Newsletter No. 30

Talking Therapies
As a Child Psychiatrist I relied heavily on communication with clients, both to understand what was troubling them and to assist their problem-solving. Those with communication difficulties were generally much harder to help.
Most of the time we take our communication processes for granted, just doing the best we can with what we‟ve got, but from time to time we should think about the processes in addition to the important material we are trying to communicate about. Such introspection might help us to improve our communication methods and achieve better results. First principles alert us to factors in the people and factors in the situation.
Factors in the situation are complex, including whether the communication is desired, as in an anxious person seeking help from a trusted therapist, or required, as in Juvenile Justice assessments, which also highlight such things as the power differential between the people involved and the possible consequences of the
communication. Factors in people are even more complex, including physical, intellectual, language and social/emotional components. In abstract, these principles seem blindingly obvious but in practice there are many subtle barriers that may be overlooked. In the communication domain the language component is predominant although the other components are also very important and may escape our acknowledgment. If we are unaware of barriers we are less effective at dealing with their consequences. Let me tell you about my “Road to Damascus” with language.
For many years at the Alfred Child and Adolescent Mental Health Service I ran a Learning Disabilities Clinic. Our multi- disciplinary assessment team saw hundreds of children whose literacy and numeracy was well below that of their classmates. About 75% had significant language impairments, mostly in expressive language but also often with receptive and sometimes with pragmatic difficulties. By „impairment‟ I mean performance in the lowest decile of standardised tests. A subset of about 15% also had significant impairment in visuo-spatial processing; these were the ones which were most difficult to help. About 5% of referrals had visuo-spatial difficulties without language impairment, and the remainder had predominantly social/ emotional reasons for their poor school performance, including absenteeism, anxiety and depressive disorders, attentional difficulties and a miniscule number of early psychosis or organic brain disorders.
Over all about a quarter of our clients had emotional disturbances. With language- delayed children any emotional disturbance seemed much more often to be the result of the language difficulties than the cause of them.
The Learning Difficulties Clinic run by my colleagues at the Austin Hospital CAMHS found a very different pattern of impairments. They found a much higher prevalence of visuo-spatial and mixed impairments, and a much higher prevalence of attentional problems. The reason for this difference was that social/emotional disturbance was a pre- requisite for entry to their program. If we looked at the subset of Alfred clientele who had emotional disturbances, the pattern of impairments would have been quite similar to that seen at the Austin CAMHS. Many themes emerge from this comparison.
With the Alfred clientele being more of a community-based sample and the Austin clientele being more of a child psychiatric sample there are clear indicators of biologically-based associations between emotional disorder and learning difficulties. The right hemisphere based visuo-spatial problems and associated attentional difficulties are clearly more often accompanied by emotional disturbance than the left hemisphere based developmental delays in language although the latter also have their vulnerabilities. It is an important reminder that there is a biological component underpinning emotional communications. We have to be reminded of this because the extent of the impairment is often unrecognized.
Talking with parents about the results of assessment of their child’s learning problems often involved describing severe language disability that they found difficult to believe. Children functioning at the first or second centile for their age were perceived as “normal” because their monosyllabic and uninformative comments were not manifestly incorrect. The fact that
they were incapable of stringing together a coherent explanation of anything was attributed to their being “reserved” or “shy”. Whilst speech disorders like stuttering were almost universally acknowledged, language impairments were not. This lack of recognition of language disability was also noted in school teachers and to my horror I realized it also applied to me. I, too, had been seeing children for emotional assessment without realizing the extent of their language difficulties until revealed by formal testing. Once this had dawned upon me, my clinical practice was forever changed.
Using play materials and more concrete forms of communication with very young or non-verbal children is a stock-in-trade for child psychiatrists and psychologists but when conversation is the chosen form of communication it is essential to consciously gauge the level of language functioning. There are many pointers, such as the vocabulary, the length and complexity of sentences and the capacity for descriptive imagery compared to that expected of a person of that age. Effective communication requires conversation at a level that is mutually understood. This reminds me of a school that discovered many troublesome students did not understand their textbooks and behaved much better when given textbooks they could understand.
It has long been recognized that there is a strong link between language and mental health disorders. Whereas about a quarter of the population have some degree of mental health difficulty, and about ten percent have some degree of language difficulty, the overlap is quite marked. About a quarter of people with mental health difficulty also have a language difficulty. I am profoundly grateful to my Speech Pathology colleagues for educating me about language disorder, as this is not at all well taught in psychiatric training. Because it is not adequately acknowledged, there is minimal provision for specialist programs within mental health services, even in areas where the clientele is particularly vulnerable. One obvious example is in Juvenile Justice.
Not only do young people in the Juvenile Justice system have a high prevalence of mental health difficulties, they also have a high prevalence of language disorders. However, in Australia there is little provision for these needs, and little recognition of the importance of such provision. MHYFVic advocates provision of specialist language programs for assistance of Juvenile Justice clients as an evidence-based preventive mental health intervention to improve long-term outcomes. The after dinner speaker at our forthcoming Annual General Meeting, Laura Caire, has just returned from a Creswick Foundation fellowship visit to the United Kingdom studying services there.
Allan Mawdsley

Annual General Meeting
The MHYFVic Annual General Meeting will be held at 7.00pm on Wednesday 24th August 2011 at the Hot Honey Café, 40 Armstrong Street, Middle Park. The business part of the meeting will begin sharp at 7.00pm to be followed by a pleasant low-cost meal beginning at 7.30pm. The menu has been circulated by email and the meal must be pre-ordered for catering purposes; if you have not received the email please contact our Honorary Secretary on Prashnitha@gmail.com
After the meal there will be an after dinner presentation by Laura Caire, “Talking with Young Offenders”.

Laura Caire
Laura Caire has been practising speech pathology for nine years with experience in the areas of traumatic brain injury, adult
acute and sub-acute care, early intervention, education and mental health. Earlier this year, Laura undertook the 2010 Creswick Foundation Fellowship in Child & Adolescent Development, spending time in the UK with specialists in the field of speech-language pathology and youth justice. She is currently employed as a mental health clinician at the Early in Life Mental Health Service (formerly CAMHS) working with adolescents who have significant social, emotional and behavioural difficulties. Laura’s role includes case management, milieu therapy, program development, group facilitation and speech pathology as part of a multi- disciplinary team. She is currently undertaking the Graduate Diploma in Forensic Behavioural Science through Monash University and is passionate about meeting the speech, language and communication needs of young people involved in the justice system.
Talking with Young Offenders – The importance of speech, language and communication development in promoting mental health”
Social and emotional development is closely connected to speech, language and communication development. This is because verbal and non-verbal communication is fundamental to socialisation, understanding and expressing emotions, coping with distress, thinking and problem-solving, self-regulation of emotions and behaviour and academic success. Within the child and adolescent mental health field, language is the basic tool for most forms of assessment and intervention. Verbally based assessments and psychotherapies assume a child‟s understanding and use of language. However, 50-80% of children and young people with social, emotional and behavioural disorders have speech, language and/or communication impairment. It is therefore crucial to understand how these are related, the impact on a child or young person’s mental health and what can be done to ensure maximise the effectiveness of mental health interventions.
The presentation will cover what communication is, the characteristics and consequences of communication impairment, the relationship between communication disorders and mental health, the role of mental health speech pathologists and what you can do to support young people with mental health issues who may have speech, language and communication difficulties.

History Corner is held over until the next Edition due to the absence overseas of our Correspondent.

Membership renewal
Subscriptions run for the financial year and should be paid before our Annual General meeting early in the new year. The fee remains at $20 and applies to organizations as well as individuals.

MHYF Vic Committee
* President, Jo Grimwade
* Vice-President, Jenny Luntz
* Past President: Allan Mawdsley
* Secretary, Nitha Prakash
* Treasurer & Membership Secretary, Lillian Tribe
* Projects Coordinator, Suzie Dean
* WebMaster, Ron Ingram
* Newsletter Editor, Allan Mawdsley
* Youth Consumer Representative, vacant
* Members without portfolio: Miriam Tisher, Sarina Smale