A qualitative study of A qualitative study of parents’ & professionals’ opinionsparents’ & professionals’ opinions

FACILITATING PARTICIPATION IN FACILITATING PARTICIPATION IN CHILDREN WITH CHILDREN WITH

4-LIMB CEREBRAL PALSY4-LIMB CEREBRAL PALSY or or

Understanding your diagnosis – Understanding your diagnosis – does it matter?does it matter?

Research TeamResearch Team Nicky Wood, Consultant Clinical Psychologist, Nicky Wood, Consultant Clinical Psychologist,

EKHUFTEKHUFT Marian Nairac, OT, Team Coordinator School Marian Nairac, OT, Team Coordinator School

Age Therapies Team, Kent Community Health Age Therapies Team, Kent Community Health Trust (KCHT)Trust (KCHT)

Kerynne Thompson, Undergraduate Student Kerynne Thompson, Undergraduate Student Psychologist on Placement, UKCPsychologist on Placement, UKC

Freidl Van Vuuren, Freidl Van Vuuren, SLT, Kent Communication & SLT, Kent Communication & Assistive Technology Service (Kent CAT), KCHTAssistive Technology Service (Kent CAT), KCHT

Becky Judge, SLT EKHUFTBecky Judge, SLT EKHUFT

BackgroundBackground Emerged from issues/questions from clinical Emerged from issues/questions from clinical

practice re participation during therapy and other practice re participation during therapy and other activitiesactivities

Nothing currently available specific to 4 limb CPNothing currently available specific to 4 limb CP Resources we have found involve children with Resources we have found involve children with

speechspeech Ideas – MarianIdeas – Marian Research background – NickyResearch background – Nicky Data collection, write up – KerynneData collection, write up – Kerynne With wider consultation and expertise from With wider consultation and expertise from

project teamproject team

Clarifying terms Clarifying terms Cerebral palsyCerebral palsy (CP) one of most common causes of (CP) one of most common causes of

childhood disability 2.5 per 1000 births (Stanley et al. 2000) childhood disability 2.5 per 1000 births (Stanley et al. 2000) Children included in the study had 4 limb involvement and Children included in the study had 4 limb involvement and limited or no speech.limited or no speech.

Children included in the study had a Gross Motor Function Children included in the study had a Gross Motor Function Classification System (GMFCS) of IV or V and a Manual Classification System (GMFCS) of IV or V and a Manual Ability Classification System (MACS) of IV or VAbility Classification System (MACS) of IV or V

The International Classification of Functioning, Disability and The International Classification of Functioning, Disability and Health (ICF) (WHO 2001), Health (ICF) (WHO 2001), participationparticipation is defined by an is defined by an individual’s involvement in life situations and environmental individual’s involvement in life situations and environmental factors. When such factors are found to have a positive factors. When such factors are found to have a positive influence on participation, they are termed influence on participation, they are termed ‘facilitators‘facilitators’; ’; negative influences are termed negative influences are termed ‘barriers’‘barriers’

ParticipationParticipation

C&YP with CP have significant barriers to C&YP with CP have significant barriers to participation in education, personal care and participation in education, personal care and recreation, and participate less than their recreation, and participate less than their non-disabled C&YP (Parkes et al, 2010)non-disabled C&YP (Parkes et al, 2010)

To be effective self-advocate need to know To be effective self-advocate need to know yourself; research findings that C&YP have a yourself; research findings that C&YP have a lack of understanding about their disability lack of understanding about their disability and its impact on their lives (Abernathy & and its impact on their lives (Abernathy & Taylor, 2009; Jones, 2006)Taylor, 2009; Jones, 2006)

What do C&YP with CP know about their diagnosis What do C&YP with CP know about their diagnosis and prognosis?and prognosis?

C&YP with physical disabilities think they may C&YP with physical disabilities think they may outgrow their outgrow their impairmentimpairment (Connors & Stalker, 2007) (Connors & Stalker, 2007)

These C&YP can develop erroneous ideas to make sense of These C&YP can develop erroneous ideas to make sense of their circumstances – can lead to their circumstances – can lead to self-blameself-blame and and guiltguilt (Jones, (Jones, 2006) 2006)

These impact These impact self-esteemself-esteem; can lead to long-term difficulties and ; can lead to long-term difficulties and confusion about disabilityconfusion about disability. Also has implications with regard to . Also has implications with regard to realistic decision makingrealistic decision making and having and having obtainable future goalsobtainable future goals

Learned helplessness (LH) - individuals who have others make Learned helplessness (LH) - individuals who have others make too many life decisions for them can become too many life decisions for them can become passivepassive and and develop develop learned helplessnesslearned helplessness (Abernathy & Obenchain, 2003; (Abernathy & Obenchain, 2003; Seligman, 1975) Seligman, 1975)

Young adults with LH can have Young adults with LH can have unrealistic appraisal of their unrealistic appraisal of their abilitiesabilities; denying disability. Although non-disabled individuals ; denying disability. Although non-disabled individuals can also have can also have unrealistic expectations. unrealistic expectations. Need to develop Need to develop accurate sense of self to strive for reachable goals (Zetlin & accurate sense of self to strive for reachable goals (Zetlin & Hosseini,1989) Hosseini,1989)

How do they know about their diagnosis?How do they know about their diagnosis? Parents/carers take responsibility of advocating; are often the Parents/carers take responsibility of advocating; are often the main source main source

of explanationof explanation regarding C&YP impairments regarding C&YP impairments ……but but not much discussionnot much discussion within families. Some parents express within families. Some parents express dreaddread at at

being asked for explanations, can give general reasons such as child is being asked for explanations, can give general reasons such as child is ‘special’ or it was ‘God’s plan’. (Connors & Stalker, 2007) ‘special’ or it was ‘God’s plan’. (Connors & Stalker, 2007)

Only in some cases did they explain that impairment was due to an accident Only in some cases did they explain that impairment was due to an accident or illness around birth; though still or illness around birth; though still quite vague explanations quite vague explanations

Sometimes role had been delegated to teachers, but research suggests that Sometimes role had been delegated to teachers, but research suggests that many remain many remain unskilled or not confidentunskilled or not confident in the task in the task

Research into specific activities and discussions that teachers do in class to Research into specific activities and discussions that teachers do in class to increase C&YPs understanding. Results show lack of communication increase C&YPs understanding. Results show lack of communication between students and teachers regarding disability Abernathy & Taylor between students and teachers regarding disability Abernathy & Taylor (2009) (2009)

Central idea:Central idea: enabling C&YP to access information re their enabling C&YP to access information re their disorder is empowering, they can make informed decisions disorder is empowering, they can make informed decisions regarding their lifestyle and welfare, including opportunity to regarding their lifestyle and welfare, including opportunity to manage their personal needs = manage their personal needs = participation increaseparticipation increase

Aims of Research?Aims of Research? Overarching aimOverarching aim – the need to do something about this lack of – the need to do something about this lack of

understanding, produce something to address this need, esp necessary understanding, produce something to address this need, esp necessary with C&YP with CP with no functional speechwith C&YP with CP with no functional speech

Design is Design is qualitativequalitative and and exploratoryexploratory, using topic guide, open-ended , using topic guide, open-ended semi-structured interview formatsemi-structured interview format

Primary: Primary: To identify needs of C&YP regarding information about their diagnosis To identify needs of C&YP regarding information about their diagnosis

and prognosis and prognosis To get adults’ ideas about what might be useful in terms of a resourceTo get adults’ ideas about what might be useful in terms of a resource Secondary:Secondary: develop an appropriate resource to aid C&YP with CP in develop an appropriate resource to aid C&YP with CP in

understanding their condition understanding their condition

Areas interview covered:Areas interview covered: The extent to which C&YP understand their diagnosis and prognosis The extent to which C&YP understand their diagnosis and prognosis Their understandings of health care & interventions they receiveTheir understandings of health care & interventions they receive Barriers in receiving health care or education due to lack of Barriers in receiving health care or education due to lack of

understanding of their condition understanding of their condition What adults feel is needed to address these issuesWhat adults feel is needed to address these issues How such a resource might be presented and used How such a resource might be presented and used

ParticipantsParticipants Inclusion criteriaInclusion criteria C&YP with 4 limb CP C&YP with 4 limb CP Limited or no functional speech Limited or no functional speech Assumed unimpaired cognitionAssumed unimpaired cognition Service users within the hospital trust Service users within the hospital trust

Primary school-aged children:3 boys,1 girl aged 6-10 were identified by Primary school-aged children:3 boys,1 girl aged 6-10 were identified by members of the research team members of the research team

Children all using AAC Children all using AAC (Augmentative and Alternative Communication)(Augmentative and Alternative Communication) supports. 4 children - all wheelchair users who use eye pointing supports. 4 children - all wheelchair users who use eye pointing communication books, communication cards and/ or switches and eye communication books, communication cards and/ or switches and eye gaze to access communicationgaze to access communication

Pragmatic Pragmatic samplingsampling - capture parental and professional opinion re - capture parental and professional opinion re needs of a particular subset of children, rather than a statistically needs of a particular subset of children, rather than a statistically representative samplerepresentative sample

Parents contacted by letter & info sheet asking them to opt in. Parents Parents contacted by letter & info sheet asking them to opt in. Parents asked to nominate professionals to interviewasked to nominate professionals to interview

11 participants: 4 mums, 5 therapists; 2 Teaching Assistants11 participants: 4 mums, 5 therapists; 2 Teaching Assistants Been working with the children identified for 1-6 yearsBeen working with the children identified for 1-6 years

DataData All interviews about 30 minsAll interviews about 30 mins All interviews audiotaped and transcribedAll interviews audiotaped and transcribed Analysed using Analysed using Grounded TheoryGrounded Theory (Glaser & Strauss, 1967) (Glaser & Strauss, 1967) Groups data into themes reflecting participants’ opinions, Groups data into themes reflecting participants’ opinions,

thoughts and feelingsthoughts and feelings Inter-rater reliabilityInter-rater reliability First 5 interviews were independently analysed by 2 First 5 interviews were independently analysed by 2

researchersresearchers Initial themes identified by each independentlyInitial themes identified by each independently Initial themes compared and assessed for consistency Initial themes compared and assessed for consistency Initial themes were further developed, refined, discussed by 3 Initial themes were further developed, refined, discussed by 3

team members across latter transcripts team members across latter transcripts Thematic framework for analysis identifiedThematic framework for analysis identified Framework was applied to each transcriptFramework was applied to each transcript Themes grouped as necessaryThemes grouped as necessary

Results – What we foundResults – What we found Qu: What do you think X understands about his/her condition?Qu: What do you think X understands about his/her condition?

Overarching theme: Not thought about it much at all and a bit Overarching theme: Not thought about it much at all and a bit thrown by the question!thrown by the question!

Across topic areas and questions. Adults were able to then go on and Across topic areas and questions. Adults were able to then go on and talk about why and talk about their thoughts re what children knew and talk about why and talk about their thoughts re what children knew and how they came to know it how they came to know it

““I don’t know, I’ve never been asked that question, so it’s quite I don’t know, I’ve never been asked that question, so it’s quite tricky to be answering” (P3)tricky to be answering” (P3)

““Yeah, that’s a hard one. Don’t know, really don’t know” (P5)Yeah, that’s a hard one. Don’t know, really don’t know” (P5) ““I haven’t got a clue” (P10)I haven’t got a clue” (P10)

But many felt it was an important issue that they perhaps should have But many felt it was an important issue that they perhaps should have given more thought to given more thought to

““That’s terrible, we haven’t –” (P3)That’s terrible, we haven’t –” (P3) ““It’s good to raise this sort of awareness and whether X does have It’s good to raise this sort of awareness and whether X does have

an understanding because I hadn’t considered it” (P7)an understanding because I hadn’t considered it” (P7)

Child’s Understanding of Their Condition cont.Child’s Understanding of Their Condition cont.

Theme: Communication Difficulties Theme: Communication Difficulties Major barrier to adults being unsure. Often making assumptions as to to the child’s understanding.

““I could only guess or surmise…” (P2)I could only guess or surmise…” (P2) ““Probably because his communication isn’t good so we’ve never even Probably because his communication isn’t good so we’ve never even

asked the question” (P3)asked the question” (P3)

Theme: Assumed Limited UnderstandingTheme: Assumed Limited Understanding.. Due to the limitations of Due to the limitations of having CP, adults thought C&YP had basic awareness of their condition having CP, adults thought C&YP had basic awareness of their condition

““... he knows it affects the way his body controls his arms and his ... he knows it affects the way his body controls his arms and his legs” (P1).legs” (P1).

“ “he understand that there’s things he can do, things he can’t do, he understand that there’s things he can do, things he can’t do, things he finds harder” (P3)things he finds harder” (P3)

Reported some conversations, but no understanding of complexity: “…“…we’ve said that he was poorly when he was first born and there we’ve said that he was poorly when he was first born and there

were a few problems and he had to stay in the special care unit” (P1).were a few problems and he had to stay in the special care unit” (P1). “… “…we’ve said it’s come from brain damage but what he actually we’ve said it’s come from brain damage but what he actually

comprehends of that and fully takes in, we’re not sure” (P5)comprehends of that and fully takes in, we’re not sure” (P5)

Child’s Understanding of Their Condition cont.Child’s Understanding of Their Condition cont. Theme: Knowledge Due to Difference from Other ChildrenTheme: Knowledge Due to Difference from Other Children 3/4 3/4

were in mainstream, so diffs to typically developing peers are clear. were in mainstream, so diffs to typically developing peers are clear. Majority had sibsMajority had sibs

“…“…she knows that she’s in a chair, she knows that she’s not she knows that she’s in a chair, she knows that she’s not moving the same as other people” (P8).moving the same as other people” (P8).

“…“…he can see what’s around him that he’s not able to get up and he can see what’s around him that he’s not able to get up and walk like the other children […] and he’s not quite the same as walk like the other children […] and he’s not quite the same as his little sister” (P7)his little sister” (P7)

Theme: Lack of Sureness about FutureTheme: Lack of Sureness about Future.. Adults reported not being Adults reported not being sure re C&YP’s understanding of future (n=6) sure re C&YP’s understanding of future (n=6)

““She has regular physio, she has a walking frame so in some She has regular physio, she has a walking frame so in some respects, you can see where she would think ‘is this not going respects, you can see where she would think ‘is this not going to change over time?’” (P11).to change over time?’” (P11).

““Although we’ve never said that ‘you’re going to talk’ or Although we’ve never said that ‘you’re going to talk’ or anything like that, I think he still thinks that he will one day.”anything like that, I think he still thinks that he will one day.”

““She’s going to be a physiotherapist, that’s what she’s put down She’s going to be a physiotherapist, that’s what she’s put down that she want to do […] and that’s sometimes when you think that she want to do […] and that’s sometimes when you think ‘has she realised?’”‘has she realised?’”

How Had Adults Communicated With Child About CP?How Had Adults Communicated With Child About CP? Overarching Theme: Limited Communication Regarding CPOverarching Theme: Limited Communication Regarding CP.. Adults Adults

reported having not really communicated with children about their reported having not really communicated with children about their condition condition

Theme: Conversations When needed.Theme: Conversations When needed. The majority (n=9) reported that The majority (n=9) reported that communication tended to happen when needed, e.g .during therapy or class communication tended to happen when needed, e.g .during therapy or class

“… ‘“… ‘if you don’t sit properly in your chair, your back will hurt when you get if you don’t sit properly in your chair, your back will hurt when you get older’…” (P2)older’…” (P2)

Reports of not wanting to burden children with Reports of not wanting to burden children with “too much detail […] that "might “too much detail […] that "might frighten or upset [them]”frighten or upset [them]” (P1)(P1) and were aware of need to be sensitive. and were aware of need to be sensitive. " I might " I might just open a can of worms” (P2)just open a can of worms” (P2)

Theme: Age as a Barrier for Discussion.Theme: Age as a Barrier for Discussion. ?best age to do this:?best age to do this: ““I probably wouldn’t discuss that until they got maybe a little bit I probably wouldn’t discuss that until they got maybe a little bit

older…” (P9)older…” (P9)

Also emotional maturity; would C&YP be able to handle info?Also emotional maturity; would C&YP be able to handle info? ““He can make mountains out of molehills so I don’t want to say He can make mountains out of molehills so I don’t want to say

something that’s going to have a completely unexpected something that’s going to have a completely unexpected consequence” (P1)consequence” (P1)

"…he’s quite emotionally immature so sometimes he’ll get cross "…he’s quite emotionally immature so sometimes he’ll get cross about the slightest little thing” (P5)about the slightest little thing” (P5)

How Had Adults Communicated With Child About CP?How Had Adults Communicated With Child About CP?

Theme: Limited Resources.Theme: Limited Resources. Lack of communication Lack of communication due to lack of relevant literature and help. Some due to lack of relevant literature and help. Some mentioned resources e.g. mentioned resources e.g. the Motability magazinethe Motability magazine, the Scope websitehe Scope website & Mr. TumbleMr. Tumble

None could id. a resource for C&YP with CP, None could id. a resource for C&YP with CP, however a storybook was mentionedhowever a storybook was mentioned“…about a “…about a child in a wheelchair…” (P5)child in a wheelchair…” (P5) to which there to which there seemed to be different responses from children:seemed to be different responses from children:

“…“…he really enjoyed that and wanted to read it he really enjoyed that and wanted to read it several times” (P5). several times” (P5).

“…“…it wasn’t that great… [it didn’t have] much of a it wasn’t that great… [it didn’t have] much of a good story, it didn’t capture him” (P3)good story, it didn’t capture him” (P3)

Theme: Concern re Whose Role it is to Discuss Theme: Concern re Whose Role it is to Discuss CP.CP. majority (n=5) of professionals felt not their role. majority (n=5) of professionals felt not their role. They assumed it was parents’ roleThey assumed it was parents’ role

Barriers to ParticipationBarriers to Participation Theme: Practicalities of Having 4 limb CP. Theme: Practicalities of Having 4 limb CP. Need Need

for adult support to facilitate participation. E.g. for adult support to facilitate participation. E.g. Physical support, supervision and someone who is Physical support, supervision and someone who is familiar with the C&YP communication style and any familiar with the C&YP communication style and any AAC.AAC.

““He’s very limited with participation it’s only what’s He’s very limited with participation it’s only what’s provided for him what he can do” (P7)provided for him what he can do” (P7)

“…“…for him to go to after school club, we’ve had to for him to go to after school club, we’ve had to specifically arrange one-to-one support for specifically arrange one-to-one support for him…” (P1).him…” (P1).

Theme: Intra-child factorsTheme: Intra-child factors.. Emotional/sensory/physical factorsEmotional/sensory/physical factors beyond having beyond having the condition itself, yet in their own right limit the the condition itself, yet in their own right limit the child’s participationchild’s participation

Barriers to ParticipationBarriers to Participation Sub-themes:Sub-themes: Frustration and upset;Frustration and upset; “…he’ll get cross and then it “…he’ll get cross and then it

just crescendos into this big major tantrum that then just crescendos into this big major tantrum that then stops him from doing other things.” (P5)stops him from doing other things.” (P5)

Anxiety;Anxiety; of the unfamiliar and anticipatory anxiety. of the unfamiliar and anticipatory anxiety. “…“…he can be quite fearful of new situations and you he can be quite fearful of new situations and you have to stage manage some of those things” (P1)have to stage manage some of those things” (P1)

Sensory Issues.Sensory Issues. ““He’s quite sensitive to noise … He’s quite sensitive to noise … what he tends to do is anticipate that in new what he tends to do is anticipate that in new situations there’s going to be a noise that he doesn’t situations there’s going to be a noise that he doesn’t like… a couple of years ago, we took him to a circus like… a couple of years ago, we took him to a circus and that was fine to start with but some noise set and that was fine to start with but some noise set him off and I had to take him out and then we sat him off and I had to take him out and then we sat watching the circus from the door, the tent” (P5)watching the circus from the door, the tent” (P5)

AlsoAlso low motivation, and fatigue low motivation, and fatigue..

What a resource should look likeWhat a resource should look likeIf something were available to help C&YP understand their If something were available to help C&YP understand their

condition what would it look like?condition what would it look like?

Book formatBook format (n=7) simple to use, portability and (n=7) simple to use, portability and also its ready availabilityalso its ready availability

““He likes the computer but he has to be much He likes the computer but he has to be much more supported to use a computer. Whereas to more supported to use a computer. Whereas to use a book you could get it out at any time, you use a book you could get it out at any time, you can use it in a bigger variety of settings” (P4)can use it in a bigger variety of settings” (P4)

Technology basedTechnology based (n=6) good storage and flexible (n=6) good storage and flexible

“…“…that would allow something to be stored, to that would allow something to be stored, to have photographs in, and to be a really personal have photographs in, and to be a really personal resource…” (P6)resource…” (P6)

What a Resource Should Look LikeWhat a Resource Should Look Like Normalised: Normalised: be like other mainstream resources:be like other mainstream resources:““Something that would come off a shelf and would be read Something that would come off a shelf and would be read

along with other books. I don’t think it [needs to be] along with other books. I don’t think it [needs to be] announced as a special needs book” (P4)announced as a special needs book” (P4)

“…“…something that can also be read by other people who something that can also be read by other people who are interested and to whom it affects – for example, the are interested and to whom it affects – for example, the rest of the family, the class, and things like that. So it rest of the family, the class, and things like that. So it needs to be not necessarily directed specifically at X” needs to be not necessarily directed specifically at X” (P1) (P1)

Positivity and Sensitivity:Positivity and Sensitivity: +ve +ve aspects should be thereaspects should be there::“…“…real positive; this is what you can do, just because real positive; this is what you can do, just because

you’re in a chair, just because you can’t do this… or you’re in a chair, just because you can’t do this… or people think you can’t, you can achieve a lot of things” people think you can’t, you can achieve a lot of things” (P8)(P8)

What Should be in the Resource?What Should be in the Resource? Explanation of CP and of CauseExplanation of CP and of Cause “…‘“…‘what is CP?’ because some children with what is CP?’ because some children with

CP are completely mobile, and without a CP are completely mobile, and without a really good eye you might even not pick them really good eye you might even not pick them out or you have children like X who are out or you have children like X who are totally dependent or some children who are totally dependent or some children who are even more affected than X” (P 2)even more affected than X” (P 2)

Prognosis and life developmentPrognosis and life development““When she gets older, hopefully we’ll be able When she gets older, hopefully we’ll be able

to get somewhere where she can live, her to get somewhere where she can live, her own living area, independent, employ her own living area, independent, employ her own people to look after her” (P8)own people to look after her” (P8)

““Real actual people talking about maybe their Real actual people talking about maybe their childhood and what they’ve achieved” (P6)childhood and what they’ve achieved” (P6)

What Should be in the Resource?What Should be in the Resource?

Understanding of treatmentsUnderstanding of treatments Facilitation of choice making and decision takingFacilitation of choice making and decision taking Objectivity and independence of resourceObjectivity and independence of resource““I just think it would be really nice for X to be in control I just think it would be really nice for X to be in control

of something that’s not being done to X, not being of something that’s not being done to X, not being read to X, not being put upon X…” (P11) read to X, not being put upon X…” (P11)

or hearing about their condition in a tangential way:or hearing about their condition in a tangential way:““He might come across other children in senior school He might come across other children in senior school

who know a lot more than he does… you don’t really who know a lot more than he does… you don’t really want the first thing he understands about it to come want the first thing he understands about it to come from another teenager” (P 2)from another teenager” (P 2)

Conclusions & ReflectionsConclusions & Reflections Surprise at some of the findings:Surprise at some of the findings:

Central issueCentral issue - Many participants given little thought to the C&YP’s - Many participants given little thought to the C&YP’s understanding of their condition, but during interviews recognised this as understanding of their condition, but during interviews recognised this as a relevant issuea relevant issue

Our initial conceptions vs actual findings: we assumed lack of Our initial conceptions vs actual findings: we assumed lack of understanding was a key issue as barrier to participation, but participants understanding was a key issue as barrier to participation, but participants identified practicalities of the condition itself as barriers e.g. identified practicalities of the condition itself as barriers e.g. communication and physical difficultiescommunication and physical difficulties

Most reported Most reported not doing much to inform C&YPnot doing much to inform C&YP about their condition and about their condition and identified barriers to this e.g. communication. When this did happen often identified barriers to this e.g. communication. When this did happen often it was in the form of ‘ad hoc’ conversations. not systematic info. gaps in it was in the form of ‘ad hoc’ conversations. not systematic info. gaps in info, no chance to address questions ; no way to determine just how info, no chance to address questions ; no way to determine just how much information children may or may not want; no way check much information children may or may not want; no way check understanding and consequences of receiving this informationunderstanding and consequences of receiving this information

Lack of relevant resources to facilitate discussionLack of relevant resources to facilitate discussion was an identified was an identified issue. Indicating need for resourceissue. Indicating need for resource

Adults were Adults were generally enthusiasticgenerally enthusiastic regarding the development of a regarding the development of a resource. Differing ideas about what this should look likeresource. Differing ideas about what this should look like

Next Steps Next Steps

Produce prototypesProduce prototypes Focus group responses to prototypeFocus group responses to prototype New student starting September 2013New student starting September 2013

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