Specialist Registrar Training

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Specialist Registrar Training

• Disability Dr. Roger Jenkins
• Child Protection Dr. Jo Lewis

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• www.speakingforourselves.org.uk/index.php

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Get it right from the start

• Think about the important things to remember
  when breaking bad news.

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Right from the Start Video
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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?

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• 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.

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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.

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Head Injury

• What are the three major causes of head injury in
  children in the UK?

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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)

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Head Injury

• What risk factors dispose to head injury?
• How might the presence of these prior factors
  affect outcome?

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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.

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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?

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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

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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.

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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.

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Traumatic Brain Injury

• What brain structures are characteristically
  vulnerable after TBI?
• What characteristic deficits may be expected to
  arise from damage to these areas?

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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

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Challenging Behaviour

• What kinds of challenging behaviours have you
  encountered in children and young people with
  learning difficulties?

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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.

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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?)

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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.

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Sleep Disturbance

• Antihistamines
• Benzodiazepines
• Melatonin
• Risperidone

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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?

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Vulnerable to Abuse

• Why do you think disabled children are more
  vulnerable to abuse?

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Tea break

• Over to Jo Lewis