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Specialist Registrar Training Disability – Dr. Roger Jenkins Child Protection – Dr. Jo Lewis • www.speakingforourselves.org.uk/index.php Get it right from the start Think about the important things to remember when breaking bad news. Right from the Start Video Response to Disability • Think about a child who has acquired their disability suddenly after a period of normal development. • Do you think this is different to a child with a congenital or early disability? • Are there differences in emotional or support needs for the family? • Sudden and dramatic change in the hopes and expectations of the child. • Sudden need to understand the ‘system’. • How do you deal with Agencies whose processes are designed around static or slowly changing needs? They tend not to be responsive to rapid change in ability or need. Head Injury • Head injury is the most common acquired neurological disability in children. • Survival from head injury is improving. • Good outcome is not improving. • Therefore survivors with disability is increasing. Head Injury • What are the three major causes of head injury in children in the UK? Head Injury • Road traffic accidents (Passenger or pedestrian) – What are the new regulations for passengers? • Falls (Particularly within the home) • Non-accidental / shaking injury (10% of total of those with serious head injury) Head Injury • What risk factors dispose to head injury? • How might the presence of these prior factors affect outcome? Head Injury • Related to socio-economic gradient. • Teenage males and increased risk taking behaviours. • Pre-morbid impulsivity and ADHD, learning disability. • Families are already disadvantaged and now have to accommodate the consequences of the injury. • The risk taking behaviour may continue into the recovery phase. • The core symptoms may have ongoing effects after the injury. Medium and Long-term Management • Disability specialists will become more involved in medium and long-term care of these patients. • What medium and long-term disabilities might follow from severe head injury? All cortical functions can be affected. • Physical problems – – – – Fatigability, epilepsy, headaches Vertigo, hydrocephalus, motor deficits Speech difficulties, sensory impairment Feeding difficulties, endocrine abnormalities • Intellectual deficits • Behavioural difficulties • Social/family difficulties Intellectual deficits • The more severe the HI and encephalopathy, the greater the risk of intellectual deficit. • Remember that 30% of children with head injury already have a pre-existing learning difficulty. • How much of the current deficit is due to the injury? • Difficult question if compensation involved. Cognitive Deficits • There are a wide range of possible cognitive impairments, but there are some characteristic patterns. • Some are subtle and are often not recognised. • Identification and appropriate intervention can have wide-ranging effects on school performance and behavioural difficulties. • Change in global IQ, with specific memory and learning difficulties. Traumatic Brain Injury • What brain structures are characteristically vulnerable after TBI? • What characteristic deficits may be expected to arise from damage to these areas? Traumatic Brain Injury • Inferior frontal and temporal lobes. • Dysexecutive syndrome. – – – – – – – Problems learning new material Better performance in highly structured environment Perform misleadingly well in psychological testing Struggle with expected emerging independence Reputation of being unreliable and disorganised Literal interpretation, leading to poor relationships Problems with maintaining or switching attention Challenging Behaviour • What kinds of challenging behaviours have you encountered in children and young people with learning difficulties? Sleep Disturbance • Very common in all children. • 20% of two year olds wake through the night. • 14% of three year olds. • More common in children with learning difficulties. • 86% of under five year olds. • 81% of six to eleven year olds. • 77% of twelve to sixteen year olds. Sleep Disturbance • Sleep disturbance is often persistent. • Associated with difficult daytime behaviours. • Associated with increased family stress as carers need their own sleep in order to function. • (Increased obesity?) Sleep Disturbance • Try to understand any causative factors. • Pain – Subluxation of the hip – Gastro-oesophageal reflux disorder • Sleeping during the day – Under stimulation during travel to school • Advice and behaviour modification first • Medication to be considered. Sleep Disturbance • Antihistamines • Benzodiazepines • Melatonin • Risperidone Abuse and Disabled Children: Hidden Needs. Cook P, and Standen P, Child Abuse Review, 11, 1-18, 2002 • Prospective study in The Midlands (1997-98) • Case conference plus disability (35 children) • Disability – 83% learning disability – 17% physical disability • Abuse – – – – 43% sexual 34% physical 20% neglect One case of emotional • Abuser known? Vulnerable to Abuse • Why do you think disabled children are more vulnerable to abuse? Tea break • Over to Jo Lewis