What mental health professionals working with CYP need to know about child development – Dr. Max Davie

Matt Kempen
Marketing Manager for ACAMH

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Dr. Max Davie, Community Paediatrician specialising in child development, gives a talk as part of the ACAMH educational series of talks on child development.

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Dr. Max Davie
Dr. Max Davie

Dr. Max Davie is a consultant community paediatrician, working in Lambeth as part of Evelina London Community services. He has a special clinical interest in the assessment and diagnosis of neurodevelopmental conditions in school-age children. He is Officer for Health Improvement at the RCPCH, and trustee and founder of the charity ADHD UK.

Transcript

Hello, my name is Max Davie. I’m a community paediatrician specialising in child development. And I’m going to give you a talk today as part of the ACAMH educational series of talks on child development. ACAMH, of course, is the Association of Child and Adolescent Mental Health. And so what I wanted to focus on is what mental health professionals working with children and young people need to know about child development. I’ve been a consultant community paediatrician for just over ten years working nearby in Lambeth. And what I’m presenting is really a combination of scientific but also clinical experience.

So, in the outline of today, I’m going to start off with a little bit of theory about how child development works, and then why it matters, why you as either students, or perhaps professionals, working around mental health care should care about this. And then I’ll do a bit more of a deep dive into the different aspects of development. Any division of development into different subcategories is going to be arbitrary. But these are the ones that I have chosen in this case.

It may not be the ones that you find in a textbook, but it works for me and it works I mean in terms of explaining what is happening. I will concentrate a lot of my attention on the under five age group. Because in order to understand, say, a 11 year old who may have autism, and ADHD, you need to understand what the expectations of a three year old…what the skills that have not developed earlier in that child’s life are in order to understand how their behaviour has evolved over time.

So there is a bit of a focus on under fives. But, actually, all of the lessons from this apply to any age group.

This is part one of two talks I’ll be recording today, actually, the other being on neurodevelopmental assessment. And they’re very much a pair. If you want to know more about how to actually do the assessment then I would suggest that you watch this and then watch the other one.

So how does development happen? It’s a complex process borne born out of fairly simple elements. So the first thing is what I’ve put up there, which is a kind of menu. This is actually a menu from 1944. By the way, all images in this slideshow are licensed for commercial, non-commercial reuse. So there’s no problems there. But this is…so this was sort of, you know, what a magazine would published so that a housewife in that day would be able to produce the perfect meal, although it looks a bit bizarre.

The point is genetics is a recipe, it is not a blueprint. It is not something that specifies exactly what’s going to happen. Like a cook will interpret it and it may end up looking a little different to this picture, so the relationship between the genetic code and what comes out at the end is complex. And one of the main reasons it’s complex is it gets filtered, this information from the genetics, because that’s what it is. Genetics code is information, gets filtered through the environment.

And I’ve used the image of a stick of Brighton rock. Because what it is, is a sort of cylindrical filter. You get filtered over time. If you think of time as a dimension of that. I’ll explain a little bit more in a minute. And then this is embodied, encapsulated, physically in the brain. And the brain is a central processing unit exactly the way that a computer is. And so, there’s a real truth to the idea that the brain is just a computer.

But that’s only one way, one level, at which to understand what happens within the brain. And then, of course, you get to observable behaviour. This is actually part of the handwritten and annotated script for 2001 A Space Odyssey, which is, extraordinarily, available online.

The point is, this is a work in progress. What you see on the screen is partly conditioned by what’s on the page. But, as time goes on, things adapt. And, actually, the process of behaving, the process of producing behaviour, also affects subsequent scripts. And so, that becomes important. So genetics, it’s important when you’re thinking about genetics that you think not necessarily about looking for particular genetic conditions, although I will in my neurodevelopmental assessment talk, talk a bit about particular conditions you can find.

It’s much more important to think about genetic potential. A lot of developmental conditions run in families, but not tied to particular genes. It’s more that having developmental problems in your family just makes you generally more likely to have that developmental problem, or indeed developmental problems more generally. And so, it’s very unlikely that we’ll have single genes that map to particular traits and conditions. And I would caution you to be very cautious about any article or news story that suggests otherwise.

The other thing to be a little bit cautious about is the excitement around epigenetics although that seems to be calming down a little bit. We’ve always known that the expression of genes is conditioned by the environment. There has always been that gene environment interaction. And, in fact, epigenetics…all epigenetics is is a discovery of the mechanisms by which that process happens. It’s exciting because you can potentially modify it, but it doesn’t change how we think about genetics and how we think about the environment.

This is the larger image here is a picture of the ecological model of child development. So this is a nod to the kind of psychological theories of child development, which is not the subject of this talk. There’s obviously very, very, clever and good people theorising around this. But this is a much more practical talk from a clinician. But the point about putting it up is that actually this does look a little bit like my Brighton rock in that you have different aspects within the time period in question, ranging from the individual, to the cultural, but also you have this element of time.

I prefer and find clearer this diagram. But if you imagine the person’s biology and then their psychology outside their family, and the broader community, and that being encased within a stick of rock, and, at all points, the development of the child being conditioned by all of these things. And the other thing is that the size of these is not fixed.

So, for a very young child, family will be very large and community relatively small, whereas, for an older child, community becomes bigger, particularly peers. And so, this is a dynamic. This is a dynamic process and also with very strong interrelationships between the different aspects. So in terms of thinking at the level of the brain, all of this is also happening at a brain level. And what you’re essentially getting is neural networks. When the baby is born, I sort of think of their brains as being full of static.

There are too many synapses. And so, you can’t get any kind of sense from them. And, almost, if you look at babies and you watch babies, you can almost see that there’s just too much firing off and it’s not coordinated. And what happens is this process of synaptic pruning, which leads to neuronal networks. And the neuronal networks are often distributed across the brain in space. And so, that’s why we’re moving away from the idea of different areas of the brain doing particular things, albeit that some are important in certain processes.

And what happens when you look at child development is you get these very simple subroutines. Let’s take one example. Grabbing a rattle for a baby, that is a very simple subroutine. And then what happens over time is the subroutines become more complex. They get combined and they become more accurate. And that really is a simple way of thinking of the process of child development. Now, this process doesn’t happen automatically. It’s affected…it’s sort of programmed by genetics. But, also, at a kind of…in real time, really affected by two things.

One is sensory input. So, ultimately, of course, your family, how your parents treat you, how your peers treat you, it matters. But, at the brain level, that’s all sensory input. That can be interpreted, of course, and conditioned by your own emotional state and your own interpretation.

But it is basically sensory input. But additional to that is the neuroendocrine input. So the stress hormones, the other sort of chemical changes which occur often as a result of emotional changes within the brain, which affects its own development.

So there get the sort of story which is not massively clear, as yet, about the chronic stress, and the effect of that on child development, and an area which I think the science is much less clear than some people would have us believe. And the other point about this process is partly as a result of these environmental factors, but, also, as a result of a wide variance of genetic input, there is very large variance around established norms, probably more for things like language and communication than perhaps for motor skills. And that actually makes motor skills quite useful for you as a mental health professional, for reasons that I will explain.

When you look at someone’s observable developmental skills, of course, you are just looking at what they do, how they respond to things. And I think it’s important, when you’re interpreting that, to think about how it is that we develop and refine a new skill.

So if I, for instance, was going to want to take up knitting, this is not something that’s going to happen. But let’s just say for the sake of argument, I want to learn knitting. I’d want to try it and then work out and sense in some way that my initial attempts were bodged and terrible. And, so, then it would get to feedback, for instance, from my wife, who’s an accomplished knitter, about what I should do better and then try something different. And then there’s a sort of iterative process of essentially trial and error.

And it’s only when…but of course I could watch a video or read some instructions. But only because I am older, because I am an adult does instruction really work very well. For young children, and, actually, for anyone for whom the task is cognitively complex, instruction is probably less good than just trying something and getting it wrong and then trying it again. And so, for young children, the implications of that, which seems quite obvious, is that for young children, they need motivation.

So, they need to want to communicate, say, or move around or play. They need to have the opportunity to try something, to be the opportunity to sense for themselves the result of that, not be told what it is, but to work out for themselves what it is. And get feedback, usually positive and encouraging feedback from an adult, and then be encouraged to try again. That, in a way, encapsulates the role of a parent in bringing up a child and encouraging child development in a very simple way.

And, actually, if you look at some of the more deficient parenting practices, they usually fall down in one of those ways. So if you’re thinking about development, thinking, and observable, skills, think about what has happened in that process. If it hasn’t happened, has any of these things, this opportunity for trial and error broken down?

And is that important? Now, that is a process, but then, of course, you have the feedback loops which make it much less of a linear process and much more of a complex and iterative process.

So, of course, the behaviours themselves form part of the environment, the responses of others form part of the environment, which is why we’ve got a whole family section of my diagram. And then that, of course, will feed back into the brain and into the child’s own psychology and therefore into what we would call kind of internal working models of how they respond to things and how they how they behave. So that’s all quite theoretical, but I think it’s an important base line. It’s important when you are thinking about child development, particularly if you’re seeing somebody clinically to think a little bit about why it is that there may be some particular brakes on their development.

And this is sort of a bit more sciencey frankly. There may be some quiet pathology, and by which I mean essentially medical pathology. So it’s important to have a little think about the in utero conditions in which the child has emerged. Drugs, both legal, and illegal, have effects. And I think it is important, particularly if you possibly can, to find out if any alcohol was used during pregnancy as that does seem to be, on a population level, the most important substance for causing neurodevelopmental problems in later life.

But then, of course, it’s very important to think about what happens around birth. Birth is a very dangerous time for babies. And as well as, unfortunately, losing some babies, a lot of babies suffer some kind of injury or a sort of biological insult, for instance, losing blood delivery to the brain for a period of time. After birth, of course, you have a period where the child is quite vulnerable to disease and probably the most key and important diseases, which fortunately we’re making some progress against are meningitis and encephalitis.

So if you’ve managed to get away without those, then, actually, most other childhood illnesses will mainly have an effect on child development by essentially reducing your ability to do that process of trial and error because you’re just unwell. And, actually, that can usually be caught up. However, when you look at the environment, there’s a huge number of potential factors which restrict potential. But I think I want to…it’s worth just nailing down a few that are really, really, important.

Maternal health. And what I mean by maternal health is both maternal physical and mental health. It’s really striking to me how many mothers of children with very difficult behaviour come in and they themselves have physical health difficulties. It is physical work, parenting a child particularly…and it’s still the case that mothers do the majority of caring of young children. That is very physical work. And if you’re not able to do that physical work due to some kind of physical disability, or condition, then that does make things more difficult. Both parents’ mental health is also important.

And this, of course, has multiple reasons why this might be the case. And this may not be the audience that needs to have huge a lecture about the effects of parental mental health. But, broadly speaking, I think it’s important to bear in mind that parental mental health is both genetically important, and also important in affecting the responsiveness of the parent to the child’s cues and their ability to do that. Trial and error, support that trial and error process that children need to develop. And then the socioeconomic conditions. Across most of the areas that we’ll be talking about today, with the exception of gross motor skills, really, there is a socioeconomic gradient. So the poorer children will do less well.

In Lambeth, historically, we felt that children who were at the lower end of the scale, by the time they get to school are somewhere between six and 12 months behind simply by being poorer. So there is a real problem there. I’m a bit cautious, though, and some people talk about neglect as a cause of child development, developmental problems. So the reason for that is really twofold. One is that what you mean by neglect is generally that the family are not able to meet the needs of the child. And there may be many, many, reasons why that might be. Partly that the family may have mental health problems, or substance use problems, or just have poor housing or poverty.

And so, neglect is not necessarily a very good word to use for that. And, secondly, one of the reasons why the family might not be able to meet the needs of the child is that the child has additional needs. And so, I have seen, you know, lots of families where the diagnosis, for instance, of autism is being questioned because it’s thought to be all these behaviours are due to neglect, whereas in fact, it’s simply that the family is not able to cope with the child.

So a little bit of caution, I think, around those terms. It’s just worth spending a couple of minutes, because, if you look online, particularly, and you think about debates around mental health, there is a lot of squabbling and there’s a lot of kind of disagreements. And I think looking at this model does give you an idea of why that might be.

So different people…there’s two reasons. One is, different people see different things. So if you’re a geneticist, you’re looking at the recipe, and you’re looking at the observable behaviours, and you’re making correlations between those two. If you’re a biological psychiatrist, someone who’s very interested in the brain, you’ll look at your brain scans, and you’ll look at the observable behaviours, and you’ll see correlations there, and that’s great. If you’re a psychologist, particular psychologist, who has sort of more steeped in the…perhaps the psychoanalytic tradition, or somebody who’s very concerned with attachment, then you’ll see the environment as being primary and, of course, the observable behaviours will come out of the environment for you.

But, of course, because you’ve seen this talk, you can now take a balanced view. And you understand that all of these things are part of a process, and that they’re also involved in feedback loops. And so, you’re able to take a balanced view and you don’t have to get involved in any of these, frankly, quite tedious arguments. The second reason why there may be misunderstandings, and different points of view, is that actually sometimes people are asking two different questions when they’re thinking about child development.

So, someone who’s got a more of a biological bent may say about this imaginary child, Danny, “Why is it that Danny has an ADHD brain?” If, let’s say, they’re thinking that Danny has ADHD. And so, then the question becomes, “Why does Danny’s brain have these particular characteristics?”

And it’s at the level really of cognitive strengths and difficulties. I’ve put up, for visual reasons, a sort of brain scan. But the point is, it’s about what kind of brain does Danny have? Somebody who has a more environmental bent might be asking the question, “Why can’t Danny behave in class?” And those are two different questions. Whether or not Danny has an ADHD brain is important for the second question, but it doesn’t answer the second question.

It may be there’s lots and lots of other reasons why Danny doesn’t behave in class. And, actually, it may be that Danny’s ADHD brain does not stop him behaving in class. People with ADHD brains do behave sometimes.

So, sometimes I think we get confused by the fact that we think we’re talking about the same thing and we’re actually talking about different things. And clarifying that can solve a lot of problems when you’re having debates within your teams or within your supervisors about child development. So the question is, then, “Why does child development matter for a mental health professional?” If you’re thinking, as a mental health professional or a student, you think about emotions and behaviour and you’re trying to explain emotions or behaviour, why does it matter?

Are you looking for an explanation? So, you find a diagnosis or you find a condition and that explains things. I want to say now, that is not the case. None of these conditions or types of brain explain behaviour. What they do is they act as a backdrop. This is one of these lovely old paper, or card, theatres that you can buy and sort of shuffle little dolls and little figures around in.

But the the point of a backdrop is that it conditions what is possible. It constrains what is possible. And it makes certain things more likely. But it doesn’t determine what happens. The emotions, the relationships, the fights and the dynamics that go on between people, within families, within peer groups, still happen, but they just happen against a backdrop, which is determined by the child’s development.

So I think that’s a really important point, that we’re not presenting an alternative reason for children to have particular behaviours or emotions. We’re just thinking about they’re the backdrop for them. So that all said that is sort of the introductory section.

I just want to talk a little bit about motor skills and why, as mental health professionals, you might think that these are important. Because this is the area where I think that they get a bit neglected when people are within mental health services. Someone with poor motor skills, whether they are difficulty with large motor large movements, so that would be gross motor skills, or fine manipulative movements, which are, sort of, fine motor skills, although the distinction is blurry, doesn’t really matter.

Anyone who has difficulty in there will have worse social functioning, worse self-esteem and worse mental health. So there’s a risk factor for mental health difficulties. If you have coordination difficulties, that is essentially difficulty with accurately sequencing and moving your body. This is often associated with difficulties with planning, and thinking ahead, and, also, with difficulties with attention, which brings it into the kind of ADHD frame, which is very much a core part of mental health practice.

So understanding coordination and developmental coordination disorder, particularly, and understanding how sequencing, and planning, can really affect the child’s life, if there are difficulties, I think is really important when you’re looking at this population. Motor skills are closely related to sensory modulation. Sensory modulation is almost like a kind of mixing desk within your head. So when sensory inputs come into our head, they are modulated. So, for instance, at the moment, my hearing is quite sensitive because I’m in a quiet room.

If I was on a bus in Brixton, and I stepped off the bus, then immediately my hearing would be turned down because otherwise I’d get overwhelmed. And there’s that kind of unconscious modulation that’s really important in helping us to cope. If we don’t modulate things, it can affect our coordination. Because a lot of the feedback that we need to be accurate is to do with proprioception or sensing our body in space, or fine touch, just to sort of work out exactly how hard we’re gripping that door or that pencil.

But, also, sensory modulation is related to difficulties around coping with noise, coping with crowds, coping with clothes, which you see a lot in the autistic spectrum, but, also, in all developmental conditions really, you can get problems with sensory modulation. So they’re related to motor skills, but they’re also a wider problem. And I’ll talk about them more in my other talk about neurodevelopmental assessment. If you have a child who has behaviour which is difficult, or challenging, and you’re thinking about neurodevelopmental disorders or whether this is sort of more an environmental cause, actually, the presence of motor skills deficits is quite important, particularly gross motor skill deficits, because those are not particularly affected as much by environmental causes.

And so, it can be quite a useful indicator to you that this is a new developmental difference you’re dealing with rather than an environmentally driven one. I find that quite helpful. But, of course, another reason why we need motor skills is that they underlie the ability to self care. And it’s very difficult to be a 15 year old who still can’t quite look after themselves and who, you know, can’t quite wipe themselves properly, after the toilet, or dress themselves, effectively, when they’re kind of at PE at school.

So I think motor skills are important for all of those reasons.

So very, very, briefly, and we can have a whole lecture about this slide, what happens in gross motor skills for the first five years or so? So the first year is all about running. It’s a battle against gravity. You go from being a sort of prone infant that can’t even sort of turn themselves, to being able to stand up and start to totter along. And the second year is really about turning that very wide based, not very efficient, toddler gait into something more akin to an adult gait.

Not quite adult yet, they’re still called toddlers after all. But they’re able to run, they’re able to start moving, moving faster, changing direction, more quickly. And they start the process of being able to climb things as anyone who has had a two year old is aware. The third year, so, up to three, climbing develops much more effectively. And, also, you get things like jumping. Also, at this point, you start to be able to use things like trikes. And that’s the beginning of being able to do two things at once. So it’s much more of a dynamic age for their gross motor skills.

Between three and four there’s quite a lot of focus on ball skills, throwing, catching, kicking. And that’s where you have the beginnings of being able to anticipate other things. If you think about catching, just as an example, catching is kind of a miracle in that you can look at an object, anticipate where it’s going to be in a few seconds, place your hand in that place and then move your hand in a particular way that you’ll be able to slow it, slow that object down, while, at the same time, encasing it.

I’m still not very good at it. But the fact that people are good at it seems to me constantly to be a miracle. And it’s those tiny little miracles that we’re taking for granted that other people can’t do that are really important in child development, unpacking the little things that we take…that we do without thinking. And thinking about, well, what is it that it takes to be able to do that thing? I think that’s one of the really fascinating things about child developmental practice.

Now, generally speaking, as I’ve said before, what we’re doing in child development is taking simple things, and making them more accurate, and sequencing them together in more complex combinations. Coordination and sequencing essentially is what happens after four. You get the same things done better and in more complex combinations. The same is true of fine motor skills, just to jump to that. Fine motor skills, the first year is really spent trying to grab hold of things, initially, in the palm, but, then, towards the end of the first year, you use the pincer grip much more.

The second year is more about being able to place things. And you don’t really…unless you’ve thought about it, you don’t realise that actually putting something accurately is much more difficult than picking it up. And that’s why paediatricians are notoriously obsessed with children’s stacking towers. And it’s not because we just like towers, it’s because the placing, the placement, is a really important foundational fine motor skill. We also like towers, towers are good.

The third year really is about…so, at the end of the second year, you don’t really care where the object goes in between where it starts and when it finishes. So this is why a two year old typically is trying to eat yoghurt with a spoon, it will go everywhere. But by three it’s much more accurate, because what they’ve done is that they’ve started to pay attention to the trajectory of the object, so that they’re able to get it in their mouth without it going all over their chin, a little bit more, but it’s a work in progress.

And from three to four, again, it’s the similar kind of movements that are being used before but better planned and more accurate. So, just to take an example, three and four is a big year for drawing, it’s a big year for developing pencil skills. And so, a lot of the things it will test there is…so, let’s, for example, say the experience of drawing a square, which is a bit older than this but just to take an example. You have to think in your head where the square is going to be before you start.

You’ve got to…because your first line will then determine where all your other lines are going to be. And if you haven’t got that kind of practice of planning something in advance, you’re not going to be able to do it. So here we have bringing in planning, bringing in sequencing and, to an extent, attention spans into the heart of your fine motor skills. So, even from a very early age, if this becomes indivisible from that kind of group of cognitive skills.

So, moving on, that was the quickest motor skills.

And now, I’m sure my occupational therapy, and physiotherapy, colleagues would be aghast that I got through that so quickly, but there you are. Language skills now, I’m going to annoy the speech and language therapists. Why are language skills important to you? Well, I mean, the main thing I think the most important thing, is that if you’re thinking about somebody who has got behavioural problems, particularly oppositional defiant behaviours, or conduct behaviours, you’ve really got to think about language. Because if you cannot communicate with language, if you cannot communicate your emotions with the language, if you don’t have a good link with the person that you’re talking to, in language terms, you will express your emotions in behaviour.

And, therefore, if those emotions are negative, the behaviour is going to be negative. So attention to language, particularly in young children with behavioural problems, is vital. I think it’s also important when a child is not speaking to understand why that might be. So selective mutism is now seen as an anxiety disorder and is very much in the CAMHS preserve.

But, actually, a lot of these children also have communication deficits, which is why they weren’t speaking, in the first place, because they find it difficult. And so, teasing out what’s going on requires both mental health and child development skills. Again, if you have somebody, even if they’re not exhibiting behaviour, and they’ve not got mutism, if they have developmental language problems, they have worse psychosocial functioning in exactly the same way as before. They’re more likely, later on, to get in trouble with the police, less likely to have employment.

So there’s lots and lots of problems. And, actually, language, it’s closely related to academic achievement, partly by being closely linked to dyslexia, but just, generally, because so much of classroom activities are verbally driven. If you sit, if you stand or observe a classroom, how many words the teacher produces in explaining these activities and how few visual things they produce to support those words, it really always strikes me every time I do a school observation. So language is really important in getting you through school.

And if you have a problem there you will fall behind, even if you’re otherwise able, which leads, of course, to frustration and to poor behaviour.

So, what happens in language progression? Broadly speaking, and, again, I mean very, very, quick. The first year is about babble. The first year is about making words which…sorry, making sounds which are not quite words. They sound a bit like words. And the important thing is, particularly for thinking later about autism is that they are directed at people, that they are communicative, in intent, and that becomes very important. You usually have your first word about one, as everybody knows. But the second year of life, I think, is fascinating.

You don’t usually produce more than one word at a time. And what I mean by that is you may produce two words, but they’re not connected. They’re not connected in a single piece of meaning. So, for instance, if you go, “Bottle me” and they may be connected, but only if what you’re trying to say is, “Give me the bottle.” If you’re just saying those two words out of context, then that’s not a phrase.

It’s got to be the same kind of unit of meaning. What happens in the first year, though is, you get a lot of words in the second half of the second year. So, usually, you get a point where the child is bumbling along, having a few words and then they take off. And if that hasn’t happened by two, then you may have a problem. So it’s a nice little rule of thumb that if a two year old’s parent can still count how many words they have, then you may have a problem, or the parent is very good at counting, which is possible.

Phrases emerge in this around two and this third year is really interesting. Because if you look at a two year old and how they speak, it really depends on who they’re speaking to. So, to an adult, they will produce short two to three word phrases in answer to questions or as requests.

If you watch them playing either with another child or on their own, they are producing a vast amount more speech. But a lot of it is what’s called rather charmingly ‘scribble talk.’ So it’s [inaudible 00:33:29]. And it is…it sounds like speech, but there’s no sense to it. But, occasionally, words will emerge. And that is how they are practicing, essentially, how they are kind of trying out different sounds in their mouth and kind of trying to piece together. And it’s absolutely vital, it’s vital for their language development.

So the last thing we should do is be training and kind of drilling these children in kind of adult interactions. They need that time. And I think that’s why play becomes very, very, important for language progression at this point. Between three and four, you’ve basically got the emergence of grammar. So they start to be able to use negatives, comparatives. So more, less, and superlatives, you know, the biggest, the smallest. So they start to be able to compare things.

Colour and numbers start to emerge as well around this age. And then between four and five and, again, this is, sort of, simple things being in place and then just more complexity emerging, over time, and you start to get the use of tense. So, you know, past tense, and future tense, and, essentially, just get more complexity, putting the elements that are in place together in more and more complex phrases both in terms…and sentences, both in terms of what they produce and also what they’re able to understand. Although even here already…so, there has been in the past in kind of textbooks of child development, a milestone around four and a half of being able to retain X number of instructions.

And that has always struck me as ridiculous. Because the ability to retain instructions is not a language skill. It is an attention skill. And yet they are putting it under language. So by the time you get to four, or five, it becomes very difficult to be absolutely clear about what is language, what is attention, what is social communication, as I’ll talk about in a minute.

But the point is these phases have to be gone through in order to get to that point. And, really, if you are worried about a language problem, in an older child, you need to talk to your speech and language therapy colleagues. So, social communication. In a way, I don’t need to tell this audience why social communication is important, because autistic spectrum disorders are all over mental health, rightly, because of the huge high rates of mental health comorbidity within autistic spectrum people, but, also, because many of the presentations of child behaviour, or emotional presentations, could be autistic spectrum disorders.

And there is a lot of kind of thinking about autistic spectrum in diagnostic assessment terms within mental health services. So, obviously, social communication is a central deficit of autistic spectrum disorder. I would say it’s the central deficit. What I mean by that is, I’m not saying that social communication difficulties mean you have autism, but it is the…of the areas of autism it is almost the one which is most specific. If you have a social communication deficit, you probably need to think about autism.

Whereas if you have social interaction difficulties, there’s lots of reasons why that might be. If you’re a bit rigid, and anxious, there’s lots of reasons why that may be. But social communication is really quite fundamental to autism, but not specific as I’ve said. Of course, if you have social communication difficulties, whether or not you have a diagnosis of autism, that will lead to social isolation, you will not be able to problem solve, because you don’t understand other people’s intentions, you don’t understand other people’s communication.

And so, problem solving, you will lose your temper. You will find it very, very, difficult to negotiate, particularly as you get older, when you leave the very protective and structured environment of the primary school and go into secondary school that’s where these kids really do struggle. And, of course, again, once you get past the very simple and structured academic task of primary school and you start to have to think for yourself a little bit more, and be more creative, and understand things, in a more flexible way, having social communication difficulties impairs your academic progress and you will definitely underperform.

So what happens in social communication?

At this point I have to move away from the idea of milestones. I’ve never been a huge fan of them, in most settings. But in social communication it really doesn’t make sense. Because rather than there being particular phases that you go through, I like to think of social communication and the socialisation I’m going to talk about a bit more like a flower opening.

This is a picture of a lotus opening. So each petal will open in turn. But while the inner petals are opening, the outer ones are still opening. So I’m going to present this in a sort of order. But each process is overlapping, and doing its own thing, while the others are starting. Obviously, one of the first things you think about in social communication is eye contact. But this isn’t a dichotomous thing. Whatever you might think from kind of if you’ve studied, studied the ADOS assessment, the point about eye contact is that it’s used whether or not it’s used as a tool.

Lots of people with autism make eye contact, lots of people without autism don’t make eye contact, for lots of reasons. The point is, whether you use it as a tool to make and break social contact. Whether it is your use of eye contact, in a sense, is communicative. So if I don’t want to talk to you, do I use avoiding eye contact a lot to communicate the fact I don’t want to talk to you? If I’m trying to engage you, trying to convince you, am I making my eye contact more intent as I am currently with this camera?

Along with that comes pointing and showing. So showing is almost the first thing, in fact, where the child will come up to you very proudly and show what he has done. And that will often involve the use of eye contact to direct you to the thing that they’re doing. So, often, looking at you, looking at the thing. And that will…they will then intend for you to look at it.

But, actually, in order for them to understand that that will have that effect, they need, in a way, to have a very simple and primitive form of theory of mind.

Now, we’re not going to go into theory of mind in detail, but, essentially, they have to understand that you have intentions, and you have thoughts, and that you will respond in a similar way to how they would respond. And so, they have to have that little thing. Pointing is a little bit more sophisticated. And the sort of pointing that we’re interested in is sort of illustrated here, which is, “Look at that isn’t it interesting” rather than, “Look at that, give it to me.”

And, again, the pointing that we’re interested in is the one where you use eye contact, along with pointing, in order to make sure the person looked at the thing you’re looking at. Along with that though, of course, there’s always body language and gesture. And, again, this very much develops over time. It isn’t something that, boom, appears. Gesture is very important in terms of…both in terms of how they use gesture in the way that I do with kind of for emphasis, or if they’re using just simple things like waving, and beckoning, whether they use those sorts of things. And, particularly, young children, a lack of ever using waving or any kind of conventional gestures like that can be very important.

But for older children and for adolescents it’s often about body language, about how their body language feels to other people and whether it matches how they’re feeling and also how other people’s body language is interpreted by the person. So do they get it when people are annoyed with them? Do they get it when people are trying not to talk to them and they are kind of backing off? Do they get it when, you know, an older…do they get it when somebody is attracted to them? Do they understand those things?

And that really is very much context driven and it’s almost…it’s less helpful to think about milestones and more helpful to think about how the person exists in their social world, and whether they interpret body language appropriately for that social world. Because, of course, culturally, there’ll be very big differences in how people use body language and how expressive they are. So, I think we should be a bit cautious about kind of imposing our own judgements on that.

Conversation, again, develops over time. Two year olds who are playing together, we talked about the scribble talk, in a sense, there’s a kind of conversation going on here. And the mark of a conversation is that you are listening to the other person and then putting something in that’s relevant, even if it’s just kind of a little scribble or a talk. And then you’re building on the other person’s content in some way. So it can…and two year olds can do a conversation.

But, then again, you know, 15 year olds can have a conversation. It doesn’t…it can be just a series of grunts, it can be a series of just non-verbal stuff. But that’s because it’s not…the conversation is not about what words you are using, it’s about the the intent and the dance of building something together. And this is a big deficit, particularly more able children, and young people, on the autistic spectrum. They can’t build that stuff together because they don’t understand what the other person is getting at often. Another way in which they can struggle, and, particularly, we’re talking about older children here is describing things. And often they just don’t bother.

But when they do try to describe things, people with poor social communication can’t understand what you don’t know.

So, I mean, the thing I like best in clinic is to get people to explain the video games that they play. Now, I happen to probably know what the game is. But what’s really fun is asking them to describe it. And, often, they’ll come up with just random details about the game and not tell me how you win, and what you have to do, and what it looks like. Because they can’t see the wood for the trees. And I think that in less trivial terms becomes a big problem when they’re trying to describe why they got in trouble, and they’re just coming up with a load of random nonsense, people will be cross with them.

People won’t understand that they’re just struggling. In the same way, negotiation becomes very important over time. And, again, you don’t need necessarily me to hammer home the fact that understanding other people’s intentions, other people’s motivations, is very important when you’re trying to negotiate with them, when you’re trying, in a sense, to manipulate them. And this is very difficult if you have a social communication deficit. I’ve bundled a lot of the rest of child development under socialisation. And you probably won’t find this in a textbook. But I think it’s really important. And I’ve put under it, social interaction, social understanding, sort of, cognitive flexibility. And all those first three things are very much things that are problematic in autistic spectrum disorders and also behavioural innovation, which is sort of the main deficit of ADHD, and attention skills, which I suspect is related.

I’ve put them all together because they’re all so strongly interconnected that it’s very hard to split them out when you’re thinking about how a child develops, and, also, the kind of the final outcome of developing all of these skills is an ability to live in society, an ability to be a member of a family, to be a member of a class, by which I mean a class in the school.

So it’s quite possible to have somebody who has good cognitive skills, good motor skills and good language skills, but is totally incapable of being those things. It is socialisation that allows us to do it. Now, the image I put up here is an interesting one. And I think it sort of shows that socialisation is perhaps the most socially and economically and socioeconomically driven, developmental skill. This is a map of antisocial crime rates across London.

And if you were to place a map of income against these, it would be the same map. The poorer areas are almost all the areas where there are high rates, shown in red, of antisocial behaviour. The exception, of course, is this one here near Heathrow. But, of course, I think that’s because there’s a young offenders institute in that area, and those kids are therefore registered to that area, which gives a false impression, in case anyone has picked that up.

So let’s talk a little bit about social development, and how that develops over time. I did want to bring in attachment briefly, just partly to give any reassurance that we don’t think it’s important. We do think it’s important. Some people, of course, base their whole theory of child development upon attachment. I’m not sure that I would put the whole thing on it.

But the development of attachment, which I see as a biological system of…as Bowlby originally saw it, which allows the the child, or infant, to, in response to threats, seek and find comfort. That is a very, very important thing, particularly in the first year of life, but continues, exactly the same way, using my analogy of the lotus, continues to develop over time.

At the same time, if attachment goes well, and we can talk another time about what well means, play becomes much more easy to do. Because what sort of a good attachment strategy gives you is the confidence to explore the world from a secure base. And, so, play becomes very important, initially, because of mechanical play, but then more social play but pretend play. And just understanding how the person plays is really, really, important, not as milestones, not as you have to do this, this and this, but as an indicator of their underlying ability to understand other people and their underlying ability to be flexible with other people.

And, of course, their opportunities to play and their working models of how you deal with conflict. This becomes very important later in life. So, a child who has frankly grown up in a household where conflict is solved with violence, and aggression, well that will go into their play. So, that is somewhere where the environment becomes very, very, important. Later on in life, they obviously become more independent.

I think the first sign of independence is actually something that as a society we often bemoan, which is the terrible twos. The terrible twos happens because the child realises that there’s this big person who has been bossing them around.

They don’t have to do as they say. And they test out what happens when they don’t do as they say and they find those kind of boundaries.

And that is the beginning of independence, it’s the beginning of independent thought. Now, I’m not saying that we should welcome, and embrace, it. But just think about, well, this is what’s happening here. They have their own world, and their own view, and it’s coming into conflict with the adult world. And that is a process that happens over time. Over time, of course, they then develop self care skills, they develop the drive to do things for themselves.

And, again, that’s to go back to our example of wanting something. That drive to be independent then drives the development of self care skills. And children who are not interested in being independent will never develop those skills. Friendships are really interesting. And if you think about friendships, which usually I know you could say that children of friends, before this, but really kind of two and a half or three is when proper friendship emerges. The thing about a friend is that they are not fixed and immutable in your life.

Broadly speaking, your family is fixed, and immutable, of course, with exceptions. But a friend, how strong your relationship with your friend is very much depends on how you treat them. And this obviously continues through life. But that is a big change, because these people will come and go. You will stop being friends with people quite quickly. And so, that ability to negotiate and understand the rules of friendship, which are never written down, and no one has ever written them down, is very, very, difficult.

And, again, if you have problems with your social understanding, you will struggle with your friendships. And so, friendships become very important, when you’re thinking about autism. And then, of course, there’s social expectations. To take a very basic example, when you have a child, when children troop into reception at the age of four, or five, everyone puts their coats up on a peg, conventionally. Often, after a few days, the children are not told to do this, but it’s just expected, because they’ve done it for a few days, they will continue to do it.

But, actually, someone who doesn’t have that kind of brain, who doesn’t understand social expectations, again, somebody perhaps on the autistic spectrum or who just hasn’t got that kind of practice of understanding, and meeting, expectations just may not understand that. And then they get into trouble, and be shouted at, and then it will unravel from there. So that’s a very, very, quick canter through child development. But I hope it has just given you an idea that child development is very, very, important in understanding the underpinning, the underlying difficulties, that might lead to emotional and behavioural difficulties within mental health practice.

I have given you some kind of ideas of milestones, but it’s much, much, more important to think about functional difficulties. Think what it is that the child needs to do in their life that they’re not able to do. And, therefore, you will be able to be much more grounded, and much, much, more focused in your questioning, and your investigation, of what the child’s underlying child developmental profile is. It’s very important, as well, to involve your local specialist. Child development is an area where there are actually probably quite a lot of people working in your area, geographically, who know a lot about it. And there will always be a local speech and language therapy department and a local occupational therapy department.

There will be schools with special needs coordinators, and educational psychologists. And there is a lot of child development expertise around. And so, as mental health professionals, I would just appeal to you, if you think that there’s a problem with child development, involve those people, reach out, because they’ll be more than happy to help, I hope. I hope that we can talk about anything that I’ve said in this talk. And if there’s anything that needs clearing up, or isn’t clear, I’m sure we’ll be able to answer any questions via the ACAMH website.

But thank you very much for listening in the meantime.

Discussion

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Thank you for this lecture, it’s beautifully explained

Matt Kempen

We have another lecture from Dr. Davie on Neurodevelopmental Assessment that you might also be interested in. Remember if you are an ACAMH Member you can receive a CPD certificate for watching these lectures

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