A pioneering partnership of education and health services has proved effective in meeting the needs of the sizeable proportion of children with emotional-behavioural problems in nursery who also have significant language difficulties.
We have had a speech and language therapist (SLT) in the Early Years Intervention Team (EYIT) since 1999. The post is employed and managed by Camden Education and the Early Years Speech and Language Therapy Service, Islington Primary Care Trust.
A great advantage of this way of working is that the team's SLT has strong links with others in local clinics and can carry over intervention strategies directly into nurseries.
Success story
One example of the success of this partnership was Danny, three years and ten months old, who was first seen by the SLT at his local clinic with his exhausted mum, Sandra. After a lengthy and difficult assessment, where Danny made repeated attempts to escape from the room and hit both the therapist and his mother, he was diagnosed with severe Specific Language Impairment (SLI). This meant that his language development was progressing slowly compared with other skills and he was like a much younger child in his understanding and talking.
From the research, we know that language delays often underlie challenging behaviour. In Danny's case, there were significant behaviour problems at nursery and home. As was seen in the clinic, he often resorted to physical means like hitting and spitting when attempting to negotiate with adults, including his mother and his peers at his nursery. After a spate of escalating tantrums with staff and peers at nursery, his keyworker, Becky, referred Danny to the EYIT.
First port of call
Following his referral, the EYIT teacher specialising in language and communication development met with Becky in the nursery. Becky talked about how she constantly gave Sandra negative feedback about Danny and that this was affecting their relationship. Sandra was sometimes tearful, sometimes angry, and always anticipated the worst.
Becky felt that she and other staff reported the 'bad bits', such as, 'He threw the ball at Simone's face', but knew that this was unavoidable because Danny's behaviour sometimes resulted in people being upset or injured. Becky was afraid that Danny risked being labelled 'the naughty child' - she had seen children avoid him and staff become anxious when assigned to him. Becky felt that his mother knew this too.
Observation and assessment
The next step was to enlist the support of the team's SLT. Armed with the clinic therapist's detailed assessment findings and Becky's account, the team's SLT and specialist teacher observed Danny within nursery. These observations were invaluable, as they showed that indeed Danny did not understand much of the language used by adults. Children far younger than Danny were observed sitting in the circle ready for the story, while he remained standing at the door, still in his apron, looking confused.
Observations of one-to-one interactions between Danny and staff, particularly when he was playing with his favourite activity - sand and water - were clues to the difficulties Danny was experiencing with language and interaction and consequently triggering his difficult behaviour.
Adults typically expect children acquiring language to 'act their age'. Research tells us that adults change and increase the complexity of their language in response to advances in the child's language. This is very important for normally-developing children, as it provides scaffolding for learning more complex vocabulary and grammar.
However, Danny was around one and a half years delayed in his understanding of language and talking and in associated developmental areas of attention, play skills and social skills (we often see delays in these other areas in children with SLI). This meant that Danny was not doing what would be expected at his age.
Research also shows that in an effort to help the late talker, their caregivers talk more. They ask more questions, they make more suggestions and they give more directions. As a result the balance of interaction changes, with the adult taking the lead in conversation and the child becoming a passive participant.
In this case, rather than the adult helping language, they may inadvertently be stifling the child's attempts to talk. For a nursery-aged child, parents and educators have the most frequent contact and meaningful relationships with the child, so both are key in addressing their needs.
One to one
After observing Danny and Becky's interaction, the SLT decided to address some of these problems by offering a course of Adult-Child Interaction Therapy (ACI).
The team's teacher set about putting in place general strategies for the management of Danny's language and behaviour problems in the wider environment of the classroom (see suggested reading).
ACI helps adults see developmentally-delayed children in a positive light, to listen to them and respond to their attempts to communicate. It involves the SLT making videos of the keyworker and the child playing in a five-minute one-to-one session in the nursery. Danny's favourite sand activities were initially chosen so that it would be more motivating. The SLT and keyworker then observe the video together and the keyworker uses a self-rating scale to evaluate their interaction with the child.
Becky rated herself on how often she:
n asked questions n made suggestions n allowed time for Danny to talk first n praised Danny.
She then chose an aim - one thing that she should change in order to give Danny the lead in his play or talking. Another video was made to show the effects of this.
What we (and many researchers) find is that when the adult stops asking questions and really listens to the child, over time the child attempts words and phrases to talk about what they are doing. When the child uses a word or phrase, the adult copies. Children find this to be reinforcing and their confidence slowly builds. The child may then copy the adult; this is the beginning of a conversation. Videoing the play session is a useful tool to help the educator reflect on their own practice.
A course of ACI usually takes place once a week for four weeks, allowing the keyworker plenty of time to practise skills day to day in the nursery. It also gives the young child the opportunity to enjoy their daily 'special time' by being able to play with a trusted and responsive adult.
The EYIT teacher also supported Becky in enskilling other staff by presenting at staff meetings how they should engage with Danny and other children who were slow to talk.
The EYIT teacher helped staff understand the wider impact of language impairment and its effects on behaviour. We know from experience that there is no 'quick fix' or immediate solution, just an effort by all caregivers to support a child through the process of making sense of the speech they hear and giving them the confidence to try talking themselves. Support was also given to Danny's mother.
Positive outcome
Becky quickly adapted her interaction, gaining the skills of supportive listening and responding. As she understood Danny's level of development, she simplified her language and gave him extra time to talk. By simplifying and repeating instructions, Danny joined in more successfully. His language attempts became clearer and his frustration then reduced accordingly.
A key principle of ACI is praising the child and giving him positive feedback.
These skills also helped Becky in giving positive feedback to Danny's mother every day, however small.
