speech & language therapy in practice, autumn 2003

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Autumn 03 speechmag In need of inspiration? Doing a literature review? Looking to update your practice?Or simply wanting to locate an article youread recently? Our cumulative index facility is there to help. The speechmag website enables you to: View the contents pages of the last four issues Search the cumulative index for abstracts of previous articles by author name and subjectOrder a copy of a back article online. PlusThe editor has selected the previous articles you mightparticularly want to look at if you liked the articles inthe Autumn 03 issue of Speech 8r Language Therapyin Practice. If you don't have previous issues of themagazine, check out the abstracts on this website andtake advantage of our new article ordering service.If you liked ..see (198) Wri9ht, L.: Getting to knowyou, (199) McNeil, c.: TIpping the scales, (200)Blight, A.: Fighting fire with fire. All fromSummer 2002, How I manage stammering inadults.

look at (090)Code, C. (Winter 1999) Meeting expectations.what about (183) Irvine, C. (Spring2002) Preliminary findings of an informallongitudinal study into the research I practiceinterlace: noting the influence of extra trees inthe wood rather than throwing the baby out withthe bath-water.

you mightbe interested in (065) Park, K. (Summer 1999)Whose needs come first? (Reprinted in full at:www.speechmag.com/archiveslkeithpark.html.)see (111) Law, J.:Good questions, good answers, (112) Valentine,c.: No assumptions, (113) Langhorne, P., Legg, L.,Pollock, A. 8r Sellars, C.: The burning questions.All from Spring 2000, How I put practice intoresearch.

consider (123) Stow, C. 8r Pert, S.(Summer 2000) My top resources.Also on the site news about future issues, reprintedarticles from previous issues, links to other sites ofpractical value and information about writing for themagazine. Pay us a visit soon.Remember you can also subscribeor renew online via a secure selVer!

Win Basic Verbs inSimpleSettingsLooking fo r up-to-date materials tohelp you work on verbs? Carry,dance, eat, jump, run, sleep, washand yawn are just some of the 48frequent y used actions featuri ngin a new ColorCard se t , demonstrated by male and female subjects of a variety of ages . (Alongwith Familiar Verbs in Contextwhich will be published in

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Win Pip the puppetYou've seen Molly, now meet Pip. If you could use a male puppetto teach sign ing and speech sound practice, now's your chance!Pip can wear a hearing aid and show mouth shape, tongue positioning and hand and finger movements.Pip normally retails at 89.95 but LDA is making him availableFREE to a lucky reader of Speech & Language Therapy inPractice.To enter, simply send your name and address marked 'Speech &Language Therapy in Pract ice - Pip offer' to Sarah Co llins,Marketing Co-ordinator, LDA, Abbeygate House, East Road,Cambridge CB 1 1DB . The closing date fo r receipt of entries is25th October and the winnerwill be notified by1st November.Pip and his friendMolly are availableon 30 daysapproval fromLOA,tel. 01945463441.

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20031368-2105

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ril Nicoll 2003of Speech & Languagein Practice reflect theof the individual authorsnot necessarily the views ofpublisher. Publication ofis not an

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picture by Paul Reid (posed bySee p.16

Inside coverAut umn 03 speechmagReader offersWin Pip the puppet and BasicVerbs in Simple Settings.2 News / Comment4 Taking the long view"We ...have to just go with theflow of all that happens in theday opportunity service.Personally Iam taking a verylong view. I hope that over thenext year or so some of thehiccups will be ironed out sothat this programme will runsmoothly and an increasednumber of service users willbecome involved. "Yasmin Shah reports on the

16 COVER STORY Sociologica l pe rspectives oninequa lity se ries (4 )Ethnicit y and culture: anunequal power"It is widely acknowledged that speech andlanguage therapists (and all other healthprofessionals) should be sensitive to thecultural needs of various minority ethnicgroups. However, Holland & Hogg (2001)have rightly identified that, whilst healthprofessionals are encouraged to do this,there is a definite lack of leadership withinthe health care services on such culturalissues. "People in minority ethnic groups andcultures face complex and wide-rangingdiscrimination. Sarah Earle examineshow we can help reverse th is trend.

introduction of a Focused Interaction programme to aDay Opportunity Service for people with severelearning disabilities.7 "Here's one I made earlier ...Speech and language therapists will forever be in need oflow-cost ideas for flexible therapy activities and materials.Alison Roberts, who suggested this new column, kicksoff with some gem s of her own: Question dice, Spin thebottle and Spidergram8 A bright SPPARC"Although the final number of carer participantsnumbered only four, for them it was a new andextremely worthwhile experience as reported in theirwritten evaluations throughout the programme. "'Supporting Partners of People with Aphasia inRelationships and Conversation' (SPPARC) wasdeveloped in London. Can its positive findings bereplicated in a rural area? Linda Armstrong andHelen McGrane investigate.

11 Further readingAgeing, bilingualism, communication, epilepsy Idysphonia, dysphagia.

12 Functional communica tion : theimpact of PECS"Generally, the study showed that there was an overallincrease in the number of communicative attempts madeand that Group 1 (who had been using PECSTM for fourmonths longer than Group 2) showed an increase in therange and quality of their Functions of Communication ."The Picture Exchange Communication System (PECSTM)aims to teach individual users to initiate communication.Sarah Heneker and lisa Maclaren Page investigatethe effectiveness of introducing the approach to wholeclasses within a school.Sadly, since this was written, Lisa died as a result of aroad traffic accident. This article is in her memory.

18 Revi ews Neurodisability, AAC, inclusion, conversational practice, dysphag ia, semantics, assessment and phonological awareness.

20 Letter to t he editor Fundamental questions from Patricia Sims

21 Altered perception"The concept of contrastingperceptions with reality is aninteresting one. If anything else,when perceptions are not in tunewith reality, this challenges andencourages previous attitudes tobe altered or modified. "How do people who stammerthink others perceive them, andare they right? Do people who

don't stammer find everyday speaking situations aseasy as people who stammer seem to think? Guetlee finds some answers.

24 How I put research into pract ice'''Evidence based practice' sounds good, but updatingour practice as new information becomes available isnot always easy. .. Our contributors present the case -you, the jury, must decide. "Nina Soloff is research coordinator for her service inMilton Keynes, Sue Roulstone and colleagues arebased at the Speech & Language Therapy ResearchUnit in Bristol and Avril Nicoll reflects on howCarole Pound and Susie Parr are putting theirresearch into practice at the London Connect Centre.

Back page M y t op resourc s"If you are the sort of person who can look at abrick and think, 'Mmm , if I drilled a hole in that andput it on a cord it would be a really unusualnecklace. Perhaps I can get another one, break it intwo, and make matching earrings .. .', research maybe for you."Paula leslie and Pauline Meek are clinical researchspeech and language therapists and practisingclinicians.

In future issues ..AAC DYSARTHRIA DYSPHAGIA SCHOOLS AND CLINICS COLLABORATION

SURE START ...and introducing WINNING WAYS (WORKING WITH A LIFE COACH)

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
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new s

CAN TALK! State of the Aimingthousand early years settings across the UK are totraining pack to help staff increase their eNation

The UK's top airlines are effectively barring disabledof speech and language development. Highpeople from booking flights online by failing to meetwith ideas and inventive ways to promote

I CAN TALK 1 initiative also aims to provide early yearsminimum accessibility standards on their websites. Schools need to provide better support fo r

skills and help them to seek support for National computing and disability charity Abil ityNet Gypsy Traveller children - the mi nority ethnicTesco Baby & Toddler Club has audited nine airline websites for accessibility to people group most at risk in the country's schools,

packs which include a video narrated with visual impai rment, dyslexia or a physical disability according to new government guidance.Michael Buerk, a booklet and a wall chart. affecting mouse use. The charity points out that the Aiming High: Raising the Achievement ofcompanies are missing out on potential buying Gypsy Traveller Pupils sets out how schools can

of Speech & Language Therapists,CAN and endorsed by

power. It adds, "From October 2004, when extensions overcome diffi culties arising from institutionalpack includes a video based on the acronym TALK to the Disability Discrimination Act come into force, racism, low teacher expectations and inter

g together, Attention and listening, Level of websites will have to be accessible as a matter of law." rupted learning to raise achievement. It alsoRoad shows have Virgin Atlantic, which performed particularly poorly includes examples of current good practice.

UK to introduce the pack. in the survey, has since made a public commitment to A recent survey of England's local educationGill Edelman says, "What makes I CAN TALKI improve the accessibility of its website. authorities suggested there are about 42,000is that it demonstrates how making use of The survey of airline sites is the first of a planned series of Gypsy Traveller children in England. An Ofsted

and play activities in early years settings 'State of the eNation' reports designed as an awareness report in 1999 said, "Although some make ahave a remarkable effect on speech and language campaign to draw attention to the issue of accessibility reasonably promising star t in the primary

CAN is proud to and to help disabled people find the best websites for school, by the time they reach secondary levelsuch an important resource to so many their needs. On-line newspapers, supermarkets and bank their generally low attainment is a matter of

across the UK." ing services will also come under scrutiny. serious concern."www.abilitynet.co .uk See www.standards.dfes.gov.ukJethnicminorities.

On the movetroke in Parliamenttrategy i-to-i UK (which runs voluntary healthThe first All Parliamentary Group fo r Stroke has been launched to highlighta strategic move, tw o top placements overseas) is now atissues affecting people with stroke and to encourage more investment in Woodside Housestroke prevention, care and research.joined the 261 Low LaneThe Stroke Association is providing practical help to the group which is call Leeds LS18 5NYof ing fo r more public awareness campaigns highlighting the simple things Tel 0113 205 4620people can do to reduce their risk, especially getting their blood pressure Fax 0113 205 4619the appoint checked regularly. It also wants to see greater awareness that stroke affectsof Pat Ie Prevost and young as well as elderly people, and to encourage more hospitals to open The Scottish Council on Deafness has moved tostroke units in line with government targets. Central Chamberswww.stroke.org.uk Suite A 1 t Floor"We are grateful to 93 Hope StreetA character in BBC One's sitcom Glasgow G2 6LDo have committed to give OynaVpx All About Me will acquire a new Tel 0141 2482474freely of their time and voice in the forthcoming series, Text 0141 2482477less able on T V ~ Fax 0141 2482479.ourtesy of a DynaVox commu

nication aid.appointments coincide The Encephalitis Support Group is continuingStarring Jasper Carrott, anda move to new premises, its work under the banner of The Encephalitisdescribed as offering a fresh'-'with training suite, Society - action for support, awareness andinsight into 21st century life inwith SIGNALONG becom research.Britain, this second series seesof the Open For further information contact the Society at: ~ . ? 4 ~ the Craddock family reacti ng toNetwork, able to The Encephalitis Resource Centrej. L " ~ ~ ~ ' the arrival of a new baby. Whilecourses which carry r - .. - - ~ ~ 7B Saville Streetthe others are bound up with

.- Maltontheir own concerns, Raj sees thecharity sees th s as opening " \ ',"-. North Yorkshirebig picture and, with his longway to significant expansion Y017 7LLC/oc/(wi5e from centre' front Jamil Dhillol1 awaited communication aid, heSIGNALONG training as (Rdj). Ryan (.1rmghr (Perer). Almd Iqbal " Helpline 01653699599(Kav.!a . Na'alid Keery F .h., (5"1" and , can now have his say. Admin Line 01653692583be able to franchise Roben G>rM (Leo). DynaVox distributors Sunrise Fax 01653 604369to suitably qualified Medical say their aid was chosen against strong competition because it was so www.encephalitis.infoeasy to programme and create new vocabulary. Jamil Dhillon, who plays Raj,w.signalong.org.uk commented, "I was surprised how easy I found the DynaVox to use. It's real Atasic Scotland can be found atly simple, I only had to be shown how to use it once or twice and then I just 1, Prospect 3~ - ""-'-. worked the rest out fo r myself." Sunrise Medical's David Morgan added, "I Gemini Crescent y , ~ . . . . . . - .. 1.. . . am really pleased that the DynaVox communication aid will be seen on -'. j Dundee Technology Parknational TV in a normal family environment. For too long we have treated Dundee DD2 lTY~ - ~ people with any sort of disability as someone to be stared at - perhaps this Tel 01382 561891'\.' --1"- initiative will promote better acceptance of people who have the need for.. Fax 013B2 568391...'. ... products like these." Helpline 08453 55 55 77I. Pro""" and Thelmil Gro1t..J:;;" www.afasic.org.ukww.dynavox.co.ukSPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
http:///reader/full/www.abilitynet.co.ukhttp:///reader/full/www.abilitynet.co.ukhttp:///reader/full/www.abilitynet.co.ukhttp://www.standards.dfes.gov.ukjethnicminorities/http://www.standards.dfes.gov.ukjethnicminorities/http://www.standards.dfes.gov.ukjethnicminorities/http://www.ican.org.uk/http://www.stroke.org.uk/http://www.stroke.org.uk/http://www.stroke.org.uk/http://www.stroke.org.uk/http://www.stroke.org.uk/http://www.encephalitis.info/http://www.encephalitis.info/http://www.encephalitis.info/http://www.signalong.org.uk/http://www.signalong.org.uk/http://www.signalong.org.uk/http://www.afasic.org.uk/http:///reader/full/www.dynavox.co.ukhttp:///reader/full/www.abilitynet.co.ukhttp://www.standards.dfes.gov.ukjethnicminorities/http://www.ican.org.uk/http://www.stroke.org.uk/http://www.encephalitis.info/http://www.signalong.org.uk/http://www.afasic.org.uk/http:///reader/full/www.dynavox.co.uk


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news & comment

gaps with autism spectrum disorders and their fami

are still falling between the gaps when it comes tothe National Autistic Society found that

with autism and Asperger Syndrome don't fi tways of thinking about disability or the eligi

used to measure support needs. The mainless able to access support are peopleas 'high functioning', those in the transition

with the lowestof respondent

training .Rights in Reality, How people with autism

are still missingon their rights. From the NAS, wwwnas.org.uk.

tipspart of Alzheimer's Awareness Week, the

top ten tips for simplethat might protect against dementia:

smokeof saturated fat and salt

regular exercisein moderation

plenty of fruit and vegetablesoily fish once a week

your GP check your blood and cholesterol levels- wear a helmet for cycling and

boxan active social life with outside interests and

Do a daily crossword puzzle

National Patient Safety Agency has widened itsto include an allied health professionals project

a former podiatrist at the helm.of patient safety among the allied health

ls and will work with staff groups to developrole of the National Patient Safety Agency is to

safety of NHS clients by promoting a cultureto

to support this.

Trustannouncedare being created

to bring together children's social, educationservices into a single local structure.

idea is that money and staff can be pooled and inforshared to offer better support and protection.

initial wave will be funded for three years and manyalso involve partners from other statutory agencies

voluntary sector. They vary inand scope, with some focusing on particularly vul

such as those with disabilities.

Avr il Nicol l ,Editor

33 Kinnear SquareLaurencekirk

tel/ansa/ fax0 1561 37741S

e-mailavrilnico ll@speechmag .com

... comment. .. An e.nqu ri ngmlnaWhat makes a good evidence based practitioner?Nina Soloff (p.25) would approve of the fact that I am already asking aquestion. Patricia Sims (p .20) asks even more, and Paula Leslie & Pauline Meek(back page) also believe that, "Curiosity or, to use a technical term, nosiness"is a vital quality for research and practice.There is a danger in an NHS world where protocols and risk managementpredominate that we lose our sense of wonder, and become unable to seethe wood for the trees. Combining research with practice is an excellent wayto appreciate how we can bring about evidence based change in our way ofworking, as staff at the Speech & Language Therapy Research Unit (p.26) andthe London Connect Centre (p.27) have found. Thinking out of the box is avital quality for research and practice.In her final sociological perspectives on inequality article (p.16), Sarah Earlecontinues to give us points to consider and act on from a wide range ofdisciplines. Open-mindedness is a vital quality for research and practice.When what starts of f as a question leads on to an investigation - whatever itsscientific value - the way that the results affect your practice can take you bysurprise. Guet Lee (p.21) has picked holes in her survey of perceptions ofpeople who don't stammer compared with those who do. Nonetheless, theprocess has proved to be a valuable therapeutic tool. Seeing the positives is avital quality for research and practice.In reality, of course, research is never finished. Yasmin Shah (p.4) has a goodterm for this - 'work in progress' - and she has had to keep going and adaptaccording to the latest changes foisted upon her. In our new column, "Here'sone I made earlier" (p.?). Alison Roberts transforms simple, low-cost materialsand ideas into fun activities. Ongoing flexibility is a vital qual ity for researchand practice.Linda Armstrong & Helen McGrane (p .8) wondered if an off-the-shelf packagedeveloped in London was flexible enough to be effective in a rural area.Although there were logistical problems and final numbers were small, thebenefits were clear, and they suggest ways of improving uptake in the future.An ability to problem-solve is a vital quality for research and practice.Family, friends and colleagues of Lisa MacLaren Page will still be asking thequestion "why?" following her untimely death and unfortuna tely on thisoccasion there are no answers. Lisa was a valued subscriber to this magazinefor five years since her student days, and the research she carried out withSarah Heneker (p.12) demonstrates to me that she was a sensitive, reflectiveand methodical therapist - vital qualities for research and practice.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 3
http://www.alzheimers.org.uk/http:///reader/full/www.npsa.nhs.ukhttp://www.dfes.gov.uk/mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.alzheimers.org.uk/http:///reader/full/www.npsa.nhs.ukhttp://www.dfes.gov.uk/mailto:[email protected]


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work in progress

a In view Even when enthusiasm, cooperation and support

from the top are available, changing a culture isn'tYasmin Shah reports on the successes and what

is still to be achieved following the introduction of aInteraction progralTlme to aDay Opportunity

SeNice for people with severe learning disabilities.


aretrainingchangeamulti-

. ~ wo different but crucial needs areoften identified by speech andlanguage t erap iSTs:1. the need fOf organisations to takeon board therapy programmes - to'own' them -fOf successful outcomes .2. the limited speech MId language

therapy services allocated to meet the needs of service users with speech and languag interventionrequirements.Finding ourselves in this situatio , e developeda Focused Interaction project wh-ch com binesIntensive Interaction and Ind- 'dualiied SensoryEnvironment work.

Intensive Interaction as desaibed by Nind &Hewett (2001, p.vi) is, 'A spe


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~ In progressservices and is committed to

for service users. In the day opportunitytwo sessions are run daily, led by Day

or Sen ior Day Centre Officers.staff are generally assigned to those servicewho have more complex needs and have

support. In this day opportunitywork with one servicethe morning, and another in the after

. Sometimes care staff are assigned to supthe running of sessions.

Focused Interaction programme developeda referral for three service users who

skills. These service users, Larry, Nina andopportunity service daily.

assessing the three referred service users, itthat they would benefit from an

to developwith other people,

that using an Individualised Sensory

Figure 1 Record form used in Focuse d InteractionName of client -Name of staffDate Location ._-_..DID THE SERVICE USER ..Give eye contactRespond vocallyInitiate vocallyReach I look towards youFollow or move away from youUse facial expressionsUse meaningful sounds(This means sounds I words that can be translated,for example "Oi" meaning "Come here!")Show anticipationShow they wanted moreTake turns with you in activityWhat happened? (Describe the sequence)

What do you think was important about thissession?

How did it feel to you?

would beof building up more.

aware of the need for therapy toas often as possible, and by

who were familiar to the serviceGiven that much time is spent

to deliver a programme,fo r carers to leave or be re

that as the speech andoften is difficult to

model of service delivery to.

the therapy needs of thesewith the manager, and suggest

for effective intervention, aof staff needed to be trained

1998; Nind & Hewett, 2001) . We then developedour skills through role-play with each other andobserved each other working with one of the designated service users. Della later attended a training day in Intensive Interaction but we did notwant to wait for the formal training before wewere able to launch this project.

We felt that both objective measures of the service users' responses and subjective impressions ofthe staff needed to be recorded, so we designeda form that we hoped would be easy and clear touse. This combined elements of forms developedby Nind & Hewett (2001) and Bunning (1996).

Della and I then delivered staff training. Thiscons isted of a formal training session,presented three times to cover all participating staff, as well as session leaders.Including session leaders was part ofinvolving all levels of staff in the projectso that they would be able to support thestaff who were carrying out FocusedInteraction. Within the training sessions

My rolewould be todesign theprogramme,train all staff,and tosupport staffon a regularbasis

opportunity service staff personMy role would be to design the programme,

to support staff on a regularas well as the day opportunity service pro

. The manager was most supto work with me on this project.

user-friendlyto keep things as simple and user-friendlyThe idea was that the programme

sive Interaction and then,of the service users as well as those of

staff developed, Individualised Sensorywould be introduced. Much time

spent on Intensive Interaction, partly for staffworking directly with Larry,

without using any equipment. Ifound that people can easily focus on equip

the service user., much time was spent with the designated

to teach her whatis and why it works. This was

by readings (Bunning, 1996; Irvine,

both knowledge and experiential skills were developedthrough listening, observationand role-play.

Following the formal stafftraining session, Della or Isupported the staff as theyworked with Larry, Helen andNina. Staff were asked tospend at least ten minutesmorning and afternoondoing Focused Interaction,and to then fill out the recordform. We felt that stipulatinga minimum t ime would resultin more success than specifying a longer period . We alsohoped that, as staff became

more comfortable, they would naturallyspend more time doing FocusedInteraction, and that the style of theirgeneral interactions with these threepeople would shift. We also tried toschedule a formal meeting with staffevery six to eight weeks to discuss anyissues and to share our experiences.Project has changedFocused Interaction has now been running in theday opportunity service for ten months. The formof the project has changed quite considerably.

Initially, more than 10 staff were involved. Wefound that some were more comfortable workingin the Focused Interaction style than others. Wealso found that staff were reluctant to fill ou trecord sheets. The feedback from staff meetingswas positive overall . Staff felt that they were seeing changes in Helen and Nina, and this wasencouraging. Some feedback was also critical - forexample, some staff expressed their v iew thatthey felt it was childish to mirror behaviour.

Della and I responded to the feedback by1. redesigning (with staff input) the record fo rm to

make it simpler to understand and to use (figure 1).



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work in progress

staff to fill out a simple questionnaireexperience using Focused Interaction

giving them the opportunity to withdrawThe five staff who returned

questionnaire wanted to stay in the project.our staff group then stood at five, but allcomfortable delivering Focused

felt that they could see theof it.to be more present with

core group of staff. It became The support service I This means that thethat, without our regular trained core group of staff only

they felt they were of the day work with Helen and Ninain a vacuum, and perhaps when they relieve the contractopportunityto decreased motivation ed agency staff. Staff pointed

delivering Focused Interaction . out in one of the group meetservice managerand ings that this would reallyencouragement. This meant that I impact on Focused Interaction.has been awork with whoever was When staff worked all morning

Focused Interaction when I critical enabling with Helen or Nina, they could

more confidence'. Helen is also signing 'want' torequest an object during Focused Interaction withjust a minimal prompt.

These are highly significant shihs for both Helenand Nina, attributable to their participation in theFocused Interaction.Things have recently changed again. All individual support workers are being supplied by an

agency. And Larry no longerattends the day opportunity

at the day opportunity service and Della would do so during the week. factor.

the skills of staff further.videotaped ourselves working

Helen and Nina and later reviewed thesewith staff. The video camera was also

to record staff as they delivered FocusedThe recordings were later reviewed

identify areas of good practice as well as toby the staff on their skills.

now, five day opportunity service staff wereFocused Interaction. Della

I continued to try to support staff regularly,were not able to do so as ohen as needed. We

that staff were not delivering Focusedas ohen as we had asked and hoped

This was partly explained by staffing shortwithin the day opportunity service as staff

or took summer annual leave.and Helen have continued to make slow

subtle changes. Both young women haveattending the day opportunity service for

years. Nina used to become quite agitated,would butt her head against her chair and

others. She would leave group areas freShe is now calmer, head butts and

less and stays in group settings, toleratbeing close to others far more. It is also clear

she is engaging more with others both durFocused Interaction sessions and outside

them. This engagement is demonstrated byto staff and looking at, or in

direction of, staff.has}lways been more responsive to oth

than Nina and at home would talk to herbut her language was not reported to be

that is, she did not use speech toquestions or to get her needs met. At the

opportunity service Helen rarely used herspontaneously, and never in a functionally

manner. Now she occasionally saysname of the staff member she is with when

Focused Interaction, sings Iines ofand is reported by her mother to, 'have

choose their time to do FocusedInteraction. Perhaps more significantly, the relationship thathad developed between Nina

and Helen and the staff would obviously be affected now that they were only to spend ten-minuteperiods together.Back to the drawing boardSo again it has been back to the drawing board .We have also analysed the forms with respect tofrequency of delivery of Focused Interactionexpressed as a percentage of sessions in whichFocused Interaction was delivered per month.The res ul ts were disappointing. We have beengetting return rates of 13-51 per cent per monthfor the nine months that the data has beenanalysed, this in spite of the positive changes inthe skills of Nina and Helen. We have shared withthe day opportunity service manager the problems of delivering Focused Interaction only inbreak times, and also the poor rate of delivery.

The plan now is that all the agency staff will betrained in Focused Interaction through tw o formal sessions and support to the individual agencystaff. The delivery of Focused Interaction will bewritten into their contract and the manager willdiscuss this with the agency manager. In addition,all staff in the day opportunity service will be keptappraised of Focused Interaction through updatesin weekly staff meetings. Della and I will also support staff in delivering Focused Interaction. I willdo so weekly and Della one to three times perweek.

This project continues to be 'a work in progress'.It is very exciting to see how two service users aremaking clear gains as evidenced in increased tolerance of others, decreased challenging behaviour, increased use of words, and the develop ment of use of a single sign to communicate arequest. The qual ity of life experienced by bothHelen and Nina has been enhanced.Unfortunately Larry, the other service user, is nolonger at the day opportunity service.

Critical enabling factorThe support of the day opportunity service manager has been a critical enablin g factor. He hasfreed up a staff person to coordinate the day-today run ning of the programme and has made itkno wn to all staff in the day opportuni ty servicethat this work is important a d needs to be carried out. He has also sent the coordinator to betrained in Intensive Interaction, an conti nues tobe supportive as evidenced by ping nto placemeasures to ensure that th e pro gramme ofFocused Interaction is delivere!L

Another key factor has been that both Della andI have needed to be flexible and responsive tostaff and also to the needs of the day opportunityservice as changes happen. his has meant, andco nt inues to mean, considerable time on a constantbasis for the weekly support of staff, collection andanalysis of records, and regular staff meetings.

We also have to just go wi th the flow of all thathappens in the day opport nity service.Personally I am taking a ve ry long ie . I hopethat over the next year or so som e of he hiccupswill be ironed out so that this programme will runsmoothly and an increased numbe of serviceusers will become involved.

Eventually I envisage that this programme willbecome part of the fabric of service delivery at the dayopportunity service, without the intensi e involvement of speech and language therapy services.Yasmin Shah is Senior Speech and LanguageTherapist, Advisor in Cha llenging Be aviour, withthe Community Learning Disab il ity Team, Speech& Language Therapy Department, East KentCoastal Primary Care Trust.ReferencesBunning, K. (1996) The rinci p les of an'Individualised Sensory Environment'. Bulletin ofthe Royal College of Speech & LanguageTherapists 52, 9-10.Irvine, C. (199B) Addressi 9 e Ne eds of Adultswi th Profound and Multiple ea rni ng Disabilitiesin Social Services Provision. In: Hewett, D. & Nind,M. (eds) Interaction in Act ion - Reflections on theuse of Intensive Interaction . London: DavidFulton.Nind, M. & Hewett, D. (2001 ) Practical Guide toIntensive Interaction . Plymouth: BILDPublications.

Reflections Do I have a clear vision to worktowards? Do I see changes that arebeyond my control as a barrieror a cha lIenge? Do I provide training in a

variety of ways to maximise itsimpact?



9/32

here 's on e I made earlier ...

DVDs/ PlayStation/ txt and chat-rooms may be all the rage/but speech and language therapists will forever be inneed of low-cost ideas for flexible therapy activitiesand materials . Alison Roberts/ who suggested thiscolumn/ kicks off with some gems of ner own.I I I IHere's one Imade earlier.

dicefo.r COditfSa!lO(, bAddrvrg in grOlAt'l5or~ r m i r ~

10cm deep foam (safer than wood)indelible ink pen

into 10cm cubes (I

face of one of the dice write a- who, what, where,

(You could w rite otherclasses such as adverbs and

other cubes, fo r use inr games.)

practiceTake turns to roll the dice

ask another member of thewith the word

face of the dice.You could develop this - as I do - by

ng' alongside photo-cards of people/ activities, and

up questions to ask them. I also have a'a ien' who sometimes sits in

and is asked questions; the groupto think what its response would be.

. The question dice is alsofor MA KATON practicestaff training days.

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Naiisworth, Gioucestershire.


Spin the bottleThiS ~ I p e ofaCfflli j rfiU$t he the best lJalueejlcr lIS p O < ; l b d i f f e Ol/U irmile hi U,O() f

! . J -" ...ili1()9,(lonol1 ClV;!A 'I cos/) Ylext 10 101Y1lrgMaterialsv 1 empty plastic bottlev sheets of sticky labelsva table with a

forgivi ng surfaceArtistryWrite the labels appropriately fo rwhat you are working on. It could ~be categories, in which case youwou d need to write the different categorieson the labels, and stick them in a large circleon the table .In practice1. Your clients sit around the table and taketurns to spin the bottle, naming things inthe nearest category pointed to by thebottle when it stops.2. You could write or illustrate words fo rsign language practice. I ha ve used thisgame for 're-bonding' a group after alongish break. The labe s I wrote were"Since last time I've been to ... ""Since la st time I've met...""Since last time I've learnt. . ""Since last time I've made .. ""Since last time something that was on thenews... "" Since last time something that changed forme was... "

~ e ~ 1 , , , ~ p ' orlarelai-tYlitY


10/32

replica ti on

if you w ant to support carers further use video as a therapyto ol understand uptake ofyour service

'Supporting Partners of Peoplewith Aphasia in Relationshipsand Conversation' (SPPARC)was developed in London and

is a proven method ofimproving interpersonalcommunication. But can itspositive findings bereplicated in a rural areawhere distance and populationfigures are so different?Linda Armstrong and HelenMcGrane investigate.

upporting Partners of People ' i Aphasia inRelat ionships and Conve rsation (SPPARC) (Lock et ai,2001 ) brings together very successfu lly two threads ofspeech and language therapy for people with aphasia carer support and conve rsational analysis, Carer supportha s been an integral part of the rna agement of aphasiafor some t ime now . Conversat iona l analysis is a relatively

new concept in aphasia therapy but has alre ady ~ shown to be aneffective techni que for the assessment and anagement of acquiredlanguage problems (Wilkinson et ai, 1998).In SPPARC , he conversational partners of pei>p e . h aphasia areincluded in 0 separate group programmes, eoch ru ning once a weekfor eight weeks. SPPARC can also be prov ided 0 a - ,,-to-one bas is.Althou gh t e effectiveness of the programme IS proven, it cannot be

pres umed that ' will be eas ily implemented in a r -a l area, particularlywh ere there are small population centres, as rba a rural areas pro vide many different challenges in service pro isi n. r roject aimed toinvestigate hether this method of impr oving irrrerp..,dfSOn al communication coul d be replicated in our rural area. We v e pleased to findthat it could , although the number of carers we rea( as small andwe identified a num ber of logisti cal problems for co "de ation if theprogramme ere to be repeated in our area .

Discussion of possible group participan ts withspeech and language therapy colleagues

Familiarisation with the programme Decision re : location of project groupS

Weeks 7-14 Eight-week support programm e Video recordings of person with aphasia and

partner Analysis of videos

Weeks 15-22 Eightweek conversational training prog rammeWeeks 2328 Second video recording

Analysis of videos Project report

Information and supportWe allocated 28 on ce week ly sessions for prepara ' ni ng andreporting of the project (table 1). The first half o _ rogramme provides the pal1icipants with information and suppo 'or exa mple onstroke and aphasia, and has been demonstrated by the programme'sauthors to be a necessary precursor to the seco nd ' . lD( and her colleagues fo und that, follo wing a stroke, the conversa :' al style of thepartner often changes in an attempt to adapt t co mmunication situation, for example they may adopt a more tea( e -therapist'style of con ersation and try to correct speech SO!) rors, even whenthe message is clea r. The second group programm e is sp-e


11/32

set of sequential selection exclusion criteria was established to helpcarers would be invited to part icipate in the pro

'Carer' here means a family member or friend who regularlyin conversation with the person with aphasia (it does not

of the person with aphasia). The speechin our adult service evaluated each client oncase load for the client's and their carer's suitability for inclusion.

the time of this audit, the adult ser- Changes include, totalled 174 clients. The fo r example,of this exercise are shown in table 2, conversationallists the criteria and the number of partners asking fewercarers who did not meet each. Eleven per cent of the clients yes-no questions and

carers were suitable for inclusion . engaging in fewerease of delivery of the pro 'repeat after me' , its excel lent resources and exchanges.

as with all groups, to try to overcome .

89 per cent of our caseload was not suitable (see table 2). In19 carers were invited to participate in the programme. From table

with a range of medical(a). As our adul t service also includes a ther

with a commitment to voice, this number may be disproportionto adult services that may be neurology-based .

other main reasons for exclusion were those stroke clients whonot dysphasic (mainly clients with dysphagia only) (b), followed byof carFr (c) or the carer not being fi t for participating in the pro

(d) . Other reasons fo r exclusion were that the person withwas very unwell (2); the carer was not motivated to participate

and language therapy (2); the aphasia was so mild that it didaffect conversational ability (1); the person with aphasia had multi

(2); and one person with aphasia was very new toto be assessed.

the programmethought that two groups would run. We had envisagedwas

10 Criterion description No. failingcriterion (%)

Medical diagnosis of 110 (63.2%)cerebrovascular accident (in theabsence of head injury, dementiaor other progressive illness)Has dysphasia (plus other 18 (10.3%)communication or swallowingdiagnosis)Has a carer 8 (4.6%)Carer able to participate 8 (4.6%)physically, cognitively andemotionallyCarer able to commit to 16 3 (1 .7%)two-hour sessionsCarer able to travel, if necessary 0Any other reason for unsuitability 8 (4.6%)for SPPARC

1SS(89%)

participate in SPPARC. Ten responded that they were interested andable to attend. Tab le 3 shows their relationship to the people with aphasia.

Table 3 Initial parti cipantsRelationship Perth group Blairgowrie groupHusband 4 1Wife 2 1Partner 1Daughter 1TOTAL 6 4

Unfortunately, half of the Blairgowrie group carers had to withdrawfor family reasons before thei r group began and so it was cancelled . Thespeech and language therapist whose geographical area includesBlairgowrie tried to offer the programme on an individual basis to thetw o remaining possible participants, who lived 30 miles apart, butfound it could not be done within her usual service delivery pattern.Two of the Perth group participants had to withdraw during the programme because of personal or family illness.

repl

planned for the main populat ion centre in our area (Perth) where an initial group of six carers could participate. Being a city, it was not difficultto identify suitable premises, and we arranged to locate the group inthe local Association of Voluntary Services building in the afternoon.We planned to run the other group in a small rural town (Blairgowrie)in the morning. Finding a suitable venue for this took some more ingenuity but a local GP's surgery was the final choice. During this search, areferral was made fo r a past client, so 20 carers received an invitation to

While a nine-to-five programme fits in nicely with a speech and language therapist's remit, it does not suit many carers who may be themain 'bread-winners' or full-time carers of the family. This was highlighted in criterion (e), where tw o carers were excluded as they wereknown to be in full-time employment and a third was the main carer offour young children . Again this cropped up as the main reason for thefive ' invited' carers who were interested but not able to participate, asthey worked or for other reasons could not commit to a daytime programme. Unfortunately, at the time of the project, this problem couldnot be specifically addressed.

The wide geographical distribution of potential participants fo r ourmainly rural service is 2500 square miles. The possible distances to betravelled to a speech and language therapy event are vast compared toa city-based programme. In some households the person who survivedthe stroke was the only driver, with the carer being left without privatetransport. A rural bus service is obviously less frequent, may not bedirect to location and, with greater distances to be travelled, incursexpense of time, energy and money (often by older people) . From ourown experience of SPPARC, this was a de-motivating factor fo r someparticipants. There are several possible solutions to the problem of distance and transport: if group numbers were larger, we could position groups as near as

possible to the participants' homes - but it may be difficult to findsuitable premises and, practically, it is very difficult to get sustainablegroup numbers in rural areas

prior to the programme beginning, we could find out if people withprivate transport can give lifts to those who do not have transport

if we had funds, bus or taxi hire could be arranged or we could use avolunteer driver scheme

in years to come, the greater availability of telemedicine could help.The current solution is to locate the group in the largest urban area,with best public transport links.



12/32

repl ication

integral part of the programme is a videothe person with aphasia and

carer, which is made before and after contional training . This is then used as person

of good conversational strategies andmay be adapted to facilitatetwo-way conversation. Only two

the carers (and their partners) were willing toso, for us, this was the least

of the programme delivery. A furtherwas with the actual recordings that were

For one dyad, for example, we felt that thewas not representative of the conversa

of the couple. Instead of the usualthe video recording showed a

of test questions. To improvise we decideduse the programme's many video clips of people

aphasia and their carers, instead of personclips . The participants found these very usefulconsolidating the materials with 'live' examples.

the recordings that were made wereused as part of the individualised training, we

able to use them as training for ourselves in. This analysis would also be used as a

of effectiveness. The checklists are veryand we found that our individualvery similar, so we felt quite secure

the reliability of our observations.point of view of the del ivery of the pro

, the detailed session plans and handoutsan excellent resource, which has not had

be adapted . The materials are clear and wellSPPARC really is an 'off-the-shelf' procould probably be run in conjunction

experienced speech and language therapy.

the final number of carer participantsonly four, for them it was a new andworthwhile experience as reported in

their written evaluations throughout the programme (half-way and final reviews of bothparts). Not all carers were able to attend the Perthgroup every week, as they also had unexpectedhealth and other family problems/commitments.However, their return to the group following res-olution of these crises indicated the importance ofthe programme to them. The evaluations wereunanimously very positive about the benefits ofSPPARC and about the concept of them beingtogether as carers to share experiences: ' .. even though we were learning we could also

laugh (very important).' 'I have found out lots of things I didn't know

about.' ' ..we all had similar experiences.' 'Yes I have really enjoyed it, as we have all been

able to discuss our partners' difficulties.'

Carers' groupAs a result of this project, a monthly evening carers'group has been piloted for the carers who attendedthe Perth group as well as for those carers whoare unable to attend sessions during the day. Aspeech and language therapist was responsiblefor both the administration and facilitation of thegroup. This group has been evaluated very positively by the carers who attended (mainly two of thePerth group carers and two younger carers who hadbeen unable to attend that group) and a proposalhas been made for funding so that it can continue.As the numbers remain very small, the proposal isfor a group for carers of people with any acquiredneurological communication impairment, and forstaffing to include a speech and language therapyassistant (to undertake the group's administration)and a speech and language therapist.

Discuss ion 's taking place about the programmewith local speech and language therapy colleagueswho work wi t h children with autism. Although the

programme materials are quite specific to strokeand dysphasia, its framework has the potential tobe more widely applied in speech and languagetherapy.Linda Armstrong is employed by Tayside PrimaryCare NHS Trust and is based at the Speech andLanguage Therapy Department, Perth RoyalInfirmary. and Helen McGrane at the School ofSpeech and Language Sciences, Queen MargaretUniversity College, Edinburgh.AcknowledgementThe Speech and Language Therapy Departmentof Perth and Kinross Local Heal an d Social CareCo-operative thanks the Che s Hea rt and StrokeScotland for funding th s project.ReferencesLock, S., Wilkinson, R. & Bryan, K. (2001)Supporting Partners of People with Aphasia withRelationships and Con versat ions (SPPARC).Speech mark Publishing: Bicester.Wil k inson, R., Bryan, K. & Lock. S. e al (1998)Th erapy using conversation a alysi> : helping coupl es adapt to aphasia in conversation.In ternational Journal of Language &Communication Disorders 33 (Supplement).

Reflections Do I offer a service that is flexible

enough to meet t he needs ofpeople with comp lex r5pon sibili ties? Do I look at wh y people may not be using my service and work to wards so lut ion s? Do I adapt programmes to suit the nature of the location?

Training directoryIf you are looking for counselling and psy-chotherapy related train ing in the UK , the19th edition of the British Association forCounselling and Psychotherapy's Directoryincludes over 1200 courses .

Grandpa's had a strokeThe Stroke Association has produced a leaflet to he lp childrencome to terms with family members who have had a stroke.A spokesman said, ot only does it explain to chil dren whata stroke is, in easy to understand terms, but it also t eac esthem that it is oka y to be scared." people, the Foundat ion eople withFor a copy of Gran dpa's had a stroke, tel. 01604623933 .raining in Counselling and Psychotherapy 11-----------------------11 Learning Disabilities has shed twoDirectory 2003, [19, tel. 0870443 5172 or

order online at www.bacp.co.uk. Proud Owner of a Speech__ E 5 i I B ! ! ! ! ! ! ! I ! ! ! ! ! ! ! ! ! ! ! ! ! : : : : ! ! ! ~ ! I C I I ! ! ! 5 ' " 1mped imentMac' versionTopologika have released the early language pack Speaking for Myself for Apple Macintosh. An updated Windows version Speaking for Myself 2 will be released early in 2004. Prices from 34.95 + VAT for a single user. Available for Apple Macintosh OS 8.5 and above (including OSX in Classic mode) and Windows.

Author Tom Cribbin, ho has cerebral palsy, wants to inspirereaders with this book by demonstrating that all peoplE haveability despite their d isabilities. Using humorous or emo ionaJanecdotes to emphasise his points, he says that the t itle ofthe book is about an attitude which not only helps impro ehis speech flu en cy bu allows him to regard his spee ch in alighthearted way.[8.94 inc. airmail pos ting from Canada, for details e-mail

See www . t o p o l o g i k a . c om . t h oma s [email protected].

information booklets to sllJIport theirmental health and e ellbeing.The booklets draw d ire

See www.learningdisab - - OI9..tJ .

Meeting emotionalneedsAs young people w ith lea . disabilities are four times as likely to experiencemental health problem as ot young

see p.1 e ResourcesSPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
http:///reader/full/www.bacp.co.ukhttp:///reader/full/www.bacp.co.ukmailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.xn--learningdisab-i9-1k05b/http://www.xn--learningdisab-i9-1k05b/http://www.xn--learningdisab-i9-1k05b/http://www.xn--learningdisab-i9-1k05b/http://www.xn--learningdisab-i9-1k05b/http://www.xn--learningdisab-i9-1k05b/http:///reader/full/www.bacp.co.ukmailto:[email protected]://www.xn--learningdisab-i9-1k05b/


13/32

P.W., Belafsky, P.c.,J., Mattucci, K.F. & Ditkoff, M. (2003) The asso

with thin liquids. Otolaryngol Head Neck128 (1) 99102.

The study goal was to evaluate the associationsensory deficits, pharyngealand the prevalence of aspiration with thin

STUDY DESIGN AND SETIlNG: We conducted a204 consecutive patients undergoing

endoscopic evaluation of swallowing with sensoryand an assessment of pharyngeal motor function

squeeze). Patients were divided into 6 groupson the results of sensory and motor testing in

Subjects were given 5 ml of thin liquid,the prevalence of aspiration in each group was com

RESULTS: The mean age of the entire cohort was 65female). The prevalence of aspiration in patients

sensation was 2% (3 of 137)with intact pharyngeal motor function and 29%

7) when pharyngeal motor function was impaired (P


14/32

on line observ at io ns

ISwant to

improve functionalcommunicationstaff identify andmaximise all

communicationopportu n tiesclarify your role

The Picture ExchangeCommunication System(PECSTM) aims to teach

individual users to initiatecommunication.Sarah Heneker andLisa MacLaren Pageinvestigate the

effectiveness of introducingthe approach to wholeclasses within a school.

Sarah writes, "Sadly, sincethis article was written, Lisa

died as a result of a roadtraffic accident. Lisa was atalented and dedicated

speech and languagetherapist and friend to thewhole team. She will begreatly missed. This al'ticle

is in her memory. /I

unctiona communication:

PECSTM is a system that aims to teach spontaneouscommunication (Frost & Bondy, 1994). The abilityto initiate communicative exchanges is paramountfrom the outset and this is achieved by the studentexchanging a symbol of a desired item in order toobtain it. This system has been rapidly introducedinto a number of locations in which we work .

A local school for children on the autistic spectrum undertook an extensive programme of stafftraining in PECSTM and set out to integrate the sys-tem into their school day. They decided that, inaddition to individual PECSTM programmes, theywould offer two groups of children an entirePECSTM environment.

'Group l ' began in September 2000 andinvolved all the children in a specified class. Theentire environment was set up to facilitate theideas of PECSTM . Parents received support andadvice from class staff around the use of the sys-tem at home. 'Group 2' began in January 2001and involved a smaller group within another class.Just prior to this, class staff and parents of thechildren within the group attended a formalPECSTM training course.

We wanted to evaluate the impact that intro-ducing PECSTM had on:1. the amount that the children were

communicating,2. the functions of the communication,3. the methods of communication,4. the level of adult support needed to achieve this.Figure 1 Commun ica tive parameters obse rved

We wanted to be as non-intrusive as possiblewhilst encompassing the whole communicativeenvironment in our evaluation . We thereforechose on line observations, watching the childrenin their everyday environments. The data was co llected through interval recording which involvedthe use of a dictaphone to prompt the therapistwhen to begin and cease observation periods .The four different contexts in which the children

were observed - 'free play', 'snack', 'swimming'and 'structured teaching' - were adapted fromWood et ai 's study (1998) . 'Freeplay' and 'swi mming' were defined as 'unstructured', where theadult's attention on the children was variable,thus providing opportunities for attention gaining. 'Snack' and 'structured teaching weredefined as 'structured'. Within 'snack' the communication opportunitie s were highly predictable(for example, choice making), whilst within 'structured teaching' communication opportunitieswere less predictable as the nature of the sessionsmake them more variable.We designed an observation schedule and all

observing therapists were trained to ensure consistency. There were two observation phases: baseline follow-up.Each child was observed fo r a total of one

hour and four minutes over all contexts. Thecommunicative parameters we observed are infigure 1.

Level of cueing t Function ofcommunication Method ofcommunication Manner inwhich adult'sattentionwas gained

Adult'sresponse Level ofpromptingneeded toexchangesymbol

Physical Prompt Requesting Physical Not None None Model Question Presence ofObject I Event Presence ofListener Contextual andInteroceptive

Greeting Rejecting Commenting Labelling Responding Anticipating

Object Gestural Symbol Vocal Gesture andVocal Symbol andVocal Symbol andSigning

PhysicalPrompt Environmental Spontaneous AlreadyGained

Explained'NotPossible' Actioned

PhysicalPrompt GesturalPromptSpontaneous

tThe continuum used to observe the 'level of cueing' was based on that devised by Halle (1987) in hisresearch on spontaneous language.

12 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003


15/32

e imgact of PECSTM 1in years 1 to 3 (age range 6;08 to

out in2000 when PECSTM had been recentlyAt baseline the group's communica

skills varied - few used any clear words andmain method of communication was physical

as leading the adult to the item or trying toto a required item),

out 10 months later, Wefor each part of

evaluation:Amount of Communication (Total Number Communicative Acts)

changed by the following amounts: BASELINE FOLLOW-UP

-

12 21- - - , - - - - ~ - - - -9 20

26 22 - - - - ~ - --- ;--15 29the Total Number of Communicative

during swimming decreased at follow-up,children were using more sophisticated forms

communication and needed less prompting toso,Function of Communication

was the main function at both

line, 'commenting', 'greeting '

At follow-up, the use of these functions haduse of them across situations

to have generalised,

Method, of Communicationbaseline this was generally symbols, At

of communication'symbols' ('snack' and 'structured teaching')

felt the high occurrence of the use of symbolsof no symbols

e duri ng swimming) was due to theof the use of PECSTM,

In all but one context ('freeplay'), symbol useincreased, Children's spontaneous use of symbolsvaried at follow-up - some would seek out theirPECSTM folder spontaneously, whereas otherstended to need prompting, The children wereoften using their most effective form of communication within the given situation (for example,if they were playing a joint attention game withstaff, then using physical, gestural or vocal meansappeared to be most appropriate), and this issomething that we strongly advocate,4. Level of support needed

The 'Presence of an Object or Event' remainedthe main level of stimulus to which the childrenwere responding for al l activities,

The children did not show an increase in spontaneously gaining the adult's attention, and thisremains a key area to focus on, However, they didappear to have learnt the importance of needingsomebody's attention before communicating withthem, The children showed a striking increase inthe number of attempts they made to communicate following the adult giving the child theirattention (from 48 per cent to 88 per cent),

The children learnt the process of exchangingsymbols over the period of observation, At baseline, the children generally either did no texchange the symbol, or required a physicalprompt to do so, At follow-up, the children werespontaneously attempting to exchange the sym-bols in 95 per cent of cases, This, however, did notalways result in a successful communicativeexchange, as the adult's attention had not alwaysbeen gained first.

Group 2Group 2 consisted of children in years 4 and 5 (agerange 9;04 to 10;10 at follow-up), Baseline wascarried out in January 2001, Prior to this, PECSTMhad been used solely within snack with no generalisation observed, Children were receiving structured PECSTM teaching sessions at phases 1 to 3(see figure 2) during the baseline observationweek, At baseline the group had a stock of spoken words or phrases, but their functional use waslimited,

Follow-up was carried out six months later, Aswith group 1, we have highlighted the key findings fo r each part of our evaluation:1. Amount of Communication (Total Numberof Communicative Acts)

This changed by the following amounts:

- BASELINE FOLLOW-UPFreeplay 1 - - - ~ - -5SnackSwimming

8I

163 11 --,Structured teaching 16 I 10

Although the Total Number of CommunicativeActs was observed to decrease in 'structured teaching' at follow-up, the students were being taughtthe more independent skills of commenting forthe first time, and this may have had an impact onthe amount of communication observed,2. Function of Communication'Requesting' was the main function at bothbaseline and follow-up,

(In addition, at follow-up, 'commenting' was evident in 'structured teaching' as it was being taught.)3. Method of CommunicationOver the period of observation, the children wereobserved to move towards using more formalmethods of communication across all contexts,

The children were also increasingly using a combination of methods at follow-up (such as 'physicaland vocal' or 'physical and gestural') even if theywere not always using symbols, Symbols were notalways readily accessible during all activities forthis group,

Symbol use increased in 'snack' and in 'structured teaching', During 'swimming' no symbolswere available during either baseline or followup, In 'freeplay' use of symbols remained thesame, The children's spontaneous use of symbolsvaried at follow-up - some would seek out theirPECSTM folder spontaneously, whereas otherstended to need prompting,

Figure 2 Phases of PECSTMPhase 1 Identifying a reinforcer and

teaching picture exchangePhase 2 Increasing spontaneity and rangePhase 3 Introducing th e concept of choicePhase 4 Introducing sentencesPhase 5 Responding to the question,

'What do you want?'Phase 6 Commenting in response to a

question



16/32

o n l ine observations

Level of support needed'Presence of an Object / Event' remained

to during 'snack' and 'swimming .for 'freeplay', responses became

'Presence of a Listener' as the level ofto initiate communication.

'structured teaching', responses became less'Presence of an

t' to a 'Question'. This appears to bethe children were being taught the com-

ime.data showed an increase in spontaneously

ring 'snack' andNo major

was observed'teaching', but the chl'ldren

appeared to show less frustrati on and were ableto accept that they could not always have whatthey had asked for. When us ing symbols, we oftensaw them waiting patiently if the adu lt was notable to give them their attention immediately.

Group 1 communicated more at baseline thangroup 2 and made more progress in relat ion toNumber of Communicative Acts, but we mustacknowledge that the time between baseline andfollow-up wa s longer. We also need to be sensi-tive to the fact that group 1 were younger children who had had less experience of communication breakdowns than group 2. This supports theneed for early intervention.

This study gave us the opportunity to observePECSTM being used with a whole class group andin all situations versus a sub group. For us, this has

clarified the importance of thewhole environment be ing con -

Sarah Heneker and Lisa Ma cLaren Page arespeech and language therapists working forNorth Surrey Primary Care Trust.For further information, please contact Sarah at:Speech and Language Therapy Department,Bournewood Resource Centre, North SurreyPrimary Care Trust, North West Surrey TherapyServices, Guildford Road, Chertsey, Surrey, KT1 6OQA. Tel: 01932 722866 E-ma il:sarah [email protected] .AcknowledgementsWe would like to express our thanks o staff and stu dents and Freemantles School in Chertsey, Surrey.

ReferencesHalle, J. (1987) TeachingLanguage in the NaturalEnv ironment

already gained not, the use of such an approachwere uSing more in the studythe entirety of the facilitates staff to identify and Handicaps 12.ducive to PECS TM Irrespective of An Analysis ofwhether children use PECSTM or children involved Sponta neity. The Association

for Persons with Severe

- soph isticatedp.'free play' forms ofbe a less communication

consequently, thext in which the and needed

less liketo be communica less prompti ng

for Group 1, the to do soin this group

learnt the processexchanging symbols. At ba seline, there was-up, spontaneous exchange occurred on aver-96 per cent of the time fo r all interact ion s

in communicationwas an

increase in the number of communicatives made and that Group 1 (who had been

PECSTM for four months longer than Groupshowed an increase in the range and quality of

of Communication. Symbol usemore formalised methods of communication

and children showed a greater awareof the importance of having somebody's

,efore communicating with them . Theobserved to use PECSTM with

and not with their peers .fact that The Presence of Object / Event

level of stimulus in order tois an interesting observation. A fur

identify whether this iscase 18 months on , and for which

tive functions.we noted that,

ma ximise all communicative Frost, L.A. & Bondy, A.S.appeared topportunities. (1994) PECSTM The PictureExchange CommunicationChallenges for the show less System Training Manual .future Wood, P., Clarke, M. &

We have many challenges for the frustration and McConachie, H.R. (1998) Thefuture . Communication is a CASTLE Projectprocess that is dynamic in nature. were able to Communication Aids andIt is therefore important that Speech and Languageopportunities continue to be Therapy in the Learn ingccept that theyidentified and set up to provide Environment. Schoolcould not alwaysommunicative environments in Observation Procedure.which the children are able to Copyright PWood, Instituteconsolidate, general ise and of Child Health.ave what they

expand the skills that they havelearnt. To achieve this, staff need to had asked for Resourcescontinue to constantly think aheadand plan for future communicativeopportunities and ensure that sufficient symbolsare always readily available.

Speech and language therapists have an ongoingrole wit h the introduction and implementation ofPECSTM. Thi s should include:1. Advising on the communicative env ironment

and monitoring vocabulary and languagelevels .

2. Stressing the importance of the developmentalsymbolic hierarchy to ensure that children areworking at a level where they are successful,moving towards a higher symbolic level asappropriate. This may mean working at anobject level before moving onto the higherlevel of symbolism.

3. Ensuring that communication is multi-moda .PECSTM should be considered alongside, andnot to the detriment of, other communicationsystems .

4. Ensuring that care is taken to movemethodically through the PECSTM phases, at anappropriate pace for the child, general singskills at each level before mov ing onto the next.

Further information aboutPECSTM (including courses)

from Pyramid Educational Consultants UK Ltd,Pavilion Hou se, 6 Old Steine, Brighton BN11EJ, tel.01273609555, www.pecs .org.uk.

Re ections Do I have an organisedapproach to observing clients? Do I evaluate therapy in termsof the amount, functions andmethods of communication and

the level of support needed toachieve this? Do I give clients the

opportunity to practise using the most effective form of communication fo r a given situation?

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.pecs.org.uk/http://www.pecs.org.uk/http://www.pecs.org.uk/http://www.pecs.org.uk/http://www.pecs.org.uk/mailto:[email protected]://www.pecs.org.uk/


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Areato

services.

new s extra

disabled person."Parkinson'salso how the person affected can be supported to inter- The report also highlighted a drastic shortage of carethe world around them. homes, meaning that families are being split apart asadvisoryMS Trust believes the survey findings also have J2J individuals are forced to move out of their area toPa rkin 'i(ln"swith other chronic medical groups take up the only available options.John Grooms is using the information toThe Parkinson's Disease Society has establishedwith multiple sclerosis shape its future services and to calion oth

Advisory Groups throughout England in an effortUK . The MS Trust is celebrating its 10th ers to take up the challenge.improve services for people with Parkinson's and their carers. A summary and full copy of the report is avail-Each of the eleven groups will have representatives with spe-Information Needs of People with Multiple able from the John Grooms National Office cialist skills and experience from health and social services, asis available from the MS Trust, tel. ring supporter services on 020 7452 2121,well as service users . The groups will aim to champion thee-mail [email protected] .uk. wwwjohngrooms.org.uk.cause of Parkinson's across their area and to ensure thedevelopment and improvement of localslams Meeting four times a year, each advisory group will

be led by the Society's Community Servicesservice SupportManager for that area.www.parkinsons.org.uk from the start

and language therapy student who is also a vol Three sets of linked guidelines for professionals aim to cre-for the Dysphasia Support Service in Stockport is calling ate stronger partnerships between parents and education,

cutbacks in the service to be reversed. health and social services providers.says that the The guidelines, published by the government in England inNHS Primary Care Trust is refusing to fully fund the shortfall of the Dysphasia Support association with voluntary bodies, advise professionals on

work which in recent years had been met by the Stroke Association. As a result, the ser- how to provide family centred services with access to the latorganiser has had her hours cut by half, reducing the number of times groups can meet and est advances in health technology. The authors hope they

of two centres likely. Regular group meetings at a stroke rehabilitation unit will break down the barriers to early identification and. Louise says that the cutbacks are also affecting the number of home ensure that children receive effective support.

total number of clients receiving services, leading to lengthy waits and a growing Together From the Start, from the Department for Educationand Skills and the Department of Health, promotes a more

on commented, "Stroke patients are losing out yet again and it will have a coordinated, family-centred approach to multi-agency working.other services. We are disappointed that the primary care trust could not Developing Early Intervention I Support Services fo r Deaf

to continue funding the dysphasia support work, especially as Children and their Families is from the Department forers and stroke patients generally value the service so highly." Education and Skills in conjunction with the Royal National

"We are encouraging PCTs to invest more in stroke services, not less, because Institute for the Deaf, and is designed to assist local educationwill make it even more of a authorities dealing with the ramifications of Newborn

for people affected by stroke. There are 300,000 people at anyone time cop Hearing Screening.with disabilities as a result of stroke and it is well-established that less would have had to Right From the Start Template comes from SCOPE and a numberwith disability if more patients had access to specialised stroke services. of other voluntary bodies and professional organisations

the financial difficulties, to continue working with the with the backing of the Department of Health. It coversto develop a comprehensive stroke service." breaking news of disability and promotes a culture of

Walters would like to hear from anyone experiencing similar cutbacks in other areas, respect for children and parents..com. tel. 0161 442 7460. The guidance is at www.dfes.gov.uklsenl.

with experience of working with children who are on the autistic spectrum? for Education Service is compiling a database of speech and language therapists with an interest in autistic spec-

disorders. Information on this database will be made available to people with autistic spectrum disorders and their families. The service provides information and support to enable parents who have children on the autis tic spectrum to get the most appropriate educational provision for their

. We aim to empower parents and enable them to make informed choices and decisions about their child's education. to be included on this list please email [email protected] .uk Please title your email 'Speech and Language Therapist'. write to Advocacy for Education Service, 393 City Road, Islington, London, EClV 1NG.

S informationbe improvedprovision at the time of diagnosis of mUltiple sclerosis is better than it

to be but there is considerable scope for improvement according to recentsurvey funded by the MS Trust used qualitative and quantitative

with 11 focus groups involving 103 people and a questionnaire completpeople with multiple sclerosis . Specific recommendations have beenas a result of the findings. Firstly, information should be developed for threemunities - people with multiple sclerosis, the general public (including

of those affected) and service providers. Secondly, informationbe provided in an appropriate and positive way that takes account of the

needs and motivates them to take action. Finally, appropriateneeds to be created and provided both for the time of

address the disease itself

Where.do G\.,",ohn Groomsyou think W Ol k ll ' 'J WI1I1 clisabl fl ri peopl eyou're going?A comprehensive review of the current and future needs of disabled peoplehas been described by the John Grooms charity as a damning indictment ofBritain in 2003.Funded by the Lloyds TSB Foundations fo r John Grooms, Where do you thinkyou're going? concluded that a number of factors are leading to increases in thenumbers of disabled people and yet services are not being provided at a speedto match this. One example is long-term support for premature babies as theyreach adulthood. The charity said, "I t is only in the last 20 years that we haveseen hope given to those babies; but adulthood fo r them and their families pre

sents the reality of unsuitable housing, inflexible care and a lack offacilities to support the need for independence of that young

http://www.parkinsons.org.uk/http://www.parkinsons.org.uk/http://www.parkinsons.org.uk/http:///reader/full/Where.dohttp://www.parkinsons.org.uk/http:///reader/full/Where.do


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and cui r .an unequal powerM

odern Britain is culturally diverseand most recent figures suggestthat the minority ethnic populationincludes 4.6 million people, or 7.9per cent of the population (ONS,

2002) (see table 1). It is widely acknowledged thatspeech and language therapists (and all otherhealth professionals) should be sensitive to the cultural needs of various minority ethnic groups.However, Holland & Hogg (2001) have rightlyidentified that, whilst health professionals areencouraged to do this, there is a definite lack ofleadership within the health care services on suchcultural issues.Table 1: The UK Popul at ion by ethn ic grou p, April 2001

PercentagesPercentage Percentageof total of minoritypopulation ethnicpopulation

White 92 .2 nfaMixed 0.8 11 .0Asian or Asian British Indian 1.7 21.7 Pakistani 1.3 16.7 Bangladeshi 0.5 6.1 Other Asian 0.4 5.7 Black or Black British Black Caribbean 1.0 13.6 Black African o.g 12 .0 Black Other 0.1 1.5 Chinese 0.3 4.2Other 0.6 7.4 Not stated 0.2 nfa All minority ethnic 7.6 100.0 population All population 100 nfaSource: ONS (2002)It is useful to begin by defining what we mean

by the terms 'race' and 'ethnicity'. The term 'race'is commonly used and usually refers to genetic orphysical variations between groups of people skin colour is a good example of this. However,soc iologists pre fer to use the term 'ethnicity' as thisrecognises the socially constructed nature of 'difference'. Sociologists usually agree that ethnicity

refers to a common ancestry, a particular geographical territory, and those who share a language, religion and social customs (Fenton , 1999).Other indicators of ethnicity might include diet,name and nationality.HeterogeneityIt is important to recognise that minority ethnicgroups are not homogenous, and that there is agreat deal of heterogeneity, including differencesof socio-economic status, gender and age,amongst others. More recently, sociologists havehighlighted how the term 'ethnic' usually refersto those in minority ethnic groups, rather thanthe 'White' majority. However, Pfeffer (1998)argues that the term 'White ' is unhelpful as it caninclude people of Irish origin and Jews, amongstothers, reflecting a rather diverse range of needsand experiences. Defining ethnicity is complexand there is no universally agreed classification.However, the most recently recommended classifica-tion for ethnic identification can be seen in figure 1.

Figure 1 Classification of Ethnic Groups n BritainWhiteBritishIrishOther WhiteMixedWhite and Black CaribbeanWhite and Black AfricanWhite and As ianOther MixedAsian or Asian BritishIndianPakistaniBangladeshiOther AsianBlack or Black BritishBlack CaribbeanBlack AfricanOther BlackChinese or Other ethnic groupChineseOther ethnic groupSource: ONS (2002)In spite of the difficulty of defining ethnicity

and measuring differences between ethn icgroups, research studies time and again demonstrate wide-ranging inequalities .

Surveys have consistently shown that the healthof most minority ethnic groups is significantly

AUTUMN 2003


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co v er story : inequal i ty series ( 4 )

that of the general population. The research with Black and White stu However, it is important to beIt should beSurvey for England (DoH, 1999) dents in the United States, they cautious when considering culrecognised that thethat Pakistani and Bangladeshi men are argue that White people are more tural differences. Ahmad (1994)to four times more likely to describe thei r likely to perceive Black people's therapist is always argues that minority ethnic cultures

as 'bad' or 'very bad'; Black Caribbean speech negatively: as loud, ostenta are often demonised as 'wrong'in a position ofas likely. The same survey tious, aggressive, active and argu or 'bad' in comparison to thosepower relative tothat Pakistani and Bangladeshi men and mentative. This is relevant to thera of the so-called 'White' majority.

Black Caribbean women, are most pists because, as they argue, speech their client. Studies also demonstrate that,to report suffering from cardiovascular dis- style stereotypes exist' not on Iy to within education, children from

conditions (for example, heart attack, stroke, describe "what is" but to prescribe "what should minority ethnic groups feel devalued, and assump-. Indeed, Bangladeshi men report rates of be'" (Popp et ai, 2003: 317). Figure 2 lists points to tions are often incorrectly made by teachers, based

disease that are 70 per cent higher consider in relation to ethnicity and language. on perceived cultural 'differences' (for example, seeof the general population. Rates of dia Brah & Minhas, 1983).Figure 2 Ethnicity and languag e: points to co nsideralso significant with Bangladeshi men Other theorists suggest that it is impossible to wh y children from minority ethnic groups understand the experiences of minority ethnicsix times more likely to may be either over or under-representedrt this cond ition (DoH, 1999). groups without considering structural factors andwithin your case load;is relevant to ask if speech that an analysis of culture alone is inappropriate

services for adults plan for (Smaje, 1996; Karlsen & Nazroo, 2002) . In generalhigher incidence of stroke in people from some

whether you expect English to be thedominant language; terms, people in minority ethnic groups are more

. There is some evidence to likely to be socially excluded; that is, they are whether you perpetuate racist speech more likely to be living in poverty, to be unemstyle stereotypes.an inferior service from the NHS compared ployed or in low -paid employment and are moreservice received by others. Torkington (1991), Understanding ethnic inequalities is complex likely to have a lower standard of living than the

that there is a lack of knowl and there are several perspectives. One explanation general popu lation (ONS, 2002). Indeed, NazrooNHS staff of the conditions that suggests a genetic component. Traditionally, this (1997) argues that material deprivation probably

affect people from minori ty ethnic groups. explanation has been used to explain differences in accounts for most of the inequalities betweenalso show evidence of levels of IQ, although this has been widely discredited. ethnic groups and Karlsen & Nazroo (2002) argue

and racist discrimination, leading to poorer More recently, theories of genetic variation have that experiences of racism and perceptions ofcare (for example, see Bowler, 1993). been used to explain differences in the prevalence racist disc rimination are also strongly related toand privilege can be mediated and perpet o f some health conditions, for example, diabetes, inequality. In other words, many sociologists suggest

2001). Indeed, hypertension and sickle cell disease. However, Braun that it is not ethnic culture and identity per se& Jones (1999: 530) suggest that language has (2002) argues that our knowledge of the history of which leads to inequality, but the marginalisation

social realities, populations and thei r identities and affiliations is of people in minority ethnic groups.discourses, and representing particular too vague and incomplete to make such an asser- There is no single explanation that can accountbe overlooked, nor tion , and furthermore that, for ethnic inequalities and it is likely that there

is not surprising, therefore, that 'the current emphasis on genetic explanations rei- are multiple factors. A recent study of languageen from minority ethnic groups are often over fies racial and ethnic classifications by reinforcing development in West African children (Law,

in referrals to speech and language the notion of biological difference rooted in 2000), for example, demonstrates that delays in(Law, 2000), although it is difficult to assess genetics . This reification leads to stigmatization of speech and language may be related to stress,

how widespread this is. There is also evidence racial and ethnic minorities and to research strate- unemployment, financial worries, immigrationsome areas, minority gies that divert attention from status, as well as the influence of cultural beliefsbe under-represent It is important confronting the multidimensional and expectations, which place high expectationsn relation to the overall population ways in which racism, not race, on children .to recognise1999) . influences patterns of disease.' Speech and language therapists clearly need tothat minority (Braun, 2002: 160). be aware of cultural differences that may affectethnic groups This implies that other factors practice. Clients from some minority ethnic back

English is the language must contribute to the patterns of grounds may differ in relation to language, reliare notin Britain, inequality that can be found with- gious beliefs, and beliefs about health, illness andhomogenous,language use is extensive in healthcare, education and else- disability; these may all influence compliance andand that there isprobab ly underestimated. Pugh where. adherence to treatment. Similarly, the therapist

(1999) argue that mistaken a great deal of needs to be wary of stereotyping clients accordingabout Dynamic and changing to so-called ethnic categories, recognising bothheterogeneitylanguages and that minority Cultural variations between ethnic homogeneity across ethnic groups and hetero

issues may be oversimplified in practice . groups are often thought to account for a wide geneity within groups. e x a m p l ~ of this was noted by the Royal variety of inequalities. Sociologists regard culture as It should be recognised that the therapist is

of Nursing (cited in Holland & Hogg, a set of beliefs and

speech & language therapy in practice, autumn 2003

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