Transcript for
Identifying developmental concerns in school-aged children

Narrator [00:00:02] Welcome to the Emerging Minds’ podcast.

Sophie Guy [00:00:08] You’re with Sophie Guy, and in this episode I’m joined by Susan Pagel, a speech pathologist from Queensland, to talk about a guide that she and her colleagues have developed to help practitioners identify developmental concerns in children. Called the ‘Red Flags Guide’, there is a version for little ones aged zero to five years and also one for school aged children, which has been developed more recently. Susan is team leader of an integrated multidisciplinary child development service in Brisbane, as well as being co-chair of the Child Development Subnetwork in Queensland. She completed her Bachelor of Speech Pathology over 20 years ago and has worked in rural and remote Queensland as well as in the UK and Brisbane. Our conversation today focuses on the Guide for school-aged children, which was developed in response to the challenge of identifying developmental concerns when they occur alongside mental health and medical complexities.

Sophie Guy [00:01:05] Hi, Susan, welcome and thank you very much for joining me on the Emerging Minds podcast.

Susan Pagel [00:01:10] Thank you for having me today. It’s great to be able to share the work we’ve been doing within developmental services. So eager to talk about that today and let our listeners know about these great resources that the Child Development Service has been producing.

Sophie Guy [00:01:26] Great. So we’re here to talk about a resource that you’ve developed called the Red Flags Guide that aims to help practitioners tease apart the challenges that children might present with to support their access to early intervention and the right services. I’m looking forward to this conversation, I think it will be really valuable because I’ve certainly come to realise myself through working in this space that when talking about children’s development and talking about children’s social and emotional wellbeing, particularly when it comes to young children, that these are really interrelated concepts and things that we’re talking about. And because of this, it’s important that we are able to identify and differentiate the particular concerns that a child might be presenting with. So to get started. Susan, I wondered if you could tell us a little bit about your background and how you came to be working in the child development space.

Susan Pagel [00:02:20] So my professional background is as a speech pathologist and I have been working probably around Queensland. I did a bit of work out rural in western Queensland and north, some of the remote Cape and Torres Strait and then recently in metro, all with paediatric clients. So I’ve had a very strong work history of working with little ones from zero up to about nine as my clinical practice. And then I became team leader of one of the child development services within the Brisbane area. And most recently, my experience was as a team leader in the Queensland Children’s Hospital, where we started to work a lot more with the adolescent group, so our nine year-olds and above. So I was really, really lucky to work with an amazing group of professionals. So paediatricians, social workers, psychologists, speech pathologists, physiotherapists, occupational therapists, and nurses and I learnt so much from working from them with the adolescent group as well, and understand that a lot of our challenges of our adolescents in development, as well as mental health, as well as medical comorbidity, particularly within the Queensland Children’s Hospital.

Susan Pagel [00:03:37] I’m also the co-chair of the Child Development Subnetwork. And through that role, we’ve been doing a lot of collaboration with our partners across the state in thinking about how we provide services to school aged children. Historically, early intervention in child development services is provided to zero to five year olds. But our five plus don’t always have great access to multidisciplinary allied health services. So we’ve been talking across the state also about how do we support young children from the ages of five up with developmental challenges? And then what happens when we have the additional comorbidities such as mental health and medical comorbidities as well. And how do we partner with our other services to support an understanding of the developmental challenges?

Sophie Guy [00:04:30] OK, and where is that at? Is that still an ongoing piece of work to find a way of reaching that age group?

Susan Pagel [00:04:37] Yes. So we’ve had a little bit of shift. We’ve been in our Cairns service, they were, they had applied for a grant to provide some developmental services to children, I think up to about nine. So that was great to have those additional allied health services there. And our Roma-based services and Ipswich-based services have also extended their age range up to about 18. So that’s great as well.

Sophie Guy [00:05:01] Maybe if we now shift to having you tell us about the Red Flags Guide, and I’m interested to know how this fits in with what you’re talking about, about the work you’ve done to increase access to services around early intervention. Could you tell us about the Red Flags Guiide and why it was developed?

Susan Pagel [00:05:18] Yes, sure. So we have two Red Flags Guides. So some of the listeners may be familiar with our Red Flags Guide for early intervention. That was released a number of years ago and it’s been widely disseminated and available through a number of internet platforms. And just recently, we’ve developed the Red Flags Guide for school aged children. So that’s just very recent. The idea for both of these guides happened to occur over food, which is the funny aspect of both of them. So it was just an informal conversation that led to the inception of both the guides and the early intervention Red Flags Guide occurred after a discussion with a colleague in the lunchroom. My colleague Jenny was explaining her frustration about speaking to a family who had identified concerns with their young person two years ago and had sought advice and was told to wait. And then by the time that they were referred, due to waiting times, it was two years from the identification of the difficulty before they actually accessed services. And that impacted the developmental outcomes for this little poppit. And it was not only the one case, it was a number of different cases. So Jenny and I had a bit of a problem solve to think about how can we change what was happening with referrals? How do we give parents the tools so that when they’ve got concerns, they can go to a referring professional and say ‘I’ve really got concerns, can you help me here?’ But also to guide our primary care clinicians in referrals. So we know that our GPs have a wonderful range of skills and our child health nurses have a wonderful range of skills. But we wanted to supplement those skills with an easy to reference guide to support appropriate referral. And so that was where the guide was developed. And the absolute aim of that guide was to be very, very simple, very, very accessible. And for any parent to be able to pick that up and access that to have conversations with their referring professional around that.

Susan Pagel [00:07:20] And it’s had great success, which was really good. So we had a change in referrals. The Guide was implemented internationally and it was very successful. And because of that success, we were thinking ‘oh, wouldn’t it be great to to shine a light on our school age children as well?’. Because we weren’t getting appropriate referrals at times for those school age kids. Particularly the ones that had the comorbid medical or developmental challenges. And this was additionally highlighted by a clinic we ran. So we were lucky to run a neurodevelopmental clinic for children with congenital heart disease, and that was run in conjunction with CHD LIFE.

Sophie Guy [00:07:59] What’s that? [CNC] What’s CHD LIFE?

Susan Pagel [00:08:01]  Yeah, so it’s congenital heart disease arm of the cardiac group, which is run by Karen Eagleson. And she looks at neurodevelopmental outcomes for children with congenital heart disease. So she’s involved in maternal health and then looking at appropriate follow up for children with congenital heart disease. There is a link I can send if anybody’s interested in that. There’s what we call the Pink Book, which is a great resource for children with congenital heart disease and neurodevelopmental outcomes. And it’s got some great recommendations following a project in that space. But as part of that, we trialled a clinic, a follow up clinic for children with congenital heart disease. And we found that there was great early intervention options for these families. So they were able to access the services up to about five. But accessing services after that was a bit more challenging. Some of them had some fantastic gen paeds but what was missing was the integrated allied health approach. And we were able to trial that for a short time. And what we actually found is these children, particularly after the age of nine, were presenting with some additional challenges that weren’t identified before. And we often find that at the age of nine, we have a bit of a transition with children’s cognition and their language where higher level skills don’t necessarily come in for children, particularly if they’ve had a bit of a bumpy start to life. So a bit of early traumatic history, medical complexity, and then they have these developmental challenges that emerge around about that age. They often start to struggle at school. Learning isn’t as easy for them. And then, you know, a referral is often indicated. But the lack of integrated allied health response, they might not get the developmental understanding that they require.

Susan Pagel [00:09:55] And we found through this pilot study that there was these emerging language, literacy, and learning concerns for these over nines. We also found that there were some early mental health markers as well. So some actually required a referral to our mental health services. Some required referrals to Headspace. So we noticed that there was some concerns around self-esteem. There was concerns around morbidity and awareness of morbidity, and some were separate to that. So we again were questioning how do we help identify these school age children with emerging developmental concerns and what tools can we use to support the referral? The challenge that we had with the school aged children was that we don’t have milestones really for children eight and above. So if you look for milestones, you can find that pretty much for children up to about eight. But by the time that they’re eight, they’ve consolidated a lot of their learning, walking, talking, and playing skills. And then what we noticed that emerges is the subtle developmental markers or behavioural challenges. And it’s really quite tricky to tease apart. And so we had lots of discussion in the creation of the school age guide to try to help referrers tease it apart enough to support a referral to a developmental service.

Susan Pagel [00:11:20] So unlike the early Red Flags, which is very more milestone and domain based, the school aged Red Flags is more functional based. So we look at is the child having functional difficulties within their environment? And what does that look like? And I’m thinking about our GPLO, Aaron Chambers, was helping me with the creation of this resource. He said to me ‘what’s the difference between a six year-old with attention difficulties and a 12 year-old with an attentional difficulties? And which one do you refer?’ And so we started to develop, on the Red Flags Guide there’s an impact statement, which is down the bottom of the guide, and it basically talks about what areas does this developmental challenge impact on the child. So does it impact in one task, one environment or all tasks, all environments? So that would probably be the difference. We would, as a specialist service, we would take children where there was an impact in most tasks, most environments to all tasks, all environments. Whereas if the child was only having difficulties with one task in one environment, then we might suggest a private service or some type of support through school or something along those lines.

Susan Pagel [00:12:31] So then when you think about a six year-old, a six year-old may have significant impacts on every task that they do every day compared to the 12 year-old who might just get a bit distracted in maths because it’s not his favourite subject. So the frequency or severity scale was really important to tease that out, to think about function. Then we had the other questions, I guess, about how do you differentiate between a mental health presentation and a developmental presentation. And we know that that often coexists. So a child who might be socially withdrawn, that could be developmental. It could be mental health related. But it’s tricky to tease out. So we again designed the Guide with sort of like the two sides to it. So one side of the Guide is mainly developmental markers. So you would have to have some of those developmental markers, particularly difficulties with learning or understanding another’s view or giving relevant information, as well as the additional behavioural or emotional markers to support a referral. But we also know that we operate on a one door policy. So if we get a referral, we look at that referral as a whole and get the information and if it’s not appropriate for a developmental service, we redirect it to our mental health partners. So I guess in answer to the question, that’s sort of why it was developed. It was developed from a need that was identified. Yeah [yeah] from the community and professionals.

Sophie Guy [00:13:58] Okay. Thank you. That was a really rich introduction and explanation of the service landscape and what’s going on in Queensland and why you decided to develop the Guide. It’s really interesting. I was curious to ask the reason that referrals are not really happening. How much is it to do with that there aren’t services for children and how much is it to do with, you know, for example, general practitioners who are having to be able to recognise and respond to an immense amount of conditions and problems, not necessarily being that familiar with knowing when to refer?

Susan Pagel [00:14:35] Oh, yes, that’s a really good question. And I probably can’t answer it with specifics. [Sure. Yeah] I know that there has been a long history in lack of services for the school aged children, and there’s also probably been different perceptions of the role of the school in supporting developmental outcomes at times. So we do work really closely with our education partners in supporting children’s developmental understanding. And we do get referrals for children, but it’s often at the point of crisis for our complex developmental school-aged children. So it’s almost when everything else has been tried and then we get the referral. So it’s almost that they’re at risk of suspension or they’re at the risk of harm to themselves or everything has been tried in the book and nothing is working. So we we do get a pattern of referrals in that space. But I guess we’re trying to also raise the awareness of the developmental comorbidity in this age group. And we often know that it’s tricky to differentiate when we’ve got those overlays. So, you know, I’ve got a particular interest in the medical complexity and know that parents are really grateful that their child is walking and talking and eating and surviving. So development is probably secondary to all of the other things that they’re managing at the moment. And we did some really great work, again through the Network, in identifying the developmental challenges of children with significant health needs. And again, we found a really great increase of children who are medically complex accessing services in the early years. But it’s almost once you’ve gone through that sort of hump of everything’s tracking long okay, we really want to raise the awareness that there’s some key points where we just need to keep an eye on their development.

Susan Pagel [00:16:22] One of the things that we do with the Red Flags is we have a little sort of like an education pocket on the Guide. And the one that we’ve used for the school age Guide is an acronym called TEAM. And it’s to sort of like give a quick little guide to things to keep an eye on in the school age group. So we often sort of say keep an eye on transitions. And to make it brief, I’ve talked about age nine, grade nine, as well as entering high school and entering primary school. And the reason why I choose the age nine, grade nine is due to those developmental changes that happen at that time. So we often know at age nine, as I explained earlier, we have a change in their language and cognition so that children who might not have appeared to have developmental challenges may start to present with developmental and learning challenges. And grade nine, I find that’s a really important transition for some of our chronic developmental kiddies. So these are kids who already have a developmental challenges and then they’re going through that extra transition in grade nine where they’ve got that self of identity and perception of self in the world. And we often find that some of our children about that age represent needing additional specialist services. It’s a real key transition for them. And then the ‘E’ goes on to comorbidity. So exploring within comorbidity, which I’ve discussed. The ‘A’ is around looking across context. So remember when I referred to the frequency and severity scale? Developmental difficulties are pervasive. We would expect them in all contexts, so we would expect them in school and home and in the community. And if they’re not occurring over those contexts, we would ask the question why? So sometimes we know that children are well supported at home and they’re having challenges at school because of the learning pressure. They’ve still got the developmental challenge across the environments. It’s just that the context supports that in different ways. And we’ve got other children that have particular behaviours in certain environments and not in others. So it’s a good question to explore. And we also know that it’s important to monitor children across time.

Susan Pagel [00:18:28] So I guess it’s it’s complex. It’s a really complex area. And when we were developing the guide, I had lots and lots of discussions with lots of people across professions. GPs, CIMHS clinicians, education professionals, and I was constantly asking the question ‘what’s an easy way to identify developmental difficulties within this population?’ And it was really difficult to quantify how you do that. So I think it’s the combination of the history of lack of services in conjunction with the comorbidity maybe in a way overshadowing the developmental presentation. So if you’ve got a very unwell child that takes priority over the developmental for a parent. Not always, but most of the time that is their absolute priority unless the parent’s educated otherwise, which is starting to happen. And then the trickiness in actually teasing that out in the school age population, it’s really, really tricky work. So it takes sometimes a multidisciplinary team or various professions a number of hours to be able to tease out a diagnostic presentation in some of our school age kiddies. So it’s a really, really complex process and I guess the Guide was developed just to support the referral. If we can identify the kiddies that might need that, get them to a tertiary service, and then as professionals, we work collaboratively with really trying to nut out what is going on for this little little young person. So it is a very lengthy process to get that understanding.

Sophie Guy [00:20:01] Mm hmm, yeah, and I can see how this Guide has done a careful job of really trying to bring together, like you say, what is very complex and trying to make sense of it in a way that I can see would be really useful. And I was interested that you said you sort of intended for parents to be able to use as well. Have parents been taking it up and do you know how they’re finding it?

Susan Pagel [00:20:23] Yes. So we know that with the early intervention Red Flags, that’s just absolutely had huge take up by parents. Parents refer to it. It’s Accessible in waiting rooms. It’s very, very useful for parents. With the school aged Guide, it hasn’t been as widely disseminated as yet. We did have some consultation with the Consumer Advisory Council as part of QCH and they found it very useful in their situation. However, we’ve been clear with some of our marketing around it’s to support conversations. So we really encourage that parents have a conversation with a health professional around their concerns because we know it can be quite tricky to tease out. So for a well-educated parent who’s got great health literacy, we still know that that developmental support’s required and that the interface with a GP is very beneficial. Also to to rule out other things that might be contributing to the picture. So we know our GPs are great at supporting sleep. So checking in on sleep issues which might be impacting on the developmental presentation. We know that awareness of health and diet and a lot of our GPs are quite skilled in those early mental health markers as well. So we would really encourage this to be done in conjunction with a health professional and particulary a GP to rule out any organic or other causes that might be contributing to the picture. Because we know that we still have high demand. We are getting referrals for a number of different children. We do have high demand. So we wouldn’t want a child to be waiting for services and then not have those basic organic screens completed, which our GPs do a great job at doing to make sure that there’s nothing underlying for their behaviour.

Sophie Guy [00:22:12] Yep. And so I can see it obviously lends itself very naturally to general practice and the allied health world. Is it something that has been taken up or you’ve been promoting within the more social services out there as well?

Susan Pagel [00:22:26] Yes. So we have liaised with the Child Youth Mental Health Services regarding this Guide. That was part of the creation of that. We’ve also disseminated it through the Indigenous Health Worker Network as part of our relationship with the Child Development Subnetwork. And we’re hoping after it gets published on relevant internet platforms, we’ll be able to then provide links to schools and other additional social services that work with young people. We’re in early creation of this Guide and dissemination of this Guide, as we’re starting to do it, I’m curious to to get feedback on useful tips or tricks to go along with the Guide, if that’s something to help access for health professionals to use it. But what I did find is consistently through the creation of the Guide, if I gave it to a health professional, they picked it up, they understood it immediately, which is great. It’s just in that again, sort of explaining some of the nuances behind it, which is how to use the frequency scale and which are the sort of developmental markers and which are the mental health markers and how do they overlap.

Sophie Guy [00:23:28] I was curious. You mentioned about the consulting you did in the development of it. Could you just talk a little bit more about how the school age Guide was developed? What was that process?

Susan Pagel [00:23:40] So we used a number of different elements to create the Guide. My first iteration of the Guide was to match the early intervention Red Flags Guide along with the domains and ages. However, that didn’t work because when I put six year-old and nine year-old, the domains were the same. They both had difficulties with attention or they both had difficulties with understanding jokes. So it was really tricky to differentiate in layman’s terms about difficulties that children might have in the school age population. So through lots of consultation with lots of different people, we ended up coming up with a function and impact type model, which was talking about which functional skills do these children typically present with and then what is the impact of that. To support the identification of those items we actually did a referral review, so we reviewed 50 referrals and we identified what was identified by the referring professional and what was noted in a first session with with a specialist service. And what we found is there was a lot of really great developmental markers identified. But typically what was missed were difficulties with language and difficulties with activities of daily living. So those were the things. That were not commonly reported on that we often picked up in that initial session. The ‘Your concerns’ was pretty much pulled through the common referral questions, whereas ‘Together we will explore’ started to identify things that were not typically identified by referring professionals that would have been useful as part of that process.

Susan Pagel [00:25:22] We also backed that up with the current evidence. So we did a literature review of all of the current developmental markers for school aged children. And we looked at a lot of the forensic literature about children who were in youth justice system and what developmental markers were identified in that population. It’s quite concerning the comorbidity between children who are accessing in our youth justice system and the comorbidity of unidentified developmental difficulties. Up to about 50 to 60 per cent of severe language difficulties in some of our studies that we read. [Wow.] The young people were talking and communicating, but they just didn’t have the language expected or the language skills expected for their age. So they were missing out some of the higher level language skills, which we try to reflect in the document. Things like giving relevant information and understanding jokes and understanding another person’s perspective. And so that’s why we chose some of those items. We also got some information from our clients. So some of our families. Why have you come here? What have you identified that’s a concern? And so we got some really lovely language around that to put in the Guide. And we also did a little bit more of a focus on some of the more subtle developmental markers in that age group. We know that if a child presents with significant developmental markers, we know that our health professionals will refer those children to a developmental service. So we wanted to put some of the more subtle markers in as well, things that wouldn’t typically be asked as part of an interview.

Sophie Guy [00:26:53] OK, yeah, it’s really comprehensive. Well, finally then, where to next? You’ve got this second version of the Guide and you’re trying to get it available online. Have you got plans for what to do next with this Guide?

Susan Pagel [00:27:06] We really do want to get it out to our professionals that refer children. We’ve released it through the Child Development Subnetwork and through a GP master’s class. And then we will do probably a dissemination strategy through some of our medical links. So we know that our early intervention Red Flag is used commonly as a training tool for our registrars and fellows, our junior doctors. So we’ll have a strategy to get that through there. And we’re also hoping to do a release to our education partners as well, to be able to have that information available for schools. And then probably the other dissemination pattern we’re looking at, where we’ve done a lot of work with already is through our child and youth mental health partners. We’ve used it a couple of times informally to support case discussion around developmental referral and to support that conversation with families around developmental markers that may warrant referral as well.

Sophie Guy [00:28:03] Well, I can say that a lot of hard work and careful thought has gone into this resource and it sounds really, really valuable. And thank you very much, Susan, for joining me today to talk about the Red Flags Guide.

Susan Pagel [00:28:16] My pleasure.

Narrator [00:28:19] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.