Author Archives: Helen

Are children with autism included in mainstream provisions? Perspectives from neurotypical 7-11 year olds in the North East of England.

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Here is the abstract from Emily Erceylan’s final year research project, supervised by Dr Carol Moxam.

Are children with autism included in mainstream provisions? Perspectives from neurotypical 7-11 year olds in the North East of England.

Neurotypical peer-exclusion of children with autism in mainstream provisions is a current issue, which has detrimental consequences for those with autism (APPGA, 2017). This study reports 77 neurotypical children’s perspectives towards inclusion of children with autism, in the North East of England. Participants completed a questionnaire in relation to a hypothetical child (character) from a vignette, with four variations of characters: 1) neurotypical male; 2) neurotypical female; 3) male with autism; 4) female with autism. Participants were randomly assigned to one of the four conditions.

Data from the questionnaire measured participant perspectives towards inclusion of the character. Three variables were investigated on participant responses: 1) Character autism status; 2) Character gender; 3) Participant gender. 5-point Likert scales obtained quantitative data which measured perspectives towards inclusion; analysed statistically. Comment boxes obtained qualitative data and provided insight into quantitative findings; analysed with deductive Thematic Analysis (Braun & Clarke, 2006).

Findings confirmed that characters with autism were perceived to be less included by participants than neurotypical characters, to a highly statistically significant level. The influence of character or participant gender were not statistically significant. Although, qualitative data found that female characters received more positive comments, and, found that female participants provided slightly more positive ratings than male participants.

Overall, findings confirm claims from APPGA (2017); neurotypical children hold negative perspectives towards inclusion of children with autism. Thus, findings suggest that mainstream schools, concerned about peer-inclusion of children with autism, should attempt to change perspectives of neurotypical pupils, through teaching autism awareness (NAS, 2019e).

Key words: Autism, neurotypical, mainstream primary education, inclusion, perspectives.

The Speech & Language Society No Voice (AAC) Challenge

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No Voice (AAC) Challenge

On the week of the 6th November 2017 Speech and Language Therapy students took part in a No Voice Challenge. For one day of the week they used a range of Alternative and Augmentative Communication aids instead of speaking with the aim of raising awareness of the importance of Speech and Language Therapy as part of the Giving Voice Campaign. The Regional Communication Aid Service kindly lent us high tech tablets with symbol programmes installed, e trans frames and communication charts. Other AAC approaches adopted included VOCA apps on our phones, symbol apps, signing, writing, alphabet boards and drawing.

Below are some comments from those who took part:

What AAC/ strategies did you use the most?

  • Typing on a laptop/ phone was the easiest by far- hard to imagine how tough it must be for our clients who can’t type if they don’t have the language/literacy/ motor skills.
  • Signing and gestures came naturally to me as I gesture a lot when I speak anyway. When gestures or signing failed, I tended to write. My hands were essential for my ‘voice’. I couldn’t reply anytime someone spoke to me when I had my hands full such as walking down a corridor.
  • The E Trans frame was so difficult! It took such a long time to use. If it was my only means of communication I would say very little and be quite depressed.

 How did you feel?

  • Really frustrated! I feel like that is a word we use a lot but it is TRUE!! Also felt rude when I couldn’t say excuse me/ thank you and people didn’t see me signing. Isolated from conversations.
  • Makes you feel like not bothering because it is so much effort to get your message across.
  • Sometimes I just gave up when communicating because it was so hard. I felt isolated, frustrated and self-conscious. By the end of the day I was emotionally and mentally drained. At 5pm I went home and accidentally fell asleep!
  • When you have nothing and all your contributions are minutes after the original point was made in conversation- frustration builds.

 

How did others react to you?

  • I got bad vibes from some people who I couldn’t say “excuse me” to. Speech therapy students were quite good at waiting for you to finish what you wanted to say but some non-SLTs really weren’t.
  • I was appreciative of people adapting their communication for me e.g. being patient and waiting to respond via my VOCA app.
  • I went to Subway with my order on a whiteboard and they thought I was crazy. They may my order though. It was so time pressured as there was a huge queue behind me.
  • As there was nothing visible about not being able to speak people are surprised when they realise you’re not talking.

 

How did it impact your participation?

  • Conversations often moved so quickly that by the time I had written what I wanted to say the conversation had already moved on. It was so hard trying to convey something complex in a limited time span. I couldn’t do it- I struggled.
  • I couldn’t really contribute in class. A lecturer asked me for an answer and I couldn’t reply.
  • People walked off when I was trying to communicate, I couldn’t get people’s attention without tapping them on the shoulder. It was very hard to participate in group conversations because the conversation would change before I could input. I didn’t realise how quickly people give up trying to have a conversation when you can’t talk back.
  • Anything more than a basic yes/no or good/bad response required writing, gesturing, typing to using an app which takes much longer.
  • People spoke to me less.
  • I couldn’t sing in the shower and small things like that have a big impact!

 

How will this experience influence how you work with clients?

  • When they say they’re tired I can understand why. Giving adequate time means more than you think. Communication difficulties would be a nightmare- lots of strategies were needed.
  • I will give them loads of time to reply and not sit over them like I’m being inpatient. I understand why my non-verbal client didn’t want to use the iPad app- it was so frustrating.
  • I will certainly make sure I am aware of my own body language, pitch etc.
  • I think it’s help me grow in empathy and compassion towards them, experiencing in a really small way just something of how difficult it must be. I’ve grown in respect for how they keep going after understanding a little more of what a challenge having a communication difficulty must be.
  • I can understand more deeply the importance of groups such as NETA where service users can meet others experiencing similar communication difficulties. For me, it really helped being around others who were taking part in the challenge and who could understand the difficulties.

 

We learnt a lot through the No Voice Challenge and would recommend it to anyone working with people with communication difficulties. It has helped us gain a small insight into what life is like for some of our service users. We’d like to thank everyone who sponsored us and helped us raise £532.13 (including Gift Aid at time of writing) for the Percy Hedley Foundation.

Embedding Evidence Based Practice into the Pre-registration Speech and Language Therapy Programmes

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Background
Evidence Based Practice (EBP) is now a crucial component of the practice of all speech and language therapists (SLTs). It is essential that all SLTs possess the skills necessary to formulate clinical questions, find and evaluate the evidence and integrate it appropriately into their clinical practice. Here at Newcastle University we offer the first Masters degree in EBP in communication disorders. We have also embedded EBP into the pre-registration degree programmes so that graduates have a range of skills that they can apply to any case they may come across in their clinical practice.
The EBP strand in the Speech and Language Sciences curriculum arose from a joint initiative in 2005 by three members of staff to provide a strong link between taught clinical academic and research modules (reported in Klee, Stringer, & Howard, 2009). Use of the evidence base was well established throughout all teaching, but not all students were demonstrating transfer of research into their clinical academic work or their clinical practice. The aim of explicit EBP teaching was to support students in this aspect of knowledge transfer.
The first steps were to introduce to the BSc programme a final year option module in Principles of EBP and an EBP question into a third year clinical case report. For MSc students a half day EBP workshop was delivered towards the end of their first semester as part of their taught clinical module. Subsequently, skills related to EBP have been introduced at earlier and earlier stages in both programmes following feedback from students. A series of standalone lectures/seminars in induction week for different stages and the final year EBP option have now been replaced by strategically placed lectures and joined up teaching across research and clinical academic modules as described below.

EBP for all students
There is an extensive online EBP resource on Blackboard (the virtual learning environment) available to all students and staff in speech and language sciences (includes CPD and post-registration masters and PhD students). This includes links to websites, critical appraisal checklists, research guidance and other related resources. Students are encouraged to take resources with them for use in clinical practice when they graduate. Email support is available to graduates as they move into work to support integration of EBP into their clinical practice.
Critical use of evidence is integrated into all assessment marking criteria (as appropriate) across all programmes. The requirement for students to demonstrate ability to critically appraise evidence and link it to the theoretical basis of assessment and intervention is assessed with the demand increasing as they progress through the programme.

EBP in the BSc Speech and Language Sciences Curriculum
Stage One
In the first year, principles of EBP are explicitly taught as part of the Speech & Language Pathology I module. This module is taught in the second part of semester two and comprises two Problem Based Learning (PBL) components covering both an adult acquired and a developmental case. The EBP strand is introduced as part of Developmental Speech Difficulties I by way of a short lecture followed by group work. Students are given pre-reading comprising a paper about intervention for phonological awareness. The lecture introduces students to the three basic components of EBP; to the hierarchy of evidence; to critical appraisal and the link to research methods and statistics teaching is made explicit. As a resource they are given copies of the RCSLT Bulletin EBP tutorials that will help them understand the professional and practice context of EBP (Stringer, 2010a, 2010b, 2010c, 2010d, 2010e, 2010f, 2010g). The group work comprises completion of a bespoke critical appraisal checklist in the form of an online wiki. This format allows them to contribute as a group and individually and to access work by all groups.
Stage Two
In the second year students are encouraged to apply their knowledge of research methods and statistics to a broader range of intervention studies. In Speech & Language Pathology II PBL Cases module, students use the bespoke critical appraisal checklist for intervention studies as a basis for critical evaluation of interventions for a total of eight clinical areas (four adult acquired and four developmental speech and language difficulties). During their clinical placements (in house clinics) students are supported to explicitly link evidence and theory to the interventions they are using.
Stage Three
At this stage, there is an implicit expectation in all modules that students will be critically using the evidence base. In Research Methods in Practice III students are introduced to a broader range of research methodologies building on their knowledge of quantitative methods and introducing qualitative methods, mixed methods and surveys and questionnaires. They are given extensive practice in critical appraisal of studies using different methodologies and at different levels of the hierarchy of evidence. They are also given practice formulating research questions arising out of practice-type questions (compared to clinical questions). As a component of their clinical placement assessment, students are required to write a case report about one of their clients, with explicit reference to the evidence base for their intervention and/or assessment.
Stage Four
The demand for evidential support is now explicit for all students in all aspect of their academic and clinical work. This includes: use of evidence based interventions in clinical practice; exploration of the evidence base in the Advance Clinical Practice options modules; linking the evidence base to policy, legislation and practice in the Professional Issues module. Demonstration of critical appraisal skills is required in the literature review of the students’ research project dissertations. Students are given additional opportunity to practice writing EBP (PICO) questions and information that will support them to be EBP champions in their first clinical post as a newly qualified practitioner.

EBP in the MSc Language Pathology Curriculum
Stage One
Prior to the start of module teaching, students are introduced to the principles of EBP in a one day workshop focussing on an introduction to Developmental Speech Difficulties. Students are introduced to the three basic components of EBP; to the hierarchy of evidence and to critical appraisal. In small groups they are required to critically appraise an intervention study and create a resource for the whole cohort. In the MSc Speech & Language Pathology I PBL Cases module, students use the bespoke critical appraisal checklist for intervention studies as a basis for critical evaluation of interventions for a total of eight clinical areas (four adult acquired and four developmental speech and language difficulties). During their first clinical placement (in house clinic) students are supported to explicitly link evidence and theory to the interventions they are using. This is extended into their first external clinical placement.
Stage Two
Students are now expected to be critically using the evidence base as appropriate in all modules. They are required to demonstrate the links between the evidence base and policy, legislation and practice in the MSc Clinical and Professional Education module. At this stage, students are required to undertake a clinical placement focussing intensively on one client; this is written up as their master’s thesis Extended Case Report. It expected that the assessment, intervention and subsequent analysis will be evidence based.

Future considerations
The integration of EBP into clinical academic and research modules is possibly at an optimum level now for students to be confident and skilled in their access and use of the evidence base underpinning Speech and Language Therapy practice after they graduate. However, it is continually monitored and modified in response to student and staff feedback to ensure at each stage that our students are adequately and appropriately skilled in this area.
Students are increasingly questioning the evidence base of interventions they are observing while on clinical placements. They are aware that this can be sensitive. Some of these observations arise due to commissioned work patterns or to the demands of the organisation over riding clinical decision making e.g. a set number of sessions per client regardless of clinical need; clinic-based rather than school-based intervention. It is necessary for students to be equipped and supported to engage in productive discussion with their clinical educators (CEs) about the evidence base of interventions, without them feeling at risk when it comes to their placement assessment. Clinical educators should also be prepared to explicitly engage in evidence discussions with students and require students to demonstrate the evidence base of their assessment and intervention. Newcastle University Speech and Language Sciences staff support students and CEs in this conversation through training provided at the University (e.g. CE training) and throughout the region.

Helen Stringer

References
Klee, T., Stringer, H., & Howard, D. (2009). Teaching evidence-based practice to speech and language therapy students in the United Kingdom. Evidence-Based Communication Assessment and Intervention, 3(4), 195 – 207. doi: 10.1080/17489530903399103
Stringer, H. (2010a). Changing Practice. RCSLT Bulletin, 673, 28.
Stringer, H. (2010b). Evaluating the Written Evidence. RCSLT Bulletin, 672, 22.
Stringer, H. (2010c). Evidence Based Practice in Action. RCSLT Bulletin, 674, 21-22.
Stringer, H. (2010d). Formulating Evidence Based Practice Questions. RCSLT Bulletin, 670, 22.
Stringer, H. (2010e). From the Research Strategy to Practice. RCSLT Bulletin, 698, 22.
Stringer, H. (2010f). Searching for Evidence. RCSLT Bulletin, 671, 22.
Stringer, H. (2010g). What is Evidence Based Practice? RCSLT Bulletin, 699, 22.

Comparing apples with broccoli: stepping out on the path to national outcome measures

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Ever since I first qualified as a speech and language therapist we have been discussing the need to measure the outcome of our interventions. Almost twenty years ago when I was a service manager in Newcastle we knew that we would need to provide data about our outcomes to our managers and commissioners. In an attempt to get ahead of the game and be well prepared for when the request came, we invited Pam Enderby up to Newcastle to talk to us about her newly developing Therapy Outcome Measures (TOMs). Based on the principles of the newly emerging WHO ICF (since redeveloped and modified) TOMs was, as far as I know, the first outcome measurement tool that considered multiple aspects of the client and did so in a holistic way (Enderby & John, 1999).  At that time we really collected data for our own edification and amusement as no one ever asked us for it.  

We live in a different world now and the need to demonstrate the effectiveness of our interventions has become pressing, as the structure and drivers behind commissioning have changed. However, we have no set of outcome measures that are acceptable to all and the danger we have now is that services will develop outcome measures independently that are not comparable. Commissioners will not be able to accurately or appropriately compare services with each other or evaluate their outcomes and the consequence will have a negative impact on the quality of client care. As a profession we need to be able to rise above our fierce independence as autonomous practitioners and  devise a system for measuring outcomes that enables us to compare like with like.

The Royal College of Speech and Language Therapists (RCSLT) has picked up the baton and is leading an initiative to develop national outcome measures by consensus through engaging as many SLTs in England as possible. On October 10th 2013 RCSLT held a Summit meeting in Birmingham to start the process. Although I am no longer working at the service delivery sharp end, I have been involved in the outcome measure work with RCSLT because it links into a research project that I am involved with in collaboration with RCSLT and Newcastle University Culture Lab (http://www.ncl.ac.uk/culturelab/). Consequently, at the Summit, I sat with the dysfluency group although I have no expertise and limited knowledge in that area. A Theory of Change (http://www.theoryofchange.org/what-is-theory-of-change/#6) process was used to develop some preliminary ideas at this meeting which we took forward with the North East Regional Dysfluency Clinical Excellence Network (NERDCEN) a fortnight later.

Theory of Change provided a framework for us to consider the outcomes of intervention for children, young people and adults with dysfluent speech. Theory of Change takes us from the ultimate outcomes of our intervention to consider the intermediate outcomes that contribute to them and then to the activities that we need to undertake in order to achieve the goals. The combined outstanding brain power in the room took remarkably little time to come to a consensus in each of these areas. I think this was partly down to the fact that they had been talking about outcome measures for several years and had a fairly good idea where they were heading and partly down to the structure provided by Theory of Change. Another contributing and helpful factor on the day was the presence of Dominique Lowenthal, Professional Development Services Manager at RCSLT, who has a lot of experience using Theory of Change in different RCSLT projects. Dominique guided us through each stage so that the relevant points were considered and everyone’s views were taken into account. The result is not yet an outcome measure (or two) but a path on the way and a consensus of the experts in this region. This work will continue with input from NERDCEN and RCSLT over the next few months. The aim is to have a set of outcome measures that are agreed across all SLTs that can be used in the RCSLT/Culture Lab/Speech & Language Sciences project. We are on our way to being able to compare apples with apples (even if some are red and some are green) rather than continuing to have apples in one hand and broccoli in the other while we vainly search for similarities.

 Thanks to: @domlowenthal and all the NERDCEN SLTs.

 Helen Stringer

 References

Enderby, Pam ;  John, Alex; (1999). Therapy outcome measures in speech and language therapy: comparing performance between different providers. International Journal of Language & Communication Disorders, 34(4), 417-429. doi: doi:10.1080/136828299247360