Disability, Leadership, Preparing for Adulthood, SEND

Special educational needs and disability: time to restore a differential diagnosis approach

By Anita Devi

In a previous blog, I have written about synthesis of assessment.  Today, I want to share my thoughts on why differential diagnosis is an important part of supporting children and young people with SEND and their families. To be clear, this is not a debate about the medical model or the social model of inclusion.  It is a conversation about ‘how’ we identify needs accurately, so that we can put the right support in place.  I will use examples from my own professional journey as a SENCO, SEND Advisory Teacher and SEND Consultant to illustrate some key issues.

Differential diagnosis is the process of differentiating between two or more conditions which share similar signs or symptoms. To be effective differential diagnosis requires three key components:

  1. Firstly – everyone round the table has a voice and difference is to be welcomed.  On many occasion, children and young people may present with some symptoms and behaviours in one environment and not in another.  What is relevant here is the difference.  By accepting both observations as correct, we are better placed to consider the environmental factors that are having an effect.  No one voice should be given more weighting than another and where possible, evidence should be sought.  Awhile back I was training panel members in a local authority to make consistent decisions regarding 9.14 & 9.54 of the SEND Code of Practice 2015.  An evidence-based approach is vital for consistency.  In one case that we reviewed, throughout the paperwork practitioners referred to a conversation where the child was said to have a diagnosis of X.  This conversation was repeatedly referred to as the primary need of the child.  It was a medical condition.  Yet, in fact there had been no formal diagnosis.  The comment (and subsequent basis for the plan) arose from anxious parents raising the possibility of this condition.  This possibility condition turned into, “She has …” in the reports and subsequent decisions (to the detriment of the child) were based on that possibility condition. Further investigations revealed the child did not have this condition and any support, intervention or treatment put in place had simply served to delay accurate identification and provision.  How different the story would have been if someone had asked for evidence of the diagnosis.
  2. Symptoms need to be perceived as holistic patterns in the current moment and over time (i.e. historical).  As a SENCO, I devised a form for teachers to record symptoms they were seeing in the classroom and over time / year groups. A symptom is a physical or internal feature indicating a condition or need. This form helped us collectively discuss with parents and understand the child’s needs better.  Too often, it is possible to consider only one or two things and depending on the lens adopted, a label is attached.  Two case studies edify how easy it is to misdiagnose.

Child A was presenting with symptoms that everyone including a private assessor diagnosed as dyslexia.  As a SEND advisory teacher, I met with the parents and ask them questions about Child A’s development history and daily routines.  Child A regularly bumped into things and presented with other co-ordination difficulties that the parents had assumed was Child A being clumsy.  Further investigation revealed Child A had dyspraxia. Whilst there is an overlap between symptoms of dyspraxia and dyslexia; the latter predominantly focuses on a difficulties in learning to read, write and spell.  Therefore, any interventions put in place may have missed other significant areas of need.

Child B was a bright year 5 student, who took part in several community team sports and orally was able to articulate high levels of knowledge and creativity.  The difficulties arose with reading and writing.  Parents engaged the services of a dyslexia specialist, who diagnosed dyslexia and suggested a 10-week intervention programme, that only the specialist could provide.  I undertook a reading test of real and nonsense words.  As Child B read, I noticed erratic eye movement.  Child B’s eyes would jump three letters forward, then two letters back.  A similar patter emerged when reading high frequency words in a sentence. I referred Child B to an eye specialist, who confirmed my observation and Child B was given eye movement corrective glasses. Entering Year 6 (with his glasses), Child B was a quite different student.

3. The third component is possibly the hardest for stakeholders to take on board.  Differential diagnosis works through 5 core thinking skills:

      • analysis
      • interpretation
      • inference
      • deduction
      • problem-solving

Therefore, differential diagnosis requires up-to-date knowledge of research and accepting the possibility ‘of getting it wrong’.  Child C was unable to access the maths curriculum.  Demonstrated ability placed Child C as working three years below his age.  One option would have been to place the child in an intervention group and support development of mathematical foundation skills.  However, the SENCO decided to commission a dynamic assessment test.  This basically assesses cognitive processes, in the moment i.e. as they are happening.  Child C was cognitively age appropriate.  However, a look through the historical records showed Child C had had many supply teachers for maths and as a result had significant ‘gaps’ in learning.  This was not a SEN issue.

As part of the work I do, I am often asked for a good-practice example of an Education Health Care Plan (EHCP) and 5-star examples of well-written outcomes.  I have yet to find one and I have worked across several local authorities.  The issue is the plan has become about form filling, not the connected bigger picture of understanding the child and presenting symptoms.    In one local authority project, I reviewed the Advices written for more than 30 EHCPs.  I also then reviewed the associated plans.  What was apparent was the reports by specialists focused on one or two voices, at the expense of their own professional knowledge.  When I then met these specialists, they then shared with me their reluctance to express their opinion, as it differed to others.  I regularly undertook statutory assessment of pupils and a key part of my report writing was to consolidate conflicting pieces of evidence to clearly discern the child’s needs and then the provision needed to be put in place to meet those needs (sometimes multiple).  On many occasions, less is more meant I had to acutely define a catalyst approach for supporting the child.  The current system (post SEND Reforms) shies away from difference and differing opinions.  I think this is a mistake and as a result, I am not convinced we are identifying needs and provision accurately.  The system is resources-driven, not identification-based from differing evidence-based perspectives.

One of the areas I lead training on most regularly is enabling SEND Leaders to discern ‘why’ an intervention / support is needed and ‘how’ it should be delivered.  The why and how are intrinsically linked.  To discern this knowledge, SEND Leaders need to look beyond the data and look at patterns across several factors. Knowing the why really does change the how.

What is needed for improvement?

I would suggest two factors are needed to drive improvement and ensure a better system for identification.  The first is ‘protected CPD time’ for SEND Leaders.  This is in complete contrast to current SENCO Workload Survey approach and I have written more about this here  The SENCo workload survey, mistakenly focuses on ‘protected work time’.

The second is a recognition and acceptance of difference at all levels.  This needs to be evident within settings and at local authority level. Only then can we begin to discern patterns, environmental factors, and historical issues for accurate identification of needs.

If both were in place, over time we would see a system where open conversations were prevalent and the single goal of ensuring the child progresses becomes the focus.  Naturally, this involves a conversation about defining progression.  However, this is the 21st century; young people and adults with an educational need and/or disability should be able to contribute to society through employment, they should be able to live independent healthy lives and be included in the community.  So, if we are serious about the ‘preparing for adulthood’ outcomes, we have a responsibility to employ a differential diagnostic approach to accurately identify need and the provision needed.  I would be interested in your thoughts, especially if you disagree with me!

About Anita Devi

Anita has had an extensive career in education.  Her why is based around the ‘Joy of Learning’.  As such, she focuses on what enables learners and what hinders them and more importantly, what can she do to improve the system.  Amongst her many other roles, Anita leads #TeamADL

To find out more visit www.AnitaDevi.com

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