Dr Susan McCool
It is the aim of this paper to explore an often-overlooked aspect of the education and well-being of children in residential care: the claim that there is a high rate of undetected communication impairment among children in “public care” (Cross, 2004). Unmet communication need has serious effects on a child's education (Audet and Tankersley, 1999). The impact extends beyond academic attainment to encompass important educational and developmental aspects such as emotions and relationships, behaviour and self-regulation and, more broadly, participation and inclusion.
This paper outlines the nature of communication impairment, and examines the evidence for unidentified needs among children in residential care. It then explores what happens when needs remain unmet. The paper concludes with consideration of why services may fail both to recognise and respond to these needs, and offers examples of how some services have tried to respond to these issues.
What is communication impairment?
Communication is something that we all do, in many different ways, every day; so most of us think we have a reasonably good understanding of what is involved. In a professional context, however, the terms used have particular meanings that are worthy of a little thought (Wintgens, 2001). One of the best explanations uses the metaphor of children's puzzles (MacKay and Anderson, 2000). Lots of us think of communication as being like a puzzle where several individual pieces fit into a wooden inset board, representing aspects such as speech sounds, meaningful words, and grammar. All the pieces are related but they each have their own place in the whole. In reality, it is more complicated than that. Not only does each of these aspects have two sides to it (understanding and use) but they all affect each other and are affected by outside influences such as the communication context. That is why Mackay and Anderson (2000) suggest that we should instead be thinking about a “Rubik” cube, where all the aspects of communication within an individual are interrelated, as well as varying in response to interaction with others” thoughts, deeds and communication.
In development, difficulties can occur at any level, and with any of the individual “blocks” of the communication “puzzle”. That is true for all children and, it will be argued, is all the more likely for looked-after children. It is also suggested that this group are at higher risk of impairment in the interpersonal aspects of two-way communication, often referred to as pragmatics. Difficulties of this kind may appear subtle, or they may be masked by the more evident behaviours that can arise when they are not detected.
Are there high levels of undetected communication impairment among children in residential care?
Children in care are at least as likely as their peers to experience communication impairment. Difficulties with speech, language and communication are among the most common developmental problems in children (Law, 1992). Such difficulties have been reported at rates of up to 55% of pre-school children in areas of socioeconomic deprivation (Locke, Ginsborg and Peers, 2002). It is accepted that in the general population, 10% of school-aged children will have difficulties with speech, language or communication that are likely to have a detrimental effect on their education (Royal College of Speech and Language Therapists [RCSLT], 2006) and that levels are likely to be higher among vulnerable groups, including those living in areas of socioeconomic disadvantage or amongst looked-after children.
Even typically-occurring levels of need are less likely to have been picked up in this group. For a substantial number of children in residential care, it is likely that prior access to speech and language therapy (SLT) services may have been denied them owing to the circumstances leading to them being there, including parental abuse or neglect (Cross, 2004). Further, it is widely accepted that once in the system, looked-after and accommodated children face tremendous barriers in accessing universal and specialist health services (Dunnett, White, Butterfield and Callowhill, 2006) within which most SLT services are located.
Importantly, there is reason to suggest that rates of communication difficulty may actually be higher in children who are “looked after”. Regrettably, there is no published research available specifically in this area. This is in itself an indicator of the neglect that has blighted this important area to date. It is possible, however, to draw together findings from research in related areas, and make some reasonable assumptions.
There is evidence, for instance, that children who experience impoverishment in their early language environment (Law, 1992) and inadequacies in their early caregiver relationships (Madigan et al., 2007) show delays and disruption in the acquisition of key skills related to communication, emotions and behaviour. These aspects are likely to be present in many looked-after children.
Psychological distress and emotional behavioural problems have been found to exist almost universally amongst children and young people in residential care (Residential Care Health Project, 2004). There are now clearly established associations between particular types of speech/language difficulty and particular kinds of behaviour problems (van Daal, Verhoeven and van Balkom, 2007).
Children whose language problems persist beyond the age of five years have been shown to have poorer psychosocial outcomes into adolescence (Snowling et al., 2006) and adulthood (Clegg et al., 2005). Ground-breaking research by Gilmour et al. (2004) found signs of communicative problems in a substantial proportion of children whose disruptive behaviour, rather then language, had been causing concern. The difficulties experienced by the children were similar in type and magnitude to those found in autism spectrum conditions.
Bamford and Wolkind (1988, cited in Cross, 2004) found that young people in the care system were at higher risk of psychiatric disorder than any other easily identifiable group. Worryingly, a high proportion of the problems had gone undetected. Furthermore, while estimates vary, it is said that between 50 and 90% of youngsters with psychiatric disorders also have communication disorders (Cohen, 1996).
Another possible reason for children being in residential care is the presence of disability (Pinney, 2005). Many disabling conditions are associated with speech, language or communication impairments: these include developmental delay, learning disability, physical disability, hearing impairment and autism spectrum conditions (RCSLT, 2006).
To summarize, then, research has shown associations between communication impairment on the one hand and negative early experiences, behaviour problems, mental health issues and disability on the other. All of the features in the latter category are accepted as occurring to a greater degree among children who are looked after and accommodated; indeed, it is reasonable to assume that a cluster of such features may lead to the decision to accommodate a child in residential care rather than in other contexts. Combined, this makes it more likely that communication problems will be more common amongst this group. The fact that no elevated incidence of this kind has been reported leads naturally to the possible conclusion that many of these problems go undetected.
For children in residential care who have unmet communication needs, there is a likelihood that they will struggle to attain the academic, personal and social outcomes desired in today’s education system. This is explored below.
Despite long-held concerns that children and young people in public care do not realise their academic potential, there is compelling evidence that this unacceptable situation persists (Connelly and Chakrabarti, 2007). Recent figures presented by those authors show that a substantial majority of care leavers do not gain any qualifications. Furthermore, it is for children among those looked after away from home that the highest level of educational difficulty and the lowest level of educational achievement are reported.
From the communication difficulties perspective, there are similarly longstanding concerns around the academic underachievement of children with speech, language and communication difficulties. A plethora of studies reviewed by Schachter (1996) reflected the consensus that persisting difficulties of this kind lead to underachievement in every conceivable domain of academic attainment.
Again, these observations are supported by very recent findings in a literature review commissioned by the Scottish Executive on the needs and experiences of people with communication support needs (Law et al., 2007), which presented the evidence that children in this group often under-perform in the highly verbal and communicatively complex environment of schools.
What barriers must be faced, then, by the children hampered not only by the fact of their placement in residential care, but additionally by the presence of unmet communication needs? Although the precise mechanism by which these factors interact is not known, the adverse effects are likely to be complex and compound, producing an effect larger than the sum of its parts.
Broader educational aspirations
Academic outcome, whilst undoubtedly important, is not the only aspiration in contemporary education. In Scotland, for example, A Curriculum for Excellence (Curriculum Review Group, 2004) emphasises learning, understanding and achievement that is broader than examinations and relevant to modern life. It promotes four key capacities in Scotland's children and young people in order that they become: successful learners; confident individuals; responsible citizens and effective contributors.
Evidently, these outcomes are closely tied to the individual’s emotional, social and behavioural development, and there is every reason to suggest that these areas may prove just as challenging as academic achievement for the group considered in this paper. It is suggested (Cross, 2004) that emotional and behavioural problems may be the most prevalent issue affecting children in public care. Additionally, it has been demonstrated that risks combine in a cumulative manner with regard to child behaviour outcomes (Appleyard et al., 2005), indicating that children in residential care who also have communication needs are particularly vulnerable.
Family risk factors are among the strongest predictors of adverse mental health outcomes in early and middle childhood. Research cited by Dwyer, Nicholson and Battistuta (2003) suggests that poor parenting practices, marital conflict and parental mental ill-health constitute some of the highest risk factors. Such circumstances may well have been encountered previously by a high proportion of children in residential care. Combined with the possibility of changes and disruptions while living away from home, it seems reasonable to suggest that children in public care face greater barriers than others with regard to emotional well-being as a foundation for educational aspirations such as the development of “confident individuals”.
Equally, there is a convincing knowledge base (Donahue, Hartas and Cole, 1999) indicating that the social and emotional development of children with language impairment is vulnerable to such a degree that close and ongoing monitoring is warranted. Children whose language impairment persists into the school years are at a higher risk of psychiatric disorder in adolescence (Snowling et al., 2006). Long-term follow-up shows that individuals with developmental language disorders show poor psychosocial outcomes well into adulthood, with deleterious effects on relationships, employment, capacity to live independently and mental health (Clegg et al., 2005).
Less well established, but showing promising outcomes, is a strand of research investigating the presence of undetected communication deficits in children whose behaviour had been causing concern. In one study, over two-thirds of pupils who had been excluded from schools in Hackney were found to have social communication impairments similar in nature and degree to children on the autism spectrum (Gilmour et al., 2004).
Alarming rates of exclusion from school are reported for children who are looked after (Connelly and Chakrabarti, 2007). In Scotland, the figures show a six times higher rate of school exclusion for children who are looked after, compared to those who are not. If it is accepted that exclusion from school is one indicator of problem behaviour, then this statistic indicates something of the magnitude of the issue. Exclusions at this rate seem rather at odds with stated educational aims of fostering “effective contributors” and “responsible citizens”, far less “successful learners” especially in the light of the suggestion above that proportion of those excluded may have undetected and unmet communication support needs.
Reasons for undetected and unmet communication need
Understandably, a key priority for a child in the care system is establishing secure living arrangements. This is closely followed by the need to ensure the physical care of the child. “Unseen” issues such as communication impairments can assume lesser immediate importance in such pressing circumstances (Cross, 2004). Moreover, in a system that is stretched and necessarily reactive, overt manifestations of communication difficulties in the form of disruptive behaviour can invoke a response targeting the behaviour, rather than exploring underlying causes.
It can be difficult to identify problems with communication. Some impairments in this area can be relatively subtle, and may only be apparent to people whose awareness has been raised through training. Examples of these include receptive language impairments and pragmatic disorders. Difficulties may be apparent only in certain contexts, and may easily be missed in busy, fast-moving everyday interactions. What is more, the way they present in individual children can change over time, meaning that a deep understanding of a child gained over a long period may be necessary before suspicions of a possible difficulty are raised. This opportunity may not arise in circumstances involving frequent changes of placement or high turnover of staff. Research indicates that problems of placement disruption and high staff turnover can frequently affect the lives of looked-after children (Berridge and Brodie, 1998; Colton and Roberts, 2007).
Cross (2004) adds that the statutory dimensions of assessment laid down for looked-after children neglect the whole area of communication skills. She attributes to this the “startling number” of young people in public care she and her colleagues have come across with previously unrecognised communication difficulties. One recent example from the Scottish context is the important publication Looked-after children and young people: We can and must do better (Scottish Executive, 2007). Based on widespread consultation, and with a wide and holistic scope, it nonetheless makes no mention of children's communication skills.
Other practitioners have focused their criticisms on system issues, based primarily on frequent and unplanned moves of children. Work by speech and language therapists in Lambeth (Conway and Stokes, 2005) reported that frequent placement disruptions resulted in services being discontinued or prematurely duplicated, children facing long waits for assessments following transfer between services, and undergoing repeated assessment rather than receiving intervention.
Lack of co-ordination between services has been blamed for the failure to address any communication needs that are identified. Problems result from differences in boundaries between local authority areas and health areas, which can influence matters such as remits and budgets. Cross (2004) argues that communication is a particularly special case in this regard, falling as it does between the interests of both health and education agencies, yet being accepted as the full responsibility of neither.
How can services respond?
There have been calls for the development of advocacy services for this vulnerable group of children (Priestley, 2001) to minimise disadvantage and increase equity of access to services. One speech and language therapy service has reported favourably on a pilot project for pre-school children that aimed to establish an advocacy role, as well as to trial a prioritisation service for initial assessment and to follow closely the movements of these children (Conway and Stokes, 2005).
The success of the pilot led to the planned expansion of this work to school-aged children (by far the larger number). It was also proposed to extend the remit of the “link therapist”, to include training and outreach to speech and language therapists responsible for these children in school settings. Follow-up work by McKinson (2007) revealed that while partial progress had been made towards these goals, several developments had been postponed pending additional funding. In the intervening period, the context had changed markedly, with the move towards integrated children's services. Therapists, supported by the publication of the profession's position paper (Gasgoine, 2006) were working to ensure that developments arising from the pilot would become integral in the new ways of working.
Inter-agency working is required if the communication support needs of children in residential care are to be recognised and addressed. There is motivation to improve the situation from within the speech and language therapy profession. It is hoped that, with corresponding drive from the other relevant agencies, much can be done to improve the educational outlook for this vulnerable group of children.
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This feature: McCool, S. (2008). Communication
impairments in children in residential care: an
overlooked aspect of their education and well-being? Scottish Journal of Residential Child Care August/September 2008, pp. 50-59