“I didn’t know what I didn’t know!”: Improving confidence of postgraduate psychology students to support children with language difficulties through a targeted education intervention

Abstract

Psychology students receive little content related to supporting mental health among children with language difficulties (language difficulties), which contributes to low confidence to support this population. Postgraduate psychology students (n = 96) received an education intervention (one lecture and one tutorial) on links between language and mental health difficulties and implications for practice. Knowledge, experience, and confidence were explored via pre- and post-surveys and follow-up interviews. Over 40% of students reported low levels of knowledge, education, and confidence to support people with language difficulties. Confidence significantly increased following the education intervention (p < .001). Interview data provide preliminary evidence of the effectiveness of the education intervention in enhancing awareness of links between language difficulties and mental health and the value of collaboration between psychology and speech-language pathology (SLP). These findings support the involvement of SLPs in psychology training; however, both disciplines must continue to advocate for ongoing collaborative learning opportunities to promote positive outcomes for children with language difficulties.

Keywords:

• mental health
• developmental language disorder
• dyslexia
• education
• psychology
• speech-language pathology

Introduction

Approximately 25% of Australian children live with low language proficiency, meaning that their understanding and use of spoken and written language falls below levels expected for their age and/or year of schooling (Goldfeld et al., 2018; Hill et al., 2023; Lum, Powell, & Snow, 2018; Norbury et al., 2021). Language difficulties). Many factors may contribute to the presence of language difficulties. Higher rates of low language proficiency are observed amongst children from low socioeconomic areas, those who have had reduced exposure to language rich environments, and/or speak English an additional language (Goldfeld et al., 2018; Lum, Powell, & Snow, 2018; Norbury et al., 2021). However, up to 10% of children experience severe and persistent language difficulties that are neurocognitive in origin and cannot be explained by medical or sociocultural factors. These children may meet criteria for developmental language disorder; persistent difficulties in expressive and receptive language) (Bishop et al., 2016; Reilly et al., 2017) and/or developmental dyslexia (persistent difficulties in reading and spelling; Wagner et al., 2020).

Irrespective of underlying aetiology, low language proficiency places a young person at substantially elevated risk of internalising and externalising mental health problems (Conti-Ramsden et al., 2019; Donolato et al., 2021). Regarding internalising, low language proficiency is associated with increased stress, worry, anxiety, depression (Belhadj et al., 2015; Botting et al., 2016). Externalising difficulties associated with poor language include disruptive behaviour and aggression (Anderson et al., 2014). Young people with low language skills are more likely than their peers to experience suicidal thoughts, academic disengagement, and incarceration (Anderson et al., 2014; McBride et al., 1997). Consequently, a large proportion of young people engaging with formal mental health support are likely to exhibit difficulties with language skills (Scarselli et al., 2022). Yet, evidence-based psychological interventions are predominantly “talking therapies” and inaccessible and/or inappropriate for people with language or literacy difficulties (Hobson et al., 2023). Furthermore, mental health practitioners have reported reduced confidence to work with people with language difficulties (Hancock et al., 2023) which, in part, has been attributed to limited pre-service and/or professional training in adapting or delivering treatments with clients with low language proficiency (Hancock et al., 2023; Hobson et al., 2020). Importantly, Hancock and colleagues (2023) suggested multidisciplinary education – driven by collaboration between experts in language and mental health – would be a key enabler of the provision of timely and accessible mental health for people with language difficulties.

Consistent with these findings, Speech Pathology Australia (SPA), Australia’s national body for speech pathology, has recognised the role of speech-language pathologists (SLPs) in “collaborating with other mental health professionals….to ensure communication difficulties are considered in the context of mental health interventions” (p.3). Critically, the position statement highlights the need for this training and advocacy to occur within the population of “university students who are likely to work with people with mental health difficulties” (SPA, 2018, p. 6). To the best of our knowledge, there has been no prior investigation into the effectiveness of the education interventions to improve knowledge and confidence of future mental health professionals to support young people with language difficulties.

Aim

We developed course content on the topic of language and mental health for postgraduate psychology students as part of their clinical training. The aim of the current study was to investigate the efficacy of this course content on self-perceived confidence to support young people with language difficulties amongst postgraduate students enrolled in an Australian Master of Professional Psychology (MPP) program.

Method

Study Design

We used an explanatory sequential mixed methods design to explore the effect of targeted education intervention (described below) on students’ self-perceived confidence to support young people with co-occurring language and mental health difficulties. To obtain a greater understanding of students’ perspectives on changes to their confidence and their experience of the intervention, data were triangulated using an online survey (completed pre- and post-intervention) and an additional 1:1 interview with a member of the research team (Fetters et al., 2013). Ethics approval was obtained from the Curtin University Human Research Ethics Committee (HRE2022-0468).

Participants

The participants in this research project were students enrolled in the Master of Professional Psychology (MPP) program at Curtin University. Students were eligible to participate in the research if they were currently enrolled in the program and had taken part in the lecture and tutorial content as outlined below. Between 2022 and 2023, there were 96 students enrolled in the MPP program.

Study Context

The MPP program is a one-year program of coursework and placement accredited by the Australian Psychology Accreditation Council. The coursework covers topics relevant to professional psychology (e.g., assessment and intervention across the lifespan) and placements are offered in a range of settings including schools. MPP students are provisionally registered psychologists with variable duration and breadth of clinical experience. The education intervention delivered in this study took place within a unit that develops theoretical knowledge and skills required to deliver psychological interventions to children and adolescents. Prior to the education intervention described in this study, the MPP program at Curtin University, has not included content related to language and literacy development or disorder.

Education Intervention

The education intervention comprised a two-hour lecture and a one-hour tutorial developed by two authors of this paper (a qualified SLP and a mental health researcher with training in educational and developmental psychology). The lecture included three sections related to language and mental health. Section one presented foundational concepts related to language, and its importance for socioemotional development, school, and work. Section two described low language proficiency, generally, as well two common disorders of language (oral and written): developmental language disorder and dyslexia, with insights into prevalence, diagnosis, and functional impact. The additional focus on developmental language disorder and dyslexia was driven by their high prevalence in educational settings (Reilly et al., 2017; Wagner et al., 2020) and the educators' areas of expertise. Section three related to implications of language difficulties – broadly - for psychological practice, addressing assessment (and intervention processes. Section three covered strategies to support language in clinical practice, including visual aids and teaching relevant vocabulary (e.g., emotion words; Tingir et al., 2019; Zimmerman et al., 2020). The tutorial was centred around three case studies (see supplementary materials). Students worked in small groups to discuss an allocated case study and generate responses to activity questions/prompts to inform whole-class discussion.

Survey

All students enrolled in the unit were invited to complete an anonymised online survey before and after engaging in the education intervention. The pre-intervention survey was completed in the first 15-minutes of the lecture. The post-intervention survey was advertised to the students via email immediately after the tutorial session, with weekly reminder emails sent to the students for three weeks post tutorial. Both surveys were hosted on Qualtrics. The pre-content survey (see supplementary material) aimed to capture students’ prior professional experience and/or education and training related to language and literacy difficulties using multiple choice and open-text response questions. Further, students were asked to provide ratings of their confidence to support young people with language difficulties. The post-content survey invited students to rate their perceived confidence to support young people with co-occurring language and mental health difficulties; comment on what they valued about the education intervention, what should be changed, and any other contributions related to education or practice in this area.

The Therapy Confidence Scale

Students’ confidence to support young people with language difficulties was assessed using an adapted version of the Therapy Confidence Scale – Intellectual Disabilities (TCS-ID; Dagnan et al., 2015). The TCS-ID is a 14-item self-report questionnaire to assess mental health practitioners’ confidence to work with people with intellectual disabilities. The TCS-ID has good internal consistency (Cronbach's α=.93) and test-retest reliability (r = .83; Dagnan et al., 2015). The first author of this study adapted the TCS-ID to measure students’ confidence to support people with language difficulties (the TCS-LD) (see Supplementary Material). Minimal adaptations were made beyond replacing ‘intellectual disability’ with ‘language difficulty’, e.g., "How confident are you that you can listen carefully to concerns presented by a client with language difficulties?". Students rated their confidence on a 5-point Likert scale from 1 (Not confident) to 5 (Highly confident) on each item (Dagnan et al.,2015; Hinde & Mason, 2020). The total score represents an overall measure of self-confidence to support people with language difficulties (maximum score = 70). Cronbach’s alpha for pre-intervention survey was α = 0.88 and for the post-survey was α = 0.93, indicating good internal consistency.

Semi-structured Interview

After completing the post-content questionnaire, students were invited to take part in a follow-up interview with a member of the research team. The aim of the interview was to explore student’s perspectives on assessment and/or intervention for mental health in young people with language and communication difficulties, the perceived impact of language difficulties on mental health practice, and experience of the lecture and tutorial content (interview guide available in supplementary materials). The interviews lasted approximately 30 minutes and took place either face-to-face on the University campus or via WebEx (at the participant’s discretion). Interviews were audio-recorded and transcribed for analysis. All interviews took place within four (4) weeks of the education intervention.

Data analysis

Quantitative data

Descriptive and frequency statistics were calculated to represent the characteristics of the sample, including the proportion (%) of students who have direct clinical experience working with people with language difficulties and relevant education and training. Independent and paired-samples t-tests were used to examine changes in TCS-language difficulties total scores following the education intervention (alpha level was set at p <.05) across the whole cohort and on a subset of participants whose scores could be matched pre- and post-intervention.

Qualitative data

Interview transcripts and open-box comments to survey questions were combined for analysis. Coding took place at both an inductive and deductive-level as outlined by Braun and Clarke (2022). From this, two themes were developed to address the research question. Direct quotations from participants were used to illustrate each theme.

Results

Participants

Of 96 students who engaged in the lecture and tutorial content between 2022 and 2023, 80 (83.3%) responded to the pre-content and/or post-content questionnaire. Eighty participants completed the pre-content questionnaire, and 30 participants (31.3%) completed the post-content questionnaire. 16 students (18.8%) completed both the pre-content and post-content questionnaire. Five students took part in the additional qualitative interview.

Survey

Of the total sample, 47.5% (n = 38) reported previous experience working with young people with language difficulties, and 21.3% (n = 17) reported prior training related to supporting people with language difficulties. Of those who reported previous experience working with people with language difficulties, the majority (n = 20) attributed this experience to working with people with autism spectrum disorder. Others noted experience working with people with developmental disorders (e.g., language difficulties; n = 6), dyslexia (n = 5), specific learning disorders (n = 4), and/or acquired brain injuries (n = 4).

Overall, the student sample reported significantly higher TCS-language difficulties total scores after engaging in the education intervention (M = 53.67, SD = 7.73) compared to pre-intervention scores (M = 43.05, SD = 7.92), t(108) = −6.30, p<.001, d = 7.87 (large effect). The same pattern was observed following a paired samples t-test of the 16 participants¹ who completed both the pre-content and post-content questionnaires (see descriptive statistics for individual items in Table 1). On average, participants’ total self-confidence scores were 8.50 (95% CI [−12.87, −4.13]), higher after engaging with the education intervention (M=54.94, SD= 9.20) compared to pre-intervention scores (M = 45.44, SD = 5.94), t(15) = 4.15, p<.001, d= 8.20 (large effect). Two themes were developed from the analysis of data from the semi-structured Interviews and open-box survey responses.

Table 1. Descriptive statistics for individual items on the TCS-LD* (n = 16)

	Pre	Post
TCS-LD Item	M(SD)	M(SD)
How confident are you that you can listen carefully to concerns presented by a client with a language difficulty?	3.81(.83)	4.13(.81)
How confident are you that you can be empathetic towards a client with a language difficulty?	4.75(.45)	4.50(.63)
How confident are you that you can understand special issues related to having a language difficulty, and its impact on a person’s life?	3.06(.77)	3.94(.68)
How confident are you that you can communicate with a client who has a language difficulty?	3.44(.81)	3.81(.98)
How confident are you that you can develop a therapeutic relationship with a client who has a language difficulty?	3.50(1.10)	3.94(1.00)
How confident are you that you can gather information from a client with a language difficulty, so that their difficulties can be better understood?	2.94(.85)	3.81(.91)
How confident are you that you can use assessments in a way that a client with a language difficulty will understand?	2.56(.96)	3.38(.62)
How confident are you that you can explain results of an assessment process to a client with a language difficulty?	2.63(.72)	3.38(.89)
How confident are you that you can use knowledge about mental health issues in formulating the problems of a client with a language difficulty?	3.06(.68)	3.88(.72)
How confident are you that you can help a client with a language difficulty to identify issues that need to be considered in sessions?	2.94(.85)	3.56(.89)
How confident are you that you can use knowledge of mental health interventions to work effectively with a client who has a language difficulty?	3.13(.62)	3.69(.79)
How confident are you that you can identify therapeutic approaches that will be effective for a client with language difficulty?	2.94(.85)	3.75(.77)
How confident are you that you can work with care-givers and other important people in the lives of people with a language difficulty?	3.81(1.11)	4.31(.95)_
How confident are you that you can end intervention with a client who has a language difficulty in an effective manner?	2.88(1.09)	3.88(1.02)

Note: The TCS-LD is an adapted version of the Therapy Confidence Scale-Intellectual Disabilities (Dagnan et al., 2015).

Theme 1: Awareness comes first but skills needed next

Across the dataset there was a sense that receiving the education intervention was the first time some students had reflected on the link between mental health and language difficulties. Relatedly, many of the interviewees were not aware of receiving any the education intervention of this nature in their undergraduate program. Developing student awareness of links between language difficulties and mental health was one of the aspects of the course content that students appreciated and perceived that this contributed to their levels of confidence. For instance, in their evaluation of the intervention, one student wrote:

“It [the course content] opened my perspective to understanding people with language difficulties much more.”

Similarly, in their interview, one student commented:

“Communication is the basis of doing psychological work. So, if there's something there that is going to impact on someone's ability to communicate and receive communication, then that just feels like that is something that's so basic and important that we're just not aware of.” (P.01)

Some students reflected on the contribution of a lack of awareness about language difficulties to stigma or discrimination in the therapy context and beyond. For instance:

I think it's great to even get the awareness out there and to get the conversation going. I think there's a tendency to think that if someone has language difficulties, it means on an intellectual level they may not be as competent. (P.03)

Relatedly, when asked about barriers to psychological work, many students expressed their perception that language difficulties may be a barrier to traditional, language-heavy therapy approaches. For instance:

“Therapy is inherently a talking process so this would have to look differently, and you would probably need to find a psych that has some more specialised training in this area.”

In contrast to this comment (above) which suggests referral to a specialist psychologist may be what is required, many other students expressed a perception that all psychologists have a responsibility to adapt their methods to accommodate for language difficulties. Indeed, translating knowledge and awareness to the skills to adapt practice is where many students felt they needed further support and training to enhance their confidence. When asked about changes to the course content, many students expressed wanting more examples, case studies, role plays, opportunities for mentoring or ongoing professional development to develop their skills in working with people with language difficulties. For instance:

“I would love to hear about case examples of clients with language difficulties and how treatment was modified to suit their individual needs, to grasp an idea of how we might do this in practice.”

Theme 2: The value of inter-disciplinary practice

When asked about what they valued about the course content, many students reflected on the interprofessional approach, for instance:

“Hearing multi-disciplinary perspectives and understanding how to work as a team to best support people with learning/language difficulties.”

Relatedly, one student mentioned that they wanted to learn more about a broader range of language difficulties and some students expressed value of, and interest in, learning about what SLPs do. For instance, when asked about improvements to the course content, one student wrote:

“…provide more information about what a Speech Pathologist does, to assist in understanding of what it is like for a client to be engaging with a speechy [speech and language pathologist].”

There was a sense across the dataset that many students were aware that they may need to work alongside other allied health professionals in the future In fact, the importance of working confidently in an interprofessional fashion, in particular, psychologists partnering with SLPs to support the mental health and wellbeing of children with language difficulties was a recurring pattern across the dataset. For example, one interviewee expressed concern that children may “fall though the gaps” if health professionals work in isolation.

“I think we're just too individualised with our approaches to treatment. I think there needs to be a lot of cross-collaboration going on.”

Discussion

We aimed to determine whether targeted education intervention related to language and mental health could enhance MPP students’ self-perceived confidence to support young people with language difficulties. Past research has indicated reduced levels of knowledge and self-confidence amongst psychologists and mental health professionals related to supporting young people with co-occurring mental health and language difficulties (Hancock et al., 2023; Hobson et al., 2020). Targeted interventions at the pre-service level – or during tertiary training – have been identified as a key enabler of accessible and effective mental health support (Hronis et al., 2018; Man et al., 2017).

Relative to the total possible score on the TCS-LD, our data showed low levels of confidence amongst students. Interestingly, the central tendency and spread of total TCS-LD scores and individual items prior to the education intervention are comparable to those reported by Hronis et al (2021) in their study of therapeutic confidence of qualified Australian psychologists in the context of intellectual disability. Survey and interview data also indicated variable, yet generally limited, knowledge, and prior education related to language difficulties and implications mental health support, which is also in keeping with former studies (Hancock et al., 2023; Hobson et al., 2020). We do note that approximately one-fifth of students reported receiving previous education related to language difficulties, which may have been presented in undergraduate curricula or professional development prior to engaging in the education intervention. However, students who did receive prior education in this area were in the minority..

Generally, the education intervention increased the therapeutic confidence of MPP students based on changes to TCS-LD total scores. However, as the survey was live for three weeks following the intervention, it is not possible to conclude whether this change reflects an immediate post-intervention effort or a spaced effect of the content on students’ confidence. Further investigation into the maintenance of confidence levels over time following a similar education intervention is warranted. Despite this, our findings echo past research that has demonstrated the effectiveness of curriculum content in enhancing students’ confidence to support people with disabilities (Boyd et al., 2008). To our knowledge, this is the first study to document such improvements in the context of child language difficulties and mental health.

Our qualitative data indicated that one of the key drivers of this enhanced confidence was an increase in awareness of language and literacy difficulties, their impact on mental health, and implications for mental health assessment and treatment. Indeed, for most participants this was the first time they had received dedicated education intervention related to language and literacy difficulties across their undergraduate or postgraduate studies. This is a similar trend as that which has been observed for mental health and co-occurring intellectual (Hronis et al., 2018) and acquired disabilities (Baker et al., 2021), where psychologists attribute a critical lack of professional and training development to reduced clinical self-confidence. While the education intervention in this study was effective in enhancing awareness and confidence, our qualitative data indicate that students require more in-depth and ongoing support to enhance their skills. Mental health professionals would benefit from exposure to relevant, and freely available resources published by organisations such as the DLD Project and Raising Awareness of DLD (RADLD), particularly those related to socioemotional and mental health outcomes.

The students’ reflections on the need for greater support to develop skills is unsurprising given the education intervention aligned more closely with knowledge-based learning (Bailey & Ragland, 2022). That is, the lecture and tutorial aimed to enhance students understanding of language and literacy disorders, their prevalence, and impact on mental health. While the content covered the need for, and potential ways to, adapt mental health assessment and treatment processes, the students were not provided with the opportunity to practice or demonstrate these skills. Our results indicate that SLPs should be involved in the development and delivery of authentic, engaging, and practice-based opportunities within psychology units to further develop students’ clinical competence and confidence (Bailey & Ragland, 2022). Indeed, clinical education is a vital component of the curriculum in most health science courses providing students with the opportunity to develop their competence in the application of theory to practice (Brewer et al., 2009). Our results, in keeping with past literature, indicate that psychology students would benefit from working alongside SLPs to support clients with co-occurring language and mental health difficulties during clinical placements, which are “the ideal learning environment for developing skills conduct to collaborative practice” (Hilton & Morris, 2001, p.173) in the context of mental health (Marcussen et al., 2019).

Consistent with the position of SPA (2018), MPP students recognised the value of, and need for, involvement of SLPs in mental health. Specifically, the students recognised the value of receiving interprofessional learning from SLPs during their studies. This is consistent with the view that exposure to a range of professions relevant to mental health is critical to enhance clinical confidence and competence amongst clinicians working with young people with co-occurring challenges, including language difficulties (Hancock et al., 2023; Hobson et al., 2020; Man et al., 2017). Consistent with criticisms of contemporary mental health services, the students commented on the tendency for professionals to work in ‘silos’ and acknowledged potential consequences for children’s timely access to support (Doll et al., 2017). Importantly, students commented on the effect of speech pathology lecture and tutorial content on their perceived confidence and readiness to work with SLPs in the future. However, our findings indicated a need for more detailed orientation to the scope of practice of SLPs and their role in mental health. This information is widely available through SPA and could be easily integrated into psychology curricula.

Limitations and Future Directions

This study should be interpreted in light of several limitations. The education intervention focused on child language difficulties, including developmental language disorder and developmental dyslexia, including their prevalence, diagnostic criteria, characteristics, and overlap with mental health difficulties. While this focus was largely determined by the MPP unit in which content was delivered, information related to adult mental health and acquired language or literacy difficulties should be considered when designing future curricula. Second, due to an administrative error, within-subject comparisons of TCS-LD scores could only be carried out on a subset of students within the cohort. While the result of this analysis was consistent with data from the broader cohort, future studies should investigate within-subject changes in confidence on a larger scale. Third, participants’ confidence was collected at two points only (pre and post intervention). Consequently, we are unable to conclude whether the increased confidence levels observed in this study would be maintained over time. It is possible that confidence may in fact decrease over time. Indeed, an inverse relationship between confidence and knowledge over time has been reported in medical (Clanton et al., 2014) and health education literature (Moreno et al., 2021), akin to a ‘clinical competency’ version of the Dunning-Kruger effect (Dunning, 2011). Mental health practitioners may require ongoing education and/or professional development to support therapeutic confidence levels in the long-term. Finally, this was a novel exploration into the effectiveness of education intervention provided to MPP students using an adapted measure of therapeutic confidence. To our knowledge, this is the first time a tool of this nature has been used to measure the confidence of mental health professionals to support people with language difficulties. The adapted TCS-language difficulties was sensitive to changes in students’ confidence following the lecture and tutorial; thereby providing preliminary support for its use. Our results indicated good internal consistency of the measure; further exploration of the reliability of the tool would be a salient avenue for future research.

Our study demonstrate that one lecture and one tutorial session were sufficient to bring about observable change in MPP students’ confidence to support young people with language difficulties. However, we recognise these sessions – though effective –are not sufficient to enhance students’ clinical knowledge and skills to provide mental health assessment and treatment to this population. Future studies should examine the benefits of extended education interventions that integrate knowledge- and skill-based learning, with authentic and practical learning opportunities, such as would occur in clinical placement or supervised exposure in practice in collaboration with SLPs. Our study provides preliminary support for collaboration between SLP and psychology in the education of postgraduate psychology students and its impact on their confidence to support young people with language difficulties. However, SLPs must continue to advocate for their role in the lifelong education of mental health professionals. These efforts will ensure that mental health professionals develop and consolidate the knowledge and skills required to provide timely, accessible, and targeted mental health support to young people who experience challenges with language and communication.

Acknowledgements

The authors wish to acknowledge, Associate Professor Trevor Mazzuchelli, who was instrumental in facilitating the education intervention.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Mark Boyes is supported by the National Health and Medical Research Council, Australia (Investigator Grant 1173043). This project was funded by Curtin School of Allied Health, Western Australia.

Notes

1 Due to an administrative error, we were only able to conduct within-subjects comparisons pre- and post-content on a subset of participants (n = 16). The pattern of results was identical to the pattern in the full sample.