Play is an Assessment Tool!

I thought I’d write a little bit today about the importance of play in the speech & language therapist’s arsenal of assessment tools. You’ll probably find this post useful if you are a speech and language therapy student, a newly qualified SLT or a parent wanting to know more about how SLTs work.

It’s very easy to watch a speech therapist(or, for that matter, occupational therapist, psychologist or teacher) at work and to say ‘But they’re just playing! What’s so special about that?’. Simply playing with a child is not something that most people immediately think of as an assessment tool. In fact you can learn a HUGE amount about a young person’s communication and interaction skills if you know what to look for! This is where the professional training and skills come in.

Play is an essential part of development and it is where we learn thousands of fundamental skills that relate to language development, motor skills, social interaction, physical skills, imagination and understanding of the world. It is so natural and ‘everyday’ that it’s very easy to dismiss as ‘just playing’ without understanding that engaging play offers endless opportunities to observe the development of a massive range of skills. Play starts to develop within weeks of being born and almost all children engage in play at some level. This means that play based assessment is accessible to almost every child unlike more formal assessments which require well developed joint attention, listening skills, understanding of the basic test instructions (eg ‘point to…’), co-operation, auditory memory and indeed the desire to please.

As well as being a useful way to assess a child who cannot engage in formal assessment, play can also give you access to the ‘bigger picture’ of a child’s use of communication in a real life, functional context. So, what is a speech and language therapist assessing while a child plays?

  1. The play itself! – Play itself has a developmental order and can be broken down into several different social categories (that’s a separate post in itself!). A speech and language therapist will look to see what level the child’s play is at because play skills underlie communication development. The broad stages are Exploratory Play (touching, feeling, mouthing), Relational Play (banging things together, dropping them, stacking etc), Pretend Play (simple pretending like feeding teddy) and Imaginative Play (truly imaginative play using objects to represent other things or involving imagined objects or characters). Pretend play is an important stage in communication development as the abstract thinking processes involved are also necessary for increasingly abstract and creative use of language. Play development is also divided into levels of social development, the broadest divisions being; Solitary play (completely alone), Parallel play (plays alongside but not with others), Co-operative play (plays jointly and interactively with others). Observing the social stage of a child’s play gives a good insight into their social communication – eg a child who prefers solitary play is less likely to engage in communication with others.
  2. Expressive language – most children talk or vocalise while they play. They are usually quite relaxed as they do this so you get a representative view of their abilities. An SLT will be looking first to see if the child does talk or vocalise while playing. If they do, the SLT will look to see what vocabulary is used, whether the child combines words, what sort of sentences are used and what language functions they express (eg, greetings, requests, refusal, comments…).
  3. Understanding – while a child is playing, it is possible to get an idea of their level of understanding. Speech and language therapists are highly trained to do this as it is not as easy as it sounds! To ensure that the child truly understands the language used, you must ensure that there is a choice for every key word in the sentence. For example, if you give a child a dolly and a hairbrush only, they don’t need to understand any words to follow the instruction ‘Brush dolly’s hair’ because the situation gives it away. However, if you had a dolly, a teddy, a brush and a sponge and you said ‘Brush Teddy’s feet’, the child would have to understand 3 key words: ‘brush’ (not wash), ‘Teddy’ (not dolly) and ‘feet’ (not hair, tummy or other body part).
  4. Social skills – Play gives away a lot of information about social interaction. In addition to the social level of play (solitary, parallel or co-operative), play also allows the therapist to observe eye contact, turn taking and non verbal communication like use of gesture and facial expression. The skill of the SLT here is to break each of these areas down and ‘put a finger on’ the problem area. For example, most people will be able to tell you if a child’s eye contact is unusual or not but in most cases won’t be able to pinpoint why they think that. It is not enough to say that a child makes more or less eye contact than usual, after all, natural eye contact isn’t measured in minutes and seconds! A more important consideration is what functions eye contact is used for. A speech and language therapist is trained to recognise and specify the subtle functions of eye contact such as reference to another person, specific communicative functions (eg, your turn, help me, more), and direction of communication.

There are many advantages to assessing a child through play. First and foremost is that it is fun for the child! Secondy, the child usually does not realise they’re being assessed and this creates a relaxed atmosphere which builds trust and rapport with the therapist. Finally a comfortable and relaxed atmosphere is more conducive to communication and often allows you to see things you may not get in a more formal setting. An added advantage is that building that trust and rapport early on means that you have a better chance of getting the child to constructively engage in formal assessment at a later date if you need to.
So there you go! Play, it’s not rocket science, but it is!

Mobile Speech Therapy in Scotland.

When I got back from holiday in the North of Scotland I was surprised and pleased to see that I had a nice email from an overseas speech therapist asking about the mobile speech therapy room with a view doing something similar.  As a few people have asked about the mobile therapy room in the past, I thought it was a good excuse to put up a post about the speech therapy room and some of the practical thinking behind it. So here we go!

The mobile therapy room is a great environment for therapists and for clients alike. I felt it was really important to get the look and feel of the therapy room’s interior right.  It was extremely important to me that the room felt like a friendly therapy work space rather than a camper van or a dingy office. It had to be comfortable, easy to work in as well as safe and suitable for clients. A lot of thinking and planning had to be done by my husband (Van Conversion Department!!) and I to make sure that we achieved what I was after.

360 degree view inside the Mobile Speech Therapy Room – left click and drag to rotate the image.

The advantages of a mobile therapy room for therapists and clients.

For speech therapists, a mobile therapy room like mine is great as you have complete control over the therapy environment (not that I’m a control freak!). You can easily make the environment more or less stimulating to the senses depending on your client. This is really important with some children who are easily distracted or those who have sensory processing issues.  To this end, I made the walls in the therapy room Velcro friendly which is great for all sorts of activities including using symbols for communication, visual timetables and interactive use of visual supports. A fortunate extra that we didn’t think of in the first instance is that you get various metal walls in a van and, as you can now get printable magnetic sheets, you have additional options for displays and communication boards.

As well as having a very controllable therapy room, you have the advantage of being far less reliant on a school or nursery to find you a suitable work space when you visit. In my years working in the state sector, I have worked in some pretty bizarre corners of schools and nurseries. Many educational establishments are pushed for space and as an occasional (and sometimes frequent!!) visitor a speech & language therapist is bottom of the dibs list for a quiet room. Unfortunate as many of our clients have great problems paying attention, discriminating sounds and filtering sensory information in the best of circumstances! Certainly working in cupboards, corridors and cloak rooms is not helpful. When starting a private therapy business I wanted to make it as easy as possible to visit children in schools or nurseries to give the most thorough and appropriate therapy to a child. Having a mobile therapy room has really helped as I am less of a spatial inconvenience to a school (as long as there is a little space to squeeze into the car park!) and the extra help and support I can offer is often much better appreciated with the practicalities of accommodation dealt with.

For clients, there are numerous advantages of a mobile therapy room whether I’m seeing them at school, nursery or at home.  As described above, having my own workspace makes it much easier for me as an independent therapist to visit a child at school or nursery which can be more productive for some children as well as being more convenient for some parents. At clients’ homes, the mobile therapy room is useful because it provides a separate work area away from siblings, TVs, toys or other distractions.  I have to say as well that the mobile therapy room has been a huge hit with many of the children I see! For many of my younger clients, getting into it is a bit of an adventure and I find that this helps to put them into a good frame of mind for learning. 

Considerations about making a mobile speech therapy room.

If you are a therapist thinking of doing anything similar I have outlined below what I think are a few important considerations to bear in mind.

Access

Access to the mobile therapy room is something you have to consider with regard to your client group, parking and safe access. I opted for sliding doors on both sides of the vehicle as well as rear doors and a parking camera (helps to watch out for pedestrians when reversing).  The configuration I have opted for allows me to park close to a wall and still safely and easily get into or out of the van. This proves extremely useful in some school car parks which can be very tight for space. It also ensures that you always have access to the van from the pavement which I felt was really important when working with children.  Bear in mind that vans are generally designed with adults and deliveries in mind and the steps are therefore quite high.  I use an additional plastic step for small children so they can easily get into the van. You should also note that the position of the doors will affect how you lay out your room. To make the best use of the space in mine, I made covers for the side step wells so that I get full use of the floor space when the side doors are shut.

Planning and Van layout

The mobile speech therapy room on deliveryA new empty van can seem huge but it doesn’t take much to start filling it up! Space inside the therapy room is obviously essential and you need to think carefully about minimising wasted space without making the room seem cluttered or ending up with a huge van.  You also have to make sure it’s safe when you’re driving between appointments while ensuring that it’s quick and easy to set up and pack away your resources. I also decided that being able to stand up normally in the therapy room was important from a space point of view and also out of respect for my poor, abused back! Choosing quite a large vehicle meant that I have the space to work with a range of clients easily and that there is adequate room for parents or carers to join the sessions. With my empty van ready for action, It was time to make use of the living room floor and lots of paper to try out various layouts. Despite our best planning efforts, a lot of evolution took place as we built the van interior with various ideas changing as we went along. Internal boxes for each therapy sessionIn the end, we only made one cupboard to store equipment for each day. Inside it has space for up to 8 plastic Ikea boxes into which I can pack the materials for each of the sessions I have planned for the day.  There is also spare space for a few bigger items so that you can keep any distractions out of sight.  It was only late in the building process that a friend’s 11 year old son suggested sliding doors on the cupboard. My husband and I looked at each other with a look of “why didn’t we think of that?!”.  Sometimes the best ideas come from the most innocent minds! The sliding doors a great space saver, they don’t open when you are driving and they help keep the room neat.  The top of the cupboard makes a nice workspace that is ideal if you want to stand up to write up notes (being kind to your back again!). The work tables are mounted up against the bulkhead on adjustable height racks and can be set up as one table, no tables or 2 tables at any height.  This is great as it is really easy to configure the layout for all age ranges as you can see in the photos. The bulkhead is a really worthwhile feature as it separates out the cab area of the van from the therapy area which really clarifies the environment for both me and my clients.  It also provides an extra space for parents to sit and observe a session from if they so wish.

Easy to make the mobile therapy room safe to drive

Strap the chairs down, make sure the cupboard doors are closed and the mobile therapy room is made safe to drive.

Electrics and power.

Easy to work in the dark in the vanMy husband and I spent a long time thinking about how best to do the electrics in the therapy room.  We thought the room had to be well lit, warm, easy to clean inside and not cause the van’s battery to go flat. To that end we went with 2 leisure batteries, a 240V inverter, 12V LED lighting and 12V power for the heater fan. If you’re building something similar, you’ll need to consider what you want to power, which appliance will use the most power and what your maximum current draw will be.  We felt that the lighting would be the most used electric item in the van in the winter (the heater’s very efficient!) and we wanted to minimise the amount of power this used.  By staying at 12V for the lighting and using warm LED’s we minimised how much power we used from the battery. The LED lights also do not flicke rand hum in the way that fluorescent tubes do so are less distracting for clients with sensory processing difficulties. For the inverter, we thought it was worth going for something powerful enough to provide enough current for a hoover, small kettle or perhaps a microwave. Although I have not needed these yet, It’s definitely worth planning for various eventualities.  A word of caution about the inverter though – we have learned that it is worth getting a pure sine wave inverter with a good amperage. Whilst this is an extra expense over a quasi sine wave or square wave inverter, it will be fully compatible with everything you may want to run.  I’m going to have to replace our inverter as I’ve found that I can’t run a variable speed fan from it (just as well we’ve had rubbish weather this summer!) and I’m sure there will be other devices that will have problems too.

Lighting

Skylights in the mobile therapy room

Skylights in the mobile therapy room

Having spent too long working in rooms with no or very small windows, I wanted as much natural light as possible in the mobile therapy room.  In addition to the side windows, I went for windows in the rear doors and 2 large roof skylights for natural lighting. This makes for a really light and airy feel inside the mobile therapy room. For the dark winter period, we installed 11 warm LED spot lights in the roof and which make the van a good work environment even if it’s dark outside.  We also added some door lighting strips along the side steps but, I have to confess, that was mainly because we liked the sticky backed LED strips you can buy! Looks good though!

Insulation & Heating

Insulating the walls in the mobile speech therapy roomIt’s really important to think about your local environment and climate when it comes to insulation & heating. You will need the ability to both heat and cool your van. We made sure we insulated the therapy room really well with a combination of Celotex and insulating lambs wool. The Celotex worked well on the floor and behind the large wall panels with wool stuffed into any gaps. For the roof, a thick layer of wool was the way forward. All this insulation helps keep things warm in the winter and cool in the summer but, as you can imagine, this alone is not enough to cope with a Scottish winter. For a bit of extra heat, I have a very efficient Eberspacher heater. These heaters use diesel from your fuel tank but are much more efficient than having the van engine turned on and using the van’s in built heating.  The Eberspacher is a heater designed for boats, buses and camper vans and comes in a variety of powers to suit whatever needs you have. I went for a reasonably powerful one so that I could heat the room up quickly if necessary. It certainly works, last winter it got the therapy room from a decidedly chilly -9C inside to a pleasant 18C in the space of 15 minutes. The main unit is fitted between the seats in the cab of the van with just the output vent opening into the back. In terms of noise, it’s pretty quiet with a little bit of clicking when it starts up then just the noise of the airflow. It is thermostat controlled so it will automatically switch itself on and off to reach the temperature you have set it to.

One additional advantage of the good insulation is it keeps the van nice and quiet inside regardless of the weather conditions outside.  Cooling has not been an issue so far (see Scottish weather for explanation!!) but I have made sun/privacy shades for the summer months and they certainly help to keep the temperature down when the sun is out. For a bit of airflow, I can open the windows in the back of the van and I have a tower fan to increase the airflow if needed.

Ergonomics

Like many SLTs and teachers, I have had time off work in the past with a bad back. It was therefore really important to me to make the mobile therapy room back-friendly. To that end I have a nice comfy seat with lumbar support for driving, the tables are adjustable, I have comfortable lightweight chairs and a kneeling stool for working at a low table or on the floor. We had a look at folding chairs from a space perspective but it was clear that the only way to go for me was standard upright chairs but these have a handy place to live in the corner of the speech therapy room and give somewhere for a parent to sit. For working at a low table or on the floor, I use a kneeling stool which is both incredibly comfortable and nice and compact making it easy to store. For small children I managed to get hold of a single classroom chair – not easy, be warned they’ll want to sell you 30 or charge you £50 delivery for one! I had to go a bit ‘zen’ to find a good kneeling stool as they’re surprisingly difficult to find. Mine is actually a Buddhist prayer stool made by a company called Blue Banyan.

 

 

 

Economics

So is it financially worth it? This is a really tough question to answer, however bear in mind that there is no point in going into speech therapy if you want to get rich! In my mind I have planned the mobile therapy room to have a 10 year life span but it has meant quite a lot of upfront cash costs as I couldn’t find a second hand vehicle that suited my needs.  Getting a new vehicle meant adding lots of extras from the factory options list as well as the additional extras kitting the van out once it arrived.  If you are starting a new business then it is definitely quite high risk to do something like this without an established client base. Having said that, the therapy room is quite an asset and can be used as a good selling point for your business. If you have an established business or larger speech therapy practice, then (depending on your geographical area) I think something like this could be a really useful and welcome addition to your service.  In the long term I think the mobile therapy room will pay for itself by helping Blethers to provide a service that well suits its clients but, as this is still early days, I can’t say for sure.  You definitely have to plan your days and sessions efficiently so you are not spending too much time driving around while still fulfilling the needs of your clients. There will almost always be a mixture of some clients who take more time to visit and some who are just around the corner.

You should also consider some of the other, harder to measure economic upsides though. The mobile therapy room makes for a really nice place to do your paperwork where you won’t get disturbed and I have had lovely peaceful sessions overlooking the bridges in the Firth of Forth and writing up notes watching the waves at Dunbar or the gannets at Bass Rock.  This is far more pleasant than any classroom or speech therapy office and it’s something you really can’t put a price on.

If you would like to know more any more specific information about the speech therapy room please feel free to contact me.