Speech & Language Therapy in Practice, Winter 2005

7/28/2019 Speech & Language Therapy in Practice, Winter 2005

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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

name and address to [email protected], or

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-

lished by Little Knowall. The book is now in a

second edition with the ISBN 0-9547921-1-4.

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

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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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6/32

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


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


7/32


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


8/32

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?


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)


9/32SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005 7

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


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



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

[email protected].

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


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.


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.



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.

EXPERT GUIDANCE:


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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.

EXPERT GUIDANCE:


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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:

[email protected]

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



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

Speech & Language Therapy in Practice, Winter 2005

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