“Those who are hardest to love need it the most.” – Socrates
We are a team of mental health professionals (in the fields of psychiatry, psychology, and speech/language pathology) who have had the honour of working closely together for over 20 years, as members of the Developmental Evaluation and Consultation (DEC) team, a multidisciplinary assessment team at Thistletown Regional Centre, Toronto, which was Ontario’s largest regional mental health centre for children and youth. (It has since been closed.)
Many of the children we saw had multiple previous assessments, diagnoses, and interventions, but still presented with serious issues at home, school, and/or in the community. Each child and family posed a unique story and there was usually a diagnostic puzzle to be solved. We valued team work and saw the importance of the multiple lenses and perspectives of professional disciplines. Most often there was a complex interplay of factors. Children tend to be referred for services based on what adults see as the most impairing deficit, which is usually the more obvious behavioural and attentional challenges.
Following is one of our unique cases that highlights the importance of early identification of mental health problems and learning/language issues in children and youth (names and identifying details of the case have been changed). We hope that this story will amplify the conversation about mental health and learning in children and youth.
Out of Control
“We have a 10-year-old boy who is out of control; he refuses to go to school, sniffs gas, steals, and won’t listen!” The Children Aid Society (CAS) worker was desperate for help understanding the new admission into their care.
Adam was apprehended and placed in an “emergency home” as his mother could no longer keep him safe. His behaviour was escalating and becoming extremely risky. He was running into traffic, disappearing from home, and showed poor impulse control. Adam had multiple diagnostic labels, including Oppositional Defiant Disorder (ODD), Attention Deficit Disorder (ADD) and Conduct Disorder (CD). Adam’s family was well known to the local CAS as they had received multiple calls over the years, reporting concerns about parental supervision, domestic violence, alcohol misuse, and emotional abuse. The CAS referred Adam for a DEC assessment.
School History
Adam, a Grade 5 student, had not been attending school due to behavioural difficulties, which began in the primary grades. School reports documented repeated themes of “difficulty regulating emotion and behaviour,” poor peer interaction and work refusal. Adam was reported to be a “bright boy” and “capable of doing better.” In fact, he was the unbeaten chess champion of his grade. The school worked hard in dealing with Adam’s “extreme behaviours and aggression.” He was frequently in time-out at the principal’s office. He also had multiple suspensions. Despite these measures, Adam was becoming increasingly oppositional and school avoidant. Psycho-educational testing conducted by the school psychologist showed Adam’s overall intelligence to be in the average range, with above average scores in math reasoning. However, there was a discrepancy between the level of his cognitive skills and his achievement scores. Adam performed very poorly on the reading tests. The school was eager for help understanding Adam.
TEAM ASSESSMENT
Adam’s challenges could best be understood as a complex interplay of multiple factors, including systemic factors (family and environment) and individual factors.
Systemic Factors: Born into Adversity
Adam was shaped by the milieu in which he was raised. The assessment team (psychiatrist, social worker, psychologist, speech/language pathologist and occupational therapist) was struck by the profound adversity that Adam had faced since birth. Adam’s mother was herself a victim of a sad early history and she continued to struggle with many issues. Sadly, Adam had witnessed domestic abuse on many occasions. Adam’s mother did her best to meet Adam’s physical needs; however, she was preoccupied with her own personal struggles and was thus unable to engage with Adam at an emotional level in a way that could foster a secure, well-organized attachment and promote feelings of safety and trust.
Adam’s emotional and behavioural difficulties were felt to be an expression of his underlying feelings of fear and insecurity. Children who have experienced violence, and are fearful or anxious, become vigilant. They may become triggered by seemingly simple cues which they perceive as threats, which may not be evident to teachers or other adults. Adam’s ability to learn efficiently was altered by his state of stress or fear. In a state of stress, thinking and behaviour are mediated by the lower, more primitive parts of the brain, resulting in more reactive and reflexive responses. In order for Adam to learn, to access the cortex, he needed to be in a state of calm.
Individual Factors: Developmental Language Disorder
While Adam’s expressive language skills were thought to be well developed, testing by the speech/language pathologist identified the presence of a specific auditory-based weakness affecting phonemic awareness, the foundation for reading. Phonemic awareness refers to the ability to segment, identify, or manipulate sounds in words. Adam’s phonemic awareness weakness impacted his transition to literacy, a critical developmental accomplishment during the first three years of school, when children make the shift from “learning to read” to “reading to learn.” Adam’s subtle language-based deficit also interfered with short-term auditory memory, language processing and word retrieval. The language weakness also impacted Adam’s ability to use inner language to self-regulate his emotions and behaviour, an important role of language that is often unrecognized. Inner language allows the child to think before acting, control impulses, and use words to communicate ideas and feelings. The identified language/reading weaknesses, together with the significant social-emotional stressors, explain Adam’s school avoidance and behaviour.
Diagnosis
The word “diagnosis” is derived from the Greek word gnosis, which means “to know.” As professionals, it is our obligation “to know,” yet our extensive experience working as a team has shown us how easy it is to miss underlying problems, and often “not know” what underlies behaviour. Given this deeper understanding of Adam, he was given the diagnoses Developmental Trauma Disorder, Developmental Language Disorder (DLD) and a Reading Disability.
Conclusion and Recommendations
Adam is typical of the clients referred to our team, with an early history of adversity and behavioural/learning challenges. Behaviour is the most obvious and easily identified presenting problem, often masking other issues. Adam needed the support of a multidisciplinary team to address his complex high needs. It was important to intervene as soon as possible, to avoid any further escalation of behaviour. Sadly, children and youth in the child welfare system with severe behavioural challenges are at risk of crossing over to the youth justice system, a phenomenon referred to as “cross-over” kids. Firstly and most importantly, issues of placement and family needed to be addressed, so that Adam could feel secure and calm.
Children like Adam are extremely challenging in the classroom. Teachers often have no way of knowing what underlies behaviour. However, equipped with the awareness of the impact of early psychosocial adversity, and the complex interaction of symptoms in co-occurring reading/language and emotional/behavioural problems, teachers can play an important role in referring children like Adam for further professional help. Adam’s acting out behaviour may have been his way of asking for help. The referral for a speech and language assessment was very helpful in identifying and addressing his phonemic deficits and addressing his reading needs. Reading is fundamental to success and well being, and thus it was important for Adam to receive systematic intervention to accelerate his progress relative to his peers. A caring teacher can help steer a child like Adam toward a better trajectory and escape the so called “school-to-prison pipeline.”
Jocelyn Kadish
Jocelyn Kadish B.A. (Sp&H.Th), M.Ed (Lang. & Learn. Dis), B.A. (Speech & Hearing Therapy), University of Witwatersrand, Johannesburg, South Africa. M.Ed. Master of Education (Specializing in Language and Learning Disabilities), York University, Toronto, ON. Full-time Lecturer and Clinical Supervisor, Dpt of Logopaedics University of Cape Town, Cape Town, South Africa. Experience working in children’s mental health in Toronto. Adjunct Lecturer, University of Toronto, Graduate Department of Speech-Language Pathology, Faculty of Medicine. Member: The College of Audiologists and Speech-Language Pathologists (CASLPO).
Dr. Catherine Grimes
Dr. Catherine Grimes, M.A, Ph.D. Psychology, MA Queens University, Kingston, ON. Ph.D. York- University, Toronto, ON. Thistletown Regional Centre, (TRC) Toronto, ON. Manager of Community Based Day Treatment-School Program (TRC). Coordinator for the Developmental Evaluation Clinic (DEC). Private Clinical Practice conducting individual psychotherapy. Consultant with the Catholic Children’s Aid Society of Toronto.
Dr. Mariam Vania
Dr. Mariam Vania, MBBCh, FRCP©. Medical Degree – University of Witwatersrand, South Africa (1961). Psychiatry: Child & Adolescent, and Adult Psychiatry, University of Toronto (in 1976.). Dr. Vania has extensive experience working in Children’s Mental Health settings in Toronto. Dr. Vania has a part-time solo practice for individual and family therapy. Member of the Royal College of Physicians & Surgeons of Canada.
Connie Taras
Connie Taras Gold M.S. BA in Honours Psychology from McGill University, Montreal, Quebec and M.S. in Speech Language Pathology from Purdue University, West Lafayette, Indiana. Experience working in Children’s Mental Health settings in the Toronto area. In addition to private practice, Connie is the consulting Speech Language Pathologist on the Neonatal Intensive Care Follow-Up team at Sunnybrook Hospital in Toronto and is a lecturer at the University of Toronto where she teaches Interactive Communications Skills to International graduate students. Member: The College of Audiologists and Speech-Language Pathologists (CASLPO).
This article is featured in Canadian Teacher Magazine’s Fall 2021 issue.