You are on page 1of 32

ISSN 1368-2105

Spring 2005

&

http://www.speechmag.com

POWER SHARING

in Practice

How I bridge the gaps


Education settings

Laryngectomy
A wellness focus

Frameworks
Getting the message

Evidence based practice


Tightening up on relaxation

Family Learning
Are we ready?

PLUS...The Awareness key...Heres one I made earlier...My top resources... and featuring Written Communication

Reader offers
WIN PIP AND MOLLY

WIN PHOTOSYMBOLS #1

Looking for quality, ready-to-use photosymbols to create total communication Pip the Puppet proved so popular in an Autumn 03 reader offer that LDA has environments? Well, Photosymbols #1 has over 1500 images covering 40 decided to give readers of Speech & Language Therapy in Practice another themes including health, work, where you live, sex and relationships, transport, opportunity to win him - and his partner Molly! rights, money and community. A single user pack normally costs 400 + VAT, The puppets features enable you to show: but Speech & Language Therapy in Practice has a copy available FREE to a Mouth shapes lucky reader, courtesy of Worth 1000 Words Ltd. Tongue positioning This computer based resource works on a PC or a Mac, and images are Finger movement for signing sized and ready for commercial print, inkjet, photocopying and websites. They can also have a hearing aid fitted, and are surface For your chance to win, simply write your name and address on a postcard washable. with the title Photosymbols #1 reader offer and post to Pete Le Grys, Pip and Molly normally retail at 89.99 each. Pip will go to Worth 1000 Words Ltd, 4a Greenway the first entrant drawn out of the hat, and Molly to the Centre, Doncaster Road, Bristol, BS10 second. 5PY by 25th April 2005. The winner For your chance to win, simply send your name and will be notified by 1st May. address marked Speech & Language Therapy in More information is on www.phoPractice - Pip & Molly offer to Lisa Alderdice, tosymbols.com, or telephone Marketing Assistant, LDA, Abbeygate House, 0117 959 4424. Worth 1000 East Road, Cambridge CB1 1DB. The closing Words donates 15 per cent of date for receipt of entries is 25th April, and profits to PEOPLELIKEME, and the winner will be notified by 1st May. aims to support unfunded and Pip and his friend Molly are available on 30 self-advocacy groups. days approval from LDA, tel. 0845 120 4776. The lucky winners of Expressive Verbs ColorCards in the Winter 04 issue, courtesy of Speechmark Publishing Ltd, were Fionnuala Langford, Julianne Bolton and Valerie Knight. Congratulations!

Spring05speechmag
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. Also on the site - news about future issues, reprinted articles from previous issues, links to other sites of practical value and information about writing for the magazine.

Focus on... empowerment


In addition to the empowerment theme running through Spring 2005, the editor has selected articles from earlier magazines to support you as you consider the power balance in your relationship with clients and carers. If you dont have previous issues of the magazine, check out the abstracts on www.speechmag.com and take advantage of our article ordering service.
(244) Armstrong, L. & McGrane, H. (2003) A bright SPPARC. Autumn: 8-10. (236) Speirs, L. (2003) Oats not so simple. Summer: 18-20. (212) Poole, S. (2002) PECS appeal. Winter: 4-7. (194) Wade, J. & Woodward, S. (2002) This is IT. Summer: 13-16. (173) Nicoll, A. (2001) Imprints of the mind. Winter: 14-18. BONUS! New at www.speechmag.com/ reprintedarticles.html. (137) Robinson, R. & Bailey, K. (2000) Early goals bring a result. Winter: 20-23. (128) Millard, S., Cook, F. & Fry, J. (2000) Homebase - but not DIY. Autumn: 20-23. (037) Levens, V., Gooding, S. & Gooding, J. (1998) An adult with Retts Syndrome: the feelings and outcomes. Autumn: 4-6. (019) Johnson, M. (1997) Lost in a moving stream - auditory sequential memory deficits. Winter: 18-21.

NEW from SPEECHMAG


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. Remember - you can also subscribe or renew online via a secure server!

www.speechmag.com Pay us a visit soon.

SPRING 2005
(publication date 28/02/05) 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 SPRING 05 SPEECHMAG, READER OFFERS


Win Pip and Molly, Photosymbols#1 and The Test of Morpheme Usage (p.16).

18 TIGHTENING UP ON RELAXATION
There is a huge research deficit in the application of relaxation methods in speech and language therapy. Their effectiveness in the treatment of different communication disorder patterns has not been proven on a scientific level; rather, their application in the context of speech and language therapy is based on everyday hypotheses. While most evaluation studies of relaxation in speech and language therapy report significant improvements, Marcus Stck, Thomas Rigotti & Ulrike Ldtke are concerned by their lack of scientific rigour.

2 NEWS / COMMENT 4 GETTING THE MESSAGE


This is a really positive view of communication development for the parents. Many may describe their child as a non-communicator but, after looking at the messages structure, they can identify three or four messages that they recognise their child as giving. I then set targets, using the principles of changes to well known routines, to extend the range of messages that the child communicates. Charlotte Child works with children who are early communicators. Here, she follows up on her Choices, Changes and Challenges framework (see Summer 04) by focusing on the dynamic communication of First Messages.

21 HERES ONE I MADE EARLIER...


Alison Roberts returns with more low-cost ideas for flexible therapy activities: in a spin, paint splotch predictions and timeline.

www.speechmag.com

7 E-MAIL TO THE EDITOR FAMILY LEARNING - ARE WE READY?


Karen Davies, Terrie Murphy & Sarah Tweedle are convinced by the case for programmes combining language development in young children with support for adult learning - but wonder if the profession is ready to campaign for this extended role?

22 KEYS TO WINNING WAYS SERIES (2) THE APPRECIATION KEY

IN FUTURE ISSUES... VOICE

DYSPHAGIA

8 REVIEWS
Careers, learning disability, phonological awareness, articulation, education, hearing impairment, voice, literacy, software, computing.

...we are all human and, until we EARLY YEARS reach the dizzy heights of Ghandi, Mother Teresa, or Buddha, a little bit SENSORY INTEGRATION of gratitude goes a very long way. It GOAL SETTING also has the added advantage of zapping negative thinking. CRITICAL APPRAISAL In the second article of our series to TRAINING encourage reflection and personal growth, life coach Jo Middlemiss explains how you can practise an attitude of gratitude.

10 VICTIMS? - NOT A BIT OF IT!


...it is quite incidental that, in fact, all participants acquired hands-free speech. What we actually saw was huge changes in their confidence, personal strength in the new roles that they took on and a hike in their levels of motivation. Fiona Hewerdine & Linda Laugesen explain how getting involved in an anti-smoking campaign and organising workshops for people with a laryngectomy has empowered clients in a variety of ways.

24 COVER STORY HOW I BRIDGE THE GAPS


(1) ASSESSING THE STRUCTURE Margaret Margerieson, Ros Hunter & Adrienne Fenton find and bridge the G.A.P.S. with a new assessment of social communication skills of teenagers with moderate learning disabilities. (2) STRENGTHENING THE FOUNDATIONS Joanna Manz reconciles the different aims of therapists and teachers through a regular snack session for mainstream special needs pupils with persisting eating and drinking difficulties. (3) SCALING THE SCAFFOLDING Lizzie Davies tells how Storyboards have helped children construct their own adventure stories in an education achievement zone.

Cover photo by Van Werninck Studio, Montrose. Pictured at the snack group (see page 26) (L - R) are Christine Fisher with pupils Ailsa, Kayleigh, Bethany and Caitlin.

14 THE WRITE STUFF?


Petrea Woolards team in London have given a lot of thought to shaping information, asking questions like, Who are the reports for? How are appointments being made? Is it essential that I write in this way? If so, how do I provide the person its about with something that is useful to them? Avrill Nicoll reflects on the professions approach to written communication within the bigger picture of user involvement and accessibility.

BACK COVER: MY TOP RESOURCES


Its the perfect book for reflecting, not just on work, but life in general. There are sections on boosting confidence, strengthening your relationships and tackling your obstacles. Great fun. Voice specialist and psychotherapist Jayne Comins on Your pocket life-coach by Carole Gaskell, one of Jaynes top ten books to help you make changes in your professional and personal life.

17 FURTHER READING
Research, language development, aphasia, adolescents, hearing impairment.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

NEWS

Reducing the isolation of MND


The Motor Neurone Disease Association is appealing for health and social care professionals to use their skills and professional background as volunteer visitors. Glynis Atherton, Director of Regional Support, describes the role of Association Visitor as a demanding but very rewarding opportunity for anyone who wants to build their portfolio or use their professional skills in retirement. Whether or not they are seen by a whole range of professionals, people affected by motor neurone disease feel isolated and alone, and Association Visitors are specially-trained volunteers who provide friendship and support. The Association has more than 300 visitors, but needs to recruit and train more to meet growing demand. The comprehensive training programme recently won a National Training Award. See www.mndassociation.org or tel. Ros Norris on 01604 611826 The deadline for entries for for an information pack. the British Aphasiology Society student essay and project prizes is 8 July 2005. www.bas.org.uk/prizes.htm

Making contact confidentially


Contact a Familys webbased linking service scooped first place for best confidential e-mail service at the 2004 Helpline Awards. The service, www.makingcontact.org, was singled out as providing a new and exciting method to access information and support, while at the same time protecting callers confidentiality. It enables families with disabled children to get in touch with each other across the UK - and even across the world, important when the child has a rare condition.

Student prizes

Association Visitor Chris Glover, a retired speech and language therapist, with Norman Gray, who has motor neurone disease

A more equal society?

As a general election looms, a study has asked if Britain is now a more equal society than it was when New Labour came to power in 1997. A team from the Centre for Analysis of Social Exclusion drew on more than 500 separate sources for the study, which was supported by the Joseph Rowntree Foundation and the Economic and Social Research Council. They conclude that, while the government has taken poverty and social exclusion very seriously and made genuine progress in reducing disadvantage in key areas, Britain remains a very unequal society. A concentration of tax and benefit reforms to tackle child poverty has benefited low-income families with children the most. Such families have increased spending on clothing, footwear, games, toys and food for children while not increasing their spending on alcohol and tobacco. However, the researchers suggest vague or limited policies have resulted in little evidence of a narrowing of health gaps between social groups and, while poorer schools have shown the best improvement in primary education, the picture at secondary level is more mixed, and strong social class differences remain in levels of attainment. Dr Kitty Stewart, who co-edited the study, notes that overall improvements in health and education can leave the most disadvantaged lagging even further behind. The report highlights that the needs of disabled children have not been selected for special attention. Ethnic inequalities remain high, particularly for the high proportion of Pakistani and Bangladeshi populations on very low incomes. In poorer neighbourhoods crime is an ongoing concern - but Sure Start is mentioned as being popular with residents. In contrast to the general trend, asylum seekers suffer from policies that actively increase social exclusion. A more equal society? New Labour, poverty, inequality and exclusion, 19.99 + 2.75 p&p, tel. 01235 465500 or see summary free at www.jrf.org.uk.

Women and stroke


The Stroke Association has called for more research to understand the link between migraines and an increased risk of ischaemic stroke, particularly in women taking oral contraceptives. This follows publication of an article in the British Medical Journal that adds to the growing body of evidence for this link. The Association also welcomed a separate paper, which concluded that hormone replacement therapy cannot be recommended as a preventative measure for stroke. http://bmj.bmjjournals.com/ (both articles January 2005) www.stroke.org.uk

With work-related stress the biggest occupational cause of working days lost through injury or ill-health, the Health and Safety Executive is helping large employers work with employees to manage the risk. Their approach is based on a continuous improvement model featuring a benchmarking tool and Management Standards that define the characteristics of an organisation where stress is managed effectively. It has been developed with input from businesses, professional bodies and unions and highlights how good organisation, job design and management keep stress levels in check. The organisation Acas has produced a booklet Stress at Work giving practical advice on handling stress issues in the workplace, free at www.acas.org.uk. Employers or employees can obtain free confidential advice on the Acas helpline, 08457 47 47 47. www.hse.gov.uk/stress

Keep stress in check

Teachers TV launched
Taking your work home has taken on a new dimension with the launch of a professional development television channel aimed at teachers and anyone involved with education. The first ever government funded public service broadcasting channel for a professional group, Teachers TV is editorially independent and supported by an interactive website with downloadable resources. Programming will cover training, education news, classroom observation and analysis, resource reviews and curriculum-based programmes for use in the classroom. The channel is available 24/7 on digital satellite and cable and overnight on Freeview.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

NEWS & COMMENT

Early intervention proposal


Do you think there is a case for a National Centre for Early Intervention? And how could it add value at a local level? Commissioned by the Department for Education and Skills, the learning disability charity Mencap is leading a feasibility study to set up a pan-disability National Centre for Early Intervention. As part of the project a discussion forum has been launched at www.earlyintervention.org.uk. Mencap is gathering views about how the centre will carry out its functions and how it can add value at a local level. To join in the discussion, email password@earlyintervention.org.uk for a password.

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

Course is MAGIC
A youth development course to increase self esteem and self awareness has been accredited by the Open College Network. MAGIC, from the UK College of Life Coaching, is designed to complement formal and informal education and covers themes including listening, initiative and confident communication. www.ukcollegeoflifecoaching.com/

Power sharing

Parents needed for survey


Afasic is asking readers to direct potential respondents to a survey that aims to improve the future for young people with speech, language and communication impairments. The charitys chief executive Linda Lascelles says calls to the Afasic helpline suggest parents face a postcode lottery finding help for themselves and their children. Some dont understand what is wrong with their child or know where to seek help. Others are made to feel their childs disorder is their fault. Afasic is asking parents of affected children to log onto the confidential survey at www.afasic.org.uk by 30 April, so the charity can inform the government about what is happening in each region. In the longer term, it hopes this will lead to the development of minimum standards.

Plural succeeds Singular


The founder of Singular publishing, sold to Delmar in 1998, is venturing into the communication sciences market again - this time with a publishing house called Plural. Dr Sadanand Singh said, We plan to develop new and ground-breaking products and widen the scope of communication disorders across a range of disciplines. Already, we have plans to publish books and other electronic media products that will help take the science, understanding, assessment and treatment of communication disorders to a new, higher level in a way that no other publisher can, or will do. The first titles will be released in May. Anyone interested in submitting manuscripts or ideas for consideration will find more information at www.pluralpublishing.com.

tel/ansa/fax When I first became acquainted with notions of power and empowerment at a 01561 377415 study day around 12 years ago, I was bowled over by the implications and possibilities. According to my husband, though, empower is just a meaningless, e-mail avrilnicoll@speechmag.com pretentious, trendy buzz-word. I can understand that his view is jaded by the way it is over-used in his workplace lets empower the staff by letting them choose the office furniture being a recent example. However, his reaction suggests that he would benefit from practising an attitude of gratitude (Jo Middlemiss, p.22) or from perusing our back page where Jayne Comins suggests 10 books to help bring about change in your personal and professional life. But whatever he thinks of the word, the reality is that life becomes better for everyone when people are empowered, as Fiona Hewerdine & Linda Laugesen (p.10) discovered. Involving their laryngectomy clients in preventative work and state of the art workshops led to them all developing hands-free speech. But much more importantly, they took on a diversity of active roles, including problem-solvers, presenters, mentors, entertainers, carers, peer reviewers and inventors. Charlotte Child (p.4) is clearly a speech and language therapist empowered as she whizzes through all these roles in her work on First Messages. She takes care to understand where the child, the parents and the education staff are coming from. By enabling them all to see the child as a communicator, progress is allowed to happen. Power sharing is evident in How I bridge the gaps. Our authors have built successful partnerships with education staff to enable pupils to develop better social communication (p.24), eating and drinking (p.26) and storytelling (p.27) skills. Karen Davies and colleagues too (p.7) see the value of working with adult carers to benefit children. Will their powerful call for the profession to embrace this model be heard? Thomas Rigotti and colleagues (p.18) dont pull their punches either in assessing the woeful state of research into relaxation methods in speech and language therapy. How can we share the power of relaxation with clients if we dont even know how best to ensure it works? There is so much that we dont know. And so much our clients can tell us if we only let them. That study day I attended was with Carole Pound, now of Connect, the communication disability network, where empowerment is in with the bricks. Our feature on written communication (p.14) shows that many therapists are doing similarly groundbreaking work on user involvement and accessibility across a range of client groups. As interviewee Deborah Green says, I really feel for the first time in a long time service users are being involved and were making real changes together. Office furniture notwithstanding, more empowerment to your elbow.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

FRAMEWORKS

Getting the m
IF YOU WANT TO MAKE THERAPY FUN EXTEND A CLIENTS RANGE ASSESS COMMUNICATION PROGRESS

When working with children who are early communicators, do you feel you are too reliant on set words, a teddy, picture cards and luck? Charlotte Child certainly did, so set out to find a more effective alternative. Here, she follows up her work on Choices, Changes and Challenges (2004a; b) by focusing on the dynamic communication of First Messages.

hat do you do with a child who is an intentional communicator using a few gestures, vocalisations and early words but is not yet at the single word level? Coupe OKane & Goldbart (1998) discuss research evidence that shows the undue emphasis on the teaching of labelling [being] counterproductive to language development and, indeed, such a focus leading to failure to develop functional communication at the single word level. Current good practice includes combining play-based activities and cognitive development - modelling the vocabulary, following the childs lead during play and commenting on what they are doing - with a strong emphasis on adult-child interaction. The structure of Choices, Changes and Challenges (Child, 2004a; 2004b) allowed me to provide a really functional overview of this phase of development. The ideas were incorporated from well documented good practice, but presented in a logical format that other people could relate and buy in to. Most importantly, though, it took the focus off the development of the childs linguistic skills and onto their development as communicators using whatever skills they already had. However, as a speech and language therapist, I also needed a framework within which I could assess the childrens progress. Also, as I continued to expand my work, it was the range of messages that the changes generated - and the pitfalls of successfully planning them that both interested and challenged me the most. I realised that these issues were linking to some work I had already introduced within the nursery class at Bidwell Brook School, where I was trying to address the transition into first words through using the concept of early meanings. Through combining these ideas I now have an additional framework, First Messages, which has been an extremely useful and fun expansion to my work on functional communication over the last eighteen months.

the first things that children start to tell us about are the people, objects, events and situations in their lives ...its a very dynamic message rather than a set word.

Importance and meaning


Leonard (1984, cited by Coupe OKane & Goldbart, 1998) describes early meanings as aspects of cognitive structure that the child may attempt to communicate about. In other words, the first things that children start to tell us about are the people, objects, events and situations in their lives that have importance and meaning to them. Its a very dynamic message rather than a set word. A common example is the situation where every time a parent sees the rather large family cat waddle into the room, they point it out to their child

and say cat, and they do the same when they see a cat in the street, at someone elses house, in books and on television. One day the child sees the cat walk into the room, and points and says dah; the parent is delighted - theyve learnt the word cat (at last) and they are whisked off to Grandmas to show off their first word. However, the child doesnt show any recognition of Grandmas cat, or indeed any other cat they come upon in their travels, and the parent reports that their child used the word cat once - but not any more. One reason for this (and there are many considerations) is that the child wasnt saying Hey, look, theres a cat (a furry feline that likes milk and mice) but Hey, look, I know what that is and it lives in my house. The child was communicating what the situation meant to them rather than labelling the things involved. (A word of warning: the meaning may be rather specific to the child, like an in-joke, as with our daughter who said Gellar Gellar every time that she saw the dogs in the garden - and we still havent got a clue what she was on about.) Using the concept of early meanings to promote a childs communication skills isnt new; programmes commonly include bye bye, all gone and more. However, they are just the tip of the iceberg and, most excitingly, arent merely a stopgap between communicative behaviours and first words, as they structure and drive the development of a childs communicative and linguistic skills from this point through to two and three word phrases. My framework (table 1) is based on the model in the chapter Teaching First Meanings (Coupe OKane & Goldbart, 1998) which cites the influence of the work of Bloom (1973), Bloom & Lahey (1978) and Leonard (1984). In the original list there are twelve early meanings that can be communicated. However, I have removed denial as, the way I interpreted it, it developed at a later stage than the rest. Also, I included the message thats wrong in rejection as this seemed to be of equal importance to simply rejecting an event or object, and was a common message from creating errors. I kept the original titles in brackets for easy reference to the theory, but used a more descriptive title with families and other people. The phrases after each title are what the child might say if they had the words and helps to illustrate the message and make it more real. I have also developed a much fuller version of this for the families to work from that describes each message with real examples from my own children or my friends (Child, in press). (This necessitated

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

FRAMEWORKS
Table 1 Framework: First Messages
1. APPEARED (EXISTENCE) I know what that is! look 2. DISAPPEARED (DISAPPEARANCE) all gone, no, bye bye Telling you about something that has disappeared, or is disappearing Or a request for something or someone to disappear 3. STOPPED (RECURRENCE) more, again, all gone,finished Telling you about something that has disappeared, or is disappearing Or a request for it to continue 4. GONE MISSING (NON-EXISTENCE) name of thing?,gone, Wheres... Communicating that someone or something is missing from its normal place 5. WHERE THINGS ARE (LOCATION) there, name of place, look, on, up Telling you where someone or something is Or a request that something is put in that place 6. WHOSE IS WHOSE? (POSSESSION) mine Communicating ownership 7. REJECTION no way, stop, I dont want to do this, thats wrong. Communicating that a person or object or event is not wanted Or a request for the current activity to stop Or telling you when something is wrong 8. TO SHOW THAT THEY WANT TO MAKE SOMETHING HAPPEN (be the agent) me I want to do it Communicating that they (the child) want to do something that is going on to happen to them too 9. TO SHOW THAT THEY WANT SOMETHING TO HAPPEN TO THEM (be the object) and me Communicating that they want something that is going on to happen to them too 10. COMMENTING ON AN ACTIVITY up go uh-oh Commenting on mishaps Telling you what is going on 11. TO COMMENT ON SOMETHING yucky nice

message
endless patience from my family, particularly when my then eighteen month old daughter scrambled up onto the settee with a conscientious uh-oh as my wine glass went flying. Like all great researchers, though, I reached for my ever ready notebook with an oh, so thats a comment on an action as my long-suffering husband reached for a cloth...)

Positive view
Using these examples to talk to the families reinforced that this is a universal framework not reliant on the child developing the conventional forms of communication such as words or signing. Just as you can describe the functions of language (such as gaining attention, requesting, giving information) as forming the fundamental framework onto which communicative behaviours slot, so too can you view the messages. The ability to communicate the meaning comes first and the child simply becomes more sophisticated in the way they get meanings across. This is a really positive view of communication development for the parents. Many may describe their child as a non-communicator but, after looking at the messages structure, they can identify three or four messages that they recognise their child as giving. I then set targets, using the principles of changes to well known routines, to extend the range of messages that the child communicates. As with all frameworks, there are some technical bits. Firstly there are three pre-requisites that relate to the child being an intentional communicator. Where the child has learnt that they can get an adult to do things for them by using a range of different behaviours, I describe this to parents as If I do ...You do.... At an early stage these are still hit and miss but, at the later stage, the child is remarkably persistent until they get their message across; I refer to this established stage as If I do ...you do...and I wont give up! 1. Cognitive: The child is able to demonstrate an understanding of objects through using a range of them appropriately on themselves (understanding through use). This cognitive point of development is particularly relevant when planning changes as the child needs to have a solid understanding of what should be going on to make the change significant to them. If a child has not yet reached this stage, I continue to focus on choice making (table 2). 2. Communicative: The child is able to use some form of gesture / looking / vocalisation to get a message across and to communicate at least a small range of intentions such as to request and inform (that is, the child is an intentional communicator). 3. Social Interactional: The child is able to have their attention directed to give joint attention to events and objects.

Table 2 Choice making


Can the child make a clear and satisfied choice between two offered items?

YES

Move onto ideas from Changes.

NO
Can the child make a clear and satisfied choice between a favourite and disliked item? Start to make the items more similar in preference.

YES

NO
Will the child take a single offered item if they want it? (And ignore it or push it away if they dont.) Start offering a totally irrelevant or strongly disliked item at the same time as you offer the item you know they like.

YES

NO
Rather than simply handing the child their cup, food, toys/ objects, pause and wait for the child to show an interest or reach to what you are holding.

Can they reach and hold objects?

YES

NO
Do they react as things are about to happen?

YES

NO
Do they react after something has happened?

YES

Develop a Communication Passport that clearly outlines the messages that the child communicates and how you know when they are happy/unhappy like /dislike something want / dont want something.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

FRAMEWORKS

If a child has a strong own agenda, then they are unlikely to be aware or interested in social messages. However, I still find this structure to be useful for these children in identifying and joint planning around meltdown messages. Secondly, there are two stages of development: a. The child recognises and understands whats going on The biscuit tin isnt in its usual place and the child may look around for it, they may walk away or they may get really cross with the cupboard; they know that it should be there and isnt. After Grandma has left the house and youve shut the door, your child sits and waves to the door; they understand that someone has disappeared. As these examples show, the adult can observe the child using a range of behaviours which show that they understand whats going on but dont try to tell anyone else about it. b. The child communicates about what the situation means to them When they discover that the biscuit tin is missing they pull the adult to the cupboard or shout for attention until you help. As Grandma is leaving the house they begin to wave, communicating a bye message. Such messages can all be communicated through a combination of communicative behaviours that are unmistakably aimed at another person including: gestures nodding / shaking head, waving, holding out their hand (as a request to be given something), holding out an object (to show it or to give it), pointing, and personalised gestures that the child makes up for themselves vocalisations protowords (a consistent pattern of sounds), right through to two or three word phrases. This breakdown, taken from the Early Communication Assessment in Communication Before Speech (Coupe OKane & Goldbart, 1998), has been the most important expansion to the changes work and my working knowledge. So often after carefully planning a relevant and meaningful change in a childs routine with their parent or with school staff, the feedback would be that nothing happened; the child had simply looked at the adult, or looked at the situation, and maybe smiled or got cross, leaving the parents feeling disheartened and convinced that both the ideas and the new speech and language therapist were decidedly dodgy. However, through breaking it down into the cognitive recognition of the message and then communicating about it to another person, it immediately became clear that the shocked look as the parent put the sock onto their childs hand wasnt a failure but the first stage - the fact that their child did not give a message about what was happening was the very reason that we were working on it. Of course, planning the changes continued to be very important, as what worked for one family didnt for another, emphasising the need for me as the clinician to understand fully the underlying principles

and not just produce a few formulated ideas. I learnt that early changes worked best within clearly understood routines and those with anticipation - so boots in the bath was harder than putting one sock on the childs foot and the second on their hand. I also found that having another adult acting as the childs support was particularly important. There always seemed something rather disingenuous about setting up a situation, for example giving the child the wrong shoes, and then prompting them to tell me that I had got it wrong. It was ever so much more natural and effective with another person working with the child as their advocate - picking up on their uncertainty by clarifying the situation (youve got the wrong shoes), directing them (lets tell Charlotte), and modelling the message (not my shoes), then encouraging the child to have a go at telling me in whatever way that they could. It is important not to set any linguistic targets within these activities in order to maintain the focus on the communication of the message rather than on how the message is communicated.

planning the changes continued to be very important, as what worked for one family didnt for another

Useful and relevant


Well, I said that it has been a fun eighteen months, but my greatest satisfaction has always come from the families successes and hearing how useful and relevant the focus on messages has been for them. Two great moments come from Oscar and Jemima. Oscar had a new puppy and, one day when it was being particularly boisterous, he gained his mums attention and then waved bye bye to it - a wonderful request for disappearance. Jemima and her mum made up a great game of getting into the car and being put into the wrong seat. It started off with the usual shocked uh-oh, mums lost it again look to shrieks of laughter all round. Best of all was when the families and staff at school started to recognise and report back on the new messages themselves, and the sizeable shift from measuring a childs progress in terms of the words they were using to the expansion in the range of messages they were communicating. This work has opened up a whole area of further interest and research for me. It is making sense of the theory and enabling me to translate this into practice. I havent abandoned my linguistic framework, nor do I suggest that it is a replacement, but it does provide a very effective tool within which to assess and plan for children in the earliest stages of linguistic development (from intentional communicators to one and two word level expressive skills),

and it makes the most of their learning style through focusing on the quality of the communication environment and their interactions. Where we cannot rely on children developing more sophisticated language based skills, simply increasing the range of messages that they can communicate has a very positive effect on both their behaviour and peoples perceptions of them as communicators. For children with autistic spectrum disorders who have good technical language skills, revisiting this pragmatic level of development has encouraged more purposeful use of the linguistic skills that they already have. Introducing the ideas to the nursery at Bidwell Brook School and John Parkes Unit, the child development centre, has also been a great experience. We immediately enjoyed the freedom of the ideas and the progress that we saw in the way that the children communicated, the very best indicator that youre getting it right. Best of all it is much more fun, much more effective - and I finally feel that I have got something positive to offer children in these stages that doesnt rely on a teddy, picture cards and luck. Charlotte Child (e-mail chaos@hgf.eclipse.co.uk) is a speech and language therapist with South Devon Healthcare NHS Trust.

Acknowledgement
A huge thank you to Sheena Burdett, nursery teacher, and all the learning support assistants at Bidwell Brook Special School, who again allowed and helped me to try out some rather weird and wacky things. Without their trust this project would never have got off the ground. Also to my daughters - who forced me to live my work, and still think that wearing pants on their head is normal.

References
Child, C. (2004a) Choices, Changes and Challenges. South Devon Healthcare NHS Trust. Available on disk for 6.00, e-mail chaos@hgf.eclipse.co.uk for more information. Child, C. (2004b) It aint what you say, its the way that you say it. Speech & Language Therapy in Practice. Summer: 14-16. Child, C. (2006, in press) The Communication Profile. Speechmark. Coupe OKane, J. & Goldbart, J. (1998) Communication Before Speech. David Fulton: London.

DO I NOTE AND LEARN FROM NATURALLY OCCURRING EXAMPLES OF THERAPY GOALS OR STRATEGIES? DO I RECOGNISE THAT INDIVIDUALISATION OF THERAPY IS CRUCIAL TO ITS SUCCESS? DO I MAKE DIRECT COMMUNICATION THERAPY MORE AUTHENTIC BY INCLUDING A THIRD PARTY TO SUPPORT THE CLIENT?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

E-MAIL TO THE EDITOR

Karen Davies and colleagues are convinced by the case for programmes combining language development in young children with support for adult learning but wonder if the profession is ready to campaign for this extended role?

FAMILY LEARNING ARE WE READY?


Dear Avril, How can we make a difference to our children if we feel uncomfortable with ourselves and with our children? How can we overcome our own feelings of failure if school taught us about failure? How can we enjoy communication if we feel tense and downhearted? The reality is that many parents feel this way - and our experience suggests speech and language therapists ignore it at their peril. Speech and language workers in the Sure Start Team in Partington and Carrington in Manchester took up the challenge of making a real difference for parents, as well as children. By turning more traditional objectives upside down, the speech and language workers aimed to support a group of parents to develop their own confidence and skills in communicating. This was achieved in partnership with another government-funded initiative called Early Start that was taking place across the whole borough of Trafford as part of the work of Family Learning. Parents and children participated in a short course that aimed to revive an interest in learning for the adults and improve interaction between parents and their children. The Basic Skills Agencys Early Start programme provided a number of specific aims that had to be fulfilled. These had to be met using a flexible approach that contributed to parents own learning as much as the childrens. The speech and language therapist focused on three key objectives: 1. to give parents an understanding of the kind of interaction that helps their children to explore, communicate and understand the world 2. to provide relevant activities for babies and young children to extend their communication skills 3. to create opportunities for parents to enhance their own language and literacy skills. How could a programme combine language development in small children with supporting adult learning and development? Partnership with parents is a routine part of a therapists role, with encouraging communication between parents and children an essential aim in many of our intervention programmes. However, when we encounter the parent who has significant communication difficulties themselves, we often accept that the parents are doing their best and hurriedly recommend a nursery placement to provide compensatory support for language development. Early Start aimed to help parents discover the pleasure of communication with each other, so creating a springboard for positive communication with their own children. The focus of the learning was communication, using Hanens You Make the Difference (Manolson et al, 1995) as the structure for the programme. Hands-on learning took place with each other, and with their children, enabling a journey of discovery for a group of uncertain and inhibited parents. Details of the programme were well planned. The speech and language workers were confident and the support was well organised, but the keys to success could not have been predicted. Firstly, the families were carefully chosen and nurtured. A familiar Sure Start worker encouraged and facilitated parents to participate. Secondly, the format was relaxed and welcoming, with an informal lunch forming a crucial part of the session. Every family received a toy that linked directly with the activities discussed in the workshop. The speech and language workers quickly recognised that the parents were reluctant communicators, but gradually they responded to the positive encouragement of the tutors and began to warm to the natural communication that they could share with their children. This kind of experience is irresistible and, over the weeks, they began to enjoy each others company. The formal evaluation was positive, but the more compelling evidence came from the comments that parents made. Ive learnt to listen to my child more and Ive learnt how to connect with my children are powerful endorsements of a programme that aimed to nurture parents as well as children. What kind of message would these parents have for those of us responsible for planning services?

Beyond Sure Start


The success of the programme was dependent on skilled practitioners taking advantage of opportunities arising from unlikely sources. Family Learning has an imperative to promote adult learning, but how refreshing to recognise learning as a broad concept to encompass communication, language and interaction in the family. This may be the most valuable learning a parent ever has an opportunity to do, leading to greater confidence in participating in their local community as well as within their family. Practitioners saw opportunities and modified agendas, taking advantage of skills and resources available through two high profile initiatives, Sure Start and Family Learning. The process of extending this beyond a small, targeted area requires even greater opportunism, together with the tireless enthusiasm of practitioners prepared to experiment and move beyond the confines of Sure Start. This must be the challenge that every Sure Start programme embraces, leading the way for other areas to support children and their families in providing creative and responsive services. This requires an approach that does not rely on example only but active participation in initiatives outside the usual Sure Start boundaries. I wonder if the speech and language therapy profession has the energy or the inclination to campaign for this extended role? In our moments of doubt we need to remind ourselves of the parents we have worked with, and the differences they have experienced as they have learnt to communicate. Making the difference is so compelling that we must find ways of extending this essential work. Karen Davies, Terrie Murphy & Sarah Tweedle Speech and Language Therapy Department Trafford Healthcare NHS Trust
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

References
Manolson, A., Ward, S. & Dodington, N. (1995) You Make the Difference In Helping Your Child Learn. The Hanen Centre: Toronto. Further information Early Start (Basic Skills Agency), see www.basic-skills.co.uk or www.literacytrust.org.uk. Family Learning, see http://www.campaign-forlearning.org.uk/campaigns/ familylearning/ familylearningindex.htm Sure Start, see www.surestart.gov.uk.

REVIEWS

reviews
COMPUTING
AlphaSmart Neo Computer Companion AlphaSmart Inc 185.00 ex VAT addition to social skills work with adolescents in mainstream secondary schools. Sue Lawrence is a senior speech and language therapist, Blackburn with Darwen Primary Care Trust.

Value for money


The Neo is a recording tool for written language aimed largely at pupils with specific learning difficulties. It acts as an electronic notepad that can be connected to a PC to enable work to be edited further or printed. Neo is rugged and has the advantages of a selection of font sizes and keyboard features to facilitate access by disabled students. However, the device doesnt yet have all the features of earlier AlphaSmarts. Although its quick and easy to master the basics and has a user-friendly manual, the PC hook-up can cause a few headaches! At 185.00, Neo is certainly value for money but, as a writing tool without voice output, is more likely to be useful to our special educational needs teacher colleagues than to many speech and language therapists in their everyday work. Sue Rowney is a speech and language therapist who works in special needs for North Tees Primary Care Trust.

SOFTWARE
Chatback V.2 (A sound recording program for speech therapy & auditory skills) Xavier Educational Software (available on 28 days approval, tel. 01248 382616 or see http://xavier.bangor.ac.uk) Single user licence 42.95 Site licence 63.75

Its fun - and I can do it on my own


This little programme bills itself as a simple utility in which to present students with recorded spoken words for them to listen to and repeat. SIMPLE? It certainly is simple to use. The user interface is excellent with large, clearly identified buttons for functions and settings. The users manual is also clear, with step-bystep instructions for installation, tutorials and additional user settings. It is straightforward to add or delete users, practice lists or stored recordings. USEFUL? It does what it says! It allows you to record individual spoken words and organise them into lists for practice. Its a bit like a more sophisticated version of the old Language Master machine, for those of you with long memories. There are four separate programmes in the package. 1. The Studio is for the therapist or teacher to record words, create student files and make up word lists for practice. 2. The Teacher is for sessions working alongside a user. On a mouse click, the student sees a speech waveform as well as hearing the recorded master version of the word, which is presented in written form at the top of the screen. The student records their version. They then see the master waveform at the top of the screen and theirs below, and they can listen to the two in sequence with a single mouse click. Another mouse click gives them the ability to pick up and drag their waveform over the

LEARNING DISABILITY
Talkabout Relationships Alex Kelly Speechmark ISBN 0 86388 405 9

35.95

Amusing cartoon illustrations


This well-presented package involves: a readable and well-referenced theoretical introduction an assessment section group exercises and worksheets on self-esteem and relationships. Each section is well structured with photocopiable resources including some amusing cartoon illustrations. I would use the framework and ideas in Talkabout Relationships. Some of the worksheet concepts are too complex for my client group, teenagers and young adults with severe learning disabilities. I would need to simplify language and concepts and provide additional symbol / picture support. However, it would be a welcome

master one for comparison. You can increase the recording time for practice items to 4 or 6 seconds, which is helpful for those with slow speech initiation or production. There is also a facility to hear the individual phonemes in the target word while seeing the sequence of mouth shapes: this requires the therapist to have entered both the master pronunciation and the phoneme sequence. I was pleased to find I could alter the phoneme recordings to make them more appropriate for the Scottish vowel system. 3. The Practice programme is for students working independently, and this is really the strength of the programme, since it provides an excellent resource for regular practice, for example in between sessions with a therapist. Similar comparison facilities are available as in the Teacher screen with the addition of a coloured self-rating scale at the bottom of the screen (cool / warm / hot). Multiple attempts can be made and the final version is saved to file. 4. The Checker allows the therapist or teacher to inspect the recordings saved to file, along with the students self-rating. LIMITATIONS? The master recording time is fixed at two seconds so the programme is suitable only for single word practice. Users need to understand that waveforms are not absolute, otherwise their inability to produce a perfect match may cause upset. TECHNICAL? It needs a Windows PC with a sound card, a microphone and at least 16MB of available memory - I have been running it in Windows 98 on a fairly old PC (Pentium II processor) and it appears to be very stable and reliable in this environment. The authors recommend a combined headset (headphones with an attached boom microphone) and we have found this works best for the child practising independently, but I use a separate microphone and speakers when working alongside the child. My field trial of Chatback has been with an 11-year-old boy with a complex speech and language disorder, co-ordination difficulties and attention deficit hyperactivity disorder. Ryan is a bright lad with

good computer skills. His current speech targets revolve around segmentation, manipulation and accurate production of syllables within polysyllabic words (syllables tend to be telescoped, omitted or lose articulatory precision). Here is Ryans review: This programme is good for me because it helps me with my vowels and my syllables. Chatback lets you hear the words you say. If you say, Blah, blah, blah, it will say, Blah, blah, blah back to you. If you say it too loud, youll get sore ears! Miss Reid adds words in, and we collect words on a bit of paper that I cant say very well, like digital, and then I try it to improve it. Chatback says it exactly as I say so if I say it a different way, I can see it and hear it. I like it because its fun and I can do it on my own. Jennifer Reid is a speech and language therapist with NHS Fife.

VOICE
The Teaching Voice (2nd ed) Stephanie Martin & Lyn Darnley Whurr ISBN 1 86156 436 8 19.50

Easy to navigate
This book has been set out logically and is well presented. The text is to the point and the chapters follow a clear sequence of subject areas. Each paragraph is well labelled, making the book quick and easy to navigate and a useful source of information for any professional whose voice is an integral part of their work. The speech and language therapist will find pertinent, succinct answers to many questions often raised by voice clients in everyday practice, and it would form a solid information base for work with individuals or group therapy sessions. The many issues which can impact on the voice have been thoroughly discussed in an easy to read yet professional manner, and there are strategies and exercises clearly set out for work on specific problem areas. The diagrams of the cartilages of the larynx are unfortunately too simplistic to be meaningful to anyone without prior knowledge, and information on the best approach to encourage clients in a

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

REVIEWS

sometimes embarrassing therapeutic process is sadly missing, but these are minor niggles in an otherwise excellent resource. Valerie Birch is a community speech and language therapist in Maryport, Cumbria.

ARTICULATION
Elocution for Beginners Video (also available on DVD and audiocassette) Liza Page Available from: 8 Crisp Road, Lewes, East Sussex 22 inc. p&p.

Uninspiring
Despite its rather uninspiring title, this video might have been engaging and a useful resource in therapy. This was not to be, as the video is exactly what it says on the tin. The format is dull and, by definition, repetitive. Liza Page sounds condescending; this might be counter-productive in a therapeutic setting. However, an adult with mild dysarthria or dyspraxia may benefit from the visual and auditory cues if they were self-motivated enough to persevere with the repetitive format. The only hint of humour was purely unintentional, in the choice of oldfashioned phrases and tongue twisters. Not one for the wish list. Carrie Croston is a specialist speech and language therapist working with adults with voice disorders and acquired neurological disorders in West Hertfordshire.

qualifications in teaching and speech and language therapy. Her book covers every aspect of phonological awareness (terminology, development, assessment, possible difficulties and intervention techniques) but is not light reading, and it is not easy to interpret the summaries without wading through lots of research data. This is not something you would take off the shelf to use in practice. However, if you had a particular interest in literacy, you would find all you need to know. A useful addition to the reference section, and suitable for most levels of experience if the reader is able to stick with it. Shona Hughes is a speech and language therapist at Perth Royal Infirmary.

HEARING IMPAIRMENT
Effective Communication with People who have Hearing Difficulties Jill Mansfield Speechmark ISBN 0 86388 341 9 39.95

Draws on personal experience


This welcome book raises awareness and knowledge of effective communication with people who have hearing difficulties. Aimed at an adult client group, the information can be used by a wide range of people: carers, health and educational professionals. Set out as a training manual in a well presented, easy to read format, it is divided into 20 chapters with essential information presented on photocopiable handouts. Examples include: how we hear; what can go wrong hearing aid use lip reading / finger spelling speech and language difficulties The author draws on her personal experience of deafness. Case scenarios illustrate communication strategies. Contact details of relevant organisations are provided. This represents good value for money and is a useful addition to a resource library. Anne McMahon is advisory speech and language therapist for The Speech & Language Development Project (seconded from Down Lisburn Trust to work in a Local Education & Library Board, Northern Ireland).

LITERACY
Listening for Literacy: Early Phonemic Awareness Activities for Young Children Aileen Lau-Dickinson & Gail Raymond Love Publishing Company ISBN 0 89108 286 7 25.00

thinking and reasoning word play (sounds and meaning) explaining and describing reporting and debating using speech effectively. Each area suggests games for children at different levels, which are well described and applied to different subjects of the National Curriculum. When I left some ideas from this book with a Special Educational Needs Co-ordinator, she immediately put it on her list of books to buy. Classroom assistants could easily follow the activities independently and teachers would be helped with ideas for individual education plan targets. Well worth the money! Sarah Fraser is a speech and language therapist with East Elmbridge and Mid Surrey Primary Care Trust, working in mainstream primary schools in the Epsom area.

CAREERS
A Career in Speech and Language Therapy Jannet A Wright & Myra Kersner Metacom Education ISBN 0 9547457 0 1 12.95

Unbelievably poor
This American manual provides resources aimed at increasing phonemic awareness in preschoolers and gives useful definitions of speech terms such as blending and segmenting. The activities are limited and uninspiring and seem illogically ordered - for example, the auditory discrimination activity follows the sound production activity. The quality of the pictures is unbelievably poor. Cobbled together half-heartedly, they lack consistency, charm and are frequently difficult to recognise. The idea of a neat phonics framework for non-therapists to use in a preschool setting is a good one, but in this instance it has been appallingly executed. There are so many other more visually pleasing resources in the market place that, frankly, I would be embarrassed to use any of the visuals from this manual in any situation. Your 25 would be better spent elsewhere. Laura Seeley is a speech and language therapist with East Kent NHS Primary Care Teaching Trust.

An excellent insight
This book gives an excellent insight for a student of my age and stage of experience. Packed full of information about the field, and what sort of person you have to be to become a speech and language therapist, it also gives tips for university interviews. As the authors are both speech and language therapy lecturers, they know what needs to be heard in the interview situation, and their advice will be taken on board. The many case studies, explaining the problems and the treatment used, offer a useful insight into everyday life in the clinic. Very easy to read, as it is split down into small sections, this book will be most enjoyable to a student thinking about a career in speech and language therapy or to a careers advisor who knows little about the subject. Definitely value for money - I would recommend it to anyone interested in this field. Thomas Simkins is studying A Levels in Psychology, English Language and ICT at Carr Hill Sixth Form in Kirkham.

PHONOLOGICAL AWARENESS
Phonological Awareness Gail T. Gillon Taylor & Francis Books Ltd IBSN 1 57230 964 4 26.95

EDUCATION
Understanding and using Spoken Language: Games for 7 to 9 year olds Catherine Delamain and Jill Spring Speechmark ISBN 0 86388 515 2 32.95

Not light reading


I was looking forward to reading this as, in our department, we often discuss what is our role with children with literacy difficulties as opposed to support for learning or educational psychology colleagues? However, I wasnt to find a quick answer. Gail Gillon is a lecturer and researcher in New Zealand with

Lots of great ideas


This is an excellent resource for teachers and speech and language therapists in mainstream schools, with lots of great ideas for use with children in years 3 and 4. In three main sections - Understanding spoken language, Using spoken language and Teaching resources - it covers: active listening and memory

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

HEALTH PROMOTION

Right: Some laryngectomees attending a workshop in Tauranga, New Zealand Far right: Laryngectomee tutor demonstrating the use of a Servox to a group of Primary School children and teenagers on Matakana Island, Bay of Plenty, North Island, New Zealand

Victims? - Not a
IF YOU WANT TO EMPOWER YOUR CLIENTS IMPLEMENT A NATIONAL STRATEGY LOCALLY RUN WORKSHOPS

Recommendations in a national cancer strategy led to Fiona Hewerdine and Linda Laugesen getting involved in an antismoking campaign and organising workshops for people with a laryngectomy. Here, they explain how both ventures have empowered clients in a variety of ways.

e were recently prompted to examine our work with laryngectomees as a consequence of New Zealands cancer and palliative care strategy. The population served by our speech-language therapy team at Tauranga Hospital, situated in the North Island of New Zealand, includes a high proportion of Maori people. The document made recommendations about equity of access for Maori and non-Maori people, as well as enhancing information provision, helping with prevention, ensuring ease of access - particularly in rural areas - and maximising quality of life. We asked ourselves what this meant for us, and how we could enhance the care of our laryngectomy patients in the Bay of Plenty? The outcome was the provision of preventative education to a high-risk population (part 1) and a successful laryngectomy workshop (part 2).

Part 1: Preventative education to a high risk population


One of the strong focuses of New Zealands cancer and palliative care strategic document was prevention. As speech-language therapists generally do little preventative work, we were not sure whether this was our role or not. However, one of our laryngectomees had voiced an interest in visiting local schools to talk about the health disadvantages of smoking. Charged up by this and our cancer document, we decided to

pilot our first preventative trip. Our target area was a small Maori community, situated on one of the offshore islands in the Bay of Plenty. The island people are almost exclusively Maori; such populations have higher health needs including a younger death rate for males and females than their Pakeha (non-Maori) counterparts, and a very high rate of use of tobacco and other drugs. The purpose of our visit was to educate children at the local school about the potential consequences of smoking, one of which could be laryngectomy. Working with the local Maori support worker, we took one of our laryngectomees (a Servox and surgical voice user) and a Maori speaking speech-language therapist. We worked with three different age groups of children and, while we changed the pitch and tempo of the presentations, across the groups we had a running theme: 1) What does voice mean to us, and how do we use it? 2) How is voice created? Lets look at some of the anatomy (larynx model used). 3) Lets see a video of the larynx and the role the voice box plays in the production of speech (Newtons Apple video). 4) Footage of laryngectomy surgery. We only showed this video to the teenagers and not to the primary school children. For the younger students, we explained what it would be like to have a voice box taken away. With guidance, we had them draw a voice box with the corresponding parts of voice production, and also feel for vocal fold vibration. 5) Introduction of our laryngectomee, who took the floor with confidence and showed the children his Servox device, giving them the opportunity to use it themselves. The students looked at his stoma and heard stories of him inhaling a moth and being very scared. They learned that he could not go surfing anymore and that he had been frightened coming over to the island because he had had to travel by boat. He also would not go out fishing anymore. Fishing is an important part of Maori life, as is singing, so these were two important cultural activities

10

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

HEALTH PROMOTION

bit of it!
that the children understood could be lost through smoking. During his presentation to the students, our laryngectomee successfully played the role of a tutor, an advocate for wellhealth and an ambassador for anti-smoking.

Role models
We only spent 11/2 hours with each class, but the learning they seemed to show, and the insights they had gained from our laryngectomee (see letters in figure 1), made us feel quite strongly that we had affected a preventative measure. We have heard from the Maori worker on the island that a number of parents have been prompted by their children to give up their fags. This is great! There can be no better teachers and role models than children for their parents and grandparents. On a poignant note, our laryngectomee said to us on the way home, If I affected one child and stopped them from smoking and getting cancer, my experience as a laryngectomee will have been worthwhile. We have now been asked back to the island to help promote an anti-smoking campaign for the adult population. This will co-occur with the provision of nicotine patches by the Maori healthcare workers and we are following this with a visit to provide laryngectomy education.

Part 2 - Laryngectomy workshop


Providing a workshop in the management of laryngectomy can be not only an empowering experience for the laryngectomee, but also a uniquely rewarding experience as a speech-language therapist. Titled State of the Art in the Management of Laryngectomy, our six week workshop was hosted by two speech-language therapists and a well-experienced and vivacious female laryngectomee. Our primary aim of running this New Zealand first workshop was to facilitate an educational opportunity, looking at the latest laryngectomy products on the market from various companies. We also endeavoured to create a real workshop focus by providing the participants with

Figure 1 Feedback

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

11

HEALTH PROMOTION

our laryngectomee successfully played the role of a tutor, an advocate for well-health and an ambassador for anti-smoking

the chance to play with a variety of equipment, such as handsfree devices, shower guards, humidification systems and bibs. We wanted to provide access to optimum equipment and then a communication environment to practise, experiment and feel supported. This workshop had no cost to the laryngectomy participants, apart from organising their own transport to and from the venue. As with any type of workshop, adequate planning is imperative. One aspect of planning that we felt contributed to the workshops success was meeting with our laryngectomee co-host in the initial stages of our preparation. This allowed us to have insight from a laryngectomees perspective. From this initial meeting, we generated a plan of such things as course content, handout materials, suitable videos, equipment to trial, a timetable of events, appropriacy of venue and invitations. As our oldest participant was 87 years of age, we felt it was very important to offer an easy access venue. Our workshop was located in a room on the ground floor of the hospital, with drop-off parking and wheelchair access. We carried out our workshop sessions once a week for the six-week period, with the sessions running for approximately one and half-hours in the morning. They were structured so that each subsequent session built on the previous one, therefore we recommended to participants that they try and commit themselves to attend the full course to gain the most benefit. Carers were also encouraged to attend all six sessions to provide support for their laryngectomee and also for their own education and learning. Course content over the six-week period is in figure 2.

Measurable spin-offs
The workshop really gave us the opportunity to look at the change within our patients. We were delighted by the measurable spin-offs and gains from our laryngectomees in support of each other, the changing self-confidence, and the diversity of roles that these people are now performing. Victims? - not a bit of it. Reflecting on our practice, we had seen our patients take on many active roles (figure 3): 1. Authority and Problem-Solver At the beginning of the course, we had agreed on an equal partnership of those running the course. However, it was not long before our laryngectomee co-host naturally took the lead in guiding and counselling us about our recommendations to the workshop participants. While she was sensitive and respectful of our understanding of anatomy and physiology, our laryngectomee was keen to share her wisdom and to problem-solve with the patients, for their best outcome. 2. Presenter One of our laryngectomees had attended an International Symposium and he agreed to talk about his experiences. It was his observations about not being a victim of cancer that inspired us to reflect on the fact that our laryngectomees are certainly survivors and not victims. 3. Mentor During our six-week period, the amount of coaching and mentoring done by our patients was remarkable. It was quite easy for the speech-language therapists to stand back and the sessions almost ran without our direction, as they provided peer support for each other. 4. Entertainer One might expect laryngectomees to play a passive role in communication; to be able to respond but not to take the floor or the spotlight. We suggested a competition - the completion of a limerick. Almost everybody that entered the competition chose to take the floor themselves and read their own entries. It was quite clear to us that laryngectomees do not have to play a passive role in the interactional process. These were entertainers, people empowered. 5. Nursing care Maori patients have a great respect for the head - it is tapu, which means sacred. Invasion through cancerous surgery of the head and neck can be extremely traumatic for a Maori person. Our workshop participants appeared to be very sensitive to these considerations when they were supporting one another. 6. Peer review The mentoring and care that we had seen extended from the participants was also reflected in their care and intuitive interest and acknowledgement of the carers. It was great to see patients supporting other peoples carers and taking the initial steps of discussing potentially risky or sensitive areas. 7. Inventor Kiwis are renowned for their ingenuity and we saw excellent examples of the personalisation and customisation of equipment. One of our laryngectomees created his own stoma studs, and moulded plastic himself to make the device fit his hands-free equipment. Another of our patients, who was a mechanic, customised his own humidification system with the use of a condom. (This was very successful for the first 20 seconds, until he ran out of air and the condom wouldnt roll back and allow him to breathe!)

Figure 2 Course content Session One: Introduction and housekeeping issues Syllabus discussed and provided as handout Presentation from Blom-Singer rep and equipment display Speech-language therapist and co-host laryngectomee presented a candid interview re: use of Blom-Singer hands-free device Video of Blom-Singer equipment Demo of application of Blom-Singer hands-free device from co-host laryngectomee Session Two: Session plan outlined Presentation on hands-free Provox II device Candid interview with co-host laryngectomee re: use of Provox II hands-free device Video of layrngectomee using Provox II hands-free device Demo application of Provox II hands-free device from co-host laryngectomee Prompt for participants to bring their own equipment for next session, for example valves, housing, mirror, torch / headlight Session Three: Session plan outlined Interactive display on various supplies, including stoma studs, cleaning equipment, laryngectomy tubes, cravats, shower guards Participants divided into three smaller groups and provided with hands on trials of hands-free devices Ordering of equipment Session Four: Session plan outlined Further interactive display on various supplies Further trials of hands-free devices with individual participants Chorus coaching from co-host laryngectomee during hands-free practice session Video session of laryngectomy operation Session Five: Session plan outlined Troubleshooting Humidification systems presentation Experimentation with different hands-free devices Session Six: Session plan outlined Further presentation from Blom-Singer rep Laryngectomee guest speaker presented on international laryngectomy conference Talkathon - limericks, prize giving and certificates of attendance Evaluation forms

12

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

HEALTH PROMOTION

Figure 3 Multiple roles taken and grown by our laryngectomee victors - a wellness focus

Trainer Problem-solver Speaker Inventor Financial Manager Peer Mentor Preventative Counsellor

Partnership & Team Player Planner

Empowered patient

Authority Mentor Counsellor Nurse

Entertainer

Next time
Weve reflected on the good, but what about the bad and the ugly? There are several things we would do differently next time. Firstly, we would always make sure we read the labels on the videos carefully. Inadvertently picking up the wrong video, we demonstrated laryngectomy surgery in the middle of morning tea to a group of patients and carers. While three quarters of them were riveted on the edge of their seat, the other quarter of the room were rushing for the sick bowls. A dreadful error, and no forewarning of the atrocious pictures. We also wanted to make a training video for New Zealand of our experience, so we videoed all the sessions. While this was really good for the purpose we had in mind, it would be nice to have had one less thing to do during the sessions. Trying to video tape footage and keep the ball rolling with all the different needs, and also have the time to observe the changes that were going on, needed 20 pairs of eyes, 40 pairs of hands and at least 200 pairs of ears. Additionally, laryngectomy speech volume in a big room can be very difficult to carry; particularly the age groups that we are often working with, who have hearing loss. Therefore, it would have been good to have had a roaming microphone to walk around the group to ensure everyone was heard. A lesson from session one was that, as people arrive, it is helpful to have soft background music, because the room was often too quiet, which delayed peoples feeling of security and hence level of interaction. Our final bad and ugly comment comes from the amount of work that is required behind the scenes. Preparation time in the initial set-up stages of the workshop and before each session was probably one of the biggest investments required. Time packing up post-session and dealing with some of the incidental work generated within the sessions was also significant. As it was our intention to allow all the participants to experiment with different gear, this took a huge amount of bookkeeping and auditing. Despite the time and financial cost involved in setting up and running the workshop, we now feel that we have a very usable working document that could easily be picked up again at some stage in the future and implemented, without all the initial planning time being required. We have chosen to write this article to demonstrate and reflect on empowerment for our laryngectomy patients. In considering our own goals, we were very keen to identify our workshops as State of the Art for laryngectomy rather than

calling them a hands-free group, in case patients were not able to master hands-free speech. So far, we have made no reference to their level of success, as it is quite incidental that, in fact, all participants acquired hands-free speech. What we actually saw was huge changes in their confidence, personal strength in the new roles that they took on and a hike in their levels of motivation. Really, we have looked at the shift from potential victims to victors - people who have become empowered and succeeded in the battle against head and neck cancer. Fiona Hewerdine is team leader of speech-language therapy and Linda Laugesen a staff speech-language therapist at the Bay of Plenty District Health Board, Tauranga Hospital, Private Bag 12024, Tauranga, New Zealand, tel. 07 579 8785.

Useful reading
Evans, E. (1993) Working with Laryngectomy. Oxon: Winslow Press. Lauder. E. (1997) Self Help for the Laryngectomee. Texas: Lauder Enterprises, Inc.

Resources
Reference document for cancer control strategy and New Zealand cancer strategic document and palliative care strategy for New Zealand: www.moh.govt.nz. Living with Laryngectomy, Life as a Laryngectomee and Yes, you can have a new start! are all available from Atos Medical, see www.atosmedical.com. The video How is my voice different from your voice is produced by Newtons Apple, St Paul, Minnesota, USA, see www.voicecraft.com.au. A video documenting our laryngectomy workshop is available for 15.00 (inc. VAT) + 5.00 postage. Please contact Fiona Hewerdine at fiona.hewerdine@bopdhb.govt.nz.

It was great to see patients supporting other peoples carers and taking the initial steps of discussing potentially risky or sensitive areas.

DO I HARNESS THE ENERGY OF CLIENTS TO ENHANCE THE TRAINING I OFFER? DO I CONSIDER HOW CULTURAL FACTORS CAN HELP ME GET MESSAGES ACROSS? DO I SEE OPPORTUNITIES FOR A WELLNESS FOCUS IN MY WORK?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

13

FEATURE ON...WRITTEN COMMUNICATION

When writing Nicoll (1996), I was constantly challenging and changing the way I compose initial assessment reports. I routinely sent copies of reports to parents, varying length and complexity depending on the desired effect. By the time I left clinical practice in 2002, I was writing all reports directly to parents / clients, with copies to professionals. My client-centred approach did not however bear much scrutiny as, although I had consulted colleagues about the content and style of a series of information leaflets, I had not asked the target group of parents for their thoughts. I wonder what I would do differently now - and how written communication will have changed in 10 years time? We use writing for so many purposes at work appointment letters, reports, advice sheets, information leaflets, posters, case notes - aimed at people from a range of backgrounds, abilities and interests. The environment is full of the written word. So how do the roughly 1 in 5 adults who have difficulty with basic literacy and numeracy (Moser, 1999, cited in DH, 2003) manage with daily activities as diverse as travel, interpreting food and medication labels, completing forms, applying for jobs and finding out and remembering something they want to know? And how do we enable everyone to access what they need without dumbing down? For Susanne Simms, a lecturer at UCE in Birmingham, dyslexia teacher and former private speech and language therapist, being able to say what you mean in writing is a fundamental but undervalued skill. She urges us to take responsibility: You have a message to get across. If you dont manage to do it, your report will not be as successful as you would like. An online toolkit (DH, 2003) provides guidance for anyone who produces written information for NHS patients, their carers and the public such as leaflets, booklets, single sheets or posters. All our communication must be clear, cost-effective, straightforward, modern, accessible, honest and respectful. Tips to make writing clear - use present and active tenses, lower case letters and a question and answer format - are included, along with checklists and templates to help you plan information leaflets. This guidance suggests planning and writing should come before consultation with service users - but there are advantages to starting with the consultation. Otherwise we risk turning people off by telling them what we think they should want to know, rather than what they actually need or want.

The write
In the Winter 04 issue we looked at how the profession can contribute to making new buildings more accessible. Here, Avril Nicoll continues the accessibility theme as she reflects on our approach to written communication

Pages from The Stroke and Aphasia Handbook (Parr et al, 2004).

The charity Mencap (2002) continues to develop its knowledge of accessibility by asking people with learning disabilities for their views. They suggest, Wherever possible involve your audience in the creative process. Seek the advice and ideas of people with learning disabilities as early as possible. When researching and developing the new Stroke and Aphasia Handbook, Parr et al (2004) noted that information is rarely given directly to the person with aphasia. So, as well as setting up an advisory panel of people with aphasia and getting ideas and feedback from other individuals and groups of people with aphasia and their relatives as the writing progressed, the book starts with the words: People with stroke and aphasia, this book is for you. Legislation and key policy developments drive changes in services, and user involvement, evidence based practice and accessibility are current themes. The Stroke and Aphasia Handbook really scores here, being full of respect for autonomy, the influence of time, the need to find out more,

and aphasia as a life-changing event. Sometimes, however, people putting changes into practice miss the point. While Kingston Primary Care Trust speech and language therapist Deborah Green considers the white paper Valuing People (DH, 2001) to be a watershed, the immediate effect was for her department to be swamped with requests to make leaflets more accessible. As Deborah says, How can you make a 50 page document accessible? Non Elias is a speech and language therapy support worker in a team for adults with learning disabilities in Wales. Her core work includes involving service users and making written information accessible. Projects have included daily schedule boards, menus, leaflets, shopping lists and information boards using photos and symbols.

Changing a culture
In Southwark, Petrea Woolards team got a new post to help services become more accessible to people with learning disabilities and to increase

14

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

FEATURE ON...WRITTEN COMMUNICATION

stuff?
involvement of service users. That therapist found out from service user forums how people should ask for their opinion and how the environment should be set up. The department also assists people with learning disabilities to become trainers of other organisations on how best to give information to service users. This training encourages people to recognise that accessibility is about interaction - and changing a culture to make it friendly and welcoming. It is important to realise that images help explain the text and are not just there to make the material look accessible (Mencap, 2002) and to consider whether a leaflet / brochure / CD / DVD / audiotape / person to person is the most appropriate medium. Deborah Green is enthusiastic about alternatives to leaflets. She understands that people with learning disabilities find the most helpful ways to receive information are 1. for someone to sit down with them and talk about it 2. a drama presentation 3. a video. She says, It is important to be creative, to think about how you can take someone into context and to have the opportunity to repeat three or four times. Her team now has an Easy Information Group of service users. Everything that has been designed to be accessible is brought to the group to road test in the way it is intended to be presented, and for feedback on what they think of it and what they understand by it. The vast majority are written documents which do not always produce expected comments, for example the frequent appearance of an ear symbol in an audiology document was interpreted as pork chops. Also, a leaflet (A4 folded in three) was read all the way across rather than in sections. The Easy Information Group was introduced through a presentation, followed by a role play, then the song, Nice N Easy. Deborah says, A year ago, wed never have been brave enough to make it real. I really feel for the first time in a long time service users are being involved and were making real changes together. However, she cautions that being person centred means not making assumptions about the level of involvement service users want to have. For example, when working on Health Action Plans, some clients just want to know that they can choose the colour of their folder before they talk about what might be in them. Differentiation is also important to Louise Scrivener, the first speech and language therapist in a womens forensic service in Birmingham. She wanted to find a way of doing an assessment report that would allow her client to take responsibility for her communication. The method she used also provided a model for other professionals

and raised the profile of speech and language therapy at the same time. Over a few sessions, Louise assessed her client then they analysed the results together. Louise wrote up the assessment in parts and went over it with the client, changing any words or sections she didnt understand. They then agreed who would be invited to a presentation to discuss the results. While the entire report was on overheads, the client also had a summary as a prompt. The process got good feedback from the other professionals who attended and the client has asked to work with Louise again.

Facilitative approach
Over at the University of Central England in Birmingham, Susanne Simms also believes that time spent explaining things to clients pays off as both the clients and other professionals can then access the information more easily. We cannot assume that coming from a medical or educational background means people interpret terms (even everyday words) in the same way. Explaining what the impact of a child or adults impairment will have in different contexts enables others to make sense of what you write more easily. Susanne sees a tension between the expert model where the speech and language therapist knows it all and the partnership model where the therapist and the client work together. The expert model moves the profession towards a focus on impairment, while the latter frees us up to think holistically. Susanne has been complimented by tribunals for her clarity in report writing. She believes this is because she explains what problems mean for the child, the family, the school, the therapist and other people, and uses language which enables people to access her meaning even if she isnt actually there. Alison Webb is another speech and language therapist whose general report writing has been influenced by her work with tribunals and Special Educational Needs & Disability Tribunal training. In a legal situation the stakes are high - and when a well-written report obviates the need for court proceedings, everyone benefits. Alison, an independent therapist in Peterborough, now avoids what the parent-led organisation Afasic calls weasel words - benefit from, opportunity to, access to, regular, input, contact, facilitated by - and is far more precise about everything including therapy setting, frequency, type, timescales, targets and reviews. She includes information about her qualifications and experience as well as evidence to back up her recommendations. (Mencap guidelines (2002) suggest putting your photograph at the end of a letter so the reader knows who you are.)

When composing reports or other information, advice from the Plain English Campaign can be useful - but putting it all into practice is easier said than done! This independent pressure group wants to see all public information written in a language that the intended audience can understand and act on from a single reading. The group defines public information as anything people have to read to get by in their daily lives. As well as listing alternative words (why use commence when start will do the same job more effectively?), the campaigners suggest you make writing clearer by using: short sentences mostly active verbs verbs rather than the nouns formed from them you and me words that are appropriate for the reader instructions (with a please) positive language. The Plain English Campaign says that if you spend more than an hour a day writing you are, to an extent, a professional writer. But what can we learn from the real professionals? Taking account of the readers perspective is meat and drink to copywriter Chris Gregory, and he has used this skill to help his wife - speech and language therapist Neera Malhotra construct leaflets and articles. Looking over his companys website, there are many suggestions for people in business which we could adopt, including: Research and preparation time is vital. Be personal - always consider that you are addressing an individual. If you can, visualise in your minds eye the person - or typical person you are writing to. It is usually fairly easy to list the features of a service - but, if you want to engage people, you need to make the benefits of these features clear. Decide on the key messages you want to convey. Allow time to get something down on paper, return to it after a couple of days, amend it, read it aloud and get it checked by other people. Chris says, In every communication, try hard to put a limit on the number of points you want to get across. Ideally, there should be one key point, with the others of a subsidiary and related nature. The more points you try to include, the less likely any one of them will be adequately communicated.

Louise...wanted to find a way of doing an assessment report that would allow her client to take responsibility for her communication.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

15

FEATURE ON...WRITTEN COMMUNICATION

Whatever it takes
Customer focus in business is driven by a wish to increase sales but the concept is not too far removed from a person centred speech and language therapist wishing to improve accessibility. As Evans (2002) says in discussing the background to Mencaps guidance, do whatever it takes to make your writing accessible to your audience. For Bethan Jones, who is developing advice leaflets for parents in Sandwell where literacy levels are low, this means focusing on soundbites, captions and cartoons and a video. For Vanessa Crowe it meant embarking on a training programme and producing a resource called Stickerpack (Crowe, 2003). She realised there were accessibility problems when swallowing guidelines in her Edinburgh elderly care stroke unit werent being adhered to. From discussion with staff, it seemed there were three elements - non-compliance, a need for training and limitations of the communication method used (a sheet of paper above a bed). Research told Vanessa that information is retained and remembered more easily if it is given in more than one way, for example written text and pictures. Taking road signs as a model, she gradually built up a collection of symbol stickers to go on a display board. Backed up by the speech and language therapy team and an ongoing training programme, there was an improvement in compliance, and it was noticeable that auxiliary workers who didnt have English as a first language learned the symbol meanings quickly. As Carole Pound and Susie Parr might say, the information stuck. They run a study day for Connect, the communication disability network, called A toolkit for making information stick. I was interested to hear how policy is being put into practice, particularly in the field of aphasia, and how greater user involvement and increased accessibility are part of a bigger picture of people taking - and being allowed - more responsibility for their own health and well-being. The course usefully includes rating scales for assessing information in your own setting, divided into three areas of clarity, process and tone. Reflecting the experiences of others in this article, the key messages are: Information is the foundation of involvement Information can be enabling or disabling Theres more to accessible information than large print or pictures Information is a dynamic, multi-faceted process The shape that information takes depends on the person, the time and the context.

Petrea Woolards team in London have given a lot of thought to shaping information, asking questions like, Who are the reports for? How are appointments being made? Is it essential that I write in this way? If so, how do I provide the person its about with something that is useful to them? Talking Mats (Murphy, 1998) is excellent for gathering opinions and goal setting with clients. Sometimes PowerPoint presentations are used for reports, and people with more complex difficulties who are leaving school get a CD ROM with video clips made, so the receiving service providers can meet the person before they actually meet them. Technology, such as the internet, is also used by Petreas team to look out and improve practice. Jan Roach, a speech and language therapist at St Andrews Hospital in Northampton, comments that life has changed enormously in the past two years with wider access to e-mail and the internet. She is very positive about the resulting opportunities to update more people more easily, reduce paper, and get immediate access to information discussed by clients. What advances in accessibility will technology produce in 10 years time? Ken Fee is a top interactive designer of software for games consoles. He is keen to research how the intuitive nature of games could be harnessed to benefit people with communication disabilities, but is concerned that funding bodies dont fully appreciate that a generation raised on electronic games will benefit hugely from research that needs to start now if it is to be applied in 10 years time.

Intuitive flow
Ken expects wireless technology and hand-held devices to take off, with less reliance on keyboards and modems. The intuitive flow offered by selection menus, with up/down buttons, means there will be less and less need to rely on user manuals. He believes we should exploit the opportunities of new media to promote interaction, and reminds us that, Anything that someone wants to show to someone else should be entertaining and involving for the person presenting it as well as the person receiving it. Writing is one way people demonstrate how clever they are. If I was back in clinic tomorrow, I would remind myself that cleverness in public information lies in increasing access to written communication and in asking whether it is the write stuff in the first place. In 10 years time, Petrea Woolard hopes that specialist services for people with learning disabilities will all have well supported forums where people can express their views, and that people accessing generic services will have an easier time of it - whether they have English as a second language, aphasia or any other communication difficulty. She says the ultimate test of our accessibility efforts will be whether or not someone providing a service realises, That isnt helpful - Ill need to change the way Im saying it.

References
Crowe, V.J. (2003) Stickerpack: Safe Eating and Swallowing. University of Stirling Dementia Services Development Centre. DH (2001) Valuing people: a new strategy for learning disability for the 21st century. Department of Health: London. DH (2003) Toolkit for producing patient information, Version 2.0. The Department of Health: London. Evans, S. (2002) Accessibility unit at Mencap. Bulletin of the Royal College of Speech & Language Therapists June 602: 20. Mencap (2002) Am I making myself clear? . http://www.mencap.org.uk/download/making_myself_clear.pdf Murphy, J. (1998) Talking Mats: speech and language research in practice. Speech & Language Therapy in Practice. Autumn: 11-14. Nicoll, A. (1996) Initial assessment reports have to fulfil many functions. Human Communication. Summer Supplement: 6-7. Parr, S., Pound, C., Byng, S., Moss, B. & Long, B. (2004) The Stroke and Aphasia Handbook. Connect Press, e-mail carolecross@ukconnect.org.

Practical points: written communication


1. Take responsibility for getting your message across 2. Consult service users as early as possible 3. Know your key messages 4.Allow time for planning and checking 5. Be clear, precise, straightforward, honest and respectful 6. Speak to individuals 7. Develop a friendly and welcoming culture 8. Use different media flexibly 9. Problem-solve and think holistically 10.Have vision

Resources
Afasic - see www.afasic.org.uk Chris Gregory - www.mortongregory.com Connect training courses - www.ukconnect.org or e-mail carolecross@ukconnect.org Ken Fee - e-mail albanart@aol.com Plain English Campaign - www.plainenglish.co.uk

Reader offer

WIN THE TEST OF MORPHEME USAGE


With morphemes playing an essential role in the development of expressive language, speech and language therapist Neil Stevens spotted a gap in the assessment market. Speechmark Publishing Ltd is now giving FIVE lucky readers the chance to win a copy of his new test in a FREE prize draw. The Test of Morpheme Usage is designed to follow developmental norms and to be quick and easy to administer to clients of all ages. It includes 21 colour photograph cards and photocopiable scoring sheets. To enter, send your name and address to Speech & Language Therapy in Practice - Test of Morpheme Usage offer, Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ by 25th April 2005. The winners will be notified by 1st May. The Test of Morpheme Usage is available for 36.00 + VAT along with a free catalogue from Speechmark, tel. 01869 244644.

16

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

FURTHER READING

further reading
Research
Meadows, K.A. (2003) So you want to do research? 5: Questionnaire design [review]. Br J Commun Nurs 8 (12): 652-70. This article describes the key aspects in the design, construction and adaptation of survey questionnaires. There are different types of questionnaire, each of which has its advantages and disadvantages. Aspects of constructing the questionnaire are discussed in detail; choosing the mode of administration; the objectives of the survey; availability of resources; characteristics of the target population; and quality of data. Issues concerning the identification of the questionnaires content, wording and sequencing of the questions through to the overall appearance and layout of the questionnaire are also considered. Differences in the role of open-ended and closed questions, together with their strengths and weaknesses, are outlined, and the need to undertake pre-testing and piloting as an integral part of questionnaire development is highlighted. Finally, issues around the adaptation of existing questionnaires are discussed with particular emphasis on their use in different language and cultural groups, and the need to achieve conceptual, content, semantic, operational and functional equivalence is described. An overview of the translation process is provided. (33 References). everyday situations. The interviews were analysed with regard to coherence of speech, coping with emotional problems, reflectivity, child representation of both parents, and verbal and nonverbal expression of feelings. Boys from separated parents had incoherent speech, difficulties in coping with emotional problems, a poorer reflectivity (thinking about their own mental states and those of others), they represented neither parent supportively and did not show their feelings openly. These results can be traced back to an insecure attachment representation of the boys with separated parents.

Aphasia
Linebarger, M.C., McCall, D. & Berndt, R.S. (2004) The role of processing support in the remediation of aphasic language production disorders. Cognit Neuropsychol 21 (2/3/4): 267-82. Performance factors such as resource or memory limitations, as opposed to loss of linguistic knowledge per se, are increasingly implicated in aphasic language impairments. Here we investigate the consequences of this hypothesis for the remediation of aphasic language production. Two nonfluent aphasic subjects used a computerised communication system (CS) to practice narrative production. The CS serves primarily as a processing prosthesis, allowing the user to record spoken sentence elements, replay these elements, and build them up into larger structures by manipulating icons on the screen. Use of the CS in conjunction with explicit training of syntactic structure has been reported to bring about gains in unaided language production. Here we examine the treatment impact of CS-based processing support alone. Eleven weeks of independent home use of the CS resulted in some marked changes in one subjects production of unaided spoken narratives. The most striking and consistent changes involved more structured and informative speech. The second subject, who presented with far more severe lexical impairments, did not show comparable gains in the structural properties of his unaided speech, but was able to produce

This regular feature aims to provide information about articles in other journals which may be of interest to readers. The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire YO7 4PP, tel. 01765 640283, fax 01765 640556. Annual rates are CDs (for Windows 95): Institution 90 Individual 70 Printed version: Institution 72 Individual 50. Cheques are payable to Biomedical Research Indexing.
markedly more structured narratives when aided by the CS. These results support the performance hypothesis because the CS provided no structure-modelling or feedback. In addition, the first subjects treatment gains indicate that practising narrative production with processing support may be effective in bringing about increased structural complexity and informativeness in aphasic speech. This is congruent with other claims in the literature that increasing the complexity or difficulty of the training material may in some cases increase the efficacy of the treatment.

Adolescents
Bohm, B. (2004) Differences in the speech of 10- to 13-year-old boys from divorced and nondivorced families against the background of emotional attachment. Folia Phoniatr Logopaed 56 (1): 41-50. An increasing number of children in Germany live with one parent alone and have to cope with the separation or divorce of their parents. Emotional drawbacks have frequently been hypothesized for these children. This study investigated whether such experiences are reflected in speech behaviour. Interviews were conducted with 28 10- to 13-year-old boys from separated parents (physical separation of the parents was 2 years before the investigation) and were compared with interviews with 26 boys whose parents were living together, focusing on attachment-related themes and

Hearing impairment
Roberts, J.E., Rosenfeld, R.M. & Zeisel, S.A. (2004) Otitis media and speech and language: a meta-analysis of prospective studies. Pediatrics 113 (3 Pt 1): e238-48. OBJECTIVE: Considerable controversy surrounds whether a history of otitis media with effusion (OME) in early childhood causes later speech and language problems. We conducted a meta-analysis of prospective studies to determine: 1) whether a history of OME in early childhood is related to

receptive language, expressive language, vocabulary, syntax, or speech development in children 1 to 5 years old and 2) whether hearing loss caused by otitis media in early childhood is related to childrens receptive language or expressive language through 2 years of age. METHODS: We searched online databases and bibliographies of OME studies and reviews for prospective or randomised clinical trials published between January 1966 and October 2002 that examined the relationship of OME or OME-associated hearing loss in early childhood to childrens later speech and language development. The original search identified 38 studies, of which 14 had data suitable for calculating a pooled correlation coefficient (correlational studies) or standard difference between parallel groups (group studies). Random-effects meta-analysis was used to pool data when at least 3 studies had usable data for a particular outcome. RESULTS: We performed 11 meta-analyses. There were no significant findings for the analyses of OME during early childhood versus receptive or expressive language during the preschool years in the correlation studies. Similarly, there were no significant findings for OME versus vocabulary, syntax, or speech during the preschool years. Conversely, there was a significant negative association between OME and preschoolers receptive and expressive language (lower language) (0.24 and 0.25 standard difference, respectively) in the group studies. Additionally, hearing was also related to receptive and expressive language in infancy (3%-9% of variance). CONCLUSIONS: Our results indicate no to very small negative associations of OME and associated hearing loss to childrens later speech and language development. These findings may overestimate the impact of OME on outcomes, because most studies did not adjust for known confounding variables (such as socioeconomic status) and excluded data not suitable for statistical pooling, especially from methodologically sound studies. Although some OME language differences were detectable by metaanalysis due to increased statistical power, the clinical relevance for otherwise healthy children is uncertain.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

17

EVIDENCE BASED PRACTICE

Tightening up

on relaxation
Do you use relaxation methods in your work? How do you decide if a client would benefit and what particular approaches would suit? While most evaluation studies of relaxation in speech and language therapy report significant improvements, Marcus Stck, Thomas Rigotti and Ulrike Ldtke are concerned by their lack of scientific rigour.
hile the use of relaxation techniques in speech and language therapy is widespread, this utilisation, as well as belief in their effectiveness, often seems to be based on everyday theoretical presumptions rather than on empirical evidence - a situation that has a detrimental effect on the scientific reputation of relaxation methods. In this literature review of relaxation methods for speech, language and communication disorders over the last 30 years, we try to answer the questions: 1) Which speech and language therapy-related disorder patterns have been examined most frequently for their response to relaxation? 2) What relaxation methods have been investigated? Which methods have been combined? 3) What methodologies have the studies been based on? 4) How effective is the application of relaxation methods in speech and language therapy? We took great effort in acquiring, as completely as possible, all papers relating to this subject in the form of monographs, papers in anthologies, review articles and dissertations. Research was by title and / or keywords in the medline, psyndex and psyclit databases from 1972 to 2002. The initial 111 papers were reduced to 80 in the course of the selection process. By applying liberal criteria, we gave priority to thematic relevance over methodological quality. We excluded only those papers that did not study relaxation methods as applied speech and language therapy techniques, such as purely theoretical papers, metastudies on partial aspects, and papers on educational and training concepts. We coded the studies by country of origin, date of publication, speech and language therapy pattern examined, relaxation method applied and research method used. 1) Which speech and language therapy-related disorder patterns have been examined most frequently for their response to relaxation? Here we had the problem of bringing a highly divergent multinational terminology into line. To reflect the current situation in German-speaking countries, coding was effected according to the disorder pattern classification described in the manual of speech therapy pedagogy and speech therapy (Grohnfeldt, 2001), while only dyslexia and psychogenic cough habit used in the AngloAmerican world have been included in terms of terminology and / or context.

Figure 1 shows the percentage analysis. It is striking that investigations in stuttering carried out between 1972 and 2002 account for 56.5 per cent of all studies considered, followed by dysphonia and language development retardation at 10.6 per cent each, then dyslexia at 8 per cent. The first two are not surprising, since stuttering and voice defects can be regarded as classical psychoreactive disorders, attributed to mental-emotional processes, which causally justify the application of relaxation methods. Centralised speech disorders such as aphasia and apraxia, as well as organic disorders such as laryngectomy, are marginal fields amongst relaxation research activities, but the central disorder groups of language development retardation and dyslexia have to be analysed in more detail. Firstly, we assume there is an interdisciplinary methodological hypothesis that children respond very well to relaxation methods. Secondly, it is noticeable that a changed understanding of the consequences of speech, language and communication disorders in children has contributed to an upswing in research since 1987.
Figure 1 Frequency of studies by speech defect patterns (LDR = Language Development Retardation)

IF YOU ARE INTERESTED IN CARRYING OUT A LITERATURE REVIEW COMBINING TREATMENT METHODS A EUROPEAN PERSPECTIVE ON SPEECH AND LANGUAGE THERAPY
Marcus Stck

Dyslexia 8% Dysphonia 11% Laryngectomy 2% Mutism 1% Psychogenic Cough Habit 1%

Apraxia 2%

Aphasia 6%

Stutter 57%

LDR 11%

Speech Anxiety 1%

Thomas Rigotti

Ulrike Ldtke

2) What relaxation methods have been investigated? Which methods have been combined? We classified the relaxation methods according to Vaitl & Petermann (2000): Relaxation (unspecific) - no specific technique is named and there is no detailed description Relaxation (specific) - we created this as a generic term to cover specifically named techniques, for example cinesiology, which occurred only once but were described in detail Autosuggestion (Schultz, 1973) Progressive muscle relaxation (Jacobson, 1929)

18

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

EVIDENCE BASED PRACTICE

Muscle relaxation oriented towards behaviour therapy as a comprehensive term for techniques based on systematic desensibilisation (Wolpe, 1958) and consequent modifications, for example self-control methods (Wolpe & Lazarus, 1966) Yoga relaxation as a generic term for different Yoga techniques, inducing the psychophysiological relaxation reaction in different ways, such as through body postures (asana) or breathing exercises (pranayama) Massage as a generic term for different massage techniques Biofeedback as a generic term for EEG feedback, EMG feedback, vasomotoric feedback and cardiovascular feedback Imagination as a generic term for classical behaviourtherapy imagination techniques, such as rationalemotive therapy (Ellis & Grieger, 1977), imagination control technique such as Guided Imaginal Coping (Watkins et al, 1988) and emotional imagination including Emotive Imagination (Lang, 1977) as well as independent approaches, such as Guided Affective Imagery (formerly Catathyme picture experiencing - Leuner, 1970) or the Simonton Method (Simonton et al, 1980) Meditation as a generic term for several techniques of specific meditative systems such as Zen-buddhist meditation, Yoga meditation or Transcendental meditation. The main difficulty was the intermingling of different levels: autosuggestion and progressive muscle relaxation are specifically defined, widespread, classical relaxation methods; while behaviour-therapy oriented muscle relaxation, Yoga relaxation, massage, biofeedback, imagination and meditation are generic terms for entire philosophies or systems of relaxation techniques.
Figure 2 Relaxation methods that have been investigated in speech and language therapy

In a very large group of studies (14.1 per cent, n =12), several relaxation methods have been considered in a combination. In 6 out of these 12 studies, biofeedback was combined with other methods, all without detailed specification and once with the addition of meditation. Biofeedback was examined only 6 times in the 80 studies grouped together but there is not a single study which looked at its application in a completely isolated manner. Imagination was considered a total of five times in the 12 combining studies. Progressive muscle relaxation was examined in combination with other methods only twice: once with behaviouroriented muscle relaxation, once with imagination. In total, progressive muscle relaxation was looked at five times within the 80 studies and three times as an isolated method. 3) What methodologies have the studies been based on? For this question, we coded the studies on the basis of the research methods explicitly mentioned in the keywords or in the abstract, which were specified according to international databases as: Empirical Study Empirical Study & Follow-up Study Clinical Case Report Experience Report Review combinations of several methods. This showed that the application of relaxation methods in the context of speech and language therapy had, in most cases, been investigated by empirical studies or experience reports: empirical studies alone 23 times (27 per cent), 9 times in combination with follow-up inquiries (10.6 per

cent), and experience reports alone 26 times (30.6 per cent). Clinical case reports have been used alone 16 times (18.8 per cent) and once (1.2 per cent) in combination with a follow-up study. Reviews alone have been used in 7 cases (8.2 per cent), 2 times (2.4 per cent) in combination with clinical case reports, and once (1.2 per cent) in combination with an experience report. Table 1 allows us to estimate whether certain disorder patterns are associated with particular methodological approaches (quantitative-empirical versus non-statistical), as it shows the percentage ratios between these two approach categories. The effectiveness of relaxation methods to treat stuttering has been particularly well examined, with a wide range of methods employed. However, while experience reports have been used 18 times (42.8 per cent), clinical case reports have only been given once (2.4 per cent). Apraxia - also in combination with aphasia - has not yet been covered by an empirical study, nor have mutism, laryngectomy, psychogenic cough habit and speech anxiety. Non-statistical approaches clearly prevail on all the disorder patterns. Only stuttering and language development retardation do not show too large an imbalance versus empirical approaches. 4. How effective is the application of relaxation methods in speech and language therapy? To gain a first insight here, we examined the empirical studies carried out for the individual disorder patterns as an isolated group, and filtered out statements on their effectiveness given in the abstracts. We did not take apraxia, laryngectomy, mutism, psychogenic cough habit and speech anxiety

Table 1 Ratios between the approach categories per disorder pattern

Several methods combined Biofeedback 14% 0% Massage 1% Yoga relaxation 1% Meditation 4% Progressive muscle relaxation 4% Relaxation (specific) 4% Behavioural or muscle relaxation 8%

Disorder pattern Aphasia Apraxia Aphasia and Apraxia Dyslexia

Investigation method applied Empirical Study Clinical Case Report Review Review Empirical Study Clinical Case Report Experience Report Empirical Study Clinical Case Report Experience Report Combined: Clinical Case Report & Follow-up Review Clinical Case Report Clinical Case Report Combined: Clinical Case Report & Review Empirical Study Clinical Case Report Experience Report Experience Report Empirical Study Combined: Empirical Study & Follow-up Study Clinical Case Report Experience Report Combined: Experience Report & Review Review Combined: Review & Clinical Case Report Review

Relaxation (unspecific) 27%

Number of studies 2 3 1 1 2 4 1 3 2 2 1 1 1 1 1 4 1 4 1 9 9 1 18 1 4 1 1

Ratio in per cent 40.0 60.0 28.6 / 71.4

Dysphonia

33.3 / 66.7

Laryngectomy

Autosuggestion 13%

Imagination 24%

Mutism Psychogenic Habit Cough Language development retardation Speech anxiety Stuttering

What is generally worrying in figure 2 is the high theory deficit, inaccuracy and lack of detail in research methods; at 27 per cent, relaxation (unspecific) represents the largest group of studies. The second largest group imagination is also a collective group, since the abstracts almost exclusively indicate the generic term instead of well-specified imaginative techniques. The third largest group, several methods, is also very heterogeneous, with a trend towards combining imagination with any other possible method, without taking into account theoretical compatibility. Amongst the specific methods, autosuggestion constitutes the only exemplary exception (12.9 per cent).

44.4 / 55.6 -

42.9 / 57.1

Stuttering & Speech anxiety Stuttering & Dyslexia

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

19

EVIDENCE BASED PRACTICE

Starting Point for health visitors


I CAN, the charity that helps children communicate, has developed a Starting Point on speech, language and communication needs for health visitors. The online information service is a dedicated section of the Talking Point website, and follows consultation with health visitors about the information they need to identify and support children with speech, language and communication difficulties and their parents. Health visitors are already the largest single referrers of children to community speech and language therapy services, and their early intervention can prove crucial to the outcome. They said they would most value information on key stages of childrens speech and language development and the influencing factors, different types of language difficulty, practical advice and strategies for language development to share with families and information and advice sheets to give out. In addition the site, funded by the Department of Health, gives them the opportunity to ask questions of experts, to browse abstracts of successful multidisciplinary working and to access training and conference information. www.talkingpoint.org.uk/startingpoint

news extra

into account given the lack of empirical studies. As table 2 shows, the result is a very heterogeneous picture, which cannot be described by numbers, but only by citation:
Table 2 Details on the effectiveness of relaxation methods in empirical studies

Disorder pattern Aphasia Dyslexia Dysphonia

Number Number of of empirical test studies persons 2 23 6 2 3 ? 60 8 1 16 8 10 2 ? 1 1 5 40 ? 9 24 57 1 4 61 8 8 10 6 10 25 89

Details on effectiveness significant not significant significant significant findings in 7 condition unchanged high significance it may enhance might benefit can be enhanced ? highly significant significant significant 77% improvement successful significant significant 74% improvement considerable improvements changes ? 5 considerably improved significant 90% improvement symptom reduction improvement effective multilateral effect

Language development retardation Stuttering

18

Their effectiveness in the treatment of different communication disorder patterns has not been proven on a scientific level; rather, their application in the context of speech and language therapy is based on everyday hypotheses. This gap urgently needs to be filled by adequate research designs: Relaxation methods should be examined specifically f o r their effect on non-psychoreactive disorder patterns (organic, central and development-related phenomena) Research has to focus on highly accurate, specific methods without watering-down and inexact mixing Generally, empirical studies have to be supported by statistical methods Such statistical methods should be applied to all disorder patterns, not only stuttering and language development retardation Meta-analyses should be performed to come to general conclusions concerning the effectiveness of relaxation methods in the treatment of speech, language and communication disorders. Taking into account all methodological limitations, our results point towards the usefulness of integrating relaxation methods. We would therefore like to encourage not only scientists but also practitioners to evaluate the application of relaxation methods in speech and language therapy. We hope our review will lead to more strictly designed research that will determine the best way of using relaxation methods to benefit people with language, speech and communication needs. Marcus Stck, PhD (e-mail stueck@rz.uni-leipzig.de) and Thomas Rigotti, MSc (e-mail rigotti@uni-leipzig.de) are Psychologists based at the Institute of Applied Psychology, University of Leipzig, Seeburgstr. 14-20, D04103 Leipzig. Ulrike Ldtke, PhD (e-mail uluedtke@uni-bremen.de) is a speech and language therapist based at Erziehungs- und Bildungswissenschaft, Department of Education Sciences, University of Bremen, Bibliothekstr. 1 - 28359 Bremen. References used for the literature review are available on the speechmag website www.speechmag.com.

Duty a big deal for disabled people


Public sector bodies, including health and education, will have a duty to promote disability equality in all aspects of their work from next year. Changes to the Disability Discrimination Act being introduced by the government will work in a similar way to the Race Relations Amendment Act. The Disability Rights Commission is consulting on a draft Code of Practice it has drawn up to support the amended legislation. Chairman of the Disability Rights Commission, Bert Massie, said, The Code of Practice will help people understand major changes to duties on the public sector. It is hard to overstate just how big a deal the new duty will be for disabled people. The three month consultation period ends on 21st April 2005 and the final Code will be available in December 2005. Versions of The Duty to Promote Disability Equality: Statutory Code of Practice are available from www.drc-gb.org or Helpline 08457 622 633. (Please specify England & Wales or Scotland.)

Although about two thirds of the studies designate effectiveness by terms such as significant or improved, the extreme heterogeneity and the lack of figures suggest that we cannot generalise statements about effectiveness. We need detailed methodological verification (research design, baseline, drop-out rate, parallelisation of groups) before a study can be designated empirical. This theory deficit is also reflected in the research methodology of the individual studies. It is alarming that experience reports, accounting for 31 per cent, constitute the largest methodological group (see table 1). Moreover, when the non-statistical experience reports, clinical case reports and abstract papers are grouped together and contrasted with the 27 per cent group of empirical studies - without taking into account the 15 per cent group of combined methods - they account for 58 per cent of the total. This general methodological imbalance shows that we need more emphasis on the application of statistical methods - and the positive trend from the studies on stuttering and language development retardation demonstrates this is possible. There is a huge research deficit in the application of relaxation methods in speech and language therapy.

References
Ellis, A. & Grieger, R. (Eds.) (1977) Handbook of RationalEmotive Therapy. New York: Springer Publishing Company. Grohnfeldt, M. (Ed.) (2001) Lehrbuch der Sprachheilpdagogik und Logopdie, Bd.2: Erscheinungsformen und Strungsbilder. Stuttgart: Kohlhammer. Jacobson, E. (1929) Progressive Relaxation. Chicago: University of Chicago Press. Lang, P.J. (1977) Imagery in therapy: An information processing analysis of fear. Behavior Therapy 8 (5): 862-886. Leuner, H. (1970) Katathymes Bilderleben. Stuttgart: Thieme. Schultz, I.H. (1973) Das Autogene Training. Stuttgart: Georg Thieme Verlag. Simonton, O.C., Mathews-Simonton, S. & Sparks, T.F. (1980) Psychological intervention in the treatment of cancer. Psychosomatics 21: 226-233. Vaitl, D. & Petermann, F. (Eds.) (2000) Handbuch der Entspannungsverfahren. Bd.1: Grundlagen und Methoden. Weinheim: Beltz. Watkins, P.L., Sturgis, E.T. & Clum, G.A. (1988) Guided imaginal coping: An integrative treatment for panic disorder. Journal of Behaviour Therapy and Experimental Psychiatry 19 (2): 147-155. Wolpe, J. (1958) Psychotherapy by reciprocal inhibition. Oxford, England: Stanford University Press. Wolpe, J. & Lazarus, A.A. (1966) Behavior therapy technique. New York: Pergamon Press.

DO I APPRECIATE THE RELATIVE MERITS OF DIFFERENT LEVELS OF EVIDENCE? DO I GET THE MOST OUT OF LITERATURE SEARCHES BY LOOKING FOR THEME FIRST, METHODOLOGY SECOND? DO I ALLOW THE LACK OF INTERNATIONAL AGREEMENT ON DESCRIPTIVE TERMINOLOGY TO LIMIT MY ACCESS TO RESEARCH STUDIES?

20

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

HERES ONE I MADE EARLIER...

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

Heres one I made earlier...


TIMELINE PAINT SPLOTCH PREDICTIONS
MATERIALS
Heavy weight A4 paper Watercolour paints in tubes, avoiding browns and black Pens This is a self-awareness activity, for just one client or for a group. This activity helps students to learn about time, peoples ages and history. Bear in mind that you will need to place this piece of work on a long wall, with the length depending upon whether you think your timeline will turn out to be small, neat and tidy, or big and sprawling, maybe with illustrations; also depending on how long a period of time you want to represent. (Also remember that when your group of students finds out how very old you are, you will be the subject of much mirth. My advice is to make sure some other, even older, members of staff are mentioned on it or some old celebrities who are rated as cool, such as football coaches, or TV characters.)

IN A SPIN
MATERIALS

This is an alternative activity to Facial Expressions Dice (see Spring 2004, p.23), for having fun at the same time as learning about the relationship between emotions and facial expressions.

An empty plastic drinks bottle to act as a pointer White blank cards (Taskmaster blanks are excellent) Coloured card, cut to business-card size (using coloured card makes the game look more interesting, and differentiates between the pack of loose cards and the ones stuck on the table) Blu-Tac Pen Good solid flat table

IN PRACTICE (I)
Each client makes a wish to do with their current communication target, such as I want to get better at using the phone, I want to make a friend or I want to improve at smiling at people. Try to encourage realistic targets that could be achieved within the course of therapy. These targets are written a little way above the bottom of the paper, which can be landscape or portrait way round - it doesnt matter. The paper is now folded down the middle and opened up again. Small blobs of different colours of paint are squeezed fairly closely together in the upper part of the centre fold. Now the paper is re-folded and pressed flat. Unfold your paper and here is an instant work of art that you can interpret together. Perhaps you can see a telephone or a bit of cable there, or a pair of shaking hands, or a smile. You may have to be very imaginative, but you should be able to see something, which can be a prediction that the target can be achieved. If possible, make a frame for each picture by cutting a large rectangular hole into another sheet of paper, but take care that the written wish is still visible. These make colourful wall displays en masse and are taken down and evaluated together at the end of the course - were the predictors right? Maybe things are going the way the predictor said, but you interpreted the time for improvement wrongly. You should of course engineer things in such a way that something positive can be celebrated.

MATERIALS
A long roll of paper - we used craft paper sold this way, but you could use decorators lining paper Felt tip pens

IN PRACTICE
Decide how long you want your timeline to represent. We began just before the 2nd World War, but you may have some fossil fanatics in your group who would want prehistoric times included. Draw a line centrally, the length of the paper, and divide this line into one-, ten-, and hundredyear sections (if you include prehistory youll have to have thousand and million year sections, perhaps in a different colour which would allow you to represent them in an abbreviated form). Mark on it some important events, some connected with politics, some with sport, some with royalty, some with the emergence or breakup of pop bands, and whatever else is a popular topic in your group. You might include the founding date of your school or college. Together, write on your chart the dates of birth of people in your organisation, and of your group members and maybe, if appropriate, of their parents. Count up the sections from their birth date to the present day to show how being born earlier means you will be older. You can now talk about concepts of time and look at magazine, newspaper or other photos to demonstrate how people age. If your group includes artists, you could illustrate your timeline, or you could add photos. Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

BRAWN
Write emotion words on the Taskmaster (or plain white) cards. These will vary according to the ability of your clients, but could include happy, sad, excited, disgusted, surprised, tired, depressed, proud, bored, in pain, annoyed, giggly, shocked, interested, disapproving. The coloured cards should say: 1. What makes me feel...? 2. What does my face do when I feel...? 3. What might I say when I feel...? 4. What does my body do when I feel...? 5. How do I sound when I feel...? 6. What helps me when I feel...? 7. What might other people do differently from me when they feel...? 8. Are there times when I should not look...?

IN PRACTICE
Apply the coloured cards in a circle around the table, using the Blu-Tac. Place the empty bottle in the centre, and take turns to pick up a loose card from the stack, and spin the bottle so that the top points at a question. You will arrive at a question such as What does my face do when I feel... GIGGLY? The client whose turn it is should have a try at making the correct face, and if the group is amenable, others can then join in. You may have some clients in the group who need to check in a mirror.

IN PRACTICE (II)
You can also make the splotches first, and then use them to help you decide which area the client should work on next. We have used them for a fun activity in January, to predict something general that might happen during the year.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

21

KEYS TO WINNING WAYS SERIES (2)

The appreciation
Recently I received an e-mail from a former client, just wishing me Happy New Year and up-dating me on some changes she had made in her life. Her final comment, though, fairly rocked me back. One of our main areas of work had been on her relationship with her mother, and she said, I am eternally grateful for the work we did on this relationship. Things have never been better; we see each other now as two grown-up friends, and actually seek opportunities to be together. Without going into any details, this would have been an impossibility four years ago. This client did not have many sessions and has obviously put in the work to get this result. I had virtually forgotten our sessions, but the small gesture of appreciation made a huge impact. It made my day, the rest of which I tackled with renewed vigour and determination. But why was that? I believe that, no matter how grounded or enlightened any of us might be, it is always renewing for a contribution to be recognised and approved of. I dont mean to confuse this with the business of self-esteem being dependent on the opinion of others - far from it. We must rate ourselves according to our own standards and values and stop being limited by the ill-formed judgements of others. However we are all human and, until we reach the dizzy heights of Ghandi, Mother Teresa, or Buddha, a little bit of gratitude goes a very long way. It also has the added advantage of zapping negative thinking. This set me thinking about our second key, Appreciation, or an attitude of gratitude - and I decided to trawl through my life thinking about all the things I appreciate. I do my best thinking while walking, and started with my immediate surroundings, then moved on to my family, friends and business associates, deliberately skipping over the things that did not inspire appreciation. Then I went back to the first moments of my life, just to see who I would say thank you to if I could. I was having fun until I got to my primary one teacher. She was old school, even for those days, and the humiliation of being spanked for rubbing a lovely big glob of red paint into a wooden desk is still burned into my grown-up heart. Is there anything here that I can be grateful for? I wondered. On putting the humiliation aside, I

In the second article of our series to encourage reflection and personal growth, life coach Jo Middlemiss explains how you can practise an attitude of gratitude - and why it is worth putting in the work needed to appreciate the bright side.

APPRECIATION: The key for Mary?


Mary had been in the same post for 10 years and had always enjoyed it. Recently, though, lots of things had been getting on her nerves. She felt taken for granted in the schools she visited, and cross that her manager had appeared to ignore an audit she had undertaken. New, younger members of staff had joined the department and seemed to be from a completely different generation. Mary felt that it was perhaps time to move on or away, taking her skills and knowledge with her. Jo says, Working to develop an attitude of gratitude could really help Mary. By observing every time someone says thank you to her, and making sure she notices and takes opportunities to thank other people, Mary would create a more appreciative culture. In turn this would help Mary to recognise successes, however small, and to feel more positive about herself and other people. She would then be in a better frame of mind to decide what direction she really wants to take - and to make any changes for positive rather than negative reasons.

How many times has something that seemed like a disaster or failure actually turned out for the best, teaching you an invaluable lesson?

remembered that she had given me one of the greatest gifts of my life, the ability to read with enthusiasm and joy. She was also a wonderful artist and used to illustrate stories on the blackboard. I remember that all 45 of us were entranced at story time. Its a small example of a small incident but, without the search for appreciation, I would have missed an opportunity to remember something very important to me. I would say thank you now to Miss Burns, but she is long gone to her eternal reward.

IF YOU WANT TO FACE EACH DAY WITH RENEWED VIGOUR IMPROVE YOUR RELATIONSHIPS RECOGNISE NON-MATERIAL GIFTS
unconsciously. If Appreciation is to be used to best advantage, then it must be consciously practised, perhaps by asking yourself Who am I grateful to? What did s/he do? Why am I grateful? How can I show it? This can apply to happy things but also to less than positive experiences. How many times has something that seemed like a disaster or failure actually turned out for the best, teaching you an invaluable lesson? One of my best friends has a very advanced case of secondary breast cancer but starts her day with a search for things to appreciate. This diverts her from her own problems and she tackles each day with renewed vigour. Susan Jeffers, in her book End the Struggle and Dance With Life, emphasises this by opening her chapter on gratitude with the quotation: In daily life, we must see that it is not happiness that makes us grateful, but gratefulness

Impact on others
This reminds me of a fictional book I read over the holidays, The Five People You Meet in Heaven, by Mitch Albom. It is not a religious book, but it does explore the idea that we never really know the impact we are having on others just by living out our lives either consciously or

22

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

RESOURCES

key
that makes us happy (Brother David Steindl-Rast). And this leads me on to the key that is the topic of our next article, Abundance - for when appreciation is present, we see the world in a different light. Everyone has inside himself... A piece of good news! The good news is that you really dont know how great you can be, How much you can love, What you can accomplish, What your potential is. How can you top good news like this? The above was not written by some sage or guru or me, but by a twelve year old Anne Frank (see Frank et al, 1997), forced to live a life of cramped restriction simply because she was Jewish. If she could appreciate the wonders of our potential, then perhaps we can all try just a little bit harder to look on the bright side. Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk. Jo offers readers a confidential and complimentary halfhour telephone coaching session (for the cost only of your call.)

resources
Lets sign
DEAFSIGN has a range of British Sign Language resources for use with all educational systems based on BSL. The Lets Sign Series has been developed by Deaf and hearing contributors for use in schools, at home and in adult education by people of all ages and abilities.

Free learning disability resource

1) Lets Sign & Write (CD-Rom with manual), by Cath Smith and Widgit Software
800 commonly used signs and variations in plain line drawings or full colour that can be inserted into Word or Publisher or used in Symbol Software for tailor-made materials. 42 single site user, 53 multiple user, single geographical site

Check The Map is a not-for-profit site that gives free promotion to all learning disability services across the UK and Ireland. The developers have likened it to a learning disability Yellow Pages as you can search by town, region or category to find every service. You can also promote any learning disability related service or resource without any charge. www.checkthemap.org

Inclusive childminding
A CD-ROM training resource, Inclusive Childminding working with disabled children, is aimed at supporting registered childminders to feel more confident in their ability to work with disabled children. 30 inc. p&p, e-mail the National Childminding Association for England and Wales on info@ncma.org.uk.

2) Lets Sign Dictionary


Over 1300 BLS signs, suitable for beginners and BSL Level 1 & 2 courses. 13.99

New from Signalong


The whole Signalong Basic Vocabulary Phase 1 manual is now available on a CD-ROM of animated signs modelled by five different virtual signers. Other releases are The Well Man, with signs for mens health issues and self-examination, and Playtime: Book 1 - My Toys, to help introduce signing at an early stage through play. The Signalong Database is 39.50, The Well Man is 12.00 and My Toys 8.00, tel. 0870 7743752. www.signalong.org.uk

3) Lets Sign Early Years collection a. Early Years & Baby Signs
48 of the most useful first signs for babies and young children with A3 reminder posters. 6.99

Book about caring


A book reviewed in the Fragile X Societys newsletter may be of interest to anyone working with carers. The Selfish Pigs Guide to Caring was written by the husband of someone suffering from Huntingtons Disease, but reviewer Kathryn Silk says the honesty of the feelings expressed and the information covered is relevant to anyone who is a carer. The Selfish Pigs Guide to Caring by Hugh Marriott, 9.95, e-mail polperro.press@virgin.net. www.fragilex.org.uk

b. Flashcards
The same 48 signs on laminated cards with captions to describe movement. 9.99 All from Forest Books, plus 2 p&p per order, tel. 01594 833858, e-mail forest@forestbooks.com. www.deafsign.com, contact cath@deafsign.com, tel: 01642 580505.

Hearing dogs awareness


School children can learn about deafness and hearing dogs through an awareness raising pack from the Hearing Dogs for Deaf People charity. The Togs for Dogs Day Schools Information Pack supports key stages 1-2 and 3-4 of the national curriculum and is available on request to all schools and childrens community groups. To register, tel. 01844 348100 or see www.hearing-dogs.co.uk.

All about stroke


The Stroke Association website has been re-designed with new features including Professionals - a section where you can find out about research funding, conferences and regional support services All About Stroke - answers to your questions Publications shops - order specialist publications and resource packs free. www.stroke.org.uk

References
Albom, M. (2004) The Five People You Meet in Heaven. Time Warner Paperbacks. Frank, A., Frank, O., Pressler, M. & Massotty, S. (1997) The Diary of a Young Girl: Definitive Edition. Penguin Books Ltd. Jeffers, S. (2005) End the Struggle and Dance With Life: How to Build Yourself Up When the World Gets You Down. Hodder Mobius.

Early support
Early Support Professional Guidance seeks to ensure that young children, particularly those with complex health needs, receive coordinated, high quality child and family centred services based on assessed need. Written for health, education, social services and voluntary agencies, with input from families, the guidance explains what is involved in achieving the standards set out in the National Service Framework for Children. The Early Support Pilot Programme is a government initiative to improve services for disabled children under three and their families. www.espp.org.uk

Best practice in Downs Syndrome


A website for health professionals, run by the UK Downs Syndrome Medical Interest Group, encourages best practice medical care for people with Downs Syndrome in the UK and Ireland. It includes the UK Downs Syndrome growth charts. www.dsmig.org.uk For more resources see p. 28
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

23

HOW I

HOW I ASSESSING
BRIDGING THE GAPS (1):

BRIDGE

THE STRUCTURE
GIVEN THE LIMITATIONS OF PUBLISHED MATERIAL, HOW DO YOU MAKE A COMPREHENSIVE ASSESSMENT OF THE SOCIAL COMMUNICATION SKILLS OF TEENAGERS WITH MODERATE LEARNING DISABILITIES? MARGARET MARGERISON, ROS HUNTER AND ADRIENNE FENTON FIND AND BRIDGE THE GAPS - WITH THEIR APTLY NAMED GROUP ASSESSMENT PROCEDURE IN SCHOOLS.

THE GAPS

Ros Hunter, Adrienne Fenton and Margaret Margerison

A
THE 125TH ANNIVERSARY OF THE TAY RAIL BRIDGE DISASTER SAW A RE-EXAMINATION OF THE EVIDENCE RELATING TO ITS COLLAPSE, WITH THE BLAME PINNED ON FUNDAMENTAL DESIGN FAULTS FOLLOWED BY INADEQUATE MONITORING AND MAINTENANCE. ALTHOUGH THE BRIDGES BUILT BY SPEECH AND LANGUAGE THERAPISTS ARE ANALOGOUS, THE PRINCIPLES SHOULD BE THE SAME - WHETHER THEY RELATE TO OUR LINKS WITH OTHER PROFESSIONALS OR TO HELPING OUR CLIENTS. HERE, OUR THREE CONTRIBUTIONS FOCUS ON BRIDGING GAPS IN AN EDUCATION SETTING.
BRIDGING THE GAPS (1): ASSESSING THE STRUCTURE MARGARET MARGERISON AND ADRIENNE FENTON, SPEECH AND LANGUAGE THERAPISTS, AND ROS HUNTER, SPEECH AND LANGUAGE THERAPY ASSISTANT, ARE THE ALD TEAM BASED AT DONCASTER GATE HOSPITAL, ROTHERHAM PRIMARY CARE TRUST. CONTACT MARGARET.MARGERISON@ROTHERHAMPCT.NHS.UK. BRIDGING THE GAPS (2): STRENGTHENING THE FOUNDATIONS JOANNA MANZ, SPEECH AND LANGUAGE THERAPIST, IS SPECIAL NEEDS COORDINATOR IN ANGUS FOR NHS TAYSIDE. CONTACT SPEECH & LANGUAGE THERAPY DEPARTMENT, ABBEY HEALTH CENTRE, EAST ABBEY STREET, ARBROATH, ANGUS DD11 1EN, TEL. 01241 430303, E-MAIL JOANNA.MANZ@TPCT.SCOT.NHS.UK. BRIDGING THE GAPS (3): SCALING THE SCAFFOLDING LIZZIE DAVIES IS A SPEECH AND LANGUAGE THERAPIST WITH BRIDGWATER EXCELLENCE CLUSTER WHICH HAS LINKS WITH SOMERSET COAST PCT SPEECH AND LANGUAGE THERAPY SERVICE. CONTACT WESTOVER GREEN SCHOOL, WESTOVER GREEN, BRIDGWATER, SOMERSET TA6 7HB.

s a small speech and language therapy team working in Rotherham with 14-16 year olds in special schools prior to their transition to further placements, we provide a two-year programme of social communication groups, each weekly session fitting in with each schools timetable. Groups contain a maximum of six students, referred by school staff, and are facilitated by one speech and language therapist and one speech and language therapy assistant. Our aim is to provide students with the social skills they need in the big wide world. The arrival of a newly qualified therapist provided us with the opportunity to reassess the work we were doing with these groups and to try to meet the needs of all members of the team for a more structured, easily accessible therapy approach which is assessment-led. We began by examining our problems, and found: 1. We needed to address referral issues Referrals to the group by school staff were sometimes inappropriate. Students with behavioural problems were often included, resulting in disruption - and on occasion destruction - of group interaction. At times, students appeared to have been referred because others in their friendship group had been put forward as prospective participants. Students who had had speech and language therapy in the past and had some residual speech difficulties appeared regularly at the beginning of each academic year. Very small numbers were referred by school staff some years and this led us to speculate as to their understanding of what we were doing and of the nature of social communication deficits. 2. Full and accurate information was necessary at a much earlier stage Information was not available in respect of students communication skills when the groups started. Either students had not previously been seen by the speech and language therapy paediatric department as their speech / language abilities were commensurate with general cognitive levels, or they had been discharged several years previously. This necessitated a quick assessment of their comprehension levels but our knowledge of other skill levels only emerged slowly as the course progressed. Students personal and educational information was not always provided, exposing both students and speech and language therapy staff to potential and unnecessary embarrassment and distress (example in figure 1a).

24

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

HOW I
Figure 1 Case examples
Figure 2 Group Assessment Procedure for Schools/Colleges (G.A.P.S.) (2003) For use with small moderate learning disability / more able severe learning disability groups. The following skills are to be assessed over the first one / two terms of a two year programme. (These categories are not mutually exclusive and activities targeted to assess certain abilities may provide information to enable scoring on others without the need for specific assessment.) A B C D E F G H I NON VERBAL ABILITIES VERBAL ABILITIES ATTENTION AND LISTENING ABILITIES CONVERSATIONAL ELEMENTS AWARENESS OF LISTENER NEEDS CONFIDENCE SELF AWARENESS COMPLEX / HIGHER LEVEL SKILLS LANGUAGE USAGE IN THE WIDER CONTEXT (RED) (YELLOW) (PALE BLUE) (BLUE) (GREEN) (ORANGE) (PURPLE) (CREAM) (PINK)

a) Information
The problem: Anna regularly appeared tearful / upset. Information was again requested from staff and an irrelevant reason was obtained. The solution: Information was eventually obtained that Annas father was in hospital with a serious illness and speech and language therapy staff were then able to deal with the situation in an appropriately sensitive manner. Anna is now much more confident and able to discuss her true feelings within the group. It is unfortunate that this information was not provided on the original referral form.

b) Group selection
The problem: A group was referred by school staff comprising three teenage boys who were in a friendship group Craig had few social communication problems but dominated and manipulated the behaviour of the others and tried to take over control of the therapy session. Kyle was regarded as having selective mutism in school and was receiving psychological and psychiatric support. He did, however, communicate in whispers with the other two. Andrew was less able receptively than the other two, who ganged up against him on a regular basis. The solution: Craig was discharged from the group. The following September Kyle and Andrew were joined by two other appropriately referred students and the group is now going well.

SCORING IN RESPECT OF APPROPRIATE USE OF ABILITY 0 1 2 3 4 Never appropriate Appropriate with prompting Occasionally appropriate without prompting Often appropriate without prompting Always appropriate without prompting

3. Group selection procedures required greater attention Group dynamics could be problematic (see figure 1b). Major difficulties with group cohesion could develop as a result of diverse ability levels amongst group members. School staff would refer students from within class or year ranges without reference to their intellectual abilities or social functioning. From our experience, groups comprised solely of teenage boys tend to be less productive, whereas a mixed gender group provides a better balance and is more likely to engage fully with the aims of the programme. 4. An off-the-shelf approach that covered all social communication areas was needed to provide early confidence and an inbuilt structure There is still a dearth of published materials for this age and ability level, despite the development of interest in social skills in recent years. Many of the activities we use are primarily paediatric in origin, and have required adaptation. The Social Use of Language Programme (Rinaldi, 1992) / Talkabout (Kelly, 1996) / Socially Speaking (Schroeder, 1997) are useful resources to dip into but we felt the need for additional stimulating material for our client group. In the past we have brainstormed activities prior to a group session but many of these spur-of-the-moment ideas were never committed to paper, and were thus forgotten and lost as a future resource. Teenagers can be a difficult client group to engage and motivate. Activities need to be fun as well as sufficiently sensitive to probe strengths and needs. Some participants need an adversarial or chance element within tasks whereas others do not. All preferences have to be met to maintain interest and cooperation. The whole area of work is a difficult one, especially for students and newly qualified therapists. It can be difficult to know where to begin or how to feel confident in the choice of aims, activities and materials. 5. A time efficient, effective system was essential The time factor has always been a major issue in a small department hard-pressed in respect of contact demands. Finding time to plan details of the current weeks session was a problem. The choice was usually between when driving back from the mornings group or while eating a sandwich / writing up notes / both. When time is of the essence, clarity of purpose is essential. The content of session plans made prior to meeting the students needed adapting as the programme progressed in accordance with emerging information as to members abilities. Because of this constant shifting of input, by the end of the two-year programme we felt that there were gaps, and we were not satisfied that our assessment had sufficiently covered all relevant areas.

Furthermore, it was apparent to us that one session a week given to this kind of activity was only enough to partially, not fully, achieve our aims. So, having recognised the problems, what did we do about them? Firstly, we changed the format of our referral form to include information that we needed before commencing our programme, such as reading levels and any family difficulties. We then developed a screening profile in respect of social communication with the intention that school staff would complete one for every student at the end of Year 9 so that we would receive them before the start of our programme. It could then be determined which students were in need of specific intervention in this area. Finally, we developed the GAPS (Group Assessment Procedure in Schools). This comprises a list of areas of social communication skills for assessment plus the activities required for that assessment and subsequent therapy, all based on our own practices with some help from pre-existing published procedures. Figure 2 gives a breakdown of the general skill areas, subdivided into specific skills, each rated in accordance with a scoring scale. Activities and tasks are assigned to each specific skill. We thought long and hard about our scoring scale (see foot of figure 2). Our result, whilst not being a truly objective measure (seemingly unachievable in this kind of work), gives an indication of areas to be targeted for input and of progress made. How, then, is it all working? The first draft of GAPS is being piloted this academic year. We feel, a few months into assessment, that it may be a little over long, although we have found some minor omissions. But, as our initial working template, it will give us valuable experience and will soon be an acceptable finished product. There have been some problems implementing the GAPS because of school timetables and priorities and it has taken longer than anticipated to work through the whole assessment. We intend to consult with school staff prior to commencement of next years programme to try and remedy this and to enlist their help with reinforcement of therapy aims on a continuing basis. We are considering offering input to groups on a twice-weekly basis in order to cover some areas such as emotional literacy in more depth. Information gained from the GAPS assessment, and consequent therapy, will be disseminated by our transition reports, although we have yet to develop a pro forma to facilitate this.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

25

HOW I
Figure 3 Example of an early assessment session It is important not to try to focus on too many areas in a single session, if good observational data is to be obtained. It is generally not possible to take notes during a session as this destroys the group dynamic, so reliance on facilitators memory is necessary. Completion of the score sheets collaboratively and as soon as possible after the end of the session has therefore proved to be very important. Skill to be assessed a. Emotions - awareness (own) Assessment Activity: How I feel today chart b. Emotions - expression Assessment Activity: As a. (by observation) c. Memory (Visual) Assessment Activity: Kims game Lotto game d. Eye-focus (on object/task) Assessment Activity: As c. (by observation) e. Posture and gait Assessment Activity: Observation f. Use of hands Assessment Activity: Observation A4 A8 A2 A10 G10 Assessment coding G9

BRIDGING THE GAPS (2):

STRENGTHENING
THE FOUNDATIONS
HOW DO YOU RECONCILE A THERAPISTS AIMS OF EXPERIMENTATION, INDEPENDENCE AND FOOD MANIPULATION BY PUPILS WITH EDUCATION STAFFS FOCUS ON MANNERS AND NUTRITION? FOR JOANNA MANZ, THE KEY WAS TO INVEST TIME IN PREPARATION AND NEGOTIATION OF A REGULAR SNACK SESSION.

There are definite benefits already apparent: therapy is assessment led the GAPS is a standalone assessment procedure for assessing social communication skills an auditable scale measures outcomes lists of activities and materials required are at hand for assessment and subsequent therapy input, leading to a reduction in preparation and thinking time quality of materials has been enhanced as a result of more detailed long-term planning the wide range of activities caters for all students preferences and learning styles colour-coding of materials and coloured storage boxes corresponding to assessment areas assist speedy accessibility an off the shelf procedure gives confidence and easy access to therapists, especially those new to this field of work the GAPS is very flexible, giving therapists control over which areas to assess and when (see figure 3 for a sample assessment session). the GAPS can be used in Further Education colleges and Adult Day Centres. the GAPS can give a useful measure of students social communication skills on entering into adult placements; this can provide evidence to assist decisions as to the level of support needed for individual students the GAPS raises the awareness of school staff as to the nature of communication and the relevance of speech and language therapy work to their students lives the use of the GAPS will strengthen working links with education staff with some amendments to activities, the GAPS could be used by therapists working with younger children or clients with specific pragmatic deficits / autism. And, apart from these benefits, the GAPS is fun!

n August 2002, the new primary 1 intake at one of our local support bases for pupils with special needs within a mainstream school included three pupils who had persisting difficulty with eating and drinking. These children had a range of special educational needs, including moderate and severe learning difficulties. Each presented with a different type and severity of disorder, but all had developed what could be described as maladaptive responses to eating. These included behavioural difficulties, severe texture intolerance, and problems developing independence in food handling and preparation. Two of the pupils had a history of involvement with the speech and language therapist as infants, their primary difficulties having been related to problems with weaning and texture intolerance. The remaining pupil had a diagnosis of autistic spectrum disorder and was described as a very fussy eater. None of the pupils was at risk of choking. They were all able to demonstrate a competent swallow, but chewing was poorly developed. Teaching and support staff has expressed concern about the pupils eating and drinking, both in terms of the restricted range of food types eaten and management of mealtime routines. They needed to know how best to help the pupils. The speech and language therapist decided to set up a snack and independence group within the school setting, to promote new skills for eating and drinking which would reduce maladaptive behaviours and develop better patterns of eating. The support for learning assistants were extremely experienced in dealing with pupils with a range of complex needs. In addition, this unit had a long history of excellent collaboration between teachers, support for learning assistants and all visiting therapists. However, using a snack group to promote eating and drinking was a relatively new concept, and the need to establish shared goals for the group was essential. The idea had already been discussed with parents at a routine meeting with the speech and language therapist on their entry to school. During discussion with all staff involved with pupils at the base, it quickly became clear that support staff - who had primary responsibility for supervising mealtimes - considered that the development of good table manners and nutrition were their main concerns. The aim for the speech and language therapist initially conflicted with this, as experimentation, independence and food manipulation were the primary objectives. Before the group could be set up, the speech and language therapist had to ensure all staff had a full awareness of the aims of the group, and were able to be fully committed to the process.

Food play
Firstly, I decided that any activities to encourage significant change in eating behavior should be attempted outwith set mealtimes. Winstock (1994, p.69), when describing the significance of self-feeding to the development of eating, stresses the importance of the childs exploration of foods. This messy stage (normally occurring between 9-12 months) conflicted with aims for other pupils at mealtimes of the development of socially acceptable table manners. McCurtain (1997) also supports it: Outside of mealtimes allow food play. This will serve to rake the pressure from feeding and create a more relaxed feeling about it. For this reason, the snack group was arranged at a time during the school day when the pupils were not normally eating. Another factor vital to change was motivation. There is often an assumption that

References
Kelly, A. (1996) Talkabout. Winslow Press. Rinaldi, W. (1992) Social Use of Language Programme. NFER-Nelson. Schroeder, A. (1997) Socially Speaking. LDA.

Further reading
Andersen-Wood, L. & Smith, B.R. (1997) Working With Pragmatics. Winslow Press. Jeffries, J.A.H. & Jeffries, R.D. (1992) Practical Language Activities. ECL Publications. Kelly, A. (2000) Working With Adults With a Learning Disability. Winslow Press.

26

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

HOW I

food is in itself highly motivating for children and, if a child is having difficulty, simply providing more quality or exotic foods will help fussy eaters. In their summary of factors affecting development of eating, Masel & Franklin (1996) conclude that play and choice making are vital to the normal development of eating skills, without the need for external reinforcement (p.51). Being involved in the preparation of foods is also important. Again, Winstock advocates the active involvement of the child in food preparation, as these routine events provide valuable learning experiences. It may be difficult to involve a child with special needs in such everyday activities (p.70). These issues were discussed at several meetings with staff, and the rationale explained and agreed. As a result, we decided to go ahead with the group at school. I stressed the importance of support for learning staff being highly involved with the planning and evaluation process.

BRIDGING THE GAPS (3):

SCALING THE
ONCE UPON A TIME, A SPEECH AND LANGUAGE THERAPIST AND TEACHERS IN AN EDUCATION ACHIEVEMENT ZONE TARGETED STORYTELLING IN JUNIOR AGED CHILDREN TO RAISE ATTAINMENT. AS LIZZIE DAVIES RELATES, STORYBOARDS PROVED TO BE A MOST USEFUL TOOL, PROVIDING THE SCAFFOLDING THE CHILDREN NEEDED TO CONSTRUCT THEIR OWN ADVENTURE STORIES...

SCAFFOLDING

Relaxed approach
Structured presentation of small amounts of foods was introduced. We chose a range of textures, encouraging smell, touch and temperature to be experienced by the pupils. It was made clear from the outset that the pupils did not have to try any of the foods. A relaxed approach was essential as initially pupils were resistant to handling foods at all, and this reluctance was vigorously expressed in many ways, the preferred one being to throw. It was important that the sessions were kept short (15-20 minutes) as our pupils had moderate to severe cognitive difficulties with associated difficulties maintaining attention. A key factor in the structure of the group was to introduce a very small amount of the pupils preferred food, after week 4, to allow the pupils to associate the group experience with taste as well as experimentation. This has been an important aspect of the success for pupils, as preferred foods are introduced and associated with new food experiences. Six group sessions took place in the first term. At the end of this period the outcomes were: emergence of positive anticipatory behaviours pupils sat independently for the length of the group all pupils had tried two new tastes! one of the pupils who had preferred to be fed had shown new interest in very basic preparation of foods (spreading, chopping) during a food project running concurrently in the unit, two pupils from the group tried new foods. During the next two terms, we ran 10 sessions. Outcomes for this block were: development of interaction / appropriate behaviours during snack emergence of appropriate expressions of food preferences (and a marked and welcome reduction of throwing) parental reports from two families of their children trying new food at home. The use of snack as a foundation for children and adults with special needs to build interaction and eating has often been described anecdotally as effective. There have been special challenges for such a therapy within a mainstream school, as staff had to consider new issues related to the development of eating. The process involved changing practice and required careful negotiation and preparation between speech and language therapy and education staff. It has been seen as very successful and has developed since the initial group as an assessment facility for any pupil coming into the unit who may have difficulties with any aspect of eating and drinking. When the unit introduced PECS (Frost & Bondy, 1994) into its curriculum, snack group provided an important structured setting to encourage development and generalisation. We have also made clear that, ideally, occupational therapy colleagues should be involved, although staffing issues have made this difficult.

istening to stories is something we enjoy both as adults and as children. As adults we often underestimate what is needed to identify with characters and emotions in stories. We rightly have high expectations of children. We want children to explore our rich language and to be able to use vocabulary appropriately in a variety of contexts. For children to think creatively and write their own stories, much needs to be put in place to provide the essential scaffolding which will enable children to develop their ideas and then write them down. Speech and language therapists and teachers in Bridgwater Education Achievement Zone (see background in figure 1) therefore decided to target storytelling skills in one of the areas junior schools. The year 3 staff at the school decided that the literacy focus for one half terms work would be on adventure stories. This would include introducing the children, aged 7-8, to adventure stories and encouraging them to make up their own stories, which they would retell verbally and in written form. From past experience and knowledge of their classes, the teachers predicted that the children would experience difficulties in creating their own stories due to lack of imaginative play, limited vocabulary and problems with sequencing ideas. We anticipated that the children would need a considerable amount of help to develop their stories. A joint planning meeting was arranged with all year three teachers and the speech and language therapist in the first half of the summer term 2003. The meeting provided a forum for planning what needed to be undertaken and how the speech and language therapist would work with the teachers. This Figure 1 Background to Education Achievement Zones
The first tranche of Education Achievement Zones (EAZs) were set up in 1999. Bridgwater EAZ came into being in January 2000. Schools, local education authorities or a combination of agencies had to apply for EAZ funding having identified a number of schools who wanted to work together to break the cycle of underachievement. The government was looking for businesses and schools to find innovative ways of raising standards. Core funding for EAZs comes from the Department for Education & Skills, but they were also charged with raising private sponsorship. One of the core priorities in Bridgwater has been to raise the language and communication skills of children across all age groups (Astin et al, 2002). To help achieve this, three speech and language therapists were appointed to work alongside teachers. Their task was to help teachers to develop a greater insight and understanding of language development and, where necessary, change classroom practice. create a more vibrant classroom which would enable children to access the curriculum recognise childrens preferred learning styles and develop appropriate resources.

Acknowledgements
Thanks to the staff and pupils at the Support Base, Lochside Primary School, Montrose, Angus.

References

Frost, L.A. & Bondy, A.S. (1994) The Picture Exchange Communication System Training Manual. Pyramid Educational Consultants UK Ltd. Masel, C. & Franklin, L. (1996) Management of Eating Difficulties in Young Children with Failure to Thrive. Australian Communication Quarterly. Spring. McCurtain, A. (1997) The Manual Of Paediatric Feeding Practice. Winslow. Winstock, A. (1994) The Practical Management of Eating and Drinking Difficulties in Children. Winslow.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

27

HOW I
Figure 2 Layout of storyboard
Opening storylines Who - characters

Figure 3 List of vocabulary agreed with the children


Opening lines - At breakfast; Once upon a time; He opened the door and.....; It was dark; They heard a noise; One night... Characters - pirate, dragon, ghost, prince and princess, monster, fairy Adjectives - fierce, clever, old, huge, small, beautiful, scaly, scary, sparkly Place - space, cave, forest, island, sea, bedroom, castle, palace Action / what Happened - in the sand they found; fall in a crater; fly to the moon; crawl in a cave; bouncing ball; swimming with crocodiles; climb the mountains; creep along the secret passage; hide behind the tree; unlock the box Ending Lines - He lived happily ever after; What a lot of things they had seen; That was an exciting day after all; She was very tired and fell asleep; He didnt want to see another ...; At the end of the day, he went home.

led to a discussion on the importance Adjectives of giving children a visual structure and Where - place relevant vocabulary to help them devise their own stories. We decided What happened that the Education Achievement Zone Ending / conclusion speech and language therapist and assistant would produce a storyboard using symbols to help the children construct their own stories. We also agreed that children must be given the opportunity to talk through their stories in small groups before writing any ideas down on paper. The storyboard was designed so that the symbols could be used to construct an adventure story. Children would be able to select an opening for the story, characters, words to describe those characters, where and what adventures took place and the story ending. The layout of the board is in figure 2.

Visual structure
The symbols were backed on velcro so the children could physically take them off the board and then lay them out in front of them. This provided the children with a visual structure for their particular story. We gave considerable thought to the vocabulary and characters presented on the board. We wanted to provide the children with characters they could identify with, the opportunity to extend their imaginations, a wider vocabulary, and the ability to link different words together. Some of the characters chosen were in the latest Harry Potter film and were of significant interest to the children, while others were familiar as they were taken from fairy tales and other books which had been read in class. The characters included a wizard, dragon, ghost, monster, boy, pirate, prince and princess. Adjectives were also used on the storyboards which fitted in with the requirements of the National Literacy framework for teaching year three. The words chosen could be linked to the characters. They included fierce, clever, old, huge, small, beautiful, scaly, scary and sparkly. These words were meant to provide the children with some ideas for character descriptions but did not stop them from using their own describing words. A list of words chosen by the children for each section is in figure 3. The teacher introduced the work by reading an adventure story. This was done to help the children understand the pace, action and style which needs to be present in such stories. It became clear very quickly that many children were not able to empathise with the characters.

Opportunity to talk
We therefore decided that the speech and language therapist would work with a group of six children at a time on the storyboard. The children were given the opportunity to talk about stories they enjoyed listening to or reading themselves. A discussion was then held with the group on the types of stories that had been described. This was necessary as very few children understood the concept of classifying different types of stories. The concept of beginning, middle and end and how this are applied to storytelling was also discussed in the small group. The speech and language therapist then made up her own adventure story in front of the group to demonstrate how the symbols and structure of the storyboard could be used. The group then jointly constructed their own adventure story using the sto-

ryboard. One child decided the opening, one the characters and so on. As the children added new elements to their story the speech and language therapist retold the story back to them, so that they could hear the story from the beginning and also how it developed. This gave the children the opportunity to hear the same words used in the story several times. All responses from the children were accepted, although some degree of negotiation was required between the children as their excitement grew and they all wanted to contribute. The children worked well together and all contributed fully. The visual vocabulary provided by the symbols helped children try out new words and phrases that they had heard but had not been able to link together or use in context. Children were able to share ideas, develop their imagination and sort out events sequentially. As the ideas developed, the children seemed to gain in self-confidence and verbal fluency. Once the story had been completed, the children retold their group story to the teacher and the rest of the class. The teacher then encouraged the children to write up their stories in their books. These were also typed up using Writing with Symbols (Widgit, 2000) and left with the teacher as a class resource. The storyboard is acknowledged by teachers as being a really good tool and having an impact on childrens writing skills. There is also a greater awareness of the importance of teachers using visual materials to support childrens learning. We have learned and confirmed that: children need a structure to help them develop the skills of storytelling and writing many children need to have vocabulary presented to them visually small group sessions enhance speaking and listening skills, as all children are able to contribute and support one another, which in turn helps to raise self-esteem and confidence it is important to build in time for children to speak to an audience it is essential to spend time encouraging children to talk though their ideas before writing them down it is important to demonstrate the use of tools, in this case the storyboard.

References
Astin, L., Roberts, K., Withey, E. & Crawshaw, M. (2002) Improving communication with EAZe. Speech & Language Therapy in Practice Winter: 8-11.

Resources
Writing with Symbols 2000 (version 2.6) is published by Widgit Software Ltd, see www.widgit.com.

Posters for dads...

resources

Contact a Family has free posters (produced with the support of the Parenting Fund) showing positive images of dads with disabled children and encouraging dads to use Contact a Familys services. Free copies from the Helpline: e-mail: helpline@cafamily.org.uk or tel. 0808 808 3555.

In the absence of prevention and cure, Top Tips for Helping your Child Through Glue Ear offers guidance to parents to ensure children hear and understand what is being said. From Defeating Deafness, freephone 0808 808 2222, e-mail info@defeatingdeafness.org.

Glue ear tips

PC kids

A software program from Advanced Brain Technologies (www.advancedbrain.com) has been developed to teach children aged 3-6 the basics in using a personal computer, as well as promoting memory and reading skills. Shellys My First Computer Game - Goldilocks and the Three Bears, $29.95, see www.shellythesnail.com.

28

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

Subscription form for Speech & Language Therapy in Practice

NAPLIC (National Association of Professionals concerned with Language Impairment in Children) Residential Conference: Speech, language and communication needs: current trends in theory and practice 19-20 March 2005, University of Warwick From 225 www.naplic.org.uk I CAN Conference: How working together in the early years can have an increased impact on childrens communication development 22 April 2005, London Speakers include Ann Gross from Sure Start and Elizabeth Andrews from the Early Support Programme. www.ican.org.uk, tel. 0845 225 4073 Courses 7 March 2005, Birmingham Improving Short-Term Memory Skills using Mastering Memory or Memory Bricks London Dyspraxia: Working Together Towards Effective Practice 11 March 2005, Edinburgh: Play and Communication Therapy: a non-directive approach Speech and Language Impairment in Secondary Schools: What Is It and What Do I Do About It? 17 March 2005, Nottingham Intensive Interaction Tel. 020 7674 2790 or book online at www.ican.org.uk/professional development. British Aphasiology Society Biennial Conference 4-7 September 2005, Colchester www.bas.org.uk The Encephalitis Society Encephalitis explored: assessment, rehabilitation and therapies 6-7 September 2005, York e-mail conference@encephalitis.info Le Congrs international de la Fdration nationale des orthophonistes Comprendre 14-16 October 2005, Toulouse Information about submitting abstracts from: Secrtariat du Congrs de Toulouse 2005, 24 bd Andrieu 81000 ALBI, e-mail CongresScientifiqueFno.Toulouse2005@laposte.net.

events

PERSONAL RATES

26 personal UK 22 part-time (5 or fewer sessions) (UK only) 19 student / unpaid / assistant (UK only) 31 Europe personal 35 other overseas personal

AUTHORITY/DEPARTMENTAL RATES
46 authorities UK / Europe 51 other overseas authorities
Bulk orders (sent to any single work address): 2 copies for 54 3 copies for 75 4 copies for 92 5 6 or 7 copies for 21 each. Total price

EUROZONE RATES
Note: Cheque and direct payment only. Credit card payments can only be deducted in sterling at the rates advertised above.

45 Personal 37 student / unpaid 67 authority / department


IBAN NUMBER: IBAN GB44 BOFS 8020 0608 3990 01

Bulk orders (sent to any single work address):

2 copies for 79 3 copies for 110 4 copies for 134 5 6 or 7 copies for 31 each. Total price
SWIFT BIC: BOFSGBSIEUG

Special offer for personal subscribers - Introduce a colleague* to Speech & Language Therapy in Practice and you both get an extra issue - free!
The new subscriber fills up their details on the form and puts your name in the recommended by space. Once their payment has been received, they will get 5 copies for the price of 4 in their first years subscription, and you will be notified that your subscription period has been moved on by three months. So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in Practice. Remember - you will get an extra issue for every new subscriber you bring in. *Must be a NEW subscriber to the magazine.

Cheques payable to AVRIL NICOLL BUSINESS. OR Please debit my Visa / Mastercard / Switch card: (Card payments cannot be accepted without a signature.) Card number: Expiry date: Switch only: Issue No. OR Valid from date:
(if issue no. not available)

Signature:

NAME: RECOMMENDED BY: (if applicable) HOME ADDRESS:

POSTCODE:

HOME TEL.

CONTRIBUTIONS TO SPEECH & LANGUAGE THERAPY IN PRACTICE:


Contact the Editor for more information and / or to discuss your plans. Please note: articles must be of practical use to clinicians use case examples and list useful resources length is generally around 2500 words supply copy on disk if possible keep statistical information and references to a minimum photographs will be returned

WORK ADDRESS:
POSTCODE:

WORK TEL. e-mail: Please note acknowledgements and renewal notices are sent automatically. From outside the UK, Return to: Avril Nicoll, Speech & Language Therapy in Practice, the address is: FREEPOST SCO2255 Avril Nicoll LAURENCEKIRK 33 Kinnear Square Aberdeenshire Laurencekirk AB30 1ZL Aberdeenshire Tel/fax +44 (0) 1561 377415, e-mail avrilnicoll@speechmag.com www.speechmag.com AB30 1UL
It would be very helpful if you could complete the following information:
Job title(s): Name of employer / university: Topics you would like to see covered:

IMPORTANT NOTICE
SUBSCRIBERS SHOULD CONTACT THE PUBLISHER IF THEY HAVE NOT RECEIVED THEIR MAGAZINE(S) WITHIN TWO WEEKS OF THE PUBLICATION DATE, OR IF THERE ARE ANY PROBLEMS WITH THE MAGAZINE ITSELF. TEL: 01561 377415
SPEECH & LANGUAGE THERAPY IN PRACTICE IS PUBLISHED ON THE LAST MONDAY OF FEBRUARY (SPRING), MAY (SUMMER), AUGUST (AUTUMN) AND NOVEMBER (WINTER).

Your personal details will only be used for the purposes of Speech & Language Therapy in Practice magazine and will not be passed to any third party.

SUBSCRIPTION FORM SUBSCRIPTION FORM SUBSCRIPTION FORM

MYTOPRESOURCES
1. BUILD YOUR OWN RAINBOW: WORKBOOK FOR CAREER AND LIFE MANAGEMENT BY BARRIE HOPSON & MIKE SCALLY (MOST RECENT EDITION 1999, MANAGEMENT BOOKS 2000) Packed with exercises, this A4 manual is designed to help you analyse and develop your skills, interests and ambitions. You interact with the book by filling in charts, questionnaires and boxes so you get to know your transferable skills, values and most comfortable career pattern for example. The personal profile you gain at the end of the book can be checked against jobs, education and training opportunities as well as leisure interests. The idea is that you see a greater range of possibilities for change. My first major career change occurred immediately after reading this book, thanks also to my manager at the time who supported me in making the transition. 2. GETTING THINGS DONE: THE ART OF STRESS-FREE PRODUCTIVITY BY DAVID ALLEN (2002, PIATKUS BOOKS) My entire admin system is based on this guide written by an American management consultant. I read it three times before I got the hang of it, but it was time well spent and Ive found the system easy. Ive been using it now for about two years. Its unthinkable to go back to suspension files in filing cabinets. If you apply the principle one new file in, one old file out, or one sheet of paper filed, one out, you can manage the volume better. 3. SHOULD I STAY OR SHOULD I GO: HOW TO MAKE THAT CRUCIAL JOB MOVE DECISION BY JIM BRIGHT (2003, PRENTICE HALL) If youve ever procrastinated over leaving a job, then this handbook helps you clarify the issues involved. Written by a Sydney-based organisational psychologist, you learn how to assess yourself and your organisation and also how to tell when youve gone as far as youll go in the workplace youre in. There are checklists to decide when to take stock or move on, and whether your boss wants to promote you. 4. YOUR POCKET LIFE-COACH: 10 MINUTES A DAY TO TRANSFORM YOUR LIFE AND YOUR WORK BY CAROLE GASKELL (2001, HARPERCOLLINS) This deceptively small book is big on ideas and activities. I like it because it feels manageable to complete and you get a sense of achievement early on in reading it. Examples of questions asked are: What are your three biggest achievements in the past few years? What are your three biggest challenges? What top three lessons have you learned? Its the perfect book for reflecting, not just on work, but life in general. There are sections on boosting confidence, strengthening your relationships and tackling your obstacles. Great fun. 5. GROW - THE MODERN WOMANS HANDBOOK BY LYNNE FRANKS (2004, HAY HOUSE) Male speech and language therapists may want to skip this one as its specifically aimed at women who wish to get in touch with their feminine centre. This public relations guru, allegedly the role model for Edina in the BBC programme Absolutely Fabulous, has put together an encyclopaedia of womens issues with entertaining exercises and advice. Ten friendly neighbourhood practices was my favourite piece of wisdom. Franks ideas made me rethink and cultivate my sense of community and I now make more effort to be neighbourly. Having focused so much on work, leisure and close relationships, feeling involved in my local area has made me appreciate where I live much more. 6. STRIKE A NEW CAREER DEAL: BUILD A GREAT FUTURE IN THE CHANGING WORLD OF WORK BY CAROLE PEMBERTON (1995, FINANCIAL TIMES PRENTICE HALL) Having been impressed by a solutionfocused career management day by the author, I was prompted to buy the book. If you just want to concentrate on sorting out your career, then this may be the book for you. There is plenty of information on the way careers are now and are likely to be in the future. The expectations you have of your working life are examined, as is your own fit with your job and organisation. By the end of the book you will have learned some skills for negotiating and managing your career. 7. FIND THE BALANCE: ESSENTIAL STEPS TO FULFILMENT IN YOUR WORK AND LIFE BY DEBORAH TOM (2004, BBC BOOKS) If finding the right balance between the time you spend on work and time with your personal commitments is bugging you, then buy this book. The robust questionnaires manage not to irritate as many magazine ones do, and this is probably because the author is a chartered occupational psychologist. This book bears some resemblance to Build Your Own Rainbow (see no.1), but without the fun format. 8. YOUR MONEY OR YOUR LIFE: A PRACTICAL GUIDE TO SOLVING YOUR FINANCIAL PROBLEMS AND AFFORDING A LIFE YOULL LOVE BY ALVIN HALL (2003, CORONET BOOKS) It goes without saying that, in order to make career or other life changes, you need to take into account your money situation. This guide helps you take charge of your finances without it seeming to be boring. I find a lot of women still leave it to men to take charge of financial planning and its still the case that women are more likely to be in debt than men. One activity is to write down everything you spend each day for a few weeks or months, under columns, to work out where your money goes. I had a few shocks because I hadnt realised how much Id been spending on snacks and subscriptions. 9. THE CONFIDENCE PLAN: ESSENTIAL STEPS TO A NEW YOU BY SARAH LITVINOFF (2004, BBC BOOKS) This could be a good book to get started with, as it gives you a chance to build up your confidence and motivation first. Youre asked to spend some time on working out what makes you feel good and there are activities to help you build up your energy level. There are also tasks to work out what drains you. I was less keen on exorcizing your negative past and changing negative thoughts because it sounds like pull yourself together - and, if you really have low self-esteem, therapy would be more creative. I hadnt thought about burning scented oils for helping confidence but I am using them more. Im using lime at the moment, which is supposed to wake you up. 10. 1001 WAYS TO RELAX: HOW TO BEAT STRESS AND FIND PERFECT CALM BY MIKE GEORGE (2003, DUNCAN BAIRD PUBLISHERS) If all the above is leaving you exhausted, then chill out with this chunky and beautifully illustrated book. Relaxation ideas are given for mind, body and soul, as well as for work situations and being with other people. The author lists numerous creative ideas for getting out of bed in the morning and winding down in the evening. Dont try idea number 308 in your speech and language therapy department, unless you want a phalanx of fire engines turning up outside your door: Purge your fears with a ritual. Write them on a piece of paper, and either throw the paper into the flames of a fire, or light it with a candle. There are less challenging ideas, and it makes a great present.

IN ADDITION TO PERSONAL THERAPY AND CAREER COUNSELLING, VOICE SPECIALIST AND PSYCHOTHERAPIST JAYNE COMINS HAS FOUND TEN GUIDES PARTICULARLY HELPFUL IN BRINGING ABOUT SHORT- AND LONG-TERM CHANGES TO HER PROFESSIONAL AND PERSONAL LIFE. JAYNE SAYS THESE HANDBOOKS HAVE GIVEN HER A WAY OF THINKING CREATIVELY ABOUT CHANGES SHE MIGHT BE NEEDING TO MAKE - OR IS VAGUELY AWARE OF - REGARDING WORK, FRIENDSHIPS AND LEISURE. SHE FINDS HOLIDAYS A GOOD TIME TO REFLECT ON LIFE GENERALLY, AND TO THINK ABOUT WHAT SHED LIKE TO BE DIFFERENT.