Category Archives: Policy

The challenge of discharging children with lisps

Resources are tight in the National Health Service: think one full time therapist with a caseload of around 125 children. So we have to pay close attention during our initial assessments to make sure children meet our criteria for therapy.

For speech sound therapy, children need to have at least 3 processes and reduced intelligibility, as well as age appropriate language and attention skills to qualify. So we give children with lisps, or difficulties with /th/, activities to practise at home, and discharge them. In some cases that’s easier said than done …

I can understand why parents are anxious about lisps; they worry about teasing and bullying. Sometimes I find it hard to reason with them; they’re trying to do the best for their child and I’m trying to manage the needs of a large caseload. We’re in conflict.

I almost want to play them video clips of my pre-verbal child with autism, my dyspraxic child, or my child with a severe stammer and explain that these children are my priority. Not great for confidentiality and probably not effective either!

Empowering parents to support their own child seems like the best strategy. If I can elicit an accurate /s/ in isolation during the session, I can usually convince the parents to agree to discharge. I explain the hierarchy for generalising the sound into conversation and give them written instructions for home practice.

If I can’t prompt the child to produce the correct sound in isolation (I find those lateral lisps tricky!) I tend to go down the ‘your child is not stimulable / ready’ route. I ask the parents to practise discrimination tasks with their child, talk about how the sound is produced and come back in 6 months to a year if the child hasn’t made progress and they’re still concerned.

How do you deal with parents who won’t accept that their child doesn’t meet the criteria for intervention?

Drawing a new map in speech and language therapy—thoughts from Seth Godin’s “Linchpin”

I’ve just finished reading Seth Godin’s Linchpin and his message resonated with me. Godin asks readers to make a choice and then share his ideas, so here goes!

Godin describes a linchpin as “an individual who can walk into chaos and create order, someone who can invent, connect, create and make things happen… linchpins are geniuses, artists and givers of gifts.” He says that although we were trained to be cogs in a giant machine, we can choose to re-train ourselves to become indispensable.

Linchpins don’t wait for instructions, they make their own maps. They overcome the resistance (the lizard brain that tells us our ideas will never work and everyone will laugh at us) and get their ideas out into the world.

In a recent team meeting at work, it was easy to see the therapists whose lizard brains were in control; they suggested we stop trying new ways of working and go back to the old way! Fortunately my team also has a linchpin or two; they’re generous with their gifts and keen to make change. I’m trying to be a linchpin too; we’re starting to draw our own map, overcome the resistance, and ship our ideas.

I recommend checking out the Linchpin Manifesto (PDF link) and reading the book. We need more linchpins in the National Health Service! What do you think?

Care Aims in education vs. medical model

Clare Grace raised a great question in response to my post from 2009, Clinical Risk vs. Clinical Need: managing workload and throughput:

My biggest conundrum at the minute, is that the risk assessment tools are very medical model – and don’t seem to reflect anything within the tools/structures of education – and 80% of our caseload is working into an educational setting – any thoughts or ideas would be greatly appreciated.

Although I’m no longer working in the same service, I can remember discussions about how the approach fitted with our work in education.

I’m looking at Malcomess’ “risk” and “clinical risk” grids. The risk assessment requires judgements about functional impact on Activities for Daily Living (ADL) and environmental adaptation. We can consider ADL in the classroom. In terms of environmental adaptation I’ve found a note I wrote on one of the handouts saying: “score environment which is least adaptive (and central.)” So a child in an educational environment which is significantly contributing to risk would score highly on the context column.

In terms of clinical risk we discussed thinking about school staff as well as carers in the first column: motivation for change / carer responsibility. We need to consider who in the child’s life is primary, in relation to impact. A teacher who is unable or unwilling to collaborate in the treatment process would cause a child to score lower in this column (if the SLT service was entirely school based.)

What do you think about using the tools in education settings?

Clinical Risk vs. Clinical Need: managing workload and throughput

At the beginning of the year I attended a two day training course: “Advanced Clinical Reasoning and Effective Clinical Decision Making”, facilitated by Kate Malcomess. It was an intense two days, at the end of which my brain hurt!

Kate talked a lot about risk, which she defines as, “the degree to which harm is foreseeable.” This led us to think about who can best manage a child’s risk, which is linked to the three levels of care: universal, targeted, and specialist. At the universal level—that is, for all children—we should be supporting parents to enable them to manage their child’s risk.

We discussed clinical risk, “the degree to which foreseeable harm can be managed by your intervention,” which you can think of as effectiveness. Then there’s clinical need, “the input needed to reduce risk and achieve predicted outcomes, ” which approximates to the amount of clinical input needed. Kate suggests using a clinical risk vs. clinical need grid, to prioritise workload and increase throughput.

Let’s consider a child who has both high clinical risk and high clinical need. An SLT can effectively reduce risk for this child, but a large amount of input is required. In contrast, a child who has high clinical risk but low clinical need, requires only a small amount of input for risk to be effectively reduced.

If we prioritised these high clinical risk, low clinical need children we would increase throughput: the number of children moving through the system, i.e. the children whose referrals are accepted, are assessed, offered intervention and then discharged. Currently it seems like most children are stuck at the intervention stage—we don’t discharge many, so throughput is small. If we could increase throughput, we would reduce waiting times, which may lead to more cheerful parents (and therapists!).

This way of thinking turns the traditional model, that I’m used to, on its head—there is no mention of using severity to make these types of decisions.

So how do we start? Kate talked about caseload profiling as a first step: looking at where on the risk vs. need grid we would place the children currently on the caseload. Then we can work on throughput, while keeping a record of unmet needs, to show to our commisioners. It’s going to be a lot of work, but I’m looking forward to the challenge, and want to start making some changes… I’ll keep you updated!

Bercow Review: children’s centres, training and money

I have a great way of keeping up to date with SLT issues in the media: my Grandma calls me whenever she spots relevant stories in the newspaper! She pointed out the article in the Independent which features an interview with John Bercow (an MP), and quotes Beth Junor and Stephen Parsons — both friends from Hackney.

The article prompted me to read the executive summary of The Bercow Report: Services for Children and Young People with Speech, Language and Communication Needs, and the government’s response. Lots of the recommendations in the report seem sensible; a few particularly jumped out at me.

I’m encouraged that some of the recommendations are already common practice; in some areas where Children’s Centres have successfully been implemented, I’ve observed that speech, language and communication is being made a priority (recommendation 11).

Having come across teachers who anxiously refer children with lisps to me, but seem unaware of the those with severe language delay, I think developing teachers’ understanding of speech, language and communication needs (SLCN) is vital (recommendations 21 and 22). Training teachers will aid early identification and allow SLTs to use their time more effectively.

Recommendation 14 talks about issuing guidance to schools on the use of funding, in order to meet the needs of all children with SLCN. I’ve often suggested to schools that pupils would benefit from various inexpensive resources, only to be told, “there is no budget left this year, talk to me again next year!” So a reminder of the requirement to meet all children’s needs may mean that staff on the ground, working with the children on the SLT caseload, have adequate resources.

In their response to the report, the government announced a £40 million programme called “Every Child A Talker.” The programme is supposed to ensure that early years staff can support children’s speaking and listening. It sounds great; I’ve seen how effective joint working with early years staff can be. Bring on the £40 million!

The Bercow Review has got speech and language into the news this week: for example, this article from the BBC. Just raising awareness is helpful. I’ve only read the summary, but how exciting that the Government might have too! Anyone delved into the actual report? Which recommendations do you think the Government will actually implement? It would be interesting to hear what other people make of it.