Child Disability Payment decision making guide
Attention with bodily functions
Attention with bodily functions means providing personal care, prompting or motivating either in relation to:
- bodily functions
- assistance with communication needs (CDP regs, reg. 11(6)(b))
Bodily function means the normal action of any organ of the body or of a number of organs acting together (CDP regs, reg. 2(2)). This includes the brain.
Common examples of bodily functions that case managers may wish to consider include:
- breathing
- dressing and undressing
- drinking
- eating
- emptying the bowels or bladder
- hearing
- seeing
- speaking
- sitting
- moving around indoors
- sleeping.
The list is not exhaustive.
Case managers should apply their own judgment based on the application and any supporting information available to consider:
- whether the individual has a disability
- what impact the individual’s disability has on their bodily functions
- whether the person reasonably requires attention from another person in connection with those bodily functions
- how often the attention is required and how long it takes.
Attention should:
- involve service of a close, personal nature carried out in the presence of the individual
- be needed for something that the individual would normally do for themselves
- not be something which can be done by anyone in the household.
Ciri is 7 and has cystic fibrosis. She can become breathless very easily from minimal activity. She needs attention from another person in relation to her bodily functions because she is unable to do them herself.
Ciri needs help to bathe and dress herself. This is because doing so herself can leave her breathless. When Ciri becomes breathless, it can take between 5 to 10 minutes to recover. Ciri would be unable to bathe or dress herself without this attention because she would have to take multiple breaks to recover from her breathlessness.
Attention does not need to involve physical contact. It can involve the spoken word. Where attention is provided by speaking to the individual, it should take place in the physical presence of the individual. This could include encouraging, persuading or reassuring the individual.
Activities that normally do not involve attention with a bodily function are:
- cooking
- shopping
- domestic tasks, such as housework.
There may be some situations where help with a domestic task is closely associated with a bodily function. It may be considered as attention when it forms part of an episode of attention in connection with that function.
Ryan is 7 years old and experiences nocturnal enuresis due to his Type 1 Diabetes. This means bed wetting.
His mum has to, at least once a night:
- help him change
- remove his soiled bed clothes
- put them in the washing machine
- put new bedding on his bed.
This attention is closely associated with Ryan’s bodily function of maintaining continence. The case manager can consider this attention in determining whether Ryan meets the entitlement criteria for the care component.
The following paragraphs guide case managers on the impact some conditions might have on an individual’s ability to manage their bodily functions
Breathing
An individual may need help with:
- positioning themselves whilst seated or in bed
- connecting oxygen supplies or fitting masks
- physical therapy
because they:
- are at risk of being unable to sit up in bed
- have reduced manual dexterity
- need physical therapy to maintain their airways.
Jo is 7 years old and has cystic fibrosis which causes problems with her breathing. Her parents have to ensure that she is propped up in bed, as she cannot breathe reasonably well when lying flat. If Jo slides down the bed, she becomes very breathless. Her parents also have to perform physiotherapy to ensure Jo can breathe more easily.
Washing, bathing and personal hygiene
An individual may need help with:
- washing
- cleaning teeth
- caring for their hair, nails and skin
because they either:
- are physically not able to carrying out these activities
- have a tendency to neglect personal hygiene due to a mental health condition.
Dressing and undressing
An individual may need help with:
- selecting suitable clothing
- being motivated to dress, undress and change clothing
- fastening clothes and shoes
- putting on clothes in the correct order
because they either:
- are physically not able to carrying out these activities
- have poor motivation due to a mental health condition
- are forgetful.
Attention with dressing and undressing may be needed at the start and end of the day.
If an individual has a condition that causes them to have episodes of incontinence, they may need to change clothing more frequently.
Some individuals may have a neurological or cognitive disability that means they need prompting to either:
- dress appropriately
- put clothing on in the correct order.
Eating, drinking and taking nutrition
An individual may need help with:
- cutting up food
- seeing food on a plate
- chewing and swallowing
- conveying food or drink to their mouth
- motivation to eat
- using a tube to take nutrition
because they:
- are physically not able to carrying out these activities
- need help with managing a feeding tube
- have poor motivation due to a mental health condition
- are forgetful
- have a visual disability.
Some disabilities can make cutting up food or feeding difficult. Case managers should take the use of special cutlery or other aids into account when assessing the amount of help needed.
Use of aids can only be considered if they remove the need for attention. An individual using aids may still need attention.
Chloe is 10 years old and has Juvenile Idiopathic Arthritis. The joints in her hands and wrists make it difficult for her to use cutlery. This is because she isn’t able to grip them comfortably. Chloe’s mothers invest in some specially adapted cutlery. This cutlery is more comfortable for Chloe to use. This means she is able to eat without needing attention from another person.
Continence and Use of Toilet
An individual may need help with:
- getting to and from the toilet
- managing clothing whilst there
- getting on and off the toilet
- managing cleanliness
- changing incontinence pads
- managing stoma and colostomy bags
because they:
- are physically not able to carry out these activities
- they do not get enough warning of the need to use the toilet
- are forgetful or not aware of how to manage toilet needs.
Case managers should consider a need for attention with:
- changing or washing clothing
- cleaning or emptying commodes.
This attention should be given as part of a single period of attention in connection with the bodily function.
Case managers should take into account the use of aids or appliances, like a frame or a hoist when assessing the amount of help needed.
Use of aids can only be considered if they remove the need for attention. An individual using aids may still need attention.
Hearing
An individual may need help with:
- learning sign language or to lip read
- understanding speech and recognising sounds
- having words repeated, re-phrased or explained
- making themselves understood.
This is because the individual cannot communicate effectively in real world environments without such assistance.
An individual who is able to communicate directly with another person through a combination of sign language, hearing and lip reading does not necessarily amount to needing attention in every case. This is because the individual may or may not be able to communicate independently.
Claire is 6 and has been assessed as being moderately to severely deaf from birth due to a genetic condition. She uses hearing aids. Her parents have been supported by Claire’s speech and language therapist to teach her to understand speech and recognise sounds from birth. Claire’s parents spend a lot of time repeating words, reinforcing learning and explaining things to her. One on one, face to face in aquiet environment, Claire can communicate without assistance. However, at school, Claire struggles to hear the teacher in the classroom as it is noisy, and she often struggles to keep up and needs instructions to be repeated.
The Case Manager determines that Claire is entitled to the middle rate care component. This is because Claire needs attention to assist with communication needs. This attention is in excess of a hearing child of the same age and takes place during multiple episodes across the day, when she communicates with others and when she is required to practice new words more than a child of the same age.
If a person or carer has to either:
- speak loudly
- more slowly
- listen more carefully
in order to communicate with an individual, this can sometimes be seen as providing attention. Whether these efforts amount to attention depend upon the nature and complexity of the information being communicated, as well as the child or young person’s ability to use sign language or to lip read independently.
Craig is 14 years old and has full hearing in his right ear. However, following an injury to his ear drum, he has mild to moderate hearing loss in his left ear. Craig is able to hear conversations at home and at school and will turn his head to help if someone is talking quietly. Craig doesn’t find this impacts him at all at school, but gets the school bus home twice a week when his Dad can’t pick him up. The school bus is very noisy with other children shouting. Craig finds it hard to hear his friend talking to him when sat on the left, so will always sit to the right of his friends so he can hear over the noise.
The case manager determines Craig does not meet the criteria for the lowest rate of the care component as his hearing loss does not mean he requires extra attention to communicate independently. Craig does not have needs at this time that meet the threshold for any award, however This needs in relation to his ear drum injury may change in future.
Martha is 8 and had cytomegalovirus as a child, which left her with mild sensorineural hearing loss. She struggles to hear some low frequency sounds, and wears hearing aids to help hear low frequencies. Martha’s school have been very supportive throughout her learning and development and make accommodations for her needs, such as:
- a Teacher for the Deaf, who helps with her hearing aids
- teachers positioning themselves in the classroom or sports field so that Martha can see them well enough to lip read instructions
- good lighting and acoustics so Martha can hear well.
When Martha’s hearing aids run out of batteries, she needs help from teachers or her parents to change them, as they are key to her learning.
Martha was awarded a middle rate care award 2 years ago, while she was receiving regular speech therapy. This helped her learn to sound words which included the lower frequencies she could not hear well. Having been supported for a number of years by a speech therapist, Martha no longer needs speech therapy and has learned to make sounds well to engage with her peers and her learning at school.
At a regular review, the case manager determines the level of attention required by Martha would now be considered to be less than frequent, but a significant portion of the day in connection with her communication. The case manager also sets a review period of 3 years, with the understanding that Martha’s needs may change or worsen around the time she enters secondary school and the complexity of language she is learning changes, and it is important she continues to receive the right level of award appropriate to her needs.
Attention may be reasonably required if communication is made significantly more effective by having an interpreter. In most cases this will be a family member, carer or third party. The interpreter is providing attention with the bodily functions of hearing and speaking. Whether the attention is considered frequent is determined by the amount of attention required, not the degree of communication achieved
Seeing
An individual who is visually impaired may need:
- help with reading letters
- help with choosing appropriate clothing
- guidance, by touch or by verbal prompting to avoid harm when walking in unfamiliar surroundings
- places, objects and situations verbally described to them
- verbal instructions given to them
- encouragement, prompting or reassurance from another individual whilst they are physically present with them.
This is because the individual is unable to effectively see the world around them, this may be due to one or a combination of the following:
- reduced clarity of vision (blurred vision)
- reduced field of vision
- sensitivity to light
- reduced depth perception
The list is not exhaustive.
Where attention is provided by speaking to the individual, it should take place in the physical presence of the individual.
An individual who is visually impaired may also require help with other bodily functions such as:
- washing and bathing as they may require help getting in and out of a bath/shower, or help differentiating types of toiletries
- eating and drinking as they may require help cutting up food and identifying where food is on a plate to avoid spills
- dressing as they may require extra support to ensure that they are dressed appropriately or require help using fastenings/zips for example
- maintaining personal hygiene
- moving around indoors to help avoid bumping into objects
- communication and social skills as they may require help in the form of additional physical contact and/or verbal instructions to describe and reassure the individual of their social surroundings, for example an individual with a visual impairment may be unable to visually recognise a familiar person or may be unable to pick up on non-verbal cues such as smiling when engaging socially with others.
This list is not exhaustive
An individual who is visually impaired may also require additional supervision substantially in excess of the needs of another child of the same age. Additional supervision may be required depending on the age of the child, the severity of their visual impairment and on any additional disabilities they may have, as the individual may require continual supervision throughout the day to avoid substantial danger to themselves or others due to being unaware of the dangers of their surroundings
Yusuf is 5 years old. He was born very prematurely and received a diagnosis of Cerebral Palsy. Cerebral Palsy happens if the brain does not develop normally whilst in the womb or is damaged soon after birth. This greatly affects Yusuf’s use of his left arm and leg. His muscles are tight especially when trying to move them quickly, and Yusuf finds it difficult to move impacting the range of movement that is possible.
Yusuf has also had a diagnosis of Cerebral Visual Impairment (CVI) which is the name given to a person who cannot see very well or cannot understand what they are seeing due to some parts of their brain not working as it should. As with cerebral palsy this is the result of a baby’s brain being damaged and not developing in the usual way.
Yusuf’s mum has detailed that she needs to help Yusuf with all areas of his daily needs due to his restricted movement with his left upper and lower limb. His mum will assist with washing and bathing as he, at times, requires support with sitting in the bath. She also has to assist with dressing Yusuf due to his restricted movement. Yusuf’s mum has to cut all food as Yusuf is unable to manage this on his own.
At night Yusuf's sleeping can be a major challenge due to pain and movement issues he experiences. Yusuf's mum gets up regularly during the night to comfort Yusuf because of the pain he experiences.
Yusuf’s vision problems complicate his condition and he has been provided with specialist support in his school to work with him on all lessons. Yusuf has a weekly visit from a sensory impairment worker who helps him learn to mobilise around his home and school. The sensory impairment worker has provided a letter confirming that they have been working with Yusuf since he turned 5.
Some children with CVI experience an improvement in their vision over time as their brain develops different pathways to compensate, however Yusuf’s CVI is from birth and has not improved.
Supporting information has been provided by Yusuf’s ophthalmologist who confirms his condition, that this is lifelong and that he has significantly reduced vision.
The practitioner reviews the case with the case manager explaining the impact of cerebral palsy on Yusuf, and also the added challenge of Yusuf’s vision problems which adds difficulty to his day to day life.
The case manager reviews the information provided in the application by Yusuf’s mum and the supporting information and awards the highest rate care component having taken into consideration Yusuf’s care needs.
Maria is 7 years old and was diagnosed with nystagmus at 8 months. Nystagmus causes repetitive, involuntary eye movements.
Maria’s nystagmus has caused reduced vision in both of her eyes and problems with her balance. Maria attends regular ophthalmology reviews and wears glasses to correct a longsighted (hypermetropic) refractive error. Supporting information has been provided by Maria’s ophthalmologist to confirm this. Although her glasses slightly improve her vision, there is still notable restriction.
Maria’s mum has noted Maria requires assistance with washing and bathing, ensuring safety with the depth of water. She needs assistance with dressing, with clothes that are easy to put on and take off, with garments that have obvious fronts and backs. Being able to recognise suitable clothing and with tying shoelaces. She also needs support with cutting up food on her plate and uses dishes and cups that do not tip over easily. Maria is also assisted with safety around the home, protecting her from hot items within the kitchen. Child proof locks remain on all the cupboards which contain medicines and sharp objects. Maria is also encouraged with tidying to avoid trip hazards.
Maria requires large print for all of her schoolwork. She gets extra time to complete reading tasks and has been provided with a computer to complete her schoolwork using an enlarged font. Maria gets tired after a lot of reading so has breaks built into her school day.
Due to Maria’s balance difficulties, and reduced vision, she has a buddy who helps her move around the school between classes. The school make sure the classrooms and hallways are free from clutter.
The case manager determines Maria meets criteria for an award of middle rate care as she requires frequent attention throughout the day in connection with her bodily functions. These needs would be considered to be in excess of the needs of another child the same age.
She is not entitled to the highest rate of the care component because she does not require supervision or prolonged or repeated attention at night.
Getting in and out of bed
Individuals may need help in getting in and out of bed because of their disability. Some individuals use of aids/equipment to overcome these difficulties These should be taken into account in assessing the amount of attention that is reasonably required. An individual may still need attention even when using aids.
Sammy is 5 years old and has Duchenne Muscular Dystrophy. He uses a monkey bar to sit up bed in the morning. His parents need to help Sammy get out of bed and stand up. At night when Sammy goes to bed his parents help him sit down on the bed. He then uses the monkey bar to lie down in bed. Sammy’s case manager determines that Sammy needs attention when getting both in and out of the bed.
Turning over in bed
There are many conditions which make it difficult for the individual to turn over in bed. This may lead to significant discomfort or skin damage.
Ruaridh is 4 years old, has paraplegia and has a loss of skin sensation when lying in bed.
If he is not regularly turned at night there is a significant risk of both:
- his skin breaking down
- pressure sores forming.
Ruaridh has a special mattress that diminishes this risk. However, he still needs to be turned a few times at night. The case manager determines the Ruaridh needs attention in connection with his bodily functions at night.
Sleeping
An individual who experiences discomfort or distress, may have difficulty sleeping without attention from another person.
Sandy is 10 years old and has past trauma. Sandy attends CBT (cognitive behavioural therapy) sessions every 2 to 4 weeks. His father applied for CDP for night needs as Sandy frequently wakes during the night as a result of having nightmares and night terrors. To help Sandy settle, his father talks to him to calm him down before he can get back to sleep. This happens once or twice a night, 4 to 5 nights per week and takes about an hour each time to settle him. The case manager decides that Sandy satisfies the night criterion and is therefore entitled to the middle rate of the care component.
Individuals with certain mental health conditions can experience disturbed sleep and/or distressing dreams. They may have to be comforted, reassured and settled back to sleep.
The individual may also have a physical condition that means they require attention from another person to become comfortable in bed. This is because of the way their condition affects or limits them. They may also require help to turn over or to sit up in bed.
Moving around indoors
An individual may need help with:
- getting in and out of a chair
- moving from one room to another
- getting up and down stairs because they have:
- reduced power or movement in their arms or legs
- poor balance
- poor co-ordination.
It may be unreasonable to expect the individual to remain in one room for an entire day case managers should consider:
- the frequency of assistance needed
- any aids or appliances that are appropriate to the individual’s needs and age.
Taking medication
An individual may need assistance from another person to take medication if they experience, for
example:
- reduced manual dexterity
- memory difficulties
- periods of confusion.
Children will probably always need assistance with taking medication. A young person may also need assistance, although this may depend on their age and level of understanding.
Frequent throughout the day
“Frequent” means several times and should be given its ordinary meaning. There is no strict numerical test but it is unlikely that once or twice would amount to “frequent”. The case manager should consider all the facts of the case. The attention must be required throughout the day (CDP regs, reg. 11(1)(c)).
“Throughout” means the period from the beginning of the day to the end of the day.
Attention given first thing in the morning, again at lunch time and again in the evening, is not normally regarded as frequently throughout the day.
Fiona has reduced grip and manual dexterity due to juvenile idiopathic arthritis. She needs attention to use cutlery at each meal time (breakfast, lunch, and dinner). She does not require any other attention throughout the day. The case manager determines that Fiona does not need frequent attention throughout the day