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ISSN 1368-2105

Summer 2007

Assessments assessed Child language, aphasia, bilingualism Total communication Shifting perceptions Sharing your experience Doing the write thing Face value Specialist treatments How I extend the reach Partnerships in childrens services

I know exactly where it is but I dont know where its going


Images as signposts

PLUSWinning Ways Following the arrowHeres one I made earliermore great reader offers My Top Resources for new technologyand featuring self-help groups. Signposting the way www.speechmag.com

Reader offers

Win the forthcoming 4th edition of The Psychology of Language!


Trevor Harley, who co-wrote our article 'I know exactly where it is but I don't know where it's going' (p.6), is also author of comprehensive psycholinguistic textbook 'The Psychology of Language'. And with a 4th edition due out soon, Psychology Press is giving THREE readers the chance to win a FREE copy. The text focuses on the processes involved in understanding and producing language, covering reading, writing, speaking and listening. An accompanying CD ROM includes materials to test your understanding of each chapter. While our student readers might be particularly interested in this offer, it is also relevant to any therapist working with children or adults with speech and language difficulties. For your chance to win, e-mail your name and address to competitions@psypress.com by 25th July. The lucky winners will be notified by 1st August 2007 and will be sent their copy on publication. For more information on Psychology Press publications see www.psypress.com. The Psychology of Language will retail at 27.50 Paperback or 54.95 Hardback.

Win Interactive Literacy software for Years 3 & 4!


Do you work with education professionals? Are you looking for new ways to deliver the literacy curriculum strands of reading, writing, speaking and listening? Then the award-winning Smart Learning Interactive Literacy software for Years 3 & 4 (Scotland P4-P7) could provide an answer and Speech & Language Therapy in Practice has a copy to give away FREE to a lucky reader. This software won a BETT Award 2007 for Digital Content (Primary Core Subjects). It can be used by non-specialists at whole class, small group or individual level. It is designed for use with interactive whiteboards, and to cater for pupils with different learning styles. To enter this free prize draw, simply e-mail your name and address to prizedraw@smart-learning.co.uk by 25th July. The lucky winner will be notified by 1st August 2007. Smart Learnings Interactive Literacy Series is also available for Years 1 & 2 and Years 5 & 6. Interactive Literacy for Years 3 & 4 retails at 125 + VAT. For further information, see www.smart-learning.co.uk.

Summer 07 speechmag
As this issue goes to press we are making exciting changes to the speechmag website so keep an eye on www.speechmag.com and be part of it!
REPRINTED ARTICLES VIEW FOR FREE! Cook, L. & Trim, K. (2006) Interactive whiteboards: the long and the short of it, Speech & Language Therapy in Practice Winter, pp.22-24. McCollum, D. (2006) Listen and learn, Speech & Language Therapy in Practice Autumn, pp. 4-6.

www.speechmag.com

Summer07 contents
Summer 2007 (publication date 28 May 2007) ISSN 1368-2105 INSIDE COVER: Reader Offers, Summer 07 Speechmag Win Interactive Literacy Software and The Psychology of Language.

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

SHIFTING PERCEPTIONS As the project progressed there was some increase in use of the tools with the learners. Some carers became more confident in using them and two achieved the induction level in Somerset Total Communication. This was a particularly exciting aspect of the project as we had hoped it would develop a more standard communication in different areas of the learners lives. Julia Tester reflects on a small scale curriculum action research project using Somerset Total Communication with two groups of learners with severe and complex needs resulting from congenital or acquired difficulties.

COVER STORY: I KNOW EXACTLY WHERE IT IS BUT I DONT KNOW WHERE ITS GOING When Helen feels confident that she has captured the production she practises and celebrates by playing with the word. Around Christmas time she delighted in exclaiming Have a piece of Stollen, Do you like Stollen?, Would you care for some Stollen? Laorag Hunter, Helen Gowland, Siobhan MacAndrew and Trevor Harley discuss the use of images as signposts in therapy and the kind of service we need to provide to ensure such opportunities are not missed.

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ASSESSMENTS ASSESSED Our series of in-depth reviews continues with Teaching Talking (2nd edn), One Step at a Time, CELF-4UK, Stroke Talk and the Bilingual Speech Sound Screen (Pakistani Heritage Languages). DOING THE WRITE THING Writing with another person can be a great motivator, having to produce work to show your co-author often proving a great incentive to write. And it can be fun. You may also find yourselves supporting each other in unexpected ways, particularly if physical and emotional writing peaks and troughs are complementary rather than simultaneous. Have you considered writing about your work but not quite found the courage? Myra Kersner and Jannet Wright help you to get started and keep going all the way to the finishing line. FACE VALUE There is no quick fix for facial palsy and clients do not move from the list quickly; we are talking years not months. It draws on many of our skills to work with these clients as the effect of facial palsy is devastating both physically and psychologically. Penny Gravill outlines the benefits of two specialist facial palsy treatments which she offers on the NHS and more recently at a Satellite Centre for an independent provider.

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

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HERES ONE I MADE EARLIER News and weather round-up; Newspaper headlines; Soapbox.

E-MAIL TO THE EDITOR Cochrane Systematic Review speech and language therapy for aphasia following stroke.

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FEATURE SELF-HELP ME IF YOU CAN Speech and language therapists are acutely aware of how isolating a communication disability can be. Many people with communication difficulties face a particular challenge in finding and participating in social activities including self-help initiatives. Avril Nicoll asks what contribution self-help groups can make to how someone adapts to and manages their communication difficulty, and where speech and language therapy comes in. WINNING WAYS: FOLLOWING THE ARROW the ordinary everyday often does present us with challenges that we sidestep because we dont think that we have the guts or determination to follow through. My personal challenge is to follow through on what I have set myself. Breaking an arrow with her throat confirms for life coach Jo Middlemiss that, with the right attitude and support, we can all follow through our goals.

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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.
Cover photo of Helen Gowland and Laorag Hunter by Paul Reid.

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HOW I EXTEND THE REACH Across the UK we are moving towards integrating childrens services - but learning to work more closely with other agencies is not a straightforward task. Our contributors focus on two imaginative partnership projects that are succeeding in breaking down barriers. (1) PREPARING FOR INDEPENDENCE With many children unable to access therapy, school training needs unmet and jobs for new graduates at a premium, Debbie Halden, Kirsty Ferguson and Jill Kennedy report on a 6 month collaborative project between a cluster of primary schools and a speech and language therapy service. (2) FUNDING GAPS Julie Coley welcomes the opportunity to be part of a properly resourced and managed Childrens Fund project to improve the speaking and listening skills of children who would not normally access speech and language therapy. REVIEWS Management, voice, Aspergers Syndrome, AAC , working memory, developmental dyspraxia.

BACK COVER: MY TOP RESOURCES Social networking websites are useful in therapy with individuals who have maintained a site prior to acquiring a communication disability, perhaps as a result of a brain injury. They enable therapists to find out more about the individuals past, replacing or enhancing information from carers. The site can help initiate and inspire conversation and may act as a potential forum for clients to contact others who are also members. New technology is developing at breathtaking speed, but are we upto-date with its potential use in therapy? Tayside speech and language therapists Gill Cameron, Jaclyn Dallas, Judy Goodfellow, Lorraine Hope, Caitriona Hutton, Gillian Nixon, Rebecca Richardson, Karen Rodger and Lesley Smith discuss some of the developments they have seen across paediatric, adult learning disability and adult services. IN FUTURE ISSUES: SERVICE REORGANISATION...ORAL MOTOR...NLP... OUTCOME MEASURES...DYSARTHRIA...CARE PATHWAY (FEEDING)... TALKING MATS...STUDENT PLACEMENTS

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NEWS

Hearing Dogs
Hearing Dogs for Deaf People is encouraging children and adults to learn about deafness and support its work. The charity has produced free information packs to complement National Curriculum Key Stages 1-2 and 3-4 and one for adults. The childrens packs include card games using sign language symbols and a drama workshop to encourage children to empathise with deaf people and think about the impact of their own actions and attitudes. Packs are available from 01844 348133 or e-mail togsfordogs@ hearingdogs.org.uk

Book magic
Bookstart is promoting its free book gifting programme with an online marketing campaign emphasising the magical and rewarding experience of reading to children. The You Baby Book Magic campaign aims to increase awareness of the free book scheme, which provides three packs of free books to every child at key stages of their development. Packs are distributed to children at 7 months, 18 months and 3 years old through health visitors, libraries and nursery schools. The website also provides parents with advice on which books to read with their children, book reviews, a message board and the opportunity to sign up to the Bookstart newsletter and receive an introductory booklet about reading with children. www.youbabybookmagic.org.uk

Fraser and Robbie Nicoll say thank you to Frances, and give her a handbag as a leaving present.

Frances retires
After more than 7 years as administration assistant for Speech & Language Therapy in Practice, Frances Eddison has handed in her keys and is preparing to move to Yorkshire with her husband Alan for their retirement. Frances spent one day a week in the home office managing subscriptions, dealing with finance departments, organising book reviewers and generally ensuring the smooth running of the business. Editor Avril Nicoll says, Frances was a real find. She started working for the magazine shortly before I had my second son, when I was feeling completely overwhelmed. It has been fantastic being able to rely on someone who pays attention to detail and is so good with people. More than that, Frances has been like an extra member of our family. While we are delighted for her that she is returning to an area she loves, we are going to miss her.

From www.youbabybookmagic.org.uk

HPC appointment
Professor Karen Bryan has joined the Health Professions Council as the registrant speech and language therapy member. Karen was selected through a public appointment process to fill the vacancy created when Anna van der Gaag was elected President in July 2006. She is a consultant speech and language therapist in forensic mental health and a Professor of Clinical Practice and Director of the Healthcare Workforce Research Centre at the University of Surrey. Anna van der Gaag said, Karen has joined the Council at an exciting and challenging time, when the government has recommended that the HPC regulate applied psychologists, psychotherapists and counsellors as well as health care scientists. Having worked closely with psychologists during her career Karen will no doubt be involved in the preparations for regulation of these professions. Her policy work and research skills will also be of great benefit to the work of the Council. www.hpc-uk.org

Beverley Hughes, Minister for Children and Families, and Ivan Lewis, Minister for Care Services, launch the Early Talk roll-out at South Acton Childrens Centre in West London.

Strategic partnership announced


Childrens communication charity I CAN, the Department for Education and Skills and the Department of Health are to roll-out I CANs Early Talk programme to up to 200 Sure Start childrens centres across England. Early Talk is an evidence-based programme designed to aid the communication development of all pre-school children through integrated therapy and educational approaches. It operates in settings that provide day care and / or education to children under five, such as childrens centres. By ensuring that all children learn in communicationfriendly environments the ultimate aim is for children with severe and complex communication difficulties to have their needs met in one comprehensive service. I CAN Chief Executive Virginia Beardshaw said, We are delighted to be working with the government to create a new model of third sector and statutory sector collaboration. Central to this is the way that I CANs expertise in childrens communication will shape Childrens Services. Effective language skills are essential for children to achieve and are fundamental to the achievement of all five Every Child Matters outcomes. This strategic partnership acknowledges the critical importance of childrens speech and language skills to their future life chances. www.ican.org.uk

The Puncs special offer


Compass Books is offering Speech & Language Therapy in Practice readers the full set of The Puncs at a special price of 25, inc. p&p. This compares with a retail price of 4.99 for each of the 7 books. The Puncs include Fergus Full Stop and Henrietta Hyphen-Hyphen. The Puncs were reviewed positively in the Winter 05 issue. www.thepuncs.com

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2007

NEWS AND COMMENT

comment Comment:
Suzanne and Tracy do the RABBIT sign as they sing I dig my garden

Singing Hands
Singing / signing duo Singing Hands recently contributed to five episodes of Cbeebies Something Special. Suzanne Miell-Ingram and Tracy Upton both parents of a child with special educational needs teach children Makaton through nursery rhymes, action songs, games and stories. Their two new signed songbooks produced in conjunction with the Makaton Vocabulary Development Project will be reviewed in a future issue. www.singinghands.co.uk

Signposting the way


I once wore out my shoes in Glasgow looking for Sauchiehall Street. I have driven across Aberdeen trying to find Union Street. I knew where I was - and where I wanted to be - but I didnt know where I was going. (Naturally I preferred to go round in circles rather than ask for directions to such major thoroughfares.) With a strong sense of purpose but a poor sense of direction, I rely on road signs to get from A to B. Signposting is widely used in aphasia therapy to describe one of the roles of a speech and language therapist, particularly for people in the acute phase. Seven years on from her brain haemorrhage, Helen Gowland (on p.6 with her co-navigators) continues to discover new signposts to guide her on her journey with aphasia as, I know exactly where it is but I dont know where its going. Our self-help feature (p.17) shows such are tools essential, but we each have to choose where we want to go and when, and how we want to get there. Speech and language therapists help clients by making sure the signposts are in place and dont get obscured over time by neglect just when they might prove useful. We also recognise that, to a large extent, people are happiest when they plan and find their own way. There are always alternative routes to the same destination, and a choice of travelling companion. Myra Kersner and Jannet Wright (p.14) share their significant experience of writing together for publication but also emphasise its intensely personal nature and the need to develop your own style. Sometimes a journey is focused and uni-directional, like our need to find out more about assessment options (p.10). But when we want to negotiate the Spaghetti Junction of multi-agency partnerships, the number of routes and the complexity of intersections means specific direction and considerate driving are essential to keep things moving. Governments across the UK and a series of guideline groups (see news pages) have clearly stated this is the way forward. How I extend the reach (p.24) looks at how we can make it work on the ground. Just as technological innovations have added computerised notices to our roads signage, Penny Gravill (p.20) demonstrates they are also assisting clients and informing the direction of therapy. I have so far avoided sat nav (for fear I would end up in the sea or a field), but have taken on board what the top technology resources (back page) say about social networking; watch out for developments with www.speechmag.com. Sometimes we just need to slow down to notice signs. Julia Tester (p.4) describes her emotional response when a learner who generally spent group sessions with their eyes closed filled an extended pause with an unexpected communication. At other times we need to make a conscious decision to make use of what the signs are telling us. For life coach Jo Middlemiss (p.23), an arrow proved to be one of the strongest indicators that we can all follow through our goals. So if youre feeling a bit lost or lacking in direction remember there are lots of experiences out there for you and that Speech & Language Therapy in Practice offers signposts to help you on your way.

Ataxia guidelines
Ataxia UK has published a set of clinical guidelines for healthcare professionals, covering the diagnosis and management of progressive ataxias. Dr Anja Lowit of Strathclyde University represented speech and language therapy on the guideline development group. Early referral for information and support is recommended. A dedicated appendix details appropriate management of dysarthria and how a therapist can support the client and their family in dealing with the impact of a progressive communication and swallowing difficulty. A summary document is available for GPs, but does not specifically mention speech and language therapy. Ataxia UK says that some 10,000 adults in the UK have a form of cerebellar ataxia. www.ataxia.org.uk/page.builder/clinical_guidelines.html

Transition care pathway


The Association for Childrens Palliative Care has worked with young people to produce a framework to help those with a terminal illness or life-limiting condition, their families and professionals plan for their future and move from child to adult services. The emphasis throughout is on holistic teams for therapy and care, with a personcentred plan and adequate funding. One young person is quoted to illustrate why this is so important: I need a speaking valve. I saw an ENT consultant last summer and he is really slow. Im still waiting to hear from him. It gets a bit complicated. He said I could speak. He had to speak to some people before he could come back to me and say that. The Transition Care Pathway: A Framework for the Development of Integrated Multi-Agency Care Pathways for Young People with Life-threatening and Life-limiting Conditions, downloadable at www.act.org.uk/dmdocuments/transition_care_pathway.pdf.

Rehab in Scotland
Scotland has a new model for rehabilitation. The development of this delivery framework has been led by service users including Olivia Giles who lost her lower legs and lower arms to meningitis in 2002, necessitating a lengthy period of rehabilitation. The process involved consultation with over 250 service users and 300 professionals from health and social care. A national group will oversee the implementation of the framework. Each NHS Board will have a local rehabilitation coordinator and there will also be a managed knowledge network accessible by health and social care practitioners and service users. The framework emphasises the importance of thinking differently from before: All health and social care professionals involved in developing or delivering rehabilitation services shouldlook beyond traditional methods of providing services and engage in service redesign and role development in partnership with individuals and carers. This will enable them to create new models of service that reach across historical professional and service boundaries. Coordinated, integrated and fit for purpose: A Delivery Framework for Adult Rehabilitation in Scotland, see www.scotland.gov.uk/Publications/2007/02/20154247/12.

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

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

TOTAL COMMUNICATION

work as a curriculum leader and a teacher of communication in a large further education college. The learners on my course all have cognitive difficulties, either from birth or acquired later in life. In 2005 a group of us - teachers, learning facilitators, families and carers - agreed we would run a small scale curriculum action research project to clarify the benefits of using Somerset Total Communication with our two groups of learners. We wanted to know if: both groups could be taught in the same way individuals in both groups could learn to use Somerset Total Communication tools there was a measurable increase in self-confidence all would show an interest. In class we use the communication tools of Somerset Total Communication, mainly with the learners with congenital difficulties. Somerset Total Communication is a multi-agency partnership led and jointly funded by Somerset County Council and Somerset Health Community to ensure a consistent cradle to grave strategy (www.somerset.gov.uk/somerset/socialservices/pi/stc/, accessed 2 November 2006). At our college we have a service level agreement with Somerset Total Communication which allows us to access support from the speech and language therapist who works there and the network of Somerset Total Communication co-ordinators. This partnership provides a service that includes lifelong support for people with communication challenges, a library of resources that can be used to support communication for this client group, and training for those working with them. All our learners respond well to the resources - objects of reference, pictures and symbols to support the spoken word - and we use them in class. Our research project was to be submitted for my Masters dissertation (Prince, 2006). My personal journey to this point began when I volunteered to work with a child with a brain injury in the early 1980s. This set me on a path that led me to work in clinics designing home programmes for families and people with brain injury. I then set up and provided a massage and aromatherapy service to people with both congenital and acquired difficulties before moving from this into support and education. To fulfil these roles I have studied ITEC (The International Examination Board) massage, anatomy / physiology, and aromatherapy, British Sign Language to level 2, Somerset Total Communication and Deaf Blind communication skills. I have a Certificate in Education and a Masters in Special Education which later included consideration of speech and language difficulties. I have also studied Damaged Brains and Neural Nets with the Open University.

Shifting perceptions
Photo by Mark Palmer (www.allaboutcapture.co.uk)

Perceived relevance
Prior to starting the research I liaised with the Somerset Total Communication speech and language therapist and the speech and language therapist at the local hospital. This was invaluable for us in starting the project as, before we carried out the work, we wished to ascertain its perceived relevance to colleagues, related professionals, clients, carers and families. We also wanted to identify specific focus points and any prior appropriate research that could inform the team. I found information relating to the positive use of Somerset Total Communication with people with congenital learning difficulties but was unable to find

Julia Tester reflects on a small scale curriculum action research project using Somerset Total Communication with two groups of learners with severe and complex needs resulting from congenital or acquired difficulties.
reports of its use with people with acquired brain injuries of the severity experienced by some of our learners. Those with the greatest challenges to learning move on a scale from being asleep - or with their eyes open and unable to communicate with intent - through to having their eyes open and being able to communicate with intent. People who seem to have low levels of awareness are not easily assessed and may appear to fluctuate in their responses. I found articles dealing with people on the minimally conscious scale of value for increasing my understanding of the issues (Laureys et al., 2000; Katz, 2001; Weil 2005). The project was in two phases. It set out to teach five signs or symbols to six people (three with congenital difficulties and three with acquired), all between their late 30s to early 50s. These symbols were person specific and chosen as a result of input from the clients and / or carers, family or learning facilitators. The aim was to establish communicative abilities for each learner and to identify any problems with methods, as well as familiarising the learners and everyone involved with the process. It was then repeated five months later to clarify the initial results and identify retained skills. To do this we observed and recorded responses to previously learned

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

TOTAL COMMUNICATION

signs or symbols and gave the learners the opportunity to learn five new signs or symbols and thus develop the process further. During the project the learners were all exposed to Somerset Total Communication at college during their weekly communication session. On our programme the learners have an option to attend several short sessions per week. The choices include: Communication, Information Technology and a Craft subject. When not at college the learners are supported by carers in residential or nursing homes. During this time they have opportunities to access the community; for example, two learners with congenital difficulties attend a bread making class.

certificate for recognising three symbols. We were aware that it is possible these learners had experienced Somerset Total Communication previously in attending a day centre or in a residential home and that prior learning may have predisposed them to engage with it again. We are also aware that we had used Somerset Total Communication with them - albeit in a less focused way - so it wasnt totally new.

More standard communication


As the project progressed there was some increase in use of the tools with the learners. Some carers became more confident in using them and two achieved the induction level in Somerset Total Communication. This was a particularly exciting aspect of the project as we had hoped it would develop a more standard communication in different areas of the learners lives. The method used for our recording was participant observers. We recorded on a formal checklist any communicative response observed, including eye/hand movements, vocalisations, gestures and signs. I found it extremely exciting to see the increase in communicative behaviour between the learners and staff. On one occasion I was greeting the learners who all sat in a communication circle. Some spoke, some signed and one learner generally remained with their eyes closed. This particular morning I paused, longer than usual, to

This project taught me a great deal about...the need to give time to our learners to respond.
Two of the learners with acquired difficulties were less likely to have encountered signs and symbols prior to their disabilities and one had used them but we were not aware of duration or intensity of their involvement. All three had been exposed to Somerset Total Communication at college prior to the research but again in a less focused way. Of this group two people achieved certificates for recognising five or more symbols and one learner for recognising three symbols. Two of this group had not spoken in college and have started doing so (single words and couplets). We feel it is not possible to judge to what degree the increased attention given by learning facilitators during the project and the stimulation of using an accessible communication method contributed to this and how much was natural progression and recovery from their brain trauma (with a resulting increase in wakeful periods). However, having observed the learners increase in attention and developing confidence in using Somerset Total Communication, I personally do not doubt that the communication tools were beneficial. We found learners with congenital difficulties required a longer period of input before they showed confidence in using signs and/or symbols. We felt that this may be due to the fact that they had never developed a wide vocabulary at any point in their lives in the way that learners with acquired difficulties had. Dyer (2001) comments, what we speak and what we write and how we read form only a minuscule part of the language we use in our waking and indeed in our sleeping hours. It follows that much of language development takes place in the head. Partly this is a factor of brain maturity (p.79). As the groups require different amounts of input we feel it is more appropriate to teach the two groups separately. Due to fluctuations in attention, it wasnt easy judging whether learners showed increased interest in their sessions. However the fact that learners with acquired difficulties spent more time with their eyes open, and that all learners acquired a certificate, indicates engagement in the sessions.

ing facilitator or family member with little or no experience of this type of recording). Also on reflection I have become aware of the problem of possible inconsistency when different people complete questionnaires for a client due to staff availability and response. The project is small scale and focuses on individuals at a specific time in their lives. This makes it difficult to reproduce. However it is exciting that our learners with acquired severe and complex communication needs responded positively. On a personal level I learned a great deal from my studies, not least about how little I knew then and now, and how much there is still to learn in order to provide the best service to these amazing learners. I would hope that others may feel motivated to offer these communication tools to people with acquired brain injury, to give them further opportunity to start to communicate again. If anyone wishes to do so I would value the opportunity to liaise and SLTP support in any way possible. Julia Tester is a curriculum leader and a teacher of communication at Somerset College of Arts and Technology, email: Greystarh@yahoo.co.uk.

References
Brown, N., McLinden, M. & Porter, J. (2003) Sensory Needs, in Lacey, P. & Ouvry, C. (eds.) People with Profound and Multiple Learning Disabilities. London: David Fulton, pp.29-38. Dyer, C. (2001) Teaching Pupils with Severe and Complex Difficulties. London: Jessica Kinglsey Publishers. Katz, D. I. (2001) Minimally Conscious States [Online] Available at: www.kurzweilai.net/articles/art0161.html (Accessed: 9 March 2007). Laureys, S., Faymonville, M-E., Degueldre, C., Del Fiore, G., Damas, P., Lambermont, B., Janssens, N., Aerts, J., Franck, G., Luxen, A., Moonen, G., Lamy, M. & Maquet, P. (2000) Auditory processing in the vegetative state, Brain 123(8), pp. 1589-1601 [Online]. Available at: http://brain. oupjournals.org/cgi/content/full/123/8/1589 (Accessed 9 March 2007). Prince, J. (2006) An Evaluation of Teaching & Learning Somerset Total Communication in a Further Education College to Two Groups of Learners. One group with Acquired and the Other with Congenital Severe and Complex Needs. MEd dissertation. The University of Birmingham. Weill Cornell (2005) Giving Voice to Hidden Lives, The Weill Cornell Scope July-August [Online]. Available at: www.med.cornell.edu/publications/pdf/thescope/2005-07-08 (Accessed 9 March 2007).

I found it extremely exciting to see the increase in communicative behaviour between the learners and staff.
allow time for response. My mind was elsewhere, on the next stage of the lesson. Suddenly I heard a colleague draw in a breath and I refocused on the learner who had now opened their eyes and was moving their hand and arm up to sign good morning. They were smiling and appeared excited by their own ability to respond. I felt very emotional at this point and wondered what had triggered the learner to communicate that particular morning. Had I approached them differently? Was the temperature in the room different? Was it the extra time given? Was it that this was one of their waking times? As they had previously responded more during one-to-one time, we were very excited that they seemed happy and had responded in the group circle situation. This incident marked a shift in my perceptions. As Brown et al. (2003) said, The necessary concentration on the learner in order to encourage and extend these exchanges is also likely to make us aware that the learner has in fact a number of expressive actions of which we may have been unaware (p.33). The outcome of the project was that both groups were able to learn and use Somerset Total Communication when taught in the same way. Two learners with congenital difficulties achieved certificates for recognising five or more symbols and one learner achieved a

Resource
Information on Somerset Total Communication is at www.somerset.gov.uk/somerset/socialservices/pi/stc/.

Time to respond
This project taught me a great deal about my own receptive communication skills and about the need to give time to our learners to respond. I have also become aware of the difficulties of analysing responses to questionnaires (and of all the potential for genuine under/ over attributing of skills) and the difficulties for those filling in questionnaires (whose role may be carer, learn-

REFLECTIONS DO I PAUSE SUFFICIENTLY FOR LEARNERS TO RESPOND? DO I THINK LATERALLY WHEN SEARCHING THE LITERATURE? DO I APPRECIATE THE LIMITATIONS OF USING QUESTIONNAIRES?

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

COVER STORY: THERAPY

I know exactly wher but I dont know wh


READ THIS IF YOU ARE INTERESTED IN USING COMMUNICATION AIDS AS THERAPY TOOLS HOW IMPAIRMENT AND FUNCTIONAL THERAPY APPROACHES WORK TOGETHER DESIGNING THERAPY COLLABORATIVELY WITH CLIENTS Trevor Harley is also author of comprehensive psycholinguistic textbook 'The Psychology of Language'. For your chance to win a FREE copy of this book, see the Reader Offer on the inside front cover.

Photo: Paul Reid.

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

Photo: Paul Reid.

COVER STORY: THERAPY

re it is here its going


When Laorag Hunter offered Helen Gowland a high-tech aid as a communication strategy, neither suspected it would become a means of facilitating Helens use of multi-syllabic words in everyday speech. Here, with Siobhan MacAndrew and Trevor Harley, they discuss the use of images as signposts in therapy and the kind of service we need to provide to ensure such opportunities are not missed.
his article describes a specific component of therapy, a solution-focused approach that is simple to implement. This therapy evolved collaboratively when the introduction of a high-tech aid as a communication strategy opened up unplanned possibilities. We find it particularly exciting because it is having a measurable impact on a client with conduction aphasia seven years after onset. Our story starts seven years ago, when Helen Gowland settled down one evening to watch Jools Holland on TV. This was a moment of relaxation in a schedule involving many roles. Helen worked full-time as a specialist physiotherapist, researcher at an international level, Chair of the school Parent Teacher Association, wife, mother to three teenagers and daughter to an elderly father. She remembers wondering that evening why paramedics were in her house. Helens next memory is ten days later in neurosurgery finding herself with a large surgical wound in her skull, unable to speak or to understand what people were saying. It took a long time to fully grasp what had happened. Helen had suffered a sub-arachnoid haemorrhage from a large left middle cerebral artery aneurysm. An emergency craniotomy was required to clip the aneurysm. Two days later Helen experienced delayed ischaemia with seizures and severe aphasia.

Figure 2 Meta-linguistic awareness A print showing how Helen senses her aphasia. Reprinted by kind permission of Christine Kingsley.

Changing needs
Helens partnership with speech and language therapist Laorag has continued and developed over the seven years. Episodes of care have responded to her changing

needs and varied in type and length. Reasons for therapy have included assessment, rehabilitation, supporting and enabling (Malcolmess, 2001). Additionally, Helen has opted in to resources and projects including group work, computer classes and visual arts. Complicating factors affecting rehabilitation have included wound infections, removal of her temporal bone-flap with later cranioplasty to close the skull, and issues relating to epilepsy and side effects of medication. Helens communication profile resembles that of the syndrome of Conduction Aphasia (Goodglass & Kaplan, 1983). Key features are fluent and grammatical speech; difficulty in the sequential order of speech sounds in naming and repetition; greater difficulty with longer words; good awareness of errors; repeated attempts at error correction (a characteristic known as conduite dapproche) and relatively spared comprehension. Helen has excellent conversational skills and is exceptionally resourceful at getting her ideas across through total communication methods. When she is unable to express the full content of her message she will use drawing, fragmentary writing, pantomime, circumlocution and even singing. Helens speech is easy to understand and is fluent and grammatical. These strengths contrast with a history of severely impaired noun production in spontaneous speech, spoken naming, written naming and repetition. Helens understanding in everyday situations is good but vulnerable to errors in times, days and numbers. She notices increased difficulties understanding in groups where there are

rapid shifts of turn and when there is background noise. Formal assessment shows comprehension breakdown in sentences if the context does not assist in understanding the relationship between items. In terms of naming (figure 1), Helens assessment record shows a history of word form errors (literal paraphasias), many of which are non-words. Alternatively, attempts are aborted after inability to start the word or after producing only the initial phonemes. Helens errors increase with word length and she makes more deletions or substitutions towards the end of words. Less frequently, Helen makes semantic errors, such as substituting father for husband.
Figure 1 Naming examples

Mug muck monk mug Hoover hoola Cigarette sigarant Speakability speakaleekie

Cognitive neuropsychological models of speech production detail the component processes in speech production (see for example Levelt, 1989). With reference to such models, Den Ouden & Bastiaanse (2005) conclude that the symptoms of conduction dysphasia are associated with impaired phonological encoding. This stage between word form selection and articulatory planning - incorporates a slot-filler mechanism that maps the sounds (fillers) onto their position (slots) in a word frame (Nickels, 1997). Den Ouden & Bastiaanse (2005) suggest
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COVER STORY: THERAPY

Figure 5 Target word examples

that, as well as a mapping deficit, the error patterns of some people with conduction aphasia are secondary to a verbal memory deficit. In these cases speech errors result from difficulties retaining the activation of the phonological plan.

Figure 3 Alphabet links

Letter Link word Link Picture Homophone type A eight Near homophone

Meta-linguistic awareness
Helens descriptions of her experience when naming suggest having word form knowledge with inability to complete the phonological form. These descriptions show a high level of meta-linguistic awareness (see figure 2, p.7): I know the meaning of the word but I dont know what it looks like. I know exactly where it is but I dont know where its going. Sometimes I can start it but I dont really know how to say it properly. Helens written naming follows a similar pattern to her speech in that she writes partial word forms. She frequently writes more letters of a word than sounds she can say. When letters are omitted she can often indicate the correct number of letters or syllables. Helens reading is slow and limited to short pieces. She has great difficulty recognising function words such as prepositions, conjunctions and determiners. This is a symptom of phonological dyslexia. Impaired reading by letter to sound conversion (grapheme to phoneme route) forces reading via the semantic route (Harley, 2001). Words with poor semantic representations such as function words are therefore read poorly (Friedman et al., 2002). Helen compensates for this difficulty by using text-to-speech software to aid reading comprehension.

bee

Homophone

sea

Homophone

Delia

Near homophone

Speech production stuck


Through semantic type therapy (Nickels, 2002) and practice of specific word sets Helen slowly made modest gains in naming. At the start of this therapy Helens speech production was stable; this could be re-phrased as stuck. Laorag offered a communication aid as a back-up to speech to help transfer of information such as address, phone number, numbers, and commonly used family details. Helen liked the idea of using the aid to practise speech but using it in interactions did not appeal. She felt the aid was too big, too slow and difficult for people to read. She thought that people would be too busy to attend to it and that it negatively affected perception of her competence. Helen wanted to say letter names as they frequently occur, for example, in addresses, clothing sizes, names of companies and medication (for example, DD2, RAC, CPR). Letter names cannot be read by letter to sound conversion and are disadvantaged in reading via a semantic route because they are low in semantic value. Friedman et al. (2002) increased function word reading in two people with phonological dyslexia. Using paired associate learning Friedman improved reading of function words (low semantic value) by pairing with homophones high in semantic value (not/knot, knows/nose). This is an example of a reorganisation of function where intact processes are used to compensate for impaired processes. We linked the alphabet with semantically rich homophones and near homophones that Helen found meaningful (figure 3). Near homophones begin with a sound that is the same as the letter name. These links were reinforced by storing a picture of the link word along with a recording of the letter name in a Dynamo digitised speech communication aid.

Helen found the discipline to practise challenging but her ability to say letter names improved. Interestingly, the method enabled Helen to say letter names in sequence (eg. MP). This suggested a potential to sequence single syllables to produce multi-syllabic words if each syllable was associated with a picture cue. Helen was enthusiastic and quickly identified long words she wanted to say such as aphasia, Glenrothes, Victoria. Laorag was concerned that this was too ambitious as until now work on spoken output had mainly been on single syllable, picturable words. For our multi-syllabic words therapy, Helen makes lists of words that she wants to say and use but is unable to produce (target words). The lists typically consist of written fragments of each word (1-3 letters) accompanied by a drawing for picturable items. For more abstract words (eg. policy, resources) additional clues in the form of gestures or associated words are required from Helen before Laorag can identify the target word. Helens chosen vocabulary reflects personal, family and professional interests, needs, seasons and world events. Most items are 2-5 syllables in length (figure 4).
Figure 4 Target vocabulary (selected by Helen)

Fun
Laorag segments the target word into syllables and suggests single syllable words that are homophones or near homophones for each syllable. An image to represent each single syllable word is selected from the Picture Communication Symbols set (Mayer-Johnson, 1981). Where there is more than one possible image Helen selects the one that is most meaningful to her. Associating each syllable with a Picture Communication Symbol has drawn upon Helens strengths in word meaning, foreign languages, wide-ranging knowledge and creativity. It has also been a fun part of therapy for both of us! We make a page for each target word on the Dynamo. Each syllable is represented by a picture of the associated image from the Picture Communication Symbols accompanied by the written form of the word. The syllable is recorded so that when the picture is touched the syllable is heard (figure 5). Initially, Laorag made the recordings but after two to three months of therapy Helen could independently say and record the single syllable words. By activating the pictures in sequence Helen hears her recorded production of the whole word built up syllable

Aphasia Glenrothes Victoria Hospital Manchester Inverness Ambulance Pharmacist Greece Management International Marks and Spencer St Andrews Hideko Japan Mackinlay Egypt

Relations Continence Chlamydia University Paddington Psychology Budapest Communication Australia Thorburn Ipswich Cambridge First Aid Africa Sudan Switzerland Umbrella

Antique America Islam Computer Politics Czech Republic Graduate Exam Leaflet CBIR Aneurysm Internet Sociology Pakistan Tsunami Neurology Stollen

Sandwich Sainsbury Age Concern Address Stepney Anatomy HRT Theatre Courgette Broccoli Coleslaw SR flour Statement Parliament Bric-a-brac DVD Strathearn

Human Resources Cathedral Elephant Animal Policy MSP Novel Concert Ozone Lebanon South Columbia Falkland Prescription 1955

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REFLECTIONS DO I RECOGNISE THAT STABLE CAN FEEL STUCK? DO I OFFER A SERVICE BOUND BY ARBITRARY TIME LIMITS OR FLEXIBLE TO A CLIENTS CHANGING NEED? DO I EVER THINK ABOUT WRITING AN ARTICLE WITH A CLIENT?

by syllable. After listening a few times and considering the image associated with each syllable Helen is usually able within the session to record the target word as a whole item on the Dynamo page. At this point, her production often automatically alters to accommodate the normal stress pattern of the target word. It is as if Helens memory for production of the word is reactivated. When Helen feels confident that she has captured the production she practises and celebrates by playing with the word. Around Christmas time she delighted in exclaiming Have a piece of Stollen, Do you like Stollen?, Would you care for some Stollen? She also confesses to continuing this practice by talking to herself on the bus ride home. Helen is comfortable to delete words from the Dynamo once she is satisfied that she can independently recall the graphic for the single syllables which subsequently cue her spoken production of the whole multi-syllabic word. When a previously used syllable occurs in a new target word Helen sometimes feels the addition of the graphic in the Dynamo is unnecessary and the written form of the syllable appears alone. Occasionally Helen requests that a Picture Communication Symbol is changed, if she finds it doesnt mean anything. For example trail to represent the second syllable in Australia was changed from a path to a child trailing a pull-along toy. Therapy sessions are approximately bimonthly and no preparation is required by the therapist secondary to sessions. Helen feels this schedule is appropriate to establish new vocabulary and it also accommodates Helens activities including volunteer work, committee work, family commitments and holidays. Four to six target words are added each session and in 17 months Helen has mastered the production of over 70 target multi-syllabic words. Helen is now occasionally able to generate images for two syllable words independently of therapy sessions.

Self-generated cues
Helens ability to say target words and use these in real communicative situations shows notable increase. Additionally, there are signs of carryover in her use of self-generated cues. Within sessions Helen has become faster at producing target words. Qualitative changes are also apparent in Helens reflections. Helen has a sense of achievement and feeling of progression as opposed to previously feeling stuck. The positive outcome for Helen is also clear as she describes imagined fears, for example, what if we hadnt tried this?, what if you had discharged me?, what if you have to take the Dynamo away?

We agree with Nickels (2002) that for the clinician understanding how the therapy worked is a luxury and would add that given the complex variables in typical therapy this can feel like impossibility! However, our method draws upon several therapy approaches, functional, re-organisation and stimulation: 1. The goal is functional to allow Helen to say the words she wants to use and is driven by Helens requirements and aspirations. 2. We achieve production of previously errorful words through an alternative route (re-organisation). The pictures in sequence give Helen sufficient information to allow phonetic encoding. This may be a direct effect of improved phonological assembly. Alternatively, improved production could be a consequence of improved monitoring. Each picture allows Helen to know the one syllable target which she can check and correct at a pre-speech production stage. 3. Once production of the multi-syllabic word is enabled, Helen can go on to practise in a stimulus-response manner (stimulation). This strengthens the connections between semantic and phonological processing giving the possibility of the therapy being effective through rehabilitation of impaired processes. Helen has rated features from most to least important for her. (The comments are in Helens own words.) 1. The picture is most important. I dont look at the letters at all. The picture opens it (the word) up for me. 2. Quick results. 3. The words are always there for me to check if Im not sure. Thats reassuring. 4. The words are the ones I really need and want to have. 5. I can practise on my own, even in my bed. It (the Dynamo) is easy to carry around in my bag. 6. Its interesting to show others what Im doing in therapy and I can explain that its about pictures. 7. Im not bothered whether its my own speech or not, but I am glad that its not American. Our success illustrates that therapy to improve a production disorder can be effective many years post-onset. Although we dont know if this would have worked earlier for Helen, it has prompted Laorag to earlier and more creative trialling of stimulability in speech production with other clients.

rather than within set time boundaries. The method developed through dedicated time for continuing professional development activities, particularly Laorags attendance at British Aphasiology Society conferences. Of equal importance is a management commitment to provide and maintain communication aids for clients. Client need, therapist knowledge and the availability of technology changes over time. In this therapy these variables came together to give a rewarding outcome. Giving people with aphasia the opportunity to review therapy options could be of benefit long after their initial period of rehabilitation. Laorag Hunter is a speech and language therapist at the Centre for Brain Injury Rehabilitiation, Royal Victoria Hospital, Dundee, DD2 1SP, e-mail laorag.hunter@nhs.net. Helen Gowland is Chair of Tayside Speakability and a member of the Aphasia Scotland project steering group. Siobhan MacAndrew is a psychologist in the division of psychology at Abertay University and Trevor Harley is Dean of School and Chair of Cognitive Psychology at Dundee University and the author of The Psychology of Language (see reader offer on inside front cover).

References
Den Ouden, D.B. and Bastiaanse, R. (2005) Phonological encoding and conduction aphasia, in Hartsuiker, R.J., Bastiaanse, R., Postma, A. and Wijnen, F. (eds.) Phonological Encoding and Monitoring in Normal and Pathological Speech. Hove: Psychology Press, pp 86-101. Friedman, R.B., Sample, D.M. & Nitzberg Lott, S. (2002) The role of representation in the use of paired associate learning for rehabilitation of alexia, Neuropsychologia 40, pp.223-234. Goodglass, H. and Kaplan, E. (1983) The assessment of aphasia and related disorders. 2nd edn. Philadelphia: Lea and Febiger. Harley, T.A. (2001) The psychology of language. 2nd edn. Hove: Psychology Press. Levelt, W.J.M. (1989) Speaking: From intention to articulation. Cambridge MA: HIT Press. Malcomess, K. (2001) The Reason for Care, Bulletin of the Royal College of Speech and Language Therapists 595 (November), pp.12-14. Mayer-Johnson (1981) Picture Communication Index. Solana Beach CA. Nickels, L. (1997) Spoken word production and its breakdown in aphasia. Hove: Psychology Press. Nickels, L. (2002) Therapy for naming disorders: Revisiting, revising and reviewing, Aphasiology, 16(10/11), pp. 935-979.

Flexible service
Aspects of our organisation and management have been vital in enabling this work. Our service is flexible to deliver therapy according to client need and potential for change

Resources
The British Aphasiology Society, www.bas.org.uk The Dynamo Communication Aid is available from Dynavox Systems Ltd, Sunrise Medical Building, High Street, WollasSLTP ton, West Midlands, DY8 4PS (www.dynavox.co.uk)
SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

ASSESSMENTS ASSESSED (2)

Assessments assessed
We continue our series of in-depth reviews to help you decide if an assessment or programme would meet your needs.
Teaching Talking
While this programme provides a sound introductory framework for education professionals, Gila Falkus believes they should be trained to this level before they start working with children.
Teaching Talking (2nd edn) A screening and intervention programme for children with speech and language difficulties Ann Locke and Maggie Beech nfer Nelson 76.00
eaching Talking is a screening, assessment and intervention programme for children with speech or language difficulties. It is intended for use in early years settings and primary schools with children up to the age of 11. The authors are both highly experienced and knowledgeable. Ann Locke is a qualified speech and language therapist, teacher and educational psychologist. Maggie Beech is an Education Consultant with a wide experience of working in Special Needs. The programme is clearly written and contains a great deal of information and sound advice. Its basic philosophy of wanting to empower educational professionals to provide appropriate support and to understand how communication is fundamental to all areas of the curriculum is unexceptionable. The programme requires a whole nursery or whole school approach led by senior management. A typical roll-out would extend over the course of a school year. The first edition was published in 1991. This second edition aims to reflect the revised SEN Code of Practice, changes in legislation and the plethora of new guidance and curriculum objectives. The original procedures and materials have been revised, partly in the light of user feedback, to provide more background information on communication difficulties, particularly dyspraxia, autism, selective mutism and stammering, and to make the programme more user-friendly. There is one completely new chapter that provides 8 illustrative case studies. The programme has three components: a procedures handbook, an activities handbook and assessment and intervention materials, some of which can be photocopied, though the Detailed Profiles forms need to be purchased separately. There are also three levels of intervention that tie in with the special education needs (SEN) frameworks. First comes Identification and Initial Support. All children are screened; those who may be having difficulty with some aspect of language development are identified and classroom strategies to support them are put in place. The next level is Small Group Intervention (this equates to the level of Early Years or School Action in the revised Code of Practice). Children who are not benefiting sufficiently from Initial Support are assessed in more detail and teaching activities are selected from the activities handbook. The third level is Detailed Profiling which equates to Early Years or School Action Plus in the Code of Practice. Children who are not benefiting sufficiently from Small-Group Intervention are assessed in greater detail and further teaching activities are selected. The programme is comprehensive and sound. One disappointment was that the importance of early referral to speech and language therapy was not stressed. The authors advise that Any child whose speech is very difficult to understand or whose language, understanding or use appears to be particularly delayed should also be referred to SLT, particularly if they are over the age of 3. This seems far too late. Empowering educational professionals should mean that referrals to speech and language therapy are made more promptly, not delayed. Two pieces of advice seem particularly suspect. The suggestion that teachers should not feel any need to identify children with specific language impairment before the age of five or six could lead to a child missing out on a place in a language unit. The recommendation that children who stammer should be referred over five years runs counter to the drive for early referral. The authors complain (justifiably) that involving outside agencies can be extremely complex and timeconsuming. But the same can be said about the task of getting to grips with the system and paperwork of this programme. In addition to the two manuals, there is the Early Years Screen (in two parts) or the Primary Screen, 5 different levels of Language Records for the Early Years, the Primary Speaking and Listening Charts and Teaching Charts, the Starter Record Forms, and the Detailed Profiles. Staff could easily be worrying about the procedures of the programme instead of focusing on the children. One final gripe, though more against government than the authors: why do educational professionals need programmes like this? We know that language is the key to education and that communication skills are essential to childrens social and emotional well-being. We also know that speech and language difficulties are the most common developmental problem of the preschool years and are often responsible for subsequent literacy difficulties. The information in this programme is at an introductory level. Shouldnt all educational professionals be trained to this level before they start working with children? However, until this happy day arrives, Teaching Talking provides a sound framework. I might recommend it to settings that have a particularly dedicated and wellorganised SENCO or Manager. But speech and language therapy services certainly need to ensure that they have a much stronger profile in early years settings than the authors envisage here. Gila Falkus is manager for early years speech and language therapy with Hammersmith & Fulham, Kensington & Chelsea, Westminster PCTs.

One Step at a Time


Sarah Colquhoun and colleagues welcome this programmes evidence for teaching spoken language in nurseries and primary schools, but find it short on practical activities for early years settings.
One Step at a Time (A structured programme for teaching spoken language in nurseries and primary schools) (2006) Ann Locke with Don Locke Network Continuum Education 24.95

ncreasingly therapists are being called upon to provide consultative advice / intervention and support to set up language groups within education or early years provision rather than providing direct input. A structured programme for teaching spoken language in nurseries and primary schools which proposes to make this process clearer and easier will always be welcome. This programme consists of a single manual / book containing the theoretical basis for the approach, the procedure in stages and the checklists to be used initially and afterwards for evaluation. Suggestions of session plans are included along with an age related description of language and communication development from birth to nine years. The theoretical basis is faultless and Ann Locke presents a lot of evidence based research to help justify running it. She identifies several fundamentally important aspects which may well be beneficial for our colleagues who work in educational settings and are pressured by other curriculum demands. These include the importance of oral language development over literacy skills and the use of familiar everyday routines. However, the programme later appears to adopt a literacy based approach of choosing, explaining and then displaying target words, which seems more suited only to schools rather than early years settings as well. While it is stated that the programme can be adapted, obvious adaptation is lacking. For example, the use of real objects or pictures is recommended as an entry in the main body of the text rather than as a clear, salient bullet point. The programme contains useful advice about promoting oral language skills. It repeats the teaching method mantra of modelling, prompting, highlighting and rewarding in each section and provides examples of activities. However, the two example planning sheets relate only to the listening and narrative sections of the programme. For the remaining sections rather more general advice and examples are provided within the body of the text, which makes finding out what one should be doing rather more arduous. The most common feedback from nursery staff was that the programme is very text dense, and extracting the information required was quite time-consuming.

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They would have preferred visuals, text boxes and bullet point summaries of the most relevant information. The checklists are relatively simple for a speech and language therapist to use. However feedback from the nursery teachers suggested some confusion about the procedure of banding the children. They were also reluctant to adopt the practice of carrying on with the current word selection until all children had grasped them fully. They felt this had the potential to bore some children who either knew them already or learnt them quickly, whilst putting pressure on others to catch up. There is also a lack of concrete guidance about what exactly should be changing in terms of teaching practice in the two early stages. For example, it states: Almost any nursery activity can be used for teaching conversation skills, but two activities are particularly useful. These activities - Talk Time and Circle games - are then given a brief explanation but no detailed information about how to do them more effectively vis--vis promotion of oral language skills. The very useful Eight tips for promoting talk with young children only appears on page 104 after the two early sections Getting started and Conversation Skills. It would have been more usefully presented right at the very beginning. Indeed, re-ordering the information to start with tips / general advice followed by stages / activities and ending with supporting research would prevent duplication and help readers filter out the information not directly linked to the programme. Whilst the principles of teaching methods are repeated throughout, we felt that more session plans or real life examples for adapting some of the principles would be useful. The advice for activities within the earlier sections seems too general with few specific procedures suggested and little in the way of linking it to more specific advice about the adult-child interaction principles outlined in the Eight tips. Despite the initial assertion of working through familiar daily routines, the programme also advocates several potentially time-consuming activities requiring additional staff resources. These include carrying out the initial screening over the course of at least a week and using two members of staff, and daily talk time of 10-15 minutes for all children either in small or large groups. In my experience some nursery staff struggle to achieve regular time for small group sessions without support from management. On the other hand, management support may be a positive effect of implementing the programme. The longer group sessions also advocated may prove even harder to set up in some settings; again, full backing from management is needed. At just under 25.00 One Step at a Time is a cheaper resource than many. However its text dense nature means that a significant investment of time is needed to get to grips with the stages, procedure and also the checklists and then impart this to nursery staff who are themselves under pressure of time. The programme contains many useful tips and research. Within the right setting - where support from management and time for running the groups is freely available it would be a valuable resource. Where staff: child ratios are already stretched to the limit it is probably not practicable. I am sure there are more user-friendly

resources out there which could be combined to good effect with the strongly theoretical / curriculum-based approach of this programme. Sarah Colquhoun is a speech and language therapist with Waltham Forest Primary Care Trust. She thanks Lloyd Park and St Andrews nursery staff and children for their help in carrying out the review.

CELF-4UK
Jine Milton and Mary Moore find this latest version of the Clinical Evaluation of Language Fundamentals thorough for assessing language performance and its relationship to educational tasks.
CELF-4 UK Eleanor Semel, Elisabeth H. Wiig & Wayne Secord (2006) Harcourt Assessment 519.35 (inc. VAT)
he Clinical Evaluation of Language Fundamentals Fourth UK Edition (CELF-4 UK) is an individually administered clinical tool for the identification, diagnosis, and follow-up evaluation of language and communication disorders in clients aged 5-16. The authors had some specific goals in mind when they redesigned the CELF-3UK. They aimed to: - make it more user-friendly - determine whether or not a client has a language disorder by administering only 4 core sub-tests - expand the test to include descriptive and authentic measures of communication skills - include sub-tests that probe underlying clinical behaviours. The stimulus books have been improved by the addition of section markers. Many therapists will be happy to see the back of the geometric shapes in the Concepts and Following Directions section. Now you do not have to rely on clients knowing the name of the shapes. These have been replaced by familiar objects, which are in colour for the younger children. Clients told us they preferred this new colour format and design. Fortunately, a separate question sheet has been provided for administering the Concepts and Following Directions section. Reading the instructions - now on the back of each page of the easel format book - and observing the clients response would be very difficult. The absence of this sections questions on the record form means that, without the manual at hand, you dont know which errors the child made. The Word Classes section for younger children now has pictures, therefore reducing memory load. There are now two record forms specific for age-bands. Unfortunately the item analysis summaries are no longer in the record forms. Again, this means that the therapist will have to consult the manual, which wont always be available. The CELF-4 can now be used for children between 5 and 16, therefore covering all school-age children. The CELF-4 now features a Core Language score involving four sub-tests (Concepts and Following Directions, Word Structure, Recalling Sentences, and Formulated Sentences), which can be used to determine whether there is a language disorder or not. The clini-

cian then decides which of the other sub-tests should be administered. An expressive section has been added to the Word Classes sub-test. As well as saying which two words go together the client now has to say why. There are two new vocabulary sub-tests: Expressive Vocabulary in the younger test and Expressive Vocabulary and Definitions in the older test. Working Memory and Phonological Awareness sections have also been added. There is a comprehensive Pragmatics Profile as well as an Observational Rating Scale. The latter is filled in by teachers, parents and clients and is a useful measure of pragmatics and use of language in context, something missing from the CELF-3. The CELF-4 is a comprehensive, clinically useful assessment covering all aspects of language, other than phonology. It is expensive and you could be duplicating assessments you already have in the clinic. We would recommend it as the authors have taken on board previous criticism regarding how thoroughly the test covers language performance and its relationship to educational tasks. The CELF-3 acknowledged that further additional formal and informal assessment would need to be undertaken to assess, for example, word and concept development, language use and interpersonal communication abilities. The CELF-4 assesses these and also other underlying skills, such as working memory and phonological awareness, which are fundamental to planning intervention. Jacqueline Milton and Mary Moore are speech and language therapists with Aberdeen City Speech and Language Therapy Team, NHS Grampian.

Stroke Talk
Used selectively, Sarah Harwood and colleagues and patients from a stroke unit recommend this resource for people with aphasia.
Stroke Talk: A Communication Resource for Hospital Care (2006) Sophie Cottrell and Alex Davies Connect Press 60 (inc. photocopiable material) his resource is aimed at people with aphasia following a stroke. It is designed to improve the accessibility of the information they receive during their acute and rehabilitation hospital stay. The format helps them to understand and remember the information and it can be used to ask questions. The book covers the roles of the different multidisciplinary team members and the tests and procedures that can occur during the hospital stay, and provides information about the stroke journey. There is also a section describing medications and common infections, such as MRSA. Photocopiable aphasiafriendly appointment cards are included that can be left with the client to remind them when they are going for specific tests / procedures. The sections are ordered alphabetically; each section contains a description using written words, pictures, photographs and symbols to explain that particular area to

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the client. The written language is kept short and simple, with key words highlighted. The appropriate member of staff should go through the relevant section of the book with the client, slowly reading over the text, while pointing to the parts of the book, and repeating if needed. The person with aphasia is to be encouraged to use the resource to ask for more information or for clarity on topics, or to express their feelings about different matters. We trialled the pack over a period of 8 weeks during November and December 2006 within our acute and rehabilitation stroke units. Different members of the multidisciplinary team used the resource with a number of people with aphasia, who were also asked to give feedback. The response from the people with aphasia was dependant on the severity of their aphasia. For those with less severe difficulties, the feedback was positive. They indicated that it had helped clarify issues and enabled them to find out more about things that were relevant to them, which they previously would not have been able to do. For some people with a more severe aphasia the pack was less beneficial. It was evident through non-verbal communication that they were still struggling to understand the information being given and that there was too much information on the page for them to follow. The general feedback from the multidisciplinary team was positive, although the following comments were made: Not all areas that therapists would have liked to be covered in the book were, for example, the physiotherapists felt that a basic description of chest physio, - with diagrams for deep breaths etc. would have been very useful. The layout of the resource was difficult to follow. Sections that intuitively would follow on well from each other were separated, as the book is arranged alphabetically, and this made it more difficult to use. Speech and language therapists felt that the layout for describing our role would have been better if it had separated the descriptions for eating / drinking from communication. The resource was felt to be very useful for some people with aphasia. It improved their understanding, and enabled them to ask questions that they would not previously have been able to ask. It covers areas that may previously not have been discussed with people with aphasia, due to their comprehension difficulties. The resource was felt to be good value, and will continue to

be used regularly with the appropriate people on the ward. All staff that used it felt they would recommend it to other stroke units for use on their wards. Sarah Harwood is a speech and language therapist at Glasgow Royal Infirmary.

Bilingual Speech Sound Screen


Although it has limitations, South Birmingham speech and language therapy staff find this a useful tool.
Bilingual Speech Sound Screen: Pakistani Heritage Languages Mirpuri, Punjabi, Urdu (2006) Carol Stow & Sean Pert Speechmark 44.95+VAT his assessment has been designed to be a rapid screen for use with Pakistani heritage children who have Mirpuri, Punjabi and Urdu as their mother tongue. It consists of 21 target words as well as supplementary word lists, which allow the speech and language therapist to probe the childs skills in more depth. The assessment has been designed to be administered by a speech and language therapist who does not speak the identified languages. However if a monolingual therapist administered it s/he would not recognise some of the phonetic errors that we have noticed in the transcription. For example: the /t/ in /topi/ (hat) is not a dentalised t but more a retroflex sound the/u/ vowel in /dud/ (milk) is a shorter /u/ vowel for the Mirpuri and Punjabi language whereas it is the longer /u:/ vowel in the Urdu language the /d/ in /anda:/ (egg) is a retroflex and not an alveolar sound. It would be useful if these could be amended in any future version as they mean that a monolingual therapist will think correct realisations are errors, or mispronounce words they want a child to imitate. In the meantime we strongly recommend that the assessment should be administered by a bilingual speech and language therapist or a bilingual co-worker working with a monolingual therapist so that phonetic errors can be minimised and natural speech patterns maintained. We used the screen with children from 3 to 8 years, as these are the ages the assessment has been designed

for. Its easy and straightforward and it is useful to have the target words for each language on the record form. The vocabulary chosen is appropriate and children from this community will be familiar with it. The pictures are a good size. Some were quite clear and elicited the target words. However others were dull, of a poor quality, and did not elicit the target word. For example, responses for the target clothes included: mummy doing work sweeping cleaning and for the target pot/dish/meal a child responded by saying its messy. This shows that the pictures are not as clear as they have been thought to be, and perhaps it would be better with fewer items on each page. Some children found some pictures scary, such as the boy to elicit the target word eyes. A couple of children responded to this by saying it was a monster! The parents were also not totally happy with the pictures and one mum commented even I didnt know that for one of them. The assessment has been designed to elicit a speech sample in the childrens mother tongue. However we all noted that, although we were using the mother tongue to encourage the child to speak in his/her mother tongue, the children were deciding which language to respond in. For example, they used the English names for the animal pictures. Children under the age of 4 who had not been exposed to the English language for long responded in their mother tongue and it was easier to obtain a sample of speech in the mother tongue from them. This assessment may not be a valid tool with children 5 years and over as they have had longer exposure to the English language and may prefer to communicate in both languages or in English only. To some extent this invalidates the speech sample. Our overall impression is that this particular screen is easy to use and handle. If used with the help of bilingual co-workers and considering some of the issues we have noted it can be a useful tool for everyday clinical work. This assessment was reviewed by a team of speech and language therapists and speech and language therapy assistants from the Childrens Speech and Language Therapy Department in South Birmingham NHS Primary Care Trust.

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SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

ROLE HERES ONE EXTENDED I MADE EARLIER

Heres one I made earlier...


Alison Roberts with yet more low-cost, flexible therapy suggestions suitable for a variety of client groups.
Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

News and weather round-up


MATERIALS Cassette or CD player 2 recordings of the news and weather, one from some time ago (preferably a month or more back) and one very recent one. Its best to use news that is not too upsetting or disturbing.

This is a useful memory exercise as well as a helpful way of demonstrating how topical events can enrich conversation. It is not an easy task; most people listen to the weather forecast and promptly forget most of what was said. As far as the news is concerned they are more successful, but not brilliant. (Try testing it on yourself be honest, it wasnt easy was it?) This exercise really needs forward planning as you should have some old news to practise with at rst.
IN PRACTICE (1) Play the old news first. Ask for a volunteer to repeat the main headline. Now ask other group members for any further points they remember. Play the news back again and see how much was remembered. Now try the weather forecast. See if anyone can remember the forecast for the local area, then see if the weather for other areas can be recalled. Repeat the whole exercise using a recent broadcast. The trick is, of course, careful and active listening. IN PRACTICE (II) Make the point that knowing what is in the news will be a valuable asset for making contributions in conversations, especially if your client has the problem of not being able to think of what to say. Have a short discussion about the main - or most interesting - points of the news, and see if anyone has any opinions they would be willing to share.

Newspaper headlines
MATERIALS Newspapers (Tabloids seem to be best at producing both intentional and unintentional puns. Local papers are also good sources).

This activity will further the clients work on ambiguity, and should be a source of humour.
IN PRACTICE Present the puns on the list one at a time, and work out together which is the ambiguous word in each headline. Now go through the papers and see if anyone can find any new puns. Examples: Miners Refuse to Work After Death Drunk Gets Nine Months in Violin Case Hospitals are Sued by 7 Foot Doctors Panda Mating Fails; Vet Takes Over Squad Helps Dog Bite Victim Shot off Womans Leg Helps Golfer to Victory Enraged Cow Injures Farmer with Axe Juvenile Court to Try Shooting Defendant Stolen Painting Found by Tree Two Sisters Reunited After Fifteen Years in Checkout Counter Red Tape Holds Up New Bridge Man Struck by Lightening Faces Battery Charge Kids Make Nutritious Snacks Sex Education Delayed, Teachers Request Training Include Your Children When Baking Cookies Head Seeks Arms These are notices rather than headlines but just as ambiguous! Cats Eyes Removed Baby Changing Rooms Eye Drops Off Shelf

Soapbox
MATERIALS Video or DVD recordings of radio or TV soaps, such as The Archers, Eastenders, Coronation Street, Neighbours. Use whichever programme is deemed to be cool. Find a longish piece of conversation in which 2 or 3 people are talking pleasantly and evenly not arguing. Equipment to play back recordings. Paper and pens Stopwatch

This is a listening, remembering, understanding and analysing activity which can be applied to conversational technique, especially length of turn/contribution. Because it uses popular TV programmes, there is usually no trouble motivating clients to do this work. Many clients on the autism spectrum nd they can learn useful tips about chatting to people from TV conversations, because they can observe in a detached way. It works well for a group of 4-5 teenagers.
IN PRACTICE (I) Introduce the recording carefully, setting the conversation in its context. Ask one client to time the conversational turns and another to write this data down. Listen to or watch the piece, jotting down the turn timings. You will probably find, as we did, that most conversational turns last for about 4-6 seconds. This can be quite a revelation for the conversational ramblers! If you feel it to be appropriate for your group you could then time the length of the real conversational turns in your session. IN PRACTICE (II) You can use this method for other aspects of conversation such as eye contact, facial expression, or topic choice. You may be able to find pieces of the programme that illustrate friendship skills like compromising on what to do, letting the friend go first, telling the truth, or offering a compliment. Be careful only to analyse for one skill at a time.

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

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WRITING FOR PUBLICATION

oes your heart sink when a colleague says, Thats a really interesting piece of work, you should write it up? After reading an article do you think, I could do that, but never get round to doing anything about it? I havent got the time, Ill write when I retire, or I cant write, are the most common excuses people hide behind for not writing up their work, but the real reason is often fear of the writing itself. And the fact is, if you have conducted an interesting piece of work, investigated a different approach or developed some new materials, you owe it to yourself and your fellow professionals to disseminate your ideas more widely. Of course every speech and language therapist can write. However difficult it may have seemed at the time all therapists have written essays or dissertations at college, or client reports since beginning work. However, it is true that many people feel overwhelmed by the prospect of writing and even the most prolific writers often find it hard to begin and complete the next article, the next chapter, the next book; each new project feeling like the first. So, how can you break this deadlock? How can you get started, and even more importantly, keep going? Writing a considered article or chapter is a process over time; it is not something that happens in one creative burst. And, as with any process, it begins with the first step. That is, facing the blank page, the stage at which many falter. Of course there are some who have no difficulties starting. For them fear of the blank page (or writers block) may occur somewhere in the middle or at any stage of the process, but let us consider how to overcome the initial fear that so often prevents the potential writer from getting beyond the opening paragraph.

Doing the write thing


Have you considered writing about your work but not quite found the courage? With a treasure trove of experience and an enviable publishing record amassed over 20 years, Myra Kersner and Jannet Wright are well placed to help you get started - and then to keep going all the way to the finishing line.
from relevant sources you have been reading; you may have a file or notebook of random thoughts you have jotted down when first thinking about the project. It is a good idea to make notes as thoughts occur to you; you always imagine you will remember them, but it is amazing how quickly you will lose even momentoussounding ideas if they are not immediately committed to paper or the computer. way of breaking the writing into manageable chunks. In addition, if appropriate to the journal, headings help break up the text for the reader. A useful technique at this stage can be to write the article as if you were telling a story, expanding the main ideas and points in everyday, colloquial language not worrying about grammar or punctuation. Crafting each sentence to perfection at this stage is likely to inhibit the thought flow. It is usually more advisable to let the ideas flow freely as this may lead in novel directions, and prevent you losing important detail. It is not a problem if you write an excessive number of words because these will no doubt be lost at the revising and editing stage. In fact it is much easier losing words in order to meet the word count target than adding them; additional words often appear as padding. Unfortunately a slowing of pace and enthusiasm, a sudden dearth of ideas, followed by a dip in energy levels, emotional stability and self-belief is an inevitable part of the writing process for even the most seasoned writers. This is the stage when many articles are lost as the writer tosses the unfinished pages into the waste basket in a fit of despair. But it is only a part of the process albeit a critical one. Now is the time to recognise that muses are definitely not to be relied upon, only hard, regular work. This is the time when it is crucial to ensure you have several writing appointments with yourself booked ahead in the diary. They do not need to be long sessions, but they do need to be regular and as closely spaced as possible so that you dont lose the thread of what you are trying to say. If you have been able to maintain the discipline thus far, you will by now be coming to the end of a completed version of your work, and you will probably feel pleased with it. But, however carefully you have crafted and nursed it to reach this stage, this is only the first draft.

A task to be completed
There is no point in waiting for the muse to take you. It probably wont. Writing is a task to be completed like any other, so make an appointment with yourself, set aside a realistic period of time in which to work, and begin. The assignment should you choose to take it is to fill as much of the empty white space on the page or the computer screen as quickly as possible. One of the most satisfying ways to do this is to brainstorm. This word often has a bad press but it is an effective way of launching into a new project. Give the opus a working title then write down anything and everything that comes into your head about the topic. This does not have to be in complete sentences, write odd words or phrases as the thoughts gain momentum. Scribble that is, whether you are writing or typing, dont worry about spelling, grammar, or coherence. Dont try to censor, or arrange your thoughts in any sequence or order. Let your mind roam freely. No thoughts are too off the wall at this stage. You will have time to organise and classify the ideas later. You may even find that what you eventually write is quite different from what you first planned in your mind, but there is nothing wrong with that, it will pay to be flexible in your thinking. Another way of covering the whiteness of a blank document quickly, particularly if you are writing directly onto a computer screen is to import some previously written material to act as a trigger or starting point. For example, you may already have some references, with quotations

Maintain the momentum


You may not be able to get beyond the ideas stage during the first session so make sure to book a series of realistic appointments with yourself; for the first flow of idea-generating adrenalin is often accompanied by a burst of enthusiasm that needs to be capitalised as quickly as possible to maintain the momentum.

identify the main theme of what you want to say, and the take home message for the reader
In order to organise the brain-stormed ideas it may be helpful next to identify the main theme of what you want to say, and the take home message for the reader. You can begin to put ideas together, organise similar thoughts under headings, now judging and discarding those that no longer seem pertinent. Writing under headings even if these are removed later not only helps with organisation and sequencing of thoughts but is a

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WRITING FOR PUBLICATION

READ THIS ARTICLE IF YOU WANT TO: OVERCOME A FEAR OF PUBLISHING FILL THE DAUNTING BLANK PAGE WRITE WITH OTHER PEOPLE

Does it comply with the requirements of the specific journal you are submitting to? Have you checked the punctuation and grammar? If you are uncertain about this there are several books you can read which are fun and easy to follow. Is the language and style appropriate for the journal to which you are submitting? Would you be interested in reading it if the manuscript arrived on your desk? Hopefully, your submission will be accepted. Although most commonly there may be some suggested, often minor, changes. If comments are included or there is an indication that, with changes, the article might be resubmitted, then it will be important to look at it again - after you have calmed down - and to consider the suggested revisions. You will usually find they are right. Unfortunately, it is possible that your article may not be accepted for publication, but although every rejection is painful reviewers are only commenting on your work, not rejecting you. The article may just not be suitable for the journals current needs, or they may already have a similar one in their publishing pipeline. You always have the option of revising it to suit a different journal and hopefully will feel able to write another article.

Write collaboratively
What many potential writers do not realise, is that this is when the real work begins. Of course when you are ready to submit your article for publication it is critical to research the market if you havent already done so to ensure that you have written your piece in a style appropriate to that journal. For example, there is no point in sending a reflective nonreferenced article to a journal that only publishes datadriven research. It is normally helpful to do this before you begin writing, but it is possible to make the appropriate adjustments at the revising and editing stage. All journals have their own format and requirements about the presentation of a manuscript, so make sure you research the journals that you wish to target. One of the most effective ways to ease the pain of writing is to write collaboratively with someone else. Where this is possible you will often find that together you are far more productive than either of you would be writing alone. Writing with another person can be a great motivator, having to produce work to show your co-author often proving a great incentive to write. And it can be fun. You may also find yourselves supporting each other in unexpected ways, particularly if physical and emotional writing peaks and troughs are complementary rather than simultaneous. Writing collaboratively highlights other issues that will need to be agreed, such as order of authorship which may relate to the amount contributed or may be alphabetical, and who will be the author for correspondence. As writing is essentially an individual experience it is important to adjust to each others style, to find a rhythm that suits you both, and this is true each time you write with a different partner. In our writing partnership we find that a half-formed thought from one will often spark a more considered idea from the other, an ungrammatical phrase from one will trigger a syntactic gem from the other. But no clumsily expressed notion is ever judged or dismissed without being fully discussed. It is also helpful if within the partnership you are able to take on complementary roles irrespective of your natural skills. For example, both of us are finishers but when writing only one takes the role of obsessive perfectionist. We are both capable of generating ideas, but usually at different stages of the writing; one particularly enjoys tracking the logic of the arguments while the other specialises in spotting omissions. But essentially we each appreciate the others contribution and together have learned to hone our craft. Naturally there are many potential pitfalls when working closely with someone who has their own views, their own style, their own vision, but the secret of a successful
SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

Revision
As any published author will tell you, good writing is all about revision, so be prepared. There are those who claim they never revise their work, but it shows. Either the work is ill-considered and rushed or it is written by someone who cannot commit their thoughts onto paper until they have honed each sentence to perfection. Such people usually write extremely slowly and may not always complete their projects, for the end product remains distant for so long, they are likely to become dispirited and lose interest. Most writers prefer to work more speedily following the flow of ideas and then to sit back and enjoy the editing and revising stage of the process, polishing the words and sentences until they are the best they can make them. It is not always easy to undertake serious editing as each word you have written may feel precious, but it is important to remove redundant language, ensure there is no repetition, and check that the major points are sequenced logically and that each idea is expressed as clearly and succinctly as possible. Now is the time to reduce verbiage and ensure that the language is appropriate for the journal that is being targeted. This is often a good time to seek the opinion of someone you trust; someone who understands what you are trying to say and can give you some honest feedback. (However, discourage them from marking your manuscript with a red pen; too close a reminder to schooldays!) It is usually helpful if you can space out your revision sessions so that each time you return to your work you have had time to gain some distance and consequently perspective, enabling you to see it afresh from the readers point of view.

Would you be interested in reading it if the manuscript arrived on your desk?


Let go
How do you know when to stop editing? How do you know when its time to let go and accept you have the final version? The answers are mainly: when it feels right; when you have said what you wanted to say concisely and to the best of your ability. The check list below might help. Read it aloud if you get tongue tied by impossible phraseology or inappropriate wording then it may still need a final polish. Ask the opinion of someone you trust. Check the presentation is it double spaced, printed on A4 paper, with appropriate paragraph line-spacing?

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partnership hinges around enjoyment, trust and commitment. We keep our writing promises to each other and as far as possible meet deadlines that are critical to our agreed targets. Our partnership survives because it continues to develop despite one of us having changed tracks to pursue a fiction-writing career, and the other having moved two hundred miles away. But the partnership continues because we have fun, the writing is stimulating and we still enjoy working together.

E-mail to the editor


Dear Avril, Speech and Language Therapy for Aphasia following stroke Cochrane Systematic Review As speech and language therapists we are very much aware that evidence-based practice is fundamental to the provision of good quality healthcare. Research evidence linked with clinical practice provides us with essential information regarding the effectiveness of healthcare interventions for our patients. There are a number of different ways of exploring aphasia therapy outcomes and issues, for example, individual case studies, case series and group studies. However, currently randomised control trials (RCTs) are considered the most robust methodology to evaluate clinical interventions, i.e. measure and demonstrate the effectiveness of therapy. Systematic reviews of such evidence are crucial as they synthesise the findings of RCTs, helping inform therapists' decisions about rehabilitation interventions and highlighting current knowledge and potential research priorities. The Cochrane Collaboration (www.cochrane.org) is an international independent organisation whose function is to disseminate accurate up-to-date information about the effects of available healthcare worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies. It has reportedly had a significant impact on practice, policy decisions and research around the world. In 1999 a Cochrane systematic review was published which presented the evidence for speech and language rehabilitation of aphasia following stroke (Greener et al., 1999). Since this publication additional evidence has been generated or is currently ongoing in many countries around the world. The review is now being updated to reflect these developments. The objective of the review is to assess if: 1. speech and language therapy is more effective than no speech and language therapy 2. speech and language therapy is more effective than support from volunteers or non-speech and language therapy professionals 3. one speech and language therapy intervention is more effective than another speech and language therapy intervention. Relevant trials have been identified through a number of different methods including the Cochrane Stroke Groups Specialised Register of Controlled Trials as well as Medline (1966-2007) and Cinahl (19822007). Academic institutions and other researchers were also contacted in order to identify further published and unpublished research in this area. The findings of this updated systematic review will be published later this year in order to provide speech and language therapists with the latest evidence for the rehabilitation of aphasia upon which they can base their clinical decisions. If readers are aware of any published and / or unpublished trials that would be appropriate for inclusion in this review update could they please contact me with the details? Dr. Helen McGrane Nursing, Midwifery and Allied Health Professions Research Unit Iris Murdoch Building University of Stirling Stirling, FK9 4LA Telephone: 01786 466285 Fax: 01786 466100 Email: helen.mcgrane@stir.ac.uk

Personal style
Finally, despite all tips and suggestions, it has to be said that writing is an intensely personal activity and there is no one way to write; we each have to develop our own style. There are however a few general tips that will help all writers. Type each reference in full into a reference list as soon as you find it. You can be sure you will not remember where it came from if you leave it till the end. Each time you begin work on the computer save the piece again with the current date. That way you will not only be able to identify the current version easily, but will also have previous versions on file in case you need to reinstate deleted passages. Back up at least one version of your work separately from your computer each night, such as on a CD, pen drive, or by emailing it to someone as an attachment. Your work is important. Happy writing!
SLTP

Myra Kersner is a Senior Lecturer at University College London and Jannet A. Wright is the Professor in Speech and Language Therapy at De Montfort University, Leicester.

REFLECTIONS DO I HAVE A CLEAR TAKE HOME MESSAGE? DO I RECOGNISE THAT THE REAL WORK OF THE WRITING PROCESS BEGINS AT THE REVISING AND EDITING STAGE? DO I ASSESS MY WRITTEN WORK FROM A READERS POINT OF VIEW?

Reference Greener, J., Enderby, P., Whurr, R. (1999) Speech and language therapy for aphasia following stroke, Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD000425. DOI: 10.1002/14651858.CD000425.

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FEATURE

Self-help me if you can


Many voluntary agencies support a diverse network of self-help groups. Avril Nicoll asks what contribution this can make to how someone adapts to and manages their communication difficulty, and where speech and language therapy comes in.

search of www.amazon.co.uk for self-help books produced over 40,000 results. The first page included classics such as Susan Jefferss Feel the fear and do it anyway and Stephen Coveys 7 habits of highly effective people. (Also The Goddess by Gisele Scanlon with life-enhancing content including what you should have in your make-up bag to tackle every problem, plucking the neatest eyebrows and looking after cashmere) Whatever the perceived problem, it seems that someone has written about how you might help yourself handle it. This proliferation is reflective of a sea-change in opinion on who holds the power to bring about change. In an essay on NHS transparency, Edwards (2006) quotes Rowe et al. (2002) as saying The professional paternalism that traditionally characterized public experiences of the health service, with patients being passive recipients of technocratic and medical expertise, now appears outmoded. Initiatives such as the Expert Patient Programme and the drive for Patient and Public Involvement recognise that individuals have much to offer not only themselves, but also their peers and health professionals. While books can open minds to different ways of coping, not all people with communication difficulties will find books accessible or applicable and in any case books do not address our need for social support. As Klein (2000) recognises, A community of kindred souls affirms for us that we are not alone. To find that community, you may need to shed your cynicism and scepticism. You may need to swallow your pride and admit that people do need people in order to be fully human. (Preface xiii) Speech and language therapists are acutely aware of how isolating a communication disability can be. Many people with communication difficulties face a particular challenge in finding and participating in social activities including self-help initiatives. So do we do enough to facilitate and support such groups? Do we value this as an integral part of our role, committing time and acting as a resource? Liverpool speech and language therapist Anita Williams has a history of following a social model of working with

When I was younger, so much younger than today I never needed anybodys help in any way. But now these days are gone, Im not so self-assured, Now I find Ive changed my mind and opened up the doors. Lennon & McCartney (1965)
READ THIS IF YOU WANT TO GIVE CLIENTS OPPORTUNITIES TO USE THEIR COMMUNICATION SKILLS GROW IN CONFIDENCE AND SELF-ESTEEM RAISE AWARENESS OF THEIR NEEDS people with long-term conditions. However her attempts to get self-help groups going had in the past started well but fizzled out and she was left with the feeling that I had done something wrong. A course at Connect the communication disability network provided welcome inspiration, and Anita has worked with John McCreadie and other users of Alternative and Augmentative Communication (AAC) to start CALLUP. A funded and statutory communication aids service means Anita has a number of able clients with sophisticated aids. With an IT student, she set up a Communication Aid Practice Group which meets fortnightly. Anita observes that users no longer feel so isolated and become competent very quickly and they also get a lot out of meeting and supporting each other. The self-help group CALLUP was the next step. Its mission is for people who use communication aids to support each other. Those involved also meet other people in a group or one-to-one to help them reach a decision about whether or not to use a communication aid. In addition, CALLUP has a buddy group where an experienced user helps a new user to manage their aid. CALLUP is also educating health staff and others on what it means to be communication disabled. John and

Anita deliver training to local staff together, John using his aid and Anita using speech. They hope to expand this to other NHS professionals. CALLUP is consulted by statutory services and is active in attending awareness days and conferences. Fundraising has been essential to securing transport but the speech and language therapy and assistant time and premises are offered by the Primary Care Trust, with a shared desk and phone line planned. CALLUP is keen to alert manufacturers, commissioners and potential users to AAC issues. John was shocked when they encountered difficulties opening a bank account. A number of us were in wheelchairs and none of us could speak without an aid. The bank wasnt wheelchair accessible but they asked us to attend a meeting in the bank! Then they wouldnt accept that a bunch of such disabled people could run and control a bank account. A banker eventually came to a group meeting to take the request to open an account and the group made their views very plain. John feels that more speech and language therapists could do with setting up self-help groups as being unable to speak knocks the confidence out of you and taking some responsibility upon yourself starts the process of regaining that. Friendship is vital to Johns adaptation, both maintaining old relationships and forging new ones. He was delighted to be asked to give a Best Man speech on his Lightwriter, and talks fondly of support gained (in relation to his percutaneous endoscopic gastrostomy) and friendship from CALLUP members from a variety of backgrounds. John lost the power of speech comparatively recently and describes the act of forming the group as a form of therapy. He is keen to offer positive advice to anyone thinking of starting a similar group (e-mail J.McCreadie@yahoo.co.uk). Anita points out that people with long-term conditions have lots of different experiences and skills; she finds the more we can draw on that the better our service becomes and the more empowered and fulfilled the users feel. Voluntary sector organisations which actively campaign on behalf of people with communication difficulties started out when the founders recognised this expertise and the need to find a voice for it. Not surprisingly,
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FEATURE

then, Afasic, Speakability and the British Stammering Association all have national networks of self-help groups which they actively support and promote. Safety in Stumblers is a Glasgow self-help group for people who stammer, with a dedicated website and e-mail forum as well as a monthly meeting. The group is held in a private area of a city centre bar and generally 5-6 people attend. The initial idea was to provide a follow-up to intensive therapy groups, so people could practise techniques such as block modification and voluntary stammering in a safe, supportive environment. The original members planned a speech / social mix, with the occasional invited speaker talking about a particular approach to managing stammering. When I visited the group, Chairperson John Mann observed that Some people come for a long time, others for a time, others for one night only and others never come. He noted that people come with different expectations but he welcomes the fact that there is no sign of embarrassment or ridicule on the faces of the people around you and you realise its not that bad after all. Callum, who is training to be a speech and language therapist, described his first self-help meeting (in Ireland) as a revelation. He explained, I had never really talked about it. Suddenly it was very easy to talk about it so open I felt a weight lifted off my shoulders. James wasnt fearful about coming to this, his first meeting. I was looking forward to it; for the first time, I wouldnt have to worry about whether I would stammer. Dev agreed. I dont really hear stammering around me, so its helpful. It shows Im not stupid theyre fine, all functioning human beings, so I dont feel so bad about stammering. Susie had been before but tonight she had second thoughts, because I would have to confront the stammer, and over the past 8 years I have avoided it. I want to feel able to be more open about it. My speech and language therapist said I have to be OK with my stammer. In the end, Im happy that I came. The group members discussed what they get from Safety in Stumblers: Humour Confidence Opportunity to practise (e.g. booking rooms, ordering drinks) Friendship Learning Ideas and options Inspiration Telling your story Chance to hear other people stammering This fits with Kleins description (2000) of the three elements of successful groups: a place to be heard; a place of acceptance; a place where one can feel cared for. Its clear that the group really appreciates the practical support of speech and language therapist Carolyn Allen, who not only encourages clients to participate but offers to accompany them to their first meeting. Carolyn herself commends the groups great support networks as they accommodate the most active of participants as well as those feeling their way in the beginning. Members suggest therapists could join more online groups so that they are really aware of what is most concerning people with communication difficulties. They also hope therapists tell people about organisations such as the British Stammering Association. They would

On a Voyage of Discovery in Dundee with the British Stammering Association

like speech and language therapy students to attend self-help groups to broaden their knowledge of the lived experience of communication disability. Whether people prefer an online forum, a Telephone Support Group both particularly useful for people in more rural areas or face to face contact, it is clear that in time those who benefit turn their attention to supporting newer members, and gain confidence and insight as a result. I attended a British Stammering Association Open Day in Dundee, organised as a mix of speakers and workshops catering for children and young people who stammer. Dr David Lilburn explained that he worked through the theory of stammering with his speech and language therapist but I had to put it into practice to tame this beast that was taking control. He went on City Lit courses, taking care of myself, getting out there and so much changed. According to David it is important to take risks, as the most rewarding time can be when you go out on a limb. But he doesnt believe you can do this alone, and advocates self-help groups which offer social chat and support, and participation in the British Stammering Association where people actively embrace you because you stammer. Another speaker Claire Pirnie had a revelatory moment when attending a European group in Holland. Far

John Mann of Safety in Stumblers scales Ladhar Bheinn for the British Stammering Association

from trying to hide their stammer as she had always done, even in speech and language therapy groups she noticed that everyone just got on with it. As a result Claire stopped trying to hide it, talked about it and started public speaking to spread awareness and found it gave her a real buzz. The impact of these speakers was clear during speech and language therapist Liz McConnells workshop on teasing and bullying, when one mother told me it had given her real hope for her sons future. Meanwhile the young people clearly relished the opportunity to have a laugh brainstorming potential solutions with their peers (bury them alive, put their head down the toilet!) The British Stammering Association open day was held at Discovery Point, a non-medical venue. When the Speakability-affiliated Speakeasy group was formed in Aberdeen for people with aphasia, those involved were also determined to meet in a hotel not a hospital. Speech and language therapist Annette Cameron has been associated with the group since its inception. She believes that the focus of speech and language therapy is now different in the early stages of stroke actively listening to the clients agenda, revealing competence and providing signposts. Some clients may wish to participate in a self-help group at an early stage. However, she also sees there is still a long way to go in providing opportunities that people will want to take up. Any established group can be a daunting prospect for new people. Speakability suggests that people who already know each other can be referred to attend their first meeting together as one way of overcoming this. Code et al. (2001, p.45) noted that membership of Speakabilitys 50 groups comes from a relatively well defined section of the aphasic population. This includes people who are mainly ambulant, living at home and with access to transport. They also tend to be relatively young and have a long-standing and relatively less severe aphasia. People who take on leading roles in such groups are more likely to have professional and managerial backgrounds. At different stages the Aberdeen Speakeasy group has concentrated on communication support; enabling people to tell their own stories; campaigning; and now social support. One successful initiative was to set up computer classes, so some members can now produce invitations, menus and lists of meetings. The group members themselves initiated the classes, and the speech and language therapist - Annette - conducted training for the staff who provide the computer classes. Annette has observed that many factors can change the course of a group personalities, deaths of members and that the speech and language therapy link has to be very flexible as a group changes. Annette cautions that there is a danger of a speech and language link therapist being overly protective of a group. It takes courage to stand back and let it take its course, remembering that they are adults with responsibility for their own lives. The therapists concern is that the group may fold, but another group can emerge. Klein (2000) talks about four basic developmental phases of successful groups. Phase one is exploratory, where people are sussing the group out, seeing if they can trust it and if it will meet their needs. Phase two sees a growing sense of closeness where people begin to feel more confident about revealing themselves. Phase three gets to the heart of the matter, searching for meaning

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FEATURE

and uncovering coping strategies. Finally phase 4 looks to the future, with people leaving, or the group re-evaluating its aims. Throughout, Klein describes the facilitators role as shifting from leader to cheerleader (p.17). Annette finds great satisfaction in seeing people whom you have worked with from the onset of their communication difficulty move through to a stage where they dont need you any more. However, she constantly questions at what point does a specific aphasia need / identity become a broader need which no longer requires input from the speech and language therapist? And are we then meeting the needs of other people with aphasia? She has seen situations where people want to develop and use certain skills but group dynamics at the time were not conducive. Code et al. (in press) point out that Self-help in aphasia is still evolving and, like other human groups, things do not always go smoothly. Misunderstandings may arise. Arrangements for meetings and outings can be casualties of impaired communication. Members may have different expectations of their groups and some may go away disappointed. Some members may be unwilling or unable to recognise the need for facilitation and support. As in other groupings of human beings, leaders may be insensitive or over dominant which can impact on the development of autonomy in members. For Annette the most rewarding part of her involvement with Speakeasy has been supporting members to effect change. Recently members have been involved in

two projects using Talking Mats. This approach not only encouraged communication skills, but also developed their confidence and self-esteem. The first project was part of the Grampian Disability Action plan. Members gave their views on GPs and hospitals, rating aspects as good / bad / indifferent. These views were then incorporated into the action plan. When a local MSP helped to set up a meeting with the First Bus Operations Director, Annette again used Talking Mats to help members think through, discuss and prepare their views. The Operations Director was delighted to find that this included positive comments and some practical suggestions, and he came back to the group with feedback. As these projects needed commitment from the speech and language therapy department and a determination not to lead or bias proceedings, Annette was particularly pleased when the manager of the Managed Clinical Network for Stroke who viewed the Talking Mats commented, That looks really empowering. And there you have it in a nutshell. Working together, clients, carers and speech and language therapists have opportunities to set up and nurture groups and online forums or blogs. Such initiatives can open up the doors to a powerful vehicle for adaptation and change. I do appreciate you being round. Help me get my feet back on the ground Lennon & McCartney (1965)

References
Code, C., Eales, C., Pearl, G., Conan, M., Cowin, K. & Hickin, J. (2001) Profiling the membership of self-help groups for aphasic people, International Journal of Language & Communication Disorders 36 (suppl), pp. 41-45. Code, C., Eales, C., Pearl, G., Conan, M., Cowin, K. & Hickin, J. (in press) Supported self-help groups for aphasic people; development and research, in Papathanasiou, I. & de Bleser, R. (eds.) The Sciences of Aphasia (Vol.1): From therapy to theory. Elsevier. Edwards, N. (2006) The transparent NHS? AIMS Journal 18(4), pp. 16-20. Klein, L.L. (2000) The Support Group Sourcebook. New York: Wiley.

Resources
Afasic www.afasic.org.uk British Stammering Association www.stammering.org/selfhelp_groups.html Expert Patient Programme www.expertpatients.co.uk Safety in Stumblers www.safetyinstumblers.org.uk Speakability www.speakability.org.uk Talking Mats www.talkingmats.com

Acknowledgements
Thanks to Chris Code, Jan Anderson, the Safety in Stumblers e-group and all the interviewees (names in bold) for giving so generously of their time and expertise SLTP to help me with this feature.

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SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

19

EXTENDED ROLE

Face value
I
have worked in the acute sector at Aberdeen Royal Infirmary for 15 years, specialising in the field of acute neurosurgery since 1995. Some clients in this specialty have facial palsy following surgical removal of an acoustic neuroma. My role in managing any swallowing difficulties immediately post-operatively was clearly defined and manageable - but how to cope with the devastating effect of a face which wont work was another story! Although its effects can be profound, acoustic neuroma is not that common; the British Acoustic Neuroma Association cites incidence as 1 in 80,000. Both the tumour itself and its surgical removal carry risk to the VIIth Cranial Nerve, or Facial Nerve. As this nerve supplies a number of areas, damage can produce a variety of symptoms: SUPPLY TO Lacrimal Glands SYMPTOM The most usual symptom is a dry eye, but the other extreme (overwatering) may also occur. Hyperacusis (an acute sensitivity to hearing) Taste affected

Facial nerve palsy is devastating, and rehabilitation places many demands on therapists as well as clients. Penny Gravill outlines the benefits of two specialist treatments which she offers on the NHS and more recently at a Satellite Centre for an independent provider.
READ THIS IF YOU ARE INTERESTED IN BIOFEEDBACK TOOLS FEEL SECURING FUNDING FOR EQUIPMENT IS TOO DIFFICULT MIGHT CONSIDER INDEPENDENT PRACTICE

the equipment (pictured) so they can use it independently at home. The road to recovery is not straightforward and, as the nerve recovers, clients can develop a condition called synkinesis. This is the stage where the nerve has essentially recovered but mass movements occur and the nerve fails to switch off . So, for example, instead of just one branch being activated when the client tries to close their eyes, the mouth also moves on the affected side. The face characteristically feels tight and so the weak eye - having once drooped and appeared larger than the normal eye - now appears smaller. The mouth may turn up in a sneer where before it had drooped. Trophic stimulation continues to encourage accurate movement but a different programme is also used to encourage the nerve to shut off and relax.

Where to go next
Having learned the principles of this form of treatment I still felt I was groping in the dark; clients made progress and I didnt know where to go next. I attended a course at Diana Farraghers clinic, The Lindens, near Manchester. As well as active exercises, I was introduced to the benefits of another tool, surface electromyography (sEMG). I was instantly a convert and set about acquiring funding to purchase one for our speech and language therapy department. (Needless to say this was not easily achieved!) The facility of managing clients with the use of electromyography has made my practice a lot easier and effective. It allows accurate objective measurement of nerve function and helps set goals for treatment as well as measuring change. Electromyography is a painless procedure where electrodes are attached to the face, ideally with the client lying down, and the function of the weak side is compared to the good side in the temporal, zygomatic, buccal and marginal mandibular branches of the facial nerve. The readings are viewed on the computer screen in the form of graphs and these can be analysed statistically. Electromyography allows precise objective measurement of nerve function, better planning and goal setting and more accurate prognostic information. It is a significant boost to a client with an apparently completely floppy face to see the graph change as the nerve tries to tell the muscle to move. Equally, synkinesis can be detected and managed. As well as a diagnostic tool, electromyography can be used for treatment in the form of biofeedback. Until the use of biofeedback I relied upon a mirror which allows the client to see what they are doing rather than encouraging them to feel what they are trying to achieve. Bio-

Stapedius (a muscle of the middle ear) Anterior 2/3 of the tongue Submaxillary and sublingual salivary glands Facial muscles (subtle role in swallowing and to prick the ears back; very obviously in facial expression and movement)

Promising
The initial frustration and limitations of treating facial palsy quickly became apparent and I was left wondering what else could be done. Diana Farragher, a physiotherapist based in the Manchester area, had pioneered and developed a treatment for facial palsy using trophic electrical stimulation and the results were promising to say the least. She had done a couple of study days in Aberdeen by the early 1990s and there appeared to be some hope of treating this debilitating condition. In order to appreciate the principles of trophic electrical stimulation, it is important to understand the function of the nerve and the muscles it serves. In a normally functioning system the nerve feeds the muscle and keeps it in good health. When a nerve is damaged, the muscle undergoes degenerative changes. The amount of muscle function lost is dependant upon the extent of nerve damage. By applying trophic electrical stimulation, the atrophy can be prevented and the nerve encouraged to grow back into healthy muscle. The client begins to notice better resting symmetry as the condition of the muscle improves, which has untold benefits on self-esteem and confidence because, as well we know, so many judgements are made (literally) at face value. Learning to apply the trophic electrical stimulation is not difficult for clients; it is a matter of sticking on electrodes, turning on the machine, setting it to the correct level and letting the machine do the work. Clients hire

Saliva production disturbed

Swallowing and facial expression / movement affected.

The rehabilitation of facial palsy is frequently associated with our colleagues in physiotherapy but I am a firm believer that as speech and language therapists we are as well equipped to meet the challenges. The physiotherapist is much more knowledgeable about the transmission of nerve impulses and the functioning of muscles but we have substantial understanding of the anatomy and physiology of the head and neck and can soon revise and extend our knowledge accordingly.

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EXTENDED ROLE

Top: Penny Gravill Below: 1. A client 4 months post acoustic neuroma surgery (no treatment) 2. A client 5 months post acoustic neuroma surgery (trophic electrical stimulation begins). 3. A client 18 months post acoustic neuroma removal, with 12 months use of Neuro4. No movement but symmetry at rest is achieved. 4. The Neuro4 trophic electrical stimulator

feedback allows to client to learn to feel a movement again and to balance it by matching the two sides of the face in an expression. In the same way, if they are experiencing synkinesis and the muscle is not relaxing, they can be taught to feel the relaxed and more normal resting levels.

Many skills
There is no quick fix for facial palsy and clients do not move from the list quickly; we are talking years not months. It draws on many of our skills to work with these clients as the effect of facial palsy is devastating both physically and psychologically. Candid and comprehensive information from a clients perspective is available on a blog by Jon Kelly, who had an acoustic neuroma removed in 2005 (www.20six.co.uk/headcase). My caseload is wide and varied. Common causes of problems include Bells Palsy, post surgical Facial and Acoustic Neuroma, parotidectomy, temporo-mandibular joint replacement, Ramsey Hunt Syndrome as well as neurological conditions including Guillain Barre Syndrome, sarcoidosis and Moebius Syndrome. There is also application within upper motor neurone and lower motor neurone stroke but frequently in these cases the facial palsy is incomplete and not one of the clients priorities for rehabilitation. In general, my experience has made me consider my approach to dysarthria management and particularly facial weakness. The face works as a whole, and we tend to think about exercising the weak side to encourage return of function. Instead, I now look at working the face bilaterally, encouraging small, equal movements that the weak side can cope with. This dampens down the good side to allow the weak side to match it and increase the size of the movement while maintaining balance and not encouraging dominance and overcompensation of the unimpaired side. There is a lot of work ongoing into the use of electromyographic biofeedback in swallowing which is exciting. We are in a good position to move forward with this as we have the equipment in Aberdeen and experience in its application, albeit to date in facial rehabilitation.

Working independently is a tremendous challenge but the 6 months it took to set it up has definitely been worth it. I remember feeling totally daunted by the prospect of data protection statements, statements of terms and conditions, BUPA recognition, tax, insurance and public liability to name a few. However, if you are considering it, you are not the first and there is a lot out there to help! People with their own businesses - whether speech and language therapists or those in other areas - are tremendously generous in sharing what they have, from advice to spreadsheets. A course run by the Association of Speech & Language Therapists in Independent Practice gave me very helpful direction and was well worth the expense. In spite of its frustrations, I get much pleasure from my NHS employment and find the working environment stimulating and challenging (as well as providing boring essentials like a pension!) The friendship and support of colleagues should not be underestimated as working in independent practice is often solitary. We may have many gripes about the NHS but, in spite of all the extras which have crept up over the years, there are systems and administrative support - and these things are tremendously time-consuming when working on your own. I still feel awkward asking for payment but remind myself that for every hour of face-to-face contact there is an awful lot more in paperwork and preparation for that session and the running of the facility. I have had, and continue to have, tremendous support from the experts at The Lindens. In this fascinating field which bridges traditionally defined medical specialities as well as paediatrics and adult caseloads, I feel that the more I learn I realise how much more there is to learn. Penny Gravill is a specialist speech and language therapist at Aberdeen Royal Infirmary and The Lindens Clinic, Aberdeen, e-mail pgravill@nhs.net (see also www.dianafarragher.co.uk).

References
REFLECTIONS DO I LOOK FOR NEW WAYS TO MAKE THE BEST USE OF MY EXPERIENCE AND SKILLS? DO I APPRECIATE THE ROLE OF SELFESTEEM AND CONFIDENCE IN RECOVERY? DO I HAVE COPING STRATEGIES FOR WORKING WITH PEOPLE LONG-TERM?
BANA leaflet (2005) A Basic Overview. Mansfield: The British Acoustic Neuroma Association. Farragher, D.J. (2005) A Loss of Face. Facial Paralysis A Guide to Self Help. 3rd edn. Manchester: Diana Farragher. Kingsley, R.E. (2000) Concise Text of Neuroscience. 2nd edn. Philadelphia: Lippincott Williams and Wilkins. Lindsay K.W., Bone I. & Callander R. (1991) Neurology and Neurosurgery Illustrated 2nd edn. London: Churchill Livingston.

Independent practice
Last year I decided to move into the field of independent practice and do this one day a week in addition to my NHS work. The Lindens Clinic asked me to join them and so The Lindens Clinic (Aberdeen) was started as the Scottish Satellite Centre. For the majority of people in Scotland it is easier and more convenient to venture to Aberdeen rather than Manchester.

Resources
The Association of Speech & Language Therapists in Independent Practice, www.helpwithtalking.com The British Acoustic Neuroma Association, see www.bana-uk.com SLTP
SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

21

RESOURCES

resources
Talking Mats
Talking Mats is a low tech tool using picture symbols to help people express themselves more effectively. An aphasia package and goal setting resource set are now available. www.talkingmats.com/package-aphasia.htm

Autism signposts
Signpost has been developed by the National Autistic Society to tailor support to the needs of individuals with autism and their parents and carers. It takes into account their age, diagnosis, gender and location. www.autism.org.uk/signpost

Talking Links
The Talking Point website now includes Talking Links for the early years. This UK-wide postcode-searchable database allows parents and practitioners to access local communication development services including speech and language therapy - for children under five. www.ican.org.uk/talkingpoint

Romani awareness
Romani has become the largest minority language in the European Union since Romania and Bulgaria joined in January. The Manchester Romani Project website has information on Romani language and linguistic research. www.llc.manchester.ac.uk/Research/Projects/romani/

React 2
React 2 software is now available. This next generation software is considered suitable for adults with aphasia, children with language needs and people with learning difficulties. Sample contents / 30 day trial, see www.propeller.net

Sleep problems
The Handsel Trust promotes effective support in the UK for all children with disabilities and special needs and their families. A new publication (Sleep? Whats that?) looks at the incidence and impact of sleep problems in families of disabled children. 15 from www.handseltrust.org/books.htm

Enabling Devices
Enabling Devices has revamped its website of learning and assistive devices. It now includes Ask Dr Steve where Steven Kanor offers free advice. www.enablingdevices.com

NAPLIC
NAPLIC is looking for new members. This national organisation for teachers, speech and language therapists and other professionals seeks to increase understanding of children and young people with speech, language and communication needs. An elected committee provides a newsletter and website and organises conferences. Membership is 20 per year. www.naplic.org.uk

Picture the Music


This CD containing specially composed music and illustrations aims to encourage creative thinking and writing in children. http://picturethemusic.com/

Protecting hearing
Deafness Research UKs latest factsheet Noise and the Younger Generation offers parents advice on protecting their childs hearing. www.deafnessresearch.org.uk/?lid=2131

Parkinsons DVD
The Parkinsons Disease Society is calling on therapists all over the UK to give out a new free DVD to patients who have recently found out they have Parkinsons. To order Being There, e-mail pr@parkinsons.org.uk.

Flexzi
Flexzi is designed to position a wide range of equipment near a user simply and flexibly. www.meru.org.uk.

Deafness and Downs Syndrome


The National Deaf Childrens Society, The Downs Syndrome Medical Interest Group (UK) and The Downs Syndrome Association have published a free booklet to support families of children with Downs Syndrome who are also deaf. Seventy per cent of children with Downs Syndrome have a conductive deafness, and glue ear can be very persistent because of the structure of the ear. Downs Syndrome and Childhood Deafness Information for families is at www.downs-syndrome.org.uk

Early years DVD


Learning to Talk, Talking to Learn is a self-study early learning resource DVD free to childcare practitioners including childminders and nursery teachers. It is presented by Dr Tanya Byron and produced by the BT Better World Campaign and I CAN. www.bt.com/betterworld/resources

news extra
Special schools guidance
Draft guidance for England from Schools Minister Andrew Adonis would require local authorities to demonstrate clearly how reorganised special needs provision would improve on their existing model, including special schools. The guidance has been sent to local authorities and SEN groups for further comment and will be finalised in the summer. www.dfes.gov.uk

Academic processing
A University Professor has been awarded a research grant from the British Council to examine how students from overseas - or minority students who have English as their second language - process information when they read English for academic purposes. Professor Cyril Weir explained, One of the biggest problems students who have English as a second language face, is processing the vast amount of academic text they are exposed to. They can waste hours going through articles and book chapters that are not relevant to the assignment they have been set. He aims to use the research findings to produce an online study guide. www.beds.ac.uk/departments/languageandcommunication/crella. Meanwhile, academics in Portsmouth have developed a mobile phone game to help international students cope with culture shock, including going to the pub and seeing public displays of affection. The game is in the final stages of development and is expected to be available for download from the University of Portsmouth website later this year.

The name remains the same


Ofsted is now the single inspectorate for education and care in England. The new group retains the same name but is now The Office for Standards in Education, Childrens Services and Skills. It covers the full range of education provision for children, young people and adults; the work of local authorities and teacher training providers; children's social care, and the work of the Children and Family Courts Advisory and Support Service. www.ofsted.gov.uk

Conductive Education support


The Foundation for Conductive Educations free Parent & Child Service has been extended by an enhanced donation from the Zurich Community Trust. This will provide parents with additional support where needed for accommodation or travel costs. www.conductive-education.org.uk

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WINNING WAYS

his article carries a health warning: dont try this at home! You may think that Im completely off the wall - but I have never felt better, or more excited, or more determined to tackle lifes challenges. Last month I was involved in a developmental day that was a showcase for alternative and complementary therapies. The people who attended could have taster sessions of treatments such as reflexology, massage, shiatsu and Reiki and could also attend a wide range of workshops. I was delivering The Antidote to Stinking Thinking, a workshop on worry. I have come to realise that worry is the most awful, useless waste of energy - and yet the majority of people keep on doing it. Asking my group why they worried, there were very many different reasons. Once you start really examining worry, you can start to jettison a habit that you learned as a young person. Giving it up is like giving up smoking. It is hard at the time, but well worth it when you come out at the other end. I have an uphill battle getting chronic worriers to give up, but low-level worriers can give it up as quick as a wink, and feel better for the rest of their lives. (Doesnt that sound tempting?) When I had finished, and delivered some new non-worriers into the world, I decided to attend a workshop myself. I chose Introduction to Firewalking. I had actually walked on hot coals about five years ago. It was a grand occasion. Although it was scary, about ten thousand people did the walking with me so I could see it was possible and it wasnt a problem at all. I felt great afterwards and believed that I would never really be scared of anything again. And that has been generally true - until this workshop. The very interesting lady introducing us to fire walking set us a rather different kind of challenge: to break an arrow while pushing it with your throat.

Following the arrow


Breaking an arrow with her throat confirms for life coach Jo Middlemiss that, with the right attitude and support, we can all follow through our goals.
READ THIS IF YOU WANT TO GIVE UP WORRY AND FEAR BELIEVE MORE IN YOURSELF AND OTHERS FOLLOW THROUGH YOUR GOALS
I got into pushing position, with shoulders ahead of feet but feet planted firmly like a warrior. The arrow was placed in my throat and the opposite end in the breadboard. The group chanted. I took my three deep breaths, thought my thought, and pushed as if my life depended on it. To my enormous relief the arrow snapped, everyone cheered and I leapt off the ground, laughing and crying and hugging people all at the same time. So weird, so exciting and so exhilarating. Honestly, talk about Feel the Fear and Do it Anyway although I doubt this is exactly what Susan Jeffers was thinking about when she wrote Pushing through fear is less frightening than living with the underlying fear that comes from a feeling of helplessness (p.27)! Of course I really DO mean dont try it at home; the instructor was experienced, confident and very safety conscious. Another participant was a gentle and elderly lady. She had quietly attended a few of the workshops during the day but had not participated with any great enthusiasm. Imagine my surprise when this woman stepped into the circle and said shed like to have a go. When the instructor asked her what she wanted to achieve she said the problem was that she didnt know. She didnt know what she was doing with her life or what to do next. She said all of this in an incredibly dull and quiet voice. The instructor stayed bright and enthusiastic. How about clarity and direction? she chirruped. I suppose so, said Mrs Dull. The arrow was put in place. The group chanted success and the old lady pushed. Nothing happened. Try again, said Mrs Enthusiasm, and, this time, hold your breath when you push. Same result. This time focus with your eyes open.

Lit up from inside


I thought it wasnt going to work. I was looking forward to seeing how the instructor would deal with something not going right. Then Mrs Dull gritted her teeth, took her deep breaths, focused and pushed and snapped that arrow. We jumped and whooped for her. I have never seen a face transform quite so dramatically. She turned into Mrs Shiny-Bright, lit up from inside. I dont know what happened to her after that but Im willing to bet that she learned something about herself that day. And I learned something about myself because I was willing to give up on her with sympathy when there was absolutely no need. She could do it just as well as I could. She only had to believe it. Now why do I tell you this story when its about such an out-of-the-ordinary thing? Well, the ordinary everyday often does present us with challenges that we sidestep because we dont think that we have the guts or determination to follow through. My personal challenge is to follow through on what I have set myself. If you would like to have a go, look up www.creativefire.co.uk. Its an amazing experience and could be life changing in more ways than one. Im going for another firewalk and I will achieve whatever goal I set myself, of that I have no doubt. After all, Ive broken an arrow with SLTP my throat!

Reference
Jeffers, S. (1997) Feel the Fear and Do It Anyway. (20th Anniversary edn.) London: Random House.

Resource
www.creativefire.co.uk

Terrified
It is hard to explain this without pictures but I will try. The instructor gave us a demonstration of the arrow breaking process. The tip of the arrow - about as sharp as a blunt pencil - was placed in the sternal notch. Someone held a breadboard with a little hole drilled in it for the feathered end of the arrow. That person was not to exert any pressure at all. The instructor then took three deep breaths, held her breath and then with deep concentration pushed into the arrow. We onlookers encouraged her with shouts. (We had to do something, or we would have stopped breathing with terror.) I couldnt believe my eyes. My heart was in my mouth and my palms were sweating. Yet while all this was happening I knew I had to do it. I watched another person do it and then, like someone possessed, heard myself volunteering. My heart was thumping; I am told I went as white as a sheet. I stated my intention but also admitted to the group that I was terrified.

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

SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

23

HOW I

HOW I EXTEND THE REACH


READ THIS IF YOU WANT TO ENCOURAGE OTHER AGENCIES TO TAKE THE LEAD TAP INTO ALTERNATIVE BUDGETARY SOURCES TARGET PEOPLE WHO MAY BE EXCLUDED FROM THERAPY

HOW I (1):

THE MOVE TOWARDS INTEGRATING CHILDRENS SERVICES IS A COMMON STRATEGY ACROSS THE UK (RCSLT, 2006) BUT LEARNING TO WORK MORE CLOSELY WITH OTHER AGENCIES IS NOT A STRAIGHTFORWARD TASK. OUR CONTRIBUTORS HERE FOCUS ON TWO IMAGINATIVE PARTNERSHIP PROJECTS THAT ARE SUCCEEDING IN BREAKING DOWN BARRIERS. Reference RCSLT (2006) Communicating Quality 3. London: Royal College of Speech & Language Therapists.

Preparing for independence


WITH MANY CHILDREN UNABLE TO ACCESS THERAPY, SCHOOL TRAINING NEEDS UNMET AND JOBS FOR NEW GRADUATES AT A PREMIUM, A 6 MONTH COLLABORATIVE PROJECT BETWEEN A CLUSTER OF PRIMARY SCHOOLS AND A SPEECH AND LANGUAGE THERAPY SERVICE OFFERS ONE SOLUTION. DEBBIE HALDEN, KIRSTY FERGUSON AND JILL KENNEDY REPORT.

EXTENDING THE REACH (1) PREPARING FOR INDEPENDENCE EXTENDING THE REACH (2) FUNDING GAPS PRACTICAL POINTS: EXTENDING THE REACH 1. 2. 3. 4. 5. 6. 7. 8. Start from a strategic level Clarify consent issues Consider skill mix Include direct therapy in the package Support others to develop their skills Provide resource materials Offer training Consider rewards and incentives for participation 9. Evaluate outcomes 10. Promote your service

est Lothian primary schools are divided into eleven cluster groups related to the eleven secondary schools into which they feed. In common with other areas, the St Kentigerns cluster has a large number of children with speech and language difficulties in their schools. Many are no longer on speech and language therapy caseloads, having been discharged for failing to attend. Others are not designated a high enough priority to receive regular therapy. Each cluster group receives a small budget to spend independently to promote the aims of its forward plan. The St Kentigerns cluster head teachers initially suggested using six months of this budget to fund speech and language therapy assistants to work in the ten primary schools. As this would have led to a high need for training and supervision, they agreed to the paediatric speech and language therapy leads alternative suggestion of employing two new graduate therapists. As well as giving the opportunity for close collaborative working between teachers and therapists, this initiative would provide the schools with people who already had basic knowledge and could be supervised more easily.

Moves the focus


This cluster group project provided an excellent opportunity for developing input along the lines of the Service Model for Packages of Support outlined in a recent position paper from the Royal College of Speech & Language Therapists (Gascoigne, 2006). This moves the focus of therapy away from the speech and language therapist taking the lead in intervention and impairment towards preparing schools to take the lead in working with the child at the level of participation. Before the speech and language therapists were employed, meetings took place between the head teachers of the primary schools involved and the paediatric lead speech and language therapist to exchange ideas and discuss the feasibility of providing for these needs. The head teachers were keen that school support staff, class teachers and support for learning teachers should receive training and the opportunity to work in close collaboration with the

therapists. They also made requests for social skills training and phonological awareness work. Kirsty Ferguson and Jill Kennedy were employed for six months, each providing eight sessions to the primary schools in the cluster group. The cluster provided the funding and the speech and language therapy service had management and employment responsibility. Five schools were allocated to each therapist. The other four sessions came from more experienced therapists who initiated the social skills training, provided in-service training to teachers and support/classroom assistants and provided supervision for the project. Supervision for Kirsty and Jill was provided at two levels. Firstly, on a fortnightly basis, they received clinical supervision from an experienced therapist who was able to discuss the management of individual cases with them. Secondly, Debbie provided supervision at a project level to check that all aims such as liaising with school staff, introducing phonological awareness groups, organising parental awareness sessions and responding to other requests from the schools were being systematically addressed. This ensured a tight roll out programme so that all agreed aims were covered in the six months of the project. At the beginning Kirsty and Jill met with individual head teachers to discuss the needs within their school and the amount of support assistant time that would be available. They carried out assessment of new referrals and children on the caseload and started individual therapy. At the same time, we offered in-service training to the schools. Support / classroom assistants were given a basic overview of comprehension, expressive language and speech difficulties in children. We also offered training to Support for Learning teachers, to provide an overview of Sunnybank Speech Sound Coding, which is widely used by speech and language therapists in West Lothian. This system for developing phonological awareness and phonic skills capitalises on the speech and language impaired childs often strongly developed visual skills by colour coding speech sounds according to their place of articulation, and can eventually include colour

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H
Figure 1 Comments from children and staff

coding of letters. At this stage we also started social skills training in two schools as a rolling programme. As the social skills groups progressed, Kirsty and Jill used some of their time to assist an experienced therapist so they could continue future groups. Support / classroom assistants also attended to develop skills which would allow them to sustain other groups following the end of the project. We provided detailed social skills packs to support / classroom assistants to help them with future groups. The next initiative we introduced was phonological awareness groups. Discussion took place with head teachers regarding suitable children, which provided the opportunity for children not on the caseload to be involved. We dealt with the issue of consent by not taking the children on to speech and language therapy caseloads. While children who were known to us had individual therapy aims, we only worked with noncaseload children in the context of these groups, teaching them general principles of phonological awareness. We used colour coding as a base for the phonological awareness groups. Support / classroom assistants were given the opportunity to assist so they could continue the groups independently. They provided valuable information about what the children had covered in class regarding sound awareness, which enabled the group content to be immediately relevant. In total, seven phonological awareness groups took place. Having helped in social skills groups run by an experienced therapist, Kirsty and Jill jointly offered social skills groups to other schools. As with the phonological awareness groups, discussions with head teachers led to children who could benefit but who were not on the caseload being offered a place. Again, no consent was sought for noncaseload children as for them we were addressing general aims rather than specifically assessed therapy goals.

Comments from children Social skills groups Dont talk over others Listen Dont fidget Look at the person who is talking I loved the games liked it all I really would have liked the group to go on for a long time Looking at mum when she is talking to me Phonological awareness groups Red sounds are made with the lips Knowing where the sounds are coming from Having fun but learning sounds at the same time Made my work easier

Comments from School Staff Social skills groups More able to take turns Listening skills improved Building confidence More able to stay calm in stressful situations More accepting of others and class group is not as difficult Whole group enjoyed working together and new friendships have been formed Staff confidence increased, good use of strategies in class setting Phonological awareness groups Children are more confident with regard to sound recognition and pronunciation. Positive change in attitude toward reading / Level A [Scottish curriculum] literacy programme/spelling

Suggestions
In addition to the main groups, schools put forward their own suggestions for additional provision. One school asked for help with structured play as they saw such sessions lending themselves to developing childrens social skills. We also saw the opportunity for vocabulary building, so Jill took both ideas into account when planning her input. She was directly involved in structured play for four weeks where she worked alongside a classroom assistant with a group of children who had been identified by the class teacher. Within the structured play sessions we aimed to develop the childrens semantics, vocabulary and social skills while at the same time skilling up the classroom assistant in these areas. Another school suggested a vocabulary and word finding group, prompted by the evident vocabulary deficits in some of the younger children. In this instance all the children included were already on our caseload. The school identified six main topics for the group: clothes, animals, transport, food, the outdoors and home. Detailed plans for each topic were provided so the support assistant could continue the group and work with other groups in a similar way in the future.

We organised a drop-in session for parents of children on the caseload from six schools. It was held at a health centre, which was fairly centrally located for the cluster group schools. We prepared information and advice sheets on comprehension, expressive language, listening, sound system and social skills development. The session gave parents the chance to gain an overview of speech and language development and ask specific questions about their childs therapy. The response to this was poor and in future we would not necessarily offer this unless schools were very keen. At the end of the project we wrote reports for all children on our caseload and gave evaluation questionnaires to all children and staff involved. The questionnaires were designed by an educational psychology research assistant. Results are encouraging, and typical comments are in figure 1. All school staff who returned the questionnaires felt the range of groups offered was successful at meeting the schools needs. Seven out of ten staff responded that needs were met a great deal. Responses from pupils were also positive. Eighteen out of 20 children involved in the social skills groups enjoyed them a lot while 19 of 21 felt that what they had learned had helped them in class. Five out of seven school staff whose children had been involved in social skills groups rated the benefits at the top end of a six point scale. Support staff in one school have already successfully continued a social skills group independently. With respect to the phonological awareness groups, 19 out of 23 children who returned the questionnaire said they enjoyed the group a lot. Seventeen of these children felt that what they had learned helped them in class. All staff who completed questionnaires about phonological awareness groups felt the groups had helped children. Four main positive themes emerged from the project audit: 1. skilling up of staff 2. resources (training / phonological awareness / social skills packs) 3. support given to the groups 4. impact on children. The project provided the opportunity for close collaboration with school staff. Children who had been discharged for failure to attend could effectively ac-

cess regular therapy. Children with severe difficulties could access twice weekly therapy. Also, children who were not on the caseload benefited from speech and language therapy input in areas such as social skills and phonological awareness. We welcomed the chance to work intensively and collaboratively with the school staff in the St Kentigerns cluster group. We would have liked to withdraw more gradually from groups through a period of offering support and advice rather than taking the group lead. Designated time for discussion with class teachers would have been appreciated and we would ideally include this in any similar future projects. An opportunity to negotiate with support / classroom assistants regarding optimum times of groups would be ideal. We plan to approach all cluster groups in West Lothian with the results of the project. One other cluster group has already expressed an interest in spending some of its budget on social skills training. We are keen to market what we can offer. Debbie Halden is a speech and language therapist in West Lothian, e-mail debbie.halden@wlt.scot.nhs.uk. Kirsty Ferguson and Jill Kennedy were the new graduate therapists involved in this project. Kirsty now works in Forth Valley while Jill has remained in West Lothian.

Acknowledgement
Thanks to Kristen Allen, Research Assistant West Lothian Educational Psychology Department for the design and implementation of the audit of the project.

References
Gascoinge, M. (2006) Supporting Children with Speech, Language and Communication Needs within Integrated Childrens Services: RCSLT Position Paper. London: Royal College of Speech & Language Therapists.

Resource
Sunnybank Speech Sound Coding originated at Sunnybank Language Unit in Aberdeen and has been further developed at Crossgates Speech and Language Class, Fife. Further information from Jennifer Reid, eSLTP mail jenniferreid@nhs.net.
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HOW I

Funding gaps
JULIE COLEY REFLECTS ON THE BENEFITS OF BEING PART OF A PROPERLY RESOURCED AND MANAGED PROJECT TO IMPROVE THE SPEAKING AND LISTENING SKILLS OF CHILDREN WHO WOULD NOT NORMALLY ACCESS SPEECH AND LANGUAGE THERAPY.
n March 2004 a two and a half year Childrens Fund Speaking and Listening Project was set up in Burtonon-Trent, Staffordshire. The Childrens Fund - a central part of the governments agenda for children and families - aims to make a real difference to the lives of children and young people at risk of social exclusion. My manager Isabel Dodsley spotted a service gap and put together a successful bid for funding. She backed up her proposal with information about the links between juvenile offending, potential social exclusion and communication skill difficulties. She also tied it in with one of the key outcomes of the government green paper Every Child Matters (Be Healthy) with a health indicator of improved speaking and listening and social interaction skills leading to enhanced self-esteem. Our project is managed and delivered by a speech and language therapist (me) and two assistants, Wendy Burton and Helen Saville. It aims to improve the speaking, listening and social interaction of children and young people by developing their: listening and attention knowledge and behaviours story telling skills through narrative ability to reason and infer social skills / self-esteem. The project was set up for children in the 5-7 year and 9-11 year age range who did not meet the criteria for accessing the mainstream speech and language therapy service but who nevertheless had been identified by schools as needing to develop or improve their skills in any or all of these areas. In addition, the project aimed to enhance the knowledge of teaching staff and parents about communication skills and to develop their skills as communication facilitators. The Childrens Fund identified places in Burton where children and young people had not been able to access other national or locally driven preventative programmes or services. They specified the two wards in Burton where we could work, so this necessarily limited the number of schools with which we could be actively involved. As the project developed we were given permission to extend and by the end of the financial year to 2007 we will have delivered the project in 10 schools. We asked the schools to help us identify children who these supportive of skill development in the classroom. One of our primary aims was to work with parents to develop and encourage their skills as primary language facilitators with their children. We were targeting some parents who had never been into school for any purpose at all. Although the numbers are relatively small we have, with the childrens encouragement, been able to inform and engage some very difficult to reach parents. We worked very closely with schools to obtain parental consent. We designed our own letter or used school pro-formas with adapted wording. Schools were very good at promoting the project (an exciting opportunity, very lucky to be chosen). We produced flyers to attract the children and used existing home school liaison staff to phone or contact parents on our behalf. Where English was a barrier we ensured that there was someone at home who could translate, or used bilingual support.

HOW I (2):

were struggling with social and communication skills development. With the assistance of a teacher, we supported this process by providing staff with a formative assessment profile based on a combination of National p-scales and National Curriculum Literacy attainment targets. We also observed the children from a social interaction perspective in the classroom setting. In addition to identifying children, this initial assessment phase would provide a baseline for ongoing evaluation and reporting to the Childrens Fund.

Incentives
We got the children to create the invites for their parents and carers to come to group sessions and actively encouraged attendance through incentives. Initially we offered small general prizes from pound type shops but with recently increased funding we have bought in games to encourage language development, communication and cooperation. We also always have refreshments. We keep parents fully informed about the aims of the work we do through leaflets (symbolised as appropriate), drop-ins and parent sessions. Home school liaison staff inform us about any special requirements of families. We send activities and ideas home with children on a regular basis and regularly ask parents for opinions and comments. The Childrens Fund also promotes and encourages the active participation of children and young people. As a team we have developed skills and knowledge about gaining opinions and feedback through involving children and young people. Satisfaction levels are monitored closely by the Childrens Fund Management team and indeed funding has depended not only on perceived improvement of skills but also on service users satisfaction (see figure 1). As well as actively inviting spoken comments, we use smiley face feedback from younger children where they select one of three faces to post in a box to indicate their satisfaction. With the older children we use red, green or amber cards for their feedback. We also use a system of reward cards linked to communication behaviours like good waiting, you didnt butt in, good ideas, and the children are encouraged to reward each other if they a identify a good behaviour in a group session. We also regularly give out certificates. Our high school children prefer to have their rewards via existing school reward systems such as merits. Childrens Fund Projects are performance managed on a quarterly basis and so staff are required to moni-

We have, with the childrens encouragement, been able to inform and engage some very difficult to reach parents. Continuity
The project is delivered in weekly one hour sessions over three terms and relies on schools making a commitment to provide accommodation. When possible we actively encourage an assistant from school to work with us, for the purpose of continuity, feedback and skill sharing. All sessions aim to develop effective listening and spoken language but focus on more specific elements of language skills as required (reasoning, inference, story telling, components, using and understanding questions, giving opinions). We evaluate all sessions at the end, and some of these observations help to inform class teachers about skill development. We have found it necessary to develop promotional resources and material to support and promote our work. The two speech and language therapy assistants have become experts in this! Training school staff has taken several forms, initially using I CANs Joint Professional Development Framework. We have actively encouraged staff to observe and participate in group sessions and to run parallel groups. As well as talking to school staff as a whole we have done talks for groups such as teaching assistants, and we share and discuss aims of group sessions to make

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tor and evaluate childrens progress regularly. Outcomes have been very positive with comments from school staff about improvements in childrens confidence and self-esteem, improved listening and attention, more contribution to class discussions and increased parental involvement in schools. With an extension of funding until March 2008 we have been able to offer our project to several new schools in the area and also to include young people in the 11-13 year age range. We have also been awarded a further sum of money to build on the work we have done so far with parents. This will involve running parent workshops to enhance their knowledge as language facilitators and attending parents evenings with display boards, resources and information regarding the importance of communication skills for life. We are also looking for alternative sources of funding in order to allow the project to run on beyond the scheduled finish date.

Photos: far left: Julie talks to parents and children Left: Helen working with some older children Below: Wendy gets the children involved

Rewarding
It has much such a difference having dedicated time, staffing and resources to carry out a project effectively! The opportunity to use and adapt my skills has been personally rewarding, and I have benefited from working alongside two assistants who take a less clinical approach to intervention. As I normally work in a Speech and Language Centre, I now feel more in touch with what is happening in mainstream schools in terms of social and educational expectations and demands on education staff. Going into schools frequently and regularly and being accessible before and after sessions has helped enormously to improve relations between health and education. The project has also created opportunities to reach more parents and children than we would normally be able to see. There are signs that the project will have ripples beyond the initial splash. Every school involved has welcomed the initiative and recognised that we need to do more to promote effective speaking and listening. They recognise that children respond to regular, focused work in a small group on basic communication skills, that they make progress and enjoy the sessions. Staff are now more easily able to identify children who may be at risk because of their poor communication skills. Teaching and support staff have picked up skills through observing sessions and some schools are setting up similar groups to run in parallel with ours. Julie Coley is a speech and language therapist with South Staffordshire Primary Care Trust. To see examples of resources developed by the team, go to www.speechmag.com.

Figure 1 Feedback

For some members of the group this is the first time they have been asked what they think and why and within a safe environment are being encouraged to form and articulate their ideas. (teaching assistant, 11-13 years) One of the boys is now confident enough to speak in front of a group. Strong links have been built between school and the speech and language therapy department. (teaching staff, 9-11 years) That was really good. Id like to come again because I could take these ideas to playschool. It was brilliant, I love the interactive stuff. (parents, 5-7 years) I find it easier to talk to teachers and parents about problems [now]. (Sarah, 12)

Resources
Every Child Matters, see www.everychildmatters.gov.uk/aims/outcomes Joint Professional Development Framework, SLTP see www.ican.org.uk

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REVIEWS

reviews
MANAGEMENT
Managing and Leading in the Allied Health Professions Robert Jones and Fiona Jenkins (Eds.) Radcliffe Publishing ISBN 1 8577 706 8 27.95

VOICE
The Odyssey of the Voice Jean Abitbol Plural Publishing ISBN 1-59756-02904

AAC
Nice Warm Socks (CD) Wren Music www.nicewarmsocks.org.uk 10.00 + 1 p&p

29.95

Not light reading


This is the first in a series of Essential Guides for allied health professionals. Topics include leadership, development of profession, legal issues and professional regulation. Although an interesting read, the tone is fairly academic. You need lots of uninterrupted time to get to grips with the material. Its not light reading and it wouldnt be easy to dip into for reference purposes. An excellent resource for formal study and a reasonable buy if you dont have any other books on the subject. If youre a busy manager this will probably sit on your office shelf looking worthy. The dark blue binding makes it ideal for this purpose!

General interest
Abitbol sets both himself and the reader a challenge; to explore the voice from the creation of life on Earth, through the anatomical and neurological features of voice in humans, to the acquisition of language in children, the numerous functions of voice, and the ways our voice can fail. He achieves this in a comprehensive - if lengthy - script. Often the turns of phrase employed become lost in the book's translation from French to English; however Abitbol drops relevant and interesting case studies into his account to good effect. This is more of a general interest book than a specific clinic text. The subject matter, while broad, would appeal to many a speech and language therapist, although many may prefer to dip in and out of various sections depending on their specific concerns. Vicky Watkins is a paediatric and adult speech and language therapist in Kings Lynn, Norfolk soon to be travelling the world!

Easy to adapt
This CD of 17 delightful songs was developed for children with special needs, including users of AAC. Some have been specially written; others are adapted traditional songs. They are mostly carefully paced and phrased and range from simple, relaxing songs to more complex rounds that can include users of voice output devices. The songs would be easy to adapt for individual abilities. Sheet music and advice on adapting for AAC is available on www.nicewarmsocks. org.uk. Free downloads of symbols, words and overlays are available from www.widgit. com using Communicate:In Print software. Some of the vocabulary and inclusion of Ghanaian and Gaelic may limit meaningfulness for some. This CD and additional resources should be useful for teachers and therapists keen for children to participate and develop interaction skills through singing. Janet Talbot is a specialist speech and language therapist with East Lancashire NHS Primary Care Trust.

The book can be quite heavy going as much of it outlines the theories of memory and discusses the evidence behind these models. There are however some more practical sections relating to the impact of working memory on ability to learn and principles of intervention. If you are looking for a book with practical games and activities this is not it - but it is a good way of developing your knowledge so that you are more prepared to tackle intervention. Anne Millen is a speech and language therapist working with children in Northern Ireland.

DEVELOPMENTAL DYSPRAXIA
Living with Dyspraxia: A Guide for adults with Developmental Dyspraxia (Revised edition) Mary Colley Jessica Kingsley Publishers ISBN 1843104520 12.99

Insight
This concise and interestingly written handbook is aimed at helping dyspraxic adults to understand their condition and its impact on work, study, social relationships and leisure activities. It contains practical tips on everyday living, including voice control, body language, cooking, study skills, driving and self-care. These could form the basis of individualised, practical therapy programmes, using the detailed Developmental Dyspraxia Questionnaire provided to construct a personal profile. There is a chapter on various therapies and interventions and many contact addresses and suggestions for further reading. The book also draws attention to the overlap with other conditions, such as Attention Deficit Hyperactivity Disorder and dyslexia. Especially fascinating - although rather sobering reading for professionals - are the accounts by four dyspraxic adults of their own experiences. I would recommend the book to teachers and parents, student therapists and clinicians (especially those working in a multidisciplinary setting) who need an insight into developmental dyspraxia as experienced by adolescent and adult clients and an overview of the help available. Zohra Jibb is a speech and language therapist working in East Lothian.

Developing the Allied Health Professional Robert Jones and Fiona Jenkins (Eds.) Radcliffe Publishing ISBN 1857757076 24.95

Quality varies widely


This second book in the series covers a range of issues that will be of interest to allied health professional team leaders and managers. Student placements, appraisal, learning for support staff and work-based learning all make an appearance. The style and quality of the contributions varies widely between authors. I really liked the brief, practical and easyto-read contribution on 360 degree appraisal, was irritated by the jovial but not very informative chapter on e-learning and deeply bored by the clinical supervision section. This volume will give most people something that inspires, something that annoys and something that cures insomnia. A bit like your average conference - and probably cheaper. Catherine Cowell manages the adult speech and language therapy service in Stockport.

ASPERGERS SYNDROME
The Complete Guide to Aspergers Syndrome Tony Attwood Jessica Kingsley ISBN 1-84310-495-4 17.99

WORKING MEMORY
Working Memory and Neurodevelopmental Disorders Tracy Pakiam Alloway & Susan E. Gathercole (eds.) Psychology Press ISBN 1-84169-560-2 39.95

A brilliant book
This book is essential reading for anyone working with children or young adults with Aspergers syndrome. It is written in a clear, concise, readable style with bullet point tables of key points at the end of each chapter. It assumes no previous knowledge of the subject. It is exceptional value for money considering the wealth of information and practical strategies and resource materials described within it. It is a brilliant book and doesnt leave my side in my work with clients with Aspergers Syndrome. Enjoy! Janet OKeefe is an independent speech and language therapist with Wordswell Limited, Ely, Cambridgeshire.

Theories and evidence


This is a topical reference book for all speech and language therapists working within schools or community clinics. As therapists we often come across working memory deficits but dont quite know what to do with them. This book discusses working memory over a range of neurodevelopemental disorders that we come across daily including dyslexia, specific language impairment, Attention Deficit Hyperactivity Disorder, Down Syndrome and autistic spectrum disorder. Each chapter stands alone, so you can pick it up and read the chapter that is relevant to you.

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SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007

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21 June 2007 The Long and the Short of it: an evening of short performances and short stories for the longest day of the year InterAct Reading Service, with Richard Briers and David Soul (InterAct supports stroke recovery by using professional actors to provide a live reading service in hospitals and at stroke clubs.) 7pm The Actors Church (St Pauls Church), Covent Garden 10 Bookings: tel. 020 7471 6789 / email info@interactreading.co.uk 10 July 2007 Singposium 2007 A singing, conducting and choral day for all who work with young singers. Organised by Music for Youth 9am-5pm Birmingham 55 Tel. 020 8870 9624, e-mail singposium@mfy.org.uk 6 September 2007 (Glasgow) 2 October 2007 (Birmingham) Establishing and running an effective Childrens Hearing Services Working Group (CHSWGs are based in local areas to ensure that all services designed to support deaf children and their families work in a co-ordinated way.) 95 Tel. 0161 275 8572 / e-mail nhsp.training@manchester.ac.uk 23-25 September 2007 Communication Matters National Symposium Leicester (Subsidised places available for people who use AAC and family members.) www.communicationmatters.org.uk/downloads/cm2007_ registration_form.pdf 9 November 2007 Quality of life and learning for people with brain injury and/or complex needs Workshops include Somerset Total Communication; communicating with people with profound and complex needs; working with people with brain injury; using information technology with learners with brain injury and accessible curriculum. 10am-4pm Taunton 100 Details: Julia Tester, tel. 01823 366525 / e-mail JFP@somerset.ac.uk.

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MY TOP RESOURCES
NEW TECHNOLOGY IS DEVELOPING AT BREATHTAKING SPEED, BUT ARE WE UP-TO-DATE WITH ITS POTENTIAL USE IN THERAPY? TAYSIDE SPEECH AND LANGUAGE THERAPISTS GILL CAMERON, JACLYN DALLAS, JUDY GOODFELLOW, LORRAINE HOPE, CAITRIONA HUTTON, GILLIAN NIXON, REBECCA RICHARDSON, KAREN RODGER AND LESLEY SMITH DISCUSS SOME OF THE DEVELOPMENTS THEY HAVE SEEN ACROSS PAEDIATRIC, ADULT LEARNING DISABILITY AND ADULT SERVICES. 1. BEBO / MYSPACE Social networking websites are used extensively by younger people from the computer generation to make friends, keep in touch with current friends and find old friends. They allow you to record information about yourself such as your interests, achievements and memories of particular events through profiles and blogs, and give you a level of control over who can view your information. Such sites are useful in therapy with individuals who have maintained a site prior to acquiring a communication disability, perhaps as a result of a brain injury. They enable therapists to find out more about the individuals past, replacing or enhancing information from carers. The site can help initiate and inspire conversation and may act as a potential forum for clients to contact others who are also members. The blogging tool can be used as an online diary to act as a memory aid. As time goes on we anticipate that more and more clients will have a presence on such sites, and we see huge potential for any client with internet access and an interest in computers. To find out if your client uses one of these sites, enter their name into a search engine or search on www.bebo.com or www.myspace.com. (If this feels like an invasion of privacy, remember that you will only be able to view what your client has decided they are happy to make publicly available.) 2. PRIORY WOODS SCHOOL WEBSITE The Priory Woods School website is useful for a wide range of paediatric and adolescent client groups. It has a ready-made cause and effect tool, which is set up for switch users, a touch screen or a mouse. Favourites range from Scooby Doo to Westlife! Therapists and parents can access these programmes online for free and can download and save them onto a CD-ROM or memory stick. Another use is for various stages of PECS (Picture Exchange Communication System) users. It helps with Stage I motivation all the way through to sentence level, (I want, I see..., I hear). We also find it motivating for children as a reward activity. www.priorywoods.middlesbrough.sch.uk/ resources/videos.htm www.pecs.org.uk 3. FILMLESS RADIOLOGY Our department is shortly to get filmless radiology and we expect it to become a favourite resource. In the past videofluoroscopy sessions involved the use of a videotape recorder. Videotapes were used to store multiple patient videofluoroscopic images. Quality was often poor and images could easily be accidentally erased. Although DVDs provide better quality, there is still a storage issue and outlay required for supply of appropriate equipment. Filmless radiology will allow for direct PC access to stored images of greatly improved quality, and allow for comparison of old and new images. It will also negate the need for storage of videotapes or DVDs. See www.pacsgroup.org.uk for overviews and guidance on procurement and implementation. (PACS stands for Picture Archiving and Communication System.) 4. MOBILE PHONES AS AN ALTERNATIVE TO AAC Mobile phones can be used to supplement speech when intelligibility is reduced, or also as a contact method if the client finds it hard to use the telephone. The therapist could be involved in rehabilitation of previous mobile phone use, or teaching mobile phone use. A predictive text facility means a client with impaired spelling skills can be successful. Most mobile phones also have a bank of stored message templates which can be adapted to suit individuals needs and would save them having to type the whole message each time (for example, please pick up my prescription). Mobile phones allow people to summon help when they need it wherever they are. They also have diary and reminder functions, which may act as memory aids for medication and appointment times. Photo galleries can be used communicatively as a prompt for conversation. 5. DIGITAL CAMERA In the adult learning disabilities team we couldnt work without a digital camera now. It offers a good quality and size of pictures and, as we can see the shot on the screen, the photos are clear and uncluttered. Creating functional communication books with local shops, people, entertainment venues, cafs etc. is a much easier task. It also makes the finished article very personalised and clearer than was previously possible. Users of AAC devices such as Say-it! SAM can personalise cells with photographs of family, friends and places. While it certainly beats processing, cutting and glueing, we have had to learn how to import photos from the camera to the computer and how to format, insert and re-size them. Up-todate software and adequate memory capacity are also essential as photographs are huge files and it is important that we can incorporate them speedily into documents. 6. MEMORY STICK / PEN DRIVE A memory stick is very useful for transferring information such as photos taken on a digital camera from a computer in a resource centre or a clients home to the computer in the office or wherever you want to work on them. (Right click on the image, then Save As... Locate your memory stick as a removable drive and give your photo or document a name.) You can also use a memory stick to take your PowerPoint presentations with you when you are offering training. You just plug the stick into the laptop computer linked to the projector. If you wish to search for potential images, logos or photos for clients AAC devices, you can load them onto your memory stick then download to a computer once you are with the client. 7. STUCK FOR MINIMAL PAIRS? Having difficulty thinking of minimal pairs? Then this is the answer to your prayers! Whether its real or non-words, and whatever the sound substitution, this website will give you lists of whatever you need, saving you lots of time. Another fantastic use is for vowel distortions; you put in the substitutions and the site produces appropriate lists of contrasting words. (Watch out as it is for English RP and not all the words will work for local accents.) http://myweb.tiscali.co.uk/wordscape/wordlist/ 8. BBC WEBSITE Facilities: News, Weather, Radio, TV, video clips, links to other sites etc. The BBC site can be used as a therapeutic tool with clients who previously enjoyed using the computer or as a novel way to access information. News articles are often short with bold headlines making them more accessible to people with aphasia. Including internet training and website navigation as part of therapy could open up some options to people at home. This site could also inspire further investigation into use of the internet as a way of finding information and as a recreational activity. www.bbc.co.uk 9. CBEEBIES WEBSITE Accessed by anyone for free, there is always something to interest any child on this particular area of the BBC website. You can use the online games or printouts of blank pictures as a reward or therapy tool; for example for early comprehension, Colour in Cliffords ears / Bobs nose / Pats hat. www.bbc.co.uk/cbeebies 10. TEXTING Everyone has experience of parents and carers who are inclined to forget their speech and language therapy appointments. This can be a frustrating waste of time. Two of us in Dundee have undertaken to set up a project to combat missed appointments by sending text reminders through the new NHS net system. If a similar project has already been done, Rebecca and Gillian would love to hear from you (e-mail rebeccarichardson@nhs.net and gnixon@nhs. net). Otherwise, watch this space!

GILL CAMERON

JACLYN DALLAS

JUDY GOODFELLOW

KAREN RODGER AND CAITRIONA HUTTON

REBECCA RICHARDSON

LESLEY SMITH