Supporting children 11/05

Supporting children with speech,language and communication

needs within integratedchildren’s services

Position PaperMarie Gascoigne

January 2006

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ReferencingThis document should be referenced as follows:

Gascoigne M. (2006)“Supporting children with speech, language and communication needs within integrated children’s services”RCSLT Position Paper, RCSLT: London

This document is available from the RCSLT website: www.rcslt.org

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Contents

1. Introduction

2. Reviewing the context

2.1 Changing context for children’s services acrossthe UK

2.2 Commissioning integrated services for children

2.3 Delivering integrated children’s services throughmulti-agency models

2.4 Workforce review

2.5 Theoretical models for speech and languagedevelopment

2.6 Current professional consensus

2.7 Summary of the context

3. Articulating the vision: focus on impact

3.1 Delivering effective support

3.2 Planning for maximum impact

3.3 Systems for strategy

3.4 Developing the workforce

4. Conclusions and way forward

Supporting children with speech, language and communication

needs within integrated children’s services

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AcknowledgementsMany have contributed to the final version of this paperand much experience and professional expertise has beenshared in debating and refining the key recommendationsoutlined as well as their underpinning principles.

The 100 or so delegates to the Children’s Services eventheld in September 2004 enabled a representative sampleof the professional membership to discuss models ofservice delivery and explore the professional consensusregarding ‘good practice’ in terms of the contribution ofthe speech and language therapist to the support ofchildren with speech, language and communicationneeds. Thanks to all those who attended and to thosewho commented on drafts of the paper.

This event was planned and facilitated by a steeringgroup consisting of members of the RCSLT EducationCommittee alongside additional representatives from the four UK countries as well as the independent andvoluntary sector: Mary Auckland, Pauline Bierne, KateDavies, Sarah Fisher, Yvette Johnson, Rosie Jones, MariaLuscombe, Nita Madhani, Nigel Miller, Pat Mobley, JaneOates, Judy Roux, Liz Shaw, Alison Stroud, Shelagh Urwin, Anne Whateley and Fiona Whyte.

Thanks also to members of the Professional DevelopmentBoard and Management Board for helpful comments ondrafts of the paper.

The practice example boxes sited throughout the paperaim to bring reality to some otherwise abstract concepts.Examples evidence practice across the profession andindividual contact details are available throughout thedocument.

It has been particularly helpful to have had thecontributions from representatives of the voluntary sector,especially ICAN and SLTs in independent practice.

Particular thanks are due to the following individuals whohave offered detailed comments and feedback at variousstages of the development of this paper. James Law andNicola Grove provided useful suggestions from anacademic perspective, which were extremely helpful andhave contributed significantly to the final structure of thepaper. Finally, Sue Roulstone and Kamini Gadhok havenot only contributed to the paper but have also providedadvice and guidance throughout the process ofproducing this document.

Introduction

This paper has been written so that the Royal College ofSpeech and Language Therapists (RCSLT) can respond torequests from respective UK governments for theprofession’s view and position regarding the role of thespeech and language therapist (SLT) within the changingcontext and development of children’s services.

The paper will also serve as a reference for speech andlanguage therapy services, commissioners from health and education, and other key stakeholders. The RCSLT isaware of the need to define and develop best practicewithin the context of national policy frameworks andconsiders this paper as crucial in informing this work.

A number of key policy initiatives over the past three tofive years are analysed in section two. There is also a briefsummary of theory underpinning intervention forcommunication disability.

Together, these provide a convincing backdrop to thevision of future speech and language therapy services,which is set out in section three: Articulating the vision:focus on impact.

The paper sets out 15 recommendations that support four key areas:

• Delivering effective support• Planning for maximum impact• Systems for strategy• Developing the workforce

As a member-led organisation, the RCSLT recognises theimportance of involving the profession in the development ofthis paper in order to achieve consensus. Consequently, thepaper sets out a framework that has been tested by the authorwith members from across the four UK countries, as well asfrom key groups, such as practitioners in independent practice,the voluntary sector and higher education institutions (HEIs).

The RCSLT envisages that, as well as informing our jointworking within each of the home countries, the paper willalso provide SLTs with a framework to support localservice development and delivery. However, the paper isnot a service planning document. The aim of the paper isto capture and disseminate key principles that the RCSLTbelieves should underpin service commissioning andprovision. It will therefore provide a framework that UKservice planners and managers can use to develop servicesthat will best meet the needs of children with speech,language and communication needs.

The focus of the paper is the role of the SLT. However, theprinciples outlined could well be applied to other AHPsworking with children and to other professionalcolleagues within integrated children’s services.

The pace of policy development and change during thepreparation of this paper is a testament to themodernisation agenda in public services. Consequently,the recommendations outlined within the paper areviewed as time-limited and a review will be necessary in2008 – a significant time in so many of the policy agendasinfluencing the document.

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Executive summary

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Key area 1 Delivering effective support

Key area 2 Planning for maximum impact

Recommendation 1:Any speech and language therapist (SLT) working with children should:• Identify the speech, language, communication or eating/drinking needs of the child as

part of, or with reference to, the appropriate multidisciplinary team (this does not imply astatic membership, more the team of relevant professionals for the individual child)

• Identify the functional impact of these needs• Consider the most appropriate context for support ie. which settings are most relevant to the

child and their family• Identify the contribution of the speech and language therapist as part of the wider team work-

ing with the child to meet the child’s needs – including the full range of options from adviceto colleagues through setting up programmes to direct intervention where appropriate.

Recommendation 2:Services should offer the full range of support for children, including direct intervention whereappropriate, while ensuring overall management includes goals relating to activity andparticipation, managed by those most relevant the child.

Recommendation 3:The RCSLT regards trans-disciplinary working as central to work with children. The RCSLTsupports the exploration of SLT roles within trans-disciplinary models and the development ofnew models that maximise the contribution of SLTs while ensuring that the specialistcontribution to the system is recognised as essential. Emerging key worker roles and leadprofessional roles are also central to this model of working if it is to be successfullyimplemented for the benefit of children and their families.

Recommendation 4:Training of others, including parents, should be viewed a central activity for SLTs tomaximise impact for the child and their family.

Recommendation 5:Service planning for children with speech, language, communication or eating/drinkingneeds should always be in partnership with other agencies.

Recommendation 6:Service planning should take account of the most functionally communicative and sociallyappropriate environment for effecting change.

Recommendation 7:There is a need to define the parameters of an appropriate advisory needs-based anddynamic approach to supporting children which integrates the concept of skill mix bothwithin the profession and across professional boundaries. The term ‘consultative’ modelshould be replaced by a more accurate description of the service being delivered. The RCSLTsupports the need for research to further define and investigate the impact of approaches,which rely on the implementation of speech and language therapy advice by others.

Recommendation 8:Service structures should reflect the changing context. Highly specialist, principal andconsultant therapists need to use time to train, develop, coach and mentor less experiencedtherapists, who in turn need to be given the opportunity to work with all caseloads. The mostspecialist need to focus their skills on the strategic developments within their specialist area.

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Recommendation 9:The RCSLT recommends that within each local authority area there needs to be an SLTprofessional lead for children, who can interpret national policy and ensure partnershipworking occurs in terms of integrated commissioning of speech and language therapyprovision, strategic planning and operational delivery. This professional lead should ideallybe a member of key strategic multi-agency planning groups and be empowered to make keystrategic decisions on behalf of local speech and language therapy services. The role of professional lead should also provide a focal point in terms of professionalstandards for all speech and language therapy provider services both within statutory andnon-statutory provider organisations (including independent practitioners).

Recommendation 10:The role of the SLT must be seen within the context of the specialist and wider workforce.Commissioners need to be aware of the unique contribution of SLTs across the populationbase.

Recommendation 11:Managers and service leads should work together with their allied health professional (AHP)colleagues as well as colleagues from education and social care, in the development of newroles, in particular the development of consultants/specialist advisory posts and cross-agency posts.

Recommendation 12:Management opportunities across agencies and across professional boundaries should bedeveloped.

Recommendation 13:The RCSLT supports the development of placements that offer student therapists a fullrange of opportunities as part of their practice-based learning and this would includeworking as part of trans-disciplinary teams.

Recommendation 14:Speech and language therapists working with children should undertake continuingprofessional development (CPD) activities across health, education and social care in orderto develop knowledge and skills that will prepare them for cross-agency roles. The RCSLTvalues CPD activities that are not limited to the health context.

Recommendation 15:The challenges of the changing context mean that business and entrepreneurial skills setswill become more relevant for senior managers. Excellent communication and negotiationskills should also be developed by all speech and language therapy service leads as part of aportfolio of leadership competence.

Key area 3 Systems for strategy

Key area 4 Developing the workforce



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1. IntroductionThis paper has been written so that the Royal College ofSpeech and Language Therapists (RCSLT) can respond torequests from respective UK governments for theprofession’s view and position regarding the role of thespeech and language therapist (SLT) within the changingcontext and development of children’s services. The paperwill also serve as a reference for speech and languagetherapy services, commissioners from health andeducation, and other key stakeholders.

Approximately 70% of the 10,000 SLTs registered in the UKwork with children. It is estimated that approximately 6-8%of children aged between 0-11 years have speech, languageand communication needs1. The prevalence for childrenwith severe and complex needs may be a further 1%.

The RCSLT is aware of the need to define and developbest practice within the context of national policyframeworks and would consider this paper as crucial ininforming this work.

As a member-led organisation, the RCSLT recognised theimportance of involving the profession in thedevelopment of this paper in order to achieve consensus.Consequently, the paper sets out a framework that hasbeen tested by the author with members from across thefour UK countries, as well as from key groups such aspractitioners in independent practice, the voluntary sectorand higher education institutions (HEIs).

The RCSLT envisages that, as well as informing our jointworking within each of the home countries, the paper willalso provide SLTs with a framework to support localservice development and delivery. However, the paper isnot a service planning document. Its aim is to capture anddisseminate key principles that the RCSLT believes shouldunderpin service commissioning and provision. It willtherefore provide a framework that UK service plannersand managers can use to develop services that will bestmeet the needs of children with speech, language andcommunication needs.

The focus of the paper is the role of the SLT. However, theprinciples outlined could well be applied to other alliedhealth professionals (AHPs) working with children and toother professional colleagues within integrated children’sservices.

The pace of policy development and change during thepreparation of this paper is a testament to themodernisation agenda in public services. Consequently,the principles outlined within the paper are viewed astime-limited and a review will be necessary in 2008 – asignificant time in so many of the policy agendasinfluencing the document.

2. Reviewing the context2.1 The changing context for children’s servicesacross UKThe legislative and policy agendas for children’s servicesacross the four UK countries have moved in the samedirection over the past three to five years, albeit withsome local variations. A useful summary is available in the4 Nations Child Policy Network, showing the policy andlegislation affecting children2.

The common themes that emerge across the UK include:• The need for statutory services to integrate delivery of

services around the child and their family. Examples ofthis include the development of Sure Start (Sure StartScotland, Sure Start NI, Cymorth in Wales) initiativessuch as Children’s Centres 3 4 5 6, the Early SupportProgramme7 and the development of Children’s Trustsor their equivalent 8

• While terminology may differ from country to country,a recognition that all agencies working with childrenhave a key role to play in all aspects of the child’sdevelopment in order for them to achieve the fiveoutcomes to:

i. Be healthyii. Stay safe iii. Enjoy and achieveiv. Make a positive contributionv. Achieve economic well-being 9

• A focus on inclusion of children with special (oradditional) needs in mainstream settings and the needfor specialist services to be delivered flexibly in order toenable inclusion10 11 12 13

• Emphasis on targeting services to address inherentinequalities due to disadvantage of whatever sort (SureStart initiatives, Looked After Children).

• The move to developing primary care services and theincreasing focus on health promotion14

• Recognition of a changing workforce profile and theneed to examine and redesign professional rolesfocusing on the competences required to deliver newintegrated services15 16

In England, the papers Creating a Patient-led NHS 17 andCommissioning a Patient-led NHS 18 signify far-reachingchanges to the mechanisms for service provision.Therapists working in children’s services may in the futurebe providing care for children whilst being employed bylocal authority-based children’s trusts, new therapyorganisations (including companies limited by guarantee,charitable organisations, independent provider consortia),or possibly as employees of foundation hospitals. The keythemes of contestability and plurality in these policypapers will result in the need for services to be offered inways that offer commissioners (whether from health,education or social care) packages that are clearlyunderstood in terms of positive impact on the relevantpopulation.

It will also be critical for SLTs and other colleagues tobecome involved in commissioning in order to influencethe commissioning processes and ensure that the addedvalue of therapists is understood.

The challenge for SLTs, along with other AHPs, andcolleagues in education and social care, is to respond to this changing context proactively and creatively.In order to respond, it is necessary to have a clearunderstanding of the key drivers and resistors that are inplay and to be able to develop creative solutions.There are capacity issues, both in terms of numbers ofindividuals needed to deliver the agenda, but also interms of competences needed. New roles requiredifferent skill sets. A change programme as significant asthat which we are experiencing for children’s servicesacross the UK will need to address capacity issues atevery level, from pre-registration to expert practitioner,and also in terms of management and leadershipcapacity.

Figure 1 (below) represents the key issues as a ‘force-field’ 19 diagram. This identifies key themes clearly and setsthe framework for exploration of these issues in this paper.

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Figure 1 Force field diagram showing key drivers and resistors within the contextof integrated children’s services

Legislative and policy framework

Workforce strategy

Services built around the child facilitated by neworganisational structures

Challenge of communicating the scope and scaleof the proposed change

Professional expectations of the familiar careerframework

Services currently build around historical structureswith embedded organisational cultures

Example 1a – Pooled budgetThe Medway pooled budget was set up in 2000 usingmatched funding from Medway PCT and MedwayCouncil to meet the speech and language needs ofchildren in special educational placements andmainstream primary schools in the Medway towns.The Medway Communication Team supports childrenin mainstream primary schools from year one to theirtransfer to secondary school. It is a multidisciplinaryteam consisting of therapists, specialist languageteachers and two SLT technicians – one for speechsounds and one for social skills. The skill mix enableschildren who need to be seen by a therapist to haveaccess to one, while allowing all children with speechand language difficulties access to SLT support.Contact Dawn West on 01634 812858 [email protected]

Example 1b – Aligned budgetThe integrated speech and language therapy servicefor children in Hackney is a service jointly managedacross City & Hackney PCT and The Learning Trust(the body responsible for education in Hackney) andstaff are employed flexibly on either PCT or LearningTrust contracts and terms and conditions. Thebudgets are held separately in each organisation, butthere is one manager with overall responsibility for theservice who is supported by management accountantsin both organisations. This method of working hasallowed the service to move forward operationally at agreater pace than might have been the case hadformal ‘pooled budgets’ been pursued.Contact [email protected]

Practice example 1

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2.2 Commissioning integrated services forchildren

Commissioners for children will take overarching policyleadership for children’s services across the traditionalboundaries of health, education and social care nationally20 21 22.These posts are established in England, Wales andNorthern Ireland, whilst in Scotland the Scottish Executiveis evaluating the added value that a single commissionerwould give23. Locally, services will see the appointment ofdirectors of children’s services or lead chief officers forchildren (Wales24) whose role will be to ensure redesignedservices meet the needs of all children, including those whoare vulnerable and/or have additional specialist needs, aslocally and flexibly as possible.

Vulnerable children and those with additional needs formpart of the population of ‘all children’. In an inclusivesociety, specialist and targeted services for these childrenshould be integral to universal mainstream provision. The integration of education, health and social care forchildren means they should be able to access all theservices they require – whether universal, targeted orspecialist, flexibly and locally wherever possible. Figure 2(right) shows how the range of services and the needs ofthe child population interface. For example, children withadditional needs may access universal, targeted andspecialist services from all agencies, while the majority ofchildren will access universal service only.

Integrated services may or may not take the form ofchildren’s trusts. For example, in Wales, children and youngpeople partnerships within each local authority area providea similar function. In Scotland, community health partner-ships bring together health, education and social services.In all cases the single commissioner for children (orequivalent in Scotland) will ensure services are commissionedin an integrated way and that joint funding streams areestablished as appropriate. The aim is to avoid duplicationof services and use resources in a more effective way.Within the health sector, the implementation of practice-based commissioning highlights the need for a fullunderstanding of the scope of practice of SLTs and rangeof service delivery for children with speech, language andcommunication needs. Equally, commissioners in educationand social care (including head teachers as well as children’strust commissioners) will need to accept greater responsibilityfor commissioning aspects of the services provided forchildren with speech, language and communication needs.

The use of ‘pooled budgets’ under Section 31 of theHealth Act 199925 is an example of existing mechanismsfor integrating resources and the services they fund. Thereare relatively few examples of these processes being usedto provide more effective support for children with speech,language and communication needs. However, the use ofaligned budgets, where many of the flexibilities of apooled budget are possible but the financial accountingsystems retain the budgets within individual organisations,is beginning to increase. The development of children’strust arrangements will no doubt result in a greater focuson these flexibilities.

Figure 2 Population of children andthe services provided

Specialistservices

Targeted services

Children with

additional needs

Vulnerablechildren

All children

Universalservices

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2.3 Delivering integrated services throughmulti-agency models

The delivery of services through integrated systems andprocesses has been conceptualised within the Every ChildMatters framework as shown in the diagram below 26.

This model shows the importance of integrating thinkingat every level to provide an integrated package as anoutcome to the child.

In Early Years these changes are being effected throughthe development of children’s centres and the main-streaming of Sure Start and similar initiatives27. Earlyeducation is provided alongside family support andrelevant health services (including speech and languagetherapy specifically).

In England, the use of the of the Early SupportProgramme targeted at the child with complex needsintroduces the concept of a key worker or leadprofessional to guide the family through the maze ofsupport needed for their child. Other examples of thisapproach include the wraparound project in NorthernIreland28.These and other programmes embrace the ‘teamaround the child’29 approach, where pathways aredeveloped with the child’s needs at the centre andtraditional professional pathways are secondary.

Extended schools and learning communities provide asimilarly community-focused base from which families canaccess services for older children and young people.

Outcome for children andyoung people

ParentsFami l i e s Commun

i ty

Inter-A

gency GovernanceIntegrated Strategy

Integrated Processes

Inte

grat

ed Front-Line Delivery

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2.4 Workforce review

Integrated commissioning sits alongside workforce reviewand the emphasis on competency based profiling of roles.The RCSLT has been proactive in this area in recognisingthe need for a competency-based framework30 31. TheChildren’s Workforce Strategy32 emanating from theDepartment of Education and Skills (England) and theUK-wide Skills for Health33, share the ambition ofredesigning the workforce to meet the needs of theservice user without assuming restrictions of existingprofessional boundaries. These cross-disciplinary and cross-agency reviews of competences, needed to deliver supportfor children with varying needs, present a challenge to all discrete professions.

The RCSLT is actively encouraging SLTs to respond tothese shifts in policy and engage in role redesign. Part ofthis process is to recognise which skills and competencesare unique to an individual who has a professionalregistration as an SLT and which are shared with others(or could be shared with others). Alongside this, theopportunity to develop new roles across traditionalprofessional and agency boundaries must be exploited.

2.5 Theory underpinning intervention forspeech, language and communication needsLanguage is the unique attribute that defines us ashumans; it is the key tool we use in shaping ourunderstanding of the world, in transmitting our culturefrom generation to generation and in forming andmaintaining social relationships. It is also the key/mainmedium of education. Children are surrounded bylanguage and for those who have difficulties acquiringlanguage, their difficulties pervade most aspects of theireveryday lives – interactions with families, attempts tomake and keep friends, learning about their world andtheir education.

Children learn language in a social context that providesthem with opportunities and motivation to interact andthat provides feedback on the success of theircommunicative attempts.

In order to effectively support children with speech andlanguage impairments, interventions must consider howbest to shape all these different contexts. As long ago as1978, Bloom and Lahey34, talked about intervention thataddresses the entire communication context in terms of:

• Children’s opportunities to communicate• Reactions children receive• Topics of conversation that are available• The language models (grammar, vocabulary, sounds)

they hear• The modality used (adapted from Bloom & Lahey, 1978)The delivery of intervention following these principlesrequires a team around a child to structure the activitiesand interaction opportunities of a child’s everyday life. It istherefore necessary and appropriate for teams rather thansole SLTs to deliver intervention. Equally as important asthe form, content and use of language, as outlined byBloom and Lahey, is recognising the child and theircommunication within the wider context in which theyexist.

Brofenbrenner’s Ecological Systems Theory35 demonstratesthe interaction between levels within the child’senvironment and highlights the need to address issuesand difficulties across the ecosystem in order to effect realchange in the child.

Figure 3 (top right) illustrates how the child is placedwithin the wider context and that the child’s developmentwill be partly dependent on the feedback within thesystem with interactions at all levels.

The understanding that the child in isolation cannot bemeaningfully supported underpins much of the integratedchildren’s agenda outlined above.

In terms of professional practice, the InternationalClassification of Functioning, Disability and Health(ICIDH-2)36 classification of impairment, activity, andparticipation provides a framework for examining thefocus for professional input within the wider context.

This framework considers input in terms of the desiredimpact for the child. Intervention can be targeted at thefollowing levels as shown in diagram opposite:

• Impairment – within the child

• Activity – addressing the impact of the impairment on the child’s ability to do certain activities

• Participation – considering the impact of theimpairment and restricted activity in terms of the child’sability to participate as they would like within theirparticular context

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Child

Society

Community

Family

Interaction

Figure 3 after Brofenbrenner (1989)

The focus for input

When shouldSLTs be workingat the level ofimpairment?

Assessment anddiagnosis?

Intervention?

Across all typesof child?

When shouldSLTs be workingat the level ofactivity?

i.e. workingto addressthe impact ofthe impairmenton theindividual’sactivities

When should SLTs be working at the level of participation? Working to ensurethat the individual opportunities for participating fully are maximised. Shouldthis be all children? Vulnerable children? Children with specific additional needs?

Impairment Activity

Participation

2.6 Current professional consensus – what isgood practice?

The RCSLT Clinical Guidelines by Consensus 37 published in2005 following extensive consultation with expert groupswithin and beyond the profession, provide a comprehensivesummary of the evidence base for different fields withinspeech and language therapy, including working withchildren across a range of disorders and a wide age range.

Communicating Quality 2 (CQ2)38 provides the professionalstandards to which all registered SLTs agree to adhere.The third edition of Communicating Quality is due to bepublished early in 2006 and this will provide updatedinformation that takes account of the significant changesin the external context over the past decade.

Neither of these texts, however, provides informationregarding the models of service delivery found to be mosteffective – the former focuses on the impairment level andthe latter on professional standards. In order to informthis paper the RCSLT held a UK- wide forum on children’sservices in September 2004. A representative sample ofSLTs from across the four UK countries, as well as fromstatutory, voluntary and independent sectors, was invitedto attend a one day event. Delegates were presented withthe policy direction from all four countries and asked toconsider a number of case studies. The case studies wereexplored in facilitated small groups. The brief was toconsider the following issues within a potential futureframework of integrated children’s services:

• What are the desired outcomes for the child?• What interventions are required to achieve these?• Why are these appropriate interventions?• How can the desired outcomes be achieved?• Where does the intervention take place?• Who delivers the intervention?

In addition, delegates were asked to consider:

• Who commissions the interventions?• Who funds the interventions?

Delegates were also asked to have in mind the need toconsider the full scope of intervention based on theICIDH-2 classification of impairment, activity, participationas outlined above.

The outputs from the case studies indicated there isconsensus regarding key features of good practice in termsof ensuring that the contribution of the SLT is set within awider context in order to be effective and to have maximumimpact on the child and their family. Clear themes includedesired outcomes that highlight activity and participationgoals as well as impairment goals, speech and languagetherapy interventions as part of a wider package ofsupport, flexibility in terms of where and how support isdelivered, and the need for SLTs to work as part of widermulti-professional and inter-agency teams.

2.7 Summary of the context

The Every Child Matters: Change for Children programme 39,while England-based, encapsulates key policy directionthat is echoed in Scotland, Wales and Northern Ireland.The move towards integrating children’s services is acommon direction of travel across the UK. Thecombination of changing legislative framework forchildren’s services, changing organisational infra-structureand changing workforce strategy results in a momentumfor change which has not been evident in the past.

The RCSLT and its membership need to be visionary inresponding to the opportunities and challenges at thistime.

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3. Articulating the vision:focus on impact

3.1 Delivering effective supportIn a continually evolving and dynamic system, it is notpossible, or desirable, to identify ‘good practice’ as anarrow construct. However, in order to maintain aprofessional integrity in a rapidly changing context, it isnecessary to identify some key elements that need to bepresent in any context where an SLT is working withchildren.

Recommendation 1:Any SLT working with children should:

• Identify the speech, language, communication oreating/drinking needs of the child as part of, or withreference to, the appropriate multidisciplinary team (thisdoes not imply a static membership, more the team ofrelevant professionals for the individual child)

• Identify the functional impact of these needs• Consider the most appropriate context for support ie.

which settings are most relevant to the child and theirfamily

• Identify the contribution of the SLT as part of the widerteam working with the child to meeting the child’s needs– including the full range of options from advice tocolleagues through setting up programmes to directintervention where appropriate.

Recommendation 2:Services should offer the full range of support forchildren, including direct intervention where appropriate,while ensuring that overall management includes goalsrelating to activity and participation, managed by thosemost relevant the child.

Figure 4 40 (below) illustrates how packages of support canbe classified according to the lead responsibility and focusof intervention. The underlying philosophy is that ifintervention and support are effective a child will typicallyfollow the direction of the arrow. It is fully acknowledgedthat not all children will be able to move away from anSLT-led package. However, there is an important premisethat for all children the need to have interventions, whichare focused on activity and participation that areembedded within the relevant context, is essential.

Figure 4 Service model for packages of support

Children centre basedspeech and language groups

Individual speechprogramme withmodelling

School run languagegroup

Language forThinkingPackage

Curriculumplanning anddifferentiation

Playgroundgames group

Curriculumbased/ classroomgroupSocial

skillsgroup

Hanen

‘Talking Time’Speech

Group

PCI Socialcommunication/complex individual

SLT set up LanguageGroup

Individual languageprogramme withmodelling

Individualassessment

Home visit for therapyand modelling

Individual assessmentin context

LEAD RESPONSIBILITY

school/settingparent

other professional

Speech andLanguage Therapist

ImpairmentFOCUS OF INTERVENTION

Participation

TRAINING

Parent trainingwith SENCO

ClassroomStrategy

Modelling

Central training

School INSETTraining

Staff training

Recommendation 3:The RCSLT regards trans-disciplinary working as central to work with children. The RCSLT supports theexploration of SLT roles within trans-disciplinary modelsand the development of new models, which maximise thecontribution of SLTs while ensuring the specialistcontribution to the system is recognised as essential.Emerging key worker roles and lead professional roles arealso central to this model of working if it is to besuccessfully implemented for the benefit of children andtheir families.

The concepts of interdisciplinary and trans-disciplinaryworking are familiar in multidisciplinary teams and showthe potential for service delivery to be streamlined for thechild and their family when teams are working so closelytogether (Figure 5 – Models of multi-professionalworking41). For this model to be successfully implementedit is essential that there is clear understanding about theindividual professional contributions and that the trans-disciplinary model is not intended to replace any of thedisciplines, but to enhance the service to the child byensuring that the child’s pathway is holistic.

Within any team and/or context, the particular skills andcompetences of any individual team members will varydepending on their training and experience. The specificroles and responsibilities regarding the planning anddelivery of any child’s care will therefore also vary. Becauseof this variation, these roles should be explicitly discussedand agreed by the team around the child.

Strong professional leadership is essential to developappropriate trans-disciplinary working models that providea positive, integrated, streamlined experience for the childand their family, while ensuring quality is maintained withthe necessary expertise within the system. When thesefactors are addressed, the trans-disciplinary modelprovides cohesive service delivery.

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Figure 5 Models of multi-professional working

CHILD IN THE

CHILD

Trans-disciplinary working

Multi-disciplinary working Interdisciplinary working

A

B CENVIRONMENT

Discipline A

Discipline B Discipline C

CHILD

Discipline A

Discipline B Discipline C



Recommendation 4:Training of others, including parents, should be viewed asa central activity for SLTs in order to maximise impact forthe child and their family

If competences are to be shared effectively with students,less experienced members of the speech and languagetherapy profession, colleagues from other disciplines and,most crucially, parents, there needs to be greaterunderstanding of the therapeutic process. Speech andlanguage therapists training others require the skills toimpart insight into the precise therapeutic interactionsthat make an activity a speech and language therapy toolas opposed to merely an activity.

They also need the time to prepare training materials anddeliver training as an integral part of the service deliveryaround a child and their family. Successful training ofothers involved in the child’s care is crucial to achievingreal change for the child in terms of their speech,language, communications and eating and drinking skills.

3.2 Planning for maximum impact

Recommendation 5:Service planning for children with speech, language,communication or eating/drinking needs shouldalways be in partnership with other agencies.

Recommendation 6:Service planning should take account of the mostfunctionally communicative and socially appropriateenvironment for effecting change.

This extends across the age range. Pre-school childrenshould be supported in the home or early years setting ifpossible. The mainstreaming of Sure Start activities withclinic approaches will facilitate this shift and children’scentres and early years settings will become the mostappropriate base from which pre-school services canoperate. For children of school age, the school settingcontinues to be the most appropriate place for support.

Example 2aThe Bridgend Children with Disabilities Team ismade up of social workers, day care support workers,family link workers, an SLT, occupational therapistand physiotherapist. The CWD steering groupinvolves heads of service from the Therapies HealthDirectorate and social services, as well as theChildren’s Partnership Coordinator. Thus planning isinformed by three Bridgend statutory agencies. Contact Rosie Jones –[email protected]

Example 2bGlasgow City Council – Provision for Children withAutistic Spectrum Disorder (ASD)

• An interagency framework group made up ofmiddle management representatives fromeducation (including psychological services), socialwork, community paediatrics and speech andlanguage therapy.

• Developing an interagency approach to assessment,diagnosis, reporting, sharing information andsupporting staff in mainstream schools which havechildren with ASD

• Protocols for joint assessment and a format for jointreporting

• Pack for mainstream schools: ‘Autistic SpectrumDisorder – Information and Procedures Pack’targeted to head teachers

• ‘Support and Development Group’ for mainstreamstaff who have or are anticipating children with ASDin their classes

• A multi-professional seminar resulting in anInteragency Action Plan

Contact Pauline Beirne –[email protected]

Practice example 2Joint service planning for children’s services

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Recommendation 7:There is a need to define the parameters of anappropriate advisory needs based and dynamic approachto supporting children that integrates the concept of skillmix both within the profession and across professionalboundaries. The term ‘consultative’ model should bereplaced by a more accurate description of the servicebeing delivered. The RCSLT supports the need forresearch to further define and investigate the impact ofapproaches, which rely on the implementation of speechand language therapy advice by others.

The term ‘consultative model’ has not helped inconveying the key principles of transferring skills andcompetences to others in order that they can supportchildren more effectively throughout their daily activities.It has been widely interpreted to mean anything from aonce a year visit to a school for annual review, to a sixweek on, six week off model within mainstream schoolwith an assistant taking over in the six weeks off (Law etal, 2000)42. Whatever approach to skill mix and sharing ofcompetence, the key role for SLTs as trainers andeducators is once again highlighted.

The positive development of service models that draw onthe skills of others within the child’s system – be theyparents, teachers, learning support assistants or others –arose from the recognition that working at the level ofimpairment (see the ICIDH-2 impairment, activity,participation outline above) is in itself of limited value tothe total life experience of the child if they are not alsoable to benefit in terms of activity and participation.Unfortunately, where models involving the delegation oftasks and programmes to others have been perceived asresource saving strategies, the positive reasons for suchapproaches have been lost. Fortunately, there areexamples of positive models where others within theworkforce around the child contribute to the achievementof speech, language and communication goals. This isimportant, as the demographics of the workforcecontinues to change significantly.

The demographic data provided by the children’sworkforce unit43 predicts a dearth of highly trainedprofessional individuals over the next 10 to 20 years. Thisshortfall in the potential workforce will be attributable todemographic and epidemiological effects rather than lackof opportunity for training.

The development of new support worker roles is thereforea logical way forward and such roles are already emerging.For example, educational health workers who areeducation-based staff with specific training for supportingall health interventions for children in educational settings.These support workers are assistant practitioners in thesense they are implementing interventions devised byqualified professionals. However, in order to be in theseroles they have had training and can demonstrate theyhave developed the necessary competences to supportchildren within the educational setting.

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Example 3aNorth West London Hospitals Trust Speech andLanguage Therapy Department and Harrow LEAPortage ServiceSpeech and language therapy assistant and portageworker run the Early Bird Programme together in anEarly Excellence CentreContact Marie Luscombe –[email protected]

Example 3bIndependent SLT developing the role of tutors,teachers, support workers and classroom assistantsthrough training in order that they can support thedelivery of support for the child.Contact Sheilagh Urwin –[email protected]

Example 3cSure Start Hailsham and Eastbourne Downs PCTSpeech and language therapy assistant and Sure Starthome visitor work together to run the Basic SkillsAgency Early Start programme. This is a programme forparents designed to improve basic skills and providepractice opportunities to develop play andcommunication with their young children.Contact Suki Ahsam –[email protected]

Example 3dA speech and language therapist and assistant workwith a designated teacher [usually the SENCo] and adesignated TA in each school on a rolling programme.‘Standard’ group programmes are demonstrated andthen run by the school staff and cascaded to other staffas necessary. Initially the group programmes focused on childrenwith additional needs and some vulnerable children,but over time it soon became clear that the benefitswere much wider. Contact Mary Auckland –[email protected]

Practice example 3Multi-agency support worker roles

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Considering the ‘horizontal’ spread of competence impliesrole redesign that involves crossing boundaries at theprofessionally qualified level. That is, looking at otherprofessional groups and considering where overlaps inskills and competence might make a sensible case for oneor the other being involved rather than both. The ‘teamaround the child’ approach for disabled children is anexample of a system that values individual professionalcontributions, but challenges assumptions about whodoes what and when44.

Figure 6 (below) presents a diagrammatic representationof the continuum of competences within the workforceand the impact of this on the point at which an SLT cansafely delegate the delivery of interventions around a child.

The decision-making process around where to draw thisline for an individual child needs to be explicit. Theconcept of risk assessment will be useful in exploring the

parameters involved. Where there is a high level ofcompetence within the child’s context, be that home,early years school or setting, it may be possible for theSLT to take on an appropriately advisory role. Where thecompetence is less certain, then the focus of the SLT, maybe best placed in developing the competence in theenvironment. The key point is that the place ‘the line isdrawn’ should be in response to the dynamicenvironment and not set in time or place.

The concept of managing a child’s speech, language,communication or eating and drinking goals as part ofthe their daily routine, and therefore undertaken by thepeople who are part of that routine, should be seen as apositive option. This is not a dilution of a specialistresource, but the effective implementation of anecological approach45 whereby the requirements of theindividual child and the setting where the goals will beaddressed are both taken into account.

Figure 6 Continuum of competences

uniquely withinthe remit of a

speechand language

therapist

canand should

be handed oncould sit either with the SLT or with another

Recommendation 8:Service structures should reflect the changing context.Highly specialist, principal and consultant therapists needto use time to train, develop, coach and mentor lessexperienced therapists who in turn need to be given theopportunity to work with all caseloads. The mostspecialist should focus their skills on the strategicdevelopments within their specialist area.

The highly experienced therapist should be used as a true‘consultant’ in the sense that they can be clinicallyaccountable for a team of less experienced but qualifiedregistered practitioners. They in turn advise a team ofassistant practitioners and/or students in delivering theprogrammes. The more senior therapist may have anoverarching responsibility for the delivery of services to alarge number of children without being directly involvedthemselves for the majority of their time. This wouldnecessitate examining roles at every level, as the seniorpractitioner may have direct regular contact with a verysmall number of families at any one time. The allocation ofchildren and families throughout the team will be basedon clearly defined criteria at specific times in theirpathway through a service. Empowering the newlyqualified practitioner and valuing the expert are equallyimportant for future service delivery.

3.3 Systems for strategy

Recommendation 9:The RCSLT recommends that within each local authorityarea there needs to be an SLT professional lead forchildren, who can interpret national policy and ensurethat partnership working occurs in terms of integratedcommissioning of speech and language therapy provision,strategic planning and operational delivery. Thisprofessional lead should ideally be a member of keystrategic multi-agency planning groups and beempowered to make key strategic decisions on behalf oflocal speech and language therapy services. The role of professional lead should also provide a focalpoint in terms of professional standards for all speechand language therapy provider services both withinstatutory and non-statutory provider organisations(including independent practitioners).

The introduction of the concepts of plurality andcontestability to the provision of statutory serviceshighlights the need for members of the speech andlanguage therapy profession, along with other AHPcolleagues, to engage at a strategic level. It will beincreasingly important for professional advice to beprovided to commissioners, who will come fromincreasingly diverse backgrounds and experiences asservices come together across traditional agencyboundaries.

Those managing speech and language therapy servicesneed to:• gain membership of key strategic multi-agency planning

groups• have the required high level negotiation skills (including

in depth knowledge of the functioning of the differentagencies)

• actively influence at director level and at a strategic levelacross agencies

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Perth & Kinross SLT Surestart ProjectThe SLT Department is running a Sure Start fundedproject that is extending the role of the SLT assistant.Two NNEB(Equivalent)-trained staff have beenrecruited. Following extensive in-house SLT trainingthe SLT(A)s are providing direct therapy programmesto children in nurseries under the supervision oftherapists. Initial results show positive outcomes forchildren, parents, nursery staff and therapists.Contact Jeanette Seaman – [email protected]

Practice example 4

Recommendation 10:The role of the SLT must be seen within the context ofthe specialist and wider workforce. Commissioners needto be aware of the unique contribution of SLTs across thepopulation base.

In considering the place of the SLT within the children’sworkforce it is essential to see the ‘whole system’.The Workforce deployment pyramid for integrated children’sservices 46 (see Figure 7 below) offers a framework in whichit can be seen that SLTs have an equal role to play at alllevels of the ‘pyramid of need’. This model proposes thatit is equally as relevant to have an SLT supporting a childwith a complex disability as it is to be involved in thepreventative work aimed at the general population of ‘allchildren’. The key factor is that the workforce dimensionof the model represents the pool of specialist resourceavailable for children at each level of need. Thesuggestion is that an SLT working with a child withspecialist additional needs will sit as part of a largeworkforce around that child and therefore needs toconsider the specific contribution that they can make asan SLT in this context. A child’s speech, language,communication or eating/drinking goals can be achievedusing a team around the child.

An SLT working within universal services at a largelypopulation focused level may, on the other hand, findthemselves as a more significant proportion of thespecialist workforce. The numbers of children impactedupon, however, will be significantly greater in this contextand therefore the proportion of ‘time per child’ for thetherapist working with ‘all children’ will be significantlyless than for the therapist working with the relatively fewchildren with additional needs.

The model also implies that all levels of experience in termsof SLT practitioner can operate at all levels of the pyramid.Clinical experts are relevant in all areas of speech andlanguage therapy practice as are student therapists. Therationale for ensuring that the unique contribution of theSLT is relevant for all children lies in the changing contextas outlined in part 1 of this paper. In an inclusive model ofservice delivery, which aims to deliver services in the mostaccessible and effective way for children and their families,it is essential that therapists can support at all levels andacross a range of settings. This model allows for thepossibility of a child with a complex communication needto be supported via a children’s centre, nursery ormainstream school in that the skills and competencesrequired can be present in all three as well as in moretraditional specialist centres and settings. The ‘wholesystem’ approach needs to extend to include all settings inwhich SLTs work.

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Figure 7 Workforce deployment pyramid for integrated children’s services

Population

SLT others

SLT others

SLT others

Childrenwith

additional needs

Vulnerablechildren

All children

Proportion ofSLT time per

child

Servicefocus

Specialistservices

Targetedservices

Universalservices

Specialist Workforce

Multi-agency working

Example 5aCOMET (Communication and Education Together)project in Northern IrelandSpeech and language therapists employed as advisorySLTs to enable teachers to identify and support childrenwith speech, language and communication difficultiesin mainstream schools. Emphasis on collaborativepractice, training and a consultative role for the SLTsContact Anne McMahon –[email protected]

Example 5bAt I CAN Dawn House School a residential care officerhas a role across the school in supporting children withaugmentative and alternative communication (AAC)devices. She uses her knowledge of communicationdisability, together with technical expertise to supportstaff in their knowledge, use and maintenance of high-tech communication aid – as well as being involved inrunning AAC groups for children.Contact Alex Hall – [email protected]

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Recommendation 11:Managers and service leads should work together withtheir AHP colleagues as well as colleagues from educationand social care, in the development of new roles, inparticular the development of consultants/specialistadvisory posts and cross-agency posts.

The development of consultant posts should offerpotential in integrated children’s services. A consultant indisability, inclusion, or neonatology could be held by anumber of professionals and SLTs are in a strong positionto compete for such posts. The reports on how consultantposts are emerging indicate that they are being createdwhere the local management are seeking to create therole. The RCSLT therefore urges managers to actively seekout those contexts where a consultant lead will enhanceservices.

Practice example 5

www.rcslt.org

3.4 Developing the workforce

In order to respond to the challenges of the integratedchildren’s agenda and ensure the appropriate skills setsare available within the workforce, there is a need toconsider training and continuing professionaldevelopment (CPD) at all levels.

Recommendation 13:The RCSLT supports the development of placements thatoffer student therapists a full range of opportunities aspart of their practice based learning and this wouldinclude working as part of trans-disciplinary teams.

This should include opportunities to work independently(with appropriate supervision) in schools and settings.This view is reflected in the RCSLT position paper onpractice placements47.

The RCSLT is concerned that newly-qualified SLTs aresometimes expected to act as ‘consultants’ to otherprofessionals despite their limited experience. Part of thisconcern arises from lack of specific experience as students.This is an issue for which the responsibility lies withpractitioners as well as the HEIs in that students can onlyaccess the placements they are offered. Increasinglyconfident newly-qualified SLTs are emerging in areaswhere placements in mainstream schools and othersettings, which offer real opportunities to manage acaseload, are available.

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Student placements

Placements in mainstream schools in GreenwichTeaching PCTStudents are placed in mainstream primary schools inpairs for one day a week for one or two terms. Thesupervising SLT attends the school four times per term.The special educational needs coordinator (SENCO) inthe school is the main point of contact for issues arisingwhen the SLT is not on site. The SLT can be contactedby mobile phone at any time. Students are involved inassessment and therapy with pupils as well as jointplanning and discussion of ideas with education staffand demonstrating activities to staff and parents. Thismodel was initially a pilot scheme following which a list of essential criteria for a successful placement wasdrawn up.For further information contact Jan Baerselman,Coordinator of Mainstream Schools Service,[email protected] or Roz Weeks, ClinicalManager of Speech and Language Therapy Servicesto Education, [email protected].

Practice example 7

Cross professional/Cross agency leadership

Example 6a – OperationalOxfordshire Integrated Service Manager. Since October 2004, the “language” strand ofCommunication, Language, Autism and SensorySupport Services (CLASS) has been managed as partof an integrated service by one of Oxfordshire’sspeech and language therapy coordinators. Theintegrated service manager (SLT) has dualaccountability – to the head of CLASS and to themanager of children’s therapy services – andmanages: teacher team leaders, teachers, therapistsand therapy and teaching assistant staff across pre-school settings, mainstream schools and additionallyresourced bases linked to mainstream schools. Contact Liz Shaw – [email protected]

Example 6b – StrategicHackney Integrated Therapy ServiceCity & Hackney PCT and The Learning Trust (thelocal provider of education services in Hackney)jointly fund an integrated therapy service with SLTsbeing employed by either organisation but managedas one team. As part of the strategic management oftherapies within the integrated agenda the children’stherapy manager is part of the SEN Senior ManagementTeam within the Learning Trust as well as part of thehealth structures within the PCT. Service planning isintegrated so as to meet the strategic objectives ofboth organisations. Contact Marie Gascoigne –[email protected]

Practice example 6

Recommendation 12:Management opportunities across agencies and acrossprofessional boundaries should be actively developed.

The integration agenda relies on professionals from allbackgrounds engaging in the development of services innew ways. In order to ensure that the needs of childrenwith speech, language and communication needs aremet, it is imperative that there is balanced representationat all levels of service planning and management.Care group management and teams based aroundchildren’s journeys are now common within manystatutory organisations. The management arrangementswithin an integrated children’s service are set to becomemore diverse and based less and less on historicprofessional groupings.

Recommendation 14:Speech and language therapists working with childrenshould undertake continuing professional development(CPD) activities across health, education and social careto develop knowledge and skills that will prepare themfor cross-agency roles.The RCSLT values CPD activities that are not limited tothe health context.

Within education, horizontal skill mix could see theemergence of new roles for SLTs as officers withineducation structures as well as health professionals.Integrated specialist learning support teams drawingtogether specialist teachers and SLTs are not uncommon,and in some areas reciprocal membership of seniormanagement teams across education and health arebeing piloted. In Scotland, the creation of communityhealth partnerships led by social care will bring furtheropportunities.

Recommendation 15:The challenges of the changing context mean thatbusiness and entrepreneurial skills sets will become morerelevant for senior managers. All speech and languageservice leads should also develop excellentcommunication and negotiation skills as part of aportfolio of leadership competence.

In order to respond as leaders in the changing context,SLTs should recognise the importance of key leadershipskills. Service leads should not only ensure that theydemonstrate these skills, but also encourage leadershipdevelopment throughout the structures for which they are responsible.

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4. Conclusions and wayforward

There are revolutionary changes underway in children’sservices across the UK. Speech and language therapists,managers and commissioners are all being required tothink in new ways and embrace new structures andprocesses.

In order to continue to keep the child and their family atthe centre of the arena, it will be necessary to continuallyre-examine the professional view in relation to theexternal context. Consequently, the recommendations setout in this paper will be reviewed in 2008 and evaluatedin the context of the reality of services at that time.

The RCSLT envisages that, as well as informing jointworking within each of the home countries, the paperwill also provide SLTs with a framework to support localservice development and delivery.

The consultation involved in the development of thispaper has in itself initiated a process within the RCSLTand its membership. The structures within the RCSLT thatwill best support the membership in responding to thechanging context for children’s services are under reviewas a result of this process. In addition, it is hoped serviceplanners and managers throughout the UK will be able touse the frameworks outlined to develop services that willbest meet the needs of children with speech, languageand communication needs in the UK.

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References1 Law J, Boyle J, Harris F, Harkness A, Nye C. (1998) ‘Screening for

speech and language delay – a systematic review of the literature’Health Technology Assessment – Volume 2 Number 9 pages 1- 184

2 The 4 Nations Child Policy Network Review 2003 – 2004www.childpolicy.org.uk/AfcStyle/DocumentDownload.cfm?DType=DocumentItem&Document=4Nannualreview0304%2Epdf

3 www.scotland.gov.uk/Topics/People/Young-People/children-families/15939/3896www.scotland.gov.uk/library5/education/sure_start_mapping.pdf

4 www.wales.gov.uk/subichildren/content/circulars/start/start-e.htmwww.wales.gov.uk/subichildren/content/entitlement/early-entitlement-2004-e.pdf

5 www.nics.gov.uk/press/hss/041216a-hss.htm6 www.surestart.gov.uk/_doc/0-1D9968.pdf7 www.earlysupport.org.uk/pilot2/index.htm8 ‘making it r wrld 2’ 05 NI Children’s Strategy

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www.scotland.gov.uk/library3/education/fcsr-00.asp22 The Commissioner for Children and Young People (Northern

Ireland) Order 2003 www.nics.gov.uk/press/ofmdfm/030626a-ofmdfm.htm

23 www.scotland.gov.uk/library3/education/fcsr-07.asp

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27 Every Child Matters website for exampleswww.everychildmatters.gov.uk/

28 www.shssb.org/partnership_working/wraparound/29 Limbrick P. (2001) www.handseltrust.org/30 Williamson K. (2001) Capable, confident and competent, RCSLT

Bulletin, 592, 12-1331 www.rcslt-members.org/membersonly/comp-introduction.shtml32 Children’s Workforce Strategy: A strategy to build a world-class

workforce for children and young people (DfES 2005) DfES/1117/2005www.dfes.gov.uk/consultations/downloadableDocs/5958-DfES-ECM.pdf

33 www.skillsforhealth.org.uk/34 Bloom L, Lahey M. (1978) Language development and disorders.

New York: Wiley35 Bronfenbrenner U. (1989). Ecological systems theory. In R. Vasta

(Ed.). Annals of child development, 6 (pp. 187-251) Six theories ofchild development. Greenwich, Conn: JAI Press

36 World Health Organisation (2001)www3.who.int/icf/ebres/english.pdf

37 RCSLT Clinical Guidelines Edited by Sylvia Taylor-Goh (2005)38 Communicating Quality 2 – Professional Standards for Speech and

Language Therapists. (RCSLT, 1996)39 www.everychildmatters.gov.uk/_files/F9E3F941DC8D4580539

EE4C743E9371D.pdf40 Service model for packages of support. Hackney Speech and

Language Therapy Integrated Service Handbook (2005)41 After M Giangreco, J York & B Rainforth 1989, cited in Mackey, S

and McQueen J, 199842 Law J, Lindsay G, Peacey N, Gascoigne MT, Soloff N, Radford J

and Band S. (2000) “Provision for Children with Speech andLanguage Needs in England and Wales: Facilitating Communicationbetween Education and Health Services” DfEE research report 239

43 Pay and workforce strategy for the children’s workforce: evidencechapter (unpublished DfES 2004)

44 www.handseltrust.org/45 Fey M. (1986) Language Intervention with Young Children San

Diego, California: College Hill Press46 Gascoigne MT. (2006) Supporting children with speech, language

and communication needs within integrated children’s services,RCSLT Position Paper, RCSLT London

47 RCSLT Position Paper: Practice Placements

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Notes

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