Paediatric in service presentation

November 2024

Paediatrics with Autism and ADHD: Communication and Management

Gem Cook- Paediatric Physiotherapist

Index

Introduction: Why this topic?

Objectives: What are we going to discuss?

Quiz: What do you already know?

Content: The fun bit

Quiz: What do you know now?

Objectives

What are we going to discuss?

Objective 1

Understand what autism and ADHD are, and how they can present in our paediatric population

Objective 2

Appreciate the influence of autism and ADHD on physiotherapy intervention

Objective 3

Consider alternative communication skills for our paediatric population with autism and ADHD

Objective 4

Discuss how physiotherapy management may differ in those with autism and ADHD

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Introduction

Why this topic?

As someone with first hand experience of autism and ADHD, I understand the impact it can have on our service users. 1 in 100 children in the UK have autism, and 5 in 100 have ADHD. This makes up a fair proportion of our case load. They are protected characteristics as per the Equality Act 2010, and we have a professional duty to abide by this. We all deliver good care to these children, but we have the potential to make it excellent.

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What is neurodiversity? A.) A variation in the nervous system that effects processing, learning and behaviour, which onsets before birth. B.) A life long condition that prevents effective processing, learning and behaviour, which onsets before birth C.) A condition that prevents effective processing, learning and behaviour, which onsets after birth

Are autism and ADHD types of learning disability? Yes No Sometimes

Quiz

What do you know already?

What language is this?A.) sign language B.) Makaton C.) English

How many children have autism and ADHD?A.) 1 in 10 have autism 1 in 100 have ADHD B.) 1 in 100 have autism, 1 in 20 have ADHD C.) 1 in 20 have autism, 1 in 10 have ADHD

• Physical
• Emotional
• Psychosocial

• Neurodevelopment disability
• Symptoms before age 12, for atheist 6 months, occurs in multiple settings, interferes with daily life
• Inattention, hyperactivity, impulsivity

• Physical
• Emotional
• Psychocial

• Neurodevelopmental disability
• Effects the nervous system
• Social interaction, repetitive/restrictive behaviours in atypical pattern, difficulty transitioning form activities, focus on detail, increased reaction to sensations
• Presentation is multi-faceted

ADHD

Autism

Understand what autism and ADHD are, and how they can present in our paediatric population

Definition: Presentation:

Definition: Presentation:

Understand the influence of autism and ADHD of physiotherapy intervention

We need to be able to tailor our physiotherapy skills to meet their needs

Healthcare statistics:- children with ADHD generally access less services - autism is a risk factor for poorer health outcomes - they are more likely to experience chronic pain and comorbidity We will see children who do not have a diagnosis of autism or ADHD, but demonstrate the traits we are discussing. Similarly, we will see children with autism and ADHD who do not show all of these traits. It is important we understand potential ways they may present and how we can adjust to that for effective assessment and treatment.

Prior to initial assessment

At their initial assessment

Between their sessions

At their follow ups

What may be important to them at their future appointments?

What could they experience at their inital assessment?

What may they be feeling prior to their first appointment?

What may be happening between their sessions?

Consider alternative communication skills for those with autism and adhd

Verbal

Non-Verbal

Other

Hydrotherapy

Psychosocial

Parent Engagement

Discuss how physiotherapy management may differ in those with autism and adhd

By now, you should have better idea of how our management will likely differ in this population

- prioritise elements of your assessment and treatment to reduce physical contact and stressors secondary to presence at the appointment - consider more/less frequent sessions and the nature of those sessions to ensure optimal care - consider wider, biopsychosocial factors associated with autism and ADHD - have resources for relaxation, social physical activity, swimming/hydrotherapy, emotional/mental support and sleep to optimise therapy input. - these patients have a differently wired brain, not a deficit, so we need to try and get on their wavelength and think in a different way if what we are doing isn't working - awareness that must explore all avenues, not assume it is secondary to autims or ADHD

Conclusions

Discuss 3 ways you may alter your communication for a child with ADHD

Discuss 3 ways autism may present in our practice and how you would adjust your practice

Discuss 3 reasons it's important to have an awareness of autism and ADHD in our practice

Review your self-assessment

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Consider the things we discussed on the previous slide about prior, during and between sessions. Consider the role of the parent in assisting communication- it will often not all be achieved in the session, they have access to the child before and after

- Professional/ evidence-based - Legal - Outcomes

- Verbal - Non-verbal - Other

A learning disability is "a reduced intellectual ability and difficulty with every day activities and onset is prior to the age of 18. It is life long and affects activities such as house hold tasks, socialising and managing money.Autism and ADHD are not learning disabilities, but they can coexist.

Most children with neurodivergency will also experience psychosocial stressors which contribute to social isolation, depression, anxiety, low self esteem and a sedentary lifestyle. There is a direct link between social isolation with a sedentary life and chronic pain. Within our scope of practice, we have the ability to recommend strategies to influence this. Education on the importance of physical activity and types of physical activity. We know that pain can negatively influence mood and mental wellbeing, we know that physical activity and social integration can improve chronic lower back pain, we know that stretches can improve tightness and strengthening can improve weakness, so it is our role to find ways to do this for this minority population- it's a chance to be creative!

Phrasing- big/little or loud/quiet pain, simple/closed/literal questions Physical- limit physical contact, utilise parent where appropriate, consider water based exercises- stretches in bath, swimming, hydrotherapy, consider relaxation techniques along side HEP Communication- prior, during and after appointments, maintain open space for feedback If you don't ask, they probably won't say Clear information and reassurance for child and parent- empowerment

Before we start, ask yourself...

I deliver excellent, individualised, optimised care tailored to those with autism and ADHD 1- strongly disagree 2- disagree 3- neither agree nor disagree 4- agree 5- strongly agree

Autism and ADHD fall under the neurodiversity umbrella. Neurodiversity is the concept that the brain's differences are a natural variation- they are not deficits, disorders or impairments. They are developmental disabilities which begin prior to birth

Parent anxiety- how will my child manage, what if they won't do something, what if they miss something Child anxiety- where am I going, what will they ask me to do, what if I can't do it

There is evidence to clinically reason the benefit of hydrotherapy in those with neurodivergency. Our service uses hydrotherapy as an adjunct to land based therapies in certain patient populations. Hydrotherapy can be appropriate for those who have difficulty stretching/strengthening on land due to the sensory challenges and those who have chronic pain. Swimming can be very beneficial for those who have limited engagement in physical activities, whether it's due to their neurodivergency or reason they're come to physiotherapy. It works their cardiac, respiratory and musculoskeletal system significantly more than on land, whilst delivering psychological benefits of water immersion.

Consider hydrotherapy

- Emotional - Physical - Social - Other

1 in 100 children in the UK have autism, and it is 4x more common in males. 1 in 20 children have ADHD.

Difficulty completing HEP- pain, sensation of adjuncts, change in routine, higher demand of executive function to remember, other life stressors Future appointments- overwhelm on day of appointment due to high emotional ask, different clinician or clinical space

Wong Baker FACES Pain Scale Non-communicating Children’s Pain Checklist – Revised (NCCPC-R) Makaton-symbols Pictures Hand signals- thumb up/down, pointing, raise hand to stop Monitor face, muscle guarding, unexpected response Utilise special interests- gather from observation or social history to build rapport and promote engagement.

I deliver excellent, individualised, optimised care tailored to those with autism and ADHD 1- strongly disagree 2- disagree 3- neither agree nor disagree 4- agree 5- strongly agree

The parent has access to their child a lot more than we do. They have the exceptional ability to understand their child in ways that we don't. They can be a significant hand in assessing, treating and engaging with the child.

Setting: noise, brightness, temperature, new person, lots of questions, distracttions- toys, other people, saying it's okay in session then not when home Emotional: emotional dysregulation due to stress, sensory issues of someone touching them, sensation of a stretch can be overstimulating Pain: difficulty communicating pain, worried about pain Structure: literal thinking, needing clear and simple instructions, longer vs shorter sessions, speaking to parent vs child, amount of toys/objects in clinical space, amount of tasks per session

Makaton is a type of sig language. It is the same world wide and uses a combination of spoken language, physical gestures and written symbols to aid communication. It is more simple than BSL as it follows the same dialect as the spoken word and is therefore often used in those who are non-verbal.

Consider: Frequency and length of appointments, adherence to HEP, strategies to promote adherence Special interests General lifestyle- schooling, sedentary lifestyle, social access, emotional and mental wellbeing Tailor communication- physical gesture, body language, facial expressions, closed questions, ability to call between sessions if difficulty Dim lights, quiet room, cool room Explain or send video of department before hand Don't interrupt tasks with positive reinforcement or overwhelm with toys Health passport- discuss completion if would benefit Hypermobility/ehlos dahnlos, anxiety/depression, obesity, insomnia, constipation/IBS, connective tissue and movement disorders, , toe walking- strong association