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evening, everyone. Thank you very much for attending our pediatric Siris Webinar this evening. I'm really excited to talk to you all about Children with additional needs is definitely a topic that I'm really passionate about. Um, on most people that have worked with me or studied with may previously know that if you get me started talking about this, I will just go on and on and on. But hopefully I can give you some useful bits and pieces of information. As always, if you have any questions, do stick them in the chat. So I will check it reasonably frequently. Um, throughout the talk, I will also ask you some questions. Um, so it's always great if you guys get involved in just, you know, there's no silly suggestions to do. Just post whatever your comes to mind in the chap. Okay, So let me just put the slides, okay? So just before we get going, um, quick word about our sponsor who I'm sure you're familiar with now, cpt me. This is a website that once you sign up, there are thousands and thousands of different CPD accredited webinars on. That is whether your doctor with the gm see a nurse with the NMC, um, or another allied health care professional. With this discount code here, you get 50% off on that is only 8 lbs for entire year. Okay, so it's cpt me now what? We're going through this evening. So first of all, I'm just going to remind you who I am, Um, and why you should kind of or why? Perhaps you might want to listen to some of things I have to say on this topic of Children with additional needs on briefly going to touch on why I think this topic is important for us is healthcare professionals, um, introduce have it just in general principles were then going to go through a load of cases, a lot of which are fictional. Although I will say I have based elements on it of my own previous experience. We're gonna discuss the examples on there will also be a you know, a little bit of ah, look of knowledge there is. Well, um, and at the end, we could do a Q, and I, um and I think I put useful resources at the end. And if not, I can always send it out afterwards. Okay, so who am I? So I'm enough. What? My one doctor in terms valley. Um, that is my dog. Never next to me. They're in the photo who's called up next to me right now. So if there's any whining or barking later in this webinar to apologize, um and I would say, More importantly, I worked at a Children's home that was attached to a special school. We specialize in epilepsy for 34 years. Uh, so that was between my first degree and my medical school degree. And I also did a part time at medical school on that was working with Children as young as nine years old, all the way through to 19 with a total variety of different conditions. So, yes, there was epilepsy, autism, spectrum disorder, learning disabilities. But there are also some much rare conditions, like proud of really, which you will touch you on a bit later. A few kind of unnamed syndromes on just a whole spectrum. Oh, different cognitive issues, behavioral issues, physical disability and mental disability. Yeah. I also worked the teacher in a school for dribbling young people with autism spectrum disorder. Did that for a couple months, which was really good fun. Um, I've also worked in an autism spectrum sort of support group that was led by cans. I did that for a couple of months while I was in medical school. Um, there are few other bits there that I put that is more to do with the main mainstream childcare, mainstream Children. Um, but I'm sure similar too many of yourselves. We will work with your with additional needs. We will work, which is very different Children present. They're different challenges. Hopefully, they'll be lots of things that you can relate to. A swell if you're up to talk. Okay. So why is this important? So why we're here this evening, so I'm not gonna bore you with statistics. And, you know, different studies and stuff come out different results. But there's lots of information out there showing that patients, both Children, teenagers and adults with learning disabilities have significantly worse health outcomes on experiences in the way they're treated, the availability of serves, the way they're accommodated, or more likely, not accommodated. Um, probably see stories in the news every now and then around this topic. And I'd like to say things are changing that. It's kind of it can still be very fitting, Ms. Unfortunately for our people with disabilities, um, as healthcare professionals, we want to provide patient centered care. Uh, you know, we treat all of our patients with different Children, young people under our care as individuals, and we try and tailor what we do to them. Um, but Children with additional needs present an additional challenge. Um, And as I put here doing with additional too young people with additional in AIDS, it can be challenging, cause his healthcare professionals, um, to perhaps conduct our normal examination or a normal history or investigations. I might be getting an X ray doing a doing a blood test on these additional challenges, whether consciously or unconsciously, can actually lead us to provide a lower, lower quality of care, a low standard of care. And I have seen it on. But it does happen, unfortunately, And yes, sometimes it is dressed up is all you know is extra. You know, this particular investigation is gonna be extra stressful for that young person because they have autism. But also it's kind of what would you know? How much effort you willing to put in tow, reduce that stress level, Given that perhaps they do need it for a high quality of care. Um, the other thing is, it could be really distressing to Children, young people and their families. Um, when they come in the hospital, when they go to the GP is the pharmacy. Um, all of those things, You know, they go to a vaccination, uh, clinic if they have bad experiences again and again, or significantly bad experiences that lead to distress that can actually lead to disengagement with healthcare. And again, that is something that I've seen in my previous rolls, working with Children, young people and their families. Um, okay, So, like I said, I'm gonna touch just in general principles. So the good news for pretty much everyone I think that's attending this webinar. So that is, well, different Allied health care professionals that work your Children, students that I want to work with Jordan or perhaps have some experience about, like, my own. But I showed you at the start, working with Children. But the good news is, you'll probably have most of the skills were gonna talk about this evening. already. So you will be good communicators because you'll be out of communicate away from, you know, toddlers all the way up to actually very intelligent young people 17, 18 or even younger. Um, and you will be used to adapting that. And that's just that's more of what we'll be talking about this evening. You'll already be patient focused. You'll know about, you know, for what we call challenging behavior techniques. Such a distracting after even young people redirecting him. So telling them what they should do, not just saying no, don't do that. Then. You about that, folks with the negatives, you know, actually say Well, you know, Please come and sit down here on. I need to do this. We tell them what they should be doing, not what they shouldn't be doing. We focus on the positives, um, again, as as professionals, but work with Children and their families were going to quite used to getting parents or carers or guardian to curves with that child. A young person, uh, to help us, um, particular know we have shyi younger Children or, you know, even babies that, as you know, come, come necessarily talk. We will actually get the parents or cares to help us with a lot of things. Whether that could be holding the trouble is still where you look in their ears or giving us the full history because the child is unable to orbit too shy. Um, and again we work with Children were used to being adaptable. We see the weird, wonderful and everything in between. Um, so again, hopefully the usual skills that you have and we're just gonna be talking about how we can apply them and hopefully increase the awareness of some of the potential issues you might run into. So just having those ideas in the back of your head will allow you to apply the skills. But I haven't mowed that you already have. So one of the first things I wanted to talk to you guys about his sensory processing or sensory processing disorder. Um, on one side of the screen here, you can see there is a book called Yours a Central guys Understanding Sensory processing disorder. I highly recommend this book. It's something that I bought when I worked in the Children's time I previously worked in. It's really basic accessible, uh, information It's a really thin paperback. It's I'm pretty sure it's less than 5 lbs off Amazon. Um, and it will tell you all about sensory processing disorder on our sensory processing disorder is commonly seen in Children with autism. Um, and the individual can be over sensitive or under sensitive to certain senses of sensory systems. I've listed here the century system. So this tibula, which is about balance, um, particular. Anyone that's interested in tea or our medical students and doctors particularly, hopefully know all about other vestibular system regulates out balance proprioception. So our awareness of where we are with in space and how are joints comptel when they're loaded and again used that to regulate arm movement Tactile. So the sensation of touch order tree, which is our hearing visual gustatory, which is also taste for olfactory, which is also known as smell so well, I said that an individual could be over or under sensitive to certain senses. A lot of the time the sensory processing disorder, the areas that were gonna pick up and, well, actually quite often only be one of these two things. Um, not sitting on my best not was okay, so what I'm saying? Like proprioceptive if you are, um, under sensitive to proprioception, you're not gonna have a very good idea of where you are in space. So you're gonna be quite clumsy. You're gonna You're going to bang into things, um, to clear. But again, with Children with ASD, you might see sensory seeking behavior. Um, so one young person I used to used to work with, he was my key child. Um, he would enjoy going really fast on the swings. He would spin round and round and round just standing there, you know, 2030 times. Something that would make you are incredibly dizzy and and run a fast as he could. And he could run the perfect straight line. And that's cause he had a very, uh nder active with pro perceptive vestibular system. So he was quite clumsy, but he really went out, and he looked for things that you know would make him make him experience those sensations. Hey, would enjoy things that crashed. He kind of almost took to being clumsy, if that makes sense. But also, we could help him regulating com using his per perceptive system by providing the pressure. Um so sometimes if he was feeling quite stressed, he would hug himself really tightly to provide himself some of that pressure. And then we would know that we need to step in and do some of that as well. Okay, so moving on to a case. So I'm going to get it up so I can also review the chat. Um, okay, so in this case is a fictional case I have to think about. What is the problem on? Stick it in the chap. Any ideas that you could think of? What's what's going on here? You have a known year old girl, Um, coming in a company by kara. She's admitted with shortness of breath and low saturations. Um and this is and I'm sure you would have seen it in those of you that one adult medicine, but Children as well refuses to wear the oxygen mask. Refuses to where the nasal specks. Um, when she's been on the ward for, you know, a couple of days, she refuses to change your clothes. Um, she screams at you when you try and examine her screams. When you know the nurses come in and try and do obs So what? What might be some of the issues that we have going on, particularly given what we've just been talking about. So why do we think she is having the quite a quite extreme reaction To think that wearing oxygen mask or, you know, people trying to put her in different clothing just give you a couple seconds sticks and things in the chat was, I'll just kind of talk through kind of what I was getting out here. So nothing's coming through at the moment. That's right. So, okay, that's a really good suggestion, actually, previous bad experience. I could absolutely be what's going on. That's something we see really commonly, Um, one bad experience or many bad experiences makes hospital even more of a stressful experience that needs to be on. Jenny has said sensory issues feel of the equipment textures of clothing against her skin, Absolutely. That is kind of what I was getting at his wife. We see it quite often in our elderly patients that don't want to tolerate the oxygen masks and nasal specs, but actually in Children if they don't want to change their clothes. One of the reasons, particularly in Children with autism or specifically, sensory processing disorder is actually, they can be incredibly sensitive, um, to the feeling of terms of tactile sensation, so they will only wear tracksuits, you know, kind of new tracksuits with very soft inside linings. And you try to get into any other close, and they will have a total knee down. Unfortunately, um, similar. They may not want to be touched. For that reason, they they do find even, You know what? You're I would consider quite a light touch with someone you know, put in their hand on ours. They can find that almost excruciatingly painful. And then again, with the know touching, I think Adrian is coming really good system. So previous bad experience that is quite often what people don't like. They touched. If they have had things where people have grabbed them or touch them inappropriately or hurt them, that's going to make me not want to be touched. So, thinking about what we can do, um, there are a few things, uh, bio means do stick down some suggestions in the chats. I will just run through some of the things that I would try or it least consider So the first thing I'm going to do is I'm gonna have a chapter, their care. Uh, so the care is probably someone that works. Or hopefully it's someone that works with this, this child a lot. And we'll know what some of the triggers are for her getting very upset. Hopefully they will notice with the reasons behind it. I would then talked to my colleagues that the occupational therapists, they can be really good at adapting both equipment on eso things like the oxygen masks and things like that, or thinking about what we can do differently to take our obs. They would have worked hopefully with young people like this before and we can ask Well, ask the care or the family. If there's family involved in this case to bring in some other clothes, she likes that. That's normally quite simple. One just you know, she doesn't like the clothes were trying to get her to change up like change into get something. We know that she does like on There are lots of things, and I think it is just getting the whole picture, finding out information from a good source, uh, and cares and parents, as I'm sure you will appreciate, are fantastic source of information. Um, and with our Children, young people additional needs with because they have quite specific needs that you might not necessarily be able to predict ahead of time. Find that information out from Apparently, care. Er is incredibly value in practice are incredibly valuable. So moving on to a slightly different case. So thinking about okay, what's going on here? And what what should we be doing? So were in Children's much department. We walk into the waiting area and we can see a six year old boy. Ah, a little bit like the chaplain got pictured here. He's sitting there. Isaac Lows, hands Covering is is is rocking backwards and forwards it. He doesn't look very happy. You look really stressed out. Um, he's a company by an adult who's trying to, you know, grab his back on the back. Given some calming, reassuring words, and it doesn't seem to be coming down much, you quickly realize he is your next patient. You're about to cool. Um, but one of the patients in a cubicle just worry. You're about to take this. Ah, young boy, you can hear a baby just starts to cry really loudly. Um, you know that they're having some blood taken or something like that. And they are just making an absolute racket. So what do we think is going on? I apologize. I missed on your fantastic suggestions. So get down to her level. Try and make it into play. Letting use a stethoscope. Excellent. Excellent suggestion, Major. In there. Really like that? Carol said to reduce the stimulus. Yes, definitely. Hospital has, like, there are loads of, you know, bright lights for Children don't like lights. There are lots of noises, Like, in this case for sure that don't like noises. So reducing other stimulus. I can really help. Uh, genius said to let examine the equipment, show how to use herself where possible. Yet that's really good. That takes away kind of some of the fear of having something done to us. We're actually looking at it ourselves, playing with ourselves. We can kind of see for ourselves, and it doesn't pose any sort of threats on distraction again. That's always always a good one to do physically for something. Like if I'm gonna take observations. Um, and then yes, moving onto this case. So overwhelmed by the noise. Particularly familiar ones. Absolutely, uh, be affected by over stimulation. And it's quiet to be a coach of the situation. Exactly. Um and I think, um, is it the nail? Um, had it find somebody quiet him to go to. So, yeah, the last thing I would want to do for this this young boy here is put him in a cubicle next to a crying baby, cause that if he finds, you know, just a busy waiting room overwhelming because of the loudness of the noise, being next to that stuff is gonna make him really uncomfortable, really upset. And it's firstly, it's going to cause him a lot of distress, which is never something we want probations. But also for me to be able to treat him, to examine him, have a conversation with the adult that's with them, or conversation with him about what's going on. I am really going to struggle as the doctor that sees him. Or if I ask one of my nursing colleagues to come in and triage him will take Bob's, um, we're going to struggle to perform tasks that we normally would so absolutely we could find somewhere quiet for him. Um, we also want wanna have a chat to the adult with him, see if he has anything else with him that helps. So I believe on the next light. I have some picture is wonderful. So these head you were quite often see Children century integration to sort out wearing these. That ear defenders, Um, pretty much the same as the ones you can buy from, like the i Y A hardware store. Um, and it doesn't totally block out noise, so you can still have a conversation with someone that's wearing them. I used to have kids, you know, sitting with me in class, wearing them, it just dampens a little noise down and takes away that extra background noise. And it just allows them to not be overwhelmed by the situation that they're in. Um, just process things a bit better. Uh, I cannot remember what these accord is. Ah, the pop, the proper things on the butterfly. Um, that seems to become really popular recently. But we do actually use these in adult medicine as well for some of our delirious or patients with dementia. Um, so my wife, Actually, quite recently. She's also left one. Um, gave one of these to one of her patients with dementia and delirium who kept pulling off his oxygen mask on down. Actually sat there quite commonly, just playing with because you just wanted something to kind of fiddle with that. Occupy his hands, and he was unable to tolerate his oxygen mask on. This chap here is doing a wonderful job of monitor modeling. Sorry. Something called a bear hug eso We use these quite often. It work for, um, providing that deep pressure. So again, that could be calming. Um, for love people, sensory processing disorder, particularly if it is that per perceptive, um, system that needs extra input. And then we have some, like to this guy was looking at on. This is a sort of thing you can see in a sense room. So some of you will be fortunate enough to work in the hospitals or settings, have a sensory room. So it's normally low light. Lots of things like this you can turn on, so the bubbles and quite calming lights. You can have music in the soft sensations, lots of different things. But they could be absolutely fantastic and a good safe place. And for a charter, a young person is getting overwhelmed. But I appreciate that. I know. Personally, my hospital does not have a sensory room. Not many of them will do. Unfortunately, um, but it's definitely something I know people have campaign for. That would be really useful. Try young people with sensory processing disorder. Okay, so just a touch on something for the more knowledge base. So autism spectrum disorder. Um, you will see this quite a lot. Both diagnosed and undiagnosed is an entire spectrum. So, you know, we can list out things that we can see in behaviors that we might see in Children or adults with autism on that, all of us in this woman I was evening will probably do one or two of these things that that does not mean that we have autism spectrum disorder. Um, it is just the way we define. It is difficulties in interaction and social communication paired with restricted interest and repetitive behaviors on it's going to be sufficient, so it actually affects their function. Um, so you can look up that this is this is a definition of taken from the ICT 11. When I was previously training, it was a try it. So it was, uh, disability and social communication. Restricted, interesting but repetitive Haider's, which I think was called rigidity of thought. Um, and it was also a, um, communication delay. So the the social aspect in communication was split up. That is no more. So, um, as I said before, there was a massive spectrum with a variety of different presentations or unique problems are unique young people, Um, and it is. It's getting more common, and some people have suggested, you know, that's because it's it's better recognized or it's more diagnosed. Um, it's just it because actually, in some air it walk. I think it's linked to certain child benefits. Um, but you will see, actually, a lot of this stuff, um, so just have a think what behaviors might indicate that child has autism spectrum disorder. And like I said, I appreciate that there are lots of perfectly normal behaviors. Um, so I shouldn't say normal is if autism is abnormal. But there are behaviors that all people do that would still make us consider what is inspecting disorder. Oh, and I'm just here in the chart now. And thank um A like a pop. It's excellent. Um, so when you rigidity of thought was one of the things that we use to look for in young Children. One of these is a lack of imaginative play. So if a young chart so most young Children might take a set of toys horse and when they're playing with it, even when they're quite young, they were calling to make it. You know, gallop, run around, tell a little story. Where is no? All but many Children with autism spectrum disorder well, actually see that plastic toy horse as a piece of plastic that is in a shape. They won't necessarily make the connection between that on a horse. And I certainly wouldn't do any play that replicates a horse will tell the story. It's very object centered. Other things, um, can also be that lack of communication skills or delayed communication skills that could be so entirely nonverbal. It could be very repetitive speech going way up to actually some young people that use very advanced. So cabinetry talk a lot. Um, but actually, just don't get the Q that you know they've come to see you as a doctor or a nurse on back. Chew away. You didn't want to spend 15 minutes talking about Pokemon, and they will continue to talk about okay, because they love Pokemon, and that's what they want to talk to you about. Any effort you made to try and direct and back on track is kind of futile. The genius difficulty and conveying emotions absolutely on recognizing emotions in others. So that really ties in with, with our difficulties an interaction, social communication, Adrian saying No filter, absolutely. These are probably some of the most honest Children or teenagers that you will ever meet. Um, they will just tell you exactly what they think. And they won't necessarily know that you actually that that's if I say this, I might upset someone. They they can't necessarily make that connection. There are lots and lots of things out there so we might see some sensory issues. We might see them flapping kind of filtering the light. We might see the rocking, hugging themselves. There are lots and lots of things that you can kind of look out for or might make you think in the back of head. Or maybe maybe this child, a young person has some additional needs, and that might be autism. Um, but by all means, we don't need to necessarily diagnosed everyone with autumn. And it's not something that, you know myself is enough. Why one would be doing it something for camps to be doing. An expert in making that diagnosis. Okay, so another case, um, this one is kind of focused around autism. So, as I said here, hospitals do not run on the time ever. Any of you have worked that in a hospital or alongside a hospital, you I'm sure you're fully aware that Yeah, things don't really run on time. So we got a 12 year old boy with known autism spectrum disorder. He is in the outpatient waiting room. His appointment is scheduled for 11. 25. The clinic is over running and you call them in 11. 45. Which to be there is actually pretty brilliant for an outpatient clinic. 2020 minutes later, 11, 45. But still, let's you know, it's a made up example. So he refuses to accompany his mother into the clinic group on He points it is watching me says no, it's, you know, it's 11. 45. It's now time to go to Starbucks. You said we're gonna go to Starbucks 11. 45. You are. You know, the doctor, the nurse. You apologize. You said we know what you know. What, You just come in. We just need to, you know, check this. And now we'll make it really quick, and then you can go to Starbucks. Do this first, then we'll go to Starbucks so he gets more and more agitated. He gets, you know, really flustered. Um, right in the face starts screaming, starts throwing things around the waiting room. I'm really the The whole situation just escalates really quickly. So what do we think has kind of led to this problem and how? How much we what we do to kind of how much we approach resolving it. So this is something that is no uncommon. Um, So with that kind of rigidity of fort leading things planned, needing a schedule, needing a routine been really important for young people. Autism? Um, that this could be away. The actually parents care is healthcare professionals. If we can tap into that routine is that system. We can get them to do the things that we would like them to do that we can get, um, something that we think is good for them. Like going to see their doctor, Um, and actually saying, Well, you know, as we might do with a younger child or someone that just doesn't like going to the hospital. Well, once we've been there, we can go and do such and such that you really like to go to Starbucks. Donald's, um you know, we could go and play in the park. Four of those good things. I think what the mistake of being made here is they tried to map that routine two times, and hospitals do not, unfortunately run on time. So as as a care of some of that used to do, um, the sort of import that these sorts of important appointments, the last thing I would do, even with some of the people I work with very time or in take it, I would not promising that anything was gonna happen at this time. Well, I would quite often trying to his tap into the order of things. So it is. We're going to do a, then be then see, Then we finished, and then you can have a reward you may even see. Have seen kind of some of them have laminated at 123 reward card. So you they got Velcro on you? Pill them off on. It's, you know, one. We get into the car and go to the hospital to, um we go and talk to the doctor. Three. We let the doctor listen to our chest within. Finished on. We'll get up. I don't know. On ice cream from their shop in the hospital on the way back. Something like that. Um, so that could be a really, really good way of doing it. I'm breaking it down into nice, easy, manageable tarts. One step tasks simple to understand. Um, and easy. Easy for someone to say. Lucky we've done this onto the next thing on to the next thing. Yeah, absolutely. Mm. Is made a suggestion of the chart. So explain the importance of hospital before going impossible. Yeah. So I think preparing these young people coming in it absolutely something that we can do. Um, So I used to read cynical social stories which used pictures and words depending on the child's ability level. Cognitive ability that is on date goes through what's gonna happen on Thursday, the 31st of March? What exactly can they expect? And again, you very much keep it two things that you can kind of guarantee. Um, And if you go through a few times before the 31st of March, they feel prepared me know what's gonna happen, and that helps them deal with it. Um, and also even. But even for something like this is having a bit of a meltdown about going to Starbucks a specific time. Actually, they may have actually a pretty high cognitive level, and you may actually better explain to them why hospital is important. Um, and actually be able to reason with them. If they are so upset, though, that they're screaming and throwing things. You may just have to reschedule and then have ah, have a chat with Mom. Dad care, uh, how we're gonna basically make the next appointment more suitable and accommodate for this yet. So it may be that he's 1st 1st on your list in the morning, and it maybe you just say, Look, we don't run on time. Done from sometimes. So there are a lot, lots of different things we can do in a situation like this. And like I said, it may be the unfortunately in this situation, you have to abandon it and have another go of making it better. So we have another case. Um, I think about how we might handle this. So we're shadowing the GP practice, nurse. One of our placement. So we're a student here at the GP. Active practice merit. You start seeing the next patient because he needs to make a phone call. And it's a 15 year old boy with autism spectrum disorder. He needs, um, Bloods. His bm I checking on a BP check for the medication that he's on. Um and, you know, you've been a bit of work with Children, a few few Children with ST. And you think Well, okay, let's start with something simple, noninvasive. Let's start with the height and weight. You know, it will build up some trust before we start sticking needles in people, which is sensible. But the patient insists that you take his BP first. Um, he continues throughout everything you do he say? No, you do it wrong. We do. This is the order. We do it in. You don't do it like that. And you're just really bad at your job. He's been quite rude. Um, how do you think we should handle it? Like, um, you know, should we be saying, you know, I'm a nursing student? I'm a medical student. I I think I know what I'm doing. Thank you. Um, you know, should we be sticking up for ourselves? Um, should we just begun? You're You're totally right. I'm dreadful at this. Um, any suggestions until how would you handle if you're in this situation? You know why? Why we're in this situation. So it seems that this is a regular patient. Um, and clearly, they have an idea. Have, like, a specific order or routine. Um, and actually, if that's plus the best way of getting this young person to have all of these investigations that we need them to have for the medication they're on, um, yet Johnny, to the words right out my mouth, Why argue? Does it really matter to you more than imagine him? No. I would hope that we all humble enough on a kind of confident in our own abilities that actually we're not going to get let one teenager or child get in our heads or upset us. We see You know what? Let's do it your way because we get what we need. Um, on, actually, yeah. He probably knows what happens better than you do a Xavi said so Just ask, ask. You know. Okay. So sorry. This is my first time meeting you. How do you normally do it with such and such? Um or how would you like us to do it? It's really patient centered. A really nice way of doing it. Um, so exactly, uh, just by into the system and you be amazed how much you can achieve. Okay, So this this next light here is about pathological demand avoidance, which is also called extreme demand avoidance Ondas, a condition that's associated with autism. It is actually quite rare. Although I will admit I have actually seen quite a few Children with this. But that's more because of the settings I've worked him. I've only seen one case in hospital. Um what what on? That was someone that they were planning on taking to surgery and German orthopedics on. To be honest, they kind of just you're on the towel. Unfortunately, um, these these young people can be a really challenge. Um, so it can essentially, they will have. They will do everything in their power to avoid even every day demands. Um, so that could be a simple as, you know, me, asking them to pass me something. So, you know, when you passed me that pen from over on that table, the answer will be no or his hearing. I might use a social strategies. They might make an excuse. Oh, my. Yeah, my legs were really tired. Or company can't reach the pen. Um, you know, that's a really quiet, you know, it's quite a nice place. Well, they might suddenly jump up and start talking about something else to distract me. Um, or you could end up with some having, you know, a mood swing, being very impulsive, shouting, screaming, trying to hit you for this. We are going to do something that's really quite routine. So it could be a really excessive extreme reaction to every day. Demons. Um, so the one that we had that was a, uh, sometimes the surgeons, it was borderline whether or not he needed his ankle fixing. Um, but any time they tried to talk to him about treatment or surgery or what was going on, um, he would get physically aggressive with seven year old boy. Um, so they if they address the everything, too, his parent that he was with hey, would remain quite come because there were no demands being made off him. Um, but basically, when when they try to, you know, as you go ahead and put a cannula on him, he had some century issues I would not tolerate, Um, Emla cream? Um, that, yeah, he really gave him a hard time. So I think in the end, they decided it was probably best for him on automatic themselves to just manage conservatively. So hopefully you won't see this too much because it can be really tricky. Um, but it does lead us on to another thing that you may see more frequently at which is violence and aggression on the right things in the news, in adult medicine, um, about seeing mawr this all the time. That's healthcare stuff, which is obviously or four really sad. Um, and I may be bias because of my background working in a, um, care home. So the shortened for everything could not be safely looked after by their parents. And I would say we were for the region. I worked in probably these Children. Young people's last stop before going to suck your mental health unit. We probably have a higher tolerance for violence and aggression. Um, but in a healthcare setting, it is not acceptable. It is not for you to manage Where the air, a doctor, physio, and the paramedic, um, managing directly that violence and aggression is not for you. You need to prioritize your safety, um, the age old argument being But how can you help the rest of the patients the rest of the young people under your care if you are hurt, Um, and obviously, you know we don't go to work to get hurt. The vast majority of this webinar will not have the training to safely manage violence and aggression, Um, particularly in some of our older Children or young people with additional needs. So if you can imagine that kind of tent temper tantrums, it's likely aggressive toddlers two or three when they're 14 in there. 6 ft three And they were almost 100 kg. And I'm not just plucking those numbers out of the air. I have worked with young people like that. Um, they can be a real difficulty to manage when they have a temper tantrum when they get quite aggressive. So prioritize your safety escalated to security. If you do need to, um and you know, obviously there are, you know, somewhat kind of. I don't want to say exceptions, you know, like if someone's being unsafe and they're about to run out in front of the road, I think most of us would probably get in their way. Um, but actually, sometimes the safest thing you could do for yourself is just getting out of the room. Um, but it's, you know, and it will be a a team effort will be talking to your seniors, talking to the security team on working out of safely manage that child ago person, um, have creative. I see three bits of advice I would give you or the three pees something lot of very long time ago when I was training to manage this sort of stuff. So positioning, proximity and plan, um, so positioning. So if we think about, um, you know where we are standing relative to watch out a young person, Um, so, you know, be standing behind exactly stress them out. We standing between them and the door because I you know, there's some situations you may need that to stop. Some of that's gone going, but also if they if they're going to escalate and try, we have to be getting out of a room. Do you want to be between them and the door equally? Do you want someone that's violent to be between you and the door? Because you will need next strategy, which kind of comes into plan, uh, proximity. Um, so just be more aware when you are within striking distance or, uh, the distance which someone can throw something at you. Um, And if you do need to be in that sort of striking area, actually, if you can get really close really, suddenly, when escalates, it takes away that leverage. But the main thing I would say is, get out, defer to security. Um, and yet just we don't We don't tolerate it. is not okay. Even if someone doesn't know what they're doing, it's, you know, it's not for us to deal with. Okay? So, communication. So you are already all really good at this? Um, with you up with adult Children, whatever you're stage, I would imagine all of you who want to work with Children are pretty good communicators. Pretty adaptable. But once again, Jordan in young people, additional needs come with additional challenges. Um, so there is kind of the stereotypical who ST type thing of lack of eye contact or I contact making them uncomfortable. Um, and that's okay. I mean, I have had conversations with people where I kind of just talk over their shoulder because I know they're more comfortable if I talk to them like bits. Um, I've worked with lots of nonverbal Children, young people, some of whom, actually, you know, their cognition is on the high level that they are just nonverbal for reasons related to their additional need. So there's there was a book called The Reason it's called. The reason I jump written by a Japanese man were Japanese. Boy, I think it's been translated English. He was nonverbal for the 1st 20 odd years. I'm power phrasing of his life despite being very intelligent. Um, because he never saw the need to talk. He didn't feel that it was necessary. Is that that was kind of part of his autism. Um, another really good route, I would recommend reading now is kind of a load of anecdotes about him explaining why he exhibited certain behaviors. Someone that was thank you quite profoundly autistic. So in attention, you will see that a lot with Children with additional needs, particularly if they have a more severe learning disability or a T h d. Literal interpretation. I would imagine a lot of you're familiar with this from working with toddlers. Um, when I worked in mainstream childcare, I saw one of my less experience where we say, unless patient colleagues getting rather irate with a two year old, uh, she was trying to put a coat on him, Um, and she kept telling him to turn around, and he just kept doing three sixties and turning back, facing her Jews. Getting more and more annoyed on, you know, started to kind of actually really kind of have ago, and I said, Look, he's done what? He's not taking them it. He's done exactly what you told him to. You need to be more specific. So you need to think about how he's interpreting what you're saying because you know he's not doing it to be silly. You told him to turn around. So he has. That's just not what you meant on. That is exactly how a lot of articles with autism, but a lot of other additional needs so further down the loan disability scale. They were quite often take what we say, literally. So we need to think very carefully about what it is that we're saying. Um, selective mutism. You can see it in Children with different read, but also actually, you see it in the general population as well. Um, communication needs are individual specific, so they may have their own way off off communicating. So if they come in with the care, our parents, they will probably be a really good person to help you communicate with that young person because they will know the tips and tricks they will know. But, um, you know that word that means almost nothing to you or I actually means something very specific to that young person and in their care setting. That is what that means. And you will need them almost a translator similar for young people with speech impediments. Economy to develop in here for it on. But I've also just included. Does anyone know what? I don't know if you can see my cursor what this book here is. But what these symbols here from then where you may not be, you may not be familiar with it. I've also put the magnet on logo there. Well, so that is a form of sign language that is used by people with learning disabilities. Also, toddlers actually use it. Basically, they're going to quite good nursery. They will use market on a really accessible sign sign language. Um, and I would say it's well worth just picking up a couple bit. So with adult patients, I was quite often say Hi, my name is James. Um and that's some of the loan disability. And even if actually I can't discuss a difficult medical problem with that person, it does let them know that I'm open to their way of communicating. Um, that kind of I am familiar with that sort of stuff. So it has, actually, you know, put smile on their face, make that much more amenable to may have made a big difference because there's nothing in the chap, But this here is something called Apex Book. So Pecs is, uh, the picture exchanged communication system, which sounds like a mouthful. Uh, you may not get a seat because it is quite small, but those are little squares off laminated paper with pictures on as a shown here. Um, and what the child a young person could do is give you a symbol, but what they want in exchange for that thing and so give you an example using the picture that we have here. So we have I want an apple. So that is obviously quite a high level sentence. So I quite from worked with ones that have the I want as just part of a strip like this yellow strip down here. It was already there, and they just put on what they want. If they want an apple, you take the apple sticker, put it down on that, and they give it to an adult on. You know, I'd look it out So you want four? So I'll go get you an apple. We might say I want to go outside. I want to play football. I want to go to the toilet. Uh, I want to go to bed, Anything like that. And basically, they can exchange their pictures that they understand to mean things. Um, for the activity or the item. Ah, that they request. Honestly. Initially, when you're teaching someone this, you do need to kind of fill whatever is they're asking for each time as they get more used to it. You can, actually. Well, okay, you want to know apples? Um, you can have an apple later, because it's dinner in 10 minutes is something that they may be able to understand again. Parents care is bones are where you're going to get the information about this occupational therapy or you're learning disability nurses can be a great results, Um, for finding out more about this sort stuff. Okay, so I just want to touch briefly on mental health. Um, obviously mental health effects Allchin in young people adults, but there is an increased incidence of mental health issues in Children and adolescents with additional needs. Um one of the big issues is because of a lot of the behaviors that sure with additional needs, can exhibit quite from the mental health issues can be missed. They can be enough. That's just part of their autism part of their learning disability. Um, which can actually mean for a lot of time, then not addressed. Um, And without your young people are very impulsive. Uh, that can lead to, uh, actually more significant risk taking behaviors and self harm they can be, and it's going risk. And they can have pretty severe trust issues on I know that this is the same for actually any of our Children. Young people with mental health that we need to do a risk assessment we need to think about, um, you know, and actually even adult with mental health issues, we need to think Well, okay, I'm gonna leave them in that clinic room for 10 minutes, just while I go and get such and such will make that phone call. What objects have I left in that? I mean, I'm sure. Well, very good thinking about Well, okay, we've got toddlers around. We can't leave a hot cup of tea. on the side, but actually are there Is there anything shark and there? Is there anything that they might used to hurt themselves? That is a sort of thing. But we need to be thinking about and just be aware. Just because someone has an additional need doesn't mean they can't have autism. Um, and actually be really depressed or be really anxious or have schizophrenia, like they're they're not necessarily mutually exclusive. So just have that in the back of the head. Um, I want well on that. Too much. Okay, So this is something that I think is really important. I think it was a dream. You mentioned this in the chart earlier, Uh, which was spot on the previous negative experiences, Um, or actually, actually, previous abuse. Um, so truly in young people have had bad experiences in hospital. Have, unfortunately, comma crap being it put harm by abuse or neglect. Um, very computer use additional challenges for us because they will not necessarily trust us. They may not want to be touched. They may find quite things that you and I or other patients and 100 sticks, like it's got a dark in here. Um, yeah, so actually, they actually find this really difficult. May not want examination even, you know, even like a abdominal examination can be really stressful for someone that's suffered sexual abuse. Um, and the reason that I've been included this it is very similar to the issues that you would see in a child, a young person that does not have additional needs. But once again, people, unfortunately, Children, young people with additional needs are at higher risk of having negative healthcare experiences. They are higher risk of abuse, and there are higher risk of neglect. So if you think about neglect because they have the additional needs additional demands, it is more like feel those additional demand need to not met for abuse. Um, unfortunately, again, you'll get, uh, you know, much older Children, young people that have quite young mental ages, so they are susceptible for being led astray. Um, they may be nonverbal, so they can't report abuse on go away. These things make them incredibly vulnerable. Um, so the things that we need to do is healthcare professionals as well as just, you know, being aware of it, looking out for the signs of abuse, neglect. Um but we need to be patient centered. We need to be accommodating. And that may mean, you know, we give them extra space, we give him extra time. If we're doing any examination, anything that we think might they might find difficult, really important. You get a chaperone. Um, and it is, you know, it's not Just protect that child in young person is to protect you as well. Um, someone that has had previous abuse or negative experiences. Um, they may be more likely to, uh, grades allegations against healthcare professionals. Um, and that's not necessarily, um, maliciously. It may be that, actually, because of their previous experiences, they misinterpret something that you've done or said, um, they may have trust issues. Building trust is gonna be harder. Um, communicate everything you're doing on. I'm sure all of you already do this rule of your patients. Um, but they're just really into the very minds. Okay, So I did mention this before product. Willie. Ah, this is a very rare condition, but it does illustrate a few points about Jordan, in your case with additional needs. So this is a neuro developmental genetic condition with constant, insatiable hunger on I I I mean constantly. They are ravenous. They were quite often eat non food items. They will pretty much eat anything that they can get their hands on. Um, which leads to obesity quite often. Um, it's picked up in infants with hypertension year. Um, they may actually initially be a low weight because of their poor suck reflex, because the hypotonia reveille to thrive. Um, but later you get identify them because of that constant food drive. Well, quite have learning disabilities on specific dysmorphic features, which you can go and look up. That lady over on that side of the screen does not have product. Really? It was just funny. Picture like out. Um, but alongside this compulsion, they're gonna have cognitive behavioral problems, coughing tantrums, um, compulsive skin picking. So I have worked one child with this, but I've worked with several others that exhibited similar tendencies. So I have seen young people eat entire unfilled oranges. There was another one that had insatiable. First he drank. Let me think so. Basically any water. So if you left a sponge in the sink after washing the dishes, he would pick up the sponge and suffer fluid out of it. I there was hand sanitizer or soap dispenser, as we might find. He would drink that. Which, as you can imagine, it's pretty pretty dangerous for a child to drink a bottle of hand sanitizer, um, similar with these Children that eat non food items if the things they're sharp if they eat, um, things a corrosive. There are loads of ways of these Children who put themselves at risk. So this is just a fairly standard kind of boring clinic room. Um, try and use your imaginations. I just have a think about what things might we find in our clinic rooms in, ah, wards on our waiting rooms that much that we might want to kind of do a quick risk assessment for our Children with additional needs or any child that we think you know, might be higher. It's not necessarily things eat and drink as in product. Willie, what things? What things will be not necessarily want them to get hold off. So, like I said before, even things like soap dispenser is hand sanitizer. That could be a risk, anything sharp so someplace, you know. Where is that? You know where is the trolley with our cannulas and needles. Um, is there sharks been in the room? Is that you know? Is that raised up? Is that is it sealed, or is that something that, actually, you know, we might think Well, okay. You know, it's kind of at my shoulder height. That's a you know, it's going to stop all of your, um, your total is getting into a sharps pen, and you'd hope most of your older Children of it more sensible. But actually, if you have someone with global delay that has the mental cognition of a toddler, it is 6 ft tool and can reach the shops. Then you're gonna have a knish. You, um, again, I have to throw. You can see our whole rack of things that can be thrown. Um, no. And as a just pointed out and, you know, little things like the, uh, the covering on the, um, the couch there. We've all seen it when babies will tell us come in and just ripped the thing to shreds. Um, and similar. You may see that sickly with our, um, Children product. Really? Who like to pick it things, but also those the sensory issues. There are lots and lots of risks on. We need to be thinking about again the environment. We're putting them in. So is it is it a safe area of thumb to go into the safe area for us to go into, um and also going back to kind of the sensory stuff we talked about? I mean, have a look at kind of how broken reflected that area is if you were very sensitive to the light. That is not gonna be a very nice area for you to go into your sensitive to sound all the sounds in there. We're gonna bounce off on there, And that's actually gonna be really hard for someone. With what? That was just my dog asking to come back up. That's gonna be a real issue for all Children. You know, people with sensory issues. Okay, so we're moving towards the end. It's just some of the few things. Um, so we want to make each strip the hospital for for work. You know, we work in a GP surgery who work for the ambulance service is we want to make all of our healthcare experiences Allchin, young people, a positive experience, but we really want to go the extra mile the extra bit of effort to make it that same positive experience. But our Children with additional need. So we want to advocate for them, advocate for them. So if you have kind of clicked into the fact well, actually, no, they really don't like being touched. Tell your colleagues if actually, you know, another person comes on ship and they were like, Well, you know what I need to do. The obs. I don't care. They're just gonna have to deal with it. No, let's advocate be an advocate for our patients that stick up for them. Let's make sure our team is on the same team. Is our young person adapt? So, yes, a lot of these consultations or time looking after the young people may not go exactly as we had planned. We may come into the situation with all these things found out on our heads. In the best of intentions. On in the first minute, everything just goes out the window and it all goes wrong. But we need to be happy to adapt and able to adapt. We need to accommodate them. We need to look at how we can be better and how we can change things for them to have a positive experience. Ask. And I cannot emphasize that enough. For my first day of the care home. I worked at one of the things I find that really looking up to. The first thing he said is I know you've got loads of experience working Children. Um, but these Jordan in young people have very specific needs on if they're not met or something goes wrong, the results can actually be pretty pretty disastrous. So don't make any assumptions. Ask, he said. Everyone has really friendly. Everyone will tell you, but just ask, Don't just launch straight and as you normally would, because actually that can result in, you know, a teenager going from quite happy and content to actually being physically violent and abusive. Um, and that's obviously not a positive experience. Um, and assess, risk assess. Um, usually the things that we've talked about keeping in the back of your head and just think about, okay, they didn't like it when I shown that light in their eyes. That's you know, is that Is that just because you know there are, uh, near toddler, and they don't know why. Or actually, is it because they're overly sensitive to light, you know, Is this meningitis or is it that actually, they're very sensitive to bright lights? And how can I How can I change my tag? And then just to summarize key points, use the feel that you've already got. All of you guys will have loads of fantastic skills in your own unique way off overcoming various challenges. The Children throw a year. Um, but just be mindful off the additional requirements adjustments that we can make, um, parents and carries their invaluable. Um, nothing, I would say. It's like the worst happens when I have taken our young people toss the tool. Um, Then when healthcare professionals assume they know exactly what they're doing, make those assumptions, um, and ignore me. Standing in the corner is on the care. Or if I come and say, Look, I know you're really busy today, and you know, you probably can't tell me when the, um appointments going to be, but we have a They really struggle with transitions. If I get them in the waiting room or you got to get them out. They'll be a real nuisance. I'm going to get, you know, I'm gonna get I'm gonna go away with them in the car somewhere was gonna wait here. Could you just tell them when the doctor's ready and run out and get them? Um, when the answer is no. And they sit in the waiting room and they end up tearing the waiting room to pieces and throwing things everywhere. Yeah. I mean, use the results. If someone's giving you a warning about something, it's normally it's normally in your interest to listen and be aware of the hospital resources we have. Um so everything. I've really mentioned these yet. Um, but in some places, they have health passport or an autism passport or a learning disability passport. And that is something that primary care will try and get out to their patients that have autism learning disability cetera, Um and it comes with a lot of information about that young person. You know how they communicate that likes and dislikes triggers for behavior, calming strategies. And that could be really useful if we're looking after one. The ward's well just reviewing them in the accu setting and and learning disability. Nice is specialty specialist nurses are fantastic on learning. Different nurses are no different. I know a lot of them do specialize more with the adult learning disability side of things. Um, but I found this really good results in the Children CD, the Ocrevus. He worked Onda as always, you know, working in pediatrics, working with Children. We work with wonderful colleagues. So if in doubt, just ask for help. Likelihood is someone else who have seen something similar or something that they can relate. And just having some of the bounce ideas off is always great. Okay, So any questions you might have in the chat there is a link to the feedback for my will also host a Lincoln that chapped that, like that is the right link. If you do have any questions to stick them in the chart, and I'll do my best to answer them, um, thank you to everyone that did throw answer in there, make this interactive. Um, I really appreciate it. I don't know if you can tell. My voice is slightly going. I'm talking just over an hour nonstop. Um, but it always helps to have some ideas to bounce. Ah, bounce around. Okay. Very welcome. Adrian and I could see Jenny. What is the difference between Prada Willie on Pekka? Okay, So, Pekar, my understanding is speaker is the intentional what? Where someone eats things that are in edible, um, and has the desire to, um with product. Willie is a specific, um, genetic condition. Um, I can't remember the exact gene deletion, mutation or whatever, but there are specific, uh, genetic criteria to diagnose. Proud of Willie on. You also have all those other features as well. A speaker where his peak up would be anyone that has the desire to eat non edible items, whether that be proud of Willie or some psychiatric issue. Um, or think police. Correct me if I'm wrong. It's seen incredibly well. Rarely an iron deficiency is well, people end up eating things like hair, and hopefully that makes sense. Cool. Global hope for welcome. Jenny. Yeah, If you have any further questions, you can always email them to us. Pediatrics, that mind a bleep dot com my can go out and have a look and try and get back to you on stuff. Um, please do fill out the feedback. I do read it. Um, we do actually look at this stuff to try and improve presentations for you guys on. So, you know, if you want stuff with mawr, Um, kind of the scientific knowledge I say scientific, more kind of fact based knowledge, or if you're quite happy with the discussions around cases, but then you feedback tell us. See that exactly the sort stuff you're looking for. If there are certain topics that you want us to the, um do you can stick that down as well? Um, anything we can do to improve or anything that you like and you want to keep doing? Do Let's know, um, we do look a little thank you very much for joining me this evening. As always, I will within the next day or two get this uploaded a Z catch, catch up on metal on, and you can also watch it on YouTube. Well, that normally takes day, day and a half. Um, and look out for more pediatrics sessions in the future. Thank you very much.