Anda di halaman 1dari 32

ISSN 1368-1205

Autumn 2008

Dysphagia management Long-term review About a boy Unlocking potential Beyond the Lightwriter Success with AAC How I take therapy into the classroom

Ready for reading

Are you getting enough? The supervision process My Top Resources Secondary school support

Children with Down Syndrome

PLUSAssessments assessedWinning WaysSoftware solutionsHeres one I made earliergreat read offersand continuing our series on user involvement Pure and simple

Reader offers

Win Copycat DVD!

Are you looking for non-directive, fun ways to facilitate early speech and language acquisition? Then Copycat could be for you. The songs and rhymes in the DVD aim to develop imitation from its most basic level (gross motor actions) to the more complex copying of real words. One section is a sing-a-long while the other provides information for parents and professionals on early language development and delay. Black Sheep Press is offering THREE copies of Copycat to Speech & Language Therapy in Practice readers. It normally retails for 15 but you have a chance to win a FREE copy by e-mailing your name and address to putting SLTiP Copycat offer in the subject line. Make sure your entry is in by 25th October - the winners will hear by 31st October 2008. For details of all Black Sheep Press resources, see

Win new speech sound therapy aids!

Speech and language therapists Sarah Costelloe and Ruth Jackson have teamed up with a professional childrens illustrator to produce packs of picture cards to support phonology work. The Speaking Matters team is offering TWO lucky readers the chance to win a COMPLETE SET of packs to date (K initial, T initial, S initial, F initial), which would normally cost 39.80. A pack includes 20 cards, with words of various lengths and to suit different vocabulary levels. Using a drywipe marker, you can write a letter or word on the card if you wish. For your chance to win, e-mail your name and address to, putting SLTiP Sound Card offer in the subject line. Your entries must be received by 25th October 2008, and the two winners will be notified by 31st October. For more details of Sarah and Ruths work, see

Reader Offer Winners

The three lucky winners of Languageland offered by Black Sheep Press in our Summer 08 issue are G. Lydiate, Swindon; K. Phillips, Amersham and C. Gibson, Kendal. Unfortunately there were technical difficulties receiving entries for the Mark Onslow video seminars, but we will re-run that offer in a future issue.

Autumn 08 speechmag
Forum for discussion of articles now up and running! Anyone can read the forum messages but only registered subscribers can post. To register, go to http://members.

NEW! Only online articles added for Autumn 08! Penny Best explains Talk and Play, an exciting new intervention for children with language delay / disorder in Sunderland. Conference reports - www. Samantha Miles on the Portsmouth Speech & Language Therapy Aphasia Action Groups 2nd multidisciplinary aphasia conference Avril Nicoll on the Association of Speech & Language Therapists' 2008 conference

Members area

For a reminder of your user name and password, e-mail The members area includes: Extra only online articles Back issues from 2000-2006

Autumn 2008 (publication date 31 August 2008) ISSN 1368-2105

Thanks to Joe and his dad for our cover picture. Taken by Karen Wright,
Thanks to Zoe, Ashleigh and Tayavalla, Camelon, Falkirk for our cover picture. Taken by Paul Reid.

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

8 COVER STORY: Ready for reading Session 3s key phrase was errorless learningThis may be a particularly effective method with children with Down Syndrome because they are susceptible to giving up easily. Constant success and the praise and confidence-boost associated with it can encourage persistence. Children with Down Syndrome have the potential to access language through reading from an early age. Gillian Lord and Karen Bailey assess the impact of a pilot group for parents and teaching assistants.
22 HOW I TAKE THERAPY INTO THE CLASSROOM (1) I once heard it said that, to be more of a therapist, sometimes you need to become more of a teacher. I think thats true. Kathleen Cavin promotes pizzazz and all that jazz, encouraging therapists to have the confidence to take on the role of a lead adult in the classroom. (2) After taking down a story, an adult could reflect on their own body language, how long they waited, and how they observed, smiled and let the child take the lead. Karen Hayon and Evi Typadi launch the Helicopter and watch teacher and child communication take off. BACK COVER - MY TOP RESOURCES In collaboration with the teacher [using an interactive whiteboard] you can make activities to support the language of the curriculum that are visual, attractive, interactive and engaging for the whole class. Marysia Nash supports secondary school students with language and communication needs.

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

4 HOW LONG TO GET A DRINK? I wondered what starting to eat again could mean for James? In front of me was the same man who barely looked at me or gestured when I first met him. I saw the bigger picture, not just about food, but interaction and motivation for communicating. Antonia Charalambos makes the case for systematic long-term dysphagia review of clients with acquired physical and communication disabilities. REVIEWS 7 Assessments assessed - An in-depth review of the Lemon and Lime Library articulation screen and resource pack 20 General - Alternative approaches, target setting, prevention, Down Syndrome, early autism, hearing impairment, articulation, learning disabilities, ColorCards, group work. 28 Software solutions Education in Stuttering Treatment with Mark Onslow, A Busy Day and TinyEYE Online Speech Therapy Telepractice. 10 USER INVOLVEMENT Some clients told us they had been worried prior to the event that they might have been out of their depth, but had been relieved to find they were able to express everything they wanted to. Focus groups of people with communication difficulties following a stroke have enabled Anna Hayes and colleagues to increase staffing and improve services. 12 ABOUT A BOY This is about just one boy; however, we feel that it has highlighted for us both the benefits of joint working, and the need for further evidence-based practice in the area of intervention with young people with profound and multiple learning difficulties. Speech and language therapist Helen Francis and occupational therapist Joanna Lloyd dedicate this article on an Individualised Sensory Environment programme with sensory integration techniques to the memory of Mark John, the young man who made it possible.

15 HERES ONE I MADE EARLIER Alison Roberts suggests the lowcost activities Standing in your shoes, Shadows and Speedy Categories. 15 WINNING WAYS Life coach Jo Middlemiss offers readers positive suggestions for coping with common problems. Here, a permanently packed car boot causes frustration. 16 BEYOND THE LIGHTWRITER The other challenge, as we see it, is not to lose sight of the primary focus of our intervention and of the device provided by our speech and language therapy service. We need to continue to enhance the communication potential of our clients - however that communication is defined in todays IT-focused world. Kevin Borrett and Nicola Clark discuss why some people move beyond text-speech solutions to integrate high-tech computer-based communication aids into their lives. 18 SUPERVISION (3) THE SUPERVISION PROCESS The more we have been involved with supervision (from both sides) the more important the concept of boundaries has become ... in terms of the delineating aspects of each relationship we encounter and ensuring we give transparency the highest importance. Sam Simpson and Cathy Sparkes continue their series on supervision practice.

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. Speech & Language Therapy in Practice can be found on EBSCOhost research databases

SUMMER 08S e-articles at E1 HOOK, SIGN AND LINKER Sure Start was keen to fund our training and set-up costs because the initiative was parent driven. Grace Windle and Jenny Hinton run Makaton Signing for Babies groups, keeping the focus firmly on early communication skills. E4 ONCE UPON A TIME IN HARROW All [therapists]had developed their skills during the week by working with other therapists and by observing how different children responded to different types of intervention. Summer narrative groups offer Nicole Goldstein and mainstream school colleagues and their young clients a different context for therapy.



Broad welcome for Bercow

The July report of the Bercow Review of services in England for children and young people with speech, language and communication needs attracted considerable mainstream media interest. The unprecedented strategic focus was driven by John Bercow MP along with organisations including the Royal College of Speech and Language Therapists, I CAN and the British Stammering Association. The huge evidencegathering exercise involved key researchers such as Sue Roulstone and James Law along with commissioners, childrens services, practitioners, parents and young people. The report makes 40 recommendations. These are organised within 5 themes which highlight the importance of early identification and intervention, joint working and a continuum of services designed around the family. They also recognise the need to raise awareness that communication is crucial and of the current systems variability and lack of equity. John Bercow says it concentrates on practical proposals which will improve services soon, together with measures to embed speech, language and communication in wider policy frameworks for the future. The recommendations have been welcomed by participating organisations. I CANs Virgina Beardshaw said, Together, we have tirelessly lobbied for greater awareness on this issue, for investment and development in the 3-million strong childrens workforce, for all settings to be communication friendly and for greater information on communication development to be available to parents and carers. Afasic was pleased to see the voices of children, young people and families in particular have been at the heart of the review but warned that local health and education services have to be made more accountable. The National Autistic Society welcomed the confirmation that provision is inadequate and must improve. The National Literacy Trust

Volunteer opportunity

believes that, as speaking and listening skills are the fundamental first stage of literacy, implementation will have a profound effect on the future literacy of the nation. Scope says it will be instrumental in ensuring that disabled children and their families are no longer denied the equipment and ongoing support they need, or sent from pillar to post to get it and hopes a future review will address the needs of adults. Professor Susan Edwards from Reading University would like to see more support for high-quality research and a national view on training places to address the lack of speech and language therapists. Discussion on the Easyspeak forum suggests that individual therapists feel let down by a shortage of specifics about caseload size, the place for direct therapy and apprenticeships and a perceived fudging of the issue of NHS / education responsibility. However, one manager said the most important legacy of the review is that it states communication is fundamental and a human right, adding that we need to keep saying that to attract funding. The government has pledged 12m to implement the recommendations and 40m to support speaking and listening in early years. A detailed implementation plan will be announced in the Autumn.

The first speech and language therapy degree course in Bangladesh has put out an urgent call for overseas volunteers particularly those who can commit long-term to help with coordinating the course, running clinical placements, research dissertations and teaching foundation subjects. The course is run by the Bangladesh Health Professions Institute affiliated to Dhaka University with support from University College London. Students attend for 4 years of theory and 1 year of internship. There are 11-15 students in each year, which means staff can offer one-to-one support and get to know the students well. As it is run in English, all students get intensive training in English as part of their degree. Course Co-ordinator Mostafa Zaman says there are plenty of exciting development opportunities depending on the length of the volunteers stay and their particular interests, and some financial support may be available. Application forms are at www.crp-bangaldesh. org, enquiries to Md. Mostafa Zaman, Course Coordinator, e-mail


The National Deaf Childrens Society is inviting schools to raise funds through a nationwide Fingerspellathon. This event will challenge school children to learn basic British Sign Language. Teaching professionals can order a pack from Alison Burrell, e-mail

Online contact
In recognition of the potential to support parents of disabled children through social networking sites, Contact a Family has opened an advice centre in Second Life as well as providing information and advice via Facebook, MySpace, bebo and YouTube. Second Life is an online 3D virtual world imagined and created by its residents. Contact a Familys virtual advice centres location is Aloft Nonprofit Commons. It is staffed by a parent adviser through his Second Life character during advertised opening hours. The project is funded by the Department for Children, Schools and Families (DCSF) Parent Know How initiative, which is designed to deliver better outcomes for children and parents. Contact a Family also has its own social networking site,;

Musical offer

Music For Starters, a specialist supplier of music, percussion and puppets for young children, is offering Speech & Language Therapy in Practice readers a 10 per cent discount when they book any of its three Autumn training courses. One of the courses, Using Music to Support Inclusion, is aimed at anyone with an interest in using music to develop language, communication and interaction with children with any form of speech, language and communication difficulty or who are learning English as an Additional Language. It is being held at Battersea Arts Centre, London on 4th November 2008. To receive their 10 per cent discount, readers should quote MFS/ST2 at the time of booking. pdf



Healthcare for All

While welcoming the report of the independent inquiry into access to healthcare for people with learning disabilities, the Foundation for People with Learning Disabilities is calling for immediate action to implement its recommendations. The inquiry was established following publication of Mencaps Death by indifference and the Disability Rights Commissions Formal Investigation into health inequalities experienced by people with learning disabilities and people with mental health problems. Among the problems reported to the inquiry were gaps in access to speech and language therapy. The report recommends that all people with learning disabilities should have a health check every year, support if they need to go into hospital, help with communication and better information. Co-director of the Foundation for People with Learning Disabilities Alison Giraud-Saunders said, This report is a blueprint for what needs to happen to end the difficulties many people with a learning disability face when trying to access the healthcare most of us take for granted. Its completely unacceptable that anyone should be disadvantaged in our healthcare system simply because they have a disability.;; www.


Pure and simple

Jemma was gonnae be a speech therapist. She saw a TV programme about it years ago and has never wavered. And while Id no inclination whatsoever to be a speech therapist, wasnae even sure what they done, part of me envied her certainty. When she graduated shed get a good steady job in the health service a job that was useful, a job you never had tae justify... Each Speech & Language Therapy in Practice showcases the variety, fascination and challenge of our work but, in Anne Donovans new book, the Glaswegian protagonist isnt sure what we do. Private Eyes BIRTSPEAK 2.0 pokes fun at BBC jargon and gobbledygook. This weeks slot highlights a job description explaining in great detail the competencies of communication, resilience and flexibility required of a gardener. Presumably a love of plants also features somewhere but, with this in mind, I set myself an Autumn 08 pure and simple challenge Gillian Lord and Karen Bailey (p.8) know that helping children who have Down Syndrome learn to read can help them learn to speak. They run groups for parents and teaching assistants, who can then do reading activities every day with the children. Helen Francis was doing speech and language therapy and Joanna Lloyd was doing occupational therapy with Mark John (p.12), but he was stuck. They worked together and he made progress. A long time after his stroke James was ready to swallow again, but couldnt tell anyone. By chance, Antonia Charalambos (p.4) reassessed him. He now eats and drinks well, takes part in activities and is happier. Antonia thinks we should regularly check up on people who have been discharged. Kevin Borrett and Nicola Clark (p.16) supply people who cant talk with communication aids. People who do well with the more complicated technology have things in common. This helps Kevin and Nicola decide which aids to try with new clients. Anna Hayes (p.10) arranged for people who have aphasia to say what they think about speech and language therapy. Their views helped the service get more staff and arrange groups that people want. The people with aphasia liked being able to make things better for others. Some secondary school pupils have communication difficulties, but dont often get the help they need. Marysia Nash (back page) has lots of useful resources which she uses with subject teachers. Kathleen Cavin, Karen Hayon and Evi Typadi (p.22) help younger children with their language development. They too work in classrooms, so teachers and support assistants see they have practical ideas. The therapists also learn from the teachers how to manage a class. Cathy Sparkes and Sam Simpson (p.18) explain how to organise supervision of our work so that we become better speech and language therapists, but to get there we have to start with the basics. While Anne Donovans character may not be sure what we do, the BBC could do worse than borrow her West of Scotland perception of competencies: Jemma was smart, sensible, got on with folk shed be brilliant at it. Pure dead simple, but.

Record performance

Afasic is attempting to get into the Guinness Book of World Records as part of its 40th birthday celebrations. The unlocking speech and language charity is aiming to get over 4,800 people taking part on Wednesday 22nd October at 9.30am for the record the most people simultaneously performing sign language to a song at different venues. Instructions for this and for a sponsored silence to be held over the week beginning 20th October from Mark Thompson, e-mail

Poetry profile

The National Literacy Trust is looking for ways to enhance the profile of poetry in the UK. The Trust is responding to what it calls worrying trends in childrens poetry including low levels of awareness among primary teachers, a shortage of new poetry books for children and few children reading poetry outside of school. It points out that poetry develops speaking and listening skills and a love of language as well as reading.

Stroke care

A Scottish NHS consultation document on heart disease and stroke care is focusing on issues which havent received the attention they might have had, such as longer-term support in the community for people who have been discharged from hospital after a stroke. The final date for responding is 24th October 2008. The Royal College of Physicians has published the third edition of its Intercollegiate Stroke Working Party National Clinical Guidelines for Stroke. It includes profession-specific guides for nurses, dieticians, physiotherapists and speech and language therapists along with new sections on commissioning and resources. A new National Institute for Health and Clinical Excellence guideline covers diagnosis and acute management of stroke and transient ischaemic attack. It includes guidance on nutrition and avoidance of aspiration pneumonia. The Royal College of Physicians reports that both guidelines were produced in close collaboration with each other and with reference to the Department of Healths 2007 National Stroke Strategy.

Reference Donovan, A. (2008) Being Emily. Edinburgh: Canongate. SPEECH & LANGUAGE THERAPY IN PRACTICE autumn 2008

caseload management

How long does it take to get a drink around here?

Antonia Charalambos makes the case for systematic long-term dysphagia review of clients with acquired physical and communication disabilities whose social isolation and dependence is compounded because they have been discharged nil by mouth.

heck of a long time if youre waiting at my local but an even longer time perhaps if youre discharged from hospital with no oral intake, a PEG tube and a communication difficulty. The decision to deem a client nil by mouth may be complex but can be carried out promptly with management systems in place. An equally complex but less guided process is when and how that same clients swallowing is reviewed once discharged - if at all. I decided to review two clients who were both on long-term percutaneous endoscopic gastrostomy (PEG) feeding following a stroke. James hadnt had any oral intake for a year and a half and Maria for six years. In this article I will explore the decisions and processes that enabled me finally to discharge one on a full oral diet and the other on desserts. Stroke is the largest single cause of severe disability in the UK (, 2008). Gordon et al. (1987) reported that 45 per cent of those admitted to hospital with a stroke had dysphagia. An altered consistency diet may be enough to reduce any possible risks such as infection but for others eating and drinking can sometimes be deemed too great a risk. If swallowing is unsafe clients may be offered a preferred route of enteral feeding such as a PEG (Verhoef & Van Rosendaal, 2001). There is evidence that a clients swallowing does improve even when they have an unsafe swallow in the acute stages. James et al. (2000) note that when patients have a feeding tube placed in the acute stages they normally return to oral feeding 3 months post stroke. Gordon et al. (1987) reported that 87 per cent of patients with stroke-induced dysphagia recover their swallow within 4 weeks. I met James and Maria when they both had a PEG in situ and no oral intake. It all began for me when another man with a PEG, on the same continuing care ward as James, reached over, put a glass to his lips and drained it. The water was being used by the nurse to flush the PEG tube. It could be argued that, for him, it was the only way to communicate that now was the time to review his swallowing. The nurses told me they got quite a fright and we soon received a call to assess him. My colleague reviewed this client and he contin4

ues to have ice creams but has not been able to be upgraded. Shortly after, the speech and language therapy department decided that all people on the continuing care wards should be reviewed, particularly those who were nil by mouth. This is when I met James.


James was a 77 year old gentleman, who had a left middle cerebral artery infarct in August 2004 and was now in a continuing care ward. The medical notes also diagnosed some cognitive difficulties. A PEG was inserted shortly after his initial hospital admission and he declined any follow-ups over the next couple of months. James presented with significant receptive language difficulties, unresponsive to AAC, no verbal output and limited gestures. No family or friends had visited or made contact since his stroke which placed limitations on a full case history. On our first meeting in December 2005, James used very few gestures or facial expressions to communicate. I greeted him and he acknowledged my presence by breaking his line of vision for a moment to look at me. I suppose it could be a normal reaction at this point in Jamess life. I considered the reasons for him to communicate in general and noted that he was moved by a hoist, PEG fed, had no visitors and there was little known social history for others to comment on. He intrigued me and, although cautious, I was excited at the prospect of changing one aspect of his life. I took a quiet moment and considered the reasons for trialling oral intake with James: he sat upright all day, he had no recent chest infections, he was awake and alert. As Crary & Groher (2006) say, In the acute stroke patient, the degree of alertness and physical endurance are key features that indicate readiness to participate fully in the swallowing evaluation process. The following day I returned armed with ice cream. This is a suitable choice because it is smooth and holds its shape on the spoon (if frozen) which helps self-feeding and, being cold and tasty, it can trigger a prompt swallow. I placed a table in front of James, scooped out the ice cream into a bowl in front of him and placed a spoon

with a napkin within reach. It had been a year and a half since he had been invited to eat and my aim was for it to be an eating experience rather than an assessment. He looked at the bowl, over to me, then back to looking straight ahead. Sitting closer I explained that we were going to try ice cream and made some excuse for limited flavours of vanilla or vanilla. I supported him to hold the spoon handle, load it and bring it up to his mouth. The whole process felt stilted initially but after the third mouthful I wasnt guiding him as much. I deemed the clearing swallows natural for someone who had not eaten for so long. There was a slight increase in the rapidity of his breathing and I couldnt check voice quality so I was a little cautious. I left it at three mouthfuls for the first swallowing trial. When his swallowing was initially assessed in September 2004 on the same ward he declined any oral intake. Timing therefore may be a key issue when carrying out PEG swallowing reviews.

my aim was for it to be an eating experience rather than an assessment

Over the next three sessions James increasingly became enthusiastic about the whole process: pulling the table closer when he saw me, licking his fingers and the spoon, picking food up that had fallen on his top, pushing the plate away when finished, pulling the lid off the ice cream and reaching for napkins. I looked at the others sitting around the dining room table, the music playing, and I wondered what starting to eat again could mean for James? In front of me was the same man who barely looked at me or gestured when I first met him. I saw the bigger picture, not just about food, but interaction and motivation for communicating.

Team decision

I spoke with the multidisciplinary team regarding the slight increase in breathing and not be-


caseload management ing able to check for changes in vocal quality but emphasised how much more enthused he had become. It was a team decision that he should commence on trials of oral intake as he didnt have a significant increase in shortness of breath and because of the positive impact on his quality of life. So I carried out five trials of ice cream over two weeks. I then set out guidelines and a swallowing diary for nurses to complete after each lunchtime trial of ice cream for a week. Once the week was over and no concerns were flagged up I continued to trial other foods such as a soft moist dessert in the same way I had initially with the ice cream, with positive results. After three weeks of trials I set James up with a meal of pured meat, carrots and mash at lunchtime when he was out in his chair and at his most alert. When he coughed twice on the pure, I took it away and had a re-think there and then. Was he vegetarian? Was he too eager? Was it too spicy? What was the consistency like of the pured meat? Did he not like it? Maybe his skills would remain at eating ice cream? After trying some of the pured meat myself, I realised it was spicy. I decided to eliminate the meat pure from the plate and try again with pured carrot and mash. James tucked in. He completed the meal with no coughing and a prompt coordinated swallow, then pushed the plate away and wiped his mouth. James appeared to tolerate the pure but the coughing at the start and slight increase in breathing pattern had highlighted to me that trials should be taken a slow pace.

I often thought of what would have happened if we hadnt reviewed him, or if his fellow patient hadnt swiped the full glass of water
I went on to trial fluids by placing a glass of unthickened juice in front of him. He nodded, picked it up, sipped a few mouthfuls then put the glass down, wiped his mouth, folded the handkerchief and put it on top of the glass. He seemed to carry out the whole process very naturally. Again, as I couldnt check his quality of voice, I worked with the nurses for a week trialling him on normal fluids. I hypothesised that his swallowing had improved and therefore opted for normal fluids as opposed to thickened. In March 2006, I discharged James from my caseload on a full oral pure diet, soft moist desserts and normal fluids. Now he sits around the dining room table on the ward, occasionally smiles and gestures for more tea. He also started going to the activity group where he is a keen painter and potter. I felt like James had set a personal milestone for me and I often thought of what would have happened if we hadnt reviewed him, or if his fellow patient hadnt swiped the full glass of water

After I discharged James I was seconded to the community team for a short while. I received a phone call from Marias daughter who told me that her mother had not had anything to eat orally for six years. Maria was 82 when I assessed her. She had had a right cerebrovascular accident in 2000 and a PEG inserted shortly after the acute event. Maria now lived in a nursing home. She sat in her room watching English television even though she was a Cantonese speaker and her daughter reported that Maria had little understanding of English. Maria and James were linked for me in that not eating and drinking meant they were more isolated than the others around them. Their isolation was also compounded by difficulty communicating due to aphasia, cognitive difficulties and / or a language barrier. Talking with the nurses I found out that Maria sat out all day, was awake and alert, moved by a hoist, PEG fed at night and had no recent chest infections. I introduced myself to Maria and worked with her daughter to explain why I was there. Maria generally sat in her room at mealtimes, not in the dining room, so she had not had any exposure to food in the last six years. Marias voice quality was clear with no oral intake. She gestured and smiled at me. Similarly to James I set out a table for her and presented her with a dish filled with scoops of ice cream, a spoon and napkins. As with James, Maria required support to load the spoon and bring it up to her mouth. She later took small licks off the spoon making mmmmm noises and repeatedly saying thank you. I wasnt sure of the accuracy of this from someone with two or three words of English but as she said it with a smile and reaching for more, I took it positively. Her daughter asked her how it was and as I waited with bated breath she said in a loud, clear voice too cold then nodded to having more. At clinical assessment her swallow was prompt, her voice did not change in quality, there was no increase in shortness of breath and the large grin ticked my box. I didnt see a reason not to continue on oral intake. Although Maria was hoisted she was able to maintain an upright sitting posture all day. PEG feeding occurred at night so this didnt interfere with any daytime tasters. The nurse excitedly reported that she would now be able to take Maria into the dining room, which I was happy about, and this sealed the deal on a weeks trial of ice cream at lunchtime. Back at the office I wrote guidelines and drafted a swallowing diary for a week for them to note amount of intake and any comments such as coughing or self-feeding. After 7 days I arrived back to see Maria and the same nurse beamed at me saying there were no concerns. I was pleased to assess her at lunchtime sitting in the dining room although I noticed that she was being fed. I reinforced the importance of selffeeding not only to reduce risks of aspiration but also for Marias independence. Langmore et al. (1998) suggest that a dependency in being fed is associated with multiple negative outcomes. Unlike James, Maria was unable to tolerate other consistencies. We tried normal cold water


and slightly thicker juice but Maria was unable to trigger a swallow, held it in her mouth and released the liquid into tissue. She did the same for warm soft moist desserts. I hypothesised that she didnt like the food, had cognitive difficulties that may have impacted, or just wasnt ready to upgrade to other food. I returned one more time two weeks later when Marias daughter was there. Her chest had remained clear and no other concerns were being reported by nursing staff. Maria had started eating ice cream and / or yoghurt twice a day and I noticed that Maria was feeding herself now with no support. Although a diagnostic assessment such as videofluroscopy could have enabled me to measure the efficiency of the swallow, note any residue in the pharynx and determine if aspiration was occuring, it was not appropriate to use at this time. It would have meant transporting both Maria and James to a neighbouring acute hospital, setting them up in an unfamiliar environment with posture and seating issues (as both were in tilt and space chairs). Their own environment seemed to set them up with the optimum opportunity to do well. Their cognitive difficulties would also have impacted on the assessment and any rehabilitation strategies such as postural changes. Also, as the acute event had happened years ago, the assessments posed different issues than they would have had in the acute stages.

I reinforced the importance of selffeeding not only to reduce risks of aspiration but also for Marias independence. Follow-up imperative
The triggers for reviewing James and Maria were accidental. When drawing together my thoughts I pondered as to how we as a profession take forward systematic reviews of patients who are nil by mouth, long-term PEG fed and perhaps aphasic. When people are unable to participate in decision making about feeding it makes it even more imperative that they are followed up by another means. It brings about the question of ethics and acting in a persons best interests, particularly in light of the Mental Capacity Act 2005 (www.publicguardian. Harper et al. (2001) highlighted how a persons dysphagia might resolve when they are no longer on a speech and language therapy caseload. The Royal College of Speech & Language Therapists have guidelines for assessing people currently on a caseload who have dysphagia. These confirm (2005, p.71), The swallow function may improve with time, allowing for some guided return to oral feeding or, in some patients, removal of the feeding tube. The National Stroke Strategy (2007, p.45) recommends an annual health and social care 5


caseload management check and the National Clinical Guidelines for Stroke state (2004, p.47), The need for enteral feeding should be kept under review and the tube removed when no longer required. However, there is no clear, standard get out clause for people who have chronic acquired physical and communication disabilities, are nil by mouth and have no opportunity to demonstrate to those around them that their dysphagia may be improving. It would be useful if time could be built in for a speech and language therapy swallowing review when a PEG feed is reviewed by a dietician or a PEG tube is reviewed by a medical team. Strong team working and negotiation with the nursing staff on guidelines and diaries is integral to my role in reviewing clients dysphagia. Gustafsson & Tibbling (1991) comment on how dysphagia can influence many aspects of life including self-esteem and leisure time. Maria and James made me think even more about the importance of food for more than just sustenance, and the holistic approach required. Improvement in swallowing not only had an effect on their eating and drinking but on others aspects of choice, interaction and independence. At times accidents can bring about positive outcomes but, if I was nil by mouth and long-term PEG fed, Id rather not leave it to chance before I was reviewed. Antonia Charalambos is a speech and language therapist with Camden PCT, e-mail antonia. SLTP REFLECTIONS DO I RECOGNISE WHEN OFFERING SYSTEMATIC REVIEW IS PREFERABLE TO INFORMATION ABOUT RE-REFERRAL? DO I SEE THE PROGNOSTIC OPPORTUNITY OF TURNING AN ASSESSMENT PROCEDURE INTO AN EXPERIENCE? DO I THINK ABOUT WHAT it WOULD MEAN TO A CLIENT TO HAVE A PARTICULAR ABILITY?
What questions does this article raise for you? Do you have any form of systematic review for clients who have been discharged? Let us know via the Autumn 08 forum at http://members.speechmag. com/forum/.

References Crary, M.A. & Groher, M.E. (2006) Reinstituting Oral Feeding in Tube-Fed Adult Patients with Dysphagia, Nutrition in Clinical Practice 21, pp.576-586. Department of Health (2007) National Stroke Strategy. Available at: (Accessed 30 June 2008). Gordon, C., Langton-Hewer, R. & Wade, D.T. (1987) Dysphagia in acute stroke, BMJ 295, pp.411-414. Gustafsson, B. & Tibbling, L. (1991) Dysphagia, an unrecognized handicap, Dysphagia 6, pp.193-199. Harper, J.R., McMurdo, M.E. & Robinson, A. (2001) Rediscovering the joy of food: the need for long-term review of swallowing ability in stroke patients, Scottish Medical Journal 46(2), pp.54-55. Intercollegiate Stroke Working Party (2004) National Clinical Guidelines for Stroke. 2nd edn. London: RCP . James, A., Kapur, K. & Hawthorne, A.B. (2000) Long term outcomes of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke, Age and Ageing 27, pp.671-676. Langmore, S., Terpenning, M., Schork, A., Chen, J.T., Murray, D., Lopatin, D. & Loesche, W.J. (1998) Predictors of aspiration pneumonia: how important is dysphagia?, Dyphagia 13, pp.69-81. Royal College of Speech & Language Therapists (2005) Clinical Guidelines. Bicester: Speechmark. Verhoef, M.J. & Van Rosendaal, G. (2001) Patient outcomes related to percutaneous endoscopic gastrostomy placement, Journal of Clinical Gastroenterology 32(1), pp.49-53.



We Are Not Stupid People First Lambeths book about how people with learning difficulties would like to be treated. 6.50, tel. 0207 642 0045, e-mail Vision Purchases equipment, goods or specialist services for children in the UK who are blind, visually impaired or dyslexic. Speech, Language and Communication Framework Competency-based Framework to help everyone who works with children evaluate strengths and areas for development. Lattitude Global Volunteering Charity coordinating overseas gap year voluntary work placements for young people from 17-25. Thrive Thrive, which promotes the advantages of gardening for people with a disability, has developed a leaflet with mental health charity Mind highlighting the power of gardening to improve emotional wellbeing. Human Rights A revised booklet from the Ministry of Justice gives people with learning difficulties advice about what the Human Rights Act means for them. DownsEd Books now available online include Speech, language and communication for individuals with Down syndrome An Overview (2000) by Sue Buckley. i=319435096 Easyhealth Accessible health information for people with learning disabilities.


assessments assessed

E-mails to the Editor Assessments assessed

ADULT LEARNING DISABILITY Hi Avril, The Adult Learning Disabilities Leads Network would like to invite speech and language therapists to take part in a review of the position paper, Speech and Language Therapy provision for adults with learning disabilities. The Network was formed in 2004 to facilitate a strategic approach to adult learning disabilities across the UK. We are holding consultation events to help update this important paper. Each event will run with the same format and framework, focusing on the role of speech and language therapy in adult learning disability dysphagia and communication. We are encouraging people to bring along examples of their work so we can include examples of good practice in the document. For more information, readers can e-mail me. The work of the Network to date has resulted in: an initial overview of service provision to adults with learning disabilities across the UK an agreement of best practice in the delivery of ALD services by consensus the opportunity to shape the future of ALD services by linking with other national organisations, including the Healthcare Commission and the Valuing People Implementation Group. We have also provided information to contribute to national responses to some of the ALD issues that have hit the headlines recently, for example the Cornwall report, Sutton and Merton Inquiry and Mencaps report, Death by Indifference. The Network consists of 17 regional groups which feed into a UK forum twice a year that is led by an elected steering committee. If you lead an ALD service and are not involved in the network, e-mail louise.oldnall@sbpct.nhs. uk for more information. Thank you, Jo Morris On behalf of the ALD Leads Network
ALD Position Paper Review Consultation Events 2008 Date Venue Booking Contact 10 September Brooklands, Birmingham 0121 329 4940 3 October Muckamore Abbey, Northern Ireland 07841 654073 21 October Devon 6 November Dunblane, Scotland 26 November Oldham 12 December RCSLT, London

We continue our series of reviews to help you decide if an assessment would meet your needs this time considering an articulation screen and resource pack.

Lemon and Lime Library

Charlotte Mustoe finds the principle and organisation of this resource appealing but notes that, until additional picture material can be incorporated, it is most suited to adult clients and older children. Lemon and Lime Library - An articulation screen & resource pack Rebecca Palmer & Athanassios Protopapas (2007) Speechmark ISBN 978-0-86388-548-8 45.99 + VAT This CD-ROM with an accompanying resource book provides materials to create tailor-made practice worksheets for therapists working with clients with articulation disorders. The CD-ROM generates word lists according to the linguistic and phonetic criteria as selected by the therapist. Words can also be added to the library by the therapist, allowing it to grow over time and to store a larger number of words for articulation practice. Tailor-made worksheets of practice words and sentences (including pictures and instructions) can be designed and printed for individual clients. There are seven levels of articulation practice: single sounds; consonantvowel combinations; DDK rates; short words; multisyllabic words; short phrases with the target sound in one word; and longer sentences saturated with the target sound. The resource book also contains an articulation screening test which has both written words and corresponding pictures (using words not included within the library) to indicate the areas of greatest difficulty and to assess the generalisation of articulation skills. It is designed to be used with both adults and children by therapists, teachers and speech and language therapy students. They must have an understanding of phonetic labels as the materials are organised in this way. The CD-ROM is easy to install and the programme itself is straightforward to use in order to create worksheets for individual clients. There are drop down menus to select criteria such as level, manner, place, voicing. However, the word lists can be limited and not all of the words have corresponding pictures (although the ones that do have nice clear images). You can expand the word lists by adding your own choice of words to personalise them for clients. This is useful (especially as these are then stored for future use), however it is a shame that you cannot upload a corresponding picture. The articulation screening test is made up of both written words and (for some words) corresponding pictures. Some of the words would be difficult for younger clients (edge, fourth, bitter) and, as the pictures are not in colour, they may not be as appealing and motivating to younger clients. The pictures that I was able to use with clients were well received as the majority of them are nice and clear with high imageability. The screening assessment was useful for older children who did not need colourful pictures to motivate them. It may also be a helpful screen for adults with communication difficulties such as dysarthria. The principle of the worksheets is extremely appealing. However, as the majority of my clients are preschool or primary school age, picture materials are vital and this resource just didnt fulfil that need. Its a shame as the idea, organisation and accessibility of the word lists is a real positive. Scope to expand the library of picture stimuli in a future edition would be very welcome. This reasonably priced assessment and therapy resource may be more practical for those working with older children or adults with articulation difficulties who can access the written material. There are some handy written phrases and sentences in the resource book to aid with generalisation of sounds into spontaneous speech. For younger clients, the word lists are useful, but you may need to source corresponding pictures from elsewhere to fill the gaps. Charlotte Mustoe is a paediatric speech and language therapist with Salisbury NHS Foundation Trust.

CAMBODIAN PROJECT Hi Avril, I have just finished a postgraduate speech and language therapy degree at City University and start my first post a voluntary one in September in Cambodia. The Cambodian project began in 2007 when three newly qualified therapists from City spent three months giving therapy to children in need and advising carers on their speech, communication and feeding difficulties. This year four of us are taking part. We will be working with children with cleft lip and palate conditions and special needs in Phnom Penh. We will receive training and supervision from Dr Debbie Sell at Great Ormond Street and Dr Tim Pring at City. As our project is self-funded, I wondered if any of your readers would consider donating resources or advice? I would also welcome suggestions of people or organisations who may be able to help us in our preparations or with funding. Medical provision in Cambodia is generally poor and beyond the financial means of most of the population. We will be working with the Childrens Surgical Centre (, where free surgery is provided for children with cleft lip and palate. The centre has a grant from the Smile Train which funds operations, an administrator and the development and running of a database but it is unable to cover speech and language therapy provision. We will also be helping at Cambodias first special needs school (www., and aiming to ensure feeding practices for those with severe disabilities in a nearby orphanage are safe. Thank you, Lindsey Kent (e-mail

cover story: early intervention

Ready for reading

Children with Down Syndrome have the potential to access language through reading from an early age. Gillian Lord and Karen Bailey assess the impact on children, parents and clinical practice of a pilot Ready for Reading group for parents and teaching assistants.

lton (2000) and Buckley (1999) showed that children with Down Syndrome have the potential to access language through reading and that this can be started from as young as 2;6 years or even earlier if the child has reached the criteria of understanding 50 words. Based on this, we used to give bespoke information about reading to individuals but reached a stage where we had sufficient families to justify a Ready for Reading pilot group. We felt a group would offer advantages of peer support and generation of ideas and complement our two existing groups for children with Down Syndrome in Manchester (Robinson & Bailey, 2000). In September 2005 we began a block of five weekly sessions of one hour, devised for parents and teaching assistants. As this was a pilot study, the age range was deliberately wide but all the children fulfilled the minimum criteria of understanding 50 signed / spoken words (Bird & Buckley, 2001). We invited parents to attend without their children where possible as the sessions were so adult-orientated. This was achieved without question from all five families; some children were in school, while others arranged childcare. The sessions were devised to be both theoretical and practical, and were supported by a handout. Each session covered a different aspect of reading and included a craft activity loosely linked to the theory of the session (figure 1). We covered the areas of pre-literacy skills, early reading skills and learning styles.
Figure 1 Session plan

Session 3s key phrase was errorGillian less learning. Rather than trial and error this is a way of teaching that means the child always succeeds in tasks presented to them. Prompts and support are given before the child can make a mistake so they learn success by imitation and practice. This may be a particularly effective method with children with Down Syndrome because they are susceptible to giving up easily. Constant success and the praise and confidence-boost associated with it can encourage persistence. Proponents of errorless learning also believe it prevents incorrect patterns becoming a habit, and that it reduces frustration for both child and caregiver. In session 4 our key phrase was word shape / envelope (figure 2). This is the visual pattern of a word that can be easily recognised through the combinaFigure 2 Word shape / envelope tion of ascending, descending and neutral characters. Word shape recognition is important for whole word reading, because it is the first step taken for all children towards learning to read (Buckley, 2001). Our key message for session 5 was carrier phrase. This is a set phrase that can be used in lots of different situations to give the experience of using sentences without overloading memory or making too many language demands, eg: I like jumping I like bananas I like Sarah.

Effective method



Session 1 Session 2

An introductory session where we listed the items parents / support workers would need to bring for future sessions. We considered the different opportunities for turn taking, sensory experiences and ideas for increasing attention and listening skills. Positive reinforcement was the key phrase for this session and the parents made a lift-the-flap book and a texture book. We explored the ways parents could share different literary experiences with their child, in addition to books. The key phrase was errorless learning and the craft activity was making a book using photographs of their childs day and an in and out board. We looked at the developmental sequence of different types of matching activities and discussed the benefits of a small sight vocabulary. The key phrase was word shape / envelope and the activity was making a lotto game using pictures of members of their family. We discussed the benefits of functional expressions such as I like and I dont like and referred to these as carrier phrases (the sessions key phrase). We also discussed the benefits of visual timetables. The craft activity was making a reading board that included a carrier phrase with alternative endings. The handouts also included useful tips and strategies.

Session 3

Session 4

Session 5

At the end of the block we asked the parents for their comments via a structured feedback form. We then asked each family to keep a detailed diary of the activities they used with their child at home and at school. A group therapist made contact with the families through visits and telephone calls over a period of 6 months. We have summarised what happened with each child in our study, in figure 3. Information on the childrens progress was provided by the parents so detail was variable. However, it indicates that all of the children made some degree of progress and, furthermore, that the parents now had the benefit of knowing the most appropriate learning styles for their child with Down Syndrome. The parents comments at the end of the block were very positive: useful and lots of new ideas to help with reading some practical skills to help with reading. To the question what do you do differently responses included: a lot more reading making material specific to my child and to suggestions for the group in future: wish they (the sessions) had started earlier handouts useful. Although we had no control group, our previous experience leads us to consider that the group and the follow-up were successful in a number of ways. Each child made progress within their capabilities. Parental awareness was raised and they became more proactive in supporting their childs reading development. For the speech and language therapists involved, the project initiated positive changes in clinical practice. We now provide information at a much earlier stage so that parents can prepare their child and adopt best practice in readiness for reading. We also discuss the benefits of sharing a reading book on a daily basis and talk consistently about errorless learning. The positive outcomes of the pilot highlighted the advantages of continuing the group in the future. SLTP


cover story: early intervention

Photos: Karen Wright Photography. Joes mum and dad attended a Ready for Reading group Gillian Lord and Karen Bailey are speech and language therapists with Manchester PCT, email / gillian. Karens earlier article with Robert Robinson is freely available at www.

Figure 3 Pilot group members

1. DQ age 2;7 years Pre-group Activities used Time spent Short attention span, a few signs Books, in and out house activity, picture match using family photos 10 minutes every other day


We would like to thank all the families that attended the group, and took part in our subsequent study. Their time and effort was much appreciated.

Learning styles Very practical, needs to be motivated by activity, errorless learning Progress made Interest and attention levels improved, using more signs spontaneously, using in / out successfully, signing while looking at books. 2. DI age 2;7 years Pre-group Activities used Time spent Spoken vocabulary of 25 words, signed vocabulary of more than 25 words, enjoyed books and could turn pages with support My day book and other books, matching objects, Jolly Phonics cards, carrier phrases 2030 minutes daily using a combination of tasks


Learning styles Errorless learning, flash cards, lots of support. Needed to be motivated to the task. Progress made Turning pages and looking through books independently, saying more spoken words, knows most sounds from Downs ed cards and some from Jolly Phonics. Picture matching ongoing. 3. SG age 3;7 years Pre-group Liked books, would sit and listen to story, able to turn pages, identified familiar objects on a picture, in school full time so some of activities carried out by teaching assistant who attended course Flap books, matching names to pictures, carrier phrase book, in / out home picture, reading books together Infrequent focused sessions due to family time constraints

Activities used Time spent

Alton, S. (2000) Reading. Children with Down Syndrome information sheet. Teddington: DSA. (Updated in 2006 and available at pdfs/Reading.pdf. Accessed 26 June 2008.) Bird, G. & Buckley, S. (2001) Reading and writing development for infants with Down Syndrome. Portsmouth: Downsed. Buckley, S. (1999) Reading Before Talking: Learning about Mental Abilities from Children with Down Syndrome. Portsmouth: Downsed. Available online at cs/downsyndrome/index.htm?page=litread. html (Accessed 26 June 2008). Buckley, S. (2001) Reading and writing for individuals with Down Syndrome an overview. Portsmouth: Downsed. Robinson, R. & Bailey, K. (2000) Early goals bring a result, Speech & Language Therapy in Practice Winter, pp.20-23.

Learning styles Errorless learning, short 5-10 minute focused sessions, awareness and need for generalising Progress made Reading family names and familiar animals, approximately 10 words, general awareness of words in the environment is developing, spoken language is developing more and mum linked this to his reading skills. 4. GW age: 3;10 years Pre-group Activities used Time spent Liked sitting and looking at books, used signs and single words, short attention span, in Foundation stage full time In / out garage , picture- picture match, Downs ed Speaking for Myself CD, visual timetable at school 5 10 minutes on focused tasks initially daily then less frequently


Downs ed (Down Syndrome Education International) Jolly Phonics Speaking for Myself CD from www.topologika. com


Learning styles Enjoyed computer format, visual, errorless learning Progress made Attention span improved, able to find name card at school, picture-picture match, word-word match. 5. JJ age 1;10 years (this child satisfied the criteria of understanding 50 words) Pre-group Matching picture-picture, recognising people by name from photograph, starting to put two signs together, verbal output some babble, loved books, excellent attention (20 min +) when sharing books Word-word match, word-picture match, in / out house, carrier phrase book, shared book time Daily reading and book time, 2-3 times a week focused task time of 1520 minutes


Activities used Time spent

Learning styles Excellent attention span, good at table top activities, errorless learning, good generalisation, use of sign to support, can be directed but likes to work at own pace Progress made Independently matching word to picture, reading family names.

How has this article been useful to you? How have you helped children with Down Syndrome access language through reading? Let us know via the Autumn 08 forum at



A clear focus
Focus groups of people with communication difficulties following a stroke have enabled Anna Hayes and colleagues to make a successful case for more staff and introduce service improvements such as more group work, a new goal setting system and aphasia-friendly information.
l-r, Amy and Mariela

here has been a big emphasis within health and social care policy on listening to the views of users and carers about the services they need and want (DH, 2000; DH, 2001). This is particularly important for those whose voices are often least heard (DH, 2006, p.157). In our work with stroke we have frequently listened to stories from clients who feel frustrated, angry and lacking control over their healthcare. Such people typically have a limited voice and as a result are frequently not involved in decision-making (Pound et al., 2000). This was the real motivation for our user involvement project. We hoped that by inviting clients to have their voice heard they would gain a sense of control and significance, and we would gain the valuable input of an often under-represented group. The East Sussex Speech and Language Therapy Service for Adults covers a large geographical area and comprises of 22 therapists, one assistant and three administration and clerical staff. We provide an assessment, diagnosis, treatment and management service for clients aged over 16 who have acquired communication and / or swallowing problems. Our project aimed to seek the views of people with communication difficulty following stroke in order to: Better understand their needs and the effects of our service on them Harmonise best practice Ensure effective use of resources Direct future planning and development of the service Help to inform our negotiations with purchasers of the service. We decided to use focus groups as we felt that even an aphasia-friendly questionnaire might deter communication-impaired people from participating, and one-to-one interviews would place impractical demands on time and resources. We thought that by using focus groups with skilled facilitation we could obtain the views of a significant number of people, including those with severe communication difficulties. Users of the service were involved at the planning stage. Members of our speech and language therapy self-help group contributed ideas and opinions regarding the design of the focus groups, questions to be asked and practicalities. We held two events, giving participants a choice of neutral and non-clinical venues. We 10

invited current users of the service and people who had been discharged within the last year. We also invited one carer / relative per client to give their views. In total we asked 70 service users and 16 planned of them to come, with 2 cancellations on the day. This represented a 20 per cent turnout, which we felt was good. Eight relatives / carers also attended. Inspiration from the work done at Connect helped us to design the sessions so that participants would understand their purpose and be able to contribute as meaningfully as possible. We obtained their views by careful use of supporting materials and skilled facilitation using the principles and techniques of supported conversation for adults with aphasia (Kagan, 1995). We split participants into small groups of no more than three people, depending on the severity of their communication disorder. Each small group was facilitated by a speech and language therapist. Relatives and carers were in a single group, again facilitated by a speech and language therapist, but separate from the participants with communication disorders as we thought their perspective and views might be different. Each event also had a speech and language therapy student who was not involved in facilitation acting as a note-taker.

Reference point

We decided to use the patient journey through the speech and language therapy service as a reference point for participants feedback. We represented this visually in the form of a picture (figure 1). The journey was broken down into three sections: 1. Waiting period after referral, and initial assessment meeting 2. Therapy period 3. Leaving therapy (discharge). For each part of the journey, we asked clients and carers to reflect on: What was good / positive? What was less good / negative? What was missing / suggestions? We decided to keep the style of questioning as open as possible to encourage participants to focus on their own unique experiences of the speech and language therapy process. We felt that this would provide us with information that participants felt was important, which we thought might be quite different from our own perceived priorities. Consequently we found that

each session yielded a vast amount of narrative data. This was initially rather daunting but with the help of the audit department we analysed the data into themes. We were relieved and pleased to receive a lot of positive feedback. The vast majority of clients and carers had good experiences of the speech and language therapy process. Comments from clients included therapist helped an awful lot; enjoyed it; explained very well; gained confidence. Examples of comments from carers were (I) didnt expect such an excellent service; I got emotional support; (carers were) included right from the start. However, we were also pleased to see that clients and carers felt able to tell us about our weaknesses. The key areas where people had identified problems were: timely and accessible information, particularly regarding what to expect prompt and adequate access to therapy for communication disorders (by comparison to swallowing disorders) and adequate amount of therapy, including reduced opportunity to attend groups. Carers in particular told us that they felt that nursing staff required more education about swallowing and communication problems. The main concern after discharge was loss of contact and support, and interestingly this was also the main anxiety for clients who had not yet been discharged. We noticed that different people had had contrasting experiences of the same thing. For example for access to information, compare the response full information about the recovery process with very difficult to get information. This might indicate inconsistencies in some areas of the speech and language therapy service, or suggest that we need to be more aware of different information needs and how people express them. We also noticed that several clients felt they had not received enough therapy, despite having had blocks of therapy for over two years. Whatever we may think about the benefits of longer-term input, there are limits on what we can offer. We hypothesised that being clearer about this at the outset of therapy, along with improving our negotiation of goals, might help some clients at least be more satisfied with the process and outcome.

Our series aims to show that user involvement can be transformational for clients, therapists and services put into practice at many different levels a powerful tool for influencing commissioners



User involvement whats your experience? Let us know at the Autumn 08 forum, http://members.
Figure 1 Visual representation of the patient journey

As a result of the focus groups we have taken steps to address the concerns that were raised, and to ensure that we build on and harmonise good practice across the service: 1. We have secured funding for a therapist to provide a service to inpatients with a communication disorder, and also funding for an assistant. We hope this will allow more groups, and enable us to provide more support for clients both as they prepare for discharge and after they have been discharged. 2. We have reviewed goal-setting and outcome measurement across the service, and developed a new system to ensure best practice. 3. All newly referred out-patients are sent a letter on receipt of referral to the speech and language therapy service, giving an indication of the likely waiting time. 4. A series of aphasia-friendly information leaflets has been created with input from clients. One is sent with the initial appointment letter explaining what to expect of therapy, whilst the others are given during sessions and contain information about communication and swallowing difficulties. 5. We have made efforts to provide more opportunities for group work, for instance Total Communication and SPPARC (Lock et al., 2001), although this has been limited by a significant proportion of therapists being simultaneously off on maternity leave / a career break. Therapists are also investigating setting up a new self-help group to replace previous groups which have come to a close. 6. We have produced communication training packs for the team to roll out to nursing and other professionals to improve their knowledge and skills with our clients. We are determined to keep user involvement at the top of our agenda. The speech and language therapy service has recently completed a multidisciplinary consultation event for people with Parkinsons disease, and we are investigating other models for user involvement. Events such as these will be useful commissioning tools

Steps taken

in the context of the ever increasing need to convince commissioners that we are providing services that our clients need and want. Whilst this user involvement exercise required a considerable amount of work, it has been hugely worthwhile. There was a real buzz at the focus group events, and all the therapists involved found the experience both stimulating and rewarding. However, our main incentive for this project was to help make our clients feel valued and involved in their healthcare. The feedback that we received certainly implied that we achieved this. Some clients told us they had been worried prior to the event that they might have been out of their depth, but had been relieved to find they were able to express everything they wanted to. Clients said they had been pleased to have the opportunity to have their say. We got a strong feeling that clients had felt listened to and for one client in particular the event was the best thing that has happened since my stroke. Anna Hayes is a speech and language therapist with the East Sussex Speech & Language Therapy Service for Adults. Anna is on a career break but you can contact Anita Smith, Regional Professional Lead ESSALTSA, Speech and Language Therapy Dept, level 1, Conquest Hospital, The Ridge, St Leonards on Sea, TN37 7RD. 01424 755470 ext 8639, e-mail

End of life competence

news extra

The End of Life Care Strategy for England says that all allied health professionals need core competences to deal with people who are dying or who have been diagnosed with an incurable illness. The strategy says that a basic knowledge and awareness of end of life care needs to run through all undergraduate training to prepare staff for this eventuality and that regulators such as the Health Professions Council will wish to consider how to ensure that the skills required for effective and sensitive care are sustained and kept up to date throughout professional careers. While the strategy acknowledges that many of standards for proficiency, education and training and professional development are applicable to end of life care, this is not explicit.

Parkinsons and mental health


With thanks to all the therapists who helped in the running of the focus groups, and to Emma Eaton and Mary Warrington for their helpful advice during the writing of this article.


Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform. Available at: (Accessed 30 June 2008). Department of Health (2001) National Service Framework for Older People. Available at: http:// Publications/PublicationsPolicyAndGuidance/ DH_4003066 (Accessed 30 June 2008). Department of Health (2006) Our health our care our say: a new direction for community services. Available at: (Accessed 25 July 2008). Kagan, A. (1995) Revealing the competence of aphasic adults through conversation: a challenge to health professionals, Topics in Stroke Rehabilitation 2(1), pp.15-28. Lock, S., Wilkinson, R. & Bryan, K. (2001) Supporting Partners of People with Aphasia in Relationships and Conversations (SPPARC). Milton Keynes: Speechmark. Pound, C., Parr, S., Lindsey, J. & Woolf, C. (2000) Beyond Aphasia: Therapies for Living with Communication Disability. Milton Keynes: Speechmark.

The Parkinsons Disease Society is to offer training in the mental health issues associated with Parkinsons to health and social care professionals. Of the 470 professionals who responded to an online questionnaire designed to assess current levels of knowledge and future training needs, 17 were speech and language therapists. The Society says that, while 12 of them had received training around Parkinsons, only 2 had included mental health aspects of the condition. It adds that only one third of the speech and language therapists stated they felt confident in their ability to identify the mental health symptoms relating to Parkinsons. The specific training programme will be piloted from February 2009. Further information is available from Jackie Spencer, Mental Health Project Manager, e-mail jspencer@parkinsons. A one day conference on 23 September has limited Parkinsons Disease Society bursaries available for professionals (see events).

Dementia development


Connect, the communication disability network SLTP -

The company behind a 5 million development in Southport say it will be an international service centre of excellence for people with dementia. Birch Abbey care home already specialises in dementia care and support but will more than triple in size under the plans by owners Melton Health Care Limited. Its chief executive Dan Lingard, a former software developer, is also behind Birch Abbeys MyAmego specialist dementia patient monitoring system. Technology also plays a part in the expansion proposals, with a camera being added to the chicken run in theliving sensory gardento provide a talking point for people who are less mobile. Dan Lingard says, We are designing in - from scratch - technology, accommodation, entertainment, activity, social interaction and a broad range of care services and features that have never been seen together under one roof in the care industry. But, crucially, this is not just about a building - it is about an attitude to dementia care, service and support.



Complex needs

About a boy
At 14, Mark John had profound and multiple learning difficulties, sensory defensiveness and severe communication difficulties. Through a collaborative Individualised Sensory Environment programme with sensory integration techniques, speech and language therapist Helen Francis and occupational therapist Joanna Lloyd opened the door to him achieving his potential. Helen and Joanna write, This article is dedicated to the memory of Mark John who sadly passed away this summer.

hen we began to work with Mark John he was a 14 year old student who had been at St. Margarets School for children with profound and multiple learning difficulties (PMLD) and complex health needs for just over a year. He was a non-verbal communicator who had particular difficulties tolerating touch, eye contact and person engagement. He smiled or stilled to listen to familiar vibrating and musical toys near him on his floor mat, and indicated a desire to interact by reaching for a helpers hand to play with them. He complained loudly when sitting in his chair in class groups, and pushed away or shut his eyes to opt out of situations involving people or touch. He used a range of idiosyncratic vocalisations and hand movements, but it was often hard to be sure which sounds were happy and which were a protest. Mark John appeared to have difficulty co-ordinating his responses, at times smiling and vocalising positively when offered an object, then pushing it away instead of holding it. At other times he would frown and look cross, but then grasp that same object. It was therefore difficult for Mark John to show preferences and for us to understand his choice making. This lack of engagement appeared to be hindering him from achieving his personal and educational potential.

Aims set jointly

At St. Margarets each student has communication aims for their Individual Education Plan (IEP) set jointly by the class teacher and speech and language therapist. Based on our observations we decided his needs were: 1. To show clear preferences by smiling / reaching, or frowning / pushing away 2. To make clear requests for more by turning toward, reaching or vocalising 3. To use differentiated vocalisations for specific intentions. Programmes and activities incorporating these would be set up for Mark John by those working with him. 12

Mark John was assessed by Helen (his speech and language therapist) for participation in an Individualised Sensory Environments (ISE) programme, a technique first developed by Bunning (1995) with young adults with profound learning difficulties who were described as hard to reach. Based on patterns of normal development, infants in the earliest stages of life receive strong tactile, vestibular and proprioceptive input from being held close, wrapped up and rocked, only later showing interest in sights and sounds. Therefore, someone who is still at an early stage of development may be seeking this type of tactile input and is most likely to respond positively when they receive it. Once they are interested they will seek for more, and ultimately interact and engage with the one who is providing that stimulation. Touch is further divided into non-touch, indirect and direct touch, and vibro-touch. Helen videoed Mark Johns baseline session; he smiled in response to air-based toys and vibro-based objects, but pushed away massagers and wet and dry objects. He was unsure about swinging and vestibular movement. The programme then takes the clients favourite objects and uses just five keywords - his name, ready, gone, more? and stop. This avoids distraction, and allows him to direct the session. If he indicates that he likes something and wants more, it is given to him; if not, there is no pressure to respond. Record forms are used for each session. Class staff agreed that Mark Johns programme (figure 1) would be carried out at least once a week initially by Helen, who would then train therapy and class assistants to carry out additional sessions. There would be a review after three months. However, the problem with Mark Johns ability to tolerate touch remained, so even the ISE programme was limited in what it could offer him. Lack of tolerance of touch was continuing to impact on his ability to access class activities, life skills (dressing, bathing, moving and handling) and social interaction. Over the same period, Mark John had been receiving occupational therapy from Joanna. As-

sessment through life skills activities and functional activities in the classroom had highlighted: His ability to learn, for example he would actively assist by taking his arms in and out of his harness whenever getting in and out of his wheelchair he learnt the routine. He was able to make differentiated responses to touch - for example by withdrawing from light touch and smiling to rough and tumble play. Withdrawal from light touch and the touch of objects including items needed for personal care and toys reduced Mark Johns ability to tolerate and co-operate with personal care tasks and to access the curriculum and his environment. Mark John responded consistently to some key objects, demonstrating his recognition of those objects for example by consistently closing his mouth to a spoon, and pushing certain toys away while accepting others. Mark John demonstrated clear understanding of cause and effect and was able to activate a switch to operate a variety of toys and equipment but was unable to do this consistently due to his sensory difficulties. Occupational therapy aims and intervention therefore included: attending to and following movement of an object, to pick up an object and pass it on to tolerate a variety of textures.

Combined programme

With both of us feeling that we had reached an impasse, we discussed Mark John and decided to combine the speech and language therapy and occupational therapy aims. We wanted to set up a programme of joint working focused on enabling Mark John to accept tactile input and communicate his preferences more clearly. We then saw Mark John for a trial period in weekly joint occupational / speech and language therapy sessions to address his tactile defensiveness and difficulty handling sensory experiences. We used a structured approach with a set routine so Mark John was able to learn to anticipate the programme, which


Figure 1 Mark Johns Individualised Sensory Environment (ISE) Programme Aims: 1. To indicate like / dislike of an object. 2. To give a distinct signal to request more of an object or activity. 3. To engage with a person interacting with him. Equipment A variety of motivating items listed below use a different selection each time Chosen Categories: Suitable Objects eg: 1. Air based (indirect non-touch contact) Japanese fan, puffa toys, battery fan 2. Vibro-based (indirect vibro-contact) Vibro-tube, vibro-massagers, vibro-toys Procedure NB Spend a brief time chatting to Mark John before starting and after finishing the programme. Note his response before, and after, the session. Record responses on form below. Apart from this chat time, only use the words outlined below during the programme. 1. Select the required number of objects from their chosen categories (see above). 2. Present item and say Mark John, ready? and demonstrate ie give fan, or turn on vibro toy and let him feel and respond 3. Withdraw item and say Gone 4. Show item and say Mark John, more? Wait for response (up to 20 seconds) If responds, give item If no response, say Mark John, more? and demonstrate (wait up to 20 secs.) Repeat stages 2 - 4 If no response, say Mark John, look (with touch cue) more? (wait up to 20 secs.) If no response, discontinue. Stop
Programme Record Sheet Stimulus/Activity Smile Introductory conversation 1st object:. 1st time more (1) more (2) 2nd object 1st time more (1) more (2) 3rd object . 1st time more (1) more (2) 4th object 1st time more (1) more (2) Closing conversation Turn towards Look towards Reach Mouthing Vocalise Still Grimace Turn away No response Other (Specify)

combined sensory integration and ISE techniques. Sensory integration theory and practice was originally devised by Dr Jean Ayres (1979) who defined it as the organisation of sensory input for use and suggested that dysfunction in sensory integration occurs when the brain cannot organise and connect or integrate sensory messages. She advocated deep pressure through joint compression and muscle compression as these are thought to be accepted as calming and organising. We wanted to see if this approach would help Mark John to organise his responses to sensory input and so to tolerate touch. We offered him a choice of toys / activities as part of his ISE programme. The aims were for Mark John to tolerate touching / holding these for longer, and for his communication signals indicating pleasure or refusal to become clearer. With the sensory integration programme, Mark Johns initial strong resistance to deep pressure, touching and being touched was gradually replaced by calmness and anticipation, even pulling the Lycra sheet a tool used for deep pressure input - around himself and giving positive vocalisations on one or two occasions. The communication approach used in the ISE programme (using few key words, and allowing Mark John to request more of particular activities), was incorporated into this too. His calmness and anticipation

began to carry over into the class activity which followed immediately after this programme. We recorded Mark Johns responses to the ISE programme each session. After 3 months we took a further video and evaluated it against his Individual Education Plan communication aims; it was clear that Mark John was making progress. As his sensory tolerance increased, so we were able to offer him a wider range of motivating activities such as air based toys, vibrating objects and deep pressure massage. As his motivation increased, so did the opportunities to engage with him. All our students are assessed and reviewed annually using the St. Margarets Developmental Curriculum (2006). At Mark Johns annual review we found: 1. Communication Mark John had achieved all his communication objectives after carrying out our programme for 5 months. His new aims were to demonstrate understanding of five to ten familiar words, to give distinct signals to request attention or more in a range of situations, and to consistently use differentiated vocalisations for specific intentions. 2. Life Skills Progress had been made in sensory tolerance and his mother reported that his increased tolerance of touch had allowed him to achieve several life

skills objectives. His new aims were to actively tolerate dressing (by not resisting; responding by pushing arm through clothes / bending arm to remove clothing). 3. Parents report His mother was pleased to note that he had begun to make eye contact with her and his father, which he had rarely done before. We concluded that this trial had been effective, and we would develop the programme and continue for a further year. We explained our intervention to Mark Johns mother, and she was keen to carry out a similar approach at home.

Clearer repertoire

We continued the joint speech and language therapy and occupational therapy sessions and extended them to twice weekly with support from class staff. Mark John began to show enjoyment of some new activities and developed a clearer repertoire of positive (smiling, laughing, high pitched vocalisations, hand-clapping) and negative (frowning, low pitched vocalisations, pushing away) responses. We were able to shape one of his vocalisations into a specific uh signal to request more, and this was used throughout other daily activities in class with success. One year on, the most exciting change was that Mark John was now clearly engaging 13


Complex needs
Figure 2 Examples of Mark Johns areas of improvement shown on St Margarets Developmental Curriculum 1: before intervention 2: after intervention An achievement continuum is used to record pupils achievements. W Working towards objectives (less than 30%) E Evidence of, or Emerging skills (30-69%) A Achieved skills (above 70%) G Generalised skills, seen in familiar and unfamiliar settings COMMUNICATION Interaction W E Motivation Attends in response to interaction 1 Actively seeks interaction 1 Gestures Makes meaningful patterns of movement during interaction 1 Facial expression Makes distinct use of facial expressions in response to interaction 1 Vocal expression Uses differentiated vocalisation for a specific intention 1 Turn taking Continues turn taking sequence 1 Initiates a turn taking sequence - Requesting Gives distinct signals for requests for more 1 Choosing Attends to 2 items and signals a preference 1 A 2 2 2 2 2 2 1 2 2 G

with his interactive partners - stilling and listening, making eye contact, taking turns in shared activities. He was even tolerating longer waiting times, sitting in his chair attending to class activities, watching his peers and trying new activities. If he shut his eyes it was now for sleeping, not for opting out. At annual review, Mark John had achieved his Individual Education Plan communication aims and made progress in 9 other areas of the Communication section (figure 2), plus a number of related areas in the Sensory Cognitive, Social and Life Skills sections of the St. Margarets Developmental Curriculum. In terms of life skills he had achieved the aims set to tolerate daily care activities and was now able to progress to taking an active part in dressing and personal care routines, and to signal preferences.

So much pleasure

His parents report had this to say: At home I have noticed a remarkable improvement in Mark Johns awareness of his surroundings and the people around him. He also communicates so much better, by actions or sounds and now uses his eyes in a more meaningful way, absorbing whats going on. All these improvements bring so much pleasure to usthere is also a great improvement to visits and outings, which he now really enjoys I am very pleased with the programmes designed specifically for him and I believe they made a huge difference to his progress this year, working with Mark John to help him reach his potential. The programme finished, as Mark John had achieved the objectives set out for him. However his progress continued as he moved on to the schools Further Education unit, where he enjoyed group activities and outings into the community in preparation for his adult life. Working together as a team with Mark John was a positive experience for us all, but it has

also raised other issues worthy of note: 1. Significant change is still possible with a young person with PMLD even into young adult life (Cass, Slonims et al., 2003) Mark John was already 14 years of age when this programme started. His parents noticed positive changes in him even during the preliminary trial phase, before they had joined in with the programme. These changes corresponded with those measured at annual review, which have been maintained and built upon since. 2. A person with PMLD may have their life enriched with a variety of sensory experiences but, until the specific areas of need are identified, they may not be able to access what is offered to them (Bunning, 2004) Mark John had been fortunate to receive appropriate educational provision, along with a happy and stimulating home life. However there were obstacles to his progress which, having been identified, could be addressed in order for him to benefit more fully. 3. Anecdotal reporting may be quite misleading and a measurement tool is essential both to identify target areas of working and to record outcomes (The Childrens Trust, 2006) On admission to St. Margarets School, his report stated that he communicated well, showing his likes and dislikes and using a range of vocalisations. However, his initial assessment on the St Margarets Developmental Curriculum showed that actually he only gave clear positive or negative signals less than 25 per cent of the time, and that he also used vocalisation with specific intention less than 25

per cent of the time. It identified his lack of eye contact and rejection of touch as problem areas, and inability to take turns or respond to peers. It also charted his progress to achieving over 75 per cent in each of these areas, as the programmes continued over the 2 year period. It also enabled appropriate target setting across the curriculum, and showed that Mark Johns progress continued to generalise after the programmes themselves had finished. This is about just one boy; however, we feel that it has highlighted for us both the benefits of joint working, and the need for further evidence-based practice in the area of intervention with young people with profound and multiple learning difficulties. Helen Francis is a speech and language therapist and Joanna Lloyd an occupational therapist at St Margarets School, Tadworth, Surrey. St Margarets is a purpose built, residential non-maintained school for children and young people with profound and multiple learning difficulties and complex medical needs, www.thechildrenstrust.


We would like to thank our colleagues at St. Margarets School who worked with Mark John, and his parents, for their support in writing this article. SLTP



Ayres, J. (1979) Sensory integration and the child. Los Angeles: Western Psychological Services. Bunning, K. (1995) The principles of an Individualised Sensory Environment, Bulletin of the Royal College of Speech & Language Therapists January. Bunning, K. (2004) Speech & Language Therapy Intervention: Frameworks and Processes. London: WileyBlackwell. Cass, H., Reilly, S., Owen, L., Wisbeach, A., Weekes, L., Slonims, V., Wigram, T. & Charman, T. (2003) Findings from a multidisciplinary clinical case series of females with Rett syndrome, Developmental Medicine & Child Neurology 45(5), pp.325-337. The Childrens Trust (2006) St. Margarets Developmental Curriculum. Tadworth: The Childrens Trust,

DO I RECOGNISE THAT AGE IS NOT IN ITSELF A BARRIER TO PROGRESS? DO I CHECK THAT I HAVE IDENTIFIED AND ADDRESSED A CLIENTS SPECIFIC AREA(S) OF NEED WHEN THEY APPEAR TO HAVE REACHED A PLATEAU? DO I USE TOOLS TO RECORD A BASELINE AND ASSESS CHANGE OBJECTIVELY? What has this article got you thinking about? Has joint working made a difference to your clients? Let us know via the Autumn 08 forum at http://members.speechmag. com/forum/.



heres one I made earlier / winning ways

Heres one I made earlier...

Alison Roberts with more low-cost, flexible therapy suggestions suitable for a variety of client groups.
The idea is to help the clients become more aware and tolerant of other peoples ideas and perspectives. It is carried out in pairs, perhaps partnering established friends or less well-acquainted people. It also promotes interviewing skills. It is quite an intimate activity, involving touch and possibly smell! In my experience, if you approach it light heartedly, there will be no complaints.
about all sorts of subjects and why. He then writes their opinions in the shoe outlines. For example I prefer to borrow videos rather than go to the cinema because I dont like such a loud noise , or I am a vegetarian because I once saw a TV programme about abattoirs or Im against pedestrian zones because they are scary at night . Try to fit in as many comments as possible. Now swap over and let the other partner do the interviewing and writing. Conclude the session by having a discussion about the expression Standing in your Shoes, and how it is possible to tolerate other peoples ideas once you know why they feel as they do.

Life coach Jo Middlemiss offers readers positive suggestions for coping with common problems.
Caroles job was changed recently. While before she was based in a clinic where she had a room, a filing cabinet and a cupboard for her resources, she is now moving around different nurseries. Her car boot is permanently full and she has very limited space to store items in the departments central clinic. Although she can see her service to the children is more effective, Carole feels rootless and frustrated that her car is no longer her own.
Speech and language therapists do get stressed about all the stuff in their cars and no doubt the rest of the family does too! On the surface Caroles situation is deeply frustrating. She seems to have had a set-up that was comfortable, secure and to her liking and now to be in the middle of an unsettling storm. But oh how our boat needs to be rocked sometimes. Caroles car has turned from her precious space into a mobile cupboard. What can she do? She can certainly readjust her attitude to the car. What is a car? What is it for? How is it organised? Is it the right size and shape for what she needs? Is there any alternative around the area of the car? How is the stuff organised in the car? Can it be taken in and out easily? And what are the freedoms of a mobile office? Attitude is again all important when looking at the change in the overall context of her job. Does Carole think beyond her own frustrations to the job she has to do - or is she communicating these frustrations to her colleagues and thus perpetuating the problem? Has she really looked for the advantages of working with a multidisciplinary team in an educational setting? Can she see this as a developing situation and look for opportunities to put down new roots? Assuming that this change has been implemented across the speech and language therapy service, Im willing to bet that Carole will be able to find a colleague with a different attitude to the workspace. If all decide to make the best of it - or the worst of it - then that is what will play out. Our thoughts are things. If the situation is totally unworkable then organise change. If it is functioning well but needs tweaking, then facilitate the tweaks by communicating with colleagues or managers. If Carole really wants her situation to change she has to put her attention constantly onto what an improved situation would look like, feel like and sound like. She must first create it in her minds eye before it can possibly appear in reality. If you can change the way you think about your life, your life will change.
Jo Middlemiss is a qualified Life Coach who offers readers a confidential complimentary half hour coaching session (for the cost only of your call), tel. 01356 648329. Her book with CD What should I tell you? A Mothers final words to her infant son is now available.

Standing in your shoes

MATERIALS Large pieces of paper eg. flip chart sheets Water-based, washable wide felt tip pens for the outline drawing Narrow felt tip pens for the writing IN PRACTICE In twos, draw around each others shoes. It is easier to do this with the shoes off, but make sure they are not drawing round their own shoes - its important that they find out about their partner. Make sure they do not draw on the shoes, especially if they are a pale colour. Now one of the partners asks the other one questions on how the partner feels


This is a lateral-thinking game that involves drawing as well as describing. It is suitable for a group, or could be used for a one-to-one session.
MATERIALS Odd objects that are flat enough to go in a photocopier. These could be: Several paperclips grouped together Some pressed flowers or leaves A pair of scissors A scrunched-up piece of net A squiggle of string A few buttons or sequins Bits of torn paper IN PRACTICE To prepare, place the odd objects to the side of the paper as you copy, so that the resulting image has an unfinished look, with room for further additions to be drawn on. Make enough copies of the odd objects for everyone in the group to have one. Try to arrange it that the participants cannot see each others work. Ask them to finish the pictures, and to add a title to them. Now they describe their work of art to the group.

Speedy categories

This is a quick filler for ends of sessions, or as an introduction to other category work.
MATERIALS Empty plastic drinks bottle Plastic counters or stickers in a range of colours, or you can even use felt-tip pens IN PRACTICE Place the coloured counters, stickers or pens in a large circle, with the bottle in the centre. Take it in turns to spin the bottle, say the name of the colour, and then think of as many items as you can in that colour. To add a sense of urgency, and only for selected groups, you can try a variation where one person begins naming items while the next one is spinning the bottle for their turn.



Beyond the Lightwriter...

Kevin Borrett and Nicola Clark suggest that factors around support, motivation, access and flexibility could be key to discovering why some people move successfully beyond simpler text-speech solutions to integrate high-tech computer-based communication aids into their lives.



ur department has been in the fortunate position of receiving a recurring AAC budget for the adult population of Portsmouth and South-East Hampshire since 2001. Initially we used the budget to build up a bank of aids that we could loan to clients on a short or long-term basis. At this time, Lightwriters were a popular and successful option for text-based communication due to their relatively straightforward provision and set-up, and were loaned out to clients with a motor speech impairment of a degenerative or acute onset such as motor neurone disease or post-stroke dysarthria. Fast-forward seven years and the field of AAC has changed somewhat. Technology has advanced rapidly and its ubiquitous presence in our everyday lives has made it much more accessible and familiar. Computer-based devices enable a level of integration with other systems and have a vastly increased number of communication and IT functions. Nowadays, in addition to devices such as Lightwriters, the department has high-tech computer-based communication aids which clients can have on long-term loan. As high-tech aids will not be suitable for all individuals who require text-speech output, it is important to undertake a case-by-case assessment looking at a range of different attributes and skills before loaning the equipment. In our recent experience there have been certain key factors and similarities amongst three clients which we felt contributed to the successful introduction and use of their devices. Looking at these factors may help to explain why other clients are not as successful at integrating technology into their day-to-day lives and are better suited to more limiting but simpler aids.

Heather with EZ keys software and a laptop computer on which to run it. She is able to access this device via a single switch. This communication aid was integrated with an Environmental Control System allowing Heather to access items such as her television, music and door openers - as well as her communication device - from a single switch.

2. Ruby

Ruby is a client in her 50s who was diagnosed with Motor Neurone Disease in January 2006 having noticed speech and swallowing difficulties for the previous six months. We provided her with a Lightwriter communication device in March 2006 and she was able to use this successfully to supplement her deteriorating spoken output. Previous employment had equipped her with typing skills and familiarity with computers. Due to her rapidly changing physical abilities, direct access gradually became more difficult, and she was struggling with e-mail and texting, which she had used as her primary method for communicating with people who were either more remote or unfamiliar. We provided her with a SmartNav head mouse, FuturePad and the Grid software to enable increased access (speed and accuracy) as well as allowing integration of spoken communication and continuing her written communication with friends and family. With this system, Ruby achieved broader independence as she was able to access the internet and shop online.

the Dynamo. After a year, when his confidence had increased around the use of technology and simple alphabet assistance, we loaned Andy a FuturePad device with the Grid software which allowed him to use a combination of pre-stored messages and vocabulary in conjunction with self-generated spontaneous output. We hoped that the use of the prediction function would enable him to use text despite his dyslexia. He accessed this device via a single switch initially but, due to improvements in physical function, he now has some ability to use a combination of joystick and direct access and alternates between these methods to enable him to communicate across a range of different situations. The provision of an Environmental Control System integrated with his communication device enabled greater independence via operation of equipment within his home.

Fuller lives

3. Andy

1. Heather

Heather is a client in her 50s who had a brainstem stroke six years ago resulting in significant physical impairment necessitating full care and assistance. Heather is fed via a percutaneous endoscopic gastrostomy tube and is anarthric following the stroke. She achieved early communication via differential movements of her head to indicate yes / no responses combined with a listener-scanning alphabet chart. We supplied 16

Andy is a client in his 40s who had a brainstem stroke three years ago resulting in significant physical impairment necessitating full care. He can manage a modified diet and fluids and is able to achieve some vocalisations, but verbal communication is very limited. Due to Andys pre-morbid dyslexia he was understandably reluctant to opt for a text-based system so we initially trialled him with a Dynamo, which allowed access to a number of hierarchically arranged pre-stored messages. At this stage, communication was via a combination of vocalisations, head movements indicating yes / no, listener-scanning alphabet chart and

Heather, Ruby and Andy became proficient AAC users and were able to live fuller lives as a result of the provision of these aids. A frequent measure of proficiency in AAC is the ability to use the device with different people in different situations (see for example Light, 1988). This was certainly the case with all three of these individuals who demonstrated the use of and need for the devices beyond their home environments, for example at local day centres or when shopping. We felt there were similarities in how these clients presented in terms of their experience, social support systems and the options offered which accounted for the successful use of their high-tech AAC devices (table 1). These correlated with our own previous experience of factors that determine the likely success or failure of a computer-based communication system. We felt these four similarities were significant: a) Support All had a supportive partner who was involved and motivated to troubleshoot minor problems and adapt the software as necessary according to the clients needs. The availability of the partner was significantly greater than that of the speech and language therapist! b) Motivation All three were highly dependent for physical



Table 1 Similarities and differences (similarities highlighted) Heather Ruby Aetiology Previous IT experience Supportive and IT literate partner Level of physical dependency Effective access achieved Stroke No Yes High Yes MND Yes Yes High Yes No Yes

Andy Stroke No Yes High Yes Yes Yes


Environmental Control System set-up Yes Low-tech options Software package Yes EZ keys

The Grid The Grid

tasks and had a paid / unpaid 24-hour care package. As they had very few alternative options for communication they were extremely motivated to master the AAC device and tolerate any glitches occurring as a result of the interface between hardware and software. In addition, the clients could see the potential scope for increasing their independence via the computer-based AAC system, which added to their motivation. c) Access Each had different methods of access (head mouse, embedded switch and joystick), but all access methods were robust enough to maintain a longer period of effective use. d) Flexibility Clients had access to low-tech and high-tech options simultaneously. They used low-tech systems when the high-tech devices were not immediately available or convenient, and switched between these modalities appropriately. This is obviously an important part of the overall AAC system without these low-tech options and the clients

flexibility in employing them, they would not have been such effective users of their systems. These three cases highlight the importance of an AAC system which incorporates and enables access to mainstream technology. This may not be important for all clients but the ongoing development of aids with this capability and the impact of IT on many peoples lives mean that careful consideration of the overlap between AAC, Environmental Control Services and computer access becomes evermore crucial in effective, client-centred care. One area for future development in working with clients who have the ability to use both traditional communication aids and IT-based communication systems is to refine the criteria used in the decision making process in order to invest appropriately in these high-cost devices. The other challenge, as we see it, is not to lose sight of the primary focus of our intervention and of the device provided by our speech and language therapy service. We need to continue to enhance the communication potential of our clients - however that communication is de-

fined in todays IT-focused world. Nicola Clark is a principal speech and language therapist and Kevin Borrett a senior generalist in the Portsmouth Adult Service, Speech & Language Therapy Services, Rehabilitation Centre, Queen Alexandra Hospital, Southwark Hill, Portsmouth, Hants. PO6 3LY, e-mail


We would like to thank the clients and their families for inspiring us to write this article and for giving their permission to share their cases SLTP and our reflections on them.



Light, J. (1988) Interaction involving individuals using augmentative and alternative communication systems: state of the art and future directions, Augmentative and Alternative Communication 4, pp.66-82.



Dynamo EZ keys software FuturePad (runs the Grid software) Lightwriter




Are you getting enough? (3) The supervision process

Sam Simpson and Cathy Sparkes continue their supervision series by exploring the nuts and bolts of roles, responsibilities and boundaries in setting up and developing a supervisory relationship.
Supervision are you getting enough? Let us know at the AUTUMN 08 forum, http://members. forum/.

l-r: Cathy and Sam

n this article we aim to discuss some practical considerations that will enable you to frame your supervision and to set up and maintain clear role relationships. Imagine you are about to embark on a brand new supervisory relationship as either a supervisor or a supervisee, or alternatively want to review an existing contract. We will start by outlining the overarching criteria prior to guiding you though the three parameters we believe to be the nuts and bolts of that process: roles, responsibilities and boundaries. OVERARCHING CRITERIA Discussion in the focus groups held to inform this series of articles has indicated that some speech and language therapy teams have written processes in place to frame the way each supervisory relationship is set up. Other services, in contrast, have a much looser arrangement. For both those with and those without an operational framework, the following overarching criteria may help you to focus on the key themes you and your team might want to consider prior to setting up a supervisory relationship: 1. Documentation (Is this standardised or individual? Who updates it each session? Where is it kept? Who has access to it?) 2. Guidelines for frequency of sessions and time allocation (Is it clear for different grades?) 3. Location options (Supervisees base? Supervisors base? Alternating? A neutral location?) 4. Choices around who supervises whom (Are supervisors allocated or does the supervisee have a choice?) 5. Availability of managerial and non-managerial / personal supervision (Is there a big enough body of supervisors to allow for non-managerial supervision?) 6. Options for a speech and language therapist to have a supervisor from a different profession (Could a speech and language therapist have a supervisor from occupational therapy, psychology, human resources?) 7. Access to funding for external supervision (Can a supervisee access someone outside of the organisation or Trust?) 8. Options for changing supervisor (Is there flexibility in choice of supervisor over time as needs / interests / work roles or preferences change?) 18

9. Types of supervision available (Are a variety of supervision genres available - peer, group, oneto-one, managerial and non-managerial?) A policy that defines a departments position in relation to these criteria gives a very explicit insight into that departments supervision culture and philosophy. It also provides a solid basis upon which, at a micro level, supervisory relationships can be formed and, at a macro level, supervision services can be evaluated. We will now turn our attention to the three parameters we believe to be paramount in the process of supervision. We will define each of these in turn, and discuss ways in which they can be made explicit at the outset of the supervisory relationship and at regular intervals throughout.

2. Responsibilities

1. Roles

Once the supervisor and supervisee have accessed their departmental supervision framework / policy, they can meet to negotiate and define the specifics of their relationship. Each dyad or group is unique and deserves attention. Hawkins and Shohet (1989) describe the supervisor as having a number of sub-roles, such as counsellor, educator, manager, boss, expert technician or clinician, colleague, monitor evaluator. Indeed, we can both readily reflect on the many roles we have been required to play or been placed in, in both the supervision we have given and received. It might be useful at this point for you to reflect on the role(s) you may have expected your supervisors to play over the years and the role(s) you yourself might have played in relation to your supervisees. To what degree has this been explicitly negotiated and agreed? Sometimes we may not be aware when we are expecting our supervisor to take on a certain role or behave in a certain way. It may also be that experiences you have had as a supervisee have shaped the roles you have been open to playing when you became a supervisor, such as coach or sounding board. We need to try to ensure that, when we start each new relationship, roles are clear but also negotiated and flexible. It is important not to adopt the same constellation of roles with everyone.

Many descriptions of the responsibilities of both the supervisor and the supervisee can be found in the literature. The following list is not exhaustive, but provides a range of ideas from which you can usefully draw in discussions with your supervisor / supervisee: Supervisor responsibilities: ensure a relaxed and safe enough space for the supervisee to bring and discuss practice issues in their own way help the supervisee explore and clarify the thinking, feelings and anxieties which underlie their practice encourage the supervisee to conceptualise new ways to construe their clients share experience, information and skill appropriately challenge practice that is perceived to be unethical, unwise or incompetent facilitate and accept feedback from the supervisee enable the supervisee to be actively involved in the supervision process fulfil the supervision contract to the best of your ability initiate and organise your own supervision. Supervisee responsibilities: identify practice issues with which you need help and ask for help become increasingly able to share freely identify what responses you want be open to feedback check your own tendencies to justify, explain or defend develop the ability to discriminate what feedback is useful be accountable and responsible for your own work be proactive in organising your own supervision fulfil supervision contract. Again it is worth considering how explicitly these responsibilities have been discussed in your past and present supervision relationships.

3. Boundaries

The more we have been involved with supervision (from both sides) the more important the concept of boundaries has become. This is not in a rigid way, but in terms of the delineating


SUPERVISION PRACTICE aspects of each relationship we encounter and ensuring we give transparency the highest importance at all levels. The following are examples of areas within the relationship where we believe attention to boundaries is needed: Frequency (amount vs. quality: would you rather see someone less regularly and get better quality supervision as opposed to seeing someone more frequently who can only partially meet your needs?) Duration (perhaps 11 hours, thereby allowing sufficient time to discuss 1-3 issues in depth) Location (accessibility, neutrality, safety, confidentiality) Timing (beginning and ending at agreed times) Interruptions (such as mobile phone, bleep, other staff) Evaluation / review (for example every 4-6 sessions) Confidentiality How cases are chosen (for instance by supervisee / supervisor, by difficulty, randomly, themed, in terms of positive outcomes?) Balance within and across sessions (such as personal issues versus professional concerns; management versus clinical issues; range of topic areas brought for discussion) Process time (for example allocate 10 minutes at the end of every session to reflect on the session, recurrent themes, changes in thinking / beliefs observed throughout the course of the session, what was most / least helpful and what the supervisee will be taking away) Supervisors awareness of their skills and limitations (may include onward referral to counsellor or GP). IN PRACTICE: BEING EXPLICIT To conclude we will consider how the three key parameters of roles, responsibilities and boundaries can be negotiated at the start of a supervisory relationship and in an ongoing capacity throughout the supervisory experience. Our thoughts are: Introductory session How much time do you allocate in the initial session to negotiating respective responsibilities, roles, boundaries and drawing up a clear supervision contract? Is this documented and, if so, who has access to it? Do you agree a timeframe following which this is reviewed and renegotiated if needed? Supervisee history, views and preferences How much time is allocated at the beginning of the relationship to discussing and reflecting on helpful / unhelpful past experiences of supervision in order to determine the supervisees wants, needs and views in relation to the roles and responsibilities they would like their supervisor to take? Supervisor and supervisee history and styles In how much depth are your histories (supervisors and supervisees) and preferred style(s) discussed as well as the responsibilities each is willing to take and roles they are prepared to play? Pre-existing relationship with each other How explicitly would the roles and responsibilities you already have in relation to each other be discussed? How might these differ or conflict with the supervisory relationship you

Box 1 Practical activities 1. Take this article to your next supervision session and reflect with your supervisee / supervisor on the 3 key parameters (roles, responsibilities, boundaries) using the points and questions as a springboard for discussion. 2. Share this article with your team in order to explore these ideas in relation to your local policy and supervision pathway.
want to establish? What boundaries may need to be re-enforced? Regular / ongoing review How frequently would you review how you are working together and whether the roles, responsibilities, and boundaries you have contracted together are being met or are still desired? Predicted changes in roles and responsibilities How often would you review whether the range of roles and responsibilities evident in supervision is sufficient or needs to be broadened or developed in different ways? Qualities / skills of supervisor / supervisee How openly do you discuss the qualities and skills both parties bring to the supervisory relationship, what is working well and what needs further re-negotiation? Mechanism for when boundaries are being disrespected To what extent do you negotiate the steps that need to be taken when the contract is not being adhered to? Feelings associated with any / all of the above What space is given to both parties openly sharing how they feel they are working together and checking out any issues / conflicts or concerns in relation to their roles, responsibilities and boundaries? How openly would you discuss other options if the relationship proved not to be satisfactory to either party? We look forward to hearing any comments you have in relation to this article and the practical activities in box 1. In our final article we will be discussing the transition from supervisee to supervisor and ways of developing the integral skills needed. Sam Simpson and Cathy Sparkes are specialist speech and language therapists. Cathy is also a trained counsellor and Sam in currently in training. Together they are

Revised training standards

news extra

The Health Professions Council, which regulates 13 professions in the UK including speech and language therapy, is consulting on its revised standards for education and training. The Council uses these standards to assess all the undergraduate programmes which lead to a speech and language therapy qualification through approval visits and annual checks. A student who successfully completes a programme which meets the standards is then eligible to apply to the Health Professions Council for registration. The standards of education and training are designed to be applicable to all professions regulated by the Council as well as those it is likely to regulate in future. The consultation runs until 14th November 2008 at Meanwhile, Health Professions Council President Anna van der Gaag has been re-elected unopposed as a Council member for speech and language therapy. In future the Council will be appointed rather than elected. Details of the recruitment process will be in the national press and on

Stroke reading service expands

The InterAct Reading Service for people who have had a stroke has awarded its first writer in residency position. The charity supports stroke recovery through using professional actors to provide a live reading service for stroke clubs and people in hospital who have had a stroke. The charity says it specialises in delivering witty and inspiring short stories designed to speed recovery by improving mood, stimulating the brain and providing much needed entertainment. Alan McCormick won the short story competition with The Sacred Elephant, inspired by an argument overheard at a restaurant. His years residency will involve visiting hospitals and meeting people who have had a stroke to discuss with them what type of genre they would like added to the services library.

Auditory training

References Resource

Hawkins, P . & Shohet, R. (1989/1993) Supervision in the Helping Professions. Milton Keynes: OUP . Sparkes, C. & Simpson, S. (2007) Are you getting enough? Developing an understanding of supervision theories, models and practice in a range of environments. Intandem course materials. SLTP

Training can improve the ability to understand speech in background noise, according to a Deafness Research UK report on ongoing work at the Institute of Hearing Research in Southampton. The charity says that work with a group of normal hearing adults trained to discriminate speech sounds embedded in noise played to the right ear points to a mechanism in the brainsteam that may, in some people, be responsible for trouble understanding speech in background noise. Importantly, auditory training may be of benefit. The charity adds, This could be particularly relevant for children with language-based learning problems, who are thought to have brainstem-related difficulty in understanding speech in noise.




Spiritual Healing with Children with Special Needs Bob Woodward Jessica Kingsley ISBN 978-1-84310-545-9 14.99

No exaggerated claims

Clinicians working with children with complex additional needs will be aware there is a plethora of alternative interventions and therapies available. Bob Woodward, an experienced special needs teacher, offers an insight into the possibly lesser known practice of spiritual healing. He makes no exaggerated claims for the specific impact of spiritual healing, but argues that the individual sessions bring stillness and peace to his pupils within the context of other therapies. There is an interesting short chapter on the background of spiritual healing. The author offers a thorough, if somewhat repetitive, anecdotal account of many of his healing sessions completed in a special school environment. This book will appeal to those wishing to know more about the complementary approach of spiritual healing. Lisa Wilson is a specialist speech and language therapist based at the Child Development Centre in Redbridge, north east London.

The clearly described activities, mainly play-based, are easily integrated into the curriculum with an individual or small group. Although aimed at 4 to 5 year olds in mainstream, some could be used with older children or in specialist settings. Many familiar activities are included but even experienced therapists will find new ideas. The book is not a substitute for a therapists input. Feedback from teachers suggests the checklist wording is potentially confusing and, as some of the scripts for activities at the earliest stage of understanding are too complex, support from a therapist is clearly preferable. As the majority of pages are not photocopiable, schools need to own a copy. We would definitely recommend it to therapists working in mainstream or specialist settings as a time-saving resource for producing programmes and IEPs. Marion Neuman and Joanna Thomas are specialist speech and language therapists working for Barnet PCT at Coppetts Wood Primary School in North London, a resourced provision for speech and language.

to read. Photocopiable checklists, evaluation records, set up ideas, information leaflet for parents, service description, learning objectives and suggested activities for classroom and home are included. I feel it is important that teaching assistants receive initial training and ongoing support from speech and language therapists to use the programme. Even though it is designed for use in the school environment, the session plans and resource templates can be adapted to suit individual or group sessions in clinic. Marie Cahill is a speech and language therapist working three days in a paediatric community care clinic and two days in an older adult rehabilation unit in South Tipperary HSE, Ireland.

group of children and provides ideas for targeted activities that can be used by practitioners and families. It complements approaches such as the Hanen program which helps parents and practitioners maximise the opportunities for communication within daily life. Pat Waterman is a senior specialist speech and language therapist with the Early Years Team, Children with Additional Needs in North Lancashire PCT.




Development in practice Speech and language activities for preschool children with Down Syndrome The Down Syndrome Educational Trust ISBN 978-903806-79-1 15.99 +3.00 p&p

Groupwork for Children with Autism Spectrum Disorder Ages 3-5 An Integrated Approach Liz Ann Davidson, Kerrie Old, Christina Howe & Alyson Eggett Speechmark ISBN 978 0 86388 583 9 29.99

Flexible and useful

School Start Programmes for Language & Sound Awareness Catherine de la Bedoyere & Catharine Lowry ISBN 9780863886133 35.00

Positive message


Achieving Speech & Language Targets Catherine Delamain & Jill Spring Speechmark ISBN 978-0-86388-579-2 35.00

Practical and easy to read

Time-saving resource

This book is aimed at professionals supporting children with speech, language and communication needs in the Foundation Stage, particularly through Individual Education Plans (IEPs). Sections on Understanding Language, Using Language and Developing Speech Sounds have photocopiable checklists to identify difficulties and suitable activities. The need to make IEP targets SMART (specific, measurable, attainable, realistic, timely) is emphasised, with helpful examples. A final section covers techniques, resources and additional activities.

School Start is a preventative programme comprising 60 group sessions for developing language skills and sound awareness in reception year children (4-5 years). Based on the Foundation Stage Curriculum, it can be delivered by teaching assistants. A checklist assessment is used to target children and evaluate outcomes. School Start was written by speech and language therapists in an infant language unit then extended for use by teaching assistants in mainstream schools. Through its three year trial it has been revised so that teaching assistants and schools feel confident to use it. Outcome measures have consistently demonstrated that children benefit, and schools have chosen to repeat the programme for successive intakes. Overall I found the book and CDROM very practical, clear and easy

This 75 minute DVD is divided into sections: Learning to talk, Learning to understand words, Communicating what you know, Learning to say words, Teaching reading to teach talking, Final comments. The many varied examples of parents working with their children are well filmed and accompanied by a full commentary. It recommends a small amount of time each day be spent on fun, structured tasks. Many of the activities are familiar, such as posting, activities based on the Derbyshire Language Scheme, and using sound cards. Reading to teach talking may be less familiar, but it is demonstrated clearly. The emphasis on errorless learning throughout is valuable. The DVD was very well received by families who said it gave them useful ideas to try. Clearly it sends a positive message to parents of young children with Down syndrome. The commentary recognises the value of using family life and everyday routines to provide round the clock speech therapy, though no examples are given. This value for money DVD identifies the particular needs of this

This book is very readable, easy to use and good value for money. It is a flexible resource that can be used to plan, run and record structured groups or to dip into for individual activity ideas. Jointly written by occupational therapists and speech and language therapists its intended for use by professionals, parents / carers and support staff working with children with Autistic Spectrum Disorders (ASD) aged 3-5. It promotes skill development through groupwork with a strong emphasis on multidisciplinary working. A practical resource, it contains 40 photocopiable activities, a range of different checklists and recording forms. The activities promote development in seven key areas (communication and language, socialisation, play, sensory, motor, behavior, emotion) and each activity is differentiated into three developmental levels. A basic understanding of ASD is helpful however it also contains a theoretical section defining ASD and the effect this profile can have on skill development, further highlighted through different case studies. A useful resource for anyone working with this client group. Maria Saj is a speech and language therapist with Greenwich Teaching Primary Care Trust.





Understanding Nonverbal Learning Disabilities: A common-sense guide for parents and professionals Maggie Mamen Jessica Kingsley Publishers ISBN 978 1 84310 593 0 12.99

Useful websites

Nonverbal learningdisabilities ismore of afamiliar term in thefields of psychology and education. This is reflected in the text as it is concerned with the associated difficulties found in academic performanceas well as communication. It is relevant to education staff, and the importance of speech and language therapy input is also highlighted. The book covers assessment and further divides nonverbal learning disabilities into subgroups: perceptual, social, written expressive and attentional. It contains easy to read chapters on management strategies and useful websites. However, as it is written from a Canadian / American perspective, parents in the UK may find it more difficult to relate to. Rachael Mutl is a newly qualified speech and language therapist recently graduated from Queen Margaret University, Edinburgh.

starting intervention at that point is being investigated more widely (eg. Amy Wetherbys research at Florida State University). I found the chapters on intervention more difficult to access and disagreed with some subjective interpretations of behaviour and communication in the children studied. However, it was interesting to note some similarities with our existing approaches such as Hanen and Intensive Interaction. There is much in this book that is thought provoking and, in my case, parts to disagree with. Although it is unlikely to be for mainstream therapists, it made me reflect on my understanding of early diagnosis and intervention in autism. It may therefore be useful for a multidisciplinary team as part of a reflection on their identification and management of infants with social communication concerns. Christopher Platt works as a paediatric speech and language therapist for Salisbury NHS Trust and independently as a partner in Springboard Speech and Language.

on the adaptable handouts (eg. communication strategies). ACE might have uses if you were running a group for parents of hearing impaired children. It could also be adapted for adolescents or young adults in an educational setting who might like its modular approach but I would avoid it as a purchase outwith its hearing impairment remit. Jennifer Keir is a speech and language therapist specialising in an Elderly Rehabilitation Unit in Dundee.


What can you see? (Find the hidden pictures) Speechmark ISBN 978 0 86388 619 5 39.99 + VAT


leads on to a range of other topics: predicting consequences, problem solving, exploring vocabulary, and developing concept knowledge, amongst others. The cards themselves seem durable and a few can easily be stuffed in a bag, making them ideal for clinicians who travel from place to place. There are enough cards in a set to share between your team, too. The new photos are eye-catchingly colourful and clear, and suitable for almost any age group. They engaged the interest of my students in mainstream and specialist schools, who also enjoyed the humour in many of the pictures. A good buy. Rebecca Mitchell is a speech and language therapist with the mainstream and specialist education teams, Enfield PCT.



Signs of Autism in Infants: Recognition and Early Intervention. Ed. Stella Acquarone Karnac Books ISBN 978-1-85575-486-7 22.50

Active Communication Education (ACE): A Program for Older People with Hearing Impairment Louise Hickson, Linda Worrall & Nerina Scarinci Speechmark ISBN 978-0-86388-614-0 33.50

Straightforward and well-organised

A challenging book

This book is edited by a psychotherapist advocating intensive early intervention based on psychoanalytical thinking for infants with possible autism. Most contributors come from a psychological / psychoanalytical background. The central premise is that it is possible to spot warning signs very early often in the first 12 months and, by intervening intensively, it may be possible to prevent the full development of autistic behaviour. These are challenging claims in a challenging book. However, the possibility of screening for very early signs and

This is an evidence based group communication awareness, education and training programme. The book gives clear guidelines for planning and organising a group with photocopiable session plans, aims, standard invitations and handouts. It is straightforward and well-organised, if a little wordy. I wondered whether it would have a wider remit within the adult acquired speech and language population. However, its focus is clearly on hearing impairment rather than communication impairment. The language is complex and the layout is not aphasiafriendly at all. Even within an elderly dysarthric population, there is too much information presented

This simple but effective resource comprises two flip books at the back of which A4 colour photo cards are placed. As the pages are turned sections are revealed to provide more information about the hidden picture. There are 30 photo cards grouped into objects and animals and people and places. The game can be played with an individual child or in a small group. The simple premise to guess the hidden picture - proves motivating for children from nursery age to 910 year olds and enables clinician or assistant to use their creativity to extend the task to target a range of aims including vocabulary and word-finding, expressive language, prediction and problem solving. Alternatively it can be used as an ice breaker or to encourage reluctant children to interact however it may not be worth purchasing solely for that purpose. Rachel Baldwin is a speech and language therapist with Knowsley PCT.


Treatment Protocols for Articulation and Phonological Disorders M.N. Hegde & Adriana PeaBrooks Plural Publishing ISBN 1-59756-084-7 $98.00 (USD)

User friendly

Whats Wrong? Speechmark ISBN 978 0 86388 617 1 26.99 + VAT

A good buy

As a clinician on the move, I like resources that can be used for a variety of purposes. This updated set is handy for informal assessment and intervention, and for group and individual work. Identifying whats wrong naturally

The book aims to provide an approach to intervention for children with phonological and articulation disorders. This is done using a series of word lists for baserate, treatment and probe sessions for each phoneme, in word initial and word final positions. Scripts are provided for each phoneme to enable the clinician to administer the protocols. These may appear too simplistic to an experienced therapist but could be useful for new graduates or technical instructors. An accompanying CD contains printable and modifiable versions of the recording sheets. I found this useful as some of the vocabulary used is American so it gives you the opportunity to individualise the word lists, making it more child specific. Picture material is not included but is available separately. This resource is user friendly with clear instructions and includes a comprehensive glossary. Kirsty MacLaren is a community based therapist working in the north west of Glasgow.



How i

How I take speech and langua

In its response to the recent Bercow Review consultation, childrens communication charity I CAN stressed that Due to the fundamental importance of communication, it is essential that all children and young people develop speech and language skills. We know that in some deprived parts of the country, 50% or more of children are arriving at primary school without the communication skills they need to learn (p.2). It added that it would like to see SLTs working in a range of ways, as part of the team around the child [their italics] working jointly with other professionals (p.6). Communicating Quality 3 confirms we should enable education staff to incorporate the aims of speech and language therapy in the planning of an individual education programme within the context of the broad curriculum. It adds that education staff can most effectively be supported to make environmental changes to support inclusion through collaborative working strategies, including joint assessment, planning and working, as well as through training workshops (p.225). Our two contributions come from speech and language therapists who are achieving just that.
I CAN (undated) I CAN response to the Bercow Review of speech, language and communication needs. Available at: (Accessed: 4 July 2008). RCSLT (2006) Communicating Quality 3. London: Royal College of Speech & Language Therapists.


Bercow Review see

1. To be more of a therapist, try becoming more of a teacher 2. Offer whole class work as well as group and individual 3. Build on communication opportunities already in the classroom 4. Use the education context for more holistic assessment 5. Be explicit about the value of adults sharing skills 6. Help staff to wait, cue, use visuals and gesture, recast and reflect 7. Confidence measures can help evaluate change 8. Allow for different skill and experience levels of education staff 9. Jointly develop specific outcome measures 10. Story telling and acting are potent tools for learning.


Promoting pizzazz - and all that jazz

Keen to have more impact on the progress of children with specific language impairment, Kathleen Cavin recognised it was time to play a leading role in the classroom. So, instead of prompting from the wings, slick your hair, wear your buckle shoes - and prepare for showtime...

Kathleen Cavin and Katie Byrne (class teacher)

Imagine you are the director of a moderately successful West End show. However, a couple of cast members are letting the side down. Your sponsor employs a consultant from America to 22

help you bring more pizzazz to their performance. The consultant watches the show, talks you through some ideas, hands you the Pizzazz Manual and then leaves. She may help the two cast members with their high kicks, but never directs the cast through a whole routine. Could this be how it feels when we give advice to class teachers and then continue to see children in small groups outside the classroom? Working in a language resource base in a large mainstream school has given me the opportunity to work alongside teachers in the classroom. The why to work in the classroom seems relatively straightforward: 1. Benefits for the child Although studies into classroom interventions are sparse there is a growing body of evidence indicating that, particularly for vocabulary and narrative based work, classroom intervention can be more effective than withdrawing the child (McGinty & Justice, 2006). Input into the classroom promotes communication skills in a more naturalistic setting and includes opportunities for children with specific language impairment to interact with their peers. Enhancing the wider communication environment of the children with specific language impairment has a positive effect on learning and behaviour. There are not only opportunities to reinforce individual speaking and listening targets of the children with specific language impairment and monitor progress, but also to observe how their language difficulties impact on them in the classroom environment. A positive effect on the speaking and listening skills of a range of children in the classroom, not just those with identified needs. 2. Benefits for the class teacher Demonstration of strategies and techniques by the speech and language therapist with the whole class group and individuals will hopefully have a longer lasting effect than discussion only. Learning new skills in this way complements a range of adult learning styles and implies a more active learning experience than passively reading notes. Problem solving with teaching colleagues using real examples from the previous lesson is a great way to learn from each other and build on previous successes. Resources can be provided which are appropriate for a number of children in the class and can be re-used throughout the term. 3. Benefits for the speech and language therapist The chance to monitor and improve your own advice and resources. Sometimes resources and strategies which work well in small groups or look good on paper arent always appropriate for whole class work. The therapist can gain valuable insights into classroom management, for example how to deal with the range of needs in the classroom

How i

age therapy into the classroom

Figure 1 Class teacher questionnaire

and maintain pace. As speech and language therapists, our training focuses on therapeutic skills developed during individual or small group training. I felt I needed to work at how these skills transferred to the classroom. Gain Brownie points! A common complaint amongst class teachers is that speech and language therapists swan in, give their advice and leave and dont appreciate the demands of the classroom. Being in class and practising what you preach at least removes this criticism and can help to build respect and understanding of your role. So that bit was easy, but how best to deliver classroom support was the source of many a debate and quite a lot of banging my head against my ergonomically designed desk. During the four years since our language resource base was first established, classroom support packages of care have evolved. This is a result of both school and language resource staff having worked to understand and make best use of different professional skills. Ive attempted a variety of models during the time Ive worked in school and have often felt dissatisfied with the impact of these sessions. The teaching staff had perceived in-class support as purely child-focused and not as an opportunity for skill sharing between the adults involved. As the resource is based on an inclusive model, where supported children are members of their mainstream class and are not taught in a separate classroom, it seemed imperative that this aspect of the language resource base input was further developed.

Name: _________________________


Figure 2 News question balls

Please circle the number which best indicates your level of confidence in using the strategies listed below to promote the communication skills of the children in your class. 1= not confident 5=very confident 1. Reducing your language levels to aid understanding 1 2 3 4 5 2. Using visuals to promote understanding 1 2 3 4 5 3. Using graded prompts to elicit a response from a child 1 2 3 4 5 4. Using basic Makaton signs to promote understanding 1 2 3 4 5 5. Scaffolding and expanding a response 1 2 3 4 5 6. Promoting word learning strategies 1 2 3 4 5 7. Including speaking and listening targets in lessons 1 2 3 4 5 Figure 3 Session planning Speech and Language Therapy Classroom Support Language Resource Class Speaking Activities Base Pupil Aim and Listening Aims To attend to adult news To relate simple news to peer including who/where/ what To be able to identify who/what/ where in adult news To be able to use first/ then in own news Identify key news questions by choosing a symbol and identifying it. Place on news board. Children look at photographs from adult news and guess topic/setting for news Adult relates news and children answer key questions Children relate own news to talk partner Key children relate own news and all use news board to check they have included who/ where/what Lesson: Literacy (News) Strategies and Resources New vocabulary: blew- place on word wall Sign key questions Give forced alternatives for blue group Use lead in phrases for P and O Model correct sentence structure

On the periphery

On reflection, I felt this was because I had not been explicit enough regarding my role and therefore had tended to stay on the periphery of whole class teaching and concentrate on small group work in the classroom. I decided to trial a different model of classroom support where I was more explicit that part of the care plan centred on developing the communication environment. This would include direct work with class teachers to promote strategies and approaches to aid children with communication difficulties. Before introducing this I presented a document outlining the purpose and aims of classroom support and the expectations of both services. I then presented the teaching staff with a questionnaire regarding their confidence in using a variety of strategies (figure 1). To provide some outcome measures and prove the value of classroom support for teachers and children, a year one class teacher and I decided to run a small project over two terms. The main focus of the support was for narrative and vocabulary work, specifically verbs. Using the questionnaire we set targets focusing on her use of strategies. These included recasting responses and developing the range of Makaton signs used to cue children. This ensured that the teacher played an active part in her learning and I had

care aims which reflected my work in developing the classroom communication environment. 1. Phase one (September to December; direct input once per week for 45 minutes plus initial joint planning session and short weekly joint planning session) The aims for this term were: To promote and extend the use of class teacher strategies and resources to support speaking, listening and understanding. To support and monitor the progress of two language resource base children towards their individual education plan communication targets. To establish whole class understanding of who / where / when / what questions and simple time connectives such as first, then and last. To extend whole class ability to relate a short personal narrative. The measures used for this term included the short teacher questionnaire. I asked the class teacher to complete the questionnaire in September and then again in December. As a

highly skilled teacher with previous experience of working with children with a range of special educational needs, pre-input she rated the majority of her skills as threes or fours. Each session was based on the format of the North Lanarkshire Writing Scheme (Wilson, 1997) where a lead adult related a simple personal narrative and then asked the class wh questions around this narrative. Children then discussed their own news in talk partners and related this news to the class group. Each session maximised the use of Makaton cueing for questions and was based around colour-coded news question balls (figure 2). Sessions started with two or three photographs of the adults news projected onto the interactive whiteboard. The adult asked the children to look at the photos in preparation for listening to the story. Strategies to promote communication skills were made explicit in the planning, and we separated aims into those for children attending the language resource base and the rest of the class (figure 3). 23


How i 2. Phase two (January-March) The aims for this phase were: To support and monitor the progress of two language resource base children towards their individual education plan communication targets. To extend class teacher knowledge and use of different approaches to developing narratives, including the use of symbol supported story mountains (based on work by Corbett, 2003). To extend the use of specific verbs in short narratives. The measures in this section included pre and post input stories from children chosen by the teacher as high ability and low ability. I took story samples from the two children in the class with specific language impairment. Subjective analysis using a skill rating form based on the Squirrel Assessment of Narrative (Carey et al., 2006) gave each child a rating out of 100. For this phase we chose two target verbs per week and incorporated them in games and in the adult story. Verbs were selected to link with class topics and texts. Two verbs per week seemed like a realistic target based on previous care aims and knowledge of the vocabulary learning potential of the class. These were then displayed on the class word wall in symbols. To aid links across the curriculum and help broaden definitions and use, the class teacher referred to the verbs during the course of the week. The stories were chosen around particular themes and settings to extend the children beyond news events and link with current curriculum topics, for example, Lost in a Dark Cave. The key points in the story were displayed in pictures on the story mountain. 3. Phase three (February-March) At this point the children were ready to extend their story telling ability and move towards imaginative narratives. The class teacher was keen to include a range of approaches to developing narratives rather than concentrate on the strategies only. The aims for this phase were therefore: To be able to identify and use a problem in a story. To promote the use of the helicopter technique in class (Gussin Paley, 1991). To promote the use of play scripts (based on work by Caterall, 1998). During this phase the children made use of role play which proved particularly beneficial

100 80 60 40 20 0

Figure 4 Pre and post input results for narrative skills scale HA = high ability (as assessed by teacher) LA = low ability (as assessed by teacher) SLI = has specific language impairment

Child 1 HA

Child 2 HA Child 3 SLI

Child 4 SLI

Child 5 LA Child 6 LA

for one of the children with specific language impairment. She was unable to make predictions when presented with sequencing cards, but during short playscripts demonstrated an ability to act out the next event and provide limited dialogue.


space to generate their own ideas. I also realised the importance of teaching the children to talk in small groups to allow them all a chance to make an oral contribution. I had to learn to accept that feedback from their peer could be valuable and that, no, I didnt need to hear everyones story every week!

So, did it work? Post-input samples and analysis indicated that all children assessed made some improvement (see figure 4). The areas indicating most improvement were vocabulary and story structure; the two areas most targeted by the input. Perhaps most interestingly, children of a range of ability improved, indicating the importance of oral work in the classroom. The class teachers post- input questionnaire also indicated an increase in confidence of least one point in using all strategies. Through informal observation I would agree with her perceptions in that I noted an increase in visuals / cueing and Makaton and increased use of recasts. From a personal point of view I gained a lot from being directly in the firing line in the classroom. Although Id given it some thought before, it really gave me a sense of the difficulties of attempting to include and extend all pupils and the challenges of pacing lessons to maintain the attention of all children. I now try to move around more, and encourage copying of gestures and sign to support stories. I also use Writing with Symbols on the interactive whiteboard instead of presenting cut-out symbols. I learned to reduce the cueing I provided for more able children and to give them more

Skilled and innovative


Carey, J., Leitao S., & Allan, L. (2006) Squirrel Story Narrative Assessment. Keighley: Black Sheep Press. Catterall, P. (1998) Facilitating Narrative Competence: Helping Children to Describe Events and Tell Stories. NAPLIC Conference Papers. (Available to order via Corbertt, P. (2003) How to Teach Story Writing at Key Stage One. London: David Fulton. Gussin Paley, V. (1991) The Boy Who Would Be a Helicopter. Cambridge, MA: Harvard University Press. McGinty, A. & Justice, L. (2006) Classroom-Based versus Pull-Out Language Intervention: An Examination of Experimental Evidence, Evidence Based Practice Briefs 1(1). Wilson, T. (1997) The North Lanarkshire Writing Scheme. Motherwell: North Lanarkshire Council.


I was very lucky to work with an extremely skilled and innovative class teacher who quickly took on board ideas and incorporated and extended new techniques demonstrated in lessons across the curriculum. Although the samples were only of six children in the class, subjective comments from the class teacher indicated that many children in the class had improved their oral narrative abilities and this had a positive effect on their written stories. When repeating this kind of model, levels of teacher expertise and awareness need to be taken into consideration. Using the confidence questionnaire to complement class observations can help establish whether a whole class approach might be effective and help to inform decisions regarding the length of time for a package of care. I think I once heard it said that, to be more of a therapist, sometimes you need to become more of a teacher. I think thats true. For me the most effective way of sharing skills is demonstration and having the confidence to take on the role of one of the lead adults in the classroom. Within the resource base I dont see classroom packages as replacing the highly individualised small group or one-toone packages of care but rather existing alongside them as one of a range of ways of supporting children with specific language impairment. So, if given the opportunity to appear on stage, dont just stay in the wings whispering prompts - have a go at directing instead. Kathleen Cavin is a Speech and Language Therapist, Co-ordinator for Language Resources, Islington PCT, London, e-mail

Makaton see Smart interactive whiteboards Writing with Symbols see 24


With thanks to Katie Bryne, Laura Coakes and Jane Ladd for their ideas and comments.

How i


The helicopter launch pad

Karen Hayon and Evi Typadi find that turn taking, listening and concentration of children with communication needs, including those with English as an Additional Language, take off when the child-centred helicopter lands in their school.
When education practitioners can plan and create conversations containing sustained periods of shared thinking with their children, these lead to better language outcomes (Sylva et al., 2003). A classroom is rich in opportunities for developing communication skills through sharing and repeating rhymes and books, news time in small groups, show and tell, oral story telling, hot seating and role playing. We are keen to address the declining verbal skills of children starting school (Palmer, 2006) by building on what schools already offer. As part of an Early Years Advisory Team early intervention project, we investigated whether the whole class helicopter story telling and story acting technique could develop childrens confidence, curiosity, creativity and communication, particularly those with English as an Additional Language and those who were shy or withdrawn or who had language and communication needs. We also hoped the technique would enable practitioners to reflect on the quality of their interactions as, when adults use strategies such as observing carefully, waiting, listening and letting children take the lead, childrens self-esteem and language development are enhanced (Girolametto & Weitzman, 2002). The helicopter story telling and story acting technique was originally devised by the educationalist Vivian Gussin Paley. The ethos is completely child-centred and child initiated. Children dictate their stories to an adult or older child (buddy). Words are written down exactly as they are said. Pronunciation errors are corrected but grammatical errors are not. The scribe repeats the words of the child while writing them down. This ensures they have heard the child correctly, slows the pace of the childs dictation and makes explicit the link between the spoken and written words. The scribe then reads the story back to the child and confirms all characters /objects to be acted out. The child decides what character they want to play (if any), and how many children will form a house or a bus for example.

plore themes from different viewpoints for example, boys can be mummies and girls Action Men. The helicopter is an excellent way of including children with English as an Additional Language, speech, language and communication needs, or those who are selectively mute. Toys or objects can be set out for the children to manipulate and the adult can comment on what the children do with the toys and make this into a story. Stories can also be made of a childs single word utterances when they look at a book with an adult. Each part can be checked with the child who can nod or shake their head to indicate agreement. The story can then be read back at the end and characters underlined. One nursery and five reception classes in six schools were involved in our project. The schools were in inner city London, in areas of high deprivation and four had a proportion of 70-95 per cent of children learning English as an Additional Language. We worked with the whole class, with the practitioner as client, and had no caseload responsibilities for individual children. Parents were informed about our visits and video consent was obtained. Parents were otherwise not involved except through informal reporting of progress of targeted children. The input was provided over eighteen months for six weeks (two schools), four months (two schools) and five months (two schools). All practitioners in the target classes, including teachers, nursery nurses and Learning Support Assistants, attended an INSET training session at the beginning of each block of sessions. The speech and language therapist introduced the technique in the first session and the teacher in each class ran all subsequent sessions (a minimum of six). At the end of the first session we identified children whose Personal, Social and Emotional (PSE) skills and language development needed investigation and support. We targeted 24 children, between three and five in each setting. Nineteen were learning English as an Additional Language and of these 18 lacked confidence in using English at school. In addition one of these had a suspected communication disorder and one a diagnosis of Autistic Spectrum Disorder. Two other children had specific language impairment.

Figure 1 PSE Scores in Baseline and Final Story Acting Sessions

Figure 2 Language Scores in Baseline and Final Story Acting Sessions


Different viewpoints

For story acting the whole class comes together. The child who has dictated the story has already chosen their character and the other children are taken in turn from their place around the stage to act out the others. This means that children can ex-

In consultation with education colleagues, we devised a termly observation sheet to record the childrens progress through the Foundation Stage in the areas of confidence and imagination in acting, turn taking, attention and listening and in narrative skills such as providing a sequence of story events, statement of character, place and time and use of connective and book language. This form incorporated many Early Learning Goals from the areas of PSE, Communication, Language & Literacy, Creative Development and Physical Development. It was used as a baseline and final measure and completed by the teacher and therapist following the initial and final videoed story acting sessions. We introduced the adult interaction targets in three schools as the project evolved.

We set SMART (Specific, Measurable, Achievable, Relevant, Time related) targets for children with language delay/disorder within the helicopter framework and noted progress in terms of achievement of targets. The children were awarded points: 1 for achieving the Beginning box, 2 for Developing, 3 for Consolidating and 4 for Achieved (figures 1 and 2). All 24 children made progress of at least 2 points over all PSE measures assessed, with an average progress of 5 points. Two children made substantial gains from 6 to 16 and 3 to 12.5 points respectively. Of the individual PSE measures children made most progress in turn taking, followed by confidence to participate and ability to listen and concentrate. All but three target children made progress on at least one of the language measures assessed. The average progress per child for language measures was 2.3 points. The results for children with English as an Additional Language show an average gain of 4.4 25


How i

Case example 1 Muna

Muna (5;3 years on 19/7/05) came into the reception class in late May 2005. Previously she had been at home as no reception place had been available. Her first language is Arabic. Her first story on 9/6 was a listing of objects around her and items in a dolls house she was playing with, with her teacher. She was very keen to dictate a story to her teacher after seeing how stories could be acted out earlier in the initial circle session. She became even more enthusiastic about story telling and story acting after seeing her own story coming to life as a play that afternoon. Muna told five stories: 09/06/05 Dad, mum. Brother, sister, baby tree, car, cat, dog, water sand, house, pen, table, chair bag, school, teacher, tea 28/06/05 Mum, brother, sister, ball, cat car eat. Look! Van, duck, rabbit, hand, ears, eat. Go to he! You bag. 05/07/05 Daddy, mummy, baby, sister, ball, cat, dog, television, van, custard when you eat daddy and mummy. Shes putting the baby in the chair and eat. And spider and Capri Sun what you drink. Book in a story watch. Talk, duck, snake, finish. 12/07/05 Daddy, mummy, big sister. Mummy and daddy morning in car. When you go morning go in swimming pool. Go in water. Sister go in splashing, splashing. Mummy and go and splash the sister. And baby crying and daddy play on him computer and the floor she play on floor baby. And splashing she go to sister to baby. Daddy laughed and sister and baby play. And look and mummy laughed and sister laughed to baby. 19/07/05 Daddy, baby, mummy, home. Baby play in water. And watch, look on TV. And sister play in game. Daddy play with sister, play in claps and in car. Me go in the water. When you go in water splash! Go in train and mummy and daddy and baby and sister go play in the fly. Listings gave way to a list plus short phrases with occasional verbs and moved to descriptions of a coherent sequence of events. Four of the five stories were acted and this may well have contributed to Munas rapid development in confidence and linguistic skills, as the teacher demonstrated excellent progress on her interaction targets which gave Muna the space and time to bring her story to life as she wanted it. By the final session Muna was so confident that the teacher would refer back to her and give her time to think how the words should be acted, that she was spontaneously showing her classmates how to stand as a TV, how to work on the computer or how a mummy would move. The acting-out would also have reinforced for Muna, via gestures, facial expression and body postures (children bending pretending to be a ball or a TV), the meanings of her words and this perhaps fed into her week on week rapid progress.

Case example 2 Patrick

Patrick (5;3 years) is statemented with full-time support. His first language is Lingala and he has a diagnosis of Autistic Spectrum Disorder. He was observed using the weekly observation prompt sheet. Patrick was enthusiastic about the helicopter from the beginning. He got up willingly from the circle in the baseline videoed session in two separate stories and stood as a prince and princess for the duration of each story. Following the baseline session an initial target around story telling was agreed to develop Patricks use of spoken language. The target was to tell a story of at least 10 words in 90% of opportunities by the end of the block. He achieved his first target by week 3. In the third session (28/02/06) Patricks story, dictated to the teacher, was acted out: Dinner, reading, feel, sneeze, dinner, dinnertime, this going where? , cow, pigs, sheep, whats that dog, a lamb, finished. Patrick was on the stage by himself and smiled broadly throughout. He spontaneously acted reading, feeling and dinner and copied the audience when they were encouraged to show pigs. Patrick got up enthusiastically and acted in three other childrens stories in this session, as a dog, as one of some horses and as a tree-chopper, moving his hands in a chopping motion with no prompting. Patricks achieved target was changed to focus on his looking and listening skills in the acting sessions. From the fourth session on he sat in the circle next to his teacher, but without direct support from his Learning Support Assistant. His new target was to participate in actions as part of the audience in 90% of appropriate opportunities for 2 stories by the end of the block. In the fourth session (07/03/06) Ps second story was acted: Baby, Dinner, Dinnertime, What King? Fly, Whats that? Dancing, Finger, Scary, Sleeping, Wheres going? Going to [indistinct], Its wake up, House, Whats that? Finished. Patrick got up spontaneously and acted the story by himself with the teacher encouraging the audience to participate with we need to help Patrick out on this one. P spontaneously put his hands on his head to indicate a Kings crown and acted dancing. He followed the suggestions of the audience for the other actions. Patrick was also very enthusiastic about acting in four other stories, well exceeding the target set. He acted as a fish, showed walking, pricked his finger and acted as a prince (all following the lead of other children). He spontaneously made a scared face when acting as a fish having a shark swim towards him. When sitting in the circle at the end of the session however his attention waned and he participated only fleetingly. In the fifth session (14/03/06) Patricks third story was acted: Dragon, Bus, Cakes, Oh no! Sleeping Patrick again acted by himself on the stage. He spontaneously acted as a dragon, eating cakes and sleeping. The teacher explicitly highlighted how Patrick was in charge of how his story was acted with Watch Patrick and copy what he does, and, Look! Patricks showing us sleeping like thislets all do it like this. Patrick acted in one other story and came up to form a castle easily. He did not participate as part of the audience but he was unwell that day. In the final session (21/03/06) Patricks fourth story was acted: My name is dragon, [In acting Patrick wanted to change this to King] dinner, doggies, Natty and Amaro, Elena, Marion, Georgina, Alexander. Finished. Patrick spontaneously acted as King and showed dinner by eating from the floor like a dog. The teacher was careful to highlight for the other children how they should watch how Patrick wanted dinner to be acted and follow his idea. Again, Patrick beamed as his story was brought to life and for the first time his classmates joined him on the stage to act as themselves. Patrick also joined in spontaneously and acted in the story which came after his, pretending to be trees cutting themselves down. He also spontaneously acted as part of the audience, pretending to cut his finger, putting a plaster on it and sleeping. In the final three stories however he did not participate as part of the audience. Overall, Patrick achieved his second target of joining in as part of the audience in 90% of appropriate opportunities for the duration of two stories in the final three sessions. He had thoroughly enjoyed and been fully included in a whole-class activity and had had the meanings of words reinforced by acting out his own stories as well as from acting out others. Patricks confidence grew markedly, boosted by his teachers increasing skill in letting Patrick know he was in charge of how his story was acted out. By the end of the block he was listening attentively for the duration of at least two stories and his Learning Support Assistant no longer needed to sit with him to help him focus. In total Patrick acted on 33 occasions over the five weeks, 16 times spontaneously.



How i points (range 2 to 9.5) for PSE and an average gain of 2 points (range 2 to 4.5) for language (see case example 1). The technique makes explicit both the links between the spoken and written word for older children in story telling and the link between the action and spoken word for younger children in the story acting. Thus a child dictating a story using single words had much greater weight given to the acting-out of each word to aid reinforcement of meaning. Children in one school also gained a better understanding of the meanings of words describing feelings. Their teacher noted: The helicopter has definitely had a big impact on the childrens ability to understand and act out such themes. Before, I had to give them a script, eg. Reem, say: yes you can share. Now they spontaneously act. One teacher was very impressed by how the helicopter encouraged children with English as an Additional Language to talk. The length of stories increased in all classes and children who would speak very little in other situations, for example at a community clinic speech and language therapy appointment, regularly gave stories of one A4 page. The technique also provides a way in for many children who have been reluctant to write and read. One child, who had not wanted to make marks on paper through most of his reception year, pretended to scribe another childs story and then asked the therapist if she would tell him a story so he could scribe it. Children enjoyed writing their own name and the stories provided meaningful material to read. Eventually some children in reception classes attempted to write their own stories to be acted out. Practitioners also commented that the termly observation sheet provided strong evidence for, and links with, English as an Additional Language record keeping in the Early Years. The termly sheet allowed practitioners to track children at a glance and could be included in the childrens profiles. shifted our philosophy in fundamental ways. The helicopter gives us the means to be much more truly childcentred. We have learned that interventions that improve the communication skills of specific children can be embedded in a classroom technique which most practitioners find easy to incorporate into weekly planning. The children are more comfortable than they often are in a clinic setting yet we can still make rigorous observations and formulate SMART targets. We have been fortunate to work on a project without a clinical caseload and within a collaborative Local Education Authority Early Years Advisory Team, but learning from the project can apply to clinic working. The project has reinforced the vital importance of using positive interaction strategies to obtain a better picture of a childs strengths and needs which leads to higher quality samples of spontaneous and connected speech. Perhaps we could also consider the toys we use to reflect what children (especially boys) have at home such as superhero toys, remote control cars and pop-up-tents. We strongly feel the project findings underline that referred children attending Early Years settings need to be seen in their nursery context for valid and maximum information to be obtained, even if this means a restructuring of priorities and more time devoted to working in and with nurseries. A session introducing the helicopter into a nursery group, when applicable, would be an excellent use of speech and language therapy time and even an initial session may well yield an excellent language sample from an identified child. In addition the speech and language therapist will gain information about a childs ability to take turns and listen in a large group and their confidence and ability to act a role. In future we would like to involve parents more in the helicopter, perhaps via invitations to visit the sessions or via coffee mornings so that parents could be encouraged to tell stories to their children and write childrens stories down at home. A colleague has run story telling and story acting sessions in a library drop-in for parents and their children in which parents gradually become scribes for their childrens stories (Tyrwhitt, 2006). We continue to offer the helicopter to private and voluntary settings as well as schools as a tried, tested and successful option for joint working. It is appealing and effective because its many different facets can meet the needs of every child in the class. Telling stories is a very basic human drive and acting them out makes sense of them and rounds off the experience. This is particularly important for children with English as an Additional Language and speech, language and communication needs. Children feel (and are given) ownership within the broad framework provided by the helicopter and their home world of Spider-Man, motorbikes and fairy castles is thus allowed to enter the classroom. This freedom of expression for the children coupled with the ability for adults to record real progress makes the helicopter a potent tool. Karen Hayon and Evi Typadi are speech and language therapists with Westminster Primary Care Trust, email


The two children with specific language impairment made gains of 4 and 5 respectively for PSE measures and 4 and 2 respectively for language. The children with suspected communication disorder and Autistic Spectrum Disorder (see case example 2) made gains of 5 and 5 for PSE measures and 2.5 and 0 for language respectively. Notably, these children made identifiable gains in PSE skills on a par with all the other targeted children using an inclusive, whole class technique. Language gains were more variable but in actual fact specific language areas are not targeted in the helicopter. This links back to its ethos as a medium for children to express themselves confidently and as a tool for adults to identify which areas of language to develop. We set adult interaction targets jointly with the teachers at the three schools visited later in the project. Each teacher identified two or three targets from: 1. Waiting for the child to act their role 2. Referring back to the child whose story it was for ideas about how to act a given role 3. Involving the audience. All teachers achieved their targets. Teachers reported increased confidence in taking stories from children in the classroom and were able to give children with English as an Additional Language and less confident children the time they needed to express themselves. They also attributed increased confidence in leading the story acting sessions to regular opportunities to discuss with the project therapists how to conduct the sessions and how to involve all children. All practitioners were very enthusiastic about continuing to run helicopter sessions. The target children made the largest gains in turn taking, listening and concentration skills. Turn taking was fostered through waiting when in the circle and also by the notion of a turn on the story list for story telling. One practitioner noted, the technique keeps a whole class of 30 children attentive because no one knows what will happen next and what the next story will contain. As part of the helicopter children are encouraged to clap and give compliments to each other about their stories. In one school, specific praise was modelled by the teacher (eg. I really liked the way you showed us a slide.) As a result the teacher noted the children were now complimenting each other at other times.


The use of the technique enabled practitioners to focus on positive interaction strategies at both story telling and story acting stages. After taking down a story, an adult could reflect on their own body language, how long they waited, and how they observed, smiled and let the child take the lead. They could praise and ask questions only tentatively and sparingly eg. Anything more? During story acting they could model active listening, waiting and curiosity. Waiting was a key strategy. It was difficult for some of the adults involved to wait initially but, once mastered, this was a powerful strategy to transfer into other classroom activities. As speech and language therapists the project has

Girolametto, L. & Weitzman, E. (2002) Language facilitation in child care settings: A social-interactionist perspective, in Enhancing Caregiver Language Facilitation in Child Care Settings. Proceedings from the Symposium. October 18. Tornoto: The Hanen Centre. Glascoe, F.P. & Sturner, R. (1999) Surveillance and Screening, in Law, J., Parkinson, A. & Tamhe, R. (eds.) Communication Difficulties in Childhood. Oxford: Radcliffe Publishing. Gussin Paley, V. (1991) The Boy Who Would Be A Helicopter. Cambridge, MA: Harvard University Press. Palmer, S. (2006) Toxic Childhood. London: Orion. Sylva, K., Melhuish, E., Sammons, P ., Siraj- Blatchford, I., Taggart, B. & Elliot, K. (2003) Effective Provision of Preschool Education Project (EPPE), Summary of Findings. London: Institute of Education ( Tyrwhitt, P. (2006) Personal communication.




Software solutions

Software solutions
Ann Adams recommends a visit to this innovative online seminar for researchbased answers to frequently asked questions about stammering in children. Education in Stuttering Treatment with Mark Onslow Treatments for preschool children


With computer software becoming ever more sophisticated and accessible for therapy, our in-depth reviews will help you decide whats hot and whats not. EDUCATION
Kate Bramley particularly welcomes the ready prepared activities at a range of levels in this adaptable and easy to set up programme. A Busy Day - An interactive and personalised reading tool for visual learners (age 3-6) SEMERC / Granada Learning ISBN 1-40606-156-5 49.95 (single user)


Are you looking for evidence to back up your treatment of preschool children who stutter? Or do you want to find out more about stuttering in this age group? If so, log in and obtain an up-to-date web-based seminar from Professor Mark Onslow. He presents a 90 minute seminar on recent research on stuttering in the preschool child in a clear and understandable way. The seminar is augmented by downloadable notes and references. This is a new and useful tool for speech and language therapists, clinicians and others who wish to refresh their knowledge of current research or those who would like to know what different methods of treatment are based on. During the course of the seminar, Mark Onslow covers frequently asked questions such as, Will treatment stop stammering?, What treatments work?, How many clinical trials are there?, Is it enough to eliminate or reduce stuttering?, How long should treatment take?, When is the best time to treat? and Does stuttering cause harm to preschool children? He also suggests topics that might be of interest for future seminar presentation and discussion. The seminar has a free introduction at www. which gives a flavour of the content and style. Depending on the exchange rate, the participant will then pay approximately 36 (students 18) for 24 hour access to the seminar plus 14 days of access to a chatroom hosted by Mark Onslow. The viewer is requested to give feedback on the experience of the online seminar facility. It is very helpful to watch the free Introduction to Stuttering seminar to become familiar with how the process works. Personally I had a few hiccups accessing and keeping online. I had trouble trying to allocate the 24 hour period that I intended to access the seminar. Would this be at home or at work? I had understood that I had to listen to the whole seminar uninterrupted. However, in reality, it was possible to stop for a bit and consult and write notes. These things are always easier at the second attempt. I would recommend a visit to this seminar as well as to the one on school-aged children. Ann Adams is a speech and language therapist (Clinic Co-ordinator) with Surrey PCT. 28

Get your webcam and headset ready Rebecca Matthews and her young clients are impressed by this videoconferencing system developed specifically to deliver speech and language therapy. TinyEYE Online Speech Therapy Telepractice Contact Roshan Hoover to discuss (

A Busy Day is an engaging computer software programme for developing the reading skills of children who learn visually. It can also be useful for teaching core everyday vocabulary in a fun and different way, and can promote fundamental social skills such as turn taking and joint attention when used with groups of students. It would be useful for speech and language therapists working directly with children but also for indirect working through teachers and parents. It is easy to set up and can be quickly personalised for each child so they can work through activities at an appropriate level. There are 3 set levels, but within each level you can programme in particular vocabulary and sentences that you want the child to work on. It is simple to use via interactive whiteboards and has switch access so a range of students can participate. The activities are based on a colourful computer-based story book which appeals to adults and children alike. By clicking on objects within the pictures, or the words below the pictures, the children receive auditory feedback on what the object / word is. There are different activities graded towards developing whole-word sight reading, matching written and heard words with pictures to develop meaning to what they read. There is verbal feedback for the childs success in each activity with fun animations, good for boosting confidence and esteem. The programme includes examples and ideas for paper based activities to work on alongside the DVD. These are useful for consolidation when a computer is not available and for carryover of skills. This programme backs up the work already done by speech and language therapists working with visual learners. However it provides it in a new format, with already prepared activities at a range of levels, always welcome news for the busy clinician. Kate Bramley is a speech and language therapist working with children with complex needs in and around Guildford, Surrey.

Travelling is increasingly expensive and there are huge demands on the clinical time of any speech and language therapist. Does videoconferencing offer a solution? TinyEYE Technologies believe that it does. Aware of reservations raised by speech and language therapists, they have set up a service to provide both the technological support and also the materials to use in an online session. TinyEYE is a videoconferencing system launched last year by American Speech Language Pathologist Marnee Brick specifically for speech and language therapists to deliver therapy. It is specific to speech and language therapy as the online games are focused on word retrieval, articulation and language development. The game is the focus on the screen but the therapist and child can see each other framed in a small part of the screen which the therapist can control. These online games can be made specific to the individual child and can be provided online after the session has finished for homework practice in an online backpack. There is a also a comprehensive client management tool that enables the therapist to set both long and short term goals, generate reports, letters and manage their schedule online. The children that enjoyed using TinyEYE with me were infant school age. They were motivated by the backpack home practice being both online and individual to them, and the 43 games so far available are very clearly geared for this age group and younger. The parents liked the backpack homework as it was organised, reliable and consistent but struggled with managing the technology. TinyEYE do offer comprehensive support phone and online tutorials - but contact was limited by the time difference between the UK and the USA. To use TinyEYE does require practice - and time to get the full benefit of what is on offer. There were some amusing linguistic differences - thumper for rabbit and the inevitable pants for trousers - and the management system would need some modification to fit in with UK jargon and individual practice. It does however provide a supported step to using videoconferencing which is potentially a great solution to save fuel and time. It is an organised approach to help busy therapists work effectively using a medium proved over the last twenty years. Rebecca Matthews is an independent speech and language therapist, and UCL Doctorate student.


Subscribers should contact the publisher if they have not received their magazine(s) within two weeks of the publication date, or if there are any problems with the magazine itself. Tel: 01561 377415 Speech & Language Therapy in Practice is published at the end of February (Spring), May (Summer), August (Autumn) and November (Winter).


Subscription form for Speech & Language Therapy in Practice


28 personal (UK) 24 part-time (5 or fewer sessions) (UK only) 21 student / unpaid / assistant (UK only) 33 personal (Europe) 37 personal (other overseas)

48 authorities (UK / Europe) 53 authorities (other overseas)
Bulk orders (sent to any single work address): 2 copies for 56 3 copies for 78 4 copies for 96 5 or more copies for 23 each. No: Total price

Note: Cheque and direct payment only. Credit card payments can only be deducted in sterling at the rates advertised above.

Meningitis: After care and After-effects Conference 17 September 2008 London Details: Louise Little, tel. 01453 768000 Parkinsons Disease: Responding to mental health issues 23 September 2008 Birmingham Some bursaries available for professionals - contact Daiga Heisters on ISAD2008 Online Conference Dont Be Afraid of Stuttering From 1 October 2008 The Communication Trust Conference Developing a workforce to support speech, language and communication for all children 10 October 2008 London 130 Speakers include John Bercow MP Working with Listening and Auditory Processing Difficulties (for teachers and therapists) 10-12 October 2008 (East Grinstead) 30-31 March 2009 (Birmingham) With Diana Crewdson and Camilla Leslie 250 e-mail Meeting the challenges of severe aphasia 4 November 2008 Connect, London 125 Afasic 40th Anniversary Conference Growing up with a speech and language impairment 6 November 2008 Edinburgh 110 A new sense of self (Coping with the social and behavioural changes following acquired brain injury in childhood and adolescence) 10 November 2008 Nottingham 145 public sector INVOLVE 6th National Conference 11-12 November 2008 Nottingham Public involvement in research: getting it right and making a difference Working with Children & Young People Show 2009 19-20 May 2009 Earls Court, London Free if pre-registered at British Aphasiology Society Biennial International Conference 9-11 September 2009 Sheffield

42 personal 35 student / unpaid 61 authority / department

Bulk orders (sent to any single work address): 2 copies for 71 3 copies for 98 4 copies for 121 5 or more copies for 29 each. No: Total price

IBAN NUMBER: IBAN GB44 BOFS 8020 0608 3990 01

The new subscriber fills up their details on the form and puts your name in the recommended by space. Once their payment has been received, they will get 5 copies for the price of 4 in their first years subscription, and you will be notified that your subscription period has been moved on by three months. So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in Practice. Remember - you will get an extra issue for every new subscriber you bring in. *Must be a NEW subscriber to the magazine.

Cheques payable to AVRIL NICOLL BUSINESS. OR Please debit my Visa / Mastercard / Switch card: (Card payments cannot be accepted without a signature.) Card number: Card security code Expiry date: Switch only: Issue No. ORValid from date:
(if issue no. not available)

(last 3 digits of number on signature strip) Signature:





WORK TEL. e-mail: Please note acknowledgements and renewal notices are sent automatically. From outside the UK, Return to: Avril Nicoll, the address is: Speech & Language Therapy in Practice, FREEPOST SCO2255 Avril Nicoll LAURENCEKIRK 33 Kinnear Square Aberdeenshire Laurencekirk AB30 1ZL Aberdeenshire Tel/fax +44 (0) 1561 377415, e-mail AB30 1UL
It would be very helpful if you could complete the following information:
Job title(s): Name of employer / university: Topics you would like to see covered:

Contact the Editor for more information and / or to discuss your plans. Please note: articles must be of practical use to clinicians use case examples and list useful resources length is generally around 2500 words supply copy by e-mail or on CD keep statistical information and references to a minimum

Contributions to Speech & Language Therapy in Practice:

Your personal details will only be used for the purposes of Speech & Language Therapy in Practice magazine and will not be passed to any th party.


Special offer for personal subscribers - Introduce a colleague* to Speech & Language Therapy in Practice and you both get an extra issue - free!

My Top Resources

1. INTERACTIVE WHITEBOARDS / DATA PROJECTORS Interactive whiteboards are usually fixed to a classroom wall and connected to a computer. The image from your computer is displayed on the whiteboard which in turn can control the computer via its touchsensitive surface. Students respond by touching the board, writing on it, or by moving text and images around. A bit scary when we first used them, these are now a familiar and useful resource. In collaboration with the teacher you can make activities to support the language of the curriculum that are visual (using images, subject to copyright), attractive, interactive and engaging for the whole class. A data projector and screen also work well to provide the visual support for learning that seems to benefit many of our students with language difficulties. Where the interactive element is not required, PowerPoint with a data projector is very useful for making classroom-friendly language supportive resources across a range of subjects. 2. STARSPELL SOFTWARE Starspell is designed to help spelling. It is also a database which allows you to provide targeted work on curriculum vocabulary by entering your own list of words for an individual or class and associating these words with a short definition or key fact. One of the games (StarPick) helps students associate the definition with the orthography. As the student has to click on each letter required one at a time, it also engages them with the phonological representation of the word (particularly when words are spelled regularly) because they probably have to segment the word into phonological units to identify the letters. This game has error free learning, while others correct errors to promote spelling. With the Scottish Curriculum for Excellence promoting literacy as every teachers responsibility, Starspell is useful to engage teachers in promoting the language and literacy of their subject. 3. CLOZEPRO SOFTWARE ClozePro has a different interface from Starspell but is useful to either reinforce vocabulary using a different task, or to provide additional information or a context for a word that has been introduced in Starspell. It allows you to create sentences that either provide a definition or a context for a word that you can then remove to a grid at the bottom. When the activity includes a few sentences, the students task is to identify the word that best fits each sentence. You can reproduce the activity as a printable worksheet. 4. BRINGING WORDS TO LIFE: ROBUST VOCABULARY INSTRUCTION Beck, I.L., Kucan, L. & McKeown, M.G. (2002) ISBN 978-1572307537 Guilford Publications This well-thumbed volume is particularly useful when working on explicit teaching of words that are not terminology. It has really alerted us to the complexity of knowing a word and to the depth of instruction required to give students useful and productive knowledge of a word. You can easily take the text (book, poem or play) a class is working with then use Beck et al.s criteria to select words for robust instruction. Vocabulary learning does not come easily to many of the young people we deal with and this book reinforces the need to provide multiple repetitions of words and also rich in-depth teaching. There are plenty ideas for how to do this and we look forward to the authors forthcoming volume, Creating Robust Vocabulary: Frequently Asked Questions and Extended Examples. 5. COLLINS COBUILD ADVANCED LEARNERS ENGLISH DICTIONARY 5th edn (2006) ISBN 978-0-00-721013-8 Cengage ELT This dictionary is intended for people learning English and comes in several versions. We use the advanced learners dictionary, the most comprehensive. As it provides definitions written in natural sounding sentences, the meanings are much more accessible than in traditional dictionaries. This makes it easier for teachers, therapists and learning assistants to explain word meanings and make resources and to define important vocabulary for students in easy to understand language. The accompanying CD ROM is a real bonus. It allows teachers and therapists to look up words very quickly. It also means that students do not need sophisticated alphabetic skills to navigate a big dictionary - they simply type in the word they wish to access and the entry appears on screen. 6. CHILDRENS WRITING AND READING: ANALYSING CLASSROOM LANGUAGE Perera, K. (1984) ISBN 978-0631136545 WileyBlackwell I heard Katherine Perera more than 20 years ago describe the linguistic features that make textbooks and worksheets difficult for children. Her lecture stayed with me! We now refer to her book when helping teachers differentiate materials to take account of the fact that our students may understand less complex grammar than their peers and be poorer readers, and may thus find learning information from written materials challenging. Although very old now this book is still an important university course text. 7. E-MAIL While we all moan about clogged in-boxes, the beauty of e-mail is the access it gives to people who might be almost impossible to phone. With it we can compose and carefully formulate a question and address it to some of the most famous academics and clinicians in the world. I am always surprised by the grace and generosity of colleagues who, in spite of extremely busy schedules, take time to bring their expertise to my computer screen with helpful replies, examples of their work or references. 8. INTERACTIVE REMOTE RESPONSE / ELECTRONIC VOTING SYSTEMS eg. (Quizdom); (Promoethean Activote) We have just started using these little hand-held voting handsets with students and are already seeing the benefits.

Used with an interactive whiteboard or data projector, the teacher or therapist devises a presentation in the form of questions, usually with a multiple choice format, and each student chooses by pushing a button on their handset. At a basic level this can really engage students and ensure they all respond. As the response is anonymous to the rest of the class, those with language difficulties are encouraged to have a go. The teacher or therapist can show the class the correct response and display the percentage who responded correctly. Away from the students, the software provides valuable information about what an individual student understands of a topic or text, and how students with language difficulties are coping compared to their peers. We have also begun using it to monitor students progress towards Individual Education Plan targets. For example for a student who had a target to learn 40 Tier 2 words (Beck et al., 2002) from their English texts, we created activities that allowed us to see how close they were. 9. STRATEGIC LEARNING: READING COMPREHENSION LEVELS 1 AND 2 Difficulties with reading comprehension are common in secondary students who have oral language comprehension difficulties. Given that reading comprehension is a very important skill both to access the curriculum and for real life, we try to address this in collaboration with teaching colleagues. It is a complex and challenging task and there is still much we have to learn. These volumes, with accompanying CDs, are useful for identifying and targeting a number of the subskills important for reading comprehension, including the use of referring words, inferencing skills and predicting. The worksheets can be printed off for student use and, although some of the material is quite American, there is still plenty that is useful. The programme also gives you ideas of activities you can devise for other texts. 10. HUMOUR See Croker, C. (2006) Lost in Translation: Misadventures in English Abroad. ISBN 1-84317-208-6 Michael OMara Books Where would we be without humour? In lectures and when providing continuing professional development, humour makes information more memorable and provides light relief, especially when information is new or challenging. Humour about language is particularly helpful and I have a few favourite malapropisms that I use when talking about vocabulary learning as well as some very funny examples from Croker (2006) of the many ways in which language can come unstuck!