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Reply To: DLD and ADHD co-morbidity

Gillian Bolton

Thank you so much for these great links.

Rachel, what you say definitely resonates with me, re differential diagnosis. Noticing, more and more, in my clinical practice, commonality between clients of a range of ages/stages/diagnosis and becoming less certain that differential diagnosis is an essential prerequisite to effective intervention. We are all achieving better understanding of neurodiversity and understanding the importance of identifying factors that affect our clients emotional & physiological regulation. For the last 3 years I have been using VERVE Child Interaction Therapy with a range of clients. Like other interactive approaches VERVE helps interaction partners – parents/carers/educators – explore, through video reflection, the most effective interaction patterns, for facilitating regulation and consequently speech, language, and communication development (https://www.jr-press.co.uk/mutual-face-watching.html).VERVE has now become, not just another tool in my kit, but THE way in which I support all clients regardless of age/stage/diagnosis. Learning with, and working through the skills of, parents through video reflection has shifted practice away from focusing on symptoms (and diagnosis) to focusing on each child’s individual underlying physiological state.

I also try to integrate the SCERTS approach and what I am seeing with my clients, not just those with autism, is that addressing Social Communication (SC) and Emotional Regulation (ER) through VERVE, combined with addressing Transactional Support (TS) according to the child’s stage of development (objects of ref, now-next boards, visual timetables etc) really covers all bases for the vast majority of my clients (i.e. unless they also need AAC).

Over the last few years I have implemented VERVE with children with language delay, DLD, DLD associated with autism and Down’s Syndrome, fluency issues, and even a toddler with a Bilateral Cleft Lip and Palate repair. They have all shown significant progress with regulation, play/cognitive skills, joint attention with others, face watching for feedback (as distinct from eye contact), increased confidence in social interaction, and significant progress in speech & language skills. Here are just a few examples;

• The youngest – a 2y old with a repaired BCLP – patterned to face watching very quickly and started using all bilabials in connected speech.

• The oldest, a 16y old with Downs Syndrome. began to make prolonged eye contact, initiate conversations, and ask questions after his TA did VERVE training. Parents also witnessed his vocabulary increase through engaging more in conversation with them at home. I worked with this young man when he was in infants and junior school for several years seeing him weekly, as an NHS SLT through his EHCP allocation, working on targets – speech sounds, linguistic targets, small peer groups trying to support social interaction – and I think I have made more progress in 4 sessions of VERVE with his TA. His parents were really surprised, having been very sceptical, by the changes in him, after the VERVE block in school – VERVE unlocking his social engagement system which made communication useful and meaningful for him.

• I have worked for about 18m with the parents of a pre-schooler presenting with autism and specific speech impairment (when he started talking he used the initial sound only ‘o’ – orange, ‘f’ – fire engine’ ‘s’ – submarine, something I had not seen before). They implemented VERVE fully across his day and saw first a change in his emotional regulation, decreased frustration, improved gross motor coordination. His play skills began to develop (now small world with simple story lines). Patterning to face watching led to watching their mouths and experimenting with sound. He now has only minor age-appropriate speech sound errors. He is using ‘learnt phrases’ functionally (‘oh dear what’s the matter’, to dad, when stuck inside the laundry basket), and combining 3-4 words for functional communication (some of his Skips blew away in the park last week and a crow ate them, he looked at his parents and told them ‘Open the bird! Get the skips!’)

Parents are intuitively skilful, however, irrespective of their child’s presenting symptoms, common patterns emerge. Through a natural tendency to anticipate need and lead the interaction they tend to dominate, doing all (or a lot of ) talking, not giving the child time (silence) to think/explore or initiate. One mum said this week ‘I am always filling the room with words’.

They do not know (as I did not) about the impact of mutual face watching.

Unwittingly, the adult’s approach, while well intentioned, and often grounded in advice they have been given – ‘talk to your child’ – typically promotes learned helplessness. Sometimes we see a marked change in the child the first time the parent experiments with a new interaction pattern and parents express amazement ‘I never knew my child was so capable!’ ‘I feel guilty that I did not realise she could do X’.

I do think labels can help parents/practitioners to understand a child’s needs (I keep recommending Barry Prizant’s wonderful book, Uniquely Human, and parents say they find it really helpful). Labels can help with accessing funding. But, like Rachel, I think there is a lot of overlap. I see a lot of the same needs/issues in the children with DS as those with autism but I don’t necessarily think, since learning more about dysregulation, that this means they have an additional diagnosis.

Sociolinguistic and psycholinguistic theories of language development were relatively new when I was at College (nearly 30 years ago!) but were favoured by the SLTs who were my mentors when I was a NQT. I have found myself not only holding on to and pursuing those approaches (training in PCIT, Intensive Interaction, Non Directive Therapy, and VERVE) but in recent years realising how vital they are for all people who present with SLCN, and far less certain of the need, and value, of working on specific S&L impairment targets discretely.

At a time when demand for SLT services – NHS and private – are high, and in some places unsustainable, interactionist approaches such as VERVE, which empower parents, are an effective use of resources. Parents, once confident with the approach, and witnessing the impact on their child/family, rarely ask for extra therapy or direct SLT led therapy.

Interested to hear other’s thoughts/experiences…