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This essay will present a child's journey through speech and language therapy within a special school setting. The main focus of the intervention is on developing and supporting early communication skills using alternative modes of communication in an inclusive environment. The client's journey will date back from 2004 to the present and consider future interventions.
The guidelines stipulated by the Data Protection Act (1998) and professional bodies the Health Profession Council (2010) and the Royal College of Speech and Language Therapists (RCSLT) (2010) regarding confidentiality have all been adhered to. Ethical guidelines were further followed by ensuring that as a looked after child, informed consent was obtained from the Local Authority (LA) in order for the student to access the child's case notes (RCSLT, 2006) (appendix 2). No identifiable information was taken offsite. To maintain anonymity the child's name has been replaced with a pseudonym, Amy.
Amy is a 14; 5 year old English speaking female. She has a medical diagnosis of Dandy-Walker Syndrome (DWS), the main feature of which is hydrocephalus and Agenesis of the Corpus Callosum (ACC) (see apprendix 1B for further details). Amy has also received a diagnosis of Global Developmental Delay (GDD) aged 4;11 because she was experiencing significant delays in achieving developmental milestones within all developmental domains, these include, fine/gross motor, speech and language, social and personal, cognitive and activities of daily living (Shevell et al, 2005). Amy did not take her first steps until 4;0 years old with the aid of a Zimmer frame or utter her first word until approximately 3;6, both skills which typically emerge between 12 and 15 months (Sheridan, Sharma and Cockeril, 2008) (see appendix 1B ).
As a result of Amy's GDD coupled with her physical and medical conditions Amy was awarded with a Statement aged 4;11 detailing the educational help she would receive. This also included a place at a special school at her parent's request and specialist resources such as staff time and special equipment to meet her physical needs. Amy currently attends a school for children with severe and profound special needs in Essex County. She is currently working at P level 6-7 towards Stage 1 of the National Curriculum and is a "very social and lively girl".
Amy's initial contact with speech and language therapy occurred while the school was under the care of the National Health Services (NHS). They subsequently withdrew their services for funding reasons before the Local Education Authority (LEA) employed a speech and language therapist (SLT) to work full-time at the school. The issues surrounding a change from the NHS to the LEA meant that under the common law duty of confidentiality, the present SLT was not permitted to access client records (RCSLT, 2005). In order to provide continuity of care, an SLT must have knowledge of the client's current speech and language therapy management within the NHS or any practice would be considered unethical (RCSLT, 2006). The SLT was therefore required to create new files. For this reason, the student will follow Amy's clinical journey from 2004 when the current SLT started at the school.
The school policy  (2007) states that every child is entitled to speech and language services provided at the school. Unfortunately, the details of Amy's referral and initial assessment are not documented. Good record keeping is essential and means that if another therapist were to pick up a clients file they would be able to see what has and has not been done and the rational for the decisions made in order to provide consistent client care (RCSLT, 2006). It is also unclear whether she was seen within 13-weeks as recommended by the RCSLTs Communicating Quality 3 (2006) and the school currently has no policy on it. From a discussion with the SLT, it was evident that Amy was assessed via classroom observations and a combination of informal and formal assessments and additional information was gathered from discussions with her foster parents and class teachers.
Many individuals with developmental disabilities have significant speech and language impairments (Abbeduto, Evans and Dolan, 2001). Amy's GDD has a significant effect on her communication abilities. During her first annual review at 7;10, the SLT stated that Amy's levels of language and speech development were "approximately at an 2 year level". A typical child her age has fluent speech that is grammatically correct (Sheridan et al, 2008). Amy understands a limited number of verbs such as "eating, but only in context" and has a "limited expressive vocabulary".
As per Amy's Statement (see appendix 1A) and following an assessment of her communication skills, the SLT and educational staff were able to make predictions about how her communication would impact on her learning and social development (Popple and Wellington, 2001). Subsequently, communication targets have been incorporated into her Individual Education Plan (IEP) to be reviewed each term in order monitor her progress. IEP's also provide feedback on the effectiveness of the intervention.
Amy's understanding of language and expression of speech is being supported in the school environment under the Total Communication Policy  which states that every child should be provided with the opportunity to communicate using a range of modalities. Total Communication benefits children with delayed speech and language development and those with learning disabilities through the use of Augmentative and Alternative Communication (AAC) which are intended to supplement speech (ASHA, 2011). AAC is a holistic view of communication which uses natural gestures or signs, symbols, real objects or vocal noises alongside speech to reinforce meaning using whatever means available (Detheridge and Detheridge, 2002).
Amy's communication needs have since been recognised and are being supported at the school. The SLT implemented a programme of intervention using a signing system to support Amy's "limited understanding and vocabulary". Signalong and Makaton are based on British Sign Language (BSL) and are designed to be used in conjunction with speech to support spoken words (McLachlan and Elks, 2007) where language difficulties arise from learning disabilities (Singalong, 2007). Signalong is being taught at the school as opposed to Makaton because it has a larger vocabulary (McLachlan and Elks, 2007) which means it is inherently more flexible.
Amy's primary means of communicating was reported as "pointing and pulling an adult hand" aged 4;11. This observation highlighted Amy's 'can-do-already- skills which are an important factor to take into consideration when deciding on which Total and Augmentative Communication system to use (McLachlan and Elks, 2007). Signing is viewed as a natural progression from gesturing (McNeill, 2004) and Amy was already demonstrating this skill. Teaching Amy Signalong would have been the option most beneficial to support her "limited understanding and use of expressive language" in a total communication environment where spoken language is supported by the use of signing and symbols.
The common perception from parents is that the introduction of AAC interventions will inhibit speech development in children (Silverman, 1995), particularly in individuals with developmental disabilities (Downden and Marriner,1995). However, DiCarlo et al's (2006) reported no apparent reductive effects on verbalisations in toddlers with or without disabilities when being taught using speech and manual signs in an inclusive environment. This helps to relieve concerns expressed by parents. However, results reflected a brief snap shop in a busy classroom and did not take into account parents perceptions of children's speech at home.
Glennen and DeCoste (1997) stated that individuals with developmental disabilities may come to rely on AAC if it is perceived as an easier mode to communicate than using speech, therefore, individuals would be less inclined to learn how to communicate using speech. However, the counterargument is that AAC actually enhances speech production in individuals with developmental disabilities (Hurd, 1995; Powell 1999). Sisson, Rowland and Barrett's (1984) case study reported that total communication (speech plus sign language) was more effective in facilitating sentence repetition than when compared with using oral methods alone in three language delayed children with learning disabilities. Similarly, Clarke, Remington and Light (1986) reported an increase in expressive speech in one child. This was later supplemented by Clarke, Remington and Light (1988) who also reported improved expressive skills in 2 children with learning difficulties following total communication.
Despite the fact that all three articles are somewhat dated, the results continue to be cited in current reviews. Millar, Light and Schlosser's (2006) meta-analysis cites all three papers and confirms the positive effects of AAC on speech production in children and adults alike. The fact that Sisson et al's (1984) study is based on American children and signs and Clarke et al's (1986;1988) is based in the UK demonstrates a degree of consensus in the data at an international level, thus contributing to best evidence. Nonetheless this area of research may benefit from current explorations of the mediating effects of sign on speech in larger British populations with longer follow-ups.
The multi-disciplinary team decision to introduce Signalong to Amy is therefore routed in best evidence. The effectiveness of the intervention can be further witnessed in Amy's attempts to indentify and realise stimulus from the South Tyneside Assessment of Phonology (1988) aged 13;7. Where previously Amy was unable to complete the phonological assessment, because she did not have the vocabulary, she was able to complete it and also support her speech with signs. This is a particularly useful skill for Amy to have and will ensure that she is able to express herself effectively particularly when faced unfamiliar people since her speech production remains unclear. Amy realised 'flower' as /faÊŠwÉ™/ and 'girl' as /geaÊŠ/. Research states that speech should be 100% intelligible by age 4 (Gleason and Ratner 2009), therefore, Amy is significantly behind her typically developing peers.
In addition to signing, Amy's intervention also includes the use of symbols to further broaden her ability to communicate, particularly in the classroom. The visual support set Picture Communication Symbols (PEC) are adopted at the school because they are considered iconic, easy for children with severe communication difficulties to use (McLachlan and Elks, 2007) and are available in colour which is motivating to new users (Detheridge and Detheridge, 2002). Amy has demonstrated good use of symbols and can now make choices from up to 6 items.
Results of a meta-analysis suggest that visual symbol sets are effective in enhancing speech production and social communicative behaviour in populations of individuals with learning difficulties (Hart and Banda, 2009). This has contributed to the evidence base that has influenced the decision to include symbols in Amy's intervention. However, it is important to bear in mind that the results were largely representative of individuals with Autistic Spectrum Disorders (ASD) (58%) and concrete visuals specifically tap into the strengths of this particular population (Hart, et al 2009). As a result, caution should be taken in directly applying results to other groups of individuals with learning difficulties.
Over the last year, Amy's Statement has been amended to include "her vision is limited". Since symbol selection relies heavily on visual skills, a reappraisal of Amy's near vision and scanning skills will be necessary to ensure ease of access. To accommodate this it may be necessary to replace current colour symbols with black and white symbols which offer greater contrast to support her vision (Clarke et al, 2001). This also highlights the importance of information sharing between teams.
Speech and language therapy intervention can be delivered in two ways, directly when the SLT works with the child on a one-to-one basis or indirectly where the SLT works with the child's parents or other professionals such as class teachers and TAs (Kersner and Wright, 2001). Money (1997) studied adults with learning difficulties and found a combination approach; working directly with the client and their carer and teaching their carer communication skills was significantly more effective in facilitating communicative competence than either approach alone. This combination approach may reflect the complexity in communication needs of individuals within this particular population (Graves, 2007).
More recently, Boyle et al (2007) compared the effects of receiving direct therapy with a SLT with indirect therapy with a trained speech and language therapist assistant (SLTA) in primary-school aged children with primary-language impairment (PLI). The results of the randomised-control trial concluded no difference in the effectiveness of service delivery between SLT and SLTA groups in terms of language outcomes. This was similarly echoed in Boyle et al's (2009) trial on children with language impairments (LI). It is encouraging to see consensus in the results as both RCTs demonstrate support in the effectiveness of adopting indirect therapy and all three studies in recognising the importance of appropriate training for staff and parents that are required to deliver the intervention.
More recently, a new philosophy has shifted the way in which services are delivered to individuals to learning disabilities (DH, 2001). Once primarily focussing on the individual with the learning disability, the focus is now on adopting a person-centred approach to promoting social inclusion by looking at the communication environment (Graves, 2007). Money and Thurman (1996) identified that communicative success would exist providing individuals with learning disabilities are given a means of communicating, reasons to communicate and opportunities to communicate. As a result, emphasis was placed on indirect interventions, i.e. via processes, people and within an individual's environment (RCSLT, 2006).
The Code of Practice for Special Education Needs (DfES) (2001) recognises communication as a fundamental in learning and progression and confirms that speech and language therapy should be integrated into the educational environment. Children with learning disabilities have been identified as having difficulties generalising (Money, 1997), therefore, communication interventions should become part of the child's everyday situations (Reid et al, 1996) and delivered within a broad context thus, opening up communication opportunities (SLCN, 2009). As a result, education-based interventions require staff to take a collaborative approach by working together and jointly agreeing on targets (Kersner and Wright, 2001).
SLTs also play a crucial role in communication training for those working with individuals with learning disabilities, including educational and health staff, social care professionals, parents and carers (ALD, 2003; SLCN, 2009). Amy's class teacher has recently attended Communicating with Children with Complex Needs training which was delivered by the SLT and which covered Amy's types of communication needs. Although the class teacher has jointly agreed on Amy's communication aims and has been working with Amy under the guidance of the SLT, in discussion it was revealed that AAC training is not a mandatory requirement and therefore, a number of staff have not received any training.
Although it has been possible to pick up signs ad-hoc within the school environment, research states that trained staffs are more accurate with their signs (Chadwick and Jolliffe, 2008). Similarly, DiCarlo et al (2006) found that those children that were exposed to signs via modelling increased in their use of signs. Without training, Amy's teacher would not have a full understanding or be able to accommodate her communication needs which could result in Amy's communicative actions potentially being disregarded. This could similarly impact on the number of opportunities made available to interact, reinforce and generalise newly acquired AAC skills (RCSLT, 2005) impacting on the effectiveness of the intervention. There is evidence to suggest that teaching assistants have had restricted access to formal training (Reid et al 1996) therefore, this may be an issue that needs to be addressed at the school in order to work towards best practice.
Parents also need to be included in this wider package of support and should be involved as they can bring their expertise about their child into therapy planning (RCSLT, 2006). While this is recommended in practice, workplace barriers can make it difficult to implement particularly in an educational setting with parents being able to attend the school and time constraints (Watts Pappas et al, 2008). Additionally, Amy is bussed into school which therefore limits contact between the parents and SLT.
Best evidence suggests that parental involvement is encouraged so that skills can be embedded into the child's home environment as well as their school environment (SLCN, 2009). From discussions with the SLT it became apparent that Amy's foster parents do not sign and have not yet accepted an invitation to attend Signalong training run by the SLT at the school. Signing is only useful outside the school environment if parents are able to understand them (Chadwick and Jolliffe, 2008) and to be effective they should be part of normal communication (McLachlan and Elks, 2007). Amy's foster parents have also received no advice on using symbols, however, they are generally more iconic than signs and usually have the word above the symbols (McLachlan and Elks, 2007). If Amy's parents are unable to attend the school, symbols may be a more practical AAC system to use to support Amy's communication attempts at home. This may require the SLT to make a home visit, make a phone call or make a note in Amy's home school diary explaining their use. It is important to ensure that they receive appropriate support and guidance which will enable them to support their child's communication needs (RCSLT, 2006).
Amy has been known to a multidisciplinary team (MDT) from a very young age due to her physical needs. This has required the SLT to work closely with other allied health professions (AHP) that are able to provide relevant details of how physical disabilities might contribute to communication difficulties (Kersner and Wright, 2001). Amy is regularly reviewed by the physiotherapist due to developing sclerosis and wears a spinal brace for support. She is also seen by the occupational therapist who works together with SLT to ensure that her environment is conducive to support her communication and learning at school. Amy has been issued with a high back padded class chair at school for comfort with arm rests. Being able to sit in a good position will support inclusion and aid attention and listening skills (Swindon LEA, 2005) which are key skills in learning.
Social services are also part of the wider case management and liaise with staff about Amy's wellbeing outside of school, particularly since she is a looked after child. Amy has moved house a number of times, thus a change in life events (Gross, 2005) which could have a psychological impact on her wellbeing. Therefore an effective intervention is one that is person-centred and requires a holistic understanding of the individual and all aspects of their life to be taken into consideration when planning an appropriate intervention (RCSLT, 2006).
Future planning in regards to intervention work for Amy will include further supporting her use of signs and symbols. From a discussion with the SLT, it was revealed that Amy's mother has requested for her to be supported in improving the clarity of speech, however, to be able to work on phonology, Amy must demonstrate phonological awareness. Unfortunately, the degree of Amy's learning disability means that she does not have the cognitive ability to do so (ref)....
In response to the literature
Amy has demonstrated improved receptive and expressive skills from the time she started school where her main form of communication was pointing to now being able to communicate her wants and needs with speech and the use of signs and symbols. However, it appears highly unlikely that she will catch up with her typically developing peers (ref) to be completed...!
Means, reason and opportunity