[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health or ACAMH for short. And this is ACAMH LEARN. So when we think about children who have difficulties with language and reading, I think the first thing I'd want to say is that for many, many years, these groups of children were thought of as separate. So you could have a language difficulty or you could have a reading difficulty. And that view in itself is a misunderstanding of the relationship between language and reading, because language is actually the foundation of reading and all reading is written language. So for instance, if you look at children who've got a significant reading problem, sometimes we call them dyslexic, about half of them will also have a language difficulty, which might actually not have been identified. And looking at it the other way, if you take children with language difficulties, who maybe are the recipients of speech and language therapy, many, many of them, maybe 60% of them are going to go on to have reading difficulties. So these two sets of difficulties are really quite similar to one another. When we think about how people misunderstand language and reading difficulties-- aside from that, first of all, when these children are growing up, so in the preschool period, they would probably seem just like normal kids. There's lots of variability in children's language skills at that stage, and obviously no child is reading. Children might just seem to be developing completely normally. What happens, though, is when they go to school, difficulties start to occur. And the reason for that is that all of our school systems are delivered through either or a language. The curriculum is verbal or through written language, which certainly when you get older, the language of books seems to be very, very important. So once children are in school, if they've got a language or a reading difficulty, they'll start to be viewed rather differently from other children. They've got a language problem, and they don't say very much. Commonly, teachers might just think they're very shy or very introverted, and therefore their language difficulty goes unnoticed, which is going to lead to difficulties later on. For other children who have language or reading problems, they might be considered to be rather lazy, because they're not really keeping up or possibly even worse possible scenario they feel that people think they're a little bit below average ability, that they're rather stupid or thick, and these terrible words used to be associated with those children historically. So what's really important, I think, is to ensure that we think about children in school, whether they have a language or reading difficulty as having particular needs. And in English schools, we use the term SLCN, speech language and communication needs. That kind of description puts the onus on the education system to service the need, rather than thinking about the child as being at fault, and possibly their behaviours being something that has to be reprimanded in some way. And the terms that are in common use, and I prefer to really name the conditions are dyslexia or specific learning difficulties for reading problems and developmental language disorder where there are significant and persistent language difficulties. So when we think about the early signs of difficulties with language or reading development, we have to think about what we call risk factors. So the signs or the behaviours that you see in a child that suggests that they might be at risk of developing reading or language problems. And the first and in a way, the major risk is something that isn't necessarily observable. It's a family risk. And children who are born where there is a parent with some developmental difficulty, the probability that they themselves will have that difficulty is quite high because some of these difficulties have a genetic basis. So for example, if we think about dyslexia, in the population, let's say 10% of children will go on to have reading difficulties. But if a child is born in a family where there is a parent who is dyslexic, the probability that they will develop dyslexia is about 40 or 45%. So there kind of fourfold increase in the probability that a child will develop dyslexia if they have a family risk of dyslexia and similar risks we can see in children who have language impairment. So the first risk factor and many in the early years, in a way the only one that we can get a handle on is family risk of dyslexia. The other risk factors tend to be in the domain of oral language. So oral language difficulties by which I mean difficulties in understanding and expressing yourself, tend to be risk factors for later problems with language and reading. Similarly, speech difficulties. Speech might be quite slow to develop, and when a child develops speech, it might be difficult to understand. There could be articulatory difficulties, and often parents will observe that the older sibling can understand the child, but they can't understand the child themselves. And those articulation difficulties if they continue, are a risk factor for later language and reading problems. But there is a difficulty here, which is that there's a lot of variability in the language development of children. And many children who are if you like, late talkers, go on to develop perfectly normally. There's just they have a slow start, and they seem to be on a slightly different trajectory to language proficiency. So the real risk factor is having a persistent speech or language problem, and we see school entry as being a critical phase. If a child comes to school with poor speech and language, then they are highly likely to have reading difficulties and highly likely to have difficulties also with aspects of numeracy, and therefore just not do well in the educational stakes. So they're the risk factors in the language domain, but also there are more specific risk factors that can be picked up closer to school entry, which are in the domain of the precursors of reading development. So this would include difficulties in learning letters or learning numbers, which are traditionally part of a preschool curriculum. These children may have difficulty with rhyme and alliteration and other sound games. And some of them really it's reported, just don't like looking at print. They just don't like-- they like being read to but they don't want to look at the print on the page. And that's where a lot of print concepts develop from. So there are a wide range if you like, cognitive risk factors for dyslexia. But then, of course beyond that, there are other risks. I mean, health is a big risk. We know that children who have low birth weight seem to be at risk of language and reading problems, though we don't really know the mechanisms by which that might be considered a causative influence. And obviously, absences from school are going to affect language and reading development. And then there are the environmental causes. Pollution has very small effects but does affect brain development and therefore is likely to affect language and reading development. But in terms of the environment, really important are schools, good schools versus not such good schools, the kind of curriculum a child receives. A child who is taught using what we used to call the look and say method, is much more likely to struggle than a child who is given a very structured diet of phonics, the kind of provision that the child receives in school, and the kind of peer group that they belong to. All of these things are risk factors. But in those early years, the early signs tend to be in that domain of oral language. So I've been talking about the risk factors associated with language and reading difficulties. And the other side of that coin are protective or promotive factors. The skills within the child and within the environment that can help that child to do better in reading to improve their language, and also to have better-- for their well-being to be better catered for. And I think it's useful to put these into three different packages. There's people in the environment who can make a big difference to a child's outcome. There are activities and then there are more formal interventions. So let's talk about the people end, first of all, because as in any developmental difficulty, the kind of support that child gets in the home is very important. And outside of the home, the extended family, grandparents can bring a lot of comfort when a child is having difficulty. But more specifically, there's been interest in the language and the literacy environment of the home. So in terms of language, it goes without saying, it's very important to talk to children. It's very important to allow them to ask questions. It's very important for them to ask what words mean and so on. And of course, there's a concern that perhaps the amount of conversation that used to go on in homes, particularly over meal times, is very much reduced in the current period, where there's quite a lot of more interest in the use of technology in the home. But generally, homes that have more books in which parents themselves are reading, so there's a passive influence of literacy in the environment and an active influence through bedtime reading, shared reading at different times of the day, are all very important aspects of the home learning environment that can support a child. And it's particularly important for a child with difficulties. I mentioned that one of the early signs of is difficulty learning letters. Well, obviously in the home, a parent can actually work on that. They can do a lot of games that involve letters. They can use-- there's quite a lot of nice card games. So in a way, the direct teaching that can be added into home literacy environment can be very helpful in those early years. And of course, this doesn't need to be done by parents. Parents can be very, very busy. There's always grandparents, and even older siblings can actually sometimes support the language or literacy development of their younger siblings. And then I want to really mention teachers. And by teachers I mean educators. So it could be the childminder. It could be the preschool teacher. It could be the teaching assistant or the primary school teacher. It's really important for them to understand the importance of spoken language and to attend to their own language. So don't speak too fast. Observe a child and if they're not understanding, recast your question, and try to speak at the level that children will understand. All of these is really very, very important for the language that's surrounding the child in school to be both rich but also at the right level. And then when you're listening to a child more one-to-one interactions, the better. To help that child to express themselves, if they're having trouble expressing themselves, scaffold what they want to say. So you help them with the different aspects of the sentence structure. If they make errors like a lot of children get the past tense wrong, they'll say, I run to school today instead of I ran. Help them to recast their sentence. So you say, yes you ran to school today, didn't you? So the child hears the correct form close to the incorrect form that they have made. So there aspects of what people in the environment might do to help a child. And then there are the activities. Well, I've already mentioned some direct teaching that sometimes goes on in some homes, but also really important is bedtime reading and shared reading other times of the day. Now, this shouldn't just be a passive activity. I mean, if you leave it too late, probably the child will fall asleep. But it needs to be very interactive. So the parent or the older sibling will read but will also be stopping talking about what's happening in the book, looking at some of the pictures and other things that are outside of the text, asking the child what they think might happen next, asking the child, what do you think the little girl feels now. So actually kind of enriching that storybook interaction. There are some aspects of learning literacy that children with language and reading difficulties have particular difficulty with, and that is with the sound structure of words. So rhyme and alliteration are the ways in which early children start to focus in on sounds but later than that, thinking about the first sound of a word, the last sound of a word, the middle sound of a word. We can use traditional name games like I-spy. But there's also a lot of commercially available activities that can help with the development of various what we call phonological skills. And these are part and parcel of what the child will learn in school, in what's described as phonics, learning how to decode words by sounding out the different phonemes, the different single syllables and blending them together. The only thing you can do to back that up is helpful. And then, of course, there are confidence building activities, which are always important with a child with difficulty to get outside of what they're not good at and do a lot of activities with what they are good at. And I think particularly, when the school years, parents have to remember that their mum and dad, they're not really the teachers. So although they will want to support, you do have to moderate that. And remember, the child also needs you to be supporting the things they're good at, be it sport or art or music and so on. And then I should come on to the more formal interventions. So I guess the first sets of interventions are around speech and language therapy. So given the preponderance of oral language difficulties in children with language and reading problems in the preschool years, ideally, you need to have support from a speech and language therapist. Now, if the child has a speech problem, by which I mean a problem articulating sounds, these are quite remediable. They can be remediated successfully with input from a speech language therapist and practise at home. More difficult is to help a child with their language comprehension and expression. And if the child is really having trouble in those early years, then help should be or at least advice should be sought. As I said, it may not be that treatment is offered at that point in the preschool years, because so many children are late talkers, but resolve their difficulties. But what's important is trying to prepare the child's speech and language for school entry, because that's when they're going to have to start reflecting on their language to learn to read. And once a child gets into school, if they're having difficulty, they really need some form of language intervention. And that could be delivered through speech and language therapy or through training teaching assistants. And those language intervention programmes typically would include vocabulary instruction. So learning new words using different senses to do that, putting those words in sentences, thinking about different meanings of words, also grammatical skills. I mentioned earlier just recasting children's sentences if they make a mistake. Narrative is really important. So telling stories perhaps starting off very, very simply with cartoons, with a couple of pictures, getting the child to say what's happening in the picture, helping them, scaffolding them, and also recasting their productions, and also work just to help them with listening and attention. So they're the components of language intervention programmes. And also I just should mention numeracy, because many children with dyslexia also have problems with arithmetic. Many also have an associated difficulty, dyscalculia. And the language of maths is really hard. We have a lot of synonyms. We have add and plus and addition. We have minus and takeaway. We have bigger, smaller, fewer, more, less. These are all very abstract words, and they need some attention in helping a child who comes to school with a language problem to learn the basics of the literacy and numeracy curriculum. So turning to mental health, this in terms of research on reading and language is a relatively new area because people thought of mental health as rather separate from learning difficulties. But we now know that many children who have language learning difficulties do go on to have a variety of mental health issues. Rather salutary finding is that if you look at referrals-- I mean, this has been reported. If you look at referrals for children who've got particularly difficulties with conduct. Many of those children will have hidden reading or language difficulties that are undiagnosed. And that's also true, of course, in our prison service that many offenders have untreated reading and language difficulties. So it's really important, I think, to be very aware of the impact that a learning difficulty can have on a child's mental health. Children go to school every day. And if they've got a difficulty every day, they have to be confronted by failure. And this is not a good thing for the development of self-esteem. So it's very important always, I think, to think about how you can build the confidence of a child who's having great difficulty with the things that every other child in their class is doing. And probably the best success stories are where a child is very, very good at sport, can excel in sport, very, very good at art or drama. Drama is very, very good for building confidence. But sadly, not all children have these talents. Nonetheless, one has to try and support them and one has to try, I think, to understand their difficulties. Strangely, what's not helpful sometimes is if there is a parent with a dyslexia, for example, but has been very successful. And people will say, well, don't worry, because look at your dad and look how successful he is. And in a way that's very demoralising for the child, because they just think I could never, ever do that. So one has to be very sensitive to their needs or has to talk to them, get them to try and understand the nature of their difficulty, that there's really a learning difference, not a learning deficit. And there are now increasing numbers of little books that you can use to read with children about children with various forms of difficulty in language and reading. In terms of other mental health problems, beyond confidence and low self-esteem, not that they are insignificant, they're very important, and if you don't attend to them, children turn away from learning. They become disengaged. And that's I think, when offending can begin, especially if they get in with the wrong crowd, as we say. But even for young children, anxiety levels can increase, particularly if they think they're going to have to be asked to read aloud. So you may have to not ask these children to read aloud in front of their friends. We know quite a lot about maths anxiety, the maths arithmetic tables. Anxiety effects that and then that affects their learning of those tables. A lot of stress, weekly spelling test. Yeah, but that's all right if you can learn your spellings. But if not every week, you've got to go through a test. You can end up being bullied if you are withdrawn a lot for quite a lot of special needs support. And you can, as I implied earlier, you can become the class clown. Everybody can laugh at you, but actually that's a behaviour problem in the beginnings of a behaviour problem. Now what we don't understand are the mechanisms here, what's leading to what. We don't know that it's the learning difficulty causing the problem, or that some children also have risk of developing other problems, possibly because of family history of anxiety and depression, or maybe family stresses. We don't know exactly what's going on here, but there is an association between reading and language difficulties and mental health problems. Also, we know that dyslexia tends to co-occur particularly with ADHD. So again, for many years undiagnosed because people thought dyslexia, children just weren't concentrating because they couldn't read. But actually many also have co-occurring attention deficit disorders and in children with language disorder very often problems with coordination, so developmental coordination disorder. And as we know, the more in a way that none of these disorders are selective. And if you have one, the likelihood of having another is increased. And just in terms of mental health as well, I think it's really important to think about teachers here. Teachers are major influences on children. And if you have a good teacher who understands you're having difficulties, whether they are purely in language and learning or also mental health, that teacher will make all the difference. So teachers also need support in trying to understand how to help children's mental health if they have a language learning problem. We now have quite a lot of evidence about the development of children with language and reading difficulties. We know about the risk factors. And we also have quite a lot of evidence from randomised trials about what are effective interventions. Unfortunately, not all of this knowledge has been shared through teacher education, and particularly not through initial teacher education. So it's really important, I think, to think about how this research evidence can influence practise. Now in British schools, we have a multi-tiered system. It's also true in the United States of Tiers. So when children go to school, we imagine they'll all have some universal provision. We call that Tier 1. If a child has difficulties keeping up in some way, they would have some usually group support. That's Tier 2. And then if they don't progress, they go into Tier 3, which is more specialist support. So thinking about this in relation to classroom practise, because ultimately that's what we need to be training teachers about, I would say if you start just before school entry and preschool, I would just say language, language, language. Because our school systems have been completely taken over by obsession about learning to read. And we have International League Tables on which countries have the highest reading standards. But without language, there is no reading. And language needs to be its own part of the curriculum to supplement reading. And certainly before school, the emphasis should be on language. But even in school, language and reading should be delivered together. Jim Rose, who wrote the review of the reading instruction back in 2006, said, ''systematic phonics should be delivered in a rich language which environment''. And that's so true and yet so likely to be forgotten when every day children are being taught phonics. So language, language, language. Language is the foundation of literacy, and comprehension is the goal of reading. You can't understand if you don't have good language. I mean, reading comprehension depends upon decoding and language comprehension, decoding itself, the ability to sound out words and to work out what words mean. That depends on language. And once you start to read text, you need to have ways of making inferences about what's not on the page. You need to understand vocabulary, different sentence structures. You need to monitor your comprehension. You need to have the skills to modify your understanding. So language is so important to reading. And if you come to the other side of writing, I mean, writing is just language on the page. And to write well, a child has to be able to create stories or factual relate facts in their head, and then put it down on the page via spelling and handwriting. So for a child with language difficulties, a lot of schooling is going to be problematic. And so we must think about that when we think about how we deliver language and reading in schools. And so in my view, we need to ensure when children go to school, there is universal enrichment in the classroom for language. So a lot of reading of books together in the class, a lot talk about vocabulary, a lot of encouragement of peer interaction around conversation. If there is that universal provision, this is a very good place to start to do reading development, because reading depends not just upon sounding out letters. It depends upon sounding out letters, putting them together and mapping them to the oral language domain. So that's your Tier 1. In the very early parts of schooling, there should be language screening, because we need to then be identifying children whose oral language skills are not at the level to be expected. And they should then go into Tier 2 and have a language intervention, which is probably going to be a group intervention, probably delivered by a teaching assistant. And then very importantly, their progress needs to be monitored. It needs to be monitored. And if it is not progressing well, then really the services of speech and language therapists should be sought. That is Tier 3. So that's for language. And you can think of a similar pattern for reading but a little bit delayed. So at the moment, at the end of the first year in school in England, we have the early years foundation stage profile, which is an assessment of children's development across 14-- I think it is areas, from language to literacy, through physical activity, through social and emotional development. And if at that point the child isn't showing a good level of development, then they should be probably given some support. And we know that language is a very strong predictor progress in all of those domains. Because as I said earlier, everything in school is delivered through language. So we need to certainly be always aware that we've got screening already built into school systems, but you can more formally assess language or you can assess it as part of your early years foundation stage profile. And then after about a year in school, the child's reading should be getting off to a good start. At the end of our year 1, we have a phonics screening check, and again, it's another point where if a child is having difficulty, they should be given support. And we know a lot about reading intervention. We know a lot about how effective reading intervention can be delivered using trained teaching assistants. So you have the two things really should be available, language intervention probably in reception, reading intervention probably in year 1, and the two things going through this tiered system. I think it's very important for teachers to be taught not just about classroom practise, but also about the science of reading. They need to understand what reading comprises. They need to understand why language is important. They need to understand why phonics is important, and they need to understand how to ensure a child becomes a fluent reader with comprehension. We in the past have had a number of national initiatives, which have tried to emphasise the importance of language or reading. We had every child reader, then we had every child a talker. And in the US they have no child-- they've had no child left behind. And that is so important. We know so much about the foundations of literacy development and the role of spoken language in that development, that we really have no excuse not to be supporting children with language and reading difficulties better, and therefore preventing them developing mental health issues. [MUSIC PLAYING]