Disproportionality in SEN referrals: why so many boys?

It seems like one of those statements that has been said so many times and is so widely accepted that it must be true: boys are more likely than girls to have special educational needs (SEN).

Over the course of 50 years, research has consistently reported that around 2/3 to 3/4 of children and young people referred for SEN support are male (Rutter et al., 1970; Vardill & Calvert, 2000). In England in 2019/20, males accounted for 73.1% of pupils with Education, Health, and Care Plans (EHCPs), the most resource-intensive form of SEN support (Department for Education, 2020).

However, the longevity of male preponderance does not necessarily justify it. The term ‘disproportionality’ refers to over- and under-representation of groups (Frederickson & Cline, 2015). Given the importance placed on fair service provision by legislation (Department for Education, 2015; U.K. Government, 2010), one would expect there to be strong evidence in SEN research to justify disproportionality based on sex. In this article, I will explore whether this is the case in relation to three possible perspectives:

1. Genuine group differences exist between males and females, meaning males are more likely to have SEN
2. Bias and misinformation exist in the processes of identification, referral, and assessment of males and females
3. Males are deliberately, and possibly justifiably, targeted more than females for SEN support

Genuine group differences

The first argument is that disproportionality in SEN referrals represents genuine differences between males and females. On the surface, this proposition seems to be supported by prevalence data on common cognitive and neurodevelopmental conditions. Dyslexia is identified at a male-to-female ratio of around 1.6-2.4:1 (Quinn & Wagner, 2015), attention-deficit hyperactivity disorder at a ratio of around 2-3:1 (Sayal et al., 2018), and autism at a ratio of around 3:1 (Loomes et al., 2017).

If genuine group differences exist, they could be influenced by neurobiological and psychosocial factors. At the neurobiological level, researchers suggest the structure and development of the male brain makes boys more susceptible to having SEN. For example, the immunoreactive theory suggests male foetuses are more vulnerable to immune attack, which can have a malign influence on the developing male brain, leading to greater likelihood of neurodevelopmental difficulties in childhood (Gualtieri & Hicks, 1985). However, research involving women with immune disorders found no association between immune dysfunction and prevalence of neurodevelopmental difficulties in offspring, suggesting the immunoreactive theory is not supported (Flannery & Liederman, 1994).

At the psychosocial level, modest evidence exists that boys and girls are treated differently by parents, based on societal norms and stereotypes (Keil, 2014). For example, in Western cultures at least, parents typically talk to girls more overall and more about emotions, play more gently with girls and encourage more role-play, and are more understanding of emotional displays in girls (Maccoby, 2003).

There is even evidence that children’s play preferences may have a biological basis, independent of how parents interact with children. Research has found that higher testosterone levels in children of both sexes positively correlate with preference for playing with stereotypically male toys (Auyeung et al., 2009). It is possible that the preferences shown by boys and the ways parents interact with boys influence their likelihood of being identified with certain SEN. For example, if parents talk less to their sons and focus less on emotions, it is possible boys have fewer opportunities to develop their receptive and expressive language skills as well as knowledge of emotional vocabulary. However, establishing causality is complex and there is currently a lack of reliable evidence (Keil, 2014).

Assessment bias

The second argument is that bias exists in processes of identification, referral, and assessment.

Identification bias may exist at the level of school staff, who typically play a role in identifying and referring for SEN support. There is consistent evidence that boys tend to behave more disruptively in classrooms than girls and that these behaviours are noticed more by teachers (Anderson, 1997; Hill, 1994). In addition, there is evidence that observations of disruptive behaviour among boys lead to more referrals for educational psychology service support (Todman et al., 1991).

In one study, whilst teachers identified significantly more males than females as having ‘behaviour problems’, EPs who worked with the same children and gave their own assessment of SEN showed no significant sex differences (McConkey & O’Connell, 1982). This supports the proposition that identification bias may exist at the school staff level, specifically in relation to boys exhibiting more disruptive behaviour. However, it should be noted that this evidence is dated, suggesting follow-up studies should be conducted to assess whether these tendencies still exist, in an educational system where teachers may have more nuanced understanding of SEN.

A second form of bias may exist at the level of specialist professionals who diagnose neurodevelopmental conditions. Taking autism as an example, girls are less likely to be assessed for autism (Loomes et al., 2017), less likely to meet diagnostic criteria even if they have similar autistic traits to boys (Lundström et al., 2019), and receive diagnoses later in childhood on average (Shattuck et al., 2009). There is evidence that female presentations, or ‘phenotypes’, of autism differ to male presentations.

One example of an autistic trait that appears to be more prevalent among autistic females is camouflaging, which involves intentionally hiding autistic characteristics and employing more neurotypical strategies in social situations (Hull et al., 2017, 2020). Given that standard instruments used to diagnose autism were developed primarily using male samples, it is possible that such instruments are biased towards identifying a male ‘phenotype’ of autism (Lundström et al., 2019). In addition, it is possible the female autistic ‘phenotype’ is less well understood by clinicians or that clinicians may hold stereotypical views that boys are more likely than girls to have autism, which may consciously or unconsciously influence their decisions.

Deliberately targeting boys

The final argument is perhaps the most controversial and speculative. Male over-representation could be explored at the whole-class or whole-school systems level. Legislation places importance on the efficient education of all children (Department for Education, 2015), which might be negatively affected by disruptive individual behaviour, which is statistically more likely to involve males (Anderson, 1997; Hill, 1994).

Schools may see disruptive behaviour as a greater threat to overall class and school functioning and achievement than SEN such as specific learning difficulties and internalising mental health difficulties that would primarily affect individuals. In addition to some forms of male SEN presenting as more noticeable, they may also be seen as more systemically problematic and therefore more in need of high-intensity support such as EPS and EHCP referrals.

If this were true, it may present an ethical dilemma over whether EPs should provide support based on what is best for school systems, and the efficient education of all children, or the SEN of individual CYP (Health and Care Professions Council, 2016). It is possible this dilemma would be viewed differently by CYP, families, school staff, and EPs, suggesting it is a complex issue.

Conclusions and implications for practice

Given the paramount importance placed on fair and justifiable service provision (Department for Education, 2015; U.K. Government, 2010), current SEN research is inconclusive and insufficient to explain the sex imbalance in terms of males having more need than females. It is likely several forms of bias are at play but the extent to which these are justifiable is complex. Given the entrenched nature of male disproportionality, what can SEN professionals do to work towards fair provision? Here are five key ideas to take away as next steps:

1. Keep and monitor demographic data on referrals to establish the extent of local disproportionality and compare it to the national picture
2. Raise disproportionality in planning and review meetings, considering what the barriers or biases may be to ensuring fair provision
3. Conduct further research, for example on whether identification bias still exists at the level of school staff referring children for EP support
4. Consider the ethical implications of disproportionality from different stakeholders’ perspectives and whether it may be justifiable
5. Learn, and share information, about female ‘phenotypes’ of neurodevelopmental conditions such as autism, including how they may differ from stereotypical male ‘phenotypes’

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