I have previously written about children that fall between the gaps, those who seem to be ‘Nobody’s Problem’. Here I have written a template letter GP that I think could help.
It was written with this scenario in mind:
- You and your child are desperate. S/he is struggling to get to school, they are coming home exhausted and are stressed beyond measure. They withdraw, dysregulate (meltdown) and/or are frequently presenting as depressed and anxious.
- It’s insidious, slowly getting worse and you are worried they will become unable to go to school at all (commonly referred to as ‘school refusal’).
- School staff sometimes help but sometimes respond with any of the following: “s/he’s fine at school”, “it’s your fault”, “s/he needs more resilience / to try harder…” and so on.
- Your child may or may not have had detentions and/or exclusions for displaying their distressed behaviour (fight or flight) at school.
- Your child may have a diagnosis of a neurodevelopmental disorder (for example ADHD, autism, dyspraxia, Tourettes or dyslexia) or you and others may suspect that they have undiagnosed differences of this kind.
- You are struggling to manage, you are worried beyond measure about your child, but s/he doesn’t qualify for any proper help. It feels as though:
- Their mental health isn’t ‘bad enough’ for children’s mental health services (CAMHS).
- They aren’t ‘disabled enough’ for the social care disabilities team to support you.
- They are not ‘far enough behind’ for school to be interested in actually understanding or helping.
- It is easier for everyone to simply blame the parents.
So here you are – at your wit’s end, with your GP. Your GP, in ten minutes, has to understand the full picture, assess your child, make records about the appointment, make a decision about his/her well-being and dictate letters and referrals. No mean feat. The GP is unlikely to know much about the EHC process, and what they do know may be inaccurate. They dislike writing letters and are frustrated by schools ignoring their advice and concerns. The GP will find it easier if you can be clear about what you want “please can you document…” or “I know that you can’t fix this but please can I test my ideas with you”. Your GP will be familiar with the concept of reasonable adjustments and The Equality Act so some of this may be transferable to your situation.
Since I first wrote this I have consulted with parents and professionals. Some themes that have arisen are tackled below:
- GP’s dislike writing letters and feel as though they lack knowledge in SEND. I hope that being given the option of a template letter this may help with the frustrations over letter writing and their perceived lack of knowledge on the SEND COP processes.
- Both parents and GP feel that medical views are ignored by those in education. A letter stating facts and medical views are, however, in my experience of great value. Firstly, it sends a clear message that they will not engage in ‘parent blame’. It will also reiterate that the child has a number of difficulties that need to be considered – and evidence that these are impacting on the child’s ability to access education. Critically, for the parents, any communication that is professional, factual and avoids blaming or accusing them or their child is worth its weight in gold. Being believed and being treated fairly is in scarce supply for many of us and we treasure it beyond measure.
- GPs can ask for an EHC assessment. They can do so using the template letter here. More information about GPs (and other professionals) requesting the EHC assessment can be found in 9.9 of the SEND Code of Practice (see here – page 144). It may help if you fill the template letter in with as much information as possible and take it to the appointment with you.
- Other comments have noted the importance and value of highlighting and documenting the following (which the template letter does):
- the impact of anxiety and of sensory and social communication differences on your child’s ability to access education;
- that revisiting the graduated approach to reassess the child’s barriers to accessing learning when new difficulties arise is essential;
- the potential harm that will come from a child continually being pressured against their ability to withstand stress. This to me is critical. In my experience, children that are struggling in the way described above are frequently battling very high levels of stress for hours every day. They are also having to manage the anxiety that inevitably comes from anticipating the day’s difficulties and then recover from hours of being adrenaline fueled. I hope that by documenting this some children will be protected from the professionals that advocate the “drag them in in their pyjamas if necessary” approach. Remeber this is a form of restraint and needs to be treated and recorded as such.
- There is a knee jerk reaction to almost any medical communication to school or the LA: “Dr’s can’t tell education what to do”. In my experience, they don’t (but conversely, teachers excessively feel free to over ride medical advice…), and this letter, in my opinion, doesn’t do that. It does though, ask that they do what the SEND COP expects of them. It raises concerns about the child’s well-being and asks that these concerns are properly evaluated in the context of education. It is a tricky one, but if the child’s well-being is to be placed at the centre, then I do feel that questions about the assessment of their needs in the school setting do need to be raised somehow. It is concerning just how muted many NHS staff feel by many of those in education.
- Finally, suggestions have been made that there needs to be a greater emphasis on both masking and the importance of early identification of difficulties and support for these within a letter to school. At the same time, some have commented to say that they feel the letter is too long. Perhaps it can be adjusted further, locally, for these factors as necessary.
Here is the letter that I wish the GPs felt able to write. It assumes a diagnosis has been made (but ‘is being investigated for’ could replace this part of the letter if necessary). It also assumes that there are no new difficulties than those that made the diagnosis (paediatrician/neuro developmental pathway assessment team) are aware of. If this were the case then a more appropriate route would be a referral back to the paediatrician for their reassessment (at the same time as a review at school perhaps).
Dear Head Teacher
I saw Peter today in clinic. He presented as exhausted and I understand that he is frequently dysregulating after school which his parents are rightly concerned about. I understand that he is also struggling with the transition of getting to school in the morning and regularly expressing concerns about school, in addition to his frequent dysregulation after school.
I am unclear as to whether he is masking his difficulties at school in order to blend in (as many children do), is responding to anxiety with a ‘freeze’ effect (which can be difficult to detect) or whether he is displaying distressed behaviour at school, but I feel that further investigation into these anxiety presentations would be essential to supporting him moving forward.
As you aware, Peter has been diagnosed with autism and other neurodevelopmental differences. It is likely that these are impacting on his ability to manage the social and sensory demands of school, leading to anxiety. It is highly likely that all of these (social and sensory demands and anxiety) are barriers to learning and as such contributing to the high levels of distress that he is currently displaying.
I understand that ‘barriers to learning’ should be assessed in school, for children with SEND as part of the graduated approach as described in the Code of Practice (2015). I am concerned about the levels of distress that he is currently experiencing, and feel that a reassessment/assessment of the impact of his anxiety and of his social communication and sensory differences have in school is essential to resolving them. It is, of course, possible that he has additional difficulties that are yet to be investigated as this is also common. If you feel there are others that warrant further medical investigation please let me know.
I am concerned about the impact on him of being expected against his ability to manage and withstand stress and distress daily. If this were to continue it could be to the detriment of his mental health. I am concerned that all that can be done at school to assess, understand and support his anxiety and neurodevelopmental differences is being done.
As you are no doubt aware, Peter’s difficulties in social communication (which can be difficult to detect in children with a strong vocabulary) mean that he will struggle to express what is difficult for him and he may need some skilled input to explore this properly. His parents should, of course, be fully involved in this process too.
I am concerned that he is supported in school so that his mental health does not deteriorate further and hope that full use of the graduated approach, with adjustments and support in the school setting as necessary, will resolve his current difficulties. However, I would support the application for an Education, Health and Care assessment if this is appropriate.
Please ensure that you copy Peter’s parents into all correspondence with me on this matter.
What do you think?
- For further information on the topic of Nobody’s Problem click here
- For copies of the SEND Code of Practice click here and see page 100
- For more information on how schools should use the graduated approach to support all children with SEN or ‘barriers to learning’ click here
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