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he report Provision of speech and lan

-
guage therapy services to children with
special educational needs (England)
(2000) advocated ‘that the greater part of
the provision for school age children with speech
and language needs should be embedded within
the curriculum and take the child’s education con-
text into consideration’. Since then many speech
and language therapy services have reorganised to
work within schools, and no longer provide a clinic
based service to school age children.
I have worked in schools most of my career, am a
strong advocate of working collaboratively with
teachers, and now manage a large diverse service. I
believe it is vital to consider a number of basic principles
and, indeed, the purpose of and process for provid-
ing a service within schools to avoid leaping from the
frying pan into the fire - and inappropriately reor-
ganising services to the detriment of all children.
Does working in schools ensure that provision is
‘embedded within the curriculum’ or takes the ‘edu-
cation context into consideration’? I would argue
that it may not, and may even be less effective if a
therapist does not have relevant training and / or
experience, or consider a few basic principles.
My other concern is what happens to preschool
children? Given that all speech and language thera-
py services suffer a shortfall in resources and that
provision into school adds increased demand to a
service, are these children getting the intervention
they need early enough and at a frequency sufficient
to reduce the possibility of severe long-term prob-
lems?
Principle 1 What is the individual need?
First, therapists should always carefully consider the
individual child’s speech and language needs and
whether they have an impact on the child’s ability to
learn. Difficulties which have the most implications
for learning are:
• Significant language delay
• Language disorder
• Some general learning difficulties where there is a
verbal / non-verbal skill discrepancy and the aim is
to reduce the discrepancy.
It may therefore be more effective to work with
these children in schools rather than in a clinic.
Sometimes a combined approach may be best initially.
For example, a child with an expressive language
disorder and developmental verbal dyspraxia may
be initially best treated by a block of intervention in
a clinic setting, followed by a period of consolida-
tion when the therapist could take the opportunity
T
to visit and advise the school. Similarly, if a child’s
primary presenting problem is a speech difficulty,
direct therapy within a clinic can be highly effective,
although sound generalisation and phonological
awareness may be best achieved at school. School
visits may also be necessary to complete assessments
in some cases, for example assessment of a child
with a possible pragmatic language disorder.
Principle 2 Who is the main focus?
It is important to then consider who should be the main
focus of input. If it is the parents, then a clinic or home
setting is likely to be the most effective environment to
facilitate change. If the child is the main focus and their
needs have implications for learning (for example con-
cept work), then the school is the best place to inter-
vene. If the difficulties have little impact on learning,
then clinic may be the most appropriate setting.
Principle 3 Why are we intervening?
Why we are intervening at all is an essential question
as this establishes the primary purpose, and enables
therapists to look ahead to the predicted outcome
for the client. Kate Malcomess developed eight care
aims, which give us a framework for considering
these important questions prior to intervention:
• Assessment - to determine the nature and
impact of the condition
• Enabling - to maximise use of existing function
• Supportive - to support the client to cope optimally
with their present condition
• Curative - to facilitate lasting change in function,
to within normal limits (chronological
age / pre-morbid state)
• Rehabilitative - to facilitate improvement / lasting
change in function
• Maintaining - to stabilise / maintain / preserve
function
• Palliative - to reduce pain and / or increase
comfort when no other change is
possible or appropriate
• Anticipatory - to prevent the development of, or
reduce the risk of difficulty
These care aims relate to the child not the environ-
ment and, once the reason for intervening is estab-
lished, therapists can then decide not only what to
do but where to do it. School visits must therefore be
considered in this context, and should be provided
when it is important that the school has a key role in
the development of the child’s skills because of the
impact the child’s difficulties have on their learning.
The combined effect of a therapist considering the
individual child’s speech and language need, who is
Out of the
frying pan,
servìce management
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +ó
ìí you
• make decìsìons about
where therapy shou¦d
take p¦ace
• work wìth / through
other proíessìona¦s
• have to prìorìtìse
resources
Read thìs
Discussions about clinic
or school based therapy
can get quite heated.
Alyson Portch warns
that, by pulling out
of clinics and
concentrating on
schools, the profession
is in danger of getting
its fingers burned.
Instead she argues we
should be grilling
ourselves about what
combination is right for
each individual, and
what will enable us to
continue giving an
appropriate service to
all children, irrespective
of their age.
A big part of the success of working in schools must
therefore be not only selecting the right children but
also learning to value the specific differences in the
roles of teachers and therapists and sharing skills to
enable us to work together to help children. From the
therapist’s point of view, this involves learning and
understanding the educational context, and a sound
knowledge of the curriculum and staged approach to
managing special educational needs via the new Code
of Practice (2001). It is therefore essential that joint /
shared training takes place in local areas to ensure this
knowledge base is established and skills developed.
‘On the job’ training is also highly beneficial as a
study by Jannet Wright (1994) highlighted; therapists
and teachers who worked together grew to really
appreciate what they learnt from each other and
increased their knowledge of what
each had to offer. This ultimately
must influence the successful out-
come for children with school based
speech and language therapy provi-
sion.
Our service is piloting a new ser-
vice for delivering speech and lan-
guage therapy to non-statemented
school aged children whose needs
would be best met through a col-
laborative approach with school
staff. The children are identified by
speech and language therapists
who complete a referral form
including current support in school
and the rationale for school based
input. We have assigned a named therapist to each
school for these children, and ensured the school
also provides a named contact with protected time
for discussion and carrying out activities. Via the
Special Educational Needs Co-ordinator (SENCO), we
ask the teaching staff to complete a two page ques-
tionnaire on each child which covers skills in listen-
ing / attention (1:1 and class group), understanding
of language (following instructions, answering ques-
tions, gleaning information from stories and class
discussions), expressive language (telling news,
vocabulary, sentences), pronunciation, use of lan-
guage (interaction with adults and peers), general
academic progress (reading, number work, writing
and spelling) and anything else they think is rele-
vant. In the questionnaire we also ask for feedback
about how useful the school has found our input. In
preparing programmes, speech and language therapy
staff draw on a list of useful assessments and therapy
materials (figure 1).
the main focus of intervention and the reason for
the proposed intervention should therefore enable
therapists to decide where it is best carried out.
Principle 4 Proper procedures
The procedure you follow is also crucial to your success.
My experience suggests that before arranging a
school visit it may be helpful to:
• Send a questionnaire to the school requesting further
information
• On receipt, either telephone the school to discuss the
information, or discuss it during the school visit.
Then:
• Arrange a visit and confirm it in writing. This letter
should clearly explain the purpose of the
visit and the format your visit will take, such
as staff you need to see, or observation in
class. The letter should also make it explicit
that parents will be invited to attend for
part of the session if they so wish.
• A letter should also be written to the parents
to inform them of this.
During the visit:
• Make any observations / assessments of the
child within class
• Share findings with staff
• Listen carefully to teachers’ concerns and
priorities (and if possible the parents’ / carers’)
• Develop shared / agreed curriculum focused
targets with the teacher and discuss and agree
ways in which these targets can be
implemented at school and monitored
• Agree roles - therapist, teacher and parent.
If it is essential that specific work is undertaken
with a child, it is important that school identifies a
named adult who will be responsible for working
with the child and therapist and implementing the
targets. This is more likely to ensure a positive out-
come. If this is not available but you consider it to
be essential, school visiting may not be beneficial.
After the school visit, provide a written record for
staff, parents and other professionals which summarises
your observations and assessment, your discussion and
any agreed plan of action, and identifies agreed targets,
strategies for achieving these and how you have agreed
these should be implemented and monitored.
Principle 5 Collaborate and learn
SENDA (2001) has strengthened the rights of children
with special educational needs to be educated in
mainstream school. This inclusive agenda means more
children with difficulties will be educated in mainstream,
creating a challenge for teachers and therapists alike.
Figure 1 Resources for school-aged children
Assessments
Bracken (1998) Bracken Test of Concepts
Bracken Basic Concept Scale - Revised.
Psychological Corporation.
Dunn, Dunn, Whetton & Pintilie (1982)
British Picture Vocabulary Scales. NFER-
Nelson.
Harrison & Portch (in preparation) School
age screen (SAS).
Renfrew (Renfrew Action Picture Test, Test
of Word Finding, Bus Story) available from
Speechmark.
Semel, Wiig & Secord (2000) Clinical
Evaluation of Language Fundamentals
(CELF-3
UK
). Psychological Corporation.
Wiig & Secord (1992) Test of Word
Knowledge. Psychological Corporation.
Therapy materials
From Learning Materials ltd, tel. 01902 454026:
Looking and Thinking (books 1-5)
Reading for Meaning (books 1-4)
Reading for Meaning More (books 1a-4a)
Reading and Thinking (books 1-5)
New Reading and Thinking (books 1-6)
From Winslow, tel. 0845 921 1777
Think it - Say it - improving reasoning and
organization skills, by Luanne Martin
(1995), £32.95
From Speechmark, www.speechmark.net
Working with pragmatics, Lucie Andersen-
Wood & Benita Rae Smith
From Black Sheep Press
www.blacksheep-epress.com
First / Last / Next
Before / After
Time
Parts of the Day
Days
Why / because
Facial Expressions
Speaking and Listening Through Narrative
From The Psychological Corporation,
www.tpc-international.com
Describe it - games to build descriptive lan-
guage skills, by Thomas-Kersting,
McCormack & Satin (1998)
CLIP Worksheets: Semel & Wiig (1991)
1. Syntax
2. Morphology
3. Pragmatics
4. Semantics
From LDA, www.LDAlearning.com
Socially Speaking - a pragmatic social skills
programme for pupils with mild to moderate
learning difficulties, by Alison Shroeder, ISBN
1 85503 252 X
From STASS, tel. 01661 822316
Cambridge Language Activity File
From ECL www.eclpublications.com
Practical Language Activities - Materials for
Clinicians and Teachers by JoAnn H. Jeffries
& Roger D. Jeffries
Auditory Processing Activities - Materials
for Clinicians and Teachers by JoAnn H.
Jeffries & Roger D. Jeffries
From Manchester Metropolitan University,
tel. 0161 247 2535
Functional Communication in the
Classroom by Maggie Johnson
into the fire?
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +;
servìce management

A big part of the
success of working
in schools must
therefore be not
only selecting the
right children but
also learning to
value the specific
differences in the
roles of teachers
and therapists
and sharing skills
p.19
servìce management
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +8
Figure 2a) Case example
Cameron has
• moderate bilateral sensori-neural hearing impairment (aided)
• severely disordered expressive skills, profoundly delayed language skills and
moderate speech difficulties (some associated with hearing impairment)
Early therapy
- Clinic based, speech and language intervention with some written
correspondence and telephone contact with school.
Year 4
- No additional funding.
Year 4 Spring term:
- Therapist works with school, parents and other professionals to get LEA
funding for extra support (at that time 15 minutes per week for 1:1 or small
group work with SENCO)
- Cameron attends clinic sessions; liaison with school for advice / strategies
established.
Year 4 Summer term / Year 4 Autumn term:
- Extra funding granted on hearing impairment needs. Prioritised by school and
parents for specific hearing impairment resources to support Cameron within
classroom.
- General classroom assistant support, continuation of 1:1 / groups with SENCO
for 15 minutes per week.
- SENCO becomes named contact
- Cameron and parents still attend clinic sessions
- Clinic input focuses on speech skills and language work / vocabulary,
especially verbs.
- Copies of advice / targets given to school via parents after each clinic session.
- Input at school limited, focusing on general advice / strategies and support
for SENCO and school staff.
- SENCO has regular meetings with staff, who then try to support / reinforce
advice given, wherever possible within the classroom environment.
Figure 2b) School visiting example
Write up of visit
- Attended school and liaised with SENCO (30mins)
- worked alongside Cameron in class (l0mins)
- 1:1 work outside the class (20mins).
Liaison with SENCO to review previous targets:
1) Cameron will now ask for repetition if not understood but not yet
consistent, therefore keep as a target
2) Cameron can now answer 5 concrete questions about a passage
he has read but he finds gleaning abstract information difficult i.e.
inferencing and prediction, therefore therapist to look at visual
information first before written/reading material
3) Cameron has met his 10-vocabulary word target and SENCO
has sent more. Therapist stated this would be an ongoing process
with new vocabulary but also needs to be filling in gaps of basic
vocabulary. Therapist discussed strategies such as word webs and
“my little book of words” to be sent home for discussion/practice
and also available to child in classroom to help self help skills and
increase independent learning.
4) Regular past tense still difficult for Cameron. Therapist discussed
why this was with SENCO, as he has fairly good irregular
forms. Due to Hearing Impairment “ed” quiet sounds at high frequency
therefore doesn’t I didn’t hear as clearly as irregular forms where
whole word changes. Discussed two forms of “ed” past tense endings
both spelt the same but pronounced “t” with quiet word endings and
with “d” in loud word ending e.g. quiet “t” = walked
loud “d” = heard
Therefore will send in picture material to work on loud “d” past
tense (reg) first then will target quiet ‘t” past tense (reg).
Also advised school to have a recording system to document when
input given on each target and if any changes observed in that skill.
Agreed with SENCO school visit after half term. Therapist then took
Cameron out to try visual inferencing which he managed well with
multichoice answers but found difficult with open ended questions B
from “Looking and Thinking” book 1. This is when information is not
in the picture at all but high level of inference is to be made therefore
target questions B, but complete A as a preparatory activity.
Back in the classroom found some vocabulary difficulties therefore dis-
cussed with SENCO ways to introduce new vocabulary before and
review after a lesson so Cameron has more cues to comprehend les-
son and vocabulary.
Therapist to write new targets and send new material to home and school.
Therapist also to telephone mum.
Figure 2c) Update to programme
Target 1
Cameron will consistently choose the correct multiple-choice questions / answers,
targeting his development of inferencing skills in “Looking and Thinking” Book 1 activities
Rationale
Cameron finds it difficult to look at visual material and make an inference from the
information he can see. This is due to the fact that the skill requires more abstract thinking.
Strategies / activities
Please use materials enclosed and answer the appropriate corresponding A/B questions
from “Looking and Thinking” Book 1. In the materials provided, multiple-choice
answers are given but Cameron may still require adult prompting to complete the
task. In particular give prompts to encourage him to think outside the immediate context
and not just how it relates to himself.
Encourage Cameron to make his reasoning process explicit eg. prompt with “how do
you know?” type questions. This will help him understand the steps he needs to go
through to make an inference / prediction. Continue to encourage Cameron to identify
when and what he has not understood.
Target 2
Cameron will consistently use a voiced loud regular past ending during structured
activities
Rationale
Cameron has difficulty using regular past tense endings (“-ed”) because of his hearing
impairment.
There are two forms of regular past tense endings
a) -ed - spoken with a “d” sound (eg. served)
b) -ed - spoken with a “t” sound (eg. walked)
“d” is a loud sound and “t” a quiet sound. Due to Cameron’s hearing impairment, the loud
regular past tense endings will be worked on initially as they are easier for him to hear.
Strategies / activities
Please use materials enclosed from “Yesterday’s Verbs” and follow instructions on
each page. Identify and group words with “-ed” endings (into loud and quiet) and
practise in writing tasks.
Target 3
Cameron will learn 80 per cent of class topic vocabulary
Rationale
Cameron has a specific problem learning new vocabulary and relating it to previous
knowledge.
Strategies / activities
Cameron to develop “my little book of words” noting key vocabulary items and new
words which he comes across. Prior to introduction of the topic, new vocabulary will
be rehearsed with Cameron and then revised after the lesson.
Use topic webs, linking words by association where possible. When explaining what
new words mean try to put them into categories and link them to words which he
already knows. Rehearse the vocabulary through action, activities and experience at
school and at home. Throughout tasks, encourage Cameron to identify any words he
has not understood.
Year 5 Spring term
- 1 hour per day learning support assistant time allocated from
funding. Used mainly for general support within classroom
(hearing aid maintenance, repeating instructions, explaining
tasks / vocabulary meanings, completion of work etc.)
- Therapist continues to work with named contact / SENCO and
occasionally with class teacher / learning support assistant.
- SENCO has regular meetings with learning support assistant
and class teacher to plan and discuss action / progress.
- Clinic therapy ends, as only language needs remain and all
parties feel these needs best met within school environment.
- Speech and language therapy school visits 1 per term.
- Frequent written correspondence and telephone contact
between all parties.
Year 5 Summer term
- 1 hour per week support not meeting all Cameron’s hearing
impairment needs and only some of speech and language
therapy needs.
- SENCO and parents feel greatest area of need is speech and
language so 1:1 hour per day with learning support assistant
focuses on speech and language therapy strategies.
- Frequency of speech and language therapy visits to school
increases to three per term.
- Focus of school visits becomes more specific and target based.
- SENCO remains named contact, having regular meetings with
class teacher and learning support assistant.
- Liaison and support for learning support assistant become
primary aim; high level of input demonstrating and advising
on tasks and approaches to use during specific 1:1 slots and
classroom support.
- SENCO continues to meet therapist at each visit to clarify
outcomes and maintain overall responsibility.
- Statement applied for and finalised to commence in Year 6.
We must not let speech and language therapy
become just another task that teachers cannot
possibly undertake. We don’t need another black
mark against our profession. If services and each
individual therapist consider the principles and
procedures listed, then appropriate decisions can
be made about where we should be targeting our
resources based on what the individual child
requires (see case example in figure 2a) - c), p.18).
This, coupled with effective training and collabo-
ration with school staff, should mean preschool
children do not suffer because of inadequate
resources and that ‘the greater part (not all) of the
provision for school age children ... is really
‘embedded within the curriculum and takes the
child’s education context into consideration’.
Alyson Portch is Head of Children’s Speech and
Language Therapy Services for Hertfordshire
Partnership NHS Trust at St Peters House, 2 Bricket
Road, St Albans AL1 3JW, tel. 01727 829415.
Acknowledgements
Thanks to Cathy Goodbun and Lisa Cookson,
speech and language therapists.
References
DfEE (2000) Provision of speech and language
therapy services to children with special educa-
tional needs (England): report of the working
group (DfEE 0319/2000). Online at
www.dfee.gov.uk/sen.
DfES (2001) SEN Code of Practice. Department for
Education & Skills. (tel publications centre on
0845 602 2260, quoting ref. 581/2001).
Malcomess, K. (2001) The reason for care. Bulletin
of the Royal College of Speech & Language
Therapists 595: 13-14.
Portch, A. & Harrison, P. (2002) Clarifying priori-
ties. Bulletin of The Royal College of Speech &
Language Therapists 599: 7-8.
Special Educational Needs & Disability Act (2001)
From The Stationery Office or online from the
Queen’s Printer of Acts of Parliament at
http://www.hmso.gov.uk/acts/acts2001/20010010.
htm). Crown Copyright 2001.
Wright, J.A. (1994) Collaboration between speech
and language therapists and teachers.
Unpublished PhD thesis, University of London.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +,
servìce management / revìews
LEARNING DISABILITIES
SOME SUGGESTIONS
SIMPLISTIC
Themed Activities for People
with Learning Difficulties
Melinda Hutchinson
Speechmark
ISBN 0 86388 307 9 £ 34.95
This resource manual has 20 objects as
the basis of activities to use with people
with ‘profound and complex learning
difficulties’. It has a very clear, straight-
forward layout, is well organised and
the activity sheets can be photocopied.
It’s very easy to read. It provides ideas
for group work, using readily available,
low cost items (for example, ‘take a
coconut’).
Whilst the book contains some creative
ideas, we found some suggestions sim-
plistic. It is therefore of limited value to
the experienced clinician and not partic-
ularly good value for money. It would be
a useful tool for teachers or generic sup-
port workers who work with people with
more moderate learning disabilities.
Rafaella Peerutin, Debbie Charles and
Louise McMillan are speech and language
therapists for adults with learning disabil-
ities in Newham Primary Care Trust.
LIFE SKILLS
OF MOST USE IN A GROUP
Skills for Daily Living:
Personal Safety
ColorCards
Speechmark
ISBN 086388 474 1 £26.95
These cards come with a booklet that
lists each situation clearly. Each card is
numbered so can be easily cross-refer-
enced to the list. The cards are well
drawn in colour and would be appro-
priate for use with adults, older chil-
dren, and adults with mild learning
disabilities. Both newly qualified and
experienced therapists could use the
cards. The basic themes - such as immi-
nent danger and everyday situations -
are good. However, some of the cards
are quite abstract or have complex
themes. This may be confusing
depending on the individual’s own
experiences of everyday situations.
A useful tool to stimulate discussion,
highlighting an individual’s level of
insight within different situations, the
cards could be used with both individ-
uals and groups. Overall, my col-
leagues and I felt they would be of
most use in a group setting.
Sue Martin is a speech and language
therapist in London.
REVlEvS
EARLY INTERVENTION
OPPORTUNITY TO GENERATE DISCUSSION
The Social Toddler (Promoting Positive
Behaviour)
Helen & Clive Dorman
The Children’s Project
ISBN 1 903275 38 5 £15.99
This is a useful and enjoyable read for both experienced and
inexperienced therapists working with toddlers and their par-
ents. The authors believe that by showing why children of 2-4
years behave the way they do, their parents and carers will be
better able to understand them and respond appropriately.
The attractive use of photo pictures showing sequences of toddler
behaviour in contexts helps the reader absorb and relate the ideas
to real situations, while avoiding telling the parent what to do.
The many examples of young children’s behaviour and development
at different stages provide the therapist with a real opportunity to
generate discussion when used together with parents. At the very
least this is a useful reference for parents and therapists seeking to
gain insight into “the mysteries of toddler thinking”.
Grainne Hampson is a senior speech and language therapist at the
Department of Child and Family Psychiatry, Mater Hospital, Dublin.
MULTI-PROFESSIONAL WORKING
COVERS BASIC CONCEPTS
Teamwork. A Guide to Successful
Collaboration in Health & Social Care
Sue Hutchings, Judy Hall & Barbara Loveday
Speechmark
ISBN 0 86388 276 5 £25.95
This book covers the basic concepts of collaboration, prerequi-
sites for success, benefits, barriers and pitfalls. Each chapter
ends with a summary of the key points discussed, and many
with an opportunity to reflect, and formulate an action plan of
personal or service level goals. The authors are from health
backgrounds (occupational therapy, physiotherapy and nursing)
although all now work in professional education. Hence some
speech and language therapy settings may find it easier to
relate to this book than others. However the general principles
of collaboration apply to all. This is a useful and practical refer-
ence for those embarking on multi-professional working.
Judith Anderson is the speech and language therapy coordi-
nator (mainstream services), Cotswold and Vale PCT.
WORD FINDING
DOES WHAT IT SAYS ON THE BOX
Find the Link (game)
Diana Williams
Speechmark
ISBN 0 86388 421 0 £48.75
This resource does ‘what it says on the box’ in that it provides an
attractive word finding and category game. The 200 good quality
Colorcard pictures are useful in themselves and ideas are given
for a number of different games. My secondary aged students
generally gave it a ‘thumbs up’ but some of the materials, partic-
ularly the clothes category pictures, are aimed at much younger
children. Also the ‘insects’ category includes an earthworm and
snail which would upset a lot of science teachers! However this
resource will not be staying in the back of my cupboard as it is
regularly requested by my students as a fun activity.
Karen Kelly is a specialist speech and language therapist at
the secondary speech and language base, Twynham School,
Christchurch, Dorset.
• Do l have guìdìng prìncìp¦es
to he¦p me p¦an and de¦ìver
my servìce'
• Do l ensure a¦¦ partìes agree
on each person’s ro¦e'
• Do l back up conversatìons
ìn wrìtìng'
Reí¦ectìons