speech & language therapy in practice, winter 2002

7/28/2019 Speech & Language Therapy in Practice, Winter 2002

1/32

Seeing the light:PECS appealI L L U M I N A T I N G P R A C T I C E

ISSN 136

WINTER

http://wwwspeechmagco

EarlyinterventionDoing itwith EAZe

ICU-TalkA can do attitudeto research

Unemployableorunemployed?

Working withaphasia

In myexperienceA frameworkby consensus

NEW SERIES

Sociologicaperspectives oninequality

How I usetherapeuti

listening

My TopResourceChild speec


2/32

Win ScallysWorld of VerbsDo you struggle to find meaningfulmaterial for working on verbs withchildren? Then get in on the actionwith Scally, a little alien who hascome to earth to learn English -and been adopted by TopologikaSoftware and its special needsconsultant Bob Black.

Scallys World of Verbs can beoperated by a variety of inputdevices - switches, touch screens, Intellikeys

- so that it is easily used by young children and those withdisabilities. Scally acts out more than 400 verbs, and there arefive activities to get children thinking about verbs in differentways.The normal retail price starts at 39.95+VAT, but Topologika hascopies to give away FREE to three lucky readers of Speech &Language Therapy in Practice. To enter, send your name andaddress to Topologika/Speech & Language Therapy in Practicecompetition, 1 South Harbour, Harbour Village, Penryn,Cornwall TR10 8LR. The closing date for receipt of entries is25th January, and the winners will be notified by 31st January.Scallys World of Verbs is available from Topologika Software,

tel. 01326 377771, www.topologika.com.

Win new narrative packsBlack Sheep Press continues its prolific output of photocopiableresources with new narrative resources. So, whats the story?Speech and language therapist Judith Carey, in partnership witha local Early Years Centre, has devised a comprehensive pack ofsession plans, games and activities to promote language skills inyoung children using the principle of Becky Shanks NarrativeTherapy Programme (see review on p.7)Language Through Listening is aimed at children enteringnursery with limited attention and listening skills. NurseryNarrative introduces the narrative skills model to nursery agedchildren, and Reception Narrative promotes further

development and enrichment of language skills at a higherlevel for those of reception age.Black Sheep Press is offering two readers a happy ending - acomplete FREE set of each of the three packs (normal price100+). For your chance to win, send your name and address toSpeech & Language Therapy in Practice - LTL offer, AlanHenson, Black Sheep Press, 67 Middleton, Cowling, Keighley, W.Yorks BD22 0DQ by 25th January. The winners will be notifiedby 31st January.

Available from Black Sheep Press, see www.blacksheep-

epress.com, or telephone 01535 631346 for a free catalogue.

Other new additions are the first set of materials in the Simple

Semantics series devised by Felicity Durham (Identifying &

Describing; Can You Get Home?) and Heavy and Light / Hot and

Cold for the Concepts in Pictures series.

In the Summer 02 issue, Anglian Pharma offered Infa-Dent Gum

Massager / Baby Soft Toothbrushes packs. They were won by

Patricia Broughton, Marion McCormick, Lisa Abba, Mary Cordle

and Mary Wickenden.

The two Speechmark titles offered in the Autumn 02 issue

proved highly popular with you. The lucky winners of The

Sourcebook of Practical Communication were Margaret Purcell,

Sarah M. Harris, Judith Hibberd, Elizabeth Reid and Emma

Gonoud. Feeding and Swallowing Disorders in Dementia goes to

Kay Guthrie, Shona Harvey, Elaine Stickland, Lynn Dangerfield

and Linda Armstrong.

Congratulations to all our winners.

Winter 02 speechmagIn need of inspiration?Doing a literature review?Or simply wanting to locate anarticle you read recently?

Our cumulative index facility isthere to help.

The speechmag website enables you to:View the contents pages of the last fourissuesSearch the cumulative index for abstracts ofprevious articles by author name and subjectOrder a copy of a back article online.

New article

The speech and language therapy contingent inthe tiny Falkland Islands is looking to expand.Pippa McHaffie extols the virtues of small classes,a Flying Santa and sitting amongst hundreds ofpenguins.

PlusThe editor has selected the previous articles youmight particularly want to look at if you liked thearticles in the Winter 02 issue of Speech &Language Therapy in Practice. If you dont haveprevious issues of the magazine, check out theabstracts on this website and take advantage of

our new article ordering service.If you liked...Kathleen Taylor & Claire Besser, try Change andInvolvement - Meeting the needs of carers(Autumn 1997): Pound, C. & Clarke, M. (010) MaryLaw lecture - Less words, more respect: learning tolive with dysphasia and difference, and Denman,A. (011) Carers - Investigating the needs.Sally Poole, see (115) Moore, T. & Irwin, A.(Summer 2000) Making an impact.Lizzie Astin & colleagues, look at (134) Hurd, A. &McQueen, D. (Winter 2000) The right things at theright time.Sarah Earle, what about (153) Earle, S. (Summer2001) Sociology: a sure start.Fiona MacAulay, try (144) Berrie, I. (Spring 2001)Invigorating the wheel.Caroline Bowens My Top Resources, see (020)Ogilvie, M., Stanbury, R. & Williams, P. (Winter1997) How I manage speech sound difficulties.Also on the site - news about future issues,reprinted articles from previous issues, links toother sites of practical value and information aboutwriting for the magazine. Pay us a visit soon.

Remember - you can also subscribe

or renew online via a secure server!

w

ww

.speechm

ag.c

om


3/32

Inside coverWinter speechmagReader offersWin Scallys World of Verbs (Topologika Software)and new narrative packs (Black Sheep Press)

News / Comment

ReviewsMultiple disabilities, phonologicalawareness, anatomy & physiology,aphasia, phonetics, play, epilepsy, music,language development, narrative.

Improvingcommunication with EAZeClassrooms look different. Symbols,

drawings and photos are being paired

with written text to assist children in

accessing the curriculum and their envi-ronment. Some teachers have come to

believe that symbols are a bridge to liter-

acy which can positively impact on the

childrens confidence and self-esteem.

Lizzie Astin, Katie Roberts, Emma Witheyand Melanie Crawshaw take us on a journey into the class-room through an Education Achievement Zone programme.

Communication aninalienable right... working closely with the intensive care unit nurse has

taught me a great deal about these patients and the

effects that having a life threatening condition and a

prolonged stay in intensive care have on the patient. These

in turn affect the patients ability to use an AAC device.

When a person wakes up in the alien environment ofan intensive care unit, they may well feel they havecome from another world - but there is light in theshape of the ICU-Talk device. Fiona MacAulay reports.

Further readingPhonology, Parkinsons disease, voice, community-focused intervention, aphasia.

IN MY EXPERIENCE: Great idea but how do we do it?... we can work across Trusts, with limited evidence

bases, using the wealth of expertise that undoubtedly

exists within our profession - and reach a consensus. Inaddition... a special interest group can be proactive in

developing practical tools and resources for therapists,

enabling us to address the government agenda within

their relatively tight timescale.

Della Money and special interest group colleaguesproduce a consensus framework for developingcommunication strategies to benefit people withlearning disabilities.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002

Unemployable or unemployed?Respondents who had a better understanding of their

aphasia were more likely to be successful in returning

to employment. One ... provided prospective employers

with a summary of her aphasia and strategies that can

be implemented to overcome her difficulties.

As the interaction of many factors influences whetheror not an individual returns to employment, Kathleen

Taylor and Claire Besserdiscover that theprofession needs toshow a bit moreimagination to be trulyworking with aphasia.

Sociologicalperspectives oninequalityseries ()

Class of : anunequal future...children from poorer

backgrounds are seen to

lack the appropriate

environment that is

needed to foster educational success. For example,

children from less affluent backgrounds are the least

likely to have access to constructive forms of play, and

will have poorer access to books, newspapers and the

internet.

Sarah Earle argues that, while we do need to developan individualised, client-centred approach, we mustalso be aware of how wider socio-economic andcultural factors influence our practice.

How I use therapeutic listeningIn the evaluation study the children were reassessed

at the end of the programme and then left for eight

weeks before being reassessed once more. The results

were beyond my expectations: all showed an

improvement greater than one would expect from

maturation. (Dilys Treharne)

Listen up and hear why our three contributors - DilysTreharne (The Listening Program), Dr Colin Lane(A.R.R.O.W.) and Karen OConnor (TherapeuticListening) - wouldnt be without their CDs andheadphones.

Back cover My Top ResourcesIts free, its phonological and its fun! ... the 700 plus

participants enjoy a growing collection of clinical

resources, a therapy ideas file, and a brilliant message

archive full of clinical insights and practical suggestions

(and a few fiery exchanges).

Australian speech-language pathologist and interneticon Caroline Bowen romps through her top tenresources for child speech.

WINTER 2002(publication date 25th November)

ISSN 1368-2105

Published by:Avril Nicoll33 Kinnear SquareLaurencekirkAB30 1ULTel/fax 01561 377415e-mail: [email protected]

Design & Production:Fiona ReidFiona Reid DesignStraitbraes FarmSt. CyrusMontrose

Website design and maintenance:Nick BowlesWebcraft UK Ltdwww.webcraft.co.uk

Printing:Manor Creative7 & 8, Edison RoadEastbourneEast SussexBN23 6PT

Editor:Avril Nicoll RegMRCSLT

Subscriptions and advertising:Tel / fax 01561 377415

Avril Nicoll 2002Contents of Speech & LanguageTherapy in Practice reflect the viewsof the individual authors and notnecessarily the views of the publisher.Publication of advertisements is notan endorsement of the advertiseror product or service offered.

Any contributions may also appearon the magazines internet site.

Cover picture by Paul Reid (posed bymodel). See p.4

IN FUTURE ISSUESUSER INVOLVEMENT ETHICS BILINGUALISM NARRATIVE

ADULT LEARNING DISABILITY APHASIA DYSPHAGIA

CONTENTS WINTER 2002

J

www.speechmag.com

PECS appealDavid ...demonstrated that he

could transfer this skill to other set-

tings. For example, [he] walked into

his brothers room and said, I want

the light off.

Finding a lack of literature on theuse of the Picture ExchangeCommunication System with adultswith a learning disability, SallyPoole starts the ball rolling with astudy of 27 year old Davidsprogress.

COVER STORY


4/32

news


Autism campaigntargets GPsGPs have been targeted in a campaign to raise awareness of autisticspectrum disorders and to promote a helpline to parents.The National Autistic Societys mailing to GPs includes a questionnaireasking them about their experiences of the assessment, referral, diag-nosis and support of clients with autistic spectrum disorders. Theresults will be published next year.www.nas.org.uk

NAS Autism Helpline, tel. 0870 600 8585 (Mon-Fri, 10am-4pm).

Supporting staff

LocumshortageAs the professions staffingdifficulties push up demandfor speech and language

therapists to fill the gaps, alocum agency is reporting ashortage of new recruits.Action Medicals CarolineEvans says, Were speaking toclients from all over the countrywho are desperate for short-term staff, but despite all ourefforts were finding it increas-ingly difficult to help them.Many clients need whole teamsof therapists and the situationis such that they are willing tobe completely flexible aboutthe candidates skills.Locum staff are generallyrequired for short-termassignments such as maternityand sickness cover and wait-ing list initiatives, so areexpected to be highly adapt-able and to enjoy a chal-lenge. Agencies compete forlocums by offering benefitssuch as accident and sicknessinsurance, funding for contin-uing professional develop-ment and high rates of pay.

Action Medical, tel. 01225

447445.

Propeller movePropeller Multimedia, supplierof React and Speech Soundson Cue software, has movedto PO Box 13791, PEEBLES,Scotland EH45 9YR, tel/fax01896 833528.

GetchattingThe national educational charity for children withspeech and language difficulties is sending out achatterbox challenge.I CAN is asking nursery workers, teachers, speechand language therapists and other professionalsworking with young children to take part in thisevent and get children talking. Preschool childrenwill be sponsored to learn and recite a joke, song,nursery rhyme, story, or anything they can, individ-ually or as part of a group to raise money for I CANswork.The charity already runs seven Early Years Centresin England, Wales and Northern Ireland, and issetting up a further seven this year, including twoin Scotland. The centres provide preschool chil-dren with integrated therapy and education plusinformation and training for parents and profes-sionals.Fundraising packs, including a free tape with sing

along songs and a Tesco Baby & Toddler Club

Parent Pack - a step-by-step guide to encouraging

childrens language development, from the

Chatterbox Challenge hotline on 0845 130 3962.

www.ican.org.uk/chatterbox.

Just not good enoughA petition signed by 50,000 people has called on the government tomake stroke care a priority.Only 27 per cent of people with a stroke are treated in stroke units,although national standards state that everyone should have this serviceby 2004. The Stroke Association quotes research showing that every day30 stroke patients die or are left seriously disabled because they are notgetting this specialist care.The National Audit of Stroke Services 2001/02 had news of progress, asnearly 75 per cent of general hospitals have stroke units and 80 per centof Trusts now have a clinician with responsibility for stroke. But blastingstroke care as moving forward at a snails pace, Margaret Goose ofthe Stroke Association calls for the words ofthe National Service Framework for OlderPeople to be put into action.

www.stroke.org.uk

Can you see meat the back?A campaign to ensure all television programmes are subtitled is seeingsteady progress.The Royal National Institute for the Deaf reports that proposedCommunications legislation would enshrine legal minimum subtitlingstandards for all forms of television, including digital, cable and satel-lite. The organisation is continuing to press for assurances on the qualityof editing, colour contrasting and descriptions of noise effects, and isbacking research into the preferred speed of subtitles for deaf and hardof hearing people. It also hopes to see an increase in subtitles on DVDsand at film screenings, and is calling for improved access to arts and cul-ture for deaf and hard of hearing people following a report which con-demned the majority of the UKs top arts and tourist attractions foreffectively excluding them.RNID Information Line tel. 0808 808 0123, text 0808 808 9000.

Cleft lip and palate geneScientists have identified the faulty gene which can cause Van der Woude, a syn-drome accounting for two per cent of babies born with a cleft lip and palate.About a third of all cases of cleft lip and palate are syndromic. In the case of Vander Woude, the childrens other physical problems tend to be missing teeth and apit in the lip. Much of the DNA detective work in this research was based on twinsin Brazil, one born with Van der Woude syndrome

and one without.The researchers hope there will be immediate benefitto affected individuals and families, especially ingenetic counselling and postnatal diagnosis.In the longer term they believe the dis-covery could lead to antenatal treatmentand a better understanding of why andhow cleft lip and palate occurs.The research, funded by Action Researchand the Wellcome Trust, has been pub-lished in the journal Nature Genetics.

The NHS needs to prepare for increasing reliance on its non-professionallyqualified support staff.According to research commissioned by the Institute for Policy Research,there is a need for agreement on the future role, training and regula-tion of this diverse group. Research Fellow Rachel Lissauer said, Theippr wants to see the future structure of our health workforce based onhow best to meet patients needs. We anticipate a significant role forsupport workers in providing elements of direct patient care. But if thecurrent neglect of their training needs and status continues, professionalstaff will remain unwilling to let go of their responsibilities or tasks.Support Staff in Health and Social Care: An Overview of Policy Issues by

John Rogers, see www.ippr.org.uk.

www.actionresearch.org.uk / www.wellcome.ac.uk


5/32SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002

news & comment

Illuminatingpractice

Dark mornings and evenings make us yearn for the blue skies of summer, when

motivation is easier to come by. But, never fear - Speech & Language Therapy in

Practice is here with the fairy lights to brighten your winter days!

Our How I section (p.24) turns the spotlight on therapeutic listening. We have all

dealt with clients who make slow or even no progress, and where we cannot see a

way forward. Proponents of The Listening Program, A.R.R.O.W. and TherapeuticListening find their approaches light the way sufficiently for their clients to be able

to benefit from other, more specific strategies.

Lack of motivation to communicate was the main barrier to progress for the young

man in Sally Pooles shining example of a case study (p.4). Through combined use of

the Picture Exchange Communication System and a widening of opportunities to use

the skills he has, his carers see flickers of true communication.

The 1995 Disability Discrimination Act was meant to break down barriers and herald a

new dawn for people with disabilities in the workplace, including those with aphasia.

Through in-depth interviews with clients, Kathleen Taylorand Claire Besser (p.18) shed

light on the reality, but also offer bright ideas for how things could be improved.

Fiona MacAulayand colleagues (p.12) also show a real flare for research that will

benefit clients. In the light of huge developments in computer hardware and software

they set out to develop a high tech device to assist intubated patients emerging from

unconsciousness into the harsh beams of an intensive care unit. While not the usual

subject matter for this magazine, the process involved a high degree of collaboration

and responsiveness which is relevant to all client groups and therapy.

Collaboration was the key to Della Moneyand colleagues (p.16) achieving their

glittering prize - a consensus framework for developing communication strategies to

benefit people with learning disabilities. Enthusiasm could have been dimmed by all the

challenges such as a short timescale and lack of an evidence base but the networking

opportunities of a special interest group ensured light at the end of the tunnel.

Phonology and internet icon Caroline Bowen (basking in the Australian sunshine) is a

networker extraordinaire. She sparkles in our back page top resources which includes

her take on Magic Lantern shows for consumers.

Lizzie Astin, Katie Roberts, Emma Witheyand Melanie Crawshaw(p.8) have workedtheir own magic in Bridgwater, coming out of the shade into the full glare of the

classroom through an Education Achievement Zone initiative. The benefits of health

and education working together can be clearly seen even in how different the

classrooms look. Unlike most therapists, these authors work with whole classes rather

than caseloads. In the first of our new sociological perspectives on inequality series

(p.21), Sarah Earle enlightens us on the influence of social class and suggests this kind

of approach allows us to tackle social exclusion more effectively.

Like a laser beam, Speech & Language Therapy in Practice authors get straight to the

point, illuminating practice and providing flashes of inspiration without leaving you

blinded by the light.

...comment...Avril Nicoll

Editor

Kinnear Square

Laurencekirk

AB UL

tel/ansa/fax

email

avrilnicoll@speechmagcom

Forum for childrenA national network forum for providers ofchildrens services aims to share and spreadgood practice.In particular it is focusing on involving youngpeople and education services, developing asingle assessment process, strengtheningchild protection, clarifying accountability

and ensuring appropriate links with youthjustice. Through the Local GovernmentAssociation website the network will publish aseries of discussion papers and case studies.www.lga.gov.uk

Neurologists neededThe Encephalitis Support Group has urgedmembers to contact MPs to raise awarenessof the need for more neurologists.The Group is backing a report from theAssociation of British Neurologists showinginequality and a lack of specialist treatmentthroughout the UK. They are calling for anincrease in the number of neurologists from350 to 1400 over the next ten years to providea round the clock service across the country.A member of the Neurological Alliance, theGroup is also one of the organisationsinvolved in the production of a report inconsultation with people who live withneurological conditions and their carers.Speedy access to high quality neurological,rehabilitation and community services is calledfor, along with a care plan, access to a keyworker and annual review to achieve a coordi-nated, seamless, patient-orientated service.

Acute Neurological Emergencies in Adults,

free from the Association of BritishNeurologists, tel. 020 7405 4060, e-mail

[email protected]

Levelling Up, 5 (12 for organisations) from

the Neurological Alliance, tel. 020 7793 5907,

e-mail [email protected]

www.esg.org.uk

Media StarsTechnology is opening up new possibilitiesfor communication and distance learningfor deaf students.A UK television distribution and videoconferencing system, MediaStar, has beeninstalled in every classroom and computerworkstation at the Junior High School 47 -School for the Deaf and Hard of Hearing inNew York. This allows deaf students tocommunicate using American sign-languagewith their colleagues and across the UnitedStates and internationally with other deafstudents using similar facilities.The schools director of technology said theynow plan to use the technology fromBerkshire company Cabletime to broadenour students horizons, teaching them newmedia skills which they might not otherwisehave the chance to develop.

www.cabletime.com


6/32

Opportunities in the communityDavids mother wanted immediate one-to-onespeech and language therapy input for him. I

explained that no input would be offered untilDavid could start accessing some day services. Thereasoning behind this was to ensure there would bea key person to carry out work with David outsidehis speech and language therapy appointments andto give David opportunities in the community topractise any skills learnt in the sessions.Funding for specialist outreach supportwas agreed and a one-to-one workerfrom a specialist autism service joinedDavid for three days each week. Theaim of this support was to help Davidaccess community services. Speech andlanguage therapy input was thenoffered in the form of fortnightly ses-sions with David and his support work-er. Following her mothers wishes,Davids sister accompanied him to allsessions and therefore became involvedin the speech and language therapy input also. Ichose the PECS approach with the aim of develop-ing Davids ability to initiate communication as wellas his spontaneous speech and eye contact.

STAGE 1 Identifying a reinforcerThe first step of PECS is to identify a reinforcer,something that the person finds motivating suchas a biscuit or ball. A symbol (photograph, pictureor line drawing) of the reinforcer is obtained. Theperson is asked to sit opposite a communicationpartner and a physical prompter is seated behindthem. The reinforcer is put in front of the person,

just out of their reach. As the person reaches forthe reinforcer, the physical prompter puts the sym-bol into their hand and supports them to put itinto the open palm of the communication partner.As soon as the symbol is handed over, the commu-nication partner rewards the person by givingthem the reinforcing item. They also give verbalreinforcement and praise by saying for example,Oh, you want a biscuit. Good! or by verbalisingwhat the person would have said: I want a bis-cuit. Good! (If the person imitates what you say,

then verbalising what they would have said can

help with problems related to pronoun reversal atthis stage.) Some communication partners alsorespond by labelling the item, as in Biscuit.Good! The person must be given the reinforcerimmediately after they hand over the symbol.Once the reinforcer is received they can then eatthe item if it is food, or hold it if it is an object suchas a ball. If biscuit is being used as a reinforcerthen small pieces can be given rather than wholebiscuits. The prompts are gradually reduced so

that eventually no physical prompteror open hand prompt by the commu-nication partner is needed.

David was introduced to stage 1. Atthe beginning symbols were used asrecommended by PECS and the writ-ten word was printed underneath aswe knew David was able to read the

word. The first reinforcer used was afood item. Initially a physicalprompter was needed to supportDavid to reach for the reinforcer butthis was gradually reduced until the

physical prompter was no longer needed. The ver-bal reinforcement given was, I want a biscuit.Good! This was chosen due to Davids echolaliaso that if he imitated the words then problemsrelated to pronoun reversal would be avoided.David was very quick to learn what to do and aftera short time started to say the name of the rein-forcer while he was exchanging the symbol for it.

STAGE 2 Spontaneity and rangeStage two involves increasing the spontaneityand range. The distance between the personand communication partner is gradually increasedby moving the communication partner away a lit-tle at a time so eventually the person has to getup out of their chair and walk over to the com-munication partner to get their attention. Alsothe symbol is gradually moved away so the personhas to move to get the symbol and give it to thecommunication partner. The physical promptermay be required initially and the amount of sup-port needed reduced as before. PECS recommendsat least 30 opportunities for exchanges to take

place during functional activities each day. Ideally

cover story


if your clients

lack motivation anopportunities tocommunicate

need structured buflexible support

rarely initiate inter

Read th

PECSappealavid is a 27 year old man with a learningdisability and autism. When I first start-ed working with him, he was living withhis mother and three siblings who wereproviding all his care. He was not access-ing any services and had few opportuni-

ties to make choices in his life or to interact with peo-ple outside his family network. Davids motherappeared to have a strong influence over the wholefamily and was very much of the opinion that Davidwould one day overcome his autism and learn tospeak.

I had just attended a two day Picture ExchangeCommunication System (PECS) course following arecommendation from a colleague. PsychologistAndrew Bondi and speech and language therapistLori Frost developed PECS over 10 years ago. It is astructured behavioural programme first used with

children with autism but now used with adults andpeople with other functional communication diffi-culties. PECS acknowledges that a person may notbe motivated to communicate by social rewardsalone, and teaches them to communicate byexchanging a symbol for a tangible reward that ismotivating for them. I decided to find out if this sixstage programme could help David.

Assessment found that David had an understandingof three key words or more. He had difficultyunderstanding complex sentences, some wh ques-tions and emotions, but responded well to visualinformation such as pictures/symbols and writtenmaterial. David was verbal but at the time ofassessment only used single words or two wordutterances. His speech was mumbled and he usedlittle eye contact or gesture. David had an under-standing of turn taking and would answer ques-tions, usually with yes or by saying single words. Hewas frequently echolalic. David had good numeracyand literacy skills and was able to read and write. Hewould spend time copying and writing out largepieces of text without necessarily understanding themeaning of what he was writing. David initiatedvery little communication, but would occasionallywrite a single word on a piece of paper and give itto someone to look at. He appeared to have littlemotivation to communicate; one reason may havebeen that all his basic needs were being met and he

had little opportunity to make choices.

DPECSacknowledgesthat a personmay not bemotivated to

communicateby socialrewards alone


7/32

the exchanges should be carried out by differentcommunication partners. David completed stage2 without any difficulty.

STAGE 3 Introducing theconcept of choiceStage three involves introducing the concept ofchoice. Two items are offered, a reinforcer and non-preferred item with the correspond-ing symbols. If the person picks upthe correct symbol for the reinforcer,then they get the item. If theychoose the wrong symbol, they getthe non-preferred one. An error cor-rection process is then carried outwhere the correct symbol for thereinforcer is shown and the person is given anotheropportunity to choose the right symbol and obtainthe reinforcer.

Initially there were some difficulties introducingstage 3 with David. He was shown two types offood, one he liked and one we knew he didnt.When offered the symbols representing these, Davidchose the symbol of the reinforcer first and receivedthe food that he liked - but then chose the symbolof the non-preferred item and proceeded to eatthat food too. He continued to choose alternatesymbols. David did not seem to understand that hewas being offered a choice and was confused aboutwhich symbol he should go for, not necessarily tak-ing the one that he preferred. At this point wedecided to deviate from the programme slightly andcreate a more natural environment to practise in.

We devised a group activity making sandwiches.This involved getting all the items needed to

make a sandwich - bread, butter, knife, plate, fill-


cover story

The six stage Picture Exchange

Communication System

recognises that a person may

need more than social rewards to

motivate them to communicate.

Finding a lack of literature on theuse of PECS with adults with a

learning disability,

Sally Poole starts the ball rollingwith a study of 27 year old

Davids progress.

ings and so on - and symbols for each item. Thesymbols were put in front of David and there werethree other people in the room. Everyone tookturns to pick up a symbol and pass it to one per-son who acted as the shopkeeper and was incharge of giving out the food. Each person gavethe symbol of the item they wanted to the shop-

keeper and were immediately rewarded by beinggiven the item and verbal reinforcement as

before. David was quick to learnwhat to do and picked up only thesymbols of the items he wanted andhanded them to the shopkeeper,clearly indicating his choice from theitems available.

This activity proved to be successful.Having practised this several times, we

decided to try using just the word rather than thesymbol and the word - and David did not have anydifficulty with this.

STAGE 4 Introducing sentencesWhen a person is able to exchange about 20 dif-ferent symbols, the idea of using a whole sen-tence is introduced. The person is taught to makea request using a whole sentence. A sentencestrip is created. At the beginning are symbols rep-resenting I want..... and a space is left at theend where another symbol can be added to com-plete the sentence. As the person reaches for thereinforcer, the physical prompter supports themto attach the symbol of the reinforcer to the endof the strip to complete the sentence and handover the complete sentence strip to the communi-cation partner. The communication partner says Iwant..... a biscuit because they are reinforcing

what the sentence says to the person.

Stage 4 was introduced to David. A sentence stripwas created using written words rather than sym-bols. The sandwich making activity was repeatedbut this time using whole sentences. David was

able to say the whole sentence when exchangingfor each item and demonstrated that he couldtransfer this skill to other settings. For example, inMcDonalds he spontaneously said, I want applepie and on another occasion walked into hisbrothers room and said, I want the light off.

STAGE 5 Responding to questionsIn Stage 5, the person is taught to respond to a ques-tion such as What do you want?. They are taughtto respond using a whole sentence as before: Iwant...... The same technique is used as in stage 4and the person is supported to complete the sen-tence strip and hand it to the communication part-ner. We carried out this stage with David using thesandwich making activity and he was able torespond to a question using a whole sentence.

STAGE 6 More sentencesStage 6 involves introducing a different sentence,I can see.... For most people this is less motivat-ing than I want... as there is no reward at theend. We practised this as a group activity, lookingat magazines and taking it in turns to point tosomething and say, I see.... adding the name ofthe item to the end of the sentence (for example,I see...... a blue sock.) David was able to do thisduring the session but was not observed to usethe sentence spontaneously.

At the end of stage 6 we agreed the key workerwould take responsibility for continuing to use PECSwith David and supporting him to use the sentenceshe had learnt in the sessions. We made some minia-ture sentences for David including I want..... and Isee...... These were put on a key ring that he couldkeep in his pocket and refer to as a visual aid

.Communicating spontaneouslyAt the end of the programme, David was using moreeye contact than he had done before starting, andseemed more aware that he needed to direct arequest to another person to communicate success-fully. He started communicating spontaneously

using more than a one-word utterance, for example

in McDonalds hespontaneouslysaid I wantapple pie

David ...demonstrated thathe could transfer this skill

to other settings. Forexample, [he] walked intohis brothers room and said,I want the light off.


8/32

cover story


saying, I want the light off. David started usingmore speech and initiating communication throughspeech rather than writing things down on paper.He also began to answer questions with an appro-priate answer rather than being echolalic or saying

yes. His sister reported that David seemed moreaware of other people - for example, he would offerhis food to share with her - and that he appeared tohave developed confidence in communicating withnew people. It is likely that this was due to a com-bination of using PECS and the increase in opportu-nities available to him. David seemed more moti-vated to communicate than previously. As well asthis he seemed pleased when he received praisefrom his family following his attempts to use speech.

One of the benefits of using PECS is that it is astructured programme with discrete goals at eachstage. This is helpful for families and carers, as theyare able to see progress as the person movesthrough the stages. The stages can, however, beadapted for individuals, as we did for David at stage3 to make it more like a real life situation.

David is one of the more able clients that I haveworked with. Despite this, this programme took overa year to complete. It is likely that someone with agreater degree of learning disability will take longerto reach each stage and may never be able to movebeyond the first or second stage. In addition successwith this programme, as with many others, is highlydependent on it being carried out regularly. The pro-gramme resulted in some positive effects in terms ofDavids communication, however maintenance anddevelopment of skills is dependent on someone takingresponsibility for continuing the work once speech

and language therapy is no longer involved.One year since closing my involvement, Davids sis-

ter is still encouraging him to use PECS, David hasstarted receiving one-to-one input from a different

organisation and we areawaiting a new referralfrom them around howto support David todevelop his use of PECS.It would be interestingto hear from other peo-ple who have used PECSwith adults with learn-ing disabilities and formore information to bepublished in this area.

Sally Poole is a speech and

language therapist work-

ing in a community

healthcare team for adults

with learning disabilities.

ResourcesFor further information about PECS (including courses)please contact:Office: 17 Prince Albert Street, Brighton, BN1 1HFTelephone: (01273) 609555Website: www.pecs-uk.com

E-mail: [email protected]

o I ensure thatients are receiving

ufficient backupom other servicesefore offering themherapy?o I follow tried and

ested formats in a

way which respondso individual need?Do I consider writingp my implementationf a particularpproach with aient?

eflections

MUSICGO WITH THE FLOWApproaches to CommunicationThrough MusicEd Margaret Corke

David Fulton PublishersISBN 1 85346 843 6 15.00This book suggests using music in imagina-tive ways to go with the flow of clientswith severe and profound learning difficul-ties and is inspired by the IntensiveInteraction approach.The text clearly describes a framework todevelop social communication skills withgood guidelines for facilitators and a help-ful trouble-shooting section. There are fewcase examples although there are suggest-ed songs to start you off. The emphasis is touse these activities flexibly.

Some therapists could be inspired to usethis approach in groups but may need con-fidence and musical knowledge to use itmost effectively.Suzanne Thurling is a speech and language

therapist at Galtres school, a secondary

school for pupils with severe and profound

learning difficulties in York.

REVIEWS

MULTIPLE DISABILITIESEASY TO FOLLOWBasic Abilities - A Whole Approach; ADevelopmental Guide for Childrenwith Multiple Disabilities

Sophie LevittSouvenir Press LtdISBN 0285631713 12.99This book for carers of a young child with multipledisabilities is written in a friendly manner and fre-quently refers to working in partnership withtherapists and teachers.Chapters on daily life activities include eating anddrinking, dressing and play. Carers select an activ-ity and there are ideas for targeting abilities with-in each activity. Abilities include using hands, lis-tening and understanding. A developmentalframework is followed and carers can record theirchilds progress.

I found the introductions lengthy and repetitivebut the practical chapters with illustrations areeasy to follow. I have looked at the book with col-leagues from other therapies. We would sharebits of it with some families to complement whatwe already give.Hazel Anderson is a senior speech and language

therapist working in a Child Development Centre,

Sure Start and NAS EarlyBird Programme in

Doncaster.

ANATOMY & PHYSIOLOGYLOSES ITS WAYBasic Medical Science for Speech

and Language Therapy StudentsM. Atkinson & S. McHanwellWhurrISBN 1 86156 238 1 29.50

This book was written to fill a gap whichexisted. The authors, after previous successwith a dentistry book, have attempted toproduce an anatomy and physiology bookaimed solely at speech and language thera-pists. The result is well ordered and coverseach area in a depth according to its rele-vance. The interspersion of topics such asthe aphasias and agnosias give an addeddimension.

This book is, however, not without prob-lems. The text often loses its way duringlengthy and complicated descriptions ofanatomical structures which could havebeen easily illustrated using a diagram. Ifread in conjunction with an anatomicalatlas and a glossary of terms, this is a usefuladdition to any collection of anatomy andphysiology books. It is not, however, thedefinitive guide that the authors may haveset out to produce.Linda Morrison is studying for a BSc in

Speech Pathology and Therapy at Queen

Margaret University College, Edinburgh.

LANGUAGE DEVELOPMENTACTIVITIES PROVED POPULAR

Helping children to build self-esteem -a photocopiable activities bookDeborah PlummerJessica Kingsley PublishersISBN 1 85302 927 0 15.95This book offers a combination of imagework andsocial use of language exercises to build self-esteem. It mainly targets children at key stages 1and 2 who stutter, have mild language impair-ments, underachieve or have poor social skills.Through photocopiable activities with instruc-tions, groups or individuals join a treasure hunt tofill their chests with precious things such as self-knowledge, awareness of others, conversationaland problem solving skills.

The activities are nicely sequenced and progress insmall, logical steps. Helen selected the mostappropriate activities with a range of dysfluentchildren but sees the advantages of covering allthe material.The tasks require a well developed imaginationand would be most successful in groups.Sometimes the printed pictures seemed a littlesimple for the challenging, imaginative tasks butgenerally the activities proved popular and pro-voked interesting thoughts and ideas.

Judy King and Helen Lennox are speech and lan-

guage therapists with Selby and York Primary Care

Trust.


9/32

PHONETICS

REASONABLY PRICED ANDRELEVANTMethods in Clinical PhoneticsMartin Ball & Orla LowryWhurrISBN 1 86156 184 919.50Well written and easy to read, a great resourceand reference book for any student studyingphonetics.The book introduces a wide variety of topicsrelevant to those who work in the speech andlanguage therapy field. It would be difficultfor non-specialist readers to understand as

some sections tended to be technical - such asthe acoustic instrumentation and articulatoryinstrumentation chapters which I have not yetcome across in my study or in my role as anassistant. However this was no problem as theauthors present the range of instruments andtechniques with clarity and illustrate themwith relevant data and examples.It is reasonably priced for students and rele-vant to everyday work in the clinic.

Jaspal Kaur is studying for a BA Linguistics and

Psychology, and working as a speech and lan-

guage therapy assistant in special schools for

the South Birmingham NHS Primary Care Trust.


reviews

PHONOLOGICALAWARENESS

USEFUL BACKGROUNDRESOURCE

Sound Practice: PhonologicalAwareness in the Classroom(second edition)Lyn Layton and Karen DeenyDavid Fulton PublishersISBN 1 85346 801 015.00A clearly written, comprehensive introduc-tion to phonological awareness for teachersand other education staff, this providesgood practical activities for both identifica-tion of difficulties (covering attention,memory, syllabification and rhyme aware-ness and production) and for interventionat all levels. It also includes coping strate-

gies for children with persisting difficulties.The book advocates early intervention andcollaborative working with speech and lan-guage therapists.Best recommended for teachers due to itsfocus on literacy development, it would beuseful as a background resource for thera-pists working in schools, or as an in-servicetraining resource. The photocopiable activi-ty sheets would be useful to include in indi-vidual education plans for schools.

Andrea Arnold and Sally Kirk are paediatric

speech and language therapists working in

Leeds.

APHASIA

NOT FOR THE FAINT-HEARTEDGrammatical Disorders in Aphasia

Ed. R.Bastiaanse & Y.GrodzinskyWhurrISBN 1 86156 135 035.00This collection of 11 papers by differentresearchers in the field of neurolinguistics isnot for the faint-hearted clinician. Nonethelessit presents the clinician with up to date investi-gations into the nature of agrammatic Brocasaphasia and deals with linguistic processes in,among others, English, Hebrew, Dutch andHungarian.A helpful chapter on Chomskys theoreticalmodel of Universal Grammar is included andcan provide a good refresher on the theoreti-

cal part of neuro-linguistic processing for theless confident clinician or student.An extensive bibliography is included.Although the collection of papers is based onprimary research and may not always be easyto digest, the book will provide sufficient foodfor thought and may help the clinician experi-enced in neuro-linguistic processing to makemore informed treatment decisions.Elsje Prins is a speech and language therapist

(Clinical Lead Neurology) at Harrogate District

Hospital.

PLAYA LOT OF INFORMATIONPlay For Children With SpecialNeeds - Including ChildrenAged 3-8Christine MacintyreDavid Fulton PublishersISBN 1 85346 935 1 14.00The author is a lecturer in education andhas written this book to explain how includ-ing play in the curriculum for children with

special needs can help to develop theirlearning, language, self-esteem and socialcommunication skills.There is a lot of information on the stagesof play and different types of special needs.The later chapters have some practical ideason incorporating play into everyday activi-ties within the mainstream setting.At 14, this book is a useful resource fortherapists starting out in the field of specialneeds or involved in the training ofpreschool or educational staff.Linda Smullen is chief paediatric speech and

language therapist with East Surrey PCT.

EPILEPSY

RATHER THEORETICALLanguage & EpilepsyYvan Lebrun & Franco FabbroWhurrISBN 1 86156 312 4 22.50This book explores the link between languageand epilepsy from every angle - some have apractical application within therapy and someare interesting but irrelevant to most thera-pists, for example ictal verbal behaviour. I wasdisappointed by the two page chapter onRemediation of verbal disorders associatedwith epilepsy which basically said that clientsshould receive verbal therapy!The first two chapters provided some goodbasic information including a thorough descrip-tion of epilepsy, treatments, names used andattitudes. The most useful chapters to thera-

pists describe the effect of epilepsy and drugsand of surgical treatments on language.Overall I found it was rather theoretical and onlyprovided brief practical information. It may beof interest to therapists specialising in epilepsy.Ruth Corkett is a speech and language therapist

with Enfield Primary Care Trust.

NARRATIVE

IDEAL FOR COLLABORATIVEWORKINGSpeaking & Listening Through

Narrative (A pack of activities andideas)Becky Shanks in collaboration withHelen RipponBlack Sheep Press 40.00This structured yet versatile pack will delighttherapists and teachers.Developed for spoken language skills it hasgreat application for improving the structureof written language. Intended to be used oversix weeks with a small group of Key Stage 1pupils, the sessions cover Introduction toNarrative; Who; Where; When; What happened;The End, with accompanying suggested lessonplans and activities. Clear interesting pictures

provide essential visual support that appeals topupils, yet are within their experience.This pack has great scope for adaptation to olderpupils with learning difficulties and those withspecific language impairment. Excellent for struc-tured teaching in the Literacy Hour with pupilsworking at different levels, as it can be used fromthe development of simple sentences to that ofthe complex narrative plot. Additionally it pro-vides resources for the structured teaching of syn-tax, morphology and vocabulary.Ideal for collaborative working in the school setting.Virginia Martin is an advisory teacher - lan-

guage impairment in Surrey.


10/32

early intervention


ducation Achievement Zones (EAZs)were established in areas across thecountry where attainment levels werelow. They are funded in part by theDepartment for Education and Skills

and by the private sector. We were appointed tospeech and language therapy posts as part of theBridgwater Education Achievement ZoneProgramme. Critically, our brief is to work along-

side teachers so that we understand the chal-lenges of teaching and they have the opportunityto develop greater insight into language develop-ment. In turn, this influences their practice andthe classroom environment, helps them recognisethe childrens preferred learning styles, and raisesattainment levels. What makes our posts so dif-ferent is that we work with teachers in wholeclass situations. This means we dont have case-loads of specific children, see children on an indi-vidual basis, write case notes, or draw up individ-ual education plans.Bridgwater EAZs aims are to:1) raise standards of achievement in the 3-19 yearage group;2) create new opportunities for learners of allages; and3) work in partnership with business, industry andthe community.

These aims will be achieved through pro-grammes that support families and learners, raisethe quality of teaching and learning, work inpartnership with business and other organisationsand join up services to tackle social exclusion.Bridgwater EAZs long-term aims are to ensurethat the young people leaving school and further

/ higher education are: well adjusted young people able to take control

of their lives

not frustrated and angry because they cannotbe understood or understand

more likely to be able to secure work/training able to communicate well with family and

friends.We were employed from 1 September 2000.

Our initial brief was open-ended and broad. Wewere asked to begin working in Reception andYear 1 classes in eight mainstream primary andinfant schools. This gave us a clear target groupand the opportunity to work with teachers andestablish ways of working which would help chil-dren gain access to the curriculum and preventbehavioural problems developing due to children

becoming frustrated through a lack of being ableto understand tasks set or simple instructions.After seeking advice from a speech and languagetherapist who worked for an EAZ in Salford, wedevised a brief (figure 1a).

Before going into the classrooms, we met withgroups of teachers and discussed the teachersunderstanding of communication and their spe-cific planning for language in the curriculum. Thisdiscussion stemmed from the brief in figure 1aand a questionnaire (figure 2), which we devisedwith the support of a research psychologist. Wespent time in the classrooms observing and build-ing a rapport with the children, teachers and non-teaching assistants. A random sample was taken

for pupil assessment in the form of the British

E

if you

are planning to changethe way you work

need to strengthen

partnerships want to encourage

multisensory techniques

Read this

In common with other areas of the country, too

many children in Bridgwater enter school with poor

communication and literacy levels. Could the

inclusion of speech and language therapists in their

general education make a difference? Lizzie Astin,

Katie Roberts, Emma Witheyand Melanie Crawshaw

take us on a journey into the classroom through anEducation Achievement Zone programme.

Improvingcommunication

with EAZe

Little girlshowing avisualdictionarythat theteacher hasmade with allYear 2 sightwords.



early intervention

Figure 1b EAZ speech and language therapybrief 2001-2002

To work in partnership with teachers in theclassroom to effect change in teacher practice inorder that the curriculum is accessible to all childrenirrespective of preferred learning style.To achieve this objective we will: provide Total Communication language training to

whole school communities. This training includes

simplifying language and increasing use of Visual,Auditory and Kinaesthetic (VAK) teaching thatinterlinks with the principles of Teaching forEffective Learning.

continue to jointly plan the curriculum with teachersat regularly scheduled intervals throughout the year.

model appropriate language and use of visual,auditory and kinaesthetic approaches in theclassroom.

work in the classroom without withdrawing anygroups of children.

evaluate the effectiveness of the project throughassessment of children, teacher observation andself evaluation.

liaise with teachers, special educational needscoordinators and learning support assistants at a

mutually agreed time for technical and linguisticsupport for the use of Total Communication(symbols, signs, etc).

continue to link and liaise with the advisoryservice for Somerset Total Communication,Teaching for Effective Learning, Physical DisabilityService, community therapists within SomersetCoast Primary Care Trust.

Figure 1a EAZ speech and language therapybrief 2000-2001

to work alongside Reception and Year 1 teachers. to identify possible blocks to childrens

learning/accessing the curriculum. to think about and identify possible training needs

of staff in schools. to ensure that teachers and others in schools

develop a better understanding of language

development, and an understanding of childrenspreferred learning styles and how this needs to betaken into consideration in teachers planning.

Bridgwater E.A.Z. ProjectSpeech and Language Therapist Questionnaire

The EAZ aims to support the acquisition and development of languageof children in Bridgwater. Your views and comments regarding commution in the classroom would help us greatly. Please could you completeshort questionnaire? Your replies are confidential. Please place the quesnaire in the envelope provided and return to one of the speech and lan

guage therapists or the EAZ office.

About the project:

1. Are you aware of the aims of the EAZ?Please tick YES NOIf you answered yes, please can you state one of the aims?

2. Were you aware that speech and language therapists were part of thject?Please tick YES NO

3. What do you think the role of the speech and language therapist ischool setting is? Please tick all that applyWorking with: whole class

small group individuals children with speech and language problems

Enhancing communication:within the classroom skills of teachers of children with speech and language problems

To: provide extra assistance in the classroom joint plan with teachers work alongside teachers liaise with teachers and classroom assistants

About Communication:

4. Please can you rate the importance of language in the following arthe curriculum?[Please rate from 0-5, 0 = not important at all, 5 = very important]

Maths

History Information Technology Geography English

Please can you briefly say why you feel some are more important than

5. How would you recognise the following in your classroom? A child with poor attention A child with language delay Low self-esteem

6. What strategies do you use with a child who has poor comprehensskills?Please tick all that applyGestures

Symbols Slowing down rate of speech Signing Raising voice

Please state any other strategies that you use:

About Planning:

7. Which areas of the curriculum if any do you formallyplan for thefollowing social skills? Please write in the box next to each social skill.ListeningEye contactTurn takingConversation skillsInitiation and maintenanceof communication

Picture Vocabulary Scales II, The Bus Story Test,and the school-age Boehm Test of Basic Concepts.This enabled us to ascertain the childrens averagelanguage levels. General weaknesses were foundin both receptive and expressive lan-guage skills but in most cases theywould not be severe enough to war-rant being referred for speech andlanguage therapy.

Good listeningWith the agreement of individualteachers, narrative skills and listeningskills were addressed initially byworking with groups of children. A common com-plaint from teachers was that the children justwerent listening and so this provided a goodstarting point for us in the schools. Our objectivewas to increase teachers understanding that lis-tening is an active process that involves a numberof skills. We took groups of children out of theclassroom and devised sessions that enabled thechildren to develop an understanding of the rulesof good listening and to practise those skills. Westarted by encouraging the children to look andmake eye contact with a speaker. We ensured thatthere were no particular linguistic or conceptualdemands entrenched in the activities. This gave usthe opportunity to provide positive feedback tothe children in the form of verbal praise, signingand symbols. Once the children had developedgood eye contact with the speaker, we used thisskill to encourage the children to actively listenand to think about the words they hear. We pro-vided the teachers with session plans and dis-cussed our approach and the children progresswith them. It was then that we encouraged theteachers to help the children generalise these

skills in the classroom by using the same signs,symbols and vocabulary. This also enabled us towork in the classroom alongside the teacher andgave us an opportunity to reinforce and model theuse of positive praise as a vehicle for enhancingself-esteem, confidence and behaviour.

We also began to analyse the childrens Bus StoryTest scores to discover that the expressive languagescores were significantly lower than the receptiveresults achieved and this also provided a discussionpoint with teachers. We helped develop childrensnarrative skills using big books or topic books. Wespent several sessions focusing on the target book:reading, making predictions, clarifying and defin-

ing vocabulary, role play, picture description, storysequencing, extending and changing the ending,setting and location of the story. This enabled us todevelop our rapport with teachers. We now planon a regular basis with teachers and work exclu-sively in the classrooms alongside them, reinforc-ing, modelling and co-teaching.

We also work with teachers to develop materialswhich support and acknowledge the childrensdifferent learning styles, the goal being to influ-ence teachers practice so all children can accessthe curriculum. In particular we are encouragingthem to use all the principles of Somerset TotalCommunication which include using signs, sym-bols, body language, gestures, photos, real

objects, drawing and facial expression; this way

Literacy

SciencePhysical educationArtDramaMusic

Simplifying language

Placing them near a teacherCalling their name to gain attention

Restricting language to short,unambiguous sentences

Using shortened instructions

What makes our posts sodifferent is that we work

with teachers in whole classsituations.

Figure 2 Text of questionnaire


12/32

teacher. Since we are not just consulting or with-drawing children we have the opportunity todemonstrate different approaches and providematerials to enhance communication. We aretraining staff and are able to support and follow

up on the training. We have had the opportunityto develop strong professional relationships withstaff and have unplanned, spontaneous conversa-tions (teachable moments) during class andbreak times.

Initially the time spent in each class was dependenton reading score results and other deprivationfactors. Recognising the importance of earlyintervention, we spent all our time in theReception and year one classes working alongsideteachers and encouraging them to use principlesof Somerset Total Communication in their dailyclassroom practice. This enabled us to introducethe principles to the school and to allow teachersto talk to each other to promote the practice. Wehave been moving up the schools and are begin-ning to work in years 2 and 3. Where we work inthe school - and what our focus is - is agreed fol-lowing discussions with the headteacher and their

senior management team, and theEAZ project director.

It has been very beneficial for usto work together as a team ofspeech and language therapists onthe same project. We have beenable to share ideas, learn from eachother, provide support, and devel-op and deliver joint training pack-ages. Between us we have also

been able to liaise with speech andlanguage therapy colleagues andothers working with a range of chil-dren with additional needs and

share and develop good practice.We have learnt a lot. Demands faced by schools

to deliver curriculum content are considerableand way beyond what we had anticipated. Thereis a significant difference in the amount of knowl-edge and expertise in language developmentteachers have as opposed to speech and languagetherapists due to the very different training pro-grammes. Many teachers have minimal languagetraining and have little understanding that lan-guage acquisition is developmental. Schools have

early intervention


to model Somerset Total Communication practicefor the teachers and allows them to observe theirpupils and another style of teaching. Our brief atthe end of the first year was rewritten in the lightof what we and staff in schools had learnt and has

become more sharply focused (figure 1b, p.9).We hope this will result in changes for the chil-dren so they will know what they are expected to do and when,as this will be communicated in a variety of ways. be able to recognise and learn more wordsbecause pictures / symbols are there next to thewords. know which areas of the room should be used fordifferent activities, therefore avoiding confusion. be able to explain to the teacher what they have

just been asked to do, and act on it. be able to learn more because they are allowedto experience more. be praised and encouraged frequently forefforts with communication. know what they have learnt and feel goodabout this.

In some schools work, we have been undertak-ing has been discussed and sup-ported by the senior managementteam and/or we have been workingclosely with the literacy coordina-tor or special educational needscoordinator. Where this approachhas been taken, certain practiceshave been established across theschool. These include visual timeta-bles, importance of using symbols

as well as word labels, develop-ment of resources and the role ofclassroom assistants. Teachers areusing more visual and kinaestheticmodes of teaching. Classrooms look different.Symbols, drawings and photos are being pairedwith written text to assist children in accessing thecurriculum and their environment. Some teachershave come to believe that symbols are a bridge toliteracy which can positively impact on the chil-drens confidence and self-esteem.

We believe we are being successful because weare spending scheduled time each week in specificclassrooms. This has allowed us to understand thechallenges of teaching and work alongside the

We qualified asSomerset TotalCommunicationtrainers and thisled to a systematictraining

programme forstaff in school.

1. Office Role play

Area - labelled with

symbols

2. Display: Seaside

vocabulary. Symbols

used to encourage

the children to use it

as an interactive

board (eg How

many buckets are

there?)

3. Visual timetable:

Placed at childrens

eye level.

1

2 3

the needs of the visual and kinaesthetic learnerswill be addressed.

Somerset Total Communication was already beingused successfully in early years and some schoolenvironments and in day centres in Somerset for

adults with learning difficulties. We qualified asSomerset Total Communication trainers and this ledto a systematic training programme for staff inschool. This training has tried to address the lack ofunderstanding of the importance of multi-sensorycommunication techniques which need to be usedwhen a childs vocabulary and understanding ofwords and concepts is limited. This is in the maindue to a lack of language and communication train-ing for teachers. The understanding and knowl-edge we have gained by working alongside teach-ers has given us the opportunity to take examplesof a breakdown in communication between theteacher and child and provide practical ways suchproblems can be overcome or, more importantly,prevented in the future.

Time to planThrough training and discussion with teachersand staff we are increasing their knowledge ofcommunication and the necessity for adults toprovide children with the appropriate languageto access the curriculum. Supply teachers are paidfor by the EAZ so there is time for the teachersand speech and language therapists to address theNational Curriculum and plan together during theschool day. Co-teaching is an excellent opportunity



early intervention

a lot of people popping in and out to offer advice,so this advice needs to be coordinated. All thiscan explain why school speech and language ther-apy programmes do not work optimally unlessthey are well supported, very specific and ideally

linked into the curriculum with a one-to-one sup-port for the child.

OpportunityThis project has provided an opportunity for pro-fessionals to work together in a way which is notnormally possible for the majority of speech andlanguage therapists or teachers. This has led togood communication becoming recognised asthe key to encouraging effective learning. Theway we work with colleagues in schools will con-tinue to change and develop. Our plans includeworking with parents and developing parent/childinteraction as children enter school, working withteachers on language development in particularcurriculum areas including science and maths, andworking with a number of teachers in the sec-ondary sector.

Our two professional groups have to worktogether to address the ever growing complexneeds of many children in mainstream education.We need to ensure that what we have learnt is notlost and that health and education work togetherto provide services in a holistic way which meetsthe needs of the child/young person rather thanthe service providers.

Lizzie Astin, Katie Roberts, Emma Withey and

Melanie Crawshaw are speech and language ther-

apists with Bridgwater Education AchievementZone which has links with Somerset Coast PCT

speech and language therapy service.

Resources Contact the Somerset Total CommunicationProject team at Resources for Learning, Parkway,Bridgwater, Somerset TA6 4RL. Boehm Test of Basic Concepts 3rd ed (Boehm-3)is available from The Psychological Corporation,www.tpc-international.com. British Picture Vocabulary Scales 2nd ed fromNFER-Nelson, www.nfer-nelson.co.uk. Bus Story Test by Catherine Renfrew fromSpeechmark, www.speechmark.net.

Stroke - good practiceThe Stroke Association has produced aresource pack for those working in social carewith responsibility for planning, commissioningand delivering services for those affected bystroke. The third in a series of guides, it iden-tifies good practice and includes case studiesand other sources of information.Stroke - good practice in social care (ref SCP)

Stroke - good practice resource pack (ref R1)

Stroke - good practice in primary care (ref PCO)

All from The Stroke Association, tel. 01604

231000.

Take the busA subscription service for nurseries, schoolsand parents includes interactive learningsoftware for children aged 3-11 linking intothe national curriculum. The Big Bus aims to

bridge a perceivedgap betweencomputer gamesand curriculumcontent.For prices and a free

taster, see

www.thebigbus.com

ADHD informationA drug company has produced a patienteducation pack for those affected byattention deficit hyperactivity disorder.Janssen-Cilag Ltd has included information on

psychological, educational and socialmeasures as well as drug treatment, alongwith suggestions for books, support groupsand internet sites.The booklet is available from prescribing

consultants and the company, tel. 01494

567567, www.concertaXL.co.uk.

Fragile XThe Fragile X Society has published a reportof the talks given at its National FamilyConference in May 2001. The genetics ofFragile X and their impact and implicationsfor families was discussed by Dr AngelaBarnicoat, while Dr Jeremy Turkspresentation was Fragile X behaviour -reducing the undesirable and enhancing thedesirable.Three booklets - Fragile X Syndrome: Anintroduction / An introduction to educationalneeds / Education and severe learningdifficulties - are available free.Details tel. 01245 231941,

e-mail [email protected].

Sex after strokeA new leaflet from the Stroke Associationdiscusses sex after stroke. The importanceof communication is emphasised, andreaders experiencing language difficulties

following a stroke are advised that aspeech and language therapist will helpthem and their partners find suitable waysof communicating their feelings andemotions for each other.Sex after stroke From The Stroke

Association, tel. 01604 623933.

Software from CrickClozePro software, from the makers ofClicker, provides a range of cloze activitiescustomisable for all ages and abilities. Userscan for example use it to work on word

finding or spelling, both on-screen and asprinted worksheets.Single user 90, additional user licence 12.From Crick Software, tel. 0845 1211691,

www.cricksoft.com.

Incentive PlusA speech and language therapy catalogueof resources for promoting effectivecommunication skills in adults and children.Tel 01908 526120, www.incentiveplus.co.uk

Downs syndromeanswersThe Downs Syndrome Association answerscommon questions with anupdated version of its mostpopular publication. TheAssociation hopes thisformat, along withincreasing use of audiotape and video, willimprove accessibility of itsmaterial for people withlearning disabilities.People with Downs

Syndrome - Your

Questions Answered

is 2.50 from the DSA, tel. 020 8682

4001, www.downs-syndrome.org.uk.

..resources...resources...

Do we plan new services in aphased way giving all involveda chance to develop their brieftogether?

Do we do our research first tofind out what people alreadyknow and where there are gaps?

Do we liaise at managementand at ground level to ensuredevelopments get established?

Reflections

Voice on the webVoice experts Gillyanne Kayes and JeremyFisher have launched Vocal Process on theweb, including a page dedicated to speechand language therapists.www.vocalprocess.net


14/32

My experience of AAC with patients in intensivecare before our study was limited. I found thatthe high-tech devices we had available in the cup-board were only occasionally useful in ICU. Thebuttons on the Parrot were too small for patientsto press, and the old-fashioned scanning Possumswhich were 4, 16 or 128 location were too bulky,slow to use and required a high degree of con-centration and coordination. The E-Tran eye-pointing frame was flexible but required a highdegree of concentration and cooperation fromthe patient. Nursing staff within intensive careencourage patients to use alphabet charts andwriting to communicate but feel these methodshave severe limitations as they require high levelsof concentration. Patients trying to use thesemethods may produce words or phrases which aremeaningless, bizarre, inappropriate or difficult tointerpret. This is supported by literature whichreports that these methods are time-consumingand frustrating (Albarron, 1991; Ashworth, 1984).Patients have also stated difficulties with thesecommunication techniques (Hafsteindottir, 1996).

Over the last ten years the little that has beenpublished for speech and language therapistsabout communication aiding or augmentation forpatients in intensive care has come mainly from

the United States (Costello, 2000; Beukelman &Mirenda, 1998; Dikeman & Kazandjian, 1995). TheAmerican intensive care unit populationsdescribed differ from those here. The UK units aremore general so they see a greater range ofpatient types with few planned admissions. ManyUS patients tend to be in highly specialised units(Mitsuda et al, 1992). In, say, a neurosurgical ICUthere may be very few patients who could useAAC due to their cognitive problems, while in asurgical ICU with planned admissions, patientscan be taught a technique prior to admission orlearn it while in the unit.

Exceptional skillsNursing staff who work within the ICU settinghave exceptional skills in questioning to elicitinformation on pain or discomfort levels but,because of the patients situation, engaging inconversation beyond the level of basic needs orunderstanding and replying to unique questionsis not possible. Low morale and depression arecommonly documented in patients experiencing aprolonged stay in ICU, and having an effectivemeans of communication is a recognised way ofreducing this. Most articles advocate the use oflow-tech AAC systems for ICU patients, statingthat high tech solutions are not suitable for theintensive care environment. However, the last 20

years has seen many advances in terms of com-

research

hen patients recovered conscious-

ness after anaesthesia or sedation,

they reported that they experienced

complete emptiness - devoid of any

thought or feelings; and their language did not

function normally. They could not make themselves

understood and therefore were unable to communi-

cate and share experiences and feelings with others.

They became aliens, strangers, when they woke up,

connected to peculiar machines and apparatus, and

tied in their beds. They had no expressions or con-

cepts for the situation, and were unable to conduct

a dialogue, and therefore unable to share their

experiences. (Granberg et al, 1999).Communication failure has been identified as one

of the most frustrating and stressful aspects of car-ing for the temporarily non-speaking, ventilatedperson in an intensive care unit (Costello, 2000).Difficulty in communicating with ventilatedpatients has been well documented in the nursingand intensive care literature (Ashworth, 1984) buttends to be glossed over by alternative and aug-mentative communication literature. This is unfor-tunate as the ICU patient population as a whole ischallenging and thought-provoking in terms ofAAC, as our three year collaborative research pro-

ject developing the ICU-Talk device has shown.

Although many patients are sedated during theirstay in intensive care, as they recover they areweaned off the ventilator, sedation is reduced, theywaken up and, at this point, most attempt to com-municate. There is also a group of patients withinICU who have conditions like Guillain BarreSyndrome, complications post meningitis, respira-tory failure, severe chest injuries and high spinalcord damage. Although receiving ventilatory sup-port, they are conscious and attempting to commu-nicate for part of their more prolonged ICU stay.These are the patients who tend to be referred tospeech and language therapy for AAC intervention.

When a person wakes

up to find themselves in

the alien environment

of an intensive care

unit, they may well feelthey have come from

another world. While

vital contact made

through current

alternative and

augmentative

communicationmethods is limited,

there is light in the

shape of the

ICU-Talk device. Fiona

MacAulayreports.

W

Communication -

an inalienable right


if you want todevelop a research idea

transfer knowledge to adifferent client group

improve yourcollaborative working

Read this

Figure 1 The ICU-Talk communication aid.


15/32

puter hardware and the limitsof what computers can do.

The department of appliedcomputing at DundeeUniversity along with theDundee speech and languagetherapy service has been devel-oping AAC systems for 15years. While working on a sys-tem for adults with aphasia wefelt that some of the principlesof reduced cognitive load, min-imal training, and transparentinterface could be used todevelop a system specificallyfor intubated patients in inten-sive care. A three year fundedcollaborative research project,ICU-Talk, was set up to developand test an AAC device forintubated patients in intensivecare. My partners in theresearch were a software engi-neer and an ICU nurse.

There were two steps in thedevelopment of the ICU-Talkdevice. The first involved iden-

tifying a suitable hardwareplatform to run the softwareand then mount the hardware.The second was to develop the ICU-Talk softwarethat would control how the device worked.

Many restrictions apply when developing an aidfor use in the intensive care environment. Risk ofinfection to and between patients is a major con-cern, so equipment must be able to withstand rig-orous cleaning with chemical solutions. Staff mustbe able to move the device out of the way quick-ly in an emergency and the patient must be ableto use it when lying or sitting in bed, or from achair. It must be able to be accessed using a rangeof input devices to compensate for a patientsphysical weakness.

The multidisciplinary project team addressedthese factors and a solution was found which waslimited by the available hardware at that time. Arugged, waterproof, flat panel screen wasobtained from Dolch. This screen weighed approx-imately seven kilograms and so required a specialheavy-duty mounting solution to allow it to besuspended safely above a patient (see figure 1).

Specific needsSoftware was developed with the specific needsof the ICU patient in mind. It had to be simple touse and easy to learn with minimal training. Two

interfaces were developed which each supported

use of the touch screen, mouse or single switchscanning (see figure 2). The interfaces weredesigned to be visually stimulating but not distract-ing, and advice was sought from a computer gamescompany as to how best to achieve this. They toldus how we could keep the animation working fromthe same direction all the time so that the userremains focused on the important central part ofthe screen. The software includes a database ofphrases organised under eight topic headings. Toensure the phrases were relevant for their intubat-ed patients, nursing staff from ICU were asked forexamples of phrases patients frequently use, andresearchers also observed and noted the communi-cation attempts made by patients. Communicationpartners during observations were usually relatives,so about half of the phrases were very personal,everyday things such as a query about a familymember, or who was walking the dog. A computerbased interview was designed for relatives. Therewere thirteen questions which asked for informa-tion like names and ages of children, and hobbies.The answers were turned directly into personalphrases in the ICU-Talk device, and were availableimmediately for the patient to use.The first prototype ICU-Talk device was finished in

May 2001 and introduced to the intensive care unit

at Ninewells Hospital, Dundee for trials with patients.Using the ICU-Talk device and working closely

with the intensive care unit nurse has taught mea great deal about these patients and the effectsthat having a life threatening condition and aprolonged stay in intensive care have on thepatient. These in turn affect the patients abilityto use an AAC device (figure 3).

Despite all the complications described, 21patients over a 12 month period have used the

ICU-Talk device. Preliminary results show thatpatients are able to use the system with only min-imal training to communicate. Most patients onlyuse it for a short period of time, as the window ofopportunity is small - perhaps only 24 to 48 hours- between having their sedation reduced so theyare awake and extubated. There have been noadmissions of people with Guillain BarreSyndrome or of other long-term alert and com-municating patients during the evaluation period,the initial target group for the ICU-Talk device.

SurprisedOne of the features that most surprised me was thepatients inability to remember anything aboutusing the ICU-Talk device or about their stay in ICU.This phenomenon is documented in the literature(Russell, 1999; Stovsky et al, 1988) and is commonlyseen in patients who have been ventilated.However, it meant that we were unable to ask thepatient how they felt about using ICU-Talk or forfeedback about what it was like communicatingwith it. A questionnaire we put together was onlycompleted by three relatives. We had difficultyaccessing relatives and patients once they were dis-charged from the unit, and no relative returnedthe questionnaire if it was posted to them. Many ofour results are therefore anecdotal - from nursingstaff, our own observations of patients using the

device and from the data recorded automatically


research

Figure 2.1 Boxes Interface showing topics

Figure 2.2 Boxes Interface showing questions

Figure 2.3 Bubbles Interface showingtopics

Figure 2.4 Bubbles Interface showingphrases

Many restrictionsapply whendeveloping anaid for usein theintensive care

environment.

Figure 3 Effect on AAC use

Presenting Possible Cause Effect on AAC usefeature

Fatigue

Generalisedweakness

Reducedcognitiveabilities

Fear/anxiety/denial ofproblems

Low mood

poor concentration poor ability to retain information hallucinations

difficulty using touch screen, mouse, joystitrackball

tire quickly tremor in hand or arm

reduces cooperation short-term memory loss (unable to retain

instructions) long-term memory loss (do not remember th

stay in ICU) difficulty following instructions

unwilling to try something new reduced concentration only want to use speech to communicate

poor motivation to participate unwilling to try something new social withdrawal therefore dont want to

communicate

medication general medical condition withdrawal of sedation

being bed bound effect of medical condition

medication general medical condition

waking up in the alienenvironment of ICU

realisation of what has happened difficulty coming to terms with

physical problems

feeling they are not getting better severity of medical condition feelings of isolation


16/32

research


ReferencesAlbarran, J.W. (1991) A review ofcommunication with intubatedpatients and those with tra-cheostomies within an intensivecare setting. Intensive CareNursing 7; 179-186.Ashworth, P. (1984). Staff-patientcommunication in coronary careunits. Journal of AdvancedNursing 9; 35-42.Beukelman, D.R. & Mirenda, P.(1999) AAC in intensive care set-tings. In: Augmentative and alterna-tive communication: Managementof severe communication disordersin children and adults, Ed.2; 515-530. Baltimore: Paul H. BrookesPublishing Company.Costello, J. (2000) AAC interven-tion in the Intensive Care Unit:The Childrens Hospital Boston

Model. Augmentative and Alternative

Communication 16; 137-153.Dikeman, K.J., & Kazandjian, M.S. (1995)Communication and Swallowing Management ofTracheostomised and Ventilator DependentAdults. Singular Publishing Group; San Diego.Granberg, A., Bergbom Engberg, I. & Lundberg,D. (1999) Acute confusion and unreal experiencesin intensive care patients in relation to the ICUsyndrome. Part 2. Intensive and Critical CareNursing 15; 19-33.Hafsteindottir, T.B. (1996) Patients experiences ofcommunication during the respirator treatment peri-od. Intensive and Critical Care Nursing 12; 261-271.Mitsuda, P.M., Baarslag-Benson, R., Hazel, K. &Therriault, T.M. (1992) Augmentative communica-tion in intensive and acute care unit settings. In:Yorkston, K.M. (ed.) AugmentativeCommunication in the Medical Setting.Communication Skill Builders:Tucson.Russell, S. (1999) An exploratory study of patientsperceptions, memories and experiences of anintensive care unit.Journal of Advanced Nursing29 (4); 783-791.Stovsky, B., Rudy, E. & Dragonette, P. (1988) Caringfor mechanically ventilated patients. Comparisonof two types of communication methods after car-diac surgery with patients with endotrachealtubes. Heart and Lung 17; 281-289.

by the ICU-Talk device, which logs allthe button presses and selectionsmade by the patient.

Patients often had difficulty in fol-lowing instructions. They were unableto take on board that their attemptsat communicating using mouthingwere unsuccessful and that, to com-municate more effectively, they need-

ed to slow down thei

speech & language therapy in practice, winter 2002

Documents