In search of co-production

Co-production. The only time I’d seen the word was in film credits, so when it appeared in a Parent Carer Forum (PCF) newsletter in 2013, I asked what it meant. I was directed to one of the Pathfinder area information booklets.  It defines co-production as:

“…when all team members together agree outcomes, coproduce recommendations, plans, actions and materials as a collective. It is an approach which builds upon meaningful participation and assumes effective consultation and information sharing. In its essence, co-production is a dynamic group process and happens in the room when there is equal value for each participant’s contribution and when there is a meaningful proportion of participants who are service users (in this case parent carers) present.” (p.10)

scaling up

Co-production turned out to be a buzzword in public services. That prompted another question. I could see how co-production could be used to develop a personalized programme of medical treatment, or an individual Education Health and Care Plan, but how could it be scaled up? A handful of patients wanting unusual therapeutic interventions, or half-a-dozen EHCPs specifying provision that has to be imported from out-of-county, is one thing. Tens, or hundreds of treatment plans or EHCPs along those lines is quite another and would require some major changes in commissioning.

I asked around. I joined several online groups and met many well-informed people. They all said ‘that’s a good question’, but no one could answer it, and no one had any examples of co-production happening at scale. This was significant. If co-production didn’t work at scale, there wasn’t much point to it.

I asked around some more. An organization called NESTA has done a good deal of work on co-production, so I read their research papers. NESTA (National Endowment for Science, Technology and the Arts) describes itself as an innovation foundation. It was founded as a non-departmental public body in 1998 with a grant from the National Lottery, and in 2010 became a charity.

Their co-production discussion papers The Challenge of Co-production, Public Services Inside Out and Right Here, Right Now, (more have been published since) were fascinating. But I couldn’t find an answer to my question about scaling up. The papers were packed with inspiring examples of co-production, but unless I missed something, all the examples looked like one-off local projects, some of which had been quite short-lived. Would co-production at scale consist of a bunch of local projects? If so, at what point would you need to do some joined-up thinking?

engagement

The NESTA papers indicated there was considerably more to co-production than producing “recommendations, plans, actions and materials as a collective”. The NESTA authors saw it as the active participation of citizens in delivering public services, a model that had significant potential to halt spiraling and unsustainable costs. The citizens’ engagement was framed in terms of ‘giving back’. There were obvious parallels with David Cameron’s ‘Big Society’.

I felt uneasy.   Big Society emphasized the importance of volunteering, but blithely overlooked limitations familiar to volunteers. I vividly remember eyebrows being raised at a local meeting where it was suggested volunteers could support elderly people discharged from hospital. One former nurse asked what training the volunteers would get. Another asked about insurance – she’d once been falsely accused, by a patient with dementia, of stealing money. It would be more cost-effective to employ a few more district nurses.

power

The Pathfinder description of co-production had a footnote to Sherry Arnstein’s 1969 paper ‘A Ladder of Citizen Participation’. Variations on the ladder of participation are widely cited.  Here’s Arnstein’s version:

arnstein

Arnstein’s paper is about the role of power structures in planning decisions in the USA, and cites numerous examples of citizen participation. In some cases, the citizens had to engage in quite robust action before getting to the point where they were actually participating.

The NESTA papers referred to power shifts, but not quite as explicitly as Arnstein does.  Parent Carer Forums often refer to the ‘empowerment’ of parents, but generally in terms of parents sharing experiences and familiarising themselves with the law.  It’s assumed that in and of itself, this will make things happen. I can’t recall seeing any references to power structures.

Parent Carer Forums do, however, report co-production taking place at a ‘strategic’ level. As far as I can ascertain, this means PCF representatives working with commissioners and providers on the design of local services. Public sector services do appear to have shifted from a ‘doing to’ to a ‘doing for’ approach, and are now en route to ‘doing with’.

How far ‘doing with’ is likely to extend is debatable.   Even if the contributions of the people ‘in the room’ are given equal weight, what about the ones who aren’t in the room? The non-verbal children? The ‘hard to reach’ parent carers who’ve never even heard of parent carer forums? And at the other end of the scale, what about the Treasury, the DfE and the Education & Skills Funding Agency?

Most PCFs are funded indirectly by the DfE and/or directly by their local authority (see p.10), so who’s in the room and what power they have over the dynamic group process are key questions.

missing pieces

Although I could see the potential for co-production, as a model it still didn’t make sense. Pieces of the jigsaw were missing.  I found frequent references to Edgar Cahn, who worked on co-production in the 1980s. The NESTA papers presented his role in terms of ‘transforming public services’ (Challenge of Co-production p.13), which didn’t quite square with his being a civil rights lawyer. Then there was Elinor Ostrom, the Nobel prize-winning economist who coined the term ‘coproduction’ in her studies of the Chicago police force in the 1970s. You don’t get a Nobel Prize for studying a police force. Something didn’t add up.

So, I read Cahn’s book No More Throw-Away People, and the 1981 paper ‘Consumers as coproducers of public services: Some economic and institutional considerations’, co-authored by Ostrom.  And had an epiphany.  Cahn and Ostrom use ‘production’ in the economic sense: an activity that creates a good or service that people value and that contributes to their well-being.  This might have been obvious to policy makers, but I’d been completely unaware of it in my reading until then.  I suspect I’m not alone.

markets and time banks

Ostrom’s analysis straddles the divide between a formal market economy that uses money as the unit of exchange, and an informal economy based on exchanges that don’t involve money. (Cahn calls them the market economy and core economy.)

Exchanges that don’t involve money are generally marginalised by the market economy even though it’s utterly dependent on them. The profits of plantation owners in the 18th century, mill owners in the 19th century, and multinationals in the 20th and 21st, have depended variously on the labour of slaves or low-paid employees, and the market economy would grind to a halt without the unpaid, invisible, behind-the-scenes labour of what Gordon Brown called ‘ordinary people’.  It’s a point Cahn makes explicitly, right after he compares the core economy to a computer operating system.  Interestingly, NESTA cite Cahn’s operating system analogy several times in The Challenge of Co-production, but omit his reference to “the subordination of women and the exploitation of minorities, immigrants and children” in his next paragraph (Cahn, p.54).

Ostrom was interested in the interface between the activity of public services and the activity of private citizens. Coproduction referred to their joint activity in producing services. Co-production can make services more efficient, but Ostrom and her colleagues identified a number of issues around the incentives for citizens to get involved.

Cahn’s contribution to the concept of co-production came about because of his pioneering work with time banks. A time bank is a system that allows people to earn credits for any activity they engage in that’s of benefit to others. The credits are based on the time spent, and can be exchanged for goods or services produced by other people. So you might earn credits by collecting library books for housebound elderly neighbours, and use the credits to pay someone to cut your lawn.

incentives

Cahn realised that time banking addressed some of the problems with incentives highlighted by Ostrom and her colleagues. Time banking:

  • Explicitly recognises, via credits, the value of activities that contribute to the wellbeing of others
  • Provides incentives for people to engage in and continue with such activities
  • Prompts people to identify and develop their skills and knowledge
  • Enables those on low incomes to participate in economic exchanges
  • Reduces economic and social inequality
  • Creates and sustains social support networks
  • Increases community stability and reduces crime
  • Facilitates the development of local businesses.

Parent carer forums and the NESTA papers also address incentives, but very differently.

The National Network of Parent Carer Forums (NNPCF) has a reward, recognition and remuneration policy. There are good reasons for parents not being out-of-pocket as a result of their participation, but the policy has had some unexpected and unwanted outcomes. Most PCFs have relatively small budgets. If, as a matter of principle, volunteers have to be rewarded financially, the budget limits the involvement of volunteers, so it’s hardly surprising PCFs report limited capacity (see p.27).

NESTA’s Public Services Inside Out goes into some detail about rewards (p.11ff), but they appear to be treated as an added extra rather than an integral feature, as incentives are in time banks. The underlying incentives of the NESTA model look more like moral indebtedness – there are frequent references to ‘giving something back’ and being ‘rewarded’ for one’s efforts.

The beauty of time banking is that it isn’t framed in terms of contributions and rewards. It’s framed in terms of exchange. People decide what activities they can offer and what activities they’d like in exchange. The exchange system is very flexible and can be modified to accommodate people’s resources and needs as they change; young children can be credited for learning and the elderly for mentoring.

Time banking also offers a way of integrating the market (money) and the core (non-money) economies. Taking family carers as an example, it would be impossible for all carers to be paid a living wage for the number of hours they work, but they could be paid in credits that could be exchanged for other services of real value, such as cleaning, child-minding or transport.

conclusion

The model of co-production adopted by Parent Carer Forums is different to the NESTA model in several respects, and both differ from the model developed by Ostrom and Cahn. There’s nothing stopping someone taking some features of the Ostrom-Cahn model and badging it ‘co-production’, but it’s unlikely to result in the significant changes in economic activity, power and well-being that Ostrom and Cahn envisaged.

Co-production, in the sense that Ostrom and Cahn used the term, offers the opportunity for everyone to be ‘in the room’, and allows the dynamic group processes to be scaled up to local and national level. It has the potential to transform economies, reduce inequality, increase the resources within communities and kick-start businesses. That’s the one I’m going for.

references

Arnstein, S. (1969).  A Ladder of Citizen Participation, Journal of the American Planning Association, 35, (4), 216-224.

Boyle, D. & Harris, M. (2009).  The Challenge of Co-production: How equal partnerships between professionals and the public are crucial to improving public services, NESTA.

Boyle, D., Coote, A., Sherwood, C., & Slay, J. (2010) Right Here, Right Now: Taking co-production into the mainstream, NESTA.

Boyle, D., Slay, J. & Stephens, L. (2010).  Public Services Inside Out: Putting co-production into practice, NESTA.

Britton, C. & Taylor, J. (2013).  Co-production with parent carers: the SE7 experience, Mott Macdonald & South-East 7.

Cahn, E. S. (2004) No More Throw-Away People: The Co-production Imperative (2nd edition).  Essential Books, Washington DC.

Contact (2017).  Parent Carer Forums in 2017, Contact.

Parks, R.B., Baker, P.C., Kiser, L., Oakerson, R., Ostrom E., Ostrom V., Percy, S.L., Vandivort, M.B., Whitaker, G.P. & Wilson, R. (1981).  Consumers as Coproducers of Public Services:  Some Economic and Institutional Considerations, Policy Studies Journal, 9 (7), 1001-1011.

 

 

 

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can’t help it, root causes and strict discipline: part 3

It’s clear from responses to the previous two posts that some further explanation is required of how the Root Cause approach to behavioural problems works. People have raised issues such as:

  • Some of the children in my class are refugees from a war zone; I don’t know how to tackle the root causes of their behaviour. Other agencies don’t seem to know either.
  • I don’t have time to teach all the children in my class individually, never mind sort out their behaviour issues.
  • How do you find out what the root causes are anyway?   Children will lie and blame anything but themselves.

All behaviour has causes, ranging from an involuntary response to physiology or the environment, through to a deliberate, carefully planned, long-term strategy. All unwanted behaviour in schools has causes too.

the environment

Unwanted behaviour often emerges if the school isn’t sufficiently explicit about its expectations. Rules such as walking in single file in corridors, no talking at certain times, are health and safety related. They reduce the risk of accidents and allow teachers to be heard. Other rules (e.g. do what teachers tell you, hand in your homework on time) facilitate learning.

The Strict Discipline model uses reward and punishment to ensure children comply with the school’s behavioural expectations. But having an explicit behavioural framework reinforced by rewards and sanctions doesn’t mean all children will keep the rules. Nor that all children are able to keep the rules. And sometimes the behavioural framework itself can cause problems.

One school I encountered experienced ongoing ‘challenging’ playground behaviour. On the wall by the door from the Y3 cloakroom to the playground was a small card bearing 13 rules for playground behaviour. Expecting 7 year-olds to memorise 13 rules seemed a bit unrealistic, and any child who stopped to read them would create a bottleneck likely to result in somebody falling over or getting their head bashed as the door was shoved open. I won’t even start on the problems caused by the coat pegs and lunchtime arrangements.

But what can schools do if a child is persistently not adhering to an explicit, carefully thought through behavioural framework, and rewards and sanctions are having no effect? My suggestion was to investigate the root causes of the behaviour.

the child

Most of us are familiar with the Root Cause model in some form or another. We know from personal experience that the causes of behaviour aren’t always obvious. We are aware (thanks to Freud) that the causes can sometimes be deep-rooted. Teachers will be aware of the cycle of deprivation theory that’s widely misinterpreted (and sometimes presented) as the Can’t Help It model. If you’ve never undertaken a root cause analysis, it’s easy to assume the causes of problematic behaviour will be nebulous and difficult to identify. That a child’s unwanted behaviour will turn out to be rooted in a dysfunctional family dynamic, or the community’s cultural expectations, or whatever. That’s often not so, even for the most apparently challenging behaviour.

For example, a pupil with a diagnosis of autism and complex specific learning difficulties attending a residential school (so yes, the school had the capacity and expertise to tackle difficult behavioural issues) began exhibiting extreme distress and ‘school refusal’. Some careful probing with the student revealed the source of the distress not to be some obscure aspect of his ‘autism’, but anxiety about being asked to do things he couldn’t do, in three particular lessons. The kid was given an opt-out card for those lessons. If it all got too much, he could show the card to the teacher and go to alternative provision. The card was never used; knowing he had an escape route was enough to allow him to cope.

The school could have explored in more detail why these particular lessons were an issue, but in this instance they didn’t need to; the problematic behaviour was avoided by a pretty simple solution. I’m sure some of the Strict Discipline adherents will at this point say that if a ‘get out of jail free’ card was available everyone would want one, but this was an approach the school used frequently and that’s not what they found. It became a kind of badge of honour to have the card but manage not to use it.

children with special educational needs or disabilities (SEND)

Old Andrew complained that the Can’t Help It model made SEND an excuse for poor behaviour. It might, but in my experience, some teachers don’t know enough about SEND to make that judgement call.

Teachers in mainstream schools have always been expected to teach at least 98% of the child population; only very small percentage of children have attended special schools. But initial teacher training (ITT) has generally focused only on the 70% of children in the middle ability range. Not surprisingly, children with specific learning difficulties or disabilities have often been problematic for mainstream schools. I’ve advocated making SEND training an integral part of ITT.  Teachers have raised objections:

  • SEND training isn’t necessary. Direct instruction and explicit rules work.
  • How can teachers be expected to provide individual tuition to each child?
  • How can teachers be expected to learn about all those different conditions?

Direct instruction and explicit rules work      Direct instruction and explicit rules can be very effective. Whether the same direct instruction and explicit rules are effective for all children is another matter. Advocates of direct instruction and explicit rules also have a tendency to question the policy of educational inclusion, and to complain about objections to exclusion. Although their complaints might be valid, there’s a fine line between ‘wanting to get on with teaching and avoid disruption for children who want to learn’, and making problem children somebody else’s problem.

How can teachers be expected to provide individual tuition to each child? They used to be expected to do this, before the education system became standardised and performance-driven. Basically, if you are teaching a very varied child population, you can have high performance if you shuffle off the more challenging pupils elsewhere. Or you can have well-educated pupils who might still not meet a narrow performance measure.  You can’t have properly differentiated tuition and high performance based on a narrow measure.

How can teachers be expected to understand all those different conditions?   They don’t need to. Whatever a child’s diagnosis, for children with SEN in mainstream schools, teachers need to know about a handful of challenges (parents are usually a good source of information too – note the ‘usually’):

  • Visual processing – does the child screw up their eyes or complain of headaches? Do they persistently misread letters/numbers or find it difficult to find a visual target?

Make appropriate modifications to material. (One child I taught couldn’t see letters or numbers in their right visual field. Shifting everything to the left was effective). Avoid classroom clutter. Get their visual functioning checked; most local authorities have an educational sensory impairment service.

  • Auditory processing – does the child ‘zone out’ when you’re talking to them, or lose track of what they are saying to you? Do they confuse particular phonemes? Do they put their hands over their ears?

Speak slowly and clearly. Give them time to respond. Get some Jolly Phonics materials for visual/kinaesthetic reinforcement (and no, I’m not talking about Learning Styles). Keep the classroom quiet. Get their auditory processing checked; speech & language therapists can help.

  • Attention/executive function – Are they easily distracted? Is it difficult to get them to switch attention between topics? Or both? Do they find it hard to remember instructions?

Sit the kid at the side/back of the room. Give verbal and/or visual cues to signal the need to switch topic. Back up verbal instructions with written ones.

  • Motor control – is the child clumsy? A chair-rocker? Poor handwriting?

Do lots of physical activities that don’t involve fine motor control. Lots of exercise involving balance and using both sides of the body simultaneously. Get an occupational therapist to advise.

  • Anxiety and unwanted behaviour – if the child is anxious or behaving in a way that’s causing problems, there is very likely to be a reason for it.

Win the child’s trust. Get them to talk – sometimes it’s best to start with what they’re interested in rather than confronting the problem head on. Find out what’s going on and find ways to fix problems together. Compromise is powerful.  Sometimes all that’s required is knowing that a teacher is really on their side.

Some teachers will argue that they can’t implement any of these suggestions because they don’t have time or can’t get access to external support services. Or that the problems are intractable and outside their control. Those things might be true, but they don’t negate the Root Cause model’s effectiveness. They do indicate that public sector services have a long way to go.

 

 

 

can’t help it, root causes and strict discipline: part 2

The second of two posts analysing Old Andrew’s view of the behaviour of children with special educational needs.

special educational needs

In the Can’t Help It model that Old Andrew satirises in Charlie and the Inclusive Chocolate Factory, special educational needs (SEN) are conflated with disability. The child is seen as “ill with ADHD” or “on the autistic spectrum”. And we’ve all seen discussions about whether children ‘really have SEN’. According to one newspaper a 2010 Ofsted report claimed that “many of these pupils did not actually suffer from any physical, emotional or educational problems”.

The SEND Code of Practice defines special educational needs in terms of the “facilities of a kind generally provided for others of the same age in mainstream schools or mainstream post-16 institutions” (p.14). In other words, the definition of SEN is a piece of string. If the facilities generally provided are brilliant, there will be hardly any children with SEN. If they are generally inadequate, there will be many children with SEN.

special educational needs and disability

Another post referred to by Old Andrew is The Blameless Part 3: the Afflicted.   He again pillories Can’t Help It as assuming “if a child is behaving badly in a lesson they must secretly be unable to do the work, and that the most likely reason a child might be unable to keep up with their peers is some form of disability or illness”.

Andrew asks why “a child unable to do their school work would misbehave rather than simply say they couldn’t do it”, completely overlooking communication difficulties ranging from children physically not being able to put the words together if under stress, to feeling intense apprehension about the consequences of drawing the problem to the teacher’s attention in public, such as jeers from peers or the teacher saying ‘you can do it you’re just not trying’ (I’ve lost count of the number of times I’ve heard that statement masquerading as ‘high expectations’).

The second charge Andrew levels at Can’t Help It is the assumption that “medical or psychological conditions directly cause involuntary incidents of poor behaviour.” Leaving aside the question of who decides what constitutes poor behaviour, Andrew draws attention to the circular reasoning that Can’t Help It entails. If a medical or psychological condition is defined in terms of behaviour, then the behaviour must be explained in terms of a medical or psychological condition.

That’s a fair criticism, but it doesn’t mean there are no medical or psychological conditions involved. Old Andrew goes on to question the existence of ‘proprioception disorder’, linking it, bizarrely, to a Ship of Fools definition of purgatory. Impaired proprioception is well established scientifically. A plausible mechanism is the variation in function of the different kinds of sensory receptor in the skin and muscles. (The best description of it I’ve found is in the late great Donna Williams’ book Nobody Nowhere.) Whether Andrew has heard of ‘proprioception disorder’ or whether or not it’s formally listed as a medical disorder, is irrelevant to whether or not variations in proprioceptive function are causal factors in children’s behaviour.

It’s the Can’t Help It model that has led, in Andrew’s opinion, to a “Special Needs racket”. I’d call it a mess rather than a racket, but a mess it certainly is.  And it’s not just about children who don’t have ‘genuine disabilities’.  Mainstream teachers are expected to teach 98% of the school population but most are trained to teach only the 70% in the middle range. If teachers don’t have the relevant expertise to teach the 15% or so of children whose performance, for whatever reason, is likely to be more than one standard deviation below average, it’s hardly surprising that they label those children as having special educational needs and expect local authorities to step in with additional resources.

children as moral agents

Old Andrew questions an assumption he thinks is implicit in Can’t Help It – that the child is ‘naturally good’. I think he’s right to question it, not because children are or are not naturally good, but because morality is only tangentially relevant to what kinds of behaviours teachers want or don’t want in their classrooms, and completely irrelevant to whether or not children can meet those expectations. The good/bad behavioural continuum is essentially a moral one, and thus open to debate.

The third post Old Andrew linked to was Needs.  He suggests that framing behaviour in terms of needs “absolves people of responsibility for their actions”. He points out the difficulty of determining what children’s needs are and how to meet them, and goes on to consider an ‘extreme example’ of a school discovering that many of its pupils were starving. If the school feels it has a moral duty to the children, it would feed all those who were starving. But if the school attributes bad behaviour to going without food, it would “cease looking for the most famished child to feed first and start feeding the worst behaved… We would be rewarding the worst behaved child with something they wanted”.  Andrew concludes “Imagine how more contentious other types of “help” (like extra attention, free holidays, help in lessons or immunity from punishment) might be”… Whenever we view human beings as something other than moral agents we are likely to end up advocating solutions which are in conflict with both our consciences and our knowledge of the human mind”.

Andrew has raised some valid points about how we figure out what needs are, how they are best met, and about the Can’t Help It model. But his alternative is to frame behaviour in terms of a simplistic behaviourist model (reward and punishment), and human beings as moral agents with consciences and minds. In short, his critique, and the alternative he posits, are based on his beliefs. He’s entitled to hold those beliefs, of course, but they don’t necessarily form an adequate framework for determining what behaviour schools want, what behaviour is most beneficial to most children in the short and long term, or how schools should best address the behaviour of children with special educational needs (as legally defined).

Andrew seems to view children as moral agents who can control their behaviour regardless of what disability they might have. The moral agents aspect of his model rests on unsupported assumptions about human nature. The behavioural control aspect is called into question by research indicating that the frontal lobes of the brain don’t fully mature until the early 20s.  Moral agency and behavioural control in young people is a controversial topic.

conclusion

The Can’t Help It model is obviously flawed and the Strict Discipline model rests on questionable assumptions. The Root Cause model, in contrast, recognises that preventing unwanted behaviours might require an analysis of the behaviour expected of children, and the reasons children aren’t meeting those expectations. It’s an evidence-based model. It doesn’t rest on beliefs or absolve children of all responsibility. It can identify environmental factors that contribute to unwanted behaviour, and can provide children with strategies that increase their ability to control what they do.  To me, it looks like the only model that’s likely to be effective.

can’t help it, root causes and strict discipline: part 1

This week Old Andrew, renowned education blogger, has drawn attention to some of his old posts about children with special educational needs. He identifies two conceptual models that focus on children’s behaviour – and overlooks a third.  In this post, I describe the models and why teachers might adopt one and not the others.

the model muddle

In Charlie and the Inclusive Chocolate Factory Andrew satirises a particular conceptual model of children’s behaviour. I’ll call  the model Can’t Help It. This view is that children identified as having special educational needs, or those from deprived backgrounds, are not responsible for behaving in ways that are unwanted by those around them. The Can’t Help It model is the one that claims criminals abused or neglected in childhood can’t be held responsible for breaking the law. I don’t doubt it’s a view held by some people, and I can understand the temptation to satirise it. It’s flawed because almost everyone could identify some adverse experience in childhood that explains why they behave in ways that distress others.

But satirising Can’t Help It is risky, because of its similarity to another conceptual model, which I’ll call Root Cause. The two models have similar surface features, but a fundamentally different deep structure. The Root Cause model claims that all behaviour has causes and if we want to prevent unwanted behaviour we have to address the causes. If we don’t do that the behaviour is likely to persist. (Ignoring causal factors is a frequent cause of re-offending; prisoners are often released into a community that prompted them to engage in criminal behaviour in the first place).

I’ve never encountered Can’t Help It as such. What I have encountered frequently is something of a hybrid between Can’t Help It and Root Cause. People are aware that there might be causes for unwanted behaviour and that those causes should be addressed, but  have no idea what the causes are or how to deal with them.

If the TES Forum is anything to go by, this is often true for teachers in mainstream schools who’ve had no special educational needs or disability training. They don’t want to apply the usual a reward/punishment approach in the case of a kid with a diagnosis of ADHD or autism, because they know it might be ineffective or make the problem worse. But they know next to nothing about ADHD or autism, so haven’t a clue how to proceed. In some cases the school appears to have just left the teacher to get on with it and is hoping for the best. Teachers in this position can’t apply Root Cause because they don’t know how, so tend to default to either Can’t Help It or to a third model I’ll call Strict Discipline.

Strict Discipline has a long history, dating back at least to Old Testament times. It also has a long history of backfiring. Children have a strong sense of fairness and will resent punishments they see as unfair or disproportionate. The resentment can last a lifetime. A Strict Discipline approach needs a robust evidential framework it’s going to be effective in both the short and long term. In Charlie and the Inclusive Chocolate Factory, Old Andrew rightly eschews Can’t Help It and appears to opt for Strict Discipline, bypassing Root Cause entirely; he describes Charlie, despite “eating nothing but bread and cabbage for six months” as “polite and well-behaved”.

Good behaviour

This evaluation of Charlie’s behaviour begs the question of what constitutes ‘well-behaved’. Teachers who identify as ‘traditional’ often refer to ‘good’ and ‘bad’ behaviour as if both are self-evident. Inevitably, behaviour isn’t that simple. ‘Traditional’ teachers appear to see behaviour on a linear continuum. At one pole is strict adherence to social norms – whatever they are deemed to be in a particular environment. At the other is complete license, assumed to result in extreme anti-social activities.

The flaws of this behaviour continuum are immediately apparent because it’s based on assumptions. The norms set by a particular teacher or school are assumed to be reasonable and attainable by all children. Those are big assumptions, as shown by the variation in different schools’ expectations and in the behaviour of children.

Even very young children are aware of different behavioural expectations. What’s allowed in Miss Green’s class isn’t tolerated in Mr Brown’s. They can do things in their grandparents’ home that their parents wouldn’t like, and that would be completely unacceptable in school. That doesn’t make Mr Brown’s expectations or those of the school right, and everybody else wrong. We all have to behave in different ways in different environments. Most children intuitively pick up and respond appropriately to these variations in expectations, but some don’t. By definition autistic children struggle to make sense of what they are expected to do, and children with attentional deficits get distracted from the task in hand.

It doesn’t follow that children with autism or ADHD should be permitted to behave how they like, nor have all their ‘whims’ catered for. Nor does it follow that every child should be expected to behave in exactly the same way. What it does mean is that if a child exhibits behaviour that’s problematic for others, the causes of the problematic behaviour should be identified and appropriate action taken. In some cases, schools and teachers do not appear to know what that appropriate action should be.

In the next post I’ll look at the flaws in the Strict Discipline model in relation to children with special educational needs.

magic beans, magic bullets and crypto-pathologies

In the previous post, I took issue with a TES article that opened with fidget-spinners and closed with describing dyslexia and ADHD as ‘crypto-pathologies’. Presumably as an analogy with cryptozoology – the study of animals that exist only in folklore. But dyslexia and ADHD are not the equivalent of bigfoot and unicorns.

To understand why, you have to unpack what’s involved in diagnosis.

diagnosis, diagnosis, diagnosis

Accurate diagnosis of health problems has always been a challenge because:

  • Some disorders* are difficult to diagnose. A broken femur, Bell’s palsy or measles are easier to figure out than hypothyroidism, inflammatory bowel disease or Alzheimer’s.
  • It’s often not clear what’s causing the disorder. Fortunately, you don’t have to know the immediate or root causes for successful treatment to be possible. Doctors have made the reasonable assumption that patients presenting with the same signs and symptoms§ are likely to have the same disorder.

Unfortunately, listing the signs and symptoms isn’t foolproof because;

  • some disorders produce different signs and symptoms in different patients
  • different disorders can have very similar signs and symptoms.

some of these disorders are not like the others…

To complicate the picture even further, some signs and symptoms are qualitatively different from the aches, pains, rashes or lumps that indicate disorders obviously located in the body;  they involve thoughts, feelings and behaviours instead. Traditionally, human beings have been assumed to consist of a physical body and non-physical parts such as mind and spirit, which is why disorders of thoughts, feelings and behaviours were originally – and still are – described as mental disorders.

Doctors have always been aware that mind can affect body and vice versa. They’ve also long known that brain damage and disease can affect thoughts, feelings, behaviours and physical health. In the early 19th century, mental disorders were usually identified by key symptoms. The problem was that the symptoms of different disorders often overlapped. A German psychiatrist, Emil Kraepelin, proposed instead classifying mental disorders according to syndromes, or patterns of co-occurring signs and symptoms. Kraepelin hoped this approach would pave the way for finding the biological causes of disorders. (In 1906, Alois Alzheimer found the plaques that caused the dementia named after him, while he was working in Kraepelin’s lab.)

Kraepelin’s approach laid the foundations for two widely used modern classification systems for mental disorders; the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, currently in its 5th edition (DSM V), and the International Classification of Diseases Classification of Mental and Behavioural Disorders published by the World Health Organisation, currently in its 10th edition (ICD-10).

Kraepelin’s hopes for his classification system have yet to be realised. That’s mainly because the brain is a difficult organ to study. You can’t poke around in it without putting your patient at risk. It’s only in the last few decades that scanning techniques have enabled researchers to look more closely at the structure and function of the brain, and the scans require interpretation –  brain imaging is still in its infancy.

you say medical, I say experiential

Kraepelin’s assumptions about distinctive patterns of signs and symptoms, and about their biological origins, were reasonable ones. His ideas, however, were almost the polar opposite to those of his famous contemporary, Sigmund Freud, who located the root causes of mental disorders in childhood experience. The debate has raged ever since. The dispute is due to the plasticity of the brain.  Brains change in structure and function over time and several factors contribute to the changes;

  • genes – determine underlying structure and function
  • physical environment e.g. biochemistry, nutrients, toxins – affects structure and function
  • experience – the brain processes information, and information changes the brain’s physical structure and biochemical function.

On one side of the debate is the medical model; in essence, it assumes that the causes of mental disorders are primarily biological, often due to a ‘chemical imbalance’. There’s evidence to support this view; medication can improve a patient’s symptoms. The problem with the medical model is that it tends to assume;

  • a ‘norm’ for human thought, feelings and behaviours – disorders are seen as departures from that norm
  • the cause of mental disorders is biochemical and the chemical ‘imbalance’ is identified (or not) through trial-and-error – errors can be catastrophic for the patient.
  • the cause is located in the individual.

On the other side of the debate is what I’ll call the experiential model (often referred to as anti-psychiatry or critical psychiatry). In essence it assumes the causes of unwanted thoughts, feelings or behaviours are primarily experiential, often due to adverse experiences in childhood. The problem with that model is that it tends to assume;

  • the root causes are experiential and not biochemical
  • the causes are due to the individual’s response to adverse experiences
  • first-hand reports of early adverse experiences are always reliable, which they’re not.

labels

Kraepelin’s classification system wasn’t definitive – it couldn’t be, because no one knew what was causing the disorders. But it offered the best chance of identifying distinct mental health problems – and thence their causes and treatments. The disorders identified in Kraepelin’s system, the DSM and ICD, were – and most still are – merely labels given to clusters of co-occurring signs and symptoms.  People showing a particular cluster are likely to share the same underlying biological causes, but that doesn’t mean they do share the same underlying causes or that the origin of the disorder is biological.

This is especially true for signs and symptoms that could have many causes. There could be any number of reasons for someone hallucinating, withdrawing, feeling depressed or anxious – or having difficulty learning to read or maintain attention.  They might not have a medical ‘disorder’ as such. But you wouldn’t know that to read through the disorders listed in the DSM or ICD. They all look like bona fide, well-established medical conditions, not like labels for bunches of symptoms that sometimes co-occur and sometimes don’t, and that have a tendency to appear or disappear with each new edition of the classification system.  That brings us to the so-called ‘crypto-pathologies’ referred to in the TES article.

Originally, terms like dyslexia were convenient and legitimate shorthand labels for specific clusters of signs or symptoms. Dyslexia means difficulty with reading, as distinct from alexia which means not being able to read at all; both problems can result from stroke or brain damage. Similarly, autism was originally a shorthand term for the withdrawn state that was one of the signs of schizophrenia – itself a label.  Delusional parasitosis is also a descriptive label (the parasites being what’s delusional, not the itching).

reification

What’s happened over time is that many of these labels have become reified – they’ve transformed from mere labels into disorders widely perceived as having an existence independent of the label. Note that I’m not saying the signs and symptoms don’t exist. There are definitely children who struggle with reading regardless of how they’ve been taught; with social interaction regardless of how they’ve been brought up; and with maintaining focus regardless of their environment. What I am saying is that there might be different causes, or multiple causes, for clusters of very similar signs and symptoms.  Similar signs and symptoms don’t mean that everybody manifesting those signs and symptoms has the same underlying medical disorder –  or even that they have a medical disorder at all.

The reification of labels has caused havoc for decades with research. If you’ve got a bunch of children with different causes for their problems with reading, but you don’t know what the different causes are so you lump all the children together according to their DSM label; or another bunch with different causes for their problems with social interaction but lump them all together; or a third bunch with different causes for their problems maintaining focus, but you lump them all together; you are not likely to find common causes in each group for the signs and symptoms.  It’s this failure to find distinctive features at the group level that has been largely responsible for claims that dyslexia, autism or ADHD ‘don’t exist’, or that treatments that have evidently worked for some individuals must be spurious because they don’t work for other individuals or for the heterogeneous group as a whole.

crypto-pathologies

Oddly, in his TES article, Tom refers to autism as an ‘identifiable condition’ but to dyslexia and ADHD as ‘crypto-pathologies’ even though the diagnostic status of autism in the DSM and ICD is on a par with that of ADHD, and with ‘specific learning disorder with impairment in reading‘ with dyslexia recognised as an alternative term (DSM), or ‘dyslexia and alexia‘ (ICD).  Delusional parasitosis, despite having the same diagnostic status and a plausible biological mechanism for its existence, is dismissed as ‘a condition that never was’.

Tom is entitled to take a view on diagnosis, obviously. He’s right to point out that reading difficulties can be due to lack of robust instruction, and inattention can be due to the absence of clear routines. He’s right to dismiss faddish simplistic (but often costly) remedies. But the research is clear that children can have difficulties with reading due to auditory and/or visual processing impairments (search Google scholar for ‘dyslexia visual auditory’), that they can have difficulties maintaining attention due to low dopamine levels – exactly what Ritalin addresses (Iversen, 2006), or that they can experience intolerable itching that feels as if it’s caused by parasites.

But Tom doesn’t refer to the research, and despite provisos such as acknowledging that some children suffer from ‘real and grave difficulties’ he effectively dismisses some of those difficulties as crypto-pathologies and implies they can be fixed by robust teaching and clear routines  –  or that they are just imaginary.  There’s a real risk, if the research is by-passed, of ‘robust teaching’ and ‘clear routines’ becoming the magic bullets and magic beans he rightly despises.

Notes

*Disorder implies a departure from the norm.  At one time, it was assumed the norm for each species was an optimal set of characteristics.  Now, the norm is statistically derived, based on 95% of the population.

§ Technically, symptoms are indicators of a disorder experienced only by the patient and signs are detectable by others.  ‘Symptoms’ is often used to include both.

Reference

Iversen, L (2006).  Speed, Ecstasy, Ritalin: The science of amphetamines.  Oxford University Press.

white knights and imaginary dragons: Tom Bennett on fidget-spinners

I’ve crossed swords – or more accurately, keyboards – with Tom Bennett, the government’s behaviour guru tsar adviser, a few times, mainly about learning styles. And about Ken Robinson. Ironic really, because broadly speaking we’re in agreement. Ken Robinson’s ideas about education are woolly and often appear to be based on opinion rather than evidence, and there’s clear evidence that teachers who use learning styles, thinking hats and brain gym probably are wasting their time. Synthetic phonics helps children read and whole school behaviour policies are essential for an effective school and so on…

My beef with Tom has been his tendency to push his conclusions further than the evidence warrants. Ken Robinson is ‘the butcher given a ticker tape parade by the National Union of Pigs‘.  Learning Styles are ‘the ouija board of serious educational research‘.  What raised red flags for me this time is a recent TES article by Tom prompted by the latest school-toy fad ‘fidget-spinners’.

fidget-spinners

Tom begins with claims that fidget-spinners can help children concentrate. He says “I await the peer-reviewed papers from the University of Mickey Mouse confirming these claims“, assuming that he knows what the evidence will be before he’s even seen it.  He then introduces the idea that ‘such things’ as fidget-spinners might help children with an ‘identifiable condition such as autism or sensory difficulties’, and goes on to cite comments from several experts about fidget-spinners in particular and sensory toys in general. We’re told “…if children habitually fidget, the correct path is for the teacher to help the child to learn better behaviour habits, unless you’ve worked with the SENCO and the family to agree on their use. The alternative is to enable and deepen the unhelpful behaviour. Our job is to support children in becoming independent, not cripple them with their own ticks [sic]”.

If a child’s fidgeting is problematic, I completely agree that a teacher’s first course of action should be to help them stop fidgeting, although Tom offers no advice about how to do this. I’d also agree that the first course of action in helping a fidgety child shouldn’t be to give them a fidget-toy.

There’s no question that children who just can’t seem to sit still, keep their hands still, or who incessantly chew their sleeves, are seeking sensory stimulation, because that’s what those activities are – by definition. It doesn’t follow that allowing children to walk about, or use fidget or chew toys will ‘cripple them with their own ticks’. These behaviours are not tics, and usually extinguish spontaneously over time. If they’re causing disruption in the classroom, questions need to be asked about school expectations and the suitability of the school provision for the child, not about learning unspecified ‘better behaviour habits’.

mouthwash

Tom then devotes an entire paragraph to, bizarrely, Listerine. His thesis is that sales of antiseptic mouthwash soared due to an advertising campaign persuading Americans that halitosis was a serious social problem. His evidence is a blogpost by Sarah Zhang, a science journalist.  Sarah’s focus is advertising that essentially invented problems to be cured by mouthwash or soap. Neither she nor Tom mention the pre-existing obsession with cleanliness that arose from the discovery – prior to the discovery of antibiotics – that a primary cause of death and debility was bacterial infections that could be significantly reduced by the use of alcohol rubs, boiling and soap.

itchy and scratchy

The Listerine advertising campaign leads Tom to consider ‘fake or misunderstood illnesses’ that he describes as ‘charlatan’. His examples are delusional parasitosis (people believe their skin is itching because it’s infested with parasites) and Morgellon’s (belief that the itching is caused by fibres). Tom says “But there are no fibres or parasites. It’s an entirely psycho-somatic condition. Pseudo sufferers turn up at their doctors scratching like mad, some even cutting themselves to dig out the imaginary threads and crypto-bugs. Some doctors even wearily prescribe placebos and creams that will relieve the “symptoms”. A condition that never was, dealt with by a cure that won’t work. Spread as much by belief as anything else, like fairies.”

Here, Tom is pushing the evidence way beyond its limits. The fact that the bugs or fibres are imaginary doesn’t mean the itching is imaginary. The skin contains several different types of tactile receptor that send information to various parts of the brain. The tactile sensory system is complex so there are several points at which a ‘malfunction’ could occur.  The fact that busy GPs – who for obvious reasons don’t have the time or resources to examine the functioning of a patient’s neural pathways at molecular level – wearily prescribe a placebo, says as much about the transmission of medical knowledge in the healthcare system as it does about patients’ beliefs.

crypto-pathologies

Tom refers to delusional parasitosis and Morgellon’s as ‘crypto-pathologies’ – whatever that means – and then introduces us to some crypto-pathologies he claims are encountered in school; dyslexia and ADHD. As he points out dyslexia and ADHD are indeed labels for ‘a collection of observed symptoms’. He’s right that some children with difficulty reading might simply need good reading tuition, and those with attention problems might simply need a good relationship with their teacher and clear routines. As he points out “…our diagnostic protocol is often blunt. Because we’re unsure what it is we’re diagnosing, and it becomes an ontological problem“.  He then says “This matters when we pump children with drugs like Ritalin to stun them still.

Again, some of Tom’s claims are correct but others are not warranted by the evidence. In the UK, Ritalin is usually prescribed by a paediatrician or psychiatrist after an extensive assessment of the child, and its effects should be carefully monitored. It’s a stimulant that increases available levels of dopamine and norepinephrine and it often enhances the ability to concentrate. It isn’t ‘pumped into’ children and it doesn’t ‘stun them still’, In the UK at least, NICE guidelines indicate it should be used as a last resort. The fact that its use has doubled in the last decade is a worrying trend. This is more likely to be due to the crisis in child and adolescent mental health services, than to an assumption that all attention problems in children are caused by a supposed medical condition we call ADHD.

Tom, rightly, targets bullshit. He says it matters because “many children suffer from very real and very grave difficulties, and it behoves us as their academic and social guardians to offer support and remedy when we can”. Understandably he wants to drive his point home. But superficial analysis and use of hyperbole risk real and grave difficulties being marginalised at best and ridiculed at worst by teachers who don’t have the time/energy/inclination to check out the detail of what he claims.

Specialist education, health and care services for children have been in dire straits for many years and the situation isn’t getting any better. This means teachers are likely to have little information about the underlying causes of children’s difficulties in school. If teachers take what Tom says at face value, there’s a real risk that children with real difficulties, whether they need to move their fingers or chew in order to concentrate, experience unbearable itching, struggle to read because of auditory, visual or working memory impairments, or have levels of dopamine that prevent them from concentrating, will be seen by some as having ‘crypto-conditions’ that can be resolved by good teaching and clear routines. If they’re not resolved, then the condition must be ‘psycho-somatic’.  Using evidence to make some points, but ignoring it to make others means the slings and arrows Tom hurls at the snake-oil salesmen and white knights galloping to save us from imaginary dragons are quite likely to be used as ammunition against the very children he seeks to help.

behavioural optometry: pros and cons

MUSEC is Macquarie University’s Special Educational Centre. Since 2005 it has been issuing one-page briefings on various topics relevant to special education; a brilliant idea and very useful for busy teachers. One of the drawbacks of a one-page briefing is that if the topic is a complex one, there might be space for a simple explanation and a couple of references only. The briefings get round that problem, in part, by putting relevant references on a central website.  One of their briefings is about behavioural optometry.

Behavioural optometry is based on the assumption that some behavioural issues (in the broadest sense) are due to problems with the way the eyes function. This could include anything from poor convergence (eyes don’t focus together) to variations in processing visual information in different coloured lights. The theory is a plausible one; visual dysfunction can cause considerable discomfort and can affect balance and co-ordination, for example.

Behavioural optometrists are sometimes consulted if children have problems with reading, because reading requires fine-grained visual (and auditory) discrimination, and even small variations in the development of the visual system can cause problems for young children. One of the reasons systematic synthetic phonics programmes are so effective in helping young children learn to decode text is because they train children in making fine-grained distinctions between graphemes (and between phonemes). But phonics programmes cannot address all visual (or auditory) processing anomalies, which is the point where behavioural optometrists often come in.

The MUSEC briefing on behavioural optometry (Issue 33) draws on two references; a 2011 report by the American Academy of Paediatrics (AAP), and a 2009 review paper by Brendan Barrett, a professor of visual development at Bradford University.  Aspects of the briefing perplexed me.  I felt it didn’t accurately reflect the conclusions of the two references because it:

  • doesn’t discriminate between treatments
  • overlooks the expertise of behavioural optometrists
  • equates lack of evidence for efficacy with inefficacy
  • assumes that what is true for a large population must be true for individuals
  • gives misleading advice to readers.

Discrimination between treatments

In its second paragraph the briefing lists three types of treatment used by behavioural optometrists; lenses and prisms, coloured lenses or overlays, and vision therapy. But from paragraph four onwards, no distinction is made between treatments – they are all referred to as ‘behavioural optometry’ and evidence (for all behavioural optometry treatments presumably) is said to be ‘singularly lacking’. Since lenses and prisms are used in what Barrett calls traditional optometry (p.5), this generalization is self-evidently inaccurate. Nor does it reflect Barrett’s conclusions. Although he highlights the scarcity of evidence and lack of support for some treatments, he also refers to treatments developed by behavioural optometrists being adopted in mainstream practice, and to evidence that supports claims involving convergence insufficiency, yoked prisms, and vision rehabilitation after brain disease/injury.

Expertise of behavioural optometrists

The briefing also appears to overlook the fact that behavioural optometrists are actually optometrists – a protected title, in the UK at least. As such, they are qualified to make independent professional judgments about the treatment of their patients. As Barrett points out, some of the controversies over treatments involve complex theoretical and technical issues; behavioural optometry isn’t the equivalent of Brain Gym. But teachers are unlikely to know that if they only read the briefing and not the references.

Lack of evidence for efficacy

Both references cited by the MUSEC briefing are reviews commissioned by professional bodies. Clearly, the American Academy of Pediatrics, the College of Optometrists or MUSEC cannot endorse or advocate treatments for which there is little or no evidence of efficacy. But individual practitioners are not issuing policy statements, they are treating individual patients. If they are using treatments for which a robust evidence base is lacking, that’s unsatisfactory, but a weak evidence base doesn’t mean that there is no evidence for efficacy, nor that the treatments in question are ineffective. Setting up RCTs of treatments for complex issues like ‘learning difficulties’ is challenging, expensive and time-consuming. As a parent, I would far rather my child try treatments that had a weak evidence base but were recommended by experienced practitioners, than wait for the Cochrane reviewers to finish a task that could take decades.

Populations vs individuals

The briefing paper says that “there is clear consensus among reading scientists that visual perception difficulties are rarely critical in reading difficulties and that the problem is typically more to do with language, specifically phonological processing.

Although this statement is right about the consensus and the role of phonological processing, one can’t assume that what’s true at a population level is true for every individual. Take, for example, convergence insufficiency (one of the areas where Barrett found evidence to support behavioural optometrists’ claims). According to the AAP report, the prevalence of convergence insufficiency is somewhere between 0.3% and 5% of the population (p.832).   So the probability of any given child having convergence insufficiency is low, but in the UK it still could affect up to 500,000 children. Although the report found no evidence that convergence insufficiency causes problems with decoding, comprehension or school achievement, it points out that it ‘can interfere with the ability to concentrate on print for a prolonged period of time’.   So even though in theory convergence insufficiency could be contributing to the difficulties of a quarter of the UK’s reluctant readers, it isn’t screened for in standard eye tests.

Advice to readers

The briefing recommends visual assessment for problems with acuity and refractive or ‘similar’ problems, but that’s not what the AAP recommends. It says:

Children with suspected learning disabilities in whom a vision problem is suspected by the child, parents, physicians, or educators should be seen by an ophthalmologist who has experience with the assessment and treatment of children, because some of these children may also have a treatable visual problem that accompanies or contributes to their primary reading or learning dysfunction.” (p. 829)

In the UK, that would require considerable persistence on the part of the child, parent or educator, although physicians might have more success.

The briefing also suggests an alternative to behavioural optometry; ‘explicit instruction in the specific areas causing difficulty’. Quite how ‘explicit instruction’ would improve problems with eye tracking, visual processing speed, visual sequential memory, visual discrimination, visual motor integration, visual spatial skills and rapid naming, never mind attention or dyspraxia where the difficulty is often discovered because the child is unable to carry out explicit instructions, is unclear.

Conclusion

I’m not claiming that behavioural optometry ‘does help children with reading difficulties’ because I don’t know whether it does or not. But that appears to be the nub of the problem – in the absence of evidence nobody knows whether it does or not. Nor which treatments help, if any. As the AAP paper says “Although it is prudent to be skeptical, especially with regard to prematurely disseminated therapies, it is important to also remain openminded.” (p.836)

I also had problems with the MUSEC briefing’s reading of Barrett’s conclusions. Although I wouldn’t go so far as to say the briefing is wrong (except perhaps about the lenses, and I’m not sure what it means by ‘explicit instruction’), its take-home message, for me, was that behavioural optometrists lack competence, that visual problems are unlikely to play any part in developmental abnormalities, and that if there are visual problems they will be limited to acuity and refractive or ‘similar’ factors. That’s not the message I got from either of the papers cited by the briefing. Obviously, on one side of A4, the authors couldn’t have covered all the relevant issues, but I felt that what they included and omitted could give the wrong impression to anyone unfamiliar with the issues.

References

American Academy of Pediatrics (2011). Joint technical report – Learning disabilities, dyslexia, and vision. Pediatrics, 127, e818-e856.

Barrett, B.T. (2009). A critical evaluation of the evidence supporting the practice of behavioural vision therapy. Ophthalmic and Physiological Optics, 29, 4-25.