplinary levels. Having lectured and consulted clients, families, professionals and students since 1993 in this field, it is highly apparent that the concept means different things to different people. In this first of four articles we will cover terminology, review different perspectives to goal negotiation, consider its relevance to client-centred working, and introduce the four key principles. In the second we will present a goal negotiation process along with a theoretical model of change that further frames this process and delineates flexible goal negotiation practices across acute, rehabilitation and community settings. In our third article we will explore the actual goal negotiation conversation, including case examples from a range of contexts. Finally, we will consider goal writing skills, represent the client voice and reflect on clinicians service developments that we have supported in recent years. This first article includes two practical tasks, which are suitable for you to do alone, with a colleague or as a team. Please now complete task 1 before continuing with the article. A. TERMINOLOGY We anticipate your reflections will highlight the broad range of meanings that are readily associated with the term goal from more professional connotations such as a target, something to work towards and outcome, to include more of a laypersons understanding relating to the goals scored in football, where there is a strong association with winning and losing, success and failure. They will also hopefully have highlighted the many different parameters of goals that people set themselves from the looser, more aspirational and potentially unrealistic personal goals that may only go acknowledged privately, through to those that we are willing to go public with and share, right to the more concrete, smaller, routine-based actions that we readily write and re-write in a daily to do list. Thus some goals are

Task 1: What do you understand by the term goal? Take 10 minutes to consider and write down your responses to the following questions: What do you understand by the term goal both in and outside of work? To what extent do you as an individual have hopes, dreams, goals? In what ways do you try to achieve them? Who / what do you turn to in order to move your life forward? When do you know the time is right to take the first step towards your hopes, dreams or aspirations? Do you plan / negotiate / set yourself goals either implicitly or explicitly? Then, either on your own or with a colleague with whom you feel comfortable, discuss and reflect on your answers.

likely to be quite specific and clearly articulated, whilst others are likely to be more vague and difficult to explain. Some will feel very possible and easily achievable, whereas others will be set year in year out, even in the knowledge that they are unlikely ever to be achieved. We also predict that different styles and personal preferences to goal negotiation will become apparent. Some of you will enjoy the task of defining clear personal goals to work towards, whereas for others the process and sense of direction will be more important than whether or not you actually achieve the final goal. Some of you will also enjoy having a focus and challenge to work towards over an extended period in anticipation of the feelings of achievement this will bring about. For others, the risk of failure and having to manage potential disappointment will be enough to deter you from setting goals outside of the day-to-day routine. All of this serves to highlight the diverse meanings, personal styles and preferences people bring to the goal negotiation table, and the importance of exploring this from the very outset to ensure a shared language and understanding. B. Perspectives and client-centredness Each person you work with, either as a client or family member, will have their own unique views and experiences of goals. It is vital to have this conversation early on, and to be proactive in engaging clients in a dialogue around what is meant by the terms and concepts that are going to be used. In this way, right from the start, goal negotiation provides a framework to develop a shared language that is embedded in the world of the client. Thus, in essence, it is truly client-centred. This initial conversation helps to promote a balance of power in the therapeutic relationship. Having

a goal negotiation process which can be used flexibly and tailored individually offers a sense of direction, particularly if the world is or has become chaotic for the client and their family. C. Key principles 1. Client involvement By client we refer not only to the person with communication difficulties, but also to their relatives, friends and carers. Client involvement at all stages and levels of goal negotiation is essential as, when the client remains central to the process, they gain insight into therapy, their recovery or development, and the entire enablement process. It will also give them some control and choice at a time when they may feel overwhelming powerlessness. In addition it provides opportunities for the review and demonstration of progress (or not). Goal negotiation can therefore offer the therapist a vehicle for increasing client commitment to and engagement in their therapy, for preparing transitions between services, and ultimately for facilitating client autonomy. 2. Identification of strengths and problems The assessment process enables each discipline and the multidisciplinary team to determine early on each clients strengths, problems, hopes and aspirations. This provides the team with information about potential areas of focus with the client. Involving the client in identifying their strengths and areas of difficulty allows for assessment of their level of self-awareness and knowledge of the implications of their condition. This is an essential stepping stone in engaging the client in directing their own management. Once all areas have been investigated and discussed, the next step is to ensure that appropriate resources within the regular multidisciplinary




team or the wider service are in place. This helps the client to understand who they can turn to, and for what support. 3. Multidisciplinary team involvement Working in the field of neurorehabilitation, there is an inherent complexity to each individual clients needs. To work with this client group to best effect, a true skill mix, excellent collaboration and respect for areas of overlap and (in turn) carryover between professionals are needed. Such effective interdisciplinary team work can be facilitated by efficient lines of communication, including formal and informal meetings, clear documentation, and a shared understanding that goal negotiation is the very foundation of neurorehabilitation. Also, to ensure that the goals negotiated with each client are personally meaningful and relevant, they need to be negotiated not only between the client and a single discipline, but with the client and the entire multidisciplinary team. We are aware that not all of you have easy access to any or all multidisciplinary team members in your respective settings. However, wherever you are based, it is always helpful to be linked or communicating with relevant professionals, whether in the NHS, voluntary sector or social services. This invariably requires a commitment to making contact with these services and being proactive in fostering ongoing relationships. 4. Goals We are very much of the opinion that goal negotiation is not purely about the setting and writing of goals, and in fact consider the actual writing of the goal to represent the final part of a complex process. It is also important to remember that not all goals negotiated have to be achieved indeed, in life we rarely achieve everything we set out to do. It is important, from the very outset, to ensure that clients do not perceive goals purely in terms of success and failure, but can appreciate there is potentially more to learn from not achieving and subsequently revising a goal than from achieving it the first time. In fact, research has demonstrated that, in order to set goals at an appropriate level of challenge for a client, optimally an 80 per cent success rate should be aimed for (Johnson, 1997). For the goals negotiated to be intrinsically motivating they need to be client-centred. In addition, for a client to experience the full impact of goal achievement the goals need to relate to a change in behaviour. A useful conceptual framework for negotiating and writing goals is shown in figure 1.
Figure 1 Framework for negotiating and writing goals WHO Will be doing WHAT Under what CONDITIONS To what DEGREE of success Within what period of TIME e.g. John will go to the cinema with a friend (James or Susan) at least once a month for the next three months Task 2: To what extent do you embrace the core principles in your goal negotiation practice and service? Take 10 minutes to consider and write down your responses to the following questions: To what extent do you truly involve clients in planning and evaluating the therapy you deliver? To what extent do you involve clients in the assessment process and determining what their strengths, difficulties, wants and priorities are? How interdisciplinary is your goal negotiation practice and service? How proactive are you at making links with any professional or service a client becomes involved in (such as the voluntary sector) if you generally work in isolation? How much time do you allocate to negotiating goals with your clients? Does the culture and philosophy of your service support client-centred goal negotiation? What terminology do you use in relation to goal negotiation? How consistently and transparently is this terminology used across clients and professionals? Then, either on your own or with a colleague with whom you feel comfortable, discuss and reflect on your answers.

In many settings goals are typically divided into two time frames, short and long. The exact length of these time frames will vary according to the work context with a short-term goal being achievable within one week to one month, and a long-term goal potentially spanning four weeks, six months or longer in some contexts. a) Long-term (discharge) goals We define long-term goals as interdisciplinary goals which reflect the clients potential lifestyle or level of participation (WHO, 2001) on discharge. One or more of the following domains are often included in long-term goals: Home Leisure Social relationships Occupation / self-occupation. Often clients need reflection time to identify meaningful long-term goals, and this requires sensitivity and patience on the part of healthcare professionals. Indeed, it is important to remember that any discussion about longer-term outcomes provides a platform for enhancing the clients understanding of their condition and potential for change, for managing their expectations, and for exploring issues such as dependence, support needs and networks, role changes, losses and the rewriting of personal narratives. Consequently it is important not to underestimate the emotional load of such discussions and the need to respect and be sensitive to the clients pace and process. This is invariably in direct conflict with NHS time pressures, lean working principles, ever increasing throughput targets and emphasis on data collection to demonstrate clinical effectiveness. Such factors often result in therapists feeling the need to negotiate goals very quickly in order to get on with the actual therapy. This rush to define a clear clinical outcome frequently results in little time and attention being given to the clients process. True collaboration and negotiation are sidelined and the actual writing of the goal becomes a professionally driven pen and paper exercise. b) Preliminary goal area vs. long-term goals We strongly advocate against rushing to write long-term goals for the sake of it. Instead we propose using a looser concept provisionally, which we have termed a preliminary goal area. This might be to return home, get out and about or meet up with friends more

regularly. A preliminary goal area provides the client and the team with a sense of overall direction under which short-term goals can be written and worked on for an interim period until a more specific long-term goal has been negotiated. This flexible process will ultimately enable the formulation of a more meaningful, client-centred long-term goal as the client gains an understanding of the therapy process, their own priorities and potential for change. c) Short-term goals By contrast, short-term goals represent a breakdown of a longer-term goal into smaller, more manageable steps (for example, John will read the Stroke Association booklet on continence and discuss it with his named nurse and wife at least once in two weeks). It is important that all short-term goals have a linear relationship with the long-term goal they relate to. Typically short-term goals are set at the level of activity and impairment (WHO, 2001) and are a combination of multidisciplinary team and single discipline goals. d) Plan of action In addition to a clients long-term and shortterm goals, other activities or roles are carried out by healthcare professionals on behalf of or for the client in support of their goals, and can often go unnoticed. We call these plans of action. Examples include organise purchase of bath board and liaise with Social Services. It is important to distinguish this professional activity from the goals carried out by the client and / or their family, and also to make sure they are documented clearly and assigned to a particular member of the team. Please now complete task 2. We hope your reflections will form a strong foundation for you to get the most out of this series. Sam Simpson (email is a specialist speech and language therapist and trainee counsellor. Cathy Sparkes is a specialist speech and language therapist and counsellor. Together they SLTP are intandem (
Reference Johnson, M. (1997) Outcome measurement: towards an interdisciplinary approach, British Journal of Therapy and Rehabilitation 4, pp.472479. Resources An explanation of lean thinking is at World Health Organisation (WHO, 2001) International Classification of Functioning, Disability and Health (ICF),




Reducing the risk

Adults with learning disabilities or mental illness are at increased risk of choking. Choking incidents are stressful for the individual involved and for anyone who has to recognise what is happening and assist. Susan Guthrie and Hazel Roddam explore the challenges for speech and language therapists and the wider multidisciplinary team, and the impact of enhanced electronic reporting of incidents and training.
He looked anxious and like he was in a state of panic. He was unable to talk or cough. He was going red at first and his eyes were bulging and watering. He then dropped to his knees and he was going blue around the lips, his eyes were rolling to the back of his head. I felt shaken and anxious that I had to carry out this practice [abdominal thrusts], however I felt a sense of relief when the client resumed normal breathing. (Account of a choking incident by a member of care staff)


ecent literature has highlighted asphyxiation from choking as an increased risk for people with learning disabilities (Samuels & Chadwick, 2006; NPSA, 2008), and also those who have a mental illness (Corcoran & Walsh, 2003; Bazemore et al., 1991). Studies indicate that dysphagia may be under-diagnosed in this population (NPSA, 2004). The nature of the relationship between dysphagia and choking and the evidence base needs further investigation. A choking incident can, however, act as a trigger. It can alert carers that an individual may be having difficulty at mealtimes, prompting referral to speech and language therapy for dysphagia assessment. While the experience of a choking incident is traumatic for the person concerned, the care staff involved also experience considerable distress. Care staff need clear guidelines for when to be concerned, and for when and how to document their concerns. For staff training, finding a working definition of choking is a priority. The literature tends to offer definitions with medical jargon. Bazemore et al.s definition includes more easily observable characteristics: a choking incident is an acute episode in which the patient coughed incessantly or experienced a colour change (with inability to speak or cough effectively) while ingesting food or drink. The solid or liquid had to be expelled to terminate the event (1991, p.3). Since 2005 Susans specialist trust for adults with learning disabilities has had a policy of reporting patient safety incidents using an electronic system accessed directly by the staff involved. These range from personal accident to a wide variety of clinical incident. This local

Susan risk management procedure then feeds into the national reporting and learning service (NRLS) database coordinated by the National Patient Safety Agency (NPSA) (figure 1). For speech and language therapists the electronic system has provided a new source of information when working with dysphagia referrals. Although fatal incidents are generally known about, in the past it has been more difficult for us to access information on near miss incidents. As part of the multidisciplinary team, we can now access all reports of suspected choking incidents for each service user. The trust includes both small community homes and on-site low and medium secure accommodation. In the last 7 years in the population of adults with mild profound learning disabilities (approximately 400 people) there have been 4 deaths due to choking on food, and 2 sudden deaths related to PICA (ingestion of non food items). The number of reported choking incidents is small; for example, in 2009 there were 40 near miss choking incidents compared to over 9000 total patient safety incidents. A


further problem is that these reports often lack information. Such absence of detailed description is of concern, as possible causes or influences for an incident may be lost. Accuracy may also be variable when reports are delayed, rushed or subjective. To address this, and with the help of the IT department, Susan added 10 further prompt questions to the standard open questions already in the electronic system. Supported by speech and language therapy led staff training workshops, these new questions aim to promote greater detail in reporting. Susan derived the prompts from discussion with nursing and care staff, then sought expert speech and language therapy consensus at the ALD Dysphagia UK network forum. The prompts are based on the need to be able to learn from incidents. They are designed to elicit greater detail; for example, describe what you saw prompts staff to include a description of clinical presentation at the time of the incident. Jargon is avoided for nonclinical staff. Susans workshops also raised issues around Basic Life Support (BLS) training. This



Figure 1 National reporting and learning The National Patient Safety Agency (NPSA) National Reporting and Learning Service (RLS) website states: Information from reported incidents helps the NHS understand why things go wrong and how to stop them happening again. Within a local NHS organisation, a serious event may be perceived as a one-off. Reporting to the RLS can reveal similar incidents in other parts of the NHS and can also help identify learning from incidents in different organisations. The RLS helps NHS organisations understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent future harm to patients. (How reports are used) Accessed: 20 January 2011

a measuring scale which can be used and understood by all and crucially - repeated more reliably (figure 2). 2. Frequency The number of incidents appears similar between people in community houses (with a more elderly population, more diagnoses of physical disability) and those in medium / low secure provision (younger population with more diagnoses of mental illness, personality disorder), with 7 per cent of the total service users in this trust experiencing a choking incident. However, a noticeable difference is seen in the medium / low secure accommodation incident reports. They record more examples of service users who have experienced more than three repeat incidents over a 12 month period. 3. Location The majority of incidents take place in usual home settings, and many fewer are reported for eating out. The proportion of meals eaten away from home is much smaller, but this statistic may also be explained by staff comments such as he eats much slower, more politely [sic] when out and about. However feedback and screening would suggest that staff are also less likely to report incidents occurring off-site. 4. Timing Unsurprisingly the majority of incidents (70 per cent) occur at mealtimes, with a strong tendency (42 per cent) at evening meal (tea) (figure 3). The potential influencing factors for incidents at this time of day are complex and multiple. The literature generally refers to factors such as physical and mental health status, behaviours, fatigue and medication. However discussion with nursing staff has suggested many environmental and social factors. There are many stresses for staff around producing and supervising a main meal at the end of a long shift. Self-induced or peer pressure for service users, such as feeling the need to rush to get finished, may also contribute. In this trust immediately after tea is the opportunity for social club, phone calls home, free time or a cigarette. All are highly motivating but also a potential source of anxiety and tension, and incident reports in general show an increase at this time of day. We can attempt to untangle these complex influences via ward round discussions and multidisciplinary team intervention. However, further research is needed to establish an evidence base, as we do not know what influencing factors are significant and what outcomes can be achieved in terms of intervention and risk mitigation. 5. Food types Seventy six per cent of incidents give some description of a solid food item causing choking. The type of bolus described reflects the frequency of evening meal incidents (figure 4).

Figure 2 Measuring scale: Severity of choking incident (degree of first aid) and frequency of occurrence over 12 month period Spontaneous cough 20% Cough after staff prompt 10% Backslaps 44% Abdominal thrusts 5% Paramedic 5% Details unspecified 16%

Figure 3 Timing of choking incidents (Data over period mid 2005- end 2007) 4% 24% 20%

breakfast lunch evening meal (tea)

6% 4%

late snack (supper) unknown not mealtime


Figure 4 Type of bolus

Unspecified Unspecifed food meat

8 8

Bread/ toast





is a mandatory requirement for health care staff (Resuscitation Council UK guidelines) but feedback from agency staff indicates it is not always accessed before they start work with service users. Care staff also highlighted practical problems in attempting the standard recommended BLS procedures with people who are obese, in wheelchairs, or have severe physical disabilities. Susan referred this to the BLS trainer who will now offer individualised guidelines to ensure care staff are able to administer first aid in an emergency. This development made us re-evaluate how far our role and professional responsibility as speech and language therapists extends, and led to a closer working relationship with the BLS trainer.

The database now shows a steady increase in reporting of choking incidents, although it is clear from discussion with care staff that some are still not being reported. We have carried out an informal review of care staff incident reports over a 12 month period and selected 6 themed comments which have implications for practice: 1. Severity The majority of reports now describe the extent of first aid or intervention, which gives a more objective measure of the severity of an incident. Such incidents are emotional and stressful for all concerned and, throughout this work, it has been difficult to achieve objective reporting. It is therefore useful to try to create




Editors choice

So many journals, so little time! Editor Avril Nicoll gives a brief flavour of articles on stammering that have got her thinking.

Many clients are so afraid of the reaction if a listener realises they stammer that they go to any lengths not to do it. InListener perceptions of stuttering, prolonged speech, and verbal avoidance behaviors, Von Tiling lays bare the cost, as excessive use of verbal avoidance behaviors like interjections, revisions, incomplete phrases, and pauses make people who stutter look more incompetent than the use of stuttered speech or prolonged speech (p.9). I found the process of this research and the concepts it discussed very thoughtprovoking (core vs associated behaviours, emotional vs communicative competence, entity vs incremental theory). J Commun Dis (2010), in press Plexico, Manning & DiLollo make a convincing case in Client perceptions of effective and ineffective therapeutic alliances during treatment for stuttering for giving more attention to the effectiveness of a clinician rather than focusing solely on the treatment. Citing Brown (2004), they warn that failure to do so limits the potential to improve outcomes and to lower costs (p.350). Their qualitative study investigated the characteristics associated with effective and ineffective clinicians solely from the point of view of the client. Im not sure that the clients were as diverse as the authors believed (8 were speech pathologists!), but the findings ring true. The summary in table 3 could be used for reflection or team discussion. Journal of Fluency Disorders (2010) 35, pp.333-354 In Stuttered and fluent speakers heart rate and skin conductance in response to fluent and stuttered speech, Zhang, Kalinowski, Saltuklaroglu & Hudock replicate previous findings that listening to someone with a moderate-severe stammer induces two significant negative physiological responses in comparison to fluent speech.This study was different in that one group were people who stammer but, interestingly, they showed the same pattern of responses. The authors believe that, The results may provide a unique perspective for helping PWS to understand the negative responses they encounter in their daily interactions with others, and bolster the notion that stuttering therapists should put an emphasis on reducing the aberrance and abnormality of primary and secondary stuttering behaviours in the initial phases of stuttering treatment (p.673). IJLCD (2010) 45(6), pp.670-680

The higher incidence of tougher, more chewy textures involved in these choking incidents would appear from this small sample to match with the High Risk foods attached to the National descriptors (BDA, 2009). However texture modification leading to changes in food choices and tastes offered must take into account individual circumstances, capacity and quality of life issues around mealtimes. For example, some people are keen to avoid the foods they perceive as difficult to process but others are resistant to change. As a multidisciplinary team we have to consider the impact of changing food and drink choices, balancing this with needs of palliative care, mental illness and challenging behaviours (Langmore, 1999). 6. Clinical presentation of individual incident It has become increasingly clear from care staff comments that the signs of choking are not always obvious or immediately visible. A minority of the reports from care staff have described experiencing a delay in recognising the onset of choking, and there are accounts of service users who become silent and inert when choking. The lack of movement and absence of agitated behaviour in these service users may not attract the attention of the care staff. In addition, familiar staff are more able to identify when an individual is not exhibiting normal behaviour, while agency or unfamiliar staff can miss subtle changes. Full detailed recording of clinical presentation (such as prompting what did you see?) is crucial to ensure quick identification and intervention for further incidents. Given the transitory nature of care staff (NPSA, 2004) it is essential to document fully each suspected incident to allow handover of potentially life saving information. However research is needed to establish what information is relevant, influential and significant and then how this can be used to mitigate risk of future incidents.

Footnote At the time of writing, the NPSA (National Patient Safety Agency) is expected to be abolished as the overall coordinator of learning from healthcare safety incidents. The transfer of the NPSAs different functions is being explored by the Department of Health. References Bazemore, P., Tonkonogy, J. & Ananth, R.(1991) Dysphagia in psychiatric patients: clinical and videofluoroscopic study, Dysphagia 6(1), pp.2-5. BDA (2009) National Descriptors for Texture Modification in Adults. Available at: http:// NationalDescriptorsTextureModificationAdults. pdf (Accessed 21 January 2011). Corcoran, E. & Walsh, D. (2003) Obstructive asphyxia: a cause of excess mortality in psychiatric patients, Irish Journal of Psychiatric Medicine 20(3), pp.88-89. Available at: http:// (Accessed 21 January 2011). Langmore, S.E. (1999) Issues in the management of dysphagia, Folia Phoniatrica et Logopaedica 51, pp.220-230. NPSA (2004) Understanding the patient safety issues for people with learning disabilities. Available at: resources/?EntryId45=92328 (Accessed: 21 January 2011). NPSA (2008) Resuscitation in mental health and learning disability settings: Rapid response report. Available at: http://www.nrls.npsa.nhs. uk/resources/?entryid45=59895 (Accessed: 21 January 2011). Samuels, R. & Chadwick, D. (2006) Predictors of asphyxiation risk in adults with intellectual disabilities and dysphagia, Journal of Intellectual Disability Research 50(5), pp.362-370. Resources ALD Dysphagia UK network forum, email Resuscitation Council UK guidelines - www.

Further analysis

The factors influencing choking can be numerous and complex. To explain and then attempt to prevent further incidents as a multidisciplinary team, we need to identify potential risk factors. This may include aspects of a persons diagnosis their physical skills and the presence of dysphagia, mental illness, behaviours, medication history but may also include external influences such as environmental and social factors. We are trying to source funding for further analysis of the nature of choking incidents and the influences present using the wealth of information generated by the incident reports. With a stronger evidence base it will be possible to begin to research strategies to SLTP reduce risk in this area. Susan Guthrie is a Specialist Speech and Language Therapist with East Lancashire Community Health Services and Calderstones Partnership NHS Foundation Trust, email susan.guthrie@ Dr Hazel Roddam is Principal Lecturer in Research, University of Central Lancashire, email

Clinical questions and challenges 1. Would you recognise if your patient was choking? 2. Could you give standard basic life support or are there complicating factors? 3. Do you know whether choking has happened before? 4. Is there an underlying dysphagia? 5. Can we show that intervention reduces the risk of further incidents?
How has this article changed your thinking? Let us know - see information about Speech & Language Therapy in Practices Critical Friends at



HERES ONE / reviews

Heres one I made earlier...

Alison Roberts with more low cost, flexible and fun therapy suggestions for groups True story
This memory activity helps clients to listen, and to learn something about each other. It could be something about their biography, or maybe an event last weekend, such as a barbecue or a trip to a zoo. It also requires the person telling their story to plan something reasonably coherent, for which they may need some help. If your group of clients prefers, they can tell made-up stories. It is best for a group of four teenagers or adults. IN PRACTICE a. Person A tells their story, which should last approximately half a minute. b. Person B repeats the story as exactly as possible, trying to use the same words and inflections. c. Person C mimes it. d. Person D tells it again, but as a character such as an old woman or a reporter might. e. Together think of some questions that would extend the information originally given. f. Now person B tells their story, and the procedure is repeated. g. When everyone has told their story try to remember Person As story. h. The outcome should demonstrate that, if the clients really focus on other peoples news or biographies, they can remember and use them to form part of a conversation. The point can also be made that, if the story is remembered, it can be referred to at a later date, showing interest and therefore possibly helping to build a friendship.

Foundation Role Plays for Autism Andrew Nelson Jessica Kingsley ISBN 978-1-84905-063-0 34.99

An excellent resource

This is a practical resource for anyone working with young people with autism spectrum disorder. It offers pre-prepared activities to enable participants to make choices and practise skills in a safe imaginary situation. I particularly loved the sections aimed at siblings, parents and peers as there are very few resources available for these groups. These role plays are most suited for older children or young adults as they require higher levels of language ability and have a written feedback form for each activity. This is an excellent resource for therapists working with young people with high functioning autism. I will be passing it on to our therapist dedicated to the secondary school service and the Youth Offending Team. Louisa Waters is Principal speech and language therapist, Childrens Therapy Team, Medway Community Healthcare.


Every cloud
MATERIALS List of problems Paper and pens

This activity has two main purposes: lateral thinking practice, and how to be optimistic. Clients who are working on idiom will also learn the meaning of the expression Every cloud has a silver lining.

Benjamin Writer-Messy / Jake Monkey-Tail Priya Desai Learning Cycle Ltd ISBN 978-0-9565247-0-6 / 978-0-9565247-1-3 5.99 / 6.99

Hard work to hold attention

IN PRACTICE Write a problem at the top of the page, such as Amy broke her ankle but. Now, as a group, brainstorm some positive points about such a situation. These could be: she found that her true friends rallied round to help her; she found out different ways of doing things (like bouncing down the stairs on her bottom, and drinking her tea beside the kettle rather than carry it to her table); she learnt to use crutches, and in so doing her arms got stronger; people wrote funny things on her plaster; she was given lots of flowers. Other hypothetical problems and positive points might include: There was a power cut (but - we ate by candlelight; we had a log fire; we teamed up with others and had a bonfire; we saved a bit on electricity). We missed the train (but - while waiting we took the opportunity to have a coffee in the station caf; we caught a later one which was a through train; we spent another day on holiday). Our car broke down (but - at last we were able to benefit from all those years of paying in to the RAC; two of us could go and get everyone an ice cream; it made us decide to buy a new car; it made us decide to sell the car and use public transport instead). Faith failed her driving test (but - she was able to have a bit more practice before driving alone so was a safer driver in the end; she didnt need her own car yet; so could save on petrol money; one less driver means a bit less pollution; she shared a lift with someone who became a friend). When you have tackled some hypothetical situations you might feel that the group is able to look at some actual problems of their own. Its best to stick to fairly light problems that will pass in time rather than examining deeper difficulties.

Both these beautifully illustrated books feature characters who have writing problems. Benjamin Writer-Messys handwriting is illegible and Jake Monkey-Tail cannot spell. Writing and spelling difficulties, perhaps even more than poor reading, can seriously affect confidence, self-esteem and motivation. Ms Desai, a speech and language therapist, aims to encourage children to identify with the characters in her stories. Both Benjamin and Jake, with the help of a little magic, win through to conquer their difficulties and gain praise and respect. Both books also touch on the need for hard work and practice. I am not sure whether the stories are intended for children with language impairment. Some of my own young clients (aged 7-9) enjoyed Benjamin Writer-Messy but I had to work hard to hold their attention. Jake Monkey-Tail proved too long and its language too advanced for this particular group. As the stories are concerned with writing and spelling, I consulted an occupational therapist and a teacher. We all felt that, as motivating tales, both stories could be valuable as a resource for pupils needing a multidisciplinary approach to literacy. They would be less useful in a community clinic. Zohra Jibb is a specialist speech and language therapist with NHS Lothian.



Reading and Dyslexia in Different Orthographies Nicola Brunswick, Sine McDougall and Paul de Mornay Davies (eds) Psychology Press ISBN 978-1-84169-712-3 39.95

Not a quick reference

This account of current research on reading and dyslexia in different languages is a theoretical read. Although stated as being suitable for teachers, my teaching colleague found the technical language a bit much and preferred the summary I provided. Nevertheless, I look forward to sharing the information with my educational psychology colleagues. As a specific language impairment therapist working bilingually I found the information interesting and informative. It was pleasing to read literature with regards to the Welsh language. Although I would refer to the book again, I found I needed time to process the information and it could not be used as a quick reference during a busy day. In the current climate a hardback book is quite expensive when unlikely to be used on a regular basis and more suited to specialist clinical areas. Lowri Jones is a specialist speech and language therapist in specific language impairment working in bilingual (Welsh/English) mainstream primary schools for Betsi Cadwaladr University Health Board, North Wales.

compared. The sound is described together with a photograph, diagram, ultrasound image and EPG frame. Older children and adults would find the photo and diagram useful. Unless they have experience of EPG, the frames are quite difficult to explain. So, useful to brush up on exactly how a sound is produced and possibly for training other professionals, although we found day-to-day clinical application more limited. Sarah Braithwaite is a speech and language therapist with Language Resource Provisions for NHS Tower Hamlets.


Autism and the Edges of the Known World Sensitivities, Language and Constructed Reality Olga Bogdashina Jessica Kingsley ISBN 978-1-84905-042-5 13.99

a young boy. This is a useful insight into a live intensive interaction session. The DVD gives a powerful demonstration of intensive interaction which cannot be done as easily or clearly in a book. It will definitely encourage the watcher to put these ideas into practice and will be extremely useful for therapists and teachers / support staff working with children or adults with autism whose communication is severely impaired. It would also be a useful tool when training others or explaining intensive interaction. Karen Large is a speech and language therapist with Hertfordshire Community Healthcare Services, working with children and young people with learning difficulties.


Theoretical insight


Speech Sounds A Pictorial Guide to Typical and Atypical Speech ISBN 978-1-59756-106-8 57.00 Seeing Speech A Quick Guide to Speech Sounds ISBN 978-1-59756-322-2 26.00 Sharynne McLeod and Sadanand Singh Plural

This book gives an interesting and theoretical insight into different sensory experiences of individuals with autism spectrum disorder. The key points are about the difficulties individuals have with filtering stimuli, and how this leads to sensory deprivation. The author links in experiences of individuals with autism to reinforce the key points and help make the information more accessible. It is not quick to read, and will not provide you with practical ideas or easily accessible information you could give to families. However it would be a good book if you want to look at theories behind sensory difficulties in autism. Fiona Alexander is a speech and language therapist with NHS Greater Glasgow & Clyde.

Perspectives on Individual Differences Affecting Therapeutic Change in Communication Disorders Amy Weiss Psychology Press ISBN 978-1-84872-887-5 40.00

Summarises the research

Useful to brush up


This is two resources a reference book and a smaller flip book. Reference book: Each English sound is described and pictured in a photograph, schematic diagram, ultrasound image and EPG (electropalatography) frame. The sequence of producing the sound, in a range of word positions, is discussed, as is the intra- and inter- speaker variability of each sound. This varies in detail considerably, sometimes covering a range of client groups and languages. This detailed book would be useful for students, for clinicians building a clear picture of a target sound and therapists working with children with complex speech sound disorders. Flip book: Each sound is represented on each side of the divided pages. Each side can be flipped independently so any two sounds can be

Autism and Intensive Interaction Using body language to reach children on the autistic spectrum DVD Phoebe Caldwell with Matt Houghton and Penny Myton Jessica Kingsley ISBN 978-1-84905-088-3 19.99

The thirteen chapters written by different authors focus mainly on research and interventions for children with a range of communication disorders including specific language impairment, speech disorders, literacy difficulties, bilingual clients, autistic spectrum disorder, cochlear impants and cleft palate. Each chapter summarises the research and evidence for intervention in these areas and how individual differences in clients impact on success or failure in therapy. The book is not easy to read and does not really tell us anything new. It was however useful as a reminder of evidence based practice, and in arguing the importance of considering differences in clients (such as personality types, social competency and family environment) as well as the clinicians experience when deciding on therapy approaches. It is expensive for what it offers, but may be useful as a departmental reference. Alison Muir is a speech and language therapist working with children with complex additional support needs in Stirling.

Powerful demonstration

Part 1 of this practical DVD is a discussion on the significance of sensory information in young people with autism. This is backed up by footage of Phoebe working with a number of students and using their body language to begin to open channels of interaction and communication. Part 2 raises the issues of the appropriateness of touch when working with young people. I found this particularly useful as some of the interactions observed use quite an intimate level of contact. Part 3 is non edited video footage of a complete intervention with


Understanding Dyspraxia A guide for parents and teachers Maureen Boon Jessica Kingsley ISBN 9781849050692 12.99

Jargon-free language

I reviewed this book myself and sought comments from two sets of parents. The jargon-free language made the book very concise and easy to read and the clearly




defined chapters make it easy to find particular information. As a basic grade therapist I found it extremely interesting and informative, however it may be of limited benefit to specialists. Some of the excellent practical ideas are of more use to physiotherapists and occupational therapists. The descriptive case studies throughout were a particular highlight to both myself and the parents. Information is split into age groups, which the parents felt was useful as they could go to specific sections. The book is excellent value for money but, as the title says, is more targeted at parents and teachers than speech and language therapists. Lynsey McDowell is a community paediatric therapist in Newry, Northern Ireland.


Working with Families in Speech-Language Pathology Nicole Watts Pappas & Sharynne McLeod Plural ISBN 978-1-59756-241-6 38.00

A one stop shop

This book links research to clinical practice with studies of parents perceptions of their involvement in their childs intervention. It explores families relationships with the therapist to inform us of the most effective ways of interacting with and involving parents. It is useful in all contexts of childrens speech and language therapy and for all ages and stages of careers - as a student textbook, as an introduction for less experienced therapists to truly working with families and as a refresher of good practice. The style of this well-written book is informative and accessible and its evidence base is strong. The research and practice is balanced and representative of work in the US, UK, Canada and Australia. This book may appear quite expensive, however its relevance, accessibility, resource base and evidence make it a one stop shop for therapists working in any context with children and their families. Helen Daly is service manager in Wakefield.

With 39 contributors from across the globe, it presents a wide range of interventions. Each is allocated its own chapter (which follows the same structure to enable critical comparison) and the evidence base is considered in great detail. It is well worth reading the introduction, and there are summary charts detailing the main components of each intervention. Old favourites such as minimal pair, metaphonological and psycholinguistic intervention are included, along with newer ones such as family-friendly and complexity intervention. In an accompanying DVD, contributing authors demonstrate key components for most interventions, generally bringing them to life (who would have thought non-linear phonology could prompt me to get the dressing up box out?) Overall, the reader is provided with sufficient information to select appropriate intervention for individual children, and to try out new ones. This detailed reference book for students and clinicians is a must buy for any paediatric speech and language therapy department. Oonagh Reilly is a Senior Lecturer at Birmingham City University and Honorary speech and language therapist in South Staffs PCT.


Embedding Evidence-Based Practice in Speech and Language Therapy International Examples Hazel Roddam and Jemma Skeat (eds) Wiley-Blackwell ISBN 978-0-470-74329-4 29.99

A valuable resource


Ethnographic Fieldwork - A Beginners Guide Jan Blommaert & Jie Dong Multilingual matters ISBN 978-1-84769-294-8 14.95

A wider perspective

This book is the product of a UK / Australian collaboration with worldwide contributors including the editors. The 34 short chapters, organised into six sections, clearly take the reader from understanding what evidencebased practice is, through many salient aspects of its application, to future directions. One section includes chapters focusing on everyday and more unusual client groups and contexts, such as those with psychogenic dysphonia or in an adult stroke unit as well as prosody therapy, stroke dysphagia and bilingual dysfluency in children. Although scholarly, it is mainly written by clinicians for clinicians. Because of the importance and immediate relevance of the topic to current clinical practice as well as the transferable methods described, this book would be a valuable resource for a wide range of readers students, newly qualified therapists, lecturers, experienced therapists and managers. Linda Armstrong is a speech and language therapist working with adults in the Perth and Kinross community who have acquired communication and/or swallowing disorders.


Interventions for Speech Sound Disorders in Children A. Lynn Williams, Sharynne McLeod, Rebecca J. McCauley Paul H. Brookes ISBN 978-1-59857-018-2 62.50

A must buy

This excellent book achieves its aim of describing, analysing and exposing readers to a broad spectrum of intervention approaches for all types of child speech sound disorders.

This title would not normally attract my eye, and it received a few face pulls from colleagues. First impressions were not good and the explanation of ethnography was quite difficult to digest. However, once I waded through the initial (short) chapters, I could see the applicability to clinical practice. Those embarking on research would find it useful as it gives a wider perspective of data collection: ... the target of scientific method is simplification and reduction of complexity ... ethnography is precisely the opposite. It gives a methodology on the sequence of collecting and analysing ethnographical data, as reality is kaleidoscopic, complex, complicated and often a patchwork of overlapping activities. Language, communication and culture do not occur in a vacuum, hence the importance of a structured observation of the context in which they occur. Although not necessarily a clinical companion, it gives a view on how to look at the bigger picture and delve into individual narratives and stories, so as clinicians we may construct our own learning process. Gwenan Roberts is a consultant speech and language therapist in Conwy with Betsi Cadwaladr University Health Board.


Aspergirls Empowering Females with Asperger Syndrome Rudy Simone Jessica Kingsley ISBN 978-1-84905-826-1 12.99

Accessible and touching

In the accessible and relevant Aspergirls, Rudy Simone takes the reader through the stages of life from childhood to old age, looking at issues such as the Aspergirls meltdowns, stims (self-stimulatory behaviour), literal thinking, socialising and sexuality. It is written in a touching, often humorous and very practical style, effectively providing a life manual for females with Asperger Syndrome. The anecdotes from Aspergirls she has interviewed broaden the readers insight into what it must be like to live with this syndrome. At the end of each chapter Simone sums up key points for her Aspergirl readers and their parents. Whilst this can at times feel repetitive, we would anticipate it being a helpful strategy for her target audience. Liz Phippen and Charmian Hewson-Ekornrd are speech and language therapists working for Symbol UK at Penn School, Buckinghamshire.



journal club

Journal club 3: systematic reviews

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 systematic reviews.


here has been an explosion of literature relevant to speech and language therapy over the course of my working life. An article which reviews the current state of play in a relevant area may appeal to timepressed clinicians. Can we expect a review to be more comprehensive than an article on a single piece of research? Should it avoid the need to comb the literature for articles on original research? And may we assume that the scope of the review will be better than we could do ourselves, the reviewers being more knowledgeable than us? Well, the answer is probably both yes and no. Reviews may indeed provide a ready-made synthesis of the available research but they too are open to that enemy of science, bias. This fact, along with the huge expansion, particularly in the medical literature, has led to the development of a new type of review method. The sorts of reviews many of us grew up with, like those presented in textbooks, have been reclassified variously as overviews, narrative reviews, or simply non-systematic reviews. The systematic review has become one of the core tools of evidence-based practice. If you can get your head round its principles and methods, you will find you are much better equipped to deal with the current literature. The landscape of a systematic review may feel

very foreign to the uninitiated my advice is to persevere, because well-conducted systematic reviews on areas of current concern for speech and language therapy services are invaluable. In Fife, we have found appraising systematic reviews in our journal clubs really helpful (even if they do nip your head to begin with!)

my advice is to persevere because well-conducted systematic reviews on areas of current concern for speech and language therapy services are invaluable
The critical appraisal tool for speech and language therapists presented here has been developed primarily from CASP (PHRU, 2006). It provides a structured framework for reading and appraising reports which summarise the

results of primary research studies. It can be used for systematic reviews with or without meta-analysis (when the reviewers attempt to combine the numerical results from various studies). These methods are at the top level of the evidence hierarchy, so authors often use the actual terms, systematic review or metaanalysis, in the title of the article. The results of a systematic review rely not only on the quantity and quality of the primary studies included but also on how well the review and synthesis was conducted. However, a well-conducted systematic review should provide more definitive evidence than any other type of study, even if the results relate only to a circumscribed area. The tool can also be used for other types of review but, for a non-systematic or narrative review, you may wish to use selectively this and the Expert Opinion tool presented in the first article in this series (Reid, 2010). As with other critical appraisal tools, the main themes to be addressed revolve around the study results, their validity (how true they are) and to what extent, if any, they might apply to the appraisers own context. As previously, magazine subscribers may download a formatted version of the appraisal tool at www. to use on their own or with colleagues in a journal club.



journal club
Question 1: What question was being asked, and is this an important clinical question? or exclusion of particular designs. As you read more systematic reviews, you will begin to get a better feel for this. The prestigious Cochrane Collaboration (, along with other authorities on evidence-based medicine, will try to convince you that a respectable review of an intervention should include only randomised controlled trials (RCTs). This may well be an attainable goal for medical treatments. However, in many areas of speech and language therapy practice, the only available evidence comes from small scale, exploratory studies. Moreover, the UK Medical Research Councils Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Health (2000) advocates the use of small-scale and exploratory designs in the early phases of development of evidence-informed interventions. Those engaged in systematic reviews may need to take into account the level of maturity of the field of research before deciding where to draw the line. Inclusion criteria set too high up the evidence hierarchy increase the danger of arriving at the nil result of, for example, a Cochrane review of treatment for acquired dysarthria (Sellars et al., 2005) it found no studies met its inclusion criteria. This result may be a trigger for future research in this area, but it is distinctly unhelpful for clinicians looking for clues to potentially promising treatments, and by default promotes the expert opinion route with all its potential biases. Question 3: Did the reviewers try to identify all relevant studies? Like other aspects of evidence-based practice, appraisal points are scored by playing the game by the rules: systematic reviews should provide an exhaustive summary of the literature relevant to the question in hand, so reviewers are expected to have tried to identify all sources of evidence including those that are in the grey literature (such as dissertations, unpublished studies or articles in obscure publications.) For appraising exhaustiveness, the relevant questions to ask are: Did they follow up reference lists? Did they make personal contact with experts? Did they search for unpublished studies? Did they search for non-English-language studies? If they did, they will mention it, because they know this earns them credit towards publication in respected, peer-reviewed journals! If they failed to do so, is there a danger their review has been seriously compromised? Hmm, I leave you to form your own opinion Question 4: Did the reviewers assess the quality of the included studies?

Try formulating the reviewers stated aims into a research question if they have not done so explicitly in the article. Is the question clearly focused in terms of the PICO framework, which we discussed in the first article of the series (Reid, 2010): Population studied Intervention given (if it is an intervention study) Control / comparison (if applicable) Outcomes considered? Is this question important for your clinical practice? If the reviewers question does not quite fit the bill, what question(s) do you wish they had asked instead? Question 2: Did the review include the right type of study?

The article should present clear inclusion and/or exclusion criteria, so home into this section of the article to consider whether the included studies address the reviews question. Sometimes the primary studies have been designed to answer a different question, so it is important to check that a studys inclusion in the review is justified. Do the included studies have an appropriate study design? In my experience, those who are new to critical appraisal or research design may be inclined to feel that the views of the reviewers are more valid than their own. Deal with any feelings of inadequacy by reading carefully the reviewers rationale for inclusion

Which bibliographic databases were used? If you are not yet familiar with the nomenclature, consider whether more than one database was searched. Beware reviews that use only one database source the field of speech and language therapy is so cross-disciplinary that it is impossible to predict which journals contain potentially useful articles. For example, my default setting for rapid literature searching is to search simultaneously MEDLINE, PsychINFO and possibly ERIC ( if the question involves school-aged children. This produces some duplicates but also many unique references from only one database.

The main consideration is whether a clear, pre-determined strategy was used to decide which studies were included. Look for a set of defined categories that together form the definition of quality the reviewers have adopted, plus a scoring system there may be a table of the included studies showing the points awarded against each quality criterion. These sorts of tables often interfere with the readability of an article but you should try not to skip them. They really are crucial to understanding the results of the review and you may find that one or more primary studies are worth following up. It is also important that more than one assessor has been involved in rating and scoring the studies. This provides evidence that the quality system is objective and reliable enough to support the credibility of the results.



Question 5: How are the results presented and what is the main result?

Figure 1 A reminder about Confidence Intervals Confidence intervals allow you to estimate the strength of the evidence and whether it is definitive (in other words, you dont need further studies to check the result). A single study gives you only one example of the difference between two measures, two groups etc. If you repeated the same study several times, you would not get exactly the same result each time. You cant know what the real difference is, especially from one study. Calculating a 90 per cent confidence interval around your result allows you to say that there is a 90 per cent chance that the true result lies within this range. If an author is interpreting the confidence interval appropriately, you should see comments about both the extent to which their results support their original hypothesis as well as whether any further studies need to be done. Confidence intervals which straddle zero suggest that there may be no real difference or that your study used too few participants for you to detect the effect definitively.

The two components of this question are stated in this order for a reason: how results are expressed can have an important influence on what you perceive as the main result. You need to consider: whether the reviewers interpretation of numbers was sensible how the results are expressed (for example, odds ratio; means and confidence intervals (figure 1)) and how large and how meaningful this size of result is. Some systematic reviews provide an assessment of quality followed by a verbal synthesis in the form of one or more conclusions, with an indication of the strength of the current evidence for each. In terms of the main result, it can be instructive trying to sum up the bottom-line result of the review in one sentence it does help when trying to communicate the gist of your appraisal to others. And your clinical bottom-line will certainly be needed if your appraisal is to be combined with the appraisal of other evidence in order to produce a clinical guideline or a best practice standard, whether for your local context or for a wider audience. Question 6: Samantha If the results of thePaula studies have been combined, was it reasonable to do so?

Some systematic reviews go beyond qualitative synthesis and present a meta-analysis of the quantitative data from included studies. One

crucial concept here is the notion of effect size. (Dont panic! Im going to talk about numbers now but stay with me) Calculating an effect size is a method for quantifying the effectiveness of an intervention, allowing you to compare or combine the results of different studies. Numerical calculations are used to produce a number (a statistic!) so you can then compare like-with-like across different studies. You can think of it as similar to converting raw scores to standard scores in formal assessments it allows you to compare a clients performance in different areas of functioning, for example receptive vocabulary vs. comprehension of sentences. The value of a Cohens d or other statistic tells you about how big a change has been found in the outcome measure for the intervention. Whether changes can be attributed wholly to the intervention is a moot point, but in general the bigger the average change the effect size the more likely we are to believe it was caused by the intervention. A weak effect does not equate to no effect, but it may not show up conclusively in some study designs. To detect weak effects, you usually need lots of study participants. This may be where a meta-analysis comes into its own, as combining the data from lots of smaller studies of a relatively weak effect can provide much more definitive evidence that the intervention really does have an effect. You will come across different methods for analysing effect sizes. Percentage of nonoverlapping data (PND) provides a means of translating the results of individual studies into a common currency so you can evaluate them side-by-side. It can be applied to research designs that are lower down the evidence hierarchy, such as single-subject designs (also known as n=1 studies). In figure 2, can you work out which intervention had the stronger effect? For both studies, there is an area of overlap (see arrows) where the relatively high pre-intervention scores of some participants are the same as those of the people with the lowest post-intervention scores. However, this area of overlap is much smaller for intervention B, which translates into a stronger effect size and, numerically, to a larger percentage of non-overlapping data. For study B, we can be more confident that the changes in participants performance was indeed treatment effects and/or that the design

ensured that other influences on performance were controlled. Calculation of percentage of non-overlapping data may be used to combine the results of small-scale studies for a systematic review with meta-analysis. Meta-analysis of more robust studies, such as RCTs, is more likely to be reported using a forest plot (figure 3) or blobbogram (see the logo of the Cochrane Collaboration). These provide a visual display of the effect sizes associated with the included studies, the confidence intervals of their results, a summary effect size and confidence interval. The convention is for them to include an identifier for each study on the left (in order of year of publication), and some scary statistics on the right though if you can deal with them, you will find they answer the question about how results are expressed. Weighting is about how much each study contributed to the overall summary measure the bigger the blob, the more influential the study. One of our adult acquired journal clubs appraised a review of treatments for dysphagia in neurological disorders (Ashford et al., 2009). We found the heavy weighting of a couple of large Logemann studies a concern, because the participants in the Logemann studies were skewed towards people with Parkinsons Disease and dementia, with very small numbers of people with stroke very different, we thought, from the Fife caseload profile. Question 7: Can the results be applied to the local population?

Clinical recommendations may be offered by reviewers, but without an accumulation of robust, scientific evidence, these are often



Figure 2 Effect size Intervention A prepostIntervention B prepostBlack et al., 1999 Connor, 2002 Drake et al., 2005 Scores in the overlapping area could either be from pre- or from post-testing Elder et al., 2005 Foukes, 2009 Figure 3 Forest plot example (fictional)

Key Measure of effect, and therefore weighting, in metaanalysis Confidence interval Line of no effect Summary measure of effect - lateral spread shows confidence interval

fairly circumspect. You need to address the usual considerations about potential differences between the population covered by the review and your own, and whether your local setting is different from that of the review to the extent that its results cannot reasonably be applied. You also need to consider whether the intervention is practical and acceptable to clients in your own setting. Question 8: Were all important outcomes considered?


Consider whether any reported benefit outweighs any risk and/or additional cost. If this information is not reported, can it be filled in from elsewhere? And finally... A good example of a clinically helpful review, in my opinion, was one we reviewed last year in an adult learning disability journal club. The study (van Oorsouw et al., 2009) posed a question the group felt was extremely important for them, regarding which aspects of staff training are related to improvements in staff behaviour. The authors included single-subject and small sample studies and found 55 studies that met their criteria, which provided relevant data from over 500 participants. Meta-analysis (using percentage non-overlapping data) was applied to the data from all the participants. The results suggested that a combination of in-service (using multiple techniques) with coaching-on-the-job (featuring verbal feedback) is the most powerful format. Even though these results did not really add to what the group already believed, it is important for us to have evidence to support what we are currently doing as well as information to help us break new ground. The journal club session helped the staff feel more confident in their practice and gave them ammunition for resisting pressure to undertake staff training that was unlikely to be effective. The study results were also of great interest to paediatric and adult acquired staff. These days pretty much every speech and language therapist has to do staff training, whether this is with health, education or social care staff, so this review also spoke to their concerns about

how to design and deliver training effectively. Of course, what we really need to know is how to bring about long-term, sustained change in staff behaviour, but unfortunately this study SLTP did not speak to that question. Jennifer Reid is a consultant speech and language therapist with NHS Fife, email


You should try to think whether the reviewers have considered the outcomes of the review from all angles, that is from the point of view of clients, families and carers, and the wider community, as well as speech and language therapists and other professionals, service managers and policy makers. Question 9: Should policy or practice change as a result of the evidence contained in this review?

Ashford, J., McCabe, D.M.A., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N., Schooling, T. & Smith Hammond, C. (2009) Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Part III - Impact of dysphagia treatments on populations with neurological disorders, Journal of Rehabilitation Research & Development 46(2), pp.195-204. Medical Research Council (2000) A Framework for development and evaluation of RCTs for Complex Interventions to Improve Health. Available at http:// htm?d=MRC003372 (Accessed 18 February 2011.) Public Health Research Unit (2006) Critical Appraisal Skills Programme. Available at: Pages/PHD/CASP.htm (Accessed: 18 February 2011.) Reid, J. (2010) Journal Club: expert opinion, Speech & Language Therapy in Practice Autumn, pp.17-21. Sellars, C., Hughes, T. & Langthorne, P. (2005) Speech and language therapy for dysarthria due to nonprogressive brain damage, Cochrane Database of Systematic Reviews Issue 3. Art. No: CD002088. DOI: 10.1002/14651858.CD002088.pub2. van Oorsouw, W.M.W.J., Embregts, P.J.C.M., Bosman, A.M.T. & Jahoda, A. (2009) Training staff serving clients with intellectual disabilities: a meta-analysis of aspects determining effectiveness, Research in Developmental Disabilities 30(3), pp. 503-511.

Critical appraisal for speech and language therapists (CASLT) Download the systematic review framework document from Use it yourself or with colleagues in a journal club, and let us know how you get on (email



Resource reviews
When budgets are tight, our in-depth reviews by practising speech and language therapists help you find affordable resources that are right for you and your clients. EMPOWERING PARENTS
Speech Quest (subscription pricing - see details in review)

Well thought out, thorough and educational


EYBIC (Early Years Based Information Carrying) Word pack Henrietta McLachlan & Liz Elks, illus. Livi Rowe Elklan 35.00

Useful and affordable

EYBIC consists of a book and CD. It aims to develop childrens communication and language skills. Suitable for pre-school children with language delay, older children with more significant language difficulties and children who are learning English as a second language, the pack includes training sessions for parents and education staff. It empowers parents to reinforce ideas at home and helps education staff to understand and apply the principles within the classroom. EYBIC provides: A PowerPoint workshop presentation Teaching notes Parent Information Booklet Home activities pack with easy to follow explanations for parents Record form for recording progress Black & white and colour printable resources for use in clinic. All speech and language therapists with a knowledge of Information Carrying Words could use this resource as a therapy tool and training package. Each component is clearly set out and requires minimal preparation. The home activities pack and teaching resources are user friendly with straightforward instructions and easy to use materials. EYBIC would be a useful and affordable resource for any paediatric speech and language therapy department. Julie Mackie and Kirsten Manson are paediatric speech and language therapists at Glassgreen Centre, Elgin.

Speech Quest is an independent website devised by speech and language therapists. It aims to enable parents/carers to assess their childs communication between 6 months and 5 years, and to provide them with a communication profile and a tailored programme which they can carry out independently at home. If any area shows significant difficulties, parents are clearly signposted to see their GP or health visitor for a referral to a speech and language therapist. In addition to the website, there are links to YouTube tutorials which talk through the whole process from completing the assessment to filling in activity record sheets. The website is generally easy to navigate, with an appealing layout. Once a parent or carer has registered, they complete a free test questionnaire, in fact, a series of detailed online questionnaires that are presented in two sections. The Foundation section examines Attention and Listening, Play and Interaction skills, while the Language section looks at Understanding Talk, Talking and Making Speech Sounds. Results are expressed as a percentage score, and a traffic light colour coding system is used, with red, amber and green to indicate whether (a) the child needs referral on (red scoring less than 25 per cent); (b) child would benefit from recommended activities tailored to results and parents are therefore encouraged to purchase the full assessment (amber - 26-75 per cent) or (c) child is progressing well but they can still purchase the assessment if they would like (green over 75 per cent). It may be worth noting that the term assessment across the Speech Quest website seems to refer to the assessment results, rather than any actual assessment (which takes the form of questionnaires). This terminology may be confusing for parents or professionals using the site. The questionnaire is not exhaustive: for example, articulation difficulties are not covered in great detail, so it may fail to highlight less salient difficulties such as a 4 year old with a lateralised or dentalised production of /s/. However, the same section provides good general identification and support for those with developmental speech delay and appropriately flags up those with a more profound phonological disorder. Parents/carers then have the option of (1) paying 7.95 to view the full assessment results, or (2) paying a one-off fee for the more extensive assessment breakdown and targeted activities (currently 19.95 for access for a year, or 34.95 for unlimited access). The second option also gives the opportunity of retesting and monitoring progress. It provides new activities as the old ones are completed, as well as the useful feature of being able to adapt activities if they are found to be too difficult. Parents are given attractive, easy to navigate sheets of activities and game ideas, as well as forms to record progress each month, and these can also be downloaded and printed out. Tips and advice are given along the way, based on everyday routines, activities and resources. Parents/carers are also given the opportunity to ask the therapist a question at the cost of 9.95. This could present a difficulty if more of an ongoing dialogue is required, perhaps becoming expensive? However, it might give a specific answer to any concern that was not identified by the questionnaire. Speech Quest could be a useful resource to bridge the gap between referral and intervention for parents whose child is on a lengthy waiting list, as well as for parents who are concerned about their childs development and considering referral. The website effectively targets language delayed children and those with simple speech delay, and provides simple activities that can be carried out at home. It highlights the importance of sharing assessment results, recommendations and activities to all the childs caregivers. Speech Quest consistently emphasises the importance of the foundation stages of language and it encourages parents / carers to consider all aspects of communication by ensuring that all parts of the questionnaire are completed before results are given. Whilst this may be frustrating if a parent is only concerned about one aspect, for example speech sounds, it ensures that these other important aspects are highlighted to parents who may not be aware of them. The cost of viewing the assessment results and/or activities and the level of questioning does limit the clientele who can afford to and are able to access and utilise the site, particularly those with more than one child. However, the degree of advice and information provided in such an interactive and user friendly manner offers good value for money. The website covers an impressive breadth of information, empowering the parent/carer to affect positive changes in their child. Speech Quest is a well thought out, thorough and educational website which provides appropriate signposting and functional, practical advice to its target client group. Jo Cardy and Juliet Vale are speech and language therapists with Buckinghamshire Healthcare Trust.



resource reviews / TRAINING

Opening doors
Talking Dice Starter Pack ISBN 1-84795-083-3 25.52 + VAT Teachers Notes and Student Workbook 0-9550429-0-9 14.99 + VAT Linguascope

A fun way to learn

Talking Dice is a practical resource which aims to get children talking. It is targeted at children with English as an Additional Language, but could also be used with children on the speech and Language therapy caseload. The resource is clear and easy to use and, as most children enjoy playing with dice, is a fun way to learn and practise language structures in expressive speech. The starter pack consists of 25 dice, each covering a different topic such as clothes, hobbies, countries, parts of the body. Each dice therefore has six pictures per topic and more than one dice can be used at any time. Accompanying the dice there is a Teachers Notes book and a Student Workbook. The workbook contains 40 photocopiable sheets (copyright permission must be applied for) and the teachers book explains how to use each worksheet and expand it. Each worksheet shows which dice to use for a particular language structure. These include: use of why-because; opposites; question and answers; comparing things; connecting ideas; vocabulary; verbs and tenses. I found it very useful to look up in the index what I wanted to work on with a child and have a game and worksheet provided. I think this resource would work well in language groups where certain language areas are being targeted. The Talking Dice website contains useful information including E-Talking Dice, an interactive software version for school whiteboards. The worksheets encourage writing of sentences. As a speech and language therapist I would be more interested in the verbal expression of the target, but in a school setting this dimension could be utilised. Also there is only one worksheet for each target area so the therapist or teaching staff need to use their imagination to expand the ideas. The resource is easily portable, value for money and I would recommend it as a useful tool, particularly in schools. Faith Lewis is a speech and language therapist working in clinic and mainstream schools for NHS Leeds Community Healthcare.

Using the results of her practice-based research, Kit Clewley made a successful case for carer communication training groups to be provided as an essential element of aphasia intervention. She now finds a 3 stage model, which includes joint client / carer groups, offers the best outcome and use of resources.
ollowing his stroke, Mr Williams received 7 months of individual speech and language therapy, focusing on dyspraxia, gesture, inconsistent yes / no, drawing and using a communication book. Despite this input, he used no communication strategies besides facial expression and intonation. He relied on Mrs Williams to ask him yes / no questions, to which his answers were inconsistent. He responded to his wife but did not tend to initiate communication beyond his basic needs. Mrs Williams did not encourage her husband to use any communication strategies and never used any - such as drawing or gesture - herself. She did use strategies to help Mr Williamss comprehension but tended to rely on yes / no questions and guessing to understand him. Mr Williams attended a social club with wellknown friends and hospital appointments, but was not confident enough to leave the house for any other reason. This scenario will be a familiar frustration to many of you, as will the question what can we do about it? In Wrexham and Flintshire we have for several years offered communication therapy groups to people with aphasia. These were based on the Supported Conversation for Adults with Aphasia approach (SCA) (Kagan et al., 1996 a; b) and provided the opportunity to engage in functional communication. Clients tended to join at the point where they required consolidation of identified functional communication strategies. Although the clients improved in using their communication strategies in the group, we found they were not generalising into the home environment or other functional settings. Similarly, carers were not using the communication strategies we advised them to try. Although this could be partly a result of limited liaison, we felt it was primarily due to the carers needing hands-on communication skills training (Hoen et al., 1997; Rice et al., 1987). We recognised that the client cannot be seen in isolation. To achieve optimal return of


function and well-being, they must be treated alongside those with whom they communicate on a daily basis. At this point, evidence in the literature suggested that untrained conversation partners can pose a barrier to effective communication (Kagan et al., 2001). In addition, research studies firmly established the value of training partners, usually on a 1:1 basis in the home setting. (Cunningham & Ward, 2003; Simmons et al., 1987). Training carers on a 1:1 basis was not considered feasible, as we had limited resources and such an approach would not explore the potential benefits of peer support. I therefore undertook a research project in 2005 which looked at the advantages of providing tailored communication training in a group setting to carers of clients who presented with aphasia (Barber, 2006; 2007). The research was supported by the then North East Wales NHS Trust, and carried out in accordance with its Ethics requirements and consent procedures. The project

Kit Clewley (nee Barber) (right) is a specialist speech and language therapist at Maelor Hospital in Wrexham, email kit.clewley@ Technical instructors Jill Roberts (left) and Berne Roberts (centre) are key members of the communication training programme team.



demonstrated that improvements occurred not only in the carers interaction skills following the training, but also in the clients. My conclusions were that: 1. Carer training should be available automatically alongside direct client intervention for those who need it. 2. Training the partners of communication therapy group clients in a group format benefits both carer and client and has the potential to reduce 1:1 and group therapy time. 3. Most carers, including those with longstanding experience of cerebral vascular accident, valued peer support highly. They indicated that the group reduced feelings of isolation, promoted problem-solving, helped them to share experiences, and gave greater understanding and the opportunity to learn from one another. 4. Speech and language therapists routinely advise carers how to achieve effective, natural interaction with their partners. However, for carers to modify communication strategies consistently, they also need designated, ongoing training sessions where they can practise in a supportive environment with their peers. These research recommendations were accepted by the Trust (now Betsi Cadwaladr University Health Board). After discussion with speech and language therapy management, we provided 10 weeks of communication training as set out in the research to five groups of carers over the period 2005-2009. The training incorporated handouts primarily from Supporting Partners of People with Aphasia in Relationships and Conversation (SPPARC) (Lock et al., 2001) and video footage from SPPARC, SCA and our communication therapy groups. Sessions included roleplay exercises, personalised video analysis, feedback and discussion to provide the carers with as much hands-on experience and support as possible.
Figure 1 The three stages Stage 1

Carer communication training group 10 week training programme comprising principles from SPPARC (Lock et al., 2001) and SCA (Kagan et al., 1996 a; b; 2001) Feedback Stage 2

Client communication strategies group 10 weeks practising communication strategies at a functional level

Client and carer training consolidation group 10 week consolidation of carer communication with clients and carers working together Feedback Stage 3

Client and carer functional goals group Flexible number of weeks where clients and carers work together to identify and achieve functional goals before discharge Feedback Discharge

with moderate-severe dyspraxia. Most were 6-11 months post onset, and one was 1 year 10 months post onset. Stage 1 Carer communication training group and client communication strategies group Five carers received weekly training of 1.5 hours for 10 weeks. (The sixth had to withdraw two weeks before the start due to her partner being taken ill.) The training was revised slightly from the programme provided previously, but continued to be based on the SPPARC and SCA approaches. This group was run by a speech and language therapist, a technical instructor and a volunteer. At the same time as the carer training, the five clients attended a communication strategies group where they worked on their strategies at a functional level. This was run by a technical instructor and a volunteer. Stage 2 Client and carer training consolidation group In this group, the carers and clients worked together on the principles of SCA and SPPARC. The principal aims were to ensure that: 1. the carers increased their confidence to put


Although the carers and clients demonstrated improvements in their interaction skills, there was still a problem with generalisation into the functional setting. The carers remained convinced that their partners required further speech and language therapy, despite the fact that they now possessed the skills necessary to support their partners to communicate well. They frequently expressed the opinion that their partner communicated better with the speech and language therapist and technical instructor, and would not communicate in the same way with them at home. To address this, in September 2009 we devised and offered a 3-stage Communication Training Programme to a maximum of six clients and their carers (figure 1). All the clients presented with moderate-severe receptive and expressive aphasia, and five presented

training into practice. We asked them to use the training with their own partner and with the other clients in the group. This gave them the opportunity to use their skills in situations where knowledge could not be assumed. It also enabled them to observe how well their partner could communicate when adequately supported by a peer rather than a therapist or technical instructor. 2. the clients began to accept that their partners were changing long-standing interaction patterns by implementing the training. They were encouraged by their partners to comply with requests to use alternative communication strategies, rather than to expect their partners to engage in habitual interaction patterns such as guessing the word. The carers and clients were also expected to carry out work at home between sessions to help generalise the training and acceptance of its usage outside the clinical setting. This group took place each week for 1.5 hours for 10 weeks. It was run by two technical instructors and two volunteers, one from the Association of Voluntary Organisations in Wrexham and the other from the Communication Support Service. Both had



received the carer communication training. The speech and language therapist attended sessions at the beginning, middle and near the end of stage 2 to provide guidance and support to the technical instructors. Attendance was variable due to bad weather and ill health. This resulted in three couples no longer attending by week 5, leaving only two couples to complete stage 2 and move on to stage 3. Stage 3 Client and carer functional goals group Here, clients and carers set functional goals to achieve up to and following discharge. They worked as a group to establish how these goals could be met through a process of problemsolving, suggestion and support. We gave each couple a toolkit to provide them with the means to achieve functional goals identified in the group and future goals. The tools were specific to each couple. They comprised supported conversation techniques, updated communication books, I have difficulty communicating cards and practical tips derived from peer support. This 1.5 hour weekly group only ran for two weeks as there were only two remaining couples and their confidence to achieve the set goals with the tools provided was high. The duration of stage 3 in future groups is expected to be flexible, as factors such as number of members and confidence levels are significant. The group at stage 3 was run by one technical instructor and one volunteer due to the reduction in numbers. The speech and language therapist attended the first session to provide guidance and support to the technical instructors. There was a break of three weeks between each of the three stages, and the group members were discharged from the speech and language therapy service at the end of stage 3. making more comments versus asking questions no longer demanding the correct target from their partners reducing test questions following their partners lead encouraging their partner to express an opinion. Feedback from partners following stage 1 indicated that they placed great value in seeing and hearing how others cope with similar conditions, not being alone and receiving useful hints. In feedback after stage 2, the carers thought it was good to work with their own partner but also with someone elses. When asked if stage 2 had made a difference to the way they communicate at home the answer was Yes completely. Comments included: We can discuss things better It gave me more confidence with him He does more using his communication book. He writes more in his book and started saying more words because of this. The carers felt there had been a complete change in their confidence levels when communicating with their partners: I am more relaxed I understand him more and we both dont get as frustrated as we used to do and he has a lot more confidence doing things himself. They also indicated that their partners had enjoyed the group. One client was at first not sure but enjoyed the weekly group meetings as the weeks went on. Also nice group of people he made friends with. In future I propose to obtain feedback after all three stages, as shown in figure 1. completely. In future programmes we will give the carers greater control in carrying out supported conversation techniques earlier in stage 2 by reducing the amount of direct intervention provided by the technical instructor at the outset. Client reluctance to use communication strategies with partners is however always likely to be a problem, and could be due to a number of factors including personalities, expectations and relationships. The breaks between the stages will be reduced given the length of the programme and the need to keep momentum and motivation going. I propose to use a one week break in the next programme. The videoed communication sessions had a tendency to turn into a therapeutic session as opposed to a functional conversation. To obtain as accurate a measure a possible of natural interaction patterns, future videoed sessions will be based on an activity such as those used in the communication strategies group, which are more successful in terms of achieving functional communication.

Stepping stone

Goals and outcomes

Prior to stage 1, a technical instructor videoed clients and their partners having a conversation at home. This procedure was repeated with the two remaining couples following stage 2. Using principally the SPPARC approach, I analysed the interaction patterns of the client and partner to: establish communication goals for each couple set a baseline measurement provide an outcome measure. Improvements were clearly shown in the interaction patterns of both the clients and the carers. The clients demonstrated improvements with comprehension, yes / no confusion, and use of drawing and writing to communicate. The carers showed improvements by: encouraging their partners to use communication strategies versus guessing the word using these strategies themselves giving their partners more time to communicate

We have found that clients bond faster if they are joining a group which is already established
In stage 1, the carers bonded immediately but the clients took four weeks before they began to interact with one another. We expect this process to take longer for the clients because of the level of aphasia. However, we have found that clients bond more quickly if they are joining a group which is already established, as new members see communication strategies being used straightaway, and this encourages them to use these strategies faster. In future it may be possible to establish a client communication strategies group from which appropriate members can access the communication training programme. In stage 2, He wont do it with me at home was still a common feeling beyond the midpoint. We attempted to address this by asking carers to work with different clients to improve confidence levels. Although this worked well, it did not solve the problem

I invited the Communication Support Service (CSS) organiser for the local area to the last session in stage 3. The larger CSS group based in the community setting forms a natural stepping stone from the safe, contained and clinical environment of the communication training programme, and offers the clients the opportunity to maintain their communicative strategies and increase their communicative confidence. Inviting the organiser worked well as the clients were able to: 1. ask questions about the group 2. meet the organiser, which made the idea of attending for the first time less daunting 3. support each other by agreeing to attend together. Because they were present, the carers also improved their understanding of CSS objectives. Carers do not usually attend the CSS group and therefore do not have the same opportunities to maintain their skills in this setting. However, the CSS is planning the introduction of supported conversation groups in the local area and it may be possible to work with them in developing these groups so that the carers are also included. Within the communication training programme, clients and partners practise their communication strategies and therefore build communicative confidence in a supportive environment with their peers. We found that it engenders a sense of empowerment in both the client and partner enabling: the carer to reduce their protection of the client and increase their support the client to demonstrate their full communicative potential to the carer the client and carer to improve acceptance of their new life context and how it can be optimised both parties to open doors to functional life goals which have been closed until now.



Whilst the initiative is still at an early stage, we are convinced that the communication training programme exhibits significant benefits for client care and is cost-effective (figure 2). Present arrangements require six clients and carers to trigger stage 1 for optimum use of resources. There may be reduced participant numbers in stages 2 and 3, for example due to ill health, but this can be offset by reducing the technical instructor resource in these later stages. We believe these findings demonstrate that carer communication training is an essential consideration in aphasia intervention and should be provided as a matter of routine to those who require it. Mr and Mrs Williams agree. After the Communication Training Programme, Mrs Williams encouraged her husband to use drawing, gesture, writing and a communication book. She also used these strategies herself and Mr Williams successfully used them with her support. He was also able to gesture and draw spontaneously on occasion. He still relied on Mrs Williams to lead the conversation but his participation in it was greater. Mr and Mrs Williams goals on discharge included attending the CSS group, planning a journey on a bus to visit nearby towns, and working towards returning to drive. Both indicated that they felt very positive about the future: This is the start of SLTP the rest of our lives now.
References Barber, K. (2006) Pilot study to investigate the benefits of providing tailored communication training in a group format to family members/partners of clients who present with aphasia. Unpublished. Barber, K. (2007) Group communication, RCSLT Bulletin 660, pp.16-17. Cunningham, R. & Ward, D. (2003) Evaluation of a training programme to facilitate conversation Stage 1 Carer group Potential no. of clients Staff resource 6 1 SLT 1 TI 1 Volunteer Client group 6 1 TI 1 Volunteer 6 2 TIs 2 Volunteers SLT supervision Stage 2 Joint group 6 2 TIs 2 Volunteers SLT supervision Stage 3

Figure 2 Staff resource between people with aphasia and their partners, Aphasiology 17 (8), pp.687-707. Hoen, B., Thelander, M. & Worsley, J. (1997) Improvement in psychological well-being of people with aphasia and their families: Evaluation of a community-based programme, Aphasiology 11(7), pp.681-691. Kagan, A., Winckel, J. & Shumway, E. (1996a) Pictographic communication resources. North York, Canada: Pat Arato Aphasia Centre. Kagan, A., Winckel, J. & Shumway, E. (1996b) Supported conversation for aphasic adults: Enhancing communicative access (Video). North York, Canada: Pat Arato Aphasia Centre. Kagan, A., Black, S.E., Duchan, J.F., SimmonsMackie, N. & Square, P. (2001) Training volunteers as conversation partners using Supported Conversation for Adults with Aphasia (SCA): A Controlled Trial, Journal of Speech, Language and Hearing Research 44, pp.624-638. Lock, S., Wilkinson, R. & Bryan, K. (2001) Supporting Partners of People with Aphasia in Relationships & Conversation (SPPARC). Milton Keynes: Speechmark. Rice, B., Paull, A. & Muller, D.J. (1987) An evaluation of a social support group for spouses of aphasic partners, Aphasiology 1(3), pp.247-256. Simmons, N.N., Kearns, K.P. & Potechin, G. (1987) Treatment of Aphasia Through Family Member Training, in Brookshire, R. (ed.) Clinical Aphasiology Conference Proceedings. Minneapolis, MI:BRK, pp.106-115. Resource The Communication Support Service is run by the Stroke Association in a number of local areas across the UK, see

Kit Clewley (nee Barber) is a specialist speech and language therapist at Maelor Hospital in Wrexham, email

How can you apply this article to your own practice? Let us know via Speech & Language Therapy in Practices Critical Friends at www.


The Frenchay Screening Tool for AAC is now available as a first step in assessment (80). php?cPath=42&products_id=228 AuKids magazine for parents of children with autism is co-edited by speech and language therapist Tori Houghton. 10 for 4 quarterly issues, Interactive version of Avril Websters Going to the Hairdresser now free online. A website aimed at getting the public involved in clinical research. Scope has introduced Meeting Point, a closed online forum for young disabled people living in England and Wales. young-people/meeting-point

Brook has revised its sex education and personal development modular resource for young people with learning disabilities. Living Your Life, 120, Stuttering Stan Takes a Stand is now available as a free flash-animated storybook. books/stuttering_stan/stuttering_stan.html UEA (University of East Anglia) has updated its undergraduate degree course profile. The seven documents that make up the Language Support Model for Teachers resource are freely accessible at w w speechlanguagetherapy/resources/lsm/ Reading for Life is the National Literacy Trusts social marketing campaign to reach people who are least likely to read.

The Contact a Family Directory summarisies 430 disabilities and health conditions and details UK support groups. Available online and in print, tel. 020 7608 8700. Messages from the National Literacy Trusts Face to Face project might help therapists to promote good communication between parents and babies. baby/policy_research/2612 An online dungarees firm says a major part of its client base is people with disabilities. The Meningitis Trust has posters and leaflets to support its Dont wait for a rash campaign. Downloadable publications from the disability campaigning network RADAR by and for people living with injury, ill health or disability cover work, money and IT.



boundary issues (4)

Where work and home life meet

Joe Reynolds considers the following scenario:
You have just completed a house purchase. When you next visit the property, you recognise the family that has moved in to the house next door. They have a child with severe learning difficulties, and have made several complaints to the NHS body you work for about the speech and language therapy service you provide to the child...
It hardly needs saying that buying a house and moving is a major life-event, in personal and emotional terms as well as practically and financially. Similarly, making a complaint - or being complained about - can cause great anxiety for families and professionals, regardless of whether the complaint is justified. This scenario brings together two stressful situations, where emotional responses can make it more difficult to maintain boundaries. The specific scenario where a new neighbour turns out to be a parent who has complained about our clinical work may be rare. It is however an extreme version of a much more common experience. Though they may not often be immediate neighbours, how often do we and a service user and their family live in the same community, and come into contact in non-work settings? We could be members of the same church, golf club, political party or amateur dramatics society. We could both be parents of children attending the same school or sports club. Or we could be colleagues in the NHS or other services. In any of these cases, the challenge is to maintain boundaries through clarity about roles, while not damaging the therapeutic relationship. Professionals tend to be very clear about this; away from work we are offduty, and not acting in a speech and language therapy role. Carers and service users often understand this in a social context, but some find it difficult to avoid asking for speech and language therapy advice or clarification. It is essential to have ways to avoid getting drawn into providing clinical advice in social and off-duty situations. At the same time, we remain bound by professional obligations to preserve confidentiality and to maintain high standards of personal conduct (HPC, 2008). We are therefore never completely out of role. Relations with neighbours may be cordial, but they are not necessarily friends in the deeper sense. There are practical benefits to good neighbourly relations, to do with security, local environmental problems or community networks, for example. But these can be quite consistent with clear boundaries, and most people are able to negotiate how far they want to become closer friends with their neighbours. Boundaries can however become much more complicated where there is a grievance or dispute. The substance of a complaint about NHS care can vary widely, and not all complaints are critical of clinicians or of service delivery. Many are about waiting lists, waiting times, why so 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 new series we think through the sort of everyday events which although they receive much less attention also need to be on our ethical radar screen. little therapy time is provided to a particular facility, or dissatisfaction with the model of service provision. These matters are ultimately about commissioning decisions at a strategic level, and are not always amenable to simple resolution by the therapist or their manager. Some complainants are also struggling with their own grief and bereavement over the disability of their family member, which can colour the way they voice their dissatisfaction. These instances need not have any implications for continuing positive relations between family and therapist, though it is important to recognise if the complaint becomes an obstacle to progress in the therapeutic partnership. In a smaller number of cases, the complaint is about the speech and language therapists assessment or management. Here there is some scope for the complaint to be handled informally by local action. Many such instances are settled through further discussion, review meetings with other partners, or through a clinical second opinion. Service managers have to provide the right support to staff affected by complaints, as well as ensuring that lessons are learnt if necessary, and that complainants receive honest answers. The role of the Chief Executive in replying to formal complaints adds a further pressure on the people involved. These can be difficult processes for therapists. It is vital to take a professional approach, and to avoid personalising the disagreement. If we take the matter personally, it becomes difficult to return to the therapeutic partnership later on. Particular problems arise where families or service users themselves have strayed into personal comment in their complaints or in local discussions. Occasionally there is no prospect of restoring trust in the relationship, and the only option is to arrange for care to be transferred to another therapist. In any case, it is critical that therapists in this situation receive effective support from their manager and from the other staff dealing with the complaint. In the scenario we started with, there could be many reasons why the family have pursued their dispute. Relations between the therapist and the family may be quite open and positive, in which case the additional status as new neighbours should not be problematic. A comprehensive complaints procedure should include whatever mediation and conciliation is needed to allow therapy to continue in the future. Ideally, the complaint can be put behind us once it is resolved. Conversely, it may be difficult and complicated to establish the new relationship as neighbours, and for everyone to understand that this is distinct from the relationship in the clinical setting. It may be necessary to discuss the difference quite explicitly with the parents. They also need to understand that our obligation to maintain confidentiality extends to off-duty hours, and that we would never comment on or discuss anything about our service users and internal NHS matters such as complaints. This applies even when other neighbours and our own family may be aware that we are providing a clinical service to the child in question. It would be regrettable if the previous professional contacts were to prevent the establishment of neighbourly relations, especially when these need not go beyond day-to-day practical matters. Where work and home life meet in a particularly complex and distressing way, it is essential that our line manager is aware of the unusual pressures on professional boundaries. Non-managerial supervision from a suitably qualified and experienced person will also be useful to make it easier to see the situation as dispassionately as possible, and to continue SLTP effective care for the child. Dr Joe Reynolds is a retired member of the Royal College of Speech & Language Therapists, email
Reference Health Professions Council (2008) Standards of conduct, performance and ethics. Available at: http:// copyofSCPEJuly2008.pdf (Accessed: 26 January 2011).



how i

How I get signing into practice (1):

Its Signsational!
After completing training courses in signing, parents, carers and staff may lack the confidence and skills to actually use the signs they have learnt. The speech and language therapy team for people with learning disabilities at Yourhealthcare describe the Signsational way they found to address this.









s a team of speech and language therapists working with adults with learning disabilities we constantly promote the use of signs in the everyday environment to support communication. Despite a rolling programme of training encouraging people to use sign in the home environment, we were aware that many parents and staff were coming away from signing courses having learnt the signs but not the skills and confidence to put them into use. We wanted to provide an effective way of overcoming the barriers and giving staff, carers and family members the confidence to use signing as part of their everyday communication with our service users. Two of us had experience of working on intensive Kith and Kids 2:1 holiday projects with children and adults with learning disabilities, and were impressed by the positive outcomes and success. This led to the idea of designing an intensive signing course that included both service users and their carers. We chose a fun title that we hoped would capture the spirit of the course. Signsational was a light-hearted and catchy name that we thought would appeal to all participants. We chose a pleasant community facility in the high street near to local amenities and shops as the venue. We aimed to create an intensive signing / total communication focused environment that would illustrate to parents and carers how positively people respond to a signing environment, how successful and effective it can be, and how easily it can be implemented in homes and day centres. It was important for us to demonstrate that signing is not just about giving instructions, but about everyday

chatting and interaction. We wanted to develop peoples enthusiasm, skills and confidence to use signs in a natural way, and move people with basic signing skills on to being more confident and fluid. We adopted a Total Communication approach, using photographs, and signing throughout. We circulated information to promote Signsational, and invited referrals. We considered anyone who used signing to communicate, regardless of age or cognitive ability. Nine service users attended, each with a member of their family or care staff. The participants ranged from a man in his mid 50s to the youngest, a teenager. The most important element for acceptance was commitment from staff / carers / family; we asked them to sign a contract to attend for the whole week. The course was planned sufficiently in advance so that at least four of the six speech and language therapists and both our assistants could attend and facilitate. We also invited students from City and UCL to join us as part of their placements, so it was a big, bubbly group! Other health professionals were also welcome to observe. Planning the activities was the most time intensive aspect of the project. We used a wide range of activities previously developed in other groups to facilitate skills such as turn taking, anticipation, listening and participation. The speech and language therapy assistants gathered together and made resources including costumes and props for the story activities, materials for the craft sessions, refreshments, music and sound effects compilation cds. We prepared documentation such as an accessible information booklet for service users, a contract for both carers and service

users, booklets of signs and an accessible story book. A speech and language therapist or assistant or students also made visits to the homes before and after the group to conduct pre- and post-group measures. The four days of the Signsational course involved practical and fun activities with an intensive approach to the use of signs (figure 1). We used music to mark activities and provide structure. Every day the same piece of music was played at the beginning of an activity, for example Everything stops for tea for the tea break and Aquarium from Carnival of the animals for the relaxation activity. We used music throughout to provide mood and atmosphere and to engage the participants emotionally. We found music provided an opportunity for people to express themselves and interact in a poignant way. There were many special moments where groups members spontaneously expressed themselves through a performance of dance and movement. This has given us food for thought about the link between communication, music and movement. People began bringing in their favourite music to play in break and lunch times. It created more opportunities and established some common ground on which to form bonds and friendships. In terms of outcomes, the speech and language therapy team observed throughout the Signsational week an increase in both quantity and quality of signs (accuracy and appropriateness) from the service users and carers. There was also an increase in the level of interaction and communication between the service users, for example, initiating communication, anticipation, turn taking and participation in the activities. This is backed



how i
Figure 1 Structure of the week DAY 1 An afternoon signing workshop for the people accompanying the service users. We taught them a core vocabulary of signs in a functional and conversational way and covered the signs for the story telling activity. DAYS 2 - 5 10.00 Good morning activity. This provided an opportunity for sharing news and promoting conversational skills. 10.10-11.00 Morning signing activities: structured turn taking games and activities focusing on specific topics for signs. Tea Break opportunities to make choices, take responsibility for offering drinks and to sign in an informal, conversational way. 11.3012.30 Community / practical activity. We recognised that for some of the carers using sign out and about was difficult, so this involved everyone going out into the community to shop for items to use in the following practical session. The practical sessions always linked in to the afternoons story telling. An example was to buy decorations for party invitations, make the invitation to invite another person from the group and then post the letter for the Friday afternoon party. Lunch break more opportunities to sign in an informal, conversational way and use signing in the community. People were encouraged to go out and use the local cafs and shops. 13.3014.50 Afternoon story telling activity: A story was told over the four days Alice in Wonderland. This activity was based on Nicola Groves work where a story is told using a series of games and activities using a multi-sensory approach. 14.50-15.00 Relaxing time using a parachute, specific relaxing music and glowing balloons. Key for figures 2-4: pre-Signsational post-Signsational

Figure 2 Number of signs observed 20 15 10 5 0 A B C D Service user E

No. of signs Level of confidence

Figure 3 Confidence using signs at home

up by the change in pre- and post- measures for clients use of sign (some are illustrated in figure 2) and carers reported confidence signing at home and out and about following their participation in Signsational (some shown in figure 3). Feedback from staff also implies that service users and staff are signing more and can be more easily encouraged to use signs when required: I didnt know much about signing before the course but I learned a lot and feel very confident about signing now. Its good shes learnt signs otherwise she wouldnt be able to communicate. Seeing other proficient signers makes me realise how useful signing is and makes me want to learn it more...consistent signers around her will help her learn. [pre-Signsational] Although Id done the 2 day course I still lacked confidence. [postSignsational] Fabulous system to learn signs. Im more confident in working out signs on bigger words. Our service users are able to communicate better and are able to let us know what their needs are by signing. We have since run two further Signsational courses for service users and their carers in November 2009 and May 2010 and held Christmas parties in both 2009 and 2010 to get together again and maintain the friendships that formed. Both courses have been as successful as the first, and had 100 per cent attendance. Where there is a need we will continue to support service users and their carers for as long as possible to maintain a total communication, signing environment. If you are considering this kind of approach, it is worth noting that we have learned not to underestimate the amount of preparation time required each time to put on the week. This is especially from the speech and language therapy assistants, who are fantastic at sourcing and making all the resources for the story groups. We clear their caseload SLTP ahead of time so they can do it all!

This article was written by the speech and language therapy team for people with learning disabilities at Yourhealthcare. For further information on the morning activities or copies of the Signsational accessible contract and information booklet and the general information pack for carers, contact Deborah Green (email, Wendy Reed (email wendy. or Roz Angier (email Acknowledgement The PLD SLT team at Your healthcare would particularly like to thank Nicky Chibah speech and language therapy assistant extraordinaire for her outstanding contribution to the Signsational project. Recommended reading Chadwick, D. and Joliffe, J. (2008) A pilot investigation into the efficacy of a signing training strategy for staff working with adults with intellectual disabilities, British Journal of Learning Disabilities 37(1), pp.34-42. Graves, J. (2000) Vocabulary needs in augmentative and alternative communication: a sample of conversational topics between staff providing services to adults with learning difficulties and their service users, British Journal of Learning Disabilities 28(3), pp.113-119. Grove, N. & Park, K. (1996) Odyssey Now. London. Jessica Kingsley Publishers. OCallaghan, P. (2008) Rise and sign, Speech & Language Therapy in Practice Summer, pp.11-13. Powell, G. (1999) Current research findings to support the use of signs with adults and children who have intellectual and communication difficulties. Available at: http:// (Accessed: 11 January 2011). Volpato, D., Orton, D. & Blackburn, D. (1986) Making Progress with Makaton, Nursing Times 30 April, pp.33-35. Available at: http:// (Accessed: 11 January 2011). Resource

10 8 6 4 2 0 F G H Carers I

Figure 4 Confidence using signs out and about Level of confidence 10 8 6 4 2 0 F G H Carers I

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Learning by teaching
As a Regional Makaton Tutor, Non Thwaite has a special interest in the transfer of training in the use of sign to everyday settings. Having discovered the potential of giving pupils the power to teach Makaton to staff, Non carried out a promising Makaton peer tutor pilot project with the support of an Action Learning Set of other therapists, a clinical psychologist and a university lecturer.

How I get signing into practice (2):

ven though Makaton workshops are met with enthusiasm and receive great feedback, skills learnt arent always transferred to and used in the everyday settings of participants as much as they could be. Since qualifying as a Regional Makaton Tutor Ive been exploring ways of addressing this, particularly at Ysgol Pendalar, a special needs school in Caernarfon, North Wales, because we are aiming for a Centre of Excellence Award from the Makaton Charity. To obtain then keep - the award, a high standard of signing and symbol use by all staff has to be achieved. This would be a strong incentive for the school to maintain excellent standards of Makaton use, thereby having a positive impact on the communication environment for the pupils. I sent a questionnaire to school staff at Ysgol Pendalar to find out what helped and hindered them to use Makaton. One trend was that staff felt less confident signing in the presence of professionals such as me, and more confident when they were with children who signed. This set me thinking - why not reverse things and allow the children to adopt the role of a Makaton tutor? I set up a mini project in 2008 to introduce signing to fringe members of staff. I asked for volunteers amongst the older pupils to teach some basic Makaton signs to the taxi drivers and escorts whilst they waited for the school doors to open at the end of the day. I didnt formally evaluate this, but could see the pupils and taxi staff enjoyed themselves. It seemed an effective way of introducing signing, and less intimidating than if I had done it myself. I had also been inspired by Tamsin Crothers of 1Voice when she spoke about the importance of AAC users having role models (Claxton & Crothers, 2007). I started thinking that, if some older pupils acted as peer tutors to younger pupils, they could possibly teach and consolidate new skills, act as positive role models, and maybe even encourage staff to sign more. Topping (2005) states the benefits of peer tutoring are well documented and reciprocal; this effect is described as learning by teaching.

Cover photo of (l-r) Ashlee, Non and Jieu by Steve Ford,

Although there is research supporting the use of peer tutoring in mainstream and special needs schools, I havent been able to find any that specifically looks at AAC. I discussed my ideas with my line manager who facilitated a meeting with Steve Noone, Clinical Psychologist. Following this an Action Learning Set was established whose membership consisted of speech and language therapists from the Learning Disability Team, Steve Noone and Dr Carl Hughes, Co-Director of the Applied Behaviour

Analysis course at Bangor University. This group provided me with support and encouragement to develop my ideas into a pilot project. If it hadnt been for the group I probably would have set up the project quickly without much thought about formalising data collection and evaluation. Too often I think that we as therapists have great ideas that, with some reins, thinking and planning, could be developed into valuable evaluation projects. The group helped me think in a




Figure 1 Number of times Jieu signed spontaneously while looking through the book Pre intervention 2 Immediately post intervention 22 1 month post intervention 18 2 months post intervention 20

more systematic way and took the mystery out of research. I realised it doesnt have to be complex - in fact, they encouraged me to slim things down. I learnt that if the project was to throw out more questions than it answered, this would only be a good thing. I remember being surprised when some completed questionnaires were labelled as really good data. On discussion, I realised what a fortunate position we are in as practising clinicians. We have a rich source of data at our fingertips and, because of the relationship we have with school staff, its not a problem to obtain it.

days. The sessions took place on beanbags in the reading room of Jieus classroom, a quiet and familiar place. The sessions were videotaped by the classroom assistant and lasted about ten minutes. Jieu sat on my knee and, although I didnt take an active part in the storytelling, I prompted Ashlee when she made a very occasional mistake and praised and encouraged both Ashlee and Jieu. I looked at the effect of the intervention on Jieu in several ways: Baseline Data 1. Multiple Probe testing a few weeks before intervention and immediately before intervention: Asking Jieu to imitate my signs (can you do this?) Asking Jieu to sign to a verbal command (can you sign biscuit?) Testing his comprehension of the signs (Wheres the biscuit?) Testing his expressive signing in response to a visual prompt (show him a picture of a biscuit / actual biscuit and ask Whats this?) 2. I asked Jieus teacher to keep data regarding the signs he used (spontaneous and imitated) before intervention 3. I looked at the story book with Jieu to see if / what he would spontaneously sign before the intervention Data collection during intervention 1. Video of each of the five sessions 2. Jieus teacher to keep data on the signs used throughout the day during the intervention period. Data collection after intervention 1. Multiple Probe Testing repeated 2. Teacher to continue to keep data 3. Looked at the story with Jieu to see if / what he spontaneously signed immediately after the last session, and then a few months post intervention. Pre intervention, Jieu only signed twice whilst looking at the story. Post intervention, Jieu signed up to 22 times whilst looking at the book, and this effect seemed to be maintained over time (figure 1). According to Jieus teacher he also generalised some of the signs (such as sand) to the classroom setting. Of the ten signs used in the story, Jieu signed seven of them, with sand and biscuit being signed the most. Interestingly, in one of the pre intervention assessments, Jieu was very interested in obtaining the sand and biscuit. This seems to


As I enjoy creative writing I decided to write a short story that the peer tutor could read and sign to the younger pupil. I devised a simple story about a mischievous teddy and dolly. The language was at a one to three key word level. I selected functional vocabulary that would be useful in the everyday life of the classroom, including teddy, dolly, sand, biscuit, yes, no, more, eat, look and bye. The left page included the script of the story along with matching symbols on Velcro strips. The right hand page had a cartoon picture to match what was being said and signed. Teachers from the primary and secondary areas identified Ashlee and Jieu as suitable candidates. Ashlee attends the Older Unit where she receives her education as well as work experience opportunities. She is a sociable young woman who has well developed expressive language, excellent memory, well developed literacy skills and a good level of comprehension of spoken language. Jieu is in the youngest class of the school. He expresses himself mostly with signs, symbols, some vocalisations / words and body language. He enjoys looking at books, making jigsaws and singing, especially the Bob the Builder theme. Both Ashlee and Jieus parents gave written consent for their children to be involved. The first part of the project involved teaching the story to Ashlee, the peer tutor, until she was fluent at reading and signing the story. We met three times and followed a Model, Teach, Test style of teaching. I modelled the story (Model) then we read and signed through the story together (Teach) and then Ashlee read and signed the story by herself (Test). This gave a definite, predictable and safe shape to our sessions and was an effective way for her to learn. Once Ashlee was fluent, we arranged for her to read the story to Jieu once a day over five

confirm that signs which represent attractive or motivating items are often picked up and used quicker. No significant effects were seen on the multiple probe assessment when post and pre intervention data was compared. However, whilst watching the video clips, I observed many positive changes. It became apparent that the quality and accuracy of Jieus signs for look and biscuit improved as the sessions went on. This is a very positive effect as it will make Jieus communication easier for others to understand. Jieu communicated in a multi modal way during the session, sometimes pointing to symbols then signing them, and quite often vocalising or saying close approximations to words as he signed. Questionnaires from teaching staff completed seven months post intervention were positive. Jieus teacher felt that he had benefited by learning new signs which he still uses, thus suggesting that Jieu had generalised what he had learnt during the storytelling sessions to other environments. I asked staff if they would do anything different in future as a result of the project. Responses included a suggestion to leave a copy of the story book in class so that Jieu could become a peer tutor himself to other members of his class, and a new story book to develop the project further. One teacher responded that he was going to make more of an effort to use Makaton to aid pupils comprehension and communication skills. Another member of staff said she had learnt that repetition of a signed story was an effective way of teaching new signs. Effects on self-esteem can be hard to quantify, but observations and comments suggest that taking part in the project had a positive effect on the peer tutors self-esteem and confidence. Both teachers reported that Ashlees self confidence had grown as a result of being a peer tutor. On the first day, Ashlee was noticeably shy, walking down the corridor with tense shoulders. By day five, she skipped. Ashlee said that reading the story to Jieu made her feel good and happy and that her mum was proud of her. Both Jieu and Ashlee seemed to enjoy the sessions and the staff questionnaires confirmed that they thought this too. Both received a star of the week badge in assembly for their involvement in the project. Video clips were shown during school assembly to share their success with the rest of the school. The project had a nice ripple effect. More than one teacher said to Ashlee that they were impressed with and proud of her. One day, on the way back to class after a session, a




teacher from another class asked Ashlee what she had been up to - and Ashlee walked in and spontaneously read and signed the story to that whole class. The teacher was amazed that Ashlee knew all she did, and actually learnt a few signs from watching her. Whilst teaching the story to Ashlee we both looked back at the video of our sessions. This worked as a powerful reinforcer for Ashlee as I was able to point out the positive bits where she did really well. Jieu also taught some signs to Ashlee, for example from Old MacDonald, so the learning was two-way. I hypothesised that Jieu would learn new signs from Ashlee but I hadnt considered that he would take any notice of the sentence strips and symbols included in the story book as a prompt and reading support for Ashlee. Jieu was really interested in these, tearing off the Velcroed sentence strips, and often pointing to symbols above words before signing them. This shows the potential positive effect on literacy skills. I think he was interested in being able to physically handle the sentence strips by tearing them off. e. encouraging school staff to repeat similar ideas and to make more of an effort to use Makaton signing f. developing ideas within the school regarding integrating peer tutoring into the curriculum g. gathering evidence to help Ysgol Pendalar gain a Centre of Excellence award h. giving me huge job satisfaction! So far three students from the Applied Behaviour Analysis (ABA) Masters at Bangor University have used my project as a basis for their research thesis. Ive been involved with the planning and procedure aspects of their research, giving advice on clinical aspects such as using Talking Mats as a measure of self-esteem with the peer tutors, and how to pitch language. One aspect I advised on was involving the peer tutors classroom assistants rather than the ABA students in teaching the story book to the peer tutors. I wanted school Acknowledgements Id like to thank the many people whove been involved in this project: Gwenan Roberts and the learning disabilities speech and language therapy team for their support as well as members of the Action Learning Set including Steve Noone and Carl Hughes; Pete Jones who drew the gorgeous cartoons to go with the story; Val Jones, speech and language therapy assistant, for all the laminating and Velcro work; Wendi Evans (Assistant Head, Makaton Co-ordinator, Local Makaton Tutor and Jieus teacher); Clare (Jieus classroom assistant and brilliant camera woman during the project); Geraint Roberts (Ashlees classroom teacher) and Ieuan Roberts (Headmaster) for all their support, generous time and for allowing me the opportunity to do the project at Ysgol Pendalar. Id also like to thank Ashlee and Jieus parents for consenting to their involvement. My biggest thanks go to Ashlee and Jieu, who were brilliant, taught me a lot, and whose company I enjoyed very much. References Claxton, K. & Crothers, T. (2007) Role Models: Who Needs em?, Communication Matters 21(1), pp. 2-4. Available at: http://www. (Accessed: 18 January 2011). Hooper, H. & Walker, M. (2002) Makaton peer tutoring evaluation: 10 years on, British Journal of Learning Disabilities 30(1), pp.38-42(5). Topping, K.J. (2005) Trends in Peer Learning, Educational Psychology, 25(6), pp.631-645. Resources ABA Masters, Bangor - psychology/postgraduate/masters/aba.php Action Learning Sets see www. ASDAN - Makaton - 1Voice - Talking Mats -

Impact on behaviour

The videos captured a clear link between language levels / visuals and behaviour. When I tested Jieu on his ability to sign to verbal command can you sign biscuit? he withdrew and became agitated. He was much more involved when the tests were visually supported (with signs and or symbols). I felt uncomfortable using verbal commands alone to communicate with Jieu as it wasnt fair on him, therefore discontinued this aspect of the multiple probe assessment. This type of video clip would be useful during training as an example to show that how we communicate has an impact on someones level of comprehension and, consequently, their behaviour. I also sent out a brief questionnaire to Jieu and Ashlees parents asking them for feedback. Jieus parents wrote, The project did help Jieu a lot to do Makaton signs. Hes been using them at home. Hes so brilliant at it. Well done and thank you very much for your help. Ashlees parents wrote, Ashlee really enjoyed the project and enjoyed the responsibility - it made her feel really grown up! The teacher of the secondary age pupils is considering including this peer tutoring work as part of the ASDAN accreditation scheme in the future. The peer tutoring project had many positive effects including a. developing the frequency and accuracy of the tutees ability to sign whilst looking at a story book, with anecdotal evidence of generalisation to everyday situations b. providing the tutee with a role model who uses Makaton signing c. an increase in the peer tutors self-esteem and confidence d. an opportunity to show Makaton in action and its benefits to the whole school

I wanted school staff to be empowered to run similar sessions independently in the future and also to make sure that the whole school was an integral part of the research
staff to be empowered to run similar sessions independently in the future and also to make sure that the whole school was an integral part of the research. Research has shown that, where peer tutoring schemes using Makaton have been set up, they were only maintained in establishments where a facilitator remained (Hooper & Walker, 2002). I therefore felt it was imperative to have school staff as facilitators. The project has been expanded and includes a number of peer tutors and tutees as well as a control group. Initial results appear positive and the students are writing up their theses. From chatting to some of the peer tutors they seem very proud of the work theyve done and are keen to do more. A classroom assistant asked me when the next story book would be coming out, so its good to know that this is an approach that generates enthusiasm amongst both pupils and staff. I would encourage therapists to liaise and set up links with their local university. There is much to be learnt and - similar to peer tutoring - its not a one sided relationship as, during meetings, it felt as though the learning SLTP occurring was reciprocal. Non Thwaite is a Highly Specialist Speech and Language Therapist with Betsi Cadwaladr University Health Board, and a Regional Makaton Tutor, email

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2-3 April 2011 NAPLIC Conference in association with The Communication Trust Championing Better Communication: Theory, Practice and Innovation Warwick University Keynotes including: Jean Gross, Julie Dockrell, James Law, Sue Roulstone Naidex Independent living for children and adults National 5-7 April, Birmingham Scotland 14-15 September South 19-20 October 8-9 April 2011 TES Education North Education, early years and special needs show Manchester Communication Matters roadshows 2011 Shrewsbury 11 May, Newton Abbott, 17 May, Horsham 27 May, Carlisle 7 June, Belfast 21 June Free but places must be reserved. 25-26 May 2011 Primary Care Birmingham NEC Free to practising speech and language therapists, includes one day dedicated to adults and one to children with speech, language and communication needs. 13-14 June 2011 Child Language Seminar Newcastle Keynote speakers: Maggie Snowling, James Law, Sheena Reilly, Elizabeth Pena. 15-17 June 2011 Lost for Words: Lost for Life? City University, London Speech, language and communication needs in older children and young people 21-22 June 2011 Autism Cymru 4th international conference Cardiff Speakers include Temple Grandin, Brenda Smith Myles, Sally J. Rogers and Tony Charman.

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Back issues and exclusive extras. For a reminder of your user name and password, email New! All four 2009 issues now available as pdfs New! Karen Bamford & Rachael Kasch (p.4) offer a process map for change of accommodation, and a flowchart to help you establish an individuals understanding around this. New! Print off the systematic review framework document by Jennifer Reid (p.18) from .

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Communicating ethics (Winter 10, E4-E6) You have been asked to provide a second opinion for the parents of a five year old boy who has profound physical and cognitive disabilities... Jois Stansfield and Jane Handley explore how an ethical framework can help speech and language therapists and students negotiate a path to what feels like the right outcome for a given situation at a given time.

Reprinted articles (

Dean, E. (2009) Adapting to complexity, Speech & Language Therapy in Practice Summer, pp.4-6. Foggit, E. (2010) What are you like?, Speech & Language Therapy in Practice Summer, pp.8-10.

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Claire Butler is a Clinical Lead SPEECH AND LANGUAGE THERAPIST in adult dysphagia, based at East Surrey Hospital in Redhill. She is also A NATIONAL ADVISeR IN ADULT DYSPHAGIA FOR THE ROYAL COLLEGE OF sPEECH & LANGUAGE THERAPISTS (rcslt). WHILE THESE ARE CLAIRES personal thoughts on what SHE needS to be a good RCSLT Adviser, she says The role - AND THEREFORE THE MOST USEFUL RESOURCES - may be quite different from one SPEECH AND LANGUAGE THERAPIST TO ANOTHER. 1. THE ADVISER NETWORK Questions posed to RCSLT advisers are often sent out to all the advisers for the relevant area. This means if I dont know the answer to a query, or have nothing to add to the discussion, someone else invariably will. The adviser lead in RCSLT also monitors all responses (which must be copied in to her) so that no query gets forgotten. This is an extra backup to ensure that every individual remembers to respond to everything they wish to, and that no person posing a query is left without an answer. The advisers responses are often sent only to the person who posed the question, but I find it much more useful when responses are sent to all. If I havent given a reply myself, I often learn a lot from the response of others and, where I have been able to help, others may have a different viewpoint, which again I can learn from. 2. EMAIL For me, all adviser work is carried out via email. When I first signed up, I chose not to provide phone or postal contact details, mainly because I carry out the adviser work in my own time from home. As a result, email is the key part of my toolkit. But it isnt just a case of wanting to keep my phone number private. Email has revolutionised the way we communicate, enabling therapists from anywhere in the UK to send a query which can be in the inbox of specialists around the country within minutes. This allows for a more considered response while maintaining a fast turnaround, without the pressure to answer instantly which is inherent in a phone call. If one or other party wishes to share items such as documentation, papers or references, these can be sent immediately rather than waiting for the post. Finally, the use of email allows for a record of the conversation to be kept for future reference and as an aide memoire. 3. FLEXIBILITY This particular attribute is important as much in the person acting as an adviser as in the network itself. Due to the flexibility of RCSLT, I have been able to continue as an adviser during two lots of maternity leave, and have fitted the role around a fluctuating caseload when working. I am able to do as much or as little as I wish to fit the time I have available, and there is no pressure to do more than I feel comfortable with. The flexibility of the role allows me to tailor it to my own circumstances, choosing between the different aspects of the remit. This can include replying to individual queries, sitting on working parties, responding to the media or commenting on future publications. I have been able to elect not to take part in certain activities which would be 5. ORGANISATION SYSTEM Being an RCSLT Adviser can be very hit and miss. At times there will be weeks on end with no contact from RCSLT, but at others the queries and requests to participate come in thick and fast. Its at these busier times in particular that a system for organising the requests proves invaluable. My own preference is to make use of my Gmail account. Ive set it up to incorporate a series of labels. These indicate whether items require action, are waiting for someone else or are being kept purely for reference (both short and long-term). There is also a specific label indicating those items which relate to my adviser role. With Gmail allowing me to add multiple labels to each email, I can easily see when there are items which require my attention, while keeping my inbox clear for new emails arriving. In addition, with Gmail automatically storing emails back and forth on the same subject as a conversation, I have an easy to follow reference source for each query I deal with. At regular intervals, each adviser is asked to provide a breakdown of their recent adviser activity and the Gmail system with its labelled emails allows me to pick out quickly the relevant items for this report. 6. COLLEAGUES It is just as important as an adviser to know when you cant be of help as to know when you can, and it would be unrealistic to expect to answer every query. However, over the years, I have built up a fantastic network of colleagues in many specialisms. When Im unable to answer a query, its often a case of but I know someone who can. Being an RCSLT adviser isnt for everyone, and many therapists with a great degree of specialist knowledge and experience choose not to or are not able to take on that commitment. However, the majority of my contacts in that category are happy for me to put them in touch with someone who has posted a query if I feel they can be of more help than I can. In this way, my colleague network becomes a fantastic resource, allowing me to introduce individuals who can assist one another but who may otherwise have never got in touch. I am also lucky enough to be a member of an active local dysphagia support group. This helps to keep me focused on recent developments in the world of dysphagia, and challenges my thinking in areas which I may otherwise take for granted. Members of RCSLT can find out more about becoming an adviser at members/advisers/intro.

difficult to achieve, such as those requiring regular travel to meetings. In terms of my own flexibility, I need to be able to respond well to the variations in workload of the adviser role. Ive also learnt that I have a great resource of personal knowledge and experience, much of which is transferable. This enables me to give a useful response to some queries that lie outside my immediate area of work. 4. RESEARCH TOOLS Even the best adviser cannot have all information about a given subject at their fingertips. Although advisers need a strong basis of knowledge and experience in their chosen area, they also need to know how to research areas they may be less familiar with. For me, research ranges from a simple Google search (usually when I have a strong idea of the answer already but want to check some facts) to a full scan of the databases. The Dysphagia Resource Center (http:// is a searchable American site with a wealth of information including discussion boards (where users support one another with clinical issues), articles about particular disorders or technical terminology, and links to useful websites. Its not the prettiest of websites and its important to remember that the information represents the personal view of the individual who has posted it, but there are some pearls of wisdom to be found. Databases, my favourite being MEDLINE, allow for detailed searching of everything thats been published about a particular topic. Once you learn to search a database properly (something most hospital libraries should be able to teach you if you dont already know), you can find everything from the oldest published works to cutting edge research in your chosen subject.