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ISSN 1368-2105

Spring 2006


The call for home delivery

Total communication
Photo opportunities

Reducing non-attendance

Applying project management skills

Expert guidance

Leading by example
- an aphasia conference

How I inform my decisions

in paediatric dysphagia

PLUS.The Assurance keyHeres one I made earlierMy Top Resources clinical educationand featuring Learning styles

Reader offer

PHONEME FACTORY SOUND SORTER COMPETITION WIN LEARNING STYLES IN ACTION Speech & Language Therapy in Practice has teamed up with inclusion software publisher, SEMERC, to give you the chance to win a copy of the new Phoneme Factory Sound Sorter a program designed by speech and language therapist Yvonne Wren for use with children with phonological impairment. Phoneme Factory Sound Sorter consists of seven activities to develop childrens listening and discrimination, including phoneme detection, phoneme blending, minimal pairs and rhyme awareness. The program contains a range of preset activities that match common difficulties in childrens speech, and further settings are available for teachers and speech and language therapists to address less common phonological problems. NEW from Network Continuum Education, this sequel to Barbara Prashnigs The Power of Diversity (see feature on p.4) explores how to implement personalised learning in real and varied contexts. Learning Styles in Action covers the nursery to university and includes sections on using learning styles to help problem pupils and multisensory teaching and learning. The book usually retails at 14.95, but Network Continuum Education is giving FIVE copies away FREE to a lucky reader. For your chance to win, simply send your name and address to: Carol Thompson, Marketing Assistant, Network Continuum Education, PO Box 635, Stafford ST16 1BF, or email your address to: The closing date for receipt of entries is 25th April 2006 and the winners will be notified by 1st May. For more details about this and other Network Continuum Education resources, or to order a free catalogue, see or call 01785 225515.

To enter, simply send your name, job title and contact details to
This offer ends 25th April 2006 and the winner will be notified by 5th May. Phoneme Factory Sound Sorter costs 59 for a single user. Further details on this and other software packages at

The lucky winners of Little Knowalls Naughty Bus books in the Winter 05 reader offer were Karen Royle and Julianne Bolton. Linda Collier, Faith Lewis and Lesley Wright all now have a set of Blob Tree Posters thanks to Incentive Publishings offer in the same issue. Congratulations and keep those entries coming!

To subscribe to our FREE e-update service for readers of Speech & Language Therapy in Practice, e-mail Your details will not be passed to any third party.
If you want to find out more about some of the topics in this magazine, you may be interested in the following articles from earlier issues. Remember, if you dont have access to them, check out the abstracts on and take advantage of our article ordering service.
Morris, T. (2004) Turning up or turning off? Summer: 26-27. Available in full FREE at Morris, T. & Stein, L. (2005) Stepping stones. Autumn: 4-6.


Our cumulative index facility is now database-driven! This means you can search for articles from the Spring 2004 issue by author, title or text, and we have also grouped articles under new categories. (The index of abstracts from Summer 1997-Winter 2003 is still available online. You can search it by author, category or through using the speechmag sites search facility.) When you find an abstract that inspires you, you can order a copy of the full article for a small charge via our secure server.

Total communication
From How I advance total communication: Brown, L., Muir, M., Grant, K., Clark, L. & Fletcher, J. (2004) Reaching out. Winter: 24-26. Hartley, K., Gray, R. & Edmonstone, A. (2004) Extending the reach. Winter: 27-28.

Learning styles
(103) Junor, B. (2000) In his own style. Spring: 8-10.

(161) McGrane, H. & Stansfield, J. (2001) Strength in compromise. Autumn: 8-11. Stansfield, J. & Hobden, C. (1999) Whose right? whos right? Winter: 17-19. Available in full FREE at:

Aphasia and well-being

(173) Nicoll, A. (2001) Imprints of the mind. Winter: 14-18. Available in full FREE at: Pay us a visit soon.

The most popular location for assessment was the clients home. Parents gave a number of reasons for this choice, which included convenience and the performance of the child. From this we conclude that previous non-attendance was generally not due to a parental reluctance for their child to be assessed but rather inconvenient appointments or venues. Working in collaboration with local speech and language therapy services, Sure Start therapists Samanatha David and Marie Hackshall researched the potential of telephone contact with the offer of a home visit to reduce non-attendance at initial appointments.

AAC, software, professional issues, games, social skills, parenting, emotional intelligence, child language, voice, cleft palate, aphasia, dysphagia.


conversation is intrinsic to everyday interaction, and others learning the skills of supported conversation allows people with aphasia to remain included. Kevin Borrett reports on a multidisciplinary aphasia day conference where delegates put the medical model to one side and reflected on how they could influence broader well-being.

Cover photo by Paul Reid (see page 14). Posed by models.


(publication date 27/02/06) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: Design & Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Website design and maintenance: Nick Bowles Webcraft UK Ltd Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2006 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. Win Phoneme Factory Sound Sorter and Barbara Prashnigs new book Learning Styles in Action!


Geoff is a fine and effective speech and language therapist. After several years he feels that it is time for him to go for a promotion. However, he is terrified of speaking in public and also of being interviewed. His fear of failure means he stays in his position feeling more and more frustrated with himself Life coach Jo Middlemiss believes that confidence or the lack of it impacts on everything we do. In the sixth of our series to encourage reflection and personal growth, she asks us to trust ourselves enough to reclaim our self-assurance.


In researching this article I have learned there is room for me to be a lot more tolerant, not only of other peoples learning styles, but also of my own. Avril Nicoll finds out that a little of what you prefer can make a big difference in inspiring yourself, your clients, students and colleagues to learn.



Our two contributors ask clinical questions about the significance of penetration and respiratory disorders in children. Their suggestions for practice show how important it is to try to look at the whole picture and to report evidence accurately, including any uncertainty. (1) PENETRATING QUESTIONS Does penetration during swallowing in children indicate dysphagia or risk of aspiration? What do we do when we see it? Charlotte Buswell goes in search of answers. (2) QUESTIONING ASSUMPTIONS Rebecca Howarths experience with a teenager with Cri du Chat syndrome has led her to reIN FUTURE think some of her assumptions when ISSUES... assessing, making a prognosis and APHASIA planning management of children with respiratory illness and dysphagia.


We were recently put in the very fortunate position of having a number of support workers seconded to us. These communication development workers are enabling us to provide a tailored service to more clients and to grow as a team. Alison Matthews and Terry Baynham celebrate the opportunities of skill mix for improving service quality, using the example of providing a photo rota for an adult with learning disabilities.


Allied health professionals undertake many developments that require them to structure and plan their timeUnfortunately, without an understanding of how to manage projects, those developments often become complicated, never-ending and stressful. Satty Boyes and her management consultant husband James explain how applying project management skills to real-life projects can enhance personal development and everyday practice and ultimately lead to better outcomes.





Alison Roberts with more low-cost therapy activities: T-shirt Activity; Customised Jenga; Alternative Odd One Out.

our values base is as important as an TOTAL evidence base in decision making, but COMMUNICATION ethical reasoning is not well represented STAMMERING in the speech and language therapy literature. The Seedhouse ethical grid (1988) is clear without being simplistic; a model which can be applied to practical problems. Jois Stansfield, Professor and Programme Leader of the BSc Hons in Speech Pathology and Therapy at Manchester Metropolitan University.



Research announcement welcomed

The Royal College of Speech & Language Therapists and user-led organisations are celebrating the announcement of research into the communication support needs of people with communication impairment in Scotland. The announcement followed a debate in the Scottish Parliament which called for comprehensive research and the development of a communication strategy for Scotland. MSPs described contact from constituents with different types of communication support needs a stammer, dyslexia, aphasia - and called for greater understanding of the disabling barriers they face on an everyday basis. At a reception at the Scottish Parliament hosted by the RCSLT Councillor for Scotland Kay Fegan, Communities Minister Malcolm Chisholm said he was particularly impressed by the proposed research method which will examine the lived

Website wins praise

The National Deaf Childrens Societys website has been Highly Commended in the British Medical Associations 2005 Patient Information Award (websites). Launched in March 2003, an average of 20,000 users per month search through over 2,000 pages of information. Users can download publications and fact sheets, find out about services and support across the UK and share knowledge and experiences through the Parent Place. Sarah Johns, NDCS helpline and publications manager commented: Three babies are born deaf every day and 90% of deaf children are born to hearing parents with little experience of deafness. With this in mind, parents of deaf children need accessible information and support so they can make informed choices for their childs future.

Communities Minister Malcolm Chisholm talks to Christina Meacham and Loraine Boyle from Different Strokes at the RCSLT Reception at the Scottish Parliament

experience of people with communication support needs. He added that the work leading to the research announcement made it clear that the research has to cross policy areas of health, education, justice and equal opportunities.

Speaking from the Heart

A plea for resources

Amy Jensen is a volunteer speech and language therapist, working at the Centre for the Rehabilitation of the Paralysed in Savar, Dhaka. This charitable institution has set up the Bangladeshi Health Professions Institute, which is running Bangladeshs first ever course in Speech and Language Therapy. It is a BSc Hons course, over four years, and it is affiliated to University College London and Jahangirnagar University in Dhaka. Amy is teaching the first set of students, who are now in their second year. Amy says that, while the students have access to a library containing some speech and language therapy-related books, the books are quite outdated and access to the internet can be very difficult due to high cost and an inadequate computer system. She adds I worry that the students are not able to get to get hold of up-to-date information on what is happening in the profession, which puts them at a disadvantage compared to their peers in the developed world. If any of your readers would like to contribute in any way toward the education of these students, we would love to hear from them. Amy Jensen, e-mail or Cristy Gaskill, e-mail

Dr David Lilburn of self-help group Safety in Stumblers describes his experience of medical school, and ultimate triumph on achieving excellent grades for his final oral exam at an open day called Speaking from the Heart. Organised by the Scottish Branch of the British Stammering Association, around 50 people who stammer, family members, therapists and teachers gathered to share ideas, and heard testimonies covering education, career and being covert. BSA Scotland hopes to organise an open day specifically for children, young people and families as part of next years programme.

Jayne Comins
Just a year ago, Jayne Comins shared her top resources for bringing about short- and long- term changes to your professional and personal life. The choices reflected her full and varied career and interests - which spanned speech and language therapy, psychotherapy, opera singing, occupational and organisational psychology, information work, training and writing and her equally dynamic and positive approach to life. Sadly, Jayne died at the end of January. I first met Jayne when she was Information Officer for the then College of Speech Therapists. Over the years she constantly impressed and inspired with her innovation and drive, and her love of learning and applying new knowledge. Jaynes commitment to helping people find ways to help themselves always made me think, and continues to influence the direction of this magazine. In spite of her too-short life, in all of her roles colleague, ambassador, friend, mentor to name but a few - Jayne leaves a tremendous legacy. Avril Nicoll, Editor Jayne was an active member of the Association of Speech & Language Therapists in Independent Practice. Sue Bell, a fellow member, is to undertake a 100 mile sponsored walk as a Tribute to Jayne, with proceeds divided equally between the Institute of Cancer Research and ASLTIP. If you would like to contribute, e-mail Sue at or tel. 01962 774479.

We have reprinted Jaynes last two articles for Speech & Language Therapy in Practice at Comins, J. (2004) My Top Resources: How to stay organised. Autumn. Comins, J. (2005) My Top Resources: Guides to change. Spring.



Training role
Speech and language therapist Beckie Whiteman has been appointed to a new post of training facilitator for Oxfordshire Childrens Therapy Services, and is keen to make contact with other therapists with this unusual remit. Beckie says, The post was created because we needed someone in the department to have an overview of what we provide as a service in terms of training. This is especially in light of integrated services and working more closely with colleagues from other services. Beckies responsibilities include auditing all training delivered by speech and language therapists, finding out what schools, parents and other professionals want, and developing integrated and accessible training packages. e-mail

Avril Nicoll, Editor 33 Kinnear Square Laurencekirk AB30 1UL

Get it on time
Parkinsons Disease Awareness Week (24-30 April) will highlight the problems for people with Parkinsons when they are admitted to hospitals and care homes and dont receive their medication on time. Get it on time wants staff to move away from rigidly-timed drug rounds that can lead to people with Parkinsons becoming ill and disabled unnecessarily. The Parkinsons Disease Society is lobbying for each hospital and care home to adopt, implement and monitor a policy to ensure each person will receive the correct medicine, at the right time, when they are admitted.

tel/ansa/fax 01561 377415 Style can be defined as, A quality of imagination and individuality e-mail

Learning in style

expressed in ones actions and tastes ( inner assurance (p.22), our other authors are off down the catwalk of these pages, with this seasons issue as always showing a range of influences. From Sure Starts collaboration with local speech and language therapy services, we have Sam David and Marie Hackshall (p.14) modelling a new system for initial assessments that has cut down on that most frustrating of entries the no shows. The paediatric dysphagia stable is strongly represented, with both Charlotte Buswell (p.24) and Rebecca Howarth (p.27) building on the trend towards evidence based practice and informed choice. Alison Matthews and Terry Baynham (p7.) pause together for the camera, secure in the knowledge that they have set up the scene to capture the best shot. The Kevin Borrett collection (p.20) first appeared at a conference on well-being in aphasia. This follow-up confirms that the military look of the white coat has been replaced with the softer shapes and flowing lines of the social model. Husband and wife partnership James and Satty Boyess show (p.10) is delivered on time and according to plan, thanks to their renowned project management skills. Meanwhile, Alison Roberts continues to perfect a sophisticated look from cheap and cheerful materials (p.13). And Jois Stansfields vintage back page rounds it all off with an eclectic mix of resources that draws inspiration from her journey to a professorship in Manchester. So, adjust the lighting, turn up the sound hey, you can even give us a twirl if you want (see feature on p.4). Whatever your ideal conditions for a good read, Speech & Language Therapy in Practice is most definitely about learning in style. While Jo Middlemiss explains why this needs a solid foundation of

Excellence award
Joint appointments, rotational posts and student and service user initiatives are some of the planned benefits of a 5 year joint award to UCE Birmingham, Birmingham Childrens Hospital and University Hospital Birmingham. The three organisations have been granted a Centre for Excellence in Teaching and Learning (CETL) award to improve staff and student experiences. The recipients say it will particularly affect student nurses, speech and language therapists, radiographers, social workers and operating department practitioners.

Ill get by with a little help

An older peoples inquiry has confirmed that they value support which enables them to live in their own homes and to have a life worth living. The inquiry into that little bit of help that would make a difference was funded by the Joseph Rowntree Foundation, and the largest group was made up of older people themselves, in discussion with policy-makers, practitioners, academics and commentators. Examples of existing simple support services that older people found especially valuable included a volunteering project to help people around the home on their discharge from hospital, a befriending service, pet care, night visits, gardening and home maintenance and repair, and social and learning activities. Download That little bit of help (Briefing Note 3) from details.asp? pubID=727.



Learning in sty
ow are you approaching reading this article? Are you wandering around the room munching an apple as you read chunks in between thinking about other things? Are you in the bath with lots of bubbles and music playing in the background? Are you sitting purposefully at a desk in a brightly lit and quiet office, highlighter pen and ruler at the ready to note key points? Are you happy to absorb and choose how to apply the information yourself, or are you looking forward to discussing the possibilities with your peers? The chances are that how you read Speech & Language Therapy in Practice tells you a lot about your own learning style. Ive had people apologise to me after saying they keep their magazine beside the toilet, as if this was somehow an insult. In fact, its an indication that they learn most effectively when reading a bit at a time while they take a welcome and undisturbed break from the world around them. In researching this article I have learned there is room for me to be a lot more tolerant, not only of other peoples learning styles, but also of my own. I now know Im not being unreasonable when I chase the family out of my home office saying I cant work well alongside other people or with background noise. Its actually true. As learning styles guru Barbara Prashnig says, it is always the little things which make a big difference to people (1998, p. 37). Barbara believes that discovering and working with our own personal learning style and understanding how other people may differ has the potential to revolutionise not just education and lifelong learning but all sorts of personal and work relationships. While we should play to our strengths and preferences, particularly when we are younger, we should ultimately aim to develop flexibility, as mental rigidity (either strongly analytical or holistic, left- or right- brain style) will not be sufficient to cope with our fast-changing world. (p.285). She also suggests that not being in touch with our personal style, or even habitually using non-preferences because we think thats how we ought to behave, is a recipe for stress, exhaustion, frustration and depression. University of Ulster lecturer Aileen Patterson agrees that helping students understand and work with their own learning style is a priority. Students and practice educators on clinical supervision courses are often given a VARK questionnaire so they can find out if their predominant learning style is Visual, Auditory, Reading or Kinaesthetic (can be completed online at index.asp). This website also says that the fifty to seventy per cent of the population who have multiple preferences have the potential to choose to adapt to suit the person they are interacting with ( In practical terms, it is suggested that students with strong visual preferences should experiment with underlining and highlighting, and ways of turning heard or read information into images and graphics. If learning by aural methods is more of a preference, attendance at lectures is likely to be essential, as is learning by reading aloud, discussion and listening to tape recordings. Students who learn most by reading and writing appreciate handouts and textbooks, take detailed notes and always have a dictionary handy. Finally, the do-ers, the kinaesthetic learners, need opportunities to use all their senses, have hands-on experience and lots of real-life examples. Aileen also recommends looking at the Honey & Mumford Learning Styles Questionnaire ( which enables people to find out if they are predominantly Activists (hands on), Reflectors (tell me), Theorists (convince me) or Pragmatists (show me). It makes sense that student education consists of opportunities to learn in all these ways, so that everyone is engaged and also has the opportunity to develop flexibility. Placements, reflective diaries, individual / paired / group work, video, reading and discussion all have their place. In her books, Barbara Prashnig cautions that there is a tendency to teach in the way that we feel comfortable learning. As therapists, it is therefore clearly important that we understand our own style as well as that of our clients so we can make learning about communication fun and motivating for everyone. Figure 1 shows the Learning Styles Pyramid Model with all the components that Barbara takes into account in her Learning Styles Analysis.

Clinical reasoning
Using this approach does add another dimension to our clinical reasoning. For example, take Alec who has aphasia and lacks




How can you motivate and inspire yourself, your clients, students and colleagues to learn? As Avril Nicoll finds out, a little of what you prefer can make a big difference.
tackling it. Barbara works at a resource for older children with language impairment, and the ethos of curiosity, self-awareness and discovery means the pupils gain insight into their own learning styles and aspects of other learning styles they could adopt and adapt. It is vital that thinking aloud is modelled by staff: Oh dear, Ive got a problem with ____, I wonder what I did the last time this happened? Who did I ask for help? Staff can also make it clear that their role is not to answer pupils questions for them, but to think aloud about how they might tackle it themselves and encourage the pupil to consider how they want to go about it. Barbaras teacher colleague in the resource, Angela Peel, says pupils are almost tricked into reading, as they are encouraged to notice, What would a good reader do? Barbara believes that wonder and curiosity about learning is innate, but that tapping into and expanding it is where learning styles awareness can be so important. She says that as speech and language therapists it is important we encourage teachers to accommodate learning styles David actually learns better when hes able to hang off the seat and swing his legs; Lee concentrates more when he looks out of the window rather than at you. Barbara Prashnigs new book (2006, see reader offer) answers many of the frequently asked questions about the practicalities of using and applying the findings of her learning style analysis in classrooms. She says, The golden rule is teaching to the majority while catering for the minority. This means incorporating teaching methods for all those who show preferences / flexibilities in certain elements while allowing the few remaining others to learn in a different, often opposite way. (p.57)

confidence in social situations. It seems obvious he would benefit from a group, but this could be a disaster if Alec prefers to do his learning in ways that dont involve other people. Similarly, we might think it makes sense to encourage the parents of 6 year old Jason to switch off background noise when doing sound homework - but perhaps having carefully chosen music playing would actually enhance his concentration. Then theres Lucy, a fitness instructor with vocal nodules who wants her voice to be better but seems to lack motivation for therapy tasks; support for change could be provided by getting her to choose an incentive system and matching all her other learning style preferences. And what about Seema, 14 years old and coping with high level language difficulties in a mainstream secondary? A highly tactile person, it may be that fiddling with a Koosh ball in class is the main support she needs to get the most out of lessons. Speech and language therapist Zein Pereira specialises in working with children with specific language impairment. She identifies the learning style Visual / Auditory / Kinaesthetic each child uses habitually and then what combination of VAK would enhance input processing. She says, I find that multisensory input per se isnt always the best approach, as many children with specific language impairment overload. It can be more helpful to gradually layer VAK cues and strategies, for example by demonstrating a task silently, then repeating the demonstration with minimal language or a symbol added. Zeins interest in learning styles was inspired by a two-day training course from speech and language therapist and dyslexia teacher Jane Mitchell (see Jane looked at the learning process, learning styles, memory theory and metacognition. Zein says, The course transformed the way I worked with children with specific language impairment, and 11 years on continues to inform my practice. One of the outcomes for Zein was an appreciation of the importance of a metacognitive perspective. This includes spending time raising a childs awareness of where they are at with a specific skill, and establishing with the child why that skill is functionally important. For example, if she is working on developing the use of conjunctions, Zein will spend a few sessions highlighting the conjunctions that are already being used and linking this with the function(s) of conjunctions, associating a memorable image / catchphrase with that function as appropriate. This lets the child develop their metalinguistic understanding as well as plan the modalities and rehearse the skills they will use to successfully complete a task (for example: identifying a specified conjunction in a short piece of text; joining two given phrases / sentences using a specified conjunction). Zein initially makes each tiny step explicit and ensures she praises each child with clear and tailored feedback to reinforce and expand their self-correction and self-cueing strategies. She finds that gradually a child can develop the confidence and independence to actively use the strategies that match their most effective learning style within their social and learning environments. Barbara Clarkson is another speech and language therapist who is convinced that metacognition - thinking about thinking is the key to accelerating linguistic development. She says that making thinking concrete and real means it exists and so can be changed. In her experience, liking the way you learn has a strong impact on self-esteem and confidence and, whatever the task, you have to know how you know how to go about

While we should play to our strengths and preferences... we should ultimately aim to develop flexibility

Mix of methods
In devising training programmes for groups of adults who work with people with learning disabilities, speech and language therapist Sarah Heneker tries to apply what research has already identified as effective. Sessions therefore include a mix of methods, including the trainer standing and talking, discussion, video and experiential practical activities, such as working in pairs with one person blindfolded and reflecting on how it felt to have different levels of verbal support to complete a task. Aware that some of the training offered was more effective than others, Sarah decided to compare the impact of two of
Figure 1 Prashnig Pyramid Model Creative Learning (see



the courses. The first course she selected was a 1/2 day offered as part of a rolling programme of induction for new staff in group homes for adults with learning disabilities. The second was a day long course for a staff group in one home, where beforehand Sarah spoke to the homes manager to find out the communication support needs of the residents. The training for both was similar, and included a basic model of communication when and how communication can break down strategies to support communication specific packages that are available practical activities. The difference with the second course was that the facilitators were able to make explicit connections between what was being discussed and individual residents. Staff on both courses knew that their learning was going to be followed up. They answered a pre-course questionnaire, then had the same questions presented over the phone or on paper at 7 then 11 months after the course. While the staff attending the first course had increased awareness of communication as a two-way process, the impact of their own communication, the importance of context and the need to try out different approaches, they didnt remember the strategies and found it difficult to relate the course content to clients. Although they had retained information they didnt necessarily think it was useful, and they didnt mention the need for consistency from staff which had been stressed during the training. In contrast, the home staffs awareness of formal approaches, trying out different strategies and differing needs all increased, and they had carried out action planning, for example by making a staff rota board. The peer support offered by training together and relating the content to individual residents meant they could action plan and problem solve together. Sarah says the induction 1/2 day course is no longer offered because it was not effective in changing practice. There is high staff turnover and because the staff on induction are new to the job they have a lack of experience to bring to the training. Her evaluation backs up research findings that a one-off generalised training is not effective. Rather, we need to offer training that is specific and experiential, and support a personalised action plan. When offering training to carers, engaging with clients or liaising with other professionals we come across people who have been turned off learning because of previous bad experiences, and who do not realise that learning should be fun, easy, stressfree and have long-lasting effects (Prashnig, 1998, p. 5). Speech and language therapist Belinda Walker, a Trades Union Learning Rep for Amicus, is passionate about the benefits of lifelong learning. Her name is on the staff intranet as a contact for anyone who wants to access training, particularly at the moment in relation to the Knowledge and Skills Framework. She can point people in the direction of suitable evening classes, short courses or post-qualification opportunities as well as possible sources of funding. Belinda says the trades union movement started with a desire to re-educate people so they could get better qualifications and jobs, and that the need is no less now. She believes being aware of your own learning style allows you to take control. Barbara Prashnig agrees (1998, p. 306): To deal with any situation successfully you need to know YOURSELF and how to handle your weaknesses; you also need to know YOUR STYLE and how to utilize your strengths. So by now the apple will have been succeeded by a bag of crisps, the bubbles in the bath will have disappeared, and the magazine will be distinguished by yellow highlights. Or perhaps you are starting reading here?! Whatever your learning style, I hope you have found in this feature a little thing that will make a big difference.

Sessions include a mix of methods, including the trainer standing and talking, discussion, video and experiential practical activities

Prashnig, B. (1998) The Power of Diversity: New Ways of Learning and Teaching through Learning Styles. Stafford: Network Educational Press, Prashnig, B. (2006) Learning Styles in Action. Stafford: Network Continuum Education,

Thanks to all the speech and language therapists (names in bold) who helped with this article, and to Carol Thompson at Network Continuum Education.

See reader offer on inside front cover win one of FIVE copies of Barbara Prashnigs new book Learning Styles in Action!

Recommended Reading
STAMMERING Anderson, J.D., Pellowski, M.W. & Conture, E.G. (2005) Childhood stuttering and dissociations across linguistic domains, Journal of Fluency Disorders 30, pp. 219-253. Alison Nicholas is a speech and language therapist at the Michael Palin Centre for Stammering Children and works with children, adolescents and adults who stammer. She is also involved in research evaluating the effectiveness of therapy at the Centre and investigating the temperament of children who stammer. Alison says: I was particularly interested in this paper given my clinical experience of working with children who stammer and the speech and language profiles they often present with. It describes a study aimed at further exploring the speech and language skills of children who stammer. The issue of whether children who stammer differ from children who do not stammer in terms of their linguistic abilities has been a topic of much interest and controversy for a number of years. This paper investigates whether children who stammer may present with dissociations or mismatches between different areas of their speech and language skills. Participants were 45 children who stammer and 45 children who do not stammer between the ages of 3:0 and 5:11 years and they were assessed using four standardised speech and language assessments. Although the group of children who stammer presented with speech and language skills within normal limits, they generally scored lower than the children who do not stammer on all the measures. Also the children who stammer were three times more likely than the children who do not stammer to have mismatches across the various speech and language areas investigated. Some patterns of mismatches were between their speech sound skills and overall language ability or between their overall expressive language ability and their one-word expressive vocabulary skills. The authors propose that these mismatches may be making it harder for these children to establish or maintain normally fluent speech. This paper reminds us how important it is for speech and language therapists to routinely assess the speech and language skills of children who stammer. Also, although some children who stammer may present with speech and language skills within normal limits, this does not rule out the presence of subtle difficulties or mismatches, which may be undermining their ability to be fluent.



Photo opportunities
Speech and language therapy team leader Alison Matthews and communication development worker Terry Baynham celebrate the opportunities of skill mix for improving service quality, using the example of providing a photo rota for an adult with learning disabilities.


Alison Matthews

Terry Baynham

here are currently only two speech and language therapists working for the adult learning disability service in Oldham (both posts four days per week). We were recently put in the very fortunate position of having a number of support workers seconded to us. These communication development workers are enabling us to provide a tailored service to more clients and to grow as a team. These staff have experience of working with adults with learning disabilities in day centres and supported living and we are developing their role (not to be confused with that of our total communication co-ordinators, on secondment to us one and a half days per month). While the role is similar to that of a speech and language therapy assistant, the communication development worker has more specialist knowledge and practical experience of adults with learning disabilities and undertakes additional training provided in-house, and externally where funds allow. There are now five communication development workers, so in the last 12 months our team has tripled in size. Each development worker has their own caseload supervised by the therapist and team manager and we are beginning to see potential for specialising within the team itself. To give you an idea of how the system works for clients, we will describe total communication work using photographs undertaken by one of the communication development workers (Terry) with Leslie, a fifty year old man with learning disabilities, and his carers. Leslie lived with his mother, who had been his sole carer for some considerable time until her sudden death. He had been accessing social service day provision at an outreach centre without any major problems. Upon the death of his mother the situation became critical and a place within social services supported accommodation was found for him as a matter of urgency. As can be imagined the sudden upheaval placed consider-

able strain on Leslie and also on the service providers. Staff from Supported Living made a referral to the Communication Therapy Team (speech and language therapy) requesting a Communication Dictionary.

Listen to me
Communication dictionaries have been developed in Oldham as a means of recording how an individuals communication is recognised and responded to. The dictionaries are based on the listen to me section in essential lifestyle planning (ELP) and a version developed by Anne ClarkeKehoe in the training pack Bringing People Back Home. The dictionary is divided into two parts; part one looks at the non verbal communication and any spoken language used by the service user and how it is interpreted by the carers and staff team. It also identifies how staff and carers should respond to the service user in order to develop communication in a consistent fashion. Part two of the communication dictionary process involves collating detailed information from teams and families about the persons skills in understanding spoken language. This aspect of the persons communication impairment can often be overlooked thus disabling the individual, usually by over-estimating their capacity to follow conversations and instructions. During part two of the communication dictionary process strategies are agreed and adopted to further develop the service users communication. Leslies team members agreed they needed a method for him to remember, or be reminded of, who was on duty in his new home whilst he wasnt there. This issue was causing him considerable stress, which in turn led to incidents of both aggressive and challenging behaviour. I asked Terry, one of the communication development workers seconded to the communication therapy team, to develop a strategy to assist Leslie.

Each development worker has their own caseload supervised by the therapist and team manager



Photographic rota
Figure 1 Using photographs issues to consider

Symbolic development
As we develop we go through stages of understanding how things can be represented. Some of the people we support will be at different stages on this path of development. The first stage is understanding the real object (knowing what it is for). We then understand photos of that object, later a drawing, a symbol and a finally written word that means that object.

As with symbolic development, understanding perspective is a skill some of the people we support may not have. We know that people in the distance look smaller than people close up, but this may be confusing for some people. Try to get as near to the thing you are taking the picture of to make it fill the whole photo.

Focusing on part rather than the whole meaning

The photo may have something in it that the person focuses on rather than what was the intended meaning (for example, being interested in a packet of crisps on a table in a photograph which was meant to represent kitchen.)

Visual difficulties
Does the person need to wear glasses? Find out whether the person you are supporting has any age related eye problems such as cataracts. This will distort what the photo looks like. Some people dont have an actual problem with their eyes, but the messages going from the eyes to the brain get distorted or the brain cant deal with them properly. Some people find it hard to focus on photos because the muscles controlling their eyes arent working properly. You may see their eyes rapidly moving from side to side. This is called nystagmus. For further information, the Royal National Institute for the Blind has a useful Helpline, tel. 0845 766 9999.

Expressive, receptive or both?

Photos can be used to help someone understand (receptive language). They can be used for people to give us information (expressive language). For example we may start telling someone that we are going to the park by showing them a photo of the park (receptive). In the future they could point to the picture of the park to say they want to go there (expressive).

Where / How ?
Do the photos need to be accessible to people on the wall, or in a book or wallet? Could they be on colour coded card? Do the people who will be using the system need training? Discuss which photos are a priority and start with them. Think about the things the person would be motivated to talk about.

We agreed that a photographic rota might help. Leslie would be able to put a picture of the member of staff from the rota into his wallet to remind himself. He would also be able to convey that information to day service staff. Prior to the introduction of the photographic rota the incidents of challenging or aggressive behaviour had escalated to, on average, three per week, mostly due to Leslies inability to remember and impart the information to staff. This conduct had the knock-on effect of disrupting the lives and services of other service users and staff. Terry arranged several visits to see Leslie, both in a home situation and in the day centre. He issued both staff teams with a digital camera and asked them to supply photographs of each member of staff against a neutral background. The day service staff team also supplied photographs of activities undertaken by Leslie on a regular basis in order to assist him in planning these activities. In photography for total communication purposes, extra care needs to be taken with the quality. Staff were advised to ensure good lighting, with the subject in the centre and in focus, and no distractions in the foreground or background. The staff photographs were printed credit card size and placed in a wallet. They were accompanied by instructions on their use, which amounted to: Give Leslie a photograph of the staff member carrying out sleeping in duties on that day to place in his wallet. This should be done in the morning at a regular time to develop consistency. Tell Leslie that the photograph is there and who it is. Replace the previous days photograph in the wallet. Encourage Leslie to look in his wallet for the photograph rather than struggle to tell staff who is on duty. (Initially at least.) Day service staff or volunteers should be encouraged to ask Leslie to show them who is on duty if he cant remember, by using that days photograph. Initially Leslie thought that the photographs were his to keep in his wallet but was quite happy after a short period to exchange the previous days photograph for the current days. He has however become quite attached to one or two of the staff photographs and copies have had to be made as he would not return them. This has helped the process by identifying staff to whom Leslie is particularly attached. He is now much calmer and the stress caused by his inability to remember the staff member has now gone. He uses the photographs daily and is proud to show other people. He is also using photographs to tell staff where he would like to go and Terry is building up a library of these. There are still occasional lapses (approximately one per week) but these are easily dealt with by reminding Leslie of the photographs in his wallet. This process also helps the staff team by keeping the strategy fresh in their minds.



In control
The major achievement of the process has been the reduction of incidences of challenging behaviour. There is now consistency of approach by staff, both at his home and his day service. Leslie is in control because he holds the relevant information and the service users around Leslie now have an improved quality of service too, as incidents of Leslies challenging behaviour have decreased dramatically. As with Leslie, the use of photographs to enable service users to understand who will be supporting them can be a good starting point for introducing photographs as a means of communicating. Our team has developed information for staff to consider against individual clients when they are introducing photos for communication purposes (figure 1) and a checklist for developing a photo rota (figure 2). The checklist includes practical questions that should ensure there is also planning for maintenance of the system. Although we are anxiously awaiting the results of a service review which may mean we are allocated additional resources for speech and language therapists, our experience of communication development workers confirms that, rather than being a compromise or a threat, skill mix is something to celebrate. Alison Matthews is speech and language therapy team leader and Terry Baynham is a former communication development worker with the Oldham Communication Therapy Team, The Hollies, Frederick Street, Oldham OL8 4BD, e-mail The Oldham team will shortly be opening a Communication Resource room, and are collecting photos of places and activities to create a web-based library.

Figure 2 Photo rota questions

1. Does the person you are developing the rota for recognise team members photographs? Take photos first to find out. Take well-lit photographs which are uncluttered. Go through them with the individual, and try asking questions to see if the service user knows who is who. 2. What size photos can you use? How big or small can they be? Digital cameras are really useful as you can produce different sizes of the same photograph. 3. Do you need to separate the day into morning, afternoon or evening? Perhaps morning, daytime and night-time might be more meaningful. Maybe you will need to separate out each section with a line or box. 4. Do you need a symbol or line drawing to help indicate morning, daytime or night? 5. Would different colours for each section help or confuse the person? 6. How many days at a time will you lay out? For example if you do the full weeks rota, are you sure the person can understand the idea of a full week? Would it be best to start with a day at a time? 7. Do you need to pair up the member of staff with an activity, or would this be too complicated? 8. Do the photographs need to be laminated? 9. How will you fix them onto the chart or rota board? Do you need to use Velcro? Can the service user be encouraged to take part in this? 10. Where will the rota be on display? Where will you store the photos that arent being used? 11. When you start off the rota, who will be responsible each day for ensuring it is used? 12. Are there other people who need to know about the idea of a photo rota, such as the persons family, friends, college, the day centre? 13. Do you need spare copies in case the originals are damaged? 14. If the idea to introduce a photo rota came from the repeated requests by the service user for information about who is on duty next? or whos on the sleep tonight? bear in mind that this may be a way of the person engaging you in conversation and, rather than reducing the requests for information, it may increase them, or they may find another repetitive question as a means of asking for interaction. Treat this as a request such as talk to me. It may also be a means of the person expressing anxiety about what is happening next.

Essential Lifestyle Planning see (accessed 11 January 2006). Szivos, S. & Clarke-Kehoe, A. (1990) Bringing People Back Home - developing communication skills. South East Thames Regional Health Authority with the Centre for Applied Psychology of Social Care, University of Kent.





Applying project management skills

Already a good organiser and time manager, Satty Boyes was surprised to discover the extra benefits of learning about and applying project management skills to real-life projects, big and small. Here, with her management consultant husband James, she explains how the experience can enhance personal development and everyday practice and ultimately lead to better outcomes.


ne of the Allied Health Professional ten key roles identifies a role in managing projects (DH, 2003). Consequently, there has been an increasing focus on developing project management training and skills for allied health professionals. Although it is clear why managers may need project management training, it may seem less obvious why clinicians would benefit. Allied health professionals undertake many developments that require them to structure and plan their time. They do that largely without realising that these could be managed as projects. Instead, they try to rely solely upon their organisational and time management skills. Unfortunately, without an understanding of how to manage projects, those developments often become complicated, never-ending and stressful. I have learnt that using those traditional skills isnt always enough. The more complex the job, the more value the project management approach offers. In April 2004 I was seconded to a project team to develop a competency-based postgraduate dysphagia course. Initially, the project team was confident that we had planned the project very well. We felt we were very clear about the tasks ahead of us. My husband James is a director of OLC (Europe) Ltd, a management training and consultancy company that specialises in project management. I talked our plans through with him and he suggested that we might benefit from formal project man-

agement training. While the team was somewhat sceptical of the benefit of the training (after all, we believed we had already planned the project very well!) we took up James offer. Although before the training we were confident about our plans, after the training we realised the enormous impact that a carefully planned approach would offer both to managing the project and to the outcomes it would ultimately deliver. On a broader level, the skills developed from the training have transferred easily into my everyday work as a clinician, transforming the way I manage tasks and service development. For example, the project management approach has enabled me to structure more clearly the way my personal appraisal objectives are achieved which has greatly aided my own personal development. The training has also enabled me to develop strong project plans for service improvements such as introducing dysphagia screening across the hospital.

Good planning is also integral to quality improvement as shown by Demings cycle of continuous improvement (1992). Effective managers start by planning their actions. Those plans are then put into practice. Next, the manager monitors progress to check the plan is delivering the desired result. Finally they act upon the result, either by implementing the plan more widely or changing it as required. When used repeatedly, that cycle improves quality over time (see figure 1).

Figure 1 Plan-Do-Check-Act cycle for continuous improvement


The Oxford Dictionary defines a project as: a plan; a scheme a planned undertaking. Planning is therefore integral to effective project management. That sentiment is expressed by the Quality Guru Juran who argues that planning is the most basic and important managerial function (Juran, 1992, p.1). The project management methodology works in just the same way. To show that, in figure 2 each P-D-C-A (Plan-Do-Check-Act) phase is discussed using our own project as an example.




Figure 2 Plan-Do-Check-Act cycle for our project

We began the project by describing our overall objective in one sentence. James asked questions (who, what, when, why, where, how) to ensure clarity. We adopted that sentence as our mission statement (figure 3). Next, we identified the project stakeholders and checked that they were in the steering group. That was important because, for any project to work, it is vital that the people who need to support it are identified and signed-up to it. That allows everyone to take responsibility for the projects success and accept ownership of it. The next step was to map the project out. In order to draw the project onto paper we first had to understand it and its complexities very well. Ultimately, you cannot manage what you dont understand. We started by using our mission statement to develop specific project objectives. We then identified tasks for each objective. We used Post-it notes and a board to do this - our mission went at the top, objectives went underneath while tasks were listed by objective. Postit notes could be moved about and made our drawing easier to change. That became our MOT board (Mission, Objective, Task). As we worked, we saw our project grow and develop structure (figure 3).
Figure 3 The MOT (MissionObjective-Task) Board

The next stage involved mapping tasks against time. We re-used our Post-it notes by putting them into the order that they would need to be completed in (rather than grouping them by objective). That showed us which tasks could run concurrently and helped us to graphically map out the work ahead of us in a logical and time effective sequence (this formed the basis of our Gannt chart shown in figure 5, p.12). The project had initially been set a time-frame of 16 weeks. It quickly became obvious that that deadline was arbitrary because the time-map showed that the realistic minimum projected duration was 23 weeks. We built in some buffer-time and concluded that the project would need at least 25 weeks to complete. We then approached the steering group with comprehensive plans and successfully negotiated more time. The alternative was to drop some objectives thereby limiting the projects scope.

met just after the milestones. That made review meetings very productive. We were able to review our progress at crucial project stages and approach the steering group only when decisions were needed or feedback required. Next we established how to measure our success. We listed factors crucial for project success and defined how each could be measured (see figure 4).

Figure 4 Sample project critical success factors (CSFs) and key performance indicators (KPIs) CSF 1 Number of questionnaires filled in correctly and returned promptly Number of acceptably completed questionnaires returned as a percentage of those sent out


for any project to work, it is vital that the people who need to support it are identified and signed-up to it.
Despite us believing (before training) that we had fully planned the project, our new approach vastly improved our understanding of what was required, in what order and how that would actually be done. Without training we would have committed to the impossible job of doing 25 weeks work in 16 weeks. We would have risked failing to deliver the project on time. The next task was to develop measures to check performance. We reviewed each task and identified when chunks of work would be finished (for example, course content completed). Those events became project milestones. We used those to timetable meetings with the steering group. Rather than meeting at regular fixed intervals we

CSF 2 Sufficient numbers of participants and supervisors apply to enable the course to run 100% of course participants have allocated supervision


CSF 3 Sufficient admin support is available to support planning and implementation The admin support required by the project team is able to be met by the 7 hours per week funded


The final stage involved risk assessment. We identified threats to the project and ranked them based on their likelihood of occurring and their potential impact. By thinking about risk in advance we were able to minimise those threats. Priority threats were dealt with by adapting the project plan (for example, providing supervisor training) while some (such as staff sickness) could not be influenced. In both cases the team felt more in control; forewarned is forearmed! Finally, the plans were condensed into a single document the Project Brief. This identified: Stakeholders Project manager and team Project start / end date Critical success factors and key performance indicators Objectives, tasks and deadlines. We distributed the brief to all stakeholders and used it to communicate our plans and the expected outcome.

Our enjoyment of doing the project was greatly increased by the planning we had already done. With hindsight I can see that we may have a tendency to



Figure 5 Extract from the Gannt Chart showing tasks, timescales and responsibilities

PRACTICAL POINTS: Project management

Project planning promotes the delivery of specific objectives within realistic
timescales through the comprehensive forward planning of all activities.

Project management skills are as useful to clinicians as they are to managers. Effective planning is best achieved when a team adopts a structured approach. The P-D-C-A (plan-do-check-act) cycle leads to continuous quality improvement.
jump straight into the doing phase of a project and we suffer as a result. To guarantee success you have to plan - doing becomes much easier and less stressful if you know what to expect in advance. We used a live Excel spreadsheet to document the ongoing project. We listed every objective and task, and created a Gannt chart (figure 5). As we completed tasks we crossed them through, thereby charting progress over time. Ultimately, we were able to evaluate our strengths and weaknesses. That has enabled us to learn from our experiences and improve (and start the P-D-C-A cycle again). I have also been able to apply my learning more broadly to my everyday work this is continuous improvement in action.

Deming, W.E. (1992) Out of the crisis. 18th edn. Cambridge: Cambridge University Press. Department of Health (2003) The Chief Health Professions Officers Ten Key Roles for Allied Health Professionals. Department of Health. Gateway reference number 1769. Juran, J.M. (1992) Juran on quality by design the new steps for planning quality into goods and services. 1st edn. USA: The Free Press.

The team delivered its project on time and within budget. Planning helped us break a complex project down into manageable chunks and work together efficiently. Planning made us more productive, gave us greater clarity about the projects scope and allowed us to use our time more effectively. A comprehensively planned approach reduced the potential stress the project could have caused and allowed us to enjoy the work we did. Satty Boyes is Clinical Lead Adults with Acquired Disorders, Salford PCT, and James Boyes is Commercial Director OLC (Europe) Ltd,

We identified our checking mechanisms very early on milestones, steering group meetings, critical success factors and key performance indicators. By planning those in advance, all of our measurement tools were quickly in place. That allowed us to focus on doing the project to the best of our ability.

Project Team: Satty Boyes (Salford PCT), Sue McCormick (North Manchester PCT), Sarah Wallace (South Manchester University Hospitals NHS Trust) Project Manager: Karen Davies (Trafford PCT) This project was funded by Greater Manchester Strategic Health Authority and supported by COMSALT OLC (Europe) Ltd provided invaluable project management training and support.

As the project progressed we acted on our checks the project plan was changed as we went.

news extra
Tinytalk nursery first Call for
As baby signing classes continue to attract interest and debate across the UK, one provider, TinyTalk, has announced its first accreditation of a nursery in Scotland. Scottish TinyTalk Nursery teacher Nicki Sinclair provided the training for staff at the Small World Nursery in Brechin. The package includes ways of recording and reporting childrens progress, and is set in the context of SureStarts Birth to Three Supporting our Youngest Children. Lyn, the manger and owner of the nursery, says she is delighted with the progress shown in the baby room within a few short weeks. Katie Mayne, founder of TinyTalk, adds Baby signing bridges such a wide gap, between when babies can understand so much (from around 6 months old) until when they can actually verbalise their needs (generally between 18 to 24 months). Baby signing reduces the frustration levels of both the babies and their carers as babies have a way of making sense of what people are saying as well as a means to be understood. For more information about the initiative contact the TinyTalk Nursery Programme Coordinator, Lucy Marriott on 01285 770899 or email

Welfare concerns
The National Autistic Society has expressed concern about the Welfare Reform Green Paper, published in January. While the charity welcomes the focus on providing additional support to help people into employment, evidence from the Societys employment consultancy Prospects shows that helping people with autism find work often requires specialist, ongoing support and the Society is doubtful that this support will be available, or that staff involved in the assessment process for accessing benefit will be sufficiently trained in autism. Mia Rosenblatt, Policy Officer for Adults, says, The NAS is concerned that individuals with autism may be penalised for not appearing to be fully engaged in the proposed work preparation process, when their behaviour is a consequence of their disability. NAS research has shown that existing knowledge of autism among Disability Employment Advisers is low. Only 33 per cent of Advisers felt they had sufficient knowledge to support clients with autism to find work. The NAS has information packs available for people with autism who are looking for work and for employers with advice on supporting an individual with autism in the workplace. To download information packs, visit

standard information
Parents of under fives want more information about their childs communication development according to the charity that helps children communicate. As part of its awareness-raising Make Chatter Matter Week, I CAN commissioned a survey of 476 UK parents of children under five. More than half said they received no information on communication development during their childs first year, and eight in ten respondents said they would find it essential or very helpful to receive information about the stages of their babys communication development. I CAN is calling for parents to receive standard information on communication development as part of the material they receive as new parents.





Heres one I made earlier...

A good fun activity for a group at the end of a course of therapy. It is essential to have a solid table with a flat surface for this game, otherwise you will spend the whole session rebuilding the tower! For the same reason, only do this activity with clients who have a steady hand. A game of Jenga (Hasbro, approx. 6.99), or, if you are very enterprising / impecunious, you could cut the little blocks yourself but you would have to be fussy about sanding them thoroughly so that they will slide out of the tower easily. A black felt tip pen.


This is a relatively expensive activity, but was very much enjoyed by our clients, and you might ask for contributions towards the cost. It is best done in a group, as a sociable activity. The idea is to decorate the t-shirts as a form of self-expression, showing the clients main interests. You may need to help the clients with the task, so that they end up with something they would actually wear. However, you may find, as we did, that they are very artistic, and dont need much help.

Cheap cotton t-shirts one for each client. White ones make the most impact. (Its best to wash them first, as the decoration will stick on better.) Fabric paints and pens in several colours. Hardboard or large trays and paper. Somewhere large and flat to store the shirts while they dry.

There are two plain sides on each Jenga block, and all you do is write forfeits on them. You can collect ideas for these from other games such as The Ungame (Talicor), Lets Talk (Winslow), All about Me (from Incentive Plus), or you can make the ideas up yourself. It is helpful to have forfeits of different types, for example category areas such as My favourite food or Name 3 farm animals as well as more philosophical ones such as If I won a million pounds I would or If I had a time-travel machine I would go Also give some social skill types such as Greet everyone in the group in a different way, or What would you do if your friend was in a bad mood? and some silly ones such as Walk round the table like an old lady or Make a noise like a chicken.

1. Make lists of your clients interests. We had horse riding, various pop bands and other music, dolphins, cats and dogs, cookery, and many more. They will be decorating their own shirts rather than each others, so it doesnt matter how individual their ideas are train timetables are acceptable if thats what turns you on! 2. Clients should outline their designs in pencil on paper first, not straight onto the fabric. Simple outlines and lettering work best. Not all the ideas will be easy to make into pictures, so some can be left as lettering. 3. It is also wise to let the clients try out the feel and effect of the fabric pens on some paper before using them on the shirts. 4. Before you start decorating the shirts place them on pieces of hardboard, or large trays, to keep them flat. Also, insert some paper between the layers of the garment to prevent the colours leaking through to the back. 5. Copy your design from the pencil and paper prototype, starting at the top to avoid smudging it. [Warning - dont fold it while it is wet; keep flat until dry. If they want to decorate both sides, you will need to do the second side the following session.]

Play as for ordinary Jenga, but after you have pulled out a brick you have to carry out the forfeit. There is a forfeit on each side, making a choice. I have had no trouble with the same forfeit coming up more than once in a session, because there are no right answers to the questions, so you can have several peoples thoughts on the same subject. The one who knocks the tower down has the job of rebuilding!


This is a lateral thinking game for a group of fairly able clients who must already have grasped the notion of the traditional odd one out. The idea is that the clients stretch their minds to seek the less obvious oddities. This can help with observational skills. The core ability to think laterally is also, I believe, helpful in being able to think of conversational topics. I have found that a good discussion about difference / similarity / uniqueness can emerge from this.

Odd one Out cards or sets of objects that show easy and obvious odd ones out you could use themed objects such as cutlery, plastic farm animals, tools, make-up etc.

Place a number of objects in a theme together; say four red toy cars and one of a different colour, and add a red lipstick or a red flower. It is a moot point as to whether the differently coloured car, or the flower is the odd one. You could try office equipment, all but one beginning with the letter s (scissors, sellotape, pencil, stapler, stamp) and one other thing beginning with s (for example a scarf). The pencil is odd because it doesnt begin with s, and the scarf is also odd in not being office equipment. Or what about party and party games equipment balloons, straws, whistles, party blowouts and crisps; and a recorder. Is the recorder odd (non-party) or are the crisps odd (edible)?

There is a type of glue that you spread onto photocopied designs, and then iron on. We found this a good idea for some, but you need to follow the instructions carefully, otherwise the paper sticks on and is hard to shift. If you use this method you need to complete the ironing part of the process before adding any other fabric pen designs, as some fabric pens are heat intolerant.

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.



The interface between Sure Start programmes and their local speech and language therapy services is an important one. Each programme will develop their own links and procedures for liaising with the NHS services. To date different models of practice have arisen in response to local needs and priorities. (Law, 2001, p.5) Working in collaboration with local speech and language therapy services, Sure Start therapists Samanatha David and Marie Hackshall researched the potential of telephone contact with the offer of a home visit to reduce nonattendance at initial appointments.

The call for home de

Marie Hackshall and Samanatha David





wo areas within Margate, Kent have Sure Start programmes established. Sure Start Millmead (SS1) is a trailblazer programme which was set up in 2000 and Sure Start Margate (SS2) is a 5th wave programme, established in 2002. Both areas have an identified high level of need and this is supported by a Thanet Jarman score (scale of deprivation) of 21.32, which is over twenty times the national average (DH, 2000). Collaboration between the local speech and language therapy service and Sure Start from the outset of the programmes identified the need for an alternative approach to ensure families have access to local speech and language therapy services. The traditional model of service delivery within the Margate area of East Kent Coastal Teaching Primary Care Trust was clinic and playgroup based initial assessment and therapy. Families were offered an initial appointment within three months of referral. Initial contact was made with the childs family via an appointment letter, which was sent 2-4 weeks prior to the first appointment. An audit exploring the rate of non-attendance at initial clinic speech and language therapy appointments was carried out in July 2003 by Maggie Johnson (speech and language therapist). Non-attendance was found to be at 33 per cent (0-16 years) across the whole of the Margate area. However when this was analysed further in specific geographical areas, it was found that within the Sure Starts Millmead and Margate, non-attendance for children aged 0-4 years was 53 per cent and 40 per cent respectively. Following this study, a proposal for a research post to investigate different models of service delivery, service uptake and customer satisfaction within speech and language therapy was developed. As Sure Start is not intended to replace existing service, rather. add value to what is already available (Law, 2001, p.5), it was agreed by Sure Start and local speech and language therapy managers that a number of new approaches would be trialled alongside the traditional clinic service currently in place. Sure Start Millmead and Sure Start Margate agreed to fund a research project for a 12 month period (July 2003 Aug 2004) which aimed to improve take up of initial appointments. Within the Millmead Sure Start area existing speech and language therapy time and resources funded by Sure Start were used (0.2 whole time equivalent), whilst Margate Sure Start funded 0.2 whole time equivalent specifically to investigate and improve attendance. The new pathway of care for initial assessments was carried out by two senior speech and language therapists. During the study we found it beneficial to have two therapists involved as it provided an opportunity for support and supervision.

way for initial assessment project. The changes to service delivery with this client group included: 1. Where possible we contacted all families by telephone within one week of a referral being processed. For those families whose phone number was unavailable (SS1: 9 and SS2: 5), we sent a letter requesting the family to contact the speech and language therapist to arrange an appointment. If no response was received within two weeks, we sent a standard appointment letter offering an initial appointment at a local clinic. In some cases at Sure Start Millmead a home visit was offered because the therapist felt that this would be a more appropriate venue for an initial appointment. 2. Those parents contacted by telephone were offered the choice of having the initial assessment appointment at the local clinic, at home or in the childs preschool setting. 3. Appointment times and dates were arranged by telephone and confirmed in writing. All appointments were carried out within one month of receipt of referral. 4. Feedback about the assessment process was obtained from parents / carers via an anonymous questionnaire, sent out with a stamped addressed envelope, following the appointment. We evaluated the effectiveness of this approach in reducing the number of people who did not attend initial speech and language therapy appointments over a 12 month period in September 2004: 1. Telephone contact We contacted 38 families in SS1 and 35 in SS2 by telephone to arrange an initial appointment. The average time from referral process to contact was 26.1 days (SS1) and 8 days (SS2). Of those families who returned the questionnaire (SS1 = 23.3 per cent and SS2 = 42.5 per cent return rate), 90 per cent (SS1) and 83.3 per cent (SS2) felt it was useful to receive a telephone call to arrange the appointment but also to discuss what the assessment would involve. 2. Number of did not attends Figure 1 depicts a difference recorded in the did not attend percentage between 2002/3 and 2003/4. When home visits were offered alongside clinic assessments 10.6 per cent (SS1) and 7.5 per cent (SS2) of children did not attend, in comparison to 53 per cent (SS1) and 40 per cent (SS2) for the year 2002/03. As a comparison, within the local clinic where the traditional pathway was used, the did not attend rate remained relatively consistent for the two years (2002/3 = 25.7 per cent and 2003/4 = 24.6 per cent).
Figure 1 Number of did not attends

Sure Start pathway

All children who were referred for a speech and language therapy assessment aged between 0 and 4 years living in the Sure Start Millmead (SS1; n=47) and Sure Start Margate (SS2; n=40) catchment areas were included in the Sure Start pathSPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006



3. Uptake of home appointments The choice of assessment venue is shown in figures 2a (SS1) and 2b (SS2). Families were offered a choice of clinic, home or playgroup. There was a clear difference between the take up of home and clinic visits, with the majority of parents preferring a home visit.
Figure 2 (a) Sure Start 1 Chosen assessment venue

use of the telephone when booking appointments can be a contributory factor when attempting to increase attendance. Our findings indicated that of those who did not attend, 80 per cent in SS1 and 100 per cent in SS2 could not be contacted by telephone, either because the family did not have a telephone number or because it had changed since the referral and other professionals did not have the new number. The most popular location for assessment was the clients home. Parents gave a number of reasons for this choice, which included convenience and the performance of the child. From this we conclude that previous non-attendance was generally not due to a parental reluctance for their child to be assessed but rather inconvenient appointments or venues.

Figure 2 (b) Sure Start 2 Chosen assessment venue

Opportunity to discuss
Every attempt was made to contact families within four weeks to arrange the initial assessment. We feel this may have decreased the likelihood of carers either forgetting the appointment time or deciding over time that their child no longer required the service. Stathopulu et al. (2003) support this in that, if the child had waited more than four weeks for an assessment they were more likely to fail to attend. However within this it has to be considered that therapist and parental time commitments do not always allow this to happen. What seems to be of importance is giving the parent an opportunity to discuss their childs language development or the assessment process as soon as possible after the referral has been made.

The questionnaire responses gave us some reasons as to why parents preferred the home visiting option. These included: relaxed environment convenience (including transport issues and timing) response of the child. 4. Analysing did not attends Five families in SS1 and three families in SS2 did not attend an initial appointment; either they were not in for the home visit, or they failed to attend a pre-arranged clinic appointment. Of these all but one did not have a contact telephone number, and therefore the appointment had been arranged by letter and not by telephone. None of the families who did not attend had moved out of the area. The therapist contacted the families of all those who did not attend an initial appointment to offer one further appointment. In both SS1 and SS2, 100 per cent attended.

the increase in attendance recorded across the year at initial assessments is due to a combination of a number of changes in service delivery.
Marie with a parent and child at their home It is evident that both within the Sure Start Millmead and Margate areas an alternative model of service delivery has proved to be a positive move in reducing non-attendance. Whilst this was our original aim, we have also concluded that involving parents in arranging the appointments not only reduces the barriers to accessing the service but also empowers them to take an active role in their childs development. By initiating contact

to discuss the appointment time, parents had an opportunity to find out about the assessment and give their views regarding their childs development prior to the assessment taking place. During the assessment there were opportunities to model strategies within the home for promoting language development. It is evident from clinical experience that parents often feel they need specific toys or activities to carry out therapy. This illusion is broken down within the home environment and parents become empowered to develop their childs language through everyday routine and play. We believe that the research has been beneficial for all involved. The East Kent Coastal PCT speech and language therapy department has increased parent / carer satisfaction and efficiency in provision for this client group, whilst Sure Start has a more localised service which addresses the needs of the immediate community. Following the project evaluation, it was decided that the option of a home visit assessment would be offered to all pre-school children across the Canterbury, Coastal and Thanet areas of the East Kent Coastal Teaching PCT. We agreed that this would not be of benefit to school aged children, as on the whole the assessment process requires a quiet environment where standardised and often lengthy assessments can be completed. The team also decided that, where possible, initial assessments would be arranged by telephone. We have seen how we can improve attendance for initial assessment, but what about attendance for therapy? Recently it became possible to site speech and language therapy clinics within the SS1 and SS2 areas and as a result to offer people more localised venues for post-assessment sessions; however the effectiveness of this on increasing attendance for therapy is a study in itself!

Department of Health (2000) Compendium of Clinical and Health Indicators. December. (See Law, J. (2001) Promoting Speech and Language Development - Guidance for Sure Start programmes. Available at: (Accessed: 12 January 2006). Morris, T., & Stein, L. (2005) Stepping Stones, Speech and Language Therapy in Practice Autumn, pp. 4-6. Stathopulu, E., Ajetunmobi, S. & Selling, D. (2003) Non attendance in community paediatric clinics in Dartford, Gravesham and Swanley PCT, Quality in Primary Care 11, pp.163-5. Stewart, F. & Williams, L. (1998) Pre-school Assessment Project Comparing Assessment in the Clinic or Home, International Journal of Language and Communication Disorders 33 (supplement).

Changes in service delivery

We cannot attribute the increase in attendance recorded across the year at initial assessments to one isolating factor; rather, it is due to a combination of a number of changes in service delivery: telephone contact to arrange an appointment (with a letter confirming the appointment) offering a choice of venue arranging a time convenient to the carer arranging the appointment within four weeks of referral. Use of the telephone as a key factor in increasing attendance is highlighted by previous studies. Stewart & Williams (1998, p.520) found that attendance rates for assessment were directly correlated with prior contact by phone to establish the appointment. Morris (2005) also found that









NextUp Talker software with AT&T Natural Voices NextUp Technologies, $99.95 + voices

Any text file can be read aloud

This Text-to-Speech computer application for people with speech difficulties converts text into a choice of over 20 natural sounding voices. It can be used as an individuals main communication aid, allowing for pre-planned frameworks of messages - and shortcuts - to help speed up conversation. Clients who have good word recognition could benefit from using this program, however considerable time may need to be invested in training. A spelling checker and predictive text would have been useful for those with spelling and reading difficulties. A portable computer and a suitable access method are essential to ensure participation in a range of communication settings. Great for those assisted by auditory feedback as any text file can be read aloud, assisting reading comprehension. Karen Mann is a senior speech and language therapist at UCLH, London.

covers up-to-the-minute professional issues, making it an ideal resource for every departmental bookshelf! Jenny Bland is a newly qualified speech and language therapist working in Adult Learning Disabilities in Shropshire.

Lets Draw 80 cards, instructions and ideas Speechmark Publishing Ltd 13.50 + VAT

Clients responded well

This is a very useful set of picture cards, designed to promote communication through drawing with both children and adults. They come in a handy, playing-card sized box, with instructions for various activities and games. We tried them successfully with adults with acquired aphasia, to promote drawing for communicative purposes. The images are clear, black and white line drawings, and pictures are grouped into categories ranging from basic shapes to fairly complex images, and including verbs, thus allowing development and progression of skills. Our clients responded well to the activities, and I believe the cards could be equally attractive to children. Given their flexibility, portability and value for money, these cards have proven to be a welcome addition to existing picture resources. I would be very interested in seeing the other sets in the range. Jenny Taylor is a speech and language therapist working with adults with acquired communication disorders in Ayrshire.

Syllabification Leaps and Bounds Multimedia Ltd ISBN 0-9546521-1-8 45.00 (inc. VAT)

depending on the childrens abilities. My only criticism would be that the board sometimes appeared very busy and distracting for those children with more severe interaction difficulties. The adult facilitator role is therefore very important. Gail Boyle has a mixed caseload in Inverclyde, including community clinics and mainstream schools. She is specialising in autistic spectrum disorder and has an interest in dysfluency.

A motivating learning tool

This CD-ROM provides activities to increase childrens awareness of syllables in words and to practise separating and combining syllables. It has several strengths: easy to use instructions and support notes are easy to understand can be used by assistants and parents as well as teachers / therapists has high quality real voice audio options: male voice, female voice, no voice activities have two levels and build in complexity a resource bank of pictures, worksheets and word lists is available to download and print. Key Stage 1 and Key Stage 2 children enjoyed the activities, especially the humorous cartoon at the end of each activity. The CD will be a useful supplement to phonological awareness work for children at Key Stage 1 and for any child with difficulties in phonological awareness. An adult is needed to interact with the child and facilitate learning, however with familiarity the child can work through some activities alone. The activities can be used with one child, paired children or a facilitated small group. Having reviewed this, I am interested in looking at the rest of the series; Disc 1: Listening and Rhyming, and forthcoming discs which will include segmentation and alliteration skills. In our mainstream schools service I would recommend this CD to SENCos, therapists and teachers as a motivating learning tool for a specific area of phonological awareness. Lindsay Malekzai, speech and language therapist, coordinates the Joint Communication Team to mainstream schools in Bexley, Kent.

FEESST: Flexible Endoscopic Evaluation of Swallowing with Sensory Testing Jonathon E. Aviv & Thomas Murry Plural Publishing Inc ISBN 1-59756-000-6 75.00

A straightforward how to do it guide

This is an eye-catching and compact manual of Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST), although perhaps a little on the light side given the purchase price of 75.00. If you fancy trying FEESST this is a straightforward How to do it illustrated guide including chapters on equipment, safety and assessment outcomes. Much of the books content however is aimed at medical practitioners and I was left with questions about the usefulness of this technique in a routine clinical setting. The content that is most relevant to speech and language therapists is largely available in previously published papers. In summary, if you want an easy-toread FEESST manual then this book is for you, notwithstanding the fairly steep price. Annette Kelly is a specialist speech and language therapist working in head and neck cancer and dysphagia in London.

Speech and Language: Clinical Process and Practice (2nd edn) Monica Bray and Celia Todd Whurr Publishing ISBN 1-86156-496-1 19.99

The Time to Talk Game Alison Schroeder LDA 29.99 + VAT

This book is a must buy for all speech and language therapy students and should be on the recommended reading lists of all universities offering speech and language therapy courses. It is written in an easy-to-read style and can be dipped into as and when questions arise. It covers some areas which are not necessarily touched on in formal lectures, and is invaluable before commencing clinical placement. A useful security blanket during the transition from student to newly qualified clinician, but could be of equal use to colleagues returning to the profession after a career break. This second edition

Valuable if providing outreach support

You will find this bright and colourful board game very useful if you work with children aged 4-8 years who have problems with peer interaction and social skills in general. It works best if you can involve peers who can provide a good social skills model, therefore it is not necessarily a clinic game but valuable if you are providing outreach support to schools. Once familiar with the icons and rules, this game is easy to play and at 29.99 + VAT manageable for most cash strapped departments. It comes with a detailed instruction booklet that provides ideas for basic or advanced tasks to complete

Blob Posters Pip Wilson and Ian Long Incentive Publishing 16.00 + VAT

Useful and adaptable

This set of four A3 colour posters features a group of cartoon characters the Blobs - in social




interactions on the Blob Tree. The posters are suitable for use with adults and school-age children and the guide which comes with them includes suggestions for activities, although I felt some of these may be rather too abstract for clients with speech and language difficulties. I have used the posters with groups of 11 and 13 year olds to talk about feelings and social skills such as expressing disagreement and respecting others opinions. I found them a useful resource which can be adapted to the needs of the group as a warm-up activity or the basis of a therapy session. Linda May is a speech and language therapist with Maldon and South Chelmsford PCT.

Language for Thinking - A Structured Approach for Young Children Stephen Parsons & Anna Branagan Speechmark Publishing Ltd ISBN 0 86388 575 6 32.95

Versatile and practical

This resource is useful and relevant in clinics and schools, enjoyable to use and value for money. It provides a good range of scenarios to use and step-by-step instructions (although these have some pitfalls in practice. For example, in the assessment at text level, they didnt state whether or not you took the text away from the child once they had read it). Materials can be extended and used flexibly to address specific areas of language. You need to be aware of the memory load involved for some children. Scoring of the assessment is subjective and example responses would benefit from an explanation of why they have been given a certain score. On assessment, children often appeared demotivated by saying what had happened in the story and then repeating themselves by answering factual questions about it. However, a versatile and practical resource overall. Zo Duckett and Carolyn Angell are speech and language resource therapists at Holmer Green Senior School, High Wycombe.

head injury and brain tumours and these are illustrated by case studies. I would recommend this book to paediatric therapists working with brain injury or disease in acute and rehabilitation settings. Sarah Mason is lead speech and language therapist, Inpatient Team, Birmingham Childrens Hospital.

Practical Intervention for Cleft Palate Speech Jane Russell & Liz Albery Speechmark Publishing Ltd ISBN 0 86388 513 6 32.95

A must have
This book is a must have for any busy speech and language therapy department and will prove to be a useful resource for any therapist working with an individual with a cleft. Following major organisational changes in cleft care the book aims to equip local and cleft link therapists with the knowledge and handout resources necessary to coordinate with specialist surgical centres. The book is divided into 7 easy-toread sections which cover the total care pathway from assessment to therapy. It includes advice for working with teenagers and adults, an area overlooked in many books. Comprehensive appendices offer articulation worksheets as well as advice sheets to give to teachers, practical therapy ideas and a useful list for resources. Some of the sound sheets would be useful in any phonology work. Karen Shuttleworth is the Cleft Link Therapist in South Cumbria.

Common Parenting Issues: Handouts for professional working with children and families Cathy Betoin Speechmark Publishing Ltd ISBN 0 86388 533 0 39.95

General rather than specialist

This is a useful resource pack for busy practitioners trying to address the needs of a diverse range of families. It includes 51 photocopiable leaflets for practitioners to give out to parents and families and covers a range of topics from feeding young infants to managing difficult teenage behaviours. The leaflets can be photocopied from the book or printed directly from the CD-ROM. A number of topics are relevant to communication including: Songs and rhymes to develop language, attention and play skills, Encouraging eye contact: the beginnings of social communication and Helping your child to talk. The leaflets are clear, concise and easy to read. So many topics are covered that this is definitely a general rather than specialist resource. As a result it may be most useful to multidisciplinary teams in Sure Start programmes or GP surgeries rather than speech and language therapy services. Margo Turnbull is an Early Talk Advisor with I CAN in London.

vocal demand and anxiety and stress to voice geneogram. Patients mark a yes / no response for each statement to create a Voice Impact Profile. The varied case examples may have been more useful if they included an action plan. Patients commented on the time for completion (10-15 minutes) but experienced minimal confusion. Several said an additional sometimes response was needed. The resulting profile does clearly highlight areas of concern to them and may prove a useful starting point for addressing specific issues such as referral to counselling. Although designed to measure progress over time, for several questions no change is possible. The questionnaire has undergone preliminary testing, but no mention is made of statistical analysis and I suspect there is some redundancy. Further research is needed to validate its format. Until then the VoiSS and Voice Handicap Index (see references - available free and extensively proven) will remain widely used. Clare Lee is lead voice therapist at the Royal Shrewsbury Hospital.
References Jacobson, B.H., Johnson, A., Grywalski, C., Silbergleit, A., Jacobson, G. & Benniger, M.S. (1997) The Voice Handicap Index (VHI): Development and Validation, American Journal of Speech Language Pathology 6(3), pp. 66-70. Wilson, J.A., Webb, A., Carding, P.N., Steen, I.N., Mackenzie, K. & Deary, I.J. (2004) The Voice Symptom Scale (VoiSS) and the Vocal Handicap Index (VHI): a comparison of structure and content, Clin. Otolaryngol. 29, pp. 169-174.

Children With Acquired Aphasias 2nd edn Janet Lees Whurr Publishers ISBN 1 86156 490 2 25.00

The Puncs offer

Following Valerie Cochranes review of The Puncs by Barbara Cooper in our Winter 05 issue, we have been advised that Speech & Language Therapy in Practice readers can benefit from a special offer price of 25 (inc p&p) for the complete set of 7 books. The books normally retail at 4.99 each.
To take advantage of this offer, see, or phone 0845 159 3740.

A good overview
This is not a book to dip into for quick therapy solutions. It is an academic text that presents a good overview of the current state of knowledge about acquired aphasia in childhood. Lees addresses some of the key issues in this field of work: classification of acquired language disorders is problematic, standard assessment materials are not always appropriate, outcomes are uncertain and the challenge is knowing what to do, when and for how long. In addition, there are useful chapters describing specific causes of acquired aphasias such as stroke,

VIP: Voice Impact Profile Stephanie Martin & Myra Lockhart Speechmark Publishing Ltd ISBN 0 86388 527 6 39.95

A starting point
Written by the well-known authors of Working with Voice Disorders, this book and CD-ROM provide a subjective, qualitative measure of the voice. Both are clearly laid out and easy to use. The 100 questions (in 10 sections) provide a very thorough assessment covering all aspects of voice from




Conference calls:
A multidisciplinary aphasia day conference invited delegates to put the medical model to one side and reflect on how they can influence the broader well-being of people with aphasia and their families. Kevin Borrett reports.

1. The context
The concept of the patient experience as people make their way through the health system is familiar to all of us, yet rarely will a practising speech and language therapist have direct firsthand experience of what our clients go through. Speakers brought a wealth of research and information to encourage us to reflect on how we work with and for people with aphasia. With the medical model safely tucked away, this conference had a distinct emphasis on the broader well-being of the client. It recognised the impact of aphasia, the quality of interaction we can provide through adapting communication and the ways in which we can equip families and carers with the skills to enable a level of communication that each individual with aphasia can be satisfied with. Margaret Meikle FRCSLT, professional advisor and manager, set the conference in the context of the 60th anniversary of the Royal College of Speech & Language Therapists. It was also an honour for the organisers to have Trust Chief Executive Sheila Clark highlighting the incidence and prevalence of aphasia within the stroke population, as well as drawing on personal experiences given by people with aphasia. Presenting the Aphasia Action Groups local 3-year Aphasia Strategy, Lynn Dangerfield spoke of the desire to substantially increase the profile of aphasia to other professional and non-professional groups through support and training. The groups vision is to inspire a confident and dynamic speech and language therapy service to support and develop the skills of anyone involved with aphasia. To enable the successful involvement of voluntary groups and carers, as well as other therapy, medical and nursing services, the group has recognised the importance of leading by example, taking a proactive approach by establishing a clear strategy and adhering to it. It has given new impetus to working with people with aphasia for all speech and language therapists within the service, and a number of in-service training groups and events have been set up over the past 18 months. This training has reinvigorated our ways of approaching aphasia therapy, looking at case studies, conversation techniques, recent research, training initiatives and group work for people with aphasia.

the medical model and its neglect of psychological elements and emotional adjustment experienced by patients. He described the emotional states accompanying aphasia, as well as methods of assessing and working with emotional change following aphasia. He gave a description of what he labelled jollification, the act of denying negative aspects of an experience by shutting down difficult or negative communication. As therapists, we would recognise this as the continued use of social language such as Im sure itll sort itself out and Everything will be okay even in inappropriate circumstances. One of the skills of working with people with aphasia is allowing the exploration of negative communication as it occurs.


Research presented by Dr. Caroline Ellis-Hill provided insight into the experience of stroke, gathering qualitative data in the form of comments from family members. With people reacting very differently to their strokes, Caroline looked at the experience of change after stroke and its psychological and emotional impact on the spouses. Applying the concept of Life Narratives as described by a number of authors in the 1980s, Caroline formed the image of life threads fraying, unravelling and re-joining. This was used to convey the sense of disruption across different elements of peoples lives, and the varied, unpredictable and inconsistent re-connecting of those elements post-stroke. She described two studies - the first conducted life narrative interviews with 10 people admitted to hospital following a stroke (2 of whom had expressive dysphasia), while the second study concentrated on 25 spouses (19 wives, 6 husbands). Half of the patients in the second study had unspecified communication problems. A series of examples from the interviewees exposed the sudden shock, the fundamental changes in life, the effects on lives governed by hospital visiting times, fear of the future and the sense of abandonment felt by the spouses as their partners health is the focus for all attention. Her presentation confirmed the role of therapists in providing suitable support for spouses, whether through basic counselling or knowledge of locally available services and support groups.

2. Psychosocial Impact
Clinical Neuropsychologist Dr. Richard Maddicks, presenting on psychosocial and emotional adjustment in aphasia, talked of the persistent dominance of

Caroline touched upon aphasia lightly, and was primarily concerned with the more general stroke experience. However, the majority of our clients and their carers, partners and families will also have the experience of aphasia to contend with;




Leading by example
the shock of coming to terms with the effects of a stroke is continually held back by the communication difficulty. The irony is that life narrative interviews will have been especially difficult for patients with aphasia, and yet their experience of stroke will have an added dimension. Aphasia will, to a greater or lesser degree, compromise their ability to express true feelings and character, and therefore the picture we get will always have greater potential to be distorted. Sally McVicker, Speech and Language Therapy Outreach Co-Coordinator from Connect, combined recent research and practical therapy techniques for meeting the long-term needs of people with severe aphasia. Applying the activity and participation factors to her definition of severe aphasia, she referred to the loss of opportunity and confidence, the sense of isolation, and being vulnerable to others (non-aphasic) opinions, actions and beliefs. She introduced the audience to an unpublished ethnographic survey undertaken by Susie Parr in 2004 to demonstrate the social exclusion felt by people with severe aphasia. An extract showed how mundane, inadequate and isolating the experience of an aphasic patient can be, how others judge that persons communication skills, and how the lack of social communication can prevent a suitable environment for promoting recovery. although better qualified staff were more likely to show an improved quality of interaction, being more aware of aphasia and its impact on communication. Such research identifies perfectly the need for carefully tailored training, targeting specific gaps in aphasia knowledge and practical skills for different staff groups. A one size fits all aphasia training programme will not meet the needs of our health service colleagues.

sentences), techniques (humour, writing, giving time), and props (magazines, items, pen and paper). Sallys very strong final message was that conversation is intrinsic to everyday interaction, and others learning the skills of supported conversation allows people with aphasia to remain included.

Patricia Sheridan related her personal experience of stroke and subsequent aphasia 12 months ago. A former Social Services manager, she has obviously not allowed her vocal and outspoken nature to be compromised by the aphasia she has been left with. The emphasis here was purely on her personal description of events unfolding, her recollection of detail during the haze of the immediate onset of the stroke and dealing with doctors and medical staff afterwards. Evidently, she was extremely grateful for the help and companionship of her closest friends during this time, and it was a clear reminder that for all the clinical expertise suddenly thrust at our clients, strong relationships also play their part in the rehabilitation process.

3. Teams and relationships

Ann Ashburn, Professor of Rehabilitation at Southampton University, and Clare Gordon, Nurse Consultant in Stroke, presented on multidisciplinary rehabilitation with people with aphasia. Ann discussed patients active participation in rehabilitation with physiotherapists and occupational therapists, and the therapists underlying skills training, including feedback and practice. The therapeutic partnership is important in establishing potential positive and negative indicators for rehabilitation outcomes, and Ann looked at factors affecting this partnership, such as poor motivation and concentration, as well as frustration at lack of improvement.

4. Assessment and therapy

Emma Gale, from the Royal Hospital for Neurodisability, presented her pilot study investigating different methods of assessing auditory comprehension by looking at how Yes/No assessments are provided, and aphasic responses to them. Applying linguistic analysis to determine the easier and more difficult question structures, her aim was to assess whether people with aphasia perform differently on different types of yes/no questions, and whether their performance on these questions gives us accurate information about their overall level of comprehension. It was intended to identify a suitable assessment method for people who have minimal movement, no vision, are not orientated and have severely limited biographical memory. Emmas research demonstrated the need to closely monitor assessment language to enable accurate assessment, looking at difficulty with verbs, the level of semantic processing required and the frequency effect of specific vocabulary. It showed that the range and complexity of closed questions for assessment purposes has a direct effect on the measurement of comprehension levels.

Colin Barnes and Bow Ramm explored the relationship shown in research, assessment and therapy between communication difficulties in dementia and aphasia. For example, Pohjasvaara et al. (1998) identified 30 per cent of stroke patients who went on to develop dementia within three months of their stroke, and dysphasia was identified as a risk factor for dementia. Standard measures for memory and cognitive abilities such as the Mini-Mental State Examination (MMSE) are heavily loaded with language-based tasks and may complicate results for someone with a primary aphasia. The parallels with aphasia were evident in the overall aims that Colin and Bow identified for communication interventions in dementia: exploiting strengths, accommodating weaknesses, encouraging carers to adjust approaches and expectations, promoting appropriate communication opportunities. Intervention approaches also emphasised the benefits of group work as well as one-to-one, equally important for post-stroke aphasia therapy.

5. Further reading recommended by speakers

Beaumont, J.G., Marjoribanks, J., Flury, S. & Lintern, T. (1999) Assessing auditory comprehension in the context of severe physical disability: the PACST, Brain Injury 13(2), pp. 99-112. Breese, E.L. & Ellis, A.E. (2004) Auditory comprehension: Is multiple choice really good enough?, Brain and Language 89, pp. 3-8. Code, C. & Herrman, M. (2003) The relevance of emotional and psychosocial factors in aphasia to rehabilitation, Neuropsychological Rehabilitation 13(1/2), pp. 109-132. Dalton, P. (1994) Counselling people with neurogenic communication problems, in Dalton, P. Counselling people with Communication Problems. London: Sage Publications Ltd. Hinterberger, T., Birbaumer, N. & Flor, H (2005) Assessment of cognitive function and communication ability in a completely locked-in patient, Neurology 64, pp. 1307-1308. Kauhanen, M., Korpelainen, J.T. & Hiltunen, P. (1999) Post-stroke depression correlates with cognitive impairment and neurological deficits. Stroke 30(9), pp. 1875-1880. MacKenzie, S., Gale, E. & Munday, R. (in press) PASWORD: The Putney Auditory Single Word Yes/No Assessment. Pohjasvaara, T., Erkinjuntti, T., Ylikoski, R., Hietanen, M., Vataja, R. & Kaste, M. (1998) Clinical determinants of post-stroke dementia. Stroke 29(1), pp. 75-81.

With communication being crucial to such a relationship, Clare Gordon presented some excellent research into communication between nurses and patients with aphasia. Meaningful communication, training issues, and appropriate levels of social interaction were considered in relation to staff knowledge, qualifications and education levels, the type of ward and its environment, the idea of popular patients and the overall ethos of particular wards. Conversational analysis showed a dominance of nurse-led, task-orientated talk, often with short turns. Interestingly, the results showed that less qualified staff, such as Health Care Support Workers, were more likely to interact with patients socially, beyond nursing tasks,

Sally McVicker gave practical ideas for supported conversation in different contexts: goal setting during rehabilitation, talking about stroke and aphasia, conversations with relatives, talking about an interest. This was further broken down into issues (tiredness, impatience, people finishing




The assurance key

Life coach Jo Middlemiss believes that confidence or the lack of it impacts on everything we do. In the sixth of our series to encourage reflection and personal growth, she asks us to trust ourselves enough to reclaim our self-assurance.
ASSURANCE: The key for Geoff?
Geoff is a fine and effective speech and language therapist. After several years he feels that it is time for him to go for a promotion. However, he is terrified of speaking in public and also of being interviewed. His fear of failure means he stays in his position feeling more and more frustrated with himself. Geoff needs to turn the assurance key. As Maria sang in the Sound of Music (lyrics by Oscar Hammerstein II, 1959), So let them bring on all their problems Ill do better than my best I have confidence theyll put me to the test But Ill make them see I have confidence in me I have confidence in sunshine I have confidence in rain I have confidence that spring will come again Besides which you see I have confidence in me.

It is up to each and every one of us to reclaim and own our assurance.

his is actually Mark 2 of this article. Mark 1 was obviously a perfectly crafted, brilliantly researched piece of academic excellence entitled, Assurance - The key to Joyful Living. Way back in November I was so far ahead of myself I was almost meeting myself on the way back. How I wish procrastination that key to miserable living - hadnt ruled the roost. I didnt send our editor the draft, and a horrible accident occurred whereby I lost the entire contents of my hard drive and all articles including the new one. (Procrastination also caused the absence of back-up. The best piece of advice in this modern world is Back up your documents!) So my 2006 started with Woe is me! - not the positive attitude I normally like to present. So, with every tool in my toolkit, I set about changing my attitude. I had to. It was sickening me and everyone around me. As I was enduring it, I somehow knew it was good for me - that this was a real test of what I believe in, even though it was created through an apparently random set of circumstances. But are circumstances really random? Isnt it possible that, in accepting responsibility without guilt or blame, I am much more likely to get a satisfactory outcome? The reality of cause and effect is that, for this outstanding inconvenience to have some constructive and formative effect on my life, I have to be confident there is a benefit and an opportunity. Time will tell. More and more I am recognising that confidence - or the lack of it - really does impact pervasively on everything we do. I frequently hear that people do remember feeling confident once, or in certain circumstances. Within their comfort zone most people are self-assured. Confident with family and friends, confident with children, old people and animals, confident doing voluntary work or, like Geoff (see box), in an unpromoted position. What is this about?

As I was considering this article, Marias song from The Sound of Music kept coming into my head. Her theme really is that confidence is about faith and trust in your own ability. If you speak to ten different people you will get ten different versions of what confidence is. A family could be complimented on their outgoing, chatty children and another person will think those same children are cocky and irritating. Self-assurance does indeed come in many forms, but lack of it seems to me to be locked up with a fear of being judged by ones fellows. I have worked with many people who are perfectly good drivers but examination fear cripples their skill. My friend is a teacher in a school that is about to be inspected. She is an experienced and talented teacher, so why is she not sleeping? Sensible people allow the assessors to take on the mantle of arch-enemy. They see the situation and the examiner as dangerous for them and therefore their body produces adrenalin and all the symptoms of panic. This not only robs them of the opportunity to achieve their hearts desire but also provides them with something to blame. They can blame their instructor, their examiner, the weather, the car - anything bar examining their own attitude which really is the interference that has stopped the achievement of potential. So, whats to do? What needs to change? Well, firstly we have to get out of our own way. Because we are often obsessed with the views of others - whether that be approval or criticism - we stay stuck and immobile. Everyone is entitled to an opinion. If there is a single person on the planet that you have an opinion about then you must accept that others opinions are equally valid.

Its OK to make a mistake

Geoffs fear of speaking in public stems directly from being laughed at as a child. He subconsciously expects ridicule and




consequently he avoids it at every turn. He has nothing in his rule book that says its OK to make a mistake, so he stays in his low level appointment because his fear of failure stops him from applying for other appointments. He constantly notices colleagues who can speak comfortably without a note and is jealous of them. With a critical eye stemming from his lack of selfassurance, Geoff dismisses them as bluffers who make mistakes. Our work will focus on Geoffs message and not on him. We will explore what it is Geoff has to offer the people he is speaking to as opposed to what they may or may not be thinking about him. I shall also introduce Geoff to some effective mind and thinking techniques. Imagination can help to reduce the fear factor. How afraid would you be if all these people were one inch high, or if the room was full fairies, angels, babies or puppies? Think of the most confident person you know. Visualise that person delivering your presentation or interview. How would they hold themselves, present themselves or prepare themselves? Choose a role model. Act as if. When I had to deliver my first talk I pretended to be Judi Dench and that my audience were loving and appreciative chickens. On another occasion I was coaching a dance student who was also suffering from a desperate lack of confidence. I asked when she was at her best: When I dance as if no one is watching. She had her own answer. Po Bronson (2004) recounts the stories of many people who pushed through their limits and made fairly dramatic changes in their lives. One of his subjects, Anthony Andrews, says (p.85), Its about confidence. With me, its always about confidence. When I approach a situation with confidence, I lean in, I figure it out, I succeed. When I lack confidence, I pull back and withdraw. Andrews goes on to say that his confidence was taken away from him as a boy. It is up to each and every one of us to reclaim and own our assurance. It isnt lost. Its there. It just has to be accessed by removing the blocks by hook or by crook. The starting point is to trust yourself. Be assured no-one else can do it for you.

HPC in Focus
The Health Professions Council now has an e-newsletter to keep people informed about its work. It is available at the beginning of every month. To subscribe to HPC in Focus, e-mail or see

Pre-thickened drinks

SL Drinks are pre-thickened drinks created to help people with dysypahgia reach and maintain their target hydration levels. The manufacturer says they virtually eliminate the risk of preparing the incorrect fluid consistency and other problems allied to mixing drinks using existing thickeners. All drinks, hot and cold, are supplied containing the right quantity of thickener, identified by different coloured cups. The carer only has to add water to a measured line, stir and serve. For more information or to order, tel. 08452 22 22 05

Your web, your way

The BBC and computing and disability charity AbilityNet have launched a new website to help people with disability get the most out of the Internet, whatever their ability or disability, and regardless of the operating system they use. The site offers help with making changes to browsers, operating systems and computers by giving advice on specialist hardware and software. My Web, My Way, see

Aphasia forum Starting out

Aphasia Now is an aphasia-friendly web forum for the aphasic community. The site includes news, articles and research. Key public sector workers in London including speech and language therapists are invited to the Evening Standard Homes & Property Live 2006 Show to find out how they can be helped onto the property ladder. The show is at the Business Design Centre, Islington, from 7-9 April 2006. Meanwhile, speech and language therapists working for NHS Scotland have a new support and development scheme to help further their career and experience. If taking up a post which has been vacant for at least six months, the therapist will receive a one-off allocation of 3000, and further funding will be available to the supporting team. Recently qualified therapists can also be part of Flying Start NHS which attracts 4500 throughout the course of the programme. For experienced staff, the Scottish Executive Allied Health Professionals scholarship makes 5000 available to investigate good practice in the UK and abroad and review existing systems.

Motability advice ABA website School Talk

A new leaflet for health professionals from Motability aims to update them about services to help disabled people become mobile. The charity estimates 1.2 million people have not taken up Motability schemes but could benefit. e-mail

Bronson, P. (2004) What Should I Do With My Life? London: Vintage.

Sharon Gabison, a mother of a child on the autistic spectrum, has developed a Canadian based website for parents / caregivers / professionals interested in ABA (Applied Behavioural Analysis). The site includes free downloads.

Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, Jo offers readers a confidential and complimentary half-hour telephone coaching session (for the cost only of your call.)

The Communications Forum has developed a DVD/CM ROM based training and information resource for all staff working with children with speech, language and communication needs in England at Key Stage 2. School Talk aims to provide practical ways to ensure children are properly supported and included in school life. The resource will be introduced to health and education professionals through ten regional cascade training events. The 25 fee includes one day of training and the School Talk DVD/CD ROM. Details, see

Stammering in Scotland

Training CD ROMS for teachers of children who stammer have been distributed to schools across Scotland. One is for primary staff, one for secondary, and the other for secondary pupils preparing their English oral work. Copies available from the British Stammering Association for 12.99, see


HOW I...



Jamie* (11 months) was developmentally and neurologically doing well for his age. He had however had several chest infections, some requiring hospital admissions. Investigations suggested aspiration may be the reason for his respiratory problems, and had excluded other possible causes. As each episode of respiratory illness appeared to relate to feeding he was by now nonorally fed. Jamies parents and paediatrician wanted detail on the safety of his swallow. Jamies videofluoroscopy showed that milk penetrated into his laryngeal vestibule during swallows. As he propelled milk through his pharynx and on past his larynx, a small volume momentarily flicked under his epiglottis penetrating into his laryngeal vestibule, but appeared to remain part of the bolus. It did not go as far as the vocal cords. The milk in his larynx cleared completely as the bolus continued on into his oesophagus. All other aspects of swallowing were normal and we did not observe any aspiration. However, we didnt know if the penetration suggested Jamie was at risk of aspirating on other swallows. We decided to trial non-oral feeding for 4 months, and respiratory symptoms reduced. Very gradually we reintroduced small volumes orally. The process of returning to full oral feeding was very slow with Jamie reluctant to accept food orally. So were we right to remove Jamies oral feeding? And does the presence of penetration suggest that changes should be made to the management of a childs feeding? Penetration (figure 1) in swallowing physiology occurs when food or drink passes into the laryngeal vestibule, but does not pass below the level of the vocal cords; if it passes below the level of the vocal cords this is aspiration. Figure 1 Penetration on videofluoroscopy (shown with parental consent) Figure 1 shows a series of frames from a videofluoroscopy showing penetration into the laryngeal vestibule during the pharyngeal stage of the swallow. The arrows show: (a) Liquid in the pharynx with the main part of the bolus in the valleculae (above the epiglottis), starting to pass into the laryngeal vestibule. (b) and (c) Liquid penetrating under the epiglottis and into the laryngeal vestibule as the bolus continues to pass through the pharynx (seen as a thin lining under the epiglottis). (d) the liquid clearing from the laryngeal vestibule and passing with the main part of the bolus on into the oesophagus.






The laryngeal vestibule (figure 2) is the space between the laryngeal inlet and the vestibular folds (Standring, 2004). During the swallow the larynx rises and the epiglottis lowers to direct food and liquid past the larynx towards the oesophagus. Figure 2 The interior of the larynx showing the laryngeal vestibule Aspiration has pulmonary consequences, although evidence on the relationship between the amount of aspiration and the pulmonary consequences is extremely limited (Cass et al., 2005). Children who both aspirate and have gastro oesophageal reflux are at particular risk of respiratory consequences (Morton et al.,1999). There is no evidence that penetration that clears and does not pass below the vocal cords and into the trachea has any pulmonary consequences. DeMatteo et al. (2005) compared clinical evaluation of swallowing in children with videofluoroscopy. Penetration and aspiration of fluids, but not of solids, was detected from their clinical evaluations, with coughing the best predictor. However other studies describe many children as not showing signs such as coughing or discomfort when they aspirate (Mirrett et al. 1994).

Figure 3 The 8-Point Penetration-Aspiration Scale (Rosenbek et al., 1996)

1. Material does not enter the airway 2. Material enters the airway, remains above the vocal folds, and is ejected from the airway 3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway 4. Material enters the airway, contacts the vocal folds, and is ejected from the airway 5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway 6. Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway 7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort 8. Material enters the airway, passes below the vocal folds, and no effort is made to eject
(Reprinted from Rosenbek et al. (1996), p.94, Table 2 Final version of the 8-Point PenetrationAspiration Scale. With kind permission of Springer Science and Business Media.)

Increase sensitivity
When reporting on a videofluoroscopy we describe what is recorded during screening, together with observations such as any coughing and the childs cooperation. We are aware of limitations: are the swallows representative of how the child usually feeds? / the setting is not a real mealtime / the food has barium powder mixed into it / we are not seeing a whole meal. We go to great lengths to minimise these limitations and thus increase the sensitivity of the videofluoroscopy (how good it is at picking up children with a swallowing disorder), for example by having parents feeding their child, in the childs usual position, using food, cups and utensils from home. We describe each stage of the swallow oral preparatory, oral, pharyngeal and upper oesophageal and comment on the interaction between the stages; for example oral control was poor, resulting in liquid spilling into the pharynx. The 8-Point Penetration-Aspiration Scale (Rosenbek et al., 1996) (figure 3), gives definition to our descriptions of penetration and aspiration, and may enhance our rating reliability (Stoeckli et al., 2003). Reliability (or agreement) on rating videofluoroscopies is more consistent for some swallowing features than for others. Agreement varies between clinicians. Clinicians may also vary their rating of swallowing features on separate occasions. Of all swallowing features on videofluoroscopy, it is the presence or absence of penetration and aspiration that has the most agreement between observers (McCullough et al., 2001).

So, we can be accurate at identifying penetration from the videofluoroscopy tape, but what parents and colleagues want to know is, what is its significance? This prompted me to search for evidence, with the following questions in mind: 1. Is it normal for children to penetrate? 2. Is it normal at any age or does the pattern change as children get older? 3. If it isnt normal what does it mean does it suggest a risk of aspiration (that is, an aspiration that nearly happened)? If penetration is an indicator of aspiration then, to manage the risk, we may want to modify a childs oral intake by removing consistencies on which they showed penetration. However, this can itself carry potential risks. Thickening drinks can increase the effort of drinking and if, as a result, fluid intake becomes inadequate, we may have to resort to supplementary tube feeding for fluids. If we withdraw oral feeding it can be difficult to re-establish (Mason et al, 2005) and we can disrupt or change the dynamics of social interaction around feeding by introducing tube feedings. In view of this, we need to be as sure as we can be that the evidence used in decision making is as accurate as possible.

Including uncertainty
Decisions on continuing with or modifying oral feeding on the grounds of safety of the swallow are not made on only one piece of evidence or by one person. Rather, the multidisciplinary team with the parents consider the evidence from mealtime observations, investigations and history of chest health (Cass et al., 2005). Our responsibility is to integrate the videofluoroscopy findings with the mealtime observations and to be accurate in reporting and interpreting findings using the best available evidence. Where evidence is weak we have a responsibility to say so. By presenting evidence accurately, and including any uncertainty, parents can make an informed decision about their childs feeding. I found little in searches of databases and texts on penetration in children, and much of it contradictory. Terminology used to describe the depth of passage of material into the larynx was inconsistent across studies, which may account for some of the variations in findings. I also searched adult literature, although there are reservations about applying adult data to children as several aspects of the anatomy and physiology of swallowing differ. There are however more adult studies and evidence can be stronger as, for example, ethical permission for videofluoroscopies with healthy adults is more likely to be obtained.

1. Healthy Adults
In a study of 150 healthy adults (age range 20-79), each swallowing one large mouthful of barium contrast, Ekberg & Nylander (1982) observed penetration into the subepiglottic region of the laryngeal vestibule in eight participants (5.3%), but none into the supraglottic region. Robbins et al. (1999), looking at how the swallows in 98 healthy adults (age range 21-84) were distributed on the 8-Point Penetration-Aspiration Scale (figure 3), evaluated 2 to 4 swallows of 3ml boluses per participant much smaller than a usual adult bolus. Penetration was found to point 2 in 16.5% of the total swallows, to point 3 in 2.8% of swallows, and aspiration in one swallow in an elderly man. All others were to point 1.



This evidence in adults is on a limited number of swallows. The Ekberg study on small volumes suggests that penetration occurs in healthy adults, but to high rather than low in the laryngeal vestibule.

nasogastric tube while continuing with small amounts of pures orally. Sarah will be reviewed in the videofluoroscopy clinic before deciding on whether she will need continued tube feeding.

2. Healthy Children
Arvedson & Lefton-Greif (1998) suggest that, in infants, penetration which clears may be seen on the first couple of swallows, but should be considered abnormal if the amount penetrated increases through a feed. Three studies evaluated children with upper gastrointestinal symptoms. In such studies the child lies down on their side, the pharyngeal stage of the first few swallows of liquid is screened and screening then moves down the oesophagus to the stomach. Only the first (Delzell et al 1999), specifically set out to look at whether penetration is seen in normal swallowing. Of the 34 children (ages 7 days to 16 months mean 4 months), 33 showed penetration; 16 of these penetrated in over half of their swallows, and a further 5 on every swallow. Delzell concluded penetration is a normal finding in infants and children who have no evidence of swallowing dysfunction (p.764). The second study (Newman et al., 1991), of 21 infants (ages 3 days to 170 days mean 50 days), looked at the initial 3 to 5 sucks and found that infants with normal swallowing did not show penetration into the supraglottic area. Neither of these two studies looked at healthy infants.They had all been referred because of gastrointestinal symptoms such as vomiting which can themselves be associated with swallowing problems (Mathisen et al., 1999). In the third study Mercado-Deane et al. (2001) examined the incidence of swallowing problems in 472 full-term infants (under 12 months), referred with vomiting and respiratory symptoms, but no other difficulties. All were first evaluated on upper gastrointestinal studies where laryngeal penetration was found in 19 (13%) of the infants. Videofluoroscopies were carried out on 16 of these 19 infants; 6 aspirated on videofluoroscopy.

Suggestions for practice

Taking the evidence into account, my suggestions for practice are: 1. If we see penetration without aspiration, point out that there is insufficient evidence on whether this is normal in children or not. 2. Report the volumes the child had, and at what point during a feed penetration or aspiration was seen. 3. Quantify the depth of penetration into the laryngeal vestibule; depending on the quality of the image, in practice this can be difficult. 4. Where clinical symptoms or respiratory investigations suggest aspiration, or where we see penetration, give an extended feed of the childs usual feed volume. Screen intermittently to see if the child progresses to aspirate later in the feed. Parents are good at judging when their child is about to reach the end of their bottle / drink; with their guidance we can ensure we screen their last swallows. 5. If planning an extended feed, discuss this with the radiologist at the outset so the videofluoroscopy can be completed within safe radiation exposure limits. 6. Allow for longer appointments as extended feeds take more time in the x-ray room. 7. Apply the evidence on using extended feeds to clinical evaluations it confirms the value of observing feeding across a meal, not just for a few swallows. 8. Not all children need to have an extended feed. Plan each childs videofluoroscopy around the information that it hopes to provide. Children with severe, complex swallowing disorders may only need to be screened during videofluoroscopy on a few initial swallows to describe their swallowing pattern. * Names have been changed. Charlotte Buswell is a specialist speech and language therapist employed by Newcastle upon Tyne Hospitals NHS Trust. She is on year 2 of the MSc in Speech and Swallowing Research, School of Surgical and Reproductive Sciences, University of Newcastle upon Tyne.

3. Children with dysphagia

I reviewed two studies that specifically looked at penetration in children with dysphagia. Newman et al. (2001) reviewed findings from 43 consecutive videofluoroscopies of dysphagic infants (ages 1 week - 11.5 months, mean-5.25 months), with a range of aetiologies. On 2oz of milk, 40% of infants penetrated; half of these infants also aspirated. Of the nine who aspirated, six had some swallows where they just penetrated. Penetration and aspiration did not occur in early swallows; rather penetration occurred at a mean of 50 seconds into the bottle, and aspiration at a mean of 60 seconds. Friedman & Frazier (2000) looked at depth of penetration in 125 childrens (7 days - 19 years) videofluoroscopies, on a range of consistencies. They defined deep penetration as material entering the lower one-third of the laryngeal vestibule, and moderate penetration as entering the upper twothirds. Moderate penetration was seen in 19% of the children, and in a further 31% deep penetration was seen. Aspiration was seen in 85% of the children who showed deep penetration. Deep penetration was associated with thin consistencies and a delay in initiating the swallow, but, interestingly, not with oral motor impairment. These authors conclude that deep penetration is predictive of aspiration in dysphagic children. My team now evaluates clients in the light of the evidence described, and is seeing benefits for clients and families. For example, Sarah* was referred for a videofluoroscopy at 8 months with respiratory illness, felt to be due to aspiration. We screened initial swallows on her bottle and found no penetration or aspiration. Extending the feed, we found that after around 50 mls she started to penetrate during swallows. Continuing with the bottle and screening intermittently, we saw silent aspiration. With this evidence of aspiration, together with that from the respiratory investigations, her parents were able to make a more informed decision about whether to continue to feed her orally with a liquid consistency. Had we followed our earlier practice and only evaluated the first part of her feeding on her bottle, the videofluoroscopy would have missed the penetration of milk and the subsequent aspiration. Her parents decided to give her fluids by


Arvedson, J.C. & Lefton-Greif, M.A. (1998) Pediatric Videofluoroscopic Swallow Studies. San Antonio, Texas: Communication Skill Builders. Cass, H., Wallis, C., Ryan, M., Reilly, S. & McHugh, K. (2005) Assessing pulmonary consequences of dysphagia in children with neurological disabilities: when to intervene?, Developmental Medicine & Child Neurology 47 (5), pp. 347-352. Delzell, P.B., Kraus, R.A., Gaisie, G. & Lerner, G.E. (1999) Laryngeal penetration: a predictor of aspiration in infants?, Pediatric Radiology 29 (10), pp. 762-5. DeMatteo, C., Matovich, D. & Hjartarson, A. (2005) Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties, Developmental Medicine & Child Neurology 47 (3), pp. 149-57. Ekberg, O. & Nylander, G. (1982). Cineradiography of the pharyngeal stage of deglutition in 150 individuals without dysphagia, British Journal of Radiology 55 (652), pp. 253-257. Friedman, B. & Frazier, J.B. (2000). Deep laryngeal penetration as a predictor of aspiration, Dysphagia 15 (3), pp. 153-8. Mason, S.J., Harris, G. & Blissett, J. (2005) Tube feeding in infancy: implications for the development of normal eating and drinking skills, Dysphagia 20 (1), pp. 46-61. Mathisen, B., Worrall, L., Masel, J., Wall, C. & Shepherd, R.W. (1999) Feeding problems in infants with gastro-oesophageal reflux disease: A controlled study, Journal of Paediatric Child Health 35 (2), pp. 163-169. McCullough, G. M., Wertz, R.T., Rosenbeck, J.C., Mills, R.H., Webb, W.G. & Ross, K.B. (2001) Inter- and intrajudge reliability for videofluoroscopic swallowing evaluation measures, Dysphagia 16 (2), pp. 110-118. Mercado-Deane, M.G., Burton, E.M., Harlow, S.A., Glover, A.S., Deane, D.A., Guill, M.F. & Hudson, V. (2001) Swallowing dysfunction in infants less than 1 year of age, Pediatric Radiology 31 (6), pp. 423-8. Mirrett, P. L., Riski, J.E., Glascott, J. & Johnson, V. (1994) Videofluoroscopic assessment of children with severe spastic cerebral palsy, Dysphagia 9 (3), pp. 174-179. Morton, R.E., Wheatley, R. & Minford, J. (1999) Respiratory tract infections due to direct and reflux aspiration in children with severe neurodisability, Developmental Medicine & Child Neurology 41 (5), pp. 329-334. Newman, L.A., Cleveland, R.H., Blickman, J.G., Hillman, R.E. & Jaramillo, D. (1991) Videofluoroscopic Analysis of the Infant Swallow, Investigative Radiology 26 (10), pp. 870-73. Newman, L.A., Keckley, C., Petersen, M.C. & Hamner, A. (2001) Swallowing function and medical diagnoses in infants suspected of dysphagia, Pediatrics 108 (6). Robbins, J.A., Coyle, J., Rosenbek, J., Roecker, E. & Wood, J. (1999) Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale, Dysphagia 14 (4), pp. 228-32. Rosenbek, J.C., Robbins, J.A., Roecker, E.B., Coyle, J.L. & Wood, J.L. (1996) A PenetrationAspiration Scale, Dysphagia 11 (2), pp. 93-98. Standring, S., Ed. (2004) Grays anatomy: the anatomical basis of clinical practice. Edinburgh: Elsiever Churchill Livingstone. Stoeckli, S.J., Huisman, T.A., Seifert, B. & Martin-Harris, B.J. (2003) Interrater reliability of videofluoroscopic swallow evaluation, Dysphagia 18 (1), pp. 53-57.




Rosie (15 years) has Cri du Chat syndrome. She was admitted to hospital in April 2004 for elective spinal surgery. Two days later she presented with increasing respiratory distress (SaO2 80%, increased respiratory rate, requiring frequent suctioning), and was placed nil by mouth by her medical team. One week post-surgery she was continuing to deteriorate and subsequently was intubated and ventilated for four days. I saw her for speech and language therapy swallowing assessment six days after extubation. A swallow was present but cervical auscultation showed it was significantly delayed with severe pharyngeal residue. Rosie also had excessive oral and pharyngeal secretions and a decreased SaO2 / increased respiratory rate with feeding. This was demonstrated by vital signs which were monitored pre/during/post feeding trials. At this stage I recommended she was nil by mouth and referred Rosie for a videofluoroscopy. On videofluoroscopic examination four days later, Rosie took two teaspoons of pure. Poor oral skills were evident, with no sign of bolus formation or attempts at anterior-posterior transfer. There was delay in triggering of a swallow, with residue in the pyriform sinus for 20 seconds, incomplete airway closure, and aspiration before, during and after the swallow. There was no attempt to clear the pharyngeal residue, and only a weak and delayed cough in response to the episodes of aspiration. On the Rosenbek et al. (1996) penetration-aspiration classification, Rosie scored 7. The procedure was stopped at this point due to clinical risk. Following this, Rosie was continued nil by mouth and it was clear at that time to me and the medical team that the prospect of non-oral feeding would have to be discussed with her parents. This assessment process left me with several questions: 1) Rosie was ventilated via an Endotracheal tube for four days. Had the period of ventilation caused any of symptoms seen? This seemed unlikely at this stage post-extubation to be a significant causal factor. 2) What was the effect of Rosies underlying neurological diagnosis on her swallow? Cri du Chat is a chromosome disorder with characteristics which can include hypotonia / failure to thrive / learning difficulties. The literature regarding feeding disorders points towards nutrition as the main issue, although there are some reports of chronic aspiration in the syndrome. 3) How much was acute respiratory illness affecting Rosies swallow? 4) What was recovery potential? At this stage I was pessimistic and felt that Rosie would require long-term non-oral feeding due to the severity of her dysphagia. 5) Was this dysphagia primarily neurological or respiratory? My initial feelings were that Rosie had been chronically and silently aspirating for some time. I felt that the combination of this, her poor nutrition on admission and the anaesthetic had led to an acute aspiration episode that had resulted in her current respiratory difficulties. My feeling therefore was that her underlying neurological condition was the primary cause of her dysphagia, but that it had been compounded by respiratory difficulties. Rosie continued on nasogastric tube feeds. Gastrostomy was discussed with but refused by her parents as they felt oral feeding was of great importance to Rosie, so wanted it pursued if at all possible. We therefore agreed as a

team to do a repeat videofluoroscopy when her respiratory status improved to the extent that: 1. Suction / chest physiotherapy was no longer needed 2. Oxygen saturations were 90% or above in air 3. Secretions were clear in colouring. At this repeat videofluoroscopy (six weeks post-extubation / four weeks post-initial videofluoroscopy), I assessed Rosie with pure (x 4 teaspoons), soft solid (1 mouthful) and fluid (20mls @40% weight for volume). Oral intake was small because of Rosies limited ability to comply, but it was clear that her oral stage had improved, with good bolus formation and transition. Her swallow was initiated within normal limits and there was no aspiration or penetration (Rosenbek et al., 1996, classification = 1). The mild post-swallow residue in her pyriform sinus was cleared, and Rosie was started on a full oral diet and normal fluids as she had been prior to admission. She has had no further complications with regard to safety of feeding, although nutrition remains a concern. I now had some answers to my questions. Contrary to my initial thinking, Rosies dysphagia was primarily respiratory-based. Her recovery was full and correlated with respiratory recovery. So how do we ensure we take sufficient cognisance of the impact of respiratory disorders in older children? First, we need to familiarise ourselves with the anatomy and physiology of normal, spontaneous ventilation, and understand how this appears to change from infancy to adulthood. It is clear to me that children generally have less leeway in their system to enable them to cope without having their system compromised in the event of a respiratory problem. Next, we need to be aware of the aetiologies that put children at risk of aspiration. If a child has any of the following they are likely to have a degree of dysphagia and their respiratory status should be considered as contributing significantly to their potential dysphagia: Chronic lung disease Bronchopulmonary dysplasia Apnoea Airway Malacias Transoesophageal fistula Respiratory distress syndrome Central hypoventilation syndrome Spinal cord injury Neuromuscular myopathies. These disorders may result in the child needing a tracheostomy, ventilation or speaking valves. While a tracheostomy has not been found to cause aspiration (Leder & Ross, 2000), it should be considered as a potential exacerbating factor for these children. As more and more children are having ventilation needs met in the community, speech and language therapists need to develop basic understanding of the implications of ventilation modes, ranging from full ventilatory support, continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP). Children who have high positive end expiratory pressure (PEEP) requirements also present their own challenges; further information about the importance of the timing of trial swallows with such children is in Bleile (1993). There is conflicting evidence about whether tube occlusion / speaking valves (specifically the Passy-Muir valve) are influential in reducing the level of aspiration in a patient with a tracheostomy (Leder et al., 2001; Suiter et al., 2003). However, my interpretation is that, if using a Passy-Muir valve with ventilated patients, we should at least discuss with the medical team the possibility of decreasing the level of positive end expiratory pressure to allow for the restoration of physiological PEEP that the valve may bring.

Fit for assessment

Speech and language therapists should be able to make basic observations and judgements regarding a childs respiratory status and whether they are fit for a swallowing assessment. This should be considered by therapists working both in a hospital and home / school settings with respiratory-compromised children. Guidelines for establishing basic respiratory function are in figure 1 (nos.



1 and 2 reproduced by kind permission of Rachel Hufton, senior respiratory physiotherapist at Manchester Childrens Hospital). In my experience it is best to practise using a combination of patient observations, medical information and monitoring equipment in your own assessment - do not reply on one feature on its own. Figure 1 Establishing basic respiratory function
1. Obtain medical information (medical notes / nursing charts / parental reports) - How is handling tolerated: decreases in saturations / heart rate / respiratory rate? - How long does child take to recover from this? - Incidences of bradycardia (decreased heart rate) - Apnoeic spells (no respiration for > 20 secs /< 20 secs with bradycardia) - Is apnoea related to specific stimuli such as feeding / handling / position? - Temperature - < 36.5C is a contraindication for non-essential handling. 2. Observe for signs of respiratory distress - Recession: ribs and sternum pulled in on recession - Tachpnoea: respiratory rate > 60 - Grunting (attempts to expire against partially closed glottis to increase functional residual capacity of the lungs) - Neck extension - Nasal flaring - Stridor: due to inflammation / obstruction of larynx - Head bobbing: caused by use of accessory muscles of respiration - Pallor specifically reduced colour - Barrel-shaped chest: air trapping, as in bronchiolitis or asthma (NB: those in red are the most significant and are contraindications for a swallowing assessment) 3. Use monitoring equipment. Although this is mainly available in hospital, it can also be used with children at home. Normal values of note (Davies & Hassell, 2000) include: - Respiratory rate: 40-60 (newborn), 20-30 (1-6 years), 15-20 (>7 years) - Heart rate: 100-200 (newborn), 100-180 (1-3 years), 70-150 (>3 years) - Blood gases: ph 7.30-7.40 (newborn), 7.35-7.45 (>3 years) - Oxygen saturations: individual levels should be considered to ascertain what is an acceptable lower level. Do not rely on saturations as an independent indicator of respiratory status. - Cervical auscultation: to establish baseline sounds of respiration. It is essential that you undertake auscultation before oral intake, to provide a benchmark for auscultation during feeding.

3. Residue This may present both via vital signs ( saturations, heart rate / respiratory rate) as well as being audible on cervical auscultation. The residue may develop cumulatively or appear suddenly. The ability to clear this residue should be monitored during the assessment as well as its effect on respiratory status. In addition, videofluroscopy assessment enables more detailed analysis of the oral and pharyngeal stages, specifically triggering of swallow, aspiration / penetration status and pharyngeal function. Features observed may include: 4. Triggering of the swallow The swallow may be triggered appropriately with hyoid elevation beginning when the bolus is at the level of faucial arches valleculae. Research has indicated that elicitation of the swallow reflex is not dependent on stimulation of the anterior tonsillar pillars (Ali et al.,1996). Therefore, in my clinical practice, I accept triggering of the swallow at the level of the valleculae as within normal limits. In my clinical experience, it is likely that triggering of the swallow will be affected, and that the degree of this delay seems to be commensurate with the degree of respiratory impairment that is, patients with severely impaired respiratory function can show significant delay, to the level of the laryngeal vestibule. 5. Incomplete airway closure Alongside delay in initiation of the swallow there is often incomplete airway closure leading to deep penetration (aspirate penetrating below the top of the arytenoids and the top of the thyroid cartilage above the true vocal cords), and aspiration. Patients I have seen with acute respiratory disorders consistently show incomplete closure. 6. Pharyngeal residue This is caused by poor pharyngeal motility / sensation and can lead to aspiration, usually after the swallow. An inability to clear or to recognise this residue has been seen in children with acute respiratory disorders. The experience of working with Rosie and reading up on respiratory disorders has taught me several things: 1. Never underestimate the impact of respiratory disorders - whether acute or chronic - on swallowing. 2. Consider the timing of instrumental assessments, as results obtained when a patient is compromised may be misleading in terms of cause of disorder and prognosis. 3. Characteristics of swallow dysfunction that have a high correlation with neurological impairment are also seen in respiratory-compromised patients. 4. Respiratory dysphagia can exist independent of other factors (for example neurological ones), but has similar clinical features to neurological dysphagia. Consideration of the impact of respiratory status is essential in making an appropriate prognosis and management plan. Rebecca Howarth is a senior specialist speech and language therapist at Manchester Childrens Hospital / Central Manchester PCT.
Ali, G., Laundl, T.M, Wallace, K.L., deCarle, D.J. & Cook, I.J. (1996) Influence of cold stimulation on the normal pharyngeal swallow response, Dysphagia 11(1), pp. 2-8. Bleile, K. (1993) The care of children with long term tracheostomies. San Diego: Singular Publishing Group. Davies, J. & Hassell, L. (2000) Children in Intensive Care: A Nurses Survival Guide. London: Churchill Livingtone. Leder, S.B. & Ross, D.A. (2000) Investigation of the causal relationship between tracheostomy and aspiration in the acute care setting, Laryngoscope 110(4), pp. 641-644. Leder, S.B., Jo, J.K., Hill, S.E. & Traube, M. (2001) Effect of tracheotomy tube occlusion on upper esophageal sphincter and pharyngeal pressures in aspirating and non- aspirating patients, Dysphagia 16(2), pp. 79-82. Rosen, C.L., Glaze, D.G. & Frost, J.D. (1984) Hypoxemia associated with feeding in preterm infant and full term neonate, American Journal Diseases in Children 138, pp. 623-628. Rosenbek, J.C., Robbins, J.A., Roecker, E.B., Coyle, J.L. & Wood, J.L. (1996) A penetrationaspiration scale, Dysphagia 11(2), pp. 93-98. Suiter, D.M., McCullough, G.H. & Powell, P.W. (2003) Effects of cuff deflation and one way tracheostomy speaking valve placement on swallow physiology, Dysphagia 18(4), pp. 284-292.

Common characteristics
In the young infant, coordination and regulation of breathing and feeding is vital to ensure successful feeding (Rosen et al., 1984). Less well documented is the relationship between respiration and swallowing in the older child. Here, I will attempt to clarify the assessment process and identify dysphagic characteristics that from my experience are common in respiratory-compromised children. It may be that respiratory recovery brings with it recovery from the dysphagia. Before assessment / observation of feeding, it is useful to make yourself aware of typical respiratory parameters. By this I mean what are the acceptable limits for the child in terms of vital signs, pallor and effort of breathing? This information can be determined via monitoring equipment or obtained from parents / carers. The following assessments can be made without the use of videofluoroscopy (at home / in the community), using observation, monitoring equipment, carer information and cervical auscultation: 1. Swallow fatigue This can present as changes in vital signs, decrease in strength and mistiming of the swallow on cervical auscultation. It can also show through the development of pharyngeal residue as heard on cervical auscultation and typically presenting as a deterioration in skills. Such children show normal swallowing features at the beginning of the meal that deteriorate either as quickly as the initial two to three swallows, or develop over a longer period such as a ten minute meal. 2. Variable swallow strength This is most evident with the use of cervical auscultation when a variance in the strength of swallow sounds may be heard. This occurs even though the child is taking consistent volumes during the feed, and can be most evident when assessing fluids (Cichero et al., 1998).



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1) RCSLT MEMBERSHIP I have been a member of 'College' since I qualified. The Royal College of Speech & Language Therapists provides an immense service to the public and the profession through its website, which offers advice on everything from how to apply for a speech and language therapy course to responses to government publications. In the background, the organisation is influential in developing policy at a national level and providing publications which enable us as a profession to engage in best practice. The Clinical Guidelines (Taylor-Goh, 2005) are now available online in PDF format. And CQ3 - to be launched at the RCSLT conference in Belfast on 12 May 2006 - is set to become as important in this decade as Communicating Quality and CQ2 were in the last. Taylor-Goh, S. (ed.) (2005) Clinical Guidelines. Bicester: Speechmark Publishing. Available at: (Accessed: 12 January 2006). 2) BRITISH STAMMERING ASSOCIATION WEBSITE This resource, specifically focused on the needs of individuals who stutter, provides excellent and highly accessible advice for those individuals, parents and other family members, speech and language therapists and the public. It is informative and up-to-date. A fine source of information for students. Keep up the good work! 3) THE WRIGHT & AYRE STUTTERING SELF-RATING PROFILE (WASSP) This is a well-designed assessment that allows adults who stutter to state which elements of their dysfluency they consider to be a priority for intervention, and then enables re-assessment on clients own terms. Using this profile in teaching has helped students to recognise that therapy for adult clients is a joint problem solving exercise and one which can be evaluated qualitatively both by the therapist and the client. Wright, L. & Ayre, A. (2000) WASSP Wright & Ayre Stuttering Self-Rating Profile. Bicester: Winslow. 4) THE SEEDHOUSE GRID Ethics can seem dry and boring but it underpins all our clinical decision making. A new book by David Seedhouse (2005) suggests that our values base is as important as an evidence base in decision making, but ethical reasoning is not well represented in the speech and language therapy literature. The Seedhouse ethical grid (1988) is a method of identifying the areas of an issue which require ethical reasoning. At the centre (blue) is the core rationale which must always be considered, the next (red) focuses on duties and motives, the third (green) looks at possible outcomes and finally (black) come external considerations. There are many other approaches to ethical reasoning, but personally I find this one to be clear without being simplistic; a model which can be applied to practical problems (Taylor & Stansfield, 2003). Seedhouse, D. (2005) Values based health care: the fundamentals of ethical decision making. Chichester: John Wiley & Sons. Taylor, P. & Stansfield, J. (2003) Sensible solutions or daft ideas: a search for answers, Speech & Language Therapy in Practice Spring, pp. 14-16. 5) BOOK AND RESEARCH PAPER REVIEWING Research publications on stuttering alone appear at the rate of well over 200 a year in journals available to UK students. Being given the opportunity to critically evaluate new texts (for example Ward, 2006, which wont be published until June) is a great way of forcing yourself to read the original literature in depth and assess the degree to which a paper or book can be recommended to students. OK, this is not everyones cup of tea, but reviews by clinicians in the field, of newly published books, are also vital for the profession if practice is to be influenced by current evidence. Speech & Language Therapy in Practice publishes book reviews and has also started a recommended reading section: worth a thought? Ward, D. (2006) Stuttering and Cluttering. London: Psychology Press. 6) LINDY MCALLISTERS WORK ON CLINICAL EDUCATION There have been many publications on clinical education over the years including important work by Jackie Stengelhofen and Ann Parker in the UK. Lindy McAllister has written a lot on the subject and the best book I have found recently is McAllister & Lincoln (2004). This book gives a large number of practical suggestions for working with students and identifies how both student and clinical educator can grow and change during a clinical placement. McAllister, L. & Lincoln, M. (2004) Clinical Education in SpeechLanguage Pathology. London: Whurr. 7) PERSONAL ALARM Some of my clinical work over the last decade has been in secure hospital units. Security and monitoring changed considerably over the time, with increased scrutiny of visitors and very careful identification of other regulations for personal security. A personal alarm was a required part of the kit for any professional in one unit. I am glad to say I never needed to use mine, but seeing the rapid response to practice runs (or maybe they were real?) raised my awareness of personal risk management, and did make me feel secure when working with the very challenging clients in these environments. 8) PHONE A FRIEND I am never going to be a millionaire, but I do have a rich network of colleagues and friends (if not a network of rich colleagues...) whom I call upon for support and advice. These range from people with whom I studied in the dark ages (yes, you know who you are!) to clinical educators and specialists in my areas of interest, Royal College of Speech & Language Therapists advisors, and members of Special Interest Groups in fluency and learning disability. The need for peer support changes over a career but it does not go away. It helps to challenge assumptions, confront problems, confirm hunches and hopefully for me results in reflective practice and a better approach to work with students and clients. See recent articles in this magazine for more information. Nicoll, A. (2005) So crazy about all these peers..., Speech & Language Therapy in Practice Winter, pp. 22-24. Righton, T. (2005) My top resources, Speech & Language Therapy in Practice Winter, back page. 9) STUDENTS Whether in class or in clinic I learn from students. I have 'found' (and hurriedly read!) literature I was blissfully unaware of, quoted by students in assignments, which has sometimes profoundly changed my thinking. In clinic, insights from 'naive' students can also challenge preconceptions, while sometimes they lead to significant improvement of therapy. Just one example here. We were working with a child with cerebral palsy and severe learning disabilities who did not speak. A student coming from a completely different previous placement suggested selective mutism as a possibility, in addition to language and motor speech difficulties. Following a change of tack and the removal of direct attempts to encourage communication, gradually an almost silent child began to vocalise and communicate. Students come up with the unexpected and sometimes exciting alternatives to current practice. These people are the next generation of speech and language therapists and inevitably they have new ideas. Long may it continue. 10) THE JOURNEY HOME As a weekly commuter between work in Manchester and home in Scotland, the train line is a lifeline. Reliability and timekeeping have improved a great deal since I moved to Manchester and the possibility to plug in my computer in the Quiet Coach every Friday means that I can round off the weeks work and arrive home ready to enjoy the weekend in a different country. Lifework balance I think it is called?