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ISSN 1368-2105

Spring 2007

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A CUT ABOVE

Communication environments Staff training in


nursing homes
Aphasia services Broadening the mind The missing link? Life coaching Visual feedback Increasing the scope Assessments assessed Asperger syndrome, dysphagia, preschool language How I provide social communication groups Courses and resources Creative shorts Targeting bullying PLUSWinning Ways Are you being served?...Heres one I made earliermore great reader offersand My Top Resources for musical AAC

Reader offers

Win the Grammar and Phonology Screening (GAPS) test


Would you like to help parents and other professionals identify language disorders at an earlier stage? Then meet Bik, a friendly alien character who can only understand English when it is spoken by children! In the 10 minute GAPS screening programme, an adult passes messages to Bik via a child and the way the child relays the message gives clues about whether their level of language development is within normal limits or merits referral to speech and language therapy. Speech & Language Therapy in Practice readers have the chance to win a FREE copy of the professional version of this new assessment courtesy of its developer, language expert Professor Heather van der Lely. All you have to do is e-mail your name and address to Heather at h.vanderlely@ucl.ac.uk by 25th April. The lucky winner will be notified by 1st May 2007. GAPS has been standardised for UK children from 31/2 - 61/2 year olds. It has also been designed to be used by parents, carers, doctors, nursery nurses, teachers, health visitors and support workers as well as speech and language therapists. For more information on GAPS, including online ordering, see www.dldcn.com/gapstest.html. The GAPS professional version retails for 65.00 (UK).

Win The Power of Communication


Are you frustrated by a lack of funding for AAC services? Do you need to show that AAC is vital and enabling for people of all ages with complex communication needs? A new DVD from Communication Matters could be your answer. The Power of Communication gives a basic overview of AAC techniques from signing and picture charts to the most sophisticated technology. It is particularly aimed at people who make decisions about service delivery, but you could also use it as an introduction to AAC at awareness raising or educational events. Speech & Language Therapy in Practice has 3 copies to give away FREE, courtesy of Communication Matters. All you need to do is e-mail your name and address to admin@communicationmatters.org.uk or post to Communication Matters, c/o The Ace Centre, 92 Windmill Road, Oxford OX3 7DR. Entries must be received by 25th April and winners will be notified by 1st May 2007. The Power of Communication normally retails at 8 (inc.p&p), or 20 for 3 copies.

Spring 07 speechmag
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Index facility Search our abstracts at www.speechmag.com/ articles.html. When you find one that inspires you, you can order a copy of the full article for a small charge via our secure server.

Reprinted article - view for free! Saunders, H. (2006) Never too soon to start, Speech & Language Therapy in Practice Winter, pp. 16-17. Online at www.speechmag. com/archives/ heathersaunders.pdf.

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Spring07contents
SPRING 2007 (publication date 26/02/07) ISSN 1368-2105 INSIDE COVER: Reader Offers, Spring 07 Speechmag Win GAPS, The Power of Communication DVD. See also Squirrel Story Narrative Assessment and Mr Goodguess offers on p.21.

News & Comment

BROADENING THE MIND Attending the conference was a really valuable experience, giving me time to step back from a busy caseload and other pressures and reflect on my everyday practice. Having specific aims in mind when I was listening to the different presentations gave me a focus that helped me to gauge what might be possible for our service. Karen Yuill takes the opportunity of a travel scholarship to gather fresh inspiration for developing her community service for people with aphasia.

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

HERES ONE I MADE EARLIER Shan Graebe complements her back page top resources with two low-cost musical suggestions: Beads in the Drum; Rattletops.

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ASSESSMENTS ASSESSED The return of our popular series sees in-depth reviews of the Asperger Syndrome Diagnostic Scale, the New Jays Observational Dysphagia Assessments and the CELF-Preschool 2UK. LIFE COACHING: THE MISSING LINK? My training [in Life Coaching] was very poignant as it became so apparent that this could be the missing link in my work with people who stammer. Perhaps Life Coaching could take away the frustration I had begun to associate with speech and language therapy? Catherine Williamson gave up her full-time post and sold her house to train as a Life Coach in a bid to offer more to people who stammer.

INCREASING THE SCOPE We used Voicecraft techniques to improve Jims adduction, including Sob and Twang. When visualising his larynx he was able to improve the quality of his voice, having seen the changes the techniques made. His response was Can I do more of this? Its so useful to see whats happening as Im talking and also to know when Im pushing it and actually making it worse. Lindsay Doidge and Daphne Carpenter were encouraged to extend their role by offering nasendoscopy to clients with voice problems with very positive results.

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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

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COVER STORY: WHAT KATE DID AT WORK Other non-classroom ideas were also piloted at this nursing home, including the introduction of pre-thickened drinks to improve compliance to dysphagia recommendations and the development of mealtime charts in dining rooms to communicate individual residents needs. Kate Balzer and her team discover that recognising the need for staff training to improve the lives of people living in nursing homes is just the first step on a lengthy and challenging journey.

REVIEWS Social communication, autism, aphasia, inclusion, bilingualism, dysfluency, research, continuing professional development.

Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2007 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site.
Cover photo by Paul Reid. Thanks to our models.

TARGETING BULLYING Where language unit placement is considered the best option for a child this research suggests that the head teacher has a particular need to enforce all anti-bullying strategies in the school to encourage positive attitudes to disability. Are children with communication disability targeted disproportionately by school bullies? Catherine de la Bedoyere shares preliminary findings of a study in one local authority area.

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WINNING WAYS: ARE YOU BEING SERVED? As you listen to other peoples conversations this week, notice the level of sweeping generalisations that go overlooked in everyday speechIt all adds up to a mesh of subtle prejudice which may have a base in real incidents but is multiplied by myth. We cant challenge it nationally or internationally until we challenge it individually. Life coach Jo Middlemiss encourages us to start 2007 by moving on from decisions that are no longer of benefit. BACK COVER: MY TOP RESOURCES It is good to have a few body and vocal warm-up activities before each session, especially in large groups. This helps to get everyone - especially the adults - less inhibited and more ready to sing and sign. Shan Graebe uses song to help develop early interaction and more complex communication skills, especially with learners who use AAC.

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HOW I PROVIDE SOCIAL COMMUNICATION GROUPS Two contributions focus on the very specific role a speech and language therapist can play in helping children and young people with Aspergers Syndrome understand themselves and others. (1) STRUCTURE, STRENGTHS AND STRATEGIES Jane Baker explains how the mantra structure, strengths, strategies influences the content and format of social communication groups for children from 31/2 years to adulthood in South Devon. Together with Gill Rogers, she also shares resource ideas. (2) A WICKED COURSE Young people with Aspergers Syndrome need particular support to cope with job seeking and the workplace. Alison Roberts describes the pilot of a collaborative approach called WICKED (Workplace Interactions and Communication Keyskills for Everyday, and for Dating).

IN FUTURE ISSUES: FACIAL PALSY TOTAL COMMUNICATION WORKING IN SCHOOLS APHASIA WRITING FOR PUBLICATION SERVICE REORGANISATION CARE PATHWAYS 1

NEWS

Community health
A community-based health scheme could provide inspiration for therapists targeting hard to reach groups. The Belfast Casefinder scheme sees district nurses and trained lay health workers visit pubs, workplaces and community centres to offer on-the-spot assessment, information and onward referral. The organisers say it has been successful in identifying chronic disease symptoms. www.ebchip.org

Self-voice research
Colin Lane, pioneer of the A.R.R.O.W. learning technique, is looking for speech and language therapists to help set up more research and training. A.R.R.O.W. is an acronym for Aural-Read-RespondOral-Write, and the self-voice is central to its concept. Students listen to their own recorded voice, working independently through a series of comprehension and dictation exercises linked to text on a computer screen. The technique is recognised by the Basic Skills Agency and was originally developed for children with hearing impairment. Following two promising pilot projects in 2006, Dr Lane is keen to find people with an educational background to help set up wider research. He says, I see an opportunity for speech and language therapists to utilise the approach in their private work or in the NHS, and also to supplement their income by going into schools and training. The pilots, involving primary school children with a range of levels of literacy, showed rapid improvements in word attack and spelling skills with less than 4 hours of using the A.R.R.O.W. technique. A.R.R.O.W. is also used in the community with adults who have had a stroke. Dr Lane says the most marked and sustained change is in short-term memory. For further information contact Colin Lane on 01278 450932 or see www.self-voice.com/.

Delegates at the I CAN conference exhibition

Targeting Talk
The importance of language development to later literacy was underlined at a recent I CAN conference. The 450 delegates heard from Jim Rose, author of the influential Independent Review of the Teaching of Early Reading. He emphasised the need to involve parents and to concentrate on early communication skills to pave the way for high quality phonic work. While this should be available to all children, those with additional needs should be identified early so they can appropriately supported, for example through an emphasis on multisensory aspects. In the other keynote address Professor Maggie Snowling considered different types of reading difficulty. Her review of intervention studies concluded that children who enter school with poor language need intervention that includes training in vocabulary and grammatical awareness. Those who enter school with poor phonological awareness need systematic reading instruction with additional training in phoneme awareness. The conference also saw the launch of I CANs communication skills assessment tool for primary schools. Commenting on Targeting Talk, Jim Rose said, I am delighted that I CAN have devised an assessment tool for speaking and listening because that has been, if not a sin, then certainly an omission. I CAN is moving on 26th March. The charity will be sharing reception and human resources functions with the National Childrens Bureau at 8 Wakley Street, London, EC1V 7QE. www.ican.org.uk www.targetingtalk.com

Fundraising challenges
ActionAid is running 2007 fundraising challenges in the Brazilian Rainforest, Indian Himalayas, Peru Inca Trail, Tanzania Rift Valley, Cambodia and Sri Lanka. Some of these include education or building healthcare facilities. www.actionaid.org. uk/adventures

Stammering study
A longitudinal study aiming to differentiate children at risk of persistent stammering from those who would stop of their own accord is due to report in September. Researchers from the University of the West of England are using data from the Avon Longitudinal Study of Parents and Children - also known as the Children of the 90s study. They are profiling children who are still stammering at the age of 8 and comparing them with two other groups of 8 year old children: those who showed early signs of stammering but are no longer doing so and those who have never shown signs of stammering. The aim is to guide referral decisions and targeting of timely intervention. www.speech-therapy.ik.com/

Sally Byng steps down


After six demanding and fulfilling years, Professor Sally Byng is standing down as Chief Executive of the communication disability network Connect. Sally, who co-founded the organisation with Carole Pound in 2000, will remain involved with Connect on a parttime basis in relation to policy, research and consultancy work. She says, There will now be a fantastic opportunity for someone else to lead Connect as Chief Executive, capitalising on the achievements we have made. www.ukconnect.org

Barrier Free Assessment


AbilityNet, the charity that helps people with disabilities make the most of computer technology, now offers a remote assessment service supported by equipment from a loan bank. After extensive piloting, the Barrier Free Assessment is available to clients with The launch of the AbilityNet Barrier Free Assessment service phone and broadband access, in their own homes or wherever they go for work or education. Working remotely, the AbilityNet consultant can make changes to cater for different physical or visual requirements. If necessary a webcam can also be used so the consultant can see physical access problems. AbilityNet can loan any recommended equipment (hardware or software) so the client can try before they buy. Offering a remote service also reduces costs, travel time and waiting lists. While this service increases direct access to AbilityNets expertise, the charity also hopes it will transfer skills to local professionals. They say this is important because a little knowledge is often dangerous: when clients find proposed solutions difficult, uncomfortable or unreliable, it is usually enough to put them off completely. The remote assessment pilot has largely been carrier out in Scotland. This included the development of a free-to-use online assessment tool (www.abilitynet.org.uk/ raps/assessment). www.abilitynet.org.uk

Barium test success


A pre-thickened drinks manufacturer is reporting that successful barium tests mean clients can have an identifiable and repeatable consistency from initial assessment to discharge. SLOs Mathew Done says, Just adding 1.5 tablespoons to a drink gives a clear visual reference and the consistency of the drink matches those with none in. The drinks also remain smooth, and look and taste better than normal barium laden drinks. He continued, This makes it possible, for the first time ever, to have a protocol / national standard for fluid thickness using SLO drinks. Every patient will be assessed against exactly the same consistency of drink. Then once a consistency is prescribed they will receive this on the ward and in the community if they continue to use our drinks. www.slodrinks.com

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

NEWS AND COMMENT

Education Show
Visitors to the annual Education Show will be able to see a new DVD to help children with autism engage with facial expression of emotions. The Transporters was developed with Cambridge Universitys Autism Research Centre and is narrated by Stephen Fry. It uses animated vehicles, particularly trains, with suSherstons Flobot software, on view at the Education Show. perimposed human faces to teach the emotions happy, sad, angry, afraid, excited, disgusted, surprised, tired, unfriendly, kind, sorry, proud, jealous, joking and ashamed. The episodes are supported by quizzes. The DVD is free to carers of children with autism aged 2-8 years. Professor Simon Baron-Cohen says the researchers found that following a four-week period of watching the DVD for 15 minutes a day, children with high-functioning autism caught up with typically developing children of the same age in their performance on emotion recognition tasks. www.transporters.tv The Education Show includes a Special Needs Zone with seminars and over 40 suppliers exhibiting their resources. Other items being showcased include: y The Virtual Whiteboard a web-based alternative to conventional whiteboards (www.virtual-whiteboard.co.uk) y ARC training courses to help young people with learning disabilities gain employment y The Spark-Space graphic organiser for students with a conceptual learning style. (www.spark-space.com) y Flobot infant software targeting problem-solving, decision making, ordering, memory, logic and sequencing skills (www.sherston.com). The Education Show runs from 22-24 March 2007 at the NEC Birmingham and is free (tel. 0870 429 4580 or see www.education-show.co.uk.

comment Comment:

A cut above
After months of dithering, I changed to a local hairdresser last week. I was happy with the one I had been going to for several years, and there were the usual qualms about loyalty and what if it all goes wrong? But this move halved the cost and quartered the time involved without any impact on the outcome. As Jo Middlemiss points out (p.22) the original reasons for my choice were no longer valid - and it was time to do something different. Jo shows that increasing our awareness of the assumptions that lie behind our decisions can help us decide how to tackle things in a different way. When Catherine de la Bedoyere (p.20) realised there was very little evidence to back up her ideas about bullying of children with communication difficulties, she set about finding the true picture. Once final findings are available she hopes they will help people reach better decisions on school placement and support. Doing things differently can be particularly challenging for people with autistic spectrum disorder. Alison Roberts (p.27) and Jane Baker with Gill Rogers (p.24) help students cope more flexibly with change through the structure provided by their social communication groups. Like all our authors, they are generous in sharing ideas so you can do something different with your own groups. Karen Yuill (p.4) benefited from such generosity when she won a travel bursary to attend a conference and meet people working in a service similar to her own. Practical ideas - such as clients working as secret shoppers - make a difference on many levels. Like Karen, Kate Balzer (p.15) had a very clear picture of what difference she wanted to make to clients living in nursing homes. This meant she brought leadership and direction to the team, and small changes are all adding up. Sometimes, though, a change just seems too big to contemplate. We can identify with the initial reluctance Lindsay Doidge and Daphne Carpenter felt (p.8) about extending their role to offer nasendoscopy to clients with voice problems. Yet their fears proved to be unfounded and the benefits well worth the effort. It also took a lot of guts for Catherine Williamson (p.12) to give up her job to train as a life coach. Now, however, she finds the difference between speech and language therapy and life coaching is what makes the difference for her clients who stammer. Shan Graebe (p.7 and back page) likewise brings a different skill to her work. Her musical theme follows on from our last Top Resources and suggests that introducing another way in to communication can make sessions more beneficial for clients and therapists alike. As for whats different in this issue, weve reintroduced the Assessments assessed series (p.10) by popular request. We didnt have room for a feature article, but this regular section will return in Summer 07. Like a hairstylist with her scissors, your editors job is to get the cut and style of the magazine in tune with your changing needs. At Speech & Language Therapy in Practice we might not offer an Indian Head Massage, but we do hold up a mirror. So grab a coffee and enjoy.

Trust Fund advice

As many parents with disabled children have low average incomes, Contact a Family has organised free advice on investing Child Trust Fund vouchers. Since 2002 all babies have been entitled to the vouchers worth 250 or 500 depending on household income. These are for investment in special accounts to provide a lump sum at age 18. Financial advisers Peppermint Financial Solutions will provide the free telephone advice sessions, which the charity says are worth upwards of 100 an hour. To book a slot with a financial adviser, or for advice on any aspect of raising a disabled child, parents should phone Contact a Familys helpline on 0808 808 3555.

Carer consent

Speech and language therapists see working with carers as an essential part of their role but what happens when a client doesnt want this? A recent study in the British Journal of Psychiatry explores the issues around information sharing practices of mental health professionals when service users withhold consent. It identifies key guiding principles and emphasises the central role of clinical judgement. In particular this distinguishes between general and personal information, allowing support and some information to be provided without patient confidentiality being broken. Slade, M., Pinfold, V., Rapaport, J., Bellringer, S., Banerjee, S., Kuipers, E. and Huxley, P. (2007) Best practice when service users do not consent to sharing information with carers, British Journal of Psychiatry, 190, pp. 148-155.

Avril Nicoll, Editor 33 Kinnear Square, Laurencekirk AB30 1UL tel/ansa/fax 01561 377415 e-mail avrilnicoll@speechmag.com

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

SERVICE DEVELOPMENT

READ THIS IF YOU DONT APPLY FOR BURSARIES / AWARDS ARE LOOKING TO STEP BACK AND THINK WANT TO LEARN FROM OTHER SERVIICES
hen a glossy circular lands in my tray my heart sinks a little. I worry about the number of trees its taken to produce and then I worry about my to do list and when Im going to have time to read it. So, when a mustardcoloured folder titled Getting better and better with a photo of smiling health professionals appeared in January 2006, I was less than inspired. I have a lead role for the community adult service in Aberdeen. We are a small but dedicated team (5 staff, 3.6 whole time equivalents). Back then we had just started a 6-month pilot of a screening system to prioritise new referrals. We were also planning a new group for people with aphasia in conjunction with the acute service. And I was going on holiday in five days, with my diary squeezed with clients, meetings and reports to complete. Im not sure what made me look at the folder more closely. Perhaps it was that the day before Id seen the programme for the Royal College of Speech & Language Therapists conference in Belfast and it had crossed my mind that there were some interesting sessions on aphasia and user involvement. Or maybe it was the tagline How the Scottish Executive AHP Travel Scholarship can benefit everyone. I spent a few minutes looking through and found this was a new scheme providing a scholarship of up to 5000. The award would cover travel and expenses including visas, insurance support, materials and backfill costs for up to 4 weeks. It was possible to use the funding for a number of options including undertaking preliminary research activity, work shadowing in another country and conference attendance. Applicants had to demonstrate the benefits for personal career development and in terms of remodelling aspects of NHS Scotland. To meet the deadline I had to complete the form before my holiday and several times thought about binning the idea. However, the process of applying affirmed the potential usefulness of the conference sessions in developing the community adult service in Aberdeen for clients with aphasia. Across NHS Grampian we have a good track record for innovative ideas and projects involving people with aphasia. A few years ago the Grampian Aphasia Action Project (GAAP) was started following an inspiring course from the Connect centre in London. The group was made up of speech and language therapists, people with aphasia and representatives from Chest, Heart and Stroke Scotland. Amongst other things, the Project led to the creation of a self-help group and an open day for members of the public to find out more about aphasia. More recently our team has introduced a number of initiatives to increase the involvement of all clients in decision making and planning around intervention. A feedback questionnaire (designed to be used during or after treatment) was symbolised to aid those with aphasia in completing it. Reports that used to be sent to the person

Work pressures meant Karen Yuill nearly missed the chance of a travel scholarship. Luckily she realised it was an ideal opportunity to gather fresh inspiration for developing her community service for people with aphasia.

Broadening
who had referred the client (GP, district nurse) are now sent to the client, written in a style which is easier to follow and documents our agreed goals. This report is also symbolised where appropriate, and a copy sent to the referrer.

Successful
The application was duly submitted and I received a letter confirming I had been successful. The awards panel suggested I include a visit to a specialist stroke centre as part of my trip. However, since my work is in the community, I felt a community service would be more relevant. I was lucky enough to be given contact details for Catherine Donnelly, speech and language therapy manager for North and West Belfast. She was instrumental in setting up two visits. Linzi Hatch, speech and language therapist with the Community Stroke Team, gave a morning of her time to discuss the service in North and West Belfast and her particular role. We shared resources and found that in some ways our services are quite similar. She works as part of a multidisciplinary team but often finds her input with clients is longer-term than most other disciplines. They are using symbolised questionnaires to aid goal setting and trying to provide accessible information wherever possible. Group work is being undertaken with some clients with severe expressive difficulties in much the same way as the planned group in our service. The North & West Belfast service has close links with Speechmatters, part of the Stroke Association. Speechmatters is a charity dedicated to supporting people living with aphasia, their families and carers. They are contracted by four Health Boards and Health & Social Services Trusts to provide a range of long-term services. Damien Coyle, Director of Operations at Speechmatters, kindly set up a meeting with himself and three members of the team: speech and language therapist Michelle Ross, aphasia social worker Marion McKeown, and speech and language therapy assistant / conversation partner Janet Thompson. Amongst many services, they run Aphasia Conversation Groups with referrals coming from speech and language therapists in the community. The groups are run

These examples of different types of support for carers got me thinking about how we could offer more.
We also have a well-established carers training day run every six months and were about to run a new group for clients with severe expressive aphasia, both projects in collaboration with staff in the acute service. My long-term goals for the community service were to: 1. provide a range of evidence based treatments for clients with aphasia 2. include clients expectations of the service in developing treatment options and a joint goal setting approach 3. take a longer-term view of the services offered to people with aphasia and their carers, including training for public service providers. I hoped to gain more information from the Royal College conference about: y the efficacy of particular treatment approaches y references for further reading y methods of involving clients successfully in service planning and development y providing training and information to wider society about the communication barriers faced by clients with aphasia.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

SERVICE DEVELOPMENT

ting. She concluded that, whilst therapists are keen to share power, they shouldnt underestimate their expert role in helping people move on in the process of adjusting after stroke. y A study looking at the analysis of conversational data without transcription gave hope to the busy clinician with little time to spend in detailed examination of video-recorded interactions. Marian Brady, from Glasgow Caledonian University, concluded that further work is needed but initial results using a tallying process for different conversational behaviours are definitely encouraging. y On a rather different theme, radical possibilities for the future treatment of communication impairment using Brain Computer Interfaces was introduced by Morwena Collins from the Institute of Sound and Vibration research. This was fascinating and will make me think twice about my It would be great if we could just hook you up to a computer and read your thoughts but its not possible speech. Its not possible now but who knows what the future holds? Although not all the user involvement sessions focused on adults with aphasia, the presentations were all of interest: y Focus groups for clients or carers produced some insights into attitudes and expectations that can influence how therapy programmes are targeted. Rosalind Owen, University of West England, had used two groups of children one mixed group with children with diagnosed communication difficulties and their peers and a second separate group for the children with communication difficulties. Understanding what the children defined as talking versus telling made it clear that vocabulary isnt always shared. Perceived meanings need to be explicit especially if joint goal setting and choices for clients are to be meaningful. y James Law from Queen Margaret University College presented on a project using a communication booklet provided to GPs and other health centre staff to support clients with communication impairment when attending an appointment. This project highlighted the difficulties in establishing a new way of working from the grass roots level up. Interested parties took the ideas on board whilst others did not. Having new initiatives pitched at the right level to ensure adoption seemed to be the next challenge. y Another project, described by Ruth Nieuwenhuis of University of Wales Institute, had enrolled a service user with aphasia to help run a conversation group for newer service users. Whilst this had some positive outcomes for the individual including improved confidence and independence, there were some negative outcomes including fatigue. Posters were also on display ranging from the use of quality of life measures to look at the social impact of stroke to what one department had done to implement
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

Speechmatters staff l to r: Janet Thompson, Damien Coyle, Marion McKeown, Michelle Ross

the mind
by a therapist employed by Speechmatters. Carer support groups and a Living with Aphasia course for clients and their carers are well established. These examples of different types of support for carers were really interesting and got me thinking about how we could offer more for carers in Aberdeen. Our team has good links with Chest, Heart and Stroke Scotland, whose staff and volunteers provide group support for people with aphasia, and perhaps we could use these links to take the issue of support for carers forward. Speechmatters also involve people with aphasia in any training they provide to external organisations, with appropriate remuneration for their time. I was particularly interested in the training provided to staff in health board premises. These sessions are preceded by Secret Shopper visits by people with aphasia to look at signage and communication support on offer in different sites. The outcomes of these visits are used within the training to give staff clear examples of how things could be improved. This is a fantastic idea that could be used in a range of settings highlighting problems with communicative access alongside issues of physical access. tance of user involvement. One keynote speaker, Clem Stewart, had a stroke 22 years ago, and his insights into the journey hed taken and the support he received along the way were extremely moving and inspiring. There are so many ways we could be involving clients in driving service planning and delivery - and perhaps one of the simplest is by allowing service users to tell us where we are getting things right and where its not working. The needs of his family were also clear and for me the gaps in our service were highlighted once again.

There are so many ways we could be involving clients in driving service planning and delivery
A running theme of the aphasia sessions was the use of Quality of Life measures to look at outcomes in therapy as a useful way of including clients with aphasia who are often omitted from research because of the very nature of their communication difficulties: y Julie Hickin from De Montfort University presented a study that had used a very structured impairment based treatment but quality of life measures to look at outcomes. The study suggested that impairment based therapy can also impact positively on quality of life, when we can sometimes consider these two approaches as being at opposite ends of the spectrum. y Sarah Griffiths from the University of Plymouth looked at possible barriers to relationship building and empowering clients with aphasia in goal-set-

Relevance
At the conference (Realising the Vision, 10-12 May 2006) a number of presentations had direct relevance to the themes of my proposal. Some were posters with just a flavour of research or projects being undertaken. Some were 15 minute talks within organised sessions. The presentations were diverse; some very academic and research based with limited immediate clinical relevance but others surprisingly simple and very practical clinically. Themes for me were very much about the long-term impact of communication impairment and the impor-

SERVICE DEVELOPMENT

an Aphasia Strategy. Snapshots of the research and projects from different parts of the country gave me immediate references to follow up and a list of people to contact. Following my return from Belfast I felt the need to digest the information and reflect on the experience as a whole. As is often the case, busy schedules and other pressures mean that new ideas can be lost through lack of time to implement them. I tackled this through developing some short and long-term goals in conjunction with the other members of the adult team: 1. Short-term goals To introduce accessible information about the service and what we provide as well as pictorial appointment cards. To work with acute service colleagues to set up a carers support group. To follow up references on quality of life measures as a way of evaluating outcomes of therapy / intervention. To approach the local aphasia self-help group and clients for help in evaluating current and future attempts to provide accessible information, and to take part in future training. 2. Long-term goals To provide a joint Speech and Language Therapy / Counselling / Social Work model of support to clients and carers with aphasia. Consider training need within our service for formalised counselling skills.

To introduce quality of life measures into every episode of care for clients with aphasia. To approach local aphasia selfhelp group and clients to take part in focus groups to establish how they would like to see the service change / develop.

Unfortunately by the time this is printed the other deadlines for this particular award will have passed but I would urge everyone to think about the opportunities available that might be relevant to projects in your department. Who knows? There might be something sitting in your in tray right now! Karen Yuill is a speech and language therapist with the Community Adult Team, Speech & Language Therapy Department, Aberdeen City Community Health Partnership, NHS Grampian, e-mail karen.yuill@nhs.net.

Valuable experience
Attending the conference was a really valuable experience, giving me time to step back from a busy caseload and other pressures and reflect on my everyday practice. Having specific aims in mind when I was listening to the different presentations gave me a focus that helped me to gauge what might be possible for our service. The visits to services in Belfast were a great opportunity to share resources and to hear about practice and initiatives that include and consult service users in a meaningful way and offer short and long-term support to carers. Our team has already started on all the short-term goals we set and Im confident our service will continue to evolve to meet the needs of our clients and their carers. The Scottish Executive made 13 awards in February 2006 to speech and language therapists, physiotherapists, occupational therapists and podiatrists. More than half were for overseas destinations (Canada, Australia, USA). Successful applicants were expected to write a summary report for the Scottish Executive and pursue publication to ensure dissemination. I look forward to reading what the other successful speech and language therapists in Scotland did with their awards.

Acknowledgements
Thanks to Catherine Donnelly and Linzi Hatch (Belfast); Damien Coyle, Michelle Ross, Janet Thompson and Marion McKeown (Speechmatters); Jacqui Lunday (AHP Professions Officer) and Uriel Jamieson (Nursing, Midwifery and AHP Directorate, Scottish Executive); Pamela Cornwallis (Principal Speech and Language Therapist) and the Aberdeen Community Adult Speech and Language Therapy Team; and Aileen Robinson (Chest, Heart and Stroke Scotland). SLTP

REFLECTIONS DO I FORM SPECIFIC AIMS TO GIVE CONFERENCE ATTENDANCE A FOCUS? DO I RECOGNISE AN APPLICATION PROCESS CAN, IN ITSELF, CLARIFY GOALS? DO I MAKE TIME TO DIGEST AND REFLECT ON TRAINING?

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SLTP

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

HERES ONE I MADE EARLIER

Heres one I made earlier...


Shan Graebe complements her My Top Resources (back page) with two low-cost, musical suggestions.
Shan Graebe is based at 100 Cheltenham Road, Gloucester GL2 0LX, e-mail shan.graebe@btinternet.com.

Beads in the drum

This seems to be a very attractive sound and sensation for people who are at an early stage of development. Make sure you routinely inspect it for damage. (It is easy to replace the Glastop if necessary.)
BRAWN 1. Snip the beads from the string if necessary. Put some in the Frisbee and make sure they will roll freely around when there is a lid placed on it. You can vary the number of beads to give different effects. 2. Cut out two circles of Glastop. One should be exactly the same size as the free edge round the Frisbee. The other should be 11/2cm bigger. Fold each circle into quarters, but only crease a tiny portion in the centre. Make a small mark on the plastic, showing the centre of each circle. Remove the paper from the sticky plastic and, matching the two centres, place one circle on top of the other, sticky sides together. 3. Place the plastic on the Frisbee so that the smaller circle fits inside the circumference of the Frisbee and the larger circle is overlapping the edge. 4. Using scissors, cut small V-shapes all around the edge of the larger plastic circle. Do not cut right to the edge, but just a little in front of it. Then bend the tabs you have cut onto the outer edge of the Frisbee. These must be secured by tape. Some holographic tapes work, as well as super sticky duct tape. IN PRACTICE It can be held close to the person so they can feel the vibrations and hear the gentle rolling sounds. Those with very limited physical control can join in by having the beads in the drum resting on their hands or arms. You can facilitate any movement they make to get the beads rolling. It is useful for promoting attention to object. I usually sing a short song as we play together (e-mail me if you would like to know my tune, shan. graebe@btinternet.com): Rolling the beads in the drum Rolling the beads in the drum We are rolling, rolling, rolling Rolling the beads in the drum. At the end of the song the drum can be removed from sight. You can then wait for some indication from the learner that s/he would like the activity repeated. If you want to promote eye contact, bring the drum up to your eye level and give a big positive affirmation with your voice and face that the learner has requested more. A similar routine works well for AAC users. The AAC singer activates his/her device and sings the first line of the song. You then bring out the drum and sing the rest of the song while the learner rolls the beads around. You can add some fun by saying s/he must NOT knock it onto the floor, and then feign horror when that is where it inevitably ends up!

MATERIALS One cheap plastic Frisbee Large shiny plastic beads. These are often sold on a string as decorations; you just need to snip them apart. Glastop - this is like sticky backed plastic, but is more rigid. It is available from glass merchants. Small sharp scissors Strong duct or holographic sticky tape

Rattletops

This instrument is popular with most learners, but is particularly suited to those who may have physical control diculties.
BRAWN 1. Using the awl, make a small hole in the centre of each bottle top by pressing down and through it onto a chopping board. 2. Take your elastic and wrap a piece of sellotape around the end so that you can form a point which will draw the elastic through the holes. 3. Thread half the tops onto the elastic, making sure each pair of tops meets face to face. 4. Leave about 20cm of elastic at one end and tie a knot there, making sure the tops cannot move over it. Tie another knot at the other end of the tops, just stretching the elastic a little to give a tight fit. 5. Then thread the elastic through one piece of plastic tubing. Allowing for some elastic to show on either side of the tubing, tie a knot in it. Then thread the rest of the tops on and tie a knot at the end of those tops. Thread the elastic through the second piece of tubing and tie it to the loose end of elastic. This makes two handles with two rows of rattletops strung between. IN PRACTICE The learner holds one handle and you stretch the rattletops between you. (Some learners need to have the handle padded with Velcro fabric or enabled to maintain grip with a glove such as Active Hands see www.activehands.co.uk). The real benefit is that your shaking movements are mirrored by the learner as your shake travels along to his/her arm. Conversely, s/he may be able to make your relaxed arm shake about. This gives a great sense of joint action and includes a bit of safe rough and tumble activity. There is a song which goes with this instrument (recorded on the Nice Warm Socks CD, www.nicewarmsocks.org.uk): Shaking, shaking, shaking the rattletops Shaking, shaking, shaking the rattletops Shaking, shaking, shaking the rattletops Shaking the rattletops together. It also works well for AAC singers. The whole song could be recorded onto a voice output device requiring one or more activations. The song can then be sung by both parties actively and enthusiastically. And it is amazing how often the rattletops get pinged from one to the other.

MATERIALS A quantity of clean plastic milk bottle tops (about 36) Elastic An awl Some sellotape Rigid plastic tubing (available from hardware stores), two pieces cut to 10cm

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

VISUAL FEEDBACK

Lindsay Doidge and Daphne Carpenter were initially reluctant to extend their role by offering nasendoscopy to clients with voice problems. But pioneering speech and language therapists and their forward-thinking ENT department encouraged them to go for it with very positive results.

READ THIS IF YOU ARE WARY OF INVASIVE PROCEDURES WANT CLIENTS TO SEE THE DIFFERENCE NEED AN EXTRA PUSH TO GO FOR IT

Increasing th
an effort to address perceived shortcomings in the provision of ENT services. Amongst other initiatives, it recommended extended training for professions like speech and language therapy to fulfil NHS waiting list targets.

n 2001 we were inspired and challenged by Helen Rattenburys presentation at the 5th Newcastle Voice Conference describing the use of nasendoscopy in her practice. At that time only 7 per cent of ENT speech and language therapists were trained to do this. At the 9th Newcastle Voice Conference we attended the excellent presentation by Sue Jones describing how she uses nasendoscopy to assess patients in her clinics. This motivated us to share our experience of setting up a nasendoscopy voice treatment clinic. Nasendoscopy can be used to examine a client from the nasal cavity to the larynx. The procedure involves inserting a small flexible tube called an endoscope through the nose. Real-time images are transmitted to a TV monitor. While it was developed as an assessment instrument for use by ENT surgeons, its potential value as a visual feedback tool in therapy sessions for voice, velopharyngeal dysfunction and dysphagia is gradually being recognised. Our ENT colleagues had wanted us to develop nasendoscopy skills for a long time, saying that as professionals working with voice we should have as ready access to laryngeal images as they do. We knew this would also enable us and our patients to benefit from the objectivity the procedure would provide. However, like many speech and language therapists, we were reluctant due to its perceived invasiveness. But, encouraged by Helen Rattenbury that this could only enhance the service we offer our patients, we realised we really needed to go for it! The publication of Action on ENT(2002) gave us another push. This NHS Modernisation Agency document was

Competencies
We therefore enrolled on an excellent day run by the speech and language therapy team at the Royal National Throat, Nose and Ear Hospital, Grays Inn Road. We subsequently built up our competencies with additional training and supervision from our own ENT team. Action On ENT encouraged speech and language

We have been pleased to find that patients are able to tolerate the procedure for as long as the therapists arm can hold out!
therapy-led parallel clinics, which are specialist voice clinics run concurrently with general ENT clinics. Patients are triaged and selected for such parallel clinics, and almost always have a non-organic diagnosis such as muscular tension dysphonia. However, we felt nasendoscopy was of most benefit to us and our patients in a treatment / therapy environment, so we set up our existing clinic once our competencies were completed in December 2002.

We run our clinic on a fortnightly basis in the ENT OutPatients Department with nursing support. Immediate medical support must be available should any emergency or other unforeseen event arise (epistaxis, vasovagal episode, laryngospasm or tissue trauma). We see three to four patients per session, allowing 45-60 minutes with each. Voicecraft is our main therapeutic intervention with adult patients who have organic voice disorders. The techniques encourage the patient to understand the importance of releasing laryngeal constriction prior to working on sustained voicing and improved voice quality. Voicecraft lends itself well to the visual feedback that nasendoscopy can provide. We use the ENT departments Laryngograph software with recording facility, TV monitor and nasendoscope. Two of us run the clinic; one therapist scopes the patient which frees the other (treating) therapist to show the relevant area on the screen and aid understanding with demonstration. We introduce new treatment techniques and encourage patients to use the treatment techniques we have already taught them. We focus on both successes and problems. If a patient has found a particular technique difficult to master and has stopped making progress, they are often able to move forward following the procedure. The patients have the benefit of immediate visual feedback, which helps them to correct mistakes they may not have been aware they were making. We have high numbers of occupational voice users such as professional singers in this area. All are particularly interested in seeing how their voices work. We also see other professional voice users such as teachers and call centre operators.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

VISUAL FEEDBACK

he scope
Focus shifts
Initially patients can be apprehensive when the procedure is outlined to them. However, once they can view their own larynx on the screen, we find the focus shifts; we have a high degree of compliance and they report very positively. We have been pleased to find that patients are able to tolerate the procedure for as long as the therapists arm can hold out! We have had two patients decline nasendoscopy in the three years the clinic has been running, and have never received any negative reactions from those undergoing it. Indeed, patients report that the Voice Treatment Clinic has been an invaluable part of the therapeutic process. A brief case example is in figure 1.

Figure 1 Case example Jim - a teacher and amateur singer - presented with a fixed left arytenoid following neck injury. His voice was weak and breathy due to the inability to adduct his vocal folds on phonation. He had a good mucosal wave on the vocal folds, but these did not adduct. We used Voicecraft techniques to improve Jims adduction, including Sob and Twang. When visualising his larynx he was able to improve the quality of his voice, having seen the changes the techniques made. His response was Can I do more of this? Its so useful to see whats happening as Im talking and also to know when Im pushing it and actually making it worse.

Other feedback has included: its fascinating to have it confirmed that I was doing what I thought I was doing; I never thought it looked like that!; it helped link the feeling with the seeing; .. that makes sense of the model you showed me; I wish the doctor had let me see that. We are in the process of compiling a formal feedback form and a patient self-rating scale to audit our effectiveness. Depending on funding, a potential development of this clinic is to use it to discharge patients with non-organic conditions from the speech and language therapy and ENT caseload, thereby reducing clinic time and cutting waiting lists for ENT clinics. Once treatment has been completed, ENT are happy for us to do this. As this is not a diagnostic clinic, we routinely obtain consent from the patient to show the recording of the procedure to their doctor for his or her information. We have on several occasions needed to show recordings to our medical colleagues when we have observed a worrying laryngeal change. Not only has the use of nasendoscopy as part of our therapy enhanced our patient care, it has also improved our standing as members of the ENT team. In addition we have helped two of our ENT doctors to organise and run an in-house training package in nasendoscopy, to enable more speech and language therapists to develop these skills. Some therapists have used this training as part of objective assessment of swallowing (FEES Fibreoptic Endoscopic Evaluation of Swallowing), so this development is very exciting. If anyone is planning to set up a similar clinic in their area we would be pleased to hear from them.

REFLECTIONS DO I LISTEN WHEN PEOPLE ENCOURAGE ME TO UNDERTAKE AN EXTENDED ROLE? DO I SEE THE WIDER BENEFITS OF WORKING MORE CLOSELY WITH PROFESSIONAL COLLEAGUES? DO I LOOK FOR WAYS TO REDUCE WAITING LISTS AND STREAMLINE PATIENT JOURNEYS?
Lindsay Doidge and Daphne Carpenter are specialist speech and language therapists with South Devon Healthcare Trust, Crow Thorne Unit, Torbay Hospital, Torquay, Devon TQ2 7AA, tel.01803 654931.

References
Jones, S. (2006) SLT endoscopy applications, 9th Newcastle Voice Therapy Conference. Newcastle, UK, June. NHS Modernisation Agency (2002) Action on ENT. Crown copyright. Available at: www.institute.nhs.uk/Products/ActiononENTGoodPracticeGuide.htm (Accessed 8 January 2007). Rattenbury, H. (2001) Can SLTs afford not to be doing their own fibreoptic nasendoscopy?5th Newcastle Voice Conference. Newcastle, UK, June.

Resource
Voicecraft see www.voicecraft.com.au
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007 SLTP

ASSESSMENTS ASSESSED (1)

Assessments assessed
The return of our popular series of in-depth reviews to help you decide if an assessment would meet your needs.
Asperger Syndrome Diagnostic Scale (ASDS)
Alison Hunter tries out this scale and finds it useful and quick.
Asperger Syndrome Diagnostic Scale (ASDS) (2000) Brenda Myles, Stacy Jones-Bock and Richard L Simpson Harcourt Assessment 97.63
I work within a multi-agency diagnostic and intervention team for children with autism and Aspergers Syndrome. Currently we use a combination of formal and informal assessments within our team, but do not routinely use rating scales as part of our diagnostic assessment. I was therefore interested to see whether the Asperger Syndrome Diagnostic Scale (ASDS) would be a useful tool to use within our team. The Asperger Syndrome Diagnostic Scale is described as a quick and easy to use rating scale that can help you determine whether a child has Asperger Syndrome. For children from 5 to 18, it consists of 50 yes / no questions. The publisher states that the scale takes 10 to 15 minutes to complete. It can be used with anyone who knows the child well, such as parents, teacher, siblings or therapists. The questions are drawn from five specific areas of behaviour: cognitive, maladaptive, language, social and sensori-motor. Once the assessment is complete the items are scored and then converted to an Aspergers Syndrome Quotient. This score is then interpreted to give the probability of an individual having a diagnosis of Aspergers Syndrome. The ASDS Kit includes an examiners manual and 50 forms. The manual has a brief history of Aspergers Syndrome. It also gives instructions about how to administer and score the assessment. I was able to use the assessment twice. Colin is a 9 year old boy who had been referred to our team with some unusual behaviours. He had initially been seen by a Mental Health Practitioner who felt that his communication and interaction style was unusual. We both met his mum to carry out the questionnaire with her. The manual suggests that the rater (parent / teacher / other professional) is given the form to fill in independently. I found that Colins mother needed significant support to fill in the questionnaire; I read the statements on the scale to her and also needed to explain their exact meaning in more detail. The rater has to decide whether a behaviour is observed or not. Colins mother sometimes found it difficult to judge the answer to the statement. It took about 25 minutes to complete the assessment. Martin is a complex 7 year old boy who was undergoing assessment within our Child & Adolescent Mental Health Team. He has language impairment and social communication difficulties. Part of his assessment included a school observation and discussion with his teacher. I used the ASDS with his teacher. She found it easy to rate the statements and was able to complete the scale in 10 minutes. On both occasions I found it quick and easy to score the assessment. The Aspergers Syndrome Quotient - and thence the interpretation of this into a probability of an individual having a diagnosis of Aspergers Syndrome - was a useful guide to establish whether further assessment was warranted. I found it particularly useful with Martins teacher as it also prompted her to give me additional information about his social communication difficulties. The ASDS appears to be a useful tool for speech and language therapists and other professionals with assessment and diagnostic teams. Its great advantage is that it is quick to use. I feel it would be of particular use with teachers and other professionals to provide additional information about a childs social communication difficulties within school. The inclusion of specific questions about cognitive skills and sensori-motor difficulties is useful, as these may not always be observed within clinical settings. Alison Hunter is a specialist speech and language therapist working within the Child and Adolescent Mental Health Service in Manchester. There are guide sheets for each section giving examples of relevant information and how that may affect the safety of the swallowing process. The assessment sheets are photocopiable and enable detailed information about the childs abilities, mealtime environments and carers concerns to be recorded easily. There are sheets to record your hypothesis, plan further management strategies and record relevant information to send to other professionals. The Jays Assessment package is an extremely useful, adaptable tool which enables efficient recording of a wide range of diagnostic information to support effective clinical management. Kerry Wreford-Bush is a specialist speech and language therapist working with children with physical disabilities at Craig y Parc School, Cardiff.

New Jays Observational Assessment of Dysphagia (Adult Learning Disability Version)


Antoinette Forbes welcomes the clarity, detail and flexibility of this version.

New Jays Observational Dysphagia Assessments (2006) Paediatric Version (2nd edn) (180) Adult Learning Disability Version (2nd edn) (180) Adult Version (180) Judi Hibberd and Jeanne Taylor www.quest-training.com

These three assessments were reviewed separately. Each version costs 180 (additional copies of that version 40 within the same department). Two versions come at the discounted rate of 300, and all three versions for 450. Postage and packing is 5 per copy (UK).

New Jays Observational Assessment of Dysphagia (Paediatric Version)


Kerry Wreford-Bush finds this tool focuses the assessment, decision-making and information sharing process.
The New Jays Assessment is a valuable tool for therapists working in the expanding field of paediatric dysphagia, especially therapists newly qualified in this area. The assessment is specifically designed for use with children aged two and over. It is a thorough, well structured, flexible and easy to use package. It focuses the assessment and therapeutic decision making process by giving a selection of assessment areas which the therapist can use as desired.

This assessment consists of a manual and assessment booklet. It is primarily aimed at experienced clinicians who have already been trained in the area of dysphagia. However, the manual is an excellent resource for those entering the field of dysphagia as it provides a clear rationale for each aspect of the assessment. The original version - published in June 2000 - has been updated, with changes evident in all sections of the assessment. In particular the section on risk assessment and hypothesis reflects the increased awareness of the importance of risk assessment, especially in this area. The assessment is extremely detailed and could be seen as time-consuming. However the authors stress that it should be used with flexibility and that clinicians should complete only relevant sections. The authors have strived for a balance between the theory and practical aspects of working with this client group. This is demonstrated in the concluding summaries, one for the patients notes and the second for other professionals, which indicate clearly the problems identified and the future treatment required. Overall a very useful resource that is definitely worth the money. Antoinette Forbes is a speech and language therapist who is solely responsible for the adult learning disability service in Foyle Trust, Northern Ireland.

New Jays Observational Assessment of Dysphagia (Adult Version)


Although it is thorough, this assessment would not be Claire Croppers first choice.
This assessment is described as for use by trained therapists, but I did not feel it offered any new or innovative

10

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

ASSESSMENTS ASSESSED (1)

ways of working or recording information. Of course we are all striving for better ways of working and achieving best practice but I did not feel this was offered. In fact, it appeared quite long-winded with lots of time-consuming written sheets. However, the authors do describe it as a complete and flexible package. I felt the assessment sections were thorough and a useful way of sharing information with others but you would need to adapt and be flexible in your approach to its usage. Indeed, certain sections may be more appropriate for certain client groups, for example clients with a learning disability compared to elderly care home residents. This assessment is not one that I would choose first to pick up off the shelf. I feel it is something that would need to be worked with and adapted in order to feel the benefits. In terms of value for money I thought it was quite expensive, but more justifiable if purchased as a whole department resource across different adult client groups. Claire Cropper is a senior specialist speech and language therapist with Central Lancashire Primary Care Trust.

CELF-Preschool 2UK
Louise Tweedie finds the revisions in this second edition have enhanced its appeal to her as a clinician.
Clinical Evaluation of Language Fundamentals Preschool - Second UK Edition, (CELF-Preschool 2UK) Wiig, E.H., Secord, W.A. and Semel, E.M. (2006) Harcourt Assessment 320.01 (inc. VAT)
As CELF assessments are key departmental resources, I awaited this edition with anticipation. Over 800 children in 100 schools across the UK took part in standardisation and the project team have done a good job. The CELF-Preschool 2UK allows comprehensive assessment of a childs language from 3;0 years to 6;11 years. The process is in 4 levels, but the elements and order selected depend on clinical judgement, the childs functional language performance and the referral questions that must be answered (Wiig et al., 2006, p.2). A large part resembles the old version, but new elements extend the traditional purpose of assessing receptive and expressive language (levels 1 and 2) into looking at pre-literacy development and phonological awareness (level 3) and pragmatic language skills (level 4). Although other tools already assess these areas in detail, it is useful to have a quick option within the same format - and anything which reduces the amount I have to carry is welcome. Three subtests can be used as a time-saving screen. Scaling Scores replace Standard Scores, and age equivalents are now available for each subtest. The manual is very detailed. The subtest administration descriptions are useful, especially as they include additional information about the relationship to development skills and curriculum, relationship to home and classroom activities, item analyses, ideas for extension testing and clinicians notes. The main stimulus book appeared larger and heavier, but the pictures are colourful and less ambiguous. The

stimulus book has colour coded tabs separating the subtests, matched to a colour coded record form. The stimulus for each item is now included in the book and on a separate laminated sheet for Concepts & Following Directions, as this can be hard to carry out. These changes make for easier administration, but the summary information on the record form is more complex. While I am becoming used to this, the stimulus sentence for each item is not always included on the record form, leaving just A B C D to circle. This makes it difficult to write reports without the full assessment in front of you. The floor and ceiling have been extended. More links to the CELF 4 (516 years) are included to enable an overlap for 56 year olds; previously I found there could be a big drop in scores. A new Word Classes subtest is excellent and involves the child saying which two pictures go together and then explaining why. Pictures are used rather than just spoken words, which reduces the auditory memory load for young children. Recalling Sentences in Context has a new story; younger children found this difficult in the previous version. Finally, the norms have been extensively researched and updated, which makes the assessment robust and clinically effective. I work with children in pre-schools, foundation units and in clinic. I have administered the CELF Preschool 2UK to a number of children and their response has been very good. For language delayed and disordered children, it provided information about their skills. Jack (4;11 years), for example, is in a mainstream school foundation stage Reception class. He has language difficulties, immature listening and attention skills and speech sound delay. In the results (table 1) his receptive score appears higher than his expressive, but the manual showed this was not significant. There was no difference between language content and structure. I used the rating scales Table 1 Jacks results SUBTEST

with Jacks mother and class teacher which showed that Jacks pragmatic skills were a real strength, although turn taking was difficult. Pre-literacy skills are also very delayed. We agreed to target: Use of function words (he/she; is), as Word Structure was his lowest score and both his mother and class teacher commented he sounded babyish and could be difficult to follow. These words are also in the Reception year National Literacy Strategy (DfES, 1998) high frequency words list for sight reading. Listening and taking turns with peers in a small group, based on attention and listening difficulties during assessment and comments during the Descriptive Pragmatics Profile. As well as Jack, using Phonological Awareness and Recalling Sentences in Context with a child with a specific speech sound disorder helped me to rule out such difficulties. A 3 year old with attention and listening difficulties found the format difficult so I used a toy based assessment instead. The CELF Preschool 2UK is a useful and comprehensive language assessment for young children. The revisions have enhanced its appeal to clinicians and you certainly get a lot for your money. Louise Tweedie is a specialist speech and language therapist (Early Years) with East Cheshire NHS Trust.

References
DfES (1998) National Literacy Strategy Framework for Teaching. London: Department for Education and Skills. Wiig, E.H., Secord, W.A, & Semel, E.M. (2006) Clinical Evaluation of Language Fundamentals Preschool - Second UK Edition SLTP - Examiners Manual. London: Harcourt Assessment.

SCALED SCORE (with 90% confidence interval) average = 10, average range = 7 13 7 (5 9) 2 (0 - 4) 5 ( 3 - 7) 5 (3 7) 5 ( 4 - 6) 4 (1 7)

PERCENTILE RANK average = 50, average range = 16 84

Sentence Structure Word Structure Expressive Vocabulary Concepts & Following Directions Recalling Sentences Basic Concepts Additional: Pre-Literacy Rating Scale Descriptive Pragmatics Profile Composite scores: INDEX

16 0.4 5 5 5 2

DID NOT MEET CRITERION FOR HIS AGE DID MEET CRITERION FOR HIS AGE

-------

STANDARD SCORE (with 90% confidence interval) average = 100, average range = 85 115 69 (63 75) 73 (66 80) 65 (59 71) 69 (62 76) 69 (63 75)

PERCENTILE RANK average = 50, average range = 16 84 2 4 1 2 2

Core Language Index Receptive Language Index Expressive Language Index Language Content Index Language Structure Index

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

11

EXTENDED ROLE

Life coaching: the missing link?


READ THIS IF YOU WANT TO ACQUIRE TOOLS TO CHALLENGE NEGATIVE BELIEFS PROMOTE SELFCONFIDENCE AND SELF-BELIEF ENSURE A CLIENT CAN MAINTAIN THEIR PROGRESS

Frustrated by the limits of her effectiveness as a speech and language therapist, Catherine Williamson gave up her fulltime post and sold her house to train as a Life Coach. Here she explains how this has enhanced what she can offer and brought particular benefits to people who stammer.
says, If we want changes in our lives, we have to make the changes. It may be changes in style, shape, situation or attitude. We can choose the easy route or the hard one but choose we must (2006, p.23). Five years ago my personal circumstances were not good and I wanted to make changes. At the Vitality Show in London I came across Life Coaching and developed my interest through self-help books. I finally took the plunge, gave up my full-time job and put my house on the market. With support from my parents, I started work as a locum and used the profit from the house to train as a Life Coach. In 2006 I qualified through NobleManhattan Coaching. This inspired me to re-vamp my own life and start up my business Meet The Real You.

and self awareness. Martin (2001) says, The Life Coach uses the power of commitment to enable their clients to achieve beneficial and measurable results in all areas of their lives. Life Coaching is a holistic process that has the power to balance and harmonise life. My training was very poignant as it became so apparent that this could be the missing link in my work with people who stammer. Perhaps Life Coaching could take away the frustration I had begun to associate with speech and language therapy?

A wall of ash
Who benefits most from a Life Coaching approach? This puzzled me until one of my clients came to the realisation that what happened to her speech was not an act of random chance. It was related to what she did and she was the one in control. This client made the analogy that at one time she viewed her speech as a huge wall to climb over. (In my experience this is a common theme.) With the realisation that she was in control, her view changed to the image of a wall made of ash that she could actually walk right through. For the client - and me - this was a revelation. She knew that her stammer was not something she had to get over or indeed accept. She was going through that wall on her terms and she was going to set the standard. The key turning point was that she knew she could do it. In my opinion, that self-belief is what allows a client to benefit from Life Coaching. Perhaps you have understood this to be the case for many years of practice. I guess I knew this too - but the training allowed me to let the client uncover this for themselves. That is the true value of Life Coaching. All my years of experience, supposed wisdom and knowledge count for nothing unless the client comes to their own conclusions. This process can take a long time. Sadly, in NHS therapy provision, there is often not the time available to explore this. Or perhaps there is not enough evidence yet behind this approach? I hope that, by writing about it and evaluating outcomes, I can add to the evidence base. Inside each and every one of us we have the capacity to be brilliant but sometimes things get in the way, steer us off course and before we know it we are on the treadmill of life, bored, stuck in a rut and feeling there is no way out. The common factor in my clients was their lack of self-belief and self-confidence. Once their fluency goal had been achieved they did not then change their beliefs about themselves to become a fluent speaker. They ended up speaking fluently but waiting for all of it

have been a speech and language therapist for over 11 years spending much of that time working with people who stammer. I have been repeatedly frustrated that therapy techniques only work to a certain point - then something happens, fluency is lost and the stammer comes back with a vengeance. In therapy I spent a lot of time teaching adults and children techniques to modify their speaking. Easy onset, block modification and voluntary stammering all help to change a clients spoken behaviour. The theory is that, if you change your behaviour to become more fluent, then your self-confidence will also rise and fluency will be extended. In addition to these techniques I incorporated a Personal Construct approach, whereby the client was encouraged to view themselves in a different light. Kelly (1991) wrote, We take the stand that there are always some alternative constructions available to choose among in dealing with the world. No one needs to paint himself into a corner; no one needs to be completely hemmed in by circumstances. Similar approaches include Solution Focused Brief Therapy, Cognitive Behavioural Therapy and - perhaps more in vogue now - Neuro-Linguistic Programming (NLP). All these tools offer the client a different way of overcoming or managing difficulties. Readers of Speech & Language Therapy in Practice are familiar with Life Coach Jo Middlemiss and her excellent series Winning Ways. Jos articles give a great insight into Life Coaching and how it pays to keep an open mind, to be positive and to make changes if we are not happy. Jo
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

All my years of experience, supposed wisdom and knowledge count for nothing unless the client comes to their own conclusions.
Life Coaching helps people to identify negative beliefs and work on changing them to more positive behaviour patterns. Coaching is normally a conversation, or series of conversations, which helps to create personal growth

12

EXTENDED ROLE
Knowledge & Education Paradigm

Self Image:
No confidence, negative, frustrated, angry

Behaviour:
Avoid words, look away, not speak, block, blush, mumble...

Personal Belief Attitude Feeling

Self Talk:
You are pathetic, See cant even spell your own name
Figure 1 My interpretation of The Loop

Action Results
Figure 2 Format for change

to come crashing down - which inevitably it did. One of my personal goals has been to look at why this happens and to see if Life Coaching can provide the answers. Life Coaching supports people in identifying what they truly want to get out of life. People who stammer often say, I just want my stammer to go away, but they have not perhaps really imagined how this will impact on their life and the lives of others around them. How will it change them as a person? If they change, what impact will it have on friends and family? If they do not stammer, what will they be doing instead? What will that feel like? Look like?

Control
Visualisation is a powerful tool used in Life Coaching to imagine a different way of being. Pastor, author and teacher William Arthur Ward (1921-1994) said: If you can imagine it, you can achieve it. If you can dream it, you can become it. These empowering words suggest that we all have control over our lives. Once this new way of being can be visualised, in minute detail, the process of how to get from where you are now to where you want to be begins. According to Pieffer (2005), No matter where the origins of your problem habit lie, you will benefit from developing new resources. This is another great example of what Life Coaching can do. It can open up a new set of possibilities and options, a new way to look at a problem and a way to establish more productive ways to deal with it. Positive affirmations (self talk) is an excellent resource to develop as the impact can transform your whole life because Change your thoughts, and you change your destiny (Murphy, 1988). Peiffer says, what the mind can perceive, the mind can achieve (2005). The subconscious mind is the control centre of all our physical responses and of our emotional responses. If you have a problem that is emotion driven you need to access the subconscious level of your mind to bring about change. Logical thinking and logical solutions will not do the trick because the problem is not located in the rational level. In terms of people who stammer, working on fluent speech techniques alone will not help because quite often the problem has a much deeper emotional attachment. Strategies are needed which employ the subconscious level of the mind. Martin (2001) devised the idea of The Loop (figure 1) where, to make changes, you have to change each part of that loop not just one bit. In my speech and language therapy work I often focused on changing behavior (pro-

moting fluency), thus neglecting to change the internal chatter (self talk) and beliefs that go with the behaviour. When we consider change in any area of our lives there is an identified format to follow to ensure that it becomes longer lasting (figure 2). Knowledge & Education is all about looking at reality. How do other people speak? What do they do when they stumble over words? One hundred per cent fluency is perhaps not entirely realistic. Paradigm refers to making links with your own situation: How does this fit in with me? Changes in personal belief are essential as the person has to believe that they can become the kind of speaker they would like to be. When you change your beliefs then your attitude also changes, you become more positive, more confident, more willing to push out of your comfort zone. If our attitudes change then so do

Working on fluent speech techniques alone will not help. Strategies are needed which employ the subconscious level of the mind.
our feelings which results in a change in action and this in turn gives us the results we wanted. Such models are effective tools because they require the client to go right back to check that their own understanding is valid and correct before permanent changes can be made. Denise (43) has stammered since she was 7. Over the years she has managed to hide her dysfluency through a sophisticated method of avoidance to the point that no one knows she stammers. However the down side is that she can appear standoffish and withdrawn, two qualities which do not represent who she is. Denise described her main problem as being unable to say her name, especially when speaking on the telephone. So Denise tried some Life Coaching - with significant results: Knowledge & Education Denise worked out what actually happened when a phone call went right (10 out of 10 score). She could identify the features - shoulders relaxed, sit up straight, jaw and tongue relaxed - and she recognised she had the ability to do it.

Paradigm Denise did a mock call with me, which she executed perfectly for the first time ever and then asked, Can I really do this? She was able to see that things could be done in a different way; there was an alternative. If she could be that good with me, then she could with anyone. Personal Belief After multiple attempts ringing me, Denise was consistently able to achieve 10/10 and her belief started to change to I can do this. This is important because she started to see her success as something other than a fluke. Attitude Denise began to realise she could take control. Her performance was something she did, not something that just happened. Her attitude of Its just a fluke was being replaced by something more consistent; she was building up evidence to support her changing beliefs. Feeling How emotional was that session?! Denise broke down in tears when she realised this was within her grasp. She had never dared to believe it was possible. Action This prompted Denise to go out and test her theory. Although she may not have been 10/10 on every call she never went below her personal bench mark of 7/10. Increased action promoted increased belief that she could do this and do this well. Results Denise can now consistently call me up and say her name without getting stuck or worrying about it. She now knows that she can do it. These results are spilling over into her day to day life. She can do it. What was my role in this? Denise came up with all of the answers. I reflected back what she was saying, re-phrased with slightly different words which she then heard with new meaning. I didnt let her old beliefs undermine this new found evidence. I helped her to create a new understanding of her ability based on fact, not the negative beliefs which kept her locked in the past. Coaching conversations normally take place over the telephone. Speaking on the telephone can be very difficult for many people, including those who stammer. I have an underlying knowledge and education about stammering and over 11 years experience as a speech and language therapist conversing with people who stammer. From a clients perspective this possibly sets me apart and makes me more approachable than other Life Coaches.
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13

EXTENDED ROLE

Qualities
In the same vein most speech and language therapists have many of the qualities required of a Life Coach good listening, empathy, the ability to reflect. The difference in Life Coaching is that the client has all of the answers, not the therapist. The coach is merely the facilitator who helps the expert the client - come to their own conclusions. I believe that Life Coaching works, but what do my clients think? Here are two examples: I decided to try life coaching after reading Catherines advert in the British Stammering Association Newsletter. I was at a stage where I knew I needed to go back into speech therapy to get a grip on my negative thinking patterns. I didnt know what to expect, I wasnt nervous, just apprehensive about how this would differ from normal speech therapy. Catherine has a very precise way of helping you to break things down and view them in a different way; she also has exercises which guide you to look at yourself. I had a really positive experience with life coaching and it helped me to think differently. Since I began my life coaching I have been raving about it to everyone, I can only say, give it a go and you will understand why.

Life coaching has allowed me to free myself from my self defeating thoughts and helped me to grow in self-confidence through challenging myself to change how I viewed myself. I had very little self-belief and lacked confidence in my abilities. By challenging these through life coaching I have been able to acknowledge my own self worth. These changes have had a huge impact on my life as I now believe in myself and I am also much happier. Catherine Williamson is a Qualified Life Coach and Speech & Language Therapist, www.meettherealu.co.uk, e-mail catherine@meettherealu.co.uk. She offers the first session free to new clients, and is happy to help people who want to make positive changes in areas of their life including speaking, weight loss, relationships and personal growth.

Murphy, J. (2000) The Power of Your Subconscious Mind. London: Pocket Books. Pieffer, V. (2005) Banish Bad Habits Forever. London: Piatkus Books.

Resources
Noble-Manhattan Coaching see www.noble-manhattan.com The Vitality Show see www.thevitalityshow.co.uk

References
Kelly, G.A. (1991) The Psychology of Personal Constructs. Oxford: Routledge. Martin, C. (2001) The Life Coaching Handbook. Carmarthen: Crown House Publishing. Middlemiss, J. (2006) Grey(ish) power, Speech & Language Therapy in Practice Autumn, pp. 22-23.

REFLECTIONS DO I RECOGNISE WHEN A CLIENTS EMOTIONAL ATTACHMENT IS BLOCKING PROGRESS? DO I ENABLE CLIENTS TO COME TO THEIR OWN CONCLUSIONS ABOUT WHAT THEY NEED TO CHANGE? DO I MAKE THE MOST OF THE OPTION OF TELEPHONE CONTACT?

news extra

Speech in noise
The Royal National Institute for the Deaf has raised concerns that children with a developmental problem distinguishing speech in noise are not being detected or helped. Research had previously shown that some seven year olds cannot distinguish speech against background noise compared with adults but the new claim is based on the results of a self-selecting sample of over 2000 children aged 10-14. One in five of these young people had no problems with their ears as such but in a telephone hearing check were cognitively unable to distinguish speech sounds clearly in noisy environments. The government has introduced regulations relating to acoustic environments in new schools but the RNID is calling on all schools to ensure they have the best acoustic environment for children to hear properly to enable them to get the most benefit from their education. The charity says, The use of straightforward microphone and speaker systems or sound field systems could significantly address this problem in all schools and benefit teachers and pupils in all acoustic environments. The telephone hearing check can be taken by calling 0845 600 5555. RNID has tips for teachers on ways to communicate more clearly in the classroom, available on request. www.breakingthesoundbarrier.org.uk; www.rnid.org.uk

Post-16 provision assessed


A report into provision for 16-18 year olds with learning difficulties in post-16 settings in England has concluded that the better colleges have good links to specialist services such as speech and language therapy. One example highlighted is a speech and language therapist with an extended role as a pastoral teacher in personal, social and health education: This helped learners to develop an alignment of body language with speech in a range of teaching and learning activities other than in a therapeutic setting. (p.9) The report expresses serious concerns about the assessment process for such students, preparation for real-life work and support for transitions. However, the report is clear that all colleges surveyed made effective use of methods including supported communication systems to enable learners to express their views. Current provision and outcomes for 1618-year-old learners with learning difficulties and/ or disabilities in colleges. Ofsted January 2007 Ref HMI 2371 Crown copyright. www.ofsted. gov.uk

Walkie Talkie

In another practical move to promote good communication between parents and children, the Talk to Your Baby campaign is calling for manufacturers to make sociable buggies more widely available and affordable. The Walkie Talkie label is available from the National Literacy Trusts early language campaign for use by manufacturers and retailers. It can be used to promote buggies which have pusher-facing facilities. Speech and language therapist Professor James Law is supporting the campaign. He says, There is nothing sadder than watching parents pushing buggies, perhaps wearing headphones, completely cut off from their child. The buggy which faces towards the parent provides the parent with all sorts of opportunities for interaction, making the trip all the more enjoyable for both parties. www.talktoyourbaby.org.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

Parkinsons research

The Parkinsons Disease Society has decided to fund an assessment of what speech and language therapy services are provided specifically for people with Parkinsons. Dr Nick Miller at the University of Newcastle has been funded for 18 months to conduct a national survey of speech and language therapy provision for people with Parkinsons Disease, to include therapists practice, and perceptions of patients and carers. Nick says, We are hoping to start getting the questionnaires out in April/May, with links from the websites of the Royal College of Speech & Language Therapists and the Parkinsons Disease Society. These links should be open for several months. Respondents will be able to return the questionnaire over the web, by e-mail or as a hard copy. The commitment is part of the Societys biggest ever investment in research. www.parkinsons.org.uk

14

COVER STORY

What Kate Did at Work


I mean to do something grand. I dont know what yet; but when Im grown up I shall find out. (Katy Carr in What Katy Did) Kate Balzer and her team discover that recognising the need for staff training to improve the lives of people living in nursing homes is just the first step on a lengthy and challenging journey.

am one of five whole time equivalent speech and language therapists working with the over 16s in the community for Lambeth Primary Care Trust. My clients have acquired communication and / or swallowing difficulties and about half of them live in nursing homes. Out of 11 nursing homes in the borough of Lambeth, 8 are near my base, the Whittington Centre in Streatham. As Im so involved in nursing homes, I felt that improving the experience of people living in them through effective training of nurses and health care assistants was a major priority for our service. This view is shared locally, nationally and professionally. Locally, in 1997 we had a Challenge Fund Project Specialist On-going Nursing and Therapy Needs in the Private Sector Nursing Homes in Lambeth. This assessed the extent and nature of specialist community nursing, equipment and therapy input required in the private sector nursing homes in Lambeth, in accordance with the NHS Continuing Care Policy. Recommendations were made regarding the level of therapy needed and the potential training required by the nursing home staff. Areas of training need identified included swallowing and communication disorders. The report also made it clear that training has to be ongoing due to the level of staff turnover in homes. The Care Homes Support Team was established across Lambeth, Southwark and Lewisham in 2001 to assess and review the health care needs of residents in care homes and to develop the practice of staff. One way the Care Homes Support Team has progressed this is to collate and offer an annual brochure of training. Local care homes themselves have also identified training needs following piloting of the Essence of Care Food and Nutrition benchmark (DH, 2001). Staff development needs in care homes have also been highlighted at a national level:

Better Care, Higher Standards Charters (DH, 1999) guidance on the development of joint local charters for people who need long term care NSF for Older People (DH, 2001) - eight standards which aim to provide person-centred care, remove age discrimination, promote older peoples health and independence and to fit the services around peoples needs The development of the National Care Standards Commission (2002, arising from the Care Standards Act, 2000), an independent watchdog set up to regulate social care services and private and voluntary health care. Training in nursing homes has long been recognised by speech and language therapists as an area for development (Ramm, 1997) and various means of training have been described (for example Freedman & Booth, 2005). Communicating Quality 3 (RCSLT, 2006) advises that dysphagia referrals no longer require GP consent but rather can come from any member of the multidisciplinary team. It also suggests that professionals involved will usually have had some training in dysphagia identification from the SLTs (p.191). Our nursing homes in Lambeth seemed an ideal setting to trial and explore this model of working.

READ THIS IF YOU WANT TO IMPROVE COMMUNICATION ENVIRONMENTS CATER FOR DIFFERENT LEARNING STYLES MAKE A CASE FOR TEAM AWAY DAYS

Different approaches
Over the years we have tried different approaches to training staff in nursing homes. Firstly, following the Challenge Fund Project (1997), we developed a training package that was implemented in the then seven private sector nursing homes in Lambeth between August 2001 and August 2002. The package was fairly traditional in its classroom style presentation, but we did attempt to involve participants as much as possible. In total 54 staff attended the communication training and 52 attended the swallowing train-

ing. Just under a third of attendees at all sessions were trained Nurses, the others being mainly Health Care Assistants. Evaluation of this training package revealed that staff felt more confident in managing residents with swallow and communication disorders and that their knowledge increased. A difficulty arising from implementing this training package was the lack of input from the homes before and after training (for example failing to complete questionnaires) and low attendance, which in one case meant a session had to be cancelled. Next, we made adaptations to the package and repeated the programme of training between September 2004 September 2005 across all private sector nursing homes (at this point nine) and one NHS home. In total 110 staff attended the communication workshop and 109 attended the swallowing workshop. The different qualifications of staff members were also recorded and the ratio of Registered General Nurses to Health Care Assistants worsened at only one nurse to every assistant. While it is important to train the health care assistants, who will be seeing and feeding residents daily, it is equally important to train the qualified nurses who write care plans and give instructions. New evaluation questionnaires were completed immediately following
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

15

COVER STORY

Figure 1 Evaluation of Communication Workshop 2004 / 5


8 8 8 8.5 8.5 9

on Figure 4 Communication True / False Quiz Tick true or false for each of the following... TRUE FALSE You should pretend to understand if you dont Clients with end stage dementia dont initiate conversation A Speech and Language Therapist only sees clients in therapy centres People only communicate in order to share information You can communicate through posture Dysarthria symptoms always present in the same way A dysphasic client will have difficulty in articulation

Figure 5 Swallowing True / False Quiz Tick true or false for each of the following... TRUE FALSE Dysphagia isnt a disease itself but a symptom Getting enough food and drink is the only reason for safe swallowing Coughing can push food/drink away from the Airway Change in breathing pattern may indicate swallowing problems Soft foods are the first option for managing dysphagia You need thickener to make a thin drink Soft food needs pureeing GPs must sign a referral for a swallow assessment Pocketing of food in the cheeks is dangerous A client with frequent chest infections should be referred to a SLT Figure 7 Evaluation of Swallowing Quiz 2006

confidence - score out of 10 (self-rated) Identifying difficulties Dealing with difficulties Knowing when to refer Knowing where to go Methods and materials Usefulness Overall

Figure 2 Evaluation of Swallowing Workshop 2004 / 5


8.5 8 8 9 9 9.5

confidence - score out of 10 (self-rated) Identifying difficulties Dealing with difficulties Knowing when to refer Knowing where to go Methods and materials Usefulness Overall

When a client gets stuck in communication, you should offer suggestions When a client makes an error you should correct them Low mood can affect communication Figure 6 Evaluation of Communication Quiz 2006

Figure 3 Referrals from nursing home staff 2004 / 5


3.5 3 2.5 2 1.5 1 0.5 0
04 04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05 05 05 05 05 05 05 n b r r y n l g p t v c n b r r y n l g p t v c Ja Fe Ma Ap Ma Ju Ju Au Se Oc No De Ja Fe Ma Ap Ma Ju Ju Au Se Oc No De

9
9

introduction of training
7
question number

7
question number

5 3 1
0 after before 5 10 15 20 number of participants answering correctly 25

5 3 1
0 2 after before 4 6 8 10 12 number of participants answering correctly 14

the training and the results are in figures 1 (communication) and 2 (swallowing). Although the evaluation revealed confidence and satisfaction with the training no before / after comparison was recorded. A measure of knowledge gained had proved too lengthy during the previous training (2001/2) and did not measure carry over to practice so we didnt use it on this occasion. Furthermore, the difficulties of logistics and commitment were repeated - and dont appear to be confined to Lambeth (Freedman & Booth, 2005). The only measure we can draw on to tell if we made a difference is the number of referrals received from nursing home staff before and after training. Figure 3 shows an increase in referrals to one centre (the Whittington Centre) coinciding with the introduction of training sessions to nursing homes in that area in January 2005. This does however only show an increase in awareness rather than any positive changes in practice, and the appropriacy of the referrals isnt recorded. Recognising that we needed a more strategic approach, in August 2005 the speech and language therapy team met to discuss improvements and changes that they would like to see in nursing homes. This included:

staff knowing why were there appropriate and complete referrals an environment that supports communication enough time, support and care at mealtimes. We developed and prioritised possible ways to trigger these changes during further away day sessions. Practical ideas included: 1. recommending the use of pre-thickened drinks rather than simply giving consistency advice 2. introducing Dysphagia Information files to every nurses station 3. developing meal time charts to be put in every dining room explaining and reiterating individual client needs 4. providing staff with a flowchart to ensure that a speech and language therapy referral is the most appropriate course of action 5. setting up an internet page to publicise the speech and language therapy service and referrals procedure 6. using work with individual clients to demonstrate good practice to staff 7. offering classroom training specific to nurses (who might refer) and carers.

New methods
Through discussion we generally agreed that formal classroom based sessions would not suit everyone. Nor would they achieve the aims of training - to develop practice thereby improving the experience of residents in care homes. Kolbs experiential learning theory (1984) and Honey & Mumfords Learning Styles (1982) validate this view, and prompted us to think about new methods. For example a theoretical discussion may benefit some staff while practical experience and / or feedback from colleagues may reinforce knowledge in others. Concurrently, the development of the Care Homes Support Team provided new opportunities to develop training. Speech and language therapy training sessions can be advertised in the Care Homes Support Team training brochure. Attendees register through the Support Team, who then book the venue and arrange audiovisual equipment, handouts, certificates of attendance and analysis of evaluation. The individual Support Team nurses also provide an onsite resource able to follow up and feedback. All costs are met by the Care Homes Support Team. The speech and language therapists

16

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

COVER STORY

Figure 8 Referral considerations Should I refer to Speech & Language Therapy for a swallowing assessment? Before making a referral, consider: Is the person fed through a tube (eg. a PEG)? If yes, consult the Home Enteral Nutrition team* Is the problem due to loose or missing dentures (false teeth)? If yes, refer to the dentist* Is the client eating and/or drinking less? If yes, discuss with the GP and maybe refer to the dietitian * Does the client need equipment to help with eating and drinking? If yes, refer to Occupational Therapy * Does the client need to be better positioned to eat and drink? If yes, refer to Physiotherapy* or discuss with your manual handling advisor Is the only difficulty in swallowing tablets or medication? Discuss with the pharmacist* Has the person been seen by speech and language therapy before? If yes, look to see if there are already recommendations in place and if things have changed Is the client drowsy and unable to stay awake for 15 minutes? If yes refer to GP * if unsure of how to refer to local services. ask GP

Figure 9 September 2006 questionnaire Please complete this form after every visit to a nursing home during the month of September 2006. 1. Was the original referral appropriate? 2. Was the referral complete? 3. Were the staff expecting you when you arrived? 4. Do you feel that the staff knew the SLT role? (i.e. why you were there) 5. Do you feel that the staff knew their role? (eg. referring to dentist first, following care plan) 6. If youve visited before, have the staff acted on your advice? (re: consistencies, AAC charts etc.) 7. Were you able to speak to the relevant staff? 8. Does the environment support communication? (activities, 1:1 time, awareness, choices etc.) 9. Is there enough time, support and care at mealtimes? 10. Does there appear to be good communication between staff? (care planning etc.) 11. Are there any problems obtaining different consistencies for clients? 12. Have you had any communication referrals from this home in the last 3 months?
NB: By staff we include nurses, carers, managers, activity co-ordinators, kitchen staff etc.

YES

NO

N/A

Additional Comments (continue overleaf if necessary).....................................................................

who lead the sessions do so as part of their normal jobs and we hold courses at nursing homes, so our costs are mainly for stationery. In the eight months to date, several of these innovations have been piloted in Lambeth. Classroom sessions - similar to those held in previous years - have been offered centrally through the Care Homes Support Team Training Brochure (rather than in individual nursing homes). The consequent increase in the kudos of the workshops has resulted in a good response (21 and 13 staff have attended single communication and swallowing sessions respectively) and no sessions have had to be cancelled. A before-and-after evaluation in the form of a short quiz (figures 4 & 5) revealed an increase in knowledge in all areas (figures 6 & 7). This classroom training will continue in the forthcoming academic year although the package will be adapted to better suit the needs of Health Care Assistants who form the majority of participants (now three for every one Nurse). This training will focus more on practical problem solving - for example how to feed a client with dementia - rather than theory such as the stages of swallowing. Thanks to the involvement of neighbouring speech and language therapy teams, the training is also to be extended to nursing homes in boroughs of Southwark and Lewisham (also catered for by the Care Homes Support Team). In addition to this the Primary Care Trust employed a locum speech and language therapist to carry out a 6 month level of need project (ending in March 2006) at the largest local nursing home. This gave a unique opportunity to pilot specialised training for trained nurses and the use of a questionnaire to guide referrals (figure 8). The training involved more theory (stages of swallowing; possible reasons for a swallowing problem) and focused on screening before referring to speech and lan-

guage therapy. Pending publication of Communicating Quality 3 (RCSLT, 2006), the GP at this nursing home also allowed a blanket referral system enabling an opportunity to pilot referrals from trained nursing staff. Other non-classroom ideas were also piloted at this nursing home, including the introduction of pre-thickened drinks to improve compliance to dysphagia recommendations and the development of mealtime charts in dining rooms to communicate individual residents needs. Katy was too much in earnest now not to improve. Month by month she learned how to manage a little better, and a little better still. Matters went on more smoothly. (from What Katy Did) The August 2005 wish list of what speech and language therapists in Lambeth wanted to see change in nursing homes will ultimately provide a qualitative measure of our input. During the month of September 2006 therapists were to complete a short questionnaire (figure 9) each time they visited a nursing home. Over the following 6 months all our ideas were being rolled out to all eleven nursing homes in Lambeth. Repeating the questionnaire on all nursing home visits in March 2007, following implementation of all our ideas, should show improvement We will let you know how we get on. Kate Balzer is a Principal Speech and Language Therapist at the Whittington Centre, 11-13 Rutford Road, Streatham, London SW16 2DQ, tel. 020 8243 2500, e-mail kate.balzer@ lambethpct.nhs.uk.

Department of Health (2001) National Service Framework for Older People. Crown Copyright (available online at www.dh.gov.uk). Department of Health, Department of the Environment, Transport and the Regions (1999) Better Care, Higher Standards: A Charter for Long Term Care. Crown Copyright (available online at www.dh.gov.uk). Freedman, N. & Booth, K. (2005) Turn up and tune, Speech & Language Therapy in Practice, Autumn, pp. 20-22. Great Britain. Care Standards Act 2000: Elizabeth II. Chapter 14 (2000) London: The Stationery Office (available online at http://www.opsi.gov.uk/acts/acts2000/20000014.htm). Honey, P. & Mumford, A. (1982) Manual of Learning Styles. Peter Honey Publications. Kolb, D.A. (1984) Experiential Learning. Englewood Cliffs, NJ: Prentice Hall. Ramm, B. (1997) How well do we communicate with nursing and residential homes?, Bulletin of the Royal College of Speech & Language Therapists. June. RCSLT (2006) Communicating Quality 3: RCSLTs Guidance on Best Practice in Service Organisation and Provision. London: SLTP Royal College of Speech & Language Therapists.

References
Coolidge, S. (1872) What Katy Did. London: Puffin Classics. Department of Health (2001; 2003; 2006) Essence of Care: Patient-focused Benchmarks for Clinical Governance. Crown Copyright (available online at www.dh.gov.uk).

REFLECTIONS DO I SPECIFY THE CHANGE I WANT TO SEE AND COME UP WITH PRACTICAL IDEAS TO GET THERE? DO I USE LEGISLATION AND POLICY TO SUPPORT PROJECTS I AM MANAGING? DO I RECOGNISE THAT INCREASED AWARENESS FOLLOWING TRAINING IS NOT THE SAME AS A CHANGE IN PRACTICE?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

17

REVIEWS

reviews
AUTISM
Sensory Perceptual Issues in Autism and Asperger Syndrome. Olga Bogdashina Jessica Kingsley ISBN 1843101661 14.95
professionals as her family deal with autism 24/7. I went home wanting to start our school Autism Base again from scratch beginning by binning the fluorescent lights! Naomi Anne Hewerdine is a speech and language therapist in a special needs high school. conversation. Because Better Conversations is also written from personal experiences, it does not feel patronising. My only criticism would be that it is a little repetitive. Jenny McHattie lives in Banchory.

Real life examples


The beginning of the book is hard going as it is quite theoretical. Bogdashinas main idea is that many of the difficulties we look for to diagnose autism are symptoms of differences in sensory processing. For example, prosopagnosia (face blindness) would lead to problems understanding and using eye contact. Each section ends with a What to look for list of common behaviours with real life examples. The most useful part is a parental questionnaire. The results are plotted on to colour coded charts or Rainbows. This would be useful in a multidisciplinary team approach to autism spectrum disorder provision.

APHASIA
Caring and Coping A Guide for Relatives Connect (www.ukconnect.org) ISBN 0-95360424-1 7.50 + 1.50p&p

DYSFLUENCY
Stuttering Joseph Kalinowski & Tim Saltuklaroglu Plural Publishing ISBN 1-59756-011-1 27.50

To the point
I read this guide from a relatives point of view after my father suffered a stroke four months ago, resulting in him being unable to read or write. The information is laid out in simple and common sense terms. To use personal experiences is an excellent idea, which definitely made us feel that we were not alone and could relate to the practicalities of every day life. The guide is practical and to the point. It is informative about financial and emotional matters for the carer, giving you a list of options when in despair about these particular problems. Caring & Coping should be read by every relative of a person who has aphasiaand read out to the person who has aphasia!

Easy and enjoyable to read


The style of writing in this book was easy and enjoyable to read, being enriched with brief personal anecdotes both authors stutter. The overview of the traditionally used stuttering techniques gives some practical suggestions for clinic work. However, most of the book focuses on the research for the authors theories of stuttering, leading to the development of an effective in-the-ear auditory feedback device. Ideas are given on how to introduce this to a client and how to combine it with traditional behavioural methods to increase its effect. This takes up a relatively small part of the book and would be useful to therapists with clients using the new in-the-ear devices. At present these are few, though I would expect this to increase in the future. Kate Hamer is a speech and language therapist with Berkshire West Primary Care Trust.

are well explained and practical ways and case studies are discussed to show different qualitative methodologies. The book is split into three parts: Planning the research discusses the nature of qualitative research and strategic choices in research planning, and identifies seven key decisions for research planning. Doing the research looks at different methodologies including combining quantitative and qualitative approaches within a single case study, conversation analysis and new approaches such as interpretive phenomenological analysis. This is a step-by-step prescriptive procedure and features a structured set of stages for analysis. Presenting the research identifies four key points for presenting and helping the status and credibility of the research. The glossary is a great idea for people needing a refresher course in terminology of research. With a huge onus on evidence based practice and audits, this book will prove very useful to the everyday clinician, regardless of banding! Samera Mian is a speech and language therapist working for Trafford Primary Care Trust.

Communication Issues in Autism and Asperger Syndrome Olga Bogdashina Jessica Kingsley ISBN 1843102676 16.95

CPD
The Practice-Based Educator (A reflective tool for CPD and accreditation) Vinette Cross, Ann Moore, Jane Morris, Lynne Caladine, Ros Hilton & Helen Bristow Wiley ISBN 1-86156-422-8 24.99

Enlightening quotes
This book was easier to read than Sensory Perceptual Issues, and more pertinent to a speech and language therapist. It does refer back to the earlier book but you can get a lot from just this one. Bogdashina revises linguistic theories and normal child language development. The main discussion is that autistic people have a sensory language, whereas the rest of us have a linguistic one. She expands on how sensory perception difficulties affect learning. She reviews current popular interventions (PECS, signing, Lovaas). What they say paragraphs are enlightening quotes from autistic people, and illustrations by autistic people make it very readable. I was inspired to read these books after I attended a days training that Olga gave in Oldham. She is a very lively and engaging speaker. You could tell she really inspired people by the animated discussions at break times. Her use of real life examples had insights you dont get from other

Better Conversations A Guide for Relatives Connect ISBN 0-9536042-2-5 7.50 + 1.50p&p

Explained many things


Again, I read this from a relatives point of view. Like Caring & Coping it is very easy to read, with bullet points, which are good for a quick reference. The quick guide to ideas for conversation is particularly helpful. Conversation is natural, but when talking to someone with aphasia you have to think, plan and slow down your conversation, thus forward planning is almost necessary at times. Reading this also explained many things to me and my family - for example, the tiredness, and cutting out other distractions when focusing on a

An excellent addition
RESEARCH
Qualitative Research for Allied Health Professionals Challenging Choices Linda Finlay & Claire Ballinger Wiley ISBN 0-470-01963-8 24.99
For anyone whose role is to facilitate and develop a positive and good-quality learning environment, this book is great value for money and an excellent addition to your resource list. It relates directly to clinical educator accreditation schemes introduced by the College of Occupational Therapists and Chartered Society of Physiotherapists. The authors are not from a speech and language therapy background - but dont be put off. Information is broken up into bite size chunks and is easy to read. Each chapter is self-contained so you can dip into the topics that interest you most. The authors have adapted the text to appeal to different learning styles and included

Very useful to the everyday clinician


Much thought has evidently gone into making the book easy to follow and use. The challenging choices of research

18

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

REVIEWS

theory, practical application, activities and reflection. This is an excellent tool for newly qualified therapists to develop a sense of reflective learning and personal development from an early stage, and for the more experienced clinician to recognise and record their own professional development as a clinical educator. Equally useful whether you supervise newly qualified therapists, work with assistants or provide education to peers or colleagues. Alison Newton is a speech and language therapist with Heart of England NHS Foundation Trust.

rating charts from the original Talkabout book. Although the blurb indicates relevance to all groups this resource would probably not suit infant school aged or developmentally young people. That apart, I strongly recommend it for work with people with autistic spectrum conditions, learning disabilities, or emotional and behavioural difficulties. Its user-friendly style makes it accessible to speech and language therapists, teachers, assistants, parents, nurses, social workers and support or day care staff. Maria Featch is a specialist speech and language therapist.

section of this book particularly informative and relevant to my clinical area as I work with bilingual children daily. There is little published research in the field of the acquisition of Welsh phonology and this chapter of the book fills the current gap and provides food for thought for future research. Catrin Thomas is a paediatric speech and language therapist working in a language unit and mainstream schools for Conwy & Denbighshire NHS Trust.

visitors who raise any concerns about autism in the pre-school age group. Teri Boutwood is a specialist speech and language therapist working with school aged children with autistic spectrum disorders in Dorset.

INCLUSION
A World of Difference tackling inclusion in schools Rosemary Sage Network Educational Press Ltd ISBN 1 85539130 9 17.95

AUTISM
Somethings Not Right. the clues that

SOCIAL COMMUNICATION
Talkabout DVD: Social Communication Skills Alex Kelly Speechmark ISBN 0-86388-567-5 24.94 + VAT

BILINGUALISM
Phonological Development and Disorders in Children A Multilingual Perspective Zhu Hua and Barbara Dodd Multilingual Matters Ltd ISBN 1-85359-889-5 49.95

might mean autism DVD Kids First Merton Parents Forum Freely available for download on www.kids-first.org.uk

Useful to dip in and out of


For teachers, learning support assistants and allied health professionals alike this book provides a basic theoretical grounding in social, gender and learning differences as they present in an educational setting. The author provides an outline of the key skills that support the child in a learning environment. Information provided throughout the book on language / phonological and cognitive skills will be most useful for education staff but are at quite a basic level for speech and language therapists. The top tips given throughout each chapter provide some useful and practical ideas as do the case studies. While this is perhaps not a book to read in one sitting it will be a useful tool to dip in and out of for those wanting to challenge the traditional approach to education and inclusion. Siobhan Mawhirk is a specialist speech and language therapist with the Autism Service, 91 Cupar Street, North &West Belfast, BT13 2LJ.

Simple, clear and accessible


This short, parent-produced DVD will be a useful addition to any speech and language therapists resource cupboard. Accessible to many parents, this DVD provides clear, unambiguous information about the types of behaviour normally associated with the triad of impairment in autism. Parents from a range of backgrounds provide accounts of how difficulties may present in practice. The range of difficulties across the spectrum is discussed although the section on communication focuses predominantly on the more severe end. Some simple clear advice is also provided with guidance and reassurance of what parents should do if they are concerned. This would be an ideal resource to share or recommend to parents or health

A dream to use
At last! The excellent Talkabout series now includes this well-produced DVD of acted scenes demonstrating the skills introduced and taught via the series. The DVD is a dream to use and will breathe new life into social skills groups, particularly where having only one facilitator restricts role playing. It is packed with realistic scenes in which a diverse range of characters model social behavior - good and poor - in fairly plausible settings. An idiot-proof accompanying booklet describes each scene and proposes discussion points. It also covers assessment (p.3), suggesting use of the

Food for thought


This is a useful book for therapists working with bilingual children as well as those who are researching phonological acquisition or want to increase their knowledge in this area. It covers a range of languages including Arabic, Cantonese, Spanish, Maltese and Welsh and examines case studies and provides tables of phonemic inventory for the languages studied. Although the style of this book is formal, it is quite readable and the layout makes it easy to dip in and out of, particularly to access the information in the tables. I found the Welsh-English Bilingual

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

19

ADVERTISEMENT

CREATIVE SHORTS

was recently asked by I CAN to write an article for parents on the Talking Point website about communication disability and bullying. This task made me aware of how many opinions I already hold on the topic: bullying is more likely to happen to children with communication disability; bullying happens less often in special school. I was surprised to learn that there is actually very little evidence to back up these assumptions. I did discover some interesting research, however, suggesting that children in language units may fare worse than those in mainstream or special school (Knox & Conti-Ramsden, 2003). I decided to use my position as co-ordinator of speech and language services in one local authority to gather more information. I hoped this would be a pragmatic way of getting some more evidence to answer the questions I had, which would then inform liaison with education staff and priorities for therapy: 1. Do children with communication disability experience more bullying than typically developing children? 2. Does this vary according to school setting (mainstream, language unit or special school)? 3. Is age at school a factor? So far we have interviewed 96 children from Reception to Year 11 in mainstream, infant and junior language units and special schools. We have targeted children with communication disability from our caseload. Each target child was matched with a randomly selected typically developing child from the same form group. Consent was obtained at each location from the head teacher and was readily given as they were generally keen to discover how their anti-bullying strategies were working. The children who were interviewed were told that we wanted to discover how happy they were at school but that their names would not be recorded on the answer sheet. Every child was questioned using a questionnaire My life in school (Arora & Wolverhampton, 1992) about their experiences during the past week in school. This tool was chosen as it was used in a research study investigating bullying and specific language impairment (Knox & ContiRamsden, 2003). It measures the childs own report of how they interpreted an event, rather than attempting to gather objective data on incidences of bullying made known to school authorities. Such data is commonly thought to represent only the tip of the iceberg. There is a danger that self report by children may exaggerate the extent of the problem, however there is strength in investigating how children themselves perceive positive and negative events in school. The questions administered range from happy and positive experiences to those that would be unhappy and negative. Some of the unhappy experiences fit the definition of being bullied. The quiz is quick, taking around 5 minutes including training. The language of the questionnaire is simple and only requires a pointing response to one of three symbols (never / once / more than once). The child is first trained to understand how to answer about events during that week in school (How often did you have lunch this week? = Point to more than once). The test could not continue if children were unable to use concepts relating to time and frequency. This eliminated a few children in Reception. When Knox & Conti-Ramsden used this questionnaire they applied stiff criteria to score items that they consid-

Targeting bullying
ered bullying. We decided to include some more items that we felt were victimisation, such as got a gang onto me. But we only scored events that the child said had happened more than once that week. So far our results give us the following raw data: 1. Under the criteria we used for bullying, the children we interviewed with communication disability did experience more than typically developing children (more than double) see figure 1. 2. The children we interviewed with communication disability experienced most bullying events when in a language unit, but there was little difference between children with communication disability in mainstream and special school see figure 2. 3. We do not have sufficient data yet to draw conclusions about the effect of age; so far we suspect that our junior age children in language units are the most likely to be the victims of bullying. Figure 1 Bullying events related to communication disability
Average number of bullying events

Are children with communication disability targeted disproportionately by school bullies? Does school setting or age make a difference? How might this affect decisions on school placement and support? Catherine de la Bedoyere shares preliminary findings of a study in one local authority area.

There are many ways of looking at the results depending on what is scored as bullying. Narrow descriptors for bullying are tried to kick me or tried to hit me, whilst broad descriptors include called me names or got a gang on me. Broad and narrow descriptions of bullying both showed that the children with communication disability in our sample suffered more bullying than other children. We were only able to look at the older age range (10+) across two special schools as our therapists in these settings were unavailable until the end of term. Also we found it was very difficult to interview controls children without any communication disability - in special school. In the end we selected some children who had primarily physical difficulties or emotional difficulties. It just so happened that these children appeared to be the happiest we talked to! Our results provide clear evidence to support the view that children with communication disability are particuFigure 2 Bullying events related to location
Average number of bullying events

1.4 1.2 1 0.8 0.6 0.4 0.2 0


CD TDC CD = Children with Communication Disability (N = 58) TDC = Typically Developing Children (N = 38)

2 1.5 1 0.5 0
MS LU SS MS = Children with communication disability in mainstream schools LU = Children with communication disability in Language Units SS = Children with communication disability in Special Schools

20

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

CREATIVE SHORTS / READER OFFER

larly vulnerable to bullying in school, and that special consideration needs to be given to the pros and cons of a language unit placement for the childs overall benefit. In Kingston we have developed inclusion alternatives to language units that have produced good outcomes for the children, both in terms of impairment and social function. Where language unit placement is considered the best option for a child this research suggests that the head teacher has a particular need to enforce all anti-bullying strategies in the school to encourage positive attitudes to disability.

WIN SQUIRREL STORY NARRATIVE ASSESSMENT AND MR GOODGUESS!


Black Sheep Press continues its association with Speech & Language Therapy in Practice by offering two new assessments in a free prize draw.

Positive note
No-one wants any child to experience bullying. But being on the receiving end of a small number of unpleasant occurrences seems to the norm for all children, in whatever setting. On a more positive note our data shows us that: When we include all bullying events, even if they happened just once in the previous week, the average child with communication disability only experienced around three bullying events in a week; typically developing children experienced between two and three. Again when we include all bullying events (one or more in the week), a quarter of the children with communication disability did not experience any. If we apply only narrow descriptors for bullying, this rises to 66 per cent. It is worth remembering that having a communication disability does not, in itself, mean that a child will experience bullying. At no time did my team discover a child whose experiences gave them such concern that they felt it was necessary to take further action to help the child. These are the preliminary findings from just one local authority. We intend to gather more data before reaching firm conclusions and suggesting a practical response. I hope this article has captured your interest and inspired you to help us collect data; if so please contact me for details.

First up is Squirrel Story, a semi-formal narrative assessment to help you with therapy goals and curriculum planning for any child with language needs. It includes instructions and a stimulus booklet and the score sheets are photocopiable. Aimed at children from three to six years, Squirrel Story is not norm referenced although guideline scores are presented from a sample of 100 children. Designed to be administered quickly by therapists, teachers, early years workers and teaching assistants, the resource provides a profile of six key areas of narrative. Squirrel Story normally costs 35 but you have a chance to win one of TWO copies FREE. Simply e-mail your name and address with Squirrel Story offer in the subject line to alan@ blacksheeppress.co.uk. All entries must be received by 25th April. The winners will be notified by 1st May 2007.

References
Arora, T. & Wolverhampton, L. (1992) My Life in School Checklist, in Sharp, S. & Smith, P. (eds.) Tackling bullying in your school. London: Routledge. De La Bedoyere, C. (2006) Dealing with Bullies & Bullying, Talking Point [Online]. Available at: www.talkingpoint. org.uk (Accessed 4 January 2007). Knox E & Conti-Ramsden G (2003) Bullying risks of 11 year old children with specific language impairment: does school placement matter?, International Journal of Language & Communication Disorders 38(1), pp.1-12. SLTP

Mr Goodguess
Next we have Mr Goodguess, a pack of 65 worksheets to help children develop skills in drawing inferences. Five sections cover home, out and about, events, emotions and useful things, and include sheets for home practice. As the name suggests, the tasks involve discussing the illustrated scenarios and considering What Mr Goodguess thinks... Designer Catherine Redmayne suggests the resource is most appropriate for children with a language age between 41/2 and 6 years. Mr Goodguess is available in A4 card format or on a CD-Rom which is licensed for five computers on one site. To win one of TWO copies of the CD version FREE, e-mail your name and address with Mr Goodguess offer in the subject line to alan@blacksheeppress. co.uk by 25th April. The winners will be notified by 1st May 2007. The full range of Black Sheep Press resources is at www.blacksheep-epress.com.

Catherine de la Bedoyere is co-ordinator of speech and language services for East Sussex County Council, e-mail Catherine_ de_la_bedoyere@ hotmail.com.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

Reader offers
21

Squirrel Story

WINNING WAYS

s I sit down to write this article my ears are alerted to the radio quietly murmuring in the background. Radio 4 is running a series called Books to change your life by. Bel Mooney is introducing 15 minute segments of some of the most famous so-called self-help books. On Monday it was How to Win Friends and Influence People. The authors point seemed to be that if we show genuine interest in others then others will warm to us. On Tuesday the chosen book was Zen and the Art of Motorcycle Maintenance. This was a book that one of my sons tried to get me to read years ago - but two pages in left me cold with disinterest. Hearing a section of it made me see that I had missed a very important read, for this author had seen a system in motor bikes and their engines and journeys that I would never have dreamed of. However, I have recently discovered that Zen thinking is hugely useful for getting this world of ours into perspective. The Wednesday extract was from Dorothy Rowes The Successful Self. To my delight, she was discussing the very topic of this article. She maintains that suffering comes from three places: the planet, our body and our refusal to understand ourselves. Alone, our ability to influence the planet is pretty minimal, although together we can do much. The other two sources of suffering are inextricably linked - but our refusal to understand ourselves is the relevant one for this article.

Are you being served?


While decisions and choices made long ago can serve us well through life, they can also keep us stuck in a rut. Life coach Jo Middlemiss encourages us to start 2007 with a greater degree of awareness so we can move on from decisions that are no longer of benefit.
READ THIS IF YOU NEVER / ALWAYS / DONT NEED TO UNDERSTAND YOURSELF BETTER WANT TO CHANGE, GROW AND LIVE
with What look, Miss? which caused even more annoyance. Consequently my school life was not a great experience, but during my teaching days I could always recognise that look on the faces of my own pupils! For years I never thought to challenge my decision - and perhaps my teacher would be surprised at the effect of her sudden burst of anger. My teachers would also be surprised to know that my lifes work now is about helping people to understand, deal with and release emotions rather than suppress, repress and bury them. A relative by marriage was badly beaten by older boys at his boarding school. He sobbed in a cold toilet cubicle for hours because he didnt want to be seen by his peers or by the bullies, but on that night a huge part of his emotional life was shut down. The next time he dropped a tear was at the death of an aged Labrador. He is a very senior person now, but the decision to bury tough emotional reactions turns up in his shoulders and in sleeplessness. So in this first article of the New Year I would like to encourage readers to review decisions made once but which no longer serve. You will recognise these decisions in yourself and others when you hear, I never; I always; I dont; In our family thats not the way we do things and so on and so on. Although we make some valuable decisions which serve us through life, for the most part we can stay stuck in unhelpful positions simply from a failure to look at decisions with some degree of awareness. Only last week I attended the funeral of an old friend. Another friend, who was even closer to them, chose not to come because she never goes to fu-

nerals. That of course is her prerogative, but it is also a family tradition: The women of our family dont go to funerals. She missed so much from that decision. The funeral was uplifting and joyous and enormously supportive to the bereaved family. To challenge old decisions, one has to be prepared to embrace change. Much has been written about change but two quotes encompass my view very well. I believe it was Winston Churchill who said something like, Take change by the hand or it will take you by the throat. Another favourite is credited to Gail Sheeley: If we dont change we dont grow. If we dont grow, were not really living.

I believe
As we start this year it is a good idea to review the past year and make note of all the things that worked well for us. All the things we are grateful for and all the things we could have improved on had we the luxury of that very fine science - hindsight. Then make a What I believe about list. Here are some ideas to help you: Women Men Young people Work Relationships Money Friends My body Myself Commitment Life Death. As the answers you give are completely private there is no option but to be honest. When you have finished, put an asterisk beside the beliefs that uphold and support you and circle the ones that cause negative thoughts in your head. Where do these beliefs come from and are you being served by continuing to live by them? Could they be a result of conditioning from a long time ago? I have a client who believes that Women cant be trusted. He holds this belief because he perceives that he was let down by both his mother and his ex-wife. Now this man professes to want to be in a stable and loving relationship and also to work with women, yet his underlying philosophy about women is that they cannot be trusted. The result? - Internal conflict on a grand scale. Looking at and challenging that belief became our task. We did a search for women that he did in fact trust. (I was glad to be included in his list but there were several others.) So the belief was recognised as a very unhelpful sweeping generalisation. We then set about changing the nature of that belief. Firstly he had to learn to trust himself and his own instincts. Secondly he had to be completely trustworthy himself, recognising that most people are capable of

Survival decisions
At a very early stage in our lives we make survival decisions and we begin to design our model of the world. Tiny children learn that, to be looked after, they need to be good. This conditioning is reinforced endlessly by well-meaning and malevolent adults alike. I once heard my very loving and generous husband saying to our toddler, Big boys of two and a half dont cry! Really! But that very little boy of two and a half learned that day that crying somehow wasnt manly. My big husband of fifty eight has since learned the value of crying.

For years I never thought to challenge my decision - and perhaps my teacher would be surprised at the effect of her sudden burst of anger.
When I was five, I too made a crying decision. One day during my first year at school I was picked up and spanked for playing with a big blob of paint on a cleaned surface. I shook for the rest of the day with humiliation and shock, but can remember to this moment my decision that I would never cry in school. And I never did. This resolution did not work for me because I acquired a look that irritated teachers beyond knowing. I was frequently told to wipe that look off your face and I would always respond

22

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

WINNING WAYS

resources
AAC
Phrase Maker is an AAC device where users can select pre-recorded words and / or phrases to create their own sentences. It includes a single switch mode and costs $429.95. www.enablingdevices.com

Language Games
A Plymouth Sure Start team has released a CD of resources. Language Games includes original artwork for the user to make games to promote young childrens communication skills in a variety of settings. The material includes lotto boards, Funny Faces and Washing Line. Prices are from 47, with discounts for orders of more than 5. Details: Wendy Myers (Receptionist), LARK Childrens Centre, tel. 01752 313293.

RCP leaets
double-dealing in certain circumstances. Finally he had to put his mind to attracting trustworthy women rather than repelling them with his own lack of trust. His new belief became: I trust myself to recognise the many trustworthy women that I meet. As you listen to other peoples conversations this week, notice the level of sweeping generalisations that go overlooked in everyday speech: All politicians are liars; Men dont show their emotions; Young people today; Muslims; Catholics...; Americans... etcetera, etcetera. It all adds up to a mesh of subtle prejudice which may have a base in real incidents but is multiplied by myth. The Royal College of Psychiatrists has produced leaflets on obsessive compulsive disorder and self-harm. www.rcpsych.ac.uk

Fixing the NHS


The BBC and the Open University are supporting the 3-programme television series Can Gerry Robinson Fix the NHS? with a website. www.open2.net/nhs

Transitions
The Fragile X Society Winter 2006 newsletter includes several articles relating to transitions, including holidays from residential placements, death in the family and supported living. Tel. 01371 875100

Parkinsons Awareness
Parkinsons Awareness Week runs from 16-22 April 2007. The Parkinsons Disease Society will be launching a DVD aimed at all newly diagnosed people. www.parkinsons.org.uk

Deafness story
Moonbird is a story book for 4-8 year olds by Joyce Dunbar, whose son, like herself, went deaf at the age of 5. A synopsis (www.amazon.co.uk) says, A Moonchild blows a bubble that pops on an Earth baby and surrounds him in silence. He cannot hear or speak. His parents, a King and Queen, are devastated when they realize but a Moonbird teaches the little prince how to use his hands and eyes to communicate. (Source: oneinseven (RNID))

Put an asterisk beside the beliefs that uphold and support you and circle the ones that cause negative thoughts in your head.
We cant challenge it nationally or internationally until we challenge it individually. So that is how I intend to launch 2007. Dont let old decisions and resolutions blight your happy tomorrows. As Mahatma Ghandi almost said, We must be the change we want to see. References Carnegie, D. (2007) How to Win Friends and Influence People. London: Vermilion. Mooney, B. (2007) Books to Change Your Life By. Radio 4, Monday 1 Friday 5 January. Pirsig, R.M. (1999) Zen and the Art of Motorcycle Maintenance. London: Vintage. Rowe, D. (1996) The Successful Self. London: HarperCollins. SLTP

Changing Places
The Changing Places Consortium website includes a map showing the locations of Changing Places public toilets. These have enough space for disabled people and their carers and the right equipment. Six Changing Places toilets won certification in the 2006 Loo of the Year Awards. www.changing-places.org; www.loo.co.uk

Signalong on CD
Signalong is phasing out photocopiable resources in favour of CDs and is planning to make publications available for purchase online. Other new resources include Babys First Words, Going to School, On the Slopes and We Have Feelings Too. www.signalong.org.uk

Global contact
Contact a Familys web service to ease contact between parents of children with rare conditions across the globe is now available to speakers of languages other than English. The site itself has also been translated into Arabic, Farsi, Simplified Chinese and Somali, to cater for the majority of new entrants to the UK. www.makingcontact.org

Medical translation
Doctor Babel offers translation of a simple medical record into other languages, for people to take with them when they travel abroad (20). The website includes a printable leaflet for professionals to give to clients and a free translatable dialogue for use by medical professionals. (Source: The Encephalitis Society) www.doctorbabel.com/downloads/patient-flier.pdf

Head and neck guidelines


The Scottish Intercollegiate Guidelines Network has published clinical guidelines on diagnosis and management of head and neck cancer. Emer Scanlon was the speech and language therapy representative on the group. www.sign.ac.uk/pdf/sign90.pdf

Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www. dreamzwork. co.uk. Jo offers readers a complimentary half-hour telephone coaching session (for the cost only of your call). You may want to phone Jo if you are going through a major change (such as coping with being a student, starting a first job, promotion or returning to work after a career break), or if you find yourself in circumstances which make it difficult for you to do your job in the way you want to. While all Jos work informs Winning Ways, your contact is confidential, and no personal or identifying details will be given.

Screening test
GAPS (Grammar and Phonology Screening) is a new 10 minute test for 31/2 - 61/2 year olds designed to be used by a variety of professionals and parents. Researcher Professor Heather van der Lely is confident that the test will pick up many cases of language problems that would otherwise be missed by teachers, parents and clinicians. It may also identify the true extent of language impairment in children. www.dldcn.com

Home software
Topologika Software is offering a buy three, get the cheapest free promotion on its home editions. www.topologika.com

Boardmaker 6
Boardmaker V6 is now available from Don Johnston, with special prices until 30th April. www.donjohnston.co.uk

Reading scheme
POPS (Plenty of Potential) resources started two years ago when the mother of a child with additional support needs got frustrated with the limitations of his reading scheme. (Source: Afasic News) www.pops-resources.com

New avours
SLO pre-thickened drinks now come in a peach version (available on prescription) and a Cadburys Hot Chocolate. The manufacturers have also produced an information leaflet which can be included in a patients notes on discharge. www.slodrinks.com

Disability training
Scope has developed an interactive training toolkit for Disability Equality Training to enable people in organisations of any size to gain an effective understanding quickly. www.scope.org.uk/work/det/
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

CPD
The Health Professions Council has sample continuing professional development profiles on its website. www.hpc-uk.org/registrants/cpd/sampleprofiles

23

HOW I

HOW I PROVIDE SOCIAL CO


READ THIS IF YOU WANT PRACTICAL IDEAS FOR GROUP WORK STUDENTS TO LEARN BY DOING TO FACILITATE TRANSITIONS

CHILDREN AND YOUNG PEOPLE WITH HIGH LEVEL AUTISM AND ASPERGERS SYNDROME ARE CHALLENGED BY SITUATIONS DEMANDING SOCIAL COMMUNICATION SKILLS. EVEN WHEN THEY ARE PERFECTLY ABLE TO CARRY OUT TASKS ASSOCIATED WITH SCHOOL, LEISURE ACTIVITIES AND THE WORKPLACE, THEY CAN FACE SERIOUS PROBLEMS COPING WITH ASPECTS INVOLVING INTERACTION WITH OTHER PEOPLE. THIS CAN LEAD TO OR EXACERBATE SOCIAL EXCLUSION AND MENTAL HEALTH ISSUES. OUR TWO CONTRIBUTIONS FOCUS ON THE VERY SPECIFIC ROLE A SPEECH AND LANGUAGE THERAPIST CAN PLAY IN HELPING CHILDREN AND YOUNG PEOPLE WITH ASPERGERS SYNDROME UNDERSTAND THEMSELVES AND OTHERS THROUGH BRINGING TOGETHER THE RIGHT PEOPLE AT THE RIGHT TIME IN THE RIGHT WAY. SOCIAL COMMUNICATION GROUPS (1) STRUCTURE, STRENGTHS AND STRATEGIES SOCIAL COMMUNICATION GROUPS (2) A WICKED COURSE

Structure, strengths and strategies


JANE BAKER EXPLAINS HOW THE MANTRA STRUCTURE, STRENGTHS, STRATEGIES INFLUENCES THE CONTENT AND FORMAT OF SOCIAL COMMUNICATION GROUPS FOR CHILDREN FROM 31/2 YEARS TO ADULTHOOD IN SOUTH DEVON. TOGETHER WITH GILL ROGERS, SHE ALSO SHARES RESOURCE IDEAS.
In Baker (2005) I discussed the 4 us Model of the South Devon Aspergers Group. This includes four components: a support group for parents, a youth group, a sibling group and social communication groups. Preparing children with Aspergers Syndrome for a social life requires us to use structure, build on strengths and develop strategies. I therefore thought it would be useful to discuss the social communication groups in more detail. There are four different age groups running at any time. The Own Agenda group is for children from 31/2-5 years. We have two Social Communication Skills groups for primary school aged children (5-8 years and 9-11+ years) and one for secondary school aged children (11+ -19 years). games, to begin to tolerate other childrens agendas, and ultimately to begin to remember another childs preferences. We play games such as:
Name game Each child chooses another child they want to roll the ball to. They have to look at that child, say their name, then roll the ball to them. The receiving child then gets the next turn. The therapist assists by giving forced alternatives and reminders if necessary. Change can be introduced by using different balls or soft toys, or even an invisible ball. Collecting game Using cards with different sets of pictures (like snap cards), each child chooses one or two to be the ones they collect. All children lay their chosen cards faceup so the others can see them. The children take it in turns to pick a card from the remaining pile, then identify the collector by name and give the card to them. The recipient thanks the giver by name.

HOW I (1):

1) OWN AGENDA GROUP


The Own Agenda Group is designed for children suspected of having higher functioning autism / Aspergers Syndrome. It includes pre-schoolers presenting as own agenda children but not necessarily having an autistic spectrum diagnosis. This group runs for half an hour weekly at Kingsteignton Medical Practice with a maximum of six children. Parents are encouraged to chat and exchange information in the waiting room, and are given photocopied sheets of group games to play at home. Here are two abridged examples:
Bricks game Take turns piling up bricks until they fall over. Use phrases like my turn; your turn; daddys turn. Once your child is tolerating the involvement of others in the game, you can ask, Whose turn now? Whats in the pillow case? Put lots of different toys / unusual items in a pillow case. Take turns to take an object out use suspense and make it exciting (no peeking!) Encourage your child to notice everyones turn. When the object comes out, model appreciative noises (wow!; thats interesting!) Talk about whose turn next? and the process of passing on the bag, offer praise (good passing!) and work to keep their interest up.

We keep a simple rating scale (1 = poor / 2 = variable / 3 = good) for willingness to participate, eye contact, turn taking, response to / interest in others and listening. One of the most useful outcomes is the friendships that develop between parents and the children, who often meet up independently and continue to support each other.

SOCIAL COMMUNICATION GROUPS - PRIMARY


We run two groups for primary school age children as part of the South Devon Aspergers Group Asperations. Both have a similar structure and a maximum of eight children. Gill Rogers runs the 5-8 year old group while I take the 9-11+. Each member of the group has a credit card sized membership card with the rules of the group in symbol form on both sides (figure 1). These are: Be part of the group Take your turn to talk, share turns Listen to others Ask questions Be kind to others Learn to change your attitude No interrupting No violence No shouting No swearing or name-calling Dont be boring Keep to your own space.

The group aims are to switch the children on to each other, to notice each other, to share turns with each other, to listen to requests from each other and respond appropriately, to be part of the group and play the group

24

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

HOW I

OMMUNICATION GROUPS
In addition to having their own membership card, the rules are reinforced visually by the therapist showing the relevant rule card (for example, change your attitude) as a reminder. We have a zero-tolerance policy towards violence to keep everyone feeling safe. We have a system of yellow cards. If a child hits / hurts another child they are given a yellow card and have to leave immediately with their parent / carer. They are banned for one meeting. They have two chances; if they are given three yellow cards during their membership they are asked to leave permanently. This permanent exclusion has never had to be enforced. While both groups run to a similar structure, the similarities and differences are explained in more detail below.

Figure 1 Membership card

2) 5-8 YEARS
Gill Rogers says: For this age group the focus is to introduce each concept through games. I find the games in figure 2 particularly useful. As many of the concepts are abstract, they are introduced at a concrete level and then graduated to the abstract level. For example, news is introduced by playing a game saying whether an item is old or new (concrete) and then getting them to identify what is old or new information about themselves (abstract) that the group doesnt already know. This of course leads to a lot of discussion and is core to the difficulties they are encountering due to theory of mind. It is also reinforced through the debate as to whether someone has asked a relevant question - thumbs up - or an irrelevant question - thumbs down - to maintain a topic or build friendship skills. Similarly, feelings are introduced starting with what the child likes; either food or what they like playing with (concrete). Then a drawing is made of what they look like when they are playing with that item and then the language to describe how they are feeling at that time is taught (abstract). The focus on playing games is core in order to create and explore the dynamics of interaction as it happens, in much the same way as conversational analysis. It has the effect of pacing the interaction so we can isolate breakdowns in communication and work on them. A games environment is extremely difficult for this population as it highlights the same difficulties they are experiencing in social interaction and society. Each game has its own set of rules, just like each social situation. These have to be learnt and adhered to for success, but many are not explicit and are context specific. Many of the children do not want to play games due to previous failure and lack of understanding of what went wrong. For example, they may understand the object of a game is to come first and, if this doesnt happen, perceive they have failed. Giving them confidence just to participate by talking through all these issues is vital - in particular, How to lose gracefully, even though you may be angry! I

Figure 2 Games for 5-8 years group GAME MANUFACTURER News UNO Blink Murder Pass the Gesture Fruit Salad (animals) The Socially Speaking Game Whose Voice? LDA (Alison Shroeder) Mattel

SKILLS As 9-11+ group Change, game play, consequences Looking Turn-taking, looking, being part of a group Listening, turn-taking, looking Variety of social skills

Social communication skills pack, Listening awareness Fowler & Baber (2002), East Kent Coastal Teaching Primary Care Trust Awareness of self and others Early Learning Centre Team building working towards balancing all the monkeys as a team Identifying significant information, asking questions, extension MB Games LDA cards Awareness of facial features and differences Problem-solving Using question forms Self-esteem When, how, how much and where Indicating levels of anger, happiness etc. I am happy when I am good at Self-esteem MB Games The Puppet Company Turn-taking, team play, winning and losing Emotions the child selects appropriate response to a situation Looking, listening, team play Tomy Turn-taking, anticipation, winning and losing Sharing experiences, strategies to try

Drawing selves and partner Monkey Business 20 questions Guess Who? What Would You Do? Question dice Giving and receiving compliments Commenting Making visual graded chart Sentence completion Jenga Feelings glove (Emotions faces on each fingers) Pass the Ball Pop Up Pirate Problem-solving as a group Discussing what is teasing, bullying, name-calling Describing an object, identifying its main features Self-assessment What is a friendship? Change Tokens Why? Because Jane Baker (Unpublished) LDA cards

What do others need to know? (function, shape, size, where would you use it?) Insight

Motivating children to make changes and understand change Picking out relevant information to predict

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HOW I

have recently introduced complimenting the winner verbally or shaking hands so they can focus on an appropriate action response rather than reacting to their own feelings. And of course games are what children play. They enable friendships to develop through a common focus (Attwood, 2003).

3) 9-11+ YEARS
Before the group begins, each child is given a job or target. This is a specific skill that needs practising by that particular child as ascertained by the child themselves, the therapist and sometimes by a consensus of the group members. This gives valuable feedback and can include a functional skill (giving & receiving crticism; assertiveness), conversation skills (repair strategies; ending), awareness skills (self awareness; group awareness) or non-verbal communication (proximity; facial expression). The job / target is written / symbol drawn on a highly coloured post-it note along with the childs name. Points are awarded throughout the session when the child shows evidence for that target behaviour. Targets are used in both the primary aged groups, but these older children are encouraged to choose their own target.

I present the problem to the children and ask them to give me their ideas on how to solve it. I then feed back the results at the next meeting.
Typically the group runs for an hour (the younger group is slightly shorter). We start with news. This is information sharing with the other members who are expected to listen in order to ask a relevant question about that childs news. We explain why this is an important skill to learn for making friends. In telling news, children are learning that the experiences of their lives are not necessarily already known about or understood by others, and that they need to take time to explain (theory of mind). They need to learn the amount of detail to tell; not too much or it may prove to be boring to the others, but not too little either. They need to learn that news is new information, or extra information on previously given topics. They also need to learn what topics might interest the others. They then get to choose who will ask them a question (remembering who has already asked a question and who still needs to ask). This means paying attention to the other members in the group and trying to remember their names. If they have forgotten someones name, they learn how to ask them politely. They need to listen to the chosen persons question and reply relevantly to them. They need to learn to respond without annoyance if the person hasnt quite understood them, and how to clarify, or correct misunderstandings. In this older group we have a target called extension to try and continue the conversation for as long as possible. This might include giving anecdotes or compliments.

Everyone has to ask a relevant question. (If one member is finding this difficult we encourage others to help them out by suggesting questions they might like to ask.) The news giver chooses someone who hasnt yet told their news. Again, this encourages attention to the other members. News telling can take up at least half the time available - and be a lively forum for discussion and debate. After news, we spend time on a particular skill, such as compliments, and role-play its use. Sometimes we have a problem-solving exercise. I bring a real problem I have at home (usually to do with my cat!) I present the problem to the children and ask them to give me their ideas on how to solve it. I then feed back the results at the next meeting. I encourage the children to bring their own problems to the group and get suggestions from themselves and the others on different ways to solve them. This often leads the children to ask if they can have a job / target outside of the group in their home or school lives, and ask their parent to give them points for achieving it (for example, stop beating up my younger brother). They go armed with suggestions and solutions. This helps generalise what they have learnt in the group to their everyday lives. Often we work with strength cards, an exercise designed to help children see and appreciate the strengths they do have. Encouraging good self-esteem is a major target for us. We finish with a game of some sort. This could be UNO, which is a great favourite. Not only is it a good turn-sharing game, but the order of play can change at any moment so everyone has to pay attention to everyone elses turn to play the game. UNO is also a great way of teaching children to change their attitude when they get fed up / disappointed / angry, and also a good way of pointing out cool behaviour. The children learn so much from each other. We also like the hat game. Each group member gets 5 chocolate buttons but is not allowed to eat them until the end of the game. They take turns to speak, perhaps to a topic. The person wearing the hat is the only one allowed to speak. If anyone else speaks or makes silly noises they have to give a chocolate button to the speaker who can eat or save it. (Parents can model losing a button!) This game teaches children to hold on to what they want to say until it is their turn, and also the pleasure of being listened to without interruption. Parents can extend this into everyday life; if the child interrupts while they are on the phone, they can say the phone has the hat. Or, if they have two children vying for attention, they can point to one and say hat. An excellent board game is Friendship Island (Incentive Plus) where the children have to answer questions on friendship skills and are rewarded for recognising useful strategies for making friends. We also give tokens for politeness, passing the dice and saying thank you. Other useful board games are Socially Speaking (LDA) and Say and Do Positive Pragmatic Gameboards (Gill & De Ninno, available from Taskmaster).

expectation that everyone contributes and everyone tells their news for the week. We usually expand the discussion from whatever is brought up. If bullying or any problem is an issue, we discuss it and investigate it with a solution focused approach. We always have felttips and plain paper handy for doodling as this seems to help loosen up the conversation. The young people who attend the Asperations 11+ group do not have to come to the Social Communication group; it is entirely voluntary. If they prefer to play pool with another young person that is entirely appropriate and fulfilling our purpose. However, if they do choose to come to the group, they are expected to stay for the hour. One of the main purposes of this group is to provide the young people with a regular meeting where they are accepted, a place where they feel safe enough to explore all those teenage concerns (Who am I? Why am I like I am? How am I different? Is it OK to be different? Why cant I make friends? How can I get a girl/boy friend?) as well as learning social communication skills. The group is a place where its OK to make mistakes and where the participants get very straightforward feedback on solutions from their peers.

We always have felttips and plain paper handy for doodling as this seems to help loosen up the conversation.
Parents have recently asked for an anger management course for both parents and children, which we have started on alternate weeks. The 11+ group is extended in the holidays by the Holiday Play scheme run by our Play Worker. This includes trips to the cinema, swimming pool, zoo and other attractions, as well as themed events in the Youth Club. We also have parties and celebrations to mark key anniversaries. The children are all sent birthday cards from the group. One of the parents takes responsibility for sending them out (with permission from the childs parent / carer). Gill and I run training workshops for people wanting to set up Social Communication Groups in their setting based on the East Kent Social Communication Workbook, and using the Training CD ROM kindly permitted by Fiona Fowler and Caroline Baber. Do get in touch if you would be interested in finding out more. Jane Baker (e-mail jane.baker@nhs.net) and Gill Rogers are speech and language therapists with South Devon Healthcare Trust.

References
4) SOCIAL COMMUNICATION SKILLS 11 + GROUP
The 11+ group is much less structured, and follows more the lines of a conversation based very loosely on the Attwood, T. (2003) Aspergers Syndrome. [DVD] London: Jessica Kingsley. Baker, J. (2005) Asperations 4 U, Speech & Language Therapy in Practice Winter, pp. 27-28.

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HOW I

A WICKED course
I work at Ruskin Mill College, where there are nearly 100 students from 16-22 years. Almost all have a diagnosis on the autism spectrum, mainly Aspergers Syndrome. The students spend 3-4 years at the college. It offers a variety of land-based, craft and art skills and is founded on Anthroposophical (Steiner) principles, especially the ethos of learning by doing. I see all students for an initial assessment when they attend a trial 3-day period at the college in the year before they intend to take up a place. I write a report, adding the proposed speech and language therapy care plan and indications for tutors and houseparents. This covers communication-based information and strategies they will need to help the student make the most of their time. Students receive therapy in various ways: one-to-one Social Use of Language Programme and discussion groups (role-play and discussion are good ways to put into practice the ethos of learning through doing) monitoring while in craft sessions advice to staff. Usually a combination of approaches takes place over the 3-4 years. By the time the students complete their years at Ruskin Mill they have acquired many useful and rare craft, land and art skills that they can be proud of, as well as furthering their basic skills in literacy and numeracy. Generally they have also received some Careers Guidance, as well as speech and language and other therapies. The students have usually begun to pull all the threads of this therapeutic education together to form a picture of themselves as people who would be an asset to a workforce and who deserve to have fulfilled lives in terms of social interactions and relationships. However, I have found there is often a need for one last opportunity to refresh some social and relationship skills. In addition, I was aware these students would also benefit from further careers guidance, especially in connection with interview techniques. Carol Webber is the college Careers tutor. She aims to set targets for each college leaver, arranges work experience and helps them with the design of their curriculum vitae (CV), application forms and job searches. She also talks about appropriateness of dress for interviews.

HOW I (2):

YOUNG PEOPLE WITH ASPERGERS SYNDROME NEED PARTICULAR SUPPORT TO COPE WITH JOB SEEKING AND THE WORKPLACE. ALISON ROBERTS DESCRIBES THE PILOT OF A COLLABORATIVE APPROACH CALLED WICKED (WORKPLACE INTERACTIONS AND COMMUNICATION KEYSKILLS FOR EVERYDAY, AND FOR DATING).
We decided to pilot a course called WICKED (Workplace Interactions and Communication Keyskills for Everyday, and for Dating) with two groups of leavers. My role was to design and coordinate the course, and I had help throughout from my great assistant Julia. We had five members of staff, enough to manage any difficulties encountered as the courses were taking place off-site, but not so many that students would be inhibited. Carol offered to provide two sessions regarding job searching and we were very lucky that two retired careers guidance staff, Norma Kay and Mandy Garstang, were able to join us. Norma maintains a link with the careers guidance course at the University of the West of England where she lectured, and Mandy is also a magistrate. They have a great deal of experience in working with young people and could carry out the mock interviews and generally offer help and advice. The local Connexions team were very happy for us to go ahead, although they were unable to provide input this time. We selected 12 students, 6 for each course (11 young men; 1 young woman). They had all been reassessed before the course, as part of our regular tracking and watching brief systems. We selected on the basis of: 1. Their intention to find a job and independent or semiindependent living accommodation when they leave, together with their personal tutors opinion that this would be realistic. 2. Their willingness to embark on the WICKED course. 3. Their most recent assessment showing that their speech and language levels would allow them to manage in the workplace.

Figure 1 The Conversation Strategies Checklist This profiling tool and list of possible therapy ideas is in the process of being published. It can be used 1:1, or in a group. It looks at 26 conversational strategies and considers a further 10 discussion points to help with conversation. Examples include strategies that explore: The use of open rather than closed questions Being a bit up to date with the latest news Knowing yourself be ready to say a bit about what makes you interesting BUT be careful not to bore people! and discussion points that explore: What is the point of chat? How do people seek regard through conversation? Is a conversation a performance? Figure 2 Course Questionnaire (Post-course we also asked what they thought of it and how we could improve it.) 1. Which topics of conversation are useful in any situation? Give 3 or more examples. 2. Where can you look for a job? Give 3 or more examples. 3. What does preparation for an interview involve? 4. What does the average bloke talk about with his mates? Give 5 or more examples. 5. What does the average girl talk about with her mates? Give 5 or more examples. 6. Why have coffee and tea breaks at work? Give as many reasons as you can.

similar one afterwards (figure 2). Scribes were provided here and throughout the course where needed. The results of the pre-course questionnaire would also indicate any areas where extra work was needed, over that already planned. We decided that each course would take place over two days. Mock job interviews would take place alongside other activities. We used the following approaches (not necessarily in this order): 1. Introduction - Social and work relationships We discussed job matches and partner matches; both kinds of partnerships require mutual respect and interest. Both relationships are helped when we know who we are; our history, preferences, abilities and areas where we can improve. Both require us to listen, and need us to find out about and take the others needs and preferences into consideration. Both partners and employers/employees give and accept compliments, even flattery! We played The Introductions Game. By chatting to a partner (staff or student), the participants found out six interesting things about them, and wrote these down on separate sheets initialled with the interviewees name (we used these later in the CV section). They then introduced the person to the whole group, giving as much information as they could remember / had noted down. 2. Conversation skills applicable to social and interview settings Many of the students had previously participated in Social Use of Language Programme groups where they began to understand conversational rules. Some of these had evolved into Discussion and Dating Skills groups. They had also worked with the Language Choices course, learning to prioritise their discourse. Some recapping formed a bridge into communication in the workplace setting. We also referred to similarities and differences in interactions between social partners such as friends, girlfriend/boyfriend and employment partner.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

Preparatory meetings
The staff had two preparatory meetings. We discussed the idea that an interview is a type of formalised conversation, and touched upon the different types of social codes needed for interview settings, for talking with a boss and for talking to colleagues. I mentioned that coffee and lunch breaks are often more of a problem to people with autism spectrum disorder than the actual work. I followed this up with a pack of information: 1. Official Diagnostic Criteria DSM IV on Aspergers Syndrome 2. The Triad of Impairments (Attwood, 2006) 3. Makesense training resources (Aspergers and Adolescence; Theory of Mind; Central Coherence Theory; Executive Functioning) 4. The Extreme Male Brain theory (Baron-Cohen, 2004) 5. Two home-grown information sheets (Tips on working with students with Aspergers Syndrome; The Conversation Strategies Checklist (figure 1)). To evaluate the efficiency of the course we asked the students to fill in a brief questionnaire beforehand, and a

Role-play
Like me, Carol felt there was a need for students to recap on skills needed for employment, and to role-play mock interviews. Many communication skills needed for interviews and in workplace settings are similar to those needed for social interactions in general, and therefore to work on these together made sense.

27

HOW I

3. Self-esteem and CVs Careers staff stressed that the students need to be able to sell themselves at interviews and when supplying CVs. This connects with therapy sessions where the students had been encouraged to focus on their interests and attributes. Most had previously filled in a Positive Points Chart and a spidergram (Roberts, 2003) or Mindmap of interests, to increase their self-knowledge and esteem, and to fuel conversation topics. Some of them had taken this further, into the concept of the Social CV. We recapped on social CVs and built up job CVs by placing the sheets from The Introductions Game into the sections of a Venn diagram, showing which CV topics would be appropriate in interview, social and / or dating situations. In this way the course recapped on social CVs and built up job CVs. 4. Body Language Many of our students had worked on eye contact, facial expression and gesture / posture for social interactions, but not specifically for interviews. We used modelled examples and role-play to demonstrate how to convey attention, interest and friendliness. We used a game called Moods to separate items on the agenda that required concentration, and as a follow-up to the work on body language. It was an excellent tool for helping to improve understanding and use of facial expression. 5. Interview Video As suggested by Norma, we showed a video - First Impressions Last - at the beginning of discussions about interviews. 6. An Introduction to Job Searching We used newspapers and other sources Carol had found as a basis for search and discussion. We discussed the types of questions jobseekers would need to ask. We also reflected on work experience. 7. Mock Job Interviews Mandy and Norma carried out mock job interviews, being careful to remind the students these were just for practice (not real jobs). They devised a set of questions, but retained a flexibility to allow for the different types of hypothetical jobs being applied for. 8. The Conversation Strategies Checklist (figure 1) While the interviews were going on the remainder of the group recapped or examined for the first time a home-grown and useful document The Conversation Strategies Checklist - of about 30 ideas for improving the quality of our conversations. Some students were able to tick the strategies they had observed others using, or that they had used themselves. We took a look at several different newspapers, with a view to selecting items suitable to include in a conversation, stressing the importance of remembering that items that show I am Profound must be balanced by Keeping it Light. The students picked out the best articles for discussion. We also played Taboo! (Hasbro), which focuses in a playful way on what not to say. 9. Dating Skills In our regular group sessions we have been using games and quizzes designed for discussion of dating, covering such issues and skills as: What constitutes attraction?

How does friendship become dating? What to do on a first date? Most of the students had not worked with these games before but were enthusiastic participants and keen to collect useful tips. Some cartoons from a Bart Simpson book were useful in revealing mens versus womens preferred conversational topics! 10. Film - HITCH (Will Smith) We showed this very light-hearted look at dating and social strategies in two sessions, on the afternoons of both days of the courses. 11. Being the Experts on Aspergers We had a discussion on Aspergers Syndrome using magazine and newspaper articles, (including one by Chris and Gisela Slater-Walker on Asperger relationships). We also discussed aspects of Aspergers that can make people with Aspergers more employable than other people, (sticklers for correct detail, honest, good at finishing tasks). 12. Bullying in the workplace We had a discussion about what constitutes bullying in the workplace, and examined avoidance, reporting and repair strategies, using the Childline document as a basis. We also examined and discussed some of the Speechmark Social Behaviour Cards that depict adult bullying situations. 13. Other items on the agenda Coffee and tea breaks were social interludes but required the students to put into practice some of the conversation strategies they had learnt. We distributed Survival Skills Booklets written by two other students at Ruskin Mill. These light-hearted publications contained alternating survival skills life survival skills (such as camping know-how) interspersed with social survival tips learnt at their Social Use of Language Programme group.

pleased with the immediate improvements shown by students, but felt a longer-term follow-up might be needed to show real absorption of all the information. This might need to be several months or longer after the course, when they would have left Ruskin Mill and either be working or still looking for work. Some students had already received speech and language therapy as a feature of their curriculum at Ruskin Mill because their original assessments showed a need for it. All except one of these students started off with higher pre-course questionnaire results, and showed an average improvement of 4.5 points. Those who had not received it started with lower pre-course questionnaire results but improved by an average of 6.6 points. The end results showed a final average of 17.6 points amongst the no-previous-therapy students, and a final average of 21.8 amongst the had-previous-therapy students. Previous speech and language therapy helped students to gain higher points in the pre-course questionnaire so, despite lower levels four years ago, they had become more aware of social and interview skills, and had held on to this improvement even outside their usual setting. At the same time this relatively small amount of therapy on the course helped those who had not had previous input. The course was generally felt to have been a success, but a few changes would improve it for next time. These include different timing within the academic year even more pre-course preparation longer-term assessment of benefits to students. Norma is hoping that I can talk to University of the West of England students about autism and that Ruskin Mill students might then be able to have further practice interviews with them. Mandy was able to contribute to a useful discussion about bullying from her perspective as a magistrate, and the ripples are also spreading as she is passing information about Aspergers Syndrome to clerks at her Court. Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire, e-mail alison.roberts@good-communication.co.uk.

Recap information
We handed out post-course questionnaires to see how much information had been absorbed. Each student went away with a wallet containing recap information about general social skills, conversation techniques, interview skills, bullying avoidance, CV writing, job hunting, relationship skills, dating tips, and a certificate of attendance on the course. We assessed the effectiveness of the pilot in various ways. The repeat questionnaire was scored by counting the number of valid ideas given for each of the six sections covering different key areas of social and employment skills. Every student showed improvement and the average was 5.5 points (able to think of 5 or 6 more ideas over all the questions). All but one of the students commented spontaneously that they had improved in at least one area. Most commonly this included preparing for interviews, thinking of topics for conversations, keeping conversations going and understanding Aspergers Syndrome. (The remaining student showed the greatest improvement from pre- to post-course questionnaire!) Student engagement in the course proved difficult to assess objectively, but they tended to start hesitantly and gradually become more involved. Carol mentioned that two students had found jobs since coming on the course. Norma and Mandy were

References
Attwood, T. (2006) The Complete Guide to Aspergers Syndrome. London: Jessica Kingsley. Baron-Cohen, S. (2004) The Essential Difference: Men, Women and the Extreme Male Brain. London:Penguin. Buzan, T. & Buzan, B. (2006) The Mind Map Book. London: BBC Active. Roberts, A. (2003) Heres one I made earlier, Speech & Language Therapy in Practice Autumn, p.7.

Resources
Bullying Information Sheets - www.childline.org.uk DSM IV (1994) American Psychiatric Association information at www.behavenet.com/capsules/disorders/d4class.htm First Impressions Last video - www.jumpcutuk.com/. Hitch (2005) Sony Pictures DVD Social Use of Language Programme and Language Choices www.wendyrinaldi.com Training Resources from www.makesensetraining.co.uk

Bibliography
Carlgreen, F. (1996) Education Towards Freedom. Totnes: Lanthorn Press. Edmonds, G. & Worton, D. (2006) The Asperger Love Guide. Bristol: Lucky Duck Books. Hawkins, G. (2004) How to Find Work that Works for People with Asperger Syndrome. London: Jessica Kingsley. Jackson, L. (2002) Freaks, Geeks and Asperger Syndrome. London: Jessica Kingsley. Pease, A. (1999) Body Language. London: Butterworth-Heinemann. Sheils, R. (2002) Good formula for Success in Asperger, in NAS Asperger United Anthology. London: National Autistic Society. The Animal Debate (date unknown) [Video] Team Video Productions, www. team-video.co.uk/txt/txt-critical.htm. SLTP

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MY TOP RESOURCES
1. PROVIDING VISUAL CUES AND INFORMATION It is essential to have a good graphic symbol software program. Communicate: In Print 2 is available from Widgit Software. You can use it to make colourful and attractive resources to support the songs. I find that showing large symbols helps the children (and the adults) to remember the words and to sing more confidently and attentively. There are ready-made symbol resources to support the songs on Nice Warm Socks available as free downloads on the Widgit website. A valuable add-on to Communicate: In Print 2 is Lets Sign and Write v2. You can make a grid of the signs used for each song and give copies to staff and families, to remind them how to make the signs accurately. www.widgit.com 2. ALTERNATIVE AND AUGMENTATIVE COMMUNICATION DEVICES Keep a supply of simple voice output devices so that AAC singers can join in and also refine their switch access skills. I particularly like the sequencing devices such as Step by Step (135), Sequencer (115) and BIGstep (116). You can record in the repeated lines, or even the whole of a song sung as a round. The AAC singer can then lead the singing. Another good device is the 4Talk4 (229). There are many songs that have four simple lines. The AAC singer can either sing it all or maybe lead the call so that other singers can sing the response. They might also sing each line in turn with another singer. All these Voice Output Communication Aids are available from QED (Quality Enabling Devices Ltd) on www.qedonline.co.uk. Prices quoted are as at January 2007 and exclude VAT. 3. MAKING THE VOICE SOUND LIKE ME It is important to use age and gender appropriate voices on voice output devices. I find the best way to manage this consistently is to use a mini disk recorder with loudspeakers. There are other technologies which will also work well. I find a willing volunteer who can sing clearly and fairly accurately. S/he learns and then sings the phrases that need to be recorded onto the voice output device. These songs are best sung slowly, so you need to get the pace right. You then have a permanent stock of songs and lines ready. You will need to keep the pitch consistent, either by using a pitch pipe or by listening to the AAC device first. Make sure you record a lead in phrase if other people will be joining in with the AAC singer, for example OhhhhGo through the gateway no matter where it takes you. 4. KEEPING RESOURCES ORGANISED PART 1 It is a good idea to store the flat resources for each song in a labelled plastic pouch. This will include a copy of the sheet music, the lyrics printed large so you can quickly refer to them if necessary, symbols for overlays and switch caps. Also include any other symbol resources you will need, such as matt laminated A4 or A5 symbols, symbolised lyrics, illustrated books of the lyrics and graphic representations of the signs. It is useful to keep details of how a song is best organised for a particular group and also of ways you have adapted a song that works well. 7. GETTING READY TO SING It is good to have a few body and vocal warmup activities before each session, especially in large groups. This helps to get everyone - especially the adults - less inhibited and more ready to sing and sign. We do some bending, stretching and shaking movements which everyone can join in at whatever level they are able. Voice warm-ups can include things like yawning loudly, shouting hiya to someone across the street, saying your name or a rhyme with your tongue hanging loosely out (guaranteed to make everyone smile) or making miaow sounds as if the cat is locked out. I find everyone loves to join in these silly noisemaking sessions and the singing is better because of it. 8. MUSICAL ACCOMPANIMENT Most songs are best sung unaccompanied, but some can benefit from simple instruments. Some of my most successful instruments are ones I have made myself and are therefore very cheap. Ocean drums are wonderful but also expensive and can be fragile. I have made a similar instrument out of a Frisbee and some gold beads. There is a simple song that can go with it and it can be played with any learner, whatever their physical control ability. It can make a gentle noise but can also be knocked around the room with no ill effect. Another favourite is the rattletops. This consists of plastic milk bottle tops which have been strung onto elastic, with a handle at each end. This song is included on the Nice Warm Socks CD. For details of how to make these, see Heres one I made earlier p.7. 9. DEVELOPING YOUR OWN VOICE Find ways of releasing your own natural voice. You could join a community choir, or find a natural voice teacher or group near you see www.naturalvoice.net. There is an excellent Study Break held in Devon each October half term, where you can explore ways of finding and using your own natural voice, individually and in groups contact Wren Music through www.nicewarmsocks.org.uk. 10. (RE-)SOURCE OF INSPIRATION Keep a copy of the CD Nice Warm Socks available. Get to know the songs by playing them, thinking of ways to use them and singing along on the way to work. Your voice and your body will then be ready to sing in whatever setting you work. Then start adapting and creating your own songs to suit your particular client group. www.nicewarmsocks.org.uk

SHAN GRAEBE M.A., MRCSLT WORKED FOR MANY YEARS AT A SPECIAL SCHOOL IN READING, SUPPORTING LEARNERS WHO HAVE MULTIPLE NEEDS AND ESPECIALLY THOSE WHO USE AAC. ANOTHER MAJOR INTEREST IS IN RESEARCHING, SINGING AND PERFORMING TRADITIONAL ENGLISH SONGS. OVER THE YEARS, SHAN HAS GAINED KNOWLEDGE AND EXPERIENCE IN COMBINING THESE TWO ASPECTS IN ORDER TO DELIVER EFFECTIVE ACTIVITIES TO SUPPORT COMMUNICATION. IN COLLABORATION WITH A PROFESSIONAL MUSICIAN AND A SPECIALIST MUSIC TEACHER, SHE HAS RECENTLY RELEASED A CD OF SONGS NICE WARM SOCKS. THESE SONGS HAVE BEEN ADAPTED FROM TRADITIONAL MATERIAL OR WRITTEN WITH THE DEVELOPMENTAL PROGRESS OF CHILDREN IN MIND, PARTICULARLY THOSE WHO HAVE ADDITIONAL NEEDS AND ARE AAC USERS. SHAN SAYS, THERE IS A GROWING BODY OF BIOEVOLUTIONARY THEORY AND NEUROPHYSIOLOGICAL AND DEVELOPMENTAL RESEARCH WHICH SUPPORTS USING SONG TO HELP DEVELOP EARLY INTERACTION AND MORE COMPLEX COMMUNICATION SKILLS. THIS IS AN APPROACH THAT CAN BE USED BY ANYONE, INCLUDING FAMILIES, TEACHERS, CARERS AND THERAPISTS. IT ONLY NEEDS SOME SUITABLE SONGS AND A PERSON WILLING TO SING THEM, USING THEIR OWN VOICE IN THEIR OWN WAY. SHAN IS BASED AT 100 CHELTENHAM ROAD, GLOUCESTER GL2 0LX, E-MAIL SHAN.GRAEBE@BTINERNET.COM.

5. KEEPING RESOURCES ORGANISED PART 2 Organise the bulky resources you will need by keeping them in bags which have the song title written on them. I have obtained ripstop fabric off cuts which are easily sewn into drawstring bags of any size. For the title song Nice Warm Socks we need several items of clothing. The song is a cumulative one, and learners can choose which item they want such as nice warm trousers, nice warm hat, nice warm trainers, nice warm jumper Nice Warm Socks. Ripstop fabric offcuts available from Point North mail order, www.profabrics.co.uk. 6. DISPLAY Make a large free-standing board which is covered in Velcro fabric. You can then stick self adhesive hook Velcro on the back of your matt laminated symbols. I have also made a Velcro fabric apron, so I can stick symbols onto my front, and still have my hands free for signing and shuffling resources. www.spentex.co.uk/catalogue_public/ (search for Velcro)