In recent years, we have seen an increase in the incidence of mental health concerns for children and young people with complex SEN. Indeed, a child with a learning disability is six times more likely to present with a mental health difficulty throughout his/her life than a child without one (Emerson and Hatton, 2007). Studies also show a need for greater awareness of these issues when specific conditions are considered. For example, 70 per cent of children with autistic spectrum disorders (ASD) will have a mental health concern at some point in their life (National Autistic Society, 2010). For some children with other complex SEN, the true extent of the problem is still unknown.
Why, though, might this group of children and young people be more vulnerable? Emerson and Hatton’s work highlights some interesting risk factors in the lives of children with complex SEN which may make them more predisposed to developing a mental health concern. These include social exclusion, poverty, lack of verbal communication skills and low cognitive ability.
It can be very difficult for school staff to know whether to attribute behaviours to a child’s primary diagnosis or identified SEN, or a separate mental health concern. This is often referred to as diagnostic overshadowing (Bernard, et al., 2010). This confusion was found particularly in teaching staff within some special schools who, for example, found it hard to identify high levels of anxiety as a potential additional mental health concern in children with a diagnosis of ASD (NASS, 2007).
Typically, mental health concerns in children with complex SEN have been identified by observing behaviours, such as increases in challenging incidents or withdrawal from activities. However, in children who have profound and multiple needs, it may be that we need to be aware of more physical responses to identify distress, such as sweating, eye movements and body posture (Cooper, 2008).
Lack of Knowledge
Research has shown that, within some services, there is a lack of specialised knowledge regarding mental health in children with complex SEN. A number of reports have mentioned a difficultly in accessing child and adolescent mental health services (CAMHS) for those children and young people with complex SEN, and that long referral times and a lack of specialised knowledge create serious barriers for schools in securing appropriate support (NASS, 2007; Fergusson et al., 2008; Rose, et al., 2009). Sometimes, a mental health concern has been attributed as part of the child’s SEN and, as a consequence, limited support is available for those who need it. NASS (2007) found that this might be due to two factors: low expectations in respect to the individual’s behaviour, or a causal factor in behaviour that schools and professionals were unable to explain
Additionally, education and care staff have reported feeling that they don’t know what a mental health need is, or how to respond to a pupil who may have a mental health concern/or a dual diagnosis of a mental health need in addition to their complex SEN (NASS, 2007). However, it is important for staff working in schools to recognise that they are often better equipped with knowledge about the child than any other professional, and this knowledge is extremely valuable in spotting issues of concern and supporting pupils to receive appropriate help. In some cases, though, lack of knowledge leads to lack of confidence in identifying concerns about a young person’s mental health. This also has an impact on the support and care offered to the individuals concerned.
Children and young people with limited or no verbal communication may find it difficult to express their concerns and feelings, and school staff often find it hard to interpret their needs or distress. Additionally, some clinical assessment tools that are designed for the general population of children and young people may not be adaptable for situations involving children with severe and complex needs who may have communication difficulties or low cognitive ability, leaving their problems unidentified and often untreated. Bernard (2010) suggests that in order to try and assess the mental health of a child or young person with a learning disability we need to take a comprehensive and multi-disciplinary approach that considers aspects such as observations, past history, and a reliance on information from third parties, including teachers, parents, and social workers, who know the individual well.
Lack of training
Emerson and Hatton found that 42 per cent of mental health concerns are dealt with by school and education staff, but NASS found that staff lack training within this area and there is a great need for help and advice in the identification of concerns and how to refer these on to other professionals. Fergusson at al. (2008) found that, although the majority of staff had wide experience of working with individuals with complex SEN, they had not had the opportunity to access specific mental health training to support them in distinguishing between characteristics of the existing SEN and possible mental health problems, or the opportunity to learn about appropriate ways of responding to individual needs when they have identified a concern.
Although the issues around mental health in children with complex needs are complex in themselves, and research within this area is ever evolving, there needs to be an improvement in the training and support offered to schools. Fergusson et al. also suggest that provision of appropriate support for children with complex needs depends on the establishment of an informed picture of the mental health needs in this population. By raising awareness and equipping school and care staff to be alert to potential concerns, more children who need support will be identified.
A recent research project, Making Sense of Mental Health, suggests that to identify any potential issues we should be observing any changes in many different aspects of the child’s life, so that we take a holistic approach to understanding their mental health. This includes looking for changes in areas such as their emotions, relationships, communication, and thinking and learning, not just solely behavioural changes.
There is also a need to improve communication with external services, such as CAMHS, to ensure that children and young people are being supported adequately. The report This is What We Want (Foundation for People with Learning Difficulties, 2006) showed that young people with complex SEN want to have access to the same services as everybody else. The National CAMHS Review (2008) also proposed that all children and young people should have equal access to services, regardless of disability. Additionally, if someone does have a disability or SEN, they should expect that their mental health needs will be assessed alongside their other needs, regardless of which need is initially identified. S/he should also expect an individualised package of care appropriate to his/her personal circumstances (Department of Health, 2008). However, this may not be happening for a large number of individuals with complex needs and additional mental health concerns.
In Making Sense of Mental Health, research emphasised the importance of forming good working relationships with external services to encourage the formation of strong and effective links to mental health support for pupils. This includes strategies such as joint working and training, a mutual understanding of roles and good communication between schools and external services (Pettit, 2003).
Recently, the mental health of children and young people with SEN has been mentioned in the Government’s response to its SEN Green Paper. Here, the Government says that it aims to fund different organisations to support children and young people who have SEN with their mental health needs, including activities such as:
The Department for Education (DfE) has also commissioned the BOND consortium, led by the charity YoungMinds, to work with the voluntary and community sectors to develop their capacity to offer early intervention mental health support, including to schools.
These recent developments provide encouragement that things may be beginning to change. However, although the knowledge base of interventions that are effective for children with complex needs is evolving slowly, it is still the case that the mental health needs of these children and young people go largely unnoticed. As our health and education services evolve to meet mental health needs in the general population, it is important that equal consideration is given to those children and young people who may have a mental health concern and complex SEN.
Rachel Allan is the SEN and Mental Health Resource Developer working as part of a knowledge transfer partnership between the National Association of Independent and Non-maintained Special Schools (NASS) and The University of Northampton. This project has developed an e-learning resource for school staff about how to identify, record and respond to the mental health needs of pupils with complex SEN in their care: