early intervention

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if you have the opportunity to be innovative want to provide a community based, inclusive service plan at a strategic or operational level

Sure Start: the final fron

learnt of many tales of woe, as well as wishes. Actively seeking out and listening to their community enabled them to develop a plan of action at both a strategic and operational level. The two chosen ones felt honoured to work in partnership and be given the opportunity to take on this challenge. However, they felt understandably apprehensive about taking on such a diverse role. They felt that a united front was a stronger force than a divided one. During Sure Start team meetings it quickly became apparent that they appeared alien to the other chosen ones from around the galaxy. They had to work at being accepted. Rather than orbiting around the planet, they had to land on site regularly, especially in a social capacity (lunch-time). Their title as speech and language therapists merely functioned to isolate them from the team and hence they came to be known as Sure Start speech and language workers. Their apparel was another obvious issue. They appeared very clinical in their dress code, which affected their rapport with the community. Fabrics such as cotton and wool were replaced with denim. They worked together to establish an allegiance with the entire community, so that the success of their mission became even more tangible and so the story continues... ............ Play & Say is a six week workshop devised to promote speech and language development predominantly with children under four. It is aimed at showing carers how they can help their childs speech and language development by having fun together and playing. At present, we are targeting the local parent and toddler groups. The workshop was piloted with successful results in January to February 2002 and we have subsequently completed a further four Play & Say workshops within the two Sure Start areas. These were five very different groups and we therefore adapted Play & Say to suit individual needs. We subsequently spent approximately three months loitering with intent - visiting community settings, being seen and talking to staff and families about current opportunities to promote language development and potential future partnerships. During this time we got to know various members of the community quite well and vice versa. During visits to local nurseries we discovered their concerns about the lack of verbal communication skills that children were displaying and their lack of readiness for reading and writing. This is consistent with the findings of Locke et al (2002) in their study based in the local area. They reported a link between poor verbal skills and a difficulty acquiring academic skills. Teachers reported a number of difficulties to us, namely: limited vocabulary, sentence formulation skills, attention and listening skills, turn taking skills, knowledge of nursery rhymes and lack of ability to participate in group times. They felt that a potential contributory factor was a lack of verbal interaction in the pre-school years and a lack of attendance at or active involvement in parent and toddler groups. From here we decided to investigate the local preschool provision. Again, this involved loitering with intent and talking to the children and carers, as well as observing. The environments varied. However, there appeared to be a number of carers viewing the group as support for themselves, whilst they sat quite separately from the children, who were left to play with little supervision and minimal adult interaction. From our observations it seemed that many of the children showed restricted symbolic play skills even at three to four years of age, with difficulties not dissimilar to those noted by the nursery staff. Snack time often had no set routine. In general, children were given food and drink and left to sit or wander around, whilst carers sat together. When discussed with fellow Sure Start Workers they reported the same findings and noted a lack of motivation to be more active on the carers part. This was consistent with our discussions with carers, which indicated that the carers needed support from each other and adult conversation. They did however show interest in our ideas for activities to promote language, and responded with positive comments. As early intervention has been shown to have a positive effect on children with general developmental delay or more specific speech and lan-

Alison Cooke & Dana Taylor report back on their joint mission to bring specialist knowledge of early speech and language development to two culturally diverse Sure Start locations in Sheffield.

e were asked recently what our recommendations would be for up-and-coming Sure Start speech and language therapy posts. Following a year of joint targeting of early language promotion in community settings, our answer was: two speech and language therapists working in a skill mix partnership. So, why do we feel this is so crucial? Just as the medical profession heard of The Gatekeeper and the Wizard (Mathers et al 1989), we thought a galactic perspective would be an appropriate analogy to reflect our experiences initially, before we give a more mainstream account. So here goes... A long, long time ago, in a galaxy far, far away (Sheffield), a chosen one....no, actually two chosen ones, were brought forth to fulfil their destiny as speech and language therapists (well, speech and language workers, but that comes later) within Sure Start. The future had yet to unfold. Sure Start, a new entity within the galaxy, remained formidable and their task was to promote early language development and early identification, and to empower the community. The challenge was indeed a great one but, together in partnership, they knew they could rise to it. In the early stages of their allegiance, the plan was a simple one...to loiter with intent and let themselves be known to the community. The aim was to dispel the myths around speech and language therapy and to ensure they were approachable. Armed with little more than a packet of plasters, they set out on foot (trainers at the ready) wherever possible to drop in at community venues and put names to faces. During their travels they

Loitering with intent

We started co-working in Sure Start in July 2001. We were excited to have been offered such a challenging role, but at the same time a little apprehensive. The Sure Start areas we work in are culturally diverse, one having over 42 languages spoken in one community. We therefore felt it was essential to find out what the community really needed in terms of communication before setting an agenda.

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ntier
guage difficulties (Glascoe & Sturner 2000), we decided to take action and Play & Say evolved.

Danas son Dominik helps Alison perfect her technique!

Figure 1 A typical Play & Say workshop Week One: Introduction Carers are introduced to the idea of playing & saying in this week. They are given verbal and written information about the aims and practicalities of the workshop. Carers fill in a consent form, a snack time information sheet and a Starter Vocabulary Checklist (Locke, 1985) (with help from us as necessary). Filling in the vocabulary checklist enables us and carers to monitor progress of individual children. Additionally, it helps us determine what level to pitch language activities at. Week Two: Nursery Rhymes Each carer sits with their child and the hello song is sung to all the children. We then sing have a turn and pass it on and the children are given a choice of two action nursery rhymes. This is presented visually in the form of symbol cards for each rhyme. The children choose a card (with / without naming the rhyme, depending on verbal ability) and place it on the choice board (attached by Velcro). We model the key vocabulary for the children and sing each rhyme together (with words available for those who dont know them). We then sing bye bye to each child and give them a reward sticker and a home activity pack. Week Three: Listening & Attention / Animal Theme Again, the hello song is sung. After singing the have a turn song, each child selects a small animal picture from a bag and matches it to the appropriate larger picture (again, with / without naming the animal). The animal words and noises are modelled for the children. We then sing the have a turn song and each child selects an animal picture, which they wave in the air during Old MacDonald. We finish the session by singing bye bye giving a reward sticker and a home activity pack. Week Four: Snack Time Choices A structured snack time is demonstrated, using a choice of two items of food and drink. These are food / drinks that the group would normally have. Symbols for each choice are used to reinforce these visually and to involve non-verbal children in making choices. The have a turn song is sung and carers are encouraged to partake in this activity, supervising and interacting with the children. This demonstrates how they can promote language by giving the children choices. The symbols are exchanged for the requested item. The session is ended with the bye bye song, giving of reward stickers and home activity packs. Week Five: Body Parts Fun with water week! Again, hello is sung. Children and carers are encouraged to bath dolly together, the adult reinforcing body parts vocabulary and concepts. We then look at the body parts lotto and sing Heads, Shoulders... and bye bye. Reward stickers and a home activity pack are given. Week Six: Evaluation (Play & Say Toys) Evaluation forms are given to carers. Help is given as necessary to ensure that everyone is able to express their opinion. There are opportunities to discuss follow up workshops and time for carers to talk privately about any concerns they may have about their childs speech and / or language. We also talk about toys that help you to Play & Say with your child, and provide written information. Favourite activities are repeated. Certificates are given to both carer and child. Play & Say songs Hello (made up tune) Hello Meena, Hello Meena, Hello Meena, Were glad you came to play. Have A Turn (London Bridge Is Falling Down) Have a turn and pass it on, pass it on, pass it on, Have a turn and pass it on, Pass it on to Jamie. Bye Bye (made up tune) Bye bye Max, Bye bye Max, Bye bye Max, Were glad you came to play.

Inclusive
Our initial criteria were to run a workshop that was community based and inclusive. We wanted carers to have the choice of opting in or out. We did not want to offer a speech and language therapy group. Following the ethos of Sure Start, we wanted all children, regardless of their language abilities, to be included. As carers had shown an interest in our ideas to promote language development, we wanted to give them something that would benefit both themselves and their child. We knew it had to be realistic, so that they could take it on board and generalise it to their own environments. We were already aware that many of the carers we talked to saw Parent Toddler Groups as a support system for themselves, plus a chance for their child to play with others. We therefore needed a way to show carers activities that they could continue in the group and at home, as well as continuing to have adult conversation and some time out. The aim is to demonstrate hands on strategies to enable and empower carers to promote language development and feel confident transferring these skills to any environment. For example, singing hello and bye-bye to the children and have a turn and pass it on encourages social use of language and makes them feel like a special member of the group. Carers can then continue to sing these at home, singing hello in the morning, bye-bye to toys as they are tidied away or have a turn while playing a family game. This promotes interaction and the essential precursors to effective everyday social communication. It also encourages the acquisition of social tools that prepare a child for their entry to nursery and make active participation less daunting. Groups of approximately four to six children (depending on ages) and their carers are taken on a rotational basis. They are taken to a quiet area within the setting. The carers are encouraged to be with their child throughout the activities and to Play & Say together. After each session the carers are given a Play & Say home activity pack. This contains ideas and games related to the theme of that particular session, for example a nursery rhyme activity booklet. A typical workshop, including songs used, is described in figure 1.

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REVIEWS
Well-known phrase
Play & Say has been successful. It is now a well-known phrase within the community - in many different languages. We have been evaluating Play & Say in a number of ways, namely through feedback forms, vocabulary checklists, informal interviews and keeping field notes. By collating this information, we have been able to conclude that it has been a productive initiative. We have used feedback in a positive way to adapt the workshop to make it as effective as possible. Sure Start has received a number of phone calls from carers requesting further information and when / where they could attend. A waiting list has developed. Monitoring suggests that word of mouth appears to be the main source of community information regarding Play & Say. This indicates the impact it has had on the community and the encouraging reviews we are getting from local people. In one area we are compiling Play & Say toy packs, consisting of symbolic play items such as a doll and tea-set, that children will receive after completing the six week Play & Say workshops. Workshops are continuing to be run on a regular basis. Additionally, Play & Say is being piloted in a nursery environment, with so far positive results. However, with increased demands on our time, we are looking to train other people to take on this enabling role. We have initiated a City wide training programme. This includes initial training on Play & Say, which will be followed by participants shadowing a workshop in order to be able to run them independently. As we become involved with new Sure Start programmes, we are constantly extending the opportunities to Play & Say and hope the momentum and success will long continue. Working in partnership has been highly rewarding. Being able to work in such an exciting and innovative area together has enabled us to be more creative and effective than if we had been working alone. It has facilitated the targeting of a larger population size and allowed us to deliver speech and language information to a wide range of settings. We have learnt a lot during this past year. We have learnt about transdisciplinary, interdisciplinary and multidisciplinary ways of working. We have gained an insight and developed skills around working in a diverse cultural environment. Tackling problems together has been far easier than facing them in isolation and we have been able to reflect on our experiences. This has enabled us to continually develop ways of working that promote good evidence based practice and mean we work with the community for the community. May the force be with you! Dana Taylor is a Specialist Sure Start Speech & Language Worker / Therapist and Alison Cooke a Senior Sure Start Speech & Language Worker / Therapist with Sheffield Speech & Language Therapy Agency Sure Start Team.

CHILD VOICE

AN EXCELLENT OVERVIEW
Working With Childrens Voice Disorders Jenny Hunt and Alyson Slater Speechmark ISBN 0 86388 279 X 34.95
This book provides an excellent overview of child voice development and disorder and should appeal to both the generalist and specialist therapist for its accessible and practical format. It gives an overview of the development of the infant and juvenile larynges and the contributory and maintaining factors of voice problems, and practical advice is included for case history details, the assessment and evaluation of the childs voice and subsequent management strategies. Layout is good with subheadings and bullet points to help the busy therapist. A series of photocopiable handouts covering information about voice, exercises, record sheets and letters provides a timesaving resource. Recommended in terms of content and value to therapists who have infrequent contact with paediatric voice problems. It should prove to be a very practical resource in any clinic. Karen Shuttleworth and Alison Taylor are Speech and Language Therapists working for Morecambe Bay Primary Care Trust.

LANGUAGE

CLEAR AND RELEVANT

Basic Verbs ColorCards Speechmark ISBN 0 86388 476 8 25.95 + VAT

This pack contains 48 large format colour photocards presented in a sturdy box. The photographs are clear with relevant subject matter and should encourage vocabulary expansion in clients of all ages. The background colour enhances rather than detracts from the target verb thus reducing visual perceptual problems for some clients. This resource would be beneficial to all therapists working with both individuals and groups and it will help to encompass many therapy aims in areas such as verbal comprehension, expressive language, sentence formulation and indeed general communication skills. Children enjoy and respond well to the colour photographs and we would recommend this set as a valuable asset to any therapist requiring a set of action pictures. Alison Taylor and Karen Shuttleworth are Speech and Language Therapists working for Morecambe Bay Primary Care Trust.

EDUCATION

STRAIGHTFORWARD GUIDE
How to ... Identify & Support Children with Speech and Language Difficulties Jane Speake LDA ISBN 1 85503 361 5 9.95
This straightforward guide for teachers, SENCOs and teaching assistants will help them identify primary aged children who have speech and language difficulties. Terminology is covered. There is an overview of the roles of education and speech and language therapy plus a discussion of collaborative working. Inclusion of AFASIC checklists provides a structured approach to observation and a basis for referrals. The most useful section identifies strategies for support and gives specific ideas on helping the child to manage in the classroom. Ideas on multi-sensory materials and experiences are given and difficulties are linked to the curriculum. There is an excellent section on ideas to underpin semantic development. Well written and inexpensive, this is good on basic ideas but limited in follow-up; speech and language therapy extension would be advisable. More resources and more on IEP targets would improve it. A resource for therapists working in mainstream schools to recommend if opportunities for training are limited. Noreen Marks is a speech and language therapist in Essex.

References
Glascoe & Sturner (2000) Surveillance and Screening: In Law, J., Parkinson, A. & Tamhne, R. (Eds) (2000) Communication Difficulties In Childhood - A Practical Guide. Radcliffe Medical Press. Locke, A. (1985) Living Language. Putting Words Together. NFER-Nelson. Locke, A., Ginsborg, J. & Peers, I. (2002) Development and disadvantage: implications for the early years and beyond. International Journal of Language and Communication Disorders 37 (1): 3-15. Mathers, N.J. & Hodgkin, P. (1989) The Gatekeeper and the Wizard - a fairytale. BMJ 298:172-4.

Reflections
Do I get out and network or do I expect people to come to me? Do I take advantage of opportunities to work with colleagues? Do I work with the community for the community?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004