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O N W A R D S A N D U P W A R D S
Competency in
head and neck
When is good enough?
Long-term care
Training with SOAP
Collaborating
for
Communication
Clinics and
schools
Out of the
frying pan...
How I
augment
AAC
My top resources
Music in therapy
And introducing
Winning Ways
Evidence
based
practice:
a climbing frame
not a cage
Peter 8
The at
No scary wolf for Peter this time, but still a
story to capture the interest of young
school-aged children. Black Sheep Press is
offering copies of this narrative re-tell
assessment to THREE lucky Speech &
Language Therapy in Practice readers - FREE!
Peter and the Cat can be used with children from 5 to 9 years, pri-
marily those with language delay / disorder, but also for more
general screening. The task is not norm-referenced, but gives a
descriptive profile of the childs development of key narrative
competencies which can be linked directly to intervention goals.
For your chance to win, send your name and address to Speech &
Language Therapy in Practice - P&C offer, Alan Henson, Black
Sheep Press, 67 Middleton, Cowling, Keighley, W. Yorks BD22 0DQ
by 25th January. The winners will be notified by 1st February, and
are asked to let Black Sheep Press know what they think of the
resource.
Peter & the Cat consists of an A5 booklet illustrating the story in 9
full colour pictures, an instruction booklet and photocopiable
cards for transcription and analysis. It is available from Black
Sheep Press, see www.blacksheep-epress.com, or telephone 01535
631346 for a free catalogue.
Karen Phillips was the lucky winner of Pip the puppet in the Autumn 03
issue, courtesy of LDA. Speechmarks Basic Verbs colorcards go to Joanne
Sheldon, Margaret Purcell, Joanna Hardman, Irene Dobbin and Ms
Caulfield. Congratulations to you all!
WINTER 03 speechmag
In need of inspiration?
Doing a literature review?
Looking to update your practice?
Or simply wanting to locate an article you
read recently?
Our cumulative index facility is there to help.
The speechmag website enables you to:
View the contents pages of the last four
issues
Search the cumulative index for abstracts of
previous articles by author name and subject
Order a copy of a back article online.
Plus
The editor has selected some previous articles you
might particularly want to look at if you liked the arti-
cles in the Winter 03 issue of Speech & Language
Therapy in Practice. If you dont have previous issues of
the magazine, check out the abstracts on this website
and take advantage of our new article ordering service.
New! Conference report
The CPLOL / RCSLT conference on evidence based prac-
tice left Frances Harris (p.20) wanting to continue to
climb; read editor Avril Nicolls report on the web.
If you liked...
Wendy Prevezer, see (176) Finlay, C.: Be brave and sing
up!, (177) Bruce, H.: A healing force, (178) Magee, W.:
Creating opportunities. All from Winter 2001, How I
use music in therapy.
Linda Armstrong & Alison Bain, look at (160) Talbot, K.
& Stinchcombe, J. (Autumn 2001) A question of taste.
Lorna Gamberini, what about (084) Robinson, F.
(Autumn 1999) Setting the standard, or (162) Harris, C.
(Autumn 2001) Ahead-and-neck of the field.
Jo Middlemiss, you might be interested in (031)
Shewell, C. (Summer 1998) The Counsellor as Travelling
Companion.
Karen Heins, check out (174) Rinaldi, W. (Winter 2001)
Access all areas.
Alyson Portch, try (128) Millard, S., Cook, F. & Fry, J.
(Autumn 2000) Homebase - but not DIY.
How I augment AAC, consider (pre-dates abstracts)
Cameron, C. & Murphy, J. (Human Communication, 5
(2), 1996) Skill sharing - training in the use of low tech
communication systems, or (pre-dates abstracts) Grist,
E., Davies, A. & Bradburn, J. (Human Communication, 5
(4), 1996) High spec, low tech.
Also on the site - news about future issues, reprinted
articles from previous issues, links to other sites of
practical value and information about writing for the
magazine. Pay us a visit soon.
Remember - you can also subscribe
or renew online via a secure server!
www.speechmag.com
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vn TROG-
Is your TROG a bit dog-eared? Not to worry,
author Dorothy Bishop also felt it was
time for an update, and has revised and
extended the format to include:
All new items
New national UK norms
Upward age extension
More scope for qualitative
analysis
List of TROG research studies with different client groups.
The Test for Reception of Grammar - Version 2 normally retails
at 147.77 (manual, stimulus book and 25 record forms) but the
Psychological Corporation is offering a FREE copy to a lucky
reader of Speech & Language Therapy in Practice.
For your chance to win, simply write your name and address on a
postcard with the title TROG-2 Reader Offer and post to: Liz
Akers, The Psychological Corporation, 32 Jamestown Road,
London NW1 7BY.
The Test for Reception of Grammar - Version 2 is available along
with a free catalogue from The Psychological Corporation, tel.
020 7424 4512, www.trog-2.co.uk.
lnsde cover
vnter o speechmag
Reader oers
Win TROG-2 and Peter & The Cat.
News / omment
( vhen s good enough'
While there is a wealth of literature on the effects of
surgery and radiotherapy on the swallowing process,
there is relatively little about speech and language
therapy intervention and even less on the level of
expertise or experience on which that intervention
should be based.
Lorna Gamberini explores the concept of sufficient
competency when working with people with dysphagia
associated with head and neck cancer.
; lurther readng
Child language, articulation, voice, head injury,
Huntingtons disease.
8 The need or SOAP
Swallowing......on a plate
(OLoughlin & Shanley, 1996) is an
Australian dysphagia
management (training)
programme designed for use in
nursing homes so that, following
training, nursing home staff
would be able to provide basic
assessment and management
strategies for their patients.
When Linda Armstrong and
Alison Bain found out they were piloting the same
off-the-shelf package (SOAP), they were interested to
compare methods and results.
++ oaboratng or ommuncaton
Teaching assistants participated fully in the sessions by
preparing materials, observing my demonstration of
activities, then implementing the activities with the
children themselves, and taking notes on the childrens
abilities in the different tasks.
In the Collaborating for Communication project,
Karen Heins and colleagues found an efficient and
effective way of managing clients with speech and
language difficulties in mainstream schools.
+( vnnng vays seres (+)
lrom caterpar to buttery
People come to coaching because they want to make
changes in their lives. If people just want to wander
round the mulberry bush a few times, only to be
reassured that their problem really does have no
solution, then Im not the coach for them.
Life Coach Jo Middlemiss believes that every
challenge has a solution and that, ultimately, the only
person you can change is yourself.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +
+ Heres one l made earer...
Alison Roberts continues to generate low-cost
ideas for flexible therapy activities: Car logo
pelmanism, How I help people poster and
Cooperation tin.
+ Out o the ryng pan, nto the
re'
The combined effect of a therapist considering the
individual childs speech and language need, who is
the main focus of intervention and the reason for
the proposed intervention should enable therapists
to decide where it is best carried out.
Alyson Portch argues that, instead of pulling out of
clinics and concentrating on schools, we should be
grilling ourselves about what combination is right
for each individual.
+, 8 Revews
Downs Syndrome, learning disabilities, working
with education, early intervention,
social communication, life skills,
multi-professional working and
word finding.
+ e-mas to the edtor
Writing for people with dementia;
raising awareness of DownsEd.
How l augment AA
The many different types of
communication book meet different
needs. In an ideal environment,
people with communication
difficulties can use not just one but as many as they
find helpful. (Sally Millar)
Janet Scott on choosing a graphic symbol system,
Sally Millar on communication books and Cheryl
Davies on AAC (alternative and augmentative
communication) service development.
Back over Ny top resources
Contrary to popular belief, even musical people need
to practise. On my early morning walks I rehearse songs
(internally, not usually out loud!) and make up or
adapt words, to the steady beat of my footsteps.
Wendy Prevezer brings her dual role of speech and
language therapist and musician to her work.
WINTER 2003
(publication date 24th November)
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 2003
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.
Cover picture by Paul Reid (posed by
model). See p.20
In future issues...
SURE START
STORYTELLING
DYSARTHRIA
DYSPHAGIA
ADOLESCENTS
CHILD VOICE
COLLABORATION
STUDENT TRAINING
w
w
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s
p
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c
h
m
a
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c
o
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Evdence based practce: a
chaenge or speech and
anguage therapsts
The sound bite of the weekend goes
to Kath Williamson: Evidence based
practice should be a climbing frame
and not a cage. I want to continue to
climb.
Frances Harris dissects the
proceedings of CPLOLs 5th European
Congress.
o OVER STORY
news
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
Manager is disheartened
A speech and language therapy manager is disheartened that more than nine months
of negotiation has failed to solve a Dysphasia Support Service funding crisis.
In the Autumn 03 issue, we reported on the campaign by volunteer and speech and lan-
guage therapy student Louise Walters to have cuts to the Dysphasia Support Service in
Stockport reversed. Karen Davies, head of speech and language therapy in Trafford, says
that the situation across the north west of England is far more complex than Stroke
Association volunteers have been led to believe, and that it is too simplistic to blame
Trusts. She explains, The Stroke Association told all the Trusts commissioning services in
the north west that the amount of money they were receiving was no longer sufficient
to cover the costs of running the service and maintaining the support from the Stroke
Association charity. They therefore told the Trusts that, unless they increased the budget
allocated to the Dysphasia Support Service by 10,000, their services would be cut.
Karen continues, The 10,000 that is being requested is additional money. I am in the
unusual situation of holding the budget for the Trafford Dysphasia Support Service,
which means I can track back the funding provided by our Trust - and I can assure volun-
teers it has always been increased in line with inflation. She says her concern is that it is
not at all clear what the additional money is for and, at a time when most Trusts are
struggling financially and juggling priorities, it seems reasonable to expect to influence
the way a service is delivered or, at the very least, have detailed information about how
public money is being used.
Karen believes that, while reconfiguration of Trusts and regionalisation by the Stroke
Association have contributed to the complexity of the situation, the Stroke Association
needs to show more commitment to working in partnership with the Trusts, and to rais-
ing funds by other means. She comments, If the Stroke Association had match funded
the original budget provided by my Trust we would have a Rolls Royce service. Sadly,
instead we have a reduced service, and many disheartened users and volunteers.
Team leaders
Clinical teams in England can now access a leadership programme aimed at developing
the leadership qualities of all team members to improve client care.
Participating teams will work with facilitators over a 12 month period using techniques
such as action learning, patient stories, observations of care and 360 degree feedback.
The NHS Leadership Centre also recently held a conference to look at ways of increasing
diversity at a senior level, so that skilled leaders from ethnic communities are fairly rep-
resented at all levels.
Further information: The Clinical Teams Programme, NHS Leadership Centre, tel. 0207 647
3847 or e-mail clinical.leadership@rcn.org.uk.
From assumptions to hard evidence
The people behind a new national Stroke Rehabilitation Research
Centre hope their work will provide the NHS with evidence that
stroke services are worth developing.
The Stroke Association is providing funding of 500,000 to the
University of Southampton where researchers will be focusing on long-
term recovery of movement. The effects of mental rehearsal of activ-
ity and functional electrical stimulation will be examined, along with
the reasons for poor balance and frequent falls experienced by some
people following a stroke. Quality of life interviews with stroke sur-
vivors and carers will also inform therapy developments.
Head of the research Professor Ann Ashburn says, There is a kind of
accepted wisdom amongst therapists that certain things work. We
think that we can do better for our patients and get things on a much
more scientific footing. Instead of basing therapy on myths and
assumptions, we need hard evidence about what works best so that
everyone who has had a stroke can reach their full potential. She
concludes, The aim ultimately is to benefit patients directly and to
ensure we are developing sound value for money therapies.
www.stroke.org.uk
Art Works in Mental Health
Following a period at Londons Royal College of Art, the Art Works
in Mental Health exhibition is to tour Cardiff, Manchester,
Edinburgh and Birmingham.
One hundred and twenty works were selected by a distinguished review
panel from open submission including two and three dimensional pieces
and creative writing. Organisers recognise that creative expression can
help people to tolerate mental distress and increase understanding
about how important acceptance by other people is to recovery.
On average, one in four people experiences a mental health prob-
lem in the course of a year.
Entries can be viewed on
www.artworksinmentalhealth.co.uk.
Talking Point
The website developed as a one-
stop shop for information and sup-
port relating to children with speech,
language and communication difficul-
ties is reporting early success.
Officially launched by Sophie Wessex
on 8th September, Talking Point wel-
comes the involvement of parents and professionals in time-limited
online discussion groups. Topics have included The new school year -
sharing concerns and solutions and Enabling children with speech,
language and communication difficulties to access the curriculum. To
contribute or read the postings you need to register as a user of the
website by supplying your e-mail and a password.
Talking Point is a collaborative venture between I CAN, Afasic and
the Royal College of Speech & Language Therapists, with finance
from BT and Lloyds TSB Foundation for England and Wales.
www.talkingpoint.org.uk
Stroke progress criticised
Health Which? has drawn attention to the poor progress on stroke
units being made in England and Wales.
The government has set a target for all people with a stroke to be treat-
ed in stroke units by 2004. Scotland is now estimated to have between
60 and 70 per cent of the beds needed to provide people with a stroke
unit place for their entire hospital stay, and a strategy requiring patients
to be admitted to a unit within 24 hours of hospital admission. In
England and Wales only 36 per cent of stroke patients are able to spend
any time in a stroke unit. Acting Editor Sue Freeman says, The
Government must ensure that proper provision of acute stroke beds for
patients immediately following a stroke is addressed and equally it must
address the provision of rehabilitation beds for longer term recovery to
improve the UKs unenviable record in survival after a stroke.
The Consumers Association publishes Health Which? six times a
year, tel. 0845 924 5000 for details.
Following the
success of the
2 0 0 3
C h a t t e r b o x
C h a l l e n g e ,
organising chari-
ty I CAN is bringing it back bigger, better
and LOUDER in 2004.
This years event involved an estimated
75,000 preschool children learning songs,
nursery rhymes and stories. Sponsorship
from parents raised over 100,000 for
children with speech, language and com-
munication difficulties at I CANs Early
Years Centres. Encouraging nursery work-
ers, teachers and other staff who work
with young children to register for the
2004 challenge, Chief Executive Gill
Edelman says, Chatterbox Challenge is a
fun event with educational value that will
also raise awareness and vitally needed
funds to help us achieve our goals.
Chatterbox Challenge hotline, tel. 0870
350 0095, or see www.ican.org.uk/chatter-
box for a free fundraising ChatterPack.
On the move
The Fragile X Society is now
at:
Rood End House
6 Stortford Road
Great Dunmow
Essex CM6 1DA
tel. 01371 875100
family phone line 01424
813147
www.fragilex.org.uk
Lets talk about sex
Finding information and practical advice on
growing up, puberty and sex for disabled
young people is almost impossible, accord-
ing to the UK wide charity for families with
disabled children.
Contact a Family has therefore joined forces
with the Arthrogryposis Group to produce a
comprehensive, cartoon-illustrated pack
containing a series of publications offering
advice for the teenager, the parent, the
social worker and the health professional. A
pack for teachers will follow. Areas covered
include self-esteem, making and keeping
friends, personal relationships, body image,
sex and relationship education at school and
at home, and there are tips for young dis-
abled teenagers from their peers.
The pack, Growing up, sexuality and the young
disabled person, has been funded by the
Department for Education and Skills and will
be available from the end of January 2004, free
of charge to parents and professionals. The
Arthrogryposis Group is a charity supporting
families affected by multiple joint contractures.
Contact a Family freephone helpline 0808
808 3555, e-mail helpline@cafamily.org.uk.
Chatter
Matters
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
news 8 comment
Onwards and upwards
Frances Harris (p.20) likes Kath Williamsons description of evidence based
practice as a climbing frame not a cage. Watching young children on a
climbing frame, you get a sense of the different ways speech and language
therapists might approach evidence based practice: some attack fearlessly
while others are wary and careful; some are methodical and purposeful, and
others imaginative and daring.
The level of supervision a child needs on a climbing frame varies according to
their age and stage and the level of difficulty of the particular frame.
Younger children need the reassuring presence of an adult who can step in if
they get into difficulties. Lorna Gamberini (p.4) is clear that part of being
competent as a therapist is knowing when we need help. Jo Middlemiss (p.14)
would agree: a winner is someone who willingly shares what they do know
and acknowledges what they dont. Life coaching can provide the support
you need to make a climb, and I hope readers will benefit from the
opportunity of working with a coach who is taking a particular interest in the
challenges of our profession.
One day a familiar climbing frame can be a pirate ship, the next a jungle -
but the structure itself remains the same. Karen Heins (p.11) has used this
principle to great effect when planning programmes for teaching assistants
to carry out. Linda Armstrong & Alison Bain (p.8) borrowed structure from a
dysphagia management programme and applied it to their different
situations - comparing and contrasting outcomes.
Our local park hasnt held the same appeal since the roundabout was closed
off - reducing choice reduces opportunities for children to get what they
need at a particular time. Alyson Portch (p.16) cautions against going down
that road in speech and language therapy, believing we need to tailor a
combination of clinic and school services to the needs of individuals.
I suspect the contributors to How I augment AAC (p.23) would do rather
well if they were asked to design a climbing frame, as the decision making
process must be similar to introducing a graphic symbol system, a
communication book or even a new service. It wouldnt surprise me if Alison
Roberts (p.15) - who surely missed her vocation as a Blue Peter presenter -
could find a cheaper way of constructing it. And who better than Wendy
Prevezer (back page) to devise a climbing song to help us on our way?
A climbing frame offers challenge, variety and social interaction. And,
however many people are on it, theres always room for more to go onwards
and upwards.
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Help for self-harm
Are you aware of levels of self-harm and suicide among
adolescents, and would you know where to find help?
The British Association for Counselling and
Psychotherapy has launched a website for teachers in
secondary schools as part of World Mental Health Day
2003 which focused on emotional and behavioural dis-
orders of children and adolescents. The Association is
concerned that there has been an increase of 75 per
cent in suicide by young men in 10 years, and that
research suggests 1 in 17 adolescents may be self-harm-
ing. As mental health problems in young people are a
clear predictor of difficulties in adulthood, they have
worked with teaching unions to provide a web resource
where teachers can get more information and help.
www.bacp.co.uk/emotional
Bookstart update
A report from Bookstart Australia discusses how
speech pathologists are working in conjunction with
librarians and child health nurses to promote reading
and book sharing with very young children, and how
it can help speech and language development.
Meanwhile, Bookstart in the UK has rolled out
Booktouch nationwide through health visitors, parents
and visual impairment teachers.
www.booktrust.org.uk
Residential development
A specialist college for disabled young people from
throughout the UK has opened a purpose-built resi-
dential development for its students.
Campbell Court at Treloar College in Hampshire has
seven new state-of-the-art studio flats to be used as part
of the Colleges Independence Training Programme.
High tech equipment in the open-plan one-bedroom
flat enables the student to self-manage home activities
such as cooking, washing, shopping and leisure.
D/deaf forum
A forum under development in Somerset aims to give
deaf and hard of hearing people a collective voice.
The D/deaf Forum will provide an opportunity for
people who have something in common to get
together and share experiences, and to identify barri-
ers and service improvements. Community Worker
Claire Crowley also points out that such a group can
provide good practice information, for example if
approached by a theatre for advice on improving their
facilities for deaf people.
Bath & Wells Diocesan Council of D/deaf People,
Phone/fax 01761 239272, minicom 01761 239273, e-
mail claire.crowley@ukonline.co.uk.
Post-grad in Asperger syndrome
Professionals working in the field of autistic spectrum
disorders now have the opportunity to study for a
post-graduate certificate in Asperger syndrome.
The result of a collaboration between the National
Autistic Society and Sheffield Hallam University, cours-
es will be held in Leicester, Leeds and Cheltenham.
Module 1 provides an introduction including social
behaviour and skills and sensory and perceptual
issues. Module 2 is a work-based independent study
unit. Speakers and advisors include Dr Tony Attwood
and Dr Simon Baron-Cohen.
Further information and application forms from The
National Autistic Society Training & Consultancy
Department, tel. 0115 911 3363 or e-mail
training@nas.org.uk.
ollowing the Calman-Hine Reports
standards for patient-centred deliv-
ery of cancer services (1994), we have
seen a shift in organisation and deliv-
ery, including centralisation to cancer
centres or units. This allows patients
to have access to multidisciplinary
teams with knowledge, expertise and experience
in specific cancers. The downside
is that patients may have to travel
considerable distances, especially
where there is a need for ongoing
rehabilitation.
Head and neck cancer patients
often need to attend speech and
language therapy for communica-
tion and swallowing difficulties
resulting from their treatments.
Because of the distances involved,
responsibility is often devolved to
the local community therapist.
All speech and language thera-
pists working with adults with
dysphagia are required to have
post-graduate training. For the majority this is at
a post-registration level, as relatively few go on to
the Advanced level (RCSLT, 1999). It is likely that
their training is largely neurologically based,
competences
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 (
reflecting most caseloads, but to what extent
does this prepare them to treat dysphagia in head
and neck cancer patients?
In 1999 the RCSLT Education Committee
Dysphagia Working Group published recommen-
dations as to the necessary knowledge base and
skills level for pre-registration, post-registration
and advanced level dysphagia education. Figure 1
shows my interpretation of how this applies to
patients with head and neck cancer.
Figure 1 Expected competence
No. of speech Level of Expected competence
and language training (dysphagia associated with
therapists head and neck cancer)
All Pre- Good knowledge of normal
registration anatomy and physiology
of the head and neck,
and of the normal swallow.
All of those Post- Knowledge of the needs of
working with registration clients with complex with
adult dysphagia conditions.
Relatively few Advanced Ability to manage clients
of those post- with complex conditions.
working with registration
adults with
dysphagia
While there is a wealth of literature on the
effects of surgery and radiotherapy on the swal-
lowing process, there is relatively little about
speech and language therapy intervention and
even less on the level of expertise or experience
on which that intervention should be based. The
BAO-HNS Consensus Document (2000), for exam-
ple, in its chapter on speech and swallowing reha-
bilitation talks of team members having suffi-
cient post-qualification experience (as well as a
major clinical component in this field). The case
example in figure 2 (p.5) shows why it is impor-
tant that the therapist dealing with people with
head and neck cancer has knowledge of:
1) Staging of tumours
The first time I encountered the staging classifica-
tion of tumours (BAO-HNS, 2000) in medical
notes, it was a complete mystery. Although the
speech and language therapist is not involved in
the staging progress it is important
to have a clear understanding of the
implications in terms of the likely
surgery and prognosis, and of the
nature of cancer generally.
2) Pre-operative counselling
The head and neck client group is
unique in that the patient is seen first-
ly with a normal / functional (albeit
diseased) swallowing process, before
the sudden onset of dysphagia
brought about by surgery and / or
radiotherapy and / or chemotherapy.
Doyle (1999) states that pre-operative
counselling provides the single most
important dimension in patient care, therefore
therapists working with this client group need to
ensure they have the necessary skills.
Doyle (1999) talks about using the process of
l
When does a speech and
language therapist have
sufficient competency to
manage a client whose
difficulties fall outside the
remit of standard training?
Lorna Gamberini explores
this in relation to people
with dysphagia associated
with head and neck
cancer and finds that, as a
profession, we have much
to ponder.
you are nterested n
how tranng and
experence combne to
mprove competency
provdng servces to a
arge geographca area
mprovng the journey
rom acute to
communty servces
Read ths
When is good
enough?
Post-registration
training should
give a therapist
the tools, but
they may need
to be applied a
little differently
to this group than
to neurological
patients.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
competences
Figure 2 Case example
Pre-operatively
Mary (64), retired, married
A social drinker and ex-smoker. Year-long history sore throats (initial tonsil biopsy -
no significant abnormality)
New investigations found
- poorly differentiated squamous cell carcinoma
- a lesion within the left tonsillar fossa, extending anteriorly to the anterior pillar
and floor of mouth, and posteriorly to the posterior tonsillar pillar
- Classification: T2 N1 M0
Combined clinic (ENT surgeon, maxillo-facial surgeon, oncologist, speech and
language therapist, head and neck nurse)
Consented to extensive surgery with adjuvant radiotherapy
Pre-operative counselling with speech and language therapist and head and neck nurse.
Surgery
left selective neck dissection: level I-III
resection of tonsillar tumour, involving posterior pharyngeal wall and soft palate
mandibulectomy
radical forearm free flap
skin graft
tracheostomy.
Post-operatively (acute)
transferred to Intensive Treatment Unit with naso-gastric tube in situ, and cuffed no8
Shiley tracheostomy tube.
24 hours: ENT ward on intravenous fluids, cuff deflated on tracheostomy tube (speech and
language therapist contact for support; communicating effectively by writing and mouthing)
2 days: naso-gastric feeds
4 days: tracheostomy tube removed by surgeon
speech and language therapy assessment: left sided tongue weakness and loss of
sensation to the left side of tongue, lip and jaw. Trial swallows with fluids triggered
effectively; no obvious pharyngeal stage problems but some pooling of fluid on the
left. Recommended trial of free fluids, with postural modification to aid transit of bolus.
5 days: managing fluids well. Assessed on smooth, semi-solid consistency, some
pocketing in the left sulcus, remedied by postural modification. Oral transit slow, but no
pharyngeal stage problems. Naso-gastric tube removed; started on liquidised diet.
6 days: managing fluids well and tolerating liquidised diet
8 days: discharged home into care of local therapist.
Post-operatively (community)
Week 2: Coping with free fluids (including fortified drinks) and smooth semi-solids.
Complying well with postural modifications.
After clearance from the surgeon, range of motion exercises introduced. Reiterated advice
re- range of motion exercises, particularly in lessening build up of fibrotic
tissue and discussed possible deterioration in swallow during radiotherapy.
Week 3: Radiotherapy started, continuing with range of motion exercises, oral intake
increased substantially.
Week 4: Tolerating radiotherapy. Some discomfort, but not interfering with oral intake.
Continuing exercises - managing without postural modification.
Week 5: Struggling with range of motion exercises - very painful. Fluids easiest (relying
heavily on dietary supplements). After discussion with head and neck nurse and
oncologist, prescribed Oromorph to help with pain and advised on strategies for coping
with dry mouth (xerostemia).
Weeks 6/7: Mary rather disheartened. Very particular about appearance and, although
oedema and suture lines as a result of the surgery tolerated, added disfigurement from
radiotherapy skin changes is proving difficult.
Some difficulty triggering swallow, fibrotic tissue in tongue base. Losing weight as oral
intake decreases. Candida and taste changes affecting appetite. Very tired from
radiotherapy. Reassured should see improvement in 2-3 weeks. Dietitian to contact again
to advise about food choices.
Week 8: Pain and oedema reduced. Candida cleared. Oral intake easier. Coping with
xerostemia well. Feels able to start range of motion exercises again - encouraged.
Week 10: Less pain. Appetite returning, despite continuing taste changes. Swallow
triggering faster. Does not need postural modification. Mary trialling new textures herself
and feeling much more optimistic about returning to pre-operative diet.
Four months post-operatively: Good progress. Range of motion exercises regularly, rapidly
putting weight back on. Able to eat most foods, even if modified form. Xerostemia and
taste changes persist.
pre-operative counselling for the therapist and
patient to set common goals for rehabilitation.
Logemann (1983) discusses the difficulty of initiating
therapy post-operatively with a patient who has
been unprepared for the problems of swallowing.
Although consent for surgery or radiotherapy is
obtained primarily by medical and surgical members
of the team, the speech and language therapist has
an important role in ensuring that the patient is
fully aware of the consequences for speech and
swallowing.
3) Tracheostomy tubes and their effect on
swallowing
Knowledge of the needs of clients with tra-
cheostomy is included in the Dysphagia Working
Groups recommendations for inclusion in post-
registration courses. Any patient who presents
with a compromised airway because of a head
and neck tumour may require a tracheostomy
(Ridley, 1999) Additionally, a tracheostomy may
be performed as a temporary measure until soft
tissue swelling has resolved post-operatively.
4) Swallowing assessment
Skill in selection and interpretation of swallowing
assessment procedures such as videofluoroscopy
and FEES (Fiberoptic Endoscopic Evaluation of
Swallowing) covers all client groups (RCSLT,
1999b). Here, however, to interpret the results of
any assessment accurately, the therapist must
have a very good understanding of the nature of
cancer, of the structural changes that have taken
place after surgery and of the effects of any con-
comitant treatment (Ridley, 1999).
5) Management of swallowing problems
Ability to use appropriate compensatory tech-
niques, exercises, positioning and change in consis-
tencies is a desired outcome of post-registration
training. Sullivan (1999) states that, for people with
head and neck cancer, therapy goals typically focus
on compensation rather than long-term improve-
ment of swallowing function. Post-registration
training should give a therapist the tools, but they
may need to be applied a little differently to this
group than to neurological patients.
6) Multidisciplinary team working
Post-registration courses aim to give speech and
language therapists knowledge of multidisciplinary
team working. The therapist is very much a core
member of the team providing an integrated service
to people with head and neck cancer, and has an
important role in raising awareness of swallowing
problems with the other team members.
7) Radiotherapy and its effects
Any therapist working with this client group needs to
be aware of potential treatment induced swallowing
problems, and prevention and therapy strategies.
The speech and language therapist has the best
knowledge of a patients swallowing status post-
operatively. She can therefore advise the team
Acknowledgement
With thanks to Linda Slack, Macmillan speech and
language therapist for North Cumbria who
looked after Mary at the acute stage.
References
British Association of Otolaryngologists - Head
and Neck Surgeons (2000) Effective Head and
Neck Management - Second Consensus
Document.
Burgess, L. (1994) Facing the reality of head and
neck cancer. Nursing Standard 8 (23): 30-34.
Calman, K. & Hine, D. (1995) A Policy Framework
for Commissioning Cancer Services. London:
Department of Health.
Doyle, P. (1999) Postlaryngectomy speech rehabil-
itation: contemporary considerations in clinical
care. Journal of Speech-Language Pathology and
Audiology 23 (3): 109-115.
Harris, C. (2001) Ahead and neck of the field.
Speech & Language Therapy in Practice. Autumn:
12-13.
Logemann, J. (1983) Evaluation and Treatment of
Swallowing Disorders. Pro-ed, Austin, Texas.
Ridley, M. (1999) Effects of surgery for head and
neck cancer. In Sullivan, P. & Guildford, A. (Eds)
Swallowing Intervention in Oncology. Singular
Publishing Group: San Diego/London.
Robinson, H.F. (1999) How I manage head and
neck cancer: Setting the standard. Speech &
Language Therapy in Practice. Autumn: 23-24.
Royal College of Speech & Language Therapists
(1996) Communicating Quality 2. RCSLT: London.
Royal College of Speech & Language Therapists
(1999a) Dysphagia Working Group:
Recommendations for Pre and Post-registration
Education and Training. RCSLT: London.
Royal College of Speech & Language Therapists
(1999b) Invasive Procedures Guidelines. RCSLT:
London.
Sullivan, P. (1999) Clinical Dysphagia Intervention.
In Sullivan, P. & Guildford, A. (Eds) Swallowing
Intervention in Oncology. Singular Publishing
Group: San Diego/London.
Williamson, K. (2000) The best things for the best
reasons. Bulletin of the Royal College of Speech &
Language Therapists. October.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003
competences
before the onset of radiotherapy or
chemotherapy as to any need for non-oral
nutrition once the treatment effects are
added to the effects of surgery. It is unlikely
that this specialised and highly important
knowledge would be included in general
training.
8) Body image
Both head and neck cancer and the treat-
ments for it can affect an individuals
appearance. Burgess (1994) includes not only phys-
ical change but also change in bodily function or
control of the bodys activities, and the speech and
language therapist needs to have an awareness of
the possible psychological implications.
Writing about the background to the RCSLT
Competencies Project, Williamson (2000) states
that: Although some skills and knowledge are
core to speech and language therapy profession-
alism, their profile and depth will vary according
to particular clients demands, contexts and ther-
apists responsibilities. On its own, attendance at
a dysphagia course does not make a therapist
competent. A therapist who has attended a post-
registration course, and has much clinical experi-
ence, can easily be as competent to treat dyspha-
gia in a head and neck patient as someone like me
who attended an Advanced course, but had rela-
tively little clinical experience. Experience may
come about by direct patient contact, or simply
from working with the multidisciplinary team. In
attending the Combined Clinic each week, I
learned a significant amount about the whole
spectrum of head and neck care - prevention,
recurrence, palliative care, carotid blow out for
example - all of which informed my practice.
Communicating Quality 2 (RCSLT, 1996) states that
therapists working with this client group tend to
learn by experience.
In outlining the content of dysphagia courses,
the Dysphagia Working Group makes it clear that,
while a therapist completing the course would be
expected to be able to work without supervision,
the ability to know when to ask for support
would mean the therapist is working competent-
ly. What may be problematic is ensuring that that
support is available.
The literature suggests that speech and lan-
guage therapy intervention for this client group is
optimally delivered by therapists with specific
responsibilities for head and neck cancer (RCSLT,
1996; Ridley, 1999; BAO-HNS, 2000), who will be
part of multidisciplinary teams working in cancer
centres. If the therapist linked to a particular centre
has the ability to be peripatetic, this may not be a
problem. However, if geographical or time con-
straints prevent this, there is a dilemma as to
whether the patient will travel for rehabilitation, or
be seen by the local speech and language therapist.
Would a local therapist, without specialist training
or specific clinical experience be appropriately
qualified, and would they be able to deliver high
quality, safe and effective treat-
ment (Calman & Hine, 1994)? I
believe the answer is possi-
bly. I cannot be more positive
due to uncertainty over the
amount of support the thera-
pist would receive. Issues of
competence and asking for sup-
port do not take account of fac-
tors such as Trust boundaries,
geography and politics, which
can hamper communication between therapists
and the contact that is needed to provide appro-
priate support. Harris (2001) describes a clinical
liaison group set up to improve communication
between professionals, vital when patients are
travelling across Trusts.
At the acute stage, there should be support from
the other members of the multidisciplinary team,
whereas a community therapist may be working in
isolation, and dealing with the head and neck can-
cer patient at what is often the most traumatic
time. Discharge home can bring about a stark reali-
sation of problems they have to overcome. The
swallowing problem may take on more significance
when the choice is no longer from a hospital menu
and the social aspect of eating comes to the fore,
and all this at a time when further treatment may
start and worsen the dysphagia.
General dysphagia training gives therapists a
good basic grounding in managing dysphagia in
head and neck cancer patients. If there are very
good support systems in place, it is possible that a
generally trained therapist could successfully
manage the dysphagia. However, there are still
aspects of care, such as pre-operative counselling,
that are so important to the outcome of the reha-
bilitation that they should remain within the
remit of a therapist with specific responsibilities
to this client group.
Robinson (1999) reports on the drawing up of the
Head and Neck Oncology Consensus document,
and the fact that some of the objectives were
unachievable in certain areas because of issues such
as geography. Despite this, they were included
because, ultimately, they were good practice, and
could be used to help highlight deficiencies in local
service provision. This process needs to continue to
ensure parity of service for head and neck cancer
patients, no matter where they live.
I am not sure if it is possible to quantify the level
of expertise and training required to work with this
client group, but it is an area that the profession
needs to explore. For the sake of career progression,
continuing professional development and ultimate-
ly patient care, it would be helpful to have some
way of gauging when ones experience is sufficient.
Lorna Gamberini is a speech and language thera-
pist who works with ENT clients for Morecambe
Bay Primary Care Trust. This article is based on the
essay component of the Advanced Dysphagia
Course (Head & Neck Module) which was written
while Lorna worked for West Cumbria Primary
Care Trust.
Issues of
competence
and asking for
support do not
take account
of factors such
as Trust
boundaries,
geography
and politics
Do l recognse when to ask or
support, and do l know where
to get t'
Do l see myse as an
ndvdua or part o a network
o servce provson'
Do l expand my knowedge
through nvovement n
mutdscpnary ventures'
Reectons
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 ;
urther readng
lURTHER
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journas whch
may be o nterest
to readers.
The Edtor has
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summares rom a
Speech 8 language
Database comped
by Bomedca
Research lndexng.
Every artce n
over thrty journas
s abstracted or
ths database,
suppemented by a
monthy scan o
Medline to pck
out reevant
artces rom others.
To subscrbe to the
Index to Recent
Literature on
Speech & Language
contact
hrstopher Norrs,
Downe, Badersby,
Thrsk, North
Yorkshre YO; (PP,
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VOlE
Laccourreye, O., Papon, J-F., Kania, R., Crevier-
Buchman, L., Brasnu, D. & Hans, S. (2003)
Intracordal injection of autologous fat in patients
with unilateral laryngeal nerve paralysis: long-
term results from the patients perspective
(review). Laryngoscope 113 (3): 541-5.
OBJECTIVE: Based on 80 patients with a previously
nonsurgically treated unilateral laryngeal nerve
paralysis (ULNP) and according to the patients self-
assessment, the authors document the long-term
results achieved with the intracordal injection of
autologous fat. STUDY DESIGN: Retrospective series,
inception cohort. METHODS: Kaplan-Meier actuarial
life table method and univariate analysis. RESULTS:
None of the 80 patients died in the immediate post-
operative period. Morbidity included haematoma at
the donor site (in three patients), development of an
intracordal cyst at the injection site (in three
patients), fat extrusion at the injection site (in one
patient), and temporary tracheotomy (in one
patient). The initial and ultimate overall success rates
were 96.2% and 77.2%, respectively. In univariate
analysis, none of the variables under analysis (gender,
age, associated neurological lesions, associated pneu-
monectomy, associated neoplasia, cause of the ULNP,
side of the ULNP, nerve involved, delay between the
onset of the ULNP and the intracordal injection,
severity of the symptoms, mode of harvesting the
autologous fat, and surgeon who performed the
injection) was statistically related to the ultimate
outcome after the intracordal injection of autologous
fat. Among the group of 45 patients in whom the
intracordal injection was initially considered to be
successful with no further recovery of motion of the
true vocal cord and a minimum survival of 12
months, the ultimate overall success rate was 62.2%,
and the 3-month, 6-month, and 12-month Kaplan-
Meier actuarial estimates for success were 91.1%,
72.8%, and 63.1%, respectively. CONCLUSIONS: In
the present study, data confirm that the intracordal
injection of autologous fat is a useful and safe procedure
in patients with ULNP. However, the impossibility of
exactly predicting the amount of resorption of the
injected fat and the lack of predictability of the duration
of the results, together with the good and stable results
achieved at the authors department with the medi-
alization thyroplasty led the authors to reduce its
current use. (23 References)
HllD lANGUAGE
Widen, S.C. & Russell, J.A. (2003) A closer look
at preschoolers freely produced labels for
facial expressions. Dev Psychol 39 (1): 114-28.
Childrens performance on free labelling of proto-
typical facial expressions of basic emotions is modest
and improves only gradually. In 3 data sets (N = 80,
ages 4 or 5 years; N = 160, ages 2 to 5 years; N = 80,
ages 3 to 4 years), errors remained even when
method factors (poor stimuli, unavailability of an
appropriate label, or the difficulty of a production
task) were controlled. Childrens use of emotion
labels increased with age in a systematic order:
Happy, angry, and sad emerged early and in that
order, were more accessible, and were applied
broadly (overgeneralised) but systematically. Scared,
surprised, and disgusted emerged later and often in
that order, were less accessible, and were applied
narrowly.
ARTlUlATlON
Hohoff, A., Seifert, E., Fillion, D., Stamm, T., Heinecke, A. & Ehmer,
U. (2003) Speech performance in lingual orthodontic patients
measured by sonagraphy and auditive analysis. Am J Orthod
Dentofacial Orthop 123 (2): 146-52.
Aesthetically appealing, externally invisible, lingually applied orthodontic
brackets are in increasing demand. Because the brackets are placed lin-
gually, however, they appear to cause some problems with respect to
speech. This study is the first to present a prospective evaluation of the
articulation of 23 patients with lingual brackets by means of an innovative
combination of test methods. An acoustic, objective evaluation of articulation
measured by digital sonagraphy was related to a semiobjective auditive
evaluation by 10 speech professionals, to a semiobjective auditive evaluation
by close contacts of the patients, and to a subjective auditive evaluation by
the patients themselves, the latter 2 using standardised questionnaires.
The tests were performed before (T1), within 24 hours after (T2), and 3
months (+/- 1 week) after (T3) the start of therapy. In comparison with
the initial findings, a significant deterioration in articulation was recorded
with all test methods at T2 and T3. Using a new combination of methods,
our investigations show the need for detailed briefing of patients about
the extent and duration of changes in speech resulting from lingual
brackets.
HEAD lNJURY
Dunn, L.T., Fitzpatrick, M.O., Beard, D. & Henry, J.M. (2003) Patients with
a head injury who talk and die in the 1990s. J Trauma 54 (3): 497-502.
BACKGROUND: Patients who talk and die after head injury may repre-
sent a group who suffer delayed and therefore potentially preventable
complications after injury. We have compared the clinical and pathologic
features of patients who talk and die with those who talk and live after
head injury. METHODS: Data collected prospectively by the Scottish
Trauma Audit Group were used to identify patients with a head injury
and classify them according to verbal response at admission to hospital.
All talking patients in the catchment area of a regional neurosurgical
centre were selected and those who died were compared with those who
survived. RESULTS: Seven hundred eighty-nine talking patients were identified.
Seven hundred twenty-seven patients survived and 62 died. Patients who
talked and died were older, had more severe extracranial injuries, had
lower consciousness levels, and reached theatre more quickly than those
who talked and lived. Thirty-one of the patients that died had extra-axial
haematomas. CONCLUSION: Even with increased availability of computed
tomographic scanning, some patients still talk and die after head injury.
HUNTlNGTONS DlSEASE
Bilney, B., Morris, M.E. & Perry, A. (2003) Effectiveness of physio-
therapy, occupational therapy, and speech pathology for people
with Huntingtons disease: a systematic review. Neurorehabil
Neural Repair 17 (1): 12-24.
This review provides a summary of the current literature examining the
outcomes of physiotherapy, occupational therapy, and speech pathology
interventions for people with Huntingtons disease. The literature was
retrieved via a systematic search using a combination of key words that
included Huntingtons disease, physiotherapy, occupational therapy, and
speech pathology. The electronic databases for Medline, Embase, CINAHL,
Cochrane Controlled Trials Register, and PEDro were searched up to May
2002. Articles meeting the review criteria were graded for study type and
rated for quality using checklists to assess study validity and methodology.
The majority of articles that examined therapy outcomes for people with
Huntingtons disease were derived from observational studies of low
methodological quality. A low level of evidence exists to support the use
of physiotherapy for addressing impairments of balance, muscle strength,
and flexibility. There was a small amount of evidence to support the use
of speech pathology for the management of eating and swallowing dis-
orders. The current evidence is insufficient to make strong recommendations
regarding the usefulness of physiotherapy, occupational therapy, or
speech pathology for people with Huntingtons disease. There is further
need for therapy outcomes research in Huntingtons disease so that clinicians
may use evidence-based practice to assist clinical decision making. (80
References).
tranng
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 8
Basic strategies
Swallowing......on a plate (OLoughlin & Shanley, 1996)
is an Australian dysphagiamanagement (training) pro-
gramme designed for use in nursing homes so that,
following training, nursing home staff would be able
to provide basic assessment and management strate-
gies for their patients. It provides information about
swallowing problems and their management in
user-friendly handouts and information sheets. It
introduces specific forms and protocols that provide
a model to help implementation of the package
within the home. Five modules cover the following
topics: understanding the swallowing process; the
assessment and management of swallowing prob-
lems; implementation of the SOAP programme in
the nursing home; supplementary information and
resources. The modules are designed to be taught
to other staff by an experienced registered nurse.
SOAP includes four instruments:
1. a prefeeding checklist (swallowing screening tool);
2. swallowing assessment checklist (observation at
mealtime, noting consistency of food and drink,
position of client, level of dependence and
obviously presence of swallowing problems);
3. swallowing management index (details of possible
problems and related strategies such as feeding
techniques to aid lip closure) and
4. swallowing care plan. Importantly the care plan
provides details of supervision required, special
procedures necessary, positioning - location and
posture, equipment required and client-specific
advice gained from the swallowing management
index (see figure 1, p.9).
A pilot SOAP project within a Renfrewshire NHS
continuing care hospital is reported fully else-
where (Bain, 2003) so we will summarise it here
before we compare it to one
undertaken in Tayside.
Renfrewshire is a mixed urban and
rural community situated southwest
of Glasgow with approximately
30,000 people over the age of 65
years. A very limited specialist com-
munity / domiciliary speech and
language therapy service of assess-
ment and advice (with no review)
for clients over 65 years with swal-
lowing problems is available. It is
therefore necessary to consider
any model of care that will max-
imise the effectiveness of this limited service.
The essential features of the Renfrewshire project
were the introduction of a new model of care which
ensured that, following the training and implemen-
tation period, regular speech and language therapy
review of clients could be achieved. Rather than
relying on self-directed study, all nursing staff
(including auxiliaries / nursing assistants) in a long
you want to
ncrease knowedge
and change workng
practces
provde cear and
supported care
pathways
prove ong-term
eectveness
Read ths
his article is not about infection con-
trol, but a training package called
Swallowing......on a plate (SOAP for
short). Our two Scottish speech and
language therapy services coinciden-
tally and simultaneously piloted this
package in markedly different ways and we thought
it would be useful to compare them. Importantly, we
found that, even though it is slow and difficult to
achieve successful new multidisciplinary working,
this model of care can be used and adapted to dif-
ferent environments.
So, why is such a package needed? Dysphagia is
recognised in the literature and in clinical experi-
ence as a widespread problem in the long-term
care settings of residential and (especially) nursing
homes as well as in continuing care wards for
older people (Smithard, 1996; Steele et al, 1997;
Kayser-Jones & Pengilly, 1999). Management of
swallowing difficulties may however not be part of
the training or knowledge-base of staff
in these institutions and so residents
and clients with dysphagia may be
experiencing unnecessary malnutrition,
dehydration, chest infections and
problems taking medication among
other side-effects of inadequately
managed dysphagia, including acute
hospital admissions.
Specialist speech and language
therapy and dietetic services to these
locations are often restricted by
resource limitations. One solution to
this problem has been to provide
training to staff in swallowing and dysphagia
management. Speech and language therapy
training programmes however have been devel-
oped locally and mainly for hospital settings
(acute wards and stroke units), without validity
and reliability being established (Gravill, 1999;
Magnus, 2001). Long-term effectiveness is rarely
reported.
T
We included a
control home so
that measures
devised for the
project could be
assessed for
test-retest
reliability.
The need
When Linda Armstrong and
Alison Bain found out they were
piloting the same off-the-shelf
package, they were naturally
interested to compare methods
and results. Swallowing......on a
plate (SOAP) may benefit people
with dysphagia, but the principles
are relevant to any client group
where the aim is to train other
professionals in basic assessment
and management.
Linda Armstrong
stay hospital received training (either one or two
sessions) over eight consecutive days. Link nurses
were identified to screen clients for swallowing
problems and develop care plans for managing their
dysphagia. The speech and language therapist
assessed the appropriateness of each care plan and
monitored each identified client fortnightly over the
six month pilot period. Assessment of the effective-
ness of the training was measured in terms of
increased staff knowledge and more appropriate
feeding behaviour (as deemed by observation of
mealtimes by the speech and language therapist).
Effects of training
The aim of the project undertaken in rural Tayside
was to evaluate the short- and longer-term effects
of in-service training on acquired dysphagia with
residential and nursing home staff using a published
training package. The project objectives were:
to evaluate SOAP as a training package for local use
to evaluate the effectiveness of SOAP in increasing
knowledge and changing working practices
and so to improve the quality of care for people
with acquired neurological swallowing problems.
The project focused on the two residential and two
nursing homes in the catchment area for GPs based
in one of the five geographical localities of Perth
and Kinross Local Health and Social Care Co-opera-
tive (LHSCC). The local community hospital was also
initially included, as there was an identified training
need which had not been met as part of the rolling
community hospital training programme (because
of staff shortage in the hospital). Its client popula-
tion is more transient than that of the homes and it
has a different balance of trained and untrained
staff. However, the SOAP training package and its
protocols appeared possibly to be applicable also in
the hospital setting. In addition we reckoned that, if
both the community hospital and the homes in the
locality were using the same method of identifying
and managing swallowing problems, transfer of
information about individual people in either direc-
tion would be expedited. We also included a control
home in another locality, so that measures devised
for the project could be assessed for test-retest reli-
ability. For this home, the initial day-long training
was offered following two baseline assessments.
We used a number of outcome measures pre- and
post-training to examine the short- and long-term
effectiveness of the programme. These were: com-
parison of referral / re-referral rate and quality of
referral (speech and language therapy and dietetics);
resident profiles and swallowing environment obser-
vations (nutrition checklist, swallowing environment
checklist); a food / fluid customer satisfaction ques-
tionnaire; SOAP knowledge quiz and training day
evaluation sheets. At the end of the project, we sent
a short questionnaire to home managers / matrons.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 ,
tranng
for SOAP
Figure 1 Sample Care Plan
Background:
Step 1: Prefeeding Assessment Checklist
May lead to either Nil-by-mouth / onward referral or Step 2: Swallowing Assessment Checklist
Refer to solutions in Swallowing Management Index and develop Step 4: Swallowing Care Plan
Case history:
This case history is taken from the SOAP Manual (p48)
Mrs White had a right CVA three years ago. She has a left facial droop, slurred speech and has no dentures. She sometimes
coughs with thin fluids, takes a long time to eat her meals, is losing weight and has difficulty swallowing her medication.
She often slips down in her chair, and pockets food in her mouth.
SOAP step 4:
Swallowing Care Plan (See SOAP Manual, p51)
Devised by Grainne OLoughlin & Chris Shanley 1996
USE: To be filled out by a registered nurse and reviewed as necessary. To be used by all persons feeding or super-
vising a resident at mealtimes, as a guideline for safe swallowing.
Residents Name: .
(Please tick any boxes that apply)
DIET
Diet consistency:
Normal
Soft
Minced & Mashed
Puree
Diabetic Diet: Yes No Other Special Diet:
PREFEEDING
Supervision:
Needs to be fed
Needs to be supervised
Doesnt need supervision
Comments:
POSITIONING
Location for mealtime:
Upright in bed
Upright in chair
At dining table
Comments:
EQUIPMENT
Adapted cutlery Plate guard Cut-out cup
Straw for drinks Spouted cup Clothing protection
Other equipment
Comments:
SPECIFIC ASSISTANCE FOR RESIDENT
Please insert specific instructions needed to assist this resident.
(Use the information from the Swallowing Management Index)
. , , ,
, . ,
, . , ,
' . , ,
STOP FEEDING if resident is drowsy, coughing, choking or aspirating.
Staff to be aware of procedure in event of choking.
Signed
Date
1996 Centre for Education & Research on Ageing and Inner West Geriatrics & Rehabilitation Service. Reproduced with permission.
Fluid Consistency:
Thin
Thick
Very thick
Administration of Medications:
Give as normal
Liquid form only
Crush and mix with puree
Special Instructions
Additional requirements:
Dentures
Glasses
Hearing Aid
Special procedures:
Suction on standby
To be fed by specified staff only
Posture for feeding:
Keep head in midline
Cushion/pillow for support:
- behind head
- behind back
- under arm L / R
tranng
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +o
Do l seek out exstng o-the-
she packages beore spendng
tme deveopng my own'
Do l network wth other speech
and anguage therapsts to
compare methods and resuts'
Do l pan how l w assess
reabty, vadty and ong-term
eectveness o a project'
Reectons
Response to the project varied among the care
homes and the hospital (see table 1). Two baseline
measures were taken at the control home but two
planned training days were cancelled by this home
because of staffing problems; staff shortage was
given as the reason at the community hospital too.
The referral rate to speech and language thera-
py and dietetics did not increase post-training.
Resident profiles (describing swallowing prob-
lems and their management) pre- and post-train-
ing depended on the member of staff reporting -
there was little reliability. Swallowing environ-
ments in the residential homes were very positive.
In the nursing homes, post-training improvement
was seen in one (NH1) but not the other (NH2,
whose commitment to the project appeared to
peter out). In the control home, no change was
noted from the first baseline measure to the sec-
ond. Satisfaction among a sample of residents
varied among the homes. Participants at the
training day showed a significant improvement in
knowledge immediately post-training. This
improvement was sustained over six months by
the staff who attended the follow-up half-day
(several of the participants had left by then).
There are several implications for the use of
SOAP in care homes:
This package can promote increased knowledge
about dysphagia and change in working practice
and should be rolled out on an ongoing basis to
other homes in the Local Health and Social Care
Co-operative.
Small changes are needed to reflect UK
circumstances (for example, food items and
vocabulary).
Responses among the homes varied. Perhaps in
future homes that are willing to commit to change
(if necessary) and able to give staff protected
time should be targeted.
Another way forward would be the development
of a dedicated team of allied health professionals
for residential and nursing homes. The remit of
this team would include both ongoing training
and assessment / management of residents
chronic problems. A model for this exists in
Glasgow (Scott, 1999).
Used quite differently
SOAP was used quite differently in the two pro-
jects (see summary in table 2). The composition of
project staff in the two areas shows that either
one person or a team can run a training project.
There was also variation in planning time, with
protracted discussions required in Renfrewshire
and a much shorter lead-in time in Tayside. In
both projects we trained staff looking after older
people in institutions where turnover of clients /
residents is likely to be slow, but where the same
cannot necessarily be said for staff turnover. The
number of staff trained was very different. The
model used in Renfrewshire is our preferred one,
in which all staff received training. In Tayside the
range of staff grades and experience was prob-
lematic in terms of generalisation of the training
to the homes. Training time was longer in Tayside
than in Renfrewshire but the model of care in
Renfrewshire was introduced in the continuing
care hospital rather than in any care homes.
The Tayside project included a wider range of
outcome measures, most of which were developed
specifically, for example customer satisfaction ratings
and quality and rate of referrals. Three of the
homes changed working practice after their train-
ing as measured by observation of swallowing
environment and feeding practices at mealtimes;
however the changes were much less widespread
than those achieved by the blanket training in the
continuing care hospital. There it was noted that
length and quality of mealtimes had improved,
and that appropriateness of feeding strategies had
improved significantly. Importantly, the speech and
language therapist was able to monitor clients reg-
ularly and thus, we feel, provided a more effective
speech and language therapy service as a result of
implementing the SOAP model.
So, would we use the SOAP training package
again? YES.
And do we recommend it for use either in care
homes or long stay hospitals? YES.
Linda Armstrong is a speech and language therapist
working for Perth & Kinross LHSCC, NHS Tayside,
e-mail linda.armstrong.slt@tpct.scot.nhs.uk and Alison
Bain a speech and language therapist with NHS Argyll
and Clyde at New Sneddon Street, Paisley (contact via
e-mail Wendy.Toner@renver-pct.scot.nhs.uk).
References
Bain, A. (2003) Swallowing on a plate. Bulletin of
the Royal College of Speech and Language
Therapists. May.
coaboraton
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +
Figure 1 Sample session plan and homework sheet
Session 4: Telling Stories
Preparation:
You will need pictures of scenes (such as a family at the beach; children going shopping) and
problems (for example a child who has lost something or fallen over). You will also need the
picture cues for the different stages in the story plan.
Session Plan:
Revise Homework: Ask students what are the three things they need to remember to follow
instructions (look, listen, repeat). (1 min)
Setting/Beginning: Revise that when questions are about time (have a picture of a clock),
who questions are about people (have a picture of people) and, where questions are about
place (have a picture of a house). Show the pictures of different scenes, and ask the children
to make up when, who and where (for example, One hot day, mum, dad and Sam were
at the beach.) If when is not clear, then just use One day. For the first 1-2 pictures, think
up the setting as a group. Then give each child a picture of a scene, and ask them to make
up the setting (when, who and where). (5 mins)
Problem and Ending: Show the children pictures of different problems, and ask them to
explain what the problem is, think how the characters would feel in these situations, and two
or three things that they could do to solve the problem. For younger children it is fine if they
can only think of one solution, but older children should be able to think of at least two
possible solutions. As above, do the first 1-2 pictures as a group, and then give each of the
children a different picture to discuss the problem. If the child can only think of one solution
to the problem, ask the rest of the group if they can think of any other ideas. Once a number
of solutions have been suggested, ask the child to choose one as the ending, and then
explain how the characters would have felt in the end. (8 mins).
Children make up a story to do with the class topic: Ask the children to think of a story that
fits in with the class topic. Use the same prompts as above to generate a setting, problem
and ending. For example, if the topic is Ancient Egypt, the setting could be Thousands of
years ago, a pharaoh and his slaves were living in Egypt, and then the children can continue
the story by thinking of a problem that the pharaoh could have. Sometimes the children
need to be led through the different solutions by the adult saying First the pharaoh tried....,
but...., then the pharaoh tried ....., but ..... In the end...... (6 mins).
Children act out the story: Give each child a different role in the story, and they can act it
out. If there is time, you can switch the roles over and act it out again. (5 mins)
Children retell the story in their own words: Use the picture cues to help them remember all
the important stages in the story; perhaps each child could take a section (e.g. first child
setting, second child problem etc.). (5 mins)
(Note: Story plan is adapted from Speech Pathology, Liverpool Health Service, Sydney).
figure 1.
Teaching assistants participated fully in the ses-
sions by preparing materials, observing my
demonstration of activities, then implementing
the activities with the children themselves, and
taking notes on the childrens abilities in the dif-
ferent tasks. All schools were provided with a
written information package so that they could
run the same groups independently in the future.
3. Speech sounds
Children needing phonology therapy were seen
either in small groups or individually. A teaching
assistant jointly ran each session with me, and
brought toys and activities available in school to
provide motivation.
4. Workshops for teachers, teaching
assistants and parents
School staff and parents were invited to attend a
one hour workshop on working with children with
speech and language difficulties. Five out of the
eight schools chose to hold workshops. Some schools
preferred joint parent and staff training, while the oth-
ers decided to have separate sessions for parents and
staff. The number of participants in each workshop
ranged from about six to more than twenty.
5. Providing experience for more recently
qualified therapists
The mainstream school team was keen to encour-
age more recently qualified therapists to consider
working in schools. Therapists were therefore invit-
ed to spend five days working on the project in one
school, and three chose to participate. An infor-
mation package included advice on assessing
school-aged children, writing reports and prepar-
ing programmes. A resource file contained infor-
mation on expected speech and language develop-
ment in school-aged children, programmes for dif-
ferent areas of language, speech and fluency, and
pre-prepared training packages for delivering
workshops to school staff and parents.
6. Reports
At the end of the weekly visits, each child received
a report using a standard format to explain the
group sessions and provide further ideas for
helping children at home and in school.
At the end of the programme, special educa-
tional needs co-ordinators and the more recently
qualified therapists completed a questionnaire to
provide feedback about the project. Their com-
ments are summarised in figure 2.
One day hands-on workshop
After the success of the first two terms of the pilot
project, we decided to extend the training to
other schools in the area. To involve as many
schools as possible, the training was condensed to
a one day hands-on workshop held at each par-
ticipating school. Ten schools chose to be involved.
All schools identified at least one teaching assistant
who would attend all day, so that they could under-
stand how the programme worked as a whole.
Some schools then chose to send different teaching
assistants to each session, or else to have three to
four teaching assistants who attended all sessions.
After initially observing the therapist, the teaching
Language Group Homework
Session 4: Telling Stories
Today we have been working on telling stories. Here is a story plan to help your child tell stories
with you at home, or if they have to prepare a story in class.
If your child has difficulty with writing stories, then they can start by just putting 1-2 key words in
each of the boxes. If necessary, later they can expand these key words to make full sentences.
WHEN did the story happen?
WHO was in the story?
WHERE were they?
What was the PROBLEM?
How did they FEEL?
How did they try to FIX the problem?
(Think of 2-3 possible solutions)
How did the story END?
How did they FEEL?
Manchester Metropolitan University: Manchester.
Manz, J. (2000) Positive teamwork. Bulletin of the Royal
College of Speech and Language Therapists, March.
Portch, A. & Harrison, P. (2002) Clarifying priorities.
Bulletin of the Royal College of Speech and
Language Therapists, March.
Pritchard Dodge, E., Andrews, M. & Andrews, J. (2000)
Communication and collaboration. In: Pritchard
Dodge, E. (Ed) The survival guide for school-based
speech-language pathologists. Singular: San Diego.
Withey, C. (2000) Developing language skills
through playscripts training course. Riverside
Community Health Care, London, 29 June 2000.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +
coaboraton
assistants were actively involved in carrying out the
activities themselves with the children and taking
notes. Each session ran with different children from
the school, as using the same group of children all
day would have been too tiring for them. One
topic was used for all sessions (school), but teach-
ing assistants were encouraged to think how to
adapt the activities for current topics in their own
classes. A sample timetable is in figure 3, although
specific times were adapted for individual schools.
Four recently qualified therapists and a speech
and language therapy student participated in the
training days. The therapists were provided with
the session plans beforehand, and chose to run
two of the group sessions. It was easier for them
to get time away from their regular work for just
one day rather than five days.
After the training days in the ten schools, 64
questionnaires with completed confidence ratings
were returned. Of these, 79 per cent reported
increased confidence in working with at least one
area of speech or language, while 47 per cent
reported increased confidence in three or more
areas. One of the speech and language therapists
involved volunteered to take on a caseload of
mainstream schools, while the others were planning
to incorporate the ideas into their current work.
The comments were generally very positive, and
the perceived benefits were similar to those reported
by the schools in the weekly version of the project.
The main criticism was from teaching assistants who
were only able to attend for one group session;
they would have liked to see how the other groups
worked, and to have had more practice with the
children. Another suggestion was having more
advice on other areas of communication, such as
social skills development. On a one day training
workshop, the special educational needs co-ordina-
tors had to make compromises in deciding how
many teaching assistants could be released from
classes during the day, and not all areas of speech
and language therapy could be covered.
Effective method
The Collaborating for Communication project has
been a very effective method of providing hands-
on training with real children so that teaching
assistants can run groups for students with speech
and language difficulties. It would be valuable to
extend the training to other schools in the area,
and follow up the schools involved to find out if
the groups are still running and if the strategies
are being used in class work. A second training
programme could also be developed to target
other areas of communication difficulty, such as
focusing further on speech sounds and phonemic
awareness, grammar, voice care for staff and stu-
dents, and social communication skills. Continuing
to develop our collaboration with teachers, teach-
ing assistants and parents will enable us to be
much more effective in implementing therapy for
students with speech and language difficulties.
Karen Heins is a speech and language therapist.
Copies of the Collaborating for Communication
training manual are available, with all the materials
needed to run the project, including notes for
presenters, strategies for getting teaching assis-
Figure 3 Sample timetable
9.10 Introduction: Expectations, confidence rating scale for working with speech and language
difficulties. Explanation of the days sessions, and how to run the groups with weekly sessions.
9.30 Language Group 1: Understanding stories
10.15 Break
10.30 Language Group 2: Building vocabulary
11.15 Language Group 3: Listening and following instructions
12.00 Lunch
1.00 Language Group 4: Telling stories
1.45 Working with speech sounds: Therapy activities for one child with a phonology programme.
2.15 Question and answer session: Adapting groups for future use, confidence ratings
after the day, feedback.
tants actively involved, session plans for language
groups, visual cue sheets, homework, and stan-
dard report and letter formats. Please contact
Karen at 34 Op der Sterz, Fentange L-5823,
Luxembourg, e-mail karen.heins@pt.lu.
Acknowledgements
Many thanks to all the speech and language therapists
and schools who participated in the project for
their enthusiasm, commitment, advice and sugges-
tions. Thanks in particular to Kat McKeown,
speech and language therapist, for her sugges-
tions in the initial development of the project, to
Louise Ring, speech and language therapist, for
the child report format, to Jackie Charlton, speech
and language therapist, for the confidence rating
scale, and to Rachel Meinertzhagen, teacher, who
developed the story plan bookmark.
References
RCSLT (1996) Communicating Quality 2. Professional
standards for speech and language therapists. Royal
College of Speech and Language Therapists: London.
Johnson, M. (1998) Functional Language in the
Classroom. Clinical Communication Material,
Do l try to act on eedback
receved about my servce'
Do l provde programmes that are
meanngu both to those
mpementng them and to my
cents'
Do l encourage recenty quaed
sta nto my partcuar ed'
Reectons
Figure 2 Comments about Collaborating for Communication
Key benefits reported by schools:
Practical demonstrations and participation
made more sense than on paper.
Improved confidence and skills in supporting
students with speech and language needs.
Children enjoyed sessions and groups allowed
all children on the caseload to be included.
Closer links with the speech and language
therapy department.
Strategies used in groups were extended to
the classroom.
Main disadvantages and suggested improvements
from the schools:
Timetabling and grouping children, withdrawing
teaching assistant support from classrooms and
finding space in the school to run the groups.
Teachers would have liked to be more
involved.
Less time for assessments of children, and the
concentrated support of a day a week over a
five week period reduced visits from speech
and language therapy for the rest of the year.
Perhaps children could attend language groups
during the holidays as they had in the past.
Future plans of the schools:
6/8 schools plan to continue the language
groups, as well as incorporating the ideas
into class work.
The other schools plan to use the strategies
within existing class work.
One school was creating an advice file for
working with speech and language difficulties.
A bookmark with the story plan was devised for
all students to keep with their reading books.
Key benefits reported by the more recently
qualified therapists:
Developed confidence in training teaching
assistants.
Many therapy ideas and useful resources.
Seeing how language therapy can encompass
National Curriculum areas, and be adapted
for future use by schools.
Useful for coping with large numbers on
the caseload.
Main disadvantages and suggested improvements
from the more recently qualified therapists:
Reduced time for therapists usual area of work,
and stretched them in another direction.
Project was general, with limited opportunity
to focus on more specific issues.
Teaching assistants would benefit from a
briefing meeting before the groups and then
another meeting in the last week for questions
and adapting the project for their own use.
A rating scale could measure the teaching
assistants confidence in working with children
with speech and language difficulties before
and after the project.
Future plans of the more recently qualified
therapists:
One therapist has decided to increase the
amount of school-based work in her caseload.
Another therapist was planning to run similar
groups in the schools she visits.
The third therapist will use the programmes
and advice when preparing reports for
school-aged students.
wnnng ways seres (+)
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +(
Susan came to me in a terrible
state, crying most of the time.
She had a job, which she had
applied for with great enthusi-
asm. Everything about it
appealed to her, and she
thought she would be able to
work to her strengths.
Unfortunately, the stress of
staying ahead of the job, juggling a busy home life
and operating alongside someone with a very dif-
ferent working style meant Susan had totally lost
sight of herself. Her self-esteem and self-confidence
were rock bottom. Interestingly enough, she didnt
look like she wasnt coping - but, although she
looked fabulous, she was falling apart inside.
When we are overwhelmed everything becomes a
challenge. My tactic with Susan was to get her to
tease out the big tangle of problems. To write them
all down and look at ways of tackling them one at a
time. We called solving the problems a project.
Suddenly our work had a purpose, with a beginning
and an end. Each challenge was graded with a level
of difficulty rating - 10 is unbearable, 1 isnt a prob-
lem at all. Then we set to, picking the challenges off
one at a time. One of the main things causing Susan
to be so frustrated was that her very best qualities
were not being put to good use. With time spent on
building her self-esteem she was able to approach
her boss and explain in a calm way that she was
unable to give of her best because of poor commu-
nication and poor organisation in the workplace.
Susan also reviewed how she looked on her work
colleague. We explored the reasons why this other
person behaved the way she did, and looked to
changing Susans attitude rather than expecting the
colleague to change. Eventually, Susan decided to
change her job but by that time was sure enough of
herself to go for the kind of workplace where she
would be able to contribute according to her skills.
Life Coaching is about transformation, from caterpillar
to butterfly. This might sound fanciful, but hold your
opinion just for a minute. People come to coaching
because they want to make changes in their lives. If peo-
ple just want to wander round the mulberry bush a few
times, only to be reassured that their problem really
does have no solution, then Im not the coach for them.
I always assume that the only person you can
change is yourself. When Viktor Frankl was impris-
oned in a concentration camp and had literally every-
thing taken away from him, he states that the only
thing he had any control over was his own attitude.
Managing director
I also believe that every challenge has a solution. It
might not be the obvious one but there will be one
and, through coaching, the client will find it. Through
coaching, people can discover the rules and values
that govern their lives. We all live by rules and values
but, if you dont actually know what they are, then
someone else is running your life. Coaching helps you
to be the managing director of your own life.
Sadly, we live in a competitive world. Our society
values those who win the race, get to the top of the
slippery pole of promotion, and elbow all difficulties
out of the way in order to gain that elusive thing -
success. However, the winning ways that this column
will be dedicated to are not necessarily those valued
by the vast majority of society. In my work, both in the
coaching and the counselling field, I endlessly meet
people who would seem to be successful but are
deeply unhappy because they eventually realise that,
if success means living in a state of stress and pretence,
staying ahead and not being themselves then,
although it might look like winning, it feels like losing.
Winners are people who recognise the boundless
potential in themselves and others. They see them-
selves and anyone that they deal with as wonderfully
unique. The most important thing to them is not
achievement, but being honest enough to be yourself
in all situations. As Shakespeare said in Hamlet,
This above all: to thine own self be true, And it
must follow, as the night the day, Thou canst not
then be false to any man.
From caterpillar to
butterfly
you want to
work to your strengths
make changes n your e
nd soutons
Read ths
Life Coach Jo Middlemiss
believes that every challenge
has a solution and that,
ultimately, the only person
you can change is yourself.
If you feel ready for a
transformation, read on...
Once you decide to be a winner you can give up the
energy loss that goes into putting on a performance.
Winners need not fret about what other people are
thinking about them. They know the difference
between acting caring and being caring, acting the
fool and being a fool. If they know something, they
helpfully share it; if they dont know something, they
are not afraid to acknowledge that fact. Not hiding
behind a mask frees up a winner to step into their
own confidence. They have realistic views of their
own strengths and weaknesses. They are prepared to
listen to the opinions of others, but generally come
up with their own considered judgement about how
to behave. Winners do not play the victim role, nor
do they blame others for the situation in which they
find themselves. Wherever they are, they know deep
down that they are their own bosses. Winners get
their timing right. Their responses are appropriate.
They know about and acknowledge their emotions
as helpful signals. They love life and rejoice in their
own and others achievements. They are brave in the
face of setbacks and joyful about ordinary things.
Even when the world seems a terrible place, winners
do not see themselves as powerless. When Mother
Teresa was challenged that her work was but a drop
in the ocean, she quoted Armand Marquiset in reply:
The ocean is made up of drops. A winner works to
make the world a better place.
My guiding principles when working with a client are
firstly to believe in their unique magnificence, no matter
who they are, and secondly to get them to believe that
they only have to be better at being themselves. They
are already fine and good enough, but limiting beliefs
and behaviours may be holding them back.
How can we apply these two ideas to this winning
ways column?
To apply coaching techniques directly and specifically
to the speech and language situation.
To recognise that speech and language therapists
are people like everyone else.
Issues around promotions, interpersonal relationships,
work / life balance, physical / mental / spiritual
health can all be included plus a sharing of the trials
which seem to be unique to the profession.
I am learning about the huge range of your work
through preliminary discussions with speech and
language therapists. Your charges range from
preschool infants to elderly people who have had a
stroke. Your profession is sometimes misunderstood
as just about speaking when in fact it is about effec-
tive communication. Other challenges you face
include juggling caseloads, balancing work and life
and even seemingly minor ones such as carrying
equipment around.
As I go through back issues of Speech & Language
Therapy in Practice to read myself into the challenge
of writing for it, I am impressed with the high level of
ongoing professional development, not to mention
the wide range of situations in which therapists might
find themselves. Common to many of the articles is an
emphasis on inclusion for all and Valuing People,
but frustration can build when you feel your
employers dont value you as much as you value
your clients. In Unlocking the voice (Steven et al,
2002), I also saw many parallels with coaching. In
coaching we might say we are unlocking the voice
and also the heart. As Dr Bernie Segal says in his
wonderful book Love Medicine and Miracles,
...when you live in your heart magic happens.
Would you tell me, please, which way I ought to go
from here? That depends a good deal on where
you want to get to, said the Cat. I dont much care
where - said Alice. Then it doesnt matter which
way you go, said the Cat. - so long as I get some-
where Alice added as an explanation.
(From Alice in Wonderland by Lewis Carroll.)
Jo Middlemiss is a qualified Life Coach with a back-
ground in education and relationship counselling,
tel. 01356 648329, www.dreamzwork.co.uk.
References
Frankl, V. (1997) Mans Search for Meaning. Simon &
Schuster Inc.
Siegel, B.S. (1998) Love, Medicine and Miracles:
Lessons Learned about Self-Healing from a Surgeons
Experience with Exceptional Patients. Perennial.
Steven, L., Thompson, J. & Brown, D. (2002)
Unlocking the voice. Speech & Language Therapy in
Practice Autumn: 14-17.
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 new 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. However, we need your help to gather material
to make the issues - and their potential solutions - as
realistic and relevant as possible for readers.
Jo is therefore offering 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).
heres one l made earer
Alison Roberts continues to generate low-cost ideas
for flexible therapy activities.
Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +
Do l know the rues and vaues governng
my e'
Do l share what l know and acknowedge
what l dont'
Do l aow mtng bees and behavours
to hod me back'
Reectons
Materials
Card. Index cards, or half-size index cards.
Taskmasters blank cards would give a superior
effect (5.75 for 200, see www.taskmasteronline.co.uk).
As many pictures of car logos as you can get your
hands on. (Weekend newspaper colour supplements,
or other car magazines are good sources.)
Instead of car logos, you could use clothing logos
(Nike, Adidas and so on), or small pictures of
cosmetic items like nail varnish and shampoo, or
the ever popular chocolate bars. In fact you can
use anything that fits on your cards. Some
supermarkets produce good photos of food and
other items in their leaflet handouts, so this can
provide another source of free pictures.
Brawn
Learn or make a note of the car manufacturer
corresponding to each logo, or write on the cards.
Stick one logo on each card. Note: you can vary the
level of difficulty in picture pairing, choosing to show
either identical images, or perhaps the logo on one
card and an image of the car itself on the other.
In practice (I)
1. Place the cards face up on the table. The number
presented at a time is up to you, but I have found
it best to start with three pairs to convey the idea,
and then build up. (For some clients you may end
up with as many as 15 pairs on the table.) Turn
the cards over and muddle them up.
2. Turn two cards over. If they are a pair, the player
keeps them. If not, turn them over again.
3. Play passes to the next person. The winner is the
one with the most pairs.
In practice (II) (a version of Kims Game)
1. Place just one of each of the card pairs (so that all
the cards are different) face up on the table. The
number presented at a time is up to you. I have
found it best to start with three to convey the
idea, and then build up.
2. Turn the cards over and muddle them up. Take
away one card, hide it, and turn the others face up
again. The client must guess which one has gone.
3. You could of course take away more than one
card at a time.
Materials
one round biscuit tin, approximately 20cm
in diameter
three 2-metre lengths of strong nylon cord.
six rubber grommets, large enough for the
cord to pass through
treats!
Brawn
1. Drill six equally spaced holes around the side of
the tin, about halfway down the side, the diameter
of the inner core of the grommets.
2. Fit the grommets on the holes in the tin.
3. Tie the cords together in the middle, and thread
the ends through the grommets.
4. Tie knots in the ends of the cords to form handles.
In practice
1. Sit the participants in a circle on the floor, or
around a table, with the tin in the centre.
2. Each person should hold a rope.
3. Place six treats in the tin - in a bag is a hygienic
idea - and state that they may only take one treat,
and that they may only do so when the tin touches
them. (If your group has challenging behaviour, you
may need to restrict the number to one treat at a
time, and then top up after each turn.)
4. They are now allowed to pull on the ropes, but
they will soon find that the tin will only touch some-
one if everyone allows it to - that is, five people must
slacken their ropes while one person pulls.
Car logo pelmanism
, , , ,
Materials
Paper
Photocopier
Artistry
Place your, or your clients, hand on the platen of the
photocopier; close the lid and preferably cover with
a white cloth to exclude daylight. Take a photocopy
and then copy this several times once you are satisfied
with the image. Older teenagers seem to like to
photocopy their own hands. (If you have any Health
& Safety qualms about photocopying clients hands
then you can draw around their hands instead.)
In practice
Use the hand image to make an insightful and
esteem raising poster. Head the poster How I
help or As a friend I ...
Fill in a quality or two in each finger, or the
palm. You may need to add white stickers if
the palm is too dark on the photocopy.
Consider using the other copies for similar
posters, such as My strengths, My hobbies,
My favourite sports.
For a group setting you could cut out the hands
and stick them onto a larger sheet as if reaching
for each other.
How I help people poster
, , , ' ,
Cooperation tin
, , , , , , , ',
, ,, ' ,
, , ' ,
Heres one
I made earlier...
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 childs 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 childs speech and language needs and
whether they have an impact on the childs 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 childs
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 childs skills because of the
impact the childs difficulties have on their learning.
The combined effect of a therapist considering the
individual childs speech and language need, who is
Out of the
frying pan,
servce management
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003 +
you
make decsons about
where therapy shoud
take pace
work wth / through
other proessonas
have to prortse
resources
Read ths
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
therapists 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 +;
servce management
A communication book is a
simple, low-tech aid to commu-
nication either on its own or as
part of a range of augmenta-
tive communication methods.
Communication books are on a
continuum.
At one end of the continuum are resources
whose primary purpose is to provide listeners and
potential communication partners with back-
ground and day-to-day information about the
person (which might or might not be accessible to
the client). These include Personal
Communication Passports (Millar, 2003) and home
school / centre diaries.
In the middle ground are resources such as a sym-
bol diary, which provide some element of back-
ground information, and also a shared context for
conversation using text, photos, pictures and sym-
bols. Other examples are:
a scrapbook or Clue Book in which the writer
attaches objects of significance, such as a birthday
candle, shop receipt or cinema ticket, plus a
prompt to launch an appropriate conversation
path (Guess where we went on Saturday).
a more structured Conversation Book which
scripts exact questions for the communication
partner (Ask me where I went at the weekend;
Ask me where I like to go best) alongside the
symbols which will provide the answers.
a photograph album to stimulate conversation.
Captions or accompanying stories can be written
in symbols if that helps. (The easy-to-use new
Talking Photo Album (Liberator, 32) is a cheap
and cheerful way to turn photo albums into
communication aids.)
Towards the other end of the continuum are
resources used more independently for day-to-day
interactive communication. Displays can be of a
limited amount of vocabulary linked to one specific
setting or topic, or a full-scale vocabulary bank.
Symbols can be displayed in all sorts of ways,
including: laminated topic sheets (such as for use in
the importance of not neglecting these grammatical
features when he spontaneously generated this
novel message: Grandpa sore leg get (then he
selected the past participle key) got bandage. I
was so excited to hear this as he had only been pro-
vided with a symbol based electronic communica-
tion aid three months previously, when he was 3;11.
Abbot (2000) provides a useful overview of the
main reasons for using graphic symbols, such as
for accessing information, to support inclusion, to
aid comprehension, to develop literacy skills. It
can be helpful to ask yourself:
Why do I want to use the symbols?
What am I hoping to achieve?
Why am I introducing symbols in the first place?
In addition, you should consider:
What other graphic symbols systems are in use?
Look not just at the clients current school or
resource centre, but also at what is used in the
local environment and wider community.
What support is available?
Symbols become more functional if they are not
the preserve of the therapy cupboard! Look for
computer packages for writing, symbol games,
books with symbol support, using symbols in
email, symbolised websites.
Symbols are becoming more mainstream in our
increasingly visual, pictographic world. Graphic
symbols are on crisp packets, our computer
screens, clothes labels, by the side of roads, at air-
ports. Symbols can make a real difference for the
people we work with (see Walker & Keating
2000a and b; Trapnell & Chapman, 2002).
However, remember that the graphic symbol set
used is the language encoding system for its user -
how they think, how they work out what the world
means. Dont change or introduce a new system with-
out a lot of thought. Try to be consistent across all the
different things the person uses - computer program
for writing, the symbol set in their high-tech aid and
in their low-tech display. Apart from that, dont worry
too much about which symbol system to use. Just
choose one, and get out there and use it!
References
Abbott, C. (ed) (2000) Symbols Now. Widgit
Software Ltd.
Aitken, S. & Buultjens. M. (1992) Vision for Doing:
Assessing Functional Vision of Learners who are
Multiply Disabled. Moray House Publications,
Sensory Series No. 2.
Huer, M.B. (2000) Examining Perceptions of
Graphic Symbols Across Cultures: Preliminary Study
of the Impact of Culture/Ethnicity. Augmentative
and Alternative Communication 16 (3): 180-185.
MacDonald, A. (1998) Symbol Systems, in Wilson,
A. (ed.): Augmentative Communication in
Practice: an Introduction - revised edition. CALL
Centre, University of Edinburgh.
Phillips, J. (2001) The Culture of Community: Do par-
ents and speech and language therapists mean the
same thing when they talk about play? Paper pre-
sented at the XXV IALP World Congress, Montreal.
Rowland, C. & Schweigert, P. (1989) Tangible
Symbols: Symbolic Communication for Individuals
with Multisensory Impairments. Augmentative
and Alternative Communication 16 (2): 61-78.
Rowland, C. & Schweigert, P. (2000) Tangible
Symbols, Tangible Outcomes. Augmentative and
Alternative Communication 5 (4): 226-234.
Sutton, A., Soto, G. & Blockberger, S. (2002)
Grammatical Issues in Graphic Symbol
Communication. Augmentative and Alternative
Communication 18 (3): 192-204.
Trapnell, N. & Chapman, J. (2002) Reading with
Symbols at Frederick Holmes School.
Communication Matters 16 (1): 29-31.
Walker, L. & Keating, F. (2000a) Being Arrested.
Grampian Primary Care NHS Trust (for more infor-
mation contact Lynn Walker, Speech and Language
Therapy Department, Woodlands Hospital,
Craigton Road, Cults, Aberdeen AB15 9PR).
Walker, L. & Keating, F. (2000b) Being a Witness.
Grampian Primary Care NHS Trust (see 2002a).
Resources
Blissymbols (Blissymbolics UK c/o the ACE Centre,
92 Windmill Road, Headington, Oxford OX3 7DR)
Makaton (The Makaton Vocabulary Development
Project, 31 Firwood Drive, Camberley, Surrey GU15 3QD)
Picture Communication Symbols (Mayer-Johnson
Co., Box 1579, Solana Beach, CA92075-1579, USA)
Rebus (Widgit Software Ltd., 124 Cambridge
Science Park, Milton Road, Cambridge CB4 0ZS)
DynaSyms (Sunrise Medical Ltd., AAC Department,
Sunrise Business Park, High Street, Wollaston,
West Midlands DY8 4PS)
Minspeak (Prentke Romich International,
Minerva House, Minerva Business Park,
Lynchwood, Peterborough, Cambs PE2 6FT)
Bonnington Symbol System (Bonnington Resource
Centre, 200 Bonnington Road, Edinburgh EH6 5NL)
Speakability, 1 Royal Street, London SE1 7LL.
Communication - by the book
Sally Millar explains how
different communication
books match different
clients abilities and
situations.
Look, stop, come, like, help
I (me, mine), you/yours, Mum, Dad,
More, not
(I need the) toilet: I feel bad;
Ive finished; more please; I like it; I dont like it; I
want; I need
Whats happening?; When?
Youve got that a bit wrong, Im going to start
again; its something like; opposite; sounds like
(Yes & No unless they can be indicated clearly in
some other, unaided, way.)
I like to mount this frequently used vocabulary
on the inside covers of the book, around the out-
side of the symbol pages that are cut smaller than
the total area of the binder. Another strategy is to
have the core vocabulary on a separate page
attached to the inside cover of the front of the
book that unfolds out to the left hand side, to be
permanently visible and accessible whilst the user
turns to different vocabulary pages of the book to
the right. With smaller books, the actions and sen-
tence starters might be down the left hand side of
each page, with descriptors across the top of the
page, each colour-coded.
3. Symbol books and language development
To develop a users linguistic ability, the book
needs to reflect the users actual level of language
and cognition ability, plus room for growth.
Latham (2003) has developed a prototype com-
munication book design based on her earlier work
at the Redway School (Latham & Miles, 1997) in
which vocabulary is not only divided up into core
and fringe vocabulary but also into developmental
stages 1-5 (matching the bands outlined in the
book). A Stage 1 left-hand core page has a few key
words and phrases, while a Stage 5 core page has
fold-outs with a full set of core chat words,
questions, pronouns, and starters.
It is important, however, not to overlook low
tech, simple options. One of my most successful
AAC solutions consisted of a piece of white paper
with the letters of the alphabet on it (in QWERTY
rather than alphabetic layout, to link with com-
puter use) cut to size and inserted into a clear
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2003