6 November 2019

Do something! Just sit there

Paediatrics Psychology

Recently I attended a psychology seminar at the Royal Melbourne Children’s Hospital. The theme of the day was Trauma: Neurobiology, Development and Intervention. A string of “eureka moments” made the day memorable and one to be shared.

Professor Pam Snow’s keynote was a valuable reminder that skills in oral language and literacy developed early in life are crucial for life-long health and social well-being. The first two thousand days of life is the first critical window of opportunity in a child’s life.

Not all children get the same chances. Professor Snow, a speech pathologist, pointed to the work of Hart and Risley1 (1995), which demonstrated that children’s exposure to language-stimulating environments varies with the position of their family on the social gradient. Children of professional parents are exposed to 2153 child-directed words per hour. Children of working class parents hear 1251 such words per hour. Children of parents on social benefits hear 616 such words per hour.

The differences are not merely a matter of quantity. The quality of parental communication differs too.The children at the lower end of the gradient hear talk that is largely about giving instructions. At the other end of the gradient language is more often warm and encouraging; more often elaborating and extending. This experience has a positive impact on the architecture and chemistry of the developing brain. Missing out has the opposite effect.

It was fascinating to be reminded of the complexity and nuance needed to understand literal and non-literal meanings in language. The latter include our capacity to recognise and appreciate similes, metaphors, idiom, jokes, sarcasm, analogy and irony.

Ponder the disadvantage when unable to detect, appreciate and utilise these non-literal meanings when communication is critical.

Another critical window occurs the first three or four years of primary school. It is here that children transition from learning to read, to reading to learn.

The drive to talk can be seen as built in to the developing human. Reading is different; humans have only been reading for 6000 years. Becoming literate is a crucial life skill that needs to be taught, rather than something that can be left to innately develop. Once literate, vocabulary expands by reading rather than by conversation. To use Professor Snow’s metaphor, reading is parasitic on oral language.

“With evidence-based techniques, 95% of children can be taught to read,” Professor Snow said.

Eureka moment? “Early language and literacy must be accelerated, not simply promoted, if children who arrive at school behind their peers are to have a fair go.”

This keynote laid the foundation for the emotional impact generated by the next presentation.

Dr Linda Gonzalez, clinical psychologist, described the four-hour assessment she had undertaken with a teen referred by the court. Calvin* had previously been diagnosed as having an intellectual disability.

Calvin had limited language and literacy skills. Diminished skills in these domains are one of the developmental outcomes of toxic stress experienced in early childhood compounded, in his case, by an impoverished environment for language stimulation in his first two thousand days.

Adverse child experience often results in hyper-vigilance and emotional instability – a damaged brain response to fear. For young people such as Calvin, the slightest misreading of “threat” in the environment may trigger an exaggerated fight, flight or freeze response. When the response is “fight” or “act out” it is often described as a “melt down” or as “losing it” or as “oppositional and defiant”.

Calvin had both. He had limited language and literacy skills and he was hyper-vigilant. Calvin’s trajectory towards either detention or life on the margins of society was predictable early in his life.

The red flag was missed and with it the opportunity to accelerate his acquisition of language and literacy skills. Through no fault of his own, and for preventable reasons, he is ill-equipped to have a go.

No matter how enlightened the modern police and court system may be, this mixture of restricted skills in language and literacy combined with hyper-vigilant fearfulness makes a just outcome exquisitely difficult to achieve.

Calvin’s preventable language and literacy disability means that he struggles to understand the policeman’s narrative and to develop his own. His preventable adverse child experiences result in behaviours which test police, courts, and the wider social systems, including the “health” system.

Eureka moment? The ability to establish rapport and sustain a four-hour assessment is a tribute to Dr Gonzalez’s clinical skill to “bring Calvin into her calm and not join his chaos.”2 Her report included the caveat that Calvin’s behaviour demonstrated during this assessment may not be replicated in other environments; environments in which he does not feel safe or where rapport is not established.

Tom Brunzell from Berry Street wrapped up the day superbly. Curious readers will profit by visiting the Berry Street website3 to find the elements of their purpose-driven approach. As I listened to Tom Brunzell I was fired up by the resonances Berry Street has with Bernie Shakeshaft’s BackTrack. “Working with high-risk kids is a game of inches.”4 As Tom put it: “It takes time!”

Eureka moment? Both Berry Street and BackTrack share fundamental principles. Both reconnect damaged young people with “life, their families, education and their communities. And, most importantly, with themselves.” They light up the path for the transformation of service provision within the health service and beyond.

Footnote

This guest editorial is dedicated to Isobel Ivill a speech pathologist who is working within three Early Education and Care Centres in Doonside, NSW under the umbrella of Thrive at Five in Doonside. The Western Sydney Primary Health Network (WentWest) and the Local Health District that founded, fund and support the work. And dedicated also to the staff of Doonside Technological High School who have undertaken the Berry Street Training. Evidence of impact in Doonside is being sought. It will take time and a mastery of the balance between knowing when to: “Do something, don’t just sit there”; and on the other hand: “Do something, just sit there.”5

* Calvin is a fictional name

Dr Michael Fasher is Adjunct Associate Professor at the University of Sydney and Conjoint Associate Professor at Western Sydney University

References:

1.https://psycnet.apa.org/record/1995-98021-000

2. Tom Brunzell

3. https://www.google.com/search?client=safari&rls=en&q=Berry+Street&ie=UTF-8&oe=UTF-8

4. How one man and his dogs are changing the lives of rural kids, Back on Track. Bernie Shakeshaft and James Knight. Hachette Australia. 2019

5. The latter marvellous phrase belongs to a fellow GP whose name I can’t recall.