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ISSN 1368-1205

Spring 2010

Goal setting The EKOS solution Talking Matters Mental state assessment Listen with Lucy Making the most of early years Every Child a Talker Ideas and resources Cognitive therapy in dementia What does this house believe? Good journey? Life after laryngectomy

The case for speech and language therapy

Adducator spasmodic dysphonia:

PLUS...heres one I made top resources... in brief ...reader offers...and introducing our new ethics series Cultivating curiosity

Spring 2010 (publication date 28 February 2010) ISSN 1368-2105

Sue Addlestone with Matt. Picture by Karen Wright, 12 COVER STORY: ADDUCTOR SPASMODIC DYSPHONIA: A CASE FOR SPEECH AND LANGUAGE THERAPY Had I based my therapy purely on what Matt told me at initial interviews, I would not have addressed the emotional side of Matts adductor spasmodic dysphonia. It was only when I began combining direct voice therapy with psychological therapy that a successful outcome was achieved. Sue Addlestone presents a robust response to Focht and Leslies conclusion in our Spring 09 issue that speech and language therapists should offer Botox to clients with adductor spasmodic dysphonia. 16 DOES THIS HOUSE BELIEVE IN COGNITIVE THERAPY? ...answering a seemingly simple question was difficult because: the literature and use of terminology is so unclear; clinical practice with people with dementia varies across different countries; there is a lack of consensus about the role of speech and language therapists and the boundaries with occupational therapists, which further blurs attempts to define what we do. Vanetta John and Paula Leslie attempt to untangle the case for cognitive therapy with people with dementia. 19 BOUNDARY ISSUES You are a member of Facebook. It is obviously open to you to search for clients or their parents on this social networking site, and to look at any information they have chosen to make publicly available. But are there implications about what you do with this if, for example, it makes it clear they are unhappy with the service they are receiving? Jois Stansfield and Frances McAleer respond to the first scenario of our new ethics series. 20 REVIEWS Voice, literacy, signing, professional writing, emotional intelligence, behaviour, dysphagia, Aspergers syndrome, dementia, listening skills, early intervention, professional issues, dyspraxia, autism, speech development. 23 HOW I MAKE THE MOST OF EARLY YEARS (1) EVERYDAY TALK One of our teachers said in her feedback to us: For the first time I actually know what to look for in a childs communication and can give parents specific and accurate reports. Cynthia Pelman finds Every Child a Talker a mine of practical resources for therapists working with the universal child in collaboration with early years practitioners. (2) LISTEN WITH LUCY ...the group leader presents many of the activities we are so familiar with, aimed at teaching the children the basics of good listening, such as to look at who is talking, think about the words, be quiet, and sit still. Sharon Garforth on how training for early years practitioners is impacting on attention and listening skills in children under four. 25 READER OFFERS Win Feeding and Nutrition in Children with Neurodevelopmental Disability and Elklans EYBIC Word Pack. See also discount offers on pages 28 and 30. 30 MY TOP RESOURCES In her second article for this issue, Cynthia Pelman recommends books she uses when working with small groups of children in education settings.

Published by: Avril Nicoll, 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail:

Printing: Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT

4 GOAL SETTING Our priorities were to create aims that would both demonstrate the range of our involvement with people and allow the client to set their goals and work towards them with any member of staff involved. We didnt want to create aims for each profession. Margaret Metcalfe argues that the special features of the East Kent Outcome System (EKOS) make it an invaluable tool. 6 EDITORS CHOICE 7 HERES ONE I MADE EARLIER Alison Roberts with two low cost therapy suggestions with a dating theme Snakes and Ladders, and Plenty more fish in the sea. 8 TRANSDISCIPLINARY ASSESSMENT Gregs mother spontaneously commented on two separate occasions that she felt the Talking Mat was an easier way for her son to express his thoughts and feelings around a difficult area. Child & Adolescent Mental Health Services therapist Yvonne Macleman uses Talking Mats with a young man with Aspergers Syndrome to facilitate an accurate mental state assessment. 10 WINNING WAYS How often Ive longed to shout in a restaurant, Switch off the wallpaper music! Im trying to talk! Clifford Hughes had a laryngectomy in 2001. His personal story of rediscovering his voice is introduced by life coach Jo Middlemiss. 15 IN BRIEF Three readers get on their soapbox. Dysfluency specialist Winifred Ashmore reminds us of the powerful effect our choice of words can have on the therapy process, Sian Owens makes a plea for information to be truly accessible and Sheina Stockton defends the place of direct therapy.

Editor Avril Nicoll, Speech and Language Therapist

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Avril Nicoll 2010 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



End of life dilemmas

A multidisciplinary team of healthcare professionals, medico-legal experts and patient representatives has made recommendations to improve nutrition strategy at the end of life, concluding that nil by mouth should be a last resort, rather than the default option. The teams report, Oral feeding difficulties and dilemmas A guide to practical care, particularly towards the end of life, recognises the ongoing lack of consensus, including among doctors, about when artificial nutrition and hydration is appropriate. Its recommendations include having oral intake, modified as necessary, as the main aim. This may involve considering a risk management approach to ensure quality of life, even when a swallow is deemed to be unsafe. Tube feeding must have very clear clinical objectives and should never be based on the convenience of staff or carers or be a criterion for admission to a care institution. The report also recognises the need for sufficient staff, particularly at mealtimes, to assist people with eating and drinking and give them the time they need. It recommends that nutrition support teams should be available to work with people with oral feeding difficulties and their families. Illustrative case studies are included to help prepare healthcare professionals for engaging with patients and families to decide the best course of action. The Royal College of Physicians says, The ultimate aim of the report is to improve care by providing healthcare professionals, patients, their families and carers with practical advice that has a sound legal and ethical basis, and to prevent distressing and complicated disagreements. The report has been endorsed by the Royal College of Speech & Language Therapists, the Association of British Neurologists, British Association for Parenteral and Enteral Nutrition, British Dietetic Association, British Geriatrics Society and the Royal College of Nursing. Sarah Haynes, head of speech and language therapy at the Royal Hospital for Neurodisability, contributed to the guidelines. She commented, This report provides a really good single resource for health care staff on how to support people with oral feeding difficulties. However, 72 per cent of patients and residents at her centre are wholly or partly dependent on tube feeding. Sarah is keen to point out that this option should also be recognised as crucial to a patients care and quality of life when necessary, and every support given so that those affected can make an informed decision. Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life, Royal College of Physicians / British Society of Gastroenterology, 20, pubs/brochure.aspx?e=29.

The blog run by Speech & Language Therapy in Practice editor Avril Nicoll was awarded the Speechwoman Site of the Month for January 2010. Speechwoman is the alter ego of Australian therapist Caroline Bowen, who runs a renowned website and phonology e-group. Since June 1998, Speechwoman has selected "an outstanding speech-language-pathology related website" as her site of the month. Speechwoman notes that the "immensely readable" Speech & Language Therapy in Practice magazine is supported by the speechmag website, a presence on Facebook and the editor's blog. Explaining why she chose to recognise the blog she says, "As well as being a skilled editor Avril has a lively and engaging writing style, so it comes as no surprise that her blog is interesting, informative and entertaining." The blog gets a maximum triple plus 'excellent' rating for quality, usability and design and a double plus for authority, reflecting the Speech & Language Therapy in Practice aim of bridging the gap between academia / research and practice. The speechmag blog is at Visitors can follow the Facebook link to become a fan and receive blog updates via their feeds. Caroline Bowens site is at http://

Speechmag blog award

Anna van der Gaag has been made a Public Appointments Ambassador as part of a government programme to encourage more people to apply for public appointments. The government is keen to see more women, people from ethnic minorities and people with disabilities sitting on boards. Anna, a research speech and language therapist, is Chair of the Health Professions Council. The Council has an equal split of men and women, and a commitment to a culture of equality and diversity throughout the organisation. Anna says, I have found being a public appointee a hugely rewarding experience. I hope my experience will inspire others from different backgrounds with skills to bring to public boards to come forward. Vacancies include positions with a number of NHS Trusts, College Boards of Governors, Sport England and the Probation Trust. Mentoring is available.

Opportunities in public life

Volunteers needed

The Stroke Association is looking for volunteers in Essex and Suffolk to ensure newly developed support groups are successful. The Association is introducing Long Term Support Co-ordinators as one of a wide range of services. The role involves supporting existing stroke groups and developing new groups. The groups aim to provide a range of activities including exercise, back to work support, carers support and communication support. A spokeswoman explained, These groups will be dynamic in their approach, meeting the needs of the people within them, while the focus will be on re-enablement, inclusion and supporting Life after Stroke. She added, The volunteers are needed to run groups, organise activities, support stroke survivors during groups and much more in fact anything that ensures the smooth running of the groups. Anyone in the Essex and Suffolk area who can offer a few hours should contact the East regional office on 01284 760006. For nationwide volunteering opportunities with the Stroke Association, see

Life after stroke in England

Connect the communication disability network is celebrating after receiving grants of 430,000 to fund the second phase of its Access to Life project. The money is coming from the Tavistock Trust for Aphasia and the Charles Wolfson Charitable Trust, two of the bodies who funded the original three year pilot in Cornwall. Access to Life is a strategic part of Connects work in supporting people living with aphasia. The organisation describes the pilot as a blueprint for the extension of services across England which will enable people living with aphasia to use their knowledge and experience to deliver and develop services for others with aphasia. This can include conversation groups and befriending services in hospital and at home. In Cornwall, the pilot has led to the joint commissioning of the services by Cornwall County Council and the Cornwall and Scilly Isles NHS Trust for a further two years. Its success hinged on partnerships between people living with aphasia, local NHS trusts, speech and language therapy departments, the Directorate of Social Care and input from other voluntary and charitable organisations. A service commissioner commented, Access to Life was really effective and transmogrified into a social movement beyond just health. It gave us a solution for peer-led services. Further information about how Connect can help in your area is available from David Williams, Director of Business Development, tel. 020 7367 0870.;



Blindness and musicality

One of the authors of a study into the relationship between visual impairment and musicality is calling for greater investment in services and facilities to help visually impaired children realise their musical potential and derive the full educational and therapeutic benefits. Professor Adam Ockelford says that children who have lost their sight because they were born prematurely are around 4,000 times more likely than sighted youngsters to develop exceptional musical abilities such as perfect pitch. His research also concluded that young blind children including those with learning difficulties and autism - are likely to have a greater fascination and interest in music than those with full or even partial sight. He cites the example of blind musicians including Ray Charles, Stevie Wonder, Andrea Bocelli and Derek Paravicini, who also has severe learning difficulties and autism. Professor Ockelford explains, Music can allow young children to mark out events in their daily routine and can be a substitute language for children who cannot communicate in other ways. This is most important for blind children who cant see at all. He cautions that parents and teachers should be aware that blind children may learn music very differently from sighted children, with a greater emphasis on picking out tunes on an instrument by ear. The findings are in Focus on Music 2: Exploring the musicality of children and young people with retinopathy of prematurity, by Adam Ockelford and Christina Matawa, IOE Publications,


Cultivating curiosity
I recently participated in a Guardian online Live Q&A session about speech and language therapy as a career. In answer to What sort of skills and attributes are needed to be successful in speech and language therapy?, panellist Rosemarie Hayhow said, If you can retain a sense of curiosity and a willingness to reflect upon your practice and learn from colleagues, clients and reading then you will be successful. Curiosity has certainly driven the authors of our This House Believes series, but on this occasion (p.16) Vanetta John and Paula Leslie found the debate particularly challenging. Paula told me they persevered because weve got to try to make some sort of sense in areas where we really are uncertain clinically. Much of what we do is about clinical exploration, where we go on the facts available to us but retain an I wonder... readiness to change direction. If Sue Addlestone (p.12) had forced the psychological aspect of adductor spasmodic dysphonia too early, would her therapy with Matt have been so successful? Sue was prompted to write about her work by an earlier article which made the case for a different approach. In Brief this issue (p.15) sees three readers set out their beliefs to provoke discussion. People who write for you are always curious to know what impact their article has had. Margaret Metcalfe (p.4) is particularly keen for you to use the Critical Friends peer review process as individuals or teams, as her managers are looking for more evidence around the East Kent Outcome System. Sharon Garforth (p.26) has had a very natural and unforced journey from clinical work into publishing, through continually asking what if...? Our new ethics series (p.19) encourages us to cultivate our curiosity about the boundaries of our profession that perhaps dont get enough attention. Retaining a sense of wonder about our work may also be fuelled by a change of direction, as shown by Yvonne Maclemans insights (p.8). Even when change is not through choice, it is possible to show incredible resilience. As Jo Middlemiss says of Clifford Hughes (p.10), not only did he find a new way, he found other avenues to share his passion and joie de vivre. Something about the joy of curiosity is infectious. Cynthia Pelman (p.23 and p.30) bubbles over with an endless supply of practical ideas and resources. It is notable that many of them hinge on provoking the curiosity of the children and professionals she works with. Blogger Donald Latumahina suggests curiosity helps make your mind active instead of passive, and observant of new ideas, while opening up new worlds and possibilities and bringing excitement to your life. As always, thats exactly what this issue of Speech & Language Therapy in Practice aims to do too. Enjoy!
References Break into speech and language therapy, Guardian online Live Q&A session, 3/2/10, Donald Latumahinas blog entry on curiosity, productivity/4-reasons-why-curiosity-is-important-and-how-to-develop-it.html

Consensus on Duchenne care

Action Duchenne has hailed an international consensus document of best practice in care as the first step towards ending the current postcode lottery for people living with Duchenne Muscular Dystrophy. The extensive process to develop the Standards of Care took three years, and included expert panels from around the world considering more than 70,000 different clinical scenarios. The document, Diagnosis and management of Duchenne muscular dystrophy, has been published online by the Lancet Neurology. Communication and swallowing difficulties are a common feature of this condition, and recommended treatment and the role of speech and language therapy as part of the multidisciplinary team is covered. Duchenne muscular dystrophy is a severe muscle wasting condition affecting 1 in 3,500 newborn boys worldwide. Onset is in early childhood and the ensuing progressive muscle weakness and wasting leads to affected individuals becoming wheelchair bound by their early teens. Without treatment, the condition leads to death by the early twenties. Nick Caitlin of Action Duchenne is delighted the standards are now published, because the care and treatment received makes such a huge difference to length and quality of life for our children. He added that it is crucial that the NHS agrees to adopt these recommendations as they will, give health service professionals a solid baseline from which to work to improve care for our children. A family guide based on the document is in preparation. Lancet_complete_with_erratum.pdf

Glue ear pilot

A research team is seeking children aged 4-11 years with a history of glue ear to help with a web-based pilot that ultimately aims to become a monitoring aid to help better management of the condition. Deafness Research UK and Southampton University are inviting children, supervised by their parents, to register their interest at the pilot website. They can then complete a quick parental questionnaire and a short web-based test which will help researchers measure school-aged children's hearing function and disability. The TADAST (Two Alternative Auditory Disability and Speech Reception Test) will be used to help identify children who are most likely to suffer from the hearing, learning and social problems that can result from glue ear. The test involves listening to a BBC presenter speaking against background noise of a similar level to that found in a classroom environment. Register interest at



EKOS - a SMART solution

Community Stroke Teams in Nottingham have been using the East Kent Outcome System for 7 years as an integral part of case management. Frustrated by the lack of peer reviewed published articles on EKOS, Margaret Metcalfe argues that its special features make it an invaluable tool for clients, therapists, teams, managers and commissioners.

Our priorities were to create aims that would both demonstrate the range of our involvement with people and allow the client to set their goals and work towards them with any member of staff involved. We didnt want to create aims for each profession. Instead, we wanted aims that reflected the goals of our clients and enabled each member of staff to offer appropriate interventions for that identified goal. Such aims could include: To enable [the client] to participate in [their chosen leisure interest] To enable [the client] to engage in voluntary work / paid work / education To enable [the client] to improve their psychological wellbeing. Margaret Metcalfe (front left) with members of the County Community Stroke Team in Nottingham n Nottingham we have two Community Stroke Teams made up of occupational therapists, physiotherapists, specialist mental health nurses, speech and language therapists and rehabilitation support workers. We see people at home and in other community settings and seek to work together to offer coordinated care that is focused on what the client (and their significant others) want. In 2000 we were aware that our goal setting with clients was somewhat ad hoc. We did not review it systematically, and it didnt give us data that could be presented to managers about the outcomes we were achieving. I was asked to look for a system we could use - and that would give us some quantifiable information. Given the complex nature of our clients and the inter-disciplinary approach we use, we didnt feel that the Barthel Index (Mahoney & Barthel, 1965) would provide sufficiently sensitive information. In any case, it doesnt collect data on communication, swallowing or mental health needs. We also looked at Therapy Outcome Measures (Enderby & John, 1999). Again we felt these would not give information about the range and complexity of our work. We also wanted a system that would allow people to set their own goals. A team occupational therapist and I attended a day run by Maggie Johnson on the

East Kent Outcome System (EKOS) (Johnson, 1997; Johnson & Elias, 2002). Before the day had even concluded we both felt that this system would provide quantifiable data, and work in a person-focused way across a variety of timescales with whatever complexity of clinical need. We recognise that EKOS is not an outcome measure per se but a system that can demonstrate goal achievement using the goals of the client rather than the goals of the team. Specific uni-professional outcome measures can also be used within the system where appropriate.

this system would provide quantifiable data, and work in a person-focused way across a variety of timescales with whatever complexity of clinical need
Some aims are more likely to be unidisciplinary. For example, To enable [the client] to maintain muscle length and joint range of movement is most likely to involve the physiotherapist rather than other members of the team, but this is not the principle we wanted overall. The goal sheets (available at remained very similar to the sheets we were used to working with. There was a column for what was happening already and a column for the goal and whether or not it was achieved, with a review date identified, but we added the ingredients of EKOS to enable quantifiable information to be gathered: 1. a box for the Health Benefit. Based on World Health Organisation guidelines, these are Reassuring, Resolving, Restoring, Preserving, Modifying, Avoiding Harm, Supporting, Promotion and Informing.

Making it happen

When we offered EKOS as an option to the team they agreed to explore its use, and work began to develop the processes we needed to apply it in our setting. As a whole team (then 8 people of the disciplines mentioned), we met for two afternoons to: discuss the concepts of EKOS agree our team aims (EKOS has elements that are consistent across teams and elements that are developed by the team to demonstrate the particular work of that team) adapt our existing goal sheets to use the EKOS ingredients agree ways of making EKOS happen.


Assessment is the process by which we select the appropriate health benefit, not a benefit in itself. Our health benefit sheet, including coding, definition, examples and helpful hints is available at www. 2. a specified Aim on the sheet to ease administration. 3. a place for giving the Outcome and the Contributing Factor if appropriate. Contributing factors recognise that outcomes can be affected negatively by a variety of things. These may be within or outside of our control and can include things like the goal set was too ambitious, the client became ill, or the client did not engage in therapy. Other teams might also add a box for Client Group but we dont need this. For collecting information there are EKOS codes for health benefits and contributing factors, so we also created codes we could use for our aims (figure 1). We continue to use the goal sheets we created at the start and have added aims around pain and advising on selfmanagement, as we found our clients needs demanded this. When we have been able to use the system with joint goal setting and review, it has been very helpful, successful and motivating. While individual clinicians also continue to find EKOS useful when used in a unidisciplinary way, we have found - in common with every other goal setting system - that the usefulness of EKOS depends on the clinician using it. EKOS requires not only the ability to write SMART (Specific, Measurable, Achievable, Relevant / Realistic, Time-bound) targets, but agreement that focused goalsetting is useful, and the willingness to confer with colleagues when the benefits of intervention are perceived as hard to quantify. Since setting up the system there have been significant changes in staffing and team structures and it has been harder to maintain the original enthusiasm and rationale for adopting the system. We have built time in to our regular case discussion to look at and discuss goals especially when there are difficulties with setting SMART goals, as there inevitably are with some people with complex needs. We are also looking at initiatives such as clinical audit to recapture the clinical focus of our first meetings. We have been unable to secure funding or support to develop a database to gather and return the information we would like to be able to present. We have therefore set aside half a day a year to collate the numbers of good and poor outcomes overall, health benefit to outcome, aim to outcome and also the relevant contributing factors, and create a report.

Figure 1 Aims for the Community Stroke Team EKOS Plan To enable client to participate in their chosen leisure interest To enable client to reach their desired potential in - domestic activities of daily living - personal activities of daily living To enable client to engage in voluntary work or paid work or education To enable client to participate in satisfying conversations To enable client to receive the service they want/need To enable client to use appropriate transport To provide reassurance that no intervention is needed To maximise normal movement To enable client to move safely in their desired environment To enable client to improve their psychological well being To support and / or maintain and / or improve existing social circumstances To enable client to access and use written material to their potential To provide information / assessment / support to enable client to make choices around food / fluid intake methods that are safe and to potential To enable the client to set realistic objectives To enable client to maintain muscle length and joint range of movement To enable client to engage in interaction To support carers through their reaction to the current situation To facilitate pain management To provide advice, information and support to enable client to continue their future rehabilitation LEI ADL


Scaling (initially developed in 1968 by Kiresuk & Sherman), there is very little about EKOS. The managers also report that commissioners want a sense of the impairment level at which people enter the service and the level they attain when they leave (such as given

we have found - in common with every other goal setting system - that the usefulness of EKOS depends on the clinician using it
by the Barthel Index) rather than data about good and poor outcomes linked to a range of health gains following intervention. However, a recent meeting with commissioners indicated significant interest in the reports generated by EKOS and this is being pursued. I understand that commissioners in other regions have also been impressed with EKOS, which is encouraging.

Significant interest

The lack of peer reviewed published articles about EKOS has led some managers in the teams to feel uneasy about using it. While there are multiple articles written about other outcome systems such as Goal Attainment

EKOS has brought many benefits to our team: 1. It has improved collaboration within the team by giving us a common vocabulary for discussing clients and looking at their progress and expectations. 2. It is a flexible system that allows for change in response to client needs and clinical initiatives. 3. It has focused our interventions because it provides for systematic reviews and therefore indicates to clinician and client when therapy can no longer be useful. 4. The focused interventions have also decreased contact time while goals are still usually being met. 5. It has enabled clients to recognise their achievements and progress and made it evident when the team has completed useful interventions on occasion people have said to us that, although they want to go on improving, they can see that they no longer need our intervention for that to happen. 6. Within the Community Stroke Teams we have peer supervision for clinical interventions and so the EKOS goals have helped to focus these discussions on improving planning, engaging clients and setting goals.


We have also found the idea of Contributing Factors useful. Paying attention to this has enabled us to look at what is within our control and reflect on aspects of our learning and practice, as well as demonstrating the times when the poor outcome was outside our control (see case example in figure 2). We have found our annual report useful for ongoing learning as a team, as it identifies where we can get better at writing SMART goals and how we can improve on how we demonstrate the range of our work. The report enables us to see the aims and health benefits that we recognise are relevant to our client group but which we have not used very often for example, last year we noticed our Health Promotion had not been consistently documented. It is also useful for highlighting the areas in which we and our clients do well along with areas that need attention. This helps us recognise where we need some clinical education and development or to work with other teams. For example we consistently achieve more than 80 per cent good outcomes in improving function in activities of daily living. However, for our work in maintaining function where there is a co-existing deteriorating neurological condition, we only achieve around 50 per cent good outcomes. After a successful trial period, EKOS has been a mandatory part of case management within our service for 7 years. As a team we continue to feel that EKOS adds sufficient benefit both to our clients and to us as staff to keep it as an expected aspect of management. Our managers are now asking us to collect Barthel Index scores and the Euroquol (Euroquol Group, 1990) pre- and post- our intervention to supplement the information on achievement of goals. We will continue to review the value of EKOS and its use within the team and to deal with the queries that arise, ensuring that it remains relevant to clients, their families, the team, management and government priorities. SLTP Margaret Metcalfe is principal speech and language therapist with Nottinghamshire Community Health, e-mail Margaret.Metcalfe@
References Enderby, P.M. & John, A. (1999) Therapy outcome measures in speech and language therapy: comparing performance between different providers, International Journal of Language and Communication Disorders 34(4), pp.417-429. Euroquol Group (1990) Euroquol - a new facility for the measurement of health-related quality of life, Health Policy 16, pp.199-208. Johnson, M. (1997) Outcome Measurement: towards an interdisciplinary approach, British Journal of Therapy and Rehabilitation 4(9), pp.472-477. Johnson, M. & Elias, A. (2002) East Kent Outcome System for speech and language therapy. Eastern & Coastal Kent Community Services. (E-mail Annie. Mahoney, F.I. & Barthel, D. (1965) Functional evaluation: the Barthel Index, Maryland State Medical Journal 14, pp.56-61.

Figure 2 Case example Gavin

Gavin was referred to the Community Stroke Team needing intervention from occupational therapy, physiotherapy and speech and language therapy. His intervention lasted 14 months and we wrote 12 sets of goals with him during that time. Gavins goals were shared so that I was involved in encouraging him to make a hot drink. At the same time, the occupational therapist and physiotherapist knew the particular areas of difficulty in communication and so when to actively support conversation and when to give Gavin more time to work on his output. On the occasion that a reading goal was not achieved the Contributing Factor was Over Ambitious Goal. This led me to reflect on my expectations of work on reading and to adjust the timescales to appropriately reflect the complexity of what we were hoping to achieve. The goal sheets reflect the fact that the goal was re-set and achieved next time, showing that time was the relevant factor. Gavin said of the goal setting process, When I know I am good then it helps me. I asked him to clarify what he meant. He indicated in the conversation that it is hard to feel that he is making progress and so having evidence of his progress is encouraging and motivating.

Editors choice

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

The exploratory study Examining the Communicative Function of Challenging Behaviour in Fragile X Syndromeuses parental report and contrived scenarios to investigate what reinforces aggressive, destructive and self-injurious behaviours. Langthorne & McGill suggest that, rather than using challenging behaviour for social attention, children with fragile X are more likely to be motivated by a wish to escape from unpleasant situations or to access preferred items or activities. While the authors highlight the studys flaws, the contrived situations approach has potential, as does the conclusion that, with this information, we can teach the child different ways of meeting these needs at an early age. The Fragile X Society Newsletter Research Supplement (2009) November, Issue 48 Sometimes research seems obvious but draws attention to and extends understanding of how to address difficult issues and develop services. In The Loneliness Experiences of Young Adults with Cerebral Palsy who use Alternative and Augmentative Communication, Cooper, Balandin & Trembath find that support networks, AAC systems and communication technologies mitigate experiences of loneliness. The reported exchange with Frank (p.158) shows the importance of giving clients the opportunity to discuss things rather than making assumptions. In this case his mother learnt he didnt like her speaking for him, so was able to change. Augmentative and Alternative Communication (2009) 25(3), pp.154-164. Ive always struggled with kids whose problems with speech appear to be associated with ear, nose and throat issues. Do you wait for surgery or begin therapy straight away? Lundberg, McAllister, Samuelsson, Ericsson & Hultcrantzs Phonological development in children with obstructive sleep-disordered breathing confirms that surgery helps other problems with which adeontonsillar hypertrophy is associated. However, it does not resolve phonology problems, perhaps because the learned pattern has been internalised. The authors say tonsillotomy may be a better surgical option than tonsillectomy, and that speech and language therapy needs to start as early as possible. Clinical Linguistics & Phonetics (2009), 23(10), pp.751-761.

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In view of the lack of peer reviewed articles on EKOS, a Critical Friends appraisal of this article would be particularly welcome. See www.


Heres one I made earlier

Heres one I made earlier...

Snakes and Ladders

Alison Roberts with two more low cost, flexible and fun therapy suggestions for groups, this time with a dating theme.

My old Victorian version of Snakes and Ladders was a sort of morality judgement. The person who won was deemed to be the most virtuous, while the loser was a low sinner! The numbers attached to the 7 snakes and 7 ladders related to a list of vices and virtues in the lid of the box. Modern versions have more snakes and ladders, but I thought it would be useful to use a modification of the old system as a light-hearted model for a dating game that promotes discussion. As long as the board you buy has 13 vices and 13 virtues this should work (and all the new versions Ive seen fit the bill). IN PRACTICE - Snakes 24 Vanity You spend far too long staring at yourself in the mirror and choosing clothes. 27 Envy While out on a date you keep talking about how another girl or boy has all the things you want; you put yourself in a bad mood and spoil the evening. 36 Anger You cant agree on things and keep arguing. 50 Laziness You never make an effort to look nice or try hard to make the date go well. 54 Avarice - You cant let him / her out of your sight. You dont like it if he / she talks to anyone else. 60 Gluttony You eat too quickly on your date to a restaurant, and then spoil the date by being sick. 69 Lust You go too far too fast, and it puts your partner off. 83 Drunkenness - You drink too much on a date, and that leads to you behaving badly. 88 Meanness You never offer to pay your way on a date, so your partner cant afford to take you out so often. 90 Dishonesty You told them it doesnt matter if you are late back. This gets you both into trouble. 92 Rudeness You forget to say thank you for a good evening. You forget to compliment your partner. 95 Vulgarity You keep burping, or worse, on the date. 99 Lateness You keep being late for dates and meetings. IN PRACTICE - Ladders 3 Modesty You are not out to impress just by the way you look. On a date that involves a country walk you wear the right clothes. 12 Humour You laugh at your partners jokes, and make some good ones of your own. 15 Chilled-ness You dont get flustered if your partner has a different opinion. You can agree to differ. 18 Organisation You try to make sure the day will go well; youve arranged to visit some nice places. 21 Liberality Your partners needs are more important to you than your own. You are happy to see the film your partner wants to see, even though its not your choice. 47 Moderation You eat just the right amount, feeling healthy for a pleasant walk after lunch. 49 Reserve You prefer to wait until the third date before attempting a proper kiss. 53 Temperance You remember not to mix grape and grain, and are happy to have soft drinks too. You are in control this way. 57 Generosity You offer to pay for your partner sometimes. You remember his/her birthday. 59 Honesty You would never two-time your partner. 64 Politeness You paid your partner a compliment. You said how much you enjoyed the film / outing. 72 Selfcontrol You needed to burp, but managed not to. You were the perfect lady / gentleman. 82 Reliability You are always there when you say you will be.

Plenty more fish in the sea

This is a humorous game about relationships, for teens and upwards. It is also a good way to introduce the concept of Plenty more fish in the sea for those who keep being disappointed by their dates. MATERIALS Large piece of firm cardboard for the base of your game, painted blue, and perhaps with some fish, seaweed, and rocks drawn or painted on to it, to add to the seaside effect. Small magnets with holes (obtainable from craft shops), 30 cm lengths of string tied through the magnet holes Paper clips, which you clip onto cards (business card blanks are ideal). On each of these stick a magazine picture of one person. You need males and females of types such as the following:1. Goths 2. Boffins 3. Arty types 4. Business people 5. Farmers 6. Nautical folk 7. Medics 8. Students 9. Models 10. Sportspeople You can add as many more types as you can think of / get pictures to represent. You need a selection of about 20-30 people. You could also use the Speechmark Colorcards Occupations set, but make sure that the magnets are capable of supporting these comparatively heavy cards, and put in an equal number of pictures of males and females. IN PRACTICE Place all the cards upside down on the sea. Ask your clients to describe their ideal partner for a date. They hold a fishing line and catch a person. The chances are that the person they catch will not match their ideal; however, they have to map out a conversation with that person before thinking of a way to move on to someone else. They need to give an idea of how they would greet that person, which topics they might talk about, questions they might ask, comments/compliments they might give.


Talking Matters
Yvonne Macleman is one of a small but growing number of speech and language therapists who have made the transition from traditional to emerging areas of practice. As a practical example of how our profession can play an integral part in Child & Adolescent Mental Health Services (CAMHS), she describes how she used Talking Mats with a young man with Aspergers Syndrome to facilitate an accurate mental state assessment.

hild & Adolescent Mental Health Services (CAMHS) are an integral part of children and young peoples services. Speech and language therapists in CAMHS are however few and far between; in Scotland there are currently only 5.5 whole time equivalents, of which I am one. This is despite it being well recognised that communication difficulties and emotional/behavioural difficulties often co-exist. Cohen et al. (1998), for example, found that 38 per cent of children referred to child psychiatric services met one or more criteria for previously identified language impairment while 41 per cent met the criterion for unsuspected language impairment. In total 63.6 per cent of the children referred had language impairment. The link between communication impairments and emotional or behavioural disturbance cannot be thought about solely in simple terms such as primary or secondary conditions. The relationship is complex, as both areas are closely interrelated, and it requires genuinely integrated approaches to minimise the impact of these difficulties. Speech and language therapists with skills in communication impairment and in the field of mental health can provide this (Sellars, 2009). My post working with young people in CAMHS was created in 2003, and is currently split between the West of Scotland Adolescent In-Patient Unit at Skye House and one of the CAMHS out-patient teams. Speech and language therapists working within CAMHS settings use a transdisciplinary working model, taking on the specialist speech and language therapy role and at the same time working beyond traditional boundaries to function as integral members of the mental health team. This means that I may identify a language or communication impairment, but will not usually provide direct therapy. Although I will often liaise with and refer on to my colleagues in child health speech and language therapy, my role is indirect, namely facilitation of effective communication within mental health assessment and psychological therapies. I link closely with a young persons family, school, home or residential placement, and support effective communication between the young person and their commu-

nication partner, within the context of their mental health problem. This model is identified as a key element by the Royal College of Speech and Language Therapists (Gascoigne 2006) and our own service (Sellars, 2009).

Exciting challenge

Moving from adult learning disability services to mental health was a new and exciting challenge for me, with both similarities and differences in clinical knowledge and culture. I spent significant amounts of time reading around areas like attachment theory, eating disorders and psychosis, and have benefited from this new knowledge. I continue to work through Greater Glasgow & Clyde NHS New-to-CAMHS package, which I have found very useful. It has taken me a while to adjust to the move from a social model of disability in adult learning disability to a predominantly medical model of impairment in CAMHS. However I have also been able to bring my previous experience with me, and have recently started training my nursing colleagues in Skye House in inclusive communication strategies to help their engagement and communicative success with the young people in the wards. I have new experiences of working with other professionals like family therapists, psychotherapists, liaison teachers and forensic psychologists. I work as part of CAMHS, and as such, a referral cannot be made to me as a speech and language therapist in isolation. In terms of training and continuing professional development, I attend courses around areas like depression, autism spectrum disorder and cognitive behaviour therapy. I am also a committee member of the Scottish Speech and Language Therapy Specific Interest Group in Mental Health. My move into mental health highlighted for me the co-morbid nature of mental health problems across all client groups with speech, language and communication needs. The knowledge I have now about CAMHS would have been useful in my previous posts. CAMHS referrals come through GPs, and I would have felt more confident about making an onward referral to a GP about a child or young person

referred to the speech and language therapy department who may be presenting with a possible co-morbid depression, anxiety disorder, eating disorder or psychosis. Young people are referred to CAMHS for a range of mental health problems. They will usually complete a mental state assessment as part of a transdisciplinary assessment from which a psychiatric diagnosis can be made. The key to this assessment is communication, relying on effective sending and receiving of messages between the mental health professional and the client. The young persons responses are essential for completion of the assessment and formulation of a treatment plan, and this is where the speech and language therapy contribution to the team can really pay off, as this case example illustrates.


Greg, a 17 year old boy with a diagnosis of Aspergers Syndrome, was referred to a local CAMHS service for an urgent assessment due to his presentation of low mood, loss of interest and pleasure in daily life, and suicidal ideation. The referring agent noted that he was unable to describe his thoughts in any detail and that, in his previous assessment for Aspergers Syndrome, the assessment team had been keen to exclude a co-morbid depression but were unable to do so due to his lack of motivation to communicate. Howlin (1997), cited in RCSLT (2009), says, The inability of people with autism to communicate feelings of disturbance, anxiety or distress can also mean that it is often very difficult to diagnose depressive or anxiety states, particularly for clinicians who have little knowledge or understanding of developmental disorders. After discussion with the transdisciplinary team, I developed a Talking Mat mental state assessment with the consultant psychiatrist in preparation for Gregs appointment. Talking Mats is a low technology communication framework involving sets of symbols, which was originally developed for use with adults with learning disabilities, and is now being used more widely with a range of client groups. It is designed to help people with


communication difficulties to think about issues discussed with them, and provide them with a way to express their opinions effectively. As the Talking Mats website explains, it can help people arrive at a decision by providing a structure where information is presented in small chunks supported by symbols. It gives people time and space to think about information, work out what it means and say what they feel in a visual way that can be easily recorded ( The first appointment was attended by Greg, his mother, the consultant psychiatrist and me. The consultant psychiatrist says, The aim of the session was to attempt to undertake a more satisfactory mental state assessment of Greg, who had found it extremely difficult and stressful to communicate verbally in his first meeting with psychology colleagues. We explained the use of Talking Mats, demonstrated the materials and sought Gregs consent. I gave Greg the corresponding symbol for each question the psychiatrist asked. He was able to create a complete Talking Mat, which gave us a good insight into his internal thoughts and feelings, as well as any biological changes which are associated with depressive states like eating and sleeping patterns. From the Talking Mat, we were able to establish that Greg: feels worse in the morning, and feels tired all the time has suicidal thoughts quite often, but has made no plans to end his life does not feel hopeful about the future very often is not often able to do anything to make himself feel better is usually sleeping well, but does not know if he is eating well. Greg was given a diagnosis of a moderate depressive illness, and a follow-up phone call confirmed he wished to start taking antidepressant medication. He was clear that, although using the Talking Mats made speaking about his feelings easier, he did not want to engage in any form of talking therapy such as cognitive behaviour therapy. Gregs mother spontaneously commented on two separate occasions that she felt the Talking Mat was an easier way for her son to express his thoughts and feelings around a difficult area.

Use of Talking Mats with Greg Review appointments at two and four months after starting medication showed an improvement in Gregs mood and overall functioning. It is not possible to compare the use of Talking Mats directly, as symbols were added and omitted as dictated by the conversation during review appointments. However, some themes emerged: hopeful about the future moved from not very often to maybe tired moved from yes to quite often enjoying home moved from quite often to yes enjoying friends moved from quite often to yes taking anti-depressants consistent yes response. From the Talking Mat it was also possible to see Gregs increase in anxiety around going to college. We were able to offer support around this normal response, as well as highlighting this to his mother as a possible area for further discussion at home. Greg has now started attending college and his anti-depressant medication continues to be monitored by his GP. Consultation with academic colleagues allowed me to reflect on the implications of replicating this approach with other young people. This raised a number of questions: a. Do Talking Mats help with / enhance psychiatric diagnoses? b. Could the themes explored by Talking Mats be analysed qualitatively? c. Could Talking Mats help to determine if a mental health treatment has been effective? d. How reliable are Talking Mat responses? Do responses vary in a young person dependent, for example, on the time of day of the assessment? e. Could a Talking Mat mental state assessment be correlated with a published mental state assessment, like the KiddieSADS-PL (semi-structured diagnostic interview designed to assess current and past episodes of psychopathology in children and adolescents from 6-18 years), or the Beck Depression Inventory (selfreport questionnaire designed to assess the intensity of depression in young people and adults from 13-80 years)? I also wonder about the emotional impact of a mental state Talking Mat from a parents perspective, and how it might feel seeing your son or daughters difficult thoughts and feelings displayed in black and white. My family therapy colleague however commented that he thought the Talking Mat could actually be emotionally containing for both the young person and their family. From a communication point of view, I would avoid using double negatives in future Talking Mats. I had originally designed these to build in some level of reliability of response from Greg, who was able to cope with this level of language structure, but for many clients it would simply add to the language demands of a process which is meant to take the pressure off. Gregs case illustrates the value of Talking Mats within the CAMHS setting for the professionals, the family and most importantly the client. I now need to consider how to develop the evidence to prove the effectiveness of using Talking Mats to facilitate mental state assessment, as I am keen to demonstrate the many practical ways in which speech and language therapists are a valuable and integral part of transdisciplinary CAMHS teams. SLTP Yvonne Macleman is a speech and language therapist with Child & Adolescent Mental Health Service (CAMHS), NHS Greater Glasgow & Clyde, e-mail

Quality and quantity

The psychiatrist and I agreed that the Talking Mat had increased both the quality and quantity of information gained from Greg, thereby allowing a diagnosis to be made and treatment plan formulated. As Coakes (2006, p.10) says, For children with emotional behavioural difficulties, attention deficit / hyperactivity disorder or autism spectrum disorder and associated moderate /severe language difficulties, Talking Mats has been proven to increase their ability to express their views in comparison to a verbal discussion. This is achieved by Talking Mats facilitating both engagement and linguistic ability.



Acknowledgments References

Thanks go to Greg, CAMHS colleagues, Leila Mackie and Professor James Law. Coakes, L.A. (2006) Evaluating the ability of children with social emotional behavioural and communication difficulties (SEBCD) to express their views using Talking Mats. Unpublished report. Cohen, N.J., Barwick, M.A., Horodezky, N.B., Vallance, D.D. & Im, N. (1998) Language, Achievement, and Cognitive Processing in Psychiatrically Disturbed Children with Previously Identified and Unsuspected Language Impairments, Journal of Child Psychology and Psychiatry 39(6), pp.865-877. Gascoigne, M. (2006) Supporting children with speech, language and communication needs within integrated children's services. London: Royal College of Speech & Language Therapists. Available at: free-pub/Supporting_children-website.pdf (Accessed 14 January 2010). RCSLT (2009) MH20 Inquiry into Child and Adolescent Mental Health Services. London: Royal College of Speech & Language Therapists. Available at: http://www.scottish.parliament. uk/s3/committees/hs/inquiries/mentalhealthservices/MH20.pdf (Accessed 29 January 2010). Sellars, V. (2009) Speech and Language Therapy within Child & Adolescent Mental Health Teams. NHS Greater Glasgow & Clyde unpublished departmental position paper.

Good journey?
Photo of Clifford courtesy of Geoff Wilson/RCSLT


Beck Depression Inventory, see cat=1426&skey=2646. Kiddie-SADS-PL: latest version / usage rights at Video clips of a variety of clients using Talking Mats are available at

Clifford Hughes had a laryngectomy in 2001. His personal story of the everyday psychological, physiological and social challenges he faces and how he has rediscovered his voice serves to remind us why we chose the speech and language therapy profession.
Every now and then someone comes fleetingly into your life and makes a profound impression. Clifford Hughes is one of those people. I was asked by a friend to give a talk to a local group of which Clifford was a member. The group was random and eclectic and I later discovered that they had no idea what I was going to talk about. That always helps I find, because then I can talk about anything I like; an open opportunity to do my own thing. After my allotted time, and some lively feedback, the tea was wheeled in and I had the chance to speak to a few interested souls. Clifford came to speak to me. He describes very well in his article what it is like for him to speak and the enormous debt that he owes to the speech and language therapists who helped him along the way. But here we have a human being who would seem to have lost everything that made him him. In a way, he was his voice. That was how he communicated and connected with the world. It would be like a sculptor losing her hands or an athlete losing his limbs. No so with Clifford. He set about finding another way. He knew the talent was still there even though the method of communication was gone. But not only did he find a new way, he found other avenues to share his passion and joie de vivre. He shares his deep knowing that HE was not his voice but much much more. He is an example of the famous Churchillian words, Never never never never ever give up. I dont know how often you as speech and language therapists get to hear what a fabulous job you do. I hope this article will remind you that your work of enabling people to communicate more effectively is a pearl beyond price, and that there is no price to put on the courage of the human heart. Jo Middlemiss is a qualified Life Coach, who offers readers a complimentary half hour coaching session (for the cost only of your call). Please note that Jo moved in May 2009 and her new telephone number is 07803589959.

Do you wish to comment on the impact this article has had on you? Please see the information about Speech & Language Therapy in Practices Critical Friends at



Winning ways
y voice had been my life. I made my first broadcast from London at the age of 12 as a Boy SOPRANO. As an ALTO I won a choral scholarship to the world famous Choir of Kings College, Cambridge. On the recital, oratorio, opera merry-go-round I was called by the Scotsman Music Critic (Edinburgh Festival 1974) Scotlands foremost lyric TENOR. Now, as a laryngectomee, Im a Chaliapinesque BASS. (How about that? A serial vocal quartet!) But singing was only a third of my life as a professional performer. I was a teacher, headmaster in the independent sector for eleven years at Beaconhurst School, Bridge of Allan and Loretto Junior School just outside Edinburgh. Then, after a three years Bachelor of Divinity course as a mature - if not slightly geriatric - student at New College, Edinburgh, I was ordained Minister of one of Scotlands most magnificent churches, St Marys Haddington. Singer, Teacher, Preacher...then Zapp! I woke up in the intensive care unit at St Johns Livingston on 20 January 2001 unable even to whisper. My first visitor was my wife Kathleen. I tried to lean on one elbow and write her a few words. I got as far as Good journey? then we both broke down and wept. Looking back over eight years, I can summarise my experience under three categories: the psychological challenges, the physiological changes, and the problems of socialisation. 1. Psychological challenges I can confirm passing through the perfectly natural human reactions to bereavement prescribed by Elizabeth Kubler Ross. Denial. Its just a virus. Suck another Fishermans Friend or a lemon Strepsil. Anger. Why me? The answer to that, of course, is Why not me? There are, after all, 100,000 laryngectomees world wide. Disbelief. Bargaining. Blame, Depression, Despair until, at length, I reached the magic word Acceptance. The Apostle Paul, probably a victim of malaria picked up on his missionary journeys, goes a step further. He speaks of rejoicing in my infirmity. When youve started to laugh with others at your problems and frustrations, you realise you are there. 2. Physiological changes You are suddenly a Neck Breather. The trachea and the oesophagus are now linked by a small silicon valve, the size of your pinkie nail, like a capital H. Because theres no breathing through the nose and mouth, the sense of smell has vanished. Is gas escaping? Is the bread baking? Have I overdone the after-shave? I no longer need to blow my nose; instead I have to blow my throat. There are some advantages, though. I cant spit. I cant be breathalysed. At an accident, or in a routine procedure for the administration of oxygen, there is no point in clamping the mask over my mouth and nose. I was having trouble explaining this to a young nurse before undergoing a colonoscopy. The gastroenterologist hove into view. Im a neck breather, I explained. Ah! Sorry! he replied with a winning smile, Im a bottom doctor.

3. Social problems When the valve clogs up with mucus, speech can become impossible. One needs a private place, a mirror, good light, a finely focused torch, tweezers, a brush like a miniature chimney sweeps brush, a gauze swab or a tissue or a few pieces of loo paper, and a shelf to put things on, in order to make communication possible again. Tell me, how many Gentlemens Loos offer such basics? The hole in the throat, the stoma, is protected by a filter the size of a 10p piece. Its called an HME, a Heat and Moister Equaliser. Watch out for sneezes! If youre not prepared, a sneeze will propel the filter across a room like an exocet missile. The most traumatic experience is a valve change. Inevitably, perhaps after six months or so, the valve will leak liquid from the oesophagus into the trachea to cause coughing and spluttering. Speech and language therapists who specialise in head and neck cancers are well practised in the art of changing valves, yanking out the old and popping in the new. But its never an enjoyable experience. Not long ago, I became aware of what felt like a growth, about the size of a bit of muesli, on my tongue. The last thing I needed was cancer of the tongue. I saw a head and neck cancer nurse. She quickly reassured me that it was nothing more than a sort of fungus which could be easily treated and eliminated. I am a lover of limericks and couldnt resist writing to her: The praises of nurses Ive sung; Theyre caring, compassionate, young; But Oh! The disgrace To be told to my face: Hey! Cliff! Youve a brown hairy tongue!

A hidden disability

In recent years, disability legislation has moved forward in leaps and bounds to cater for people with mobility problems. But what about the many of us who suffer from what might be called a hidden disability? Its difficult, sometimes impossible, to converse in a crowded room. One simply cannot project ones voice in an ambiently noisy environment. How often Ive longed to shout in a restaurant, Switch off the wallpaper music! Im trying to talk! I am an active member of the Civic Participation Network, which is the first project of Communication Forum Scotland, an informal alliance of organisations representing people of all ages with varied communication support needs. The network aims to remove barriers to active citizenship for people with communication support needs. In practice, this has led me to: speak at conferences arranged by and for speech and language therapists and support workers (I was glad to know that SWIG is not a drinking club, but the Support Workers Interest Group!) lecture to speech and language therapy students at Queen Margaret and Strathclyde Universities lobby at the Scottish Parliament for funds

to campaign for improvements to promote inclusion in Scottish society get amongst the movers and shakers in society to get them to understand that so many folk are coping with a hidden disability. Most movingly, I have also been asked to speak with people who are facing up to a laryngectomy operation. I recall, with immense gratitude, a visit to my bedside at St Johns Livingston from a Lady Lary with a strong Mid Calder accent who gave me confidence that, after the trauma, I would be ME again! With the appropriate support theres no stopping me. Ive got my life back and am performing again! Thanks are due to a succession of speech and language therapists, and to my family and close friends who taught me to laugh at my inability to aspirate the letter h (I will lift up mine eyes unto the ills; From whence cometh my elp?) Also particularly to the lady in my congregation at St Marys Haddington who confided to me, Clifford, I think your new voice is really rather sexy! Let me finish with an anonymous version of the Beatitudes which I came across recently: Blessed are you who take time to listen to our difficult speech, for you know that if we persevere, we can be understood; Blessed are you who walk with us in public places and ignore the stares of strangers, for in your friendship we find relaxation; Blessed are you who never bid us hurry up, for often we need time rather than help; Blessed are you who stand beside us as we enter new ventures, for our failures will be outweighed by times when we surprise ourselves and you; Blessed are you who ask for our help, for our greatest need is to be needed; Blessed are you who help us by the grace of Christ, for often we need the help we cannot ask for; Blessed are you when by all these things you show us that we are not individuals because of our disability, but by the acceptance from God which no disability can destroy. SLTP Rejoice and be exceeding glad! Rev Clifford Hughes lives in Kinross. In 2009 he became the first service user to receive an Honorary Fellowship from the Royal College of Speech & Language Therapists for his work in championing the interests of people with communication support needs. Clifford is prepared to travel anywhere to tell his story, including tracks from his LPs, e-mail or tel. 01577 840506. Resources includes a downloadable toolkit Talk for Scotland, which offers advice to decisionmakers and service providers on engaging with people who have communication support needs Elizabeth Kubler Ross books and information at




Adductor spasmodic dys a case for speech and lan

Sue Addlestone achieves good results with an approach that takes into account both the physical factors and emotional needs of people with adductor spasmodic dysphonia. Here, with her client Matt, she presents a robust response to Kendrea Focht and Paula Leslies conclusion in our Spring 09 issue that speech and language therapists should offer Botox in such cases.

dductor spasmodic dysphonia is a dystonia of the larynx which leads to abnormal patterns of phonation. Clients typically present with a voice which alternates between being intermittently extremely strained, and then completely normal, due to involuntary over-adduction of the vocal cords. It sounds as though the speakers throat is being strangled and then released. The resultant abnormal voice quality is present at all times, unlike certain other dysphonias which may come and go dependent on the time of day, number of conversation partners, background noise and so on. The cause of adductor spasmodic dysphonia has never been fully explained and there remains much debate as to whether the aetiology is neurological and / or emotional. In the Spring 09 issue, the conclusion of This House Believes (Focht & Leslie, 2009, p.21), was that Botox is currently considered the gold standard for treatment of adductor spasmodic dysphonia. The recommendation is that Botox be offered as the primary treatment for adductor spasmodic dysphonia, but what of speech and language therapy intervention in the management of this condition? I work as Clinical Lead in Voice at North Manchester General Hospital, which serves a population of 3.2 million. The number of clients presenting with adductor spasmodic dysphonia is small relative to my overall caseload. We do not have an ENT consultant on site who specialises in Botox, although there is a specialist locally who does. The ENT consultants at my hospital tend to approach adductor spasmodic dysphonia by prescribing drugs if they feel this is appropriate; for example, anti-reflux medication if there is an indication of gastro-oesophageal reflux disease (commonly referred to as GORD) or by

trying a short course of diazepam as a muscle relaxant. But, in the main, they refer these patients for voice therapy. My experience of managing clients with adductor spasmodic dysphonia leads me to reject the use of Botox. This is because I achieve successful outcomes through direct voice therapy combined with psychological therapy. I have based my therapy approach around literature and studies (for example, Anari et al., 2007; Cannito et al., 1994; Heaver, 1959; Zung, 1967). Cannito (1991) compared eighteen clients with adductor spasmodic dysphonia (ASD) to controls and found that over half of those with the condition had significantly impaired performance on psychometric measures of depression and anxiety (p.322). He recommended that from a clinical standpoint, [it] is critical that emotional disorders in ASD patients are identified (p.323). Shapir (1995) states that if the diagnosis of ASD is based on l-r, Ashleigh, Sam and Emma symptoms alone, patients[are] subjected to undue medical treatment (p.275). In treating people with adductor spasmodic dysphonia, speech and language therapists must therefore focus not only the clients voice, but also on the emotional component, as illustrated by one of my clients.


Matt is a 39 year old mental health nurse consultant. He was referred to me with a diagnosis of gastro-oesophageal reflux disease and adductor spasmodic dysphonia. The ENT consultant had previously treated Matt for GORD and had seen him for review on two occasions, with no improvement in the dysphonia. When Matt first presented in clinic, it took him 75 seconds to read the first two paragraphs of Arthur the Rat (author unknown)

compared to 34 seconds after therapy. The fact that it took Matt over twice as long to read the passage at initial assessment is due to the effect that adductor spasmodic dysphonia has on breath support. The condition leads to intermittent occlusion/restriction of airflow, which makes speaking slow and effortful. I carried out a perceptual analysis of Matts dysphonia using the GRABS scale (Hirano, 1981), where voice quality is evaluated using the parameters of Grade (overall voice quality), Roughness, weakness (Asthenicity), Breathiness and Strain (0 = normal, 1 = mild, 2 = moderate, 3 = severe). Matt obtained a score of 11 out of a possible maximum of 15. On a selfevaluation form made up of questions relating to functional, physical and emotional domains (see Deary et al., 1999), Matt scored 47 out of a maximum possible 60. This gave his vocal disability a classification of severe (where mild is less than 20, moderate is 2140 and severe is more than 41). Matts report of his voice disability indicated that, although it took a great deal of effort to speak, colleagues and his own patients were used to his voice, and he had not needed to make alterations at his place of work. In fact since the onset of the dysphonia, his job role had improved and he had gained an award for outstanding service to his profession. Family and friends had also adapted to his way of speaking. However Matt was keenly aware that his voice problem was becoming progressively worse. He had also become disillusioned by the lack of improvement: My voice had progressed from an initial something far more debilitating. It had reached the point where it had become impossible to complete more than a few words.I became intensely conscious that I had no control over the sound that would come out of my mouth.




sphonia: nguage therapy

I attended weekly appointments which initially focused on specific vocal exercises. With practice, it soon became apparent that I could perform these with some success at both the therapy sessions and in private, but I could not maintain this in general conversation. The target of therapy changed to incorporate psychological interventions. Through this, I became aware that, in the build up to the onset of my dysphonia and in the months following the symptoms, I had been subjected to several life stressors. It was through exploring these, in conjunction with voice therapy, that I became aware that, while I found vocalising difficult, my own anxieties and emotions were significantly exacerbating the problem. Increasingly I [had begun] to isolate myself professionally and socially. The psychological interventions I used with Matt consisted of a combination of different therapies. I have gained skills and experience in these areas mainly through self-directed learning, but also through attending training courses. I often use a combination of these practices when working with clients with dysphonia and also dysfluency. In Matts case, I used person-centred counselling techniques, Cognitive Behavioural Therapy (Butcher et al., 2007) and also incorporated the timeline from Draw on your emotions (Sunderland & Engleheart, 1993). This approach to treatment led Matt to report that: within a very short space of time I found there were increasing periods where my voice was clear. After four weeks I attended a social event where my voice was even worse than it had been for the preceding weeks and I found this to be a particularly frustrating experience. However the next day I found that my voice had virtually returned to normal. My final session involved improving the pitch of my voice and work around my view of the future..I now have complete control overmy vocal cords.I am confident in my ability to identify my condition at an early stage and modify my behaviour.

Sue and Matt, photo by It is recommended that, when taking a voice history, clinicians should fully appreciate the (clients) psychological history (Butcher et al., 2007, p.8). If this is not done, the speech and language therapist will fail to deliver the appropriate form of therapy (p.8). In spite of Matts experience in the field of mental health, during the entire case history process he was at a loss to pinpoint any life events which he felt were significant enough to precipitate his dysphonia. I planned Matts therapy based on the information I had collected at his initial interview, beginning with direct voice exercises. However, I was mindful that adductor spasmodic dysphonia often fits the model developed by Butcher et al. (2007, p.25) as a Type 1 conversion voice disorder: Typically the patient will be resistant to exploring a psychological cause for the voice disorder (and)will not complain of anxiety and depression (despite)having a significant dysphonia. Had I based my therapy purely on what Matt told me at initial interviews, I would not have addressed the emotional side of Matts adductor spasmodic dysphonia. It was only when I began combining direct voice therapy with psychological therapy that a successful outcome was achieved. Prior to using psychological approaches, Matt made virtually no progress with voice exercises:

Back in control

I saw Matt for six sessions of therapy over a period of three months. At his final appointment I arranged to monitor his progress by phone at fortnightly intervals. After the second call Matt reported feeling back in control of his voice, and we agreed on discharge. By treating people with adductor spasmodic dysphonia exclusively with direct voice



therapy, clinicians can fail to address the emotional issues which are symptomatic of the impaired performance on psychometric measures of depression and anxiety discovered by Cannito (1991, p.322). As a result, such clients fail to make any progress. The medics may then recommend Botox, which is not without its problems (Focht & Leslie, 2009). The evidence of the value of a combined therapy approach is summed up by Matt: Everyone loses their voice at some time in their lives but this is usually for a few hours a day. To lose your ability to speak removes something distinctly human from your make-up. I am walking and talking proof that a blanket ENT approach isnt going to work, as I actually deteriorated during my ENT treatment phase. Voice therapy has not just given me back the ability to speak - it has given me back SLTP my life. Sue Addlestone is Clinical Lead in Voice at North Manchester General Hospital, Clinical Lead in Dysfluency (Adults) at Stepping Hill Hospital and Clinical Lead in Dysfluency (Paediatric) at Manchester PCT. She is Associate Lecturer in Voice at Manchester Metropolitan University. You can contact Sue by e-mail, Acknowledgement Sincere thanks to Matt for his contribution to this article. His time, dedication and commitment in helping to offer an alternative to other sufferers has been invaluable.
References Anari, S., Carding, P., Hawthorne, M., Deakin, J. & Drinnan, M. (2007) Nonpharmacological effects of botulinum toxin on the life quality of patients with spasmodic dysphonia, Laryngoscope 117, pp.1888-1892. Butcher, P., Elias, A. & Cavalli, L. (2007) Understanding and treating psychogenic voice disorders: A CBT Framework. London: John Wiley and sons Ltd. Cannito, M. (1991) Emotional considerations in spasmodic dysphonia: psychometric quantification, Journal of Communication Disorders 24, pp.313-329. Cannito, M., Murray, T. & Woodson, G. (1994) Spasmodic dysphonia, emotional states and Botulinum Toxin treatment, Arch Otolaryngolgoy Head and Neck Surgery 120, pp.310-316. Deary, I., Webb, A., MacKenzie, K., Wilson, J. & Carding, P. (1999) Short, self-report voice symptom scales: Psychometric characteristics of the Voice Handicap Index-10 and the Vocal performance questionnaire, Journal of Voice 13, pp.557-569. Focht, K. & Leslie, P. (2009) This House Believes in Botox, Speech & Language Therapy in Practice Spring, pp.20-21. Heaver, L. (1959) Spastic dysphonia II: Psychiatric considerations, Logos 2, pp.15-24. Hirano, M. (1981) Clinical examination of voice, in Arnold, G.E., Winckle, F. & Wyke, B.D. (eds) Disorders of Human Communication. New York: Springer. Shapir, S. (1995) Psychogenic spasmodic dysphonia: a case study with expert opinions, Journal of Voice 9 (3), pp.270-281. Sunderland, M. & Engleheart, P. (1993) Draw on your emotions. Bicester: Winslow Press. Zung, W. (1967) Factors influencing the self rating depression scale, Arch Gen Psych 16, pp.543-547. Resource Arthur the Rat is a standard passage, origin unknown, with the original purpose of sampling all the phonemes in American English. It is freely available on the internet, for example at Arthur+the+Rat.

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In Brief...
In Brief is supported by

Brief items (up to 500 words) may include therapy or assessment tips or a description of a resource you have developed. It may also be a reflection on the best piece of advice I have been given, or the things I wish theyd told me at University. Alternatively, it offers an opportunity for you to get on your soapbox! Although what you write will be substantially your own work, please acknowledge any influences. E-mail your entries to One lucky contributor in each issue will receive 50 in vouchers from Speechmark, a company which publishes a wide range of practical resources for health and education professionals working with people of all ages (visit for more information).

sense. Some clients feel that this is better conveyed by the term acknowledge. This may seem very obvious, and of course the use and meaning of words continues to evolve. But this example has brought home to me afresh the realisation that the actual words we use in the therapeutic process have powerful effects, and that they can sometimes be changed for the better. Winifred Ashmore is a specialist speech and language therapist in adult dysfluency in Oldham.
Reference van Riper, C. (1973) The Treatment of Stuttering. New Jersey: Prentice- Hall.

Hands-off hands-on
Sheina Stockton defends the place of direct therapy.

How liberating
Sian Owens makes a plea for information to be truly accessible magine to go abroad and understand, whatever the language. How liberating would that be? We all have moments when we dont understand. Words used are difficult, or unfamiliar acronyms are not understood in context, and were afraid to voice this because were scared of looking stupid and drawing attention to ourselves in a negative way. We dont feel confident or comfortable to speak out. If we experience this, then how much more do the individuals we work with who have some sort of communication difficulty? As speech and language therapists were familiar with simplifying sentences or thinking of alternative ways to present information, without being patronising. By considering a persons perspectives and abilities, we try to find ways to explain difficult concepts, and avoid unfamiliar vocabulary and long sentences. But I perceive that Total Communication and accessible information needs to go one step further. Everyone has a right to be involved and included at their own level of ability. Those of us who work with service users with learning disability aim to use basic language and vocabulary, and consistent signage, symbols and visuals. If we can achieve this, then these resources will carry over into other areas. They will then be of value to individuals who have had a stroke, or have a hearing impairment and associated communication difficulties, specific language impairment, or English as an additional language. Communication is important to everyone to prevent isolation. The ability and opportunity to understand is essential to this. Any system or method that enables people to do this has to be a positive thing. To contribute to this in some way is a privilege. Sian Owens is an advanced specialist speech and language therapist with the Learning Disability Team, Betsi Cadwaladr University Health Board.

Accept or acknowledge?
Win Ashmore reminds us of the powerful effect our choice of words can have on the therapy process. provide a community-based service to adults who stammer, mainly using the process model derived from van Riper (1973) of Identification, Desensitisation, Modification and Stabilisation (IDMAS). To begin changing a stammer, the person who stammers needs to accept not only that it exists, but also what it is like in detail. This can be extremely difficult and painful, because of complex behavioural, emotional and cognitive defences. Through working with clients I have come to question whether using the term acceptance creates an unnecessary further barrier. Some have said to me, But I cant accept my stammer! or I wont accept it! Thats obviously true, because otherwise they would not have come for therapy. Some clients have found that acknowledgement of the stammer is a more useful term than acceptance. Perhaps this is because the word acceptance has other meanings, for example a positive response to social, cultural, ethical and other differences, which we not only accept but even celebrate. People who come to speech and language therapy do not accept stammering in that sense, and they want to reduce its control over their lives. To do that, however, they need to engage with and accept it - but only in a neutral, factual

en years ago, I left the NHS. The primary feeling which provoked the move was that I am at heart a hands-on therapist who loves working with young people, untangling their problems and helping them to move forward. I can chair meetings, write policy documents, train others and write therapy programs. I still do all of this, but I trained to work with young people and that is what I wish to spend the majority of my time doing. I am lucky to have contracts with a number of state and independent schools, both within mainstream and special education. Most of my work is with teenagers who have complex difficulties linked to the autistic spectrum or long-term language disorders. I work with teaching and speech and language therapy assistants, carry out training with teaching staff and, where appropriate, leave programs of work to be carried out in school. However I spend most of my time doing hands-on therapy, week after week, mostly in small groups but also on an individual basis when appropriate. Even after 30 years in the business, I am still unable to carry out a one-off assessment on some of these complex youngsters and leave a useful program of work for someone else to do. I need to spend time working with them to untangle the underlying difficulties and focus therapy on the core problems. The teaching assistants have all had training from various sources, but still find it hard to know when to move a pupil on, how to react if they become stuck, and to spot clues which indicate a need to adapt the program. My concern with our profession at present is that we are in danger of talking ourselves out of direct work with children. We still train our new therapists in this role, but increasingly we seem to be adopting an assess-and-advise model of support rather than hands-on. It is very important to ensure a range of inputs, and to have a good skill mix. However, this is very different from adopting the attitude that hands-on therapy is wrong. I have been criticised for actually working with children, as if this was an archaic way of delivering a service. This is despite the fact that the schools who employ me have been profoundly dissatisfied with the advisory model and have found money to support direct therapy. If schools can see the benefits, I find it very hard to understand why some of my NHS speech and language therapy colleagues do not. I am very aware of the profound shortage of therapists in some services and therefore the need to avoid over-committing staff to provide direct input. However, being honest about the reasons for the input model is one thing. To move to a position of being convinced that this is the only acceptable model is a different ball game altogether, and one which I really hope will not prevail. Sheina Stockton is an independent speech and language therapist in the Worcester area.



this house believes

Advice on speech and language therapy as a career from a Guardian online Live Q&A session. Ataxia UK best practice guidelines for the diagnosis and management of people with progressive ataxia have been updated and expanded. They include a large section on speech and language therapy from Anna Farrell, Melissa Loucas, Anja Lowit and Lucy Rodriguez. Free from tel. 020 7582 1444 or email research@ Talking Mats has launched To see ourselves as others see us: a resource for comparing perspectives and enhancing understanding within relationships. It is intended to support people with aphasia and their families, and aid goal-setting negotiations. Sanimatic is an inclusive design electrically controlled rise and fall WC which can be paired with an adjustable height washbasin. Video demo at Music for Starters e-newsletters include lots of tips for introducing rhyme, rhythm and song to groups of children. I CAN is to benefit from the proceeds of a Words for You CD, where actors read poems set to classical music. See video at This service sends print, Braille and audio letters anywhere in the world. The audio letter is a real human voice. (Source = Liz Panton via 1Voice) One Plus One, the relationships research organisation, with a series of short online articles to help couples strengthen their relationship while having a child with additional needs. (Source = Contact a Family) This BSL books and materials website includes free downloads and games. iMinds is a general knowledge alternative to music on MP3 players. This draft guidance for partnership working between allied health professions and education includes features of good practice. h t t p : / / w w w. s c o t l a n d . g o v. u k / P u b l i c a tions/2009/12/01152951/0 A project to make public health educational resources available across the world free of charge.

New free guide for parents of children with cerebral palsy under the age of five years includes tips on learning through play. Tel. Scope Response on 0808 800 3333, or see preview at scope-parents-pack-preview.pdf Cash Counts from Contact a Family is an online service dedicated to ensuring families with disabled children are getting every penny they are entitled to. Information for people undergoing radiotherapy and chemotherapy treatment about the prevention and treatment of oral mucositis, a side effect which can interfere with speech and swallowing. (NB Produced by the manufacturers of Caphosol mouth rinse.) Communication Matters small grants scheme 2010 welcomes applications from not for profit organisations in the UK. Communication in the Classroom Workshops for Secondary Schools, by Susan Stewart and Amanda Hampshire, is now available. A3 colour posters featuring 10-12 Signalong signs on topics including leisure, questions, snacks, sports and taking a stand. 3.50 each or 2.50 if you order 4 or more + 2.50 p&p. Rebecca Matthews ( has discovered a new support possibility for young people with communication difficulties taking exams. An oral language modifier is an adult who can rephrase any question in an exam but only at the request of the student. w w w. j cq. o rg. u k / a t t a c h m e n t s / p u b lished/1096/25.%20AARASC%200910.pdf 1Voice provides a network and support for children who use communication aids and their families. The one-off membership fee of 10 includes a DVD listen to me and electronic newsletters. Responsibility in Healthcare: Changing the Culture is a discussion paper from centre-right think tank 2020health. t/sites/2020/ pdf/2020cultchng-1.pdf This issue of the INVOLVE newsletter includes an article by Gwen Harlow and Carolyn Morris on the impact on individuals of being involved in research as service users.


This House Believes explained

In her teaching, Paula Leslie uses a debating idea from the British Medical Journal to get her students to critically review a controversial subject. By understanding the strengths and weaknesses of the arguments on both sides, the students are better prepared to develop their own views. Students are strictly limited in word count and number of references to foster concise and relevant writing. Their work is now being adapted for Speech & Language Therapy in Practice. The debating format means: the Proposition is required to prove its case, while the Opposition aims to show why the Proposition is wrong either side can interrupt with a point of information while the other side is speaking our authors reach a conclusion based on the evidence and readers can continue the floor debate via the Critical Friends process see


Paula Vanetta John is a clinical fellow in the medical speech-language pathology clinical doctoral program at the University of Pittsburgh, USA, email vdj3@pitt. edu. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, e-mail Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists.



this house believes

This House Believes in cognitive therapy

Vanetta John and Paula Leslie attempt to untangle the case for cognitive therapy with people with dementia, and find cautiously in favour of a global cognitive stimulation approach. Background
We found this debate a huge challenge. Paula is highly experienced in critiquing papers and is a champion of evidence based practice. At the time of drafting the paper, Vanetta was a second year Masters student participating in mandatory clinical training at a skilled nursing facility where at least 90 per cent of the clients suffer from cognitive impairment, ranging from a mild form to severe Alzheimers dementia. Yet answering a seemingly simple question was difficult because: a. the literature and use of terminology is so unclear b. clinical practice with people with dementia varies across different countries c. the lack of consensus about the role of speech and language therapists and the boundaries with occupational therapists further blurs attempts to define what we do. We hope our paper will stimulate further debate and clarification of cognitive therapy with people with dementia. We also hope it will encourage you to continue to try to make sense of areas where we really are uncertain clinically. For the purpose of this paper we are not including cognitive behaviour therapy (CBT). This is defined (Editors AHD, 2007) as, A highly structured psychotherapeutic method used to alter distorted attitudes and problem behavior by identifying and replacing negative inaccurate thoughts and changing the rewards for behaviors. Although CBT may feature in speech and language therapy work with people with dementia, it is substantially different in aims from the cognitive therapy we focus on in our debate. POINT OF INFORMATION: The authors did not use a control group so it is impossible to compare with a no treatment condition. The authors were unable to randomise clients to the treatment groups and, while they did not do the training, they were not blinded to who received which treatment.

The proposition case: a global approach works

The main goal of a cognitive intervention program is to maximise the clients functioning, improve cognitive skills, and reduce problem behaviours. People with dementia can derive benefits from cognitive therapy programs.

Defining the topic

More people are living longer, with a corresponding increase in conditions such as dementia. In most cases dementia is a progressive syndrome. The disease process interrupts a number of higher cortical functions including memory, intellect and cognition. Speech and language therapy input for people with dementia aims to help their communication skills, and can include a focus on improving cognitive function. Communication and cognition contribute significantly to a persons quality of life. The three main types of cognitive therapy used with this population are cognitive stimulation (global), cognitive training (specific) and cognitive rehabilitation (individualised) (Clare & Woods, 2004). Cognitive stimulation involves participation in group activities and discussions focusing on an overall enhancement in cognition and social functioning. Cognitive training uses guided practice in individual cognitive domains. Cognitive rehabilitation is an individualised patient-centred approach geared at improving functioning in everyday life. Each of these approaches targets people with varying degrees of severity of cognitive impairment. Owing to the progressive nature of dementia, their effectiveness is uncertain.

A global approach

One approach to treating people with dementia is the use of a global technique. A global treatment program targets a general reorientation of the client and overall cognitive stimulation in the context of activities that are social and enjoyable. This approach contrasts with a cognitive specific program which targets specific aspects of cognition such as procedural memory. Farina et al. (2006) compared these two approaches to cognitive therapy in a study of 32 people with a diagnosis of a possible or probable Alzheimers Dementia with mild to moderate cognitive impairment. The authors found no statistically significant difference between the two treatment groups on improvement in cognitive functioning and on a measure of everyday functioning. But, after a 6-month follow up, therapy gains were maintained in the global group. In addition, participants receiving the global stimulation demonstrated a statistically significant reduction in behavioural disturbances. This caused a ripple effect as it also reduced caregiver distress. The authors concluded that global stimulation resulted in better outcomes than a cognitive specific training program.

In any therapy program cognitive change should not be the only measure of the success of an intervention: the clients quality of life must be considered. A study by Woods et al. (2006) aimed to find out if there is a relationship between improvement in cognitive functioning and quality of life (QoL) measures. A cognitive stimulation therapy approach which encompasses a global stimulation technique was used. The authors reported that there was a significant positive effect on the QoL-Alzheimers Dementia score. Improved cognition correlated highly with quality of life in the areas of memory, social functioning, and activity level. The authors concluded that a cognition-based approach such as cognitive stimulation therapy can have a direct impact on a clients quality of life. Improvement in quality of life also significantly correlated with a reduction in depression and improvement in communication. The authors explained that these results make sense because the program involved group interaction. The activities used were cognitively stimulating, social and enjoyable. This study had a good sample size of 201 participants and they were randomised to the different treatment groups. The authors were also blinded to which participants were in each group. Clear, detailed analyses to determine variability in difference scores and correlation between variables were conducted, making this a very strong study.

Quality of life

Summing up the case for the proposition

Certain types of cognitive therapy programs are effective in improving cognitive function and improving the clients quality of life. Quality of life improvements also involve a reduction in the behavioural issues brought about by the dementia.



This house believes

The opposition case: confusion reigns supreme

There is a serious lack of standardisation in terminology, evidence and practice in cognitive therapy with respect to people with dementia. The focus of cognitive training, a form of cognitive therapy, is on guided practice of individual areas of cognition such as memory, attention and executive function. These methods operate on the premise that targeting one domain will improve or maintain functioning in that domain (Clare & Woods, 2004) and also generalise to other areas of cognitive functioning. Despite claims made by some studies, a systematic review conducted by Clare & Woods (2003) revealed no significant positive effects of cognitive training. This study provides robust evidence because it was a well-designed systematic review. The authors had specific inclusion and exclusion criteria which had to be met; the studies included were all randomised control trials and 9 met the criteria for review. The authors pointed out that the lack of effectiveness of this type of approach may be partly attributed to its focus on targeting specific areas of deficit and how these are addressed in therapy. They argue that it tends to highlight clients areas of deficits/weakness which may reduce their motivation to participate. POINTS OF INFORMATION: 1. The authors reported no negative outcomes for this training. 2. It is important to realise that, while a cognitive training program may bring about improvement in different cognitive domains, it may not generalise to the everyday lives of the client and the caregivers. A cognitive therapy program such as cognitive stimulation is more meaningful because it impacts the emotional and behavioural aspects of the client and the well-being of the caregivers.

ties and relaxing (Arrighi et al., 2009). A goal of cognitive therapy is to improve the persons ability to function in their daily lives. Kurz et al. (2009) examined the use of a multi-component rehabilitation programme in people with mild cognitive impairment. The authors compared 10 people with mild dementia to 18 with a mild cognitive impairment on four measures of cognitive function: activities of daily living, mood, verbal and nonverbal episodic memory. They found that, following this 4-week structured group program, the people with mild cognitive impairment saw a significant improvement on all four measures. Those with mild dementia showed a non-significant improvement on verbal episodic memory and a slightly reduced depression score, but no change on activities of daily living. POINTS OF INFORMATION: 1. This study has a number of limitations including small sample size and lack of a control intervention. The authors admit to not basing the intervention on a consistent theoretical background or to using established neuropsychological techniques. 2. Maintenance of function in a progressive disorder should be considered equal to improvement in stable conditions.

Judgement: The motion is carried

Summing up the opposition case

The techniques considered have questionable evidence and, in some areas, intervention can make the situation worse. Confusion over terminology contributes to the poor evidence for cognitive therapy with this client group and thus practice should be halted until we have clearer evidence and guidelines.
References Arrighi, H.M., McLaughlin, T. & Leibman, C. (2009) Prevalence and impact of dementia-related functional limitations in the United States, 2001 to 2005, Alzheimers Disease and Associated Disorders Jun 29 (Epub ahead of print). Clare, L. & Woods, R.T. (2004) Cognitive training and cognitive rehabilitation for people with early-stage Alzheimers disease: A review, Neuropsychological Rehabilitation 14(4), pp.385-401. Clare, L. & Woods, B. (2003) Cognitive rehabilitation and cognitive training for early-stage Alzheimers disease and vascular dementia, Cochrane Database of Systematic Reviews 4, pp.1-40. Editors of the American Heritage Dictionaries (2007) The American Heritage Stedmans Medical Dictionary. Boston, MA: Hougton Mifflin Company. Farina, E., Mantovani, F., Fioravanti, R., Pignatti, R., Chiavari, L., Imbornone, E., Olivotto, F., Alberoni, M., Mariani, C. & Nemni, R. (2006) Evaluating two group programmes of cognitive training in mild-to-moderate AD: Is there any difference between a global stimulation and a cognitive-specific one?, Aging & Mental Health 10(3), pp.211-218. Kurz, A., Pohl, C., Ramsenthaler, M. & Sorg, C. (2009) Cognitive rehabilitation in patients with mild cognitive impairment, International Journal of Geriatric Psychiatry 24, pp.163-168. National Collaborating Centre for Mental Health (2007) Dementia: The NICE-SCIE guideline on supporting people with dementia and their carers in health and social care. Leicester: The British Psychological Society. Woods, B., Thorgrimsen, L., Spector, A., Royan, L. & Orrell, M. (2006) Improved quality of life and cognitive stimulation therapy in dementia, Aging & Mental Health 10(3), pp.219-226.

Negative behaviour

Behavioural issues are a reported key finding in people with dementia. These issues may limit the individuals ability to interact with others. Caregiver distress is a common co-occurrence and intervention programs should address this. Clare & Woods (2004) argue that a cognitive specific program may not be motivating and may therefore lead to an escalation of negative behaviours in a client with behavioural problems. This is important to know since a large percentage of therapists are using a cognitive specific approach with people with dementia. POINT OF INFORMATION: This finding provides added support for the use of a more global stimulation approach to cognitive intervention in people with dementia, given that behavioural issues are a common co-occurrence.

Functional limitations

As dementia related symptoms increase, there can be a corresponding decrease in clients ability to perform functional tasks such as going out to shops, participating in social activi-

Cognitive therapy is one of the major interventions for people with dementia. Its purpose is to improve the clients cognitive functioning and quality of life. Speech and language therapists in various settings must use the best available evidence to support treatment decisions. People with cognitive impairments including dementia may not be able to express their values and preferences regarding treatment. We have a responsibility to the client and family to provide valid and reliable information about the options. The research evidence that we use needs to be of the highest quality. The studies examining the efficacy of cognitive therapy have used a range of designs including randomised controlled trials. They had participants with mild to moderate dementia. More research is needed to determine whether cognitive treatments have a positive effect on people who fall into the severe category. This is important because this is the main patient population in long-term care facilities. People with dementia are often institutionalised when their caregivers are unable to care for them. This can result in a greater likelihood of depression, behavioural problems and disorientation. Our chosen treatment approach must have an effect on the whole person and not just some aspects of cognition such as memory and attention. A global stimulation approach targets all aspects of the individual and has been shown to be effective. Each individual case should be considered in light of the most relevant evidence. It would be necessary to examine this method with those who are more severely affected. The NICE (National Institute for Health and Clinical Excellence) Guideline on dementia (NCCMH, 2007) summarises the position: People with mild-to-moderate dementia of all types should be given the opportunity to participate in a structured group cognitive stimulation programme. This should be commissioned and provided by a range of health and social care staff with appropriate training and supervision, and offered irrespective of any drug prescribed for the treatment of cognitive symptoms of dementia. (p.25) The authors acknowledge that there is no evidence either for many issues that we are concerned with, or that the aims of the research match the objectives of the clinical intervention (NCCMH, 2007). The findings of the research, derived from a range of study types and evidence strength and quality, is that cognitive therapy is effective in treating some people with dementia. There is a paucity of evidence on issues in severe dementia. Some methods have proven to be more effective than others and the method chosen will depend on the severity of the clients deficits and other co-existing conditions. Despite the limitations of some methods, our considered opinion is that the benefits of case by case evaluated cognitive therapy outweigh the drawbacks.




Jois Stansfield and Frances McAleer consider the following scenario:

Brought to (Face)book
BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics 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. (HPC, 2008). The Royal College of Speech & Language Therapists code of ethics and professional behaviour (RCSLT, 2006) is also helpful in reminding us of our duties. Ethical reasoning can be supported by tools such as the Seedhouse grid and Values Exchange (Seedhouse, 2009). Ethical principles and guidelines may not have been designed to deal with current forms of communication, but they can be used to guide professional and personal behaviour. Nevertheless, ultimately it is up to each of us to judge what is correct behaviour. Our duty towards our clients includes ensuring that the well-being of the clients is not compromised by any action or omission on the part of the SLT (RCSLT, 2006, p.12) and that we should have effective and proper communication with them. This might suggest that if we see a criticism of the speech and language therapy service we are offering on a social networking site, we should respond, either directly through the site, or later once we meet the client in clinic. But we are also required to avoid inappropriate or disruptive personal relationships with clients (RCSLT, 2006, p.11), so this would need to be considered carefully. The fact that we have read such a comment, even though it is in the public domain, might be considered by the client to be inappropriate, disruptive or improper communication. With regard to professional conduct, reading clients status updates may be seen as a conflict of interest: we know the client in our professional rather than personal capacity.

You are a member of Facebook. It is obviously open to you to search for clients or their parents on this social networking site, and to look at any information they have chosen to make publicly available. But are there implications about what you do with this if, for example, it makes it clear they are unhappy with the service they are receiving?

lectronic communication in general and social networking sites in particular have changed the way we communicate in profound ways. The social networking sites that are best known in the UK include Twitter, Bebo, Mumsnet, LinkedIn, Friends Reunited, WAYN and MySpace, with the highest profile currently enjoyed by Facebook. These media have a powerful capacity to speed up communication and many of us use them in the same way as having face to face conversations. One difference is that a spoken conversation is not recorded in any written form as it takes place, while social networking site conversations are. Social networking sites have their own vocabulary and etiquette. In terms of confidentiality, by signing up to something like Facebook you agree for them to have access to the information that you have provided and you choose how much of that information is available to the public. In principle, what you can see about people should be what they want you to be able to see. It is possible to keep your profile 'private' if you select the right options, however not everyone does. Depending on your privacy settings, anyone whom you choose to be your friend, or friends of friends or everyone can see most of your information. This can be anything from your photos to your status updates, for example, if you were to sound off about something or someone. It can mean that something written in the heat of the moment can be there for all to see, long after the moment has passed. Comments can, of course, be deleted by whichever party has written them (so long as they are quick enough to do so before anyone important notices them!) so, if you do realise a few hours later that what you wrote was not perhaps your best idea, it is possible to retract a statement before everyone has seen it. With the nature of Facebook, though, you can be fairly certain that at least one or two people will have and so there will be some form of consequence, even if it is just from your real friends. Clients, students and professionals are all likely to use social networking sites and to have electronic conversations which they do not keep private. So what are the ethical issues? The particular focus is the boundary between private and public behaviour. The Health Professions Council states we must be professional and ethical, act with integrity and honesty and behave appropriately



Has the client already identified themselves as a client and us as their therapist? Should we respond at all, with or without making it explicit how we know the person concerned? Probably not. If responding in a public arena, we need to be very clear about the limits of confidentiality as we must not compromise these. So far as personal conduct is concerned, it is worth remembering that our own use of social networking sites must be sufficiently prudent that it does not bring us or the profession into disrepute, so discretion in posting photographs, opinions and even in vocabulary usage is called for. Would you really want your client, boss, clinical educator (or mother) seeing the content of your public pages? Clients are at liberty to hold forth, comment, and even praise online. Most do not have the same professional restrictions on their personal lives as speech and language therapists. As speech and language therapists, we have a duty to act with integrity in public but also in our personal lives. This does not mean that we can all be paragons of virtue, but that we consider the effects of our actions, including those when using social networking sites, and reflect on if or how these may influence peoples views of our profession. Jois Stansfield is Professor of Speech Pathology at Manchester Metropolian University. Frances McAleer graduated from Manchester Metropolian University in 2007 with an honours degree in International Fashion Marketing. She is Joiss daughter, and definitely does not let her mother read her Facebook pages.
References Health Professions Council (2008) Standards of conduct, performance and ethics. London: HPC. Royal College of Speech and Language Therapists (2006) Communicating Quality 3. London: RCSLT. Seedhouse, D. (2009) Values Exchange. Available at: (Accessed: 17 August 2009).




Classics in Voice and Laryngology Ryan C. Branski & Lucian Sulica (eds.) Plural Publishing 978-1-59756-242-3 85.00

speech and language therapist working with young children to incorporate some of the many practical tips into everyday practice. Rose Begbie is a speech and language therapist working in early years with Surrey Community Health Services.

for an individuals collection, could be a priceless addition to the departments resources. Vicky Brady is a paediatric speech and language therapist working for Central and Eastern Cheshire PCT.

Not bedtime reading

This well-structured compilation of 38 reprinted review articles and papers (published 1967-2007) covers laryngology, voice science and research. It is classified into 15 subject groups from Phonatory Anatomy through to Laryngeal Transplant. In covering such a wide range, the number of articles chosen for each area is very small and highly selective. Some of the articles have been reproduced with poor quality pictures. The book puts a large number of papers at your fingertips and may be useful as a means of quickly accessing full articles. It is neither light bedtime reading nor highly practical in the clinic, but could be of interest to students, those specialising in the field and our medical colleagues. This book is expensive and I would question whether it is value for money. Possibly a useful addition to a departments library, but not to sit on the shelf of every therapist. Ruth Wallace is a principal speech and language therapist in head and neck with York Hospital NHS Foundation Trust.


Lets Sign Dictionary Everyday BSL (2nd edn) Cath Smith Co-Sign Communications ISBN 978-1-905913-10-7 15.99

Practical Ideas for Emotional Intelligence Adele Clark & Jacqui Blades Speechmark ISBN 978-0-86388-611-9 36.99



Hands-on and applicable


Emergent Literacy and Language Development: Promoting Learning in Early Childhood Paula M Rhyner (ed.) Guildford Press ISBN 978-1-60623-300-9 24.00

This dictionary is a fantastic resource for anyone studying BSL levels 1 and 2 or those wishing to brush up on their sign vocabulary. The dictionary contains over 2,000 up-to-date signs printed in a large, clear format. Each entry is shown as if the reader is facing the signer and shows the start and end positions for each sign very clearly. A written description is included under each illustration, providing essential information relating to handshape, movement of the sign and any facial expression required. The dictionary also includes a separate section of topic specific vocabulary such as days of the week, months of the year, weather, occupations and animals, providing a perfect revision guide for BSL level 1 exams. The only negative aspect is its size, as an A4 book is not easy to carry around. However, this minor point is easily outweighed by its usefulness. Definitely value for money. Debbie Gutteridge is a speech and language therapist in Barking and Dagenham, currently studying for BSL level 2.

Wealth of information

Without specialist knowledge in the development of literacy this book is not one for dipping into but it is well worth the re-reading required to fully appreciate the wealth of information on theory, research and practical considerations. Beginning with an overview of emergent literacy it continues with chapters focusing on the authors particular areas of expertise. The chapters on Book Sharing and the Development of Meaning, Metaphonological Awareness and Early Writing and Spelling Development are most interesting to therapists working in early years settings. The chapter on Multiculturalism is aimed at the American reader but the principles are easy to apply to the UK. There is extensive use of references and four of the six chapters describe case studies which illustrate the practical application of the intervention strategies outlined, taking into account the unique circumstances of individual children. The book is probably most useful to teachers, those with a particular interest in literacy or those working in education settings, but there is enough evidence presented on thebi-directional relationship between oral language and written language development to encourage any


Professional Writing in Speech-Language Pathology and Audiology Robert Goldfarb & Yula C. Serpanos Plural Publishing ISBN 978-1-59756-175-4 51.00

This practical and easily accessible resource book is aimed at a range of professionals working with young people aged 10-18. It provides easy to use photocopiable resource sheets for use with individuals, pairs or small groups, and is ideal for any level of experience. The chapters deal with issues including bullying, self-esteem, family change and study skills. As a therapist with a varied and demanding caseload, I found it interesting and applicable to many of the pupils I work with. The worksheets are well presented and need little or no preparation. I will definitely dip in for specific resources such as dealing with transition to high school. Whether I would have time to work directly on many of the issues is doubtful; there are usually professionals far more qualified, or they do not come under our official remit (eg. self-harming). However, speech and language therapists may find this resource useful if it does fall to them to deal with emotional issues, as all too often there is overlap with communication. A very hands-on and useful resource to have in my toolkit. Hayley Kilmartin is a specialist speech and language therapist working in North Wales with secondary aged pupils and pupils with specific language impairment.


A priceless addition

The light-hearted, often humorous tone to this book makes the topic of professional writing a little easier to digest and almost enjoyable to read. Its ideal for any therapist wanting upto-date guidance on the dos and donts of their written work as legal documentation, but particularly for those just starting out. It excels in its discussions of report writing if nothing else, delivering relevant information on a whole host of valuable topics, including common grammatical errors, correct terminology and the required content for diagnostic / clinical reports. It provides extensive examples throughout, consolidates each chapter with various refresher exercises and makes it simple to check whats been learned. Overall a useful text which, if a little over-priced

50 Top Tips for Managing Behaviour Dave Stott Speechmark ISBN 978-0-86388-678-2 39.99

Exudes an air of calm

Dave Stott has worked in education for 30 years and his approach to behaviour management is down to earth. Although clearly aimed at teachers this book grabbed me from the start. Stott gets right to the point by describing 50 behaviour management problems and leaving the reader with a tip for each. It is easily readable and exudes an air of calm from Tip1 (Behaviour management during cover lessons Top Tip: Establish simple procedures) to Tip 50 (Who wants the last word Top tip: Scripted responses work reaction inflames). The format allows the reader to jump to their area




of interest without trawling through lengthy descriptions and is therefore easy to dip into during a spare 10 minutes. Each Tip helps us consider the bigger picture by highlighting the feelings and needs of the adults and pupils involved as well as classroom or school procedures and culture. The advice provided makes sense and I will use this photocopiable resource and share it with teaching colleagues. Rhona Williamson is a community speech and language therapist working with children and young people in Airdrie, NHS Lanarkshire.

I would also advise students to read it. Not essential for speech and language therapists but interesting nonetheless. Jennifer McAlpine is a specialist speech and language therapist (challenging behaviour) at the Greenbank Centre in Edinburgh.

particular benefit to students, newly qualified therapists and assistants, or for therapists to recommend to other early years practitioners. Janet Robinson is a speech and language therapist working in Childrens Centres in Keighley, West Yorkshire.



Connecting through Music with People with Dementia: A Guide for Caregivers Robin Reo Jessica Kingsley ISBN 978-1-84310-905-1 14-99


Dysphagia post trauma Elizabeth C. Ward & Angela T. Morgan Plural Publishing ISBN 978-1-59756-236-2 44.00

First Steps in Intervention with Your Child with Autism Frameworks for Communication Phil Christie, Elizabeth Newson, Wendy Prevezer & Susie Chandler Jessica Kingsley ISBN 978-1-84905-011-1 12.99

May be patronising

Highly recommended

This compact yet comprehensive work examines dysphagia in the setting of trauma from a variety of aetiologies, including brain and spinal injury, burns, and multiple and iatrogenic trauma. It is aimed at both newly qualified therapists unfamiliar with this area, and experienced therapists seeking supportive evidence for best practice. Chapters are themed and structured to include epidemiology, pathophysiology and basic anatomical considerations before embarking on evidenced, practical assessment and management guidance. Whilst lengthy, the text is easily read, well headed and edited from the perspective of therapists who clearly have clinical experience and an understanding of the pitfalls of management in the real world. I thoroughly enjoyed this book, and would highly recommend it for departments with a trauma caseload. Alison Davison is a speech and language therapist in regional neurosciences at Newcastle General Hospital.

This simple book gives an overview of music therapy. It details melody, rhythm, song choice and techniques. It is useful even if the carer has no musical knowledge. There are many examples but some seem to benefit the author rather than the person with dementia. It contains outdated terminology and errors in the text. Many of the songs in the appendix are American or too old. The author suggests using songs from the decade when the resident was a teenager or young adult, but some of the titles are from the 1890s! This is a simple and quickly read text but some may find it repetitive and patronising. It is overpriced at 14.99 but perhaps useful for carers to request from the local library. Julie Baker is a specialist speech and language therapist working with older people with mental health needs for NHS North Staffordshire Community Healthcare.

Enjoyable and informative


This enjoyable, easy to read, informative book champions initial intervention with preschool children with autism. It contains many practical ideas and strategies centred around interactive play and early social communication that can also be applied to school age children if they are at an early stage. It is designed to be used directly by parents looking to understand better what autism means in relation to their own child, and so help to improve their play, understanding, and communication. It is also a useful reference for both newly qualified and more experienced therapists working to support families, as it links in very well to everyday clinical work with this client group. It is good value for money for departments on a budget. Cath Gallacher is a specialist speech and language therapist at the Frances Wright Preschool Centre in Dundee.

Attention and Listening in the Early Years Sharon Garforth (see also pp.26-28) Jessica Kingsley ISBN 978 1 84905 024 1 19.99




Workplace Skills and Professional Issues in Speech-Language Pathology Betsy Partin Vinson Plural Publishing ISBN 978-1-59756-203-4 38.00

Asperger syndrome and Anxiety - A guide to Successful Stress Management Nick Dubin Jessica Kingsley ISBN 978-1-84310-895-5 13.99

One to recommend

Although interesting for speech and language therapists, the style and prose of this book make it more relevant as the author intended for people with Asperger Syndrome. It is full of useful strategies for reducing stress, and offers a real insight into the perspective of those with Asperger Syndrome. A note of caution though; while this is a book to recommend to people who have Asperger Syndrome, it is not for everyone and I would suggest you read it first, as at times it can be confusing.

This easy to read programme was designed as an alternative to a circle time group for 2-4 year olds. It provides 6 sample themes and plans plus additional alternative songs/rhymes and activities with graded adjustments to the activities to stretch the skills of the group participants. Each plan consists of 2 versions. Version 1 provides additional detail to aid preparation with a shorter version 2 available for reference during the group. Whilst many of the activities are probably not new to many, the ready-made plans will save valuable preparation time. This makes it a costeffective resource for busy staff, although time will still be required to further reduce the version 2 plans (currently 7 pages) for realistic reference during groups. The structured activities and objectives, along with the authors recommendations regarding the practical aspects of groups (venue, group size, length) will be of

A reference point

Aimed at therapists starting out in their career, this book covers a wide range of professional issues including job interviews, legislation, professional standards and practical workplace skills. Unfortunately many of the chapters are American orientated and of limited use to the UK reader, although the latter part is more generic. I found it is easy to read and particularly liked the insightful section on leadership with strategies for time management and burn-out avoidance. There is also useful coverage of hygiene precautions, ethical issues, counselling clients with communication disorders, clinical-decision making and becoming a clinical supervisor. Despite the American focus, I learned a lot. I would recommend it as a reference point and will certainly dip into it in my role as a clinical



educator. It would be of great interest to those wanting to compare the UK and American professional bodies (RCSLT and ASHA) or preparing to work in the USA. Ali Tempest is a lecturer at De Montfort University. can be photocopied for instructional use. Theories behind dyspraxia are not discussed as the books remit is of a practical nature. An extremely useful resource. Rachel Fulluck is a speech and language therapist with Addenbrookes NHS Trust, and also works independently.

Challenge Me! Amanda Elliot Jessica Kingsley ISBN 978-1-84310-946-4 19.56


Hands on Dyspraxia - Supporting Children and Young People with Sensory and Motor Learning Challenges Jill Christmas Speechmark ISBN 9780863886539 39.99


Not useful

Mommy I Am Special and So Are You Dana R. Jones DTA Publishing ISBN 9781936042012 7.67

Practical strategies

This book aimed at parents, teachers and allied health professionals differentiates dyspraxia and developmental co-ordination disorder, discusses the challenges of living with dyspraxia and provides practical support strategies. Based on the authors experiences as an occupational therapist, it offers hands-on advice and ideas. Chapters cover the topics of Sensory Integration, Eye and Hand Skills, Visual Perception, Bilateral Integration, Primitive Reflexes, Living Skills and General Body Awareness Exercises. Each chapter follows a similar format defining and describing the presenting problem, discussing the issues and challenges faced by the child and then offering practical support strategies. The information is clearly presented and ADVERTISEMENT


This American, religiously-pitched workbook is aimed at children with autism and special needs. It could be useful for disability awareness work with less challenged young people, who have an interest in or an understanding of Christianity and religion. Some points raised are relevant, however others could be confusing for many students. Biblical references are linked to each key point, but these would be too abstract for many of my students. Some of the quotes are quite wordy! It is pleasantly illustrated, compactly sized and reasonably priced but I would probably not use it in my school for either group or one-to-one sessions. Julianne Macrae is a specialist speech and language therapist and Centre Manager of the Post 11 Autistic Centre, Jarrow School, Tyne & Wear.

This resource comprises of 56 laminated cards that target oro-motor activities such as inhalation, exhalation, lip and tongue movements and facial expressions. It also includes cards to work on sounds. The cards are attractive, with well illustrated characters and each clearly states the exercise to be practised, for example: Make a big smile with lips closed (card 26). However, I dont think this product would be very useful for the busy paediatric therapist. For younger children many of the activities would be more easily done using a mirror and/ or instructions from the therapist. I also doubt the value of the activities for working on sounds such as Practise saying the names of everyday objects as clearly as you can (card 49) and Practise saying the vowels A, E, I, O, U (card 45). The author doesnt give any evidence for the activities. I wouldnt get a lot of use from this product. Definitely not a must-have for me. Deirdre Tobin is a senior speech and language therapist in Cork, Ireland, working in a community SLTP care setting with children.

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How I make the most of early years (1):

Everyday talk
very Child a Talker (ECAT) is a National Strategies programme in England to support staff in the Early Years Foundation Stage to develop childrens speaking and listening skills. Local authorities are employing Early Language Consultants to work with lead practitioners in targeted settings. Their role is a practical one; as explained in DCSF (2009), they are expected to: share understanding about how language develops from 0-5 interact with and talk to children effectively regularly monitor how children's language is developing support identification of children who might be falling behind consider how to get parents more involved design, plan and lead on language activities. As an Early Language Consultant in Hackney, an inner city London borough, I am charged with putting these ECAT principles into practice. I share my post with Sheila Harrison from the local education department (The Learning Trust), and benefit from her long experience in early years teaching and training. This collaboration has worked really well as we have been able to pool our knowledge and experience. Sheila is familiar with application of Early Years Foundation Stage principles in preschools, and with issues around early years education in general, such as managing outside time and snack time with large groups of children. I bring my knowledge of early language, help teachers identify children having difficulty with communication, and advise on strategies to develop communication skills. Many boroughs have decided to use this joint model for ECAT consultants. Being seconded to the education department in Hackney has resulted in lots of joint planning and training with other education staff working in early years posts. We have also provided very successful training to childminders, and Sheila is participating in a baby room training project across the borough to promote good communication skills with the very youngest children. This includes training staff in using Treasure Baskets (for children up to 1 year old), and in encouraging heuristic play (for the 1-2 year olds) (Goldschmeid & Jackson, 2003; Hughes, 2006).

Cynthia Pelman finds the Every Child a Talker programme a mine of practical resources for therapists working with the universal child in collaboration with early years practitioners.

Read this if you are interested in A collaborative approach Group work Evaluation tools

Cynthia and Sheila


The principles of ECAT are familiar to speech and language therapists, but the challenge is to transmit this to teachers in a way which is relevant and acceptable. One of the main benefits of the programme is that it is couched in education-speak rather than in speech and language therapy jargon. The ECAT guidance notes are situated within the framework of the four principles of the Early Years Foundation Stage: the unique child; positive relationships; enabling environments; learning and development (DCSF, 2008a). This makes the rationale behind each activity immediately recognisable for teachers and teaching assistants and is the key reason why they have adopted it enthusiastically. The ECAT programme is full of many useful resources for the speech and language therapist working with the universal child in

collaboration with early years practitioners. The ECAT guidance manual (DCSF, 2008b) includes a section on Making the most of everyday activities. This means we are not asking teachers to change their daily routine, or to learn and apply new programmes. Instead, we are simply asking them to expand on activities which are already happening in early years settings, extending them to promote language development. The ideas in this section are suitable for group work, as the children can all join in the discussion. This overcomes another of the hurdles which arises when trying to achieve collaborative work between teachers - who work with groups and classes - and speech and language therapists, who are more focused on individuals. Some examples of everyday activities which can be expanded for language development include water play, sand tray play and making a camp:



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a) Water play
Most children love to play with water and it offers endless opportunities to develop language concepts. With a bit of lateral thinking you can create variations in the water itself, as well as varying the objects you put in the water. Changes to the water itself: change consistency (add cornflour) change colours using food colouring (make bottles of different colours and then mix them to see what happens) add glitter; add oil (will it mix? will it float?); slowly add warmer or colder water for discussion and comparison (too cold, a bit warmer, very warm, too warm); add a large block of ice and see how long it takes to melt (what makes it melt faster?) Find an ice tray which makes fish-shaped ice cubes; get the children involved in making the ice cubes, waiting until they are frozen (how long? is it hard yet?) and then watching them melt in the water and disappear. What you put in the water: Get the children to help you create scenes from nature, such as The sea (miniature world fish, shells, octopus, seaweed); A beach (sand, miniature chairs, balls, dolls, bits of fabric for towels, miniature boats) A polar icecap (large blocks of ice, miniature polar bears and penguins) Scientific concepts: Number, capacity: use containers of different sizes and shapes (how many little cups will it take to fill up a bottle with water? which one has more water in it, the tall thin one or the short fat one? more/ less, full/empty) Motion and flow: containers of different sizes and shapes, some with big holes, some with tiny holes; looking at how fast the water comes out of different openings (fast/slow, little/lots); making waves by gently tipping flat icetrays to make big waves at each end; moving water from one container to another; using plastic tubing (catheter tubes!) to transfer water from one place to another (concepts of speed, direction, capacity, full/empty, fast/slow) Water and its power (water wheels and pumps) Floating and sinking (bits of wood, metal, sponge) and, of course, bubbles!

Sand variations: Dry sand and damp sand create many different possibilities for pouring and building Mixing the sand with pretty pebbles (easy to remove and provide scope to talk about concepts of texture and weight) What you can put in the sand: Besides the usual sieves, buckets and other containers, you can hide things in the sand, for example Diggers and trucks (moving sand from one place to another, loading, emptying) Miniature world objects in the sand and in the diggers (concepts of place and position: under, on top) Create scenes from nature: * A desert using dry grass, twigs, snakes and insects which live in deserts * An oasis in the desert (palm trees, camels, a bottle top with some water in it) * Fossils (can lead to a fossil hunting trip at the beach) * Bury miniature world monsters and dinosaurs to discover Imaginative play: Buried treasure: shiny things which can then be put in treasure boxes - each child gets a matchbox to decorate, using glue, glitter and sequins; a treasure map can show spatial reference points such as top left corner / next to the tree / under the rock. Scientific concepts: Concepts of shape and size: such as round things vs. square things (bury marbles, small balls, blocks, bottle tops, the spheres from roll-on deodorants), which can then be sorted into two piles, round or square. You can do the same with long things vs. short things including ribbons, toy snakes Making marks, lines and patterns in dry or slightly damp sand: concepts such as straight / crooked / curved / wavy lines

Many settings tend to have the water and sand trays set out before the children arrive, but it always generates lots of conversation when we get the children involved in creating the scenes (what else do we need for a beach?) When teachers make changes to the layout of the nursery, it is a good idea for them to talk to the children about why they are doing it and to ask them what they think about it, and whether they think it is better this way. This kind of group planning and evaluation can stimulate social skills, creativity and imagination as well as language. Another useful resource in the ECAT manual is its evaluation tools. One of these is the Enabling Environment audit, which requires teachers to draw a plan of their setting, marking each activity area (such as role play / dressing up area, mark-making area, sand play area, book corner) on the plan, and then evaluating in which spaces lots of talk takes place, and in which areas little talk takes place. Areas which are then found not to be conducive to talking can be changed by very simple means, for example by moving the mark-making table to a better-lit space, or by moving the reading area away from the noisy play.

Areas which are ... not conducive to talking can be changed by very simple means, for example by moving the mark-making table to a better-lit space
The ECAT tool which has had the biggest effect in my experience is the individual child language audit. Teachers are trained to use a four-strand framework (listening and attention, understanding language, speech sounds and talk, social skills and play) and each child is monitored four times (once every school term). The effect of this has been to clarify for teachers what is actually expected of a child at each stage of development. One of our teachers said in her feedback to us: For the first time I actually know what to look for in a childs communication and can give parents specific and accurate reports. No amount of theoretical training on the stages of development can improve on the year-long, hands-on experience of making judgments about the stages and achievements of each individual child in the classroom, and watching them progress from one level to the next. Surprisingly, this audit format is not available in the ECAT guidance, but you can access it via the members area of

c) Creating a camp
Children love to hide away in small secret spaces. Many Early Years settings have high ceilings and too much activity, clutter and noise for really good conversations to take place. You can buy inexpensive pop-up tents, or better still provide blankets, sheets, big boxes, tables, broomsticks stabilised in buckets of sand, and pegs so that the children can make their own camps and secret hiding places. Camps can be indoors or outside. Take the reading corner outside the classroom and have a story session inside a tent; make snack time a picnic in the camp. Elizabeth Jarmans website on Communication Friendly Spaces is full of ideas for what to put inside the camps, and how to use interesting lighting and soft finishes to make them really inviting.

b) Sand play
As with water, you can vary both the sand itself, and what you put in the sand.



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Sadly, the budget for ECAT is finite and the formal programme ends this year. Sheila and I have been frantically pushing for sustainability of the wonderful ideas in ECAT by offering training to a wide range of education and speech and language practitioners, by producing manuals and writing this article. We hope many people will access the materials online and make good SLTP use of this wonderful resource. Cynthia Pelman is an Early Language Consultant with The Learning Trust in Hackney, e-mail

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DCSF (2008a) Practice Guidance for the Early Years Foundation Stage. Reading: The National Strategies. Available at http://nationalstrategies. (Accessed 28 January 2010). DCSF (2008b) Every Child a Talker: Guidance for Early Language Lead Practitioners. Reading: The National Strategies. Available at uk/node/153355 (Accessed 28 January 2010). DCSF (2009) Early Years e-newsletter, Section 3 Every Child a Talker. Available at: (Accessed 28 January 2010). Goldschmied, E. & Jackson, S. (2003) People Under Three: Young People in Day Care. (2nd edn) New York: Routledge. Hughes, A. (2006) Developing Play for the Under Threes: The Treasure Basket and Heuristic Play. London: David Fulton.



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Following their article in our Winter 09 issue, Liz Elks and Henrietta McLachlan of Elklan are offering THREE free copies of their new early years resource. The Early Years Based Information Carrying Word Pack is a resource of pictures and activities on topics including ourselves, clothing, food, toys, home and animals. It aims to promote the vocabulary, comprehension, listening, auditory sequential memory, expressive language and social communication skills of a wide range of children through the principle of Information Carrying Words. As well as careful explanation, home activities and a checklist to monitor progress, the Pack includes material to run a two and half hour training session for parents and early years practitioners. The authors suggest that, in addition to supporting early learning goals and collaborative working, the resource is useful for children learning additional languages. The EYBIC Word Pack normally costs 35. To enter this FREE prize draw, simply e-mail your name and address with EYBIC Speechmag Offer in the subject line to henrietta@elklan. by 25th April 2010. The winners will be notified by 1st May. For further information about this and other Elklan products and training, visit www.

Communication Friendly Spaces, see www. ECAT individual child audit form available at

Reflections Do I consider the influence of space, privacy and location on talk? Do I couch the training I offer in meaningful language and frameworks? Do I recognise that, with lateral thinking, the opportunities are endless?
Do you wish to comment on the impact this article has had on you? Please see guidance for Speech & Language Therapy in Practices Critical Friends at www.

Reader offer winner

Congratulations to Katy Mackay, the winner of the 25 voucher to spend online at, offered in our Winter 09 issue.




How I make the most of early years (2):

Listen with Lucy

developed the Attention and Listening in the Early Years programme, or Listen with Lucy as it is known locally in Shropshire, having heard concerns from teachers and heads of local schools that an increasing number of children were entering their reception classes without adequate attention, listening and language skills for accessing the National Curriculum. This was reflected in a national survey of head teachers by the National Literacy Trust (2001). At the time, there were already many settings in North Shropshire running the SALLEY (Structured Activities for Language and Literacy in the Early Years) programme (Boucher et al., 2002) for children aged 3 years and up. However, at the time I was working for a Sure Start programme, and realised that I was in the ideal position to set up an initiative which facilitated the development of childrens attention skills from a much younger age. Sessions run by Sure Start, like many early years sessions, included a circle time. I wanted the programme I developed to be sustainable by the staff, so decided my best option would be to develop something they could use as an alternative to the traditional story or rhyme time. As a community speech and language therapist I already had activities I used when working with individual children with attention difficulties. When considering the actual content of the programme, I simply put these into a group format. I also added song and a puppet (Lucy the lop-eared rabbit) to gain the childrens interest and to help make the session fun. Listen with Lucy is designed to be run as an alternative to the traditional circle-time group. It includes a story in the form of a theme such as The Farm or A Day at Home, and rhymes and songs, all of which are excellent attention and listening activities in their own right. However, in a Listen with Lucy group, the children are taken beyond the stage at which these commonly used circle-time activities are sufficient to stretch their skills, and carefully devised adjustments are made to the songs as well as listening activities and games.

Are you sitting comfortably? Then Sharon Garforth will begin her tale of how Listen with Lucy training for early years practitioners in Shropshire is impacting on attention and listening skills in children under four.

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A strong foundation

The group uses the same general format for each session, therefore taking advantage of routine, repetition and familiarity to aid the childrens learning. Within that format the group leader presents many of the activities we are so familiar with, aimed at teaching the children the basics of good listening, such as to look at who is talking, think about the words, be quiet, and sit still. The early years practitioner has often not come across this idea of breaking the skill of listening down into these constituSharon Garforth ent parts. However during their training they soon take the new ideas on board, and learn to promote them during the group and generally in the classroom. The result is a significant effect on the early years practitioners ability to gain the attention of their class and of individuals, and therefore their ability to nurture the development of the childrens skills in listening and concentrating. Of course, if the early years practitioners are supporting the childrens attention skills, they are also developing a strong foundation for all areas of learning for that child, including learning to communicate. I give the bulk of the training during weekly visits over a period of about 10 weeks (a term). Each week the same group of children takes part in a Listen with Lucy session which is run initially by myself (about three weeks),

then jointly by myself and the early years practitioner (about three weeks), and finally (for the last few weeks) solely by the early years practitioner. By the final week the practitioner has gained sufficient skills not only to run the group independently, but also to begin to create their own themes for future Listen with Lucy sessions. I tend to give hands-on training to only one practitioner within the setting, so that at least one person gets sufficient instruction, but I encourage the setting to allow a second practitioner to sit in and receive a more indirect schooling. This has the advantage that the second person can take over during training should the named practitioner be unable to attend a session; also it is advisable for each setting to have more



than one member of staff trained to support sustainability of the programme within the setting once the training is complete. I encourage the two trained members of staff to pass on their skills to further colleagues wherever possible. Over the 10 weeks of training a setting, it is both enjoyable and rewarding to see the early years practitioners progress. They go on from the nerves and uncertainties of learning the aims, skills and methods for running this type of group, to become confident, proficient and often inventive Listen with Lucy group leaders. Some practitioners need more support than others to achieve this, but I am continually and regularly bowled over with the creative and intuitive talent demonstrated by local early years staff - and by their entertaining and accomplished puppetry skills, at times far better than my own! Caroline Bowers (Oswestry Methodist Preschool) created her own Listen with Lucy session with the theme of The Seaside and came up with the following song as part of that (sung to the tune of What shall we do with the drunken sailor?): The rain came down and the tide came up The rain came down and the tide came up The rain came down and the tide came up And the sand came tumbling down Caroline prepared the children beforehand by telling them (and showing them how) to listen out for the words up and down in the song, and use their hands to make the up and down movements as appropriate. At the end of the song you can add further random ups and downs (for example up, down, down, up) to encourage the children to extend their abilities to listen and look. Viv Holloway (Cockshutt Playgroup) devised a session using the theme of Going to School especially for children about to start at the local nursery. It included an activity where all the children were given a musical instrument. She then talked about the different clocks which the children would hear in and around the nursery school while demonstrating different volumes of ticking sound and encouraging the children to listen and join in with their instrument thus: What does the clock in the school say?... Tick tock tick tock tick tock (medium volume) What does the clock in the class say?... Ticka ticka ticka (Quiet volume) What does the clock in the church say?... Tock tock tock (Loud volume) Figure 1 Self-assessment results from an early years setting

Before and after

I evaluate the training with a questionnaire which requires the early years practitioners to make subjective decisions about the childrens attention skills along a simple continuum in three situations: one-to-one with a member of staff; in a small group with a member of staff leading; and in a whole class situation with a

member of staff leading. The questionnaire is completed by the main early years practitioner being trained. This is done both before the 10 week course and again after the 10 weeks for comparison. Over the past 3 years, the 12 settings trained in the north of Shropshire all showed good progress in the attention skills of the groups of children involved, as illustrated by the results from one of the settings (figure 1). These graphs show that, in the opinion of the practitioners who have run Listen with Lucy, as a group, the childrens attention skills were increased post-group, compared to pregroup, in all three situations. I use a second evaluation form to ask the main practitioner to give their opinion about the training and the programme itself. Feedback has been universally positive, with comments on the programme including: I realised (during the training) what listening really entailed

it gave us a chance to see how important good listening can be the children will [following the programme] sit longer for tasks, activities and story time, allowing them to get more out of the sessions there was a significant improvement in [the childrens] concentration and listening skills. Following the programmes success and popularity within Sure Start sessions, and a request from an Area Special Educational Needs Coordinator (SENCo), my manager and I decided that I should offer the training to early years practitioners outside the realms of Sure Start, in local preschools. This training went on to attract a number of settings, across the north of the county at first. The programme was also supported and promoted by Development Officers and Childrens Centre Area Teachers from the early years team who had noticed how well Listen with Lucy works with Letters and Sounds, a



Department of Children, Schools and Families initiative. A waiting list of settings wanting to be trained began to develop. More speech and language therapists and Sure Start Childrens Centre Services staff were trained as trainers, and the training of early years practitioners continues to this day across the whole of Shropshire. Also, of two Every Child a Talker (ECAT) consultants working in the county of Shropshire, one has made Listen with Lucy training mandatory for her 20 settings, and the other consultant has offered the programme as an option to the settings in her area. they will be using control groups to control for development of attention skills due to factors other than attendance at a Listen with Lucy group. Also, the Shropshire Councils Early Years team plan to track the children who have attended a Listen with Lucy group to the Foundation Stage to measure outcomes. After about a year of running the programme, when I became aware of the growing success and popularity of Listen with Lucy, I began to believe that speech and language therapists and early years practitioners beyond the borders of Shropshire might also find the programme useful. Consequently I approached my managers about having the manual for the programme published. They were happy for me to do this so I set out to search for a publisher through the internet, and two years later the manual which I had already written to train practitioners in Shropshire was accepted by Jessica Kingsley Publishers. There was a fair amount of work required to make the manual into a publishable book, not least the lengthy copyright searches required. But finally Attention and Listening in the Early Years (Garforth, 2009) was out, and 250 copies were sold in the first 2 months. I hope this article will give you a taste of what Listen with Lucy involves and that, if you decide to run the programme, you find it a useful tool for supporting children to develop their listening and attention skills, and an effective resource for training early years practitioners on your patch.

Services, Shropshire, whose support and enthusiasm regarding the Listen with Lucy programme has been invaluable. Thanks also to my colleagues in Early Years who have inspired and supported the programme throughout.


Effective and enjoyable

Speech and language therapists whom I have trained to run Listen with Lucy have fed back that the programme is both effective and enjoyable to run. Some of these therapists have gone on to train early years settings themselves, and one introduced Listen with Lucy into a language group at a Child Development Centre. From my own experience, the strengths of the Listen with Lucy programme are that It is easily achievable and sustainable for the early years settings. This is because it is relatively straightforward for early years practitioners to learn how to run the group. It does not require them to learn a whole new set of skills from scratch but instead to build on skills which they often already have, such as storytelling, and singing songs and rhymes. Also most settings already run a circle-time at some point in the day, so replacing this regularly with a Listen with Lucy session helps their new training fit neatly into their daily routine; It is versatile in that it can be used to facilitate the attention skills of all children of the targeted age in a preventive way, or be used with children with diagnosed attention difficulties; The training which early years practitioners receive often spills over into other practice, not just while they are running the group, so that promoting good listening becomes more of a priority throughout the day and consequently supports all other learning situations; It is a programme which, in the fun way it is delivered using songs, games and a puppet, is generally popular with practitioners and children alike; and of course, for the children in particular, learning is more effective if it is fun. Although I have already been evaluating the programme, the present method does not take into account the effect of any other activities for facilitating good listening skills which the setting may already be practising. Consequently, further evaluation is planned in order to be sure of the specific effectiveness of the Listen with Lucy programme. With this in mind, the speech and language therapy service will be evaluating, across the county, all new settings to be trained between January 2010 and January 2011. This time, in the interest of making the evaluation more robust,

Boucher, B., Hurd, A. & McQueen, D. (2002) SALLEY: Structured Activities for Language and Literacy in the Early Years. Birmingham: Questions Publishing Company. Garforth, S. (2009) Attention and Listening in the Early Years. London: Jessica Kingsley. National Literacy Trust (2001) Early Years Language Survey of Head Teachers. London: NLT. Available at: survey.html. (Accessed: 21 January 2010).


Every Child a Talker (ECAT), see http:// node/153355. Letters and Sounds: Principles and practice of high quality phonics, see http:// node/84969

Sharon Garforth is a speech and language therapist seconded by the Telford and Wrekin Primary Care Trust to Shropshire Council Sure Start Childrens Centre Services. Please contact Sharon by e-mail if you are interested in the training.

Reflections Do I react in a practical way to concerns raised by other professionals? Do I think about what will help to make a new programme sustainable? Do I make learning fun for everyone?
Do you wish to comment on the impact this article has had on you? Please see guidance for Speech & Language Therapy in Practices Critical Friends at www.


My thanks go to all my colleagues in the paediatric speech and language therapy department of the Telford and Wrekin PCT, and those at the Sure Start Childrens Centre

Jessica Kingsley Publishers is offering Sharons book at a discounted rate to readers of Speech & Language Therapy in Practice. To order a copy of Attention and Listening in the Early Years at the special Reader Offer price of 18.99 (no p+p), visit www. and enter the following promotional code - gar0241. See also the review on p.21.



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My Top Resources
outdoor clothes, then put the coats or hats in a pile and talk about whose coat this is). Another lovely idea is the Travelling Game: take 5 photos of specific places in the playground (such as the slide, a tree, the sandpit) and 5 photos of a child moving in a specific way (walking, hopping, running, rolling). Each child can choose one Place card and one Moving card and tell the other children to move in that way towards that place. Children can also take turns to take the camera home and take photographs of their home, their family or their favourite toys, and then tell the others about their pictures the next day. CYNTHIA PELMAN IS A SPEECH AND LANGUAGE THERAPIST WORKING AS AN EARLY LANGUAGE CONSULTANT IN HACKNEY ON THE ECAT (EVERY CHILD A TALKER) PROGRAMME, E-MAIL CYNTHIA@CYNTHIAPELMAN.COM. HERE SHE SHARES SOME OF HER FAVOURITE RESOURCES FOR WORKING WITH GROUPS OF CHILDREN IN THE EARLY YEARS. There is more information on Persona Dolls at the website and in Bowles, M. (2004) The Little Book of Persona Dolls. London: Featherstone Publications. Communicating Matters is produced by Sure Start. The CD referred to is apparently no longer available, but more recent materials are available through the Prolog publications line on 08456 022260.

Helping Young Children to Think Creatively Ros Bayley & Lynn Broadbent 8.50
Each page in this book describes how to set up a scenario in the classroom or outside which will make children curious and amazed. How did that cooked spaghetti get to be hanging in the tree? Does it grow on the tree? Does it belong to a bird? Whose are these huge dirty boots which we found when we came in to school this morning? Do giants visit the school during the night? What do they do here and when do they disappear? Will he come back to pick up his shoes? How did that suitcase full of beach clothing get to be on the table? Who could be going on holiday and what will they do there? And why did they leave their suitcase here? Can we find out who it is and give it back to them?

awrence Educational is a publisher of really practical and inexpensive spiralbound educational books, which contain a host of useful ideas for working with groups of children and developing their language. I use these when working with small groups of children in education settings, as the ideas they contain are so imaginative that everyone gets inspired - including the class teacher who very often then buys the book and starts using the ideas in the classroom. What better way to bridge the much-spoken-of gap between speech and language therapists and teachers? No need for formal training or Powerpoint - just wonderful imaginative ideas. I have bought and regularly use many of them from shop/all_prodmanf.php, but these three are my personal favourites. Each page of each of these books contains a new and exciting idea. For those of you who are struggling to make universal work effective in schools and nurseries, and to share their work with teachers, this is a wonderful way to start.

Storylines: An anthology of 50 ideas for using large puppets, dolls and soft toys in early years settings Ros Bayley 12.50
Storylines is written by Ros Bayley, who contributes heavily to this publishers output. It contains some very exciting short stories, which are told to the children only as far as the dramatic high point. At that stage, the narrators role (your role) ends, and the children are encouraged to pick up the story from that point and to continue narrating it to the group. This can take the story in any direction, and indeed every group of children will come up with something different. For example, the story The Lost Teddy tells about a favourite teddy who gets lost when the child is playing outside. Months later, he and his friends are again playing outside and they find the Teddy. Why has he not been found before? And where has he been all this time? Another example, which is beautifully shown on an old CD from Communicating Matters (Module 2 Manual, September 2005), tells about some children who went into the wood and got lost. They try to think what to do and each one has a suggestion - but Ros ends her telling of the story by saying, so thats their problem- theyre lost! And they dont know what to do! The CD shows Ros Bayley, who is a wonderfully expressive and dramatic storyteller, using Persona dolls and we see how the children become totally focused on these dolls, to the point that they stop seeing Ros and seem to perceive of the dolls as real children lost in the forest. Any soft toys or dolls can be used in place of Persona Dolls. Sadly this CD is very hard to come by and I have tried to order it without success.

Picture This: 50 Exciting Ways to Use a Camera Helen Bromley 12.50

I love this book. Photographs can be used in so many ways to develop language: from making your own sequencing cards (showing the sequence of actions involved in making playdough, or fruit salad, or growing plants from seed) to possessive pronouns (take a picture of each person in the setting in their coats and

Lawrence Educational was delighted to hear about Cynthias recommendation, and is offering a special 10% discount to Speech & Language Therapy in Practice readers who order any of its products online at www. educationalpublications. com. To receive the discount, quote SMD10.