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Candice Lazarus and Helen Kirk look at the role of speech and language therapists in child mental health

When children and young people with learning disabilities access learning disability child and adolescent mental health services (LD CAMHS), they are supported by a variety of professionals, including psychiatrists, clinical psychologists, nurses, and support workers, who work with families to manage mental health difficulties and/or challenging behaviour. Communication difficulties are common in those with learning disabilities and are associated with an increased prevalence of challenging behaviour, as this is often a form of communication (Royal College of Speech and Language Therapists, 2009).



Techniques to support and develop communication are recommended by the positive behaviour support (PBS) model to increase wellbeing and quality of life (PBS Coalition UK, 2015). With expertise in the area of communication, speech and language therapists (SLTs) are well placed to deliver such support. However, SLT positions within LD CAMHS teams are historically unevenly distributed across the UK, despite developments in service provision within SLT over the years (British Institute of Learning Disabilities, 2002). This article reflects on the unique contributions that SLTs bring to LD CAMHS and also the challenges that present to the role.

SLTs provide in-depth assessment to inform others of communication abilities and tailor support to maximise communication for the individual. For example, an assessment of verbal comprehension will consider the level of language to use with a young person. This may also highlight processing difficulties, specific concepts or grammatical structures that should be avoided, or whether visual resources would be beneficial. Specialist assessments and interventions like these can impact greatly on the wellbeing of the young person and those who support them.

The work of an SLT takes place in a variety of settings, allowing them to work with children, families, teachers and professionals, both directly and indirectly. A crucial aspect of the role is to deliver training to team members, other professionals and parents in areas such as language development, the use of visual resources to support communication and alternative and augmentative communication systems, for example the Picture Exchange Communication System (PECS) and Makaton.

SLTs may, on occasion, also provide consultations to mainstream CAMHS, particularly regarding the area of autism. This can involve contributing to assessment and advising on communication strategies.

A different way of working


Working in a team like LD CAMHS which is close functioning and dynamic, with regular team meetings, case discussions and supervision, can prove to be a challenge for SLTs, who typically work autonomously. The emphasis on information sharing and working closely with one or more team members can be difficult, as this requires consideration of the roles of others in the workplace as well just their own. However, a smaller caseload than carried by many other SLTs provides the opportunity to work more holistically, which can bring increased job satisfaction.

As the role focuses on the mental health of the young people, this contributes to the already complex nature of the learning disability client group. This can be challenging as undergraduate SLT training is often limited in the amount of mental health teaching provided; this can affect therapists’ confidence to take on such a role. However, having skilled and knowledgeable colleagues within LD CAMHS provides crucial and valuable support and also an opportunity to learn new skills.

It is likely that there will only be one SLT within an LD CAMHS team, which can present additional potential issues. Being a lone voice may make it more difficult to challenge the views of others; however, it means that as the communication expert, the contribution of the SLT is often valued. As other health professionals in the team may already have some knowledge and experience of communication and language, the SLT may feel the necessity to provide more specialist knowledge and skills, which can be the catalyst for continued professional development. Although regular and formal supervision is provided by team members, clinical SLT supervision has to be sought elsewhere and professionals with the relevant skills in this cohort may not be readily accessed.

Below is an example of an LD CAMHS case that received involvement from SLT. It demonstrates how the SLT was integral to this young person being understood and achieving positive outcomes.

Michael’s story

A 16-year-old young man – let’s call him Michael – was referred to LD CAMHS for support with managing his anger. The team had concerns around his communication, thus an SLT assessment was completed to provide recommendations on ways to support his communication.

Findings from Michael’s assessment
Strengths:

  • he is polite and has learnt to engage in social norms, such as shaking hands
  • he is able to follow rules and repeat chunks of dialogue, such as, reciting poems. However, his spontaneous language is simpler in construction and does not contain depth of content and meaning.

Difficulties:

  • he requires additional time to process information 
  • he struggles to clarify what he means
  • he takes things at face value
  • he has problems differentiating reality from fantasy
  • he has problems describing why something might happen
  • he struggles with making inferences
  • he struggles following two-way conversations.

Michael’s eloquence masked his abilities and his comprehension was greatly overestimated. His comprehension ability was in the here and now, and he had trouble with time concepts. This caused difficulty relating events chronologically; for example, he would retell a situation that happened weeks ago but inferred that it was more recent. He had a good memory for events, but not in the order in which they occurred. This led to him getting into trouble as what he said was often not believed. As the complexity of the commands increased, so did his anxiety and his behaviour was more difficult to manage.   

Recommendations from assessment

It was recommended that the team use a narrative approach to communication to help structure and develop Michael’s story telling. This teaches skills to retell a story and leads to self-generation of experiences. Visual resources were also recommended, such as timetables and calendars, as a way to help understanding of time and sequencing of events.

Impact of the work
The approach helped the family and teachers understand Michael’s needs through reflecting on the times they may have expected too much from him and how they can change their approach in the future.

The team were also able to provide the school with training on the narrative approach, which led to this intervention being widened across the school to support other pupils with communication and language difficulties.

Further information

Candice Lazarus (pictured above right) is an Assistant Clinical Psychologist and Helen Kirk (pictured above left) is an SLT in LD CAMHS with Chesterfield Royal Hospital NHS Foundation Trust, working with children and young people with moderate to severe learning disabilities across North Derbyshire. They would like to thank Dr Martha Laxton-Kane (Consultant Clinical Psychologist) for her assistance with this article.

References

Factsheet: Communication. (2002) British Institute of Learning Disabilities.

Positive Behaviour Support: A Competence Framework (2015). Positive Behaviour Support (PBS) Coalition UK.

Resource Manual for Commissioning and Planning Services for SLCN (2009). Royal College of Speech and Language Therapists.

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