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ISSN 1368-2105

Autumn2004

http://www.speechmag.com

JABADAO:
Interactive storytelling
A midsummer nights conversation

a song and dance about communication

Early intervention
A bump start

How I look for solutions


Placements, team reliability, compliance with recommendations

Collaboration
A holistic approach

Care pathways
No borderline

My top resources
Getting organised

Winning Ways
Setting your compass

A D D I N G

C O L O U R

Autumn04speechmag
The editor has selected some previous articles you might particularly want to look at if you liked the articles in the NEWLY REPRINTED Autumn 04 issue of Speech & Language Therapy in Practice. If you Turning on the spotlight by Carole Kaldor, Jannet Tanner and dont have previous issues of the magazine, check out the abstracts Pat Robinson (152) from the Summer 2001 issue is reprinted at on this website and take advantage of our new article ordering service. www.speechmag.com. This article describes the Spotlights on If you liked... Language Communication System ( Carole Kaldor). Sasha Bemrose see (042) Taylor, L.: Working with parents, (043) Bell, J.: Fiends or Friends?, (044) Dunseath, A.: Dynamic viewing and (045) Watters, L.: Also on the site - news about Valuable videos. All from Autumn 1998, How I view childrens television. future issues, reprinted articles Amy Duck & Sarah Weeks look at (117) Gill, S. & Ridley, J. (Summer 2000) from previous issues, links to Reshaping opportunities, sharing good practice. other sites of practical value and Susan Munros parachute what about (021) Wilcox, D., Burns, S-J. & information about writing for Mcfadzean, A. (Winter 1997) My Top Resources (No. 10 gives instructions for the magazine. making one!) Pay us a visit soon. A Midsummer Nights Conversation you might be interested in (180) Park, K. Remember - you can also (Spring 2002) Switching on to Shakespeare: A Midsummer Nights Dream. subscribe or renew online via a Christina Barnes and Jill Dyer check out (206) Howard, S. & Hughes, C. (Autumn 2002) From last to first resort. secure server! Jo Frost try (191) Patterson, A. (Spring 2002) My top resources - undergraduate education. Hannah Crawford consider (209) Samuels, R. & Chadwick, D. (Autumn 2002) Read all about it! Fred the Head stops Mars Bars in bed.

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AUTUMN 2004
(publication date 30th August) 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 2004 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 04 SPEECHMAG 2 NEWS / COMMENT 4 COVER STORY JABADAO - MAKING A SONG AND DANCE ABOUT COMMUNICATION
So was I searching for the impossible? A therapeutic approach which not only focused on the needs of my clients with profound and multiple learning disabilities but also provided a forum for training staff to carry out appropriate activities outwith speech and language therapy sessions. Surely I was asking too much? However, a chance discussion with a physiotherapy colleague revealed JABADAO as a potential resolution. Susan Munro discovers that the JABADAO framework can provide lasting opportunities for progress by people with profound and multiple learning disabilities.

14 NO BORDERLINE - JUST A PATHWAY


We hope that, through use of these documents, children will receive an appropriate level of service; that more therapy time will be available to those children with significant needs, and that it will be clearer which clients should be either discharged or transferred to other clinical caseloads. Christina Barnes & colleagues in a regional special interest group in deafness have developed a care pathway to improve equity of service for clients.

18 REVIEWS
(See also p.6) Functional assessment, phonological awareness, language development, selective mutism, intervention, clinical education, head injury, ColorCards, software.

19 YOU CANT LEARN TO SWIM ON DRY LAND


Regarding their learning experiences, nothing can be taken for granted - our students do not learn incidentally. Everything must be explicit, and what might appear as lack of variation in approaches is in fact a deliberate teaching technique particularly relevant to these students. Amy Duck & Sarah Weeks dive in with a holistic approach to developing functional communication and community living skills.

7HERES ONE I MADE EARLIER...


Alison Roberts returns with more low-cost ideas for flexible therapy activities: same and different chains, talking stick and totem pole.

22 WINNING WAYS SERIES [4] COMPASS SET TO TRUE NORTH


When establishing values, I dont just ask clients if they know what their values are. If I did that, they would intellectualise and operate from their heads. I want them to speak from their lives and their hearts. Do you know what is driving you? What IN FUTURE must you have - or a part of you dies? Life ISSUES... coach Jo Middlemiss suggests we chart a course based on values. DYSPHAGIA

8 A MIDSUMMER NIGHTS CONVERSATION


Keith wants to get away from specially constructed settings and the dreaded functional vocabulary to high status venues and participation in fun activities...Again and again he talks of interactive storytelling leading to his clients doing things that people with learning disabilities are not supposed to do. Avril Nicoll meets Keith Park and Nevin Gouda to find out how interactive storytelling works for people with complex support needs.

www.speechmag.com

24 HOW I LOOK FOR SOLUTIONS

VOICE BABY SIGNING

10 READER OFFER
Win Speechmarks Interactive Storytelling.

10 A BUMP START
By supporting parents antenatally and giving them information on what the baby is capable of doing, the parents become proactive at the earliest stage. They feel involved and important which gives them confidence. If they form an attachment before the baby is born, they are more likely to interact with the baby as soon as it is born. Recognising that disadvantaged groups need support to lay the foundations of communication, Sasha Bemrose & Lynn Lynch joined forces with a cartoonist to develop an antenatal pack.

Cover picture by Paul Reid / Angus Pictures. Lochlands Resource Centre, Arbroath. Clockwise left to right: Aden Devlin, Pamela Christie, Dorothy Simon, Robin Dundas, Susan Munro (specialist speech and language therapist). See p.4

Whatever problems you face as speech and language therapists, WORD FINDING underlying issues are likely to DIFFICULTIES include service organisation, TOTAL COMMUNICATION training, and working with other ENVIRONMENTS people. Undaunted, our contributors ask the questions, LARYNGECTOMY acknowledge the reality and seek creative solutions. EARLY YEARS Alison Newton & Jo Frost on student SENSORY placements, Jill Dyer on improving team INTEGRATION reliability in videofluoroscopy & Hannah Crawford on compliance with recommendations.

13 FURTHER READING
Aphasia, normative data, language disorder, voice, hearing impairment.

BACK COVER MY TOP RESOURCES


This system [day file] has replaced my daily list of things to do; currently the file divides into phone/email, action, maybe (such as events I might go to or books I might order), tickler (something Id like to do, but its a long way ahead), and waiting for (for example copies of order forms, notes of messages Ive left). Jayne Comins offers ten tips for getting organised.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

NEWS

Call for aggressive management of stroke


The gloves are off - time for more aggressive management of stroke. This is the stark message from the Royal College of Physicians on publication of its updated clinical guidelines on stroke care. Developed by a multidisciplinary group on the basis of clinical evidence and in consultation with stroke patients and their carers, the guidelines emphasise prevention and call for stroke to receive higher priority and faster treatment. New topics include screening and allowing for cognitive impairment, and the need for specialist rehabilitation in the community and a more involved role in decisions on discharge and transfer by patients and their carers. Welcoming the guidelines, Dr Joanne Knight of The Stroke Association said, Stroke is currently the UKs third biggest killer, and as such should be treated as a medical emergency. Better organisation of existing therapies could make a real difference to a persons outcome after their stroke. Dr Tony Rudd, chair of the group who produced the guidelines, says, Many of the treatments are simple, common sense interventions and yet not often delivered. Modern, high technology medicine is also beginning to have an impact on stroke. These guidelines are based on the most up-to-date evidence. They are applicable to all people involved in providing care for patients with stroke and should be made widely available. A paediatric guideline is planned produced jointly with the Royal College of Paediatrics and Child Health. Meanwhile, recent research appears to support the increased use of preventative medicine. Published in the Lancet, the Oxford Vascular Study report notes that major stroke incidence in Oxfordshire has dropped by 40 per cent over the past 20 years. Commenting on the findings, The Stroke Association, who part-funded the research, emphasised the importance of simple lifestyle changes as well as more proactive medical treatment in prevention of stroke. www.rcplondon.ac.uk www.stroke.org.uk

Online shopping gap


Every little helps - but supermarkets are generally failing to address the online shopping needs of disabled customers. Of the UKs five most prominent supermarkets, computing and disability charity AbilityNet found only Tescos alternative website is easily accessed by people with a visual impairment, dyslexia or physical disability making mouse use difficult. The charity suggests that Sainsburys, Morrisons, Asda and Somerfield are missing out on a market worth millions. Asda and Morrisons have pledged to make their home shopping facilities compliant with the Disability Discrimination Act in the near future. Julie Howell, Digital Policy Development Officer at the RNIB, comments, Many fully-sighted people find Tescos simply designed Access site offers them a better user experience than any other supermarket website. Developed for vision-impaired users, it now takes a surprising 13 million a year, and seems to attract a much wider audience than originally intended. A research report from the Joseph Rowntree Foundation, Does the Internet open up research opportunities for disabled people? is available at www.jrf.org.uk/knowledge/findings/socialcare/524.asp. www.tesco.com/access www.abilitynet.org.uk

PLEASE NOTE
The price of Speechmarks The Brain Injury Workbook, reviewed in our Summer issue, has been revised for 2004, and is now 35.95. The Maggie Johnson reference in Charlotte Childs article Choices, changes and challenges article in the Summer 04 issue should have read Functional LANGUAGE in the classroom.

Christopher Place to open new wing


A London centre for babies and children under five who have hearing impairment or speech, language and communication difficulties has expanded its capacity for therapy provision by 50 per cent. Christopher Place, a registered charity, combines nursery education and therapy, and currently caters for around 250 communication impaired children a year. Its new wing, to be opened by Patron Evelyn Glennie on 22 September, features state of the art, acoustically treated classrooms, one-to-one therapy booths, a bespoke outdoor play area, parents room and space for professional development training (see events on inside back cover). More information on the architect-designed provision will appear in a feature in the Winter 04 issue of Speech & Language Therapy in Practice. www.speech-lang.org.uk

Former US President reduced stigma of Alzheimers


The Alzheimers Society has paid tribute to Ronald Reagan for raising awareness and reducing the stigma of the disease. The former US President, who died in June, made a public declaration that he had Alzheimers disease in November 1994. The chief executive of the Alzheimers Society said this was, a uniquely courageous act. It confirmed him as a champion for the millions of people and their carers in the world who are affected by this progressive and ultimately fatal neurological disease. The Alzheimers Society has been the UK partner of the Ronald and Nancy Reagan Research Foundation since 1995. The charity believes that the international media coverage following his announcement ensured that thousands more individuals and carers were encouraged to seek help from their nearest Alzheimers societies and to talk about their experiences. As the charitys work continues, it has drawn attention to cruel and unethical drug holidays which mean that a significant number of people experience rapid deterioration which cannot be reversed. Drug holidays are used to determine whether or not a person is benefiting from the treatment, but the society points out there is no evidence to support this practice. It hopes the National Institute of Clinical Excellence will move to end the practice in new guidelines expected in 2005. www.alzheimers.org.uk

Disappointment with government response


The National Autistic Society is disappointed that the government has decided not to bring people with social and communication impairments explicitly into disability legislation. The joint scrutiny committee of the Draft Disability Discrimination Bill had recommended that the definition of disability should cover social interaction and communication. Gavin Owen from the National Autistic Society said, We are deeply concerned that this response demonstrates a fundamental misunderstanding of what autism is and how it affects people in their day-to-day life. People with an autistic spectrum disorder should not have to take individual legal cases to court in order to have their disability recognised within this legislation. However, he added that the society welcomes the governments acceptance of other key recommendations which will prioritise the provision of accessible audio-visual information on public transport and ensure that General Examination Boards take communication disorders into full account when setting exams. www.autism.org.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

NEWS & COMMENT

Positive results from mobile DAF


Manufacturers of a delayed auditory feedback device as small as a mobile phone are reporting positive results in initial trials with people who stammer. Designed in Belgium by a Technical Engineer who stutters, DEFSTUT (Defeat Stuttering) was tested by 30 adults who stammer, over a period of three months with minimal professional support. Positive effects were apparent on 80 per cent of users, with stammering decreasing and fluency increasing because of the natural speech slowing effect. Professor J. van Borsel of the University of Ghent in Belgium comments, Contrary to what we feared at the beginning of our research, the participants hadnt got used to Delayed Auditory Feedback to the extent that the positive effect decreased. Although stammering didnt totally disappear, all the people were very positive about their experience. Many of them are now able to make telephone calls. The distributors would welcome comments from speech and language therapists on the usefulness of DEFSTUT. They offer a 14 day money back guarantee, as delayed auditory feedback is not effective for everyone who stammers. www.defstut.co.uk

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

Adding colour

Mental Capacity Bill aims to empower vulnerable people


People who lack capacity, either through disability, mental illness, brain injury or illnesses such as dementia are to be placed at the heart of decision-making. The Mental Capacity Bill aims to empower vulnerable people to make as many decisions for themselves as possible and, where they cant, to protect them and their carers by setting out who can make decisions on their behalf, in what situations and how they should go about this. It would also make neglect or ill treatment of a person who lacks capacity a criminal offence. Joint champion of the Bill, Health Minister Rosie Winterton, said, The Bill provides a clear legal framework for health and social care professionals, carers and anyone acting on behalf of people who lack capacity. www.dca.gov.uk/capacity/index.htm www.makingdecisions.org.uk/alliance.htm.

Petition for change


Speech and language therapists in Scotland are inviting colleagues across the UK to sign an epetition to the Scottish Parliament. The e-petition asks the Scottish Parliament to discuss the implications of Agenda for Change for the profession. It can be viewed and signed at http://itc.napier.ac.uk/e-petitionscot/list_petitions.asp. The closing date is 20th September 2004.

tel/ansa/fax If you were a colour, what colour would you be? Stark white, fired-up red, laid-back 01561 377415 purple, solid black? Maybe this summers grey weather has left you feeling blue. If so, get working on a clarification of your values (Jo Middlemiss, p.22) e-mail and let Speech & Language Therapy in Practices move to full colour brighten avrilnicoll@speechmag.com your day! I suspect that, if Keith Park were a colour, he would be whatever colour his clients needed him to be at any given time, but you can check this out for yourselves by joining Keith and Nevin Gouda at interactive storytelling workshops at Shakespeares Globe Theatre (see p.8). The colourful props and variety of musical styles used in JABADAO (p.4) are reflected in the vibrancy of our front cover. Susan Munro and her clients clearly revel in this approach, designed to encourage interaction, movement and relationships. Importantly, it also allows clients with profound and multiple learning disabilities to show their true colours as communicators. Some of our clients are reliant on pale images to guide them, but Amy Duck & Sarah Weeks (p.19) painstakingly support children with speech and language impairments and learning disabilities to fill in the colour and detail that will enable them to develop independent life skills and functional communication. All vulnerable groups struggle to access information. When speech and language therapist Sasha Bemrose and midwife Lynn Lynch (p.10) wanted greater uptake of antenatal education in their Sure Start area, they enlisted the help of a cartoonist. The use of colourful cartoon material - rather than dense black text which relies on literacy - has been pivotal to an increase in effectiveness. Issues in speech and language therapy are rarely if ever black and white, as our How I contributors (p.24) can attest. However, by taking an organised approach to common problems - good communication, coordination, planning, audit and review of the literature - they have come up with a spectrum of ideas which may add up to a solution. Colour can help us to get organised and stay organised, according to Jayne Comins (back page), who counts vibrant purple and cheerful blue ringbinders among her favoured tools. And, when Christina Barnes and colleagues (p.14) were developing their care pathways for deaf children to improve equity of service, colour coding was essential to the organisation of the flow diagrams to keep them clear and unambiguous. Speech & Language Therapy in Practice aims to reflect the diverse shades, hues and mix of our profession and our clients. So, if this magazine were a colour, what colour would it be? Well, full colour - naturally!

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

COVER STORY

IF YOU HAVE A LIMITED EQUIPMENT BUDGET NEED TO MOTIVATE CARERS WANT TO HAVE FUN WHILE YOU WORK

People with profound and multiple learning disabilities suffer from the erroneous perception that they are non-communicators. Susan Munro discovers that the JABADAO framework can bridge the gap between the perception and the reality - and provide lasting opportunities for progress.

ost speech and language therapists in the learning disability field have a steadily increasing number of people with profound and multiple learning disabilities on their caseload. However, finding relevant literature on therapeutic approaches can be difficult, as the majority of literature focuses on people with mild-moderate learning disabilities and methods which, more often than not, are inapplicable or irrelevant to people with profound and multiple learning disabilities. In addition, many experienced therapists yearn for new and inspiring ways to work with clients with such complex communication support needs. With a desire to find a therapeutic approach which both facilitated the development of early communication skills and motivated and inspired a variety of staff groups, I set out on a quest which culminated in the discovery of JABADAO. Over the last decade the literature available to speech and language therapists about intervention approaches specific to working with people with profound and multiple learning disabilities has gradually increased. Much has been written about the use of objects of reference (Park, 1995; 1997; 1999), storytelling (Park 1998; 2000; 2001), Individualised Sensory Environments (ISE) (Bunning, 1996; Dutton, 1996; Smidt, 1996) and Intensive Interaction (Nind & Hewett, 1994; 1998;

Irvine, 2001), and it has been heartening to read reports on the positive benefits of traditionally non-speech and language therapy approaches such as hydrotherapy (Bartlett, 1999) and art therapy (Hill, 1997). However, one of the significant difficulties facing therapists who work with people with profound and multiple learning disabilities is the need to pass skills on to other people involved in that persons care and development. People with profound and multiple learning disabilities need much more regular input than most speech and language therapy services can provide and, therefore, success is often dependent on the cooperation and understanding of others. A review of the literature on approaches to staff training indicates that, to be effective, it must: a) take place in the workplace b) be based around the situations and contexts that commonly feature in the member of staffs daily work c) focus on the client or clients with whom the member of staff most frequently interacts and d) involve a more experienced colleague who knows the needs of the client and has opportunities to work alongside the staff member (Purcell et al, 2000). This would suggest that parallel working with a member of staff who will carry out a specific approach in the speech and language therapists absence is imperative if this model of therapy is to be effective.

JABADAO
Making a song and dance

about communication

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

COVER STORY

So was I searching for the impossible? A therapeutic approach which not only focused on the needs of my clients with profound and multiple learning disabilities but also provided a forum for training staff to carry out appropriate activities outwith speech and language therapy sessions. Surely I was asking too much? However, a chance discussion with a physiotherapy colleague revealed JABADAO as a potential resolution.

A catalyst
JABADAO is well known to many physiotherapists working in the fields of learning disability, paediatrics and mental health. It uses music and colourful props - such as parachutes, balls, ribbons and scarves - as a catalyst for encouraging interaction, promoting movement and supporting relationships amongst participants. The approach is based on the assertions that a) the ability to make and maintain positive relationships is an essential aspect of an individuals life, underpinning the ability to learn, to be healthy, and to be happy b) movement is the most direct medium of human communication we possess. It focuses on building relationships through techniques such as mirroring, witnessing and patterning, thus creating a movement dialogue either between two individuals or amongst a group. Probably the most significant principle of
Figure 1 Recording form

JABADAO is that each individuals experience is central. JABADAO does not suggest or direct ways in which to respond; rather, it seeks to encourage and support an individuals spontaneous reactions, and then to make it possible to share this with others. As such, JABADAO provides a way of working with each person as they are, and emphasises the building of relationships as the basis for meeting all other goals. Literature evaluating the benefits of JABADAO is easy to find (Tufnell et al, 2000; Greenland, 2000; Crichton et al, 2000). However, despite the fact that communication appears to be a key theme throughout, there is no evidence of its use by speech and language therapists. As a result, the evidence presented is anecdotal and there is no documentation of the impact of JABADAO on specific aspects of communication. However, I was so inspired by what I read that I decided to undertake my own analysis of JABADAO as a potential therapeutic approach for people with profound and multiple learning disabilities. So, after completing a three-day JABADAO course, I set up a small research group to investigate the specific communication benefits of JABADAO for people with profound and multiple learning disabilities. The group was run in a day centre for eight consecutive weekly sessions. The group comprised of eight adults with profound and multiple learning disabilities, four members of staff from the day centre, a speech and language therapy assistant

and me. We created a recording form (figure 1) to identify and categorise target communication skills, which the speech and language therapy assistant and I used to take baseline measurements and for weekly recording after each group session. We also recorded each session on video, which allowed us to analyse and document the responses of group members in more detail than could have been gained from observation alone. The group was well attended by both clients and staff and each session included a balance of group activities and opportunities for work with individuals or in pairs. We used a wide range of musical styles, from Cajun Folk to Classical, and a balance of vocal and instrumental music. Props included a parachute, velvet covered elastic, balls, balloons, ribbon sticks and colourful scarves. One of the favourite group activities involved the parachute and balloon - raising the balloon higher and higher until it burst on the artex ceiling (though I did eventually run out of balloons!) The group participants were responsible for selecting both the music and the props for each activity, and the biggest lesson for the staff was to learn how to respond rather than direct.

Great success
At the end of the eight-week research project it was obvious that JABADAO had been a great success for all those involved. All participants showed some development of target communication skills and

JABADAO Speech & Language Therapy Aims


Date: ______________________________ physical prompt fleeting fleeting physical prompt physical prompt unintentional physical prompt facial/vocal limited physical prompts physical prompts occasionally no no no verbal prompt part session short sustained verbal prompt verbal prompt intentional (occasional) verbal prompt pointing/gesture full verbal prompts verbal prompts regularly yes yes yes full full long sustained self-initiated self-initiated intentional (regular) self-initiated sign/speech

Name: _____________________________________ General Participation Attention Eye Contact Turn-taking Imitation Initiation Choice-making Expression Awareness of Group Engaging with Staff Engaging with Peers Assisting Peers none none none none none none none none none none none none

Communication

Relationships

self-initiated self-initiated

Physical Contact

Tolerates Indirect Touch Tolerates Direct Touch Initiates Touch

Comments
Participation & Attention Communication Relationships Physical Contact

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

COVER STORY

reviews
CLINICAL EDUCATION Clinical Education in Speech-Language Pathology Lindy McAllister & Michelle Lincoln Whurr ISBN: 1-86156-310-8 20.00

Well-referenced and sensible


This excellent text will be of use to students and clinical educators at every stage of their professional development. The eight wellreferenced chapters identify what goes on in clinical education - the good and the bad - and offer sensible insights from a Humanistic approach. The clearly written text is mixed with many tables, vignettes and several learning exercises. This is not a quick-fix manual. It is a serious attempt to raise the professional status of clinical education. Universities and clinical placement providers would do well to buy this book for their students and staff. Josie Roy is a speech and language therapist at Astley Ainslie Hospital in Edinburgh. HEAD INJURY Head Injury: A Practical Guide Trevor Powell Speechmark ISBN 0 86388 451 2 19.95

Refreshingly clear
This readable guide introduces head injury from basic anatomy to acute care, rehabilitation, and beyond to life adjustments for the individual and the family unit. True to its title, the book offers jargon-free explanations and practical coping strategies for the physical, cognitive, emotional and behavioural impact of head injury. Personal accounts of clients and carers poignantly illustrate each of the areas discussed and contribute to a useful and accessible resource for clients, their carers and family. It also provides a refreshingly clear and comprehensive overview for students and therapists new to the field of head injury. Hannah McQueen is a speech and language therapist working for Coventry PCT. LANGUAGE DEVELOPMENT StoryCards: Verbs (picture cards and finger puppets) Sue Duggleby & Ross Duggleby Speechmark ISBN 0 86388 450 4 41.06

Sat in the cupboard


We reviewed this as a team, and the fact that it has sat in the cupboard for three months is revealing. Working with children with specific language impairment, we feel the pictures are too complex visually, with unfamiliar characters / vocabulary such as ostrich. There are quite a lot of pictures per sequence and we do not feel the resource is functional. You could use it to consolidate verb work, but we feel a little bewildered by it. We feel that therapists working in the community are even less likely to find this expensive resource useful. The specific language impairment service of the speech and language therapy department at City Hospitals Sunderland is Ruth Colmer, Lisa Bergstrand, Helen Cochrane, Jill Elstob, Julie Bell and Jeannie Williamson.

half of the group members showed development in at least 50 per cent of the recorded areas. Across the whole group the most common developments were in the areas of turn taking, imitation, initiation, choice-making and engagement with peers. The most important finding for me was that the participants with the most severe physical and sensory impairments actually made the most significant gains from their own baseline assessment, and tended to show the most significant development in the areas of participation, attention, eyecontact and engagement with staff. The group was also well-received by the day centre staff who reported not only their personal enjoyment of the sessions but also their realisation of the abilities and potential of the participants. They were enthusiastic about continuing JABADAO groups outwith allocated speech and language therapy time but voiced concerns over the practicalities relating to such staff intensive sessions; the more complex the needs of the participants, the higher the staff ratio required. However, despite this, more than a year on, JABADAO groups continue to be a regular feature on the day centre timetable and run with the same level of enthusiasm as they did at the beginning. This response from the day centre staff is equally important to me as a speech and language therapist. Often the most crucial, and difficult, objective for the speech and language therapist working with people with profound and multiple learning disabilities is to alter the commonly-held perception that they are non-communicators. If we can challenge these attitudes then we can truly begin to make a difference in peoples lives, as it is only once the key people in their environment view the individual as a potential communicative partner that we can begin to implement intervention strategies to develop their communication further. JABADAO appears to be another tool the speech and language therapist can use to bridge this gap. It is very likely that JABADAO has many more useful applications for speech and language therapists working with a variety of client groups. It has certainly become a core aspect of the service I provide because: it values each person involved and allows each individual to participate in their own way it helps non-speech and language therapy staff to focus on an individuals abilities rather than their disabilities its fun, and motivates staff to run regular sessions it doesnt require hi-tech, complicated or expensive equipment. Susan Munro is a specialist speech and language therapist with Tayside Primary Care NHS Trust, tel. 01382 346005 or e-mail susan.munro@tpct.scot.nhs.uk.

Resources
For further information about JABADAO - Centre for the Study of Movement, Learning and Health, see www.jabadao.org or tel. 0113 231 0650.

References
Bartlett, C. (1999) In at the deep end. Therapy Weekly November 4: 12. Bunning, K. (1996) The principles of an Individualised Sensory Environment. Bulletin of the Royal College of Speech & Language Therapists January: 9-10. Crichton, S., Greenland, P. & Perrin, T. (2000) The JABADAO Elderly Papers, JABADAO Publications, England. Dutton, L. (1996) Steps to engagement through Individualised Sensory Environment (ISE) therapy. Human Communication Nov/Dec: 16-18. Greenland, P. (2000) Hopping Home Backwards. JABADAO Publications, England. Hill, C. (1997) A sequence of sequins. Bulletin of the Royal College of Speech & Language Therapists November: 14-16. Irvine, C. (2001) On the floor and playing... Bulletin of the Royal College of Speech & Language Therapists November: 9-11. Nind, M. & Hewett, D. (1994) Access to communication: Developing the basics of communication with people with severe learning disabilities through intensive interaction. David Fulton: London. Nind, M. & Hewett, D. (1998) Interaction in Action: Reflections on the Use of Intensive Interaction. David Fulton: London. Park, K. (1995) Using objects of reference: A review of the literature. European Journal of Special Needs Education 10 (1): 40-46. Park, K. (1997) Choosing and using objects of reference. The SLD Experience 19: 16-17. Park, K. (1998) Dickens for all: Inclusive approaches to literature and communication for people with severe and profound learning disabilities. The British Journal of Special Education 25 (3): 114-118. Park, K. (1999) Whose needs come first? Speech & Language Therapy in Practice Summer: 4-6. Park, K. (2000) Riverrun and pricking thumbs. The SLD Experience 25: 11-13. Park, K. (2001) Interactive storytelling: a multidisciplinary plot. Speech & Language Therapy in Practice Summer: 4-7. Purcell, M., McConkey, R. & Morris, I. (2000) Staff communication with people with intellectual disabilities: the impact of a work based training programme. International Journal of Language and Communication Disorders 35 (1): 147-158. Smidt, A. (1996) Turning around the negative spirals. Bulletin of the Royal College of Speech & Language Therapists January: 11. Tufnell, M., Greenland, P., Crichton, S., Dymoke, K. & Coaten, R. (2000) What dancers do that other health workers dont... JABADAO Publications, England.

DO I USE APPROACHES THAT HELP CARERS RESPOND RATHER THAN DIRECT? DO I BORROW IDEAS FROM OTHER DISCIPLINES AND ASSESS THEIR APPLICABILITY? DO I RECOGNISE THAT THE BUILDING OF RELATIONSHIPS UNDERPINS ALL LEARNING?

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

HERES ONE I MADE EARLIER...

Heres one I made earlier...


ALISON ROBERTS RETURNS WITH SOME MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONS.

TOTEM POLE
A fun activity which is useful for a teenage social language group. Native American peoples totem poles depict animals that reflect or encourage aspects of their culture and personalities. We made one that was designed to encourage various conversational skills. Perhaps not quite so aesthetically pleasing as the original carved wood variety, but calls upon a cooperative approach, and results in an object with impact!

SAME AND TALKING STICK DIFFERENT CHAINS


This is a pressure-free way for your clients to consider peoples unique qualities and their similarities. If you have a wall available, it also makes a rather good display, with especially high impact if there are several together.

MATERIALS
A cardboard tube with as big a diameter as possible. We obtained one that had been the centre of a carpet roll, and cut off a 5-foot length. The actual cutting is quite a job, and needs a bit of muscle and a saw Large sheets of strong paper in shades of brown Felt tips, scissors and glue String and parcel tape

A useful, cheap and easy item to make with a teenage social language group where turn taking seems to be a problem. It will help if the group is already interested in Native American people and their culture - maybe linking with a classroom project - but this is not absolutely vital; you yourself may be able to enthuse them about the culture by showing pictures or books.

MATERIALS
Long strips of paper - lining wallpaper cut lengthways into three will be tough, cheap, and long Good scissors Felt tip pens

MATERIALS
A stick - I would tend to err on the side of too small rather than too big, as sticks can be used as weapons String Scissors and glue Beads - nice glass ones would add to the quality of and respect for this item, which you may find yourself using in such groups for years A few feathers

IN PRACTICE
First you need to talk through the aspects of conversation that you are hoping to target. The group should already be aware of the meaning of terminology such as Eye Contact, Listening Skills, Topic Maintenance/Focus, Body Language, and Turn taking. Decide on animals that could be associated with each conversational skill. We chose an owl for eye contact, a bat for listening, a heron for topic maintenance/focus (a heron is a regular visitor to the lake outside the mill where we work), and a peacock for body language (admittedly from the wrong continent, but an excellent example of animal body language, and one that they all knew). For turn taking we added a paper Talking Stick half way down, but you could demonstrate poor turn taking, by adding a pig not noted for polite turn taking at the trough! Once the length of the pole has been cut, you need to fix tying points so that you will be able to attach your finished pole to a wall. We stuck lengths of string around the pole, but you could drill pairs of holes with string through instead. In either case, dont scrimp on the length of string you allow to hang out, and make sure you have aligned them to correspond with attachment points in your room. Now you need to draw the animals on to the paper - each client can be in charge of an animal. The trick is to keep the drawings tall, so that they will just overlap when stuck to the pole, and the right size to cover the perimeter of the pole. The finished effect of the pole will be enhanced if, when you cut out the animals, you allow ears, wings, and beaks to protrude, by careful cutting round the shapes. Glue them to the pole, leaving your strings out. Attach the pole to the wall using the strings. Stick labels that mention the animal / conversation skill connection either on each animal, or on the wall, beside your pole.
Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

BRAWN
Fold your paper into a concertina. You will probably be able to cut through about 10 layers of paper at a time, and each flat area will need to be big enough to draw a person on, so approximately 30 inches will be about right - but experiment! Draw a person outline (2-dimensional, not a stick man), on to the front, and cut out. A key point to make, if your clients are making these themselves, is that the hands or elbows (if hands on hips), or outer edges of skirt, or shoes must stretch to the outside edge - otherwise you will end up with a lot of separate paper people rather than a chain. If you create more than one joining point the chain will be stronger.

BRAWN
1. Form a groove around the stick, using a penknife - probably best to do this bit on your own before the session, to avoid disaster. 2. Tie the string around the stick, and attach the beads and feathers to the string.

IN PRACTICE
It will be helpful to have a list of discussion subjects relevant to your particular client group. These could be local / national newspaper headlines, or issues currently topical to the school or college where you work (could be to do with clothes, food). Try to make the subject something that they have opinions about. Each group member should be encouraged to offer an opinion, but may only speak while they are holding the stick. Begin by passing the stick in order round the circle, but work towards group members silently indicating their desire to speak, to form a more natural conversation. If you have an overly wordy person in the group you may need to introduce a one-minute rule, so that the others do not get bored. Take care to arrange it so that reluctant speakers also join in. It is worth remembering that turn taking not only requires the disciplines of joining in, and waiting for a turn, but also of remembering what you have to say until a good moment arrives. Before doing this activity it may be useful to allow a group to talk all at once and then point out that the conversation is not working because no one can hear what anyone else is saying. Then you will have good grounds for proceeding.

IN PRACTICE I
Once the paper shapes have been cut out and opened up, you will be able to discuss how people in general are similar to look at, and you can talk about other similarities and emphasise our common humanity. You might also want to make the point that, if we were all exactly the same, life would be boring. Now you can move on to uniqueness / individuality, by decorating the people, being sure to make some female and some male, of various ethnicities, hair colour, some with glasses, varying ages and so on. As well as talking about external appearance, you might want to mention peoples differing preferences, lifestyles, etc., and could add words to the cutouts bodies to indicate these differences.

IN PRACTICE II
If you widen the concertinas so that you can fit in two people on the front, holding hands, you can make one more obviously female and one more male, or one fatter, or one in a wheelchair for example. You can also add speech bubbles.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

INCLUSION

Advisory teacher Keith Park and speech and language therapist Nevin Gouda tell Avril Nicoll about interactive storytelling, and how anyone can do it - even you.

A midsummer nights conversation H


eres looking at you, kid. Keith Park does a mean impression of Humphrey Bogart. And for that matter John Wayne, Prince Charles, Peter Sellers, Bob Hoskins and even Darth Vader. He makes a pretty good job of Welsh and Scottish accents as well as Cockney, and throws in some Arabic and Hebrew for good measure. Appropriately, Im at the Globe Theatre on Londons south bank to meet interactive storytelling guru Keith Park and speech and language therapist Nevin Gouda. Im keen to understand more about how interactive storytelling works for people with complex support needs, and how easily it could be incorporated into everyday settings and activities. Keith is an advisory teacher for SENSE (The National Deafblind Rubella Association) in Lewisham, London. While I am in the process of researching a feature on new builds specially designed for people with communication difficulties, Keith is taking people with the highest support needs to the Globe Theatre stage to re-enact Shakespeare plays in several community languages as well as English. Interactive storytellings experiential nature quickly becomes clear - and, rather than wondering how great literature can be made accessible to people with profound and multiple disabilities, my thoughts turn to how on earth I can make interactive storytelling accessible to readers via a printed article...

A human level
Keith wants to get away from specially constructed settings and the dreaded functional vocabulary to high status venues and participation in fun activities. He dislikes the way that a lot of special education is devoid of humour, a grind, and wants to animate people and get them more involved on a human level. Again and again he talks of interactive storytelling leading to his clients doing things that people with learning disabilities are not supposed to do. Interactive storytelling began in 1987 with Homers Odyssey, in collaboration with Nicola Grove, as a reaction against seeing a group of adults with learning disabilities being led in a rendition of If youre happy and you know it. Since then it has snowballed, and culminated in the recent publication of a book (see our reader offer). The scope of interactive storytelling is as wide as we want it to be - from Shakespeare and classic writers through poetry, film, television and our own experience. By making it a rich multisensory experience, everyone can be included, whatever their level of ability - and they will often surprise with what they can do. So far, the Shakespeare work has included A Midsummer Nights Dream (see Speech &
Nevin Gouda and Keith Park outside the Globe Theatre

IF YOU THINK YOUR CLIENTS SHOULD HAVE FUN! VOCABULARY THAT IS MORE THAN FUNCTIONAL OPPORTUNITIES TO GO ANYWHERE ANYONE ELSE DOES

Language Therapy in Practice, Spring 2002), Romeo & Juliet and Othello. Part of the star crossed lovers season at the Globe, the relevance of Romeo & Juliet to modern day life is clear, as Keith and Nevins version sets the Montagues and Capulets as Jews and Arabs, both talking of peace and of learning lessons, but with the cycle of destruction ultimately continuing. Keith has just learned that the Globe has agreed to make its stage available to his groups for at least eight Mondays in its closed season, and is excited at the prospect of seeing Othello enacted on the famous stage, to coincide with the current Shakespeare and Islam theme. Nevin - who is also Keiths Arabic adviser - and Keith collaborated for several months to produce an accessible version of Othello (see figure 1). But surely it must be difficult to teach Othello to people with learning disabilities? On the contrary, Nevin assures me, the Lewisham College students involved took just two goes to master it. Othello uses three languages - English extracts of original Shakespearean text, Arabic (which would

probably have been Othellos first language) and signs from British Sign Language. Nevin is enthusiastic about the benefits of interactive storytelling, not just for the students themselves, but for staff training. She had faced the frustrations of many in our profession when tutors were reluctant to attend signing groups. Interactive storytelling has allowed the desire for training to happen naturally, as the tutors have seen the benefits in a real situation and are asking her for more. Shakespeare is not exactly top of many school pupils lists, so why would it appeal to children and adults with complex support needs? Keith points out that most of Shakespeares audience would have been illiterate, so the meaning had to come from what they observed on stage. His work therefore lends itself beautifully to different codes and registers, and is strongly emotional, rhythmical and directional (me/you/him/her/all of you), giving many opportunities for over-the-top and melodramatic gesture, sounds and acting. Furthermore, in the plotlines you can find oppor-

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

INCLUSION
Figure 1 Othello Interactive Storytelling Group, Lewisham College

WORKSHOP INVITATION
Readers of Speech & Language Therapy in Practice are welcome to join in the Othello interactive storytelling workshops at Shakespeares Globe Theatre, on Monday and Friday mornings, from 10.30-11.30am from Monday October 4th to Friday December 10th (except for the week of half-term, beginning October 28th). Workshop participants will include teenagers and adults with severe and profound learning disabilities. Please contact Keith Park (e-mail keithpark1@onetel.net.uk; tel/fax 020 8699 6098; mobile 07791 174 740) for more details. (NB Please do not try to contact the Globe Theatre directly.)

Students signing vengeance

tunities to explore stages of development. For example, if you want Theory of Mind, look no further than Macbeth, when a murderer has to pin the deed on someone else. A minimalist approach is very deliberate. There are no costumes and only rarely are props used, so that students engage with the script itself. The emphasis is on the interactive - the aim is language and communication, and making stories more interactive is the therapeutic bit. Call and response is key. At a signal, everyone makes a response in any way they can, be it words, gesture, sound, or pressing a switch with a pre-recorded phrase. A call and response pattern automatically allows for lots of repetition of key words, and for experimentation with vocal register, which can be a great stress reducer for the students. By creating a circle of people on the stage, the energy moves towards the centre, where a student can go. This often results in the students not only responding but initiating; for example, as everyone waits for a particular user to press their switch to kick off the story. I wonder how this works with large groups. Keith tells me he began his time as a visiting teacher by making a point of asking class teachers what they wanted from him. They said they wanted his students - who are deaf blind with profound and multiple learning disabilities - to have the opportunity to experience whole group work. Counterintuitively, Keith now finds that, the bigger the spread of strengths and needs in the group, the better it is. By basing the group around the needs of the most disabled person there, that person is included and other people are sparked off, for example through signing. He has also done some work with mainstream and high support needs students working together, and has letters from the mainstream pupils which clearly show the positive effect of the contact, and how it starts to break down fears and barriers.

telling students, and exploited by the use of different languages and modalities. One student did a gesture in such a way that made it clear he was having a laugh by turning [sala:m] into <salami>, and talk of peace jokingly became talk of peas (and broccoli and carrots and so on). Interactive storytelling is by no means confined to Shakespeare. And, while the free-and-easylooking Shakespearean pieces are highly structured and take a long time to prepare, other uses of interactive storytelling are much more spontaneous and can easily be improvised. Keith and Nevin have observed carer participants using the strategies, such as lines from stories their clients have been involved in, to calm them down and to keep them occupied while they are waiting to do something else, as well as just for fun and interaction. I press Keith and Nevin: But surely you have to be a bit of an extrovert, and to have an encyclopaedic knowledge of the arts, and a background in drama? They insist this isnt the case - they have no drama training - and that even the shyest person can end up using a call and response approach to good effect. So, what ideas can they offer to fledgling participants? Firstly, they suggest putting together a story or poem from your own background. Start off with something simple and embroider it. Try one word poetry, saying your name over and over with appropriately fun intonation, progressively knocking off phonemes, until you are left with just one. Remember that nothing can be wrong observe children at this developmental stage having fun playing with rhyme, meaning and emphasis, and youll get the idea of the inclusive silliness of it all.

A good ice breaker with staff who are a bit shy to join in is the call Give us a crisp, give us a crisp with each person progressively adding flavours and everyone saying Yum, yum. While responses automatically start with salt and vinegar and cheese and onion, more exotic and fantastic flavours - cold custard, dandelion and nettle - are bound to creep in to increase the enjoyment and loosen inhibitions. Think as well about how different concepts can be covered through bending storylines. For example, in Jack and the Beanstalk, Keith uses the idea that people are poor listeners: Ive got some beans. You got some jeans? NO, Ive got some beans. You got some queens? NOOO... etc. Ending with You know, you do my ead in! On the storytracks website, a collaboration between Keith and Nicola Grove, they say: Stories give meaning to our lives - we are storytelling creatures who are constantly reviewing and interpreting our experiences and making links with what has happened to others. In so doing, we develop a sense of who we are, and we learn to connect and feel for others. Its now clear to me that, rather than asking why people with complex support needs would want to do Shakespeare, we should be asking why anyone wouldnt? So, go on Keith - play it again. Keith Park is an advisory teacher for SENSE in Lewisham, tel. 020 8699 6098. Nevin Gouda is a speech and language therapist with Lewisham Community Team for Adults with Learning Disabilities, tel. 020 8698 6788. For more information on Keith Park and Nicola Groves storytelling workshops, see www.storytracks.com.

READER OFFER WIN KEITH PARKS INTERACTIVE STORYTELLING


Is your appetite whetted for more?
Speechmark Publishing Ltd is offering a copy of Interactive Storytelling - Developing Inclusive Stories for Children and Adults to readers of Speech & Language Therapy in Practice, in a FREE prize draw. The hands-on manual includes folktale and pantomime, stories from around the world, Shakespeare, Charles Dickens, poetry and song, and growing your own stories. To enter, send your name and address to Speech & Language Therapy in Practice - Interactive Storytelling offer, Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ by 25th October. The winners will be notified by 1st November.
Interactive Storytelling by Keith Park is available for 29.95 along with a free catalogue from Speechmark, tel. 01869 244644.

Having a laugh
Keith believes he isnt so much teaching Shakespeare as using it - he works very flexibly, throwing in different lines and improvising as seems appropriate. Shakespeare made his name by playing with language; this love of words and the way they sound is shared by interactive story-

From Summer 04: the lucky winner of ERRNI (The Expression, REception and Recall of Narrative Instrument), courtesy of Harcourt Assessmen is Katie Lea in Barnsley. The Butt Non-Verbal Reasoning Test from Speechmark Publishing goes to Helen Millward, Judith Delve and Janis Halber Congratulations to you all.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

EARLY INTERVENTION

IF YOU ARE WORKING TO IMPROVE ATTENDANCE RATES WITH PEOPLE WHO ARE DISADVANTAGED AND SOCIALLY EXCLUDED ON MAKING INFORMATION MORE ACCESSIBLE

A bump start
During a pregnancy, parents can be very receptive to new information about their babys development. Recognising that disadvantaged groups need support to lay the foundations of communication, Sasha Bemrose and Lynn Lynch joined forces with a cartoonist to develop an antenatal pack, appropriately titled Your Bump and Beyond.

Sasha Bemrose

rom the moment of birth - and even before - a baby is a social being that finds and engages in interaction with other humans Lynn Lynch and the wider environment. An excellent opportunity exists in pregnancy to lay the foundations of interaction and communication, so we have developed an evidence based pictorial information pack. Your Bump and Beyond can be used with parents in the antenatal and postnatal period to enhance parent-baby bonding and maxHuw Evans imise the babys full potential. It has been piloted in the South Wales Valleys of Rhondda Cynon Taff with 30 mothers. Due to its success - and demand - it has been printed, and is now available to buy. So, how did it all start? The Welsh Assembly Government (2001) emphasises the importance of clinical networking to provide effective care. As a Surestart speech and language therapist, Sasha was keen to work with families and children in a preventative way. She had attended a conference (Hodzic, 2002) that emphasised that babies can develop before they are born, and the importance of parent-baby bonding at the earliest stages. With this in mind she realised the importance of working with families in the antenatal stage. At the same time, Lynn was aware of a recent study looking at the speech and language abilities of children in the local area. The findings emphasised the level of delay that children living in this area of deprivation suffer. Lynn had been involved in a previous project using pictorial information with vulnerable woman. She, too, was looking to develop a way of working with expectant and young mothers to improve the skills of young children. At the time of our consultation we had therefore identified a need for understandable, accessible information that would encourage positive interaction and communication skills prior to birth and in the early postnatal days. We pooled Sashas knowledge of early interaction and communication and Lynns knowledge of pregnancy and working with vulnerable women - and Your Bump and Beyond was the result. Rhondda Cynon Taff is an area of significant socio-economic deprivation with poor health status across all demographic groupings. It has the highest rate of conception in Wales in the 13-15 age group (RCT Surestart Plan, 20002002). We recognise that parents and their children in this area are some of the most vulnerable families at risk of disadvantage and social exclusion.

Surestart (DfES, 2001) recognises that a childs communication skills can only be developed with adequate stimulation and response from others. Babies are social beings and need someone to respond to their communication. The seeds for development are laid in the earliest stages of baby-parent interaction. Research into the speech and language abilities of nursery school children within one of the South Wales valleys found that the majority of children were performing well below their expected age ability on speech and language measures (Merthyr Tydfil County Borough Council, 1998). Ward (2000) indicates that children whose language development is delayed are at high risk of developing educational, social and emotional problems. Early experience has an effect on later development, and patterns of interaction can be set as early as three months of age (Brazelton, 1992). In the early stages, the main carers need to be attentive and responsive to their baby to facilitate this interaction. By supporting parents antenatally and giving them information on what the baby is capable of doing, the parents become proactive at the earliest stage. They feel involved and important which gives them confidence. If they form an attachment before the baby is born, they are more likely to interact with the baby as soon as it is born. In addition, we have found that antenatal parents are keen to learn and have been very receptive to new information. Research suggests that a baby begins to learn in utero, and that this is an opportunity to increase maternal awareness and interaction prior to birth (Hodzic, 2002; Van de Carr & Lehrer, 1997; Verny 1981). Hodzic (2002) argues that stimulation during pregnancy will improve attachment as well as interaction between mother and baby. Studies indicate that the prenate is more capable than previously believed. There is evidence to show that, during the sixth month of pregnancy, the baby can see, hear, taste, experience, feel, remember and even learn (Verny, 1981). These concepts are explained to the parents and supported by cartoon material and research examples. They can relate the information to their own experience. For example, they are shown how the prenate communicates through kicking, what music is soothing for the baby, and how the baby responds to their voice when it is born.

Original cartoon material


Vulnerable groups do not have access to information for a variety of reasons, issues with literacy being one (DH, 2001). We therefore felt it was vital that any information was presented in an accessible and accepted form where access of information was not dependent on literacy levels. For this reason we have used original cartoon material with minimal written text. It is clear from the research and from our experience that parents and children in the local area require support to develop effective interaction skills. These skills can be learnt before the baby is born. A way of working needed to be developed which was accessible and attractive to this particular client group. With these points in mind we developed a pack to address the following objectives: support parent-baby attachment prior to birth support parent-baby attachment post birth establish good patterns of parent-baby communication from an early age provide the baby with maximum stimulation to aid their brain development, physical development and growth, hearing and communication skills (Verny, 1981) increase parents self esteem involve family members reduce sibling rivalry. Your Bump and Beyond consists of cartoon picture cards to show to mothers and their families, a handbook for the professional to use that explains each picture card, and activities that can be photocopied and given to parents to practise. The pack has been split into two main areas: learning before birth (figure 1) and learning as a baby (figure 2). All of the examples are fully referenced.

Seeds for development


The link between family deprivation and child learning is complex and multi directional. Children from deprived areas are disadvantaged in their learning due to many factors such as family stresses, economic difficulties, parental experiences of education, their limited literacy skills and low self-esteem.

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EARLY INTERVENTION

Figure 1 Part one: Learning before birth


This pack consists of seven double-sided picture cards. The contents have been split into two sections: what your baby can do before they are born, and things to do to help your baby. The pack helps the parents to be aware that the baby is able to develop skills before they are born. It shows the parents ways of stimulating their baby that can help to give them a head start when they are born. This early parent-baby interaction aids attachment and early communication. This may prevent later difficulties, such as language delay, from developing. The following pictures illustrate the pictorial cards, and extracts have been taken from the handbook for professionals. By 24 weeks of pregnancy, your baby can hear music and voices. Your baby does not like loud noises and will tell you so by kicking and moving. Your baby will move its body in rhythm to your talking. When your baby is born, it is calmed by the sound of your voice and other familiar voices. Newborn babies can pick up their mothers and fathers voice within an hour of birth. Tapes of a human heartbeat were played into a nursery with newborn babies. Those babies who heard the tape did better than those who did not hear the tape (they ate more, weighed more, slept more, breathed better and cried less). Touching and rubbing your tummy will help your baby develop good physical skills and feel relaxed. It will also help you feel relaxed. Sing the Action Song. This incorporates many of the ways you can help your baby before they are born - it involves singing, listening to music, touch and movement.

Ten midwives from one of the South Wales valleys have taken part in the pilot study since January 2003. Each was asked to use the packs with ten mothers. Evaluation forms were simple and asked for feedback from the midwife and the mother. To date, thirty evaluation forms have been returned (figure 3). The pilot has shown that the cartoon pictures have been received very well by the women and midwives and have potential for further use by other professionals.

Figure 3 Evaluation
FEEDBACK FROM MIDWIVES

Question Has the pack been easy to use? -Yes -No Has the pack been easy to understand? - Yes - No In what setting have you used the cards? - at home (one-to-one) - parent craft (antenatal group) Who have you used the cards with? - regular caseload - complex caseload How did you use the cards? - out of sequence - sequentially Has the pack aided you in the delivery of information? - Yes - No Do you feel the client has benefited? - Yes - No
FEEDBACK FROM MOTHERS

Response 30 (100%) 0 30 (100%) 0 25 (83%) 5 (17%) 12 (40%) 18 (60%) 0 30 (100%) 30 (100%) 0 28 (93%) 2 (7%) Response 21 (70%) 9 (30%) 30 (100%) 0 28 (93%) 2 (2%) 27 (90%) 0 3 (10%)

Figure 2 Pack two: Learning as a baby


This pack consists of five double-sided picture cards. The information emphasises the importance of the birth environment and the need for the baby to be held and to hear a familiar voice. The content continues to focus on the ways parents / carers can communicate with their baby through touch and sound in the very early days. This has a positive impact on the baby and also the parents, and may help to increase attachment and parental coping strategies. The first hour with your baby after they are born is especially important. It should be quiet with no distractions, avoiding bright lights. You should be as comfortable and relaxed as possible. Both mother and baby need time to recover. Relatives may need to be told to wait a while before they see you and the new baby. You and one other close person to you should be alone with the baby for at least the first hour. Skin-to-skin contact is especially important. A baby that is laid on their mothers tummy will automatically inch their way towards the breast. All babies are different. They have different temperaments and levels of alertness and respond to change in different ways. By 72 hours, newborns can detect the difference between happy and sad expressions. Your baby will respond in the same way - if they see a happy face they will feel happy.

Question Is this your first baby? - Yes - No Did you learn anything new? - Yes - No Did you try out any of the activities? - Yes - No Has the information helped your baby? - Yes - No - Dont know
COMMENTS FROM MOTHERS

Question Did you learn anything new? I was aware in pregnancy that when I spoke my baby moved - that means he or she knows me. I had a mobile phone for Christmas and I kept the tune on that calmed my babys movements. I talk all the time to my baby since you said it can hear me. I really feel as though I know her or him already, it knows me. After I went home (from hospital) and spoke, my baby turned towards me. I felt really important and loved, special. Question Has the information helped your baby? My baby looks right at me when I speak. I always look at my baby when I speak. I have found ways of calming my baby just by singing and touching my mam says I will spoil him but I dont listen. One women with clinical depression commented: I felt very involved and important to my baby when I was pregnant. It made me feel good.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

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EARLY INTERVENTION

resources
About Cerebral Palsy
Scope has launched a free updating service for anyone interested in cerebral palsy. About Cerebral Palsy will appear at least three times a year, and include features, interesting websites and information on new research and literature. It is available electronically as a pdf, or as a hard copy. See www.scope.org.uk/publications/ aboutcp.shtml or contact the Scope Library and Information Unit on 0207 619 7342

Choice in healthcare
A six-monthly directory and website aims to provide independent information to people who want to make more choices about where they receive their NHS treatment. nhs Family Choice is published by Cyworks, see www.nhsfamilychoice.com

Face Former
Distributors of Face Former, a functional muscle training device and programme developed by a German speech and language therapist in 1998, are hoping to expand its appeal to the UK and Ireland. 34.99 with volume discounts from www.faceformer.co.uk

Talking Point
The Talking Point website continues to expand, with the addition of material on writing individual education plans, secondary education, supporting children with speech, language and communication difficulties, and evaluation of a training programme for early years settings. Regular Ask the panel events including Managing social development and behaviour in children and young people with speech, language and communication needs are also proving popular. www.talkingpoint.org.uk aims to be the first stop online for information on speech, language and communication difficulties in children

Prenatal auditory stimulation


A product providing prenatal auditory stimulation has been relaunched in the UK. BabyPlus is a small digital audio unit worn on a belt around the abdomen when a mother is pregnant. It plays sequences of sounds with the aim of stimulating the babys developing brain. 145 inc. UK delivery, see www.baby-plus.co.uk, tel. 01869 253552

The pack has also been informally piloted in a local antenatal group in a community flat. The group was set up to deal with the level of non-attendance (50 per cent) at the local antenatal clinic and parent craft groups. The pack was presented alongside creative activities such as making nursery rhyme books, crib pictures and mobiles. The use of the pack alongside practical ideas provided a forum for discussion and the involvement of other family members. At a recent group a sibling who had made a nursery rhyme book told her father, If I sing to the baby, when its born it will know who I am. The parents and children enjoy making resources for the baby and report that they find it relaxing. There is now mainly full attendance at these groups. During pregnancy, parents are keen and enthusiastic to learn about ways to help their baby. If they learn to communicate with their baby at this early stage it sets up good patterns once the baby is born and helps to form positive attachments. Research suggests that early stimulation before the child is born can enhance the babys brain development, physical development and growth, hearing and communication skills (Hodzic, 2002; Verny, 1981). By singing lullabies, as well as through simple interactive games, parents can establish strong prenatal bonding by conveying emotions like love (Hodzic, 2002). We hope that this pack will provide an accessible, useful tool for midwives and other professionals to use with mothers-to-be, new mothers and families to support the dissemination of information. Your Bump and Beyond was developed by Sasha Bemrose MSc, BSc (Hons), ACS, MRCSLT, MHPC, a specialist speech and language therapist employed by Surestart Rhondda Cynon Taff, Wales and Lynn Lynch MSc, BSc (Hons), RM, RN, FETCH a consultant midwife with North Glamorgan NHS Trust. Huw Evans was the cartoonist. It has been presented at the European Regional Conference Nurses Federation in Malta, at the Royal College of Midwives Conference in Cardiff and also at the Surestart Conference in Warwick.

Resources
Your Bump and Beyond Antenatal Packs available from Childrens Information Service, Ty Trevithick, Abercynon, Mountain Ash, CF45 4UQ, tel. 0800 180 4151. Cost 30 (with 3 p&p). SEAL - Society for Effective Affective Learning - www.seal.org.uk, tel. 020 83653869.

Stroke and Aphasia


As well as providing easy to understand, comprehensive information, the new Stroke and Aphasia Handbook is intended as a tool to support people with aphasia in asking questions, having discussions and conversations, and making choices and decisions. 23.50 inc. p&p (not-for-profit) from Connect tel. 020 7367 0840, e-mail info@ukconnect.org

Hearing aid toolkit


Defeating Deafness has produced a toolkit which tells people what to expect when getting hearing aids, how to make the most of audiologist visits and where the latest technology is headed. www.defeatingdeafness.org

References
Brazelton, T.B. (1992) Touch Points: Your childs emotional and behavioural development. Reading Mass: Addison-Wesley. Department for Education and Skills (2001) Surestart - Promoting Speech and Language Development - Guidance for Surestart Programmes. DfES Publications. Department of Health (2001) The confidential enquiries into maternal deaths in the UK: Why mothers die (1997-1999). The Department of Health, Social Services and Public Safety: Northern. Hodzic, P.K. (2002) Prenatal Learning - The Blossoming Brain. Notes from SEAL conference Sewing the seeds of learning - July, Derby. Merthyr Tydfil County Borough Council (1998) Merthyr Tydfil Peoples in Community Document. Rhondda Cynon Taff Surestart Plan (2000-2002) All children deserve a Surestart. Van de Carr, R. & Lehrer, M. (1997) While you are expecting. Your own prenatal classroom. Humanics Trade: Atlanta. Verny, T. (1981) The Secret Life of the Unborn Child. Dell Publishing: New York. Ward, S. (2000) Babytalk. The Pioneering book that will change childcare forever. Century Publications. Welsh Assembly Government (2001) Improving the Health of Wales. NHS Wales, January.

Diagnosis support pack


A Contact a Family pack aims to provide health professionals with practical suggestions on how best to communicate information and offer support to parents at or around the time of a diagnosis. The Support Pack for Health Professionals - Working with families affected by a disability or health condition from pregnancy to preschool downloadable from www.cafamily.org.uk/packs.html

What about faith?


The Foundation for People with Learning Disabilities has produced a good practice guide for services on meeting the religious needs of people with learning disabilities. The guide provides practical advice on how services can support adults in their religious expression, and explains why it is important to take the religious needs of people with learning disabilities seriously. The Foundations related publications include Why are we here?, What is important to you?, No Box to Tick and Religious Expression, a Fundamental Human Right What about faith? is 45, from the Foundation for People with Learning Disabilities, tel. 020 7802 0304 or see www.learningdisabilities.org.uk

Voice software
Vocal Processs Jeremy Fisher has compiled a list of voice analysis software that can be used to produce spectrograms, some available as freeware or shareware. See www.vocalprocess.net

DO I ATTACH SUFFICIENT IMPORTANCE TO CLINICAL NETWORKING? DO I ENSURE CLIENTS AND CARERS FEEL INVOLVED, IMPORTANT AND CONFIDENT? DO I PROVIDE THERAPY AND MATERIALS THAT ARE EVIDENCE BASED?

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

FURTHER READING

further reading
Aphasia
Eames, S., McKenna, K., Worrall, L. & Read, S. (2003) The suitability of written education materials for stroke survivors and their carers. Topics Stroke Rehabil 10 (3): 70-83. This study evaluated the suitability of written materials for stroke survivors and their carers. Twenty stroke survivors and 14 carers were interviewed about the stroke information they had received and their perceptions of the content and presentation of materials of increasing reading difficulty. The mean readability level of materials (grade 9) was higher than participants mean reading ability (grade 7-8). Satisfaction with materials decreased as the content became more difficult to read. Seventy-five percent reported that their information needs were not met in hospital. More stroke survivors with aphasia wanted support from health professionals to read and understand written information, and identified simple language, large font size, colour, and diagrams to complement the text as being important features of written materials. Simple materials that meet clients information needs and design preferences may optimally inform them about stroke.

Language disorder
Larson, V.L. & McKinley, N.L. (2003) Service delivery options for secondary students with language disorders. Semin Speech Lang 24 (3): 181-98. Numerous adolescents are still undetected, unserved, and underserved by speech-language pathologists, resulting in astronomical financial and psychological costs to them and society. The purpose of this article is to provide an overview of past and present service delivery options for adolescents with language disorders. Before illustrating the authors recommended model, the following background is provided: an overview of the three stages of adolescent development, characteristic expectations and problems for older students with language disorders, and a rationale for adolescent speech-language services. The comprehensive service delivery model for secondary-level speech-language students, designed and reported by the authors, consists of six components: information dissemination, identification, assessment, program planning, intervention, and follow-up. Some of the unique features of the comprehensive model are presenting services as a course for credit, providing grades, and using supportive course titles such as Individualized Communication Class.

This regular feature aims to provide information about articles in other journals which may be of interest to readers. The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire YO7 4PP, tel. 01765 640283, fax 01765 640556. Annual rates are CDs (for Windows 95): Institution 90 Individual 70 Printed version: Institution 72 Individual 50. Cheques are payable to Biomedical Research Indexing.

and emphasizes the need for a wellorganized voice training program in future professional voice users. However, it is disturbing to note that the lectures and training on vocal hygiene failed to influence voiceconserving habits.

Hearing impairment
Priwin, C., Stenfelt, S., Granstrom, G., Tjellstrom, A. & Hakansson, B. (2004) Bilateral bone-anchored hearing aids (BAHAs): an audiometric evaluation. Laryngoscope 114 (1): 77-84. OBJECTIVES: Since the technique to implant bone-anchored hearing aids (BAHAs) with the use of osseointegrated implants was developed in 1977, more than 15,000 patients have been fitted with BAHAs worldwide. Although the majority have bilateral hearing loss, they are primarily fitted unilaterally. The main objective of this study was to reveal benefits and drawbacks of bilateral fitting of BAHAs in patients with symmetric or slight asymmetric bone-conduction thresholds. The possible effects were divided into three categories: hearing thresholds, directional hearing, and binaural hearing. STUDY DESIGN: Prospective study of 12 patients with bilateral BAHAs. METHODS: Baseline audiometry, directional hearing, speech reception thresholds in quiet and in noise, and binaural masking level difference were tested when BAHAs were fitted unilaterally and bilaterally. RESULTS: Eleven of the 12 patients used bilateral BAHAs on a daily basis. Tests performed in the study show a significant improvement in sound localization with bilateral BAHAs; the results with unilateral fitting were close to the chance level. Furthermore, with bilateral application, the improvement of the speech reception threshold in quiet was 5.4 dB. An improvement with bilateral fitting was also found for speech reception in noise. CONCLUSIONS: Overall, the results with bilateral fitted BAHAs were better than with unilaterally fitted BAHA; the benefit is not only caused simply by bilateral stimulation but also, to some extent, by binaural hearing. Bilateral BAHAs should be considered for patients with bilateral hearing loss otherwise suitable for BAHAs.

Normative data
Lahar, C.J., Tun, P.A. & Wingfield, A. (2004) Sentence-final word completion norms for young, middle-aged, and older adults. J Gerontol B Psychol Sci Soc Sci 59 (1): 7-10. This report describes sentence-final word completion norms for 119 sentence contexts based on the original sentence completion norms of Bloom and Fischler (1980). Four sets of norms are made available for 358 adults, representing young, middle-aged, young-old, and old-old samples. Notable in these norms is a high degree of consistency in responses among all four age samples. Differences in relation to the original Bloom and Fischler norms appear in responses to low contextually constraining sentences. Results show that the recency with which normative data are collected is an important variable to consider when making use of norms.

Voice
Timmermans, B., De Bodt, M.S., Wuyts, F.L. & Van De Heyning, P.H. (2004) Training outcome in future professional voice users after 18 months of voice training. Folia Phoniatr Logopaed 56 (2): 120-9. The long-term influence of vocal hygiene education and the effectiveness of voice training was studied in 46 students. Twenty-three subjects received vocal hygiene education during 1 school year and voice training during 2 school years (18 months). The remaining 23 subjects received neither vocal hygiene education nor voice training. The voice training consisted of technical workshops (30 h a year with groups of 5-8 subjects) and vocal coaching in the radio and drama projects (30 h whole class). Lectures

(30 h) provided a theoretical background on breathing, articulation, voicing and vocal hygiene. A multidimensional test battery containing the GRBAS scale, videolaryngostroboscopy, maximum phonation time, jitter, lowest intensity, highest frequency, Dysphonia Severity Index (DSI) and Voice Handicap Index (VHI) was applied before and after 18 months to evaluate the effect of voice training over time. A questionnaire on daily habits was presented before the lectures, and after 18 months to detect the long-term effect of the lectures. The objectively measured voice quality (DSI) of the trained group improved significantly over time (p < 0.001) due to training (p = 0.008). This was not the case in the untrained group. The self-assessed VHI changed over time (p < 0.001) in both groups: from 18.4 to 14.4 in the trained group, and 20.1 to 15.3 in the untrained group. However, the VHI scores of both groups remained high. The results of the daily habit questionnaire showed that the initial high degree of smoking, vocal abuse, stress and late meals was not influenced by the lectures or training and remained high. This study demonstrates the positive outcome

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

13

CARE PATHWAYS

No borderline
Figure 1 Assessment pathway (children who have a hearing impairment)

IF YOU WANT TO BE CONFIDENT AND CONSISTENT PROVIDE A SEAMLESS SERVICE HAVE MORE TIME FOR THOSE MOST IN NEED

SPEECH AND LANGUAGE THERAPY CHILDREN WHO HAVE A HEARING IMPAIRMENT PATHWAY FOR ASSESSMENT
Christina Barnes

Historically, trust boundaries have caused problems for our clients, and led to charges that the NHS operates a postcode lottery. Now, Christina Barnes and colleagues in a regional special interest group in deafness have developed a care pathway to improve equity of service for clients wherever they live.

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

CARE PATHWAYS

e - just a pathway
Figure 2 Intervention pathway (preschool)

SPEECH AND LANGUAGE THERAPY CHILDREN WHO HAVE A HEARING IMPAIRMENT PATHWAY FOR INTERVENTION PRE SCHOOL

pecial interest groups are a crucial part of a speech and language therapists continuing professional development (RCSLT, 1996). In South Wales and the West we recognise this by having a strong membership of our special interest group in deafness. Many of our members travel long distances to attend our termly meetings and, whilst we always seek to have outside speakers, we share from our own experience (presenting case studies, reflecting on particular areas of work), report back on courses, and contribute on Royal College matters, for example the competencies project. We all benefit from the non-managerial group supervision that is afforded in this context; indeed, clinical queries / clinical supervision is a standing item on our agenda. Over time it became clear that we should address the issues around our working practice, to aim for continuity of provision in spite of variations in funding across health service boundaries. We began this process in March 2002 in response to a request from the All Wales Managers to develop a care pathway of intervention and assessment. A care pathway is a process by which a clinician may be prompted to make appropriate decisions regarding clinical management. We began by looking at various pathways that had been devised previously. Of these we found the phonology pathway (Owen et al, 2001a; 2001b) to be most user-friendly, as it took the form of a flow chart that was easy to follow. We broke into buzz groups and brainstormed the essential information that we wanted to include. Our objectives were that the care pathway should be client needs led as far as possible an aid to clinical management decision-making transparent enough to be understood by other speech and language therapists transparent enough to be understood by other health and education professionals. As creating one pathway would be far too busy visually - and consequently confusing - we focused on three pathways, one for assessment (figure 1) and two for intervention (preschool and school aged, figures 2-3). As a member of the team that had developed the phonology pathway, it naturally fell to me to take the lead role. The progress towards the final draft was slow, mainly due to our meeting schedule. Between the following three meetings the pathways were edited and revised, and group proof reading led to further revisions. We aimed to make the care pathway as user-friendly as possible to all members in their various contexts. We arrived at our final draft in June 2003 and are now putting it into full practice. As far as possible, a colour code was used to prompt the user of the care pathway: Green: exit / moving towards discharge Red: clinical decision action point Blue: question to aid clinical decision-making Black: clerical action point Orange: warning (is this the right decision? Are there extraneous circumstances?) We decided it was appropriate to quantify the levels of service a client should expect to receive, and produced a document based on unpublished work by the speech and language therapy department in North Bristol. It aids clinical management decision-making within the care pathway framework, and is therefore printed on the reverse of both intervention care pathways (figure 4).
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CARE PATHWAYS

Figure 3 Intervention pathway (school age)

SPEECH AND LANGUAGE THERAPY CHILDREN WHO HAVE A HEARING IMPAIRMENT PATHWAY FOR INTERVENTION SCHOOL AGE

Figure 4 Levels of service (Based on work by the North Bristol Trust speech and language therapists)

LEVEL CRITERIA FOR PROVISION Level 1 Advice and communication with other agencies required Childs communication needs are best met within their daily environment, eg. ...childs profile may include: a) General language delay b) Immature speech c) Listening and attention control difficulties The most appropriate deliverers of the communication programme / targets are the daily communication partners Named carer / worker / assistant is available and able to follow advice

Level 2 As above PLUS The deliverers of the programme will require specific training eg. ...childs profile may include: a) Phonological difficulties b) Mild receptive and / or expressive language difficulty c) Use of communication aid or other AAC required d) Specific social communication difficulty Level 3 At this point therapy CANNOT be delivered by any other agency / person due to the specific nature of the work High level of liaison with other agencies required Carers and other professionals working with the child will require specific training and a high level of support ...Childs profile may include: a) specialised phonological or articulation work b) specific receptive language difficulties c) specific expressive language difficulties d) need specific resources

We are now in a position to work with these documents throughout our region. They can be easily laminated and slipped into a therapists briefcase for reference. We hope that, through use of these documents, children will receive an appropriate level of service; that more therapy time will be available to those children with significant needs, and that it will be clearer which clients should be either discharged or transferred to other clinical caseloads. Thus, the specialist speech and language therapist within a trust may release a little more time for the consultative, advisory and training aspects of their role, and therapists new to this branch of the service will be able to make clinical judgements with more confidence and consistency, safe in the knowledge that their colleagues around the region are working in a similar way. (See case examples in figure 5a-b.) We also feel that the care pathway may be used as a tool in communicating our role and decision-

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SPRING 2004 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

CARE PATHWAYS

Figure 5a Using the Assessment Pathway (school age)

MANAGEMENT Written communication programme with targets. Planned with carer or teachers as appropriate. Main carers and professionals informed as appropriate. Agreed implementation strategy to include: a) Identified carer / worker / assistant to be responsible for implementation of the targets / programme b) Terms of speech and language therapy involvement outlined and agreed c) Evaluation date agreed As above PLUS An agreed number of sessions with named worker / carer and child, as appropriate, for demonstration purposes only

A secondary school special educational needs coordinator referred Harriet early in year 7 (chronological age 11;0y). She had a statement of special educational needs and had transferred to secondary school from a moderate learning difficulties unit. Her mild, mixed sensori-neural and conductive hearing loss had only been identified within the previous six months and she had been prescribed a hearing aid for her right ear. I offered an initial interview in school and completed a full assessment of auditory memory, auditory discrimination, receptive language, expressive language and phonology. Evaluation of the assessments, liaison with the learning support team and other reports identified a child who was performing well on many language-based tasks. Despite the moderate learning difficulties statement she was performing within the average range on vocabulary tests, formulating sentences and listening to paragraphs (CELF-3UK). Harriet had significant difficulty with auditory recall, performed just below average on the TROG and found Oral Directions (CELF-3UK) very challenging particularly the elements related to
Figure 5b Using the assessment and intervention (preschool) pathways

left/right orientation and those containing more that four information carrying words. Her baseline secondary cognitive ability tests had identified a child of low ability in the language (written), spatial and quantitive sub-tests. Teachers found her difficult to understand, as she tended to speak rapidly and quietly. Her support teacher found her profile to be rather more consistent with a child with a specific learning difficulty (dyslexia) rather than a moderate learning difficulty. However, her language profile was not typical of a child with specific learning difficulties. Thus the question Is the language delay of concern considering all factors eg. hearing age, level of ability and degree of hearing loss? was difficult to answer... and the conclusion uncertain has led to a period of monitoring and evaluation which will include a re-referral to the educational psychologist by the special educational needs coordinator. However, I felt it was appropriate to include a report with initial advice on management and strategies. If no further concerns are expressed before her next annual review, Harriet will be discharged from the speech and language therapy service.

Background: Jason is 2;5y. Mother contracted cytomegalovirus whilst pregnant. Profound sensori neural deafness on one side. Suspected moderate-severe conductive on other side. Not being offered grommets, as risk of damaging only ear with useful hearing for speech. Some minor physical / coordination problems but otherwise development seems appropriate. Severe problems with dribbling. Attends nursery three sessions per week. Teacher of the deaf sees fortnightly. Pathway for assessment: Does he have a hearing impairment? Yes Is it sensori neural loss? Yes, but also congenital conductive. Offer Assessment with teacher of the deaf - done. Evaulate assessment - done. Is language delay a concern - yes (Language delay of over a year. Only just beginning to use single words meaningfully. Parents using key signs.) Write report, advice etc. Go to intervention pathway

As above PLUS It is appropriate for the child to receive an intense period of direct therapy for an agreed period of time Development of specific resources is required

Pathway for intervention (pre-school): Has child been identified as needing intervention? Yes Does child meet local resources criteria? Yes Evaluate level - 2 Provide programme and training: Advice given at nursery, home and to teacher of the deaf. Attendance at special needs review meeting with mum, paediatrician, physiotherapist, nursery, teacher of the deaf Offer special training to parents eg. Hanen: Mum invited to attend fortnightly communication group for parents of preschool deaf children. Parent interaction advice given at home. Provide language programme in consultation with other professionals / suggest targets: Advice given for individual education plan. Teacher of the deaf responsible for applying for additional funding. Has child made progress? Yes, but re-evaluate - still requires ongoing support at level 2. Termly visits planned to support family and regular meetings with nursery and teacher of the deaf to help plan individual education plan. (Anna Duncan, speech and language therapist)

making to other professionals - for example, that it is not the specialist role to treat language delay resulting from otitis media with effusion. We are also aware that, unfortunately, the history of some posts may make it challenging to reduce the level of service, say if a particular school has had therapy provided for three sessions a week. We hope however that, by use of the pathway and explanation of the levels of service, others will acknowledge that a client needs led service benefits all. We will audit the pathway over time to evaluate if it is possible for speech and language therapists working in the specialist area of paediatric hearing impairment and deafness to provide an equitable service across health service boundaries. Christina M. Barnes is a specialist speech and language therapist with West Wiltshire NHS Primary Care Trust, tel. 01225 766161. This article was written on behalf of members of the South Wales and West Region Special Interest Group in Deafness,

and the care pathways are based on work by the speech and language therapy department of West Wilts and North Wilts PCT.

References
Owen, R., de la Croix, H., Lewin, J., Lawer, E. & Davies, S. (2001a) A first class team. Speech & Language Therapy in Practice Spring: 16-20. Owen, R., Lewin, J., Lawer, E., de la Croix, H. & Davies, S. (2001b) Equity of service: A protocol for management of children with speech problems. International Journal of Language & Communication Disorders 36 (Supp): 110-4. Royal College of Speech & Language Therapists (1996) Communicating Quality 2: Professional standards for speech and language therapists.

www.harcourt-uk.com Hanen, see www.hanen.org Parent-child interaction therapy: an alternative approach to the management of childrens language difficulties, see I CAN training at www.ican.org.uk TROG (Test for Reception of Grammar) - version 2 now available from Harcourt Education, www.harcourt-uk.com

Resources
CELF-3UK (Clinical Evaluation of Language Fundamentals) from Harcourt Education,

DO I PARTICIPATE FULLY IN SPECIAL INTEREST GROUPS? DO I CONSULT EFFECTIVELY ON NEW DEVELOPMENTS? DO I MAKE DECISIONS THAT ARE CLIENT NEEDS LED AND TRANSPARENT?

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17

REVIEWS

reviews
PHONOLOGICAL AWARENESS Phonological Awareness Series Disc 1 - Listening and Rhyme (CD-ROM) Leaps and Bounds Multimedia, tel. 0191 413 1818 ISBN 0-9546521-0-X 45.00

Ready made worksheets


This CD ROM provides a range of activities including listening to sounds, completing well-known nursery rhymes, and generating rhyming words. Strengths Useful for informal assessment Activities at different levels to meet individual needs Easy to follow onscreen instructions and supporting information for therapists, teachers and parents Ready made worksheets provide reinforcement activities Black and white and coloured pictures can be downloaded and printed to produce games and worksheets. Limitations Programme appeared slow when loading and changing menus Limited use of animation and stimulating sound to maintain interest Limited range of levels Vocabulary at easier level may be too difficult for younger children It is reasonable value for money. Dorothy Donker is a language development support teacher with the Language Development Service (Aberdeenshire).

Size does exactly what it says on the packet, and also includes long/short and little/big/bigger. All in all, a useful and child-friendly addition to any clinicians range of equipment; lightweight, versatile and easy on the budget. I like them. Libby Inglis is a speech and language therapist in community clinics in Shropshire.

SELECTIVE MUTISM Selective Mutism In Children (Second Edition) Tony Cline & Sylvia Baldwin Whurr ISBN 1 86156 362 0 27.50

All the information required


This encyclopaedic book gives the reader all the information required to treat this rare communication problem, which can fall between the two stools of speech and language therapy and clinical psychology. The information is clearly presented and easy to access. Helpfully, the authors commend specific chapters. Essential reading are those on assessment and treatment, which relate well together. A user-friendly grid format with notation is suggested to record a baseline assessment and to chart progress. Well presented, well researched and well priced, this book is a worthwhile addition to paediatric speech and language therapy department resources. Melanie White is a senior paediatric speech and language therapist with Colchester PCT.

in the disruptive and unnatural environment of an acute hospital, using an interview approach. Covering the spectrum of potential hospital communication problems from aphasia to lack of fluency in English, it takes 45 minutes to administer at initial interview. Aims, clearly stated, are to: 1.Describe a patients ability to communicate in hospital situations. 2.Provide information to other staff about specific communication strategies. 3.Identify communication situations in hospital for direct therapy intervention. Therapists experienced in the acute field will find this innovative, but I believe inexperienced speech and language therapists and students will find it most beneficial. The IFCI is well explained with clear assessment forms included for photocopying. Though some of the psychometric analyses are based on small numbers, the authors justify their position with such a pragmatic tool. I particularly liked the communication support the therapist gives the client during the initial interview to maximise their potential to communicate. Such strategies are then documented and shared with other healthcare staff with immediate effect. At 32.95 it is good value for money and a highly novel means of approaching the needs of our inpatient clients. Lindsay King is a speech and language therapist at Penrith Hospital, Cumbria.

CD. Activities integrate speaking, reading and spelling of verbs, using Key Stage 1 vocabulary. The book and CD are easy to use. Activities are printed from the CD for individual, group or class use. This is not a stand alone product but, together with Scallys World of Verbs, is a useful programme for mainstream primary schools, language units and special schools. If you are already using Scallys World of Verbs, this Activity and Resource Pack is an economical, time saving addition. Lindsay Malekzai is a speech and language therapist and coordinator of the speech and language therapy team to mainstream schools for Bexley NHS Care Trust.

INTERVENTION Speech & Language Therapy Intervention - Frameworks & Processes Karen Bunning Whurr ISBN 1 86156 400 7 25.00

Audience is unclear
The theme of this book is that all therapy, across all boundaries (such as adult / paediatric), has a common core in planning, describing, analysis and intervention. The first half sets out a common theoretical framework of interventions and the second half describes processes of intervention with some good real-life interactions analysed using the glossary of enactment processes. The audience is unclear. For a pre-registration student, it pulls together in summary all the influences that come to bear on real-life therapist / client interactions, but its a long read with some fairly opaque jargon, and the time might be better spent getting more practical experience. More experienced therapists will be reassured to find the text reinforces what they know already, while the references may be helpful to identify best practice. Lynn Holmes is a community paediatric therapist in Thirsk, and has responsibility for training and developing collaborative working with schools in Hambleton & Richmondshire PCT.

COLORCARDS Pocket ColorCards: Hows Teddy? How Many? Heads and Tails & Shape and Size Speechmark 5.95 each +VAT

I like them
These packets of cards are colourful, portable and versatile. They cover a range of concepts needed in most therapy situations for children. Hows Teddy? shows children and teddy covering a wide range of emotions. How Many? has numbers in a variety of everyday situations and includes whole and part. Heads and Tails has familiar objects cut in half to cover beginnings and ends. Shape and

ASSESSMENT IFCI: Inpatient Functional Communication Interview Robyn OHalloran, Linda Worrall, Deborah Toffolo, Chris Code & Louise Hickson Speechmark ISBN 0 86388 506 3 32.95

SOFTWARE The Scally Activity & Resource Pack (book and CD) Cheryl Dobbs & Pat Minton Topologika Software Ltd, tel. 01326 377771 14.95 + VAT

Useful additional programme


Do you know Scally the computer animated alien? This new Activity and Resource Pack supports the Scallys World of Verbs software programme (single user licence 34.95 from Topologika). It contains a book of 12 games, 20 activity sheets and a

Highly novel approach


This Australian designed measure does exactly what it says on the tin! It assesses - from a refreshingly functional perspective - the communication problems inherent

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

COLLABORATION

You cant learn to swim on dry land


D
avid (13) is unable to attempt any element of road safety tasks independently and is very nervous about using the road. He cannot correctly sequence the stages of crossing a road safely. In addition, he has gross motor difficulties due to dyspraxia. His parents are fearful about him taking part in road safety sessions. Tanya (14) is unable to manage any food preparation and cleaning up independently and needs oneto-one support to access this part of the curriculum. She finds the sequencing of the tasks difficult and is unable to use equipment such as knives safely. She is still heavily dependent on adults at home and school to help with basic skills of independent living, and is unable to identify the benefits of developing skills in these areas. The white paper, Valuing People, highlighted the inadequacies of the current transition process for children with special educational needs moving on from school into their adult lives. We think the problem lies not only within the transition process, but in the educational approach used in the years leading up to it. The national curriculum is particularly failing those with speech and language impairment, communication and interaction difficulties and learning difficulties, with many completing formal education without the necessary learning and consolidation of skills. This leaves them vulnerable to an increased risk of developing mental health problems, of acquiring a criminal record, and the inability to function independently, form a relationship or hold down a job (Agran et al, 1989; Clegg et al, 1999). Within our national curriculum, the learning of real skills for independent living (effective interaction skills, life skills and self-confidence) is often neglected. Even where the ethos intends to promote life skills, the emphasis is on inappropriate tasks that have no functional impact on day-to-day adult lives - for example learning about French cuisine in cooking. In other settings, life skills is treated as a secondary aim behind academic or vocational goals. Most mainstream students learn life skills incidentally, from interacting with their peers, teachers and families. Unfortunately, this cannot be assumed with students who have learning and communication difficulties. Despite efforts to differentiate programmes of study, the national curriculum does not meet their long-term needs because it:

Amy Duck and Sarah Weeks take issue with a national curriculum that leaves children with speech and language impairments and learning disabilities flailing like fish out of water. They call on us to dive in with a more holistic approach to developing functional communication and community living skills.

thus limiting their opportunity to see good social models or practise their own behaviours. They also tend to have a restricted social network and consequently a lack of emotional support. To this extent, the students with perhaps the greatest emotional needs are let down by the national curriculum. As stated by Gardner (1993), interpersonal and intrapersonal skills are as vital to healthy functioning as mathematical competence.

Understanding and responsibility


Personal social and health education at Key Stages Three and Four of the national curriculum aims to help pupils lead confident, healthy and responsible lives as individuals and members of society. Under knowledge, skills and understanding at Key Stage Three it states that pupils should be taught to reflect on and assess their strengths in relation to personality, work and leisure and, similarly, to recognise how others see them and be able to give and receive constructive feedback and praise. However, these two objectives are amongst a list of 26, and therefore cannot be given the time needed; we would need to focus on these alone to address the pupils particular difficulties. Instead, these objectives are only part of a wider personal social and health education syllabus - and this is only one of several subjects squashed into the fast-paced educational week. The curriculum should emphasise skills that are functionally and longitudinally relevant. Students need to develop skills that will enable them to live, work and interact in integrated community settings when they are adults (Morse & Schuster, 2000). Even the proposed changes for the 14-19 curriculum (DfES, 2003) with its work-related learning element do not allow enough flexibility or focus specifically on the basics. The outcome of the current situation for our students is that they: continue from Key Stage Three into Key Stage Four with only a few of the more able working towards accreditation in their preferred subjects have poor awareness of their own strengths and weaknesses, low confidence and greatly reduced independence in a range of daily living tasks have poor social skills and social competence great difficulty with adapting to unfamiliar environments and making and maintaining friendships have only two to four years left in education. Successfully trained adaptive behaviours that can

Amy Duck

Sarah Weeks

IF YOU ARE DISENCHANTED WITH POLICY DIRECTIONS PREPARING CLIENTS FOR TRANSITIONS WORKING ON SKILLS FOR LIFE
does not address the students learning style is too prescriptive does not give enough emphasis to improving social skills does not address the students emotional development. Consequently, the students cannot assimilate information readily, and cannot make connections between units of learning, or predict and understand the consequences of their actions. They do not have the language skills to access the mainly literature-based learning resources of the academic curriculum, nor do they have the communication skills to engage in interactive learning approaches used in the classroom. Furthermore, they often cannot keep pace with the breadth of information covered in the time-scales permitted. Their failure has a negative impact on their selfconfidence and their desire to succeed. In addition, they often have reduced exposure to social situations,

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COLLABORATION

Figure 1 Pre- and post-assessment

PRE-TOPIC:
For every topic we carry out a pre- and post-topic assessment, here relating to getting ready to go out 1. Students were informed they would be going out on Friday to do some Christmas shopping 2. For homework, they were asked to think about what they would need to take with them 3. Class-based assessment was carried out on the morning of the trip by observation of what students had brought (for example, coat, lunch, money, shopping list, watch, travel-pass, bag, sensible walking shoes) 4. This was recorded in detail for each pupil 5. The trip went ahead 6. After the trip the students were encouraged to reflect on and evaluate the success of the trip relative to them having the necessary items 7. The students comments fed into pre-topic pupils records. Outcomes included a student without a coat, a student without money, all but one student without a shopping list, no travel-passes, half the pupils expecting to have school dinners, no watches, one student without a bag, one student in high heels, only three Christmas presents were purchased amongst the whole group (10 students).

TOPIC:
Over a period of 12 weeks we aimed to increase the students awareness of the tasks involved in planning and carrying out a shopping trip. Techniques included visual prompts (mind maps, symbols), self and peerevaluation within circle time, small individual targets, repetition of the task in a real-life community-based setting both in school time and as a part of their homework. The activities always went ahead regardless of the students level of preparation. This allowed them to begin to understand the consequences of their own actions (even to the point of standing at a bus stop letting four buses pass until a student thought to put his hand out to indicate that the bus should stop!) Intrinsic motivation was fostered in circle time through discussions about how the task directly related to the students aspirations for their futures, for example being able to buy a gift for a potential boyfriend or girlfriend.

lead to increased normalisation include eating, tooth brushing, grooming, dressing, toilet-training, housekeeping, shopping, phone conversations and prevention of home accidents (Matson et al, 1990). Some very successful programmes have been developed, including work experience, community service, rural environmental science, do-it-yourself, leisure and recreation, survival cookery, and environmental studies. However, we have several criticisms of these programmes. Firstly, they are aimed at a mainstream population, and access to the work is often prohibited due to language and literacy demands. Secondly, they do not provide a total curriculum - rather they offer the students a repertoire of practical skills. For example, a topic on shopping may teach how to buy three items, use a range of coins, get the right change and keep the receipt. However, it does not teach the personal value or the ability to adapt appropriately to the social context, for example how to ask for assistance, stand in a queue, obtain clarification and repair situations, be assertive (when receiving the wrong change), refrain from anti-social behaviour (handling produce). The life skills are taught in isolation without addressing the wider barriers to their learning. As Morse & Schuster (2000) say, pupils need more from their education than how to change a plug. In addition, these programmes typically feature as a lesson within a curriculum of many other traditional subjects, and therefore there is limited opportunity to reinforce and generalise the skills through repetition and consolidation in different settings, essential to meaningful learning. By contrast, we believe a holistic approach to the teaching of life skills is imperative. We therefore carried out some research with secondary aged students (13-16 years) in a special school. All had a statement of special educational needs, some with additional learning difficulties such as autistic spectrum disorder and attention deficit hyperactivity disorder.

Appropriate and relevant


Our intervention programme covers all areas of the curriculum and is designed to convince the pupils of the relevance of school work to their own life and needs. It uses life skills and communication across all curriculum areas so that literacy and, in particular, real life or functional literacy can be taught and experienced in all subjects. This curriculum model encourages teachers to attempt to put learning into a relevant context for students so that they can transfer skills in an appropriate and relevant manner. The main objectives are to: develop students functional literacy and numeracy skills develop practical life skills and aid the students ability to apply learning experiences to real life develop self-awareness skills and raise self-esteem develop functional communication skills and social competence return the initiative for learning, reasoning and decision-making back to the pupil improve confidence across a range of settings. There is a need for flexibility in structuring the sessions. However, all sessions include introducing a topic, classroom-based teaching, community-based learning and reflecting on performance. The aims and the pedagogical approaches are consistent as our students learn by repetition and reinforcement. Regarding their learning experiences, nothing can be taken for granted - our students do not learn incidentally. Everything must be explicit, and what might appear as lack of variation in approaches is in fact a deliberate teaching technique particularly relevant to these students. In contrast to other life skills programmes, our method of teaching encompasses three areas: 1. Social Competence: The fundamentals of interacting with a range of others 2. Social-Emotional Development: Owning their disability

POST-TOPIC:
Repetition of stages 1 to 7 with the focus on shopping for the end of term party. Outcomes included all students having appropriate attire, as well as bag, money and lunch, 9 out of 10 remembering to bring a shopping list and 6 out of 10 wearing a watch (only half of these could actually tell the time), one student had a travel-pass. In most cases the correct items were purchased with supervision, however two of the students continued to need a high level of adult support.

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COLLABORATION

Awareness of their potential and limitations Wanting to influence their future Developing confidence and self-esteem Developing social networks 3. Life Skills: Personal hygiene Preparing food Personal safety Self-organisation. The programme was designed to address directly the students learning styles and counter the difficulties they face. The programme focuses on increasing the students participation within their environment or community, thus increasing their control over the events that affect them and fostering intrinsic motivation for self-development. Within the programme, students tackle any identified area of weakness such as getting about, using money, and applying for a job. They learn to increase their understanding of their strengths and weaknesses, and to gain insight into the challenges that face them - to appreciate the consequences of their current situation on their future hopes and dreams. This allows the students to own their individual problems, and can be translated into specific learning goals. The development of communication skills underpins all aspects of the class- and communitybased activities used in the programme, which is delivered by teacher and therapist simultaneously. It teaches social skills in context to enhance social performance, and works on language skills and communication strategies to improve daily functioning. We have developed and trialled a complete methodology to support this structure. Figure 1 shows a pre- and post-assessment example. Our method has entailed a deliberate move away from isolated lessons for individual subjects to a flexible, integrated approach to key skills that can be constantly reinforced in community activities through contextual learning. In our programme, a wide range of national curriculum subjects is covered to achieve breadth and balance, and the programme draws on key objectives from the literacy and numeracy strategies. However, the difference is that the content of all lessons is functional and meaningful to the students now and in their adult lives. The methodology encompasses many teaching techniques. For example: Baseline assessments, as it is essential to have an accurate picture of how the pupils perform in various settings to encourage meaningful learning, appropriate to the needs of each pupil. Consideration to the order in which particular skills are taught. When an area for development is selected on the basis of developing long-term independence, priority skills are identified for each pupil. For example, to cross the road, one student may need to learn the vocabulary for right and left and another the significance of indicators.

The students with perhaps the greatest emotional needs are let down by the national curriculum.

The broad topic area is introduced and a class aim decided on through student discussion facilitated by teaching staff. We produce short, medium and long- terms plans within the overall framework of the programme to allow for progression in terms of each students level of responsibility, readiness for involvement and development. Other techniques include the extensive use of circle time for self- and peer-review and the making of short, medium and long-term targets in conjunction with the student. We encourage self-rating to develop the students self-evaluation skills, and the recording of data in various mediums to help the student keep track of their progress. We use multi-sensory educational resources, visual tools such as mind maps and bullet point lists, and visual displays to aid learning and retention. In addition, the teaching of other curriculum areas such as information and communication technology and library skills is integrated into the above topics. We also work with parents to extend the learning outside the classroom and reinforce skills learnt within the school environment. We find that, through this functional curriculum, students gain skills that are immediately useful, enabling them to live a more autonomous life. David followed a programme including road safety sessions. We helped him understand the beneficial consequences of learning such a task as well as developing his ability to chunk the task into sequential stages. Following supported practice in context, and self-evaluation and praise for each small step achieved, David is now able to walk around the areas both near to school and local to where he lives. This was achieved in one year alongside various other elements of the programme. It has developed his confidence to participate in tasks independently and increased his motivation to accomplish other functional skills. Similar strategies were employed with Tanya for her food preparation and personal hygiene course, and considerable progress was witnessed in the course of the year. At Tanyas Annual Conference Review, her parents proudly reported that she now sets an alarm clock, wakes up the whole family, gets washed and dressed and ready for school, makes breakfast and clears away and then makes a packed lunch without any supervi-

The development of communication skills underpins all aspects of the classand communitybased activities used in the programme, which is delivered by teacher and therapist simultaneously.

sion. Tanya gained great pleasure and pride in these achievements and was motivated to set more personal goals and targets. The implications this has for her future are enormous and she has already been able to participate independently in a short work experience placement. For further information on the research or more details on the methodologies and teaching practices behind their approach, please contact the authors. Sarah Weeks (usernameweeks@hotmail.com) is a senior teacher at Spring Common School, a special school in Cambridgeshire. As 14-19 manager her primary role is to develop the curriculum, oversee transition and prepare pupils for adult life. Sarah also has a sister with learning disabilities. Amy Duck (amy.k@tinyworld.co.uk) is a senior specialist speech and language therapist working with adults with learning disabilities in Waltham Forest Primary Care Trust. She has previously worked in special schools with primary and secondary aged children. As a child her family fostered many children with social, communication, emotional and behavioural difficulties.

References

Agran, N., Martin, J.E. & Mithaug, D.E. (1989) Achieving transition through adaptability instruction. Teaching Exceptional Children 21 (2): 4-7. Clegg, J., Hollis, C. & Rutter, M. (1999) Life sentence. Bulletin of the Royal College of Speech & Language Therapists Nov: 16-18. DfES (2003) 14-19: opportunity and excellence. Available at www.dfes.gov.uk/14-19. Crown Copyright 2003. Department of Health (2001) Valuing People: a new strategy for learning disability for the 21st century. DH: London. Gardner, H. (1993) The Unschooled Mind: How Children Think and How Schools Should Teach. Basic Books. Matson, J., Taras, M., Sevin, J., Loves, S. & Fridley, D. (1990) Teaching self help skills to autistic mentally retarded children. Research in Developmental Disabilities 11: 361-378. Morse, T. & Schuster, J. (2000) Teaching elementary students with moderate intellectual disability how to shop for groceries. Exceptional Children 66 (2): 273-288.

1. TAKE NOTHING FOR GRANTED 2. DEVELOP SOCIAL AND EMOTIONAL COMPETENCE 3. MAKE LEARNING MEANINGFUL TO INDIVIDUAL LIVES AND NEEDS 4. EMBED PRACTICAL SKILLS IN A TOTAL APPROACH 5. REPEAT, REINFORCE, GENERALISE, CONSOLIDATE

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WINNING WAYS SERIES (4)

Compass set
to true north
Do you experience confusion and indecision, frustration and agitation? Do you know what is driving you? What must you have - or a part of you dies? Life coach Jo Middlemiss suggests we chart a course based on values.
Kevin is a speech and language therapist working within a hospital. The conversation I had with him was both stimulating and inspiring. Kevin had chosen speech and language therapy as a second career. He had always worked with people but was further motivated to make more of a difference to the lives of others. He works as part of a team. He has a huge variety of clients although he specialises in working with people who have had a stroke. He thinks his salary is adequate for his needs but has no desire to be a millionaire. When I asked him about the challenges that face him in his work he admitted that there are some - but he welcomes them as they all contribute to his learning and development. He doesnt beat himself up over mistakes but tries not to make the same one twice. So, in this short but helpful conversation, I could tell this is a young man who needs no coaching. His life is balanced yet varied. He loves his work and yet has many interests outside the hospital including horse riding and climbing. He enjoys the camaraderie of teamwork but is aware of and dedicated to his personal contribution. His life is purposeful and he has strategies in place for dealing with stress. In short, his values are clear. But what are values? Does everyone have them? Do we need them? How do they affect our lives? The majority of people have a vague idea about the number of their own values, and an even vaguer idea of how the multitude of values that people hold actually affects the way society functions. Susan is a very successful person to the outside world. Her marriage broke up when her child was only two. She is on good terms with her ex and is well motivated to keep on developing and growing in her life. She has switched from a standard profession to becoming a freelance consultant. She is not a person who is afraid to make changes or take risks. Susans peak moments were achieving her degree and the moment her son set off on his first solo adventure. Through discussion, the values that emerged are: Health / Well-being Love Risk taking / Adventure Achievement. Next we look at suppressed values. These emerge at times when a client gets angry, frustrated or disappointed. Susan became agitated if she was stuck in what she considered to be a dead end position. The feeling of being trapped indicates a value of freedom. She loathed derogatory chat at work and became irritated when people were uncooperative. This indicates values of: Honesty Teamwork Loyalty. When I asked Susan what she would not be without, she immediately said that she has to have time on her own. She also values her health and fitness. She loves outdoor activities not only for the physical element but because she feels connected to the grandness of nature. Shopping on a Saturday afternoon is her idea of hell. The important question to ask yourself is what must you have - or else a part of you dies? In Susans case this is: Connection with nature / Spirituality Health / Fitness Adventure.

Clarification exercise
When I start working with a client who - unlike Kevin - experiences confusion and indecision in his or her life, I use a values clarification exercise (figure 1). People often seek clarity in order to make difficult decisions with confidence. So often we do not know what is driving us - but I dont think you can achieve your dreams or ambitions without a clear idea of what that is. Our values create the essence of who we are. When we behave in a way that crosses our values, then we feel uncomfortable and uneasy. For example, if you gossip about a friend and you have a value around loyalty, you will immediately feel uncomfortable and hope that they wont find out. If you have a value around courtesy and respect, you will be very upset with litter and loutish behaviour. You values are not set in concrete and

IF YOU * STRUGGLE TO MAKE CHOICES * REACT NEGATIVELY IN CERTAIN SITUATIONS * HAVE OBSESSIVE BEHAVIOURS

Mutated value
Finally come the questions that are sometimes a bit uncomfortable. What is it about you that drives other people mad? When do you know that you are being a bit obsessive or going over-thetop? Think of the times when people have said things like, Youre such a control freak! or Lighten up! What about the times that you drove yourself well beyond the demands of the job or the circumstances you were in? Our obsessive behaviour often indicates a value taken to extreme. A value of order could appear as obsessive tidiness. (Not my problem but Im working on

the clarification only speaks for the present time the only moment of time that we have to work with. When establishing values, I dont just ask clients if they know what their values are. If I did that, they would intellectualise and operate from their heads. I want them to speak from their lives and their hearts. The whole session usually takes about an hour. Firstly I ask the client to think of a couple of peak moments in his or her life...

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WINNING WAYS SERIES (4)

Figure 1 Sample Values List (Dreamzwork)

The following list is representative of words and phrases that illustrate values. You may combine two or three values so long as critical distinctions are not lost. (For example, Honesty/Integrity/Truthfulness maintains a single distinction, but Honesty/Integrity/Freedom combines concepts, and is therefore less clear.) Humour Directness Partnership Productivity Service Contribution Excellence Freedom Focus Love Harmony Success Accomplishment Orderliness Honesty Appreciation Adventure Security Enthusiasm Tradition To be known Growth Contribution Aesthetics Participation Performance Collaboration Community Personal power Connectedness Appreciation Acknowledgement Friendship Spirituality Empowerment Full self-expression Integrity Creativity Independence Nurturing Joy Beauty Authenticity Risk taking Peace Elegance Vitality Health Trust

Would you like to: Identify and achieve your dreams Unlock your potential Confront difficult decisions Shake off restrictive behaviours and limiting beliefs Gain and maintain mental and spiritual balance Be aware of and use your talent? Our series Winning Ways with Personal Life Coach Jo Middlemiss aims to help you find out how you can be better at what you do, and better at being you. To gather material to make the issues - and their potential solutions - as realistic and relevant as possible for readers, Jo offers readers a confidential and complimentary half-hour telephone coaching session (for the cost only of your call). Although Winning Ways will be based on what is raised in the calls, you can be reassured that details will be altered so that it will not be possible to identify individuals.

CALL JO ON 01356 648329 (www.dreamzwork.co.uk).

it!) Being overly sensitive could be to do with honouring a value of respect. An obsessive behaviour can in reality be a mutated value, so it must not be ignored but pulled back a little and honoured. So, when you have listed your values, what do you do next? Well, quite simply, it is time to be aware of what you are doing in your life and work that honours your values. Create the list and prioritise the order. Then start asking yourself some challenging questions. If you hear yourself complaining about never having enough money, where is your value for wealth and success? If you are lonely and isolated, what are you doing or not doing to get connected with friends and family? If you cant squeeze into your clothes what respect are you paying to a value of health and well-being? I am an enthusiastic fan of Stephen Covey (Covey, 1999). His theory on effective ways of living is based on principles. He says that most effective people, like Kevin, are actually off course most of the time, but know which direction they are going in and so are able to self-correct. He is an advocate of starting with the end in mind so that you at least know the direction in which you are travelling. A compass, not a clock - and the awareness that in any situation there is a moment when we can choose our response: Between stimulus and

Our values create the essence of who we are. When we behave in a way that crosses our values, then we feel uncomfortable and uneasy

response, there is a space. In that space lies our freedom and power to choose our response. In our response lies our growth and our happiness. Stephen Covey does not attribute this quote, but he says that it made a huge impact on him, as it did on me. Once we become aware of the gap we can go further and press the pause button, giving ourselves some more space. Within the space, according to Covey, is our self-awareness, conscience, imagination, free will and humour. All this sounds like there would be no time to do anything because we would be so busy thinking about what to do but, in reality, it all goes on in a matter of micro seconds because our brains are such speedy computers. (My brother came in after a long day at work and his teenage girls were sniping at each other. Wherever one sat, the younger one wanted her to be somewhere else. Finally my brother asked reasonably, Well, where can she sit? The answer came back Who asked you a******? My brother says, Time seemed to slow and I had a moment to decide whether to let it pass and dismiss it as teenage angst or go completely berserk. I decided to go completely berserk! So it is possible to choose strong, natural reactions - but at least be aware that you are doing it.) I didnt discuss with Kevin if he has ever given his values any thought, but I could sense that he has

all he needs to stay on course, and that his compass is indeed set to true north. We all face a challenge in our quest to achieve our potential and lifes purpose. To be like Kevin, consider these three questions (Drummond, 2004): Who are you? Why are you living and working in the way that you are? What might you yet become and do with your life?

References
Covey, S.R. (1999) The 7 Habits of Highly Effective Families. Simon & Schuster. Drummond, N. (2004) The Spirit of Success: How to Connect Your Heart to Your Head in Work and Life. Hodder & Stoughton General.

Further reading
Whitworth, L., Kimsey-House, H. & Sandahl, P. (1998) Co-Active Coaching: New Skills for Coaching People Toward Success in Work and Life.

DO I START WITH THE END IN MIND? DO I MAKE SPACE FOR MY SELFAWARENESS, CONSCIENCE, IMAGINATION, FREE WILL AND HUMOUR? DO I ENSURE THAT MY LIFE AND WORK HONOUR MY VALUES?

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HOW I

HOW I LOOK FOR


SOLUTIONS
WHATEVER PROBLEMS YOU FACE AS SPEECH AND LANGUAGE THERAPISTS, UNDERLYING ISSUES ARE LIKELY TO INCLUDE SERVICE ORGANISATION, TRAINING, AND WORKING WITH OTHER PEOPLE. UNDAUNTED, OUR CONTRIBUTORS ASK THE QUESTIONS, ACKNOWLEDGE THE REALITY AND SEEK CREATIVE SOLUTIONS.
THE QUESTION (1): CAN WE DESIGN BETTER PLACEMENTS? ALISON NEWTON AND JO FROST ARE SPEECH AND LANGUAGE THERAPISTS AND STUDENT PLACEMENT COORDINATORS WITH BIRMINGHAM HEARTLANDS & SOLIHULL NHS TRUST AND SOUTH BIRMINGHAM PRIMARY Jo Frost CARE TRUST RESPECTIVELY. THE QUESTION (2): HOW RELIABLE IS OUR TEAM? JILL DYER IS CLINICAL LEAD IN DYSPHAGIA, DEPARTMENT OF SPEECH AND LANGUAGE THERAPY, UNIVERSITY HOSPITAL NORTH DURHAM, NORTH ROAD, DURHAM DH1 5TW, TEL/FAX 0191 333 2608, E-MAIL JILL.DYER@CDDAH.NHS.UK. THE QUESTION (3): WHAT MORE CAN WE DO? HANNAH CRAWFORD IS A SPECIALIST SPEECH AND LANGUAGE THERAPIST (DYSPHAGIA IN ADULTS WITH LEARNING DISABILITIES), DERWENTSIDE INTEGRATED LEARNING DISABILITY TEAM, ASHDALE HOUSE, ASHDALE ROAD, CONSETT, CO. DURHAM DH8 6LZ, TEL. 01207 584226, E-MAIL HANNAH.CRAWFORD@CDDPS.NORTHY.NHS.UK.

THE QUESTION (1):


ALISON NEWTON AND JO FROST COORDINATE STUDENT PLACEMENTS ACROSS A COMMUNITY AND AN ACUTE TRUST. THEIR EXPERIENCE SUGGESTS THAT A STUDENTS LEARNING EXPERIENCE IS INFLUENCED LESS BY PLACEMENT DESIGN THAN BY GOOD COMMUNICATION AND ORGANISATION.

CAN WE DESIGN
BETTER PLACEMENTS?

n our role as student coordinators in two different trusts we are facing the need to increase the number of student placements, but are also continually challenging the way we deliver placement experiences. The open and supportive nature of both our managers and the therapists with whom we work means we have been able to explore a different model of placement and openly evaluate it. So, how did we get on? In October 2002, we were planning to welcome second year students from the University of Central England for their ten week block. The benefit for the students of our two trusts working together is experience of working in both a community and an acute trust. Normally our shared placements are arranged so that the student has two days per week with one trust and two days per week in the other for the duration of the ten weeks. In practice, this means two days per week with paediatric client groups and two with adult client groups. Each week, therefore, the student works with four different therapists, in up to four different locations, with a complete change in client group, and a different set of trust rules and policies. We wondered whether this was the optimum way for a student to achieve their potential and decided to meet to discuss a new structure. Having discussed various options, we designed a placement model which offered two students the opportunity to spend five consecutive weeks at South Birmingham Primary Care Trust, focusing on a range of paediatric disorders - and five consecutive weeks at Birmingham Heartlands & Solihull NHS Trust focusing on adult acquired disorders including dysphagia. Each trust would still provide ten weeks of placement in total, only this time the students would trade places with each other after week five. Before the placement began we identified primary aims: To enable the student to immerse themselves in one client group within one trust at a time, for a more fluid and intensive learning experience To promote a placement structure that would facilitate a students learning. Our additional aims were: To challenge current methods of implementing placements To foster cross trust relationships for the benefit of both students and clinicians. Alison met the two students prior to the placement at the usual meeting provided by the University of Central England. Placement details were explained and each student received timetables from both trusts. Student A would spend their first five weeks with South Birmingham Primary Care Trust and student B would spend their first five weeks with Birmingham Heartlands & Solihull NHS Trust. At the end of week five they would both attend an interim meeting with their therapists to discuss their progress and to hand over this information to the other trust. At the beginning of week six they would trade places. Each student had two case studies to complete. One had to be submitted by week five and another after the end of the placement. This meant that our placement structure did not jeopardise their case studies but in fact fell in quite neatly. In each trust, one of the therapists working with the student was the chief clinical supervisor. They had a weekly meeting with the student to discuss their experiences so far and progress towards their aims and objectives, and to discuss any problems.

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HOW I

Communication paramount
Communication between the two trusts was paramount to the success of this placement model. A well-organised interim meeting - a combination of a visit from the university tutor and a hand over to the other trust - was a crucial part of the design. Invitations and a detailed agenda were sent to therapists from both of the trusts, the students and their tutors. At the interim meeting, each trust held a discussion with their student and their university tutor focusing on progress so far and aims for the rest of the placement. Therapists from each trust were given guidelines to facilitate structured discussion and written evaluation. After this discussion, the two groups re-convened and the written evaluation was used to feed back to the other trust. In this way, each trust had an idea of the skills the student had developed thus far, and the objectives they had achieved and those they were still working towards for the remainder of the placement. At the end of the placement, the chief clinical supervisors gathered feedback and evaluation from each of the therapists and wrote the final report, so the views of all therapists from both trusts were entered into both reports. Both students gained a percentage grade from each trust to reflect their abilities during the placement. For each student, the two grades were averaged to leave one final grade for the placement. We asked the therapists, the students and the tutors for their feedback regarding this particular model of second year placement. Therapists report that the challenge is to strike a balance between the desire to demonstrate to the student what speech and language therapy is all about and the need to allow the student the time and space to develop their own skills. Therapists want to show the student a diverse range of client groups and locations because we want them to be intrigued, motivated and interested by the variety that they see, and we also want students to realise the range of skills they need to develop to become successful clinicians. But, as well as making the placement interesting and varied, we have to contrast this with the stability and familiarity of regular clients so the student gets a chance to develop crucial core skills. Students often report that the logistical challenge of too many weekly changes is the most difficult aspect of their placement. It was our hypothesis that limiting weekly changes in location and client group would help the student settle in more quickly and improve the consolidation of skills development, whilst still experiencing the variety that working in different trusts offers. At the end of the placement, our informal analysis of the feedback from all parties involved suggested that the success of the placement depended much more on the skills, aptitude and learning ability of the individual student than on the placement design per se. The student who is a confident independent learner with a good basic clinical knowledge would benefit from this placement model. But common sense suggests that this student would also cope better with the original design compared to a student with less well-developed skills at this point in their training. Therapists felt this new design of placement was less satisfying for them as clinical teachers because they had a student for five instead of the usual ten weeks. We did not expect that the learning goals normally achieved in ten weeks would be achieved in five, so there was no additional pressure, but the therapists preferred to be part of the complete ten week process of each students development. We had anticipated that core skills learnt by the student in the first half of the placement would be transferred to the second half of the placement, but this depended very much on the aptitude of the student. Our analysis demonstrated that there are certain key elements of the placement that influence a students learning experience more than the logistical design. We therefore reflected upon some of the components of the placement that facilitated the students learning: Pre-placement planning between student co-ordinators. Good communication of information to the student, the therapists and the university tutors prior to the placement. Motivated and flexible clinical teachers. Establishing the students learning style and an impression of their skills and areas of need at an early stage.

A weekly review of the students progress by the chief clinical supervisor. A well planned and organised meeting with students, therapists and tutors midway through the placement to evaluate progress thus far and aims for the rest of the placement. Regular contact between supervising clinicians from both trusts to compare opinions about the students performance. Regular liaison between student placement coordinators. Excellent organisation all the way through the placement from all parties. Facilitating an open, honest relationship between the student and the clinical teachers. If implementing this design again, we would consider lengthening the placement to eleven weeks and using week six as a reading week. We will use the positive aspects of this experience to develop and strengthen our professional links in order to continue to provide quality student placements in the future across our trusts. We will also place a greater emphasis on encouraging students to identify their learning styles, and actively seek to evaluate the impact this has on their placement experience.

Acknowledgement
With thanks to the students and therapists involved.

THE QUESTION (2):

HOW RELIABLE IS
IS YOUR VIDEOFLUOROSCOPY INTERPRETATION GOLD-STANDARD OR IN NEED OF SOME POLISHING? JILL DYER CONSIDERS INTERRATER RELIABILITY AND HOW IT CAN BE IMPROVED.
hilst demand for speech and language therapists with dysphagia skills continues to grow (Scholten & Russell, 2000), training guidelines and tools which aid reliable, accurate videofluoroscopy examination and interpretation remain limited (RCSLT, 1999a; ASHA, 1997). A lack of videofluoroscopy interpretation reliability amongst any dysphagia team is a cause for concern. Obvious consequences of poor inter-rater reliability are variations in videofluoroscopy assessment findings and treatment planning, resulting in inequitable patient management. It also presents a serious problem where serial videofluoroscopy swallowing studies are required and, through necessity, a colleague administers the examination (due to sick leave, annual leave, staffing changes and so on). Dysphagia teams across the country should ask themselves: Are we interpreting videofluoroscopy examinations in the same accurate, reliable way for every patient irrespective of which experienced therapist is leading the study? And, in the case of serial videofluoroscopy swallowing studies, Has the patients swallowing function improved or deteriorated in real terms between examinations, or are we simply interpreting the same results differently? Speech and language therapists who assist in or lead a videofluoroscopy clinic are required to have undertaken postgraduate training and experience (RCSLT, 1996). The Royal College of Speech & Language Therapists clinical guidelines (van der Gaag, 1998) stipulate that this experience must be a minimum of 40 hours supervised clinical contact time with dysphagic clients over a three to six month period (RCSLT, 1999b). Following this training and experience, the speech and language therapist is expected to be able to interpret videofluoroscopy
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

OUR TEAM?

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HOW I

examinations and recommend appropriate management. However, the guidelines do not state the number of hours of videofluoroscopy interpretation nor the range of routine and complex diagnostic examinations required to become a competent practitioner in this field. It is therefore perhaps not surprising that speech and language therapists score poorly on inter-rater reliability tests of videofluoroscopy interpretation (McCullogh et al, 2001; Wilcox et al, 1996). Variations in the education and training of speech and language therapists in the reporting of videofluoroscopy are not the only reason for poor inter-rater reliability. In a recent study by Stoeckli et al (2003) nine experienced raters demonstrated that, without agreement on defined parameters, clinicians cannot hope to be reliable in videofluoroscopy interpretation. High reliability was achieved only for aspiration / penetration where a pre-defined numeric scale was used. This highlights the fundamental problem with videofluoroscopy interpretation: that it is, in essence, a descriptive process, and therefore allows a wide degree of variability. Of course, reliability does not preclude validity - a clinicians interpretation may be the same as a colleagues, but still wrong. It is therefore vital that supervisors of therapists training in dysphagia are themselves experts in videofluoroscopy interpretation. Other studies have shown that reliability can be improved where interpretation post-videofluoroscopy swallowing studies is discussed as a group as well as where interpretation training has been carried out (Scott et al, 1998). In a pilot study of videofluoroscopy practice patterns, clinicians who performed a greater number of videofluoroscopy swallowing studies per week were more accurate in judging examinations than those with less exposure (Murray & Jacobson, 2000), highlighting the need for the lead reporting clinician to have regular access to videofluoroscopy clinics. Whilst current techniques allow measurement of bolus movement, duration and coordination of the swallowing events in time, further research is required to develop accessible clinical tools that are able to quantify symptoms of swallowing dysfunction - which will in turn improve reporting accuracy and inter-rater reliability. For example, clinicians need a reliable method of measuring residue in the valleculae and pyriform sinuses to establish where the boundaries of mild / moderate / severe pharyngeal retention begin and end. I hope that the Royal College of Speech & Language Therapists will address the education and training inconsistencies of speech and language therapists in videofluoroscopy interpretation via the competencies project and / or Communicating Quality 3, both due for publication at the end of 2005. At present, the question remains: what steps can speech and language therapy dysphagia teams take to ensure that expertise in interpretation of videofluoroscopy examinations reaches or remains at an acceptable level of reliability? The North Durham dysphagia team is striving to maintain these videofluoroscopy standards: Dysphagia supervisors complete an accredited advanced level dysphagia training programme, which includes complex videofluoroscopy interpretation. New graduates undertake an accredited post-basic training course, which includes six months of close supervision (+ 40 hours direct dysphagia patient contact) as well as maintaining a log of directly supervised videofluoroscopy reporting and interpretation experience. Dysphagia supervisors sign-off the videofluoroscopy log only when a sufficient degree of experience has been built up in a range of disorders (the timeframe may vary depending on new graduates access to the videofluoroscopy clinic.) The videofluoroscopy swallowing studies log is maintained for a minimum of one year. Videofluoroscopy swallowing studies are carried out with two speech and language therapists (one of whom is a specialist who regularly administers videofluoroscopy) and either a trained designated radiographer or radiologist. The video should be analysed together and reported on promptly after the procedure, using slow-motion playback. Terminology and parameters of where each structure begins and ends are agreed. Consensus opinion is routinely sought for videofluoroscopy interpretation, especially where observations of severity of dysfunction are required. We have agreement on which swallowing abnormalities determine recommendation of specific management strategies.

Consensus opinion improves videofluoroscopy reliability

A client undergoing a videofluoroscopic swallowing study

Regular videofluoroscopy interpretation peer support group meetings are held. We carry out regular team audit of videofluoroscopy interpretation. Our standards also include consistent use of the following procedures by all dysphagia team members: An agreed videofluoroscopy reporting protocol to ensure standardised bolus volumes, consistencies and presentation. We use Logemann (1998) but an alternative is Palmer et al (1993). A standardised reporting style and reporting template. Evidence-based tools such as the Aspiration / Penetration Scale (Rosenbek et al, 1996). Speech and language therapy dysphagia teams cannot claim that videofluoroscopy examination is the gold-standard for investigation of swallowing abnormalities (ODonoghue & Bagnall, 1999) in their own departments without attempting to address the fundamental issues which directly impact upon reliability.

References
American Speech-Language Hearing Association (1997) Graduate curriculum on swallowing and swallowing disorders (adult and paediatric dysphagia). Special Interest Division Swallowing and Swallowing disorders 13. Asha Desk Reference: 248a-248n. Logemann, J.A. (1998) Evaluation and Treatment of Swallowing Disorders. Austin, Texas, Pro-Ed. McCullogh, G., Wertz, R., Rosenbek, J., Mills, R., Webb, W. & Ross, K. (2001) Inter-and Intrajudge Reliability for Videofluoroscopic Swallowing Evaluation Measures. Dysphagia 16:110-118. Murray, J. & Jacobson, S. (2000) Pilot data on videofluoroscopy practice patterns and performance. In Conference Proceedings: International Study Day in Videofluoroscopy (Oct. 2001) Newcastle upon Tyne. ODonoghue, S. & Bagnall, A. (1999) Videofluoroscopic evaluation in the

26

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HOW I

assessment of swallowing disorders in paediatric and adult populations. Folia Phoniatr Logop 51: 4. Palmer, J.B., Kuhlmeier, K., Tippett, D.C. & Lynch, C. (1993) A protocol for the videofluorographic swallowing study. Dysphagia 8: 209-214. Royal College of Speech and Language Therapists (1996) Communicating Quality 2: Professional Standards for Speech and Language Therapists. Royal College of Speech and Language Therapists (1999a) Guidelines for Invasive Procedures Radiological Imaging. Royal College of Speech and Language Therapists (1999b) Advanced Studies Committee: Recommendations for Pre and Post-registration Dysphagia Education and Training. Rosenbek, J., Robbins, J., Roecker, E., Coylem J. & Wood, J. (1996) A Penetration-Aspiration Scale. Dysphagia 11: 93-98. Scholten, I. & Russell, A. (2000) Learning about the dynamic swallowing process using an interactive multimedia program. Dysphagia 15 (1): 10-17. Scott, A., Perry, A. & Bench, J. (1998) A study of inter-rater reliability when using videofluoroscopy as an assessment of swallowing. Dysphagia 13: 223-227. Stoeckli, S., Thierry, A., Huismann, M., Burkhardt, S. & Martin-Harris, B. (2003) Inter-rater Reliability of Videofluoroscopic Evaluation. Dysphagia 18: 53-57. van der Gaag, A. (1998) Clinical Guidelines by Consensus for Speech and Language Therapists. Royal College of Speech and Language Therapists. Wilcox, F., Liss, J. & Siegel, G.M. (1996) Interjudge agreement in videofluoroscopic studies of swallowing. Journal of Speech and Hearing Research 39 (1): 144-152.

For people with learning disabilities, dysphagia can create complex health issues (Aziz & Cambell-Taylor, 1999; Beange et al, 1995; Eyman et al, 1990; Rogers et al, 1994). However, there is not a great deal of research that focuses on the dysphagia in people with learning disabilities. Chadwick et al (2002; 2003) investigated carer knowledge, and carer implementation of speech and language therapy dysphagia recommendations. They found a 45 per cent knowledge of guidelines, but a 76 per cent adherence to guidelines. Within the general field of adult learning disability there is a body of research that looks at the issue of carer awareness of and compliance with recommendations. It suggests that clients problems tend to be underestimated by staff (Cumella et al, 2000; Kerr et al, 2003; Stanfield et al, 2003). For recommendations to be implemented successfully, the researchers suggest that issues such as staff training and inclusion in the writing of guidelines, staff support and supervision, pay, promotion, career structure, rosters, staff ratios and the environment need to be considered (Malin, 2000; Marshall et al, 2003). Other recent research considers parental compliance with medical guidelines for their children. It highlights a wide variation in compliance rates, from 30-98 per cent, depending on conditions such as the education level of the parent, the severity of symptoms, observation of use of equipment, whether information sheets and specialist education are provided, beliefs in the efficacy of the treatment and ongoing support from therapists (Cheng et al, 2002; Cork et al, 2003; de Jongste et al, 2002; Searle et al, 2002).

Consider our support


As practitioners we are reliant on carers for implementing recommendations and monitoring clients skills and health. It is important that we consider our support to care staff in the light of these findings. We looked at this research as a department, and agreed we often observe non-compliance with recommendations. When we discussed this informally with staff, various issues were cited as barriers, including staff turnover, lack of information being passed on, lack of awareness of recommendations, ethos of the environment and practical difficulties with the recommendations. We are now carrying out a study within social care day centres to look at how much staff are able to follow multidisciplinary dysphagia recommendations. We observe clients eating and drinking, as we would do in the course of normal service delivery, recording how many and which recommendations are being followed. We also give a questionnaire to carers. Initial findings are that carers are complying with recommendations approximately two thirds of the time. Further research is ongoing, and will provide more depth and detail to these results. So far, the carers who have responded have not been able to offer any suggestions as to how we could improve our service to increase compliance. In the light of these initial findings, and those of the National Patient Safety Agency, we are considering the following actions to help improve dysphagia service delivery within County Durham for clients such as Mr Rennie: Having a dysphagia coordinator for the locality integrated teams to help avoid confusion for care staff. This coordinator could be any one of the professionals involved with the client, as long as they provide eating and drinking support. Once multidisciplinary assessment has taken place, the carers contact their coordinator with any query about eating and drinking. S/he then forwards any concerns to the appropriate professional. Ensuring that dysphagic symptoms are made explicit on the care coordination assessment documentation, so that any concerns are highlighted as soon as a client enters the integrated service. Liaising with care coordinators to have any necessary eating and drinking support highlighted in person centred plans. Liaising with human resource personnel to discuss the possibility of eating and drinking support being individually documented on care staff job descriptions. Liaising with training departments to develop a dysphagia awareness module, to be included with induction training for care staff. Running focus groups - with the carers who responded to the questionnaires to discuss the results of the research, barriers to implementation of recommendations, and ideas to improve the speech and language therapy service they receive. These issues affect all practitioners who are reliant on staff for implementing recommendations. The last of our clients are now moving from health-based
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

THE QUESTION (3):

WHAT MORE CAN WE DO?


SPEECH AND LANGUAGE THERAPISTS ARE FREQUENTLY RELIANT ON OTHER PEOPLE TO IMPLEMENT THEIR RECOMMENDATIONS. FRUSTRATED BY LACK OF COMPLIANCE BY STAFF CARING FOR PEOPLE WITH LEARNING DISABILITIES AND DYSPHAGIA, HANNAH CRAWFORD AND COLLEAGUES LOOK TO THE LITERATURE FOR INSPIRATION.

r Rennie is a 73-year-old man with moderate learning disabilities, mild dysphagia and asthma. He has a history of choking on unmodified food. Recent videofluroscopy indicated some aspiration on normal liquids. Recommendations were to provide a soft mashed diet and drinks thickened to a custard consistency. On review, Mr Rennie was receiving a pured diet, with all the food pured together. Despite day centre staff and the speech and language therapist discussing this issue with the kitchen staff, and the speech and language therapist raising it with the centre managers, Mr Rennie continues to receive all his food pured together. In February 2004, the National Patient Safety Agency published a report about patient safety issues for people with learning disabilities. The report detailed five priority areas that needed addressing, one of which was swallowing difficulties / dysphagia. The report discusses issues that put people with learning disabilities at risk. These include the confusion caused by differences between health and social care models; guidelines not being implemented in social care settings; and a lack of awareness about dysphagic symptoms and their consequences.

27

HOW I

institutions to social care provision within the community. It is crucial for the health and well-being of our clients that we think creatively about how we support both staff and clients within these establishments. Once we have developed systems that work, it is also crucial that we continue to provide this support on a long-term basis, to compensate for issues such as high staff turnover. Dysphagia in adult learning disability is a relatively small field, and there are too many people like Mr Rennie. We would welcome any opportunity to discuss these findings and network with other practitioners.

References
Aziz, S.J. & Cambell-Taylor, I. (1999) Neglect and abuse associated with undernutrition in long-term care in North America: Causes and solutions. Journal of Elder Abuse and Neglect 10: 91-117. Beange, H., McElduff, A. & Baker, W. (1995) Medical disorders of adults with mental retardation: a population study. American Journal on Mental Retardation, 99 (6): 595-604. Chadwick, D.D., Jolliffe, J. & Goldbart, J. (2002) Carer knowledge of dysphagia management strategies. International Journal of Language & Communication Disorders 37 (3): 345-357. Chadwick, D.D., Jolliffe, J. & Goldbart, J. (2003) Adherence to eating and drinking guidelines for adults with intellectual disabilities and dysphagia. American Journal on Mental Retardation 108 (3): 202-211. Cheng, N.G., Browne, G.J., Lam, L.T., Yeoh, R. & Oomens, M. (2002) Spacer compliance after discharge following a mild to moderate asthma attack. Archives of Disease in Childhood 87 (4): 302-305. Cork, M.J., Britton, J., Butler, L., Young, S., Murphy, R. & Keohane, S.G. (2003) Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. British Journal of Dermatology 149 (3): 582-589. Cumella, S., Ransford, N., Lyons, J. & Burnham, H. (2000) Needs for oral care

among people with intellectual disability not in contact with Community Dental Services. Journal of Intellectual Disability Research 44 (: 45-52. de Jongste, J.C., Janssens, H.M. & Van der Wouden, J. (2002) Effectiveness of pharmacotherapy in asthmatic preschool children. Allergy 57: 42-47. Eyman, R., Grossman, H., Chaney, R. & Call, T. (1990) The life expectancy of profoundly handicapped people with mental retardation.The New England Journal of Medicine 323 (9): 584-589. Kerr, A.M., McCulloch, D., Oliver, K., McLean, B., Coleman, E., Law, T., Beaton, P., Wallace, S., Newell, E., Eccles, T. & Prescott, R.J. (2003) Medical needs of people with intellectual disability require regular reassessment, and the provision of client- and carer-held reports. Journal of Intellectual Disability Research 47: 134-145. Malin, N.A. (2000) Evaluating clinical supervision in community homes and teams serving adults with learning disabilities. Journal of Advanced Nursing 31 (3): 548-557. Marshall, D., McConkey, R. & Moore, G. (2003) Obesity in people with intellectual disabilities: the impact of nurse-led health screenings and health promotion activities. Journal of Advanced Nursing 41 (2): 147-153. NPSA (2004) Understanding the patient safety issues for people with learning disabilities. National Patient Safety Agency 002 JAN04. Rogers, B., Stratton, P., Msall, M., Andres, M., Champlain, M., Koerner, P. & Piazza, J. (1994) Long-term morbidity and management strategies of tracheal aspiration in adults with severe developmental disabilities. American Journal on Mental Retardation 98 (4): 490-498. Searle, A., Norman, P., Harrad, R. & Vedhara, K. (2002) Psychosocial and clinical determinants of compliance with occlusion therapy for amblyopic children. Eye 16 (2): 150-155. Stanfield, M., Scully, C., Davison, M.F. & Porter, S. (2003) Oral healthcare of clients with learning disability: changes following relocation from hospital to community. British Dental Journal 194 (5): 271-277.

events
Cleft Lip & Palate Association First International Conference 14 September 2004 Society of Medicine, London Speakers include Lisa Crampin and Brian Sommerlad Details: tel. Gareth Davies on 020 7833 4883 The Speech, Language and Hearing Centre, Christopher Place Joint working between occupational therapists and speech and language therapists in managing children with autism and related disorders 14 September 2004 Anita McKiernan, specialist speech and language therapist & Denise Ward, senior occupational therapist 50 Details: tel 020 7383 3834, www.speech-lang.org.uk 28 The Son-Rise Program, Autism Treatment Center of America Breakthrough strategies for autism spectrum disorders 16 September - 2 October 2004 - various venues across the UK Raun K. Kaufman Free - pre-registration required To reserve seats, register at www.son-rise.org National Autistic Society Access to services by adults with Asperger syndrome 23 September 2004 Manchester Conference Centre 116.33 (professionals), 70.50 (parents) First time with autistic spectrum disorders 29 September 2004 Bristol 116.33 (professionals) Tel 0115 911 3367, e-mail conference@nas.org.uk The Scottish Learning Festival 22-23 September SECC, Glasgow Ticket Hotline: 0870 366 7096 Education Show London and Special Needs London 30 September - 2 October Olympia, London Ticket Hotline: 0870 429 4334 The Educational Technology Show 12-15 January 2005 Olympia London Ticket Hotline: 0870 429 4574 Professional training course in Fast ForWord Language-Learning Programmes 25 September 2004 Park Crescent Conference Centre, Great Portland Street, London 249 Details: Aditi Silverstein, MA, CCCSLP, e-mail innovativetx@att.net or see www.innovative-therapies.com Stroke Awareness Week 4-10 October 2004 Details: tel 01604 623919, e-mail strokeawareness@stroke.org.uk Johansen Sound Therapy 5-8 October 2004 South Queensferry, 350 Details: tel. 0131 337 5427, e-mail camilla.leslie@ johansensoundtherapy.com NAPLIC (National Association of Professionals concerned with Language Impairment in Children) Speech, Language and Communication Needs: Current Trends in Theory and Practice 19-20 March 2005 Warwick University Keynote speakers: Dorothy Bishop, Nicola Botting & Gina ContiRamsden, Julie Dockrell, James Law, Penny Roy & Shula Chiat, Maggie Vance Details: www.naplic.org.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004

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MYTOPRESOURCES
1. FILING CABINET Ive got rid of hanging files and find it much easier to store and retrieve labelled document wallets. I make sure I have a stack of these so I dont run out. Ideally Id have drawers with those movable metal plates at the back. I try to file everything in a general A-Z system method. Rather than have a bulging file where everything under one heading is kept together, I subdivide. For example I have several wallets for the Association of Speech & Language Therapists in Independent Practice and they are labelled as ASLTIP - AGMs, ASLTIP - medico-legal, ASLTIP - contact information. I used to think that a single sheet of paper didnt warrant a wallet of its own. I now realise that, using this system, single pages are really easy to find. 2. DAY FILE This is a vibrant purple polypropylene ringbinder that I check each day. I store paper in transparent pockets under different sections. This system has replaced my daily list of things to do; currently the file divides into phone/email, action, maybe (such as events I might go to or books I might order), tickler (something Id like to do, but its a long way ahead), and waiting for (for example copies of order forms, notes of messages Ive left). 3. LARGE-CAPACITY MAGAZINE FILES These are used by librarians and office staff for filing upright magazines, journals and catalogues. Having given up on them in the past because I found them to be too thin and flimsy, I found some fat, brown, sturdy ones in Paperchase. Now my stuff doesnt fall over. I have two and they sit on a shelf within swivel distance, meaning that I dont end up ploughing through a tip on my desk. I keep one magazine file for project folders needing immediate action, for example, City University lecture and Vocal cord palsy audit. The other one is used for articles and journals I might want to read. It means I can grab something from the file if a patient cancels or Im about to catch the train. 4. CONTINUING PROFESSIONAL DEVELOPMENT FILE Ive had fun with this one. I think its important to treat yourself to an attractive good-quality ringbinder, and I like looking at - and feeling - mine. Its a cheerful turquoise one, making it easy to find. All my professional activities are filed under different sections and near the front I have my curriculum vitae, biographies, job descriptions, certificates of registration and memberships as well as my Royal College of Speech & Language Therapists personal log. Apart from being required to record this information, you never know when you might need it. 5. ZODIAC DIARY I have diaries which are kept in the department at my hospital sites, but I still need my own diary for an overall picture of the week and for my private work and social life. Call me oldfashioned, but I still prefer a paper diary. Ive used a Letts Zodiac diary for a few years now and its by far the best one Ive ever had. Its a week at a glance across two pages and theres equal space for every day as well as for morning, afternoon and evening, giving you a total of twelve spaces a day, plus a space a day to write in deadlines. I also like the fact that appointment times are not printed for you so its more flexible. I find this system only works if you use a pencil and rubber so you can make changes to the appointments. The diary hooks into a slim, leather Filofax. 6. FILOFAX Both my gorgeous Psion organisers broke down tragically. I smashed the first one when it fell and my second one crashed badly. I got bored having to back them up and recharge them. I also became obsessed by lists and then was terrified of theft. Having said that, I still miss having one. Theres something deeply satisfying about their neatness and compactness, and theyre great for retrieving information. You only need a key word and up it all pops. My black leather Filofax is a thin, soft, sleek version and it gets recharged with polish and a duster. To keep it slim I dont use section dividers but have alphabet letters stuck to the top of each page. I only use it for addresses and other contact information and I use narrow-lined pages. Its too frustrating trying to fit everyones address, second home, emails, faxes, mobiles and landline phones in those little spaces that Filofax address pages provide. 7. BLANK BUSINESS CARDS I use these to write down errand lists. Theyre great for fitting into a purse or wallet so you wont lose them, you can buy them easily from a good stationers, and a box lasts ages. I still use backs of old envelopes and recycled Christmas cards for big supermarket shopping lists. 8. SAMSONITE MINI BACKPACK I bought one after being recommended it by a friend and colleague. They come in light brown or black and have a deep, zipped inside pocket where I keep my Filofax and diary, and a zipped outer pocket where I keep my mobile, keys and train tickets. I sponge them down regularly with washing up liquid to keep them looking smart. Less than 30 each, theyre found in the travel section of major stores. 9. FOLDABLE BAG Well, it was either another bag or a lipstick. These clever, lightweight, unisex shoulder bags are ideal for carrying piles of stuff from one end of the hospital to another or for shopping on the way home. They fold up really small into a zipped pouch. I found mine in a Japanese store called Muji. I believe there are branches up and down the country as well as abroad. 10. HOLIDAY AND COURSES LISTS Put me on a plane and I switch off from work alarmingly easily. When I return I have a block about what I did on the day before my holiday. I scribble a list of what I do that day and what I need to do the minute I return. It helps to get my brain in gear. I also have on computer a list of everything Im likely to need if I go on holiday, attend a conference requiring me to be away, and if Im running a course myself. It saves wasting time having to rethink lists.

THESE IDEAS ON HOW TO STAY ORGANISED ARE FROM JAYNE COMINS, A SPEECH AND LANGUAGE THERAPIST AND PSYCHOTHERAPIST WHO WORKS AT QUEEN ELIZABETH AND THE WELLINGTON HOSPITALS IN LONDON, AND IN PRIVATE PRACTICE. JAYNE TRAINED AS AN OCCUPATIONAL AND ORGANISATIONAL PSYCHOLOGIST BEFORE BECOMING THE FIRST INFORMATION OFFICER AT WHAT WAS THEN CALLED THE COLLEGE OF SPEECH THERAPISTS. NEEDING TO RETRIEVE A VAST RANGE OF INFORMATION, OFTEN AT A MOMENTS NOTICE, JAYNE WISHED SHE WAS BETTER AT BEING ABLE TO WORK AMIDST MESS AND CLUTTER! SHE FINDS A CLEAR DESK HELPS HER TO THINK CLEARLY, AND LIKES TO KNOW THAT SHE CAN QUICKLY PUT HER HANDS ON INFORMATION WHEN SHE NEEDS IT.