Week 11 SEMH Student Slides 2024-2025 PDF

Children’s speech, language and communication development in the context of complex vulnerabilities: Attention Deficit Hyperactivity Disorder (ADHD) and Reluctant Talkers Professor Judy Clegg, School of AHPN&M HCS 2023/6304 1 Learning Outcomes...

Children’s speech, language and communication development in the context of complex vulnerabilities: Attention Deficit Hyperactivity Disorder (ADHD) and Reluctant Talkers Professor Judy Clegg, School of AHPN&M HCS 2023/6304 1 Learning Outcomes By the end of the session, students should be able to: ∙ Show a basic understanding of children’s social, emotional & mental health (SEMH). ∙ Describe relevant developmental theory in children’s SEMH;1) social-emotional competence and 2) attachment ∙ Identify behaviours that characterise two child SEMH difficulties 1) Attention Deficit Hyperactivity Disorder (ADHD) and 2) reluctant talkers/selective mutism ∙ Show a basic understanding of how children’s speech, language and communication difficulties can be involved with children’s SEMH difficulties HCS 2023/6304 2 A medical/psychiatry definition Childhood psychiatric disorder is a term used to describe children who show severe impairments in their behaviour, development, learning, mood and social functioning, where these are not adequately explained solely by primary medical factors Diagnosed by child and adolescent psychiatrists, paediatricians and/or clinical psychologists Usually managed by Child and Adolescent Mental Health Services (CAMHS) Other services, e.g., Schools, Social Services, Educational Psychologists, Multi Agency Support Teams (MAST) and others HCS 2023/6304 3 An educational definition SEMH (Social, Emotional & Mental Health) is a term that was introduced in the Special Educational Need and Disabilities (SEND) Code of Practice in 2014. It replaced the terms BESD (Behaviour Emotional Social Development) and EBD (Emotional & Behaviour Difficulties). The new abbreviation, SEMH, was the first term to drop the word ‘behaviour’, in an attempt to emphasise that behaviour is only ever a way of communicating something more significant. In other words, referring to behaviour meant that many practitioners were focusing on the behaviours on display, rather than the needs behind the behaviour. Interesting and very useful website here: Home – SEMH HCS 2023/6304 4 Developmental Theory: Social-emotional development and competence (Denham 2006;2009) A complex psychological construct Generally – children who are able to positively engage with those around them and are able to regulate or manage their emotions and how they express these emotions. A foundation for engagement and learning Interacts with other development, e.g., language and communication HCS 2023/6304 5 Social-emotional competence Social competence: child engages appropriately in social interaction Attachment: child established a secure attachment with a primary carer from birth Emotional competence: child aware of their emotions and those of others and are able to manage/regulate how they express or show these emotions to others Self-perceived competence: child is aware of their own strengths/weaknesses in relation to their peers and are able to use this in their own motivations Temperament: child’s intrinsic personality in how he/she reacts to experiences and then manages these Disruptions to the above can put the child at risk of SEMH difficulties HCS 2023/6304 6 Two questions to consider: 1. To what extent are children’s developing communication skills needed for socio-emotional competence? 2. To what extent is social-emotional competence necessary for children to be competent communicators? What do you think? HCS 2023/6304 7 An example Why is language important for mental health? Professor Norbury and colleagues Why is language important for mental health? - YouTube HCS 2023/6304 8 Attachment A term used to refer to the process by which a caregiver/parent establishes a relationship with their child which makes the child feel safe, secure and protected (Benoit 2004; Bowlby 1969) Secure attachment is the foundation of a child’s development in terms of psycho- social adjustment Attachment can be disrupted by seriously inadequate caregiving environments such as severe neglect, emotional and physical abuse The above can have a significant impact on children’s social-emotional development and overall development HCS 2023/6304 9 James Identify the signs indicating SEMH difficulties: James was 10 years old when he was referred to CAMHS due to concerns about his emotional well being and extremely poor progress at school. James lives with his Father as he was removed from his Mother’s care because of neglect, emotional and physical abuse. His attendance at school in the past has been poor. Although he now attends regularly he has made very little progress over the last two years. James spends a lot of time in a world of his own, he has a very short attention span and he passively resists any attempts from staff in encouraging him to write, e.g., when asked James gets up and leaves the classroom – this happens frequently. James does not interact with the children at school although he can respond well with adults in a one to one situation. Staff at school have felt that James is able to do the work but chooses not to do it. At home, his Father reports that James is dreamy and disorganised and very dependent on his Father for help with everyday tasks, e.g., getting dressed. James will make up long complicated stories about events that have happened to him which are clearly not true. When challenged about these James insists that they are true. HCS 2023/6304 10 Christopher Identify the signs indicating SEMH difficulties Christopher was 8 years old when his GP referred him to a Child Psychiatrist. Christopher lives with his adoptive parents who he went to live when he was 4 years old. Christopher was finally removed from his Mother’s care at the age of 4 years due to emotional and physical abuse. Christopher’s mother has schizophrenia and very little is known about his Father. Christopher has been permanently excluded from his school due to his behaviour. Professionals report that Christopher is unable to sit still, he rocks in his chair and then stands up on the chair, walks around the room and is then very difficult to prompt to return to sit down. He is significantly behind in his schoolwork - he cannot read or write. Teachers report that Christopher frequently interrupts conversations, is very talkative and obsessed by any electronic equipment. Christopher interacts inappropriately with both adults and other children. He often pushes others and is aggressive towards them. At home, his adoptive parents report that Christopher is becoming more difficult to manage. He does not sleep at night and does not respond to any instructions. Christopher becomes very upset over trivial incidents, e.g., a fire alarm going off or an appointment not being kept and he seems to think that it is his fault when ‘things do not go right’. HCS 2023/6304 11 Attention Deficit Hyperactivity Disorder (ADHD) (1) Defined as a neurodevelopmental disorder Continuum of severity Defining features of ADHD are: 1) impulsiveness: persistently interrupt others, engage in impulsive behaviour where they are unable to think about the consequences of the behaviour, difficulty waiting for his/her turn, blurts out answers before the question is finished 2) inattention: impaired attention, e.g., unable to attend to a task sufficiently, very easily distracted, difficulties maintaining attention to one task, does not seem to listen when spoken to, does not follow instructions through 3) Hyper or over-activity: very fidgety, runs about or climbs excessively in inappropriate situations, described as constantly being ‘on the go’, talk excessively, poor sleep HCS 2023/6304 12 Hyperkinetic Disorder A term sometimes used for children with more severe symptoms, usually in the hyperactivity domain although still need to be symptoms in all three domains HCS 2023/6304 13 Video Clip Activities - ADHD Watch the video clip aimed at children from the National Centre of Mental Health https://www.ncmh.info/videos-and-podcasts/animations/ Consider how the descriptions of ADHD fit in with the behavioural diagnosis What sort of approaches or strategies are used to support children with ADHD? HCS 2023/6304 14 Attention Deficit Hyperactivity Disorder (ADHD) (2) Behaviours usually have to present before the age of 12 years The behaviours impact negatively on the child across several aspects or domains of the child’s life/multiple settings, e.g., in school and at home, Difficulties in psycho-social functioning, for example: 1) the behaviours can result in anti-social behaviour 2) peer and family relationships are affected because of the disruptive behaviour 3) progress at school is negatively impacted HCS 2023/6304 15 Attention Deficit Hyperactivity Disorder (ADHD) (3) DSM-V Update Recognition that ADHD continues into adult life ADHD symptoms must be present before 12 years (compared to 7 years in DSM –IV) Recognition of co-morbidity HCS 2023/6304 16 Attention Deficit Hyperactivity Disorder (ADHD) (4) In the UK it is estimated that 5% of children under 18 years have a diagnosis of ADHD – this is thought to be an under- estimate with many other undiagnosed cases Majority of cases are referred from primary care, i.e., GPs Boys diagnosed more frequently than girls Comorbidity: ADHD is often diagnosed in the presence of other neurodevelopmental disorders, e.g., learning disability, ASD, DLD No single risk factor explains ADHD – mix of environmental and genetic factors including having a biological relative with ADHD, extreme early life adversity, pre and post natal exposure to lead, low birth weight/prematurity HCS 2023/6304 17 Re-thinking ADHD (Bisset et al., 2023; Franke et al., 2023) Neurodiversity movement; moved into ADHD community as well as the autism community Moving away from viewing ADHS only as a 'disorder' or 'impairment' Moving into a strengths based approach ADHD does not necessarily need medical intervention Positive traits of ADHD , e.g., hyperfocus, resilience, creativity, energy More complex in children and people who have ADHD co-morbid with other developmental differences and learning disabilities Bisset, M., et al., (2023). Practitioner review: it's time to bridge the gap - understanding the unmet needs of consumers with attention deficit/hyperactivity disorder - a systematic review and recommentations. Journal of Child Psychology & Psychiatry, 64, 6, 845-847 Franke, B., et al., (2023) Editorial: Is it time to modernise the concept of ADHD! Journal of Child Psychology & Psychiatry, 64, 6, 848-858 18 Children with ADHD Management aims to combine medical, psychological and behavioural approached with emphasis on the family and school Medical: psychostimulants (Methylphenidate (Ritalin) and Amphetamine derivatives) are the most prescribed stimulant for ADHD - can have significant side effects, e.g., weight loss Psychological: helping the child and those involved to understand their child, e.g., the child has difficulties with attention – not ‘bad behaviour’ Parent/carer support : facilitating effective strategies for the child and those involved to support the child, e.g., sleep hygiene School based interventions: enabling schools to implement strategies for the children they work with, e.g., physical break HCS 2023/6304 19 Children with ADHD Let’s look at some of these here 5 Evidence Based ADHD Teaching Strategies - SEMH As we read these, consider why/how these are effective in terms of what we know about ADHD HCS 2023/6304 20 Speech, language and communication in ADHD Speech, language and communication difficulties are often identified in children with ADHD It is usually very difficult to understand why speech and language difficulties may be co-morbid with ADHD However, here are some potential explanations that have been suggested: HCS 2023/6304 21 Explanations for the co-morbidity between speech and language difficulties and ADHD Co-morbidity of neurodevelopmental disorders, e.g., a child with DLD may be more likely to have ADHD than a child without ADHD Children with ADHD can often have mild learning disability which will slow their rate of language learning Difficulties in attention can impact on how well the children can listen and attend to their environment and thus affect their language learning Difficulties with impulsivity can impact on social communication, e.g. blurting out answers or not waiting for a turn Working with a child with DLD or speech, language and communication differences: will need to work with/manage the ADHD in any SLC interventions, this can make intervention more challenging/longer HCS 2023/6304 22 ADHD – in summary A neurodevelopmental disorder High co-morbidity Defined by 1) inattention; 2) impulsivity and 3: hyperactivity Speech, language and communication difficulties are common As SLTs, need to consider how to work effectively with children who have ADHD HCS 2023/6304 23 Reluctant Talkers/Selective Mutism: Diagnostic Criteria (DSM – V): Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., in classroom), despite speaking in other situations (e.g., at home) Interferes with education or occupation achievement or social communication Must last for at least one month (not 1st month of school) Not due to lack of knowledge of or comfort with the language in use. Not better explained by communication disorder (e.g., stuttering) HCS 2023/6304 24 Other useful information Previously termed ‘elective mutism’ but renamed as ‘selective mutism’, and sometime referred to as ‘reluctant talkers’ Often starts in children between the ages of 2 and 5 years Prevalence approximately 1 in 140 children under 8 years of age (Bergman et al., 2002; Elizur & Perednik, 2003). Co-morbidity is common Slightly more common in girls (Cline & Baldwin 1994) Can have significant negative impact on education/learning and social relationships Understood as an anxiety disorder More common now as part of children ‘refusing’ to attend school (post COVID pandemic) HCS 2023/6304 25 Video Clip Activity- Reluctant Talkers Watch the video clip from 2021: https://www.itv.com/news/granada/2021-10-20/selective-mutism- struggling-in-silence Relate the descriptions of the diagnostic features of selective mutism/reluctant talkers to the children in the videos. There is also this video to watch of a young adult with selective mutism (if you're interested_ https://www.bbc.co.uk/news/articles/cj0j8qydl70o HCS 2023/6304 26 Anxiety is… Three main symptom domains Apprehension: fear something ‘bad’ is going to happen Motor tension: increased stress/tension Autonomic activity: ‘fight or flight’ responses What could anxiety look like in a school age child (5-10 years)? How could a school age child show their apprehension, motor tension and autonomic activity? HCS 2023/6304 27 Reluctant Talkers Non-pharmacological (i.e., behavioural) interventions for selective mutism/reluctant talkers Selective Mutism/Reluctant Talkers as an anxiety disorder Reduce the anxiety about talking De-sensitise child to talking and increase their confidence in talking by considering: 1.Child’s communication environment 2.Communication load of the communication task Johnson & Wintgens (2013); Oerbeck et al., (2013; 2017; 2018), Hipolito et al., 2023 Emerging evidence base for these communication approaches – see Hipolito et al., (2023) HCS 2023/6304 28 Case/Activity Talking stages – easy to hard Situations – easy to hard 1. Vocalisations 1. Classroom 2. Whispering simple responses 2. With the key family member 3. Private audio recordings 3. With the classroom teacher in an individual situation 4. Whispering in answering to questions 4. With the dinner lady in the dining room 5. Saying written messages 5. With the head teacher 6. Full/loud voice 6. In individual sessions with more targeted support, 7. Whispering printed messages i.e., speech and language therapy sessions, SEMH worker 8. Gestures 9. Soft voice 10. Loud whispering of printed messages HCS 2023/6304 29 Stages of confident speaking (adapted from Johnson & Wintgens (2006)) 1. No communication or participation 2. Co-operation but limited communication 3. Visual but not verbal communication 4. Can use non-verbal sounds 5. Can speak within ‘earshot’ of someone 6. Single words with certain people 7. Connected speech with certain people 8. Generalising to others 9. Communicating freely HCS 2023/6304 30 A Case Study: 9 years male Not spoken in nursery/school context since 3 years of age Diagnosis of ASD at 3 years Significant SEMH difficulties Mental health difficulties in the family Mainstream school with support Tier 4 CAMHS provision HCS 2023/6304 31 Stages of confident speaking (adapted from Johnson & Wintgens (2006) 1. No communication or participation 2. Co-operation but limited communication 3. Visual but not verbal communication 4. Can use non-verbal sounds 5. Can speak within ‘earshot’ of someone 6. Single words with certain people 7. Connected speech with certain people 8. Generalising to others 9. Communicating freely HCS 2023/6304 32 Intervention Appropriate target – use non-verbal sounds Subgroup of the multi-disciplinary team Specific settings Facilitate, encourage and use non-verbal communication Visual communication Specific communication tasks (low loads) HCS 2023/6304 33 Stages of confident speaking (adapted from Johnson & Wintgens (2006) 1. No communication or participation 2. Co-operation but limited communication 3. Visual but not verbal communication 4. Can use non-verbal sounds 5. Can speak within ‘earshot’ of someone 6. Single words with certain people 7. Connected speech with certain people 8. Generalising to others 9. Communicating freely HCS 2023/6304 34 Conclusions Range of social, emotional and mental health difficulties (SEMH) Behaviour is communication Children with speech, language and communication difficulties can also have SEMH difficulties. Need to consider developmental theory of social emotional competence and attachment when thinking about children with SEMH difficulties and speech, language and communication difficulties The defining features of ADHD are impulsiveness, inattention and hyperactivity The defining features of reluctant talkers/selective mutism are a persistent refusal to talk explained by significant anxiety HCS 2023/6304 35 Reading Recommended reading (all available through the online resources list) Clegg, J., (2021). Children’s communication and their mental health: perspectives from speech and language therapy. In O’Reilly, M., & Lester, J.N. (Eds.) (2021). Improving communication in mental health settings: evidence based recommendations from practitioner led research. Routledge, Taylor & Francis, UK The Bridge Edition about ADHD; this is published by the Association of Child & Adolescent Mental Health and available here: The Bridge - ACAMH Useful resources on the following website: http://www.selectivemutism.org.uk http://www.selectivemutism.org.uk/info-dos-donts-at-secondary-school/ Johnson, M., & Wintgens, A. The Selective Mutism Resource Manual. Speechmark Publishing Ltd, UK HCS 2023/6304 36 Other useful reading Clegg, J., (2020). Children’s Communication and their Mental Health. In Jagoe. C, & Walsh, I (Eds). Communication and mental health difficulties: Developing Theory, growing practice. J & R Press, UK. Clegg, J., Crawford, E., Spencer, S., & Matthews, D. (2021). Developmental Language Disorder (DLD) in Young People Leaving Care in England: A Study Profiling the Language, Literacy and Communication Abilities of Young People Transitioning from Care to Independence. International Journal of Environmental Research & Public Health. doi: 10.3390/ijerph18084107 Franke, B., et al., (2023) Editorial: Is it time to modernise the concept of ADHD! Journal of Child Psychology & Psychiatry, 64, 6, 845-847 Hipolito, G., Pagnamenta, E., Stacey, H., Wright, E., Joffe, V., et al., (2023). A systematic review and meta- analysis of nonpharmacological interventions for children and adolescents with selective mutism. Journal of Child Psychology & Psychiatry, https://doi.org/10.1002/jcv2.12166 Oerbeck, B., Stein, M.B., Wentzel-Larsen, T., Langsrud, O., & Kristensen, H. (2013). A randomised controlled trial of a home and school based intervention for selective mutism – defocused communication and behavioural techniques. Child and Adolescent Mental Health, HCS 2023/6304 37 References from the lecture Bergman, R. L., Piacentini, J., & McCracken, J. T. (2002). Prevalence and description of selective mutism in a school-based sample. Journal of the American Academy of Child and Adolescent Psychiatry, 41(8), 938– 946. https://doi.org/10.1097/00004583-200208000-00012 Cline, T., & Baldwin, S. (1994). Selective Mutism in Children. San Diego, CA: Singular Elizur, Y., & Perednik, R. (2003). Prevalence and description of selective mutism in immigrant and native families: A controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 42(12), 1451– 1459. https://doi.org/10.1097/00004583-200312000-00012 Giddan, J.J., Ross, J.G., Sechler, L.L. & Becker, B. (1997). Selective mutism in elementary school: multidisciplinary interventions. Language, Speech & Hearing Services in Schools, 28, 2, 127-133 Hipolito, G., Pagnamenta, E., Stacey, H., Wright, E., Joffe, V., et al., (2023). A systematic review and meta-analysis of nonpharmacological interventions for children and adolescents with selective mutism. Journal of Child Psychology & Psychiatry, https://doi.org/10.1002/jcv2.12166 Johnson, M., & Wintgens, A. The Selective Mutism Resource Manual. Speechmark Publishing Ltd, UK. Thapar, A., Cooper, M., Eyre, O. and Langley, K. (2013), Practitioner Review: What have we learnt about the causes of ADHD?. Journal of Child Psychology and Psychiatry, 54: 3–16. HCS 2023/6304 38