Speech & Language Therapy in Practice, Autumn 2004

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JABADAO:a song and danceabout communication

A D D I N G C O L O U R

ISSN 13

Autumn2004

http://www.speechmag.com

Interactive storytellingA midsummer nightsconversation

Early intervention

A bump start

CollaborationA holistic approach

Care pathwaysNo borderline

Winning Ways

Setting your compass

How I lookfor solutions

Placements,team reliability,

compliance withrecommendations

My top resourcesGetting organised


2/32

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PLUSThe editor has selected some previous articles you might

particularly want to look at if you liked the articles in theAutumn 04 issue of Speech & Language Therapy in Practice. If youdont have previous issues of the magazine, check out the abstractson this website and take advantage of our new article ordering service.

If you liked...see (042) Taylor, L.: Working with parents, (043) Bell, J.: Fiends

or Friends?, (044) Dunseath, A.: Dynamic viewing and (045) Watters, L.:Valuable videos. All from Autumn 1998, How I view childrens television.

look at (117) Gill, S. & Ridley, J. (Summer 2000)Reshaping opportunities, sharing good practice.

what about (021) Wilcox, D., Burns, S-J. &

Mcfadzean, A. (Winter 1997) My Top Resources (No. 10 gives instructions formaking one!)

you might be interested in (180) Park, K.(Spring 2002) Switching on to Shakespeare: A Midsummer Nights Dream.

check out (206) Howard, S. & Hughes, C.(Autumn 2002) From last to first resort.

try (191) Patterson, A. (Spring 2002) My top resources - undergradu-ate education.

consider (209) Samuels, R. & Chadwick, D. (Autumn 2002)Read all about it! Fred the Head stops Mars Bars in bed.

IN NEED OF INSPIRATION?DOING A LITERATURE REVIEW?LOOKING TO UPDATE YOUR PRACTICE?OR SIMPLY WANTING TO LOCATE AN ARTICLE

YOU READ RECENTLY?OUR CUMULATIVE INDEX FACILITY IS THERETO HELP.

The speechmag website enables you to:View the contents pages of the last four issuesSearch the cumulative index for abstracts of previous articlesby author name and subjectOrder copies of up to 5 back articles online.

Autumn04speechmag

Also on the site - news aboutfuture issues, reprinted articlesfrom previous issues, links toother sites of practical value and

information about writing forthe magazine.Pay us a visit soon.Remember - you can alsosubscribe or renew online via asecure server!

Sasha Bemrose

Amy Duck & Sarah Weeks

Susan Munros parachute

Christina Barnes and Jill Dyer

Jo Frost

Hannah Crawford

A Midsummer Nights Conversation

NEWLY REPRINTEDTurning on the spotlight by Carole Kaldor, Jannet Tanner andPat Robinson (152) from the Summer 2001 issue is reprinted atwww.speechmag.com. This article describes the Spotlights onLanguage Communication System ( Carole Kaldor).

www.speechmag.comADVERTISEMENT


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INSIDE COVER

AUTUMN 04 SPEECHMAG2 NEWS / COMMENT

7HERES ONE I MADE EARLIER...Alison Roberts returns with more low-cost ideas forflexible therapy activities: same and different chains,talking stick and totem pole.

8 A MIDSUMMER NIGHTS CONVERSATIONKeith wants to get away from specially constructedsettings and the dreaded functional vocabulary tohigh status venues and participation in fun

activities...Again and again he talks of interactivestorytelling leading to his clients doing things that peoplewith learning disabilities are not supposed to do.Avril Nicollmeets Keith ParkandNevin Gouda to findout how interactive storytelling works for people withcomplex support needs.

10 READER OFFERWin Speechmarks Interactive Storytelling.

10 A BUMP STARTBy supporting parents antenatally and giving theminformation on what the baby is capable of doing, theparents become proactive at the earliest stage. They feelinvolved and important which gives them confidence. Ifthey form an attachment before the baby is born, they are

more likely to interact with the baby as soon as it is born.Recognising that disadvantaged groups need support tolay the foundations of communication, Sasha Bemrose &Lynn Lynchjoined forces with a cartoonist to develop anantenatal pack.

13 FURTHER READINGAphasia, normative data, language disorder, voice,hearing impairment.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004 1

14 NO BORDERLINE - JUST A PATHWAYWe hope that, through use of these documents, children

will receive an appropriate level of service; that moretherapy time will be available to those children withsignificant needs, and that it will be clearer which clientsshould be either discharged or transferred to otherclinical caseloads.Christina Barnes & colleagues in a regional specialinterest group in deafness have developed a care

pathway to improve equity of service for clients.

18 REVIEWS(See also p.6) Functional assessment, phonological awareness,languagedevelopment, selective mutism, intervention,clinical education, head injury, ColorCards, software.

19YOU CANT LEARN TO SWIM ON DRY LANDRegarding their learning experiences, nothing can betaken for granted - our students do not learn incidentally.Everything must be explicit, and what might appear aslack of variation in approaches is in fact a deliberateteaching technique particularly relevant to these students.Amy Duck & Sarah Weeks dive in with a holisticapproach to developing functional communication andcommunity living skills.

22 WINNING WAYS SERIES [4]COMPASS SET TO TRUE NORTHWhen establishing values, I dont just ask clients if theyknow what their values are. If I did that, they wouldintellectualise and operate from their heads. I wantthem to speak from their lives and their hearts.Do you know what is driving you? What

must you have - or a part of you dies? LifecoachJo Middlemisssuggests we charta course based on values.

24 HOW I LOOK FORSOLUTIONSWhatever problems you face asspeech and language therapists,underlying issues are likely toinclude service organisation,training, and working with otherpeople. Undaunted, ourcontributors ask the questions,acknowledge the reality and seekcreative solutions.Alison Newton & Jo Froston studentplacements,Jill Dyeron improving teamreliability in videofluoroscopy & HannahCrawfordon compliance withrecommendations.

BACK COVER MY TOP RESOURCESThis system [day file] has replaced my daily list of thingsto do; currently the file divides into phone/email,action, maybe (such as events I might go to or books Imight order), tickler (something Id like to do, but its along way ahead), and waiting for (for example copiesof order forms, notes of messages Ive left).Jayne Comins offers ten tips for getting organised.

AUTUMN 2004(publication date 30th August)

ISSN 1368-2105

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

Design & Production:Fiona ReidFiona Reid DesignStraitbraes FarmSt. CyrusMontrose

Website design andmaintenance:

Nick BowlesWebcraft UK Ltdwww.webcraft.co.uk

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

Editor:Avril Nicoll RegMRCSLT

Subscriptions and advertising:Tel / fax 01561 377415

Avril Nicoll 2004

Contents of Speech & LanguageTherapy in Practice reflect theviews of the individual authorsand not necessarily the views ofthe publisher. Publication ofadvertisements is not anendorsement of the advertiseror product or service offered.

Any contributions may alsoappear on the magazinesinternet site.

Cover picture by Paul Reid / AngusPictures. Lochlands Resource Centre,

Arbroath. Clockwise left to right: AdenDevlin, Pamela Christie, DorothySimon, Robin Dundas, Susan Munro(specialist speech and languagetherapist). See p.4

www.speechmag.com

4 COVER STORYJABADAO - MAKING A SONG ANDDANCE ABOUT COMMUNICATIONSo was I searching for the impossible? Atherapeutic approach which not only focused onthe needs of my clients with profound andmultiple learning disabilities but also provided aforum for training staff to carry out appropriateactivities outwith speech and language therapysessions. Surely I was asking too much? However, achance discussion with a physiotherapy colleague

revealed JABADAO as a potential resolution.Susan Munro discovers that the JABADAOframework can provide lasting opportunities for

progress by people with profound and multiplelearning disabilities.

IN FUTUISSUE

DYSPHAG

VO

BABY SIGNIN

WORD FINDINDIFFICULT

TOTAL COMMUNICATIOENVIRONMEN

LARYNGECTOM

EARLY YEA

SENSOINTEGRATI


4/32SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 20042

Online shopping gapEvery little helps - but supermarkets are generally failing to address

the online shopping needs of disabled customers.

Of the UKs five most prominent supermarkets, computing and disability

charity AbilityNet found only Tescos alternative website is easily accessed

by people with a visual impairment, dyslexia or physical disability making

mouse use difficult. The charity suggests that Sainsburys, Morrisons, Asda

and Somerfield are missing out on a market worth millions. Asda and

Morrisons have pledged to make their home shopping facilities compli-

ant with the Disability Discrimination Act in the near future.

Julie Howell, Digital Policy Development Officer at the RNIB, comments,

Many fully-sighted people find Tescos simply designed Access site offers

them a better user experience than any other supermarket website.

Developed for vision-impaired users, it now takes a surprising 13 million a

year, and seems to attract a much wider audience than originally intended.

A research report from the Joseph Rowntree Foundation, Does the

Internet open up research opportunities for disabled people? is avail-

able at www.jrf.org.uk/knowledge/findings/socialcare/524.asp.

www.tesco.com/access

www.abilitynet.org.uk

Former US Presidentreduced stigmaof AlzheimersThe Alzheimers Society has paid tribute to

Ronald Reagan for raising awareness and

reducing the stigma of the disease.

The former US President, who died in June,

made a public declaration that he hadAlzheimers disease in November 1994. The

chief executive of the Alzheimers Society

said this was, a uniquely courageous act. It

confirmed him as a champion for the mil-

lions of people and their carers in the world

who are affected by this progressive and

ultimately fatal neurological disease.

The Alzheimers Society has been the UK

partner of the Ronald and Nancy Reagan

Research Foundation since 1995. The charity

believes that the international media cover-

age following his announcement ensured

that thousands more individuals and carers

were encouraged to seek help from their

nearest Alzheimers societies and to talk

about their experiences.

As the charitys work continues, it has

drawn attention to cruel and unethical

drug holidays which mean that a signifi-

cant number of people experience rapid

deterioration which cannot be reversed.

Drug holidays are used to determine

whether or not a person is benefiting from

the treatment, but the society points out

there is no evidence to support this practice.

It hopes the National Institute of Clinical

Excellence will move to end the practice in

new guidelines expected in 2005.

www.alzheimers.org.uk

The gloves are off - time for more aggres-

sive management of stroke.

This is the stark message from the Royal

College of Physicians on publication of its

updated clinical guidelines on stroke care.

Developed by a multidisciplinary group on

the basis of clinical evidence and in consul-

tation with stroke patients and their carers,the guidelines emphasise prevention and

call for stroke to receive higher priority and

faster treatment. New topics include

screening and allowing for cognitive

impairment, and the need for specialist

rehabilitation in the community and a more

involved role in decisions on discharge and

transfer by patients and their carers.

Welcoming the guidelines, Dr Joanne

Knight of The Stroke Association said,

Stroke is currently the UKs third biggest

killer, and as such should be treated as a

medical emergency. Better organisation

of existing therapies could make a real

difference to a persons outcome after

their stroke.

Dr Tony Rudd, chair of the group who pro-

duced the guidelines, says, Many of the

treatments are simple, common sense

interventions and yet not often delivered.

Modern, high technology medicine is also

beginning to have an impact on stroke.

These guidelines are based on the most

up-to-date evidence. They are applicable

to all people involved in providing care

for patients with stroke and should bemade widely available.

A paediatric guideline is planned pro-

duced jointly with the Royal College of

Paediatrics and Child Health.

Meanwhile, recent research appears to

support the increased use of preventative

medicine. Published in the Lancet, the

Oxford Vascular Study report notes that

major stroke incidence in Oxfordshire has

dropped by 40 per cent over the past 20

years. Commenting on the findings, The

Stroke Association, who part-funded the

research, emphasised the importance of

simple lifestyle changes as well as more

proactive medical treatment in preven-

tion of stroke.

www.rcplondon.ac.uk

www.stroke.org.uk

PLEASE NOTE The price of Speechmarks The Brain Injury Workbook, reviewed in

our Summer issue, has been revised for 2004, and is now 35.95. The Maggie Johnson reference in Charlotte Childs article Choices,

changes and challenges article in the Summer 04 issue shouldhave read Functional LANGUAGE in the classroom.

Disappointment with government responseThe National Autistic Society is disappointed that the government has decided not to bring people with social and

communication impairments explicitly into disability legislation.

The joint scrutiny committee of the Draft Disability Discrimination Bill had recommended that the definition of

disability should cover social interaction and communication. Gavin Owen from the National Autistic Society said,

We are deeply concerned that this response demonstrates a fundamental misunderstanding of what autism is

and how it affects people in their day-to-day life. People with an autistic spectrum disorder should not have to

take individual legal cases to court in order to have their disability recognised within this legislation.

However, he added that the society welcomes the governments acceptance of other key recommendations which

will prioritise the provision of accessible audio-visual information on public transport and ensure that General

Examination Boards take communication disorders into full account when setting exams.

www.autism.org.uk

NEWS

A London centre for babies and children under five who have

hearing impairment or speech, language and communication

difficulties has expanded its capacity for therapy provision by

50 per cent.

Christopher Place, a registered charity, combines nursery education

and therapy, and currently caters for around 250 communication

impaired children a year. Its new wing, to be opened byPatron Evelyn Glennie on 22 September, features state of

the art, acoustically treated classrooms, one-to-one

therapy booths, a bespoke outdoor play area, parents

room and space for professional development training

(see events on inside back cover).

More information on the architect-designed provision

will appear in a feature in the Winter 04

issue of Speech & Language Therapy in

Practice.

www.speech-lang.org.uk

Christopher Place to open new wing

Call for aggressive management of stroke


5/32SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2004 3

Addingcolour

If you were a colour, what colour would you be? Stark white, fired-up red, laid-back

purple, solid black? Maybe this summers grey weather has left you feeling

blue. If so, get working on a clarification of your values (Jo Middlemiss, p.22) -

and let Speech & Language Therapy in Practices move to full colour brighten

your day!

I suspect that, if Keith Parkwere a colour, he would be whatever colour his

clients needed him to be at any given time, but you can check this out for

yourselves by joining Keith and Nevin Gouda at interactive storytelling

workshops at Shakespeares Globe Theatre (see p.8).

The colourful props and variety of musical styles used in JABADAO (p.4) are

reflected in the vibrancy of our front cover. Susan Munro and her clients clearly

revel in this approach, designed to encourage interaction, movement and

relationships. Importantly, it also allows clients with profound and multiple

learning disabilities to show their true colours as communicators.

Some of our clients are reliant on pale images to guide them, but Amy Duck &

Sarah Weeks (p.19) painstakingly support children with speech and language

impairments and learning disabilities to fill in the colour and detail that will

enable them to develop independent life skills and functional communication.

All vulnerable groups struggle to access information. When speech and

language therapist Sasha Bemrose and midwife Lynn Lynch (p.10) wanted

greater uptake of antenatal education in their Sure Start area, they enlisted the

help of a cartoonist. The use of colourful cartoon material - rather than dense

black text which relies on literacy - has been pivotal to an increase in

effectiveness.

Issues in speech and language therapy are rarely if ever black and white, as our

How Icontributors (p.24) can attest. However, by taking an organised approach

to common problems - good communication, coordination, planning, audit and

review of the literature - they have come up with a spectrum of ideas which

may add up to a solution.

Colour can help us to get organised and stay organised, according toJayne

Comins (back page), who counts vibrant purple and cheerful blue ringbinders

among her favoured tools. And, when Christina Barnes and colleagues (p.14)

were developing their care pathways for deaf children to improve equity of

service, colour coding was essential to the organisation of the flow diagrams to

keep them clear and unambiguous.

Speech & Language Therapy in Practice aims to reflect the diverse shades, hues

and mix of our profession and our clients. So, if this magazine were a colour,

what colour would it be? Well, full colour - naturally!

commentAvril Nicoll,

Editor

33 Kinnear SquareLaurencekirkAB30 1UL

tel/ansa/fax01561 377415

e-mail

[email protected]

Positive resultsfrom mobile DAFManufacturers of a delayed auditory feedback

device as small as a mobile phone are reporting

positive results in initial trials with people who

stammer.

Designed in Belgium by a Technical Engineer

who stutters, DEFSTUT (Defeat Stuttering) was

tested by 30 adults who stammer, over a periodof three months with minimal professional

support. Positive effects were apparent on 80

per cent of users, with stammering decreasing

and fluency increasing because of the natural

speech slowing effect.

Professor J. van Borsel of the University of

Ghent in Belgium comments, Contrary to

what we feared at the beginning of our

research, the participants hadnt got used to

Delayed Auditory Feedback to the extent that

the positive effect decreased. Although

stammering didnt totally disappear, all the

people were very positive about their

experience. Many of them are now able to

make telephone calls.

The distributors would welcome comments

from speech and language therapists on the

usefulness of DEFSTUT. They offer a 14 day

money back guarantee, as delayed auditory

feedback is not effective for everyone who

stammers.

www.defstut.co.uk

Mental Capacity Bill aimsto empower vulnerablepeoplePeople who lack capacity, either through

disability, mental illness, brain injury or illnessessuch as dementia are to be placed at the heart

of decision-making.

The Mental Capacity Bill aims to empower

vulnerable people to make as many decisions

for themselves as possible and, where they

cant, to protect them and their carers by

setting out who can make decisions on their

behalf, in what situations and how they should

go about this. It would also make neglect or ill

treatment of a person who lacks capacity a

criminal offence.

Joint champion of the Bill, Health Minister

Rosie Winterton, said, The Bill provides a clear

legal framework for health and social care

professionals, carers and anyone acting on

behalf of people who lack capacity.

www.dca.gov.uk/capacity/index.htm

www.makingdecisions.org.uk/alliance.htm.

Petition for changeSpeech and language therapists in Scotland are

inviting colleagues across the UK to sign an e-

petition to the Scottish Parliament.

The e-petition asks the Scottish Parliament to

discuss the implications of Agenda for Change

for the profession. It can be viewed and signed

at http://itc.napier.ac.uk/e-petition-

scot/list_petitions.asp. The closing date is 20th

September 2004.

NEWS & COMMENT


6/32

JABADAOMaking a song and danceabout communication

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 20044

COVER STORY

People with

profound andmultiple learningdisabilities suffer

from the erroneousperception that

they arenon-communicators.

Susan Munrodiscovers that the

JABADAOframework canbridge the gap

between theperception and the

reality - and providelasting opportunitiesfor progress.

IF YOU

HAVE A LIMITED EQUIPMENT BUDGET

NEED TO MOTIVATE CARERS

WANT TO HAVE FUN WHILE YOU WORK

ost speech and language thera-

pists in the learning disability

field have a steadily increasing

number of people with profound

and multiple learning disabilities

on their caseload. However, find-ing relevant literature on therapeutic approaches

can be difficult, as the majority of literature focuses

on people with mild-moderate learning disabilities

and methods which, more often than not, are inap-

plicable or irrelevant to people with profound and

multiple learning disabilities. In addition, many

experienced therapists yearn for new and inspiring

ways to work with clients with such complex com-

munication support needs. With a desire to find a

therapeutic approach which both facilitated the

development of early communication skills and

motivated and inspired a variety of staff groups, I

set out on a quest which culminated in the discov-

ery of JABADAO.

Over the last decade the literature available to

speech and language therapists about interven-

tion approaches specific to working with people

with profound and multiple learning disabilities

has gradually increased. Much has been written

about the use of objects of reference (Park, 1995;

1997; 1999), storytelling (Park 1998; 2000; 2001),

Individualised Sensory Environments (ISE)

(Bunning, 1996; Dutton, 1996; Smidt, 1996) and

Intensive Interaction (Nind & Hewett, 1994; 1998;

Irvine, 2001), and it has been heartening to read

reports on the positive benefits of traditionally

non-speech and language therapy approaches such

as hydrotherapy (Bartlett, 1999) and art therapy

(Hill, 1997). However, one of the significant diffi-

culties facing therapists who work with peoplewith profound and multiple learning disabilities is

the need to pass skills on to other people involved

in that persons care and development. People

with profound and multiple learning disabilities

need much more regular input than most speech

and language therapy services can provide and,

therefore, success is often dependent on the

cooperation and understanding of others.

A review of the literature on approaches to staff

training indicates that, to be effective, it must:

a) take place in the workplace

b) be based around the situations and contexts that

commonly feature in the member of staffs

daily work

c) focus on the client or clients with whom the

member of staff most frequently interacts and

d) involve a more experienced colleague who knows

the needs of the client and has opportunities to

work alongside the staff member (Purcell et al, 2000).

This would suggest that parallel working with a

member of staff who will carry out a specific

approach in the speech and language therapists

absence is imperative if this model of therapy is to

be effective.

M


7/32

Figure 1 Recording form JABADAOSpeech & Language Therapy Aims

Name: _____________________________________ Date: ______________________________

General Participation none physical prompt verbal prompt fullAttention none fleeting part session full

Communication Eye Contact none fleeting short sustained long sustainedTurn-taking none physical prompt verbal prompt self-initiatedImitation none physical prompt verbal prompt self-initiatedInitiation none unintentional intentional (occasional) intentional (regular)Choice-making none physical prompt verbal prompt self-initiatedExpression none facial/vocal pointing/gesture sign/speech

Relationships Awareness of Group none limited fullEngaging with Staff none physical prompts verbal prompts self-initiatedEngaging with Peers none physical prompts verbal prompts self-initiatedAssisting Peers none occasionally regularly

Physical Contact Tolerates Indirect Touch no yesTolerates Direct Touch no yesInitiates Touch no yes

Comments

Participation & Attention

Communication

Relationships

Physical Contact


COVER STORY

So was I searching for the impossible? A thera-

peutic approach which not only focused on the

needs of my clients with profound and multiple

learning disabilities but also provided a forum for

training staff to carry out appropriate activities

outwith speech and language therapy sessions.Surely I was asking too much? However, a chance

discussion with a physiotherapy colleague

revealed JABADAO as a potential resolution.

A catalystJABADAO is well known to many physiotherapists

working in the fields of learning disability, paedi-

atrics and mental health. It uses music and colourful

props - such as parachutes, balls, ribbons and

scarves - as a catalyst for encouraging interaction,

promoting movement and supporting relationships

amongst participants. The approach is based on the

assertions that

a) the ability to make and maintain positive

relationships is an essential aspect of an

individuals life, underpinning the ability to

learn, to be healthy, and to be happy

b) movement is the most direct medium of

human communication we possess.

It focuses on building relationships through

techniques such as mirroring, witnessing and pat-

terning, thus creating a movement dialogue

either between two individuals or amongst a

group. Probably the most significant principle of

JABADAO is that each individuals experience is cen-

tral. JABADAO does not suggest or direct ways in

which to respond; rather, it seeks to encourage and

support an individuals spontaneous reactions, and

then to make it possible to share this with others. As

such, JABADAO provides a way of working with eachperson as they are, and emphasises the building of

relationships as the basis for meeting all other goals.

Literature evaluating the benefits of JABADAO

is easy to find (Tufnell et al, 2000; Greenland,

2000; Crichton et al, 2000). However, despite the

fact that communication appears to be a key

theme throughout, there is no evidence of its use

by speech and language therapists. As a result,

the evidence presented is anecdotal and there is

no documentation of the impact of JABADAO on

specific aspects of communication. However, I was

so inspired by what I read that I decided to under-

take my own analysis of JABADAO as a potential

therapeutic approach for people with profound

and multiple learning disabilities. So, after com-

pleting a three-day JABADAO course, I set up a

small research group to investigate the specific

communication benefits of JABADAO for people

with profound and multiple learning disabilities.

The group was run in a day centre for eight con-

secutive weekly sessions. The group comprised of

eight adults with profound and multiple learning

disabilities, four members of staff from the day

centre, a speech and language therapy assistant

and me. We created a recording form (figure 1) to

identify and categorise target communication

skills, which the speech and language therapy assis-

tant and I used to take baseline measurements and

for weekly recording after each group session. We

also recorded each session on video, which allowedus to analyse and document the responses of group

members in more detail than could have been

gained from observation alone. The group was

well attended by both clients and staff and each

session included a balance of group activities and

opportunities for work with individuals or in pairs.

We used a wide range of musical styles, from Cajun

Folk to Classical, and a balance of vocal and instru-

mental music. Props included a parachute, velvet

covered elastic, balls, balloons, ribbon sticks and

colourful scarves. One of the favourite group activ-

ities involved the parachute and balloon - raising

the balloon higher and higher until it burst on the

artex ceiling (though I did eventually run out of

balloons!) The group participants were responsible

for selecting both the music and the props for each

activity, and the biggest lesson for the staff was to

learn how to respond rather than direct.

Great successAt the end of the eight-week research project it was

obvious that JABADAO had been a great success for

all those involved. All participants showed some

development of target communication skills and


8/32

DO I USE APPROACHES THAT HELP CARERS RESPOND RATHER THAN DIRECT?

DO I BORROW IDEAS FROM OTHER DISCIPLINES AND ASSESS THEIR APPLICABILITY?

DO I RECOGNISE THAT THE BUILDING OF RELATIONSHIPS UNDERPINS ALL LEARNING?


COVER STORY

half of the group members showed development

in at least 50 per cent of the recorded areas.

Across the whole group the most common devel-

opments were in the areas of turn taking, imitation,

initiation, choice-making and engagement with

peers. The most important finding for me was thatthe participants with the most severe physical and

sensory impairments actually made the most sig-

nificant gains from their own baseline assessment,

and tended to show the most significant develop-

ment in the areas of participation, attention, eye-

contact and engagement with staff.

The group was also well-received by the day cen-

tre staff who reported not only their personal

enjoyment of the sessions but also their realisation

of the abilities and potential of the participants.

They were enthusiastic about continuing

JABADAO groups outwith allocated speech and

language therapy time but voiced concerns over

the practicalities relating to such staff intensive

sessions; the more complex the needs of the par-

ticipants, the higher the staff ratio required.

However, despite this, more than a year on,

JABADAO groups continue to be a regular feature

on the day centre timetable and run with the

same level of enthusiasm as they did at the begin-

ning. This response from the day centre staff is

equally important to me as a speech and language

therapist. Often the most crucial, and difficult,

objective for the speech and language therapist

working with people with profound and multiple

learning disabilities is to alter the commonly-held

perception that they are non-communicators. If

we can challenge these attitudes then we can

truly begin to make a difference in peoples lives, asit is only once the key people in their environment

view the individual as a potential communicative

partner that we can begin to implement intervention

strategies to develop their communication further.

JABADAO appears to be another tool the speech

and language therapist can use to bridge this gap.

It is very likely that JABADAO has many more

useful applications for speech and language ther-

apists working with a variety of client groups. It

has certainly become a core aspect of the service I

provide because:

it values each person involved and allows each

individual to participate in their own way

it helps non-speech and language therapy staff

to focus on an individuals abilities rather than

their disabilities

its fun, and motivates staff to run regular sessions

it doesnt require hi-tech, complicated or

expensive equipment.

Susan Munro is a specialist speech and language ther-

apist with Tayside Primary Care NHS Trust, tel. 01382

346005 or e-mail [email protected].

ResourcesFor further information about JABADAO - Centre

for the Study of Movement, Learning and Health,

see www.jabadao.org or tel. 0113 231 0650.

ReferencesBartlett, C. (1999) In at the deep end. TherapyWeekly November 4: 12.

Bunning, K. (1996) The principles of an Individualised

Sensory Environment. Bulletin of the Royal College

of Speech & Language Therapists January: 9-10.

Crichton, S., Greenland, P. & Perrin, T. (2000) The JABADAO

Elderly Papers, JABADAO Publications, England.

Dutton, L. (1996) Steps to engagement through

Individualised Sensory Environment (ISE) therapy.

Human Communication Nov/Dec: 16-18.

Greenland, P. (2000) Hopping Home Backwards.

JABADAO Publications, England.

Hill, C. (1997) A sequence of sequins. Bulletin of

the Royal College of Speech & Language

Therapists November: 14-16.

Irvine, C. (2001) On the floor and playing...

Bulletin of the Royal College of Speech &

Language Therapists November: 9-11.

Nind, M. & Hewett, D. (1994) Access to communica-

tion: Developing the basics of communication with

people with severe learning disabilities through

intensive interaction. David Fulton: London.

Nind, M. & Hewett, D. (1998) Interaction in

Action: Reflections on the Use of Intensive

Interaction. David Fulton: London.

Park, K. (1995) Using objects of reference: A

review of the literature. European Journal of

Special Needs Education 10 (1): 40-46.

Park, K. (1997) Choosing and using objects of ref-erence. The SLD Experience 19: 16-17.

Park, K. (1998) Dickens for all: Inclusive approaches

to literature and communication for people with

severe and profound learning disabilities. The

British Journal of Special Education 25 (3): 114-118.

Park, K. (1999) Whose needs come first? Speech &

Language Therapy in Practice Summer: 4-6.

Park, K. (2000) Riverrun and pricking thumbs. The

SLD Experience 25: 11-13.

Park, K. (2001) Interactive storytelling: a multidis-

ciplinary plot. Speech & Language Therapy in

Practice Summer: 4-7.

Purcell, M., McConkey, R. & Morris, I. (2000) Staff

communication with people with intellectual dis-

abilities: the impact of a work based training pro-

gramme. International Journal of Language and

Communication Disorders 35 (1): 147-158.

Smidt, A. (1996) Turning around the negative spi-

rals. Bulletin of the Royal College of Speech &

Language Therapists January: 11.

Tufnell, M., Greenland, P., Crichton, S., Dymoke, K. &

Coaten, R. (2000) What dancers do that other health

workers dont... JABADAO Publications, England.

CLINICAL EDUCATIONClinical Education in Speech-Language PathologyLindy McAllister & Michelle LincolnWhurrISBN: 1-86156-310-8 20.00

Well-referenced and sensibleThis excellent text will be of use to students andclinical educators at every stage of theirprofessional development. The eight well-referenced chapters identify what goes on inclinical education - the good and the bad - andoffer sensible insights from a Humanistic approach.The clearly written text is mixed with many tables,vignettes and several learning exercises.This is not a quick-fix manual. It is a seriousattempt to raise the professional status ofclinical education. Universities and clinicalplacement providers would do well to buy thisbook for their students and staff.

Josie Roy is a speech and language therapist atAstley Ainslie Hospital in Edinburgh.

HEAD INJURYHead Injury: A Practical GuideTrevor PowellSpeechmarkISBN 0 86388 451 2 19.95

Refreshingly clearThis readable guide introduces head injury frombasic anatomy to acute care, rehabilitation, andbeyond to life adjustments for the individualand the family unit.True to its title, the book offers jargon-freeexplanations and practical coping strategies forthe physical, cognitive, emotional andbehavioural impact of head injury.Personal accounts of clients and carers poignantly

illustrate each of the areas discussed and contributeto a useful and accessible resource for clients, theircarers and family. It also provides a refreshinglyclear and comprehensive overview for studentsand therapists new to the field of head injury.Hannah McQueen is a speech and languagetherapist working for Coventry PCT.

LANGUAGE DEVELOPMENTStoryCards: Verbs (picture cards and finger

puppets)Sue Duggleby & Ross DugglebySpeechmarkISBN 0 86388 450 4 41.06

Sat in the cupboardWe reviewed this as a team, and the fact that it has

sat in the cupboard for three months is revealing.Working with children with specific languageimpairment, we feel the pictures are too complexvisually, with unfamiliar characters / vocabularysuch as ostrich. There are quite a lot of picturesper sequence and we do not feel the resource isfunctional. You could use it to consolidate verbwork, but we feel a little bewildered by it.We feel that therapists working in thecommunity are even less likely to find thisexpensive resource useful.The specific language impairment service of the

speech and language therapy department at CityHospitals Sunderland is Ruth Colmer, LisaBergstrand, Helen Cochrane, Jill Elstob, Julie Belland Jeannie Williamson.

reviews



HERES ONE I MADE EARLIER...

Heres one

I made earlier...ALISON ROBERTSRETURNS WITH SOME MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONS.

SAME ANDDIFFERENT CHAINSThis is a pressure-free way for your clients to

consider peoples unique qualities and their simi-

larities. If you have a wall available, it also makes

a rather good display, with especially high

impact if there are several together.

BRAWNFold your paper into a concertina. You will probably

be able to cut through about 10 layers of paper at a

time, and each flat area will need to be big enough

to draw a person on, so approximately 30 inches

will be about right - but experiment!

Draw a person outline (2-dimensional, not a

stick man), on to the front, and cut out. A key

point to make, if your clients are making these

themselves, is that the hands or elbows (if hands

on hips), or outer edges of skirt, or shoes must

stretch to the outside edge - otherwise you will

end up with a lot of separate paper people

rather than a chain. If you create more than one

joining point the chain will be stronger.

IN PRACTICE IOnce the paper shapes have been cut out and

opened up, you will be able to discuss how

people in general are similar to look at, and you

can talk about other similarities and emphasise

our common humanity. You might also want to

make the point that, if we were all exactly the

same, life would be boring.Now you can move on to uniqueness / individuality,

by decorating the people, being sure to make

some female and some male, of various ethnicities,

hair colour, some with glasses, varying ages and so

on. As well as talking about external appearance,

you might want to mention peoples differing

preferences, lifestyles, etc., and could add words to

the cutouts bodies to indicate these differences.

IN PRACTICE IIIf you widen the concertinas so that you can fit

in two people on the front, holding hands, you

can make one more obviously female and one

more male, or one fatter, or one in a wheelchair

for example. You can also add speech bubbles.

TOTEM POLEA fun activity which is useful for a teenage social

language group. Native American peoples totem

poles depict animals that reflect or encourage

aspects of their culture and personalities. We

made one that was designed to encourage

various conversational skills. Perhaps not quite so

aesthetically pleasing as the original carved wood

variety, but calls upon a cooperative approach,and results in an object with impact!

IN PRACTICEFirst you need to talk through the aspects ofconversation that you are hoping to target. The

group should already be aware of the meaning

of terminology such as Eye Contact, Listening

Skills, Topic Maintenance/Focus, Body

Language, and Turn taking.

Decide on animals that could be associated with

each conversational skill. We chose an owl for

eye contact, a bat for listening, a heron for topic

maintenance/focus (a heron is a regular visitor to

the lake outside the mill where we work), and a

peacock for body language (admittedly from the

wrong continent, but an excellent example of

animal body language, and one that they all

knew). For turn taking we added a paperTalking Stick half way down, but you could

demonstrate poor turn taking, by adding a pig -

not noted for polite turn taking at the trough!

Once the length of the pole has been cut, you

need to fix tying points so that you will be able

to attach your finished pole to a wall. We stuck

lengths of string around the pole, but you could

drill pairs of holes with string through instead. In

either case, dont scrimp on the length of string

you allow to hang out, and make sure you have

aligned them to correspond with attachment

points in your room.

Now you need to draw the animals on to the

paper - each client can be in charge of an animal.The trick is to keep the drawings tall, so that they

will just overlap when stuck to the pole, and the

right size to cover the perimeter of the pole.

The finished effect of the pole will be enhanced

if, when you cut out the animals, you allow ears,

wings, and beaks to protrude, by careful cutting

round the shapes. Glue them to the pole, leaving

your strings out.

Attach the pole to the wall using the strings.

Stick labels that mention the animal / conversa-

tion skill connection either on each animal, or on

the wall, beside your pole.

TALKING STICKA useful, cheap and easy item to make with a

teenage social language group where turn taking

seems to be a problem. It will help if the group is

already interested in Native American people

and their culture - maybe linking with a classroom

project - but this is not absolutely vital; you

yourself may be able to enthuse them about the

culture by showing pictures or books.

BRAWN1. Form a groove around the stick, using a

penknife - probably best to do this bit on your

own before the session, to avoid disaster.

2. Tie the string around the stick, and attach the

beads and feathers to the string.

IN PRACTICEIt will be helpful to have a list of discussion subjects

relevant to your particular client group. These

could be local / national newspaper headlines, or

issues currently topical to the school or college

where you work (could be to do with clothes,

food). Try to make the subject something that

they have opinions about.

Each group member should be encouraged to

offer an opinion, but may only speak while they

are holding the stick. Begin by passing the stick

in order round the circle, but work towardsgroup members silently indicating their desire to

speak, to form a more natural conversation. If

you have an overly wordy person in the group

you may need to introduce a one-minute rule, so

that the others do not get bored. Take care to

arrange it so that reluctant speakers also join in.

It is worth remembering that turn taking not

only requires the disciplines of joining in, and

waiting for a turn, but also of remembering what

you have to say until a good moment arrives.

Before doing this activity it may be useful to

allow a group to talk all at once and then point

out that the conversation is not working because

no one can hear what anyone else is saying.

Then you will have good grounds for proceeding.

MATERIALS

Long strips of paper - lining wallpaper cutlengthways into three will be tough, cheap,

and long

Good scissors

Felt tip pens

MATERIALS A stick - I would tend to err on the side oftoo small rather than too big, as sticks can

be used as weapons

String

Scissors and glue

Beads - nice glass ones would add to the

quality of and respect for this item, which you

may find yourself using in such groups for years

A few feathers

MATERIALS A cardboard tube with as big a diameter as

possible. We obtained one that had been the

centre of a carpet roll, and cut off a 5-foot

length. The actual cutting is quite a job, and

needs a bit of muscle and a saw

Large sheets of strong paper in shades of

brown

Felt tips, scissors and glue

String and parcel tape

Alison Roberts is a speech and language therapist at Ruskin

Mill Further Education College in Nailsworth, Gloucestershire.



INCLUSION

Language Therapy in Practice, Spring 2002),

Romeo & Juliet and Othello. Part of the star

crossed lovers season at the Globe, the relevance

of Romeo & Juliet to modern day life is clear, as

Keith and Nevins version sets the Montagues and

Capulets as Jews and Arabs, both talking of peace

and of learning lessons, but with the cycle of

destruction ultimately continuing.

Keith has just learned that the Globe has agreed to

make its stage available to his groups for at least

eight Mondays in its closed season, and is excited at

the prospect of seeing Othello enacted on the famous

stage, to coincide with the current Shakespeare and

Islam theme. Nevin - who is also Keiths Arabic advis-

er - and Keith collaborated for several months to pro-

duce an accessible version of Othello (see figure 1).

But surely it must be difficult to teach Othello to peo-

ple with learning disabilities? On the contrary, Nevin

assures me, the Lewisham College students involved

took just two goes to master it.

Othello uses three languages - English extracts of

original Shakespearean text, Arabic (which would

probably have been Othellos first language) and

signs from British Sign Language. Nevin is enthu-

siastic about the benefits of interactive story-

telling, not just for the students themselves, but

for staff training. She had faced the frustrations

of many in our profession when tutors were reluc-

tant to attend signing groups. Interactive story-

telling has allowed the desire for training to happen

naturally, as the tutors have seen the benefits in a

real situation and are asking her for more.

Shakespeare is not exactly top of many school

pupils lists, so why would it appeal to children

and adults with complex support needs? Keith

points out that most of Shakespeares audience

would have been illiterate, so the meaning had to

come from what they observed on stage. His

work therefore lends itself beautifully to different

codes and registers, and is strongly emotional,

rhythmical and directional (me/you/him/her/all of

you), giving many opportunities for over-the-top

and melodramatic gesture, sounds and acting.

Furthermore, in the plotlines you can find oppor-

eres looking at you, kid. Keith Park

does a mean impression of Humphrey

Bogart. And for that matter John

Wayne, Prince Charles, Peter Sellers,

Bob Hoskins and even Darth Vader. He

makes a pretty good job of Welsh and Scottish

accents as well as Cockney, and throws in some

Arabic and Hebrew for good measure.

Appropriately, Im at the Globe Theatre on

Londons south bank to meet interactive storytelling

guru Keith Park and speech and language therapist

Nevin Gouda. Im keen to understand more about

how interactive storytelling works for people with

complex support needs, and how easily it could be

incorporated into everyday settings and activities.

Keith is an advisory teacher for SENSE (The

National Deafblind Rubella Association) in

Lewisham, London. While I am in the process of

researching a feature on new builds specially

designed for people with communication difficul-

ties, Keith is taking people with the highest sup-

port needs to the Globe Theatre stage to re-enact

Shakespeare plays in several community lan-

guages as well as English. Interactive storytellings

experiential nature quickly becomes clear - and,

rather than wondering how great literature can

be made accessible to people with profound and

multiple disabilities, my thoughts turn to how on

earth I can make interactive storytelling accessibleto readers via a printed article...

A human levelKeith wants to get away from specially construct-

ed settings and the dreaded functional vocabu-

lary to high status venues and participation in

fun activities. He dislikes the way that a lot of spe-

cial education is devoid of humour, a grind, and

wants to animate people and get them more

involved on a human level. Again and again he

talks of interactive storytelling leading to his

clients doing things that people with learning

disabilities are not supposed to do.

Interactive storytelling began in 1987 with

Homers Odyssey, in collaboration with Nicola

Grove, as a reaction against seeing a group of

adults with learning disabilities being led in a

rendition of If youre happy and you know it.

Since then it has snowballed, and culminated in

the recent publication of a book (see our reader

offer). The scope of interactive storytelling is as

wide as we want it to be - from Shakespeare and

classic writers through poetry, film, television and

our own experience. By making it a rich multisensory

experience, everyone can be included, whatever

their level of ability - and they will often surprise

with what they can do.

So far, the Shakespeare work has included A

Midsummer Nights Dream (see Speech &

H

Advisory teacher Keith Parkand speech and language therapist Nevin Gouda tellAvril Nicoll about interactive storytelling, and how anyone can do it - even you.

IF YOU THINK YOUR CLIENTSSHOULD HAVE

FUN! VOCABULARY THAT ISMORE THAN FUNCTIONAL

OPPORTUNITIES TO GOANYWHERE ANYONE ELSEDOES

A midsummer nightsconversation

Nevin Gouda and Keith Park outside the Globe Theatre


11/32

Is your appetite whetted for more?Speechmark Publishing Ltd is offering a copy of Interactive Storytelling - Developing Inclusive Stories for

Children and Adults to readers of Speech & Language Therapy in Practice, in a FREE prize draw.

The hands-on manual includes folktale and pantomime, stories from around the world, Shakespeare,

Charles Dickens, poetry and song, and growing your own stories.

To enter, send your name and address to Speech & Language Therapy in Practice - Interactive Storytelling

offer, Su Underhill, Speechmark, Telford Road, Bicester, OX26 4LQ by 25th October. The winners will be

notified by 1st November.

Interactive Storytelling by Keith Park is available for 29.95 along with a free catalogue from Speechmark, tel. 01869 244644.

READER OFFER WIN KEITH PARKS INTERACTIVE STORYTELLING

A good ice breaker with staff who are a bit shy to

join in is the call Give us a crisp, give us a crisp

with each person progressively adding flavours and

everyone saying Yum, yum. While responses

automatically start with salt and vinegar and cheese

and onion, more exotic and fantastic flavours - cold

custard, dandelion and nettle - are bound to creep

in to increase the enjoyment and loosen inhibitions.

Think as well about how different concepts can be

covered through bending storylines. For example,

in Jack and the Beanstalk, Keith uses the idea that

people are poor listeners: Ive got some beans.

You got some jeans? NO, Ive got some

beans. You got some queens? NOOO... etc.

Ending with You know, you do my ead in!

On the storytracks website, a collaboration

between Keith and Nicola Grove, they say:

Stories give meaning to our lives - we are story-

telling creatures who are constantly reviewingand interpreting our experiences and making

links with what has happened to others. In so

doing, we develop a sense of who we are, and we

learn to connect and feel for others. Its now

clear to me that, rather than asking why people

with complex support needs would want to do

Shakespeare, we should be asking why anyone

wouldnt? So, go on Keith - play it again.

Keith Park is an advisory teacher for SENSE in

Lewisham, tel. 020 8699 6098. Nevin Gouda is a

speech and language therapist with Lewisham

Community Team for Adults with Learning

Disabilities, tel. 020 8698 6788. For more informa-

tion on Keith Park and Nicola Groves storytelling

workshops, see www.storytracks.com.


INCLUSION

telling students, and exploited by the use of dif-

ferent languages and modalities. One student did

a gesture in such a way that made it clear he was

having a laugh by turning [sala:m] into ,

and talk of peace jokingly became talk of peas

(and broccoli and carrots and so on).

Interactive storytelling is by no means confined

to Shakespeare. And, while the free-and-easy-

looking Shakespearean pieces are highly struc-

tured and take a long time to prepare, other uses of

interactive storytelling are much more spontaneous

and can easily be improvised. Keith and Nevin

have observed carer participants using the strategies,

such as lines from stories their clients have been

involved in, to calm them down and to keep them

occupied while they are waiting to do something

else, as well as just for fun and interaction.

I press Keith and Nevin: But surely you have to be

a bit of an extrovert, and to have an encyclopaedicknowledge of the arts, and a background in drama?

They insist this isnt the case - they have no drama

training - and that even the shyest person can end up

using a call and response approach to good effect. So,

what ideas can they offer to fledgling participants?

Firstly, they suggest putting together a story or

poem from your own background. Start off with

something simple and embroider it. Try one word

poetry, saying your name over and over with

appropriately fun intonation, progressively

knocking off phonemes, until you are left with

just one. Remember that nothing can be wrong -

observe children at this developmental stage having

fun playing with rhyme, meaning and emphasis, and

youll get the idea of the inclusive silliness of it all.

tunities to explore stages of development. For

example, if you want Theory of Mind, look no fur-

ther than Macbeth, when a murderer has to pin

the deed on someone else.

A minimalist approach is very deliberate. There

are no costumes and only rarely are props used, so

that students engage with the script itself. The

emphasis is on the interactive - the aim is lan-

guage and communication, and making stories

more interactive is the therapeutic bit.

Call and response is key. At a signal, everyone

makes a response in any way they can, be it

words, gesture, sound, or pressing a switch with a

pre-recorded phrase. A call and response pattern

automatically allows for lots of repetition of key

words, and for experimentation with vocal register,

which can be a great stress reducer for the students.

By creating a circle of people on the stage, the

energy moves towards the centre, where a stu-dent can go. This often results in the students not

only responding but initiating; for example, as

everyone waits for a particular user to press their

switch to kick off the story. I wonder how this

works with large groups. Keith tells me he began

his time as a visiting teacher by making a point of

asking class teachers what they wanted from him.

They said they wanted his students - who are deaf

blind with profound and multiple learning disabili-

ties - to have the opportunity to experience whole

group work. Counterintuitively, Keith now finds

that, the bigger the spread of strengths and needs

in the group, the better it is. By basing the group

around the needs of the most disabled person there,

that person is included and other people are

sparked off, for example through signing. He has

also done some work with mainstream and high

support needs students working together, and has

letters from the mainstream pupils which clearly

show the positive effect of the contact, and how it

starts to break down fears and barriers.

Having a laughKeith believes he isnt so much teaching

Shakespeare as using it - he works very flexibly,

throwing in different lines and improvising as

seems appropriate. Shakespeare made his name

by playing with language; this love of words and

the way they sound is shared by interactive story-

From Summer 04: the lucky winner of ERRNI (The Expression, REception and Recall of Narrative Instrument), courtesy of Harcourt Ais Katie Lea in Barnsley. The Butt Non-Verbal Reasoning Test from Speechmark Publishing goes to Helen Millward, Judith Delve and Ja

Congratulations to you all.

WORKSHOP INVITATIONReaders of Speech & Language Therapy in Practice are

welcome to join in the Othello interactive storytelling

workshops at Shakespeares Globe Theatre, on Monday

and Friday mornings, from 10.30-11.30am from MondayOctober 4th to Friday December 10th (except for the week

of half-term, beginning October 28th). Workshop partici-

pants will include teenagers and adults with severe and

profound learning disabilities. Please contact Keith Park

(e-mail [email protected]; tel/fax 020 8699 6098;

mobile 07791 174 740) for more details. (NB Please do not

try to contact the Globe Theatre directly.)

Figure 1 Othello Interactive Storytelling Group, Lewisham College

Students signing vengeance


12/32

Surestart (DfES, 2001) recognises that a childs communication skills can onlybe developed with adequate stimulation and response from others. Babies are

social beings and need someone to respond to their communication. The seeds

for development are laid in the earliest stages of baby-parent interaction.

Research into the speech and language abilities of nursery school children

within one of the South Wales valleys found that the majority of children

were performing well below their expected age ability on speech and lan-

guage measures (Merthyr Tydfil County Borough Council, 1998). Ward (2000)

indicates that children whose language development is delayed are at high

risk of developing educational, social and emotional problems.

Early experience has an effect on later development, and patterns of inter-

action can be set as early as three months of age (Brazelton, 1992). In the

early stages, the main carers need to be attentive and responsive to their baby

to facilitate this interaction. By supporting parents antenatally and giving

them information on what the baby is capable of doing, the parents become

proactive at the earliest stage. They feel involved and important which gives

them confidence. If they form an attachment before the baby is born, they

are more likely to interact with the baby as soon as it is born. In addition, we

have found that antenatal parents are keen to learn and have been very

receptive to new information.

Research suggests that a baby begins to learn in utero, and that this is an

opportunity to increase maternal awareness and interaction prior to birth

(Hodzic, 2002; Van de Carr & Lehrer, 1997; Verny 1981). Hodzic (2002) argues

that stimulation during pregnancy will improve attachment as well as inter-

action between mother and baby. Studies indicate that the prenate is more

capable than previously believed. There is evidence to show that, during the

sixth month of pregnancy, the baby can see, hear, taste, experience, feel,

remember and even learn (Verny, 1981). These concepts are explained to the

parents and supported by cartoon material and research examples. They can

relate the information to their own experience. For example, they are shownhow the prenate communicates through kicking, what music is soothing for

the baby, and how the baby responds to their voice when it is born.

Original cartoon materialVulnerable groups do not have access to information for a variety of reasons,

issues with literacy being one (DH, 2001). We therefore felt it was vital that

any information was presented in an accessible and accepted form where

access of information was not dependent on literacy levels. For this reason we

have used original cartoon material with minimal written text.

It is clear from the research and from our experience that parents and chil-

dren in the local area require support to develop effective interaction skills.

These skills can be learnt before the baby is born. A way of working needed

to be developed which was accessible and attractive to this particular client

group. With these points in mind we developed a pack to address the fol-

lowing objectives:

support parent-baby attachment prior to birth

support parent-baby attachment post birth

establish good patterns of parent-baby communication from an early age

provide the baby with maximum stimulation to aid their brain development,

physical development and growth, hearing and communication skills

(Verny, 1981)

increase parents self esteem

involve family members

reduce sibling rivalry.

Your Bump and Beyond consists of cartoon picture cards to show to mothers

and their families, a handbook for the professional to use that explains each

picture card, and activities that can be photocopied and given to parents to

practise. The pack has been split into two main areas: learning before birth (fig-

ure 1) and learning as a baby (figure 2). All of the examples are fully referenced.


A bump start

rom the moment of birth - and even before

- a baby is a social being that finds and

engages in interaction with other humans

and the wider environment. An excellent

opportunity exists in pregnancy to lay the

foundations of interaction and communication, so

we have developed an evidence based pictorial

information pack. Your Bump and Beyond can be

used with parents in the antenatal and postnatal

period to enhance parent-baby bonding and max-

imise the babys full potential. It has been piloted

in the South Wales Valleys of Rhondda Cynon Taff with 30 mothers. Due to its

success - and demand - it has been printed, and is now available to buy.

So, how did it all start? The Welsh Assembly Government (2001) emphasisesthe importance of clinical networking to provide effective care. As a Surestart

speech and language therapist, Sasha was keen to work with families and

children in a preventative way. She had attended a conference (Hodzic, 2002)

that emphasised that babies can develop before they are born, and the

importance of parent-baby bonding at the earliest stages. With this in mind

she realised the importance of working with families in the antenatal stage.

At the same time, Lynn was aware of a recent study looking at the speech and

language abilities of children in the local area. The findings emphasised the

level of delay that children living in this area of deprivation suffer. Lynn had

been involved in a previous project using pictorial information with vulnera-

ble woman. She, too, was looking to develop a way of working with expec-

tant and young mothers to improve the skills of young children.

At the time of our consultation we had therefore identified a need for

understandable, accessible information that would encourage positive inter-

action and communication skills prior to birth and in the early postnatal days.

We pooled Sashas knowledge of early interaction and communication and

Lynns knowledge of pregnancy and working with vulnerable women - and

Your Bump and Beyond was the result.

Rhondda Cynon Taff is an area of significant socio-economic deprivation

with poor health status across all demographic groupings. It has the highest

rate of conception in Wales in the 13-15 age group (RCT Surestart Plan, 2000-

2002). We recognise that parents and their children in this area are some of

the most vulnerable families at risk of disadvantage and social exclusion.

Seeds for developmentThe link between family deprivation and child learning is complex and multi

directional. Children from deprived areas are disadvantaged in their learning

due to many factors such as family stresses, economic difficulties, parental

experiences of education, their limited literacy skills and low self-esteem.

During a pregnancy, parentscan be very receptive to newinformation about their babysdevelopment. Recognising thatdisadvantaged groups needsupport to lay the foundations ofcommunication, Sasha Bemroseand Lynn Lynch joined forceswith a cartoonist to develop anantenatal pack, appropriately

titled Your Bump and Beyond.

EARLY INTERVENTION

IF YOU ARE WORKING

TO IMPROVE

ATTENDANCE RATES

WITH PEOPLE WHO

ARE DISADVANTAGED

AND SOCIALLY

EXCLUDED ON MAKING

INFORMATION MORE

ACCESSIBLE

Sasha Bemrose

Huw Evans

Lynn Lynch F



EARLY INTERVENTION

Ten midwives from one of the South Wales valleys have taken part in the pilotstudy since January 2003. Each was asked to use the packs with ten mothers.

Evaluation forms were simple and asked for feedback from the midwife and the

mother. To date, thirty evaluation forms have been returned (figure 3). The pilot

has shown that the cartoon pictures have been received very well by the women

and midwives and have potential for further use by other professionals.

Figure 1 Part one: Learning before birthThis pack consists of seven double-sided picture cards. The contentshave been split into two sections: what your baby can do before theyare born, and things to do to help your baby. The pack helps theparents to be aware that the baby is able to develop skills beforethey are born. It shows the parents ways of stimulating their babythat can help to give them a head start when they are born. This earlyparent-baby interaction aids attachment and early communication. Thismay prevent later difficulties, such as language delay, from developing.The following pictures illustrate the pictorial cards, and extracts havebeen taken from the handbook for professionals.

By 24 weeks of pregnancy, your baby canhear music and voices. Your baby does notlike loud noises and will tell you so by kickingand moving. Your baby will move its body inrhythm to your talking. When your baby isborn, it is calmed by the sound of your voiceand other familiar voices. Newborn babies

can pick up their mothers and fathers voice within an hour of birth.Tapes of a human heartbeat were played into a nursery with newbornbabies. Those babies who heard the tape did better than those who

did not hear the tape (they ate more, weighed more, slept more,breathed better and cried less).

Touching and rubbing your tummy will helpyour baby develop good physical skills andfeel relaxed. It will also help you feelrelaxed. Sing the Action Song. Thisincorporates many of the ways you canhelp your baby before they are born - it

involves singing, listening to music,touch and movement.

Figure 3 Evaluation

Question ResponseHas the pack been easy to use?-Yes 30 (100%)-No 0

Has the pack been easy to understand?- Yes 30 (100%)- No 0

In what setting have you used the cards?- at home (one-to-one) 25 (83%)- parent craft (antenatal group) 5 (17%)

Who have you used the cards with?- regular caseload 12 (40%)- complex caseload 18 (60%)

How did you use the cards?- out of sequence 0- sequentially 30 (100%)

Has the pack aided you in the delivery of information?- Yes 30 (100%)- No 0

Do you feel the client has benefited?- Yes 28 (93%)- No 2 (7%)

Question ResponseIs this your first baby?- Yes 21 (70%)- No 9 (30%)

Did you learn anything new?- Yes 30 (100%)- No 0

Did you try out any of the activities?- Yes 28 (93%)- No 2 (2%)

Has the information helped your baby?- Yes 27 (90%)- No 0- Dont know 3 (10%)

Question Did you learn anything new?I was aware in pregnancy that when I spoke my baby moved - thatmeans he or she knows me.

I had a mobile phone for Christmas and I kept the tune on thatcalmed my babys movements.

I talk all the time to my baby since you said it can hear me. I reallyfeel as though I know her or him already, it knows me.

After I went home (from hospital) and spoke, my baby turnedtowards me. I felt really important and loved, special.

Question Has the information helped your baby?My baby looks right at me when I speak.

I always look at my baby when I speak.

I have found ways of calming my baby just by singing and touching -my mam says I will spoil him but I dont listen.

One women with clinical depression commented: I felt very involved and important to my baby when I was pregnant.It made me feel good.

Figure 2 Pack two: Learning as a babyThis pack consists of five double-sided picture cards. The informationemphasises the importance of the birth environment and the needfor the baby to be held and to hear a familiar voice. The contentcontinues to focus on the ways parents / carers can communicatewith their baby through touch and sound in the very early days.This has a positive impact on the baby and also the parents, andmay help to increase attachment and parental coping strategies.

The first hour with your baby after theyare born is especially important. Itshould be quiet with no distractions,avoiding bright lights. You should be ascomfortable and relaxed as possible.Both mother and baby need time torecover. Relatives may need to be toldto wait a while before they see you and

the new baby. You and one other close person to you should bealone with the baby for at least the first hour. Skin-to-skin contactis especially important. A baby that is laid on their motherstummy will automatically inch their way towards the breast.

All babies are different. They have differenttemperaments and levels of alertness andrespond to change in different ways. By 72hours, newborns can detect the differencebetween happy and sad expressions. Yourbaby will respond in the same way - if theysee a happy face they will feel happy.

FEEDBACK FROM MIDWIVES

FEEDBACK FROM MOTHERS

COMMENTS FROM MOTHERS



EARLY INTERVENTION

The pack has also been informally piloted in a local antenatal group in a com-

munity flat. The group was set up to deal with the level of non-attendance (50

per cent) at the local antenatal clinic and parent craft groups. The pack was

presented alongside creative activities such as making nursery rhyme books,

crib pictures and mobiles. The use of the pack alongside practical ideas pro-

vided a forum for discussion and the involvement of other family members. At

a recent group a sibling who had made a nursery rhyme book told her father,

If I sing to the baby, when its born it will know who I am. The parents and chil-

dren enjoy making resources for the baby and report that they find it relaxing.

There is now mainly full attendance at these groups.During pregnancy, parents are keen and enthusiastic to learn about ways to

help their baby. If they learn to communicate with their baby at this early

stage it sets up good patterns once the baby is born and helps to form posi-

tive attachments. Research suggests that early stimulation before the child is

born can enhance the babys brain development, physical development and

growth, hearing and communication skills (Hodzic, 2002; Verny, 1981). By singing

lullabies, as well as through simple interactive games, parents can establish strong

prenatal bonding by conveying emotions like love (Hodzic, 2002).

We hope that this pack will provide an accessible, useful tool for midwives

and other professionals to use with mothers-to-be, new mothers and families

to support the dissemination of information.

Your Bump and Beyond was developed by Sasha Bemrose MSc, BSc (Hons),

ACS, MRCSLT, MHPC, a specialist speech and language therapist employed by

Surestart Rhondda Cynon Taff, Wales and Lynn Lynch MSc, BSc (Hons), RM, RN,FETCH a consultant midwife with North Glamorgan NHS Trust. Huw Evans was

the cartoonist. It has been presented at the European Regional Conference

Nurses Federation in Malta, at the Royal College of Midwives Conference in

Cardiff and also at the Surestart Conference in Warwick.

Resources Your Bump and Beyond Antenatal Packs available from Childrens

Information Service, Ty Trevithick, Abercynon, Mountain Ash, CF45 4UQ, tel.

0800 180 4151. Cost 30 (with 3 p&p).

SEAL - Society for Effective Affective Learning - www.seal.org.uk, tel. 020

83653869.

ReferencesBrazelton, T.B. (1992) Touch Points: Your childs emotional and behavioural

development. Reading Mass: Addison-Wesley.Department for Education and Skills (2001) Surestart - Promoting Speech and

Language Development - Guidance for Surestart Programmes. DfES

Publications.

Department of Health (2001) The confidential enquiries into maternal deaths

in the UK: Why mothers die (1997-1999). The Department of Health, Social

Services and Public Safety: Northern.

Hodzic, P.K. (2002) Prenatal Learning - The Blossoming Brain. Notes from SEAL

conference Sewing the seeds of learning - July, Derby.

Merthyr Tydfil County Borough Council (1998) Merthyr Tydfil Peoples in

Community Document.

Rhondda Cynon Taff Surestart Plan (2000-2002) All children deserve a

Surestart.

Van de Carr, R. & Lehrer, M. (1997) While you are expecting. Your own prena-

tal classroom. Humanics Trade: Atlanta.

Verny, T. (1981) The Secret Life of the Unborn Child. Dell Publishing: New

York.

Ward, S. (2000) Babytalk. The Pioneering book that will change childcare for-

ever. Century Publications.

Welsh Assembly Government (2001) Improving the Health of Wales. NHS

Wales, January.

DO I ATTACH SUFFICIENT IMPORTANCE TO CLINICAL NETWORKING?

DO I ENSURE CLIENTS AND CARERS FEEL INVOLVED, IMPORTANT

AND CONFIDENT?

DO I PROVIDE THERAPY AND MATERIALS THAT ARE EVIDENCE BASED?

resourcesAbout Cerebral PalsyScope has launched a free updat-ing service for anyone interestedin cerebral palsy.About Cerebral Palsy will appear

at least three times a year, andinclude features, interesting web-sites and information on newresearch and literature. It is avail-able electronically as a pdf, or as ahard copy.See www.scope.org.uk/publications/aboutcp.shtml or contact theScope Library and InformationUnit on 0207 619 7342

Talking PointThe Talking Point website continuesto expand, with the addition ofmaterial on writing individualeducation plans, secondary education,

supporting children with speech,language and communicationdifficulties, and evaluation of atraining programme for early yearssettings. Regular Ask the panelevents including Managing socialdevelopment and behaviour inchildren and young people withspeech, language and communicationneeds are also proving popular.www.talkingpoint.org.uk aims to bethe first stop online for informationon speech, language andcommunication difficulties in children

Stroke and AphasiaAs well as providing easy tounderstand, comprehensiveinformation, the new Stroke andAphasia Handbook is intended as atool to support people with aphasiain asking questions, having discussionsand conversations, and makingchoices and decisions.23.50 inc. p&p (not-for-profit)from Connect tel. 020 7367 0840,e-mail [email protected]

What about faith?The Foundation for People withLearning Disabilities has produceda good practice guide for services

on meeting the religious needs ofpeople with learning disabilities.The guide provides practical adviceon how services can support adultsin their religious expression, andexplains why it is important totake the religious needs of peoplewith learning disabilities seriously.The Foundations related publica-tions include Why are we here?,What is important to you?, No Boxto Tick and Religious Expression, aFundamental Human RightWhat about faith? is 45, from theFoundation for People with LearningDisabilities, tel. 020 7802 0304 or see

www.learningdisabilities.org.uk

Choice in healthcareA six-monthly directory and web-site aims to provide independentinformation to people who wantto make more choices about where

they receive their NHS treatment.nhs Family Choice is published byCyworks,

see www.nhsfamilychoice.com

Face FormerDistributors of Face Former, afunctional muscle training deviceand programme developed by aGerman speech and languagetherapist in 1998, are hoping toexpand its appeal to the UK andIreland.34.99 with volume discounts fromwww.faceformer.co.uk

Prenatal auditorystimulationA product providing prenatalauditory stimulation has beenrelaunched in the UK.BabyPlus is a small digital audiounit worn on a belt around theabdomen when a mother ispregnant. It plays sequences ofsounds with the aim of stimulatingthe babys developing brain.145 inc. UK delivery, seewww.baby-plus.co.uk,tel. 01869 253552

Hearing aid toolkitDefeating Deafness has produceda toolkit which tells people whatto expect when getting hearingaids, how to make the most ofaudiologist visits and where thelatest technology is headed.www.defeatingdeafness.org

Diagnosis supportpackA Contact a Family pack aims toprovide health professionals withpractical suggestions on howbest to communicateinformation and offer support

to parents at or around the timeof a diagnosis.The Support Pack for HealthProfessionals - Working withfamilies affected by a disability orhealth condition from pregnancyto preschool downloadable fromwww.cafamily.org.uk/packs.html

Voice softwareVocal Processs Jeremy Fisher hascompiled a list of voice analysissoftware that can be used toproduce spectrograms, someavailable as freeware orshareware.

See www.vocalprocess.net



AphasiaEames, S., McKenna, K., Worrall,

L. & Read, S. (2003) The suitability

of written education materials

for stroke survivors and their

carers. Topics Stroke Rehabil10

(3): 70-83.

This study evaluated the suitability of

written materials for stroke survivors

and their carers. Twenty stroke

survivors and 14 carers were

interviewed about the stroke

information they had received and

their perceptions of the content and

presentation of materials of

increasing reading difficulty. The

mean readability level of materials

(grade 9) was higher than

participants mean reading ability

(grade 7-8). Satisfaction withmaterials decreased as the content

became more difficult to read.

Seventy-five percent reported that

their information needs were not

met in hospital. More stroke survivors

with aphasia wanted support from

health professionals to read and

understand written information, and

identified simple language, large

font size, colour, and diagrams to

complement the text as being

important features of written

materials. Simple materials that meet

clients information needs and designpreferences may optimally inform

them about stroke.

Normative dataLahar, C.J., Tun, P.A. & Wingfield,

A. (2004) Sentence-final word

completion norms for young,

middle-aged, and older adults.J

Gerontol B Psychol Sci Soc Sci59

(1): 7-10.

This report describes sentence-final

word completion norms for 119

sentence contexts based on the

original sentence completion norms

of Bloom and Fischler (1980). Four

sets of norms are made available for

358 adults, representing young,

middle-aged, young-old, and old-old

samples. Notable in these norms is a

high degree of consistency in

responses among all four age

samples. Differences in relation to

the original Bloom and Fischler

norms appear in responses to low

contextually constraining sentences.

Results show that the recency with

which normative data are collected is

an important variable to consider

when making use of norms.

LanguagedisorderLarson, V.L. & McKinley, N.L.

(2003) Service delivery options

for secondary students withlanguage disorders. Semin

Speech Lang24 (3): 181-98.

Numerous adolescents are still

undetected, unserved, and

underserved by speech-language

pathologists, resulting in astronomical

financial and psychological costs to

them and society. The purpose of this

article is to provide an overview of

past and present service delivery

options for adolescents with language

disorders. Before illustrating the

authors recommended model, the

following background is provided: an

overview of the three stages of

adolescent development,

characteristic expectations and

problems for older students with

language disorders, and a rationale

for adolescent speech-language

services. The comprehensive service

delivery model for secondary-level

speech-language

Speech & Language Therapy in Practice, Autumn 2004

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