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ISSN 1368-2105

Winter 2005

www.speechmag.com

PEER SUPPORT

The case for flying KITEs


(Kids communication Impairment: Therapy Effectiveness
Recruitment
Work experience placements

Intensive groups
Complex preschoolers

Developing critical appraisal skills


Expert guidance

How I provide a service


for young people with Asperger syndrome

PLUS.The Authenticity keyHeres one I made earlierMy Top Resources lifelong learningand featuring Peer support

Reader offers
WIN NAUGHTY BUS
Are you looking for a story book that has high quality photographic pictures easily recognisable to young children? Then climb on board the Naughty Bus! Reviewing it in our Autumn 05 issue, Sue Ward said she would definitely use the book with children attending language groups in the clinic and would particularly recommend it for teachers / parents of children at the Foundation stage. Naughty Bus normally costs 9.99, but Little Knowall Publishing is giving copies away to TWO lucky readers. To enter this free prize draw, e-mail your name and address to jan@littleknowall.co.uk, or send to Jan Oke, Little Knowall Publishing, 9, Little Knowle, Budleigh Salterton, Devon, EX9 6QS. Your entries must be received by 25th January 2006, and the winners will be notified by 1st February. Naughty Bus is by Jan & Jerry Oke and published by Little Knowall. The book is now in a second edition with the ISBN 0-9547921-1-4.

WIN BLOB TREE POSTERS

New from Incentive Publishing, these four posters can be used by large or small groups or on a one-to-one basis to initiate and promote discussion of feelings. Blob figures are designed to be nonthreatening and to appeal to people all ages and with a range of language abilities. Each poster has a different set of feelings to explore and discuss. This set of posters (each 31 x 43.5cm) usually retails at 16.00, but Incentive Plus is giving THREE sets away FREE. 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 January 2006 and the winners will be notified by 1st February. For more details about this and other Incentive Plus resources, or to order a free catalogue, see www.incentiveplus.co.uk or call Hilary on 01908 526120.

The lucky winners of Sherstons LDA Language Cards Interactive are Penny Laflin, Angela Abell, Vanessa Harvey, Clare Attrill, Julianne Bolton, Elizabeth Gadsen, Karen Shuttleworth and Alison Taylor. Congratulations to you all. Keep those entries coming!

Winter05speechmag
E-UPDATE SERVICE
We now have a FREE e-update 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. 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. 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.
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.
Preschool autistic spectrum disorder
(not yet indexed) Cowan, H. (2004) A holistic approach from the outset. Summer: 12-13.

Peer initiatives
(162) Harris, C. (2001) Ahead-and-neck of the field. Autumn: 12-13. (156) Patrick, J. & Atherden, M. (2001) Patient, persistent and positive: a journey with chronic fatigue. Summer: 20-23.

Community based services for older children


(067) Paulger, B. (1999) Therapy for real life. Summer: 12-14. Reprinted in full at: www.speechmag.com/archives/barbarapaulger.html.

Evidence based service change


(032) Gibbard, D. (1998) Parent-based approaches the case for language goals. Summer: 11-13. Reprinted in full at: www.speechmag.com/archives/debgibbard.html. AND (040) Gibbard, D. (1998) From research to service development. Autumn: 16-17.

Personal development
(170) Dobson, S. (2001) When effectiveness is hard to prove. Winter: 4-7.

www.speechmag.com Pay us a visit soon.

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14 COVER STORY:
EVIDENCE BASED PRACTICE THE CASE FOR FLYING KITES
The difference is clear children in treatment made much more progress overall than those receiving no treatment. Jan Broomfield on the results of the KITE (Kids communication Impairment: Therapy Effectiveness) randomised controlled trial and what it means for speech and language therapy services.
Cover photo by Paul Reid. (See page 14) Posed by models Sally and Ailsa.

18 REVIEWS
Literacy, assessment, ColorCards, dysphagia, inclusion, guidelines.

20 KEYS TO WINNING WAYS SERIES (5) THE AUTHENTICITY KEY


The way we behave is frequently not you at all, but what you think you should be. Our conditioning is what keeps us stuck in old, useless behaviour patterns. In the fifth of our series to encourage reflection and personal growth, life coach Jo Middlemiss asks what is real and what is pretend and if looking at life in a different way will free you up to be yourself?

WINTER 2005
(publication date 28/11/05) 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 WINTER 05 SPEECHMAG, READER OFFERS


Win Naughty Bus and Blob Tree posters.

22 FEATURE PEER SUPPORT


To keep the focus and ensure each section is covered adequately, a group member takes the role of time keeper, and another the role of process manager. One group member, the presenter, tells their story and explains what help they want. The steps of the process ensure that everyone is clear about their role at a given time and that everyone gets a chance to talk. Hearing about other systems of peer support has convinced Avril Nicoll that it will be possible to introduce peer review to Speech & Language Therapy in Practice in an open and constructive way.

2 NEWS / COMMENT 4 RECRUITMENT ALL IN A DAYS WORK


our department decided to take on five Year 10 pupils for work experience, largely in response to the number of requests we were receiving and in an effort to do our bit for would-be therapists. The pupils came for five to seven days during the blocks allocated by their schools. All were local girls who had expressed an interest in speech and language therapy as a career. Clare Grennan and Jane Rogers explain why work experience placement schemes could be good news for recruitment and retention.

24 NEW! RECOMMENDED READING


Aphasia / AAC

7 INTENSIVE GROUPS A COMPLEMENTARY SERVICE


Although good practice had been adhered to, a number of the professionals involved increasingly recognised that some childrens progress in terms of interaction and communication skills had been disappointing due to insufficient frequency and intensity of specialist input. Ann Wiseman and Sharon Horswell find multiagency intensive groups can improve outcomes for preschool children with complex communication and autistic spectrum disorders.

25 HOW I PROVIDE A SERVICE FOR YOUNG PEOPLE WITH ASPERGER SYNDROME


Two examples of how imaginative and thorough planning and a focus on clients needs can change the lives of young people with Asperger syndrome and their families:

(1) LETS GET ON


Faced with increasing referrals of older children in mainstream school with social communication difficulties, Caroline Baber, Ann Clemence, Karen Ford and Ruth Watson developed tailored groups as a new package of care.

IN FUTURE ISSUES... DYSPHAGIA APHASIA

10 HERES ONE I MADE EARLIER


Alison Roberts with more low cost therapy activities: Formal and Casual Board, Breathing Strings, Also for

(2) ASPERATIONS 4 U
Jane Bakers vision of a communitybased, parent-run, specialist facility for young people with Asperger syndrome is now a reality.

ADULT LEARNING DISABILITY LEARNING STYLES PROJECT MANAGEMENT

11 EXPERT GUIDANCE DEVELOPING CRITICAL APPRAISAL SKILLS


Critical appraisal is a bit like being a detective scouring for evidence. You seek not just a fragment here or there but a full skeleton in order to close your case. Frances Harris explains how to use clinical judgement to consider the relative validity and importance of evidence presented in professional papers.

BACK COVER MY TOP RESOURCES

I met my very special Critical Friend when I first started work, and she is my most essential resource. I am fortunate in that both our professional and personal relationship has developed and matured over the years. Tracey Righton draws together her resources for lifelong learning.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

NEWS

Diamonds of the profession


Stammering specialist Daniel Hunter is the first winner of the national Speech and Language Therapist of the Year award. Daniel, who stammers himself, now has plans to join the British Stammering Associations preschool dysfluency campaign as a trainer. He says, Ive developed a model of working with under five-year-olds who stammer that involves risk profiling. The early indications are that the risk profile is able to tell us which children are at risk of persisting with stammering. This will hopefully lead to earlier intervention which we know to be very effective. The pivotal role played by the professions support workers was also recognised with an award for Speech and Language Therapy Assistant of the Year. Like Daniel, Barbara Laverty has received a 1000 cheque from award sponsors Fresenius Kabi. Her colleagues said, Barbara is well know to all primary pupils at the school through her music-based speech and language therapy groups she expertly interweaves each pupils speech and language targets into the session and motivates every participant to achieve their full potential. The national competition was initiated by the Royal College of Speech & Language Therapists to mark its Diamond Jubilee and may become an annual event. Appropriately, nominations were submitted via a range of communication methods e-mails, letters, videos, audiotapes and signs and symbols. www.rcslt.org

White paper promises personalised learning


The governments education white paper for England has provoked debate in the national media with its promises of greater freedom for schools and more power for parents. Higher Standards, Better Schools For All emphasises the importance of personalised learning to meet individual need, as well as driving up whole school performance. There will be more grouping and setting by subject ability and schools will have to show in their annual self-evaluation how all their pupils are achieving, including children with SEN and disabilities. The government says it is setting up a national training programme so that each school will have one lead professional to help with the development of tailored lessons. Tailoring of education will include promoting more effective measurement and accountability for the progress made by pupils with SEN across a wide range of abilities, facilitating early intervention and high expectations. The paper also stresses the value of groups of schools pooling resources and sharing good practice, and drawing on the links that Childrens Trusts have with other agencies. It suggests that special schools could co-locate more with mainstream schools and strengthen their role at the heart of the system by working closely with one or more mainstream schools, offering pupils a pattern of provision tailored to their needs and breaking down unhelpful barriers. Fifty more SEN specialism specialist schools will be rolled out and evaluated over the next two years. Higher Standards, Better Schools For All ( Crown Copyright, 2005) is at www.dfes.gov.uk/publications/schoolswhitepaper/.

Award for Speakeasy


The Speakeasy charity, which offers long-term support and therapeutic activities for people who have aphasia and their carers has been rewarded for its innovative team work. The Lancashire group received the PCT award for its work under the leadership of speech and language therapist Gill Pearl. Speakeasy was established over 25 years ago by speech and language therapist Stephanie Holland but until recently struggled to survive. However, with financial backing from Bury PCT, the organisation now has a clear focus and a small team which includes two people with aphasia. Gill Pearl has also been recognised with a Leading Practice Through Research award from The Health Foundation to investigate how people with aphasia can become more involved in planning service delivery. www.buryspeakeasy.org.uk www.health.org.uk
Speakeasy staff Sarah McClusky, speech and language therapist, Liz Royle, expert patient, and Gill Pearl, clinical director with Evan Boucher, chief executive of Bury PCT.

Geoff Wilson

l-r Daniel Hunter, Barbara Laverty, Chris Harrison (Managing Director of sponsors Fresenius Kabi)

Ageing warning

Help the Ageds trust for biomedical research has welcomed a House of Lords select committee report which asks the government to do more to fund scientific research that can help older people. Although disappointed that the report did not recommend setting up a National Institute of Ageing, Dr Lorna Layward of Research into Ageing said it goes a long way towards fulfilling the recommendations we provided. She went on to warn that small investments by key government departments leave the UK scandalously unprepared for the baby boomer generation who are about to enter their later lives in vast numbers. This year Research into Ageing is concentrating on stroke, dementia and incontinence. Ageing: Scientific Aspects, see www.parliament.uk/parliamentary_committees/lords_s_t_ select/stiageing.cfm http://research.helptheaged.org.uk/_research/

Standards for CPD

The Health Professions Council has approved the standards of continuing professional development that will become a legal requirement for registration. Information on how to record and submit evidence against the standards will be published in April 2006, and auditing for speech and language therapists in clinical practice, research, management and education will begin in 2009. The evidence will have to demonstrate how continuing professional development has contributed to the quality of the individuals practice and benefited the service user. Health Professions Council President Norma Brook emphasised the flexibility of its approach, saying the Council will offer a clear framework but continuing professional development will be the responsibility of the individual. www.hpc-uk.org This car sticker, suggested by a dietitian, has been produced as part of the Health Professions Councils advertising campaign to encourage members of the public to check that their health professionals are registered with the Health Professions Council. If you would like one, e-mail info@hpc-uk.org or tel. 0207 840 9806.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

NEWS & COMMENT

Deafness Research UK
A medical charity for deaf and hard of hearing people has changed its name to reflect its national status and role in pioneering research and attract more public support for its work. Deafness Research UK, formerly Defeating Deafness, has also launched a campaign to educate tinnitus sufferers and health professionals about treatment options. Tinnitus is the name for noises in the head or ear that can cause anxiety, lack of sleep and depression. www.deafnessresearch.org.uk Tinnitus information pack, tel. 020 7679 8970, e-mail info@deafnessresearch.org.uk.

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

Call for symposium posters


Afasic is calling for poster and seminar submissions for its fourth international symposium and says any illustrating innovative practice will be especially welcomed. The main themes will examine concepts of disorders, memory, genetics, intervention, outcomes, developmental aspects, and the future. Understanding developmental disorders: From theory to practice takes place from 2-5 April 2007 at Warwick University. Abstracts must be submitted online by 1 June 2006. www.afasic.org.uk

Peer support
reading Jo Middlemisss thoughts on authenticity (p.20), but his teacher had children seem more motivated to change if a fellow pupil makes a suggestion rather than the teacher. It is of course crucial that this is embarked on in a structured and constructive way, like the models of peer support described in our feature (p.22). Tracey Righton (back page) favours the one-to-one of a critical friend, while others use the strengths of a group. Properly planned, all group work offers our clients the opportunity to benefit from a peer group as Ann Clemence and colleagues (p.25) and Jane Baker (p.27) demonstrate. They have built frameworks onto a core service so the clients wider circle can also access peer support. Parents, young people with Asperger syndrome and - in Janes case - siblings find a place where they can get practical answers and feel safe and understood. Its interesting that, once wider support frameworks are in place, they become self-sufficient and give speech and language therapists another option for onward referral. Ann Wiseman & Sharon Horswell (p.7) also identified the need for a complementary service, with multi-agency input. The joint skills development suggests it is worthwhile getting your peer support from different networks, not just other speech and language therapists. Frances Harris (p.11) believes strongly that creating networks where we draw on different interests and strengths is the key to evidence based practice. As a clinician and manager tackling therapy effectiveness research on a real clinical population, Jan Broomfield (p.14) would no doubt agree. The term flying kites usually gives the impression of wishful thinking but, like all the authors in this issue, Jan presents her groundbreaking work in a way that inspires readers to believe they could achieve the same. This kind of peer support is a thread running through the Speech & Language Therapy in Practice network. And, like Jane Rogers & Clare Grennans work experience placements (p.4), it presents continuing professional development opportunities. Next year will see our peer support extended as readers share recommended reading (see taster on p.24) and become peer reviewers. So, if you might be interested in being a little teacher with this peerless publication, do give me a call.

tel/ansa/fax One day my son announced, I got a sticker today at school because we were 01561 377415 being little teachers and I was honest about a friend. No, he hadnt been
avrilnicoll@speechmag.com been on a course about harnessing peer feedback. She has found it very effective in bringing about academic and behavioural change, and notices the

e-mail

All aboard for I CAN


I CAN has agreed to use the term communication disability to encompass the problems faced by the 1.2 million children and young people across the UK with speech, language or communication difficulties or delays. New chief executive officer Virginia Beardshaw says, a specific term is needed to make the issue easier to understand and talk about. www.ican.org.uk Free ChatterPacks for I CANs 2006 Chatterbox Challenge are now available. The sponsored chat-along, from 6-12 February, sees children perform a song, rhyme, story or poem at their home, playgroup or nursery. The theme for 2006 is the sea. As well as sponsorship from LeapFrog toys, this year again sees the magazine Nursery World as the Challenges media partner. I CAN explains this link-up is a natural synergy as Nursery workers encourage and support childrens communication skills at the most critical period the early years. Nurseries need to play a vital role in identifying and supporting children who have a communication disability and Nursery World magazine is key to helping I CAN reach out to this audience with our message about communication skills as the springboard to lifelong learning, literacy and social development. To register for a ChatterPack call 0870 45 85 475 or go to www.chatterboxchallenge.org.uk.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

RECRUITMENT

All in a days work...


READ THIS
IF YOU ARE LOOKING TO ACCOMMODATE WORK EXPERIENCE REQUESTS IMPROVE RECRUITMENT ENHANCE YOUR CONTINUING PROFESSIONAL DEVELOPMENT

Is the targeted offer of work experience placements a useful weapon in the professions recruitment and retention battle or just another task for overstretched therapists? Clare Grennan and Jane Rogers report on a new scheme in Dudley and explain why they will be doing it again.

Claire (left) and Jane (right) are pictured with the 2005 group of work experience pupils

HS Trusts invest a lot of money and time in staff recruitment and retention (NHS Careers, 2004). They know they must continue to do so, not only in the shortterm, but also to ensure a ready pool of employees for the future. This is particularly essential as the health service takes on the modernisation programme to which it is committed (NHS Careers, 2004). Increasingly, trusts are looking for new and imaginative approaches to recruitment (NHS Careers, 2004), and we see offering well-organised work experience placements as one way we can contribute. In addition to the departments regular commitment to taking undergraduate students, we have previously provided ad hoc observation sessions to prospective students. During the summer term 2004, our department decided to take on five Year 10 pupils for work experience, largely in response to the number of requests we were receiving and in an effort to do our bit for would-be therapists. The pupils came for five to seven days during the blocks allocated by their schools. All were local girls who had expressed an interest in speech and language therapy as a career. In preparation, we put together some guidelines: who we take procedures an induction pack (figure 1) information for staff (what pupils can do, support available). Pupils also had to sign a confidentiality agreement and receive occupational health clearance. As

the pupils were all due to start around the same time, we held a pre-placement meeting to go through the induction pack as a group and answer any questions. Pupils had also been - or were planning to go - to a careers talk within the department. The guidelines involved a lot of work and adaptation as a result of ongoing reflection and feedback. We accessed additional support and advice from Trust practice placement managers, the West Midlands regional clinical placements co-ordinators group and our speech and language therapy service manager. We referred to Trust guidelines as well as to information from the NHS Careers service. As organisers, we were also prepared to provide additional support to enable any pupil with a disability to participate.

Mixed programme
Each pupil had a mixed programme with staff from a range of teams across the department (hearing impairment, mainstream, pre-school, adults, general office). Admin and clerical staff (1), speech and language therapy assistants (4) and speech and language therapists (18, including newly qualified) were involved in the supervision of work experience pupils. Because of the nature of what we do, pupils were mostly going to be observing us. However, the schools were keen for the pupils to get some experience of working. We were also concerned that pupils may tire of simply observing, so we put together a list of potential jobs that pupils could do as a guideline for supervising staff: assisting staff during assessment / treatment sessions

preparing therapy materials making up files / filing cleaning / tidying toys or other equipment sending out appointments photocopying making tea. The learning objectives for the pupils were to: 1. find out about the role of the person you are with 2. learn about communication disorders 3. participate in therapy sessions where appropriate 4. assist with preparation of therapy materials 5. assist with administrative tasks. Following the work experience programme, we asked supervising staff and pupils to complete feedback forms. We asked staff to rate / comment on the organisation of the placement / support available to them, what they found particularly useful, and what they would recommend changing. We also asked them how the placement contributed to their own learning and development, and gave them the opportunity to add any other comments. The return rate was poor (7/18 therapists) but we did get a spread of grades (1, 2, team manager) and teams (mainstream, pre-school, hearing impairment, adults), and the responses included some constructive ideas. Organisation / support was rated as: Excellent 3/7 Good 2/7 Fair 2/7. In addition, 6/7 found the pre-placement information pack useful. One therapist in mainstream said that, due to school activities and teachers stress levels during the final weeks of term, this is not the best placement for a whole day. Another commented that nurseries were a nice way for the pupils to see

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

RECRUITMENT
Figure 2 Observation sheet
Childs Name: Childs Age: Therapists Name: Students Name: 1. What was the therapist working on during the session?

Figure 1 Induction pack contents


1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Health check form Honorary contract Placement programme Badge Confidentiality form In emergency form Service profile and structure Places of work Hours of work on placement Travel and breaks Health and safety / Infection control Dress code Learning objectives Speech and language therapy career workshop form Liaison with school / training establishment Certificate of attendance and summary report Feedback questionnaire Useful websites

2. What sorts of strategies did he/she use? (think about what she is saying; what toys / materials are being used)

3. Do you think that the goals for the session were achieved? Why?

4. What factors do you think influenced the childs ability to learn the new skill?

5. How did the therapist involve other people in the session (eg. parents, teacher, assistant)?

6. How did the therapist encourage the child to work on targets in other settings (eg home, school / nursery)?

7. Do you have any comments, questions or suggestions about the session?

that we dont just work in clinics, but added that it was difficult to involve them in everything that was going on. One therapist queried whether the pupils had had any information about speech and language therapy before they came, as they were often quiet and didnt have lots of questions. Recognising that this may have been a reflection of their age and experience, she put together an observation sheet (figure 2) for the pupils to fill in. As well as giving the pupils something to do, it provided a focus for discussion. This form has since been circulated to all staff. The same therapist wanted more information about what should be expected from the pupils, or what they could do for example, could she take them into meetings? She found the observation sheet useful for getting them thinking about what we do and why, but also felt more individual information about the student and what related subjects they were doing at school would have helped. In terms of professional development, grade one therapists commented that the process aided reflection and teaching, and that it was good to see how much they knew and to experience having someone sitting in on the session. One therapist said it provided her with an insight into what it would be like to have a student, and the team manager also commented that, as she hadnt had any kind of student for some time, the experience made her

stop and think. She then went on to have a second year speech and language therapy undergraduate student in the autumn term. In addition, a therapist working in hearing impairment with children and young adults commented that it helped promote deaf awareness, and reminded her of the level of communication that her clients have to cope with in the real world with unfamiliar people.

Gained confidence
The assistants and admin and clerical staff member involved didnt return their feedback forms, as they had been unsure what to put, but were happy to discuss their thoughts (3/4; 1/1). Interestingly, only one felt the process contributed to her own personal development, in this case because she gained confidence in being observed and answering questions relating to the activities, as well as getting someone else involved. This was particularly important as she was about to have classroom assistants observing some of her sessions. Like the therapists, they were happy to help with pupils development. They also felt it was good for the pupils to see the wider workings of the department. Two remarked that some pupils were more enthusiastic than others, and one commented that the majority didnt know what grades they needed to do the degree. Other comments included one therapist stating she had come to Dudley as a schoolgirl to observe and was happy to be able to do the same for

grade one therapists commented that the process aided reflection and teaching

somebody else. Another specifically said she was happy to do it again. The general feeling from the assistants / clerical staff however was that the pupils came and went. The questionnaire response rate from the pupils was good (4/5), and gave us an insight into what they got out of the experience, and whether our efforts were potentially positive for staff recruitment. Pupils were asked to rate / comment on the organisation and support from supervising staff, the variety of experience offered, what they found particularly useful / not useful, and whether the placement met their learning goals. Three pupils rated the placement organisation as excellent, and one rated it as good. The coordinators were thanked for their organisation of the placements and the friendliness and helpfulness of supervising staff was commented on. The induction meeting was reported to be particularly useful. All four pupils rated the variety of experience as excellent. Positive comments were made, including that every day was different, and that it was thoroughly enjoyable to see all aspects of the speech and language therapists role. As well as the variety, pupils commented positively on being able to observe the interaction between the therapist and other professionals such as physiotherapists. One added that she had particularly enjoyed the childrens clinic. All four pupils stated there was nothing they did not find particularly useful. Importantly, all four also said that the placement met their learning goals and three of them added that it had confirmed their interest in speech and language therapy as a career.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

RECRUITMENT

Figure 3 Work experience flow chart


enquiry received and checked for suitability by co-ordinators send welcome letter and health questionnaire

To assist our decision-making about future work experience placements, we carried out a subsequent survey in December 2004. We asked all clinical staff (therapists and assistants): whether they had work experience in speech and language therapy before applying for their course (degree / NNEB etc.) if yes, whether they found it useful whether they had the work experience with Dudley speech and language therapy department if they hadnt had work experience, whether they would have found it useful. Twenty nine out of 40 therapists responded (28 answered correctly) and seven out of eight assistants responded (6 answered correctly, 1 said not applicable). Sixteen therapists had had work experience in speech and language therapy, three of them in Dudley. A further ten had observation sessions as opposed to work experience, three of them in Dudley. Two therapists had not had work experience in speech and language therapy. Of the 16 that had had work experience, 15 found it useful. The other therapist said it was not very well explained (she had not come to Dudley!) Positive comments included: it made me pursue speech and language therapy rather than my other work experience career it helped in preparation for interview (for the university place) far more real than written descriptions of role, and opportunity to ask lots of questions to confirm career choice gave an insight into career choice and the client groups we work with. Of the 10 that had had observation sessions, 9 found them useful. One said that more sessions would have been helpful, and another that she had observed just one day in a clinic with lots of did not attends. She felt that when she was applying for courses, more than one days observation was expected of her. The two therapists who had not had any work experience thought they would have found it useful. Six assistants stated they had not had any work experience in speech and language therapy before doing their training. One had worked closely with the therapists in the school where she had been working, which she found useful. The other five all said they would have found work experience useful.

health clearance received from Occupational Health send honorary contract (two copies) induction pack timetable and locations (copy to speech and language therapy offices) emergency contact numbers (reciprocal) on placement - ID badge provided; advised on health and safety in each setting supervised work experience / observation liaison with school / establishment as appropriate feedback forms completed by staff in each setting and returned to co-ordinators exit telephone call from co-ordinator to student ID badge returned feedback form completed by student (handed in or sent later) Certificate & Summary Report sent to student (copy to school / establishment)

pupils commented positively on being able to observe the interaction between the therapist and other professionals

Groundwork
The work experience placement programme was a learning curve with lots of hard work, but we think the feedback was tremendously positive both staff side and pupil side. A lot of the groundwork has been done and we now have a comprehensive set of guidelines. We are going to repeat it this summer and there will be ongoing reflection and

adaptation as appropriate. We will be sticking with around five pupils as we found it a good number to manage. Due to the numbers of people involved (staff and pupils) and the amount of paperwork, we think organisation and enthusiasm is the key to success. We found the work experience flow chart particularly useful (figure 3) and have since developed an accompanying tick list, to help keep on track of what needs to be done. Since this work experience programme was initiated, we have spoken to the service manager, the area service managers, the team managers and principal speech and language therapists about linking clinical teaching more formally into the appraisal process. We have suggested that staff are actively encouraged in their appraisal to take work experience students, in addition to attending a clinical teaching workshop at the local university. The rationale behind this is to give therapists practical experience and confidence in accommodating students. We feel that that the positive comments regarding professional development made from the sample of therapists surveyed reinforces this and we hope that it will aid the undergraduate student placement allocation process.

Through liaising with colleagues in other trusts at the West Midlands regional clinical co-ordinators group, we are aware that many departments do not take work experience pupils. We therefore intend to promote what we have done to other speech and language therapists and professional groups. We have already fed-back to our departmental district meeting and to the West Midlands regional clinical co-ordinators group, where we promoted it as a continuing professional development opportunity as well as being positive for recruitment. Clare Grennan and Jane Rogers are highly specialist speech and language therapists / student co-ordinators with Dudley South Primary Care Trust. For further information, contact Clare on 01384 456111 ext 4565, e-mail Clare.Grennan@dgoh.nhs.uk, or Jane on 01384 366400, e-mail Jane.Rogers@dudley.nhs.uk

Reference
NHS Careers (2004) Work Experience. Building the future of the team. Guidelines for managers. March. (Only available to NHS employees online, tel. NHS Careers on 0845 60 60 655 for details.)

Further resources
Royal College of Speech & Language Therapists, see www.rcslt.org NHS Careers, www.nhscareers.nhs.uk.

REFLECTIONS
DO I HELP PROJECT LEADERS BY GIVING CONSTRUCTIVE FEEDBACK? DO I ACTIVELY ENCOURAGE OTHERS TO JOIN THE PROFESSION? DO I RECOGNISE PROFESSIONAL DEVELOPMENT OPPORTUNITIES WHEN THEY ARISE?

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

INTENSIVE GROUPS

Enhanced provision:
READ THIS
IF YOU WANT TO SHARE SPECIALIST SKILLS MORE EFFECTIVELY WORK COLLABORATIVELY WITH OTHER PROFESSIONALS OFFER CLIENTS A GROUP ENVIRONMENT TAILORED TO THEIR NEEDS
There is a long established tradition of collaborative working between the preschool advisory service, Portage service, speech and language therapy service Ann Wiseman and other health professionals in Torbay. In recent years children with a complex communication disorder have been referred to one or more of the services, and weekly Portage visits for some famiSharon Horswell lies and advice to families / carers and preschools have been offered. Regular individual education plan meetings have been coordinated to ensure consistency of approach and targets across the different environments. In addition, all parents / carers whose child has received a diagnosis of an autistic spectrum disorder have been offered the opportunity to attend the National Autistic Societys EarlyBird course run by the speech and language therapy service. Although good practice had been adhered to, a number of the professionals involved increasingly recognised that some childrens progress in terms of interaction and communication skills had been disappointing due to insufficient frequency and intensity of specialist input. In addition some staff had been introduced to the Picture Exchange Communication System (PECS) and realised that, to implement this effectively, enhanced provision was necessary. Ann therefore sought and obtained funding from the Torbay Early Years Development and Childcare Partnership to pilot an intensive communication group to be run on a twice weekly basis, staffed by a preschool advisory teacher, a speech and language therapist and a nursery nurse. In addition the Portage service was extended to provide up to three visits a week for these children to reinforce communication and interac-

a complementary service
Dissatisfied with the progress of preschool children with complex communication and autistic spectrum disorders, Ann Wiseman and Sharon Horswell organised multi-agency intensive groups to complement the established service. The good outcomes for the childrens communication, interaction skills and behaviour were mirrored by the development of staff skills in working together, planning and training others.

The intensive communication group tion skills at home and to support the parents. The outcomes of the group were very encouraging but, to set them in context, we will start with an account of the groups aims and structure. We established the foundation of the group on the following tenets: 1. The proven effectiveness of collaborative multiagency working, as discussed in the Together from the Start model (DH, 2003). 2. A strong research basis indicating that early years intervention is crucial in establishing longterm change and development of communication and interaction skills (see for example BerruetaClement, 1984; Dawson & Osterling, 1997; Garland et al., 1981). 3. The group must complement established provision, such as EarlyBird, Portage, speech and language therapy and outreach, offered by the speech and language therapy and preschool advisory services. 4. The need to create an optimally responsive communication environment for children who do not have the ability to develop adequate communication and interaction skills from typical communicative environments (for example at home and at preschool). 5. The need to provide a specialist adult-rich environment to enable the children to establish communication systems such as PECS, that require a high level of support in the initial stages. 6. The need to provide training, offer support and share information with parents / carers, preschool staff and other professionals. 7. The need for children to learn to participate in group activities and begin to tolerate and interact with others in close proximity.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

INTENSIVE GROUPS

Six children were to attend for two mornings per week (09.45-12.00) from January 2004 - April 2004, a total of 20 sessions. Referrals were received from preschool advisory teachers, speech and language therapists and staff from the Child Development Centre. All of the children referred had a diagnosis of an autistic spectrum disorder or a complex communication disorder. All of the children already attended their local preschool group and this was to continue. We chose six children from the potential referrals according to their age (with those nearest to school age being given priority) and the support they were already receiving (such as Portage, learning support assistance at preschool, EarlyBird course). Transport was provided for children and their parents free of charge, with three parents choosing to act as escorts for their children. Three of the children selected for the group had a diagnosis of autistic spectrum disorder and three a complex communication disorder (two with a query of autistic spectrum disorder).

Strengthen relationships
We chose the playroom at the Child Development Centre (John Parkes Unit) in Torbay for our accommodation, for the following reasons: Suitable equipment and furniture. Support from a nursery nurse who has received relevant training for this group of children. A large attractive playroom with an integral toilet and a wealth of suitable activities and toys. Easy access to a large, attractive outside play area, where communication opportunities have been maximised. Initial and ongoing assessment of children with special educational needs is continuous at the unit and some of the children and their parents / carers referred to the group were already familiar with the playroom and nursery nurse. In addition we anticipated that establishing the group at the unit would strengthen relationships between various professionals and thus improve the services offered to both the children and their parents / carers. Our group had three main aims: 1. To create a safe secure environment in which the children were happy to part from their parents / carers. 2. To develop the communication, social interaction and imaginary play skills of the children. 3. To enskill parents / carers and preschool staff in working effectively with the child in their care.

structure, PECS, intensive interaction (Nind & Hewett, 2001), backward chaining (Baker & Brightman, 1997), and modelling of behaviours and language. We established a whole group visual timetable of the morning routine from the first session, indicating to the children the main transition points. In addition we taught children the skill of managing their own individual timetable independently. Transition points were: 9.45 Settling and playing with activities of the childs choosing 10.15 Hello time and singing 10.30 Outside play 11.00 Toileting and hand washing 11.05 Storytime 11.15 Snack 11.30 Playing with activities 11.55 Tidying up 12.00 Goodbye time The routine has elements of free play, individual time spent with an adult to develop specific skills, turn taking activities with another child and also group activities. We established a photo choice board of favourite toys / activities so the children could request items by pointing or exchanging a picture as appropriate. We placed toys within sight but out of reach, to encourage the children to communicate their preferences. We set up activities for the children with an essential component missing (such as a train track with the trains just out of reach), therefore encouraging the children to make a request. An outside symbol choice board was used to enable the children to request out of sight toys (such as ride along items locked in a shed), activities such as being pushed on a swing and social routines such as tickle and chase.

allows them to practise commenting. We found it necessary to give the children quite a long settling period when they first arrived, with some favourite toys being available to assist them in adjusting to the environment. Hello time was used to help children to learn their own and others names, to tolerate sitting as part of the group, and to introduce them to some repetitive preschool rhymes. Story time was always simple, with an abundance of visual aids and at times some familiar music such as the Thomas the Tank Engine theme - to stimulate their interest. After the story we checked understanding using simple language and reference to the pictures. We saw snack time as an ideal opportunity to capitalise on communication as, for some of the children, motivation was maximised. We asked parents to send their childs favourite foods, and children requested these items verbally or by using pictures of the food / drink items. One child had been introduced to PECS before starting at the group and two others were introduced to the system in a formalised way as indicated by the PECS manual. (Two of these three have an autistic spectrum disorder.) The others all used pictures to extend their communication and social interaction skills.

Individual targets
We initially established individual childrens targets by two means: 1. Use of a detailed checklist of pragmatic skills (Dewart & Summers, 1988) filled out in conjunction with each childs parents. 2. Observation of each childs communication, interaction and play skills during the first two group sessions. Then, at the end of each session, the staff collectively wrote up their observations for each child. Once a week, at a planning meeting, each childs targets were reviewed in the light of observations made and new targets set for the coming week. We shared information in a number of ways. We contacted parents by telephone each week to discuss progress and new targets set, and to suggest ways of generalising skills at home. Informal sharing of information was carried out at the beginning and end of each session, although staff were keen to keep this to the minimum to ensure that children remained calm and left the group when they were expecting to. The Portage home visitor attended planning meetings to ensure continuity of support for the child and their carers. Preschool staff, parents, the Portage home visitor, the preschool advisory teacher and the speech and language therapist met once or twice a term at individual education plan meetings held at the preschool to review progress and establish targets together. We also held an open evening at the end of February. This was in two parts. The first part was for preschool staff, speech and language therapists and Portage workers involved with the children. The second part was for parents. During the evening

we set up the environment to capitalise on communication opportunities, taking into account that all the children in the group were strong visual learners
Adults in the group wore a bracelet with key symbols attached (I want, help, wait, and finish), which they or the child could easily access. In addition adults wore a pocketed apron with a Velcro strip on the front to which they could attach symbols for the child to exchange with or simply to clarify communication between adult and child. Between each change of activity we gathered the children together. We showed them a picture board of toys and areas of the classroom they may have been playing with and asked the question, What have you been playing with? Some children responded verbally given the visual prompt, while others were prompted by an adult to indicate their activity by pointing. This process, often repeated, helps the children to recall the recent past, establishes the idea of a sequence and

Communication opportunities
To achieve these aims, we set up the environment to capitalise on communication opportunities, taking into account that all the children in the group were strong visual learners. We planned each session to provide a wide range of motivating activities, as discussed with parents. Within this framework we implemented tried and tested techniques to maximise communication opportunities and develop skills. These included visual

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

INTENSIVE GROUPS

we explained the layout of the nursery with its relevance to the development of language and social interaction skills. We discussed the curriculum of the group, and parents and preschool staff were able to look at some video footage to illustrate the strategies being used by adults within the group to achieve the targets set for individual children.

5 STEPS TO BETTER PRACTICE: INTENSIVE GROUPS


1. LOOK TO BUILD ON AND COMPLEMENT ESTABLISHED SERVICES 2. CONSIDER A RANGE OF FACTORS WHEN CHOOSING ACCOMMODATION 3. IDENTIFY A VARIETY OF WAYS TO PROVIDE SUPPORT, TRAINING AND INFORMATION 4. STRUCTURE ACTIVITIES TO DEVELOP USEFUL REAL LIFE SKILLS 5. MEASURE OUTCOMES IN A WAY THAT DEMONSTRATES SUSTAINABILITY
and ask to be chased, and the other most severely affected child began to play in parallel and to accept approaches from other children. Some parents reported that these skills had generalised to the preschool setting, and five of the six children were beginning to interact with their peers. One parent reported that her son had started to enjoy sharing a book with an adult for the first time. Comparing initial and post-group assessments, all of the children made progress with both turn taking and initiating in structured activities, taught systematically through joint action routines. c. Behaviour We tackled issues as they arose, working closely with both preschools and homes. Sharing and simple negotiation skills were developed through modelling and the use of a range of prompts: verbal, visual and physical. One child became severely anxious when it was time to leave. He was showing similar difficulties at his preschool. Following discussion, visual structure was implemented to prepare him for this transition, and the problem was resolved in both settings after three weeks on the programme.

Outcomes
1. Differential diagnosis Two of the initial group of six children had received a query diagnosis of autistic spectrum disorder. Through working intensively on communication, interaction, and play skills, this diagnosis was ruled out and both were given a diagnosis of language delay with associated behavioural difficulties. 2. Development of the childrens skills. We used The Pragmatics Profile of Early Communication Skills (Dewart & Summers, 1988) to assess all the children at the beginning and end of the pilot (January 04 / July 04). We recorded the following outcomes: a. Communication Initially none of the children were able to gain an adults attention in an appropriate manner, or to greet others without a prompt, or to comment. Following the pilot all of the children made gains in the frequency and range of functions of communication. For example the children began to gain an adults attention appropriately by calling their name and / or approaching them. Five of the six children became able to greet adults and four of the group were able to make simple comments. Significant gains were made by all the children in the areas of expressive communication, both in qualitative and quantitative terms as recorded on the Pragmatics Profile (Dewart & Summers, 1988). Two of the children were enabled to use PECS. This resulted in them developing an intention to communicate, and also persistence and clarity of communication. Some parents reported that their children had become much clearer in asserting their independence, and were less passive in their communicative attempts. For example one child who used to passively accept No, now persists in handing his mother the PECS strip I want. On initial assessment one parent reported that her son did not respond to any verbal direction, however simple. Following the period of the pilot group, he was able to understand simple commands in familiar contexts, such as Get your shoes. b. Interaction skills All of the children made progress in their abilities to interact and play with their peers. At the start of the group, five of the children would play in parallel with others, and the sixth child, the most severely autistic of the group, could not tolerate others in his proximity. By the end, the three nonautistic children and one autistic child had begun to develop co-operative play. Of the other two autistic children, one began to approach his peers

emphasis on practical aspects of management. A spin-off from this training has been the improved effectiveness of individual education plan meetings. Because of a greater shared understanding and knowledge of the parties involved, clearer goals are established and greater progress is seen across all settings. Information and training for school staff receiving children from the group has been greatly enhanced and some class teachers have been able to visit a child within the group setting prior to the child starting school. Preschool special educational needs coordinators have also been given the opportunity to visit the group as part of their Stage 2 training. We also recognise that the skills of those working within the group have developed through the constant weekly process of discussions with parents / carers, target setting and evaluation. The development of these skills has enhanced the work of both the preschool advisory / area special educational needs co-ordinator service and the service offered by the staff of the John Parkes unit. Overall feedback from parents / carers and other professionals, and the recorded development of the childrens skills, suggests that the group has proved to be a valuable additional resource to existing provision for preschool children in the Torbay Area with a severe complex communication disorder or an autistic spectrum disorder. Ann Wiseman is a Preschool Advisory Teacher SEN / Area SENCo, e-mail ann.wiseman@torbay.gov.uk. Sharon Horswell is a speech and language therapist with South Devon Health Care Trust, e-mail sharon.horswell@nhs.net.

References
Baker, B.L. & Brightman, A.J. (1997) Steps to Independence: Teaching Everyday Skills to Children with Special Needs. 3rd edn. Baltimore, Maryland: Paul H. Brookes. Berrueta-Clement, J.R. et al. (1984) Changed Lives: The Effects of the Perry Preschool Project on Youths Through Age 19. Ypsilanti, MI : High/Scope Educational Research Foundation. Dawson,G. & Osterling, J. (1997) Early Intervention in Autism, in Guralnick, M.J. (ed.) The Effectiveness of Early Intervention. Kansas City: Paul H. Brookes. Department of Health (2003) Together from the Start: Practical guidance for professionals working with disabled children (birth to third birthday) and their families, LASSL (2003)4. Available at: http://www.dfes.gov.uk/consultations/downloadableDocs/177_1.doc (Accessed: 3 October 2005). Dewart, H. & Summers, S. (1988) The Pragmatics Profile of Early Communication Skills. Windsor: NFER-Nelson. Garland, C., Stone, N.W., Swanson, J. & Woodruff (eds.) (1981) Early Intervention for Children with Special Needs and their Families: Findings and Recommendations, Westar Series Paper No. 11 Seattle, WA: University of Washington. Nind, M. & Hewett, D. (2001) A Practical Guide to Intensive Interaction. Kidderminster: BILD publications.

Sustainability
An important question for every group is sustainability. After consideration of the feedback from parents / carers and professionals following the pilot period, Torbay Early Years Partnership decided to fund the project for a further six months. The education authority has since decided to incorporate teacher and transport costs into its overall budget. Training evenings are held once a term for parents / carers, and a wide range of professionals involved with each child about to make the transition to mainstream or special school are invited. The room is set up to show how visual structure is implemented, and video footage is shown to illustrate how we work towards goals. We put the

Resources
National Autistic Societys EarlyBird Programme, see www.nas.org.uk The National Portage Association, see www.portage.org.uk PECS, see www.pecs.org.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

HERES ONE I MADE EARLIER...

Heres one I made earlier...


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

FORMAL AND CASUAL BOARD


A wall-mounted display for a group to make. It helps clients learn about the various social codes needed for different situations. Good fun to create, and forms the basis for many discussions.

BREATHING STRINGS

MATERIALS
Squared or graph paper As many newspaper or magazine pictures as you can find depicting people in different social contexts such as barbecues, weddings, legal trials, dances. (As a general rule local papers are a good source of photos of casual events, while the nationals, especially broadsheets, yield formal images.) Large board (either a piece of hardboard about 1 metre by 1.5 metres, or for a neater effect, a large pinboard in a frame, obtainable from DIY shops). Glue or pins, felt tips, scissors.

This is a fun and simple way to encourage deeper breathing by youngsters, as part of a course on breathing techniques. You can use it one-to-one or as a group activity. Take care not to encourage overly deep breathing, or your clients could become dizzy. A word of warning regarding physical contact dont do the measuring around the clients chest yourself. If they are unable to do their own measuring you should ask the parent, or else abandon this idea.

MATERIALS
String the soft white cotton variety, or you could use narrow cotton tape. Felt tips of many colours, and biros. Wire coat hanger (if you are doing this activity with a group).

BRAWN
Cut lengths of string approximately 15 cms longer than your clients lower chest measurement. Mark off 8 cms at one end with the biro this is the bit that the client will hold, and which will later become the attachment to the coat hanger.

BRAWN
With the board placed landscape, draw a vertical line about a fifth of the way across, and stick or pin a strip of squared or graph paper into this area. This paper forms your Graph of Formality, so must stretch from the bottom to the top of the board. Along the bottom of this graph, sideways on, you will later write various scenarios some will be those shown in the newspaper pictures, and others that your clients themselves may encounter. Write the word Formal on a sticker at the top of the remaining part of the board (the poster area), and similarly Casual at the bottom.

IN PRACTICE
The idea is to form breathing gauges by marking in different colours four points on the string that represent the clients chest measurement when they are 1) breathing fully out, 2) naturally breathing in, 3) breathing in deeply and 4) breathing in really deeply. Take care over the possible issue of hyperventilation. You may need to have breaks between each breath. You now have a baseline measurement for these four chest positions (fully exhaled, naturally inhaled, more deeply inhaled, fully inhaled). If you are working as a group you will need to label the strings with the clients names. Tie the strings loosely onto the coat hangers so that you can remove them at the next or subsequent session and see if there is any change. If / when there is an increase, just keep adding more colours. If you have enough of these coloured strings, you can leave them on the hanger together, to make an interesting wall decoration.

IN PRACTICE
1. The clients cut out the pictures and stick or pin them on the poster area of the board, deciding between them how far up towards the formal or down towards the casual they should be placed. You should end up with a bottom row of casual images such as a group of people in a pub or on a beach or picnic. Then, working upwards, there will be several rows of progressively more formal images, including scenes such as shopping, school / college / work cafs, doctors waiting rooms and appointments, until you reach the formal settings such as funerals, and state banquets. (They dont have to be situations the clients have experienced, in fact the more extreme the better). 2. Fill in your graph, colouring in the vertical bars on the graph paper, as far up towards the formal, or down towards the casual as the group decides. The scenarios for which you have already stuck on pictures will come as far up the graph as they were placed on the poster. 3. Now the clients add their own scenarios to the graph, again writing sideways at the bottom of it. Situations might include going to the snooker hall; work experience at the garden centre; phoning home; phoning Mums office; texting a friend; visiting an elderly relative. You may need to give guidance as to whether for example phoning mums office is more or less formal than asking for something in a shop.

ALSO FOR
This is a lateral thinking game for a group of clients of any age.

MATERIALS
Objects that are readily to hand, in any office, or you can supplement with common kitchen utensils, handbag contents or other items.

IN PRACTICE
Pick up an item such as a paperclip and think of an alternative use for it. Each client just thinks of one new use, then passes it on to the next person who does the same. When no one can think of any more uses, pick up a new item. The new uses can be as wild and wacky as you like. For example, a pencil could be used as a plant support, a chopstick, a hair decoration, a window prop, or a stick for a paper windmill. A paperclip could be used as a hairgrip, an earring, a link from a paperclip necklace, or a tool for extracting something stuck in a crevice. You can take the opportunity to make the point that two heads are better than one at this, and that if we all pool our ideas we can have better results (this also links into friendship skills).

VARIATIONS
Add little speech bubbles to the pictures, with greetings set at the appropriate level, ranging from Hi to Morning, to Good Morning and so on. If you write these on post-it notes you can vary the type of bubble, to include farewells, and conversational topics. Discuss, and possibly write on the poster, appropriate forms of non-verbal greetings, such as High fives, handshakes, salutes, even curtsies! Also discuss appropriate clothing for each scenario.

SEASONAL VARIATION
Think of alternative uses for Christmas items such as tinsel, decorated cake board, Father Christmas hat, stocking, pudding basin. Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

EVIDENCE BASED PRACTICE

EXPERT GUIDANCE:

Developing critical appraisal skills


Evidence based practice is more than a set of skills it is a way of working and practising our profession. A key element is critical appraisal, where we use clinical judgement to consider the relative validity and importance of evidence presented in professional papers. Frances Harris takes us through the process.
A. KEY QUESTIONS When we read a paper, there are two key questions to answer. 1. Is the stated result valid? and 2. Is the result important? Critical appraisal is a bit like being a detective scouring for evidence. You seek not just a fragment here or there but a full skeleton in order to close your case. Validity relates largely to the matter of study design and method. The method is the backbone of the evidence being reported. From this backbone hang like limbs the issues of clinical importance and statistical importance. Any bias in the method, or scope for error in measurement, weakens the backbone, and reduces the importance of the results. This is good news for those who dislike reading the statistics section (often in the Results part). A thorough reading of the Method might reveal that the statistics have no backbone, and so you do not need to bother with the results at all. B. STUDY DESIGNS AND THEIR VALIDITY The research questions will frame the type of investigation needed (Pring, 2005). Greenhalgh (2001) gives a thorough listing of designs and their uses. Research questions which seek to interpret or describe behaviour usually lead to a qualitative research design. The design is often a descriptive, correlational investigation of variables, for example finding out more about the reasons why parents fail to attend a clinic appointment, or the factors making it more likely that a parent will pursue a set home programme with a language delayed child. Qualitative study designs might be used for examining responses in natural settings rather than in controlled (experimental) conditions. Quantitative research questions which seek to measure behaviour might lead to an experimental or quasi-experimental design. In such designs the experimenter tries to manipulate one variable (the independent variable) to observe the effect on the dependent variable. Experimental designs are classically suited to the medical setting where it is easier to control all the variables except the dosage of a medicine. Relationships of cause and effect can then be deduced. For example, children with similar clinical presentations could be randomly allocated into two groups, of which only one group receives therapy. In a quasi-experimental design, however, not all the variables can be controlled, and as a result the relationship between cause and effect is not certain. An example would be sorting children into groups according to language levels (language normal and language delayed) and observing features of the prenatal and perinatal history. Here the presence or absence of language delay is not manipulated, so we need care in drawing any conclusions about the cause of their language delay (example from Pring, 2005). Sometimes in speech and language therapy the best design we can feasibly operate is quasi-experimental (not experimental) and this means we have to be careful about the claims we make for relationships between the key variables of a study.

EXPERT GUIDANCE:
ASKING QUESTIONS UNDERSTANDING
STATISTICS

CHANGING PRACTICE

A good fit between the design of a study and its research question is the key to its validity.
A good fit between the design of a study and its research question is the key to its validity. When it comes to appraising the validity (or rigour) of the design, look for ways in which error was minimised and potential bias avoided. Look too for evidence of detail which would allow replication of the study. What evidence is there for good quality control, such as reliability between coders, or resolving differences of coding? Checklists for the validity of research designs can be found in Greenhalgh (2001) or Bury & Mead (1998). C. STATISTICS: SOME BASICS The statistics section of any paper is usually a big turnoff. Numbers start to swim before the eyes.

Readers look hopefully for a graph or picture to inform them. Before you start to read any numbers, take a look at what the numbers are trying to do. Most studies are looking at a sample of people, with or without clinical conditions, in order to make an observation about a wider target population. The measurements for the sample lead to an estimate of a population measure. The average height of a seven year old boy, for example, is derived from measuring a sample of seven year old boys, since it is not feasible to measure each and every child. In reality, the actual height of seven year old boys varies widely, and is thought to follow the classic Normal curve shape. Many studies make an assumption that their sample data is normally distributed, in order to perform the family of statistical tests called parametric tests. When reading a study, look for evidence that the researchers have checked their distribution characteristics. Consider too the study sample: are any assumptions being made by the researchers about the distribution that the sample comes from? Is it a clinical or a normal sample? Is it appropriate to compare results for this sample to the target population? Being only an estimate, a statistic has its own range of accuracy. The confidence interval is a way of expressing the accuracy, or bounds, of the estimate, with a specified level of certainty. Taking the height example, a study might conclude the average height of a seven year old boy was 120cm, and quote a 95 per cent confidence interval of 95 to 145cm. This would mean that 95 per cent of the time, the actual (but difficult to measure) average height of such boys would fall between 95 and 145cm. Clearly a wide confidence interval is not much use for the purpose of making boys trousers. However it could be acceptable if my purpose related to minimum depths of 80cm in a swimming pool. Further, the level of accuracy demanded of a statistic is linked to its purpose. In other words, a statistic (an estimate), its range of accuracy, and its purpose all have to be taken together. Somehow statistics and numbers are associated with pinning things down and reducing uncertainties.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

11

EVIDENCE BASED PRACTICE

EXPERT GUIDANCE:
We hope that by taking clinical measures we can be sure of a clients case status, or of progress within therapy. However the numbers will only do what we ask of them. It is still the practitioner who determines the dividing line between the clinical and normal case, even if we use statistical conventions to help us. Our own tolerance for risk will determine where we set the boundaries or thresholds. One way of looking at evidence-based practice is that we use the evidence to help us quantify risk, and to communicate this to our clients. At some point in clinical decision making with a client we hand over a degree of risk to the client too. They have to decide for example whether to take up a course of therapy, based on the expected outcomes with or without treatment. So a statistic is an estimate based on various assumptions about the population distribution, with its own likelihood of being (in)accurate, which can only be used in conjunction with clinical judgement and its own context. To ease yourself into useful and manageable statistics I suggest: Greenhalghs (2001) chapter on Statistics for the Non-statistician: descriptive and very readable. Pring (2005) An excellent overview of designs, why we need statistics, how to use them, and what research can tell us. The online text Statistics at Square One is very clear. Visit http://bmj.bmjjournals.cpm/ collections/statsbk/index.shtml There is also a CD package available from the NHS Critical Appraisal Skills programme for self-study using a PC (but not needing the internet) at http://www.update-software.com/CASP. when the difference in study group results crosses this threshold then the results are declared significant. The disadvantage of the method is that clinically important results may not reach this statistical threshold for significance. Moreover we have no additional information about the degree of differences. An improvement on this situation is to use a confidence interval. Confidence intervals put upper and lower bounds on an estimate (such as treatment effect size), indicating the range within which (within conventional limits of uncertainty) the true effect size might lie. If the range reported by the study includes the zero value (that is, the value indicating no treatment effect) then the treatment is not significantly different from the control group. Both statistical significance levels and confidence intervals are subject to their own levels of uncertainty: the conventional limit is to report with a 95 per cent certainty. This means one in 20 findings are spurious, due to chance. Failure to achieve statistical significance may be due to insufficient cases (small sample sizes). This is referred to as a problem of power. The power of a study represents the probability of finding a true difference between regimens where there is one. Very broadly speaking, increasing the number of subjects increases the probability of finding a genuine difference between distinct groups. Usually the power level of a study is set at 80 per cent. This means that there is a 20 per cent chance of the error in which the study concludes there is NOT a difference between regimens when the true state is that there is. For the purposes of critical appraisal the question is: if the finding was not statistically significant, was the study sample large enough to detect a difference? E. IS THE RESULT IMPORTANT CLINICALLY? Clinical significance addresses the questions: 1) Should the study lead to changes in clinician behaviour? 2) Or does the study lead to improvement of quality of life for a client? Clinical importance is a separate judgement to statistical significance. A large study could show as significant a small observed difference, which may not have a clinical usefulness. Conversely, a clinically important difference may not be revealed by a study as statistically significant. It is important to remember that in this sense the numbers can get it wrong. Clinical impact can be determined by key statistics for certain study designs. Here I set out two classic statistics used in medical approaches to evidencebased medicine, (i) the likelihood ratio (LR) and (ii) the number needed to treat (NNT). Although these are medical statistics, they could usefully be used in presenting some therapy findings, especially screening procedures and outcomes-based therapy trials. (i) Likelihood ratio For a screening study, the likelihood ratio [strictly the positive LR] is the factor by which your estimate of presence of condition X is changed by doing the screening test. A very useful screen is one that increases your confidence in your judgement about condition X. A likelihood ratio of 1 or close to 1 indicates almost nil added value in doing the screening test. Likelihood ratios may be numbers larger than 1 or less than 1. (If instead the study only reports percentages for sensitivity and specificity, the positive likelihood ratio may be calculated as sensitivity / [100-specificity]). A guide to interpreting likelihood ratios is in Table 1.
Table 1 Interpreting likelihood ratios

Range of positive Clinical likelihood ratio significance (LR+) 10 or more or Less than 0.1 5 to 10 or 0.1-0.2 2.5 to 5 or 0.2 to 0.5 HIGH

MODERATE

LOW

As Pring puts it, we never prove anything: we just show that a result is fairly unlikely to be due to chance.
D. IS THE RESULT IMPORTANT STATISTICALLY? The type of investigation often determines which statistic will be used. Then that statistic needs to be interpreted appropriately, to determine its impact. By far the most frequently cited statistic is the significance level p. Statistical significance addresses the question: are the conclusions of the study likely to be true? The term statistical significance is a form of shorthand. It is a way of expressing (within conventional limits of uncertainty) that the results of the experimental groups are so different that the researchers reject the idea that there is no difference between them. As Pring (2005, p.19) puts it, we never prove anything: we just show that a result is fairly unlikely to be due to chance. Statistical significance levels act as a threshold;

(ii) Number needed to treat For a therapy impact study, a medical approach would look at the number of clients above or below a given threshold, for example the number of children who were joining two key words into phrases, compared to the number still at a single key word level. (This approach puts clients into one of two groups, rather than looking at them descriptively by their mean length of utterance, for example.) The consequence is that each client can then contribute a positive or negative outcome [or event] to the study. Table 2 gives demonstration calculations for a notional study with 41 children in the control group, and 40 in the experimental group. The control event rate (CER) of 37 out of 41 indicates that 37 children in the control group were still classed as at a single word level by the end of the study, compared to 25 of the experimental group. Here, the experimental event rate (EER) is 25 out of 40. The basis of quantifying results is to look at the progress of an experimental group, over and above a control group, by looking at the risks of each group. If a treatment is effective then the experimental group should be at reduced risk of a poor outcome event. So if a language group is working, there should be a reduced risk of the event of a child being classified at single key word level. The number of events is counted in both the control group and the experimental group. The difference in event rates [CER- EER] is called the absolute risk reduction (ARR). It is also possible to derive the relative risk

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EVIDENCE BASED PRACTICE

reduction (RRR), which apportions the absolute risk reduction over the number of events in the control group. The reciprocal of absolute risk reduction is the
Table 2 Demonstration calculations (notional study)

Note that clinical importance is


ARR/CER = Relative risk reduction (RRR) (confidence interval) 1/ARR = Number needed to treat (NNT) (confidence interval)

PRACTICAL POINTS: Critical appraisal

Control event rate (CER)

Experimental event rate (EER)

CER-EER = Absolute risk reduction (ARR) (confidence interval)

37 / 41 = 0.902 25 / 40 = 0.625 0.277 (0.10 0.45)


number needed to treat (NNT). By convention this is rounded upwards to the nearest whole number. It represents the number of clients needing treatment as per the study protocol to prevent one additional poor outcome (in terms of the event outcome in the study.) A relative risk reduction of more than 25 per cent is desirable, and more than 50 per cent would be clinically significant. A relative risk reduction of 100 per cent represents total success; the treatment would remove all risk events and the experimental event rate would be zero. Lower numbers needed to treat are desirable, or a number needed to treat which is lower than alternative treatment regimes. A confidence interval can be calculated on the number needed to treat, and this sets a range for the interpretation of the clinical significance of the result. F. GETTING RESULTS INTO PRACTICE 1. Ask questions Asking questions is vital to reflective practice. (Even if we have done our phonology groups for donkeys years, why do we do it?) Have a folder or box in clinic that can receive questions. Then later, on reviewing the set of questions at clinic meetings, agree who will be responsible for tracking down an answer and how this will be fed back to the team. Clearly more than one clinician might be involved in this process. 2. Reading groups The art of reading to check the validity of findings and to assess their applicability can be practised in reading groups. Work time set aside to discuss articles with colleagues can reinforce the use of critical appraisal checklists and give confidence in interpreting results. A key for success would be a clinical leader or mentor who can facilitate the clinical discussion. Tasks of the group would be to select topics for discussion, search for relevant articles, read and appraise selected articles and then discuss applicability of findings. Topics can be selected one week for discussion in later weeks, after the relevant literature has been locat-

0.277 / 0.902 = 1 / 0.277 = 3.6 30.7 % (rounded up to 4) (11 % - 50 %) (2 to 10)

ed. A typical format might be: a) Discussion of topics to address, with selection of one topic A. This will be the focus of a literature search before the next meeting. b) Report back from designated group member on the results of literature search for topic B. This literature is distributed for appraisal before the next meeting. c) Appraisal of literature on topic C, as distributed at the previous meeting. d) Generate a summary of findings for local situation. 3. Assess applicability of research Once the literature has been appraised for its validity and its importance, consider how it could be applied to a particular clinical setting. Is this proposed screening test / therapy regime feasible? Is it affordable, or available? Does the study sample population have similarities with the population in my clinical setting? Would clients be willing partners in this approach? 4. The practice environment The organisational environment of the clinician may well determine their success in implementing evidence based practice. There need to be: Mechanisms by which individual and organisational change can take place Effective communication systems across staff groups and locations Staged approaches to change, with prior analysis of which mechanisms to use Adequate resources and staff with appropriate skills to change practice Strategies for monitoring, supporting and maintaining changes. Access to information technology, in collaboration with information services experts is vital for carrying out internet searches of literature databases and information services (such as online journals and synoptic journals). Networks of professionals are also fundamental. Networking between researchers and clinicians ensures that the researchers are addressing the

a separate judgement to statistical significance; the numbers can get it wrong. Be careful about the claims you make for relationships between the key variables of a study. Remember that a statistic is an estimate to be used in conjunction with clinical judgement and its own context. Look for detail in papers that would allow replication and show how errors were minimised and bias avoided. Know when and how to hand a degree of risk over to your client. Network and share expertise.
clinicians queries in a relevant way. This improves applicability and validity of any findings. G. WORKING COLLABORATIVELY Evidence-based practice is more than a set of skills. It is a way of working and practising our profession. Everyone asks questions already, at some level, so a good starting point for evidence-based practice is to ask clinically-driven questions. This habit can be developed so that clinicians are regularly reflecting on their practice. But the evidencebased practice toolkit is broad indeed and, although everyone can ask questions, not everyone can do everything - ask a decent clinical question, search the internet, track down valid articles, interpret results and then implement change in their practice. A few, maybe. The rest of us learn to build up networks and make teams to share our expertise. Collaboration is the key to ensuring that our practice is based on evidence. Have fun finding your skeletons! Frances Harris is a paediatric speech and language therapist for South Cambridgeshire PCT. Comments are welcome: frances@16copperfields.freeserve.co.uk

References
Bury, T. & Mead, J. (1998) Evidence-based healthcare: a practical guide for therapists. Oxford: Butterworth-Heineman. Greenhalgh, T. (2001) How to read a paper. 2nd edn. London: BMJ. Pring, T. (2005) Research Methods in Communication Disorders. London: Whurr.

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The case for f


READ THIS
IF YOU ARE INTERESTED IN RESEARCH COVERING A GENUINE CLINICAL POPULATION TACKLING STAFF SHORTAGES AND WAITING LISTS EVIDENCE FROM RANDOMISED CONTROLLED TRIALS

A randomised controlled trial on a real clinical population that shows therapy effectiveness for children with communication impairment? If this sounds like someone is flying kites, meet Jan Broomfield who gave the Kids communication Impairment: Therapy Effectiveness project its wings

as your service or department ever been faced with a serious staffing crisis? Do you want to contribute to the evidence base for the profession? The paediatric speech and language therapy team in Middlesbrough were in just this position in 1997 and dealt with the situation as an opportunity. As team leader, I sought funding for a randomised controlled trial and analysis / evaluation time and discussed post-graduate research qualifications with the local speech and language therapy training university, Newcastle upon Tyne. Over 100,000 was secured from the then NHS Executive (Northern and Yorkshire Region) and I enrolled for a PhD. The KITE Kids communication Impairment: Therapy Effectiveness project - was born. The intention of the study was to conduct a randomised controlled trial, looking at issues such as treatment versus no treatment and the timing of intervention - effectively the impact of waiting lists. The influence of population factors, case history issues and co-occurring deficits on these outcomes will be looked at in detail at a later date. However, when I looked at the literature about the nature of the a caseload, I found little information. So the study became two-fold, incorporating not only the therapy effectiveness elements, but also investigating the nature of referrals received.

The mainstream paediatric service has a service head / team leader whose specialism is phonological disorders a clinical co-ordinator whose specialism is cleft palate, ENT and related disorders two senior specialists in specific speech and language impairment and dysfluency one specialist in language unit / language resource base generalist therapists who have paediatric services as part of their caseload and speech and language therapy assistants. This equated to 6 whole time equivalent therapists and 3 whole time equivalent assistants in post at the start of the study.

Randomisation was conducted off-site, and assessing therapists, treating therapists and assistants were all blinded to the group allocation of each child in their care.
The service is based in five community clinics. There are over 100 primary schools in the locality, and the move to school-based services has not yet happened due to sheer numbers and the desire to base service reconfiguration on sound evidence, which is starting to be available. However as Sure Start programmes become integrated into Childrens Centres in England and services are asked to follow this ethos, we hope to start the transition to locality speech and language therapy teams and increase our contact with schools and nurseries in the near future.

Population
Middlesbrough Primary Care Trust provides speech and language therapy services for children in the Middlesbrough and Redcar Cleveland areas in the North East of England. The population is in the region of 300,000 and there are 4,000 new births each year. Nine Sure Start projects have been set up in the locality (after recruitment to the study), and four wards fall into the top ten most deprived in the UK (www.statistics.gov.uk). Much of the population resides in urban areas, but there is a proportion of rural and farming communities. The speech and language therapy service of Middlesbrough Primary Care Trust has two main sections mainstream paediatric, including language units / resource bases and assessment classes / support bases in mainstream schools, and special needs, including learning disability, physical disability, hearing impairment and autistic spectrum disorders. The speech and language therapy service for adult neurological / acquired disorders is provided by South Tees Acute Trust. Additionally, the nine Sure Start programmes in the locality have speech and language therapy provision that is seconded from Middlesbrough Primary Care Trust.

Frameworks
As much of our direct therapy contact occurs in small groups, often run by experienced assistants and supported by therapists, the department has developed clinical criteria and care pathways. This enables an equitable service to be given by all staff. Further, we have developed therapy packages containing objectives, resources and homework packs for our most common therapy targets, so that the assistants have frameworks available off the shelf for much of their work. Clearly each staff member adjusts and adapts the framework to their style and the individual cases they are seeing, but the basics remain the same. The packages are based on established therapy procedures such as Derbyshire Language Scheme (Masidlover & Knowles, 1982), phonological contrast therapy including Metaphon (Dean & Howell, 1994), Core

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flying KITEs
Vocabulary (Dodd, 2005) and articulation therapy (Van Riper, discussed in Weiss et al., 1987). At the time of the study (19992000), our waiting time between referral and assessment was eight weeks, and those children receiving immediate treatment waited a maximum of six weeks from assessment to treatment. Between January 1999 and April 2000, we received 1100 referrals. Of these, 164 failed to attend for assessment and 108 were found to be within the norm and were discharged at their first appointment. Given the short time between referral and assessment, there was not time for problems to have resolved, so there is an issue around training referrers although this finding matches that of Enderby & Petherham (2001) and therefore is not unique. Of the remaining children, 58 presented with dysfluency as their main difficulty, 22 with ENT related difficulties and 8 were transferred to the special needs team for complex needs; the other 740 had speech / language difficulties as their main presenting problem, and of these 730 consented to be involved in the study. It is these 730 who are discussed here (only 10 of these dropped out during the first six month phase and 20 more over the second). Of the 730, 50 per cent were referred by their health visitor, 23 per cent by school staff and 11 per cent by parents. Almost 75 per cent were less than five years old, with 22 per cent aged two, 27 per cent aged three, 19 per cent aged four and 6 per cent aged 1 (typically almost 2). The age range was 1;9 years to 15 years. There were three boys for every girl. Twelve per cent were identified as having severe / profound difficulties, scoring at below minus 2 standard deviations on formal assessments, and may therefore be classed as having specific speech and language impairment (WHO definition, 1993). The socio-economic distribution reflected that of the local population, which fits a known pattern of referrer selection in areas of high deprivation. Referrers tell us that, whereas they refer almost everyone with communication difficulty from affluent areas, they are selective in areas of high deprivation and dont tend to refer for straightforward delays as theyd refer almost every child. Instead, they refer if there is parental concern because they are more likely to attend and / or where the communication difficulty is severe and / or a high priority for the child and family. Case history factors considered were language onset, general development, hearing, health / medical, feeding, behaviour, family history, family size and care concern. For each case history question no more than 31.5 per cent of responders reported a difficulty, so for each issue at least 68.5 per cent of responders reported no concerns. Every combination of case history factors was found, from none to all. The most common occurrences were behaviour of concern to parents (31.5 per cent), early language delay (30.5 per cent had first word after 18 months) and developmental delay (30.5 per cent walked after 18 months). Caseload factors are discussed in more detail in Broomfield & Dodd (2004a; 2004b). Detailed and wide ranging assessments were conducted with every child and in virtually all cases multiple aspects of speech and language development were impaired. The areas assessed were comprehension, expression including expressive vocabulary, speech including error pattern analysis and consistency rating, phonological awareness, oromotor skill, pragmatics and nonverbal ability. We sub-grouped the 730 according to their main area of difficulty 410 language, of whom 224 had a comprehension diagnosis and 186 had an expressive diagnosis, and 320 speech, of whom 184 had phonological delay, 96 phonological disorder (66 consistent and 30 inconsistent) and 40 had articulation disorder. Interestingly, no child was identified as having developmental verbal dyspraxia at their initial assessment. The study took the form of a randomised controlled trial and this article offers a summary of clinical effectiveness findings. We are preparing papers examining the outcomes but meanwhile readers interested in more detailed statistical information are referred to Broomfield & Dodd (2005a; 2005b).

Randomisation
Interventions were offered over a twelve month period after the recruitment of each individual. Randomisation was conducted off-site, and assessing therapists, treating therapists and assistants were all blinded to the group allocation of each child in their care. We asked parents not to

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Table 1 Summary of study design STUDY PHASE Initial assessment GROUP 1 GROUP 2 GROUP 3

Figure 1 Change in the first 6 months

0 months

0 months

0 months

First treatment No phase (0-6m) Treatment treatment Treatment Interim assessment Second treatment phase (6-12m) Final assessment

The next question is, do waiting lists actually matter? Figure 3 shows the change made when time limited therapy is provided immediately after assessment and within three months of referral (group 1) compared with time limited therapy provided following a six month wait after initial assessment (group 2). Figure 3 Change in group 1 vs group 2

6 months

6 months

6 months

No treatment Treatment Treatment

Treatment

No Treatment

(adjusted t test, t=11.58, p < 0.001)


12 months 12 months 12 months

say anything to assessing therapists until after the assessment was completed, and also asked them not to discuss group allocation with treating therapists; therapists reported that parents rarely commented and stuck to the agreement. Children were randomised into one of three groups group one was the immediate treatment group, group two was the deferred treatment group and group three was the ongoing treatment group (see table 1). It is important to remember that children followed established care pathways during their treatment phases and therefore contact was rarely weekly ongoing therapy. Typically, children received a 6-12 week block of weekly therapy followed by a review period. The average contact time was eight hours, with the range being 0-27 hours. Change is measured in z scores a standard measure converting all assessment scores to a single scale (rather than trying to contrast standard deviations / standard scores / age equivalents depending on the assessment used). A z score of zero means that age commensurate progress was maintained but no loss or gain occurred so a child with an two year performance lag at initial assessment continues to have a two year lag when re-assessed six months later. A positive z score shows catch-up for example a child who moves from -2 standard deviations to -1.5 standard deviations in six months, or a 2 year lag to an 18 month lag, will have a z score of 0.5 for that time period. Conversely, a negative z score shows that the deficit is growing such as a child who moves from -1.5 standard deviations to -2 standard deviations, or an 18 month lag to a 2 year lag, will have a z score of -0.5. The findings reported here show only the mean change for each group. Figure 1 compares change in the first 6 months between the treatment groups (group 1 + group 3) and the no treatment group (group 2).

The difference is clear children in treatment made much more progress overall than those receiving no treatment. It is important to compare with no treatment to reflect natural spontaneous change. But does diagnosis affect this finding? Figure 2 shows the mean treatment and no treatment outcomes for the first six months for each diagnostic category. Figure 2 Mean outcomes by diagnostic category

(adjusted t test, t=3.02, p = 0.003) The difference is less remarkable this time, but is still apparent. Children receiving therapy sooner do better when therapy input is limited. Again, does diagnosis affect this finding? Figure 4 shows the mean outcomes of immediate and deferred intervention for each diagnostic category. Figure 4 Group 1 vs group 2 by diagnostic category

It is clear that the greatest overall therapy impact was made for the diagnosis of comprehension difficulties. However, both comprehension and expression cases made a degree of spontaneous change, and this is far less in evidence in any of the speech types. This finding may help service prioritisation and focus, in that children with speech difficulties where we dont see progress without intervention may be more in need of direct speech and language therapy, while more indirect work with children with language problems may still effect major change. We made the least difference with the expressive group and so are reconsidering our provision as there is a question over effectiveness and efficiency when compared with the other groups.

It is clear that, for all diagnoses except one, waiting for six months prior to beginning intervention slows progress made. This is particularly marked for comprehension difficulties and for articulation disorder. (The inconsistent phonological disorder category had small numbers and therefore the findings were not powerful. However, as the results buck the general trend, they warrant further investigation.)

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Implications for practice


The findings have a number of implications for practice: 1. There is a clear need to consult referrers about who they refer, in an effort both to reduce the normal cases referred and to address the selection issues in lower socio-economic areas. 2. The issue of case history taking needs to be considered. Since no clear aetiological or influencing factor was identified, what is the purpose of these questions and how can we be sure that we are sourcing information accurately? We need to be asking ourselves how reliable the responses we get are, and if there could be a better way of finding the answers we really need to know. 3. The issue of assessment appears clear. Since 12 per cent of cases had complex severe / profound difficulties, and very few children had problems isolated to one aspect of communication (Broomfield & Dodd 2004a; 2004b) there is a need for assessments to be broad ranging (van der Gaag, 1995). 4. Treatment, based on care pathways and intervention packages and delivered in clinics, has been shown to be effective. However, there is differential impact between diagnoses. Perhaps different service delivery models should be considered for different diagnoses at least until evidence to the contrary is available. 5. Waiting lists have a detrimental effect. Although the difference in outcome between immediate intervention and a six-month wait is small, there may be a cumulative effect. Further, even with a six month wait, each case is likely to require additional input to achieve the same outcome, leading to longer waiting times, and so the vicious circle continues. It may be that this evidence can be used to secure waiting list initiative moneys for services.

language stimulation activities with under-fives (Sure Start projects) implementing diagnostic language groups with 5-7 year olds with significant language difficulties (Key Stage 1 in the English school structure) to identify specific language impairment and therefore prioritise such cases for more intensive input providing advice, support and guidance for children aged over 7 with language difficulties, developing curriculum linked targets integrated into the Individual Education Plan conducting diagnostic speech groups with all children who have a speech deficit of over 12 months, enabling differential diagnosis followed by specific therapy approach to be made, as appropriate making client concern and commitment to change key in dealing with articulation disorders.

Acknowledgements
I would like to thank the children and families involved in the study, the paediatric speech and language therapy staff, both past and present, the NHSE for funding and Professor Barbara Dodd for her endless patience, support and enthusiasm.

References
Broomfield, J. & Dodd, B. (2004a) Children with speech and language disability: Caseload Characteristics, International Journal of Language and Communication Disorders 39(3), pp. 303-324. Broomfield, J. & Dodd, B. (2004b) The nature of referred subtypes of primary speech disability, Child Language Teaching and Therapy 20(2), pp. 135-151. Broomfield, J. & Dodd, B. (2005a) Epidemiology of speech disorders, in Dodd, B. Differential diagnosis and treatment of children with speech disorder. 2nd edn. London: Whurr, pp. 83-99. Broomfield, J. & Dodd, B. (2005b) Clinical effectiveness, in Dodd, B. Differential diagnosis and treatment of children with speech disorder. 2nd edn. London: Whurr, pp. 211-230. Dodd, B. (2005) Differential diagnosis and treatment of children with speech disorder. 2nd edn. London: Whurr. Howell, J. & Dean, E. (1994) Treating phonological disorders in children. London: Whurr. Masidlover, M. & Knowles, W. (1982) Derbyshire Language Scheme. Derbyshire: Derbyshire County Council. Petherham, B. & Enderby, P. (2001) Demographic and epidemiological analysis of patients referred to Speech and Language Therapy at eleven centres, 1987 1995, International Journal of Language and Communication Disorders 36(4), pp. 515-525. van der Gaag A. (ed.) (1995) Communicating Quality: professional standards for Speech and Language Therapists. London: Royal College of Speech & Language Therapists. Weiss C., Gordon, M. & Lillywhite, H. (1987) Clinical management of articulatory and phonologic disorders. Baltimore: Williams and Wilkins. World Health Organisation (1993) The ICD-10 classification for mental and behavioural disorders in children: diagnostic criteria for research. Geneva: W.H.O. DENCE?

We have spent some considerable time looking at the findings and the implications in detail and changing the face of our service One-day workshop
In response to requests for information about the study and its findings, together with a desire to make the findings real for individual therapists and services, I have developed a one-day workshop which not only explores the study findings in more detail, but also encourages participants to consider how they can use the evidence to influence their practice. Workshops can be run in a locality or region whereby participants subscribe on an individual basis, or for individual services, perhaps as part of a service review exercise.

Children receiving therapy sooner do better when therapy input is limited. Changing the face of our service
So, based on the findings of the study, what have we done in Middlesbrough? We have spent some considerable time as a department looking at the findings and the implications in detail, consulting with senior level staff in both health and education and changing the face of our service. The key changes we have implemented - many as pilots or under ongoing monitoring so we can make informed comparisons - are a rolling training programme for health visitors a package of training programmes for school staff conducting language health promotion and

Jan Broomfield is a consultant speech and language therapist (paediatrics) working for Middlesbrough Primary Care Trust. For further information, please contact Jan at Speech and Language Therapy Department, 157 Southfield Road, Middlesbrough TS1 3HF, tel. 01642 246603, e-mail jan.broomfield@nhs.net.

REFLECTIONS
DO I RECEIVE PROBLEMS AS A BURDEN OR AN OPPORTUNITY FOR CHANGE? DO I QUESTION THE VALUE OF ROUTINE TASKS SUCH AS CASE HISTORY TAKING? DO I CHECK MY PRACTICE AGAINST NEW EVIDENCE?

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REVIEWS

reviews
SOFTWARE
Scallys World update Following the review of Scallys World Letters and Nouns (Topologika Software) in the last issue, we received the following email from Topologikas Brian Kerslake: Melanie Eltomes review in the Autumn 05 issue of the early version of this product mentioned some sample quality issues and a gremlin that resulted in an s for sheep. We addressed this in a free upgrade which unfortunately Melanie did not receive. We always aim to provide high quality, flexible software for busy professionals and encourage users to contact us to discuss any problems. We are happy to supply the free upgrade to any reader who still has version 1. See www.topologika.com or telephone 01326 377771. virtually identical and this is the aspect of the original that we in our small team would most like to have seen modified. The author does explain that it was not possible to make any substantive changes as the assessment is standardised, but this omission does detract from the value to practitioners of the new version. Its main area of strength lies in the updating of the accompanying text, which gives not only clear aims and instructions as before but excellent and current information sections on interpretation and theoretical background. The CASP provides a useful basis for assessment but the second edition may be seen as an expensive luxury for a service already possessing the original. Margaret Margerison is principal speech and language therapist with the team for adults and young people with learning disabilities, Rotherham PCT.

LITERACY (1)
Signalong Companion to Oxford Reading Tree Gill Kennard The Signalong Group ISBN 1 902317 72 6 18.50 + 1.75 p&p

Impressive and well thought-through


For parents, support assistants and school staff trained in Signalong, this very practical hands-on resource ensures easy access to signs relating to Oxford Reading Tree vocabulary. The layout includes a useful review of basic signing skills and key hand shapes, cross-referencing with the books and stages of the reading system, diagrammatic pictures illustrating the sign for each word with a concise explanation, and an index of key words. The pictures are very clear and easy to follow. I particularly like the way they depict males and females from a range of cultures. This resource helps to ensure that the links between the signed word and the written word are made explicit for the learner. This can only be positive for a childs word learning at the written, signed and spoken levels. This impressive, well thoughtthrough resource will prove good value for money and appeal to a range of professionals in this area of literacy development. Carol Moxam is a paediatric speech and language therapist running an independent Literacy Clinic at the University of Newcastle.

ASSESSMENT
CASP (2nd edn) Anna van der Gaag Speech Profiles ISBN 0 9513249 1 8

GUIDELINES
149.95 RCSLT Clinical Guidelines Sylvia Taylor-Goh Speechmark Publishing Ltd ISBN 0 86388 505 5 42.00

Still useful but revision disappoints


At first glance the second edition of the CASP (Communication Assessment Profile) differs very little from the first, published in 1988. This provides a useful onestop-shop for assessment of the communication skills of adults with learning difficulties of varying degrees, especially where briefcase capacity is limited. It sets the scene for students and newly qualified therapists who need a starting point in assessing this client group, not only in essential linguistic areas but also in pragmatics. It looks at how such skills are matched to the environment in which they need to function. The CASP gives good indicators of aspects of communication where further investigation is necessary. For experienced clinicians it has always been a useful resource for dipping into. Its various approaches to assessment include observations, checklists, structured tasks and conversation, utilising information from both carers and therapists. The revised edition, it has to be said, proved a bit of a disappointment. The photographic material is alas

Invaluable
The Royal College of Speech & Language Therapists Clinical Guidelines, published in the form of a manual, expands on the 1998 edition. The new format is easy to use, being divided into twelve sections. Each contains a core guideline, table of evidence and recommendations. Clinicians, managers and service users will find this resource invaluable when managing speech, language and communication difficulties or disorders. The body of evidence is presented in tables and is drawn from recent research literature and the current consensus of clinical experts and service users. The guidelines will help to inform and guide the clinical decision-making process toward best practice. Each study allows therapists to make informed, appropriate choices, for children and adults. Mary Keeley is a speech and language therapist currently working in community clinics and specialising in disorders of fluency in children for Eastern Wakefield NHS PCT.

Fergus Full Stop, Ethel Exclamation Mark, Colin Comma, Quentin Question Mark, Henrietta Hyphen-Hyphen and Alec Apostrophe, who could fail to be entertained! The books could be used with children in primary and secondary schools and with dyslexic children and adults. They immediately grab the readers attention with their colourful illustrations and unusual style of writing (white on black paper). The book covers are so attractive that they make you want to find out more. Once opened, you simply must read to the end of the book as each humorous story unfolds. More information is given in a checklist at the end of the book. This series is a must-have item, especially for any professional dealing with literacy problems. Perhaps a little expensive at 4.99 per book, but well worth it. Comments from adults and children are very positive, ranging from lovely books, really fun, great pictures and exciting to where can I buy them? Thoroughly recommended. Valerie Cochrane is a speech and language therapist in private practice specialising in dyslexia.

INCLUSION
Mother-Teachers: Insights into inclusion Barbara Ann Cole David Fulton Publishers ISBN 1-84312-179-4 18.00

Interesting personal accounts


This is an interesting read for anybody involved with special educational needs. The author presents seven personal accounts, including her own, of teachers who are also mothers of children with special educational needs. Their stories are thought-provoking and highlight the complexities and contradictions of inclusion and exclusion in mainstream and special education. They offer an insight into different experiences and perspectives of the system from a personal and practical point of view. I found the chapter on sociological discourses and subsequent references throughout the book a

LITERACY (2)
The Puncs Barbara Cooper, Illus. Maggie Raynor Compass Books Ltd ISBN 0-9547932-0-X/-1-8/-2-6/-3-4/4-2/-5-0/-6-9 34.93 / 4.99 each (7 books)

Where can I buy them?


This is a delightful series of books that are an adventure in punctuation. There are seven books in total, which cover the subject of punctuation with a title book The Puncs and a separate story for each colourful punc family member. With names such as

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resources
bit heavy, but each story can be enjoyed without getting too bogged down with this theory. The book also provides a useful overview of the context and political background to special educational needs. A good one for the library. Samantha Edmonds is a speech and language therapist (Mainstream Schools) with West of Cornwall PCT. resource of high relevance for stimulating narrative skills, word retrieval, information recall, logical reasoning, inference, prediction, interpretation of emotions, feeling and reactions to social situations. From my experience in presenting the cards to adults with mild learning disabilities, the age appropriate scenes evoked high interest. However tasks involving ordering the pictures in sequence and interpreting associated emotions proved to be very difficult due to the high demands on integrating and interpreting all the information in each picture. (The pictures were useful for highlighting the communication difficulties typically associated with cognitive impairments.) Overall, this is a valuable resource for the experienced clinician, skilled in adapting activities and providing appropriate supports according to client needs. Colorcards - Sequences: 6 & 8-Step for Children Speechmark Publishing Ltd ISBN 0 86388 558 6 25.95+VAT

Stammering papers
Papers from the 8th International Online Conference on Stuttering are available free on the internet on Judy Kusters website. The conference was timed to coincide with the International Stuttering Awareness Day on 22 October 2005 and had contributions from 65 people from 20 different countries. Papers include Evidence based treatment of school aged stutterers and The why and how of voluntary stuttering. www.stutteringhomepage.com

Disability advice
The Health Professions Council has produced a guide for disabled people who want to become health professionals and for staff working in admissions on approved courses. Guidance on the Councils health reference requirements is also available for applicants and doctors. The Council is consulting on the content of the two documents until 9 December 2005. A disabled persons guide to becoming a health professional and Information about the health reference, see www.hpc-uk.org/aboutus/consultations/.

DYSPHAGIA
Swallowing Guidelines Individualised Programmes of Care Elizabeth Boaden & Jo Walker Speechmark Publishing Ltd ISBN 0-86388-517-9 34.95

A good idea in theory


This resource is a good idea in theory. It has templates which cover different areas of advice, from oral desensitisation exercises to the feeding environment and textures / consistencies. A CD-Rom allows you to select the advice required and produce an individually tailored guideline. Ironically, I found it quite time-consuming (quicker with practice?) and you had no control over the lay out. Too many abbreviations, codes and options seemed to over-complicate things. My area is adult neurology (acute and community), so perhaps it would have more relevance in learning disabilities. However, it is a good resource and has made me think about and extend the advice that I give patients (albeit I still write / type that advice!) Caroline Appleby is a specialist speech and language therapist working in adult neurology and voice in Mansfield.

Narrative is Talking Point

A web information centre for communication development and disability in children is focusing on intervention using a narrative approach. Articles and lists of resources and story books to help narrative skills at different stages are available. Talking Point is run by I CAN, the charity that helps children communicate, in partnership with the Royal College of Speech and Language Therapists and Afasic. The narrative event runs until 6 January 2006. www.talkingpoint.org.uk

AAC in Scotland

Highly recommended
This attractive set of colour sequencing cards represents experiences of children across a range of age, gender and ethnic backgrounds. The pictures reflect interesting modern social situations, and an interesting story line can be associated with each sequence, and simplified or elaborated on according to needs of the individual or group. The accompanying booklet provides clear description of the package and some practical ideas for use. The cards are fun to use with individuals or groups for teaching and practising sentence sequencing, story-telling, vocabulary enrichment, pragmatic language skills, comprehension, logical reasoning and carry-over from speech and fluency programmes. Highly recommended for speech and language therapists working with school-aged children. Frances Casey is senior speech and language therapist for learning disability, Community Services Area 8, Northern Area, Health Services Executive, Dublin.

Augmentative Communication in Practice: Scotland has set up a website. It features papers and useful information relating to AAC including study days and AAC User Project Awards. www.acipscotland.org.uk

Fragile X transition

The Fragile X Society has published parents experiences and helpful resources and questions to ask when managing the difficult transition from school to local further education college. e-mail info@fragilex.org.uk

Keeping track

A company that provides mobile location and alert systems is promoting its technology as beneficial to lone workers in the NHS. TrackaPhone can trigger an alarm which alerts other parties if there is an assault, provides a location and records evidence. The company says the system costs around 1 per person per day. www.trackaphone.com

COLORCARDS
ColorCards Sequences: 6 & 8-Step for Adults Speechmark Publishing Ltd ISBN 0 86388 558 8 25.95+VAT

Neurological website

The Brain & Spine Foundation has developed a website to help people with neurological disorders. It includes answers to frequently asked questions, a discussion forum moderated by neuroscience healthcare professionals and booklets for download. www.brainandspine.org.uk

Valuable for experienced clinician


This versatile set of picture sequencing cards represents familiar, modern life experiences. The social scenes appeal to a diverse range of adult clients and the accompanying booklet provides comprehensive description of the resource and guidelines for application. This is a multi-purpose

ICT in Scotland

A new set of 11 advice sheets from the CALL Centre and Learning and Teaching Scotland consider ICT and inclusion in a Scottish context, taking account of the Education (Additional Support for Learning) (Scotland) Act 2004 and the accompanying Code of Practice. www.callcentrescotland.org.uk

PARIS on mobiles

PARIS, the Public Autism Resource and Information Service portal, is now available on mobile phones. www.info.autism.org.uk/mobile
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

19

KEYS TO WINNING WAYS (5)

The authenticity key


In the fifth of our series to encourage reflection and personal growth, life coach Jo Middlemiss asks what is real and what is pretend and if looking at life in a different way will free you up to be yourself?
AUTHENTICITY: The key for Liz and Jim?
Liz is sick of being all things to all people. She feels she has been living a lie for many years. But she simply wont allow her real self to come out in case it rebounds on her and leaves her friendless and alone. Jim meanwhile has wonderful ideas about how he can take his practice forward but is concerned that his modernising approach will land him in a situation that he cant handle. Can he take that risk? Is it time for Liz and Jim to turn the authenticity key? After all, the best present in the world is the gift that you already possess. To be yourself.
Here is Edward Bear coming down the stairs now, bump, bump, bump, on the back of the head, behind Christopher Robin. It is, as far as he knows, the only way of coming down the stairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. And then he feels that perhaps there isnt. (Milne, 1978, p.1) This is the opening sentence of Winnie-ThePooh, a book much beloved by my children when they were young, and read many times by me. However, Ive only just noticed this first sentence as something really quite significant and profound. In my work I often deal with people who cant see their way out of a situation. Like Edward Bear they think there might be a solution, if only the bumping would stop. How many times do we think this way? (Someone said to me once that the first sign of madness is continuing to do the same thing while expecting a different result.) I recently had my elderly mother staying with me. She is a bright, attractive, interesting and accomplished woman. She proudly announces that she still has all her marbles - but unbeknownst to her some of them are rattling around a bit and messing up her short-term memory. Spending a few days with her is like living on the set of Groundhog Day. Funnily enough this is one of my favourite films. The main character lives the same day over and over until he gets it just right. He is only liberated when his behaviour is authentic and his love is absolute and unconditional. My mother is 90, still walks everywhere, and minds strongly that she had her driving licence taken off her a few months ago. She plays competitive bridge and loves to buy shoes and beautiful clothes. The memory problems are however hard for us to come to terms with. I never thought her an impatient person but something about being 90 has made her want things immediately. So the paradox of having to exercise extreme patience in the presence of impatience is quite a challenge. For example, pretending not to know something that she has told me two minutes previously feels like cheating, but saying I know annoys her! I am trying to work out if this is the real her naughtily popping up, or if it is something to do with changes in the brain. Perhaps she has been pretending to be virtuous all these years and never really dealt with the irritation she felt with others? I dont know and Ill never know for sure. It has got me thinking, though, about what is real and what is pretend. And why it is that, like Liz, we feel we have to present a particular face just to be all things to all men. Why shoulds and oughts and musts get in the way of us being our true selves. In The Power of Intention Dr Wayne W. Dyer says that we must try to let our reputations go because they are not really ours to hold: It resides in the minds of others. If you speak to thirty people you will have thirty different reputations. Apparently there is even a book out called What you think about me is none of my business. I like that idea because it stops me doing what I do for approval but because I know it is the right and authentic thing to do. So why is it important to be real? In my view it is important because it acknowledges that we are unique from day one. There is no-one else quite like me who can do what I was designed to do or be what I was designed to be. Of course being unique does not allow you to get away with that old chestnut, Thats just me. Ive always been like this. These are words I am positively allergic to. I was talking to a woman the other day who has split up from two husbands, for exactly the same reason. Another woman I know has tried every faddy diet in the world, but has never made the connection between her extra weight and the food she puts in her mouth. A third person has lived with a husband who has been serially unfaithful to her for all of their forty-year marriage. Changing her behaviour has only just occurred to her.

Question and challenge

The way we behave is frequently not you at all, but what you think you should be. Our conditioning is what keeps us stuck in old, useless behaviour patterns. Very often we are still saying and doing things right into middle age that our parents and teachers habitually said or did, even though our situation and circumstances are completely different and we are different people. Certainly retain the good stuff, but question and challenge the ideas and beliefs that keep you stuck and bumping your head on the stairs. If you find this difficult, remember that there are always at least two ways to look at everything. Just look at the picture below (credited as My wife and my mother-in-law, W.E. Hill, circa 1915. More examples on http://brisray.com/optill/othis.htm): What do you see? Some people see a young woman, and some see an old hag. Some are able to see both. This way of thinking is very effective. It stops us jumping to conclusions and making rash judgements before we have all the facts. Its worth remembering that we never have all the facts. Have you ever had the experience of making your mind up about someone or something, and then feeling a bit stupid because of a little snip of information which would have made all the difference to your conclusion? In Stephen Coveys The Seven Habits of Highly Effective People he tells the following story (pp.3031). He was sitting in an underground carriage early in the morning and people were pretty subdued. There was a youngish man sitting next to him. The mans three children were running wild on the tube, screaming and chasing each other around. Covey couldnt contain his irritation and asked the man if he could make an effort to control them. The intrusion shook the young man out of his reverie: Oh, youre right. I guess I should do something about it. We just came from the hospital where their mother died about an hour ago. I dont know what to think, and I guess they dont know how to handle it either. Covey was overwhelmed with embarrassment, sympathy and confusion. He tells this story against himself, and now believes in the mantra, Curious, not Critical. Having the confidence to really be yourself involves humility just as much as it involves pride, self-esteem and self-confidence. It is not about being brash or

20

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

KEYS TO WINNING WAYS (5)

READ THIS

news extra
Barriers for AHPs
A research team from the University of Liverpool has found that the psychological contract between the NHS and allied health professionals has been and is still being violated at all levels. Clinical psychologist Jan Bogg describes a psychological contract as a set of informal and imprecise rules relating to issues like an employers approach to training and development, compensation and promotion. Her research team distinguished three different types of barrier to career progression: the relatively low profile of allied health professionals, cultural barriers, and organisational barriers. They recommended the NHS should create new, clinical career paths, increase opportunities for training, promote flexible working practices and protect those who use them from discrimination. In addition, they say the NHS needs to do more to promote, implement and evaluate its commitments to breaking down barriers. Source: www.liverpool.ac.uk/researchintelligence www.liverpool.ac.uk/clinpsy/breakingbarriers

IF YOU DO THE SAME THINGS BUT EXPECT A DIFFERENT RESULT WANT TO BE CURIOUS RATHER THAN CRITICAL WOULD LIKE TO BE YOU, NOT WHAT YOU SHOULD BE

unchanging. If we really want people to accept us in an unconditional way then we must offer the same to others. This is what Margery Williams was talking about in the famous childrens book The Velveteen Rabbit (p15-16): Real isnt how you are made. Its a thing that happens to you. When a child loves you for a long long time, not just to play with, but REALLY loves you, then you become REAL. It doesnt happen all at once. You become. It takes a long time. Thats why it doesnt happen to people who break easily, or have sharp edges, or have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in the joints and very shabby. But these things dont matter at all because once you are REAL you cant be ugly, except to people who dont understand. (I dont know about you but we have a bear in our house who is approximately 57 years old and has been loved REAL by two small boys exactly in the way of The Velveteen Rabbit.) Becoming real and authentic may well involve looking at life in alternative ways. What better advice could be given than that from Shakespeare in Hamlet, to thine own self be true, And it must follow, as night the day, Thou canst not then be false to any man. So if you feel as if you are repeatedly bumping your head, stop and think. There might just be a better way of coming down the stairs. Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk.

Ataxia needs highlighted

International Ataxia Awareness Day was marked this year for the first time by both Ataxia UK and the Ataxia-Telangiectasia Society and focused on the difficulties around obtaining an accurate diagnosis. While Ataxia UK is for all people affected by ataxia, the Ataxia-Telangiectasia Society focuses on young people with that particular form of the disorder. Ataxia is a life-limiting neurological disorder affecting coordination that can strike people of any age. There is no cure, and the charities raise funds for research and to help families cope. www.ataxia.org.uk

Stroke transfer

Following a successful pilot, a new tool is now available nationally to improve the delivery and continuity of care for people who have had a stroke. The Stroke Transfer of Care (ToC) document was developed to smooth the transition for patients from secondary to primary care. It includes key information on initial diagnosis, investigations undertaken, assessments, medications, lifestyle advice, rehabilitation and follow-up appointments and home care arrangements. The pilot revealed that 92 per cent of participating GPs stated they did not receive a document similar to the ToC protocol when their patients left hospital. Copies of the form completed by the hospital consultant go to the GP as well as the patient, and there is also a card for the patient providing clear information regarding their medication, lifestyle advice and aftercare arrangements. Interestingly, the document includes key indicators related to the GMS contract, helping the GP to achieve GMS targets and related financial rewards. Dr Tony Rudd, Chair of the Intercollegiate Stroke Group, co-authored the document with a GP. He said, One of the most common complaints patients have is that they feel abandoned when they leave hospital. Often this is due to failure to communicate effectively. This new document is a useful tool to ensure that essential information does not get lost when care is transferred after a devastating illness. The document is downloadable from the website of the Royal College of Physicians, www.rcplondon.ac.uk/pubs/books/stroketoc/.

Deaf children need better mental health services

References
Cole-Whittaker, T. (1991) What you think of me is none of my business. New York: Jove Books. Covey, S.R. (1992) The Seven Habits of Highly Effective People. London: Simon and Shuster UK Ltd. Dyer, W.W. (2004) The Power of Intention. California: Hay House, Inc. Milne, A.A. (1978) Winnie-The-Pooh. London: Methuens Childrens Books. Williams, M. (2004) The Velveteen Rabbit. London: Egmont Books Ltd.

The National Deaf Childrens Society is campaigning to improve mental health services for deaf children in Northern Ireland. The charity was funded to prepare a report on the current situation by the four health and social services boards in the country through the Northern Ireland Mental Health and Deafness Forum. For the first time this enabled reliable data to be gathered on the 1166 deaf children and young people in Northern Ireland. As 90 per cent of deaf children are born to hearing parents, the Society points out it is important that parents get support to understand their childs deafness and to develop their own positive approach. However, the data demonstrated 12 per cent fewer cases than would be expected of deaf children and their families accessing Child and Adolescent Mental Health services. The report recommends a programme of structured intervention from diagnosis onwards should be developed, along with a range of activities to enable communication development and an intervention programme in schools to promote positive mental health and problem-solving skills. A preventative mental health strategy should also encourage schools to have specific anti-bullying policies and practice. The report also calls for a feasibility study on setting up a specialist child protection service, and suggests that two primary mental health care workers should be appointed to work specifically with and for deaf children and young people in the country. www.ndcs.org.uk
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21

FEATURE ON PEER SUPPORT

So crazy about all


ut I would not be caught dead with jewellery in my While the concept of introducing peer ears (Misheard lyrics at www.amiright.com/misheard/artist/ review to Speech & Language Therapy in simonpaul.shtml) Paul Simons actual words in the song Still Crazy Practice appealed, editor Avril Nicoll was After All These Years were a more thoughtful But I would not be convicted by a jury of my peers. Perusing some of the keen to avoid the known pitfalls of the exchanges on online e-groups or talking to people who have peer review for a journal article, you could be forprocess. However, hearing about other undergone given for thinking differently - but there are many reasons to the potential of peer support and a lot of information systems of peer support has convinced her explore around to help you achieve a system that works for you. With work playing such a central role in many peoples lives, that it will be possible to do this in an and continuing professional development now an integral open and constructive way. part of what we do, Erik de Hann argues that peer consulta-

A MODEL OF PEER SUPPORT

tion is an approach entirely in keeping with the spirit of our times (p.xv). In his book Learning with colleagues: an action guide to peer consultation he discusses (p.xvi) how this involves: entering into a deeper relationship with your colleagues in order to learn from them being vulnerable and openly discussing your strengths and weaknesses finding the limits of your expertise and exploring the territory beyond those limits together with your colleagues seeing this process of searching and exploration as an integral part of your work. In this issues My Top Resources for lifelong learning (back page), Tracey Righton explains how she has taken this route with a critical friend. She says this kind of relationship needs mutual trust and respect, and an expectation that this process will grow, change and develop over time. In Trafford, peer support started on a one-to-one basis, then changed two years ago into a professional support group system, with groups chosen according to caseload type and ranging from three to seven members meeting every six weeks. The usual focus of the discussion has been cases, good practice and clinical problems and successes. Although the system was good, clinical lead Terrie Murphy felt it could be even better. She explains, Rather than a hierarchical model where an expert hands out advice, I wanted a model where everyone in the group felt they had something to offer everyone else. It was important that any new model should build on the strengths of the existing one. When Terrie questioned staff, they said they liked the cohesive feel of the groups, and the respect and support they offered. They also commented on the listening skills and positive attitude and feedback of members, the skill mix and variety of expertise, and the willingness to share knowledge. Answers to a question about benefits for members were similarly encouraging, as the system is seen to offer the chance to be reflective and offload, to problem solve and exchange practical ideas and to build confidence both as individuals and as teams. Terries evaluation led to some important developments. As some group members met regularly anyway, and so had less to discuss, groups now rotate on an annual basis to keep fresh-

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

Illustration by Graeme Howard

FEATURE ON PEER SUPPORT

these peers...
ness and objectivity. There are fewer groups, each with five or six members and a better balance of skill mix. The biggest change, however, followed a very practical and tailored training day to develop a Solution Focused Reflecting Team process that would help staff improve their support for each other. Drawing on Solution Focused Brief Therapy (see for example Burns, 2005), this model sees a group discuss a specific work difficulty in a structured way in 30 minutes. To keep the focus and ensure each section is covered adequately, a group member takes the role of time keeper, and another the role of process manager. One group member, the presenter, tells their story and explains what help they want. The steps of the process (figure 1) ensure that everyone is clear about their role at a given time and that everyone gets a chance to talk. Figure 1 Solution Focused Reflecting Team process Preparing (pre-meeting) The presenter comes to the group with a specific request for help with a workrelated issue. The presenter outlines the issues. The team members are silent. In turn, each team member asks one question of the presenter to understand the situation more clearly. The presenter can answer the specific question but everyone else is silent. Team members take turns telling the presenter what they have noticed about the issues or the presentation that impresses them. Team members take it in turns to wonder aloud about aspects of the situation and possibilities. The presenter can make notes but is silent. The presenter responds by setting out what s/he is going to do. The other group members are silent. matters can be discussed. The group doesnt replace local individual supervision or other initiatives such as journal clubs, instead operating as an adjunct to existing support systems. It is specific to junior speech and language therapists working with adults but crosses community, acute and rehab teams in three boroughs (five trusts, one private rehab unit). The group usually has about eight people attending for an hour and a half every two months, and the location and chairperson rotate, with the chairperson responsible for the agenda and minutes. Objectives include sharing information on the structures of the different trusts for example referrals, reporting and staffing - as well as discussing specific topics and getting feedback from courses. Sam says the group is also an opportunity to reflect on complex or unusual cases or situations, and it is important that this includes both positive and negative examples. The members reached an agreement on confidentiality to protect members, clients and the profession. Looking over minutes from previous meetings, it is clear that the group fulfils a variety of functions (see examples in figure 1), and that activities such as product reviews or discussion about practice frequently highlight other important issues. Kat Bowers describes the group as fantastic and adds that after the initial planning it has needed very little time in terms of organisation. She is grateful to the various managers concerned for allowing staff the time to attend, and points out that it has been so successful it is now used in recruitment advertising. Sam Livingston adds that, although they have been contacted by speech and language therapists in other boroughs who want to join, the members decided to keep to the three boroughs, as we all really enjoy the discussions that occur in a smaller group. However, plans are afoot to start an e-mail support group for junior therapists to send out general questions to a wider group. Figure 1 Examples of peer support group activity Reviews of resources, for example of a new assessment and how it fits in with existing assessments (led on to consideration of informed consent and how the psychology department could assist) A report on a study day, leading to discussion about a social (as opposed to medical) approach to note writing in the acute setting. Brief debate about joint therapy assessment sessions, and agreement to bring any relevant documentation from different areas to the next meeting. Recommendation of a recent literature review paper in a peer reviewed journal. Feedback on a facilitated user involvement day which included mechanisms to ensure the findings are put into practice. Agreement to share one team's goals resource. Presentation of a case study with brain storming of ideas. Topic based discussion (running groups; report writing).

Presenting (5 mins) Clarifying (8 mins)

the group is also an opportunity to reflect on complex or unusual cases or situations, and it is important that this includes both positive and negative examples.

Affirming (3 mins)

Reflecting (10 mins)

Closing (4 mins)

Terrie enthuses, it is so satisfying. I used to come up with lots of ideas and suggestions for people but with this approach they ultimately arrive at their own solutions. We have to remember that any problem is todays problem and tomorrow it will be something different so developing a solution focus is a skill for life. Junior staff Sam Livingston, a speech and language therapist with the Southwark community team in London, and her colleagues Lucy Wakefield from Lewisham Hospital and Kat Bowers of the Lambeth adult team recognised they would benefit from more support. Their solution was a peer group that provides a forum where clinical and non-clinical

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

23

FEATURE ON PEER SUPPORT / RECOMMENDED READING


Both the Trafford and the London experiences suggest that, whatever the method of peer support chosen, it is important that group members have confidence in it and can see it is making a difference. de Haan (2005) outlines 15 different formal peer consultation methods and suggests a toolbox approach, with a method selected to suit the purpose and the number of people involved. He separates the needs of the profession from the needs of the person, suggesting the first benefits from a uni-disciplinary group and the second from a multidisciplinary composition. The Lambeth, Southwark & Lewisham's peer support group is closest to de Haans Supervision method concentrating as it does on practical issues such as procedures, guidelines, working methods and resources. Learning from success is a method that Terrie Murphy would surely endorse. It recognises that, while it is often easier to identify areas for improvement, it is also important to reflect on and nurture what has gone well. The gossip method also has similarities to the Trafford model in that one member tells a story, then listens while the others discuss it. A main difference is that the issue holder takes a seat outside the circle and turns away from the group to ensure they influence the consultants as little as possible. de Haan says it is eminently suitable for making someone aware of the rules, convictions and assumptions that govern his or her own actions and perceptions. This makes it a method that can help to broaden someones mindset (2005, p.39). Bernie Brophy-Arnott is a speech and language therapy manager in Dundee, working with people with learning disabilities. The department is in the early stages of planning a peer support system that Bernie hopes will be positive for staff as well as for equity of service. Having been on the receiving end of peer review for journal articles she is aware of the importance of a supportive department in taking you through the process. She points out that, although journal peer review is rigorous which is good and allows you to rehearse your argument in preparation for speaking at conferences - it is not a nurturing process. Peer review for journals is generally anonymous and carried out by at least two reviewers with the aim of ensuring objectivity and very high scientific standards. Comments received can vary from the constructive, helpful and logical to the nit-picky and rude. To illustrate how to provide a constructive review, Wager et al. (2002, p.46) take a novel approach with a section on How not to do informal review (Phrase all your remarks as questions, preferably sarcastic ones; Insert exclamation marks at the end of each paragraph; Wherever possible add a personal attack on the intelligence of the writer). While this makes very funny reading there is a serious side to it. Therapists braving the written market put heart and soul into it and, in terms of Speech & Language Therapy in Practice at least, such reviewing styles would be completely unacceptable. Along with other readers, Bernie Brophy-Arnott is enthusiastic about the prospect of peer review in Speech & Language Therapy in Practice, as long as it retains its focus on clients in context and generation of ideas for people to think about. Drawing on the strengths of the models of peer support described, our peer review will be a structured and transparent process. It will be supportive and constructive to authors. It will also guide readers in critical appraisal of evidence that has come from a clinical perspective. While misheard lyrics show we dont always hear what we are meant to hear, with a system that ensures shared understanding of context, careful listening and clear expression, you will not be convicted by a jury of your peers.

Drawing on the strengths of the models of peer support described, our peer review will be a structured and transparent process

Acknowledgements
Thanks to all the therapists who contributed to this article (names in bold), and to the readers who have been so enthusiastic in helping me plan the introduction of peer review.

References
Burns, K. (2005) Focus on Solutions A health professionals guide. London: Whurr. de Haan, E. (2005) Learning with colleagues An action guide for peer consultation. Basingstoke: Palgrave MacMillan. Wager, E., Godlee, F. & Jefferson, T. (2002) How to survive peer review. London: BMJ Books.

Resources
The Trafford training was offered by E. Veronica Bliss of Missing Link Support Services ltd, see www.missinglinksupportservice.co.uk. If you would like more information about applying to become a peer reviewer for Speech & Language Therapy in Practice, e-mail the editor avrilnicoll@speechmag.com or call Avril on 01561 377415.

New! Recommended Reading!


Given the overwhelming amount of information available, we need to be selective in what we read. Even then we find that papers do not always include an explicit link between the theory / experiment and its direct or indirect implications for practice. Articles in journals have gone through a painstaking process of peer review but it is ultimately for you, the reader, to judge whether the stated result is a) valid and b) clinically important in other words, why and how the article will change your practice. In this new section, readers explain in around 200 words why they would recommend a particular article from a peer reviewed journal to their colleagues. While this is a personal response that focuses on clinical importance and practicalities, the author may also wish to comment on factors such as study design / validity and statistics / statistical significance. APHASIA / AAC van de Sandt-Koenderman, M.W.M.E. (2004) High-tech AAC and aphasia: widening horizons? Aphasiology 18(3), pp. 245-263. Linda Armstrong is based in Perth Royal Infirmary and works in community settings with people with acquired neurological communication and / or swallowing disorders. She is an RCSLT aphasia adviser. Linda Armstrong says: This article is one of the papers in a special issue of Aphasiology on computers and aphasia. It reminds us that the evidence on the effectiveness of AAC with people with aphasia is limited, despite the first computer-based aid for this clientgroup being reported in 1982 and how computers have developed for general use since then. It encourages people who are working in this area to publish their findings (most of the references in the paper are from the 1990s). The author reviews the available literature on factors influencing the functional usefulness of low-tech AAC for people with aphasia and describes the few computer-based systems available. This paper focuses on the many aspects of the person, their individualised experience of aphasia and their communicative environment, all of which must be taken into account when assessing the persons suitability for AAC - the person with severe aphasia may also, for other reasons, be the person least suited to AAC use. It made me reflect on the timing of AAC introduction (low-tech and high-tech) - it should not be a last resort - and on the amount of training required. As is often the case, the paper concludes that there are still more questions than answers.

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005

HOW I

HOW I
PROVIDE A SERVICE
FOR YOUNG PEOPLE WITH

LETS GET ON
FACED WITH INCREASING REFERRALS OF OLDER CHILDREN IN MAINSTREAM SCHOOL WITH SOCIAL COMMUNICATION DIFFICULTIES, CAROLINE BABER, ANN CLEMENCE, KAREN FORD AND RUTH WATSON DEVELOPED A PACKAGE OF CARE THAT HAS BENEFITED THE DEPARTMENT AS WELL AS THE YOUNG PEOPLE AND THEIR FAMILIES.
l-r: Ann Clemence, Ruth Watson, Caroline Baber and Karen Ford

ASPERGER
SYNDROME
WHAT KIND OF SERVICE DO YOU PROVIDE FOR YOUNG PEOPLE WITH SOCIAL COMMUNICATION DIFFICULTIES? IS THIS DRIVEN BY NEED, EVIDENCE AND VISION, OR STAGNATED BY HISTORICAL FACTORS AND OTHER PRIORITIES? HERE WE HAVE TWO EXAMPLES OF HOW IMAGINATIVE AND THOROUGH PLANNING AND A FOCUS ON CLIENTS NEEDS CAN CHANGE THE LIVES OF YOUNG PEOPLE WITH ASPERGER SYNDROME AND THEIR FAMILIES.
CAROLINE BABER, ANN CLEMENCE, KAREN FORD & RUTH WATSON, SPEECH & LANGUAGE THERAPY DEPARTMENT, ROYAL SEA BATHING HOSPITAL, CANTERBURY ROAD, MARGATE CT9 5NS, TEL. 01843 229073. JANE BAKER, SPEECH & LANGUAGE THERAPY DEPARTMENT, SOUTH DEVON HEALTHCARE TRUST, KINGSTEIGNTON MEDICAL PRACTICE, WHITEWAY ROAD, KINGSTEIGNTON, DEVON TQ12 3HL, TEL. 01626 357098.

istorically our speech and language therapy paediatric department has offered a one-off assessment / advice package to students in mainstream secondary schools. An increasing number of such referrals querying social communication disorders (50 over a two month period) caused us particular concern, as often these students had no previous contact with the department. The numbers had a negative impact on waiting lists for initial assessments at community clinics. These young people were experiencing considerable difficulties coping in school; a number were excluded or attending school on a part-time basis, they were generally quite isolated from their peer group and often perceived themselves to be victims of bullying. Many were receiving support via CAMHS (Child and Adolescent Mental Health Services) for anxiety, depression, anger management and other behavioural issues. A survey of our therapists identified some concerns with this policy of advice and closure whilst recognising the need to match service delivery to staffing levels. The assessment / advice package was very time consuming. Less experienced staff required considerable levels of support, and it was also felt to be unsatisfactory for therapists to acknowledge these clients difficulties and then close their case. Families felt unsupported by the service. We set up a pilot project to see if the department could offer these children social skills therapy in a relaxed and sociable context. The project, facilitated by four therapists, offered 16 children and their parents 16 weeks of contact, two of which were needed for pre-assessment and two for post-assessment. We also allocated five sessions for planning and evaluation; although this is not practical in the longterm it gave us the time we needed to reflect and revise. Parents and children made their own way to the venue which was convenient for bus and rail travel. Initial baselines were established using: a student questionnaire based on Lets Get On (Improving Social Skills) a parent questionnaire developed from the above five minutes of video recording assessed on a pragmatic observation checklist (based on Johnston et al., 1991). The students identified having a friend and anger management as their main concerns. The parents identified their main concerns about their children being lack of friends and difficult behaviour. The pragmatic observation profile logged a complete lack of any of the following behaviours in the students: asking for clarification telling others when they made an error making choices expressing feelings. During our first session it became apparent that the parents also required our support and we decided to meet this need by running a parents group alongside the childrens groups. A more formal and structured format evolved for the childrens groups as they required greater direction to achieve the set objectives and enable greater participation. It was also necessary to divide the group into smaller more manageable groups and this was done with the intention of returning to the large group format by the end of the course.
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HOW I
Figure 1 Case example: Toby Toby was struggling to cope with his pending transition to secondary school and his mother was finding his behaviour difficult to manage. When the groups started, Toby and his mother were both very anxious about the whole process. On the first evening Toby was unable to enter the room with the other students and sat crying in an office. To his credit, and his mothers, they persisted in attending. Toby initially could not cope with even a small group as he found it impossible to accept anyone elses point of view or interest. He struck up a relationship with one other boy with the support of one key therapist. Toby was able to cope in this restricted pair and begin to target some of the issues that caused difficulties for him. Once Toby was secure the next hurdle he had to cope with was a change of therapist which he managed really well. This surprised his mother who had anticipated that Toby would not want to work with any of the other therapists and felt that, prior to the groups, Toby would have found this change of significant adult too much to accept. Other children were gradually added to the initial pairing without any problems. The final success came when Toby was able to join the large group and to continue attending and enjoying it in this large, noisy and busy environment, interacting equally well with any of the other young people or supporting therapists. During the course of the groups Toby announced that for the first time ever he had a friend. His mother observed that Toby felt safe at the group and therefore did not feel he had to compete for attention. Tobys

mother felt that the group helped Toby to understand his diagnosis and in fact he was able to explain to a teacher that he had Asperger syndrome and that was why he found some things difficult in class. This was a significant step forward as Toby had previously felt any difficulties arose from other peoples problems. The successful outcome of giving this message did wonders for Tobys self-confidence and self-esteem. Tobys mother also noted that Toby had a better understanding of appropriate social behaviour and this was demonstrated when Toby was able to go to the dentist and cooperate with a basic examination for the first time! We noted that Tobys turn taking and listening skills improved. He was better able to accommodate others interests and this allowed him to behave in a more age appropriate way restricting immature behaviours to time outside of the more structured group context. In his final assessment we observed Toby as able to ask yes / no questions, initiate conversation, establish a topic, make choices and express feelings. These behaviours had not been established at initial assessment. Having a friend and being able to participate in a bigger group resulted in a more confident, mature and happy boy and a reduction in complaints about school and from school staff. Tobys mother really appreciated being able to make friends with parents from other Asperger families. Toby and his mother now attend the parent-run social group and mum says Toby has coped better than expected with his first year at secondary school.

Two groups were set up initially according to assessment of need. This arrangement was still not suited to those students who had significant difficulty and one group was split again to accommodate two students as a pair (see case example in figure 1). After the first term it was possible to merge these smaller groups resulting in one group (A) for the Year 6 students and another (B) for the Year 7-9 students. They ran from 16.30-17.30 and 17.30-18.30 respectively. The groups targeted behaviours that the students had identified at assessment. Group A followed a programme of social skills activities, pragmatic game boards (including Say and Do Positive Pragmatic Game Boards) and games encouraging social interaction for the first term. Group B followed a programme of social skills activities, more focused activities to address anger management (including Breaking the Chains of Anger game) and games encouraging social interaction. These objectives continued into the second term and both groups also worked on self-awareness, awareness of others and developing friendship skills. The parent group identified the areas they wanted information about: statementing, behaviour management, understanding autistic spectrum disorder, family support, occupational therapy, the National Autistic Society, teachers perspectives. We arranged a programme of short talks from appropriate speakers to cover these areas. The parents also spent time sharing their own experiences and coping strategies. Both parents and children valued the opportunity to talk about the difficulties they coped with on a regular basis.

had not been observed in any of the students at pre-group assessment were now emerging (for example seeking clarification; establishing a topic). Analysis of the parents questionnaires showed no significant changes in their perceptions of their childs presenting difficulties. All the parents however demonstrated greater understanding of the nature of those difficulties that previously had been interpreted as bad behaviour. The parents also commented on increased confidence in interacting with and managing their children.

Exhausting and exciting


For us as a team this project was exhausting and exciting. It allowed us to trial a package of care which promises to be an effective and satisfactory means for managing this client group. The project furthered a sense of team working within a newly formed team and less experienced staff were able to work alongside and learn from more experienced colleagues. Consequently we have now allocated four outreach sessions to support and extend this work monitoring groups as assessment / diagnostic tools for children with queried social communication disorders. Four groups have been held since the pilot, and follow-up groups will be offered to children across different localities in the Trust which will allow us to reach more families and address our service concerns of imbalanced waiting lists caused by this client group. The content of the group activities will allow therapists concerns to be addressed. Liaison with our colleagues in education and health is earmarked as a priority as we would like to have a multi-agency approach to this work. At the request of one of our school clusters we have arranged a full day conference in autism. We have also developed a training package to offer to our local secondary schools to raise staff awareness and understanding of this client group. We plan to deliver this along with our school cluster colleagues. The families weekly social group has continued to meet at another venue and they have taken on full responsibility for this group. This is an invaluable and much needed resource for the area, and we refer new clients to this group. Caroline Baber, Ann Clemence, Karen Ford and Ruth Watson are speech and language therapists with East Kent Coastal Teaching Primary Care Trust.

Outcome
So what was the outcome? Qualitatively there were significant improvements. The group proved a useful means of confirming / correcting a diagnosis. The students loved the peer contact they found within the group and for all of them it was the first time they felt they had a friend. Some of the students discovered they went to the same school and some were even in the same class. This knowledge and peer support helped students improve their self-image and self-esteem as measured pre / post group. The students were happy to acknowledge their diagnosis and enjoyed talking about it with one another. Parents reported students being able to explain their difficulties to subject teachers and other class members, reflecting their increased confidence. They particularly commented on the pleasure the children had gained from regular peer support and how important this contact was. The parents, supported by the East Kent National Autistic Society, have consequently established a weekly social group where students can go to enjoy a variety of activities with their friends, and families can meet up. (The group is known as the Thanet Autistic Zone.) Quantitatively the results were rather mixed. The student questionnaires indicated an apparent increase in their problems with social interaction, although we would argue that this reflected the students increased awareness of their difficulties with social interaction. Analysis of the pragmatics observation profile, however, showed clear differences between pre- and post- group assessment. There was improvement in all areas. Behaviours that

Reference
Johnston, E.B., Weinrich, B.D. & Glaser, A.J. (1991) A Sourcebook of Pragmatic Activities: Theory and Intervention for Language Therapy. Communication Skill Builders.

Resources
Fowler, F. & Baber, C. (2002) Social communication skills pack. Margate: East Kent Coastal Teaching Primary Care Trust. Breaking the Chains of Anger is available from Incentive Plus, www.incentiveplus.co.uk Lets Get On (Improving Social Skills), Northumberland County Council, is also supplied by Incentive Plus. Say and Do Positive Pragmatic Game Boards, by Gill & DeNinno, available from Taskmaster, www.taskmasteonline.co.uk For a copy of the programme for group B parents, e-mail avrilnicoll@speechmag.com

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HOW I

ASPERATIONS 4 U
OVER THE PAST FIVE YEARS, JANE BAKER HAS SEEN HER VISION OF A COMMUNITY-BASED, PARENT-RUN, SPECIALIST FACILITY FOR YOUNG PEOPLE WITH ASPERGER SYNDROME AND THEIR FAMILIES BECOME A REALITY. HERE SHE EXPLAINS WHY HER ENTHUSIASM AND PASSION FOR THE 4 US MODEL IS AS STRONG AS EVER.

ix years ago I had a conversation with a parent of a 14 year old recently recognised as having Asperger syndrome. She spoke movingly of the isolation and misunderstanding that the family had endured over many years and how, despite wanting a friend for a long time, her son had only just found one. That set me wondering. Who do you choose as your friends? People who think like you do? People with similar life experiences? People who understand you easily? People you dont need to explain basic differences to? People who accept you as you are and love you despite your foibles? So, if you had a strongly systemising brain (Baron-Cohen, 2004) as people with autistic spectrum disorder and Asperger syndrome have would you choose someone with an empathising brain as your close friend? You might, but probably youd go for someone with whom you clicked because you instinctively knew how they ticked. And if you were a parent of a child with specific challenges would you be interested in meeting similar parents regularly? With these thoughts in mind, I was motivated to bring such families together back in January 2000. I was lucky to work with a manager who supported initiatives, and with colleagues who were enthusiastic and passionate about providing a different service to this client group. Since then the group has evolved from a speech and language therapy-led group at the local medical practice into a parent-run organisation (since January 2003) that meets in a Youth Centre at the heart of the community. The South Devon Aspergers Group follows what I have called the 4 us Model and is about social inclusion for children with Asperger syndrome and pragmatic difficulties, and support in the community for their families. The children refer to it as Asperations. The 4 us Model has four components 1. Support group for parents of children with Asperger syndrome and pragmatic difficulties. A place to talk and listen to others who understand, to gain moral support from others with similar experiences and emotional responses, to share problems, and to explore solutions and coping strategies. It includes a resource library, and talks and problem-solving with multi-agency professionals from Child and Family Guidance, Child Health Directorate, social services, health, education (outreach teams and special educational needs co-ordinators), National Autistic Society and Parent Partnership. Sessions for the parents on relaxation, yoga and so on are planned. 2. Youth group for the children. 3. Sibling group with a play worker, having fun and also responding to their needs. 4. Social communication skills groups run by speech and language therapists using group interaction games and roleplay to teach specific skills in context. We also provide training and help to set up similar groups in other settings. There are two groups (5+ years and 11+ years) running on different days after school 4.30pm 6.00pm term-time only. They are held at Kingsteignton Youth Centre which has the facilities to cater for all four needs at the same time. Although there is no transport available, there is a nearby bus stop. The sibling group (run by a play worker), the parents support group, resource library / speakers (run by the parents) and the communication skills groups offered by the speech and language therapists all meet at the same time in the same building. This makes it much easier for the families to access the service. We all get together for the final 30 minutes so the children with Asperger syn-

drome can have their Youth Club (run by the youth leader) together with their siblings, and the speech and language therapists are available to talk to the parents, give feedback, pass on new information and so on. One hundred and ninety families have been involved in this initiative since it started. Currently 53 families attend either regularly or spasmodically. Some come every other week, others once a month, others every week depending on their circumstances. Sometimes families stop coming for a while and then reappear when they need to or when it has become possible or convenient again. Amongst other things, parent volunteers provide a regular newsletter, maintain the resource library, befriend new families, provide refreshments, develop leaflets, collect donations and club fees, apply for grants, approach local businesses for donations, run raffles, fundraise, liaise with other local groups and the National Autistic Society, supervise the pool table and photocopy new information. In other words, as the South Devon Aspergers Group, they manage Asperations.

Funding
The initial funding for the speech and language therapy time came from within existing resources as a pilot. After a year the parent-led committee succeeded in getting funding from various bodies such as Awards for All, South West Foundation Grant, Teignbridge Primary Care Trust, Zero plus 14 and other local charities. This fundraising now covers the running costs of the venue (15 a session), and the speech and language therapy, play worker and nationally qualified youth worker time (in total 38 per hour) as well as equipment when required. Regular questionnaires to parents and children ensure that current needs are being met and allow for future development. The latest initiatives are to apply for charity status, and to run a holiday play scheme for the 11+ group. So why is the 4 us Model needed? Children with Asperger syndrome have specific difficulties in understanding the rules of social interaction (Attwood, 1998). They want to make friends but cant read other children, and often their attempts end in failure. They may have difficulty in controlling their anger and do not understand how this affects other people. They may be hypersensitive to criticism, and be unable to tolerate teasing as they take language and situations very literally. They do not understand sarcasm. They are often hypersensitive to noise and large crowds. They are often described as loners, always on the outside, feeling like aliens in the playground (Sainsbury, 2000). Other children often do not want to play with them and, as a result, they become isolated and excluded. They can become easy targets for bullies, most especially because of the way they respond to the teasing. When the child with Asperger syndrome is the only child in the family, often the whole family becomes isolated and misses out on the normal socialisation of childrearing. The child does not get invited to birthday parties and the parents dont get included in social gatherings by default. Some children are home educated and have few opportunities to mix with other children. The 4 us Model aims to counter all these disadvantages by a) Acknowledging that the parents are the experts in bringing up their children. b) Enabling parents and children to learn that they are not alone, so reducing isolation and empowering families. c) Acknowledging the support the parents, siblings and children can give to and receive from each other through offering opportunities to share experiences and information. d) Ensuring siblings get some attention for themselves. e) Providing a safe place where children with Asperger syndrome can learn the rules of social interaction in a systematic way in a communication skills group led by a specialist in communication (speech and language therapist). f) Giving the children the opportunity to practise these skills in a community setting and to explore their emotions / feelings, new friendships and ways of behaving. Through learning how to repair mistakes and try again in a non-judgemental environment until they have practised, learnt, and gained the confidence to use these social communication skills and coping strategies in everyday life and at school, we hope they will become properly included in the community. g) Helping the children understand why they are different while enabling real friendships with others who think like they do, so they have the experience of truly belonging to a group of people who understand.
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HOW I
Figure 1 Samples of feedback from evaluation questionnaires 1. Parents: Why do you come to the group? Its the only place I actually feel safe with my two Asperger children. They have learned a huge amount in pragmatic communication skills from Janes work, social integration, self-esteem and inclusion for the children and us. Some weeks I support others and other weeks I am supported. It works and its a break. Thank you. I needed somewhere that I could meet and talk with people that had children like mine. Also somewhere that my child could mix with children like himself and feel at easeI feel as if I am no longer the only person with a child that suffers from Aspergers. Also when my son does have a bad time coping at the group people understand and do not judge. My life feels less stressful having somewhere to go once a week. For my son to develop better social skills and perhaps friendship, support for myself and his sister so she can understand that other people have problems with their siblings. Its professional and especially geared to autistic children, so they gain the maximum benefit from the therapy. Also any problems they are experiencing in everyday life can be discussed. Helps them deal with life in general. Because Id go insane if I didnt. Gregory doesnt feel the odd one out here and is not bullied. I get a lot of input from other parents and useful information. 2. Parents: What do you find most useful about the group? I have learned more from the support network in the group about Asperger syndrome and coping strategies than anywhere else (with all the agencies that are supposed to help / be on our side but seem to only hinder and cause stress!!! i.e. local education authority system, social services etc.) I feel supported by the parents and I have learned so much from the speakers. We all understand the children in our group with no sideways looks.

3. Parents: What do you find least useful, or what would you like changing? It takes an hour by bus and I would prefer a similar facility to be available locally. I dont like the amount of time / effort spent fundraising to pay for facilities, the constant form filling to acquire funds as well as supporting our children on a daily basis. I find it least useful when the social communication skills groups arent running as my child can get over excited in the hall and its hard to calm him down afterwards but he is getting better. 4. Young people: Why do you come to the group? Because I do. Because Ive got Aspergers. Because Mum makes me! Also because I enjoy the environment and like the people. I want to make friends! I come to the group because sometimes I have behavioural problems, but mostly I just come for fun. 5. Young people: What do you find most useful about the group? Meet new friends, have fun. I dont like it when the others shout loud. I want the others to be a little quiet. I like seeing everyone and I like listening to peoples news. To do exsparmets. Its nice that everyone who has Asperger syndrome can get together and be cooperative.

h) Catering for the significant number of children in the group who are school refusers, or have home tuition directly as a result of their difficulties with peer interaction at school. This is often the only opportunity for these isolated children to meet, play and interact with their peer group. Some have learnt to avoid their peer group at school. They need a process for learning and change to enable them to overcome their isolation. They will not learn this without systematic intervention because of the very nature of their condition. i) Encouraging good self-esteem and addressing the fact that depression in teenagers with Asperger syndrome is common (Wing, 1981; Attwood, 1998; Sainsbury, 2000; Ghaziuddin, 2005). Being part of a group, understanding who you are, why you are different, how you are the same as other people, and having fun with like-minded individuals will help counteract feelings of depression and the sense of not belonging. There have been no facilities for the families and individuals with Asperger syndrome in our area in the past as it is only recently that their difficulties have been recognised by professionals and the general public. In my experience, there is still widespread ignorance and myth surrounding the condition. Getting together should help empower families and educate professionals and the wider public, and so enable an understanding - and therefore acceptance - of people who are different. The All Party Parliamentary Group on Autisms Manifesto (see www.nas.org.uk/nas/jsp/polopoly.jsp?d=159&a=2411) aims to ensure that, by 2013, All children and adults with autism will have access to leisure facilities and meaningful activity tailored to their needs and interests. This should be shaped in a way that promotes social inclusion and, where appropriate, should involve family members and friends and All children and adults will be supported to develop their social skills and understanding. True inclusion is our ultimate goal. There is a massive need for this type of provision locally (see figure 1).Many parents cannot access the group because it is not local to them. Why dont we help them set up this model throughout the country?

Jane Baker is a speech and language therapist with South Devon Healthcare Trust, e-mail jane.baker@nhs.net. To accompany this article, copies of Janes supporting documentation Steps in Setting up the 4 us Model, Draft Group Constitution, and The 4 us Model leaflet: Social Communication in Context are available on www.speechmag.com. Jane will discuss the social communication groups in more detail in a future article.

Acknowledgements
With special acknowledgement to Gill Rogers, speech and language therapist, Sarah Diaz the youth centre manager and youth worker, Clare Ryder our playworker, Sue Bolt (district co-ordinator Teignbridge 0-14+), everyone who has worked for Asperations in the past and most especially the parents on the committee past and present, Christina (late) and Denis Adcock, Nici Loughlin, Teresa Holmes, Paula Lands, Elaine Geary, Dawn Cooper, Helen Farrance, Christina Smith, Janet Carter and Malcolm Gray, Phil and Anne Torr, Becki Tucker, Elaine Tucker, Diane Hill, Elaine James, Karen Barry, Rebecca Tulloch, Maxine MacIntosh, Gaynor Raisey and everyone else.

References
Attwood, T. (1998) Aspergers Syndrome A Guide for Parents and Professionals. London: Jessica Kingsley Publishers. Baron-Cohen, S. (2004) The Essential Difference: Men, Women and the Extreme Male Brain. London: Penguin Books Ltd. Ghaziuddin, M. (2005) Mental Health Aspects of Autism and Aspergers Syndrome. London: Jessica Kingsley Publishers. Sainsbury, C. (2000) Martian in the Playground Understanding the schoolchild with Aspergers Syndrome. Bristol: Lucky Duck Publishing. Wing, L. (1981) Aspergers Syndrome: a clinical account, Psychological Medicine 11, pp. 115-130.

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Connect 16-18 January 2006 Working with people with stroke and aphasia London Many other courses available (including Meeting the challenges of severe aphasia, The good goal-setting guide, Training the trainers). www.ukconnect.org Communicate courses 2 February 2006 AAC Strategies: Tools for Success across Environments. Carol Goossens Ph.D. 1 March 2006 Making a difference in real life with AAC: Creating communication opportunities. 23 March 2006 Ready.. aim.. fire! Developing switching and scanning skills. 27 April 2006 Kith, Kin and Co: Training communication partners. 24 May 2006 VOCA toolkit: essentials for introducing a Voice Output Communication Aid. Cost varies. Newcastle-upon-Tyne / Middlesborough. Contact Communicate 0191 2195640, e-mail communicate@nap.nhs.uk CALL Centre 2 March 2006 Interactive Whiteboards Edinburgh Many other courses available www.callcentrescotland.org.uk/training 12th International Aphasia Rehabilitation Conference 5-6 June 2006 Sheffield 200 Keynote speakers include Sally Byng, David Howard, Richard Katz and Jane Marshall. www.trainingmadeeasy.co.uk Fragile X Society National Family Conference 17 June 2006 Birmingham e-mail info@fragilex.org.uk Augmentative Communication in Practice: Scotland 8 November 2006 Successful literacy for children with severe communication difficulties Dr Karen Erickson www.acipscotland.org.uk Afasic Fourth International Symposium 2-5 April 2007 University of Warwick Details: e-mail carol@lingwoods.demon.co.uk.

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MYTOPRESOURCES
1. MASLOWS HIERARCHY OF NEEDS I use this when thinking about how best to facilitate groups, be it in teaching, treating clients, or working with colleagues. It reminds me that individuals need to be physically and emotionally comfortable to achieve their full potential for learning. Maslow, A. (1970) Motivation and Personality. 2nd edn. Harper & Row. (This edition is no longer available to buy, but there is a 1987 version published by Longman.) 2. MODEL OF THE MANAGEMENT PROCESS (Righton & Riley, 1996) Oonagh Riley and I developed this model while I was working at the University of Central England. It reflects the Universitys course philosophy in the 1990s which, I believe, grew out of and was developed from Jackie Stengelhofens work in the 1980s. This is a cyclical model, it contrasts with the linear models developed in the early 1990s, and is a useful tool for discussing and developing our beliefs about how we practise as a profession. Oonagh refined the model and published it in 2001. Stengelhofen, J. (1992) Teaching Students in Clinical Settings (Therapy in Practice). Cheltenham: Nelson Thornes. Riley, O. (2001) Managing children individually and in groups, in Kersner, M. & Wright, J. (ed.) Speech and Language Therapy: The Decision Making Process when working with Children. London: David Fulton Publishers, chapter 4. 3. WILLIAMSONS ICEBERG & COMPETENCIES (2001) Again this is a thought provoking and useful tool in helping me to think about what we do as a profession and why. I particularly like the emphasis placed on the skill of empathy as core to our profession. Empathy can be defined as: the ability to consider thoughtfully anothers feelings while making intelligent decisions (Strickland, p.114). Strickland, D. (2000) Emotional Intelligence: The most potent factor in the success equation, Journal of Nursing Administration, 30(3), pp.112-117. Williamson, K. (2001) Capable, confident and competent, Bulletin of the Royal College of Speech & Language Therapists, August, pp.12-13. 4. GARDNERS THEORY OF MULTIPLE INTELLIGENCES Gardner proposed his theory in 1983. He challenged the common belief at that time that cognition is unitary and that individuals can be adequately described as having a single, quantifiable intelligence, (Campbell et al., 2004, p.xix). He describes eight intelligences: Linguistic, LogicalMathematical, Spatial, Bodily-Kinaesthetic, Musical, Interpersonal, Intrapersonal and Natural. I think this theory is logical. It often allows me to make sense of how people can be naturally able in some areas and not so able in others. In relation to therapy and teaching it reminds me that we need try to teach so that everyone can learn - and what a complex task this is! Campbell, L., Campbell, B. & Dickinson, D. (1995) Teaching and Learning through Multiple Intelligences. Boston: Allyn & Bacon. 5. REFLECTIVE DIARY I did a certificate in education in 1996 and one of the many skills I learned was how to keep and use a reflective diary. My diary helps me to analyse my approach, whether it be to teaching, supervising or in practice with a client. Im afraid my diary is quite intermittent and I tend to use it when Im having a problem, rather than to celebrate the positives in my practice! Hopefully the increased emphasis on reflection in practice as part of our Continuing Professional Development will make me place more emphasis on my successes in future. Johns, C. (2002) Guided Reflection. Advancing Practice. Oxford: Blackwell Science Ltd. 6. BLOOMS TAXONOMY In the 1950s Bloom and a group of colleagues identified three domains of educational activity: Cognitive (Knowledge), Affective (Attitude) and Psychomotor (Skills). I find it useful to refer to the cognitive domain when developing my therapy plans, and also when teaching specific skills which call for a very structured approach. It particularly helps me to pitch my input or teaching at the right level. See Clark, D. (2001) Learning Domains or Blooms Taxonomy. Available at:http:/ www.nwlink.com/~donclark/hrd/bloom. html (Accessed: 19 September 2005). 7. MY OWN DYSPHAGIA ASSESSMENT (Smith, 1993) I developed my own bedside dysphagia assessment as a result of attending an excellent dysphagia course at University College London, run by Diana Moir and Gillie Kennedy in 1991. They promoted a very functional approach to swallowing assessment and my assessment is based on the principles of that teaching. I also believe it is necessary to have an assessment which reflects our management of dysphagic clients. For example, in general in the UK unlike the approach advocated by Logemann (1998) - we tend to use texture modification as our first line of management, and our assessment should reflect that. Kennedy, G., Pring, T. & Fawcus, R. (1993) No place for motor speech acts in dysphagia? Intelligibility and swallowing difficulties in stroke and Parkinsons disease patients, BJDC 28(2), pp. 213-226. Logemann, J.A. (1998) Evaluation and Treatment of Swallowing Disorders. 2nd edn. Austin, TX: Pro-Ed. Smith, T. (1993) Speech & Language Therapy Initial Dysphagia Assessment. Unpublished. Copyright Factorlogic Limited. (Contact the author for more details.) 8. MIND MAPS Tony Buzan argues that mind mapping encourages us to use both sides of our brain to make sense of things and therefore learn more effectively. He suggests that we usually employ the left side of our brains the most when were making notes or studying, using mainly lists or writing notes. He argues that if we use more visual and pictorial images we tap into our right brain and utilise more function, thus encouraging us to learn more effectively. I use mind maps for problem solving and also as an extension of brain storming to pull together thoughts and ideas from a group. Buzan, T. (2003) Mind Maps for Kids. London: Harper Collins. 9. MY CRITICAL FRIEND I met my very special Critical Friend when I first started work, and she is my most essential resource. I am fortunate in that both our professional and personal relationship has developed and matured over the years. Biggs (2003, p.254) describes it as a complex role, part partner, part consultant, but most of all a mirror to facilitate reflection. Finding a critical friend is a very personal thing. There are the formal work routes where you might develop a trusting relationship with a designated mentor or team leader, or where you might come to rely on colleagues in your clinical supervision process. You can also go down a less formal route by finding someone you just really click with, for example at college or in a Specific Interest Group. I dont think there are any hard and fast rules, but it needs to be a relationship where there is mutual trust and respect, and an expectation that this process will grow, change and develop over time. Biggs, J. (2003) Teaching for Quality Learning at University. What the Student Does. 2nd edn. London: OU Press. 10. ASSERTIVENESS I use the skills I learned on my assertiveness course in all areas of my life. Given the opportunity, I also try to pass them on and teach some of them to clients, students and colleagues. I believe these are core skills for all speech and language therapists; if we practise to facilitate change, we should first be able to understand, analyse and change our own behaviours.

TRACEY RIGHTON MSc (HUMAN COMMUNICATION) IS A SPECIALIST SPEECH AND LANGUAGE THERAPIST IN THE MANAGEMENT OF ADULTS WITH COMMUNICATION AND / OR SWALLOWING DIFFICULTIES. TRACEY HAS EXPERIENCE OF BOTH ACUTE AND COMMUNITY SETTINGS IN THE FIELDS OF ADULT NEUROLOGY, VOICE AND MENTAL HEALTH IN OLDER ADULTS. SHE HAS DEVELOPED A SPECIALIST INTEREST IN THE MANAGEMENT OF DYSPHAGIA IN ADULTS AND IN CHILDREN WITH LEARNING DIFFICULTIES AND WAS A FOUNDER MEMBER OF THE FIRST ROYAL COLLEGE OF SPEECH & LANGUAGE THERAPISTS SPECIFIC INTEREST GROUP IN DYSPHAGIA AS A SENIOR LECTURER AT THE UNIVERSITY OF CENTRAL ENGLAND AND ON THE ADVANCED DYSPHAGIA COURSE, TRACEY DEVELOPED HER INTEREST IN TEACHING AND LEARNING BY PROVIDING SUPPORT, ADVICE AND STUDY SESSIONS FOR THE ADVANCED DYSPHAGIA COURSE TEAM, AND FOR UNDERGRADUATE AND QUALIFIED SPEECH AND LANGUAGE THERAPISTS. SHE HAS ALSO DEVELOPED AND RUN A ONE YEAR STUDY SKILLS COURSE FOR SPEECH AND LANGUAGE THERAPY CADETS. TRACEY WORKS PART-TIME FOR SOUTH WORCESTERSHIRE (NHS) PCT AND IS EXTERNAL ASSESSOR FOR THE ADVANCED DYSPHAGIA COURSE AT MANCHESTER METROPOLITAN UNIVERSITY. HERE, SHE DRAWS TOGETHER HER TOP RESOURCES FOR LIFELONG LEARNING.