Speech, language and communication needs and mental health: the experiences of speech and language therapists and mental health professionals

Abstract

Background

While the relationship between speech, language and communication needs (SLCN) and mental health difficulties has been recognized, speech and language therapists (SLTs), and mental health professionals face challenges in assessing and treating children with these co‐occurring needs. There exists a gap in the evidence base for best practice for professionals working with children and young people (CYP) who experience difficulties in both areas.

Aims

To explore the views of SLTs and mental health clinicians about their experiences of working with CYP exhibiting co‐occurring SLCN and mental health difficulties.

Methods & Procedures

Semi‐structured interviews were conducted with eight SLTs and six mental health professionals, including psychotherapists, clinical psychologists, play therapists and counsellors, with experience working with CYP with SLCN. Interviews were analysed using reflexive thematic analysis and themes were identified from the data.

Outcomes & Results

Participants felt that SLCN and mental health difficulties frequently co‐occur. Participants described how CYP with SLCN and mental health issues commonly experience difficulties across and between the domains of language and cognition, emotional well‐being and challenging behaviour. Findings suggest that there are organizational limitations in the fields of SLT and mental health that have implications for the efficacy of assessment and treatment of CYP with SLCN and mental health difficulties. Traditional talking therapies were perceived to be inaccessible and ineffective for CYP with SLCN and mental health difficulties. Interventions blending behaviour and emotion programmes with language and communication interventions were considered potentially beneficial.

Conclusions & Implications

Future research should explore and evaluate current services and service set‐up in SLT and mental health. The findings from this study have important implications for the efficacy of treatments provided to this population suggesting that more research needs to be done into effective diagnosis and interventions for this population.

WHAT THIS PAPER ADDS

What is already known on the subject

• Research suggests that CYP with SLCN, such as developmental language disorder (DLD), are likely to experience mental health difficulties including depression, anxiety and poor emotional well‐being. CYP who experience difficulties with SLCN and poor mental health are not well understood and this area remains under‐researched. This has implications for clinician knowledge and therefore the effective diagnosis and treatment of children and adolescents experiencing SLCN and mental health difficulties. In addition, little is known about the accessibility of talking therapies to CYP presenting with SLCN and mental health difficulties.

What this paper adds to existing knowledge

• SLCN issues are understood by SLTs and mental health issues are understood by mental health professionals, but where these co‐occur difficulties exist for the diagnostic process, with professionals perceiving that CYP in this category are often undiagnosed or misdiagnosed. Organizational boundaries between SLT and mental health were perceived to contribute to a lack of understanding of SLCN and mental health needs, which has implications for effective diagnosis and treatment. Traditional talking therapies were thought to be inaccessible for CYP with SLCN and mental health difficulties. Interventions used in both SLT and psychotherapy were perceived as clinically useful if combined.

What are the potential or actual clinical implications of this work?

• This paper highlights implications for the accessibility and efficacy of the assessment and treatment provided to this population and to the organization of services currently treating this group of CYP. A direction for future research would be to undertake service evaluations and intervention‐based studies.

INTRODUCTION

The relationship between speech, language and communication needs (SLCN) and mental health is interwoven and highly complex and often poses real problems for speech and language therapists (SLTs) and mental health professionals to understand, diagnose and treat. SLCN is a broad category that covers a wide range of conditions affecting speech, language and communication (Bishop et al., 2017). For simplicity and consistency, the term ‘mental health’ or ‘mental health difficulties’ will be used to refer to children and young people (CYP) with social–emotional and mental health needs, anxiety and depression.

The aim of this study was to explore the views of SLTs and mental health clinicians about their experiences of working with CYP with SLCN and mental health difficulties and, if identified by participants, to explore issues around language and social communication disorders. We begin by first reviewing the existing evidence on the links between language, communication and mental health.

Language, social communication and mental health

There is extensive evidence that language and communication problems co‐occur with mental health problems, although the mechanisms behind this relationship remain unclear. Poor language skills are common in CYP with emotional–behavioural disorders. A 2014 systematic review reported that four out of five children with emotional–behavioural disorders had at least mild language difficulties that had not been previously identified (Hollo et al., 2014). Poor mental health can present as challenging behaviour, and is associated with disorders of social communication and language (Georgiades et al., 2010). In addition to externalizing problems, children with social communication difficulties (SCDs) are likely to experience anxiety (Moree & Davis, 2010). Cohen et al. (2013) and Wadman et al. (2011) reported that anxiety symptoms frequently occur in individuals with DLD in young adulthood. DLD can severely impact on mental health, and an increased risk for depressive symptoms has been consistently reported in this group. For example, clinical levels of depression range from 20% to 39% in children and adolescents with DLD compared with 14–18% in peers without DLD (Conti‐Ramsden & Botting, 2008). Difficulties with language and communication can affect daily living and extend across the lifespan to affect life outcomes. For instance, young offenders with language impairment are at a higher risk for mental health problems (Snow & Powell, 2004) and one of the biggest predictors of reoffending is unrecognized DLD (Winstanley et al., 2019).

It is possible that certain aspects of language and communication hold particular relevance for mental health. Van den Bedem et al. (2018) reported specifically more semantic problems in individuals with DLD and the contribution of this to the prediction of depressive symptoms. Children with pragmatic language difficulties also appear prone to emotional and psychosocial difficulties (Cohen et al., 2013). For example, in a community‐based longitudinal study, Sullivan et al. (2016) reported an association between poor pragmatic language in childhood and adolescent psychotic experiences, and that poor pragmatic language skills preceded early adolescent depression. Some children with pragmatic language impairments also show difficulties recognizing facial emotions (Merkenschlager et al., 2012), which may impact on their ability to respond appropriately to others and to form close relationships with those around them (Merkenschlager et al., 2012). Van den Bedem et al. (2018) suggested that children with social communication problems are more likely to adopt maladaptive emotional regulation strategies. These maladaptive strategies may contribute to the prediction of higher levels of depressive symptoms. Children with SLCN are also more likely to be the target of bullying and to experience emotional difficulties compared with their typically developing peers (Lloyd‐Esenkaya et al., 2021). SCDs are thought to predict social anxiety, and those who experience peer victimization are likely to present with SCDs (Pickard et al., 2018).

In clinical practice, those commonly diagnosed with SCDs and/or autism spectrum disorder (ASD) may also present with pragmatic problems. Research shows that CYP with ASD and SCDs meet the diagnostic criteria for co‐morbid diagnoses of depression and anxiety disorders (Hofvander et al., 2009). The prevalence of mental health disorders in ASD is high. For example, in an interview study of 54 young adults with Asperger syndrome, 70% reported experiencing one major episode of depression and 56% reported experiencing anxiety disorders (Lugnegard et al., 2011). Furthermore, children with SCDs as part of ASD experience attention and challenging behaviour disorders (Moree & Davis, 2010; Georgiades et al., 2010) and this may lead to poor mental health.

Another factor that may link language, communication and mental health is the role of emotions and the impact of language and communication upon emotional processes. The ability to effectively vocalize feelings and thoughts relies heavily upon robust language skills, especially in relation to gaining a sense of self‐expression, self‐control and emotional insight (Unsworth & Engle, 2007). Neuropsychological evidence also highlights that damage to classic language areas in the brain affects emotion processing. Computerised tomography (CT) scans of patients who had sustained a traumatic brain injury found that damage to the inferior frontal gyrus (i.e., Broca's area) was associated with increased alexithymia scores (difficulties identifying and describing one's own emotions) (Hobson et al., 2018). Similarly, communication problems of people who have had a stroke are associated with high alexithymia scores, even after accounting for depression and anxiety (Hobson et al., 2020). Such research has led to the proposal that the link between language and identifying emotions is intrinsic, and that language impairment could contribute to alexithymia and/or vice versa. This has been coined as the alexithymia language hypothesis (Hobson et al., 2020). While these studies reflect data from acquired language disorders (i.e., following traumatic brain injury or stroke), Hobson et al. (2020) suggests that individuals with developmental language problems are also likely to experience difficulties with alexithymia. Indeed, initial examinations of levels of alexithymia in DLD suggest that, at least according to children's parents, children with DLD have higher alexithymic traits and problems with recognizing and expressing their own emotions (Hobson & van den Bedem, 2021). If language problems lead to greater alexithymic traits, it would be expected that such emotional problems will increase the risk for mental health problems and impact on treatment.

Interventions for mental health and SLCN

There are clear links between language and communication problems and mental health, and plausible models for how these two domains interact. It is thus pertinent to ask: What can interventions do to help and are current interventions suitable for CYP with SLCN? The use of appropriately modified talking therapies for CYP with language and SCDs is lacking evidence. Nonetheless, deficits in speech, language and communication would be expected to negatively impact the effect of talking therapies as CYP with SLCN would have difficulties with understanding pragmatic and inferential language, understanding and using narrative language, and understanding and interpreting emotions. Furthermore, difficulties communicating abstract concepts in verbal and non‐verbal children have been identified as limiting factors to effectively access psychological therapies (Lang et al., 2010). Thus, social communication and language difficulties may reduce the accessibility and therefore efficacy of traditional talking therapies.

There appears little acknowledgement about the role of language and communication in modifications of talking therapies. The National Institute for Health and Care Excellence (NICE) guidelines for the use of psychosocial interventions with adults with ASD (NICE, 2013) recommend using plain English during therapy sessions and avoiding the use of metaphors. In addition, much of the research in this area has focused largely on the use of cognitive behavioural therapy (CBT) in children and adolescents and often with overt SLCN such as voice disorders, stammering and selective mutism (Bercow et al., 2016; Menzies et al., 2008). There is also a growing body of research on the use of adapted talking therapies for adults with SLCN. For instance, the Solution Focused Brief Therapy (SFBT) in Poststroke Aphasia SOFIA trial (Northcott et al., 2021) applied modified SFBT so that it was accessible to language‐impaired stoke survivors. There is no direct evidence for the use of adapted talking therapies in CYP with DLD or language impairments.

Without knowledge about the nature of the SLCN, suitable access to a talking therapy may be ineffective. For instance, individuals with ASD have more trouble understanding psychotherapy concepts than non‐autistic controls (Hall et al., 2015). Furthermore, differences in social communication may mean a lack of social chat, difficulties initiating and maintaining conversations and interpreting language literally, all of which would significantly impact upon effective accessibility to talking therapies (Bliss & Edmonds, 2008).

In summary, despite the evidence for a relationship between SLCN and mental health needs, there are considerable knowledge gaps in understanding the impact of SLCN on the efficacy and accessibility of treatments, and the role of SLCN in traditional talking therapies has been largely unexplored. Little is known about clinicians’ perspectives of SLCN and mental health difficulties. Therefore, to inform and build the evidence base, the current study explored the views and experiences of clinicians assessing and treating CYP with SLCN and mental health difficulties. The aim of the study was to explore clinicians’ experiences of working with CYP with SLCN and mental health difficulties. The study addressed the following research questions:

• With what difficulties do CYP with SLCN and mental health needs typically present?

• How do clinicians experience assessing and delivering therapies to CYP with SLCN and mental health difficulties?

• What treatments are thought to be clinically useful for CYP with SLCN and mental health difficulties?

METHOD

Research design

A qualitative research design using reflexive thematic analysis (TA) was chosen for this study in order to obtain a richness and depth to the data set that would appropriately answer the research questions. This approach facilitated an exploration of clinician experiences, observations and knowledge. A reflexive approach to TA was chosen due to the emphasis placed on the importance of the researcher's subjectivity as an analytic resource, and the reflexive engagement with theory, data and interpretation (Braun & Clarke, 2020). A reflexive approach is compatible with experiential qualitative research and was fundamental to the research questions. The approach adopted was an active and flexible process with the acknowledgement of theory. This process ensured a quality demonstrated in gold standard TA (Braun & Clarke, 2020). Interview questions were semi‐structured in nature; an interview guide and questions were constructed (see in the additional supporting information) and followed from a flexible and dynamic perspective. The questions were designed to be open‐ended to facilitate flow of conversation with the aim to build rapport and encourage participants to talk about issues pertinent to the research questions.

Participants and recruitment

This study received ethical approval from University College London (LCD‐2020‐10). This study involved 14 clinicians: eight SLTs and six mental health professionals (Table 1). Inclusion criteria were that participants should be qualified allied health professionals in the field of speech and language therapy or mental health. Participants had to have sufficient professional experience (at least one year post‐qualification) working with CYP. Participants were provided with an information sheet written in plain English regarding the research area, interview procedure and research aims. Informed consent was obtained before each interview and participants were given the opportunity to ask questions.

TABLE 1.

Participant characteristics

Participant	Gender	Profession	Specialism/client group	Postgraduate qualifications
1	Female	Speech and language therapist	Developmental language disorder and challenging behaviour	No
2	Female	Speech and language therapist	Deafness	No
3	Female	Speech and language therapist	Acute neurology, neurosurgery specializing in communication and dysphagia	No
4	Female	Speech and language therapist	Autism spectrum disorder	No
5	Female	Speech and language therapist	Youth justice team	No
6	Female	Speech and language therapist	Complex needs and early years preventative	No
7	Male	Speech and language therapist	Child adolescent mental health service (CAMHS)/mental health	No
8	Female	Speech and language therapist	Complex needs and behaviour support	Yes
9	Female	Play therapist	Mixed paediatric caseload specializing in attachment disorders	Yes
10	Female	Clinical psychologist	Learning disabilities and autism spectrum disorder	No
11	Female	Psychotherapist	School counselling: bereavement, anxiety, changes at home, social issues, challenging behaviour	Yes
12	Female	Counsellor	Anxiety, depression, ADHD concurrent with autism spectrum disorders, adjustment disorders, grief and loss	No
13	Female	Clinical psychologist	CAMHS/mental health	Yes
14	Female	Counsellor	School counselling: bereavement, anxiety, changes at home, social issues, challenging behaviour	Yes

Data collection

Interviews lasted for up to one hour and were conducted by the first author online via Microsoft Teams video conferencing software. Video‐audio data were collected. Online interviews were chosen for participant convenience and to ensure that the research could take place despite COVID‐19 pandemic restrictions. Each interview was recorded and transcribed verbatim by the first author and field notes were taken. Personally identifying information such as names and places of work were not transcribed to ensure participant anonymity. Video recordings were securely stored under encryption and deleted after analysis.

Data analysis

The transcribed interviews were subjected to an inductive thematic analysis. An inductive approach to thematic analysis was chosen due to the acknowledgement that epistemological assumptions would inevitably inform the analytic process (Braun & Clarke, 2020). However, the recognition that thematic analysis is a theoretically flexible approach was accepted and informed the analytic process. Therefore, the approach was descriptive but not wholly atheoretical. A flexible, active and interactive approach was central to the data analysis to support the process of theme generation, as opposed to theme emergence which could be deemed as not reflective of the data and the positionality of the researchers (Braun & Clarke, 2020).

NVivo 20 software was used to support line‐by‐line coding of all transcripts. A reflective diary was used to support the identification of themes from codes. Online team coding was conducted with two postgraduate research students and three senior researchers to support the process of reflexivity and refinement of theme generation. The first author presented raw data, identified codes and initial generated themes to the coding group; these were discussed, challenged and refined.

Reflexivity

As reflexive TA captures the skills the researcher brings to the process (Braun & Clarke, 2020: 6), it is necessary to consider the researcher's perspective. The lead author is a female clinical academic SLT specializing in paediatric ASD, DLD and challenging behaviour. She is also a solution‐focused therapist and practices hypnotherapy with children and adults. The current project formed part of the lead researcher's pre‐doctoral clinical fellowship funded by The National Institute of Health Research. The co‐authors are senior researchers with experience in the fields of speech and language therapy and psychology with research in aphasia and solution‐focused brief therapy, alexithymia and SLCN. Participants were informed about the lead researcher's occupation, background and research aims. The lead researcher's interests and aims were not shared with the participants, and the researcher attempted to maintain a neutral stance throughout the interviews in order to obtain a true picture of clinicians’ experiences and understanding of specific subtypes of SLCN and their relationship to mental health.

RESULTS

Four main themes were generated from the data: (1) boundaries around professional relationships, (2) knowledge of SLCN and mental health, (3) being misunderstood: how CYP are perceived by others and (4) blended interventions. These are summarized in Figure 1. We unpack each theme and its subthemes below.

FIGURE 1.

Summary of the main themes and subthemes [Colour figure can be viewed at wileyonlinelibrary.com]

Note: SLT, speech and language therapy; MH, mental health; MDT, multidisciplinary team.

In addition, data were gathered regarding how participants characterize this population. SLCN and difficulties with mental health were identified by participants as frequently co‐occurring. These data are presented following a discussion of the four themes under Figure 2: SLCN and mental health difficulties: typical difficulties reported in this population.

FIGURE 2.

Speech, language and communication needs (SLCN) and mental health difficulties: typical difficulties reported in this population [Colour figure can be viewed at wileyonlinelibrary.com]

Theme 1: Boundaries around professional relationships

This theme describes observed discrepancies in the identification of children with SLCN and mental health difficulties, and discrepancies in approaches to working with this population between mental health professional participants and SLT participants. Differences in service provision, professional practice and lack of multidisciplinary team working were cited by participants as contributing factors to the observed discrepancies.

One subtheme concerned marked differences in the organization of SLT and mental health services. SLT and mental health services were not only considered differently organized but also highly variable depending upon postcode, funding and service set‐up. How services were set‐up was construed to play a large part in the appropriate management, or perceived mismanagement, of children with SLCN and mental health difficulties. Service boundaries were identified as contributing to a range of difficulties working across and between disciplines. For example, SLTs discussed difficulties referring to services such as child and adolescent mental health services (CAMHS), often receiving referral rejections from CAMHS with limited or no feedback. Other examples cited by participants were related to limited feedback or acknowledgement to receiving patient reports, a physical distance between services, and difficulties identifying appropriate treatment pathways for CYP with SLCN and mental health difficulties, particularly in mental health services. ‘Lots of referrals get rejected, so many referrals that we really feel as a team need CAMHS support’ (participant (P)5: SLT).

Participants described how services are often entirely separate and working in respective isolation. This was interpreted to contribute to a limited or total absence of joint working, resulting in a lack of knowledge of each profession's discipline and of discipline protocols, for example, referral systems, use of screening for appropriate referrals and confidentiality policies. Service level differences were also cited as causing difficulties identifying which discipline should assess and manage CYP. ‘It was sort of, oh no, that has to be CAMHS, CAMHS has to deal with them, and if they were under seven, then CAMHS would say, oh no, that has to be speech therapy, speech therapy is dealing with them’ (P3: SLT).

A second subtheme was limited multidisciplinary team (MDT) working. An MDT is a group of health or social care workers and professionals who are members of different disciplines, each of which provides a specific service to service users (Hodder Education, 2021). Differences in service provision and service funding resulting in a separation of professionals, both at a geographic and organization level, was construed as a contributing factor to limited MDT working between mental health and speech and language therapy. Participants described how SLTs and mental health professionals are often not part of the same MDT and therefore have fewer opportunities to provide integrated care. SLT participants commented that their profession is often unaccounted for within acute mental health services, and one mental health professional considered her role under the safeguarding team as being cut‐off from the SLT's role which was under the SEN team. In addition, some participants attributed limited MDT working to policy level differences such as psychological services not sharing information with SLT due to confidentiality policies and differences in patient note systems:

‘we're often funded by different streams and funded by different people, we work in different health trusts quite often, and that actually has massive implications for the fact a) that you're not physically in the same building, so you don't get to see these people very often, but that even things about how we collect data, our electronic patient systems, we often use very different data technology that, that can make things very difficult in terms of information sharing’. (P13: mental health professional)

SLT participants also described a lack of approachability from mental health professionals which was seen as alienating and limiting from a diagnostic and therapeutic perspective, further contributing to limited MDT working, collaboration and cohesion between these professional groups.

‘because you've talked about an incident or challenging behaviour or something like that, certain psychology colleagues see that as inappropriate or you've overstepped a boundary because you're talking about a kind of emotion when that's something that they do, or they perceive themselves as doing quite exclusively’. (P7: SLT)

Theme 2: Knowledge of SLCN and mental health difficulties

The first theme ‘Boundaries around professional relationships’ directly interacts with the second theme ‘Knowledge of SLCN and mental health difficulties’. A perceived lack of shared knowledge was seen to be related to limited opportunities for multidisciplinary experiences and the clinical service set‐up overall.

The first subtheme concerned the ‘visibility’ of SLCN. It was construed that potentially less immediately obvious SLCN, such as DLD, are less likely to be identified by mental health professionals than more visible SLCN, such as stammering and selective mutism. Visible SLCNs discussed more frequently by mental health professionals as opposed to invisible SLCNs. This discrepancy was described by participants as potentially contributing to unidentified SLCN and mental health difficulties within mental health services, and the lack of knowledge universally with assessment and treatment of this population.

‘I don't think that's typical for mental health practitioners (to consider language difficulties). No, I would definitely think I know my team, the teams that I've worked in, most people would not think about language, particularly language disorders in a young person as part of the part of their (psychology) assessment, unless a parent disclosed something like that, or unless they were very, it was very clear evidence that there were quite obvious difficulties’. (P13: mental health professional)

Difficulty teasing out SLCN from mental health issues (and vice versa) was also interpreted as contributing to a lack of knowledge regarding appropriate diagnosis of CYP with SLCN and mental health difficulties. It was construed that a lack of understanding of the relationship between SLCN and mental health often impacts upon which professional should and would assess and treat this population. Participants discussed how social skills historically have been explicitly taught by SLTs but that mental health professionals are increasingly using this approach as an intervention strategy. Participants discussed a general lack of clarity around role boundaries which could sometimes lead to perceptions of overstepping a professional role or boundary. ‘In my kind of experience, I find certain psychologists very much see emotion, or kinds of challenging behaviour as their domain and they don't like anyone stepping into it’ (P7: SLT).

Barriers to accessing talking therapies was the second subtheme. Knowledge around diagnosis was construed as relating directly to providing appropriate interventions for this population, particularly regarding talking therapies. Traditional talking therapies were interpreted as being potentially inaccessible and inflexible for individuals presenting with SLCN and mental health difficulties, particularly if language difficulties were unidentified. SLTs and some mental health professional participants viewed psychological therapies as language heavy, involving higher level language and concepts that CYP with SLCN would struggle to comprehend and verbalize.

‘I might go and observe a psychology session with them and then the language they're using is far too complex the, the psychological language, the therapy materials, they often use a metaphorical language, they're using kind of these images and symbolism, which is far too complex for the person in general and then they're not really understanding’ (P7: SLT).

Due to a perceived lack of knowledge, identification of CYP with less visible SLCN might be missed by mental health professionals and unaccounted for within traditional psychological therapies. SLT participants described how in such instances appropriate accessibility and efficacy of talking therapies for CYP with SLCN may be compromised. ‘I'm not sure how much they know about these particular children's language needs and like how therefore their intervention with DEAF‐CAMHS‐H [CAMHS for the hearing impaired] is delivered effectively’ (P2: SLT).

Theme 3: Being misunderstood/labelled as naughty

Both SLT and mental health professional participants construed CYP presenting with SLCN and mental health difficulties as misunderstood and often perceived negatively by staff, carers, parents and the wider environment. In particular, difficulties with challenging behaviour, dysregulation and disengagement were interpreted by participants as being misunderstood and perceived as ‘naughty’. Participants considered the high prevalence of behaviours such as disengagement, a distrust of professionals and school refusal as contributing to this perception. Participants interpreted this population as commonly using non‐typical social communication skills that may result in difficulties building and maintaining relationships with peers, staff, parents and carers, further contributing to a negative perception. Difficulties with understanding and expressing language were seen to be related directly to instances of challenging behaviour.

‘We tend to get a lot of young people who are presenting at school, with quite significant behavioural difficulties and we tend to find that being viewed as a behavioural child, rather than a child that's got underlying language needs that have been un‐diagnosed’ (P5: SLT).

Theme 4: Blended interventions

The final theme concerns blended interventions. This theme describes participants’ descriptions of optimum interventions for CYP with SLCN and mental health difficulties. It was construed that working with the systems and environment around CYP is clinically useful for this population.

The first subtheme concerns working with the environment. The use of positive behavioural support systems, emotional regulation strategies and programmes, staff training, and the involvement of parents within interventions were deemed as clinically useful interventions for CYP experiencing SLCN and mental health issues. Parent–child interaction therapy (PCIT) is used by SLTs with the aim of improving interactions between children and their parents/carers (Falkus et al., 2016). Theraplay is used by psychotherapists to support healthy child/caregiver attachments (Institute of Theraplay, 2021). Both PCIT and Theraplay offer similar programmes where parents are involved as part of the intervention process. Participants discussed the potential of combining or utilizing such approaches in a more joined‐up manner for future targeted interventions. A functional approach to mitigating SLCN was also construed as beneficial for this population. Participants discussed how targeting specific aspects of SLCN may not be as beneficial as focusing on increasing overall functioning and well‐being of CYP.

‘So, I think in terms of delivering therapy, lots of it is about that environmental to therapeutics, so sort of, let's see if we can normalize the environment as much as we can in this environment and support behaviour through communication’ (P3: SLT).

The second subtheme concerned supports for communication. This theme was discussed universally by participants. The need to adapt language and consider therapist delivery within all diagnostic and therapeutic processes was seen as paramount for CYP experiencing SLCN and mental health difficulties. Using simple or no language to take the pressure off a requirement for verbal communication was interpreted as being necessary within any intervention for this population. Other visual supports, such as talking mats (Murphy et al., 2013) and communication systems, such as visual timetables and ‘now and next’ boards, were considered useful.

‘The use visuals, the use of visuals full stop. Whether that's visual or written timetable, even if the child has literacy so implementing a sort of routine on a timetable and consistent use of that across the day, I think works well’ (P4: SLT).

Play therapy or the use of play as a vehicle for access to psychological therapy for CYP with SLCN and mental health difficulties was considered a potentially useful psychological approach for this population due to the lack of emphasis upon verbal communication:

‘So, I think the use of toys and play can help bring their outer world about what's going on when, what they see inside and speech doesn't need to be, it doesn't need to be a part of that’ (P12: mental health professional).

‘I think the therapy it's different because I'm not expecting, they don't have to talk’ (P11: mental health professional).

Explicitly teaching higher level language was deemed an important intervention strategy, particularly in relation to comprehending and expressing emotions. One SLT participant described how they had combined a cognitive developmental theory of emotion and a psychotherapy model, with a vocabulary intervention directed through talking mats (Murphy et al., 2013) to facilitate communication. This was discussed and explored as a potentially useful way to develop emotion vocabulary comprehension and processing with this population.

‘You give people labels to understand what they're feeling physically, and then you move it onto more cognitive levels where that's the more kind of established sort of CBT, that kind of approach where they're thinking about their emotions and their thoughts … then you move on to the word level stage (of the vocabulary intervention) and that's very much around introducing kind of very basic semantic understanding of the word of the meaning and then you're building in the syntax and you're trying to get a really deep, you're trying to get there because they often have a vague notion of what certain words mean, but their understanding is very poor so you're trying to really reinforce a particular meaning or understanding of an emotion word’ (P7: SLT).

Merging interventions drawing upon practices from speech and language therapy and mental health was discussed. For instance, an SLT talked about how they had successfully combined shape coding (Ebbels, 2021), which is an established intervention used by SLTs, with social communication, emotional regulation, and transactional support (SCERTS), which is a behaviour intervention (Prizant et al., 2006). Participants also interpreted the use of relatable, non‐hypothetical language, and teaching how emotions look and feel in the body as being clinically necessary for this population. Participants advocated for the need to modify and adapt traditional talking therapies such as cognitive behavioural therapy and using an individualized approach. ‘Lots of more sort of explicit ways of doing things and using lots of examples from his own his own life and things that he would bring to the session rather than me coming up with example’ (P13: mental health professional).

Common difficulties reported by interviewees to be seen in CYP with SLCN and poor mental health

In addition to the themes described above, participants generated discussion regarding how they characterize this population. In answer to the question ‘can you tell me about some of the difficulties these CYP experience?’, participants described a range of difficulties this population typically present with. This is not a diagnostic criterion; it is a set of descriptions used by participants to describe their experience of this population (Figure 2).

Participants felt that characterizing the overall presentation of this population is often problematic. Participants reported that it is difficult to determine what is specifically a SLCN and what is a mental health need. SLCN and difficulties with mental health were identified by participants as frequently co‐occurring. Key aspects of development were identified by participants as being typically delayed or disordered with CYP experiencing SLCN and mental health difficulties. Participants reported that CYP in this population would commonly experience difficulties across these areas. The first area identified was emotional well‐being. Participants felt that this population significantly struggle with feelings of self‐consciousness, low self‐esteem, and anxiety, often about the presence of a communication impairment, and the impact of their communication difficulty on their experiences with the world around them. Participants felt that difficulties with self‐esteem and anxiety could sometimes result in poor emotional resilience. One participant described how young offenders are at particular risk of developing low self‐esteem because of multiple exclusions from education and therefore a sense of rejection that they may experience throughout life. Another participant described how difficulties with SLCN could impact on their well‐being and levels of anxiety and distress and behaviour. ‘We definitely see those children, they're often very anxious and there is definitely an impact of some of their difficulties on their well‐being, self‐esteem and their mental health’ (P5: SLT).

The second common characteristic was challenging behaviour. Participants described this population as typically experiencing difficulties with engagement, staying on task, and finding it hard to comply with work in the classroom or, with other professionals. Typical behavioural difficulties were problems with emotional regulation and the presence of anger or aggressive behaviours. Participants described how CYP can be disruptive or conversely appear withdrawn and isolated in social situations. Other reported difficulties in this area were with attention and listening and with building and maintaining relationships, particularly with peers.

‘We see quite a lot of, we describe it as anxiety for the children that, that I work with and dysregulation is a term that I've been using much more recently, so that can present as very elevated, it can present us physical aggression, some self‐harm and behaviours, yeah, sort of, socially inappropriate behaviours in terms of removing clothes and smearing and that sort of thing’ (P10: mental health professional).

The final area identified as characteristic of this population was language and cognition. Participants felt that this category of CYP experience difficulties with general language comprehension, processing of spoken language and with their expressive language. ‘Verbally he (a patient) appeared to understand things very well or he had a good, he had a good vocabulary, but actually his understanding was limited so he could be quite misleading’ (P13: mental health professional).

Difficulties with executive function was also discussed, often in relation to CYP being able to appropriately plan and organize themselves. One participant cited how it is common for CYP to arrive late to lessons, getting lost en‐route and forgetting school equipment. Difficulties with verbal reasoning were also described as commonly present with this population. ‘They're breaking their curfews and they end up in trouble with the police and things because they can't tell the time’ (P5: SLT).

Difficulties with metacognition (thinking about thinking) was also highlighted by participants as a typical difficulty seen in these CYP. Difficulties with insight, being able to monitor their communication and planning how to approach a learning task were all discussed as typical problems for this population. ‘They may not have insight into their own language use or behaviour’ (P2: SLT).

‘Difficulties with higher order language and the use of sophisticated, abstract and emotional language was also reported. Participants reported CYP in this population often experience difficulties understanding and using emotion language, particularly labelling emotions. They don't know what it means when somebody uses those words (emotional words), or is sarcastic’ (P5: SLT).

The misunderstanding of negative constructions was discussed as being a barrier to understanding emotions:

‘You might conceive that someone's doing something to you because you can't understand negative constructions, for instance, you just you assume everyone's just doing things to you but you're the one who's not quite understanding like the word no, or negative things’ (P7: SLT).

Difficulties with being able to understand abstract language and using language in a more abstract way to make predictions, use hypothetical language and humour was also cited as a typical difficulty in this population. ‘He would struggle with transferring that knowledge from a discussion about a hypothetical person to himself’ (P10: mental health professional).

DISCUSSION

The current study explored the experiences and views of SLTs and mental health professionals working with CYP with SLCN and mental health difficulties. Discussion around CYP with SCDs such as ASD, and developmental language disorder (DLD) was of particular interest. SLTs and mental health professionals in this study perceived certain subtypes of SLCN to commonly co‐occur with mental health difficulties. Findings suggest that there are organizational and service set‐up boundaries between SLTs and mental health clinicians, which has implications for the efficacy of assessment and treatment of this population. Findings also suggest that this population is often misunderstood and misidentified. The current research indicates that combined approaches in SLT and mental health may be beneficial for CYP who present with co‐occurring SLCN and mental health needs.

The current research has also identified that distinct barriers exist between mental health clinicians and SLTs which has led to boundaries between these professional groups. The most significant barrier was found to be around service organization and set‐up. Participants described how, as professionals, they felt organizational difficulties led to feelings of ‘failing’ this cohort. Findings suggest that mental health professionals and SLTs are often not in the same MDT and that SLT is often not a recognised professional group within children and adolescent mental health services. SLT and mental health services appear to be functioning in parallel, working under different teams, services, NHS trusts, local authorities, and sometimes entirely different organizations. Service set‐up and organization limitations were deemed to result in fewer opportunities for MDT working which has a negative impact on the knowledge professionals have of CYP with co‐occurring SLCN and mental health difficulties. Within the United Kingdom there is currently an ongoing consultation process with The Royal College of Speech and Language Therapists (RCSLT) and CAMHS to recognise the role of SLT within mental services and to increase SLT roles within core CAMHS services.

The current research highlights how a lack of understanding of this population is a clinical concern and has been described by participants in this study as having implications for effective diagnosis and treatment. The current study also illustrates that availability of joined up and multidisciplinary services for this population is scarce. This has resulted in a lack of shared knowledge about this population, leading to challenges with diagnosis, particularly with CYP who exhibit invisible SLCN and mental health difficulties such as DLD. The current research highlights that CYP with co‐occurring SLCN and mental health difficulties may be undiagnosed or misdiagnosed by professionals. This may mean CYP in this population fail to receive appropriately modified and evidence‐based treatment. The current findings resonate with other recent investigations of parents’ experiences concerning mental health support for their children with SLCN. Parents have reported concerns that mental health treatments were not accessible for their children and lacked adaptations necessary for them to work for children with conditions such as DLD (Hobson et al., 2021).

Typical behaviours and characteristics of CYP with co‐occurring SLCN and mental health needs are often misunderstood by parents, carers and professionals resulting in this population being misinterpreted and often labelled as ‘naughty’. Behaviours that are typically misunderstood include anger or emotional outbursts due to difficulties with emotional regulation, disengagement, language difficulties and problems with building and maintaining adult and peer relationships. Participants reported that children in this population are frequently ‘angry’ or show aggressive behaviours, and experience difficulties with friendships, can be distrusting of professionals, and are likely to show poor school attendance. Participants observed that CYP in this population are also likely to experience school expulsion, attendance to pupil referral units, and in some cases youth offending institutions/team (YOT).

A key finding was that interventions used in both speech and language therapy and psychotherapy are perceived as clinically useful if combined. Other research (Bercow et al., 2016; Menzies et al., 2018) has applied mental health interventions to specific subtypes of SLCN such as stammering, selective mutism and ASD, but little in relation to DLD. Participants discussed how they have successfully blended behaviour and emotion programmes with language and communication interventions. Similarly, participants discussed how combining traditional talking therapies, such as CBT, with modifications to account for communication difficulties, such as using visual supports, can be beneficial.

Hollo et al. (2014) has called for the development of interventions to ameliorate the effects of these dual deficits. Findings from the current study show that some existing or modified interventions are anecdotally effective. A good starting point for future research would be with the exploration of adapted traditional talking therapies and psychological therapies combined with SLT. A preliminary finding from the current research is that play therapy could also offer a potentially useful psychological therapy for CYP with co‐occurring SLCN and mental health difficulties due to its child‐led nature and lack of emphasis upon language and communication. Interestingly, play therapy was also raised by parents of children with DLD in the study by Hobson et al. (2021) as an approach that they felt would be worth pursuing. This has yet to be directly explored in individuals with SLCN but could offer further direction for future research into interventions for this population.

Findings from the current research show that it is not typical for mental health clinicians to consider language and communication skills within their assessment and treatment processes. The potential impact of this omission was described by participants as limiting CYP with co‐occurring SLCN and mental health needs to therapies that would likely be inaccessible. The current study has found that traditional talking therapies may not be modified for this population, unless the CYP have an obvious or diagnosed SLCN. This has implications for the efficacy of treatments provided, highlighting that traditional talking therapies, if not appropriately modified, are likely to be suboptimal for this cohort. Participants felt that traditional talking therapies could be reasonably adjusted to be accessible to individuals with SLCN. In a recent intervention study where aphasic adult patients received SFBT, Northcott et al. (2015) concluded that modifying question forms of therapy enabled greater accessibility.

Clinicians identified that CYP with SLCN and mental health difficulties most commonly experience difficulties across and between the domains of language and cognition, emotional well‐being and challenging behaviour. Fundamentally, participants considered that it is typical for CYP to present with co‐occurring SLCN and mental health difficulties, that is, difficulties across speech, language and communication and mental health. Previous research reports that children and adolescents with DLD and ASD are likely to experience difficulties with anxiety and depression (Cohen et al., 2013; Hofvander et al., 2009; Wadman et al., 2011). Results from the current study reflect this, indicating that difficulties with language and social communication are likely to interact with mental health difficulties. In addition, participants felt that SLCN can profoundly affect a person's social and emotional well‐being, and this can lead to poor mental health.

Participants described how CYP typically experiencing difficulties with higher level language are likely to find understanding and expressing emotions challenging. This supports existing frameworks such as the alexithymia language hypothesis (Hobson et al., 2020) which proposes that because of the intrinsic relationship between language and emotions, CYP with conditions such as ASD and DLD may be more likely to experience co‐occurring difficulties with mental health.

A limitation of the current study was that some of the participants were recruited from the researcher's professional network. Thus, a convenience sample was used and therefore potential selection bias may have been present, resulting in a failure to capture important perspectives from hard‐to‐reach participants. However, it is important to note that the range of participant specialities, knowledge and skill set was heterogenous and diverse.

Clear directions for future research have been identified from the results of the current study. The service organization, set‐up and service provision for this population is problematic. Future studies could explore and evaluate current services, set‐up and structure across and between SLT and mental health. The findings from the current study have important implications for the efficacy of treatments provided to this population, suggesting that more research needs to be done in this area. There exists a large gap in the evidence base for intervention‐based studies with this population. Larger scale intervention studies could also provide evidence for the efficacy of psychological approaches with this population. Future studies could also explore the adaptability of traditional talking therapies, combining approaches drawn from SLT and psychological therapies and the exploration of play therapy. Intervention studies analysing the efficacy of psychological therapies in children and adolescents with SLCN should arguably be conducted in part with SLT to provide input regarding SLCN. Modifications to talking therapies in young people with SLCN are therefore necessary in order to reflect and treat the presence of SLCN and mental health difficulties. Research from Solution Focused Brief Therapy (SFBT) in Poststroke Aphasia SOFIA trial (Northcott et al., 2021) suggests that modifications to SFBT is a promising psychotherapy approach for adults with aphasia, and that it is possible to adapt a language‐based psychological intervention for people with language disorders. In addition, behavioural activation therapy has also been shown to be successfully modifiable for adults with aphasia (Thomas et al., 2013) but further evidence, especially in a paediatric population, is scarce.

The current study aimed to describe typical presentations of this population, clinician experiences treating this population and clinically useful treatment approaches. The findings present a picture of the problems CYP with SLCN and mental health needs commonly experience and has enabled the documentation of a range of clinician experiences and views to inform and build a limited evidence base. Findings suggest that there are distinct organizational and service set‐up limitations with implications for the assessment and treatment of CYP with SLCN and mental health difficulties. Interventions drawing upon SLT, and mental health approaches may be beneficial for this population.

Supporting information

Supporting Information

Hancock, A. , Northcott, S. , Hobson, H. , & Clarke, M. (2023) Speech, language and communication needs and mental health: the experiences of speech and language therapists and mental health professionals. International Journal of Language & Communication Disorders, 58, 52–66. 10.1111/1460-6984.12767

DATA AVAILABILITY STATEMENT

Data are available on request due to privacy/ethical restrictions. The data are not publicly available due to privacy or ethical restrictions.