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if you want tocreate a positive communication environmentshare knowledge and your decision-making

processbreak goals down into logical steps

Read this

ow many times have you come away from a productive

meeting having agreed some very clear aims and ideas -

only to find three weeks down the line that these plans

are faltering or abandoned? Or the other situation when

you have been going on and on about developing look-

ing, listening and turn taking skills - only to be greeted

one morning by a teacher fresh off a course telling you enthusiastical-

ly how she will be implementing this new approach in her class.

Familiar? Well it certainly brings back painful memories to me. So

why were my suggestions failing to get going and yet similar sugges-

tions, when delivered through a package, were firing peoples enthu-

siasm? What was I doing wrong?

I believe that its all in the framework. Thats why these approaches

such as the Social Use of Language Programme (Rinaldi, 1992),

Intensive Interaction (Nind & Hewett, 1994) and the Picture Exchange

Communication System (Frost & Bondy, 1994) have been so successful

and so important in helping us to develop and establish these ideas in

the places where we work. They all provide a clear framework of why,

what, howand when that enables the user to understand the under-

lying principles and therefore effect real change within their practice.

I decided therefore to apply this principle to my joint work with the

teachers at Bidwell Brook Special School in our quest to create a posi-

tive communication environment throughout the school. This task,

from bitter experience, can feel like trying to get the pot of gold atthe end of the rainbow; depending on where you stand your perspec-

tive of the end point - and therefore the route - is very different. And,

most significantly in our jobs, what do we do if the teacher goes off in

a totally different direction?

ResponsibilityIt seems that we often voice frustration that our ideas and recommenda-

tions have not been taken on board. It could be argued that the respon-

sibility for ensuring that a child is provided with a suitable communication

environment lies with the person in charge of that environment: the

teacher or the parents. How they choose to run their classroom or home

is clearly their choice and ultimately their risk (Malcomess, 2001).

However Kate Malcomess challenges us, through the use of Care

Aims, to reflect upon our practice, to identify both the strengths and

weaknesses in our intervention, and to make changes. It then becomes

clear that the responsibility lies with us to get our practice right. If our

aim is that a child is provided with lots of real reasons to communicate,

then one of our underlying tasks, as well as direct intervention, is to

ensure that we get the information over to the teachers, families or

carers in a clear accessible way that enables them to understand fully:

where the child is

where you want to get to

why you want to get there and

how youre going to do it,

so that they can take an active role in decision making and developing

their own ideas.

For us, these ideas came together in a booklet Choices, Changes &

Challenges that encapsulates the way I work through the school and

follows a broadly developmental hierarchy.

It aint what you say

its the way that yoH

How do we improve collaboration with parentsand teachers of children with special needs? For

Charlotte Child, the experience of conceiving andpiloting Choices, Changes & Challenges

is proof that its all in the framework.

rlottes daughtersose to be photographed with her! A Bidwell Brook leaver group

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say itFundamental stepBeing able to make Choices, or being perceived as

able to make a choice, is the most fundamental

step for a child to being viewed and treated as a

communicator. Once children have begun to

develop their language skills, we need to focus on

extending these skills through their use, rather

than on tasks that teach vocabulary. Changes pro-

vides a structure that is based on making smallchanges within well-known routine situations

that create a communicative need. Finally

Challenges focuses on a more reasoned use of

communication and includes clarification and

repair skills.

Once the booklet was done I used it as the basis

of my sessions with the families and staff. This

meant that we could work from a shared text, I was

able to discuss and explain the information, and we

could make decisions from it. Crucially they could

take the booklet home and re-read it, which helped

the families in particular to remember certain

strategies and helpful hints. However I am always

very careful to point out that it provides a frame-

work and not a formula (see practical examples).

1. Choices

I realised very quickly in my work with families

and staff that such a simple concept as offering

choices was indeed far from simple in achieving,

and the whole area needed to broken down into

logical steps (see figure 1 for examples).

Figure 1 Examples from Choices

Start with choices that your child can see If your child doesnt reach and make a

choice... How will you know if your child is

making a real choice?

(Child, 2004)

Very often I found that people hadnt perceived

their child as being able to make a choice or to

communicate - so they either anticipated their

preferences and needs, or their experiences of

offering choices were frustrating and dishearten-

ing. A really important step for some families was

recognising the judgements that they were

already making about whether their child liked or

disliked something - and realising that choice-

making starts with these reactions. More proac-

tive choice-making will be whether or not they

reach towards the item that you are holding in

front of them and eventually, for some children,

making a choice between two offered items.

Practical example I: using Choices.Paul is a 5 year old boy with Downs Syndrome. He lives with his parents David and Sue, and older brotherMatthew.When I first met Paul and his parents, they described him as using a couple of signs (for more and biscuit) andsome sounds and words. They felt he understood most of what they said, but didnt necessarily always chooseto respond.Targets had been set to further his understanding and use of signs and words but it was becoming clear thatPaul wasnt very motivated by this work and it was becoming frustrating all round.

Paul, who had fleeting attention, was wandering around the television fiddling, and began to get cross andagitated, occasionally banging his hands together and using a grumpy cry. Sue explained this meant that Paulwas after something, and that he was using his version of the more sign to tell her.After Paul settled we talked more about the way that he communicated and we came up with a list of behavioursand a need for his parents to both notice and interpret. Paul had never yet indicated what he specifically wanted.My overall feeling was that Paul actually had little functional use of his signs, sounds or words in order tocommunicate a message. The earlier behaviours I had observed had not been directed at the adults; he hadsimply been reacting with frustration at the television not coming on with the right programme and, althoughhis use of the more sign was really positive, indicating that he knew the context in which to use a sign, itwasnt actually providing any real information.

Take controlThe introduction of choice-making is a critical part of enabling a child to use whatever communication behavioursthey have to begin to take control and lead an interaction. Its also easy to set up across the childs differentenvironments, and allows people to feel that they are helping and respecting the childs own wishes. It may be

the first time that people have actually experienced the child indicating a preference.David and Sue felt their experiences of offering any sort of choice to Paul hadnt worked and that he simplywasnt interested. Paul usually ignored any attempt by an adult to direct him and make suggestions. I reassuredthem that this was just part of where he was in his development rather than a specific problem, and that itwould be a very good idea to look at choice-making again, but this time in a more structured way.I introduced the ideas about making choices using the booklet. Immediately David and Sue could see that makingchoices was a starting point and was based on previously published work that had been tried and tested, ratherthan just an off-the-cuff suggestion. We discussed how the skill of making choices develops, and ideas to try out. Ileft the booklet with them and they knew they could contact me before our next appointment in two weeks time.I would love to report that that was it and that on my next visit Paul was making clear choices. It wasnt, andthat isnt my message. It took an enormous amount of hard work, with lengthy and challenging discussions andquite often that feeling for me of being in free fall not knowing what the outcome would be. However, whatclearly helped was the use of the joint framework so that David and Sue were able to follow up the ideas, trythem out and make informed choices themselves about what they felt their son needed and the kind of support

they wanted from me.It helped us to get through the issues about how do you know he is making a choice if you offer two thingsthat he quite likes? What do you do if he turns and runs off? Where do you stand? How do you hold the items?Why do you hold the items and whats this choice-making business anyway - he can help himself to most thingsand makes choices that way!I can happily report though that, through their hard persistence, Paul is indeed now making clear choices,reaching towards what he wants and beginning to use his sounds, signs and words at the same time.

Practical example II: using Changes to structure a classroom interactionenvironmentI had been running groups using the Social Use of Language Programme (Rinaldi, 1992) in a class of ninechildren for some time, working together with both the teacher and learning support assistant. Over time theideas had become absorbed into the everyday activities and I had got to the point where I felt that I needed tointroduce another new idea. The children were aged 6-7, all with severe learning difficulties, including two withautism using Picture Exchange Communication System (PECS) books.

We started to look at how we could create spontaneous reasons for the children to communicate during theday, prompted by in part by the development of the PECS approach, and agreed that it was equally importantfor all the children in the class.However as I sat there with the staff suggesting the old favourites such as just a drop of paint, no pencil,things out of reach, I didnt need their bemused faces to know that such hotchpotch planning wasnt terriblypractical. It also became very clear that we were viewing the whole thing rather differently; I could see all my dis-ruptions creating motivating reasons to communicate - they could foresee behavioural meltdowns and not beingready for playtime. Quite honestly they had a point, and so this was the beginning of drawing up the framework.The process of organising exactly what I meant by Changes and trying out ways of creating them helped me togain a lot more confidence in target setting and evaluating outcomes and I became a lot more realistic in myexpectations. Having the framework meant the teaching staff could see where my ideas had stemmed from andthen adapt them to their own style and needs within the class.It also enabled us to see a clear progression over the school year, identify any particularly tricky areas for individ-uals and essentially create a naturally communicative environment that extended beyond the snack routine and

beyond the speech and language therapy slot.

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Common situations and questions that I

addressed in this section included:

How do I know if my child is really making a

choice?

What do I do if they dont react? and

Clear ideas to try when things dont go to plan.

2. ChangesFor some time in schools I had been using Joint

Action Routines (J.A.R.) (Coupe OKane &

Goldbart, 1998), which focuses on creating

changes within everyday routines that prompt

communication and interaction. This had worked

well but, in trying to recreate the same approach

with families, I realised that I ended up structuring

it so much that the suggestions were rather rigid

and, if the families didnt agree with them or the

suggestions didnt immediately work, they were

quickly dropped or discounted.

With the written structure the families were

able to develop their own ideas in keeping with

their belief systems and environments. It also pro-

vided the opportunity for us to evaluate jointly

how things had gone and to plan the next step.

Changes is organised into three areas:

a. new events - includes new choices.

b. errors - making mistakes.

c. omissions - missing things out.

I also split errors and omissions into person / action

/ item in order to prompt a range of different ideas

when planning (see figure 2 for examples).

Figure 2 Examples from Changes

Changesa. New Event

New Choices - a different biscuit / drink /video / game

Novel Events - something weird thatsworth a strange look, if not a comment:boots in the bath / sparkly wig on the dog.

b. Omissions Missing out an ITEM - no spoon, no cup,

an empty jug. Missing out an ACTION - put them on

the swing but dont push; put on theirtrousers but dont pull them up.

Missing out a PERSON - one persondoesnt get a biscuit.

c. Errors - making mistakes Incorrect ITEM - when the child asks for

an apple, you give them a banana. Incorrect ACTION - when they tell you tobrush dolly, you wash her.

Incorrect PERSON - when they tell youits Daisys, you give it to Molly.

(Child, 2004)

I gave illustrations that people could work from,

but this still needed careful discussion to make

sure that the families or staff took on the princi-

ple and didnt get hung up on the example. For

example I would commonly hear, Oh, but Jamie

wouldnt bother at all if you only put one shoe on

him. I had to be ready to say, OK, the principle

is that you make a mistake with an item. What

could you do that would cause a response with

their favourite toy?

3. ChallengesIn spite of the name, challenges should focus on a

gentle extension of changes with a problem solv-

ing element, rather than creating significant dis-

ruption (examples in figure 3).

Figure 3 Examples from Challenges

Challenges1. Opportunities to ask for more

Providing small amounts of somethingthey want - food, paint, glue.

2. Opportunities to ask for helpNot always anticipating the things yourchild needs help with - leave jars doneup, leave a door closed, remove something from the place they always expectto find it.

3. Active listening targetsDescribed by Maggie Johnson (1996) asmaking listening an active process so that

the child takes responsibility forunderstanding a message - so that ratherthan guessing or opting out, theyacknowledge the difficulty and ask forrepetition, or seek clarification.

(Child, 2004)

Again I had been working with Active Listening

Targets (Johnson, 1996; 2001) in school with good

results and had found them to be a natural progres-

sion from Joint Action Routines (Coupe OKane &

Goldbart, 1998), further developing the students

confidence in using their communication skills.

There were some initial concerns that teaching the

students to communicate the message I dont

know would encourage them to use it to opt out.However it actually allowed them to opt in, because

they were able to replace their embarrassed silence

and bowed head with a question or comment that

meant they continued to take part. Any real opt out

was tackled separately. The outcome was a far more

confident group of young people who were only

too keen to correct us and became very assertive in

ensuring they were understood.

I also included requesting more and help in

this section. I commonly found people would

introduce these quite early to children but, in

fact, by their abstract nature - you cant see a

more or a help - they are actually quite tricky to

communicate. By placing these concepts in this

section it helped people to focus on the earlier,more concrete requesting skills first.

Using the framework Choices, Changes &

Challenges has begun to make a difference to the

way we set up communication programmes in

Bidwell Brook School and to the expectations we

have of the children.

Shared partnershipPlanning around communication use has become

far more of a shared partnership. Through sharing

my knowledge and decision making process I am

able to work far more constructively with the teach-

ers and families. However it is important to stress

that this is all still very much in a developmental

phase. Colleagues within my department are just

beginning to try out the structure in their schools

and clinics and I am constantly rewriting bits of

the booklet as I go. So, no, it hasnt revolutionised

my work or the lives of the teachers at Bidwell

Brook Special school - but it feels like a really pos-itive step forward.

I am convinced that frameworks have got to be

an essential part of the way we work with other

people. Creating a shared knowledge base from

which you can all work and plan proves that its

not what you say, but how you say it.

Charlotte Child (e-mail chaos@hgf.eclipse.co.uk) is

a speech and language therapist with South

Devon Healthcare NHS Trust.

ReferencesChild, C. (2004) Choices, Changes & Challenges.

South Devon Healthcare NHS Trust. Available on

disk for 6.00, e-mail chaos@hgf.eclipse.co.uk for

more information.

Coupe OKane, J. & Goldbart, J. (1998) Communication

Before Speech. David Fulton: London.

Frost, L.A. & Bondy, A.S. (1994) The Picture

Exchange Communication System. Training

Manual. Pyramid Educational Consultants UK Ltd.

Johnson, M. (1996) [2001] Functional

Communication in the Classroom [and at home].

Contact the Commercial Office, Dept of Psychology

and Speech Pathology, The Manchester Metropolitan

University, Elizabeth Gaskell Site, Hathersage Rd,

Manchester M13 0JA, tel. 0161 247 2535.

Malcomess, K. (2001) The Reason for Care.

Bulletin of the Royal College of Speech &Language Therapists. November.

Nind, M. & Hewett, D. (1994) Access To

Communication: Developing The Basics Of

Communication With People With Severe

Learning Difficulties Through Intensive

Interaction. David Fulton: London.

Rinaldi, W. (1992) The Social Use of Language

Programme. NFER Nelson.

AcknowledgementAn enormous thank you to the staff at Bidwell

Brook Special School, Dartington, who have let

me try out so many new ideas on them and with

the children. They have smiled (or gritted their

teeth) as Ive created chaos, and even encouraged

me to try again next week. Guess what guys - Ive

thought of our next project already.

Do I yearn for revolution - or focus ona positive evolution?

Do my plans make the why, what,how and when clear?

Do I provide a framework rather thana formula?

Reflections

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 200416