Current trends in SLT practice in the UK: Application to working overseas

Report on the CTI study day 11 May 2013At the United Reformed Church, Bethnal Green, London

10.00 am – 4.30 pm

Report author: Clare Barker for Communication Therapy International

The views expressed in this report are not necessarily the views of CTI or its members.

CTI: www.commtherapyint.com ctimembership@yahoo.co.uk

Please note: Low- and middle income countries will be referred to as low-income countries in this report.

Current trends in SLT practice in the UK: application to working overseas

SUMMARY

This year’s study day focused on identifying similarities between current good practice in the UK and in developing contexts. The format and topics were as follows:

Morning

Welcome by CTI Chair, Mel Adams, with details of some relevant reading material (see “References” at the end of this report).

Same Same But Different: a discussion and workshop on transferable SLT skills for working at the universal level in the UK and overseas. Delegates considered a set of themes and how these could be applied to different contexts.

Lunch was provided and offered a networking opportunity.

Afternoon

CTI Annual General Meeting. Minutes have been circulated separately.

Working with specific impairment groups: autism, dysphagia, stammering, and AAC. Delegates each joined one group. Each group considered current UK practice, issues around transferring this practice to a low-income context, and a set of recommendations.

Feedback to whole group and end of day.

Page 2 of 11

SAME SAME BUT DIFFERENT: An introduction to transferable universal SLT skills, issues and potential challenges – led by Clare Barker and Jodie Davies

Clare Barker is a Speech and Language Therapist working in mainstream primary and secondary schools under a partnership between the NHS and the Local Authority.

Jodie Davies is a Speech and Language Therapist working in specialist education settings (primary and secondary).

Clare and Jodie have both volunteered in Cambodia at different times and in various settings, with the Rabbit School as a setting they have in common.

Part one: introduction. Clare and Jodie reminded delegates of the basic principles of the universal – targeted – specialist model for design and delivery of services, formalized as a best practice model for UK SLT services for school-age children in RCSLT’s 2006 position paper (Gascoigne, 2006). They then explained that the focus of the morning would be on the universal level because it is efficient and it reflects the United Nations Convention on the Rights of People with Disabilities (whilst specialist services should be available wherever needed, countries should promote “universal design” in products and services wherever possible). Jodie and Clare introduced a set of themes they had identified when they compared their UK practices with each other and with experiences of working in a low-income country:

Community: wherever we work, it is essential to know and understand the specific context, clarify who our partners are, and define the “universe” that is the focus of intervention

Culture: each context has its own cultures and values, including how disability is regarded and how responsibility is accorded. We need to understand these and either work with them or seek to change them.

Leadership: people respond to the priorities and instructions of their own leaders, so local leaders are crucial for sustainable input.

Working through others: it is our role to add value to what is already present, not to undermine it or to do jobs that others can do.

Ownership and responsibility: needs to be in the hands of our partners, otherwise they will remain overdependent on the Therapist.

Voice of the client: “nothing about us without us”. By definition, people with communication difficulties find it harder than peers to make their views known. It takes an active commitment to ensure they are properly represented but it is important that they are, as their views can surprise us.

To illustrate, examples were discussed from UK practice in special schools and mainstream schools and from practice in Cambodia.

Current trends in SLT practice in the UK: application to working overseas

Part Two: application. Delegates split into groups to consider these themes as they might apply in a range of international settings. They fed back as follows:

Country: Bangladesh Setting: HospitalTheme Considerations in this contextCommunity Work with local SLTs

Find out how it currently works – are there relevant MDTs to join?Culture Is there a stigma?

Stereotypes and expectations of people with communication needs Ideas/awareness Is the focus on seeking cure?

Leadership What is the awareness of MDTs? What is the referral process? Models of working – Medical?

Working through others Where does CBR operate and how? Outreach? BPF (disabled people’s organization) Training assistants

Ownership and responsibility

Clarify expectations and roles Information and understanding of prognosis

Voice of the client Awareness of their condition Priorities

Country: Sri Lanka Setting: Provincial clinicTheme Considerations in this contextCommunity Multilingual

Local SLTs Compulsory education

Culture Unregulated input Autism “shops” Breaking down negative stereotypes

Leadership Identify government priorities Working with politicians

Working through others SLTs don’t work in schools – health vs educationOwnership and responsibility Parents are trained + must then pass info on to teachersVoice of the client Mainly it is the voice of professional that is heard

Health-led SLT transfer to education is poor Parents communicate info to teacher CBR – focus groups

Page 4 of 11

Current trends in SLT practice in the UK: application to working overseas

Country: Cambodia Setting: OrphanageTheme Considerations in this contextCommunity Check appropriate working hours/timesCulture Need to take time to understand staff-children rapport – don’t

make assumptions based on our own interaction styles Understanding staff/general perception of “orphans” – what the

term means, how people feel about these childrenLeadership Expectations of the leadership: does what they expect tie in with

what you hope to contribute? Are the expectations of the “leadership” the same as those of the

staff “on the ground”?Working through others Need to clarify role of SLT + “others” + that they are aware when

to refer on to SLT Training open for all

Ownership and responsibility Promote ownership of roles + responsibilities that come with job/roleVoice of the client Encouraging focus individual interaction

How to obtain child’s views May be an area of strength in some contexts

Country: Bolivia Setting: SchoolTheme Considerations in this contextCommunity Local

MDT Professionals

Culture Language barrier How do things work? Reduced awareness of disability Implications of faith Attitude to disability Attitude to education

Leadership Link with those in senior positions Importance of community leaders Shifting/unstable leadership Trust

Working through others Volunteer activities – where they are NGOs – current activity

Page 5 of 11

Current trends in SLT practice in the UK: application to working overseas

Link with current SLT programme Information gathering

Ownership and responsibility Joint work with family Is there a curriculum?

Voice of the client DNA school – barriers to attending Disability – what are NGOs doing to give a voice? Do families feel they have a voice?

WORKING WITH SPECIFIC IMPAIRMENT GROUPS: autism, dysphagia, stammering, and AAC. Delegates divided into groups. Each group considered current UK practice related to one impairment area, issues around transferring this practice to a low-income context, and a set of recommendations. They then fed back to the whole group as follows:

Dysphagia – led by Mel Adams

Assessment InterventionLow techHigh techIssues in low-income contexts

EquipmentFeeding methods and strategiesRemedial therapy and nutrition

Issu

es in

low

-inco

me

cont

exts

Clinic in naturalistic settingLimited textures, culturally appropriate foodsWho pays for trial foods?Availability of high tech equipment + electricity

Resources + equipment availableCultural issuesLogistics (time,accessibility)Evidence baseNon-complianceSLT knowledge limitationsCostsExpectations

Solu

tions

Parents bring in food and feed childExplore culturally appropriate and available foodsLocal equipmentMarketplace, local carpenters, etc

MDT working??Seeking funding + link into local programmesLow tech alternativesExplore local food/feeding normsTraining + experimentingPrioritiesFunctional input

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Autism – led by Amy Lettington & Himali de Silva

Assessments UK Assessment overseas Assessment toolkit

FormalDISCOADIADOSCanterbury + ThanetDSM checklist

BrackenPLSCELFDerbyshireRAPT

InformalObservations – generic/structuredParental checklistsAudit – environmentReports by othersDerbyshire – keywordsSymbolic playBlanks

Some UK assessments can be used, but not norms

Useful tools Play-based assessment:

o not appropriate in some settingso adult involvement

Informal assessment – may not be acceptable

Pay for intervention – expectations Input from others Who’s in charge, e.g. of diagnosis

Find out “play” information – observe Aspects of formal assessment appropriate for

context Bubbles! People games Observe typically developing children Co-worker who speaks local language Attention activities Environmental audit Blanks – using books Using one toy at a time Feely-bag of sensory items Thorough case history – e.g. Hanen Talking Mats

Therapy UK Tool kits for overseas PCI + It takes two to talk PECS Intensive Interaction Social communication groups (including

parents). Focus: attention, listening, turn-taking, eye contact, language)

ABA, Sonrise Talking Mats Early Bird

1. Photocopiable material from ITTTTEarly Bird, Signet, Parent-friendly

2. Adapt packages3. Awareness raising re autism + different learning styles4. Value of diagnosis?5. Support group for parents6. Intensive Interaction*7. Use of PECS as a “task” vs use of symbols for communication8. Adapting adults’ communication styles. Modelling repeatedly9. Visual timetables using hand-drawn pictures10. TRAINING11. Gestures12. LANGUAGE – colour-coded semantics, Language for Thinking, general strategies, ?Black Sheep13. Playscripts

Current trends in SLT practice in the UK: application to working overseas

AAC – led by Seray Ibrahim & Miranda Macaulay

Current practice in UK Issues in low income context Options / solutions

Uni

vers

al

Training packages to schools, e.g. mainstream schools Environmental audits Whole school targets Joint working to support whole school approaches, e.g.

Makaton Parent workshops Service Level Agreements/Policies with early years and

school settings Disability awareness groups promoting communication

e.g. 1Voice, SCOPE, Communication Matters Strategic level – highlighting need for joint commissioning

across services

Lack of shared understanding Materials / resources / cost? /

sustainability (laminating, software)

Costly to attend training Helping people understand basics

of communication (importance of non verbal), including child in activities of daily life

Sign systems ?appropriate Lack of access to those who need

it most

Show example Exploring expectations Look at child as whole Incorporate current practices

locally (e.g. role of play/singing)

Recognize local culture Find out how typically

developing children learn in that setting (e.g. sibling? PCI?)

Train communication health workers

Use local groups that exist already + find ally from local group

Photograph/draw signs – agree set

Sharing stories, lobbying role, government, social services

Empowering parents Survey of families in area,

help desk in hospital

Page 8 of 11

Current trends in SLT practice in the UK: application to working overseasTa

rget

ed a

nd sp

ecia

list

MDT assessment and intervention Liaison with specialist teams e.g. diagnosis/prognosis,

equipment/bespoke equipment, further advice Direct intervention (e.g. individual/group therapy) Makaton – early signing groups for specific client groups

(e.g. young children with language delay/disorder) PECS programmes for training and delivering (e.g.

intensive summer group to establish system) Attending IEPs/shared goal setting Training others to deliver specialist intervention Parent support groups, e.g. targeted activities/therapist

led workshops Identifying child’s level of need and quantifying this, e.g.

for statements Setting up equipment and devising systes (e.g. creating

communication books/PECS books, hi-tech grids, etc)

Materials …. What materials are appropriate If parents are “trained” who can

they then share with? Language barriers for buddy

system Parent ownership/support “expert

model”? vs ??? SLTs from same country may not

be helpful

Buddy systems with UK etc

?support groups / feedback

Training for SLT – SF approach Use paper/pen/whiteboards /

natural resources, packet/objects

Page 9 of 11

Stammering – led by Trish Chilton

Closing remarks from CTI Chair, Mel AdamsMel reminded delegates of other models of appropriate service design for low-income contexts – see references.

Oral evaluation of study day.

Delegates said that key learning points from the day were as follows:1. Best practice information2. Importance of getting to know local culture3. A forum for networking, a great resource4. CTI is entering a more productive place with the study days, it's becoming more sustainable5. Useful to reflect on places visited, not just specific to countries but also generic issues across countries/cultures6. Useful to think 'who am I helping?'7. Importance of general traveling and getting used to physical environment of other countries

References and further reading

Development of a communication disability model and its implication on service delivery in low-income countries. Hartley S., Wirz S. Social Science & medicine 54 (2002) 1543-1557

Gascoigne, M. 2006. Supporting children with speech, language and communication needs within integrated services. Position paper. London: RCSLT

International Journal of Speech-Language Pathology, 2013; 15(1) This issue of IJSLP applies the WHO World Report on Disability (2011) to people with communication disability and focuses on underserved populations in the Majority and Minority world including people in Australia, Bolivia, Brazil, Ghana, India, Malaysia, South Africa, Viet Nam, Togo, Uganda, UK and US.

UNICEF http://www.unicef.org/ useful source of statistical information and information about campaigns and debates at country, regional and global levels

United Nations Convention on the Rights of Persons with Disabilities (2006) available at: http://www.un.org/disabilities/convention/conventionfull.shtml

World Health Organisation http://www.who.int useful source of statistical information and information about campaigns and debates at country, regional and global levels