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Right from when your child has a diagnosis of any kind of Special Educational Needs and Disabilities (SEND), so many words, terms, acronyms and abbreviations are thrown at families caring for children with special educational needs and disabilities, all of which many people will just assume you know. We at SEND Family Support want to […]

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ACES - adverse childhood experiences

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How to support children with ACEs in early years settings | A Unique Child | Teach Early Years

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Your actions could make the difference for a child between a future of happiness and a future of chaos, says Lorraine Jenkin...
Most people feel anecdotally that people who have had a tough childhood tend to have a tough adulthood: things that happen to us as children shape us - positively and negatively - and affect our future choices and behaviours.

However, it is only recently being appreciated how tight the correlation is between the number of Adverse Childhood Experiences (ACEs) and the health and wellbeing of adults.

What are ACEs?

ACEs are listed as children experiencing physical, sexual or emotional abuse, or growing up in a household in which there is alcohol or drug abuse, mental illness, criminality (particularly incarceration), domestic violence or parental separation.

Each one of these things is counted as a single ACE. Some children will obviously have multiple ACEs.

Certain levels - and periods - of stress are considered to be normal and indeed good for us. They teach children to cope with uncomfortable situations and build long-term resilience. However, extreme or prolonged stress changes a child at a cellular level.

Constant heightened awareness raises cortisol and adrenaline and so body chemistry becomes different compared to a child who has the occasional isolated incident to contend with.

The original ACEs research (at Kaiser Permanente, 1995-97) recognised this and found that adults who have four or more ACEs are much more likely to have poor adult health - debilitating conditions such as cancer, heart disease or diabetes.

Those with six or more ACEs have life expectancies 20 years less than their peers with none.

They are also less likely to be able to cope with everyday life without resorting to activities that inflicted the ACEs on them in the first instance: substance abuse, violence, criminality, domestic abuse, mental illness and abusive behaviours, thus continuing the cycle for their own families.

The correlation is so strong that the government is seeking to not only tackle the ACEs happening in the first place, but also educate professionals who work with children to spot those suffering and seek assistance for them - both to buffer against the ACEs and build resilience within them.

This will be multifaceted: health visitors, early years practitioners and teachers, police, fire fighters, doctors and nurses.

If you consider that the death of a woman through domestic abuse costs the government £1.8 million (Home Office statistics), then you can see the financial (let alone moral) worth of investing to prevent it.

Professional support

As professionals who work with children, you will be aware of your requirements to report to social services instances of abuse, for example.

However, many children's problems are long-running and would not necessarily be considered a reportable offence: having a parent with a mental illness, would not (necessarily) be considered a dangerous situation for a child.

However, couple that with the other parent not coping and so self-medicating with prescription pills, and endless abusive arguments between the parents that eventually ends in parental separation, and suddenly you have a child with four ACEs.

These problems are compounded for the child due to the chaos that often surrounds such behaviours: the family budget spent on alcohol rather than food, an over-medicated parent slumped on the sofa instead of reading stories for bedtime, neglect regarding the washing of clothes and bodies, and certainly no energy left for introducing exciting vegetable dishes.

A child could very quickly feel isolated or shunned by peers and so the problems are multiplied.

Constantly alert to danger, a child (and then adult) loses the ability to rationalise the severity of the threat, and so everything can be seen as a problem needing a serious reaction: this makes a child unpopular and someone to be avoided.

Fortunately, there are actions that can buffer a child against the impact of ACEs and build resilience within them. Children who have many interests outside of the home (if it is the home that is affecting them) can lessen the consequences of their ACEs.

It's not only that time spent away from the source of pain and fear lessens the occurrence, but the mind being occupied with pleasurable things can allow the brain respite from the adrenaline and cortisol, and so lessen the cellular changes.

If a child can have at least one available adult who is 'on their side', then they can weather the storm much better.

Therefore, even if there are problems within the home, if at least one parent is maintaining structures, continuity and support, then the impact of ACEs can be reduced.

Some children, sadly, won't have this and their home is a place of fear or chaos. That means that their supportive adults in, for example, their nursery or school, become even more crucial.

What you can do

Assign the identified children a stable key person, rather than likely shorter-term placements. Persist in encouraging and giving the skills for friendships - for those children, no one else may be doing this.

Children with high numbers of ACEs need to be independent much more than their peers will. Singing or engaging in crafts lifts the soul and the ability to spend hours with mates kicking a football around will provide a place for that child to go, so start it young.

Educate parents about ACEs if you can: hand out leaflets from health visitors and be more urgent with the stable relatives of the children who might be suffering.

If Granny understands that the role she needs to play is far greater than expected, then she can be the buffer between the child and the ACEs and make the difference to not only her grandchild, but her future generations.

Alert health visitors if confidentiality allows it, or urge the stable adult to do so. For those children moving up to school, inform teachers of their ACE scores to ensure no break in pressure to build resilience and to get help.

Working with children is always an important job, but for those children who have four or more ACEs, your actions could be making the difference between a future of happiness and a future of chaos.
Lorraine Jenkin is an author who has been involved in childcare for several years.

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How to support children with ACEs in early years settings | A Unique Child | Teach Early Years

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Your actions could make the difference for a child between a future of happiness and a future of chaos, says Lorraine Jenkin... Most people feel anecdotally that people who have had a tough childhood tend to have a tough adulthood: things that happen to us as children shape us - positively and negatively - and affect our future choices and behaviours.

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At own pace.

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2 hours

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10 minutes.

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It is becoming increasingly apparent that large numbers of children in this country are growing up in a high state of distress.

Around one-third of our children are living in poverty according to the Child Poverty Action Group, while the Mental Health Foundation reports that one in 10 of five to 16-year-olds has a diagnosable mental illness.

Studies conducted in England and Wales show that around half of adults suffered one adverse childhood experience (ACE) and around one in 10 endured four or more by the age of 18 (eight per cent in England, 14 per cent in Wales) (Bellis et al, 2014 & 2015).

Such ACEs include neglect, emotional, sexual and physical abuse - often perpetrated by the primary care-giver - and living in a house where there is mental illness, drug and alcohol addiction, domestic violence or parental incarceration. The long-term impact of this adversity - particularly in the very early years when children are at their most vulnerable developmentally - on educational outcomes, physical and mental health, life chances, quality and length of life is shocking. Schools, in particular, should be aware of the extent of the issue and what they can practically do in response.

Trauma is one of the possible outcomes of exposure to adversity. It occurs when a person perceives an event or set of circumstances as extremely frightening, harmful or threatening - either physically, emotionally or both. Some experiences can be so overwhelming for children and young people that it creates a sense of terror and helplessness in the short term, which can be triggered without warning later in life.

Likewise, when children experience adversity that is extreme, severe and long-lasting without adequate support from a care-giving adult, the stress response system (fight, flight or freeze) becomes over-active and recalibrated. This is known as "toxic stress" and it gradually wears the body and brain down over time.

It is a tremendously worrying situation, but fortunately there is increasing evidence and enough success stories out there to show us what needs to be done - and, as is so often the case, school is well placed to make a significant impact and change the trajectories of struggling children's lives.

I am one of the 10 per cent of children who suffered four or more ACEs. At primary school I was violent and unpredictable and at secondary school withdrawn and disengaged. I was angry, hurt, could not see the point of education and I did not trust adults. Why would I - they lie, let you down and cause you pain. No-one had bothered to show me how to express my emotions or to ask for what I needed - so I threw things. I threw books, chairs, desks, even children, and, every time I did, I got the teachers' attention.

Fortunately, thanks to a few perceptive teachers, flexibility in the school system and my welfare being more of a priority than exam results, I turned out okay. They understood what my throwing meant and took the time to build relationships with me, taught me new strategies to deal with my emotions, filled the skills gaps I had, then channelled my strength and anger into throwing javelins instead of furniture.

Somehow, these teachers just got me. I could never sit still and could not relax because I need to release my anxiety regularly. I was permanently hypervigilant, so every new room I walked into I scanned for safety and needed to choose where I sat - it was exhausting, for them and me, but they made the necessary accommodations. School was my safe place - it was the few hours of joy I experienced every day. I dreaded the holidays, evenings and weekends and tried to stay at school for as long as I could.

So now, 30 years after getting out of the frightening environment that I lived in for my first 18, I still deal with the damage done to my physical and mental health, my understanding of people and relationships, my education and my work - every day. If it had not been for those teachers, my life would have been very different and I would not have trained to be a teacher and chosen to work with children like me throughout my career.

All school staff need to understand what it is like to live in the body and life of a child experiencing adversity - but you can never truly understand it if you have not actually lived it. You cannot imagine what it is like never to feel safe and to be hypervigilant all the time. To this day the slightest noise wakes me up in the night, a door slamming activates my stress response system, people arguing and changes to my routine cause me to freeze, and unexpected questions from managers at work impact on my ability to think clearly. Those of us who have experienced adversity do what we must to get ourselves through the day.

However, schools can assist in making life better for these children and can even begin to help them heal. If our education system is supposed to prepare our children for life and give them the tools they need to succeed, we cannot ignore their suffering and must create environments that allow them to learn, flourish and fulfil their potential.

A handful of strategies implemented over a term by a few staff will not work here - there is no low-cost, quick-fix solution. This damage has been done to these children over many years and the current school system is exacerbating their difficulties. Whole school changes to policy and practice - consistently implemented - are the way to address these challenges and research tells us it is the best approach for all children, not just those who are having difficult childhoods.

There is no one-size-fits-all model either - this is complex. Buying in an intervention and training all the staff to use it will not always work - schools, particularly senior leaders, need to truly understand what they are dealing with and proactively take steps to address it, so we help children to thrive rather than just survive.

Yes, it is quicker to buy in, but all schools and contexts are different and while it can be difficult tackling these concepts, making them tangible and implementing them on the ground, it is what needs to be done. Explicit whole-school training, support, strategies and resources are therefore the best approach - this needs to be for all staff, often personalised and on-going. A few sessions can raise awareness but can merely cause frustration for teachers who are on the front-line and work in a system where the policies do not support what needs to be done.

Zero tolerance, punitive behaviour policies are ineffective and there is plenty of research to support this. They especially do not work for children who have had difficult childhoods, as incentive or threat-based strategies are not powerful enough to stop deep-rooted behaviour that has served as protection in the past. Restorative practices are needed to improve and repair relationships between people and communities. Mercifully schools are beginning to replace "discipline" policies with "relationship" polices.

Children experiencing adversity are likely to be a year behind their peers academically by the time they finish year 6. It seems some secondary schools have started to prepare children who are lagging behind from year 7 for GCSEs, but narrowing the curriculum and focusing on the basics for these children is the wrong approach. They need music, art, drama, dance, sport and technology - subjects that are practical with therapeutic qualities that help children regulate, allow them to feel a sense of success, let them express themselves and their creativity, and help to repair some of the damage done to the brain through early adversity.

These children also need the most qualified and experienced staff. Not unqualified teachers, teaching assistants or supply staff - permanent, knowledgeable professionals who understand what has happened to them and the impact it has had on their bodies and minds. Staff who will be there consistently and compassionately, no matter what these children throw at them.

Ultimately, schools need to become ACE-aware, Attachment-aware and trauma-informed to create safe environments for our children, build supportive and trusting relationships with them, teach them the skills to regulate their disregulated bodies so they can begin to manage their emotions and behaviour, and get to a place where they are ready to learn.

Recommended tools that can have a significant impact include:

Continuously maintain an awareness of the impact of ACEs, toxic stress and trauma and strive to ensure that all pupils feel safe, supported and connected.

Maintain a safe, predictable, calm environment that prioritises relationships and consistency.

Show unconditional positive regard to all pupils (and school staff) at all times.

Remember that behaviour is a symptom of the problem, not the problem. Be curious about behaviour - ask "what happened to you?" rather than "what is wrong with you?"

Eliminate stress triggers from the environment - loud voices, abrupt sounds, etc.

Take an interest in the pupils - they need to know you care.

Teach pupils to self-regulate and calm their stress response system.

Listen to the pupils more and talk at them less.

Focus on the positive - communicate pupils' successes to them and their families regularly.

Support the pupils' care-givers and connect with the whole family - it improves the pupils' outcomes.

Follow your instincts - welcome them back after a break.

Take care of yourself - the children need you to be at your best.

Do not take things personally - it is not about you.

Implementing these changes and success with these pupils will be slow and challenging, but the evidence is clear - if we continue as we are many vulnerable children are likely to struggle for the rest of their lives.

Lynn Miles is a lecturer in education at Teesside University, which offers related ACE short courses, whole school CPD and, from September 2019, an MA Education (Trauma Informed Practice).

References

National Household Survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England, Bellis et al, BMC Medicine, 2014.

Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population, Bellis et al, Public Health Wales, 2015.

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Adverse childhood experiences and the implications for schools

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Half of children will live through an adverse childhood experience and around one in 10 will suffer four or more. How can schools support these young people? Lynn Miles, who suffered ACEs herself, explains more and offers her advice

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Supporting Autistic Children in the Classroom | National Autistic Society | Twinkl - Bing video

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Supporting Autistic Children in the Classroom | National Autistic Society | Twinkl

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Teaching students who have suffered complex trauma.

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Teaching students who have suffered complex trauma.

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At own pace.

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This course has been certified by the CPD Certification Service as conforming to continuing professional development principles. Find out more.

Learn how to support students who have experienced complex trauma

Complex trauma affects the physical, emotional and social development of children and adolescents.

In order to minimise harm, teachers and school leaders need to respond appropriately using trauma-informed practices and policies.

In this course, you'll get an introduction to what complex trauma is and how it affects young people's development at school.

You'll understand the neuroscience behind the behaviours presented by students who have experienced complex trauma.

You'll learn how to apply trauma-informed strategies and policies that will minimise the risk to students and school staff.

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What topics will you cover?

Attachment and trauma theories

The neuroscience behind the behaviours presented by students who have experienced complex trauma

The impact on those who support students who have experienced complex trauma

Strategies for minimising the risk to students in classrooms and schools

The importance of applying trauma-informed practice and programs in schools

Who is this accredited by?

The CPD Certification Service:

The CPD Certification Service was established in 1996 and is the leading independent CPD accreditation institution operating across industry sectors to complement the CPD policies of professional and academic bodies.

Learning on this course

On every step of the course you can meet other learners, share your ideas and join in with active discussions in the comments.

What will you achieve?

By the end of the course, you'll be able to...

Describe what complex trauma is and how it affects children's and adolescents' development

Describe the neurobiological impact of complex trauma on children's and adolescents' behaviours at school

Identify trauma-informed practices that could minimise risk to school students who have experienced complex trauma

Who is the course for?

This course is designed for teaching staff and education leaders who want to improve their professional practice. It may also be of interest to health and social care workers.

For Australian educators, this course aligns with the following Australian Professional Standards for Teachers (APST):
* 1.1, 1.2, 1.5
* 3.3, 3.5
* 4.1, 4.3, 4.4
* 6

Learning on FutureLearn

Your learning, your rules

Courses are split into weeks, activities, and steps to help you keep track of your learning

Learn through a mix of bite-sized videos, long- and short-form articles, audio, and practical activities

Stay motivated by using the Progress page to keep track of your step completion and assessment scores

Join a global classroom

Experience the power of social learning, and get inspired by an international network of learners

Share ideas with your peers and course educators on every step of the course

Join the conversation by reading, @ing, liking, bookmarking, and replying to comments from others

Map your progress

As you work through the course, use notifications and the Progress page to guide your learning

Whenever you're ready, mark each step as complete, you're in control

Complete 90% of course steps and all of the assessments to earn your certificate

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Teaching Students with Complex Trauma - Online Course

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Get an introduction to what complex trauma is, how it affects children and adolescents, with this course from Queensland University of Technology.

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12 hours at your own pace

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The new MOOC will help parents and carers of children with autism.

A new massive, open, online course (MOOC) designed and delivered by psychologists at the University of Bath launches this week for Autism Awareness Week, aiming to help parents and teachers of children on the autism spectrum.

The free course, 'Good Practice in Autism Education' which is offered by academics in the University's Centre for Applied Autism Research, is conducted online over four-weeks.

It is designed to give parents, carers and teachers more information on educational requirements of children on the autism spectrum, to reflect on what constitutes good practice in autism education settings, and to compare specific examples of good practice in autism education.

In view of the current situation many parents now find themselves in, home-schooling children, the researchers behind the MOOC hope it can give parents with autistic children practical tips on getting through the next few months and beyond.

Director of the Centre for Applied Autism Research, Professor Mark Brosnan, explained: "The course has been designed to be accessible to the whole autism community. As well as a wide range of useful information and resources, there are discussion forums for parents and teachers to share their experiences with each other.

"In light of recent events, the course starts with top tips and a discussion around supporting children on the autism spectrum's learning at home".

Over four-weeks, participants will learn more about autism and intellectual disabilities, developing an inclusive curriculum and good practice in autism education. It will also provide an opportunity to share good practice with other learners.

You can access and sign up for the free, online course, which starts on Monday 30 March, via https://www.futurelearn.com/courses/autism-education. There are no prior educational requirements.

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University of Bath launches free online autism course to help parents and teachers

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A new massive, open, online course (MOOC) designed and delivered by psychologists at the University of Bath launches this week for Autism Awareness Week, aiming to help parents and teachers of children on the autism spectrum. The free course, 'Good Practice in Autism Education' which is offered by academics in the University's Centre for Applied Autism Research, is conducted online over four-weeks.

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5 minutes.

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20 mins

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At own pace.

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*Speech, language and communication needs 

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*Speech, language and communication needs 

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20 hours of study

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©1999-2023. All rights reserved. The Open University is incorporated by Royal Charter (RC 000391), an exempt charity in England & Wales and a charity registered in Scotland (SC 038302). The Open University is authorised and regulated by the Financial Conduct Authority in relation to its secondary activity of credit broking.

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3 minutes.

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8 minutes

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Speech and Language Top Tips – Solihull Children's Community Therapies (uhb.nhs.uk)

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*General section about Social, Emotional & Mental Health needs

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*General section about Social, Emotional & Mental Health needs

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1 hour

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Free online sensory processing course for teachers, assistants and parents

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GriffinOT's free sensory course gives an introduction to the senses and sensory processing. It helps educators and parents to understand sensory behaviours.

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15 minutes

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What is Dyslexia? - The Dyslexia Association

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Dyslexia is a learning difficulty that primarily affects the skills involved in accurate and fluent word reading and spelling. Characteristic features of dyslexia are difficulties in phonological awareness, verbal memory and verbal processing speed. Dyslexia occurs across the range of intellectual abilities. It is best thought of as a continuum, not a distinct category, and there are no clear cut-off points. Co-occurring difficulties may be seen in aspects of language, motor coordination, mental calculation, concentration and personal organisation, but these are not, by themselves, markers of dyslexia. A good indication of the severity and persistence of dyslexic difficulties can be gained by examining how the individual responds or has responded to well-founded intervention.

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Dyscalculia: An Overview – Smart Kids (smartkidswithld.org)

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Dyscalculia is a specific learning disability that impacts the ability to perform and make sense of mathematics. A life-long developmental disorder present from birth, dyscalculia is much more than a dislike of math: it is a difference in how the brain processes math. While many children may find math demanding or boring, for those with dyscalculia, learning math is overwhelming, confusing, frustrating, and painful.

Is This Your Child?

The hallmark of dyscalculia is a persistent inability to retrieve arithmetic facts from memory. Kids with dyscalculia find it difficult to acquire basic mathematical concepts and to understand and process math-related tasks - from counting, calculating, and memorizing to reasoning mathematically. They may not understand quantities or concepts such as bigger or smaller/biggest or smallest; they may fail to understand that the numeral 5 is the same as the word five.

Dyscalculia often co-exists with other disabilities, such as developmental dyslexia or ADHD. When a child with dyscalculia has dyslexia or ADHD, it becomes even more grueling for her to focus on mathematical formulas or to attempt complex multi-step problems that require a strong working memory.

There is no specific blood test or brain imaging procedure for detecting dyscalculia. However, risk factors can be identified early in a child's life, long before she learns-or fails at-arithmetic.

Diagnosing Dyscalculia

If you suspect your child has symptoms of dyscalculia, speak with your child's teacher about how she is doing in math compared with her peers. Ask your child's school to conduct a formal evaluation, or get a referral from your primary-care physician for an independent psycho-educational evaluation.

If your child is diagnosed with dyscalculia, the evaluator will include her specific learning difficulties (e.g., fractions, long division, geometry, etc.).

Addressing Dyscalculia

While there is no cure or medication for dyscalculia, identifying signs early will help your child dramatically. Long-term, the goal is for your child to develop the calculation and reasoning skills necessary to solve math problems successfully.

Based on the assessment, a learning specialist will develop a plan to target your child's individual needs, help her build core readiness skills and connections between different concepts, and assist her in developing strategies she can implement throughout her life.

If your child has an Individualized Education Program (IEP) or a Section 504 Plan, schools must provide appropriate accommodations and modifications for students struggling with dyscalculia. Intervention options include:

Extra time on tests

Frequent classwork checks

Step-by-step instructions for multi-step problems

Sample problems on the board and in a reference notebook

Calculators

Straightforward reference charts, diagrams or three-dimensional representations

Uncluttered, easy-to-read worksheets

Fewer assigned problems to assess understanding

This article is based on ADDitude Magazine's webinar, Understanding Dyscalculia: How to Recognize & Address Math Learning Disabilities, given by Daniel Ansari, PhD; and articles about dyscalculia, by Devon Frye, in ADDitude Magazine. Eve Kessler, Esq., a criminal appellate attorney with The Legal Aid Society, NYC, is co-founder of SPED*NET, Special Education Network of Wilton (CT) and a Contributing Editor for Smart Kids with Learning Disabilities.

Related Smart Kids Topics

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Dyscalculia is a specific learning disability that impacts the ability to perform and make sense of mathematics. A life-long developmental disorder present from birth, dyscalculia is much more than a dislike of math: it is a difference in how the brain processes math.

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35 minutes.

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Webinar:  Supporting girls & young women with Aspergers & Autism in mainstream educational settings

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6 hours

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This free course, Attachment in the early years, covers theory and research in the area of attachment in early childhood. In the 1950s, John Bowlby was the first person to develop a theory about ...

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Foetal Alcohol Spectrum Disorders (FASDs) and Children With Disabilities – Redbridge Safeguarding Children Partnership (redbridgescp.org.uk)

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Introduction

One of the causes of physical disabilities and learning disabilities in children is Foetal Alcohol Sydrome (FAS). This is a pattern of disabilities that can develop in a baby as it grows in the womb. It happens because the pregnant mother drinks alcohol. FAS is one of a group of conditions. The whole group is called foetal alcohol spectrum disorders (FASDs). Other conditions within this range are:

Alcohol-related birth defects (ARBDs)

Partial foetal alcohol syndrome (pFAS)

Alcohol-related neuro-developmental disorder (ARND)

Babies born with FAS have a set group of symptoms. These can include different shapes to their faces, restricted development and some mental difficulties. People with the other conditions in the spectrum may not have this exact match of problems. They have some of them, or other problems because of alcohol consumed before their birth.

A baby in the womb (foetus) gets all its nourishment from its mother's bloodstream. Alcohol in the mother's blood can pass through the placenta to the baby's blood. So if a pregnant mother drinks alcohol, it passes through the baby too. Alcohol is a toxic substance, so it can poison the developing foetus. In the nine months in the womb, the baby develops and forms. Poisons in the blood can damage the baby. The damage depends on which part is developing at that time. The brain is continually forming, so it can be damaged at any stage of pregnancy. In the first three months the organs are developing. So, this is the time when the heart, eyes, and kidneys might be harmed. Later, when the foetus is growing fast, alcohol can slow this down.

FAS and FASD only occur in babies born to mothers who drink alcohol during pregnancy. It is not known exactly how much alcohol is safe in pregnancy but heavy drinking and binge drinking are more likely to cause damage to the baby. Not every mother who drinks heavily in pregnancy has a baby with FAS. So there seem to be other factors that make it more likely to happen. These may include genetics, mother's general health and diet, stress, mother's age and whether the mother smokes or not.

FAS is entirely preventable. Women should be advised that if they are pregnant or planning a pregnancy that they shouldn't drink alcohol. It is not known exactly how much alcohol it is safe to drink in pregnancy so it is safest not to drink any at all. However, there is no definite evidence that small amounts of alcohol cause harm. National Institute for Health and Care Excellence (NICE) guidelines in the UK advise that if you are pregnant, do not drink at all if possible.

In the UK nobody is sure exactly how common FAS is. This is because it is difficult to diagnose. Also, there is no system for reporting it. It is known, however, that FAS is one of the most common reasons for children to have mental or behavioural problems.

FAS has three classic groups of abnormality:

(a) Differences in face shape including:

A small head.

The groove between the nose and lip is flattened.

A thin upper lip.

A flat bridge of the nose, which tends to be short and upturned.

Drooping eyelids (ptosis).

A 'railroad track' shape to the outer part of the ears.

Small eyes that are closer together.

Skin folds of the upper eyelids (epicanthic folds).

(b) Developmental delay with small size and low weight, with children growing up to be shorter than average adults.

(c) Mental and behavioural difficulties

These happen because alcohol damages the brain as it forms. They can include:

Lower-than-average IQ.

Hyperactivity.

Difficulty with paying attention.

Memory problems.

Difficulty with seeing the consequences of one's own actions.

Poor judgement.

Impulsive behaviour and not being able to control impulses.

Poor problem-solving skills.

Difficulty understanding things like time, money, and maths.

Difficulty getting on with other people, immature behaviour, aggressive behaviour.

Speech and language delay.

Problems sucking and feeding in the newborn (and sometimes symptoms of alcohol withdrawal).

There may also be some of the other problems from the whole range of FASD. These include:

Poor hearing or vision.

Abnormalities of the valves of the heart.

Kidney problems or genital abnormalities.

Bone and joint problems.

There is no test for FAS. It can only be diagnosed by spotting the typical features. Also by suspecting or knowing the mother may have drunk alcohol during pregnancy. Tests might be done to check there is no other reason for the abnormalities. Diagnosis can only be undertaken by a trained medical practitioner. FAS may not be detected at birth but can become apparent later in life and carries lifelong implications.

There is no particular treatment. Babies with FAS and FASD will have the problems for the rest of their lives. However, if the condition is picked up early, they will suffer the effects less. They can be helped and understood.

There is no cure for FAS so babies born with it will be affected throughout their lives and may experience a wide range of difficulties in relation to education, socialising, and behavioural difficulties. Getting the diagnosis of FAS right is good for the child. If it is known what is wrong with them, they can be helped. If the diagnosis is made early they can access special help. They will have fewer problems if they are in a loving and understanding family. All different agencies working with children and families, including health, social care, schools etc. can help children and adults with FAS.

Further Guidance

Further information and guidance on FAS can be found on the following websites:

The NSPCC has published a report All Babies Count: Spotlight on Drugs and Alcohol which includes research into FAS and is useful reading for practitioners. Also, the All Party Parliamentary Group for FASD published a report in December 2015 on the picture of FASD in the UK and other related documents.

There are support groups with provide guidance, help and support to families affected by FAS.

Community Care published an article on FASDs in September 2016.

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One of the causes of physical disabilities and learning disabilities in children is Foetal Alcohol Sydrome (FAS). This is a pattern of disabilities that can develop in a baby as it grows in the womb. It happens because the pregnant mother drinks alcohol. FAS is one of a group of conditions.

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60 minutes

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Speech and Language UK: Changing young lives

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Difficulties with speech sounds can include:

Muscles used to create different sounds. This can be due to muscle weakness and may be linked to conditions such as cerebral palsy.

Sending messages from the brain to make different speech sounds. This may sometimes be described as 'dyspraxia'.

Learning and using different sounds to make words. This can be called 'phonological difficulties'.

Phonological difficulties

Some children have difficulty in learning and using sounds in the right places for words.

Usually, most children will be using a full range of speech sounds by the time they are 5 years-old. Some children, however, will have difficulty in developing these skills. Primary-aged children may be experiencing difficulties if they:

Only use a small number of sounds.

Are swapping one sound for another e.g saying 'tat' instead of 'cat'.

Are missing the ends off words.

Have difficulty with vowel sounds e.g. saying 'poor' instead of 'pear' or 'pot' instead of 'pat'.

Have difficulty with long or complicated words like 'banana' or 'aeroplane'.

Good sound skills are needed when learning to talk. They are also important for developing reading and spelling.

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Difficulties with speech sounds can include: Muscles used to create different sounds. This can be due to muscle weakness and may be linked to conditions such as cerebral palsy. Sending messages from the brain to make different speech sounds. This may sometimes be described as 'dyspraxia'. Learning and using different sounds to make words.

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Wellbeing For Children: Confidence And Self-Esteem - Bing video

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Wellbeing For Children: Confidence And Self-Esteem

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Sensory processing, co-ordination and attachment 

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Sensory processing, co-ordination and attachment 

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Developmental Language Disorder - ACAMH

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ACAMH uses cookies in order to deliver a personalised, responsive service and to improve the site.

About the Author

Professor Courtenay Norbury is Professor of Developmental Disorders of Language and Communication at Psychology and Language Sciences, University College London. She is the Director of the Literacy, Language and Communication (LiLaC) Lab and a Fellow of the Royal College of Speech and Language Therapists.

She obtained her PhD in Experimental Psychology at the University of Oxford, working with Professor Dorothy Bishop on the overlapping language profiles that characterise autism spectrum disorder and 'specific' language impairment. Professor Norbury's current research focuses on language disorders and how language interacts with other aspects of development. She is leading SCALES, a population study of language development and disorder from school entry. She is also a founding member of the RADLD campaign.

Developmental Language Disorders (DLD)

Developmental language disorder (DLD) is diagnosed when a child's language skills are persistently below the level expected for the child's age. In DLD, language deficits occur in the absence of a known biomedical condition, such as autism spectrum disorder or Down syndrome, and interfere with the child's ability to communicate effectively with other people. Expressive language is characterised by non-specific words and short simple sentences to express meanings beyond the age at which children may be using more complex language. For example, when typical children can say 'that boy cuts shapes out paper with sharp scissors', the child with DLD might say 'him doing cuts' to express the same idea. Though such limitations of expressive language are readily apparent, for many children, understanding of language (receptive language) is also a challenge. Language disorders emerge in early childhood, have a significant impact on everyday social interactions or educational progress, and persist throughout the school years and into adulthood.

Aspects of language may be variably impaired and include:

Phonology (speech sounds)

Semantics (vocabulary)

Syntax (grammar) and morphology (endings on words that express grammatical relationships, like past tense -ed in English)

Discourse (narrative, conversation)

Pragmatics (social communication, inferencing, figurative language)

The exact cause of DLD is not known, but it is likely that there are several interacting genetic and environmental factors, rather than one single identifiable cause.

Behavioural interventions are the most common approach to treating DLD. Such interventions are typically carried out by speech-language therapists, though in some instances therapy may be delivered by parents or education staff under the supervision of the speech-language therapist. These interventions can significantly enhance a child's ability to communicate and can increase competence in specific areas of language, but, as yet, there is no cure for DLD.

Introduction

The terminology for children's language problems has been extremely variable and confusing, with many different labels being used by different professional groups (D. V. M. Bishop, 2017). In the UK, education services include DLD under the umbrella term SLCN, or speech, language and communication needs. In research, 'specific language impairment' or SLI was the term most commonly used, but there has been growing recognition that language is rarely selectively impaired and considerable controversy about the use of non-verbal IQ scores in diagnosis and treatment decisions. For example, children with non-verbal IQ scores below 85 are frequently excluded from research studies (Reilly et al., 2014) and denied access to specialist clinical services (Dockrell, Lindsay, Letchford, & Mackie, 2006).

The lack of consistency in terminology has been directly linked to poor public awareness of DLD (D.V.M. Bishop, 2010). To address this issue, the CATALISE consortium recently undertook a Delphi exercise to achieve consensus on diagnostic terms and criteria (D. V. M. Bishop, Snowling, Thompson, Greenhalgh, & and the, 2017). This cross-disciplinary panel of experts recommended the term Developmental Language Disorder, to denote a problem with language that stems from atypical developmental processes (as opposed to acquired brain damage, as in stroke or head injury) and to convey the serious nature and potential long term consequences of language deficits. DLD includes SLI, but allows for more variable non-verbal cognitive abilities. Including 'disorder' in the diagnostic label also provides consistency with other neurodevelopmental conditions such as 'autism spectrum disorder' or 'attention deficit hyperactivity disorder'.

Language is a multi-faceted system and it is likely that children will show variable patterns of skill and deficit. Efforts to identify sub-types of language disorder have generally not been successful and many large scale studies report that assessments of different language domains tend to load on a common language factor (Tomblin & Zhang, 2006). The current recommendation is that clinicians outline the particular child's profile of strength and deficit, recognising that this profile may change over time.

Phonology/speech sounds: Phonology is concerned with the rules that govern how sounds are combined together in words. Children with phonological deficits may fail to distinguish between certain speech sounds, such as 't' and 'k', so that 'cat' is produced as 'tat'. While these sorts of phonological errors are common in typically developing toddlers, some error patterns are atypical (e.g. replacing 't' with 'k' so that 'cat' becomes 'kak'), and most errors resolve by the time children are 4-5 years old (Bowen, 2015). Persistent phonological deficits may reduce intelligibility of speech and difficulties identifying and manipulating speech sounds within words (phonological awareness) is associated with difficulties learning to read.

Grammar/syntax: Grammar refers to the rules that govern how to combine words into sentences (syntax) and how to combine parts of words together such as adding grammatical endings to verbs like -ing or -ed (morphology). Grammar is often a disproportionate area of deficit for children with DLD. For instance, a child with DLD may say 'him walk to school', instead of 'he walked to school with his friends yesterday'. Comprehension of sentences can also be affected, especially when word order does not convey who did what to whom. For instance, there may be difficulty understanding sentences like 'the boy was chased by the girl' as children with DLD may interpret this as the boy doing the chasing.

Semantics: Semantics refers to children's ability to understand the meaning of words and how words are related to one another. Children with DLD often have difficulties learning new words. They may therefore have limited vocabularies and the words they do know may not have the same depth of understanding seen in children with typical language development (McGregor, Oleson, Bahnsen, & Duff, 2013).

Discourse and Pragmatics: Discourse refers to longer stretches of connected language, like conversation and narrative. Children with DLD very often have deficits in narrative (i.e. telling a story in a logical, coherent sequence) (Gillam et al., 2018) and may find it difficult to maintain the thread of conversation. Pragmatics refers to the appropriate use of language in social contexts. Pragmatic deficits may manifest as poor at turn-taking in conversation, maintaining the topic of conversation, or being able to repair conversations that breakdown by asking for clarification. Pragmatics may also refer to the comprehension and use of linguistic forms that rely on context to disambiguate meaning, for example, non-literal language like metaphors and idioms, or making an inference (Adams, 2002).

Prevalence

Prevalence estimates of DLD may vary depending on the severity criteria for language, and whether or not non-verbal ability is used as an exclusion criterion. The most recent UK population study (Norbury et al., 2016) yielded a prevalence estimate at age 5-6 years of 7.58%, equivalent to two children in every Year 1 class. An additional 2.34% of children met criteria for language disorder, but also had intellectual disability and/or another known biomedical condition, such as autism or Down syndrome. The functional impact of DLD was evident in that only 12% of children identified as having DLD met early curriculum targets.

While clinical reports suggest more boys are affected, epidemiological studies have not identified sex differences in prevalence (Norbury et al., 2016; Tomblin et al., 1997). This suggests that girls may be under-identified in community settings.

DLD rarely occurs in isolation and children with DLD are at increased risk for a range of co-occurring conditions including:

Attention deficit hyperactivity disorder (ADHD)

Motor deficit (e.g. Developmental Co-ordination Disorder)

Reading disorders (including both dyslexia and reading comprehension deficits)

Speech sound disorders

Social, emotional, and behaviour problems

In adolescence, children with a history of DLD are twice as likely as peers without language disorder to experience internalising, externalising, and ADHD-type psychopathologies (Yew & O'Kearney, 2013) and approximately 1/3 of adolescents referred to tertiary child and adolescent mental health services have previously unidentified language disorder (Cohen et al., 1998).

From school entry DLD is persistent and characterised by parallel rates of language growth relative to peers (Law, Tomblin, & Zhang, 2008; Norbury et al., 2017). As a consequence, there is currently little evidence that children with DLD are able to narrow the language gap with typically developing peers. Young people with DLD are therefore more likely to leave school with fewer academic qualifications (Snowling, Adams, Bishop, & Stothard, 2001) , and may experience on-going problems with employment, intimate relationships, and mental health (Conti-Ramsden, Durkin, Toseeb, Botting, & Pickles, 2018; Johnson, Beitchman, & Brownlie, 2010).

What we already know

Causes

A common perception in the general public is that DLD results from poor parenting and a lack of appropriate language input during development. While there are social gradients in language, such that DLD is more common in areas of socio-economic disadvantage (Law, Charlton, Dockrell, Gascoigne, McKean, & Theakston, 2017), it is in fact a much more complicated picture.

There is strong consensus that DLD is heavily influenced by genetic factors (D. V. M. Bishop, 2006). This evidence comes from twin studies, in which two twins are growing up together in the same household. These studies capitalise on the fact that there are two different kinds of twins; identical twins, who share the same genes, and non-identical (fraternal) twins who are genetically different. The question twin studies try to answer is 'how similar are twins on measures of language?' As all twins are exposed to the same home environment, differences in the strength of similarity between identical and fraternal twins is suggestive of genetic influence. Numerous studies have shown that while non-identical twins may differ radically in their language skills, identical twins tend to be much more similar in language ability. Of course, there can be some variation in the severity and persistence of DLD in identical twins, indicating that non-genetic factors (such as chance experiences, differences in school or peer experiences, illness, etc.) affect the course of disorder, but it is unusual to find a child with DLD who has an identical twin with typical language.

The recognition that genetic factors play a role also informs us about environmental circumstances. Many children with DLD will grow up to be adults with DLD. They will likely have lower levels of literacy and educational attainment (Snowling et al. 2001) and this may result in fewer opportunities to obtain high paying jobs (Conti-Ramsden et al. 2018; Johnson et al. 2010). Reading books to children or verbal communication may not come naturally to some parents of children with DLD. Thus, although there is considerable evidence that DLD is more common in children from socio-economically disadvantaged backgrounds, but this likely reflects both genetic and environmental vulnerabilities (D. V. Bishop, 2014).

Just because genetic factors are important does not mean that we are powerless to intervene. Parent language input and conversation, education, and specialist language interventions can all make meaningful improvements to children's language and communication skills.

Diagnosis and assessment

Longitudinal studies consistently demonstrate stability in language status from school entry, with greater instability when children are identified in the pre-school years (Bornstein, Hahn, & Putnick, 2016; McKean et al., 2017). More specifically, about 40% of children identified with language delay by age 4 have spontaneously resolved by school entry (D. V. Bishop & Edmundson, 1987). Early language skills predict small amounts of variance in later language ability (Duff, Reen, Plunkett, & Nation, 2015) and therefore universal screening is not recommended as it is not reliable enough and identifies too many false positives (D. V. Bishop, Snowling, Thompson, Greenhalgh, & consortium, 2016).

Consideration of multiple risk factors may improve identification (Christensen, Taylor, & Zubrick, 2017). Risk factors associated with persistent DLD include:

Family history of language or literacy deficits

Socio-economic disadvantage

Poor maternal education

Lower non-verbal cognitive abilities

Early developmental delays

DLD in the classroom may be difficult to notice if the child is quiet and able to follow the actions of other children in the classroom, without truly understanding the language or instructions. Teachers are more likely to notice obvious speech problems and/or behaviour difficulties, difficulties learning core curriculum content, and problems with learning how to read. Children presenting with such difficulties in the classroom should be referred for a language assessment.

Speech-language therapists are the primary professionals charged with assessment and diagnosis of DLD in the UK, though a multi-disciplinary team may be required for differential diagnosis of an associated biomedical condition. Associated conditions may include:

autism spectrum disorder (ASD)

sensori-neural hearing loss

neurodegenerative conditions

brain injury

acquired epileptic aphasia in childhood

genetic conditions such as Down syndrome

cerebral palsy

intellectual disability

Diagnosis of DLD requires the following:

The child has significant language deficits relative to age expectations that create obstacles to communication or learning in everyday life,

The child's language problems are persistent and unlikely to resolve by five years of age,

The problems are not associated with a known biomedical condition, as listed above

Diagnosis will involve parent/carer interview of family history, observation of the child's language and communication strategies in everyday contexts, and direct assessment of language skills using standardised assessment. Tomblin (Tomblin et al., 1997) proposed that assessment focus on the EpiSLI criterion: five composite scores representing performance in three domains of language (vocabulary, grammar, and narration) and two modalities (comprehension and production); clinicians may rely more heavily on omnibus tests of language, and measures of narrative ability have been shown to have good prognostic ability (D. V. Bishop & Edmundson, 1987). Cut-off scores on these measures are arbitrary, though typically children scoring in the lowest 7-10% on two or more composite scores are identified as having DLD. Test scores should always be considered in relation to functional impact (i.e. how language is impacting on school, social relationships, and self-esteem) in the diagnostic process.

Treatment

Currently, treatment for DLD is variable and many common approaches lack a sound evidence base. Service delivery may be focused on 'tiers' or 'levels' of intervention, including Universal approaches designed to benefit all children (e.g. specific training packages for education staff focused on enhancing language development), Targeted interventions that may be aimed at children with less severe deficits and carried out by non-specialist providers, and Specialist services in which SLTs provide direct and/or individualised treatments to children with the most-significant needs (Ebbels, McCartney, Slonims, Dockrell, & Norbury, 2018).

Large scale, high-quality randomised controlled trials are still relatively uncommon in the field and this makes it difficult to assess clinical efficacy (see Law, Dennis, Charlton, 2017, Cochrane Review protocol for overview). Children's language will improve over time, and without controlled studies, it can be hard to know how much of observed change is down to a specific treatment approach (cf. (Wake et al., 2011). In general, trials show significant, positive treatment effects for direct interventions with specific language targets including vocabulary, expressive grammar, and some elements of narrative and discourse (see Ebbels et al. 2018 for a summary). Receptive language skills appear much more resistant to treatment. Large scale studies of targeted language interventions show more variable outcomes (Bleses et al., 2017) and at best, modest treatment effects (Burgoyne, Gardner, Whiteley, Snowling, & Hulme, 2017; Fricke et al., 2017). Available evidence suggests that interventions in which education staff are asked to be the main delivery agents of SLT intervention, without on-going monitoring and support from specialist services (i.e. the "consultative" approach) are not effective (McCartney, Boyle, Ellis, Bannatyne, & Turnbull, 2011).

The take home message seems to be that children with DLD can learn aspects of language that they are specifically taught, but this learning rarely generalises to other aspects of language or other academic/developmental skills. In addition, changing a language trajectory remains challenging and is likely to take considerable time and on-going effort.

Areas of uncertainty

Despite recent advances in understanding the biological basis of DLD, we are still a long way from understanding how various genetic risk factors influence brain development, how differences in brain development affect learning, and why these differences would have disproportionate effects on language learning (Krishnan, Watkins, & Bishop, 2016). Nor do we fully understand how genetic and environmental influences interact to yield the heterogeneous profile of DLD that we see.

We don't know whether or how language disorders could be prevented, in part because early assessment of language is less reliable and therefore not strongly predictive of later language ability (Bornstein & Putnick, 2012). Many practitioners and policy makers advocate for early intervention, but a large percentage of young children will make significant language improvement without intervention. Prioritising the under-5s could therefore result in treating large numbers of typically developing children and divert precious therapy resources from children with persistent language learning needs (Norbury, 2015). On the other hand, resolving language disorder after the age of 4 is challenging. We need to know if there is an optimal age to intervene, and whether there may be periods later in development when intensive intervention may be particularly beneficial.

We know that children with DLD are at increased risk for poor social, emotional, and behavioural outcomes. We don't understand the mechanisms that underpin this risk but school failure (Tomblin, Zhang, Buckwalter, & Catts, 2000), variable education provisions (Bao, Brownlie, & Beitchman, 2016), poor peer negotiating skills (Im-Bolter, Cohen, & Farnia, 2013) and poor emotion recognition/regulation (Salmon, O'Kearney, Reese, & Fortune, 2016) are all potential candidates. Given the large numbers of children with DLD presenting to CAMHS services, we urgently need to know how children with DLD access 'talking therapies' and what modifications to standard psychological treatments are required to ensure maximum benefit for children with DLD and their families.

Our intervention evidence base is improving all the time, but we are still a long way from understanding what kinds of interventions work best, when, and for whom. In general, short periods of intervention may be sufficient to teach new vocabulary or grammatical forms (Ebbels, van der Lely, & Dockrell, 2007), but making significant improvements to a child's overall language function is likely to take considerable time and sustained input (McCartney, 2017). We do not know the impact of common co-occurring conditions, such as general cognitive deficits, attention deficits, motor deficits, on response to treatment, or whether improvements in language functioning generalise to other aspects of development (e.g. improved social skills, behaviour, academic attainment).

Providing the dosage necessary to make significant change in language proficiency remains an on-going challenge given limited therapeutic resources. Robust studies of on-line or computerised interventions for language are almost non-existent and urgently needed to evaluate whether such approaches could supplement face-to-face interventions.

What's in the pipeline?

Previously, brain imaging studies of DLD have focused on the integrity of left hemisphere language regions in the developing brain. More recently, researchers have focused on neural circuits involved in learning and memory, particularly circuits involved in learning motor sequences and statistical regularities in language input (Krishnan, Watkins & Bishop, 2016). Such studies could elucidate how interventions might circumvent language learning obstacles, either by increasing input, or providing more explicit cues to learning.

Many children with DLD are not referred to clinical services, or may wait a long time for speech-language therapy assessment. While speech-language therapists have traditionally been employed by the NHS, more and more education services are buying therapy time directly. Therapists working in collaboration with education staff may facilitate more direct links between the child's language needs and how these impact social and academic demands of the classroom.

There is increasing recognition that children with DLD grow up to be adults with considerable language needs. To date there has been little research on this population and few, if any, services to support them. Researchers and stakeholders are now exploring ways to identify these adults and what they require in terms of skills development, employment, and mental health.

Useful resources and websites

Afasic: Parent-focused charity for families of children with DLD.

The Communication Trust: The What Works database is a searchable database of commonly used intervention programmes and a rating of the quality of evidence available for that programme.

ICAN: Communication charity providing information and support to the children's workforce
Royal College of Speech Language Therapists
speechBITE: Australian database curating published trials of intervention and treatment efficacy searchable by language domain

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McGregor, K. K., Oleson, J., Bahnsen, A., & Duff, D. (2013). Children with developmental language impairment have vocabulary deficits characterized by limited breadth and depth. Int J Lang Commun Disord, 48(3), 307-319. doi:10.1111/1460-6984.12008

McKean, C., Wraith, D., Eadie, P., Cook, F., Mensah, F., & Reilly, S. (2017). Subgroups in language trajectories from 4 to 11 years: the nature and predictors of stable, improving and decreasing language trajectory groups. J Child Psychol Psychiatry, 58(10), 1081-1091. doi:10.1111/jcpp.12790

Norbury, C. F. (2015). Editorial: Early intervention in response to language delays-is there a danger of putting too many eggs in the wrong basket? J Child Psychol Psychiatry, 56(8), 835-836. doi:10.1111/jcpp.12446

Norbury, C. F., Gooch, D., Wray, C., Baird, G., Charman, T., Simonoff, E., . . . Pickles, A. (2016). The impact of nonverbal ability on prevalence and clinical presentation of language disorder: evidence from a population study. J Child Psychol Psychiatry, 57(11), 1247-1257. doi:10.1111/jcpp.12573

Norbury, C. F., Vamvakas, G., Gooch, D., Baird, G., Charman, T., Simonoff, E., & Pickles, A. (2017). Language growth in children with heterogeneous language disorders: a population study. J Child Psychol Psychiatry, 58(10), 1092-1105. doi:10.1111/jcpp.12793

Reilly, S., Tomblin, B., Law, J., McKean, C., Mensah, F. K., Morgan, A., . . . Wake, M. (2014). Specific language impairment: a convenient label for whom? Int J Lang Commun Disord, 49(4), 416-451. doi:10.1111/1460-6984.12102

Salmon, K., O'Kearney, R., Reese, E., & Fortune, C. A. (2016). The Role of Language Skill in Child Psychopathology: Implications for Intervention in the Early Years. Clin Child Fam Psychol Rev, 19(4), 352-367. doi:10.1007/s10567-016-0214-1

Snowling, M. J., Adams, J. W., Bishop, D. V., & Stothard, S. E. (2001). Educational attainments of school leavers with a preschool history of speech-language impairments. Int J Lang Commun Disord, 36(2), 173-183.

Tomblin, J. B., Records, N. L., Buckwalter, P., Zhang, X., Smith, E., & O'Brien, M. (1997). Prevalence of specific language impairment in kindergarten children. J Speech Lang Hear Res, 40(6), 1245-1260.

Tomblin, J. B., & Zhang, X. (2006). The dimensionality of language ability in school-age children. J Speech Lang Hear Res, 49(6), 1193-1208. doi:10.1044/1092-4388(2006/086)

Tomblin, J. B., Zhang, X., Buckwalter, P., & Catts, H. (2000). The association of reading disability, behavioral disorders, and language impairment among second-grade children. J Child Psychol Psychiatry, 41(4), 473-482.

Wake, M., Tobin, S., Girolametto, L., Ukoumunne, O. C., Gold, L., Levickis, P., . . . Reilly, S. (2011). Outcomes of population based language promotion for slow to talk toddlers at ages 2 and 3 years: Let's Learn Language cluster randomised controlled trial. BMJ, 343, d4741. doi: 10.1136/bmj.d4741

Yew, S. G. K., & O'Kearney, R. (2013). Emotional and behavioural outcomes later in childhood and adolescence for children with specific language impairments: meta-analyses of controlled prospective studies. Journal of Child Psychology and Psychiatry, 54, 516-524. . doi: 10.1111/jcpp.12009

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DLD - Developmental Language Disorder - ACAMH

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Developmental language disorder (DLD) is diagnosed when a child's language skills are persistently below the level expected for the child's age. In DLD, language deficits occur in the absence of a known biomedical condition, such as autism spectrum disorder or Down syndrome, and interfere with the child's ability to communicate effectively with other people.

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What Is ADHD? Meaning, Symptoms & Tests.

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What Is ADHD? Meaning, Symptoms & Tests.

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20 minutes.

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What Is ADHD? Symptoms & Meaning

ADHD stands for attention deficit hyperactivity disorder, a complex brain disorder that impacts approximately 11% of children and almost 5% of adults in the U.S. ADHD is a developmental impairment of the brain's executive functions. People with ADHD have trouble with impulse-control, focusing, and organization.

Neuroscience, brain imaging, and clinical research tell us a few important things: ADHD is not a behavior disorder. ADHD is not a mental illness. ADHD is not a specific learning disability. ADHD is, instead, a developmental impairment of the brain's self-management system. Both adults and children can be diagnosed with ADHD.

ADHD Symptoms

What are the signs of being ADHD? Common ADHD symptoms include:

ADHD symptoms vary by individual. You or your child may experience all or just some of the above symptoms, along with others detailed in the DSM-V.
[ADHD Directory: Find an ADHD Specialist or Clinic Near You]
Many patients and clinicians describe ADHD as an iceberg, where most symptoms lay hiding under the surface - out of sight but ever present. If you think you or a loved one might have ADHD, take one of our free, anonymous tests below to see if you should seek a formal diagnosis.

What Are the 3 Types of ADHD?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) previously identified three types of ADHD:

Primarily hyperactive-impulsive type

Primarily inattentive type (formerly called ADD)

Primarily combined type

Primarily Hyperactive-Impulsive ADHD

People with primarily hyperactive-impulsive ADHD act "as if driven by a motor" with little impulse control - moving, squirming, and talking at even the most inappropriate times. They are impulsive, impatient, and interrupt others.

Primarily Inattentive ADHD (Formerly ADD)

People with the inattentive subtype of ADHD have difficulty focusing, finishing tasks, and following instructions. They are easily distracted and forgetful. They may be daydreamers who lose track of homework, cell phones, and conversations with regularity.

Experts believe that many children with the inattentive subtype of ADHD may go undiagnosed because they do not tend to disrupt the learning environment.
[Free Download: An In-Depth Guide to Inattentive ADHD]
Primarily Combined Type ADHD

Individuals with combined-type ADHD display a mixture of all the symptoms outlined above. A physician will diagnose patients with this Combined Type ADHD, of they meet the guidelines for Primarily Inattentive ADHD and Primarily Hyperactive-Impulsive ADHD. That is, they must exhibit 6 of the 9 symptoms identified for each sub-type.

How Do Physicians Diagnose the Type of ADHD?

These subtypes are now considered "presentations" in the most recent version of the DSM, the DSM-V. Researchers determined that people often move from one subtype to another. For example, a child may present as primarily hyperactive-impulsive in preschool, and lose much of the hyperarousal in adolescence to fit the primarily inattentive presentation. In college and adulthood, the same individual may transition to combined presentation.

The subtypes were primarily based on overt behavioral symptoms, and ignored less visible symptoms like emotional dysregulation, cognitive patterns, and sleep difficulties. Behavioral symptoms imperfectly capture the defining features of ADHD. Non-behavioral characteristics are increasingly recognized in research and diagnosis.

What Are the Symptoms of Each ADHD Subtype?

The symptoms of ADHD are spelled out in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which lists nine symptoms that suggest ADHD-Primarily Inattentive and nine that suggest ADHD-Primarily Hyperactive/Impulsive. A child may be diagnosed with ADHD only if he or she exhibits at least six of nine symptoms from one of the lists below, and if the symptoms have been noticeable for at least six months in two or more settings - for example, at home and at school. What's more, the symptoms must interfere with the child's functioning or development, and at least some of the symptoms must have been apparent before age 12. Older teens and adults may need to consistently demonstrate just five of these symptoms in multiple settings.
What Are the 9 Symptoms of ADHD - Primarily Inattentive Type?

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments)

Take the Self-Test: Symptoms of Inattentive ADHD in Children

Take the Self-Test: Symptoms of Inattentive ADHD in Adults

What Are the 9 Symptoms of ADHD - Primarily Hyperactive-Impulsive Type?

Often fidgets with or taps hands or feet or squirms in seat.

Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

Often unable to play or engage in leisure activities quietly.

Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

Often talks excessively.

Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation).

Often has difficulty waiting his or her turn (e.g., while waiting in line).

Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing)."

Take the Self-Test: Symptoms of Hyperactive & Impulsive ADHD in Children

Take the Self-Test: Symptoms of Hyperactive & Impulsive ADHD in Adults

What Causes ADHD?

The causes of ADHD remain somewhat unclear. Research suggests that genetics and heredity play a large part in determining who gets ADHD. However, scientists are still investigating whether certain genes, especially ones linked to the neurotransmitter dopamine, play a defined role in developing ADHD.

Additional research suggests that exposure to certain chemicals may increase a child's risk of having ADHD.

ADHD is not caused by bad parenting, too much sugar, or too many video games. ADHD is a brain-based, biological disorder. Brain imaging studies and other research show many physiological differences in the brains of individuals with ADHD.

How is ADHD Diagnosed?

There is no single test for ADHD. To make a diagnosis, your doctor will assess for any ADHD symptoms exhibited by you or your child in the past six months. They will also do a physical exam and review your medical history to rule out any other medical or psychiatric conditions that could be causing symptoms.

Your doctor or specialists will perform an assessment using the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which details the symptoms listed above.

ADHD Diagnosis in Children

A child may be diagnosed with ADHD only if he or she exhibits at least six of nine symptoms outlined in DSM-V, and if the symptoms have been noticeable for at least six months in two or more settings - for example, at home and at school. What's more, the symptoms must interfere with the child's functioning or development, and at least some of the symptoms must have been apparent before age 12. Most children with ADHD receive a diagnosis in elementary school.

When diagnosing a child, your doctor or specialist may also review school records and questionnaires completed by your child's teacher and/or caretakers. They will likely talk with and observe your child, as well as conduct screening for learning disabilities. They will also rule out other conditions that share similar symptoms to ADHD.

ADHD Diagnosis in Adults

Older teens and adults may need to consistently demonstrate just five of these symptoms in multiple settings. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before the age of 12. Symptoms must also not be better explained by another disorder.

ADHD in Children

According to the Centers for Disease Control and Prevention, 1 in 10 children between the age of 5 and 17 receive an ADHD diagnosis, making ADHD one of the most common childhood neurodevelopmental disorders in the U.S.

The symptoms of ADHD are often identified at school, as many children with ADHD have difficulty succeeding in a classroom setting. While teachers cannot diagnose ADHD, they are often the first to suspect ADHD in children as the symptoms typically affect school performance or disrupt the rest of the class.

Many symptoms of ADHD can be typical childhood behaviors, so it can be difficult to know if a child is displaying ADHD symptoms. Children with primarily hyperactive-impulsive ADHD may initially be seen as disruptive or misbehaving, as they are often hyper, impulsive, and impatient, and may interrupt at inappropriate times.

Boys are more than twice as likely as girls to receive an ADHD diagnosis, in part because ADHD is still wrongly considered a male disorder and because boys are more likely than girls to exhibit outward signs of hyperactivity.

Adult ADHD

ADHD is diagnosed in roughy 4.4% of the adult population in the U.S., although this figure is thought to be underreported, as up to 85% of children with ADHD are at risk for having the disorder as adults, and only 10.9% of adults with ADHD receive treatment.

Untreated ADHD in adults can negatively impact many aspects of life, including work, relationships, and mental health. Symptoms such as trouble managing time, impatience, disorganization, forgetfulness, and mood swings can all cause problems for an individual not actively taking steps to manage their ADHD.

Adult ADHD seldom exists alone. Roughly 60% to 70% of adults with ADHD have a comorbid disorder , such as anxiety, mood disorder, or substance abuse. If you suspect you may have adult ADHD, consult with your doctor or mental health professional about diagnosis and treatment so you can improve your well-being and quality of life.

ADHD Treatment

The best treatment strategies for ADHD are multimodal ones - combinations of several different, complementary approaches that work together to reduce symptoms. For one person, this ideal combination may include ADHD medication, nutrition, exercise, and behavioral therapy. For another, it may mean taking ADHD supplements and vitamins, practicing mindfulness, and spending lots of time outdoors in nature. More and more, pediatric and adult patients are pairing stimulant medication with digital therapies like EndeavorRx, which is available by prescription for patients age 8 to 12, or pinpointed apps like EndeavorOTC, a new mobile video game designed to improve focus in adults with ADHD.

Finding the right ADHD treatments - and managing them - takes research, planning, organization, and persistence. Early on, talk with your child's doctor about your options.

ADHD Medication

For children aged 6 and over or adults, medication may be an important part of the treatment plan. Finding the right medication to manage ADHD typically involves some trial and error but can lead to a significant reduction in symptoms.

The two main types of medication used to treat ADHD are stimulants and non-stimulants.

Central nervous system (CNS) stimulants, like Ritalin or Adderall, are the most prescribed ADHD medications. These ADHD medications work by increasing the amounts of the chemicals dopamine and norepinephrine in the brain, which help with focus. There are three categories of stimulant medications:

Short-acting (taken a few times a day)

Intermediate-acting (taken less often)

Long-acting (taken one a day)

If stimulants cause problematic side effects, or simply are not effective, your doctor may suggest trying a non-stimulant medication, like Strattera or Intuniv.

Non-stimulant ADHD medications are considered second-line or third-line treatments because the level of benefits and response rates are significantly lower. Meaning, stimulant medications are more effective at relieving symptoms for a larger percentage of people.

ADHD medications can have many benefits, as well as side effects. The decision to manage ADHD symptoms with medication can be a difficult one. Learn more about the risks and benefits of stimulants and non-stimulants, medication options, how to gauge effectiveness, and more.

What Is the Definition of ADHD?

"Attention deficit" is, some experts assert, a misleading name. "Attention deregulation" might be a more accurate description since most people with ADHD have more than enough attention - they just can't harness it in the right direction at the right time with any consistency. And so individuals with ADHD hyperfocus and lose track of time, or misplace their keys, or blurt out an unrelated thought when their focus breaks free from its chains.

Understanding ADHD: Next Steps

Sources

¹ "Data & Statistics." Centers for Disease Control and Prevention. Ed. Center for Disease Control. Centers for Disease Control and Prevention, 14 Feb. 2017. Web. 14 Mar. 2017.
² Association, American Psychiatric, ed. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington: American Psychiatric, 2014.
³ Association, American Psychiatric, ed. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington: American Psychiatric, 2014.
⁴ Thapar, Anita, and Evangelia Stergiakouli. "An Overview on the Genetics of ADHD." Xin li xue bao. Acta psychologica Sinica (Aug. 2008) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2854824/
⁵ Philip J. Landrigan, Jordan Slutsky. Are Learning Disabilities Linked to Environmental Factors? Learning Disabilities Worldwide. https://www.ldworldwide.org/environmental-toxins
⁶ Dovey, Dana. "Doctors May Soon Be Able To Diagnose ADHD With An MRI Scan." Medical Daily. IBT Media Inc., 30 Apr. 2014. Web. 14 Mar. 2017.
⁷ https://www.(d(.gov/nchs/fastats/adhd.htm
⁸ https://www.(d(.gov/nchs/fastats/adhd.htm
⁹ Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., Zaslavsky, A. M. (2006). The Prevalence and Correlates of Adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry. 163, 716-723.
¹⁰ Donzelli, G., et al."The Association between Lead and Attention-Deficit/Hyperactivity Disorder: A Systematic Review." International Journal of Environmental Research and Public Health. January 2019, 16:3. doi: 10.3390/ijerph16030382

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What Is ADHD? Attention Deficit Hyperactivity Disorder in Children and Adults

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ADHD (attention deficit hyperactivity disorder) is a neurological disorder that impacts the parts of the brain that help us plan, focus on, and execute tasks. ADHD symptoms vary by sub-type - inattentive, hyperactive, or combined - and are often more difficult to diagnose in girls and adults.

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See dyslexia differently (a short animation)

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See dyslexia differently (a short animation)

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Practical ideas for supporting and understanding emotional regulation.

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Podcast #2: Emotional regulation, behaviour and autism with Adem Cetindamar

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In this podcast episode, Steph and Adem discuss emotional regulation strategies for children and young people with autism.

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50 minutes

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At your own pace

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The National FASD website is a vital resource for information and support related to Fetal Alcohol Spectrum Disorder, offering guidance and support.

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How can I support my child with PDA? - Support for Parents from Action For Children

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Support for Parents from Action For Children

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How can I support my child with PDA? - Support for Parents from Action For Children

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Pathological Demand Avoidance (PDA) is a 'behaviour profile'. Children and young people with PDA avoid everyday demands and can require a lot of support.

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30 minutes

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Herefordshire and Worcestershire Health and Care NHS Trust

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What is SLCN?

Speech, language and communication needs (SLCN) is the term given to describe the extensive range of needs related to all aspects of communication - from understanding others to forming sounds, words and sentences to expressing ideas and emotions and using language socially.

It is estimated that 10% of all children have long term or persistent speech, language and communication needs (SLCN) - the most prevalent special educational need identified by primary schools. In Worcestershire this figure is equivalent to 12,000 children and young people aged 0-19 years, with over 6,000 children and young people known to the Speech and Language Therapy Service. Some schools in deprived areas of Worcestershire have identified 50% of all 5 year olds entering school with delayed receptive language skills.

Download the Worcestershire SLCN Pathway Fact Sheets [PDF] using the links below
2.1 What is SLCN [pdf] 2.2 What is the impact of SLCN [pdf] 2.3 SLCN and SEN [pdf]
Useful links

The Communication Trust is a coalition of nearly 50 voluntary and community organisations with expertise in speech, language and communication. The Trust raises awarenesss of SLCN, promotes best practice amongst the children's workforce and provides an extensive range of information about SLCN.

The SEND Gateway is an online portal offering professionals free, easy access to high quality information, resources and training for meeting the needs of children with SEND.

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Herefordshire and Worcestershire Health and Care NHS Trust

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Own pace

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On this page, you'll find information on a wide range of issues that are important to blind and partially sighted young people.

School life and planning ahead

Our school life and planning ahead section covers choosing subjects, exams and study skills, after-school clubs and activities as well as how to start planning for life after school and moving on to college or work.

Starting college

If you are thinking about going to college then have a look at our starting college section. Find information on choosing the right college for you, what support is available at college and funding advice. You will also find useful study tips and hear about other student's experiences of starting college.

Starting university

There are lots to think about before going to university. You need to find the right course, get clear on application processes and it's handy to know where you can get financial help. Read on and you will discover lots of practical support for anything from choosing the right university and funding advice to how to make the most of student life!

Starting work

Starting work may seem daunting, but this section will help you to identify the people who can advise you about career choices, help with interview preparation, give guidance about work experience and volunteering and advise about the support mechanisms available, such as the Access to Work scheme.

Transition guides

We've created handy guides for blind and partially sighted young people who are about to move into higher education and work.

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If you're affected by sight loss, we're here for you

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Hello and welcome to my resource blog for all things related to positive child mental health, SEND and staff wellbeing.

These areas have always been of interest to me throughout my 23 years in education and has been at the heart of the various roles and further postgraduate learning I have undertaken in that time. I have noticed over my time in education a marked increase in mental health issues in children and colleagues in various institutions. As professionals, we are never short of work supporting children and families in this area.

I am also the editor of Teacher toolkit ( https://www.teachertoolkit.co.uk/author/l-how/) and I have behind me a wealth of experience writing academically for qualifications. Currently I hold NPQH, MA Education with SEND and Mental Health focus, NASENCO award, FCCT and Elklan Speech and Language award. I have also undertaken training in Trauma in Education and accreditation and coaching qualification.

Through my SENCO work, I have been training new SENCOs with SEND Station as well as developing my own SENCO training programs. I am a practicing SENCO for one day a week as well.

Looking forward, I am now really keen to diversify my writing further, continuing to add to my already popular blog, as well as building my consultancy work in supporting schools and teachers. As a mum of two primary school children, I can appreciate first hand the pressure children, educators and parents are under!

If you want to know a bit more about what I'm about, this article was written about me:
https://inspodaily.co.uk/2021/04/23/mental-health-blog-advice-positive-young-minds/
Any feedback and comments on posts are gratefully received and I am also happy to take requests of area you are struggling with so just ping me a message or look on my consultancy page to see what's on offer.

Thanks for reading,

Lynn How

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Hello and welcome to my resource blog for all things related to positive child mental health, SEND and staff wellbeing. These areas have always been of interest to me throughout my 23 years in education

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20 minutes.

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Understanding dyslexia and literacy difficulties 

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Understanding dyslexia and literacy difficulties 

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Life More Extraordinary with Lucy Parsons

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Podcast: Play in new window | Download

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How to help a child with dyscalculia

Many people feel defined as 'not-a-Maths-person', but for Dyscalculics it is more than that - they cannot distinguish the number quantity from the number symbol. Without the right support and learning, numbers are mere "squiggles". On today's show, I interview Dyscaculia expert Judy Hornigold to uncover what this learning difference is, and how it affects an estimated 3 - 6% of the population. We learn how to best support your child, and what effective tools and techniques help Dyscalculics thrive as independent individuals.

About Judy

Judy is an independent educational consultant specialising in dyscalculia and dyslexia and has been a Singapore Maths trainer, for UK based Maths No Problem since 2014. She has developed the PGCert in Dyscalculia and Maths Learning Difficulties for Edge Hill University and an accredited dyscalculia course for the British Dyslexia Association. She's also a lecturer and author of several books.

What we explore on the show

What dyscalculia is

What kinds of tasks children find difficult when they have dyscalculia The signs that your child might have dyscalculia How dyscalculia is diagnosed How to help a child with dyscalculia - strategies to help children overcome their difficulties How to communicate with schools and teachers about what helps your child to learn The relation between dyslexia and dyscalculia

Connect with Judy

Resources
Singapore Bar Modelling Times Fables - by Jessie Wilson British Dyslexia Association
Useful links
How to leave a podcast review for The School Success Formula
My book, The Ten Step Guide to Acing Every Exam You Ever Take .
Ten Steps to Exam Success download. Supportive Parents, Successful Students facebook group
Contact Lucy by email: lucy@lifemoreextraordinary.com

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[57] How to help a child with Dyscalculia with Judy Hornigold - Life More Extraordinary with Lucy Parsons

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Children with dyscalculia find it hard to understand basic number concepts. In this podcast episode we learn how to help a child with dyscalculia.

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At own pace

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Supporting individuals and families affected by dyspraxia/DCD

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5 minutes

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At a glance

Dysgraphia refers to a challenge with writing.

It impacts skills like handwriting, typing, and spelling.

There are many ways people with dysgraphia can improve their writing skills.

Dysgraphia is a term that refers to trouble with writing. Many experts view dysgraphia as challenges with a set of skills known as transcription. These skills - handwriting, typing, and spelling - allow us to produce writing.

Trouble expressing your thoughts in writing isn't formally recognized as part of dysgraphia. That's a learning disability known as written expression disorder. But when people struggle with transcription, it can get in the way of thinking about ideas and how to convey them.

For example, people with dysgraphia may write more slowly than others. That can affect how well they express themselves in writing. Plus, they tend to have trouble with spelling because it's hard for them to form letters when they write.

Dysgraphia isn't a matter of intelligence. The challenges are often caused by trouble with motor skills. Those skills can improve with help. And people with dysgraphia may also be eligible to use accommodations at work or at school.

About the author

About the author

The Understood Team is made up of passionate writers and editors. Many of them have kids who learn and think differently.

Reviewed by

Reviewed by

Charles A. MacArthur, PhD is a professor emeritus of special education. He researches writing instruction, self-regulated strategies, and assistive technology.

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Dysgraphia is a writing challenge that affects skills like handwriting, typing, and spelling. It's not technically a learning disability, but it can affect learning.

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Supporting autistic children in the classroom

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Supporting autistic children in the classroom

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12 hours.

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Unable to play video. Please enable JavaScript or consider upgrading your browser.

Hello, this course provides a comprehensive introduction into Good Practice in Autism Education. It has been developed specifically for anyone working with autistic children and young people in education, as well as autistic people themselves. The course starts by discussing what autism is, as well as the role of special educational needs and disabilities within schools. Inclusion can be a difficult concept to define, and different models of inclusive education are discussed, including mainstream schools, special schools, and autism units attached to mainstream schools. What constitutes good practice in autism education is discussed, as is how to consider the evidence base for these good practices. Finally, we explore how to share good practice you is education Europe-wide.

The course runs for four weeks, and contains a range of learning opportunities, including forums to discuss your ideas with other learners. The course is accessible to everyone working in education, so please come and join us.

Learning on this course

On every step of the course you can meet other learners, share your ideas and join in with active discussions in the comments.

What will you achieve?

By the end of the course, you'll be able to...

Identify the educational requirements of children on the autism spectrum with and without intellectual (learning) difficulties

Explain the concept of inclusion to promote inclusive culture, policies and practices within mainstream schools

Reflect on what constitutes good practice for autism within educational settings

Compare specific examples of good practice in autism education

Endorsers and supporters

funded by

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Autism and Education - Free Online Course - FutureLearn

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Understand more about autism and intellectual disabilities, and develop good practice in autism education with this free online course from the University of Bath.

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The relationship between ACE’s and the later development of harming behaviours. 

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The relationship between ACE’s and the later development of harming behaviours. 

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25 minutes

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Dan Johnson, Clinical Director of Kibble a special intervention service supporting children at risk, talks to freelance journalist Jo Carlowe about trauma and ACE's.

The relationship between ACE's and the later development of health-harming behaviours, mental health issues and chronic disease noted by both anecdotal experience of Dan and supported by clinical research implies the great need for intervention. Dan and Jo discuss trauma-informed care, the impact of the ACE's framework on clinical practice and government policy and the difference between adversity and trauma.

They also touch upon Kibble's work, and as the chair of ACAMH's Scottish Branch their goals to spread knowledge on children and young people's mental health and provide CPD training.

You can listen to this podcast directly on our website or on the following platforms; SoundCloud, iTunes, Spotify, CastBox, Deezer, Google Podcasts and Radio.com (not available in the EU).

Transcript

Intro: This podcast is brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short. You can find more podcasts and other resources on our website www.acamh.org and follow us on social media by searching 'ACAMH'.

Interviewer: Hello, welcome to the In Conversation... podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I'm Jo Carlowe, a freelance journalist with a specialism in psychology. Today I'm interviewing forensic psychologist Dan Johnson, who is the Clinical Director with Kibble Education and Care Centre in Paisley. Dan is also the chair of ACAMH Scotland. He has worked in secure settings for nearly two decades and is passionate about the development and implementation of trauma-informed care.

Interviewer: Dan welcome. Thank you for joining me. Can you start with an introduction about who you are and what you do?

Dan Johnson: Yeah, sure. So I've been a forensic psychologist for about 20 years, I hate to admit, and I started off in prisons, working with adults, and I've gradually kind of worked with younger and younger people. And I've worked in secure care and residential care for the last, I'm not sure, ten or I've maybe a few more years than that and I've kind of got into the whole drawing form thing because anecdotally, just, I mean, every single young person and adult, I think, that I've worked with, have had really concerning behaviours. I've also had really really difficult lives, particularly childhoods, and once you notice that you start wondering what you can do about it. The answer to that question tends to be, for me anyway, reform.

Interviewer: Dan, you've worked for many years in secure settings with young people who have been exposed adverse and traumatic events. How did this come to be the main focus of your work? What sparked your interest?

Dan Johnson: Yeah, I think when you work with young people and you see these really concerning behaviours,that they are referred to you because of that behaviour, you quickly notice that they've had these experiences, and that those experiences seem to have some kind ofcausal role or that these behaviours are rooted in these experiences. And so, whilst focus on the behaviours, you know can be useful and appropriate, sometimes actually trying to work out where they came from and responding to that I think could be more effective. I'm not saying I didn't notice any success with kind of behaviour-focused approaches, but I think you need both. I think you need to look at these experiences as important.

Interviewer: Right. there's been a great deal of interest in the impact of adverse childhood experiences, usually referred to as ACEs. Why do you think this has happened in recent years? Why has there been a surge in interest in ACEs?

Dan Johnson: Yeah. It's really interesting, isn't it? Because this stuff's been knocking about for 20 years.

Interviewer: Wow, that long?

Dan Johnson: Yeah, I think it was the, you know,in the early 90s, the original papers. I think it's a bit of, you know, an alignment of the Moon stars, kind of thing. In one way they're really, really accessible, so anyone, regardless of your level of kind of background in this stuff, can understand the way the message of the ACEs research is translated.

I think also it's really intuitive. So, you know, if you ask anyone if I asked my Nan, I always use this example, my Nan who worked in factories, if she thought that bad childhoods might lead to later difficulties. I think intuitively she, anyone would agree with that. The reason it's got so popular now is a trickier question. I think it may have something to do with the increasing loudness of lived experience, of people who have had these experiences being listened to and empowered. That may be part of it, but the reason why it's happened now is in a tricky one that unfortunately, I can't answer. I'm not too sure.

Interviewer: It's an interesting one, isn't it? There are many studies that find a relationship between adverse childhood experiences and later association with health-harming behaviours, mental health issues and chronic disease. Can you give some of the headline findings that help illustrate this relationship?

Dan Johnson: Yeah. Yeah, the brief... the headline, as you say, is that the degree in nature and severity and breadth, I suppose, of adversity and trauma in childhood is linked, or associated, with the degree in nature of later adult difficulties.

So, and that kind of goes across most adult difficulties as well, so be it ADHD, antisocial personality disorder, psychosis, many of these things have an association with childhood adversity and trauma. And when we say adversity and trauma we're talking about things like childhood sexual abuse, physical neglect or physical abuse, things like that that are at the extremeend of adversity.

And I think we have to be cautious here that it often is an association rather than being categorically a causal link. I remember from, you know, doing correlations at uni, they are just an association and there are some people that have made some very good points in that if you look for an association between a lot of things, you will find it where there may not be a causal factor. Now personally, you know, my anecdotal evidence and reading of the science, convinces me that there is some kind of causal element there, but we do need to be cautious because the science isn't quite there to demonstrate that yet.

Interviewer: Okay, what does the science say about the causal element?

Dan Johnson: Well, it's a really tricky one because, ethically, we can't experiment, you know. I hope no psychologist wants to get a group of kids and put them through adversity just to see what happens. Until someone works out an ethical way to experiment we'll never really be able to show casual influence. There has been some really interesting longitudinal twin studies that are kind of really getting close as you can really to show that there's a causal influence but, you know, scientists are always cautious aren't they. They're not going to state it categorically without that experimental methodology.

Interviewer: What impact has the ACEs framework and its findings had on clinical practice. So, how have things changed in light of what we know about the impact of those adverse experiences.

Dan Johnson: Yeah, I can only talk for Scotland and really for this kind of residential secure care. That's about where I work. I think it's definitely a change for the better. I think what you have in some pockets, and again it's not uniform, it's not everywhere, but in some split areas, people really acknowledging that role of experience more. So if I think about 15 years, ago in my little world anyway, the medical model was dominant and people didn't really challenge that. And now there's a kind of nice hybrid between, yes that medical model can really give us some really helpful perspectives and responses, as well as, as can this perspective of experience and the role of that in later difficulties. I think it's a mixed bag though, so beyond the clinical practice, you know in Scotland the ACEs thing's become a real movement with the First Minister talking about it and huge national conferences. And it's like anything, the way those findings and messages are interpreted is the important bit.

Interviewer: You mentioned that ACEs has already got the attention of governments across the UK and specifically in Scotland. How have these findings influenced policy so far? And what more would you like to see?

Dan Johnson: Yeah it's in some ways very good. So in Scotland, there is a huge national project to train the workforce in trauma. And I think that's a really, really good thing. I think the more people that understand this and understand the root of difficulty the more helpful responses and the less counter-productive responses there will be. There's been a lot of money put behind that as well to get people trained in a way that's standardised, for want of a better word, across different services. And that's everybody. That's not just your kind of psychologist or therapist, it's the GP receptionist, it's, you know, everybody that might be working directly with someone that has experience trauma.

I think there's, there's lots more that can be done and for me, in general, I think we're better at responding to these difficulties for children than we are adults. I see young people that we work with, you know in some circumstances getting a really robust and high level of service, partly because of the experiences they've had, partly because of the behaviours that's then, you know led to, but as they become 16, 17, 18, there's a cliff edge and those services and supports aren't as available. And the way that we, you know, that services see these children kind of flips from them being this, you know, traumatized child to this problematic adult. And, actually, I don't think that's fair on them or useful for services either.

Interviewer: Right? So that's a real area where you'd like to see change.

Dan Johnson: Absolutely. And again, it's problematic because it all costs money doesn't it? But yeah, I think, I think that the longer we see individuals as individuals' difficulties as rooted in these experiences, the better it is for, for everybody.

Interviewer: Now, there is an argument that the ACEs approach is over simplistic as it doesn't account for severity or duration of adversity. It doesn't consider resilience and it conflates adversity and trauma. I think it would personally be useful in you can explain the difference between adversity and trauma.

Dan Johnson: Yeah. Yeah. So those those criticisms are all completely legitimate and I think with the ACEs framework, it's really important to take a kind of critical-framed perspective, a balanced perspective. There's quite a lot of evangelism, if that's the right word, about ACEs and, you know, it's good to be behind something, but, you know, I'm an open-minded sceptic. You need to keep a bit of balance with these things.

I think, like everything, its strengths are its weaknesses as well. So that ACEs framework is so accessible you can even convince politicians of it, but that simplicity is its weakness as well because it does oversimplify many things. And the analogy that is, if we're looking at an individual's difficulties as a whole, the explanation of that could be seen as something as complex as a city, say or something, you know, as big, as complex as that. The ACEs is a little bit like shining a spotlight on one street or one suburb of that city. It's just part of this, rather than the whole thing. You've got all the protective factors, attachment, you know, biology, culture all these many many of the things that all are important part of explaining difficulties. But that doesn't mean we should get rid of it just means we should be balanced about how we look at it.

Going back to the second part of the question about the difference between adversity and trauma. So there's lots written about this. In fact, we can get into some real semantic circular arguments with all this kind of stuff. For me though personally, you know, it's it comes down to the individual and I know this is a little bit of a get-out clause, but how that individual defines what the most powerful harmful experience of their life is kind of up to them. So if you know, I might meet a young person in this sector look at the file and think, oh, that day they were stabbed in a gang fight, or whatever it was, that must be their traumatic experience when, in fact, that might be normal to them. They might not have even thought twice about it. But another experience say, the police coming through the door, or being moved into care or something that we maybe would never even think of, might be to them the most difficult and overwhelming experience. So this time, you know, I'll leave the academics to debate the semantics and the definitions but I kind of like that individualistic perspective in practice.

Interviewer: So there's a sort of relational aspect to it rather than just ticking a box of what the practitioner thinks is traumatic or...

Dan Johnson: Yeah. Yeah. I mean, I think a good rule of thumb is that a definition of trauma is that which overwhelms the individual. I kind of like that word overwhelms. It's, be that physically or spiritually or mentally or you know, the different levels, but I don't think it's for me to say what events can do that and what events can't. I think that's, that's up to the individual.

Interviewer: Okay. I'm going to move on to trauma-informed care which has become the leading approach for organizations seeking to respond to effects of adversity in trauma. What is trauma-informed care and how does it work?

Dan Johnson: Oh, this is the million-dollar question. There's a lot written about the difference between trauma and adversity. There's much, much more written about what trauma-informed care is and how you do it. So, I think if you'd have to distill it right down to its essence, for me in practice, it's about people saying, 'hang on, if this was me, if I'd experienced these things or if my daughter or my niece or my grandson or whatever, had experienced these things. What would I want them to get from this service or from me as a practitioner?' And when you start asking that question, the answer is often different things to what we're already doing, things of compassion and trust and safety and all these kind of nice values. That to me is, when it comes down to it, when people are arguing in practice, when that question comes out people tend to get agreement and consensus about what the right action is.

One of my favourite definitions is that it's a way of thinking not about what's wrong with people, but what's happened to them. And I always vowed that I'd never start quoting sound bites and everything, but that is a nice kind of way that summarizes the approach.

In a way it's almost easy to say what it's not than what it is. So it's not a treatment modality like CBT or EMDR or anything like that. It's much more an approach or an ethos that might have more kind of similarity to, say, like a children's rights perspective or a child focus, you know approach. It's a way of practising across the whole board rather than, say, you know, a therapist doing a particular modality.

So I know that's vague and I think one of the key problems with trauma-informed care is it is hard to make tangible. It's difficult and I've sat in meetings where you know, with a group of managers in secure care and they've been diametrically opposed about what the right action is, and both have been arguing that their point of view is the trauma-informed care point of view.

So, there are many definitions and I know what I've said before was maybe a little vague. So, one of the frameworks I like is from SAMHSA, which is the Substance Abuse and Mental Health Agency of America, and they break it down to four Rs, which is: Realize prevalence in your clients and your staff; Recognize the impact of this or acknowledge that it's actually impacted on the individuals; Respond in ways with that knowledge, so create a helpful response to those young people or service users and finally; Resist re-traumatization, so don't mirror or replicate things that those children may have, or those adults may have, experienced in the past. And recently in Scotland, people have been talking about the fifth R, which is that it's all about Relationships, that relationships that were part of the key response to what people need after these experiences.

Interviewer: How can stakeholders implement trauma-informed care? And where can they go to learn more about it?

Dan Johnson: Yeah. So, there are so many resources online at the minute. I recommend the NHS Knowledge and Skills trauma, Trauma Knowledge and Skills Framework, which is a really nice way of exploring all these concepts and telling people the skills and knowledge they need to be able to practise in an informed care way, trauma-informed care way sorry. There's also lots, like, on the SAMHSA website.

There's also Trauma Informed Oregon which is really good. And there's also some authors called Fallot and Harris that have done some nice self-assessment tools that practitioners can go through and, you know, self-evaluate on their service for their practice. I think it's F-A-L-L-O-T and Harris.

And I think, I should have checked this before I started, but it's creating the, basically if you Google trauma-informed care most of this stuff will come up.

Interviewer: Okay, great. And what does the research show with regards to the effectiveness of trauma-informed care?

Dan Johnson: Good question. Not much unfortunately. It's growing but there's definitely not enough, for me anyway, to be able to say oh this is a resounding powerful effect. Anecdotally I think it is, but there's still not, you know, the robust science that we would like. There's some interesting stuff about implementation across, like, huge child welfare agencies in America that shows it's good and it's the right direction. But I think, I think there's something on top of all that which is, I think it's, it's a little bit like, you know, the UN rights perspective or a child focus thing which is, it's a good thing to do anyway. It's kind of like a moral or ethical obligation, in a way, to do anyway, whether it shows that it improves things dramatically or not. So, for example, if some of the values that are behind trauma-informed care, of providing service users or children with trust and safety and empowerment and choice and collaboration. I find it hard to come up with a reason why you wouldn't do that anyway. No, it's, it's a good idea. Right? It's a nice thing to do. It's a moral thing to do.

Interviewer: Are there any other research projects that excite you? That you'd like to mention?

Dan Johnson: Yeah, I think I already have actually. I think these longitudinal twin studies that just, you know, such a rich source of data really, and knowledge, just really sort of helping us understand more about why children with these experiences experience so many difficulties in many different ways either. It's not just depression or anxiety. Is this overall difficulty with mental health and mental illness that people are really struggling with. And I think the more we learn about that, I mean, that's, that could be so rich for helping us respond to these children and adults.

Interviewer: Are there any interim findings that you can mention now that are interesting for these twin longitudinal studies?

Dan Johnson: Just to repeat what I said earlier I suppose, which is, you know, that some of them are getting as close as we can pretty much get, I think, to saying that there is a causal role between these traumatic experiences and difficulty throughout life.

I think I should put a caveat to that which is one of the negatives to all this language about adversity and trauma and the associations in later life is that it gets predeterministic way of thinking where people think, oh, I'm on this path now and my fate will be difficulty, I will experience these things. But we're just talking in a general level here. This is a bit like what's an analogy, the smoking research where, you know, in general, if you smoke you are going to suffer disease and die earlier, but that doesn't mean that Auntie Jean who smoked 20 a day hasn't got to a hundred, you know. It's at the level of the individual we always have to be aware that this, this doesn't have diagnostic power in a way. It's the individual can always, is always different to these general findings.

Interviewer: What else is in the pipeline that you'd like to mention?

Dan Johnson: In terms of Scotland, there's a lot of money going into making sure the workforce and children's and health services are trauma-informed, that these knowledge and skills are there. And it's just so exciting to see what's going to happen with that. Like what's the actual change in practice. you know in my own organisation I can think of some real tangible meaningful improvements that have happened. There's still loads to do, it's not all perfect, you know, just because you're trauma-informed doesn't mean you're faultless, but thinking about that on a much larger scale and a national scale is pretty exciting. I do think this is really an opportunity for some significant meaningful change across services in general.

Interviewer: And you've just mentioned your organization, you're the Clinical Director at Kibble Education and Care Centre. Can you say a little bit about what Kibble does and who it works with?

Dan Johnson: Yeah. Yeah, so we are basically a children's charity and we provide effectively a continuum of care from secure care on one side, all the way through to residential foster services, semi-independent living, primary schools education that kind of stuff, and I suppose just if there's any... you know, some good people here trying to do things the right way, they really are. So if anybody else is of a similar, you know ethos, I'll be really interested in linking in with them and seeing what they're up to and seeing if we can, you know, join forces basically.

Interviewer: And what's the best way for them to contact you?

Dan Johnson: You could just Google Kibble and Dan Johnson or, Kibble should come up, there's only other dog food that's called kibble as well, so don't phone that one. And yeah, just ask for myself or anyone. We've got a team of psychologists and therapists and systemic family workers and the like so if you're interested, you can just link in with them as well.

Interviewer: Great. Dan you're chair of ACAMH Scotland. What are you doing as a ? And how is ACAMH healthy?

Dan Johnson: Yes, we basically a kind of small, I was gonna say ragtag band - that's maybe not the right word - but you know, we're just a small bunch of volunteers who try and make sure that there's there's knowledge and CPD and information going out about children's mental health and how we can respond to that and create it. So we've got a few events coming up. I think the next one is in January, which is all about creating therapeutic environments, physically and psychologically. That's a twilight event which is really cheap just to plug it. I think it's £25 and all this is not for profit. I think that's one that I want to emphasize. This is this is a, you know, this is about getting information knowledge out there for its own sake. So, if anyone's interested in helping us out, if anybody wants to just volunteer their services or even attend they can either email me, or I think there's a Twitter thing for ACAMH as well, just Google us and we can get in touch and try and make it happen.

Interviewer: But if I could ask just, if you have a takeaway message for those listening to this podcast?

Dan Johnson: Yeah, I think the takeaway should be that trying to understand difficulties of individuals as rooted in these these adverse and traumatic experiences can only be a good thing. And to inform the way we respond to that and to reflect on how we can do things better, I think is a really, really good step in the right direction.

Interviewer: Brilliant. Dan, thank you ever so much. For more details on Dan Johnson and his work, please visit the ACAMH website. That's www.acamh.org and Twitter at acamh. ACAMH is spelt A C A M H.

Outro: This podcast was brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short.

ENDS
Dan Johnson
A forensic psychologist and Clinical Director of Kibble education and care centre in Paisley. He has worked in in secure settings for nearly two decades and is passionate about the development and implementation of trauma and informed care. Dan is also the chair of ACAMH's Scottish Branch.

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In Conversation... Trauma and ACE's with Dan Johnson - ACAMH

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Dan Johnson and Jo Carlowe discuss trauma-informed care, the impact of the ACE's framework on clinical practice and government policy and the difference between adversity and trauma.

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At your own pace

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Understanding sensory processing issues 

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Understanding sensory processing issues 

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60 minutes

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Sensory processing issues are difficulties with organizing and responding to information that comes in through the senses. Kids may be oversensitive to sensory input, undersensitive, or both.

What are sensory processing issues? The term refers to trouble managing information that comes in through the senses. These issues, sometimes called sensory processing disorder or sensory integration disorder, can have a big impact on learning and on everyday life.

This guide can answer basic questions about sensory processing issues. You'll also find expert advice, strategies to use at home, and information on the best supports for your child at school.

Snapshot: What sensory processing issues are

In some people, the brain has trouble organizing and responding to information from the senses. Certain sounds, sights, smells, textures, and tastes can create a feeling of "sensory overload." Bright or flickering lights, loud noises, certain textures of food, and scratchy clothing are just some of the triggers that can make kids feel overwhelmed and upset.

There are two types of sensory processing challenges, and many kids experience a mix of the two. One is oversensitivity (hypersensitivity). This leads to sensory avoiding - kids avoid sensory input because it's too overwhelming. The other is undersensitivity (hyposensitivity). This causes kids to be sensory seeking - they look for more sensory stimulation.

Often, kids with sensory processing issues are oversensitive. They try to avoid sensations they find intolerable.

But some kids seek more sensory input, not less. They may want to touch things and feel physical contact and pressure. They may also be undersensitive to pain and have an unusually high tolerance for it. That's why they may prefer playing rough and not understand if they're hurting someone.

Some kids may be both sensory avoiding and sensory seeking. They may be oversensitive to some sensations, and undersensitive to others. A child's reactions can also change from one day to the next, or even throughout the day, depending on the environment or situation.

Sensory processing issues aren't a specific learning disability. But they can still have a large impact on learning.

Sensory processing issues signs and symptoms

What you or your child's teacher might see depends on two things. The first is the trigger - the sensory input that's overwhelming your child. The second is the type of sensory processing challenge your child has.

Kids who are sensory avoiding may react to a wide range of triggers. These can include loud sounds, uncomfortable clothing, crowded spaces, or certain food smells or textures, among others. Whatever the trigger, the reaction can sometimes be extreme.

Here are some other signs you might see in your child:

Is easily overwhelmed by people and places

Seeks out quiet spots in noisy, crowded environments

Is easily startled by sudden noises

Is bothered by bright light

Refuses to wear itchy or otherwise uncomfortable clothing

Avoids touching people or hugging them

Has a strong reaction to the texture or smell of certain foods

Refuses to try new foods and has a very limited diet of preferred foods

Gets upset about small changes in routine or environment and avoids trying new things

Kids who are undersensitive to sensory input have the opposite situation. They often have a need for movement. And they may seek out input like spicy or sour tastes and physical contact and pressure.

Here are some other signs you might see in your child at different ages:

Constantly touches objects

Plays roughly and takes physical risks

Has a high tolerance for pain

Often squirms and fidgets

Is constantly on the move

Invades other people's personal space

Often gets distracted or feels anxious

Is clumsy and uncoordinated

Keep in mind that kids aren't always one or the other. Some kids may be sensory seeking in certain situations and sensory avoiding in others, depending on how that child is coping or self-regulating at the time. That's why it's so important to observe your child's reactions and to try to anticipate what triggers them.

What can co-occur with sensory processing issues

Sensory processing issues aren't a diagnosis on their own. But they often co-occur with two conditions: ADHD and autism. Kids don't have to have ADHD or autism to have sensory processing issues, however.

Some of the signs of ADHD may look similar to the signs of sensory processing issues. Kids with either of these conditions might need to be in constant motion, for instance. But the reasons would be different.

Possible causes of sensory processing issues

Researchers are looking into biological reasons for these issues. Some research suggests they can be genetic. Researchers are also looking into birth complications and other environmental factors. But so far, there's no known cause of sensory processing issues.

ADHD and autism often co-occur with sensory issues. They don't cause them, however.

How sensory processing issues are diagnosed

Sensory processing issues aren't a formal diagnosis, although they used to be diagnosed as "sensory processing disorder." You might hear a professional evaluator say something like, "Your child has trouble processing sensory information."

There are a few tests professionals can use to identify sensory processing issues. These include Sensory Integration and Praxis Tests (SIPT) and the Sensory Processing Measure (SPM) checklist.

Occupational therapists (OTs) are often qualified to identify and create treatment plans for sensory challenges in kids. Other professionals may be able to identify sensory processing issues, too. These include:

How professionals can help with sensory processing issues

There are no medications for sensory processing issues. But there are professionals who can help your child learn strategies to cope with sensory challenges.

OTs often work with kids with sensory issues. They help kids find ways to be less overwhelmed by sensory input. You may have heard of a treatment known as sensory integration therapy. But more often therapists might create what's called a sensory diet.

This is a tailored plan of physical activities. It helps kids learn to calm themselves and regulate their behavior and emotions. And that makes them more open to learning and socializing.

Here are some things that might be included in a sensory diet:

Jumping jacks

Rolling on a therapy ball

Push-ups

Hopping up and down

Climbing ladders and going down slides

At school, your child might be able to get accommodations through a 504 plan. (If your child has an IEP for another issue, it could include accommodations for sensory issues, too.) The teacher may also give your child informal supports.

Classroom accommodations to help kids with sensory processing issues might include:

Allowing your child to use a fidget

Providing a quiet space or earplugs for noise sensitivity

Telling your child ahead of time about a change in routine

Seating your child away from doors, windows or buzzing lights

Allowing your child to take exercise breaks to self-regulate

How you can help your child with sensory processing issues

It's important to find support for you, too:

Key takeaways

Kids with sensory processing issues can be oversensitive, undersensitive, or both.

Occupational therapists can help kids learn to manage their sensory challenges.

Understanding your child's reactions and triggers is key to helping your child cope.

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What is sensory processing disorder, and how does it affect kids? Use this comprehensive guide to understand sensory processing disorder in children.

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25 minutes.

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Developmental Language Disorder (DLD) - What every class teacher needs to know!

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At own pace.

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The ADHD Foundation is the largest provider of training in ADHD and neurodevelopmental conditions for professionals in the UK.

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An in-depth talk about dyslexia with practical advice

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An in-depth talk about dyslexia with practical advice

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23 minutes

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Michael Rosen talks in depth about dyslexia: what it is, how to understand it and useful advice for parents and teachers, with expert Professor Maggie Snowling CBE, President of St John's College, Oxford.
Producer Beth O'Dea.

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Michael Rosen talks in depth about dyslexia with expert Professor Maggie Snowling.

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4 minutes

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Childhood dyspraxia: James' story | NHS - Bing video

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Childhood dyspraxia: James’ story | NHS - Bing video

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Dysgraphia: An Overview – Smart Kids (smartkidswithld.org)

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Children with dysgraphia struggle to write, often causing them to experience emotional stress and anxiety. Because they have good verbal skills, parents and teachers expect them to write at the same level as they speak; when they don't, they may be mistakenly thought of as lacking motivation or careless.

Dysgraphia can occur alone, or in children who also have dyslexia, other language disorders, or ADHD.

Causes

Writing is a complex process. It involves working memory and shifting among tasks that include generating ideas, thinking of words and word meaning, organizing good sentences, planning, and self-monitoring-all executive functions. Difficulty in any of the basic language or motor skills or in the executive functions needed to combine them end with the same result: problems with written expression.

In addition, difficulty controlling fine motor skills, sequencing the hand movements needed to write, or controlling spatial accuracy can cause non-language based dysgraphia.

Treatment

It is critical to identify the underlying problems resulting in dysgraphia; there might be more than one. An Occupational Therapist using a multi-sensory approach can address problems with handwriting, motor sequencing or visual spatial skills. A Speech and Language Therapist or a Special Education teacher can help with language-based problems such as the mastery of grammar, word usage, sequencing, and composition of sentences. A Special Education teacher will work with tools such as a graphic organizer, thought bubbles, and other strategies to help deal with specific executive function problems.

Accommodations are often needed to help dysgraphic children handle written work, including reduction of the load of writing in class and in homework, extended time to produce written work, and assistive technology to allow dictation.

Most dysgraphic children benefit from being allowed to use a keyboard and a word processing program, which reduces motor demands and allows them to edit and reorganize written work. Since writing is difficult, children benefit from Smart Boards on laptops or tablets to record writing on the board, and accommodations for note taking, such as using another student's notes or a study guide/outline of lecture information provided by the teacher. Many children with dysgraphia are allowed to use alternative methods to demonstrate knowledge rather than written exams.

Demands for written expression are constant across every subject and increase in every grade. Even in early grades, teachers need to be sensitive to dysgraphia when assigning projects to produce posters to be hung on the classroom walls or to write letters correctly on the lines. Children with dysgraphia need encouragement and remediation; there is nothing more discouraging than getting a paper back filled with red circles, corrections, and criticism.
Marcia Eckerd is an evaluator, consultant, and therapist who specializes in working with children with NLD and autism-spectrum disorders.
Related Smart Kids Topics

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Children with dysgraphia struggle to write, often causing them to experience emotional stress and anxiety. Because they have good verbal skills, parents and teachers expect them to write at the same level as they speak; when they don't, they may be mistakenly thought of as lacking motivation or careless.

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NCFE Level 2: Understanding Autism.
At own pace.

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Throughout this qualification, you will gain an understanding of the spectrum of autistic disorders and how they can affect people in a variety of ways, as well as exploring the importance of using a person-centred approach to provide support.

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9 minutes.

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Trauma and the Nervous System: A Polyvagal Perspective

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30 minutes

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Fetal Alcohol Spectrum Disorder: Daniel and Jakob

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6 minutes

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What is Pathological Demand Avoidance (PDA)?

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Supporting deaf children in special schools

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Tourettes Action is a support and research charity working to improve the lives of people living with Tourette Syndrome. Our services include online live-chat and email support, a befriender network, information, webinars, events and resources.

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40 minutes

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20 minutes

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In this episode, we talk about common adjustments teachers make in the classroom to support students who are blind or vision impaired. Students who are blind have complete or near-complete vision loss. Students with vision impairment have decreased ability to see.

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Association for Child & Adolescent Mental Health 

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Association for Child & Adolescent Mental Health 

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Welcome to ACAMH

Our vision: Sharing best evidence, improving practice. We aspire for ACAMH to become a major portal, access point for anyone seeking the most expertly digested understanding and interpretations of the best evidence available.

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The Association for Child and Adolescent Mental Health (ACAMH)

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The Association for Child and Adolescent Mental Health (ACAMH) provides information, training and evidence to health professionals.

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3 minutes

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What we know and don’t yet know about DLD

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What we know and don’t yet know about DLD

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30 minutes.

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ACAMH uses cookies in order to deliver a personalised, responsive service and to improve the site.

About the Author

Professor Courtenay Norbury is Professor of Developmental Disorders of Language and Communication at Psychology and Language Sciences, University College London. She is the Director of the Literacy, Language and Communication (LiLaC) Lab and a Fellow of the Royal College of Speech and Language Therapists.

She obtained her PhD in Experimental Psychology at the University of Oxford, working with Professor Dorothy Bishop on the overlapping language profiles that characterise autism spectrum disorder and 'specific' language impairment. Professor Norbury's current research focuses on language disorders and how language interacts with other aspects of development. She is leading SCALES, a population study of language development and disorder from school entry. She is also a founding member of the RADLD campaign.

Developmental Language Disorders (DLD)

Developmental language disorder (DLD) is diagnosed when a child's language skills are persistently below the level expected for the child's age. In DLD, language deficits occur in the absence of a known biomedical condition, such as autism spectrum disorder or Down syndrome, and interfere with the child's ability to communicate effectively with other people. Expressive language is characterised by non-specific words and short simple sentences to express meanings beyond the age at which children may be using more complex language. For example, when typical children can say 'that boy cuts shapes out paper with sharp scissors', the child with DLD might say 'him doing cuts' to express the same idea. Though such limitations of expressive language are readily apparent, for many children, understanding of language (receptive language) is also a challenge. Language disorders emerge in early childhood, have a significant impact on everyday social interactions or educational progress, and persist throughout the school years and into adulthood.

Aspects of language may be variably impaired and include:

Phonology (speech sounds)

Semantics (vocabulary)

Syntax (grammar) and morphology (endings on words that express grammatical relationships, like past tense -ed in English)

Discourse (narrative, conversation)

Pragmatics (social communication, inferencing, figurative language)

The exact cause of DLD is not known, but it is likely that there are several interacting genetic and environmental factors, rather than one single identifiable cause.

Behavioural interventions are the most common approach to treating DLD. Such interventions are typically carried out by speech-language therapists, though in some instances therapy may be delivered by parents or education staff under the supervision of the speech-language therapist. These interventions can significantly enhance a child's ability to communicate and can increase competence in specific areas of language, but, as yet, there is no cure for DLD.

Introduction

The terminology for children's language problems has been extremely variable and confusing, with many different labels being used by different professional groups (D. V. M. Bishop, 2017). In the UK, education services include DLD under the umbrella term SLCN, or speech, language and communication needs. In research, 'specific language impairment' or SLI was the term most commonly used, but there has been growing recognition that language is rarely selectively impaired and considerable controversy about the use of non-verbal IQ scores in diagnosis and treatment decisions. For example, children with non-verbal IQ scores below 85 are frequently excluded from research studies (Reilly et al., 2014) and denied access to specialist clinical services (Dockrell, Lindsay, Letchford, & Mackie, 2006).

The lack of consistency in terminology has been directly linked to poor public awareness of DLD (D.V.M. Bishop, 2010). To address this issue, the CATALISE consortium recently undertook a Delphi exercise to achieve consensus on diagnostic terms and criteria (D. V. M. Bishop, Snowling, Thompson, Greenhalgh, & and the, 2017). This cross-disciplinary panel of experts recommended the term Developmental Language Disorder, to denote a problem with language that stems from atypical developmental processes (as opposed to acquired brain damage, as in stroke or head injury) and to convey the serious nature and potential long term consequences of language deficits. DLD includes SLI, but allows for more variable non-verbal cognitive abilities. Including 'disorder' in the diagnostic label also provides consistency with other neurodevelopmental conditions such as 'autism spectrum disorder' or 'attention deficit hyperactivity disorder'.

Language is a multi-faceted system and it is likely that children will show variable patterns of skill and deficit. Efforts to identify sub-types of language disorder have generally not been successful and many large scale studies report that assessments of different language domains tend to load on a common language factor (Tomblin & Zhang, 2006). The current recommendation is that clinicians outline the particular child's profile of strength and deficit, recognising that this profile may change over time.

Phonology/speech sounds: Phonology is concerned with the rules that govern how sounds are combined together in words. Children with phonological deficits may fail to distinguish between certain speech sounds, such as 't' and 'k', so that 'cat' is produced as 'tat'. While these sorts of phonological errors are common in typically developing toddlers, some error patterns are atypical (e.g. replacing 't' with 'k' so that 'cat' becomes 'kak'), and most errors resolve by the time children are 4-5 years old (Bowen, 2015). Persistent phonological deficits may reduce intelligibility of speech and difficulties identifying and manipulating speech sounds within words (phonological awareness) is associated with difficulties learning to read.

Grammar/syntax: Grammar refers to the rules that govern how to combine words into sentences (syntax) and how to combine parts of words together such as adding grammatical endings to verbs like -ing or -ed (morphology). Grammar is often a disproportionate area of deficit for children with DLD. For instance, a child with DLD may say 'him walk to school', instead of 'he walked to school with his friends yesterday'. Comprehension of sentences can also be affected, especially when word order does not convey who did what to whom. For instance, there may be difficulty understanding sentences like 'the boy was chased by the girl' as children with DLD may interpret this as the boy doing the chasing.

Semantics: Semantics refers to children's ability to understand the meaning of words and how words are related to one another. Children with DLD often have difficulties learning new words. They may therefore have limited vocabularies and the words they do know may not have the same depth of understanding seen in children with typical language development (McGregor, Oleson, Bahnsen, & Duff, 2013).

Discourse and Pragmatics: Discourse refers to longer stretches of connected language, like conversation and narrative. Children with DLD very often have deficits in narrative (i.e. telling a story in a logical, coherent sequence) (Gillam et al., 2018) and may find it difficult to maintain the thread of conversation. Pragmatics refers to the appropriate use of language in social contexts. Pragmatic deficits may manifest as poor at turn-taking in conversation, maintaining the topic of conversation, or being able to repair conversations that breakdown by asking for clarification. Pragmatics may also refer to the comprehension and use of linguistic forms that rely on context to disambiguate meaning, for example, non-literal language like metaphors and idioms, or making an inference (Adams, 2002).

Prevalence

Prevalence estimates of DLD may vary depending on the severity criteria for language, and whether or not non-verbal ability is used as an exclusion criterion. The most recent UK population study (Norbury et al., 2016) yielded a prevalence estimate at age 5-6 years of 7.58%, equivalent to two children in every Year 1 class. An additional 2.34% of children met criteria for language disorder, but also had intellectual disability and/or another known biomedical condition, such as autism or Down syndrome. The functional impact of DLD was evident in that only 12% of children identified as having DLD met early curriculum targets.

While clinical reports suggest more boys are affected, epidemiological studies have not identified sex differences in prevalence (Norbury et al., 2016; Tomblin et al., 1997). This suggests that girls may be under-identified in community settings.

DLD rarely occurs in isolation and children with DLD are at increased risk for a range of co-occurring conditions including:

Attention deficit hyperactivity disorder (ADHD)

Motor deficit (e.g. Developmental Co-ordination Disorder)

Reading disorders (including both dyslexia and reading comprehension deficits)

Speech sound disorders

Social, emotional, and behaviour problems

In adolescence, children with a history of DLD are twice as likely as peers without language disorder to experience internalising, externalising, and ADHD-type psychopathologies (Yew & O'Kearney, 2013) and approximately 1/3 of adolescents referred to tertiary child and adolescent mental health services have previously unidentified language disorder (Cohen et al., 1998).

From school entry DLD is persistent and characterised by parallel rates of language growth relative to peers (Law, Tomblin, & Zhang, 2008; Norbury et al., 2017). As a consequence, there is currently little evidence that children with DLD are able to narrow the language gap with typically developing peers. Young people with DLD are therefore more likely to leave school with fewer academic qualifications (Snowling, Adams, Bishop, & Stothard, 2001) , and may experience on-going problems with employment, intimate relationships, and mental health (Conti-Ramsden, Durkin, Toseeb, Botting, & Pickles, 2018; Johnson, Beitchman, & Brownlie, 2010).

What we already know

Causes

A common perception in the general public is that DLD results from poor parenting and a lack of appropriate language input during development. While there are social gradients in language, such that DLD is more common in areas of socio-economic disadvantage (Law, Charlton, Dockrell, Gascoigne, McKean, & Theakston, 2017), it is in fact a much more complicated picture.

There is strong consensus that DLD is heavily influenced by genetic factors (D. V. M. Bishop, 2006). This evidence comes from twin studies, in which two twins are growing up together in the same household. These studies capitalise on the fact that there are two different kinds of twins; identical twins, who share the same genes, and non-identical (fraternal) twins who are genetically different. The question twin studies try to answer is 'how similar are twins on measures of language?' As all twins are exposed to the same home environment, differences in the strength of similarity between identical and fraternal twins is suggestive of genetic influence. Numerous studies have shown that while non-identical twins may differ radically in their language skills, identical twins tend to be much more similar in language ability. Of course, there can be some variation in the severity and persistence of DLD in identical twins, indicating that non-genetic factors (such as chance experiences, differences in school or peer experiences, illness, etc.) affect the course of disorder, but it is unusual to find a child with DLD who has an identical twin with typical language.

The recognition that genetic factors play a role also informs us about environmental circumstances. Many children with DLD will grow up to be adults with DLD. They will likely have lower levels of literacy and educational attainment (Snowling et al. 2001) and this may result in fewer opportunities to obtain high paying jobs (Conti-Ramsden et al. 2018; Johnson et al. 2010). Reading books to children or verbal communication may not come naturally to some parents of children with DLD. Thus, although there is considerable evidence that DLD is more common in children from socio-economically disadvantaged backgrounds, but this likely reflects both genetic and environmental vulnerabilities (D. V. Bishop, 2014).

Just because genetic factors are important does not mean that we are powerless to intervene. Parent language input and conversation, education, and specialist language interventions can all make meaningful improvements to children's language and communication skills.

Diagnosis and assessment

Longitudinal studies consistently demonstrate stability in language status from school entry, with greater instability when children are identified in the pre-school years (Bornstein, Hahn, & Putnick, 2016; McKean et al., 2017). More specifically, about 40% of children identified with language delay by age 4 have spontaneously resolved by school entry (D. V. Bishop & Edmundson, 1987). Early language skills predict small amounts of variance in later language ability (Duff, Reen, Plunkett, & Nation, 2015) and therefore universal screening is not recommended as it is not reliable enough and identifies too many false positives (D. V. Bishop, Snowling, Thompson, Greenhalgh, & consortium, 2016).

Consideration of multiple risk factors may improve identification (Christensen, Taylor, & Zubrick, 2017). Risk factors associated with persistent DLD include:

Family history of language or literacy deficits

Socio-economic disadvantage

Poor maternal education

Lower non-verbal cognitive abilities

Early developmental delays

DLD in the classroom may be difficult to notice if the child is quiet and able to follow the actions of other children in the classroom, without truly understanding the language or instructions. Teachers are more likely to notice obvious speech problems and/or behaviour difficulties, difficulties learning core curriculum content, and problems with learning how to read. Children presenting with such difficulties in the classroom should be referred for a language assessment.

Speech-language therapists are the primary professionals charged with assessment and diagnosis of DLD in the UK, though a multi-disciplinary team may be required for differential diagnosis of an associated biomedical condition. Associated conditions may include:

autism spectrum disorder (ASD)

sensori-neural hearing loss

neurodegenerative conditions

brain injury

acquired epileptic aphasia in childhood

genetic conditions such as Down syndrome

cerebral palsy

intellectual disability

Diagnosis of DLD requires the following:

The child has significant language deficits relative to age expectations that create obstacles to communication or learning in everyday life,

The child's language problems are persistent and unlikely to resolve by five years of age,

The problems are not associated with a known biomedical condition, as listed above

Diagnosis will involve parent/carer interview of family history, observation of the child's language and communication strategies in everyday contexts, and direct assessment of language skills using standardised assessment. Tomblin (Tomblin et al., 1997) proposed that assessment focus on the EpiSLI criterion: five composite scores representing performance in three domains of language (vocabulary, grammar, and narration) and two modalities (comprehension and production); clinicians may rely more heavily on omnibus tests of language, and measures of narrative ability have been shown to have good prognostic ability (D. V. Bishop & Edmundson, 1987). Cut-off scores on these measures are arbitrary, though typically children scoring in the lowest 7-10% on two or more composite scores are identified as having DLD. Test scores should always be considered in relation to functional impact (i.e. how language is impacting on school, social relationships, and self-esteem) in the diagnostic process.

Treatment

Currently, treatment for DLD is variable and many common approaches lack a sound evidence base. Service delivery may be focused on 'tiers' or 'levels' of intervention, including Universal approaches designed to benefit all children (e.g. specific training packages for education staff focused on enhancing language development), Targeted interventions that may be aimed at children with less severe deficits and carried out by non-specialist providers, and Specialist services in which SLTs provide direct and/or individualised treatments to children with the most-significant needs (Ebbels, McCartney, Slonims, Dockrell, & Norbury, 2018).

Large scale, high-quality randomised controlled trials are still relatively uncommon in the field and this makes it difficult to assess clinical efficacy (see Law, Dennis, Charlton, 2017, Cochrane Review protocol for overview). Children's language will improve over time, and without controlled studies, it can be hard to know how much of observed change is down to a specific treatment approach (cf. (Wake et al., 2011). In general, trials show significant, positive treatment effects for direct interventions with specific language targets including vocabulary, expressive grammar, and some elements of narrative and discourse (see Ebbels et al. 2018 for a summary). Receptive language skills appear much more resistant to treatment. Large scale studies of targeted language interventions show more variable outcomes (Bleses et al., 2017) and at best, modest treatment effects (Burgoyne, Gardner, Whiteley, Snowling, & Hulme, 2017; Fricke et al., 2017). Available evidence suggests that interventions in which education staff are asked to be the main delivery agents of SLT intervention, without on-going monitoring and support from specialist services (i.e. the "consultative" approach) are not effective (McCartney, Boyle, Ellis, Bannatyne, & Turnbull, 2011).

The take home message seems to be that children with DLD can learn aspects of language that they are specifically taught, but this learning rarely generalises to other aspects of language or other academic/developmental skills. In addition, changing a language trajectory remains challenging and is likely to take considerable time and on-going effort.

Areas of uncertainty

Despite recent advances in understanding the biological basis of DLD, we are still a long way from understanding how various genetic risk factors influence brain development, how differences in brain development affect learning, and why these differences would have disproportionate effects on language learning (Krishnan, Watkins, & Bishop, 2016). Nor do we fully understand how genetic and environmental influences interact to yield the heterogeneous profile of DLD that we see.

We don't know whether or how language disorders could be prevented, in part because early assessment of language is less reliable and therefore not strongly predictive of later language ability (Bornstein & Putnick, 2012). Many practitioners and policy makers advocate for early intervention, but a large percentage of young children will make significant language improvement without intervention. Prioritising the under-5s could therefore result in treating large numbers of typically developing children and divert precious therapy resources from children with persistent language learning needs (Norbury, 2015). On the other hand, resolving language disorder after the age of 4 is challenging. We need to know if there is an optimal age to intervene, and whether there may be periods later in development when intensive intervention may be particularly beneficial.

We know that children with DLD are at increased risk for poor social, emotional, and behavioural outcomes. We don't understand the mechanisms that underpin this risk but school failure (Tomblin, Zhang, Buckwalter, & Catts, 2000), variable education provisions (Bao, Brownlie, & Beitchman, 2016), poor peer negotiating skills (Im-Bolter, Cohen, & Farnia, 2013) and poor emotion recognition/regulation (Salmon, O'Kearney, Reese, & Fortune, 2016) are all potential candidates. Given the large numbers of children with DLD presenting to CAMHS services, we urgently need to know how children with DLD access 'talking therapies' and what modifications to standard psychological treatments are required to ensure maximum benefit for children with DLD and their families.

Our intervention evidence base is improving all the time, but we are still a long way from understanding what kinds of interventions work best, when, and for whom. In general, short periods of intervention may be sufficient to teach new vocabulary or grammatical forms (Ebbels, van der Lely, & Dockrell, 2007), but making significant improvements to a child's overall language function is likely to take considerable time and sustained input (McCartney, 2017). We do not know the impact of common co-occurring conditions, such as general cognitive deficits, attention deficits, motor deficits, on response to treatment, or whether improvements in language functioning generalise to other aspects of development (e.g. improved social skills, behaviour, academic attainment).

Providing the dosage necessary to make significant change in language proficiency remains an on-going challenge given limited therapeutic resources. Robust studies of on-line or computerised interventions for language are almost non-existent and urgently needed to evaluate whether such approaches could supplement face-to-face interventions.

What's in the pipeline?

Previously, brain imaging studies of DLD have focused on the integrity of left hemisphere language regions in the developing brain. More recently, researchers have focused on neural circuits involved in learning and memory, particularly circuits involved in learning motor sequences and statistical regularities in language input (Krishnan, Watkins & Bishop, 2016). Such studies could elucidate how interventions might circumvent language learning obstacles, either by increasing input, or providing more explicit cues to learning.

Many children with DLD are not referred to clinical services, or may wait a long time for speech-language therapy assessment. While speech-language therapists have traditionally been employed by the NHS, more and more education services are buying therapy time directly. Therapists working in collaboration with education staff may facilitate more direct links between the child's language needs and how these impact social and academic demands of the classroom.

There is increasing recognition that children with DLD grow up to be adults with considerable language needs. To date there has been little research on this population and few, if any, services to support them. Researchers and stakeholders are now exploring ways to identify these adults and what they require in terms of skills development, employment, and mental health.

Useful resources and websites

Afasic: Parent-focused charity for families of children with DLD.

The Communication Trust: The What Works database is a searchable database of commonly used intervention programmes and a rating of the quality of evidence available for that programme.

ICAN: Communication charity providing information and support to the children's workforce
Royal College of Speech Language Therapists
speechBITE: Australian database curating published trials of intervention and treatment efficacy searchable by language domain

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Gillam, S. L., Olszewski, A., Squires, K., Wolfe, K., Slocum, T., & Gillam, R. B. (2018). Improving Narrative Production in Children With Language Disorders: An Early-Stage Efficacy Study of a Narrative Intervention Program. Lang Speech Hear Serv Sch, 49(2), 197-212. doi:10.1044/2017_LSHSS-17-0047

Im-Bolter, N., Cohen, N. J., & Farnia, F. (2013). I thought we were good: social cognition, figurative language, and adolescent psychopathology. J Child Psychol Psychiatry, 54(7), 724-732. doi:10.1111/jcpp.12067

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Krishnan, S., Watkins, K. E., & Bishop, D. V. (2016). Neurobiological Basis of Language Learning Difficulties. Trends Cogn Sci, 20(9), 701-714. doi:10.1016/j.tics.2016.06.012

Law, J., Tomblin, J. B., & Zhang, X. (2008). Characterizing the growth trajectories of language-impaired children between 7 and 11 years of age. J Speech Lang Hear Res, 51(3), 739-749. doi:10.1044/1092-4388(2008/052)

Law, J., Charlton, J., Dockrell, J., Gascoigne, M., McKean, C. and Theakston, A. (2017). Early Language Development: Needs, provision, and intervention for preschool children from socio-economically disadvantaged backgrounds: A Report for the Education Endowment Foundation.

Law J, Dennis JA, Charlton JJV. Speech and language therapy interventions for children with primary speech and/or language disorders. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD012490. DOI: 10.1002/14651858.CD012490.

McCartney, E. (2017). Commentary: So was it worth it? A commentary on Fricke et al. and Hagen et al. (2017). J Child Psychol Psychiatry, 58(10), 1152-1154. doi:10.1111/jcpp.12796

McCartney, E., Boyle, J., Ellis, S., Bannatyne, S., & Turnbull, M. (2011). Indirect language therapy for children with persistent language impairment in mainstream primary schools: outcomes from a cohort intervention. Int J Lang Commun Disord, 46(1), 74-82. doi:10.3109/13682820903560302

McGregor, K. K., Oleson, J., Bahnsen, A., & Duff, D. (2013). Children with developmental language impairment have vocabulary deficits characterized by limited breadth and depth. Int J Lang Commun Disord, 48(3), 307-319. doi:10.1111/1460-6984.12008

McKean, C., Wraith, D., Eadie, P., Cook, F., Mensah, F., & Reilly, S. (2017). Subgroups in language trajectories from 4 to 11 years: the nature and predictors of stable, improving and decreasing language trajectory groups. J Child Psychol Psychiatry, 58(10), 1081-1091. doi:10.1111/jcpp.12790

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Norbury, C. F., Gooch, D., Wray, C., Baird, G., Charman, T., Simonoff, E., . . . Pickles, A. (2016). The impact of nonverbal ability on prevalence and clinical presentation of language disorder: evidence from a population study. J Child Psychol Psychiatry, 57(11), 1247-1257. doi:10.1111/jcpp.12573

Norbury, C. F., Vamvakas, G., Gooch, D., Baird, G., Charman, T., Simonoff, E., & Pickles, A. (2017). Language growth in children with heterogeneous language disorders: a population study. J Child Psychol Psychiatry, 58(10), 1092-1105. doi:10.1111/jcpp.12793

Reilly, S., Tomblin, B., Law, J., McKean, C., Mensah, F. K., Morgan, A., . . . Wake, M. (2014). Specific language impairment: a convenient label for whom? Int J Lang Commun Disord, 49(4), 416-451. doi:10.1111/1460-6984.12102

Salmon, K., O'Kearney, R., Reese, E., & Fortune, C. A. (2016). The Role of Language Skill in Child Psychopathology: Implications for Intervention in the Early Years. Clin Child Fam Psychol Rev, 19(4), 352-367. doi:10.1007/s10567-016-0214-1

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Tomblin, J. B., Records, N. L., Buckwalter, P., Zhang, X., Smith, E., & O'Brien, M. (1997). Prevalence of specific language impairment in kindergarten children. J Speech Lang Hear Res, 40(6), 1245-1260.

Tomblin, J. B., & Zhang, X. (2006). The dimensionality of language ability in school-age children. J Speech Lang Hear Res, 49(6), 1193-1208. doi:10.1044/1092-4388(2006/086)

Tomblin, J. B., Zhang, X., Buckwalter, P., & Catts, H. (2000). The association of reading disability, behavioral disorders, and language impairment among second-grade children. J Child Psychol Psychiatry, 41(4), 473-482.

Wake, M., Tobin, S., Girolametto, L., Ukoumunne, O. C., Gold, L., Levickis, P., . . . Reilly, S. (2011). Outcomes of population based language promotion for slow to talk toddlers at ages 2 and 3 years: Let's Learn Language cluster randomised controlled trial. BMJ, 343, d4741. doi: 10.1136/bmj.d4741

Yew, S. G. K., & O'Kearney, R. (2013). Emotional and behavioural outcomes later in childhood and adolescence for children with specific language impairments: meta-analyses of controlled prospective studies. Journal of Child Psychology and Psychiatry, 54, 516-524. . doi: 10.1111/jcpp.12009

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DLD - Developmental Language Disorder - ACAMH

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Developmental language disorder (DLD) is diagnosed when a child's language skills are persistently below the level expected for the child's age. In DLD, language deficits occur in the absence of a known biomedical condition, such as autism spectrum disorder or Down syndrome, and interfere with the child's ability to communicate effectively with other people.

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What is ADHD and what help is available?

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What is ADHD and what help is available?

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25 minutes

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Free from the OU: Dyslexia and inclusive practice

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Free from the OU: Dyslexia and inclusive practice

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3 hours

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About this course
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Welcome to the course

Introduction to Dyslexia and Inclusive Practice is the first of three free online modules developed to complement the 2015 Education Scotland Route Map for Dyslexia and Inclusive Practice and support the professional standards from the General Teaching Council for Scotland.

This free module aims to provide teachers and local authority staff with an awareness of what dyslexia is, its impact and how it can be supported within an inclusive school community. It may also be of interest if you work in the vo luntary sector or simply have an interest in dyslexia and inclusive practice.

If you complete the module, you will receive a digital badge and a Statement of Participation (which can take up to 24 hours to be issued to your email address and appear in your profile).

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Please note: if you download the Word or PDF version of the learning materials to study offline and return to complete the quizzes which can only be done online, you will need to click through the online version of the learning materials to complete the criteria for your digital badge.

This course was originally published on 28 March 2017. This is the updated version, revised in March 2021.

This is the first of three modules by Dyslexia Scotland and Addressing Dyslexia with the support of the Opening Educational Practices in Scotland project.

The second module is Supporting Dyslexia, Inclusive Practice and Literacy.

The third module is Dyslexia: Identification and Support.

Dyslexia Scotland would like to offer people who have completed the 3 Modules the opportunity to sign up for free electronic membership with Dyslexia Scotland, as a way of continuing to build on their professional learning.
Dyslexia Scotland
Addressing Dyslexia Toolkit
Opening Educational Practices in Scotland

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After studying this introductory module and participating in the tasks you will have an awareness of:

The education context in Scotland and the national agenda

What dyslexia is and its impact

Dyslexia and inclusive practice

Effective communication

How dyslexia is identified

Information and practical support strategies

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OLCreate: Introduction to Dyslexia and Inclusive Practice 2.0 Introduction to Dyslexia and Inclusive Practice

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Ratings 4.1 out of 5 stars You can start learning at any time. By signing up and enrolling you can track your progress and earn a Statement of Participation upon completion, all for free.

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5 minutes

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Lots of kids struggle with math, but for some the difficulties go beyond a little bit of frustration. If your child's math troubles are serious - and persistent - they may be a sign of a learning disorder called dyscalculia.

Dyscalculia is a term used to describe specific learning disabilities that affect a child's ability to understand, learn, and perform math and number-based operations.

Though research on prevalence is limited, it's estimated that between 5 and 7% of elementary school aged children may have dyscalculia. It's also currently thought that dyscalculia occurs equally in both genders.

No. Not all difficulties in math class - even serious ones - are caused by dyscalculia. Disorders like dyslexia, visual or auditory processing, ADHD, and others can also impact a child's ability to meet expectations in completing math problems. It's also possible for kids who do have dyscalculia to have other learning disabilities as well. Many do.

A young child with dyscalculia may:

Have difficulty recognizing numbers

Be delayed in learning to count

Struggle to connect numerical symbols (5) with their corresponding words (five)

Have difficulty recognizing patterns and placing things in order

Lose track when counting

Need to use visual aids - like fingers - to help count

And as math becomes a major part of the school day, kids with dyscalculia are likely to:

Have significant difficulty learning basic math functions like addition and subtraction, times tables and more

Be unable to grasp the concepts behind word problems and other non-numerical math calculations

Have difficulty estimating how long it will take to complete a task

Struggle with math homework assignments and tests

Have difficulty keeping at grade-level in math

Struggle to process visual-spatial ideas like graphs and charts

The impact of dyscalculia doesn't stop when math class ends. The disorder can also affect kids outside of school. Children with dyscalculia also:

Have trouble remembering numbers such as zip codes, phone numbers, or game scores

Struggle with money matters such as making change, counting bills, calculating a tip, splitting a check or estimating how much something will cost.

Have difficulty judging the length of distances and how long it will take to get from one location to another

Struggle to remember directions

Have a hard time telling left from right

Get easily frustrated by games that require consistent score keeping, number strategies or counting

Have difficulty reading clocks and telling time

The biggest sign of a specific learning disorder is a notable discrepancy between ability and aptitude. A kid with dyscalculia may preform well in other subjects - such as English or history - but have very low grades in math and math-based classes.

In the DSM-5, dyscalculia is called "specific learning disability with impairment in mathematics," but "dyscalculia" is still an accepted term and is used by schools and learning specialists.

There is no specific test for dyscalculia. Taking the following steps can help you get your child the help and accommodations he needs.

Visit your doctor: Rule out any medical issues such as hearing or vision impairment that could be impacting your child's learning process.

Consult with your teacher: Ask your child's math teacher to note the areas where he has the most trouble, and any and all strategies that help.

Ask about other areas: It's estimated that as many as half of kids with dyscalculia also have another learning issue. Understanding your child's complete learning profile will help you advocate for his needs

Consult a specialist: Once you've done the groundwork, talk to a learning professional who can evaluate your child and give you specific feedback on how to help.

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How to Spot Dyscalculia - Child Mind Institute

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When math difficulties mean something more - what are the signs, symptoms causes and condition of dyscalculia, for parents and educators.

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35 minutes

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Association for Child and Adolescent Mental Health

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Developmental Coordination Disorder - Professor Amanda Kirby

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6 minutes

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At own pace.

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How can you support autistic children and young people? Explore all of the resources created by the Autism Education Trust, independently and in partnership

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5 minutes

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Childhood Trauma and the Brain | UK Trauma Council

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30 minutes

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Dr. Jennifer Shields & Dr. Sarah Brown discuss Fetal Alcohol Spectrum Disorder (FASD) with freelance journalist Jo Carlowe.

FASD is the most common preventable non-genetic cause of neurodevelopmental disorders in the UK. FASD is an umbrella term used to describe the range of effects that can occur in an individual with prenatal alcohol exposure. These effects can have lifelong implications including physical, mental, behavior, and/or learning issues.

You can listen to this podcast directly on our website or on the following platforms; SoundCloud, iTunes, Spotify, CastBox, Deezer, Google Podcasts and Radio.com (not available in the EU).

Transcript

Intro Speaker: This podcast is brought to you by the Association for Child and Adolescent mental health, ACAMH for short. You can find more podcasts and other resources on our website www.acamh.org and follow us on social media by searching ACAMH.

Interviewer: Hello. Welcome to the in conversation podcast series for the Association for Child and Adolescent mental health or ACAMH for short. I'm Jo Carlowe, a freelance journalist with a specialism in Psychology. Today I'm interviewing principal clinical psychologist Dr. Jennifer Shields and consultant paediatrician Dr. Sarah Brown of the Scottish government fetal alcohol advisory and support team. Jennifer and Sarah will be giving us an overview on fetal alcohol spectrum disorder, FASD, which is the most common preventable non-genetic cause of neurodevelopmental disorders in the UK. Welcome Jennifer and Sarah. Can you start by introducing yourselves?

Dr. Sarah Brown: Hello. My name is Sarah Brown and I work alongside Jen in Ayrshire.

Dr. Jennifer Shields: And hi I'm Jennifer Shields. I'm a clinical psychologist based in this fetal alcoholic advisory support team.

Interviewer: Fantastic, and fetal alcohol spectrum disorder is an umbrella term for several diagnoses related to prenatal exposure to alcohol what precisely does FASD encompass?

Dr. Sarah Brown: So people may be more familiar with the term fetal alcohol syndrome, which was first described the late 1960s and 1970s seventies and that really described a syndrome where the were marked physical features such as small head, poor growth and quite distinct facial features. However, a bit like autism over the years we have realized it's much more of a broader spectrum and FASD would refer to the whole spectrum of conditions which for the vast majority in fact ninety percent have none of the physical features that you would see in the first described people alcohol syndrome group. So only ten percent would have different facial features, ninety percent of those affected by FASD have no physical features.

Dr. Jennifer Shields: According to other international classification systems, people might have heard of FASD under the diagnostic term of a new developmental disorder fetal alcohol exposed. And so that's just a different way of saying the same thing but FASD is the more recognized term.

Interviewer: Right? Thank you. There's always debate about whether or not women should drink during pregnancy. And I know in two thousand and sixteen the UK chief medical officer changed the guidance to say no alcohol should be consumed in pregnancy. So when you're talking about prenatal exposure to alcohol leading to FASD. Just how much drinking is harmful?

Dr. Jennifer Shields: To me it's a bit like drinking and driving, it's people realize that they shouldn't drink and drive because it increases your risk, and people accept that quite readily, however, when it comes to pregnancy and drinking those same risks the more you the more you more alcohol you drink during a pregnancy the higher the alcohol exposure to the pregnancy, the more likely you are of having FASD, but just because you drink during pregnancy doesn't mean that you will necessarily have an affected child. And that's what makes the messaging really really difficult.

We are certainly not advocating that people drink any alcohol in pregnancy and the arguments around what is the safe limit, is a bit like we're not having a similar conversation about what is the least number of cigarettes that you can smoke in pregnancy. It's because alcohol is so wrapped into our culture that people feel that we should be able to find the safe floor limit. But the evidence would tell us that we don't know what's safe and that's what makes the advice to be on the safest possible side of the advice being given as it's no alcohol, no risk.

Interviewer: Can you start by giving some details of the types of congenital anomalies that one sees caused by exposure to alcohol in the womb?

Dr. Jennifer Shields: So I think you can probably put these down into structural anomalies and maybe kind of more functional anomalies. In terms of the structure anomalies people may be familiar with the facial features which I mentioned briefly earlier, and that is the thinner blood that we note from new slightly smaller eye openings. We also know that alcohol can increase your risk of having a congenital heart abnormality and also differences within the way that your brain is developing. So you might have a very thin or absent corpus callosum. These are just the structural abnormalities that we can see and there's more than I've mentioned here. But what is common across all those affected previously by alcohol is the neurodevelopmental consequences of fetal alcoholic exposure.

Dr. Sarah Brown: Yeah, and in terms of the functional differences it might not be that these differences in the brain wiring would show up in a brain scan for example, but what we see are marked differences in how children are able to process information, protect extensity information, to remember to be able to problem-solve and so there's lots of thinking and cognitive problems that can be picked up through certain psychological assessments.

Interviewer: Right and how might it manifest in terms of behavioral issues?

Dr. Jennifer Shields: Yeah, so I think what's interesting about if you esteem and you think about the types of children who might present at a Child and Adolescent Mental Health Service, for example, a lot of these children are presenting with distress, and that distress might appear like significant behavioral difficulties through refusal, not wanting to remain in the classroom. They may have meltdowns at home, may lash out and and you know be verbally abusive and and seem to have meltdowns a lot of the time and sometimes this is a real relationship to how the brain is functioning and and how it might not be conducive to learning in a mainstream classroom environment where it's quite noisy. There's lots going on lots, to be filtered out, these children have very similar sensitive problems to that kids who are autistic and they have lots of learning and behavioral differences to other neurotypical children. And it just depends on them meeting a clinician who has the range of lenses in order to understand that this could be a potential explanation.

Interviewer: So what other signs are there to alert health professionals to the presence of FASD?

Dr. Sarah Brown: There are the facial features which may be picked up when a child is younger or in primary school. The main thing is taking a good alcohol history, which is something that I think people need to put more training in.

Dr. Jennifer Shields: Yeah. I mean, I guess just echoing what Sarah said about ninety percent of these children won't have facial features. The presence of an alcohol history, so that could come from a conversation that the ACAMH clinician is meeting with a family for the first time you'll might be able to ask a series of questions about pre-pregnancy lifestyle in a conversational way, not just asking did you drink in pregnancy? Because that normally illicits a "yes or no" response. Mainly a "no" response, actually asking about when somebody realized they were pregnant what the lifestyle was like up until then, what their diet, stress, smoking, alcohol or other drug taking status was, but in a very sort of conversational way and that is the sign that would alert you to the possibility of FASD. But as we said not all alcohol in most pregnancies lead to FASD.

Interviewer: And how well-trained are health professionals in asking those types of questions in what sounds like it has to be a non-judgmental way?

Dr. Sarah Brown: I think it's getting better. But I think you would agree Jen, there's a large piece of work needing done probably across many specialties within health, but also within multi-agency teams and really and education to raise the awareness and be able to speak about alcohol exposed pregnancies in our non-judgmental, non-stigmatizing manner, and I think the first step that would be embedded in our curriculums across professional groups regarding FASD in terms of awareness raising, but in particular taking that sense of alcohol history regardless of the assessment process that you think you might be needing to do. So if a child is brought in for an autism assessment I still think there's merit in taking a good alcohol history as part of your your developmental process.

Interviewer: In my intro I described FASD as the most common preventable non-genetic cause of neurodevelopmental disorders in the UK. Just how big is this problem? What is the prevalence?

Dr. Sarah Brown: Well, there is, I have to be upfront and say there's a lack of research in this area, I guess we've got the problem where there's no data. There's no problem. There's no action. And therefore there's not been a lot of impetus to get data unless until fairly recently, but there has now been in the last year Sharon Maguire and colleagues in Bristol did a screenings study. So this isn't about diagnostic outcomes, but from screening a large cohort of individuals as part of a previous study their estimates lie between six percent and seventeen percent. That sounds like a very high number, but when we look at the biological data that we have from a Glasgow based study which looked at meconium and biomarkers of alcohol, they found that forty percent of the children born had alcohol biomarkers and actually fifteen percent had those biomarkers to a very high level which indicated routine drinking in pregnancy to levels that would be teratogenic to a fetus. So it's a big issue that we need to confront.

Interviewer: I'm wondering whether people with FASD are unaware of what is happening to them and why they have the issues they have?

Dr. Sarah Brown: A really good question. I think a lot of the time the individuals that we've spoken with, in particular the adult community tell us that they're very aware that things are different for them, that they don't seem to fit this world like they see their peers coping with school and relationships and independent living and particularly for teenagers these individuals are very self-aware that things aren't right. And the consequence is that they have misunderstood presentations to see cams or mental health services at large and and receive interventions for things in like merging anxiety at really underpinning reason for that, difference is something new development and it's not been understood.

Interviewer: How is FASD diagnosed, when it all goes right. What happens?

Dr. Sarah Brown: So I think it would depend on the age of the individual. If a wee one is born and we know that there has been a high level of alcohol exposure during pregnancy. It may have a small head circumference, it may have facial features and that's something that can be detected you know at birth or shortly thereafter, and appropriate diagnoses depending on the timing and the family situation. It may be potentially diagnosed by that point. I was say for the vast majority it's later on during either childhood or into adulthood and that would depend on their physical presentation. But also the new developmental presentation. We certainly see children presenting at different ages and it seems to relate to when the kind of environment becomes slightly less supportive. So it might be going from preschool years and Nursery into primary one or reception think in England. Equally when it gets about middle school, middle primary school and children are being expected to do a little bit more for themselves, that might be where there's a bigger gap growing between them and their peer groups.

And again to secondary school, that's a big time for referral simply because the environment is not as supportive. You don't have a single classroom. You've got to get yourself around schools. So once the concern has been flagged up and if we have a positive alcohol history, then that is actually referred in boring your developmental assessment. And as part of that new development assessment, we would look to see what we think is the most likely cause that you would with any presenting industrial illness as an edit or is the psychologist?

And I think that if you felt that alcohol was a significant contributing factor, then we would involve our wider multiple disciplinary team. When the child is I mean, it's very difficult to do this I would say under the age of five even maybe seven depending on the child's ability. So it's often kind of that middle primary school age where they present, and at that point if they were having difficulties learning to ride a bike or are quite clumsy. You can catch a ball, tie their shoelaces, if it was functional difficulties related to their fine motor, gross motor skills. We would ask our colleagues in occupational therapy to see the child and assess them.

Dr. Jennifer Shields: For me having an assessment of their language standardized assessment can be very very useful. We know that the children, young people are often able to express themselves very, well. It may not be entirely age appropriate as to the peer group, but it is good enough that you wouldn't necessarily pick up on there being a big difference in the content or structure of their language, but that can often mask a difficulty with understanding language and they can be very lost within busy settings and busy classrooms and more complex instructions. So for me referring on to speech and language therapy to get a good understanding of both their core language skills, and the pragmatics of their language is really really important.

My role as a pediatrician is to look for I suppose the underlying cause or any associated health conditions. So for me, it's great examining whether they have any birthmarks, any structural abnormalities, if their head size is appropriate for their age. If they have any facial features. And but also thinking about any inherited vulnerability, so any genetic contributions that may make a child more prone to having some learning difficulties or difficulties with education or mental health issues. Another line of my work is in children who are care experienced. These are children who've been in the looked after in accommodated service, and often the histories that you have for these children are very patchy and the understanding they have of their family makeup or their family history can be lacking. I think it's particularly important for this group to ensure that there's not been a small inherited micro-deletion or duplication, which is the one small change in your genetic material, because that may offer an explanation as to why their parents struggle to meet their needs. And that might be in addition to a prenatal alcohol exposure because of moms difficulties, and knew what she was facing in life. So I think it's all about piecing together information as a pediatrician about that medical history and health history and any head injuries or severe illnesses really that might also have contributed to a new developmental picture. I think that one of the biggest kind of pieces of work is by my colleagues in Psychology and although Jane is the principal local psychologist for this we do work within a team where we have the skills within a cam psychology department who can all work with these these young people.

Interviewer: Right, you've described best practice, but how good are clinicians and other health professionals at making a correct diagnosis? Does that good practice happen enough?

Dr. Jennifer Shields: Well at the minute, I think it's fair to see that there are only two main centers or health boards that are providing that systematic approach to FASD assessment, and there are pockets of good practice happening in other health boards. But it's just new and emerging within their new developmental pathways. And so to my knowledge in Surrey and borders there's the national FASD center. Run by Dr. Raja Mukherjee and partners in Psychology. And he's also a consultant psychiatrist for a number of new developmental conditions, so, he's a very suddenly spread resource I must say. And there's ourselves in NHS Ayrshire and Arran but within Scotland we've been trying to encourage other health boards, and they are doing as I said pockets of assessment here and there for fetal alcohol spectrum disorders. Generally in a multi-disciplinary neuro developmental pathway approach. It's not specialist centres like you have in Surrey in England. So I feel like we have got a long way to go, but the fact that Scotland have now produced signed guidelines so it's sort of the move to the nice guidelines in England and we understand now in England there will be a nice quality standard for FASD which I hope will promote in clinicians and health professionals to get training to make the correct diagnosis because I think the risk of misdiagnosis is high and I think the further risks as a society of us to know what to identifying this will have huge impact on prevention or the lack of prevention.

Interviewer: So if the condition is misdiagnosed, mistaken, perhaps for autism spectrum disorder or ADHD. What harm is caused by that misdiagnosis?

Dr. Jennifer Shields: Well I think for some of those children there will be benefits of being understood as having a typical neurodevelopment and certainly, you know, children can benefit from stimulant medication, but perhaps for children with FASD there are going to be brain areas that are affected beyond social communication, social interaction that aren't identified and therefore the interventions that follow will not fit the profile of that child. And similarly, if children are misdiagnosed as having ADHD, and actually the reason for their distractibility, fidgetyness and impulsivity is coming from more a brain structured place rather than a neuro chemical place then potentially these children will have medication that has limited efficacy and certainly even in the kids that have FASD and ADHD there are different medications. That would be your first line medication that is different to general pathway for ADHD management.

But I mean, I'm a psychologist speaking about this but I've learned a lot from psychologists and psychiatrists who work in the FASD field and I hope I'm doing a good enough job to represent your thinking on that. But I think it's about accurate diagnosis coming from a good understanding of the profound strengths of different difficulties. If you think it's autism or ADHD, then you're going to be missing a large part of the picture.

Interviewer: So what happens when a correct diagnosis is made how are children with FASD and their families helped and perhaps you can talk about some of the existing interventions?

Dr. Jennifer Shields: Yes. So I think the correct diagnosis also comes as part of a bigger picture of the correct understanding of the brain profile. So for example, if a child has got language comprehension difficulties that are now eliminated by speech and language therapy that their motor difficulties are understood, that we can see that their executive function is very difficult for them to control and pulsivity, for example, there's a whole range of environmental and and multi-disciplinary interventions that would affect that profile. It's really about making sure the child gets the right understanding and sometimes very simple environmental adaptations in the school environment can have a huge benefit to the child. So bringing down the sensory stimulus changing the position in class, the teacher knowing about the comprehension problems, knowing about the motor difficulties, seeing that impulsivity in a different light as our brain based problem, not just behavior, can change the responses of others, the understanding of the family and can provide a meaningful lens by which the child's behaviors, distress and emotions can be understood. So there's lots of things that we can do for these children, but it does follow the correct profile and diagnosis being constructed.

Interviewer: What does the research show us with regard the efficacy and effectiveness of the existing support and interventions for children with FASD?

Dr. Jennifer Shields: The broad strokes of that is that the earlier that you identify and diagnose with appropriate the better the outcomes are for children, because people understand them, they are able to adapt the environment, adapt communication and offer support where appropriate. So, basically the evidence states if you're able to provide that understanding in the diagnosis before the age of eight, then you have got the greater ability to augment the trajectory of that child and steer them away from the negative outcomes, which can be you know, disengagement from school, addiction problems, homelessness, unemployment, and I guess generally being misunderstood for much of their adult lives. These children function at a different level to their chronological age.

So, as Sarah said adjusting expectations can have a huge meaning to families and to the individuals themselves and our adult community, tell us that that being understood is the most important bit. And actually that is what helps them to find a new self-identity, self-concept and does reduce the likelihood of mental health problems because in those who aren't identified 95% will have mental health difficulties. So it's as much as trying to promote the positive and harness the strengths and also trying to diminish all the barriers that lie in the way of the child and to avoid those negative outcomes.

Interviewer: If it is known that there has been prenatal alcohol exposure. Is there anything that can be done preventatively to reduce the risk of FASD?

Dr. Sarah Brown: I think the most important thing is to recognize if you're pregnant. Even if you have been drinking stopping drinking any further alcohol is extremely beneficial.

Dr. Jennifer Shields: The other thing is that the children that the research that we know about these children indicates that if you're able to offer stability particularly from an attachment perspective having care givers who are attuned, that they are these children protected from any trauma or further victimization because a lot of these children do have those complexities, but they don not cause the degree of neuro developmental difference as you know attachment trauma, and I went to be clear on that. But if there is to be harm reduction it is stopping alcohol at the earliest point ensuring the pregnancies are well supported, that the diet is good and in mom-to-be and that yeah, those those early years that is well supported as possible.

Interviewer: Right, and talking about research are either of you working on any specific trials or projects with regards FASD that you'd like to share?

Dr. Jennifer Shields: Yes so our teams looking to be much more active in the research fields, we're looking to build up evidence on the neurodevelopmental profiles of these children using all the results of the multi-disciplinary team assessments. But I think most importantly we are looking to hear the voices of those who have the lived experience and what we want to find out is perspectives on FASD diagnosis from the perspective of birth moms, from adoptive parents, from the individuals themselves who have FASD and to see what they think about how our future services should be shaped. So that's our priority for our team We are also going to be writing up papers on our service evaluation that we conducted in NHS Ayrshire and Arran, and we've also got interesting genetic findings that Sarah is looking to explore. So but with our partners in FASD, we've got some parenting intervention work that we're looking at and we're also excited to hear our colleagues are looking at active case ascertainment in England, which I think will be really helpful in terms of being able to get people that definitive answer of how prevalent FASD is in the UK. So there's lots happening, but we need lots more people to be interested in FASD and to help take that forward.

Interviewer: With regards the near future, what else is needed either in terms of research or policy that you would like to see come to fruition?

Dr. Sarah Brown: I think that what I would like to see is this been given a much higher recognition and platform within governments and also within the research communities of universities. The funding that is attributable to FASD is very very minimal and it is an area where we need so much more research and for it to be seen as being the priority that it needs to be in terms of improving the kind of social economic outlook for not just individuals, but also society and the damage that alcohol can do prenatally. And I think to me that would be be something that we all need to work on to get it on to the agendas of policy makers, funders and people who develop curriculums for all the relevant and professionals involved in care of young people and adults.

Interviewer: That's great, we've covered an awful lot. Is there anything else you'd like to add perhaps as a takeaway message for those listening to this podcast?

Dr. Sarah Brown: I mean I think for me I always say to people when I'm giving a lecture that if you don't remember anything else from this apart from no alcohol, no risk. If you protect any future pregnancies that you have from prenatal alcohol exposure. If you can spread that message with your family members, nieces, nephews, boyfriends, husbands. I mean to me it's about everyone playing their part in the prevention message. And it's as simple as if you're drinking don't drive. If your drinking it should be that you avoid pregnancy and ensuring that contraceptive options are explored both for the young people we work with and for anybody really in the community and I think that no alcohol, no risk message needs to be really used in lots of the contacts we have with people both socially and professionally.

Dr. Jennifer Shields: Yeah and for me, I think for me it's FASD is everybody's business whether you work or are a researcher in criminal justice, in addiction and mental health, in child and young people's health. Whether you work in cardiac or whether you work in a clinic that's for for something else. This has got to be on your radar. It's affecting so many people in so many different ways and many of which we don't understand that we can't allow this to just be something that child mental health or paediatric departments need to be involved in. This has got to be everybody's business and prevention is key. And for those that are affected. They just want to be seen. They describe themselves as hidden in plain sight and they require identification, diagnosis and support like any other child and we just need to make sure we upskill as many people as we can and raise awareness of FASD and that's why we thought this podcast would be a great thing to do and if people are able to share that then we would be very grateful.

Interviewer: Right, fantastic it's been really fascinating. Thank you Dr.Jennifer Shields and Dr.Sarah Brown for your enlightening overview of fetal alcohol spectrum disorder. For more details visit the ACAMH website www.acamh.org and Twitter at ACAMH. ACAMH is spelt ACAMH.

Outro: This podcast was brought to you by the Association for Child and Adolescent mental health, ACAMH for short.

ENDS
Principal Clinical Psychologist for the Scottish Government Fetal Alcohol Advisory and Support Team (FAAST) based in NHS Ayrshire and Arran. Principal Educator for Autism (NHS Education Scotland)
Following two years working for the West Dunbartonshire Acquired Brain Injury Service, Dr. Shields completed her Doctorate in Clinical Psychology at the University of Glasgow. Alongside her clinical post within the Child & Adolescent Mental Health Service in North Ayrshire, she also completed a Post Graduate Diploma in Paediatric Clinical Neuropsychology at University College London. Dr. Shields has a longstanding interest in neurodevelopmental conditions and acquired brain injury. She was a member of the working group for the SIGN Guideline for Autism (145) and is currently a member of the working group for the SIGN Guideline for FASD.
Consultant Paediatrician, Rainbow House Child Development Centre, NHS Ayrshire & Arran
Dr Brown has longstanding interests in advocating for the needs of Looked After and Accommodated Children and is the Lead Paediatrician for LAAC Health within Ayrshire. Dr Brown is the Lead Clinician for the Scottish Government Fetal Alcohol Advisory and Support Team and is committed to supporting the nationwide development of FASD services and improving clinician confidence in the diagnosis of FASD. She regularly teaches and presents at conferences on Fetal Alcohol Spectrum Disorders and is a member of the FASD SIGN Guideline Group.

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In Conversation... Fetal Alcohol Spectrum Disorder (FASD) - ACAMH

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Dr. Jennifer Shields & Dr. Sarah Brown discuss Fetal Alcohol Spectrum Disorder (FASD), the most common preventable non-genetic cause of neurodevelopmental disorders in the UK.

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40 minutes

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Harry J. Thompson was born in Edgware and grew up in Barnet in north London. He is currently based in London, UK. An avid reader & researcher, Harry speaks publicly and is heavily involved in projects & research on all topics around neurodiversity and autism; namely, Pathological Demand Avoidance, a behavior profile within the Autism Spectrum.

Harry began to write the first draft of his book in 2015. After connecting with many autistic & PDA families, he pivoted his direction and completed his book in about 6 weeks, a memoir entitled the PDA Paradox: The Highs and Lows of My Life on a Little-Known Part of the Autism Spectrum, published in February 2019. He launched his YouTube channel in 2017.

Harry has been elected to a Fellowship of the Royal Society of Arts (FRSA), in recognition of his work in the field of PDA, and also in recognition of the publication of his book.

BACKGROUND READING

The PDA Paradox, PDA, Harry's website, Harry's YouTube channel, Harry's Facebook page

Download a transcript of episode 54, made possible by supporters in our Patreon family. Click to join them.

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Episode 54: Understanding Pathological Demand Avoidance - The Neurodiversity Podcast

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Pathological Demand Avoidance is a newer concept for many in the US, but it's old hat for Harry Thompson.

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20 minutes

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There are some ups and downs to navigate when you're the only kid in school with hearing loss. Hear what it takes to go mainstream and what accommodations are needed.

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Executive Skill Building in Teens with Tourette Syndrome

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CPD Online Short Course: An introduction to speech, language and communication

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CPD Online Short Course: An introduction to speech, language and communication

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Own pace

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Supporting the visually impaired learner

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Supporting the visually impaired learner

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20 minutes

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Exploring common issues faced by blind and partially sighted students, and tips for achievement in the classroom
It is estimated that around 25,000 children and young people in England and Wales have a sight impairment that requires specialist education support. Of these, more than 60 per cent are educated in mainstream schools where their requirements might not be so easy to address. As many as half of young people with a sight impairment also have additional disabilities. So how can schools ensure that blind and partially sighted learners are best supported?

According to the Royal National Institute of Blind People (RNIB), severe visual impairment or blindness can substantially delay early childhood development and learning. Even a moderate visual impairment can have a notable impact. So what are the learning issues that schools should consider?

The main functional effects of visual impairment include central or peripheral vision loss, poor image sharpness, low contrast sensitivity or adaptability to light, and impaired eye movement or colour loss; but not all visual impairment is the same. A person's "functional revision" is a key concept here, referring to what can be seen, rather than what can't.

Adopting this mindset allows educators to consider how a learner's level of useful vision can be maximised. Considering the practical implications for the individual learner is vital; the distinctions in their educational needs will have a direct impact on the teaching and learning approaches required.

Blind learners

Educationally blind learners have a level of sight that is insufficient to learn visually, and so rely on their other senses. Distinguishing between those who have had some past sight and those who have never seen, may influence the visual concepts they can understand.
Questions to consider:

how much sight, if any, does the learner have and how useful is it?

how competent is the student with Braille and tactile skills?

what experience of vision does the learner have, if any?

how competent is the student in moving around the classroom independently?

Partially sighted learners

Partially sighted learners still work primarily through the visual medium, and make up the majority of learners with visual impairment. Their needs vary considerably and many work with normal print, which can create difficulties as their needs may be underestimated.
Questions to consider:

is the student's level of sight stable or variable and under what conditions?

is the learner's field of vision restricted?

what size/style of print is comfortable for the student?

does the learner have particular preferences for the learning environment, in terms of, for example, lighting or choice of seat?

Impact on learning

Stevie Wonder said, "Just because a man lacks the use of his eyes, doesn't mean he lacks vision." This is an important lesson; we may be inclined subconsciously to have different expectations of academic achievement for learners with visual impairment, but there is no direct correlation between visual impairment and intelligence. Most learners with visual impairment have the same range of intelligence and abilities as their sighted peers, just with additional barriers. More than a third will have some additional needs that may affect their learning.

Of course, additional barriers can affect a number of areas, such as the speed of working, communication skills (particularly reading or writing), environmental and spatial awareness, and social interaction, with a reduced ability to recognise body language and facial expressions. As a result, students can suffer from lower self-confidence which can have a negative impact on learning.

What is needed to succeed?

Inclusion is key to the successful education of students with visual impairment. According to The Centre for Studies in Inclusive Education, inclusive education means disabled and non-disabled young people learning together in ordinary school provision, with appropriate networks of support. They should have access to the same information, at the same time and, if possible, in the same way to participate in and enjoy mainstream settings to the best of their abilities, whatever their needs. Leoni Masterson, qualified teacher of the visually impaired (QTVI) at Linden Lodge School, explains: "Blind and visually impaired students face barriers to learning. If we can break down these barriers through tactile resources, we are promoting inclusion. They can take part in activities they've not been able to before."

In mainstream settings, it is important to make the most of specialist support that is available. Many mainstream educators will not have the skill set to teach specialist areas such as Braille, but QTVIs can visit and work closely with schools to advise how to meet children's needs through inclusive teaching and learning methodology. Each local authority has a vision impairment service which includes at least one QTVI.

Educators should also consider what they can do to enrich the learning process. As Leoni notes, "Visually impaired and blind children need a rich learning environment as sometimes they miss out on the visual clues." Sighted children's learning is constantly reinforced by things such as colours, shapes, people and landscapes. These give us a wealth of information subconsciously. Learners with visual impairment have reduced opportunities for incidental learning, so it is important to include as much multi-sensory learning in the classroom as possible, such as touch or smell. Also consider that visual and spatial concepts need more explanation; many learners with visual impairment struggle with concepts such as brighter versus darker, or telling which object is bigger at a glance.

Social inclusion is also important. Helen Keller said that "The chief handicap of the blind is not blindness, but the attitude of seeing people towards them." To reduce the risk of the student being ostracised by peers, consider the Circle of Friends approach, designed to enhance inclusion in a mainstream setting. It creates a support network for the student, with a peer group encouraged to look at their own behaviour, and understand the behaviour and difficulties of the student with visual impairment, in order to develop strategies and practical solutions to help them. In time, this can close the gap whilst strengthening core social skills.

Tips and ideas for the classroom

The classroom environment can have a significant impact on the success of teaching and learning. On top of dealing with core health and safety issues, it is important to consider the room's sensory nature. Your school might have had an audit conducted by a QTVI to suggest improvements, but here are some questions to consider for your classroom:

is the space clear and tidy to allow easier movement?

are frequently used resources kept in the same accessible place, and labelled?

is the level of lighting right for the learner?

are learners with visual impairment sitting close to a power source if they are using accessible ICT devices?

do you use real objects to support your teaching?

have you allowed adequate space for any special equipment or large print resources to be stored and used?

Accessible resources

Jennifer Williamson, resources technician at Joseph Clarke School, highlights the importance of accessible resources: "For students who have visual impairment, it is really important to strengthen their learning; therefore, learning materials need to be interesting enough to engage them."

Consider the issue of time for both staff and students. Visually impaired learners will often require extra time to process information and complete tasks, so using the simplest formats can help them. Make sure you and any support staff have the time to modify materials to include, for example, larger print or bolder colours. Providing both a print and a digital copy can be useful as this can be further adapted by the student to suit, if needed.

If you don't have time to modify items, look out for pre-created versions; a wide range of Braille materials, audio-visual resources, and tactile pictures and diagrams is available from various educational suppliers.

Role of access technology

Access technology has enormous potential for supporting learners with visual impairment across different ages and abilities. Assistive technology, such as audio-visual devices or software, allows students to work at their own pace and, with the right training, often independently. Technology isn't a magic wand, though; to be a success, it requires the right device, training and time. When this is achieved, students can take control of part of their learning journey, improving not only their academic progress, but also their self-confidence in learning and wider life.

If we can metaphorically open our eyes to the specific needs of visually impaired students, and take the time to recognise the impact they have on their learning and social integration, we can take the first steps towards making education an inclusive process.

Further information

Robene Dutta is Managing Director at educational publisher Mantra Lingua:
www.mantralingua.com

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Supporting the visually impaired learner * SEN Magazine

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Exploring common issues faced by blind and partially sighted students, and tips for achievement in the classroom

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The following are links to resources recommended by people within the Down Syndrome community:

General information, advice, and support

DanceSyndrome An inclusive arts charity providing a range of opportunities for individuals and organisations to work with them through inspiring workshops, leadership training and performances. Regular session take place across the North West of England but they also perform at events across the UK. Twitter:@DanceSyndrome

Making Chromosomes count- a new magazine for the Down Syndrome community. You can visit the website to subscribe and receive your copy of Down Syndrome Community News and please get in touch with them if you would like to feature in future newsletters.

Stepping stones: A collection of stories detailing the challenges, opportunities, tears and joy of raising a child with Down Syndrome

Education

Going To School a book created by the Cornwall Down Syndrome Support Group. This is an inclusive book for preschool/reception year children that features pictures of the school day and includes images of children with Down Syndrome going about their school day alongside their typical peers. Read the ChatterPack review of the book here This 27 page Makaton download accompanies the book and includes all the signs and symbols to support communication around the school day plus visual timetable, etc
Speech, language, communication and literacy skills

Cartersyard phonics: Carter's Yard Phonics Flashcards are a set of 64, interactive 'talking' flashcards that are used in classrooms throughout the UK. The fun, engaging, multi-sensory cards are the perfect phonics accessory for home and school. Discount code to use at checkout: 2VC3HY9H

Shape coding - Introduction to Shape Coding by its creator, Susan Ebbels

Teaching number skills and concepts:

discusses the use of Numicon number teaching materials with children with Down syndrome. The theory underlying the design of the materials is discussed, the teaching approach and methodology are described and evidence supporting effectiveness is outlined

Training and consultancy services

LETS Go! provides specialist consultancy services for children with Down syndrome. We offer Down syndrome specific training, information, support and services for families, education providers, professionals, and organisations.

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Resources to support children, young people and adults with Down Syndrome

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The following are links to resources recommended by people within the Down Syndrome community: General information, advice, and support A book from Wouldn't Change a Thing For new parents of children with Down Syndrome, but many schools and organisations have requested a copy. We fund these for free for new parents, support groups and maternity units.

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ADHD is the most common neurodevelopmental disorder in childhood, affecting around five per cent of children and about two and a half per cent of adults worldwide. There's a common stereotype of a boy running around the classroom, but ADHD is actually much more complicated. And, often, more problematic than that. As well as being an issue itself, ADHD has been proven time and time again, to be a risk factor for issues with mental health. As well as educational and employment problems in later life. As well as other issues, such as substance abuse and getting into trouble with the authorities. In our course-

Understanding ADHD- we cover four broad areas: One, what is ADHD? What do we mean by symptom? And, what's a disorder? Two, what's it like to live with ADHD? Three, what do we know about the causes or risk factors, both genetic and environmental? And four, treatment- both pharmaceutical and non-pharmaceutical. Many of our students are teachers, educators more generally, or parents themselves. And, consequently, we have included practical, evidence-based content throughout this course. So, alongside the latest research, we'll also follow the journey of several families who have children with ADHD, who join us to speak about when they first realised something wasn't right, right through to diagnosis and treatment. We also speak with a number of professionals who work with children with ADHD.

And when you hear these stories, you'll see that it's clear that whilst we are making progress, there's still some room for improvement. And we'll also address some of the controversies of ADHD. Like, why medication is often the go-to treat. The issue of side effects and the role of diet. So, join us over the next four weeks, as we take an evidence-based, practical tour through ADHD.

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Understand ADHD - Online Course | King's College London

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Explore the latest research about ADHD including ADHD diagnosis, treatment and ADHD symptoms with this online ADHD course from King's College London.

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Free from Microsoft: dyslexia awareness 

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Free from Microsoft: dyslexia awareness 

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1 hour

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Educator Center Overview - Microsoft Learn Educator Center

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Microsoft Learn for Educators takes the best of Microsoft Learn online learning paths and helps you to bring instructor-led training materials from Microsoft into your courses. This program provides members with access to Microsoft ready-to-teach curriculum and teaching materials aligned to industry-recognized Microsoft Certifications.

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When kids have dyscalculia, it impacts how well they learn and do math in school. But having poor number sense and other math skills can also lead to all sorts of challenges in daily life.

For example, kids with dyscalculia may have trouble with amounts, time, distance, speed, counting, mental math, and remembering numbers. Those difficulties can show up in ways you might not expect or recognize as being related to math.

Here are 10 surprising ways dyscalculia can impact kids.

About the author

Reviewed by

Tell us what interests you

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Dyscalculia can impact kids in unexpected ways. Here are 10 surprising behaviors you may see in your child with dyscalculia.

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Challenges faced by children, and practical tips

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Challenges faced by children, and practical tips

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32 minutes

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Today's episode is about dyspraxia, a developmental disorder which is most often associated with challenges related to motor coordination but is also often marked by disorganization, clumsiness and poor short-term memory. My guest, Victoria Biggs, knows first-hand what it's like to grow up with dyspraxia. When she was sixteen years old, she actually wrote a book to help teens like her get through adolescence called Caged in Chaos: A Dyspraxic Guide to Breaking Free.

Vicky is a university research fellow and lecturer, a teacher in a school for children with trauma-related mental health problems, a writer, and a story. In addition to having dyspraxia, Vicky is also autistic. In our conversation today, Vicky talks us through her own story of growing up with dyspraxia and shares her personal insights on how parents and teachers can better support dyspraxic children.

About Victoria: My name is Victoria Biggs. I usually go by Vicky. I'm a university research fellow and lecturer, a teacher in a school for children with trauma-related mental health problems, a writer, a storyteller, and the property of a cat named Lottie. I'm also autistic and dyspraxic.

When I was sixteen years old, I wrote a book called Caged in Chaos: A Dyspraxic Guide to Breaking Free, a light-hearted guerrilla guide to adolescence and everything it throws at you. Since it came out I've been a regular guest speaker and trainer on autistic spectrum disorders, dyspraxia, and other specific learning difficulties (SpLD). Whoever you are - a parent of a struggling child, a teacher wondering how to support the SpLD students in your class, or a person with SpLD yourself - I hope you will find something useful and encouraging on my site. Learn more here.
THINGS YOU'LL LEARN FROM THIS EPISODE:

The primary challenges children and teens with dyspraxia face while growing up

Practical tips for supporting teens with dyspraxia

What Victoria believes schools and society can do better to support kids with learning differences

How Victoria's experience with dyspraxia has influenced her as a special education teacher

The most important considerations for parents of newly diagnosed dyspraxic children
RESOURCES MENTIONED:

Victoria Biggs professional / academic website

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TPP 174: Victoria Biggs Shares Her Story of Being Dyspraxic

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Today's episode is about dyspraxia, a developmental disorder which is most often associated with challenges related to motor coordination but is also often marked by disorganization, clumsiness and poor short-term memory. My guest, Victoria Biggs, knows first-hand what it's like to grow up with dyspraxia.

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How to support children with dysgraphia 

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How to support children with dysgraphia 

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70 minutes

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Or click on your preferred podcast player link!

Welcome to the show notes for Episode 31 of the OT Schoolhouse Podcast.

Just when Dyslexia seemed to be the new buzzword in IEP meetings, Dysgraphia and Dyscalculia joined in on the fun. Dysgraphia, especially, has cemented itself into the confines of the Occupational Therapy world. If there is an IEP team using the word Dysgraphia, there is sure to be an OT evaluation to follow.

In this episode of the OT Schoolhouse Podcast, Jayson interviews the author of the Handwriting Brain-Body DisConnect, Cheri Dotterer, MS, OTR/L.

Cheri has been an Occupational Therapist for over 20 years. Much of that time has been serving students who have been referred to her for handwriting concerns. With that said, it was her own children's struggles that really got her into studying Dyslexia, Dysgraphia, and Dyscalculia.

Listen in on this episode to learn how Cheri defines Dysgraphia and explains what the six types of Dysgraphia are. She also shares how we as OTs can help students to overcome some of the problems they face by using the Motor Learning Model and The Sensory Integration Model.

Quick reminder: Links to Amazon.com and other websites on this page may be affiliate links. Affiliate links benefit the OT Schoolhouse at no additional cost to you. I appreciate your support by using these links.

The below references were mentioned throughout Episode 31

Handwriting Brain-Body DisConnect:

Adaptive teaching techniques to unlock a child's dysgraphia for the classroom and at home

By Cheri Dotterer, MS, OTR/L

Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs.

Have any questions or comments about the podcast? Email Jayson at Jayson@otschoolhouse.com

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OTS 31: Unpacking Dysgraphia Featuring Cheri Dotterer, MS, OTR/L

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Episode 31 of the OT Schoolhouse Podcast