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ISSN 1368-1205

Spring 2008

Are you getting enough? Our new supervision series Health promotion Greater expectations Caseload management A drop-in clinic Community learning Qual-IT Service development An aphasia strategy Research in practice The best laid plans How I meet my information needs Developing information literacy

Skill mix

Time for communication

PLUSWinning WaysAssessments assessedHeres one I made earlier

speechmag.com latest and a great reader offer. Space for reflection


Reader offer

Win Lemon & Lime Library!

Do you work with children or adults who would benefit from tailor-made articulation worksheets? Then our FREE prize draw is for you. Speechmark Publishing is offering THREE lucky readers a copy of the newly released Lemon & Lime Library An Articulation Screen & Resource Pack, which retails at 45.99 + VAT. Developed by speech and language therapist Rebecca Palmer and researcher Athanassios Protopapas, the interactive CD-ROM resource profiles a clients articulation, identifies areas for treatment and provides the tools for the therapist to create customised practice worksheets. The seven levels of practice are: single sounds, CV combinations, DDK rates, single syllable then multisyllabic words, short phrases and longer sentences. For your chance to win, e-mail your name and address to Speech & Language Therapy in Practice editor avrilnicoll@speechmag.com by 25th April 2008, putting LLL offer in the subject line. The winners will be notified by 30th April. For a Speechmark catalogue, tel. 0845 034 4610. Speechmark is now based at 70 Alston Drive, Bradwell Abbey, Milton Keynes MK13 9HG.

Reader Offer Winners

The three lucky winners of the Off We Go! series reader offer in our Autumn 07 issue, courtesy of Speechmark, are Sarah Chandler, Gill Allen and Jenny Murphy. Meanwhile Plural Publishings book Head and Neck Cancer offered in the Winter 07 issue is on its way to Janice Dey. Congratulations to you all.

Spring 08 speechmag

Our social networking experiment has ended thanks to everyone who participated in this. You now need only ONE user name and password for the members area at www.speechmag. com/Members/. For a reminder of yours, e-mail avrilnicoll@speechmag.com. The area includes: Messages from the editor Back issues from 2000-2006 A forum specifically for discussion of Speech & Language Therapy in Practice articles Occasional extras from authors Only online articles

NEW! Only online articles added for Spring 08! Alison Newton and Linzie Priestnal discuss the process of arriving at their departments new policy for prioritisation of adult inpatients. Maggie Robinson on making services more accessible through a gradual approach to school-based speech and language therapy.

Spring 2008 (publication date 29 February 2008) ISSN 1368-2105

8 COVER STORY: SKILL MIX one of the big advantages of the communication support officer role is that it gives clients the benefit of time. This gets them back into the way of having conversations and gives people who have an element of institutionalisation some choice and independence. Mike Harrison with Rosanne Lyddon, Cathy Harris and Yunus Hansdot on a three year Leonard Cheshire Disability Communication Project involving communication support workers, speech and language therapists and a programme of staff training. 24 ASSESSMENTS ASSESSED Our in-depth reviews consider the Communication Development Profile and the Communication Disability Profile. 26 HOW I MEET MY INFORMATION NEEDS Information seeking is much more than solving problems, finding facts or making decisions it can also be about sense-making and creativity. How do you develop your information literacy and encourage it in your clients and colleagues? Editor Avril Nicoll talks to speech and language therapists Katie Cullinan, Rebecca Matthews, Kerry Wreford-Bush and Alison Hodson. BACK COVER SUPERVISION (1) supervision is not a static, defined set of skills and roles. It is a fluid relationship encompassing a wide range of skills and techniques. Sam Simpson and Cathy Sparkes begin our new series for 2008 with an exploration of why supervision is important and a practical activity to help you make sense of your own supervision history.

Published by: Avril Nicoll, 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com

Cover photo of Cathy Harris and Yunus Hansdot courtesy of Leonard Cheshire Disability.

INSIDE COVER: Reader offer Win Lemon & Lime Library An Articulation Screen & Resource Pack 2 NEWS AND COMMENT 4 DO DROP IN Drop-in clinics are exciting to runas you have to make decisions quickly as to the possible diagnosis and whether to discharge the child, allowing spontaneous development to take place, or ask the parent to come back in three to six months. Maeve Guly explores how a dropin service can benefit children, their parents and your own professional development. 7 HERES ONE I MADE EARLIER... Alison Roberts suggests Phonbola; Life of Riley; Havent you changed! 11 A DRIVING FORCE Regular in-house staff workshops have included feedback from courses and conferences, article reviews, clinical case discussions, reviewing new resources and developing an aphasia resource file, all of which have led to changes in our practice. Dissatisfaction with their aphasia service motivated the Portsmouth adult team to take a strategic approach. Nicola Clark and Sheena Nineham reflect on the difference this is making. 13 WINNING WAYS Following Agenda for Change, Melanie feels undervalued. Life Coach Jo Middlemiss offers positive suggestions.

Design & Production: Fiona Reid, Fiona Reid Design Straitbraes Farm, St. Cyrus, Montrose Angus DD10 0DS Printing: Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT Editor: Avril Nicoll, Speech and Language Therapist

14 GREATER EXPECTATIONS one of the key factors in influencing change is altering the perception of parents and professionals that it is normal for children in deprived areas to present with delayed skills. Nicola Brooke looks back on the first three years of a speech and language therapy health promotion post which offers targeted training and multimedia resources. 17 THE BEST LAID PLANS Understanding the use of PEG tubes for adults with learning disabilities is an ever more critical concern with the likely increase in incidence of dementia due to improved life expectancy. Although Paula Leslie, Hannah Crawford and Heather Wilkinsons research project into percutaneous endoscopic gastrostomy tube feeding of adults with learning disabilities at end of life did not go to plan, there have been useful outcomes. 20 REVIEWS Dementia, dysfluency, groups, early intervention, comprehension, advocacy, autism, rehabilitation, cognitive impairment and phonics. 22 QUAL-IT I believe that my own memory difficulties enable me to have greater understanding of our learners as I too need strategies for learning that can be employed by some of them. Peter Tester offers tuition in information technology to learners with severe neurological difficulties, as part of a project to enhance their quality of life.

Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2008 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.



Childhood dementia call

Do you have an interest in childhood dementia? The Dementia Services Development Centre is proposing a conference on childhood dementia for 21 May 2008. They would like to hear from anyone who is interested in attending, participating or providing information. Dementia can be used to describe the condition of children who have progressive cognitive decline as a result of rare genetic syndromes or epileptic encephalopathies. Contact Juanita Green, tel. 01786 467740, e-mail j.l.green@stir.ac.uk


Positive messages

Publishing changes
The speech and language therapy publishing world has seen a number of changes in recent months. Speechmark has been sold to Electric Word which in 2007 also acquired Incentive Plus. Both brands are managed by former speech and language therapist Catherine McAllister. Meanwhile nferNelson has ended its formal relationship with founding educational research charity NFER and is now known as GL Assessment, and Harcourt Assessment (formerly the Psychological Corporation) has been taken over by Pearson.

Doncaster Stammering Association has made a CD of music to raise awareness of stammering and its effects. The songs - S-S-S-S-Stammering is Cool, Dont Finish My Sentence, Avoidance Blues, Look Me in the Eye, time2talk and Exercising the Exorcised - were recorded by the Associations self-help group and 14 children aged 7-12 who are clients of speech and language therapist Hilary Liddle. They worked with professional musicians to develop the lyrics and had access to state of the art recording facilities. British Stammering Association Education Officer Cherry Hughes says that participants confidence increased: Talking and singing openly about their stammering helped them to feel less sensitive about it. Projecting positive messages about stammering helped to increase their own self-esteem. Two downloadable tracks and all the lyrics are at www.stammering.org/ time2talk.html, where you can also order the CD for 4.00 (inc. UK p&p). In a separate venture, 12 young people who use AAC made a DVD with a support team including researchers, film producers and musicians. Listen to Me includes a music track composed by the teenagers, a documentary about their communication with AAC and a section promoting the 1Voice group. The DVD is 8.00 (or a donation). www.youtube.com/watch?v=w5ZlUnU8Oeo or www.1voice.info

A report from the National Autistic Society concludes that over 60 per cent of adults with autism in England do not have enough support to meet their needs. Based on the largest ever UK survey of adults with autism and their families, along with local authorities and health services, the I Exist report starts a new phase of the charitys think differently about autism campaign. The Society is concerned that 67 per cent of local authorities do not keep a record of how many adults with autism are in their area and 65 per cent do not know how many adults with autism they support. Sixty one per cent of adults with autism included in the survey rely on their family financially, 40 per cent live with their parents and at least 1 in 3 experience mental health difficulties so it is not surprising that 92 per cent of parents are worried about their son or daughters future when they are no longer able to care for them. Interestingly, 60 per cent of the parents believe that support at an earlier stage would have prevented problems developing. I Exist also highlights the problem of adults with Asperger syndrome missing out on support because they dont fit neatly into categories such as learning disability or mental health services. When surveyed, an adult called Neil said the support he would like is speech therapy and music therapy. The Liverpool Asperger Team, headed up by speech and language therapist Chris Austin, is highlighted as an example of good practice. The National Autistic Society says, For too long adults with autism have found themselves isolated and ignored; they struggle to access support and are often dependent on their families. It does not have to be like this. The charity is calling on the government to fund a UK prevalence study so that services can be planned and delivered effectively. It also wants to see better training for health and social care staff who assess need and an increase in low level support where adults with autism access social skills training, social groups and befriending schemes. The report applies to England. Separate reports are due for Scotland and Wales. Download I Exist at www.think-differently.org.uk

I Exist

Listen to Me

Palliative pathways

Interestingly, a childrens charity is also highlighting the positive impact of music on childrens concentration, confidence, self-esteem and social interaction. Coram, whose work supports vulnerable children and their families, developed a three year study to test the effectiveness of its music therapy service as there were no standardised measures available. Unlike the majority of specialist clinical services, Corams music therapy is based within a community centre, engaging directly with children, their families and external agencies. The community-based team includes childcare workers, clinical psychologists, child psychotherapists, early years practitioners, family support workers, play workers, social workers and teachers. www.coram.org.uk

The Association for Childrens Palliative Care has been awarded funding for three years to help life-limited young people prepare for the transition from childrens to adults palliative care services. Advancements in treatment mean that some children with conditions such as Duchenne Muscular Dystrophy are living longer than was previously expected yet the charity says planning for transition is poor and adult services lack the specialist knowledge to support them. The award will fund 12 new transition posts to roll out a Transition Care Pathway across the UK. www.act.org.uk



Holistic approach to Parkinsons


West Kent speech and language therapist Catherine Jones is one of the contributors to a comprehensive Professionals Guide to Parkinsons Disease. The free booklet from The Parkinsons Disease Society aims to reflect the importance of the multidisciplinary team to effective intervention. It draws on expertise from eight different professions general practice, nursing, dietetics, occupational therapy, pharmacy, physiotherapy, social work and speech and language therapy. The nursing contribution includes communication and swallowing difficulties and how nurses can help, and the occupational therapy section also covers strategies to support communication. In the social work part, Smales Exchange Model is suggested as a way of empowering someone with communication difficulties to participate fully in the assessment process. Catherine commented, I would encourage speech and language therapists to order a free copy. Having information available at your fingertips on a number of disciplines as well as your own will go a long way towards helping speech and language therapists involved in the management of Parkinsons get a holistic view of the condition. www.parkinsons.org.uk/PDF/PubProfessionalGuideNov07.pdf

Space for reflection

In the first of our new series on supervision (back page), Sam Simpson and Cathy Sparkes talk about the importance of creating space for reflection. This is also crucial to the development of Speech & Language Therapy in Practice, with reader feedback playing a central part. Reflecting on recent questionnaire responses I am clear that you choose to subscribe because the magazine is useful, interesting, readable and - above all - practical. In spite of time pressures you would welcome more issues. You like tools such as read this if and reflections but would prefer a larger type size and less use of dark colour. You have not found the websites social networking experiment tempting or user-friendly. I hope therefore that you find the increased type size and reduction in dark colour backgrounds helpful, and the revamped www.speechmag.com/Members/ area straightforward to use. You can access it with your user name and password for back issues from 2000-2006, extras to complement articles in the magazine, updates from me, and a forum for discussion of articles. When possible, I will also include online only articles of the same standard and design as the print publication. Whether in print or online, Speech & Language Therapy in Practice encourages both authors and readers to create space for reflection. In this issue Maeve Guly audits her drop-in clinic (p.4), Nicola Brooke looks back on the first three years of her health promotion post (p.14) and Lynn Dangerfield and Sheena Nineham review the impact of their departments aphasia strategy (p.11). All demonstrate the value of pausing to look back on what you have achieved and learnt and of thinking about how it will influence where you go next. The Leonard Cheshire Disability Communication Project (p.8) and Peter Testers focus on quality of life (p.22) also give us the opportunity to reflect on the contribution different professionals and new technology can make to supporting our clients. Meanwhile, Paula Leslie, Hannah Crawford and Heather Wilkinson (p.17) help us understand that space for reflection can be just as useful when things dont go to plan as when they do. Ideas for thought-provoking feature articles such as How I meet my information needs (Katie Cullinan, Rebecca Matthews, Kerry Wreford-Bush and Alison Hodson, p.26) are often sparked when I mull over things you have said or written to me so do keep those ideas coming!

Involved in research

A conference to promote public involvement in research is giving presenters the opportunity to showcase their work in ways which might be particularly welcomed by people with communication support needs. While the customary options of posters, poster talks, papers and workshops are available, other formats suggested include a DVD, a short play or drawing. INVOLVEs 6th national conference is Public involvement in research Getting it right and making a difference. The organisation hopes presentations will include experiences of what has worked well and what has not, organisational and cultural barriers, the difference public involvement has made to the way research is prioritised, commissioned or granted ethics approval and the development of user-controlled research. The conference is from 11-12 November 2008 in Nottingham. The closing date for applying to do a presentation is 7 April. INVOLVE provides guidelines on producing accessible presentations and has a conference fund to help applicants from local, voluntary and community organisations, self-help groups and individual members of the public attend. INVOLVE is a national advisory group, funded by the Department of Health England. Its main task is to promote and support public involvement in NHS, public health and social care research and development. Its vision is for public perspectives to be integrated into the whole research cycle as a way of enriching research and enthusing all those who are involved in it. www.invo.org.uk/pdfs/Call4Presd4.pdf

Primary Talk

An accreditation system that promotes communication supportive environments for all children in primary schools is being piloted and evaluated with the aim of being rolled out nationally in 2009. I CAN has formed a partnership with Somerset Total Communication and Somerset Local Authority to develop Primary Talk, a follow on from the charitys Early Talk programme. Primary Talk includes staff training and a web based resource. Regional Advisors have been appointed in the pilot areas of Somerset, Bradford and Walsall and evaluation is being carried out by Joy Stackhouse and colleagues at the University of Sheffield. www.ican.org.uk



Do drop in
Most of us are familiar with the pressures of large caseloads, waiting lists, late referrals and non-attendance at community clinics. Maeve Guly explores how a drop-in service can help address all these issues, benefiting children, their parents and your own professional development.

he idea of speech and language drop-in clinics is not new but, as I am unaware of any information about them in the literature, I would like to share my experience of running one for six years. I will describe who comes to the clinic, how I run it and what I do to help the parents and children who attend. Finally, I will ask the all important question - are they useful? I work in a community clinic in Tavistock, a small country town in Devon surrounded by nine villages within a seven mile radius. Public transport is poor and it can be difficult for parents without a car to access our service. In families where both parents are working, knowing the drop-in clinic dates well in advance makes it easier to get time off from work. Drop-in sessions are run twice a month at the main clinic and approximately twice a term at playgroups in rural settings. For the purpose of this article I am reviewing a consecutive sample of 150 children from the main clinic. The drop-in clinic does not provide an indepth assessment. Rather, it is an informal opportunity to gauge what the childs problem is, and to offer advice and reassurance until further therapy can be given should this be necessary. Posters advertise the drop-in clinics at GP surgeries and preschools but most people who come have been recommended to do so by their health visitor. If health visitors are concerned about a child - and the parent consents to a referral - we ask them to fill
Figure 1 Drop in clinic attendances in age
40 35 30

in one of our standard referral forms just in case the child doesnt turn up to the drop-in clinic. The drop-in clinic mainly serves a preschool population but I have made it known to the local schools that I will see children with phonology problems who might have fallen through the net and who may be experiencing literacy difficulties as a result. The ages of those attending are in figure 1. Of the 150 children, 97 (65 per cent) were male and 53 (35 per cent) were female, showing the male predominance in a typical speech and language therapy caseload.

these parents would probably have waited and worried for a longer period before being referred via the traditional route.


Posters advertise the dropin clinics at GP surgeries and preschools but most people who come have been recommended to do so by their health visitor.
The fact that the majority of children were aged between 2 and 4 years was as I expected. There is often a lot of parental anxiety between 2-2 years if children are slow to develop first words and are not linking two words together. At 3 years there is concern as children start preschools that their speech will not be understood by unfamiliar listeners. From 4 years fewer children attend the drop-in clinic and, when they do, it is often with speech sound delay; they may still be having problems with /s/, /f/, //, /k/, /g/ sounds. My primary finding for each child is in figure 2. There is however overlap, for example some children with speech difficulties may also have expressive language delay and /or comprehension problems.
Figure 2 Primary findings Number 74 34 12 3 27 % 49.3 22.7 8 2 18

It is unusual to see children under the age of 2 years but, in each case where this happened, it was appropriate that the parents should seek advice. Those attending included a child who had had meningitis the previous year, a child with tongue tie and a mother who had had postnatal depression and was worried about the effects on her child. A health visitor referred a family who had an unrealistic expectation of their childs language development at 16 months. One mother had a child already on our caseload with a language disorder and she was very anxious about her second child at 23 months. The sixth child came because there was a history of autism in the family and the child was showing signs of not interacting and communicating at 22 months. Without access to the drop-in clinic

Speech impairment Receptive and Expressive Language problems Dysfluency Autistic Spectrum Disorder Within normal limits / should resolve spontaneously
1 - 1.5 1.5 - 2 2 - 2.5 2.5 - 3 3 - 3.5 3.5 - 4 4 - 4.5 4.5 - 5 5 - 5.5 5.5 - 6 6 - 6.5


25 20 15 10 5 0

Age (years)


CASELOAD MANAGEMENT The largest group was children with speech difficulties, which accords with Broomfield and Dodds (2004) findings when they looked at caseload characteristics. Seventy one children (47.3 per cent) had delayed speech sound development, 8 associated with otitis media and 3 with tongue tie. Three children (2 per cent) had a phonological disorder. Thirty four children (22.7 per cent) had delayed language development, 7 (4.7 per cent) with a primary problem with comprehension. Fifteen families had two or more children presenting with communication problems, the majority being phonological difficulties. The challenge of the drop-in clinic is that you cannot get prepared in advance for individual children. As the health visitor only fills in one of our standard referral forms if she is particularly concerned about a child, for the majority the childs age and general problem will not be known beforehand. I have to hand: A box with a cup, two plates (red and yellow), a brick, a key, a spoon and a big and little teddy to see how many key words are understood. A concept box with toys to check the childs understanding of big / little, full / empty, on / under, top / bottom, long / short, behind / in front and colours. Objects such as a brush, bike, car, cup, banana and spoon to see if the child understands the functions of objects eg. what do you eat?(usually understood from 2 years). Phonological Screening Test (Stevens & Isles, 2001) or for younger children Everyday Objects pictures (Speechmark, 1999). I put the pictures into a fishing game to get an idea of the childs vocabulary and speech sound development. The Preschool Language Scale-3(UK) (Boucher & Lewis, 1997), as it provides an age related assessment of a childs auditory comprehension and expressive communication. South Tyneside Assessment of Syntactic Structures (Armstrong & Ainley, 1999) for checking language development. The Symbolic Play Test (Lowe & Costello, 1998), which can be useful to gauge the functional play of children up to three years who are not talking. A feely bag with objects and toys for younger children to get a sample of their vocabulary and functional play. A Playmobil park and farm with animals to hear childrens spontaneous language in play and to observe imaginative play. Inset puzzles, stacking beakers, cause and effect toys, puppets and books (eg. Laa Laas Ball and a Spot lift-up-the-flaps book) to observe general play, development and communication. I usually spend approximately -1 hour with each family. As part of the assessment, I take a brief case history of birth, milestones, communication, when hearing was last tested and outcome, feeding and general health. Following the assessment, I prioritise the child on a low / medium / high scale depending on the severity of the communication impairment and its impact on the child and carer. From my sample of 150 children, I gave 38 (25.3 per cent) a high rating, 31 (20.6 per cent) a medium rating, 54 (36 per cent) a low priority and found 27 (18 per cent) were within normal limits. Of the children who had a low priority rating, 40 were given appointments. When the other 14 parents were contacted by phone they said they no longer had concerns and did not need further input. Of the 27 children who were discharged, two were re-referred, one because she was still fronting /k/ and /g/ sounds six months later and there was a lot of parental anxiety. The other child had come to the drop-in aged 15 months because he was a quiet baby who hadnt babbled very much but he was starting to vocalise more and was saying two words. He was discharged with advice and came back to the drop-in at 2 years because he was slow to develop first words; he went on to have phonological problems. no longer available but Glue ear - a guide for parents (NDCS) is also useful. When I rate children as a low priority it is important to give the parents clear advice as to my expectation of progress. So, for example, I might ask them to come back to the drop-in clinic if the child is not linking two words by 2 years 6 months or their speech is still unintelligible at three years. The handout showing the development of speech sounds will hopefully reassure parents who worry when their children aged three years are using common immature patterns, substituting [t] for /k/ or reducing /s/ clusters.

Safety net

Helpful for parents

I have found the Firth & Venkatesh (1999) hand-outs on eye contact, turn-taking, making choices and playing together very helpful for parents. The Ann Locke First Words (1985) and the verb lists and ways of encouraging them are very useful. I often give advice from the Hanen programme It Takes Two To Talk to reduce and simplify the language used with a child and to pause and give the child time to respond. Leaflets about the possible effects of prolonged dummy use and ideas to wean the child off them are also available.

The clinic can also provide advice to families who may not be able to keep standard appointments, and some parents may just prefer the chance to talk to a therapist before a formal referral is made.
I have ready-made packs that can be loaned to parents for the most frequent sounds that need remediation - /s/, /f/, /k/ word initial and final, with lots of ideas for games. It has been my experience that parents are more likely to play games that are attractively presented and have already been coloured and laminated. The advice sheets from Elklan (1999) on ways to help the child whose speech is difficult to understand, and explaining how to teach basic concepts, are also very useful. We give British Stammering Association advice leaflets to parents and to staff in preschools and nurseries on how to help the dysfluent child. After the initial contact at the drop-in clinic, only five of the twelve children with dysfluency needed a follow-up appointment, which suggests that the advice was effective. I have found the leaflets Making the most of hearing (2000) and Helping children who have a mild conductive hearing loss from the Royal National Institute for the Deaf to be very helpful for giving parents practical advice and sharing ideas with preschool settings. These are

The drop-in clinics appear to be useful in a number of ways. The feedback from health visitors is very positive. When they are doing their 2 and 4 year checks they can immediately recommend the drop-in clinic if they are worried about a childs development. In some areas health visitors are regrettably no longer doing 2 year checks so a drop-in clinic will provide an essential safety net to identify speech and language delay / disorder as early as possible. Drop-in clinics are also useful for training purposes as trainee health visitors and student paediatric nurses can see the diversity of communication needs we encounter. Early intervention is one of the key benefits, and the drop-in clinic gives an opportunity for parents with children under the age of 2 years to seek advice. It can be reassuring to a parent to find their childs speech and language development is within normal limits, and such children can be discharged rather than being unnecessarily on a waiting list. Indeed, drop-in clinics reduce waiting lists and can be a means of picking up high priority cases early. If, for example, children are showing signs of being on the autistic spectrum we can seek an early appointment with a paediatrician to consider a diagnosis. Referrals can be made to the Early Years Advisor and parents can access the EarlyBird Parent Support Programme to get strategies to cope with challenging behaviour. In general, seeing a child earlier should help to relieve frustration. Parental anxiety can be reduced through advice on how to encourage their child to speak and what to do when they cant understand what their child says. In children with dysfluency in particular, early advice may prevent a more significant problem developing. The clinic can also provide advice to families who may not be able to keep standard appointments, and some parents may just prefer the chance to talk to a therapist before a formal referral is made. The child is only taken onto the caseload if a further appointment is needed, with the person who recommended the parent to the drop-in clinic regarded as the referring agent. There are, of course, some disadvantages. It can be frustrating if no-one turns up to a clinic, although I can usefully do some paperwork if this happens. I can be overstretched if more than three families come to the same clinic and have to be seen within two hours. In practice this does not happen often and, when it does, I can offer some advice and see them again within a three month period. 5


caseload management Although drop-in clinics are useful for training speech and language therapy students in taking case histories and making diagnoses, the unpredictability of whether anyone will attend can pose a problem.


Drop-in clinics are exciting to run as there is always an element of the unknown: you never know who will walk through the door! They keep you on your toes as you have to make decisions quickly as to the possible diagnosis and whether to discharge the child, allowing spontaneous development to take place, or ask the parent to come back in three to six months. According to Kate Malcomess, a duty of care starts at the initial consultation if child-specific advice has been given. Accordingly, a child who is taken onto the main caseload will be offered an appointment within three months but in the meantime a request to get a childs hearing

Running the drop-in clinic has improved my prediction skills about the improvement a child should make in a given time.
checked can be made or a referral made to a paediatrician or Early Years Advisor should this be necessary. As a therapist I have often been cautious, wanting to review children to check that spontaneous recovery has taken place. I am now happier to discharge knowing that a parent can easily access the drop-in if there are further concerns. Running the drop-in clinic has improved my prediction skills

about the improvement a child should make in a given time. This involves adapting my knowledge of normal development to take into account delay - which may for example have been associated with glue ear - and giving the parent an expectation of what the child should be doing in a 3-6 month period. Interestingly the drop-in clinic - in terms of the ratio of impairment - provides a microcosm of the whole caseload for the clinic which shows that it is representative of need. It provides a speedy access to the speech and language therapy service. This is appreciated by parents and health visitors, our main referrers, and my experience suggests it is an efficient caseload management tool. Maeve Guly is a speech and language therapist at Tavistock Clinic, 70 Plymouth Road, Tavistock, Devon. SLTP


Armstrong, S. & Ainley, M. (1999) South Tyneside Assessment of Syntactic Structures. Ponteland: STASS. Boucher, J. & Lewis, V. (1997) Preschool Language Scale-3 UK Edition. London: Pearson. Broomfield, J. & Dodd, B. (2004) Children with speech and language disability: caseload characteristics, International Journal of Language and Communication Disorders 38(3), pp.303-324. Elks, E. & McLachlan, H. (1999) Early Language Builders. Cornwall: Elklan. Firth, C. & Venkatesh, K. (1999) Semantic-Pragmatic Language Disorder. Milton Keynes: Speechmark. Locke, A. (1985) Living Language. London: NFER-Nelson. Lowe, M. & Costello, A.J. (1998) Symbolic Play Test. London: GL Assessment. Manolson, A. (1992) It Takes Two To Talk. Toronto: The Hanen Centre. Speechmark (1999) Pocket ColorCards: Early Objects. Milton Keynes: Speechmark. Stevens, N. & Isles, D. (2001) Phonological Screening Assessment. Milton Keynes: Speechmark.

DO I HAVE SYSTEMS FOR PRIORITISATION, FOLLOW-UP AND ONWARD REFERRAL? DO I REVIEW MY CASELOAD STATISTICS TO INFORM MY PLANNING? DO I WELCOME UNPREDICTABILITY AS A WAY OF HONING MY DECISIONMAKING? How has this article been helpful to you? Have you found drop-in clinics a useful tool? Let us know via the Spring 08 forum at www.speechmag.com/ Members/



British Stammering Association leaflets see www.stammering.org/pac.html EarlyBird Parent Support Training see www.nas.org.uk/earlybird Malcomess Care Aims Model see www.careaims.com National Deaf Childrens Society - www.ndcs.org.uk

Tilting larynx
Get your paper, scissors, glue and paper fasteners ready - Vocal Process offers a free Build Your Own Tilting Larynx template at www.vocalprocess.co.uk/resources/build_your_own_ tilting_larynx.pdf

End of caring

Challenging behaviour

Communication and Challenging Behaviour is a 45 minute DVD aimed at parent carers. It focuses on four individuals with severe learning disabilities and includes interviews with family, carers and speech and language therapist Jill Bradshaw. The DVD is 31.50 (inc. UK p&p) but free to parent carers. www.challengingbehaviour.org.uk

When caring comes to an end is a short, practical guide to help carers whose responsibilities are changing, for example when the person they care for moves into a residential home or dies. www.carersuk.org/hub_content/Information/Orderpublications/Factsheetsbooklets/UK9014/BookletWhencaringcomestoanendOct2007.pdf

Get it on time

The Parkinsons Disease Society has a free Get it on time washbag of tips and advice to help people with Parkinsons get their medication on time during a hospital stay. The Society also has UK countryspecific leaflets to help people report an incident to the National Patient Safety Agency. Tel. 01473 212115, e-mail pds@sharward.co.uk

Communication Matters

Thinking tools

The I Think2 Electronic Toolbox includes 48 thinking tools which young people can use to solve problems, including Venn diagrams, memory maps, decision-making trees and reliability grids. www.alite.co.uk

A new DVD aims to help Asian families with deaf children. Communication Matters is available in Urdu, Punjabi, Sylheti, English, British Sign Language and subtitles. It features 13 young people and their families, and gives a clear message that deafness should not be a barrier to learning. Free from the NDCS (the National Deaf Childrens Society) Freephone Helpline 0808 800 8880 or email helpline@ndcs.org.uk

Road crash support

BrakeCare offers free training courses for health professionals in the North West, North East and South East of England (including London) on supporting people affected by road crashes. www.brake.org.uk/index.php?p=1112

HCA dementia course

Film choice

Fragile X

The Fragile X Society has updated its Introductory Booklet to relate to adults as well as children with Fragile X. It also has genetic information available in Gujarati, Punjabi, Urdu and Turkish with translations in Arabic and Farsi due this year. www.fragilex.org.uk

The Diving Bell and The Butterfly is a film depicting the true story of Jean-Domnique Bauby, editor-in-chief of French Elle, who had a massive stroke at the age of 43. Left with locked-in syndrome, the film shows how an eye blink communication system allowed him to unlock the diving bell that his body had become with the butterfly of his imagination. www.thedivingbellmovie.co.uk

The Dementia Services Development Centre has introduced a six part self-study course to help health care assistants think about how they respond to the person with dementia. www.dementia.stir.ac.uk/documents/HCA-CourseFlyer.pdf

Inclusive awards

Mencap has introduced a Gateway Award 8 to 13 to bring children and young people together in inclusive settings to take part in interesting challenges in four activity zones: active, adventure, people and the planets, Soundz arty. www.mencap.org.uk/html/gateway/8-13_award.asp


heres one I made earlier

Heres one I made earlier...

MATERIALS Big jar (Ive found that extra large jars of pickled gherkins are quite easy to find. If your therapy room has an unforgiving floor you will need to find a plastic jar instead.) Pen Small pieces of thin, foldable card MATERIALS As many battered old toy cars as you can find, the worse their condition the better Or, and more appropriate for older clients, pictures of real old bangers (you can get these from a specialist magazine on stock car racing) Alternatively use other old vehicles / pictures such as buses, trains, and motorbikes

Alison Roberts with more low-cost, flexible therapy suggestions suitable for a variety of client groups.

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire. BRAWN Write words, phrases etc containing your clients target sound on the cards. Alternatively, if your client is a non-reader draw little pictures, or, if you have them, you could use Widgit symbols. IN PRACTICE (I) Simply place the folded cards in the jar, put the lid on, and roll it towards your client. They pick out a card and read it / name it. IN PRACTICE (II) The client makes a sentence containing the jar word. a monkey. Finally, you can decide and describe the fate of the car, perhaps to start a new life, after being repaired and repainted, or to be crushed and made into saucepans! Try to end the cars life on a reasonably positive note.

This is a fun addition to your phonological materials. You can use it as a one to one activity, or in a group.

Life of Riley
This is a lateral thinking activity for a group of fairly able children or young teenagers. It also helps to develop narrative skills. The idea is to explain how the cars could have got into such a state. Extra praise should be given for the funniest or most outlandish ideas.

IN PRACTICE Ask clients to make up a story to explain the current condition of the car. You can get the ball rolling yourself, for example describing how a vehicle started life as a family car, and was stolen and used as a getaway car, or got left in a beach car park when the tide came in. It was later sold to a new driver as a first car, but kept being badly parked, bumping into posts etc. It might even have been taken to a safari park and re-engineered by

Havent you changed!

A series of games for a group of clients to encourage observation of other people. It is also a good opportunity to practise Makaton or other signs.

MATERIALS Scarves, hats, glasses, jackets and so on for versions I and II There are several, progressively harder, ways to approach this. IN PRACTICE (I) You must have the change items outside the room. One of the clients is scrutinised by the others, goes out, puts on a hat, or a pair of glasses, returns to the room, and the others say what has changed. IN PRACTICE (II) A client goes out of the room while someone left inside changes something about themselves, such as putting on a jacket, with the others in the group remaining neutral. The other client returns and examines those already in the room, selecting the changer. IN PRACTICE (III) A client goes out of the room and the others decide on a facial expression, a Makaton sign, or a way of sitting, for example

with arms or legs crossed. They are all doing this action when the client returns for a short while to look at them, but nothing is said. Now the client goes out again, and the group adopts a different facial expression, Makaton sign, or pose, and when the client re-enters s/he must state what is different about the group. IN PRACTICE (IV) A still more difficult version is a new take on a parlour game. One person exits, and the others decide on an overt action and a covert action. The overt action could be to pass around something like an open or closed book, but covertly the action is sitting with the legs either apart or together. When the person re-enters the room s/he sits down with the group, and tries to join in with the groups activity. The first one in the group (one who is in on the secret) statesI pass on this book open, or,I pass on this book closed. The book will be randomly open or closed;

it is the position of the legs that goes with the words. The one who is excluded from the Secret tries to work out what the covert posture is. Another statement could be I pass on these scissors crossed, or I pass on these scissors uncrossed; again that would happen randomly; it would be the legs that are crossed or uncrossed. You could try I pass on this tea towel folded or I pass on this tea towel unfolded, when it would actually be the arms that are folded or not. (Passing the towel on with folded arms is possible to do!) Or try I pass on this pencil upright/ leaning, but it would really be your posture that is upright, or inclining slightly to one side. Then there could beI pass on this pen pointing up/down, and with the other hand slightly point up or down. Your own or your clients imaginations will suggest more of these; all you have to remember is that you need a statement which can apply both to an object and a bodily action.


cover story: skill mix

Time for communi

With speech and language therapists in short supply and people with communication support needs missing out on the benefits of AAC (augmentative and alternative communication), imaginative solutions are called for. Mike Harrison, Rosanne Lyddon, Cathy Harris and Yunus Hansdot are part of a three year Leonard Cheshire Disability Communication Project involving communication support workers, speech and language therapists and a programme of staff training.

lmost half of Leonard Cheshire Disabilitys residential service users have communication impairments associated with congenital or acquired conditions such as cerebral palsy, multiple sclerosis and acquired brain injury. The nationwide shortage of speech and language therapists - and the priority given to dysphagia management - means that such clients may not be able to access the help they need. An award winning Communication Project championed by the charity is working to overcome this through employing communication support officers and offering training to staff (box 1, p.10). The charity has recruited a team of ten communication support officers, one for each of the Leonard Cheshire Disability geographic regions. The communication support officers visit service users, staff and volunteers regularly to assist them in developing more effective communication methods and to make sure that speech and language therapy recommendations are put into effect within the service users own environment. Journey time to clients can be up to 4 hours depending on the area covered. On average a communication support officer sees 8-10 clients at a time, spending 60-90 hours with each, although this can be less if there is a simple solution. On receiving a referral, the communication support officer checks if a speech and language therapist is already involved, then makes contact with them. The majority of clients referred have no AAC system in place, and some have old or obsolete equipment which is no longer insured. The ethos of the project is to find a low tech and low cost solution if possible. The communication support officers all have PCS Boardmaker, so can introduce Communication Passports, symbol books and spell books if they will be helpful. Training has been provided by the Communication Aid Centre at Frenchay Hospital in Bristol, and the communication support officers can use the CAC-Frenchay Screen for AAC.

tion by a team from University College London. It is funded by a grant of 737,000 from the Big Lottery Fund, with additional funding from UniChem (part of Alliance Boots) and Lloyds TSB Foundation for England and Wales. It has been introduced in Leonard Cheshire Disability services throughout the UK, following a successful pilot project in the charitys central region, which covers Bedfordshire, Berkshire, Buckinghamshire, Gloucestershire, Hertfordshire, Northamptonshire, Oxfordshire and Warwickshire. Leonard Cheshire Disability has a fundraiser in each region so, if the NHS and Social Services will not or cannot fund a high tech communication aid when a need is identified, the charity tries to source funding that includes a commitment to maintain the aid.

The ethos of the project is to find a low tech and low cost solution if possible.
The project started with communication support officer Rosanne Lyddon. She had been a care assistant for 6 years and was not particularly experienced with speech and language therapy issues, so describes the development of the project as a learning curve. Her work involves assisting the service users to explore and improve their own personal communication system(s) and also look at how other people communicate with them. Sometimes her role is to raise awareness of an individuals communication style and preferences. This might include someone who indicates yes / no with an eye flicker, or agreeing with a client how many times it is acceptable to ask them to repeat something before they resort to an aid. One lady with a degenerative condition is keen to maintain her speech for as long as possible. She was anxious that a communication aid would make her lazy, but is happy with the support of a spell board. Rosanne feels one of the big advantages of the communication support officer role is that it

gives clients the benefit of time. This gets them back into the way of having conversations and gives people who have an element of institutionalisation some choice and independence. Clients can also be involved in creating their own Communication Passport or Book. Talking Mats has proved useful for finding out about a clients likes and dislikes. The communication support officers encourage clients to be as honest as possible about where they live / staff / residents / money, but only pass on the comments with consent. A side effect is that this offers information about the daily routine which is useful when it comes to programming a high tech aid. Making sure that the support package is delivered to the service user in an accessible and empowering way has the knock-on effect of improving the communication skills of everyone connected with the service. This has two benefits. The speech and language therapists have someone who will follow up their recommendations and work with clients on a regular basis. And, just as important, the communication support officers become a ready source of support for clients, ensuring that their communication needs are understood and catered for by staff. Turnover of staff can be high in residential services, but the communication support officers ensure continuity for this particularly vulnerable group of clients.

Reaching people


The Communication Project is being independently evaluated throughout its three year dura-

Often disabled children and young adults with communication impairments are well catered for at school, but support can fall away as they reach adulthood. The Communication Project is reaching people who have not had access to speech and language therapy as they move into the community or into residential services, and do not have appropriate ongoing support in the environment in which they live. Yunus Hansdot (37) has cerebral palsy and is a resident at Leonard Cheshire Disabilitys service in Cheltenham. Staff supporting Yunus on a daily basis first asked Rosanne for advice in October 2005 because they realised that he was upset but did not know why. He wanted to tell them hed


like to change his key worker but he was finding it difficult to express himself. He was visibly frustrated and everyone thought it was a bigger problem than it was, remembers Rosanne. Yunus has good auditory comprehension and recognition of symbols but very limited intelligible speech. The first thing Rosanne did was renew his Bliss book - a communication aid based on symbols which can be used in isolation or in sequence to create a message. When you meet Yunus you can see that he has a lot to offer, says Rosanne. He has a wicked sense of fun and likes to crack jokes also he has a sense of adventure. Seven years ago, Yunus undertook a sponsored tandem skydive to raise funds for a communication aid - the Pathfinder with Minspeak - which was then purchased. This is an excellent device but it was not right for him. Rosanne recognised this and discussed the problem with the service manager and staff who had worked with Yunus. It was agreed that Yunus should be referred to a speech and language therapist. Cathy Harris, lead therapist for communication aids in the adult service at Gloucestershire NHS Primary Care Trust, says that Yunus case highlights the need for ongoing specialist assessment and input for people who use communication aids, especially after the transition from education to adult services. When I met Yunus, he was finding his current communication aid very frustrating. He was adamant he didnt want to try to use it. Yet he is a great total communicator and knew what he wanted from a speech output device, especially in relation to size and accessibility. Cathy was able to reassess his current needs fully, and Yunus has been supplied with a more appropriate device a Dynamo. If someone isnt assessed by a speech and language therapist, money can be wasted on inappropriate equipment. Its about looking at a persons environment, assessing their needs and abilities, giving them choice, and not being afraid to try different things out over a period of time. The trial period is really important as it can show whether the device is going to be useful to them in the longer term, says Cathy. The Dynamo is mounted on Yunus wheelchair on a quick release mount. The touch screen

cover story: skill mix

L-R Cathy Harris, Rosanne Lyddon, Yunus Hansdot. Courtesy of Leonard Cheshire Disability.

Making sure that the support package is delivered to the service user in an accessible and empowering way has the knock-on effect of improving the communication skills of everyone connected with the service.
is divided into nine sections, for ease of access, and the chosen category headings reflect Yunus needs and interests. Once Yunus feels confident locating and accessing one level, new vocabulary is added onto the next level. Rosanne has learned to programme the Dynamo and works with him to make sure that all the information is personal and up-todate. So, for example, hobbies includes motorbikes. Yunus loves Harley Davidson bikes and goes to the International Motorcycle & Scooter Show at the NEC in Birmingham each year. Information and comments can be added before and after the event. In the cold drink section there is Bud please and If I cant have a Bacardi Ill just have a coke. He also has a swearing section but hes careful how he uses this. Cathy says the advantage of speech output is that someone can more easily attract attention

and ask questions, so they are initiating speech and communication rather than just being in response mode. The Dynamo is still just one part of Yunuss communication system. He also uses his low tech Bliss book and Rosanne is working on putting together a Communication Passport, which will help new staff build a relationship with Yunus and understand his needs and preferences more quickly. Key to all his communication and having his needs met are a supportive environment and staff with time and the necessary skills. After the initial assessment and input, Cathy only needs to visit Yunus every few months, but Rosannes ongoing role is crucial. Cathy knows that she can rely on Rosanne to put her recommendations into practice and to let her know if a problem arises. One of Rosannes priorities is to make sure all staff know that Yunus has his Dynamo when he needs it. Rosanne also meets Yunus regularly to work on his vocabulary on the Dynamo, which they are expanding all the time. In residential homes, service users benefit from having a person like Rosanne, especially if there are frequent changes of care staff, says Cathy. In addition to training staff, Rosanne supports and encourages Yunus to use his communication systems. The role of the speech and language therapist is to assess, plan and deliver intervention and then to enable the communication support officers to follow up any recommendations, supporting them as necessary.

Interactive and confident

Now that Yunus is well supported he is making full use of his low tech Bliss book and high tech Dynamo communication systems. The Dynamo means that he is able to interact much 9


cover story: skill mix more readily when he goes out and meets people. Rosanne says that members of staff have noticed a difference in Yunus since he started using the Dynamo. Hes able to be more interactive in group activities, more verbal and more confident. Cathy feels the way Leonard Cheshire Disabilitys Communication Project is accessing expertise is invaluable. Knowing my visits will be followed up is key. The communication support worker can make sure that recommendations are acted upon, which benefits the clients who may not be able to speak up for themselves. With constraints on spending in the NHS, Cathy adds it is crucial that resources and equipment are strategically deployed. The Communication Project is an excellent initiative. It utilises a collaborative approach to care, with an understanding of the importance of services being delivered where a person lives. Individuals feel more supported and are able to make the best use of their communication systems in their own environment. Rosannes enthusiasm also shows no signs of diminishing. As a communication support officer she has access to the membership benefits of Communication Matters and to equipment roadshows, healthcare exhibitions and the expertise of suppliers such as Possum. The team is also extending links with other agencies such as the ACE Centre in Oxford, University College London and Scope. So, what keeps her going? Rosanne says, I want to see it through because I have been involved for so long. I really enjoy doing the job, working with service users even on the bad days when I want to throw the laptop out! Starting with someone who may have nothing and seeing them at the SLTP end, just making that bit of difference. Rosanne Lyddon can be contacted on 01295 713250. Mike Harrison is the Leonard Cheshire Disability Communication Project Co-ordinator, Central Office, 30 Millbank, London SW1P 4QD. Leonard Cheshire Disability supports over 21,000 disabled people in the UK and works in 52 countries. It campaigns for change and provides innovative services that give disabled people the opportunity to live life their way. Visit www.LCDisability.org for more information.

Box 1 Communication training An important element of the project is the training course that Leonard Cheshire Disability staff receive, which ensures they give service users the best possible support for their communication needs. The course recently received recognition at the Greater London Training Awards, when Leonard Cheshire Disability was presented with a Highly Commended award. This is part of the National Training Awards which were set up to celebrate businesses, organisations and individuals that achieve outstanding success through training and development. The awards are sponsored by City & Guilds. The charity has so far trained approximately 250 staff and volunteers, raising awareness of communication issues and introducing AAC techniques ranging from simple symbol boards and Talking Mats to sophisticated voice output aids. The course was collaboratively developed by Tom Presland and Marianne Scobie of Leonard Cheshire Disabilitys Service User Support Team, with help from the charitys Regional Training Manager, Diane Perry. All staff who work with people with communication impairments at Leonard Cheshire Disability will attend this course over the next three years.


ACE Centre Oxford, www.ace-centre.org.uk Bliss Symbolics a symbolic graphical language, www.blisssymbolics.us Boardmaker with Picture Communication Symbols, www.mayer-johnson.com Communication Matters, a UK charity concerned with AAC needs, www.communicationmatters.org.uk Communication Passport a low tech resource to help with communication of personal information related to a persons care and preferences, www.callcentrescotland.org.uk Dynamo a symbol based communication aid with a dynamic display and digitized speech output, www. dynavox.co.uk Frenchay Hospital Communication Aid Centre and Screening Tool, www.cacfrenchay.nhs.uk/ Pathfinder a powerful communication aid with synthesized speech output using Minspeak language system accessed via a static keyboard, www.prentkeromich.co.uk Scope, a UK disability organisation, whose focus is people with cerebral palsy, www.scope.org.uk Talking Mats a low tech communication framework involving symbol sets, www.talkingmats.com University College London project evaluation, www.ucl.ac.uk/HCS/research/projects/?projectid=45

DO I SEE THE INCREASE IN SUPPORT WORKERS AS AN OPPORTUNITY TO SPREAD GOOD COMMUNICATION PRACTICE? DO I ACCESS RESOURCES FROM THE VOLUNTARY SECTOR? DO I USE PROJECT MANAGEMENT PRINCIPLES WHEN PLANNING A SERVICE DEVELOPMENT? How has this article been helpful to you? What is your experience of working with the voluntary sector and support staff? Let us know via the Spring 08 forum at www. speechmag.com/Members/


news extra

SEN outcomes debated

A private Members Bill to require central collection and annual publication of information relating to children with a range of Special Educational Needs has passed its second reading in Parliament and is being supported by the Government. A private Members Bill is a proposal for new legislation that is debated by Parliament. Sharon Hodgson MPs motivation for initiating it came from personal experience. Her son, diagnosed as severely dyslexic, has had variable speech and language therapy input depending on the familys location rather than his needs. She believes that analysing existing data and gathering new information that focuses on monitoring outcomes will raise expectations and achievement. The MP said, It will be a step in the right direction to record whether children with SEN are happy, safe, enjoying school, achieving personal targets, making a positive contribution to society and, where possible, going on to achieve independent economic well-being. We can then highlight the valuable contribution that children with SEN can go on to make. The Special Educational Needs (Information) Bill now goes forward to a Committee for more detailed consideration. www.publications.parliament.uk/pa/pahansard.htm

Anti-social networks

Ability Net has drawn attention to the ways that social networking websites, popular with young people, are excluding people with disabilities. The charity reviewed Facebook, MySpace, Bebo, YouTube and Yahoo. It says, Many of the barriers to accessibility we encountered could be easily remedied and it was shocking how little response we received when we approached the sites for advice on these issues. www.abilitynet.org.uk

Changing attitudes

Leonard Cheshire Disability has teamed up with the makers of Wallace & Grommit, Chicken Run and Creature Comforts for a media campaign to challenge and change attitudes towards disability. Creature Discomforts includes plasticine characters using wheelchairs, sticks or crutches, combined with the real voices and experiences of disabled people. Steve Harding-Hill from Aardman Animations commented that creating animated stories that are informative, entertaining and poignant has been an immense but incredibly satisfying challenge. www.creaturecomforts.org



A driving force
Dissatisfaction with their aphasia service led the Portsmouth adult team to steer a new course. Nicola Clark and Sheena Nineham take a pit stop to reflect on the journey so far and to signal the way ahead.

service development

few years ago, our team was experiencing growing dissatisfaction regarding the quality, quantity and equity of service provided to people with aphasia, along with unease over the familiar emphasis on dysphagia. At the same time we were all aware of national developments in the field of aphasia, such as the work of Connect and the British Aphasiology Society. We resolved to move up a gear so that the Portsmouth City Teaching PCT adult speech and language therapy department could also become a power behind the wheel of aphasia provision. The speech and language therapy service development plan 2003-2006 identified our Aphasia Strategy as a priority. In 2003, the department formed an Aphasia Action Group to develop and implement our Aphasia Strategy for the local service. The group comprised of five principal speech and language therapists working within neuro-rehabilitation and stroke, and was fully supported by our speech and language therapy professional advisor and adult services manager. The aims of the strategy were to: 1. create a communication friendly healthcare culture 2. promote a confident and enthusiastic service which supports and develops everyone involved with aphasia 3. provide an equitable service to people with aphasia 4. have a locally and nationally respected service. The Aphasia Action Group identified key areas to focus on, including establishing a programme of workshops for staff to promote staff education, development and support. We also wanted to adapt the British Aphasiology Society Care Pathway (Hirst, 2001) to make it more locally relevant, and to set up a rolling programme of Supported Conversation training. Supported Conversation was developed by Connect, the communication disability network, to offer people with aphasia opportunities for genuine adult conversation and interaction. It is designed to reduce the psychosocial consequences of aphasia. The conversation partner acts as a resource for the person with aphasia and actively shares the communication load; training provides the conversation partner with the methods and materials for achieving this.


L-R Principal speech and language therapists Lynn Dangerfield, Nicola Clark, Sheena Nineham, Grace Watson and Ruth Sullivan

We drew up a timeline to implement these key areas within the three-year Service Plan and allocated group members to take on lead responsibilities. The implementation of the strategy was achieved with current staffing levels by reviewing service priorities.

Many of the developments have been inspired by national initiatives and shaped to fit our needs locally.
Many of the developments have been inspired by national initiatives and shaped to fit our needs locally: 1. Resources There are now a number of departmentally-created aphasia-friendly tools (figure 1), such as: a) Goal-setting packs b) Consent forms c) A Medical Information File on the acute stroke ward d) Family and Social History Questionnaire e) Dysphagia Information f) Life History books. We have also produced resources and training packs including Aphasia Resource Files, Personalised Communication Folders for clients and Supported Conversation Training Packs. These are now widely available across the clinical bases. In addition we have invested in laptops, digital cameras and computer software including REACT, Aphasia Tutor and Speech Sounds on Cue for aphasia therapy.

2. Workshops Regular in-house staff workshops are run for our speech and language therapists to educate, develop and support staff, share best practice and maintain the profile of aphasia within the department. Topics have included feedback from courses and conferences, article reviews, clinical case discussions, reviewing new resources and developing an aphasia resource file, all of which have led to changes in our practice. The speakers for these workshops have been from within our department. 3. Groups We have formalised speech and language therapy involvement with groups and group therapy, establishing: a) Time to Talk groups for people with aphasia Groups are held at regular intervals across our health economy. Each group meets for 2 hours a week for 6 weeks. The Time to Talk groups principally aim to provide a forum for group members to discuss issues such as their experience of therapy and recovery, changes that have occurred in their life as a result of aphasia and ways in which they overcome their difficulties. It also aims to help members increase their confidence in their ability to communicate effectively with others. b) Carer Support Carers may attend all or some of the Time to Talk groups as observers. All carers complete an evaluation sheet at the end which asks them questions about any changes they may have noticed in their relative over the period of the group. Responses have shown that all respondents perceived positive changes in their relatives ability to communicate and in their confidence about communication. Many also noted that they gained useful insights into what it is like to have a communication difficulty. 11


service development
Figure 1 Excerpts from departmental resources

c) Structured speech and language therapy participation with the local Dysphasia Support / Communication Support Group This has taken the form of appointing a Link Therapist with a remit to: Work closely with the Communication Support Coordinator Provide ongoing training to volunteers in supporting people with aphasia to have conversations Meet regularly with group members on an individual basis to discuss the goals they want to achieve and to review these goals Disseminate these goals to the Communication Support Coordinator and the volunteers, with advice on how to help achieve them Provide a link between the speech and language therapy service and the group. 4. Conference We have successfully hosted a National MultiDisciplinary Aphasia Conference in 2005 (Borrett, 2006) and will be hosting another one on 12 May 2008 (see p. 13). So, has it worked? The ongoing evaluation of the service has been central to the Aphasia Strategy because its implementation has involved investment in staff time, not only in attending the workshops but also in developing and implementing the changes to our service to people with aphasia, and in new equipment which was financed by reprioritising our existing budget. It is therefore critical that the success is carefully measured and recorded. Staff views of different aspects of the strategy have been measured throughout the three years. One of these aspects has been the comparison of speech and language therapists perceptions of their own competence and confidence in working with clients with aphasia. On a self-rating scale of 0 (not competent) to 10 (very competent), pre-strategy the percentage of staff rating their competence level at 6 and above was 66.7 per cent whereas when 12

reviewed 2 years later this had increased to 80 per cent (see table 1). There was a similar shift in staff perceptions of their overall confidence levels.
Table 1 Competence Rating Rating Pre-strategy 2 years post-strategy (June 04) (June 06) 0-5 5.5 6-9 10 Average 33.3% 0% 66.7% 0% 6.0 13.3% 6.7% 66.7% 13.3% 7.1

Results such as these, taken together with staff comments gathered from workshop evaluations and questionnaires, are encouraging. They suggest we are taking positive steps towards one of the original aims of the strategy that of having a confident and enthusiastic aphasia service.

The ongoing evaluation of the service has been central to the Aphasia Strategy because its implementation has involved investment in staff time.
Obviously the main drivers for any changes made to the speech and language therapy service are those that will benefit the clients and other users of our service such as referrers, carers and the wider multidisciplinary team. One of the first areas where we wanted to effect change was within the department itself after all, it was not realistic to expect others to do what we ourselves were not consistently demonstrating. By building the confidence and competence levels within the department and the development of

aphasia-friendly material and supported conversation training to the multidisciplinary team, there have been positive benefits for clients accessing our service. For example, supported conversation ramps are now being used by the multidisciplinary team whereas pre-strategy this was not as evident. We acknowledge that incorporating user views of the service is an integral part of any development of the strategy. Whilst we have begun to seek user views on some aspects of the service, we will be strengthening the role of these through service user questionnaires and encouraging user views / feedback into service planning to take this strategy forward. Our plan is to maintain the momentum of the Aphasia Strategy by developing and implementing a clear process for users of the service to contribute to service developments organising another national conference for 2008 maintaining and updating our current developments continuing with our staff workshops carrying on group service delivery. We hope that our ongoing commitment to improving our service will enable us to take further steps towards being recognised as a driving force in the field of aphasia. For further information, please contact any of the Aphasia Action Group Members: Nicola Clark, e-mail Nicola.Clark@ porthosp.nhs.uk, Lynn Dangerfield, e-mail Lynn.Dangerfield2@porthosp.nhs.uk, Sheena Nineham, e-mail Sheena.Nineham@porthosp.nhs.uk, Ruth Sullivan, e-mail Ruth.Sullivan@ porthosp.nhs.uk or Grace Watson, e-mail Grace.Watson@ ports.nhs.uk.


Winning ways

Portsmouth City Teaching PCT Speech & Language Therapy dept. is hosting its 2nd Multi-Disciplinary Study Day on Living Independently with Aphasia on Monday 12th May 2008.
Speakers include Prof. Chris Code, Ruth Nieuwenhuis, Dr. Jane Williams & Service Users. A range of topics relating to the longer term impact of aphasia and stroke will be addressed. Cost: 70 For further information and an application form, contact Jane Singleton (tel: 023 92894534 or Jane.Singleton@ports.nhs.uk)

Winning Ways
Life coach Jo Middlemiss offers readers positive suggestions for coping with common problems.
Following her Agenda for Change job evaluation, Melanie feels undervalued, unappreciated and stuck. She is settled in the area, generally likes her job and has a reasonable standard of living. So why doesnt she feel more positive about things?


s is always the case, the way we see the problem is the problem. Projection is perception. For a long time I simply could not get my head around this theory. How can it be that I am actually the cause of my problems when it seems so obvious that another is to blame? Yes, we belong to a blame culture. Someone must be held responsible at all times - Where theres blame theres a claim! So Melanie feels undervalued - but what is she prepared to do about this situation? Feeling undervalued starts with self-esteem. Melanies job is reviewed and someone else has an opinion about it. If that opinion is valid, and Melanie respects the evaluation process, then she has choices to make. If on the other hand she does not accept the evaluation, then why is she stressing about it? It would be an interesting exercise for Melanie to turn her thinking around and ask, If I do not value the job of the evaluators, who then is doing the undervaluing? Our power to choose our attitude in any circumstance is the greatest freedom. Melanie can start with a review of her own attitude to her life and work, and be prepared to accept that no-one and nothing else is actually in charge of her attitude. Once a decision has been made to change her mind for a change then Melanie would benefit from looking at diet, exercise, mental stimulation and balance in order to regain that old joie de vivre! A good starting point might be the Power Morning Questions below. Write down the answers to these questions first thing every morning. They will concentrate your mind on the positive side of your life, even when things could be better. What am I happy about today? What am I excited about today? What am I proud of today? What am I grateful for today? What am I committed to today? Who do I love and who loves me?

How has this article been helpful to you? What impact have strategies had on your department? Let us know via the Spring 08 forum at www.speechmag.com/Members/.


Borrett, K. (2006) Conference Calls: Leading By Example, Speech and Language Therapy in Practice Spring, pp. 20-21. Hirst, L. (2001) British Aphasiology Society Newsletter. May.

British Aphasiology Society, www.bas.org.uk Computer software described all available from www.propeller.net Connect - the Communication Disability Network, see www.ukconnect.org


Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329. Jo offers readers a complimentary half-hour telephone coaching session (for the cost only of your call). While all Jos work informs Winning Ways, your contact is confidential and no personal or identifying details will be given.


Health promotion

Greater expectations
Nicola Brooke looks back on the first three years of a health promotion post which offers targeted training and multimedia resources to try to ensure that all children, wherever they live, have the opportunity to develop communication skills to their full potential.

tatistics on the prevalence of children with speech, language and communication needs vary considerably (Law et al., 1998) but anecdotal evidence and work carried out by I CAN (Hartshorne, 2006) seems to indicate the number of children experiencing delayed and / or impoverished language skills is on the increase. Whether this is due to increased awareness or an actual increase in incidence is not clear. What is clear is that the impact of such delays can be severe and long-term. Children entering school with delayed spoken language skills are unable to access the curriculum fully and consequently are at high risk of developing behavioural difficulties and low self-esteem. In the long-term they are more likely to leave school without the necessary qualifications to gain employment (Letts and Hall, 2003). To counter this, policies such as Every Child Matters and the National Service Framework (NSF) for children strive for preventative input rather than focusing on remediation of established difficulties. They call for more collaboration between services and with families. This all sounds like a good idea but - with constraints such as limited budgets and time - how can NHS speech and language therapy departments achieve this, and how can we measure the success of our input? I have been working as clinical lead speech and language therapist for health promotion for Southampton City Primary Care Trust since the post was created in 2004. Recent statistics for Southampton (DH, 2007) show significantly worse rates of GCSE attainment compared to the average in England, alongside significantly higher rates of income deprivation and children living in poverty. Consequently there is a strong need for health promotion activities within the city. I have been very fortunate to get joint funding to implement several initiatives targeting awareness of early speech and language acquisition. Each project has focused on increasing knowledge amongst practitioners and families of how to encourage normal language development and make onward referrals in a timely manner. There has been a strong emphasis on collaborative multi-agency working and inclusion of evaluation measures to assess effectiveness. 1. Training programme During the preschool years children access many professionals from health, education, social services and voluntary agencies including health visitors, nursery staff and childminders. In Southampton it is acknowledged that such 14

practitioners require support to increase their knowledge of early language development. Using funding from Sure Start local programmes and a Neighbourhood Renewal Fund, I devised a programme with colleagues for practitioners from all these services. The rationale is that if practitioners working with preschool children, especially those in deprived areas, can be skilled in supporting normal language acquisition it will help reduce the incidence and prevalence of preschool language delay. This in turn should improve academic outcomes for children. We have delivered the annual training programme three times and revised it several times based upon participant feedback. Whilst the main content has remained the same (see box 1) we now deliver it during a one day workshop rather than over 3-4 half days. We made this change to facilitate attendance, as many practitioners found it difficult to spare so many sessions from their work schedule. Alongside weekday workshops we now also offer evening workshops for childminders and others who are unable to attend during the day. Since implementing these changes attendance rates have increased from 69 to 83 per cent. Each workshop is delivered by two speech and language therapists, and lots of therapists from our department have been involved. This facilitates city wide


Over three years we have trained 164 practitioners from a range of disciplines. Participants have consistently demonstrated increased knowledge post training.
collaborative working and also ensures that all local therapists are promoting the same messages. We have evaluated the effectiveness of the workshops in three ways: I. Attendance registers allow us to monitor uptake of courses and the range of professionals trained. This is important as during early training we identified key professional groups who had not been invited and also patterns of failure to attend. These issues were then rectified for future workshops. II. Immediately prior to and following each workshop we ask participants to complete a questionnaire to assess their knowledge of areas covered. Analysis has allowed us to

quantify knowledge gained and to identify and alter teaching of particular areas where most participants failed to gain knowledge. III. Several months after completion we send participants a further functional questionnaire designed to evaluate how they have managed to implement their newly acquired knowledge into the workplace. This questionnaire also aims to identify any areas of training that could have been improved. The feedback has led us to offer refresher workshops to provide practical support to practitioners in converting theory into workplace practice. The content for example, clarifying referral criteria and procedures - is determined by requests from participants. The evaluations have shown positive outcomes in all instances. Over three years we have trained 164 practitioners from a range of disciplines (box 2). Participants have consistently demonstrated increased knowledge post training. During the most recent workshops participants showed limited baseline knowledge, with the majority achieving scores of between 0 and 25 per cent correct on the pre-workshop questionnaire. Post-workshop, 88 per cent achieved scores between 76 and 100 per cent correct (figure 1). Seventy one per cent of participants who returned a functional questionnaire rated the workshop as very good or excellent and 100 per cent reported that they could now identify children with feeding and communication difficulties. There will always be a percentage of children with specific speech and language difficulties who require specialist help from a speech and language therapist. However, empowering other professionals to facilitate communication development should help reduce the incidence of preventable speech and language delays resulting from impoverished language stimulation. 2. Literature Training professionals is just the tip of the iceberg when considering how to promote early communication development. Parental involve-



Box 1 Training course content What is communication? Pre-linguistic skills Receptive language How to recognise difficulties How to promote normal development and remediate difficulties Expressive language How to recognise difficulties How to promote normal development and remediate difficulties Developmental norms of language Creating opportunities for communication Speech development Categorising sounds Typical development and developmental processes How to promote normal development and remediate difficulties Eating and drinking Swallowing process Normal development Common difficulties and how to help Fluency Referral to the speech and language therapy service

Box 2 Range of professions trained Child minder Community health nurse Community worker Cook Crche worker Emotional literacy support assistant Family support worker Foster carer Health visitor Home play visitor Learning support assistant Figure 1 Recent workshop results 100 Percentage of participants
80 60 40 20 0

Librarian (book and toy) Nursery nurse Nursery practitioner Oral health educator Play project workers / supervisor Portage home visitor Pre-school practitioner Sessional worker Special needs practitioner Toy library van driver

Pre Post

Percentage of questions answered correctly

0 - 25%

26 - 50%

51 - 75%

76 - 100%

ment is central to success; if a parent is given the confidence they will do it for themselves rather than being done to. Yet reaching parents to promote communication development is not an easy task in a department severely affected by vacancies. In 2005, in collaboration with the local Childrens Information Service and using funding from Early Excellence in Cities, our department helped to script a magazine that could be distributed to families. This magazine contained information on how communication develops from birth to 4 years, top tips to promote development, ideas on how to manage dummies and television, the benefits of reading and singing to your child, how spoken language affects school transition and more. We circulated it to all families of preschool and reception aged children across the city and it was well received by parents and professionals alike. 3. Multimedia Following the success of the magazine the Childrens Information Service asked us to collaborate on a similar project but this time producing a DVD and CD-ROM. The use of disks rather than magazines to reach families has several benefits. The disk has been produced in the seven most used languages in Southampton so is accessible to a much wider audience. Additionally it includes video clips showing positive parent child interaction so families can learn by real life modelling rather than just reading advice. We made the videos in partnership with local families, so they are culturally appropriate to the local population. The disks cover speech and language development from birth to four. They are split into six developmental stages with each stage detailing what children should learn, how to help (using a film clip) and suitable home based items to play with. Additionally there are sections on frequently asked questions, how to seek further support and printable sheets summarising the disk content. Each disk has a section for parents / carers and a section for those who work with children.

They are due to be distributed to various locations including childrens centres, educational settings and community health teams. They will then be available to families via professionals who can support the implementation of the advice on the disk. We are also entering a number onto the city library catalogue so that parents and practitioners can always access a copy via their local library.

The disk includes video clips showing positive parent child interaction so families can learn by real life modelling.
Despite the huge success of the initiatives implemented so far, we need to address a number of ongoing challenges: a) Expectations Southampton is typical of many UK cities in that, whilst it has areas of affluence, it also has areas of extreme deprivation. Health promotion initiatives should help bridge the gap in achievement between children living in these different areas. However, one of the key factors in influencing change is altering the perception of parents and professionals that it is normal for children in deprived areas to present with delayed skills. All children entering state school have to access the same national curriculum regardless of where they live and their family circumstances. By accepting at a preschool stage that delays are normal for a particular geographical area - and consequently not providing support or referring on for specialist input - we are setting children up to fail on school entry, rather than to achieve to the best of their ability as promoted in Every Child Matters. b) Training gaps Reaching the right people for training will require ongoing analysis. So far we have accessed a large number and range of professionals but gaps

remain for differing reasons. Staff turnover is a major factor and its vital that new staff entering settings can access support. Staff shortages are also a difficulty; in Southampton midwifery shortages mean that we have been unable to provide training to this cohort of professionals, despite them being key to the right from the start approach to health promotion. c) Level of training Educating such eclectic groups of professionals certainly has its benefits such as sharing of knowledge from different perspectives and networking opportunities. However, one difficulty is pitching training at the right level to meet everyones needs. Most participants have been satisfied but some have expressed dissatisfaction at the level either being too low or too high. This is a difficulty experienced by other speech and language therapists providing training (Jack, 2004) and consideration is needed as to how to overcome this. d) Needs assessment Health promotion projects are only successful if a needs assessment has ascertained what requires promoting. One challenge to this is the evolving roles of early years professionals. In Southampton health visitors previously assessed childrens needs at 18 months and three years but are implementing a new strategy whereby assessments occur at two years and close liaison is implemented with childcare settings for children over three years. This change in service delivery will allow more time for domiciliary visiting for hard to reach families and those not attending pre-school but may result in new needs for example, will early education staff now need further training on informal assessment? Do health visitors require support regarding assessment of two year olds? Other needs may be culturally driven. Southampton is a culturally diverse city where a large number of languages are used so support is required with identifying language impairment versus delay in English as a result of bilingualism. There is also a need to train bilingual workers on how to assess bilingual children in their first language. 15


health promotion e) Outcome assessment Evaluation of the effectiveness of projects so far has shown positive results. However, most evaluation has focused on the process of the projects or how did it go? rather than the outcome or what has changed? In the climate of Every Child Matters and the NSF, we have to find more rigorous ways to measure the effectiveness of health promotion projects, both to ensure high quality input and to secure funding for further work. In Southampton we are considering several options including video studies of practitioners interaction with children pre and post training to analyse behaviour change and a longitudinal study of referrals to the speech and language therapy service. If health promotion work is successful in reducing preventable delays this study would expect to see an overall drop in referrals. Those received would be predominantly specific language impairment or language impairment related to a secondary diagnosis rather than straightforward delay. The projects in Southampton so far have resulted in an increased awareness of the importance of speech and language development in young children and how to facilitate age appropriate skills. They are being supported by other initiatives such as Sure Start and Portage groups which target early communication and feeding. However, a continued focus is required to maintain strategies that are being implemented and to establish new ideas to complement these. There are lots of challenges to overcome and, as with remediation work, we must continue to implement outcome measures to demonstrate evidence based practice. I am very aware that in Southampton we have a long way to go and that things wont change overnight. But through continued training, research and collaborative working we will be able to challenge perceptions and to educate professionals and families that all children need to develop early communication skills in order to succeed to the best of their ability and develop to their full potential. Nicola Brooke is Speech and Language Therapist, Clinical Lead for Health Promotion with Southampton City Primary Care Trust, tel. 02380 SLTP 716680.



APHO and Department of Health (2007) Southampton Health Profile. Available at: http://www.communityhealthprofiles.info/profiles/hp2007/lo_res/00MS-HP2007.pdf (Accessed: 24 January 2008). Department for Education and Skills (2003) Every Child Matters summary (2003). DfES Publications. Available at: http://www.everychildmatters.gov.uk/_files/B889EFF62F56A9E4C69778A869B3DA44.pdf (Accessed: 24 January 2008). Department of Health (2004) National Service Framework for children, young people and maternity services: Executive summary. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4089100 (Accessed: 24 January 2008). Hartshorne, M. (2006) The Cost to the Nation of Childrens Poor Communication. London: I CAN. Jack, A. (2004) How I am making a Sure Start Turning the future around, Speech and Language Therapy in Practice Summer, pp.24-25. Law, J., Boyle, J., Harris, F., Harkness, A. & Nye C. (1998) Screening for speech and language delay a systematic review of the literature, Health Technology Assessment 2 (9), pp.1-184. Letts, C. and Hall, E. (2003) Exploring early years professionals knowledge about speech and language and development and impairment, Child Language Teaching and Therapy 19 (2), pp.211-229.






The best laid plans...

Given the increasing use of percutaneous endoscopic gastostomy (PEG) tube insertion, it is important that we understand the implications for adults with learning disabilities at end of life, when many of them will also have developed dementia. Although Paula Leslie, Hannah Crawford and Heather Wilkinsons international research project to establish baselines did not go to plan, there have been useful outcomes in terms of networking, sharing information and preparing the ground for future research.
ercutaneous endoscopic gastrostomy (PEG) tube insertion is an effective way of providing nutrition, although indications for insertion are varied and controversial (see Guidelines and references in White, 1998; Stroud et al., 2003). A study of the workload of a newly formed PEG advice team based at the Royal Victoria Infirmary in Newcastle (Matthewson et al., 2001) reported that during 4 audit cycles (6 month periods) the rate of PEG insertions increased by 53 per cent, and the rate of PEG replacements by 315 per cent. The use of PEG tubes for people with dysphagia is increasing (Bannerman et al., 1997) with evidence of benefit in certain cases (Ayonrinde & Mcdonald, 2004). Concern has however been expressed about the use of PEG tubes for people with end-stage dementia or other progressive neurological disease. This is particularly the case in the United States of America, where it is now thought that more than one third of severely cognitively impaired residents in US nursing homes have feeding tubes (Mitchell et al., 2003). Within the generic care literature there is little evidence to support the use of tube feeding in people with dementia (Sanders & Bardhan, 2004; Mackie, 2001; Hoefler, 2000; Finucane et al., 1999), although the design of these studies must be considered carefully. In some cases, people received a PEG too far into the disease process and were already malnourished so it is hardly surprising the outcomes were not positive.

cal concern with the likely increase in incidence of dementia due to improved life expectancy. Early work in the USA and Ireland indicated that the types of care and the processes and protocols applicable to the use of PEG tubes are different from those in the UK. The State University of New York contributed towards funding so that we could develop themes arising out of their preliminary work (McCarron & Lawlor, 2003, McCarron et al., 2005). We hoped to provide useful baseline information to contribute to the development of an evidence base concerning the use of PEG tubes in the UK for adults with learning disabilities at end of life.

Paula Leslie

Hannah Crawford

Heather Wilkinson

We hoped to provide useful baseline information to contribute to the development of an evidence base
PEG tube feeding decisions and related experiences are also of great importance in other population groups, particularly where end of life issues and progressive incapacity such as dementia are involved. It is essential that decisions surrounding feeding in any population group are as consistent as possible, making the best use of available evidence, to ensure optimum care for patients.

Critical concern

Nutritional and other benefits have been found with the use of PEG tubes for adults with learning disabilities (Kennedy et al., 1997) but there is a lack of published evidence on the use of PEG tubes for this group at end of life. In the learning disabled population, people with Downs syndrome have a higher incidence of dementia than the general population (Cosgrave et al., 2000). Understanding the use of PEG tubes for adults with learning disabilities is an ever more criti-

Lay the foundation

Our exploratory study, in collaboration with State University of New York, was the first of its kind in the UK. It was designed to build on existing evidence and lay the foundation for future larger studies within the field of adult learning disability, dementia and other progressive neurological illnesses. We intended that the

results would identify areas for further research associated with feeding decisions for adults with learning disabilities at end of life. This would include identifying areas of consistency in the experiences of the client group with PEG feeds which could be compared to a control group of orally fed adults with learning disabilities, or to adults from a different population group who were also fed by PEG tube. We also intended that the study would support the production of guidelines for decision-making surrounding non-oral nutrition / hydration for adults with learning disabilities. Finally, we wanted to validate the assessment tool used in the Irish and American studies with a view to developing it for prospective studies that would build on the issues identified from analysis of the data collected in the course of this study. In addition to the authors, the research team comprised Christine Armstrong, Triage Nurse, and Dorothy Matthews, a Specialist Macmillan Nurse, both with Northgate & Prudhoe NHS Trust. We planned a retrospective review of closed files from the past 10 years of adults with a diagnosed learning disability who had had a PEG tube fitted in the 12 months prior to their death. The purpose was: a) to gather data on the reasons for PEG tube use and selected health experiences pre and post insertion, and b) having established an average period from the time of tube insertion to death, to gather data for a corresponding time period on the same selected health experiences for people with learning disabilities with certain matched characteristics but without PEG tube intervention. Local Ethical Favourable Opinion was granted by Northumberland Local Research Ethics Committee. Consent was not necessary under the Data Protection Act 1998 due to the records being closed. We examined the closed records held by an NHS Trust to identify those people who had learning disabilities and had had a PEG tube 17


RESearch inserted within 12 months prior to the date of death. Data collection focused on a list of case files drawn from the medical records database and from personal historic knowledge of patient deaths in the last ten years. The Trust is a specialist provider of services for adults with learning disabilities. We recognised there may have been people with learning disabilities in the community who had a PEG tube inserted at end of life, but limited resources meant we did not search GP records. The assessment tool was based on a record-review template previously field-tested in the Irish and American studies and developed with input from the research team. We used a checklist format and added qualitative narrative alongside entries explaining decisions made and raising questions about the data. The research team discussed notes and questions to reach consensus on how recordsbased data were recorded on the template. Key data elements included demographic characteristics of the patient, diagnosis, documented reasons for PEG tube use, incidence of chest and mouth infections, pressure sores, skin breakdowns, incidence of diarrhoea and vomiting, weight loss and gain and incidence of restraint use. We recorded medications that were being administered at the time of PEG tube insertion and at the time of death. We also noted indicators for dementia including formal diagnosis, observations of confusion and memory loss and medications such as Aricept (used in the treatment of some dementias).


Researcher reliability is an issue with any assessment tool. We aimed to maximise reliability by a pre-investigation study session in February 2005 to familiarise the researchers with the assessment tool and with practical issues experienced in the previous studies. Dr McCallion and Dr McCarron flew to Newcastle specifically to lead and facilitate this session. The researchers contributed to the development of the tool and were familiar with it.

In attempting to perform this piece of work a group of clinicians and researchers came together who otherwise might not have met
The project was funded from 1 January 2005 30 June 2005. Development of the project design and methodology and initial contacts with the Trust took place in January. A focus group meeting and assessment tool training session at the start of February was attended by the research team. The data collection period started

on the first available session following Local Research and Ethics Committee and Research & Development approvals. Two further focus group meetings took place at the end of April when analysis of the collected data was about to commence, and at the end of May in order to comment and advise on data, analysis and initial findings. A number of difficulties encountered with data collection proved to be too serious to overcome during this pilot study; this information is vital to inform the design of future studies. 1. Locating complete sets of notes was the most serious barrier. Once a person died, their notes were often fragmented and impossible to collate. 2. Notes were not formatted correctly 3. Large volume of notes per client 4. Environmental problems, such as a lack of space to decant large volume of notes per client 5. Lack of clerical support within the medical records division for locating records 6. Template was complex and did not match up with the case note sequence. Although we were unable to complete the study as originally intended we were able to host a study day, open to a wide range of disciplines who work with adults with learning disabilities and / or dementia. Attendees included health care assistants, nurses, speech and language therapists, occupational therapists, physiotherapists and hotel service representa-



Salary range of 23,458 - 31,779 pro rata dependent upon experience
Stockport Cerebral Palsy Society is a dynamic and forward thinking voluntary organisation which is proud of its record of providing high quality care services. We are looking for an enthusiastic therapist who is able to work independently and has experience of working with adults who have learning disabilities and complex needs. The work will initially be within our Skills Group day service for adults with complex disabilities but there is scope for further developments within our other services. The hours of work will be between 10 and 20 hours per week. Days and times of working are by negotiation but need to meet the needs of the service. A minimum of 2 years post-qualification experience is required. The successful candidate is likely to have experience using alternative and augmentative communication devices and experience in dysphagia management. For further information or to arrange an informal visit please contact Sarah Thomas, Skills Group Manager on 0161 432 1248. For an application pack, please contact Stockport Cerebral Palsy Society Recruitment Line on 0161 432 5252 or e-mail admin@stockportcp.co.uk. Please quote ref. no. S39 Closing date Friday 4th April 2008

3 day Specialist Speech and Language Therapy Course 16th to 18th April 2008 Sheffield
The Downs Syndrome Association has commissioned Symbol UK Ltd, who provide specialist speech and language therapy services for people who have Downs syndrome, to offer a three day course for speech and language therapists. Topics covered include: the needs of the client group across all ages; research underpinning Evidence Based Practice; and designing and delivering effective interventions. For further information or to book a place please contact Lesley Alabaf at Downs Syndrome Association, on 0845 230 0372 or email lesley.alabaf@downs-syndrome.org.uk



RESEARCH tives. The research team presented on several issues and held discussion groups around practical questions. Themes from the discussions included issues around current practice, what makes for successful intervention, our professional roles who is involved in this area and what do we do, end of life issues, and directions for future research. There are a number of future studies now in development and the research group is working on grants for submission in the near future. phagia in people with learning disabilities. We are beginning an investigation into the prevalence of dysphagia within a finite population of adults with learning disabilities. We retain a keen interest in the issues of ageing, ethics and risk that are related to dysphagia. We are also investigating how we might involve service users in our research, and how they may be able to give us some indication of how dysphagia affects their quality of life. The findings from these projects will have direct relevance to all vulnerable people facing such difficulties at the SLTP end of their lives. Paula Leslie is an Associate Professor at the University of Pittsburgh, USA, and an RCSLT Professional Advisor, e-mail pleslie@pitt.edu. Hannah Crawford is a consultant speech and language therapist for Tees, Esk & Wear Valleys NHS Trust working with adults with learning disabilities and dysphagia, e-mail Hannah.Crawford@cddps.nhs.uk. She is also an RCSLT Professional Advisor. Heather Wilkinson is Co-director of the Centre for Research on Families and Relationships at the University of Edinburgh, e-mail hwilkins@ staffmail.ed.ac.uk.

Generated ideas

In attempting to perform this piece of work a group of clinicians and researchers came together who otherwise might not have met. As far as we are aware, such a group had not formed before in this field and this generated ideas from a new mix of backgrounds. The study has led to the formation of a working group that includes the authors and Dorothy Matthews with Lynn Gibson (Physiotherapy Manager) and Dr Claud Regnard (Consultant in Palliative Care Medicine). Work based on group discussions and developed from the study day was accepted after peer review for an oral presentation at the American Speech-Language-Hearing Association (ASHA) Convention 2005. This is the largest international meeting of speech and language therapists in the world with over 12,000 delegates. The title of the meeting was Using Evidence to Support Clinical Practice. Around 275 people attended the session at 8.00 am on the first day of the convention, a clear indication of the clinical relevance. Lively debate ensued and discussion covered the literature, clinical experiences and real case studies. Several differences between UK and USA practice, legislation and ethos were highlighted. The lack of evidence in this field was emphasised again. This indicates the importance of future research. We also held a seminar on eating and drinking issues in Edinburgh (2006) at the meeting Practical approaches to supporting adults with learning disabilities who are growing older.

We are also investigating how we might involve service users in our research, and how they may be able to give us some indication of how dysphagia affects their quality of life.
Research needs to be planned carefully but even the best laid plans can go awry. Generally you should not deviate from a research protocol changing the method half way through negates the value of your results and shows you hadnt thought the process out properly to start with. Careful monitoring of the data gathering allowed us to see where a problem was arising but the protocol was followed in the knowledge that the closed cases did exist; in the end the barriers encountered in gathering complete data meant that the project ran out of time and resources. One positive outcome of the research team working together was the associated study day which gave immediate benefit to the participants in knowledge sharing and further ideas for us to work with. The area of nutrition support methods for adults with learning disabilities and at end of life is of direct clinical relevance and is increasing in priority. The multidisciplinary research group remains committed to investigating dys-




Ayonrinde, O.T. & Mcdonald, J.A. (2004) Indications, appropriateness and 30-day outcomes of patients referred for percutaneous endoscopic gastrostomy (PEG) tube insertion, Journal of Gastroenterology and Hepatology 19 Supp Oct A233. Bannerman, E., Pendlebury, J., Philips, F. & Ghosh, S. (1997) Increase in percutaneous endoscopic gastrostomy (PEG) feeding - Implications for the workload of a nutrition support team, Gut 41(4S) Supp October 90A. Cosgrave, M.P., Tyrrell, J., McCarron, M., Gill, M. & Lawlor, B.A. (2000) A five year follow-up study of dementia in persons with Downs Syndrome: early symptoms and patterns of deterioration, Irish Journal Psych Med 17(1), pp.5-11. Finucane, T., Christmas, C. & Travis, K. (1999) Tube feeding inpatients with advanced dementia: a review of the evidence, JAMA 282, pp.136570. Hoefler, J.M. (2000) Making decisions about tube feeding for severely demented patients at the end of life: Clinical, legal and ethical considerations, Death Studies 24, pp.233-254. Kennedy, M., McCombie, L., Dawes, P., McConnell, K. & Dunnigan, M.G. (1997) Nutritional support for patients with intellectual disability and nutrition/dysphagia disorders in community care, Journal of Intellectual Disability Research 41(5), pp.430-436.

Mackie, S.B. (2001) PEGs and Ethics, Gastroenterology Nursing 24(3), pp.138-142. McCarron, M. & Lawlor, B.A. (2003) Responding to the Challenges of Ageing and Dementia in Intellectual Disability in Ireland, Ageing and Mental Health 7(6), pp.413-417. McCarron, M., Gill, M., McCallion, P. & Begley, C. (2005) Health Co morbidities in Ageing Persons with Down syndrome and Alzheimers dementia, JIDR 49(7), pp.560-566. Matthewson, K.,White, S., Torrance, A., Clark, S. & Bottrill, P. (2001) A prospective study of the workload of a newly formed PEG advice team, Journal of Human Nutrition & Dietetics 14(1) pp.21-23. Mitchell, S.L., Teno, J.M., Roy, J., Kabamoto, G. & Mor, V. (2003) Clinical and Organizational Factors Associated With Advanced Cognitive Impairment, Journal of the American Medical Association 290(1), pp.7380. Sanders, D.S. & Bardhan, K.D. (2004) Feeding tubes in dementia: is there an effective UK strategy?, BMJ 329, pp. 917-918. Stroud, M., Duncan, H. & Nightingale, J. (2003) Guidelines for enteral feeding in adult hospital patients. GUT 52 (Suppl VII): vii1 vii12. White, S. (1998) Percutaneous endoscopic gastrostomy (PEG), Nursing Standard 12(28), pp.41-47.



Switching on a Light - An Introduction to life story work Dementia Services Development Centre (www.dementia.stir.ac.uk) ISBN 978 85769226 6 45.00

Raises awareness

in stammering may find some useful pointers to treatment planning. In this country, a more holistic approach is common in dealing with the complexities and treatment of stammering. At 51, probably a borrow rather than a buy. Pat Cuthbert is a paediatric speech and language therapist working for Weston Area Health Trust in North Somerset.

An easy to follow ten minute DVD with excellent accompanying booklet. This publication raises awareness of life story work and the booklet includes a training session outline for staff. The publisher recommends the DVD may be of interest to people with dementia and their family. Sensitive consideration of this is required due to the sad description of loss in dementia accompanied by melancholic music. Nice illustrations of life story work are incorporated but the DVD is principally an overview presented in a somewhat dated style. Communication issues and sad memories, important aspects of life story work, are not addressed in the DVD however these are covered in the booklet. Consequently it should be stressed the booklet and DVD always be used together. Overall, a practical introduction for staff wanting to embark on life story work or offer training. Laura Brierley is a speech and language therapist in older peoples mental health in Stockport for Pennine Care NHS Trust.


Understanding Me Susan Stewart & Amanda Hampshire STASS ISBN 978-1-874534-44-0 35.00

A lot to be gained


Treatment Protocols for Stuttering M.N. Hegde Plural Publishing ISBN 1-59756-050-2 51.00
The novel approach of this book made for interesting reading! The protocols are written as scripted scenarios for the therapist to follow. Behavioural treatments are given for preschool, school-age and adults who stammer. The eight options include Fluency Reinforcement, Response Cost, Fluency Shaping and Pause and Talk. The school-age protocols, the maintenance strategies and a few of the recording sheets have been useful in my work. A CD is provided for the therapist to individualise the recording sheets. Therapists beginning to specialise

Understanding Me is a valuable programme for older pupils at Key Stage 3 (age 11-14 years) where group members focus on understanding themselves and the nature and impact of their communication disorder. Diagnostic terms such as language impairment, attention-deficit / hyperactivity disorder and autism spectrum disorder are clearly illustrated and explained. This occurs sensitively, within the positive framework of multiple intelligences, such as Picture / Musical / Nature Intelligence, so that strengths and weaknesses are discovered. Lots of clear charts and activities produce an individual folder of work. Although outlined over 12 sessions, given the nature of the disorders a much longer period would be more realistic, as there is a lot to be gained from this useful and interesting programme. Diane Cond now works as an independent speech and language therapist, specialising in dyslexia.

the pleasures and potential pitfalls of running groups - sharing practical tips and inspiration to get you started. As many of the contributors are from the United States there are some parts, such as reimbursement, which are not so relevant but the overall usefulness of the book shines through. I have run groups for people with dysphasia and for people who stammer, and my inspiration for getting started was Aura Kagan, one of the contributors to this book. I would recommend this as a useful addition to any departments bookshelf especially for those who may be struggling to get the idea of group work across to reluctant purchasers. Belinda Walker is a speech and language therapist working at the Richard Stevens Stroke Unit at the William Harvey Hospital in Ashford, Kent and in the community - mostly following up stroke patients but also dealing with an acquired neurological and stammering caseload.


Childrens Comprehension problems in Oral and Written Language a Cognitive Perspective Kate Cain and Jane Oakhill (Eds) The Guilford Press ISBN 978-1-59385-443-0 25.95

Informative analysis

Sharing Books And Stories To Promote Language And Literacy Anne van Kleek (Editor) Plural Publishing ISBN 1-59756-091-X 35.00

Examines the evidence

This book provides a current informative analysis of why some children struggle with reading comprehension. The authors use a wealth of research to describe cognitive processes involved in comprehension difficulties. Importantly for practice, the inter-dependency of verbal skills, verbal comprehension and reading comprehension is discussed. The editors open with a chapter on typical comprehension development followed by reading comprehension difficulties. International academics contribute the next seven chapters with a focus area, including children with autism spectrum disorder; specific language impairment; attention-deficit/hyperactivity disorder and skilled deaf readers. I recommend this book to any speech and language therapist, psychologist, teacher and graduate student with a specific interest in literacy and comprehension difficulties. Lindsay Malekzai is a lead clinician in the schools speech and language therapy service in Bexley PCT.

Some useful pointers GROUPS - ADULTS

Group Treatment of Neurogenic Communication Disorders: The Expert Clinicians Approach (2nd edn) Ed. Roberta J. Elman Plural Publishing ISBN 1597560707 38.00

Highly readable

This book is both informative and highly readable. The first chapters focus on the evidence for the efficacy of group treatment and how to prove this. Later chapters are written by experienced clinicians about both

Book-sharing or dialogic reading has been championed as a powerful means of providing the foundations for decoding text and facilitating higher language skills. To this end, the governments Bookstart scheme provides families with books for all young children. However, not all families have the necessary skills or confidence to read with their children. Furthermore, there is evidence of cultural differences in book-sharing styles which may interfere with the assumed benefits. This collection of papers examines the evidence from which we may understand and promote the key elements of shared reading most likely to produce desired outcomes. The text would be of particular interest to therapists working with Sure Start Childrens Centres and Foundation Stage staff. Beryl Hylton Downing is Speech & Language Therapy Co-ordinator, Gateshead Childrens Centres.


Supportive Parenting Becoming an advocate for your child with special needs Jan Starr Campito Jessica Kingsley Publishers ISBN 978-1-84310-851-1 14.99

One dimensional

I came to this book as both a parent and a professional but found the American context and approach too difficult to relate to a UK setting. It aims to enable parents to be active in supporting their children with special needs by giving practical guidance on obtaining assessment, diagnosis and ongoing intervention. It provides a clear, analytical approach to gaining resources and includes useful guidance on managing your own emotions and preparing yourself as a parent for moving into an adult relationship with your child.




However, it does not touch on the heart of parenting, which is about supporting development through a nurturing relationship. This book is a guide to advocacy the American way. Illustrations from her own experience of parenting children with autism spectrum disorder show her own determination to access resources and drive her children to improve, but do not have wider application to the many families we work with. Advocacy became a way of life for this author. It was a campaign and there were battles to be won. Parenting is so much more than advocacy and ultimately so much more rewarding. This book is one dimensional - only read it if you want to understand how some families become entirely consumed by special needs. Karen Davies is Professional Manager for Speech and Language Therapy, Trafford PCT.

Creating Family Harmony Through Tanka: an appeal for educational reform in the 21st century Katsumi Okabe Noble House ISBN 1-56167-976-3 $19.95 (USD)

Personal viewpoint


Planning to Learn creating and using a personal planner with young people on the autism spectrum Kelly Harper-Hill and Stephanie Lord Jessica Kingsley Publishers ISBN 9781843105619 24.99

Practical focus

This practical book outlines how to make a personal planner with a young person on the autistic spectrum. The focus is on developing organisation, thinking and coping skills. The book contains 13 easy to follow session plans with photocopiable worksheets. These cover 5 topics starting with making a planner followed by plans: to calm, to be organised, to be with people and to think. This book is likely to be of interest to teachers, support workers and therapists working with young people (secondary aged and above) with autism spectrum disorder in education or community settings. This would be a good resource for settings working with this client group and speech and language therapy departments may wish to have a reference copy. Some of the material may also benefit young people with specific language impairment. Hilary Platt works as a speech and language therapist for West Sussex PCT and independently as part of Springboard Speech and Language.

From a simplistic perspective, this is a text that argues for a social model of care with the use of poetry as both a communication vehicle and a rehabilitation tool. Tanka is an ancient form of Japanese poetry containing 3-5 lines and few words. Okabe believes that personal growth depends on family harmony and that the familys role is not only an opportunity but a necessity in rehabilitation. He believes that Tanka can be a method of both developing and expressing this harmony and that there should be a shift to family focused policies in healthcare. Much of the book is Tanka itself. It taught me something about Japanese culture but this rather limited book was more personal viewpoint than explanation or evidence. Sharon Owens is a speech and language therapist working in Dorset with adults who have acquired neurological disorders.

An interesting read, crammed with fascinating information that would enhance any clinicians understanding of this often controversial topic. Study findings are presented clearly and an excellent bibliography for each chapter is up-to-date and relevant. However, it felt highly technical and scientific in places, making it difficult to tease out information relevant and useful to practice. The formal style and academic nature is maybe more suited to those studying or researching cognitive aging. Overall this was detailed, thorough and enjoyable - and certainly worth a look. However, it feels a little expensive for a book thats neither an easy read nor readily applicable to a busy clinical setting. Elise Croot is a speech and language therapist with Independent Speech and Language Therapy Services Ltd (www.islts.co.uk) working with adults in Norfolk and Suffolk.

this revised edition gives enough easily accessible information and readily useable material to make it a very useful resource for students, newly qualified and specialist therapists alike. Marion Yoxall runs a paediatric outreach speech and language therapy clinic for Bexley Care Trust, managing a varied general caseload and is also the trusts dysfluency specialist.

Riddles, Rhyme & Alliteration Jane Turner Speechmark ISBN 978-0-86388-600-3 30.99
The author wrote this book to encourage children (aged 47 yrs) to listen, concentrate and consolidate their knowledge of phonics. Each section targets one of 18 word initial consonant phonemes and contains 8 different activities: 1. Riddles (guess the target word) 2. Alliteration (do two words have the same / different initial sounds?) 3. Tongue twister sentences 4-5. Odd word out (initial sounds and rhyme) 6. Segmenting & blending CVC words 7. A story containing many target sound words to identify 8. A word search. My mainstream education colleagues felt that the book could be used as an extra to activities suggested in the Letters and Sounds programme (www.standards.dfes. gov.uk/local/clld/las.html), but was expensive and not essential. However, I found the activities ideal to support phonology programmes for school-aged pupils in Key Stages 1 and 2 (Scotland P1-P6). Pictures are provided and each activity is clearly explained, ready to photocopy and give direct to school staff. The activities would be ideal for children who can produce sounds in words but need the opportunity to practise and consolidate their use outside the therapy session. I only wish that the activities had more examples and other sections were available for medial and final sounds! A very useful therapy resource that is ready to use in any phonology programme and will save preparation time for any busy therapist. Carolyn Player is a specialist speech and language therapist working with hearing impaired children in the London borough of Bexley.


Ready to use


Working with Dysfluent Children (revised) Trudy Stewart & Jackie Turnbull Speechmark ISBN 978-0-86388-514-3 36.50

A very useful resource


Mild Cognitive Impairment International Perspectives Ed. Holly A. Tuokko & David F. Hultsch Psychology Press ISBN 1841694665 55.00

Interesting but highly technical

Mild Cognitive Impairment has been identified as an important clinical transition between normal aging and the early stages of Alzheimers disease. Since treatments for Alzheimers disease are most likely to be most effective early in the course of the disease, Mild Cognitive Impairment has become a topic of great importance all over the world. This book brings together these differing perspectives and details individual projects, theories and interventions.

This book offers many practical approaches to both assessment and therapy for dysfluent children. There is updated discussion of theoretical models and all stages of stammering, early, borderline and confirmed. Importantly it looks at both overt and covert features. Well laid out with summaries and case studies, it contains checklists / information sheets, word / sentence lists, and also outlines for group therapy, all saving much time on planning and making resources. Good reference is also made to materials available from other sources. I particularly liked the excellent section on nursery / school observation, consultation with teachers and ideas for teacher training. Whilst acknowledging service constraints the authors encourage us to continue to include the child and carers in choices about treatment, basing clinical decision making on the needs of the individual. Ever more pertinent will be the section on outcome measures. This text brings together many of the principles and approaches used when managing this client group. Reasonably priced and easy to dip in and out of,




Following an acquired brain injury in 1991, Peter Testers life moved in a new but ultimately rewarding direction. He now offers tuition in information technology to learners with severe neurological difficulties as part of a project to enhance their quality of life. Here, Peter focuses on the benefits and challenges involved.

work as part of a specialist team which offers Enhancing Quality of Life (EQOL) provision to learners with severe neurological difficulties. The team consists of four tutors, two of whom have brain injuries, and twelve learning facilitators, including one who has a brain injury. The service we offer includes options to attend communication sessions, art, ceramics / pottery and information technology. Enhancing Quality of Life (EQOL) is free at the point of delivery, and learners can access it while they continue to meet their individual learning goals. EQOL has been part of the provision offered by the Division of Student Entitlement at Somerset College since September 2002. The University of Cambridge, the Learning and Skills Development Agency carried out research to evaluate programmes for people with profound / severe and complex learning difficulties and to encourage and support additional provision throughout the country. We became a pilot college as a result of this. The majority of the learners have acquired brain injury, but a small number with brain injury from birth are included because this is the most appropriate course for them within the college. Some learners are mobile with good oral skills but memory difficulties, while at the other end of the spectrum we have learners who are manual wheelchair users with limited use of their hands, severe communication difficulties and unusual sleeping and waking patterns. Learners are referred by the local hospital, speech and language therapists, Brain Injury Rehabilitation Trust, social services, private nursing homes and individuals. The referral route is by phone, e-mail, letter or in person to the curriculum leader Julia Tester. She then meets with the prospective learner and the referring agent to discuss interests, support needs, health and safety issues, staff training requirements and goals.

learners range in age from twenty one to over seventy. Goals are set through discussion with carers, learner and tutor and range from a learner showing that they can consistently use the mouse buttons to moving the mouse to the left or right as directed. One particular learner, who has been with me for nine months, had an initial goal of Use mouse button and has a current learning goal of Follow instruction to access Internet. At the other end of the spectrum a learner has the goal to Follow instructions and produce 10 pieces of work on Leisure and Tourism, the current topic. Another learner with memory impairment has goals to log on independently (including his password), receive and send e-mails and produce a PowerPoint presentation on Leisure & Tourism. Learning facilitators monitor and record progress towards goals on a pre-printed record sheet. This record is shared with the learner and carers at regular reviews either at college or at the learners care / nursing home.


Goals are set through discussion with carers, learner and tutor
Sessions start with a group activity such as taking part in an online crossword. This is to encourage communication but also to allow for learners to come in at different times (due to transport issues) without disrupting the presentation of the days IT activity. During these group activities learning facilitators assist learners who have little or no speech and provide symbol or sign options or encourage hand squeezes to make choices. Using the interactive whiteboard, I then demonstrate the task of the day. This might be searching the internet for information on the current topic or using the information found to create PowerPoint slides. Learners are encouraged to ask questions and ample time is given for them to do so. Learners then access their e-mail accounts to communicate with each other and to receive an e-mail from me as part of the input of the sessions lesson.

To encourage and enhance their use of the mouse, some learners follow individual learning plans and use Intellipics software or the online games which are part of the EQOL website (www.eqol.co.ok). The class cupboard has a Giant Tracker Ball Mouse, various shaped joysticks and Intellikeys. The computers have Intellipics software installed and each learner has accessibility settings, including sticky keys, configured with their log-on. We find the Giant Tracker Ball Mouse helpful for some learners with problems using their fingers as it allows them to manipulate it by rolling it with their palm. The joystick has proved beneficial for two learners who find it hard to open their hands fully as the slim grip allows them to manipulate it without needing to have a wide grasp. Intellipics a beautiful piece of software based on images has been excellent for learners who are unable to follow text. I have found the Sticky keys setting helpful for learners who are unable to lightly press and release keys.

One-to-one support

Linked curriculum

The curriculum for all the EQOL topics is linked so that lessons have the same focus. My role is to deliver information technology (IT). I follow the topics of the communication lessons but with the learners using the internet and email to gather information. Classes of about five 22

Most learners require one-to-one support and it is beneficial if the person supporting has knowledge of the subject and of the learners needs. Absences are an ongoing difficulty and cannot be planned for, or always dealt with through replacement. If we have enough notice we can sometimes call in a relief staff member (although the relief team is not large). The other option is to ask the care home to send in support for that session and if they have enough staff on rota they will often do this. On a practical level the need to keep copious and detailed records to evidence every small step forward is sometimes a burden on staff who are only employed to deliver / support on specific sessions. Late arrival and early departure of learners due to dependence on community or care home transport also causes minor disruptions to sessions but we plan the lesson delivery to minimise this difficulty.


COMMUNITY LEARNING When considering the learners own barriers one of the greatest must be severe memory impairment requiring constant repetition. Due to this, the pace of the session is slow and we regularly return to previous learning in order to maintain and further develop skills. No one would feel that these difficulties in any way detract from the rewards of seeing increased confidence, self-esteem and communication blossoming within the groups. Another bonus is hearing and reading the views of carers and families on learner progress. progress with their learning. On the internet we found AbilityNet (www.abilitynet.org.uk) and also learnt from Speech & Language Therapy in Practice, in which we read an article about CATS (Computers and Therapy Support) and their project with IT and people with brain injury (Styles et al., 2006). We then made contact and have been to meetings. We work closely with the Brain Injury Rehabilitation Trust, local care / nursing homes and social services. We have had contact with the excellent ABIES (Acquired Brain Injury Education Service) at Evesham College, and we attend various brain injury conferences. This year Julia attended a conference at the Royal Neurological Hospital where we learned of cutting edge work being carried out with brain-computer interfaces. We aim to offer teaching and learning online for those who are too unwell to attend college. The developing website www.eqol.co.uk will hold lessons that can be accessed from nursing and residential homes and we will work closely with the carers there. This is a new venture and the college is allowing Julia and me to work with a group of new learners at their home to establish how best to implement this outreach distance learning. The college also offers care home staff access to some of the training provided for college staff, and this is reciprocated. Whilst we feel we have developed some expertise we realise there is still a great deal to learn. We are excited about the possibilities of e-Learning and welcome comments and ideas relating to our website. Peter Tester is an EQOL IT tutor at Somerset College, e-mail peter@eqol.co.uk. For further information about EQOL at Somerset College, contact the Curriculum Leader Julia Tester, tel. 01823 366525, e-mail: julia@eqol.co.uk. See also Tester, J. (2007) Shifting perceptions, Speech & Language Therapy in SLTP Practice Summer, pp. 4-5.

news extra
Sight after Sixty
The Eyecare Trust has highlighted the consequences of elderly people missing out on regular eye checks, such as depression and falls. A Sight after Sixty investigation found that more than a quarter of those surveyed said the quality of their vision restricts their daily routine and more than half said it prevents them from reading books and magazines. False perceptions about the cost of checks and glasses seem to be a barrier. The charity wants to raise awareness of the importance of regular checks. As well as enabling early detection of medical conditions, this ensures people can have the correct prescription and so prevent vision-related falls. http://eyecaretrust.org.uk

Personal development

Finally there is our own personal development and growth of communication skills. I am told that I used to have hesitating gaps when I was delivering to the class and that now I speak louder and more fluently. I do feel more relaxed addressing a group.

Dependence on community or care home transport causes minor disruptions to sessions but we plan the lesson delivery to minimise this.
My background is in computer programming, and I had my own business prior to a brain injury resulting from a car accident in 1991. I have specific difficulties in recalling names but I am able to learn facts. After my disability I successfully completed my Certificate in Education, LeTOL (learning to teach on line) and ITOL (implementing teaching on line). I believe that my own memory difficulties enable me to have greater understanding of our learners as I too need strategies for learning that can be employed by some of them. I find that the rate of delivery of the lessons needs to be steady and particularly - that topics need to be clearly separated to avoid the confusion caused by trying to hold simultaneously onto several threads of thought. Vital to the success of our work is evaluating and supporting each learner in finding the hardware and software that enables them to

Read for pleasure in 2008

The National Literacy Trust wants reading for pleasure to come top of the literacy agenda in 2008. The organisation also suggests that a greater emphasis on non-traditional media such as magazines, websites and e-mail will engage more young people with reading and help them to see themselves as readers. www.literacytrust.org.uk www.yearofreading.org.uk

Dyslexia pilot


DO I TAKE ACCOUNT OF INEVITABLE PROBLEMS WITH COMMUNITY TRANSPORT IN MY PLANNING? DO I FOLLOW UP ARTICLES AND USE CONFERENCES AND THE INTERNET TO EXCHANGE IDEAS, RESOURCES AND EXPERTISE? DO I VIEW MY WORK AS A LEARNING CONTEXT FOR BOTH CLIENTS AND PROFESSIONALS? How has this article been helpful to you? Are your clients getting the opportunity to access community learning? Let us know via the Spring 08 forum at www. speechmag.com/Members/

A pilot scheme to help children who have dyslexia has been launched in England. A result of the Every Child a Reader programme, the scheme will provide intensive support for children in 10 local authority areas, half receiving one-to-one Reading Recovery support and the other half receiving one-toone tuition from specialist dyslexia teachers. Funding has also been provided for Dyslexia Action to run Partnership for Literacy pilots in a further 10 schools and for the British Dyslexia Association to develop their helpline. www.dyslexiaaction.org.uk/ www.bdadyslexia.org.uk/


Styles, V., Woodward, S. & Davies, A. (2006) Windows of opportunity, Speech & Language Therapy in Practice Autumn, pp. 24-25.

Teacher training


Brain Injury Rehabilitation Trust www.birt.co.uk/ Intellikeys and Intellipics www.synapseadaptive.com/intellitools/IntelliKeys.html Joysticks and roller balls/trackballs, keyboards and a range of mice - www.techready.co.uk/ Assistive-Technology/Trackballs-and-Joysticks Sticky keys - www.microsoft.com/windowsxp/using/setup/learnmore/tips/le1.mspx Track Ball Mouse - www.dyslexic.com/itemdesc.asp?ic=2225&eq=&Tp=

Speech and language therapist Gillian Bolton would like to hear from speech and language therapists and teachers who would be interested in attending a training day to become APEC course leaders. APEC2 (Assessing and Promoting Effective Communication) is a training package for use in schools which Gillian wrote about in our Winter 06 issue (www.speechmag.com/ Members/). www.apectraining.co.uk / tel. 01788 576488



Our in-depth reviews help you decide if an assessment would meet your needs. Here, readers consider the Communication Development Profile for young children with learning disabilities and the Communication Disability Profile for use with people with aphasia.

Assessments assessed

Communication Development Profile

Kathy Sherrit and Rachel McDermott find this a well organised and holistic way to describe a childs communication and identify appropriate therapy goals.

Communication Development Profile Charlotte Child Speechmark 45.99 + VAT

The Communication Development Profile is a questionnaire based clinical tool in CDROM and book format which aims to enable adults who know a child well to contribute to assessment and goal setting. It provides a shared understanding of where the childs communication skills lie in comparison to each other, resulting in a better understanding of the speech and language therapists clinical decisions and recommendations for therapy. It does not claim to be a standalone assessment and suggests the use of formal assessment where appropriate. While it is built around the P-Levels used in the English Teaching curriculum, it is not reliant on them and can be used independently to support joint discussions based on speech and language therapy findings within the extended curriculum in Scotland. The Profile describes five key areas of communication development from birth through to the development and use of grammatical sentences: Attention Comprehension Expression Sound system Use of Communication. There are questionnaires for each area which provide a framework for discussion with a parent and / or carer. There is also an overview 24

form (Communication Profile Grid) which gives a clear summary of the childs communication abilities demonstrating areas of strength and weakness. This should be particularly useful as evidence to demonstrate where therapy / support should be focused or, indeed, whether speech and language therapy intervention is actually required. Charlotte details an interesting intervention approach that may be useful when redesigning services to special schools. She suggests different types of input depending on the childs Communication Phase: Early Communicators - Indirect support through helping carers recognise the childs needs and preferences. Developing Communicators Indirect support through helping carers adapt their style of interaction. Established Communicators Direct therapy for children at a 3 word level or above. Within this framework, speech and language therapists would need to be able to make informed decisions on an individual basis for each child. We were looking forward to reviewing the Communication Development Profile as wed enjoyed previous articles Charlotte had written for Speech and Language Therapy in Practice, especially the 2004 article about Choices, Changes and Challenges. We have now had the opportunity to use the Profile with several children and carers and our impression is that it is definitely a useful clinical tool. For speech and language therapists it is clear and easy to follow, however non-speech and language therapists would have more difficulty and require our support. We work in a preschool assessment centre and nursery for children with complex needs but could certainly see its value for the school age population with learning difficulties as well. The Profile has a strong developmental focus but does not use age levels, which would be beneficial when discussing goals for older children. A particularly helpful feature of the CDROM is a screen icon which indicates the relevant page number required to fill in the questionnaire. However, it is more likely that the therapist would complete this with parents in a friendly, informal setting rather than sitting in front of a computer. A similar page-prompt on the paper questionnaire would therefore have been useful as the book was most definitely required to facilitate discussions with parents and nursery nurses, supporting a change in their expectations, and helping them to think in a slightly different way about the childs communication. These instructional pages can be photocopied a feature which should be very popular with speech and language therapists. We would also have valued having more than one worked example - one for each of the Communication Phases Charlotte describes would have been useful - and were a little

frustrated that the one example provided mentioned Choices, Changes & Challenges to help communication development with no details of what this is or how to access it. Perhaps it would be useful to market this together with the Communication Development Profile. We like the fact that functional communication is such an important part of the Profile in terms of the use of communication and what messages children are giving. However, we found this the most difficult section of the profile to complete, especially with our more complex children (such as those with visual impairment or cerebral palsy), as lots of the given examples are about looking and moving. We completed six profiles subsequent to goal setting and in only one case had we identified a different target area to the Profile, confirming that it is largely in keeping with our therapeutic instincts. Thus, while experienced speech and language therapists may not gain new knowledge and skills from this framework, it nevertheless does offer a well organised and holistic approach to describing a childs communication and identifying appropriate therapy goals. At 45.99 + VAT it is good value for money and we would recommend it to any speech and language therapists working with children who have learning difficulties. Kathy Sherrit and Rachel McDermott are speech and language therapists at the Raeden Centre in Aberdeen. Editors note: For a copy of Choices, Changes and Challenges, or to enquire about workshops, e-mail Charlotte Child, chaos@hgf.eclipse.co.uk.


Child, C. (2004) It aint what you say, its the way that you say it, Speech & Language Therapy in Practice Summer, pp.14-16.

Communication Disability Profile

Susan Anderton welcomes the freshness of an assessment that focuses on what a client with aphasia can communicate rather than what they cant.
Communication Disability Profile
Kate Swinburn with Sally Byng (2006) Connect the communication disability network 125 (plus 10 postage and packing) Extra sets of interview forms and summary score sheets 15 per 20 (plus 5 postage and packing) The Communication Disability Profile is a structured interview process designed to assess the impact of aphasia on everyday life. It has



evolved from the Disability Questionnaire section of the revised Comprehensive Aphasia Test (Swinburn et al., 2004). The aim of the Profile is to allow a person with aphasia to express their experience of living with aphasia, verbally or non-verbally. The Profile contains an easy to read manual, Picture Resource, Interview form with script, Quick Reference Guide and a Summary Score Sheet. The rating scale provides illustrations of people across a range of ethnicities, ages and gender to allow the scale to be as personal as possible. The scales are clear and easy to follow and provide consistency throughout the interview. The Picture Resource is a book illustrating different communication situations such as writing a cheque, speaking in a group, shopping. It provides clear visual support for the interview and can be used in any informal discussion about aphasia; for example I found it very useful outside the interview setting to help explain aphasia to clients and their families. In the manual the authors emphasise the need to consider timing, purpose and outcome of using the profile. They give clear guidance on who would be the most appropriate person

to manage the responses elicited by the interview process. The Profile is a tool which does not aim to assess language disorder at an impairment level. However, as rating scales are used and responses are scored, this resource can be used for reassessment to measure change and show outcomes. The clients responses in the interview can then be used as qualitative examples of language impairment. The interview has scripted questions but encourages the user to adapt this to engage and facilitate the client as much as possible. Coordinating use of the questions and pictures resources can be a little fiddly at first; however, the more familiar you become with the interview, the more natural the interview and rating process become. The interview consists of four sections: activities, participation, external influences and emotions enabling the client to rate their ability in each area. This results in a full picture of the effect of impairment and disability on function and personal experience. One client reported that it helped me see what was happeningvery important. As expected with a facilitated interview the

profile takes a lot of time and may need to be carried out over several sessions, especially as issued raised may need to be discussed in more depth. The profile also allows for results to be discussed pictorially with the client and family members. I found it refreshing to be able to assess what a client can express by using this tool rather than what they cant as in a standardised test. This Profile also gives directions for therapy to reduce barriers and help support and facilitate the person with aphasia. The Profile is value for money. The cost for the extra score sheets is fairly high as they are not photocopiable, but it supports the Connect charity organisation. This is a flexible and user friendly resource to be used in a timely way with people living with aphasia. Essential for therapists working in rehabilitation, and especially for those longerterm clients who can benefit from a social and empowering approach to therapy. Susan Anderton is a Highly Specialist Speech and Language Therapist, Acute Team Leader at Royal Berkshire Hospital, Reading.


The Communication Trust Conference

Developing a workforce to support speech, language and communication (SLC) for all children Friday 28th March 2008 BT Centre, London
Attending will provide you with: a preview of the new Speech, Language and Communication Framework (SLCF), a competency based framework to support managers and practitioners to audit and plan professional development in the context of SLC examples of successful workforce development programmes an insight into the outcome of the Bercow Review interim report into SLC shared knowledge from networking and examples of strategic thinking which support best practice in developing an integrated and skilled workforce tools with which to apply principles to individual workforce development programmes. Speakers include John Bercow, Head of the Bercow Review for Children & Young People with SLCN and Conservative MP for Buckingham.
This conference will be invaluable for those with a workforce development responsibility across the early years, schools, youth and health sectors. Delegates will include SLT managers, early years team leaders, school leaders, managers of youth, health and social services and local authority team leaders in workforce strategy, school improvement and inclusion. Book a delegate place now for just 130 at www.thecommunicationtrust.org.uk/ conference, call 0845 225 4073 or e-mail conference@thecommunicationtrust.org.uk



How I meet my inf

What motivates you to ask questions and seek answers? How do you develop your own information literacy and encourage it in your clients and colleagues? What happens when it all gets too much? Editor Avril Nicoll talks to speech and language therapists Katie Cullinan, Rebecca Matthews, Kerry Wreford-Bush and Alison Hodson to find out more.

s speech and language therapists, we have a huge need for information. This may be about the client in front of us, the prevalence of a communication impairment, how to empower individuals and families, the influence of political context on practice, health and safety, approaches to assessment, caseload management, fixing computer problems, organising transport to a conference, taking care of ourselves to name but a few. We also recognise our role in making good quality information accessible to our clients and their families so they can make informed choices about their care. At the same time, we are keen to get information out to other professionals who are in a position to make a difference to our clients by improving their day-today communication environments. While this is done largely through discussion or training courses, developments such as sophisticated software, colour printers, e-mail forums and DVD burners have given us all the opportunity to become prolific publishers of information. But there is a downside, and it affects everyone. Indeed, Wikipedia has a section dedicated to the term information overload, explained as a state of having too much information to make a decision or keep up with a topic (http:// en.wikipedia.org/wiki/Information_overload). The continuing increase in communication channels for search and dissemination (the internet, e-mail, mobile phones, instant messaging) is an obvious cause, but Wikipedia also points to the problem of contradictions and inaccuracies in what is available and the need to have the skills to compare and process different kinds of information. Learning more about our own information needs and how we meet them should therefore help us to: a) be more aware, focused and creative, and do more of what works in meeting our own information needs b) understand the information needs of our clients and our gatekeeper role c) improve our skills in liaison and training. In his comprehensive survey of research on information seeking, needs and behaviour, 26

Case (2006) says that information behaviour is a difficult area to study because it varies hugely from person to person and much of it goes on inside our head. Our information behaviour can include information seeking (a conscious effort to acquire information in response to a gap in knowledge), unintentional or passive behaviours (such as glimpsing or encountering information), and choices (like actively avoiding information). I asked four readers about their information behaviour. Katie Cullinan is a specialist paediatric speech and language therapist with UCLH NHS Foundation Trust working mainly with pre-term infants. I dont like not knowing something. I try to do my best by my clients, so its only fair that I should be up-to-date. My information behaviour has been shaped by the circumstances of my first job based in Stornoway on the Hebridean Isle of Lewis in the early 1980s. I was the only full-time speech and language therapist there, with just one very part-time colleague. While I had support from the team in Inverness and met up with them three times a year, I was relatively isolated in speech and language therapy terms. However it was a brilliant multidisciplinary experience as the team included educational psychologists, occupational therapists, physiotherapists, district nurses, teachers, and many more. Being isolated, I actually made more of an effort, and this has always stood me in good stead. Its ingrained in me to make links with relevant people because sharing ideas and information makes for a better service to clients. I have to know where to look, how to look and not be afraid to say I dont know something. In addition to the usual reading, I have always used the telephone for peer discussion and I still do that now, for example calling other therapists who work in this specialist

field for advice and discussion. I get a lot from ringing people up, although I also use the internet to look up journal articles and information sites visited by parents and can speak to the librarians at UCLHs Bloomsbury Health Care Library if I need extra help. Following a spell in Glasgow and an MSc in 1986, I moved to work in the Camden and Islington areas of London. The management style of people like Lena Rustin and Diana Moir offered fantastic opportunities for continuing professional development. I was able to go to important conferences, to change direction within the profession, to have 3 maternity leaves and be redeployed, always being hugely well supported and enjoying seeking new information. Islington PCT, as it is now, has very good staff retention so, even when I moved out of a speciality, I kept important links. There are support groups so staff meet on an area-wide basis, across acute and community services. This informal but organised opportunity sparks ideas from snippets of conversation, and enables problem-solving and networking. While the groups are primarily for support, a by-product is meeting people and deciding who is an appropriate person to approach with questions. Last year, University College Hospital decided to manage its therapists directly, so the speech and language therapists said goodbye to Islington PCT. However, I am continuing to attend management seminars offered by Islington PCTs Claire Topping where I learn more about a strategic, whole organisational approach to fostering and supporting an enquiring mind. Certain individuals have been a fantastic source of information. I work with Gillian Kennedy, a NIDCAP (Newborn Individualized Developmental Care and Assessment Program) observer and trainer in training. I had worked with adults at UCLH before preterm infants and was lucky to have somebody there if I needed to ask anything. It was like doing an apprenticeship! Sometimes, though, this is not available and you have to form your own networks. I cant imagine not wanting to seek information but I choose not to use e-networks other than e-mail. They are very useful for some people but I find them impersonal and prefer to have a conversation. I like being able to talk directly to someone so that you can seek immediate clarification if needed. I think many therapists feel confident giving advice to clients but are more reticent about sharing their expertise with peers. I am now, with experience, very keen to give information if I feel I have something to contribute. I put


formation needs


forward suggestions for the joint BAPM (British Association for Perinatal Medicine) Neonatal Dietitians and Speech and Language Therapists consensus statement on weaning pre-term babies. A number of my handouts were used for discussion, which was very rewarding. I like the teaching aspect of my job, and train other professionals and students. I usually feel a bit apprehensive if it is a huge audience but enjoy it when it comes down to it. Such ventures produce different information needs, such as finding out how to put videos into PowerPoint! Speech and language therapists are encouraged to be enquiring. We never say well thats it then! We never know it all and learning really is life-long. Rebecca Matthews is an independent speech and language therapist in Reading and a PhD student. Unlike a therapist in a team who has more colleagues to consult with, I am reliant on library and internet resources. Independent therapists dont enjoy the same ease of access to literature as those in the NHS, but I have this privilege through being a PhD student. I also read regular publications like the International Journal of Language and Communication Disorders, Child Language Teaching and Therapy, Speech & Language Therapy in Practice and the Royal College Bulletin.

I belong to an ASLTIP (Association of Speech & Language Therapists in Independent Practice) group, which meets once or twice a term and is really invaluable for sharing and gathering information. As an example a member talked about a Michael Palin Centre course they had attended and shared their reference list; there were a lot of things from her information that could influence practice. I wasnt searching for it, but it came my way. Ive noticed information can often reach me in a rather random way. A lot of my information behaviour comes from my clients they inspire me. I find myself asking questions like: What does this mean? What have I got to be aware of? Is this an issue I need to investigate? I am another one of these people that Googles and finds the internet a great resource. When I qualified 25 years ago parents werent getting hold of information independently, but now I have to be on top of it as expectations have changed. When a controversial approach such as Dore (www.dore.co.uk) comes along I need to be able to give a professional view. I think it is important to review my opinions on such topics regularly through re-checking I have the latest information. Parents want to know whats going on. I use carbon paper to ensure families have a copy of case notes. My caseload is potentially a biased group but there is still a wide variation in communication need and income. What they have in common is a motivation to access help for their child. Their aspirations can be as humble as wanting their child to have friends. When people stand at playgrounds and talk with oth-

ers there is a lot of information exchanged. In my experience this isnt a middle class phenomenon, or associated with money, but a need driven by personal values and priorities. Parents of potential and current clients e-mail quite a lot and I want to answer competently. I suspect that many people use e-mail to make enquiries as a way of managing information before they make a commitment. Im sure I drive my family mad as switching off is a problem. My parents are however a great back-up team. They cut out lots of interesting newspaper articles, which often parents and people I meet in the course of my work have read too. It influences their perceptions of what they will get from me so, if I am aware, I can make a judgement. Recently I saw a piece on genetics and autism suggesting that it can be passed on by mothers; to me this wasnt new but it was being presented as the latest thing. Its clear to me that what appears in the press is what grabs the journalists eye. As a profession we need to think about how we can influence this. Some people such as Paula Tallal (Fast ForWord) are particularly good at recognising the need for the drip, drip of repeated publishing to get an idea known about. When I worked for I CAN, the Teach Speech project came out but the evaluation wasnt published in journals and publications more available to speech and language therapists and so a good idea died a quiet death. We also need to encourage people to publish negative information as it is helpful to know when something doesnt really work. My PhD was inspired in a round about way by my clinical practice. An 11 year old boy had been prompted to ask for speech and language therapy having seen and heard himself talking on MSN to his friends. I also wanted to do less driving to my clients and these two factors prompted a casual investigation into using videoconferencing. Now I am studying for a PhD at UCL looking into what other people have done with videoconferencing that I can learn from before investing in equipment and trying it out for real. Kerry Wreford-Bush is a speech and language therapist at Craig-y-Parc, a residential school in Cardiff run by Scope for children and young people with severe physical disabilities aged from 3 to 19. I work in a very small area of speech and language therapy so it is often nice to be part of something bigger, to be involved with other 27


FEATURE: HOW I areas to keep my professional knowledge up and not get stuck in my own world. I spend a lot of time on Google, not just finding information but making decisions on its value. I start with a broad, random search and refine the search terms as I read through the results. Once I find an article I google the source to check it out, and am particularly careful to investigate further if the content of one article seems to be at odds with the others. University reading lists on the internet are useful for seeing if a writers work is viewed as best practice within academic circles. Google really is a worldwide resource, another reason why checking the source of information is so important. There is a massive difference in research and practice between the United States and Europe, partly created by the way they are funded. While some of the US material is innovative, the different environments can mean it is not applicable here. On the other hand, when I heard at a study day about Botox being used in the salivary glands to decrease excessive drooling, I searched and found a large study is underway in Australia. I was able to get in touch with the researchers by e-mail and am now being kept up-to-date with progress. The stimulus for my information behaviour is often a client. When Intrathecal Baclofen was introduced to one student to try to reduce his spasticity, I did a lot of research on it. Because this included how the treatment was going to affect the student and his family, I gained a much more holistic view of the client, his family and their communication. Im quite a 3D visual learner. If I see someone live they pique my interest and need to seek more information. Even a discussion with somebody is more likely to lead me into 2D research, although occasionally reading something inspires me to go on a course. I read the Royal College Bulletin and Speech & Language Therapy in Practice. I especially like book reviews, and they definitely influence my buying behaviour. I prefer to hear what another therapist thinks rather than trying to work out from a catalogue description if it would meet my needs. I am really motivated if I have experienced something physically, and find I am more likely to remember it. An interactive DVD is very helpful, as are activities within articles where the author enables you to link experiences to theory. Following a suggestion to drink with my stomach pulled in, legs in the air and head back was a real aha! moment for me. Experiential learning is also huge for the children and perhaps that is what attracted me to the job. I have learnt so much about the link between environmental movement and communication through unplanned involvement in Power Rangers, a very early learner drivers course for wheelchair users. Coping with simple instructions for a physical movement is an amazing feat. This shows that sometimes going off at a tangent can be a great opportunity for finding information you didnt realise you needed. 28 Alison Hodson is an independent speech and language therapist who, in addition to her independent caseload, is employed directly for 8-9 sessions a week by a non-maintained special school in Cheshire. There are always things I want to find out about. A chance comment is enough to set me thinking so my family frequently catch me day dreaming. Generally a problem presents and I either need to find a solution or to know more about it. Recently the school I work at has doubled in size. Although my workload hasnt doubled it has increased, so I am looking at the capacity issue. Do we need someone else? Do I need to work differently? Do I need to accept I cant do as much? To discover things, I like to read a book. Sometimes I do an internet search and I also talk to someone who knows. When I find information, I need a sounding board to make sense of it and sometimes I even do this to myself in a mirror. Courses, Special Interest Groups and face-to-face discussion are all helpful. As I work as an independent therapist, the ASLTIP Yahoo! group has been a lifeline for me. Without it I would have been all by myself in speech and language therapy terms. I work with some brilliant teachers, inspired classroom assistants, independent psychologists and physiotherapists, but it is great to have the opportunity to talk to other speech and language therapists as we share the same language and clinical skills and can therefore get through the subject more quickly. However, where I go depends on the information I am seeking; if it is a behaviour problem it can be more effective talking to the teacher. When you work in the NHS you automatically get dissemination of information like Agenda for Change and updates on public policy. It is very easy as an independent therapist to lose touch with the public sector but it is important to seek out enough of that information to have some idea of where it is at. Some people very naturally make connections and analyse information quickly - you see this reflected in their work and the way they live their lives. I have always sought information and, when I went into speech and language therapy training, I was very good at regurgitating facts but not so competent at analysing or applying them. While I also had interpersonal strengths, the speech and language therapy course taught me critical thinking skills which I then applied to other areas of my life. I am interested to see that my children, now 14 and 17, have both been taught much more significant study skills such as mind mapping from an earlier age. This means that, instead of learning something, they know where to find it and they do something with it. This is great if a person has the capacity for good thinking skills but if they are hovering towards autism spectrum disorder or have specific language impairment, or even if they are just a more concrete thinker, they can no longer get by through learning facts. There is so much information out there that you get swamped if you dont know how to filter it. I realise I have become swamped when the words no longer make sense or my thoughts go round in a circle and dont change. I tackle it by removing myself from the situation and doing something else such as going to the gym. I sometimes seek someone else to talk to but find the best thing is to sleep on it as its always clearer in the morning. I will even scribble on a piece of paper overnight. Talking about something completely different takes the stress level down but accepting that it is not only OK but essential to leave the problem took me a long time to learn. I am heading towards 50 and am nowhere near retiring. I want to build on the first half of my professional life without just repeating it. I am beginning to throw away 25 year old articles that I havent read yet. I couldnt bear to do this before just in case I needed them one day. Computers have changed things though and I am thinking about scanning and storing key items to give me my study space back. I will continue to ask what do I really need to know? What is safe to ignore? What do I need to deal with? And how am I going to focus on it? Case (2006) concludes his survey with lessons from Information Behaviour Research, which seem to fit with the experiences of our interviewees. It is important that we are aware of them not only to understand our own information behaviour but to help us engage with clients and other professionals: a) Formal sources and rational searches are only one part of information seeking. For most of us, other people generally satisfy our need for information on a day-to-day basis. b) More information is not always better, and we need to develop strategies for avoiding information overload. c) If we cant see the relevance of information, we can miss out on something important. It can also be difficult to accept information if it means we need to change. Although this is not one of Cases concluding lessons, he refers (pp.270271) to studies involving nurses which suggest that getting the right people as change agents in a leadership position is vital. These people will be expert and confident information seekers. d)General information is not usually helpful we need it to be customised. e) Making all information available and accessible is impossible, so we shouldnt expect it. f) Information seeking is not linear; rather it is a dynamic process and our questions and needs change as we move through it. g) Information seeking is much more than solving problems, finding facts or making decisions it can also be about sense-making and creativity.
How does this fit with your own understanding of information behaviour? Let us know via the Spring 08 forum at www. speechmag.com/Members/. Reference
Case, D.O. (2007) Looking for Information A Survey of Research on Information Seeking, Needs, and Behavior. 2nd edn. London: Academic Press. SLTP


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Supervision Practice

Are you getting enough? (1) Supervision in context

Sam Simpson and Cathy Sparkes begin this new series with an exploration of why supervision is so important and a practical activity to help you make sense of your own supervision history.

e have been given a great opportunity to bring the topic of supervision into the public arena for discussion and debate. In the current political climate pressures are ever increasing and our own well-being is paramount. We are both specialist speech and language therapists with many years experience of working with people with brain injury in a wide range of settings, including hospitals, rehabilitation units (in and out patient) and a variety of community services. Cathy is also a trained counsellor and Sam starts her counselling training in April. We are both fully committed to our own professional development and recognise the need to develop our knowledge and skills by attending courses, seminars and conferences. In addition, we both access regular non-managerial supervision which enables us to maintain a spotlight on our own personal needs and strengths in the wider working context as a means to self-care. This article is the first in a series of four in which we hope to introduce, develop and validate your understanding and insight into supervision practices. Our articles are underpinned by relevant theory and guidelines, personal stories and reflections, as well as reference to two focus groups we have run specifically for this series. Each one ends with a practical activity for you to take away in order to invite enquiry and comment. Early in both our careers we were exposed to a high standard of managerial and non-managerial supervision on a regular basis and have recognised the need to continue this as our professional journeys have progressed. In turn, our experience in the role of supervisees has affected our role as supervisors by allowing us to develop flexible approaches and styles we offer independent nonmanagerial supervision to speech and language therapists and other healthcare professionals. From consultation with a variety of speech and language therapists we know that others have not been as fortunate in their supervision experience, in particular in the area of non-managerial supervision. This could be for a variety of reasons including the culture of the organisation, absence of suitable specialists, not seeing supervision as a priority and external pressures and targets limiting time. Sadly guidance and practice appear to be very different and supervision provision is reported to be inequitable across organisations and trusts. Furthermore, a recurring question for people we consulted was:How do I know whatgoodsupervision is and where do I go to experience it? Fully negotiated relationship The term supervision is difficult to define. Hawkins & Shohet (1989, p.5) suggest supervision can be a very important part of taking care of oneself and avoiding feelings of staleness, rigidity and defensiveness which can easily occur

Cathy (L) and Sam (R)

in professions where you have to give so much of yourself. Syder & Levy (1998, p.268) say Inskipp & Proctor (1993) stress that both the supervisor and supervisee play an equal, if different role, in arriving at the agreement. As the relationship needs to be flexible to meet a variety of needs, each contract is likely to be unique to the particular dyad or group involved. In truth it can take many forms, but an underlying principle is that it is a fully negotiated relationship. The Royal College of Speech & Language Therapists supports the notion of good professional supervision in CQ3 (2006, pp.103-106). It differentiates between: 1. Line management supervision which includes topics related to person specification, job description, caseload management, individual performance reviews, meeting objectives, adherence to such professional standards, continuous professional development. 2. Clinical (non-managerial) supervision which includes reflections on interventions, the feelings that are engendered, issues arising out of the dynamics of the therapeutic relationship, enabling the supervisee to talk about areas of their work that are thought to be ineffective. In our experience, supervision is not a static, defined set of skills and roles. It is a fluid relationship encompassing a wide range of skills and techniques. In conversations with speech and language therapists and others there is often confusion as to the use of terminology around this topic. Some of the other associated terms include: Support access to a range of people in an informal / formal way, for example the management structure, colleagues within / outside the service, Royal College of Speech & Language Therapists Special Interest Groups, managers and Association of Speech & Language Therapists in Independent Practice groups Mentoring - access to someone for information and advice who is more experienced than the mentee in their given area Coaching - access to someone who is not more experienced in the area the coachee works in. The relationship between the coach and coachee is equal and it is defined by goals identified and worked towards. Action Learning access to a group in which work-based problem-solving occurs which offers scope for personal learning and development

Box 1 Your supervision journey Consider your career and the supervision you have received (as a student, junior clinician, senior clinician, specialist, manager) as well as any other life experiences of supervision you may have had. Take 20 minutes to represent your supervision journey visually (drawing / mind mapping / writing) considering the three dimensions of: Time Turning points / significant events Feelings. Either on your own, or with a colleague with whom you feel comfortable to share your journey, reflect on your experiences using the questions below: What are your first impressions as your track your experiences of supervision? How do you judge the quality of the supervision you have received? What relationship does the quality of the supervision you received have with your feelings about work and your career development? How have your supervision needs changed over time? What influencing factors have shaped your preferred style of supervision? We believe the reason why supervision is so difficult to define is that it incorporates a unique combination of these styles and approaches. What is important, however, is that roles are transparent and determined by the supervisee. Space for reflection As careers progress, we need to understand our own learning path in relation to Continuous Professional Development (CPD). The Health Professions Council defines CPD as a range of learning activities through which health professionals maintain and develop throughout their career to ensure that they retain their capacity to practise safely, effectively and legally within their evolving scope of practice (2002, p.1). The range of activities this encompasses is vast. However, we strongly believe that supervision provides a pivotal opportunity to address many aspects of our learning. It creates a space for reflection on not only what we are doing, but how and why we are doing it and who we are in the process. Access to regular supervision is also embedded within the work based learning section of the NHS Knowledge & Skills Framework (2004). We look forward to hearing any comments you have in relation to this article and the practical activity in box 1 (www.speechmag.com/Members/). Next issue we will be discussing different models and styles of supervision as well as exploring peoples personal beliefs about supervision and the influence these have in supporting or hindering access to it. Sam Simpson and Cathy Sparkes are specialist speech and language therapists and Cathy is also a trained counsellor. Together they are www.intandem.co.uk.
References Hawkins, P. & Shohet, R. (1989/1993) Supervision in the Helping Professions. Milton Keynes: OUP. Syder, D. & Levy, C. (1998) Supervision, in Syder, D. (ed.) Wanting to Talk: Counselling Case Studies in Communication Disorders. London: Whurr, pp. 256-288. HPC (2006) Your guide to our standards for continuing professional development. London: Health Professions Council. NHS KSF (2004) The NHS Knowledge & Skills Framework and the Development Review Process Appendix 1: Overview of the NHS KSF. Oct. Available at: http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4090843 (Accessed: 1 February 2008). RCSLT (2006) Communicating Quality 3. London: Royal College of Speech & Language Therapists.