More common chronic conditions in childhood
• Asthma (moderate and severe)
• Epilepsy
• Congenital heart disease
• Diabetes mellitus
• Arthritis
• Cystic fibrosis
• Chronic renal failure
• Malignancy
Factors affecting a child’s adjustment to a chronic illness The child
• The age of the child
• The age at which the illness developed. School entry and adolescence are particularly vulnerable periods
• Low intelligence or unattractiveness increase the probability of maladjustment
The illness
• Conditions with unpredictable flare-ups or recurrences are more stressful than stable conditions
• ‘Invisible’
conditions (e.g. diabetes) may be concealed and lead to a lack of acceptance
The family
• The family’s attitude and ability to function is the most critical factor in determining the child’s adjustment
• Positive warm family relationships support children
• The family need to be interested and engaged in managing the illness, attending clinics, complying with treatment and seeking help when problems occur
What you need from your evaluation
Try to confine the consequences of the condition to the minimum manifestation
Encourage normal growth and development
Assist the child in maximizing their potential in all possible areas Prevent or diminish the behavioural and social consequences of a chronic condition
Management
What is the extent of the disease and its complications in the child?
What are the physical effects (e.g. poor growth, delayed puberty) of the illness on the child?
How has the illness affected the child’s performance at home, at school and with peers?
What is the level of school absence?
How has the child adjusted to the illness?
What impact does the child’s illness have on the family and its members?
Does the child understand their illness and take responsibility for their management?
How has the family adjusted to the special impact or burden of the illness?
Who is acting as main carer? What support do they get?
Has there been change in parents work or relationship?
Have siblings had any emotional or behavioural difficulties?
Assessment
Living with chronic illness Emergency paediatrics 131 cents should also be encouraged to be seen on their own—to talk about problems, and also to begin to be responsible for their own health care. The role of the paediatrician includes:
• Counselling: Concern and empathy can go a long way in assist- ing the family to make the best of the circumstances they face. It is important that the family knows that concealing a chronic con- dition (where that is possible) is rarely helpful as it encourages the child to believe that the illness is a secret and something shameful.
• Education: An important aspect of management is educating the family about the condition. This increases trust and provides the family with skills to self-manage many aspects of the condition—
particularly critical in conditions such as asthma and diabetes.
• Coordination: Children with chronic conditions are often looked after by a variety of health professionals: consultants, therapists and dietitians, not to mention teachers and social workers. Liaison and coordination are very important as differing opinions and advice can be very confusing for the family. Specialist clinics can be helpful, especially when there is a specialist nurse to take on this role as well as offer close support.
• Genetic issues: Parents often have questions about genetic impli- cations for other children, and the affected child’s own chances of fertility. A genetics referral may be appropriate.
• Support: Chronic illness can be an isolating experience and many families do not have the support of extended family and friends. A referral to social services may be needed for advice about benefits and other services. If there are emotional and behavioural difficulties, referral for counselling may also be required. Self-help and voluntary organizations such as Diabetes UK or Epilepsy Action can be helpful and often run support groups and activities allowing families with similar problems to meet.
Involvement with school
Good liaison with school is important. Staff need to understand about the medical condition so that they can cope competently with problems. Their greatest concern is usually around acute exacerbations, but they may also need to dispense medication or understand dietary restrictions. Asking teachers to report unto- ward events such as symptoms or drug side-effects can be helpful.
A formal health care plan should be prepared to give instructions on the illness, emergency procedures and key contact details.
A child who is underachieving needs extra support. This may include help in making up work lost through absence or providing preferential seating in class. Teachers can be instrumental in helping children cope and integrate socially into school life—
particularly important if the family is not coping well. Some chil- dren may have special educational requirements that need to be met (Chapter 63).
A chronic medical condition is defined as an illness that lasts longer than 3 months, and is sufficiently severe to interfere with a child’s ordinary activities. According to the UK General Household Survey, as many as 10–20% of children experience a longstanding medical condition, with 5–10% having a moderately to severe long- term illness or disability.
The effect of chronic illness on the child
It is not only the severity and prognosis of a condition that influ- ences how a child adjusts. In fact there appears to be little relation- ship between the severity of the condition and the extent of psychosocial difficulties. Children with mild disabilities may suffer as much or more than those where the condition is severe.
It is perhaps not so surprising that emotional, behavioural and educational difficulties are two to three times more likely than in healthy children. Low self-esteem, impaired self-image, behav- ioural problems, depression, anxiety and school dysfunction are all common. They may result from the child’s own response to the chronic illness or relate to how parents, peers, professionals and society react.
Children’s ability to perform at school can be affected, placing them at risk for becoming underachievers and failures in their own eyes and the eyes of their peers. School is often missed because of acute exacerbations, outpatient appointments and hospitaliza- tions. Chronic illness affects social aspects of school life too. Fre- quent illness episodes and restrictions may exclude children from activities. Physical appearance, acute medical problems, taking medications at school and special diets all can contribute.
The effect of chronic illness on the family
When parents learn that their child has a chronic illness they tend to respond in a way similar to experiencing a bereavement. The initial reaction is shock or disbelief, followed by denial, anger and resentment, and eventually reaching an acceptance of the situa- tion. It is not surprising that clinical anxiety, depression, guilt and grief are common, particularly for mothers, who often take the major caring role. It is also not surprising that marital problems may be exacerbated.
Siblings may also be at higher risk. Anxiety, embarrassment, resentment and guilt are common, as are fears about their own well-being and the cause and nature of their sibling’s health prob- lems. Parents may be less available to their healthy children, and they may also neglect, overindulge or develop unrealistic expecta- tions for them.
We tend to focus on psychopathology and psychosocial prob- lems when considering chronic illness, but it is important to remember that the impact is not always negative. Some families seem to grow closer to each other and provide outstanding care for their children. The question often arises: ‘How do some fami- lies of chronically ill children survive so well?’
The paediatric care of children with long- term medical conditions
Paediatric care of children with chronic illnesses needs to be holis- tic and go beyond clinical management alone. Time, good com- munication and skill are needed. This is particularly so around the time of diagnosis, and also at transition points such as starting school or during adolescence. At times, parents may need the opportunity to talk without their child being present, and adoles-
KEY POINTS
• Chronic and recurrent medical problems are not uncommon
• They have a broad impact on both the child and the family
• A holistic approach involving the whole family is important
• Paediatric care should involve support, coordination of care and liaison with other professionals and school
62 Living with a disability
Giving the diagnosis: this must be carried out in a skilled way by a senior professional
Medical management: therapists' input should be provided initially at home or the child development centre, and then in nursery and school Genetic counselling: required by many families even if no obvious genetic cause is identified
Education: A Statement of Special Educational Needs describes the educational provision that must be made for a child with disabilities. Where possible the child should be integrated into mainstream school
Provision of services: Social Services are responsible for preschool childcare, respite care, home help, advice about benefits and assessment for services on leaving school. Voluntary agencies may provide support and information
Prevalence of disability
8 per 10,000 children have a significant disability of which the most common are:
• Physical and multiple disabilities Cerebral palsy
Muscular dystrophy Spinal disorders
• Severe learning difficulties Chromosomal abnormalities CNS abnormality
Idiopathic Autism
• Special senses Severe visual handicap Severe hearing loss How disability presents
• Antenatally or at birth if anomalies are present
• In the first year for motor handicaps and severe learning disabilities
• In the second or third year for moderate learning disabilities, language disorder and autism
• After cranial insults
A Child Development Team is involved for complex difficulties Professional
Developmental paediatrician Physiotherapist
Occupational therapist
Speech and language therapist
Psychologist Special needs teacher Social worker
Liaison health visitor Role
Diagnosis of medical problems Advice on medical issues
Assessment and management of gross motor difficulties, abnormal tone and prevention of deformities in cerebral palsy Provision of special equipment
Assessment and management of fine motor difficulties
Advice on toys, play and appliances to aid daily living
Advice on feeding
Assessment and management of speech, language and all aspects of communication Support and counselling of family and team Advice on special educational needs Support for the family
Advice on social service benefits, respite care, etc.
Support for the family Liaison with local health visitor
Management of disability
Assessment of disability This involves:
• A detailed assessment of the child's abilities
• Recognition of any underlying medical problem
• An assessment of the likely long-term difficulties
Parents' initial reaction to news of their child's disability is similar to bereavement; they may feel shock, fear and loss, anger and guilt. Each stage of childhood then requires further adaptation, and independence is an ongoing issue
Schools need to be prepared for any anticipated difficulties and to accommodate physical disabilities. Staff must work with therapists to implement their recommendations. Young adult disability teams can advise about options beyond high school
Living with a disability
Children with disabilities have complex health needs. Many of the issues described in Chapter 61 are relevant to families with a disa- bled child. It is important to appreciate the terminology relating to disability.
A disorder is a medically definable condition or disease; an impairment is a loss of function; disability refers to any restriction of ability (resulting from an impairment) and handicap is the
The distinction between disability and handicap is important.
One of the aims is to minimize the handicap that results from dis- ability. It is important to consider how people with disability are perceived by society—there are ongoing issues of poor accessibil- ity, prejudice and discrimination affecting people with disability.
Some parents will describe their child as having ‘special needs’
rather than as either disabled or handicapped. This term is used
Living with a disability Child health in the community 133 setting when a child may have a Statement of Special Educational
Needs.
How disability presents
Children with disabilities may be identified as a result of parental or professional concern. A syndrome or central nervous system abnormality may be identified in the antenatal period or at birth.
Babies with neonatal problems are followed up closely as they are at high risk of disability. Deafness, motor handicaps and severe learning disabilities often become apparent during the first year.
Moderate or even severe learning disabilities, language disorder and autism may not be recognized until the child is 2 or 3 years of age, when it becomes clear that their developmental progress is not normal. Problems may arise in later childhood after acute illness events such as head injury or brain tumour.
Assessment and diagnosis of a child with a disability
Identifying the underlying medical problem is one aspect of the assessment. There is also a developmental evaluation and an assessment of how the difficulties are likely to impact on the child’s family and school life. When difficulties are complex, a Child Development Team should be involved (see adjacent box).
Paediatric care
A holistic approach is needed. Sensitive support is important while parents come to terms with their child’s difficulties and at each transition. Care often involves a number of professionals, both medical and non-medical, from different specialties and agencies.
It can be helpful for families to have a named professional who acts as their key worker in coordinating the multidisciplinary team, e.g. arranging outpatient visits to different therapists on the same day to reduce absence from school.
The diagnosis of a disability is usually devastating and the way that the diagnosis is communicated is important, coming at the start of a long doctor–patient relationship. The session should be conducted in private by a senior doctor with both parents present.
There should be opportunity for questions, with a follow-up session arranged shortly after. If a baby is born with congenital anomalies, consultation with parents should take place as concerns arise, with the baby present, sharing with the family the concerns and describing the process of making a definitive diagnosis.
Once the child’s difficulties have been fully assessed, develop- mental therapy is required. This may be delivered in the child development centre, at home or at nursery. Once the child is in full-time school, the services are often delivered by community therapists who work with the child and advise school staff.
Provision of services
Agencies other than health are involved in providing services to the family:
• Education services are responsible for assessing learning difficul- ties, providing preschool home teaching, nursery schooling and education both in mainstream and special schools. Children who require medical treatments in school (such as drugs via gastros-
tomy) should have a written health care plan agreed to support staff in giving the child’s treatment
• Social services are responsible for providing preschool child care, relief care, advice about benefits and assessment for services needed on leaving school. Child protection concerns also fall into their area.
• Voluntary organizations provide support and information for families, run play facilities, provide educational opportunities and sitting services. Some are large national agencies with numerous local branches, others are smaller groups concerned with a local issue or a single diagnosis.
The child with special educational needs
Children with special needs are educated in mainstream schools where possible. Extra help with learning and physical difficulties is provided in the classroom. This often involves a special needs assistant for the child, and may also include physiotherapy, occu- pational therapy and speech and language therapy. Mainstream placement has the advantage of integrating children with special needs into a local peer group and encourages their inclusion in society from an early age. It has the benefit that other children learn to live alongside children with disabilities and view this as normal. However, there can be disadvantages such as large classes, less specific support and buildings poorly adapted for physical difficulties.
Special schools provide teaching in smaller classes. Staff have a greater experience of complex medical needs. The disadvantage is that children are not included in a wider social group. An alterna- tive approach is to have specialist units within a mainstream setting.
The Statement of Special Educational Needs
The education authority is obliged to assess children who need additional provision because of severe or complex difficulties. The assessment includes reports from an educational psychologist, a paediatrician and other professionals such as therapists and the child’s nursery or school. It clarifies the medical needs, the educa- tional needs, the needs for physical assistance, supervision and transport. A legally binding document is produced called the Statement of Special Educational Needs. The child’s educational needs and the necessary support are stated and these are reviewed on an annual basis.
Transition to adult services
There is a statutory requirement that social services make a formal assessment of a child’s long-term needs as they approach adult years for those children with a Statement of Special Educational Needs with complex health or disability problems. The assessment is conducted with information from health, education services, the young person and family. Transition from the long-term paediat- ric medical team, therapists and education setting to adult health and social care is difficult and needs careful planning. Children with severe complex needs may need residential care as adults or significant extra support to live independently. There is a need for ongoing support from specialist clinicians with expertise in adult learning disability.
63 Learning disability and autism
Attempt to find underlying cause
Early intervention and educational programmes to stimulate cognitive, language and motor development Attention to special educational needs, with Statement if severe
Behavioural difficulties must be addressed Family support and benefits should be provided General paediatric care must not be neglected
Depends on the underlying cause
Degree of independent living relates to the severity of learning disability and the underlying aetiology How learning disability presents
• Dysmorphic features may be noted at birth
• SLD presents as developmental delay before 12 months
• MLD often presents with delayed language in toddlers
• The diagnostic process is discussed in Chapter 3 Aetiology/pathophysiology
• Chromosome disorders 30%
• Identifiable disorders or syndromes 20%
• Associated with cerebral palsy, microcephaly, 20%
infantile spasms, postnatal cerebral insults
• Metabolic or degenerative disease <1%
• Idiopathic 25%
Clinical features
• Reduced intellectual functioning
• Delay in reaching developmental milestones, particularly language and social skills, in early childhood
• Often associated with:
Epilepsy
Vision and hearing deficits Communication problems Attention deficit/hyperactivity Feeding problems and failure to thrive Microcephaly
Prevalence
• 4 per 1000 children
Prognosis Management (needs to be multidisciplinary)
Paediatric follow-up
Developmental progress and physical growth require review Screening for specific associated problems in some conditions Behaviour is often an issue
Liaison with other professionals is important, particularly regarding education The family needs support
Children are said to have a learning disability when they experi- ence significantly greater difficulty than their peers in making progress with intellectual developmental skills. Intellect overlaps with all other developmental areas, so severe learning difficulty is normally part of a pattern of global developmental delay linked with problems of mobility, communication and self-care skills.
There can be many reasons why a child may have learning dif- ficulties. There may be a clear pathological cause such as Down’s syndrome or brain injury. Learning difficulties may arise as a result of neglect in early life. In many cases there is no clear genetic, neuroanatomical, metabolic or environmental cause that can be identified. This is an evolving area of medicine and ongoing advances in genetics and brain imaging science help understand a
Learning disability is termed mild, moderate, severe or pro- found according to the intellectual limitation and degree of inde- pendent self-care. Children and adults with profound learning disability are totally dependent on their carers for all activities of daily living including self-care and feeding, and usually have very limited communication. Those with severe learning difficulties may learn limited self-care and simple communication skills, but will not be able to live independently. Those with mild or moderate learning disability may live independently with support.
Paediatric management
The role of the paediatrician is to assess patterns of early develop- ment that may indicate a significant future developmental problem,