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Trans and non-binary people face multiple barriers in accessing gender affirming services, including voice and communication change (VCC). These include prolonged waiting times and a lack of access to services delivered locally (Cheng, 2020; Ellis et al., 2015). The absence of a gender service in Greater Manchester, a home to a sizeable LGBTQ+ community, resulted in significant health inequalities for the trans community. NHS England commissioned the Indigo Gender Service in Greater Manchester, one of three new primary care services. These were launched virtually due to the pandemic.The VCC team comprises three speech and language therapists (SLTs). The team aims to empower service users to discover their authentic voice, reflecting their gender identity and sense of self. Previous research has demonstrated that in-person group intervention and working with students is acceptable and effective (Pert, 2020). Translating this success into an online format is essential to service delivery during the pandemic due to the heightened risk of COVID- 19 transmission via aerosol generation (Castillo-Allendes et al., 2020). Benefits of online delivery to the trans community have been identified, such as eliminating travelling costs and time. These benefits will be retained in the future.The VCC service provides an innovative group therapy model. This includes workshop elements sandwiched with small group breakout activities. Support is delivered by volunteer students and qualified SLTs, trained and supervised by the VCC team. Service users can access videos of exercises online between sessions as part of home practice.Due to the increasing demand for VCC and paucity of SLTs trained in this field (Cheng, 2020), the team endeavours to upskill our profession to address this long-term workforce challenge. Volunteers may participate remotely online, regardless of their geographical location.The Indigo Gender Service is co-produced with the trans community. The VCC team consults with the Co-Production Group to ensure that the needs of service users are met in a culturally sensitive manner. The Co-Production Group advised that accessible multimedia self-help resources be made available for home practice. For example, subtitled videos of exercises have been made available on the service’s website. These resources increase trans and non-binary people’s autonomy and confidence in VCC (Cheng, 2020).Service users completed VCC groups of six two-hour sessions over a three week period. Detailed feedback was collected from service users at an outcome appointment. Service users found the online format acceptable and valued input from students. During outcome appointments two weeks after intervention, service users showed progress towards achieving their individual VCC goals. They are invited to VCC self-help groups, empowering service users to continue to develop and sustain authentic voice.Evaluation of VCC online groups supports previous findings that group intervention involving students is an acceptable and effective therapy option for trans individuals. The team will report this service delivery model in relation to gender identity (trans men, trans women, and non-binary service users). Service improvement suggestions incorporated to date include peer-to-peer interaction opportunities, exploration of cisheteronormativity, and development of e-learning resources to free up time for further workshop activities. AuthorsSean Pert, The University of ManchesterNigel Cheng, Indigo Gender Service, Greater Manchester Lizzie Jenner, Indigo Gender Service, Greater Manchester

Bilingual clients frequently feature on speech and language therapists' caseloads and yet they are rarely assessed and treated in their mother tongue. There are few assessments targeting languages other than English. Culturally and linguistically appropriate assessment and remediation materials should be devised for the differing needs of each distinct population. This paper describes the Pakistani Heritage Asian population in Rochdale and one of the first steps taken to address its needs: the development of an early expressive language assessment and remediation package for paediatric clients. Reference is made to the importance of identifying the exact languages spoken, especially when the use of one language may be perceived as denoting lower social status. Semantic and syntactic issues involved in constructing assessments are highlighted.

Diagnosis of speech disorder in children acquiring two languages is problematic. There are few norms for bilingual language acquisition, and speech-language path-ologists are unlikely to speak both languages of the bilingual populations they serve. Further, knowledge concerning the phonological structure of many languages is limited. This article describes the development of a phonological assessment for bilingual children. The assessment was administered to normally developing bilingual children as well as children suspected of speech disorder. The children with speech disorder were referred to the Rochdale Healthcare NHS Trust Speech and Language Therapy Department for assessment of their speech. All of the children spoke either Mirpuri, Punjabi or Urdu at home but were exposed to English at nursery or school. The phonological development of bilingual children in each language is described. The normally developing children showed phonological error patterns in English that would be considered atypical of normal monolingual development in English. The error patterns of two children with speech disorder are also described. The error patterns are consistent with research evidence concerning subgroups of speech disorder in monolingual and bilingual children. The findings provide further support for the hypothesis that symptoms (surface error patterns) of speech disorder are language independent, (i.e., that a single deficit underlies the speech disorder across both languages). The clinical implications for assessment and treatment of speech disorder in children exposed to more than one language are discussed.

INTRODUCTIONKing-Denborough syndrome is an autosomal dominant or sporadic genetic disorder characterised by malignant hyperthermia and a collection of phenotypical characteristics including short stature, skeletal abnormalities and facial dysmorphia (King et al. 1972, Graham et al. 1998). Speech and language disorder and dysphagia have not previously been reported as features of this syndrome.METHODThis paper presents two detailed case studies which describe the assessment and treatment of two brothers, Haider and Bilal presenting with the syndrome. Both children experienced communication impairments and the older brother has subsequently presented with progressive swallowing difficulties in his teenage years. The children come from a Pakistani heritage home where Mirpuri is spoken in addition to English. FINDINGSAged 3;0 Haider* was referred to speech and language therapy by the Paediatrician. Assessment showed that he was only using single word nouns in English and two-word combinations (verb + patient) in Mirpuri. Audiology reported hearing within normal limits and the Educational Psychology Service reported average non-verbal abilities. A diagnosis of language impairment (LI) was made and Haider was offered a place at the local language unit. At this time it was recognised that he had subtle gross motor difficulties and deformity of the spine and sternum. Haider was discharged from the speech and language therapy service aged 7;1 as his communication skills were satisfactory. King-Denborough syndrome was not diagnosed until age 10;0 following a malignant hyperthermia episode during surgery: a reaction to anaesthesia which is a recognised feature of this syndrome.Haider was re-referred by the Paediatrician aged 13;0 with dysphagia. Haider reported a one year history of painful swallowing and nausea. He had a recent chest infection, was coughing at night and had lost weight. A videofluoroscopy showed fluids were spilling into the pharyngeal area. Haider was using a chin-tuck to clear the bolus from the oral cavity. Repeated swallows indicated fatigue leading to an uncoordinated swallow. A gastrostomy was discussed but rejected by Haider. Currently Haider remains under the care of the multidisciplinary team.Aged 3;4 Bilal* was referred to speech and language therapy by the Community Paediatrician. At this time the speech and language therapist discussed the possibility that Bilal had the same syndrome as his older brother. This was confirmed following genetic tests. Bilal was able to follow simple instructions, had no recognisable words and some vocalisations. A diagnosis of LI was made and Bilal attended the language unit. Hussain continues to require speech and language therapy and has not as yet presented with any dysphagia.*(Names have been changed to protect anonymity).CONCLUSIONSThis paper will present the first evidence of language impairment and dysphagia as features of King-Denborough syndrome, expanding the existing evidence base. Additionally it will demonstrate that intervention for minority language children is effective when delivered in their mother tongue, regardless of the initial severity of the presenting disorder. Both children now have bilingual language skills which match their non-language impaired peers.REFERENCESGRAHAM, G.E., SILVER, K., ARLET, V., and DER KALOUSTIAN, V. HUSSAIN., 1998, King syndrome: further clinical variability and review of the literature. American Journal of Medical Genetics, 78, 254-259.KING, J.O., DENBOROUGH, HUSSAIN. A. and ZAPF, P.W., 1972, Inheritance of malignant hyperpyrexia. The Lancet, February 12, 1972, 365-370.

In an environment where bilingual adults codeswitch routinely, children are likely to show codeswitching in their own utterances from an early age. However, child language has rarely been studied from this viewpoint and codeswitching may be viewed negatively by many educators and other professionals involved with bilingual children. This research examines codeswitching recorded during the assessment of two groups of preschool Mirpuri speaking children living in Rochdale, U.K. The children's codeswitched utterances are examined using the Myers-Scotton Matrix Language Frame (MLF) and 4M models. The results show that codeswitching was common. Codeswitched utterances were generally longer than utterances that did not display codeswitching and they conformed to the MLF/4M models. Codeswitched utterances may be the most representative utterances of a bilingual child's expressive potential; only when speaking to a fellow bilingual who accepts codeswitching is the bilingual child able to express him- or herself to this potential. Codeswitched utterances, and not solely L1 or L2 utterances, should therefore form the basis for establishing bilingual norms of bilingual language acquisition for populations where codeswitching is effectively the L1.

This paper describes the development of a phonological assessment procedure for children speaking Mirpuri, Punjabi or Urdu in combination with English. The Rochdale Assessment of Mirpuri Phonology (RAMP) was produced in response to the practical difficulties of a monolingual therapist wishing to assess a child's phonological systems across all languages used. The assessment is currently being used both as a clinical tool within the Rochdale Healthcare NHS Trust Speech and Language Therapy Department and as a research tool in collaboration with the Department of Speech, University of Newcastle to provide further data on patterns of bilingual phonological acquisition. Outcomes include therapy targeted more accurately at deficits within each phonological system.

This paper reports work in progress to develop an assessment procedure for expressive language, to be used with children living in the Rochdale area of the UK and speaking Mirpuri, Punjabi and/or Urdu. The assessment materials and procedure are described, together with the principles for scoring. Normative data is currently being collected. Children tested so far have demonstrated the need to allow for code-switching and lexical borrowing and that attention to ‘literal’ translation of the target language is required. Discrepancies between reported and actual languages used are also noted. Expressive language appears unexpectedly sparse in some cases. Possible reasons for this are discussed. This research has highlighted many difficulties in attempting to construct an assessment of this kind.