Assessing the mental health of neurodivergent children and young people at school

Dr Kirstie Rees, Educational psychologist and author of The Mental Health and Wellbeing of Children and Young People with Learning Difficulties; A Guide for Educators, offers some advice to help you assess the mental health and wellbeing of neurodivergent children and young people in a school or nursery setting.  

1.  Think about Mental Health and Wellbeing on a Continuum

A clear definition of mental health and wellbeing will make you feel more confident about assessing a child's needs. It can be useful for adults, and pupils, to visualise mental health and wellbeing as being on a continuum – ranging from feeling happy and content, achieving a sense of belonging and participating in meaningful activities on one end of the continuum, to experiencing chronic and enduring mental health difficulties on the other. Where any of us are on the continuum will change, depending on what has happened to us, where we are, what we are doing and the support network around us. Working out where a young person is on the mental health and wellbeing continuum and considering the impact of different environments, relationships and strategies will enable us to provide support – or to gain support from other professionals – which moves them towards the more positive end of this continuum.

Key question: Which factors (e.g. environment, peers, activities) contribute to the child moving up (or down) the mental health continuum during the course of a school day?

2. Consider the child, and then their diagnosis

Some of the children you support may have (or be awaiting assessment of) diagnoses such as autism or ADHD. Others may have learning difficulties or disabilities. A diagnosis can help you to gain a deeper understanding of a child's challenges, as well as their strengths. It can also reduce the amount of time you need to carry out an assessment of their needs. Although the neurodiversity movement marks a move away from the language of 'deficits' to one  of 'differences', the connotations that are attributed to a diagnosis, especially one which identifies a child or young person as being different from others, continue to influence how they are understood, as well as how they may perceive themselves. At times, it can increase the likelihood of people resorting to stereotypes or using short cuts, rather than basing their assessment on an in-depth understanding of the child or young person. When you talk about a child's diagnosis, this should be based on your knowledge of the individual child or young person, and on their views about what is beneficial to them.

Key question: How does a child's diagnosis help you to understand their strengths and contribute to a positive sense of who they are?

3. Take time to get to know the child or young person

It is much easier to understand when a neurodivergent child or young person is struggling if we know how they function when their health and wellbeing is good. This is particularly the case for children and young people who have learning disabilities, and who may have a very limited repertoire of behaviours to indicate when things are not ok. Other neurodivergent young people may be able to express themselves orally, but often find it difficult to make sense of how they are feeling, or to filter out the barrage of thoughts crowding their heads. Taking the time to get to know children and young people's likes and needs, and the places and people which make them feel comfortable, makes it easier identify when something is wrong, even if they can't – or won't – tell us.

Key question: What regular and motivating activities can you do with the child, which fit easily into the school day?

4. Liaise with those who know them best

Obtaining an in-depth knowledge of a child's mental health and wellbeing involves collecting assessment information from different sources and from those who know the child or young person best. In school, this is not always their class teacher. It may be a teaching assistant, another subject teacher, or a member of staff who takes a club they attend. Parents and teaching or support staff are often best placed to identify the signs that indicate a change in a child or young person's mental health and wellbeing (e.g., loss of appetite; change in sleep pattern and appetite; physiological changes such as fatigue or reduced engagement in activities; increase in behaviours such as self-harming or avoiding school). These key adults are also the ones who can provide information about where and how often these changes occur, and how long they last.

Key question: Are there other multi-agency professionals who have been working with the child who can contribute to a holistic assessment of how they are coping?

5. Don't underestimate the impact of the environment

School can provide children and young people with safety, consistency and a sense of belonging. Yet for children who have a more rigid thinking pattern and specific sensory needs, or who are stressed by change and unexpected events, many aspects of the school environment can adversely affect their wellbeing. Consider the different environments that children and young people access during the course of a day. Even in a small school or nursery setting, children have to manage a number of diverse settings and transitions throughout the day, including different rooms (e.g. hall, classroom, office, library), different activities and relationships in each class, and different settings (e.g., playground, sports pitch, corridor).

Key question: How do smaller transitions such as a change from one activity to another, or a change in teacher for the day influence a child's wellbeing?

6. Think about what has happened to them (not what is wrong with them)

Often, an assessment of a children's mental health focuses on 'what is wrong with them,' rather than considering what has happened to them, and around them. A holistic assessment of mental health takes a broader perspective and explores the interaction of the different environments and experiences on a child's wellbeing, including the home environment, their attachment experiences and trauma, as well as the impact of the cultural and social environment.

At times, the presentation of children who have experienced trauma may look similar to that of children and young people who are neurodivergent. For example, children who have suffered trauma may have difficulty processing sensory information or demonstrate very elevated anxiety levels and poor self-regulation. In some cases, a child's behaviours will be indicative of trauma that they have suffered, compounded by their neurodivergence. This requires involvement from all those supporting the child, and a sensitive reflection on events which may be experienced as traumatic for children and young people. Supporting a child's needs depends upon having safe and dependable adults who help to buffer them from the impact of trauma.

Key question: Have there been any recent events (e.g. a difficult change or loss) which have impacted on the child's presentation, or which have triggered previous feelings of grief, anger or anxiety?

7. Work out their Sensory Profile

How we process, interpret and integrate the sensory information that we receive from our environment determines how well we engage with activities. Managing our sensory input helps us to feel balanced and regulated, and to cope with big emotions. Many neurodivergent children and young people struggle to manage a lot of the sensory stimuli that they interact with from their internal and external environments. They may pay too much or too little attention to it. This can mean that they become dysregulated or overwhelmed.

Knowing a child or young person's sensory preferences and thresholds allows us to set up environments and plan activities that meet their sensory needs. This requires us to go beyond the five senses that we learn about at school (sight, taste, hearing, smell and touch) and to consider the vestibular and proprioception senses, which help us to interpret sensory information from our internal world. Whilst the vestibular sense is linked to balance and movement, our proprioception helps us understand where our body is in relation to objects around us. (These senses are often impacted in children and young people with learning disabilities).

Key question: How can your knowledge of a child's sensory preferences support them to stay regulated? (E.g. do they need more movement activities or time outside, or do they need time away from noise and in a small and quiet space?)

8. Match your Communication with theirs

A child's behaviours communicate to us what they are feeling, even if they cannot tell us using words, and even if they cannot make sense of it themselves. When neurodivergent  children and young people, or children with learning disabilities experience stress or anxiety, they will find it even harder to process and understand what is being said, or to 'use their words' in a way that is easily understood by others. They will also be less likely to have recourse to strategies that help them to calm down and to self-regulate. This may lead to them using other ways – such as crying or withdrawing and becoming very quiet – to communicate their needs and their level of distress.

Making sense of a child's communication skills (and interpreting their behaviour as communication) means that you will notice changes and behaviours which they use to communicate that things are not ok. This allows us to respond in a way that meets the child's needs, whilst supporting them to communicate their needs in a way that is more easily understood by others.

Key question: How do you adapt the strategies you use to support the communication of a child or young person? (e.g. the words you use objects, visuals, gestures, movement etc) 

9. Emphasise Exceptions, Motivators and Strengths

When we are concerned about a child's mental health and wellbeing it  can be easy to focus on what is wrong, and what is not working. Adopting a solution-focused approach, whilst keeping in mind the things that are contributing to a child struggling, can empower the child. Work with the child to find 'exceptions' – times or activities when they are feeling better, engaged, or connected to those around them. Highlighting their strengths – and building these into their day- can support the development of their interests or passions. This is also key to them developing coping strategies. 

Key question: How can you tell when a child is motivated or engaged in an activity? (e.g., what is their expression like, how do they communicate, move etc.)

10. And remember…Assessment is Intervention

Thinking about all of the factors that influence a child or young person's mental health and wellbeing enables you to build up a picture of how they are coping at school. Getting alongside a child or young person and getting to know them is not just part of your assessment, it is an integral part of an intervention too – and will ensure that the strategies and interventions you use to support them are based on a real understanding of their strengths, difficulties and motivators, and their means of communication. This is the most effective way to enhance a child's mental health and wellbeing over time.

Key question: What approaches and strategies have you used as part of the assessment process which have helped to enhance a child's mental health and wellbeing?