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service delivery

Talk & Play Speech and language therapy services continually change to meet local needs and the wishes of users. Penny Best looks back on the development of a new type of care package offered for preschool children with language difficulties.

a family friendly intervention


READ THIS IF YOU NEED MORE CARE PATHWAY OPTIONS WANT TO ADDRESS INTERACTION IN A NONCONFRONTATIONAL WAY FACE WAITING LIST AND ATTENDANCE ISSUES

he city of Sunderland in the North-East of England has a population of around 300,000 and a high percentage of deprivation. Over the past year the speech and language therapy service introduced Talk & Play, an exciting new type of intervention for young children with language difficulties. This is proving popular with staff and families. The process started in Summer 2006, as staff were dissatisfied with what we offered to children with language delay / disorder. A small working group met to plan a positive way forward. We asked colleagues within the region to give us information about their pathway for these children, did a literature search, and drew up an action plan. As a result of this, we felt that our pathway of care for pre-nursery and preschool children (aged 2 4) with language difficulties was too limited. At that time we were offering them two options: Active Support appointments, where we were seeing the children and their parents every few
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weeks to update advice, knowing that intervention through parents can be a very effective way of working Review appointments, where we were simply monitoring their progress. After many years we had stopped offering preschool language intervention groups as too often we had felt we were testing the children rather than teaching them. Alongside this we had lost experienced staff, and had felt that working with children on a one-to-one basis was

had at times proved extremely effective for some of our children, we found there were many families who were unable or unwilling to access them. We looked into the reasons for this and concluded that it was due to factors such as a central location rather than a local one, there being no child present for the parent to hide behind, and a lack of childcare while the parent(s) attended the group.

Within the community

too often we had felt we were testing the children rather than teaching them
going to be more effective, offering Hanen (It Takes Two to Talk) parent groups where appropriate. However, the Hanen groups then ceased in our mainstream service in 2006 due to the intensity of staff needed together with the commitment of the parents. Although these groups

Our new pathway of care involves the parent and child attending Talk & Play sessions with other families, usually in a local Childrens Centre. Rather than the health centre, this takes them into a more family-friendly building within the community. Up to four children attend, each with their parent(s) or carer. Sessions last up to 90 minutes and run approximately monthly in each location, which we book at least a term in advance. The therapist brings along toys and activities and sets them out in the room rather like a playgroup to encourage play and interaction

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between the parent and child. The parents can choose the location, such as the one that is nearest or that has the shortest waiting list. The expectation is that they will play and interact with their child throughout the session. Meanwhile the therapist rotates around the different families observing, interacting with the child, demonstrating and offering advice for the parent to try out in the session. We find the child usually becomes at ease in the play setting and no child or parent feels the professional attention is on them constantly, as is the case in a routine clinic appointment.

We find the child usually becomes at ease in the play setting


We do not actively encourage the children to play together, as our aims are to improve parentchild interaction. However, if the children gravitate towards each we dont discourage the contact, although we may then have to change the aims of the session a little, as the parent may be unable to practise specific activities with their child at the time. Parents have no knowledge of the other families apart from first names of children and parents unless they choose to share this information with each other. We find some parents use other parents as informal support within the sessions. This occurs more frequently if families attend more than one Talk & Play session alongside each other. We summarise our advice and write it down for the parent before they leave the session. We offer up to three Talk & Play sessions depending on progress. This number ensures through-put of families
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whilst being sufficient to enable the parent to make changes in their interaction style to facilitate their childs language. Families join in wherever a slot becomes available as there is a rolling programme in each location. We feel a reminder phone call is an important part of the Talk & Play package. We do this 1-4 days before the session, leaving a message on an answering machine if necessary. This ensures good attendance despite the fact that the sessions are monthly rather than weekly. Interestingly, when we sent a questionnaire to parents about Talk & Play, 64 per cent of them responded positively to the reminder phone call. After the three Talk & Play sessions we occasionally offer a home visit to help a parent consolidate the advice given in the play setting in their home environment. We then transfer the child back to their local community therapist. Intervention is often then on a less intense basis than previously necessary as the parent has been given a lot of advice about interacting with their child, and has usually generalised this to the childs benefit. Any onward referrals to other professionals still continue at the appropriate point in the childs care, either by the local or the Talk & Play therapist. When we introduced Talk & Play, we also offered parent-only sessions across half the venues in the city but take-up was poor, even when crche facilities were offered. It appears to us that families in our area in general feel they need their child with them when they are receiving help for them, and are not comfortable with the idea of such a group. We therefore doubled the Talk & Play sessions, which has been very successful. However, we didnt

want to lose the parent-only option completely. Where she feels it is appropriate, the Talk & Play therapist can offer parent-only group followup sessions at a central location in the city. Although take-up so far has been limited, as we expected, the parents who have attended have seen it as a useful service. They find it gives them the chance to focus and think about ways in which they can help their child without other distractions.

the Talk & Play therapist can offer parent-only group follow-up sessions
Over the past 12 months since the Talk & Play sessions have been started: 75 children have been referred by their local therapists 68 families have attended one or more sessions 3 families changed their minds before attending 4 families have not attended.

Positive

To audit the intervention, we sent questionnaires to referring therapists and to parents, no more than 5 months after they had finished attendance at Talk & Play. We received a 100 per cent return rate from therapists and a 33 per cent return rate from parents. The staff were positive about the alternative pathway and about the progress made by many children, resulting from positive changes in the parental interaction style. They reported some practical difficulties such as describing locations and dealing with the waiting list. Most parents saw some progress and could quote some of the advice they had been given. A small number felt that one-to-one therapy was more appropriate for them.

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We took several actions as a result of the audit. We now provide maps of the locations and a parentfriendly written summary at the end of the session for each family, and have updated the Talk & Play information leaflet for parents. We offer further training to our staff, including a video of sessions, to ensure they set up realistic parental expectations about what is provided in Talk & Play and the likely progress of their child. We also have a planned timetable of staff who will further their own development through helping at the sessions. Talk and Play has now been accepted as one of the pathways within our community service. Staff see it as a very positive way to help many of our families and tackle parent-child interaction in a non-confrontational way. Penny Best is Head Speech and Language Therapist (Paediatric Service) with the Sunderland Speech and Language Therapy Department, email penny.best@chs.northy.nhs.uk. Resources The Hanen Centre see www. hanen.org

Following the Darzi NHS Next Stage Review report, the Social Market Foundation is to focus its research on public perceptions of the change of emphasis in health policy from disease-management to health promotion, where people are encouraged to take responsibility for their own health and lifestyle. The think tank has also published overviews of current policy debates (Focussing on Health Systems, Financing Pressures, Commissioning, Providers, and Patients). www.smf.co.uk/health-project.html www.ournhs.nhs.uk/ Meanwhile the Department of Health is consulting on an NHS Constitution which sets out principles to guide how all parts of the NHS should act and make decisions as well as rights for patients and staff and responsibilities. The consultation ends on 17 October 2008. www.dh.gov.uk/en/Consultations/Liveconsultations/DH_085812

Next stage for the NHS

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Older peoples mental health

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REFLECTIONS
DO I INVESTIGATE ALTERNATIVE COMMUNITYBASED ACCOMMODATION FOR THERAPY? DO I HAVE AN APPOINTMENT REMINDER SYSTEM? DO I HAVE SUFFICIENT FLEXIBILITY WITHIN CARE PACKAGES TO CATER FOR ADDITIONAL INDIVIDUAL NEEDS?
What has this article got you thinking about? What models of care have you changed and why? Let us know via the Autumn 08 forum at http:// members.speechmag.com/forum/.

The Department of Healths consultation on a Draft National Dementia Strategy for England closes on 11th September. Its three key themes are improving public and professional awareness, early diagnosis and intervention and improving quality of care. In response to the consultation, a group of key organisations including Age Concern, the Royal College of Psychiatrists and the Royal College of Nursing have launched a consensus statement calling for a comprehensive commitment to address the full range of mental health problems in later life without the fragmentation of older peoples mental health into diagnostic silos, erroneously ignoring the complex interdependencies and multiple pathologies. www.dh.gov.uk/en/Consultations/Liveconsultations/DH_085570 www.snpearstesting.org/consensusfinal.pdf

Dyslexia review

As part of a review in England into how children with dyslexia learn best, Sir Jim Rose is asking anyone with an interest in dyslexia to send in personal accounts and experiences. Responses should be in by 10th October 2008, with the review recommendations being published in early 2009. www.dcsf.gov.uk/jimroseanddyslexia/index.shtml Sir Jim Roses last independent review recommended ways that teachers can improve their teaching of early reading, in particular through introducing systematic teaching of phonics. An Ofsted survey of trainee teachers is generally positive about how providers of initial teacher training have responded to the recommendations but says more needs to be done to ensure trainees understand the links between phonic skills for early reading (blending) and for writing (segmenting to spell). www.ofsted.gov.uk/publications/070257

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2008