Wednesday, 20 September 2017

Assessing the SLCN of a child with PDA

When I did the PDA webinar for the PDA Society recently (to listen click here), a SLT asked me for tips for assessing a  child with PDA. I said that they usually weren't too bad for initial assessment as children with PDA often enjoy being centre of attention and novel situations. It is often much  worse when trying to engage with  therapy. I usually use a dog in the sessions so he makes life easier.

However, I was reminded at the weekend, that this is not always the case and that we need tips and strategies to get us though these potentially trickier situations.

Just remind ourselves of the main features of PDA:

·         obsessively resisting ordinary demands
·         appearing sociable on the surface but lacking depth in their understanding (often recognised by parents early on)
·         excessive mood swings, often switching suddenly
·         comfortable (sometimes to an extreme extent) in role play and pretending
·         language delay, seemingly as a result of passivity, but often with a good degree of 'catch-up'
·         obsessive behaviour, often focused on people rather than things.

We need to assess them to get an accurate picture of strengths, be able to give strategies for family and staff and to be able to devise a programme of work to address their issues and  to maximise their potential. Obviously,  the 2 areas we are concerned with are language processing and social communication.

We need to be aware that they do not like people to know they are struggling so they may
pretend/hide/disguise, distract or get angry..... or all 3.

1. Pretend, hide, disguise:
This is  a key factor in PDA. A parent may ask them to do something very simple such as turn off the TV but they will have a wide range of reasons why they can't e.g. my legs don't work, I can't find the remote, I can't reach the remote, I'm too tired etc. This can escalate if pushed. You may find similar issues when trying to assess. They might say, 'I'm not doing your stupid tests and you cant make me' or 'you're only being nice to me so I'll work with you and I'm not falling for it.' That is true, so we need things in our tool box to ensure we can get a full picture of SLCN.
2. Distract verbally or physically:
Many of the children with PDA I have worked with, have either tried to shock or frighten me. I have lost count of the times I've been asked 'the worse thing they can think of' (Boringly similar with tween/teenage boys) and even had one boy who said 'you can't go yet because you haven't had sex with my dad.' The key is to be very nonchalant and either ignore or pretend you hear that everyday: 'Ah, No thanks, I'm a bit busy'.
One poor 10 year old lad who had been in a secure unit for 3 months, enjoyed scaring visitors by poking their eyes. This was also because he had a deep sensory-seeking need which wasn't being addressed and he got what he needed from firstly the fear of the visitor but then the 2 burly male nurses bundling him to the floor as he manically laughed in their faces. Of course they thought he was some possessed devil child and didn't see him as the frighted,very anxious boy he really is.
3. Get angry with themselves or others:
The anger may come out of the blue and may not be seen coming. They may look perfectly happy, even relaxed but remember they have cultivated hiding their difficulties. The anger may take the form of them hurting themselves such as banging their heads on the table or may be at you or your things.
So what can we do:
1. Realise that it is anxiety based and keep calm. Never take it personally, never be offended. Ignore wherever possible. I have 3 rules: no hurting themselves, no hurting me and no damaging property. Other then that, I go with the flow.
2. Use all the strategies you would for making language simple that we preach to others. 
2. Give choices e.g. of which room to use, which order for the activities, which assessments even. This will help them feel in control. You may find a schedule of the session useful; picture photos or the written words.
3. Scale back demands by some of these strategies based on the 'Positive PDA' booklet:

Using indirect language

e.g instead of saying we're going to say “I wonder if we can...”

 “Shall we see if we can beat the clock...” ,“Maybe we could investigate…”
This means avoiding direct language such as“It’s time for you to...” ,“You’ve  got to...”, “You  need to...”
Allow take up time 

Plant the seed of what you would like to happen at the start of the session, but don’t expect it to happen straight away. 

Use the child’s interests
Using characters of interest can help de-personalise demands, as you are not personally asking them to do something. For example, if the child loves Peppa pig, get Mummy Pig to make the requests. Older ones may like a Starwars character or even the queen who  makes the  rules, so it isn't your rules. 
Use humour. 

If you feel the tension rising, humour is a fantastic distraction. You could try making jokes, using physical humour (exaggerated facial expressions, or silly walks), being silly or feigning ignorance.
Use distraction

Distraction can be a handy way to temporarily press ‘pause’ and ease the child’s anxiety.

Add other activities into the mix 

e.g. bubbles, popping balloons or blowing up and letting go, a feelie bag of sensory materials. 'If we just finish this, we will be able to do .....'.

The main thing to remember, especially as you feel exhausted at the end, is that this is for  a short time. Their parents live with this all the time! 

So good luck! Let me know how you get on.

Tuesday, 12 September 2017

We don't want you to teach colour, shape and size yet!

As you know we have just launched our new parent hub so we can  offer our advice and support to more parents.  We've done that because I believe all parents want the best for their child but if they don't know what that is, how can they?

As school has just started, I've heard so many conversations about what child can do. The clear favourites are counting, colours and shapes because that's what parents think they need to be teaching their little ones. However, teachers can do that when they're ready. They need to child to be at the right level to do that but there's important things that are needed first, language and  communication wise.

What teachers need little Johnie to be able to know, is the right vocabulary for his everyday needs, to be able to answer simple what, where questions and to be able to listen.

We use the Blank levels to explain the right order. We need to be able to answer blank level 1 questions before blank level 2

Blank level 1

  ·         Matching  e.g. Find one like this

·         Identifying a Source of noise e.g. what can you hear? 

·         Naming objects e.g. what is it?

·         Naming people e.g. who is that?

·         Naming actions e.g. what are you doing? 

·         Imitation e.g. Say this 

Blank  Level 2 

  ·         Describe scene e.g. what’s happened? (still in view)

·         Remembering information e.g. Who/what/where?

·         Finishing sentence e.g. Finish this ….

·         Identify and describe characteristics of objects e.g. what size is it? What shape? What colour? How many? How does it taste/smell/feel? Where is it?

·         Identifying object functions e.g. Show me the one we use for …

·         Identifying differences e.g. how are these different?

·         Naming object from category  e.g. Tell me something that's a type of

It makes the teacher's life a little easier if they can answer these questions. Oh yes, plus be able to go to the toilet by themselves and certainly be out of nappies!! Let me know what you think.

Consultant Speech and Language Therapist

Friday, 8 September 2017

Help for parents: join the club

The Communication Trust estimates that over 1 million children in the UK have speech, language and communication in the UK difficulties yet the number of speech and language therapists is falling. More and more parents are being left to fend for themselves but where do they look? Where can they go for help?

We been moved to action due to serious concerns that parents of children with speech are not getting sufficient access to good quality evidence based advice. We have become increasingly worried when we see parents who are on NHS waiting lists asking for advice and then being told they should be doing X Y or Z from other parents. Others are using ‘Dr Google’ which we all know can be very alarming and point us in a completely wrong direction, in many instances’. At Small Talk Speech and Language therapy, we know that language and communication targets should be integrated into everyday routines as much as possible. Children learn language in the situations where they need to know the words so no amount of flashcards or worksheets can do that. Other children have problems generalising what they learn so again, it must be in the real situation.

Activities which are done everyday that both motivate and interest the child are always going to work better than things that the child isn’t interested in. Snack time, meal-times and bathtime or even getting onto the car. Parents are busy so it can’t be extra work for them.

We have created a membership club for parents so that they can have access to real live speech and language therapists so they can ask the questions and have good, evidence based advice. They have webinars and short ‘how-to’ clips plus lots of other tips and tricks to help. There will also be a forum so other parents can talk about what they found useful.

They will have a monthly podcast show, the Smart Talkers Super Saturday Show, to look in depth at  current topics and interview relevant expert in the field. They will also have parents who have been in similar situations  talk about their family’s journey.

My blood pressure rises every-time I see bad advice being given. It’s well meant but wrong and is not in the best interests of the parent or the child. Self esteem in the child and parent confidence are so important.

We have launched the Parent Hub and hope to be able to support many more parents.

Consultant Speech and Language Therapist
Small Talk Speech & Language Therapy

Tuesday, 22 August 2017

Developing a parent hub

We aim to support the parents we see through the process of speech and language therapy. While we aim to do this the best way we know how, there are many who do not have access to a speech and language therapist at all.

We are setting up a membership club to aim to do this for people we don't see. To make sure it is exactly right, we would really appreciate your help.

Please see the survey for the parent hub by clicking here

Thank you very much!

Tuesday, 8 August 2017

Short-term gain vs quality outcomes

The Royal College of speech and language therapists commissioned a cost-saving matrix to help services demonstrate the value of SLTs to national and local decision makers, while at the same time showing evidence of efficiency and value for money. All public services, and the professionals who deliver them, are under increased financial scrutiny and the pressure which ensues. As you no doubt know, there is more pressure than ever before to show how taxpayer funded services are cost-effective and how they meet local and national priorities.

The language unit at Flash Ley in Stafford has been a great example of specialist provision for children who are bright but have disordered speech and/or language skills. Specialist teachers and speech and language therapists have worked together to maximise the child's potential and they then return to mainstream school to be with their peers when they are more able to cope. I know several who have been. I met them when they were in nursery and knew they'd find it hard to cope in mainstream schools but they had normal learning ability so a generic special school would not be the answer.

Flash Ley had teachers who were more qualified and experienced in SLCN plus enhanced input from specialist SLTs. Working together gives the best way forwards.

Having worked for 30 years, I witnessed the first language units and the fights to have more. We knew then, as we know now, they are the answer for many children with disordered speech and language.

When I first worked, my NHS head of department was a lady whose views were never questioned. Partly because counsellors or managers daren't but also because she was the professional so she knew best. That's a long-gone scenario and, I for one, would never have managed a typical Judith Waterman peer over her glasses, half as well as she did. It said 'stupid man' without need for words!

There are 2 reasons why closing language units are not a good idea:

1. It's not good for the long term outcome of the children. These children have great potential.

2. The savings are only short term. For every £1 invested in enhanced speech and language therapy for children with SLI generates £6.43 through increased lifetime earnings.

This is in comparison to routine speech and language therapy, where enhanced therapy results in an additional 5,500 students achieving five or more GCSEs A* - C (or equivalent).

The resulting benefit of providing enhanced therapy for all children aged six to 10 who currently have SLI exceeds the cost of the speech and language therapy by £741.8 million.

Further analysis shows the estimated annual net benefit is £623.4m in England, £58m in Scotland, £36.1m in Wales and £24.2m in Northern Ireland.

 PLUS: parents will fight to take up specialist school places out of county (it's one of the few clinical areas where there is an evidence base to say they need enhanced!) so the LEA will have to pay thousands in legal fees to fight this. If and when parents win, these are the figures they might need the LEA to cough up:

Alderwasley  From £57,689.00  
Bladen House £82,223
Dawn House 25k (2013 figures)
 (figures from google so may not be up to date)

What will the provision look like for the children who should go to a language unit? It maybe a half-termly visit from  a SLT to school with extra TA support. This is not what the evidence say works best: the children who require the most specialist teaching are in the charge of the least qualified members of staff (absolutely no disrespect to the TAs but that's the fact).

As an independent SLT, whose team can offer weekly or more regularly, I'm not complaining as we can offer what they need BUT it's short sighted. Let's hope the other language unit in Staffs is more successful at fighting it.

Wednesday, 2 August 2017

Second common scenario

Last time, I talked about a common scenario for secondary school, this time I will share a common primary school one.

Picture the scene: playtime in small primary school:

Boy, L, aged 9 is knocked over by another boy who was playing football, 'Sorry!' he shouts as he runs off. L is very angry as he had bumped into someone last week and had been told off and had to stand by the teacher. He had been messing about and had been 'an accident waiting to happen' according to the teacher. So he duly reports the other boy to the teacher on duty. 'I saw L, it was an accident, don't worry about it,' she responds.

L has quite a black and white view of life and doesn't really see the difference. His vocabulary isn't great so the term 'accident' had been used last week and again today so what is different?

He's irritated so argues with the teacher, 'But he did it, it wasn't an accident'. The teacher is calm for a short while but then equally irritated (she's probably got so much to do, she'd rather not be doing a duty anyway).

He's angry now so shouts at the teacher as he would his mum (he doesn't know those pragmatic rules where he should be modifying his language to his teacher). The teacher is now furious and sends him to the headteacher.

L still doesn't see that he should not argue/be respectful so yells at the headteacher. He is now so upset by the sheer injustice of the situation and can't hear any reason whatsoever,

L is excluded for the rest of the week!

If they could understand that he has:

  • poor auditory memory
  • difficulty remembering and learning new vocabulary
  • rigid thinking
  • lack of pragmatic awareness
They might handle him differently.

If the school set up was communication friendly and staff knew about these difficulties it would make their life and poor L's life so much easier.

Speech and language therapists have a valuable role to play in assessing child with behaviour difficulties. All behavior is communication, it's telling us something. There's no point in working on the symptoms i.e. rudeness, shouting at teacher etc, we need to understand the cause because then we can address it.

Unfortunately, there are may Ls out there but it upsets me every time!

Monday, 17 July 2017

Secondary schools don't need speech and language therapists.... or do they?

I have a few common scenarios which show how speech, language and communication issues can be the predominant cause of behaviour problems. These scenarios are very common so could be about anyone of 6 or 7 clients currently known to me. This is the first one:

Teenage girl, second year of secondary school. No issues noted in primary apart from maybe a few 'fallings out' with other girls. No previous behaviour issues at home or at school. Perhaps she's even been a model student. 

Since starting secondary school, however  everything has started to fall apart: at home she's sulky, rude even abusive to parents, shuts herself away, won't go anywhere, friendships may have broken down, parents describe 'melt-downs' when she comes in. At school they didn't notice anything in particular and were quite surprised to hear of the behaviour at home in year 7 but this year, she is falling behind and they are constantly reporting her behaviour which is usually similar to this scenario with E aged 13 years:

Teacher presenting a  power-point which needs to be copied down
E. hasn't finished when teacher moves it on
E 'Excuse me sir can you just leave that a bit longer as I haven't finished?'
Teacher 'No E you'll have to stay at the end as everyone else has finished' E looks round and sees that 3 others haven't either
E 'No sir that's not true x, y and z haven't either'
Teacher 'E you're trying my patience, we've discussed your behaviour!'
E 'But Sir I'm not being naughty, I'm trying to do my work, I just need 2 more minutes please?'
Teacher 'That's it, you have a detention'
E 'For god's sake how stupid? I just want 2 minutes'
Teacher: That's 2 detentions young lady'
E 'I cant believe you're doing this I just want to do my work and you're treating me like this'

Sometimes it escalates further and sometimes EVEN further.

Sometimes the child is excluded.

The child may have 14 detentions in a 2 week period as in one case or 101 since xmas in another. 

Why should a child behave this way?

In the cases I have been dealing with:

1. slower processing skills
2. poor auditory memory
3. both of the above lead to difficulty understanding longer and more complex questions
4. literal understanding of language
5. lack of social skills/pragmatic ability means they don't modify their language for teachers so yell as they would to their parents
6. Rigid thinking means they cant 'let it go' because their sense of justice is so well developed they aren't wrong so the teacher must be
7. Can't see another's point of view 
7. An awareness of their difficulties but a desire to mask them means their anxiety levels are already heightened so it doesn't take much to 'set them off'

It has become a dreadful, seemingly untenable situation. School will have tried all their usual strategies for behaviour problems but nothing works. Yet the answers are simple strategies and an understanding of the problems. It amazing how we can make a HUGE difference by explaining to teachers why the child is doing what they're doing, if we now see them as struggling rather than defiant, abusive etc, we can avoid getting into many of the situations which have previously been a nightmare.

Some of these children may have undetected ASD but some will have language and communication difficulties which are not part of the spectrum. Hormones and personalities play their part too!

  • A one page profile needs to explain what the child finds difficult. Just the process of completing one of these may make the child feel respected and understood which is an important start.
  • Making sure all the child's staff have read and acknowledged the profile
  • Everything as visual as possible including  a print out of the power-point, gestures, notes. These can all be used to make aspects of the day clearer including the timetable, what a pupil will be learning in that lesson, expected behaviour, key vocabulary and information, the sequence of steps within an activity, names of equipment and where it is stored, etc.
  • Make sure the child is happy where they are sitting. I like them at the front so they can see the teacher and the teacher can see them but the child may well be uncomfortable at the front and want to be at the back. Sitting with a friend can be really helpful
  • Encourage an ethos where all pupils are encouraged to ask questions and seek clarification.
  • Have a code so they can let you know when thy haven't understood that no-one else will notice e.g. bag on desk, pencil case moved 
  • Agree how you can check they have understood
  • Expected behaviour is clearly described e.g. School ‘rules’ and ‘charters’, etc are written in simple, symbol or visual photos form so that pupils can understand them.
  • Quiet space is available for time-out or individual study.
  • A reflections log or journal where the child can write about what went well as well as what went wrong. Even better have  a mentor who can meet with the child regularly to discuss this
SLCN is just as big a problem in secondary school as in primary. In the secondary classroom, language is the foundation for participation in, and access to, most aspects of the school curriculum. Many aspects of written language, such as narrative or understanding what you're reading, can be limited by delayed language skills; 'by secondary age there is an increasing amount of figurative language in text books. The same is also true of ‘teacher talk’: 37% of teacher instructions in secondary schools contain multiple meanings, 20% with at least one idiom. As learning becomes more reliant on independent study, language enables pupils to make contact with others; to organise, manage and evaluate experiences; to influence and inform' (ICAN)

Last week I visited 6 secondary schools and was delighted with their positive responses. We all want whats best for the young person but we need to understand what this is to be able to do that. You may think that they don't need a speech and language therapy assessment as they speak fluently but if the usual strategies don't work, we can probably help fill in the missing links. Behaviour IS communication, we just have to work out what it's telling us.