This session focused on Dr. Maxine Winstanley’s JCPP paper ‘Developmental language disorders and risk of recidivism among young offenders’ first published 14 July 2020. A panel, comprising Dr. Maxine Winstanley, independent expert Dr. Richard Church, and Douglas Badenoch, discussed the research and its implications, and answered questions posed by delegates online, all facilitated by Andre Tomlin (@Mental_Elf).
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Slides from the session
To get the most from the session we suggest reading/watching the following resources;
- Our Research Digest of the paper, a 2 min read
- Mental Elf blog by Douglas Badenoch, a 2 min read, Young offenders with developmental language disorder were twice as likely to reoffend after 12 months
- Dr. Maxine Winstanley’s 6 min video abstract of the paper
- The full open access paper doi.org/10.1111/jcpp.13299
- The Special Educational Needs and Disability Reforms and Speech, Language and Communication Needs in the Youth Justice Sector: Findings from a Survey of Youth Justice Services in England
- Raising Awareness of Developmental Language Disorder website (Previously RALLI campaign) has resources that explain what DLD is, the impact it can have, how to get help and how to raise awareness.
- The Communication Trust is a coalition of over 50 not-for-profit organisations. Working together we support everyone who works with children and young people in England to support their speech, language and communication.
- ACAMH Topic Guide on Developmental Language Disorder written by Professor Courtenay Norbury, Professor of Developmental Disorders of Language and Communication at Psychology and Language Sciences, University College London.
- This collection of Research Digests contains content from ACAMH’s two main academic outputs on Developmental Language Disorder (DLD), in the Journal of Child Psychology and Psychiatry and Child and Adolescent Mental Health.
Andre Tomlin – Hi, everyone. Pleasure to be here. I’m Andre Tomlin from the Mental Elf, and we are going talk about developmental language disorders and young offenders and re-offending tonight, a really interesting piece of research led by Maxine Winstanley, who’s with us here at the campfire this evening. So if it is your first time here, welcome. This is a very relaxed, thought-provoking, online journal club that we’re going to run for the next hour. And as Matt says, we’ve got a couple of hundred people here in the webinar.
First of all, if you could share poll one, Matt, we want to know who you are. So thanks a lot for introducing yourselves in the chat. Carry on doing that. Tell us what your background is, what your primary role is attending this event. There’s a poll that’s just popped up in the screen and hopefully your kind of professional affiliation appears on that list. If it doesn’t, there’s an “other” at the bottom. We just want to get a sense of what kind of people we’ve got here in the webinar this evening so we can make the session as specific and relevant to you as possible.
Fantastic. So that’s great, as expected, we’ve got nearly half of the audience are speech and language therapists, so that’s brilliant, wonderful to have such a great response. I think this is the best attended campfire that we’ve run so far. So, yeah, big up the SLT community. Well done, guys. Really nice to have you joining and discussing this with us. And yeah, you can turn that off, Matt. We don’t need the slides just now. We can make do with. Yeah. Pictures of human beings for the time being. Thank you.
So I’m just going to introduce the people that are here. First of all, Dr. Maxine Winstanley, she’s a speech and language therapist. She’s the course leader for the master’s course in SLT at the University of Central Lancashire. She’s our kind of guest speaker talking about her research. So you’ll be hearing from her very soon. We also have a forensic and child and adolescent psychiatrist who many of you will know, Dr. Richard Church. He is the hospital medical director at Cygnet Health Care and has lots of experience in this field. Two of my colleagues here on the Camp Fire, an information scientist and fellow Elf, Douglas Badenoch, he’s going to be here this evening talking about the paper and giving you lots of critical appraisal tips and thinking about the strengths and limitations of this research. And also our colleague, Dr. Celine Ryckaert, who’s a psychiatrist and researcher from King’s College, London, who’s part of the team here who’s going to be working in the chat and helping us make sure we answer as many questions as possible.
So first of all, many of you know will this area very well, some of you less well. So we thought we’d start off by setting the scene. I wanted to start by asking Richard to give us a kind of psychiatrist service perspective on this population of people, young people in the criminal justice system who may or may not have developed mental language disorder. People who are offending, maybe reoffending. Just paint us a picture, Richard, of the lives of people, and, yeah, give us a sense of that?
Dr. Richard Church – Absolutely, and thank you for inviting me to be part of your campfire. I’m really pleased to be here, and it’s really great news that there are just so many attendees. When I saw the attendance poll, I thought, “Wow,” not just really impressive to see so many speech and language therapists, of course, but just to see the breadth represented there. I think that’s a real strength of ACAMH, and I feel very much in the minority here as a psychiatrist, and that’s a very healthy thing, I think, for me. So to be honest, I hope that I’m enriched by today, really. I hope to learn a lot. And if I can share something that might be useful or interesting to someone, then fantastic. Let me tell you a little bit about my medical or psychiatrist perspective on this area, including speech and language therapy, because actually, if you’d asked me 20 years ago when I was at medical school about speech and language therapy, I would have probably guessed it was something very specialised and very niche and that I might not really come across in my professional career. I had a very limited understanding of it. But I guess during that time, during the last 10 or 20 years, my understanding of speech and language therapy has developed. I think from everyone I’ve spoken to and everything I’ve read and seen, I think speech and language therapy itself has really developed.
So 10 years ago, when I was a forensic psychiatry trainee working in a high-secure hospital, I had the good fortune to come across a speech and language therapist working there, Karen Bryant, who really opened my eyes to this very specialist area and the fact that as providers of the service, we’d been designing services with the convenience of both delivering the service in mind, for example, delivering groups, therapeutic groups to patients, it’s very cost effective and quick. And, you know, it’s fantastic, very convenient. But actually, are each of those individuals in that group able to engage and benefit from that intervention? I think it was really speech and language therapy that highlighted that actually we were delivering interventions that perhaps really were not having the impact that we wanted them to, that the individuals that we thought we were treating actually maybe were completely unable to engage in the therapy that we were happily delivering.
And I think when I started working in the more specialist field of youth offending services, then it was really a discovery, a landmark moment, maybe, an important time in speech and language therapy itself when they became part of the multidisciplinary team actually in youth justice settings. And actually, I came to have a more day-to-day working relationship with professionals in this field. And of course, I’d worked a lot with clinical psychology and other therapists, but there was something just very specific about speech and language therapy that made it particularly interesting and relevant, especially in youth justice. And I think that’s the point where not just in the youth offending teams in the community, but also through expert witness work in the courts, actually, through the work of intermediaries and so on, that I came to that deep understanding. I thought you were about to ask something, Andre.
Andre Tomlin – Yeah, I suppose I was going to ask. It’s an impossible question to answer. That’s why I’m kind of wondering about asking it. But, you know, you can’t generalise because it’s a very diverse group of people. But, you know, people who use youth offender services, tell us something about that group and are there common, you know, issues that they have, or problems that you’re helping them with, life backgrounds that you’re helping them address, just paint a picture of that group for us.
Dr. Richard Church – Well, I think it would be fair to say that it’s a group that’s very disadvantaged in a number of ways. We’re talking about the group of young people who come into contact with the youth justice system. And we’re looking at a disadvantage in every domain you can think of, really. I think genetic vulnerability to a number of disorders, psychosocial adversity, and disadvantage in educational attainment, impoverishment, really, of opportunity in a number of ways. And I think comorbidity is just the rule, actually, rather than the exception, so the coexisting of mental disorders, safeguarding concerns, all that psychosocial complexity, maybe family or child custody issues, alongside specific or general learning disabilities and other forms of adversity, not just in the young person, but in their families and in their communities.
So, of course, it can feel quite overwhelming for practitioners. And the Youth Justice Board publish annual reports, which are very informative, really helpful. We can see that there are some very significant trends over the last 10 years, the number of young people in custody has reduced tremendously to under 1,000 now for some time, the number of young people being convicted of offences has steadily reduced and first-time entrants have reduced. The area that’s remained stubbornly high is reoffending. And this is a particular area of interest for the Youth Justice Service and actually for those with an academic interest in the field because there are some unanswered questions.
And actually, that’s, of course, the reason why this article by Maxine is particularly interesting and deserves the attention that we’re giving it here. I think, quite apart from anything else, it’s an extraordinary achievement to have interviewed 145 young people and completed all those assessments on them. Because it’s a group that can be very difficult to engage and engage for this period of time in order to do all of those tests and, really, to see the work that’s been done by Maxine and the team is really extraordinary.
Andre Tomlin – Thank you. That’s a nice segue. I will take that and move with it. So, for me, the reason this is such a great webinar to be holding is because this is such an important population of young people who really need help and who are often ignored by research and often removed from or ignored by services. So it’s great that we’re talking about such a disadvantaged population who have so many inequalities that they face.
So let’s start talking about DLD. Maxine, over to you. So what are developmental language disorders, first of all? Give us an overview.
Dr. Maxine Winstanley – OK, thank you very much for inviting me here, I feel really privileged and honoured to be here and thank you to everybody else who at the end of the start of your working week, at the end of your working day, must be absolutely exhausted, yet you’ve chosen to come here. So I’m really, really grateful to all of you. So, a developmental language disorder describes when somebody has persistent difficulties with using or understanding language. These problems actually affect functioning in everyday life and in educational progress. So a developmental language disorder makes it hard for young people to use specific vocabulary rather than an empty vocabulary such as “stuff” and “thing”, they find it hard to learn new words, they have a very shallow vocabulary, and because of that, they can find it very hard to express themselves and say what they want to say, tell their story, articulate their ideas and their feelings. They find it difficult to produce long and complex sentences.
Now, we don’t use long and complex sentences to be fancy. We use them because we want to express ideas and link ideas. So, for instance, if you want to say what happened to whom and when something happened, you would have to use a complex sentence to say that. So young people with developmental language disorder can have really impoverished narrative skills and find it very hard to tell their story. So, if a psychologist wants a young person to tell them something they’ve seen or a ward manager wants an account of something that’s happened on the ward that day, a young person with DLD may actually come across as somebody who’s being quite evasive or holding back or perhaps a little bit rude, perhaps even guilty.
And it’s really important that we keep at the forefront of our mind that language is actually a two channelled process. So we’re not just thinking about what these young people can say, their expressive language skills, which is actually reasonably visible to us. But we’re also thinking about what these young people can understand, so their receptive language skills, and that’s pretty invisible to us. Young people with DLD have a great difficulty processing information, understanding complex sentences, following instructions, keeping up with conversation, or social banter. They find it very difficult to comprehend vocabulary relating to emotions or mental states, and young people with developmental language disorder often describe to me as a feeling of really not understanding all the words around them. Like quite often people are speaking in a foreign language or the sounds come at them all jumbled up, and they express frustration at not being able to keep up with conversations or not being able to articulate what they want to say, or not being able to keep up with conversations and social banter with their friends, they find that very difficult.
And these difficulties can actually often masquerade as, or even be attributed to laziness or troublesome behaviour. So it’s a persistent, pervasive disorder and it’s diagnosed by a speech and language therapist and it can occur with other neurodevelopmental disorders. And once again, they can sometimes mask the language disorder. So people may see the autism, but they might not see the language disorder. I think when we consider that language is really fundamental to how we interact with the world, how we make friends, how we learn from the world, how we express our worries and our ideas, it’s not surprising that DLD actually commonly does co-occur with externalising and internalising difficulties.
And once again, these can mask the language disorder. So perhaps referring adults will refer on because they see this overt behaviour, but without really giving much thought to the underlying language difficulties. Language difficulties affect literacy, they affect your ability to make friends, your emotional well-being, and DLD doesn’t subside with time. We have children with DLD, we have adolescents with DLD, and we have adults with DLD. It doesn’t just disappear.
And what we find is quite often that they can manifest as really complex psychosocial impairments and mental health difficulties, reduced vocational employment and engagement and literacy problems. So they are really, really far reaching. And it’s interesting really that Richard said about this cohort of young people, because when I started this research, I would often ask people to just describe when you think of the typical young person in contact with youth justice, what comes to mind, what do you think of? I used to ask that question an awful lot and I’d always get, “Well, male, aged between 10 to 17, low socioeconomic status, perhaps dropped out of school, perhaps a looked-after child.” But nobody ever, ever mentioned language to me. It was always the same subset of descriptors they would use and never language. So I’m really pleased and really grateful that you’re letting me discuss my work and everybody’s here to learn about. It’s absolutely fantastic, so thank you very much.
Andre Tomlin – Thank you. Great intro. So we’re also going to talk about your research in a bit more detail soon. We’re also going to talk towards the end of the webinar about what we can do to help people with DLD, some of the resources that are available. So if you’re sitting here thinking, “Okay, I’d love to get some help to help people,” we have some links and we’ll share those later on. But, Richard, I just wanted to kind of ask you, having heard Maxine do that introduction, have you got any kind of reflections or any questions for Maxine?
Dr. Richard Church – Well. I don’t know if now’s the time to ask a couple of questions that I did have on my mind actually about developmental language disorder, because my understanding of this is that it would need to be a level of function and language that’s out of keeping with overall IQ, but something that, for example, if someone has a mild or moderate learning disability and has language in keeping with that, then they wouldn’t have a separate diagnosis of developmental language disorder, they’d just have a diagnosis of learning disability. So I guess that’s my question, really, in order to diagnose a developmental language disorder, does there need to be a discrepancy in cognitive testing, for example, with other areas of function?
Dr. Maxine Winstanley – Thank you, Richard, and I think recent empirical research and observation studies and longitudinal studies have really shone a light on this and how we actually diagnose it now. So, language disorder is kind of an umbrella term, really, and it can be split between language disorder and language disorder associated with. So we could have language disorder associated with autism, or language disorder associated with intellectual disability, or some other neurodevelopmental disorder.
“In association with” doesn’t mean “explained by”. It just means that this is the context that we understand that young person’s language disorder. So this exclusionary discrepancy that we used to have with regards IQ, the research tells us really that those people with a lower IQ still react the same to intervention and they are still worthy of having this diagnosis of language disorder because they still can get so much from the intervention. They’re eligible for assessment and intervention.
I think Professor Courtenay Norbury has done a population study in Surrey a couple of years ago. And what she found is there was approximately 10% of young people with language disorder and 7.5% of those were what we would usually have classed as specific language impairment, which I think is what you’re talking about, Richard, where we had this non-verbal IQ discrepancy. But what she was finding was that there was no real justification for that anymore with how these young people reacted to intervention and how they changed over time. And also just their overall profile was the same. So there was no need to have that discrepancy anymore. So we would see, as I say, two brackets of language disorder: language disorder and then language disorder associated with. But that certainly doesn’t mean explained away by the autism or the intellectual disability.
Andre Tomlin – OK, that’s nice, Maxine. Thank you. Let’s move on to the research, because we need to have enough time to kind of get our teeth into this paper and ask some questions and explore what we’re going to do with this evidence. So I’m going to hand over to my colleague, Douglas, who’s going to talk a little bit about the paper and his appraisal of the paper. Before we do, Matt, can you share poll two now? Some of you guys in the audience will have had a look at Maxine’s paper already, and that’s great if you have. If you’ve done your homework, you’re going to get extra brownie points. Tell us what you think of it. Tell us to what extent this paper has changed your perspective on developmental language disorders and reoffending, and if you haven’t read the paper yet then don’t worry about answering this poll, because we’re going to ask it again later and you’ll have a second chance to tell us what you think. We just want to start getting a sense of what you think of this paper. Is it relevant? Is it useful? Is it going to change your perspective, potentially change your practise?
OK, thank you very much, everyone, so we’ve got quite a positive response already, so the largest response is eight out of ten, nearly a quarter of you have said more that, nine or 10 out of 10, and other people are mostly grouped around five, six, seven, and there’s one or two also who’ve said less so, around two or three. So we’ll revisit that later. Thanks, Matt. Douglas, over to you.
Douglas Badenoch – Thanks very much, Andre. Matt, I was wondering if you could jump in to slide four for us, please. Thank you. So I ran a critical appraisal of this paper using the CASP critical appraisal checklist, which some folks may be familiar with, we’ll just look at the structure of that in a second. I also wrote the blog on The Mental Elf based on that appraisal. So if you want a little bit more detail than what we’ve got in these slides, not much more, then you can find that on the blog. It’s good to see the questions coming in, some questions about the study population and comorbidities and how we define and understand DLD that we’ve addressed. So we can add to that list and hopefully through the session explore them with the researcher being in the room.
So the first thing when I looked at the study was that there were two research questions being addressed in the paper. The first question that Maxine and her colleagues were looking at, the prevalence of DLD amongst first-time offenders, and that’s the sort of statistic you would want to do some survey-based activity on. But the second thing they wanted to do was to recruit a cohort of people that they could follow forwards in time to detect a link between the existence of developmental language disorder and subsequent reoffending. So that’s the sort of prospective observational study that the right fit for a critical appraisal there was the cohort study checklist.
So, looking at the key details of any cohort study, the first thing you need to know is who the people are and how they were recruited to the study that took part. The second one was how did they establish the exposure, if you like, in our cohort study, how did we establish whether people had developmental language disorder? And then thirdly, we need to know did they establish the right outcome? Did they have a reliable method for assessing the people’s outcomes at the end of the study? So in this case, we have followed the participants for almost a year. Most people were followed for a year and the ones who weren’t, it was only slightly less than that. We have, I guess, a fairly objective outcome measure in the sense that if people were convicted or not, that gives us a nice binary outcome that we can work with.
This slide is going to be in our slide pack, but what I’ve done is I’ve pulled the CASP questions off the checklist and just summarised them so you can have an at-a-glance view. In the CASP method, one of the things we’re keen on doing is exploring some of the reasons why you might not be clear about something rather than just saying, “Oh, if everything isn’t perfect, then we forget about it,” because as I guess we’ll probably hear there are often limitations in how much detail you can put in the published report of a study. However, it’s important, I think, to go through this process because too often we see things published that might mislead us or that might contain bias.
So we’ve already looked at the first question, the first CASP question, which was understanding the study questions. We move on then to look at point two, which is how the cohort of participants were recruited. I think we’ve already seen some mention of that in the chat. One of the concerns I had in reading the paper was that some of the participants just didn’t participate. They tried quite hard to get a consecutive group of participants, which is a real strength. But inevitably, there were some people that weren’t able to participate. So we’ll ask maybe Maxine to comment on that. But it did seem that quite good effort was made to achieve a good cohort of participants. So I was happy with that. And in fact, the only kind of two other questions I had about it were how did we get a reliable classification of people with DLD? And I think that relates to some of the concerns that folk maybe have expressed so far around potential for overlap with other conditions. But again, that’s something that’s inherent in the nature of it. And we can’t just sort of rule things out on that basis. So that’s just something to remember, I suppose.
The second point at this stage was the fifth point around the potential for confounding factors. And again, potential for other conditions could be involved. There could be things that we haven’t thought of. They went to quite considerable lengths to measure adversity, non-verbal IQ and other things which we know might influence reoffending. But there might always be something that you haven’t thought of or that hasn’t been measured that could be at play here. So that’s really something to bear in mind before we then move forward to think about the implications and the findings of the study.
So I wonder if we could just pop up poll three, please, Matt. So I just wanted to, having given my own view, what the view of the participants were on whether you think this paper provides valid evidence that we can rely on. And you can put yes, no, or not sure, and further details we can discuss in the chat window.
Well, that’s a very clear vote in favour. But there is maybe a substantial number of people, including myself at first sight, that maybe weren’t sure about a few things. So I wonder, at that point, if we could just jump onto the next slide, please, Matt, and I’ll maybe just summarise some of those concerns.
So that just summarises the concerns that I outlined just now, and I thought that might be a good point to pass over to Maxine, because we’ve talked through some of these, and it might be a good opportunity for Maxine to answer some of the questions, particularly around the potential for overlap with interactions with other conditions.
Dr. Maxine Winstanley – Yeah, most definitely. Obviously, that is really difficult and as Richard has said, comorbidity is the norm here and certainly not the exception. What I did do was when I started the study, the only exclusionary criteria I had was that English had to be a first language because I really wanted it to reflect the young people that come through youth justice rather than having all these exclusionary criteria. I wanted it to reflect the young people that came through youth justice. So I didn’t have any exclusionary criteria. What I did do, though, was I did what we call a sensitivity analysis on the data. So I reported the data with the 145 participants that I had. But then I ran what we call quite a few different sensitivity analyses. One of them was where I excluded all the participants who had a known neurodevelopmental disorder or an EHCP with something noted on it. So all the young people that had autism, ADHD, they were all taken out of that analysis, and I just ran the analysis without those in, and I got the same set of results.
Same with the adversity score really, so the adversity score was made up of five different variables and they included, I’m going from memory here now, it feels like the seven dwarfs, I can never remember them all, but it was whether or not your parents were in paid employment, whether or not you were in education or employment or training and all these five variables. What I did was I ran each one separately, so I put each one of those through in case I diluted actually the effect they had on recidivism, and that didn’t make any difference either. Then I also put all five of those variables in separately. Now, when I did that, obviously, I was over-fitting the model because I only had 145 participants. So, to put all of those in separately was really over-fitting it. But I wanted to do it just to see how it came out. And once again, I came out with the same set of results, nothing I did really changed those results, and DLD was always the biggest predictor of recidivism, ranging from something like 2.4 right up to 2.8, depending upon each set of those sensitivity analyses. So as I said, I did run the model a few different ways to check that I was getting the right results each time, and all the results were consistent.
I think, with regards recruiting of participants, you are right, it is really difficult, it was a two channel process, really, because some of the young offenders who scored very low on the crime matrix, they went through what we call kind of a diversionary subset, they didn’t go through the youth offending team. So I had to have a separate way that I recruited those young people because they only met with a worker once for three hours. So I didn’t really get a chance to build up a good relationship with those young people, though still quite a lot of them did take part in the research. And then anybody who scored three to eight on the crime matrix, they went through the youth offending team. And each youth offending team were really, really good at driving the research forward. The manager in each youth offending team made it part of the young person’s initiation to the service, really, that they would be told once the youth offending worker had built up a relationship with them, they would be told about the research and asked if they wanted to be involved.
And obviously parents were invited to come to the session. Youth offending team workers were invited to come to the session. So we were always going to have that self selection bias really for those that did turn up and those that didn’t turn up. And we can think perhaps some of them, maybe some of them didn’t turn up because they thought, “Oh, crikey, language is really difficult for me. I don’t want to go to that.” Although I’ve reported on 145 young people, I did see a lot more than that, but it was quite evident as we sat down to go through the measures that they were really, really struggling. So the right thing to do was to stop what we were doing and not count them in the data. So it could actually be an under-representation of the young people with language difficulties as opposed to an over-representation.
Douglas Badenoch – Thanks for that. That’s an amazing picture of how you managed to get the study integrated into practice. Tell us about your wellies, how important they were.
Dr. Maxine Winstanley – Yeah, they were really important because the young people that just had a kind of a one-stop session, which was a three hour session, it was all built around kind of paying back to society and reparation. So what we would do is usually meet for three hours at perhaps a care home and we would do gardening there. Or perhaps, you know, I think places have these allotments, and some of those are empty. So we used to go and do those up. What I used to do was just go and take my Wellington boots with me, and a week before the young people came to the session, they would be sent information about the research. So I just turned up to see if they wanted to get involved with the research. And if they didn’t, I would just put my wellies on and just help them really. And quite often I’d spent about 30 minutes chatting to somebody and they’d say, “Well, actually, I really would like to have a go at this,” and they’d get involved. So it’s just about making those connection with the young people really and just being involved in what they were doing. It was really important.
Douglas Badenoch – So quite literally, getting your hands and feet dirty. I mean, I think it’s quite a nice metaphor, that, and it addresses one of the fundamental questions here around the messiness of diagnosis and who’s got one and who hasn’t and who’s been missed and what other conditions are available. That is just real life, isn’t it? If you wanted to do a study which everything was just focussed down on one thing, you’d never find anyone to participate in it. So this is absolutely essential that we embrace this kind of thing.
I wonder if we could quickly throw up the next poll. So I wanted to just think about the extent of the findings, the size of the effect. Do you think it’s important we can… The broad finding of the study was that people who showed up with DLD were around two and a half times more likely to reoffend within a year later. Now, which does seem quite a big effect. I just wondered what the feelings of the group were from looking at the paper. Does this look like important evidence to you? Just give us a quick click and then we’ll slide back into the next slide. Do you want to see what folk are saying?
Dr. Maxine Winstanley – Can I just quickly answer a question, would that be OK?
Douglas Badenoch – Yes, please go for it.
Dr. Maxine Winstanley – It’s quicker for me to say than to type it. Everybody had to have English as a first language. I can see someone’s asked about the participants being bilingual. The problem I had was because some went through the youth offending team and some went through this diversionary, I could only collect data that both departments collected. So the youth offending team obviously collected better data than the diversionary team. So I don’t have details on the amount of people that were bilingual, but they all had English as a first language. It’s a very important point. Thank you.
Douglas Badenoch – Yes, thank you. Matt, could you just quickly pop up the next slide? I do take on board the fact that there was a mass rush to say “this is important evidence”. I don’t want to just say it again, but it’s worth saying it, I think. I think there’s something about when you put a study that’s an observational study and therefore there may be some limits around what all we can say, when you’ve got something that says, “Look, this group might well be two and a half times as likely to reoffend,” you’ve got cause for concern in terms of thinking, “Well, hang on, are we just doing this all wrong? Do we need to rethink how we’re doing things?”
The other finding for this group was that around 60% had a developmental language disorder. So those are the kind of findings, according to our two questions. I think we’re all probably on the same page where we think this is an important finding and probably now is a good time to pop back to a discussion of the importance of this evidence. So, I wonder if you’d like to kick us off, Maxine, just by in terms of your findings, how surprised were you by the findings?
Dr. Maxine Winstanley – I wasn’t surprised at all, really. I did feel that DLD would come out as a strong predictor, perhaps not as strong as it is, as I’ve found, but I was confident that… I was really mindful of the fact that I kept reading research from people like Professor Karen Bryant and Professor Pamela Snow about the fact that DLD is over-represented in people in young offending institutions. But I was always concerned, well, if we go backwards to when they first come into contact with the Criminal Justice Service are we pushing them further up that ladder, that criminal ladder, because we’re not getting it right at the first port of call, really. So I think what I was surprised at was the fact that 60% of the young people came out with the diagnosis of DLD. I think I thought that would be lower. That kind of equates to the young people in young offenders’ institutions as well, and I thought it perhaps would be lower because we were forcing them up the ladder. So that was my surprising find really out of the research. But yeah, definitely, I think going forward, I’m really hoping that people see that there is a role for speech and language therapy in this arena and the specialism we bring and just how important these language skills are to the talking therapies that are used everywhere. And as a speech and language therapist, what I want is to make sure that there’s equity for all the young people. So people with developmental language disorder, I want them to be able to access these rehabilitation that’s on offer.
Douglas Badenoch – I think that’s an absolutely crucial point, isn’t it? The equity here. Richard, do you want to have a quick word on the paper before we open up to broader discussions? I’m seeing loads of questions coming in, so we need to make sure that we run through those questions.
Dr. Richard Church – Yes. Thank you. There are lots of interesting questions. I wonder if some of our participants might also be wondering what I was thinking about the comorbidity, looking at the more traditional psychiatric diagnoses like depression, anxiety, post-traumatic stress disorder, because that’s not something that the paper explicitly looks at but is a well known comorbidity. So I guess my question to Maxine as well would be, are we saying that regardless of comorbidity, whether the developmental language disorder exists with another disorder such as PTSD or not, it doesn’t actually matter. They’ve got that language disorder, they’ve got that impairment, and perhaps it’s that that is particularly significant in mediating this vulnerability to recidivism and the desisters, whether they have depression or PTSD, anxiety, or whatever else, their better language function maybe serves them to desist. Is that how we think about comorbidity with thoses other diagnoses, Maxine?
Dr. Maxine Winstanley – Yes, yes, I mean, it is really, really difficult to tease everything apart, especially when these young people come to us as adolescents and a lot of these difficulties have gone undiagnosed and unrecognised. It’s hard to work backwards and tease this apart. But when you’ve got language disorder associated with something, you still have that language disorder. You still find it difficult to access those talking therapies. So it is something that needs addressing and something that needs recognising. As I say, quite often, these other neurodevelopmental conditions or these other diagnoses that they have can often mask the language disorder, which is a shame, really, because it does definitely need addressing and it needs help, and it also needs modification to the rehabilitation that they’re given and that’s offered to them.
Douglas Badenoch – I think that’s one of the strengths of the observational approach, and I think to explore the ins and outs of all the different ways of categorising participants, you would need a much bigger study for a start. So I think that, in some ways, although we can’t answer definitively all these questions, I think taking that simple, if we’re happy with the way that we identified the language disorder, then we’ve got something important, and, you know, that may just change our perspective on things a little bit.
I’m just seeing a great comment just now about I think Julie, thank you for saying, “Not just implications for therapies, but just how we all approach young people, talking with children to resolve problems is relied upon everywhere.” So it’s maybe something that, you know, it is beyond just this group.
Andre Tomlin – That’s really interesting, isn’t it? What are we going to do about it? I wonder, Maxine and Richard, if you can kind of respond in general to some of these questions about interventions. So Judy’s comment, really interesting, Sinead also talking about appropriate ways that we can help people with DLD if the normal verbally mediated interventions are not appropriate. Kirstie is also talking about animal assisted interventions. Really interesting, thinking about how they might be useful for other groups of young people, potentially also useful for people with DLD.
What needs to change in the system? What sort of interventions do we need to be delivering for young people with DLD, and presumably the subgroups of young people with DLD and other things going on as well?
Dr. Maxine Winstanley – Yeah, I think it is really very difficult. I mean, there’s a huge disparity, really, I think in our current knowledge concerning language skills of young people in the Youth Justice Service and the policy frameworks and the services that are there to support them. I think it’s also very challenging as well, because although we’re certainly making strides in that area, speech and language therapists aren’t always known for working in youth justice. I mean, thankfully, the tide is changing on that now, but historically we’re not. So it’s really looking about how we can embed ourselves in that service and make a huge difference.
I mean, I am a huge believer in all children and young people who present with social, emotional and mental health and conduct disorders should have a full speech, language and communication assessment to get a full profile of that young person’s language ability, and then we can establish what their language skills are. We can start with a base level of where they are. We can make sure we work collaboratively together to deliver joint sessions so that these young people are going to get the most out of those sessions. I think that’s really important to get a full profile of that young person so that the MDT are completely aware of that, so that we can really move forward for them.
When I’ve worked in social and mental health settings and I’ve worked in youth justice, there are some kind of like go-to resources that I’ve used. I’ve often used things like talking mats. I have found comic strip stories really, really beneficial, where each little piece of information has been put on a sticky note and put down, and then the young people can move them about to make sure they get the right time frame as to when these things happened. Lots of colour coding to what somebody was thinking, to what they said, so their emotions, and really making these things that are so important, extremely explicit for the young person, and not having that assumption of knowledge.
Andre Tomlin – Richard, do you want to come in? It feels like we’re quite early on in the development of services here that are going to help this group of people. Are there some examples here of speech and language therapists working in the youth offending system, working in criminal justice that we can kind of build on and, you know, spread out across the country?
Dr. Richard Church – Well, absolutely. I think it’s becoming the norm, I’d like to think, in youth justice settings. What I think is is really interesting but not perhaps interesting to everyone, but from a managerial and commissioning perspective, how actually wider or universal provision is achieved. Does it depend on individual leadership within the youth offending service? Where does that speech and language therapist actually lie organisationally in terms of their employer? Should they be employed by the NHS, actually? Or local paediatric teams often provide speech and language therapists to youth offending services. Sometimes they are more closely linked to the mental health team. So I think that there are those questions because they have implications for commissioning, of course, and funding those posts, but also for the really important bits of supervision and joint-working and real inclusion in the different sorts of meetings that young people in this field have, CPA meetings or other sorts of meetings. So that’s a perspective that can be put into different kinds of youth justice service reports, pre-sentence reports and so on.
So I think everyone’s on a learning curve, really, and I think a lot of it does depend on the leadership locally of the youth justice and health services. I think where there’s a will to develop provision, I think it can really happen because there’s an appetite for it. From the comments I’ve seen, there’s real interest in the Royal College of Speech and Language Therapy, actually, in mental health, and perhaps this particular field now. So I think that’s the first point. We need to make this provision available and then have a structure that enables effective joint working and incorporating the results of these very valuable assessments then into care plans for a way forward.
Andre Tomlin – Thank you. I think it’d be really interesting also in the time we’ve got left to talk a bit about priorities in terms of research. So what other questions should we be answering, do you think? If there are research funders on the campfire this evening and they’re thinking, “I’ve got a spare million pounds that I can push your way, Maxine.” What would you be doing next?
Dr. Maxine Winstanley – Yeah, I’m really interested in doing extra research really in this area to move it forward. I think there’s a few things that I was unable to look at because I did do other measures than what’s reported in this paper. So I also looked at the literacy of these young people and I looked at their narrative skills as well. I can see some of the speech and language therapists have really struggled to keep up with the questions, they’ve come in so fast. But have asked questions about inference and prediction and verbal reasoning, and they are really, really important things that could have been missed that I should have looked at. I only looked at structural language skills. Going forward it’d be really important, I think, to look at pragmatic language skills as we know that they can mediate the relationship really between social disadvantage and behavioural outcomes. So that’s something I would like to look at. I would like to look at how we can embed speech and language therapy really into youth offending teams and doing some kind of small-scale studies on perhaps response to intervention. So having those tiers, having that universal and targeted and specialist tier and how a speech and language therapist can feed into each of those tiers but in a youth justice service. That would be really important for me. And I’m always keen, really, to listen to what the people working in Youth Justice would like to find, the questions they would like answering, because they’re the important drivers and they certainly helped me drive this research forward. And without them, I wouldn’t have been able to do it.
Andre Tomlin – Thinking upstream from there, lots of questions about the role of schools, earlier intervention. What do you think we can be doing in terms of system changes to be identifying these young people before they get into the youth justice system?
Dr. Maxine Winstanley – Yeah, most certainly, I think, you know, if we think of Professor Karen Bryant’s compounding risk model, this is what she says, you know, there’s been plenty of chances really to intervene for this young person before they’ve got to the Youth Justice Service. And it’s a shame that we haven’t, and I think sometimes that’s why Youth Justice staff felt a little bit ill-equipped to be able to pick out those with language disorder, because they would say to me, “Well, actually, this young person’s been in school. If if a teacher hasn’t recognised it, it’s really difficult. How am I supposed to recognise it?” But, as I said before, I really do feel that any young person who has got any kind of behavioural difficulties should be flagged up for a speech and language assessment so we can get that baseline and know their language abilities.
And also earlier on, any difficulties with literacy, you know, so early stages in school, actually, they’re teaching you to read, aren’t they? And then eventually we turn about seven or eight and actually then we’re reading to learn. It flips. So, if you’ve not learnt how to read, then that reading to learn ship will sail without you and you’ll really start to fall behind. So I think those are other points that we could intervene and certainly hopefully get in there and make a difference.
Andre Tomlin – Thank you. Richard, any final comments in terms of system changes further upstream?
Dr. Richard Church – Well, I think that speech and language therapists should be really encouraged by this important publication. I think speech and language therapists should not be working in isolation. I think they can sometimes be a little bit disconnected from other teams and also not working with each other. For example, someone working as an intermediary in the court setting or doing an assessment for court may not communicate as they should, perhaps, with others working in the youth offending team or the CAMHS team. So I would love to see an end to isolated working and really more integrated working with multidisciplinary teams, with a professional network around children, and actually to see really empowered speech and language therapists do this and be recognised as a really valuable part of the multidisciplinary team.
Andre Tomlin – Thank you. OK, we’re out of time, I’m afraid so I’m going to draw this to a close quickly.
Douglas Badenoch – Matt, can you jump in with poll five? We need to know how much our chat has changed your life.
Andre Tomlin – So this one is talking about the paper itself, to what extent has this paper changed your perspective on DLD and reoffending? So this is the one we asked before, but now you’ve all had a chance to think about it in detail, tell us what you think.
Matt – Just while you’re voting on that, if you do want ACAMH to provide more DLD events, do please email firstname.lastname@example.org. The more people we get saying that we want to put on events like this, then the more evidence we will have to be able to show to our board that we should be doing things like this. So I’m just going to stop this poll now.
Andre Tomlin – That’s even more positive than it was before. We’ve kind of slightly moved up.
Douglas Badenoch – Yeah, definitely.
Andre Tomlin – That’s great, and the final poll, Matt, and while we’ve got the final poll up, we’ll just say thank you to people for joining us. Thanks very much to the audience. As I said at the start, this is the best attended campfire we’ve done so far. So really great that you joined us. Thank you for taking the time and thank you for the lovely comments. And yeah, feel free to tweet @camhsCampfire. If you’re on Twitter, tell people what you thought of this.
And if you’ve got any constructive, critical feedback, please email that to us as well. We’re really interested in things you think we can improve about the events as well as sitting here and basking in the lovely thank you’s. Big thanks to Maxine and to Richard for coming along this evening to talk about the paper and for sharing their experience. Really great stuff and keep up the amazing work. Thank you, Douglas, and to Matt and to Celine for their input into the webinar.
There are lots of resources on the website. And, as Matt said earlier on, we’ve got two more of these booked in. If you’re interested in PTSD, then you can join us on the 28th of March to listen to Rachel Hiller talking about a new paper. And if you’re interested in ADHD, then you can join us on the 25th of May for Stephanie Amy’s paper. And yeah, we hope to see you at some point in the near future.
ACAMH’s vision is to be ‘Sharing best evidence, improving practice’, to this end in December 2020 we launched ‘CAMHS around the Campfire’, a free monthly virtual journal club, run in conjunction with André Tomlin. We use #CAMHScampfire on Twitter to amplify the discussion.
Each 1-hour meeting features a new piece of research, which we discuss in an informal journal club session. The focus is on critical appraisal of the research and implications for practice. Primarily targeted at CAMHS practitioners, and researchers, ‘CAMHS around the Campfire’ will be publicly accessible, free to attend, and relevant to a wider audience.
About the panel
Maxine is a paediatric Speech and Language Therapist who has recent clinical experience focussing on integrating speech and language therapy into psychiatric and forensic services for young people. She has been involved in the development of the MSc Speech and Language Therapy programme and her research concentrates on the prevalence of developmental language disorder and socioemotional difficulties in the young offender population and investigates language competence as a variable with respect to rates of recidivism.
Within the university Maxine was part of a small team responsible for the design and planning of the MSc Speech and Language therapy programme. She will be involved in the delivery of the brand new pre-reg MSc course when it commences in January 2021. As clinical placement co-ordinator for the speech and language therapy programme, she will be responsible for working across the north west with clinical partners to deliver high quality clinical education. She has published in speech and language therapy journals as well as psychology and psychiatry journals.
Maxine is a Speech and Language Therapist with experience as a clinician and a manager working within NHS, educational and forensic contexts. Her clinical expertise is particularly around working with adolescents on secure wards and in the youth justice service where she has experience of developing services and implementing new clinical pathways. Before joining the University of Central Lancashire, Maxine was a lecturer at the University of Manchester with responsibilities for undergraduate teaching on BSc Speech and Language therapy and postgraduate teaching on MRes in Psychological Sciences. She has delivered and designed teaching materials across a range of modules including clinical and professional practice, research methods, clinical linguistics and developmental language disorder. Additionally, she has overseen BSc research projects and been a clinical examiner across a range of modules. Working with youth offending teams her research has profiled the psycholinguistic and socioemotional characteristics of young offenders with and without Developmental Language Disorder (DLD) and detail gender differences. In addition, she investigated language competence as a variable with respect to rates of recidivism and severity of crime and her work is the first to study the predictive utility of DLD status for reoffending.
Dr. Church studied medicine at the University of Cambridge and undertook general psychiatric training at South London and Maudsley NHS Foundation Trust. He trained in child and adolescent psychiatry on the Maudsley rotation, and then in forensic psychiatry at West London Mental Health NHS Trust, subsequently working as a Consultant Psychiatrist and Lead Clinician in the London Borough of Lambeth.
After working in the NHS for over 15 years, in November 2017 Dr Church joined Cygnet Woking as Medical Director and Consultant Forensic Psychiatrist on Oaktree Ward, a Female Low Secure Unit. He is passionate about quality improvement, recovery and involvement of service users and family in care planning and the delivery of services.
Bio and image via Cygnet Health Care
Dr Church also has longstanding academic interests in offender health, youth justice, safeguarding and medicolegal aspects of forensic psychiatry including fitness to plead, psychiatric defences, risk assessment and risk management. He is an Honorary Clinical Senior Lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, and serves on a number of national and international boards and committees.
André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He’s worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service. *The Mental Elf is a blogging platform that presents expert summaries of the latest reliable research and disseminates this evidence across social media. They have published thousands of blogs over the last 10 years, written by experts and discussed by patients, practitioners and researchers. This innovative digital platform helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol, surrounded by dogs, elflings and lots of woodland!
Bio via The Mental Elf
I am an information scientist with an interest in making knowledge from systematic research more accessible to people who need it. This means you. I’ve been attempting this in the area of Evidence-Based Health Care since 1995. So far the results have been mixed. For some reason we expected busy clinicians to search databases and appraise papers instead of seeing patients. We also expected publishers to make the research freely available to the people who paid for it. Ha! Hence The National Elf service.