SERVICE DEVELOPMENT

Lets CHAT

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Getting speech and language therapy services to the most vulnerable and deprived children is a challenge. NHS Forth Valleys Communication Help and Awareness Team (CHAT) introduced and evaluated a Whole Nursery Narrative Approach in areas of disadvantage across three Scottish local authority areas. Here, they report on the projects positive outcomes for language development and for school readiness. Additional information on the curricular impact is provided by Diane Cairns, one of the senior early childhood educators involved.

s is widely appreciated in the world of speech and language therapy, language development for children living in areas of social-economic disadvantage is significantly depressed in comparison with their cognitive abilities (Locke et al., 2002, p.1). Communication difficulties are the most common neuro-developmental condition. It is vital that children with communication difficulties receive appropriate early intervention to give them the best chance of making progress during the optimum time for language acquisition. Within NHS Forth Valley (covering the three local authority areas of Stirling, Falkirk and Clackmannanshire) our head of service Mary Turnbull identified a gap in the speech and language therapy service for vulnerable families with children in the 0-5 years age group. To address this, she submitted an application in August 2002 to the Changing Childrens Services Fund for 4.5 whole time equivalent speech and language therapy posts. This fund was set up to provide transitional funding for integrated services and new approaches in Scotland that would deliver better outcomes for the most vulnerable and deprived children and young people. Funding was initially granted for two years for 3 whole time equivalent speech and language therapists, to be shared equally across the three areas. This small group began work in January 2003 as CHAT (Communication Help and Awareness Team). Funding beyond the initial period has so far been granted on a year-by-year basis from each Local Authority. Our overall aim is to enable those involved with children in the early years to work together to maximise childrens language and social development in order to promote later literacy and communication skills. We are achieving this through: 1. Prevention By raising awareness of normal language development, encouraging joint working and helping parents to enjoy developing their

childs language in a fun way, CHAT hopes to reduce the number of children who require specialist help. 2. Promotion By providing both formal and informal training in all aspects of communication to those involved with children in the early years (05), CHAT promotes best practice. Our 2 day training course Supporting and Identifying Children with Speech and Language Difficulties (adapted from Habgood et al., 1999) is delivered to nursery staff, with an adapted version for health visitors, childminders, GPs and relevant professionals from independent agencies. 3. Prioritisation By providing training, CHAT hopes to enable other professionals and parents to identify and prioritise the children who need specific intervention. 4. Provision By increasing the accessibility of the speech and language therapy service in local communities, we are able to target the hard to reach population and provide increased support for parents, families and other professionals such as health visitors, social workers and family support workers. We are proactive in offering group and one-to-one sessions at baby clinics, toddler / playgroups, young mothers groups and antenatal groups. The parents are usually very keen to ask questions, for example about dummy use, television viewing and their other children. 5. Production With funding for printing from the speech and language therapy budget, CHAT has produced relevant and easy to read leaflets, posters and information packs for community wide distribution through doctors surgeries, libraries, Bookstart packs (now the Scottish Book Trust), baby clinics, playgroups and nurseries. These five objectives formed the foundation of the work of CHAT, and its steering group also identified overarching aims of health promotion and raising language attainment.

This steering group of speech and language therapists, including manager Mary Turnbull and the CHAT team, meets at least once a term. We initially selected nurseries in areas of deprivation where we had the highest fail to attend rates for our service. Throughout the project, the CHAT team has worked with early years staff in these nurseries to deliver the Whole Nursery Narrative Approach, a 10 week programme adapted from Carey et al. (2007). The sessions: target attention, listening, turn taking, vocabulary and sequencing skills. follow a specific structure in that there is always a hello song, an activity, a story and a goodbye song to finish. Positive praise is given for good listening, good sitting, good turn taking and good looking. use visual materials from the pack. This primarily consists of picture material, however with younger children the use of real objects is recommended. cover different topics each week (figure 1). These focus on strengthening the childrens understanding of the elements that make up a simple story, namely who, where when and finally what happened. cover vocabulary reinforced by activities, songs, rhymes and Makaton signing. From August 2007 until March 2008 CHAT therapists investigated the effectiveness of this Whole Nursery Narrative Approach. We wanted to find out if it a. improved the narrative / language skills of the children b. enhanced these skills when combined with preschool nursery education c. could be replicated. If we were able to demonstrate effectiveness through comparing results from two different nurseries in each geographical area, we would be better placed to meet our objective of promoting the integration of the approach into the preschool curriculum. To prove that the study could be replicated with similar results, we matched two nurseries in each geographical area (Stirling, Falkirk and

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Figure 1 Session topics WHO 1. 2. 3. 4. 5. me and my family animals insects jungle and zoo animals people who help us

WHERE 6. sound location 7. where would you find it? 8. animals and insects where they live WHEN 9. night and day 10. narrative session using 3 little pigs / little red riding hood

Figure 2 Session plan example (Session 5, People Who Help Us) ACTIVITIES Rules of good looking / listening / sitting sit children in a semi-circle MATERIALS good looking, good listening, good sitting cards (yellow) good looking, good listening, good sitting Makaton signs ball who sheet (pink) who Makaton sign

Hello Song, with names pass the ball to a child while saying the childs name sing the Hello song ask each child who to sing to next Who is in the box? give clues for each child to guess who is in the box

People Who Help Us pictures - people and associated items box who sheet (pink) who Makaton sign People Who Help Us pictures who sheet (pink) who Makaton sign objects of reference pictures from pack People Who Help Us pictures - people and associated items who sheet (pink) who Makaton sign People Who Help Us pictures lotto board of people who help us who sheet (pink) who Makaton sign

Clackmannanshire) as best as possible. For example, in Stirling, both selected nurseries were classes within primary schools in small former mining villages. We did not, however, match individual children for language ability.

Jump up if... give clues such as who works with animals? for each child to jump if it is their person Objects of reference Objects that different professionals use Card Game put people on the floor. Give each child two cards to put beside the right person. Who Lotto

Selection process

We had a total of 88 children involved, with up to 24 children in their preschool year in each participating nursery. These children were selected by the nursery staff with no criteria imposed on the selection process, and our results have to be interpreted with that in mind. As we anticipated, the staff selected some children with previously acknowledged language difficulties. Once the nursery identified the children, we provided a parental consent letter. This gave information about the group and specified that, although the children had been selected to participate, it did not mean that they had difficulties with speech and language. Although parents were given a chance to opt out, none did. CHAT therapists visited the designated nursery one day per week to see the selected children, running four language groups each day. The groups included a maximum of six children, one early years worker / early

Story The Tiger Who Came to Tea Goodbye Song sit children in a semi-circle pass the ball to a child while saying each childs name sing the Goodbye song ask each child to choose who to sing to next

Book by Judith Kerr, The Tiger Who Came to Tea ball who sheet (pink) who Makaton sign

childhood educator who had attended our 2 day training programme and one CHAT therapist. CHAT staff requested the use of a relatively quiet, distraction-free environment where possible. Groups ran for between 30 and 45 minutes. The early years worker / early childhood educator repeated the group plan with the same children on a day in the same week

when the CHAT therapist was not in nursery. An example of a session plan is in figure 2. CHAT therapists devised a set of four parent workshops which are made available during the Whole Nursery Narrative Approach. These cover early language and literacy development. We advertised them via posters and leaflets, and nursery staff invited the parents of participating children to attend.

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We held them at the start of the nursery session (morning / afternoon) and they lasted around 40 minutes. Uptake differed between nurseries, with attendance ranging from 3075 per cent. We used two assessments, the Action Picture Test (Renfrew, 1997) and the Squirrel Story Narrative Assessment (Carey, 2006) with the children. We took a baseline measure before the groups started, then re-assessed following the 10 week programme (figure 3).
Figure 3 Assessment programme Pre screen nursery August September December January March 10 week narrative sessions Post screen nursery A Pre screen nursery B 10 week narrative sessions Post screen nursery B

Results

We collected results from all three areas. In Clackmannanshire the narrative groups were unfortunately disrupted in Nursery B due to the therapists ill health. As only 6 out of the 10 weeks were completed, it was inappropriate to carry out post course assessment. Aim 1 To investigate whether the Whole Nursery Narrative Approach improves narrative/ language skills in pre-school children Across all three geographical areas, 100 per cent of the children who completed the programme had increased information and grammar raw scores on the Action Picture Test (Renfrew, 1997). On information scores, a significant majority achieved an age equivalent increase greater than their increase in chronological age. The childrens grammar scores highlight interesting results on post intervention assessment; more children had age equivalent scores that were above their chronological age. Grammar is not taught throughout the 10 week programme, so this suggests there may be a positive effect on grammar development when focusing on narrative skills. All except two children (total = 86) achieved substantially higher scores on the Squirrel Story Narrative Assessment. We therefore feel it is fair to conclude that the Whole Nursery Narrative Approach does improve narrative and language skills in preschool children. Although there was some variation in the amount of change, it is positive that children from each nursery improved on their pre-intervention scores. Aim 2 To investigate whether the Whole Nursery Narrative Approach enhances narrative / language skills when combined with preschool nursery education in comparison with preschool nursery education alone To do this, we compared assessment results from the second screening of Nursery A (after intervention) in relation to the scores from the initial screening of Nursery B (before intervention). All these assessments were administered during the same week in December 2007. The children in Nursery B were also in their pre-school year and therefore around the same age as the children in Nursery A. Both sets of children had been in nursery for the same amount of time and therefore the only difference between the groups was that

children from Nursery A had received the 10 week group programme of narrative input. In two of the three geographical areas (Falkirk and Stirling), children from Nursery A scored higher for both Information and Grammar on the Action Picture Test and were more capable with narrative (Squirrel Story) than their peers in Nursery B. Both groups of children had been in nursery for the same length of time. It would therefore appear that 10 weeks of the Whole Nursery Narrative Approach in addition to 10 weeks at nursery enhances language skills more than nursery education alone. This was not shown as clearly in Clackmannanshire where the nursery B scores pre-intervention were closer to those of Nursery A post-intervention. We felt this might reflect poorer matching, as the children from Nursery B were from an area of higher socio-economic status than those from Nursery A. We noted however, that, relative to themselves, most children at Nursery A improved their scores. Aim 3 To investigate whether the Whole Nursery Narrative Approach can be replicated in other establishments with similar results This has been clearly demonstrated by this project. We replicated results across all three geographical areas, with all three Nursery A groups showing improved language and narrative skills after the 10 week intervention period. Results were also replicated in two of the areas (Falkirk & Stirling) with Nursery B children. In Clackmannanshire, where we could not measure Nursery B due to the therapists illness, informal feedback suggests these children would have followed the same pattern, as nursery staff were already aware of the benefits: Groups have been so beneficial [The groups] tied in with needs we found in the nursery It provided an opportunity for children to have a quiet time to focus on their talking in an otherwise busy and noisy nursery Children who were otherwise quiet gained in confidence to contribute We would like to continue this approach next year. The second comment also suggests that,

although the groups were planned by speech and language therapists, the Whole Nursery Narrative Approach is relevant to the needs of nurseries. The approach is continuing to be popular and is used by some nurseries with only minimal support from us (figure 4).

Wider impact

Having completed one successful service evaluation using measures familiar to speech and language therapists, the CHAT team was keen in 2010 to investigate the wider impact of the Whole Nursery Narrative Approach. In particular, we wanted to find out if there was any impact on general school readiness. While there is no single specific measure of school readiness, for the purpose of this evaluation we considered language concepts needed for primary one as well as social communication skills as indicators. In addition to the assessments used in the 2007-2008 evaluation, we administered the Bracken School Readiness Composite (SRC) (in Bracken, 2006). We also decided that a measure of cognitive maturity would be useful, as we suspected there may be a correlation between cognitive ability and a childs capacity to improve their language skills. For this we used the GoodenoughHarris Drawing Test (1963). The methodology for this evaluation was consistent with the previous study, with the exception of the additional assessments and selection. We assessed the children before and after involvement in the 10 week programme. We used one nursery in each area (three in total) and concentrated on pre and post group assessment results for each. However, this time, we matched the nurseries in terms of their scoring on the Scottish Index of Deprivation, looking at the percentage of the population who are income deprived and the percentage of the working age population who are employment deprived. Following participation in the 10-week groups, between 77.7 per cent and 100 per cent of the children made improvements in their language and communication skills. They also made progress in their school readiness (Bracken, 2006). It appeared that, irrespective of cognitive maturity, the majority of children showed improvements in the concepts that parents and nurseries traditionally teach in preparation for primary one. While these

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Figure 4 The curricular impact at Cornton Nursery Diane Cairns, senior early childhood educator, writes...

ornton Nursery is a standalone early years establishment serving a community situated in an area of urban deprivation. It assists 109 families on varying levels and accommodates children from three months to five years of age. It has a team of 16 early years professionals who work closely with many visiting specialists. Through collective professional observations it was noted that an increasing number of children had reduced and impaired language skills. Due to close partnership working with the speech and language therapist Hazel McKellar and lengthy professional discussions, it was concluded that many children would benefit from narrative language sessions. This would potentially raise achievements across the learning environment and help eradicate any further issues, while highlighting areas for further specialist language input. This proposal was put to the team, who collectively agreed that it would be an excellent way forward. A staff member was selected to deliver this narrative approach and worked jointly with the speech and language therapist on a weekly basis for ten weeks. Each staff member in the 3-5 play room was jointly trained by their colleague and the therapist on a rotational basis, and any staff member who had not accessed the CHAT training programme was promptly put forward to do so. The therapist was then approached to help with early language intervention for children aged 0-3, resulting in the enhancement of the Baby Chat programme. This was already being delivered but is now heavily assisted by Makaton signing, which helps staff reinforce the spoken word. On evaluation of the narrative sessions, a handful of children were then chosen to engage in a phonological awareness group. This was again developed jointly with the speech and language therapist to help with the childrens preparation for going to school. On further reflection and detailed observations, we soon realised that the fundamental principles of the narrative approach were assisting with our other programmes such as Fun Friends and transition, so we increased the weekly session to twice weekly. The nursery also arranged for the speech and language therapist to come along to the parent information evening, where the strong message of joint partnership working to provide positive outcomes for children was given. This also gave parents and carers the opportunity to find out from a professional specialist exactly what their children were involved in. The fundamental principles of the narrative approach are now fully embedded into daily practice. They mirror the nursery contexts for learning, thus enabling staff to use this approach to extend childrens natural dispositions and interests. Staff in the 3-5 room now own a box of narrative resources, ensuring its daily delivery. Due to limited space within the establishment the sessions are run in group areas. Although they are seldom free from distraction, we feel this helps the childrens concentration skills and their ability to filter out background noise, which again will be an expectation when they enter school. This holistic and whole nursery approach is proving invaluable and allows flexibility of learning. Differentiation can be taken into account, as it encapsulates the principles for design from the Scottish Curriculum for Excellence offering challenge and enjoyment; breadth; progression; depth; personalisation and choice; coherence and relevance. This early intervention approach is also assisting us to execute core areas from the Early Years Framework and displays multiprofessional working for children in a very positive and successful manner. To date childrens expressive language and listening skills have significantly increased and all staff have gained an increased awareness of language and its importance for communication and thought processes. All this said, the attitude of staff and their willingness to engage and work through difficult logistics and limited resources needs to be commended, as does the speech and language therapists commitment to our establishment. As she herself stated it was the true spirit of learning and trying things out together that made it all worthwhile.

All photos show children at Clackmannan Nursery enjoying a narrative group

concepts are not a focus of the 10 week Whole Nursery Narrative Approach, it would appear that targeting listening skills has a positive impact on childrens readiness to learn in the nursery environment. If funding allows, the CHAT team will continue the valued pre-referral work, training and involvement with children between the ages 0-5 and their families who live in vulnerable communities. The CHAT team would also consider carrying out some more formal research into tracking the children involved in this study throughout the early years of primary education. We anticipate that they will continue to make progress with SLTP language and narrative skills. Nicola Orr ([email protected]) and Claire MacLean ([email protected]) are speech and language therapists with the Forth Valley CHAT team. Liz Richie is a former member of the CHAT team, now retired.

References
Bracken, B.A. (2006) Bracken Basic Concept Scale Revised (BBCS-3:R). Oxford: Pearson. Carey, J. (2006) Squirrel Story. Keighley: Black Sheep Press. Carey, J. et al. (2007) Nursery Narrative (2nd edn). Keighley: Black Sheep Press. Harris, D.B. & Goodenough, F.L. (1963) Goodenough-Harris Drawing Test. Oxford: Pearson. Locke, A., Ginsborg, J. & Peers, I. (2002) Development and disadvantage: implications for the early years and beyond, International Journal of Language & Communication Disorders 37(1), pp.3-15. Habgood, L., Wheeler, K., Battye, A., Falkus, G., Hayon, K. & Typadi, E. (2003) The Community Early Years Training Pack (revised edn). London: Hammersmith & Fulham PCT, Kensington & Chelsea PCT, Westminster PCT. Renfrew, C. (1997) Action Picture Test. Milton Keynes: Speechmark.

REFLECTIONS DO I IDENTIFY GAPS IN SERVICE THAT MATCH AVAILABLE SOURCES OF FUNDING? DO I ADAPT TRIED AND TESTED RESOURCES RATHER THAN REINVENTING THE WHEEL? DO I PUT IN THE TIME AND UNDERSTANDING NEEDED TO TAKE OTHER PROFESSIONALS ALONG WITH ME?
To comment on the difference this article has made to you, see information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

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