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Any questions?
Teachers are encouraged to question children, but Nicola Harvey and Belinda Robbins are working with language unit staff on more indirect interaction techniques to develop childrens play and expressive language.

READ THIS IF YOU WANT TO SHIFT THE EMPHASIS FROM QUESTIONING TO COMMENTING TESTING TO TEACHING KNOWLEDGE TO APPLICATION

e are speech and language therapists working as a whole time equivalent in a primary language unit setting, with 36 children across three classes. The children have a wide range of speech, language and communication needs. In each class the specialist class teacher is supported by 2-4 teaching assistants. In January 2009, we discussed with the teacher in charge ways in which we could develop the knowledge and skills of the staff. Although some had attended basic speech and language therapy training, they reported feeling unsure of how to apply this knowledge within the classroom context, and how to adapt it for children with differing strengths and needs. Our observations of the school staff interacting with the children highlighted a high level of questioning. This is typical of school staff working with language disordered children (Sadler & Mogford, 1997). The class teachers reported one of the key areas in teacher training is to get the child thinking by asking plenty of open who/what/where questions. This ethos was passed on to the teaching assistants. We observed an emphasis on both open and closed questioning from all school staff in the language unit. The closed questions in particular restricted the childs expression. Indirect interaction techniques such as commenting rather than questioning have a positive effect on a childs language development (Laskey & Klopp, 1982). With this in mind, we decided to use the principles of Parent Child Interaction (Kelman & Shneider, 1994) to build on the existing skills of the school staff and develop pupils language in a variety of contexts. Cummins & Hulme (1997, p.4) explain the main principle is partnership with parents, enhancing their knowledge and understanding of their child, with the therapists theoretical and clinical experience. This approach has been used with preschool children with communication difficulties such as dysfluency and language delay, and includes videoing as an essential component. In our classroom observation, many of the children demonstrated early play skills - such as crashing cars together - with very little symbolic or imaginative play. Others focused on construction or familiar items such as a train set which they tended to use in a repetitive way. Some staff commented that the children often argued or were bored during free play sessions, and became destructive. Staff also identified

difficulty knowing how to play with the children. As Parent Child Interaction is primarily play based, it provides a good opportunity to develop play skills of both staff and children. With the teacher in charge we chose two teaching assistants to train, based on factors such as experience and the age of children worked with. We initially chose individual rather than group training as Belinda had used this model with parents and it appeared to work well in terms of motivation as well as developing skills. It enabled the training to be tailored specifically for the needs and strengths of the parent and we felt this was also true for the school setting. The demands on the teaching assistant would possibly be higher because they would be expected to adapt their skills across children with a range of difficulties. Using our knowledge of the strengths and needs of the two teaching assistants, Laura and Fraser, we put together a plan. This included: session planning, how much time was required / available, how we were going to measure success and record data, which children were to be targeted, and organising video recording and television playback facilities. For each teaching assistant, the initial session consisted of: explanation of the therapy aims completion of an adult: child interaction rating sheet, where the assistant rated their current skills in areas such as levels of questioning and commenting a 5 minute video of the assistant interacting with a child with large doll play materials, with the therapist noting language and play skills of the adult and child. We then analysed the assistants utterances, scoring percentage levels of comments, questions and commands. setting up Special Time with a child for a minimum of 3 x 5 minutes a week. The assistants each received weekly sessions of 45 minutes. Initially both of us were present. As Nicola had not been trained in the approach, this gave her the opportunity to develop additional skills. These sessions provided time for teaching assistant feedback relating to Special Time, identification of strengths, joint agreement of areas to target, modelling of skills, feedback and problem solving (figure 1). Data collection and recording of adult and child language and play skills continued for each session. We shared results with the assistants to illustrate

Belinda (l) and Nicola (r)

ongoing progress and encouraged them to select different children as their confidence and skills increased. This provided the opportunity to learn to adapt their style to meet the individual needs of each child. We also encouraged a variety of play materials, so the assistants could experience the usefulness of toys that promote imaginative play. We also used the sessions as an opportunity to explain the childs speech and language needs, their targets, and ways the assistants could use their skills and knowledge in other contexts. When the sessions had been running for a few weeks, there were times when only one of us could be present. This enabled us to reflect on the usefulness of having one or two therapists for each session (figure 2). Laura and Fraser had the opportunity to meet and video each other for peer support, when sessions with us were not possible.

Positive effect

In June we asked each assistant to repeat the adult: child interaction rating sheet, and complete an evaluation sheet. We also compared the data from the first and final video sessions (figure 3). For both, the nature of their interaction style had shifted to a less directive approach. This had a positive effect on the childs language levels and interaction. For example, one child showed 1-2 word phrases such as cut it consistently on the first video. After two training sessions the same child with the same assistant was producing 3-4 word utterances such as pushing train round track. The childs class teacher commented that she

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had never seen the child so motivated and expressive as in the second video. Many of the children copied previously modelled play in subsequent sessions. They also showed a developing preference away from construction materials to more languageadding friendly imaginative play materials. Laura said on her evaluation form: really enjoyed the sessions and learnt a lot (5/5 on rating scale) Now asking less questions, allowing the child to speak at their own pace and when they feel comfortable Both knowledge and confidence levels increased from rating 2/5 to 4/5 Sessions well balanced; liked the opportunity to watch the video and gain feedback. Lauras adult: child interaction rating sheet (Never, Sometimes, Usually, Always) showed an improvement in 7/10 areas, the most significant in figure 4, with no change in 3/10. Fraser said on his evaluation form: enjoyable to work in a different environment with children, and to have time to think about what I was doing (4/5 on rating scale), Will try and use my imagination more, and try to remember to go with the flow. Both knowledge and confidence levels increased from 2/5 to 4/5 Would have liked more defined practice time and an environment where the children were less aware of the camera. Frasers adult: child interaction rating sheet showed an improvement in 3/10 areas, no change for 6/10 areas and, for 1 area, a reduced rating. He felt he had improved in reducing levels of questions (usually - sometimes), praising (sometimes - usually) and talking slowly (sometimes - usually). We were particularly pleased with Lauras progress. She had asked to be involved in the training, and we observed her using the techniques in the classroom with a range of children. She remained motivated and focused throughout, and completed the Special Time practice sessions as agreed. She reported she would be happy to work alongside a colleague to share her skills and knowledge in the new term. Fraser also showed good progress within the structured clinic sessions, and particularly benefited from modelling from the speech and language therapist. He struggled to complete the Special Time practice regularly and did not always attend the weekly sessions. The apparent mismatch between his observed progress on the video data and self-perception on the rating scales possibly illustrated Frasers lack of confidence in generalising his skills into everyday activities. We met with the teacher in charge to feed back the results. All staff felt more training with this approach would be beneficial. We therefore agreed to train all members of the team, and to facilitate opportunities to generalise skills learnt by regularly working with staff in the classroom.
Figure 1 A typical session At the start of each session we asked the teaching assistant to provide feedback on how the five minute sessions had gone in relation to the agreed aim of the week. They had the opportunity to discuss any perceived strengths (often difficult to elicit!) and difficulties (usually the place they wanted to start!) They also discussed any practical difficulties limiting opportunities for 1:1 practice, such as SATS (national tests) week. Nicola or Belinda then brought the child to the session while the assistant prepared toys they wanted to use. One of us videoed a short play session and made an on-line count of the type of utterance used by the assistant for approximately 5 minutes while the other recorded language and play samples. One of us then continued to video and record information while the other joined the assistant to model interaction and play skills. We all then watched the video with specific aims / thoughts in mind, such as level of questioning or the different responses of the child to the type of toys chosen. We paused the video at times to emphasise points, particularly when the assistants behaviour had effected a positive change. The emphasis was always on giving the assistant the opportunity to note any behaviour, first under the guidance of the therapist (What is happening here?) to more directive support if necessary (What happened when you added a comment there?) It was occasionally necessary to tell the assistant the positive. Most often this was to draw attention to the childs body language / expression showing that they were ready and waiting for any language that was to be given. We often reiterated how important the assistants role was in developing the childrens language, and that every interaction with the child presented this opportunity - not just in the classroom, but in the walk across to the playground and queuing up for lunch. The assistant, with our support if necessary, evaluated whether the aim of the week had been achieved. At the end, we all agreed on the aim for the following week. If a new strategy was appropriate, we asked them to spend five minutes, three times a week, using it. We also wrote aims down. Figure 2 Two therapists per session Advantages: Language sample, play skills and tallies recorded as the assistant was interacting with the child. The division of tasks between us resulted in more accurate and comprehensive information. Ability to record immediately the effect on the childs language / interaction / play skills when the assistant followed ideas modelled by the therapist The therapist not involved in interaction able to note down areas to discuss during video playback Immediate feedback to the assistant Peer support and sharing of knowledge / skills Flexible camera positioning Disadvantages: Demand on limited resources affected number of children being seen May be too intense for some assistants Figure 3 Pre and post intervention videos - teaching assistant utterances Laura Jan 09 % Comments % Questions % Commands 30% 63% 7% June 09 87% 13% 0% Jan 09 26% 74% 0% Fraser June 09 84% 16% 0%

Figure 4 Lauras rating sheet Jan 09 I wait for the child to start talking I ask the child a lot of questions Never Usually June 09 Always Never

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Adapted group

We adapted some group child interaction training (which Belinda had co-written with a preschool colleague) to be more relevant to staff in a school setting. We organised training across all the classes, initially with the focus on all the teaching assistants. The training took place in two 1 hour sessions, with a video task in the two weeks between. The first session included an introduction to key skills such as adding comments, repeating, and following the childs lead, with each demonstrated by us. We set a task for the following session, which required a five minute video of each staff member interacting with a child using the key skills. The second session included providing information regarding the development and types of play, and discussing and sharing the videos. We initially thought some of the staff would be reluctant to share their videos with colleagues. In fact all were happy to do so and stated this was the most valuable part of the training. Submission of the videos prior to the second session gave us the opportunity to prepare comments/questions ratios and individual written feedback for each staff member (figure 5). Writing the feedback was very time consuming and we only had one comment on it from a total of 13. If we were to do the training again, we may omit this part unless the school staff specifically ask for it. All the assistants requested that teachers also attend the training as they were keen to see the principles learnt reflected in lesson planning. We therefore repeated the training for the three teachers (and one assistant who had missed the original training). The training was very well received, and encouraged the school staff to think about interacting with the children in a different way. They reported the use of commenting was extremely beneficial. They felt it led to the emphasis being on teaching rather than continual testing to find out what they knew through questioning. There is a place within communication and teaching for the use of questions to develop a childs thinking, problem-solving and conversational skills, but one teaching assistant commented she felt empowered that such a relatively small shift in emphasis made such a large difference to the flow of an activity. She reported that, as a result of using the techniques, the activities were less adult led and more exploratory, with greater levels of information exchanged. We organised a weekly play session with the teachers to continue to develop the skills learnt, and to provide opportunities for us to model ways of extending existing skills. We agreed the class teachers would timetable additional play sessions throughout the week. We are continuing to adapt the format as necessary, with regular feedback and problem-solving with all staff. SLTP Nicola Harvey and Belinda Robbins are speech and language therapists with Medway PCT, email nicolaharvey1@nhs.net or belinda. robbins@nhs.net.

Teaching assistant Emma OSullivan, who participated in the group training, is pictured using her interaction skills with Joe.

Figure 5 Written feedback Never I follow what the child wants to do Sometimes Usually Always

You waited and followed the childs focus of interest and allowed him to talk about what he wanted to. You gently redirected his play when it became destructive. You left plenty of silences to allow the child time to think. You spoke very slowly and clearly and this was mirrored by the child, resulting in him saying some complex sentences - excellent!

I wait for the child to start talking (with words or gestures) I show I am listening by repeating what is said I interpret the childs response at their level I comment on what the child is doing I use specific praise with the child during play

You repeated back what the child had said, and added language well.

You took the opportunities to model vocabulary at the appropriate time. The child responded particularly well to this and began to comment himself during the session. Indirect praise shown by following his lead/comments. Nice use of non-verbal (gesture, body language and facial expression.

COMMENTS: You did really well at using low levels of questions (only 1 question for each 4 comments you made). Your calm and measured approach worked well with the child as he can get over-excited, which is a barrier to his learning. By keeping him calm and on task you made full use of the opportunities to develop his language and learning.

References

Cummins, K. & Hulme, S. (1997) Video a reflective tool, Speech & Language Therapy in Practice Autumn, pp.4-7. Available at: http:// www.speechmag.com/content/files/Microsoft_ Word__Video.pdf (Accessed 5 July 2010). Kelman, E. & Schneider, C. (1994) ParentChild Interaction: an alternative approach to the management of childrens language difficulties, Child Language Teaching & Therapy 10(1), pp.81-94. Lasky, E. & Klopp, K. (1982) Parent child interaction in normal and language disordered children, Journal of Speech & Hearing Disorders 47, pp.7-18. Sadler, J. & Mogford-Bevan, K. (1997) Teacher Talk with children with language disorders: four case studies 1, Child Language Teaching & Therapy 13(1), pp.15-36.

REFLECTIONS DO I ADAPT APPROACHES FROM ONE CONTEXT TO SUIT ANOTHER? DO I HIGHLIGHT EVERYDAY OPPORTUNITIES TO PRACTISE COMMUNICATION TECHNIQUES? DO I RECOGNISE THE POWER OF VIDEO FOR DEMONSTRATING AND CONFIRMING PROGRESS?

Acknowledgements

We would like to thank the staff at Swale Speech & Language Unit, and Laura Dunn, speech and language therapist, Sittingbourne Memorial Hospital.

To comment on the difference this article has made to you, see information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/ About/Friends.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010