Communication in action

Communication in action

A parent contacted me about their child who is due to be discharged from Speech & Language Therapy. Child has done a (generic) programme and can answer all the questions on the worksheets. However, the same child still struggles to start and keep conversations going. 


My response was:

Tests and assessments are not ‘communication in real life’. Test results tell us something about the knowledge the child has about the tests or worksheets. It also gives us an idea of what they might understand and how they process information. It does not mean they can use the communication skills independently. 


For any other parent whose child can ‘talk the talk’ but does not ‘walk the walk’, here are the steps to becoming an independent communicator: 


1. (with others) experience the situation.


2. (with others) experience communication about the situation.


3. (with others) think about the communication and the situation using words and pictures.

4. (with others) practice words, language, and communication in structured situations.


5. on your own, practice communication BUT think about the situation afterwards with others who know you well. 

6. communicate independently. 


These steps are what ‘transferring skills’ is all about. So often people are expected to make the transition from step number 3 (reflecting on communication) to number 6 (independent communication). 


Being supported to go through all the steps is ‘communication in action’. It is practical and it is functional communication. It is what Speech & Language Therapists do and what they can support others to do when they are commissioned to spend the time (properly) with everybody involved. 

Let’s get back to basic

Predictability and routine go ‘hand in hand’. They help us feel safe and calm.

Visual time tables, calendars, objects of reference, ‘talking through the day or week’ are in my mind pretty fundamental stuff. Knowing what happens next communicates some sort of predictability.

If you can’t predict what happens next, or if anxiety means you are uncertain about next steps; someone showing you (visually) helps anchor you to the ‘here and now’.

In my work (with children and adults), having ‘visual structure’ to the day is more often the exception than the norm. We have seen anxiety and mental health problems for autistic people and people with social communication disorders soar.

I am making a tentative link between the ‘loss of structures’ and reduced wellbeing. If the importance of predictability and routine is forgotten, we are expecting people to navigate their routine on top of everything else that may be unsettling them.

Helping a person make sense of their day is pretty fundamental stuff, yet somehow it has gone off the radar everywhere.

Let’s get back to basics!

Courage is relative

Courage is relative to your situation.

The media is full of stories about children and adults undertaking feats we traditionally associate with courage and bravery. It makes us all feel hopeful!

This post is about those whose courage look insignificant to the popular idea of courage:

When you have autism or communication problems and you keep being misunderstood; starting conversations and speaking up takes courage.

When you socialise differently and you are ostracized, ignored or bullied; entering social situations takes courage.

If your anxiety plays out in fears of contamination or social rejection; going to school takes courage.

When your sensory system functions differently; wearing school uniforms, entering the dining hall or the play ground takes courage.

This post is not about belittling the amazing things other people can do. It is just a recognition that some kids display courage by doing the little things other people take for granted.

How do you take yours…? Communication that is

If you have a communication disorder or need, public services should give you information in an accessible format.

This makes services inclusive and it means you should get more out of your time with them. Accessible communication is a great idea, and it is law (2016 Accessible Communication Standards AND the 2010 Equality Act).

The problem is that ‘accessible information’ is generally non-existent or seen as simplified writing with a few pictures on top. If you have autism and you process language well, being presented with a few pictures can feel very patronising.

What makes information accessible depends on what the person’s communication style and needs are:

‘Plain English’ is information without hidden meaning and complex inferences.

‘Social stories’ explain what the situation is, social concepts, and conventions for the situation.

‘Easy read’ uses simplified text with images to explain key words.

‘Accessible typography’ makes text accessible by using appropriate size lettering, familiar, and distinguishable fonts.

‘Subtitles and captions’ (for video information) make spoken language visible and give valuable extra processing time.

‘Sign language & gesture’ convey the information visually. Gestures (such as Makaton) focus on important keywords. Gestures slow down processing demands.

One thing you should know:

When you go to a public service, you should be asked if you or the person you support have any problems accessing information or communication. If you confirm, it should be recorded in your notes.

All services should make attempts at making their information to you accessible. Speech & Language Therapists are uniquely placed to adapt information BUT it is everybody’s job to communicate and give information that is accessible (and therefore inclusive).

The above is the ‘should do’ although not every service does. Or the accessible information is the generic ‘easy read’.

Your role in making public services more inclusive and accessible could be to work out what your specific needs are (do you need ‘plain English’, ‘easy read’, ‘social stories’ etc?).

In the most friendly and non-confrontational manner (you know I like when we all get on!!): remind services you have a communication need, remind services it is their duty to make information inclusive (go easy!), tell them what works for you, and if possible show them examples of how you understand best.

This post is inspired by the brilliant @Sarahmarieob on Twitter. Follow her!

Did you know your brain is a detective?

We all work out what people mean by what they say. However, there is a slight difference in how autistic and non-autistic people make sense of communication.

Non-autistic people generally only need some (not all) information to work out the gist of a situation. It is a sort of ‘saver mode’. It helps ignore what is less relevant and focus attention on what is considered important. The name of this processing ‘trick’ is ‘central coherence’ (a lot of you hear me go on about it!). Central to working out the gist of a situation is the ability to make inferences about other people’s thoughts and intentions.


The non-autistic brain generally tends to focus on social information. Somehow social and emotional information is interesting and important to our brains. What goes in comes out; a lot of what is communicated is therefore social stuff.


Some autistic people may pay attention to detail but not necessarily the social detail. Or they may pay attention to everything and then deduct what is not necessary as they go along. This is possibly why some people find it easier to reject information in order to work out what they want, rather than being able to tell you off their own back.


In communication, I so often see autistic children and adults who have to hear and think through absolutely everything to work out what is meant by what is said.


For example, the class teacher might say:


“Thankfully we got Ella in our class to tell us all what we did wrong”.
Working out if the teacher is stating a fact, is sincere, joking, or sarcastic, the autistic child has to:


Work out any previous information that indicates Ella is particularly knowledgeable.

Work out if there was any social rules broken leading to the teacher’s comment.


Work out the teacher’s facial expressions and the way the sentence has been said.


Work out what his or her peers’ reaction mean.


Most of the time, deductive processing works effectively and other people will not necessarily notice a systemising approach has been used. Sometimes the result of this process ends with a conclusion that is different to what was intended by the situation or the other person.


This is a genuine misunderstanding, but misunderstandings can be seen as lazy, wilful or obstructive by others. However, if you work out the line of thinking (and how the deductions are made) you can see that the conclusion makes perfect sense. Even if different from what is intended.


Another aspect that is generally not appreciated is how effortful deductive processing of non-autistic communication can be. It is why people fatigue, have meltdowns, or look as if they are disengaged. These negative behaviours communicate the person is ‘full to the brim’ in terms of processing communication.


The problem is also that the effort put in to making sense does not really get acknowledged by other people. It is not appreciated that the person works harder at something non-autistic people take for granted. The result is the person feels or is made to feel stupid rather than feeling they have reached a fair limit. That time out is needed!


It makes for more diverse experiences if we acknowledge the difference in how autistic and non-autistic people make sense of information. We can use this to tell autistic kids: you are not stupid, your brain has to work like a detective. It is not wrong, it is just different.

Autism & transition to adult services

The voice of autistic children, adolescents and their families is needed now more than ever.


It is the stories and opinions that help change provisions and services. It is the ‘case examples’ that help systems think about what we do and how we can do it differently.

As I see it, collectively the ‘Experts by Experience’ are powerful when you have your say in right forums.


So here’s the point:


NCEPOD is focusing on ‘Transition to Adulthood’ and they need keen candidates to take part.


I am proud to represent my professional body (RCSLT) on the working group.

If you join, your involvement will help shape the study. The study is likely to influence future provision (fingers crossed).


A bit of context if you are interested…


The 2009 Autism Act identifies that there needs to be guidance for services and provision as children move to adult services (section 2.5.d).


The SEND Code of Practice identifies that planning for adulthood should start in year 9 of secondary education.


Yet we know that many autistic adolescents ‘drop off the radar’ in teenage years. Some describe this phase as the ‘shadow years’. It is a time of missed opportunities and the consequences can be severe for some!


If you are interested and want to take part, contact NCEPOD directly on: transition@ncepod.org.uk


(NCEPOD stands for: National Confidential Enquiry into Patient Outcome and Death).

Isn’t that just their autism?

Diagnostic overshadowing

‘Diagnostic overshadowing’ happens when professionals and practitioners focus on the person’s disability and fail to explore anything else that can help us understand what goes on for the person. 

When diagnostic overshadowing occurs for autistic people; mental and physical health problems, sensory pain, language and communication problems, and social discrimination are attributed to autism only. I have been to SEND tribunals where this comment was made:

 “…isn’t that just not their autism?!”

(in case you are curious my response was: “no, it is additional communication needs and it affects their mental health and access to education). 

Diagnostic overshadowing is dangerous when everybody lacks any curiosity about what is going on for the person. This is also known as ‘therapeutic disdain’.

When we see autism only (and forget that there is more to all of us than one defining characteristic), we forget to ask ourselves and the person:

Are you in pain?, are you being bullied?,  is your sensory environment just too much?, are you confused about x?. 

The comment: “isn’t that just their autism?” is dangerous because it assumes autism is status quo. It assumes nothing can be done to enable the person to communicate, learn and relate in a way that is meaningful and useful to them.

The comment: “isn’t it just their autism?!” is the reason why it is argued that person centred and specialist speech & language therapy is not necessary for autistic children or that a child with communication problems cannot access counselling. 

If we don’t challenge this statement (or any other statement that indicates ‘diagnostic overshadowing’); the risk is that we remove hope (and support) that the person can develop and thrive in their own way. 

It is lazy thinking at best and harmful neglect at worst.

We need a little more clarity… honesty even!

Title of post

The second paragraph of every single independent speech, language and communication report I write includes a ‘statement of truth’.

Every independent professional will include a ‘statement of truth’ in their reports.

Essentially, the ‘statement of truth’ is my promise that I write about the child’s communication needs to help the special educational needs & disability process. It is also a promise that I will not be unduly influenced by whoever pays for the report (i.e. the child’s parents).

I write about the person and their communication needs. I think carefully about what support the person needs to learn, thrive, and function socially, emotionally and communicatively. I base my recommendations on evidence I gather about the person and the evidence base developed by my profession. I try to be fair on services in my opinions.

Most independent practitioners take the ‘statement of truth‘ very seriously because clinical impartiality is a the core of our reputation.

However….

Evidence from independent practitioners is generally initially dismissed by Local Authorities because it is paid for by families. The underlying message is that evidence is wrongly influenced by the child’s parents, no matter how good and accurate it is. Eventually it gets included but it is an unnecessary battle.

Evidence is scrutinised by administrators who generally have little practical experience of what it is about so the likelihood of understanding the content is reduced. Some of the evidence is complex stuff so why would they necessarily understand? When the content is not understood, vital information is missed out in Education, Health and Care Plans.

Here’s the irony:

Evidence produced by local authority and NHS professionals DOES NOT include a statement of truth.

Most public sector employees have a duty to deliver care, free at the point of access. Services are underfunded so any therapy has to be shared between as many people as possible. As there is not enough to go around, only children who are most at risk can access help (also known as prioritisation).

The reports I have read from most professions are brief and focus on the child’s needs in relation to what is available from public service. My interpretation is that their evidence is influenced by ‘who has paid for the report’ (i.e. Local Authority or NHS). These reports are often used as evidence of need rather than evidence of service availability. We are talking about two very separate matters!

So here’s an idea:

What if everybody (public sector and independent practitioners) have to work from a ‘statement of truth’ even if we end up identifying support that is not commissioned properly for. A basic tenet should be that is all about the child’s needs, not what is funded.

If more services and families worked together rather than arguing over the service availability versus a child’s needs, there would be a sense of honesty in the process. Families might stop feeling undermined when they hear; “we just can’t do x” instead of being told “your child just doesn’t need x”.

And maybe these two forces should join up to fight for better services for all children rather than being pitted against each other.

Encompassing interest?

Encompassing interest?

Unseasonal theme aside, who associates Christmas with tortoises?

Apparently I did when I was 9 years old.

This image is a reminder that childhood is a unique time for special interests, preoccupations and obsessions. Mine was tortoises. However the quality of my preoccupation was more of a beloved pet than making me a custodian of all tortoise related knowledge.

A cuppa and a natter

Definitely my cup of tea

Getting back to normal?

One of the little adaptations to office life to keep us safe from the coronavirus: don’t make cups of tea for each other.

Fair enough but it has made me think of what ‘a cuppa’ means to me from a language & social communication perspective:

A cuppa is part of a predictable ritualistic behaviour: a hot drink is generally offered and accepted when we visit someone’s home. The offer of a refreshment is a social expectation.

The offer of a cuppa can be withheld if the person is not that welcome or the visit is more formal. Not offering can signal displeasure or set boundaries for the relationships.

A cuppa can be used for turn taking: it is my turn to put the kettle on. Do you fancy a brew?

A cuppa can be the vehicle for a friendly heated debate about how to ‘make a proper cup of tea’ (add milk before or after hot water???). It is a way of developing arguments or participating in non-threatening banter.

A cuppa can pave the way for sharing stories or anecdotes: On my holiday to x, I was gasping for a proper hot brew and all I got was…‘.

A cuppa in a seasonal vessel (e.g. a Christmas mug in September) can spark conversations about what we think about the Christmas season (arguments for or against Christmas parties always welcome).

A cuppa can be used to check on spoken and practical sequencing skills.

A cuppa can be used to practice vocabulary for everything tea related. It can also teach time concepts and vocabulary.

And whatever does this mean to anyone unfamiliar with the British brew: milk, two sugars, please?! Inferential processing at its best!

When I work in clinic environments I always offer to make a drink.

(Autism) diagnostic assessments: the ‘cuppa exchange’ shows me something about how the person reacts to the offer and interacts during the tea making process. Chatting side by side (not direct eye contact) can help along the interaction. It is a perfect opportunity to observe small talk skills.

The funny thing is that I have had to explain (thankfully only to a few) why I make clients a cuppa in a proper cup and why I don’t just use the reception vending machine. The inference is that I am doing too much or ‘acting the servant‘.

My thinking is that it is one kind gesture I can do for my clients, patients and service users (and their families). They frequently share personal information about their difficulties and vulnerabilities. At least I can show a bit of compassion and nurturing by making a brew.

This is where the emotional communication comes in. Looking after each other by serving a nice cup of tea can signal compassion to a person who feels really anxious or exhausted by their situation.

Cups of tea build relationships some might say but we all knew that, didn’t we?

More than words?

I like the simplicity of this image. It would take reams of text to explain these complex concepts, which the illustrator has explained with simple ‘dots and lines’.

In the spirit of this image, I will write no more!

(except to say, I do not know who the illustrator is but that I downloaded it from @WillemKuyken)


Let’s not be stubborn…

Black & white thinking

Ever thought about why some people seem so set in their views and opinions? 


We use the term ‘black and white’ to talk about clearly defined and opposing information. It is also used derogatorily to talk about people who won’t or don’t change their mind. 


‘Black and white thinking’ has in the past been associated with autism; many autistic people talk about ‘binary thinking’ instead. ‘Black and white thinking’ is often used by non-autistic people as a short hand term for ‘rigid thinking’. 

Linking binary thinking with rigidity is unfair but probably happens because it is also associated with (autistic) logical style of communicating thoughts and ideas. 


To be able to think flexibly (and not be so ‘darn black and white in our thinking’) requires a broad selection of higher level language skills. The core language skill needed is our ability to make sense of the words in context. Understanding language in context helps us detect ambiguity and ambivalence, we work out inference and appreciate the nuances of what people say. 


Words in context is what we speechies call ‘pragmatics’ and its impact on the person’s understanding and thinking is frequently underestimated. This in turn can affect the person’s emotional well being. 


Let me put this to you: if you struggled to work out what a person means by what they say. If you struggled with how the same cluster of words means different things depending on the situation and who speaks them; we would all more than likely prefer neat and clearly defined information. 


Lack of ambiguity makes us all feel secure and makes the world appear more certain. So when a person looks set in their views; think anxiety, think insecurity and consider that the person may need for predictability rather than it being a matter of rigidity of thinking only. 

Communication & mental health

Statistics of mental health and communication

These are are the sobering statistics of the relationship between speech, language and communication needs and mental health:

“84% of attendees at psychiatric services had a language impairment and 74% had communication difficulties (including autism). 81% of children with social, emotional and mental health needs have undetected speech, language and communication needs”.

(Royal College of Speech & Language Therapy).

Problems with communication can affect ability to access ‘talking therapies’. I’ve heard of children with mental health problems who have been denied counselling because they have a language disorder (it was assumed they could not engage with therapy because of their communication needs).

Remember that services have a duty to make information accessible (2014 Equality Act and 2016 Accessible Information Stanrdards).

It means that supporting people with speech, language and communication needs to access support for mental health is everybody’s duty. Speech and Language Therapists have a unique role in this but are nevertheless underfunded and underrepresented across all sectors.

Communication load.

From time to time we all need a bit of extra time to make sense of what someone has said. This is known as processing time. Complexity and familiarity tend to make us need more and less time respectively. 


Some autistic people need extra time processing information when the information is social or the person has to read between the lines (inference). Some argue they only need extra processing time when they have to make sense of non-autistic people’s style of communication!

I am currently working with an insightful young girl on her making sense of her autism. We were talking about needing extra time to sort out information in her head. She described this extra processing time as her ‘loading dots’. 


What a marvellous term and so illustrative of how time is needed to ‘load’ the full picture for what has been said. It also suggests that the ‘picture’ is no less in quality (i.e. it is not about being ‘stupid’ or ‘slow’). 


Two communication strategies you can use to reduce the processing time a person needs when you communicate together are:


1. Do not overload with lots of information. Only give one or two ideas at a time. Remember that ‘not responding’ might mean the person is processing what you have said. Don’t go ruining a perfectly good line of thinking by interjecting or adding additional information. 


2. Be specific about what you mean by what you say. Use less of the inferential, floral language that helps some but rarely autistic people. 

Language for thinking

Language for thinking

Happy Friday folks!

I also love words and know so many autistic people who have a special interest in words too.

Remember we use language for thinking… So here’s a shout out to all you linguists out there!

Subjectivity of need

Severity of autism

The severity of autism cannot be quantified easily. Some autistic people who communicate using words are considered to have mild autism whereas those with non-verbal autism are seen to be severe.


I have meet very intelligent and eloquent autistic people who are severely debilitated by anxiety and problems with independent living. In contrast, I’ve met people with learning disabilities who have an enviable life because they are well cared for by people who understand and appreciate their differences.
How severely someone is affected by autism can vary depending on where they are, who they are with and what demands are placed on them.

So if we should want to quantify severity of autism; the person living it should be the judge of how severe they think it is, not professionals, teachers or commissioners.

Disorder or a matter of difference?

The only time “disorder” is really needed to talk about autism, is at the during a diagnostic assessment (in order to meet clinical diagnostic criteria). At any other point we need to think in terms of “difference” and “opportunities”. 


From a communication perspective:

The diagnostic pointer of “repetitive and stereotyped speech” during diagnostic assessments becomes attempts at engaging in conversation using known information in everyday life. It is different from what might be socially expected but we should look at the intention (engaging in conversation? seeking reassurance? or speaking about something enjoyable to self?). 
The opportunities lie in supporting the person to develop more language for conversation and participating in interactions where needs can be met and conversation can be enjoyable and effective for both.