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.

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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.