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ISSN 1368-1205

Summer 2008

Ethics Informed refusal? Aphasia Optimal learning Total communication Rise and sign Early interaction Talking hands Inclusion Poetry and drama workshops Are you getting enough? Supervision models and barriers My Top Resources Adult stammering
PLUSAssessments assessedWinning WaysSoftware SolutionsHeres one I made earlier two great reader offersand introducing our new series on user involvement.

Are you listening?


Getting the most from respite

The feelgood factor

www.speechmag.com

Reader offer

Win Languageland!
Black Sheep Press is offering FREE copies of Languageland to THREE lucky readers of Speech & Language Therapy in Practice. Speech and language therapists can use Languageland as a detailed training package to support class teachers in improving the speaking and listening skills of children aged from 3-7 years. It has also been designed as a complete language resource for teachers with modified lesson plans so they can include children with speech, language and communication needs. The package, including CD, usually costs 70. For your chance to win, e-mail your name and address to Gillian@blacksheeppress. co.uk, putting SLTiP Languageland offer in the subject line. Languageland has been developed over the past seven years through funding from Newcastle-Under-Lyme NHS PCT and Staffordshire LEA, where it is used extensively. For further information on the programme and its outcomes see Wright, A. (2003) Lets go to Languageland, RCSLT Bulletin, 613 (May), pp.8-9. For details of all Black Sheep Press resources, see www.blacksheeppress.co.uk.

Win video training by Mark Onslow!

Do you work with children who stammer? Are you interested in new continuing professional development opportunities? Then this offer is for you, as Professor Mark Onslow (Lidcombe Programme) is offering access to one of his online video seminars FREE to THREE lucky readers of Speech & Language Therapy in Practice. While one 90 minute seminar considers treatments for preschool children, the other concentrates on those of school age. As the intention is to make research evidence applicable to practice, Mark Onslow discusses treatment options in terms of what works, how fast and how well. He also explores the long-term impact of treatment. You can view a free introductory video at www.stutter-ed.com. Each 24 hour seminar prize includes a downloadable worksheet and reference list and 14 days access to a chat room hosted by Mark Onslow. For your chance to win, e-mail your name and address to Amanda Burke amandaburke63@gmail.com by 25th July 2008, putting Speech & Language Therapy in Practice offer in the subject line and stating whether you would prefer the preschool or school age seminar. The winners will be notified by 31st July. Each seminar usually costs 79.00 Australian dollars (approximately 38.00). Current speech and language therapy students outside Australia qualify for a 50 per cent discount. For more information see www.stutter-ed.com.

Reader Offer Winners

The lucky winner of the React2 software offered by Propeller Multimedia in our Winter 07 issue is Louise Slorach. Meanwhile Speechmarks Lemon & Lime Library in the Spring 08 issue has gone to Douglas Bell, Helen Smith and Catherine Ward. Congratulations to you all!

Summer 08 speechmag
Forum
Forum for discussion of articles now up and running! Anyone can read the forum messages but only registered subscribers can post. To register, go to http://members. speechmag.com/forum/.

NEW! Only online articles to be added soon!


Grace Windle and Jenny Henton on MAKATON Signing for Babies as part of Sure Start Nicole Goldstein on summer groups in Harrow for children with language and communication difficulties.

Members area

For a reminder of your user name and password, e-mail avrilnicoll@speechmag.com The members area includes: Extra only online articles Back issues from 2000-2006 www.speechmag.com/Members/

Summer 2008 (publication date 31 May 2008) ISSN 1368-2105

Summer08contents
Thanks to Zoe, Ashleigh and Tayavalla, Camelon, Falkirk for our cover picture. Taken by Paul Reid.

14 COVER STORY: ARE YOU LISTENING? To embed inclusive communication practice into organisations is a challenge but this respite service has achieved it. Elaine Crighton, Isabel Forsyth and Lois Cameron explain how young people at Tayavalla respite unit are now getting the most from their break.

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

Design & Production: Fiona Reid, Fiona Reid Design Straitbraes Farm, St. Cyrus, Montrose Angus DD10 0DS Printing: Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT Editor: Avril Nicoll, Speech and Language Therapist

Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2008 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

4 INFORMED REFUSAL? Prior to undertaking this review I tended towards the opinion that, if a child required a gastrostomy, they had been failed in some way. However, my view may be changing. Moira Wares investigates food refusal in adolescents with complex physical and learning needs. 7 HERES ONE I MADE EARLIER Alison Roberts suggests the lowcost activities Give and take and Cooperation balloons. 8 THE MAYTOR, THE SHORPINE AND THE TRAIGOL If people with aphasia were able to demonstrate new linguistic learning, then this might open up a new approach to therapy, in which even previously held words might be treated as new. Mythical creatures help Helen McGrane and Linda Armstrong explore whether individualised optimal learning approaches might improve the effectiveness of aphasia therapy. 11 RISE AND SIGN It didnt take long for us to realise that the benefits of signing far exceeded our original expectations. Pupils understanding was enhanced by the additional visual clue provided. Polly OCallaghan considers the success of a strategy to establish Signalong as part of a total communication approach in a special needs school. 16 USER INVOLVEMENT We now offer choices for everything and the service as a whole has shifted towards having more user involvement. Mariela Angulo and Amy Wolfendens childrens centres project introduces our new series. 18 SUPERVISION (2) MODELS AND BARRIERS The power of therapists internal beliefs about and understanding of supervision became evident and heavily influenced their perception of the usefulness of supervision and their willingness to access it. Sam Simpson and Cathy Sparkes continue their series on supervision practice.

20 REVIEWS Literacy, Storycards, autism, palliative care, learning disability, social stories, voice, complex needs, motor speech, aphasia. 22 TALKING HANDS We introduce signs with objects (where possible), songs and stories to make the sessions as interactive as possible and give parents ideas for activities to carry out at home. A year ago Amanda Baxter was sitting on the baby signing fence, but practical experience in an Early Start context has persuaded her of its use in enhancing parent-child communication skills. 24 ASSESSMENTS ASSESSED Our in-depth reviews consider the KiddyCAT for preschool children who stammer and the Verb and Noun Test for adults with aphasia. 25 WINNING WAYS If we have a dream and a passion, it is vital to acknowledge the hints, hunches and directives that come from deep within. As her book project comes to fruition, life coach Jo Middlemiss encourages you to believe in your dreams.

26 JOINING IN AS NEVER BEFORE Staff learnt how to make classic literature fun and accessible to pupils with severe, profound and complex disabilities. This approach has provided inspiration for condensing a story or topic down to key points and re-producing it as a short song with repetition that all students can access. Liz Skilton reflects on the difference workshops at the Globe Theatre with Keith Park have made to teaching and learning at a district special school. 28 SOFTWARE SOLUTIONS Two discs from the Leaps & Bounds Phonological Awareness Series reviewed. BACK COVER MY TOP RESOURCES it really helped me to speak slowly and clearly. I learned eye contact: when I speak I look at the person, and that helps me to be more assertive. Danny Smith is one of ten students and speech and language therapists describing what makes the City Lit, a centre of excellence in adult stammering therapy, so special. Other contributors are Carolyn Cheasman, Jan Logan, Rachel Everard, Sam Simpson, Paul Harris, Blanche Keaveney, Jamal Muse, Joanna Puzey and Flora Swartland.

SPRING 08s e-articles at www.speechmag.com/Members/ E1 DECISION TIME We dont claim to have solved the problem of how to prioritiseBut we now have a policy that will be evaluated and reviewed in the light of our knowledge, research, clinical experiences and national policy. Alison Newton and Linzie Priestnall engage their teams in a prioritisation process to ensure their adult inpatients receivea consistently fair speech and language therapy service. E4 A QUIET EVOLUTION At the start of the project we carried out initial assessments and reviews in the clinic, only offering speech and language therapy in school to those needing regular appointments. Nevertheless the failure to attend rate was halved within the first 6 months. Maggie Robinson on the advantages of her teams gradual shift ofservices from clinics to schools for children from nursery age.
IN FUTURE ISSUES: DOWNS SYNDROMEINTEGRATED SENSORY ENVIRONMENTS WORKING WITH TEACHERSEPGDYSPHAGIAAACCHILDRENS CENTRES

news

Practical ideas in Bercow Review


Following 6 months of consultation, the Bercow Reviews interim report has produced a number of practical ideas for improving services for children and young people in England with speech, language and communication needs. Although there should be no surprises for speech and language therapists, the focus on parents views and their emotions - from puzzlement to frustration to anger to despair to determination (p.14) - provides food for thought. One is quoted (p.20), It was fine getting as far as the assessment, and then I really grew to hate the word monitoring because they kept saying especially with my child monitor, monitor, monitor, monitor and they monitored him until it was too late and then we couldnt get anything. Five key themes are identified, including an end to the postcode lottery of services. Communication has to be seen as a priority, with early identification and intervention the key to better outcomes. A continuum of services should be designed around each child, with joint working critical at the levels of service planning, commissioning and delivery. The consultation process found too little continuity of speech and language therapy and too high turnover, with decreasing support as children get older. In addition, The relationship between health and education with regard to speech and language services was seen as incomprehensible or even ridiculous by parents (p.22). This was highlighted when the senior health and local authority commissioners from one area met each other for the first time when giving evidence. Over the next few months the review will consider what can be learnt from the many areas where partnerships are working well and where the focus is on outcomes not outputs. Ideas under scrutiny include introducing screening, a greater input on speech, language and communication needs at initial teacher training level and a more strategic approach to helping young offenders. The final report will be presented in July. www.dcsf.gov.uk/bercowreview/docs/Bercow_ Interim_Report.pdf

Keeping Safe
The National Autistic Society and the Co-operative Bank have launched a campaign to raise awareness of autism among criminal justice professionals. The Keeping Safe programme has already helped young people with Asperger syndrome in schools across the UK to recognise dangerous situations and learn about the risks of crime. The next phase will offer guidance to police officers, magistrates and probation officers on how to recognise autistic behaviours and what to do if they suspect a young person may have autism. A resource pack includes an at a glance card, a comprehensive guide and a DVD. www.nas.org.uk

Therapy shortfall for Parkinsons


The largest ever survey in the UK of people with Parkinsons Disease has found that 63 per cent of them have never been assessed for or received speech and language therapy. For occupational therapy the figure was even higher (66 per cent) while almost half (46 per cent) have never been assessed for physiotherapy. This is in spite of guidance from the National Institute for Health and Clinical Excellence that all three therapies should be available for people with Parkinsons. While it notes the improvement since its last survey in 1997, the Parkinsons Disease Society is calling for commissioners of services to ensure that a multidisciplinary service is in place so people can access the support they need. More than 13,000 members of the Society responded to the survey. Access to all types of therapy was worse in England than in other parts of the UK. Survey respondents rated this as a top campaigning priority for the Society. Life with Parkinsons today room for improvement at www.parkinsons.org.uk/pdf/memberssurvey_fullreport.pdf

IT awards

National computer and disability charity AbilityNet is seeking entries for the Access IT Awards from groups and individuals who are using technology to improve the quality of life of people with disabilities and the elderly. The four categories are assistive technology use, assistive technology innovation in transportation, assistive technology innovation at work and assistive technology innovation at home. The closing date for entries is 18 June 2008. www.access-it-awards.org

Learning disability petition

The Learning Disability Coalition needs 10,000 signatures on its petition for better funding for learning disability services. The Coalition is a group of 10 charities including the Fragile X Society, Mencap and the British Institute for Learning Disabilities. It is gathering evidence that greater investment is needed to ensure the 2001 Valuing People report can be implemented in the way it was intended. www.learningdisabilitycoalition.org.uk

Total collaboration
The Signalong Group and Widgit Software have agreed to collaborate on the development of complementary resources in sign and symbol format. The agreement commits both organisations to exchanging information about projects under development so that practitioners can readily meet the total communication needs of a broader range of users. Signalongs diagrams are gradually being reformulated to be compatible with Widgits Communicate: In Print programme. www.signalong.org.uk; www.widgit.com

Beth Moulam receives the first new Lightwriter SL40 from David Collison, Chairman of Toby Churchill and company founder Toby Churchill. The SL40 has an out-facing daylight readable display, Natural Selection prediction, a choice of high quality Acapela voices, built-in SMS texting and an adjustable keyboard. www.toby-churchill.com

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

NEWS & COMMENT

AAC to improve in Scotland

The Scottish government is setting up a short-life AAC working group to report on how equipment provision and essential supporting services can be improved. Around 20 people including service users and representatives from the existing national and regional AAC centres will sit on the 6 month group. The move follows a successful campaign spearheaded by the Royal College of Speech & Language Therapists, Capability Scotland and AAC in Practice. This resulted in a debate in the Scottish Parliament which was opened by MSP Nanette Milne using a DynaVox. A 2007 survey found that only 16 per cent of Scots who require a communication aid are getting the equipment and support they need and that there is a postcode lottery, with more than half of the health board areas rated as poor in their provision. www.rcslt.org

Comment:

The feelgood factor


What I particularly notice in this issue is the thoughtfulness and enthusiasm the authors and reviewers bring to their work, and the enjoyment they get out of making communication a priority. Our exuberant cover girls are testament to the benefits of really trying to understand the barriers to inclusive communication environments, then using this information to identify solutions. And Elaine Crighton, Isabel Forsyth and Lois Cameron (p.14) find good practice like enthusiasm - is infectious: one visit to Tayavalla [respite centre] has a huge impact. Polly OCallaghan (p.11) is also experiencing success as one of the key players in getting a total communication approach embedded in a special needs school. Ensuring it is fun for all has been crucial. Similarly, Liz Skilton (p.26) is very aware of the role of positive energy in motivating and including everyone, from clients with complex needs to the staff who care for them. Meanwhile Amanda Baxter (p.22) uses baby signing as a hook to get parents and babies enjoying early interaction. As I explain on p.16, I have personal reasons for feeling good about our new series on user involvement. Mariela Angulo and Amy Wolfenden (p.17) and our top resources from the City Lit (back page) show the zest for communication that results when professional thinking shifts from a position of authority to one of collaborative inquiry. Supervision (Sam Simpson and Cathy Sparkes, p.18) is clearly one way of inspiring therapists to follow this path. Collaborative inquiry is a particular challenge when clients have the most limited ability to communicate, but Moira Wares (p.4) recognises it sometimes involves asking painful questions, seeking honest answers and re-thinking our views. While Helen McGrane and Linda Armstrong (p.8) concentrate on an individual living with very severe aphasia in difficult circumstances, their research findings are full of optimism about improving therapy effectiveness through finding the best learning approach for each client. As Jo Middlemiss (p.25) says, Dont try to find a way to happiness, happiness is the way. I hope this issue, as always, helps you feel good about what you already do and buoyant about the future.

Experienced campaigner at Connect

Connect the communication disability network - has welcomed its new chief executive Phyllis Campbell-McRae. Previous incumbents Sally Byng and Carole Pound are speech and language therapists, but Phylliss background includes senior roles with Amnesty International, Greenpeace, the RNID and the Advocacy Project. Carole commented, We are delighted to have Phyllis on board. She brings a wealth of knowledge and experience from her previous roles in the voluntary sector, particularly in the arenas of policy and communications. This is an exciting time for people living with aphasia and we are confident Phyllis will help push forward the agenda on aphasia, access and awareness. www.ukconnect.org

Positive on communication support

The Stroke Association has launched a new campaign to improve services for people with aphasia. The charity says its report Lost Without Words highlights very low levels of awareness among the public, health professionals and key decision makers in health and social care policy, and the profound impact of aphasia on peoples quality of life. The report is based on a qualitative study using focus groups of people who attend or have attended one of the Associations communication support groups. The 21 people involved were very positive about the value of long-term communication group support for clients and carers. The report calls on Primary Care Trusts to gather data on incidence and monitor each stroke survivors needs through regular long-term reviews. It also wants to extend its Communication Support Services so they become integral to the stroke care pathway and to ensure referral from multidisciplinary teams and speech and language therapists. www.stroke.org.uk

CASP in colour

The popular CASP (Communication Assessement Profile) is to be revised using new colour photos. A limited number of copies of the new version will be available to therapists who are willing to offer feedback on the prototype. If you are interested, contact Anna van der Gaag, e-mail annavandergaag@ btinternet.com.

Stammering information programme

Following a visit to the Michael Palin Centre for Stammering Children in November, Ed Balls has announced 340,000 of government funding for the specialist facility to provide schools with information, advice and training materials on how best to support children and young people who stammer. The Secretary of State for Children, Schools and Families says the programme will be rolled out to all schools in England by 2010 and the resources will also be available online. www.stammeringcentre.org

P.S. Remember we now have online only articles published after the magazine for you to print off as a supplement. In Spring 08, Alison Newton and Linzie Priestnall describe a prioritisation process for adult inpatients and Maggie Robinson discusses a gradual shift to school-based services for children. Articles on MAKATON Signing for Babies and summer groups for children will be added soon.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

ethics

Informed refusal?
Moira Wares investigates food refusal in adolescents with complex physical and learning needs.
2. Acute events
Most people lose their appetite when they have an acute illness, therefore this should be considered early when there is a refusal to eat. The child may have a sore throat, ear infection or cold. I have found children who have recently experienced seizures are often unwilling to eat. Seizure activity frequently increases at puberty so my adolescent clients may be more affected. Clients who have just experienced surgery often lose their appetite because they are in pain and feeling low. Three of my clients have had acute episodes affecting their appetite. One boy was recovering from major orthopaedic surgery, one had an increase in seizure activity and one girl had very low haemoglobin making her weak and tired.
READ THIS IF YOU WANT TO UNDERSTAND A PATTERN OF EVENTS RELATE RESEARCH EVIDENCE TO CLIENTS CARRY OUT MORE COMPREHENSIVE ASSESSMENT

n the five years I have been managing the dysphagia caseload in a special school, a number of adolescent clients with complex needs have started to clench their teeth together and turn their head away when offered food. As each case occurred in isolation it is only by looking retrospectively I have become concerned that a pattern has emerged. Prior to these episodes of food refusal each child ate adequately, although all have oral-motor problems and are on modified texture diets. On investigation, a similar pattern of behaviour was taking place at home. These pupils have difficulty communicating and only one is able to respond with yes / no. All reached adolescence before they started to exhibit this behaviour. In an emotional moment I wondered if they were telling us that they had had enough of life? While there is a wealth of articles on the adolescent feeding disorders anorexia nervosa and bulimia nervosa, there is very little specific research relating to this client group. I hoped to use what evidence there is to plan how to approach future cases. Feeding problems in children with neurological impairment are common and severe. Sullivan et al. (2000) suggest that around a third are significantly undernourished, with growth retardation most closely associated with inadequate intake as a result of self-feeding impairment and oral-motor dysfunction. Morris and Klein (2000, p.626) state that assessment should commence by looking at what is happening with the childs eating and what events have led there. It is also important to look at whether the child is displaying any other episodes of non-cooperation. Severe communication difficulties make assessment of a problem much more complicated. A child may well be showing symptoms of a behavioural feeding disorder but there are also many organic reasons for food refusal which require investigation:

fensive role of the emetic reflex as it facilitates the subsequent avoidance of foods that previously caused illness. It may be that, by refusing to eat, some of my client group are avoiding what they perceive to be a stimulus for nausea.

5. Constipation

assessment should commence by looking at what is happening with the child's eating and what events have led there.
3. Gastroesophageal Reflux
Gastroesophageal reflux (GOR) is when the lower oesophageal sphincter fails to work properly and stomach contents return to the oesophagus. This may cause discomfort and pain but when the condition becomes chronic, as is common in cerebral palsy, it can affect appetite, health and growth. GOR is considered to be very common in children with neurological impairments. Rogers (2004) states that investigations using oesophageal pH studies and upper gastrointestinal endoscopy have revealed gastroesophageal reflux rates of 70-90 per cent in children with cerebral palsy who present with failure to thrive, food refusal, small volume feeds and vomiting. It is likely that GOR accounts for at least one of my clients refusing to eat. He lost so much weight that a gastrostomy was performed to avoid him being malnourished.

Children with feeding difficulties frequently suffer from constipation. Due to oral problems and a modified texture diet, fibre consumption and fluid intake are often limited. As the bowel is stimulated by exercise, the childs difficulties in physical movement and poor muscle tone add to the problem. Constipation creates a vicious cycle. Because it is difficult and painful to pass a stool the child withholds, increasing the constipation and creating a feeling of constant fullness which causes discomfort and deters appetite. Another side effect is an increase in mucous production. Morris & Klein (2000) suggest this can affect taste and smell, trigger gagging, retching and choking and increase the aspiration risk. This would explain why some of my caseload retch and gag even before food is offered and they appear not to want to eat. One of my clients suffers from constipation so badly that she has had to be admitted to hospital for surgery because of an impacted bowel.

6. Dental Problems

1. Oral-motor problems

If feeding has been adequate up to adolescence can problems with oral-motor dysfunction start to impact at this time? With the onset of puberty and the normal teenage growth spurt an increase in calories is required. It may be that, due to poor motor skills, it is not possible for the child to take in enough food to sustain growth and energy. All of my cases have oral-motor problems but have reached adolescence managing to sustain an adequate intake. Oral dysfunction makes any additional problem increase in significance, especially during puberty. 4

4. Nausea

Nausea reduces appetite and is associated with conditions such as gastric flu, headaches, liver and kidney failure and gastroesophageal reflux. It may also appear as a side effect of some medications. In a limited study, Richards and Andrews (2004) concluded that nausea is part of the de-

Sore teeth and gums can cause food refusal for fear of further discomfort and pain. Children with cerebral palsy and feeding disorders are more prone to tooth decay, oral problems and dental diseases (Morris & Klein, 2000, p.349; Stanford, 2000; Ravel, 2001): Food remains may be left in the oral cavity. A reduction of acid-neutralising saliva production may occur as a side effect of medications, dehydration and mouth breathing. Re-chewing, regurgitation and re-swallowing of previously ingested food causes acid contents of the stomach to damage teeth. Control of oral musculature, involuntary muscular activity, and an inability to perform oral hygiene procedures contribute to the increased incidence of gum disease.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

ethics Anti-seizure medications cause hypertrophy, which makes control of dental plaque difficult. Clenching and grinding of teeth can cause pain, as can tongue, cheek and lip biting. Pouching: placement of food or medicine between the cheek and teeth for a long time can cause dental decay. Sucrose-containing oral medication increases the risk of dental decay. It may be that my client group are refusing food because of discomfort in their mouth. Being adolescent, it may be that teeth are erupting which can cause a sore aching mouth. elevated symptoms of anorexia nervosa and picky eating in adolescence. They could not conclude whether this was because of lesser feelings of hunger, ability to ignore hunger or learned patterns of food avoidance following discomfort. They also found fighting at family mealtimes in early childhood was associated with elevated rates of food avoidances in adolescence. Non-organic reasons for food refusal can include: is similar to the general population. Phillip et al. (2005) found the majority of carers of young people with profound and multiple learning disabilities were alert to specific signs of change in emotional and mental well-being. Factors causing depression and stress included: External bereavement, moving house, change in staff, change in routine, parental separation, parental stress, transition, lack of stimulation Internal physical illness, pain, puberty, menstruation. These findings are particularly relevant to my client group. It would not be surprising if they suffer from emotional disorders such as anxiety and depression. They have increased medical problems, eating difficulties and are unable to communicate their needs easily. Indeed, one of the few ways they are able to exert some control is by stopping eating. This makes it increasingly important to examine the reasons and look at emotional as well as physical needs. Many of the factors feature significantly in the lives of my cases. One girl experienced moving house and family upset when her sister was taken into care. She has a pattern of refusing to eat when she returns to school after holidays which may indicate a problem with transition. One of the boys was in extremely low spirits following surgery and was helped by anti-depressant medication.

1. Negative feeding experiences

7. Medication

Medication, given to help and improve health, may have side effects that impinge on nutrition and decrease appetite. The relationship between drugs and appetite can be complex. For example, antibiotics, cortisone medications and diuretics all decrease zinc absorption or increase its excretion from the body. Zinc deficiencies can contribute to a reduced appetite and hypersensitivity or hyposensitivity of taste. Some medications for seizures may cause reduced appetite or anorexia, while others for muscle relaxation, seizures and gastroesophageal reflux may cause vomiting, nausea and constipation (Morris & Klein, 2000, p.341). It is important to look carefully at the drug therapy each of my clients receives as it may contribute to a sudden refusal to eat. One of the girls was given iron tablets which can cause constipation. Food refusal may be as a result of fatigue due to heart problems or respiratory distress. The physical effort of eating may require more energy than is available. Rogers et al. (1993) suggest children with severe cerebral palsy with a history of progressive fatigue during oral feeding and significant pharyngeal dysfunction may be at a risk for mealtime hypoxemia. Morton et al. (1997) looked at the feeding abilities of 20 girls with Rett syndrome, 4 of whom showed a deterioration in eating in association with breathing problems and apnoeic episodes during feeding. They also found a progressive decline in oral-pharyngeal skills. The numbers are too small for valid conclusions but the findings could well explain the major factor, of many, as to why one of my clients was reluctant to eat.

Medically based feeding issues can lead to disruption in the feeding relationship, and vice versa (Morris & Klein, 2000). Sullivan et al. (2000) reported that, on average, parents of children with disabilities spend 3.5 hours per day feeding their child compared with 0.8 hours for parents with non-disabled children. The more help the child needed, and the more extra food preparation required, the greater the caregivers stress at mealtimes.

Feeders need to be able to read the child's communication attempts so they may be sympathetic to their needs and wants
Reilly & Skuse (1992) surveyed the eating patterns of 12 children with cerebral palsy who had feeding problems related to poor oral motor skills. There was a lack of caregiver speech and the children were fed in a mechanical manner, but interactions improved as soon as eating finished. In my experience feeder anxiety levels increase when children do not take what is considered an adequate amount. Unfortunately, this often leads to the adoption of aversive techniques (coaxing, force feeding), usually resulting in a negative response. Whether because of perceived worry on the childs part or because the child finds himself in an even more unpleasant situation, stress levels are escalated still further. Feeding experiences are often disagreeable because of thoughtlessness. Lunch is never appealing if feeders talk about how unappetising the food looks, and the atmosphere is not conducive to eating if the conversation does not include the child. Feeders need to be able to read the childs communication attempts so they may be sympathetic to their needs and wants. In service training is carried out regularly in school to remind staff about making mealtimes as pleasurable as possible. When one girl started to refuse to eat, staff found it difficult not to voice their concerns while feeding her and tried to coax her to take some food. This resulted in a negative atmosphere.

3. Fear

8. Reduced endurance

Psychological issues

To gain a full picture it is also important to look at psychological issues that can contribute to the development, maintenance and exacerbation of eating problems. Adolescence is a time of rapid growth and development, with biologic, psychosocial and emotional changes. It is a time when feeding problems become prevalent. There has been a great deal of research into anorexia nervosa and bulimia nervosa but there is still debate on whether they are caused by physiological or psychological factors. It is most likely to be a complex interrelationship of both. Marchi & Cohen (1990) found digestive problems in early childhood were predictive of

2. Mental Health Problems

Depression is often associated with eating disorders. Sometimes more food than necessary is consumed to provide comfort but, for others, a depressed state means a total loss of appetite. The range of mental health problems experienced by young people with learning disabilities

Fear leading to loss of appetite and refusal to eat may manifest itself in different ways. The parents and I believe one of my clients refused to eat because of a fear of choking. After a choking episode at home and being rushed to hospital by ambulance my client was reluctant to try eating again and his parents were extremely anxious about feeding him. Chatoor et al. (1988) reviewed five cases of children who presented with food refusal after an episode of choking. All had a history of psychological issues, and became even more dependant on their parents. Their fear of choking and food refusal appeared to represent a fear of dying and being separated from their parents. My client was also in a depressed state when the choking incident occurred, finding it hard to recover from major orthopaedic surgery. It may be that he had a fear of more pain and being in hospital. The texture of his food was modified from minced to liquidised which, along with medication for depression, aided recovery. However, because of poor oral motor skills, he was unable to eat enough to regain weight and received a gastrostomy. Morris & Klein (2000, p.115) state that children who have experienced physical or sexual abuse, especially around the mouth, may react by refusing to eat. While food refusal may also be because of a fear of lumps in food, and many children show reluctance to eat certain textures, I dont think this is particularly relevant to my client group. Having reviewed the literature I plan to: 1. Look at each child in a global way and not identify problems in isolation. Several treatment strategies may be used concurrently. 5

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

ethics 2. Use video to look at the feeding environment and how we improve the quality of interaction at mealtimes. 3. Consider Phillip et al.s training resource (2005) to raise awareness of emotional and mental well being in people with profound and multiple disabilities. 4. Continue work on oral-motor skills to improve chewing, but not expect it to improve growth. 5. Suggest our team adopts a target of greater practical and emotional support for families feeding children with severe disabilities. 6. Continue to make the most of a helpful and supportive multidisciplinary team (discussion, shared decision making, united front to parents / carers). 7. Ensure full medical and dental assessments. 8. Request input from a psychologist regarding the childs mental health and family situation. The feeding problems experienced by children with cerebral palsy put them at very high risk for growth failure and poor health (Rogers, 2004). Would any of the causes for refusing to eat have such an effect on a child who was well nourished? Prior to undertaking this review I tended towards the opinion that, if a child required a gastrostomy, they had been failed in some way. However, my view may be changing. The literature around gastrostomy is persuasive on quality of life, safety and growth but further research looking at all the evidence relating to gastrostomy, including that of parental concerns, is necessary. SLTP Moira Wares is a specialist speech and language therapist in Dundee with NHS Tayside. Her full reference list is at http://www.speechmag.com/ Members/Extras.

References

Chatoor, I., Conley, C. & Dickson, L. (1988) Food refusal after an incident of choking, J Am Acad Child Adolesc Psych 27(5), pp.535-40. Marchi, M. & Cohen, P. (1990) Early childhood eating behaviors and adolescent eating disorders, J Am Acad Child Adolesc Psych 29(1), pp.112-7. Morris, S.E. & Klein, M.D. (2000) Pre-Feeding Skills. (2nd edn) Therapy Skill Builders. Morton, RE., Bonas, R., Minford, J., Kerr, A. & Ellis, R.E. (1997) Feeding ability in Rett syndrome, Dev Med Child Neurol 39(5), pp.331-335. Phillip, M., Lambe, L. & Hogg, J. (2005) The Well Being Project: Identifying and meeting the needs of young people with profound and multiple learning disabilities and their carers, in Making Us Count. Foundation for People with Learning Disabilities. Ravel, D. (2001) Oral Health for Children with Cerebral Palsy. Available at: http://www.angelfire. com/nc/kidsdental/topic32cp.html (Accessed: 29 April 2008). How has this article been helpful to you? Reilly, S. & Skuse, D. (1992) Characteristics and management of feeding problems of young What experience do you have of working children with cerebral palsy, Dev Med Child Neurol 34(5), pp.379-88. with adolescents with complex needs? Richards, C. & Andrews, P. (2004) Food refusal: A sign of nausea?, J Pediatr Gastronenterol Nutr Let us know via the Summer 08 forum at 38(2), pp.227-228. http://members.speechmag.com/forum/. Rogers, B., Arvedson, J., Msall, M. & Demerath, R. (1993) Hypoxemia during oral feeding of children with severe cerebral palsy, Dev Med Child Neurol 35(1), pp.3-10. Rogers, B. (2004) Feeding method and health outcomes of children with cerebral palsy, J Pediatr 145(2 Suppl), pp.S28-32. Stanford T. (2000) Cerebral palsy and dentistry. Available at: http://www.geocities.com/aneecp/dental.htm (Accessed 29 April 2008). Sullivan, P.B., Lambert, B., Rose, M., Ford-Adams, M., Johnson, A. & Griffiths, P. (2000) Prevalence and severity of feeding problems in children with neurological impairment: Oxford Feeding Study, Dev Med Child Neurol 42(10), pp.674-80.

REFLECTIONS DO I REMEMBER THAT CLIENTS ARE EXPERIENCING NORMAL LIFE EVENTS IN ADDITION TO ANY SPECIFIC ISSUES? DO I ALLOW MY THINKING TO SHIFT WHEN NEW EVIDENCE CHALLENGES MY BELIEFS? DO I CONSIDER HOW THE INTERACTION OF TREATMENTS WILL GET THE BEST BENEFIT AND DO LEAST HARM?

resources
Say it Works
Propeller Multimedia has added Say it Works, a life skills and social issues CD picture library, to its portfolio. It has also released the Life Skills Module of React 2. www.propeller.net

Talk About Change Bookshine

Young people aged 12-26 years with life-limiting conditions have made a DVD resource. www.talkaboutchange.co.uk/ Bookshine is a new pack of free books and information from Bookstart specially designed to suit the needs of deaf children from 0-5 years. www.bookstart.org.uk

Involving people

Young Mencap

Mencap has launched an interactive website designed with and for young people with a learning disability. www.mencap.org.uk/youngmencap

Childcare information

Software tutorial

AbilityNet has produced an online Dragon Naturally Speaking tutorial to help employees with disabilities such as dyslexia access computer technology via voice recognition software. www.abilitynettraining.org (35)

The Daycare Trust offers free information about childcare for parents, and campaigns for high quality affordable childcare for all. www.daycaretrust.org.uk

The Council for Disabled Children has released a booklet on how to involve children and young people with communication impairments in decision making. www.participationworks.org.uk/ResourcesHub/Pa rticipationWorksResources/tabid/316/Default.aspx On a similar theme, Bristol Universitys resource is for involving children with little or no speech in decision making. w w w. b r i s . a c . u k / n o r a h f r y / d o w n l o a d / iwanttochoosetoo.pdf

CBT online

Young people

Deafness worldwide

Family Friendly working with deaf children and their communities worldwide is a comprehensive action learning resource to help organisations working with deaf children and families throughout the world, particularly where poverty and isolation are issues. www.deafchildworldwide.info 6

A new charity and membership organisation is creating a focus for all professionals and organisations working in the field of young peoples health. www.youngpeopleshealth.org.uk/

Living Life to the Full is a free online life skills course written by a psychiatrist who specialises in Cognitive Behaviour Therapy. The developers have tried to make the course accessible to a wide range of people. www.livinglifetothefull.com

Locked-in syndrome

Special holidays

Therapeutic Holidays is a charitable organisation in Crete offering holidays combined with activities for people with special needs. www.therapeutic-holidays.org.gr

The MegaBee writing tablet has been developed with the help of people with locked-in syndrome at Stoke Mandeville Hospital. www.megabee.net

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

heres one I made earlier

Heres one I made earlier...


Give and take
MATERIALS Storylines you will need to invent some of these yourself and get some from local and national newspapers and some from magazines. You are looking for stories that show a polarity of argument, and about which the clients already have opinions. IN PRACTICE (I) Find out what the clients think about the stories, eg. in a story about shoplifting, probably one client will sympathise with the shoplifter and one will be more inclined to support the law. In an environmental story, one client might favour banning private cars, whilst another might put personal freedom first. In an invented story, say about a sibling argument over which film to see at the cinema, a gangstertype movie, or a cartoon, you will probably find a supporter for each side. Other invented MATERIALS * Balloons * A pin * Wide, soft felt tips PREPARATION The first thing to establish is whether any of the participants have a fear of balloons! Quite often people on the autism spectrum worry that a balloon will explode in their face. One thing to try is the controlled pop a way in which they can be in charge of a gentle pop. All you need to do is to blow up an extra balloon, a little softer than its full capacity, and now show the clients how to take the pin, and gently stick it into the wrinkled, slightly thicker area around the knot. The balloon will not explode loudly, but will merely puff and deflate. Once this has been done the clients tend to feel they have control

Alison Roberts with more low-cost, flexible therapy suggestions suitable for a variety of client groups.

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire. scenarios might include Our College should have a uniform, or All junk food should be banned. The twist is that once you have established who favours which side of the argument, you require them to argue the other persons case. This takes the heat out of the argument, making it into an exercise rather than just a quarrel. It also makes them see the problem from the other persons point of view. As well as the proponents of each side of the argument you need to have a mediator. This figure asks each side in turn to do the following: 1. State their case, and then listen in silence to the statement from the other side. 2. Restate their case, adding anything else in the light of the other persons statement, and listen in silence to the other persons restatement. over the balloons, and are therefore not worried about them any more. Now ask everyone to blow up a balloon, again not too hard. They should draw a face on each balloon with the soft felt tips. IN PRACTICE In the original party games, either the balloon is placed between the foreheads of the partners and the pairs race sideways, or the balloon is passed from one person to the next between the knees. However, for people with autism spectrum disorder, such closeness can be intolerable. In this humorous buffered-contact version, the balloon is sandwiched between the shoulders of two clients who are standing side-byside with the balloons drawn-on face looking forward. Two pairs of clients with their sandwiched bal3. Offer one compromise that the other side might accept, trying to be sure that both sides give some ground. 4. Agree on a course of action. The mediator now reiterates the problem, the compromises, and the conclusion reached. It is wise to begin with distant, theoretical problems, and then gradually work towards problems which the clients might be familiar with. IN PRACTICE (II) If some of the clients are willing, once some hypothetical problems have been negotiated it can be helpful to discuss any real issues that are communication-based, eg. My houseparent often wants me to wash up when its not my turn. In this case the client actually involved in the disagreement should be an onlooker rather than a participant. loons stand opposite each other, and then carefully walk towards each other so that the balloon faces eventually reach conversational distance from each other. If the balloons are still in place by the time the couples meet, they can proceed to the next stage. Now the clients make their balloons have a conversation with each other. The couple who first let their balloon drop are out. They will find that the funnier the chat the more likely the balloons are to fall. Other methods of making the opposite couple drop their balloon are to make comments about something that is either high up, or on the floor. Moving about will risk losing the pressure, and so losing the balloon. The last ones with a balloon are the winners.

A great role-play game for learning negotiation techniques and how to make and accept compromise. There is a difference between negotiating and debating, in that negotiating does not produce one winner - in fact, a win-win situation should be the outcome. You need three clients for each role-play, but it is preferable to have more than that in the group, to ensure that you can find people with opinions about each subject. People with Aspergers Syndrome find this activity very useful.

Cooperation balloons

This fun activity is an adapted classic party game. A biggish group of eight clients is ideal, although it can be done with four. The game helps to establish a mood of cooperation and fun, encourages practice in greetings and social chat, and illustrates the benefits of working with a partner. The partners need to be of roughly equal height.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

learning

The Maytor, the Shorpine and the Traigol


Helen McGrane introduced mythical creatures to people with aphasia to explore whether individualised optimal learning approaches might improve the effectiveness of aphasia therapy. Here, with Linda Armstrong, she discusses the outcomes of that research and the implications for practice.

peech and language therapists have a wide range of assessments available now to look at many different aspects of a persons aphasia. We also have a wide range of materials for and approaches to therapy. But how does therapy work? How does speech and language therapy affect the brain of a person with aphasia? Is the client re-accessing previously held linguistic information and / or are new neural pathways being laid down? Why does it work better with some people than others? Should we be using optimal learning approaches such as encouraging errorless learning so that the person does not rehearse errorful or maladaptive responses? These are questions to which we still have no robust answers. Helen set out to begin to answer them by exploring one possible cerebral mechanism by which people with aphasia might be able to benefit in therapy new linguistic learning using optimal learning approaches such as staggered learning and an errorless learning approach. Several people have already examined learning in people with aphasia, but none using a set of stimuli in which both the word forms and the word meanings were new. If people with aphasia were able to demonstrate new linguistic learning, then this might open up a new approach to therapy, in which even previously held words might be treated as new.

Creature creations

Helen created 20 creatures, each with a unique image, name, skill, food and habitat (figure 1). Twelve people under the age of 65 years (six female and six male) of varied age, years in education, employment and severity of aphasia particiFigure 1 Examples of creatures

pated in four individual daily and consecutive training sessions, in which five new words were taught per day. The training sessions Helen McGrane used a staggered and errorless learning approach and included independent learning time (up to a maximum of 30 minutes), in which the participants could try to learn as many details as they could about each creature (name, skill, habitat and food) alone and in whatever manner they chose. They were told they could use any manner of learning that they wished and were given the option of choosing any, all or none of the following tasks to aid their learning of the stimuli: listen to the details to be learned via a taperecording (name, skill, habitat and food) as many times as they wished look at the written and picture representations of the vocabulary practise writing the word forms and associated meanings / attributes through copying the above material practise semantic and syllable matching tasks that would be similar to assessments they would later complete. The participants attempted a hierarchy of tasks at the end of each session to assess their learning of that days five new words. Those unable to demonstrate their learning by saying or writing the words could do so in other ways, such as matching a written word to the image, matching the initial written syllable with its final syllable and indicating how many syllables each creatures name had. Full details of the screening, training and assessment procedure are available from Helen. All twelve participants learned some new linguistic information, even those with significant language impairment. Their scores ranged from 15 per cent to 99 per cent on the assessment of their learning. All participants were invited to participate in a delayed assessment session that took place 3-5 days following the final training session. Ten participants agreed. Their retention of original information learned ranged from 49 per cent to 83 per cent. One participant, with severe aphasia, illustrates the procedure.

Linda Armstrong

READ THIS IF YOU WANT HOPE FOR CLIENTS WITH SIGNIFICANT, CHRONIC IMPAIRMENTS UP-TO-DATE INFORMATION ON PRINCIPLES OF THEORIES OF LEARNING CLIENTS TO MAKE THE MOST OF INDEPENDENT LEARNING TIME

June (pseudonym) June was a 60 year-old widow who lived alone, with carers visiting daily and regular contact from her family. She presented with upper and lower hemiparesis on her dominant side and mobilised with a wheelchair, following a left intra-cerebral haemorrhage 146 months prior to participating in the study. This was Junes second stroke. She had been a factory worker and had nine years of education. Before the training sessions began, Junes mood, language (single word processing and connected speech) and cognition were screened. On the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983), June scored 16 for both anxiety and depression. This is the highest possible abnormal score indicating high emotional status for both anxiety and depression, some of which may have been related to her relatively recent bereavement. The language screening consisted mainly of parts of the PALPA (Kay et al., 1992) and pictures from Snodgrass & Vanderwart (1980) as well as narration of the Cinderella story (spoken and written) and the Cognitive Linguistic Quick Test (CLQT) (HelmEstabrooks, 2001). Junes score profile on the language screening is shown in table 1 and plotted onto Ellis & Youngs (1996) cognitive neuropsychological model of language in figure 2, where the pale highlight indicates impairment.
Table 1

Junes language screening data Language screening scores Word Non-word Listening lexical decision 8/8 7/8 Repetition 8/8 5/8 Reading lexical decision 5/8 7/8 Reading aloud 4/8 0/8 Spelling 0.5/6 0/6 15/15 10/15 12/15 (shapes) (pictures) (words) 9.5/12 18 (severe)

Categorisation Naming CLQT language

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

learning The CLQT language subtest indicated that June had severe language impairment. Her language screening data suggested that she had many language difficulties at single word level. June indicated that she could not read or spell very well prior to her stroke but the exact extent of her previous literacy was unclear. Her spontaneous speech was limited to three single words (ken [know], no, yes] and, as can be seen in figure 2, most of the modules and pathways were impaired to some degree. June had difficulty repeating non-words, reading aloud and spelling words and non-words and also naming. She had some difficulties categorising pictures (67 per cent correct) and words (80 per cent correct). June was unable to narrate the Cinderella story either in spoken or in written form. Despite evidence of comprehension difficulties it was evident that June understood all instructions, especially when given examples. We predicted that she would find it difficult to demonstrate the learning of new vocabulary in any format due to her severe language impairment. The cognitive sub-tests of the CLQT indicated that June had mild attention, executive function and visuospatial skill impairment and moderately impaired memory and clock drawing skills (table 2). However she demonstrated adequate visuospatial skills to engage in the training and assessment tasks by drawing detailed pictures of the creatures and copying the new words accurately. The severity of Junes memory impairment would predict a difficulty learning and recalling the new vocabulary. The scoring system of the CLQT only accepts verbal answers as valid responses to the tasks, which may underestimate the memory abilities of non-verbal participants with aphasia. However, June also had difficulty learning the non-linguistic task (stepping-stone route), only achieving 44 per cent on immediate recall and 22 per cent on delayed recall. This indicates a poor capacity to learn new information. Junes performance on each task designed to assess her learning is in table 3 with a summary of her ability to learn the new vocabulary for immediate recall assessments. June was unable to recall any of the new words spontaneously either in spoken or written form. She was also unable to recognise the words in listening or reading recognition tasks. June selected the correct number of syllables for three creatures and accurately completed the written syllable matching task for four words. She matched nine new spoken words with the correct picture and eight when reading the new words.
Table 3

All twelve participants learned some new linguistic information, even those with significant language impairment Guidance required
June was one of three participants who required guidance in organising her independent learning time (possibly relating to her cognitive impairment or limited experience of education). She listened to the audio recording of the creatures phonological representation and semantic features and practised some of the assessment tasks. This guidance was required for each of the four training sessions and, although June was offered the full 30 minutes for each session, she chose to utilise only 55 minutes (46 per cent) of the total allotted independent learning time.

Junes performance on learning new vocabulary Assessment task Score Name (spoken) Name (written) Skill (spoken or written) Habitat (spoken or written) Food (spoken or written) Auditory lexical decision Lexical decision (reading) Picture-syllable matching Syllable completion Reading aloud Word-picture matching (name) (spoken) Word-picture matching (name) (written) Word-picture matching (skill) (spoken) Word-picture matching (skill) (written) Categorisation (habitat, food) (picture) Categorisation (habitat, food) (written) Total (possible maximum score of 320) 0 0 0 4 5 0 0 3 4 0 9 8 7 1 6 3 50

Figure 2 Representation of Junes single word processing abilities SPOKEN WORD PICTURE WRITTEN WORD

Auditory Abstract Phonological Letter Analyses Identification

Visual/ Object Recognition Phonological Orthographic Input Input Lexicon Lexicon Semantic System Acoustic to Letter to Phonological Phonological conversion conversion Phonological Output Lexicon Orthographic Output Lexicon Copy Letters

Junes score represents 16 per cent of the potential total. In light of the low score, we considered the element of a chance performance on the tasks. However, the data indicated that June was able to word-picture match (both spoken and written) for five of the new words. She was also able to identify the skills for three of these new creatures and for two of them she also identified their habitat and food. Therefore we were confident that June demonstrated the ability to learn some information about the new words despite the severity of her aphasia, her mood and her cognitive impairments.

Ability to learn

Phonological Output Buffer


Table 2

Phonological to Letter Conversion

Graphemic Output Buffer

Speech

Writing

Junes cognitive screening data Cognitive sub-test scores on CLQT Stepping-stone Route Attention Memory Executive Visuospatial Clock Non-linguistic function skills drawing learning 126 117 23 72 8 6 Mild Moderate Mild Mild Moderate 33%

This investigation of new learning in aphasia demonstrated that people with varying degrees of aphasia severity, cognitive ability and mood can learn new linguistic material. Those participants unable to speak or write effectively had the opportunity to show what they had learned through a range of tasks and response types. The main findings indicate that people with impaired language systems can demonstrate the ability to learn new language representations. The process of aphasia rehabilitation may therefore involve both the facilitation of already held information, inaccessible as a result of the stroke, as well as the process of new learning perhaps of previously known but now forgotten words. These results have several implications for aphasia therapy, some of which highlight the potential for speech and language therapists to make much more use of principles for theories of learning within their aphasia therapy programmes. Errorless learning asserts that people learn more successfully if they are prevented from 9

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

learning making and reinforcing their own errors (Fillingham et al., 2003) thus reducing the likelihood of incorrect memory traces being laid down. The concept which has been successfully used in the rehabilitation of people with memory impairments (Kessels & de Haan, 2003) looks as if it will find a very useful home in aphasia rehabilitation. It suggests that we should learn in a fashion that minimises guessing and maximises the trials where there is a strong chance of achieving the correct answer. Such approaches may contradict some therapeutic approaches where clients are encouraged to guess correct responses. However, the danger of creating and strengthening maladaptive connections through repetition and rehearsal of incorrect responses can only serve to reduce the functional impact of therapy and the creation of patterns of accurate responses. We cannot be certain that the participants in this investigation entirely employed an errorless learning approach to their independent learning time, but this was used during the training sessions and encouraged during the independent learning time. Mckissock & Ward (2007) showed that their errorless condition was most beneficial, while it did not require the participants to name the picture. Although further exploration is needed in this area speech and language therapists need to consider this in planning therapy tasks. The provision of adequate time for repetition and consolidation of therapeutic stimuli appears to be an essential component for therapy. Statistical correlation suggested that the longer participants spent consolidating the new vocabulary the more successful they were in learning the new words and retrieving them from long-term memory. Therefore, ensuring that consolidation time is planned into therapy is important for our clients. The once weekly speech and language therapy session, with ideas and / or tasks left for the client to undertake until the next session however may be of no benefit to clients like June, who are unable to structure their independent learning time. For them, discussion of learning strategies pre-therapy and during the therapy programme may increase the effectiveness of the face-to-face contact as well as time spent by the client on speech and language therapy in between contacts. In terms of appropriate referrals for aphasia rehabilitation, the study highlights that participants both in the acute and chronic stages of recovery demonstrated the ability to learn the new vocabulary. These findings are consistent with those studies that demonstrate the restitution of language by people in the chronic stages of aphasia and refute the idea that language rehabilitation for those in the chronic stages of stroke should only incorporate compensation strategies rather than facilitation of further restitution of language. Therefore, we as speech and language therapists need to consider this when referred people in the chronic stages of stroke. ing by rote, yet others used writing and drawing to help their learning and some people preferred to carry out the tasks. Could this explain why people with apparently similar characteristics of language impairment respond differently to rehabilitation efforts? Although the same stimuli might be used in therapy, could the differing approaches to learning provide an explanation for the differences found in the recovery of aphasia? This information could be fundamental to the success of language rehabilitation in that problems in facilitating the restitution of language may not be caused by the particular tasks we are employing but rather the manner in which they are presented to individuals. Perhaps discovering the optimum learning strategy for each client before embarking on the therapeutic process would identify the best methods and processes to use during their customised rehabilitation process. Speech and language therapists may therefore find it helpful to include an evaluation of the individuals learning style in their initial assessment before deciding on what type of therapy to offer. Currently there is no method of assessing the learning preferences of people with aphasia. Helen is working on developing such a tool. Helen McGrane completed this investigation while undertaking her PhD at Queen Margaret University College. She is now Clinical Research Fellow at Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, FK9 4LA. Linda Armstrong was her Director of Studies and is a speech and language therapist at Perth Royal Infirmary, Perth, PH1 1NX. Helens QMUC SSRC Theses Online version of her PhD thesis is available at http://www.roundtable.ac.uk/ ssrc/pubs/McGrane2006PhD.pdf.

people with impaired language systems can demonstrate the ability to learn new language representations
Speech and language therapists are well aware of the impact of cognitive impairments on the rehabilitation of aphasia and the difficulty of measuring the level of impairment with assessments that rely on speech and language, the very responses that are impaired by aphasia. In such clients the reduction of the cognitive load may help, for example through the use of a staggered learning approach where they are gradually presented with targeted words for rehabilitation.

Preferred method

Finally, qualitative observations in this study suggested that although participants were all given the same optional tasks to help learn the new vocabulary in their independent learning time, they tended to employ a preferred method of learning consistently across the four training sessions. For example, some people listened to the tape-recording a number of times, others read the list of words aloud repeatedly as if learn-

References

Ellis, A.W. & Young, A.W. (1996) Human Cognitive Neuropsychology. Hove: Psychology Press. Fillingham, J. K., Hodgson, C., Sage, K. & Lambon Ralph, M. A. (2003) The application of errorless learning to aphasic disorders: a review of theory and practice, Neuropsychological Rehabilitation 13(3), pp.337-363. Helm-Estabrooks, N. (2001) Cognitive Linguistic Quick Test. USA: The Psychological Corporation. Kay, J., Lesser, R. & Coltheart, M. (1992) PALPA: Psycholinguistic Assessments of Language Processing in Aphasia. Hove: Erlbaum. Kessels, R.P.C. & de Haan, H.F. (2003) Implicit learning in memory rehabilitation: a metaanalysis on errorless learning and vanishing cues methods, Journal of Clinical and Experimental Neuropsychology 25, pp.805-814. Mckissock, S. & Ward, J. (2007) Do errors matter? Errorless and errorful learning in anomic picture naming, Neuropsychological Rehabilitation 17, pp.355-373. Snodgrass, J. G. & Vanderwart, M. (1980) A standardized set of 260 pictures: norms for name agreement, image agreement, familiarity, and visual complexity, Journal of Experimental Psychology: Human Learning and Memory 6(2), pp.174-215. Zigmond, A.S. & Snaith, R.P. (1983) The hospital anxiety and depression scale, Acta Psychiatrica Scandinavica 67, pp. 361-370. 10
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

REFLECTIONS DO I ASK ABOUT INDIVIDUAL LEARNING PREFERENCES DURING ASSESSMENT AND USE THAT INFORMATION WHEN PLANNING THERAPY? DO I SCHEDULE APPOINTMENTS FLEXIBLY ACCORDING TO INDIVIDUAL NEED AND AVAILABLE EVIDENCE? DO I REDUCE COGNITIVE LOAD, GIVE SUFFICIENT TIME FOR REPETITION AND CONSOLIDATION AND SUPPORT A CLIENTS INDEPENDENT LEARNING TIME?
How has this article been helpful to you? What theories of learning are you using in your work? Let us know via the Summer 08 forum at http://members. speechmag.com/forum/.

Rise and sign


Establishing Signalong as part of a total communication approach in a special needs school has helped pupils develop their comprehension, expressive language and communication skills and have fun in the process. Polly OCallaghan considers the success of the strategy and how ongoing challenges will be met.

Total communication

L-R Frances Duffy, Sarah Doherty, Alison Dennis, Polly OCallaghan, Lin Artus.

READ THIS IF YOU WANT TO CAPITALISE ON NATURALLY OCCURRING COMMUNICATION MAKE CHANGES TO AN ENVIRONMENT MOTIVATE INDIVIDUALS, CARERS AND COMMUNITIES

s speech and language therapists working in the educational setting know, there have been significant changes in the special needs sector. For our school it has led to a population shift down the scale of learning difficulties. Whereas previously most of our pupils had moderate learning difficulties, we were increasingly being referred pupils with severe learning difficulties and more complex speech, language and behavioural needs. With the school specialising in communication difficulties, our department is continually looking for ways to develop the communication support available for pupils. The shift in population has meant we are working with a different client group, thus requiring new skills to ensure these more complex needs are met. Our speech and language department has successfully implemented a variety of low and high tech AAC (alternative and augmentative communication) aids for many of the pupils. As a school we took a Total Communication approach; in fostering the use of a combination of systems all children are encouraged to communicate, each using the most effective method in terms of their own needs. Our AAC devices range from VOCA (voice output) to simple Mayer-Johnson symbol boards and we work with the pupils, parents, special support assistants and teaching staff to ensure the aids are used to maximise understanding and communication opportunities in all areas of the curriculum. For us to develop our Total Communication approach, we decided as a school to introduce key word signing to extend the range of AAC available to pupils. Many children already used some signing spontaneously to help convey their meaning. As an AAC modality, signing seems to capitalise on an already naturally occurring developmental process. In normal child language development most children will use gesture prior to the development of speech as the primary linguistic mode and, as adults, we naturally use gestures to emphasise the message we want to convey to a child. For individuals with learning difficulties, who often have profound short term auditory mem-

ory and processing problems, the use of manual signs provides visual information to support the spoken word. As with the use of symbols and pictures, providing visual information is more concrete and accessible to many individuals with learning difficulties. However, signing has the advantage of being very instant and more readily available to the individual in that all too familiar situation where communication aids have been left at home! We did not want to replace our existing AAC modalities, and were aware that signing would not be suitable for many pupils, but felt it would add to the communicative opportunities available within our learning environment. We chose the Signalong sign system because of its clear, easy to make, iconic signs with a large catalogue of resources for adult and child use. Signalong is a sign supporting system based on British Sign Language used primarily to assist communication in cases of language problems associated with learning difficulties. Sarah Doherty, a very experienced special needs teacher from our school, trained as a Signalong tutor over the summer break. The tutor course is a five day intensive course for individuals with some previous Signalong experience. Although many speech and language therapists qualify as tutors, it is also attended by a number of other professionals such as teachers. We considered the high caseload demands in the speech and language therapy department and decided we didnt have the flexibility to allow for the significant amount of time needed to train all the staff and run courses elsewhere during the school working week. Instead, we would use our time and skills to work with the Signalong tutor in developing the signing skills of our pupils and helping staff to use sign effectively. Having already completed the foundation course, Sarah volunteered to attend the tutor course and allocated one and a half days of her teaching week to train staff in Signalong. The tutor course allows participants to deliver the Phase 1 foundation course in Signalong. Upon completion of this 16 hour accredited course with a final assessment, trainees are able

to generate any Signalong sign from the drawing and written description provided by the Signalong Group as well as covering a core vocabulary of approximately 350 signs. It also helps trainees understand some communication concepts important when working with individuals with learning difficulties including the use of key words, symbolic development, generalisation and over-generalisation. Sarahs task was to train all the staff in school including Special Support Assistants, teachers, catering staff and care staff. The course was also available to parents and people from the wider community and other schools. Sarah worked with us in planning how to establish Signalong effectively in our school. Our longterm aim was that, by the end of the academic year, our school community would be using Signalong as part of our Total Communication approach.

Raise the profile

As soon as our first foundation course was up and running, we began to publicise signing as much as possible around the school. We wanted to raise the profile of signing to staff, pupils, parents and the wider community. First, we set up some clubs. For our younger pupils (9-16 years), we ran a break time healthy snack club. Pupils sat in a group and requested in turn a fruit or vegetable snack. We modelled a selection of request sentences in sign for the pupils such as Give me apple please, more apple please I want apple please. We chose two different snacks each week as a way of developing signing vocabulary. At lunch time, we ran a signing chat club for the older pupils (16-19 years). We sat in a group around a table and pupils were given a cup of tea (which they asked for in sign) and we allowed the students to lead simple discussions such as favourite colours, animals and foods, teaching them some new topic signs each week. We worked with the music department to develop a repertoire of songs which incorporated signing for the pupils in their assemblies and Mass services. We chose simple, repetitive songs with a lively chorus as well as some slow 11

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Total communication

Snack Club

reflective songs for Mass services. We sang songs like Rise and Shine and The Wise Man Built in Mass and assemblies while in clubs and class activities chose pop songs such as Reach for the Stars with the older pupils and nursery rhymes like Twinkle Twinkle with the younger children. The speech and language department led a weekly singing practice where we taught the signs with the music. We sang one or two songs from the repertoire to perform each week in a service and I stood at the front of the hall with two pupils who knew the signs, signing the songs to remind other pupils and staff of the signs. The pupils loved coming to the front of the hall and it proved a real motivator to learn the signs! We encouraged the pupils to develop their signing skills by offering achievement awards. We had three vocabulary award certificates: green for pupils who knew 50 signs, orange for pupils who could sign 20 words and red for pupils with 10 signs. We chose set vocabulary for the awards, which was useful within the school environment. We gave each class three coloured posters of the signing words for each award and encouraged our trained assistants to help the children learn the signs in any spare minutes during the day. We wanted to make the scheme accessible to all our pupils, so we also had a fourth certificate called the significant achievement award. This recognised if a pupil was making any noteworthy signing progress for example, it may be a significant achievement for one pupil simply to make the thank you sign. In addition, we had a sign of the week and awarded pupils with plus points for their house teams if they were able to make the sign. We chose social phrases like good morning or functional words or phrases like toilet and help me. To make sure the parents were aware of our work, we worked some signs into our Christmas play performance with a whole school song at the end using signs. We also made a Signalong newsletter with photos of the pupils and details of all the things we had been doing and pupils achievements which we sent home to all the parents. Soon parents were expressing an interest and some had enrolled on our foundation course. One of our most successful signing events was a sponsored Sing and Signalong. We asked each class to perform a song of their choice with sign in a whole school Signalong afternoon. Pupils dressed up in costumes and performed it on stage to an audience of our staff, pupils and parents raising money for Edirisa UK (www.edirisa.org.uk), a charity supporting education in Uganda. The pupils loved performing and really enjoyed showing off their signing skills. 12

Snack Club

Exceeded expectations

It didnt take long for us to realise that the benefits of signing far exceeded our original expectations. Pupils understanding was enhanced by the additional visual clue provided. The slowed speech (which naturally occurs when we use sign to support our speech) gave the pupils much needed extra language processing time. For pupils who had difficulties with eye contact and attention, eye contact was encouraged and the gaze could be more easily drawn back as the child was prompted to look at the face and wait for the next sign. A particularly successful case for us was a pupil with autism spectrum disorder, moderate learning difficulties and an intense shyness with using spoken language. When trying to talk to him, he would turn his body away from the speaker and would speak in a barely audible whisper if at all. When we started using sign, we saw a huge improvement in his body language and eye contact, as he looked at the speakers hands for signs and started to join in with lessons by contributing with sign. There was often a reduction in behavioural issues as children were more engaged with the speaker and improved in concentration. Particularly noticeable in our healthy snack club, signing was helping pupils in their sentence sequencing skills. It seemed to assist pupils in understanding the units of a sentence, in turn enabling them to recreate the sentence themselves in the correct sequence, something which has often been a real challenge for our pupils. Aside from the noticeable speech and language gains, above all it seemed to be universally enjoyed by the pupils and gave a different dimension to my speech and language sessions.

I have forgotten all the signs I dont want to sign in case I make a mistake The pupils I work with can speak so I dont need to sign I just forget to use it. It was clear that just completing the course was not going to be enough to get everyone using signing and some of our staff needed ongoing support and teaching. We took several steps to meet this challenge: 1. Individually tailored course delivery what words are relevant to them? The foundation course covers just over 350 signs, which may seem a lot to remember for many people. It is important to stress to people learning Signalong that they should focus primarily on vocabulary relevant to them. To help our trainees, we worked out key signing vocabulary relevant to each group, as for example a special support assistant would need different key signing vocabulary to the catering staff. Although Sarah covered all the vocabulary in her course, we worked with her in tailoring her courses with activities based around the vocabulary relevant to the individual trainees signing needs. We also worked with individuals who had extra duties such as running a breakfast club in learning the vocabulary needed for that specific situation. 2. Developing signing confidence giving staff a role Events such as our sponsored Sing and Signalong day, where the classroom staff were required to work out signs for a song to teach their class, were great for encouraging staff to use their signing skills. We also gave staff a pupil signing partner, so they could teach signs for the pupil to work towards a Signalong vocabulary award. We got as many staff as possible involved in assembly and Mass services and tried to ensure there was a Signalong aspect to most of the whole school events. 3. Revision and education As with learning a foreign language, if you dont use signing you quickly forget. We held regular revision meetings where we played Signalong

Enthusiasm and challenges

Although there was lots of initial enthusiasm For Signalong, we were met with plenty of challenges along the way. We found that, although our trainees were demonstrating they were competent signers during the training sessions, it was disappointing to see that many were just not using it at all with the pupils. Reasons given included:

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Total communication
Tips for Signing 1. Always speak when you sign, using the sign concurrently with your words 2. Only sign the key words 3. Always face the child 4. Encourage good looking before you sign 5. Praise any attempts to sign - even if they are not accurate - to increase signing confidence 6. If a child signs incorrectly, model the sign correctly and help the child make the sign by shaping the childs hand while saying the word 7. Try to teach new signs in a context with real objects (eg. if you are teaching food words, have the food there and encourage pupils to request the foods using the sign they are trying to learn) 8. Make signing fun, using it with music, drama and games.

Voice Care Network

news extra

Roz Comins, Founder of the Voice Care Network UK, has stepped down as coordinator. The Network now has an office administrator and a development officer, Phyllida Furse. The organisations three key commitments are to provide continuous professional development opportunities for voice tutors and speech and language therapists, offer prevention-focused voice workshops throughout the UK and gather research on the benefits of keeping voices healthy. www.voicecare.org.uk

Sing and Signalong

games to keep staff up-to-date and using their skills. We talked to staff about their pupils needs and explained how they could use signing effectively with them. We helped staff appreciate that, even if the pupils they worked with could speak, using Signalong may help their understanding, and we used specific examples of where it had been particularly effective. We also made videos of speech and language sessions where we had seen significant communication and / or behavioural improvements, to give motivation to staff.

A long way to go

foundation course covers a basic vocabulary that is adequate for working in the ModerateSevere learning difficulties group. If used effectively, Signalong can greatly improve the communication partnership and is a useful modality for many individuals with learning difficulties. The introduction of Signalong in our school has been fun and enjoyable and I look forward to continuing to develop new and exciting ways of using signing to enhance communication and learning in our school environment. Polly OCallaghan is a speech and language therapists at Pield Heath House School, Uxbridge, Middlesex, tel. 01895 258507.

We still have a long way to go with our Signalong challenge. We need to continue to work with the staff we have trained to ensure they keep up their signing skills. Important for us is further work with parents for the transfer of signing skills into the home environment. As with all AAC, there is often resistance from parents, as many worry it will hinder their childs ability to develop spoken language. We may need to talk with particular parents to alleviate these concerns and encourage them to develop some signing skills themselves. We also hope to work with the wider community such as the pupils care workers to help our children with communication outside of the school environment. Signalong has been hugely popular with staff, pupils and many of the parents at our school. The

Acknowledgements

My thanks to all staff who supported the launch of Signalong at Pield Heath House School. A big thank you especially to Sarah Doherty, Signalong tutor and R.E. teacher; Frances Duffy, Head of Speech and Language Therapy; Lin Artus, a volunteer in the speech and language department; and Alison DenSLTP nis, social communication skills teacher.

ORC International is reporting that 41 per cent of passenger transport employees in customer facing roles in the UK lack communication skills. The research companys survey of 1000 passenger transport employees and employers was carried out on behalf of the employer-led training organisation GoSkills to provide greater insight into the skills gap that exists in basic numeracy, literacy, IT and communication skills. It also found that 23 per cent lack basic skills, that English firms fare worse in comparison with Wales and Scotland and that the language barrier between native and non-native English speakers is a problem for many companies. Respondents said the main barriers to addressing the skills gap through training are lack of time and funding. www.goskills.org

Transport employees lack communication skills

PECS in the frame

Resources

Mayer-Johnson Picture Communication Symbols, www.mayer-johnson.com Rise and Shine! (CD / DVD) http:// km.churchinsight.com/Shop Sign & Rhyme DVD temporarily unavailable (more information from www.signalong.org.uk) Signalong Basic Vocabulary Phase 1 www.signalong.org.uk

REFLECTIONS DO I HAVE A CLEAR RATIONALE FOR INTRODUCING A NEW COMMUNICATION TOOL OR MODE? DO I RECOGNISE WHEN IT IS EFFICIENT FOR ANOTHER PROFESSIONAL TO OFFER CORE TRAINING WHILE I USE MY SKILLS IN A STRATEGIC SUPPORTING CAPACITY? DO I HAVE A REALISTIC PLAN FOR MAINTAINING AND DEVELOPING THE APPROACH IN THE LONGER TERM?
How has this article been helpful to you? What are your experiences of introducing a total communication approach? Let us know via the Summer 08 forum at http://members.speechmag.com/forum/.

Pyramid Educational Consultants are running a photography competition to catch the best in PECS practice. The Picture Exchange Communication System has been used in the UK now for 10 years. The prize is a day of free consultancy. www.pecs.org.uk/photocomp.htm (deadline 1st August).

Road volunteers

The national road safety charity Brake is urgently seeking volunteers from the health professions to provide immediate practical and emotional support to families and individuals who are newly bereaved as a result of death on the road. Training, debriefing and support will be provided. e-mail Diane Bevan, brakecare@brake.org.uk

Time to Get Equal

Recommended reading

Layton, T.L. & Savino, M.A. (1990) Acquiring a communication system by sign and speech in a child with Downs syndrome: a longitudinal investigation, Child Language Teaching and Therapy 6, pp.59 -76. Powel, G. & Clibbens, J. (2003) Augmentative Communication, in Bochner, S. & Jones, J. Child Language Development, learning to talk (2nd edn). London: WileyBlackwell. Rondal, J. & Buckley, S. (2003) Speech and Language Intervention in Downs Syndrome. London: WileyBlackwell.

Williams, G. (2002) Augmentative and Alternative Communication, in Abudarham, S. & Hurd, A. (eds) Management of communication needs in people with learning difficulties. London: WileyBlackwell.

Scope is calling for one million people to campaign together to tackle injustice, break down barriers and challenge disablism. The charitys Time to Get Equal Week runs from 9-15 June. Activities include an online petition at http://petitions.pm.gov.uk/noreservations which asks the government to ratify the UN Convention on the Rights of Persons with Disabilities in full, without reservation or limitation, by December 2008. www.scope.org.uk

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COVER STORY: SKILL MIX

Are you listening?


A new communication development worker post, collaboration with speech and language therapy and a robust training plan has made a respite unit called Tayavalla an inspiring inclusive communication environment. Elaine Crighton, Isabel Forsyth and Lois Cameron explain how children and young people are now getting the most from their break.

espite presents specific communication challenges in that the children and young people are away from their most familiar communication partners and most familiar communicative context. However, it also provides a huge communication opportunity because of the emphasis on individual care and providing meaningful activity to make the stay fun. So how can we ensure a consistent approach to communication when children go to respite? Tayavalla is a residential short break unit in Falkirk run by the childrens charity NCH Scotland. It provides a respite service to approximately 35 young people who live in the Forth Valley area. This large geographical part of Central Scotland encompasses three councils - Falkirk, Stirling and Clackmannan - each with a range of schools attended by young people who also access Tayavalla. There are 10 speech and language therapists providing input to these schools. In addition, a few children attend schools outwith these local authority areas, which further increases the complexity of liaison and ensuring the communication needs of the young people are addressed. The speech and Language therapy service has always had good informal links with Tayavalla, although input in the past was on an ad hoc, caseby-case basis. We had also delivered two days of training on Inclusive Communication to staff at Tayavalla. This gave them background information about different levels of understanding and how to recognise communication breakdown, and an overview of strategies that could support the communication skills of the children. The training had highlighted to the staff the areas they would like to explore and have time to develop further. They were keen to support the children requiring alternative and augmentative communication (AAC) to participate more fully in activities and decision making, but felt they lacked the practical skills and confidence to put this into place.

nication Development Worker was appointed for 25 hours a week for a year. The appointee, Isabel Forsyth, came from the staff of the respite setting and knew the staff and children very well. The focus of the Communication Development Workers post was to develop and extend the communication environment for the young people attending respite. Staff from Tayavalla and the speech and language therapy service established a steering group to oversee the Are You Listening? project. The group agreed the design of an Action Research model, set clear goals and provided a mechanism for measuring outcomes. It also identified two key areas: 1. children and young peoples communication 2. staff development needs. The initial stage of the project involved devising before and after questionnaires for both the staff and the young people. The staff questionnaire was designed to highlight communication development needs so that appropriate training could be provided. The young persons questionnaire was devised to look at how they were communicating, and whether this information was available to staff at Tayavalla. The staff questionnaire looked at: Knowledge of communication development and augmented systems Knowledge and confidence for switches, objects of reference, signing and the computer Confidence in drawing to facilitate choice Access to resources (symbols, communication aids, digital photography). The areas of need identified for training were: using switches, the computer, and photography.

Training plan

Learning with Care

At around the same time, Falkirk Council approached NCH offering Learning with Care, a fund to develop Looked After Childrens educational attainment. Since communication skills were seen as fundamental to the childrens development and attainment, a proposal was developed in partnership with key staff from the speech and language therapy service to create a post to promote childrens communication. As a result, a Commu14

From this information, a training plan was developed involving informal and formal methods. Informally, the Communication Development Worker was available and had the time to support other staff to operate the computer and the digital camera. She was able to assist with practical difficulties such as how to use the software and how to download photos, so that as many staff as possible were able to create visual supports for the children. The speech and language therapy service also provided a training session on AAC and using simple technology for the staff at Tayavalla. This was kept practical with just a short introduction to what is meant by AAC. We divided the staff into small groups and gave each group a scenario they might

come across in a respite setting, involving a child with a communication difficulty. We asked them to carry out the role-play initially without the use of simple technology, as this gave them the opportunity to explore how it might feel to have a communication difficulty in this setting. We then asked them to re-try using the equipment we gave them. This created a lot of discussion, and staff were able to identify other situations where they could use the technology. They reported feeling more confident about having a go now they had been given a chance to play with the tools and to see they could easily be incorporated into daily routines. Analysis of the before and after staff questionnaires showed that staff knowledge, confidence and competence increased in every area covered in the questionnaire, except knowledge of communication development which stayed the same. (This could have been because the team already had a high level of training in this from speech and language therapy.) Staff became more confident in using the computer and were able to produce digital images to support communication, which in turn made the digital photography more accessible. Childrens questionnaires were completed using the project files (in consultation with children and families where required). As the study was time limited, the steering group highlighted 12 children with high level communication needs to work more closely with. The questionnaire consisted of only two questions. The first focused on the information available to staff on how the child communicated. The second question focused on the childs communication and looked at: 1) how the child was communicating, i.e. the systems being used 2) what the child was communicating, i.e. the communicative functions was it just needs and wants, was it to make a joke? 3) where the child was communicating, i.e. the different settings.

READ THIS IF YOU WANT TO FORM PARTNERSHIPS WITH LOCAL AUTHORITIES AND THE VOLUNTARY SECTOR OFFER EFFECTIVE TRAINING WITH FOLLOW-UP SUPPORT ENABLE CLIENTS TO DEVELOP COMMUNICATION IN DIFFERENT CONTEXTS

Communication Support Plan

The results showed that, for some young people, there was no formal information accessible to the staff at Tayavalla at the beginning of the study. This highlighted the need to have accessi-

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

COVER STORY: SKILL MIX

Isabel with Zoe and Ashleigh and a Talking Mat at Tayavalla. Photo by Paul Reid.

ble information on the young persons communication skills available to all staff, and prompted the idea of writing a Communication Support Plan for each young person. Speech and language therapists working in one of the secondary schools attended by the young people using Tayavalla had introduced Communication Profiles (adapted from Valentine, 2003) as a way of sharing information with teaching staff. This had proved very useful in school as it is one A4 sheet with information about the pupils communication skills, their likes and dislikes and any other important information. The key issue in developing a summary sheet is around the rigour and process of gathering the information to ensure its accuracy and relevance for the young person. The profile gives a summary of the kind of information that might be in a Communication Passport (Millar, 2003) but is a quick reference sheet that can be read by supply teachers or new members of staff who need to get to know the pupil quickly before the class starts. Where young people had a Communication Profile already in place, this made the information more accessible and easy to translate into the Communication Support Plan being introduced at Tayavalla. Where these were not available the same type of information could be gained from speech and language therapy reports and Individual Education Programmes, but the information was not as readily accessible and often included jargon that was not easy to translate. For us, the key results of this project are: 1. All staff had access to appropriate and up-todate information to support the young peoples communication. 2. Improved staff confidence in using switches, Voice Output Communication Aids and the digital camera to support communication.

3. Improved staff confidence in facilitating choice, and in their ability to communicate more effectively to meet the range of childrens needs. 4. A significant increase in the young peoples opportunity to communicate because of improved access to communication systems. This resulted in improved quality of interaction and an increase in their participation. 5. Inclusive communication strategies are well embedded in the project to the benefit of the young people, parents, staff and other agencies. There is easy access to a library of relevant symbols and photographs. A key indicator of success is that these resources and the AAC equipment box now require frequent tidying! 6. Promotion of good practice in interagency working. 7. Significant parental involvement in the communication strategies promoted by the project was unanticipated but welcome. 8. It provides a good example of inclusive communication in practice that can support the overall objectives of the speech and language therapy service. It is invaluable to be able to show people what we mean by an inclusive communication environment - and one visit to Tayavalla has a huge impact. The project has shown there are many benefits from having a Communication Development Worker. While some of these were predictable, others were unexpected. She is able to: take ownership and disseminate to the other staff involved in a way that they find easy to understand and relate to. understand the opportunities provided as part of the routines in the respite setting and encourage realistic targets. contribute knowledge about communication in a setting other than school to enable a more holistic approach.

Case Example Alison Before the communication development work, Tayavalla staff had no formal information on how Alison communicated. She had yes/no symbols on her tray but during the summer break the tray had been replaced and staff werent sure if the symbol position for yes/no had been significant! However, once all the information about Alisons communication had been gathered and the Communication Development Worker had observed her using the Etran frame at school, staff were able to offer her much more appropriate support at Tayavalla. She could eye point really quickly and was so obviously motivated when she got the opportunity. Staff were then able to move on from yes/no questions to using the Etran frame with a range of symbols and photos to involve her in many more aspects of life at Tayavalla than had been possible in the past. The AAC training session had also included a scenario of a child using eye pointing to participate in a story, and had given staff an opportunity to practise the skills of interpreting eye pointing and presenting information in this way. This led on to an opportunity to support Alison in providing a report for her review. She attended Tayavalla with her mum two days before and did some opinion-forming type communication using the Etran Frame in a Talking Mat format (Murphy & Cameron, 2002). We took photographs of the results and compiled a review report. The meeting was then held at Tayavalla to help Alison make the link between the work shed done and the meeting. She came on the day of the meeting and chose to present the report in person. When the meeting turned to talk about adaptations in the bathroom because she had grown she drew herself up to full height in her chair, letting those around her know she understood. When the staff acknowledged how tall she was becoming she smiled confidently. This had a significant impact on all present.

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COVER STORY / user involvement help ensure that skills learnt in the school setting can be transferred to a respite setting. use her increased contact with parents and families to ensure strategies are consistent across all environments, and offer invaluable support. Using the strategies in a care setting provides an important role model for parents. The study has shown the important role that residential units can play in furthering childrens communication skills when they provide a setting in which children can continue to develop and practise them. The partnership between the Communication Development Worker and the speech and language therapy service has been key to the success of developing a quality communication environment. Isabels energy to focus solely on communication proved a huge impetus to change and success. To embed inclusive communication practice into organisations is a challenge but this respite service has achieved it and is able to make sure staff have the skills to listen to what the children and young people are saying, no matter how they are able to say it. Are you Listening? won the Scottish Care Accolade Award 2007 for Innovative and/or imaginative training programme. We are delighted that this project has also received funding for a further three years from the Big Lottery. Part of this funding includes the extension of the skills developed within the respite setting to other places that the children and young people use in the community. This will continue to ensure that everyone is listening to them, no matter how complex their communication needs. Elaine Crighton and Lois Cameron are Speech and Language Therapists working for NHS Forth Valley, Speech & Language Therapy Department, Euro House, Wellgreen Place, Stirling Fk8 2DJ, e-mail lois.cameron@ fvpc.scot.nhs.uk, and Isabel Forsyth is the Communication Development Worker for NCH Tayavalla. SLTP

Looking in the mirror

User involvement whats your experience? Let us know at the Summer 08 forum, http://members.speechmag.com/fo

Editor Avril Nicoll introduces our new series on user involvement.


I originally planned to do a single feature on user involvement but was so overwhelmed by offers of help that I decided to run a series instead. While user involvement is enshrined in all NHS policy documents, I have a very personal reason for wanting to see this aspiration put into practice.

REFLECTIONS DO I NURTURE THE ABILITY OF SUPPORT STAFF TO GIVE TIME AND PRACTICAL SUPPORT TO INDIVIDUALS? DO I NOTICE SIGNS OF CHANGE IN PRACTICE SUCH AS A REGULARLY UNTIDY RESOURCE BOX? DO I MAKE INFORMATION ABOUT A CLIENTS COMMUNICATION ACCESSIBLE?
How has this article been helpful to you? Do you have other stories from inclusive communication environments? Let us know via the Summer 08 forum at http:// members.speechmag.com/forum/. References

Millar, S. (2003) Personal Communication Passports: Guidelines for Good Practice. Edinburgh: Call Centre. Murphy, J. and Cameron, L. (2002) Let your mats do the talking, Speech and Language Therapy in Practice Spring, pp.18-20. Valentine, C. & McConkey, R. (2003) The Communication Profile & its use with a learning disabilities population, Evidencebased practice: a challenge for speech and language therapists. CPLOL 5th European Congress. Edinburgh 57 September.Further information from cathvalentine@devon.gov.uk.

When I qualified 20 years ago it was normal practice for therapists to call clients patients. Both children and adults were seen on their own, or with parents and partners present merely as onlookers. The patient had an impairment that needed to be fixed, and the therapist was the expert who held the answers. Case notes, reports and discussions were reserved for professionals. Choice really came down to whether or not a client chose to turn up. For whatever reasons, this made me uneasy and I was keen to do things differently. From the start I tried to be responsive to individual need and to involve families. I was also very influenced by the pioneering work on empowerment by people like Carole Pound who went on to co-found Connect, the communication disability network. I enjoyed campaigning during Speak Week to get the needs of people with communication impairments in the public eye. But the real change in my attitude came about when I had my children. A deep rage at the way I had been treated led me to become involved in campaigning for improved, woman-centred services. I have now been a user representative at Montrose Maternity Unit for 8 years (www.birthinangus.org.uk). Although I was nervous at the start (who was I to be telling professionals how to do their job?) I now feel incredibly privileged to have been part of the driving force behind major changes that have benefited so many women and babies. The midwifery team leader says, The changes at Montrose have been more than cosmetic there has been a fundamental shift in our attitude, philosophy and our very language. This evolution may have taken place without the input of our users, but it is unlikely. They held a mirror to our service, and we did not like the reflection (Winters, 2006). But the midwives hold a mirror up to me too, and I learn such a lot. I now understand far more about the benefits of helping people locate and draw on their own internal resources, to find their own way and solutions and about using language with other people that constantly reinforces a belief in their strength and ability. I also have a deeper appreciation of the importance of the relationship between client and therapist and what it means for the personal development of both. As Santorelli (1999) says, For too long care has been conceived of as either practitioner-centred or patient-centred. In actuality, the healing relationship has always been a crucible for mutual transformation. I hope this series will inspire you to have the confidence to make genuine user involvement a reality. Please use the forum to share your own experiences - http://members.speechmag.com/forum/.
References Santorelli, S. (1999) Heal Thyself Lessons on Mindfulness in Medicine. New York: Bell Tower. Winters, P. (2006) Holding up a mirror: the impact of user involvement, AIMS Journal 18(3), pp.12-13. Available online at http://www.aims.org.uk/Journal/Vol18No3/holdingUpAMirror. htm (Accessed: 8 May 2008).

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

User involvement

Listening and learning


Mariela Angulo and Amy Wolfenden on how the process of gathering views from children, childrens centre staff, parents and speech and language therapists has shifted the focus of the service and resulted in a closer, more reflective team.

orum/

ur project aimed to evaluate the services provided by speech and language therapists working across children centres in the Bradford district by seeking feedback from service users. The need for the project was highlighted in a childrens fund evaluation (2006) which recommended we ensure children using the service are involved in service delivery. The audit suggested a creative, participatory approach that reflected the needs of children experiencing language difficulties. We wanted to improve our service by listening to people but had a number of anxieties. How would we get the childrens views? How would we feel about peer evaluation by other speech and language therapists? Would parents feel they had to say positive things? Would we manage not to guide people in their answers? We divided the users of our service into four main subgroups and obtained information from each in different ways: 1. Children To gather the childrens views we used Talking Mats (Murphy, 1998). We did this in a group setting with six groups of 4-6 children aged from 2-4 years. We showed them photographs and pictures from their sessions so they could indicate the activities they liked and disliked, although we tend to think the photographs give a good indication of their level of enjoyment anyway. Most of the children understood the task and enjoyed using the Mats to tell us their views. However, some children struggled to understand the idea and others purposefully chose the opposite for amusement! It was interesting to see how dominant leaders emerged, and how many were influenced in their opinions by others. We found this a really useful activity for communication, and we now incorporate it into our daily practice. 2. Childrens centre staff and teachers We used a comments books and matrix questions to gather views of this group. Staff gave open and honest feedback about speech and language therapists and their value. Most comments were positive and some also identified areas for service improvement and collaborative working. We sought feedback from centre managers regarding the overall speech and language therapy service provision. Most comments were positive and emphasised the importance of this input for childrens confidence, well-being and overall development and to the childrens centre ethos. Many managers were pleased with our input and some even said we had exceeded expectations while others highlighted areas for improvement. 3. Parents / Carers The parents expressed their views through comments books and Parent Child Interaction Group evaluation forms. They commented on

individual therapists, therapy blocks received, service provision and advice given for home. Overall, comments were extremely positive and highlighted how both parents and children enjoyed attending the sessions. They also noted the longterm benefits through changes seen in their children at home following early interaction advice. Parents appreciated the convenience and flexibility of attending local childrens centres and the informal, child-focused approach of the therapists. 4. Speech and language therapists We used two methods of data collection with therapists: a) giving children choices in daily practice questionnaire b) peer evaluation. Offering choices is an important way of listening to children. We therefore asked each childrens centre therapist to complete a reflective questionnaire detailing how choices are offered to children in everyday provision. The responses showed that choices are offered in different ways including activity, equipment, location (home visit option where appropriate, indoor / outdoor play in childrens centre settings, or areas such as home corner / sand) and by going with the childs interest following the Hanen techniques of observing, waiting and listening (Manolson, 1992) and responding to the childs attempts to communicate. We also designed a peer evaluation questionnaire based on the SSCAN technique as discussed in Weitzman & Greenberg (2002). The focus was on the interaction between the speech and language therapist and the children in groups. We were looking for recognition that small groups are best, the setting up of an appropriate activity, careful observation of each childs level of participation or interaction, adaptation of response to each childs needs and an ability to keep this going. All the therapists were aware of the childs attention, participation and interaction and adapted their interaction accordingly. Signs and symbols were not always used. All therapists changed physical position and repeatedly used the childs name. Therapists responded by imitation, using gesture and extending play sequences. However, depending on the nature of the group, some therapists followed a more structured approach. All therapists used sincere questions and comments. Some groups used more focused questions while in others the emphasis was on commenting and modelling. While turn-taking and parent participation was encouraged, there was less opportunity in more structured groups for the children to interact with each other.

l-r, Amy and Mariela

We now offer choices for everything. We think more about the location of therapy, such as whether a home visit or different setting would be more appropriate. Our manager has been supportive throughout and the service as a whole has shifted towards having more user involvement. We want to provide evidence based practice but we need feedback that we are getting it right. While many things are easily changed on a daily basis, some issues are more structural and strategic. However, we have been able to draw them to the attention of managers so user views are being heard. The project relates well to clinical governance, in particular patient, public and carer involvement, clinical effectiveness, communication and team working. It also highlighted the importance of listening to children, and reinforced for us the messages that are in the literature. Listening to children: plays an important role in early interaction and how it impacts on developing communication, language and literacy (Rich, 2002) can help ensure that they are valued and feel valued (Rich, 2004) ensures that their physical, emotional and cognitive needs are met (Rich, 2004) results in increased opportunities for practitioners to reflect on practice (Clark et al., 2003) is vital in establishing respectful relationships with the children we work with (Dickins, 2004). Mariela Angulo and Amy Wolfenden are therapists with Bradford and Airedale Teaching PCT. Please forward any comments to our team leader Margaret Greer, e-mail margaret.greer@bradford.nhs.uk. Acknowledgement We would like to thank past and present children centre team members for their hard work and SLTP support during this project.
References
Clark, A., McQuail, S. & Moss, P . (2003) Exploring the Field of Listening to and Consulting with Young Children. London: Thomas Coram Research Unit. Dickins, M. (2004) Listening to young disabled children. Listening as a way of life. London: National Childrens Bureau. Manolson, A. (1992) It Takes Two To Talk. Toronto: The Hanen Centre. Murphy, J. (1998) Talking Mats: Speech and language research in practice, Speech & Language Therapy in Practice Autumn, pp.11-14. Available online at www.speechmag.com/Reprints (Accessed 8 May 2008). Rich, D. (2002) More Than Words: Children developing communication, language and literacy. London: The British Association for Early Childhood Education. Rich, D. (2004) Listening to babies. Listening as a way of life. London: National Childrens Bureau. Weitzman, E. & Greenberg, J. (2002) Learning Language and Loving It. Toronto: The Hanen Centre.

Choices

As a team, this has brought us even closer than before. We are more aware of the issue and constantly use what we have learnt to reflect on our practice.

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17

SUPERVISION PRACTICE

Are you getting enough? (2) Supervision models and barriers


In the second of four articles, Sam Simpson and Cathy Sparkes explore supervision approaches and beliefs. Their two-part practical activity (box 1) is designed to help you reflect on your own experience, whether you have accessed supervision or not.
Supervision are you getting enough? Let us know at the Summer 08 forum, http://members. speechmag.com/ forum/.

n this series we hope to introduce, develop and validate your understanding and insight into supervision practices. In our first article we set out to define supervision and demonstrate that it is a fluid relationship encompassing a wide range of skills and techniques. Reflecting on our own experiences of supervision, we can recognise the different styles and approaches we have received and offered. These have been determined through negotiation with our respective supervisors and supervisees both at the start and at regular intervals throughout the relationship. We intend to help you to see your supervision history in relation to some of these approaches and models. In addition, we hope to enlighten you as to why sometimes it can be difficult to access supervision.

tion of each compol-r: Cathy and Sam nent will vary in each supervisory relationship and across different settings and time. 2. A developmental model of supervision Hawkins and Shohet (1989) report that supervisors need to have a range of styles and approaches which are modified as the counsellor (supervisee) gains in experience and enters different definable developmental stages. Their developmental model asserts there are four levels to the supervision relationship, each with its own unique features. We will explain some of the key features of each level: Level 1 Childhood - Novice At this level the supervisee is characterised by trainee dependence on the supervisor. Whilst highly-motivated, s/he often presents as anxious, insecure about his/her role and ability and lacking in insight. Supervisees tend to lack an overview of the whole therapeutic process, are prone to theorising prematurely and exhibit over-concern with their own performance. Stoltenberg & Delworth (1987, p.56) report that supervisees at this level tend to focus on specific aspects of the clients history, current situation, or personality assessment data to the exclusion of the other relevant information. Grand conclusions may be based on rather discreet pieces of information. In terms of the role of the supervisor, s/he needs to provide a clearly structured environment which includes positive feedback and encouragement to the supervisees to return from premature judgement of both the client and themselves to attending to what actually took place (Hawkins & Shohet, 1989, p.49). They need to focus on the content of the supervisees work with the client and the detail of what happened in the session (attending to what is). In addition, they need to support the supervisee to see the detail of individual sessions within a larger context (over time, to clients outside life and personal history). According to Stoltenberg & Delworth (1987, p.64), balancing support and uncertainty is the major challenge facing supervisors of beginning therapists. Level 2 Adolescence - Journeyman At this level the supervisee fluctuates between

dependence and autonomy, and between overconfidence and being overwhelmed. S/he is less simplistic and single-focused, but can be more reactive to their clients. Supervisees at this stage may also test out their supervisors authority. The supervisor needs to be less structured and didactic than with level 1 trainees, but a good deal of emotional holding is necessary as the trainees may oscillate between excitement and depressive feelings of not being able to cope, or perhaps even of being in the wrong job (Hawkins & Shohet, 1989, p.51). Level 3 Early Adulthood Independent Craftsman The supervisee now demonstrates a more flexible approach to client management and is able to see their client in a wider context, having developed helicopter skills (the ability to be fully present with the client in the session, but simultaneously have an overview that enables appreciation of the present content and process in the context of the total process of the therapeutic relationship, the clients personal history and life patterns, the clients external life circumstances, as well as the clients life stage, social context and ethnic background). Stoltenberg & Delworth (1987, p.20) comment that supervisees will show increased professional self-confidence, with only conditional dependency on the supervisor. He or she has greater insight and shows more stable motivation. In relation to the role of the supervisor, supervision becomes more collegial, with sharing and exemplification augmented by professional and personal confrontation (Stoltenberg & Delworth, 1987, p.20). Level 4 Full Maturity Master Craftsman The supervisee is characterised by personal autonomy, insightful awareness, personal security, stable motivation and an awareness of the need to confront personal and professional problems (Stoltenberg & Delworth, 1987, p.20). S/he often becomes a supervisor at this stage, which consolidates and deepens their own learning. Now supervision is not viewed so much in terms of acquiring more knowledge, but of allowing knowledge to be deepened and integrated.

A. MODELS

It is our intention to give an insight into the fact that there are many ways of offering and receiving supervision and that every relationship will benefit from an array of styles depending on who the relationship is with and at what stage of the supervisees journey they are accessing it. Each dyad is unique. We have selected three models to illustrate the multidimensionality of supervision. We consider all three to be complementary and do not favour one over another. 1. A functions model of supervision Prochter (undated, in Hawkins & Shohet, 1989) describes a model that differentiates between the three main processes of supervision: i) Formative and Educative Functions involve facilitating the supervisee to develop their skills, understanding and abilities, thereby enabling them to reflect on their practice, recognise strengths and weaknesses and develop skills and knowledge ii) Restorative / Supportive Functions thereby providing the supervisee with opportunities to explore and vent feelings, address emotional responses and understand their underlying causation iii) Normative / Managerial Functions concerned with ensuring high standards of practice and that the supervisees work stays within the organisational objectives. In practice there is considerable overlap between the processes, and the relative contribu18

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

SUPERVISION PRACTICE At this level, the supervisor has a role in listening to deeper meanings and wider implications and in focusing on paralleling, transference and counter transference as well as providing access to other approaches or key models. 3. A tasks model of supervision Carroll (1996) addresses the generic tasks of supervision rather than any particular framework. His hope is that effective supervisors will select tasks appropriate to their supervisees learning. The following is an outline of those tasks: Teaching: enabling the integration of theory into practice. Counselling: aims to raise awareness and understanding of the therapists own baggage. If personal issues are recurrent, it may be appropriate for the therapist to access counselling to address these. Monitoring professional / ethical issues as a supervision task: to ensure clear boundaries and accountability. Evaluation: thereby encouraging self-monitoring and challenging work that falls short of good standards. Consultation: the attention given to process in supervision. Administrative: involving exploring the implications of the therapists work in the different contexts that they operate, including confidentiality, documentation and service cultures.

We realise looking back over our careers that, in spite of good intentions and a true commitment, there have been times we have found it more difficult to access supervision due to personal, organisational or cultural pressures. We can both identify times when we accessed supervision less regularly than optimal due to work pressures or the gradual realisation that the current supervision set-up was no longer working as effectively. We can all be affected by external pressures or relationships. The Sheffield Project (1992-1994) quoted by Syder & Levy (1998) is a good example that, even when the conditions seem to be right, issues around access are nevertheless apparent. As part of a pilot study, supervision was made available to all 60 speech and language therapists working in Sheffield between 1992 and 1994. Therapists were able to self-refer for non-managerial supervision, which was not compulsory and offered free of charge. Everyone was entitled to time out from work and a range of neutral and central locations were made available. Sessions were confidential and feedback was gathered from those who opted for supervision as well as from those who declined. Reported gains for therapists who opted to take up the offer were multiple: Talking through my reasoning behind decisions and checking out what personal biases have gone into them Becoming more aware of my prejudices with a particular client group I feel less drained by work now. However, a number of stumbling blocks were identified: Insufficient time due to other work commitments Feelings of guilt about taking the time

B. BARRIERS AND BLOCKS

Box 1 Your supervision journey 1. Take a few moments to reflect on the type of supervision you are receiving / have received and could / would like to receive in the context of the three models in this article. Where possible reflect with a colleague and share your experiences. 2. Look at your supervision journey and consider your personal supervision beliefs over time. You might be pro / anti / somewhere in between be honest with yourself. Having read the article, are your beliefs represented? How have your beliefs impacted on your commitment to accessing regular personal supervision? How do your beliefs compare with those of your manager / service / organisation?
Anxiety that a friendship with the supervisor might interfere with the process Put off by the term supervision Not feeling the need to use it at this stage Feel adequately supported by colleagues Feeling happy with work life, therefore supervision is superfluous Supervision is only for when things are not going well, for problem clients or for times of stress / distress at work Supervision is a perk. Thus, in spite of having created the culture and core conditions for an entire service to have access to non-managerial supervision and having minimised the external barriers, take up was nonetheless an issue. The power of therapists internal beliefs about and understanding of supervision became evident and heavily influenced their perception of the usefulness of supervision and their willingness to access it. Syder & Levy (1998) discuss the range of possible barriers to embracing supervision as follows: Reluctance to re-live the uncertainties of student clinics Reluctance to put ourselves in a situation where either our peers or our managers are given licence to criticise Feeling expected to know more than we do / to have acquired more skills than we know we possess Uncertainty regarding boundaries (supervision, counselling, teaching) Feeling that supervision will wear away at our authority with younger therapists Difficulty seeing what supervision can offer

having worked for a number of years and developed a style of working with which we are content Uncertainty regarding where to go and find it. Hawkins & Shohet (1989) also reflect on the possible barriers to access: Previous experience of supervision Personal inhibition The supervisory relationship Organisational blocks Practical blocks (eg. financial, geographical, availability of suitable supervisor) Cultural blocks within the organisation Cultural blocks within the profession. It is indeed interesting to consider the history of supervision in counselling as compared to speech and language therapy. Counselling training has long allied itself to an andragogic approach to learning, whereby students take responsibility for their own learning and aim to become self-directed learners. From an andragogic perspective, learning is seen as lifelong with supervision representing the major way counsellors continue their professional development after training. In contrast, speech and language therapists have traditionally been trained in a pedagogic manner, which corresponds to the medical model strongly associated with the initial practice of the profession. Thus students were seen as empty vessels that have to be filled, examined and then deemed competent to practise (Syder & Levy, 1998, p.259). Recent shifts in student speech and language therapy training programmes show a move towards an andragogic approach, which is further underlined by developments in reflective practice and continuing professional development postqualification. Discussions in the focus groups we held for this series have highlighted that, whilst professionally the importance of supervision is being increasingly recognised and embraced by younger generations of therapists, traditional attitudes still remain and can have a strong cultural influence at a departmental, service and organisational level. We look forward to hearing any comments you have. In the next issue we will be discussing the process of supervision, roles, responsibilities SLTP and boundaries. Sam Simpson and Cathy Sparkes are specialist speech and language therapists and Cathy is also a trained counsellor. Together they are www.intandem.co.uk.

References

Carroll M. (1996) Counselling Supervision: Theory, Skills and Practice. London: Cassell. Hawkins, P. & Shohet, R. (1989/1993) Supervision in the Helping Professions. Milton Keynes: OUP. Stoltenberg, C. & Delworth, U. (1987) Supervising Counsellors and Therapists. San Fransisco: Josey Bass. Syder, D. & Levy, C. (1998) Supervision, in Syder, D. (1998) Wanting to Talk: Counselling Case Studies in Communication Disorders. London: Whurr, pp.256-288. 19

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

reviews

reviews
LITERACY
The Story Maker Frances Dickens and Kirstin Lewis Speechmark ISBN 9780863886027 29.99

Stimulating

This photocopiable resource designed to promote creative writing for 4-11 year olds is practical, easy to use and beautifully illustrated. It is divided into 12 sections covering key elements of creative story writing including characters, settings, objects, time and weather. Each section gives lots of visual cues and adjectives to stimulate ideas and enable the child to write a story with more depth and imagination. This resource would be valuable for vocabulary expansion work as it covers a wide range of nouns, verbs, adjectives and concepts. The section on characters feelings would be helpful for children with autism spectrum disorder. While the book provides lots of stimulating ideas it does not address overall story sequencing / planning, so would need to be used in conjunction with techniques such as mind mapping. Useful for teachers, therapists and parents, this would be particularly valuable to therapists working collaboratively with teachers in special schools or mainstreaming projects on vocabulary / literacy skills. Mildred Hamill is a speech and language therapist at Thornfield House School, County Antrim, a special school for children with specific language impairment.

pictures, four at each level. These value-for-money cards are great for resourced language provisions, schools and key stage 2 children. The manuals are written in 9 different languages, so this could also be a useful multilingual resource. Laura Baker is a special needs speech and language therapist at Winchester and Eastleigh.

AUTISM (1)

Growing up with Autism Robin L. Gabriels and Dina E. Hill Guilford Press ISBN 1-59385-459-5 23.00

Not an essential buy

A heavily Americanised book which does not always relate to speech and language therapy work, for example chapters on occupational therapy and different types of sensory disorders and assessments. However, useful management strategies, early communication information and links to emotions websites are included. This book is not easy to dip into but snippets will enhance work with children with autism spectrum disorder. It would be value for money if re-written for the UK audience, otherwise not an essential buy. Andrea Robinson is a paediatric community speech and language therapist with Derbyshire County PCT working in mainstream and special schools.

are likely to be engaging for the intended audience. Speech and language therapists in all school environments would find this useful, especially if running groups for social skills. Though the framework means it can be used by itself, the modular activities could be dipped into and used as required, without necessarily running all or most of the others. Many of the activities could easily be adapted for older students in special school environments. Unlike some other publications for drama with this client group, it has a wealth of short, easily set-up ideas. Linda Robinson is a specialist speech and language therapist working with children aged 7-19 who have Autism or Asperger Syndrome at The Robert Ogden School, a National Autistic Society School in Rotherham, South Yorkshire.

LEARNING DISABILITY

Understanding Learning Disability and Dementia Diana Kerr Jessica Kingsley Publishers ISBN 978-1-84310-442 18.99

Excellent place to start

PALLIATIVE CARE

Resilience in Palliative Care Achievement in Adversity Barbara Monroe & David Oliviere Oxford University Press ISBN 978-0-19-920641-4 29.95

Food for thought

AUTISM (2)

STORYCARDS

Sequences Narrative Sue Duggleby & Ross Duggleby Speechmark 978-0-86388-550-1 (Sequences) 978-0-86388-549-5 (Narrative) 34.99 + VAT each

Using Drama with Children on the Autism Spectrum Carmel Conn Speechmark ISBN 978-0-86388-601-0 34.99

Wealth of ideas

Motivating and fun

These colourful, simple resources use computer style animated pictures and the motivating jungle animals capture interest. Felt puppets to match makes a fun game and assessment tool as children do not feel under pressure. The narrative set has 12 picture cards for each of the 4 stories, and they can be shortened. The manual details a script and the cards are clearly labelled. The sequencing set has 3, 4 and 5 part sequencing

This book is intended for mainstream and special needs children with autism spectrum disorders aged between 5 and 11. Activities for children within both mainstream and special school settings can be delivered by teachers, speech and language therapists or drama teachers. The book is well laid out and follows clear developmental lines, backed up by short assessments and clear goals. The package could be used as the basis for a social skills group, and has many ideas which

This book gives an interesting introduction to resilience, a concept which has received increasing attention in healthcare in recent years. The books purpose is to explore the meaning of the concept in relation to palliative care and to give those working in this area food for thought about how we might promote resilience in clients and families as well as teams and organisations. The book includes contributions from a wide range of authors from all over the world who are well known in the field of palliative care. As such, each chapter stands alone, giving the book the feel of a collection of papers. It was very relevant to me in the middle of trying to design a research project around goal setting in palliative care. It would be a useful addition to the library shelves of anyone working in palliative care and could be used as a reference as well as to promote discussion among team members. Sally Boa is a speech and language therapist with the Area Rehabilitation Team at Falkirk Royal Infirmary

This book is an excellent place to start for clinicians who have little experience supporting adults with learning disability and dementia. The chapters are informative, well written and clearly structured, each with a summary paragraph so clinicians can decide if its a relevant read. The book details interventions and presents the pros and cons. The interventions are practical and mostly cost-effective to implement. The book shows how a change in staff belief and actions can have a hugely beneficial impact on a service users wellbeing. Carers and peers are not forgotten and suggestions are made about how to support them too. I really enjoyed this book. I learnt a great deal and am sure other clinicians new to this area will too. Sarah Browning is a recently qualified speech and language therapist with the Somerset Community Team for Adults with Learning Disabilities.

SOCIAL STORIES

Off We Go Series Avril Webster Originally Speechmark, now Off We Go Publishing, www.offwego.ie

Going to the Dentist 978 0 86388 631 7 Going to the Doctor 978 0 86388 632 4 Going to the Hairdresser 978 0 86388 633 1 Going to the Restaurant 978 0 86388 634 8 Going to the Supermarket 978 0 86388 630 0 Going Swimming 978 0 86388 635 5

6.99 each

A good talking point

The children loved these books. They are brightly coloured and just the right length to hold their interest. The simple stories describe everyday events or activities such as going to a restaurant, going swimming and going to the dentist.

20

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

reviews

They are aimed at 3-7 year olds and are designed to help prepare children for participating in the event. The books use simple, easy to understand sentences and are written in the first person. They have clear pictures which themselves provide a good talking point. While they are an excellent way to introduce the event or activity to the child, promoting appropriate and positive behaviour, for many children with disabilities they will need to be adapted to relate to their own personal experience. The books are a useful starting point for teachers and parents who are not familiar with writing and using social stories, and provide a good example on which to base a story for an individual child. Leanne Beattie is a senior speech and language therapist working for Therapy Focus, Perth, Western Australia with children with disabilities.

COMPLEX NEEDS

Children with Complex and Continuing Health Needs Jaqui Hewitt-Taylor Jessica Kingsley ISBN 9781843105022 18.99

Moving and relevant Real and positive This very readable book focuses
on the real life experiences of children with complex and continuing health needs and their families rather than the medical or technical aspects of their care and support. Many moving insights are given from different perspectives, including the child, parents, siblings, support and healthcare staff, into typical and regular experiences and barriers for such families. I found all the chapters relevant to my everyday working life as part of multidisciplinary team in a Child Development Centre and especially the chapters on diagnosis, premature babies and families. It is very easy to dip into with clear, accurate chapter headings and a useful glossary. Pippa Hutton is a specialist speech and language therapist working with children with complex special needs at the Child Development Centre in York.

Having a stroke, being a parent Connect Ideas Series, www.uk-connect.org ISBN 978-1-906315-01-6 7.50+1.50p&p
This book comes with a DVD of people telling their stories. We reviewed it with two clients with aphasia. Neal has six children aged 2 months to 13 years, and Angie has four children aged 11-25. Neal and Angie both preferred watching the DVD to reading the book as it was easier to understand, and they could play it through several times. Different types of stroke, ages and points of view are covered. Neal felt that knowing peoples stories made it real. Angie felt the stories were positive. It was generally easy to follow, however both thought that some of the speakers on the DVD spoke too quickly and that the quality of recording could have been better. The book contained useful information that could be kept and re-

APHASIA

VOICE

Textbook of Voice Disorders Albert L. Merati & Steven A. Bielamowicz Plural Publishing ISBN 1-59756 -137-1 57.00

read. Angie read it through with her husband and one of her daughters. Neal wanted to take the book away again to show to his older son. Both Neal and Angie felt that having the book earlier would have helped them and their children, especially Neals older ones and Angies younger ones. Neal would have liked more support whilst in hospital, to help deal with the emotional aspects of having aphasia. He had asked his children not to come and see him in hospital. Angies children were older but scared. Neal feels that everyone with children should read this book and watch the DVD as it will help them to get used to each other and talk about what has happened: helps yousometimes you think you are the only oneIm thinking my god look what happened to her.cos the way its writtenits rightno matter how old they are. Angie said, 11 to 20as long as they take it in and they read. Ruth Sullivan and Joanna Kerr are speech and language therapists with Portsmouth City PCT. Neal and Angie are clients with aphasia.
ADVERTISEMENT

Refreshing and modern

MOTOR SPEECH

This book is a refreshing and modern addition to current voice publications. Core information on the diagnosis and management of voice disorders is presented in a practical, highly readable format, supported throughout by excellent anatomical images and illustrations. Chapters include key points, review Q & A and controversy boxes, making this an ideal introductory text for students and a useful reference for clinicians. As a student, I found it particularly useful as a point of reference when thinking about specific voice clients. While the chapters which dealt with anatomy and physiology were especially helpful I had to refer to other sources for specific information on management / assessment. At 57, this book would be a useful addition to any department, however I would suggest students borrow not buy! Louise Ferguson is a final year speech and language therapy student at the University of Ulster, Northern Ireland.

Motor Speech Disorders Gary Weismer Plural Publishing ISBN 1-59756-115-0 47.50

Not for the fainthearted

An American text book, this collection of academic essays is heavily weightedtowardsdysarthria.Themes include neural perspectives, breathing, segmental articulation, speech perception and, more unusually, dysphagia. Some chapters are confusingly organised or not for the fainthearted, delving deep into the realms of advanced physics, and most suitable for those working in research. Other sections are much more accessible, providing undergraduates with a useful summary of classification, assessment and theoretical approaches to intervention in dysarthria. This book would be an informative and up-to-date addition to the university library, but students or clinicians seeking a more practical approach would need to look elsewhere. Caroline Cooter is a newly qualified speech and language therapist, working with the adult-acquired service in Lincolnshire tPCT.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

21

Early interaction

Talking hands
A year ago Amanda Baxter was sitting on the baby signing fence, but practical experience in an Early Start context has persuaded her of its use in enhancing carer-child communication skills.

he use of symbolic gestures and signs with babies has been popularised by such programmes as Something Special on BBC2. While gesture is a natural part of communication, and official signing systems such as the BSL derived Makaton and Signalong are an established part of a speech and language therapists toolkit, the profession is divided on the issue of formal signing with babies in the absence of an identified need (Clarke, 2004; Grove et al., 2004; Garrett et al., 2005). This controversy is based on whether the use of structured signing interactions actually impedes caregiver communication at the expense of language stimulation activities (Slonims, 2005) and also whether there is any need to use signs with typically developing children receiving appropriate environmental stimulation. The validity of symbolic gesture programmes and their role in language development has also been questioned. Research has focused on evaluating the impact on early communication skills, for example increased attempts at initiation, impact on joint attention and onset of expressive language development (Acredolo & Goodwyn, 1985). Parents using symbolic gestures (whether iconic or part of an established signing system) have reported lower distress for both them and their child attributed to their childs ability to communicate their needs pre-verbally (Allen, 2004; www.literacytrust.org.uk). Acredolo & Goodwyn (cited by Allen, 2004) also comment that when caregivers are using symbolic gesturing they are automatically using other language stimulation strategies such as following their childs interest, using simple language and labelling at their childs language level. However, it is difficult to attribute the latter effect solely to the use of symbolic gestures (whether iconic or part of an established signing system) or the general communication environment. As with many other interventions in the profession it is difficult to measure impact due to the lack of randomised control trials (Cyne Johnston et al., 2005). However, baby signing is used within Sure Start programmes (Allen, 2004) and in equivalent programmes in Canada and the United States (Early Headstart) as a means of preventative intervention. The aims are to reduce childrens distress cues (and, by association, parental anxiety) and enhance interactions between parents and young children, by promoting communication strategies such as following the childs focus of interest, making eye contact and using simple key words. It is also used as a means of 22

promoting inclusion in diverse communities. In Newham we have Early Start, created by merging funding from Early Years and Sure Start. This enables families of children under 5 throughout Newham to access a range of services. Carers are offered a programme of support from the antenatal stage going on to include postnatal groups, baby massage courses and then baby signing groups. Speech and language therapists are involved in ante and postnatal groups and some therapists have trained in baby massage so they can promote the importance of early attachment as a foundation for early communication skills. Baby signing groups (Talking Hands) are offered in a variety of community locations and most recently at Baby Clubs in different programmes across Newham. Baby clubs can be attended by carers with babies under 12 months. Numbers vary but there have been up to 20 parents at a recent Talking Hands group. The groups are usually facilitated by a speech and language therapist and a speech and language therapy assistant. Parents attend with their babies (up to 18 months) and older children, as they can learn and model signs for their younger siblings.

READ THIS IF YOU ARE INTERESTED IN EARLY INTERVENTION ENHANCING CAREGIVER / CLIENT INTERACTION HEALTH PROMOTION GROUPS

Themes

The groups focus on a number of signs derived from the Signalong system and run for a block of 5 or 6 weeks. The first week gives an overview of the philosophy behind keyword signing and introduces the BSL alphabet to make name signs. Each week signs are introduced around the following themes: My family and home Mealtimes Going out Bathtime (incorporating getting ready) Bedtime and storytime. This enables us to teach and use a range of signs that broadly reflect early language development (nouns and verbs) and relate to environmental language use. We introduce signs with objects (where possible), songs and stories to make the sessions as interactive as possible and to give parents ideas for activities to carry out at home. In the Bathtime session we have items such as bubbles to try out, and objects such as towel, soap, sponge and duck which are introduced with the word and the sign. We then sing songs like This is the way we wash our hair / brush our teeth and Five Little Ducks. We also have simple stories that incorporate bathtime activities. The intention is to introduce signs to parents so they can use them at home during everyday routines in a more naturalistic setting.

These groups also enable us to discuss early communication activities with carers and to facilitate idea sharing among the group. By getting carers to play with bubbles, for example, they can see how their babies respond and track the bubbles. We can discuss principles of positive carer-child interaction such as observing, waiting and listening to their baby (Manolson, 1992). Working with one carer enabled her to wait to see how her baby would respond to bubbles, which then gave him the space to respond by moving his arms, initiating eye contact with her and vocalising. Informal observation and parental report have shown us that the children initiated, attended and listened for longer periods and showed reduced distress cues when symbolic gestures (signs, iconic signs and actions for songs) were used. However, we wanted to do a more formal evaluation of the impact of symbolic gesture on a range of early communication skills: Eye contact Attention Response to symbolic gesture Joint attention Copying gestures. Initially we used an observation form (figure 1) in groups to look at carers skills and babies responses. We adapted this from a form used in carer-child interaction groups. Each skill / aspect is given a score (the grid numbers), depending on its perceived difficulty. We attempted to measure observable carer behaviour / learning (in relation to symbolic gesturing) and the childs communication. We encourage hand over hand signing / gestures in songs to promote kinaesthetic learning. We graded childrens communication skills in a roughly developmental hierarchy. We also gave out a pre-group questionnaire which we had used with previous groups. This looked at strategies being used at home to help communication development and whether carers had any concerns. The language stimulation strategies mentioned included watching CBeebies, reading books and singing songs. In terms of outcomes, we used data from the five parents who attended consistently. Change in their behaviour is in figure 2. All could produce signs in the group and use hand over hand with their children in songs. They

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

early interaction
Figure 1 Observation form Week No 1 2 3 4 5 6 Figure 2 Parent behaviours

Parent
Produces sign in group Uses hand over hand with child in songs Spontaneous approximation to sign/gesture

Parent total Child


Looks at parent Responds to sign (coos, smiles, moves, vocalises) Copies gestures / signs Produces sign spontaneously Imitates noises Imitates word Spontaneous 1 word (not verb)

7 6 5 4 3 2 1 0

score

week 1 week 5

3 PARENT

Figure 3 Naming language stimulation strategies

number of strategies

Child total

7 6 5 4 3 2 1 0

pre post

3 PARENT

also increased in spontaneous approximation to signs and gestures by week 5. In future we would extend the observation form to include carer-child interaction strategies. The number of language stimulation strategies that parents could name had increased (figure 3). These included answers from reading books and singing songs to using gestures, using simple language, watching what hes interested in and waiting for her to respond. Carers were able to name targeted, specific strategies to promote and enhance language development. Overall we found that the basic observation form was not sufficiently specific or sensitive enough to measure the aspects we were looking at. We wanted to see if there was an increase in the number of times babies made eye contact with carers and also to see if there was a change in the duration of eye contact, as this would suggest enhanced interaction between carer and child.

Baseline

A future direction for this group is to obtain a baseline in the first session, record when signs are being used and use a tally count analysis. This would enable us to compare the babies responses to carers to find out, for example, whether duration and frequency of eye contact increased when the carer used these in speech or whether babies responded by cooing / smiling

more when gesture / sign was being used. Comments from parents have been very positive. Three have said that their 10 month old babies have been making approximations to signs requesting food items. Other parents have commented that various signs are useful for signalling aspects of everyday routines, such as finished or bath time, and that this has helped in reducing tantrums and distress. Carers using two or more languages have also reported that they have found signing a useful way for reinforcing vocabulary items when presented to their children in different languages. We spoke to three parents from a previous baby signing group to see if they were using signs with their babies. One had gone on to take a Signalong course, as Talking Hands had developed her interest in signing. She uses signs to signal everyday routines and early concepts such as more. Two other parents said they use signs when singing. Baby signing is a very popular group in Early Start and feedback from parents is positive about enhancing carer-child interaction and promoting the development of early language skills. We will continue to develop our outcome measures. When I began running baby signing groups a year ago I didnt know which side of the baby signing fence I stood on, as much of the focus has been about promoting the longitudinal effects of baby signing such as the age of first

words and size of vocabulary. However, I have become a convert to the effects of signing and symbolic gesture as a means to enhance early communication skills, as my own observations have shown the frequency and duration of eye contact from babies increases, ensuring a longer period of attention. Parents report reduced frustration or anxiety (for both themselves and their children) with babies who have been introduced to signing and symbolic gesturing as part of everyday routines. They also report that they feel signs and symbolic gestures add to songs and books and develop their babys ability to copy, join in and request preferred activities or items. At the time of writing Amanda Baxter was a speech and language therapist with Early Start Newham. She is now working as a speech and language therapist for childrens centres in Waltham Forest PCT, e-mail Amanda.Baxter@wf-pct.nhs.uk.

References

Allen, T. (2004) Signing the way, Speech and Language Therapy in Practice Winter, pp.4-6. Acredelo, L. & Goodwyn, S. (1985) Symbolic gesturing in language development: A case study, Human Development 28, pp.40-49. Clarke, J. (2004) Hope you can see what Im saying, Bulletin of the Royal College of Speech & Language Therapists 631 (Nov), pp.10-11. Cyne Johnston, J., Durieux-Smith, A. & Bloom, K. (2005) Teaching gestural signs to infants to advance child development: A review of the evidence, First Language 25 (2), pp.235-251. Garrett, S-A., Owens, E., Ford, J. & Spooner, F. (2005) Your views on baby signing, Bulletin of the Royal College of Speech & Language Therapists 633 (Jan), pp.10-11. Grove, N., Herman, R., Morgan, G. & Woll, B. (2004) Baby signing: the view from the sceptics, Bulletin of the Royal College of Speech & Language Therapists 631 (Nov), pp.12-13. Manolson, A. (1992) It Takes Two To Talk. Toronto: The Hanen Centre. Slonims, V. (2005) To sign or not to sign? That is the question, Bulletin of the Royal College of Speech & Language Therapists 637 (May), pp.12-13.

REFLECTIONS DO I SEEK TO UNDERSTAND WHY PEOPLE ARE CRITICAL OF AN APPROACH BEFORE I DECIDE WHETHER AND HOW TO TEST IT OUT? DO I RECOGNISE THE IMPORTANCE OF DEVELOPING OUTCOME MEASURES THAT GO BEYOND HOW MUCH SOMEONE HAS ENJOYED THERAPY? DO I FIND OUT HOW PEOPLE ACTUALLY USE THE INFORMATION PROVIDED AT A GROUP ONCE IT IS FINISHED?
How has this article been helpful to you? Have you changed your views on baby signing? Let us know via the Summer 08 forum at http://members.speechmag. com/forum/.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

23

ASSESSMENTS ASSESSED

We continue our series of reviews to help you decide if an assessment would meet your needs, this time considering KiddyCAT and the VAN. KiddyCAT
Louise Tweedie finds this questionnaire gives preschool children who stammer a voice to express how they feel about their speech and provides an opportunity to discuss this with their parents.
KiddyCAT (Communication Attitude Test for Preschool and Kindergarten Children Who Stutter) Martine Vanryckeghem and Gene J. Brutten (2006) Plural Publishing (www.nbinternational. com or tel. 01235 527311) ISBN 1-59756-117-7 44.00 (manual and 50 test forms)
The KiddyCAT consists of a series of 12 questions designed to test the attitude of 3-6 year old children who stammer towards their speech. I have to admit to being initially sceptical about the value of this assessment. Typically in the preschool age group we rely on parental views about whether the child who stammers is aware of their speech difficulty, and observations of the childs behaviour, to guide our clinical intervention. A child chatting confidently may suggest a positive attitude, whereas a child who is reluctant to talk and covers their mouth may suggest a negative attitude and awareness of their difficulty. The reliance on parental views is discussed in the manual, as well as previously held beliefs that a negative attitude towards stammering is more likely in school aged than preschool children. The KiddyCAT provides a standardised test procedure for identifying a childs attitude towards their speech. The test was normed on a US population. Children who stutter (CWS) scored significantly higher on the assessment than children who do not stutter (CWNS), demonstrating a more negative attitude towards their speech. There was no difference according to gender in either group, but age was a factor. Younger children (3-4 years) scored higher than older children (56 years) for both groups, although it was only statistically significant for the CWNS group. It 24

Assessments assessed

would be useful to gain a normative sample of the UK population to compare attitudes and beliefs in both cultures. I used the KiddyCAT to assess two children during individual clinic sessions. They are both boys aged 4 years 3 months, and are receiving intervention for stammering. I also sought the opinion of their parents. I found the test easy and quick to administer. I used Monkey Business as a play activity, as suggested by the manual, to help keep the child on task. This worked well as both children were motivated and appeared to enjoy the game. The test was designed to reflect the linguistic and reading level of preschool children, because the language used in the Communication Attitude Test (Brutten, 1984) with school aged children was not felt to be appropriate. I feel this has been achieved on the whole. In the initial instructions to introduce the test and check that the child understands the procedure, the child is asked to say yes if they think what I say about their talking is true, and no if they think what I say about their talking is not true. One parent felt that using true / not true was a little confusing and that right / wrong may be better. Both children appeared to understand the process for the 12 test questions. It is important to stick to the test wording, in order to use the standardised data. The questions ask the same thing in a number of ways (for example, Is talking hard for you? and Do you think that talking is difficult?) One parent pointed out that this is good questionnaire design as it helps to show consistency in the childs answers. Both children responded well to the test. Jon gave very confident, definite answers. He scored 0, showing a very positive attitude towards his speech (average for CWS = 4.38, SD 2.78). His mother was not surprised and feels that he does not consider himself to be different, as he identifies smooth and bumpy talking in everybody else around him. Joe was also able to answer the questions well. He scored 3, which is within the average range for both CWS and CWNS (average for CWNS = 1.79, SD 1.78). His mother felt that his answers were accurate. She feels that he is generally confident, very chatty and only occasionally shows frustration. The test indicated that he thinks he finds talking hard overall, but that words come out easily, he talks well with everybody and people like how he talks. I asked the parents if the test had added to our knowledge about their childs stammer. They both felt that it had confirmed what they thought, but that it was a useful way to hear that from the child. Overall, I felt that the KiddyCAT gives the child who stammers a voice to express how they feel about their speech and provides an opportunity to discuss this with their parents.

Reference

Brutten, G. (1984) The Communication Attitude Test, unpublished manuscript. Now part of the Behaviour Assessment Battery for School-Age Children who Stutter (Brutten and Vanryckeghem, 2006). This will be reviewed in a future issue. Louise Tweedie is a specialist speech and language therapist with East Cheshire NHS Trust. Her interests include early years, Childrens Centres and stammering.

VAN

Annette Cameron hopes a DVD version of this video-based assessment will be released as it is useful for investigating and comparing noun and verb production in people with aphasia.
Verb and Noun Test Janet Webster and Helen Bird STASS Publications ISBN 978-1-874534-30-3

65.80

The purpose of the Verb and Noun Test (VAN) is to investigate the retrieval of verbs and nouns in aphasia. The authors give a clear theoretical background to the models of processing, and explain that most studies on word retrieval have focused on nouns. They cite studies that have shown a contrast between the retrieval of nouns and verbs i.e. that people with agrammatism have more difficulty with verb retrieval, but people with anomia have more difficulty with nouns. The authors explain that the usual methodology in word retrieval studies has been confrontation naming of single words. They acknowledge this approach is appropriate for assessment of concrete nouns, but not so appropriate for verbs. They highlight the difficulty in using line drawings that are static to assess verbs and suggest the medium of video may enable assessment of a wider range of verbs. The test consists of video clips of nouns and verbs. The items were chosen and matched according to frequency, imageability, phoneme and syllable length. A control study was conducted with 30 subjects. The test was then trialled with 57 people with aphasia. Thirty two people had fluent aphasia and twenty five had non-fluent aphasia. Seventy four per cent scored below the normal range on the test. Of these, 83 per cent of the people with fluent aphasia, and all of the people with non-fluent aphasia, had more difficulty with verbs than nouns. The test is divided into two sections one for verbs and one for nouns. Each section takes

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

Winning ways

about ten minutes. Verbs are assessed before nouns. There are three practice items. Each clip is shown in turn and the person with aphasia is asked to watch the clip, wait until the screen goes blank, then to tell the examiner in one word what is happening (for verbs), or what it is (for nouns). The theoretical basis of the test appears very sound. In practice the following can occur: 1. Nouns are produced on the verb section eg. tree for decorate, bubbles for blow, cards, a game or playing cards for win, getting an injection, got hiccups. This tended to happen before the screen had gone blank. The person adhered to the instructions for the practice items at the beginning, but repetition of the instructions was often required during the assessment. 2. Possible ambiguity or semantic errors Verb section: Carry walking Choose eat Mow cutting Arrest stop or mugging - this may be particularly ambiguous in Scotland as the police helmet is different to that in the video clip, so people may not necessarily recognise it as police Kiss sneezing Whisper smooching Nod speaking Noun section: bean pea pod castle church cap hat It was interesting to note that most of these occurred on earlier items in the verb section, but throughout on the noun section. 3. Scoring Appropriate nouns or verbs may be produced, but not the targets eg. scribble for colour, handing a parcel for deliver, and writing for sign. People with aphasia appeared to like this assessment. They suggested that the pictures could be made clearer - some too dark (eg. stairs). Overall, this is a very useful assessment to investigate and compare noun and verb production. I would certainly consider using this tool in clinical practice where appropriate. It would be even more beneficial to clinicians if the test could be produced on DVD. Annette Cameron is a speech and language therapist working with the Mobile Stroke Team at Aberdeen Royal Infirmary. She is also membership secretary of the British Aphasiology Society.

What should I tell you?


have been writing for Speech & Language Therapy in Practice for nearly five years. When Avril first asked me I was delighted and not a little daunted. Still, as I am not one to turn down an opportunity and had a little knowledge of the work of speech and language therapists, I said yes immediately. Over the years my interest in and admiration for the profession has grown, and I have been educated as I have gone along. But when it comes down to it speech and language therapists are people - and people the world over have challenges, obstacles and opportunities in equal measure. My mantras throughout Winning Ways have been: The way we see the problem is the problem. If nothing changes, nothing changes. Dont try to find a way to happiness, happiness is the way. To be able to choose our attitude in any given situation is the greatest freedom. Through the course of this year and last I have been seriously applying these attitudes to my own life and work. If we have a dream and a passion, it is vital to acknowledge the hints, hunches and directives that come from deep within. It was my goal to compile a book about my younger sister Margaret, who died from cancer twenty six years ago at the age of 31. She left behind a tape for her son Francis, who was two and half when she died. She stipulated that he was not to hear it until he was 21. This came to pass and my book is a consequence of what happened next. Seeing the book come to fruition has emphasised to me that, if a thing is worth doing and you feel driven to do it, dont let anything stand in your way. I knew at a very deep level this was something I had to do. So when the obstacles appeared - and they did! - I was able to see them as just obstacles. Because the vision was so clear, there was a solution to each one. In February 2007 I made the scrappiest dream board in the world, but on it I included what I wanted to achieve before April 2008. All is concluded only a month later than my target, pretty good timing in the world of publishing. Now the dream board was actually stuck behind a cupboard and I had completely forgotten about it. The book idea hit a major log-jam last summer and the shape of the whole thing changed six months ago. Still, here it is - a real live book. It is immensely satisfying for me just to look at it, let alone think about the job it may do. I believe the book was quietly heading for completion even when I wasnt working on it. Through the gestation period I wasnt thinking, This is the dream coming true. It was much more plodding and pedestrian. To put our attention and consideration into a goal is one thing, but it is important to release our attachment to the outcome. It will happen when it happens; it will be as it will be. Knowing deep down that it is the right thing to do keeps up the momentum. Time and energy are not spent stressing about the outcome and you are carried downstream. I know from all the phone calls and coaching sessions that many of you have dreams of how you can improve or change the profession or your position in it. So I can only say, set your intention, believe in yourself, dont let nay sayers put you off, release your attachment to the outcome - and go for it! Jo Middlemisss newly released book with CD What should I tell you? A Mothers final words to her infant son is available for 9.95 + p&p from Jo, telephone 01356 648329 or order online at www.printmatters.info. A percentage of all proceeds is donated to Marie Curie Cancer Care. Jo is a qualified Life Coach who offers readers a confidential complimentary half hour telephone coaching session (for the cost only of your call).
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

Life coach Jo Middlemiss encourages you to believe in your dreams.

25

inclusion

Joining in as never before


Whether or not people with severe learning disabilities learn to read and write, literacy is still achievable. Liz Skilton looks back on inclusive poetry and drama workshops with Keith Park at the Globe Theatre, and reflects on the difference the experience has made to teaching and learning at a district Special School.

ost definitions of literacy refer to reading and writing text. However, people with severe learning disabilities are unlikely to read and write as competently as their typically developing peers (Lacey, 2005). Recent poetry and drama workshops by Keith Park with students at Milestone School have had a profound impact on teaching and learning for the pupils who took part, and I have been reflecting on the effectiveness of this approach in enabling people with severe learning disabilities to become literate. According to the original National Literacy Strategy, literacy unites the important skills of reading and writing (DfEE, 1998, p.3) but, for pupils who do not learn to read and write, I believe a wider view must be taken. Although speaking and listening are included in the original Strategy (DfEE, 1988) they are not separately identified in the Framework, and reading and writing tend to dominate the document. In the folder Supporting Pupils with Special Educational Needs in the Literacy Hour (DfEE, 2000a) there is little reference to anything other than conventional word, text and sentence level work and in the Foundation Curriculum (DfEE, 2000b) the expectation is of progression towards conventional reading and writing (Lacey, 2005, p.44). This is not inclusive of people with severe learning disabilities. Speaking and listening are given much more importance in the Primary National Strategy (DfES, 2006), as four of the twelve strands relate to speaking, listening and responding, group discussion and interaction and drama. Equals (2003) produced schemes of work to help in planning literacy for pupils with severe learning disabilities. This wider view of literacy is built on the QCA (2001, p.6) guidelines for pupils with learning difficulties: Learning English encompasses all aspects of communication non-verbal, verbal and written. Work in English promotes learning across the curriculum and underpins pupils achievements and participation in all aspects of their lives. 26

English offers pupils with learning difficulties opportunities to: Develop the ability to respond, to listen and to understand Interact and communicate effectively with others in a range of social situations Make choices, obtain information, question and be actively involved in decision making Develop creativity and imagination Have access to a wide range of literature to enrich and broaden their experience. While some learners with severe learning disabilities are able to learn to read and write, for others literacy involves the development of communication skills such as shared attention, turn-taking, anticipation and participation which are generic to all subjects at levels P1-P3 (QCA, 2001). Traditionally the approach to literacy teaching at Milestone, a district Special School, tended to be conventional and based on the Literacy Hour (DfEE, 1998). This recommends that both primary and secondary pupils have one hour per day and lessons generally follow the four part structure where the aim is to teach the skills necessary for the development of reading and writing.

READ THIS IF YOU WANT TO CHALLENGE THE TRADITIONAL APPROACH BRING ENERGY TO YOUR SESSIONS ENSURE TRAINING CROSSES OVER INTO PRACTICE

Rich opportunities

Lacey et al. (2007) cite Layton et al.s idea of inclusive literacy where the most profoundly disabled can take part. Longhorn (2001, p.1) says, Literacy is far more than accessing the skills required for reading, writing, speaking and listening. Literacy offers rich opportunities to be literate through poetry, drama, literature and making their own marks on the world. It also offers many openings to become literate in their communication and emotions. Access to literature through drama and storytelling is one of the most developed aspects of inclusive literacy for people with severe learning disabilities. Nicola Grove and Keith Park have found ways of using drama and storytelling to help even the most profoundly disabled person to access, experience and indeed enjoy literature. Excited about his work and wanting to challenge

the conventional notion of literacy, I approached Keith Park at a Communication Matters conference in November 2006 and asked him to work with us at Milestone School. Keith provides group activities to students with severe and profound and multiple learning disabilities that enables them to understand the rhythm and atmosphere of the literature using call and response, even if they cannot understand the words. The main aim of an interactive storytelling activity is to use a given text to create an atmosphere through sound and vision, providing opportunities for pupils and staff to react and participate. In the workshops Keith adapted many poems and songs, and verses from Shakespeares A Midsummer Nights Dream and Macbeth. Staff and students formed a circle in the room giving the impression of equality as there is no beginning or end. The performance of the text is based upon a communication framework concerned with the development of important early communication skills (Grove & Park, 1996) so that participants experience the story while having opportunities to develop these skills (table 1). We also used the QCA (2001) framework for recognising attainment to evaluate the impact of the workshops in greater detail and as a useful way of recording participation of individuals (table 2).

Provided a context

Analysis of the workshops confirms that the drama provided a context in which pupils with severe learning disabilities can learn communication skills and access and explore literature. All students showed an increase in levels of engagement and participation. The name song at the beginning and end introduces the students to what we are about to do but also welcomes and acknowledges each student individually. They all responded in a positive

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

inclusion
Table 1 Communication skills developed during the workshops

Communication skill Awareness Anticipation Turn-taking Showing self Showing objects Giving objects Seeking physical proximity Gaze alteration Joint attention Declarative pointing
Table 2 Impact of workshops

Evidence in the video awareness of the words and sentences by acting them out, gesturing awareness of themselves in the group as well as others by looking at or pointing at each other awareness of familiarity of repeated activities anticipated what was coming next due to the repetition of lines and activities verbalised and gestured to show anticipation of favourite activities occurred throughout the session (at the beginning when saying hello and at the end when saying goodbye; students develop awareness of their own turn as well as whose turn is next) is built into the call & response technique as students listen to the storyteller and then respond by repeating the lines demonstrated this is me behaviour when it was their turn in the name game or in an activity. (Some showed signs of excitement while others were embarrassed. Some moved to the middle of the circle to take the lead or be the focus of an activity. Some looked at their teacher, and smiled or laughed.) not used not used touched each other on the arm or shoulder, some looked at their neighbour or teacher one student walked across the room several times to approach different staff to seek a response from each of them one student walked across the room to lay on the floor in the middle of the circle in front of Keith would look towards Keith and back at a familiar adult as a means of shared attention all were fully engaged throughout the sessions; attention of the whole group was on Keith for the duration as they watched to find out what to do or say next looked at Keith then back at a familiar adult to indicate look at that

QCA (2001) framework Evaluation Encounter: being present, The wooden floor of the Globe Theatre is like a large resonance board so all students could feel the vibration of stamping feet. being provided with One student walked across the room to sit down on the floor directly sensations in front of Keith. Also walked into the middle of the circle - students circled him and crowded in, providing him with whole body vibrations, auditory stimuli from the call and response and visual sensation of light and dark. A four beat rhythm is natural for clapping and stamping. One student who usually has difficulty with group and unfamiliar activities remained in hall for the duration of the workshop (forty minutes). Awareness: noticing that One student rocked from side to side for all activities, smiled when her turn, paused between activities to wait for the next. something is going on One student clapped and stamped his feet to the rhythm while looking at the video camera. One student lifted up his head and smiled in response to his name being called. Enjoyment by smiling, laughing, moving in time to the rhythm, clapping, Attention and Response: stamping their feet. showing surprise, enjoyment, dissatisfaction Looked towards Keith Park for cues. Listened to the words and acted upon them by jumping, sleeping, Engagement: directed dancing, showing understanding of the language. attention, intentional looking, listening, showing Two students were supported to operate a Big Mack to contribute to the story or poem. interest, recognition Three individuals moved to the centre of the circle spontaneously when Participation: supported participation, sharing, turn-taking the focus was on them.

for students individually but all other poems and literature would involve learning lines and text that may be difficult to memorise. They did appreciate however that having no resources to get ready helps reduce planning and preparation time. Staff also felt some of them may lack the confidence to present materials in this way. Overall they considered it a much more inclusive approach to literature for the students. They learnt how to make classic literature fun and accessible to pupils with severe, profound and complex disabilities. This approach has provided inspiration for condensing a story or topic down to key points and re-producing it as a short song with repetition that all students can access. This project has also provided an opportunity for collaboration between teaching staff and speech and language therapists. We were able, with our different skills, experience and perspectives, to work together to develop literacy for all pupils, especially those for whom speaking and listening is more important than reading and writing.

way by showing both recognition that it was their turn and emotion (smiling, laughing or turning away in embarrassment) that it was about them. The name song also provided the opportunity for students to acknowledge each other. Students who do not normally look at each other looked at Keith, closely following his gestures, signs, movements, and words. All students got into the energy of the session the clapping, stamping, whole body movements, facial expression conveying meaning behind the words or lines, freedom to move across the room or stage or to initiate a song. The technique of call and response and switching codes by using different voices or genres caused a powerful response from pupils with severe learning disabilities as the different stress and intonation patterns add an extra sensory dimension. Grove & Park (1996) claim that language, rather than being decoded and understood, is something that can be experienced. They suggest that an understanding of the meaning of the text can come not from decoding it, but from experiencing it directly, exactly what happened.

Staff evaluations were positive too. I asked them what they liked and did not like about the sessions, and to comment on student participation and how this approach could be carried over into the classroom. Staff were pleased with the students levels of participation and engagement. They liked the active nature of the workshops and noted that pupils who are usually difficult to engage with actively participated. They commented on their own confidence to participate and that it was more noticeable if they did not join in. They liked the circular formation of the group, the individual introductions of each student with the name song and how Keith involved all pupils and staff equally. They liked how everyone participated in their own way. The dramatic delivery seemed to capture their attention and interest and the repetition was of benefit too. They liked that Keith followed the lead of the students by responding to their requests or responses. Two comments were: could we go to the Globe every Friday and could Keith come to our school each week. In terms of carryover into the classroom, staff felt it would be easy to repeat the name song

Confidence boost

Following on from the Globe workshops, Keith facilitated a whole school training day on 17th April to explore inclusive storytelling further. This provided an opportunity for staff to see our students joining in as never before. It also enabled staff to develop their own interactive storytelling skills. Keith asked them to write a short interactive story in groups that they could use in class the next day and all staff took part. The whole school training day gave the confidence boost and follow-up needed to get the approach into practice. We also had a coffee-morning in May to share this work with parents of the students involved. It was wonderful that a couple of students were able to join us as they really enjoyed watching the DVD with their parents and singing the songs and poems again. Since then a DVD has been produced and all students who took part were given their personal copy to take home. This project has helped us review our approach to literacy in school in that Literacy for learners who dont learn to read and write is not conven27

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

INCLUSION tional (Lacey et al., 2007) yet there are many ways in which people with severe learning disabilities can become literate. During these workshops students demonstrated much higher levels of engagement and participation than usual and made good use of their communications skills. The workshops also enabled students to access literature that they perhaps would not have otherwise experienced. The success of this project can be directly attributed to the excitement and impact of visiting the Globe Theatre as well as collaboration between the Literacy and AAC Co-ordinators, support assistants, speech and language therapy team, students and parents. This project has made us think about the needs of those pupils who will not learn to read or write, as well as providing ways of further stretching those pupils who have learned to read and write. The interactive storytelling has inspired teachers to think about their delivery of literacy for pupils with severe and profound and multiple learning disabilities - after all, storytelling is far more important than reading and writing and a SLTP good starting point for literature. Liz Skilton is Speech & Language Therapy Coordinator at Milestone School in Kent, tel. 01474 709420. Her suggestions for further reading are at www.speechmag.com/Members/Extras.

References

DfEE (2000a) The National Literacy Strategy: Supporting Pupils with Special Educational Needs in the Literacy Hour. London: DfEE DfEE (2000b) Curriculum Guidance for the Foundation Stage. London: DfEE DfES (1998) The National Literacy Strategy. London: DfES DfES (2006) The Primary National Strategy. See various publications at http://www.standards.dfes. gov.uk/primary/publications/. (Accessed: 8 May 2008). Equals (2003) Literacy Strategy for the National Curriculum for Pupils with Learning Difficulties: Literacy Teachers Guide. North Shields: Equals. Grove, N. & Park, K. (1996) Odyssey Now. London: Jessica Kingsley. Lacey, P. (2005) University of Birmingham, Learning Difficulties (Severe Profound & Complex), Unit 3: Teaching and Learning. Lacey, P., Layton, L., Miller, C., Goldbart, J. & Lawson, H. (2007) What is literacy for students with severe learning difficulties? Exploring conventional and inclusive literacy, Journal of Research in Special Educational Needs 7(3), pp.149-160. Longhorn, F. (2001) Literacy for Very Special People. Bedford: Catalyst Education Resources Limited. QCA/DfEE (2001) Planning, Teaching and Assessing the Curriculum for Pupils with Learning Difficulties. London: QCA Publications.

REFLECTIONS DO I ENCOURAGE CLIENTS TO EXPERIENCE LANGUAGE THROUGH ALL THEIR SENSES? DO I ENABLE PEOPLE TO PARTICIPATE IN THEIR OWN WAY AS INDIVIDUALS AND PART OF A GROUP? DO I RECOGNISE THAT MULTIPROFESSIONAL TRAINING CAN ENHANCE COLLABORATIVE PRACTICE?
How has this article been helpful to you? What have you done to promote inclusive literacy? Let us know via the Summer 08 forum at http://members.speechmag. com/forum/.

Software solutions
PHONOLOGICAL AWARENESS
Lynne Millard appreciates the range of activities, clear instructions and feedback phrases on these value-for-money discs. Phonological Awareness Series Leaps & Bounds Multimedia Disc 3 Alliteration ISBN 0-9546521-2-6 54.88 (single user) Disc 4 Segmentation ISBN 0-9546521-3-4 37.25 (single user)

With computer software becoming ever more sophisticated and accessible for therapy, our in-depth reviews will help you decide whats hot and whats not.
ally clear and there is a range of activities to choose from including lotto, racetrack and sorting games. The activities are designed to change with each visit so that pupils cant simply remember the answers and there are many different games focusing on the same target. Individual worksheets and games can be prepared to suit each individual using jpeg images or similar. In addition, you can print off a score sheet to measure progress over time. The menus are straightforward and you can jump to areas of the disc easily. You are also able to lock the child into the task so they cannot inadvertently exit the activity. The user is able to choose from different sound groups and then sub sort into level of ability and amount of pictures used. Clear instructions use English voices and you can choose from male, female or no voice. I like the phrases used when the child makes an error, for example, sorry thats not right, almost there, and give it another shot. Encouraging ones are given for correct answers including excellent, brilliant and nice one. On the whole I liked the discs and feel they are value for money. I would use them if I had regular access to a computer with the children I work with, balanced alongside activities not reliant on information technology. On the negative side I found that sometimes it could be difficult for a child to manipulate the mouse to the exact spot, which may then result in a false error as the incorrect word is played. When I tried it I had occasional moments where the computer said no! even though it was the correct answer. There are a few words that may not always be clear to the child, for example pants/trousers. The pictures are not always immediately identifiable but, when the sound is on, this is not a problem and would only be an issue for silent sorting activities if the child were not familiar with the pictures. There is, however, a word list on each disc. I would recommend this to teachers and support staff in schools but only on the proviso that someone accompanies the child during the activities to avoid random clicking to find the correct answer. Lynne Millard is a senior specialist speech and language therapist with Cambridgeshire PCT and an independent practitioner. She works in mainstream schools with children who have severe and complex needs and in a community clinic and also delivers regular, accredited training to teaching assistants working in both mainstream and special schools. Acknowledgement Thanks to my colleague Jenny Newcombe (Cambridgeshire PCT) for her valuable input.

These discs are the 3rd and 4th in a phonological awareness series. Further details can be found at www.curriculumonline.gov.uk or www.speechleaps. com where there is technical help available. The Alliteration disc encourages children to understand about the initial sounds in words. It also aims to help them generate their own words when an initial sound is specified. The Segmentation disc provides activities to help children identify and manipulate sounds in words. It also offers activities to help children remove parts of compound words as well as removing sounds from the beginning and end of words. Both discs are easy to access and provide the user with the additional benefit of being able to print off work sheets and games. The pictures are visu28

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My Top Resources

SPEECH THERAPY AT CITY LIT (www.citylit.ac.uk/stammeringtherapy), A CENTRE OF EXCELLENCE IN ADULT STAMMERING THERAPY, WAS RECENTLY AWARDED THE PRESTIGIOUS QUEENS ANNIVERSARY PRIZE. STUDENTS AND THERAPISTS DESCRIBE WHAT MAKES THIS SERVICE SO SPECIAL.
1. Carolyn Cheasman, City Lit therapist I feel lucky to work for an organisation which, despite limited budgets, has the imagination to understand the value of supporting myself and my colleagues in attending training courses and conferences. For example, two of us attended a weeks training at The American Institute of Stuttering in New York and as a result we have radically altered our stammering therapy intensive course. Although we do make significant financial contributions to our own training as budgets are tight, we have always been supported in terms of time off to attend events. We have also had fortnightly nonmanagerial supervision for many years with an external supervisor. 2. Jan Logan, City Lit therapist Offering stammering therapy in an educational setting fits well with my philosophy about stammering, what it is and what might help, and has provided a context where the students have become my biggest resource. Therapy is based on a partnership model with the person who stammers bringing a wealth of experience about stammering to therapy. Students are seen as active learners with shared responsibility for therapy / learning. This is in line with the general philosophy of adult education which is about student-centred learning and empowering learners. Group-work is a positive choice enabling students to support, learn from and provide positive role models for each other. I have met and worked with many people who stammer they have been my teachers and I continue to learn from them. 3. Rachel Everard, City Lit therapist Its rewarding and stimulating to be able to offer training to qualified speech and language therapists throughout the UK and beyond on a range of topics. The topics are very varied and include adult stammering therapy together with more generic subjects such as counselling skills, supporting the process of change, group work, assertiveness, setting up supervision networks and, the most recent addition to our repertoire, Mindfulness meditation for speech and language therapists. Its exciting to share with our colleagues our knowledge and experience and to learn from them. We involve our clients in our training courses on adult stammering therapy and thats often a highlight for everyone involved. 4. Sam Simpson, speech and language therapist I have attended four courses at City Lit, all instrumental in shaping my work with adults with acquired neurological difficulties following stroke and traumatic brain injury, as well as adults who stammer. Working with Adults who Stammer embraced the practical application of theory in a dynamic group environment. Counselling Skills addressed areas not included in my undergraduate training such as facilitating the transition from doing to being with clients and valuing listening and witnessing of personal narratives rather than solving problems. The Group and I Theory, Process and Dynamic enabled me to develop my theoretical knowledge of working with groups, to become more attentive in managing the process as well as the task and to reflect on me in the group situation. Most recently Mindfulness based practice for SLTs confirmed the Lits unique group based learning approach fosters a personal journey of exploration and discovery that parallels and underpins a professional one. It offers a safe, supportive, yet challenging environment where I have gained insight, knowledge and inspiration. 5. Paul Harris, student (Stammering therapy: an integrated approach) I attended an integrated speech therapy course in 2007 and learnt speech-management techniques alongside a fluency-shaping technique (Vocal Fold Management). This made a positive impact on my speech. Daily use of VFM led to increased fluency - as a result my confidence increased. I use VFM at work, particularly in meetings and using the phone. Although still a novice using VFM I feel a sense of liberation when breathing correctly and speaking fluently. I am becoming less sensitive about using VFM and now use it less consciously. Practice is essential and occasionally I forget to use VFM. As a result of increased fluency the world feels a better place. Stammering is a lot about fear VFM as a resource greatly reduced my fear. 6. Blanche Keaveney, student (Interiorised stammering) The interiorised stammering course at City Lit made a huge impact on my life. I have stammered ever since I can remember and went to great lengths to conceal it. The interiorised course enabled me to confront it for the first time. By so doing it has freed me from the fear I felt about my stammer. With the support of the therapist and other students, I was able to move from a place of shame to being able to talk about stammering openly. For me the outcomes of therapy are freedom from fear and shame, and emotional and intellectual growth. I now wonder why I lived for 57 years like that I feel I have had two lives really: pre and post City Lit. 7. Jamal Muse, student (Block modification) Attending the Intensive Block Modification course has been one of the best decisions I have made. The course provided a holistic approach to stammering, not only focusing on the stammer itself but also the psychological baggage most, if not all, people who stammer experience. The Block Modification techniques proved indispensable in moments of stammering, allowing me to break free out of a stammer with ease. The thing that made the biggest difference was the desensitisation I received to stammering. There is absolutely nothing wrong with

Peter Davies (City Lit Principal), Jan Logan, Carolyn Cheasman and Rachel Everard with the Queens Anniversary Prize

stammering, so I neednt feel embarrassed or ashamed! City Lit advocated voluntary stammering which, paradoxically, made me feel at ease and comfortable and I thus experienced a heightened level of fluency. 8. Joanna Puzey, student (Block modification) One of the most important aspects for me about the course I attended at City Lit was being in a group with other people who stammer. Sharing thoughts and feelings and allowing myself to stammer openly with other people who stammer was an invaluable part of the therapy progress. It was definitely worth travelling all the way from Weymouth to attend this block modification course. I feel strongly that had it not been for this therapy I would have carried on hiding my stammer and feeling miserable about it. 9. Danny Smith, student (Block modification and Communication skills for people with learning difficulties who stammer) I like my course because Ill be able to talk to my group of my people, speaking about my speech therapy. But it really helped me to speak slowly and clearly.I learned eye contact: when I speak I look at the person, and that helps me to be more assertive.It really helped change my speech - it will be useful, cause Ill be able to get people to understand me a bit more. The best bit - I actually liked talking games to help your speech.We had to hold an object and each person had to hold it, one person to talk. We had to think about our names, and each person who got their own name, they had to do a bit of miming, and each person said my favourite food and my name being called Danny, to describe my favourite food.So we had to pretend to eat it!That is funny! 10. Flora Swartland, student (Mindfulness meditation for people who stammer) Having attended an interiorised stammering course, I didnt want to end the process so I signed up for mindful meditation. I started with little expectation, just a willingness to learn and open-mindedness. I felt the benefit quickly. While cycling home, I was much more sensitive and aware to details around me, such as the light, movement of trees and an overall calmness. A clich perhaps, but a small awakening which made me feel happy. And it helped with my stammer. It helps me be more aware of my emotions, which play a large part in a persons stammer, and to be more in the here and now when Im ruminating over an embarrassing stammer that day or worrying about an event tomorrow. I sit quietly, focus on my breath and put things into perspective. Most of all it helps me slow down, stay calm and gives me a place to return to if Im feeling tense about my speech. Its a simple technique I can use any time or place.