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ISSN 1368-2105

Summer 2005

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http://www.speechmag.com

SOWING SEEDS

in Practice

Early years
A joint strategy

Benchmarking
Oral tasters

Work in progress
Capacity to consent

How I review the literature to change practice

An integrated approach in every sense

PLUS...The Abundance Key...Heres one I made earlier...My Top Themes...and featuring Breaking bad news

Reader offers
WIN PHONOMENA
Phonomena is a computer game designed to accelerate language learning across ages and abilities with short periods of edge of competence training in phonological awareness. MindWeavers has developed the software from neuroscience and phonetic research at Oxford University. It draws on the learners own resources through training the senses so that improvement continues after the training - not only in skills practised but in standard tests of language and literacy. (Trials with children with language impairment showed that 6 hours of training improved word discrimination by an average of 1.8 years.) Phonomena is normally 34 + VAT for use on a single computer, but we have copies for THREE readers in a FREE prize draw. To enter, just send your name and address to the Speech & Language Therapy in Practice Phonomena offer, c/o Aga Soltysik - Marketing, MindWeavers Ltd, Oxford Centre for Innovation, Mill Street, Oxford OX2 0JX or email to aga.soltysik@mindweavers.co.uk. The closing date for receipt of entries is 25th July, and the winners will be notified by 1st August. More information about trials with various groups is on www.mindweavers.co.uk, where you can also order Phonomena.

WIN MINI MESSAGE POSTERS


New from Incentive Publishing, these mini message posters can be displayed, used as a thought for today or act as triggers for group therapy discussion. Developed in conjunction with SEAL (the Society for Effective Affective Learning), the posters use sensible, hard hitting and reflective language to encourage young people to recognise the importance of honesty, integrity, responsibility and achievement. The wisdom embedded in these memorable quotations from famous people could stimulate discussion and debate among people of all ages, and provide an insight into the richness of language. These 30 mini message posters (each 28 x 10cm) usually retail at 27.00, but Incentive Plus is giving THREE sets away FREE to lucky readers. For your chance to win, simply send your name and address to: Hilary Whates, Incentive Plus Limited, 6 Fernfield Farm, Whaddon Road, Little Horwood, Milton Keynes, MK17 0PR, or email your address to hilary@incentiveplus.co.uk. The closing date for receipt of entries is 25th July and the winners will be notified by 1st August. For more details about this and other Incentive Plus resources, see www.incentiveplus.co.uk or call Hilary on 01908 526120.

Angela Crocker was the lucky winner of the Photosymbols #1 from Worth1000Words, one of three reader offers in the Spring 05 issue. Speechmarks Test of Morpheme Usage is on its way to Lorna Meech, Margaret Veitch, Alison Taylor, Helen Smith and Julianne Bolton. And LDAs Pip and Molly puppets have new homes with Lianne Carroll and Elizabeth Downey. Congratulations to you all - and keep those entries coming!

Summer05speechmag
In need of inspiration? Doing a literature review? Looking to update your practice? Or simply wanting to locate an article you read recently? Our cumulative index facility is there to help.

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We now have a FREE eupdate service for readers of Speech & Language Therapy in Practice who just cant wait for the next issue to arrive! To subscribe, e-mail avrilnicoll@speechmag.com. 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. If you dont have access to them, check out the abstracts on www.speechmag.com and take advantage of our article ordering service.

The speechmag website enables you to: View the contents pages of the last four issues Search the cumulative index for abstracts of previous articles by author name and subject Order copies of up to 5 back articles online.

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Sowing seeds... Anonymous, Dyble, A., Knight, L., Birkett, E., Byers, V. & Tuffney, J. (1995) The Colleges Golden Ages. Human Communication 4 (4). BONUS! New at www.speechmag.com/reprintedarticles.html. Oral tasters... (236) Speirs, L. (2003) Oats not so simple. Summer: 18-20. Sensory integration... (142) Barnes, S. (2001) Sense and sensitivity: Part 1. Spring: 4-7. (154) Barnes, S. (2001) Sense and sensitivity: Speech-language therapist and Part 2. Summer: 16-18. audiologist Heather Graz reflects Research and practice... on how non-practising time in (249) Soloff, N. (2003) Gathering the evidence. Chile has given her lessons in Autumn: 25-26. communication that couldnt be Preventative work in nurseries... taught in a classroom. See (134) Hurd, A. & McQueen, D. (2000) The right www.speechmag.com/ things at the right time. Winter: 8-11.

NEW article

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originalarticles.html.

SUMMER 2005
(publication date 30/05/05) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Design & Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Website design and maintenance: Nick Bowles Webcraft UK Ltd www.webcraft.co.uk 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 2005 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.

INSIDE COVER SUMMER 05 SPEECHMAG, READER OFFERS


Win mini message posters and Phonomena software.

16 FACING THE FEAR


For obvious reasons there are no randomised controlled trial results for breaking bad news, and no gold standard procedures... However, we need no more than common sense to know that the way news is given impacts on how it is received, and that we can all learn to improve our skills. In our latest feature article, Avril Nicoll asks why we fear breaking bad news, and how we can get better at doing it.

2 NEWS / COMMENT 4 COVER STORY AN INTEGRATED APPROACH - IN EVERY SENSE


Findings of outcome measures indicate an 89 per cent improvement in all areas of speech and language assessed. Some of these areas, for example conceptual development, received direct intervention as part of the group treatment; others did not. Speech and language therapist Donna McCollum and occupational therapist Geraldine Teague on their joint sensory integrative group for preschool children with specific language impairment.

19 KEYS TO WINNING WAYS SERIES (3) THE ABUNDANCE KEY


Shona has forgotten that the reason she loved her work so much was because she brought the free flowing mode of creative teaching to her work. She has allowed herself to get stuck in analytical thinking, and that lets in the old enemy - fear. In the third article in our series to encourage reflection and personal growth, life coach Jo Middlemiss asks if you can see the abundance within?

20 TO TASTE OR NOT TO TASTE? 8 REVIEWS


Communication disorders, software, language development, AAC, research, memory, phonological awareness. ...we should consider not only a persons physical health, but also psychological impact on the client and carers, social inclusion, ethics, feelings and emotions. Human rights, legal rights and client choice must also be highlighted. Yvonne Macleman considers the evidence around the use of oral tasters with adults with learning disabilities who have a percutaneous endoscopic gastrostomy / jejunostomy.

9 HERES ONE I MADE EARLIER...


Alison Roberts with more low-cost ideas for flexible therapy activities: butterfly game, where am I looking? and a customised guess who.

10 ENRICHING THE EARLY YEARS


Relationship building was an important aspect of the training sessions. The group valued sharing ideas and good practice, and became very supportive of each other. Carol Sutton & Joanna Sedgemore report on a joint, strategic response to the increasing numbers of nursery aged children being referred with speech and language delay in Wolverhampton.

23 RESOURCES 24 HOW I REVIEW THE LITERATURE TO CHANGE PRACTICE


(1) FINDING THE EVIDENCE
Annette Kellys clients are at the heart of her enthusiasm for reviewing and critically appraising the literature and they are reaping the benefits.

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IN FUTURE ISSUES... GOAL SETTING CRITICAL APPRAISAL EARLY YEARS DYSPHAGIA HEAD AND NECK CANCER GROUPS ASPERGERS SYNDROME

(2) IMPROVING STUDY DESIGN


Margaret Young reviewed the literature to ensure that her study design would prove whether or not the Modified Evans Blue Dye swallowing test is necessary for people with a tracheostomy.

13 WORK IN PROGRESS CAPACITY TO CONSENT


Mr Brady demonstrated that he was able to paraphrase, compare alternatives, begin to express his owns thoughts and discuss consequences. However he continued to have difficulty applying the information to himself. We also found that he was highly suggestible to leading questions. On feeding this information back to the team it was agreed this meant that, while Mr Brady demonstrated partial capacity, he continued to be vulnerable. If you work with any client group where assessing capacity to consent is an issue, you need to be aware of new legislation and its implications for your practice. Louise Scrivener brings us up to speed.

(3) MATCHING PRACTICE TO THEORY

Is the gag reflex related to swallowing? Does an absent gag reflex suggest dysphagia? Pippa Hales sorts out the fact from the fiction. With additional comments from Lorna Gamberini and Rita Oliver.

BACK COVER MY TOP THEMES


Clinically, we should be cautious about specific diagnosis and prediction, particularly with children under five, and always emphasise potential for change and development. Editor Avril Nicoll on the NAPLIC conference, Speech, language and communication needs: current trends in theory and practice.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

Cover photo by Paul Reid. Posed by model.

NEWS

Charity says services need to change


Young people with learning disabilities experiencing mental health problems arent getting the help they need, according to a charity report. The Foundation for People with Learning Disabilities say that 40 per cent of young people with learning disabilities are likely to develop a mental health problem such as depression and anxiety each year. The Making us Count report finds that young people have a lack of opportunities available for friendships, social activities, education and employment and those in need of help encounter difficulties when trying to reach services. In addition, pathways to referral for support are vague, and there are often long delays to assessment and intervention services. Making us Count, see www.learningdisabilities.org.uk. An arm of the Mental Health Foundation, the Foundation for People with Learning Disabilities uses research and projects to promote the rights of people with learning disabilities and their families. The Foundation has welcomed the new mental capacity legislation for England and Wales, noting that several key inclusions are the result of its campaigning, for example strong provisions to ensure that a person should not be considered incapable because insufficient time has been taken to help them understand and be understood. From 2007, the Mental Capacity Act will provide a coherent legal framework for people who may not be able to make their own decisions because of a learning disability, illness or mental health problems.

Back up for carers


A carers charity is calling for better emergency back up for carers and increased awareness of where such help already exists. The report, Back Me Up - supporting carers when they need it most, draws on the stories of over a thousand carers who describe in their own words a crisis situation and how it affected their lives. Examples include being unable to be with other family members during bereavement or terminal illness, and struggling to arrange alternative care when struck by illness and hospitalisation. The report points to simple, inexpensive solutions such as the 24 hour Care Emergency Scheme operated by 20 local authorities. This telephone service sorts out replacement care at short notice and puts a pre-prepared emergency plan into operation with a single call. As well as calling for this service to be available nationwide, the report suggests carers would benefit from professional help in planning for emergencies and increased awareness of new technology such as fall monitors to give more peace of mind. Carers can get information on planning for an emergency on the Carers UK website. www.carersuk.org/backmeup

200m no longer ring-fenced Award for A national charity that campaigns for inclusive play Interactive is accusing the government of failing disabled chilStorytelling dren following the announcement in January that
Speechmark Publishing has won the 2005 Special Education resources award for Keith Parks Interactive Storytelling: Developing Inclusive Stories for Children and Adults. Keiths work is familiar to Speech & Language Therapy in Practice readers (Summer 99, Summer 01, Spring 02, Autumn 04). Interactive Storytelling is a hands-on manual providing guidance and calland-response stories to enable teachers in mainstream and special schools, therapists, parents and anyone working with children or adults in community settings to use performance and recital to bring stories, drama and poetry to life for people of all abilities including those with profound and multiple disabilities, learning disabilities, autistic spectrum disorders and specific language impairments. Keith, an advisory teacher for Sense in Lewisham, is running an Othello theatre workshop with Charlton School, a special school in Greenwich, for the BBC 1 Night of Shakespeare on July 3rd. www.speechmark.net; www.storytracks.com

200 million earmarked for investment in childrens play will no longer be ring-fenced. As we have reported previously (Spring 04), Kids had welcomed the 2004 Childrens Play Review for England and Wales which set out how best to invest the New Opportunities Fund money earmarked for improving childrens play opportunities. Chief executive Dr Sam Brier now says, The Play Review recommended that every area should be required to devote funds to the needs of disabled children and young people. But the government is now only saying that it agrees in principle to targeting funds on those most in need - and falls short of specifically referring to disabled children. Kids is calling for a clear statement from the government that it intends to address the play and inclusion needs of disabled children both financially and strategically. www.kids-online.org.uk

Joint service accredited


The passion, energy, commitment and drive of key individuals within these teams was a key factor in the accreditation of a joint outreach service for preschool children with speech, language and communication needs. A team of speech and language therapists and early years support teachers working for Calderdale and Huddersfield NHS Trust and the Calderdale Council Childrens Services Unit support at least 50 preschool children. They successfully met all the quality standards demanded by I CANs Early Years Accreditation Scheme. Funded by the Department for Education and Skills, the scheme was developed to set the standard for high quality integrated therapy and education for preschool children with a speech, language and communication difficulty. www.ican.org.uk

Multi-media campaign aims to make a difference


Early evaluation of a Welsh multi-media advertising campaign suggests it is getting across its message that Talking to your children can make all the difference. The campaign is the fourth in a series of campaigns undertaken as part of the Welsh Assembly Governments 40 million National Basic Skills Strategy. To date, over 70,000 copies of the Talking Together pack have been distributed and, while pre-campaign results showed that 57 per cent of parents surveyed thought the best age to introduce a child to songs, rhymes and sharing books was six months, this has now risen to 85 per cent. In addition to press and outdoor advertising, television adverts in English and Welsh use gentle humour approach with an element of surprise, and finish with a number to call for a pack to help viewers talk to their baby or young toddler. The campaign was precipitated by a survey of head teachers in Wales conducted by the Basic Skills Agency in 2002. It found that more and more children were starting school without the speaking and listening skills needed. You can view the television adverts, pack and poster online at www.basic-skillswales.org/bsastrategy.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

NEWS & COMMENT

Autism database
A new free online resource should enable better access to services for people with autism and their families, and be responsive to their changing needs. The Public Autism Resource and Information Service (PARIS) is a searchable database of thousands of autism services across the UK including schools, day centres, support groups and training courses. Managed by the National Autistic Society, the project has three year cause partnership funding from Vodafone UK. Phil Dimmocks, PARIS Project Manager said the society is, fully committed to ensuring that the information in PARIS is as up-to-date and as comprehensive as possible. PARIS is a growing resource and we welcome feedback and comments from the public, and encourage them to let us know of any autism specific services which are not currently on the PARIS database. The mobile phone version will be launched later this year. www.info.autism.org.uk

comment
Avril Nicoll, Editor 33 Kinnear Square Laurencekirk AB30 1UL

Sowing seeds

Laryngectomy safety call


The National Patient Safety Agency is calling for improved training of NHS staff who may be involved in the emergency care of patients with a long-term tracheostomy. In response to lobbying from the National Association of Laryngectomy Clubs, the Agency has sent out guidance and recommendations to NHS organisations. This aims to ensure that, if required, oxygen is given via the stoma, and mucous plugs blocking the airway are removed. Bert Culling, President of the National Association of Laryngectomee Clubs said, The correct technique in the care of neck breathers has been a serious concern of our organisation for many years and we are delighted that the Agency is tackling this problem. Laryngectomy patients and emergency care - see www.npsa.nhs.uk

NSF launched
The Long-term Conditions National Service Framework has now been launched, and aims to transform the way health and social care services support people in England to live with long-term neurological conditions. The Department of Health points out that the principles are also relevant to service development for other long-term conditions. Key themes include independent living, care planned around the needs and choices of the individuals, easier, timely access to services and joint working across agencies. The UK disability organisation Scope has welcomed it as part of a broader structure which will empower disabled people to live indepdently in the community, but continues to be disappointed that it is not backed by ringfenced or adequate resources. www.dh.gov.uk/longtermnsf; www.scope.org.uk

tel/ansa/fax Another birthday has brought with it the appalling realisation that its 17 years 01561 377415 since I qualified. One effect is that, when I attend conferences such as NAPLIC (back page) or work on features (p.16), I am aware of looking backwards. I e-mail reflect on the way things used to be and how they have changed, how I would avrilnicoll@speechmag.com have handled a situation in the past and why I would do it differently today. However I console myself that I am still young enough to look forwards as well, and wonder how the seeds being sown today will bear fruit for future generations? Shonas predicament (p.19) as an experienced but unfulfilled therapist will be familiar to many of you, but solving career stagnation is not always easy. In The abundance key, Jo Middlemiss plants Carlson & Baileys idea of choosing either free-flowing or analytical / processing modes of thinking depending on the need of the moment. As they say (1998, p.22), Free-flowing-mode thinking is essential to all personal growth, change, development, and evolution. When we learn to live in this mode most of the time and we reserve the processing mode for tasks that require planning, calculating, and analyzing, life becomes much easier and calmer. Alison Roberts (p.9) must be a master of free-flowing thinking, but has to move into processing mode to get it down on paper so you can replicate her practical therapy ideas. Donna McCollum & Geraldine Teague (p.4) are in free-flowing mode when they plan their sensory integration therapy sessions to appeal to preschool children. The analytical mode comes into its own when assessing the all important outcomes. Carol Sutton & Joanna Sedgemore (p.10) needed an analytical strategic approach for their collaborative early years project but also ensured it would enable free-flowing thinking of participants. Similarly, our How I contributors (p.24) use their analytical / processing mode to plough through a critical appraisal of relevant literature efficiently and effectively. Their free-flowing mode roots, feeds and waters their literature review so that it ultimately benefits clients. As Yvonne Macleman (p.20) says in relation to oral tasters for adults with learning disabilities and dysphagia, Within this very clinical debate lies the core of the issue - the client themselves. And there we have it. Free-flowing thinking incubates empowerment, happiness, a solution focus, reflection, user involvement and the bigger picture. This needs to be protected - but not smothered by - the analytical approach required for evidence based practice, risk assessment, protocols, programmes, critical appraisal and legal frameworks. We hope to find out more about how Reference therapists are weathering this through work in progress (Louise Scrivener, p.13). Carlson, R. & Bailey, J. (1998) Slowing Down to With the Royal College of Speech & Language Therapists also celebrating a the Speed of Life: How to birthday (its 60th), we can be grateful to our predecessors for planting seeds that Create a More Peaceful, Simpler Life from the Inside gave us room to grow. And with judicious use of free flowing and analytical modes Out. Hodder Mobius. of thinking, we can do the same for our successors.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

COVER STORY

Figure 1 Sensory integration - background information

Integration
The concept of sensory integration was initiated and developed by the late Dr Jean Ayres, an occupational therapist in the USA. She describes Sensory Integration as the neurological process that organises sensation from ones own body and from the environment, and makes it possible to use the body effectively within the environment (Ayres, 1989, cited in Fisher et al, 1991). Dr Ayres was particularly interested in the way in which sensory processing and motor planning disorders interfered with activities of daily living and learning. Information that is organised and integrated comes from five senses auditory, vestibular, proprioceptive, tactile and visual. Ayres hypothesised that development of these basic sensory systems and the integration of their information on the lower subcortical and brainstem area is necessary before higher-level skills will develop normally. This integration helps us function throughout life; normally this process develops between the ages of 3 - 7 years but continues to make progress and integrate after this time. Ayres considered the years between 3 and 7 to be a crucial period for sensory integration because of the brains receptiveness to sensations and its capacity for organising them at this time. The vestibular system forms the basic relationship of a person to gravity and the physical world. This system seems to prime the rest of our nervous system to operate effectively. It is the major organiser of all other sensory channels and so is thought to contribute to the development of language, understanding and speech (Ayres, 1978, cited in Mauer, 1999, p.386). The tactile system refers to touch and the way the nervous system processes the many kinds of touch from the external environment - light touch, deep pressure, temperature and pain. This system has strong links to social, emotional and body scheme development and serves as a basis for the development of praxis, perception and cognitive functioning. The proprioceptive system develops through weight bearing and movement against gravity. This sense is critical in maturation of reflexes and it provides information from muscles, joints and ligaments of the entire body. It tells us where our body parts are in relation to each other and to space, without needing to use our sense of vision. Visual feedback is important in monitoring posture and movement; visual / proprioceptive integration is critical to the refinement of spatial concepts and body percept (Fisher & Bundy, 1989; Mathews, 1988). It helps regulate attention and gives the brain vital information about a body pattern or movement that is needed in order to repeat or correct a movement pattern. This has obvious implications for functional and speech development.

Dysfunction
When children are unable to successfully integrate information from the five senses they are said to have a sensory integration dysfunction. The sensory systems are still receiving the sensations but they are unable to interpret them. There are several types of sensory integration dysfunction. The most common are the childs inefficiency in registration, modulation and discrimination of different sensory inputs. If a child cannot register information correctly he will pay little attention to most things. When a child over responds, under responds or fluctuates in response to sensory input, they are exhibiting a sensory-modulation disorder. Attention, alertness and arousal are important for basic survival. They contribute to the ability to filter out irrelevant information, to tune into important elements in the environment, to process new information for learning, and to engage in purposeful activity. The process of sustained attention, particularly the ability to differentiate novel and familiar stimuli, has been identified as important in the development of later cognition (Bornstein & Sigman, 1986; Fagan, 1982; Rose & Wallace, 1985; Ruff, 1986 - all cited in DeGangi, 1994). Sensory discriminatory disorders are a childs reduced ability to discriminate, touch, movement or body position. Dysfunction can occur within a specific sensory system - vestibular, proprioceptive or tactile - or within a combination of systems, for example tactileproprioceptive (otherwise known as the somatosensory system). The vestibular system is the balance sense, and a dysfunction results in gravitational insecurity and resistance to movement. Children exhibiting this dysfunction also seek out abnormal amounts of vestibular stimulation such as through rocking, or they avoid certain types of movement. These tendencies interfere with normal play and functional activities. The vestibular system is also responsible for muscle coordination and modulation, with a deficit affecting the articulators, body language and other non-verbal expression. Children who have a dysfunctional tactile system are likely to have difficulties in learning fine motor skills and to display tactile defensiveness by withdrawing when someone touches them. This will have obvious effects with social bonding, both in the home and preschool environment. It is through the tactile system that a child gains a sense of security and emotional well-being. Tactile dysfunction may also result in problems in articulating sounds, developing basic concept awareness and independence skills. Proprioception is the conscious and unconscious awareness of body position and movement. It is often described as the muscle sense. The common signs of a dysfunction are clumsiness, lack of awareness of body position in space, problems manipulating small objects and learning new motor activities. Difficulties of this nature can be seen in body dyspraxia as well as oral and verbal dyspraxia.

Therapy
Ayres suggested that the end product of sensory integrative therapy is the ability to communicate through language (1979, cited in Mauer, 1999, p. 387). Sensory integration treatment itself should directly improve speech and language skills without specifically targeting language abilities. The goal of sensory integration treatment is to produce mature, spontaneous adaptive responses to sensations in a meaningful, selfdirected activity within a controlled sensory environment. 4
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

Therapists who adopt this treatment technique use various pieces of equipment to provide appropriate sensory input. To provide vestibular input, suspended equipment such as platform, booster and sling swings, scooter boards and climbing apparatus is used. Tactile stimulation can be acquired by use of textured mitts, carpet squares and large inflatable therapy balls rolled across the body. Employing weighted blankets, trampolines and pushing, lifting and carrying heavy items can provide proprioceptive input.

COVER STORY

Figure 2 Session example

Session 8

Each child undresses to t-shirt and shorts to develop independence in self-care, and enable the therapist to provide proprioceptive and tactile stimuli to legs, feet, arms and hands as required. Each child chooses a coloured shape to wear on their t-shirt, and sits on the corresponding shape on a large therapy mat (focusing point for beginning of each new activity).

9.30 - 9.40 Warm-up gross motor activity

Children take turns on trampoline, to get proprioceptive input and enhance their alert state. Some children require a weighted bear hug vest, or are involved in other sensory stimuli to achieve their optimum state of alertness.

An integrated approach in every sense


IF YOU ARE INTERESTED IN BOTTOM-UP APPROACHES MULTIDISCIPLINARY WORKING EARLY INTERVENTION
Donna and Geraldine

9.40-9.50 Blow football


Using thick straws and polystyrene balls (developing oral-motor control and interpersonal skills such as turntaking, respect of each childs spatial area).

9.50-10.00 Hello song


Incorporating gross motor actions, motor planning, animal and vehicle sounds.

10.00 -10.25 Combined speech and language / occupational therapy activity


Introduce body parts, then play the mannequin game. Child lies in prone position on scooter-board and retrieves body parts: in the ball pool (developing tactile, proprioceptive and perceptual skills) on the ramp (developing sensory and motor-planning skills) under a large weighted therapy mat (developing proprioceptive, tactile and spatial awareness) and places body parts on mannequin.

Do slings, scooter boards and climbing apparatus have a role in speech and language therapy? Donna McCollum and occupational therapist colleague Geraldine Teague share the outcomes of their joint sensory integrative group therapy for preschool children with specific language impairment.

10.25 -10.40 Break / Independence training


Therapist chooses a helper to carry juice and biscuits on tray, and pour juice. Use straws. Followed by free-play with multisensory balls.

10.40 -11.10 Combined speech and language / occupational therapy activity


Musical chairs. When music stops, sits on the chair with the body part that corresponds to their chosen item of clothing eg. head-hat (developing classification and spatial awareness skills). Children put on socks, shoes and trousers.

11.10 -11.20 Story time


Children are more attentive and responsive to stories after receiving the appropriate sensory diet facilitated by the therapists during the previous activities.

11.20 -11.30 Individual / group parental discussion time


Outline progress made, and activities for home-practice.

n July 2001 both the Homefirst Community Trust paediatric occupational therapy and speech and language therapy departments in Magherafelt moved into the new Oaktree Therapy Centre. The rooms were purpose-built for group intervention and up-to-date technology was incorporated; for example, video linking allowing the parents to view their childrens sessions as well as giving the therapists an opportunity to tape the therapy sessions. A specialist speech and language therapist and occupational therapist, we are both trained in sensory integration techniques (figure 1). The building design meant we could establish this kind of group as a main form of service delivery for preschool children with a specific language impairment. Planning of the building included the structures necessary to accommodate the suspended equipment, and funding was given for other specialist sensory integration equipment including swings, ramps, trampolines and scooters. To evaluate the inter-disciplinary sensory integrative group therapy approach with these children, we considered two aspects of the service. Firstly, we noted formal improvements in the childs communication skills and, secondly,

parental satisfaction with the joint therapy approach and the resources available. We assessed 30 preschool children. Sixteen were suitable for a joint model of intervention as they presented with both a specific language impairment and also had sensory integration dysfunction. Three groups of five to six children received group therapy of two sessions per week, each lasting approximately two hours over a course of seven weeks. Although a pure sensory integrative approach was not adopted, there was a strong sensory integration basis to the model of service delivery (see session plan in figure 2). We also visited each childs playgroup / nursery school to encourage an integrated approach to the childs development. At the end of the seven-week block, we invited parents to the therapy centre for a progress meeting. Future therapy intervention was also discussed and we asked parents to complete a confidential questionnaire on the service. We gave each child an (approximately) threemonth consolidation block before being reviewed by both disciplines to monitor progress. We reassessed the children on certain aspects of their performance and speech and language skills, to allow pre- and post-therapy outcomes measures to be compared.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

COVER STORY

Thirty one children were offered appointments for assessment (figure 3) with one failure to attend. Sixteen were identified as suitable for this joint group therapy and were involved in this type of therapy provision (52 per cent). Fifteen were subsequently used for the outcome measures project. One child was not included as he was referred back to community speech and language therapy after the group as he no longer presented with a specific language impairment.
Figure 3 Children referred for assessment
Children not presenting with a sensory integration dysfunction

NUMBER OF WORDS

We assessed understanding of basic concepts (figure 6) using the Basic Concepts Sub Test of the Celf-Preschool (Wiig et al, 2000). Twelve children (80 per cent) improved, with a range from 10 - 50 standard scores.
Figure 6 Change in understanding of basic concepts

Figure 9 Change in greatest length of utterance


Post-group

7 6 5 4 3 2 1 0 1 2 3 4 5 6

Pre-group

180 160 140 120 100 80 60 40 20 0

Post-group Pre-group

7 8 9 10 11 12 13 14 15 SUBJECTS

STANDARD SCORE

52%

45%

Children who did not attend for assessment Children presenting with a specific language impairment and a sensory integration dysfunction

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 SUBJECTS

3%

STANDARD SCORE

The mean age of children starting the group was 3;9, range 3;3-4;2. The ratio of male to female children was 5:3. Children were assessed before they started the group therapy intervention and then approximately six months later. We assessed attention levels (figure 4) using Cooper et al (1978). Childrens attention and listening skills can be profiled using the four levels identified. Within each level there are three different stages of development. Thirteen of the children (86.6 per cent) moved up one level, one child moved up two levels and one child stayed at level 3.
Figure 4 Change in attention levels
12 LEVELS OF ATTENTION 9 6 3 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 SUBJECTS
Post-group Pre-group

The childs range of expressive vocabulary was assessed using the Labels Sub Test of the CelfPreschool (Wiig et al, 2000) (figure 7). Twelve children (80 per cent) improved, with the increase ranging between 10 and 60 standard scores.
Figure 7 Change in naming of vocabulary

160 140 120 100 80 60 40 20 0

Post-group Pre-group

Fourteen of the sixteen parent / carer questionnaires were completed (87.5 per cent). Results show that: - 14 (100 per cent) rated the facility their child received therapy in as excellent. - 11 (78.6 per cent) rated the joint service in terms of the assessment procedure as excellent, three (21.4 per cent) as very good. - 9 (64.3 per cent) rated the amount of therapy as excellent, four (28.6 per cent) as very good, and one (7.1 per cent) as good. - 11 (78.6 per cent) rated the quality of therapy received as excellent, three (21.4 per cent) as very good. - 7 (50 per cent) felt their child had made excellent progress in speech and language and occupational therapy since the beginning of their treatment, six (42.9 per cent) very good progress, and one parent (7.1 per cent) some progress.

Improvement
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
SUBJECTS

We charted the childrens phonological impairments using the six different levels ranging from very severe (0) to age appropriate speech (5) (adapted from Enderby & John, 1997) (figure 8). Fourteen children (93.3 per cent) improved, while the other child had no phonological impairment from the outset.
Figure 8 Change in phonology

This project was designed to evaluate the use of sensory integration principles in a joint occupational and speech and language therapy group for preschool children with specific language impairment. The two main goals were to compare pre- and post- treatment results and to evaluate parental satisfaction with

SEVERITY OF IMPAIRMENT

We assessed understanding of vocabulary using the British Picture Vocabulary Scale (Dunn et al, 1997) (figure 5). All the childrens standard scores increased, ranging from an increase of 2 to 33.
Figure 5 Change in understanding of vocabulary

6 5 4 3
(SEE APPENDIX 3)

sensory integration treatment itself can directly improve speech and language skills without specifically targeting language abilities
this service. Findings of outcome measures indicate an 89 per cent improvement in all areas of speech and language assessed. Some of these areas, for example conceptual development, received direct intervention as part of the group treatment; others did not. It is interesting to note that both areas improved. This strongly supports the view that sensory integration treatment itself can directly improve speech and language skills without specifically targeting language abilities. This study clearly demonstrates that using sensory integration principles and adopting the two positive beliefs of early intervention and multidisciplinary working can add up to a powerful

Post-group Pre-group

120 115 110 105 100 95 90 85 80 75 70

2 1 0

Post-group Pre-group

STANDARD SCORE

1 2 3 4

5 6 7 8 9 10 11 12 13 14 15 SUBJECTS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
SUBJECTS

We informally assessed the childrens greatest length of utterance heard at the initial assessment and review (figure 9). Twelve children (80 per cent) increased in the length of utterances heard.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

COVER STORY
ADVERTISEMENT

method of developing a childs communication skills. An integrated treatment plan can capitalise on the ways on which sensory-motor and speechlanguage skills integrate. With an integrated approach, professionals may be better able to identify the nature of the underlying neurobehavioural dysfunction and its possible contribution to deviant or delayed communication skills (Mauer, 1999). Sixteen of the thirty children with specific language impairment in this study (53.3 per cent) were identified as having sensory integration dysfunctions. Although this is a small study it has obvious implications for future assessment and treatment of children with specific language impairment. Because speech and language acquisition depends on multiple sensory processes, it is important for speech and language therapists working in the field of specific language impairment to understand the normal sensory integration process that is required for communication. This will enable them to refer appropriate children for an in-depth assessment by a trained occupational therapist. The benefits of carrying out assessment / treatment in a joint occupational / speech and language therapy format are evident in this study. We feel that the additional fact that the speech and language therapist was also trained in sensory integration enhanced the group dynamics and team approach. As one of the parents said in their evaluation: At present only a few children are lucky enough to be able to access the group therapy sessions. I know that there are waiting lists and as a parent I feel that with expanding this service more needy children would be able to have the same advantage of both these therapies. Donna McCollum is a senior clinical specialist speech and language therapist (specific language impairment) and Geraldine Teague a head III clinical specialist occupational therapist at the Oaktree Therapy Centre, 53 Hospital Road, Magherafelt, Co. Londonderry, Northern Ireland, BT45 5EX, tel. 028 7936 5080, e-mail slt.oaktree@homefirst.n-i.nhs.uk.

Anxious? So would you be if someone else directed your day and you didnt know what to expect. Information is the key.
Four sets of symbols are available: Food, Attendance, Social & Travel.

Although this is a small study it has obvious implications for future assessment and treatment of children with specific language impairment.
DeGangi, G.A. (1994) Documenting Sensorimotor Progress, A Paediatric Therapists Guide. Therapy Skill Builders, Psychological Corporation. Dunn, L.M., Dunn, L.M., Whetton, C. & Burley, J. (1997) British Picture Vocabulary Scale: Second Edition. NFER Nelson. Enderby, P. & John, A. (1997) Therapy Outcome Measures. Singular Press. Fisher, A.G., Murray, E.A. & Bundy, A.C. (1991) Sensory integration: theory and practice. F.A. Davis Company. Mauer, D.M. (1999) Issues and application of sensory integration theory and treatment with children with language disorders. Language, Speech and Hearing Services in Schools 30: 383-392. Wiig, E.H., Secord, W. & Semel, E. (2000) CELFPreschoolUK. The Psychological Corporation.

Symbols Sets are 23 per category - Key fob is 5 - Folder is 7

School Set 100 symbols. 40

All symbols are 3.5cm x 3.5cm. Symbols arrive laminated with velcro attached.

References
Cooper, J., Moodley, M. & Reynell, J. (1978) Helping Language Development: A Developmental Programme for Children with Early Learning Handicaps. London: Edward Arnold.

Tel: 07946 569900 E-mail: aoa@wisterialodge.fsnet.co.uk Web: www.autism-out-about.co.uk


Buy on the Web Site Or Order by Post (Brochure Available)

DO I TRY TO IDENTIFY PREMISES THAT CAN ACCOMMODATE MULTIDISCIPLINARY GROUPS? DO I RECOGNISE WHEN CLIENTS HAVE UNDERLYING DIFFICULTIES THAT WOULD BENEFIT FROM A JOINT THERAPY APPROACH? DO I HAVE SUFFICIENT UNDERSTANDING OF NORMALITY IN AREAS OTHER THAN SPEECH AND LANGUAGE?

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

REVIEWS

reviews
COMMUNICATION DISORDERS
Dictionary of Communication Disorders (4th ed) David Morris Whurr ISBN 1 86156 285 3 25.00 clear examples from past research. Well worth the money. Andrea Robinson is a 2nd Year BSc (Hons) Human Communication (Speech and Language Therapy) student at Leicester DeMontfort University.

A good buy
A key requirement of a dictionary of any kind is that it is easy to navigate. This book certainly meets this requirement. Entries are clear and the layout is attractive and user-friendly. This book provides comprehensive coverage of up-to-date terms used in the field of speech and language therapy. This includes entries for a wide range of published assessments. In addition, appendix 1 lists the assessments described in the text. There is comprehensive coverage of relevant medical conditions with details regarding associated speech and language difficulties. Helpfully, websites addresses for support groups are included. Many entries also provide references for further reading, supported by a 30-page bibliography which maintains the user-friendly style. This book is easy to use for busy therapists who may need to check something quickly. Its also a worthwhile resource for any department involved in clinical education of students. For 25, a good buy. Una OShiel is speech and language therapy manager, Community Services, North Cork, Health Service Executive, Southern Area.

MEMORY
Short-Term Memory Difficulties in Children Joanne Rudland Speechmark ISBN 0 86388 441 5 29.95

Useful and well-structured


This is a useful, well-structured resource for an area of language difficulty often overlooked. The introduction is brief and easy to read. Two main strategies are outlined - visualising and repetition. There is an informal, baseline assessment and aims are clearly stated, ready to include in an individual education plan. There are 15 different activities, each incorporating four different levels. The worksheets are all photocopiable and activities require only basic materials. Relevant for both clinic or education based therapy and recommended for children aged 7 to 11, although secondary pupils may benefit too. There are also very clear advice sheets for schools and parents. Kate Hayman is a speech and language therapist in Stirling.

manipulating phonemes. Two of the children needed lots of positive reinforcement to persist when they got a number of responses incorrect. It did seem to be effective and I would feel very happy to let a teaching assistant carry on doing Phonomena, once the children have been assessed as having - for example - reasonable auditory memory. Ann Forrester is a speech and language therapist from Swindon Primary Care Trust working in mainstream primary education.

effect around the people in the cards with a pink background. While especially valuable for school aged children with speech, language and communication needs, this resource would serve other client groups well, and extend non-verbal communication in those with limited expressive language. Jill Johnson is a speech and language therapist working with statemented children in mainstream schools, and for Wycombe Primary Care Trust.

LANGUAGE DEVELOPMENT (I)


Colorcards Sequences: 4-Step Speechmark ISBN 086388 526 8 25.95 + VAT

AAC (I)
Listening to Children 2004 Stuart Aitken and Sally Millar CALL Centre, The University of Edinburgh & Sense Scotland ISBN 1 898042 26 8 15.00+2 p&p

A good basic resource


This pack offers 12 four-step sequences on good size sturdy cards. The photos are modern and show a good range of situations and age groups, relevant mainly to a paediatric client group. The pack suggests using the cards for describing, ordering, predicting, logical thinking and using gesture but the cards can easily be used in many clinic and school situations. Theyre versatile, easily portable and a good basic resource. Could be a good investment if youre short on photo cards in your clinic. Jill Laurillard is a speech and language therapist in Otley, West Yorkshire, for East Leeds PCT.

How to make our lives easier!


This is an easy to follow, practical resource pack for therapists working with children who use AAC. It describes and reviews materials such as personal communication passports, symbol systems, visual timetables and talking mats with guidance on how to use them more fully. The pack is a sequel to a 2002 resource pack called Listening to Children with Communication Support Needs. There is an A4 size book with a CD of both resources.You can use the CD to adapt observation sheets, communication passports and so on to use with your own students. There are hyperlinks throughout the text which allow you to find relevant articles and web pages. How to make our lives easier! Catriona Scott is the deputy head of speech and language therapy for Trafford PCTs.

RESEARCH
Research Methods in Communication Disorders Tim Pring Whurr ISBN 1 86156 097 4

PHONOLOGICAL AWARENESS
Phonomena MindWeavers Single licence 34.00, multi licence 169.50

LANGUAGE DEVELOPMENT (II)


ColorCards - Expressive Verbs Speechmark ISBN 0 86388 525 X 25.95+VAT

19.50

Did seem to be effective


Phonomena is a computer game to develop phonological awareness. Through repetitive training, it works on the ability to distinguish between phonemes from the major contrasting categories. The software adapts to the responses of the child. It is aimed at 6-16 year-old children with learning difficulties, although the developers have carried out field trials with a variety of groups. We tried out Phonomena with three children using it for twenty minutes twice weekly over about a month. One other child hadnt been able to use it, as he couldnt remember who had said what. After training, I observed some improvements in remembering items on an alliteration task and in

A human touch
The author has given research methods a human touch, using humour and plain English (where possible). He shows an understanding of the needs of speech and language therapy students but at the necessary depths (quite deep at times, at this stage of my experience!) to maintain interest and learning. The chapters are logical and will be easy to dip into in the future. Included are complicated looking formulae, which show how computer packages in research methods calculate data. The exercises amalgamate the theory with relevance to speech and language therapy. The answers at the back give lots of interesting,

Evoke thought and laughter


This versatile, 48 photocard set has an apt but not immediately appealing title. It depicts such non-verbal expressions and actions as pouting, shoulder shrugging and beckoning. Applications include developing an understanding of non-verbal language and the vocabulary used to describe it, encouraging creative thinking and formulating complex sentences. The booklet suggests less obvious ideas such as the classification of actions that express love and affection, anger and hostility. The large format cards create an impact and lend themselves to group work. They depict real life, fascinate, and evoke thought and laughter. One minor negative observation: several children homed in on a halo

AAC (II)
Augmentative and Alternative Communication in Severe Disabilities - Beyond Poverty (Eds) Erna Alant & Lyle L. Lloyd Whurr ISBN 1 86156 439 2 25.00

Worthwhile and stimulating


This book is a great addition to the community-based speech and language therapists bookshelf. It is not an easy read but clinicians seeking a greater understanding of the relationship between poverty and disability will find it particularly intriguing. Its useful for those providing AAC intervention in poverty and funding-limited contexts. Adapted for both adult and paediatric caseloads, the reader is presented with

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

HERES ONE I MADE EARLIER...

a range of theoretical and practical tips for maximising AAC intervention and long-term quality of life beyond specific therapy goals. The main theme is for AAC intervention to be versatile, effective and - most importantly sustainable. This book focuses on how this can be achieved through a support-based (rather than needsbased) approach. Individual, family and community strengths provide the resource for success within a community-based context. A worthwhile and stimulating purchase! Karen Weinberg is a speech and language therapist in London.

Heres one I made earlier...


ALISON ROBERTS WITH MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONS SUITABLE FOR A VARIETY OF CLIENT GROUPS.

BUTTERFLY GAME CUSTOMISED WHOS A fun game for any client, but particularly those with WHO / GUESS WHO short attention spans (Butterfly Minds), or those whose This is a fun way for clients to learn to put names to
targets you are trying to disguise, rather than turn them off therapy. faces, especially in a new environment.

SOFTWARE
Speaking for Myself PLUS Bob Black Topologika 39 + VAT (single user); 179 unlimited site licence

MATERIALS
You need a way of choosing a number. Either use a dice (bought, or home made out of sponge), or spin an empty plastic bottle, which ends up pointing at a numbered sticker applied to the table. Several activities (6 if you are using a dice). Some of these will be for that clients specific targets could be some facial expression cards to copy, some find the difference cards to work out, some sequence cards, maybe a category heading (sports / hobbies) for your client to respond to. Other relief activities could be some bubble-blow, some tiddly-winks and a saucer, or two or three balls to try juggling with. Paper carrier bags or shoeboxes, preferably plaincoloured, to hide the activities in, and some stickers to apply to them to give the number corresponding to the dice or spin-a-bottle numbers.

MATERIALS
One Whos Who or Guess Who game, available from most toyshops, or you may have an old one available. (You could make one, but the effort will be great, and the end effect may be less professional than your client is used to). Photos of all those people whose names and faces you want your client to learn; you will need 3 copies of each. You need enough different photos to fill the spaces on the flip-up board (mine has 20). Where I work we have a student handbook, which contains conveniently-sized photos of all the staff. You might have to take your photos yourself, or perhaps the clients could do this as a project. Card or stiff paper. Small labels.

Enjoyable and well-presented


An easy to use CD with accompanying booklets, full of colourful graphics / animations that will maintain the interest of most children, even those with poor concentration skills. Four main areas are represented with pictures, written words, spoken words and Signalong video: 1. Flash Cards 2. Talking Stories - 2-3 word level 3. Games and Diversions - number, shape, colour, positional language 4. Talking Nursery Rhymes - with animations that the children loved, each with a humorous ending - involves listening, watching, singing along to, or as a clozed sentence exercise, both on production and reading skills. Although not used during this trial, a number of operating methods can be employed, depending on client needs - the mouse, keyboard, switches, touch-screen or access ......via an overlay keyboard, with some limitations for switch users. Loading of the software can take a little time, but moving about the different programmes is quite easy. It might be more financially viable to have an unlimited site licence, given the possible number of children using the programme at once, as the CD is required at all times. Overall, an enjoyable, visually wellpresented programme that can be used for the early developmental stages of language and reading, especially for those children who find traditional classroom methods challenging. Wendy Anderson is a speech and language therapist for NHS Ayrshire & Arran Community Division.

IN PRACTICE
Simply roll the dice or spin the bottle, check the number, and carry out the corresponding activity; just do one card from the corresponding box, or one blow of the bubbles, for example, not too long at each task.

BRAWN
Pop out all the original pictures from both boards. Put these and the loose cards to one side and reserve for when you want to change back. Use an original picture as a template to draw around for a good fit. Simply put your new pictures in place of the originals, labelling them as you go. You must have the same selection of photos on each board, but not in the same positions. The third set of photos is needed for the loose cards, and these can be stuck on to the card or stiff paper. They also need labelling.

WHERE AM I LOOKING? A game to encourage eye contact, without the


pressure of meeting each others gaze. It is also a good opportunity to practise Makaton or other signs.

MATERIALS
Small objects (such as a cup, pen, ball, food items) Photo cards, preferably of single nouns

IN PRACTICE
Just follow the rules on the box. It is a good plan to have roughly equal numbers of males and females represented. For ease of play its also a good idea to choose the photos of staff members with the most individual features - beards, glasses, hats, scarves, beetling eyebrows are good news! However, if your staff all look a bit similar you can modify the question-asking part to include topics such as type of job, for example, Does this person work in the office? Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

IN PRACTICE
1. The therapist shows the clients each object / photocard and makes sure that they know the name or sign for it. 2. The items are placed around the room allowing the clients to watch. 3. The therapist asks, What am I looking at? with a steady gaze at the item, and the clients must guess, and name or sign it. 4. Now the clients can take turns to have a go at this.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

STRATEGY

Enriching the early years


With increasing numbers of nursery aged children being referred with speech and language delay, managers from the service, a local education authority and a university college joined forces to ensure a strategic, coordinated response. Team speech and language therapists Carol Sutton and Joanna Sedgemore report.
READ THIS IF YOU WANT TO TRY TO REDUCE REFERRALS PLAN A TRAINING PROGRAMME IMPROVE YOUR COLLABORATIVE PRACTICE

Carol Sutton

Joanna Sedgemore

n increasing number of referrals to speech and language therapy seemed to indicate to us that a significant number of children in Wolverhampton now enter nursery with delayed communication skills. To address this, Wolverhampton speech and language therapy department, Wolverhampton local education authority and University College Worcester set up a one year project (April 2002 to April 2003). A high level of training from speech and language therapy was an integral part of this project. Two members of the speech and language therapy team made up one whole time equivalent. University College Worcester also appointed a member of staff to oversee the research part of the project and to provide training on language enrichment within the nursery environment. Our objectives were to: 1. Increase early years practitioners knowledge of normal, delayed and disordered communication development 2. Increase early years practitioners skills in facilitating communication through a language rich environment 3. Develop a screening tool to promote appropriate and timely referral to speech and language therapy. The local education authority approached a number of early years settings that had not previously been involved in Sure Start or Education Action Zone initiatives and asked them if they wanted to commit to the project. Eight of the respondents, with children aged 3 and 4 years, were selected to take part. They consisted of two local education authority nursery schools and six local education authority nurseries attached to mainstream primary schools. The nurseries varied in size from 15 to 40 children per session, and from 2 to 6 members of staff. Three of the nurseries included children from ethnically diverse cultures. Each setting needed to commit one member of staff to the project for one year. These project early years practitioners needed to be available during our weekly visits to discuss the communication needs of individual children, and appropriate modifications to the language environment, such as visual timetables or labelling objects. These visits were intended to address the communication needs of all children within the

nursery, not just those already known to the speech and language therapy department. We sent a letter addressing the issue of consent to parents from each nursery and none refused permission. The eight project early years practitioners, a mixture of teachers and nursery nurses, were also required to attend a whole days training session on a fortnightly basis and then cascade the information to all other members of their setting. The training sessions were split into three terms and included a mixture of direct teaching, small group work, and whole group discussions. Topics covered in term 1 were: What is communication? Speech development Receptive language Expressive language Social communication Dysfluency. Each topic addressed normal versus delayed / disordered development. We aimed to make the sessions as interactive as possible, encouraging and valuing contributions from each practitioner. Tips to encourage the development of each of these topics - and therefore help create a language rich environment - were provided. This included strategy posters for display in the nurseries and to give to parents. As the project progressed, sharing ideas and experiences became an invaluable aspect of the training (figure 1). We set time aside for this, and developed a booklet of the ideas. Relationship building was an important aspect of the training sessions. The group valued sharing ideas and good practice, and became very supportive of each other. As an example, practitioners arranged informal visits to each others nurseries throughout the year. Participants also visited an Early Years Centre of Excellence. This gave them the opportunity to discuss how such a centre addresses the communication needs of children.

An active role
The knowledge gained during term one meant that participants could play an active role in developing the screening tool with us. We ran a trial of the draft screen on six children from each nursery. All of these children had been in nursery for one term. This gave them the chance to settle in, and for staff to get to know them, to reduce the need for one-to-one assessment by withdrawal - something the early years inspector particularly wanted to avoid. We suggested the nurseries should trial the screen on two higher, two medium and two lower ability children. We made adjustments following the trial and presented the final screen to the early years inspector. This input, and comments from practitioners involved, led to us developing two levels of screening, the first a quick screen (figure 2), to be administered to all children following one term in nursery. This would identify those in need of the more detailed screen to be

10

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

STRATEGY
Figure 1 Examples of ideas generated during training sessions

Strategies for language development


Planned opportunities for speaking and listening Engage child by talking about their interests Role play / using play situations Circle time for choices / turn taking etc, singing nursery rhymes Using key words, rather than complex language Bilingual support as appropriate Visual timetables / displays Working with parents, toy and book loan

Strategies to develop listening skills


Use visual aids Use of puppets with stories Small group work In groups, sit child close to speaker Use music and sound effects (rhymes / songs) Use rewards eg. stickers / charts Listening games (guess the instrument) Attention boxes

used at the beginning of the second term to indicate which children to refer to speech and language therapy. We did, however, say not to delay referral if the child had glaringly obvious communication needs. The early years inspector suggested that, for the more detailed screen, we build on the Early Profile used in Wolverhampton. This was first developed in 1999, and has since been revised following the introduction in 2000 of the Foundation Key Stage and in 2002/3 of the National Foundation Stage Profile. The profile aims to encourage a coherent and consistent approach to the profiling of children, from birth to five, in all settings within the city of Wolverhampton. (Wolverhampton Early Years Development and Childcare Partnership, 2003). Once a child has been in nursery for approximately one term, the quick screen is completed. Scores indicate whether a child requires the more detailed screen, would benefit from language enrichment, or is progressing within normal limits. We hoped that the more detailed screen would only need to be carried out on a small number of children, and trials indeed indicated that the majority of children would benefit from language enrichment rather than specialist input from the speech and language therapy department.

Figure 2 The quick screen Name: Age: years months

QUICK SCREEN
Listening and Understanding
Understands a large number of objects by name Responds to simple instructions Shows understanding of simple stories (comments made and response to questions) ___ ___ ___ Total /3

Vocabulary and Expressive Language


Indicates needs and wants by gesture, word or sound Has a wide vocabulary of basic words Uses short phrases of 3 to 5 words ___ ___ ___ Total /3

Social Communication
Uses eye contact appropriately (i.e. not fleeting/absent/excessive) Interacts appropriately with other children Responds appropriately to questions and requests ___ ___ ___ Total /3

Observations
We developed the detailed screen so it could be done via observations within the nursery during child initiated and / or adult focused activities. This would save time and reduce the need for one-to-one assessment. The early years practitioners came up with a list of ideas / activities to extract this information. This included role-play activities, counting activities, and circle time. Practitioners completed questionnaires throughout the project. These were distributed pre- and post-project, and at the end of each term. Before and after the project, they were asked to rate how confident they felt in identifying children with speech sound difficulties and language difficulties (figure 3). Practitioners felt more confident in identifying speech difficulties than they did language difficulties before the project started. However, post-project, confidence levels in both areas increased, with a notable increase in identifying language difficulties. We also collected a large amount of qualitative data via questionnaires. Participants were asked how they had personally benefited from being involved in the project. They said: Knowledge of speech and language difficulties has increased. New ideas / strategies to use in the nursery to support children with communication difficulties. Good professional development. Working with others as a team and exchanging ideas. Knowledge of assessing children increased. Easier to identify children having problems with speech sounds and so better able to understand them.

Speech Sounds
Speech can be understood by a variety of people ___ Total /1

Figure 3 Pre- and post- confidence levels

Speech:

Confidence level Very confident Fairly confident Not confident Very unsure

Pre 0 5 2 0

Post 1 6 0 0 (One participant did not return the postproject questionnaire so was not used in this analysis)

Language:

Confidence level Very confident Fairly confident Not confident Very unsure

Pre 0 2 4 1

Post 1 6 0 0

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

11

STRATEGY
Figure 4 Programme of training day

Morning session
Introduction: history of the screen, outline of the day, and expectations Icebreaker - as a group gelling activity to encourage interaction between participants I CAN video An overview of communication in young children covering: - areas of communication development / factors involved in language delay - receptive language - expressive language - speech - social communication - dysfluency

been a lot of very hard work put into this project. Schools need this type of tool. Congratulations (November 2003). The project has reinforced some of our beliefs and given us pointers for the future direction of the speech and language therapy service. It confirms that collaborative work is essential if the childs communication needs are to be supported effectively. We have become more aware of time pressures on nursery staff and more able to give advice on supporting childrens communication needs through everyday and group activities.

Key worker
We felt the support for children was more effective when all staff, not just those involved in the project, took on board advice and ideas. However, the project experience also suggests that nurseries need to provide an identified key worker who is able to attend training, liaise with the speech and language therapist, and carry out specific activities with children with communications needs. This key worker should endeavour to involve parents / carers as much as possible as, for a variety of reasons, it is not always possible for a speech and language therapist to meet parents directly. A high proportion of children enter early years settings in Wolverhampton with delayed communication skills. This has significant implications in terms of nurseries providing a communication rich environment and indicates a specific training need for all practitioners in early years settings. This is being addressed via the local education authority. Although not specifically targeted in the project, many of the children were also identified as having limited attention and listening skills. This can often have a negative impact on the development of communication skills. Early years practitioners would therefore benefit from training and advice in this area, and this suggestion has been highlighted with the early years inspector. Finally, given that high numbers of children are entering nursery education with speech and language delay, parents / carers would benefit from support and advice in developing their childs communication skills from birth. This is happening in small pockets but not as yet on a larger scale. We have also done some separate training for health visitors who refer to our service. Our three project objectives were met and those involved have judged the project a success. Training is still ongoing, so any effect on referral rates will be assessed at a later date. Carol Sutton and Joanna Sedgemore are speech and language therapists with Wolverhampton City Primary Care Trust, Red Hill Street Health Centre, Red Hill Street, Wolverhampton WV1 1NR, e-mail carol.sutton@wolvespct.nhs.uk or joanna.sedgemore@wolvespct.nhs.uk.

Afternoon session
Overview of speech and language therapy service in Wolverhampton Screening tool - information pack and how to administer screen - quick screen - each section explained, followed by practical application on fictitious child - detailed screen - each section explained, followed by practical application on fictitious child Strategy pack distributed and explained Evaluation

NURSERIES NEED TO PROVIDE AN IDENTIFIED KEY WORKER WHO IS ABLE TO ATTEND TRAINING, LIAISE WITH THE SPEECH AND LANGUAGE THERAPIST, AND CARRY OUT SPECIFIC ACTIVITIES WITH CHILDREN WITH COMMUNICATIONS NEEDS.

Able to discuss individual children directly with the speech and language therapist. Becoming more aware of the different needs and approaches to individual children. Participants were also asked how they felt their nursery had benefited from the project. They said: Speech and language therapists coming into the setting and working with children. Noticed a difference in the children involved in the project. Other staff benefited from feedback of the sessions. Working directly with the speech and language therapist. Greater awareness of problems leads to earlier detection. Children more comfortable in their own environment. Regular joint goal setting. Speech and language therapist provides support for the whole team. Parents feel comfortable and happy to see the speech and language therapist in the nursery. More confident in speaking to parents about individual childrens communication needs. Following this positive feedback on the project, the local education authority was keen to introduce the screen to all early years settings in Wolverhampton. The organisers envisaged that one member of staff from each setting would receive a days training, and three such days were scheduled for 2003/4 (see programme in figure 4). To date, approximately 75 settings have received the training, and are using the screening tool to refer to speech and language therapy. We have now been asked to provide an additional two days of training to ensure that all remaining settings have been covered. Further evaluation will be carried out following these dates, but the majority of comments received to date have been positive and encouraging: Fantastic day - its nice to go back to school with something useful that has the potential in the long term to reduce the work load. Obviously there has

Acknowledgements
Many thanks to all the project early years practitioners for their constant support, ideas and enthusiasm.

References
Wolverhampton Early Years Development and Childcare Partnership (2003) Early Profile. I CAN (2003) Helping Childrens Speech and Language Development in the Early Years. Video.

DO I MAKE SUFFICIENT EFFORT TO UNDERSTAND THE PRESSURES ON OTHER WORKERS AND TO TAILOR ADVICE TO THEIR SETTING? DO I BUILD IN OPPORTUNITIES FOR RELATIONSHIP FORMING AMONG COURSE PARTICIPANTS DURING TRAINING? DO I CLARIFY LEVELS OF CLINICAL NEED AND WHERE THESE NEEDS ARE BEST MET?

12

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

WORK IN PROGRESS

Yes or no - do we know?
IF YOU WANT TO WORK WITHIN THE FRAMEWORK OF THE LAW GIVE CLIENTS THE CHANCE TO TAKE RISKS MAINTAIN THE BOUNDARIES OF YOUR ROLE

If you work with any client group where assessing capacity to consent is an issue, you need to be aware of new legislation and its implications for your practice. Louise Scrivener looks at capacity to consent to treatment and to broader lifestyle decisions, and brings us up to speed with how this is being tackled in North Warwickshire.

bjective three of Valuing People (2001a) identifies the need to increase and support choice / control for people with learning disabilities. However, in practice, this is becoming an increasingly complex issue for clinicians, particularly when considering issues around capacity to consent (Murphy & OCallaghan, 2004). This article reviews the current legislation and how I am beginning to put the theoretical issues into a practical framework. This may also be relevant to therapists working with other client groups, for example therapists who have to gain consent for treatment from parents / carers of young clients, or from adults with acquired brain injuries.

7. Parents and relatives of people over the age of 18 do not have the right to give consent on behalf of a person; however, it is recommended that they are involved in the process as much as is practicable without breaching confidentiality. (Lord Chancellors Department, 2003; The Mental Capacity Bill, 2004)

B. CONSENTING TO MEDICAL TREATMENT


In 2002 the Department of Health identified information that professionals need to provide for people with learning disabilities before they can make a decision regarding treatment. This included: What will happen? Why it may be good for you? What it could feel like? Any potential problems? Possible extent of improvements? Not listed, but surely also required, are: Are there any other options? What may happen if you dont go ahead with treatment? It is recommended that to demonstrate capacity a person must be able to: retain the information given compare alternatives, express their own thoughts, and discuss possible consequences apply the information to themselves (Lord Chancellors Department, 2003; Wong et al, 2000). Therefore the professionals need to: provide sufficient information assess competency to make the decision ensure the person is acting voluntarily (DH, 2001b). Treatment may still be provided, even if a person is considered to lack capacity to consent. In this case treatment will be in best interests. Where this is used, the multidisciplinary team needs to ensure that the potential benefits are greater than any potential burden (Lord Chancellors Department, 2003). The Department of Health (2001b) also recommends that the clients wishes be taken into account, and parents / relatives are consulted where this doesnt breach confidentiality.

A. LEGISLATION
The recently released Mental Capacity Bill (2004) defines in detail when a person is considered to lack capacity, and how professionals must act if a person is established to lack capacity. There appear to be two sides to the consent debate: assessing capacity to consent to treatment, and assessing capacity to consent to broader lifestyle decisions. The first has received more attention, possibly as it seems to be more straightforward in terms of the decisions made and also because the debate has been around for longer. However, we are increasingly realising the importance of ensuring that people with learning disabilities are offered choices in their lives. This means that clinicians are coming across cases where clients are making life decisions that can increase choice and opportunity but that can also increase their vulnerability and make caring for them more complex. That is not to say that people with learning disabilities shouldnt be offered choices - of course they should - however, as professionals, we need to ensure that we are aware of and adhering to any legislation provided by the government. The law says that: 1. Everybody has the right to make decisions within their own lives. 2. People are assumed to have capacity, unless it can be shown otherwise. 3. Assessments must be made in each case, for each decision. 4. Consent is a process, not a one off event (DH, 2001b). 5. Treatment can still go ahead for people who have been determined to lack capacity if it is considered in best interests. 6. People need to be involved in all stages of the process, even is it is established that they lack capacity.

C. CONSENTING TO SOCIAL LIFESTYLE CHOICES


This debate can be very broad in terms of subjects considered. For example, it could involve capacity to consent to sexual relationships, going to the pub, drinking alcohol, taking drugs, having children; in fact the list is endless. This is a complex debate for professionals as: there is a lack of legal clarity moral perceptions vary between professionals about right and wrong

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WORK IN PROGRESS
one possible outcome of intervention is the restriction of freedom this will have to be balanced with the need to protect vulnerable adults. Therefore a team needs to research each area it is considering to find out if there are specific laws which can be applied, as Murphy & OCallaghan (2004) did when looking at a functional assessment of capacity to consent to a sexual relationship. The Lord Chancellors report states that, Healthcare professionals have no authority to make any other sorts of decisions, such as personal or welfare decisions - however Brown (2004) points out that ... autonomy cannot be equated with non-involvement and that some decisions need to be made to protect vulnerable adults from possible abuse or exploitation. psychologist in North Warwickshire. It shows how the team needs to gather information and agree the resources to be used in the initial stages. It is also important at this stage that the team is very clear about the possible outcomes, as the client will need to be informed of these before entering into the assessment. Two allocated professionals then need to carry out the work with the client, before feeding back to the team who can agree the outcome. This work has many dimensions to it. I have taken the guidelines used to assess capacity to consent to medical treatment (Lord Chancellors Department, 2003; Wong et al, 2000), and applied them to the worked example in figure 2, and the consent flowchart. The Department of Health (2001b) discusses the need to ensure a person is under no pressure to respond in a certain way. This has also led me to consider suggestibility / acquiescence when carrying out an assessment. Clare & Gudjonsson (1993) found people with learning disabilities to be more suggestible when presented with leading questions in interview sit-

it is difficult to maintain the boundaries and we need to highlight that our role is to facilitate the communication, not to provide the content of any discussions.

D. THE ASSESSMENT PROCESS


Figure 1 shows a suggested process for assessing capacity to consent. This flowchart was developed following discussions with Liz Chesters, a clinical Figure 1 Consent process (North Warwickshire Primary Care Trust)

Assessing capacity to consent to specific social situations


TEAM
COMMUNICATION ASSESSMENTS

2 ALLOCATED PROFESSIONALS
CLIENT AGREES TO PARTICIPATE. CONSIDER GAINING THEIR THOUGHTS, FEELINGS AND BEHAVIOURS AS A BASELINE. PRESENT INFORMATION IN AGREED FORMAT. ASSESSMENT SESSION: CHECK CLIENTS ABILITY TO 1. PARAPHRASE 2. COMPARE ALTERNATIVES 3. EXPRESS OWN THOUGHTS 4. DISCUSS POSSIBLE CONSEQUENCES 5. APPLY THE INFORMATION TO THEMSELVES THIS CAN BE DONE BY: FREE ACCOUNT ANSWERING SPECIFIC (PRE-AGREED) QUESTIONS

TEAM
EVIDENCE COLLECTED THAT CLIENT DOES HAVE CAPACITY TO CONSENT. TEAM SUPPORTS THEIR DECISION.

RISK ASSESSMENTS

PSYCHOLOGY ASSESSMENTS

NB. AT THIS STAGE NEED TO RATE RISKS, IDENTIFY ONE AREA TO TARGET, FORMULATE QUESTIONS AND CONSIDER THE POSSIBLE OPTIONS/ OUTCOMES

AGREE RESOURCES E.G. PLAN CONSENT SESSIONS, AGREE WHAT INFORMATION CAN THE TEAM REASONABLY EXPECT A PERSON TO KNOW? DECIDE WHO WILL BE INVOLVED IN THE NEXT STAGE

R E V I E W R E G U L A R L Y
(OR AS SITUATION CHANGES)

CONSENT SESSION(S) WITH CLIENT. EXPLAIN OPTIONS AND POSSIBLE OUTCOMES

EVIDENCE COLLECTED THAT CLIENT DOES NOT HAVE CAPACITY TO CONSENT.

CLIENT DOES NOT AGREE TO PARTICIPATE

TEAM MAKES A DECISION IN BEST INTERESTS

RECORD DISCUSSIONS / DECISIONS AT ALL STAGES

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WORK IN PROGRESS
uations. They developed an assessment tool, but it is also possible to assess suggestibility informally by gathering examples during a conversation. Endres (1997) discusses using an informal approach through asking questions about a peripheral subject. However he cautions that to a certain extent we may all be suggestible to some questions, and that it is normal to be led by some questions. The speech and language therapists role in this situation should be quite straightforward - supporting communication between the clients and the other professionals, and also supporting the development of any necessary resources. In my experience, however, it is difficult to maintain the boundaries and we need to highlight that our role is to facilitate the communication, not to provide the content of any discussions. The multidisciplinary team needs to be aware of the need for skilled professionals to facilitate communication to ensure that real and true choices are being expressed. Professionals without the necessary knowledge base can incorrectly assume that capacity can be assessed in general terms - without appreciating that we can only consider capacity to consent to specific issues. The process is (and needs to be) much more complex than this. This highlights how the whole team needs to be aware of the process. Professionals carrying out the assessment need to be impartial. They should not be setting an outcome and then gaining evidence to support it. The team needs to decide what it is reasonable to expect a person to know before it can agree on the assessment process. We need to ensure that choices offered are real and that a clients wishes will be respected even if professionals do not agree with their choice. We need to allow risk taking! The team needs to responsibly balance health and safety concerns with an individuals right to take risks in their lives. The National Service Framework for Children, Young People and Maternity Services (2004) identifies the importance of this factor when promoting inclusion.

F. PROGRESSING THE WORK


What other resources / solutions have you found helpful in assessing capacity for consent? In what way is your practice changing as a result of the new legislation? How does Louises experience with adults with learning disabilities differ from what is happening with other client groups? Through the work in progress section we are looking for readers to share their ideas, big or small, so everyone can benefit. If you have something to add, please e-mail or telephone the editor, avrilnicoll@speechmag.com / 01561 377415. Louise Scrivener is a specialist speech and language therapist with North Warwickshire NHS Trust, e-mail louise.scrivener@nhs.net

E. RECOMMENDATIONS
After participating in the consent debate on a very practical level, I would recommend: Figure 2 Case example

Mr Brady (34) lives in supported housing. He has been drinking excessively, and coming home drunk. He spends most of his weekends in the pub, and has on several occasions come home with bruises although he has denied fighting. Staff are concerned about the risks Mr Brady is placing himself in, but also the long term effects on his health. He is unable to take his evening medication (which cannot be changed) when he comes home drunk. They are finding it increasingly difficult to manage this behaviour. Following an initial meeting, the team agreed I would carry out the work with the community nurse who has know Mr Brady for many years. The team agreed we needed to discuss drinking with Mr Brady, and the possible implications including short and long-term effects on your body, associated risks (such as increasing vulnerability), risks of not taking medication and the possible effect on his current placement. During an initial consent session, the process and rationale was explained to Mr Brady. We needed to gain his consent to carry out this piece of work. Using an accessible format, we explained about the flowchart and that the team may have made a decision in best interests if he did not agree to participate. Mr Brady then essentially had two options: 1) to participate in the piece of work - determining his capacity to consent to drinking or 2) to refuse to participate. However, we also felt there was a third option that needed to be discussed. 3) Mr Brady may have elected to participate but not engaged fully - this would prevent a true assessment. Mr Brady agreed to the first option, and we spent the first session discussing his personal thoughts and feelings about alcohol and being in the pub. We then spent eight sessions discussing this in further detail with him, and providing him with information. At this stage I was pleased to have another professional to work with, as I was able to maintain that I could only facilitate the communication and help develop resources, but was not in a position to set the content of our sessions. We moved on to the assessment, where we recognised the need to gather information regarding his ability to paraphrase, compare alternatives, express his own thoughts and discuss possible consequences, and also to apply the information to himself. This is taken from the capacity assessment guidelines used when considering medical treatment. Wong et al (2000) support the use of uninterrupted disclosure or free account, which we used before moving on to asking a series of specific questions. Mr Brady demonstrated that he was able to paraphrase, compare alternatives, begin to express his own thoughts and discuss consequences. However he continued to have difficulty applying the information to himself. We also found that he was highly suggestible to leading questions. On feeding this information back to the team it was agreed this meant that, while Mr Brady demonstrated partial capacity, he continued to be vulnerable. We have agreed a contract with Mr Brady in which he can visit the pub on certain occasions, will monitor his own drinking, and will continue to develop the information we provided with staff at his home. We have also referred Mr Brady for Cognitive Behaviour Therapy, to explore the links between thoughts, feelings and actions.

References
Brown, H. (2004) Valuing People Learning Disabilities Strategy Document: Abuse and protection issues. Salomans Centre for Applied Social and Psychological development. Clare, I. & Gudjonsson, G. (1993) Interrogative suggestibility, confabulation and acquiescence in people with mild learning disabilities (mental handicap): implications for reliability during police interrogations. British Journal of Clinical Psychology 32 (3): 295-301. DH (2001a) Valuing people: a new strategy for learning disability for the 21st century. Department of Health, www.valuingpeople.gov.uk. DH (2001b) Seeking Consent: working with people with learning disabilities. Department of Health, www.dh.gov.uk (search consent). DH (2002) Consent. A guide for people with learning disabilities. Department of Health, www.dh.gov.uk (search consent). DH (2004) National Service Framework for children, young people and maternity services. Department of Health, www.dh.gov.uk. Endres, J. (1997) The suggestibility of the child witnesses: The role of individual differences and their assessment. Journal of Credibility assessment and Witness Psychology 1 (2): 44-67. Lord Chancellors Department (2003) Making decisions, Helping people who have difficulty deciding for themselves - a guide for healthcare professionals. Mental Capacity Bill (2004) The United Kingdom Parliament. www.publications.parliament.uk. Murphy, G. & OCallaghan, A. (2004) Capacity of adults with intellectual disabilities to consent to sexual relationships. Psychological Medicine 34 (7): 1347-1357. Wong, J., Clare, I., Holland, A., Watson, P. & Gunn, M. (2000) The capacity of people with a mental disability to make a health care decision. Psychological Medicine 30 (2): 295-306.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

15

FEATURE ON...BREAKING NEWS

Facing the
We can all repeat stories from families and friends of how bad news has been broken in an apparently thoughtless, inhumane, cold or unclear way. With greater life experience, I have gained more insight into how parents, clients and carers might be affected by the realisation that there is something wrong with their perfect child, or that they have lost or are losing the person they were or the person they knew. As my awareness has developed, the idea of breaking bad news has in many ways become more daunting. While I have some good experience to draw on, I also have dreadful memories of handling such situations really badly. For obvious reasons there are no randomised controlled trial results for breaking bad news, and no gold standard procedures. Vandekieft (2001) says several professional groups have published consensus guidelines, but that few are evidencebased, and clinical efficacy of many standard recommendations has not been demonstrated empirically. However, we need no more than common sense to know that the way news is given impacts on how it is received, and that we can all learn to improve our skills. According to the Foundation for People with Learning Disabilities (Davies, 2005), a badly handled diagnosis can result in a family rejecting much needed further help and support. Negative and distressing experiences can lead to distrust, and consequently families are left to deal with extra pressures. The report has led to the production of a booklet to help families of a young child with a learning disability access emotional and practical support. Appropriately named First Impressions it says that, For most parents the moment of receiving the news of their childs diagnosis is life-changing. The first reaction can include shock, numbness, disbelief, hurt, anger, anxiety, fear, feeling vulnerable and isolated, joy and overwhelming love for their child - and often a mixture of these emotions.

Arguably, one of the most difficult aspects of our work is discussing a diagnosis or the need for onward referral with clients, carers and parents. Avril Nicoll asks why we fear breaking bad news, and how we can get better at doing it.
about how professionals and the family will all work together. But why is this so difficult? Independent speech and language therapist Geraldine Wotton has experience of picking up the pieces following a clumsy and sometimes inaccurate / distorted diagnosis which makes parents so full of fear that a realistic view is obscured. She thinks there is too much of a split between diagnostics and therapeutics, and that those doing the initial diagnosis are therefore not aware of the potential for change in spite of that diagnosis. Through a far closer alliance between those within diagnostic and therapeutics, a joining metaphorically of the head and the heart, she believes the professionals at the start of the process will be able to provide a clearer clinical picture more confidently, and break the news more humanely. inadvertently work against this. Birmingham based speech and language therapist Nibbhaya suggests that our discomfort with breaking news is linked to our need to feel in control, and that we benefit from letting go. We need to remember - and get across to clients - that change and development is constant and nobody can predict what the future will bring. Notwithstanding this, Brewin (1996) recommends that the professional giving bad news shows leadership qualities such as staying calm, showing confidence and being decisive, to give strength in a crisis. Establishing trust and rapport is essential and may sometimes be at least as important as the information given (p.20). A message given in a positive way is better understood and better for morale. People like optimism in the sense of I cant promise, but what we are hoping is... (p.58). Our training and experience give us the professional responsibility and should also make us feel confident in showing this kind of leadership. Preparation is also a factor in how confident we feel, and it shows. The first contact people have with a speech and language therapy department is routine to us but can be absolutely terrifying for them. What messages do our appointment system, pre-appointment information and waiting area send out? How welcoming, private and safe is our environment? Are we seated at the same level, alongside rather than behind a desk? Do we have a box of tissues handy? Being friendly, putting people at ease and showing evidence of preparation for the visit instils confidence and works on trust before anything to do with communication need is discussed. In clinics we tend to make do with the space we have, but perhaps we need to use it more flexibly. Reflecting on how she was told her daughter had a congenital heart problem, Williamson (2004) suggests we make time just to allow parents a

a badly handled diagnosis can result in a family rejecting much needed further help and support.
Angela Jones, a specialist therapist in Rhondda Cynon Taff, is also critical of what she believes is the reductionist, science-based approach to understanding the mechanism responsible for the patients difficulties, and considers this underlies a paternalistic model when providing information. Its not so long ago that parents sat outside the therapy room, or that it was thought best not to tell people if they had a life limiting disease so as to protect them. Society has moved on to recognising that people are best at making decisions for themselves - but as individuals we can

Listen well
The booklet makes it clear that professionals need to listen well to families concerns, follow up the initial appointment, and give the right amount of information at the right time. Support needs to encompass the extended family, how to access further information and benefits and reassurance

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FEATURE ON...BREAKING NEWS

fear
they have any ideas what might be going on. Have they seen someone similar or anything on television that might be relevant? The hope is that the parent will use the word autism so that the therapist can say, Yes, I was thinking about that as well. Finding out what a parent, client or relative already knows or thinks is essential. It gives voice to their fears, is a start to them finding their own solutions, and it helps you judge how to pitch your follow-up information at the right level. Often, as in the case of autistic spectrum disorder, or when you suspect an undiagnosed neurological disorder, you will be the professional who breaks the news in the sense of raising the possibility but an onward referral is needed to confirm it. When Keighley speech and language therapist Sarah Chamberlin is suggesting referral to a paediatrician, she uses her paediatrician colleagues three strand approach with parents: that problems could be due to learning difficulties, autistic spectrum disorder, or that they may not have any identifiable cause. Sarah says the advantage is that it raises questions, but doesnt immediately suggest one area. This means difficulties can be discussed without premature labels, thus keeping the focus on the difficulties rather than their cause. Brewin (1996) recommends discussing prognosis before diagnosis. Although he is specifically referring to cancer treatment, it seems reasonable to assume the same principles apply whatever the problem. His rationale is that a diagnostic label can be such a shock that nothing else is taken in. Rather than the relative being a passive recipient of news, they are involved in an exchange, and you are following their lead in terms of the timing and of how much and what type of information you give. Brewin also describes how watching the face of the person you are speaking to will give you feedback about how well what you are saying is being understood, when you have given as much information as they want, when you should be silent, when you need to listen and when it is time to stop. Preventing stigma - It could happen to anyone - is also useful, and a session should always end with a summary and an agreement for a follow-up meeting. phase, and provides the therapeutic part of the dialogue. The aim is to help the patient try to name their feelings. Naming something in a sense gives it an existence independent from the person...If powerful feelings emerge (fear, anger) they soon subside once acknowledged (1995, p.20). It is important for the professional to stay calm and give the client, parent or carer time and space to do this. As one half of a specialist speech and language therapy and counselling partnership (www.intandem.co.uk), Sam Simpson is well qualified to explain why personal barriers may make it difficult for professionals to create this space. Such barriers can include our personal level of comfort with expression and open discussion of strong emotions, perhaps because of our family culture, or the way we respond ourselves to such challenges. We all have personal beliefs and prejudices, and different experiences of disability and death, as well as different levels of self-awareness that can lead us to over-identify with clients. Our personal therapy style and perception of the breadth of our role can make us reluctant to leave our comfort zone, and this may also be influenced by the culture of the department we work in. Therapists who have more interest and confidence in using counselling skills and access to supervision (preferably non-managerial) and support are more likely to feel comfortable with the breaking news aspect of our role.

Posed by models
chance to sit alone (not on public view) and have a cup of tea (even if the last thing as a parent you want to do is drink the tea). Given that a recent study is reported to have shown that discovering a child has a food allergy can cause parents more anxiety than learning they themselves have cancer (Redfern, 2005), it would be foolish to assume we can predict the intensity of reaction on the basis of our perception of the seriousness of the situation. Equally, we cannot assume our perception that the news is bad will be shared.

Peter Kaye emphasises the concept of interlacing facts with questions about feelings How do you feel about what Ive just said?
Geraldine Wotton agrees that supervision is essential, particularly when we are dealing with people who have had a bad experience and therefore find it hard to trust and open up. Being able to detect the blocks, theirs and ours, is vital. Without this, the process of hearing, telling and moving on can become seriously undermined and threaten the therapeutic outcome. Working with a different client group - adults with learning disabilities - Angela Jones has also become very conscious that I may become biased and could project my values onto carers. I attempt to identify any possible biases and address these and my own possible feelings of distress in order to provide impartial professional advice.

Developing trust
Williamson (2004) found that Being allowed time to ask questions and having honest and frank answers was hugely important in developing trust. By the time someone reaches speech and language therapy, they may well already have an idea about what the problem is. Nibbhaya and Nicki Mason have done some inservice work for speech and language therapy colleagues in Birmingham on discussing the possibility of autistic spectrum disorder with parents. After both the parents and the speech and language therapist have described the childs strengths and weaknesses, they ask the parents if

Ventilation of feelings
In the preface to his excellent and concise book Breaking Bad News - A ten step approach, Peter Kaye emphasises the concept of interlacing facts with questions about feelings - How do you feel about what Ive just said?; How does this leave you feeling at the moment? Indeed, Kaye explains that ventilation of feelings is the KEY

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FEATURE ON...BREAKING NEWS


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Nibbhaya cautions that we have to accept that we cannot decide for other people when they will take on board what we are saying; this is part and parcel of surrendering control. If we become a target for unresolved anger, we must not take it personally. Brewin (1996) says, Never hold it against the patient that he chooses not to accept your advice. Stress that his decision will not impair future relations - nor your wish to go on helping him in every possible way (p.76). There are cases where this is never resolved, but I learnt a valuable lesson from one client who appeared to be in complete denial of his fairly severe aphasia. On the third re-referral, some five years after onset, I was astonished to find a warm welcome, calm acceptance and a desire for therapy.

Look after yourself


This is intense stuff. Sam Simpson suggests it is very important to look after yourself, by recognising yourself and your own needs within the therapy relationship, and the impact of the clients issues on yourself and on the multidisciplinary team. Other practical tips include sharing feelings with colleagues before and after, having access to joint sessions with colleagues, and familiarising yourself with options for onward referral (within your speech and language therapy team, multidisciplinary team or externally). Personally, Sam has found supervision, further training and independent reading in a variety of different counselling approaches has provided her with a range of useful frameworks and practical resources. These have enhanced her practice in listening to and assisting clients and their families to face difficult issues and painful decisions. Medical humanities, including ethics and informed consent, may be another source of support. Angela Joness work involves breaking news that may mean a change in life circumstances, such as onward referral for non-oral nutrition when a clients swallowing function has declined. Better understanding of the emotions, values and ethical elements of our practice has given her a wider perspective and guidance for clinical decision-making. Kaye (1995) defines bad news as any information that drastically alters a patients view of their future

for the worse. While it can be challenging to deliver, it is important so that trust is maintained, uncertainty reduced, appropriate adjustment enabled and a disabling conspiracy of silence prevented. We may not have the gold standard research to back us up but it seems clear that, if you find yourself using jargon, not listening or feeling the urge to keep talking, you are distancing yourself and blocking people from expressing their feelings and fears. As Kaye (1995) says, a person has a right, but not a duty, to hear bad news, which is why negotiation is needed to agree on the type and amount of information that ...[they] will find helpful at that moment. Empathy comes from being honest and open, listening well, encouraging the expression of feelings, following the client, carer or parents lead, and leaving the door open. To break news in an empathic way, we have to face the fear - and do it anyway.

Acknowledgements
Many thanks to all the speech and language therapists (names in bold) who provided information for this article.

References
Brewin, T. (1996) Relating to the Relatives - breaking bad news, communication and support. Radcliffe Medical Press: Oxford. Davies, J. (2005) First Impressions: Emotional and practical support for families of a young child with a learning disability. A guide for practitioners and service commissioners. The Foundation for People with Learning Disabilities. Kaye, P. (1995) Breaking Bad News - A ten step approach. EPL Publications. (Only available from EPL Publications, 41 Park Avenue North, Northampton NN3 2HT, 4.50.) Radcliffe, S. (2005) Press release sent to Speech & Language Therapy in Practice on behalf of the University of Derby. Vandekieft, G.K. (2001) Breaking Bad News. American Family Physician www.aafp.org/afp/20011215/ 1975.html [Date accessed 20/4/05]. Williamson, A. (2004) Breaking bad news: a parents perspective. Midwives 7 (4): 170-171.

PRACTICAL POINTS: A-E OF BREAKING NEWS


ADVANCE PREPARATION - TIME, KNOWLEDGE, EMOTIONS BUILD A THERAPEUTIC ENVIRONMENT / RELATIONSHIP COMMUNICATE WELL - FOLLOW THE CLIENTS LEAD DEAL WITH CLIENT AND FAMILY REACTIONS ENCOURAGE AND VALIDATE EMOTIONS - INCLUDING YOUR OWN AND THOSE OF YOUR TEAM.
(BASED ON VANDEKIEFT, 2001)

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KEYS TO WINNING WAYS SERIES (3)

KEYS
TO WINNING WAYS

The abundance key


In the third article of our series to encourage reflection and personal growth, life coach Jo Middlemiss asks if you can see the abundance within?
at a desert - a place full of wonder, life, interest and variety - and seeing only sand. We can look at abundance in two ways. What do you see when you read this sentence? ABUNDANCEISNOWHERE Is abundance now here? Or is it nowhere? Either answer is correct depending on your perspective. Seeing the world as an abundant place is a key to happiness and fulfilment because of the impact that that thinking has on your actions. That sense of abundance comes from within and therefore you will begin to recognise that you are good enough, you do have the necessary skills to solve the problems that seem to bring you down. Although you may have lived with a lifetime of conditioning that tells you something different, you can shake off that conditioning and rewrite your script. In their book Slowing down to the speed of life, Richard Carlson and Joseph Bailey have some very interesting points to make. It is our thinking that makes all the difference to our mental health, and choosing a style of thinking appropriate to the situation is what frees us from stress. Sometimes we need to be in a processing and analytical mode, at other times we need to be in free flowing mode.

I will not die an unlived life I will not live in fear of falling Or of catching fire I choose to inhabit my days To allow my living to open me Making me less afraid More accessible To loosen my heart So that it becomes a wing, a torch, a promise I choose to risk my significance. To live so that which comes to me as seed Goes to the next as blossom And that which comes to me as blossom Goes on as fruit. (Dawna Markova, I Will Not Die An Unlived Life) I came across this poem as I was listening to the radio in the middle of a restless night. After being printed as part of a book (Markova, 1991), it became an internet favourite and has inspired one of the authors subsequent offerings (Markova, 2000). I love this poem because it embodies so much of my own philosophy. What does it mean to risk my significance? That is the pivotal line for, if we could only stop fretting about our so-called position in life, how much freer we would be. I was walking once with a client who was very sad and perplexed: I just feel like a nobody! I pondered that for a while. Of course I understood what she meant; she felt that she did not count and had no significance to risk. However, I always like to see if there is a possible way to look at a situation that seems impossible. Something that she thought was the ultimate in sadness, I thought could be rather marvellous. Just imagine if you really were no-body! If you were needless. What would you be if this physical cage did not restrict you? You could fly, sing or dance. You could go anywhere your imagination could take you. You could have the experiences of birds or water or butterflies. There is so much abundance around that we simply wont see it, or we have lost the ability to see it. It is like looking

IF YOU ARE STUCK - BUT WANT TO FLOW AGAIN FEARFUL - BUT NEED TO BREAK FREE STRESSED - BUT KEEN TO THINK DIFFERENTLY
understand that it will eventually come back to me. He just said, Thats cool. And I thought that was a cool answer. I used to have a tight, frugal mentality, vaguely resenting the cost of everything and tut tutting about value for money. I now realise that money is simply energy and that, if we hang on tightly, it wont be able to flow. There is enough for all of us - food, water, heat and love - but it gets stuck. An abundance mentality means allowing all these things to flow. (Just think of the response to the Tsunami disaster.) It means knowing that giving love brings us love, that being generous opens our eyes to the joy of giving and that it always has a return, even if it is only a smile or our own selfgenerated warm glow. It isnt about stuff. It is never about stuff. It is always about attitude and perception - and that is what makes I will not die an unlived life such a wonderful poem. Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk. Jo offers readers a confidential and complimentary half-hour telephone coaching session (for the cost only of your call.)

Bursting with life


As I write, there is deep snow on the ground outside. It all looks frozen and sterile and yet it is bursting with life. There are snowdrops, aconites, crocuses, winterflowering cherry and a host of other early risers. They know nothing of scarcity. Have you ever thought about the fact that, even if we feel poor, in this country we are in the top 10 per cent of the worlds wealthiest? Have you ever tried giving a present to someone anonymously? Really secretly, telling nobody? Itll give you a real buzz. Have you tried paying for the car behind you when you go over a toll bridge? People are so shocked that someone would do that. I write with love and joy on every cheque and have only been asked once why I did it, by a young man in a bookshop. I told him, Its because I like to think of money flowing and circulating, and I

References
Carlson, R. & Bailey, J. (1998) Slowing Down to the Speed of Life: How to Create a More Peaceful, Simpler Life from the Inside Out. Hodder Mobius. Markova, D. (1991) The Art of the Possible: Compassionate Approach to Understanding the Way People Think, Learn and Communicate. Conari Press. Markova, D. (2000) I Will Not Die an Unlived Life: Reclaiming Purpose and Passion. Conari Press.

Shona is a speech and language therapist in an influential promoted post. She used to love her work and was passionate about making a difference. She feels frustrated and bored now, even though others more junior to her look to her for help and advice. Things have got so bad she is considering resigning. Jo says: Shona has forgotten that the reason she loved her work so much was because she brought the free flowing mode of creative teaching to her work. She has allowed herself to get stuck in analytical thinking, and that lets in the old enemy - fear. She is fearful that she might try something intuitive, which wont work, so she may be shown up as something less than expert. This fearful thinking has led her down a very narrow cul-de-sac with no seeming way out other than leaving. What a waste, and what sadness for the clients and juniors who would benefit from her expertise! She has lost sight of the abundance within for fear of the non-existent famine without. By concentrating on re-awakening her free flowing creativity in all aspects of her life, Shona will find new passion for the same work.

ABUNDANCE: The key for Shona?

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To taste or
IF YOU ARE INTERESTED IN QUALITY OF LIFE HUMAN RIGHTS INFORMED CHOICE

That is the question posed by Yvonne Macleman as she considers the limited and conflicting evidence around the use of oral tasters with adults with learning disabilities who have a percutaneous endoscopic gastrostomy / jejunostomy (PEG / PEJ). Her answer lies in the client being at the centre of the decision-making process about when rather than if - oral tasters are offered.

y early dysphagia experience was with adults with acquired disorders, where I learned about the all or nothing concept around oral intake versus tube feeding. This concept appears to negate the need for speech and language therapy involvement and does not support the necessity of oral tasters. I remember a particular comment - Mr Wilson has a PEG - you dont need to be involved. Working with adults with learning disabilities in both Lanarkshire and Glasgow, I found an increasing number of people were presenting with dysphagia that was seriously impacting on their health, well-being and quality of life. Management often involved a team discussion around the decision to refer for gastrostomy / jejunostomy. This led me to contemplate my previous experience, and to ask if speech and language therapists should continue to be involved after tube placement, and in what capacity. I began to question both the use and safety of oral tasters, and the evidence. A literature review revealed a dearth of information specific to adults with learning disabilities, with most research around older people with acquired dysphagia and / or people with dementia. But what does the limited literature tell us? And what current best practice should we use as a benchmark? A pivotal discussion at an American Speech-Language Hearing Association conference suggested that clients who are nil by mouth for some time may stop swallowing their saliva at

the normal rate (Hill et al, 1997), and therefore are potentially aspirating saliva. There is a history of establishing a link between aspiration and gastrostomy feeding (Campbell-Taylor & Fisher, 1987; Taylor, 2002), with PEG / PEJ being performed as a long-term solution to prevent the continued aspiration of foodstuffs. Indeed, there is evidence that, post-PEG / PEJ, some people develop aspiration for the first time, and other people continue to aspirate (Finucane & Bynum, 1996). The risk to elderly patients of aspiration pneumonia after PEG may actually be greater than that of a small amount of oral intake, as these patients spend much time in a reclined position (Campbell-Taylor & Fisher, 1987). For the same reason, this may also apply to many adults with learning disabilities. Other support for continued oral intake proposes a dedicated attempt to feed by hand, and suggests PEG as a last resort (Finucane & Bynum, 1996). A key statement concludes that PEG is just as likely to cause the problems that it is thought to prevent (Campbell-Taylor & Fisher, 1987). Thinking about oral tasters, PEG and aspiration from the physiological / chest perspective alone would seem to support therapists recommending oral tasters. However, looking at chest status only can often lead to us advising against oral tasters. Why is there this discrepancy between custom and practice and the literature evidence? Is there a tendency to err on the side of caution? And is this the most sensible plan of intervention in the absence of a sound evidence base? If we consider oral tasters solely from a physical perspective proposing nil by mouth after PEG - are we actually maintaining or even increasing the risk of aspiration of both saliva and refluxed materials? Further physical factors complicating the picture are the bodys tolerance for aspiration (Huxley et al, 1978), increased prevalence of reflux in the population of people with learning disabilities (Bhmer, 1996), and how pathogenic different foods, fluids and saliva are (Holas, in Garon et al, 1997). Within this very clinical debate lies the core of the issue - the client themselves. We have to, and should, consider: The clients quality of life - physical and emotional health and social inclusion. The clients rights - both within a human and legal framework. The right to choose, and if the client can make an informed choice. Quality of life is a complex issue. It is clearly not enough to decide for or against oral tasters on clinical grounds alone, when we are supporting real clients in real life.

Basic human need


We cannot underestimate the basic human need for food and fluid, and how this need is instinctively fulfilled by oral intake. Langmore (1999) states, most people agree that exclusive tube feeding clearly diminishes a persons quality of life, and advocates avoiding tube feeding altogether. She goes on to say, the psychological perception of thirst appears to be only adequately quenched by drinking a thin liquid; and water seems to be a superior choice to satisfy this need.

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not to taste
This is endorsed by Garon et al (1997), who reported on 20 patients with PEG following cerebrovascular accident, 10 of whom were allowed free access to water. All 20 patients were allowed thickened fluids. The study group reported being highly satisfied and highly pleased with free access to water, and that even small sips of water made a big difference. Conversely, in the control group, nobody reported satisfaction with the thickened fluids only. Groher (1990) endorses the use of ice chips in palliative care, and Leff et al (1994) allowed all tube-fed nursing home residents the chance to eat, regardless of coughing or choking. This leaves the speech and language therapist in a dilemma but considering the clients right and ability to choose can help. In the current climate of user and carer involvement, capacity to consent and human rights, it is essential to place the discussion around oral tasters within a person-centred framework. The Adults with Incapacity Scotland (2000) Act is a useful tool in supporting the client to be at the centre of the decision-making process regarding oral tasters. The act states that a person is deemed able to consent until proven otherwise. It is known that carers cannot consent on behalf of an adult with a learning disability, unless guardianship and / or power of attorney has been granted. This contrasts directly with Lo et al (1986), who found that 79 per cent of patients would want relatives to make decisions around health care needs for them, should they be unable to consent themselves. In order for the client to make an informed choice, the act requires a person to: understand the choice and the consequences of that choice make the choice act on the choice communicate the choice remember the choice made. As speech and language therapists, we are in an excellent position to support our client in the decision-making process around oral tasters. However, if consent cannot be sought from the client, either to accept or reject tasters, then the Act states that a group of significant people should decide for the client, based on the principles of minimum intervention, past and present wishes and the clients best interests. The Act emphasises the use of all methods of communication to support the person to make an informed choice, rather than precluding them from doing so. We must also consider a clients human rights, and both the Disability Discrimination Act (1995) and Human Rights Act (2000) should lead us to consider the ethics behind the oral taster discussion. the patients best interests, and stress how difficult it is to feel emotionally detached from your client, friend or relative if you have to withhold or withdraw nutrition. The emotional impact is not only felt by the client, but also by those close to them. Leff et al (1994) present the view that food and water are basic human rights, and that tube feeding may often start in a coercive atmosphere of pressure from physicians, families and carers: The presence of the tube and its use may create the impression that it is crucial for the maintenance of life. Whether or not oral tasters may indeed create similar feelings of anxiety for both the client and carers is debatable, but what is clear is that this must be included as a factor in the decisionmaking process either for or against tasters. The ethical debate is summarised concisely by Peck et al (1990), who question the goal of tube feeding - life, comfort or calories? The literature is conflicting and confusing, and the clinician is left in a clinical, moral and ethical dilemma with regard to oral tasters. In light of this, I continued to question my own practice. I sought opinions from colleagues and friends. As I found no literature looking specifically at oral tasters for adults with learning disabilities, I developed a questionnaire to establish a benchmark expert opinion. Oral tasters were defined as teaspoonful-sized amounts of foods and / or fluids which are swallowed. Textures of tasters were taken from the draft National Descriptors for Texture Modification in Adults (BDA & RCSLT, 2002). I sent 33 questionnaires to speech and language therapists working with adults with learning disabilities in Scotland and England. I excluded speech and language therapists working with clients with acute neurological change as such clients often experience sudden onset and spontaneous improvement, and have an aim of recovery. In contrast our goal with adults with learning disability is often maintenance, as they are likely to have chronic dysphagia that has been present from birth and is deteriorating with age. From a return of 20 questionnaires, 15 respondents recommended oral tasters. Of these 15 respondents, no one gave only one reason for recommending the tasters. It is reassuring to note that quality of life was rated by all respondents as a reason for continuing oral intake through tasters, and that a team approach to decision-making is often used; with client, carer and multidisciplinary team members all rating highly in the responses. Other reasons given were Aim was to return to eating and drinking orally Peer discussion Client showing interest in other people eating Risk of aspiration was minimal for quantity given Discussion with GP Recommended by the speech and language therapist in hospital. This tends to support the notion that decisions around and with the client are rarely made on one variable alone. In terms of oral tasters offered, food texture C, with a smooth, uniform consistency that will drop off a spoon rather than pour, is offered more often than other food types. Small

As I found no literature looking specifically at oral tasters for adults with learning disabilities, I developed a questionnaire to establish a benchmark expert opinion.

Best interests
In their paper outlining the ethics around feeding and nutrition, Miskovitz et al (1988) discuss the view that the provision of food and water is not morally distinguishable from other life-sustaining medical treatments that may be withheld or withdrawn from time to time. This emotive topic is included in Wolfsen & Kozarek (1992), who emphasise the importance of

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BENCHMARKING
amounts (1-3 teaspoons) were offered, and this was usually at mealtimes. It is worth noting that at mealtimes gave a comparatively high response rate, as this would reflect social inclusion of the person with a PEG with people eating orally during mealtimes. Further evaluation could question respondents about client-led timings for oral tasters, and whether mealtimes was understood as PEG feeding times or oral mealtimes. A range of fluid textures were offered, with thin fluid, naturally thick fluid and thickened fluids stages 2 and 3 being offered most often. Therapists were less likely to offer stage 1 thickened fluids (which can be drunk through a straw), or no fluids at all. Interestingly, of those five therapists who did not offer tasters to their clients, aspiration / chest status was cited as a reason by all respondents. Texture C foodstuffs with water in a large scale study similar to that of Garon et al (1997). Meanwhile, I am involved in further distribution of the taster questionnaire to a wider spectrum of health and social care professionals, including physiotherapists and dietitians. Yvonne Macleman is a speech and language therapist working for the Glasgow Learning Disability Partnership, e-mail Yvonne.Macleman@sw.glasgow.gov.uk. This article is based on an essay prepared for the Manchester Advanced (Level 3) Dysphagia Course, Adult Learning Disability Module. Yvonne is currently involved with Manchester Metropolitan University, looking at further research into this area.

Opinion has shifted


In supporting the adult with a learning disability who has dysphagia, and receives food and fluid via PEG, our goal must be to maximise health and maintain a good quality of life. In evaluating all the evidence, my opinion has shifted towards always considering and assessing for oral tasters post-PEG. To allow this to happen, we should consider not only a persons physical health, but also psychological impact on the client and carers, social inclusion, ethics, feelings and emotions. Human rights, legal rights and client choice must also be highlighted. The decision must be both client-centred and client-led, done with rather than to the person. What does this mean in practice? We need to develop a set of guidelines, rather than a prescriptive protocol. These guidelines should essentially indicate risk factors both for and against oral tasters, including all of the above parameters. Currently, if the decision is made to pursue oral tasters, the following questions may be considered:

References
British Dietetic Association & Royal College of Speech and Language Therapists (2002) National Descriptors for Texture Modification in Adults. Bhmer, C.J.M. (1996) Gastro-Oesophageal Reflux Disease in Intellectually Disabled Individuals. Amsterdam, The Netherlands: VU University Press. Campbell-Taylor, I. & Fisher, R.H. (1987) The clinical case against tube feeding in palliative care of the elderly. JAGS 35: 1100-1104. Finucane, T.E. & Bynum, J.P.W. (1996) Use of tube feeding to prevent aspiration pneumonia. Lancet 348: 1421-24. Garon, B.R., Engle, M. & Ormiston, C. (1997) A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. J Neuro Rehab. 11: 139-148. Groher, M.E. (1990) Ethical dilemas in providing nutrition. Dysphagia 5: 102-109. Hill, M.C., Hill, K.A.W. & Loma, L. (1997) Salivary flow, swallow frequency, and oral microflora in NPO patients. Exhibit presented at ASHA Annual Convention. Nov 20th-23rd. HMSO (1995) Disability Discrimination Act. HMSO (2000) Human Rights Act. Huxley, E.J., Viroslav, J., Gray, W.R. & Pierce A.K. (1978) Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am Jour Med 64: 564-568. Langmore, S.E. (1999) Issues in the management of dysphagia. Folia Phoniatr Logop 51: 220-230. Leff, B., Cheuvront, N. & Russell, W. (1994) Discontinuing feeding tubes in a community nursing home. The Gerontologist 34 (1): 130-133. Lo, B., McLeod, G.A. & Saika, G. (1986) Patient attitudes to discussing life-sustaining treatment. Arch Intern Med 146: 1613-15. Miskovitz, P., Weg, A. & Groher, M. (1988) Must dysphagic patients always receive food and water? Dysphagia 2: 125-126. Peck, A., Cohen, C.E. & Mulvihill, M.N. (1990) Long-term enteral feeding of aged demented nursing home patients. JAGS 38: 1195-98. Scottish Executive (2000) Adults with Incapacity (Scotland) Act 2000. Taylor, H.M. (2002) Pneumonia frequencies with different enteral tube feeding access sites. Am J Ment Retard 107 (3): 175-180. Wolfsen, H.C. & Kozarek, R.A. (1992) Perantaneous endoscopic gastrostomy. Ethical considerations. Gast Endosc Clin N Amer 2: 259-271.

The decision must be both clientcentred and client-led, done with rather than to the person.

Who?
A team decision, with the client at the centre of the decisionmaking process.

What?
Water (Garon et al, 1997), or Texture C foodstuffs (a smooth, uniform consistency that has a slow rate of oral and pharyngeal transit).

How Much?
1-3 teaspoons of food or fluid.

When?
Outwith mealtimes (presuming that mealtimes are times when a bolus PEG feed is given). This contrasts with questionnaire results, but would allow monitoring of a persons chest, and avoid confusing aspiration of tasters with refluxed material. However, this does present a challenge for carers to ensure social inclusion while eating and drinking.

How?
With the client eating and drinking independently, if at all possible (Langmore, 1999), in company, and socially included. Further research in the area of oral tasters is needed, specifically looking at adults with learning disabilities, possibly comparing

DO I RECOGNISE THAT TREATMENT MAY EXACERBATE PROBLEMS IT IS INTENDED TO SOLVE? DO I SUPPORT REAL CLIENTS IN REAL LIFE, OR DO I STICK RIGIDLY TO CLINICAL GROUNDS FOR DECISIONS? DO I ASK THE WHO, WHAT, WHEN AND HOW QUESTIONS THAT TAKE EVIDENCE INTO PRACTICE?

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RESOURCES

Public INVOLVEment
INVOLVE is a national advisory group funded by the Department of Health to promote public involvement in research to improve practice in health and social care. Its website includes information, guidelines, reports and a database of research projects where public involvement is making a difference right from the start of the process. www.invo.org.uk

resources

Traditional British as a pure


Mr Gills Traditional British Pures, a new range of texture modified meals suitable for Category C dysphagic patients, is available across the NHS. The 15 dishes include Chip Shop Fried Fish, with real batter, and Lancashire Hot Pot. Each contains less than 0.6g of sodium and over 500 calories per 300g. But, just as importantly, the manufacturers aim that they should all look appealing, smell delicious and taste like real food. www.texturemodifiedfoods.com

Black Sheep Press


New resources from Black Sheep Press include phonological awareness packs in Irish, 4 part sequences, Think About It for inferencing and reasoning, Barrier Worksheets and Fun with Narrative. They are available on card or CD. Black Sheep Press, tel. 01535 631 346, www.blacksheep-epress.com.

Driving assessment
The Stroke Association reports that researchers have found the Stroke Drivers Screening Assessment a more accurate predictor of driving ability following a stroke than independent advice given by a doctor. It is suitable for use by therapists and other medical staff. www.stroke.org.uk 84.50 + VAT from Nottingham Rehab supplies, tel. 0845 120 4522 (www.nrs-uk.co.uk). The assessment has also been trialled on people with head injury, multiple sclerosis and dementia.

Tips in eight languages


The National Literacy Trusts Talk To Your Baby campaign has produced a series of illustrated duallanguage quick tips for parents and practitioners. The tips have been translated into eight languages: Panjabi, Gujarati, Urdu, French, Tamil, Chinese, Arabic and Bengali. A master copy with space for practitioners to add their own translations is also available. The English text appears alongside each translation so the tips can be shared among all members of the extended family. Topics covered are sharing books, dummies, songs and rhymes, play, television, talking together, bilingualism and the social newborn. Download free from www.talktoyourbaby.org.uk.

Make Headway
Headway - the brain injury association has released an updated information booklet illustrated by cartoonist Bill Tidy. It has also produced credit card sized cards which survivors of a brain injury can use discreetly to alert others to their problems. (Source: The Encephalitis Society, www.encephalitis.info.) Welfare Benefits for brain injury survivors, see www.headway.org.uk Survivor cards, freephone 0808 800 2244

Directory for 2005


Contact a Familys 2005 Directory of Specific Conditions and Rare Disorders includes 25 new entries on recently diagnosed rare conditions such as Costello Syndrome and Ohtahara Syndrome, and a more detailed Cancer entry. Over 380 conditions and articles are featured, together with all relevant support groups. All entries are written or checked by medical experts. 35 book version; 88.13 single user copy on CDROM with extra information and a quarterly update; 29.38 for a single on-line user. Tel. 020 7608 8700 or see www.cafamily.org.uk.

If you want to Put up a poster for Parkinsons, contact the Parkinsons Disease Society on 020 7963 9300.

Listening as a way of life


Sure Start has funded 5 leaflets from the National Childrens Bureau on the theme of Listening as a way of life. The series aims to help practitioners design creative and individual ways of listening to children and each other. Titles include, Supporting parents and carers to listen: Guide for practitioners and Listening to young disabled children. Download free at www.earlychildhood.org.uk

Website for hard of hearing


Deaf and hard-of-hearing people and their families may want to access information, guidance and online support at a new website, www.talkhearing.com

Discussion paper
A discussion paper exploring reasons behind a perceived decline in young childrens language and communication skills is available at www.literacytrust.org.uk/ talktoyourbaby/researchindex.html.

New from Toby Churchill


Toby Churchill breaks the barrier between communication aids and environmental control with adVOCAte+, a small communication aid with trainable infrared and full environmental control capability. The company has also introduced a British English male and female voice across its Lightwriter range. Toby Churchill Ltd, tel. 01962 842792.

Inclusion
Don Johnston Special Needs has packages aimed at helping inclusion of pupils with literacy problems. SOLO includes Co:Writer, Draft:Builder, Write:OutLoud and introduces Read:OutLoud, while Write:OutLoud To Go for the Dana supports pupils when they want to write, wherever they are. Don Johnston Special Needs, tel. 01925 256500, www.donjohnston.co.uk.

National Clinical Director for Children, Professor Al Aynsley-Green, launches the Directory

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HOW I

HOW I FINDING THE REVIEW THE


REVIEWING (1):
ANNETTE KELLYS CLIENTS ARE AT THE HEART OF HER ENTHUSIASM FOR REVIEWING AND CRITICALLY APPRAISING THE LITERATURE AND THEY ARE REAPING THE BENEFITS.

LITERATURE TO CHANGE
REVIEWING (1) FINDING THE EVIDENCE REVIEWING (2) IMPROVING STUDY DESIGN REVIEWING (3) MATCHING PRACTICE TO THEORY
LITERATURE REVIEWS TELL US HOW A PARTICULAR ISSUE HAS BEEN EXAMINED ALREADY, AND WHAT STAGE OUR KNOWLEDGE IS AT. THEY EITHER PROVIDE US WITH EVIDENCE FOR OR AGAINST, OR DEMONSTRATE THAT THE CASE IS NOT PROVEN. THEY PREVENT REINVENTION OF THE WHEEL AND, USED WELL, GUIDE US IN DEVISING MORE TARGETED AND ROBUST STUDIES. IN ADDITION TO THEIR DAY JOBS, OUR CONTRIBUTORS ARE ALL MSC STUDENTS AT THE UNIVERSITY OF NEWCASTLE-UPON-TYNE. THEY CONSIDER HOW LEARNING TO SEARCH FOR EVIDENCE AND CRITICALLY APPRAISE IT HAS CHANGED THEIR PRACTICE. ANNETTE KELLY IS A SPEECH AND LANGUAGE THERAPIST AND LEAD CLINICIAN FOR HEAD AND NECK AND AIRWAY DISORDERS AT THE ROYAL NATIONAL THROAT NOSE AND EAR HOSPITAL, GRAYS INN ROAD, LONDON WC1X 8DA, TEL. 020 7915 1480. FROM JUNE 2005, SHE WILL BE THE SPEECH AND LANGUAGE THERAPY LEAD CLINICIAN FOR HEAD AND NECK AT THE HEAD AND NECK ONCOLOGY UNIT, UNIVERSITY COLLEGE LONDON. MARGARET YOUNG IS WITH THE SPEECH AND LANGUAGE THERAPY DEPARTMENT, SOUTH WING, MANOR HOSPITAL, MOAT ROAD, WALSALL WS2 9PS, TEL. 01922 721172 EXTENSION 6266, E-MAIL SPEECHTHERAPY@WALSALLHOSPITALS.NHS.UK. PIPPA HALES IS A SPEECH AND LANGUAGE THERAPIST WITH ADDENBROOKES NHS TRUST, CAMBRIDGE. LORNA GAMBERINI IS A SPEECH AND LANGUAGE THERAPIST WITH MORECAMBE BAY PRIMARY CARE TRUST. RITA OLIVER IS A SPEECH AND LANGUAGE THERAPIST WITH THE SPECIALIST LEARNING DISABILITY SERVICE IN CHESTERFIELD, E-MAIL RITA.OLIVER@CHESTERFIELDPCT.NHS.UK.

EVIDENCE
started to think about using evidence-based practice a few years ago when a motivated (but frustrated) patient turned to me mid-therapy session and said With respect, is there any evidence that this really works, and how long do I need to do this for? Up until then, I had operated on a largely cookbook approach, following a recipe of diagnosis (using a combination of observation and standardised assessments) and well-worn therapy approaches. While I had always reviewed therapy outcomes at regular intervals, I had never really thought to question whether what I was doing was based on good quality evidence. There is a growing emphasis on evidence-based practice in our profession and we are increasingly asked to justify our methods and their outcomes, not just to patients but also to students, professional colleagues and even financial managers. That patient was a young professional who had just undergone extensive surgery and radiotherapy treatment for a large oropharyngeal cancer. In addition to dealing with the side affects of his oncology treatment and the impact of this on his work and relationships, I was asking him to carry out a heavy regime of daily exercises, and his exasperation was completely understandable. His question really made me think - is there any evidence that these exercises improve function in head and neck patients? For how long is therapy necessary and relevant after head and neck oncology treatment? Are there any markers that predict long-term functional prognosis? Initially, I thought that searching the literature for relevant publications to answer a clinical question would be easy. I discovered however that it can be

PRACTICE

LORNA GAMBERINI SAYS I have been surprised by the horrifying gap in the evidence base for an awful lot of the things that we do in everyday practice because its always been done that way. Although it feels like a terrible chore at first to critically appraise papers, the skills to do so develop very quickly, especially if you have a good source book to fall back on (such as Greenhalgh, 2001). Two of my literature searches have been of particular clinical relevance. 1) the use or otherwise of topical anaesthesia for fibreoptic nasendocopy - having completed a nasendoscopy course and being faced with consultants who have opposing views, I found the evidence justified spraying the nose. 2) the effect of reflux on the voice - I now feel much more confident about educating medical staff, including GPs, about certain patients need for reflux medication if reflux is causing globus or dysphonia.

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HOW I

extremely frustrating and time-consuming if done in a haphazard way. My initial searches tended to yield either no articles at all or several thousand, the majority of which were useless to me. Honing the search to yield a handful of relevant and high quality publications was proving beyond my skills, and I was fortunate enough to be given some one-to-one training by an expert research librarian. This really opened my eyes to the value of using a consistent and systematic search strategy. For example, I discovered that while the Medline database is huge and contains most medical journals, it is an American database and therefore may miss out some European publications. Running the search through a European medical database such as Embase may pick up a few relevant additional publications. Relatively few speech and language therapy topics seem to be covered by Cochrane reviews but, given the quality of these systematic reviews, its generally worth taking a look. Finally, I have found it useful to widen the search to include databases such as the nursing and allied health database CINAHL that index therapy (rather than medical) journals. My librarian gave me lots of advice on the databases most relevant to my field of work (head and neck oncology and ENT).

tions can be directly downloaded and printed off which can save weeks of waiting if your library doesnt hold the journals you need. Again, Greenhalghs book provides a good basic overview of steps to critically appraising a paper.

Journal clubs
With the ever-increasing demands on our professional time, finding time to search the literature sometimes seems impossible and literature searches often get put at the bottom of the to do list. However, given the hours we spend treating patients and the time we ask patients to invest in carrying out therapy at home, taking an hour or two to work out whether this time is being spent usefully is easily justified. Journal clubs are probably the answer therapists can take it in turns to search the literature for evidence to answer a real clinical question or to support an assessment or therapy method. Sharing the results of literature searches limits the time investment required to practice in an evidence-based way, and avoids therapists reinventing the wheel. With reference to the patient with supraglottic cancer I discovered that, while there were few relevant papers with sufficient subject numbers to provide strong evidence to answer his question, the combined available evidence suggested that effortful swallowing manoeuvres (such as the Mendelsohn and the effortful swallow) do improve swallowing efficiency in patients with head and neck cancer. Giving him this information seemed to offer him the extra motivation he needed to commit to the intensive therapy programme of Shaker exercises, base of tongue exercises and effortful swallowing manoeuvres. At six months post-oncology treatment he was managing a normal diet and maintaining his weight without supplementary feeding. Work published since that time (Perry et al, 2003) suggests that the head and neck cancer patients communication and swallowing function at six months may be predictive, indicating that intensive therapy in the first few months after oncology treatment is a worthwhile investment to maximise long-term function. With regards to the patient considering partial arytenoidectomy and cordectomy, my search at that time revealed few studies that systematically evaluated voice and swallowing outcomes after similar surgery. The limited evidence available (and anecdotal evidence from similar cases treated at our hospital) suggested that her voice would be weaker and breathy after the surgery but her swallowing should be unaffected in the long term. She was keen to get rid of her tracheostomy and, after weighing up the options, chose to have the surgery to improve her breathing. Her airway improved significantly and she remains tracheostomy-free. Her swallowing was unaffected by the surgery but, as predicted, her voice was breathy and low in volume due to persistent air escape on phonation. Her voice had improved a few months after the surgery, although it will never be as strong and loud as her previously normal voice. Overall, she reported that she was happy with the outcome of her decision. In summary, there are three simple strategies that have helped me to develop an evidence-based approach to my clinical practice: a. Using the research librarian in my Trust library - the teaching session was only two hours long but has saved me many hours of frustrating and fruitless searching. b.Using the databases that are most relevant to my clinical population and work. I try to avoid relying on only one database (even for a quick search) as Ive discovered this often misses out valuable publications. c. Using a systematic search method, rather than entering random search terms into the database. This has had the added bonus of making me really think about clinical question I want answered, rather than just vaguely searching for any articles published about a broad subject area.

Patient-centred
The librarian taught me to use a quick, patient-centred search strategy based on the acronym PICO: Patient, Intervention, (Comparison), Outcome. For example, a patient with a bilateral vocal fold palsy contemplating undergoing partial arytenoidectomy to improve her airway asked me how the procedure would impact on her voice and swallowing function, compared to the option of retaining her tracheostomy. In this case, I carried out the search using the following strategy: Patient: Bilateral vocal fold palsy Intervention: Arytenoidectomy: Partial arytenoidectomy: Partial cordectomy; Comparison: Tracheostomy Outcome: Swallowing, Voice. When searching a database, the librarian suggested brainstorming all the relevant synonyms for search terms, such as swallowing, deglutition, dysphagia, deglutition disorders remembering to use American terminology where appropriate. For tips on making searching easier and more productive, I have found Tricia Greenhalghs book How to Read a Paper invaluable as she breaks searching down into easy steps, giving plenty of relevant examples. Completing a successful search that yields a manageable number of highly relevant publications is very satisfying. However, thats only the beginning, and getting the papers from the library (or asking the librarian to order them in) and then reading them with some critical appraisal of the methodology and results can be pretty time-consuming. Fortunately, many recent publica-

RITA OLIVER COMMENTS, There is a certain amount of reticence amongst radiologists and speech and language therapists in acute sectors when people with learning disabilities are referred for videofluoroscopic swallowing assessments. It is an expensive procedure which involves many professionals, and my aim was to provide evidence to justify developing the videofluoroscopy clinic for this client group. Although there is a dearth of research studies regarding videofluoroscopy and learning disabled clients, careful review of available literature, critical evaluation of reliability of other assessment tools like cervical auscultation and pulse oximetry, and considering other patient groups (stroke, elderly dementia) has enabled me to confidently make the case for videofluoroscopy assessments and identify the clients who are most likely to benefit. Armed with the knowledge, I have been able to establish closer working links and ensure my clients are getting the treatment that is evidence based and in their best interest.

References
Greenhalgh, T. (2001) (2nd ed) How to Read a Paper. The basics of evidence based medicine. BMJ Books. Perry, A.R., Shaw, M.A. & Cotton, S. (2003) An evaluation of functional outcomes (speech, swallowing) in patients attending speech pathology after head and neck cancer treatment(s): results and analysis at 12 months postintervention. Journal of Laryngology & Otology 117 (5):368-81.

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REVIEWING (2):

IMPROVING

STUDY DESIGN
IF A SINGLE CLINICAL ASSESSMENT WAS AS GOOD AS A MORE TIME-CONSUMING INVASIVE TEST, WOULDNT YOU WANT TO KNOW? MARGARET YOUNG REVIEWED THE LITERATURE TO ENSURE THAT HER STUDY DESIGN WOULD PROVE WHETHER OR NOT THE MODIFIED EVANS BLUE DYE SWALLOWING TEST IS NECESSARY FOR PEOPLE WITH A TRACHEOSTOMY.

may be subsequently aspirated. In studies where patients have been assessed with both fluids and diet in one assessment session (ONeil-Pirozzi et al, 2003) and only suctioned once following each consistency, the evidence from the suctioning may have been invalidated by the previous bolus. Variables such as cuff status (Brady et al, 1999; Peruzzi et al, 2001) have not been controlled and the amounts of blue dye used may not have been sufficient to be clearly seen on suctioning (Brady et al, 1999). The amount and consistency of each bolus are not always fully described (Belafsky et al, 2003; Donzelli et al, 2001) or controlled (Peruzzi et al, 2001).

Clear identification
Dikeman & Kazandjian (1996) suggest that the blue dye swallowing assessment should involve giving the patient one amount (teaspoons / sips) and one consistency (pured / soft / semi-solid) at each session. This allows for clear identification of what amount and consistency the patient has either passed or failed the assessment on and informs the therapists management decisions. In a study where regular suctioning was carried out following the administration of one amount and one consistency, Belafsky et al (2003) report a high level of acuity for the Modified Evans Blue Dye test, with an overall sensitivity* of 82 per cent when compared to FEES. However, the assessment procedure for pured diet was not described and the raw data was not provided. The modified blue dye test carried out in these studies was by a number of different health professionals and a formal assessment procedure was not always used, although this has been recognised as being possibly influential when carrying out this test (Peruzzi et al, 2001). Would the accuracy of the modified blue dye test improve if it were carried out as a structured test of function by dysphagia trained speech and language therapists who not only evaluate the evidence from suctioning but also use their clinical judgement before reaching a decision as to diet and fluids?

he Modified Evans Blue Dye swallowing test is used to identify gross aspiration in tracheostomy patients. It is a simple, available and inexpensive assessment tool. However, a drawback is that it is time-consuming. The procedure, if optimally performed over several sessions, can take from 48 to 72 hours (Dikeman & Kazandjian, 1995). It can delay the commencement of oral diet and fluids and also the subsequent removal of the nasogastric tube. So, do speech and language therapists need to carry it out to identify a tracheostomy patient at risk of aspiration or can their clinical judgement interpret tests of function (Tippett & Siebens, 1996) without the aid of the blue dye? At Manor Hospital, Walsall, West Midlands, we decided to carry out a preliminary investigation into whether a dysphagia trained speech and language therapist, using a clinical bedside swallowing assessment, is able to predict with the same accuracy the risk of aspiration without using blue dye. I turned to the literature for information that would help with the design of the study. The Modified Evans Blue Dye procedure is based on the Evans Blue Dye Test that involved adding dye to a patients saliva followed by suctioning through the tracheal tube (Cameron et al, 1973). It then became the modified test when it was added to diet and fluids (Thompson-Henry & Braddock, 1995). The dye is easily distinguishable from other secretions and, if suctioned from the trachea, can signal a link between the oral cavity and the trachea that should not occur when swallowing (Dikeman & Kazandjian, 1995). The modified test is recommended as a screening assessment (Brady et al, 1999; Belafsky et al, 2003; Donzelli et al, 2001; Peruzzi et al, 2001) to identify both the risk of aspiration and the need for formal diagnostic evaluations such as videofluoroscopy or fiberoptic endoscopic evaluation of the swallow (FEES). This is as a result of studies that have questioned the accuracy of the modified test. In 1995, Thompson-Henry & Braddock reported that the Modified Evans Blue Dye test was unable to identify aspiration when compared with the results of videofluoroscopy and FEES. However, this study was small (with only five patients), it was retrospective, and it had inconsistent time delays between the two procedures with no explanation of the oral status of the patients between the two procedures. In studies where a simultaneous comparison was made between the Modified Evans Blue Dye test and either FEES or videofluoroscopy, the modified test failed to identify approximately 50 per cent of the patients who had aspirated. However, patients were only suctioned once (Donzelli et al, 2001; ONeil-Pirozzi et al, 2003; Peruzzi et al, 2001) or only when aspiration was observed on videofluoroscopy (Brady et al, 1999). Dikeman & Kazandjian (1995) suggest that suctioning should be carried out more than once, which reflects Cameron et als procedure (1973). They report that this is particularly important with thicker consistencies to identify any pharyngeal residue that
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

Prospective study
We conducted a six month prospective, consecutive study of adult patients in the high dependency unit with a tracheostomy tube. All patients included were breathing independently and had a deflated cuff. They were assessed using blue dye in the bolus by a speech and language therapist with at least one years experience. Only one consistency (fluids / pured diet) and one amount (teaspoons / sips) were used at each assessment session. Following each assessment, the therapist wrote a prediction in her case notes as to whether the results of the suction - carried out by the nursing team - would be positive (blue dye suctioned) or negative (no blue dye suctioned). After the speech and language therapist left the ward, the patient was suctioned and then suctioned again within the hour. The results of suctioning were documented in the patients bedside nursing document. Recommendations regarding oral or non-oral diet / fluids were based on the evidence from suctioning (if blue dye was suctioned) or on the therapists recommendations if she had concerns regarding the possibility of aspiration. We compared the positive and negative results from suctioning with the predictions made by the speech and language therapists to determine the accuracy of their clinical judgement. Our results identified all patients who tested positive (blue dye recovered from the tracheostomy site when suctioned) resulting in 100 per cent sensitivity* for our predictions on teaspoons of water and diet. Specificity** was lower (87 per cent for water and 92 per cent for diet) which reflects a number of positive predictions made by the therapist that were not confirmed by suctioning. In these cases, the therapist had made her recommendations based on her prediction, not the evidence from suctioning. There are no results for other amounts and consistencies because either the patient did not have a negative result or they were transferred from the high dependency unit and no longer met the criteria for the study. The clinical swallowing assessment and the Modified Evans Blue Dye test are not gold standard assessment procedures but they may be the only assessments available on a high dependency unit. However, this study has identified that a clinical swallowing assessment carried out by a dysphagia trained speech and language therapist can accurately predict a risk of aspiration in this client group. Evidence from the therapists case notes and the ward documentation confirmed that the

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patients in this study who had a negative result from the clinical swallowing assessment progressed successively from non-oral to normal diet and fluids. Following this study, I presented the results to the adult team in Walsall. After discussion, we decided that in future tracheostomy patients would be assessed using the clinical swallowing assessment without the aid of blue dye. This allows patients with only minimal or no dysphagia to commence diet and fluids after only one assessment procedure.
*Sensitivity is used here in its research sense, meaning the percentage of true positives identified. Similarly, here **specificity refers to the percentage of true negatives identified. In this study, it was most crucial to have excellent sensitivity.

References
Belafsky, P.C., Blumenfeld, L., LePage, A. & Nahrstedt, K. (2003) The accuracy of the Modified Evans Blue Dye test in predicting aspiration. The Laryngoscope 113 November: 1969-1972. Brady, S.L., Hildner, C.D. & Hutchins, B.F. (1999) Simultaneous videofluoroscopic swallow study and Modified Evans Blue Dye procedure: An evaluation of blue dye visualization in cases of known aspiration. Dysphagia 14: 146-149.

Cameron, J.L., Reynolds, J. & Zuidema, G.D. (1973) Aspiration in patients with tracheostomies. Surgical Gynecology Obstetrics 136: 68-70. Dikeman, K.J. & Kazandjian, M.S. (1995) Communication and swallowing management of tracheostomized and ventilator-dependent adults. Singular Publishing Group. Donzelli, J., Brady, S., Wesling, M. & Craney, M. (2001) Simultaneous Modified Evans Blue Dye procedure and video nasal endoscopic evaluation of the swallow. The Laryngoscope 111 October: 1746-1749. ONeil-Pirozzi, T.M., Lisiecki, D.J., Momose, K.J., Connors, J.J. & Milliner, M.P. (2003) Simultaneous modified barium swallow and blue dye tests: A determination of the accuracy of blue dye test aspiration findings. Dysphagia 18: 32-38. Peruzzi, W.T., Logemann, J.A., Currie, D. & Moen, S.G. (2001) Assessment of aspiration in patients with tracheostomies: Comparison of the bedside colored dye assessment with videofluoroscopic examination. Respiratory Care 46 (3): 243-247. Thompson-Henry, S. & Braddock, B. (1995) The Modified Evans Blue Dye procedure fails to detect aspiration in the tracheostomized patient; Five case reports. Dysphagia 10: 172-174. Tippett, D.C. & Siebens, A.A. (1996) Reconsidering the value of the Modified Evans Blue Dye test: A comment on Thompson-Henry and Braddock (1995). Dysphagia 11: 78-81.

REVIEWING (3):

MATCHING PRACTICE

TO THEORY
IS THE GAG REFLEX RELATED TO SWALLOWING? DOES AN ABSENT GAG REFLEX SUGGEST DYSPHAGIA? PIPPA HALES SORTS OUT THE FACT FROM THE FICTION - AND FINDS THE FULL STORY IS YET TO UNFOLD.

t basic dysphagia courses speech and language therapists are being taught that the gag reflex is not related to swallowing. So why is it that speech and language therapists continue to assess the gag reflex and doctors continue to refer to speech and language therapy following the discovery of an absent gag reflex (Leder, 1996; Perry, 2001)? The gag reflex is a protective response triggered by a foreign stimulus with the purpose of ejecting it (Leder, 1997). The response to this stimulus has been observed as a lowering of the mandible, forward and downward movement of the tongue, and pharyngeal and velar constriction (Leder, 1996). There is some discrepancy as to the neural control of the gag reflex. Most papers agree that the motor portion of the gag is controlled by the vagus nerve and that sensory innervation involves the glossopharyngeal nerve. However, there is apparent indecision as to whether the superior laryngeal branch of the vagus nerve is also involved in the afferent pathway (Leder, 1997; Hamdy et al, 1998; Bleach, 1993; Aviv et al, 2002). Studies show that speech and language therapists do assess the gag reflex. One study examining the consistency of clinical assessments across clinicians found that 58 per cent of the speech and language therapists surveyed indicated that they usually or always assess the gag reflex (Mathers-Schmidt & Kurlinski, 2003). Members of the medical profession also assess the gag reflex in relation to swallowing. One study looked at the screening methods used to identify dysphagia in acute stroke patients (Perry, 2001). They found that doctors were the only profession in the study to include the gag reflex as part of the swallow screen.

The procedure used to assess the gag reflex is varied. One study assessed the gag reflex at bedside by holding a cotton swab against the posterior oropharyngeal wall for up to ten seconds or until a gag was elicited, yet in their laryngoscopic assessment they elicited the gag by touching the laryngoscope against the epiglottis or laryngeal vestibule (Kaye et al, 1997). Another study used a tongue blade to touch the base of the tongue, soft palate, uvula and posterior pharyngeal wall to elicit the reflex (Leder, 1996). One prospective study examined the accuracy of six clinical indicators in determining the frequency of aspiration in acute stroke patients (Daniels et al, 1998). A bedside assessment was followed up by videofluoroscopy. They found that an absent gag reflex was significantly related to aspiration. The paper fails to mention what proportion of the 55 subjects assessed had a normal gag reflex and were still dysphagic. Another study looked at the role of flexible laryngoscopy in assessing aspiration in 105 patients (Kaye et al, 1997). Both bedside assessment and videofluoroscopy were compared against flexible laryngoscopy. They concluded that an absent gag reflex is correlated with aspiration, however, the results of this study appear to have been misinterpreted. The bedside examination found that the gag reflex was absent in 14.3 per cent of subjects, yet just 8.7 per cent of all subjects aspirated during the flexible laryngoscopy. When assessed again using videofluoroscopy 31.4 per cent of the subjects aspirated. They later state that an absent gag reflex was found to be a weak risk factor for aspiration. As the three assessments were not carried out simultaneously, the reliability of the results has clearly been affected. One further paper studied 70 patients with bilateral strokes using neurologic and videofluoroscopic assessment to determine the characteristics associated with dysphagia (Horner et al, 1990). This study found that those subjects with an abnormal gag reflex (62.6 per cent) aspirated more often than those with a normal gag reflex (29.6 per cent). They found an abnormal gag reflex to be a significant, independent predictor of aspiration. In this study, however, the authors define an abnormal gag reflex to include asymmetric, diminished, delayed or hyperactive, potentially overstressing the significance of the results relating to the abnormal gag reflex.

Healthy subjects
One study looked at pharyngeal sensation and the presence of the gag reflex in 140 healthy subjects (Davies et al, 1995). They found that the gag reflex was absent bilaterally in 43 per cent of their elderly subjects and 26 per cent of their young subjects. They concluded that, as the majority of stroke patients are over the age of 65 and that they observed an absent gag reflex more frequently in this age group, it should no longer be considered a useful bedside test of swallowing after acute stroke.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

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Another study, carried out retrospectively, examined 120 neurological patients using bedside examination, indirect laryngoscopy and videofluoroscopy to establish if a link between an absent gag reflex and aspiration exists (Bleach, 1993). No correlation was found. The design of this study could have been improved if the three assessments had been performed simultaneously; however, as a retrospective study it was well designed, enhancing the value of its results. One further paper studied patients referred for a swallowing assessment as a result of an absent gag reflex to determine if its absence predicts dysphagia (Leder, 1996). This found that 36 per cent of the subjects were non dysphagic and concluded that an absent gag reflex does not predict dysphagia. However, the design of the study was not entirely appropriate to its aim; for example, some of the clinical indicators used to predict dysphagia have since been proven to be unreliable, such as wet, gargling voice quality (Warms & Richards, 2000). It also failed to state whether the subjects were actually followed up objectively with a videofluoroscopy or whether this was purely suggested as a possible assessment option. The sample size was also small with just 14 subjects. The most powerful observation of this review is the marked inconsistencies across every area of the topic. Firstly it is clear that the gag reflex continues to be tested to assess swallow function. Secondly it is apparent that there is no clear, defined method for assessing the gag reflex and finally - and perhaps more fundamentally - there is little agreement as to what is being assessed when the gag reflex is tested. This inconsistency is a reflection of the inconsistencies across the available literature and the quality of research surrounding this topic. This will not improve until quality research is carried out. Until then there is insufficient evidence to support us including the gag reflex in our dysphagia assessments. This evaluation supports the view that we should reconsider what we are teaching dysphagia students. We currently teach them that the gag reflex is not related to swallow function; instead we should be presenting the existing research and encouraging them and our colleagues to examine and challenge the evidence supporting their clinical practice.

References
Aviv, J.E., Spitzer, J., Cohen, M., Ma, G., Belafsky, P. & Close, L.G. (2002) Laryngeal adductor reflex and pharyngeal squeeze as predictors of laryngeal penetration and aspiration. Laryngoscope 112 (2): 338-41. Bleach, N.R. (1993) The gag reflex and aspiration: a retrospective analysis of 120 patients assessed by videofluoroscopy. Clinical Otolaryngology & Allied Sciences 18 (4): 303-7. Daniels, S.K., Brailey, K., Priestly, D.H., Herrington, L.R., Weisberg, L.A. & Foundas, A.L. (1998) Aspiration in patients with acute stroke. Archives of Physical Medicine & Rehabilitation 79 (1): 14-9. Davies, A.E., Kidd, D., Stone, S.P. & MacMahon, J. (1995) Pharyngeal sensation and gag reflex in healthy subjects. Lancet 345 (8948): 487-8. Hamdy, S., Aziz, Q., Rothwell, J.C., Hobson, A. & Thompson, D.G. (1998) Sensorimotor modulation of human cortical swallowing pathways. Journal of Physiology 506 (Pt 3): 857-66. Horner, J., Massey, E.W. & Brazer, S.R. (1990) Aspiration in bilateral stroke patients. Neurology 40 (11): 1686-8. Kaye, G.M., Zorowitz, R.D. & Baredes, S. (1997) Role of flexible laryngoscopy in evaluating aspiration [comment]. Annals of Otology, Rhinology & Laryngology 106 (8): 705-9. Leder, S.B. (1996) Gag reflex and dysphagia. Head & Neck 18 (2): 138-41. Leder, S.B. (1997) Videofluoroscopic evaluation of aspiration with visual examination of the gag reflex and velar movement [comment]. Dysphagia 12 (1): 21-3. Mathers-Schmidt, B.A. & Kurlinski, M. (2003) Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decisionmaking. Dysphagia 18 (2): 114-25. Perry L. (2001) Screening swallowing function of patients with acute stroke. Part one: Identification, implementation and initial evaluation of a screening tool for use by nurses. Journal of Clinical Nursing 10 (4): 463-73. Warms, T. & Richards, J. (2000) Wet voice as a predictor of penetration and aspiration in oropharyngeal dysphagia. Dysphagia 15: 84-88.

news extra
Valuing people with autism
The National Autistic Society is expressing concern that adults with Asperger syndrome are deemed too able to access services. The charity says the 2001 plan Valuing People states, Adults with Asperger syndrome or higher functioning autism are not precluded from using learning disability services, and may, where appropriate, require an assessment of their social functioning and social skills in order to establish their level of need. In practice, they say this is not happening, and that local authorities should be held to account when their eligibility criteria exclude people with autism. Meanwhile, the Society says it has been successful in its efforts to ensure that the pre-legislative report by the Parliamentary Joint Committee on the Draft Mental Health Bill distinguishes the core condition of autism from mental health issues which may be co-morbid. It believes this will reduce the chances of inappropriate treatment and detention. www.nas.org.uk Foundation for People with Learning Disabilities. The aim of the green paper Independence, Well-being and Choice is to find ways of evaluating services and of giving people more control over their own lives and choice in the services they receive. Suggestions include each authority having a Director of Adult Social Services, training for family carers and individuals having more control over their own budgets. Hazel Morgan, Co-Director of the Foundation for People with Learning Disabilities emphasises that Individualised funding is an exciting way forward, but people with learning disabilities and their families will need good support to access it. The consultation is available in a variety of formats, including an easy-read booklet from Mencaps accessibility department, with an accompanying CD. Replies to the consultation should be in by 28th July 2005. Full details on www.dh.gov.uk. of specialist services, the report notes that in too many instances brain scans and swallowing checks are not being done. Only two-thirds of patients have documented evidence that multidisciplinary working is happening, and poor communication is also still a major issue. The report says that patients and carers need more adequate information about causes, treatment and prognosis, as well as advice on preventing another stroke. The Audit, funded by the Healthcare Commission, was carried out on behalf of the Intercollegiate Stroke Group by the Royal College of Physicians Clinical Effectiveness and Evaluation Unit. It is the first audit of stroke to involve 100 per cent participation for hospitals in England, Wales and Northern Ireland and to have results published for each NHS Trust. www.rcplondon.ac.uk

Concern over swallowing checks


The Stroke Association has expressed grave concern that one third of stroke patients in England, Wales and Northern Ireland in 2004 had no record of being checked for dysphagia following admission to hospital. Although the National Sentinel Audit for Stroke 2004 records a dramatic improvement in the provision

Are your rewards too sweet?


The British Dental Health Foundation has reacted angrily to the suggestion in an article on the government website Teachernet that sweets could be included in a package of rewards for good behaviour. The Foundation says that sugary foods should be limited to mealtimes wherever possible and rewards that affect a childs oral health should never be given in school.

Consultation shows good intentions


A government consultation on social care for adults shows good intentions according to the

28

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2005

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MYTOPTHEMES
1. PREDICTION / RISK There was a welcome emphasis on prediction. For example, Penny Roy is investigating whether very early processing skills are better predictors of outcome than existing language measures in young children referred to speech and language therapy with concerns over language. She is looking at the potential of non-word repetition as a predictive marker, but the emphasis is on the assessments being quick to complete and fun. The particular risks associated with poor comprehension are becoming clearer. For example, Gina Conti-Ramsden and Nicola Botting found that the children with specific language impairment who were bullied were more likely to have poor - as opposed to average - comprehension. Undetected comprehension problems are significant for children with emotional behavioural disorders according to James Law. And Maggie Vance found poor comprehenders struggled in their ability to cope in noise compared to quiet. Clinically, we should be cautious about specific diagnosis and prediction, particularly with children under five, and always emphasise potential for change and development. Gina Conti-Ramsden says outcome seems to depend on how, for example, IQ interacts with other factors rather than the level of IQ per se. In therapy it may help to manage the risk by supporting the resilience factors. 2. AUDITORY THERAPY Maggie Vances view is that auditory deficits are neither a necessary nor sufficient cause of specific language impairment, but may be one of a number of factors for at least some children. We should be aware that the ability to cope with speech in noise is developmental and may also be diagnostic. We need more clinical assessments, but in the meantime can deliver a combination of therapy to children whose auditory skills are weak: I. Top-down: traditional language therapy, enhancing the ability to use context to support weak speech input processing skills and the detrimental effect of background noise. II. Environmental modification: Classroom noise ranges from 35-70dB, but 35dB is desirable. Amplification to improve signal to noise ratio is commercially available but not proven effective. Clear speech (slower, more frequent and longer pauses, clear articulation, greater pitch range) is understood more easily than conversational speech. III. Bottom-up: training auditory discrimination and listening skills, including environmental sounds and minimal pair work. But be aware that computer based training has mixed efficacy results... ... Dorothy Bishop did such a study in schools with children with receptive language impairment. With no significant or generalisable effect, the study was stopped. Dorothy is now sceptical about whether phonological awareness is the key to improving literacy in such children. In general, she says whatever we are teaching them, learning occurs very, very slowly, and the children need small amounts from shorter, more regular input. 3. WORKING WITH SCHOOLS Julie Dockrell explained that good practice is a social construct which may be necessary for - but it not the same as - effective practice. Identifying impact, assessing, monitoring, auditing and changing structure are examples of good practice but outcomes are the measure of effective practice. We need to think about how the individual therapy, programmes and training we offer will improve attainment. Julie hopes to see the development of an oral language curriculum based on research evidence. She also wants a focus on developmental trajectories and identification of effective intervention. In schools with good practice in the education of children with specific speech and language difficulties, Julies findings leave us with questions: Learning support assistants play a major role with children with speech, language and communication needs - are they sufficiently supported? Educational psychologists and speech and language therapists have little contact would the children benefit from more? Parents feel teachers do not understand the impact of the difficulties. They also feel well informed but not involved ... 4. SUPPORTING PARENTS James Law believes there is a resistance around parental involvement in education from professionals, and also some parents, perhaps because of their own negative experiences of school. Teacher Jill McMinn and Gill Britten, a family learning co-ordinator, believe such parents are under huge stress and that this affects their ability to become involved. The impact on the family includes loss, guilt, denial, resentment, isolation, fear of the future and exhaustion. Supporting the child is relentless and can be repetitive and boring. Rather than language, parents are concerned about everyday issues such as tooth and hair brusing, getting dressed and going places. Anxiety and stress can mean worries are blown out of all proportion and that stress blocks clear thinking - increasing involvement could be like opening a Pandoras box. Parents rarely have switchoff time for themselves. Jill and Gill have worked incredibly hard together to reach parents of children in a language resource. They warn that the initial stages were particularly traumatic. Gill has introduced a variety of non-verbal techniques to enable parents to explore their feelings, relationships and needs. SPEC (Supporting Parents of Exceptional Children) - contact jillmcminn.public@ bigfoot.com to order a research report. 5. CHANGING NEED MEANS CHANGING PROVISION The children with specific language impairment in Gina Conti-Ramsden and Nicola Bottings study have now reached the age of 16. Their continuing difficulties are not only to do with communication, but with quality of life. Their families also need ongoing support with a wide range of issues. In general, being bullied, poor social skills and (co-morbid) mental health problems are more likely in this group. In therapy, our assessment and support must acknowledge these wider concerns. We need to look beyond language scores and listen and ask the right questions so we can help them reach their potential. We should consider offering cooperative group experiences and peer mediated intervention as well as teaching social skills, working with the family and training teachers. We should promote opportunities for vocational studies and be reassuring that a work environment may in time serve these pupils better than a school. 6. HONESTY IS THE BEST POLICY Rather than attempting to fill in the hole for young adults with high level social communication difficulties, Helen Ortner works to bridge the gap. This means being honest about their difficulties, using video to challenge beliefs, and referring for cognitive behaviour therapy to help with rigid thought patterns. Honesty has to include allowing failure, however hard it is to do. It is also important not to tolerate unacceptable behaviours. James Law reported that reviews of social skills training are not encouraging, but that this may be because low dosage intervention is not worthwhile. Helen teaches specific social skills in context, and does social autopsies (unpicking situations that went wrong and planning for the next time). She finds she can push clients in a way that parents cant because there arent the emotional ties. But even better, sibling and peer mentoring is useful because of the level of honesty they are prepared to show. 7. THE FUTURE Dorothy Bishop believes we all have a responsibility to bring research and practice closer together. She is very keen to evaluate the effectiveness of interventions by creating randomised controlled trial conditions in clinics and schools. She says it is very important that the researcher does not know which group the client has been assigned to, and that the assignment is random, as otherwise it is too easy to deceive yourself about effectiveness. As Director of the Centre for Integrated Healthcare Research at Queen Margaret University College, James Law is keen on good quality research. As narrative reviews are biased because they start with an opinion, he favours systematic reviews that start with a predetermined research question. James recommends quoting systematic reviews when putting forward an article for publication, and looking for such evidence nationally and internationally: www.cochrane.org; http://eppi.ioe.ac.uk. www.campbellcollaboration.org; We are where we are, but its clear from this conference we have a fair idea where were going. As Gina Conti-Ramsden said, we need to remember that we are working in a relatively new area and that our understanding will keep changing with longitudinal studies that examine the wider impact of speech, language and communication needs. www.naplic.org.uk

MAGGIE VANCE

JULIE DOCKRELL

GILL BRITTEN

JILL MCMINN

GINA CONTI-RAMSDEN

DOROTHY BISHOP

The NAPLIC conference: Speech, language and communication needs: current trends in theory and practice gave editor Avril Nicoll plenty of food for thought. NAPLIC is the National Association of Professionals concerned with Language Impairment in Children. The conference was on 19-20 March, 2005 at the University of Warwick.