INTENSIVE GROUPS

Enhanced provision:
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IF YOU WANT TO SHARE SPECIALIST SKILLS MORE EFFECTIVELY WORK COLLABORATIVELY WITH OTHER PROFESSIONALS OFFER CLIENTS A GROUP ENVIRONMENT TAILORED TO THEIR NEEDS
There is a long established tradition of collaborative working between the preschool advisory service, Portage service, speech and language therapy service Ann Wiseman and other health professionals in Torbay. In recent years children with a complex communication disorder have been referred to one or more of the services, and weekly Portage visits for some famiSharon Horswell lies and advice to families / carers and preschools have been offered. Regular individual education plan meetings have been coordinated to ensure consistency of approach and targets across the different environments. In addition, all parents / carers whose child has received a diagnosis of an autistic spectrum disorder have been offered the opportunity to attend the National Autistic Societys EarlyBird course run by the speech and language therapy service. Although good practice had been adhered to, a number of the professionals involved increasingly recognised that some childrens progress in terms of interaction and communication skills had been disappointing due to insufficient frequency and intensity of specialist input. In addition some staff had been introduced to the Picture Exchange Communication System (PECS) and realised that, to implement this effectively, enhanced provision was necessary. Ann therefore sought and obtained funding from the Torbay Early Years Development and Childcare Partnership to pilot an intensive communication group to be run on a twice weekly basis, staffed by a preschool advisory teacher, a speech and language therapist and a nursery nurse. In addition the Portage service was extended to provide up to three visits a week for these children to reinforce communication and interac-

a complementary service
Dissatisfied with the progress of preschool children with complex communication and autistic spectrum disorders, Ann Wiseman and Sharon Horswell organised multi-agency intensive groups to complement the established service. The good outcomes for the childrens communication, interaction skills and behaviour were mirrored by the development of staff skills in working together, planning and training others.

The intensive communication group tion skills at home and to support the parents. The outcomes of the group were very encouraging but, to set them in context, we will start with an account of the groups aims and structure. We established the foundation of the group on the following tenets: 1. The proven effectiveness of collaborative multiagency working, as discussed in the Together from the Start model (DH, 2003). 2. A strong research basis indicating that early years intervention is crucial in establishing longterm change and development of communication and interaction skills (see for example BerruetaClement, 1984; Dawson & Osterling, 1997; Garland et al., 1981). 3. The group must complement established provision, such as EarlyBird, Portage, speech and language therapy and outreach, offered by the speech and language therapy and preschool advisory services. 4. The need to create an optimally responsive communication environment for children who do not have the ability to develop adequate communication and interaction skills from typical communicative environments (for example at home and at preschool). 5. The need to provide a specialist adult-rich environment to enable the children to establish communication systems such as PECS, that require a high level of support in the initial stages. 6. The need to provide training, offer support and share information with parents / carers, preschool staff and other professionals. 7. The need for children to learn to participate in group activities and begin to tolerate and interact with others in close proximity.

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Six children were to attend for two mornings per week (09.45-12.00) from January 2004 - April 2004, a total of 20 sessions. Referrals were received from preschool advisory teachers, speech and language therapists and staff from the Child Development Centre. All of the children referred had a diagnosis of an autistic spectrum disorder or a complex communication disorder. All of the children already attended their local preschool group and this was to continue. We chose six children from the potential referrals according to their age (with those nearest to school age being given priority) and the support they were already receiving (such as Portage, learning support assistance at preschool, EarlyBird course). Transport was provided for children and their parents free of charge, with three parents choosing to act as escorts for their children. Three of the children selected for the group had a diagnosis of autistic spectrum disorder and three a complex communication disorder (two with a query of autistic spectrum disorder).

Strengthen relationships
We chose the playroom at the Child Development Centre (John Parkes Unit) in Torbay for our accommodation, for the following reasons: Suitable equipment and furniture. Support from a nursery nurse who has received relevant training for this group of children. A large attractive playroom with an integral toilet and a wealth of suitable activities and toys. Easy access to a large, attractive outside play area, where communication opportunities have been maximised. Initial and ongoing assessment of children with special educational needs is continuous at the unit and some of the children and their parents / carers referred to the group were already familiar with the playroom and nursery nurse. In addition we anticipated that establishing the group at the unit would strengthen relationships between various professionals and thus improve the services offered to both the children and their parents / carers. Our group had three main aims: 1. To create a safe secure environment in which the children were happy to part from their parents / carers. 2. To develop the communication, social interaction and imaginary play skills of the children. 3. To enskill parents / carers and preschool staff in working effectively with the child in their care.

structure, PECS, intensive interaction (Nind & Hewett, 2001), backward chaining (Baker & Brightman, 1997), and modelling of behaviours and language. We established a whole group visual timetable of the morning routine from the first session, indicating to the children the main transition points. In addition we taught children the skill of managing their own individual timetable independently. Transition points were: 9.45 Settling and playing with activities of the childs choosing 10.15 Hello time and singing 10.30 Outside play 11.00 Toileting and hand washing 11.05 Storytime 11.15 Snack 11.30 Playing with activities 11.55 Tidying up 12.00 Goodbye time The routine has elements of free play, individual time spent with an adult to develop specific skills, turn taking activities with another child and also group activities. We established a photo choice board of favourite toys / activities so the children could request items by pointing or exchanging a picture as appropriate. We placed toys within sight but out of reach, to encourage the children to communicate their preferences. We set up activities for the children with an essential component missing (such as a train track with the trains just out of reach), therefore encouraging the children to make a request. An outside symbol choice board was used to enable the children to request out of sight toys (such as ride along items locked in a shed), activities such as being pushed on a swing and social routines such as tickle and chase.

allows them to practise commenting. We found it necessary to give the children quite a long settling period when they first arrived, with some favourite toys being available to assist them in adjusting to the environment. Hello time was used to help children to learn their own and others names, to tolerate sitting as part of the group, and to introduce them to some repetitive preschool rhymes. Story time was always simple, with an abundance of visual aids and at times some familiar music such as the Thomas the Tank Engine theme - to stimulate their interest. After the story we checked understanding using simple language and reference to the pictures. We saw snack time as an ideal opportunity to capitalise on communication as, for some of the children, motivation was maximised. We asked parents to send their childs favourite foods, and children requested these items verbally or by using pictures of the food / drink items. One child had been introduced to PECS before starting at the group and two others were introduced to the system in a formalised way as indicated by the PECS manual. (Two of these three have an autistic spectrum disorder.) The others all used pictures to extend their communication and social interaction skills.

Individual targets
We initially established individual childrens targets by two means: 1. Use of a detailed checklist of pragmatic skills (Dewart & Summers, 1988) filled out in conjunction with each childs parents. 2. Observation of each childs communication, interaction and play skills during the first two group sessions. Then, at the end of each session, the staff collectively wrote up their observations for each child. Once a week, at a planning meeting, each childs targets were reviewed in the light of observations made and new targets set for the coming week. We shared information in a number of ways. We contacted parents by telephone each week to discuss progress and new targets set, and to suggest ways of generalising skills at home. Informal sharing of information was carried out at the beginning and end of each session, although staff were keen to keep this to the minimum to ensure that children remained calm and left the group when they were expecting to. The Portage home visitor attended planning meetings to ensure continuity of support for the child and their carers. Preschool staff, parents, the Portage home visitor, the preschool advisory teacher and the speech and language therapist met once or twice a term at individual education plan meetings held at the preschool to review progress and establish targets together. We also held an open evening at the end of February. This was in two parts. The first part was for preschool staff, speech and language therapists and Portage workers involved with the children. The second part was for parents. During the evening

we set up the environment to capitalise on communication opportunities, taking into account that all the children in the group were strong visual learners
Adults in the group wore a bracelet with key symbols attached (I want, help, wait, and finish), which they or the child could easily access. In addition adults wore a pocketed apron with a Velcro strip on the front to which they could attach symbols for the child to exchange with or simply to clarify communication between adult and child. Between each change of activity we gathered the children together. We showed them a picture board of toys and areas of the classroom they may have been playing with and asked the question, What have you been playing with? Some children responded verbally given the visual prompt, while others were prompted by an adult to indicate their activity by pointing. This process, often repeated, helps the children to recall the recent past, establishes the idea of a sequence and

Communication opportunities
To achieve these aims, we set up the environment to capitalise on communication opportunities, taking into account that all the children in the group were strong visual learners. We planned each session to provide a wide range of motivating activities, as discussed with parents. Within this framework we implemented tried and tested techniques to maximise communication opportunities and develop skills. These included visual

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we explained the layout of the nursery with its relevance to the development of language and social interaction skills. We discussed the curriculum of the group, and parents and preschool staff were able to look at some video footage to illustrate the strategies being used by adults within the group to achieve the targets set for individual children.

5 STEPS TO BETTER PRACTICE: INTENSIVE GROUPS

1. LOOK TO BUILD ON AND COMPLEMENT ESTABLISHED SERVICES 2. CONSIDER A RANGE OF FACTORS WHEN CHOOSING ACCOMMODATION 3. IDENTIFY A VARIETY OF WAYS TO PROVIDE SUPPORT, TRAINING AND INFORMATION 4. STRUCTURE ACTIVITIES TO DEVELOP USEFUL REAL LIFE SKILLS 5. MEASURE OUTCOMES IN A WAY THAT DEMONSTRATES SUSTAINABILITY
and ask to be chased, and the other most severely affected child began to play in parallel and to accept approaches from other children. Some parents reported that these skills had generalised to the preschool setting, and five of the six children were beginning to interact with their peers. One parent reported that her son had started to enjoy sharing a book with an adult for the first time. Comparing initial and post-group assessments, all of the children made progress with both turn taking and initiating in structured activities, taught systematically through joint action routines. c. Behaviour We tackled issues as they arose, working closely with both preschools and homes. Sharing and simple negotiation skills were developed through modelling and the use of a range of prompts: verbal, visual and physical. One child became severely anxious when it was time to leave. He was showing similar difficulties at his preschool. Following discussion, visual structure was implemented to prepare him for this transition, and the problem was resolved in both settings after three weeks on the programme.

Outcomes
1. Differential diagnosis Two of the initial group of six children had received a query diagnosis of autistic spectrum disorder. Through working intensively on communication, interaction, and play skills, this diagnosis was ruled out and both were given a diagnosis of language delay with associated behavioural difficulties. 2. Development of the childrens skills. We used The Pragmatics Profile of Early Communication Skills (Dewart & Summers, 1988) to assess all the children at the beginning and end of the pilot (January 04 / July 04). We recorded the following outcomes: a. Communication Initially none of the children were able to gain an adults attention in an appropriate manner, or to greet others without a prompt, or to comment. Following the pilot all of the children made gains in the frequency and range of functions of communication. For example the children began to gain an adults attention appropriately by calling their name and / or approaching them. Five of the six children became able to greet adults and four of the group were able to make simple comments. Significant gains were made by all the children in the areas of expressive communication, both in qualitative and quantitative terms as recorded on the Pragmatics Profile (Dewart & Summers, 1988). Two of the children were enabled to use PECS. This resulted in them developing an intention to communicate, and also persistence and clarity of communication. Some parents reported that their children had become much clearer in asserting their independence, and were less passive in their communicative attempts. For example one child who used to passively accept No, now persists in handing his mother the PECS strip I want. On initial assessment one parent reported that her son did not respond to any verbal direction, however simple. Following the period of the pilot group, he was able to understand simple commands in familiar contexts, such as Get your shoes. b. Interaction skills All of the children made progress in their abilities to interact and play with their peers. At the start of the group, five of the children would play in parallel with others, and the sixth child, the most severely autistic of the group, could not tolerate others in his proximity. By the end, the three nonautistic children and one autistic child had begun to develop co-operative play. Of the other two autistic children, one began to approach his peers

emphasis on practical aspects of management. A spin-off from this training has been the improved effectiveness of individual education plan meetings. Because of a greater shared understanding and knowledge of the parties involved, clearer goals are established and greater progress is seen across all settings. Information and training for school staff receiving children from the group has been greatly enhanced and some class teachers have been able to visit a child within the group setting prior to the child starting school. Preschool special educational needs coordinators have also been given the opportunity to visit the group as part of their Stage 2 training. We also recognise that the skills of those working within the group have developed through the constant weekly process of discussions with parents / carers, target setting and evaluation. The development of these skills has enhanced the work of both the preschool advisory / area special educational needs co-ordinator service and the service offered by the staff of the John Parkes unit. Overall feedback from parents / carers and other professionals, and the recorded development of the childrens skills, suggests that the group has proved to be a valuable additional resource to existing provision for preschool children in the Torbay Area with a severe complex communication disorder or an autistic spectrum disorder. Ann Wiseman is a Preschool Advisory Teacher SEN / Area SENCo, e-mail ann.wiseman@torbay.gov.uk. Sharon Horswell is a speech and language therapist with South Devon Health Care Trust, e-mail sharon.horswell@nhs.net.

References
Baker, B.L. & Brightman, A.J. (1997) Steps to Independence: Teaching Everyday Skills to Children with Special Needs. 3rd edn. Baltimore, Maryland: Paul H. Brookes. Berrueta-Clement, J.R. et al. (1984) Changed Lives: The Effects of the Perry Preschool Project on Youths Through Age 19. Ypsilanti, MI : High/Scope Educational Research Foundation. Dawson,G. & Osterling, J. (1997) Early Intervention in Autism, in Guralnick, M.J. (ed.) The Effectiveness of Early Intervention. Kansas City: Paul H. Brookes. Department of Health (2003) Together from the Start: Practical guidance for professionals working with disabled children (birth to third birthday) and their families, LASSL (2003)4. Available at: http://www.dfes.gov.uk/consultations/downloadableDocs/177_1.doc (Accessed: 3 October 2005). Dewart, H. & Summers, S. (1988) The Pragmatics Profile of Early Communication Skills. Windsor: NFER-Nelson. Garland, C., Stone, N.W., Swanson, J. & Woodruff (eds.) (1981) Early Intervention for Children with Special Needs and their Families: Findings and Recommendations, Westar Series Paper No. 11 Seattle, WA: University of Washington. Nind, M. & Hewett, D. (2001) A Practical Guide to Intensive Interaction. Kidderminster: BILD publications.

Sustainability
An important question for every group is sustainability. After consideration of the feedback from parents / carers and professionals following the pilot period, Torbay Early Years Partnership decided to fund the project for a further six months. The education authority has since decided to incorporate teacher and transport costs into its overall budget. Training evenings are held once a term for parents / carers, and a wide range of professionals involved with each child about to make the transition to mainstream or special school are invited. The room is set up to show how visual structure is implemented, and video footage is shown to illustrate how we work towards goals. We put the

Resources
National Autistic Societys EarlyBird Programme, see www.nas.org.uk The National Portage Association, see www.portage.org.uk PECS, see www.pecs.org.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2005