Childhood disability Flashcards
What is the definition of disability?
someone who has a physical or
mental impairment that results in a marked, pervasive limitation of activity
Definition of impairment
an abnormality or loss of function
* In the UK 7.3% of children are reported to experience disability
Types of impairments
Physical
E.g. cerebral palsy, brain injury, neuromuscular disorders, musculoskeletal conditions-ABI
* Sensory Impairments
Hearing and visual impairments
* Learning e.g. low IQ
* Neurodevelopmental disorders
E.g. ADHD, Autism -
* Emotional/Behavioral
E.g. Depression Conduct disorder, attachment disorder D
What determines disability - biopsychosocial model
Biological
Social
Psychological
Mental Health
What determines disability?
- Disability is best considered using a ‘biopsychosocial model’
- 2 people with the same impairment may experience different levels of disability
- Social background and environment as well as the impairment determine disability.
- A medical diagnosis does not give us information about a childs level of
- FUNCTIONING
- ACTIVITY
- and their ability to PARTICIPATE
WHO-DAS-WORLD HEALTH ORGANISATION
DISABILITY ASSESSMENT SCHEDULE
- A generic assessment instrument for health and disability
- Used across all diseases, including mental, neurological and addictive disorders
- Short, simple and easy to administer (5 to 20 minutes)
- Applicable in both clinical and general population settings
- A tool to produce standardized disability levels and profiles
- Applicable across cultures, in all adult populations
- Directly linked at the level of the concepts to the International Classification of Functioning, Disability
and Health (ICF)
WHODAS 2.0 COVERS 6 DOMAINS OF
FUNCTIONING
- Cognition – understanding & communicating
- Mobility– moving & getting around
- Self-care– hygiene, dressing, eating & staying alone
- Social– interacting with other people
- Life activities– domestic responsibilities, leisure, work & school
- Participation– joining in community activities
HOW DOES THE IMPACT OF THE IMPAIRMENT VARIES BETWEEN
INDIVIDUALS AND WILL CHANGE OVER AN INDIVIDUALS LIFE
COURSE. A CHILD’S SUPPORT WILL NEED TO BE RESPONSIVE TO
THIS.
Medical diagnosis
(the impairment) +
Social Factors
Environment
Cultural factors
Life stage
>
Level of disability
>
Participation and functioning
How can we support children with impairments
Holistic assessments
* Address medical, social, environmental and psychological factors for the best outcomes
* Child focused
* Involves work with a multi-disciplinary team
- ASHLEY IS A 2 I/2 YEAR OLD WITH WILLIAMS SYNDROME HE HAS THE TYPICAL FEATURES
WITH GLOBAL DEVELOPMENTAL IMPAIRMENT,DYSMORPHIC FEATURES VISUAL
IMPAIRMENT POOR GROWTH AND SUPRAVALVULAR AORTIC STENOSIS
Dad was violent towards Mum and they have separated. Mum has been housed in local
authority accommodation away from her family. Mum is struggling on her own with
limited English and is low in mood. - AB is not walking, he has no language and is behind in his fine motor skills. How would
you support AB
HEALTH - EDUCATION - SOCIAL CARE
* Physiotherapy
* Speech and Language therapy
* Dietician
* Doctors-Paediatrician and Cardiologist
* GP-Mum to seek support for her mental health
* Portage/ Early years inclusion
* Housing support worker
* Social worker
* Team around the child meetings
TYLER IS 10 YEARS OLD, HE WAS BORN EXTREMELY PREMATURELY AT 25 WEEKS
GESTATION. HE HAS BILATERAL CEREBRAL PALSY. HE USES A WHEELCHAIR FOR MOBILITY.
HE IS DEPENDENT ON HIS CARERS FOR ACTIVITIES OF DAILY LIVING. YOU SEE HIM IN
CLINIC, WHAT DO YOU WANT TO REVIEW?
- WHO-DISABILITY ASSESSMENT SCALE
- 6 DOMAINS
- Health –education –social support
- Cognition
- Mobility-hand function
- Communication
- Self care -Feeding
- Sleep
- Equipment needs and assistive technology
- Educational provision
- Emotional/behavioural needs
- Optimising participation
- Disability living allowance, respite care, direct payments
- Social work involvement – childrens disability team
CONNOR IS 8 YEARS OLD, HE HAS RECENTLY BEEN DIAGNOSED WITH AUTISM
HE HAS STRUGGLED IN MAIN STREAM SCHOOL WITH LEARNING , COMMUNICATION AND SOCIAL
INTERACTION. HE DIFFICULTIES CAN CAUSE BEHAVIORAL OUTBURSTS AND HE HAS BEEN
EXCLUDED FROM SCHOOL SEVERAL TIMES.
HOW CAN YOU ASSESS HIM AND SUPPORT HIM?
- Autism Assessment –Social communication/Interaction style
- Speech and language therapy –Level of communication
- Educational psychology assessment –Cognitive assessment
- Emotional support and family support –Clinical psychology /Primary Mental Health Workers /
- School based support –
- Nurture groups and social skills support
- Autism team to offer strategies
- Intervention
- Needs My plan / EHCP-Education and Health care plan -Special school
FATIMA IS A 3 YEAR OLD BORN IN SYRIA.SHE HAS RECENTLY MOVED TO THE UK AND
STARTED NURSEY WHERE SHE WAS FOUND TO BE QUIET WITH NO SPOKEN LANGUAGE.
HEARING ASSESSMENT FOUND HER TO HAVE A SEVERE SENSORINEURAL HEARING LOSS.
WHAT DO YOU DO NOW
Audiology Hearing aids
* Referral for consideration of cochlear implant
* Community / Neurodisability Paediatrician
* Speech and language therapy
* May need to consider alternative forms of communication e.g. sign languag
* Education
* Teacher for the deaf
* Increased risk of social, emotional, education difficulties so need to work with education to optimize support
* Social care –Trauma/Loss –Emotional aspects
* Immigration status –Community support
JO IS A 9 YEAR OLD WITH GENDER DYSPHORIA REFERRED FOR AN
AUTISM ASSESSMENT . JO BECAME SUICIDAL WHEN BREAST
DEVELOPMENT WAS NOTED
- Doctor
- 3 specialist psychologists
- Endocrine consultant –Gonadotrophin analogue
- Home educated
- Voluntary sector -Role
Important factors about disabled people
- Disabled children are more likely to live in poverty
- Parents are more likely to be unemployed
- Higher rates of mental health needs
- Poorer physical health and lower life expectancy
What are the treatment goals for the quality of life?
- Our definition of quality of life is: The degree to which a person enjoys the important
possibilities of his/her life. - Being –who one is
- Belonging –how one fits into the environment
- Becoming –How to have purposeful activities in order to achieve ones goals
What are the aims of management to improve the quality of life?
- Listening
- Medical support
- Educational support
- Social -Financial support – disability living allowance
- Emotional support
- Voluntary sector
- Co-ordination of support
Epidemiology of hearing loss
11 million in UK with some form of hearing loss- 1 in 6 people
40% adults over 50 have a hearing loss
70% adults by age of 70 are affected
About 2 million people have hearing aids, but only 1.4 million use them regularly
It is estimated by 2031 14.5 million people will have a hearing loss- 20% of population
It takes an average of 10 years for people to seek help
Childhood incidence of hearing loss
More than 45,000 children
Half born with a significant hearing loss (about 1 in 1000 births), half develop or acquire it in childhood.
Increases to 1 in every 100 babies who have spent more than 48 hours in intensive care
Sheffield – approx. 800 children.
90% are born to hearing parents
As many as 40% of deaf children have additional or complex needs
Personal impact of hearing loss
Hearing loss is major unrecognised long term health condition
Hearing loss associated with increased chronic health conditions e.g diabetes, sight loss, increased risk falls
Unaddressed hearing loss gives:
Communication difficulties
Social isolation
Depression (2.5 times more likely with hearing loss)
Reduced quality life and loss independence
Increased risk dementia
When is hearing routinely tested?
Newborn Hearing Screening Programme
aims at birth to identify >40dBHL moderate, severe and profound deafness
Misses mild losses or sloping losses
School Screening Programme
When start full time school
Hearing concerns are identified
By parents, education or health professional
Speech and Language concerns
Communication concerns
Which high risk groups is monitored in the long term for hearing?
Cystic Fibrosis/ Chemotherapy before and after treatments due medication
CMV (Cytomegalovirus)
Head Trauma
Cleft lip/palate
Downs Syndrome
What are the aims of a hearing test?
measure hearing threshold (dB)
be frequency specific (Hz)
test for hearing threshold for speech sound
obtain single ear information
differentiate between conductive, sensorineural and mixed losses
compare aided and unaided responses
monitor fluctuating or progressive hearing loss
What is an audiogram
Graphical representation of Hearing thresholds of different frequencies (x axis) as a function of sound intensity (y axis)
Mild and moderate hearing loss?
Mild (20 – 40 dBHL). Would hear what is said in a quiet room, but not in background noise. May not hear a whispered conversation. May use hearing aids.
Moderate (41 - 70 dBHL) Will benefit from hearing aids, and may be able to follow a conversation in a quiet room using them. Would have difficulty in a group or with background noise.
Severe to profound hearing loss
71 - 95 dBHL) Would use hearing aids, with them may be able to follow a conversation in a quiet room if the person was close to them, but would need additional communication support in other situations. Without aids would not hear speech.
Profound (96+ dBHL) Would use hearing aids or cochlear implant, would hear little without them. Would probably need additional communication support especially in background noise. Without aids would not hear speech or most environmental sounds
What can hearing loss occur from?
Hearing loss can occur from a problem with the outer ear, middle ear or the cochlea or nerve of hearing.
Any problems with these areas can lead to a hearing loss
What are the types of hearing loss?
Conductive Hearing Loss
Sensori-neural Hearing Loss
Mixed Hearing Loss
What is conductive loss a problem of?
Middle ear problem
Some Possible
Causes
Glue ear
Ear wax
Middle ear infection
perforated eardrum
abnormality of the outer ear
eustachian tube dysfunction
Management of CHL
Most conductive losses will resolve themselves over time
ENT may insert grommets
Hearing Aids may be offered for persistent losses if parents decline surgery
In the case of permanent conductive losses, Bone Anchored Hearing Aid (BAHA) may be fitted
What is sensorineural Hearing loss a problem of?
A problem with the inner ear
The degree and shape
of the loss varies
depending on the
severity of the damage
and where it occurs in
the cochlea.
Management of sensorineural hearing loss
Sensori-neural losses are usually permanent
These losses are usually managed by hearing aids
The aim is to raise the level of hearing so that as much speech is as audible as possible
In the case of profound hearing losses, who cannot receive sufficient benefit from hearing aids, cochlear implants may be recommended
Subjective (behavioural) testing
Test performed subject to developmental age of the patient
Requires the patient to perform an action in response to the sound
How do we manage mixed loss
The conductive element will be addressed first.
A hearing aid will be issued to help make all parts of speech audible, especially the high frequencies.
How do we test hearing
This is dependant on the age and development of the child
Objective (not a behavioural test)
Subjective (behavioural testing)
When does subjective testing occur?
Distraction Test- 6-18 Months
Visual Reinforcement Audiometry- 6-30 Months
Performance Testing- 24 Months+
Pure Tone Audiometry- 3 years+
What is distraction testing?
Age: 6-18 month (developmentally)
Requires infant to be able to sit and have good head control
Requires 2 trained testers
Distractor (Tester 1) and Assistant (Tester 2)
How is the distraction test done?
Distractor captures/controls infant’s attention on to table with use of a toy.
When infant is suitably attentive, the Distractor phases out the play activity
Assistant presents stimuli
Response-Infant turns to look for sound
Distractor judges whether infant’s response is valid (also looks for parental cues or any distress)
If valid, infant is rewarded. E.g. verbal, visual, tactile reward
Assistant measures stimuli using SLM
Use of “No Sound Trials” to ascertain if infant is turning without sound being presented- i.e. if test is reliable
All stimuli should vary in presentation so that they do not become rhythmical
Minimal Response Level= 30dBA
binaural test, but may give some idea regarding significant ear differences due to localisation
Pitfalls are:
Visual cues
Auditory cues
Olfactory Cues
How does Visual Reinforcement Audiometry (VRA) work?
Age 6-30 months (Developmentally)
2 Testers
Condition at estimated Supra-threshold level (e.g. 70dBHL) with stimuli and re-inforcer together (Conditioning)
Once the child is conditioned to turning to re-inforcer then the stimuli intensity is dropped quickly (20dBHL per response) until no response.
Once conditioning is successful, then 20 down/10 up then 10down/5 up presentation procedure is used
Require 2/3 ascending responses for threshold
Minimal Response Level 25dBHL
Stimuli- Warble Tone or NBN.
Can be performed either Binaurally (through loudspeaker) or using single (insert earphones) or unmasked bone conduction
Dependent on child interest
use of variety of re-inforcers have been shown to produce increased number of responses (Marriage, 2009)
VRA is first behavioural test that you can perform single ear measures for
Rhythmical play in association with stimulus presentation
Toys or behaviour of tester/parent that is too distracting
Attempting to condition to sub-threshold stimuli
Additional behavioural cues given by Parent or Testers
Features of performance testing
Age: 30 months+
Tester 1 at Audiometer
Tester 2 with child- responsible for conditioning and maintaining child’s attention
Co-operative testing using binaural stimuli
Task: child performs action i.e. jumping a toy man into a boat when they hear a noise.
Requires the child to wait for a sound
How does audiometry work?
30 months+
May require 1 or 2 testers (dependent on age and abilities of the child)
Involves child wearing headphones or insert earphones
Child responds in the same way as Binaural Performance test
Start at a relatively easy sound intensity
Once child responses are repeatable, drop level using a 10down, 5 up procedure
Threshold 2/3 ascending responses to find threshold
20dbHL or better is considered within normal limits
What are some objective hearing tests
Otoacoustic Emissions-Performed on babies in the newborn screens
Auditory Brainstem Response (ABR)- Performed for more detailed information after the OAE test
