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When Children Can’t Communicate Pain

A few years back my daughter (age five at the time) seemed a bit “off” when she came home from school.  She was withdrawn, tired, and “didn’t want to talk about it”.  She is my kid that struggles to communicate her needs, especially when she is upset, so I tried to give her some time and control over when she would be comfortable talking about it.  Eventually, I went over to her and in stroking her hair realized this had blood in it.  I pulled her bangs aside and noticed a bump, large bruise, and blood on her head, in her hair, and around her temple.  When I asked her what happened, she burst into tears.  Through some coaxing, I got her to tell me that she had fallen on the playground, hit her head, and was so embarrassed about this she didn’t want to tell anyone.  Her teacher picked up on the fact that something was wrong and sent her to talk to the principal.  To the principal she reported nausea, a headache, and was visibly upset, but wouldn’t tell the principal what happened, and the bump and blood on her head and hair was not noticed.  After I got her to calm down, and did some basic mommy first aid, I explained to her the importance of telling adults about these things in case they are serious and need immediate attention. 

The ability to communicate pain and discomfort is invaluable – it not only allows a person to express how they are feeling in order to receive medical attention, but also can help them to obtain medication or treatment to make the pain more manageable.  However, many children (and some adults for that matter) are unable to express their pain due to a difficulty with communication, or a developmental or intellectual disability.  This can make it very difficult for health practitioners and family members to decipher their level of pain following an injury, medical procedure, or with illness.

For children that cannot verbally communicate pain, there are other methods that can help.  For example, the Non-communicating Children’s Pain Checklist (NCCPC-R) was designed for children who are unable to speak due to a cognitive disability.  The NCCPC-R can be completed by a caregiver within the child’s home environment, and measures observations of the child’s vocalizations, social interactions, facial expressions, activity level, appearance of body and limbs, physiological signs, eating, and sleeping.  In addition to the home-based version, a postoperative version of the NCCPC-R also exists.

Interestingly, studies have shown that the expression of pain by children with Autism Spectrum Disorder is not significantly different from typically developing children or even from children with intellectual disabilities. However, what does seem to be different is the length of the behavioral reactions of children with Autism, after the source of pain has been removed. This information may be surprising to some, as it is often thought that children with Autism are insensitive or have a high tolerance to pain.  Therefore, caregivers and healthcare professionals need to be aware that although a child with Autism (or any developmental disability for that matter) may be unable to verbally communicate their level of pain, we cannot assume that they are not in pain.  We need to be able to look beyond verbal communication.  One method, using observation, is the FLACC scale (Face, Legs, Activity, Cry, Consolability).  With this, pain in children and adults who are unable to communicate are observed through are range of symptoms that are scored from 0 to 2.

So while my daughter is capable of communicating verbally, emotional upset and embarrassment prevented her from taking the important step of telling an adult about what happened.  Through her behavior and presentation, her teacher, the principal and I were able to see that something was wrong, and eventually, when she was comfortable talking about it, I figured out what happened.  Thus, behavior, verbal or not, is a key indication of how a child is feeling.  It is important for parents and healthcare providers to be aware of the signs of pain in children, verbal or non-verbal, as their bodies can very well communicate their level of pain when they cannot do so through words.

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The Benefits of Yoga: Body and Mind

Yoga is a fantastic, low impact way to exercise and take care of your mind and body.  Its increasing popularity in the Western world has created many easy ways for you to get involved. Yoga is a great way to achieve balanced living as the principals of Yoga promote peace, kindness, and overall well-being.  The following infographic from the Huffington Post shows the impact yoga can have on your body and mind whether you try it once or practice for years.
Namaste.

 

Read the full article:

The Huffington Post: How Yoga Changes Your Body, Starting The Day You Begin

 

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Winter Is On Its Way: Stay Safe on The Road

Winter is well on its way!  Snow has fallen and temperatures are dropping.  It’s time to get out your boots, hats and snow gear, but also time to ensure your vehicle is prepared for the blustery winter weather ahead. Winter weather can provide many pleasures:  building snowmen, skiing, outdoor skating and the beauty of the freshly fallen snow.  However, winter weather can also bring many dangers, especially on the road, and can take a toll on your vehicle.  From tires to wipers, the following article gives tips on how to prepare your vehicle for the cold and stormy weather that awaits.  Be sure you and your vehicle are prepared for winter, and to keep yourself and others safe, always drive according to weather conditions.

How To Prepare Your Car For Winter Survival

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Healthier Portion Sizes

Eating out is always a treat.  More recently restaurants are even expanding menus to include healthier options.  However, the portions are often excessive.  In fact, the following from care2.com discusses how portion sizes have increased dramatically over the past 60 years. What can you do about it?   Remember, the size of your fist is the size of your stomach.  Next time you go out to eat, count how many fists worth of food are actually put in front of you.  Ask your server, before receiving your meal, to pack up half in a take out container and eat the half that is given to you to help control the size of your portion.  You’ll be doing your body a favour and you’ll have tasty leftovers for the next day!

Care2.com: Portion Sizes Have Grown This Much in 60 Years

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National Child Day

Written by Justine Huszczynski, Occupational Therapist

 

Today marks the date when Canada adopted the United Nations Convention on the Rights of the Child (UNCRC).  Simply put, the UNCRC is a treaty that outlines the basic human rights for children and youth.

                                             

Among other rights, the UNCRC outlines “survival and development rights” which are explained as “the basic rights to life, survival and development of one’s full potential”.  Looking into this a little deeper, Article 23 under the “survival and development rights” states:

 

“Children who have any kind of disability have the right to special care and support, as well as all the rights in the Convention, so that they can live full and independent lives.”

           

So, how is Canada ensuring that the rights of children with disabilities are being fulfilled?  Of course, we have public healthcare which provides children prompt access to medical attention.  But Article 23 goes beyond this.  It also includes the right to services – therapy services perhaps – that children with “any kind of disability” should be able to access such that they can become independent adults and experience a fulfilling life.

 

While Ontario offers plenty of publicly funded early intervention services for children with disabilities (based on the availability of twenty government-funded children’s treatment centres across the province), how are the outrageous waitlists for some of the most valuable services offered in these centres acceptable?  For example, last year the Toronto Star surveyed nine of the government-funded treatment centres and found average waitlist times ranging from one to FOUR years for a child to receive intensive behavioural intervention (IBI) therapy.

 

So how does this follow the guidelines of the UNCRC? Honestly, it doesn’t.  Simply having a service available to a child with a disability is not enough.  The service needs to be provided.  Long waitlists do not allow children to “live full and independent lives” but in fact can stifle a child’s development by denying access to programs that are most effective as “early intervention”.

 

Therefore, while we celebrate how far we have come to secure the rights of children, we need to look ahead and aim for a brighter future for those children that may need some extra support – sooner rather than later.  An example of striving for a brighter future comes from the parents of one of my clients who devoted their time to being their child’s advocate when “he didn’t have a voice”.  After this young client was denied services by one of the government-funded children’s treatment centres in Ontario, his parents scheduled a meeting with their local Member of Provincial Parliament (MPP) to advocate for their son’s dire need for early intervention services.  As a result of the advocacy skills of my client’s parents, the MPP ordered the treatment centre to complete a reassessment and the child was granted the early intervention services that he absolutely deserved and required.  During a conversation with the mother of this client, she stated, “It is my job to be make my child’s life better”.   This statement is heartwarming, and perhaps we should view it as a challenge.  A challenge for all of us – therapists, health professionals, teachers, citizens, governments– to truly make it our “job” to ensure children are given the best life possible.  So take the challenge and advocate for our children – ask more questions, get second opinions, research the available charitable funding, schedule meetings with your MPP, school board trustee, and don’t take no for an answer.  

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Brain Health and Sports: Use Your Head… Don’t Abuse It

Earlier on the blog we discussed the dangers of concussions in both football and hockey; however, many across the world are now concerned about potential brain damage that can occur from other sports such as soccer and rugby.  Although these sports do not have as much hard contact as hockey or football, they are rough and knocks to the head are still likely to occur.  The following from Reuters Canada discusses the growing instances of head injury in sports other than boxing, football and hockey.  It is so important no matter what your sport to wear a proper equipment, and to know the signs and symptoms of a concussion or brain damage.  Remember, play smart and play safe!   

Reuters: Brain damage concussion fears seep into rugby and soccer

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An Uprising?

I recently wrote paper for my business law course.  In this, I talked about the auto insurance industry and demonstrated through case law examples of insurer negligence, failed fiduciary duty, professional and assessment issues, and how some insurer behavior even seems to violate the Charter of Rights and Freedoms.  Once I know I passed my assignment, I will post some of the findings here.

But what I realized in writing my paper is that third party assessors are immune in law.  These are the assessors insurers hire when they want a second opinion.  While I believe in the need for a “check and balance”, the quality of these opinions is deteriorating.  Now, we are seeing completely unsupported  benefit denials, issues with assessor behavior (questionable comments made to the claimant, very short exams costing thousands), errors in reporting (sometimes the client’s name is even wrong in parts), and even some fudging of professional credentials and experience (no Dr. Grant is not an Orthopedic Surgeon).  As a treating OT, I see the aftermath of this – clients feel victimized, some even abused, some angry, and some sink deeper into a depression from the comments they read that have so wrongly captured the problems they have.  People are trying to go to the Colleges to complain, but are saying this is ineffective.

I also discovered with my paper that third party assessors do not owe a claimant a “duty of care” and as such cannot be negligent.  They can breach professional standards, and for that be held accountable by a College (if they have one), but cannot be sued for negligence or failed fiduciary duties.  Does knowing this make these assessors more ruthless?  Or, perhaps they don’t know this as I too used to be one of these assessors and always felt that I did owe a duty of care and ensured I provided a level of professional courteousness and respect for the client, even if the intent was not to form a treating relationship.  I never saw a line between me as an “OT” and me as an “assessor”.  They were always one and the same.  But maybe that is why I never had a college complaint, or a client or other therapist call me after an assessment and tell me I was out to lunch.

I feel an uprising coming.  A time where the people of Ontario, who rely on their insurer to fulfill a contract after an accident, get sick of the way they are being treated by some adjusters and assessors and demand a solution.  One such solution has presented itself in Colorado.  With this, Colorado’s uprising resulted in new Independent Medical Examination Legislation that is working to solve the problems that bad assessments were creating.  Here are some highlights:

The legislation requires that independent assessors be in the same specialty as the treating practitioner (including chiropractors, psychologists, or orthopedic surgeons), and earn less than half their income from disability assessments.  Most important, their process ensures that the assessor is acceptable to both the insurer and the patient. Assessors are held to a higher standard than treating providers, considering their position of power.  In the new system, 75% of assessments have concluded that the initial diagnosis and treatment was appropriate, 20% partly appropriate, and only 5% inappropriate or unrelated to the accident.  Further, dispute times have been greatly reduced, saving significant dollars (www.colorado.gov).

How about we try something like that FSCO, IBC and friends?  But I know that before you can do this, you first need to recognize how the behavior and actions of some insurers are driving up costs, that bad assessments are ultimately resources wasted, and that costly disputes in court are resulting from both.  Could it be that maybe, just maybe, fraud is only one of your problems?