ISSN 1368-1205

Summer 2010

The Enneagram Personality matters Yes we can A Kenyan homecoming Winning Ways At the ASHS Convention Instrumental assessment for dysphagia What does this house believe? How I assess for specific language impairment A snapshot from Ireland My Top Resources A focus on solutions

Total communication: a kick start

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Summer 2010 publication date 31 May 2010) ISSN 1368-2105

Summer10contents
4 COVER STORY: KICK STARTING TOTAL COMMUNICATION As a direct result of offering drop-ins at the road shows, we have developed a new model of working called See A SaLT. These sessions provide practical advice and support without people having to wait a long time for a more traditional service . Driven by a desire to see the communication needs of adults with learning disabilities given a higher priority, Helen Page and Viki Baker kick started an ambitious programme of cultural change. Thanks to our cover models Cherry and her sister Holly, pictured at the Kick Start Festival of Togetherness by John Cole (www.johncole.co.uk). 6 EDITORS CHOICE 7 HERES ONE I MADE EARLIER Alison Roberts with a low cost therapy idea - Older or younger? 7 READER OFFERS Win Communication in the Classroom and a Talking Dice Starter Pack. See also To See Ourselves As Others See Us on p.2. 8 EMPATHY The rational, slightly distant type 5... will probably want us to stick to the facts and get on with assessment and therapy, whereas the sensitive and selfaware type 4 will probably need careful handling of their feelings beforehand. Eric Foggitt on how the Enneagram can help personal and professional development, workplace relationships and clinical outcomes. 11 WINNING WAYS If that email ever arrives in your inbox offering you the chance of a lifetime, we urge you to take it. Claire Butler and Roger Newman overcame their fears to present at the ASHA Convention. Commentary from Life Coach Jo Middlemiss. 14 REVIEWS Dementia, daily living, feeding difficulties, theatre voice, early years, how we learn, social communication, autism, deafness, signing. 16 DOES THIS HOUSE BELIEVE IN INSTRUMENTAL ASSESSMENT? Instrumental testing serves an integral role in dysphagia diagnosis and treatment. Clinicians must recognise the potential dangers and impracticalities of over-using instrumental measures. Samantha Procaccini and Paula Leslie consider the arguments for instrumental assessement of all acute patients with dysphagia. 19 SUSTAINABILITY There needs to be as much planning at the start of projects, new initiatives or redesigns as to how the input will be sustained long-term. Lois Cameron reflects on what pioneers of the profession in Kenya can tell us about improving practice in the UK. 22 IN BRIEF Sheina Stockton finds treasures in teaching English as a foreign language resources. 22 ASSESSMENTS ASSESSED Sandra Polding road tests Measures of Childrens Mental Health and Psychological Wellbeing. 23 BOUNDARY ISSUES You are working with a client / parent of a client who smokes heavily. To what extent is such lifestyle choice and information the responsibility of a speech and language therapist? Roger Newman responds to the second scenario of our ethics series. 24 HOW I ASSESS FOR SPECIFIC LANGUAGE IMPAIRMENT What assessment tools do I use and why do I use them? Are there new assessments in my department which I have not had time to look at yet? Rena Lyons audits assessment practice in Ireland and draws lessons for practice. 30 MY TOP RESOURCES ...clients are able to imagine a preferred future that involves a description of what they want rather than what they dont want. Kidge Burns shares the secrets of being successful with solution focused brief therapy.

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NEWS

HPC online

Health Professions Council registrants can now change their contact details, renew their registration and pay their fees online at www.hpc-uk.org/registrants/account/.

Empower point

Treasure hunt

Following their article in the Summer 09 issue, Lesley Smith and Laorag Hunter presented a poster about using dynamic PowerPoint as a therapy tool at the British Aphasiology Society conference. Laorag says, After the conference we had requests to deliver seminars on the topic. As this wasnt possible due to time constraints, we have made a PowerPoint presentation which we are happy to send on a CD to anyone interested in learning more about this. Email Laorag.hunter@nhs.net Ref. Munro, L., Hunter, L., Smith, L. & Johnson, V. (2009) How I put learning into practice (2): Empower point, Speech & Language Therapy in Practice Summer, pp.26-28.

Research funding secured

The Underwood Trust has donated 1.2 million to secure the future of work by the Speech and Language Therapy Research Unit in Bristol. Professor Sue Roulstone said, We are grateful for this very generous support that will enable the team to find solutions for people who experience speech, language and communication difficulties. We are committed to detailed analysis of what therapies work best, how technologies used by professionals working in this arena might be put to better use and to find out more about why some people with speech and communication difficulties cope better than others. www.speech-therapy.ik.com/ www.theunderwoodtrust.org.uk/

Speech and language therapist Christina McRoe has recently returned from Romania where she introduced Treasure Bags to promote play and communication skills among children with disabilities who spent their early years in an orphanage. Christina joined social enterprise L.I.F.E. as a specialist volunteer to evaluate the childrens communication needs and develop a suitable programme. She says, The children have spent many years in orphanages and, although they are now living in family flats, they continue to suffer the effects of being institutionalised. They do not receive an education and have very few resources. While I was out there, I realised that some of the methods we use here in Liverpool to help children with communication difficulties could easily be implemented in Romania. The problems faced by children in Romanian orphanages came to the attention of a horrified world in the early 1990s. The hopelessly overcrowded and understaffed state-run institutions were completely incapable of providing the care and attention that a child needs to develop and thrive, and the longterm legacy in terms of their mental health and communication skills emerged over the following years. Unfortunately poverty and the culture in Romania means the practice of families abandoning children at orphanages continues, and charities and organisations have an uphill task to meet basic needs. After visiting projects in Bucharest and Slatina, Christina developed her programme using Treasure Bags, themed around sensory items, colour, listening and dressing up. She is now training other volunteers to work with the children, and is appealing for people or organisations to sponsor a 15 bag. She also welcomes items to include in the bag, such as sunglasses, beads, bangles, hats, floaty scarves, hair bands and mirrors. L.I.F.E., see www.lifeimprovement-uk.com/ index.htm. To sponsor a bag or offer equipment, contact Christina on 07913 230396.

Seeing ourselves as others see us

Speech and language therapists were well represented at the 2010 Advancing Healthcare Awards which recognise allied health projects that make a real difference to patients lives. A team from the Talking Mats Research and Development Centre at the University of Stirling took the Enhancing self-care and independent living award for their latest resource, To see ourselves as others see us. The resource was developed as part of an Economic & Social Research Council funded project which looked at the impact of aphasia on close relationships. It assessed three levels of perspective: what people think about themselves, what they think about their partners, and what they think their partners think about them. It found there were often differences in the views of people with aphasia and their partners, and that this could lead to significant misunderstandings. Developers Morag Place, Joan Murphy and Alex Gillespie hope the tool will help clients and their families understand each other better and aid decision-making and goal-setting negotiations. Two other speech and language therapy projects were shortlisted for different categories. Kelly Halligan and Lorraine Coulter have responded to poor attendance in a deprived area of West Belfast by taking services out of clinics and into schools. The outcomes for the children support the decision to change the way the service is provided. In Liverpool, Janet Sparrow and Anita Williams were recognised for designing and implementing a skill mix plan which resulted in the adult community waiting list being reduced from 81 weeks to just 1.

Win To see ourselves as others see us!

To celebrate their success at the 2010 Advancing Healthcare Awards, the Talking Mats Research and Development Centre is offering a copy of To see ourselves as others see us to a lucky reader of Speech & Language Therapy in Practice. This new resource includes a mat, a set of communication symbols, a booklet and a DVD showing the Talking Mats framework being used as a tool for comparing perspectives. Although developed for people with aphasia and their communication partners, it could be used with other client groups. The package would normally cost 125 + VAT. For your chance to win a FREE copy, email your name and address with SLTiP Talking Mats offer in the subject line to info@talkingmats.com. Your entries need to be in by 25th July 2010. The winner will be notified by 1st August. For more details of this and other Talking Mats resources, visit www.talkingmats.com.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2010

NEWS & COMMENT

Special projects

Special care baby charity Bliss is inviting applications for its Innovation in Care Fund, and is giving priority to the development of small practice interventions from professionals including speech and language therapists. A spokeswoman said, We will consider applications for any project that has the potential to make a contribution to Bliss mission: to improve survival rates and quality of life of babies born sick and premature. Funding up to the and in the region of 30,000 per year is available, for a maximum of two years. The closing date for preliminary applications is Friday 30th July 2010. www.bliss.org.uk / email Zoe Chivers zoec@bliss.org.uk

Comment:

Yes we can
In 1997 just after I bought Speech & Language Therapy in Practice a new government was swept into office on a wave of optimism. The policy context we now take for granted was introduced under their watch devolution of powers including health services to Scotland, Wales and Northern Ireland, and initiatives in England such as Sure Start, Every Disabled Child Matters, the Stroke Strategy and Valuing People. We can argue over resources, bureaucracy and organisational structures but as individuals and departments we drive the aspirations of policy into practice, thus changing cultures. The benefits when this is achieved are beautifully illustrated by Helen Page and Viki Baker (p.4) and our cover picture from the Festival of Togetherness. Another cultural shift is in attitudes to smoking, underpinned by changes in legislation. At first sight this seems to have nothing to do with our profession, but Roger Newmans (p.23) exploration of the issues suggests it should come under our ethical radar. The political scene has been as influenced by the technological revolution as other aspects of our lives. After examining the evidence for offering instrumental assessment to all people referred with acute dysphagia, Samantha Procaccini and Paula Leslie (p.16) remind us that technology is a tool, to be used only if our clinical judgement suggests it is appropriate. In her audit of assessment practice, Rena Lyons (p.24) emphasises we improve clinical judgement by taking time out for reflection. She also points to the interactive nature of policy formation: we have as much right and ability to influence policy as we have responsibility to enact it. A small band of speech and language therapists in East Africa are working on a sustainable policy solution for countries such as Kenya. The lack of understanding of hidden disability seems overwhelming, but the Barack Obama spirit of Yes we can is influential. For Lois Cameron (p.19), spending time with these early pioneers reaffirmed how the power of working with others... enables people to achieve great things. Our new UK government is putting the rhetoric of working in partnership and the reality of the choices, compromises and priorities we all make every day in our working lives into practice. The Prime Minister and his Deputy have taken a strong lead, and it is fascinating seeing the different levels of ability individuals have to cope with this change. Eric Foggitts (p.8) article on the Enneagram may shed light on the challenges of working in any sort of coalition as well as potential solutions! There is no doubt that the architects of the new politics are taking a risk. But as Claire Butler, Roger Newman and Jo Middlemiss discuss (p.11), facing up to the hard work and fears of moving out of our comfort zone are worth it for the sense of achievement of a job well done. Whatever challenges the coming months and years throw us personally and professionally, the tools of solution focused brief therapy (Kidge Burns, p.32) are there to help us show, Yes we can.

Good practice in Childrens Centres

As part of a project aimed at supporting speech and language therapists working in Childrens Centres, Sue Rogers has created a Virtual Learning Environment which therapists can sign up to. A virtual learning environment is a secure web-based area for accessing information. This one will give therapists working in Childrens Centres summaries of national policies and relevant information. It will also include details of packages that can be used to promote communication skills as recommended by a range of Childrens Centres speech and language therapists. The project was funded by the charity Spurgeons, which supports children and young people from disadvantaged communities. Spurgeons provides particular input to Childrens Centres. Any Childrens Centre speech and language therapist can join the Virtual Learning Environment by emailing Sue (jamesandsue@googlemail. com). She will then send you instructions, a user name and login details and invite you to share examples of good practice with fellow users via a standard form which takes no more than 10 minutes to complete.

Oldham PCT speech and language therapists Amber Kraus and Ruth King who work with children and adults with learning disabilities aim to raise 4000 for MENCAP (www.mencap.org.uk) by trekking up Mount Kilimanjaro. To sponsor the team, contact Amber.Kraus@oldham.gov.uk.

MENCAP trek

Children in need in childcare

An Ofsted survey of good practice for children in need in childcare suggests that speech and language therapists taking their services to the child contributes to a coordinated approach that parents and professionals value. The small-scale report into 25 settings from childminders to Childrens Centres in England, including two exclusively for children with special educational needs, highlights rigorous self-evaluation as central to success. The report includes innovative ways in which staff communicate with parents, and emphasises strong links with professionals from a range of other agencies. It also points out that a focus on inclusion has a positive effect on all children as they develop considerable sensitivity in supporting their peers and learning about difference. www.ofsted.gov.uk/Ofsted-home/Publications-and-research/Browse-all-by/ Documents-by-type/Thematic-reports/Children-in-need-in-childcare Source: Contact a Family e-Newsletter

Mutual Caring

The Foundation for People with Learning Disabilities has developed a range of resources as a result of its Mutual Caring project which considers the needs of people with learning disabilities and their elderly parents. The project recognises that the balance of care in many families shifts as both parties age, and that services need to get better at identifying and supporting the many people with a learning disability (possibly up to 29,000) who live with an older family member over the age of 70. In some cases, families fear making the extent of the mutual caring known in case they are separated. The project has produced resources to help develop improved service provision, including booklets for those affected and for the professionals involved. www.learningdisabilities.org.uk/our-work/family-support/mutual-caring/

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2010

COVER STORY: COMMUNITY DEVELOPMENT

Kick Starting Total Communication

Driven by a desire to see the communication needs of adults with learning disabilities given a higher priority, Helen Page and Viki Baker kick started an ambitious programme of cultural change, where communication is seen as the solution rather than the problem.
READ THIS IF YOU WANT TO GET COMMUNICATION ON THE COMMISSIONING MAP DELIVER A SOLUTION FOCUSED, USER-LED SERVICE WORK OUTSIDE TRADITIONAL BOUNDARIES TO MAKE THINGS HAPPEN

s with most speech and language therapists working in adult learning disabilities, our team in Sussex was frustrated that basic communication issues for many of our clients were not being addressed or given high priority by the services they received. For example a hearing impaired client who can sign, living in a non-signing environment; nonverbal clients being described as unable to communicate. Our team felt communication would continue to be a low priority without increased drive, awareness, understanding and energy targeted to this crucial area by the local Commissioners and Learning Disabilities Partnership Board. These boards have been set up across the country as directed in Valuing People (DH, 2001) and reinforced in Valuing People Now (DH, 2009) to ensure that people with a learning disability and their carers have a say in planning and developing services and policies. Viki Baker is Professional Advisor for Speech and Language Therapy at Sussex Partnership NHS Foundation Trust. She designed a project which would both kick start an agenda to address the communication needs of people with learning disabilities and be part of establishing a Total Communication Strategy for East Sussex. The Kick Start Communication project was all about changing a culture. It would place communication central to policy and planning, and view it as the solution and not the problem facing local services. A project proposal to the Learning Disability Development Fund in 2007 successfully secured funding for venues, resources and one day a week of speech and language therapy time to coordinate the project. Kick Start Phase 1 started in 2007 with a series of road shows across East Sussex in community venues such as the civic centre in Uckfield. These road shows showcased and promoted total communication. They were designed for users and for people who support, care for, or come into daily contact with people with a learning disability in the course of their work.

I was keen to take on the role of the Kick Start Communication project worker, and the whole team relished the idea of working outside their traditional professional roles in this new and creative way. We worked in partnership with local users, carers, voluntary organisations, advocacy services and local authority and policy officers to plan and organise the events. They joined us from the beginning, doing everything from being members of the steering group through to running stalls and workshops.

Immediate impact

The road shows enabled people with learning disabilities to see and try out a range of total communication approaches and tools. They also proved a good way to increase families, carers and support services awareness of total communication approaches and resources. The stalls showed how simple, practical ideas can make a big difference and immediately have an impact on the daily lives of people with learning disabilities. We think what made the road shows successful was the range of resources on offer. While there were some commercially produced aids, the majority were simple paper examples that could easily be made by carers using the information sheets provided. There were over 15 stalls including ones on visual planners, talking mats, intensive interaction, signing, voice output aids and making simple communication aids. It was an opportunity for those attending to see examples of best practice and to meet service users on the speech and language therapy caseload who already have effective communication systems. In addition speech and language therapists offered a drop-in service where people could come and discuss any communication issues. They went away with ideas and resources which they could develop further. One happy visitor went home with a key ring to make his communication aid. His speech was unclear but he refused to carry a communication

Our cover star Cherry Lane (centre) enjoys the Festival of Togetherness (p.6) with carer Helen Martin (left) and sister Holly Holt. Photo by John Cole.

book. This was reducing his independence as he was relying on carers to communicate on his behalf. The speech and language therapist suggested using small laminated cards with set phrases and symbols representing activities and topics he wants and needs to communicate, and attaching them to a key ring. In the first year nearly 500 people attended three road shows across East Sussex. They came from a wide range of backgrounds, locations and services, and over half had a learning disability. Other attendees were staff / carers, professionals working in the adults with learning disabilities field and members of the public. The feedback gathered at these events was all overwhelmingly positive. One mother commented, This is the most helpful conversation I have had in my whole experience of professionals talking about my daughter, and she is 19, it was really worth me coming. A residential staff member wrote absolutely brilliant and very inspirational, I cant wait to try some ideas out when I get back to work. Sussex Partnership NHS Foundation Trust gave its innovative services award to this project in 2007. The success of Kick Start Communication Phase 1 put total communication on the commissioning map

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2010

COVER STORY: COMMUNITY DEVELOPMENT

as a top priority and secured funding for year 2. The East Sussex Commissioning strategy Strong Voices Big Ideas has key objectives and funding for total communication work in East Sussex, and has enabled a series of other total communication projects to obtain funding via a Total Communication Strategy. Kick Start Phase 2 provided a combination of training initiatives, road show events, speech and language therapy drop-ins and workshops, all of which focused on prevention of communication difficulties. They gave staff the information and tools to make their work places into Total Communication Environments, where signing, gesture and using pictures are part of the culture. Kick Start also acts as a signposting service to other East Sussex communication projects such as an intensive interaction project and new training initiatives. We improved road shows by increasing resources, marketing, and developing the drop-in service. We ran a programme of workshops concurrently at road shows. One popular session was by Decoda, a local social enterprise specialising in working with people with profound disabilities. As Tom Smurthaite of Decoda says, they are using sound and music as a catalyst for change and to spark new ways of communicating. Two hundred people attended the annual maxi road show in 2008, and 80 of these were people with a learning disability. We also introduced mini road shows which travel to residential services to consult around communication and to link with local person centred planning initiatives. We held mini road shows at the Conquest Hospital, Hastings and the Eastbourne District General Hospital, as part of Learning Disability Week. These mini road shows were aimed at hospital staff and focused on resources relevant to the hospital setting, for example simple pictures showing procedures such as injections and blood pressure, and the best ways to communicate with people with a learning disability who receive outpatient services. and strategic planning of services across East Sussex for people with learning disability. One member, Tim, came to a session in Eastbourne where a number of people got together to plan and agree the standards and evidence. We then took the draft standards to the full Involvement Matters Team. They went through each standard doing role plays, exploring the meaning and impact of the standards and thinking about their own views and experiences. We have successfully secured further funding for 2009/10. This will enable the Kick Start team to use the resources and ideas developed over the last three years to establish a programme of events including: a road show and workshops targeted at families and focusing on transition / school leavers and higher education, run in partnership with education / colleges and paid services a whole range of innovative workshops to ensure implementation of the Total Communication Standards a series of mini road shows aimed at improving competencies and knowledge of both the learning disability workforce and the general public to improve quality of relationships for people with a learning disability targeting universal services such as libraries, police and transport, in partnership with the Community Connections project which employs staff with learning disabilities extending total communication awareness into the public domain such as supermarkets and leisure centres. We have learnt a lot from the past three years and will put this knowledge to good use. For example we will target supermarkets that already employ people with learning disability. Their experiences of working will directly influence our displays to make them more relevant to staff and customers. We will ensure that the road shows demonstrate and model total communication through stalls, workshops, speech and language therapy drop-ins, drama, music and make-and-do activities in creative and energising ways.

Case examples Darren Darrens carers brought him along to See A SaLT to try and get help for his high anxiety around activities. The therapists recommended using photos on a visual timetable to plan his day. The carers were invited to our total communication training on visual planners and produced a timetable to suit Darrens needs. He is much less anxious now he can see what is going to happen. Paula Paula has a severe learning disability and is very difficult to reach. She has a range of self-stimulatory behaviours and shows no motivation to be with other people. The See A SaLT therapists suggested introducing intensive interaction with Paula. This is an approach where interactions are led by the person with a learning disability. The therapists also signposted the carers to Inter-act Now, the East Sussex Intensive Interaction Network. This brings all those using or interested in using intensive interaction together to share experience, develop skills and support those wanting to promote an intensive interaction approach within services.

New model

As a direct result of offering drop-ins at the road shows, we have developed a new model of working called See A SaLT. These sessions provide practical advice and support without people having to wait a long time for a more traditional service. They are a quicker and more efficient way of managing the caseload. Sessions are solution focused and user-led. The See A Salt sessions are provided as a part of the Total Communication Strategy. They work effectively because they are one element of a comprehensive range of services (see case examples). We have established with users and carers a set of Total Communication Standards in services to monitor and audit approaches. Members of the Involvement Matters Team were involved in creating the standards. This group of people with learning disabilities work for the Learning Disability Partnership Board. They are involved in co-designing

Real stories

The Learning Disability Development Fund has financed a Total Communication Resource pack. This is a booklet detailing all the total communication resources available to people with learning disabilities. Its exciting features include real stories of people using their communication aids successfully, photos and signposting to websites, organisations and local groups. It also includes the Total Communication Standards. We have produced a short film of local people with a learning disability communicating to show that total communication is about building relationships and self-esteem, getting to know each other and togetherness. It is a very inspirational film and a great introduction to our training.

We are working on our second film which will link directly to the Total Communication Resource pack. It will show people demonstrating how communication tools such as picture timetables help them in their day-to-day lives. Excerpts from this film will be used as part of an online resource pack. For example, when the pack describes a communication passport, you will be able to click on the icon of a passport to see a short film of someone using one. Both films will be available on DVD and the online package will be available some time in 2010. Kick Start has highlighted the communication needs of people with learning disabilities and provided a preventative approach to addressing these needs. It has influenced commissioners in the establishment of an East Sussex Total Communication Strategy, of which Kick Start is a key component. The current emphasis is on engaging with specific services around developing person centred approaches. We are working in partnership with local projects and focusing on specific community groups. We are confident that this will establish total communication in a far-reaching and nationally progressive way. Kick Start Communication has created a real energy and desire for change in East Sussex, and those of us involved are driven and committed to continue providing and developing this valuable service. Kick Start Communication has been extended to Brighton & Hove, West Sussex and other localities in the trust. There has just been a Total Communication road show in Brighton & Hove, and the topic is very much on their Learning Disability Partnership Board agenda. Hopefully these developments will produce similar outcomes for people with a learning disability and their families and carers.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2010

COVER STORY: COMMUNITY DEVELOPMENT

Our latest venture is a Festival of Togetherness, a specialised total communication road show. Although all our clients are welcome, it is targeted at people across our region with high support needs and those who are hard to reach due to limited communication / interaction skills. Our multidisciplinary team members, local organisations and enterprises will come along to share their knowledge, show their wares and offer a very interactive environment. We are having zones rather than stalls, which is more suitable for our targeted visitors. All zones will use all the senses (sight, touch, hearing, smell and taste). The sensory zone will include sensory cooking such as smoothie making, with additional trays for smelling, touching and tasting ingredients. It will also have sensory boxes with examples and free starter kits for making your own. The communication zone will look at objects of reference, intensive interaction, switches and environmental aids. In addition to a movement and music zone, a chill-out zone will include massage, aromatherapy and reiki. The outdoor space will have kite flying, a fire engine, a pony, art, a marquee, picnic area and live music. In the large sports hall Decoda will be creating a safe and interactive environment using their decodamaze, an inflatable everchanging environment of sounds and images, as well as their music gym and sensory igloo. Our aim is to make the whole event a model of good communication and togetherness. We too often see communication tools not being used, in the backs of cupboards, and people described as having no language or no effective means of communicating, having things done to them rather than being offered ways to communicate. We want to get across that communication is a two-way relationship and will only be successful if the communication partners are using the same language. We also want to demonstrate how important it is to build relationships, to share experiences and to learn together. Framework 4 Change is helping us organise the event. This local organisation has been part of our previous Kick Start, holding stalls and workshops. They very much wanted to set up the Festival of Togetherness with us to embed work on total communication within their community way of thinking. Their representative Helen Zeida says, Frameworks 4 Change works to create deep culture change which results in a shift from service to community thinking and action. The shift changes the perception of people who need paid support from that of passive recipient to active citizen. We have thought very carefully about creating a place of welcome, joy, safety, exploration and learning for all our visitors. To ensure they can enjoy the day fully, we are providing changing facilities, showers, hoists, picnic blankets and a cafe. We also have a dedicated crew of helpers who are passionate about total communication. Their job will be to welcome and connect with the people who come to be with us on the day, supporting SLTP everyone to have a fabulous time. Helen Page is the Kick Start Communication Project Worker, email hpage105@hotmail.co.uk, and Viki Baker is Clinical Director for Learning Disabilities / Professional Advisor for Speech and Language Therapy at Sussex Partnership NHS Foundation Trust.

References

Editors choice

Department of Health (2001) Valuing people a new strategy for learning disability for the 21st century a white paper. Available at: http:// www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ DH_4009153 (Accessed: 22 April 2010). Department of Health (2009) Valuing people now: a new three-year strategy for people with learning disabilities. Available at: http://www. dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ DH_093377 (Accessed: 22 April 2010).

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

Resources

Decoda - www.decoda.org East Sussex Learning Disability Partnership Board - www.eastsussex.gov.uk/socialcare/ adults/disability/learning/partnershipboard. htm Frameworks 4 Change www.frameworks4change.co.uk/ Intensive Interaction www.intensiveinteraction.co.uk Learning Disability Week www.mencap. org.uk/page.asp?id=9879 Strong Voices Big ideas (East Sussex Commissioning Strategy) www.eastsussex. gov.uk/socialcare/policiesandplans/ adultservices/commissioningstrategies/ default.htm Talking Mats www.talkingmats.com

Sue Gerhardt argues that loving, responsive parenting in the early years facilitates emotional self-regulation, with life-long implications for communication and mental health. She explores the development of stress, and helpful and unhelpful learned responses. Although on first reading it seemed to lack hope, Why Love Matters lays the groundwork for developing solutions. It draws on different disciplines, and much of the language used and techniques discussed are familiar to speech and language therapists. Can we take something from the assertion that it is time to give priority to relationships over goal-oriented behaviour? Why Love Matters (2004), Routledge, ISBN 978-1-58391-817-3 What can we do to become more attuned to the ethical aspect of our work? Following in-depth exploration using scenarios and expert responses, Richard Body and Lindy McAllister identify themes, all of which have practical implications. It helps to talk things through, negotiate roles and boundaries, become more aware of where the power lies in relationships and recognise the tensions between organisational, professional and personal values. Our clients also benefit when we pay more attention to the nuances of the language we use; depending on the context, the word yet can do much to inspire or to induce despair. Ethics in Speech and Language Therapy (2009), Wiley-Blackwell, ISBN 978-0-470-05888-6 Editor Sue Roulstone dedicates Prioritising Child Health to families who have to fight for resources for the children and practitioners who are struggling against the odds to provide services. Among the parents and practitioners writing in the first section, a childrens palliative care nurse bringing prioritisation issues into particularly sharp focus. The theoretical section contains a wonderfully thoughtprovoking contrast between a philosopher drawing on Marxist perspectives and an economist. The most important message is to be much more explicit about our decision making. Contrary to what we might think, with open debate public confidence will grow. Prioritising Child Health Practice and Principles (2007), Routledge, ISBN 978-0-415-37634-1

REFLECTIONS DO I KEEP THINGS SIMPLE WITH OPPORTUNITIES TO SEE, TRY AND LEARN? DO I FIND WHAT IS ALREADY WORKING AND BUILD ON IT? DO I REALISE THAT, WHEN COMMUNICATION IS CENTRAL TO POLICY, THE FUNDING FOLLOWS?

Do you wish to comment on the difference this article has made to you? See the information about Speech & Language Therapy in Practices Critical Friends at www. speechmag.com/About/Friends.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2010

HERES ONE I MADE EARLIER / READER OFFERS

Heres one I made earlier...

Alison Roberts with a low cost, flexible and fun therapy suggestion for groups. Older or younger?
This game is based on the old favourite card game of Sevens. This version promotes judgement of peoples ages. Ideally you will have 4 players, although you can play with 3, 5 or 6. MATERIALS 28 blank cards the Taskmaster ones are good (but quite small), or you can use blank business cards, or index cards or postcards Glue Stick-on stars Cut out magazine pictures, of people of varying ages and types. You need to have 4 sets of 7 cards that range in age. You need 4 babies, 4 toddlers, 4 children, 4 teenagers, 4 young adults, 4 middle aged people, and 4 elderly folk. They need to be able to fit on the cards. Good sources are Mothercare catalogues, teen magazines, newspaper colour supplements, and Saga magazines. Lined paper and pen. BRAWN Stick the pictures on the cards. Arrange the sets into 4 vertical columns, with a baby at the top of each, then a toddler, then a child, and so on until you have the 4 elderly folk at the bottom of the columns. Now number the cards, writing in the top right hand corner of each card as follows: - Babies are 1, Toddlers are 2 Children are 3, Teenagers are 4, young adults are 5, Middle aged people are 6, and Seniors are 7. Stick stars by the teenagers. IN PRACTICE (I) . Deal out 5 cards each (more players = fewer cards). Place the stack of spare cards face down on the table. If you are not familiar with Sevens it may look complicated, but actually is really easy. These are the rules: The player to the left of the dealer picks up a card from the stack, adding it to his hand. He then puts down, face up, a teenager (the starred card), if he has one. If he has not got a teenager he discards one card (to the bottom of the stack), and play passes to his left. This continues until a player has a teenager card, which is placed face up, with the play then passing to the left. This next player takes a card from the stack, and then either puts down another teenager face up next to the first teenager, or puts a slightly older or younger person above or below the teenager card, i.e. the numbers will be consecutive. He then discards a card. Play then passes to his left. This player can add another teenager card next to the existing teenager cards, or add a card above or below any of the cards currently displayed, providing of course the card placed down is in the right chronological sequence. You should end up with 4 lines of people cards ranging in age, with 3 people cards above the teenager leading back to babyhood, and 3 below leading to old age. The one who is first to use all his cards is the winner. IN PRACTICE (II) Use the same cards, and simply place the cards in age order.

Win Communication in the Classroom!

Are you looking for a practical resource to support your work in secondary schools and Key Stage 2? STASS Publications is giving away a FREE copy of its new package Communication in the Classroom Workshops for Secondary Schools to a lucky reader of Speech & Language Therapy in Practice. The photocopiable resource with CD ROM includes six workshops for secondary teachers and support staff, and three workshops for secondary students. Topics include vocabulary, comprehension, social skills and stammering. The sessions are based around practical activities where the participants experience for themselves what it is like to have communication difficulties. While the staff learn a range of classroom support strategies, students are encouraged to be more understanding of their classmates who struggle with communication. Communication in the Classroom would normally cost you 60 + VAT. For your chance to win a FREE copy, email your name and address to stass@stass.co.uk with STASS speechmag offer in the subject line by 25th July 2010. The winner will be notified by 1st August. Communication in the Classroom authors Susan Stewart and Amanda Hampshire also wrote Understanding Me, available from STASS Publications. For more details of these and other resources, visit www.stasspublications.co.uk.

Reader offers

Win a Talking Dice starter pack!

Whether you work with children or adults, Talking Dice offer an alternative way of approaching language tasks. The picture dice come in 25 topics including food, hobbies, daily routine, housework, accommodation, transport, weather and sports, so could be used for work on vocabulary, word finding and use of language. A starter pack contains 25 dice, one from each topic area. It usually costs 25.52 + VAT. For your chance to win a FREE Talking Dice Starter Pack, email your name and address with Talking Dice Competition Entry in the subject line to contact@linguascope.com by 25th July 2010. The winner will be notified by 1st August. For more information about Talking Dice, including free games ideas, visit www.talkingdice.co.uk/.

Reader offer winners

Congratulations to Kirsty McLaughlan, Dorothy Grant and Amy Ford, the winners of Mac Keiths Feeding and Nutrition in Children with Neurodevelopmental Disability and to Lisa McNally, Catherine Byrne and Heather Price who won Elklans EYBIC (Early Years Based Information Carrying) Word Pack, both competitions in our Spring 10 issue!
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2010

EMPATHY

What are you like?

How much of a part does personality play in the success of therapy? Eric Foggitt introduces us to the Enneagram and explains the difference it can make to our personal and professional development, workplace relationships and clinical outcomes.
ome years ago I was responsible for organising in-service training for my colleagues. I set up a day course entitled Why did I do that? led by a visiting speaker who had written and spoken widely on the topic. It was fascinating and, as usual for such study days, provoked many more new questions than it answered. The course title remained with me and reared its head in many different situations, whether at work, in relationships or thinking about politics. Why did I do that? is an awkward question because the answer, if truth be told, is often I dont know! Think of the times when we react to a situation in a particular way then berate ourselves for being so foolish, or when we establish an instant rapport with someone, or when a new colleague says something fairly anodyne which brushes us up the wrong way and we take a dislike to them. The Enneagram is a psychodynamic way of answering the question. Based on very ancient thinking rooted in Egyptian, Hebrew and early Christian and Sufi Muslim ideas, it has been transformed in recent years by followers of Karl Gustav Jung and others into a sophisticated and fascinating system giving insights into our own and others characters. What makes it enticing is the availability of testing resources on the internet and increasing access to training opportunities. I hope in this article to whet your appetite by opening up some of the possibilities the Enneagram offers speech and language therapists. The Greek words for nine - ennea and word gramma provide a starting-point in understanding what the Enneagram is about. There are nine basic personality types and everyone fits into one of them. Each type has variants, and people also differ in their maturity, experience and culture, so any two individuals of the same type may not look at first sight very similar at all. Why are there only nine different types? Put most simply, there is a limit to the resources we have to deal with the world. We can use our heads (thoughts and concepts) or our hearts (feelings and emotions) or our bodies (gut instincts and passion). It doesnt matter where we localise these abilities; different cultures and languages vary in this. All that matters for the present is that we recognise these three sets of abilities.

READ THIS IF YOU WANT TO BRING OUT YOUR BEST SIDE HELP CLIENTS UNDERSTAND THEMSELVES MORE ENJOY GOOD WORKING RELATIONSHIPS

Type
1

Positive qualities
Conscientious and ethical, with a strong sense of right and wrong. At best: wise, discerning, even heroic. Empathetic, sincere, and warm-hearted. At best: altruistic and loving. Self-assured, attractive and charming. At best: authentic role-models. Self-aware, sensitive, and reserved. At best: inspired and creative. Alert, insightful, and curious. At best: visionary pioneers. Committed and securityoriented. At best: stable, self-reliant and brave. Extroverted, optimistic and spontaneous. At best: focused and joyful. Self-confident, strong and assertive. At best: inspiring and brave leaders. Accepting, trusting and stable. At best: indomitable conflict-healers.

Manifestations
Teachers, crusaders, advocates for change. Striving to improve things. Carers and counsellors. Friendly, generous and selfsacrificing. Close to others. Diplomatic and poised; ambitious and competent. Team players. Emotionally honest, empathetic and personal. Independent, innovative, and inventive. Scientists. Good with ideas and theories. Troubleshooters who foresee problems; foster cooperation; hard working, reliable. Talented and practical; versatile and efficient. Selfstarters. Resourceful, straighttalking and decisive; controlling. Able and willing to take charge. Quiet and likeable; optimistic and supportive; peace-makers.

Problems
Resentment and impatience. Critical.

Sentimentality and flattery. Concern with image and competitiveness. Self-pity and moodiness. Isolated and intense; eccentric. Decision-making and excess caution.

Focus and discipline.

Vulnerability and anger.

Inertia and conflict.

All of us use all three, but we have preferences which were more comfortable with than the others, just as we are usually more skilled with one hand than the other. Our preferences determine our type. Types 2, 3 and 4 are said to be heart types who are much influenced by feelings; 5, 6 and 7 head types who are more comfortable with thinking; and 8, 9 and 1 gut or body types who are more instinctual and passionate. While fuller information on the different types can be readily found at the Enneagram Institute website, table 1 provides a very rough outline of the nine types. You may find it helpful to think about yourself and others you know as you read through it. The outlines are simply shorthand caricatures which do not do justice to the intricate complexity

of each type; nor do they take into account variations due to personal experiences, mood, lifestyle and local culture. Although no-one actually changes type, we may mature and become more peaceable, wise or effective as we deal with the demands of life, or we may become more stressed and out of balance, with the result that other attitudes, feelings and behaviours come to the fore. Thus there are very wide variations within each type. How can we determine which type someone fits into? The Riso-Hudson Enneagram Type Indicator (RHETI) is a self-assessment tool created by the Enneagram Institute to enable accurate typing. Its availability on the internet makes it very easy to access, and studies (such as Newgent, 2001) have confirmed its accuracy (well in excess of 75 per cent) as well as its

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EMPATHY
correlation with better-known tests such as Costa & McCraes NEO PI-R. Anyone with an interest in the subject and ready to part with $10 is able to complete the RHETI online. Other tools are also available such as the screening-type technique outlined in Riso & Hudson (1999). On the other hand, simply studying in-depth outlines of each type may be more helpful to others. It is axiomatic to this approach that we are the best judges of our own type. Whilst I may have an opinion about someone elses type, and that opinion may help me in better relating to that person, ultimately it is the individuals right to have the final say.

Deep insight

There are five main ways in which the Enneagram may be helpful to speech and language therapists. Firstly, it will be of personal interest to many therapists simply wanting to get some insight into their own personalities. Why did I do that? is an important question, and the correct answer helps us get to the root of who we are, what we are like and what kind of work we should do. Many of us who have engaged in Enneagram training have found that it changes the way we treat people and adds depth to our relationships because it enables deep insight into others attitudes and needs. Secondly, as discussed recently in this magazine (Middlemiss, 2009), conflicts at work can be a source of considerable stress. Understanding their cause (and we may be part of the problem as often as the solution!) will offer us a way forward in resolving them. It may be that one colleague (a type 5, for instance) takes a very rational approach, whereas another (a type 4) approaches it with a greater degree of emotional intelligence. But the former may berate the latter for being overly indulgent and emotional, while the latter might complain that the other is too cold and distant. The truth is, both approaches have their value. The Enneagram offers us mutual understanding, so that we can work better together and benefit from each others strengths rather than complain about each others weaknesses. Thirdly, we recognise that we come to the therapeutic situation not as cold, distant professionals but as human beings. Firstly we bring our humanity, then we bring our skills. The Enneagram helps us with the Burnsian task (as in his poem To a Louse) of seeing ourselves as others see us, hence enabling us to modify our behaviours so as to establish a better rapport with clients. We may come over as somewhat cold, or as controlling, or even as overly emotional. The notion that we can maintain a professional and impersonal faade is of course nave, as our real personalities find a way to break through. Fourthly, and again touching on areas recently covered in the excellent Winning Ways series, the Enneagram helps in professional development. Some types work independently more easily than others; some will work as team players whilst others will be

Eric says of himself:

I am a type 7, which means I am a head type. I am good at initiative and I enjoy many varied challenges. Although I dont need a lot of encouragement to keep going, I resent too many restrictions and rules, because freedom is a strong root need for me. Like many 7s I am good with languages I speak four fairly fluently but I dont have good emotional antennae. I have a lot of inner energy, but I can come over as too strong and assertive without realising it. Work-wise I have had a varied career, because staying in the same post or rather doing the same kind of work would be boring. I have a good deal of autonomy, and I flourish this way. I am good at getting things done, being more task-focused than person-focused, but I recognise my need to have people near me who will attend to those things I do less well, such as detail!

pioneers; some will be enthusiasts who need a light touch management approach and others will be highly effective plodders attending to detail. Without proper self-understanding it is easy to either fall into the wrong job, or indeed to fail to move on into the greater demands of another one. Self-understanding will also reveal the needs that we have from work: for instance, the satisfaction of client progress, or the reward of thanks, or the sense that we have helped someone function better. Higher pay may be very welcome for those who are adept at the exercise of power, but for the expert clinician the reduced client workload may make it a very mixed blessing. Finally, with in-depth Enneagram training, therapists may be able to offer help to their clients. Fransellas work with Kellys Personal Construct Theory (Fransella, 1972; Fransella et al., 2004) has helped many people who stammer and others to gain a better understanding of themselves and of the inner conflicts which can cause stammering. The Enneagram offers a psychodynamic perspective enabling a wide range of clients to gain insights into their own behaviour, which in turn helps in remediation. We can see the Enneagram as a psychological tool which helps us to assess our clients personalities more deliberately and objectively than we usually do. It is commonplace to suggest that we make all sorts of judgments about people unconsciously. Even before they have spoken to us we have observed

their clothing, hair colour and style, and body language and drawn our conclusions. While we routinely find comments in clients notes such as the vague (Mr X is a nice gentleman) or subjective (A likeable lady of 84) or valueladen (Jim is difficult and resentful), the Enneagram provides us with more objective terms. These aim to outline the clients personality rather than simply reflect our biases and, indeed, our own personalities. The Enneagram therefore helps us to respond to client needs more effectively and is a powerful tool in the task of ensuring clientcentred care. The rational, slightly distant type 5, for instance, will probably want us to stick to the facts and get on with assessment and therapy, whereas the sensitive and self-aware type 4 will probably need careful handling of their feelings beforehand. Moreover, some types will appeal to us personally more than others, because of our own type. (How many of us have had the experience of clicking with one client, but just failing to gel with another?) Bringing these facts into the open and dealing with them accordingly helps us start the therapist-client relationship on a better footing. The Enneagram is not about labelling people or putting them into boxes; rather it is about identifying those tendencies which govern the way we think, feel and react. It has the potential to help us genuinely empathise with clients, as we better understand the way they experience life.

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Furthermore, having an understanding of clients personality types can guide us in choice of treatment. Type ones will typically want to make things as perfect as possible and may be deeply critical of themselves when they fall short; type sixes may be very reliant on the therapist and trust his / her judgment, whilst entertaining doubts about themselves; type eights often want to retain or regain control of their lives and may deeply resent their reliance on the therapist. So what, then, are the benefits of the Enneagram in therapy and client management?
Case example 1: Mary Mary (53) was referred by her GP, having been examined by an ENT Consultant who had found nothing anatomically wrong. She was dysphonic, with supralaryngeal tension, a non-smoker and occasional drinker. No recent stressful incidents were reported. During assessment I offered Mary the option of help with self-appraisal using the Enneagram, which she willingly took up. She and her husband accessed online Enneagram material and Mary took the test. Study of the results revealed that she was probably a type 6: a questioning, somewhat hesitant person, with a lack of confidence in her own judgments. When we discussed her employment, it became apparent that this was the primary source of stress. It required her to give polished demonstrations of quite complex tasks to groups of up to 20. These are skills which the Enneagram associates strongly with type 3 her weak spot. Marys job was demanding attitudes and behaviours which her type 6 personality found very stressful. This insight enabled her to make the decision she had been hesitating over changing jobs. It also enabled her to reflect about her planned future employment and determine that it would not give her unexpected and unwanted stressors. A review appointment revealed that her voice problems had disappeared. Case example 2: Robert Robert (56) was referred by his GP. A stammerer since childhood, Roberts speech had recently deteriorated and, according the referral letter, was affecting his marital relationship. He took the online Enneagram test (RHETI) with his wife alongside him, and she then also took the test. They both came for subsequent sessions. The key insight Robert attained was his tendency to resort to an inner world of fantasy a key element of his type 9 personality. His wife sensed this and felt excluded from it. But Robert noted his wifes tendency to dwell on inner feelings and strong memories (key elements of her type 4 personality). They found it very helpful to identify these tendencies and to commit to avoiding them because they caused friction between them. Roberts inner world is doubly attractive when communication is problematic, and he came to understand that his anxiety about speaking stems from reluctance to be on show. Yet this is precisely the kind of development which the Enneagram suggests as helpful to Roberts type: when type 9s mature and grow they tend to show some of the type 3 characteristics such as a readiness to be on show. Therapy on Roberts speech skills continues. He recognises that he has grown in confidence, which in turn enables him to speak more fluently. He stammers less than previously. Case example 3: Darren Darren (41) was referred by his GP, for treatment for dysphonia. He is a music teacher and professional singer. He reported that he performs to large audiences and sometimes under considerable pressure, but it was teaching groups of primary children which provoked dysphonic episodes. He took the online Enneagram test (RHETI) and identified himself as a type 7. Challenges such as oneman shows and large audiences were not stressors, but the limited and rule-laden elements of primary teaching were. Teaching also requires skills usually associated with type 1 personalities, and this is the stress point for type 7. As with Mary in the first case example, Darrens work was pressing all the wrong buttons. Darrens improvement came with: (1) recognising the stressors for what they truly were. This understanding reduced their impact. (2) reconstruing how he saw his work and recognising that it enabled him (financially) to do what he really wanted to do perform on the stage. It thus became a liberator rather than a constraint. He has virtually no dysphonic episodes, and is now on review.

Client-centred

The Enneagram approach is strongly clientcentred because the goal is to understand how the client sees his problem. We are aiming to see through the clients eyes, as it were, and we can make a start on this sometimes even before the client does. Secondly, it is client-initiated. The speech and language therapists role is to facilitate the clients self-understanding by appropriate questioning, encouragement and support. It is a journey of self-discovery and, as with many journeys, travelling is more informative than arriving. But, for all sorts of reasons, some clients do not want to embark on the journey of self-discovery. We need to respect that choice, not least because people vary in their readiness to explore the issues with which the Enneagram deals. Thirdly, it is client-led. Every individual is the best expert on him/herself and, while we can observe behaviour, only the client can tell us whats going on inside. On several occasions I have been surprised to discover how wrong my initial impressions were. The kind of stresses which lie at the root of some dysphonias, for instance, may force people to behave in a very unfamiliar way. I have marvelled at a friends behaviour and remarked, I didnt think she would do that! But thats the point: when people are stressed, they may behave in very unpredictable ways, hence the importance of allowing the client to voice their inner feelings and be guided by them. A key learning outcome from case examples 1-3 is that what is stressful for one client is not for another. If we understand something of a clients personality we can better determine what they will find stressful. The Enneagram is a welcome addition to the therapists armoury of tools. It provides an alternative way of seeing familiar issues and problems. Above all, it helps us to be more overt and objective in an area where we are usually vague and subjective what people SLTP are actually like. Eric Foggitt, speech and language therapist, is Adult Acquired Team Lead for East and Midlothian Community Health Partnership. He offers training in the Enneagram through his independent consultancy (www.9Gscotland. co.uk) as does the Enneagram Institute (www. enneagraminstitute.com). Eric can be contacted by e-mail on info9G@btinternet.com.

References

Fransella, F. (1972) Personal Change and Reconstruction. London: Academic Press. Fransella, F., Bell, R. & Bannister, D. (2004) A Manual for Repertory Grid Technique (2nd edition). Chichester: John Wiley & Sons. Middlemiss, J. (2009) Conflicting ideas, Speech & Language Therapy in Practice Autumn, p.11. Newgent, R. (2001) An investigation of the reliability and validity of the Riso-Hudson Enneagram Type Indicator, Dissertation Abstracts International 62(02), 474A (UMI No. 3005901). Riso, D.R. & Hudson, R. (1999) The Wisdom of the Enneagram. New York: Bantam.

Recommended reading

DeMello, A. (1990) Awareness. New York: Doubleday. Jung, C.G. (1974) Psychological Types. Princeton, NJ: Princeton University Press.

REFLECTIONS DO I TAKE ACCOUNT OF THE IMPACT THAT PERSONALITY HAS ON RESPONSE TO THERAPY? DO I TRY TO SEE SITUATIONS THROUGH A CLIENT OR COLLEAGUES EYES? DO I RECOGNISE, VALUE AND MAKE THE MOST OF PEOPLES STRENGTHS INCLUDING MY OWN?
Do you wish to comment on the impact this article has had on you? Please see the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

Resources

NEO PI-R www.neopir.co.uk/index.html RHETI www.enneagraminstitute.com/ discover.asp

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2010

WINNING WAYS

Who knows where it will lead?

ASHA is the American Speech-Language-Hearing Association, the professional and credentialing body for speech-language pathologists, audiologists and speech, language and hearing scientists in the USA. Its Annual Convention attracts expert speakers and well-known names from around the globe. When UK speech and language therapists Claire Butler and Roger Newman were invited to present at ASHA 2009 they were taken by surprise - and not a little daunted! Here they recount how they overcame their terror, doubts and competing priorities, and prepared themselves for this chance of a lifetime.
for a short course, which people would be paying an additional $60 to attend. I was to be on a panel alongside big names from the world of swallowology names I knew from the books on my shelf and the papers Id been reading for the previous 15 years. I was originally slated for a 20 minute slot but, as the discussions went on, my time extended first to 30 and eventually 40 minutes. The pressure was building steadily. Preparation for ASHA made use of all the skills Id learnt during my MSc. I sourced all the recent papers and guidelines I could find in the area of dysphagia screening, and read and critiqued them as they arrived. With the help of colleagues I contacted speech and language therapists around the UK to ask about their current dysphagia screening practices, what guidelines they were following and whether they had particular issues or concerns. All this was done in my own time and had to be completed while balancing work and family life. One of the more surreal moments during the process was a conference call with the other speakers eminent names in swallowology in America and Canada - while simultaneously trying to get my little girl ready for bed. But as time went on I began to create the structure for the presentation and the whole project started to come together. A couple of things I hadnt anticipated almost threw me off course. One was discovering that ASHA would need the completed presentation much earlier than I expected. In fact, the finalised PowerPoint slides needed to be with them over two months before the convention date, so a CD of presentations could be provided for attendees. Around this time I also discovered I was pregnant with our second child which, although wonderful news, was an additional complication around my plans for ASHA.

New Orleans Morial Convention Center

Claires story
was approaching the end of maternity leave when I was first contacted about presenting at the ASHA convention in New Orleans. ASHA were looking for someone to present the UK Perspective on Dysphagia Screening. My name was put forward by Paula Leslie; we had become friends when she was my MSc tutor 5 years earlier. Having been away from work for over a year, immersed in nappies and bedtime routines, my initial reaction was no way! Although tempted from the very beginning, I felt out of touch with the world of dysphagia and quite frankly terrified. A quick response was needed and as I sat down over the next couple of hours I realised

that, with my knowledge and experience, maybe I did have something to offer. More importantly, other people clearly believed it was something I was capable of. When I discussed it with my husband he confirmed what Id started to appreciate already this was one opportunity not to be missed. With agreement that ASHA would pay at least some of the costs, saying no was getting harder. The exhilaration I felt on accepting confirmed Id made the right choice. I dont think I really believed I was presenting at ASHA until the official emails started to arrive a few weeks later. As the details of what Id let myself in for became apparent, the anxiety levels began to rise. What started as purely a presentation turned into presenting

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WINNING WAYS

Never a perfect time

For the last few weeks before the trip, every spare moment was spent reading through my presentation and gradually tweaking and fine-tuning what I wanted to say. If I thought doing an MSc while working full-time was hard, preparing an ASHA presentation while caring for a toddler and battling with morning sickness and pregnancy exhaustion was on another level! The trick was to remember what I was aiming for every time I really thought about my imminent trip to New Orleans, all the hard work became bearable. The truth is theres never a perfect time to do these things and I remember some wise words from Paul Carding in Newcastle: life always gets in the way. Opportunities like this dont come along every day and personally I now try to grab them every time. Attending ASHA was an experience Ill never forget. My taxi from the airport brought me right past the doors to the convention centre. Almost a mile later, when we reached the other end of the building, my jaw was nearly on the floor I could hardly believe I was going to be presenting in that huge building in just a few hours. I certainly felt fortunate that my short course was scheduled for first thing on the first day. It meant less time for the nerves to build up and I knew I could relax once the presentation was over. The logistics of presenting at such an immense convention, with more than 10,000 attendees and in such a massive building were interesting to say the least. I arrived a good 40 minutes before my short course was scheduled to begin, plenty of time - or so I thought. Five minutes of brisk walking and I was only as far into the building as the queues to register. As an overseas attendee, my registration pack hadnt been sent out to me in advance, requiring me to queue to collect my badge, convention schedule and goody bag. As we slowly edged forward, I had visions of still standing there when the presentation was due to begin. Luckily, on being told I was presenting that morning, everyone was more than happy to let me jump the queue. Amazingly it took another ten minutes of walking to reach the room where my short course was due to take place. Not for the first time my MSc training came in handy with 15 minutes to spare I discovered my memory stick couldnt be recognised, but luckily I had a backup on DVD. During the presentation itself, I was probably the most nervous Ive ever been in my life. Despite the long walk, almost 300 individuals turned up to hear us speak, the biggest group Ive ever presented to. Ive been told it came across really well, but from my perspective I noticed every little point where I stumbled on words or my voice began to struggle. Being told I only had 10 minutes left to speak, when in fact I had 20, really didnt help. I know from my MSc experience that the speaker is their own worst critic, so I had to rely on the feedback I received, which was all good. Most heartening was to be grabbed by

a stranger in the corridors of the convention centre some 24 hours later and told how much they had enjoyed my talk. Once my presentation was over, the rest of convention was mine to enjoy. Its an exhausting experience, a whirlwind of presentations and networking opportunities. For me, the most exciting aspect of the whole thing was the people I got to meet. In the three days of the convention I made friends and work contacts from around the world. These contacts are invaluable in so many ways helping me with evidence based practice, giving me a wider sounding board for ideas and making further personal challenges more likely to come my way in the future. I can honestly say that the entire experience has been well worth all the hard work involved. After finding out about my invitation to present, I had a variety of responses from friends and colleagues. Many were pleased that I had such a great opportunity and impressed with the achievement of being invited. But a significant number asked why these things just fall into my lap. Ill admit that a degree of this was down to luck the right person was in the right place at the right time to put my name into the frame. However, the underlying reasons why I came to be presenting at ASHA were hard work and dedication to a challenge. I put myself forward for my MSc, for presentations at events in the UK, for writing articles for publication and for becoming a Royal College of Speech & Language Therapists advisor. Although Ive had support from my employer wherever they can, most of the work for all these things has been done in my own time. Im still an ordinary, everyday speech and language therapist, but I do what I can to challenge myself. I feel proud of being invited to present at an international conference and of accepting and achieving that goal.

itself, but it soon got a great deal bigger. After the article was turned down by many peer reviewed journals, I was contacted out of the blue by Dr Jay Rosenbek from the University of Florida. My heart was in my mouth as I opened the email to find he was asking for the manuscript. He was editing a book on rare dysphagia and wondered if Id like to contribute. Although aim for the top and work your way down didnt seem to succeed at first, we got even higher than the top, and the journey continued.

The important stuff

Rogers story

y story began many years ago after being enticed into the world of academia when a patient was admitted to hospital after hanging himself in a suicide attempt. It may sound gruesome, but for him the end result was not what he had set out to do, and for me it was entirely different. The patient presented to me with acute dysphagia, but his CT brain scan was clear and he did not have any other noticeable damage, except what I spotted when I captured the image of the fracture upon videofluoroscopy. His swallowing function had been significantly affected something Id never come across before. After speaking to Maggie Lee Huckabee at a local course, she looked at me sternly and instructed me to write it up. My first thought was why?, and my immediate subsequent thought was ok, why not? The story began. I made contact with Dr Paula Leslie, formerly of the University of Newcastle, who helped me a great deal. Her philosophy is aim for the top and work your way down. We eventually agreed that the article could be a joint venture, something of a privilege in

After much hard work, deliberation and editing to turn the article into the chapter required, it was finally accepted for publication in an international textbook. I couldnt believe it. Having achieved what I thought was the ultimate, the books co-editor Dr Harrison Jones emailed and invited me to present the chapter at ASHA. Jaw dropping and heart stopping are the words that spring to mind. I quickly emailed back and accepted his invitation, without giving a thought to cost, flights, accommodation, material to present you know, the important stuff. I had about six months to prepare everything. Paula was the only person I knew who was definitely going but she was presenting in various other short-courses. She asked if Id mind doing this one alone as Id done all the hard work. There was a compliment in there somewhere, but I was feeling pretty dumbstruck at the thought of presenting as part of an international convention alone. The presentation had to be perfect. I was going to be talking to the worlds greatest researchers in swallowology, potentially being asked horrible questions I didnt know the answer to. I had to keep telling myself that the condition I was presenting is extremely rare; I was the one whod done the research into it; I knew what I was talking about. Trying to convince myself of all this was extremely difficult, nigh on impossible, but it was the only way I could do this. My wife must have heard the presentation a thousand times, and strangely enough she now knows all about the hyoid bone and its connections too. The presentation was finally complete. I made three copies of it, and emailed it to myself several times at various addresses. Paula was kind enough to take the presentation too. Like Claire, upon arriving in New Orleans I was horrified to see the size of the convention centre. I know the citizens of the USA like to do things on a bigger scale, but this building was immense, literally one mile long. I was constantly reminded of this as my hotel was directly opposite and full of ASHAs attendees in other words, potentially my audience. After exploring New Orleans itself on the first day I arrived, I collected my registration pack with all the things Claire mentioned, and retired to my hotel to practise the presentation one more time. My two hour time slot was also scheduled for the first day, something Ill always be thankful for, although I had no power over when it was going to be.

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WINNING WAYS

Jo Middlemiss comments...

Front (l-r) Roger Newman, Justin Roe (SLT, Royal Marsden), Claire Butler Back Dr Jim Coyle and Dr Paula Leslie, both University of Pittsburgh I met up with Paula who introduced me to Claire. Wed never met before and both looked as pale as each other. Seeing another novice helped us relax a little into the concept of being in a huge convention centre in an unfamiliar city in the United States, about to present to some of the worlds leading figures. Despite having conversed via cyberspace with my editors, I had never met or spoken to them before. The first time I met Harrison was when I went onto the stage in the giant ballroom I was about to present in. He reassured me everything would be OK, then I was called to give my talk. I turned round to see the other presenters on the front table. I appreciated how big this was when I saw who they were, and Im certainly glad I hadnt realised before. Dry mouth syndrome as Claire and I nicknamed it set in. The glasses of water in front of me were my comfort as I tried desperately to see the people at the back of the room, but they were too far away. This thing I was doing was out of my league, but it cant have been, I was there, Id been invited, I knew what I was talking about, I was giving my presentation. These thoughts raced through my head but I finally became more comfortable with the concept of speaking at an international convention - five minutes into my presentation. The dry mouth syndrome cleared up; the images were very well appreciated by the audience; the topic was understood; I had made my point clear; the questions were answered coherently; the applause commenced Id done it, presentation successfully achieved. I could enjoy the rest of the convention with the proud feeling of accomplishment that had been waiting to explode for the previous six months. This opportunity has not only provided me with a huge amount of experience in both writing and presenting but, with friends and international work contacts made, other prospects have since arisen. Frightening as it may be, I can say I would look now at the situation with very different eyes. Claire and I are no longer the novice speakers, as we have the experience of presenting at ASHA 2009 to our names.

Always with us

This is something which will always be with us it will always be on our CVs and our continuing professional development profiles, and the friends and work contacts that weve made can never be taken away. If that email ever arrives in your inbox offering you the chance of a lifetime, we urge you to take it. It will be hard work, and it will take over your life for a time, but believe us both when we say it is worth it. SLTP Who knows where it will lead Claire Butler is the clinical lead speech and language therapist for adult dysphagia at East Surrey Hospital in Redhill, email pingucb@ googlemail.com. Roger Newman is senior specialist speech and language therapist at Royal Preston Hospital, email Roger.Newman@lthtr.nhs. uk. Information on the ASHA 2010 Convention in Philadelphia, 18th-20th November, is at www. asha.org/events/convention/.

Singer-songwriter Beth Nielsen Chapman is one of these characters who has grown through adversity. Her husband died when her child was young, she developed breast cancer a few years later, and only last year needed an operation to remove a benign tumour from her brain. The first symptom was a blanking out of the words she was searching for. As she was wheeled in for her operation she had no idea whether her language would be returned to her but, within hours, the lyrics which had been stacking up were unblocked. The result is a beautiful album Back to Love. Beth wrote one of the songs Happiness the day all her hair fell out during treatment. One line stands out for me: All those fears I held as truth. It reminds me that so often we convince ourselves of our own weakness rather than our strengths. Claire and Roger do not allow their fears to make the decisions. They remind themselves of strengths rather than weaknesses. They listen to and seek help from those who believe in and encourage them, and prepare incredibly well for their presentations and any predictable eventuality. I enjoy the honesty of their nerves, their surprise at having been chosen, their ability to say Why not? rather than Why me? and their complete refusal to give in to good excuses to dodge the challenge. We see that the benefits and opportunities for learning and growth far outweigh the energy they spent in preparation and planning. Sometimes when attending huge events we might be tempted to think these things are easy for some but not for others. This is a mistake. If Claire and Roger had not been prepared to put their heads above the parapet and take the risk of stretching themselves beyond their comfort zones, they would have lost far, far more than they gained - and never have known it. This poem by Arthur William Ward says it all:
To Risk To laugh is to risk appearing a fool, To weep is to risk appearing sentimental. To reach out to another is to risk involvement, To expose feelings is to explore your true self. To place your ideas and dreams before a crowd is to risk their loss. To love is to risk not being loved in return, To live is to risk dying, To hope is to risk despair, To try is to risk failure. But risks must be taken because the biggest hazard in life is to risk nothing. The person who risks nothing, does nothing, has nothing, is nothing. He may avoid suffering and sorrow, But he cannot learn, feel, change, grow or live. Chained by his servitude he is a slave who has forfeited all freedom. Only the person who risks is free. The pessimist complains about the wind; The optimist expects it to change; And the realist adjusts his sails.

REFLECTIONS DO I FIRST WEIGH UP THE IMPORTANCE OF AN IDEA AND THEN TAKE CARE OF THE LOGISTICS? DO I USE PREVIOUS EXPERIENCES TO HELP ME COPE WITH NEW ONES? DO I REALISE THAT LUCK IS OFTEN ASSOCIATED WITH HARD WORK, AN ELEMENT OF RISK TAKING AND DOGGED DETERMINATION?
Do you wish to comment on the difference this article has made to you? See the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

Qualified Life Coach Jo Middlemiss offers readers a complimentary half hour coaching session (for the cost only of your call), tel. 07803589959.

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REVIEWS

reviews
DEMENTIA
Telling Tales About Dementia Lucy Whitman (ed.) Jessica Kingsley ISBN 978-1-84310-941-9 14.99

A compelling read

Weve suffered a robbery / the most vile cowardly steal / Silently, invisibly, impalpably / the thief fled our lives, / leaving behind / a trail of destruction / deprivation / desperation and dislocations, / indifferent to all sufferings / unmoved by our sorrow. (Verse 1, Feisty Love by Maria Smith (p. 77) Lucy Whitman has assembled thirty brief narratives of those who have cared for loved-ones with dementia. Grouped under three headings, she martials accounts which illustrate common experiences of carers from various socio-cultural perspectives. Whitmans intention is to shine a torch on the path that others have trodden in the bewildering world entered when supporting someone with this devastating condition. Why should speech and language therapists read these very personal tales of disintegration, dislocation and loss? As Whitman says, You may not be affected by dementia today, but perhaps tomorrow, you will be. Furthermore, she hopes the book will contribute to the greater awareness within the health and social care professions regarding the needs of sufferers and carers. Telling Talesis a testament to human attachment, resourcefulness and humour in the face of immense challenge. It is a compelling read. Beryl Hylton Downing is a retired speech and language therapist living in Northumberland.

The children I trialled the books on reported they enjoyed the bold pictures and liked discussing the extra things going on in some of the pictures. The illustrations prompted further comments and the statements allowed the children to formulate utterances to express their own experiences. They also stated they liked the use of the clock throughout the book. Each book has a sequence of no more than 12 pictures and statements. This can limit some of the story details, so they are unable to be expanded further. For example Going to buy shoes could discuss what might happen if there are not the right shoes in their size. The language used is clear, aiming for positively worded statements. However this restricts the language to present tense structures only. I would recommend these books for families and professionals alike. They are a useful resource to be used as part of preparation for daily living or by therapists for use in narrative therapy groups or as part of topic based literacy or language groups in schools. They could also be used by families as reading books offering early readers the opportunity to bridge the gap between factual and fictional reading. Helen Burnford is a specialist speech and language therapist in paediatric special needs with Abertawe Bro Morgannwg University Health Board, based in Brigend, South Wales.

THEATRE VOICE

Breath in Action Ed. Jane Boston & Rena Cook Jessica Kingsley ISBN 9781843109426 16.99

Obvious passion

FEEDING DIFFICULTIES

Seventeen easy-to-read chapters bring together short, comprehensive and wide-ranging views of breath work from Eastern and Western cultures in the context of the theatre voice practitioner. The subjects range from a review of how breathing works, relevance to alignment, Qi Gong Breathing, and breath work in relation to text. There is a continual reminder of the holistic aspect of breath and voice in general that is, the impact of social conditioning, emotions and the communication intent. The exercises, where shown, are well laid out and illustrate the ideas expressed in the relevant chapter, but some were not as easy to follow as others. I would have welcomed more of the good case histories. You may argue with some of the imagery and views but not with the obvious passion expressed. This is an inexpensive and fascinating book for those interested in finding out more about what influences the theatre voice practitioner. Melanie Mehta is a specialist speech and language therapist in voice disorders at Guys Hospital, London and Spoken Voice Teacher at the London Academy of Music and Dramatic Art (LAMDA).

DAILY LIVING

Feeding and Nutrition in Children with Neurodevelopmental Disability Ed. Peter B. Sullivan Mac Keith Press ISBN 978-1-898683-60-5 20.00

EARLY YEARS

Off We Go! Going to Buy Shoes; Going to Buy Clothes; Going to a Birthday Party; Going to the Optician; Going on a Plane; Going to the Cinema Avril Webster Off We Go Publishing 9781906583088; 9781906583071; 9781906583064;9781906583101; 9781906583118; 9781906583095 Euro 7.99 each or Euro 39.99 for the set

Useful resources

For families or professionals

I initially thought these books were an attempt at a type of Social Story. On closer inspection they are clearly not trying to be that at all. They are a series of books aimed at younger children and have been written by a mother of a child with severe learning difficulties. Originally they were devised to help prepare her son for different events he would encounter in his daily life. The author has followed advice from a speech and language therapist regarding the sequencing of the stories, the length of utterances used and the use of familiar language. The books also have a clock on key pages throughout the story to support the time line.

The importance of the multidisciplinary team in the management of feeding difficulties in children with neurodisabilities is the focus of this practical guide. There are contributions from paediatric gastroenterologists, paediatric dieticians, a specialist speech and language therapist and a clinical research nurse. It acknowledges the tremendous difficulties faced by families caring for their children and the vital role they have in managing feeding issues. Real life scenarios are presented by the editor with further reference to the relevant chapters. The appendices contain useful resources for clinicians: the cerebral palsy growth charts, information on formula, supplements and thickeners and a feeding and dietary assessment form. I found chapters 6 and 7 relating to assessment, management and special investigations of gastrointestinal disorders interesting and informative. This book represents good value for money and is a must for any multidisciplinary feeding team or therapist undertaking postgraduate dysphagia training. Marie Swindells is a speech and language therapist working with pre-school children with special needs and dysphagia in South Birmingham PCT.

Supporting Childrens Creativity Through Music, Dance, Drama and Art (Creative Conversations in the Early Years) Ed. Fleur Griffiths David Fulton ISBN 978-0-415-48966-9 19.99

Very inspirational

Written by a group of early years professionals, including speech and language therapists, this book aims to inspire and enable practitioners to facilitate childrens creative development through the arts. All 10 chapters make for very easy reading. Throughout there are case studies, thought-provoking tips and practical examples of how to implement the ideas presented. Of particular interest to speech and language therapists will be talking tables and story telling and story acting as they contain a heavier emphasis on supporting childrens language development. The chapters on listening more and talking less and enriched environments would give an excellent basis for discussion with enthusiastic early years practitioners who wish to develop the creativity and interactions of children within their setting. Each chapter would be of use if read separately, but the reader would gain most benefit if the book was read in its entirety.

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REVIEWS

This reasonably priced book is probably of most use to early years practitioners - however I found it very inspirational and would highly recommend it to therapists who work closely with early years settings. Abi Longland is a speech and language therapist for Hertfordshire Community Health Services.

AUTISM

Motivate to communicate! 300 Games and Activities for Your Child with Autism Simone Griffin & Dianne Sandler Jessica Kingsley ISBN 978-1-84905-041-8 12.99

SIGNING

Lets Sign Songs for Children (book) / Lets Sign with Babies can Sign (Vol. 1) (CD) Cath Smith & Vicki Gilbert / Vicki Gilbert Co-Sign Communications / Babies Can Sign ISBN 978-10905913-12-1 / n/a 6.99 / 8.00 See www.deafbooks.co.uk

HOW WE LEARN

Introducing Neuroeducational Research Neuroscience, education and the brain from contexts to practice Paul Howard-Jones Routledge ISBN 978-0-415-47201-2 24.99

Occasional flashes

Not easy to read

Neuroeducational research is a new field. It aims to link the scientists with the educationalists in understanding how we learn. This book touches on some relevant topics to speech and language therapy such as using brain imaging to predict future literacy skills. It looks at the evidence to support fashionable approaches including brain gym and omega 3. This book was informative but unfortunately not easy to read. I found it to be a good basis to understand more from. As a practicing clinician I feel that an article on the topic would have the same effect (perhaps in Speech & Language Therapy in Practice!) and would reach a wider audience. Speech and language therapist Sally Legerton is Lead Clinician of Mainstream Schools, Surrey Community Health.

This book contains some imaginative play ideas that are organised sensibly, so easy to find. The activities use everyday household items, so most families could use at least some immediately. The book seems to be pitched more towards children with spoken language, and the theory touches on big topics very briefly, which could be confusing for families. Activities arent clearly linked to autism specifically or to the core communication skills they target. I would therefore be cautious about recommending this book to parents or professionals who dont have a robust understanding of autism spectrum disorder and a childs specific needs. There are better resources available for this price. I will keep it on my shelf for occasional flashes of inspiration, and it may be useful for newly qualified speech and language therapists. Sarah Matthews, a speech and language therapist in community clinics and with children with complex needs, reviewed this book in conjunction with a school SENCo.

Sensible tips

DEAFNESS

SOCIAL COMMUNICATION

The Communication Toolkit Assessing and Developing Social Communication Skills in Children and Adolescents Belinda Medhurst Hinton House ISBN 978-1906531-26-3 29.99

Literacy and Deafness (Listening and Spoken Language) Lyn Robertson Plural Publishing ISBN 978-1-59756-290-4 $65.00 (USD)

The Lets Sign book contains words for 17 songs, mainly well known nursery rhymes. Key words in capitals are accompanied by a sign illustration on the same page. You can hear each of the songs performed on the CD. The book includes an introduction explaining the theory behind it: the authors firmly support the use of BSL (British Sign Language) in baby signing and for all children who sign to encourage understanding between the hearing and Deaf worlds. There are also some sensible tips on using sign with babies, and on signing stories to ensure good adult-child communication. My local playgroup liked the layout showing which words to sign and avoiding the danger of including too many signs for beginners. Some of the signs are hard to work out from illustrations alone; you would have to know them already or have them demonstrated and then use the book as a memory jogger. The book would not be of use in settings that use specially devised Total Communication signs. Otherwise it could be a helpful and fun resource for playgroups, nurseries and carers who are new to signing with babies and young children. If the setting / carer can only afford one, they should go for the book with the CD as an optional extra. Helen Rose is a specialist speech and language therapist in Gloucestershire.

Confusing

Invaluable

An inspirational resource for both the young person and therapist, this draws on a whole range of tried and tested approaches. While not a one stop shop for ALL your social communication skills requirements, it is an invaluable toolkit to assess and develop skills in 8 to 16 year olds, with particular emphasis on self-concept and self-esteem. User-friendly for therapists and non-therapists alike, this is a welcome resource for working with the individual, but is equally adaptable for groups. Our students commented: It helped release my thoughts (Andre, Year 5); It made me think all about me (Rhys, Year 6). It has even succeeded with the reluctant passive year 11 student other resources have failed to reach! Exceptional value for money, but a ring bound version would be more photocopy friendly. Kathryn Locker and Babs Turner are speech and language therapists with the Mainstream Schools Team, Community Health Buckinghamshire.

The preface states the author came at this from both a research-based and a personal point of view. This makes for a somewhat confusing book, which seems to be uncertain as to whether it is a self-help guide for parents or a literature review for professionals. The author is clearly passionate about her subject, but this reduces objectivity and the book is peppered with her personal opinions. Some chapters are useful and relevant, including one of two contributed by other authors (Technology and Listening), which provides an up-to-date overview of the different electronic options available for todays hearing impaired clients. The chapter on Hearing, Listening and Literacy details some good approaches to developing listening skills. However, the majority of the remaining chapters contain little that is new to speech and language therapy as a profession, or are too heavily based in the US education system to be easily transferrable to the UK. Helena Rameckers is an independent speech and language therapist working in South West Scotland and specialising in paediatric Down Syndrome.

DEMENTIA

Early Psychosocial Interventions in Dementia Ed. Esme Moniz-Cook & Jill Manthorpe Jessica Kingsley ISBN 978-1-84310-683-8 19.99

Essential reading

This book describes early psychosocial treatment in dementia care. It focuses on evidence- backed therapy for those with a new or early diagnosis. The book crosses European boundaries and offers us opportunities to hear from both our own as well as European practitioners. Despite the content being entirely relevant, unfortunately none of the contributors are speech and language therapists. The chapters examine current best practice and in turn discuss what works and what doesnt. It is easy to read, laid out well, backed up by references and illustrated by case examples. I have found this book essential reading for my work as a dementia specialist and I would happily recommend it. Marie Gilbert is a specialist speech and language therapist with Cheshire and Wirrel Partnership Trust.

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THIS HOUSE BELIEVES

OUR SERIES AIMS TO DEVELOP YOUR SKILLS FOR CRITICAL APPRAISAL MAKING DECISIONS EVIDENCE BASED PRACTICE

This House Believes

Oropharyngeal dysphagia is the term used to describe swallow impairment. Swallowing difficulty can arise from nerve, muscle or structural damage to the oropharyngeal tract including the oral cavity, pharynx and upper oesophageal sphincter. Speech and language therapists have a primary role in the assessment and treatment of oropharyngeal dysphagia. International and national organisations agree that both non-instrumental and instrumental procedures are within the speech and language therapists scope of practice and require a specific level of training (ASHA , 2002; NCCAC, 2006; RCSLT, 2006) . The clinical swallowing evaluation usually includes reviewing medical history, patient and carer interviewing, completion of the oro-facial sensory motor examination, and observing the patient during trial swallows. The instrumental examination typically includes videofluoroscopy or fibreoptic endoscopy. The primary goals of dysphagia assessment include: a. determining the presence or absence of a disorder b. describing its nature and cause c. evaluating impacts on quality of life d. designing an effective treatment plan. There is broad agreement on the goals but how we achieve these has historically been the source of controversy (Splaingard et al., 1988). There are mixed opinions as to the need and use for both the non-instrumental and instrumental procedures. Many clinicians view the clinical swallowing evaluation as a starting point for gathering information to determine the need for an instrumental examination. Others have shunned the subjectivity and methodological inconsistencies of noninstrumental procedures, concluding that the instrumental examination is essential in all cases. A recent prospective study showed marked variability in clinical decision making and in conducting non-instrumental procedures (Pettigrew & O'Toole, 2007). These findings were comparable to previous studies showing high variability in clinical practice and clinical decision making (Mathers-Schmidt & Kurlinski, 2003; Bateman et al., 2007).

Samantha Procaccini and Paula Leslie weigh up the evidence for offe endoscopy to all people referred with acute dysphagia, but find the s
practice raises concerns for methodological efficacy and ultimately patient care. In response to the growing expectation of consistent evidence based practice, our debate considers the evidence for and against a requirement for instrumental procedures on all acute patients referred for a swallowing evaluation.

This House Believes explained

In her teaching, Paula Leslie uses a debating idea from the British Medical Journal to get her students to critically review a controversial subject. By understanding the strengths and weaknesses of the arguments on both sides, the students are better prepared to develop their own views. Students are strictly limited in word count and number of references to foster concise and relevant writing. Their work is now being adapted for Speech & Language Therapy in Practice. The debating format means: the Proposition is required to prove its case, while the Opposition aims to show why the Proposition is wrong either side can interrupt with a point of information while the other side is speaking our authors reach a conclusion based on the evidence and readers can continue the floor debate via the Critical Friends process see www. speechmag.com/About/Friends.

Background

Samantha

Paula

The proposition case is that clinicians should complete an instrumental exam on all acute care patients referred for swallow evaluation. Swallowing is a complex process involving the coordination of several covert physiological systems. Clinicians wishing to achieve objective clinical methods for detecting swallowing dysfunction have been plagued by the complexity of the physiology. One of the problems that dysphagia clinicians face is the difficulty of identifying aspiration. A false negative exam (when a patient is incorrectly identified as having no problem) may lead to potentially devastating outcomes in the medical course of a patient. Dehydration, malnutrition, and aspiration pneumonia are reported complications for those suffering from dysphagia. A recent study showed that the negative predictive value of aspiration or penetration was 64 per cent when a tracheostomised patient passed the clinical swallowing evaluation. This meant that over one third of the patients who passed later failed the instrumental examination (fibreoptic endoscopic evaluation of swallowing) (Hales et al., 2008). This study also concluded that fibreoptic evaluation of swallowing is highly valuable in routine assessment of swallowing. POINT OF INFORMATION The Hales paper clearly states that for those patients identified as having a problem on clinical evaluation the use of further instrumental assessment is unnecessary simply to identify if there is a problem. This supports the view that requiring instrumental examinations on all acute patients is unwarranted unless the instrumental exam is used to define the nature of the swallow impairment. The clinical swallowing evaluation is often used as the standard measure for assessing dysphagia in medical settings. The accuracy of such methods for detecting aspiration is widely scrutinised amongst clinicians and researchers. The clinical swallowing evaluation has been

The proposition case: external evidence increases clinical efficacy

Samantha Procaccini is a speechlanguage pathologist at the University of Pittsburgh Medical Center-Passavant in Pittsburgh, USA, and a clinical fellow in the medical speech language pathology clinical doctoral program at the University of Pittsburgh, USA, email sjp52@pitt. edu. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, email pleslie@pitt.edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists.

Defining the topic

Dysphagia assessment procedures must be clear, consistent and evidence based. An accurate dysphagia assessment is paramount to providing effective treatments for patients. Inappropriate or inaccurate assessments can put patients at risk of malnutrition, dehydration, anxiety, respiratory infection and even death (Hudson et al., 2000). Variability in any type of clinical

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THIS HOUSE BELIEVES

s in instrumental assessment
criticised for its inability to define pharyngeal phase abnormalities and silent aspiration. Additionally, use of the clinical swallowing evaluation alone has been criticised for being unreliable in guiding dietary management and treatment recommendations of patients with dysphagia. Leder & Espinosa (2002) reported reliance on non-instrumental measures alone for diagnosing and treating dysphagia led to underestimation in patients with aspiration and overestimation in patients who did not aspirate. McCullough et al. (2001) confirmed more efficacy data is needed if the clinical swallowing evaluation is used to predict aspiration on videofluoroscopy. POINT OF INFORMATION: Dr Leder has subsequently changed his position and advocates the use of a simple 3oz water swallow test as being sufficient: Importantly, for the first time it has been shown that if the 3-ounce water swallow test is passed, diet recommendations can be made without further objective dysphagia testing. (Suiter & Leder, 2008) Even if the clinical swallowing evaluation accurately detects aspiration, the clinician is unable to judge either the amount or whether compensatory strategies or manoeuvres reduce aspiration risk. To adequately address the cause of a swallow impairment we must be able to evaluate the physiology, and this requires instrumental imaging.

ering instrumental assessment in the form of videofluoroscopy or fibreoptic scales tip to a more patient-centred, needs-led approach. Summing up the case for the proposition

There is a drive to increase evidence based practice in clinical decision making. Universally implementing instrumental examinations on all patients referred for a swallow evaluation would provide the external evidence needed to achieve the highest quality patient care. Video documentation would serve as a vehicle to substantiate diagnostic and treatment recommendations. A department better equipped to perform evidence based practices and cutting edge dysphagia services is more likely to gain transdisciplinary respect, and potentially more referrals. Based on the results of instrumental assessments, treatment recommendations and dietary management can be made with greater clinical efficacy.

POINT OF INFORMATION: Acute care patients may have different impairments and therefore requirements to rehabilitation patients. By the time patients get to rehabilitation they should have already had the instrumental exams and so the cause of the swallow impairment would be known.

Danger of test focus

A false positive exam (when a patient is incorrectly identified as having a problem) can also lead to potentially negative effects on a patient's quality of life, independence, and life satisfaction. Patients may be placed on a diet modification following a clinical swallowing evaluation when there is no need. Although it is documented that patients can be adequately hydrated with thickened liquids (Sharpe et al., 2007), there is a high risk of dehydration for patients receiving thickened liquids. This is related to reduced intake of liquids from refusing thickened liquids (Finestone et al., 2001). Colodny (2005) surveyed 63 patients with dysphagia who were considered to be "noncompliant" with the speech and language therapists recommendations. The second most common response for justifying noncompliance was dissatisfaction with diet modifications. Determining the need for diet modification should be justified by evidence and the use of instrumental imaging could help patients understand why recommendations are being made.

Diet modification

Instrumental evaluations of swallowing are not required for all acute care patients referred for a swallow evaluation. Detecting aspiration is not the sole or even primary objective of the clinical swallowing evaluation. McCullough et al. (2005) pointed out that it serves a wide range of purposes including 1. documentation of feeding position 2. amount of oral intake 3. eating efficiency and 4. overall pleasure derived. The clinical swallowing evaluation quite importantly aims to establish the need to conduct an instrumental examination. During the clinical swallowing evaluation it should become clear if the factors are more or less oropharyngeal related, for example the patient who had a stroke a year ago but the event precipitating the referral was vomiting whilst asleep and subsequent chest problems. Factors such as simple fatigue may be the primary reason for the swallow impairment. Westergren et al. (2002) investigated eating difficulties in a group of hospital rehabilitation residents aged 65+ years. The most common eating difficulties were low food consumption, manipulation of food on the plate and variable speed of eating. The primary characteristic of eating difficulties overall and in non-assisted patients was low energy - people simply didnt have enough energy to finish their meal. Low energy is an insidious problem and often not identified in patients who dont receive assistance. This is a serious issue as low energy had the strongest correlation with malnutrition.

The opposition case: clinical judgement is needed

Videofluoroscopy and fibreoptic endoscopic evaluations of swallowing have historically been considered gold standard instrumental measures for evaluating dysphagia. There is a danger that we focus too much on one test and forget the complexity of physical and psychological issues involved in maintaining adequate nutrition and hydration and the non-physiological aspects of eating and drinking. Some experts advocate for 100 per cent requirement of videofluoroscopy using the threat of litigation as pressure, without regard to the many other factors involved (Tanner, 2006.) Psychosocial factors are equally important. People with eating difficulties may feel embarrassed and fear socialising over a meal. Leow et al. (2009) showed that dysphagia carried a high level of burden for those with Parkinson's disease. The burden of having dysphagia may lead to a loss of appetite, social isolation and embarrassment, raising the potential for depression and anxiety (Eckberg et al., 2002; Westergren et al., 2002).

Summing up the opposition case

The use of instrumental assessment must be deemed appropriate and this requires clinical judgment. Pollens (2004) pointed out using instrumental testing would be inappropriate if i. the results were not going to change clinical management ii. the patient was too medically fragile or iii. the patient refused. Evidence based practice standards require that medical practitioners use their best clinical judgement and adhere to a patient-centred care model. Take the scenario where a speech and language therapist receives a swallowing referral for a patient just recently placed on palliative care for end stage lung cancer. The patient and carer make an informed choice to refuse an altered diet and participation in instrumental testing measures. In this clinical case, ordering an instrumental exam would be a pure act of paternalism and violation of the ethical principles of autonomy and informed consent.

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THIS HOUSE BELIEVES

Judgement: Motion defeated

Instrumental testing serves an integral role in dysphagia diagnosis and treatment. Clinicians must recognise the potential dangers and impracticalities of over-using instrumental measures. Technological advances have made equipment more accessible. We must provide fair and equitable treatment to all according to the medical ethical principle of justice. A requirement for all acute care patients to have an instrumental exam has consequences in terms of budget and staff availability. Acute care facilities often have a large volume of patients referred for swallow evaluations. Completing unnecessary testing would result in increased hospital costs and lengthier hospitalisations. There is very little robust evidence linking dysphagia assessment and intervention with long-term or global health outcomes. We practise in a culture that is increasingly risk averse, but without evidence supporting our fears. Many patients are still restricted in their diets based on observation of aspiration during a videofluoroscopy sometimes without any other evidence. Yet we have evidence that thickened drinks result in dehydration (Finestone et al., 2001), a major health risk factor. Universal use of instrumental measures in swallow evaluation is not always appropriate. Instrumental exams are an essential tool but, even when we know there is a problem from the clinical evaluation, we might not recommend a further instrumental. The evidence from Hales et al. (2008) shows we are good at identifying that there is a problem. What we do then will vary - for some patients it will be to consider 100 per cent non-oral supplementation, for others it will be to try consistencies that they can cope with, and for others it will be to analyse it further through an instrumental examination. The clinical swallowing evaluation assesses much more than just aspiration or physiology and so the informed clinician can make a judgement regarding the nature of the swallow impairment. This allows for prioritisation for subsequent evaluation which may include instrumental testing. Clinicians should not use the lack of resources as an excuse for not requiring instrumental testing. Services should be requested based on patient need rather than what service is available. Clinicians need to be evidence based thinkers and practitioners, aware of what a full dysphagia evaluation requires and what the instrumental exam can tell us as a part of it. We propose that instrumental exams are NOT required for all acute patients. Equally, the clinical swallowing evaluation should be comprehensive, so we do not support Leders position on the use of a simple water test. Further recommendations after the clinical swallowing evaluation should be based on patient need and understanding of the consequences of our recommendations. This position applies to all evaluations of patients with dysphagia in all settings, not just the acute wards.

American Speech-Language-Hearing Association. (2002). Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders [Position Statement]. Available from www.asha.org/policy. Bateman, C., Leslie, P. & Drinnan, M.J. (2007) 'Adult dysphagia assessment in the UK and Ireland: are SLTs assessing the same factors?', Dysphagia 22(3), pp.174-86. Colodny, N. (2005) 'Dysphagic independent feeders' justifications for noncompliance with recommendations by a speech-language pathologist', Am J Speech Lang Pathol 14(1), pp.61-70. Eckberg, L.A., Hamm, L.J. & Soltis, J.A. (2002) 'Breaking free of restraints', Provider 28(7), pp.57-60, 62. Finestone, H.M., Foley, N.C., Woodbury, M.G. & Greene-Finestone, L. (2001) 'Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies', Arch Phys Med Rehabil 82(12), pp.1744-6. Hales, P.A., Drinnan, M.J. & Wilson, J.A. (2008) 'The added value of fibreoptic endoscopic evaluation of swallowing in tracheostomy weaning', Clin Otolaryngol 33(4), pp.319-24. Hudson, H.M., Daubert, C.R. & Mills, R.H. (2000) 'The interdependency of protein-energy malnutrition, aging, and dysphagia', Dysphagia 15(1), pp.31-8. Leder, S.B. & Espinosa, J.F. (2002) 'Aspiration risk after acute stroke: comparison of clinical examination and fiberoptic endoscopic evaluation of swallowing', Dysphagia 17(3), pp.214-8. Leow, L.P., Huckabee, M-L, Anderson, T. & Beckert, L. (2009) 'The Impact of Dysphagia on Quality of Life in Ageing and Parkinson's Disease as Measured by the Swallowing Quality of Life (SWALQOL) Questionnaire', Dysphagia [online]. DOI 10.1007/s00455-009-9245-9. Mathers-Schmidt, B.A. & Kurlinski, M. (2003) 'Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decision-making', Dysphagia 18(2), pp.114-25. McCullough, G. H., Rosenbek, J.C., Wertz, R.T., McCoy, S. & Mann, G. (2005) 'Utility of clinical swallowing examination measures for detecting aspiration post-stroke', J Speech Lang Hear Res 48(6), pp.1280-93. McCullough, G.H., Wertz, R.T. & Rosenbek, J.C. (2001) 'Sensitivity and specificity of clinical/ bedside examination signs for detecting aspiration in adults subsequent to stroke', J Commun Disord 34(1-2), pp.55-72. National Collaborating Centre for Acute Care (2006) Nutrition Support in Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. London: National Collaborating Centre for Acute Care. Pettigrew, C. M. & O'Toole, C. (2007) 'Dysphagia evaluation practices of speech and language therapists in Ireland: clinical assessment and instrumental examination decision-making', Dysphagia 22(3), pp.235-44. Pollens, R. (2004) 'Role of the speech-language pathologist in palliative hospice care', J Palliat Med 7(5), pp.694-702. Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Sharpe, K., Ward, L., Cichero, J., Sopade, P. & Halley, P. (2007) 'Thickened fluids and water absorption in rats and humans', Dysphagia 22, pp.193-203. Splaingard, M. L., Hutchins, B., Sulton, L.D. & Chaudhuri, G. (1988) 'Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment', Arch Phys Med Rehabil 69(8), pp.637-40. Suiter, D. M. & Leder, S.B. (2008) 'Clinical utility of the 3-ounce water swallow test', Dysphagia 23(3), pp.244-50. Tanner, D. (2006, February 07) 'The Forensic Aspects of Dysphagia: Investigating Medical Malpractice. The ASHA Leader [online]. Westergren, A., Ohlsson, O. & Hallberg, I.R. (2002) 'Eating difficulties in relation to gender, length of stay, and discharge to institutional care, among patients in stroke rehabilitation', Disabil Rehabil 24(10), pp.523-33.

References

Resources
The Socialeyes pack from the National Autistic Society is designed to help people with autism become more confident in social situations. www.autism.org.uk/socialeyes 3D Anatomy software is now available for speech and language therapy clinicians and lecturers, and includes a client education section. www.primalpictures.com/speech_language_ pathology.aspx The national advice and information service for additional support for learning in Scotland. www.enquire.org.uk/pcp/index.php Looking Up is a monthly international newsletter devoted to autism. www.lookingupautism.org/subscribe.html Nottingham Rehab Supplies has a 48 page brochure of equipment which may help people with dementia. Email info@nrs-uk.co.uk for a copy. The Assessment of Mental Capacity Audit Tool (AMCAT) is an online resource for staff and carers. www.amcat.org.uk/ The May 2010 Stroke Matters includes articles about involving clients and carers in research. www.stroke.org.uk/professionals/information_ and_resources/stroke_matters.html Preview NDP3 Speech Builder software for creating therapy tools based on the 700 images in the Nuffield Centre Dyspraxia Programme. www.ndp3.org/speechbuilder.html Users of Clicker and ClozePro software can now choose from three different symbol sets Widgit, Mayer-Johnson PCS and SymbolStix. www.cricksoft.com A Voice Fit for Teaching is a 24 page booklet by voice coach Caroline Cornish to give guidance to teachers on voice care and use. www.southgatepublishers.co.uk/ A simplified computer aimed at older people has just six buttons for basic tasks such as email. SimplicITy costs start at 435.99. www.discount-age.co.uk/simplicity_computers/ Source = MND Cheshire newsletter A central resource for advice on developing Personal Communication Passports. www.communicationpassports.org.uk/Home/ The National Literacy Trust has overhauled its website to include a Wiki of good practice, policy and campaigns and expert blogs. www.literacytrust.org.uk/

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Yes we can
Speech and language therapy is a fledgling concept in many African countries. On her return from the 3rd East African Speech and Language Therapy Conference in Kenya, Lois Cameron reflects on what the experience of these early pioneers can teach us about improving practice in the UK.

READ THIS IF YOU WANT TO CELEBRATE CONNECTIONS OLD AND NEW RAISE AWARENESS OF HIDDEN DISABILITIES TURN SHORTTERM INPUT TO LONG-TERM SOLUTIONS

Delegates at the 3rd East African Speech and Language Therapy Conference or seven years I lived in Nairobi as a child when, in 1967, my father was seconded from Glasgow medical school to help establish the medical school in Kenya. Up to that time Kenyan doctors had to be trained abroad. In 2009, the year of Homecoming Scotland, the great diasporas from around the world were encouraged to come and enjoy the country where they or their ancestors had been born. I made the trip the other way my Kenyan homecoming - to celebrate the connections of my childhood. I had read about the 2nd East African Speech and Language Therapy Conference at the end of 2008. I contacted the organisers to express my interest and they invited me to attend the 3rd event in 2009. This small pioneering group of therapists is trying to establish speech and language therapy within Kenya and address the needs of people with communication disability. Given my family heritage it felt a privilege to support them in any way, so I was delighted to volunteer to present at their conference. I ran two sessions; one an introduction to Talking Mats, the other a full days intermediate Talking Mats training for the speech and language therapists and support workers.

Kenya, with a population of 37 million, has a workforce that has never been more than eight speech and language therapists. This fluctuates as it is made up of residents, volunteers and partners of expatriate workers who are normally in the country on shortterm contracts. The speech and language therapists currently working in Kenya have had their initial training in a wide variety of countries: The Netherlands, USA, UK and India. The bulk of the therapists work is in Nairobi and is predominantly centred on three private hospitals, though a small proportion of work is done in outlying schools and clinics. Some of the therapists volunteer in the Kenya Institute of Special Education. Currently five therapists are based in Nairobi and two at the coast. These therapists work in immensely pressurised and isolated circumstances. It is impressive to observe the strong mutual support they give each other, and also their focus on continued professional development and ensuring they deliver a quality and up-to-date service. In addition to the seven Kenyan therapists, the conference was attended by VSO volunteers Fiona Bell and Isla Jones and student David Rochus Kyambadde, all from

the first Ugandan speech and language therapy course at Makerere University in Kampala. There were also three other UK speech and language therapy delegates and Karen Wylie, a speech and language therapist from Ghana. The conference was open to anyone with an interest in supporting the needs of those with communication impairment in East Africa and it was good to see the wide range of other professionals there: occupational therapists, rehabilitation assistants, nursery staff, special needs teachers, paediatrician, neurologist, dentist, parents and psychologists. It was heartening to experience the support from these professions and their commitment to improving services for people with communication impairment. A small professional group must particularly value the support of others and need their assistance in advocating their cause. As well as the sessions with a directly clinical focus, there was much discussion about the way forward for speech and language therapy in Kenya. This included developing a professional association and ensuring an increase in the number of therapists. There has been some discussion with the universities about establishing a course in Kenya, but the challenges are huge. Julie Marshall from Manchester Metropolitan University led a session on professional sustainability. She challenged the delegates to think about a model for delivering services to people with communication impairment that was a Kenyan solution not just one imported from other countries. She raised the issues of personal versus national sustainability. Individuals contributing on a short-term basis can try to come up with a local sustainable solution that will enable some carryover once they have left. National sustainability involves a vision for the country as a whole and needs a strategic plan in place to achieve it.

Challenging

The experience of the Ugandan course was interesting and gave much food for thought. VSO established the course in conjunction with Makerere University two years ago, with the first students enrolling in February 2008. The VSO volunteers co-ordinate the course, sourcing lecturers from other university

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SUSTAINABILITY
departments and through specialists visiting from abroad. These are two really challenging VSO positions and the complexity of their task seems quite overwhelming to me. I really admire the courage and professionalism with which the VSO therapists are supporting the first cohort of 13 students, who are now in their second year. The short-term nature of VSO makes continuity and professional skill mix an extra. In addition, in a country where there are no long-term qualified speech and language therapists, professional support for these students when they qualify will be very limited if not non-existent. The question also remains whether there will be posts for them on qualifying. The first cohort of occupational therapists to graduate from Makerere had to wait 10 years before there were any government funded posts. This problem has been thought about and the course planners have tried to overcome it by writing a job structure and workforce plan at the same as the curriculum, but the jury is still out on whether this will be successful. There are 15 million children in Kenya. The lack of knowledge about the prevalence and impact of communication impairment is huge. In compiling a report for I CAN, Hartshorne (2006) reviewed the literature on prevalence in the UK and concluded that around 10 per cent of all children have longterm, persistent communication support needs, including the 6 per cent with primary speech and language impairment. As a nation Kenya puts a huge emphasis on the benefits of education, yet we know communication difficulties are a significant contributing factor to problems with learning, accessing the curriculum and developing to your full potential. Dr Sid Nesbitt, the paediatrician from Gertrudes Childrens Hospital in Nairobi, stressed the likelihood that early intervention prevents the more serious consequences of later learning disabilities. On the paediatric side alone the need for services is likely to be vast. A few people in Kenya in influential positions have some understanding of this but you can count them on less than one hand. The knowledge of physical disability is growing, but it is much more difficult to get hidden disabilities taken seriously. This lack of understanding is in a context of severe competition for funding against high profile health issues such as HIV and malaria. Karen Wylie gave an example from her time working in Zambia when therapists were able to piggyback on an extensive internationally funded HIV program. Once the children had started on a course of antiretroviral drugs, many developmental delays that were contributing to their poor health and wellbeing emerged. The workers were then able to get funding for a range of therapies. The cultural context also adds further levels of complexity. In Kenya there is a feeling that doctors should solve the problem, and that there should always be a medicine or an injection. There is therefore a lack of credence

given to other professions, particularly when people do not really know who they are, what their training is and above all what they can offer and do. In this context it can be hard to establish responsibility for self-management of a condition or for environmental management like changing the interaction patterns and language support between caregiver and child. General attitudes to disability in Kenya mean it is often difficult to access the children. Disability is seen as shameful and a curse, so the child is hidden away. The mothers are usually left on their own to bring up the child, as it is viewed as their fault, so economically they find themselves in a perilous situation. Karen Kibuchi is mother of a 7 year old with complex and multiple learning disabilities. She described to me how her eyes were opened when she went to study in Manchester, and saw her daughter could get the services and support that would help her realise her potential. Returning to Kenya has been hard as no school will accept her daughter. Karen, though, is a woman with determination. She realised she could not be the only woman in Kenya in this position, so she contacted her local churches and asked for women to get in touch with her if they had a child with a disability. Within two weeks she had 32 families and has now stopped asking because she has over 50 families coming to her for support. Through sheer hard work and dogged determination she has secured funding from General Motors to build a school and from the Ministry of Education to fund the teaching staff. She has yet to secure the running costs but I have no doubt she will. In the meantime she has founded the Initiative for Learning Disabilities Kenya and continues with the huge task of working with mothers to build their confidence, self-esteem and belief that their childs disability is not their fault.

Unintended barriers

So what do I take from my experience in Kenya that can be applied to my professional work back here in the United Kingdom? Julie Marshalls presentation reminded me that I am a member of a profession that is predominantly white, female, brought up in a Judeo-Christian setting and used to accessing western health care. A visit to a country where things are so different brings that into sharp focus and made me reflect on diversity with the people I work with in the UK. Here I am not just talking about cultural diversity but also value diversity. This is something we need to challenge ourselves on continually. At the present time in the NHS equality and diversity issues can become a bit of a tick box exercise, but I suspect if we dont get this right then we will be reducing our effectiveness. We will be putting unintended barriers in the way thus reducing our ability to listen and attend to the needs of clients and their families. The East African therapists have a richness in their training tradition drawn from across five different continents. It makes me wonder if we really make use of the experience of therapists who come from a different cultural, value or training background, and if we use their eyes to see things from their perspective. Is there a tendency to expect them to fit into our mainstream and not take fully the opportunity for learning that their background and experience offers? Another learning point is around sustainability. Whilst the pressures are different the issues are similar, particularly when services are under financial constraints. There needs to be as much planning at the start of projects, new initiatives or redesigns as to how the input will be sustained long-term. There also needs to be active consideration of any unintended

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SUSTAINABILITY

Servox appeal

Talking Mats sessions at the Conference consequences of input. This is important for personal as well as service initiatives. Finally, the conference made me reaffirm that the power of working with others - be they speech and language therapists or other members of the multidisciplinary team -enables people to achieve great things. Networking and building alliances with other professionals and patient groups is a key component of change. In leadership terms we need to continue to develop our skills and capacity to do this. strategy to achieve the vision, and designed to be fit for purpose. There was acknowledgement that considerable investment and support will be needed to carry out training, and the existing number of therapists cannot commit to this. I was left impressed with a group of therapists who are working under huge workload pressures but supporting each other to ensure a work life balance and to keep professional standards high. Many of the issues faced by the East African Speech and Language Therapists would have been those facing speech and language therapists in the UK 30 years ago. After all, it is not so long since we locked people with disabilities in asylums and, while I do not know much about the start of our Royal College, I suspect we are indebted to some committed individuals who deliberated long and hard about the best way forward in terms of developing a professional association. I am sure in the future people with communication impairment in Kenya will be grateful to the pioneering work of the therapists currently working there. I was privileged to be able SLTP spend time with them. Lois Cameron is Talking Mats Development Manager at the Talking Mats Research and Development Centre, University of Stirling, tel. 01786 458105, e-mail l.f.cameron@stir.ac.uk.

Speech and language therapist Emma Shah, who has worked in Nairobi for 10 years, would welcome donations of Servoxes and Servox batteries in working order. As reported in our Winter 09 issue (p.3), trache-oesophageal puncture operations are not done in Kenya, so clients get a traditional laryngectomy with little surgical followup. Servoxes are in demand for those who cannot achieve oesophageal voice. Emma says donors should also factor in the costs of couriering the equipment to the airport in Nairobi where Emma will collect them. If you can help, contact shah.emma@gmail.com. The Kenya Association of Laryngectomees is active in running monthly meetings and residential workshops for people in outlying areas, but the organisation is dependent on donations to meet its running costs. Its organising secretary Bishop Duncan Mbogo Wanjigi has developed a website (www.laryskenya.org) which includes a Paypal facility.

Reference

Hartshorne, M. (2006) The Cost to the Nation of Childrens Poor Communication. I CANTalk Series Issue 3. London: I CAN.

Resources

Pioneering spirit

There is much pride in Kenya about Barack Obamas success, and his slogan Yes we can is an appropriate phrase. Karen Kibuchis story reflects that attitude and it is also in the pioneering spirit and professionalism of the speech and language therapists. By the end of the conference they agreed to set up a group that will be open to all who wish to develop services for people with communication impairment in East Africa. While this might evolve into a more specific professional association at a later stage, there are not sufficient numbers to sustain such an association just now. The therapists involved are using the information gathered and worked on at the conference to develop a vision for how services for people with communication impairment should be delivered in a way that is appropriate to Kenya. They recognise that raising awareness and creating a sense of ownership of the problems faced by people with communication impairment is critical, and that the preliminary work needed to be done whilst fostering and developing any key and influential relationships. They feel that this piece of work needs to be in place before the establishment of any training course; the training course can then be part of the overall

Caroline Bowens information page on SpeechLanguage Pathology in East Africa - www. speech-language-therapy.com/africa-e.html ICAN - www.ican.org.uk/Resources/ICTalk%202.aspx Initiative for Learning Disabilities Kenya www.ildkenya.org/ Kenya Institute of Special Education - www. kise.co.ke/ Makerere University College of Health Sciences - http://med.mak.ac.ug/ Talking Mats www.talkingmats.com VSO - www.vso.org.uk/volunteer/

Acknowledgements

I would like to thank all the therapists I met, in particular Laura Dykes and Emma Shah for the huge amount of work they did to organise the conference. I would also like to thank Bette Locke and the AHP travel scholarship Forth Valley for contributing towards my travel costs and Mary Turnbull, Head of the Speech and Language Therapy service for her continued support.

REFLECTIONS DO I RECOGNISE THE BENEFITS TO MYSELF AND TO OTHERS OF VOLUNTEERING? DO I ACTIVELY CONSIDER THE UNINTENDED CONSEQUENCE OF AN ACTION OR DECISION? DO I EXAMINE THE IMPACT OF DIVERSITY OF VALUES ON MY PRACTICE?
Do you wish to comment on the difference this article has made to you? See the information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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ASSESSMENTS ASSESSED / IN BRIEF

In Brief...
Wonderful treasures

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).

Assessments Assessed
Measures of Childrens Mental Health and Psychological Wellbeing Ed. Norah Frederickson and Sandra Dunsmuir GL Assessment ISBN 9780708719107 400.00 This portfolio of eight booklets for education and health professionals aims to provide a comprehensive package to measure the psychological health and wellbeing of children. The importance of positive mental health is recognised widely and government education and social policy has wellbeing as an integral part. This portfolio is designed to support professionals who work with children to meet their responsibility to account for wellbeing. The measures allow staff to design and implement work in their area and then to measure the outcomes. In addition to two overarching measures, The Childrens Global Assessment Scales and Target Monitoring and Evaluation, topics covered are:
Topic Belonging Distress Enjoyment Healthy Living Resilience Responsiveness Social Behaviours No. of Measures 6 6 6 6 6 6 6 Ages 4-18 2-18 8-18 4-adult 7-18 6-13 5-20

The majority of my work is with teenagers, usually in groups or 4 or 5. They have a range of complex language and social communication difficulties and one of our targets is to try and enable them to work together as part of a team more effectively, with all the skills which this entails. Finding interesting resources to work in small groups with the focus on communication has always been difficult, but then I started to look at the resources for teaching English as a foreign language (TEFL) and discovered wonderful treasures! Amongst these was a series called Communication Games by Jill Hadfield. There are 4 books in the series and I use the intermediate one for my secondary school work. The games are aimed for use in small group or even pairs as well as some larger group activities. Each activity is introduced with details of the group size required, the function practised and the vocabulary covered. The games are fun and innovative. Take for example The queue, where there are 30 cards describing the people in a queue to buy theatre tickets. Each member of the group has some cards and between them they have to work out the order of the queue, without letting each other see their cards. A sample card would read: You wrote postcards to pass the time. The person in front of you had a heavy suitcase. The person behind played the guitar. Other games are entitled Ideal Homes where you match wacky people to wacky houses, The Detective Game and How to get out of doing the washing up! There are 40 games with all the resources required to photocopy and all for less than 35.00. Sheina Stockton is an independent speech and language therapist in the Worcester area. Intermediate Communication Games by Jill Hadfield is published by Nelson, ISBN: 978-0-175-55872-8. ADVERTISEMENT

Each topic specific book follows the same clear, concise and straightforward structure: description of topic; theoretical frameworks (linked to latest research and government plans); description of measures (good technical and strategic data including norms); from assessment to intervention; references; specific photocopiable measures in each area. The pack will support evidence based practice and practice based evidence, together with measurable goal setting approaches. It underlines assessment as just a snapshot of any individual or group, and promotes intervention as the way to support children and young people. It will help us measure our intervention and ideally what works and what adjustments are required. While it is common sense, it is refreshing and reassuring for us to be reminded that success is measured in improving young people rather than counting how many have we seen in the last given number of weeks. I have road tested several of the measures, selected at random, and found them easy to use. They are fit for purpose and could easily be used in a variety of settings. Some may require adaptations to account for comprehension and / or literacy problems. An important role for speech and language therapists within this whole field is to adapt any materials to account for communication support needs. The pack is very easy to use. It would be possible to use all measures but more likely and indeed useful to clinicians to select them as required. I agree with the strong message in the pack that we must resist the idea that any one item is the be all and end all; we should continue to rely on clinical skills and judgement and interpret our findings in context. A really useful table at the beginning of each topic specific booklet provides, at a glance, information on aims, areas targeted and age range. This should aid the clinician in the selection of the appropriate measures. Although information on administration time is contained in each book, it would have been helpful also to have it in this table. This would be a useful addition to a departments toolkit of resources. It is relevant to the everyday work of a CAMHS (Child & Adolescent Mental Health Services) team or anyone focusing on mental health. Mental health and psychological wellbeing is a developing area within our profession and is of concern to all speech and language therapists. The pack can be used at all stages of experience and development of practice. Assistance in the interpretation of results will be required depending on experience. It is expensive, but contains 44 measures all packaged ready for use. Sandra Polding is a specialist speech and language therapist and RCSLT Adviser in Paediatric Mental Health.

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BOUNDARY ISSUES (2)

Smoke gets in your eyes

You are working with a client / parent of a client who smokes heavily. Whether you feel you want to mention it or feel very strongly that you dont to what extent is such lifestyle choice and information the responsibility of a speech and language therapist?

Roger Newman considers the following scenario:

s a speech and language therapist you come into contact with people who smoke, whether clients or their parents / relatives. You may even smoke yourself. Whatever the situation, there will be times where you ask yourself if dissuading someone from smoking is the right thing to do, and if its your role. While the number of people who smoke has gradually declined it still exists, as do smoking related illnesses - stroke, heart disease and cancer to name but a few. Many smokers take the attitude of Itll never happen to me, but it can, it does and, if they continue to smoke, the chances are significantly increased. When individuals smoke its their life, their choice and often their enjoyment. They may even understand the implications and accept the risk. If they want to smoke, who are you to tell them not to? As a health care professional you may think youre not being caring if you dont try to help. If you are a smoking cessation officer this will be in your job description but as a speech and language therapist it probably isnt. Yet smoking doesnt just affect the individual. It has implications for the health and taxation of the wider population, as well as even bigger issues for society when we consider the link between smoking and poverty. We dont operate in a vacuum; the legislative context is firmly in favour of making smoking socially unacceptable, and the NHS invests in smoking cessation services. Australia has just significantly changed its smoking legislation, meaning all cigarette packets now have to be completely plain with only the brand and product name in standard colour, position, font style and size. Tax on a packet has also increased by 25 per cent. Raising tobacco excise will generate an extra $6.4 billion over four years, the government says, and the money will be directly invested in hospitals. In the UK the risks of smoking are on the packet, information adverts about smoking are on TV and poster / leaflet campaigns, and smoking in public places is banned. We are all supposed to remind individuals not to stand in doorways smoking after all, theyre breaking the law. We see smokers standing outside the main entrance to the hospital trying to get out of the rain, but how many of us say something and risk verbal abuse? For many the easier option is just to hold your breath and walk through the cloud of smoke.

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. When youre on a home visit and the client or a relative starts smoking in front of you its their house, their environment and their choice - but its having an impact on you. Often local NHS policies regarding passive smoking exist, so you may have the protection of your employer to back you up. Asking someone not to smoke in their own house is a tricky situation to find yourself in, but you have that right - you just need the courage to do it. Dysphonia is definitely one disorder where we can legitimately dissuade the client from smoking and inform them of the risks. If youre treating a client with a voice disorder, you have a certain obligation to inform them of general vocal hygiene; the dangers of smoking, and the impact it has on the likelihood of their dysphonia improving. You may decide to talk about respiratory control and the impact that smoking has on the respiratory system this would be valid too. Communicating Quality 3 (RCSLT, 2006) mentions that lifestyle factors may be at the root of a dysphonias aetiology. This needs to be addressed and acted upon by both therapist and client for any therapy to be successful. RCSLT (2003) also state one of the key attributes to working as a speech and language therapist is the desire to improve a clients quality of life. However, another is willingness to accept your own professional limitations. So, do you cross the boundary and go one step further to tell them about the additional problems that smoking causes? You may think that bringing heart disease and

unrelated cancer as a result of smoking into a voice therapy session is pushing it a bit far, and may even ruin a well established clienttherapist relationship. As an autonomous professional the choice of whether to take that risk is yours. Other disorders experienced by our clients may be as a result of smoking, and you may think its pretty futile informing them of the risks once theyve had the floor of their mouth removed or had a stroke. They may even become significantly distressed if you remind them that theyve brought this problem about through their own lifestyle choice. However, what if they continue to smoke? They may find the situation theyre in highly distressing and take solace from smoking. They may even increase the amount they smoke. What if the smoker is the spouse / friend / carer of the client youre treating? Theyre not your client and you have no duty of care for them. Do you have a right or even a duty as a health care professional to inform them of the risks? You may also be extremely concerned for the health of a child if you know the parent is a heavy smoker who does so while the child is in the room. The situation may be quite clear when treating a child with glue ear, as research suggests a highly significant positive association between the duration of effusion and the number of smokers in the household during a childs first and second years of life (Cook & Strachan, 1999). As a speech and language therapist treating a child with glue ear you could provide this information as a basis for helping to improve the childs health, their language development, and potentially that of any other children in the household. But are the other risks of passive smoking, or even the possibility that the child may be

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BOUNDARY ISSUES (2) / HOW I

left without a parent through smoking related illness, any business or obligation of yours? It could be perceived as crossing the boundary if you mention smoking when youre treating the child for something unrelated. You may think that the trust and therapeutic relationship built up with the child and the parent could be gone in an instant, complaints could be made, and your professional competence could also be questioned. On the other hand, do you say anything to the parents about their own health, stepping over the line to inform them it can only help them too in the long run? Again, a difficult one, but the questions out there, and its up to you how you answer it. Difficult situations are bound to arise where you question how far you go when trying to do your best for a client or the people around them. Personal experience such as the loss of a family member through smoking could also be influencing you. Smoking is a lifestyle choice and an addiction, and as speech and language therapists were not here to influence decisions in that area, except where smoking is the possible cause of the problem being treated. Drawing that line is important, but even more important is deciding if and when to cross it. The World Health Organisation considers we all have a duty as health care professionals to address smoking and tobacco-related problems, stating that Public health is no ones domain but everyones arena (WHO, p.17). They go on to say that smoking related illness cuts across a vast range of health disciplines and one of a health professionals roles is to ensure all affected receive support in one way or another. So how far do you go? Is putting a Stop Smoking poster in your waiting room enough or too far? Do you go that bit further and provide advice? Do you refer on to a smoking cessation service? Its up to you how far you take it, when to draw the line, and if you cross it. Whatever your thoughts or beliefs, as a speech and language therapist you can act by yourself when appropriate, but carefully consider SLTP cooperating closely with others. Roger Newman is senior specialist speech and language therapist at Royal Preston Hospital, email Roger.Newman@lthtr.nhs.uk, and a senior lecturer in speech and language therapy at the University of Manchester.

How I assess for specific languag

A snapshot from
pecific language impairment is a complex communication disorder which can have significant social and educational implications. Early identification is needed so that appropriate management strategies can be put into place. Where specific language impairment is suspected, assessment is an important stage, as the therapist tries to differentiate this disorder from other developmental impairments. But how are we actually going about assessing for specific language impairment, and could we improve the process? To find out, a steering group of academic and clinical speech and language therapists collected data from speech and language therapists here in Ireland. A. PHASE 1 For phase one of this audit, we established a steering group and designed a survey around current practices when assessing language in children and adolescents with suspected specific language impairment. Speech and language therapists working with children in the public health services in Ireland were eligible for inclusion. We asked the Irish Association of Speech and Language Therapy Managers (n=70) to indicate the numbers of therapists of all grades who work with children. Fifty nine percent (n=41) of the managers responded with a total of 349 therapists. We distributed surveys through the managers asking these therapists to indicate which assessments they use most frequently for semantics, syntax and pragmatics in the different age groups, as it is common practice that a description of language strengths and weaknesses should include all three language dimensions (Eadie, 2003). The research team defined informal assessment as any assessment which was not standardised and norm-referenced. There was a 57 per cent response rate (199/349 surveys returned). Twenty per cent had 0-2 years experience, 45 per cent 3-9 years and 35 per cent over ten years. Fifty three percent of respondents reported that they frequently worked with children with specific language impairment, 34 per cent had sometimes, and 10 per cent had rarely. We excluded the 3 per cent who had

When you first see a child whom you suspect has specific langua assessment. But what tools do you choose and why? Rena Lyons to the available literature so that therapists, managers and educa doing and see if there is a need to change it.

never worked with these children. Forty percent of the respondents were working in or had worked in specialist classes in mainstream schools for children with specific language impairment. We asked respondents which three assessment tools they select most frequently when assessing each language dimension across three age groups. The responses for syntax are in figure 1, for semantics in figure 2 and for pragmatics in figure 3. B. PHASE 2 Phase two of the audit used a qualitative methodology to explore therapists experiences of the assessment process. Focus groups are small structured groups with selected participants, normally led by a moderator. They are designed to explore specific topics and individuals views and experiences through group discussion. We used the following topic guide: 1. When we talk about assessment of children who may have specific language impairment, what comes to mind? 2. When you are assessing children who may have specific language impairment, are there any influences on which assessment tools you use? 3. When we talk about assessment, formal and informal, what are your views on the

References

Cook, D.G. & Strachan, D.P. (1999) Summary of Effects of Parental Smoking on the Respiratory Health of Children and Implications for Research, Thorax 54, pp.357-366. RCSLT (2003) Reference Framework: Underpinning Competence to Practise. London: Royal College of Speech & Language Therapists. RCSLT (2006) Communicating Quality 3. London: Royal College of Speech & Language Therapists. WHO (2005) The role of health professionals in tobacco control. Geneva: World Health Organisation.

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HOW I
Figure 1 Assessment of syntax 100 93 90 80 60 48 40 20 0 6-12 yrs 13-18 yrs Age Groups RDLS III CELF 3 (UK) CELF-Preschool TROG RAPT INFORMAL 36 48 36 81 69

age impairment, you will naturally carry out an s audits current practice and relates the findings ators can look critically at what the profession is
use of these assessments in your clinical practice? What are the advantages and disadvantages of formal and informal assessment? 4. What outcomes of assessment make you consider a diagnosis of specific language impairment? To attract participants, we organised a seminar and asked therapists to notify the university in writing if they wished to attend and / or participate in the focus group. We allocated participants into two groups: FG1 was therapists working in community clinics and FG2 was those with specialist experience of working with children with specific language impairment (figure 4, p.26). We analysed the focus group transcripts into three organising themes and an overarching global theme (Attride-Stirling, 2001): (i) Global theme The overall global theme was that assessment is a time-consuming and complex process. Therapists have to make choices about what data needs to be collected, what contexts it needs to be collected in, who needs to be involved, and the most valid and reliable tools. All this decision-making takes place within a context of competing demands on time, policy requirements and new research and evidence in specific language impairment. In addition, experience is important in understanding what the tests actually test and in analysing results beyond test scores. (ii) Organising theme 1: The assessment process The participants in both focus groups consider that assessment is an ongoing process and not a once-off event. They highlighted the importance of collaboration and consultation with parents and other health and education professions when assessing children. They also stressed the need to collect data in a number of different contexts using a variety of assessment tools to obtain a representative profile of the childs strengths and areas of need. They talked about the significance of the case history information and levels of parental anxiety in helping clinicians shape the assessment plan. Participants consider that experience is an important factor in assessing and diagnosing

READ THIS IF YOU WANT TO APPRAISE YOUR ASSESSMENT PRACTICE RAISE THE STANDING OF INFORMAL ASSESSMENT ADOPT EMERGING APPROACHES

% of speech and language therapists

m Ireland

ge impairment:

90

0-5 yrs

children. For example they reported that with additional clinical experience, particularly working in language classes, they were more aware of the risk markers of specific language impairment. In addition familiarity with the various tests can maximise their usefulness. By really understanding what tests actually test, therapists can formulate hypotheses about the underlying impairment, identify areas which require further assessment and plan therapeutic interventions. Some participants feel constrained by policies on eligibility criteria which require standard scores. They also reported that the assessment process can be time-consuming and making a differential diagnosis can be difficult. being aware I suppose from previous experience, you may have warning signs that might be there following screening assessment [FG1] I find a wealth of information can be gained from the case history [FG 1] were forced to fit our kids into boxes to get them into language classes and I think were being pushed into it and I wonder where these criteria come from [FG2] (iii) Organising theme 2: Assessment tools This theme had two parts: standardised assessment and informal assessment. Both groups discussed the benefits of formal standardised assessments, saying they: a. provide objective and concrete measures of language abilities and a profile of strengths and needs b. can be used to examine areas in-depth c. have been developed using rigorous psychometric measures including measures of reliability and validity d. allow comparison with a sample on whom the test was developed e. can be a basis for explaining language impairments to parents and teachers f. can facilitate report writing and therapy planning g. can be quick and relatively easy to administer h. are used frequently in practice because they are required for determining eligibility for services.

% of speech and language therapists

Figure 2 Assessment of semantics 100 93 87 80 60 40 20 0 0-5 yrs 6-12 yrs 13-18 yrs Age Groups CELF 3 (UK) RDLS III BPVS CELF-Preschool RWFT INFORMAL 51 78

48

44

42

36 27

% of speech and language therapists

Figure 3 Assessment of pragmatics 100 90 84 80 60 40 20 0 60 54 51

75

46 36 38

0-5 yrs

6-12 yrs 13-18 yrs Age Groups REEL PRAGMATICS PROFILE TOPL INFORMAL

Assessment key BPVS: British Picture Vocabulary Scale (Dunn, 1997), GL Assessment CELF-Preschool: Clinical Evaluation of Language Fundamentals Preschool (Wiig, Secord & Semel, 1992), Pearson CELF3: Clinical Evaluation of Language Fundamentals 3 (Semel, Wiig & Secord,1995), Pearson Pragmatics Profile (Dewart & Summers, 1995), NFERNelson (http://wwwedit.wmin.ac.uk/psychology/pp/). RAPT: Renfrew Action Picture Test (Renfrew, 1997a), Speechmark RDLS III: Reynell Developmental Language Scales (Edwards et al., 1997), GL Assessment REEL: Receptive-Expressive Emergent Language Test (Bzoch et al. 2003), Pro-Ed RWFT: Renfrew Word Finding Test (Renfrew, 1995), Speechmark TOPL: Test of Pragmatic Language (Phelps-Terasaki & Phelps-Gunn, 1992), Ann Arbor TROG: Test of Reception of Grammar (Bishop, 2003), Pearson

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HOW I
The participants also noted the limitations. Formal assessments may not be sensitive or specific enough to identify the subtleties of specific language impairment and there are questions about validity, for example if a child has an off day. Even though they have been developed using rigorous procedures, participants also have concerns about reliability and validity in an Irish context as none are standardised on an Irish population and they may not be sensitive to cultural differences. These tests may not provide information on why a child is failing, and children may score poorly on a subtest for different reasons. In addition, participants reported that standardised testing is a crude instrument and may not provide enough information when used in isolation. They also noted a lack of suitable standardised tools to assess social communication and pragmatic ability and auditory processing. Another problem is that standardised tools measure discrete aspects of language and may not provide an integrated, valid overall picture of the childs communication abilities. Older children and adolescents may be aware of their language impairments and standardised testing may exacerbate this. I think sometimes that formal assessment doesnt pick up some of the innuendos of SLI [FG1] In language class contexts, lets say the child is not making progress on the standardised assessment and yet you are fully aware that their self-esteem has really improvedwere not tapping into measuring that in pre- and post- assessments [FG2] I think that they are useful tools [standardised assessment tools] when youre explaining to other professionals and parents ..exactly where the difficulty lies, sometimes its easier for them if they can see it on paper and when we explain what the test is about [FG2]
Years of Experience 0-2 FG1 (n=5) FG2 (n=10) 3 3-9 1 2 > 10 4 5 How frequently have you worked with children with SLI? Frequently 2 7 Sometimes 3 3 Experience in a Language Class None 5 6 4 Previous Current

Figure 4 Focus group participants

be expedient and get on with the referral or whatever paperwork and follow up has to be done afterwards [FG1] I think its [informal assessment] particularly relevant in very young children to spend time just observing and getting feedback.just getting to build up that picture before you go straight into [formal] assessment. [FG1] [informal assessment is a] truer reflection of what the child is capable of [FG2]

Many participants reported using informal assessment with children with specific language impairment. This can provide more ecologically valid data as it involves collection from a range of naturalistic communicative contexts. FG2 highlighted the benefits of language sample analysis, which can provide detailed qualitative data about a childs language. This is useful for planning intervention and may be less threatening for a child than formal testing. All participants acknowledged some limitations of informal assessment. It tends to be subjective, is not as easy to quantify as standardised measures, may be timeconsuming, and is not given the same weighting as standardised measures when determining eligibility for services. because of the demands we are under, theres often a pressure to get in there and get the assessment done so that you can

(iv) Organising theme 3: Influences on choice of assessment tools (figure 5) One of the main factors which influences choice of tools is the purpose of the assessment. Eligibility for educational resources is determined by specific standard scores and this requires therapists to select a standardised tool, which participants reported as constraining and frustrating. Where the purpose is to measure progress, or identify strengths and weaknesses, participants reported that they may select informal assessment tools. Other factors influencing choice include whether the purpose is for screening or diagnosis, satisfaction with and the length of time to administer the assessment, and characteristics of the child such as age, concentration and attention levels and severity of impairment. Participants choose specific tools to assess particular domains of language. They also discussed the value of narrative assessment tools, which can assess a range of language abilities. All reported that time influences their choice. Many participants work in busy settings with large caseloads and waiting lists, and an increasing amount of time is allocated to administration. They tend to use tests they are familiar with and may not have time to get to know new assessment tools even when they are available. C. RESULTS Not surprisingly, the results indicate a clear majority of clinicians use formal, published, standardised instruments as part of language assessment. However, they have many concerns about sensitivity to the subtleties of specific language impairment, reliability and validity and how these tools tend to fragment language into discrete components. As a result, many reported supplementing standardised tools with informal and non-standardised tasks. These provide data about the nature of the childs problem which is paramount for

planning intervention goals and selecting targets (Brackenbury & Pye, 2005). These findings are consistent with some of the literature in that therapists seem to rely on full language assessment batteries for diagnostic purposes (Eadie, 2003; Spaulding et al., 2006). However, Law (2002) says therapists in the UK have moved away from an over-reliance on standardised measurement for all but audit and research purposes. Instead, they make greater use of context-sensitive measures such as individual education plans and teachers report of adaptive and social behaviour. A small number of standardised tools dominate the clinicians choice and this is consistent with the literature (Eadie, 2003; Huang et al., 1997). This may be a result of the limited number of published language assessments, restricted resources, familiarity with assessment tools and time. The speech and language therapists also use informal assessment frequently to assess all aspects of language. The literatures agrees that descriptive assessment should always be used in conjunction with standardised tools for all purposes including screening, making placement decisions, obtaining a complete picture of a childs language competence, developing an intervention plan, and monitoring progress (Huang et al., 1997). The speech and language therapists select informal tools to assess syntax and semantics in adolescents more frequently than in the other age groups. Reed (2005) suggests this may be because fewer tests are available and those that are may not be sensitive enough to identify adolescents with language impairment. Given that adolescents are expected to use their language effectively in social, academic and vocational contexts, Reed (2005) recommends that communication in each of these needs to be included in the assessment process. Participants indicated that they use informal assessment most frequently to assess pragmatics. This is not surprising as the constraints imposed by standardised testing violate the social principles of pragmatics (Tomblin et al., 1996). Although we did not specifically ask, some participants discussed the value of assessment of narrative skills. This allows therapists to examine how children integrate sophisticated skills in semantics, syntax and pragmatics when formulating a narrative. In addition, the multifaceted nature of narrative analysis may have predictive value for later

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HOW I
Functioning (Washington, 2007) would assess the impact of speech, language and communication skills on childrens everyday activities and participation in society, as well as the impairment. Dynamic approaches to assessment focus on the childs learning potential in different conditions, including the childs responsiveness to intervention, and there is some evidence that this model may be useful for differentially diagnosing children with specific language impairment (Pena et al., 2007). Assessment of narrative skills also provides a more ecologically valid assessment of how the child integrates many different skills. 3. Taking time for critical reflection It is important for therapists to take time out of their busy clinics to critically reflect on their assessment practices, asking: What assessment tools do I use and why do I use them? Are there new assessment tools in my department which I have not had time to look at yet? Do I assess speech, language and communication skills in naturalistic settings? Is there a more systematic approach I could use for my informal assessment such as checklists or more structured recording of my observations? 4. Influencing policy Speech and language therapists need to influence policy makers on eligibility criteria for services so that informal measures will be given consideration as well as the results of standardised assessments. While this research provides a general overview of assessment practices, further well-designed studies are needed to shed light on the black box of clinical decisionmaking (Roulstone, 2001). In addition, further research is needed on how new models of assessment can be used in the assessment and diagnosis of children with specific SLTP language impairment. Rena Lyons is a Senior Lecturer, Discipline of Speech and Language Therapy, at the National University of Ireland Galway, Ireland, tel. 00 353 91 42918, e-mail rena.lyons@nuigalway.ie. This article is based on a longer paper which includes greater cross-referencing with the literature. The full reference list is at www.speechmag.com/ Members/Extras.

Policy Purpose of assessment Time Influences on choice of assessment tools Satisfaction with tools

Aspects of language to be assessed

Familiarity with tools

Childs age

Figure 5 Factors influencing choice of assessment tools

language and literacy difficulties (Eadie, 2003). Narrative is also an ecologically valid way to measure communicative competence and can help distinguish sub-groups of children with language impairments (Botting, 2002). One of the main factors which influences these therapists choice of assessment is time. Given that demand for speech and language therapy is so great, an assessment is unlikely to be undertaken if it cannot be administered quickly and efficiently (Skahan et al., 2007). Therapists choosing tests that require relatively little time for administration, interpretation, and reporting may be a reflection of time pressure on clinical decisions (Huang et al., 1997). This theme emerged strongly from the focus group discussion and is consistent with the literature whereby clinicians are caught in a dilemma between striving for best practice and acceding to time pressures, and may experience frustration and personal dissatisfaction as a result (Huang et al., 1997). Time constraints have been raised as a critical issue that may impede clinicians from completing comprehensive assessments (Skahan et al., 2007). Although this study provides a useful snapshot and preliminary data on how therapists assess and diagnose children with specific language impairment in Ireland, there were shortcomings. The response rate represents just over half of the therapists working with children in Ireland and the results must be interpreted with this in mind. Some aspects were not covered in great depth or at all to keep the survey to a reasonable length (the assessment tools section was part of a longer survey). We didnt collect data on therapists satisfaction with the specific tools, the specific purposes for which they use the tools, how the assessment procedures vary relative to client characteristics and use of emerging models of assessment such as those based on information-processing and psycholinguistic frameworks and dynamic assessment (Tyler & Tolbert, 2002). Therapists

choice of standardised assessments may have been constrained by eligibility criteria for educational resources set by the Department of Education and Science (DOES, 2003). In addition, the survey included the most recent version of the assessment tool and therapists may use other versions. In terms of informal assessment, we did not explore specific types of informal criterion-referenced or childspecific measures described in the literature such as language sampling, checklists, and information from parents, teachers and other professionals (Skahan et al., 2007). In addition, the focus groups were small and we are not claiming that the results are representative or generalisable. D. IMPROVING PRACTICE Reflecting on our findings, I feel there are ways we can improve the assessment process: 1. Making evidence accessible Specific language impairment is an umbrella term used to describe children with a range of profiles, all of which include marked language difficulties in the context of normal cognitive abilities (Botting & Conti-Ramsden, 2004). However, there is growing evidence for markers of a qualitatively distinct deficit such as specific difficulties with aspects of syntax and morphology (Bishop, 2004; Botting & ContiRamsden, 2004). This evidence base needs to be more accessible to busy clinicians so they can reflect on the implications for their practice. 2. Using new frames of reference We designed the survey using a linguistic model frame. However, there is growing recognition that other frames of reference may be useful in assessing and diagnosing children with specific language impairment. This includes assessment of information processing skills such as attention, memory and the speed of processing (Brackenbury & Pye, 2005) and psycholinguistic models (Stackhouse & Wells, 1997). The International Classification of

Acknowledgements

This research project was funded by the National University of Ireland Galway Millennium grant. Thank you to the research team who contributed to this project: Dr. Molly Byrne, Trina Corry, Lily Lalor, Helen Ruane, Ruth Shanahan, Barbara Murphy, and Colette McGinty. Thank you to Lorraine Kent for formatting the questionnaire and assisting with the quantitative data analysis. Thank you to Niamh Gallagher for her assistance with the qualitative data analysis. Thank you also to all the therapists who completed the survey and to those who participated in the focus groups.

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HOW I

Attride-Stirling, J. (2001) Thematic networks: an analytic tool for qualitative research, Qualitative Research (1), 385-405. Bishop, D. V. M. (2004) Specific Language Impairment: Diagnostic Dilemmas, in L. Verhoeven & H. van Balkom (Eds.), Classification of Developmental Language Disorders Theoretical and Clinical Implications. London: Lawrence Erlbaum Associates. Botting, N. (2002) Narrative as a tool for the assessment of linguistic and pragmatic impairments, Child Language Teaching and Therapy, 1-21. Botting, N., & Conti-Ramsden, G. (2004) Characteristics of children with specific language impairment, in L. Verhoeven & H. van Balkom (Eds.), Classification of Developmental Language Disorders Theoretical Issues and Clinical Implications. London: Erlbaum Associates. Brackenbury, T., & Pye, C. (2005) Semantic deficits in children with language impairments: issues for clinical assessment, Language, Speech, and Hearing Services in Schools, 36, pp.5-16. DOES (2003) Allocation of resources for pupils with special educational needs in national schools. Retrieved 15/11/07, from http://www. sess.ie/sess/Files/Circular_SPED_24_03.doc. Eadie, P. (2003) Speech pathology assessment practices: One assessment or many? Advances in Speech-Language Pathology, 5(1), pp.65 - 68. Huang, R., Hopkins, J. & Nippold, M. (1997) Satisfaction with standardized language testing: a survey of speech-language ADVERTISEMENT

References

pathologists, Language, Speech, and Hearing Services in Schools, 28, pp.12-29. Law, J. (2002) Having your cake and eating it: the apparent paradox of long-term outcomes of SLI, Advances in Speech-Language Pathology, 4(1), pp.65-67. Pena, E.D., Resendiz, M., & Gillam, R.B. (2007) The role of clinical judgements of modifiability in the diagnosis of language impairment, International Journal of Speech-Language Pathology, 9(4), pp.332 - 345. Reed, V. (2005) An Introduction to Children with Language Disorders. (3rd edn.) Boston: Pearson Education Inc. Roulstone, S. (2001) Consensus and variation between speech and language therapists in the assessment and selection of preschool children for intervention: a body of knowledge or idiosyncratic decisions?, International Journal of Language & Communication Disorders, 36(3), p.329. Skahan, S.M., Watson, M., & Lof, G.L. (2007) Speech-Language Pathologists Assessment Practices for Children With Suspected Speech Sound Disorders: Results of a National Survey, American Journal of Speech and Language Pathology, 16(3), pp.246-259. Spaulding, T., Plante, E. & Farinella, K. (2006). Eligibility criteria for language impairment: is the low end of normal always appropriate?, Language, Speech, and Hearing Services in Schools, 37, pp.61-72. Stackhouse, J., & Wells, B. (1997) Childrens speech and literacy difficulties - a psycholinguistic framework. London: Whurr Publishers.

Tomblin, J.B., Records, N. & Zhang, X. (1996) A system for the diagnosis of specific language impairment in kindergarten children, Journal of Speech and Hearing Research, 39, pp.1284-1294. Tyler, A.A., & Tolbert, L.C. (2002) SpeechLanguage Assessment in the Clinical Setting, American Journal of Speech and Language Pathology, 11(3), pp.215-220. Washington, K. (2007) Using the ICF within speech-language pathology: application to developmental language impairment, Advances in Speech-Language Pathology, 9(3), pp.242-255.

REFLECTIONS DO I CONSIDER HOW NEW RESEARCH INTO THE NATURE OF A COMMUNICATION DIFFICULTY IMPACTS ON HOW I ASSESS FOR IT? DO I MAKE A CONSCIOUS EFFORT TO THINK ABOUT WHAT ASSESSMENT TO CHOOSE AND WHY? DO I SET ASIDE TIME TO FAMILIARISE MYSELF WITH NEW ASSESSMENTS AS THEY BECOME AVAILABLE?
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.

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My Top Resources
KIDGE BURNS IS A SPECIALIST SPEECH AND LANGUAGE THERAPIST AT CHELSEA AND WESTMINSTER HOSPITAL IN LONDON AND A SOLUTION FOCUSED BRIEF THERAPIST AT A PRIVATE GP CLINIC. SHE IS AUTHOR OF THE BOOK FOCUS ON SOLUTIONS A HEALTH PROFESSIONALS GUIDE AND GIVES ONE OR TWO DAY TRAINING IN SOLUTION FOCUSED BRIEF THERAPY, EMAIL KIDGE.BURNS@GMAIL.COM. 1. THE CLIENT Everything begins and ends with the client and my book is simply a compilation of some solution focused conversations that highlight the clients strengths in coping with difficult situations. Solution focused brief therapy (SFBT) reminds us that our input needs to be tailored to each individual and that we need to recognise the expert patient (DH, 2001). It is up to health professionals to have conversations that generate this expertise and our job becomes much easier if we begin with the client as the expert; regardless of the context in which they find themselves, clients can find a variety of solutions which may be unrelated to the problem. Burns, K. (2005) Focus on Solutions A Health Professionals Guide. London: Whurr. DH (2001) The expert patient: a new approach to chronic disease management for the 21st century. London: Department of Health. 2. MIRACLE QUESTION What are your best hopes from coming here? and following on from this, If you wake up tomorrow morning and your hopes from coming here are realised, whats the first thing youll notice?Whether or not you like to use the miracle word (I do!) what is important is that clients are able to imagine a preferred future that involves a description of what they want rather than what they dont want. Therapy spends less time on problem causation and studies suggest sufficient improvement is often achieved within three to five sessions. A detailed history is not essential for solution focused brief therapy, making it radically different from some other therapy approaches. For a nice description of the miracle question check out www.sikt.nu. 3. SCALES Clients can focus on solutions that may not be achievable. On a scale with 10 standing for the best hopes happening and 0 standing for the opposite, we may need to look at a number which will be good enough. These self-rating scales can be invaluable in forming a baseline for both client and therapist. They can highlight attitudes of different family members and generate an opportunity for everyone to notice past achievements as well as small signs of future progress. In our department we are using the Outcome and Session Rating Scales (www.talkingcure.com) which again fits in with the UK focus on such things as patientreported outcome measures (PROMS). 4. CONVERSATION GROUPS Working in an environment such as a hospital can be difficult when the medical model dominates the way in which multidisciplinary team meetings or case conferences are run. I have found that email conversations with people, some of whom are working in very different environments to me, facilitate discussions of therapy issues or a difficult case in a way that may not be possible in everyday practice. An international list that has been very helpful to me over the years is at www.sft-l. sikt.nu/Mailist.htm, and the United Kingdom Association for Solution Focused Practice (www.ukasfp.co.uk) also provides a discussion forum. See you there! 5. CONFERENCES Following on from the previous resource, I have found it helpful to put faces to names and over the years have met many other solution focused practitioners who have become friends. If there is any spare funding available I highly recommend you take the opportunity to attend the annual European conference (www. ebta.nu) or the United Kingdom Association for Solution Focused Practice conference. There are always a great variety of workshops and the mix of different professions has enabled me to highlight the role of the speech and language therapist, as well as broaden my own view as to how we fit in with other allied health professionals. 6. TRAINING Solution focused brief therapy has been described as simple but not easy. Being asked to provide training is a good opportunity to discuss different issues and the inevitable questions that come up, such as Surely youre giving our clients unrealistic expectations? (no, not if you make sure that goals are defined in practical terms). After more than a dozen years of using a solution focused approach in my everyday practice I still feel I have so much to learn and I try to attend a two-day workshop at least once a year, usually at BRIEF, where I also attended a year-long diploma from 2005-6 (www.brief.org.uk). 7. SUPERVISION A solution focused approach can be used effectively in our own lives as well as those of our clients. It is invaluable when providing student supervision as it generates a form of reflective practice which is so important for new clinicians dealing with difficult caseloads and continuing professional development requirements. For the past couple of years we have been using a solution focused approach in our department for peer supervision; by focusing on solutions we have been able to programme a rota of Ten Minute Talks which is providing sufficient time to discuss most issues and allows those with less experience of solution focused brief therapy to give it a go. For more information read my article on supervision in www.solution-news.co.uk. 8. LOCAL GROUP One of the goals of the United Kingdom Association for Solution Focused Practice is to generate local groups throughout the country so that practitioners can have the opportunity to meet and discuss issues of immediate interest to them and their environment. This year I am The Organiser for our London SF Group which meets once a month. We have a drink, discuss what we are pleased to notice since we last met and then focus on particular areas of discussion. Regardless of how much experience each individual has of solution focused brief therapy, most people seem to enjoy the meeting. Let me know if you want me to send you an Evite! 9. READING The solution focused community is very generous in sharing ideas and material, so long as due reference is made to the source. Whereas some people use solution focused brief therapy as just another tool in the toolkit I have found that for many of my clients a solution focused conversation is all that is needed to promote positive change and the recovery of a sense of well-being, which in turn promotes changes in communication. It is encouraging to see solution focused brief therapy mentioned in NICE guidelines for palliative care (www.nice.org.uk/csgsp), for example, or Signs of Safety devised by Andrew Turnell with regard to child protection (www. signsofsafety.net). Any interviews, articles or books written by Steve de Shazer or Insoo Kim Berg are always enlightening and an insight into how they developed the approach in the USA in the 1980s. 10. DVD The best way to learn more about solution focused brief therapy is to watch it live or on DVD (DVDs of Steve de Shazer and Insoo Kim Berg can be obtained from www.sfbta.org). I try and video my work with clients as often as possible. There is much to learn by going back over a session as it can reveal comments made by clients that I have missed and it reminds me to keep listening rather than following my own agenda. When I trust in the process and allow the solution focused conversation to focus on the clients own problem-solving mechanisms, then I see effective therapy.