Inclusive and Supportive Education Congress International Special Education Conference Inclusion: Celebrating Diversity? 1st - 4th August 2005. Glasgow, Scotland

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“It’s just a phase...
he’s just one of those odd children...it’s too early for labels...”

A case for early identification and intervention with 3-5 year olds showing signs
of over-activity and complex social communication difficulties in nursery settings

Ruth Walker, Educational Psychologist
Midlothian Education Department
Greenhall Centre
Gorebridge
EH23 4PE.
ruth.walker@midlothian.gov.uk

This project studies a small group of children who are struggling to settle into nursery because of impulsive, over-active behaviour and poor communication. It argues that these are an identifiable group who need and respond to a structured programme, without which they take more long term and intransigent difficulties into school.  

The study considers each child’s progress over a five-year period from starting nursery at   three years of age to transfer into school, and then for a further three years into education. It attempts to take in a detailed consideration of their early developmental profiles, considering possible underlying patterns particularly in the areas of play, communication and learning style. Using a nursery and home target based programme it aims to reduce levels of activity and impulsiveness significantly through improving on-task play skills, communication and self confidence. The goal is a positive transition to school with maintenance of the lower activity levels and coping strategies through each child’s first three years in education.

Setting the Scene

“He’s not daft but he can’t sit, he won’t concentrate and he gives everyone hell when you get him to try.   He’s only nine and he’s given up on himself. He needs to be in a small group”

Many pupils causing concern in both Primary and Secondary education present with problems of attention, impulse control, communication and application to learning. Often with ability, they can create a significant challenge for mainstream schools. They can be the most complex to turn around in their behaviour and attitude, and the unhappiest within themselves as pupils. They may not relate well to other children, compounding their distress both in and out of school.

Children who are diagnosed with A.D.H.D. are currently the source of concern and debate within medical and educational contexts. The efficacy and long term effect of medicating children is at the forefront of research and media attention. The challenge in providing a suitable environment within mainstream schooling is considerable with many of these pupils underachieving educationally, and isolated socially. More difficult pupils may require small group education usually in special placements for children with emotional and behavioural difficulties. It is the policy of most local authorities to educate pupils with A.D.H.D. in mainstream schools, with in-school policies for this condition and Individual Educational Plans (I.E.P.s) provided for each pupil. The success of these measures is variable.

A.D.H.D. is considered a condition inherent within children from birth, and evident from parent’s own descriptions of their children from a year to eighteen months of age when levels of toddler activity are thought to be unusually high. It is uncommon for pre-school children to be medicated before their entry to school at five years. Much emphasis is placed on the importance of behavioural management alongside medication. As most literature and guidance addresses the issues for school age children and classroom management, little is available in considering the difficulties presented at three and four years of age. Discussion with parents indicate that the children may have been very difficult in their early years yet little advice has been available for the management of behaviour as it presents within the usually fairly unstructured setting of a nursery, and within the home.

Is there a connection?

It would be my own experience in assessing older school age pupils with poor impulse control, lack of application and sometimes the diagnosis of A.D.H.D. that they frequently present with:

• marked information processing difficulties in the classroom, involving both receptive and expressive language, although sometimes with good general knowledge and vocabulary
•  an anxiety about approaching and completing work leading to quiet opting out or disruptive and challenging behaviour
• some degree of semantic and/or pragmatic communication problems   resulting in a struggle making and maintaining close friendships along with an acute awareness of this failure
• specific learning difficulties with marked areas of strength and weakness

At pre-school level this group of children may present with profiles of:

• late general language development and poor processing of complex language, even though their grasp of vocabulary may sometimes be deceptively advanced
• marked emotional anxiety at demands being made upon them by adults both individually and in a group setting with strong avoidance response common, contributing in very clear ways to their over-activity
• an immaturity of relationships with other children, problems in turn-taking and sustaining eye contact, recognising the feelings of others and being able to join the complexity of unstructured social play
• delayed areas of symbolic and representational development with very limited focus, continuity and depth of quality within play; a tendency to move round quickly and   fail to settle to complete activities

It would be the hypothesis of this study that these two groups of attributes are related. Furthermore, that intervention at the pre-school stage offers important possibilities for better outcomes in school for these children.

The work – who and why?

Which child are we looking for?

The proposal for this project arose from a piece of work completed with a four year old called David. Referred in April 1998, his level of disruptiveness in nursery was almost unmanageable for a nursery school well experienced in dealing with difficult behaviour. He spent much of his morning running about, stopping only to scatter materials or to hit another child. He ran from staff who tried to reason with him. He responded to neither praise nor limits, and showed little awareness or interest in other children. The only child of professional parents, they were aware that David showed areas of ability in advance of his age and were very anxious about facing the fact that there might be a problem. An assessment of David was completed which indicated a significant receptive and expressive language problem, masked by his growing vocabulary and apparent sophistication of ideas. Also evident was a problem with symbolic expression within his immature drawing skills and very limited stereotypic symbolic play. David found settling to any activity without adult structuring problematic and at the same time the pressure of adult demands made him anxious, active and avoidant. He was negative about himself underneath the expansive exterior, and saw himself as the “bad boy” in nursery and often “the adult” at home. Deferral of his entry to primary school was agreed, and a one year programme put in place involving nursery and home. An additional member of staff was appointed allowing each member of the nursery team to be his key person for a period, thereby involving each in his progress. Feedback from different staff members contributed greatly to the planning for this complex and very challenging child.   Term by term David responded well, making strides in his ability to play, co-operate and to relate to staff and other children. He made a positive transition to school in August 2000. Now nine years old he is doing well academically and is very positive about his achievements.  

• The experience of parents

Although challenging and confusing, these children are frequently able in many respects, which causes uncertainty for parents who conclude must be something in their handling. They may be pushed to their limits by relentless overactive behaviour, their child rarely settling to play. They are concerned at the distress as they try to leave them in playgroup then nursery, sometimes giving up on both. Looking back they may be the children still kicking and screaming at the school gate every morning, six months into their first year.

Little research has addressed the early life of these children, and how overactivity may be influencing (or indeed be influenced by) the different areas of development such as language and communication, play, motor and social skills.   With increased knowledge, nursery staff are able to more accurately identify those children whose levels of activity exceed what would be ordinarily expected of a lively pre-schooler. The quality of the over-activity may have a different feel, a driven-ness to move constantly for its own sake and a need to avoid the problems which might arise if the activity stops. The genuine difficulty in inhibiting each competing event around them is a distressing and confusing experience, which can result in session after session in nursery with much movement but no sustained learning. Each child’s behaviour is individual, but what may then arise is an interruption of the ordinary experiences which lay the building blocks for smooth developmental progress. The ability to sustain play in such a way that a task is completed; the ability to maintain a social turn-taking interaction such that a friendship is made; the ability to listen to an instruction such that a task can be followed through - such ordinary events can be lost to a child who cannot settle or focus.

• Underlying mechanisms

Play and other symbolic activities such as drawing, are felt to be central to the difficulties of this group, and avoidance of settling a contributory factor in their over-activity. Parents report a disinterest in ordinary toys from an early age, and assessment observation indicates an anxiety around certain play materials, a need to control what play is engaged in and a disruptiveness when the invitation to play persists. Symbolic or pretend play creates particularly high levels of avoidance. One four year old observed with a group at the sand tray in nursery placed his hands over his ears each time another child offered him a “pretend” ice cream cone, screaming with full volume over and over “it is not an ice cream”. This genuine distress and confusion at being unable to make sense of “pretending”, and indeed a range of other subtle social rules, is thought to render the nursery experience a difficult one for this group in a way that is quite unusual. This pattern is also typical of children with autistic spectrum disorder and there are felt to be overlaps with this group, but it is important also to consider this element as a contributory mechanism in the over-activity of those who might be later considered as having early signs of A.D.H.D. More importantly the opportunity to intervene and change this pattern seems a valuable opportunity. For example, avoidance of drawing is true of 95% of this group at pre-school level, and without work these children   may this into school as an avoidance of written work.

The project structure

The project structure consists of:  

• A three hour training session with staff
• identification of appropriate children
• an initial meeting with staff and parents
• individual assessment of the child at home and in nursery
• a programme planning meeting at which an Individual Educational Plan (I.E.P.) is created together with parents and other professionals
• an eight weekly review of this plan
• a detailed and individual transition process to assist the child’s move into school
• termly reviews through to the end of their third year in school

In general the areas commonly identified as priority within I.E.P. s have been:

• support to use toys and play materials constructively
• the ability to approach and complete tasks from beginning to end
• the confidence to use drawing and other craft materials
• using language in play with others
• listening to books
• making and maintaining social relationships with other children.

Although each child is assessed as an individual, the above aspects emerge as frequent focal points within I.E.P.s.   Without a shift in the underlying dynamics of these key areas, it is felt that these children may continue to run round avoiding all activities. It seems essential to recognise the underlying anxiety driving their behaviour, alongside the important part that poor development of early symbolism plays. These central strands give invaluable clues to intervention.

The outcomes

Feedback and evaluation measures within the project indicate that the work is appreciated by those involved. Nursery staff have a way forward with children who can be otherwise confusing, unhappy and often disruptive and difficult to handle. Parents feel that they are fully involved from the outset and have an equal part to play in the drawing up of plans for their child. They experience relief at having the difficulty recognised and a way forward outlined, often very anxious about the nature of the problem, their own parenting and how their child is going to cope with school. The project offers a support mechanism through the nursery and transition to school period, within which they are fully involved.

More specifically outcomes have been very positive in terms of:

• improvement in play, social skills, communication and confidence within nursery, with significant reduction in over-activity
• good school transition with the child feeling positive and relaxed about the move
• the maintenance of overall self-confidence into school
• positive feelings on the child’s part in approaching early school   work and enjoyment of subsequent achievements  
• low anxiety levels and good focus on work
• the development of friendships within school (sometimes a longer term undertaking but able to be worked upon)

Difficulties do not entirely disappear, however, and success in all of the above has been contingent on school staff’s continuing understanding and addressing of the underlying processes for each child. Residual problems are monitored and worked on where necessary through the first three years of school when the final objective has been no further need for involvement with the psychologist by the age of nine years.

In general it is felt that the project to date has been successful for those pupils involved, the receiving schools and families. Close teamwork with parents continues to be one of the most significant factors. The way in which I.E.P. s are generated encourages full and equal involvement of parents and this in turn supports ownership and creativity in finding solutions. The transition and close monitoring of each pupil’s move to school is also very important as specific difficulties do continue to some extent. Over time, and with observations of those pupils progressing up through school, it becomes clear that a key aspect and objective is for the levels of activity, distractibility and anxiety avoidance to be significantly reduced at school transfer. The remaining issues can then be carefully defined and managed on entry, and into the child’s first three years.

Finally…Michael is a child who, at four years, could do little but run around in any space that opened up before him, ask relentlessly empty questions, swear when not attended to, throw heavy objects, and hit other children with no awareness of the consequence and generally resulting chaos. Almost unmanageable in a group setting when he came to nursery, with the work of a very insightful and determined staff over an eighteen month period, Michael settled and began to play productively, relate to other children and enjoy his success in this. His time in nursery was initially reduced to half an hour a day and painstakingly built up at a pace with which he could cope. His own very advanced ability to tell the time allowed us to involve him in this process. Carefully planned activities using visual timetables, and a reward system which made use of, amongst other things, a morning trip to see the school secretary with whom he had built a close relationship, helped to structure his time and make sense of his experience. In co-operation with his parents Michael developed the skill to monitor and manage his own anxiety, indicating to adults with a gentle squeeze of the hand, when he felt overwhelmed, an alternative to becoming challenging. He made a positive move into school and is thriving educationally and socially.

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