Use a literature review to demonstrate a critical analysis of the causes of SEBD. Introduction There is growing concern about the mental health and wellbeing of children in our schools. The Report ‘Children of the Millennium’ (2018) has reported that one child in every twelve in the UK risks having behavioural problems at every age between 3 and 14, putting them at risk of a lifetime of disadvantage and poor health. On average, children and young people with mental health difficulties go ten years between first becoming unwell and getting any help. The Report ‘Missed Opportunities’ (2018) found that mental health problems affect one in ten young people, or an average three in every classroom. With this in mind it is incumbent on schools to train staff in identifying possible mental health issues so appropriate advice and support can be sought. Purpose of the Review This literature review will look at some of the psychological approaches that can help to explain mental health problems affecting children and young people (CYP). In particular, the review will critically reflect on the various views postulated by leading theorists, psychologists, authors and neurologists, who have studied different perspectives arising from the physical, cognitive and social domains. Ayres et al (2000) lists these perspectives as biological, behavioural, cognitive-behavioural, social learning, psychodynamic, humanistic, ecosystemic and ecological perspectives. Due to the vast amount of information available on all of these perspectives, the review will focus mainly on two perspectives. Namely, the biological and psychodynamic perspectives. However, as problems of behaviour are often multi-factorial, there may be reference to other perspectives within this review. There will also be a review of recent studies relating to research into genetic links and neurological factors to behaviour. More recent literature will show a shift from the prevailing view of ‘within child’ behavioural difficulties to include external social factors using the more commonly used term social emotional behavioural difficulties (SEBD). The review will include literature surrounding the difficulties that practitioners face when identifying and making an assessment of SEBD and the effects such a label may have. It will begin with a brief historical background outlining the theories, change of perspective and legislation associated with those pupils with SEBD. Historical background Historically, philosophers and theorists have presented a number of psychological approaches or perspectives on human behaviour. Dowling (2010) states that as far back as the fourth and fifth centuries, children were seen as innately wicked, born with sin and in need of corporal punishment in order to mould them. By the 18th Century, Rousseau (1762) produced a very different perspective of the child, in his book ‘Emile’. His idea was that a child was innocent until tainted by civilization. There are still elements of these ideas in today’s theories in the argument of genetics and heredity and the belief that society and community have an effect on behavioural traits. In the early 1800s, diagnosis and interventions became the responsibility of the medical profession. The Handicapped Pupils and School Health Service Regulations, 1945 added a new category to the list of ‘handicapped’ pupils requiring special educational treatment. These pupils were categorised as ‘maladjusted pupils ... who show evidence of emotional instability or psychological disturbance’ (p165). The maladjusted were classified in 1955 by the Underwood Committee as pupils having ‘nervous, habit, organic or psychotic disorders or educational and vocational difficulties’. The term maladjusted changed in the 1981 Education Act to pupils having ‘special educational needs’. In the early 20th Century, there was a shift of focus from the medical model, which saw the child as one who should be treated and ‘cured’, to the study of emotional development. Since the revision of the special educational needs (SEN) Code of Practice (DfEE, 2001) the label for EBD has widened to include the term ‘social’. However it is not found in the SEN Code of Practice for Wales (2004). SEBD has no nationally recognised definition in Wales, but the medical profession and the Local Education Authority of Neath Port Talbot County Borough Council describe it as being ‘attributed to those who experience difficulties within various areas of their lives, including school, home life and wider community.’ (UWTSD, 2019). Assessment and stigma It is generally agreed that the process of assessing a child as SEBD is difficult and fraught with criticism as there is no ‘one size fits all’. Ayres et al, (2000) believes that making an accurate assessment of SEBD is subjective as it can be influenced by the behaviour, bias and attributes of the assessor; what one person perceives as unacceptable behaviour, may be perceived as acceptable by another. Kaufman (2001) explains this view by saying: ‘The problem of definition is made all the more difficult by differences in conceptual models, differing purposes of definition, the complexities of measuring emotions and behaviour, the range and variability of normal.’ (p23) The aim of SEBD assessment should be to give practitioners an indication of how best to meet the needs particular to the child as without an individual plan of intervention, there is a risk of a downward spiral affecting the child’s educational potential and emotional stability. In the report entitled ‘Children of the Millennium’ (2018) one of the recommendations stated: ‘The Government should ensure that reforms to mental health support in schools prioritise children with multiple risks from a young age: this should include investing in effective classroom-based programmes to boost healthy behaviour and wellbeing, and offering evidence-based support to children and families.’ (p43) Whole school improvement in areas such as wellbeing and behaviour management is therefore crucial for a safe and supportive learning environment. Schools are now beginning to employ their own school-based counsellors; train Emotional Literacy Support Assistants (ELSAs); give training in relationship therapies (eg Lego and Relationship Based Play) and language development so that staff have a better understanding of the triggers to unwanted behaviour and have a bank of knowledge of de-escalation strategies that can be employed to prevent confrontation or trauma in the CYP with whom they work. There is much debate on whether labelling someone with SEBD is more detrimental than beneficial. Ayres et al (2000) describes having a label of SEBD as stigmatising resulting in an adverse effect on the child’s self-perception and negative response from peers. Jones & Corrigan, (2014, p.9) describe stigma as ‘a socio-cultural process by which members of marginalised groups are labelled by others as abnormal, shameful or otherwise undesirable’. They believe that it is the community that creates the stigma not the individual themselves. However Hinshaw (2005) argues that self-stigmatising may occur when the child or young person internalises negative responses and has a sense of being different from peers, resulting in a negative self-evaluation as a consequence. Visser (2007) goes further and argues that as SEBD is so subjective, often the label actually contributes to the very behaviour that is causing concern. However in the study by McKeague et al (2015), they found that some young people were prepared to challenge the stigma they experienced whilst others gravitated towards peers in a similar situation. They recommended further research into the development of anti-stigma interventions to facilitate inclusion. Perspectives on Behaviour Trying to categorise behaviour into types has proliferated over the years resulting in various views about whether or not they should be categorised at all. Ayres et al (2000, p. vii) suggests that ‘all behaviour lies along a dimension, a difference in degree rather than kind’. The fact that there are so many different perspectives and approaches reflects the complexity of human behaviour. Ayres et al (2000) assert that behaviour can be as the result of a number of causes rather than simply one cause. They agree with the view that some behaviours overlap due to co-morbidity and are not stand alone. Furthermore they believe that one cause can produce a number of different behaviours. Behaviour can generally be defined as the way in which an individual conducts themselves towards others as a response to a situation or stimulus and is a measure of an individual’s feelings, needs and emotions. There is a widely used phrase that says ‘all behaviour is communication’. Ashman (2018) clarifies this further by suggesting that communication is not only about verbalisation but can be presented in challenging, adverse behaviour as a result of external influences which are not always obvious. The neurologist Dr. Feldman Barrett (2017), explains that the brain is wired in order to make predictions that help with survival and the way the brain interprets and categorize these predictions is experienced as emotion. Barret has defined a form of emotional intelligence as “emotional granularity” or “differentiation”, suggesting that this allows a person to understand and respond better to emotions resulting in improved long-term health and well-being and better social and emotional functioning. With “emotional granularity” she asserts that there is less likelihood of responding with aggression to provocations or hurtful actions of others. (i) The Biological Perspective The biological perspective promotes a within-child model of SEBD but has been criticised as seeing individuals as a problem to be ‘cured’ (Rose, 2015). Ayres et al (2000) state that the biological perspective ‘considers mental disorders to have underlying physical or organic causes’. The various approaches within the perspective include: behavioural genetics; brain biochemistry; brain anatomy and endocrinology. Behavioural genetics – Nature v Nurture Ayres et al (2000) states that the interaction between genetics and adverse environmental factors compound behavioural problems. Bronfenbrenner (1989) formulated the ‘Ecological Systems Theory’ to explain how he believes the inherent qualities of a child interacts with the environment to influence growth and development. He argued that ‘heritability should be interpreted as reflecting the capacity of the environment to invoke and nurture the development of a trait.’ Keenan & Evans (2009) support Bronfenbrenner’s view and further believe that neither genes nor the environment is rarely the sole cause of behaviour. They believe that research has led to a better understanding about how the environment influences development both in a supporting and restrictive manner. Plomin et al (1997) puts forward the argument that there is a genetic predisposition to behaviour problems. He supports the concept of heritability and through intraclass correlations on studies of identical twins, concludes that there is strong evidence that a variety of personality disorders are at least partially heritable. Plomin has been criticised for his method of study with twins but the view is currently being researched by many teams internationally and has given rise to new arguments fuelling the nature vs nurture debate. They assert that much of what we think of as nurture, is ‘irrelevant’ and has no impact on personal development. However this concept is controversial and has been criticised by many. In his book ‘Blueprint’ Plomin, (2018) states that our DNA influences personality, physiology and behaviour and indicates the likelihood that an individual will become depressed, anxious, schizophrenic or obese. Plomin believes that it is only inherited DNA and chance events beyond anyone’s control that builds personality. According to the work of Scarr (1992, 1996), genes can have an effect on the environment in three different ways: passive, evocative and active. Passive effects are where the home environment is supportive of their child’s genotype eg musical environment for musical parents. Secondly, an evocative relationship is found when characteristic traits are strengthened by the environment which reinforces the genetic predisposition. Lastly, genes can affect the environment in an active way when children seek out the environment compatible with their genetic makeup and disposition eg attending sport clubs when athletically talented. Scarr (1996) describes this as ‘niche picking’. The Brain Kate Cairns Associates (KCA, 2018) states that more than 90% of what we know about the structure, function and development of the human brain has been discovered over the last 20 years. For instance, we now know that the human brain is constantly developing and changing, producing new connections which are more effective when the brain is interacting with another human brain. Many theorists expound what they believe affects the brain and have in particular, highlighted the importance of attachment relationships between babies and caregivers to ensure optimal brain function throughout life so that they are more able to manage difficult situations. John Bowlby (1969) formed the theory of attachment which stated the importance of the affectional relationship formed in the first months/years of life between a child and parent/primary caregiver. Bowlby called this ‘monotropy’. Many educationalists have been made aware of this theory and training given to staff who work with CYP. Toxic stress In a report published for NHS Wales on the study of Adverse Childhood Experiences (ACEs), Bellis et al (2015) stated that serious childhood traumas result in toxic stress which can harm a child's brain as well as changing the development of their immunological and hormonal systems. Subsequently, those with greater exposure to ACEs are more likely to go on to develop health-harming and anti-social behaviours. Evidence suggests that multiple traumas produce harmful levels of adrenaline, cortisol and norepinephrine which impact on healthy brain development and function. Consequently, prolonged exposure to these toxic chemicals within the brain can lead to detrimental long term impact on mental and physical health and the ability to learn and behave in accordance to societal rules and boundaries. KCA (2018) state that the key to optimal brain function lies in the regulation of stress hormones, as toxic stress closes down key brain functions and affect recovery after trauma. They list the stages of recovery as stabilisation, integration and adaptation to an end goal of social responsiveness, joy in living and raised self-esteem. Diagnosed biological disorders and treatment Some mental disorders are caused by abnormal biochemical reactions in parts of the nervous system or in the anatomy or structure of the brain eg Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD). In the case of ADHD, behavioural differences affect the ability to control and direct attention. It is characterised by overactivity, impulsivity and inattention. The hyperactive-impulsive subtype usually results in behavioural difficulties through extreme overactivity and aggression. In the case of ASD, behavioural differences occur in the part of the brain primarily responsible for social and communication development. Diagnosis of these disorders can only be obtained from a neurodevelopmental team of health care professionals with reference to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). According to Ayres et al (2000) the biological perspective considers that children with disorders (such as ASD and ADHD) may have a predisposition due to their genetic background. There have been many studies to find the genetic link with ADHD and although researchers believe that 74% of ADHD risk is genetic, they have not yet firmly linked any genes with the disorder. Cormand et al in the Medical News Today (2018) reported that the neurogenetics team have found 12 genomic segments called single nucleotide polymorphisms (SNPs) which they believe could make a person susceptible to the risk of ADHD. An altogether different study published in the journal JAMA Network Open (2019) also provides a strong basis for concluding a statistical link and increased risk between caesarean section and ASD or ADHD in early childhood. There is criticism of this study however due to the meta-analysis being an epidemiological study. This makes it difficult to determine if the factor of caesarean section is in fact the main cause of ASD or ADHD. A more acceptable hypothesis is that malfunctioning neurotransmitters in the brain may be a cause of ADHD. In order to improve behaviour and attention, the treatment of methylphenidate hydrochloride medication (ie Ritalin) is very often prescribed. Travell and Visser (2006, p206), describe the administering of medication as controversial even though it is generally the preferred option for parents and teachers who struggle with challenging behaviours. Their review of studies looking at the long-term effects of medication, suggest that behavioural improvements might only be sustained as long as medication is taken. Rose (2005, p263) points out, ‘Ritalin no more ‘cures’ ADHD than aspirin cures toothache. Masking the psychic pain that disruptive behaviour indicates can provide a breathing space for parents, teacher and the child to negotiate a new and better relationship, but if the opportunity to do this is not seized, we will once again find ourselves trying to adjust the mind rather than adjust society.’ Travell and Visser (2006) conclude that the significant side effects and psychological impact of continuing medication are overlooked by parents and believe that carers and teachers should instigate alternative less intrusive interventions and behavioural methods to bring about improvements in behaviour. They suggest that the window of opportunity should not be wasted and individuals have opportunities to learn how to deal with feelings of anxiety and stress whilst taking the medication. Current research looking at ASD points to a neurobiological cause resulting in cognitive difficulties. Children diagnosed with autism have impairments in social and peer relationships together with attachment problems and generally lack empathy. They usually have language difficulties, obsessive or restrictive interests and prefer to follow a routine which if not followed, In order to support a child with autism, structured teaching building on strengths using visual processing techniques is most helpful. Social stories and modelling techniques are employed to encourage participation and interaction with peers and positive reinforcement and distraction techniques are approaches which work well to de-escalate challenging behaviours. Schools and society are beginning to think more about how they can become more autism friendly and even stores are promoting times when they keep stimuli to a minimum. Organisations such as ASD Wales support schools to help children and staff gain a better understanding of how an autistic person sees the world. (ii) The Psychodynamic Perspective This perspective relates the experiences of the early years to the stages of social and emotional growth. Sigmund Freud (1926/1959) known as the ‘Father of Psychology’, theorized on the mind (psyche) and the structure of the personality. He explained the personality as being made up of three components - the id (the unconscious and originator of basic drives), the ego (the executive part of personality) and the superego (which regulates behaviour in line with societal norms and values). It was his belief that the unconscious mind is where all deep rooted childhood experiences and relationships are held which impact on behaviour in later life. He likened the human mind to an iceberg where the visible 10% above the water represents the conscious mind and the submerged 90% represents the unconscious mind which influences underlying behaviour. Freud believed that the unconscious mind holds the neurotic symptoms, creativity and ‘Freudian slips’. Cooper et al (2000) assert that in order to effect change in the individual’s emotional state, the unconscious level should be examined closely through psychoanalysis. They agree with the general belief that although a certain amount of anxiety can be seen as healthy in some situations (ie competitive sports etc), high levels can become seriously distressing resulting in behavioural problems which may be triggered by the mobilisation of certain defence mechanisms to protect the psyche, described by Freud as ‘ego-defence mechanisms’. Pupils with SEBD may revert to some or all of these mechanisms at some point, according to the trauma experienced. Having an understanding of these enables those working with CYP to support their needs. Freud believed in the importance of psychoanalysis to help patients resolve inner conflicts. Carl Jung was a supporter of Freud’s theory about the unconscious mind and how it related to personality but elaborated on this theory with his own. He agreed with Freud that a person’s past and childhood experiences determined behaviour but also believed that we are shaped by our future too. In 1933 Jung introduced his theory that the personal unconscious was made up of ‘complexes’. He believed also that the psyche had evolutionary innate characteristics ‘imprinted’ on it from our ancestral past. He called these ‘archetypes’ which include the predisposition of fears. Many psychologists have criticised Jung’s theory of archetypes as being ‘mystical speculation’ and not scientifically robust. However, Jung’s work on extroversion and introversion has made a significant contribution to mainstream psychology which others have built on and are used today. Like Freud and Bowlby, Winnicott (1965) expounds that the type of relationship a child has with its mother during the first three years is critical to how he behaves later. Winnicott explains his theory of ‘integration and non-integration’ and the importance of ‘unconditional acceptance’ by the mother to the feeling of integration (Cooper et al 2000, p 58). This also agrees with Bowlby’s Attachment Theory (1958) which explains the belief that the security and comfort a child experienced from their primary caregiver would influence the child’s future relationships in later life. Ericson also agrees with the importance of the caregiver from birth and believed that if the care is inconsistent, unpredictable and unreliable, the child will develop feelings of ‘mistrust’ and anxiety feeling they have no confidence in their abilities. He presented the theory that there are eight stages of psychosocial development which lead to a positive or negative outcome for the personality depending on the experience during each stage. However, Bruer (1999) attempts to discredit the idea that early experiences have an ‘all-or-nothing effect’ on a child’s brain and development. In his book, ‘The Myth of the First Three Years: A New Understanding of Early Brain Development and Lifelong Learning’, he attempts to present a more balanced view of neuroscience and childhood development and correct the misinterpretations and over-generalisations of neuroscience by early intervention advocates. He believes that a lot of work in neuroscience and child psychology is not consistent with the claims made by some early childhood advocates and warns against ‘cherry picking’ science to fit pre-conceived notions and ideological biases. His assertions have been generally well received by psychiatrists, attachment theorists and policy advocates but less well by neuroscientist and psychologists. He blames deep rooted cultural beliefs that childhood experiences have lifelong consequences and that mothers are the source of these experiences, for holding onto outdated theories which includes Bowlby’s attachment theory. He does however agree that experiences in infancy do have an effect on later development but points to behavioural and neuroscientific data which suggests that irreversibility is possible and experiences throughout an individual’s lifetime are just as important. He concedes that it does matter what a parent does but does not believe that what happens in the first three years is irreversible, having lifelong effects in all areas of cognitive, social and emotional development, as it is not supported by neuroscience. Conclusion The literature shows that the theories of many of the early psychological advocates still remain at the root of the science of psychology from which new research and hypothesis can be built on. The nature versus nurture debate is still very much relevant and fuelled by continuing research from new findings into genetics (Plomin 1997, 2018). There are arguments on both sides of the debate but many agree that notwithstanding the heredity (genetic) factor and biological factors which may affect the brain, there is an importance placed on having a nurturing relationship between infant and primary caregiver for lifelong health and wellbeing (Freud (1926/1959), Jung (1933), Bowlby (1958/1969), Erikson (1982)). Studies have shown that personality can be shaped by interaction with the environment (Bronfenbrenner (1989), Bruer (2014)) but that the relationships formed from a young age have a major effect on how a person copes with the stresses of daily life. The assessment of a child with SEBD is controversial, subjective and can be stigmatising. Identification of the range of factors which may be the cause of behaviour can take a long time and will often need specialist, professional advice. The demand is growing and schools are ill-equipped at present but staff are being made more aware of the psychology of the child through training and the theory behind the strategies and interventions they can put in place. However there is a limit to what schools can offer. Reform in Additional Learning Needs (ALN), recognises the need for a multi-agency partnership, which includes health professionals, to help support children with mental health needs. Case Study - Vicky From the information available on Vicky, I have made the following observations in an attempt to determine the cause of her behaviour. I have suggested possible responses and actions that could be taken in respect of the difficulties highlighted and suggested assessment processes and possible interventions: 1. Ecosystemic factors re school: Transitioning from one school phase to another is a major milestone in anyone’s life. Vicky has recently not only transitioned from primary to secondary but has now ‘transferred to a local secondary school’ which implies that she has had to move from one secondary school to another. It is probable therefore that she has lost whatever friendship group she had in the previous school and has had to start again in a new school with new teachers and children that she may not know. I would query whether she is happy in this new school? Is it out of character for Vicky to be in trouble at school? Does the school fit with her cultural needs as well as educational needs? It is widely acknowledged that environmental factors can cause stress and anxiety (Bronfenbrenner 1989) and changes in one system can have an effect on other systems (Systems Theory). Moving schools is an experience which is a major change, requiring extra effort and a need to adapt in a new environment. There are many mixed emotions including excitement and nervousness. Possible course of Action: Family members should reassure Vicky that it is normal to feel nervous. Parents should remain calm and cheerful so that any anxiety they have doesn’t transfer to Vicky. As Vicky is reported to be an above average student, it is strange that she is beginning to act out in school and not want to attend when she has probably been a good student in the past. Parents should contact the school to ascertain whether there are any problems. Look into the possibility of there being any bullying taking place. Vicky is described as a quiet girl who does not talk much so she may not be opening up about what is going on in her new school. Also make sure that Vicky is in a class commensurate with her abilities. Teachers could undertake a Moreno sociogram to identify where Vicky stands within her peer group and possibly review seating arrangements. Speak to the Head of Pastoral Care in the school to support Vicky in settling into the new school. If it is the case that she is just a quiet reserved pupil, the school should help Vicky make new friendships through social groups or possibly buddy partners. Maybe even encourage Vicky to attend extra-curricular clubs or activities to meet and make friends with similar interests as herself. 2. Ecosystemic factors re Family: Vicky’s parents have separated and her father has left home eight months ago. Both parents now have new partners and Vicky lives with her mother and her new partner. Her father however has written to ask if she would like to come and live with him ‘permanently’. The fact that he has written to her leads me to believe that they may not be meeting face to face. This could be due to distance or animosity between parents or even refusal by Vicky to meet her father due to resentment and anger issues. Missing her father will probably put Vicky in an emotional state where she will have to deal with all kinds of feelings. Missing a loved one can result in feelings akin to grief but her emotions could be turning hostile too. The fact that he has asked her to live with him permanently may mean that he is suffering from a form of ‘parent separation anxiety’. If he has no access with Vicky then he could be feeling all sorts of emotions himself, including guilt, and he will want to rectify the situation the only way he thinks he can. Alternatively, if it is a case of parent separation anxiety then it could be that his anxiety may be being transferred to her. If there is animosity between her parents, Vicky is going to feel unhappy. Her father is ultimately asking her to choose between him and her mother which puts a lot of pressure on an eleven year old. She may be dealing with all sorts of internal struggles. Vicky’s mother reports that she is ‘becoming increasingly school phobic’. This could be due to Vicky trying to regain some control over an aspect of her life and the need to be near her mother. As her father has left, she may be feeling fear that her mother may also leave her. As both of Vicky’s parents have new partners, it could be that she is feeling a little left out. This could lead to feelings of resentment, anger and jealousy from Vicky if she feels she is no longer a priority. Sometimes a shift in dynamic within the family can skew perceptions. In order to gain both her mother and father’s attention, Vicky could be ‘acting out’ by doing things to draw the focus of attention back to herself ie refusal to do homework and getting into trouble at school. These rebellious behaviours are symptomatic of her feelings and feelings of abandonment will threaten a person’s emotional and physical survival. Lacking enough positive interaction, Vicky could be developing negative tactics to re-engage with her parents. Possible course of Action: Look for opportunities to make time for Vicky by sharing an activity or holding a conversation. Give praise whenever possible to reinforce good behaviour and decisions. Do not reward negative behaviour with what Vicky ultimately wants. Resist the temptation to lecture, nag or punish as this reaction generally only serves to keep the negative interaction going. Vicky needs to learn how to get positive attention from her parents and maintain a healthy relationship. 3. Cognitive factors: Vicky is an able young girl with ‘above average skills in all areas’ who has a reading age 4 years above her chronological age. There are no reports of learning difficulties or attendance issues in the past so it would probably be safe to assume that she has enjoyed school and learning in the past. It is recognised that children that are more able and talented need appropriate challenge. Ofsted’s Chief Inspector, Sir Michael Wilshaw (2016) stated that some schools fail children who have just transitioned from Key Stage 2 due to low expectations; disproportionate effort for lower attainers than higher attainers and insufficient challenge for the more able. Vicky could very well be bored in her classes and disengaged. Possible course of Action: Vicky’s teachers should all be aware of her ability and differentiate accordingly to the level of her ability so that she is engaged in her learning. 4. Physiological state: Vicky is described as being ‘a very quiet girl’ with ‘bouts of generally feeling afraid’, ‘she spends a great deal of time sleeping and does not want to go to school’. From this description it would seem that Vicky has low mood and possibly even depression. Some of her symptoms fall under those two categories. Major changes in life can increase the risk of depression and Vicky has had so many changes in her life in a short time, ie her parents’ separation; move to a new school; recent health problems and the introduction of new significant people to her life. People suffering depression can have trouble sleeping or sleep more than usual; interact less with friends and family; have difficulty concentrating along with other symptoms. It would seem that Vicky is showing signs of stress, insecurity and possibly even depression. She may feel unable to speak anyone about her feelings or feel that she has nobody to confide in now that she has moved schools (eg trusted teacher or friend). Possible course of Action: It is important to address issues of depression as soon as possible before it turns into a long-term problem. Vicky could be referred to Child and Mental Health Services (CAMHS) if it is thought this would be the best course of action. But first, school should be contacted to discuss any concerns they may have. It may be possible to support Vicky’s emotional state through school based interventions or a referral to the school based counsellor. Alternatively some schools have staff trained as Emotional Literacy Support Assistants (ELSAs) and she may be able to access one to one sessions or maybe she could be part of a social skills group such as ‘Circle of Friends’. This may have the advantage of building a new friendship base. Maybe the use of a ‘General Tension Scale’ would help where she could describe her level of thinking using a 10 point scale to identify situations that cause tension (eg schoolwork, being in class, being bored, etc). It would be vital to support Vicky’s emotional health as without this, she will have great difficulty concentrating on schoolwork or building any new relationships. 5. Biological factors: Vicky has reportedly had a ‘suspected epileptic fit’. It has not yet been diagnosed and may actually have been a panic attack or migraine, both of which can sometimes get mistaken for epilepsy. A panic attack is caused by feelings of worry, fear and severe anxiety. This manifests in physiological and physical symptoms. Vicky is getting into trouble at school though we do not know exactly what trouble. Walter Cannon in the 1920s described the physiological changes that occur when experiencing fear, stress or anxiety as the ‘fight-or-flight response’. Under acute stress, the body reacts by releasing hormones which are stimulated by the nervous system. This triggers release of catecholamines, which include adrenaline and noradrenaline. When stressed, the chemicals released into the body can cause problems with headaches and stomach aches. Could the suspected epilepsy be actually one of these complaints? Chronic stress can be very serious as it can cause serious health problems and result in difficulty sleeping, irritability, fatigue, and difficulty concentrating. Vicky appears to be suffering from some of these symptoms and her refusal to do homework could be due to difficulty concentrating. So if Vicky is feeling that she does not have the resources to cope with the stresses in her life, she could be prone to a strong reaction and acute or chronic stress which could be the cause of her health problems. It is widely accepted that adverse childhood experiences (ACEs), have an effect on our health. Some of Vicky’s experiences fall under those ACEs. Possible course of action: Vicky should see her GP who should check Vicky’s medical history. He may decide that an electroencephalogram (EEG) is needed to see if it can detect unusual brain activity associated with epilepsy. Alternatively an MRI scan may be required to check any possible defects in the structure of the brain or the presence of any tumours. If these tests come back negative, Vicky could possibly be diagnosed with having panic disorder. If left untreated panic disorder can cause further debilitating illnesses and increase the risk of phobias which are extreme or irrational fears of particular objects or circumstances. They can severely restrict enjoyment of life. It is concerning that her mother reports Vicky is becoming ‘increasingly school phobic’. The sooner Vicky is assessed the better to either rule out or identify any medical condition. If Vicky is diagnosed with either migraine or panic disorder, these can be treated with medication. For my own Professional Development I think I would be interested to find out more about symptoms and assessments relating to depression in children and young people as I believe there is a growing concern in many schools over the wellbeing and mental health of children. It would be interesting to look at the medical model and learn how best to advise or seek help from the appropriate agencies. There have been a few cases in my own school where I have had to call on advice from Primary CAMHS Specialists. I feel I am only just beginning to learn about the work they do and what they can and cannot do. Case Study - Jack From the information available on Jack, I have made the following observations in an attempt to determine the cause of his behaviour. I have categorised the problems and suggested possible responses and actions that could be taken in respect of the difficulties highlighted from the various perspectives causing behaviour. I have also suggested assessment processes and possible interventions: 1. Systemic/Psychoanalytical: Jack is a year 1 child who has suffered neglect, though it is not known exactly to what extent or whether it was physical or emotional neglect. As he is in long term foster care, we can assume that there were serious grounds for him to be taken from his parent/parents. Research shows that children taken into care due to neglect or abuse can end up with complex emotional and mental health needs. Many theorists and psychologists (eg Freud (1926/1959), Jung (1933), Bowlby (1958), Erikson (1982)), all place great emphasis on the important role of the mother (caregiver) on the first few years of an infant’s life. They all state that the kind of relationship received at this time influences the way a child deals with emotional and stressful situations throughout the rest of their lives. Bowlby’s theory of attachment (1969) identifies a variety of attachments which influence various behaviours as a result. More recent studies show that children who suffer adverse childhood experiences (ACEs) are more likely to have behavioural difficulties and suffer ill health later in life. Rahilly and Hendry, (2014) have found from studies that when looked after children are compared with children in the general population, they tend to have poorer outcomes in a number of areas such as educational attainment and mental and physical health and some find it hard to develop positive peer relationships. Bazalgette et al (2015) state that the care system can struggle to provide effective management and interventions to address these problems. As he is a Looked After Child (LAC), the school will be invited to the LAC review to give its observations and feed into the Support Plan. At that point, school will have an opportunity to discuss with all other interested parties such as the Health Visitor and/or Social Worker and gain a better understanding of Jack’s background. They will also be able to find out how he is settling with his foster parents and give feedback about how he is in school. 2. Biological: Jack is described as having a ‘short attention span and oppositional behaviour’. This could be due to Attention Deficit Hyperactivity Disorder (ADHD). I would query therefore whether Jack is on the ADHD pathway and whether the Educational Psychologist or Wellbeing Specialist has made an assessment which could support a referral to the Neurodevelopmental Team. If so then Jack could be diagnosed under the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and possibly be offered medication to improve his behaviour. This however is a controversial form of treatment as Rose (2005) states that it is not a ‘cure’ for the disorder though it does tend to reduce incidences of unwanted behaviour. Recent research by Plomin et al (1997) has suggested that there are genetic links to the predisposition of some illnesses and disorders. It would be beneficial therefore to find out whether there is any family history of ADHD or mental illness. This could be discussed in the LAC Reviews. Alternatively, his short attention span could be due to any trauma he may have suffered in his early life. Post-Traumatic Stress Disorder (PTSD) is a disorder caused by frightening and distressing events. It causes an imbalance of the brain by abnormal biochemical reactions. It can be treated by medication or cognitive behavioural therapy (CBT). It is often more severe if the trauma was experienced early in life, as this can affect a child's development. Research into the developing brain of a child has shown that prolonged exposure to ACEs can create toxic stress which is harmful to the brain as it reduces the ability to respond and learn. It can also result in a child going into ‘flight or flight’ mode or becoming defiant and oppositional (as is Jack). 3. Cognitive: Jack appears to have some difficulties in speech and language and children with language problems can often have difficulty with auditory memory tasks. Playing memory games in order to remember information is a fun way to help develop these skills. Jack could be of low cognitive ability. In order to find out if this is the case, he would require a cognitive assessment by an Educational Psychologist (EP). The EP would require background from Jack’s birth onwards but this may be difficult to acquire without the input of other outside agencies involved with Jack’s case. It would also be useful to find out what preferred learning style Jack has eg Kinaesthetic, visual, auditory. 4. Speech and Language: It would appear that Jack’s language skills are very much delayed. At the age of two, children generally begin to put short sentences together and by the age of 5 or 6 years, children’s communication skills are developed so that they use language in different ways e.g. discussing ideas or giving opinions. Templin (1957) estimated that by 6 years, children have a vocabulary of 14,000 words. Hart and Risely, (2003) show that children with poor vocabulary at 2 years tend to do less well at school by 7 years. In order to identify Jack’s speech, language and communication needs, assessments such as the checklist ‘Universally Speaking Age 5-11’ and Language Link (which is an online assessment tool) could be carried out. It would appear from the information given that Jack is working at a two year old level at present. Within the last few years, schools have introduced Welcomm to identify the level of understanding pre school age. Therefore school should be following the next steps recommended by that programme and monitor annually. McLachlan et al (2016) illustrate with the use of a ‘communication chain’ how the processes involved in communication are dependent on each other and how a problem in one area can impact on other areas. This could be as a result of the neglect he suffered at a young age impacting on his ability to concentrate and learn or it could be due to a hearing impairment. These should all be investigated to find out exactly what support Jack needs. McLachlan et al (2016) state that having a hearing loss can affect the development of language and learning. Further they state that good hearing is essential for listening and concentration skills so that the important words and signals are not missed which help language development and understanding. It could also have a negative impact on his behaviour through frustration of not being able to communicate his wants and needs. It is always wise to rule out any problems with poor hearing by carrying out a simple school-based hearing assessment. If there are indications of hearing difficulties, then a referral to the Hearing Impaired Team could be made and, if they agreed, they would advise carers to make a visit to the GP so that the GP can make a referral to relevant services for further assessment and treatment. There are many ways school could help Jack close the gap if his problems are of a language ‘delay’ rather than language ‘disorder’. Using strategies recommended by McLachlan et al (2016), school could help develop Jack’s listening and attention skills through adult-led games; support Jack’s understanding by using non-verbal communication so that he can make sense of the situation and understand what is being said to him; use visual strategies to represent verbal information so that he can ‘see’ what is being spoken about; promote the development of vocabulary through games, mindmaps, modelling, sequencing activities, storytelling with puppets, word games re: prepositions, emotions, adjectives, time, etc. If school believes that after carrying out interventions there is a more serious problem, such as a language ‘disorder’, then Jack could be referred to the Speech and Language Advisory Teacher to be assessed. The outcome of which may possibly lead to Jack receiving speech and language therapy. It will be important for staff to understand that Jack’s level of language is lower than that of his chronological age. The Blank Language Scheme devised by Blank, Rose and Berlin (1978) gives examples of four levels of language skills. This explains the child’s level of receptive and expressive language skills. His level of understanding will be important to know, especially when he is displaying oppositional behaviour. Asking Jack questions that he cannot understand will not help anyone as Jack will not have the language skills to respond appropriately. It would probably only serve to exacerbate the behaviour further and break down any relationships with the adult. 5. School’s response: Jack only attends school for 60 minutes a day after lunch. We are not told exactly how long this has been the case and whether there are plans to extend the time. I would question whether 60 minutes is long enough for Jack to have opportunities to develop his language. Schools use a reduced timetable with the agreement of the parent/carer for a variety of reasons. Sometimes it is used to slowly to transition a child into school until confidence is built up but in Jack’s case it would appear that school and carers have decided that he is not coping with the school day. A reduced amount of time allows him to attend school without feeling overwhelmed and unable to cope. Leaving having a good day helps to create a more positive attitude towards school rather than a negative one where he gets into trouble. It is not clear whether the reduced timetable is reviewed with school and carers. School need to think about whether it is working and whether he needs to extend the time in school to build up to a full day. They may also wish to consider when the best time for him to attend would be so that he gets optimum opportunities to socialise and develop his language skills. It is usually the case that a review takes place weekly and adjustments to the timetable are agreed upon in a Pastoral Support Plan signed by carers, additional learning needs coordinator, teacher and member of staff from the senior management team. For my Professional Development I feel I would benefit from learning more about the assessment processes at Foundation Phase and what can be put in place to support learning. It is important that children are supported from a young age and identification of problems are made early on so that frustrations do not impact on wellbeing and learning.