ASD SALT Strategies unchanged is it the right therapy?

[2006hildy]

DS aged 6 Dx High functioning Autism delayed expressive language. His speech is similar to a 2 year old and has not really changed since he was 2.

The progress has been so slow the SALT is using her in house Communication Framework as the numbers would be so small on the Standardised tests.

DS has had SALT for over three years but the strategies have hardly changed. I could probably quote one that was used in the first and last reports.

We're in the midst of an appeal for refusal to Statutory Assessment.

SALT is very much against direct SALT intervention. Is it the right therapy?

Soo frustrated.

My dd and ds are currently both engaged with SALT through the NHS. They both have 121 sessions with a s&l therapist twice a week. At one point dd was having intensive therapy of 30 mins a day, for a fortnight.

I struggle to see how group therapy could be as effective.

There's nothing wrong with narrative therapy, or indeed with watching newsround to teach the structure of narrative. What there is a problem with is doing these things in a way that has no defined goal or objective and where students are unaware of what they are doing - and particularly in the case of students with HFA, assuming that if you chuck a few colourful prompts (who? what doing? where?)at a regular activity that all students are supposed to do that it will suddenly make it terribly clear to those who struggle with it. There is no understanding of the need to work with the student's frame of reference initially and then fading this out or to provide reinforcement that is meaningful to the child and there is little will to provide it by many even if that understanding is made clear - partially, I guess, because people have no experience themselves of making these things work and are unguided, so they come to believe that students can't learn because of their condition rather than how they are being taught.

Most students in mainstream will be taught the features of narrative structure using "texts" like newsround etc, it is the way of the curriculum these days - so the "therapy" is intended to be about more explicitly identifying the structural components of the narrative e.g. setting/characters/location/episodes in a fictional text and purpose/structure of information layout in a non fiction text in a way that isn't done in the classroom. As a goal, there isn't a problem with this - it makes sense to break down a complex text into its parts if you are struggling with where to begin with it. Yet if you as a SALT (or, let's face it, as a TA/LSA) have no means of engaging the student in this process or making it make sense to them what you are doing and why AND you have very limited time to actually repeat and work through each stage before the curriculum moves on, you are confined to the use of excessive prompting (e.g. we'll stick our prompts up on the wall to say we've met your needs, but we won't actually systematically teach you what they mean so that you can use them independently). This reinforces your belief that "these children can't be taught".

Even where people are aware and have a bit more time, they don't really know what to do. So for example, recently I've been working with a colleague who has realised that a student she works with in a specialist language unit is motivated to communicate for a specific reward. Great! I said,. "Not great", she said. "She needs to want to do it herself". Well yes, that's what we want to aim for, but right now, this is the way to make her engage in the skill and then we can thin out the reinforcement and make it more generalised. "What???" she said.

The problem as I see it is that because of time constraints and a cultural expectation of education that learning is something that happens miraculously within the child by virtue of genetic endowment/brain and biology with a very minor steer from a nearby adult, the child's difficulty is seen as something that really can't be changed and therefore no one's responsibility to change. Mostly it's not ill-intentioned. People genuinely believe the stories they tell themselves about what children can and can't do, and they receive reinforcement for the belief that children "can't" from all sorts of sources. Particularly with ASD/HFA, the student's "difference" is often seen as somewhere between fascinating and frustrating depending on the child in question, and normal rules are not held to apply. To an extent of course, they don't. There does need to be more creativity and staged teaching in order to make things work.

I'm not a great advocate for the consultative model in our system if I'm honest. I think there are far too many kids on SALT caseloads that are there for "social engineering" e.g. because they don't fit a middle class model of what they "should" be talking about at a particular age even though they are actually functioning quite well within their own linguistic communities. This is why there are 100s on caseloads. The incidence of severe speech, language and communication needs or in fact general speech/language/communication issues that actually impact upon a child's day to day living is really quite low in population terms, but there are thousands and thousands of children receiving "therapy" services for issues that would either spontaneously resolve or are not really issues at all if we didn't expect everyone to enter school speaking middleclass-ese.

Thanks for your help so far.
I am stumped it has taken a while to think about my reply. I need someone to tell me what to do.

How do I get them to change from consultative model to 1-2-1 model or what other therapy is out there? Herts are notorious to digging in their heels in I could probably quote something from the bad SEN phrases thread used.

Am I losing my appeal, should I give up?

Great post (as always 9-5)
Hit the nail on the head so many times.
I am actually fine with the consultative model as long as the staff the s/lt is consulting with are mid to long term colleagues. In that way, you get to build up a very good working relationship with them. I 'consult' to my teaching colleagues and they are amazing. They'll also tell me straight off what will/won't work within the time and resources avaialble to them, so I like to think we have an honest constructive thing going on.

Assuming you have a brilliant s/lt with oodles of time to work 1:1 with a child, many might think this is great but in fact it is the people in the child's life who need to know about effective measurable ways of extending a child's communication repertoire and not the s/ltm, so ultimately that knowledge needs to be transferred. .

This post won't help Hildy but I wanted to say it.

I guess I really meant a consultative model where you see staff twice a year, there is no dedicated person to work with a child, data collection is seen as snooping on the teaching assistant and viewed with suspicion... I suppose in your terms I work consultatively as the majority of intervention is not direct and really only ever involves me trying to find the growth point/what is needed to increase independence with a target and this is then what the staff do in day to day interaction.. but I know the kids, I know the staff and I know the politics/dynamic of the school that creates contingencies for staff on site and my close contact give me multiple opportunities to shape staff international behaviour/reinforce in. Subtle way that makes staff feel I have heard/am responding etc. Very difficult to influence behaviour with only limited contact, where is contingency? I am doing a lot of reading on rft at the moment as a way of establishing contingencies with staff for real behaviour change, it seems to be useful for brief interventions.

Sorry Hildy. I wish I had a practical answer for your problem... I just don't know what it is other than pressure to get them to show what they've been doing in terms of time spent/procedures undertaken/data collected/smart target :(

Hilady's bunch have a proactive local NAS branch that the LA pay taxpayers money for 'advice and consultation' who state in public meetings that you can not and should not measure speech and language development or social skills and who attend all partnership/consultations/voluntary/information sessions events backing up the Head of Autism on this.

My heart just sinks when I read that kind of thing, Star.

It's Big Society innit. Bribing Working together with the voluntary sector.

That's outrageous.
I'd be asking for a public statment to this effect (but then those that need it to make a case are doubtless fighting myriad other battles).

It contradicts all guidance set out to LEAs and to the NHS.
There is huge pressure (quite rightly) on us all to demonstrate mesaurable outcomes.

If it's important enough to teach, it's important enough to measure.

I am feeling better now but.....

?you can't take what is seen to be a 'gold standard' approach and hold the LA to it. In an ideal world, all children would have an array of detailed baseline assessments, quantifiable intervention and regular consistent data measurement, etc. The SEN CoP doesn't give children the right to gold standard intervention, only that which is adequate.?

This is what I have been doing with the SEN Cop and the Lea Guidance Criteria.

LEA have come back with tribunal response as ?The Council opposes the appeal on the grounds that we do not consider that paras SEN Cop 7.4 & 7.34 should be applied in ds?s case.

They reckon the p**s poor SALT and AAT service is OK ?therefore concluded that a SA is not necessary 7.5 para SEN Cop.

Oh it?s tiring.

SEE, this is what I was fucking dealing with.

Hilady, I'm so sorry, but it isn't you, I promise. Your dealing with a bunch of fuckwits who don't discriminate (or rather they do).

Looking at it though, all that is being said is that they don't believe that attainment is relevant because it within an expected range.

Which is pretty much the ONLY reason that can be given for refusal and would be used regardless of whether your child should have a statement or not as the first parental jump-hoop.

You need someone to say that your ds has not made adequate progress despite schools and outside agency efforts.

You can also make a written request for levels now, and then follow it up by asking what they expect the level will be in 6 months (this information should be available if they are making judgements that he has made expected progress i.e. in order to have maded expected progress, they needed to have expected a level of progress in advance iyswim).

I have lifelong targets. To keep breathing, for example.

"Working will continue to breathe independently twenty four hours each day in 100% of opportunities afforded her without the support of a special needs assistant".

You could, if you wanted to, write it as a waffletastic "professional" yet non-SMART target, but it wouldn't make it any more under the control of anyone but the Universe/insert Higher Power of choice unless they felt like killing me. Just because it describes something that's going to happen doesn't mean it's an intervention that will bring about change.

Lifelong targets .

Oh - brings back memories:

'DS' will need to attend a mainstream setting in order to lean social skills from typically developing peers'

I wonder if these 5 year olds knew they were supposed to be teaching ds. Probably more effective than the tribunal-won allocated TA who just followed him about and stimmed with him when she wasn't tidying up for the class teacher.

And 'ds will sit independently on the carpet at carpet time using a green spot to help him identify where he must be'.

Erm, there was nothing wrong with his BOTTOM, nor his behaviour at that point. His disability caused him to have difficulties listening to and understanding the teacher. How the feck does a green spot help with that?

But I'm definately going to remember the breathing target.

Love it.

I'm an SLT; I qualified 15 years ago.

I'm in favour of consultative working to a point, but for the reasons pointed out up-thread, it is so often ineffective.

We were pushed into providing this model of intervention more than is clinically appropriate by the NHS and their scarce resources, not because we are belligerent/incapable as so many threads on this board often imply. I stopped posting advice on mumsnet a long time ago because of the attitude towards my profession.

And this is the problem - we don't stand up enough for our profession within the NHS framework and insist on providing what we feel is clinically appropriate. 'Clinically appropriate' will sometimes include consultative working (with others taking responsibility to deliver, which I must say does not always happen, and that goes for the parents as well as the staff). It will sometimes include direct work.

It will sometimes include discharging a child because they have reached a plateau or because skills are in line or in advance of general cognitive ability.

The problem is, no matter what the SLT deems 'clinically appropriate' there will always be the suspicion that he/she is making decisions based on money. Most parents don't understand clinical decision making because they are not an SLT, even though they often claim that they do. Most parents will want 'direct intervention' whether is is appropriate or not, simply because they think this will be bound to be more effective. Most parents will not want their child discharged.

9-5 hit the nail on the head when she spoke about the relatively low incidence of specific SLCN requiring direct intervention; this does not translate into actual caseload figures because of the number of children on the caseload whose difficulties will spontaneously resolve or children where language delay is secondary to environmental factors.

If we had the truly specific case and if consultative working was effectively driven and measured then we would have better 'outcomes' and SLT would be deemed very effective.

Thank-you all for your support.

I will definitely get an independent report from one of the salts recommended on the recent thread and I will ask them this. ?Ask for the component target parts then. What can you expect your ds to achieve or progress in say the next 3 months, how can you measure that this expected progress has occurred and what can you do at home to either increase his chances or speed up his meeting of the target.?

Since posting initially we have had a Speaking and Listening ?P? level result of P5 and this has not changed over the last year. They said there wasn?t one then changed their minds now that I am taking them to tribunal and there is a whole data set in the Tribunal response.

The SALT says P5 is in line with his learning although he is averaging P7 P8. Is it alot behind or just a little - seeing as 3 sublevel points is described as good progress over a year. I would have thought alot by one years worth. Are his ?skills are in line or in advance of general cognitive ability? ? I don?t think so but SALT is saying yes?

Hildy -has the SLT said you child's skills are 'in line with or in advance of general cognitive abilities' or are you inferring this? Sorry I'm not clear from your post, it seems to quote mine.

You seem to say that the SLT has a different opinion to you?

Firstly, you could have this conversation with her rather than on MN. Just tell her you don't agree and ask for an explanation. I would be happy to go through things with any parent. Parents give me a rich clinical picture of their child and they are critical in my decision making.

Also, you have made my point beautifully. You have been told something by an SLT but you don't agree. Now I'm really not trying to be inflammatory, truly. But - how are you qualified to disagree?

The reason I ask is because I have recently had nursing assistants disagree with my feeding advice. They are not qualified to disagree with my opinion in a clinical sense, yet they do so quite loudly and continue to feed patients a diet which could prove fatal.

I'm not sure why they think they can disagree. I don't disagree with my dentist - I'm not a dentist. I wouldn't argue the toss with an anaesthetist over which drug to administer for similar reasons.

I think there is a massive issue of trust. I read lots of threads where there is an inherent distrust of SLT advice due to suspicion it is motivated by finances.

What if it isn't? What if the SLT's clinical acumen is correct? Surely there is at least a chance of this? Or are we all charlatans?

I have no doubt that distrust of clinical decision making stems from shonky experience of the NHS (I've had shonky treatment myself) BUT we cannot all be tarred with the same brush. When people disagree with clinical decisions/opinions without any coherent sense of what part of the decision is incorrect, why it is incorrect, or (crucially) what the correct assessment of the situation ought to be, I cannot help but think that the problem is 'I don't like that decision.'

Almost universally, the reason for 'not liking' a clinical decision made by SLT is either 'they want to discharge my child' or 'they are not providing direct therapy.'

I would suggest that most parents would like ongoing direct therapy without imment discharge. As moondog correctly pointed out, there is no way own earth this is sustainable given the few SLTs in the and enormous referral rate.

Most importantly, it is not clinically appropriate because it would not always produce change.

"Also, you have made my point beautifully. You have been told something by an SLT but you don't agree. Now I'm really not trying to be inflammatory, truly. But - how are you qualified to disagree?"

You are joking, right?

Nursing assistants and parents - not quite the same thing.

Let's have a think here: the OP's son has been diagnosed with high functioning autism but has the speech of a two year old.

That there says that there is an issue. If those facts are true, that is a disorder. You need no more information. The assumption that therapy is not clinically appropriate because it would not produce change is probably well founded, but the reason it is well-founded is not because there is definitive proof that a child with autism can't learn these skills, it is because:
a) we don't have resources to provide the intense therapy that might make a difference
b) we don't have a solid evidence base on which to base intervention decisions that do make a difference.

Sadly Jabiru, there is an element of charlatanism in our profession. I wish it weren't so, but it is. We routinely give advice with no solid evidence:

• use natural gesture
• don't provide corrective feedback, modelling is all that is necessary
• there is a confirmed developmental trajectory for language based on good evidence - erm, no. Most of our data is woefully out of date.
• there are "modules" in the brain that account for language disorder or a "chain of communication" that has been proven beyond doubt - there isn't.

As above, the Cochrane review stated that there is insufficient evidence of our effectiveness in many areas. Now this is a good enough (perhaps the best!) reason to not offer services, but it needs to be clear that the reason for not offering services is because SERVICES are ineffective, not because a CHILD has no hope of change/improvement.

How often do we say, "we're not offering therapy because our therapy hasn't been proven to be effective and there's just no evidence that what I can offer will make a change to your child" as opposed to "the evidence says that your child doesn't need intervention because it would not produce change".

There is, in real terms, a massive difference here. Telling parents that SLTs don't have evidence to offer appropriate interventions to produce change in certain populations would mean us taking on board our own failings. Saying that [all] intervention is inappropriate because change is impossible is like placing a life sentence on a family They have to live with this reality day in and day out. The worst thing you can ever do as a professional is take away someone's hope when you have no real reason for doing so. There is quite a lot of evidence that change IS possible, actually.

I will never forget the mother of a young man with aphasia who said to me, "they told me he would be a vegetable. They said there was no hope. I nearly died that day". This was about her son who, two years later, was speaking in simple sentences but communicating about all the things that mattered to him and living his life again. Who has the right to predict the future based on the shoddy evidence base we have? Why do we have to tell the truth in a way that protects our professional ego even when it is not the best or most helpful way to communicate with families?

I tar our whole profession with this brush. We can describe communication very, very well but in many areas we don't really know how best to develop it. Description isn't what most people need or want though, they want change in real terms. I agree we often can't provide this with resourcing etc but providing a "consultative model" that is ineffective and based on poor evidence and prejudice about what is and is not possible based on diagnostic labels is, to my mind, highly unethical.

Also Jabiru, do you know that in the new DSM-V they are going to remove the requirement for language disorder to be based on a disparity between cognitive and verbal domains? I would also argue that as SALTs we are not qualified to say whether someone's language is line with learning unless we have solid evidence in the form of a standardised cognitive assessment (which are like hen's teeth..) and even then, there are issues with the accessibility of standardised tests for certain populations and different language communities.

It's really tricky. We know very little. That's the real truth. We can offer some good for some client groups but there are very many where really we haven't a clue. As a colleague said to me recently, having done her MSc she has realised that SLT is about as much use for supporting certain aspects of language/communication as waving about a crystal skull or dancing at crossroads in the moonlight.

It's uncomfortable. I have struggled with this in the 10, nearly 11 years I have been working with people with language and communication disorders... but wishing it were otherwise doesn't remove the serious challenges that are presented by a lack of evidence. Another colleague, also doing an MSc, bemoaned the fact her thesis supervisor wouldn't just accept that there was no evidence for what she was developing: "but she doesn't understand, it doesn't WORK like that in SALT.. we just don't have that solid evidence but we have to do SOMETHING". Er, no. If you can't show you are making something work, what you need to do is say that what you do doesn't work, not offer something ineffective.

The main problem I have with dd salt is that the therapist is trying everything she can to not provide resources for teaching. Instead she turns up chats about her own life a bt to the teaching assistant and then does some very low demand stuff and says that's great and off she goes. After seeing dd on an ABA programme where she was pushed and made stacks of progress, this is hard to take. I am also peeved because the TA diligently works on her speech therapy targets every day despite dd being ores with the resources and the approach. When I queried what was going on eventually and asked for more speech sound work, I was given every reason under the sun why it wasn't appropriate. I have been given incorrect info. I have spoken to independent salts who disagree with what NHS SALT is saying and are even saying that what she says is frankly unheard of. All the while I am trying to remain friendly and assertive for dd sake as she needs good input. It is very, very frustrating. I also feel that NHS salt is simply lazy. She turns up with dull black and white pictures when she knows dd is very visual and loves colourful resources. She makes no effort to make her sessions rewarding for dd. it is very very depressing.

Surely Jabiru, parents have every right, just as patients do, to question clinical decisions. I am really appalled that you would suggest they don't.

I would question the opinions of a any doctor, anaesthetist or SLT if I didn't understand or believe what they were telling me.

Working's post mirrors my own experience in that there is often a very poor evidence base for clinical decisions and this is exposed when you ask questions.

So if you want to refuse direct therapy or discharge a child, you should confidently be able to explain why such action is necessary for this child based on knowledge if what is available in terms of therapeutic intervention and based on the most recent evidence.

My experience has been that services are quick to discharge because of policies as pathways or because the individual therapist does not know what to do for the child and no because there is nothing that can't be done.

And the evidence base for successful outcomes via indirect working through a TA for children with ASD seems to be very poor, if it exists at all.That is the sort of question I would ask about direct therapy and I have every right to ask it. I am not sure why any professional wouldn't expect and be capable of answering such questions.

I am not a clinical professional but I give advice in my professional life and I would fully expect people to question me until they were happy with it.