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PEER SUPPORT
ISSN 136
Winter 2005
www.speechmag.com
RecruitmentWork experience placements
Intensive groupsComplex preschoolers
Developing criticalappraisal skillsExpert guidance
How I provide a servicefor young people with Asperger syndrome
PLUS.The Authenticity keyHeres one I made earlierMy Top Resources lifelong learningand featuring Peer support
The case forflying KITEs(Kids communication
Impairment: TherapyEffectiveness
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WIN NAUGHTY BUS
In need of inspiration? Doing a literaturereview? Looking to update your practice? Orsimply wanting to locate an article you readrecently?Our cumulative index facility is there to help.
The speechmag website enables you to:View the contents pages of the last four
issuesSearch the cumulative index for abstracts of
previous articles by author name andsubject
Order copies of up to 5 back articles online.
Are you looking for a story book that has high quality photographic pictures easily
recognisable to young children? Then climb on board the Naughty Bus! Reviewing
it in our Autumn 05 issue, Sue Ward said she would definitely use the book with
children attending language groups in the clinic and
would particularly recommend it for teachers / parents
of children at the Foundation stage.
Naughty Bus normally costs 9.99, but Little
Knowall Publishing is giving copies away to TWO lucky
readers. To enter this free prize draw, e-mail your
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send to Jan Oke, Little Knowall Publishing, 9,
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Your entries must be received by 25th January
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Naughty Bus is by Jan & Jerry Oke and pub-
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Reader offers
The lucky winners of Sherstons LDA Language Cards Interactive are Penny Laflin, Angela Abell, Vanessa Harvey, Clare Att
Julianne Bolton, Elizabeth Gadsen, Karen Shuttleworth and Alison Taylor. Congratulations to you all. Keep those entries coming!
We now have a FREEe-update service for
readers of Speech & Language Therapy in Practicewho just cant wait for the next issue to arrive! Tosubscribe, e-mail [email protected] details will not be passed to any third party.
E-UPDATE SERVICE
If you want to find out more about some of thetopics in this magazine, you may be interestedin the following articles from earlier issues. Ifyou dont have access to them, check out the
abstracts on www.speechmag.com and takeadvantage of our article ordering service.
Preschool autistic spectrum disorder(not yet indexed) Cowan, H. (2004) A holistic approach
from the outset. Summer: 12-13.
Peer initiatives(162) Harris, C. (2001)Ahead-and-neck of the field. Autumn: 12-13.
(156) Patrick, J. & Atherden, M. (2001) Patient, persistent and
positive: a journey with chronic fatigue. Summer: 20-23.
Community based services for older children(067) Paulger, B. (1999) Therapy for real life. Summer: 12-14.
Reprinted in full at: www.speechmag.com/archives/barbara-
paulger.html.
Evidence based service change(032) Gibbard, D. (1998) Parent-based approaches the case
for language goals. Summer: 11-13. Reprinted in full at:
www.speechmag.com/archives/debgibbard.html.
AND (040) Gibbard, D. (1998) From research to service
development. Autumn: 16-17.
Personal development(170) Dobson, S. (2001) When effectiveness is hard to prove.
Winter: 4-7.
Winter05speechmag
www.speechmag.com Pay us a visit soon.
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INSIDE COVERWINTER 05 SPEECHMAG, READER OFFERSWin Naughty Bus and Blob Tree posters.
2 NEWS / COMMENT
4 RECRUITMENTALL IN A DAYS WORKour department decided to take on five Year 10
pupils for work experience, largely in response to the
number of requests we were receiving and in an effort
to do our bit for would-be therapists. The pupils came
for five to seven days during the blocks allocated by
their schools. All were local girls who had expressed an
interest in speech and language therapy as a career.
Clare Grennan and Jane Rogers explain why work
experience placement schemes could be good news for
recruitment and retention.
7 INTENSIVE GROUPSA COMPLEMENTARY SERVICEAlthough good practice had been adhered to, a
number of the professionals involved increasingly
recognised that some childrens progress in terms of
interaction and communication skills had been
disappointing due to insufficient frequency and intensity
of specialist input.
Ann Wiseman and Sharon Horswell find multi-
agency intensive groups can improve outcomes for
preschool children with complex communication and
autistic spectrum disorders.
10 HERES ONE I MADE EARLIERAlison Roberts with more low cost therapy activities:
Formal and Casual Board, Breathing Strings, Also for
11 EXPERT GUIDANCEDEVELOPING CRITICAL APPRAISAL SKILLSCritical appraisal is a bit like being a detective scouring
for evidence. You seek not just a fragment here or there
but a full skeleton in order to close your case.
Frances Harris explains how to use clinical judgement
to consider the relative validity and importance of
evidence presented in professional papers.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005 1
18 REVIEWSLiteracy, assessment, ColorCards, dysphagia, inclusion,
guidelines.
20 KEYS TO WINNING WAYS SERIES (5)THE AUTHENTICITY KEYThe way we behave is frequently not you at all, but
what you think you should be. Our conditioning is what
keeps us stuck in old, useless behaviour patterns.
In the fifth of our series to encourage reflection and
personal growth, life coach Jo Middlemiss asks what is
real and what is pretend and if looking at life in a
different way will free you up to be yourself?
22 FEATUREPEER SUPPORTTo keep the focus and ensure each section is coveredadequately, a group member takes the role of time keeper,
and another the role of process manager. One group
member, the presenter, tells their story and explains what
help they want. The steps of the process ensure that
everyone is clear about their role at a given time and that
everyone gets a chance to talk.
Hearing about other systems of peer support has
convinced Avril Nicoll that it will be possible to introduce
peer review to Speech & Language Therapy in Practice
in an open and constructive way.
24 NEW! RECOMMENDED READINGAphasia / AAC
25 HOW I PROVIDE A SERVICE FORYOUNG PEOPLE WITH ASPERGERSYNDROMETwo examples of how imaginative and thorough
planning and a focus on clients needs can change the
lives of young people with Asperger syndrome and their
families:
(1) LETS GET ONFaced with increasing referrals of older children in
mainstream school with social communication
difficulties, Caroline Baber, Ann Clemence,
Karen Ford and Ruth Watson developed
tailored groups as a new package of care.
(2) ASPERATIONS 4 UJane Bakers vision of a community-
based, parent-run, specialist facility for
young people with Asperger syndrome is
now a reality.
BACK COVER MY TOP RESOURCESI met my very special Critical Friend when I first
started work, and she is my most essential resource. I
am fortunate in that both our professional and personal
relationship has developed and matured over the years.
Tracey Righton draws together her resources for
lifelong learning.
WINTER 2005
(publication date 28/11/05)
ISSN 1368-2105
Published by:Avril Nicoll33 Kinnear SquareLaurencekirkAB30 1ULTel/fax 01561 377415e-mail:[email protected]
Design & Production:Fiona ReidFiona Reid DesignStraitbraes Farm
St. CyrusMontrose
Website design and maintenance:Nick BowlesWebcraft UK Ltdwww.webcraft.co.uk
Printing:Manor Creative7 & 8, Edison RoadEastbourneEast SussexBN23 6PT
Editor:Avril Nicoll RegMRCSLT
Subscriptions and advertising:Tel / fax 01561 377415
Avril Nicoll 2005Contents of Speech & LanguageTherapy in Practice reflect the viewsof the individual authors and notnecessarily the views of the publish-er. Publication of advertisements isnot an endorsement of the advertis-er or product or service offered.
Any contributions may also appearon the magazines internet site.
www.speechmag.com
IN FUTISSU
DYSPHAAPHA
ADULT LEARNDISAB
LEARNING STY
PROJMANAGEM
Cover photo by Paul Reid. (See page
14) Posed by models Sally and Ailsa.
14 COVER STORY:EVIDENCE BASED PRACTICETHE CASE FOR FLYING KITES
The difference is clear children in treatment
made much more progress overall than thosereceiving no treatment.
Jan Broomfield on the results of the KITE
(Kids communication Impairment: Therapy
Effectiveness) randomised controlled trial
and what it means for speech and language
therapy services.
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Award for SpeakeasyThe Speakeasy charity, which offers long-term support and therapeutic activities for peo-
ple who have aphasia and their carers has been rewarded for its innovative team work.
The Lancashire group received the PCT award for its work under the leadership of
speech and language therapist Gill Pearl. Speakeasy was established over 25 years ago
by speech and language therapist Stephanie Holland but until recently struggled to sur-
vive. However, with financial backing from Bury PCT, the organisation now has a clear
focus and a small team which includes two people with aphasia.
Gill Pearl has also been recognised with a Leading Practice Through Research award
from The Health Foundation to investigate how
people with aphasia can become more involved in
planning service delivery.
www.buryspeakeasy.org.uk
www.health.org.uk
Speakeasy staff Sarah McClusky, speech and language
therapist, Liz Royle, expert patient, and Gill Pearl, clinical
director with Evan Boucher, chief executive of Bury PCT.
White paper promisespersonalised learningThe governments education white paper for England has provoked debate in the national
media with its promises of greater freedom for schools and more power for parents.
Higher Standards, Better Schools For Allemphasises the importance of personalised
learning to meet individual need, as well as driving up whole school performance.
There will be more grouping and setting by subject ability and schools will have toshow in their annual self-evaluation how all their pupils are achieving, including chil-
dren with SEN and disabilities. The government says it is setting up a national training
programme so that each school will have one lead professional to help with the devel-
opment of tailored lessons. Tailoring of education will include promoting more effec-
tive measurement and accountability for the progress made by pupils with SEN across a
wide range of abilities, facilitating early intervention and high expectations.
The paper also stresses the value of groups of schools pooling resources and sharing
good practice, and drawing on the links that Childrens Trusts have with other agencies.
It suggests that special schools could co-locate more with mainstream schools and
strengthen their role at the heart of the system by working closely with one or more
mainstream schools, offering pupils a pattern of provision tailored to their needs and
breaking down unhelpful barriers. Fifty more SEN specialism specialist schools will be
rolled out and evaluated over the next two years.
Higher Standards, Better Schools For All ( Crown Copyright, 2005) is at
www.dfes.gov.uk/publications/schoolswhitepaper/.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20052
NEWS
Standards for CPDThe Health Professions Council has approved the standards of continuing professional development that
will become a legal requirement for registration.
Information on how to record and submit evidence against the standards will be published in April 2006,
and auditing for speech and language therapists in clinical practice, research, management and education
will begin in 2009. The evidence will have to demonstrate how continuing professional development has
contributed to the quality of the individuals practice and benefited the service user.
Health Professions Council President Norma Brook emphasised the flexibility of its approach, saying the Council
will offer a clear framework but continuing professional development will be the responsibility of the individual.
www.hpc-uk.org
This car sticker, suggested by a dietitian, has been produced as part of the Health Professions Councils
advertising campaign to encourage members of the public to check that their health professionals are
registered with the Health Professions Council. If you would like one, e-mail
[email protected] or tel. 0207 840 9806.
Diamonds ofthe professionStammering specialist Daniel Hunter is the first winner of the
national Speech and Language Therapist of the Year award.
Daniel, who stammers himself, now has plans to join the British Stammering
Associations preschool dysfluency campaign as a trainer. He says, Ive devel-
oped a model of working with under five-year-olds who stammer thatinvolves risk profiling. The early indications are that the risk profile is able to
tell us which children are at risk of persisting with stammering. This will
hopefully lead to earlier intervention which we know to be very effective.
The pivotal role played by the professions support workers was also
recognised with an award for Speech and Language Therapy
Assistant of the Year. Like Daniel, Barbara Laverty has received a
1000 cheque from award sponsors Fresenius Kabi.
Her colleagues said, Barbara is well know to all primary pupils at the
school through her music-based speech and language therapy groups
she expertly interweaves each pupils speech and language targets into
the session and motivates every participant to achieve their full potential.
The national competition was initiated by the Royal College of
Speech & Language Therapists to mark its Diamond Jubilee and may
become an annual event. Appropriately, nominations were submit-
ted via a range of communication methods e-mails, letters, videos,audiotapes and signs and symbols.
www.rcslt.org
Ageing warningHelp the Ageds trust for biomedical research
has welcomed a House of Lords select commit-
tee report which asks the government to do
more to fund scientific research that can help
older people.
Although disappointed that the report did not rec-
ommend setting up a National Institute of Ageing,
Dr Lorna Layward of Research into Ageing said it
goes a long way towards fulfilling the recom-
mendations we provided. She went on to warn
that small investments by key government
departments leave the UK scandalously unpre-
pared for the baby boomer generation who are
about to enter their later lives in vast numbers.
This year Research into Ageing is concentrating
on stroke, dementia and incontinence.
Ageing: Scientific Aspects, see www.parlia-
ment.uk/parliamentary_committees/lords_s_t_
select/stiageing.cfm
http://research.helptheaged.org.uk/_research/
l-r Daniel Hunter,Barbara Laverty, Chris
Harrison (ManagingDirector of sponsors
Fresenius Kabi)
GeoffWilson
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HS Trusts invest a lot of money and time
in staff recruitment and retention (NHS
Careers, 2004). They know they must
continue to do so, not only in the short-
term, but also to ensure a ready pool of
employees for the future. This is particularlyessential as the health service takes on the mod-
ernisation programme to which it is committed
(NHS Careers, 2004). Increasingly, trusts are look-
ing for new and imaginative approaches to
recruitment (NHS Careers, 2004), and we see
offering well-organised work experience place-
ments as one way we can contribute.
In addition to the departments regular com-
mitment to taking undergraduate students, we
have previously provided ad hoc observation ses-
sions to prospective students. During the summer
term 2004, our department decided to take on
five Year 10 pupils for work experience, largely in
response to the number of requests we were
receiving and in an effort to do our bit for
would-be therapists. The pupils came for five to
seven days during the blocks allocated by their
schools. All were local girls who had expressed an
interest in speech and language therapy as a
career.
In preparation, we put together some guide-
lines:
who we take
procedures
an induction pack (figure 1)
information for staff (what pupils can do, support
available).
Pupils also had to sign a confidentiality agree-
ment and receive occupational health clearance. As
the pupils were all due to start around the same
time, we held a pre-placement meeting to go
through the induction pack as a group and answer
any questions. Pupils had also been - or were plan-
ning to go - to a careers talk within the department.
The guidelines involved a lot of work and adap-tation as a result of ongoing reflection and feed-
back. We accessed additional support and advice
from Trust practice placement managers, the West
Midlands regional clinical placements co-ordina-
tors group and our speech and language therapy
service manager. We referred to Trust guidelines
as well as to information from the NHS Careers
service. As organisers, we were also prepared to
provide additional support to enable any pupil
with a disability to participate.
Mixed programmeEach pupil had a mixed programme with staff
from a range of teams across the department
(hearing impairment, mainstream, pre-school,
adults, general office). Admin and clerical staff
(1), speech and language therapy assistants (4)
and speech and language therapists (18, including
newly qualified) were involved in the supervision
of work experience pupils. Because of the nature
of what we do, pupils were mostly going to be
observing us. However, the schools were keen for
the pupils to get some experience of working.
We were also concerned that pupils may tire of
simply observing, so we put together a list of
potential jobs that pupils could do as a guideline
for supervising staff:
assisting staff during assessment / treatment
sessions
preparing therapy materials
making up files / filing
cleaning / tidying toys or other equipment
sending out appointments
photocopying
making tea.The learning objectives for the pupils were to:
1. find out about the role of the person you are with
2. learn about communication disorders
3. participate in therapy sessions where appropriate
4. assist with preparation of therapy materials
5. assist with administrative tasks.
Following the work experience programme, we
asked supervising staff and pupils to complete
feedback forms.
We asked staff to rate / comment on the organ-
isation of the placement / support available to
them, what they found particularly useful, and
what they would recommend changing. We also
asked them how the placement contributed to
their own learning and development, and gave
them the opportunity to add any other com-
ments. The return rate was poor (7/18 therapists)
but we did get a spread of grades (1, 2, team
manager) and teams (mainstream, pre-school,
hearing impairment, adults), and the responses
included some constructive ideas.
Organisation / support was rated as: Excellent
3/7 Good 2/7 Fair 2/7. In addition, 6/7 found the
pre-placement information pack useful.
One therapist in mainstream said that, due to
school activities and teachers stress levels during
the final weeks of term, this is not the best place-
ment for a whole day. Another commented that
nurseries were a nice way for the pupils to see
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20054
RECRUITMENT
Is the targeted offer of workexperience placements a usefulweapon in the professionsrecruitment and retention battle
or just another task for over-stretched therapists? ClareGrennan and Jane Rogersreport on a new scheme inDudley and explain why theywill be doing it again.
READ THISIF YOU ARE LOOKING TO ACCOMMODATE WORK EXPERIENCE
REQUESTS
IMPROVE RECRUITMENT
ENHANCE YOUR CONTINUING
PROFESSIONAL DEVELOPMENT
N
All in a days work..
Claire (left) and Jane (right) are pictured with the 2005 group of work experience pupils
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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005 5
RECRUITMENT
Figure 1 Induction pack contents
1. Health check form2. Honorary contract3. Placement programme4. Badge5. Confidentiality form6. In emergency form7. Service profile and structure8. Places of work9. Hours of work on placement10. Travel and breaks11. Health and safety / Infection control12. Dress code13. Learning objectives
14. Speech and language therapy careerworkshop form
15. Liaison with school / trainingestablishment
16. Certificate of attendance and summaryreport
17. Feedback questionnaire18. Useful websites
Figure 2 Observation sheet
Childs Name:Childs Age:
Therapists Name:
Students Name:
1. What was the therapist working on during the session?
2. What sorts of strategies did he/she use? (think about what she is saying; what toys /materials are being used)
3. Do you think that the goals for the session were achieved? Why?
4. What factors do you think influenced the childs ability to learn the new skill?
5. How did the therapist involve other people in the session (eg. parents, teacher, assistant)?
6. How did the therapist encourage the child to work on targets in other settings (eg home,school / nursery)?
7. Do you have any comments, questions or suggestions about the session?
that we dont just work in clinics, but added that
it was difficult to involve them in everything that
was going on.
One therapist queried whether the pupils had
had any information about speech and language
therapy before they came, as they were oftenquiet and didnt have lots of questions.
Recognising that this may have been a reflection
of their age and experience, she put together an
observation sheet (figure 2) for the pupils to fill
in. As well as giving the pupils something to do, it
provided a focus for discussion. This form has
since been circulated to all staff.
The same therapist wanted more information
about what should be expected
from the pupils, or what they
could do for example, could she
take them into meetings? She
found the observation sheet use-
ful for getting them thinking
about what we do and why, but
also felt more individual informa-
tion about the student and what
related subjects they were doing
at school would have helped.
In terms of professional devel-
opment, grade one therapists
commented that the process aided reflection and
teaching, and that it was good to see how much
they knew and to experience having someone sit-
ting in on the session. One therapist said it pro-
vided her with an insight into what it would be
like to have a student, and the team manager also
commented that, as she hadnt had any kind of
student for some time, the experience made her
stop and think. She then went on to have a sec-
ond year speech and language therapy under-
graduate student in the autumn term.
In addition, a therapist working in hearing
impairment with children and young adults com-
mented that it helped promote deaf awareness,and reminded her of the level of communication
that her clients have to cope with in the real
world with unfamiliar people.
Gained confidenceThe assistants and admin and clerical staff mem-
ber involved didnt return their feedback forms,
as they had been unsure what to put, but were
happy to discuss their thoughts (3/4;
1/1). Interestingly, only one felt the
process contributed to her own person-
al development, in this case because
she gained confidence in being
observed and answering questions
relating to the activities, as well as get-
ting someone else involved. This was
particularly important as she was about
to have classroom assistants observing
some of her sessions.
Like the therapists, they were happy
to help with pupils development. They
also felt it was good for the pupils to see the
wider workings of the department. Two remarked
that some pupils were more enthusiastic than oth-
ers, and one commented that the majority didnt
know what grades they needed to do the degree.
Other comments included one therapist stating
she had come to Dudley as a schoolgirl to observe
and was happy to be able to do the same for
somebody else. Another specifically said she was
happy to do it again. The general feeling from
the assistants / clerical staff however was that
the pupils came and went.
The questionnaire response rate from the
pupils was good (4/5), and gave us an insight intowhat they got out of the experience, and whether
our efforts were potentially positive for staff
recruitment. Pupils were asked to rate / comment
on the organisation and support from supervising
staff, the variety of experience offered, what they
found particularly useful / not useful, and
whether the placement met their learning goals.
Three pupils rated the placement organisation
as excellent, and one rated it as good. The co-
ordinators were thanked for their organisation of
the placements and the friendliness and helpful-
ness of supervising staff was commented on. The
induction meeting was reported to be particular-
ly useful.
All four pupils rated the variety of experience
as excellent. Positive comments were made,
including that every day was different, and that it
was thoroughly enjoyable to see all aspects of the
speech and language therapists role. As well as
the variety, pupils commented positively on being
able to observe the interaction between the ther-
apist and other professionals such as physiothera-
pists. One added that she had particularly enjoyed
the childrens clinic. All four pupils stated there
was nothing they did not find particularly useful.
Importantly, all four also said that the place-
ment met their learning goals and three of them
added that it had confirmed their interest in
speech and language therapy as a career.
grade onetherapistscommented
that theprocess aidedreflection andteaching
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REFLECTIONS DO I HELP PROJECT LEADERS BY GIVING CONSTRUCTIVE FEEDBACK?
DO I ACTIVELY ENCOURAGE OTHERS TO JOIN THE PROFESSION?
DO I RECOGNISE PROFESSIONAL DEVELOPMENT OPPORTUNITIES WHEN THEY ARISE?
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20056
RECRUITMENT
To assist our decision-making about future
work experience placements, we carried out a
subsequent survey in December 2004. We asked
all clinical staff (therapists and assistants):
whether they had work experience in speech
and language therapy before applying for theircourse (degree / NNEB etc.)
if yes, whether they found it useful
whether they had the work experience with
Dudley speech and language therapy department
if they hadnt had work experience, whether
they would have found it useful.
Twenty nine out of 40 therapists responded (28
answered correctly) and seven out of eight assis-
tants responded (6 answered correctly, 1 said not
applicable).
Sixteen therapists had had work experience in
speech and language therapy, three of them in
Dudley. A further ten had observation sessions as
opposed to work experience, three of them in
Dudley. Two therapists had not had work experi-
ence in speech and language therapy.
Of the 16 that had had work experience, 15
found it useful. The other therapist said it was not
very well explained (she had not come to Dudley!)
Positive comments included:
it made me pursue speech and language therapy
rather than my other work experience career
it helped in preparation for interview (for the
university place)
far more real than written descriptions of role,
and opportunity to ask lots of questions to confirm
career choice
gave an insight into career
choice and the client groupswe work with.
Of the 10 that had had
observation sessions, 9 found
them useful. One said that
more sessions would have
been helpful, and another
that she had observed just one
day in a clinic with lots of did
not attends. She felt that when she was applying
for courses, more than one days observation was
expected of her.
The two therapists who had not had any work
experience thought they would have found it useful.
Six assistants stated they had not had any work
experience in speech and language therapy
before doing their training. One had worked
closely with the therapists in the school where she
had been working, which she found useful. The
other five all said they would have found work
experience useful.
GroundworkThe work experience placement programme was a
learning curve with lots of hard work, but we think
the feedback was tremendously positive both staff
side and pupil side. A lot of the groundwork has
been done and we now have a comprehensive set
of guidelines. We are going to repeat it this sum-
mer and there will be ongoing reflection and
adaptation as appropriate. We will be sticking
with around five pupils as we found it a good
number to manage.
Due to the numbers of people involved (staff and
pupils) and the amount of paperwork, we think
organisation and enthusiasm is the key to success.
We found the work experience
flow chart particularly useful
(figure 3) and have since devel-oped an accompanying tick list,
to help keep on track of what
needs to be done.
Since this work experience
programme was initiated, we
have spoken to the service
manager, the area service man-
agers, the team managers and
principal speech and language therapists about
linking clinical teaching more formally into the
appraisal process. We have suggested that staff are
actively encouraged in their appraisal to take work
experience students, in addition to attending a
clinical teaching workshop at the local university.
The rationale behind this is to give therapists prac-
tical experience and confidence in accommodating
students. We feel that that the positive comments
regarding professional development made from
the sample of therapists surveyed reinforces this
and we hope that it will aid the undergraduate stu-
dent placement allocation process.
Through liaising with colleagues in other trusts
at the West Midlands regional clinical co-ordina-
tors group, we are aware that many departments
do not take work experience pupils. We therefore
intend to promote what we have done to other
speech and language therapists and professional
groups. We have already fed-back to our depart-
mental district meeting and to the West Midlands
regional clinical co-ordinators group, where wepromoted it as a continuing professional develop-
ment opportunity as well as being positive for
recruitment.
Clare Grennan and Jane Rogers are highly specialist
speech and language therapists / student co-ordinators
with Dudley South Primary Care Trust. For further
information, contact Clare on 01384 456111 ext
4565, e-mail [email protected], or Jane
on 01384 366400, e-mail [email protected]
ReferenceNHS Careers (2004) Work Experience. Building the
future of the team. Guidelines for managers.
March. (Only available to NHS employees online,
tel. NHS Careers on 0845 60 60 655 for details.)
Further resources Royal College of Speech & Language Therapists,
see www.rcslt.org
NHS Careers, www.nhscareers.nhs.uk.
pupils commentedpositively on beingable to observe theinteraction betweenthe therapist andother professionals
Figure 3 Work experience flow chart
enquiry received and checked for suitability by co-ordinators
send welcome letter and health questionnaire
health clearance received from Occupational Health
send honorary contract (two copies)
induction pack
timetable and locations (copy to speech and language therapy offices)
emergency contact numbers (reciprocal)
on placement - ID badge provided; advised on health and safety in each setting
supervised work experience / observation
liaison with school / establishment as appropriate
feedback forms completed by staff in each setting and returned to co-ordinators
exit telephone call from co-ordinator to student
ID badge returned
feedback form completed by student (handed in or sent later)
Certificate & Summary Report sent to student (copy to school / establishment)
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INTENSIVE GROUPS
There is a long established
tradition of collaborative
working between the
preschool advisory service,
Portage service, speech and
language therapy service
and other health profession-
als in Torbay. In recent years
children with a complex com-
munication disorder have
been referred to one or more
of the services, and weekly
Portage visits for some fami-lies and advice to families /
carers and preschools have been offered. Regular
individual education plan meetings have been
coordinated to ensure consistency of approach and
targets across the different environments. In addi-
tion, all parents / carers whose child has received a
diagnosis of an autistic spectrum disorder have
been offered the opportunity to attend the
National Autistic Societys EarlyBird course run by
the speech and language therapy service.
Although good practice had been adhered to, a
number of the professionals involved increasingly
recognised that some childrens progress in terms
of interaction and communication skills had been
disappointing due to insufficient frequency and
intensity of specialist input. In addition some staff
had been introduced to the Picture Exchange
Communication System (PECS) and realised
that, to implement this effectively, enhanced pro-
vision was necessary.
Ann therefore sought and obtained funding
from the Torbay Early Years Development and
Childcare Partnership to pilot an intensive com-
munication group to be run on a twice weekly
basis, staffed by a preschool advisory teacher, a
speech and language therapist and a nursery
nurse. In addition the Portage service was extend-
ed to provide up to three visits a week for these
children to reinforce communication and interac-
therapy and outreach, offered by the speech and lan-
guage therapy and preschool advisory services.
4. The need to create an optimally responsive commu-
nication environment for children who do not have
the ability to develop adequate communication and
interaction skills from typical communicative environ-
ments (for example at home and at preschool).
5. The need to provide a specialist adult-rich envi-
ronment to enable the children to establish com-
munication systems such as PECS, that require a
high level of support in the initial stages.
6. The need to provide training, offer support and
share information with parents / carers, preschool
staff and other professionals.
7. The need for children to learn to participate in
group activities and begin to tolerate and interact
with others in close proximity.
tion skills at home and to support the parents.
The outcomes of the group were very encourag-
ing but, to set them in context, we will start with
an account of the groups aims and structure.
We established the foundation of the group on
the following tenets:
1. The proven effectiveness of collaborative multi-
agency working, as discussed in the Together
from the Startmodel (DH, 2003).
2. A strong research basis indicating that early
years intervention is crucial in establishing long-
term change and development of communication
and interaction skills (see for example Berrueta-
Clement, 1984; Dawson & Osterling, 1997;
Garland et al., 1981).
3. The group must complement established provi-
sion, such as EarlyBird, Portage, speech and language
READ THISIF YOU WANT TO
SHARE SPECIALIST SKILLS MORE EFFECTIVELY
WORK COLLABORATIVELY WITH OTHER
PROFESSIONALS
OFFER CLIENTS A GROUP ENVIRONMENT
TAILORED TO THEIR NEEDS
Enhanced provision:a complementary serviceDissatisfied with the progress of preschool children with complexcommunication and autistic spectrum disorders,Ann Wiseman andSharon Horswellorganised multi-agency intensive groups to complementthe established service. The good outcomes for the childrenscommunication, interaction skills and behaviour were mirrored by the
development of staff skills in working together, planning and training others.
Ann Wiseman
Sharon Horswell
The intensive communication group
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10/32SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20058
INTENSIVE GROUPS
Six children were to attend for two mornings
per week (09.45-12.00) from January 2004 - April
2004, a total of 20 sessions. Referrals were
received from preschool advisory teachers, speech
and language therapists and staff from the Child
Development Centre. All of the children referredhad a diagnosis of an autistic spectrum disorder or
a complex communication disorder. All of the chil-
dren already attended their local preschool group
and this was to continue.
We chose six children from the potential refer-
rals according to their age (with those nearest to
school age being given priority) and the support
they were already receiving (such as Portage,
learning support assistance at preschool, EarlyBird
course). Transport was provided for children and
their parents free of charge, with three parents
choosing to act as escorts for their children. Three
of the children selected for the group had a diag-
nosis of autistic spectrum disorder and three a
complex communication disorder (two with a
query of autistic spectrum disorder).
Strengthen relationshipsWe chose the playroom at the Child Development
Centre (John Parkes Unit) in Torbay for our accom-
modation, for the following reasons:
Suitable equipment and furniture.
Support from a nursery nurse who has received
relevant training for this group of children.
A large attractive playroom with an integral toilet
and a wealth of suitable activities and toys.
Easy access to a large, attractive outside play
area, where communication opportunities have
been maximised. Initial and ongoing assessment of children with
special educational needs is continuous at the
unit and some of the children and their parents /
carers referred to the group were already
familiar with the playroom and nursery nurse.
In addition we anticipated that establishing the
group at the unit would strengthen relationships
between various professionals and thus
improve the services offered to both the children
and their parents / carers.
Our group had three main aims:
1. To create a safe secure environment in which the
children were happy to part from their parents /
carers.
2. To develop the communication, social interaction
and imaginary play skills of the children.
3. To enskill parents / carers and preschool staff in
working effectively with the child in their care.
Communication opportunitiesTo achieve these aims, we set up the environment
to capitalise on communication opportunities,
taking into account that all the children in the
group were strong visual learners. We planned
each session to provide a wide range of motivat-
ing activities, as discussed with parents. Within
this framework we implemented tried and tested
techniques to maximise communication opportu-
nities and develop skills. These included visual
allows them to practise commenting.
We found it necessary to give the children quite
a long settling period when they first arrived,
with some favourite toys being available to assist
them in adjusting to the environment.
Hello time was used to help children to learntheir own and others names, to tolerate sitting as
part of the group, and to introduce them to some
repetitive preschool rhymes. Story time was
always simple, with an abundance of visual aids
and at times some familiar music such as the
Thomas the Tank Engine theme - to stimulate
their interest. After the story we checked under-
standing using simple language and reference to
the pictures.
We saw snack time as an ideal opportunity to
capitalise on communication as, for some of the
children, motivation was maximised. We asked
parents to send their childs favourite foods, and
children requested these items verbally or by
using pictures of the food / drink items.
One child had been introduced to PECS before
starting at the group and two others were intro-
duced to the system in a formalised way as indi-
cated by the PECS manual. (Two of these three
have an autistic spectrum disorder.) The others all
used pictures to extend their communication and
social interaction skills.
Individual targetsWe initially established individual childrens tar-
gets by two means:
1. Use of a detailed checklist of pragmatic skills
(Dewart & Summers, 1988) filled out in conjunc-
tion with each childs parents.2. Observation of each childs communication,
interaction and play skills during the first two
group sessions.
Then, at the end of each session, the staff collec-
tively wrote up their observations for each child.
Once a week, at a planning meeting, each childs
targets were reviewed in the light of observations
made and new targets set for the coming week.
We shared information in a number of ways. We
contacted parents by telephone each week to dis-
cuss progress and new targets set, and to suggest
ways of generalising skills at home. Informal sharing
of information was carried out at the beginning and
end of each session, although staff were keen to
keep this to the minimum to ensure that children
remained calm and left the group when they were
expecting to. The Portage home visitor attended
planning meetings to ensure continuity of sup-
port for the child and their carers. Preschool staff,
parents, the Portage home visitor, the preschool
advisory teacher and the speech and language
therapist met once or twice a term at individual
education plan meetings held at the preschool to
review progress and establish targets together.
We also held an open evening at the end of
February. This was in two parts. The first part was
for preschool staff, speech and language therapists
and Portage workers involved with the children.
The second part was for parents. During the evening
structure, PECS, intensive interaction (Nind &
Hewett, 2001), backward chaining (Baker &
Brightman, 1997), and modelling of behaviours
and language.
We established a whole group visual timetable of
the morning routine from the first session, indi-cating to the children the main transition points.
In addition we taught children the skill of manag-
ing their own individual timetable independently.
Transition points were:
9.45 Settling and playing with activities of the
childs choosing
10.15 Hello time and singing
10.30 Outside play
11.00 Toileting and hand washing
11.05 Storytime
11.15 Snack
11.30 Playing with activities
11.55 Tidying up
12.00 Goodbye time
The routine has elements of free play, individ-
ual time spent with an adult to develop specific
skills, turn taking activities with another child and
also group activities. We established a photo
choice board of favourite toys / activities so the
children could request items by pointing or
exchanging a picture as appropriate.
We placed toys within sight but out of reach, to
encourage the children to communicate their
preferences. We set up activities for the children
with an essential component missing (such as a
train track with the trains just out of reach),
therefore encouraging the children to make a
request. An outside symbol choice board was used
to enable the children to request out of sight toys(such as ride along items locked in a shed), activi-
ties such as being pushed on a swing and social
routines such as tickle and chase.
Adults in the group wore a bracelet with key
symbols attached (I want, help, wait, and finish),
which they or the child could easily access. In addi-
tion adults wore a pocketed apron with a Velcro
strip on the front to which they could attach sym-
bols for the child to exchange with or simply to
clarify communication between adult and child.
Between each change of activity we gathered
the children together. We showed them a picture
board of toys and areas of the classroom they may
have been playing with and asked the question,
What have you been playing with? Some chil-
dren responded verbally given the visual prompt,
while others were prompted by an adult to indi-
cate their activity by pointing. This process, often
repeated, helps the children to recall the recent
past, establishes the idea of a sequence and
we set up the environment tocapitalise on communicationopportunities, taking into accountthat all the children in the groupwere strong visual learners
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INTENSIVE GROUPS
we explained the layout of the nursery with its rele-
vance to the development of language and social
interaction skills. We discussed the curriculum of the
group, and parents and preschool staff were able to
look at some video footage to illustrate the strate-
gies being used by adults within the group toachieve the targets set for individual children.
Outcomes1. Differential diagnosis
Two of the initial group of six children had received
a query diagnosis of autistic spectrum disorder.
Through working intensively on communication,
interaction, and play skills, this diagnosis was ruled
out and both were given a diagnosis of language
delay with associated behavioural difficulties.
2. Development of the childrens skills.
We used The Pragmatics Profile of Early
Communication Skills (Dewart & Summers, 1988)
to assess all the children at the beginning and end
of the pilot (January 04 / July 04).
We recorded the following outcomes:
a. Communication
Initially none of the children were able to gain an
adults attention in an appropriate manner, or to
greet others without a prompt, or to comment.
Following the pilot all of the children made gains
in the frequency and range of functions of com-
munication. For example the children began to
gain an adults attention appropriately by calling
their name and / or approaching them. Five of the
six children became able to greet adults and four
of the group were able to make simple comments.
Significant gains were made by all the childrenin the areas of expressive communication, both in
qualitative and quantitative terms as recorded on
the Pragmatics Profile (Dewart & Summers, 1988).
Two of the children were enabled to use
PECS. This resulted in them developing an
intention to communicate, and also persistence
and clarity of communication. Some parents
reported that their children had become much
clearer in asserting their independence, and were
less passive in their communicative attempts. For
example one child who used to passively accept
No, now persists in handing his mother the
PECS strip I want.
On initial assessment one parent reported that her
son did not respond to any verbal direction, howev-
er simple. Following the period of the pilot group,
he was able to understand simple commands in
familiar contexts, such as Get your shoes.
b. Interaction skills
All of the children made progress in their abilities
to interact and play with their peers. At the start
of the group, five of the children would play in
parallel with others, and the sixth child, the most
severely autistic of the group, could not tolerate
others in his proximity. By the end, the three non-
autistic children and one autistic child had begun
to develop co-operative play. Of the other two
autistic children, one began to approach his peers
and ask to be chased, and the other most severely
affected child began to play in parallel and to
accept approaches from other children.
Some parents reported that these skills had gener-
alised to the preschool setting, and five of the six
children were beginning to interact with their peers.
One parent reported that her son had started to
enjoy sharing a book with an adult for the first time.
Comparing initial and post-group assessments, all
of the children made progress with both turn tak-
ing and initiating in structured activities, taught
systematically through joint action routines.
c. Behaviour
We tackled issues as they arose, working closely
with both preschools and homes. Sharing and sim-
ple negotiation skills were developed through
modelling and the use of a range of prompts: ver-
bal, visual and physical.
One child became severely anxious when it was
time to leave. He was showing similar difficulties
at his preschool. Following discussion, visual struc-
ture was implemented to prepare him for this
transition, and the problem was resolved in both
settings after three weeks on the programme.
SustainabilityAn important question for every group is sustain-
ability. After consideration of the feedback from
parents / carers and professionals following the pilot
period, Torbay Early Years Partnership decided to
fund the project for a further six months. The edu-
cation authority has since decided to incorporate
teacher and transport costs into its overall budget.
Training evenings are held once a term for par-
ents / carers, and a wide range of professionals
involved with each child about to make the tran-
sition to mainstream or special school are invited.
The room is set up to show how visual structure is
implemented, and video footage is shown to illus-
trate how we work towards goals. We put the
emphasis on practical aspects of management.
A spin-off from this training has been the
improved effectiveness of individual education
plan meetings. Because of a greater shared
understanding and knowledge of the parties
involved, clearer goals are established and greaterprogress is seen across all settings. Information
and training for school staff receiving children
from the group has been greatly enhanced and
some class teachers have been able to visit a child
within the group setting prior to the child starting
school. Preschool special educational needs co-
ordinators have also been given the opportunity
to visit the group as part of their Stage 2 training.
We also recognise that the skills of those work-
ing within the group have developed through the
constant weekly process of discussions with par-
ents / carers, target setting and evaluation. The
development of these skills has enhanced the
work of both the preschool advisory / area special
educational needs co-ordinator service and the
service offered by the staff of the John Parkes unit.
Overall feedback from parents / carers and other
professionals, and the recorded development of
the childrens skills, suggests that the group has
proved to be a valuable additional resource to
existing provision for preschool children in the
Torbay Area with a severe complex communica-
tion disorder or an autistic spectrum disorder.
Ann Wiseman is a Preschool Advisory Teacher SEN
/ Area SENCo, e-mail [email protected].
Sharon Horswell is a speech and language thera-
pist with South Devon Health Care Trust, e-mail
ReferencesBaker, B.L. & Brightman, A.J. (1997) Steps toIndependence: Teaching Everyday Skills to Children withSpecial Needs. 3rd edn. Baltimore, Maryland: Paul H.Brookes.Berrueta-Clement, J.R. et al. (1984) Changed Lives: TheEffects of the Perry Preschool Project on Youths ThroughAge 19. Ypsilanti, MI : High/Scope Educational ResearchFoundation.Dawson,G. & Osterling, J. (1997) Early Intervention inAutism, in Guralnick, M.J. (ed.) The Effectiveness of EarlyIntervention. Kansas City: Paul H. Brookes.Department of Health (2003) Together from the Start:Practical guidance for professionals working with dis-abled children (birth to third birthday) and their families,LASSL (2003)4. Available at: http://www.dfes.gov.uk/con-sultations/downloadableDocs/177_1.doc (Accessed: 3October 2005).Dewart, H. & Summers, S. (1988) The Pragmatics Profile ofEarly Communication Skills. Windsor: NFER-Nelson.Garland, C., Stone, N.W., Swanson, J. & Woodruff (eds.)(1981) Early Intervention for Children with Special Needsand their Families: Findings and Recommendations,Westar Series Paper No. 11 Seattle, WA: University ofWashington.Nind, M. & Hewett, D. (2001) A Practical Guide toIntensive Interaction. Kidderminster: BILD publications.
Resources National Autistic Societys EarlyBird Programme, see
www.nas.org.uk The National Portage Association, see
www.portage.org.uk
PECS, see www.pecs.org.uk
5 STEPS TOBETTER PRACTICE:INTENSIVE GROUPS1. LOOK TO BUILD ON AND
COMPLEMENT ESTABLISHEDSERVICES2. CONSIDER A RANGE OF
FACTORS WHEN CHOOSINGACCOMMODATION
3. IDENTIFY A VARIETY OF WAYSTO PROVIDE SUPPORT,TRAINING AND INFORMATION
4. STRUCTURE ACTIVITIES TODEVELOP USEFUL REAL LIFESKILLS
5. MEASURE OUTCOMES IN A
WAY THAT DEMONSTRATESSUSTAINABILITY
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12/32
BREATHING STRINGSThis is a fun and simple way to encourage deeper breathing by youngsters, as part of a courseon breathing techniques. You can use it one-to-one or as a group activity. Take care not toencourage overly deep breathing, or your clients could become dizzy. A word of warningregarding physical contact dont do the measuring around the clients chest yourself. If theyare unable to do their own measuring you should ask the parent, or else abandon this idea.
BRAWNCut lengths of string approximately 15 cms longer than your clients lower chest measurement.
Mark off 8 cms at one end with the biro this is the bit that the client will hold, and which
will later become the attachment to the coat hanger.
IN PRACTICEThe idea is to form breathing gauges by marking in different colours four points on the
string that represent the clients chest measurement when they are 1) breathing fully out,
2) naturally breathing in, 3) breathing in deeply and 4) breathing in really deeply. Take care over
the possible issue of hyperventilation. You may need to have breaks between each breath.
You now have a baseline measurement for these four chest positions (fully exhaled,
naturally inhaled, more deeply inhaled, fully inhaled). If you are working as a group
you will need to label the strings with the clients names.Tie the strings loosely onto the coat hangers so that you can remove them at the next
or subsequent session and see if there is any change. If / when there is an increase, just
keep adding more colours.
If you have enough of these coloured strings, you can leave them on the hanger together, to
make an interesting wall decoration.
ALSO FORThis is a lateral thinking game for a group of clients of any age.
IN PRACTICEPick up an item such as a paperclip and think of an alternative use for it. Each client justthinks of one new use, then passes it on to the next person who does the same. When no
one can think of any more uses, pick up a new item.
The new uses can be as wild and wacky as you like. For example, a pencil could be used as a
plant support, a chopstick, a hair decoration, a window prop, or a stick for a paper windmill.
A paperclip could be used as a hairgrip, an earring, a link from a paperclip necklace, or a tool
for extracting something stuck in a crevice.
You can take the opportunity to make the point that two heads are better than one at this,
and that if we all pool our ideas we can have better results (this also links into friendship skills).
SEASONAL VARIATIONThink of alternative uses for Christmas items such as tinsel, decorated cake board, Father
Christmas hat, stocking, pudding basin.
Heres one
I made earlier...ALISON ROBERTS WITH MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONSSUITABLE FOR A VARIETY OF CLIENT GROUPS.FORMAL AND CASUAL BOARDA wall-mounted display for a group to make. It helps clients learn about the various
social codes needed for different situations. Good fun to create, and forms the basis
for many discussions.
BRAWNWith the board placed landscape, draw a vertical line about a fifth of the way
across, and stick or pin a strip of squared or graph paper into this area. This paper
forms your Graph of Formality, so must stretch from the bottom to the top of the
board. Along the bottom of this graph, sideways on, you will later write various
scenarios some will be those shown in the newspaper pictures, and others that
your clients themselves may encounter.
Write the word Formal on a sticker at the top of the remaining part of the board
(the poster area), and similarly Casual at the bottom.
IN PRACTICE1. The clients cut out the pictures and stick or pin them on the poster area of
the board, deciding between them how far up towards the formal or down
towards the casual they should be placed. You should end up with a bottom row
of casual images such as a group of people in a pub or on a beach or picnic.
Then, working upwards, there will be several rows of progressively more formal
images, including scenes such as shopping, school / college / work cafs, doctors
waiting rooms and appointments, until you reach the formal settings such as
funerals, and state banquets. (They dont have to be situations the clients have
experienced, in fact the more extreme the better).
2. Fill in your graph, colouring in the vertical bars on the graph paper, as far up
towards the formal, or down towards the casual as the group decides. The scenarios
for which you have already stuck on pictures will come as far up the graph as they
were placed on the poster.3. Now the clients add their own scenarios to the graph, again writing sideways
at the bottom of it. Situations might include going to the snooker hall; work
experience at the garden centre; phoning home; phoning Mums office; texting
a friend; visiting an elderly relative. You may need to give guidance as to
whether for example phoning mums office is more or less formal than asking
for something in a shop.
VARIATIONSAdd little speech bubbles to the pictures, with greetings set at the appropriate level,
ranging from Hi to Morning, to Good Morning and so on. If you write these on
post-it notes you can vary the type of bubble, to include farewells, and conversational
topics.
Discuss, and possibly write on the poster, appropriate forms of non-verbal greetings,
such as High fives, handshakes, salutes, even curtsies!
Also discuss appropriate clothing for each scenario.
MATERIALS Squared or graph paper
As many newspaper or magazine pictures as you can find depicting people
in different social contexts such as barbecues, weddings, legal trials, dances.
(As a general rule local papers are a good source of photos of casual events,
while the nationals, especially broadsheets, yield formal images.)
Large board (either a piece of hardboard about 1 metre by 1.5 metres, or for
a neater effect, a large pinboard in a frame, obtainable from DIY shops).
Glue or pins, felt tips, scissors.
MATERIALS String the soft white cotton variety, or you could use narrow cotton tape.
Felt tips of many colours, and biros. Wire coat hanger (if you are doing this activity with a group).
Alison Roberts is a speech and language therapist at Ruskin
Mill Further Education College in Nailsworth, Gloucestershire.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 200510
HERES ONE I MADE EARLIER...
MATERIALSObjects that are readily to hand, in any office, or you can supplement with common kitchen
utensils, handbag contents or other items.
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13/32SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005 11
EVIDENCE BASED PRACTICE
A. KEY QUESTIONS
When we read a paper, there are two key ques-
tions to answer.
1. Is the stated result valid? and
2. Is the result important?
Critical appraisal is a bit like being a detective
scouring for evidence. You seek not just a frag-
ment here or there but a full skeleton in order to
close your case. Validity relates largely to the mat-
ter of study design and method. The method is
the backbone of the evidence being reported.
From this backbone hang like limbs the issues of
clinical importance and statistical importance.
Any bias in the method, or scope for error in mea-
surement, weakens the backbone, and reduces
the importance of the results. This is good news
for those who dislike reading the statistics section
(often in the Results part). A thorough readingof the Method might reveal that the statistics
have no backbone, and so you do not need to
bother with the results at all.
B. STUDY DESIGNS AND THEIR VALIDITY
The research questions will frame the type of
investigation needed (Pring, 2005). Greenhalgh
(2001) gives a thorough listing of designs and
their uses.
Research questions which seek to interpret or
describe behaviour usually lead to a qualitative
research design. The design is often a descriptive,
correlational investigation of variables, for example
finding out more about the reasons why parents
fail to attend a clinic appointment, or the factors
making it more likely that a parent will pursue a set
home programme with a language delayed child.
Qualitative study designs might be used for exam-
ining responses in natural settings rather than in
controlled (experimental) conditions.
Quantitative research questions which seek to
measure behaviour might lead to an experimental
or quasi-experimental design. In such designs the
experimenter tries to manipulate one variable
(the independent variable) to observe the effect
on the dependent variable. Experimental designs
are classically suited to the medical setting where
it is easier to control all the variables except the
dosage of a medicine. Relationships of cause and
effect can then be deduced. For example, children
with similar clinical presentations could be randomly
allocated into two groups, of which only one
group receives therapy. In a quasi-experimental
design, however, not all the variables can be con-
trolled, and as a result the relationship between
cause and effect is not certain. An example would
be sorting children into groups according to lan-
guage levels (language normal and language
delayed) and observing features of the prenatal
and perinatal history. Here the presence or
absence of language delay is not manipulated, so
we need care in drawing any conclusions about
the cause of their language delay (example from
Pring, 2005). Sometimes in speech and language
therapy the best design we can feasibly operate is
quasi-experimental (not experimental) and this
means we have to be careful about the claims wemake for relationships between the key variables
of a study.
A good fit between the design of a study and its
research question is the key to its validity. When it
comes to appraising the validity (or rigour) of the
design, look for ways in which error was min-
imised and potential bias avoided. Look too for
evidence of detail which would allow replication
of the study. What evidence is there for good
quality control, such as reliability between coders,
or resolving differences of coding?
Checklists for the validity of research designs can
be found in Greenhalgh (2001) or Bury & Mead
(1998).
C. STATISTICS: SOME BASICS
The statistics section of any paper is usually a big
turnoff. Numbers start to swim before the eyes.
Readers look hopefully for a graph or picture to
inform them. Before you start to read any num-
bers, take a look at what the numbers are trying
to do.
Most studies are looking at a sample of people,
with or without clinical conditions, in order to
make an observation about a wider target popu-
lation. The measurements for the sample lead to
an estimate of a population measure. The aver-
age height of a seven year old boy, for example,
is derived from measuring a sample of seven year
old boys, since it is not feasible to measure each
and every child. In reality, the actual height of
seven year old boys varies widely, and is thought
to follow the classic Normal curve shape. Many
studies make an assumption that their sample
data is normally distributed, in order to perform
the family of statistical tests called parametrictests. When reading a study, look for evidence
that the researchers have checked their distribu-
tion characteristics. Consider too the study sam-
ple: are any assumptions being made by the
researchers about the distribution that the sample
comes from? Is it a clinical or a normal sample?
Is it appropriate to compare results for this sample
to the target population?
Being only an estimate, a statistic has its own
range of accuracy. The confidence interval is a
way of expressing the accuracy, or bounds, of the
estimate, with a specified level of certainty.
Taking the height example, a study might con-
clude the average height of a seven year old boy
was 120cm, and quote a 95 per cent confidence
interval of 95 to 145cm. This would mean that 95
per cent of the time, the actual (but difficult to
measure) average height of such boys would fall
between 95 and 145cm. Clearly a wide confidence
interval is not much use for the purpose of mak-
ing boys trousers. However it could be acceptable
if my purpose related to minimum depths of 80cm
in a swimming pool. Further, the level of accuracy
demanded of a statistic is linked to its purpose. In
other words, a statistic (an estimate), its range of
accuracy, and its purpose all have to be taken
together.
Somehow statistics and numbers are associated with
pinning things down and reducing uncertainties.
EXPERTGUIDANCE:ASKING QUESTIONS
UNDERSTANDINGSTATISTICS
CHANGING PRACTICE
Developing critical appraisal skillsEvidence based practice is more than a set of skills it is a way of working and practising our profession.
A key element is critical appraisal, where we use
clinical judgement to consider the relative validity
and importance of evidence presented in professional
papers. Frances Harris takes us through the process.
A good fit betweenthe design of a studyand its researchquestion is the key toits validity.
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EVIDENCE BASED PRACTICE
when the difference in study group results crosses this
threshold then the results are declared significant.
The disadvantage of the method is that clinically
important results may not reach this statistical thresh-
old for significance. Moreover we have no additional
information about the degree of differences.An improvement on this situation is to use a
confidence interval. Confidence intervals put upper
and lower bounds on an estimate (such as treat-
ment effect size), indicating the range within which
(within conventional limits of uncertainty) the true
effect size might lie. If the range reported by the
study includes the zero value (that is, the value indi-
cating no treatment effect) then the treatment is
not significantly different from the control group.
Both statistical significance levels and confi-
dence intervals are subject to their own levels of
uncertainty: the conventional limit is to report
with a 95 per cent certainty. This means one in 20
findings are spurious, due to chance.
Failure to achieve statistical significance may be
due to insufficient cases (small sample sizes). This
is referred to as a problem of power. The power
of a study represents the probability of finding a
true difference between regimens where there is
one. Very broadly speaking, increasing the num-
ber of subjects increases the probability of finding
a genuine difference between distinct groups.
Usually the power level of a study is set at 80 per
cent. This means that there is a 20 per cent chance
of the error in which the study concludes there is
NOT a difference between regimens when the
true state is that there is.
For the purposes of critical appraisal the ques-
tion is: if the finding was not statistically signifi-cant, was the study sample large enough to
detect a difference?
E. IS THE RESULT IMPORTANT CLINICALLY?
Clinical significance addresses the questions:
1) Should the study lead to changes in clinician
behaviour?
2) Or does the study lead to improvement of quality
of life for a client?
Clinical importance is a separate judgement to
statistical significance. A large study could show
as significant a small observed difference, which
may not have a clinical usefulness. Conversely, a
clinically important difference may not be
revealed by a study as statistically significant. It is
important to remember that in this sense the
numbers can get it wrong.
Clinical impact can be determined by key statistics
for certain study designs. Here I set out two classic
statistics used in medical approaches to evidence-
based medicine, (i) the likelihood ratio (LR) and (ii)
the number needed to treat (NNT). Although these
are medical statistics, they could usefully be used in
presenting some therapy findings, especially screen-
ing procedures and outcomes-based therapy trials.
(i) Likelihood ratio
For a screening study, the likelihood ratio [strictly
the positive LR] is the factor by which your esti-
mate of presence of condition X is changed by
doing the screening test. A very useful screen is
one that increases your confidence in your judge-
ment about condition X. A likelihood ratio of 1 or
close to 1 indicates almost nil added value in
doing the screening test. Likelihood ratios may benumbers larger than 1 or less than 1. (If instead
the study only reports percentages for sensitivity
and specificity, the positive likelihood ratio may be
calculated as sensitivity / [100-specificity]). A guide
to interpreting likelihood ratios is in Table 1.
Table 1 Interpreting likelihood ratios
Range of positive Clinicallikelihood ratio significance(LR+)
10 or moreor HIGHLess than 0.1
5 to 10or MODERATE0.1-0.2
2.5 to 5or LOW 0.2 to 0.5
(ii) Number needed to treat
For a therapy impact study, a medical approach
would look at the number of clients above or
below a given threshold, for example the numberof children who were joining two key words into
phrases, compared to the number still at a single
key word level. (This approach puts clients into
one of two groups, rather than looking at them
descriptively by their mean length of utterance,
for example.) The consequence is that each client
can then contribute a positive or negative out-
come [or event] to the study. Table 2 gives
demonstration calculations for a notional study
with 41 children in the control group, and 40 in
the experimental group. The control event rate
(CER) of 37 out of 41 indicates that 37 children in
the control group were still classed as at a single
word level by the end of the study, compared to
25 of the experimental group. Here, the experi-
mental event rate (EER) is 25 out of 40.
The basis of quantifying results is to look at the
progress of an experimental group, over and
above a control group, by looking at the risks of
each group. If a treatment is effective then the
experimental group should be at reduced riskof a
poor outcome event. So if a language group is
working, there should be a reduced risk of the
event of a child being classified at single key
word level. The number of events is counted in
both the control group and the experimental
group. The difference in event rates [CER- EER] is
called the absolute risk reduction (ARR).
It is also possible to derive the relative risk
We hope that by taking clinical measures we can
be sure of a clients case status, or of progress
within therapy. However the numbers will only do
what we ask of them. It is still the practitioner
who determines the dividing line between the
clinical and normal case, even if we use statisti-cal conventions to help us. Our own tolerance for
risk will determine where we set the boundaries
or thresholds.
One way of looking at evidence-based practice
is that we use the evidence to help us quantify
risk, and to communicate this to our clients. At
some point in clinical decision making with a
client we hand over a degree of risk to the client
too. They have to decide for example whether to
take up a course of therapy, based on the expect-
ed outcomes with or without treatment.
So a statistic is an estimate based on various
assumptions about the population distribution,
with its own likelihood of being (in)accurate,
which can only be used in conjunction with clini-
cal judgement and its own context.
To ease yourself into useful and manageable sta-
tistics I suggest:
Greenhalghs (2001) chapter on Statistics for the
Non-statistician: descriptive and very readable.
Pring (2005) An excellent overview of designs,
why we need statistics, how to use them, and
what research can tell us.
The online text Statistics at Square One is very
clear. Visit http://bmj.bmjjournals.cpm/
collections/statsbk/index.shtml
There is also a CD package available from the
NHS Critical Appraisal Skills programme for
self-study using a PC (but not needing the internet)at http://www.update-software.com/CASP.
D. IS THE RESULT IMPORTANT STATISTICALLY?
The type of investigation often determines which
statistic will be used. Then that statistic needs to
be interpreted appropriately, to determine its
impact. By far the most frequently cited statistic is
the significance level p.
Statistical significance addresses the question:
are the conclusions of the study likely to be true?
The term statistical significance is a form of
shorthand. It is a way of expressing (within con-
ventional limits of uncertainty) that the results of
the experimental groups are so different that the
researchers reject the idea that there is no differ-
ence between them. As Pring (2005, p.19) puts it,
we never prove anything: we just show that a
result is fairly unlikely to be due to chance.
Statistical significance levels act as a threshold;
As Pring puts it,we never proveanything: we justshow that a result isfairly unlikely to bedue to chance.
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clinicians queries in a relevant way. This improves
applicability and validity of any findings.
G. WORKING COLLABORATIVELY
Evidence-based practice is more than a set of skills.
It is a way of working and practising our profes-
sion. Everyone asks questions already, at some
level, so a good starting point for evidence-basedpractice is to ask clinically-driven questions. This
habit can be developed so that clinicians are regu-
larly reflecting on their practice. But the evidence-
based practice toolkit is broad indeed and,
although everyone can ask questions, not every-
one can do everything - ask a decent clinical ques-
tion, search the internet, track down valid articles,
interpret results and then implement change in
their practice. A few, maybe. The rest of us learn
to build up networks and make teams to share our
expertise. Collaboration is the key to ensuring that
our practice is based on evidence.
Have fun finding your skeletons!
Frances Harris is a paediatric speech and language
therapist for South Cambridgeshire PCT.
Comments are welcome:
ReferencesBury, T. & Mead, J. (1998) Evidence-based health-
care: a practical guide for therapists. Oxford:
Butterworth-Heineman.
Greenhalgh, T. (2001) How to read a paper. 2nd
edn. London: BMJ.
Pring, T. (2005) Research Methods in
Communication Disorders. London: Whurr.
ed. A typical format might be:
a) Discussion of topics to address, with selection of
one topic A. This will be the focus of a literature
search before the next meeting.
b) Report back from designated group member on
the results of literature search for topic B. This
literature is distributed for appraisal before the
next meeting.
c) Appraisal of literature on topic C, as distributed
at the previous meeting.
d) Generate a summary of findings for local situation.
3. Assess applicability of research
Once the literature has been appraised for its valid-
ity and its importance, consider how it could be
applied to a particular clinical setting.Is this proposed screening test / therapy regime
feasible? Is it affordable, or available? Does the
study sample population have similarities with the
population in my clinical setting? Would clients be
willing partners in this approach?
4. The practice environment
The organisational environment of the clinician
may well determine their success in implementing
evidence based practice.
There need to be:
Mechanisms by which individual and organisational
change can take place
Effective communication systems across staff
groups and locations
Staged approaches to change, with prior analysis
of which mechanisms to use
Adequate resources and staff with appropriate
skills to change practice
Strategies for monitoring, supporting and
maintaining changes.
Access to information technology, in collaboration
with information services experts is vital for carry-
ing out internet searches of literature databases
and information services (such as online journals
and synoptic journals).
Networks of professionals are also fundamental.
Networking between researchers and clinicians
ensures that the researchers are addressing the
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005 13
EVIDENCE BASED PRACTICE
PRACTICAL POINTS:Critical appraisal Note that clinical importance is
a separate judgement to statistical
significance; the numbers canget it wrong.
Be careful about the claims youmake for relationships betweenthe key variables of a study.
Remember that a statistic is anestimate to be used in conjunctionwith clinical judgement and itsown context.
Look for detail in papers thatwould allow replication andshow how errors were minimised
and bias avoided. Know when and how to hand a
degree of risk over to yourclient.
Network and share expertise.
reduction (RRR), which apportions the absolute
risk reduction over the number of events in the
control group.
The reciprocal of absolute risk reduction is the
number needed to treat (NNT). By convention this
is rounded upwards to the nearest whole number.
It represents the number of clients needing treat-
ment as per the study protocol to prevent one
additional poor outcome (in terms of the event
outcome in the study.)
A relative risk reduction of more than 25 per
cent is desirable, and more than 50 per cent
would be clinically significant. A relative risk
reduction of 100 per cent represents total success;
the treatment would remove all risk events and
the experimental event rate would be zero.
Lower numbers needed to treat are desirable, or
a number needed to treat which is lower than
alternative treatment regimes. A confidence
interval can be calculated on the number neededto treat, and this sets a range for the interpreta-
tion of the clinical significance of the result.
F. GETTING RESULTS INTO PRACTICE
1. Ask questions
Asking questions is vital to reflective practice.
(Even if we have done our phonology groups for
donkeys years, why do we do it?) Have a folder or
box in clinic that can receive questions. Then later,
on reviewing the set of questions at clinic meet-
ings, agree who will be responsible for tracking
down an answer and how this will be fed back to
the team. Clearly more than one clinician might
be involved in this process.
2. Reading groups
The art of reading to check the validity of findings
and to assess their applicability can be practised in
reading groups. Work time set aside to discuss
articles with colleagues can reinforce the use of
critical appraisal checklists and give confidence in
interpreting results. A key for success would be a
clinical leader or mentor who can facilitate the
clinical discussio
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