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ISSN 1368-2105

Winter 2007

Sign, SEAL, deliver Emotional literacy Outcomes Measuring up Making an impact Using NLP Beyond impairment User feedback How I involve students Accessible Information Interprofessional education Life stories Assessments assessed Hearing impairment, dysphagia, aphasia

Location, Location, Location


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PLUS Winning WaysSoftware solutions?...My Top Resources on aphasiamore great reader offers and featuring multi-professional working.

Striking a balance

Reader offers

Win REACT 2 software!


In conjunction with Propeller Multimedia Ltd. we are offering one lucky reader a FREE single user licensed copy of the new REACT 2 speech and language therapy program, worth 475 (plus VAT). The program has in excess of 7,000 exercises in 5 modules: Auditory Processing Visual Processing Semantics Memory / Sequencing LIFE SKILLS (the new module to be launched early 2008) Reviewing REACT 2, two Australian Speech Pathologists said: The software contains a broad range of receptive and expressive language processing activities and, clearly, is based on current theory in Aphasiology. The individual tasks contain well-developed hierarchies, and have clear instructions and pictures. In addition, REACT 2 was very user-friendly, both for the clinician and the client. We believe that REACT 2 will become an invaluable clinical resource for clinicians working with aphasia. So for your chance to win: 1. Go to www.propeller.net/magazinecompetition.htm 2. Fill in your name, address and e-mail details 3. Answer the simple question 4. Submit the form before 28th February 2008. Entries with the correct answer will be included in the draw. The winner will be notified by e-mail by 15th March and the program CD dispatched to their address. React2 is a joint venture between Propeller Multimedia Ltd and NHS Borders, Scotland. Propeller Multimedia Ltd., P.O. Box 13791, Peebles EH45 9YR, tel. 01896 833528, e-mail enquiries@ propeller.net, www.propeller.net. See review of REACT 2 on p.22

Win the book Head and Neck Cancer


Plural Publishing is offering a FREE copy of the recently published Head and Neck Cancer Treatment, Rehabilitation and Outcomes to a Speech & Language Therapy in Practice reader. At a retail price of 94.00, this is a great chance to win an overview of recent advances in the field from a team of expert authors from the medical and allied health communities. To enter the free prize draw, e-mail your name and address by 25th January 2008 to avrilnicoll@ speechmag.com, putting Head and neck offer in the subject line. The winner will be notified by 1st February 2008. Further information about the Head and Neck Cancer book is on Plural Publishings website, www.pluralpublishing.com.

Reader Offer Winners


Black Sheep Press offered 5 copies of their Key Stage 2 Narrative pack in our Autumn 07 issue. They go to Fiona Fickling, Noreen Marks, Catherine Byrne, Barbara Kendray and Susan Bannatyne. Plural Publishings pre-school stammering assessment KiddyCAT is meanwhile winging its way to the other side of the world as it was won by Angelina Rose in New Zealand. Congratulations to you all and keep the entries coming as next time you could be the lucky one!

Winter 07 speechmag
New on speechmag! Conference reports
Ann French on what she took away from the 2007 IALP Congress in Copenhagen. Editor Avril Nicoll reflects on British Aphasiology Society, I CAN and Solution Focused Brief Therapy in Education events.

Steve Pape writes about the long process of recovery following a head injury and how the impact of his speech difficulties only became apparent once he was back in the big wide world Multi-professional working the discussion continues Keep up-to-date with the progress of the circle of critical friends peer review pilot through the editors blog Spring 06 and Summer 06 added to back issues

Members area

Writing

More suggestions added to our guidelines for contributors to Speech & Language Therapy in Practice / speechmag.com
For a reminder of your user name and password for the members area, e-mail avrilnicoll@speechmag.com

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Winter07 contents
Winter 2007 (publication date 30 November 2007) ISSN 1368-2105 INSIDE COVER: Reader Offers, Winter 07 Speechmag Win REACT 2 software and the book Head and Neck Cancer.

News & Comment

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

SIGN, SEAL, DELIVER It became apparent to us that the parents would benefit from looking at how giving children responsibilities can raise self-worth and confidence. Catherine Williamson and Jenny Maguire discuss the SEAL primary emotional literacy curriculum for England and a complementary workshop they offer to parents.

COVER STORY: HERES ONE I MADE EARLIER Location, Location, Location - Sheina Stockton explains how Estate Agents can support therapy groups. MEASURING UP more tools are needed to assess directly the impact of therapy at the levels of activity, participation and well-being. Dianne Webster reports on a preliminary investigation of outcome measurement by therapists working with people with aphasia in Sheffield.

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NLP IN MOTION The [group] members became active and more confident as they began to believe they themselves held the solutions to their communication issues. Maggie Wallis reflects on the difference Neuro-Linguistic Programming is making to her practice in particular the benefits it brings for people living with aphasia. ASSESSMENTS ASSESSED Our series of in-depth review continues with the Graded Auditory Speech Perception Screen (GRASPS), the Assessment of Dysphagia In Adults (A Bilingual Manual) and the Verb and Sentence Test (VAST).

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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FEATURE: TEAM TALK "As communication specialists we are particularly good at 'opening up spaces'; together with what we know clients and families want, this should give us confidence to handle whatever challenges multi-agency working presents." With big changes ahead in the structure of children's services, editor Avril Nicoll talks to Helen Daly, Christina Barnes, Judith Delve, Kate Evans, Karen Bonham, Gerry Walsh, Hayley Dench and Karen Davies about their experiences of multi-professional working across a range of client groups and settings.

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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.

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REVIEWS Self-help, syndromes, autism, Asperger Syndrome, parentchild interaction, early language, AAC, Intensive Interaction, aphasia, signing, eating and drinking, literacy. WINNING WAYS Life coach Jo Middlemiss on transitions and balance.

BEYOND IMPAIRMENT Many of the speech and language therapists described how, as a result of the study findings, they would now view dysarthria as much of a priority as other communication problems Sylvia Dickson, Marian Brady, Rose Barbour, Alex Clark and Gillian Paton bring together research participants people with dysarthria, their carers and speech and language therapists to consider the findings and implications. SOFTWARE SOLUTIONS With computer software becoming ever more sophisticated and accessible for therapy, our in-depth reviews help you decide whats hot and whats not. Our reviewers consider REACT 2 and Smart Learnings Interactive Literacy series. BACK COVER: MY TOP RESOURCES Everyone in our department was encouraged to construct their own life story book[which] can be used to start and then model supported conversation. Sheena Nineham, Joanna Kerr and Fiona Buck share the resources they could not do without in their work with people with aphasia.

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Cover photo of models Steven Winters, Craig Scott and Chris Flanagan by Paul Reid (see p.7)

HOW I INVOLVE STUDENTS Our contributors show how everyone benefits when students are seen as an additional resource rather than a burden on already stretched services. (1) ACCESS-ABILITY Alison Matthews, Emma Sims, Katie Cowburn, Amy Erwin, Amy Sadowski, Nicola Derbyshire, Lizanne Carter and Linda Collier give managerial, student and university perspectives on a service centred accessible information project for adults with learning disabilities. (2) A SAFE CONTEXT Mel Adams, Celia Harding and Andrea Lillystone support students of speech and language therapy, social work, nursing and medicine to explore issues of client assessment with the assistance of carers of people who have complex communication needs. (3) EVERYONE CAN COMMUNICATE SOMETHING Laura Brierley and colleagues introduce first year students to life story work with people with dementia and their carers in a good practice project that provides a reason to communicate as well as an understanding of the person behind the dementia.

IN FUTURE ISSUES: HEALTH PROMOTIONFOOD REFUSAL LITERACYSTORYTELLINGAPHASIA PRIORITISATION ITDROP IN CLINICSAAC

NEWS

No Voice, No Choice

Service users interviewed by Scope believe many speech and language therapists do not have the expertise necessary to assess peoples communication needs accurately or recommend appropriate equipment. Scopes No Voice, No Choice research consulted over 160 communication aid users and their families to find out the experience of people with communication impairments who use or could benefit from AAC. The report highlights a severe shortage of support and equipment. Scope is calling for the Government to initiate better data collection and funding arrangements and to secure the future of specialist services. It also makes a specific recommendation that speech and language therapists, occupational therapists and GPs should have minimum training standards on AAC use and access to a specialist resource and information portal. www.scope.org.uk/disablism/downloads/noVOICEnoCHOICE.pdf

Plea from Pakistan

The first BSc in Speech Language Therapy has started in Pakistan. The organisers are keen to have any spare books, periodicals or resources that might be of use. If you can help, contact the Coordinator Amina Siddiqui, e-mail slt@zmu.edu.pk. www.zmu.edu.pk/ speech.html

Lets Go to Languageland on CD
The Lets Go to Languageland adventures will shortly be available on CD-ROM from Black Sheep Press. Staffordshire speech and language therapist Angela Wright developed the package for use by therapists and class teachers with children aged 3-7 years. She is pictured with David Gleaves of MidTECH, the NHS Innovations Intellectual Property Hub for the West Midlands, which supported Angela through the publication process. NHS Innovation Hubs aim to ensure that a share of profits of commercialised ideas goes to the inventor and their employing Trust. www.midtech.org.uk www.blacksheeppress.co.uk

Are you Up for Reading?

Happy faces after the 2007 professional honours ceremony of the Royal College of Speech & Language Therapists. Recipients included speech and language therapists Deirdre Dyer, Jane Kerr, Eryl Evans, Kaye Radford, Sara Harris and Susan Edwards.

Communication access training case

Grief Matters for Children

Up for Reading is a sponsored event that promotes the benefits of reading and literacy for all children, including those with Down syndrome. Celebrity supporters include Maisy Mouses creator Lucy Cousins and artist Quentin Blake. Schools, nurseries and individual children can take part at any time before 31 March 2008. Money raised benefits the Down Syndrome Educational Trust. www.up-for-reading. org/

A major study into the needs of people with aphasia in Scotland concludes there is a case for communication access training to be compulsory for all staff working in public services. The Aphasia in Scotland Project report says moving and handling and child protection are examples of how such an approach can be implemented. It adds this could have widespread interagency benefits because it would also be relevant to people with sensory impairments, learning disabilities, mental health problems and those who are not able to communicate readily in English. The report suggests that speech and language therapists are moving towards a social model of working with people with aphasia. There is a need for more provision in the community at a time and place of most use to the client. In particular, services should reduce isolation by helping people with aphasia to restore, develop and maintain social networks. The report is clear, however, that this cannot be at the expense of one to one therapy, and that the number of speech and language therapists working with people with aphasia needs to increase. The researchers found a dearth of statistical information, with only three of the fourteen NHS boards able to provide data on age, gender and severity of aphasia. They see prospective data collection specific to aphasia as essential for understanding demands on service providers and effective workforce planning. This includes people under 65 who have particular needs around employment and caring for a family. The research, carried out by the Centre for Integrated Healthcare Research, included groups of service users, speech and language therapists and other professionals. A communication accessible summary of the findings is to be produced. www.nhshealthquality.org/nhsqis/3800.html

The Childhood Bereavement Network is gathering support for its campaign to ensure that all bereaved children, young people and their families have access to support wherever they live and however theyve been bereaved. The Network says the majority of young people will have been bereaved of someone close to them by the time they are sixteen. It is calling for better training and information to be available to teachers and for a greater duty on authorities to make provision and collect data. Its website includes advice and resources for professionals, families and young people themselves. www.childhoodbereavementnetwork.org.uk/news_ November2007.htm

Toolkit training
Connect has introduced a new style of training scheme so it can reach as many people as possible. The communication disability networks courses in Running a Conversation Partner Scheme and Making Communication Access a Reality are already popular. The new Toolkit style includes two days of learning, practice and discussion at Connect in London and a take home resource package so those attending can offer the training to others in their own area. www.ukconnect.org/ connectcourses.aspx

Working goals

The Government says there is growing evidence that being in work is good for health and wellbeing and it wants health professionals to help clients remain in work or return swiftly to it. The Health Work Wellbeing website includes information and resources for health professionals and the opportunity to submit case studies. www.workingforhealth.gov.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

NEWS AND COMMENT

Deaf role models

The National Deaf Childrens Society has extended its Deaf Role Model Project for deaf children aged 0-18 years living in large parts of England, Wales and Northern Ireland. The project recruits and trains a variety of deaf adults who are successful in all walks of life to visit people in their homes, at local groups, schools, colleges and youth clubs and talk about their experiences. They do not advocate any one type of communication, education, technology or medical intervention. Sally Reynolds, the charitys Family Communication Services Manager, said, This project will help deaf children feel less isolated, and help the whole family have higher expectations of what their deaf child can achieve with the right support and encouragement. The project is supported by the Big Lottery Fund. Posters, flyers and further information from Valerie Copenhagen, e-mail deafrolemodel@ndcs.org.uk.

Comment:

Striking a balance
Jo Middlemiss (p.23) used to like the phrase work/ life balance but has concluded the work/life part is unnecessary and we just need balance. This can be more difficult to achieve than we think but at least we can draw on external help, from the support of friends, family and colleagues to formal supervision or life coaching. In her new role as a life coach Catherine Williamson (p.4) finds her speech and language therapy background invaluable. While the strategies discussed in emotional literacy groups for parents are very similar to those suggested in parent-child interaction groups, there is more emphasis on parents and carers finding balance in their own lives. When we ask, we find that clients and carers are also looking for more balanced provision from services. Research participants told Sylvia Dickson and colleagues (p.18) that the emphasis on the acute stage should not be at the expense of longer term support, offered when and where it is needed most. They also said this applies to the whole team, not just speech and language therapists. As our feature on multi-professional working (p.13) shows, getting new teams functioning in new ways is a challenge. The balance of structural change, leadership and shared vision is finely tuned and absolutely dependent on effective communication. Mel Adams, Celia Harding and Andrea Lillystone (p.26) look at the advantages of starting these interprofessional conversations at an undergraduate level. When individuals have a communication difficulty it is important to provide balanced input that addresses Impairment, Activity, Participation and Wellbeing. Although our outcome measurement tools are still weighted in favour of impairment (Dee Webster, p.8), we are making real strides. Maggie Wallis (p.10) talks about the person beyond the label, while Laura Brierley (p.27) understands the person behind the dementia. The tools we choose can help clients bring a balance back to their identity. In Maggies case NLP frameworks are enabling clients to find their own solutions to living with communication impairment while Laura is giving students experience of constructing real life story books. Interestingly, speech and language therapists in Portsmouth (back page) found making their own life story books reduced the power imbalance of therapy sessions as they could exchange information with clients. As a team manager, Alison Matthews (p.24) tries to strike a balance between a service centred and a person centred approach. She is also interested in finding ways of balancing the needs of the service with our responsibility to provide quality placements for students. It is a privilege as editor of Speech & Language Therapy in Practice to learn about the many inspired directions speech and language therapists are taking. When you are facing major changes and challenges at work, a flick through the pages will remind you why you chose this profession and why we keep striving for balance.

Contributions recognised

Professor Jane Marshall has been awarded the 2007 Robin Tavistock Award in recognition of her significant contribution in the field of aphasia. Qualifying in 1987, Jane is now joint head of Language and Communication Science at City University London and a member of Aphasiologys Editorial Board. The award recognises the influence her groundbreaking research has had on aphasia therapy practice. Colleague Tim Pring commented, Janes research is both creative and practical reflecting her curiosity about the nature of the language of people with aphasia and her concern to help them through therapy. Meanwhile Professor Bill Hardcastle has been made an Honorary Doctor of Science at Edinburghs Napier University. Formerly a Professor of Speech Science at Reading University, he is currently Dean of Health Sciences and Dean of Research at Queen Margaret University, Edinburgh.

Special training

Teachers, support staff and early years practitioners in England are to receive a programme of training to help them develop their teaching strategies for children with special educational needs. Schools Minister Andrew Adonis announced the Inclusion Development Programme, which has been developed by the Department for Children, Schools and Families in partnership with charities I CAN and Dyslexia Action. The training materials will initially focus on speech, language and communication needs and dyslexia. Training on autistic spectrum disorders, behaviour and moderate learning difficulties will follow over the next four years. The Training Development Agency is also piloting specialist material for undergraduate teachers focused on giving them a good skills base for working with children with special educational needs.

Education Show brought forward

The Education Show 2008 has been brought forward from its usual date to take account of earlier Easter school holidays. The UKs biggest exhibition of educational products and resources, this free event also includes seminars and workshops. The Special Needs Zone will have nearly a hundred exhibitors, including Speechmark, I CAN, 2Simple Software, Badger Publishing, Crick Software, Three Bears Playthings, The Sensory Company and TextHelp Systems. The 2008 Show is at the NEC Birmingham from Thursday 28 February to Sunday 1 March. www.education-show.com
SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

Emotional literacy

Sign, SEAL, deliver


If Social and Emotional Aspects of Learning are crucial to a happy life, we need to consider this when planning therapy. Speech and language therapist turned life coach Catherine Williamson and life coach Jenny Maguire discuss the SEAL primary emotional literacy curriculum for England and a complementary workshop they offer to parents.

tudents who are anxious, angry or depressed dont learn; people who are in these states do not take in information efficiently or deal with it well when emotions overwhelm concentration, what is being swamped is the mental capacity cognitive scientists call working memory, the ability to hold in mind all information relevant to the task at hand. (Goleman, 1995)

READ THIS IF YOU WANT TO FORGE INTER-PROFESSIONAL COLLABORATION RAISE SELF-WORTH AND CONFIDENCE HAVE A LONG-TERM IMPACT

In a report commissioned by the Department for Education and Skills, Weare & Gray (2003) say there is sound evidence, mainly from the United States, that work on emotional and social competence and wellbeing has a wide range of educational and social benefits. This includes greater educational and work success, improved behaviour, increased inclusion, improved learning and greater social cohesion. The Government set up Social and Emotional Aspects of Learning (SEAL) in 2005 as a way of helping children in England to: 1. Be effective and successful learners 2. Make and sustain friendships 3. Deal with and resolve conflict effectively and fairly 4. Solve problems with others or by themselves 5. Manage strong feelings such as frustration, anger and anxiety 6. Be able to promote calm and optimistic states that promote the achievement of goals 7. Recover from setbacks and persist in the face of difficulties 8. Work and play cooperatively 9. Compete fairly and win and lose with dignity and respect for competitors 10. Recognise and stand up for their rights and the rights of others 11. Understand and value the differences and commonalities between people, respecting the right of others to have beliefs and values different from their own.

Life skills
Life Coaching is a dynamic approach to help people of all abilities make the most of what they are good at and is therefore an excellent complement to the SEAL initiative. Coaching is about helping children or adults understand what they find difficult and what they want to change and then to identify the steps to get there. These truly are life skills, the tools we need to become resourceful and successful in our adult lives.

Catherine Williamson

Jenny Maguire

The Special Educational Needs and Disability Division's ambition is for every child with special educational needs to reach their full potential in school, and to make a successful transition to adulthood and the world of further education, training or work (www.teachernet.gov.uk/wholeschool/ sen/). As both a speech and language therapist and Life Coach, I am particularly interested in the potential of SEAL to benefit the estimated 7.4 per cent of children (2-3 per class) who have language difficulties of varying severity (I CAN, 2001). It is recognised in the Joint Professional Development Framework (I CAN, 2001, p.6) that, In the classroom, SLCN (Speech, Language and Communication Needs) can have a major impact on childrens ability to think and learn, and can affect their behaviour and social and emotional development. A fellow Life Coach, Jenny Maguire, has a son at St Josephs Primary School in Wrightington. She noticed new school work seemed similar to some of the goal setting techniques she uses with clients. She approached the head teacher to find out if we could support this excellent practice in improving the Social & Emotional Aspects of Learning of the children by working with their parents. We shared ideas, identified common themes and got the goahead to see if parents would be interested. We sent parents an initial letter. This included a questionnaire about responsibility for ensuring these social and emotional aspects of their childs learning are met: religious input in their life feelings of self worth a high standard of reading or writing a good circle of friends the ability to voice their opinions an active role in the community a healthy lifestyle. We asked the parents to consider the responsibility they believe the child, parent or teacher has for the childs development in each area on a scale of 1-10. The response led to the first parent workshops going ahead in January 2007. Responsibility is one of the key SEAL areas. Millman (1999) says self-worth refers to your overall sense of value, worth, goodness and deservedness. Of parents who responded, 63 per cent rated their childs responsibility for their self-worth as less than 5, and 64 per cent said they would like to give their children more confidence. It became apparent to us that the parents would benefit from looking at how giving children responsibilities can raise self-worth and confidence. One parent who attended agreed to discuss getting her 8 year old a pet. The parent and child entered negotiations and agreed that if the child could show she had looked into and researched what having a pet would involve and how this would be maintained then she could have one. This parent was amazed at how much effort her child put into this and how thoroughly she thought through the implications (frequency of feeding, cage cleaning, health care). The child identified the responsibilities she needed to take and those she would need help with (buying food, bedding). Children can learn to take responsibility by using thinking skills and feelings together to guide their behaviour. Taught calming-down, problem-solving and conflict management techniques use language to empower children to make sense of their world and what is happening to them. Teachers, therapists and parents working collaboratively and creatively can give the child with speech and language needs access to the SEAL curriculum through supporting

SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

Emotional literacy

the spoken word with tools such as sign and symbols. I found my speech and language therapy background invaluable in running the parent workshops, both in conveying the importance of language and for helpful resources. Our work on praise drew on tools I used previously with children who stammer. It aims to build self-esteem by ensuring a ratio of 5 positive comments to every 1 negative (Grantham, 2000). Another workshop involved exploring how the word dont features heavily in our language and has implications for our ability to focus on what we should be doing instead.

Figure 1 Smiley rating scale

Goal setting

Interestingly, in the pre-SEAL workshop questionnaire, 33 per cent of parents who responded said it was not their childs responsibility to learn that was up to the teachers and parents to do! Yet one of the key outcomes of successful work to develop social and emotional skills is independent and autonomous children who are able to take ownership of their learning and behaviour. Speech and language therapists routinely involve children in goal setting and measuring performance using tools that are not dependent on language such as the smiley rating scale (figure 1). This experience can be helpful when exploring ways that teachers can constantly encourage children to take ownership. Ideas might include: a. involving children fully in the decision to implement the SEAL curricular approach, and making sure they, as well as adults, understand the purpose of the work and the hoped-for outcomes b. involving the children in the identification of criteria that demonstrate success c. involving children in the evaluation of their learning d. allowing children to determine their own questions for enquiry and debate e. using behaviour management techniques that

encourage children to make a choice about their behaviour (such as golden time where the children are able to choose their own reward for good behaviour) f. providing opportunities for children to determine class and playground rules and routines, and ground rules for the activities to develop their social, emotional and behavioural skills. St Josephs has a school council whereby the children help sanction poor behaviour. Our Coaching Workshops for parents play an important role because skills learnt in school are not meant to stay in school; children need to develop these skills in all aspects of their lives, and parents are the teachers who do this at home. But what if parents themselves dont know how to develop these skills? What if they dont feel empowered to teach their children the valuable skills of negotiation, compromise and responsibility? As listening professionals, speech and language therapists often find themselves supporting parents. Our workshops give a wider range of parents a rare opportunity to press pause, look at where they are now and learn how to: 1. Get their children to take responsibility for their role within the family. See Doughnut in figure 2. 2. Talk so children will listen and cooperate stop telling them what they dont want them to do and start saying what behaviour they want to see.

3. Effectively reward children to keep them motivated and keen to develop themselves. It is essential that children are involved in determining their reward. As Brophy (2004) showed, children learn more from intrinsic motivation - when they are doing a task to please themselves - rather than when they are told to do it with a reward in place. 4. Manage their time more effectively so they can spend quality time with the children. This includes leading by example. In our Goal Setting workshop, parents realised they had stopped setting themselves goals and instead focused their energy on the children. When we asked the question What do you want for your child a life full of new possibilities until they are 40 or a life full of new opportunities until they are 80? well, you could have heard a pin drop as realisation dawned. 5. Build their own self-confidence so that they provide a positive role model for their children. The feedback from the parents has been very positive: I felt that it has been one of the best presentations I have ever been to, everything was so poignant, and we just thought thats me, I do that! The difference is unbelievable. I have noticed that the children respond more positively and we are now showing them that as parents we trust them and have confidence in them.

Essential factors

The Primary National Strategy says, Social, emotional and behavioural skills underlie almost every aspect of school, home and community life, including effective learning and getting on with other people. They are fundamental to school improvement (DfES, p7,

I Would like Molly to become more responsible for one of the following chores: Saving some money Doing the dishes Looking after the pets Watering the plants Folding the washing Preparing the meals Helping with the hoovering Keeping her room tidy

This will allow me to: Spend more time doing what .......................... wants me to do See how responsible my child can be Remain calmer with my children as my workload lightens See their confidence grow

In return I will reward Molly in one of the following ways: Financially Spend agreed time together
What responsibilities does your child have?

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Figure 2 Doughnut of responsibility


SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

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Emotional literacy

2005). Identified essential factors to successful implementation of SEAL include: a. Senior management commitment to the principles and understanding of the implications. St Josephs staff are all committed to the SEAL initiative and it is carried on throughout the school. b. A school which makes sure all individuals feel valued and listened to where childrens achievements are celebrated. c. Teacher insight and knowledge into the emotional factors that affect learning. This has also developed via the parent participation in the workshops, as staff felt they understood the views and aspirations of parents more. d. The active involvement of children themselves. St Josephs have noticed the children respond well to being talked to positively. The Year 6 children had a new cloakroom and their teacher would regularly comment on how tidy it was or that certain areas were really tidy, which made the children motivated to keep it this way. e. Proactive work with parents. At St Josephs this is an on-going area of work as it is becoming more evident that the negative attitudes of some of the children are influenced by parents. Weare & Gray (2003, p.24) quote Cumbria LEA: Childrens behaviour is a consequence of their social and emotional development and their mental health; it is learned.

St Josephs wants to get parents on board so that the valuable work done in school can be reinforced at home. A Special Educational Needs Coordinator in a poorer area of Stockport said that, although he agreed with our workshop plan, he felt his parents would not be able to access this level of learning. His school is using SEAL to teach parents the basics first. Many parents can feel overwhelmed with the thought of going back into the school environment and their own experiences of education can make it hard for them to access new information. In these cases just getting them to come into school is an achievement. We have finished the project pilot and are evaluating the results. We plan to seek accreditation for the course and roll it out to other schools. We are also making links with the Qualifications and Curriculum Authority approved PEARL (Personal, Employability, Achievement and Reflection for Learning) Programme. This framework aims to be a cohesive mechanism that allows competencies in key areas such as willingness to learn, self-motivation and team work to be accurately assessed and accredited. This is the first performance based system for measuring and awarding learners social, emotional and behavioural skills. Our plans may be ambitious but we are buoyed by the schools enthusiasm and excited about the future.

Catherine Williamson (www.meettherealu.co.uk) has a BSc Speech Therapy & Pathology and a Diploma in Life Coaching. Jenny Maguire (www.noguiltzone.co.uk) has a Diploma in Life Coaching. For further information, e-mail catherine@meettherealu.co.uk.

Acknowledgement

With many thanks to Mrs Keating, Head Teacher, parents and staff at St Josephs Primary School, Wrightington, West Lancashire. SLTP
Catherine and Jenny are running The Amazing Womens Day on 27th February, 2008 at Maxwell Hall, Salford University, Manchester from 10am-4pm. The cost is 50 and the aim is for participants to Appreciate all that you are and all that you can be. Further details will be available on www.growingdreams.co.uk.

References

Brophy, J. (2004) Motivating Students to Learn. 2nd edn. NJ: Lawrence Erlbaum Associates. DfES (2006) Primary National Strategy - Excellence and Enjoyment: social and emotional aspects of learning. Crown copyright. Available online at: www.standards.dfes.gov.uk/primary/publications/banda/seal/pns_seal137805_guidance.pdf (Accessed 20 October 2007). Goleman, D. (1995) Emotional Intelligence. New York: Bantam Books. (Taken from Primary National Strategy, p8, 2005). Grantham, P. (2000) How To Build Clients Self Esteem workshop. Harrogate: Skills Development Service. (Further details at www.skillsdevelopment.co.uk/seminars.php?courseid=1.) I CAN (2001) Joint Professional Development Framework. London: I CAN. Millman, D. (1999) Everyday Enlightenment: The Twelve Gateways to Personal Growth. Warner Books. Weare, K. & Gray, G. (2003) What Works in Developing Childrens Emotional and Social Competence and Wellbeing. University of Southampton. Available online at: www.dfes.gov.uk/research/data/uploadfiles/RR456.pdf (Accessed 20 October 2007).

REFLECTIONS DO I HELP CLIENTS FIND WAYS TO COPE IN SPITE OF THEIR COMMUNICATION DIFFICULTY? DO I UNDERSTAND THAT SOME CARERS NEED TO DEVELOP THEIR OWN EMOTIONAL LITERACY BEFORE THEY CAN HELP THE CLIENT? DO I MODEL PERSONAL GOAL SETTING BEHAVIOUR? How has this article been helpful to you? What are you doing to address social and emotional aspects of learning? Let us know via the Winter 07 forum on the www.speechmag.com members area.

resources
Community Therapists
The Community Rehabilitation Team Network has been rebranded as the Community Therapists Network. It is for therapists providing care and support in the community for people living with long-term conditions. www.communitytherapy.org.uk

Politics

Telehealth

The Disability Rights Commission has produced a downloadable booklet Getting involved in a political party Information for people with learning disabilities. The DRC is now part of the Equality and Human Rights Commission. www.equalityhumanrights.com (search Publications)

React 2

The life skills module of the React 2 rehabilitation software will be ready early in 2008. Trial versions of all programs can now be downloaded from Propeller Softwares website. www.propeller.net

TinyEye technology has been developed for speech and language therapists to offer remote consultation and therapy services using a head set and web camera. www.tinyeye.com

Crime talk

Talking Mats and dementia

Transition

Crimestoppers has a new website aimed at getting young people aged 11-16+ involved in discussions about crime. www.shadowcs.co.uk/

The Transition Information Network is an alliance of organisations and individuals who want to improve the experience of disabled young peoples transition to adulthood. www.transitioninfonetwork.org.uk

Palliative care

The International Childrens Palliative Care Network advocates for and raises awareness of the needs of life-limited children and their families. www.icpcn.org.uk

A study has found the low-tech communication tool Talking Mats effective as a way of helping people at different stages of dementia to express their views, compared to their usual communication methods. It also reduced repetitive behaviour and helped to keep participants engaged in conversation. Download the report free at www.jrf.org.uk/bookshop/ eBooks/2128-talking-mats-dementia.pdf Thanks to Contact a Family (www.cafamily.org.uk), the source for several of these resources.

SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

COVER STORY: Heres one I made earlier...

Heres one I made earlier

Location, Location, Location

Sheina Stockton with a low-cost, flexible therapy suggestion suitable for a variety of client groups.
There is a huge resource of free and high quality leftover material lurking in the filing cabinets of Estate Agents. Yes, I did say Estate Agents! It occurred to me that house leaflets provide an ideal resource for working on inference and logical thinking, not to mention discussion and team building skills. We all love to look at details of other peoples houses and these leaflets give details of price, house type, size - all you have to do is write a selection of client details to match up with the houses you have details of. When I first went to an Estate Agent I was given a whole range of details on houses from 100,000 to 500,000. They were also happy to give me six or more copies of each leaflet so I didnt have to copy them. I then wrote short sketches of my clients, for example: Mr and Mrs Black have a budget of no more than 250,000. They have no children but 2 dogs. They love walking and would like to live in an older style property in the country but not too far from shops. The group then had to consider all the clients and decide which houses would be most suitable for them. This included lots of vocabulary work starting with what is a semi-detached house?, progressing to what is meant by no more than or an older style property. They also had to infer information from the client profile such as that they would need a garden if they had dogs. The young people aged 13 to 18 who have used this activity have really enjoyed it, and we have turned it around so that they can begin to write client profiles for another group to match with houses. It is an infinite resource, easily added to and great fun. Alison Roberts regularly contributes really practical and imaginative ideas to this page. She has used this idea and extended it to matching holiday wish lists to travel brochures, again a wonderful free resource. So even though Summer holidays are over we can still dream of that perfect SLTP getaway while we work! Sheina Stockton is an independent speech and language therapist in Upton upon Severn.

Picture of models Steven, Craig and Chris by Paul Reid

SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

OUTCOMES

Measuring up
READ THIS IF YOU WANT TO COMPARE AND CONTRAST WHAT COLLEAGUES ARE DOING IDENTIFY GAPS IN RESOURCES DEMONSTRATE YOU ARE MAKING A DIFFERENCE

Given the many reasons in favour of outcome measurement it is important we know what we need to measure and how we are going to do it. Dianne Webster reports on the questions arising from her preliminary investigation of outcome measurement by therapists working with people with aphasia in Sheffield.
eral months and years after. Therapists differ in their experience and there is also variation in available resources, both materials and staffing. Speech and language therapists in Sheffield have a number of tools which could be used to measure outcome. These include: formal, standardised assessments (such as TROG, Boston Naming Test, PALPA, Comprehensive Aphasia Test) or informal checklists which are used where therapy has targeted a specific element of language processing in an impairment-based approach. measures of mood and self-esteem (for example VASES, SAD-Q or DISCS (Turner-Stokes et al., 2005)) or informal rating scales if therapy has targeted psychosocial issues. TOMS or informal observational checklists, measuring therapy outcomes that have targeted access to community activities and participation in society. For the project audit I used criteria based on guidance specific to the profession, including RCSLT Clinical Guidelines (2005). I formulated standards (table 1) based on my own clinical experience and informal discussion with colleagues. To find out if these standards were being met I sent a questionnaire (based on Simmons-Mackie et al.,
Table 1 Standards

ver recent years we have become increasingly aware of the need to measure outcomes, so that we know our intervention is having an impact on clients lives. As a recently qualified therapist I was keen to get to grips with the outcome measurement tools used in my team and the wider service. I wanted to find out whether or not therapists were measuring outcome, what they were measuring, the main factors affecting outcome measurement and perceived barriers. With the support of colleagues I undertook this as a project, carrying out a literature review followed by a baseline audit and a preliminary investigation of local practices to assess the impact and outcomes of clinical service (RCSLT, 2006) at an individual therapist level. The literature review in April 2005 revealed few articles that had investigated the use of outcome measures in everyday practice. Of these, studies such as those by Simmons-Mackie et al. (2005) and Hesketh & Hopcutt (1997) revealed diversity in the range of outcome measurement tools used by clinicians. Tools were formal and informal; functional and impairment based. Account for variability Attempts to define outcome measurement reflect the wide range of variables involved. Simmons-Mackie et al. (2005, p.2) aim to account for this variability rather than trying to pin down a definition: What rehabilitation professionals measure in outcome assessment, as well as when or how outcomes are measured, depends on a range of variables such as the philosophical and experiential orientation of the person doing the assessment, the intended audience, the time and resources available, and the specific purpose of the assessment. This is certainly a helpful approach when we are considering outcome measurement in a real world setting. Aphasia therapy in Sheffield takes place in a variety of settings at different points along the stroke pathway; from the acute phase right through to sev-

2005) to a group of Sheffield speech and language therapists working primarily with adults with aphasia following stroke. The questionnaire (available in full via the Extras group on the members area at www.speechmag.com) gathers information about the setting(s) the respondent works in and the general stage they see clients at following a stroke, along with their level of experience and continuing professional development. It also asks how much time they can offer a client with aphasia and whether computer based interventions are included in their service. Respondents are invited to define outcome measurement and explain the theoretical or philosophical models or frameworks that currently influence your approach to outcome measurement in aphasia. They then answer questions about whether, when and how they measure change before moving on to sections about what influences decision-making (for example aphasia severity / evidence of spontaneous recovery / motivation of client) and whether there are significant barriers to conducting outcome assessment in your setting / with individual clients. Finally, respondents are given a list of 26 outcome tools suitable for use with people with aphasia and asked to indicate whether they use them and, if so, why (for example to determine what to do in therapy / track client progress).
Results 89% respondents measure therapy outcome 100% of those who use tools do so in 2 or more areas

Criterion Outcomes of therapy should be routinely measured (RCSLT, 2005, p.17)

Standard All therapists will measure outcomes of therapy

Measurement will reflect the range of 80% of therapists will use tools in interventions delivered and the aims agreed 2 or more of the following areas: for therapy (RCSLT, 2005, p.17) impairment, activity, participation, well-being (WHO, 2002) Speech and language therapists must 80% of therapists will be informed of have available a wide variety of potential developments in theory / practice of approaches to therapy, including awareness aphasia therapy of the latest techniques, and be informed of developments in the theory and practice of aphasia therapy (RCSLT, 1996, p.164). This will then inform outcome measurement in aphasia.

89% reported involvement in a specific aphasia-related activity

SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

OUTCOMES

Nine of the ten questionnaires were returned. I was interested to note that: 1. Eight of the nine responding therapists reported that they measured outcomes. (The other therapist worked in the acute setting and our definition of outcome measurement did not include measurement of communication to staff and family or communication facilitation.) 2. Time constraints were reported most frequently as a barrier to outcome measurement. Reported time taken to measure outcome ranged from 30 minutes to 3 hours and related to time available for therapy. Therapy intensity differs according to setting and resources (such as assistants), with more typically available in intermediate care and inpatient rehabilitation settings. 3. All 8 therapists reported using tools that involved a range of the four categories: body functions and structures (impairment), activity, participation and contextual factors (well-being). As this mirrored the therapists reported influences to outcome measurement, with all respondents mentioning a range of philosophies / models, this suggests that therapists are attempting to address and target clinical areas at a range of levels. 4. Despite therapists working at a range of levels, the majority of outcome tools used were at an impairment level (such as the Comprehensive Aphasia Test, Pyramids and Palm Trees), with only 26 per cent at an activity / participation level (for example informal functional checklists, observation checklists) and a mere 9 per cent for well-being (such as VASES). As all therapists included well-being in their definitions and use of tools, this suggests to me that more tools are needed to assess directly the impact of therapy at the levels of activity, participation and well-being.Enderby & Emerson (1995) comment that most studies investigating aphasia therapy use standardised tests to measure aphasia outcome, yet these tests may be measuring little or nothing that has been targeted in therapy. The development and availability of valid tools that measure the impact of intervention at the levels of activity, participation and well-being would allow clinicians to capture the breadth of intervention and subsequent impact on the individual. This

can then provide information to service providers and commissioners on the full range and value of speech and language therapy and its relevance to service users. 5. Respondents definitions of outcome assessment varied, with disagreement about whether this should be broad or linked to a specific area of treatment. More consensus is needed on how intervention is measured. If clarity is gained on the factors that should be considered when defining measurement, tools can then be carefully chosen to capture these parameters. 6. Many therapists reported involvement in an aphasia-specific activity. We can assume that, in addition to a specific interest in aphasia therapy, these therapists have access to research and best practice findings, and that this should inform outcome assessment and enhance good practice.

NHS, the Payment by Results system (DoH, 2002) encourages efficiency, and so measuring outcome is imperative. Commissioners also want to know that services offer value for money and meet the needs of a given population. Given the importance of this subject, further discussion and reflection on the remaining questions is needed and will form the basis of future developments on outcome measurement within speech and language therapy in Sheffield. Dianne Webster is a Specialist Speech and Language Therapist with Sheffield Primary Care Trust, e-mail d.webster@nhs.net, telephone 0114 2264034.

Acknowledgements

Questions raised

One of the main outcomes of this project was the many questions it raised: How is outcome measurement viewed? Is it seen as an integral part of a therapy block or viewed as an additional activity? How can more time be made available to measure outcome? How is outcome measurement defined and what influences this decision? Can we gather more examples of therapy currently provided at the levels of Impairment, Activity, Participation and Well-being? How can the impact of our therapy on the individual be measured appropriately, across the breadth of our input? What limitations / barriers do the care pathway and particular models of service delivery place on individual accessibility to therapy services, subsequent therapy and outcome assessment? How is the client and carers perceived impact of therapy being measured? How is this being used to inform service planning and therapy focus at different stages of the care pathway? Outcome measurement for aphasia was reported by Sheffield speech and language therapists to take place routinely. This is reassuring as it is widely accepted that measuring outcome of therapy is good practice (RCSLT, 2005; RCP, 2004). Within the

I am grateful for the time, advice and support provided by my colleagues and managers within the Sheffield Speech & Language Therapy Service. With particular thanks to Caroline Haw, Clinical Supervisor and Dr Caroline Pickstone, Research Lead. SLTP

REFLECTIONS WHEN I WANT TO FIND SOMETHING OUT, DO I START WITH BASIC TOOLS SUCH AS A LITERATURE REVIEW AND AUDIT? DO I GET INVOLVED IN GROUPS WHERE I CAN DEVELOP MY KNOWLEDGE AND SKILLS? ARE THE OUTCOMES TOOLS I USE APPROPRIATE TO THE CHANGES I WANT TO CAPTURE? How has this article been helpful to you? What are you doing to measure the outcome of your intervention? Let us know via the Winter 07 forum on the www.speechmag.com members area.

References
Department of Health (2002) Reforming NHS Financial Flows. Introducing Payment by Results. Crown Copyright. Enderby, P . & Emerson, J. (1995) Does Speech and Language Therapy Work?: A Review of the Literature. London: Whurr Publishers Ltd. Hesketh, A., & Hopcutt, B. (1997) Outcome measures for aphasia therapy: Its not what you do, its the way you measure it, European Journal of Disorders of Communication 32 (3), pp.198-203. Royal College of Speech and Language Therapists (2005) Clinical Guidelines. Bicester: Speechmark. Royal College of Physicians (2004) National clinical guidelines for stroke. 2nd edn.. London: RCP . Royal College of Speech and Language Therapists (2006) Communicating Quality 3. London: RCSLT. Royal College of Speech and Language Therapists (1996) Communicating Quality 2. London: RCSLT. Simmons-Mackie,N., Threats, T.T. and Kagan, A. (2005) Outcome assessment in aphasia: a survey, Journal of Communication Disorders 38, pp.1-27. Turner-Stokes, L. Kalamus, M., Hirani, D. & Clegg, F. (2005) The depression intensity scale circles (DISCs): a first evaluation of a simple assessment tool for depression in the context of brain injury, Journal of Neurology, Neurosurgery and Psychiatry 76, pp. 1273-1278. World Health Organisation (2002) Towards a Common Language for Functioning, Disability and Health. Geneva: WHO.

Resources (availability)
Armstrong Naming Test Whurr Publishers - out of print Boston Naming Test http://www3.parinc.com Comprehensive Aphasia Test www.languagedisordersarena.com The Pyramids and Palm Trees Test www.harcourtassessment.com Psycholinguistic Assessments of Language Processing in Aphasia (PALPA) www.languagedisordersarena.com SAD-Q (Stroke Aphasic Depression Questionnaire) freely available on www.nottingham.ac.uk/iwho/general/links.php TOMS (Therapy Outcome Measures for Rehabilitation Professionals) www.wiley.com Trog-2 (Test for Reception of Grammar) www.harcourt-uk.com VASES (Visual Analogue Self-Esteem Scale) www.speechmark.net

SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

GROUPS

NLP in motion
THE MOVING STREAM As speech and language therapists we want therapy to impact on a clients life not just specific skills. Maggie Wallis reflects on the difference Neuro-Linguistic Programming is making to her practice, including a time-limited monthly group facilitated with a palliative care pharmacist for people living with aphasia.
READ THIS IF YOU WONDER WHY OUR PROFESSIONAL ROLE IS IN CONSTANT FLUX PEOPLE CAN BEHAVE IN AN UNPRODUCTIVE WAY YOU SEE CHANGE WITHOUT CARRYOVER

Over the years there have been continuous and dramatic changes in the ways we view our role as speech and language therapists, yet we have always been dealing with the same commodity: communication. The reason for the fluctuation lies in the nature of the commodity. In many ways communication behaves like water. What we see of it is only what is reflected back to us. We observe only the effects of it, not the thing itself. Even these effects cannot be adequately measured or defined - they pass through the receptors of the brain, affecting thoughts and emotions, influencing facial expression, body language and responses in a constant flow. Communication must be in motion or it is simply words. Often our assessments measure something which is static, yet these results may have little bearing on communication behaviour. After a Lee Silverman Voice Treatment course, I returned idealistic that I now had the key to change for all my clients with Parkinsons disease. The therapy achieved what it said it would do - the client could speak with a loud voice. Even with the emphasis on carryover, what did not change so readily were the dynamics between spouses following therapy, or contexts in which the loud voice might be usefully engaged. In other words, the water may have developed a different quality but it still met the same conditions and restraints. These barriers need also to be addressed if communication is to improve in a life enhancing way. In the past we have bought into the medical model, looking at ways of mending what has become broken. We have been less focused in developing our skills of recognising and enhancing good communication. But over the past few years, with Connect blazoning the way, the psychosocial model of aphasia has begun to take precedence. Its emphasis is on looking at the environment and context in which communication occurs and making this amenable to the person who is struggling to communicate. As one manages water, so we help to improve the flow, remove barriers and redirect.

THE NLP WELL

To communicate effectively is a desire common to everyone whether or not their speech or language is impaired. One area of study that has paid particular attention to effective communication is Neuro-Linguistic Programming. NLP began as a fascination of a linguist, Richard Bandler, and a mathematician, John Grinder. They wanted to encapsulate the success of various psychotherapists who had excelled in their field. They did this by looking closely at differ-

ent aspects of their communication, resulting in a model which others could then pattern. From these beginnings NLP has been applied to various fields, again with the aim of providing a model from which others could draw to facilitate their own success. NLP has developed what it calls its presuppositions. This is an acknowledgement that, in anything we do, the assumptions we bring to bear on a task have an effect on the end result. NLP proposes that we consciously assent to particular assumptions - not because they have to be true but because they are effective in generating change. The mental posture we adopt is crucial to the response we elicit. NLP presuppositions: 1. Everyone has their own unique model of the world dependent on their experience, belief systems, and way of filtering information 2. Behind every behaviour is a positive intention for that person 3. The meaning of your communication is the response it gets 4. Present behaviour is the best choice available at the time 5. There is only feedback; each situation provides useful information, revealing whether or not you have drawn nearer to your intended goal 6. Resistance is a sign of lack of rapport and is therefore useful feedback 7. Mind and body are one unified system 8. Everyone has - or can acquire - all the resources they need. In addition there are five guidelines as to how we operate in a given situation: 1. Determining our state of mind and body and aligning this to what is called for in the current situation. An unresourceful state is one that is not producing desirable results. Breaking state is an NLP term describing the capacity to pull yourself out of an emotional state, with the intent of moving into a state that is more conducive to bringing about your desired outcome. 2. Developing rapport with whoever we need to communicate, paying particular attention to voice quality, the words we use and physiology. (NLP has developed a useful system to interpret messages we can receive through observation of body language and facial expression.) 3. Establishing outcomes so that resources required can be clearly identified. 4. Developing sensory acuity so we can usefully calibrate our effectiveness towards a given outcome. 5. Learning flexibility so we are able to recognise there are numerous ways of achieving the same outcome, and find the one that best suits our set of circumstances.

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SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

groups

Good intention

One of the NLP presuppositions suggests that, when dealing with people, we recognise the good intention behind any behaviour, however unproductive we measure the behaviour itself. It suggests by so doing that the person will view themselves in a more positive light and that our dealings immediately become solution rather than problem focused. A woman who had experienced a stroke with aphasia in her thirties returned to our department two years later. Her life had begun to settle and she wished to take in hand the enormous difficulties she was experiencing in reading. She came with her ex-husband who had provided her with a laptop and software which highlighted words on a page to aid the reading process. The program was inappropriate and drew attention to her incapacity to do the task. However, useful pointers arose: the womans desire to work on her reading ability, to work independently and to use the computer towards this end. Once supplied with a suitable program to match her current ability level, the benefits of the computer became evident without any need to question her original intentions. NLP suggests that, when dealing with peoples behaviour, we encourage ourselves and others to regard any outcome as useful feedback and never as failure. It asks us to adopt a curious rather than critical attitude to our own behaviour and that of others. Following the experience of stroke, people may feel let down by their own body and mind. NLP offers guidelines to re-establishing control over our situation, first of all by gaining insight into the lie of the land, then finding how to move through it effectively. NLP employs various frameworks to better understand our human condition.
Figure 1 The Logical Levels

and limited mobility. Word finding difficulties were the most obvious language impairment. The members brought a wide range of hobbies Filters Experience Internal including cooking, knitting, gardening, representations Beliefs See golf, socialising and hill walking. Some had Values Images Hear Memories Sounds found their particular interests reading, Feel Past experiences Feelings Smell riding, writing significantly affected by Deletion Smells Taste the stroke. Distortion Taste A specific activity launched discussion Generalisation Self Talk at each session, often with a film snippet to demonstrate a particular issue relating to The model in figure 2 is commonly seen communication, or skills that might benefit in NLP workbooks (without reference to a communication. A clip from Entrapment particular source). It can be a useful framework effectively demonstrated how non-verbal for understanding our own and others communication carries more import than verbal. communication. Most people have a preferred way As facilitators we didnt need to make this explicit of expressing themselves and storing information, and group members discussed it from their own usually in an auditory, visual or kinaesthetic form. perspectives. We were alert to issues arising It is possible to adapt our language to match the pertinent to the frameworks of NLP, and reflected preferred system of the person with whom we are these back as appropriate, on occasion drawing communicating. This can help them feel more at diagrams to demonstrate their point. ease with us. We can also be more certain they receive information in the way we intended. It is often possible to identify peoples preference in The ensuing discussion was lively and contained retrieving or generating information by attending theories about communication in general whilst to such details as their eye movements and choice also reflecting on individual experiences before of language. I once asked a voice client how he and after stroke. felt about his louder voice. He looked blankly at Group members spent a great deal of time me until I changed the question to ask how his discussing issues between themselves, but referred new voice sounded to him. He then responded to the facilitators for specific information relating enthusiastically. to their particular knowledge base. Each member
Figure 2 An NLP model of communication

Lively discussion

CHANNELLING / IRRIGATION

Beyond identity

Identity

Environment

Beliefs and values

Behaviours

Capabilities

The framework in figure 1 has been developed by Robert Dilts from the work of Gregory Bateson. To begin to embrace change, it is necessary to make sense of the change that has occurred. Following dramatic change the initial experience is often of chaos. Frameworks make it possible to organise the story so that important elements can be located and retrieved, recognising the level or levels where change has impacted. This may promote some sense of order and understanding of the situation.

Attending an NLP course on effective communication for NHS workers in the Highlands, it interested me that such a diverse group of people could be enticed to communicate, cooperate and become fascinated in each others behaviour when the focus was diverted away from our professional status and onto our communication skills. I was keen to experiment with running a post-stroke group using some of the techniques I had seen in action. The people I wished to target are regarded as low priority in terms of risk management. While impairment therapy is perhaps no longer appropriate, they are discontented because they perceive their communicative abilities have diminished following stroke. I decided to offer a monthly session for six months, catering for people from a broad geographical area as the Highlands is populated in a dispersed way. I ran the group with a pharmacist in palliative care who already had significant experience using NLP. The group members had to be coping with some degree of aphasia but able to communicate with relative independence. Their comprehension had to be adequate for them to participate and benefit and to understand that the intention of the group was not to help their speech but to assist them in dealing with their stroke and aphasia. The three males and three females identified were aged from 43 to 82 and time since the stroke was from under 1 year to 9 years. Two lived alone and additional physical factors included deafness

had skills and knowledge from their own life experience which they brought to bear. One had been involved in adult literacy work, whilst another had been a photographic journalist. Another had driven fighter planes and lectured in the RAF. Members were willing to discuss more personal issues as the months progressed. They became interested in and observant of their own and others abilities and behaviour. During the second session one member arrived having had a significant loss of temper whilst being unable to tackle a simple task at home. His wife had temporarily moved out as a result. He observed during the session the skill of another member to break state whilst dealing with similar frustration. As a result of this modelling he was able to tackle further instances of frustration in a more productive way. A healthy fascination and curiosity developed, as well as a strong bond between various members, which motivated some to maintain contact after the group had completed its six month duration. The members became active and more confident as they began to believe they themselves held the solutions to their communication issues. They listened eagerly to each other, and affirmed the useful contributions that others made. The facilitators did not have to take responsibility for stoking the momentum. The members began to assert themselves as individuals beyond the label of stroke, some even becoming aware that aspects of their stroke previously considered shameful were now defining features within the new identity they were beginning to embrace.

SPEECH & LANGUAGE THERAPY IN PRACTICE Winter 2007

11

GROUPS

Issues covered over the six sessions were: a) Significance of non-verbal communication b) Why the telephone adds stress to communication c) Preferred ways of filtering and storing information for individuals d) Possible effect of stroke on our preferred systems e) How others perceive us and what we can do to alter their perception f) How to deal with unresourceful states g) The use of humour in dispersing a fixed state h) How to move from 1st person to 3rd person to see things more in perspective i) Communication issues that exist for everyone, with or without aphasia j) How our view of the world colours the issues we regard as significant at any one time k) The value of relating to others who share our experience l) How ease of communication is dependent on whom we are communicating with and the topic m) Varying experiences in ability to read and write, and the progress that can be made n) Establishing of skills and mental rehearsal prior to activity.
Figure 3 Clinical Effectiveness Team findings

Timing All members would have preferred meetings to be more frequent Attendance Transport issues were manageable, though getting out during the winter months proved more effortful All attended regularly unless they were prevented for good reason Purpose To meet others in the same situation To find out how varied the experience of stroke can be To share and gain understanding from others experiences Benefit openness support at an opportune time in their lives encouraged to discuss things they would not normally discuss acceptance of each others difficulties time available for all members to participate as they wished Content initial exercise was a trigger to get them talking members set the agenda themselves exercises and discussion felt natural; more like conversation than a training session Facilitators teachers guiding with suggestions supportive coordinating group not interfering or dictating the content summing up conversations sometimes giving a push Outcomes improved communication abilities increased confidence in dealing with strangers and in social situations less frustration improvement in dealing with feelings in relation to stroke different understanding of how stroke had affected them desire to continue meeting.

There were also useful discussions unrelated to communication. The presence of the pharmacist enabled the members to tap into her expertise: The effect of stress on our body and whether this relates to the possibility of stroke How the sense of self resides with capabilities prior to stroke and sense of loss The usefulness of particular medications Responding to change, as described by the Kubler-Ross model (2005). We enlisted the Clinical Effectiveness Team for NHS Highland to help evaluate the group. They conducted a group interview to elicit the views of all members at a specially convened session. Their findings are in figure 3. We attempted to measure the effects more objectively using the Disability Questionnaire from the Comprehensive Aphasia Test (Swinburn et al., 2004) pre and post group. Though many responses were interesting and revealed useful information about individual participants, it did not effectively measure the parameters we were interested in because: The group had a solution focus whereas the Disability Questionnaire is problem based The questions did not cater for the subtleties of change in constructs that had appeared to take place Questions were purely about communication whereas the groups issues extended beyond these confines. We have continued to run these monthly groups to good effect and hope to establish an alternative measure that better reflects changes that might have occurred for individuals. The structure of the Communication Disability Profile (Swinburn & Byng, 2006) has the potential to reflect some of the changes in attitude evident in participants comments. As this measure looks at changes in constructs relevant to the client at a given time it should be possible to ascertain whether someone

rates anger, frustration or determination as most representative of their general state.

Ambience

This group differs from others because: 1. The ambience was largely determined by the facilitators adherence to the NLP presuppositions. 2. There was no defined structure. 3. Group members were not actively taught or led by the facilitators. Through skilful questioning and responses the participants were encouraged to explore and discover their own resources and to examine their own experience of life using various frameworks offered by NLP . 4. The skill base of each group participant (whether client or facilitator) was considered of equal value. 5. The length of time between sessions encouraged participants to integrate their learning and experience into daily life. They did not become reliant on the group. Participants who lived a fair distance away could attend and, where possible, were left to organise transport themselves to promote further independence from the group. Pound (2004, p.41) suggests, Allow your therapist expertise to interact with but not overpower the expertise of the person living with aphasia. Offer experiences and insights but do not make assumptions that they fit this particular individual. For all of us it is important to understand how we operate, and what we can do to improve our functioning in any given situation. NLP focuses on discovering as individuals where we find ourselves now - and our available resources - to realistically choose our destination and how to get there. It offers the potential to consciously access the resources we have available in communication, to be effective in our contact with others. Maggie Wallis is a speech and language therapist with NHS Highland in Inverness, e-mail maggie.wallis@ SLTP hpct.scot.nhs.uk.

References

Pound, C. (2004) Dare to be Different: The Person and the Practice, in Duchan, J.F. & Byng, S. (eds.) Challenging Aphasia Therapies. London: Psychology Press. Kubler-Ross, E. (2005) On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss. New York: Simon & Schuster Ltd. Swinburn, K., Porter, G. & Howard, D. (2004) Comprehensive Aphasia Test. London: Psychology Press. Swinburn, K. & Byng, S. (2006) Communication Disability Profile. London: Connect Press.

Resources

* Connect www.ukconnect.org * Entrapment - www.foxmovies.com/entrapment/ * Lee Silverman Voice Treatment - www.lsvt.org/ * Robert Dilts - www.nlpu.com/

REFLECTIONS DO I STRIVE FOR A CURIOUS RATHER THAN CRITICAL ATTITUDE TO MYSELF AND OTHERS? DO I ACCEPT MY MENTAL ATTITUDE IS CRUCIAL TO THE RESPONSE I RECEIVE? DO I HELP PEOPLE ACCESS THEIR OWN RESOURCES?
How has this article been helpful to you? What are you doing to help clients find their own resources? Let us know via the Winter 07 forum on the www.speechmag.com members area.

Recommended reading

Burns, K. (2005) Focus on Solutions. London: Whurr. Felson, J. & Byng, S. (2004) Challenging Aphasia Therapies. London: Psychology Press. McDermott, I. & Jago, W. (2001) Brief NLP Therapy. London: Sage. OConnor, J. (2001) NLP Workbook. London: Harper Thorsons Element. Walker, L. (2002) Consulting with NLP. Oxford: Radcliffe.

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fEATURE: multi-professional approaches

peech and language therapists are very skilled multi-disciplinary workers. In addition to being natural communicators, the nature of the job brings us into contact with a number of different teams and settings. Many of us function within teams built around a clients medical needs or place of education; these can be multi-disciplinary (within health) or multi-agency (health and education). Others particularly in the adult learning disability field are an integral part of multi-agency teams that cross health and social care. Most recently we have been involved in the transition to Childrens Trusts in England. This is seeing the removal of structural barriers between education, care, family support and health to enable formalised, fully integrated services for children. It is clear that the goal of redesigning the structure of childrens services is to improve life outcomes. As Pugh (2007, p.viii) says, Young children and their families do not see their needs for early education, health care, job or housing advice in separate silos, and neither should the professionals working with

Team talk
them. Multi-agency working was to be encouraged as the most effective way of responding to the needs of service users. But the practicalities and challenges of managing such transitions cannot be underestimated. How do we build in professional leadership and support so that the quality and standard of our individual contribution to a multi-agency service is assured? To find out how we might move forward, I asked eight speech and language therapists to share their experience of working with other professionals. Coming from a Language & Communication Resource, Helen Daly was used to working with education colleagues and parents. She feels fortunate to have been able to use that experience at a strategic level as principal speech and language therapist for paediatrics in Wakefield over a period of exciting change. Three years ago dissatisfaction among parents with the way speech and language therapy was provided to schools led health and education authorities to organise a multi-agency conference and strategy group along with parents and voluntary services. Helen says Research shows that barriers of

The advent of childrens centres in England heralds a massive change for public services, with all the ensuing hopes and fears. While speech and language therapists are already skilled multi-disciplinary operators, multiagency and fully integrated working require a further shift in attitude. Editor Avril Nicoll talks to Helen Daly, Christina Barnes, Judith Delve, Kate Evans, Karen Bonham, Gerry Walsh, Hayley Dench and Karen Davies about their experiences.
READ THIS IF YOU WANT TO MOVE CONFIDENTLY TO MULTI-AGENCY WORKING BREAK OUT OF TRADITIONAL WAYS OF WORKING INFLUENCE BUDGET HOLDERS AND COMMISSIONERS

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fEATURE: multi-professional approaches

terminology, training and practice need to be overcome. We have gone from a fairly fragmented to a very collaborative service, with people really working together to benefit all children. Parents seem happier and as a clinician I feel more confident in my role. A Training Plan for teachers, outreach teams, the diversity service and educational psychology now covers speech / language and social communication / interaction. Through I CANs audit tool School Talk, (www.ican.org.uk) schools identify their training needs, while Bradfords Talking Partners project (www.bradfordschools.net) forms the basis of joint training to schools from speech and language therapy, educational psychology and the advisory service. An outreach advisory teacher in language and communication works alongside speech and language therapists. A Post Graduate Certificate of Education in collaborative practice for teachers and speech and language therapists has started at the University of Cumbria in Wakefield and Helen hopes this will spawn outcome evaluations. With strong leadership, training and a shared philosophy, expectations and responsibilities in Wakefield are shifting. Down in Wiltshire, Christina Barnes also works with education services. As a member of the South Wales and West Special Interest Group in deafness she took a lead role in developing care pathways for assessment and intervention with children who have a hearing impairment (Barnes, 2004). These continue to be amended to suit local circumstances such as availability of specialists. Parents and other professionals feel happier because they are clear about the levels of service delivery when, who, what to expect. This has been particularly helpful in relation to working with teachers of the deaf. Christina finds care pathways help parents and other professionals adjust to the realisation that once a week therapy with a specialist may not be the most appropriate input for the child. Instead, the specialist therapist is seen as one contributor to the creation of a 24/7 enabling environment. The care pathways have training built in, and the training offered to teaching assistants includes a piece of reflective writing about the impact of their learning on how they are able to support their named pupil. Christinas vision is for needs centred care pathways written alongside specialist teachers which would help identify the lead / responsible person at different times. She muses, Perhaps education could get management support and time to write their own care pathways first, then we could work on bringing them together? Care pathways have also been transformative for Judith Delves stroke team and consistency of provision across district general hospitals in Shropshire; although this is largely a multi-disciplinary rather than multi-agency service, the results suggest care pathways could be equally useful in a multi-agency context. Judith emphasises the value of face to face discussion to effective multi-disciplinary working, but adds that care pathway paperwork lends itself to audit to ensure standards are being met. The Royal College of Physicians Guidelines on Stroke and the National Sentinel Stroke Audit Programme (www.rcplondon. ac.uk) have been a really positive driving force. As

well as highlighting the need for improved clarity of note keeping, audit results have provided evidence for a bid to train nurses to screen for dysphagia within 24 hours of admission. Although team members at the coal face were already working well together, care pathways have raised the profile of the professions contribution with nurse managers and consultants.

Think positively

Judith reckons that, Local guidelines often reflect available staffing. The only way in the modern NHS to keep standards up is through a national organisation with a lot of power saying what we are expected to deliver. While targets may seem unattainable, you can think positively about the rationale behind them and how you can go some way towards meeting them perhaps through offering training or developing information leaflets. A settled staff with good leadership helps create a flexible approach to joint working. Judith finds joint assessments particularly useful, noticing clients can communicate differently for example during a physiotherapy session in the gym. In Gloucestershire, Kate Evans also shadows clients in different environments, and a calming sensory session with an occupational therapist can carry over to a communication session.

As communication specialists we are particularly good at 'opening up spaces'; together with what we know clients and families want, this should give us confidence to handle whatever challenges multiagency working presents.
Kate works in two 8 bedded in-patient units for adults with learning disabilities who have additional mental health, autism or challenging behaviour needs. Not only is multi-disciplinary and multi-agency working an aspiration, Its the only way we can work! Care pathways are again seen as crucial, to the extent that the Trust has a care pathway co-ordinator. Kate says, Care pathways put the client at the centre and stop us being in our little ivory towers. The team uses the East Kent Outcomes System model and the focus from the start is on agreeing a core aim enabling the person to be discharged. Each professional says what they will do to enable this to happen. Within the team the communication assessment is recognised as a priority so other professionals know how to communicate effectively with the person in terms of levels of understanding, expressive ability and whether additional strategies such as visual material are needed. More radically, a New Ways of Working conference has turned a nursing recruitment problem into

an opportunity for newly qualified professionals from other disciplines. Nursing money is funding a band 5 newly qualified speech and language therapist for two years to work a full shift system. The goal is to get effective communication at all times through modelling. Initially the nursing team felt threatened but they now feel more positive, and see it in terms of supporting clients. Kate is supervising the band 5 and the impact and challenges will be formally evaluated. Multi-agency working here with social workers, advocates and independent Mental Capacity Act advisors is at an advanced level but Kate wants it to extend to better outreach partnerships and so reduce the need for readmissions. Like Kate, Karen Bonham is passionate about spreading the benefits of multi-disciplinary working. She is also in a very specialised environment, in this case a regional neurorehabilitation unit for 16-65 year olds with acquired brain injury. Karens tightly knit team uses lean working. Borrowed from industry, this approach looks at the effectiveness and efficiency of service flow to identify care pathway constraints and bottlenecks. Solutions have included increasing the team presence and ward rounds on acute sites to facilitate timely referral. This has been successful in reducing length of patient stay in the acute sector and has indicated the need for developments at the pre-admission and discharge stage of the pathway. A clinical specialist across the acute and rehabilitation sectors has been funded and there are plans to appoint a discharge liaison nurse. The physiotherapists have also started flexible scheduling of shifts so they are there when clients are dressing or carers are visiting to maximise carry over of skills. Rehabilitation diaries, key workers, a client centred approach and discharge planning from the start set up realistic expectations. If a client is aiming to go home, they are encouraged to aim to go home safely. Goal mapping identifies the steps needed to achieve their goals, however unexpected. One client wanted hair extensions! When we tied it down, it meant she wanted to fit in physically with her group of friends and develop her social communication skills. Another client had a wedding planned, so the team had to consider issues from mobility, aids, equipment and car transfers to feeding requirements, medication and working with carers.

Cross-pollination

Karen likes the role blurring of multi-disciplinary work because You can work outside the box. Newly qualified therapist Gerry Walsh also says, I really enjoy working in this way. I may have found it limiting with speech and language therapists only I like the cross-pollination and being able to problem solve. There is an opportunity on a rolling basis to learn and to impart knowledge this builds confidence and respect. Working with adults with learning disabilities across two multi-agency teams in Kent, Gerry shares an office with a clinical psychologist, two care managers and a nurse. I see us as a set of people who can work holistically together. We see the whole picture and are a group of advocates rather than just one.

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Gerry finds the different teams function in different ways according to management style, average age or even a new member of staff. While team away days, shared notes and case presentations all help, she believes the most effective way to build relationships is through spending time together and talking. Hayley Dench agrees that - while it might sound clichd- The key to the whole thing is communication. We need to create a forum for discussion where people are open, honest, and prepared to be flexible and to compromise. Your vision might need to change and that adjustment can be hard. Working for an acute Trust in Birmingham, Hayley is involved in a partnership project with three Stroke Association Communication Support Coordinators and a community Trust. While speech and language therapists focus was for clients to get the most out of groups, the Stroke Association was pushing for client-led, functional goal setting. Working together they have developed an electronic resource to help the Communication Support Coordinators and their volunteers select appropriate activities for individuals when attending the groups. The project will be evaluated for its impact but Hayley already sees that the collaborative approach has led to a more useful resource than she envisaged. It is electronic rather than paper based and referrals are now supported by suggestions of activities and the level of cueing the client benefits the most from. The terms and language used in the documentation was guided by the Communication Support Coordinators. Hayley says all parties need to stop feeling that changing the way we have always done things is a threat, as in multi-agency working it is not necessary to compromise your integrity as a professional. Karen Davies is a speech and language therapy manager in Trafford. Her job as a professional manager for speech and language therapy is due to change as all childrens services are reorganised into an integrated Children and Young People Service. A long-time advocate for children and for the profession, Karen is facing the change with a mixture of optimism and trepidation. While accepting the transition will not be smooth she recognises a can do attitude is needed, with a focus on what is best for children and families. We need respect for the people we are working with, clarity about our roles and responsibilities and an attitude that doesnt view the new structure as an instant threat to the way we work. Karen believes the service in Trafford has many examples of successful multi-agency working which should provide a blue print for further integration of services. She is in no doubt that speech and language

10 steps to better multi-professional working


1. Take responsibility - be proactive 2. Spend time talking together 3. Focus on solutions and outcomes 4. Be flexible 5. Learn from colleagues and support their learning 6. Reflect, audit and evaluate 7. Build on strengths and professional networks 8. Offer joint assessment and agree roles and responsibilities 9. Cut out the jargon 10. Show what you can contribute
Join the multi-professional working discussion in the www.speechmag.com members area.
therapy is in a strong position to become an essential partner in newly established integrated teams. If integration is carefully designed, then the outcomes should be better for our users. Karen says we should achieve: 1. Quicker access to the right support 2. Prevention of significant secondary problems 3. More joined up targets 4. Quicker access to the right support in a crisis 5. Common standards and equity of provision 6. Reduced confusion of terminology and diagnosis. Karen hopes the process will be evaluated thoroughly, with speech and language therapy taking an active role. She suggests this is an area that the Royal College of Speech & Language Therapists could be involved in commissioning. Karen has found evidence that multi-agency working is successful in smaller teams who have

professional back-up, so her main reservation is around the weakening of professional support. Professional leadership within an integrated team can guarantee standards of practice, safety, effective recruitment, supervision and continuing professional development opportunities. She is unclear how this will continue when former heads of service take on multi-agency roles. Whilst speech and language therapists are very good at creating networks of support, she believes this cannot be left up to chance and needs to be carefully planned and monitored. Gerry Walsh agrees that in multi-agency working there is more personal responsibility to ensure supervision is adequate and appropriate. Her small speech and language therapy team makes time and space to get together and are always available by phone, text and e-mail. Gerrys line manager is a care manager who used to be a nurse but she also has her head of profession and another senior colleague as a clinical resource. Similarly, Kate Evans finds day to day management and supervision by a nurse is appropriate to her working context, and she can access more specific supervision from her professional lead or from the Mental Health Special Interest Group as required. French (2007) provides a helpful historical context for multi-agency working, where current structural changes can be seen as part of a continuum rather than experienced as an isolated upheaval. In the same text Whitmarsh (2007) addresses ethical anxieties around confidentiality, a major barrier to multiagency working. She argues, Considering ethical practice as relational opens up spaces in which we can discuss the issues while trying to weigh up which principle may, on this occasion, be of over-riding use to the specific situation (p.94). As communication specialists we are particularly good at opening up spaces; together with what we know clients and families want, this should give us confidence to handle whatever challenges multiagency working presents. As for where to start if you feel you are facing a brick wall, Helen Daly suggests the answer is to Get out and find people who share your philosophy, because they do exist. The key is talking to people, finding out their viewpoint and starting from there. SLTP

Acknowledgements

Many thanks to the speech and language therapists (names in bold) who gave me their time and the benefit of their experience.

References

Barnes, C. (2004) No borderline just a pathway, Speech & Language Therapy in Practice Autumn, pp. 14-17. French, J. (2007) Multi-agency working: the historical background, in Siraj-Blatchford, I., Clarke, K. & Needham, M. (eds.) The Team Around the Child. Stoke on Trent: Trentham Books, pp. 47-66. Pugh, G. (2007) Foreword, in Siraj-Blatchford, I., Clarke, K. & Needham, M. (eds.) The Team Around the Child. Stoke on Trent: Trentham Books, pp.vii-ix. Whitmarsh, J. (2007) Negotiating the moral maze: developing ethical literacy in multi-agency settings, in Siraj-Blatchford, I., Clarke, K. & Needham, M. (eds.) The Team Around the Child. Stoke on Trent: Trentham Books, pp. 87-103.

Resources

Karen Davies recommends: Rushmer, R. & Pallis, G. (2003) Inter professional working: the wisdom of integrated working and the disaster of blurred boundaries, Public Money and Management 23 (1), pp.59-66. Karen Bonham says there is more on lean working at www.dh.gov.uk/ahpbulletin (September 2007).

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assessments assessed (4)

We continue our series of reviews to help you decide if an assessment would meet your needs, this time considering GRASPS, the Assessment of Dysphagia in Adults (English and Spanish) and the VAST.

Assessments assessed
It is essential for the tester to be thoroughly familiarised with the Test Record Form. It is vital to deliver the sets of words with the correct intonation and surprisingly difficult to do this accurately hence, practice is essential before administering the assessment on an unsuspecting child! It is also important to explain the test to the listener to establish the method of response required, whether same or different or pointing to the words / pictures on the page. When administering the intonation sets (such as no no no), one of the children and the deaf adult were confused by looking at the printed words with accents they found it easier to just listen and then say same or different. As this assessment is purely based on auditory perception, no eye contact should be made during the main part of the assessment. It is allowed in the vocabulary section (if administered). As deaf children are so used to picking up visual cues from lip patterns, some children found this difficult and were constantly turning around out of habit. This could be overcome by using an embroidery hoop with light fabric; however, the therapist must ensure that her eyes do not give any clues as to the correct response. It is important for the tester to be positioned on the cochlear implant wearers aided side. It was helpful to use the vocabulary section with all the children, to ensure they were aware of some of the less familiar words like cart, show, and pit. There is no formal scoring involved apart from pass or fail of a particular block. If the individual fails two out of five presentations on any one contrast it is counted as a fail. The assessment highlights areas of difficulty. For example, the adult I assessed has severe bilateral sensorineural hearing loss. She had problems discriminating between flat and falling intonation; also CVC (consonant, vowel, consonant) words with unvoiced labiodental or alveolar fricatives in word initial position followed by close front open vowels (eg. feet/seat). Two other participants had difficulty with flat and falling intonation and two had problems with differentiating between alveolar approximants and labialvelar approximants. The participants views varied: Boring, too long Fun, interesting, quite easy Interesting. So, to buy or not to buy? GRASPS is a screening tool to investigate speech perception of deaf children and adults. Its 66 appears a modest price to pay when compared with the majority of assessments costing far in excess of this amount. I should emphasise that it was difficult to find children on the clinical caseload with poor speech perception who were also old enough to understand and participate in the assessment. Due to the implementation of the NHSP (Newborn Hearing Screening Programme) and the MCHAS (Modernisation of Childrens Hearing Aid Services) - and therefore earlier diagnosis - and also implantation of cochlear implants at younger ages, deaf childrens speech perception and speech production abilities have generally improved. An assessment that looks at morphological endings of words may be more useful as this is an area of difficulty in speech production in many deaf children.
Amanda Compton-Cook is a highly specialist speech and language therapist for hearing impairment in Amersham.

Dysphagia in Adults
Barbara Milford likes the practical style and breadth of this assessment book and its accompanying CD-ROM.
Assessment of Dysphagia in Adults Resources and Protocols (A Bilingual Manual) Maria H. Provencia-Arambula, Dora Provencio, M.N. Hegde (2006) Plural Publishing ISBN 1-59756-095-2 57.00
This book of assessments and resource sheets contains practical information and advice in English and Spanish. The style makes it easy to read as it takes you through all aspects of dysphagia in adults. It contains information on criteria for other assessments such as FEES (Fibreoptic Endoscopic Evaluation of Swallowing) and videofluoroscopy. All speech and language therapists who work with clients with dysphagia would benefit from this book. It is also useful for training purposes, for clients, carers and other professionals. The book guides you through the whole process, offering information on all aspects of assessment procedures. This includes a patient interview, screening by nurses, videofluoroscopy, tracheostomy and bedside signs. There is an excellent introduction to using the book and sections on feeding and swallowing. Although this is aimed at the American market it could be easily anglicised as required. The bonus is the CD with downloadable files which can be modified to suit individual needs. A good buy for any department and an invaluable reference book.
Barbara Milford (Daniels) is a speech and language therapist living in Granada, Spain.

GRASPS

Amanda Compton-Cook finds this modestly priced screening test useful with a particular sub-group of people with hearing impairment.
Graded Auditory Speech Perception Screen (GRASPS) Rachael Parsloe and Jill Morrell STASS Publications 66.00
This assessment is designed to determine which acoustic cues are used by the deaf listener to perceive speech. The therapist can then use this framework to develop her own hypothesis and plan future therapy. GRASPS is suitable for both oral or signing adults and children. It consists of a ring bound A5 book containing words and pictures split into three sections: Vocabulary; Section A; Section B. Section A contains items which include determiners, thus giving additional VOT (Voice Onset Time) cues to the listener. The listener could attempt this part of the assessment even if s/he has listening ability in the very low frequencies only, combined with good temporal resolution. Section B requires the listener to have a wider ability across frequencies and a degree of frequency resolution plus temporal resolution. I used the assessment with six individuals:
9 year old girl Profound bilateral sensorineural hearing loss Cochlear implant wearer Severe bilateral sensorineural hearing loss Hearing aid wearer Severe high frequency bilateral sensori-neural hearing loss Hearing aid wearer Moderate-severe bilateral sensori-neural hearing loss Hearing aid wearer Moderate-severe bilateral sensori-neural hearing loss Hearing aid wearer Severe bilateral sensorineural hearing loss Hearing aid wearer

10 year old boy

VAST

10 year old boy

In spite of concerns about the quality of its picture material, Sharmila Bramley, Maggie Wallis, Sandra Hewitt and Iris Clarke feel this assessment has a place within specific rehabilitation and research settings.
The Verb and Sentence Test Roelien Bastiannse, Susan Edwards & Judith Rispens (2002) Age range 18-80 years Harcourt Assessment 283.22 (inc. VAT)
This comprehensive, diagnostic test for aphasia investigates the comprehension and production of verbs and sentences. It consists of a battery of 10

13 year old boy

15 year old boy

Female adult

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assessments assessed (4)

tests, one or more of which can be selected to help in understanding a clients difficulties. It is not necessary to use the whole battery as there is no aggregate score, therefore each test can be used individually. It is adapted from the original Dutch version. The authors aims are: to make use of and provide theoretically motivated linguistic insights for the assessment to be clinically relevant for the test to be useful with people with different types of aphasia. The 10 assessments cover: 1. Verb comprehension 2. Sentence comprehension 3. Grammaticality Judgement 4. Action naming 5. Filling in finite verbs 6. Infinite verbs in sentences 7. Sentence construction 8. Sentence anagrams with pictures 9. Sentence anagrams without pictures 10. Wh-anagrams. The VAST aims to fill a much-needed gap in language assessment. Having welcomed a tool that contains so many tests of verb comprehension and production, we found ourselves surprisingly hardpushed to find clients who were suitable candidates. It seems that although the VAST has been thoughtfully researched, its tests are suited to a very specific population - one that is at a significantly higher level of language function than could generally be found in the context of our district general hospital. Here, the vast majority of clients with aphasia are either very low-level or too unwell to cope with the complexity of the test. We found ourselves asking the question whether such an assessment battery has a place in an acute rehabilitation setting, at a time when more and more people are surviving strokes of extreme severity and are left with such severe communication deficits as to make this type of assessment overwhelming and not relevant to their immediate needs? Our feedback therefore is based on a handful of clients seen in the rehabilitation phase of their recovery, who were several months post-onset with higher cognitive and language skills. In general, although the VAST has a good variety of subtests and very good explanation of its linguistic and psychological basis, we felt there was incomplete guidance on how to conduct and score the tests. For instance, does a close semantic alternative to the target (cleaning for polishing) constitute a correct response? We are all experienced therapists but we each required quite an investment of time to come to grips with the scoring. On the other hand, one very useful addition to the manual is the Therapy Suggestions section with four case examples; these were interesting and helpful. One of the most salient points agreed upon by all our therapists and clients was the extremely poor quality of pictures for the tests. This is not a trivial matter for an assessment of language function, so we wondered why the pictures are drawn in scrawls and shaky scribbles rather than clean, clear pictorial representations of the intended action. There appear to be

at least two different artistic styles, one more cartoonish than the other, but equally detracting and often hard to interpret. In addition, some of the images and themes in the stimulus items are of questionable tone. The Sentence Comprehension Test has people who bite, strangle and scratch each other; one choice has a man with a gun who guards a woman bound with rope or a boy who is bound and gagged. If there is a sound argument or cognitive / psychological evidence base to justify the authors artistic approach, they make no reference to it. In the Verb Comprehension Test the pictures were hard to interpret. The arrows to the target area are intended to be helpful but some clients found them distracting. The choice of verbs also seemed obscure to some (eg. grating) and some target word choices outside the clients realm of experience (eg. conduct). In the Sentence Comprehension Test, we queried the usefulness of the subject cleft sentences (eg. it is the girl who scratches the boy), in terms of both normative frequency in English and appropriateness to this client group. The Grammaticality Test we felt was a bit misleading, as the sentences do not display incorrect syntax, but rather incorrect logical or semantic roles (eg.The man is boiled by the egg). So we were not convinced that the test distinguishes parsing from mapping impairments, as intended by the authors. We felt the Sentence Anagrams were very useful for providing contextual clues to clients and for gauging self-monitoring skills. We noted marked differences for active versus passive / reversible sentences, so one adaptation we might suggest is to record the processing time for responses as it may reflect the clients learning ability through the process. Some of the pictures were also ambiguous for eliciting the target response (eg. the boy is hitting the girl, but the girl appears to be hitting out also). In terms of the layout, with the large Comprehension Test book it was difficult to display / hide the relevant stimulus items and we found it quite unwieldy. In contrast, the format of the smaller stimulus books made these tests much easier to administer. What is nice about the VAST is that it compares performance across different conditions (such as isolation and sentence levels). But would it not provide even more valuable information if it were the same verbs being tested? Some items are repeated, but not others. The tests are, in theory, vast enough in range to offer a choice of selection for each client and, as one therapist put it, explore issues that were relevant to (him). In this sense it has very good potential for being customised to the needs of each client and for planning treatment. However, there remains the drawback of so few clients meeting the level of ability required for the test. Overall, we think the VAST is theoretically sound and has a place in some specific rehabilitation settings, perhaps as one of the resources in a large department or alternatively in a research context, but at over 283 for the entire kit, we would strongly recommend a trial period before making a commitment to obtain it.
Sharmila Bramley, Maggie Wallis, Sandra Hewitt and Iris Clarke are speech and language therapists with Inverness Hospitals Adult Services.

news extra
Bercow Review Call for Evidence
John Bercow MP is asking speech and language therapists, other professionals, parents and young people to participate in his comprehensive review of speech, language and communication needs in England. The MP is leading the review on behalf of the Secretary for Children Ed Balls and the Secretary for Health Alan Johnson. The intention is to advise the Government by July 2008 how the very best provision can be mirrored in all areas, so every young person up to 19 years old with speech and learning difficulties gets support as early as possible. The Government has given the review a very wide brief, reflected in the questionnaire which is being used to gather evidence. This evidence which must be received by 18 January 2008 - will help the review group draft its interim report. The review will encompass universal and specialist services, commissioning, accountability, management, leadership and recruitment. Specific commitment is given to consideration of effective provision of assistive and augmentative communication technology, transition and support for parents. Alan Johnson adds that, speech and language therapists have a significant public health role to play John Bercow is Chair of the All Party Parliamentary Group on Speech and Language Difficulties. He said, I am determined that this independent, non-partisan review should make a real difference to the lives of young people with communication needs, their parents and the professionals that work with them. He continued, My review and expert advisers are looking at what works, where problems lie and what practical reforms and improvements can be made. He added that although he has already started visiting speech, language and communication centres, we need the active involvement and engagement with the people that matter most children themselves, parents, schools, local authorities, speech and language therapists and professionals from across the NHS. Download the questionnaire from www.dfes.gov.uk/ consultations/

Keeping up standards

The Health Professions Council has revised its Standards of Proficiency for speech and language therapists. The minor changes follow a review by representatives from the Council, the Royal College of Speech & Language Therapists and client groups, and a consultation process. w w w. h p c - u k . o rg / a s s e t s / d o c u m e n t s / 10000529Standards_of_Proficiency_SLTs.pdf The Health Professions Council has also produced a Fitness to Practise annual report which includes information about the types of complaint it received and how it dealt with them. w w w. h p c - u k . o rg / a s s e t s / d o c u m e n t s / 10001C84FTP_annual_report_2007_cfw.pdf
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user involvement

Beyond impairment
READ THIS IF YOU WANT TO GET BETTER AT GOAL SETTING SHIFT THERAPY EMPHASIS TO ACTIVITY AND PARTICIPATION DEVELOP MORE EFFECTIVE OUTCOME MEASURES
Sylvia Dickson

Having carried out much needed research into the activity and participation elements of dysarthria with clients and carers, Sylvia Dickson, Marian Brady, Rose Barbour, Alex Clark and Gillian Paton took the unusual step of giving those involved the opportunity to reflect on the findings. What followed demonstrates the potential of the shared enthusiasm of users and therapists to transform services and outcomes.
the evidence base for speech and language therapists has been recognised (SEHD, 2002) and doing this in partnership with clients and their carers (SEHD, 2003) would generate an understanding of the activity and participation impact of dysarthria while creating a foundation from which to develop key outcome measures. Such measures would be functionally relevant, reflect the individuals experiences of activity and participation and enable therapists to evaluate the success of therapy in relation to these parameters. These developments would allow a shift in therapeutic emphasis away from the approaches currently available that focus on the pathology and the dysarthric impairment (WHO, 2001), to a participation-based focus that addresses client and carer-identified priorities. A joint project completed by the Nursing Midwifery and Allied Health Professions Research Unit, Glasgow, University of Dundee, University of Alberta, Canada and NHS Greater Glasgow and Clyde addressed this issue. Twenty-four individuals with varying severities of dysarthria following stroke were recruited from twelve hospitals across Scotland for semi-structured, in-depth interviews over a 12 month period. Therapists from six NHS Boards (Ayrshire & Arran, Forth Valley, Grampian, Greater Glasgow & Clyde, Lanarkshire and Tayside) participated in the study by approaching suitable individuals from their caseloads and informing them about it. The results are fully described elsewhere (Dickson et al., in press) but indicate that the effects of dysarthria following stroke extend beyond the physiological characteristics of the impairment. In turn, the resulting communication difficulties lead to changes in self-identity, relationships, social and emotional disruptions and feelings of stigmatisation or perceived stigmatisation. For more than half the participants, dysarthria had a negative impact on self-identity. Individuals reported feeling different, and wanting to be treated as normal. Many described changes in how their voice sounded, which also had a negative impact on self-identity. Relationship disruptions were common. Interactions with strangers were particularly problematic and were frequently associated with stigmatisation. Dysarthria also had considerable social implications, with more than two thirds of participants experiencing social disruptions. For example, speaking to people in shops or by telephone was problematic for many participants, with two thirds reporting avoidance of these situations. The communication difficulties experienced by participants also had associated emotional implications, with nearly all reporting emotional disruptions, including depression, anger and frustration. Interestingly, the impact of these difficulties was equally as significant for mildly-affected clients as it was for those with moderate impairment, with participants continually striving to get their speech back to normal. Although participants generally spoke about the negative impact of dysarthria, a few discussed how dysarthria had had a positive impact on certain aspects of their lives. One participant reported that their dysarthria had brought the family closer together, while another (who frequently worked away from home prior to his stroke) reported having a changed, more appreciative outlook on life.

ysarthria is a frequent consequence of stroke, experienced by approximately 2030 per cent of individuals in the early post-stroke stages (Warlow et al., 2000). Despite its prevalence, there is little research into the condition to inform practice. Searching the relevant electronic databases (such as Language and Linguistic Behaviour Abstracts and Cinahl) few papers focusing on stroke-related dysarthria are highlighted. A relevant Cochrane systematic review of the evidence relating to interventions for dysarthria confirms this (Sellars et al., 2005). What little information is available is concerned with the pathology of dysarthria (disease and diagnosis) and related impairments (symptoms and signs). Despite recognition of the psychosocial consequences of aphasia and other communication impairments, little consideration has been given to the activity (disability) and participation (handicap) elements of dysarthria (WHO, 2001). The central aim of a multidisciplinary stroke rehabilitation team is to ensure an individuals participation within their family, social networks and community (SIGN, 2002). Exclusion from participation in such circles however can be exacerbated by a co-existing communication impairment (Parr et al., 1997). As with many communication disorders the impact of the communication impairment extends beyond the individual to the family, in particular the spouse and children. Yet few have explored the nature of this impact of dysarthria, the obstacles experienced, expectations for the future and activities considered supportive of both the individual and communication. The critical role of speech and language therapists in communication and rehabilitation is often highlighted (SEHD, 2002) as is the key aim of poststroke dysarthria rehabilitation to maximise participation for the dysarthric speaker (SIGN, 2002). However, before this method can be adopted, an understanding of the psychosocial impact of dysarthria is required. Current approaches to the assessment, treatment and evaluation of effectiveness have arisen from the current pathology / impairment focus of the dysarthria literature and as a result are pathology / impairment-based. The need to extend

Reflections on findings

Dissemination is an important component of research and we wanted to include the research participants. We invited study participants, their carers and the recruiting speech and language therapists to comment on the results of the study; 4 participants, 4 carers and 9 therapists attended. After hearing the results, the attendees split into two groups clients/ carers and speech and language therapists - to discuss the implications of the findings on services and structures. Members of the research team recorded and facilitated the discussions. The discussions can be summarised into five themes: Delivery of therapy, Information needs, Education, Carers needs, and Discharge and longterm support. It is of note that issues arising and discussed within both groups overlapped. This clearly demonstrates the shared interest and enthusiasm for improving the support given to individuals with dysarthria and their carers.

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user involvement

1. Delivery of therapy

The groups discussed the implications of the findings in relation to the manner in which speech and language therapy is delivered to this client group. Many of the speech and language therapists described how, as a result of the study findings, they would now view dysarthria as much of a priority as other communication problems and difficulties experienced post-stroke. The individuals with dysarthria highlighted geographical and regional variations in the manner and frequency of service provision and called for these differences to be addressed. The experiences of treatment provided in small units (rural, mixed units) was discussed positively and believed to be better than that provided in larger units (stroke specific units and rehabilitation centres). Communication between departments was seen as problematic, particularly for larger units. Considerable time was spent discussing the concept of normal speech. The speech and language therapists described therapy which aims to improve speech, in many cases working towards a goal of speech that is perceived by others as normal. However, speech that is perceived as normal by others may not necessarily be considered normal by clients. This discrepancy might be reconciled by a matching of clients and carers needs to services through careful goal setting and detailed discussions of their expectations from therapy as well as recovery. The clients and carers felt a plan outlining what they could do themselves to improve the situation, including exercises and adaptive techniques, would be beneficial. The clients and their carers also suggested that an increase in the provision of services would allow a more appropriate response to the specific needs of individual clients over the course of experiencing dysarthria as a result of stroke. For example, they suggested that counselling might be offered to both clients and carers. It should be offered at different stages in the recovery (not just in the early stages) together with support and advice on moving on.

has long been identified as an area requiring attention. The group sought information in a variety of formats, not just in the form of information leaflets. Information described as helpful included the impact of dysarthria on the person and information on relevant support groups.

3. Education

Alongside providing additional information to clients and their carers the groups described the need for more information and education for the health care professionals themselves on what dysarthria is and how best to support communication with people who have dysarthria. The clients and their carers in particular highlighted the importance of adequate GP support, yet felt GPs needed more education not only in relation to dysarthria but also more generally in relation to stroke. Both groups discussed the need to raise the profile of dysarthria amongst the general public, in particular the association between stroke and the older population (the participants in our study were aged between 34 and 86). How this could actually be done was thought to be problematic, though the new stroke campaign (The Stroke Association, 2007) may go some way towards addressing the lack of knowledge about stroke amongst the general public.

important. The study highlighted that people may still be experiencing the impact of dysarthria years after its onset. The difficulties inherent in deciding when it is appropriate to discharge clients was discussed, but both groups agreed the possible psychosocial impact of dysarthria should be discussed with clients and their carers before discharge. The clients and carers recognised the difficulties for health care professionals in deciding when to offer support / advice. The speech and language therapists suggested an open door referral system might be appropriate, with clear instructions for those clients being discharged on how to re-access the service if needed. However, as talking on the telephone was now problematic for many of the clients, issuing a contact telephone number to re-access services may not be the most appropriate way. There was a clear consensus that support and services should not just be offered at the onset of dysarthria and support is needed not just from the speech and language therapy services, but from across the stroke care services. We found bringing together the people who were actively involved in the research a very valuable experience. The participants, carers and speech and language therapists who attended said they found it beneficial to hear and learn from other peoples experiences. Sylvia Dickson and Marian Brady are based at the Nursing Midwifery and Allied Health Professions Research Unit in Glasgow, Rose Barbour is based at the University of Dundee, Alex Clark is based at the University of Alberta in Canada and Gillian Paton is based at the Royal Alexandra Hospital, Paisley. Address for correspondence: Sylvia Dickson, Trial Coordinator, NMAHP Research Unit, Glasgow Caledonian University, 2nd Floor Buchanan House, Cowcaddens Road, Glasgow G4 0BA, tel. 0141 331 8106.

4. Carers needs

2. Information needs

Carers are often a clients main communicative partner and it is now commonplace for speech and language therapists to involve carers when working with clients with other acquired communication disorders such as aphasia. The carers attending this event called for increased involvement in speech and language therapy and described how they felt excluded from therapy and related discussions. It was also acknowledged however that some clients may not want carers involved in their therapy / discussions and so involvement of carers should be carefully considered. Overall both groups recognised that carers of individuals with dysarthria can be significantly affected and should be supported either on a one-to-one basis or alongside the person with dysarthria.

Acknowledgments

The individuals with dysarthria and their carers requested frequent provision of information by all health care professionals involved. The information needs of the post-stroke population and their carers

5. Discharge and long-term support

Discharge and long-term support was discussed in detail and all agreed that long-term support is very

We thank the following for their valuable contributions to this study: the individuals with dysarthria and carers for their participation; the recruiting speech and language therapists; Chief Scientist Office, Department of Health, Scottish Executive for funding; Dr. Ellen Townend and Vikki Milne for their contributions. SLTP

References

Dickson, S., Barbour, R.S., Brady, M., Clark, A.M. & Paton, G. (In press) Patients experiences of disruptions associated with poststroke dysarthria, International Journal of Language and Communication Disorders. Parr, S., Byng, S. & Gilpin, S. (1997) Talking about aphasia. Buckingham: Open University Press. Scottish Executive Health Department (2002) Building on Success. Future directions for the Allied Health Professions in Scotland. Available online at: http://www.scotland.gov.uk/Publications/2002/06/14963/7817 (Accessed 21 October 2007). Scottish Executive Health Department (2003) Partnership for Care. Scotlands health white paper. Available online at: http://www. scotland.gov.uk/Publications/2003/02/16476/18730 (Accessed 21 October 2007). Scottish Intercollegiate Guidelines Network (2002) Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning. Available online at: http://www.sign.ac.uk/pdf/sign64.pdf (Accessed 21 October 2007). Sellars, C., Hughes, T. & Langhorne, P . (2005) Speech and language therapy for dysarthria due to non-progressive brain damage, Cochrane Database of Systematic Reviews, 3. Available online at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/ CD002088/pdf_fs.html (Accessed 21 October 2007). The Stroke Association (2007) Stroke is a Medical Emergency campaign. Available online at: http://www.stroke.org.uk/campaigns/ current_campaigns/stroke_is_a_medical_emergency/index.html (Accessed 21 October 2007). Warlow, C.P ., Dennis, M.S., van Gijn, J., Hankey, G.J., Sandercock, P .A.G., Bamford, J.G. & Wardlaw, J. (2000) Stroke: a practical guide to management. 2nd edn. Oxford: Blackwell Scientific. World Health Organisation (2001) International Classification of Functioning, Disability and Health (ICF). Available online at: http://www.who.int/classifications/icf/site/onlinebrowser/icf.cfm (Accessed 21 October 2007).

DO I RECOGNISE THAT SEVERITY OF IMPAIRMENT DOES NOT NECESSARILY EQUAL SEVERITY OF IMPACT? DO I LISTEN TO CLIENTS AND FAMILIES TO FIND WHAT WOULD MAKE A DIFFERENCE TO THEM? DO I BRING PARTICIPANTS IN PROJECTS OR AUDITS TOGETHER TO REFLECT ON THE OUTCOME? How has this article been helpful to you? What are you doing to work with users to improve services? Let us know via the Winter 07 forum on the www.speechmag.com members area.

REFLECTIONS

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reviews

reviews
SELF-HELP
How to be Yourself in a World thats Different Yuko Yoshida Jessica Kingsley ISBN 1843105047 9.99

AUTISM (1)

Common sense strategies

Autism, Play and Social Interaction Lone Gammeltoft and Marianne Sollok Nordenhof Jessica Kingsley ISBN 978 1 84310 520 6 11.99

ASPERGER SYNDROME

Asperger Syndrome and Bullying Nick Durbin Jessica Kingsley ISBN 978-1-84310-846-7 12.99

EARLY LANGUAGE

Chatter Matters (For every parent and carer of children from 0-5)

Easy to use

Useful strategies

A short, informative book covering the neurology of Asperger syndrome, the problems that can be experienced and suggestions for coping, its readable, conversational style speaks very much to the person with Aspergers. It sensibly encourages the reader to consider the book with a supporter so that information can be clarified as necessary. Some very helpful and common sense strategies are suggested. Aspects of the syndrome are discussed from a positive viewpoint, and how they might be developed or harnessed to best effect in the world of the majority. It is targeted very much at the high level autistic spectrum adolescent / adult, and may help to raise their self-esteem as they read it. Clinicians will find it helpful to gain an insight into this client group and as a self- help guide to recommend to them and their carers. Louise Allwright is a speech and language therapist.

Primarily practical

SYNDROMES

The authors intention is to provide a practical source of ideas for helping children with autism improve their social skills by playing games together. The book is short, easy to read and supplemented by clear photographs, making it accessible to both parents and professionals. The games, drawing on principles from TEACCH and PECS, are generally geared towards younger children, but could be adapted for different ages and developmental levels. The book is primarily practical, but provides some insights into why children with autism struggle with play, how working on play skills can help develop social skills and how games can be adapted to make them meaningful to children with autism. Carol Parry is a speech and language therapist with many years experience, currently working in Grange Park School with secondary aged children with autism and associated learning difficulties.

Nick Durbins book on bullying and Asperger Syndrome is an interesting read for therapists with experience of Asperger Syndrome and working with school-aged pupils. It will deepen your understanding and awareness of the issues and provide useful strategies to pass on to teaching staff. Many of Nicks ideas can be incorporated within social skills therapy to develop assertiveness skills and social understanding. Parents may also wish to read the book and will particularly enjoy the sections aimed directly at them. Bullying is an important topic and the book will be a valuable addition to your library. Catherine de la Bedoyere is a speech and language therapist working with adolescents with Asperger Syndrome at Northease Manor School, East Sussex.

PARENT-CHILD INTERACTION

This parents pack consists of a DVD and charts covering language development in, babies, toddlers and preschoolers. The charts are in an easy to use fold out book format and include useful hints on what children should be doing and how to encourage development. The DVD, introduced by Dr Tanya Byron, covers typical communication development, how real families use everyday activities to support language learning as well as parents describing their childs early communication problems. Clips of real children help parents relate to the principles of following a childs lead, giving them time and using repetition and expansion. There is a fun section on nursery rhymes for the whole family to enjoy. This easy to use pack would be useful as reinforcement of advice and to help parents further understand the therapy process. Some discussion may be needed beforehand as the introduction focuses a little too much on all the disadvantages of a language delay and some parents may be sensitive about this.

Kids in the Syndrome Mix of ADHD, LD, Asperger's, Tourette's, Bipolar and more! Martin L. Kutscher Jessica Kingsley ISBN 9781843108115 12.99

AUTISM (2)

The Miller Method Arnold Miller with Kristina Chretien Jessica Kingsley ISBN 978-1-84310-722-4 19.99

Baby and Me DVD Church Street Sure Start Local Programme & The Childrens Project www.socialbaby.com 18.50 inc. p&p

Learning To Talk, Talking To Learn (A guide for early years practitioners) Both DVDs from I CAN www.ican.org.uk Each postage only direct or 9.99 where sold

Enjoyable, affordable and useful

Quality video clips

A holistic approach

This short easy-read book takes a holistic approach, detailing clear profiles for each syndrome and the associated communication problems. It is useful for those with limited knowledge of the syndromes, with a chapter on medication and an extensive list of therapy ideas. Further resources and a reading list are detailed at the back. The American clinical diagnoses and education system references can be confusing but this value-for-money book will assist parents, teachers and therapists in working together. For clinicians beginning community work it would be a valuable resource. Hilda Ridley is a speech and language therapist working with adults with learning disabilities in the Gloucestershire Partnership NHS Foundation Trust.

Enlightening perspective

If you work with children with autism then read this book. It presents an enlightening perspective into their world that will help the reader to better understand and engage more meaningfully with them. The emphasis is very much on the practical, with step-by-step examples of intervention procedures and case studies, providing you with lots of ideas that can be incorporated into your own practice. The writing is simple, largely avoiding unwieldy jargon, and each chapter is broken down into bite-size sub-sections, with a useful summary at the end. Definitely a worthwhile resource. Anthony Caldwell works with children with autism in mainstream primaryand special schools in the West Kent area.

This easy to use 15 minute DVD shows excellent practical examples of early parent-child interaction. It includes both mothers and fathers from different ethnic backgrounds and can be played in English, Arabic and Sylheti. The DVD demonstrates useful strategies for developing pre-linguistic skills such as being face to face, imitating sounds and expressions, taking turns and waiting for a response. It emphasises the importance of parents as babys best teachers. It will be most useful in Sure Start or Childrens Centre settings as a training tool or with parent groups and could be used by speech and language therapists, health visitors and midwives. At 18.50 it is an enjoyable, affordable and useful team resource. Fiona Coughlan, Leanne Armstrong and Sue Paul are the speech and language therapy team at Sure Start for All, Warrington.

This Early Years Practitioners pack uses many of the same discussions and recordings of children and carers but illustrates how techniques can be incorporated into childcare settings. Additional sections include observation of good practice (without a narrator then with) to highlight modelling / expansion / waiting, and a panel discussion about career development. This feels stilted a problem with the other panel discussions scattered through the DVDs. A teaching student road tested the pack and, despite the age group being a little young for her, she found the age norms and Top Techniques very relevant and the whole pack easy to navigate. This DVD would be well worth buying to use as part of training courses or talks as the quality of the video clips illustrating the points made is excellent and will be relevant to a wide audience. (Both DVDs have a singalong rhymes section if you

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reviews

want to try interactive learning!) Helen Phillips works for Sure Start Carlisle South. She has over 20 years experience in paediatric speech and language therapy, including 5 as part of a Sure Start Team. This involves running regular courses for parents.

AAC

The Power of Communication DVD Communication Matters 8.00 (or 20.00 for 3) inc. p&p

Enhance training

values clients as they are - rather than attempting to mould them into something we are more comfortable with - may help to allay doubts and / or fears about political correctness. Buy this if you feel passionately about this type of intervention. However, you will need to read through to glean ideas, hints or tips. One thing is clear practitioners need to feel very comfortable with this approach abandon inhibitions all who enter here! Jenny Bland is a speech and language therapist working with adults with learning disabilities in Shropshire.

This emotive DVD gives a 15 minute summary of the variety of people who would benefit from AAC. It covers a range of environments including intensive care and promotes the need for prompt funding for communication aids. It is intended particularly for service managers and purchasers to support funding applications but is concise and clear enough to enhance training or short talks. The DVD emphasises the benefits of electronic communication aids and gives a taster of how symbols can be used. It would have been useful if it could have included a closer look at other forms of AAC to support approaches such as Total or Inclusive Communication. At 8 it is cheap addition to your training resources. Caroline Hucker is a speech and language therapist with Gwent Healthcare NHS Trust.

APHASIA

Clinical Aphasiology: Future Directions (A Festschrift for Chris Code) Martin J. Ball and Jack S. Damico (Eds.) Psychology Press ISBN 978-1-84169-670-6 39.95

preschool children. The signing level ranges from simple action rhymes to fully signed songs. Songs include those from the TV series, some nursery rhymes and many original songs and rhymes. The language level is mostly simple and repetitive. The accompanying CDs include all the songs so you can sing along although I found some songs too fast to sing and sign easily! The signs are clear from the pictures and there are also photos of children and adults using the key signs. There is no sheet music. The copyright notice suggests no copies can be made, but the author says "it was our understanding that a school or parent/carer/therapist would be allowed to copy/enlarge pages for their use as with all the other Makaton resources." Ruth Corkett worked as a speech and language therapist (Preschool) with Enfield PCT but now works at Ingfield Manor School in West Sussex.

LITERACY (1)

Clinical Approaches to Emergent Literacy Intervention Laura M. Justice Plural Publishing ISBN 1-59756-092-8 29.95

Logical structure

Food for thought

INTENSIVE INTERACTION
From Isolation to Intimacy Making Friends Without Words Phoebe Caldwell with Jane Horwood Jessica Kingsley ISBN 9781843105008 12.99

Anecdotal evidence

This book examines how to reach clients who present as unreachable. Written from the personal experiences of Phoebe Caldwell, it contains anecdotal evidence of how this approach (based on Intensive Interaction) works with specific clients. With over thirty years of experience, Phoebes enthusiasm is clear from beginning to end. An interesting read for anyone working with people with severe or profound and multiple learning disabilities or autistic spectrum disorder. At times it slips into a narrative style so it can be difficult to pick out salient points. The case studies are informative but examples of unsuccessful attempts would have informed the reader of how the client may react and how long to continue. Assuring the reader that the approach

This is an interesting, up-to-the-minute text with three separate sections: conceptual, research and clinical. However, this produces a volume which is unnecessarily over-technical in places, making it difficult to separate the wheat from the chaff. This creates an unbalanced read which may alienate less experienced and less academic clinicians - a shame, since many contemporary and controversial topics are represented. Each chapter has its own individual theme, providing plentiful food for thought with full, up to date bibliographies. A nice, common thread throughout is the support and acknowledgement of the psycho-social model championed by Chris Code. Great book, but not one for dipping into in a busy clinical setting. Andrea Szego is a speech and language therapist in Reading, working with adults in acute and rehabilitation settings.

EATING AND DRINKING

The Fun with Food Programme Therapeutic intervention for children with aversion to oral feeding Arlene McCurtin (Ed.) Speechmark ISBN 978-0-86388-566-2 39.99

This very readable book covers the emergence of literacy skills in the preschool and early years population. It is designed to equip speech and language therapists with both the theory behind, and useful strategies to support, emergence of these skills. Each chapter follows a logical structure containing relevant examples or case studies and there is useful repetition of key information between the chapters. There are also many good practical ideas for individual or group activities. A valuable resource for therapists looking to deepen their knowledge of this topic or for those working in a preschool setting or special provision for speech and language impairment, where development of literacy may be a concern. Coralie Gullick is a specialist speech and language therapist working in an Enhanced Provision for Speech & Language Impairment attached to a mainstream school in Essex.

Well-researched

SIGNING

Singing Hands Book 1 & 2 (with CD) Suzanne Miell-Ingram & Tracy Upton Makaton Vocabulary Development Project 22.50 each plus p&p

Fun and engaging

A welcome Makaton resource for anyone working with preschool to Key Stage 1 children. Easy to recommend to other professionals too. Singing Hands appeared in five CBeebies Something Special programmes. The music is fun and engaging, particularly for

This well-researched book is aimed at clinicians who already have experience in paediatric dysphagia and the impact that oral feeding aversion has on the life of the child and carers. Based upon a programme tested by the author and team, components include assessment, a carers day, food before food, fun with food and review. Although the programme may be adapted for use in a variety of ways, the authors make clear any adaptations must involve and empower carers be interdisciplinary and intensive teach realistic goal setting and reviewing be based on a child-centred, holistic approach since the difficulties tend to be multi-faceted in origin. The book contains many photocopiable pages (programme details, assessment forms) and references to provide the evidence base clinicians increasingly need to persuade commissioners to fund particular projects. This could save the busy therapist time and the service money. Jenny Beatt is a speech and language therapist working in Dorset with a complex and special needs caseload to assess and develop communication and feeding / drinking skills.

LITERACY (2)

Assessment in Emergent Literacy Khara L. Pence Plural Publishing ISBN 1-59756-097-9 29.95

Well worth a read

Part of a series of American books about early literacy development, this can easily be read in isolation. Whilst many assessments discussed will not be well known to UK therapists, the book still holds relevance. The first part is more relevant to those working in advisory roles within education. The second part provides a good critique of a range of assessments, relevant to any speech and language therapist working with children. The books main strength is presenting literacy development as a complex skill highly interlinked with many linguistic processes (phonological awareness, narrative, vocabulary). Other relevant sections include English as a second language. Well worth a read particularly in light of the growing links between speech and language therapy and education. Stephanie Delvin is a speech and language therapist in Newcastle-upon-Tyne. SLTP

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Software solutions

Software solutions?
With computer software becoming ever more sophisticated and accessible for therapy, our in-depth reviews will help you decide whats hot and whats not. Here we look at REACT 2 and Smart Learnings Interactive Literacy series. REACT 2
Robin Simpson-Green finds the huge range of tasks in REACT 2 makes it a value for money resource that can significantly increase the amount of time a client spends in therapeutic activity.
REACT 2

Propeller Multimedia with NHS Borders (2007) Designed for: clients with aphasia / children and adults with learning disabilities www.propeller.net From 475 + VAT
This new software builds on the strengths of the original REACT programme (1998). The extensive range of additional tasks brings this up to the present day in computer mediated language therapy. The five core modules contained in REACT 2 Auditory Processing, Visual Processing, Semantics, Memory / Sequencing and Life Skills - have been developed in collaboration with speech and language therapists. I have trialled it with people with aphasia for this review. The software is also suitable for use with children and adults with learning disabilities. The tasks contained within the programme are based on theoretical principles, which should underlie individually targeted therapy. The content appears to be motivating for the clients I have used it with. The programme can be used one-to-one initially, to ensure the client understands the task requirements and give additional feedback. Many clients will also benefit from using REACT 2 independently to complement face-to-face intervention. Whilst others need continued support, this may not have to be from a therapist. There is a broad range of receptive tasks spoken, written and pictorial. Spoken expression is not directly targeted, due to the limitations of speech recognition technology in the present day. Tasks can however be adapted by the therapist to include spoken output.

The Auditory Processing module has activities at sound, word, sentence and conversation levels. Auditory discrimination tasks are particularly useful in a computer-mediated format if lip-reading is not indicated for the individuals therapy. There are separate spoken word naming tasks for nouns, verbs and adjectives. The understanding conversations section, which has five levels of difficulty, involves listening to a conversation and then answering questions relating to it. The task demands of this activity have more in common with everyday functional communication than traditional pen and paper activities. Visual Processing includes a wide selection of basic matching tasks. There is one cross modality matching task (picture / symbol matching that uses Mayer Johnson PCS), which is more suitable for people with a learning disability. Reading comprehension has extensive word-picture and picture-word matching, with twelve different levels in each. The Semantics module has a wide array of association and categorisation tasks. Word finding tasks involve phrase and sentence completion with picture or written word stimuli. Understanding concepts is a task which uses the same vocabulary from single word adjective naming (in the auditory processing module), but uses symbols rather than photographs. In this case the symbols will be most beneficial in reinforcing learning of concepts for children. The Memory / Sequencing module has two versions of Kims Game. The Life Skills module has particularly functional money and clock calculation tasks, including a problem solving activity. The pragmatics section includes understanding intonation and idioms; these tasks could be particularly relevant for people with right hemisphere damage and people on the autistic spectrum. The programme has appropriate vocabulary and pictorial content for the client groups it is aimed at. There is suitable variety in semantic distance of distractors; for example, in the spoken-word comprehension task there are three close distractors and one distant distractor.

Overall the hierarchy of levels within tasks is suitable, with subtly graded increases in difficulty. For some tasks the number of levels is more limited compared to others. The software has an errorful approach with opportunity given for second attempts, although self-correction is not recorded in the results. The computer-generated feedback which follows each item will appeal to many clients as it is objective. There is a huge range of tasks, from basic matching to higher-level understanding conversations. It takes time to review the content and carefully plan therapy to make the most of what is available here. The range of tasks and different levels means that this programme can be suitable for use with most people with aphasia irrespective of severity, providing they have the underlying physical and cognitive skills. The time invested in supporting clients in using this programme can significantly increase the amount of time spent in therapeutic activity, when complementary to face-to-face therapy. Overall this programme offers value for money as a resource for therapists working with adults with acquired aphasia. For clients who wish to have their own copy for home practice they have the option of purchasing individual modules to suit their needs. Robin Simpson-Green is a speech and language therapist in a stroke unit in Plymouth.

INTERACTIVE LITERACY

Susan Hyde Wright is impressed by the potential of this software for motivating pupils and facilitating effective collaboration with teachers.
Interactive literacy (teachers books and CD) Sue Ifould & Hilary Mason Designed for: Key Stage 2 (P4-P7 in Scotland) Smart Learning www.smartlearning.co.uk ISBN 1-84276-061-1/062-9/063-7/064-5 125.00 each + VAT

The use of the interactive whiteboard and literacy resources on CD-ROM has increased in schools.

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WINNING WAYS

Winning Ways
Speech and language therapists who work collaboratively with teachers or teaching assistants should be able to use, share and recommend resources that use these systems. Interactive Literacy Years 3, 4, 5, and 6 by Smart Learning is definitely worth a mention, and offers reasonable value for money if all its options are used. Each interactive CD-ROM features eighteen illustrated texts, with many of the illustrations animated. Texts range from snippets of well-known stories, plays and poetry to texts suitable for Year 6 mainstream pupils that highlight aspects of persuasion, dilemmas and issues. The quality of texts and graphics is fresh and engaging. Within each unit of text you can choose from three options - reading, writing and speaking and listening. I shared the use of the resource with a primary class teacher working with youngsters with a wide range of communication difficulties. Usually the teacher focused upon the writing or simpler reading options whereas I used the speaking and listening option most of all. I was pleased how effectively I could address a whole variety of individual language targets with the same text as the class teacher merely by using a different option. All the on screen texts can be heard by clicking on the speech bubble icon - a real plus for the struggling reader. There is also the option to run the speaking and listening screens with or without the soundtrack. This opened up the opportunity for some of the children in the class with better language skills to make up their own commentaries. I was able to print pictures from the screen to be used for sequencing tasks as well as freeze frame screens to focus on other specific language areas. The whole class found the resource enjoyable and motivating. Each CD-ROM is easy to use. It could be employed at whole class to individual levels and is ideal for facilitating effective collaborative practice. Accompanying each CD-ROM is a clear and practical Teachers Book which offers a helpful guide to each unit of work and suggests additional supportive activities and extension work and cross curricular links. It does seem possible after all, just by sitting in front of a computer or interactive whiteboard, to engage children in literacy. Susan Hyde Wright is Speech and Language Therapy Coordinator at I CAN Centre with Dawn House School, a specialist school for communication and interaction. SLTP

Life coach Jo Middlemiss considers transitions and balance

Chris has returned from maternity leave (her first child) and is working part-time. Compared with working full-time she finds it difficult to get all the required administration, liaison and preparation done, and is beginning to resent the extra hours put in at home. Sonia has decided to cut down her workload as she is coming up for retirement and has an elderly relative to look after. She has been allowed to job share but is concerned about the balance in her newly designed life.

s I type, The Byrds are singing Turn Turn Turn*, a beautiful representation of the Biblical reading from Ecclesiastes Chapter 3 verses1-8. With enormous wisdom, beauty and poetry, this tells us we need to look at all aspects of our life - even the challenging things that cause angst and difficulties - as part of the whole grand picture of the amazing journey. Chris is at a transition point. Maternity leave is an extraordinary time of life. Leave has all the connotations of holiday, yet nothing could be further from the truth. It is hard work emotionally and physically and, especially with a first child, everything has probably been turned on its head. Priorities have changed, sleep patterns are disrupted and relationships are being established and possibly renegotiated. Added to all this is the desired (or undesired) pressure to return to work. Chris is re-embarking on her career but this time there is so much more to be considered. Parttime work seems the ideal solution but Chris does not want her professionalism to be compromised. How does she stop work eating into her home life? At the other end of the spectrum Sonia is preparing to leave the profession but is not ready yet to retire completely. She is not leaving for leisure but to take on other time-consuming responsibilities. Again, chances are these will eat into her home life. We often hear the phrase Work/Life Balance. I have come to believe we dont really need the work/ life bit - we just need to think about balance. When we feel our lives going out of kilter it is always time to take stock. This can be very simple if we regularly sharpen the saw (Covey, 1989). Sadly many people never do that or they wait until things become unbearable, when the problem is much harder to solve and illness and stress are added to the pile.

Options

think about how useful that sneaking feeling of resentment is - then shift attitude and language to see what there is in the situation to appreciate sit down with pen and paper to become aware of where things really are. Sonias transition has yet to start so she can take time to prepare and consider tough decisions, making sure she doesnt get pushed under by the expectations of others. This is about survival not selfishness. Never allow other people to use your life to solve their problems if you dont take charge, someone else will. A coach once asked me to give a metaphor for what was going on in my life. I told him that it often felt like plate spinning or juggling with plates constantly being smashed or balls dropped! He asked if I could think of another metaphor involving coloured balls. After a few moments I thought of snooker. Although I know little about it, I had an instantly calming picture of the smooth green table. My coach led me to understand that all the balls were waiting for me to pot them. They were no longer falling or moving by themselves. If I made a mistake and potted the wrong ball it wouldnt fall on the floor and roll away, but would be caught in one of the pockets and wait for me to retrieve it. Suddenly my life seemed more manageable. I was back in charge and could choose how much / how little / how often I wanted to get going at the game. So, to anyone at one of lifes crossroads I would suggest you: Take time to think out what you really want Review the situation as it really is and ask yourself: what you are prepared to do to resolve the situation what you are prepared to stop doing to resolve the situation how you can enjoy the process (without resorting to anger, resentment and disappointment). To everything (turn, turn, turn) There is a season (turn, turn, turn)
SLTP

Choosing to look at and explore her options will help Chris get the balance back. She could: call a meeting with a superior to negotiate how much she is reasonably expected to do at home

*The Byrds sing Turn Turn Turn live on this You Tube clip: www.youtube.com/watch?v=aNopQq5lWqQ

Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329. Jo offers readers a complimentary half-hour telephone coaching session (for the cost only of your call). While all Jos work informs Winning Ways, your contact is confidential and no personal or identifying details will be given.

References

Covey, S. (1989) The 7 Habits of Highly Effective People. London: Simon & Schuster.
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how i involve students


With services under financial and staffing pressure (RCSLT, 2007) and a need to ensure undergraduate students have sufficient quantity and quality of placement experience, imaginative schemes are called for. These recognise students as an additional resource rather than an additional burden with a positive contribution to make to service provision. Our authors show why this benefits clients, carers, students, therapists, universities and services, at the same time playing a part in turning policy such as accessibility, user involvement and interprofessional working into reality.
Reference RCSLT (2007) Money and commissioners: managers speak out, Bulletin of the Royal College of Speech & Language Therapists 667 (November), p.7.

Access-ability
Alison Matthews, Emma Sims, Katie Cowburn, Amy Erwin, Amy Sadowski, Nicola Derbyshire, Lizanne Carter and Linda Collier give managerial, student and university perspectives on a service centred accessible information project for adults with learning disabilities.
L-R Katie, Nicola, Amy S., Amy E., Emma

HOW I (1):

Involving students (1) Access-ABILITY nvolving students (2) A safe context Involving students (3) Everybody can communicate something

1. The Team Managers view The Oldham Communication Therapy Team takes a very proactive approach to introducing service centred and person centred accessible information (Matthews & Samuels, 2006). We recently piloted a project with six speech and language therapy students from the University of Manchester on placement with us one day a week for 6 weeks. The first session involved them attending our accessible information training day. They were then given an accessible information referral* and asked to complete the piece of work. The Learning Disability Service Community Projects supported by the students included woodwork, gardening and recycling. This type of work benefits several service users in one go and falls into the category of service centred work as opposed to person centred (Matthews & Samuels, 2006). The students were supported by our Communication Development Workers (Matthews & Baynham, 2006) with some input from me as Team Manager. They visited the project sites and worked with the service users and staff to develop the resources required.

I was aware that Linda Collier from the University of Manchester is always looking to explore alternative opportunities for student placements. At the same time, as a therapist and Team Manager of an already over-stretched service, I've been keen to design placements where it feels like the service has some kind of return. This could be a particular piece of work or a reduction in waiting lists for individuals or for accessible information. As well as the benefits to the service, the accessible information has had an impact for the people with learning disabilities who are working on the Community Projects. Feedback has been positive to the extent that, the afternoon the students finished, the manager of the projects asked when he could have the next group! 2. The students view This project has been beneficial for both our professional / clinical development and the speech and language therapy team. They were able to delegate work to us, taking pressure off them by decreasing their time on projects that would have taken many weeks. With minimal input our projects were undertaken independently. This is of particular value for all therapists with large caseloads and little time to do this kind of work themselves. We benefited from the opportunity to develop skills we did not previously have and welcomed the opportunity to work with students from other years. Project 1: Gardening Centre Our project was to show the process of making a hanging basket in an accessible format for service users (figure 1). We also developed the idea of a pocket sized laminated flick-book to make the equipment and tools used at the centre more accessible for staff and service users (figure 2). Project 2: Recycling Centre We produced accessible information for the service users at the recycling centre by making a variety of vital information sheets. Our pieces included what

PRACTICAL POINTS: involving students


1. Think out of the box what can students add? 2. Consider service centred as well as person centred schemes 3. Find useful ways to accommodate larger groups 4. Structure meaningful, holistic learning contexts 5. Carers may welcome the chance to be influential 6. Exploit and develop multi-media skills 7. Support interprofessional understanding 8. Choose projects that raise awareness of impact 9. Expose students to clients strengths and personalities 10. Recognise wider benefits for the profile of the profession

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ents
to wear when out in the van, how to use scissors safely (figure 3), how to use the small shredders and how to report an accident. Project 3: Woodwork Amy S. and Lizanne say: Our task was to make information accessible for the woodwork project that runs in Oldham. When we first visited we looked around and saw what they did with the adults with learning disabilities, and we met the service users. We were then given the different information they would like to be made accessible; this included taking all the different screw sizes and making it so that the service users could find a certain size easily, giving them just a little bit more independence. For this we took each screw size and length and developed a symbol system with a corresponding colour for each length and a corresponding shape for each size. We also developed a wallet-sized booklet so the project worker could show a service user which screw they want, and then they would be able to find the same symbol on the box that holds the screws and find the right amount of screws. We were also asked to make step-by-step health and safety check posters for each machine they use, so at the beginning of each day a service user could check the machine was safe and working properly. Furthermore we made posters to show that eye and/or ear protection was necessary and must be worn when using the machine. The skills we have learnt during this placement will definitely be useful for future projects, as the process of making information accessible is applicable to other populations. We believe it was a good experience for us to meet the service users, as this helped us make the information more relevant to the users at the various sites. This project was useful for all parties as we gained practical experience in working with adults with learning disabilities, and the service users got involved with the project as well as benefiting from it. 3. The Universitys view Over the past few years we have been developing a series of clinical taster sessions which will give the students valuable clinical experience in their 1st year of studies. These sessions have included visits to Sure Start schemes, meeting people with dysphasia in their local Communication Support Groups and making Communication Passports for service users in conjunction with the Communication Therapy Team in Oldham. The Accessible Information project - offered initially to 8 students - was evaluated very highly by the students and gave them skills that can be used with a whole range of client groups. The students were able to meet adults with learning difficulties; even if they never work with this cli-

Figure 1

ent group again during their undergraduate years this experience will stay with them and may help them consider working with this client group once qualified. Building on the success of the pilot project the whole year group attended an Accessible Information Day in Oldham in November 2007 and will now be sent on a variety of placements. There has been a huge amount of interest from other services who realise there is potential in using students to make accessible information for their clients. Apart from adults with learning disabilities services, we are also sending students into several schools in the local area to make Communication Passports and information accessible for the children. Speech and language therapy students need to be reminded in their 1st year why they have chosen the profession and it is really important to include clinical experiences alongside their academic studies. The Accessible Information and Communication Passport work helps to focus them on the clinical aspects of the profession, work with a variety of clients, build their confidence in their own ability and develop clinical skills. Students do not need to be extra work for clinical educators; they can be a benefit to the service while gaining skills that will help them throughout their careers. Alison Matthews is Team Manager of the Communication Therapy Team, Rock Street Centre, Oldham, e-mail Alison.Matthews@oldham.gov.uk. Emma Sims, Katie Cowburn, Amy Erwin, Amy Sadowski, Nicola Derbyshire and Lizanne Carter are student speech and language therapists at the University of Manchester. Linda Collier is a Senior Clinical Teaching Fellow at the University of Manchester, email linda.collier@manchester.ac.uk. *The Accessible Information Referral Form is available via the Mag Extras group in the members area of www.speechmag.com.

Figure 2 Using Scissors Safely When carrying the scissors make sure the scissors are shut

Always put the scissors back on the table when they are not being used

At the end of the day, put all the scissors back into the jug

Figure 3

Acknowledgements

Thanks to Christine Marsland and Mark Booth, Communication Development Workers, and Eric Armitage.

References

Matthews, A. & Baynham, T. (2006) Photo opportunities, Speech & Language Therapy in Practice Spring, pp.7-9. Matthews, A. & Samuels, R. (2006) Conference calls: Show and Tell, Speech & Language Therapy in Practice Summer, pp.20-22 SLTP

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HOW I

A safe context
Mel Adams, Celia Harding and Andrea Lillystone support students of speech and language therapy, social work, nursing and medicine to explore issues of client assessment with the assistance of carers of people who have complex communication needs.
L to R: Mel Adams, Celia Harding, Andrea Lillystone

HOW I (2):

They had two days in January to meet each other, set ground rules and make arrangements for meeting, using the Bulletin Board on a specific web site to share information and plan their presentation for March (see example in figure 1). We invited the carers to attend the presentations and give feedback.

Reduce barriers

nterprofessional education is a relatively new initiative within health and social care undergraduate courses across the UK. It occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care (CAIPE, 2002, cited in CAIPE, 2006). Evidence is beginning to show that students benefit from interprofessional learning opportunities as an additional way to consolidate knowledge gained in clinical practice and make the link between theory and practice. This education opportunity is now being included in speech and language therapy undergraduate training to support both clinical and academic learning. Our project (January - March 2007) involved fourth year speech and language therapy undergraduates in a three day interprofessional module set up by the department of Social Work at the University of East London, the Medical School at St. Bartholomews Hospital and the departments of Nursing and Language and Communication Science at City University. This enabled students from all four disciplines to work in multi-professional groups to explore: issues of client assessment working with carers of people who have complex communication needs the clinical reasoning to support strategies for intervention within an interprofessional context. During the course the students spent time listening to carers of clients with complex communication needs as they described the person they care for and their experiences of input from services. Participants were carers of children and adults with a range of learning disabilities including difficulties on the autistic spectrum. Carers and service users are being used increasingly to support student education within a structured learning context, and this can only strengthen the formal teaching carried out in the lecture theatre and the practitioner skills learnt on placement. We acknowledged that carers require appropriate financial recognition for their services. Preproject training and organised training and access to trained counsellors were provided should there be any issues arising. (These social work, therapy and nursing professionals met the carers at an introductory session and offered de-briefing after sessions with the students.)

Education facilitators - such as university lecturers and clinical tutors - provided feedback and support to the students. In their assignment, we wanted students to assess and evaluate how the challenges of providing a client-centred service to these individuals with a communication disability could be supported by the use of innovative multimedia communication methods, as well as more focused joint professional working. The students worked collaboratively within their interprofessional groups and created a presentation.
Figure 1 Group example - Luke Our group identified what multimedia communication methods could be used to help health and social care professionals assess and develop a person centred care plan for our client Luke. In determining what methods of multi-media communication would suit Luke and help us to make an assessment of his needs we agreed we would: theme this around what Luke likes adopt a specific interactive, structured approach with some flexibility use digital images, video, sounds, communication tools that Luke uses already use as many types of media as Luke is responsive to, not just one (visual effects, sounds, PECS, Widgit Symbols, video) use pictures of people and places Luke knows use Lukes communication with mum as a model keep Luke relaxed with soothing background music / visual effects remember positive reinforcement is important remember LESS and STRESS; go SLOW and SHOW; break down into chunks. In discussing how we would develop and communicate the person centred care plan to Luke, we decided: the plan needs to consider Lukes day to day needs and the health and social factors impacting on well-being, as well as addressing his meaningful involvement in planning meetings to remember that process takes precedence over product to liaise closely with people Luke knows well. We considered the likely challenges and how we would address them: if we misunderstand Lukes communication needs we have a useless result so we need to be sure we understand Luke before we start by getting to know him and his family and friends we need to be clear about each others priorities and standards and use assessment timescales, have resources to hand and avoid duplication.

From the teaching perspective we feel the opportunity for students from different disciplines to meet together to discuss common themes and carry out joint activities may reduce cultural barriers between professions and help individuals to understand one anothers conceptual frameworks and professional vocabulary use. It also gives students the opportunity to learn about one anothers roles before miraculously being expected to know this as soon as they start working. This is an unthreatening forum in which students explain their roles and where there is time to ask one another questions for clarification, as well as reflect on experiences that they have had in placements. This hopefully encourages a more holistic view of client care, a mutual respect for one anothers professions, and raises awareness of vital issues such as multidisciplinary goal setting with clients and carers in the process. A unique aspect of this learning experience was the opportunity to hear the perspective of the caregiver away from the busy clinical context. Students felt that they had time to probe and explore more challenging aspects of care for clients who require the support of more than one service. The assignment helped students focus and refine their skills in reflective practice, communication skills with other student-professionals, team-working, consideration of the fundamental importance of communication - especially augmentative and alternative communication strategies that all involved need to be aware of - and in giving a professional oral presentation. Caregivers felt strongly that they were making a significant contribution to the student learning opportunities. In particular, they wanted the students to learn from the challenging situations both they and the person they cared for had experienced, which were usually to do with limited liaison between professional groups. They all felt it was a very important opportunity to influence health and social care students before they start working. As final years, the speech and language therapy students had already accumulated a substantial number of different clinical experiences during their training and reported gaining great benefit from the project. They particularly valued hearing the carers accounts and having the time to ask questions about how service delivery could have been improved. Although a high number of students commented that they had had some experience of multi-professional and joint working in placements, as well as some opportunities to speak to parents and explore issues, the important aspect of this learning meant they appreciated the time to explore some of these clinical issues in more detail within a safe clinical context with support staff available.

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The speech and language therapy students also felt they were able to share considerable knowledge and expertise about communication disabilities with other students relevant to their cases. They valued highly the opportunity to explore other disciplines within this learning format, as meeting other healthcare and social work students allowed them to feel more confident about understanding roles within the workplace. They felt this was a learning bonus that gave them additional knowledge just before becoming practitioners.

Mel Adams is a clinical tutor at City University and a lecturer at the UCL Institute of Child Health. Celia Harding is a lecturer at City University and a speech and language therapist at the Royal Free Hospital. Andrea Lillystone is a clinical tutor at City university and a speech and language therapists / therapy placement facilitator with Waltham Forest.

References

UK Centre for the Advancement of Interprofessional Education (2006) Interprofessional Education. CAIPE Bulletin 26, p.3. Also available at: http://www.caipe.org.uk/index. php?&page=define&nav=1 (accessed 2 November 2007).

Resources

Acknowledgement

Many thanks to the parents and carers who gave up their time to make this project a reality, and to SLTP share their very personal stories.

PECS (Picture Exchange Communication System) see www.pecs.org.uk Widgit Symbols see www.widgit.com

Everyone can communicate something


Laura Brierley and colleagues introduce first year students to life story work with people with dementia and their carers in a good practice project that provides a reason to communicate as well as an understanding of the person behind the dementia.

HOW I (3):

ur experiences of life story work within the therapy department at The Meadows, Stockport are very positive. We find it is extremely important and rewarding and the difference it can make to communication and self-esteem for people with dementia is invaluable. A number of authors have also highlighted the value of life story work (Baker, 2001a; 2001b; Bryan and Maxim, 1998; Kindell and Griffiths, 2005; Murphy, 1994) for encouraging communication in a variety of ways. Kindell and Griffiths (2005) illustrate a case where life story work is included in speech and language therapy intervention. This demonstrates how the work can provide opportunities to share important life events, focus conversation and re-kindle communication and relationships between spouses. Bryan and Maxim (1998) evaluate a life story initiative providing training in communication skills for care staff, which in turn is useful in the future planning of activities and more person centred care.

Philosophy

The central philosophy to life story work is that everybody, no matter how impaired, can communicate something. It allows the opportunity to focus on all means of communication - speech, tone of voice, facial expression, body language and personal ways that often only close carers may be able to detect. Importantly, life story work helps others to recognise that, no matter how impaired someone is, they are still a person with rights and needs who at all

times should be treated with respect and dignity. By learning to understand the person behind the dementia we can develop a greater understanding of their behaviour and needs and foster a more positive attitude. It is particularly helpful for new staff to understand who they are caring for. At The Meadows the therapy team provides input to the continuing care ward, assessment ward and day hospital as well as to people in the community. In addition to life story work within therapy interventions, staff and relatives have access to advice and training opportunities. However, we felt additional hands on work would have a fantastic impact on our resources and service. As the University of Manchester is supportive of peer placements, this combination of incentives led to a student life story project proposal. Wilcox and Simms (2007, p.8) describe the benefits of peer placements as moving away from one student with the speech and language therapist at all times during the placement as if they are attached at the hip and moving towards a more liberal paradigm of distant supervision without feeling continually watched and judged. In this situation students have the opportunity to develop their own style and problem solving ability.

Inspiration

A further inspiration for creating this type of placement was to offer a large number of first year students exposure to dementia as, due to the lack of service provision available in some areas (RCSLT,

2005), this could be their only clinical experience of dementia in their student lives. Once students qualify, skills and awareness of service needs gained on placement can be applied during their career. Consequently, a vital factor in the future development of speech and language therapy provision for people with dementia is to provide student experience. The central part of the project was to produce information about the person with dementias life story, their likes and dislikes, what they enjoy and ways they communicate their views and feelings. This information was compiled into life story books. The books include personal photographs, historical photographs, pictures and information sourced from the library or internet. At the same time first year undergraduate students had the opportunity to learn about dementia firsthand from people with dementia and their carers. They also had the chance to develop skills in sensitively collecting information from interviews, medical notes and observations. This provided some crucial first year student experience in building rapport, gaining confidence and working in a multidisciplinary framework. Eight students took part in the autumn term placement and ten in the spring term placement. All students came for a one day placement, every week, for five to six weeks. Before the placement we delivered an introductory lecture to the students on dementia and life story work at the university. At this time, as part of their university course, students were learning about Personal Communication Passports (Millar, 2003). Passports are a way of documenting and presenting information about children and adults with disabilities who are unable to speak for themselves. The students made their own Personal Communication Passports and brought them to The Meadows to share with the group. This provided a constructive, person centred activity to begin the placement. As a contrast to the communication passports, we talked about life story books and looked through books our department had made earlier. The students worked in pairs to produce two life story books. Relatives and people on the wards and in the community were invited to participate. We aimed to provide an opportunity to make a life story book for people at different stages of their dementia, as this would help the students gain a broader experience.
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Organisation the key

Meetings with relatives, carers and people with dementia if appropriate took place at The Meadows and the students worked in their pairs to interview and collect photos. This was the part that required good planning from all involved ensuring co-ordination of times and rooms ran smoothly. Organisation was key for two therapists with limited room space and up to ten students! If the person had no relatives, or relatives who were unable to participate, therapy and nursing staff helped students collect information. The students compiled the information to create a first draft book. Subsequent meetings were arranged to go through the completed book. This allowed opportunities to amend and edit the books. All the students made the books using a scanner and PowerPoint / Word software, so original photos could be returned and pages could be added or changed easily. In addition to making the books the students had the chance to go to informal talks. We arranged talks with relatives, a lady recently diagnosed with Alzheimers Disease and her husband, a Community Psychiatric Nurse and an Occupational Therapist. The students also got involved with ward activities running at the time such as communication groups and craft groups. At the end of the project we had group discussion to reflect on what we had learnt. Each student received written feedback collected from staff, people with dementia and relatives. Individual comments included: Lisa and Jo worked with TK and his wife. TK has had a difficult childhood and the process of putting the book together has helped staff reflect on this and how it may relate to his current behaviour. TKs wife enjoyed the process of putting the book together and both she and the staff have looked through the book with TK. He responded very positively. Carol and Katy worked with DT and her husband. She was residing on the assessment ward with a view to moving to a residential home. DTs book has been very important for two reasons. It gave her husband something positive to do whilst his wife was in hospital - this was a very difficult time for him as he has never been apart from her. He was very pleased with the final book, if not a little emotional when he saw it all together. The book has also been helpful to inform the assessment process. It has gone with DT to her new home and will be an excellent way for them to learn all about her. Well done and thank you for all your hard work!

Rod Simmonds enjoys his life story book with wife Fay

The interest and enthusiasm from the students really shone. Both staff and relatives have commented positively on the work the students have carried out. Staff - new staff especially - were able to find out extra information about the people they care for and this has helped promote a better understanding of communication and behaviour. The books provide an insight into people beyond the medical information often available. Relatives told senior hospital managers that they were very pleased with the project and how the students delivered this.

I had never met anybody with dementia. I was concerned about appearing patronising and how communication levels would be affected. I learnt how important life story books are for people with dementia to enable them to communicate with others and be treated like a human being. I also learnt to act as a professional with clients and carers. I valued the experience of mixing with other professionals and seeing how they interact. The placement also made me think about time management and planning. This shows that students, at a very early stage in their degree course, felt they gained in several ways from the placement. The project has relied on team work and all involved have been very supportive. As a result our profile within the service is increased and staff approach us to ask about the project. We have shared our experiences with colleagues at our local Special Interest Group to encourage similar placements. The university is also involved in projects developing communication passports (Millar, 2003) with different client groups. We feel the project was incredibly worthwhile and we thoroughly enjoyed it. We are looking forward to meeting the new students participating in the project with us this academic year! The life story work project described was run by Jackie Kindell and Laura Brierley, speech and language therapists in older peoples mental health in Stockport for Pennine Care NHS Trust, and Linda Collier, clinical tutor in the speech and language therapy department at the University of Manchester. It has been chosen as an example of good practice for a department of health publication New Ways of Working for Allied Health Professionals in Mental Health. You can contact Laura SLTP via the e-mail laura.brierley@nhs.net.

Meaningful activities

On the placement the students also learned the importance of engaging people with dementia in meaningful activities such as music, exercise, quizzes and craft work. Students were able to see that people often have untapped skills that were not always apparent in the daily routine. They learned that these skills could be used to good effect in such groups and one-to-one activities. An important part of this was recognising that people require a focus or reason to communicate and that the speech and language therapist was able to give advice on this to encourage communication. Students also gained insight into the practical aspects of hospital work including looking through medical and nursing notes, understanding ward routine and making appointments with carers. A very important part of this placement was for students to develop understanding of the impact of dementia on relatives and carers. Students displayed a respectful and empathetic approach to carers they met and were interested in both relatives and the person with dementia. Students were required to do a reflective piece of writing for their portfolios. One student wrote:

References

Baker, J. (2001a) Life Story books for the elderly mentally ill, International Journal of Language and Communication Disorders 36, pp. 185-187. Baker, J. (2001b) How I manage dementia: Living in the real world, Speech and Language Therapy in Practice Autumn, pp. 24-26. Bryan, K. & Maxim, J. (1998) Enabling care staff to relate to older communication disabled people, International Journal of Language and Communication Disorders 33, pp. 121-126. Kindell, J. & Griffiths, H. (2005) Speech and Language Therapy Intervention for People with Alzheimers Disease in Bryan, K. & Maxim, J. (eds.) Communication Disability in the Dementias. London: John Wiley & Sons, pp. 216-218. Millar, S. (2003) Personal Communication Passports: Guidelines for Good Practice. Edinburgh: CALL Centre.

Murphy, C. (1994) It started with a Seashell. Life story work and People with Dementia. Stirling: Dementia Services Development Centre. RCSLT (2005) Speech and Language Therapy Provision for People with Dementia. Position Paper. London: Royal College of Speech and Language Therapists. Wilcox, F. and Simms, S. (2007) Getting the best out of students on placement, Bulletin of the Royal College of Speech & Language Therapists August 664, pp. 8.

Resource

New Ways of Working for Allied Health Professionals in Mental Health www.newwaysofworking.org.uk/allied_health_professions/speech__language_therapy.aspx

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Connect toolkit training Running a Conversation Partner Scheme 21-22 January 2008 Making Communication Access a Reality 10-11 March 2008 500 e-mail events@ukconnect.org

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MY TOP RESOURCES
FIONA BUCK, JOANNA KERR AND SHEENA NINEHAM ARE SPEECH AND LANGUAGE THERAPISTS IN THE ADULT TEAM AT PORTSMOUTH CITY TEACHING PRIMARY CARE TRUST (TEL. 023 92286147). IN 2003 THE DEPARTMENT FORMED AN APHASIA ACTION GROUP TO DEVELOP AND IMPLEMENT AN APHASIA STRATEGY FOR PORTSMOUTH. THESE TOP RESOURCES FORM AN INTEGRAL PART OF THE STRATEGY, WHICH WILL BE REPORTED IN DETAIL IN THE SPRING 2008 ISSUE.
1. IN-HOUSE COMMUNICATION SCREENING TOOL Developed locally, this easy to administer portable profile is used as part of our initial communication assessment. It allows for both high and low level screening of expressive and receptive skills and also incorporates items with which to assess reading and writing. The screening tool helps to establish a baseline early on without the pressure of more formal testing and highlights areas that will need further exploration. Designed to fit in an A5 plastic wallet, it is an invaluable part of therapists equipment. 2. EVERYDAY OBJECTS When you need to do an impromptu assessment, everyday objects are really useful. These could include things: around the clients environment (cup, plate, chair, table) in your bag (pen, purse, money) on yourself (watch, ring). These are quick and useful tools to look informally at a clients comprehension levels and expressive abilities. If the objects are from the clients own environment they have the added advantage of being familiar and therefore more functional. 3. CONVERSATION RAMPS BOX The concepts of Conversation Ramps and Supported Conversation were originally developed by Connect - the Communication Disability Network (www.ukconnect.org). We took this idea and developed a Conversation Ramps Box as part of promoting the use of supported conversation with our clients with aphasia. Our boxes include items to facilitate conversation, such as a pen, paper, maps, magazines and picture symbols. Pen and paper can be used for word choices, for writing or for clients to express themselves through drawing. Maps can be used to ascertain where the client lives, where theyve been on holiday or where their extended family lives. All our speech and language therapy departments on acute and community hospital sites now have a portable conversation ramps box to take onto the wards, on domiciliary visits or to out-patient clinics. We also keep conversation ramps boxes at stroke rehabilitation areas for use by the multidisciplinary team. 4. THERAPISTS LIFE STORY BOOKS Speech and language therapists sometimes suggest that clients and / or their families construct a life story book as a means of providing a focus for supported conversation about topics relevant to the client. Life story books are also a means of enabling staff to understand and get to know the client a little better, especially those with severe aphasia. Everyone in our department was encouraged to construct their own life story book. It is very useful to be able to show an example of a completed life story book to a client and / or their family. Our own life story book can be used to start and then model supported conversation for example comparing information about places we have each lived. It has also been useful for us to personally experience the amount of time it takes to select specific pictures and photos and to construct the book. 5. USING COMPUTERS In 2005 the Portsmouth speech and language therapy service invested in laptops, printers and software for use with clients with aphasia. Each base now has ready access to a laptop. The laptops contain a wide range of Bungalow and REACT software (both www.propeller.net) as well as Boardmaker (www.mayer-johnson.com). We work through selected exercises with clients. In some settings we leave the laptop with the client so they can go through exercises at their own pace. We also use websites in therapy. Two in our favourites list are: the moving articulogram at www.uiowa.edu/ ~acadtech/phonetics/# the training package of how to teach specific internet skills from the link at www.shrs.uq.edu. au/cdaru/aphasiagroups/index.html. 6. ALPHABET CHARTS, LETTER AND NUMBER TILES Our in-house communication screening tool includes a laminated alphabet chart. The chart is set out so that each line starts sequentially with a vowel. We also find it useful to carry a set of letter tiles (from Scrabble or Hangman games) or letter cards (such as Kan-u-Go) for anagrams, completing words and so on. A laminated set of number tiles is also useful for auditory comprehension or recall tasks like telephone numbers. 7. COMMUNICATION FOLDERS We came up with the idea of developing personalised folders for clients with aphasia at one of our in-house aphasia workshops and this was taken forward by Lynn Dangerfield and Jenny Wilk. We decided to give the folders to clients as soon as appropriate after their stroke so information was available at an early stage. Included are aphasia-friendly resources such as a personal passport template, information about stroke and being in hospital and conversation ramps such as maps and picture charts. Information for the family is also provided in the folder, including local and national support organisations and ideas to help facilitate communication. The key benefits are that the folders are accessible, client-centred, long-term and dynamic and remain with the client throughout their aphasia journey. They are helping to improve communication access and to empower our service users with aphasia. 8. APHASIA RESOURCE FILE The adult speech and language therapy service here is spread across two acute and four community hospital sites. The therapists therefore decided to review our leaflets and exercise sheets to ensure they were all up-todate and appropriate. The resulting Aphasia Resource File contains a rationalisation of all the updated written sheets and leaflets, information on supported conversation and a collection of updated core exercises. There is also a selection of aphasia-friendly information sheets. The files are now located in each of the six bases which ensures there is a standard resource in each speech and language therapy department. 9. COMPREHENSIVE APHASIA TEST (CAT) We really like this assessment. Its described by the authors as a quick and comprehensive profile of aphasia. Whilst not quick it is certainly thorough, and offers a controlled and standardised assessment of all modalities. There is an excellent manual which must be read in some detail before embarking on the assessment with a client. Not only does it look at the impairment level but also addresses disability in a way which lends itself to goal setting. The Comprehensive Aphasia Test (2004) by Kate Swinburn, Gillian Porter and David Howard, see www.psypress.com/brochures/cat.pdf. 10. HOW TO SERIES Low tech communication systems are an essential and integral part of supporting people with speech and / or language difficulties. However they are often neglected - possibly because people may not understand how they can be used to help the communication process. In view of this Cathy Harris, a previous member of our department, developed aHow toseries. This provides a step-by-step guide on how to use an alphabet chart with auditory scanning, a phrase chart, a pacing chart, a communication passport, a talking photo album, a life book, a picture communication chart, a communication book, written word choices and Talking Mats (www.talkingmats.com). These have all been amalgamated into a folder, with a copy in each clinical base. The laminated sheets can be photocopied, which saves therapists spending time writing down instructions for clients and carers.

SHEENA NINEHAM, JOANNA KERR and FIONA BUCK