Transcript Slide 1

Manchester Metropolitan
University
Paper presented at the
Research Institute for Health and
Social Change 2007 Annual
Conference
4th -5th July 2007
Ann French
[email protected]
Developmental language
difficulty: Are ‘diagnosis’
and ‘treatment’ appropriate
concepts?
Background

Experience of working in and with mainstream
schools to support junior/secondary age
students with speech, language and
communication needs (SLCN)
 Became aware of differences between
stakeholders (education staff, health staff,
parents, students..) in ways of talking about
SLCN
 Differences may be deeper than terminology and
reflect underlying philosophies about aetiology
and management.
Developmental language difficulty
(DLD)
 ‘Diagnosis’
o
o
o
rests on 3 factors1:
Language score(s) below CA
Discrepancy between language and nonverbal scores
Difficulties not attributable to any other
cause.
How valid are these criteria?
 ‘Language
score(s) below CA’: there is no
exact dividing line between ‘normal’ and
‘abnormal’. 1
 ‘Discrepancy between language and nonverbal scores’: not a valid criterion. 1,2,3
 ‘Difficulties not attributable to any other
cause’: children with DLD often have
additional SEN.1
Additional problems for
identification of DLD

Overlap with other conditions e.g. dyslexia and autistic
spectrum disorder.4,5
 Lack of clear-cut neurological basis for DLD.4,6
 Academic outcomes are similar to those for children with
general developmental delay.3
 Relatively little is known about the ‘prognosis’ for DLD,
with/without ‘treatment’.
 Little is known about the effectiveness of ‘treatment’.
 ‘Treatment’ for most ‘symptoms’ of DVD is
indistinguishable from ‘teaching’ (So why do SLTs do
‘therapy but teachers do ‘teaching’?)
The research questions
General
 Do concepts and terminology referring to
SLCN vary across stakeholders?
 If so, what potential barriers does this
create for multi-professional working?
Specific focus for this presentation
 What advantages and what disadvantages
may arise from traditional SLT concepts of
‘diagnosis’ and ‘treatment’ of DLD?
Methodology
Design
 A small-scale exploratory study of a large mainstream secondary
school and the associated Speech and Language Therapy (SLT)
service, using a qualitative approach.
Data collection and analysis Phase 1 (See poster presentation for
findings)
 A range of central government, professional body and local policy
documents were examined using Content Analysis8.
Data collection and analysis Phase 2
 Semi-structured interviews were carried out with:
o School-based staff: the SENCo, a subject teacher, a TA, and a
Learning Support Service teacher.
o SLT staff: the paediatric Service Manager and an SLT with
responsibility for secondary schools;
o Service-users: a student with DLD and his parents.
 The data was examined using Framework Analysis9, partially
managed with a free demonstration version of ATLAS.ti.10
The potential advantages of the concepts
‘diagnosis’ and ‘treatment’ of DLD
1.
2.
3.
4.
5.
Fits with the medical model so may attract NHS
funding (SLT manager)
Parents said they didn’t like labels, but felt label was
necessary for access to a tribunal to challenge son’s
statement
May help school staff to differentiate EAL and DLD
(Teacher mainly referred to EAL)
Can provide clear objective criteria to ration access to
limited resources such as SLT, LSS, EP, TA support
May facilitate access to education resources e.g. TA
support, extra time/reader for assessments
The potential disadvantages of the
concepts ‘diagnosis’ and ‘treatment’ of DLD
1.
2.
3.
4.
5.
6.
Misunderstanding/de-skilling of stakeholders
Lack of fit with other professional models, therefore
lack of engagement of other professionals
Invalidity of the terms ‘diagnosis’ and treatment’ for
DLD
Inequitable provision for all children with SLCN
Inefficient use of limited staff resource
Unwanted side effects of ‘diagnosis’ and ‘treatment’
1. Misunderstanding/de-skilling

Medical terminology may obscure educational presentation: some
interviewees felt they knew nothing about DLD:
“I don’t know a great deal about it to start off with” (Teacher)
or that it was rare:
“I think hidden’s a. I think a small hidden group really hits. hits the
nail on the head” (SENCo)

Parents initially expected the problem to be temporary (‘treatment’
may be expected to cure or improve a condition):
“yes it was a shock to know that it was - on - ongoing - it’s still
happening” (Parent)

Parents interpreted the label ‘specific language impairment’ to
mean a need for specific SLT/educational approaches, and were
unhappy with general SEN provision:
“these very specific - you know the spiky profile - all - all these
s.specific problems” (Parent)
2. Lack of fit, and therefore of engagement

Making DLD the province of SLT, but dyslexia the province of
education, may exacerbate school focus on written v. spoken
language and make teaching staff resistant to SLT training:
“it wasn’t received well they weren’t - it wasn’t - you know - it was the hardest training I’ve ever done” (SLT Manager)

SLT advice which does not fit with school agendas may be ignored:
“they’ve got so much pressure on them for certain agendas - that if
you’re giving them an agenda that doesn’t fit - with one of their topdown agendas then - you’re really struggling” (SLT Manager)
or may antagonise staff:
“she rubbed up a lot of teachers the wrong way by going in and
saying ‘you must do this’ - ‘this is what he needs’” (LSS Teacher)

Labels may encourage teachers to see these students as ‘different’
i.e. someone else’s problem:
“you’ve got specialist teachers teaching their subject - and that is.
one of their main agendas is to - tea. to teach this and then - it’s
almost like - the next level down is looking at - those sort of issues”
(SLT)
3. Invalidity of concepts ‘diagnosis’ & ‘treatment’ for DLD

Parents emphasised need for early diagnosis:
“what I try and say to people … is – you know - get - that diagnosis as early
as possible”
but ‘diagnosis’ may only be possible (several years) retrospectively.

‘Diagnostic’ criteria are unreliable:
“she did the CELF test and then identified obviously there were these very
specific - you know the spiky profile” (Parents, describing diagnosis of SLI)
“often we find with the spiky profiles - we’ve often got more of a social
communication - type difficulty going on” (SLT manager)

Different labels may obscure common strategies (‘treatment’) for different
‘conditions’ e.g. DLD, dyslexia, MLD, EBD
“you should be able to meet all of their needs because if actually you taught
in that style - even though the causes are different some of the symptoms
are the same” (SLT Manager)

‘Diagnostic’ label may not predict academic or social functioning: individual
characteristics contribute:
“yes it’s to do with the language and things like that but more - to do with the
confidence of the child and - how they - are within themselves if they’re
comfortable with - any problems that they have or if they’re not and - how
they sort of see themselves in the world” (Teacher)
4. Inequity of provision

‘Diagnostic’ criteria may be applied rigidly to ration services: which
side of an arbitrary line you are on determines educational access.
“ when I started - children with - under the 16th centile got support now it’s the 5th” (LSS Teacher)

Criteria may lead to possibly inequitable use of resources:
“so even if they’re - em - within normal limits for their language - if
their cognition is - is that far ahead - then we would still see that as a
d. you know such a big discrepancy that we should hopefully - be
able to develop” (SLT Manager)

The most vocal parents get the best provision:
“that’s pulled together very well for parents who shout loudly” (SLT
Manager)
5. Inefficient use of staff
 Overlap of ‘conditions’ may lead to overlap of staff
resources: e.g. SENCo mentions SLT, ESSE, LSS,
CAMHS and Together Trust staff working on
communication skills

NHS funding models burden SLTs with need to rack up
‘treatments’ (SLT), when best approach which might be
training of significant others

Specialist SLT knowledge and skills may be better
expended on the most serious SLCN (LSS teacher)
6. Unwanted side effects

Having a TA may obscure from teachers the effects of DLD and therefore
need to change teaching style (SLT)
“the thing in secondary is that - the. the teachers - if there is - a visible
person there next to that child - then they know that that person - is there to
support them - so - you know - not all of the - strategies will actually - come
into play because - there’s somebody there to - to. to break the language
down” (SLT)

Assessment to arrive at ‘diagnosis’ may be a burden for the student:
“so you’d have to see it every week - all these tests same tests - hated it
sss. really really really - - really hard for me… felt like a guinea pig or
something ” (Student)

‘Treatment’ may entail extra work on top of curriculum:
“it got me really hard work - so brain was like ‘pff’ - exploding - cos I had so
many (Student)

A label may make the student feel ‘different’, ‘stupid’:
“if you do all of that - - the. the child is going to feel - worse - than it was
when it went in because - it’s made to look like an idiot - that’s how it s how the child sees himself (LSS Teacher)

Negative impact on parents, student and siblings as they pursue a
‘diagnosis’ and ‘correct’ provision:
F: “it’s a hard path and it’s - very wearing - on the parents - and to. because
you - you’re also trying to cope and you’re trying. and and our position was
trying to get - information from people to help us support (SON’S NAME) cos sometimes during that battle - you’re actually losing sight of the child and that and that also is something that you have to be very careful of that
you don’t actually lose sight of . I mean you’re so - embroiled - in the battle that the child’s actually - slipping down an even - further slippery slope
because you’re not actually doing - the thing that you should be doing with
your child to help. to help their development to help them *(2 sylls)
M: and you don’t want to - give your - anxieties over to the child either we
tried not to do that didn’t we but - whether we did or not - we don’t know we
tried to keep it happy and F: yeah always. Always - keep a positive view on it
M: and remember my other two - so we didn’t want them to be - - less
focussed on”
Conclusions
What might ‘treatment’ be needed for ?
 AAC support if required
 Expressive phonology and grammar (SLTs have specialist
knowledge)
 Social skills?? (But overlap with ESSE, LSS, CAMHS…)
What might be left to SLT-trained staff (TA, LSS) OR to educationtrained SLTs?
 Facilitating comprehension, vocabulary development, memory….
 Advising teaching staff on adjustments to teaching and assessment
What else needs to be done?
 Influencing educational policy makers to develop curricula which are
more appropriate for the less verbal/less literate
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2.
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4.
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6.
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