FEATURE

Frogs and snails and puppy dogs tails?

Speech and language therapists are mainly female and their clients are mainly male. Could we improve therapy outcomes if we had a better understanding of why and how male communication can be different? To find out, editor Avril Nicoll asks what little (and not so little) boys are really made of
Speech and language therapists strive to offer an individualised service based on clinical need and to avoid unhelpful or limiting stereotyping. Whether we are working with boys or girls, men or women, fathers or mothers should therefore be irrelevant. On the other hand, if we can understand more about why and how male communication may be different, we can potentially find a way in to engaging them in more meaningful and effective therapy. The fact is that, overall, the profession works with more males than females. Caseloads attest to the greater proportion of boys affected by developmental communication disorder. Boys are for example four times more likely to develop autism than girls (www.nas.org.uk). In the under fives, twice as many boys stammer as girls (www.stammering.org). And, in 16 months of monitoring referrals to a paediatric speech and language therapy service, Broomfield & Dodd (2004) found that seventy per cent were boys, with the proportion higher for language diagnostic categories than for the speech category. Males are two to three times more likely to have a head injury than females, rising to a ratio of 5:1 in the age group 15-29 years (www.headway.org.uk). There are 3.5-4 men for every woman who stammers (www.stammering.org). Males represent 94 per cent of the prison population (www.statistics.gov.uk). Bryan (2004) confirmed high levels of speech, language and communication difficulties among a young offender population and suggested this meant, around 40 % of young offenders might have difficulty in benefiting from verbally mediated interventions such as anger management and drug-rehabilitation courses. She continued, This would imply they might be more likely to leave prison with unresolved problems known to contribute to re-offending (p.399). In researching this topic it quickly became clear that, even where boys and men do not have a communication impairment, there are general male communication issues that impact on many areas of life learning, interacting with others, even health. According to Adam Cox (2006), the roots of this may lie in childhood, given male stereotypes and our expectations of our sons: On the time line of human development, our circumstances have changed more quickly than our genes. Genetically, our sons may still be better programmed to defend against predators than to foster co-operation in a town or an office (p.63). Cox argues that the key is teaching boys social communication skills to counteract the insidious effect of the social reinforcement they get for withholding signs of emotion. One of the ways this can be done is through encouraging their fathers to model vulnerability (holding up their hands to mistakes, saying sorry, expressing sadness), asking for help, compromising, learning from others and persevering. Cox explains how vulnerability is a terrifying prospect for many males, and efforts to hide it can result in a mask of indifference, withdrawal or anger. They need to feel they are good at things or they lose interest, confidence and self-esteem. As a result, they have even less opportunity to develop the emotional vocabulary and social skills they need to experience a healthy life. are driving a cultural change in service provision so that we support parenting in general, not just mothers. In speech and language therapy this is put into practice through programmes such as Hanen and ParentChild Interaction Therapy or via Sure Start projects, or through individual therapists involving both parents where possible. Burgess (2006) says it is essential to recognise that a different approach is needed to engage fathers: even when you are seeking to foster the same kind of behaviour from fathers and mothers towards their children, you need to remember that fathers come from a different place (p.5). However, Brid Featherstone says we need to be aware that the involvement of a father is not per se good for a child; the crucial factor is the relationship between the childs parents, and this applies whether or not the parents are together. She suggests we bear in mind that, while many men subscribe to the involved father model, the economic provider role is still important in mens construction of what it is to be a good father, perhaps because it fits with being protective. Working fathers may therefore find it difficult to balance their desire for involvement with their need to put in the hours needed to protect and provide. We also need to be aware of the particular challenges of working with young men as parents. While they have often had bad parenting themselves and express a desire to be a better parent and to be involved, Brid says they struggle with how to do this, especially when it comes to communication issues. Some men who are not used to being interdependent can be threatened by the emergence of this being to whom they feel connected. Some find after the birth that it is far harder than they expected to be an involved father and in their anxiety retreat into gender stereotypes with thoughts such as Im useless, She knows best, Id better keep out of the way. Reactions can be exacerbated by alcohol or when a man finds it difficult to express himself in a nonthreatening way. Compounding the problem with communication is the reported reluctance of men to ask for help from health service providers. Smith et al. (2006) say while the reasons for this are poorly understood, we need to be sensitive to the fact that men tend to view partners and

Compounding the problem with communication is the reported reluctance of men to ask for help from health service providers.
Interestingly, the initial inspiration for this feature was a conference presentation on the importance of fathers, and their changing role as a result of an ever-moving political and social context. Brid Featherstone (2005) said research evidence confirms it is good for men, women and children if men are involved in family life for reasons as diverse as better mental health, less criminality and better exam results. As a result, information groups such as Fathers Direct (www.fathersdirect.com) and documents such as the National Service Framework for Children, Young People and Maternity Services (DH, 2004)

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Boys have a natural competitive instinct and it is very important to them to appear confident and knowledgeable. They appreciate opportunities for leadership, risk-taking, role modelling and action, and enjoy cracking codes and finding practical solutions.

Illustration by Graeme Howard

friends as a primary resource for help, so their approach to us may be indirect. In addition, men may be less able to boost their resilience and wellbeing (salutogenesis) through personal social networks, particularly if they are in the lowest household income group or if they belong to certain minority ethnic groups, for example Chinese and Asian men (Matheson & Summerfield, 2001). The sad outcome of this is that suicide is now the single largest cause of death of men aged under 35 in England (www.menshealthforum.org.uk), while older men have the highest suicide rates in the UK, and this is strongly associated with depression, physical pain or illness, living alone, and feelings of hopelessness or guilt (www.samaritans.org.uk/ know/pdf/InfoResourcePack2004web.pdf). We may also be

less likely to recognise the impact of these factors; while depression may occur as often in men as in women, doctors are less likely to diagnose it in men (www.mind.org. uk/Information/Factsheets/Men/). In fact, the average man lives a shorter life than the average woman and for fifteen of those years can expect to be seriously or chronically ill (www.menshealth. co.uk). Ed Garrett, a community health worker in Aberdeenshire, is actively seeking ways to empower men to improve their health through the Mearns Healthy Living Network. Much of his work involves supporting the development of community social and activity groups to counteract isolation and depression in older people. For men specifically, there is a need to provide socially ac-

ceptable alternatives to the pub but, with low numbers and a vulnerable membership, the older mens group is struggling to be viable. This is unfortunate because Ed observes that the men clearly feel comfortable, have a laugh and are not having to play a role. Conversation includes lots of male-orientated banter and discussion of health issues. He says, My feeling is that the group provides a valuable social space which can act as a springboard to involvement in other activities. One member, for example, hadnt been out of his house on his own for three years but the boost to his confidence has allowed him to join other activities too. This older mens group includes men who have difficulty with mobility and self-care. Resources for Rehabilitation (1997, p.17) suggest that Accepting the limitations of a disability or chronic condition is not only psychologically liberating, but also makes daily living easier. Importantly, they warn professionals that, as men may have their masculinity threatened by accepting help, getting to this stage may be difficult and take time. However, The acceptance of realistic limitations and abilities may result in the restoration of self-esteem, the sense of control over life, and pride in achievements for men in all stages of life. Adam Coxs (2006) hooks for Raising Our Sons to Communicate and Connect might give us clues about communicating and connecting with males in general. Boys have a natural competitive instinct and it is very important to them to appear confident and knowledgeable. They like specific direction and explanation. They may have a kinaesthetic learning style which means they get more out of exploring through physical contact, handling and touching things, and moving through space and new territory, than they do out of just listening. They appreciate opportunities for leadership, risk-taking, role modelling and action, and enjoy cracking codes and finding practical solutions. While goal-directed solution making is a good therapy tool, Cox cautions that it tends to inhibit awareness of the more subtle information that enriches social perception and communication (p.23). It is therefore an idea to help boys define and articulate specific goals about things that matter to them and plan actions to achieve
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news extra
Low incidence SEN provision under scrutiny
An audit of how local authorities meet the needs of children with low incidence severe special educational needs flags up the need for the department of health to continue to address recruitment issues in speech and language therapy. Carried out by the Special Needs Consultancy, the national audit considered provision for children with severe autistic spectrum disorders, severe sensory impairment and severe behavioural, emotional and social difficulties. It looked for examples of good practice, explored gaps and made recommendations which would allow more children to have their needs met locally. In addition to addressing recruitment issues, the audit says that therapy services are looking to develop more cost-effective ways of service delivery that will enable their support to be better targeted. It mentions Harrow speech and language therapy services where direct therapy is targeted on children with more complex and long-term needs and other groups are reached indirectly through teachers and teaching assistants. The audit report suggest that there have been significant benefits where different services have come together for multi-agency training, so that there are better common understandings and a common language / repertoire of approaches available. The authors call for priority to be given to development in support and provision for older children as they move towards adulthood. In addition to the need for better support in mainstream secondary schools and local Further Education College provision, gaps relate to broader areas of family support / respite care and support for mental health issues. The National Audit of Support Services and Provision for Children with Low Incidence Needs report is at www. dfes.gov.uk/research/data/uploadfiles/RR729.pdf

them. In addition, it is important to build an emotional dictionary (p.43) by modelling lots of synonyms of emotions, providing opportunities for boys to observe and notice emotional responses and change in others, and reassuring boys that feeling confusion over emotion is normal. Interestingly, Cox adds that expressive depth is at least as important as having expressive breadth (p.234). However, if parents or therapists try to take on full responsibility for changing a boy, Cox says their efforts will fail. Self-esteem is boosted by the hard work that is needed for meaningful change even if the boys dont want to talk about the fact that they have changed! We need to capitalise on boys hunger for parental approval by encouraging adults to notice and thank them when they use social communication skills, and to convey confidence in their ability. The environment is significant too - males struggle to communicate in a one-to-one compared with less personal settings, and a safe place such as home can be a good place to start building bridges.

the teaching of speaking and listening skills is prioritised and practised. None of this is surprising, but reinforces the value of speech and language therapists supporting change in the classroom. Pickering also supports individualised action planning like individual education plans, arguing that through this a boy learns how to learn by taking greater responsibility for his learning, setting clear objectives and getting regular feedback.

Sensitive to individuals
Pickering stresses that boys are particularly sensitive to individual teachers and effective teaching, whatever the sex of the teacher. This is important as only 7 per cent of educational assistants, 13 per cent of primary and nursery teachers, 12 per cent of nurses and 12 per cent of care assistants and home carers are men (2004 figures). This isnt going to change anytime soon. In higher education, just 19 per cent of those studying education and subjects allied to medicine are males (2002/3 figures) (all EOC, 2005). And analysis of the membership of the Royal College of Speech & Language Therapists (Cobb, 2003) found that a mere 1.6 per cent of assistants, 2 per cent of full members and 2.8 per cent of students were male. So frogs and snails meet sugar and spice. But to end up with all things nice, it is clear we need to take an individualised approach that avoids stereotyping but draws appropriately on our understanding of what boys and men might really be made of.

boys are particularly sensitive to individual teachers and effective teaching, whatever the sex of the teacher.
Amidst a wealth of possible clues about the way in to boys minds, Cox includes: Dont force eye contact Avoid sarcasm and criticism Respond positively when a boy takes the initiative to talk Minimise the possibility of failure Avoid overquestioning Use expressive tools from e-mail to the arts Be task / activity orientated to encourage talk Ask more about interests and opinions and pay particular attention to the music / lyrics he likes Distinguish thoughts from feelings Understand that resistance to communication may mean a boy needs more time to understand himself how he is feeling. Many of Coxs strategies resonate with Jon Pickerings (1997) ideas for raising boys educational achievement. Pickering argues that, contrary to media spin, boys care as much about their learning as girls they just show it in a different way. To feel OK about doing well at school, they also need to have balance, with a life outside school and other interests. Rather than blaming outside factors for boys educational shortcomings, Pickering asks teachers to look for answers within their own classrooms, and from their own boys. This may include planning plenty of contrast and change (p.36), formal presentation / public speaking tasks, and having a system that allows for a speculative, risk taking and experimental approach, ending with an exam. Other suggestions include giving praise and punishment in private, capitalising on boys interest in non-fiction, and using project work which includes recording of responses. Pickering stresses that boys learn best when: work is matched to ability there is clear explanation of the task and learning stages with visual reinforcement and opportunity to ask for clarification

Acknowledgement
Thanks to Ed Garrett for his time.

References
Broomfield, J. & Dodd, B. (2004) Children with speech and language disability: caseload characteristics, International Journal of Language & Communication Disorders 39(3), pp. 303-324. Bryan, K. (2004) Prevalence of speech and language difficulties in young offenders, International Journal of Language & Communication Disorders 39(3), pp. 391-400. Burgess, A. (2006) Engaging Fathers in their Childrens Learning: tips for practitioners. Available at: www.fathersdirect.com (Accessed 3 May 2006). Cobb, J. (2003) Sex count. Unpublished: Royal College of Speech & Language Therapists. Cox, A.J. (2006) Boys of Few Words. New York: The Guilford Press. Department of Health (2004) National Service Framework for children, young people and maternity services. Crown copyright. Equal Opportunities Commission (2005) Facts About Women & Men in Great Britain. Available at: www.eoc.org. uk/pdf/facts_about_GB_2005.pdf (Accessed 3 May 2006). Featherstone, B. (2005) Antenatal education for men: Why we should engage fathers in antenatal classes, 3rd Annual Preparing for Parenthood Conference. Edinburgh 5 May. London: The National Childbirth Trust. Matheson & Summerfield (eds) (2001) Social Focus on Men. London: The Stationery Office. Pickering, J. (1997) Raising Boys Achievement. Stafford: Network Educational Press. Resources for Rehabilitation (1997) A Mans Guide to Coping with Disability. Massachusetts: Resources for Rehabilitation. Smith, J.A., Braunack-Mayer, A. & Wittert, G. (2006) What do we know about mens help-seeking and health service use?, Medical Journal of Australia 184(2), pp. 81-83. SLTP

Better communication cuts reoffending

Courses in oral communication and thinking skills not only improve prisoners quality of life in custody, but can significantly reduce their likelihood of reoffending, according to research from the Learning and Skills Development Agency (now the Learning and Skills Network). The researchers found that oral communication courses proved particularly beneficial for certain groups, particularly repeat offenders, those with shorter sentences and those with a high risk of reconviction. Prisoners found the training helped them to communicate more effectively with fellow inmates and prison staff. A scale completed by prison officers produced high ratings for control of temper and thinking before acting or speaking as positive benefits. Speech and language therapists were not involved in this research which looked at the effect of the English Speaking Boards education courses in oral communication, run in HM Prisons since 1999. The researchers recommend that oral communication skills should be given greater prominence and that the courses should be more widely available in prison and in the community. Developing oral communication and productive thinking skills in HM prisons by David Moseley and Kay Livingston see www.lsneducation.org.uk.

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