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Abstract
Previous research has focused on the close association between speech and
language dif culties and emotional and behavioural dif culties. However,
little attempt has so far been made to examine this relationship in children
with emotional or behavioural dif culties who are at risk of exclusion or who
have been excluded from school. In particular there are no data on the impact
of speech and language interventions on this group of children. This study
tests the hypothesis that children with emotional or behavioural dif culties
currently excluded from school or at risk of exclusion, receiving intervention
for their language and communications skills, would make signi cant progress
both in terms of language, self esteem and behaviour in relation to a
comparison group. Children made signi cant progress as a result of treatment
compared to no-treatment, in the areas of language and social communication
skills, and self esteem. The data suggest that, in the short term at least, the
type of intervention carried out had bene cial effects for the children
concerned. Implications for practice for speech and language therapists
and teachers working with this client group are also discussed.
Address for correspondence: James Law, Department of Language and Communication Science, City
University, Northampton Square, London EC1V 0HB. Email: J.C.Law@city.ac.uk
# Arnold 2003
10.1191=0265659003ct241oa
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Introduction
The management of children with emotional and behavioural dif culties is an
issue of enormous concern for all working in education. At one level this is
translated into the gures for school exclusions. Whilst there has been, as a
result of government policy in the UK, a fall and then a rise in permanent
exclusions from mainstream schools over the past ten years, data on the
number of temporary exclusions have not been available (DfES, 2002). This,
in effect, means that mainstream teachers are having to deal with these issues
on a routine basis in their classrooms. When asked to explain increasing
concerns about behaviour in the classroom, head teachers highlighted disobedience in various forms constantly refusing to comply with school rules,
verbal abuse or insolence to teachers, rather than physical aggression (DfE,
1992). The Audit Commission report (1996) also refers to childrens poor
literacy skills. The relationship between early learning dif culties, exclusion
and crime has been described as a downward spiral in which children who
perceive themselves to be failing in primary school (that is lacking in basic
skills), become disenchanted and drop out (Basic Skills Agency, 1997). It has
been suggested that children with special needs, in particular, may be marginalised where local nancial management and market forces operate (Boew
and Ball, 1992). The majority of children with emotional and behavioural
dif culties in a study by Parsons (1994), were referred for assessment of
their special educational needs. However, many were excluded before this
process was completed, meaning that needy children were in several cases
without any educational placement and assessment details became out of date.
To some extent this is a poorly speci ed population. The heavy social and
political emphasis placed upon school exclusion has served to mask the need
to provide support in core areas that may underlie school performance. The
relationship between emotional and behavioural dif culties and language
problems is recognised in the literature (Benner et al., 2002) but this does
not necessarily mean that this association is widely recognised in practice. Of
particular interest to the present study are recent reports of the high level of
underreporting of speech and language dif culties in these children (Cross,
1997; Cohen et al., 1998). Cohen and Lipsett (1991) found that children who
had a previously unrecognised language impairment were rated by their
mothers as more delinquent and by their teachers as exhibiting more
psychopathology and particularly more externalizing (conduct) psychopathology. They argue that children with invisible handicaps are perceived
as more dif cult. Lipsky (1985) describes marginal handicaps related to
language and learning problems, which can contribute to the perception of
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the child as problematic: normal in many ways but not in others. This view is
also supported by Paul and James (1990), who found that parents of children
with delayed language have been found to perceive their child as temperamentally dif cult and hard to manage relative to children who are developing
language normally. They argue that problems in producing or understanding
language may appear to adults as non-compliance, inattentiveness or social
withdrawal. The lack of clarity in the relationship between early language
learning dif culties and emotional and behavioural dif culties is re ected in
the level of disagreement between parents and teachers and, indeed, between
teachers from different schools (Rutter et al., 1970, 1976; Herbert, 1998;
Botting and Conti-Ramsden, 2000). This problem is exacerbated by the lack of
expertise in the assessment of childrens speech and language skills. A recent
major study of the provision of services to children with speech and language
needs in England and Wales has demonstrated that negligible levels of
resource are allocated to meet the childrens needs if they are classi ed as
having emotional and behavioural dif culties (Law et al., 2000).
The exact nature of the relationship between behavioural disorders on the
one hand and communication disorders on the other has been discussed
extensively (Baker and Cantwell, 1985). In general the conclusion drawn has
been that, for most children, early communication dif culties lead to behavioural dif culties or at least are integrally linked in a common pathway of
development that may become stronger as the child develops. Some argue that
language disorders are likely to interfere with cognitive development and to be
instrumental in causing or exacerbating behavioural problems (Cohen et al.,
1989). Others suggest that linguistic impairment is a risk factor for psychopathology in general (Baker and Cantwell, 1982; Beitchman et al., 1986). The
children at greatest risk for this were those initially diagnosed with receptive
and pervasive speech or language impairment. These may be a speci c risk
factor for later aggressive and hyperactive symptoms.
However, it has been suggested that there may be as many as ve different
possible patterns in the relationship between the two (Rutter and Lord, 1987).
The psychiatric disorder may lead to the language problem and vice versa: the
two may be different facets of the same phenomenon; the two may co-occur,
but with different causal mechanisms; there may be multiple interconnected
causal processes. Baker and Cantwell (1985) also discuss several hypotheses
regarding the possibility that communication disorders may lead to psychiatric
disturbances. Communication disorders could contribute to patterns of deviant
parentchild interactions, leading to increased stress, and vulnerability to
developing psychiatric disorders. Lack of intact language may affect social
behaviour, interaction and inner speech, which is essential for the interDownloaded from clt.sagepub.com at UNIVERSIDAD DE CHILE on August 26, 2013
Method
Participants
The 31 children referred to the project were all drawn from an inner city area.
In order to minimise bias of sampling, referral requests were sent across the
whole borough. Referring agents were either specialist teachers of children
with emotional and behavioural dif culties, educational psychologists, class
teachers in conjunction with their head teacher and=or special educational
needs coordinator (SENCO), or the head of the Primary Pupil Referral Unit
(PRU) for children already excluded from mainstream school. In most cases
the referrals were made in conjunction with a speech and language therapist
allocated to the school, but the children were not those with whom the therapist was already working.
The children were all in primary school year 5 or year 6 (ages 9 to 11 years,
mean age 10 years and 8 months) that is, coming up to the age at which they
would transfer to secondary school. They were identi ed through the relevant
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Procedure
An independent groups design was adopted. Children were assigned to two
groups. Group I, the study group, comprised ten children who received weekly
language and communication therapy during the Summer term. Group II, the
comparison group, also comprised ten children. The comparison group was to
receive no intervention while those in the study group were treated, but would
subsequently receive an intensive block of speech and language therapy. The
children in Group I were further subdivided into two groups of ve children.
Children in Group IA were attending the PRU, having already been excluded
from mainstream school, while the children in Group IB were perceived by the
referring agent to be at risk of exclusion. Only 17 of these childrens results
could be included in the nal analysis. One child would not comply with any
reassessment, one was absent for all reassessment and one was found to have
received speech and language therapy independently of the project.
For practical reasons it was not possible for children to be allocated to the
groups in a random manner, as the excluded children at the PRU had to be seen in
one group. Whilst the two groups were not therefore matched, the baseline scores
for each group were checked and no statistical differences were identi ed between
the two groups in terms of age or baseline scores. The groups were matched for
gender, with one girl in the treatment group and one in the control group.
The project was devised in three phases:
Intervention
The package of therapeutic intervention was devised through consultation with
a number of professionals. The aim was to take a holistic approach that treated
speci c language and social communication skills, and also dealt with
behaviour management, issues of self esteem and general emotional wellbeing. Guidance was provided by clinical psychologists on the setting up and
structuring of a group for children with emotional and behavioural dif culties
and also with assessments for self esteem and behaviour. Specialist behaviour
support teachers gave advice on the use of basic counselling skills and Circle
Time techniques (Mosley, 1990).
Regular sessions were run at the same time on the same day each week by
the speech and language therapist, with the support of a speech and language
therapy assistant. In the case of the PRU, support was also provided by the
class teacher plus one of the Units learning support assistants, who helped
with behaviour management and would later run similar groups. This high
adult-to-child ratio was adopted to enable the facilitation of structured activities
in a supportive and non-threatening environment. Sessions were designed to
follow a set structure (see Table 1) with speci c activities allocated to certain
adults who introduced and ran them from week to week. This familiar routine
Table 1
Duration
Activity
7 minutes
5 minutes
10 minutes
5 minutes
10 minutes
5 minutes
3 minutes
was intended to provide a sense of consistency and security, and to help the
children feel more con dent and able to experience success.
Behaviour management. The approach to running the group was to
establish a positive, secure environment in which the children could grow in
con dence in order to have the opportunity to demonstrate their strengths and
capabilities; in order to achieve this, it was important to set relatively rm
limits on childrens behaviour. Above all it was felt to be important to be fair
and consistent, very much following the guidelines set down by the New
Learning Centre (Janis-Norton, 1995), which encourages the establishment of
a positive, rm and consistent environment. It was also essential for adults to
emphasise that it was certain behaviours that they did not like or accept, and
not the child him=herself. In order to achieve this, the children devised their
own group rules to which they all agreed to adhere. They signed these rules
to indicate this, as did the adults. For children who were not abiding by their
own group rules, it was agreed between the children and therapist that they
would have one warning and if this were not observed, then there would be
time-out until that child was calm enough and felt ready to return to the
group (that is the child would go with an adult to an allocated time-out room
or area for a few minutes). In order to make this approach feel less harsh, the
therapist incorporated football warnings which were readily accessible and
culturally relevant. Thus, a warning was a yellow card and then a time-out
or red card could be shown if necessary. The aim of this approach was to
lighten the potentially punitive aspect of these measures. Red cards were
needed on only two occasions in total.
Self esteem. Each session included an opportunity for the children to talk
about their feelings, using a visual rating scale based on the work of Pretzlik and
Hindley (1993) who gave advice on the use of a colour-coded response scale.
The children were introduced to this concept during assessment, and during the
rst session they were encouraged to work together to devise their own ten-point
rating scale of self esteem. The children and adults then used this each day to
make a comment on how they were feeling, if they wished. Initially the adults
gave models and the children were encouraged to contribute too; for example,
Today Im feeling a two because my Mum shouted at me this morning.
Children were free to give a number but not explain their reason if they did not
wish to do so, and real life examples of both high and low scores were given so
that children did not feel pressure to select a high number.
Towards the end of each session, the therapist led a feedback activity to enable
group members to share what they had done. There was also the opportunity for
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everyone to say one thing that the person on their right had done well that day.
This meant that everyone had the chance to pay another child a compliment and
to hear others complimenting them. Any positive comments about others were
praised and could be reinforced by comments from the adults such as X did well
in noticing and talking about good things that others did. The ethos of the group
was to promote emotional well-being, hence all children were offered an
opportunity for special time at every session. This meant that any child
could choose to speak to any adult they wished in privacy and in con dence.
Language activities. The assessment pro les highlighted which aspects of
language skills would be best incorporated into such activities. Each session
always included the same two language activities (short, fun activities, which
were adapted and developed in different ways each time) and one longer
activity which changed from session to session. Inherent within this approach
was the need to sustain the interest and attention levels of the children
concerned, whilst also providing a familiar structure.
These activities focused on developing the following skills:
10
Table 2 Example from Semantic Skills assessment (Comparison task: ability to compare=
contrast (dogs) and explain concepts of same=different)
Score
Criteria
No evidence of
contrasting,
seems to choose
for personal=
random reasons.
Mainstream
children (year 4)
Language disordered
(year 4)
11
Score
Criteria
0 most desirable
1
2
3 least desirable
Source: Social Use of Language Programme: Primary and Pre-School Assessment Pack (Rinaldi, 1995).
such ratings. The questionnaire was modi ed slightly to make it both easier to
demonstrate a shift in opinion and to make it more accessible to children. Thus,
children could rate themselves on a scale from 0 to 4, (rather than 0 to 2)
depending on how strongly they agreed or disagreed with the statement, and a
colour-coded response scale was introduced along the lines developed by Pretzlik
and Hindley (1993) and Pretzlik and Sylva (1995). The greater the intensity of
colour in a box, the more the agreement and strength of feeling. The colours
chosen corresponded to those of the football team supported by the vast majority
of the children, and the therapist taught the children to use the rating scale by
practising with a range of statements related to their own interests, such as I am
good at football. The questionnaire is written in language which the children in
the project could understand, and the sentences were read aloud to the children.
Of the eighteen phrases, eight are reversed as a protection against systematic
reporting bias. Thus to agree with number 1 I am good at my school work
would suggest high self esteem, whereas to agree with number 2 I am picked on
at home would suggest lower self esteem.
Results
Attrition
Approximately one-sixth of the children referred to the project changed
school, due either to exclusion or parental choice, within one or two
months of referral (that is during the baseline assessment phase, before the
intervention began). In the case of children who changed to and attended a
different school, it was possible to continue to work with them at the new site.
However, for children excluded or withdrawn from school and not placed
elsewhere, it was beyond the scope of this project to work with them.
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12
Treatment group
Comparison group
Total
MannWhitney U
Signi cance (one-tailed)
Number
Mean rank
9
7
16
5.72
12.07
6.5
0.005**
13
Narrative skills
Treatment group
Comparison group
Total
MannWhitney U
Signi cance (one-tailed)
Semantic skills
Number
Mean rank
Number
Mean rank
9
7
16
11.06
5.21
8
8
16
12.25
4.75
8.5
0.012*
2
0.001**
that took place at the end of the rst period of intervention. The changes that
had occurred in the childrens skills were analysed, using MannWhitney tests
to compare the progress made by the treatment and comparison groups, and
the results are presented in Tables 4 and 5. These show signi cant differences
across all these areas, and demonstrate that relative to the comparison group
the treatment group showed improvement in, speci c social communication
skills, and speci c language skills, both narrative skills and semantic skills.
Self esteem
Table 6 gives the result of a MannWhitney test in which the changes in each
childs total score on the What I think about myself questionnaire were
analysed, in order to compare the progress of the treatment and comparison
groups. This represents a signi cant difference, showing that childrens self
esteem appeared to be enhanced as a result of receiving therapy.
Behaviour
Baseline assessment. Table 7 shows the Parents and Teachers perceptions of the childrens initial behaviour for a total of 15 children, being all the
children for whom both parents and teachers perceptions were available at
the start of the project. This does not include any of the excluded children at
Table 6
Treatment group
Comparison group
Total
MannWhitney U
Signi cance (one-tailed)
Number
Mean rank
8
8
16
11.13
5.88
11
0.028*
*p < 0.05.
3.1
2
7
0
2.3
1.7
5
0
6.4
2
9
3
3.3
1
4
1
3
1.9
7
0
9
4
14
2
C
3.3
1.6
5
0
4.4
3.3
9
0
6.3
3.2
10
1
3.9
2.5
7
0
4.5
2.8
10
0
11
3
15
5
T
4.4
2.6
9
0
6.5
3
9
1
7.9
2.2
10
3
3.3
2.4
7
0
5.4
2.3
10
2
11
3
15
5
Teachers
perceptions
Pro-social behaviour
Peer problems
Hyperactivity
Conduct problems
2.4
1.5
5
1
2
1.1
4
1
6
2.2
9
3
3.6
2.1
7
1
1.8
1.2
3
0
9
4
16
3
Emotional symptoms
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
Mean
SD
Max
Min
Parents
perceptions
Negative ranks
Positive ranks
Ties
Negative ranks
Positive ranks
Ties
Negative ranks
Positive ranks
Ties
Negative ranks
Positive ranks
Ties
Negative ranks
Positive ranks
Ties
Negative ranks
Positive ranks
Ties
7
8
0
3
9
3
8
5
2
7
6
2
10
3
2
9
4
2
No.
40
80
9
69
51
40
52.5
38.5
77.5
13.5
63.5
27.5
Sum
0.253
0.018*
0.698
0.62
0.024*
0.205
p (2-tailed)
Initial pro le of childrens emotional and behavioural dif culties from the strengths and dif culties questionnaire (Goodman, 1997)
Area of perception
Table 7
14
Child Language Teaching and Therapy
70
15
85
40
13
53
10
25
35
20
7
27
Emotional
(%)
60
10
70
20
27
47
Conduct
(%)
65
10
75
40
13
53
Hyperactivity
(%)
55
5
60
60
20
80
Peers
(%)
50
5
55
7
0
7
Pro-social
(%)
Total percentage of children perceived as falling outside the normal cut-off. This has an expected value of 20%.
Teachers Abnormal
Teachers Borderline
Teachers Totala
Parents Abnormal
Parents Borderline
Parents Totala
Table 8 Summary of parents and teachers perceptions of childrens emotional and behavioural dif culties from the strengths and
dif culties questionnaire (Goodman, 1997)
15
16
the PRU, whose parents did not return questionnaires sent out. The table also
includes the results of a comparison of these perceptions and shows that for
the scales of Pro-social (e.g., Shares readily with other children such things
as treats, toys, pencils etc.) and Conduct Problems (e.g., Often ghts with
other children or bullies them), there was a signi cant difference between
parents and teachers perceptions.
Goodman (1997) suggests bands by which the population can be divided
into normal (80%), borderline (10%) and abnormal (10%). Table 8
summarises how many border-line and abnormal results were observed.
The total (i.e., abnormal plus borderline) gures for both parents and
teachers appear much higher than the expected proportion of 20% which
Goodman suggests as the cut-off. Given the target group this is not surprising.
Post-therapy assessment. Discussions with parents and teachers following
intervention indicated that they perceived an improvement in the childrens
emotional and behavioural status. However, analysis of their perceptions as
measured by the Goodman Strengths and Dif culties Questionnaire, using
MannWhitney tests indicated that the differences were not statistically
signi cant.
17
18
of support offered to these children and that the key to working effectively
with them is the appropriate skill mix between the different professionals,
learning support assistants, classroom teachers, educational psychologists and
speech and language therapists.
Whilst initial assessment highlighted the fact that teachers were extremely
concerned about childrens emotional and behavioural status, on completion of
the package of care, all teachers described some progress made by their
pupil(s). In addition to their increased language and communication skills,
other skills were also observed in the classroom:
offering the pupils opportunities to show skills that would not be seen
elsewhere;
the children being able to develop improved attention and listening skills,
week by week;
for individual children, they identi ed bene ts in: getting used to being
listened to, being able to see tasks through to the end, opportunities to see
more of the childs potential, learning the need to listen to others thus
keeping in touch with his=her peer group.
19
progress in most areas of their childrens emotional and behavioural status. For
example, one parent said, C loved the group and people and going on the
bus . . . He is much more con dent and talks about it all the time . . . It was a very
positive experience . . .. However, the PRU requested that no direct face-to-face
or telephone contact be made with parents and unfortunately this group of
parents did not respond to any questionnaires sent. This seemed to correspond
to the fact that the parents of children still attending their mainstream school
were extremely keen for their child to be given this constructive support, and
school staff reported that parents found this approach much less threatening
compared to mental health or social service provision. It contrasted with their
experience of a negative cycle of their child being stigmatised, frequent
unproductive meetings and temporary exclusions. On the other hand, parents of
excluded children appeared very disenchanted with the system. Several
seemed to have lost con dence in the professionals.
Differences between parents and teachers perspectives
The data in Tables 7 and 8 clearly re ect the types of discrepancy between
parent and teacher in the perception of behaviour dif culties already well
characterised in the literature. Consistently, parents had a more positive view
of their childrens behaviour than did the teachers. Given that these children
had been identi ed for school exclusion, such a nding is probably not
surprising. In the majority of cases teachers did seem to change their
perceptions of the participants, and parents also perceived a change in their
childrens behaviour. Although the latter was less marked this may be
attributed to a lower level of concern in the rst instance. Such ndings
suggest that this type of intervention is likely to have had a positive effect as
far as the teachers are concerned and one might infer that this is likely to lead
to raised expectations and a more positive performance in class. At this point
we would maintain a positive but cautious position. On the basis of these
results it is not possible to extrapolate from the intervention in question to a
reduction in school exclusion. It may well be that such behavioural programmes primarily have behavioural outcomes and are not able to reach the
emotional needs of the children concerned. Nevertheless these are important
secondary ndings, which could usefully be carried forward.
Childrens perspectives
The change in attitude of some of the children was quite marked. For example,
at rst some children covered their ears when others were complimenting
them, but it gradually became easier for them to accept compliments. Also
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20
some participants initially had extremely poor self or other awareness, for
example, they were unable or unwilling to listen to others, unable to take turns
or to regulate their own contributions.
At the end of the intervention period the children expressed positive views
on the intervention. They described bene ts for themselves in terms of what
they felt they had learnt, including:
It was fun. You could learn a lot about listening and quietness . . . and
making new friends.
Its good to let other people talk when its their turn.
21
two comparison groups, one being offered no intervention at all and a second a
non-speci c intervention of comparable duration and intensity. It is not
altogether clear what the latter would be, given the relatively untested nature
of the interventions concerned with this client group. Nevertheless this issue is
a justi able concern and one that would need to be taken into consideration
when considering the results. While these ndings do not prove a causal
relationship between the intervention and the outcome it is important to point
out that it is commonly dif cult to disentangle the relationship between inputs
and outputs in complex interventions of this sort. At one level the fact that the
intervention appears to be effective on such a small sample suggests that it
warrants further investigation.
Recommendations
The ndings of this study suggest that childrens language and communication dif culties are not always identi ed when there is a strong behavioural
component in their pro le of needs.
Based on the data reported in this study, the authors recommendation is
that intervention targeting language and communication skills should be
available for all children with emotional and behavioural dif culties at risk
for school exclusion. It would also suggest a strong case for specialist
speech and language therapy intervention for children with emotional and
behavioural dif culties who have already been excluded.
In addition, the study suggests that teachers should be mindful of a childs
language and communication dif culties in particular, prior either to considering exclusion or reviewing school placement. At this stage, resources should be
available for these students to access a multi-agency team, including specialist
behavioural support teachers and speech and language therapists.
This study also shows the bene ts of class teachers, learning support
assistants, speech and language therapists, and speech and language therapy
assistants working closely together, in order for speci c skills being learnt in
therapy sessions to be generalised into the classroom.
This study also highlights the need to engage parents to work alongside the
professionals.
Future developments
The project has highlighted a number of areas for consideration in future.
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22
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