ISSN 1368-2105

Autumn 2010

Any questions? Training education staff Out in Eden Community connections Toy story Bridging silence to talk Boundary issues A complementary view How I support TEP closure An open and shut case? My Top Resources Winning ways outside the NHS PLUS...heres one I made earlier...reviews...editors choice...in brief... software solutions...and a great reader offer A spirited response www.speechmag.com

NEW! Journal Club

Critical appraisal of expert opinion

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Autumn 2010 (publication date 31 August 2010) ISSN 1368-2105

Autumn10contents
17 COVER STORY: JOURNAL CLUB (EXPERT OPINION) There are many areas of current practice for which evidence is absent, scanty or of poor quality. For some topics we may need to rely on professional consensus or expert guidance, so we also need ways of evaluating such expert knowledge . Jennifer Reid introduces our new series to help you access the speech and language therapy literature, assess its credibility and decide how to act on your findings. Cartoons by Fran Orford, www.francartoons.co.uk.

Published by: Avril Nicoll, 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 email: avrilnicoll@speechmag.com Printing: Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT Editor Avril Nicoll, Speech and Language Therapist

4 TEACHER TRAINING One teaching assistant...reported that, as a result of using the techniques, the activities were less adult led and more exploratory, with greater levels of information exchanged. Nicola Harvey and Belinda Robbins work with language unit staff on indirect interaction techniques to develop childrens play and expressive language. 7 IN BRIEF Christina Smith and colleagues develop a functional assessment of chewing for children with cerebral palsy who have a normal diet. 7 HERES ONE I MADE EARLIER Alison Roberts with a low cost therapy idea - Menu game. 8 COMMUNITY ACCESS Drama artist John Batty made the point that effective communication is the joint responsibility of staff and service users: both sides must be ready to adapt how they do things. Maggie Wallis, with Sandra Hewitt and Kari-Ann Johnston, reflects on an ongoing connection between a theatre, speech and language therapy and people with aphasia.

11 EDITORS CHOICE 12 REVIEWS Special needs, communication, phonology, autism, language cards, child development, assertiveness, storytelling, intensive interaction, listening skills, well-being, early years. 14 BILINGUALISM ...I have come across many such children playing alone on the edge of the action, unable to negotiate access to toys or to adult attention, unable to deal with peer competition and conflict... Cynthia Pelman introduces the StoryF.R.A.M.E.S approach to scaffolding opportunities for silent children to speak out. 22 BOUNDARY ISSUES You have fairly strong views on complementary therapy. Perhaps you have derived a lot of personal benefit and you are aware of the impact it could have on certain clients. Or perhaps you are very sceptical but are asked for advice from a keen client... Sue Roulstone responds to the third scenario of our ethics series. 23 SOFTWARE SOLUTIONS 3D anatomy for Speech-Language Pathology; Language Garden.

24 HOW I SUPPORT TEP CLOSURE It is important that speech and language therapists - who often change the voice prostheses, trouble shoot valve, voice and swallowing difficulties and usually know the patients very well - are able to have an informed discussion about the risks and benefits of TEP closure. Morwenna White-Thomson investigates how, when tracheoesophageal puncture doesnt work out, our involvement might help improve the success of TEP closure. 28 READER OFFER Win The Communication Toolkit. 28 RESOURCE REVIEWS In-depth reviews of Communication in the classroom - Workshops for Secondary Schools; Active Listening for Active Learning. 30 MY TOP RESOURCES: WINNING WAYS It can be daunting to take the plunge to become self employed or work for a charity, leading to self doubt. I found talking to friends and family really helped keep me on track. Kim Mears on the range of skills needed to work outside of the NHS. With a comment from life coach Jo Middlemiss.

Subscriptions and advertising: Tel / fax 01561 377415

Avril Nicoll 2010 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site.

IN FUTURE ISSUES: AUTISM...USE OF HUMOUR...EARLY INTERVENTION...MAKING PRIORITIES...SYMBOLS... APHASIA...STAMMERING...DYSPHAGIA...SIGNING...PRAGMATIC ASSESSMENT...BILINGUALISM...DEMENTIA

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Avril Nicoll interviews internationally renowned educator, editor and phonology researcher Sharynne McLeod about making sense of the literature, writing for publication and making a difference. www.speechmag.com/Resources/Originals

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news

Justice for children

Stimulating the senses
This dress is from Kingston University design student Nadja Penfolds graduation collection, which was inspired by Synaesthesia. The UK Synaesthesia Association (founded by Professor Simon Baron-Cohen) describes it as a fascinating condition, where two or more of the five senses that are normally experienced separately are involuntarily and automatically joined together. The dress has Braille symbols woven into it saying To see sounds, taste touch and hear colours. www.catwalking.com www.uksynaesthesia.com/

First come first served

Families of children with severe disabilities or special educational needs in England are being urged to apply for an Assistive Technology solution through the Home Access Programme as quickly as possible, as individual assessments will be made on a first come first served basis. Despite the decision to close the education ICT quango Becta, the coalition government in England has confirmed it will continue with the Assistive Technology element of the Home Access Programme until March 2011. ICT education specialists XMA have been awarded the contract along with iansyst to deliver equipment to aid learning for children with profound physical impairments and special educational needs. To check eligibility and apply, families should call the Home Access helpline on 0333 200 1004 or go to www.xma4ha.co.uk/ AssistiveTechnology.aspx.

Let it shine

The Health Foundations Shine Challenge 2011 offers funding for healthcare practitioners to find new approaches to delivering healthcare that reduce the need for acute hospital care while improving quality and saving money. Up to 75,000 will be invested in each of up to 18 projects. The closing date is 4 October 2010. www.health.org.uk/current_work/open_for_ applications/the_shine_challenge.html

Exceptional contribution

Professor Chris Code is the fifth recipient of The Robin Tavistock Award for his exceptional contribution in raising the profile, awareness and understanding of aphasia. Chris is co-founder and editor of the journal Aphasiology, a National Advisor to Speakability, and a Patron of the AphasiaNow website. www.aphasiatavistocktrust.org; www.speakability.org.uk; www.aphasianow.org

The Childrens Communication Coalition has called for universal and targeted screening as well as an increase in speech and language therapy to address the needs of children with communication disability within the justice pathway. The coalition partners are the Royal College of Speech & Language Therapists, the Prison Reform Trust, Sainsbury Centre for Mental Health and the Association of YOT Managers. Its report Engaging for their futures and our society has a foreword by campaigner Lord Ramsbotham in which he calls for speech and language therapy both to prevent children entering the justice system and to help them get out of it. The report includes case examples, and draws together attempts to analyse the costs of early intervention compared with the status quo. It envisages speech and language therapists being an integral part of the team around the child during early, primary or secondary years, engaging with social and youth and community workers as well as education staff to address the different needs at each stage. The Coalition is asking the government firstly to introduce early years screening to detect children with speech and language and communication needs so early intervention can be offered. Secondly, it wants local commissioners and service providers to offer involvement from Wrap Around Engagement Teams when warning signs are observed. Finally, it is calling on the government to ensure appropriate screening, specialist assessment and intervention are available to children and young people who are already in the criminal justice system. Engaging for their futures and our society Improving the life chances of children with speech, language and communication needs is available at www.rcslt.org/about/campaigns/ ccc_report_2010.

Play at IT

A scheme to give preschool children with special needs in Northern Ireland more play options through the use of IT has received funding for two more years from the Roald Dahl Foundation. The Play at IT Northern Ireland project is run by national computing and disability charity AbilityNet. It is actively seeking 50 additional nurseries and childrens centre across the province and in return offers a package of support, equipment and training including a loan bank of appropriate hardware and software. The project aims to offer greater inclusion of children with physical, vision and learning difficulties and to give them an early introduction to some of the adaptive equipment they may come to reply upon in later life. A spokesperson said, Children learn the basics of writing by scribbling with crayons from a very early age, but children with disabilities, many of whom will depend on a computer for recording information and producing written work later on, rarely have equivalent access to computers for play and learning at this crucially formative age. One beneficiary of the Play at IT scheme is Maxwell McKnight (pictured). His mum Michelle says, We had no idea how good Maxwells letter recognition was. It was a real revelation. Its such a relief to know that your child is going to feel normal and not miss out. Play at IT Northern Ireland is established in 27 early years settings and provides direct support to over 70 disabled children. Any other interested organisations should get in touch with Caroline Holden at AbilityNet, on tel. 0800 269545 or email preschool@abilitynet.org.uk.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

NEWS & COMMENT

Liberating the NHS?

While speech and language therapists and students across all four countries of the UK are concerned about pay and jobs, those in England are also absorbing the new coalition governments plans for reforming the NHS. Equity and excellence: Liberating the NHS reaffirms that the NHS remains a free, national public service and that spending will continue to increase. However, press reviews of the white paper have concentrated on the lack of detail, fears around opportunities being given to the private sector, and the cost and impact on staff morale of another structural change. While GP consortia, an NHS Commissioning Board, health and wellbeing boards and a Public Health Service are on their way, the government says it will cut bureaucracy as it has a moral obligation to release as much money as possible into supporting front-line care (p.44). It envisages a rebalancing towards clinical staffing and frontline support rather than excessive administration (p.11) and wants to ensure that clinical values direct managerial activity (p.23). So, as the paper acknowledges that, Staff who are empowered, engaged and well supported provide better patient care (p.40), what clues does it give about what might be expected of clinicians? The language is of enshrining improvement in healthcare outcomes as the central purpose of the NHS (p.49), which will improve most rapidly when clinicians are engaged, and creativity, research participation and professionalism are allowed to flourish (p.21). There is likely to be increased support for research as it is vital in providing the new knowledge needed to improve health outcomes and reduce inequalities and research is even more important when resources are under pressure (p.24). Power will be given to the front-line clinicians and patients to make it easier for professionals to do the right things for and with patients, to innovate and improve outcomes (p.9) and fit services around patients. The professions, presumably including speech and language therapy, will have a leading role in deciding the structure and content of [their] training, and quality standards (p.40). If they wish, staff will be able to form employee-led social enterprises that they themselves control, freeing them to use their front-line experience to structure services around what works best for patients (p.36). Clinicians will be expected to adopt more widespread use of patient experience surveys and real-time feedback as well as PatientReported Outcome Measures (PROMS) (p.14). Over time, patients will have access to all their health records and be able to download them to show other parties if they wish. A leaflet for patients explaining the proposed changes also says it will be easier to communicate with your doctors and nurses, eg online and by email. A reduction in centrally collected data returns which are not clinically meaningful is planned and there are no longer any production line approaches to healthcare which measure the volume but ignore the quality (p21). The Department of Health is running four consultations on its plans, which close on 11 October 2010. All publications referred to are available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_117353.

Comment:

A spirited response
When I interviewed Sharynne McLeod (p.1, speechmag) I was ready to be impressed, as I know her to be an inspirational researcher and educator. Even then, I was surprised when she remarked - in a way suggesting it was the most natural thing in the world - that, as there had been no jobs in Australia when she qualified, she created one. This involved collaborating with a friend who worked in a preschool facility to submit a successful application to a funding body. Kim Mears (p.30) encourages us to cultivate such resourcefulness, which will be increasingly important given our straitened economy and the implications for services. While it can be difficult to feel positive in such a climate, we know that challenging times can bring out our innovative and spirited side, particularly when we are passionate about what we do and inspired by our clients. Cynthia Pelman (p.14) and Morwenna White-Thomson (p.24) both take their clinical passion and enhance it through engaging in research. Cynthia presents an argument for extending speech and language therapy to bilingual children who would not usually be considered candidates, while Morwenna combines a comprehensive literature review with a survey of current practice to help improve care for people who require tracheoesophageal puncture closure. Morwennas critical appraisal of the literature is careful and thorough. Our new series by Jennifer Reid (p.17) is intended to support you too in making decisions about what to read and how to interpret and act on it. Although you can do this as an individual, small journal clubs are an ideal forum to hone your skills and increase the chances of the evidence having an impact at a service level. Sue Roulstone (who gives her attention to the ethical boundary issues for speech and language therapists raised by complementary therapy on p.22) spoke to me recently about how we might respond to current pressures. Like journal clubs, Sue stressed what small action groups can achieve through recognising shared problems and focusing on joint solutions. Adopting this kind of approach has enabled Nicola Harvey and Belinda Robbins (p.5) to address staff-pupil interaction in a language unit. It has also seen Maggie Wallis, service users and a theatre form an exciting and ongoing connection beyond the clinic room (p.8). Elsewhere our extensive reviews of book, resources and software aim to help you decide on priorities for limited budgets while Alison Roberts (p.7) continues to inspire us to be inventive in making our own resources. As Jo Middlemiss (p.30) has pointed out on many occasions, while we cant always choose our circumstances, we can try to respond in a spirited way.

Standard logo

The Health Professions Council has released a new registration logo which individual registrants can display as a sign that they meet the Councils standards. The regulatory body says the new logo is designed to be simple, bold and recognisable, providing reassurance to the public and differentiating HPCregistered professionals from non-regulated health professionals. The downloadable logo is available from the Health Professions Council website with instructions on how to use it and promote a registration. Free public information materials on the benefits of using a registered professional are available for display in areas such as waiting rooms. www.hpc-uk.org/registrants/promoting/

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

TRAINING

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

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

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

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

Belinda (l) and Nicola (r)

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

Positive effect

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

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

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

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

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

TRAINING

Adapted group

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

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

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

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

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

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

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

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

References

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

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

Acknowledgements

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

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

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

IN BRIEF / Heres one I made earlier

In Brief...

supported by

Email In Brief entries to avrilnicoll@speechmag.com. One lucky contributor in each issue receives 50 in vouchers from Speechmark (www.speechmark.net).

Implications beyond nutritional intake

Christina H. Smith (email christina.smith@ucl.ac.uk), Chris Donlan, Michael Clarke and Penney Edwards develop a functional assessment of chewing.

Heres one I made earlier...

Alison Roberts with a low cost, flexible and fun therapy suggestion for groups Menu game
In a caf I visit, there is a waiter who remembers everyones orders without writing them down. When he returns he unfailingly places each dish in front of the right person. When I asked him how he was able to do this he said that he forms a mental picture of each person eating their chosen meal. In the clinical situation we have tried a similar approach to memory exercises, with good results. The game is all the more motivating because the menu is devised by the group themselves calling on their abilities to think laterally and work cooperatively. It is also a useful activity for those working on independence or life skills. In addition the role-play element can be fun. It is suitable for a group of about 3-4 clients. MATERIALS Menu forms (sample at www.speechmag.com/Members/Extras); Pens; Biscuits (at your discretion) PREPARATION Each group member thinks of 2-3 dishes for each course and jots them down on scrap papers that are then pooled. (Its a good idea to do this part anonymously.) On examination of the types of food chosen the group decides together whether the hypothetical eating-place is an upmarket restaurant, or inclines more towards the Greasy Spoon end of the market, and whether you are going to offer two or three courses. Once you have arrived at a reasonable range of dishes you can write the list down on some of the forms. At this point you may like to stop, and do the ordering part at the next session. IN PRACTICE Begin by telling the group that memorising the list of orders will be much easier if they associate a face with a meal. Take turns to be the waiter and hand out the completed menus. The other players each request their starter and the waiter repeats each persons order immediately, and then repeats the whole group order. If the waiter feels able, he then repeats the process with the main course, and if really confident will repeat the whole groups starter and main course. Now the waiter goes out of the room, and then returns with as many plates as he can mime carrying! He then mimes placing each dish in front of the correct customer, stating what the dish actually is. He waits for a moment before miming clearing the table, exiting the room again, and coming back with the main courses, stating what they are as he places them, as before. The dessert will be the last part of his task, and is carried out in the same way. You might decide to have different waiters for each course if the activity seems to be too difficult, or if others are keen to have their go. You might want to offer biscuits to the group after all that talk of food! VARIATIONS This is well received by 18s and over instead of a caf with its food menu and waiter, you can conjure up a pub, with a list of possible drinks and a person buying a round. Each member requests a drink, and the person buying must remember which consumer requested which drink. Add peanuts and different flavours of crisps and you will have an excellent - and useful - memory game. Younger children could have a beach caf with ice creams and soft drinks.

espite having a normal diet, considerable variation exists in the chewing ability of children with physical disabilities. These children may have an adequate or good pharyngeal swallow, but nevertheless have oral preparatory difficulties which make mealtimes slow and stressful for them and their families. In order to establish a better understanding of chewing ability in children with motor disabilities we have developed and tested an innovative, simple and reliable clinical research tool utilising chewing gum. The chewing gum is composed of two different colours which are mixed in the process of chewing. Chewing ability is characterised by an analysis of: (i) how well the two different colours were mixed together, indicating ability to manipulate a bolus and mix saliva into a bolus, and (ii) how well the bolus was shaped ready to be swallowed. Assessments, including evaluations of the consistency of the gum, carried out by speech and language therapists who were blinded as to the participants, has shown the procedure to have excellent reliability. This work involved typically developing children and children with a clinical description of cerebral palsy aged between 5 and 16 years. All children ate a normal consistency diet. Perhaps unsurprisingly, differences were observed in both the ability to manipulate the bolus, and in the ability to prepare it for swallowing between these two groups, with typically developing children performing better in both cases. Chewing ability was not related to severity of cerebral palsy nor was it related to sub-groupings of cerebral palsy (that is, athetoid, spastic and so forth). For example, a child with relatively severe cerebral palsy performed equally well in chewing ability as someone with mild cerebral palsy and vice versa. Both groups improved in their performance across all parameters with increasing age, but the differences between the groups remained. We were working with two groups of children who eat a normal consistency diet; the group with cerebral palsy do not therefore have the most severe oromotor difficulties. However, the differences in their oromotor abilities, reflecting the skills required for oral preparation of a food bolus, are significant. This suggests that not only are we seeing hidden variability in this population, but also that this tool is sensitive to small differences in ability. We would anticipate that the differences this tool reveals will have implications for quality of life, stress and family wellbeing within this group of children with cerebral palsy. We may extend the use of the gum to look at oro-motor skills more generally. We aim to develop the gum for clinical assessment and for the gum to be used as an objective baseline measurement which could be repeated as required and provide a functional outcome to enhance our evidence based practice. This work suggests that a proportion of children that present with relatively mild cerebral palsy and have a normal diet still experience significant difficulties with chewing and preparing food for swallowing. This is likely to have implications beyond their nutrital intake, for example, their attitude towards mealtimes, and stress around mealtimes. Clinicians should be wary of assuming that a normal diet represents a non-problematic situation.

Further reading Davis, E., Shelly, A., Waters, E., Boyd, R., Cook, K. & Davern, M. (2009) The impact of caring for a child with cerebral palsy: quality of life for mothers and fathers, Child: Care, Health and Development 36, pp.6373. Edwards, P. (2002) Bolus preparation in children with cerebral palsy using chewing gum: a comparison with normal children. MSc Thesis, UCL, London. Liedberg, B. & wall, B. (1995) Oral bolus kneading and shaping measured with chewing gum, Dysphagia 10, pp.101-106.

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ACCESS

Out in Eden
Maggie Wallis, with Sandra Hewitt and Kari-Ann Johnston, reflects on the happy accident that led to an ongoing connection between staff at a citys community arts centre, speech and language therapists and people with aphasia, where joint responsibility for communication is seen as the key to access and inclusion.
READ THIS IF YOU WANT TO TAKE THERAPY BEYOND THE CLINIC FACILITATE SELF-HELP OFFER MEANINGFUL TRAINING They attended the drama group the following week, and both were pleased they had done so. As well as this developing into a regular habit, they began to attend other things at Eden Court, including film, dance, shows and drama. Before long they were frequent visitors, becoming a formidable pair: John the bolder personality, and Alan with more readily available speech. By their very presence they were beginning to influence the staff at Eden Court, and define how their services could be used. Alan and John were also part of a larger supportive group for people living with stroke. We were coming to an end of our block of meetings and thought it would be fun to mark this by attending an event at Eden Court. We arranged to go for a pre-theatre meal then see the production Run for Your Wife. As we had been discussing the development of a service users group, we thought it would be useful to record our experiences while attending the theatre. It was a successful evening but with a fair degree of stress involved, largely because of various situations where communication broke down. Though aphasia and dysarthria were obvious hindrances, often the source of the communication difficulty seemed to lie in the organisation or layout of the theatre.

Eden Court, Inverness, www.eden-court.co.uk

any happy accidents occur during the course of a day. Noticing and making good use of them can provide an added dimension to therapy. It was in this way that the Eden Court Project came to being. I work in the centre of Inverness, in what remains of the old Infirmary. Along from the hospital is the citys theatre. (Yes, Inverness is now officially a city!) It was closed for a significant period for redevelopment and reopened at the end of 2007 with a lot of publicity about new activities and potential within the complex. There was a desire that the theatre would become more of a community venue, and it was hosting a variety of sampler classes to find out what the uptake might be. For a while I had been interested in finding opportunities for clients that took them beyond the clinic room in ways that were relevant and of interest to the individual. I was working with a couple of men in their late fifties/early sixties. Alan and John had both experienced strokes which had revolutionised their lives. Their main means of getting around was now wheelchair and their

speech had been significantly affected, Johns by aphasia and Alans by dysarthria. John was keen to find ways of connecting with the outside world again. On his behalf, I went to speak to a drama worker to find out who could participate in Eden Courts integrated drama group, and discovered it would be defined by those who attended. I asked drama artist John Batty, who oversees drama work at Eden Court, if he might come along to meet John to talk about possibilities within the theatre. Because it was a nice day, we ended this time by going to Eden Court where we were given a guided tour. Though unplanned, physically going around the new building was an important bridge in empowering John to access the theatre facilities. The following week I had planned to see both clients for a combined session, to explore whether they might be able to support each other in conversation. We discussed the integrated drama group, and they decided to attend together. Alan was not interested in drama; his only motivation at this time was to support John.

Influence

Three speech and language therapists (myself, Sandra Hewitt and Janet Jardine) were involved in the service users group start-up. We wanted to enable our clients with aphasia to influence how services were provided in their vicinity, beginning with the one we offered as speech and language therapists. We decided on the name CLASP (Communication and Living After Stroke Partnership). The group met in the newly built Health Sciences Building, which is not part of the hospital premises. Transport could not be arranged as the group was not part of ongoing therapy. This made it more difficult for people further afield, but allowed those who did attend to do so as independent people. The focus of the first CLASP meeting was the experience of our attendance at Eden Court. Following discussion centred around an evaluation form, we collated a list of points to convey to theatre management (figure 1).

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ACCESS
We duly sent a letter and included a copy of Connects publication Access to the Arts (Jennings et al., 2006). We received a positive reply suggesting we meet with Kari-Ann, the front of house manager, to discuss things further. We arranged a date, and two of the service users group came along with me to discuss our theatre experience. Kari-Ann was very keen to ensure the theatre was inclusive. She already had experience of working with John and Alan and knew about the kind of communication breakdown that could arise. It was obvious that the theatre was experiencing a few teething problems since its reopening. Some could only be remedied by changes to the building and signage, but there was no funding, and they were beyond the remit of the front of house manager. What she did see as readily changeable was the communication behaviour of her staff. We decided to explore the possibility of providing training to enable staff to be more resourceful when dealing with people who have communication difficulties. This idea was given the blessing of NHS Highland who generously agreed to fund six of our service users to attend two shows - one before and one after the training - as a measure of its effectiveness. Eden Court theatre paid for two speech and language therapists to attend these shows too.

Spacious and easy to move around, even with wheelchairs

Signage is not well positioned No indication of finishing times for shows / cinema for people being collected or organising taxis Theatre environment Doors to toilets could not be managed without assistance for wheelchair users Seating in stalls was hard for wheelchair users to manoeuvre into Round tables provided for wheelchair access did not allow us to sit as a group Entrance and eating area tend to be noisy because of open design and lack of furnishings Our clients would prefer not to speak to strangers if at all possible; would be difficult to avoid in this environment

Provision of easy to read menu made choosing and indicating choice much easier

Meals were tasty and well-presented Eric says of himself: Meal Arrived for meal 1 hours prior to performance, but were rushing to get seats 2 minutes before the show Time pressure spoiled enjoyment of eating and made paying / finding toilet facilities and seats much more stressful Paying was complicated

Ready to adapt

Staff

Waiters were respectful and patient Theatre staff were patient and proactive

Sandra had been trained to use Connects Access material. We had a look at this together and decided to base the training on this but using some of our own adaptations so it could be more specifically relevant to the environment of the theatre. We thrashed out more detail in a planning meeting with Kari-Ann, the drama artist and one of the service users. Drama artist John Batty made the point that effective communication is the joint responsibility of staff and service users: both sides must be ready to adapt how they do things. We talked about the possibility of the theatre arranging induction tours for service users with particular needs, so they would know beforehand how to make best use of the theatre environment and the theatre would be better informed about the needs of specific client groups. These days now happen on a regular basis. We also discussed the possibility of the theatre keeping details of client needs on their database so that individuals could be appropriately catered for. Also from this meeting another idea arose. John Batty agreed to collaborate with me to create a short DVD, demonstrating the types of communication breakdown that can arise for people with aphasia using the theatre. The idea was to use this film footage as a starting point for discussion during the training. Three of our service users agreed to participate in the film. It was relatively easy to create scenarios within the theatre context that tested their communication skills, as

Not easy to recognise staff outside of reception area to ask for directions or help With further training specific to people with communication issues, the waiters could have enabled the eating process to flow more smoothly Figure 1 Points CLASP conveyed to theatre management

by this time we had some pointers from attending our pre-training show. On an arranged day we turned up at the theatre, where three staff had also agreed to participate. Prior to each filming, I took aside one of the service users and primed them as to the nature of the scenario. Without rehearsal, I filmed them interacting with a staff member who although aware that the individual had difficulties - had no prior knowledge of the intention of the communication. So each staff member and the individual living with stroke required skill in listening and delivering information. This proved a fruitful exercise for many reasons: 1. The scenes created were less abstract than role play. They derived from situations that each participant had come across within that environment. 2. The service users were participating in real communication but, because the situations were contrived, there was less anxiety about failure. 3. Each service user and the speech and language therapists observing gained useful insights about communication

capacity and practical ways of making this more effective. For instance, it became evident that one of the service users could benefit himself and those around him by carrying a communication passport. He had been resistant to this idea but, when he saw the playback of the film, was able to reflect how his lack of props had inhibited the flow of communication. Another service user had developed her own passport in a credit card wallet, and he found its size and portability pleasing. The speech and language therapist helped him develop his own. He uses taxis often and, if the time needs to be changed, is reliant on others to make the call to his taxi company. We created a page with a clock and a series of statements - I want to cancel my taxi / I want my taxi to come earlier / I want my taxi to come later. 4. What impacted on me more than anything was that each person living with aphasia chose to compromise what they were asking for. If it were

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ACCESS
possible to get an approximation to their intention, that was generally good enough. Perhaps chose is not the right word. Maybe each of them felt obliged to compromise what they were asking for, and that is one of the effects of living with aphasia? 5. Those who attended the training found the film material readily accessible because it related to their own environment. We left the practicalities of the training sessions to Kari-Ann. We agreed to carry out an afternoon and an evening two hour session to cater for different staff shifts. In all, thirty five people attended the training, a high proportion of the theatre staff. The staff responded well to the opportunity to discuss communication. We discovered they generally have other daytime jobs and bring their own perspective to the theatre work, which is mainly for enjoyment. Because people had already experienced the difficulties that can arise when someone has specific difficulty with communication, they were eager to discuss and discover solutions. The combination of the Connect material and the film allowed staff to apply what they had learned to the scenarios they were observing and suggest ways that communication could be improved.

Alan and John with Ruby, a drama worker, at the integrated drama group

Sandra Hewitt comments:

Connects The Communication Access Toolkit provided us with an excellent basis for the two hour training sessions. Both sessions turned out to be lively, interactive and fun. We included and discussed; What is communication? What is a communication disability? What is access? How to make services accessible for people with a communication disability. Making interactions, environments and documents accessible. Much of this was achieved through workshops, discussions and encouraging participants to draw on their own experiences and examples. The main focus of the training, however, became about interactions, the issues and problems that arise and how these might be overcome. The DVD material was excellent because it was relevant, real and clear, promoting much reflection amidst moments of humour, comedy and poignancy. At times we added to the discussion by highlighting issues, for example, In this clip, are there any misunderstandings that occur? How could these be avoided? What might have helped Mary book her seats? The feedback suggested most people found the video clips the most useful and memorable thing. We were pleased that the training overall was described as practical, useful, relevant and proactive. One comment perhaps sums up what we were trying to say: Not to be afraid to try and help and that its OK to ask for help.

This work is ongoing. The connection with the theatre is now made, and we are looking at ways of making its facilities available to other groups who might struggle with inclusion. I am liaising with staff to create a book to support communication in moments of crisis. The contents should enable people with communication difficulties to indicate more clearly what choices they wish to make if, for instance, they become unwell whilst at the theatre. Several of the folk with aphasia now carry a credit card size wallet with supportive information in it, following the lead of their colleague who took part in the filming. The DVD is being used widely as educational material, and has many applications. We are hoping to get funding to replicate this kind of work in the hospital environment, again using the technique of real drama to illustrate to hospital staff how communication can be enhanced within this environment.

The Eden Court perspective (Kari-Ann Johnston)

At the beginning of last year I had just started my day by going through a pile of paperwork on my desk when I came across a feedback form. It was from a group who had visited Eden Court with various access requirements. As the largest community arts centre in Scotland, a variety of people come through the doors. On any one day there are films, education classes and sold out performance going on at the same time - this can be a daunting experience if you have never visited Eden Court before. I work in this beautiful building every day so I am comfortable with my surroundings but

it wasnt until I got the feedback from Maggies group that it took me back to my first day and being in awe at the size of the building, if not slightly apprehensive about how many events can congregate under one roof. It made me think, what if I had access requirements, how would I feel then? What if I needed assistance from a member of staff but there was a communication barrier? The feedback highlighted areas we could improve on, areas we werent even aware could be problematic if you have communication difficulties. Meeting the service users and Maggie was an eye opener. Its easy to take the environment around you for granted, but to hear first hand how challenging it could be for someone with communication difficulties to visit Eden Court was insightful. With more meetings Maggie suggested training customer facing staff using the feedback from the group and combining this information with Maggie and Sandras experience. Soon the training sessions were devised and planned and we were all raring to go. We had a brilliant staff turnout to the sessions which were engaging, informative and fun. The staff enjoyed the training, in fact they were buzzing from it. The sessions raised everyones awareness about communication difficulties and how to respond in difficult or stressful situations but also reassured staff that it is ok to assist someone who may require help - they wont be offended. The experience allowed us to see its not just organisations that need to take responsibility about access. Individuals should also be taking responsibility about giving their

10

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ACCESS / EDITORS CHOICE

Editors choice

So many journals, so little time! Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.

l-r, John, Mary, Maggie Wallis and Alan after attending a Buddy Holly show!

access information. This allows the needs of the patrons to be met which in turn means a smoother and less stressful visit. Since the training we have made small steps to try and improve our services: working with different groups of people with disabilities, regular access training, and more interpreted performances than ever before. We have a virtual BSL interpreted tour of the building on youtube, Autism Friendly Film Screenings every two months and we offer familiarisation tours. With this one feedback form and support from the NHS speech and language therapy department, Eden Court has made positive changes which are ongoing with the help of groups or individuals talking to us and giving us their constructive criticism. So indeed it just goes to show where happy SLTP accidents can lead you! Maggie Wallis (email maggie.wallis@nhs.net) and Sandra Hewitt are speech and language therapists with NHS Highland. Kari-Ann Johnston is front of house manager at Eden Court Theatre, www.eden-court.co.uk.

Resource

Clinicians are hungry for evidence based recommendations about working with adolescents, but this research is of wider interest. In I dont come out with big words like other people: Interviewing adolescents as part of language profiling, Sarah Spencer, Judy Clegg and Joy Stackhouse uncover two 15 year olds with previously unidentified language difficulties then find out what they think about their talking, explaining (the difference is important), listening and understanding. Most exciting is the clinical application for setting relevant and motivating targets in partnership with clients and identifying effective learning strategies. A reminder that, when we get better at asking their opinion, clients get better at giving us clues to making therapy work. Child Language Teaching & Therapy (2010), 26(2), pp.144-162 Using visual scene displays to create a shared communication space for a person with aphasia involves only one client, one visual scene (pictures and words around his vintage car hobby) and 9 new communication partners. However I like the way Karen Hux, Megan Buechter, Sarah Wallace and Kristy Weissling distinguish restorative from compensatory intervention strategies and communicative from linguistic competence. If someone or their communication partner doubts the value of low tech aids, their approach of comparing a shared scene / only the person with aphasia seeing it / neither having access could make the benefits explicit. Aphasiology (2010), 24(5), pp.643-660 I accept this may be leftfield - and cant pretend to understand it all - but Jake Harwoods The contact space: a novel framework for intergroup contact research might just give pointers to innovative ways of promoting inclusion. The article addresses how different types of exposure to people who are different from ourselves might develop or reinforce harmony or prejudice. Its not a major leap to imagine how this might help us support our clients to find new ways of experiencing fulfilling social lives. This might involve thinking about ways to: use the media, interactive technology and imagined scenarios, work with communication partners, deal with anxiety, self-disclosure and different personality types and offer face to face versus other contacts. Journal of Language & Social Psychology (2010), 29(2), pp.147-177

The Communication Access Toolkit - How to make your interactions, documents and environment accessible to someone with communication disability is a Connect publication available as part of a 2 day training course, Making Communication Access a Reality. For details, see http://www.ukconnect.org/ connectcourses_19_289.aspx.

Reference

Jennings, M., McVicker, S. & Firenza, C. (2006) Access to the Arts for People with Communication Disability. London: Connect Press.

REFLECTIONS DO I NOTICE AND TAKE ADVANTAGE OF EVERYDAY HAPPY ACCIDENTS? DO I WORK WITH CLIENTS AND STAFF IN COMMUNITY SETTINGS? DO I USE VIDEO AND REAL DRAMA TO CHANGE COMMUNICATION BEHAVIOUR?

Acknowledgements

Thanks to Eden Court for their cooperation, and especially to Kari-Ann and John Batty for creating the DVD. Also to John Pierre Sieczkarek, NHS Assistant Manager for SE Highland CHP, who supported the project by funding the group to attend two shows.

What difference has this article made to you? Please see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/ About/Friends and let us know.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

11

REVIEWS

reviews
SPECIAL NEEDS
Choosing a School for a Child with Special Needs Ruth Birnbaum Jessica Kingsley ISBN 9781843109877 14.99

Excellent

The author, an educational psychologist, provides a comprehensive guide for parents in the selection of a school for their child. It gives detailed information on all aspects of Special Educational Needs (SEN) and the SEN Code of Practice, including the current law, range of educational provision and approaches, as well as the roles of professionals involved in assessment and therapy. She provides useful questions for parents to ask and a checklist to support parents through the selection process, finishing with a handy resources and websites section. This excellent book would also provide students and newly qualified therapists with an overview of the minefield that is SEN provision. It will go straight into our parents library. Mel Eltome is speech and language therapy paediatric team manager in Keighley.

historical development. The authors attempt to find a clinical application for each theory but some only have limited clinical use. I found some of the theories difficult to understand but others were more familiar, for example the chapter on Natural Phonology and Grunwells work. There are suggestions of practical exercises that the reader can carry out with their own clinical data. There are also review questions to test understanding of the subject and ideas for further study and project work. It would be more useful to students of phonology rather than the practising clinician. Louisa Pearce is a speech and language therapist with Bexley Care Trust, also working independently.

AUTISM

Group Interventions for Children with Autism Spectrum Disorders Albert J. Cotugno Jessica Kingsley ISBN 9781843109105 29.99

the differences they could see. Sentence development can be encouraged at the level appropriate for the child and the cards allow for progression. The concept of missing seemed a little advanced and it worked better to use the simpler form of no x or x gone. The cards have line drawings of the pictures on the back, useful if you are holding them up in a small group (except when the difference is a colour!) However, the boxes are rather heavy so they are perhaps better for clinic rather than peripatetic use. Overall, a nice stimulating activity. If your department could only buy one I would recommend Whats Different as a greater range of language structures can be elicited. Fiona Jack is a community speech and language therapist in Edinburgh.

CHILD DEVELOPMENT

Sound theory

Learning Through Child Observation Mary Fawcett Jessica Kingsley (2nd edition) ISBN 9781843106760 14.99

COMMUNICATION

Expressing Oneself / Expressing Ones Self Ed. Ezequiel Morsella Psychology Press ISBN 978-1-84872-886-8 40.00

Flawed research

This publication honours the work of Professor Robert Krauss, an American psychologist who is praised for his work with communication and gesture, plus the model he created to demonstrate its interaction. At no point in the text is the model shown, and many of the chapters often provide strong and controversial arguments into the role gesture has in social interaction. It also discusses robots as conversation partners, and examines the impact that the length of time individuals are together has on the success of their interaction. The presented research is unfortunately flawed and, although it may prove interesting to psychologists, it is not a text I would recommend for speech and language therapists. Roger Newman is senior specialist speech and language therapist at Royal Preston Hospital.

This book describes an approach for developing social competency and social skills for groups of children with autism spectrum disorders. It has three sections: the first is an introduction to autism, the second discusses key areas for intervention and the third gives information about the model of group intervention the author proposes. Useful assessment checklists are included. The intervention has a sound theoretical background, but it was disappointing that no information was provided about expected outcomes for individuals completing the group intervention. It is good value for money and would be a useful tool for speech and language therapists already running social skills groups for children with autism spectrum disorders. Alison Hunter is a specialist speech and language therapist, Child and Adolescent Mental Health Services, Manchester.

Sparked new ideas

LANGUAGE CARDS

Spot Whats Missing / Spot Whats Different Sue Duggleby & Ross Duggleby Speechmark ISBN 9780863887680 / 97 29.99 each

This is not a book we can pigeon-hole. Its strength lies in the fact that it is more than a how to guide, unlike most material for child development professionals. Fawcett discusses the advantages and disadvantages of a variety of observational methods in preschool settings. Later chapters add a subtly polemical tone, and the sections exploring biases in Western child observation are especially valuable. Fawcetts comments on the Reggio Emilia approach sparked new ideas for me, particularly in relation to group work. However, Fawcetts study also represents a missed opportunity. Its focus on preschool children implies that the need for observation ceases at the age of 7. This is strange, in a book championing the importance of the practice. Mainstream school therapists confronted with observation challenges in large primary or secondary classrooms may be disappointed. The useful ideas here need to be adapted for use outside the preschool environment. Rowena Birch is a student speech and language therapist at UCL.

Naturalistic

PHONOLOGY

Phonology for Communication Disorders Martin J. Ball, Nicole Muller & Ben Rutter Psychology Press ISBN 978-0-8058-5762-7 55.00

Useful to students
12

This text book covers in great detail many different theories of phonology and their

These colourful packs contain 24 pairs of A5 size cards. Each pair shows a scene on one card and then the same scene on the other with one, two, three or four things different or missing. Identifying and explaining the differences made for enjoyable and naturalistic language sessions. I found the cards engaged children well and the cartoon-like representation appealed to young children up to early primary school age. Even children with very limited language could be encouraged to verbalise

ASSERTIVENESS

Lets Talk: Assertiveness Sue Nicholls Speechmark 17.99 + VAT

Too abstract

This set of cards is described as a game for children or adults to improve communication and confidence. It aims to explore assertive, passive and aggressive behaviour, teach assertiveness skills and give participants

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REVIEWS

confidence to be assertive in different situations. There is a brief description of the concepts covered and some ideas for the group facilitator. The activities are presented on brightly coloured cards but dont include any picture or symbol support for people who are unable to read or have literacy difficulties. Colleagues and I were unable to identify whom we might use the resource with as the concepts seemed too abstract for our clients. Unfortunately there are no suggestions about adapting it for people with learning disabilities or communication difficulties. While the price and size are attractive, this would not replace the well-trusted and evidence based resource we already have to support development of these skills. Gail Paterson is a speech and language therapist with Bassetlaw Community Learning Disability Team, Nottinghamshire Healthcare Trust.

STORYTELLING

Stories for Talking A programme to support the early development of language through story time Rebecca Bergmann, illus. Kate Wood QEd ISBN 978-1-898873-54-9 18.50 (inc. p&p)

Interaction, including discussion on historical, theoretical and current contextual viewpoints. It is aimed at practitioners with some knowledge of the approach. For a speech and language therapist working with adults with learning disabilities it provides useful, informative and searching discussions on where intensive interaction fits in our scope of practice, and challenges the boundaries and constraints of a conventional therapy model. Throughout, the authors provide case studies to illustrate challenges they have experienced in implementing Intensive Interaction and how they have attempted to overcome these. They provide practical and useful suggestions including how to support carers and other professionals. Particularly useful is the discussion about setting up Intensive Interaction and the additional support needed at a management and strategic level. This book goes some way to support practitioners to develop a culture of Intensive Interaction and leaves the reader feeling empowered to put ideas into practice. Rebecca Finn is a speech and language therapist with Manchester PCT, working with adults with learning disabilities.

WELL-BEING

Psychological Well-Being and Acquired Communication Impairments Ed. Shelagh Brumfitt Wiley-Blackwell ISBN 978-0-470-06543-3 34.99

Sound evidence

Helpful in childcare setting

LISTENING SKILLS

This resource is a structured programme for early years practitioners. It aims to give early years workers an understanding of the needs of children with speech and language delay and disorder in story telling sessions. The book offers strategies for assessment and progress reporting. It links into the Early Learning Goals in the Early Years Foundation Stage, demonstrates how to write an Individual Education Plan and helps practitioners include parents in building their childs confidence at home. The author has laid out a structured programme for five popular stories, using three different levels of complexity, with ideas for extending the language learning throughout the week. I felt it was expensive for the quality of the illustrations but it is a useful resource that would be helpful in any childcare setting. Kate Cross is a highly specialist speech and language therapist at Vancouver Childrens Centre, a Sure Start Childrens Centre in Kings Lynn.

Teaching Children to Listen: A practical approach to developing childrens listening skills Liz Spooner & Jacqui Woodcock Continuum Books ISBN 9781441174765 19.99

This comprehensive book takes a multidisciplinary approach to assessing and managing the psychological impact of acquired communication difficulties. With contributions from well respected, experienced professionals, it covers topics ranging from evaluating anxiety and depression, the role of well-being in quality of life, group therapy from an interprofessional approach and solution focused brief therapy. Two particular strengths stood out for me firstly, its sound evidence base and secondly its practical approach with relevant case examples, specific strategies and therapeutic interventions described in detail throughout. Although very useful to have on the shelf, students, recently qualified health professionals or health professionals moving to the field of neurogenic communication difficulties would benefit most from this good value for money book. Louise Collins is a speech and language therapy manager in Connolly Hospital, Dublin.

EARLY YEARS

Practical

INTENSIVE INTERACTION
Understanding Intensive Interaction Graham Firth, Ruth Berry and Cath Irvine Jessica Kingsley 978-1-84310-982-2 17.99

Empowered

Written by authors from different professions, this book provides a background for Intensive

This practical resource is aimed at children from 3-11 years of age. It is easy to read and gives a clear overview as to the why, what and how of teaching good listening skills. It includes a Listening skills rating scale and lots of practical group activities for teaching the 4 rules of good listening. All the resources are available in colour online from the publishers. It will be of use to students, newly qualified therapists and busy classroom teachers It would have been useful to include the chapters on adapting the environment and adjusting adult talk to support listening earlier in the book, as the strategies are crucial to the success of the group activities and skills carryover. Clearer guidelines on the typical developmental stages of listening and attention would have been useful, as would more of an emphasis on the importance of developing listening in the early years (3-5 years). However, it is good to have a book that recognises and promotes the teaching of listening skills to all children. Carol Haigh is Principal Speech & Language Therapist (Early Years) and Early Language Consultant for the Every Child a Talker Programme, Bradford Early Years, Childcare & Play.

Including Children with Speech and Language Delay Aderinola Hotonu, Antonia Aldous & Ranel Schafer-Dreyer Featherstone ISBN 9781408114506 16.99

Clear examples

Primarily aimed at Early Years Practitioners, this book could also be useful for childrens centre workers, childminders, parents, students or speech and language therapists involved in training. It is attractively presented and easy to read although I sometimes found the order disjointed. It gives a basic overview of communication development (birth to 5 years), indicators of possible delay / disorder, the 6 areas of the Early Years Foundation Stage and covers issues that Early Years professionals may be asked about, such as learning two languages. A value for money, informative and practical resource, it provides clear examples of strategies and activity ideas to develop and support communication in groups or with individual children. It also covers a parents perspective and emphasises the importance of working with speech and language therapists. Fiona Coughlan is a speech and language therapy clinical advisor working in community clinics and childrens centres in Warrington.

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BILINGUALISM

Toy story
Children who are learning English as an Additional Language often go through a silent period at nursery or school, even when fluent in their first language. Arguing the case for providing such children with support, Cynthia Pelman introduces StoryF.R.A.M.E.S, a play and narrative approach designed to scaffold opportunities for English language output.

READ THIS IF YOU ARE INTERESTED IN BRIDGING SILENCE TO TALK DRAWING ON OTHER DISCIPLINES ENGLISH AS AN ADDITIONAL LANGUAGE

hildren who speak languages other than English and who are new to a school setting often go through a silent period in which they are assumed to be absorbing (inputting) the new language. It is presumed that once they have absorbed enough of the phonology, vocabulary and syntax, they will start to speak. But what of the child who remains silent for longer than is acceptable? And what of the claims of some authors (Granger 2004; Hoffman, 2008) who say that the silent period is one in which the child is not only having to acquire a new language but also a new identity to go with it? Some level of emotional difficulty might especially be the case for a child who has never attended school before, and for whom the first experience of formal education takes place in an incomprehensible language. I think we often underestimate the trauma such children experience, and too often the child is left to deal with this without any support. These children do not usually get onto speech and language therapy caseloads as they are reported to be speaking fluently at home in their first language, and are therefore assumed to be coping well. Working in Hackney, where there are reportedly 97 languages being spoken by school pupils, I have come across many such children playing alone on the edge of the action, unable to negotiate access to toys or to adult attention, unable to deal with peer competition and conflict, and sometimes not even responding to adult-initiated talk. One wonders whether a short-term simple intervention would have made all the difference? In working with such silent children I have developed a simple therapy programme which seems to be effective in helping them overcome initial difficulties in using the new language. It is not a language programme per se - it does not model or teach any specific linguistic aspects of form or content. Instead it is a way to scaffold the childs use of whatever English they have and to give them the confidence to do so. Merrill Swain (2001), working in the field of second language learning, makes a strong claim for language being learned through language use. Her research shows that rich input, while promoting advanced language comprehension skills, does not advance expressive language skills to the same extent as does providing opportunities for language

output. Swains Output Hypothesis argues that, for a complete processing of the second language, output on the part of the learner is essential. She claims that verbal social interaction, or collaborative dialogue, is where language use and language learning can co-occur. It is language use mediating language learning (Swain, 2001, p.97). The StoryF.R.A.M.E.S programme involves providing the child with a small set of miniature world toys (packed in a handymans toolbox and kept constant throughout the programme, see figure 1) and encouraging the child to play with them in any way they wish. The work is done in a quiet space away from the classroom, on a 1-1 basis. Where this programme differs from our usual speech and language therapy techniques is that it does not model linguistic form, but instead models how to create narratives out of the story that the child enacts with the toys. The vocabulary and grammar are not important here: what is important is the therapist putting the childs play into words. It appears that being present for the childs undirected play, and the making of a story based on this play, signals to them in some way an acceptance of their interests and provides a safe space in

which they can talk about their play. In this I have been strongly influenced by Paley: it is play, of course, but it is also story in action (1990, p.4). This work may be closer to play therapy than to speech and language therapy, but my experience indicates the outcome is lots of child language.

Common ground

I have called the programme StoryF.R.A.M.E.S, as the five main components are Feelings, Repeating, Adding, Modelling, and Extending. The first three draw on the work of DanonBoileau (2001) who has worked extensively with silent (not necessarily bilingual) children. These first three components have the effect of creating common ground between the child and therapist. This serves to make the child feel secure and relaxed, to know that whatever they do is of interest to the therapist, and to send the message that the child can choose to play or talk, without the adult having any expectations. So, if the child creates a play scenario where a doll sees a monster, I will verbalise the feelings (F) which I guess are in the childs mind (Oh, that is scary!) If the child says anything at all (even if it is just noises of cars

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bilingualism
crashing and ambulance sirens) I will repeat (R) verbatim what the child has said, to show that I am really listening and that the childs words are of value to me. If the child is totally silent (this is a silent child, after all) I will add some words (A) aiming to verbalise what I think they are showing me in their play (the dolly is getting into bed, she has got a lovely warm blanket or the cars are crashing). The next step Modelling (M) refers not to modelling words or grammar, but rather modelling the creation of a narrative, showing the child how a spoken story can be made out of their play. So after the child has played for a few minutes (during which I have been doing the F, R, and A parts of the programme) I will start a story which describes their play, adding a beginning and an end, and using the past tense. For example, I might say Once upon a time, there was a green car, and he drove very fast and crashed into the red car. Then the ambulance came and took the driver to hospital. The end.) I find that children often choose to play the same games over and over. Car crashes, monsters and death seem to dominate. In such a case, I can Extend (E) the story by adding in a new character or event. To do this I always keep one miniature world toy or small object in my pocket as a surprise. I might introduce this by saying something like and suddenly a butterfly came and said, can I go in your car? Sometimes the child ignores this, but usually they pick up on the new character or object and incorporate it into their play, giving me the opportunity to model another story. I make the concept of storytelling explicit, for example greeting them in the morning by saying, Do you want to come and do some storytelling? I also introduce the spoken stories by saying, I will tell you a story. The pilot programme with two children who were almost completely silent in the classroom ran for six weeks with two sessions per week. Gradually and hesitantly they started telling the stories while playing. I recorded and transcribed their stories, illustrated them with images and stapled them into book form. I gave the child the book containing their own stories to take home, so they could tell their families the story they had made up and get even more practice in language output (figure 2). As their confidence grew they spoke more and I spoke less, until the sessions were dominated by their talk and I was able to sit quietly and observe their growing language use.
Figure 1 StoryF.R.A.M.E.S a) Toolbox ingredients 2 cars 1 police car or ambulance 6 characters (some human, some animal) 2 scary things (eg. snakes, spiders, dinosaurs, robots, monsters) miniature furniture: bed, table, chairs miniature food, plates, spoon a small box, or a fence or enclosure (you can use long blocks, or Lego pieces - should be big enough for the characters to be put into) some bits of soft cloth for blankets, big enough for the characters to hide under 1 truck (big enough to fit the cars into) + Keep in your pocket a surprise character or object (doll, animal, monster, unusual car, butterfly.) b) Recipe F R A M E Feelings - talk about what the characters might be feeling Repeat - repeat the childs sounds or words verbatim Add words to verbalise what the child is playing simply describe what they are doing Model a story - use an opening and a closing phrase, and use the past tense to tell the story about what the child has been doing Extend the story by adding the surprise character when the play gets repetitive

Figure 2 Story example Verbatim transcript no.5 (see take home printed and illustrated version at www.speechmag.com/Members/Extras) Key: A= child (Aishah) C=Cynthia (researcher) Double parentheses (( )) indicates action taking place Dialogue is indicated without parentheses. UPPER CASE script indicates louder voice

Provided a scaffold

I found the results very exciting. The StoryF.R.A.M.E.S programme seemed to provide the support needed for these two children to actually use the language they had acquired; that is, it provided a scaffold for output. Both emerged from their silent period, and started to talk to other children and to their teachers in the classroom. The most thrilling feedback was that of a teacher who had known one of the children at school for 18 months, during which time she hardly spoke. Now, said the teacher, I hear her voice all over the classroom!

Speaker A ((A picks up a little dinosaur)) . C Another one! A Can we the bigger? [sic] (( I indicate that I dont understand)) A How can we do the animals bigger? C Make them bigger? A Can we do the animals bigger? C I havent got any big ones. Have you got big ones at home? A .. C .. A .. C .. A .. C .. A We can make them bigger ((Returning to her concern about making the dinosaur bigger)) C How can we? What can we do? A I think we can, like, we can, can we say abracadabra make them bigger? C Oh! We can say abracadabra. You say it. A Abracadabra. He was still tiny!! A I can put him in my crown, and I will say abracadabra. ((she was wearing a tiara on that day; she puts the dinosaur in her crown)) A ABRACADABRA! and he was still tiny! C Lets try to put him in your pocket; ((A puts him in her pocket )) A Abracadabra! He still tiny. C Oh dear! A We do it in a magic box. ((she puts the dinosaur in a box)) A Abracadabra! Oh! still tiny! C Dinosaur said, I want to be big, Maybe if you eat lots of apples, you can get bigger? A Look, he cant open his mouth ((shows me the dinosaur has a closed mouth)) and he didnt get what- what to eat. C ((C drawing a picture of a glass of water so that the dinosaur could drink)) Lets give him something to drink then. A All drinked up! C And then? A And he didnt get bigger, and he didnt get bigger! C Maybe we need to say it very loud. A ABRACADABRA!! And he was still tiny. C Oh, poor thing! A Take a magic wand ((C gives her a pencil to use as a wand)) A ABRACADABRA! He still tiny! What we gonna to do? ((with hand gesture of despair)).
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Name: Aishah Bus Story Information Raw Score Pre-test Chronological age 4 years 5 months 14 days Post-test Chronological age 4 years 6 months 29 days 19.5 [Age equivalent for native English speaker 4;6 years] 27 [Age equivalent for native English speaker 5;9 - 5;11 years] Bus Story Sentence Length 5 words [Age equivalent for native English speaker: Less than 3;9 years] 7 words [Age equivalent for native English speaker 3;9 - 4;0 years] Bus Story Subordinate Clauses 0 [Age equivalent for native English speaker: Less than 4;0 years] 0 No change R.A.P.T. Information Raw Score 18.5 [Age equivalent for native English speaker: Less than 3;6 years] 25.5 [Age equivalent for native English speaker 3;6 - 4;5 years] R.A.P.T. Grammar Raw Score 12 [Age equivalent for native English speaker: Less than 3;6 years] 19 [Age equivalent for native English speaker 3;6 - 4;5 years]

Name: Dasir Bus Story Information Raw Score Pre-test Chronological age 3 years 8 months 11 days Post-test Chronological age 3 years 9 months 26 days 14 [Age equivalent for native English speaker 4;0 years] 19 [Age equivalent for native English speaker 4;6 years] Bus Story Sentence Length 6 words [Age equivalent for native English speaker: Less than 3;9 years] 8 words [Age equivalent for native English speaker 4;1 - 5;0 years] Bus Story Subordinate Clauses 0 [Age equivalent for native English speaker: Less than 4;0 years] 2 [Age equivalent for native English speaker 4;4 - 5;0 years] R.A.P.T. Information Raw Score 28.5 [Age equivalent for native English speaker: 4;0 4;11 years] 30 [Age equivalent for native English speaker 5;0 - 5;5 years] R.A.P.T. Grammar Raw Score 16 [Age equivalent for native English speaker: 3;6 3;11 years] 16 No change

Figure 3 Pre and post-test results

An additional and unexpected benefit was that the two children not only made progress in terms of being willing to talk in the classroom, but also had significant development of both vocabulary and syntax. Both made notable progress on the Bus Story (Renfrew, 1997) and on the Action Picture Test (Renfrew, 1989) in the space of only six weeks (figure 3). The fact that both had been silent in the classroom for a long time (6 months for Dasir and 18 months for Aishah) suggests that intervention was called for. It may be the case that any 1:1 intervention would have Samantha Paula produced similar outcomes, but I believe it is the creating common ground of DanonBoileau (2001) which enabled the children to produce output and it is this which made the work effective. Although I am reporting on results with only two children and no control element, the outcomes suggest this approach merits further exploration. While children in extended silent periods are typically not thought to need speech and language therapy, there is no doubt they are experiencing difficulty with both communication and emotional and social adjustment. With children who have English as an Additional Language making up such a large proportion of the population in many inner city areas, it could be said we are not providing an equitable service if we do not include them on our caseloads.

The method is so simple that teaching assistants or volunteers can easily be trained to carry it out, so the additional load on a speech and language therapy department would be minimal. The interesting finding - that modelling narrative form instead of linguistic form can have such positive results on vocabulary and grammar - suggests that perhaps we as speech and language therapists sometimes provide too much input, and do not provide sufficient opportunities for output? I would love to hear the views of other readers. SLTP Cynthia Pelman is a speech and language therapist in London, www.cynthiapelman.com. This article is based on Cynthias thesis for her MA at the Institute of Education, University of London. The take home picture version of Aishahs story is at www.speechmag.com/Members/Extras.

Renfrew, C.E. (1989) Action Picture Test. [Now available from Milton Keynes: Speechmark.] Renfrew, C.E. (1997) Bus Story Test. Milton Keynes: Speechmark. Swain, M. (2001) The Output Hypothesis and Beyond: Mediating acquisition through collaborative dialogue, in Lantolf, J.P. (Ed) Sociocultural Theory and Second Language Learning. Oxford: Oxford University Press, pp.97-114.

References

Danon-Boileau, L. (2001) The Silent Child: exploring the world of children who do not speak. Oxford: Oxford University Press. Granger, C.A. (2004) Silence in Second Language Learning: A Psychoanalytic Reading. Bristol: Multilingual Matters. Hoffman, E. (2008) Lost in Translation: life in a new language. London: Vintage. Paley, V.G. (1990) The boy who would be a helicopter. London: Harvard University Press.

REFLECTIONS DO I PROVIDE SUFFICIENT RELAXED YET STRUCTURED OPPORTUNITIES FOR LANGUAGE OUTPUT? DO I ALWAYS CONSIDER THE IMPACT OF A COMMUNICATION DIFFICULTY ON SOCIAL INTEGRATION? DO I NOTICE WHERE A NUDGE IN THE RIGHT DIRECTION COULD MAKE A DIFFERENCE?
To comment on this article, see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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Journal club: expert opinion

Jennifer Reid introduces our new series to help you access the speech and language therapy literature, assess its credibility and decide how to act on your findings. Each instalment will take the mystery out of critically appraising a different type of journal article, starting with Expert Opinion.
ow confident are you that you can read, digest and evaluate the sorts of research articles that count as evidence? Check the expectations of the Royal College of Speech & Language Therapists (RCSLT) in figure 1. Last year I conducted a short online survey on evidence-based practice among speech and language therapy colleagues in NHS Fife in Scotland. These were some of the survey items, in case you wish to do a quick self-evaluation: hh I can find a research article that might be relevant to my work hh I can recognise whether a research article is of good quality hh I know which areas of my work are supported by systematic evidence hh I know how to evaluate my own practice in the light of new research findings hh I can change my practice to ensure it is more evidence-based hh I generally rely on other people summarising evidence for me hh My strategy for keeping up to date with developments in my field is hh I prefer to update myself by yy Reading journal articles yy Reading textbooks yy Reading whatever I can find on a topic on the internet yy Going to a SIG day, course, conference or lecture yy Talking to my colleagues hh Two areas of my practice that I would like to become more systematic and / or evidence-based are The results from the 50 Fife respondents suggested that there was room for improvement in the skills and confidence levels reported across most of the key areas highlighted in the RCSLTs minimum skills set (figure 1, no.3). Consequently, improvement in awareness and use of evidence-based practice is now embedded in the NHS Fife speech and language therapy services quality improvement strategy, and a programme of activity is underway. During

READ THIS SERIES IF YOU WANT TO yy BE MORE EVIDENCE-BASED IN YOUR PRACTICE yy FEEL MOTIVATED TO READ JOURNAL ARTICLES yy INFLUENCE THE DEVELOPMENT OF YOUR SERVICE

the past year, this programme has focused primarily on development opportunities for staff in electronic searching skills and critical appraisal. Applications of research findings to practice and evaluation of own practice will be a focus in future years. In Fife, our critical appraisal education is delivered through a series of small group journal clubs within each of our three client care groups (adult learning disability; adults with acquired disorders; paediatrics).

Figure 1 RCSLT expectations The Royal College of Speech and Language Therapists (RCSLT), in its current Research Strategy, lists the following underpinning principles: 1. All practitioners engaged in meeting the speech, language, communication and swallowing needs and disorders in the population / of their clients must use the evidence base to inform and support their clinical decision-making and as part of judging the safety, efficacy and appropriateness of their clinical practice. 2. The RCSLT expects all members will engage in a range of research related activities, (including self-directed and work-based learning) that will enable them to continue to develop their skills and knowledge throughout their careers. Speech and language therapists must demonstrate a personal commitment to ongoing education in order to continue developing their knowledge and skills when undertaking research. 3. The RCSLT expects every practitioner will have a minimum 'skills set' which will allow them to be evidence based practitioners. These skills should include searching the evidence, critical appraisal, applying research findings to practice and methods for evaluating their own practice.

Appraisal help

There are quite a lot of appraisal tools available now to help practitioners evaluate healthrelated research literature, for example the Critical Appraisal Skills Programme (CASP) tools published in 2006 by the Public Health Resource Unit in England. RCSLT Clinical Guidelines (2005: Appendix 2) also provide the very detailed set of checklists used during development of the guidelines. With these sorts of tools, you choose a specific checklist according to the methodology of the research article in question. Each checklist is a structured set of questions with points for consideration and room to record your appraisal notes. I encountered some problems when I tried to use the currently available appraisal tools in our journal clubs. Most were initially developed for appraisal of medical literature, so there is a strong emphasis on clinical trials of medical treatments. Novice users may be put off by the arcane terminology of the randomised controlled trial. By and large, current evaluation tools also favour quantitative over qualitative study designs (although the CASP toolkit does include a checklist for qualitative research). This is a problem given that qualitative methods are the ones of choice when the research either involves an under-explored area lots of those in our practice! or seeks to understand clients experiences, attitudes or beliefs.

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There are many areas of current practice for which evidence is absent, scanty or of poor quality. For some topics we may need to rely on professional consensus or expert guidance, so we also need ways of evaluating such expert knowledge. There are appraisal tools for clinical guidelines but these are not really appropriate for appraising articles such as small scale narrative reviews of an area of speech and language therapy. Nor could I find a ready-made framework for appraising the sort of information provided by, for example, single-case study designs, which can be particularly useful for providing preliminary evidence or promising avenues for further study where no other more robust research evidence exists. For our journal clubs, I have developed a set of structured appraisal frameworks. For the overall framework, as well as much of the specific content, I acknowledge a strong debt to Greenhalgh (2006) as well as to the CASP tools. However, I have extended beyond the CASP set to include, for example, appraisal of expert opinion and of single-case design studies. We also, with tongue firmly in cheek, added graphics to our worksheets to support their imageability. Theres nothing like following your own advice! For this series, these have been replaced by cartoon drawings specially commissioned by Speech & Language Therapy in Practice. (Now, just how strong is the evidence for the impact of witty graphics on the transparency of abstract vocabulary?)
Primary studies report research first hand Experiment Clinical trial (intervention study) Survey A manoeuvre is performed on a volunteer in controlled surroundings An intervention is offered to a group of patients who are followed up to see what happens to them Something is measured in a group of patients, health professionals or some other sample of individuals Summarise primary studies Draw conclusions from primary studies about how clinicians should behave Use the results of primary studies to generate decision trees to be used by health professionals and patients in making choices about clinical management Use the results of primary studies to say whether a particular course of action is a good use of resources

Secondary or integrative studies summarise and draw conclusions from primary studies

Overviews Guidelines Decision analyses

Economic analyses Table 1 Primary or secondary study? Level 1 Systematic reviews and metaanalyses Randomised controlled trials (RCTs) with (statistically) definitive results RCTs with nondefinitive results Cohort studies

All primary studies on a particular subject hunted out and critically appraised according to rigorous criteria. Participants randomly allocated to one intervention or another. Both groups followed up for a specific time period and analysed in terms of specific outcomes defined at the outset of the study. Because, on average, the groups are identical apart from the intervention, any differences in outcomes are, in theory, attributable to the intervention. Two or more groups selected on the basis of differences in their exposure to a particular agent (for example, prematurity) and followed up to see how many in each group develop a particular outcome (for example, language impairment). People with a particular condition are identified and matched with controls. Data then collected for both groups on their past exposure to possible causal agents. Representative sample of people are interviewed, examined or otherwise studied to gain answers to a particular clinical question. Considered relatively weak scientific evidence but they have the advantage of being richer in information and easier to understand and remember!

Level 2

Level 3 Level 4

Getting your bearings

Once you have found your article (more on this later in the series), your first task is, in Greenhalghs words, getting your bearings (2006, p.40). The following three questions may be helpful. 1. Why was the study done? (What clinical questions did it address?) Sometimes the authors will explicitly tell you their clinical questions. If they dont, we have found it useful to try to reformulate the authors aims as one or more questions. The PICO framework can be helpful with this: P I C O population, problem intervention control, comparison outcome

Level 5

Case-controlled studies

Level 6

Cross-sectional surveys Case reports

Level 7

Table 3 Rating a study for level of evidence

For example: In children aged under 6 years with speech sound disorder (P), is there any difference in rate of speech sound development (O) when intervention includes non-oral motor exercises (I) compared to speech sound intervention alone (C)? When you reword it like this, it is immediately obvious what things the authors needed to define and measure. So, in

the example above, their definition of speech sound disorder should link explicitly to their participant selection criteria for the study. How are they defining and measuring rate of speech sound development and does this accord with your expectations? For some research designs, you only need part of the PICO. For example: Are teenagers with a history of specific (i.e. primary) language impairment (P) more at risk of negative mental health (O) than their peers (C)? At this point, you may decide to discontinue if the question(s) posed are really not what you are looking for answers to.

2. What type of study was done? This is a crucial step as the choice of an appraisal framework is largely driven by the design and methods used in the study. Tables 1, 2 and 3 provide some definitions to help you. 3. Was the study design appropriate to the broad field of research addressed? This question gets easier with experience - the most important issues are covered within the individual appraisal tools. Broadly speaking, you are checking how well the study has been designed so as to minimise the possibility that the results are untrue, biased, misleading or unreliable. An intervention study needs to demonstrate that the outcomes resulted

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Quantitative designs involve measurement via data collection; stronger on reliability (same results every time) Therapy Testing the efficacy or effectiveness of interventions. Randomised controlled trial (RCT) is the preferred study design. Is a new diagnostic test valid (trustworthy) and reliable (gives same results all the time)? Cross-sectional survey is the preferred study design. Can a test pick up a condition at early or presymptomatic stage? Cross-sectional survey is the preferred study design. What is likely to happen to a person with a particular condition? Longitudinal survey is the preferred study design. Determining whether an agent is related to the development of a condition. Cohort or case-control study is the preferred study design, depending on rarity of the condition. Case reports may also provide crucial information. Measuring aptitudes, abilities, attitudes, beliefs or preferences. Study of documents produced by real people in real situations (for example, casenotes). Systematic recording of behaviour and talk in naturally occurring settings. The researcher takes part in the setting as well as observing. Face-to-face (or telephone) conversation with the purpose of exploring issues or topics in detail. Uses a pre-set list of questions or topics but is not restricted to these. Interview undertaken in a less structured fashion, with the purpose of getting a long story from the interviewee (typically a life story or the story of how a condition has unfolded over time). The interviewer uses only general prompts to tell me more. Method of group interview which explicitly includes and uses the group interactions to generate data.

Diagnosis

Screening

Prognosis

Causation

Psychometric studies Qualitative design methods involve exploration and interpretation via data generation; stronger on validity (closeness to the truth): preferred methods for poorly understood or relatively unexplored phenomena Documents Passive observation Participantobservation Semi-structured interview

Narrative interview

Focus Groups

Table 2 Quantitative, qualitative or mixed methods? Delegates at the 3rd East African Speech and Language Therapy Conference

from specific aspects of the intervention and not from, for example, the passage of time or receiving general attention from a nice therapist (the speech and language therapy equivalent of the placebo effect, which I think I once heard Professor Pam Enderby describe as random niceness!) You also need to have a think about whether the design of an intervention study was more about efficacy (Does it work in ideal conditions with carefully selected participants?) or effectiveness (Does it work under typical clinical conditions with a range of clients?) Logically, youre supposed to do efficacy first but, well, the path of research is sometimes more about serendipity than logic. However, if you cant work out what the researchers thought they were doing in this respect, be suspicious. There is an established pecking order within study designs in terms of weight and quality of evidence (see the Hierarchy of Evidence in table 3). However, how well the research was conducted (methodological quality) should influence how you rate it just as much as the level of evidence of the study

An intervention study needs to demonstrate that the outcomes resulted from specific aspects of the intervention and not from, for example, the passage of time or receiving general attention from a nice therapist
design. Common sense judgement is needed as well as hierarchies of study design when assessing a studys relative contribution to clinical evidence. If the study design is very wide of the mark, you may wish to conclude that it is not worth the effort of continuing with the appraisal. If on the other hand you wish to continue, you can select from your appraisal toolkit the framework that appears to fit best with the

study design. (Be aware that a mixed methods study may need you to use bits of more than one tool.)

EXPERT OPINION FRAMEWORK

I shall be presenting a range of critical appraisal tools over coming issues of the magazine. For this issue, here is an appraisal framework for expert opinion articles which are not based on systematic research or which go beyond the evidence base. It can be applied to a narrative or simple (non-systematic) review of intervention, management or decisionmaking for a specific clinical population, problem or issue, as well as for the sorts of articles that offer overviews of or advice on specific areas of clinical practice. You may download this tool as a document set up for you to print off and use as an individual or with colleagues in a journal club from www.speechmag.com/Members/CASLT. The original set of questions came from a very useful recent article in an American journal (Lass & Pannbacker, 2008):

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Question 1: What is the experts training and experience? This information should help you decide how credible this author is. However, you also need to take into account what sort of advice is being offered. Factual information needs the support of scientific evidence, so the person offering this should be able to demonstrate an understanding of research methods. Speech and language therapy craft knowledge may be more credible coming from someone with a strong background in clinical practice and / or service development. Clients themselves are the ones to offer insights into what its like to receive our services, but the interpretation of clients experiences may be most credible coming from someone with a track record in qualitative research or patient engagement for health service evaluation. Here are some ideas to explore. Do you or any of your colleagues know this person? What is their background, their institutional affiliation and status? Where in the world are they, with what sort of healthcare or other institutional system? Are they a practitioner or an academic, or do they have a foot in both camps? You can try googling them! Question 2: Is the expert trained in Evidence-Based Practice? If authors are experienced in evidence based practice methods, this will influence how they have written the article. They may mention evidence based practice principles explicitly, or the structure and content of the article may reflect this knowledge. They will also be more likely to adopt a cautious, measured approach to expressing their recommendations or opinions. Question 3: Has the treatment or other practice been published in peer-reviewed journals? Question 4b: Does the expert consider counter-evidence? It is not acceptable for authors to present only the evidence that appears to support their interpretations or recommendations. Even if counter-evidence is not available, they need to show that they have considered alternative interpretations. Question 5: Does the expert provide up-to-date information? Dont be impressed with authors who appear to be stuck in a time warp, no matter how innovative they were in the past. Knowledge moves on, as do the contexts in which our clients are living and the constraints of service provision. Check the dates of the references at the end of the article and / or within the text. Are there references or authors missing that you might have expected to see? Question 6: Is the experts opinion consistent with known facts, previous research, and theory?

Check in the references, though you may need to follow this up with a literature search. Most academic journals claim to be peer-reviewed these days. It is tempting to think that an article must surely be credible if it has got through peer review into print. Unfortunately, it seems the process is less than watertight and reviewers may not share a clinicians main concerns. It might help to understand that there is a pecking order amongst academic journals. People whose careers hinge on the rankings of their publications (that is, any current or aspiring academic) want to get their articles published in journals that are highly ranked and cited by other academics in their field, such as the Journal of Speech, Language and Hearing Research. The journal Child Language Teaching and Therapy may not be so highly ranked by academics but I bet that it is considerably more widely read by speech and language therapy practitioners. Aspiring authors have to play the game by the rules of the academic journals; this has an impact on perceptions of scientific rigour and credibility, as well as on readability and impact on practitioners. Question 4a: Does the expert consider the quality of the quoted evidence? They should be considering methodological quality and not just its level in the evidence hierarchy (see table 3).

This is where you need your speech and language therapy craft knowledge to help you as well as any awareness of what research has been undertaken in this area. Of course, there may be no relevant research, and thats why you may be reviewing an expert opinion article in the first place! Question 7: Did the expert make full disclosure of any financial interests related to products such as materials and publications?

There are lots of definitions of evidence-based healthcare but Justice (2006) stresses the importance for speech and language therapy of four key types of knowledge: 1. Information from high quality research studies and systematic literature reviews. 2. Clinicians expertise (speech and language therapy craft knowledge) because of their theoretical knowledge and clinical experience. 3. Understanding of client preferences to allow us to work effectively with people and their communities. 4. Institutional norms and policies, which constrain the scope of clinical decision-making.

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COVER STORY: JOURNAL CLUB

Its not that we dont want those who invent programmes to write about their own inventions; its just more credible when its done by those who have no commercial gains to make. A lot of the journals are now insisting that authors include a statement about any potential conflicts of interest within the text of the article. Question 8: Is the expert objective and free of bias? We have used this expert opinion framework successfully in several journal clubs. For example, here is an extract from one journal club summary, in which the central article was a research study of ParentChild Interaction Therapy (PCI) for children who stammer: We found it helpful to read about PCI in the context of a recent overview The aetiology and treatment of developmental stammering in childhood by David Ward from the University of Reading. We felt Wards overview was unbiased, objective, evidence-informed, presented from a UK standpoint and free of commercial interests. Wards overview (2008) is a succinct 5-page summary of the current state of the field. It outlines all the important issues around prevalence, diagnosis, prognosis, the developmental features of the disorder, theories of causation, intervention and speech and language therapy practice. He manages to benchmark the issues with the available evidence while not neglecting aspects of the theoretical and practice-based knowledge that contribute to speech and language therapists decision-making. You feel he understands both the academic and the clinical perspectives. The members of this journal club were community paediatric speech and language therapists who worked in a relatively sparsely populated area; they felt that they needed to keep on top of dysfluency work but never had enough clients to feel confident in their skills in this area. The Ward overview was ideal, really, because it provided a context for the focus on one particular therapy for children who stammer. Moreover, it gave them a common framework for beginning to evaluate the care pathways for children who stammer in their local population. In a different journal club, another author was less favourably rated in terms of her attention to the scientific knowledge base: This article was an easy read and the guidance relevant for our clinical practice It gave us some ideas for managing barriers and conflict in our work with parents. There was much that rang true in the family-centred approach described, and we felt that there were strong links to Care Aims and getting the patients story emphasising yet again the need for therapists to have strong emotional and negotiation skills. However, we were not convinced that the guidance had any real scientific basis. We did some googling of said author the group had no previous knowledge of her and according to the entry in her university website she had an impressive curriculum vitae, including experience of relevant clinical practice and teaching, funded research in the area, associate editorship of a peer-reviewed journal, PhD supervision and so on. However, her references were out of date, very few were research-based and she did not discuss the methodological quality or strength of the rather flimsy set of evidence she did present. The article had been published in a peer-reviewed journal with an international readership. So you really cannot make assumptions about credibility just from the SLTP fact the stuff has got into publication! Jennifer Reid is a consultant speech and language therapist with NHS Fife, email jenniferreid@nhs.net.

References

Read between the lines and look for sources of bias or unspoken influence, for example from institutional affiliations or personal beliefs. Question 9: Does the expert provide a comprehensive overview (both sides)?

Greenhalgh, T. (2006) How to read a paper: the basics of evidence-based medicine (3rd edn). Oxford: Blackwell Publishing Ltd. Justice, L. (2006) Evidence-based practice briefs: an introduction, EBP Briefs. Available at: http://www.speechandlanguage.com/ebp/ justice-intro.asp (Accessed: 19 July 2010). Lass, N.J. & Pannbacker, M. (2008) The application of evidence-based practice to nonspeech oral motor treatments, Language, Speech and Hearing Services in Schools 39(3), pp.408-421. Public Health Resource Unit (2006) Critical Appraisal Skills Programme (CASP). Oxford: PHRU. Available at: www.phru.nhs.uk/Pages/ PHD/CASP.htm (Accessed: 19 July, 2010). Taylor-Goh, S. (2005) RCSLT Clinical Guidelines. Milton Keynes: Speechmark. Ward, D. (2008) The aetiology and treatment of developmental stammering in childhood, Archives of Disease in Childhood 93(1), pp.68-71.

Is there another interpretation or approach that the expert appears to have overlooked or ignored? Question 10: Does the expert mainly cite his or her own work?

Download the expert opinion framework document from w w w. s p e e c h m a g . c o m / Members/CASLT. Use it yourself or with colleagues in a journal club, and let us know how you get on (email avrilnicoll@ speechmag.com). If you are a member of the Royal College of Speech & Language Therapists you can also see information to help you start and make the best of journal clubs at www.rcslt.org/ members/cpd/journal_clubs.
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Check the references and the text. This can be a bit of a giveaway. Its okay to cite yourself (racks up citation points for your academic ratings!) so long as you cite other authorities as well.

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A complementary view
You have fairly strong views on complementary therapy. Perhaps you have derived a lot of personal benefit and you are aware of the impact it could have on certain clients, although they havent raised the issue. Or perhaps you are very sceptical but are asked for advice from a client who is keen to try such an approach...
wonder how many readers have taken up some kind of complementary therapy. Have you tried acupuncture, visualisation, homeopathy, reflexology, osteopathy, meditation? Or perhaps someone from your family or one of your friends uses complementary approaches to health and wellbeing? What counts as complementary therapy for you? The definition from the Cochrane Collaboration (http://www.cochrane.org/policy-manual/251cochrane-complementary-medicine-fieldbursary-scheme) (accessed 23 July 2010) says that complementary medicine includes all practices and ideas that are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and wellbeing. Their definition includes a long list of treatments and practices. As an individual, where do you sit on the spectrum of belief in their effectiveness? Do you believe complementary practices to be effective, to have potential for some people and some conditions? Perhaps you view them as hocus pocus and akin to black magic? What is the basis of your belief? Have you read widely on the subject in peer reviewed journals, read books from popular psychology or is your belief based on receiving training in a particular method or on personal experience? The Cochrane Collaboration now has a field that focuses on the reviewing of complementary practices and they have reviewed the effectiveness of herbal medicine, acupuncture and aromatherapy (amongst others) in a number of contexts. As speech and language therapists under the regulation of the Health Professions Council (HPC) and our professional body, the Royal College of Speech & Language Therapists (RCSLT) our scope of practice covers those needs associated with speech, language, communication or swallowing difficulties. Other conditions, unless they impinge on these aspects of an individuals behaviour, are outside our frame of reference. So, even if we have found acupuncture effective for our own back problems and even if we are aware of peer reviewed evidence showing its effectiveness, it is outside our duty of care to an individual and therefore inappropriate for us to offer a professional opinion about it. If the conversation comes at the end of a session and is offered as a personal rather than a professional opinion, then one still has to be

Sue Roulstone considers the following scenario:

BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this new series we think through the sort of everyday events which although they receive much less attention - also need to be on our ethical radar screen. aware of the fact that, as a professional, our voice carries weight and power to influence. The client or carer has come to us for our expertise in speech, language, communication or swallowing. But, because of our professional status in that relationship, they are likely to believe us about other things too. Together you have built up trust and a relationship that then has power to influence. One therefore has a responsibility to use that power with discretion. Even if we state clearly that this is a personal opinion and outside our realm of professional expertise, our existing relationship with them as a professional puts us in a powerful position. Some complementary approaches may be perceived to be applicable to aspects of speech, language, communication or swallowing and here I have to express my own lack of knowledge of the wider literature. Certainly in my own area of expertise - primary speech and language impairments - I am unaware of any evidence base relating to the use of what I had typically considered to be complementary methods, although I am aware of them in other fields such as stuttering and voice disorders. However, Cochrane defines complementary approaches as those that sit outside the domain of conventional practice. This leads me to think more broadly about what one might consider here. Cochranes inclusion of sound therapy as an example of a complementary approach might lead one to think more in terms of those controversial or nontraditional practices (Pannbacker & Hayes, 2007) which are popular but nonetheless cause heated debates within the field.

It seems there are three key questions that practitioners should be asking with respect to the use of complementary methods: I. Is this particular approach considered by RCSLT, HPC and my managers to be within my scope of practice? II. What is the evidence for this particular approach with the particular disorder or client I am dealing with? III. How competent am I to deliver this particular approach?

I. Scope of practice

The Health Professions Council has no specific guidance about the use of complementary methods and would refer registrants firstly to the Standards of conduct, performance and ethics (HPC, 2008) which require registrants to practise within the limits of their knowledge, skills and experience, and secondly to their own professional scope of practice documents. The Royal College of Speech & Language Therapists (2008) notes that complementary therapies are not part of a speech and language therapists core practice and that, in the future, some complementary practices may become the subject of regulation. In this case, therapists wishing to use such approaches would be required to register with the relevant body. RCSLT reminds us that we should always take the advice of and work closely with our managers and employers, since the use of methods which are outside our usual scope of practice may not be covered by the standard insurance policies. It further recommends that we discuss any extended scope of practice with RCSLT advisers, adhere to local governance and risk processes, and seek out relevant policy and position papers.

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BOUNDARY ISSUES (3) / SOFTWARE SOLUTIONS

II. The evidence

If we have an agreement that a particular approach is within our scope of practice, or is agreed as an extended scope of practice with our managers, we also need to consider the evidence base for it. We have a duty laid on us by the Royal College of Speech & Language Therapists and the Health Professions Council to deliver practices that are, as far as possible, evidence based. As indicated above, the Cochrane Collaboration already has a number of systematic reviews of complementary approaches. Sound therapyhas been reviewed as part of a review of auditory integration approaches for autism spectrum disorders and as a masking technique in tinnitus. One might argue that not all traditional interventions used in routine practice have high levels of evidence associated with them; however, it is our responsibility to know what the level and nature of the evidence is and to be prepared to discuss that with regard to any interventions we offer. Writing about the use of controversial and non-traditional practices, Pannbacker & Hayes (2007) alert us to the dangers of reliance on personal testimonies, the risk of harm, and the limitations of a weak underlying theoretical rationale when evaluating the potential of interventions to be effective.

Software solutions
With technology becoming ever more sophisticated and accessible for therapy, our in-depth reviews help you decide whats hot and whats not. ANATOMY
diagrams. It would have been good to have similar sections on videofluroscopy and gastro-oesophageal reflux disease. The animation section includes 3D movements of the face, elevation / depression of the corners of the mouth, movement of larynx / pharynx and elevation / depression of the hyoid bone. This is an expensive resource and the price above only gives a single user licence. It is however a good clinical tool and resource for teaching. Ann Gosman is a specialist speech and language therapist with NHS Orkney.

3D Anatomy for Speech and Language Pathology (DVD-ROM) Ed. P.C. Belafsky, M. Coffey, D. Costello, M. Gilman, N. Lewis-McColloch, Y.A. Sumida, M.E. Atkinson, S. McHanwell & R. Tunstall Primal Pictures ISBN 978-1-907061-12-7 Single user licence 145+VAT (multi-user online licences, student and faculty pricing on request)

Deeper understanding

III. Our competence

Finally we must consider our own competence to undertake any new approach to intervention, whether traditional and accepted or complementary or controversial. The Royal College of Speech & Language Therapists provides the link to the British Complementary Medicine Association (www.bcma.co.uk) for further information on the relevant training and standards for use of complementary therapies. So, when we are next in a position where our opinion on a complementary therapy might be sought, how will we respond? Do we have our answer ready or do we have some work to do to sort out our position? Might it just be a quick response to a passing question or is there more to think about Sue Roulstone is Underwood Trust Professor of Language and Communication Impairment at the University of the West of England, based at the Speech & Language Therapy Research Unit, Frenchay Hospital, Bristol, email susan. roulstone@uwe.ac.uk.

Health Professions Council (2008) Standards of conduct, performance and ethics. Available at: http://www.hpcuk.org/assets/documents/10002367FINALcopyofSCPEJ uly2008.pdf (Accessed: 31 July 2010). Pannbacker, M. & Hayes, S. (2007) Controversial Treatment in speech-language pathology: what are the issues?, TEJAS Journal of Audiology and Speech-Language Pathology Available at: http://www.txsha.org/_pdf/ TEJAS/2007/06%20Controversial%20Treatments.pdf (Accessed 31 July 2010). Royal College of Speech & Language Therapists (2008) POLICY STATEMENT: Evolving Roles in Speech and Language Therapy. Available at: http://www.rcslt.org/members/ publications/RCSLT_Evolving_roles_Policy_Statement_ October_2008_a.pdf (Accessed: 31 July 2010).

References

This DVD-ROM is an excellent resource for students, clinical work, presentations / lectures and for training purposes. It is easy to navigate and shows hundreds of 3D anatomy views of the head and neck including facial muscles, tongue, oro nasal cavities, larynx, pharynx and ear. It is divided into six sections: anatomy, slides, movies, animations, clinical information and patient information. The anatomy plates can be built up and rotated to add or remove layers of anatomy to view and label any structure with ease. I found this enjoyable to use. It gives the experienced clinician a deeper understanding of anatomy and physiology. The illustrations can be found in any good text book but this gives a 3D effect of muscles, blood supply and innervations, with names appearing as you move the mouse. The slides are mostly related to voice disorders. The Clinical Section shows functions such as the normal swallow, voice production and articulation. This will be useful for voice clients or when training nurses in swallowing / swallow screening procedure. The clinical text is provided by a team of clinical authors based in the UK, with contributions from the USA. It is a good resource for UK audiences. Conditions in this section include acute laryngitis, vocal fold paralysis, swallowing problems after stroke and head and neck cancer. Patient Education complements the topics covered in the clinical section. The section on Fiberoptic Endoscopic Evaluation of Swallowing, for example, is explained in patient-friendly language. (What is FEES? Reasons for the procedure. Some of the risks and follow up information.) It has coloured illustrations and a short summary. Each sheet is printable and editable with images and

LANGUAGE

Language Garden www.languagegarden.org David Warr Single Licence 40.00 (inc. VAT)

Good value and fun

This is an online language programme designed primarily for young people with English as a second language. It incorporates the notion of different levels of language and shows progression from verbs, nouns to prepositions, adverbs, clauses and passives. The sentences are shown as a branch in the form of a mind map structure. One component leads from another. It also makes use of colour coding to help the learner with different components of language. We would recommend this activity as it is interactive, fun to use and has a multisensory approach, as it has listening, speaking, reading and writing activities. We found higher levels of the programme were visually very complex and wonder if this programme could be adapted into a linear model. This could then be used for language delayed / disordered clients. This is a good value resource obviously well designed by somebody who has practical experience of teaching English as a second language. Claire Watson, Karen Shuttleworth and Alison Taylor are speech and language therapists in Cumbria.

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how i

How I support TEP closure:

Surgical voice restoration through tracheoesophageal puncture (TEP) has revolutionised quality of life for many people with a laryngectomy. Morwenna White-Thomson investigates how, when it doesnt work out, the involvement of speech and language therapists might help to improve the success rate of TEP closure.

An open and shut case?

Read this if you are interested in Multidisciplinary working Problem solving clinical issues Making practice more evidence based

s is often the case, my motivation for this article came from clients. Unusually, in 2008, three of our laryngectomy patients required tracheoesophageal puncture (TEP) closure. From this experience and discussion with colleagues in the region, I became aware that this is not always a straightforward process and there is little understanding about what procedures are used, the numbers involved and which practices have better outcomes. I decided to investigate factors that might contribute to the failure of closure through a literature search and survey of ENT units in Southwest England and South Wales (WhiteThomson, 2009). Although not the focus of this article, it was interesting to note that it was not easy for the survey respondents to access basic patient data and thereby provide robust, comparative clinical information. The decision about whether to keep a voice prothesis (valve) in place ultimately lies with the ENT consultant and patient. This decision however is not always straightforward, unless closure is required on medical grounds. Head and Neck cancer is a very multidisciplinary field. It is important that speech and language therapists who often change the voice prostheses, trouble shoot valve, voice and swallowing difficulties and usually know the patients very well are able to have an informed discussion about the risks and benefits of TEP closure.

During exhalation and digital occlusion of the stoma, pulmonary air is directed through the prosthesis and into the oesophagus. The flow of air causes the pharyngoesophageal segment to vibrate and these vibrations become the laryngectomy speakers new voice. This tracheoesophageal voice is the current method of choice for communication post laryngectomy compared with oesophageal voice (which does not require a TEP) or use of an electrolarynx. It is superior to oesophageal voice both subjectively and acoustically (Callanan et al., 1995) However, it is not without complications (Malik et al., 2007). Sometimes repuncture is possible but, if it is not, the TEP has to be closed permanently.

SURGICAL VOICE RESTORATION

Surgical voice restoration via a TEP is one of the most significant developments in head and neck surgery in recent years, and is accepted as the gold standard in voice rehabilitation (Stafford, 2003). A functional voice is essential to a laryngectomy patients quality of life, and in a majority of cases successful voice rehabilitation is achieved (Op de Coul et al., 2000). Surgical voice restoration involves the creation of a fistula, known as a TEP, between the trachea and the oesophagus. A one-way silicone valve is inserted into this fistula which allows air to pass into the oesophagus, but prevents food and fluids entering the lungs.

In a retrospective study of 318 patients at the Netherlands Cancer Institute, 5 per cent of laryngectomy patients required permanent TEP closure (Op de Coul et al., 2000). In my survey of ENT units in South West England and South Wales it was 9 per cent (White-Thomson, 2009). Reasons why a TEP might be closed include persistent peripheral leakage, poor voice quality, an inability to care for the valve due to cognitive or physical difficulties and patient preference (White-Thomson 2009). However, TEP closure is not necessarily as straightforward as its formation (Judd & Bridger, 2008) and the process can be time-consuming and complex. Patients can wait several weeks for spontaneous closure to occur. Conservative methods to encourage closure vary (WhiteThomson, 2009) but might include the use of smaller catheters, cuffed trachy tubes and nasogastric feeding. If such methods are not successful then surgery will be necessary and even then patients may need to undergo more than one procedure. Although factors such as diabetes and hypothyroidism (Aguilar et al., 2001; van As-Brooks & Fuller, 2007) can potentially contribute to poor tissue health and subsequent complications related to healing, my focus is on four areas of relevance to the patients on our unit (figure 1).

TEP CLOSURE

(i) Impact of radiotherapy

Radiotherapy can lead to compromised vascularisation, with thinning of the tissues and fibrosis, which causes stiffening and rigidity. These effects can occur many years after completion of radiotherapy (Kelly, 2007). Otolaryngologists often expect to see problems related to scar formation or devascularisation following radiotherapy but retrospective studies fail to demonstrate any adverse effects with regard to surgical voice restoration (Hilgers & Balm, 1993). However, the severity of problems in radiotherapy patients may be more profound (Andrews et al., 1987) and the dosage could be significant (Singer et al., 1989). If radiotherapy affects tissue health prior to TEP closure (for example contributing to TEP widening), it might also compromise successful closure. Radiotherapy is commonly cited as a cause of peripheral leakage (Margolin et al., 2001) but no studies have shown this to be statistically significant (Kao et al., 1994). Results from papers concerned specifically with surgical procedures for TEP closure are

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how i

Figure 1 Morwennas clients Jack Jack had his laryngectomy operation in January 2008 and had undergone a course of radiotherapy. He developed cognitive difficulties post surgery and was unable to manage his valve. He was admitted to hospital in May and his TEP closed down within 3 days using conservative methods. Interestingly, he was less than five months post TEP formation. David David had his laryngectomy operation in March 1994 and had undergone a course of radiotherapy. By the middle of 2008, he was diagnosed with severe pulmonary fibrosis and presented with fairly gross intra oesophageal reflux which extended to above the level of the clavicles. Due to these co-morbidities, persistent central leakage and good ability to use oesophageal voice, TEP closure was attempted. He underwent surgical closure on two occasions, four weeks apart. The initial attempt was unsuccessful, and the outcome of the second procedure was uncertain as David sadly died. Robert Robert had his laryngectomy operation in March 2007, and did not receive any radiotherapy. One year later he was admitted to hospital with progressive dysphagia, malnutrition and significant weight loss. A nasogastric tube was inserted and four weeks later it was decided to close his TEP. He rarely used his valved voice, and had lung disease and marked breathing difficulties. Over a period of three weeks attempts to close the TEP using conservative methods were unsuccessful, so surgical closure was attempted. Unfortunately a pin-prick leak persisted and eventually his voice prosthesis was reinserted. This process took four months and included 30 days in hospital, theatre time and considerable amounts of input from different members of the multidisciplinary team, not to mention the distress it caused him.

mixed. In a retrospective study of the success rate of a simple closure technique, Moerman et al. (2004) suggested radiotherapy seemed to compromise wound healing. Perfect wound healing with immediate success happened in 6/12 patients. Two patients in this group did not receive radiotherapy. Complications occurred in the other six, who had all received radiotherapy. In a study by Rosen et al. (1997) surgical closure was successful in 13/14 cases, and all but one patient had received a full course of post operative radiotherapy. Unlike Moerman et al. (2004) they concluded that previous irradiation per se did not affect the closure rate. However, it is possible that these conflicting results might be due to the difference in surgical technique as opposed to radiotherapy alone. Inevitably, study numbers are very small, there are other variables, and most patients will have undergone a course of radiotherapy, making it difficult to get statistically significant data. Case series studies reporting successful closure rates do not always identify whether patients have undergone radiotherapy. Hosal & Myers (2001) suggest one TEP failed to close successfully due to the patient being heavily irradiated around the stoma (p.216). Judd & Bridger (2008) specifically advocate vascularised interposition grafts to counteract the effects of radiotherapy. Annyas & Escajadillo (1984) argue that using grafts outside the field of radiotherapy is a good alternative to regional muscle flaps. IN PRACTICE: It remains controversial whether radiotherapy directly affects TEP closure, and opinions differ as to its significance. Nevertheless, radiotherapy is often cited as a cause of poor wound healing and it might have a bearing on the surgical procedure chosen. When assessing a patient prior to TEP closure it is important to be aware of their radiotherapy history. How an individual has responded to radiotherapy in terms of tissue damage might be a better indication of tissue health and subsequent healing than the radiotherapy itself or the dose given.

Head and neck cancer patients often have low nutritional status due to poor dietary intake and high tobacco and alcohol intake, and between 30-50 per cent of newly diagnosed patients are malnourished (Lees et al., 1998). Surgery, radiotherapy and chemotherapy cause acute metabolic stress leading to increased nutrient demand (Black, 2009) and this can be ongoing after healing is apparently complete (Casey, 1998). Laryngectomy patients often experience difficulties with swallowing which can impact on their weight and nutritional health. In Maclean et al.s study (2009), 72 per cent reported dysphagia. This patient group is nutritionally at risk both prior to and post treatment. Casey (1998) states that malnutrition often leads to poor or delayed wound healing. She argues that, although most wounds heal given time, the rate can be improved by identifying those at risk of malnutrition early on and ensuring that diet reflects the increased demands. Gray & Cooper (2001) claim that objective data has failed to support the widely accepted view that nutrition is vital in the healing of wounds. Much of the existing evidence consists of small trials, applying different interventions and outcome measures to very variable populations (NICE, 2006). A significant body of research examines possible causes of wound infections in head and neck cancer patients but multiple contributory factors are difficult to extrapolate (Aguilar et al., 2001). Capuano et al. (2008) found weight loss in patients undergoing concomitant chemoradiotherapy correlated significantly with early mortality, infection and hospital admission in non-compliant patients. In a retrospective study of over 2,000 veteran laryngectomy patients, Schwartz et al. (2003) showed poor nutritional status had strong associations with wound complications. The authors acknowledge a lack of comprehensive data regarding other factors that might influence wound healing. For example, low preoperative albumin was associated with twice the risk of wound

(ii) Impact of nutrition

complications compared to patients with normal levels. However, low albumin levels can be an indication of chronic infection as well as malnutrition. In many papers on the outcome of surgical closure of TEPs, nutritional status is rarely mentioned. This supports Gray & Coopers claim (2001) that good nutrition is often seen as a low priority amongst health care professionals. Despite the lack of objective data, NICE (2006) guidelines (based on a combination of clinical evidence, clinical experience and expertise) state that nutritional interventions in malnourished hospital patients can reduce complications, lengths of stay and mortality. They recommend all patients are screened on admission to identify those who are malnourished or at risk of becoming so. IN PRACTICE: There are many reasons why laryngectomy patients might become malnourished. They often have poor nutrition at the time of diagnosis and treatments can impact further. Although more research is needed into the impact of poor nutrition on wound healing and the benefits of supplementation, the link between nutrition and wound healing cannot be ignored. Speech and language therapists are in a good position to be aware of any problems with swallowing, weight loss or nutrition. If there are any concerns, they should liaise with dietetic colleagues about nutritional screening and assessment prior to surgery. Given the ongoing nature of the healing process, it is also important to take into account the potential impact of poor nutrition with patients who have been discharged with an apparently healed TEP, only to return some weeks later with a slight leak.

(iii) Impact of reflux

Reflux is known to cause laryngopharygeal injury and poor mucosal healing and is associated with contact ulcers, granulomas and chronic laryngitis (Seikaly & Park, 1995).

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HOW I
Although there is less information about the effects on laryngectomy patients (Pattani et al., 2009), reflux has been cited as a cause for TEP enlargement and reduced tissue health (Gerwin et al., 1997; van As-Brooks & Fuller, 2007). Reflux is common in patients with laryngeal and pharyngeal carcinoma (Copper et al., 2000), and Smit et al. (1998) found a high incidence of reflux in laryngectomy patients. Jobe et al. (2002) suggested that tracheoesophageal voicing may worsen or even cause gastroesophageal reflux (GORD) secondary to the gastric insufflation that can occur by using the oesophagus as a reservoir for air during voicing. Although medical treatment can effectively reduce the acid content and volume of reflux, there is no mechanical barrier against regurgitation to the level of the TEP. Seikaly & Park (1995) suggest GORD may play a role in pharyngocutaneous fistula formation after laryngectomy, and that prophylactic anti-reflux medication significantly decreases the incidence of fistulas. It is possible therefore that reflux might play a role in the failure of TEP closure. Lorenz (2009) claims that, in a majority of cases, atrophy of the party wall with consecutive puncture enlargement appears to be caused by pathological reflux. IN PRACTICE Given our understanding of the effects of reflux on the larynx and the link being made between pharyngocutaneous fistulas, tissue atrophy, enlarged TEPs and GORD, it would seem prudent to screen for reflux when planning TEP closure. A careful history needs to be taken for symptoms of reflux prior to surgery. If suspected, treatment with anti-reflux medication is indicated. Purse string suturing is one of the simplest methods used. In my survey (White-Thomson, 2009), four units reported failed purse string procedures, two reported variable results and one did not use purse strings due to potential continued leakage. Malik et al. (2007) also found limited success with purse strings suturing. Samuel (2009) explains that with posterior tracheal wall suturing the oesophageal opening and the tract are not addressed, resulting in penetration of saliva and leakage through the repaired tracheal opening. Hosal & Myers (2001) describe a simple surgical technique (similar to that used with David and Robert, figure 1, p.25) with separation of the tract and suturing of the tracheal and oesophageal mucosa. Multiple layer closure of the oesophageal fistula to prevent leakage was successful in 8/9 cases. In the retrospective study by Op de Coul et al. (2000) nineteen patients underwent TEP closure for persistent peripheral leakage. All had sectioning of the fistula tract and closure of the oesophagus in two layers and the trachea in one layer. Although no details were given, it is reasonable to assume the surgery was successful, as eighteen patients went on to have a repuncture. However, using a very similar technique, Moerman et al. (2004) only had immediate success in 6/12 cases, and recommended its use be limited to nonirradiated patients. Other surgeons advocate closure using an interpostition graft. Some recommend a dermal graft; Rosen et al. (1997) had good outcomes in 13/14 patients and suggest that use of more bulky muscle flaps compromise the tracheal and oesophageal lumens, and Annyas & Escajadillo (1984) argue that the success of regional flaps can be put at risk due to radiotherapy tissue damage. In heavily irradiated patients or in other high risk conditions prone to fistula formation, the introduction of non-irradiated tissue from a site separate from the head and neck might be beneficial, for example the pectoralis major myofascial flap (Singer et al., 1989). There appears to be some clinical consensus about the benefits of sternocleidomastoid muscle flaps (Singer et al., 1989; Porter, 2009; Samuel, 2009; White-Thomson, 2009). In a case series of five patients over seven years, Judd & Bridger (2008) describe a 100 per cent successful use of a rotated sternocleidomastoid muscle as an interposition graft. They argue that, because the graft has a broad base, it can maintain a healthy vascular supply on which the repaired fistula openings can heal, and a second wound site is not needed. In patients with persistent fistulas despite several surgical attempts, Schmitz et al. (2009) reported successful use of a septal button. For a TEP that was located low in the trachea, Gehrking et al. (2007) described an allogenous collagen graft. Margolin et al. (2001) showed promising results with injection of granulocyte macrophage colony stimulating factor in promoting healing of tissues with peripheral leakage; this might have implications for the closure of TEPs in future. In practice: Matching surgical simplicity with success rate can be a challenge and many factors will influence successful closure irrespective of surgical technique. The decision regarding type of surgical procedure lies with the operating surgeon but it appears that purse string sutures are not reliable, while the introduction of an interposition graft affords consistently good results. TEP closure is relatively rare but it can be complicated, time consuming and costly. More research is required to fully understand the impact of radiotherapy, nutrition, reflux and surgery on outcomes. There is, however, sufficient evidence to argue that patients need to be given a comprehensive assessment prior to surgery to identify any risk factors that might compromise healing. Measures such as anti-reflux medication, additional nutritional support or use of a specific surgical technique can then be taken to ensure the best possible outcomes for TEP closure. I would be very interested to receive feedback on this article and to learn more about current practice in other centres. SLTP Morwenna White-Thomson is principal speech and language therapist and clinical team leader in ENT with North Bristol NHS Trust, email morwenna.white-thomson@nbt.nhs.uk. The full report of Morwennas regional survey is available at www.speechmag.com/Members/Extras.

(iv) Impact of surgical method

Surgeons use a variety of procedures for closing a TEP. Patients have already experienced major surgery, have often undergone radiotherapy and have generally struggled for a period of time with TEP related failure. Although keen to resolve these problems they are often wary of undergoing further surgery, so the aim must be to provide successful closure with the simplest technique. Most TEPs epithelialise or develop fibrosis over a period of a few months (Samuel, 2009). Because of this, long-term fistulas often do not close spontaneously (Judd & Bridger, 2008). However, de-epithelialisation or cautery to the edges of the tract may accelerate closure (Malik et al., 2007). In Holland there is consensus in practice. If a TEP is less than six months old, the valve is removed and rapid closure anticipated. If the TEP is more than six months old, a fresh cut closure is used followed by suturing or a flap repair (van As-Brooks, 2009).

Reflections Do I have an awareness of risk and protective factors that may influence recovery or progress? Do I remain alert to the unintended negative consequences of any intervention, whether surgical, medical or words? Do I record data in a way that enables me to compare outcomes?
Do you wish to comment on the impact this article has had on you? Please see guidance for Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

26

SPEECH & LANGUAGE THERAPY IN PRACTICE autumn 2010

HOW I / RESOURCES

References
Aguilar, O.G., Pardo, H.A., Vannelli, A., Simkin, D.O., Rossi, A., Rubino, A. & Simkin, D. (2001) Total Laryngectomy: Pre- and Intrasurgical Variables of Infection Risk, Int surg 86, pp.42-48. Andrews, J.C., Mickel, R.A., Hanson, D.G., Monahan, G.P. & Ward, P.H. (1987) Major complications following tracheoesophageal puncture for voice rehabilitation, Laryngoscope 97, pp.562-567. Annyas, A.A. & Escajadillo, J.R. (1984) Closure of tracheoesophageal fistulas after removal of the voice prosthesis, Laryngoscope 94, pp.1244-1245. Black, L. (2009) Nutrition following treatment for head and neck cancer. Master classes in Head and Neck Cancer management, Bristol. Callanan, V., Gurr, P., Baldwin, D., WhiteThomson, M., Beckinsale, J. & Bennett, J. (1995) Provox valve use for post-laryngectomy voice rehabilitation, Journal of Laryngology and Otology 109, pp.1068-1071. Capuano, G., Grosso, A., Gentile, P.C., Battista, M., Bianciardi, F., Di Palma, A., Pavese, I., Satta, F., Tosti, M., Palladino, A., Coiro, G. & Di Palma, M. (2008) Influence of weight on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy, Head Neck 30, pp.503-508. Casey, G. (1998) The importance of nutrition in wound healing, Nursing Standard 13(3), pp.51-56. Copper, M.P., Smit, C.F., Stanojcic, L.D., Devriese, P.P., Schouwenburg, P.F. & Mathus-Vliegen, L.M.H. (2000) High incidence of laryngopharyngeal reflux in patients with head and neck cancer, Laryngoscope 110, pp.1007-1011. Gehrking, E., Raap, M. & Sommer, K.D. (2007) Classification and Management of Tracheoesophageal and Tracheopharyngeal Fistulas after Laryngectomy, Laryngoscope 117, pp.1943-1951. Gerwin, J.M., Culton, G.L. & Gerwin, K.S. (1997) Hiatal Hernia and Reflux Complicating Prosthetic Speech, American Journal of Otolaryngology 18(1), pp.66-68. Gray, D. & Cooper, P. (2001) Nutrition and Wound Healing: What is the Link?, Journal of Wound Care 10, pp.86-89. Hilgers, F.J.M. & Balm, A.J.M. (1993) Longterm results of vocal rehabilitation after total laryngectomy with the low-resistance, indwelling Provox voice prosthesis system, Clin Otolaryngol 18, pp.517-523. Hosal, S.A. & Myers, E.N. (2001) How I do it: closure of tracheoesophageal puncture site, Head Neck 23, pp.214-216. Jobe, B.A., Rosenthal, E., Wiesberg, T.T., Cohen, J.I., Domreis, J.S., Deveney, C.W. & Sheppard, B. (2002) Surgical management of gastroesophageal reflux and outcome after laryngectomy in patients using tracheoesophageal speech, The American Journal of Surgery 183, pp.539-543. Judd, O. & Bridger, M. (2008) Failed voice restoration: closure of the tracheo-oesophageal fistula, Clinical Otolaryngology 33, pp.255-264. Kao, W.W., Mohr, R. M., Kimmel, C.A., Getch, C. & Silverman C. (1994) The Outcome and Techniques of Primary and Secondary Tracheoesophageal Puncture, Archives of Otolaryngology-Head & Neck Surgery 120 (3), pp.301-307. Kelly, L. (2007) Radiation and Chemotherapy, in Ward, E.C. & van As-Brooks, C.J. (eds) Head and Neck Cancer: treatment, rehabilitation and outcomes. San Diego: Plural Publishing. Chapter 3. Lees, J., Machtay, M., Unger, L., Einstein, G., Weber, R., Chalian, A. & Rosenthal, D. (1998) Prophylactic gastrostomy tubes in patients undergoing intensive irradiation for cancer of the head and neck, Archives of Otolaryngology, Head and Neck Surgery 124, pp.871-875.

Lorenz (2009) Poster in German, paper in preparation. Laryngectomee Rehabilitation and Surgical Voice Restoration Masterclass, Bristol. Maclean, J., Cotton, S. & Perry, A. (2009) PostLaryngectomy: Its Hard to Swallow: An Australian Study of Prevalence and Self-reports of Swallowing Function After a Total Laryngectomy, Dysphagia 24(2), pp.172-179. Malik, T., Bruce, I. & Cherry, J. (2007) Surgical complications of tracheoesophageal puncture and speech valves, Otolaryngol Head Neck Surg. 15(2), pp.117-122. Margolin, G., Masucci, G., Kuylenstierna, R., Bjorck, G., Hertegard, S. & Karling, J. (2001) Leakage around voice prosthesis in laryngectomees: treatment with local GM-CSF, Head Neck 23, pp.1006-1010. Moerman, M., Vermeersch, H. & Heylbroeck, P. (2004) A simple surgical technique for tracheoesophageal fistula closure, Eur Arch Otorhinolaryngo 261, pp.381-385. National Institute for Health and Clinical Excellence (NICE) (2006) Nutrition support for adults: Oral nutrition support, enteral tube feeding and parental nutrition, Clinical Guideline 32. Available at: http://guidance.nice.org.uk/CG32 (Accessed: 23 July 2010). Op de Coul, B.M.R., Hilgers, F.J.M., Balm, A.J.M., Tan, I.B., van den Hoogen, F. J.A. & van Tinteren, H. (2000) A Decade of Postlaryngectomy Vocal Rehabilitation in 318 Patients, Arch Otolaryngol Head Neck Surg 126, pp.1320-1328. Pattani, K.M., Morgan, M. & Nathan, C.O. (2009) Reflux as a Cause of Tracheoesophageal Puncture Failure, Laryngoscope 119, pp.121-125. Porter, G. (2009) Personal communication. Rosen, A., Scher, N. & Panje, W.R. (1997) Surgical closure of persisting failed tracheoesophageal voice fistula, Ann Otol Rhinol Laryngol 106, pp.775-778. Samuel, P. (2009) Personal communication. Schmitz, S., Van Damme, J. & Hamoir, M. (2009) A simple technique for closure of persistent tracheoesophageal fistula after total laryngectomy, Otolaryngology-Head and Neck Surgery 140, pp.601-603. Schwartz, S.R., Yeuh, B., Maynard, C., Daley, J., Henderson, W. & Khuri, S.F. (2003) Predictors of wound complications after laryngectomy: A study of over 2000 patients, Otolaryngology- Head and Neck Surgery 131(1), pp.61-68. Seikaly, H. & Park, P. (1995) Gastroesophageal reflux prophylaxis decreases the incidence of pharyngocutaneous fistula after total laryngectomy, Laryngoscope 105, pp.1220-1222. Singer, M.I., Hamaker, R.C. & Blom, E.D. (1989) Revision procedure for the Tracheoesophageal Puncture, Laryngoscope 99(7), pp.761-763. Smit, C.F., Tan, J., Mathus-Vliegen, L.M.H., Devriese, P.P., Brandsen, M., Grolman, W. & Schouwenburg, P.F. (1998) High incidence of gastropharyngeal and gastroesophageal reflux after total laryngectomy, Head and Neck pp. 619-622. Stafford, F.W. (2003) Current indications and complications of tracheoesophageal puncture for voice restoration after laryngectomy, Current opinion in Otolaryngology & Head and Neck Surgery 11, pp.89-95. van As-Brooks, C.J. & Fuller, D. (2007) Prosthetic tracheoesophageal voice restoration following total laryngectomy, in Ward, E.C. & van AsBrooks, C.J. (eds) Head and Neck Cancer, treatment, rehabilitation and outcomes. San Diego: Plural Publishing. Chapter 9. van-As Brooks, C. (2009) Laryngectomee Rehabilitation and Surgical Voice Restoration. Masterclass, Bristol. White-Thomson M. (2009) Survey of ENT units in South West England and South Wales. Available at http://www.speechmag.com/Members/Extras. (Accessed: 23 July 2010).

Resources
People with certain disabilities that affect reading (visual impairment, physical disability, severe learning disability) can apply for membership of Bookshare, a nonprofit organisation that provides books in accessible formats. www.bookshare.org A live online digital radio station with the primary aim of presenting information and entertainment of interest to people with a disability or limiting medical condition. www.ableradio.com Leisure activities and accommodation throughout the UK and abroad for people with sensory and physical impairments, their friends and families. www.holidaysforall.org Source = MNDA Cheshire Avril Webster of Off We Go! Books has signed a contract with ITV Signed Stories, and some of her books are now on the website. www.signedstories.com A case study of I CANs consultancy involvement in service redesign in Wiltshire www.ican.org.uk/consultancy/~/ media/ICAN%20website/Consultancy/ CaseStudyWiltshire_20May_2010.ashx Cricks WriteOnline now includes WorkSpace, a visual mind mapping tool so users can structure their thinking before a writing task. www.cricksoft.com/uk/products/WriteOnline/ workspace.htm The informal Verbal Reasoning Skills Assessment collated by Maggie Johnson and used in East Kent (formerly known as Canterbury & Thanet) can be purchased for 15. Tel. Denise Pritchard, 01843 282310 Vowels: Short Vowel Contrasts pack (illustrated words organised as minimal pairs) now available from Black Sheep Press, 37 + VAT. www.blacksheeppress.co.uk The Tardive Dyskinesia Center provides information on the condition (whose symptoms mimic those of Parkinsons Disease), and treatment. www.tardivedyskinesia.com A free information and advice service about bilingualism for families and educators. www.bilingualism-matters.org.uk The Encephalitis Society has reported on a wearable digital camera, designed to take photos passively while being worn by the user, as an aid for people with memory loss. www.viconrevue.com; www.encephalitis.info

SPEECH & LANGUAGE THERAPY IN PRACTICE autumn 2010

27

READER OFFER / RESOURCE REVIEWS

Win The Communication Toolkit: Assessing & Developing Social Communication Skills in Children & Adolescents

Resource reviews
TRAINING
Communication in the classroom - Workshops for Secondary Schools Susan Stewart & Amanda Hampshire, STASS, ISBN 978-1-874534-48-8, 60.00+VAT

Reader offer
28

An extra helping hand

Hinton House Publishers are offering 3 readers the chance to win a FREE copy of this practical collection of user-friendly resources for use with 8 to 16 year-olds who have social communication difficulties. The accessible, photocopiable worksheets cover subjects including self-concept, self-esteem, body language and facial expression, awareness of self and others, relationship skills, conversation & listening skills, feeling safe and staying in control. Described as Invaluable and An inspirational resource in a recent Speech & Language Therapy in Practice review, this adaptable toolkit is the latest title in Hinton Houses growing list of practical resources for speech and language therapists. For your chance to win, email your name and address, with Speechmag Communication Toolkit offer in the subject line, to info@ hintonpublishers.com by 25 October. The winners will be notified by 1 November 2010. For more information about Hinton House titles, or for details on how to submit your ideas for publication visit www.hintonpublishers.com.

This is a practical resource for speech and language therapists working in secondary schools, and for secondary SENCOs who wish to raise the profile of communication disorders within a school. It includes 6 workshops for secondary teachers/support staff/speech and language therapists and 3 workshops for secondary students. The workshops are separated into several core communicative components that cover a range of items including social skills, vocabulary, speech and stammering. They are therefore very relevant to most secondary speech and language therapists. As a newly qualified therapist the pack and the thought of carrying out these workshops was a rather daunting prospect; however, once read and practised a couple of times it is really useful to structure and help prepare training sessions and certainly gave a few extra ideas. Carrying out the full set of workshops would require a lot of time and dedication from trainer and trainees, therefore I have found it most useful to cherry pick individual workshops to meet the needs of my caseload. Although the points and activities are quite concise and mostly easy to carry out, some sections can be a little longwinded and not so easy to follow. On the other hand, the contents include fun activities to give members of the group more of an insight and understanding of an individuals difficulties. This resource includes a CD with printable materials and powerpoints. Overall it is extremely helpful for speech and language therapists who train other professionals. However for the price I feel it is only worth buying if you are required to train often or, like me, are not experienced and need an extra helping hand. Amy Ballard is a speech and language therapist working mainly in mainstream and high schools for Betsi Cadwaladr University Health Board, North Wales.

LISTENING SKILLS

Active Listening for Active Learning Maggie Johnson & Carolyn Player, QEd, ISBN 9781898873617, 65

Invaluable for teachers

Reader offer winners

The lucky winners from our Summer 10 offers are Anne Springate (To See Ourselves As Others See Us package, www.talkingmats.com), Lynne McNulty (Communication in the Classroom, www. stasspublications.co.uk) and Julie Austin (Talking Dice Starter Pack, www.talkingdice. co.uk). Congratulations to you all!

Within the classroom situation it is vital that children can communicate effectively to enable them to access the curriculum successfully. They need to be aware of any difficulties and ask for clarification when information has not been understood. This very practical resource aims to develop childrens active listening skills to help them participate more fully in the learning process. Although targeted at 412 year olds, the activities and strategies can also be used with pre-school and older postprimary children. The resource file progresses through a series of 6 steps: 1. Creating a safe environment for active listening 2. Further investigation and planning 3. Linking language to social interaction 4. Concepts of understanding and knowledge 5. Developing clarification skills 6. Maintaining active listening skills. Each section is well organised and provides a short introduction to the area being targeted, followed by a number of activities to develop particular skills. Activities are clearly explained and associated photocopiable resources are provided. I particularly liked the range of visual prompt cards included. General classroom strategies are identified, as well as those appropriate for supporting children with specific communication needs. Coding throughout the file indicates the teaching focus (individual, small group or whole class), and identifies those activities applicable for children with delayed language development or in Early Years settings. A number of classroom observation checklists are included to enable staff to screen for difficulties in specific areas, such as childrens responses to questions or ability to clarify information. The reader is also directed to other useful resources and websites where applicable. In my current role, I support mainstream teachers and classroom assistants to meet the communication needs of children within the classroom environment. This file would be a very useful resource to have at hand when working collaboratively with education staff and parents. Equally, it would be invaluable for teachers to use as they develop childrens communication skills. It is reasonably priced and readily accessible for staff in any clinic or school. Anne McMahon is an advisory speech and language therapist in mainstream schools participating in the Speech & Language Development Project, a collaboration between Health and Education (Seconded from South Eastern Health & Social Care Trust to South Eastern Education & Library Board, Northern Ireland).

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2010

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My Top Resources: Winning Ways

KIM MEARS WORKS PART-TIME AS A LONG TERM SUPPORT CO-ORDINATOR FOR THE STROKE ASSOCIATION. BEFORE THAT SHE WORKED INDEPENDENTLY AS A SPEECH AND LANGUAGE THERAPIST, HAVING PREVIOUSLY BEEN IN THE NHS. KIM SAYS, LEAVING THE NHS TO WORK PRIVATELY OR FOR ANOTHER ORGANISATION CAN BE DAUNTING BUT AT THE SAME TIME EXCITING. IT CALLS ON A RANGE OF SKILLS THAT YOU MAY ALREADY HAVE AND ONES YOU NEED TO DEVELOP TO WORK EFFECTIVELY. 1. RESILIENCE This quality is vital when you are working for yourself or in the charity sector - although you might not recognise it in yourself until after the event. Often projects or tasks require innovation, so it is important you are not easily put off by people who do not feel things will work, or by barriers in the system. If you are knocked back or stopped in your tracks, try to find another way around or an alternative method it might turn out with hindsight to be even better than your original plan. For self-improvement books, Id recommend reading The 7 habits of highly effective people by Stephen Covey (ISBN 9780684858395) and Feel the fear and do it anyway by Susan Jeffers (ISBN 978-0091907075). 2. RESOURCEFULNESS In addition to resilience it is invaluable to be resourceful in your approach. Outside the NHS you may need to rely more on yourself to find things out and come up with options for implementing new plans or methods. You also need to build up your own resources of where to go and who to ask. 3. THE INTERNET I honestly dont know what I did before the internet. To be able to find things out instantly, look up articles, stay in touch with colleagues and keep up-to-date is crucial, especially if you are working by yourself. Its a lot easier to be resourceful and prevent yourself from becoming isolated and deskilled if you have the internet. I have a list of websites I use regularly, I subscribe to relevant e-updates from journals and the Stroke Association, and am always on the lookout for new sites. One I use a lot is www.communicationpeople.co.uk, which has symbols along with guidance and templates for making communication tools. 4. GOOD CONTACTS I have come to realise it really is not what you know but who you know. The internet has helped me find new contacts and keep in touch with old ones but it is important too to get out and about and meet people. I am amazed who I have met by chance at events and conferences and how that has enabled me to continue to be resourceful. When recently I had to begin to recruit volunteers, I called a few people I knew who then put me in touch with other people and I could start the process with confidence and a few new contacts. I keep a business card folder so I can look up details quickly. I always take peoples cards because you never know when they might come in handy. I also write the numbers I use often in the back of my diary for speed of access. It is important to be a good contact as well. Having your own business cards is ideal (some websites do them for free, like www.vistaprint.co.uk). 5. SUPPORT NETWORK In the same way you need good contacts, you need supportive friends and family. It can be isolating working alone or from home. It can be daunting to take the plunge to become self employed or work for a charity, leading to self doubt. I found talking to friends and family really helped keep me on track. Watch that you dont become a bore - working on your own can mean that when your partner gets home they hear all about your day without pausing for breath! 6. SUPERVISION In an effort not to drive your friends and family mad it is important to have professional supervision. This can give you an opportunity to think about how you are progressing and to bounce ideas off another person. This can be peer supervision, which I am fortunate to have with another colleague, or external supervision with a specialist company or life coach. I cannot recommend Jo Middlemiss highly enough; she was incredibly helpful when I was setting up my business a few years ago. 7. TRAINING Continuing professional development is essential in maintaining any registration requirements and keeping yourself up-to-date. Relevant conferences are usually cheap, informative and a great way to meet people, and the sales stands let you see current resources and pick up freebies. Training outside the NHS can be difficult to find and fund, especially if you are self employed, but there are a number of places you can find training free or at a good rate (use your contacts and internet forums). You may also need to go on training to help you with your business, and the Inland Revenue offer invaluable free courses on accounts and tax returns. 8. WORK LIFE BALANCE When you are self employed or part-time and are based at home it can be difficult to manage your time effectively and not end up working all hours. Initially, I found it difficult to switch off as the work was always there. I had to make times to work, stick to them and, once the work was done, put it away out of sight. This can also help if you find it hard to get started, so you dont end up tempted to clean the house or watch TV instead of getting on with that tax return! 9. GOOD WORKING ENVIRONMENT It is quite amazing how much stuff comes with working from home: paperwork, records, equipment and - the worst offender stationery. Everything needs to be bought in bulk and then ends up stored wherever there is a space. My husband despairs at the state of our loft as so much paperwork is up there. To resolve the matter we had a walk-in cupboard built which stores all my work stuff neatly out of the way. If you have the space a dedicated area can be set up with a desk and so on - but make sure you can close the door at the end of the day to keep that work / life balance in check. 10. SENSE OF HUMOUR Finally the main resource I think is invaluable both in and out of the NHS is your sense of humour. It is always good to be able to laugh at yourself and see the funny side of things. I like to watch funny programmes and sometimes it is a life saver to get a humorous email in amongst all the demanding, serious ones. It is great to multiply the laughs by sharing funny, inoffensive stories around. Without a sense of humour life would be very hard indeed - and with it you can have a little chuckle to yourself and carry on regardless.

Life coach Jo Middlemiss says

I dont think that Ive ever been referred to before as a top tip but I am delighted to take the plaudit. Kim was one of the first speech and language therapists to take up this magazines offer of a complimentary coaching session. We went on to have a very satisfying coaching relationship. Reading this has reminded me of Kims determination to succeed and I am delighted to see her subsequent and enlightening development. I can assure you I played a tiny part - the ideas are all hers. The thing that strikes me most is the allroundness of Kims suggestions. She really has not left anything out and has included a little of everything with nothing being too dominant. I still refer to the two books she mentions, and I think we may also have discussed The Work We were Born to Doby Nick Williams (ISBN 9780007335428). When you are doing what you love and you keep life and its ups and downs in perspective, how can you fail? Of course it takes courage and resilience, especially if you are going to fly solo. But, as Kim mentions, no one is ever really alone if they take the plunge and call on all the support available. Anyone who is feeling a bit lonely or isolated in their career at the moment is going to find this article hugely helpful. Thank you Kim. Jo offers a complimentary half hour coaching session for the cost of your call, tel. 07803589959.