Parents' constructions of normality and pathology in child mental health assessments.

Central to a contemporary understanding of childhood is the developmental and clinical-medical construct of the 'normal' child. When judged to fall outside of culturally, socially and historically situated parameters of 'normality', children become labelled as 'deviant from the norm'; for instance, in mental health contexts where this may provide the basis for psychiatric diagnosis. However, judgements of a child's 'normality' are further complicated by the range of individuals who may have a stake in that construction, including parents/carers, professionals and the child themselves. Using discursive psychology, we analysed 28 video-recorded UK child mental health assessments, to examine ways that parents presented concerns about their children's development. They did this by drawing on notions of 'ab/normal', in ways that functioned to legitimise their need for services and built a rhetorical case to demonstrate clinical need; often by contrasting the child with other 'typical' children and/or contrasting the same child's behaviour in different settings or contexts. We concluded that given the growing crisis in child mental health, initial assessments play a crucial clinical role in determining diagnosis and labelling, and therefore, a critical discussion of these concepts and processes is essential.

Implications of Untreated Cleft Palate in the Developing World: Adaptation of an Outcome Measure.

OBJECTIVES: To identify the implications of living with untreated cleft palate and develop an outcome measure which reflects the broad impact of surgery but is sensitive to the physical impact, speech changes, and psychosocial implications of late intervention. Design, Participants, Setting: Focus groups and individual interviews were used to gather information on the implications of living with untreated cleft palate and the impact of subsequent surgery. Participants included 11 individuals attending a cleft department in India whose cleft had persisted into adolescence or adulthood, as well as 16 of their family members. The findings were used to assess whether the Therapy Outcome Measure (TOM) could capture the implications of untreated cleft palate and the impact of surgery beyond that of speech alone. RESULTS: The findings indicated that the implications of living with untreated cleft palate revolved around difficulties with communication, reduced autonomy, and nasal regurgitation. These issues are encapsulated within the third and fourth domains of the TOM, but there is a need for an adapted version (TOM-clp) to use in the developing world, incorporating areas specific to cleft palate. CONCLUSION: The TOM has potential as a global tool for measuring the broad impact, including the psychosocial benefit, from attending to untreated cleft palate.

Children's claims to knowledge regarding their mental health experiences and practitioners' negotiation of the problem.

OBJECTIVE: The objective was to identify how children's knowledge positions were negotiated in child mental health assessments and how this was managed by the different parties. METHODS: The child psychiatry data consisted of 28 video-recorded assessments. A conversation analysis was undertaken to examine the interactional detail between the children, parents, and practitioners. RESULTS: The findings indicated that claims to knowledge were managed in three ways. First, practitioners positioned children as 'experts' on their own health and this was sometimes accepted. Second, some children resisted this epistemic position, claiming not to have the relevant knowledge. Third, some children's claims to knowledge were negotiated and sometimes contested by adult parties who questioned their competence to share relevant information about their lives in accordance with the assessment agenda. CONCLUSION: Through question design, the practitioner was able to position the child as holding relevant knowledge regarding their situation. The child was able to take up this position or resist it in various ways. PRACTICE IMPLICATIONS: This has important implications for debates regarding children's competence to contribute to mental health interventions. Children are often treated as agents with limited knowledge, yet in the mental health assessment they are directly questioned about their own lives.

Your injury, my accident: talking at cross-purposes in rehabilitation after traumatic brain injury.

PRIMARY OBJECTIVE: To explore how traumatic brain injury (TBI) rehabilitation staff and adults who have sustained TBI refer during clinical interaction to the precipitating event. DESIGN: Interviews conducted during the initial assessment phase of TBI rehabilitation were examined using Conversation Analysis. PARTICIPANTS: Participants were nine men and one woman, all of whom had sustained TBI of sufficient severity to warrant referral for community rehabilitation. Age range was 24-50 years (mean 35 years). The period between injury and interview was between 9 months and 20 years. MAIN OUTCOMES AND RESULTS: Analysis of interactions between rehabilitation staff and people with TBI indicated discrepancies in the way they refer to the original event. Staff tended to use 'head/brain injury' in contrast to the use by people with TBI of 'accident/crash'. There were also differences of expression in terms of 'ownership' (e.g., your injury vs. the injury) and 'agency' (the degree to which the person with TBI was portrayed as having been part of the process of sustaining the TBI). CONCLUSION: The implications of these discrepancies are discussed in relation to self-identity and insight after TBI. The possible impact of this terminological tension on the rehabilitation process is also discussed.

The case for multimodal analysis of atypical interaction: questions, answers and gaze in play involving a child with autism.

Conversation analysis (CA) continues to accrue interest within clinical linguistics as a methodology that can enable elucidation of structural and sequential orderliness in interactions involving participants who produce ostensibly disordered communication behaviours. However, it can be challenging to apply CA to re-examine clinical phenomena that have initially been defined in terms of linguistics, as a logical starting point for analysis may be to focus primarily on the organisation of language ("talk") in such interactions. In this article, we argue that CA's methodological power can only be fully exploited in this research context when a multimodal analytic orientation is adopted, where due consideration is given to participants' co-ordinated use of multiple semiotic resources including, but not limited to, talk (e.g., gaze, embodied action, object use and so forth). To evidence this argument, a two-layered analysis of unusual question-answer sequences in a play episode involving a child with autism is presented. It is thereby demonstrated that only when the scope of enquiry is broadened to include gaze and other embodied action can an account be generated of orderliness within these sequences. This finding has important implications for CA's application as a research methodology within clinical linguistics.

Inflexibility as an interactional phenomenon: Using conversation analysis to re-examine a symptom of autism.

Many accounts of autism spectrum disorder (ASD) imply that the condition's behavioural 'symptoms' are direct reflexes of underlying deficits. In doing so, however, they invariably overlook the social contexts in which symptomatic behaviours occur and are identified as pathological. This study addresses this issue, using conversation analysis (CA) to examine the emergence of inflexibility, a behavioural trait symptomatic of ASD, during play involving an adult and diagnosed child. We argue that 'inflexibility' is the product of the child's strategic attempts to retain control over the unfolding interaction, within a context where such attempts breach normative expectations about adult-child play. Furthermore, it demonstrates that the adult does not resist these attempts, on occasion even explicitly providing opportunity for subsequent inflexibility. This challenges the assumption that ASD's behavioural profile solely represents the endpoint of underlying deficit, and demonstrates how 'non-impaired' speakers can be implicated in the manifestation of symptomatic behaviours.

Recognition and language in low functioning autism.

The hypothesis that a pervasive impairment of declarative memory contributes to language impairment in low functioning autism (LFA) was tested. Participants with LFA, high functioning autism (HFA), intellectual disability (ID) without autism, and typical development (TD) were given two recognition tests and four tests of lexical understanding. It was predicted that recognition would be impaired in the LFA group relative to the HFA and TD groups but not the ID group, and that recognition would correlate with lexical knowledge in the LFA group but none of the other groups. These predictions were supported except that the HFA group performed more similarly to the LFA group than expected, a finding interpreted in terms of selectively impaired episodic memory.