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Introduction

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

Welcome to this free course on child and adolescent biological, psychological and social health. This course is primarily aimed at people working in health and social care but may be useful to others with an interest in child health and wellbeing, such as those who work in early years or education.

In this course you will explore childhood development and some biological and psychological conditions that affect children and young people. These will take the focus of asthma, intellectual and development disorders, depression and anxiety and eating disorders.

This course will be based on the biopsychosocial model of health. This model of health has been in existence for quite some time. The Bio-Psycho-Social model, originally described by Engel (1977), is one that helps healthcare professionals think about a variety of elements of a person’s life to help them take a holistic view of their circumstances. It enables them to gather an individual's understanding of their situation, their strengths and their needs in relation to it and allows them to start to identify some of the key elements that are important to the person, as well as potentially identifying the ‘root causes’ of a person’s health situation. This then supports them in their collaboration with the person to help them identify interventions and other processes to improve their situation. Although the original model is 40 years old, it is still seen as useful today.

Biological elements of health include genetics, height, weight, body chemistry, presence of disease, body responses, e.g. heart rate, medications, disability.
Psychological elements include emotions, memory, perceptions, beliefs and values, attitudes, coping strategies, mental health conditions.
Social elements include family background, social status, financial status, living arrangements, family unit, education, demographics, culture.

These three aspects of health should not be viewed as independent; it is likely that there is some overlap between them and one or all can influence the other(s) as you will see as you progress through this course.

As you work through this course, you will be introduced to several different people who will help you to explore some of the biological, social and psychological aspects of health.

Liam: Liam is 16 years old; he has had severe asthma since he was a child, having been hospitalised with his asthma frequently. He is an only child, his parents separated when he was a child and he has recently experienced some challenges with his health and schooling. Liam will be used to cover psychological and social aspects of health.
Chloe: Chloe is an 11-year-old girl with asthma. Chloe will be used to cover biological and psychological aspects of health.
Parents: You will hear about the experiences of parents of children with asthma. The parents will illustrate the biological and psychological aspects of health.
Lola: Lola is a teenage girl who experiences difficulties with an eating disorder. Lola will be used to explore some psychological and social aspects of health.

This OpenLearn course is an adapted extract from the Open University course K234 Healthcare theory for practice.

Learning outcomes

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

After studying this course, you should be able to:

explain biological changes and the pathophysiology of childhood asthma
understand the experience of parents and children in childhood asthma
explain how mental health affects children and young people
understand the experience of using mental health services as a young person.

1 Childhood asthma

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

In this section, you will explore the experiences of those who have a diagnosis of childhood asthma and have often been in hospital with severe asthma attacks during childhood. You will explore the common condition found in children and young people, and how it is assessed, diagnosed and managed on a day-to-day and acute basis. You will hear Chloe’s experiences as a young person with asthma and how she copes with asthma and having an asthma attack; a parent of a child with asthma explaining how it felt to be part of the diagnostic process; and when children are hospitalised with acute episodes.

Childhood asthma (pediatric asthma) is the most common serious chronic disease in infants and children; yet is difficult to diagnose.

American Academy of Allergy Asthma & Immunology (2020)

Explore Figure 1 to learn more about the common signs, symptoms and risk factors of asthma.

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Figure 1 Signs, symptoms and risk factors of asthma in children

Long description

Activity 1 Biological development of the respiratory system (children) and pathophysiology of childhood asthma

Timing: Allow 60 minutes

Watch the following video and on a piece of paper create a labelled diagram that identifies the difference between a normal and asthmatic airway. Then produce a list of ‘triggers’ that might affect asthmatics.

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Video 1 Asthma pathophysiology / Respiratory system diseases

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Transcript: Video 1 Asthma pathophysiology / Respiratory system diseases

INSTRUCTOR

Before we talk about what asthma looks like, let’s take a look at a normal airway. So we’ve taken a cross-section of somewhere along the airway. Asthma is a small airway disease, so this is not the trachea or the stuff in your throat, but in your chest.

And one of the important players in the calibre of the structure of the airway that I want to start with is the smooth muscle layer. So we’ll use red for muscle. And this layer controls the diameter of the opening, the diameter of the lumen.

Of course, outside the muscle, there’s other things too. There’s connective tissue and cartilage, depending on if you’re high up enough on the airway. Those things are not really as affected by asthma, so we’ll just leave it like this. So we got our smooth muscle, which, smooth muscle, remember, you can’t control consciously. It reacts to the environment and usually keeps our airway nice and open like this. Label that here, smooth muscle. The inside that we have – a layer of the mucosa. So we call it the mucosal layer. Let me just label that, the mucosa. That basically coats the inside opening of the airway.

And within this layer, it’s very important that we have these glands that can secrete mucus into the lungs. They’re, therefore, lubricating the opening and keeping our lungs moist. And also when there is inflammation, or there are foreign bodies we have to get rid of, the mucus that they secrete is important in clearing out the area. So when we cough, and we cough up the phlegm, the phlegm comes from these glands that secrete the mucosa.

So they’re everywhere in the mucosal layer. And of course, here we have the lumen. This is where the air actually moves in and out. It is dry, but nice and lubricated by the mucus. So this is a quick look at what the normal lung, the normal cross-section of the airway, looks like.

And now let’s look at what happens when this person is having asthma. As you know, asthma comes in attacks. So most of the changes happen during an attack. Depending on the severity, this person might get it more often than the next patient.

So first, we still have our muscular layer. But now the lung is in spasm. The muscles are spasming, which means it’s constricting and the opening is going to be much smaller. The connective tissue, like the cartilage and other things, are still out there. So I’ll still draw it like this. But the important thing to focus on right now is the fact that the muscular layer has thickened, and it’s clamping down on this opening. In addition, the mucus layer, which is nice and round here, that I’ve drawn has swelled up in reaction to the inflammation.

So instead of a nice round opening like this, now we have this amorphous shape that further clamps down on the opening. So now look at what has happened to our lumen. It’s much smaller. And to make matters worse, don’t forget the glands.

So the glands are still here, but this time, they are also reacting to the immune response. And as a result, they’re filling up with mucus, and they’re secreting it into the lumen that’s already narrow and blocked off. So now we’ve got this swirling mucus in here.

That only makes matters worse. So look at the difference between air going through this nice, big opening and air trying to get through this. So between the constriction and all the fluid in there, we’re going to have little bubbles. That’s why you hear the popping and the wheezing when you listen to a person having an asthma attack.

The wheezing comes from the obstruction, both from mechanically narrowing this area and the extra fluid in there from these glands going crazy. So that’s how it happens. But why does this whole thing take place? What triggers asthma?

Well, that is the million dollar question, because there are so many things in the environment. What I’m drawing here are – it could be pollution. It could be smoke. It could be food or dander, anything that this particular person reacts to. These are the allergens in the air.

And when they get into the body, our body has an immune response that reacts to anything that’s foreign. Some people react more than others. And we have these antibodies that look like Y-shaped molecules. So these, in an immune reaction, tend to be IgE. That’s just the name of these antibodies.

Now the body has a tricky memory system. If it’s the first time that it’s seen these allergens, you might only get two IgEs because they’re working hard to make new ones to recognise them. But the third or fourth time, every time you get exposed, because the memory is still there, it’s easier to make the IgE each time. It’s like fighting an enemy that you’ve already fought before. So the IgE actually increases in number.

So the size of this IgE response is proportional to the size of this immune response or to this allergic response, I should say, because when the immune response goes haywire, responding to something that’s foreign and trying to fight it off, that’s called an allergy. So we’ve got these foreign allergens, whatever the trigger is, with the IgE. The job of the IgE is to recognise and pick up these foreign particles.

The IgE is in the same family of antibodies that help us fight off infections. But in this case, it goes to search for a cell we call it the mast cell. It’s spelled mast like the mast on a ship.

And inside the mast cell, it’s just floating around our body carrying little pockets of a molecule we call histamine. And histamine is the main player in any allergic reaction. Remember, if you have ever taken anything to fight off an allergy, there’s a class of drugs called the antihistamines.

So histamine is just usually walled off in the mast cell and not in our system. But the IgE antibodies we just talked about, they are friends with the mast cells. And only when they’re carrying a foreign body like this do they find a mast cell and attach to it. So every pair of the IgE that has picked up an allergen will go then look for a mast cell to attach to it like this.

This attachment right here wakes up the mast cells. So all these little pockets inside it open up. The histamine then flows out of the mast cell like this and floods into our system, into our bloodstream, causing allergic reactions everywhere. This is why you sneeze and your eyes water, you can get hives.

The whole cascade of that allergic reaction is thanks to these little histamine molecules. And in the lungs, if this person has asthma, this is exactly what happens as a result of the histamine. Let me just draw a few more particles here to show you.

And voila. We get this constriction. We get the mucosal swelling, and we get the wheezing. So asthma is really an immune response going overboard as all allergies are. It’s a part of our body’s natural response to a foreign body that then causes us harm by reacting too strongly and releasing things that cause us discomfort.

So to sum up the pathophysiology of asthma, remember, first, we’ve got the muscular layer thickening and constricting. Then we’ve got the mucosal layer swelling up. And third, we have the glands overproducing the mucus that then floods the already constricted opening.

End transcript: Video 1 Asthma pathophysiology / Respiratory system diseases

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Video 1 Asthma pathophysiology / Respiratory system diseases

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Discussion

Your diagram might have had the following features shown in Figure 2.

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Figure 2 How airways are affected by asthma

Long description

You may have identified the following triggers:

infections e.g. a cold
allergens such as pollen, animal fur or dust mites
cigarette smoke
pollution
medicines
mould
weather changes, such as cooler weather in the winter
exercise.

As a person working with or caring for children and young people with asthma, it is important that you are vigilant to signs of deterioration in health and wellbeing and that you know how and when to escalate any concerns. It is often useful to understand how asthma is diagnosed. In the next section you will look at the assessment and diagnosis of asthma.

1.1 Assessment & diagnosis

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

Assessment and diagnosis of asthma in children 5–16 years of age is slightly different to the process for adults. Before the age of 5 years, it is difficult to confirm asthma as a diagnosis (National Institute for Health and Care Excellence, 2020). The next activity will allow you to explore the assessment and diagnostic process for children and young people.

Activity 2 Guidance on assessment and diagnosis of asthma

Timing: Allow 60 minutes

You will need to access the National Institute for Clinical Health and Care Excellence (NICE) for these activities. To avoid losing your place in the course, if you are studying on a desktop you should open the link in a new tab or window by holding down Ctrl (or Cmd on a Mac) when you click on it. If you are studying on a mobile device hold down the link and select to ‘Open in New Tab’. Return here when you have finished.

Once you have access to the NICE guidelines, make sure you follow the guidance for children and young people.

Part A

Using the guidance document answer the following questions.

1. What is involved in the initial clinical assessment?

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Discussion

From Section 1.1.1:

Take a structured clinical history in people with suspected asthma. Specifically, check for:
wheeze, cough or breathlessness, and any daily or seasonal variation in these symptoms
any triggers that make symptoms worse
a personal or family history of atopic disorders.

(National Institute for Health and Care Excellence, 2020)

Algorithm A is a flowchart that outlines clinical assessment. (See section 1.1.1.)

2. What are ‘objective tests’?

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Discussion

These are ‘tests carried out to help determine whether a person has asthma, the results of which are not based on the person’s symptoms, for example, tests to measure lung function or evidence of inflammation’ (National Institute for Health and Care Excellence, 2020).

3. Why should symptoms alone not be used as an objective test?

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Discussion

Symptoms alone should not be used to diagnose asthma as they could give a false diagnosis of asthma. This would mean that the incorrect treatment could be prescribed. If people with asthma are misdiagnosed as not having asthma this could increase the risk of an asthma attack.

Do not use symptoms alone without an objective test to diagnose asthma.

Do not use a history of atopic disorders alone to diagnose asthma. (See sections 1.1.2 and 1.1.3 of the article.)

4. What is different about diagnosing children under the age of 5 compared to those over the age of 5?

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Discussion

For children under 5 with suspected asthma, treat symptoms based on observation and clinical judgement, and review the child on a regular basis (see the section on pharmacological treatment pathway for children under 5). If they still have symptoms when they reach 5 years, carry out objective tests (see the section on objective tests for diagnosing asthma in adults, young people and children aged 5 and over and Algorithm B) (Section 1.2.1 of the article).

Part B

Using the NICE guidance document ‘Algorithm B Objective tests for asthma in children and young people aged 5-16’ and the information provided for each of the three children below, make a decision about whether these children would be likely to have asthma.

Child A

Observation

Normal spirometry with a negative bronchodilator reversibility test
FeNO: 13 ppb
Peak flow readings: 250, 245, 240

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Child B

Observation

Spirometer: not known
FeNO: not known
Peak flow readings: unable to obtain

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Child C

Observation

Normal spirometry with a negative bronchodilator reversibility test
FeNO: 37 ppb
Peak flow readings: 120, 110, 115

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1.2 Diagnosis and day-to-day management of uncontrolled asthma

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

The National Institute for Health and Care Excellence (2020) defines uncontrolled asthma as:

asthma that has an impact on a person’s lifestyle or restricts their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest tightness associated with uncontrolled asthma can significantly decrease a person’s quality of life and may lead to medical emergency.

Uncontrolled asthma is determined by having symptoms for three or more days per week, having to use a ‘short-acting beta antagonist’ (SABA) (reliever) inhaler such as salbutamol for three or more days per week or waking up from sleep once or more in a week. For an occasional wheeze or asthma that is considered ‘controlled’ (i.e. it does not meet these criteria), a SABA might be the only course of treatment required. Inhaled corticosteroid (ICS) (preventer) inhalers are recommended for children and young people if they meet these criteria or if they have had an asthma attack in the preceding two years (British National Formulary, BNF, 2019). Preventer inhalers build up asthma protection over time by reducing inflammation in the lungs.

Activity 3 Having asthma

Timing: Allow 45 minutes

Listen to Audio 1.

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Audio 1

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Transcript: Audio 1

FATHER

My son’s asthma was finally diagnosed – I think he was about five years old. But it was always something we were expecting. We knew that one day they were going to say he’s got asthma, and so in one way it was bit of a relief. But on the other side of it – well, we’d basically known this for years.

The process of diagnosis came about from another admission into hospital from an asthma attack. They literally just kept reading through his charts, saw that he had been in and out of hospital a number of times that included overnight stays in hospital… personally I think they just saw, okay, he is five years old now, these symptoms don’t seem to go away – so they confirmed that he did have asthma and then we were invited to go and see an asthma specialist through our GP.

We were quite pleased about the diagnosis in a strange way. I’ve always been quite keen for him to be into sports, to be quite active. When he was younger, you could see he was just getting out of breath and he couldn’t run around all the time with the other kids.

Managing medication for our son was pretty much getting into a routine, just knowing that whenever he wakes up he’s either got to take a tablet or do an inhaler. When he goes to bed he’s got to take a tablet, do his inhalers again. Whenever you’re going out anywhere you do need to make sure that you’ve got his medication on you at all times because it never seemed to be much of a pattern – when he was younger he could be absolutely fine one day or for a week or so but then out of the blue he could start displaying symptoms and be struggling to breathe, and he would need his medication.

We had to be quite mindful of the environment that my son was in. It would appear sometimes dust would start him off. Other animals could be a trigger as well – cat fur, dog fur, that sort of thing.

There weren’t many challenges day to day. As long as you were just constantly knowing that he’s sticking to his routine for medication and that you’ve also got inhalers handy. Not so much a problem at the age he is now. He’s approaching fourteen years old, so he’s taken a bit of responsibility, as he should. He’s always got an inhaler in his pocket – he knows his routine for his medication, so that means taking tablets in the morning, taking tablets of an evening. If we’re going to be in an environment where there could be other triggers such as animal fur, a dusty environment, you make sure you take an antihistamine as well just to give himself a bit of an extra layer of protection.

As my son’s got older, it has eased a little bit as the sort of pressure on a parent. He knows that his health is his responsibility and that involves taking your medication, having an inhaler handy, don’t put yourself into an environment where you could put yourself at risk.

End transcript: Audio 1

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Audio 1

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Look through the diagnosis and treatment sections of the NICE guidelines on diagnosing, monitoring and managing asthma and conduct your own internet search on the diagnosis and treatment of asthma. Remember, to avoid losing your place in the course, if you are studying on a desktop you should open the link in a new tab or window by holding down Ctrl (or Cmd on a Mac) when you click on it. If you are studying on a mobile device hold down the link and select to ‘Open in New Tab’. Then return here when you have finished.

Make sure you are familiar with the advice on managing an asthma attack and then complete the next part of this activity.

In the audio you heard a parent talking about their experience of having a child diagnosed with asthma and some of the day-to-day considerations. Using the clinical guidance and what you have found from your own internet search, indicate the type of advice you would provide to this parent for their son, whose usual peak flow is 120.

You might also find this asthma action plan from Asthma UK useful when completing this activity.

Outline of the diagnostic process

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Everyday asthma care

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When they feel worse

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What to do in an asthma attack

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Discussion

This activity has allowed you to use clinical guidance to produce patient-facing information to help them manage their asthma.

Diagnostic process:

For children under 5 with suspected asthma, treat symptoms based on observation and clinical judgement, and review the child on a regular basis. If they still have symptoms when they reach 5 years, carry out objective tests.

If a child is unable to perform objective tests when they are aged 5:

continue to treat based on observation and clinical judgement
try doing the tests again every 6 to 12 months until satisfactory results are obtained
consider referral for specialist assessment if the child repeatedly cannot perform objective tests and is not responding to treatment.

Everyday asthma care:

Personal best peak flow is 120
ICS (preventer) such as beclomethasone (Clenil) – one puff twice daily
SABA (reliever) such as salbutamol – take two puffs at a time
They may use a spacer to administer their inhaler.

When they feel worse:

My peak flow drops below 115 (you may have estimated this differently)
ICS (preventer) – two puffs twice daily
Take reliever inhaler up to 10 puffs every 4 hours (if they need to do this then it is likely they are having an asthma attack and need urgent attention). They should not exceed the daily maximum dose
They may be prescribed a nebuliser.

What to do in an asthma attack:

You should have noted the actions to take when someone is having an asthma attack
If they are taking a maintenance and reliever inhaler in one (maintenance and reliever therapy, or MART) then it’s likely they will have been prescribed a reliever inhaler for use in emergency situations.

You will now explore what treatment is provided in hospital when someone has a severe exacerbation of asthma.

1.3 Acute episodes of asthma

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

As you will have seen from Activity 3 in the previous section, recognising when a child is having an asthma attack is important; failure to seek medical attention at the right time could be life-threatening. Acute episodes can be caused by a range of factors but are typically related to exposure to a trigger or allergen such as infections, pollen, dust, pet dander, smoke, chemical fumes or strong odours. Children who are experiencing an asthma attack typically present with shortness of breath, chest tightness, wheezing and/or coughing.

Activity 4 Acute asthma episodes – child and parent perspectives

Timing: Allow 30 minutes

Listen to the following audio of a parent talking about what it is like to have a child with severe asthma who is hospitalised, then watch the animation created by Chloe, an 11-year-old girl, talking about what it feels like to have an asthma attack.

You should make notes about the process that is followed when a child is having an asthma attack and think carefully about how the parent and child might feel during these episodes.

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Audio 2

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Transcript: Audio 2

FATHER

As my son’s got older, it’s almost easier to recognise when an attack is starting, and that’s because he sees it coming himself. He’ll tell you that he’s struggling a little bit and so you go into a routine of – have you done your inhalers? When he’s having an attack, he can take up to ten puffs of a blue Ventolin inhaler. If that doesn’t have any effect on him, from experience he knows that either we will put him in the car, get him down to A&E. If it’s really a quite worrying one, if it’s quite bad, we’ve phoned ambulances before and he’s been taken into hospital in an ambulance with blue lights on, so it’s almost easier as he gets older, but no less worrying, obviously.

Going back to when he was quite young, you’d almost see patterns in his behaviour when was struggling with asthma. He used to display some signs or make noises almost, that we would think, ‘hang on a minute, he’s struggling a little bit’. He used to try and draw a breath in and he would almost hold his breath once it was in and then he would expel it and it made almost a grunting noise. So you’d see that, you’d hear that, and you’d sort of look at him and he’d be a little bit concerned, a little bit worried. When he was younger he didn’t sort of realise that he could be struggling a little bit, he didn’t make the connection as such, but as he’s got older, he stopped making the noise that he used to make but he recognised it coming on so he would actually say, ‘I need my inhaler.’

When my son was having an attack, the hardest thing to do was stay calm. If he saw that we were getting a little bit flustered or concerned that would have an effect on him. So I think if someone is in that position, is having an attack, remain calm. The worst thing you can do is get upset yourself because they’re just going to pick up on that. So when he was having an attack you’d just literally sit with him, talk to him, make sure he’s got his inhaler, make sure he’s got anything that might make him comfortable. He used to have a teddy bear; he just liked to hold the teddy bear when he was younger, so just making a pleasant as possible environment for him.

I think the point when you realise you are going to need proper medical assistance – when he was young you do tend to – Ventolin. If you saw that’s not going to work, you’d literally and immediately decide right, he needs to go, he needs to be in an ambulance or we need to rush him down to the hospital.

We’d been aware of the 111 service that we can phone to get advice, work out next steps, but, from experience, you basically know the symptoms your child is displaying – 111 service isn’t always going to be of a great benefit to you. It might – it might help the first couple of times it happens because you’re not going to want to bother the ambulance service. But, after a while, after getting to know your child’s symptoms, you phone 999 and I’ve done that a good couple of times. He has been rushed into hospital in an ambulance and straight into critical care a good three or four times, probably.

The time periods when your child is having an attack, they can vary because the severity of an attack is evident sometimes, sometimes it’s not. Once he’s not massively responsive to the Ventolin, you know pretty much straight away that he’s going to need to go in; he’s going to have to be ambulanced into hospital and get the nebulisers.

From a parent’s perspective it can be a scary, scary experience. And maybe the first couple of times it happens, you’re not entirely sure what it is, you may not even know the severity, the possible outcomes, what they can be. The more you live with it, as a parent and obviously the child living with it, you know it can be severe, you know that they can get into quite a lot of trouble pretty quickly. So if you recognise the signs, if you know the signs from experience, I’d – I wouldn’t hesitate to phone 999.

From a child’s experience, the first time it happens, it’s going to be scary. They’re not going to know what’s going on, but also, the more they have it, I think, when they have an attack, they know that the consequences can be quite bad. So the last time my son had an attack, he was on the verge of panic. He knew that he could, potentially, stop breathing, but by that stage, luckily, we were at the hospital, he was being nebulised, he was being given medication, but you could still see he was scared, he was absolutely petrified, actually.

I’ve got experiences of being in critical care with my son and, I’ve got to say, with the hospital that we’d been to – we’ve been to two different hospitals, actually, and they’ve been both absolutely brilliant with him, professional care all the way through, really.

The things the staff do can be really helpful from a parent’s perspective because they – they tell you what’s happening, they – they keep you calm, they talk to the child. As the child gets older if they are able to be talked to and explained to, they will do – they can instil a lot of confidence. Some have struggled to remain calm at times, but if they’ve called someone, I’m guessing a senior, they’ve immediately instilled a bit of confidence, telling us what they’ve given him, what the effect could be and basically saying ‘calm down, calm down, everything’s going to be okay’, and you get to the stage where you look at the monitor as well, you see the saturated oxygen, and when you see a certain number you think ‘blimey, that’s a bit low’, but they will say ‘don’t worry, don’t worry’; then you will see the saturated oxygen level creeping up and then what they’ve told you is basically right and, have a bit of faith in them, and, hopefully, the outcome is going to be a good outcome.

Communication is vital, really, because with an asthma attack there’s – there’s a lot of fear on both sides. There’s a fear in the child, there’s a fear in the parent, and as long as you get clear communication from your healthcare professional it can put you at ease, it can put the child at ease and that, it really is, key. If they can communicate clearly, concisely, accurately, you do feel a lot better about the care your child is getting.

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Video 2 What it feels like to have an asthma attack

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Transcript: Video 2 What it feels like to have an asthma attack

[MUSIC PLAYING]

CHLOE

One cold November morning, I woke up and took my inhalers.

[SPRAYING]

I do this every morning and every night before I go to bed.

[EXHALING]

I went to school as normal. I had my maths lesson in the morning. Then we went out for our break. Normally, I would run around with my friends and play. But I have to be careful of running around in the winter months, as this can affect my asthma. So instead, I sat down on the bench watching my friends play dodgeball.

After a while, one of my friends came up to me and asked me to play with them. I completely forgot about my asthma. And it looked like they were having so much fun. So I got up to join them. I ran around with them for the rest of the break and stopped as the bell rang.

[BELL RINGING]

Out of breath, I slowly walked to my next class.

[PANTING]

As I walked through the building, I realised I was struggling to catch my breath. My chest was pounding and my heart was beating rapidly.

[HEARTBEAT]

I went to where my inhaler was kept in the classroom, and the teacher sat me down on a chair as I was having another asthma attack – the second one that month. I took out my inhaler.

[SPRAYING]

But this didn’t seem to make any difference to my breathing, which was getting out of control. I couldn’t catch my breath. I was struggling to breathe. My face turned a pale blue colour.

[GASPING]

It felt like I was trying to climb a mountain with a heavy backpack on, going nowhere. The teacher looked worried, and I was panicking. Before I knew what was happening, I was being carried off to the front office as an ambulance had been called for me.

[SIRENS]

I could hear the sirens getting closer. Then I was put into the back of an ambulance. At this point, I felt like I was being strangled by a heavy rope around my neck, squeezing tighter and tighter. I was gasping for air. I just couldn’t breathe.

When I was in the ambulance and when I arrived at the hospital, I was given a nebuliser, which is a machine with a tube coming from it that leads into a mask which was put over my face. Through the machine, liquid medicine is sprayed into the mask for me to breathe in.

[WHOOSHING]

Very slowly, my breathing returned to normal.

[MUSIC PLAYING]

Having an asthma attack is a very scary experience. When it was all over, it felt like a miracle, like I was in a dream. I could breathe again. I was so happy.

[ON-SCREEN TEXT Drawings and Voice Over by Chloe, aged 11]

End transcript: Video 2 What it feels like to have an asthma attack

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Video 2 What it feels like to have an asthma attack

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Chloe, who produced this animation, is 11 years old and has had asthma for several years. She wakes up during the night at least once per week and wheezes over three times per week, so this could be considered uncontrolled asthma. Her peak flow can be variable but is usually around 115. The National Institute for Health and Care Excellence (2020) recommends that there should be a self-management plan in place for people with asthma.

If you were caring for the child as a healthcare professional, what actions could you take to support both the child and parent when they are admitted to hospital? Think about the things they might be thinking and feeling.

In Table 1, make some notes about the things you should be thinking about and the care you should provide. For example, what communication strategies would you use? Why?

Table 1 Aspects of care needed for Chloe and parents

Aspect of care needed/action	Rationale: how would this help the parent/child?
Table 1 Aspects of care needed for Chloe and parents 1, Your response 1	Table 1 Aspects of care needed for Chloe and parents 2, Your response 2
Table 1 Aspects of care needed for Chloe and parents 3, Your response 3	Table 1 Aspects of care needed for Chloe and parents 4, Your response 4
Table 1 Aspects of care needed for Chloe and parents 5, Your response 5	Table 1 Aspects of care needed for Chloe and parents 6, Your response 6
Table 1 Aspects of care needed for Chloe and parents 7, Your response 7	Table 1 Aspects of care needed for Chloe and parents 8, Your response 8
Table 1 Aspects of care needed for Chloe and parents 9, Your response 9	Table 1 Aspects of care needed for Chloe and parents 10, Your response 10
Table 1 Aspects of care needed for Chloe and parents 11, Your response 11	Table 1 Aspects of care needed for Chloe and parents 12, Your response 12

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Discussion

You might have identified many different care needs that Chloe and parents may feel are important. Effective communication, such as active listening and distraction techniques, could be useful skills for you to use as a healthcare professional. Chloe and Chloe’s mother have identified the following areas of priority.

Chloe says:

It’s important to be reassured by the nurses when having an attack, as you do feel very scared, very panicked and confused and need someone to be calm and to make you calm. A calm person to be there to talk to you, to reassure you that everything is going to be ok, that you are safe now. Then to explain exactly what is going to happen next, step by step and why they are going to do it.

For Chloe, distraction is very important – to be distracted by the nurse with stories or a joke or two, or even an iPad with games or a book. Anything to take the mind away from what’s happening.

She highlights the importance of being kept informed of what’s going on and what might happen next. Will I go onto a ward? How long will I be there for? What happens next? Will this happen again? What can I do to help prevent it happening again?

It would helpful to be given a booklet to take away for information about attacks and medication, or be directed to a website for further information.

Chloe’s Mum says:

Advice on when to call an ambulance. When Chloe had her asthma attacks back to back within the school, at first the teachers didn’t have a clue how to deal with them as they hadn’t been trained so they panicked. As Chloe continued to get them, they decided to send all staff – the teachers, helpers and dinner ladies – for asthma training. Could this be compulsory for all schools? Maybe nurses could go into schools to train staff and to give talks on the subject to raise awareness? It would help the other children to understand what is going on; Chloe got teased a bit for using her inhaler in the class by the boys!

One of the most important things is effective communication, care and compassion for those involved. Communication strategies might take the form of verbal or non-verbal communication, e.g. active listening or the use of touch. Parents will likely feel very anxious and scared for their child, so you may have included some strategies for supporting them; sometimes this is as simple as providing a hot drink, allowing them to stay with their child or providing reassurance.

1.4 Management of acute episodes of asthma in hospital

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

Episodes of acute asthma are differentiated as moderate, severe and life-threatening. British National Formulary (2019) differentiates between these acute episodes in Table 2 below. SpO₂ measures the amount of oxygen in the blood using a pulse oximeter; in an acute episode normal saturation for children over 2 years of age is 94–98%. High flow oxygen therapy via a nasal cannula or tight-fitting face mask would typically be administered in these circumstances.

Table 2 The difference between moderate, severe and life-threatening asthma

Moderate	Severe	Life threatening
Able to talk in sentences Arterial oxygen saturation (SpO₂) ≥ 92% Peak flow ≥ 50% best or predicted Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years	Can’t complete sentences in one breath or too breathless to talk or feed SpO₂ < 92% Peak flow 33–50% best or predicted Heart rate > 140/minute in children aged 1–5 years; heart rate > 125/minute in children aged over 5 years Respiratory rate > 40/minute in children aged 1–5 years; respiratory rate > 30/minute in children aged over 5 years	Any one of the following in a child with severe asthma: SpO₂ < 92% Peak flow < 33% best or predicted Silent chest Cyanosis Poor respiratory effort Hypotension Exhaustion Confusion

Moderate

Severe

Life threatening

Able to talk in sentences
Arterial oxygen saturation (SpO₂) ≥ 92%
Peak flow ≥ 50% best or predicted
Heart rate ≤ 140/minute in children aged 1–5 years; heart rate ≤ 125/minute in children aged over 5 years
Respiratory rate ≤ 40/minute in children aged 1–5 years; respiratory rate ≤ 30/minute in children aged over 5 years

Can’t complete sentences in one breath or too breathless to talk or feed
SpO₂ < 92%
Peak flow 33–50% best or predicted
Heart rate > 140/minute in children aged 1–5 years; heart rate > 125/minute in children aged over 5 years
Respiratory rate > 40/minute in children aged 1–5 years; respiratory rate > 30/minute in children aged over 5 years

Any one of the following in a child with severe asthma:

SpO₂ < 92%
Peak flow < 33% best or predicted
Silent chest
Cyanosis
Poor respiratory effort
Hypotension
Exhaustion
Confusion

Activity 5 Typical treatment of acute episodes in the hospital environment

Timing: Allow 90 minutes

Source the following article via an internet search and respond to the points that follow. If you are a healthcare professional, you may want to complete the ‘time out’ activities in the article and use this as evidence of continuing professional development. This is not part of the course.

Article: Sheldon, G. et al. (2018) Nursing management of paediatric asthma in emergency departments. Emergency Nurse. Doi: 10.7748/en.2018.e1770

You can source this article online by entering the title into a Google search and downloading it from the source on ResearchGate.

Remember, to avoid losing your place in the course, you should search for article in a new tab or window.

Write down the risk factors from Box 1 in the article and note down how you might prevent an exacerbation of asthma.
What clinical signs and symptoms might be used when assessing the severity of an asthma exacerbation?
What is included in the examination of an acute episode of asthma?
What are the most common medications used for an acute episode of asthma?
Write a reflective account of 300–500 words about what you have learned about asthma from this article.
- What did you learn?
- How might this knowledge help you in the future?

Discussion

Some of the risk factors include respiratory tract infections, exposure to tobacco smoke, allergies, change of seasons, age, gender, pollution.
Moderate asthma: oxygen saturations of more than 92%, peak flow more than 50% of usual or predicted, no features of severe or life-threatening asthma.
Acute severe: oxygen saturations of less than 92%, peak flow 33-50% of usual or predicted, cannot form complete sentences, increase heart rate, increased respiratory rate.
Life-threatening: oxygen saturations of less than 92%, peak flow less than 33% of usual or predicted, silent chest, pale skin, low blood pressure, confusion, exhaustion.
Examination of an acute episode of asthma includes:
- taking a history to find out about the child’s activities, treatment, management and health
- an examination that includes assessment of skin and hands, breathing patterns, peak flow, movement and symmetry of the chest, any scars indicating previous surgery, check lymph nodes in the neck, expansion of the chest wall, heartrate, percussion of the chest wall, listen to the chest for example, for wheezing.
The most common medications used for an acute episode of asthma are:
- Salbutamol
- Prednisolone
- Ipratropium bromide
- Aminophylline
- Magnesium sulphate.

Section 1 has allowed you to explore complexities of child development through a biological condition, asthma. You will now explore the experiences of having a child diagnosed with a developmental/intellectual disorder/learning disability.

2 Intellectual and developmental disorders

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

This section will help you think about making information accessible for someone with a learning disability and to consider how to help people communicate concepts such as emotion. It will also explore the experiences of family members when they have little information about their child’s condition. You will finish this section by thinking about advocacy and self-advocacy of young people with a learning disability.

Before you explore the experiences related to having a child diagnosed with a learning disability, you will review some of the key elements of learning disabilities themselves.

You may have some knowledge of what a learning disability is and be aware of issues that become apparent for a person with a learning disability during various important events, such as life transitions from child to adult. For example, there are not only the biological and psychological changes for the individual and their families or carers, but also the social changes, including the transition from child to adult services, school to college etc. It is vital to remember to treat people as individuals (whether or not they have a learning disability) and in a person-centred way – placing them at the centre of any decision-making processes, helping to facilitate their understanding and helping to facilitate the communication of their decisions. This is particularly important in relation to issues such as gaining valid consent for health interventions, and relationship and financial issues, for example.

One of the ways that you can support people with communication is through developing and adapting communication systems. This can involve personalising communication to specific individuals and making information more accessible to the individual. There are many different communication systems and adaptations available to help with understanding, although some concepts such as emotions can prove difficult to portray.

The following activity will help you to explore some of the available tools and potential approaches for making information more accessible to individuals.

Activity 6 Communication of emotions

Timing: Allow 25 minutes

When thinking about making information accessible and helping people to communicate, it can be difficult knowing how to support people to express emotions.

Explore the links provided below and consider how you may try to communicate the feeling of ‘happy’ without using speech or text. Note down what you think some of the drawbacks are of trying to express emotions in the methods identified. Also note down suggestions for other potential approaches that you think may help to express emotion.

Remember, to avoid losing your place in the course, if you are studying on a desktop you should open the link in a new tab or window by holding down Ctrl (or Cmd on a Mac) when you click on it. If you are studying on a mobile device hold down the link and select to ‘Open in New Tab’. Return here when you have finished.

NHS: Guide to making information accessible for people with a learning disability
The Makaton Charity: How Makaton works
The PACE Centre on YouTube: Eyegaze communication in action
Communication Matters: Talking mats

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Discussion

Putting information into a format that is accessible for people is vital and the tools identified in this activity are extremely useful. Emotions, though, can be difficult to communicate. Some of the drawbacks may include trying to express an intensity of emotion, for example the difference between happy, very happy and ecstatic. In theory, synthesised speech can be made louder, or signs/symbols can be made bigger or have a particular colour to represent an emotion. Makaton and other sign languages can be very expressive as they are effectively ‘spoken’ by a person and you can take in information such as facial expression and other elements of body language.

2.1 Using media to express emotion

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

You will now experience an example of an expression of happiness using music and video, which will give you an opportunity to think about the benefits and drawbacks of using this type of media in the expression of emotions.

Activity 7 Using media to express emotion

Timing: Allow 5 minutes

In the previous activity you may have considered using music and/or video, art or dance to express emotions. As these are such expressive mediums, they can at times be used successfully.

Open the link to the Happy: World Down Syndrome Day video in a new tab or window and see if you think it portrays the emotion of happiness. Note your thoughts, including any potential drawbacks, about how well happiness was portrayed in the video.

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Discussion

Music, video and other expressive media can at times arguably be used to express intensity of emotion. There is a cost, for example in terms of time and other resources needed to create or collect the media, and it is less easy to use conversationally on the spur of the moment. It is important to remember though that expressing emotions has an important function for people that can relate to personal development and to positive mental health. The key to personalised, accessible information is creativity in using tools, skills or other resources which the individual can easily access.

Activities 6 and 7 have hopefully helped to remind you of the importance of some of the key elements related to communication when working with people who have learning disabilities and their families. Concepts such as accessible information, gauging a level of understanding and person-centred care are important to remember as they may well come up in early conversations with parents of children diagnosed with a learning disability.

You will now explore what it is like to have a child diagnosed with a learning disability.

2.2 Parents’ experiences of having a child with a learning disability

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

Many parents start to imagine what their child will be like while they are still developing in the womb. They imagine what they will look like, their personality, how they will grow up, how successful they will be, and so on. Obviously, it can be a worry if your child shows different developmental milestones from those expected, and a shock if at some point you realise that something might be out of the ordinary.

By exploring some of the potential thoughts and feelings family members may have if they have little information about their child’s learning disability, you can start to consider how you might go about preparing yourself to work with families in these situations.

When a child receives a diagnosis of a learning disability it can be seen as either a positive or a negative outcome by parents. For example, it could be seen as positive as it could identify a potential pathway of care and access to services that might be needed, but it could also be seen as negative as it may be a label that signifies an unknown future which may involve on-going, regular contact from health and social care professionals, into the family home.

The next activity will give you the opportunity to read some research involving mothers of children with fetal alcohol syndrome and consider their experiences in relation to having little information about the condition.

Activity 8 Parents’ experiences of a child being diagnosed with a learning disability

Timing: Allow 2 hours

Conduct an internet search for ‘parents experiences of fetal alcohol syndrome’ and ‘experiences of parents with children with a learning disability’ and start to note down some of the positive and negative experiences and the challenges faced. One particular source that may be of use is The experiences of caregivers looking after individuals with fetal alcohol spectrum disorder from Healthcare Improvement Scotland (2019), which you can find on ResearchGate.

Make notes on the thoughts and feelings of the parents in the box below.

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Discussion

Whitehurst (2011) suggests that fetal alcohol syndrome is not necessarily a well-understood disability. This can cause problems for both the parents trying to find information about the syndrome, and for health professionals who may be trying to support them. Although not every child with fetal alcohol syndrome will have a learning disability, many will, and this example has been used to highlight some of the potential issues where a lack of information may impact the family of a person with a learning disability. You might also have identified:

negative reactions from family
stigma from society
loneliness
empathy and understanding from others
adaptations required for daily life e.g. clothing, disability aids
finding places to go on holiday that are accessible
stress
impact on siblings.

Now that you have explored some of the potential issues related to having a child diagnosed with a learning disability, you are going to move on to look at the importance of remembering to hear and listen to the voice of the child or young person with a learning disability.

2.3 Hearing the voices of young people with learning disabilities

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

You may have identified that sometimes there is a tension in the role of a parent or caregiver between providing protection and nurturing and allowing growth. This can, for example, be particularly apparent during adolescence where individuals may be asserting their independence and wanting to develop relationships and to express their sexuality.

Many young people who have learning disabilities have their voices ignored as it is assumed that a parent or carer can speak for them, or that they do not really know what they want. Obviously, people of all ages (with or without a learning disability) have opinions, thoughts and ideas – and need to be able to make their choices known.

Knowing how and when to advocate for someone, or when to support someone to advocate for themselves, can be difficult. You don’t want to speak for someone when they can speak for themselves as that can disempower them; likewise you don’t want to assume that someone is comfortable talking about a sensitive subject, for example mental health or sex. Additionally, there are often parents, family members or carers who may have their view on the topic (whether they have a legal say over the issue related to the young person or not).

Activity 9 will help you explore some of the topics around supporting people to have their voices heard, potentially either by helping someone speak up for themself or speaking up for them.

Activity 9 What can you do to help advocate for young people who have a learning disability?

Timing: Allow 60 minutes

This activity will help you explore the topic of advocacy and to consider the skills that you may need to employ when addressing potentially sensitive topics with a young person and their family.

Watch Video 3 of young people with a learning disability recounting their experiences of not having their voices heard, and of how they have advocated for themselves. As you watch, make notes on how you can support young people with a learning disability in having their voices heard and consider the conversation or approach that you may need to take with their parents or carers. This will help you to identify some of the skills and learning opportunities that you may want to develop in supporting people’s voices.

Download this video clip.Video player: Video 3

Video 3

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Transcript: Video 3

[MUSIC PLAYING]

[ON-SCREEN TEXT Respecting the choices of young people with a learning disability]

LISA DAVIDSON

My name’s Lisa Davidson. I work for a place called My Life My Choice, which is a self-advocacy charity for people with learning disabilities. And today, I’m here to discuss with a number of young people about the theme of advocacy. I would love to know why you think it’s important for people with learning disabilities and yourself to have control of your own decisions.

MINTY

Because they have to personally live their lives and lead a happy and normal life without depending on family members to help them out.

RUBY

Yeah, we are in control of our own lives. We should make our own decisions as long as it’s safe and it doesn’t do anyone harm. We wouldn’t really want anyone, like, to tell us what our lives should be and what they shouldn’t be. You get to do what you want to do and socialise the way you want. You get a chance to speak up for yourself on different opinions, on different views about lots of different subjects.

SHAUN

The reason why I think it’s very important to us, being able to control our own destiny, is because so that things do not go by, like do not resuscitate being one of the examples, prime examples, actually, of how things have been recently. The good practice in this country is that people with learning disabilities who have do not resuscitate on that list is to basically kill them off, to be blunt. And that’s without asking for our permission whether to be do not resuscitate or not. In my opinion, in my humble opinion, it is wrong.

LISA DAVIDSON

Could you describe a time in your life where your choices or your opinions have not been respected?

MINTY

Basically, it was in 2009, and I had to, like, have a major operation on my mouth, and I had no choice. Either I had to have it then or later, but later in life is going to be really painful, so I had to have it then. I really don’t like it. I had, like, two months of college off, because if I fall down, I will basically ruin the operation. So I said I don’t want to go in, because I know I will have to have someone with me all the time. And I didn’t really want that.

SHAUN

I was actually in a nightclub, and I was on my way home, only to find out that actually I got locked out by my staff who actually knew I was already out working. And yet they thought it was actually OK to lock the door. So it got to a point where I still rang the doorbell, knocked the door, still no answer. So we decided – I decided to ring a colleague, and they decided to ring the police.

So it was actually staff ended locking me out even though that I knew, and so did the service manager, know, I was actually going out to do the nightclub as I normally do. It becomes necessary, because obviously for someone like me, I need my tablets. So I didn’t have my tablets that night, or I didn’t get into the house till quarter to 12. I was scared, really scared, because obviously I’m vulnerable and you don’t want a person with epilepsy on the outside. It was extremely scary. Thankfully, the police were involved.

LISA DAVIDSON

But can you think of any other times where your choices or your opinions were respected?

RUBY

So I studied media level 2 in 2013 and finished in 2014. And during the summer holidays, we were set the task to come up with a new story for one of the video projects for the course. And we had to make sure that our planning was thorough because only three were to be selected. And my media tutor picked my story. The subject was one of the three that was chosen. So I was very happy about that, and I told my friends and family about it.

SHAUN

So I decided that the best thing to do was to move out, and then the decision was made by my, lucky enough, by my support worker. And I basically picked my carer – because I had the choice of two candidates. I got very, very lucky. And I picked my carer and decided that it was the best fit for me, and it has proven that way. So I feel valued in that sense, by the learning disability team, and by the council who are working with me now.

LISA DAVIDSON

Any advice for professionals in any sort of setting on how they can best support people?

MINTY

Just take the time and listen to them. If they have a stammer, which means they find it hard to talk just sit down, go have a coffee or tea, and just listen to them. Or get equipment for them to chime in.

SHAUN

Listen to what the person’s saying. And basically, when they communicate, when the person who is vulnerable communicating, hear to what they saying, and don’t try and belittle what they’re saying, because it’s actually really important that what they’re saying is what I mean. And morals and respect, obviously. Respecting what the person is saying and what their actions are. And don’t contradict.

So basically, don’t turn it around, or don’t turn the words on to them. Say, OK, I understand what you’re saying. If you don’t agree with it, then say so, but I would personally – you’ve got to have a good reason not to agree.

RUBY

Yeah, for me, I would like my local GP doctor to speak to me, and then if I did have a support worker or carer, then they could chime in and say some things, and yeah, the doctor could ask some questions if needed. I know myself. And yeah, I can say what I want to them respectfully.

LISA DAVIDSON

Any other suggestions or advice do you have for any professionals out there?

MINTY

Take their time, do not rush, and go into a small room, or go to their home environment. They are more likely to open up in their own homes because they won’t open up in the doctor’s office, because they don’t know it.

RUBY

So like, the skills for a support worker to self-advocate the individual person as well as to the parents, it’s like, too late. Talk to the parents. And also talk to the individual about whether it could be in person or in a video chat or email or phone call about who the person is or what their hobbies are or what they do as a job or voluntary work. And also, talk to the parents as well to see if it’s OK for the support worker to work with the individual person. And respect their choices and their wants, or their needs.

SHAUN

They need to be soft speaking, and they definitely need to be – on one hand, they need to be aggressive with parents, because the parents obviously – unless they have a disability themselves, but usually they do not on the accounts I’ve heard. They would need to be more aggressive. And then with the people with the learning disability, they need to be more softer.

And I think the parents may not like the fact that the learning disability nurse or the professional’s being aggressive, but the fact is, you’re making a judgement which is wrong. I know a friend who actually – the parents actually disagreed with them getting married, even. So it wasn’t about the relationship. It has to do with marriage.

And for me personally, I think the support worker would have to sensitively let the – talk to the parents first, and then talk to the people with the learning disability and explain to the parents why it’s OK for that to happen, because the fact is – marriage is marriage, you know? You don’t diss it just because the person’s got a disability. Absolutely not.

So for me, it’s about the parents understanding that there isn’t anything bad that’s going to happen. Everyone makes assumptions at one point or another, and it’s just a bad thing to do. And we all make mistakes. We’ve just got to learn from them.

[MUSIC PLAYING]

End transcript: Video 3

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Video 3

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Discussion

You may have identified some, all or different areas for your own development:

listen for and pay attention to the choices that the child or young person is making
make information more accessible for the individual
gauge understanding
assess risks and potential consequences
sensitively raise choices with family members or carers
facilitate discussion
assess and, where appropriate, teach skills
advocate
challenge assumptions.

Helping people to have their voices heard can be a challenging but rewarding task. It also has the potential to make significant developments to a person’s autonomy and independence.

Having explored biological conditions, such as asthma, and some of the social aspects of learning disabilities, you will now explore some psychological conditions that present in childhood and adolescence.

3 Child and adolescent mental health

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

Think back to the biopsychosocial model that was referred to in the introduction to this course. When taking this into account, you can understand how mental health is just as important as physical factors in adolescent development. Half of all mental health conditions have already started to develop by the age of 14, rising to 75 per cent by the mid-twenties. However, they mostly go undetected, and therefore untreated, for many years (Public Health England, 2019).

Some of the mental illnesses that can be experienced by adolescents are emotional disorders, eating disorders, psychosis and self-harm or suicide. At the time of writing the third largest cause of death for 15–19-year-olds was suicide (Public Health England, 2018); therefore it is crucial that adults working within health and social care settings are able to recognise and respond appropriately to mental illness in adolescence. This stage is critical for laying down foundations for healthy emotional and social habits that are crucial for positive mental wellbeing at this age and beyond. Good mental health can help protect an adolescent from emotional and social problems, substance misuse, teen pregnancy and involvement with the police.

3.1 Risk factors and long-term effects

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

Although mental illness can affect anyone, it is important to be aware of the risk factors which make mental illness more likely. For example, those that have suffered emotional abuse are more likely to develop depression and/or anxiety. Many people who have been a victim of sexual abuse go on to develop post-traumatic stress disorder (PTSD).

Some of the adverse childhood experiences (ACEs) that increase the risk of child and adolescent mental health conditions are shown in Figure 3.

View larger image

Figure 3 ACEs that increase the risk of child and adolescent mental health conditions

Long description

Although this is not an exhaustive list it does give an idea of the factors which can contribute to poor mental health. If a person has experienced four or more of these in formative years then they can be six times more at risk of participating in underage sexual activity, eleven times more likely to smoke cannabis and sixteen times more likely to try drugs such as crack cocaine or heroin (Public Health England, 2018). It is also important to note that cyberbullying, online abuse or risks related to digital technologies is an emerging theme in child and adolescent mental health (Public Health England, 2018). At the time of writing an estimated 91% of 16–24-year-olds use the internet for social networking, which is associated with increased rates of anxiety, depression and poor sleep.

Certain groups of people can also be at increased risk of mental illness, such as:

Those with disabilities or additional needs may have lower confidence levels or have difficulty in forming social peer support.
Individuals from black and ethnic minority backgrounds may have been subject to discrimination, racism and prejudice. There may be an increased stigma in their community surrounding mental health making it difficult to access help and support.
Members of the LGBTQ+ community may struggle with identity issues as well as bullying and prejudice leading to them feeling excluded and isolated; fear or actual rejection from family and friends creates a breakdown in social support.

3.2 Signs and symptoms of mental illness

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

Adolescents that experience poor mental health may suffer with lack of motivation, low self-confidence and loss of interest which can lead to withdrawing from social support and education. Long term effects of this can be poor education levels, anti-social behaviour and involvement with criminal activity, all of which can have long term impacts on emotional and social outcomes later in life.

Activity 10 Signs and symptoms of mental illness

Timing: Allow 40 minutes

In the Introduction to this course you met Liam. You might remember that he is 16 years old, his parents are separated, he is an only child and he has severe asthma. He recently had a severe asthma attack that required him to stay in hospital for several days and be away from school for two weeks. When he was well enough to return to school, he was extremely anxious and scared that he might catch Covid-19 and not be able to breathe; he became extremely upset. However, in subsequent weeks there were increasing cases of Covid-19 and schools were asked to close to deliver learning remotely.

Figure 4 Covid-19 related headlines

Long description

Part A

Imagine you are a healthcare practitioner and have been asked to carry out some physical observations on Liam, who has been having trouble sleeping. He confides in you that he has not been seeing friends as he usually would. He plays on his gaming computer alone in his room for most of his free time (when not being taught remotely by the school) and stays up until the early hours of the morning. His parents and teachers have told him they are disappointed that his grades at school are declining. He does not engage in class and remains quiet unless prompted to speak.

Conduct an internet search for high quality resources (e.g. NICE) on the topic of child and adolescent mental health and read a selection of them. Take some time to think about what could be going on for Liam. Have you been able to spot any signs or symptoms of mental illness? Can you spot any risk factors that might be present, as discussed earlier in this section? What might be the root cause of some of these? Write these down in the following boxes.

Table 3 Considering Liam’s case

Have you spotted any signs or symptoms of mental illness?	Table 3 Considering Liam’s case 1, Your response 1
Can you spot any risk factors?	Table 3 Considering Liam’s case 2, Your response 2
What might be the root cause of some of these?	Table 3 Considering Liam’s case 3, Your response 3

Interactive feature not available in single page view (see it in standard view).

Discussion

You may be thinking that Liam could be showing signs of anxiety or depression.

Poor sleep could be affected by his anxiety or poor breathing due to his asthma.
Social withdrawal could be due to his anxieties around Covid-19 or feeling disappointed about his declining grades and performance.
Poor academic performance could be related to his anxieties around school. When the school moved to remote learning this could have compounded this problem; if he was not engaging in face-to-face lessons then it could be easier for him to disengage from remote lessons.

These can all be signs of poor mental health. Without the right intervention Liam may continue to socially withdraw and under perform in education. You may have noted that Liam could potentially be at risk of bullying or abuse through his online gaming or social media.

It is important to remember that adolescents may find it difficult talking to adults, especially a health professional. It is mentioned that Liam’s parents are separated; there could be more than one risk factor present in Liam’s history or current circumstance that may not be obvious. Liam may find it difficult to verbalise or understand his emotions or feel that people won’t believe, understand or be able to help him. Therefore, it is important to approach Liam in a caring and compassionate way and reassure him that it is safe to discuss anything that may be bothering him. Be mindful not to use technical language beyond the young person’s vocabulary or understanding; it is important to remember the person’s age and developmental stage while conversing with them.

Part B

Take some time to think about how you might respond to Liam’s disclosures. You should also access some resources such as NICE guidelines for depression in children and young people.

Research the process for referral in your practice area/workplace/organisation and find out where your local child and adolescent mental health (CAMHS) team are and what services they offer. There may be a CAMHS team in A&E for urgent cases.

Once you have done this, complete the table below.

Table 4 Responding to Liam’s case

What would I do?	Table 4 Responding to Liam’s case 1, Your response 4
What services are available?	Table 4 Responding to Liam’s case 2, Your response 5
What evidence is available to inform my practice?	Table 4 Responding to Liam’s case 3, Your response 6

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Discussion

It is important that you do not attempt to diagnose a mental health condition or make suggestions to Liam about what may be going on without being trained to do so. But being able to recognise and respond to signs and symptoms of mental illness is a necessary skill in your role.

You may have thought you would speak to a senior colleague or explore Liam’s concerns further. You may have thought about referring him to mental health services in your local area.

You may already be aware of mental health services in your area and the referral pathway/policy, but this activity should have allowed you to explore these further and view them in the context of other evidence such as NICE guidance. The next section will build on some of these themes, exploring social media and a young person’s experience of using mental health services.

4 Mental health and social media

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

In this section, you will be learning about mental health in terms of how social media can have an impact. You learned about some of the risk factors for mental illness in the previous section, as well as the fact that many mental health conditions can be established at a young age.

In some ways, social media is a positive experience – young people can connect with each other, as well as being able to post their own updates and see their favourite celebrities. However, for some adolescents, social media can do more damage than good, by lowering self-esteem. It can lead to insecurities about one’s own body image, including over-exercising and restricting food intake in order to meet standards found on modern-day social media. In the year 2021, 7 in 10 women and girls thought that media and advertising in general set an unrealistic beauty standard, and 6 in 10 women believed that social media pressures people to look a certain way (Dove self esteem project, 2017). Therefore, we have to consider what we can do to improve young people’s self-esteem, and look closely at how we can improve our mental well-being.

Activity 11 Social media: its positives and negatives

Timing: Allow 30 minutes

This activity is in two parts.

Part A

Put yourself in the headspace of an adolescent who is navigating their way around the world of mental health and social media, then answer the following questions by filling in the blanks as a way to better understand mental health in young people, as well as the sorts of things they experience.

When feeling low in mood, we may feel i_ _l_ _ _ _ from others.

Answer

When feeling low in mood, we may feel isolated from others.

D_ _ _ _s_ _ _ _ is a condition many can experience, leaving them feeling constantly in a low mood.

Answer

Depression is a condition many can experience, leaving them feeling constantly in a low mood.

If we worry about how we look/are, we could be low in c_ _ _ _ _ _ _ _e.

Answer

If we worry about how we look/are, we could be low in confidence.

We may have t_ _ _ _ p_ if we need to recover from mental illness. It involved speaking to someone about how you feel.

Answer

We may have therapy if we need to recover from mental illness. It involves speaking to someone about how you feel.

M_ _ _f_ _ _ _ _ _ is something we can do/follow, to feel positive and have a good frame of mind.

Answer

Mindfulness is something we can do/follow, to feel positive and have a good frame of mind.

D_ _ _ culture is a topic sometimes promoted on social media with tablets and ways to eat, but it can be dangerous to our bodies.

Answer

Diet culture is a topic sometimes promoted on social media with tablets and ways to eat, but it can be dangerous to our bodies.

We may feel _ _x_ _ _s if we worry about our appearance.

Answer

We may feel anxious if we worry about our appearance

M_ d_ _ _ _ _ _ _ is a form of treatment we may have, if we need to recover from a mental illness.

Answer

Medication is a form of treatment we may have, if we need to recover from a mental illness.

I_ _ _ _g_ _ _ is a popular social media platfrom. where you can follow celebrities and see what they post.

Answer

Instagram is a popular social media platfrom where you can follow celebrities and see what they post.

Discussion

From these questions, you may have realised that this section is going to delve deeper into how an adolescent’s confidence can change in response to social media. Social media has its benefits, but it also has its negatives.

Some positives of social media are:

You can connect with friends and family members, even making new friends and finding others with common interests.
You can follow accounts about things you’re interested in.
You can see what your favourite celebrities are up to, learn new things and see the latest trends.
From a shy or socially anxious person’s perspective, it can be a great way to connect as the anxiety about interacting in person is removed.
It can promote things that need attention, like fundraising for an important cause or donating to a particular charity.
It is a way to promote change in society, creating movements that gain attention and bring change.

This is only a short list, but it shows that social media can be a positive influence. There are many more positives to be said about social media, but for young people it’s a way to get connected and see parts of the world that otherwise may not have been available. Social media was definitely a hub of activity during the Covid-19 pandemic, when many people weren’t able to see their friends in person.

However, there are negatives, most of which can be detrimental to an adolescent’s mental health (these will be further explored later in this section):

Becoming addicted to social media takes someone away from real life and they can lose sight of important things like schoolwork or friendships.
Social media can cause anxiety for young people in terms of missing out. If someone posts what they’re doing, a young person may feel upset or anxious if they’ve not been invited along.
Being in front of a screen all day can be damaging to your eyesight, as well as affecting your sleep patterns (if used at night).
Social media can sometimes promote unhealthy behaviour for young people, including diet culture. Young people’s bodies are still developing and diet cultures can have a negative impact on their physical and mental development.
Cyber bullying, or online hate, can drive a young person into severe anxiety or depression.
Privacy can become a problem, with hackers sometimes being able to access personal information.

Part B

Read through the following 18-year-old’s opinion about social media, and what it means to them.

On the one hand, I’ve made a lot of really good friends on social media over the years. The internet makes it so much easier to find people with the same interests as you, no matter how niche they are. I’ve met people from all over the world who I can talk to about things that I probably couldn’t talk about in real life.
I think social media is also really good for raising awareness of things, and it introduces people to viewpoints that they might not have considered before. There are problems; sometimes social media can be a kind of constant stream of bad news, and I think for some people that could be really bad for their mental health. I can see the constant overload of information being very detrimental to some people, especially young people. Grooming is more common online, people are exposed to violence and graphic images at a young age, but thankfully I think a lot more people are aware of these problems nowadays, and if you know about them, you can take steps to avoid them.

Now create a mind map of the pros and cons mentioned, as well as doing some of your own research on the topic. For example, the #StatusofMind report published by the Royal Society for Public Health in 2017 gives a deeper insight into the positives and negatives of social media.

The following video from Psych Hub also shows the perspective of young people, their relationship with social media and how it affected them.

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Discussion

While there are some definite positives to social media, it should be made clear that it can have a heavy impact on mental health. Kelly et al. (2018) found that greater social media use can be related to online harassment, poor sleep, low self-esteem and poor body image; this can lead to higher depressive symptom scores. Research has shown that 91 per cent of young people (aged 12–15 years) today have a smartphone and 87 per cent have a social media profile (Ofcom, 2021). It is becoming increasingly apparent that more young people are being exposed to the dangers of social media and the impacts it can have on our mental health.

4.1 The impact of social media on mental health and body image

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

This section gives a small insight into how social media can affect someone’s perspective on their own body. With the ever-growing use of social media in young people (with at least 3.5 billion people online overall, according to Ortiz-Ospina, 2019), there is a growing emphasis on fitting a beauty standard (characteristics people are believed to need to be ‘ideal’). Smaller waistlines, perfect skin, always looking like society wants you to look – it can be a toxic headspace for both teenage boys and girls.

These beauty standards have grown over the last few years, which has made a profound impression on adolescents, who set out to appear the way their favourite celebrities or ‘influencers’ do. However, this can have damaging impacts on their mental health should they feel they don’t look physically attractive or the same as somebody else. While it is important to acknowledge that everybody is beautiful in their own ways, there are some young people who don’t think this applies to them, and feel they need to work harder to be attractive. This was, to some extent, the case for Lola. You will find out more about Lola in the following case study.

A young person’s experience

Lola is 15 years old and for the last two years running she has decided to give up all forms of chocolate for Lent. To her, it’s a big challenge as she loves chocolate – but during the second year of her doing Lent, she considers the health benefits of not eating chocolate. As well as seeing labels on food packaging with information about fat, carbohydrate and sugar content, Lola uses Instagram, where many of her friends and favourite celebrities post photos. Some of these celebrity photos are advertising things to do with fitness or a new way of living and eating. Sometimes, it’s just a photo of that person, and it makes Lola feel self-conscious about her own appearance.

Lola is in Year 10, preparing for her GCSEs. These are the first important exams in her life and will form the basis of her future. The pressure of exams, combined with social media, is causing Lola to feel like she’s losing a bit of control.

During the summer holidays, just before Lola goes into Year 11, she goes on a family holiday; she’s feeling low in confidence about the way she looks. To counter this, she’s restricting her food intake, which doesn’t go unnoticed by her family. Lola wants to have those foods she likes, yet her mind has a way of telling her it isn’t good for her.

By the time Lola has settled into Year 11, she’s weighing herself regularly, thinking constantly about the food she’s eating and being sneaky with the way she exercises. Her fingernails are also beginning to turn blue and the majority of her clothes are beginning to look big on her. She also gets agitated when she’s told to eat something. It’s her way of keeping control in a very stressful time, but to other people her behaviour is becoming extremely dangerous. One of her teachers has raised concerns, as well as two of her friends. By this point, Lola’s mother takes her to the doctor, and she’s assessed.

Activity 12 Lola’s experience

Timing: Allow 30 minutes

Part A

Imagine you are one of the medical professionals assessing Lola. Consider the information above and think about what you would do with Lola to try to help her, as well as what the proposed diagnosis might be. You could do an internet search on the things that Lola may have and put this into a mind map or make some notes below.

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Discussion

You may be considering whether Lola should be diagnosed with an eating disorder. The doctor refers Lola to a CAMHS (child and adolescent mental health services) outpatient unit after checking her weight and blood pressure. Once there, Lola is diagnosed with anorexia nervosa, an eating disorder which can affect 6 per 100,000 young people, with the highest incidence in those aged 15–19 years (National Institute for Health and Care Excellence, 2019). It is very likely, however, that due to the rapid increase in the use of social media since 2003, the figures for young people experiencing anorexia or other eating disorders have increased too.

Part B

What kinds of symptoms may Lola have been showing? You can use the information in the case study, do an internet search or use the following websites:

Information and support from Beat Eating Disorders (an online, UK-based charity to help those affected by eating disorders)
Types of eating disorders from Mind, another UK-based charity for mental health.

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Discussion

Hopefully, you will have found symptoms Lola may have (in terms of her behaviour, mental health and physical health). While there are no found causes for why somebody experiences an eating disorder, there are some potential contributing factors, regardless of which eating disorder they have – and it may not surprise you that social media and pressures have a role.

Some potential risk factors for eating disorders include:

scrolling through social media, changing beauty standards and the expectation for young people to appear a certain way – in Lola’s case, this is on Instagram
desire for perfection and a need to control things to keep them right – for Lola, she wants to do well at school and so the mounting pressure from her GCSEs may have been a risk factor for her developing an eating disorder
lacking confidence and being overly critical
major life changes – for Lola, this is her GCSEs and what she’ll do afterwards
having another mental health problem – Lola sometimes experiences anxiety, which may have contributed to her low self-esteem and need to alter the way she looks.

These are just a few risk factors, but there are other things that could contribute to forming an eating disorder.

Part C

While at the CAMHS unit, Lola is offered several types of treatment – cognitive behavioural therapy (CBT) and family-based treatment (FBT). Both treatments are successful in their own right, but differ slightly in how they are carried out.

Explore the various treatment methods listed in the websites below and consider which treatment could be most beneficial to Lola. (You’ll need to bear in mind that Lola lives with her mother, who is a single parent.)

Anorexia nervosa: treatment for children and young people from NICE
Glossary of eating disorder terms from Beat Eating Disorders.

Make some notes about which treatment you would recommend and your reasons for it.

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Discussion

You have now hopefully considered several types of treatment for Lola, including CBT and FBT. Lola and her mother choose the second of those treatments, which looks into how family members can support, and get support for, the young person who has the eating disorder. Lola stayed with these services for just over a year and a half (the final few months were affected by the Covid-19 pandemic; if this hadn’t happened, Lola might have been able to be discharged sooner).

Lola and her mother chose FBT because they have a close relationship, and because her mother needs support to be able to help Lola recover from her disorder. For Lola and her mother, this involved twice-weekly check-ups (later changed to once weekly, and then once a fortnight) and talks with both Lola and her mother separately, to see how their week had gone and what eating had been like. Lola would be weighed and have her pulse checked, to check her progress. They’d discuss things with their practitioner, such as events during the week, difficult topics, and how Lola was feeling.

To conclude this case study, read the following statement from Lola herself, post-recovery, and think about how Lola’s eating disorder may have been prevented in the first place. You could also think of ways to prevent relapse, by using the an internet search and the websites linked previously.

Lola says:

I know I could have saved myself a lot of problems. In the summer before I got referred to CAMHS, I knew there was a problem, and there were so many times when I could have said something, but I never did. I let things get worse, to the point where I had to take six weeks out of school because it was going to be detrimental to my recovery. I also nearly went to an inpatient unit because I was so ill.

While this time of my life will always be the worst, most stressful situation, I also view it as the biggest challenge I have ever overcome. My recovery was not smooth – it never is for anybody – but to finally leave the CAMHS unit for the final time and know that I was a recovered person is the thing I’m most proud of. I’m now nearly 18, three years on from when I first had problems with my eating, and I could not be further away from the person I was then!

The one piece of advice I would say to anybody, if they feel they’re struggling with food or another mental health problem, is that they should speak to someone. A friend, a family member, a teacher, a medical professional, anybody you can trust. Don’t let it get out of control, like I did, as it can end so dangerously. Just speak out, and it will get better.

Conclusion

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

On completing this course, you have explored some of the complexities of child development. Within the context of childhood asthma, these have included the development of the respiratory system, elements of the process of respiratory assessment and diagnosis, and both day-to-day management and acute hospital treatment of the condition. Additionally, you had had the opportunity to explore both family and personal experiences related to childhood asthma.

In relation to intellectual and developmental disorders, you have looked at some of the important points related to what it means to have a learning disability and points around communication and being heard. You have considered the perspectives of family members and what it was like for them to have their child receive a diagnosis of a learning disability. You have had the opportunity to build your knowledge and understanding of the situations that some of these people may be in and to identify which skills you may need to develop in order to help them effectively.

Finally, you have been given the opportunity to understand how young people experience mental health disorders and the services associated with them, along with the impact social media can have on their wellbeing. You have explored and learned more about the impacts that social media can have on a young person. Social media does have its positives, in terms of connecting people and bringing them closer together, but it can also isolate people and make them feel worse about who they are. You have researched the benefits and costs of social media and looked at the impact it can have on how someone thinks about themselves.

Through Lola’s case study, you can see how social media may contribute to someone experiencing a dangerous mental health problem. You’ve seen what else may have caused Lola to begin an unhealthy eating pattern, such as the stresses of school and the pressures that modern life brings. You’ve also been able to see what kinds of treatment Lola had, and research more on those treatments and what sorts of things Lola and her mum may have done together in family-based treatment. Through hearing from Lola herself, you have been able to see the recovery process she’s gone through and how she’s reflected on her experiences. This will have hopefully have given you an insight into the pressures young people face today.

This OpenLearn course is an adapted extract from the Open University course K234 Healthcare theory for practice.

References

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

American Academy of Allergy, Asthma & Immunology (2020) Pediatric Asthma Definition. Available at: https://www.aaaai.org/conditions-and-treatments/conditions-dictionary/pediatric-asthma#:~:text=Childhood%20asthma%20(pediatric%20asthma)%20is,Wheezing%20(whistling%20sound)%20when%20breathing (Accessed: 9 October 2020).

British National Formulary (2019) Asthma, acute. Available at: https://bnf.nice.org.uk/treatment-summary/asthma-acute.html (Accessed: 24 June 2021).

Dove self-esteem project (2017) Girls and beauty confidence: The global report. Available at: https://www.unilever.com/Images/dove-girls-beauty-confidence-report-infographic_tcm244-511240_en.pdf (Accessed: 15 July 2021).

Engel, G.L. (1977) ‘The need for a new medical model: a challenge for biomedicine’, Science, 196 (4286), pp. 129-36. doi: 10.1126/science.847460.

Healthcare Improvement Scotland (2019) The experiences of caregivers looking after individuals with Fetal Alcohol Spectrum Disorder. Available at https://www.researchgate.net/publication/330565018_The_experiences_of_caregivers_looking_after_individuals_with_Fetal_Alcohol_Spectrum_Disorder (Accessed: 16 November 2021).

Kelly, Y., Zilanawala, A., Booker, C. and Sacker, A. (2018) Social media user and adolescent mental health: findings from the UK millennium cohort study. Available at: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(18)30060-9/fulltext (Accessed: 15 July 2021).

National Institute for Health and Care Excellence (2019) Eating disorders: How common is it? Available at: https://cks.nice.org.uk/topics/eating-disorders/background-information/prevalence/ (Accessed: 15 July 2021).

National Institute for Health and Care Excellence (2020) NG80 Asthma: diagnosis, monitoring and chronic asthma management. Available at: https://www.nice.org.uk/guidance/ng80/chapter/Recommendations#diagnosing-asthma-in-young-children (Accessed: 9 October 2020).

Ofcom (2021) Children and parents: media use and attitudes report. Available at: https://www.ofcom.org.uk/__data/assets/pdf_file/0025/217825/children-and-parents-media-use-and-attitudes-report-2020-21.pdf (Accessed: 15 July 2).

Ortiz-Ospina, E. (2019) The rise of social media. Available at: https://ourworldindata.org/rise-of-social-media (Accessed: 30 April 2020).

Public Health England (2018) ‘Early years high impact area 6: Health, wellbeing and development of the child aged 2: Ready to learn, narrowing the “word gap”’. Health visitors leading the Healthy Child Programme. Public Health England. London. Available at: https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children (Accessed: 19 October 2020).

Public Health England (2019) Mental health and wellbeing: JNSA toolkit. Children and young people. Available at: https://www.gov.uk/ government/ publications/ better-mental-health-jsna-toolkit/ 5-children-and-young-people (Accessed: 8 February 2021)

Whitehurst, T. (2011) ‘Raising a Child with Foetal Alcohol Syndrome: Hearing the Parent Voice’, British Journal of Learning Disabilities, 40(3), pp. 187–93.

Acknowledgements

The Open University — Thu, 17 Feb 2022 14:34:54 GMT

This free course was written by Dr Gemma Sinead Ryan, Jessica Jackson, Eddy Hyde, Nicky Coulton, Holly Phillpot and Kayleigh Brechin (student nurse) with contributions from Mark and Chloe. It was first published in February 2022.

Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 Licence.

The material acknowledged below and within the course is Proprietary and used under licence (not subject to Creative Commons Licence). Grateful acknowledgement is made to the following sources for permission to reproduce material in this free course:

Images

Course image: ProfessionalStudioImages / iStock

Section 1, Figure 2: Illustrations / Flickr. This file is licensed under the Creative Commons CC-by-NC 2.0. https://creativecommons.org/licenses/by-nc/2.0/

Section 1.1, Girl holding a book: Image_Source_ / iStock

Section 1.1, A child eating ice cream: lechatnoir / iStock

Section 1.1, Boy smiling: gradyreese / iStock

Section 1.4, Pulse oximeter: Juanmonino / iStock

Section 2, Child in high chair: Christina Kennedy / Alamy Stock Photo

Section 2.2, Tablet with question marks: Anna Berkut / Alamy Stock Photo

Section 4.1, Woman checking her body in front of mirror: Ronstik | Dreamstime.com

Audio/Video

Section 1, Video 1: Khan Academy taken from YouTube Channel Khanacademy medicine https://youtu.be/ZKvatbn4a_I under CC-BY-NC-SA-3.0 licence https://creativecommons.org/licenses/by-nc-sa/3.0/

Section 1.3, Video 2: Drawings by Chloe Faulkner and music from Audio Network

Section 2.3, Video 3: Music from Audio Network

Every effort has been made to contact copyright owners. If any have been inadvertently overlooked, the publishers will be pleased to make the necessary arrangements at the first opportunity.

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