Manchester Metropolitan University

1. Manchester Metropolitan University Paper presented at the Research Institute for Health and Social Change 2007 Annual Conference 4th -5th July 2007 Ann French a.french@mmu.ac.uk

2. Developmental language difficulty: Are ‘diagnosis’ and ‘treatment’ appropriate concepts?

3. 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.

4. Developmental language difficulty (DLD) • ‘Diagnosis’ rests on 3 factors1: • Language score(s) below CA • Discrepancy between language and non-verbal scores • Difficulties not attributable to any other cause.

5. 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 non-verbal scores’: not a valid criterion. 1,2,3 • ‘Difficulties not attributable to any other cause’: children with DLD often have additional SEN.1

6. 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’?)

7. 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?

8. 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: • School-based staff: the SENCo, a subject teacher, a TA, and a Learning Support Service teacher. • SLT staff: the paediatric Service Manager and an SLT with responsibility for secondary schools; • 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

9. The potential advantages of the concepts ‘diagnosis’ and ‘treatment’ of DLD • 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

10. The potential disadvantages of the concepts ‘diagnosis’ and ‘treatment’ of DLD • 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’

11. 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)

12. 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 top-down 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)

13. 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)

14. 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)

15. 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)

16. 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)

17. 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”

18. 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 education- trained 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

19. References • Dockrell, J. and Messer, D. (1999). Children’s Language and Communication Difficulties. London: Cassell • Rutter, M. (2007). Specific language impairment and its causes: do we need to change our diagnostic concepts of risk processes? Afasic 4th International Symposium, April 2007; University of Warwick. • Tomblin, J.B. (2007). Adolescent outcomes of poor language ability at school entry.Afasic 4th International Symposium, April 2007; University of Warwick. • Bishop, D.V.M. (2007). SLI, dyslexia and autism - using genetics to unravel their relationship. Afasic 4th International Symposium, April 2007; University of Warwick. • Dockrell, J. (2007). Inclusion versus specialist provision: ideology versus evidence based practice for children with language and communication difficulties. Afasic 4th International Symposium, April 2007; University of Warwick. • Williams, D. (2007). The application of molecular genetics to the study of language impairments and dyslexia. Afasic 4th International Symposium, April 2007; University of Warwick. • Bronfenbrenner, U. (1997). The Ecology of Human Development. Cambridge MA: Harvard University Press. • Robson, C. (1993). Real World Research. Cambridge: Blackwell. • Ritchie, J. and Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman and R.G. Burgess (Eds). Analysing Qualitative Data. London: Routledge. • ATLAS.ti. Demo Version WIN 5.2. www.atlasti.com