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ISSN 1368-2105

Autumn 2005

http://www.speechmag.com

READING THE GAME

How I
set goals
Signing up to inclusion

Involving peers Staff training


Nursing and residential homes

Non-attendance
Work in progress

Head and neck cancer dysphagia


Expert guidance

PLUSThe Affirmation keyHeres one I made earlierMy Top Resources brain injury in the communityStammering in young adultsand featuring Positive language

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Autumn05speechmag
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Non-attendance... (206) Howard, S. & Hughes, C. (2002) From last to first resort. Autumn: 18-20. (not yet indexed) Morris, T. (2004) Turning up or turning off? Summer: 26-27. BONUS! New at www.speechmag.com/reprintedarticles.html. Training care staff... (070) Jordan, L., Bell, L., Bryan, K., Maxim, J. & Newman, C. (1999) Learning from Communicate. Summer: 18-21. (115) Moore, T. & Irwin, A. (2000) Making an impact. Summer: 4-7. Stammering in young people... (198) Wright, L.: Getting to know you; (199) McNeil, C.: Tipping the scales, both in (2002) How I manage stammering in adults. Summer: 25-28. (248) Lee, G. (2003) Altered perception. Autumn: 21-23. Dysphagia in head and neck cancer... (203) Stanier, J. (2002) A shift of emphasis. Autumn: 8-11. (253) Gamberini, L. (2003) When is good enough? Winter: 4-6.

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Autumn 2005
(publication date 29/08/05) 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 AUTUMN 05 SPEECHMAG, READER OFFER


Win one of 10 LDA Language Cards Interactive.

16 KEYS TO WINNING WAYS SERIES (4) THE AFFIRMATION KEY


We worked on reprogramming [Maureen and Jennys] habitual thought patterns using positive affirmations. A positive affirmation has three elements: Positive, Present, Personal. It really doesnt matter if initially they had no belief in it. The repetitions re-educate the subconscious mind. In the fourth of our series to encourage reflection IN FUTURE and personal growth, life coach ISSUES... Jo Middlemiss considers that joy and happiness at work and in the rest of your LEARNING STYLES life follow on from inner affirmation.

2 NEWS / COMMENT 4 WORK IN PROGRESS NON-ATTENDANCE


Partial booking by telephone allows an element of flexibility in the time or day allocated, as this had been identified as a potential barrier to attendance. We also now phone with a reminder nearer the time of the appointment as the majority of families surveyed said this would help prompt them to attend. In 2004 we heard from Tom Morris how a Sure Start team had investigated non-attendance at clinic appointments. Now he reports with Liz Stein on the steps taken to enable more people to access speech and language therapy.

www.speechmag.com

17 HERES ONE I MADE EARLIER


Alison Roberts with a low cost therapy activity: the friendship vine.

ASPERGERS SYNDROME DYSPHAGIA VOICE WORK EXPERIENCE

7 INVOLVING PEERS SIGNING UP TO INCLUSION


Staff...found that the other children consistently supported Sophie with her signing. For example, if they were outside playing they would ask her, Do you want a turn on the car? or Do you want to play in the house? (underlined words = signed words). Following her experience with a preschool child, Anna Westaway suggests that training clients peers to support their communication strategies should be integral to our early years intervention strategies.

18 FEATURE SPEAKING SKILFULLY

Traditionally speech and language CRITICAL therapy has been didactic in its methods. APRAISAL With principles such as user involvement, person-centred planning, community based GROUPS care, accessibility and the expert patient being applied more in practice, we are becoming aware of the need to adapt the language we use with clients to fit our new role as collaborator. Avril Nicoll takes a look at the growing interest in the effect of our language choices on therapy outcome.

10 CONFERENCE CALLS STAMMERING IN ADOLESCENCE


Where stammering is established or chronic any course of therapy is best viewed as a beginning, or as a continuation of work, rather than the end of it. Jane Fry of the Michael Palin Centre for Stammering Children and Avril Nicoll summarise the key themes of a workshop that Jane facilitated for therapists in Scotland.

20 STAFF TRAINING TURN UP AND TUNE IN


Staff were keen on the idea of the speech and language therapy service being able to provide individual communication advice on specific clients. One of the activities in the course was to attempt to communicate with a partner using specific communication strategies. Delegates reported this was very helpful. How do carers in nursing and residential homes develop the skills to support elderly people with acquired communication disorders? Karen Booth and Niki Freedman recount a project in Bedfordshire with promising results - for those who attended.

12 EVIDENCE BASED PRACTICE EXPERT GUIDANCE: HEAD AND NECK CANCER DYSPHAGIA
Three areas of clinical practice were appraised: pretreatment assessment, instrumental assessment and intervention. A critical review of the literature was followed by case presentations and audience debate. Jo Patterson reflects on the evidence presented when speech and language therapists specialising in head and neck cancer dysphagia met to seek consensus on their role.

23 HOW I SET GOALS


Do you have a vision? Do you have a goal? Our three contributors reflect on the process, advantages and challenges of goal setting with clients.

(1) HOW WOULD YOU GO ABOUT IT?


Sarah Easton finds out what would encourage us to make goal setting with clients an integral part of rehabilitation.

14 REVIEWS
Brief therapy, clinic resource, autistic spectrum disorder, language development, assessment, Fragile X syndrome, Downs syndrome, early years, social skills, software, literacy.

(2) DO YOU HAVE A MASTER PLAN?


Caroline Haw uses the development of a community rehabilitation team information booklet to facilitate and standardise goal setting.

(3) YOU WILL KNOW WHEN IT FEELS RIGHT


She had the motivation and a variety of tools, but Sally Boa needed a structured negotiation framework to cement her goal setting skills.

BACK COVER MY TOP RESOURCES


Cover photo of Fraser Riach by Paul Reid (see How I set goals, p23).

As you can imagine with a predominantly young, male client group, a mobile phone is usually an essential accessory - and a practical one too. Susan Anderton is a speech and language therapist in a new community brain injury team.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

NEWS

FOOD on trial

Feeding people who have swallowing problems following a stroke as soon as possible can help to reduce the number of deaths - but may increase the number surviving with severe disability. A research summary in Stroke News reports on FOOD (Feed Or Ordinary Diet), the largest ever multicentre international research into feeding policy for people with stroke. Of the 150,000 people who have a stroke each year in the UK, half have swallowing difficulties on admission to hospital and 11 per cent still have swallowing problems six months post-stroke. The researchers found a reduction in death of nearly 6 per cent for people who received early tube feeding. However, early tube feeding was associated with subsequent severe disability. Death and poor outcome were found to be significantly higher for people who were fed via PEG (percutaneous endoscopic gastrostomy) compared with nasogastric tubes. The researchers concluded that PEG feeding should be reserved for people who cannot be fed via a nasogastric tube, or where tube feeding is prolonged. A further trial looking at the routine use of oral supplements to prevent and treat undernutrition in stroke patients in hospital found that there was no benefit. Researchers concluded that supplementation should be reserved for undernourished people and those with deteriorating nutritional status. Stroke News, Summer 2005, www.stroke.org.uk

A first in the world


The Scottish Health Minister has described an online database of evidence of effectiveness in stroke care interventions as a first for Scotland and a first in the world. Launching the new website of the Stroke Therapy Evaluation Programme (STEP), Andy Kerr MSP said he was impressed with the ability of the website to make high quality information instantly accessible to health professionals within the clinical environment. The database is structured around clinical questions and provides clear evidence-based answers. Alex Pollock, physiotherapist with the STEP team, says the database is designed as a clinical tool to assist stroke care staff to make informed decisions about the treatments or services they provide to individual patients. In addition to this function, the database has also been used in the development of clinical guidelines for stroke in Scotland and Australia. www.effectivestrokecare.org/

One stop shop for care homes


The Office of Fair Trading is calling for a one-stop-shop for information on care home provision to help older people choose the right home. When older people move into a home they are often in poor physical or mental health and are vulnerable and distressed. Around half of those moving into a home do so after a period of hospitalisation; often the move has to be arranged quickly. Once in a home, few older people move to another, even if they are dissatisfied. All this makes the process difficult both for the older person and their family or representatives. The Office of Fair Trading argues that, although many difficulties are inevitable, some are not. The OFTs ten month study was initiated by a super-complaint from Which? (formerly the Consumers Association) on behalf of the umbrella organisation SPAIN (Social Policy Ageing Information Network). As well as a national gateway for consistent advice and support, the report also recommends better access to complaints procedures, greater price transparency and fairer contract terms for care home residents. Over 400,000 older people currently receive residential and nursing care in the UKs 15,700 private, voluntary and local authority care homes. Care homes for older people in the UK - A market study and supporting annexes are available on www.oft.gov.uk.

Honour for Roberta Lees


Stammering specialist and speech and language therapy lecturer Roberta Lees has been made an MBE in the Queens Birthday Honours List. Qualifying in 1966, Roberta has lectured at Strathclyde University (previously Jordanhill College of Education) since 1968 and held a variety of posts including head of department. Thanks to the links she has developed with speech and language therapists in other countries, students now have the opportunity to continue their studies for three months in locations such as Strasbourg. Particularly wellknown for her work in stammering, Roberta is also an adviser to the British Stammering Association and has presented at a number of international specialist conferences. Professing herself absolutely delighted about the honour, which comes as she is due to retire, Roberta added that it reflects the sterling work of all of my colleagues: theyre a great team.

Dyslexia friendly, user friendly


A national organisation has launched a campaign to heighten awareness that services and support put in place for people with dyslexia can benefit people with other and no disabilities as well. The Adult Dyslexia Organisations Dyslexia friendly, user friendly campaign includes a revamped website that aims to lead by example with its intuitiveness. The group has also produced a CDROM Dyslexia and Employment - Enabling Full Potential to address challenges faced by employees, employers, the unemployed, Trade Unions and support service providers. The organisation estimates that 10 per cent of the adult population is dyslexic, with 4 per cent severely affected. www.adult-dyslexia.org

Complement your career


ChildLine is looking to healthcare professionals to answer its call for 50 per cent more volunteers. The charity says that every day around 2300 children in danger or distress phone in but hundreds more cant get through. One volunteer, a recently retired paediatrician, says she benefited from the training and teamwork and that volunteering complemented her career well. She says, Although patients didnt suddenly start telling me everything, I felt I had a much greater idea of what was going on in their heads. One of the biggest insights was that Id not realised how children take responsibility for their parents welfare; how they worry about their parents and how they keep those worries to themselves. She continued, Time and again I am impressed by the ability of young children to make decisions for themselves, given the chance to talk with someone not judging the situation. Further information, tel. 0870 336 2993 or visit www.childline.org.uk.

Access to literacy

Thanks to his fathers initiative and perseverance, Matthew Over is now able to enjoy access to the same literacy programme as his peers. Matthew, who has Smith-Magenis Syndrome, uses SIGNALONG to support his communication but faced problems when trying to read full sentences and stories. As his school uses the Oxford Reading Tree series, his father Nigel started to pull an accompanying signing vocabulary together with added grammatical markers. Oxford University Press has now given SIGNALONG a free license to produce this work as a companion to the first stages of the Oxford Reading Tree series. The SIGNALONG companion to the Oxford Reading Tree is 18.50, see www.signalong.org.uk.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

NEWS & COMMENT

Breaking Through
Black and ethnic minority staff who work in the NHS and are on the verge of moving into senior leadership roles now have access to an online search facility so they can find the most suitable mentor from within the entire organisation. Diversity consultancy Performance Through Inclusion initiated the search facility as part of its contract to provide mentoring training for the Breaking Through programme. The same consultancy also offers the Inclusion Index, an online tool for measuring organisational diversity. www.leadership.modern.nhs.uk/ ethnicdiversity/breakingthrough/

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

A dream comes true


A mechanical engineer with a PhD in energy modelling has been awarded a Dreamtime Fellowship to investigate how the soul works. Melody Stokes interest was triggered by a desire to understand her sons behaviour pattern when he was struggling at school. The Fellowship was awarded by the National Endowment for Science, Technology and the Arts, a non-departmental public body investing in innovators and working to improve the climate for creativity in the UK. www.equationoflife.com; www.nesta.org.uk

Reading the game

Dont lose the music


This summer, the RNID has handed out earplugs and information about the danger of over-exposure to loud music to around 100,000 young people attending music festivals. With the rise in numbers of people owning MP3 players, the Dont lose the music campaign also advises people to take regular breaks, avoid turning up music to drown out background noise and to consider additions for in-ear headphones that allow you to listen at lower volumes in noisy environments. www.dontlosethemusic.com

I CAN has new chief executive


The charity which helps children communicate has appointed a new chief executive to succeed speech and language therapist Gill Edelman. Virginia Beardshaw joins I CAN from the British Red Cross where she was Director of UK Services. Prior to this, she spent 10 years working in the NHS, latterly as its director of modernisation in London. Virginia is also a trustee for ChildLine UK and StartHere and has a longstanding professional interest in childrens issues, policy and service development, including work on the NHS National Service Framework for Children TaskForce. I CAN says her role will involve extending the issues around childrens speech, language and communication difficulties and developing effective service responses to them. www.ican.org.uk

tel/ansa/fax Along with the rest of the household, my five year old is football daft. When 01561 377415 playing, he seems able to get into good positions to receive a ball, or to defend; he reads the game. Like our How I set goals contributors (p.23) he recognises e-mail that, while scoring goals is important, the process of getting there is the key. avrilnicoll@speechmag.com Therapists at the Michael Palin Centre for Stammering Children (Jane Fry with Avril Nicoll, p.10) also focus on process, helping young adults develop personal action plans to clarify how they will continue working towards their goals and deal with setbacks. The Michael Palin Centre training ground for young adults includes group therapy as, that way, there is both the opportunity to learn from each other and to support each other. Anna Westaway (p.7) also shows there is no substitute for input from peers. That speech and language therapy is a team game is evident in Susan Andertons top resources (back cover), and we know a team is most effective when its players have a variety of skills. My seven year old aka Statto devours facts and figures about football players, teams, games and results (Mum, will you tape the Argentinian league, its on at 4.20am?) Joking apart, as Jo Patterson demonstrates in relation to head and neck cancer dysphagia (p.12), attention to detail and an ability to analyse and cross reference is essential to make our practice more evidence based. Back on the park, there are times when even talented football players seem to lack a sense of belief. They might benefit from a visit from FRED (see Jo Middlemiss, p. 16), as well as positive affirmations. And their managers might be interested in the possibilities of positive language (feature, p.18). (I can hear it now: So, how did you manage to stay on the park and keep going despite being 5-0 down) Football clubs are constantly looking for ways to encourage supporters into the stands. Tom Morris & Liz Stein (p.4) report on their tactics to improve nonattendance at speech and language therapy clinics. Strength in depth of the therapy squad seems to be important, as different times, days and set-ups suit different clients. Footballers pay a penalty for missing training, but Karen Booth & Nikki Freedman (p.20) had no such recourse when handling non-attendance at training days for care staff in residential and nursing homes. The enthusiastic response of those who did attend means relegation is not an immediate prospect, and they continue to scout for new ways to bring people in. If youre reading Speech & Language Therapy in Practice youre reading the game. As always, I hope you find this issue a good result.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

WORK IN PROGRESS

Last year we heard from Tom Morris how a Sure Start team had investigated non-attendance at clinic appointments (Morris, 2004). Here he reports with primary care colleague Liz Stein on the steps taken to enable more people to access speech and language therapy.

Stepping stones
IF YOU WANT TO OFFER A MORE FLEXIBLE SERVICE IMPROVE COLLABORATION WITH OTHER AGENCIES FIND OUT IF CHANGES HAVE WORKED

peech and language therapy services are often difficult for hard to reach families to access, rather than non-attendance being the fault of the families themselves (Stewart, 2002). Recognising this, Sure Start in West Green & Chestnuts in Haringey, North London, looked into non-attendance at clinic-based appointments in Haringey Teaching Primary Care Trust (Morris, 2004). A local survey with a sample of both those attending and those not attending appointments led to key recommendations. Implementation of the recommendations has led to a reduction in discharge for non-attendance from over 60 per cent to just over 25 per cent. Our experience is that a number of simple steps can improve the use of a community service by preschool children.

STEP 1 DISCHARGE
A large number of children on a caseload has a direct effect on the waiting time for both assessment and therapy, a factor that had been cited by parents as influencing their likelihood to attend appointments. However, an audit in community clinics showed that 26 per cent of children on the caseload were being monitored - that is, awaiting a review rather than being discharged. This clearly increased the duties of the speech and language therapists and, subsequently, waiting times for appointments. We therefore identified criteria for therapy or discharge through the introduction of Care Pathways. A risk assessment recognises those needing prioritisation for direct short-term clinical input in the community and those needing transfer to specialist agencies such as a PreSchool Assessment Group, the Child Development Centre or the Language Panel for longer term intervention, Sure Start, or the Home Intervention Service for children with more complex needs. For those presenting with mild speech and language difficulties, discharge with advice has become standard procedure, and

reviews only take place for dysfluent children, where the risk of relapse or change is greater. However, if there is future concern for any child, parents can contact the service for further advice and/or an additional appointment without having to go back on to the waiting list.

attendance. We also now phone with a reminder nearer the time of the appointment as the majority of families surveyed said this would help prompt them to attend. We have provided a telephone help-line for families unsure as to whether or not an appointment is necessary. This means a speech and language therapist is now available to provide basic advice on activities to continue while awaiting an appointment, or simple reassurance if a referral is not considered necessary. In the survey, initial family awareness of the nature of the speech and language therapy service and what it could offer had been poor, even though almost all of the parents had identified communication difficulties in their children. To address this, Sure Start produced information cards on childrens normal speech and language development from 0 - 4 years, given out by health visitors at the childrens first home visit, as well as their 8 and 24 month checks. These were later translated into four main community languages and we are monitoring their success. Some parents without English as a first language had stated that appointment letters in their first language would have increased their likelihood to attend. These were also translated into a variety of community languages through Sure Start funding.

STEP 3 LOCATION
When asked, non-attendees identified a home visit as the most convenient location for initial appointments. We therefore added an option on the referral form for health visitors to recommend a home visit if it would be more appropriate than a clinic one. This is particularly relevant to those hard to reach families targeted by the Sure Start programme. While it is potentially beneficial, a lack of take-up or feedback from the health visitors has prevented any real evaluation, and we need to emphasise this option in further service promotion.

STEP 2 COMMUNICATION
We reallocated the speech and language therapy assistant budget to provide funding for an administrator to book the initial appointments. All appointments are now centralised, relieving clinicians of a time-consuming duty and allowing a central source of information for service users. Partial booking by telephone allows an element of flexibility in the time or day allocated, as this had been identified as a potential barrier to

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

WORK IN PROGRESS

Case example Miguel (2;6 years) was seen for an initial assessment, presenting with limited understanding at a two word level and a restricted range of vocabulary. Taken at face value, he would have been placed on the waiting list for a period of therapy. However, with support from a more senior therapist looking at the case from a wider perspective, it became apparent that he had in fact reached this level following rapid improvement over the past few months, with no reason to presume that this rate of development would decrease or come to a halt. The use of the risk assessment determined in the care pathway warranted basic advice to the parent on how to build on these skills. Miguel was discharged, not as within normal limits, but under the separate classification of mild delay, likely to resolve without direct input. If there is any future concern, Miguel can be re-referred, and will be given the next available appointment, rather than being placed at the bottom of the waiting list.
For therapy, many parents surveyed identified nursery settings as appropriate, with a preference for an environment promoting interaction with peers. The Sure Start programme provides a new nursery-based speech and language therapy service. While delivering an Early Listening Programme for all children attending the nursery, we also give advice on the appropriacy of referrals, and provide ongoing monitoring and follow-up from core service intervention. We see this as a way of reducing parental anxiety, as well as taking the pressure off the Early Years & Community team providing speech and language therapy services to nurseries. Despite the recommendation in the initial survey to expand locations for direct therapy programmes, they are still only provided in clinic settings due to the limited time available for restructuring the service. This is an area to pursue.

Figure 1 Non-attendance for initial appointments


Comparative Rate of Non-Attendance to Initial Appointments Before and After Service Adaptations

2003 2004

Figure 2 Wait for initial therapy


Comparison of Number on Waiting List for Initial Therapy Pre-and PostService Adaptations

STEP 4 SKILL MIX AND JOINT WORKING


One of the key principles of the Sure Start programme is recognising the holistic approach needed with families living in deprived areas, where many social factors act as a barrier to accessing core services. The speech and language needs of a particular child may be of minor importance when put in the context of other family issues such as housing, welfare, immigration, domestic violence and child protection. This reduces the priority given to direct speech and language therapy involvement, particularly at an initial stage. The Sure Start Community Team offers individual family outreach work, and this has been used as a means of reducing such external factors that affect a childs overall well-being. This has included the direct involvement of Sure Start speech and language therapists with allocated families, where they contribute to the general care of the family and operate as part of a multidisciplinary

In the community clinics, senior therapists now offer direct support to more junior members of staff carrying out initial assessments.
team focusing on the familys social needs as well as the individual needs of the child. Once more concerning matters have been addressed, we find a family is more likely to attend speech and language therapy appointments, and we can maintain a close collaboration between relevant services.

veyed families preference for intervention in a nursery over a clinic-based setting - not only for convenience but also as a more natural environment with increased opportunity for stimulation through peer modelling (Morris, 2004). In the community clinics, senior therapists now offer direct support to more junior members of staff carrying out initial assessments. This aims to decrease the number of children placed unnecessarily on the waiting list for intervention or review, while providing a collaborative learning environment for staff, as shown in the case example. Previously, we had identified children that could be grouped together for joint therapy (as discussed by Tilley & Barton, 2005). However, the subsequent decrease in waiting time for this part of the caseload increased the longest wait for those requiring one to one intervention. We changed this and now operate on a first come first served basis to ensure equity in service provision.

THE RESULTS
Overall, the number of children discharged for non-attendance fell dramatically, from over 60 per cent prior to the changes to just over 25 per cent after implementation. The changes were relatively simple, but soon showed themselves to be effective in increasing the attendance rate for initial appointments (see figure 1). Traditionally the summer holiday period has seen an increase in non-attendance, as shown by the peak in August 2004. This rate is, however, still lower than the August 2003 figure which we suspect had bucked the usual trend because fewer appointments had been made. Due to increased attendance at initial assessment and the new requirement for therapists to either discharge or place the child on the waiting list for therapy, the numbers awaiting initial therapy appointments almost doubled (as shown in figure 2). However, the average wait for therapy increased by only two weeks. This was mainly due to increased time

STEP 5 CASELOAD MANAGEMENT


With Sure Start speech and language therapists based directly in local nurseries, more joint decisions and onsite plans have been made with staff, resulting in clearer definitions of early identification, who to refer on to core speech and language therapy services, and strategies to implement within the nursery. This can influence effective caseload management. It marries up with the sur-

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

WORK IN PROGRESS
Figure 3 Non-attendance for first therapy appointment available for therapy made possible through the removal of reviews and the approach we adopted to discharge or onward referral to more appropriate services following first therapy. There was an overall decrease in non-attendance to therapy appointments, but this was less marked than the reduction in non-attendance for initial appointments (figure 3). Potential causal factors include a lack of concern after initial assessment, ongoing difficulties over access to sites, and limited time available to attend a series of sessions. This requires further monitoring and more in-depth exploration.
Comparative Rate of Non-Attendance to 1st Therapy Appointments Pre and Post Adaptation

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2003 2004

THE FUTURE DIRECTION


Always underlying any new proposals for service change is financial justification. The changes made so far have certainly not been costly. The use of short phone calls has reduced the cost of the administration time needed for written appointment letters and discharge. Potentially it has also reduced re-referrals and the associated administration time. We hope that in the longerterm the reduction in non-attendance will reduce the number of children resurfacing at a later date when difficulties are spotted at school. All these changes have implications for reduced costing, not only for speech and language therapy services, but also a range of other services called in to address a childs individual learning needs. Our findings point us towards increased collaboration between the speech and language therapy Early Years and Community Service and local preschool education providers. Sure Start can offer an ongoing link between the two until joint core service strategies are put into practice, particularly with the vision of Childrens Centres coming to reality. For the speech and language therapy service in the community as a whole the word flexibility has become paramount. We recognise that service provision can only be successful in meeting the needs of potential users if they are listened to and their views acted upon. A quandary is that, by increasing awareness, there could be a rise in referrals that would impact on the length of the waiting list. This is why we have a strategy to help potential referrers make more discreet decisions over who to refer, and to help therapists decide who to keep on for monitoring with support and / or advice. So far the referral rate hasnt significantly increased, although children who may previously have been missed are being picked up at an earlier stage through the ongoing presence of Sure Start speech and language therapists in drop-ins, playgroups and nurseries. This reflects the value of a carefully balanced service, incorporating the preventative and early intervention approach promoted through the core Sure Start objective of increasing all childrens level of language development during their formative years alongside the existing clinic-based service where specialist

For the speech and language therapy service in the community as a whole the word flexibility has become paramount.
and intensive speech and language therapy input can still be provided. The steps we have taken are part of a continual process. We all have a crucial role in ensuring that changes make a positive contribution to future service delivery.

PROGRESSING THE WORK


What other steps can we take to reduce nonattendance? How has your approach to non-attendance changed over the years? How does Tom and Lizs experience with preschoolers differ from measures needed to tackle non-attendance by other age groups? Through the work in progress section we are looking for readers to share their ideas, big or small, so everyone can benefit. If you have something to add, please e-mail or telephone the editor, avrilnicoll@speechmag.com / 01561 377415. Tom Morris is the Sure Start Speech & Language Therapy Co-Ordinator West Green & Chestnuts and Liz Stein the Early Years & Community Speech & Language Therapy Co-Ordinator for Haringey Teaching Primary Care Trust.

References
Morris, T. (2004) Turning up or turning off, Speech & Language Therapy in Practice, Summer, pp. 26-27. Stewart, J. (2002) Taking the service to the client, Bulletin of the Royal College of Speech & Language Therapists, October, pp. 6-8. Tilley, C. & Barton, R. (2005) Waiting list speech groups, Bulletin of the Royal College of Speech & Language Therapists, May, pp. 16-17.

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INVOLVING PEERS

Signing up to inclusion S
ophie is four years old and attends a mainstream nursery for five mornings a week, where she receives full-time support from a trained nursery nurse. Sophie has a rare chromosomal translocation associated with speech, language and learning difficulties. She has a significant delay in her language development and Makaton* signing was introduced when she was 18 months old. At the start of the block of therapy described in this article, Sophie was using approximately 30-35 single signs. I was visiting Sophie on a weekly basis at nursery for individual sessions to target specific vocabulary acquisition and language comprehension, as well as to provide support to staff working with her. Nursery staff were struggling with Sophie, due to their limited knowledge of Makaton signing and lack of confidence with incorporating it into her daily routine. They were due to attend a Makaton Foundation Workshop run by the Department of Speech and Language, but her parents and the involved professionals were concerned that Sophies interaction would still be somewhat limited to adults, as her peers would not be able to understand her signing. Sophies parents also received two individualised signing sessions from another member of our team and were very keen for Sophies friends to be able to communicate with her too.

Do we give enough time and attention to training clients peers to support their communication strategies? Following her experience with a preschool child called Sophie, Anna Westaway suggests this is not only desirable but should be integral to our early years intervention strategies.
IF YOU WANT TO REDUCE ENVIRONMENTAL BARRIERS TO COMMUNICATION HELP OTHER WORKERS INCREASE THEIR SKILLS AND CONFIDENCE DEMONSTRATE THE VALUE OF AAC IN EVERYDAY SETTINGS

Adapting the learning environment


As more and more children with special needs are included in mainstream educational settings, speech and language therapists have the challenge of providing increased levels of training and support to schools and carers. According to the Centre for Studies on Inclusive Education, barriers to learning and participation arise from the interactions between learners and the learning environment (2002, point 3). As professionals working to facilitate the educational process, we need to work to reduce these barriers by adapting the learning environment itself. Baumgart & Giangreco (1996) support this view, suggesting that not only the individual with communication impairment but also the communication partner require specialist services to enhance their communicative interaction. Our profession is experienced in supporting parents to facilitate their childrens communication (for example through Hanen workshops, see http://www.hanen.org) and also training education staff in working with children with communication difficulties (for example ELKLAN, see http://www.elklan.co.uk). However, von Tetzchner & Martinsen (1992) state that, for children requiring augmentative communication, it is advantageous if key people in a

nursery environment - including peers - can be taught strategies which may include signing skills. They also encourage facilitation of communicative opportunities with a childs peers, in order to offer more varied conversation (also supported by Sutton, 1982) and to give children the chances to be involved in everyday experiences and challenges. But do we give enough time and attention to training our clients peers to support communication strategies? Should this be integral to our early years intervention strategies?

We explained to all the children that we were going to learn about talking with our hands, and also pointed out that Sophie knew how to do this already.
With these questions in mind, we discussed the way forward with Sophie. To maximise her social and communicative development, we wanted to expose her friends in nursery to Makaton signing. Although staff and Sophie were signing throughout the day, it seemed important to create an environment where signing was fully acknowledged as an acceptable way to communicate, and where Sophies peers could support and help her to develop her communication skills.

As part of Sophies input at nursery, the staff and I agreed that I would deliver the nursery circle time once a week during my visits throughout the Autumn term 2003. We explained to all the children that we were going to learn about talking with our hands, and also pointed out that Sophie knew how to do this already. The children were incredibly accepting and none of them questioned what we were doing. Every week, I selected a topic for signs to introduce during circle time. Some of these were related to Sophies targets, some requested by the nursery and some to coincide with special events. Some broad topics, such as food, took two weeks to cover due to the amount of vocabulary. I provided the resources and led an activity for 20-30 minutes, using a combination of comprehension and expression activities to learn signs during a game (figure 1, p.8). I selected the resources from those already available within our department, such as postboxes, toy food, books and picture materials; I rarely had to spend time preparing resources for the sessions. The staff then reinforced the signs throughout the week. Symbols were used alongside the sign prompts that we placed in specific nursery areas such as the house corner, book corner and music corner. Sophie also received a 30-minute individual therapy session to target comprehension, attention and listening skills and specific signed vocabulary.

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INVOLVING PEERS
Figure 1 Games for learning signs
Vocabulary topic Home and my family Animals Food Toys Nursery areas Colours Christmas Group activity Big picture book Posting pictures into a postbox Pass the Parcel with individually wrapped toy food items Feely bag Asking children to place sign cues in each area as a prompt Making coloured paper hats for staff and children to wear Sticking pictures onto a large Christmas tree

was offered and attended a weekly group session run in clinic to build on her speech and signing skills and has continued to grow in confidence and communicative ability.

Ensuring sustainability
Sophie will start mainstream reception in September (2004) and the nursery nurse who supported her in the nursery setting will continue to work with her there. Members of staff from her new school are also receiving Makaton training from our department. As some children from Sophies nursery will also be attending reception with her, she can continue to build on the friendships she has developed, as they in turn support her communication development. Bell et al. (2001) highlight the importance of ensuring sustainability of intervention after support is withdrawn, and the training provided to Sophies peers means that the work begun in nursery can transfer to reception with them. Our Special Needs team is continuing to support children with augmentative and alternative communication needs in mainstream settings and we are hoping to support other Makaton users by offering similar packages of care to nursery and reception settings this coming year. Having established a therapy plan that can be adapted to suit the needs of each individual child, we would like to measure further the benefits of our input, as well as developing the package. We plan to: Take an accurate measure of both receptive and expressive language skills before and after input; Observe communicative interaction with adults and peers before and after input (including number of formal communicative turns and analysis of function of communication); Develop a resource library within our department of topic-based sign sheets and generalisation games / ideas for nursery to carry out each week; Encourage nursery staff to lead sessions to increase their confidence. We also intend to explain our involvement in a letter to parents of other children in the nurseries. Since Sophie has left nursery the staff have continued to use Makaton signing on a daily basis, although they currently have no children with a specific need for signing. They see it as an investment for children in the future who are using signs to support their communication, and as part of offering a supportive environment to include children with a range of needs and abilities. Working with Sophie, her peers and the dedicated nursery staff gave me the opportunity to experience an interdisciplinary team with common goals, an essential element of collaborative teamwork (Giangreco, 1997) and fundamental to the principles of inclusive education (Rainforth & York-Barr, 1997). All professionals involved with Sophie benefited from the team approach, with chances to share ideas, troubleshoot and extend Sophies individualised education plan targets as she progressed. The progress that Sophie has made is a credit to her, her parents and all the hard work and enthusiasm from the nursery staff in acquiring new skills and adapting

The children were very enthusiastic about the weekly visit from a new friendly face - especially one who brought stickers! Each week, they eagerly watched, listened and practised using signs - and showed remarkable recall of signs that theyd learnt in previous weeks. They were keen to demonstrate the signs that they had remembered when I returned each week and were motivated to learn more. With the staffs support, the children began to use Makaton signs every day in functional contexts, such as using key word signing during their planning time to indicate I am going to work with paint (underlined words = signed words).

Prior knowledge
The nursery staff reported that the support they were receiving in nursery encouraged and gave them the confidence to attend the Makaton Foundation Workshop that our department was running. They were able to start the course with some prior knowledge of Makaton rather than going in cold as complete beginners. Within the nursery setting the staff became more confident in working with Sophie, both in terms of their own Makaton signing and understanding Sophies signs. One member of staff reported that Sophie was able to use a combination of speech and sign to tell her that she had been swimming and had worn a yellow and green swimming costume. She would previously have found this very difficult to understand and was pleased to be able to interpret it, say it back to Sophie, and have Sophie confirm it. Staff also found that the other children consistently supported Sophie with her signing. For example, if they were outside playing they would ask her, Do you want a turn on the car? or Do you want to play in the house? (underlined words = signed words). The staff independently identified several ways that Makaton use could be incorporated into the daily nursery routine, such as planning time in the morning and signing a carol at their Christmas nativity play. After the terms input I was able to withdraw my weekly support knowing that the team was successfully integrating Makaton into nursery life for all the children. For Sophie this meant there were particular benefits: Sophie became a more confident and assertive communicator, using signs more regularly during her time at nursery to comment, request, reject, and for social purposes. The circle time gave her a chance to be the nursery star, as she had a head-start in Makaton signing. She was able to demonstrate signs she already knew to her peers and so play a role in helping them

to develop their skills in communicating with her. Around this time, Sophie began to expand her expressive language by using occasional two element phrases (eg. word + sign, sign + sign). The use of Makaton signing at planning time provided her with an excellent model to do this. Sophie was able to participate more fully in activities in nursery, such as joining in with signing the Christmas carol. As the children practised the carol before the concert, it was rewarding to see Sophie gradually sign more and more along with the other children and to see at the final dress rehearsal how much of the carol she had learnt. Pleasingly, Sophies acquisition of signed vocabulary increased (to 55-60 signs / words) through the regular use of signs at nursery. During individual sessions she was seen to use several signs that hadnt been targeted individually, showing how much she benefited from the signing environment. She was also keen to show me new signs she had learnt, and often demanded my attention specifically to do this.

The staff independently identified several ways that Makaton use could be incorporated into the daily nursery routine
The input that I provided in the nursery supported all those involved: Sophie, her peers, and the staff. Using a range of simple, easily available resources to carry out activities meant that there was a minimum of preparation time required for each session. It was an effective way of delivering therapy within this setting, as it targeted a number of different needs at once: Sophies need to develop her expressive language skills through signing Sophies need for those around her to understand and support her signing The nursery staffs need to learn Makaton to facilitate Sophies involvement in nursery Sophies peers need to understand and communicate with her, in order to build on their friendships with her. Since the weekly input ended I have visited Sophie in nursery once or twice each term to update sign vocabulary, to learn a song with the children at circle time and to review her communication development. The staff are confidently using Makaton in nursery and, when Sophie began to attend whole days, the staff extended its use to the afternoon children as well. Sophie

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INVOLVING PEERS

News extra
the nursery environment to create an inclusive atmosphere that all children and adults could take part in sustaining. Anna Westaway is a speech and language therapist and a Regional Makaton Tutor with South Tyneside PCT Special Needs Team based at Stanhope Parade Health Centre, Gordon Street, South Shields NE33 4JP, tel. 0191 451 6123, e-mail anna.westaway@sthct.nhs.uk. *Makaton is a communication system using signs and symbols alongside speech, used by a range of individuals with communication impairments. See http://www.makaton.org.

Communication on the political agenda


Communication impairment was on the Scottish political agenda in June, first with a working group at the Scottish Parliament and then with people who stammer presenting evidence at an equal opportunities inquiry. The short-life working group was organised by the Royal College of Speech & Language Therapists and Speech and Language Therapy Managers Network Communication Impairment Action Group. The MSPs agreed to appeal directly to ministers for a Scotland-wide strategy for people with communication impairment. In addition, they will seek a members debate and examine all legislation for its impact on people with communication impairment. The Action Group is calling for comprehensive research to identify and quantify those who have a communication impairment in Scotland as a unique group. They want the impact on health and wellbeing to be better recognised and all policy and practice to take account of the needs of people with communication impairment. www.rcslt.org Meanwhile, eight people who stammer have also visited the Scottish Parliament with the British Stammering Associations Scotland Development Manager, Jan Anderson. They gave oral evidence to the Equal Opportunities Committees Removing Barriers: Creating Opportunities inquiry which is exploring barriers and identifying positive strategies for challenging inequalities. The group commented on the three key areas of work, further and higher education and having a social life. It also called for greater recognition of stammering amongst teachers and speech and language therapists from an early age to adulthood and for improvements in speech and language therapy provision. www.stammering.org.uk/scotland

Acknowledgements
I would like to thank the staff of Hedworthfield Nursery, Jarrow for their commitment to meeting Sophies needs and also her parents for giving me their permission to write this article.

autism. The Society also believes that, although statements are bureaucratic, unless there is adequate teacher training, resourcing and accountability for progress of children with autism in schools, parents will not have the confidence that their childs needs can be met without a statement. The National Autistic Society response came as shadow education spokesman David Cameron MP called on the government to fulfil its mini-manifesto promise of a national audit of special school provision and meanwhile to have a moratorium on special school closures, and Baroness Warnock suggested the time was right for a rethink of the policy of inclusion and the special education system. www.nas.org.uk www.conservatives.com Baroness Warnocks pamphlet Special Educational Needs: A new look is available from The Philosophy of Education Society of Great Britain, see www.philosophy-of-education.org.

References
Baumgart, D. & Giangreco, M.F. (1996) Key lessons learned about inclusion, in Lehr, D. & Brown, F. (eds.) People with disabilities who challenge the system. Baltimore: Paul H. Brookes. Bell, T., Purcell, M., Walker, B. & Nisbet, N. (2001) Evaluation of a model of intervention to create a visually enriched environment. International Journal of Language and Communication Disorders, 36 (Supplement). Centre for Studies on Inclusive Education (2002) The Inclusion Charter. 2nd edn. Available at: http://www.inclusion.uwe.ac.uk/csie/charter.htm (Accessed: 25 June 2005). Giangreco, M.F. (1997) Key lessons learned about inclusive education: summary of the 1996 Schonell Memorial Lecture. International Journal of Disability, Development and Education, 44(3), pp. 193-206. Rainforth, B. & York-Barr, J. (1997) Collaborative teamwork: Integrated therapy services in educational programs for students with severe disabilities. Baltimore: Paul H. Brookes. Sutton, A.C. (1982) Augmentative communication systems: The interaction process. Annual Convention of the American Speech-LanguageHearing Association. Toronto. von Tetzchner, S. & Martinsen, H. (1992) Introduction to sign teaching and the use of communication aids. London: Whurr.

Position statement on cochlear implants


Defeating Deafness is calling for more funding to be made available to enable every adult who would benefit from a cochlear implant to have one. The charity says there are now more than 4,000 cochlear implant users in the UK but that, while most children who would benefit now receive one, many adults are missing out. It has produced a position statement which it hopes will encourage health authorities to make more funding available. Cochlear implants are designed for people with severe to profound sensorineural hearing loss as they work by stimulating the auditory nerve, bypassing damaged sensory cells in the cochlea. www.defeatingdeafness.org

Practice consultation
The Health Professions Council is inviting comment on proposals about returning to practice and managing fitness to practise. The full documents are online and comments can be submitted by post or e-mail. The consultation period ends on 9th September. www.hpc-uk.org/aboutus/consultations/ Meanwhile, the Health Professions Council has joined forces with the NHS Counter Fraud and Security Management Service to target bogus health workers, people stealing the identities of real healthcare professionals, and professionals committing fraud. The chief executives of the two organisations have signed a protocol designed to safeguard patients and staff in England and Wales through sharing information and closer working. www.cfsms.nhs.uk

Inclusion needs genuine choices


The National Autistic Society has joined in the debate on inclusion with a call for sufficient training, resources and support to enable genuine choice to meet the individual need. The society points out that, as there are 90,000 children in the UK with autism and approximately 7,500 specialist educational placements for this population, the reality for most is mainstream education. It believes that while some children with autism may do well in mainstream schools with varying levels of support, those with more complex needs may have a more inclusive experience in a specialist setting, and that this provision should not be cut as long as it is necessary for any child with

DO I UNDERSTAND THAT WORKING WITH AN INDIVIDUAL CAN INFLUENCE COMMUNICATION SUPPORT FOR OTHERS? DO I CONSIDER INCLUDING FRIENDS AND PEERS AS SUPPORTERS OF THERAPY PROGRAMMES? DO I GIVE CLIENTS THE OPPORTUNITY TO BE THE EXPERT?

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

CONFERENCE CALLS

Conference calls:
THE COMMUNICATION SKILLS APPROACH TO THE MANAGEMENT OF STAMMERING IN ADOLESCENCE WAS HELD ON 14-16 JUNE, 2005 AT STRACATHRO HOSPITAL BY BRECHIN, FACILITATED BY JANE FRY. THE DAYS WERE ENTIRELY FUNDED BY THE GANNOCHY TRUST.

Stammering in
1. Learning from history
Jane referred to the variety of approaches that we can draw on when working with people who stammer. We have a legacy of ideas and strategies, which is vital considering the varied nature of stammering and the individual nature of therapy. Speak more fluently, stutter more fluently and communication skills approaches are commonly integrated, and often applied within the broader context of psychological therapies such as Personal Construct Psychology and, more recently, Solution Focused Brief Therapy and Cognitive Therapy. Importantly, therapy in the UK is typically clientcentred, with therapists responding to the individual goals, needs and preferences of each client. ple stammer, constructing a personal iceberg of stammering (Sheehan, 2001), watching videos of stammering and ultimately observing themselves on video, and by instructing therapists how to stammer as they do. Other techniques include freezing, or holding on to the moment of stammering until physiological tension reduces, and using voluntary or deliberate stammering. By helping clients to acknowledge and confront their stammer, their objectivity and emotional distance from stammering is increased. Clients are then able to be less reactive to moments of stammering, which in turns enables them to manage these moments more calmly and with greater choice.

In June speech and language therapists from all over Scotland, including editor Avril Nicoll, gathered to hear Jane Fry speak about the Michael Palin Centre for Stammerings approach to working with teenagers. Here, Avril and Jane summarise the key themes from a workshop that showed how to integrate fluency management, communication skills therapy and cognitive reframing with young adults who stammer, and particularly highlighted the value of group work.

2. Acknowledging readiness
Jane emphasised the importance of clients being ready for therapy and being able to take responsibility for change. This is particularly the case when working with young adults, who may or may not see their stammer as a priority. As therapists our role is to offer choices about therapy and to support young adult clients in the decisions that they make, which at times may include not attending therapy. Where teenage clients express low interest in therapy we have the opportunity to validate their own decision-making as well as to provide an open door back into our services when the time is right for them. Another aspect of timing in therapy for stammering is related to the pace at which therapy moves. As therapists it is vital that we are aware of the issues that may be involved in change for clients, whether this is related to changing speech or making changes in more general communication style and interaction. Group therapy, particularly for teenagers, can be highly effective as there is both the opportunity to learn from each other and to support each other. Follow-up however is crucial to help clients maintain the changes that they make.

4. Focusing on solutions
Solution Focused Brief Therapy highlights the individuals strengths and builds on what they already do that helps them. By judicious use of language (see feature on p.18) therapists help clients to notice and explore positive changes. Clients are able to tell their story about their problem but are also helped to move towards a future when the problem is less of a concern or issue. Rating scales are used to help individuals identify where they are currently, where they would ideally like to be, and where will be an acceptable goal. This process helps to introduce the importance of establishing realistic goals with young adults who stutter. Specific signs of change are then elicited which typically focus on positive changes in communication, interaction and engaging-in-life activities as well as being focused on fluency. For example, clients may identify that when things are better they will be more fluent, and also that at this time they will be talking more, smiling more, going out more or phoning up their friends more. Avril found it instructional to see video samples of young people who stammer and are attending the Michael Palin Centre, and says their level of coping and emotional literacy is testament to the effectiveness of the therapy they are receiving. Brief therapy is very different to a traditional approach to therapy where our starting place is the clients problem. Avril notes that, when her breakaway group was given a case example of a young woman, it wasnt particularly easy to focus on the womans strengths rather than the problem. (As a colleague commented wryly, The problem is, were all Mrs Fix-its!) A good start is trying the method out on yourself.

JANE FRY IS A SPECIALIST SPEECH AND LANGUAGE THERAPIST AT THE MICHAEL PALIN CENTRE FOR STAMMERING CHILDREN IN LONDON. SHE IS ALSO QUALIFIED AS A COGNITIVE THERAPIST. THE MICHAEL PALIN CENTRE FOR STAMMERING CHILDREN ACCEPTS TERTIARY REFERRALS FOR CHILDREN UP TO 18 YEARS OF AGE AND PROVIDES SUPPORT TO THERAPISTS ACROSS THE UK. THE CENTRE RUNS AN ANNUAL 2-WEEK INTENSIVE THERAPY COURSE FOR YOUNG ADULTS AGED 16-19. FOR INFORMATION ABOUT HOW TO REFER CLIENTS TO THE CENTRE, OR ABOUT HOW TO ATTEND FUTURE WORKSHOPS, SEE WWW.STAMMERINGCENTRE.ORG OR PHONE 0207 530 4238.

3. Creating distance / desensitisation


The workshop included discussion on the importance of helping clients to become more desensitised to their stammer, and the range of activities that help with this process. Clients may be helped to identify and acknowledge both overt and covert aspects of their stammer by participating in group discussions about what happens when peo-

10

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CONFERENCE CALLS
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young adults
5. Reframing self-talk
Jane introduced some key ideas which are central to Cognitive Therapy, another of the psychological therapies used at the Michael Palin Centre. Cognitive therapy is used to help people with a variety of emotional problems, and more recently it has been applied to stammering. In Cognitive Therapy there is emphasis on the role of negative automatic thoughts and negative self-talk in affecting individuals emotional, physiological and behavioural responses to events. A central idea to both cognitive therapy and brief therapy is that our responses to problems frequently make things worse rather than better. Therapists ask questions such as What went through your mind at that moment? and If that were to happen, what would be the worst thing about that for you? to help clients identify their thoughts or predictions about stammering. They are encouraged to test out their predictions rather than accept them as fact, to consider alternative possibilities or ways of seeing things, and to develop more effective problem solving skills. Cognitive reframing refers to the process of seeing something from a different perspective and is a core part of all psychological therapies typically used in the treatment of stammering. Many therapists in the UK have completed post-graduate study in Personal Construct Psychology, Cognitive Therapy, Brief Therapy or Narrative Therapy. Further training and ongoing supervision is highly recommended by Jane for therapists who wish to develop their skills in working with the psychological aspects of stammering. group lies in it providing a forum for young adults to encourage each other and provide each other with positive feedback. Jane emphasised the value of group work for young adults and the importance of communicating with teenagers with honesty and openness. While some clients may require individual therapy first for a number of reasons, or may not find the idea of group work appealing, for many it provides an ideal opportunity to share ideas and experiences, to dismantle the isolation which often accompanies stammering, and to explore and develop their own solutions.

7. Moving on
Where stammering is established or chronic any course of therapy is best viewed as a beginning, or as a continuation of work, rather than the end of it. Our teenage clients are helped to develop personal action plans which clarify how they will continue working towards their goals as well as how they will deal with setbacks. Follow-up days are scheduled for the following 12 months after the group and clients have additional individual sessions if they wish. However there is emphasis on clients continuing independently and developing self-help skills rather than being dependent on the therapist. Our role is thus to provide a map of the territory and to help clients explore for themselves how they might manage their stammer more successfully, have more options related to fluency, and develop their confidence and skill in communicating. Questions that are often used to help clients develop their action plan include: What did you work on that was helpful? Why did you work on that? What are the most important things to keep doing? How will you make sure you keep it going? What is your advice to yourself for the future? What will you do to get back on track when things are not going well?

6. Reducing fear
It is important that as therapists we understand the degree of fear that may be associated with stammering for some clients, and that we are aware of how this fuels avoidance and struggle, as clients attempt to avoid stammering or force through moments of stammering rapidly. As therapists we have a role both in acknowledging and understanding clients fears as well as encouraging clients to expand their comfort zone and reduce avoidance, at the pace that is right for the individual. Clients are helped to gradually approach more challenging situations by working through hierarchies of situations that are meaningful to them, and within these to gradually experiment with managing their fluency differently, thinking about their communication skills and using more balanced or helpful self-talk. At the Michael Palin Centre therapists encourage clients to think in terms of having a go rather than success or failure, and to think about overall communication skills and confidence rather than focus on fluency alone. Again, the power of the

References
Sheehan, J. (2001) Message to a stutterer. Available at: http://www.stutterssc.org/joemessage.htm (Accessed: 17 July 2005).

Resources
* The Michael Palin Centre for Stammering, see www.stammeringcentre.org. * National Special Interest Group Disorders of Fluency, see www.fluencysig.org.uk * For further information on Cognitive Therapy, Jane recommends Beck, J.S. (1995) Cognitive Therapy: Basics and Beyond. NY: Guilford Press. * Introductory information about Narrative Therapy is at www.narrativeapproaches.com, Personal Construct Psychology at http://www.repgrid.com/pcp/ and Solution Focused Brief Therapy at www.brief-therapy.org (Accessed: 14 August 2005).

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11

EVIDENCE BASED PRACTICE

EXPERT GUIDANCE:

Head and neck cancer dysphagia


In November 2004, speech and language therapists specialising EXPERT GUIDANCE: in head and neck cancer dysphagia met in Newcastle to seek DRIVERS FOR CHANGE consensus on their role. Jo Patterson reflects on the evidence KEY DOCUMENTS AND RESEARCH PROFESSIONAL CONSENSUS presented and the implications for future research.

ead and neck cancer and its treatment can have devastating effects on the ability to eat and drink. Rehabilitation of swallow disorders decreases the morbidity of aspiration and allows for better nutrition, better hydration and overall improvement in quality of life (Simental & Carrau, 2004). In 1996, Communicating Quality 2 stated that there were few speech and language therapists working in this field, training at undergraduate level was sparse and that clinicians tended to learn by experience. Over the past five years there have been some significant changes in practice. The number of dedicated speech and language therapy posts has increased, many pump primed by Macmillan Cancer Relief. Our role with this client group is now recognised by a number of key head and neck cancer documents (BAH-ONS Consensus document, 2000; NICE Head and Neck Cancer Improving Outcomes Guidance, 2004; RCSLT Guidelines, 2005; Scottish Intercollegiate Guidelines Head and Neck, in press). Treatment regimes have evolved. Surgeons have developed techniques to conserve certain key structures. Radiotherapy may be used in combination with chemotherapy (chemoradiotherapy). The consequence for function is under-represented in the literature. Our evidence based study day in Newcastle sought to address some of these changes and to seek consensus on the current role of speech and language therapy with this population. Three areas of clinical practice were appraised: pre-treatment assessment, instrumental assessment and intervention. A critical review of the literature was followed by case presentations and audience debate.

establish food preferences and routines for treatment planning and tailoring patient expectations (Appleton & Machin, 1995). clarify our role within the multidisciplinary team (Sullivan & Guilford, 1999). assess for dysphagia. This is often part of the presenting symptom and patients are frequently malnourished. Remedial nutritional and swallowing strategies may be introduced in preparation for treatment. Stenson et al. (2000) documented aspiration rates ranging from 14 per cent in oral cancer rising to 80 per cent in hypopharyngeal cancers. Advanced disease results in greater pharyngeal residue and poorer transit times (Pauloski et al., 2000). collect baseline information. The collection of pretreatment data is important for evaluating the effects of treatment. Dysphagia as a consequence of treatment should not be compared to a model of normal swallowing. teach exercises or manoeuvres in preparation for the effects of treatment (Kotz et al., 2004). There is no research to support this and further work is necessary.

Pre-treatment assessment is recommended. The evidence for our role is primarily expert opinion.
2. WHAT IS THE EVIDENCE FOR INSTRUMENTAL ASSESSMENT IN HEAD AND NECK CANCER DYSPHAGIA?
(speaker Jo Patterson, Sunderland Royal Infirmary) Head and neck cancer dysphagia can be complex, multi-factorial and subject to change due to disease progression or treatment effects. Assessment is necessary to understand the altered swallow physiology, to plan treatment, and for prognostic information and safety issues regarding eating and drinking. a. Which assessment should we use? A range of assessment tools is used in head and neck cancer research. The most commonly reported are videofluoroscopy and fibreoptic endoscopic evaluation of swallowing (FEES). In an American survey, speech and language therapists more commonly

1. WHAT IS THE EVIDENCE FOR PRETREATMENT ASSESSMENT?


(speaker Mary Jackson, Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary) Pre-treatment assessment is recommended by the guidelines mentioned. The evidence for our role is primarily expert opinion. The functions are to: offer reassurance, support, give information on potential swallowing difficulties and to engage the patient in the rehabilitation process (Logemann, 1993). Individual patients vary in how they prioritise treatment effects at this stage. Cure from cancer consistently ranks highly (List et al., 2000). Where there is a choice of treatments available, and survival rates are similar information on the functional consequences can be the deciding factor.

recommended videofluoroscopy as an adjunct to their clinical assessment, especially the less experienced clinicians. However, 51 per cent had access to videofluoroscopy compared to just 3 per cent FEES, which may have influenced their decision (MathersSchmidt & Kurlinski, 2003). In terms of cost, Aviv et al. (2001) found that the average price of a videofluoroscopy for a head and neck cancer patient was $451 compared to just $321 for a FEES. b. Assessment limitations In certain circumstances either videofluoroscopy or FEES will suffice. The clinician needs to be aware of the shortcomings of each test, as in some situations they are not inter-changeable. This can be demonstrated by comparing two nasopharyngeal cancer studies. Chang et al. (2003) used videofluoroscopy and Wu et al. (2000) used FEES to assess swallowing ability. Some outcomes were remarkably similar, for example pharyngeal stasis was observed in 80 per cent of patients in both studies. FEES identified more cases of post-swallow aspiration (77 per cent versus 4 per cent). This may reflect the time limits of radiation exposure during videofluoroscopy. Higher rates of aspiration during the swallow were seen via videofluoroscopy. This cannot be viewed via endoscopy due to white out. c. The role of assessment tools in therapy Instrumental tools may have a role in providing biofeedback during therapy. Logemann et al. (1992) compared videofluoroscopy used at intervals throughout therapy with clinical assessment alone. The videofluoroscopy group tended to start oral feeding later because aspiration was identified on x-ray. Conversely, this may lead to a more conservative approach as both groups were able to tolerate aspiration. On long-term follow-up, the videofluoroscopy group had better oropharyngeal efficiency scores, suggesting that therapy techniques were more focused. FEES has also been used in therapy (Denk & Kaider, 1997). A mixture of swallowing manoeuvres was taught via endoscopy and compared to a control group. Patients benefited from the biofeedback in the early stages of treatment. Further work is needed to identify which manoeuvres are best taught by this method.

3. WHAT IS THE EVIDENCE FOR HEAD AND NECK CANCER INTERVENTIONS?


(speakers Annette Kelly, the Royal National Throat Nose and Ear Hospital, London & Emer Scanlon, Western General Hospital, Edinburgh) A loss or reduction in function of the oral and pharyngeal stages of the swallow can respond to

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EVIDENCE BASED PRACTICE

compensatory procedures and therapy techniques. a. Swallowing manoeuvres Logemann et al. (1994a) and Logemann et al. (1997a) evaluated airway protection manoeuvres in post-radiotherapy and post-supraglottic laryngectomy patients respectively. In the irradiated patients, this technique reduced or completely resolved aspiration. The majority of the post-surgical patients (88 per cent) also benefited. Zuydam et al. (2000) reported on oropharyngeal patients, treated by surgery, some with adjuvant radiotherapy. The supraglottic swallow combined with chin tuck was successful for a third of the patients with large resections, and in all of those with a small resection. Patients also received range of motion exercises. These results are promising and support our intervention, but subject numbers are small (range 9 - 13).

Head and neck cancer dysphagia can be complex, multi-factorial and subject to change due to disease progression or treatment effects.
The duration and amplitude of tongue base to pharyngeal wall contact differs across swallowing manoeuvres (Lazarus et al., 2002a). All techniques (airway protection, effortful swallow, tongue hold manoeuvre, mendelsohn) improved contact and reduced residue in three laryngeal cancer patients. The mendelsohn achieved the longest contact but the effortful swallow had greater amplitude. There was little information on the reliability of measurements and again the subject numbers were small. b. Swallowing postures Logemann et al. (1994b) looked at the effects of different postures on 32 head and neck cancer patients who were known to aspirate. Patients with the same resection exhibited different swallow physiology, so different postures were employed. The breakdown in swallowing cannot be predicted by the nature of the treatment. Eighty one per cent of patients were able to swallow without aspiration following the introduction of a posture. It was ineffective for six patients (19 per cent). They had either extended laryngeal conservation surgery or resections involving more than one site. c. Swallowing exercises The use of range of motion exercises was reviewed in a pilot study without a control group (Logemann et al., 1997b). Improved swallow efficiency was observed in oral and oropharyngeal cancer patients. Shaker et al. (2002) randomised 27 dysphagic patients to compare a suprahyoid muscle strengthening exercise to a sham exercise.

Treatment groups had mixed aetiologies and 22 per cent had received radiotherapy for head and neck cancer. There was a significant increase in anterior laryngeal excursion and upper oesophageal opening. Aspiration resolved in all patients following six weeks of the exercise. A tongue holding manoeuvre for pharyngeal wall movement was assessed in a pilot study on 11 oral cancer patients (Fujiu & Logemann, 1996). There was no statistical difference on swallow transit times, but an increase in movement was observed. Further work is needed. d. Multidisciplinary interventions Only one paper was identified on prosthetic rehabilitation, on four patients (Logemann et al., 1989). Palatal prostheses were found to improve oral control. An increase in duration of tongue base to pharyngeal wall contact was also noted. Cricopharyngeal myotomy failed to improve swallowing in a multi-centre study of head and neck cancer patients (Jacobs et al., 1999). Lazarus et al. (2002b) reported a single case study where a laryngectomy had been performed due to protracted dysphagia post-chemoradiotherapy. Although successful in rectifying aspiration, the patient was unable to generate adequate tongue pressure to clear thicker textures. As with most of the literature relating to intervention, the patients perspective was not reported.

non-treatment control groups is problematic, given that our involvement has been recommended by guidelines. Small case series or single case studies are practical and useful. 3) National agreement There are no agreed national measures to enable multi-centre projects. In the future, Phase II of the Dataset for Head and Neck Oncology (DAHNO) may generate some basic information on outcomes. The NICE Improving Outcomes Guidance (2004) calls for more research on the timing and frequency of rehabilitation and which techniques are successful for specific impairments. With small numbers of clients, it is particularly important to consider a national or multi-centre approach. Jo Patterson is a speech and language therapist at Sunderland Royal Infirmary, e-mail Jo.Patterson@chs.northy.nhs.uk. The information in this article is based on a study day Evidenced Based Practice in Head & Neck Dysphagia Management at the Freeman Hospital Newcastle upon Tyne, 19 November 2004, organised by Paul Carding and Jo Patterson.

THE FUTURE
1) The evidence base The evidence base for speech and language therapy in head and neck cancer is limited and is predominantly supported by professional consensus. The NICE evidence review (2004) did not locate any studies conducted in the UK. Such studies do exist, although they are small in number. The NICE guidelines state that, although patients appeared to benefit from therapy, there were few details given on type of treatment. Much of the literature reviewed was retrospective with potential biases. Studies should be prospective and include details of therapy. 2) Research There are difficulties in conducting research in this area. Access to resources, funding, appropriate supervision and protected time can be problematic. There are a large number of variables to consider. Patient numbers are small, becoming more apparent when broken down to site and size of tumour and type of treatment. Small case series or single case studies may be the only appropriate design for certain groups but still provide clinically relevant material. Treatment side effects can be highly individual. Common problems such as pain, ulceration, dry mouth and taste changes are further considerations when measuring swallowing ability and response to therapy. Rate of attrition can be high for longitudinal studies due to the disease prognosis, alcohol addiction and social issues. Ethical approval for

A loss or reduction in function of the oral and pharyngeal stages of the swallow can respond to compensatory procedures and therapy techniques.
Acknowledgements
I would like to thank Kate Willson, Kate McFarlane, Helen Rust and Shannon Rees for case presentations at the study day, and Fiona Robinson and Paul Carding for chairing it.

References
Appleton, J. & Machin, J. (1995) Working with Oral Cancer. Bicester: Winslow Press Ltd. Aviv, J.E., Sataloff, R.T., Cohen, M. et al. (2001) Cost-effectiveness of two types of dysphagia care in head and neck cancer: A preliminary report, ENT Journal 80(8), pp. 553-556. British Association of Otohinolaryngologists - Head and Neck Surgeons (2001) Effective Head and Neck Cancer Management: Second Consensus Document. London: Royal College of Surgeons. Chang, Y.C., Chen, S.Y., Lui,,L.T. et al. (2003) Dysphagia in patients with nasopharyngeal cancer after radiation therapy: A videofluoroscopic swallowing study, Dysphagia 18, pp. 135-143. Denk, D.M. & Kaider, A. (1997) Videoendoscopic biofeedback: a simple method to improve the efficacy of swallowing rehabilitation of patients after head and neck surgery, Otorhinolaryngology 59, pp. 100-105. Fujiu, M. & Logemann, J.A. (1996) Effect of a tongue-holding manoeuvre on posterior pharyngeal wall movement during deglutition, American J Speech-Lang Path 5, pp. 23-30. Jacobs, J.R., Logemann, J.A., Pajak, T.F., Pauloski, B.R., Collins, S., Casino, R.R. & Schuller, D.E. (1999) Failure of cricopharyn-

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EVIDENCE BASED PRACTICE / REVIEWS

reviews
geal myotomy to improve dysphagia following head and neck cancer surgery, Arch Otolaryngol Head Neck Surg 125. Kotz, T., Costello, R., Li, Y. & Posner, M. (2004) Swallowing dysfunction after chemoradiation for advanced squamous cell carcinoma of the head and neck, Head & Neck pp. 365-372. Lazarus, C., Logemann, J.A., Song, C.W., Rademaker, A.W. & Kahrilas, P.J. (2002a) Effects of voluntary maneuvers on tongue base function for swallowing, Folia Phoniatr Logop 54, pp. 171-176. Lazarus, C., Logemann, J.A., Guoxiang, S., Kahrilas, P., Pelzer, H. & Kleinjan, K. (2002b) Does laryngectomy improve swallowing after chemoradiotherapy?, Arch Otolaryngol Head Neck Surg 128, pp. 54-57. List, M.A., Stracks, J., Colangelo, L. et al. (2000) How do head and neck cancer patients prioritize treatment outcomes before initiating treatment?, Journal Clinical Otolaryngology, 18, pp. 877-884. Logemann, J.A., Kahrilas, P.J., Hurst, P., Davis, J. & Krugler, C. (1989) Effects of intraoral prosthetics on swallowing in patients with oral cancer, Dysphagia 4, pp. 118-120. Logemann, J.A., Roa Pauloski, B., Rademaker, A., Cook, B., Graner, D., Milianti, F., Beery, Q., Stein, D., Bowman, J., Lazarus, C. et al. (1992) Impact of the diagnostic procedure on outcome measures of swallowing rehabilitation in head & neck cancer patients Dysphagia 7(4), pp. 179-86. Logemann, J.A. (1993) Evaluation and treatment of swallowing disorders. Pro-Ed. Logemann, J.A., Gibbons, P., Rademaker, A.W., Pauloski, B.R., Kahrilas, P.J., Bacon, M. et al. (1994a) Mechanisms of recovery of swallow after supraglottic laryngectomy, J Spch & Hear Res 37(5), pp. 965-74. Logemann, J.A., Rademaker, A.W., Pauloski, B.R. & Kahrilas, P.J. (1994b) Effects of postural change on aspiration in head and neck surgical patients, Otolaryngology - Head & Neck Surgery 110(2), pp. 222-7. Logemann, J.A., Pauloski, B.R., Rademaker, A.W. & Colangelo, L.A. (1997a) Super-supraglottic swallow in irradiated head & neck cancer patients, Head & Neck 19, pp. 535-540. Logemann, J.A., Pauloski, B.R., Rademaker, A.W. & Colangelo, L.A. (1997b) Speech and swallowing rehabilitation for head and neck cancer patients, Oncology 11(5), pp. 651-6. Mathers-Schmidt, B.A. & Kurlinski, M. (2003) Dysphagia Evaluation practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-making, Dysphagia 18, pp. 114-125. National Institute for Clinical Excellence (2004) Improving Outcomes in Head and Neck Cancer. Available at: http://www.nice.org.uk (Accessed: 20 July 2005). Pauloski. B., Rademaker, A., Logemann, J., Stein, D., Beery, Q., Newman, L., Hanchett, C., Tusant, S. & MacCracken, E. (2000) Pretreatment swallow function in patients with head & neck cancer, Head & Neck pp. 474-482. Royal College of Speech & Language Therapists (2005) Clinical Guidelines. London: RCSLT, see www.rcslt.org Shaker, R., Easterling, C. et al. (2002) Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening, Gastroenterology 122, pp. 1314-1321. Simental, A.A. & Carrau, R.L. (2004) Assessment of swallow function in patients with head and neck cancer, Current Oncology Reports 62, pp. 162-165. Stenson, K.M., MacCracken, E., List, M. et al. (2000) Swallowing function in patients with head and neck cancer prior to treatment, Archives Otolaryngol Head Neck Surg 126(3), pp. 371-375. Sullivan, P. & Guilford, A. (1999) Swallowing intervention in Oncology. Singular publishing group. Wu, C.H., Hsiao, T.Y., Ko, J.Y. & Hsu, M.M. (2000) Dysphagia after radiotherapy: endoscopic examination of swallowing in patients with nasopharyngeal cancer, Ann Otol Rhino Laryngol 109(3), pp. 320-325. Zuydam, A.C. et al. (2000) Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma, Br J Oral & Maxillofacial Surgery 38, pp. 513-518.

BRIEF THERAPY
Focus On Solutions - A Health Professionals Guide Kidge Burns Whurr ISBN 1 86156 479 1 17.50

An excellent introduction
This book provides a practical, concise guide on how to incorporate a solutions based focus into our clinical work. It is written in a clear, readable style, giving specific examples and ideas to use with clients, and summarising each section in key points. It is like a working with tool, without being specifically focused on one client group. This book addresses most settings, that is acute, community, group work and family support. It provides the clinician with an insight into how to empower the client by enabling them to set and evaluate their own care aims and goals, using skills and abilities they themselves have identified as personal strengths. From the highly experienced therapist to the newly qualified professional, this professionals guide provides an excellent introduction to the concept of solution focused brief therapy. Elizabeth Ferguson, BA (Hons), MRCSLT is a specialist speech and language therapist in adult neurology with Wokingham PCT.

The script has interesting features to indicate movement, speed and intonation and is kept to a very simple level in terms of sentence length with generally familiar vocabulary. We tried the book with mainstream school children of 4 and 5 years of age with great success. Children with speech / language difficulties were able to follow the story and participated in discussion during and after the story. The class teacher was impressed by the amount of information the book encouraged from reluctant speakers. I would definitely use the book with children attending language groups in the clinic and would particularly recommend it for teachers / parents of children at the Foundation stage. Sue Ward is a speech and language therapist working in community clinics and mainstream schools for East Leeds PCT.

creating inclusive environments. I certainly think they have achieved this and it is a good resource for any professional team supporting schools to have. Sally Legerton, speech and language therapist, is Lead Clinician for Mainstream Schools, North Surrey PCT.

LANGUAGE DEVELOPMENT
Supporting Children with Speech and Language Cathy Allenby & Judith FearonWilson (Hull Learning Services) David Fulton Publishers ISBN 1-84312-225-1 10.00

Easy to dip into


This is a good, concise reference guide in a summarised form. It provides many helpful strategies to aid and develop a variety of skills. Example models for techniques are shown in a very accessible format. The bold print makes the book easy to dip into and locate specific details without problem. The general absence of technical language facilitates use by a range of providers. Mainstream classroom teachers would find the section on inclusion particularly helpful. The example of the speech and language individual education plan (IEP) would fit nicely into the completed scholastic IEP where required. Flowcharts, checklists and the explanations using childrens ideas were appreciated by the Support for Learning team within our school. The Support for Learning Team, Inverbrothock Primary School, Arbroath.

AUTISTIC SPECTRUM DISORDER


Supporting Children with Autistic Spectrum Disorder Colleen OConnell, Elizabeth Morling & Carole Stitt (Hull Learning Services) David Fulton Publishers ISBN 1-84312-219-7 10.00

Packed with strategies


This is an excellent resource for mainstream schools / nurseries, especially for teachers / learning support assistants who are new to supporting children with autistic spectrum disorder. It is packed with strategies which relate to curriculum topics as well as general classroom management and social skills. It gives specific examples on how to encourage independence to be used by support teaching staff. To help with supporting the family, it speaks about the wider emotional issues related to having a child with autistic spectrum disorder. The book is very succinct (49 pages). It is easy to locate information on a specific topic quickly. It aims to raise awareness and address issues involved in

CLINIC RESOURCE
Naughty Bus Jan & Jerry Oke Little Knowall Publishing ISBN 0 9547921 0 6 9.99

Encouraged reluctant speakers


This A4 sized paperback book details the antics of a toy red London bus and his toddler owner throughout the day. The pictures are photographic so are very clear and easily recognisable to young listeners. The story-line follows familiar routines such as eating breakfast, playing in the garden, splashing in the shower and going to bed at the end of a very busy day!

ASSESSMENT
Test of Morpheme Usage Neil Stevens Speechmark Publishing Ltd ISBN 0 86388 459 8 36.00+VAT

A helpful screening tool


The Test of Morpheme Usage provides therapists with a quick method of screening a clients use of 10 key morphemes (eg. possessives, past tense, auxiliaries). A range of interesting photographs and starter sentences are used to

Resources
Macmillan Cancer Relief, see www.macmillan.org.uk Scottish Intercollegiate Guidelines Network see www.sign.ac.uk

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REVIEWS

elicit responses from the client. These responses are then recorded and scored. I found the test easy to score, and photocopiable score sheets are provided. As I work with children I found the normative data (for ages 3;00 to 8;06) useful; however, I do feel that the qualitative descriptors (established, developing or absent) give a good indicator of a clients progress with particular morphemes. The assessment is probably quite child-focused in many ways, but the pictures will appeal to a range of ages and can be used fairly flexibly. Once the starter question has been asked, the pictures could be used for further discussion. Overall, this is a helpful screening tool, providing therapists with a structured approach to eliciting grammatical morphemes. It does not provide any ground-breaking results, but is useful in target setting and monitoring progress. Claire Bland is a paediatric speech and language therapist working in a community clinic, language unit, MLD unit and mainstream schools in East Cheshire NHS Trust.

strategies and ideas for individual education plan targets along with creative resource ideas give sound overall support for the education providers of children with this complex condition. Nathalie Elwood is a speech and language therapist working in Lincolnshire for South West Lincolnshire Primary Care Trust.

DOWNS SYNDROME
Supporting Children with Downs Syndrome Susan Miller, Elizabeth Morling & Susan Wong (Hull Learning Services) David Fulton Publishers ISBN 1-84312-221-9 10.00

Clear and succinct


This book provides a good overview to help support children with Downs syndrome in educational settings. It is written for teachers, support staff and parents. Produced by Hull City Council, it is a practical tool with a clear definition of Downs Syndrome, teaching strategies to meet learning styles and how to manage support staff. Generally it is easy to read and is good value for money. Each topic is covered in one or two pages and covers, for example, language development, fine motor movement, behavioural issues. Advice sheets and check lists can be photocopied. It is clear and succinct in style. Ann Gosman is a specialist speech and language therapist with NHS Orkney.

situations. The 7 simple steps to good practice focus on preventative and avoidance measures rather than just reactions once a behaviour is already occurring, which fits in with the advice we give. The section on case studies includes some positive suggestions on how to encourage children with communication / attention difficulties to engage. These could be useful as advice to give to nurseries. In my work I run regular training sessions (with a psychology colleague) entitled Understanding and managing your childs behaviour and this would definitely be a resource Id recommend for further reading. So Ill be making good use of this book! Michelle Field is a specialist speech and language therapist with Eastbourne Sure Start.

SOFTWARE
Scallys World - Letters and Nouns Brian Kerslake with Bob Black Topologika Software Ltd Single User 34.00 + VAT

May appeal to parents


This is an easy to use programme aimed at Reception and Year 1 children. The vocabulary is based on the National Literacy Strategy and the Downs Syndrome Associations First Spoken Language checklist. It provides a mixture of picture, letter and word based activities which can be tailored to individual needs. There are printable flash cards, though it is a pity the other activities were not printable. The sound quality of the phonics was poor at times with basic errors such as /s/ for sheep! The programme is rather limited as a clinic resource, but at this price may appeal to parents. Melanie Eltome is Paediatric Team Leader - Special Needs with Airedale NHS Trust.

SOCIAL SKILLS
Positive Interaction Skills Robin Dynes Speechmark Publishing Ltd ISBN 0 86388 360 5

LITERACY
34.95 Language and Literacy Learning in schools Elaine R. Silliman & Louise C. Wilkinson Taylor & Francis ISBN 1 59385 065 4 30.00

FRAGILE X SYNDROME
Supporting Children with Fragile X Syndrome Jenny Fisher, Elizabeth Morling & Francesca Murray (Hull Learning Services) David Fulton Publishers ISBN 1-84312-226-X 10.00

Useful as an additional resource


This manual aims to give a comprehensive and practical guide for nursing staff, teachers and probation officers to run groups for improving interaction skills. Each chapter covers a session on introducing such topics as Developing Support Networks, Appreciating Other Points Of View and Overcoming Shyness and Loneliness. It provides detailed plans, worksheets and handouts as well as practical tips on initiating and organising group work, which would be useful for anyone not experienced in this area. The book is well laid out and easy to read but, for speech and language therapists, some sections will lack substance - Body Language and Making Conversation are examples. The book - and especially the worksheets - could be useful to anyone working on social skills but as an additional rather than a central resource. Helen Phillips is a speech and language therapist for Sure Start, Carlisle South, Petteril Bank School, Burnett Road, CA1 4BX.

Practical use is limited


This book is steeped in research and evidence based practice. It cites many studies that may be of interest to speech and language therapists and teachers working together in language resourced schools. However, the practical use of the book is limited. I thought there were some interesting ideas for developing language / literacy in the older child, although these were not laid out in an accessible way for a busy clinician to pick up and run with. This is a fascinating book and highly useful from an academic point of view for speech and language therapists and specialist teachers who may be undertaking further studies. However, it would not be hugely useful to speech and language therapists in general and the many references to educational policies in the USA can make it hard to read for a UK audience. Stephanie Delvin is a speech and language therapist with Newcastle upon Tyne Hospitals Trust.

Sound support
This easily comprehensible guide designed for teachers, special educational needs co-ordinators and teaching assistants will help to support children with a diagnosis of Fragile X Syndrome in a mainstream school. All terminology used is explained. An overview of the roles of the various professionals within both education and clinical services encourages effective collaboration between them to support children with this complex condition. This book highlights the vital role of speech and language therapists in providing a support network for facilitating language development, while also enabling education professionals to embrace an independent approach. A very comprehensive section of

EARLY YEARS
Tried and Tested Strategies Behaviour in the Early Years Angela Glenn, Jacquie Cousins & Alicia Helps David Fulton Publishers ISBN 1-84312-104-2 13.00

Positive suggestions
This photocopiable resource, aimed at workers in early years settings, provides clearly set out ideas and strategies that can be absorbed into daily routines. The book guides adults to understand what a child is trying to communicate with their behaviour, as well as providing practical ideas on how to deal with difficult

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15

KEYS TO WINNING WAYS SERIES (4)

KEYS
TO WINNING WAYS

The affirmation key


In the fourth of our series to encourage reflection and personal growth, life coach Jo Middlemiss considers that joy and happiness at work and in the rest of your life follow on from inner affirmation.
compared this serendipitous happening with the idea that joy is something that just is when it is. When we hunt for it, it always seems just out of reach. Maureen and Jenny believed that their joy and happiness was dependent on their appearance. But underneath their appearance was all the conditioning that led them to this belief. Their thoughts about themselves were ugly and that is what they had to change before they could possibly tackle the physical manifestations of their thoughts. Through coaching I needed to bring them to the realisation that the ugliness they perceived started with them. I've been told that we all have something in the region of ninety thousand thoughts a day. The sad thing is we probably thought about eighty nine thousand of them yesterday. Most of the stream of thinking goes by unnoticed so it seems that we have no control over the thoughts and must just accept the influence of them. For thousands of years many great thinkers and philosophers have pondered on the effect of our thoughts (see for example Murphy, 2000; Forstater, 2001; Allen, 2002). I was thrilled to discover recently that chemistry lecturer Dr David Hamilton (2005) is looking into the science behind the idea that the power of thought can actually generate neurons and neural connections in the brain. His book is not an easy self-help read, but a fascinating insight. He believes our continuous replaying of ideas encourages genes to spark into action and thus generate results which we experience in our lives. Because we do not realise the power of our thoughts we are continually surprised by the results. Using this knowledge, I led Maureen and Jenny away from their obsession with their bodies to an awareness of who they really were as people. How could they begin to love and respect themselves enough to stop damaging their bodies in their habitual way? We worked on reprogramming their habitual thought patterns using positive affirmations. A positive affirmation has three elements: 1. Positive 2. Present 3. Personal. It really doesnt matter if initially they had no belief in it. The repetitions re-educate the subconscious mind. The simplest and most effective is I love and approve of myself, and this was our start point. Secondly I introduced them to my friend FRED, a mnemonic for Fear, Responsibility, Ego and Discipline. Its good to have a representation of Fred around a teddy or dog or other visual aid. Fred can show a system of self-examination that helps us put a stop to what is getting in the way of our success. F: Fear is the most awful stumbling block and, nine times out of ten, has no grounding at all. So ask yourself, What role is fear playing in this situation?; What would I be doing / saying / feeling if I wasn't afraid?

AFFIRMATION: The key for Maureen and Jenny?


Maureens issue has a pervasive influence on all of her life. She is unhappy with her weight. There is a whole segment of her mind devoted to her size. She longs for the time when she can make easy choices as to where to shop and what to wear. She is frustrated that she cant move around as much as needs to in her work as a teacher and is convinced the children would respect her more if she was thinner. She has a huge stock of coverall black items because she believes that this will not draw attention to her size. Of course she has tried everything and talking to a coach was her last hope! Jennys issue is in the opposite direction. Also believing herself to be fat and ugly, she is slowly starving herself to death. She feels constantly tired and irritable, and is getting into arguments with colleagues at work. Are these two women terribly different? What is present in their thinking and what is missing - for them to be so concerned with image that joy and happiness is denied them?
Joy and happiness are almost indefinable and yet we know for sure when we are experiencing them and when we are not. Many tracts have been written about the pursuit of happiness. The big question is, do we need to search it out or is it something that we have to accept? Having just acquired a new puppy it is fun to watch him endlessly chasing his own tail. Something that he thinks he can chase, but the more he chases the more dizzy and frustrated he becomes. He just does not know that he is chasing something he already has. Author and confirmed bachelor C.S. Lewis lived in fusty tweedy comfort in Oxford when an American woman called Joy came into his life. After this he wrote Surprised by Joy where he

Until we realise that we are responsible for the situation we find ourselves in then we cannot or will not effect change.
R: Responsibility brings us to that crucial area Cause and Effect. Until we realise that we are responsible for the situation we find ourselves in then we cannot or will not effect change. E: brings us to our Ego and what part it is playing in our immobility. The Ego is the voice that whispers What if...; What will people say...?; Who are you to think you can succeed when youve always failed before? Well I say - and Im not the first - Who are you not to? As Marianne Williamson wrote (1996, pp. 190-191), Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light not our darkness that frightens us. We ask ourselves Who am I to be brilliant, gorgeous, talented, fabulous? Actually who are you not to be?...And as we let our own light shine, we unconsciously give other people permission to do the same. As were liberated from our own fear, our presence automatically liberates others. D: And finally all this does call for Discipline. Without it we cannot really do anything. Self-discipline does not come easily to many, especially when it relates to our bodies. When both Maureen and Jenny started to see their body as something that was doing no more and no less what they were telling it to do, when they shifted their awareness to the wonder of themselves and others rather than continuously obsessing inwardly about how ugly they were, all

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

HERES ONE I MADE EARLIER

IF YOU NEED TO HARNESS THE POWER OF YOUR THOUGHTS TAKE MORE CARE OF YOURSELF SHOW GREATER SELFDISCIPLINE
sorts of beauty, joy and happiness started to appear in their lives. I asked them to answer the following questions every day for thirty days: What am I happy about today? What am I excited about today? What am I proud of today? What am I grateful for today? What am I committed to today? Who do I love and who loves me? This simple and powerful discipline takes only 10 minutes and encourages a positive outlook before the day starts. I also directed Maureen and Jenny towards Spencer Johnsons little book One Minute For Yourself. In it (2005, p. 56), he says that taking care of yourself encourages inner success and inner success is reflected as outer success: When I take care of Me, I can take better care of Thee and then Together we can take better care of We. With a switch of thinking, some constructive coaching and a good degree of understanding, discipline and affirmation, these two women are well on their way to being thoroughly effective and happy individuals. Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk. Jo offers readers a confidential and complimentary half-hour telephone coaching session (for the cost only of your call.)

Heres one I made earlier...


ALISON ROBERTS WITH ANOTHER LOW-COST, FLEXIBLE THERAPY SUGGESTION MATERIALS: SUITABLE FOR A VARIETY OF CLIENT GROUPS.

THE FRIENDSHIP VINE


This is a useful collage item to have on the wall of the clinic. It promotes understanding of the friendshipforming process. You are aiming to create an outline image of a grapevine, with roots, branches, and leaves, to which the clients can attach labels in the shape of bunches of grapes, describing the ways in which friendships benefit us, and other labels in the shape of clods of earth, stating prerequisites for achieving friendships. You will need to have constructed the base before your clients complete it. It is worth making the basic framework sturdily, if you think you would use it again. Alternatively, you could make it out of paper as a quick illustrative exercise. It may take the group more than one session to complete the vine.

MATERIALS A piece of board - A2 size is about right. Fibreboard is ideal as you can stick pins into it. Its best to use it landscape. Pale blue fabric to cover the whole board. Old polycotton sheeting is fine for this. Beige fabric to cover the lower third of the board - representing the area under the ground where roots form. Thin strip of greenish fabric to form a grass level. Brown fabric - for the vines trunk and roots. Glue (PVA is good as it doesnt show through the fabric). Leaf-green fabric (several shades of green would be great). Purple paper for the grape-bunch labels (not too dark, as you will be writing on them). Earthy-brown paper for the clod-of-earth labels. Pens, scissors, and pins. BRAWN Stick the blue fabric on the board to cover it completely and add the beige across the bottom third, forming the earth. Draw your vine on the brown fabric and cut it out. Its a good idea to make it a long-branched variety so that you will have lots of room for the bunches of grapes, also leaving room for the clods of earth. Stick your vine on, and stick the grass across where the roots meet the trunk and the earth meets the sky. Write the word FRIENDSHIP along the trunk. Now you have the basic form to which your clients can attach labels. IN PRACTICE - STAGE 1 It is important that you discuss with your clients the reasons for making the board, and begin with the benefits of being able to make friends (follow up with how to make friends later). The clients will tell you why friendship is important, but you should end up with a list including things like: company (for example when going out); someone to talk to; someone to share things and ideas with; someone to take your side; someone to send you a postcard; someone to give you support when you are feeling depressed; someone to try out jokes on. Write down all the suggestions as they are given, and then give everyone in the group some purple paper and scissors to cut out bunches of grapes to stick on the tree. (The tendency is for people to cut shapes that are too small to write on, so suggest to them that they write first, then cut out and pin on the vine.) Now you need to tackle the roots of the vine in a similar way, first discussing the foundations and responsibilities for friendship forming. Make a list, this time including such ideas as: being cheerful; providing support; being loyal; being trustworthy; sharing; keeping secrets. Other roots will mention skills such as going to places where potential friends might be; joining in; talking; recognising a true friend. It is likely that several of these areas will be unfamiliar to your clients, especially the areas that are not a problem to them, so you will need to give an outline description; however, you are not actually teaching these skills at this stage. Again make the suggestions into labels and pin them to the vine, this time using clod-shapes, at the roots. IN PRACTICE - STAGE 2 Ask everyone how they feel about the vine, and which bits apply to them. Discuss how real vines use their roots to draw nourishment from the earth, and can therefore produce grapes. Try to make the point really clearly through discussion that, if the clients work at the prerequisite skills, they will be able to reap the benefits.
Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

References
Allen, J. (2002) As a Man Thinketh. Deseret Book Company. Forstater, M. (2001) The Spiritual Teachings of Marcus Aurelius. London: Hodder Mobius. Hamilton, D. (2005) Its the Thought that Counts. Chippenham,Wilts: Dr David R. Hamilton. Johnson, S. (2005) One Minute For Yourself. London: HarperCollins Entertainment. Lewis, C.S. (2002) Surprised by Joy. London: Fount. Murphy, J. (2000) The Power of your Subconscious Mind. London: Pocket Books. Williamson, M. (1996) A Return to Love: Reflections of the Principles of a Course in Miracles. London: HarperCollins.

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FEATURE ON...POSITIVE LANGUAGE

peech and language therapists constantly seek out new tools to stimulate and encourage other people to communicate well in spite of their underlying difficulties. We are familiar with a raft of techniques modelling, recasting, forced alternatives, phonemic cueing, taking turns as speaker and listener to name a few and we make sure we share strategies with the clients communication partners. We are also schooled in customer service skills so that we are generally professional, kind and polite and appreciate the importance of a good rapport with clients and carers. Traditionally speech and language therapy has been didactic in its methods. With principles such as user involvement, person-centred planning, community based care, accessibility and the expert patient being applied more in practice, we are becoming aware of the need to adapt the language we use with clients to fit our new role as collaborator. Thinking of our own experiences as patients, we can probably all recount times when we have been spoken to in a way that has had a profoundly positive or negative effect on our thinking or recovery. Times when we felt relief, trust or hope - or in contrast the occasions that produced irritation, confusion or helplessness. These negative feelings can occur even when professionals are unfailingly polite, knowledgeable and well-meaning. So could language be the difference that makes the difference (Burns, p.4)? And how can we harness language to make a positive difference in our own work? Being a speech and language therapist can be overwhelming. We frequently have heavy caseloads, a myriad of people we should be liaising with, stressed and upset parents and clients, processes like Agenda for Change and overload of information on everything from evidence based practice to hand washing protocols. But why dont we follow the advice we often give out: You should be more positive or At least you dont? Or listen to the many people who really want share the benefit of their experience and solve our problems: You should just / I wouldnt accept / Why dont you? Ah, the power of language to criticise and silence, even when it is well-intentioned! In contrast, the use of language to engage and empower is key to the success of an approach called Solution Focused Brief Therapy. For example, applying its principles to the same problem of being overwhelmed by our work, we could expect to be asked: So what makes speech and language therapy a career worth following in spite of all these problems? If you rate your job from 0 to 10, where 0 is unbearably awful and 10 is as rewarding as you could imagine, where would you be? Whats happening already that you are at that level rather than a lower one? What rating would you accept? How will you know when you have reached that point what will be different? What are you going to do more of to get there? Solution focused brief therapy (see www.brieftherapy.org/) has been around and developing for

Speaking skilfully
Our understanding of communication and of the ways it can be enhanced is constantly changing. Avril Nicoll takes a look at the growing interest in the effect of our language choices on therapy outcome.
more than 25 years but its incorporation into the speech and language therapy toolbox is relatively recent. In her new book Focus on Solutions - A health professionals guide, speech and language therapist Kidge Burns explores how brief therapy has changed the lives of her adult clients for the better since she became hooked on the approach in 1997. She says it is about learning to look for client resources rather than learning about techniques. It is about learning to listen to the client, following the clients goals and being client led (p. 140). they already know and how much they are already doing that helps their child. At the Michael Palin Centre, therapists seek to access and maximise the instinctive, natural way parents help their child (Kelman et al., in press). Even a child with a relatively severe stammer will have a great deal of spontaneous fluency. So, what are the good things that are happening during these times that help the child to be fluent? According to Elaine the therapists role is to help parents focus on the things they are already doing (such as pausing / commenting / simplifying language / calming the child down) that help their child to be more fluent, and to do more of these things. Throughout, the emphasis is on drawing parents attention to their strengths by using positive language. Jane Fry, another member of the Michael Palin team, offers examples of how the language of solution focused brief therapy helps in the process of therapy. Therapists use language that highlights clients strengths and resources (What are you already doing that helps?; What have you found works?), suggests the possibility of change (What will you notice?; How will that be helpful to you?; What will be different when?) and reinforces the clients own ability to cope with adverse events (What has helped you cope despite?) Language is also carefully used to encourage small changes (when things are a little better). This avoidance of problematising language in order to promote a better outcome is also evident in the new Stroke and Aphasia Handbook (Parr et al., 2004). Asked for a simple definition of aphasia, a speech and language therapist is likely to reply along the lines of a language difficulty following a stroke. When people with aphasia are asked the same question, the answers are as individual as they are (figure 1) and reflect the impact of the impairment on them. Rather than focusing on impairments and problems, the communication tips enclosed in the handbook (figure 2) follow a can do format, tapping into the resourcefulness of both speaker and listener. Such an approach seeks to address the barriers that disable a person but also to acknowledge the impairment. Proponents of solution focused brief therapy say their approach is often misunder-

Optimistic and energised


Kidge agrees that the approach can be applied to performance at work, and in training and organisational contexts. She comments (p.138) that those who work in a solution focused way appear to remain more optimistic and energized than those who work from a more pathological stance and suggests that language about strengths and resources will be picked up on quickly by other members of your team. This has certainly been the experience at the Michael Palin Centre for Stammering in London, the birthplace of parent child interaction therapy. Elaine Kelman describes the influence of solution focused brief therapy on their work as a fairly subtle shift, but a really significant change for parents, particularly in terms of the language used by the therapists. The change was prompted by a realisation that, although therapists were quite clear that parents were not responsible for their childs dysfluency, the way the therapy was presented sent out the opposite message. When watching videos of themselves interacting with their children, parents inevitably picked up on all they were doing wrong (speaking too quickly, asking too many questions, talking too much). Elaine feels it is very tempting as a therapist to go along with this as it can give parents a quick and obvious goal (for example to speak more slowly or reduce the number of questions). The problem was that parents were ending up blaming themselves and their interaction style for the childs dysfluency, and consequently feeling less in touch with the resources they already had for helping their child. As Elaine says, parents often dont realise how much

18

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

Figure 2

FEATURE ON...POSITIVE LANGUAGE


Figure 1

From Parr et al. (2004) The Stroke and Aphasia Handbook costs 20. Details at www.ukconnect.org

stood as one that avoids dealing with or acknowledging problems. Berg & Steiner (2003, p. 123) for example say, we hope it becomes clear that such misperceptions derive from our emphasis on solutions. We never deny or pretend that a problem does not exist. We always speak plainly to parents about their child, even when we need to deliver unwelcome or bad news. They go on to describe a method using a glass half full of blue water to represent visually to parents at the time of diagnosis the resources a child with a learning disability already has.

Opportunity
Speech and language therapist Geraldine Wotton believes it is important to acknowledge a clients failings as well as successes, otherwise they are left unable to objectively adjudicate over their performance, in turn fostering greater dependency within the child as he looks to seek out resolution elsewhere rather than in himself. Her work has been heavily influenced by Donald Winnicott, a paediatric analyst who took the view that a childs passage through failure is an essential ingredient to their successful development, as it provides the opportunity for them with therapist or parental help to draw on their own resources to find a way through. A supportive, playful environment is essential but Geraldine finds an equally vital ingredient to fostering the microclimate of support as we move the therapeutic process forward is the language we use. This includes first name terms, a clear introduction and lots of genuine praise - for achieving, for keeping going (Boy that was a tough day but you did so well even though you were cross and sometimes impatient with me), and for finishing work. Sensitive humour and cajoling can be helpful. Geraldine says she seeks to encourage the internalisation of the learning experience by the child in a positive light: Moving them towards hearing no or thats wrong in a way that doesnt devastate or crush is very tricky at times, especially for the children who seem to possess an almost toxic fear of failure, such as some children with Down syndrome or dyspraxia. She suggests using nearly, well done

for trying or oh oh as interim verbal bridges for the child to bridge the gap from I cant to I can. For educator Marshall Rosenberg, the trick is empathic connection: no matter what words people use to express themselves, we listen for their observations, feelings and needs, and what they are requesting to enrich life (p.94). His Nonviolent Communication method seeks to establish relationships based on honesty and empathy that will eventually fulfil everyones needs (p.85). Vague language contributes to internal confusion (compare Id like you to be honest with me about therapy with I want you to tell me how you feel about what I did today and what youd like me to do differently), so requests are made in clear, positive, concrete action language that reveals what we really want. Although obviously valuable for parents and carers, any method based on language will present challenges for therapists working directly with people with linguistic impairment. Rosenberg quotes a special education teacher (p. 9) who finds the non-violent communication method can work even with children who have language delays, learning difficulties and behaviour problems. Berg & Steiner (2003, ch. 6) have lots of suggestions for working through puppets, drawing and games and, although I would argue it is the least successful chapter in their book, they also provide ideas for working with children with uncommon needs (ch. 7). And Burns (2005) is all about a solution focused approach with adults with acquired communication difficulties. We cant ignore the importance of context in facilitating both our positive language and a positive response from clients. Togher (2003) believes more shared experiences like going shopping, to a museum or for a coffee in the canteen - facilitate conversation in therapy sessions. She illustrates the point with an anecdote about a home visit, a dead duck and children due home from school and the subsequent joint relating of the story to nursing staff. She observes that Our interactions after that time were different, with an increased ease of getting ideas across to each other (p. 75). In the same book, Hewitt & Byng (2003) reflect on how their under-

standing of aphasia therapy has changed over time, coming to a realisation that participation alone is not enough and that engagement is needed; therapy should create opportunities where people feel valued and find a way of connecting with their new life. An unexpected spin-off is the improvement in communication and talking skills. Sally Byng says she now relates to people with aphasia as a colleague with expertise rather than an expert: my professional skills give me a basis from which to negotiate, discuss and share my perceptions to see how they fit with those of the person living with aphasia. Depending on the issue we are discussing I may or may not have more knowledge and expertise, and I feel free to make this clear (p.60). In Buddhism, such skilful speech is considered worthy of special emphasis in what is called the noble eightfold path, in addition to skilful action. Napthali (2003, p.136) says that The Buddha referred to speech as an axe, a tool of precision and power and a weapon capable of great damage. She suggests (p.140) that before we speak we need to wonder: Is what Im about to say true? Is it kind? Is it beneficial? Could it harm? Is now the time? Should I speak at all? She adds that making a conscious decision to speak more quietly or slowly, or to pause before responding, can be good ways of reminding yourself about the importance of skilful speech. This fits with the concept of a thinking break in solution focused brief therapy, which affords emotional space to reflect on what was learned during the session (Berg & Steiner, p.26), and with the time Rosenberg suggests we take to get in touch with what we really need before we make a response (p.152). So, if language really is the difference that makes the difference, on a scale of 0 to 10 where are you now? Where do you want to be? And how will you know when you have got there?

Acknowledgement
Thanks to Geraldine Wotton, Elaine Kelman, Jane Fry, Carole Pound and Vivienne Moss.

References
Berg, I.K. & Steiner, T. (2003) Childrens Solution Work. New York: W.W. Norton & Co. Burns, K. (2005) Focus on Solutions A health professionals guide. London: Whurr. Hewitt, A. & Byng, S. (2003) From doing to being: from participation to engagement, in Parr, S., Duchan, J. & Pound, C. (ed.) Aphasia Inside Out Reflections on Communication Disability. Maidenhead: Open University Press, pp. 51-64. Kelman, E., Nicholas, A. & Millard, S. (in press) PCI 2005 (Parent-Child Interaction Therapy). Proceedings of Oxford Dysfluency Conference 2005. Parr, S., Pound, C., Byng, S., Moss, B. & Long, B. (2004) The Stroke and Aphasia Handbook. London: Connect. Rosenberg, M.B. (2003) Nonviolent Communication: A Language of Life. California: PuddleDancer Press. Togher, L. (2003) Do I have green hair? Conversations in aphasia therapy, in Parr, S., Duchan, J. & Pound, C. (ed.) Aphasia Inside Out Reflections on Communication Disability. Maidenhead: Open University Press.

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TRAINING

Turn up and tu
Several people kindly shared their experience in offering training to homes, including the headaches in setting it up and getting people to attend, and ideas on what to include. This information helped us compose a bid to the local Primary Care Trust for consortium funding for a project offering training on acquired communication disorders - and we were successful! The project ran from October 2001 to October 2002. The funding enabled the two of us to plan and run six free half day training courses in a variety of locations in Bedfordshire, and also covered administrative support.

Participative and enjoyable


Niki and Karen

IF YOU WANT TO IMPROVE COMMUNICATION ENVIRONMENTS BID FOR PROJECT FUNDING TARGET HARD TO REACH SERVICE PROVIDERS

Elderly people with acquired communication disorders who live in nursing and residential homes depend on care workers to support their everyday conversation. But how do the carers develop the skills to do this? Karen Booth and Niki Freedman recount a training project in Bedfordshire which had promising results - for those who attended.

For the content, we devised a PowerPoint presentation of clinical theory and included plenty of thought-showering opportunities, practical activities and videos of real people with real communication disorders. The videos were a combination of our own patients who had consented to appear in training material, and published videos (Lock et al, 2001; Murphy & Scott, 1997; Parkinsons Disease Society, 1994). We intended the training to be participative and enjoyable, giving delegates the opportunity to discuss the types of problems some residents have. The course format is in figure 1. Figure 1 Course format
We started the session with questions such as What is communication? Why do we communicate? How do we communicate? What do we need to be able to communicate? Then we looked at the communication process, considering the difference between speech and language, the communication environment and nonmedical reasons for communication breakdown. Next we covered the theory - we explained medical conditions that can cause communication disorders, including Parkinsons disease, Multiple Sclerosis and other neurological conditions, with particular emphasis on stroke. A lot of time was spent defining dysarthria, dyspraxia and aphasia, with videos and discussion on real patients known to the staff members. We then looked at general communication strategies, and gave specific ideas on how to alter their own language and the communication environment - and what to do if it all goes wrong. We planned practical activities looking at normal and disordered communication. One activity involved backto-back picture description in pairs to simulate speech only, with no non-verbal communication. In another, the group tried to elicit a message from one of the course members who was role-playing someone who could only eye-blink. They had to work out how to communicate with the patient and how to modify the environment and their own communication to ensure that they successfully received the message.

WE INTENDED THE TRAINING TO BE PARTICIPATIVE AND ENJOYABLE, GIVING DELEGATES THE OPPORTUNITY TO DISCUSS THE TYPES OF PROBLEMS SOME RESIDENTS HAVE.
20

hen visiting nursing and residential homes, we often found some staff had very little knowledge and experience of acquired communication disorders. This made it hard for them to carry out therapy advice and also to manage everyday conversation with residents. We felt this had to be tackled to make progress with this client group. We decided to plan a project for improving staff communication with their residents. This would involve training to increase staff understanding of speech and language disorders, with practical activities to teach strategies and improve confidence in communicating with the residents. Firstly we needed to know if this had been done before. We looked through past editions of the Bulletin (Royal College of Speech & Language Therapists), and submitted a clinical query. This yielded several detailed responses, and referred us on to some published research. Buckwalter (1988) looked at improving nurse communication with residents. She found improved initiation and participation after staff improved their interaction and spent regular time chatting with residents. Jones (1991) wrote about student nurse education, summarising a project run in Scotland. Students were given theoretical and practical training on aphasia. This improved use of strategies and success of communication. It confirmed that both theoretical and practical training are essential.

We also had some practical planning to do. We needed a method of evaluating the course, so we devised a questionnaire to be filled in before and after attending. This looked at

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

TRAINING

une in
understanding of the different acquired communication disorders, and asked staff to gauge their ability to maximise their residents communication environment and to modify their own communication and use of strategies to aid residents in communicating. We sent a letter to 26 nursing / residential homes, specifically excluding homes for elderly people with a mental illness, as staff supporting such residents would need a different training package. We offered free half day training courses, with a choice of six dates over a five month period, in a variety of accessible locations. When staff were booked for a specific date we sent the questionnaire with a stamped addressed enveloped to be returned prior to the course. If they hadnt returned it they were asked to complete it on arrival for the training. We used our PowerPoint presentation as the course handout, and gave an attendance certificate. So, did it work? Unfortunately, attendance proved to be the biggest problem (figure 2). Figure 2 Attendance statistics
No. of courses Accepted places Attendance Failed to attend Cancelled Average attendance per course Average non-attendance per course 6 86 43 41 2 7.16 6.83

Good contributions
We felt the course was well-received and there were good contributions from delegates. Staff members showed significant improvement in their understanding of the theory and in their own confidence in maximising the communicative environment and using strategies to improve communication. A few of the homes had a high percentage of elderly mentally ill residents and this made the course less useful for them. However all of the homes had some relevant residents that they could discuss and think about as they learned the theory. Staff were keen on the idea of the speech and language therapy service being able to provide individual communication advice on specific clients. One of the activities in the course was to attempt to communicate with a partner using specific communication strategies. Delegates reported this was very helpful. The very poor attendance rate was our biggest cause for concern. Because we had received funding for the project, the course was free. We felt in hindsight that attendance may have been better if the homes had had to pay, as the managers would have been more committed and enforced attendance. A year later we wrote to the nursing and residential homes in the county offering the course again, to be charged at 20 per head to cover costs only (hall hire and refreshments, two speech and language therapists for one session, two hours administration per session, paper, ink, stamps, envelopes and photocopying). We followed up the letter with phone calls. Unfortunately, again the uptake was poor and, despite repeated phone calls, two dates were cancelled. We ran one course for 10 members of staff, all of whom attended. Again the questionnaire results show significant improvement after training (figure 4). Again the course was popular with the delegates and everyone contributed enthusiastically. Figure 4 Questionnaire Results (second course)
Average Average pre-training post-training

STAFF WERE KEEN ON THE IDEA OF THE SPEECH AND LANGUAGE THERAPY SERVICE BEING ABLE TO PROVIDE INDIVIDUAL COMMUNICATION ADVICE ON SPECIFIC CLIENTS.

Fortunately the questionnaire results showed significant improvement. Using a scale of 0 (not at all) to 5 (fully), results are in figure 3. Figure 3 Questionnaire results (first courses)
Average Average pre-training post-training How well do you feel you understand: Aphasia Dysarthria Dyspraxia Could you explain the difference between speech and language? Depending on your resident, could you modify the communication environment?

How well do you feel you understand: Aphasia Dysarthria Dyspraxia 1.22 0.78 0.78 4.11 3.67 3.78

3.01 2.02 2.23

4.34 4.27 4.27

Could you explain the difference between speech and language?

1.67

4.22

2.95

4.40

Depending on your resident, could you modify the communication environment? 1.56 Depending on your resident, could you use appropriate communication strategies? 1.67

4.22

4.22

2.66

4.70

Depending on your resident, could you use appropriate communication strategies? 3.08

4.42

Uptake was still poor, despite the charging factor (which did seem to eliminate the non-attendance issue). The costs were small so we do not feel this was a deterrent. It seems that staffing issues may have meant that several homes were unable
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TRAINING

resources
to send staff. Perhaps advanced notification would give homes sufficient time to plan staff rotas / holidays and so on? We will probably try once more, particularly as there would now be minimal preparation and course fees would cover any expenses. For future courses it may be useful to follow up on the changes previous participants have made to the environments in their homes and their communication with residents. Further research and courses attended by the speech and language therapy team have also led us to consider increasing the practical component of the course. This could include inviting people with communication difficulties, and perhaps focusing on teaching supported communication.

For more resources see page 28.

Free demo TROG-2


The TROG-2 (Test for Reception of Grammar 2) is now available in an electronic format for Windows. The complete kit includes the TROG-E CD ROM, manual, users guide and a free one year licence (210 + VAT). For a free demo disk, contact Lucy Do, Harcourt Assessment, 1 Procter Street, London WC1V 6EU, tel. 020 7911 1975, e-mail lucy.do@harcourt-uk.com.

Medical spell checker


A UK version of medical and pharmaceutical spelling software checks for accurate spelling of medical and surgical terms, procedures, diseases, drug names, acronyms, eponyms, medical devices, abbreviations, Greek terms and diacritical markings. Spellex is 70 for single users and 348 for a ten user licence. www.spellex.co.uk

Karen Booth and Niki Freedman are speech and language therapists with Bedfordshire Heartlands Primary Care Trust. Karen is based at Bedford Hospital, tel. 01234 792275 and Niki at Luton & Dunstable Hospital, Luton, tel. 01582 497049.

New from Contact a Family


Contact a Family has several new publications. 1. Parent Participation in health settings is a practical guide to involving parents in shaping service delivery. It provides examples from a variety of settings and has fourteen case studies including producing information on local services and establishing parents forums. 2. Finding medical information on the internet contains a checklist of questions parents should ask when reading medical websites. It has been written in response to concern that parents are getting wrong information and being encouraged to spend large sums of money on unnecessary treatment. 3. Making a Difference: the NSF and parents of disabled children is a guide for individual parents to help them make sense of the childrens NSF. 4. Making a Difference: how parent groups can use the Childrens NSF to influence local services. All can be ordered from Contact a Family on Tel: 020 7608 8700 or e-mail: info@cafamily.org.uk . In addition, the charity has updated its directory entry for Landau-Kleffner syndrome, see www.cafamily.org.uk/Direct/l12.html.

References
Buckwalter, K.C., Cusack, D., Beaver, M., Sidles, E. & Wadle, K. (1988) The behavioural consequences of a communication intervention on institutionalized residents with aphasia and dysarthria, Archives of Psychiatric Nursing 2(5), pp. 289-295. Jones, C. (1991) Student nurse education. Bulletin of the College of Speech & Language Therapists, May.

Training guide
The developer of speech recognition software Dragon Naturally Speaking v8 has produced a CD-ROM based video training guide to its use. 115, see www.keytools.com

Resources
Lock, S., Wilkinson, R. & Bryan, K. (2001) SPPARC (Supporting Partners of People with Aphasia in Relationships and Conversation): A Resource Pack. Bicester: Speechmark. Murphy, J. & Scott, J. (1997) Talking to people with severe communication difficulties: An introductory training video. University of Stirling, Department of Psychology. Parkinsons Disease Society (1994) Face to Face: facial animation made easier. Parkinsons Disease Society of the United Kingdom.

Text-tospeech
NextUp Talker 1.0 is text-to-speech software designed for people with medical conditions affecting their ability to talk. $99.95, free 30 day trial at www.talkforme.com/.

Brain injury book


A review in Encephalitis Today describes Deborah Wearings book Forever Today: A memoir of love and amnesia as a must read. It charts the journey of Deborah and her partner Clive, a musician whose memory is lost by Herpes Encephalitis. The reviewer says the book is educational, emotional and documents changes in brain injury services over the last 20 years. www.encephalitis.info

Acknowledgements
Thank you to Danny Scott, Greater Glasgow Primary Care Trust, and Rosemary Lester, St Georges Hospital, Sheffield for sending us ideas and references. This was a great help in providing a framework and getting us started.

REFLECTIONS ON TRAINING
DO I FIND OUT ABOUT AND LEARN FROM WHAT HAS BEEN DONE BEFORE? DO I FOLLOW IT UP TO ASSESS THE IMPACT ON CLIENTS? DO I ALLOCATE TIME TO LOGISTICS AS WELL AS CONTENT?

Changes at Vocal Process


Vocal Process, which promotes vocal expertise through training and educational programmes, has changed its web address to www.vocalprocess.co.uk. The companys publishing arm has transferred to Voicesource Limited, see www.vppl.co.uk.

Self-management
Stepping Stones to Success: An Implementation, Training and Support Framework for Lay Led Self-management is a booklet from the Expert Patients Programme and the UK voluntary sector to support the development of good practice in recruiting, training and supporting volunteers to deliver lay led self-management programmes. www.expertpatients.nhs.uk/

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

COVER STORY: HOW I...

HOW I SET GOALS


WHERE YOU GONNA BE IN TEN YEARS TIME AND WILL YOU BE HAPPY WITH THE WAY YOUVE BEEN LIVING YOUR LIFE?... COS WHEN YOURE LOOKING BACK TO NOW ON THE YEARS GONE BY WILL THERE BE SOMETHING THAT YOU SAY THAT YOU SHOULD HAVE DONE RIGHT IN YOUR LIFE? IN THE SONG TEN YEARS TIME GABRIELLE ASKS, DO YOU HAVE A VISION? DO YOU HAVE A GOAL? OUR THREE CONTRIBUTORS REFLECT ON THE PROCESS, ADVANTAGES AND CHALLENGES OF GOAL SETTING WITH CLIENTS.

HOW WOULD YOU

GO ABOUT IT?
GOAL SETTING IS MEANT TO BE INTEGRAL TO REHABILITATION BUT IT DOESNT ALWAYS HAPPEN. SARAH EASTON FINDS OUT WHAT WOULD ENCOURAGE US TO DO MORE OF IT.
Do you have a five year plan? Do you have an idea of what you wish to achieve this week? Do you have a to do list? Will you achieve all you want to, even if all the appropriate factors are in place and you have enough resources? Or might tasks get left undone for no real reason that you can explain? We all have goals in our lives, targets to be achieved, usually within a time frame. Although we are not always successful at completing them, simply having something to aim for seems to be important. That is in our private lives, but what does this mean for our work with adults with acquired communication disorders? Communicating Quality 2 (RCSLT, 1996) and Clinical Guidelines by Consensus for Speech & Language Therapists (RCSLT, 1998) both stress the importance of discussing goals - and their achievement or otherwise - with patients. Communicating Quality 2 states (p. 22) that, throughout speech and language therapy involvement, Achievable goals will have been identified and agreed between the speech and language therapist and client and carer. These will include expected outcomes and time-scales. The importance of full documentation for all appropriate professionals to access is also highlighted. This is central to patient care and all outcomes. However, Johnson & Faulkner stated at the 1995 RCSLT conference that Goal setting is often very imprecise, partly because of our lack of confidence in making predictions This lack of confidence was evident in Portsmouth five years later, with staff requesting training and support on goal setting. Hence we began by asking the question: Are we setting goals with adults with acquired communication disorders? Our department established a small descriptive case study of process with the support of Portsmouth Institute of Medicine, Health and Social Care, Portsmouth University, to learn what was happening locally. This involved all 21 speech and language therapists working with adults, over a three month period, within a Primary Care Trust covering city and rural environments, and a comprehensive range of sites and methods of service delivery. The population covered is almost 600,000 (Census, 2001). Questionnaire evidence (n=21) was supported by four semi-structured interviews. A full range of data was gathered relating to the process, factors influencing goal setting and how the patient, carers and other professionals are involved, plus examples of goals set within current cases (n=105). We used cross case analysis to interrogate the data. No patient information was accessed as this study did not set out to address the appropriateness or SMARTness of the goals set. It was purely designed to look at the process - who was involved and how. We had to get ratification from the local Ethics and Research Committee due to new regulations regarding NHS staff and premises. Full details of the study can be obtained from the author. The returned questionnaires gave a total of 65 goal statements, of which 16 (25 per cent) were the statement no goal set. Only one speech and language therapist recorded setting goals always and one stated never. The reasons given for not setting goals are in table 1.
Table 1 Reasons given for not setting goals Reason Given Problems writing a goal statement Stage in rehabilitation Find process difficult Goal is implicit / carried in head Impairment versus functional dilemma Time consuming Forget / slack practice Motivation of patient No. of responses 5 5 4 4 3 2 2 1

GOALS (1): HOW WOULD YOU GO ABOUT IT? GOALS (2): DO YOU HAVE A MASTER PLAN? GOALS (3): YOU WILL KNOW WHEN IT FEELS RIGHT
SARAH EASTON IS NOW TEAM LEADER FOR THE NEW COMMUNITY STROKE REHAB TEAM AT ST MARYS HOSPITAL, MILTON ROAD, PORTSMOUTH, PO6 3AD, TEL. 023 9228 6000 EXT 2510 OR E-MAIL SARAH.EASTON@PORTHOSP.NHS.UK. CAROLINE HAW, SPEECH AND LANGUAGE THERAPIST, COMMUNITY REHABILITATION TEAM, SHEFFIELD, TEL. 0114 2716145, E-MAIL CAROLINE.HAW@NHS.NET. SALLY BOA IS A SPEECH AND LANGUAGE THERAPIST WITH FORTH VALLEY PRIMARY CARE OPERATING DIVISION. SHE ALSO WORKS AT THE AAC RESEARCH UNIT IN THE PSYCHOLOGY DEPARTMENT AT THE UNIVERSITY OF STIRLING (WWW.AACSCOTLAND.COM), E-MAIL SALLY.BOA@STIR.AC.UK OR TEL. 01786 467645. SEE WWW.INTANDEM.CO.UK FOR DETAILS OF GOAL SETTING COURSES RUN BY CATHY SPARKES AND SAM SIMPSON.

Ten Years Time Words & Music by Jonathan Shorten & Gabriella Bobb Copyright Gabsongs (50%)/Universal Music Publishing Limited (50%). Used by permission of Music Sales Limited. All Rights Reserved. International Copyright Secured.

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We grouped factors influencing the goals set into three main themes (table 2).
Table 2 Factors influencing goals set Factors relating to the patient Level of communication ability Patient aims / priorities / concerns Patient insight / experience Patient health Factors relating to family, carers, professionals Motivation of carers / professionals Level of family involvement Cooperation of carers / professionals Multidisciplinary team goal setting process The environment Factors relating to the goal setting process Type of disorder Speech and language therapists experience or perceived ability Time required Impairment versus functional goals To demonstrate progress or lack of it No. of statements 7 3 2 1 No. of statements 5 3 2 2 1 No. of statements 4 4 3 2 2

with the measurement of communication achievement. One therapist commented in a semi-structured interview, goals that are set around communication are sometimes frustratingly woolly or so specific that they loose functional component, therefore patient and therapist question why theyve been set. This leads to difficulties in the multi-professional forum. The most senior therapist interviewed shared her very negative experience of writing linguistically based goals and then having other professionals asking her what they meant. These impairment based goals were written without the patients involvement. The speech and language therapist went through the process of writing a goal, but in fact it was a list of therapy tasks. Goals need patient involvement, with discussion, negotiation and agreement; only that way will they be fully engaged and more likely to succeed. Evidence emerged of variation between newly qualified and more experienced therapists, the latter being much more functionally based, with more junior members of staff focusing on impairment within the individual session. Another aspect to take into account is the patients wishes versus the evidence base. Most patients when asked say they want to speak normally. A dilemma for the therapist is how to translate that into acceptable goals which are measurable and achievable - and useful to all involved with the patient. 4. The type of communication disorder We recorded the main impairment for each goal set, and differences were identified in the interviews. Goal setting in dysphonia and dysarthria were shown to be easier to set due to the absence of language involvement and the acknowledgement of measurable steps, plus the fact that the patient can be a full participant in the goal setting process.

Central to the process


With all of the evidence from the questionnaires and semi-structured interviews, four final themes relating to goal setting with adults with acquired communication disorders emerged: 1. The role of communication in goal setting As speech and language therapists, we know that communication does not just involve the adult with an acquired communication disorder. Everyone must use consistent strategies to continue efficient and effective communication, and evidence has shown that these skills are not always consistently used by all involved with the patient. The communication disability does affect the goal setting process; it requires discussion, negotiation, understanding and agreement. Even with strategies confidently in place, it takes a greater commitment from everyone involved. As one member of staff commented in a semi-structured interview, You need everyone on board to be understanding.were still not that good at actually getting other people on board and understanding what we (speech and language therapists) are trying to do. 2. The patients level of involvement in their rehabilitation The communication disability is not the only factor to influence the patients level of participation. The motivation to work to fulfil their goals is affected by issues as diverse as time since onset of communication disorder, the importance of communication to the patient and their previous language use, depression, visual problems, reduced concentration and insight, plus the level of family and carer support. Time since onset is also affected by current environment. Wressel et al. (1999) wrote that people may become more passive in hospital, even if in a rehabilitation ward. One interviewee described this in relation to a patient who was very passive and not motivated whilst on the rehabilitation ward but on his transfer home was far more aware of what his difficulties were and we have actually been able to.negotiate with him 3. Dilemmas faced by speech and language therapists in the process of goal setting In 1984 Green wrote, Whilst communication therapy is not as amenable to the writing of behaviourally measurable goals as the traditional didactic approach, this need not prevent attempts being made. Twenty years later this study has shown that some speech and language therapists still find this process difficult, with a daunting range of aspects to consider. We are aware of the impairment versus functional aspects, the formulation of the goal being things to achieve rather than things to do, plus difficulties The study found that we must respect the patient and their views, needs and feelings. The type of communication impairment does affect the process, and speech and language therapists continue to have goal setting dilemmas. In our personal lives we dont always achieve all of our to do list; that isnt failure, so neither must it be for our patients. They are central to the process and their drive to attempt tasks cannot be ignored especially if they dont know what they are expected to achieve, or they just dont want to today. Following the study, we held a full day on goal setting facilitated by Cathy Sparkes. This involved all speech and language therapists working with adults, plus invited guests from nursing, occupational therapy, physiotherapy and the local Dysphasic Support. All aspects of goal setting were explored, starting with our own personal plans and how we felt about sharing them which in fact was not that easy. From there we moved onto the process of goal setting especially with the added factor of communication disorder. The day ended with teams looking at how to implement change and build our own confidence with the process. One local issue actioned was to ensure patients are not discharged too early, before they have moved through the various stages of rehabilitation. We need to give them the opportunity to address their goals at various times in various environments. We now realise that our approach to goal setting needs to relate to where the patient is at. It may well be different in the acute stage, with greater team than patient involvement, but it is equally important to continue beyond therapy to Dysphasic Support. We have addressed this recently in Portsmouth, and goal setting has become central for the adult with an acquired communication disorder attending Dysphasic Support. The renewed enthusiasm for goal setting that this research and the study day provided made us realise all that is involved in good goal setting. It is not just the writing of a statement, as it seems when making that to do list. It is integral to good patient care and positive outcomes. It does take time and clear communication, with the full involvement of the patient, but equally it is core to rehabilitation. Does everyone in your team have an understanding of what your patients are aiming to achieve, in what time scale and how best to communicate that to all involved?

Functional
We must support other professionals with all aspects of communication for goal setting, even if that means we do not have impairment based goals, but are supporting functional based goals which are not communication focused. For example, if

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the central goal is for a patient being to be able to access the toilet, the speech and language therapist can play their part in supporting the patient to achieve it. Our role would be to elicit the best way for the patient to communicate the need, and then to ensure everyone is aware of this. This vital functional, non-impairment based aspect of speech and language therapy must be fully recognised. The goal setting process is also of importance in developing the skills of others, both professional and family / carers. One therapist interviewed said, I often set goals.as a way of targeting activity for the patient but also communicating with the multidisciplinary team the areas of priority and potential. Another contributor gave a brilliant example of success with a patients wife. The goal had been fully discussed with the wife and was to use drawing in real context when necessary. But it had not been natural for the wife, and one wonders whether she fully understood her husbands communication problems. She told the therapist that when he had tried all day to communicate something to her, she eventually gave him a pen and paper which led to him drawing a bird, from which she could interpret what he was trying to say. We must also have confidence in our skills and equally must review and reflect on the process so that our skills develop further. In researching this topic I found relatively little, especially in speech and language therapy, to demonstrate what most professionals were doing. Here in Portsmouth we have set up a small group to provide support and advice, and devised new documentation for us all to use. A member of the team has reviewed the multi-professional documentation used for goal setting on a stroke rehabilitation ward, which has resulted in an increase in the communication skills

used on the ward by all professionals and carers. This supports the important fundamental that goal setting is central to all rehabilitation. All of this has begun to increase our confidence in this important aspect of the rehabilitation of acquired communication disorders. When did your team last review this core aspect of rehabilitation? Should it go on your to do list?

Acknowledgements
With many thanks to Cathy Sparks for her interesting and informative day plus advice, and to everyone in Portsmouth who has supported this study. Sarah Easton is a specialist speech and language therapist with Portsmouth City Teaching PCT.

References
Green, G. (1984) Communication in aphasia therapy: some of the procedures and issues involved. British Journal of Disorders of Communication, 19, pp. 35-46. Office of National Statistics (2001) Census. Available at www.statistics.gov.uk (Accessed: 5 July 2005). Royal College of Speech and Language Therapists (1996) Communicating Quality 2: Professional standards for speech and language therapists. London: RCSLT. Royal College of Speech and Language Therapists (1998) Clinical Guidelines by Consensus for Speech and Language Therapists. London: RCSLT. Wressel, E., Oberg, B. & Henriksson, C. (1999) The rehabilitation process for the geriatric stroke patient an exploratory study of goal setting and interventions, Disability and Rehabilitation, 21(2), pp. 80-87.

DO YOU HAVE A

MASTER PLAN?
THE DEVELOPMENT OF A COMMUNITY REHABILITATION TEAM INFORMATION BOOKLET PROVIDED CAROLINE HAW WITH A PERFECT OPPORTUNITY TO FACILITATE AND STANDARDISE GOAL SETTING WITH CLIENTS.
Our interdisciplinary Community Rehabilitation Team has a remit to facilitate early hospital discharge for patients following stroke. There is considerable energy for new ideas and ways of working, providing a very stimulating working environment. A physiotherapy colleague and I decided to produce a patient information leaflet, as all team members felt it would be useful. My particular interest was in something suitable for clients with aphasia in the acute stage after a stroke. At the same time, we were keen to take the opportunity to get away from the notion that, as the health professionals, we would know best. Patients themselves usually know best, since they hold explicit or implicit hopes for their recovery (Clark & Smith, 1998; Wade, 1998). Fostering self-determination in clients can have very positive outcomes, but requires a shift in the balance of power, and finding a way to enable clients to express their hopes (Worrall, 2000). We started to think about the importance of negotiating goals with clients (and carers), both as something to work towards, and as a way of staging their - sometimes unrealistic - long-term goals into more tangible short-term therapy goals. This standard approach would be completely different from our established goal setting process, which had been entirely controlled by therapists, away from patients in our weekly review meeting. There is considerable support in the literature for providing clients and carers with both the information they need (see for example Hangar & Mulley, 1993) and the means to express their goals (see for example Baker et al., 2001). For our rehabilitation team, with its clear-cut resources and interdisciplinary

style, it was practical to combine these two needs into a client-held booklet. The development of the booklet was a lengthy process during which much discussion and many drafts were aired. We depended on dedicated and expert help from secretarial staff. Ideas for content were derived from a variety of sources including the published literature (particularly Stroke Association), colleagues and clients and carers. We agreed it was important to 1.Bring information together in one A4 format 2.Make it of immediate use and not easy to misplace 3.Have a reasonably large text size 4.Have parts that could be customised (such as goal setting and space for extra information sheets). The booklet was developed with clients who had had a stroke in mind. It incorporates picture material (photographs, pictures to illustrate the text and pictures drawn especially to illustrate goal setting) which - although designed to ensure access to clients with aphasia and to provide them with a communication tool - would have appeal to all clients. The written text is simple in style and presented in both paragraph and bullet point form. Colour-coded pages make navigation as easy as possible and may provide extra visual appeal. Having trialled the booklet informally, we had a grand launch in July 2001 with follow-up training sessions to reach all 40 team members. We wanted to ensure that everyone - core staff, administration and clerical, stroke liaison nurses, home care staff understood the importance of the booklet and shared sufficient information to use it. They also needed the opportunity to raise questions, and this process continues via staff meetings. I ran a pilot study to find out if and how the booklet was being used, particularly in relation to goal setting, and to explore what clients thought of it. Ten clients took part. I used purposive sampling to try to capture the range of clients seen by the team in terms of age, sex, disability and geographical area. A week after discharge from the community rehabilitation team, I contacted potential interviewees by telephone. All agreed to a visit at home to discuss the booklet, and I arranged this for a short time after the phone call. Three clients had acquired language disorders, two had acquired speech disorders and two had memory impairment. All ten were back living in their own homes, one of them living alone, and all had been treated by other team members for mobility / activities of daily living issues. I conducted interviews according to a format developed to capture the range of
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Obviously in the long-term you have to be able to be capable so you have to recover more to achieve them. [Short-term] should be the more simple things in life equally as important if not more eg. washing yourself.

questions posed by the study objectives. I piloted a draft structured interview schedule on two clients. The style of questioning was designed to make it accessible to all clients, including those with speech and language disabilities. The interview used open questions, 05 rating scales, multiple-choice questions and closed (yes / no) questions. I used clinical skill to gain as much participation as possible, for example where appropriate the use of single written words. All interviews were within a six week period to control for potential variables external to the individual clients. I examined the data for six themes: Theme 1: Accessibility a) Clients opinions included
Pictures: Theyre self-explanatory - you can understand them. Font size: Yes its good as well because I have a bit of trouble with my eyes. Differrent coloured pages: It didnt really make any difference. Yes thats handy as well, you can pick out different things you want to learn about. General layout: Alright because its not official looking so its easy to read - I found those leaflets (Stroke Association) more scary.

[long-term] Means future, [short-term] means tomorrow. [long-term] Going on how long its taking me no good thinking you can do everything in a couple of months is it so most things will be long-term youd like em to be short-term. I cant get going with that, I cant think about it.

All except one indicated an understanding of these concepts which is broadly consistent with a rehabilitation therapists approach. Some participants added their own perceptions, such as short-term goals being priorities and the more simple things. Some comments demonstrated that a patients understanding of how long recovery may take changes over time, that this understanding only comes with experience and that individuals may need differing amounts of time or therapy to achieve similar levels of recovery. Theme 4: Involvement of clients in goal setting Seven clients had goals written in their booklets. Of the other three, one had goals from a hospital rehabilitation file, one had completed a list of problems but did not feel ready to set goals and one with only physical impairment was clear that my goal is to get back to normality. Participants were asked to reflect upon their own experience; to consider whether they / the team had set the right goals, whether they had worked towards these specified goals and whether they had achieved their target goals. Seven stated that they had set the right goals, worked on the goals set and achieved all or some of the goals set. Although they had no alternative experience for comparison, participants were asked what they thought of being involved in setting goals.
I think its important because they know how they feel you cant fully realise what its like to have a stroke. I would do it together. Its a good. [thumbs up] From my point of view I think its encouraging if you set your own goals and you achieve them it encourages you to carry on.

b) A 05 rating scale gauged the usefulness of each section of the booklet and a formula was used to assign a score (Useful = 4-5, Dont know = 3, Not useful = 1-2, Not applicable = 0). Usefulness

The sections for team description and goal setting scored highest. In some cases, sections of the booklet had not been used. Theme 2: Clients awareness of the purpose of the booklet
Remember I wasnt in a mental condition to accept it, but patients who were were in a position to garnish something from it. Its to write down your progress and also to inform you on strokes and how to go about it. Its to help you to get your use back, to do different things. I think it encourages you to get on with it. Im doing my exercises every day. Goal.

For all except one, the booklet was seen as closely related to the rehabilitation process. Two comments underlined the booklets role in motivating clients. Theme 3: Understanding the rehabilitation process This refers to the rehabilitation process from the therapists viewpoint. Clients sometimes hope to achieve too much too soon or do not have an understanding of the small steps needed to achieve larger scale goals. Participants were asked to say what they understood by the terms long and short-term goals. This was not easy for the communication-impaired participants to respond to.

An important basic theme was setting your own goals (8 out of 10 would do this, one wanted to set goals with a therapist, another wanted a therapist to tell her what to do) and measuring progress against your own standards. Goal setting was experienced as a positive approach. Theme 5: Clients perceptions of outcome Participants were asked to comment on whether the booklet helped rehabilitation, made no difference, or got in the way of it. Nine out of 10 said the information had helped rehabilitation, one that it made no difference. Eight out of 10 said the goal setting had helped rehabilitation. One, a client with memory problems and concomitant distress, felt it might do in time. Another said it had got in the way of rehabilitation. It might be significant that, in addition to a chronic health problems, a degree of cognitive impairment and severe communication disability, both she and her husband presented with a pessimistic view of rehabilitation. Theme 6: Variation in the process With therapists and clients bringing individual styles to the process and the customisable design of the booklet, we expected a degree of variation in how the booklet was used. However, we werent prepared for variation in its presentation (for example, photos not provided, working pages and plastic wallet rarely used). Exploration of the process of goal setting showed great variation: four clients had completed a problem list to inform goal setting goals were written down by either clients or therapists; one had used the picture page to inform goals, which she and the therapist had written together; one had used an extra rehabilitation file in which he had been involved with goal setting in hospital; one could not remember the process; one said she did not use the goal setting part of the booklet [but that she had worked with the team on goals]; one wrote a problem list with the therapist but did not set goals; one commented I was doing it off my own bat and did not have any written goals.

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Further themes emerged that are beyond the scope of this pilot: 1. The timing of the booklet, of information-provision and goal setting 2. The context of goal setting: how does the use of the booklet link with therapists weekly goal setting meetings? 3. The responses to the interviews - due to the nature of their expressive and receptive language difficulties, the aphasic clients were not able to participate as fully as the non-aphasic clients. A future study could focus on a) a greater number of aphasic clients b) the use of extra picture resources to supplement the booklet and c) a more modified, aphasia-focused interview. 4. Responses of the clients with cognitive / memory difficulties. The complexities of the therapeutic relationship are multiplied many times in an interdisciplinary community context. With our team intervention limited to 12 intensive weeks, a booklet such as Whats Your Goal? may be a useful tool for facilitating a quick engagement with the team at a very important time. It may also be a practically useful way of understanding the service provided, allowing clients, carers and therapists a means of talking about the rehabilitation process as a shared event.

Caroline Haw is a speech and language therapist with the Community Rehabilitation Team, Sheffield South West Primary Care Trust.

Acknowledgements
My sincere thanks to colleagues in the Community Rehabilitation Team, Sheffield, my managers and administrative staff, research lead Mark Parker and physiotherapist Morag Hutchinson.

References
Baker, S.M., Marshak, H.H., Rice, G.T. & Zimmerman, G.J. (2001) Patient participation in physical therapy goal-setting, Physical Therapy, May 81(5), pp. 1118-26. Clark, M.S. & Smith, D.S. (1998) The effects of depression and abnormal illness behaviour on outcome following rehabilitation from stroke, Clinical Rehabilitation, 12, pp. 73-80. Hangar, H.C. & Mulley, G.P. (1993) Questions People Ask About Stroke, Stroke 24, pp. 536-8. Wade, D.T. (1998) Rehabilitation is always given a low priority, Clinical Rehabilitation, 12, pp. 1-2. Worrall, L.E. (2000) The influence of professional values on the functional communication approach in aphasia, in Worrall, L.E. & Frattali, C.M. (ed.) Neurogenic Communication Disorders : A Functional Approach. New York: Thieme Medical Publishers.

YOU WILL KNOW WHEN


SALLY BOA ALREADY HAD THE MOTIVATION AND A VARIETY OF TOOLS BUT LEARNING ABOUT A STRUCTURED NEGOTIATION FRAMEWORK HELPED CEMENT HER GOAL SETTING SKILLS.
As a speech and language therapist within a multidisciplinary community rehabilitation team, I have grappled for many years with the theoretical and practical aspects of negotiating realistic, meaningful rehabilitation goals with clients. My interest in goal planning stems from clinical work as well as a research project I undertook in 2003. This examined whether or not the low tech Talking Mats framework (Murphy, 1998) could be used to help people identify rehabilitation goals. A recent study day gave me a further opportunity to consider goal setting frameworks (Sparkes & Simpson, 2005) and to answer some of the questions raised by my pilot study. Goal planning is an essential component of rehabilitation services. According to Schut & Stam (1994, p. 223), Goal setting is a prerequisite for interdisciplinary teamwork. They state (p. 224) that goals must: 1. Be relevant and motivating 2. Express what you want to accomplish 3. Be positively defined 4. Be put in behavioural terms 5. Be explicit and commonly understandable 6. Be attainable and enabling well-balanced planning 7. Enable measurement. Schut & Stam (1994, p. 224) also stress the importance of involving the person in the goal setting process: Something relevant for the therapist may be regarded as completely irrelevant by the patient and / or the other way round. If the patient does not regard a goal as relevant, the team runs the risk that its efforts are in vain; the patient is not motivated to work at an irrelevant goal. The Brain Injury Resource Center (1998) states that The ability to set goals is essential to effective problem solving: and by default, is essential to self management, and self determination. Given that goal planning is essential to planning effective rehabilitation, it is important that all users of a service should be allowed to participate as fully as possible in the process. It can be difficult for people with communication and / or cognitive impairments to do this and often rehabilitation teams rely on their own ingenuity and persistence in order to obtain the views of this group (Wade, 1999, p. 21). My pilot study (Boa & McFadyen, 2003) focused on helping people to consider things

IT FEELS RIGHT

that they wanted to change. The aim was to see if the use of Talking Mats could help people become more involved in the process of goal planning and help them understand what we mean by goals. The Activities and Participation component of the International Classification of Functioning, Disability and Health framework (WHO, 2001) provides us with a comprehensive list of domains which relate to life areas. I used these as a guide for the Talking Mats symbols, and the participants built up a personal picture of specific problems or issues. Initially participants were asked to consider broad topic areas. They then selected topics that they wanted to explore in greater detail. For example, this mat shows that the participants main areas of concern in terms of broad topics were mobility, self-care, leisure, health and using transport:

Using self care as the sub-topic resulted in this mat:

This showed that the participant was concerned with many aspects of self care. Using the mats helped her to think about her many difficulties one at a time. Discussing issues in this way enabled her to think about realistic goals, and also to consider positive aspects of some of the issues. Talking Mats does not provide a written goal plan as such. Rather, it helps people identify problems or issues. Further refinement and negotiation needs to take place if we are to translate these into goals. It does however
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allow us to have a visual record (captured with a digital camera) so that changes in peoples priorities can be monitored. The project demonstrated that Talking Mats is a useful tool that can be used to help people to engage in the goal planning process, but it also left me with a number of questions. A recent study day Goal Negotiation: a shared journey gave me an opportunity to find some answers. Presenters Cathy Sparkes and Sam Simpson are speech and language therapists who have worked for many years within multidisciplinary teams and now share their expertise through a joint venture, www.intandem.co.uk. They described their goal negotiation framework through a combination of formal presentation, practical exercises and discussion which balanced theory and practice. Their broad framework enables us to: * explore issues with our clients; * seek clients opinions right from the beginning; and * offer choices which are relevant and motivating. Goal planning is complex and requires a great deal of skill and flexibility. The key message from Cathy and Sam was that goal planning is a process rather than an end in itself. This can often be overlooked by professionals in busy rehabilitation teams where the emphasis may be on producing written goal plans within certain time scales. By focusing on the outcome - rather than the process - we are doing the people we work with a disservice, and perhaps are not really listening to them. The goal negotiation framework takes us logically through a progression which ensures we dont miss out these important steps, and ultimately results in relevant, motivating and realistic goals which have been negotiated with each individual. Each stage needs to be respected so that the individual can have the time and opportunity to explore their rehabilitation goals and their hopes and aspirations fully. Talking Mats is one example of a tool that fits into the Sparkes & Simpson goal negotiation framework. The study day helped answer questions raised by my pilot study (Boa & McFadyen, 2003): 1. What other methods can we use to help people gain an understanding of rehabilitation goals? By using visual methods creatively to represent what we mean, we can find out what clients see as a goal. Taking time at this stage means we can really listen to what people are saying from the beginning. A main focus of the study day was helping us as clinicians think more creatively about how we present the concept of goals to people. We reflected on what the word goal meant to each of us, and spent time thinking how we might represent this visually. The significant amount of time spent on this made me question whether we spend enough time explaining the concept of goals to the people we are trying to help. This important first step in the goal negotiation journey needs to be continued through the use of symbols, drawings, options and choices as problems are identified and negotiated into goals. 2. At what stage should we be setting goals with people and how long does this process take? Goal negotiation is a continuous process and should not be rushed. One of the first stages is to identify the clients own strengths, problems, aspirations and life goals, then to work out what they might be able to change in the context within which you are both working. Tools such as Talking Mats can be used alongside other methods such as drawing and appropriate analogies for individual clients (for example, going on a journey or thinking of different steps on a ladder). 3. How can we bridge the gap between helping people to identify issues or things that are difficult, and translating these into goals? It can be relatively easy for people to identify problems, but the difficult task is often translating these into goals which are realistic, meaningful and can be measured. Relating problems to real life contexts - and helping clients to see what they want to change and what they are happy to settle for - can help them to prioritise and sort out the precise areas they want to work on. This gives both client and therapist a clear path and direction. 4. How can we help clients to understand and relate to the actual written document (the goal plan)? With goal planning providing direction for therapy, it is essential that our clients can relate to and understand the written document, so that it can be referred to and changed during the therapy process. Engaging people in the process of setting goals from the very beginning exploring the meaning of goal, thinking about longterm and short-term goals, considering the steps needed to get there - will ensure that the written document will be relevant. Tools such as lifestyle grids (Jeffers, 1987), Mind Maps and Talking Mats can help us produce visual materials which are meaningful and have been constructed jointly with our clients. This results in a sense of common understanding, ownership and empowerment. Goal planning is a process that takes time, effort and skill. The goal planning framework (Sparkes & Simpson, 2005) provides us with a structure to ensure that the multidisciplinary team is involving people in a way that they can understand, right from the beginning of rehabilitation. Using the framework helps us to consider individuals and the situations and environments they are in, helps them to identify strengths, problems, aspirations and priorities and ultimately allows goals to be negotiated. Within this framework, a number of tools can be used, as well as our skills of negotiation. These tools, along with structures such as the International Classification of Functioning domains (WHO, 2001), ensure we no longer need to rely on our ingenuity and persistence (Wade, 1999), but that we can draw from a variety of resources. By doing this we can embark on the journey of negotiating goals with our clients, starting from a point of shared understanding and partnership. Sally Boa is a speech and language therapist in Forth Valley and at the AAC Research Unit, University of Stirling.

References
Boa, S. & McFadyen, L. (2003) Goal Setting for People with Communication Difficulites, Communication Matters 17(3), pp. 31-33. Brain Injury Resource Center (1998) Goal setting. Available at: http://www.headinjury.com/goalset.htm (Accessed: 3 July 2005). Jeffers, S. (1987) Feel the fear and do it anyway. London: Arrow Books. Murphy, J. (1998) Talking Mats: Speech and language research in practice, Speech & Language Therapy in Practice. Autumn, pp. 11-14. Schut, H.A. & Stam, H. J. (1994) Goals in rehabilitation teamwork, Disability and Rehabilitation 16(4), pp. 223-226. Sparkes, C. & Simpson, S. (2005) Goal negotiation: a shared journey: Adult Acquired Disorders (Scotland) Special Interest Group study day. Perth 10 February. Wade DT. (1999) Goal Planning in Stroke Rehabilitation: How?, Topics in Stroke Rehabiltation 6(2), pp.160-36. World Health Organisation (2001) ICF: International Classification of Functioning, Disability and Health. Geneva: WHO. Available at: www.who.int/entity/classifications/icf/en/ (Accessed: 19 July 2005).

Resources
* Mind Maps - see www.mind-map.com * Talking Mats, see www.talkingmats.com

resources
HPC website
The Health Professions Council has overhauled its website to make it easier for professionals and members of the public to use. www.hpc-uk.org

Learn from the experts

A series of pamphlets written by and for young people with an acquired brain injury - Learning from the experts - is downloadable free at www.cbituk.org.

Vocabulary software

LDA Language Cards Interactive is a series of basic language skills CD-ROMS for PC and Mac. It includes three programs - Nouns, Verbs, Prepositions & Adjectives - to help pupils build and consolidate a strong vocabulary. Speech or text can be switched off and there are four levels of difficulty. www.sherston.com

Photodynamic Therapy

A new charity aims to raise awareness of and funds for research into Photodynamic Therapy for cancer. Pre-cancer and early cancer of the mouth are among the conditions thought to be most suitable for this type of treatment. www.killingcancer.co.uk

28

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

26-28 September 2005 Effective speech and language therapy for people with Downs syndrome Teddington 200 Contact Lesley Alabaf, tel. 0845 230 0372, e-mail lalabaf@downssyndrome.org.uk 8-9 October 2005 Introduction to Lowenfeld Projective Play Therapy Cambridge 120 Contact Joyce Robinson, e-mail joyce.robinson@hpt.nhs.uk / tel. 01992 465 042. 19 October 2005 Multidisciplinary aphasia study day Topics include supporting carers, living with aphasia, aphasia with dementia and multidisciplinary goal setting. Portsmouth 65 Tel. Speech and Language Therapy, QAH Hospital, on 02392 286147. 8 November 2005 Families, stroke and aphasia - improving the service Hosted by Connect Manchester 100 Tel. Connect, 020 7367 0846 or e-mail info@ukconnect.org 2 December 2005 UK Swallowing Research Group conference The interface between respiration and deglutition, advances in swallowing assessment and new / emerging treatments. 120 Details from David Smithard, Stroke Physician and Director of R&D, East Kent Hospitals NHS Trust, tel. 01303 850202 ext. 44625, e-mail david.smithard@ekht.nhs.uk. 25 March 2006 NAPLIC Evidence Informed Practice: What works for children with speech, language and communication needs. Aston University, Birmingham From 95 www.naplic.org.uk All year The I CAN training programme has over 50 different courses to support professional development for people who support children with speech, language and communication needs. London, or locally by arrangement. www.ican.org.uk/training

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MYTOPRESOURCES
1.MOBILE PHONE As you can imagine with a predominately young, male client group, a mobile phone is usually an essential accessory and a practical one too. It can be used to store messages and set alerts for memory prompting. Clients with dysarthria can use text messages to clarify their speech and keep in touch with friends. Video and camera phones can now store pictures, video clips and text as minicommunication aids. Our clients have their own phones but my mobile is issued through work. As well as texting clients to remind them of appointment times, I also need it for contacting my team as we are all out and about in the community. 2.LEAFLETS AND APPLICATION FORMS I pick up betting slips, pay-in slips, application forms or leaflets in banks and post offices, or use freebies from magazines and newspapers. They are great for practising reading and writing for functional everyday needs. 3.CALENDARS AND DIARIES Clients often have problems with memory, initiation and concentration so helping them write in a diary or calendar can increase their independence, structure their time and help them keep track of appointments. 4.PICTURE AND SYMBOL SYSTEMS As with a lot of our client groups, picture and symbol packages* are useful for creating lowtech communication passports (http://callcentre.education. ed.ac.uk/downloads/passports/passports1.pdf), Talking Mats (www.talkingmats.co.uk) and communication books for clients with more severe comprehension and expressive difficulties. There are also lots of clipart and photos that are downloadable free from the internet (search images on Google, www.google.co.uk). Boardmaker Colour version (2004) see www.mayer-johnson.com Writing with Symbols (2000), see www.widgit.com/. 5.DIGITAL AND VIDEO CAMERA Clients often lack insight into their communication difficulties. Video is a great way of helping clients analyse their own skills and difficulties. Photos of clients, their families, or belongings and interests can be printed off from a digital camera and used to create personalised communication books and passports. A digital camera is also useful for making step-by-step instructions for clients with memory, sequencing and reading difficulties, to enable them to carry out daily tasks independently at home. 6.MOUNT WILJA HIGH LEVEL LANGUAGE ASSESSMENT This unpublished tool is very useful for highlighting cognitive and pragmatic language problems. It gives me an idea of attention and concentration skills and can be used for reassessment to measure change. (Christie, J., Clark, W. & Mortensen, L. (1986) Mount Wilja High Level Language Test. 1st edn. Sydney, NSW: Mt Wilga Rehabilitation Centre. Unpublished manuscript.) 7.DRAW ON YOUR EMOTIONS (SUNDERLAND, 1997) This very useful book helps clients describe their feelings more visually or symbolically. It has clear explanations for each template on how to help the client explain their feelings of loss, anger, frustration and so on through drawing. (Sunderland, M. (1997) Draw on your emotions. Bicester: Speechmark Publishing Limited.) 8.JOINT GOAL PLANNING We use a questionnaire and goal planning form that we adapted from the Rivermead Rehab Centre Goal Planning Forms (Wade, 1999). This allows the client to choose what is most important for them to achieve, from the outset. As a team we then use our skills to break down each goal into small achievable steps. It also allows the client and carers to state their expectations, and issues of unrealistic aims can be addressed with the team early. (Wade, D.T. (1999) Goal Planning in Stroke Rehabilitation: How? Topics In Stroke Rehabilitation, 6(2), pp. 1-7.) 9.REHAB COACH We have recently recruited a generic rehab coach who is able to spend time with clients carrying out therapy activities set out by the therapists. She is a great asset, enabling clients to carry over skills from therapy into everyday life. We are fortunate that our coach has a psychology degree, but the essential criteria was NVQ Level 3 and experience in a caring field. As a team we felt it was important that we had someone who could work independently with this client group and their families - a challenge as they have often been through significant trauma. I have worked with a uni-disciplinary speech and language therapy assistant and generic rehab assistants before. The benefit of a generic coach is that all her support is directly related to functional tasks. It would be impossible to divide tasks such as shopping into three disciplines when it requires skills related to them all. A rehab coach gives clients the repetition and access to community activities they need to regain their independence, and provides the family or carers with support. Goals are guided and reviewed regularly by the allied health professionals involved. 10. DAY CENTRES AND SUPPORT GROUPS The language, behaviour and social interaction problems that occur after head injury can lead to clients becoming isolated. Our day centres and community and voluntary groups such as Headway are an excellent source of support for clients and their families. Attending a group or centre provides a safe environment for clients to begin to regain social interaction and independence.

SUSAN ANDERTON IS THE PART-TIME SPEECH AND LANGUAGE THERAPIST IN THE COMMUNITY BRAIN INJURY TEAM, N & W BELFAST HEALTH & SOCIAL SERVICES TRUST. THE TEAM CONSISTS OF A SOCIAL WORKER, PHYSIOTHERAPIST AND OCCUPATIONAL THERAPIST, ALL PART-TIME, AND A FULL-TIME REHAB COACH. SUSAN SAYS, THE SERVICE IS STILL IN ITS INFANCY AND WE ARE HOPING TO RECRUIT A PSYCHOLOGIST AND A TEAM CO-ORDINATOR. WE OFFER A MULTIDISCIPLINARY CLIENT-CENTRED COMMUNITY SERVICE TO CLIENTS WITH ACQUIRED BRAIN INJURY. THEIR PHYSICAL, COGNITIVE, BEHAVIOURAL, LANGUAGE AND COMMUNICATION DIFFICULTIES ARE OFTEN REFERRED TO AS A HIDDEN DISABILITY (SEE WWW.HEADWAY.ORG.UK). WE AIM TO HELP CLIENTS REGAIN MAXIMUM INDEPENDENCE, AND PROVIDE SUPPORT AND EDUCATION FOR FAMILIES AND CARERS.