Asthma and behaviour – a modern parable

Asthma’s in the news at the moment because of an odd problem about something with an odd name. The problem is that it’s being overdiagnosed, diagnosis often leads to medication and too many people, many of them children, are using puffers when they don’t need to because they don’t actually have asthma, a dangerous condition in its most severe form.

From a lay perspective diagnosis might seem like an open and shut process. Medical professionals have a huge amount of knowledge in their heads and match what they see in a patient, the symptoms, with what they know could cause them.

A bit of reflection and Hey Presto, they make a diagnosis and come up with a strategy to fix the problem. We see the most positive type of diagnosis in action when we go to the doctor with a physical injury, cause and effect clearly linked and the treatment connected to both. The car door traps the finger that you show to the doctor who asks you how it happened. She judges it’s not broken but only bruised, sends you for an x-ray to be certain, gives you a once over and sends you home for tea and sympathy.

But even doctors can’t know everything, so they use reference guidelines especially when it looks likely someone has a condition for which there’s no definitive test to prove the diagnosis as is the case with asthma. The National Institute for Health and Care Excellence regulates health care and has new draft guidelines for England that say doctors should use more clinical, objective tests to back up their judgement and avoid the misdiagnosis of asthma.

The charity Asthma UK are saying that more funding is needed for research and the development of a definitive test, to eliminate the diagnostic subjectivity. Dr Samantha Walker of Asthma UK summed it up recently: “It is astonishing in the 21st century that there isn’t a test your child can take to tell if they definitely have asthma.”

Without doubt one specific objective test for asthma would be good, but certainly would be astonishing because asthma is a global term covering many different conditions with many different causes, triggered by different factors at different ages. To complicate things further symptoms that might indicate asthma change from day to day in a sufferer’s life and this overall complexity leads to it being both over- and under-diagnosed.

Off to school

As I was reading the article about asthma, it struck me that the position with regard to behaviour is similar in the way we in education attempt to diagnose and treat it as a single disorder.

Interestingly I can cut and paste from the paragraph above; “(behaviour) is a global term covering many different conditions with many different causes, triggered by different factors at different ages. Added to this the symptoms that might indicate (behaviour disorders) change from day to day in a sufferer’s life and this overall complexity leads to it being both over and under-diagnosed.”

But surely this is going too far, isn’t it? We’re educators not medics and we don’t diagnose disorders in school, we’re teachers interested in the best ways to promote learning aren’t we?

I’m not so sure. In the same way that current diagnostic methods used in the case of asthma are an uneasy mixture of subjective and objective assessments, the way we approach behaviour is a mixture of the two. We use our behaviour policy as a kind of diagnostic and treatment schedule, giving us reference guidelines. We certainly categorise bad behaviour as a disorder, a part of a child that’s is dysfunctional. School behaviour policy sets out the symptoms klthat indicate the level of severity of the disorder. We collect diagnostic data by means of unsystematic observation, but this is well-known to be unreliable and prone to observer bias. For example, badly behaved children come under more scrutiny than their well-behaved peers so their files listing symptoms grow proportionately thicker, faster. The data set is then matched to the intervention schedule in the behaviour policy and the appropriate level of punishment applied, as the treatment for the behaviour disorder.

We do seem to have medicalised what we term ‘behaviour’ as a problematic disorder of many children in schools. Even given the diffuse and fuzzy relationship between causes and effects, we stick to one-size-fits-all medical-type interventions. Where the treatment fails to cure the illness, we transfer children out of mainstream school to more specialised treatment facilities, where we assume they can be cured by specialist treatment. Maybe they’ll go to a Pupil Referral Unit where the treatment they get is intended to normalise their behaviour and enable them to return to mainstream school in a few months. When I taught in a PRU it was called ‘the revolving door’, although in practice it tended to stay closed. Or maybe they’ll get a formal diagnosis of behaviour disorder and this will be their ticket to special school, where the aim is to cure their disorder over a longer term and educate them at the same time. Or maybe we’ll shift them sideways, manage-move them to another school where they don’t know anyone and that might be the cure they need, to be a stranger in a new community – social disorientation or a fresh start? Depends how you look at it.

What questions does this raise?

Taking the essentially medical approach to behaviour and focusing on deficits, diagnosis and treatment raises some structural questions.

Is it right to cast what might be developmental issues as disorders and disabilities when they could equally well be seen as transitory phases connected with growing up and learning how to be?

The children who get swept together with the behaviour brush are likely to have additional educational needs, to be living in care, or disadvantaged in other ways and are heavily over-represented in exclusion data. Are we saying that the type of behaviour that triggers permanent exclusion is a fixed characteristic of these children and not likely to change and this justifies their ejection from their community and their school? If so why are we funding and expanding alternative provision whose intended outcome is to change them? If not why do we set such a high barrier to their transfer to high quality specialist schooling? If we don’t see bad behaviour as a fixed characteristic then are we only excluding these children because we don’t have any way of teaching them that results in their behaving differently – in other words we’re stuck so they have to go?

Are we saying that mainstream schooling is only fit to meet the needs of children at the centre of a normal distribution for a wide range of characteristics and that children who do not match up should be identified as soon as possible and directed elsewhere, to home schooling or specialist provision?

And the big questions: What’s the alternative?

There are alternatives to focusing on deficits and taking a deficit-focused diagnostic approach to the changing and often unpredictable needs of children as they grow up – and of their teachers and other adults in school for that matter.

From outside education, taking a broad view clinical psychologist Peter Kinderman proposes a shift towards a psychosocial approach to wellbeing and mental health. Martin Seligman and Mihaly Csikszentmihalyi have developed the idea of positive psychology, focusing away from the general preoccupation of psychology with dysfunction and towards positive aspects of human life, such as happiness, well-being and flourishing and human strengths such as hopefulness, creativity, intrinsic motivation, and responsibility.

As a teacher/researcher I’ve been working with the solution-focused approach to pastoral support, centred on behaviour but with the much wider application of a non-specific strengths focused approach to any hoped-for change.

There are numerous examples of committed educational professionals challenging the prevailing conventions, Nancy Gedge, Tom Sherrington, Tim Taylor for example all thinking and writing about their ideas and communicating on the web.

I believe it’s in a teacher’s nature to gravitate towards kindness and compassion as a counter-balance to the necessary control and regulation that we as adults model for growing children. I believe the shift towards the recognition of strengths and all this brings in supporting children’s healthy image of themselves and their wellbeing has come of age.

Now we need to join hands in doing more of it, more of the time, to the benefit of all.



1500 words