She talked about what speech therapy was like when she started out:

• Makaton was just being developed. She got involved with the charity and ensured the signing system was widely used in our area. Recently she taught the team to sign, “I’m dreaming of a white Christmas!”
• The Derbyshire Language Scheme didn’t exist.
• Some children were considered “ineducable.” This changed with the 1970 Education Act, after which all school age children were entitled to an education.

I might have 30+ years ahead of me as a Speech and Language Therapist. When it’s time for me to retire, what will I tell colleagues about starting out? They may be astonished to hear that we write clinical case notes on paper by hand. We consider assessments standardised if data has been collected from 1000 children. And in this era of “inclusion” hundreds of special schools still exist.

Maybe I’ll tell them I was one of the first UK therapists to start a blog! Times are changing; what will the therapy world look like in 30 years time? (I see iPads, lots and lots of iPads!)

Speechies: get with the times

Okay, so it was a content strategy conference for web people, but I think therapists need to try new ways of interacting with each other too. There’s a small community of us using Twitter. You should join us.

Share information

Therapists post links to interesting content, like this information sheet about creating social stories (PDF link) which was shared by several people I follow (e.g. @specialquest).

We also ask questions and share resources. For example @speechreka asked:

Anyone has access to this?: Quick Screen for Voice and Supplementary Documents for Identifying Pediatric Voice Disorders- LSHSS vol 35:308

And then:

I’d really appreciate it if someone can share that article. And anything dealing with paediatric voice disorders. Have an ax tomorrow…lost

Shareka got several responses from around the world, and later on shared what she’d found. Excellent timing. I was expecting a voice client for an initial assessment the next day!

Join the community

Twitter is a place to have an SLT-related chat, to share struggles and successes like this one from @speechbob:

just had the school psych tell me that one of my fluency students was talking up a storm with his strategies, made me smile.

We’re a friendly bunch, so what are you waiting for? Start tweeting and pick the brains of colleagues from all over the world. I’m @RhiannanW. See you there!

Godin describes a linchpin as “an individual who can walk into chaos and create order, someone who can invent, connect, create and make things happen… linchpins are geniuses, artists and givers of gifts.” He says that although we were trained to be cogs in a giant machine, we can choose to re-train ourselves to become indispensable.

Linchpins don’t wait for instructions, they make their own maps. They overcome the resistance (the lizard brain that tells us our ideas will never work and everyone will laugh at us) and get their ideas out into the world.

In a recent team meeting at work, it was easy to see the therapists whose lizard brains were in control; they suggested we stop trying new ways of working and go back to the old way! Fortunately my team also has a linchpin or two; they’re generous with their gifts and keen to make change. I’m trying to be a linchpin too; we’re starting to draw our own map, overcome the resistance, and ship our ideas.

I recommend checking out the Linchpin Manifesto (PDF link) and reading the book. We need more linchpins in the National Health Service! What do you think?

I’ve recently trained several practitioners in adult-child interaction, with varying degrees of success!

Training package

The training package I offer is still evolving. I usually:

• give the practitioners some written information about adult-child interaction from Elkan Early Language Builders;
• discuss the dual strategies of following a child’s lead and commenting rather than questioning;
• model these strategies; and
• make a brief video of the practitioner interacting with a child, and give feedback.

Effectiveness

I have used this package with five practitioners over the last month. Three of them responded really well: they asked thoughtful questions, reflected on their skills as they watched the video, and were able to adapt their interaction styles to become better communication partners. Result!

What about the other two? Well, one was able to identify that she asked a lot of questions; with support she began to think about how she could use comments instead. However, at the end of the session she still seemed unaware that she was being directive. The other practitioner felt she was already using both strategies, but didn’t notice herself asking questions when we watched the video. Hmm.

Reflecting on the sessions that didn’t go so well, could I achieve more by fine-tuning how I use the video? There’s lots of useful information on this topic in the Hanen “It Takes Two To Talk” programme. After reviewing it, I’ve found three ideas to try:

• considering the adult’s stage of learning,
• using coaching methods, and
• asking rather than telling.

Stages of learning

The Hanen programme describes three stages of learning: pre-aware, aware, and active. A pre-aware learner might be able to explain the strategies, but doesn’t realise that she’s not applying them. An aware learner knows the strategies and knows that she’s not yet applying them. An active learner has applied her knowledge and changed her behaviour.

So the practitioner who thought she was using the strategies but didn’t notice that she asked questions was at the pre-aware stage of learning. I should try to move her on to the next stage: to increase her awareness of her own behaviour. The Hanen information suggests making tentative statements about what you see and then “letting the tape do the talking.” I’ll try it.

Coaching

Hanen suggests coaching as another way to support an adult’s learning process, by improving the specific interaction. You can do this while the camera is running, during a brief break in filming, or by demonstrating the strategy.

So for the practitioner who was unaware of how directive she was, I could try some coaching: while the camera is running I could say something like, “don’t suggest what to play with: wait for him to show you what he wants to do.” Something else for me to try out.

Feedback: ask, don’t tell

Reflecting on the feedback I gave, I think it started well, but could be improved. I asked what the practitioner thought about the interaction, and then offered a specific focus; for example, “let’s look at when you made comments.” So far so good. But then I told them my own observations, rather than asking for theirs! By asking rather than telling, I could provide a more active learning experience, to increase the chances of learning new skills. Looks like I’ve got lots to practise!

Any ideas?

Do you use video as a teaching tool? What techniques have you found work well with pre-aware learners?

My biggest conundrum at the minute, is that the risk assessment tools are very medical model – and don’t seem to reflect anything within the tools/structures of education – and 80% of our caseload is working into an educational setting – any thoughts or ideas would be greatly appreciated.

Although I’m no longer working in the same service, I can remember discussions about how the approach fitted with our work in education.

I’m looking at Malcomess’ “risk” and “clinical risk” grids. The risk assessment requires judgements about functional impact on Activities for Daily Living (ADL) and environmental adaptation. We can consider ADL in the classroom. In terms of environmental adaptation I’ve found a note I wrote on one of the handouts saying: “score environment which is least adaptive (and central.)” So a child in an educational environment which is significantly contributing to risk would score highly on the context column.

In terms of clinical risk we discussed thinking about school staff as well as carers in the first column: motivation for change / carer responsibility. We need to consider who in the child’s life is primary, in relation to impact. A teacher who is unable or unwilling to collaborate in the treatment process would cause a child to score lower in this column (if the SLT service was entirely school based.)

What do you think about using the tools in education settings?

What is counselling?

The British Association for Counselling and Psychotherapy uses this definition:

Counselling takes place when a counsellor sees a client in a private and confidential setting to explore a difficulty the client is having, distress they may be experiencing or perhaps their dissatisfaction with life, or loss of a sense of direction and purpose. It is always at the request of the client as no one can properly be ’sent’ for counselling.

By listening attentively and patiently the counsellor can begin to perceive the difficulties from the client’s point of view and can help them to see things more clearly, possibly from a different perspective. Counselling is a way of enabling choice or change or of reducing confusion.

Why do SLTs need to use counselling skills?

SLTs work with clients (and their parents or carers) who may be experiencing denial or grief. We might need to use counselling skills if our clients:

• are unable to engage in therapy,
  
• demonstrate strong emotions,
  
• tell us they’re feeling low,
  
• are tearful, or
  
• struggle to adjust to their difficulties.

(List taken from Sparkes and Simpson, see below.) Sometimes we need to address these feelings explicitly before we are able to move forward with therapy.

One particular session with a parent left me feeling uncomfortable: her son had just been diagnosed with autism, and she spent the therapy session in tears. When I reflected on the session, it felt like I’d been unable to support her; so I decided to develop my counselling skills.

Resources and training

I searched Amazon for some books to get me started. I ordered Counselling Skills for Health Professionals by Philip Burnard and Person-Centred Counselling in Action by Dave Mearns and Brian Thorne. I found Counselling Skills for Health Professionals relevant and easy to read; it has practical ideas, short case studies, and an interesting chapter on culture and communication. In contrast, I found the language in Person-Centred Counselling in Action complicated and difficult to follow. Although it contains lots of interesting ideas—and it made me think—SLTs are not really the target audience.

I also attended a one day course called “Feeling out of your depth? Innovative approaches to using counselling skills within speech and language therapy” at University College London. The course was led by Cathy Sparkes and Sam Simpson. It was great! I took away lots of practical ideas for working with clients and families, and learnt more about my own skills and boundaries.

Using “blob people”

One of the ideas Cathy and Sam shared was using the blob people pictures. At work we use the “blob tree” as part of our initial assessment for people who stammer. I liked the list of possible questions that Cathy and Sam discussed: I can easily see how to use them in my clinical work.

The pictures show lots of blob people (who are neither male or female, young or old) in different situations; check out the blob bar! Possible questions to initiate discussion include:

• Which one are you?
• With friends, which one are you?
• Which one would you like to be?

The pictures and questions are a great resource, check them out.

Personal development target

I was prompted to think again about using counselling skills during a recent initial assessment. During the session the parents seemed to move from denial that there was a problem to grief that their son’s language was severely delayed. There was another family waiting, so I couldn’t explore the parents’ distress. Looking at the definition above, I did try to help them see things more clearly, and to reduce their confusion, but maybe I could have done more.

Is there a personal development target here somewhere? How about:

To practise using counselling skills in assessment and therapy sessions, in order to help parents think clearly and be ready to engage with therapy.

What do you think?

The change made me reflect on the positive aspects of the old job, so I’m jotting them down here.

Positives

It was a large, friendly team of therapists and I was well supported. I worked autonomously: free to manage my own time and workload.

I spent 18 months working with the same caseload, so I was able to get to know the families. When we met in the street, they would stop and chat; I felt a part of the community. I was also able to develop good working relationships with other professionals, such as staff in the Children’s Centres.

The team has a good universal service in place; they are working at the population level to raise awareness and prevent difficulties arising. In this respect they’re ahead of many other boroughs!

We were encouraged to carry out clinical projects, so I developed a drop-in group focussing on parent child interaction strategies, in my patch. With support from the Children’s Centre I was able to grow this group and access hard to reach families.

What I’m looking forward to

I think the new job will also be a positive experience; when I’ve moved through the initial ‘information overload’ phase and begin to find my feet, I hope I will enjoy the new challenge. I’m looking forward to developing the universal service and working with nursery settings.

I find starting in a new team difficult and admire locum therapists, who move from team to team regularly—I wouldn’t cope! If you’ve got any tips about how to make the transition as stress-free as possible, please add a comment!

We have several well established methods of measuring outcomes for specialist services, but measuring the outcomes of our universal work is much more difficult. More difficult, but just as important.

Definition and purpose

Let’s start with a definition.

According to Alison J L Fawcett, outcome measurement “…establish[es] the effects of an intervention on an individual or the effectiveness of a service on a defined aspect of the health or well-being of a specified population…. [it involves] administering an outcome measure on at least two occasions to document change over time…” (Principles of Assessment and Outcome Measurement for Occupational Therapists and Physiotherapists, 2007).

Outcome measurement is important for providing quality assurance (as part of clinical governance), demonstrating value, and contributing to the evidence base.

Specialist services

In clinical practice there are a number of well known methods to measure outcomes, such as Enderby’s Therapy Outcome Measures and the East Kent Outcome System. Services I’ve worked in use their own local systems, which involve writing SMART targets and stating whether they’ve been achieved at the end of a block of therapy.

When we choose an outcome measure, it’s worth considering the time required to use the system, as well as what we’ll use the data for. For example, I’m happy to spend time recording outcomes when I know the data will be used to develop care pathways, or contribute to the local evidence base. But the exercise becomes frustrating if I think the data will just sit in a file somewhere, gathering dust!

Universal services

Universal services aim to raise awareness of speech and language development for all children; ensuring that environments children spend time in are language rich, to stop difficulties arising. Universal services also support early identification and timely intervention.

Outcome measurement for universal services is messy. There’s no clear target child, SLTs are working indirectly (through other people), and we’re perhaps not so disciplined with our goal setting. We also don’t have any directly applicable tools.

Measuring outcomes for universal services is currently a hot discussion topic; it was addressed at the “SLTs in Children’s Centres” Special Interest Group. James Law suggested that outcomes need to be easy to communicate to non-specialists, while Michael Thompson talked about how we could use focus groups, observations, and workshops to measure outcomes.

An example: “facilitating language” training session

Thinking about how I can apply this to my own practice, here’s an example.

There are a number of ways we could collect outcome measurement data for a training session which aims to teach play workers how to facilitate language. Before the training session we could ask participants to complete a self rating scale, or observe each play worker interacting with a child; or if this isn’t practical, we could ask them to make a video recording. We would then need to repeat these measures after the training session.

I think it’s important to consider when to collect the post-intervention data. If the training session is aiming to teach practical skills, it might be important to give the participants time to go back into their settings to practise these skills, and consolidate their learning. Carrying out post-intervention measures 4 weeks after the training session might provide us with the most useful data.

Why bother?

Given all the challenges and difficulties I’ve mentioned here, why should we even bother to measure universal outcomes?

SLTs working with pre-school children are doing more universal work to try and reduce dependency in the population, and work more efficiently. Our commissioners require us to demonstrate that this universal work is effective. So it’s vital that we continue to develop outcome measures for this area of our work.

Have you had any luck measuring the outcomes of your universal work? Please share them here.

What is Dynamic Assessment?

Vygotsky (1978) believed that the difference between a child’s performance when he works alone and his performance when he collaborates with an adult reflects his ‘zone of proximal development’ or developmental potential. Dynamic Assessment is based on this theme, aiming to assess potential for learning rather than a ’snapshot’ of a child’s performance in a particular situation on a particular day, as measured by conventional tests.

Why use Dynamic Assessment?

I sometimes complete my set of standardised or formal assessments and end up thinking, ‘now what?’ Dynamic Assessment can highlight which cognitive processes need to be targeted, describe useful mediation techniques, and indicate next steps of learning.

Natalie suggested Dynamic Assessment may be useful for:

• differentiating between children with Specific Language Impairment and those with low language levels due to English as an Additional Language.
• finding out the modifiability of clients to plan effective intervention.
• standardising ways of measuring how responsive an individual is to language learning.
• identifying which types of intervention will benefit particular individuals.

Dynamic Assessment in action

Ruth and Natalie showed video clips which demonstrated Dynamic Assessment in action. The clips were a great learning tool; making the idea of mediation much more concrete for me. Ruth explained some techniques of mediational teaching, such as focussing on processes rather than responses, and the development of principles of learning, e.g. ‘when I take my time I can complete the task.’

Mediation can take place before, within, or after a task. There is an emphasis on metacognition (“awareness and understanding of one’s own thought processes” — Oxford American Dictionary); in the video clips the adults asked questions such as, “how did you know?” and, “how did you work it out?” Ruth advised that during mediation the adult shouldn’t over-assist, because this takes away a learning opportunity. The adult should begin with the lowest level of assistance, such as encouraging the child to identify the problem, and then help the child work out their own way of approaching the task.

For more information about Dynamic Assessment try: Hasson, N. and Joffe, V. 2007 ‘The Case for Dynamic Assessment in speech and language therapy‘, Child Language Teaching and Therapy, 23(1), 9-25.

What next?

So, if I want to see what my clients’ maximum performance is, how can I use these ideas in my assessments? Well, I can’t use mediation techniques on standardised assessments, because the mediation will make any re-testing with the same assessment unreliable. I talked to Natalie briefly about using the Renfrew Action Picture Test (RAPT). I think that if I could develop five more RAPTs (sets of ten pictures and questions) I would have enough material for the intervention (or mediation phase) and the re-assessment phase. Developing five RAPTs seems both feasible and a mammoth task, depending on which day I think about it!

In the meantime, it occurred to me that perhaps I could use the picture and question scenarios from the Language for Thinking program. There are 50 scenarios with questions at three levels; plenty to use for assessment, mediation and re-assessment.

Fancy collaborating on some new RAPT style assessments? Used the principles of Dynamic Assessment with under 5s? Please leave a comment, I’d love to hear from you!

Kerry Bray

I have been working here in New York for the last three months, and finally feel like I am getting to grips with the major similarities and differences in the professional structures and roles. It is pretty different in practice here, because the organisation of health and education is structured and funded so differently. I wouldn’t say that children receive a better or worse service in either country—there are major pros and cons to both systems.

Twice-weekly therapy sessions

Here most SLPs have a full day of pure therapy, carrying out about 10 sessions a day, mainly seeing individuals and small groups in schools or pre-schools. On average, children receive therapy two or three times per week, for half an hour. Speech and language difficulties are almost exclusively addressed at the impairment level, and there is no expectation of carry-over into the classroom or the home. Although there is lots of literature encouraging work at the activity and participation level, many therapists are paid per session—since paperwork, liaison, and training cannot be billed, it seems like there is no incentive or time to work at this level.

Seeing children so frequently, on an ongoing basis, means they make lots of progress, and you have a chance to really get to grips with each child’s strengths and needs. There’s also a surprisingly small amount of paperwork here, compared to the UK. We write just one line of progress notes per session per child, plus statistics. Each child is then evaluated once per year, and a short report and targets are written.

I arrive at 8:30 am, leave at 3 pm, and I’m paid a liveable wage (I haven’t compared salaries, as I am paid per session here.) A lot of people also do extra work in the evenings, and even at weekends.

Buying your own resources

A major downside here is that in some settings you are expected to buy your own resources.  I work in a special school one day a week, and a pre-school for the other four days. At the special school, the SLP had to buy her own colour printer and laminator. At the pre-school, these things are supplied, but there are few shared toys, or other therapy materials. As you can imagine, it takes a lot of time and money to build up resources for a huge range of abilities—I need resources for children with Profound and Multiple Learning Difficulties (PMLD), Autistic Spectrum Disorders (ASD), Oro-motor needs, or five-year-olds with language delay.

Trying not to generalise

I need to be careful not to make too many generalisations—I’ve only done volunteer work for a private practice, and paid work in three different settings, through an agency. However, I have talked to a lot of therapists, and I am always trying to find out whether my experience is typical, or not.

Are any of my British friends interested in working here? I’d be happy to answer any questions about working in the USA, versus the UK.

We’d love to hear views from SLTs and SLPs in the USA, the UK, and around the world—what are the similarities and differences between your experiences and Kerry’s? Please add a comment!