Any chiropractic practice adopting the philosophy of preventive therapy should emphasize the treatment of children, for childhood presents the golden age of prevention. Care during childhood can often foresee serious consequences of apparently slight abnormalities, thus offering the best time to take preventive measures.
The Child Visitor
Besides the child patient, a parent may visit the doctor accompanied by one or more children. Caring for these children when the patent is attended is often the responsibility of an assistant.
The Child Patient
From a human relations viewpoint, children within a practice offer a stabilizing factor. The child patient of today is the adult patient of tomorrow. If cared for intelligently, a child will become a worthy patient. They complain little, are unobservant of minor inefficiencies, do not worry about fees, and are unaware of trifling inconveniences often irritating to adults. In cases where the child is the patient, it the parent who is more often a problem than the child.
The child is preoccupied with self. Cooperation is assured if the child is understood at his level, when gentleness, kindness, and patience are offered. The child who likes the doctor and his assistants becomes an automatic booster for the practice. He will tell of his experiences to his immediate family, relatives, school chums, neighbors, and teachers. This is always beneficial to the practice: positive public relations.
The Frightened or Timid Child
The assistant may have to cope with the frightened or timid child. The correct approach to use is determined by the childís age and temperament. The technique is to put yourself in the childís place and communicate with the patient in a manner the child understands at the particular age and temperament presented.
With any child, you must
(1) win confidence,
(2) arouse interest, and
(3) gain cooperation.
Any child, as any adult, is a distinct personality that must be approached according to that personís nature.
The doctorís office may arouse fear within the child. The surroundings are new and strange; the people are new and strange; the equipment may be new and strange. The childís previous experience in a doctorís office may have resulted in a painful experience or a morbid fear of injections is associated with any doctorís office. Such fears should never be responded to by glib remarks of reassurance, laughter, or labeling the child a "sissy." On the other hand, both mother and child should be told what a good patient the child is when the child is cooperative.
The unexpected is as frightening to the typical child as a painful experience. When a child is old enough to comprehend that a procedure may cause some discomfort, they should be told beforehand and an appeal made to their braveness and "grown-up" courage. If you tell a child a procedure will not hurt and it does, confidence will be lost and you will have a difficult time being believed again. Tell the truth, and emphasize how much better the child will feel when he gets better.
Never underestimate the intelligence of the child patient. Children are keen observers, are more intelligent, and absorb much more than adults suspect. This is also true when you are speaking with a parent and you do not think the child is listening. Likewise, do not feel that the child fully understands just because he nods his head up and down in agreement.
The frightened or timid younger child is witnessed by the patient clinging to the parentís hand and being "dragged" reluctantly from room to room. Such a child, however, is usually quite intelligent and observant of every movement of you and the doctor. Under extreme suspense during examination and therapy, the frightened child will be tense and rigid. Thus, it is necessary at first to spend time to acquaint him with each procedure, explain what will be done and how, tell about the use of instruments to be employed, and win confidence beforehand.
The Bashful Child
The bashful child usually acts in a manner similar to the frightened child exception for not expressing abnormal tenseness. He often holds his motherís hand in a relaxed manner, expressing a sense of freedom and curiosity while he nuzzles the parent and uses his thumb or a finger as a pacifier. Such children usually adapt to discomfort well when handled kindly and tend to hold back tears if their tolerance is not exceeded. The jovial attitude of others can do much to bring the bashful child out of his "shell."
The Moody Child
A moody child may fluctuate from cooperativeness at one moment to hostility on another. Such moods usually reflect some casual remark made by some adult, or they may be a method to control the parent by extending or withholding cooperation. The doctor may wish to treat such a child without the presence of a parent or to ignore the situation and proceed as usual without comment.
The Hysterical Child
The assistant usually will not have the training to handle a truly hysterical child. This takes professional training that may require a stern measure. Hysteria may be an effect of fear or used as a psychologic weapon. Parents of a hysterical child should not be permitted in the treatment room.
The Unmanageable or Temperamental Child
The apparent unmanageable or temperamental child is rarely as bad as he may seem on the surface. The attitude usually reflects fears from experiences based more on the childís imagination than reality. These cases can be handled with gentleness, patience in explanations, and assurance that the patient will not be tricked in some manner. The development of confidence in you and the doctor is primary. This type of child should be treated alone, not in the presence of a parent, where the "chip on the shoulder" has little impression. Children of this nature respond exceptionally well to staff once they are convinced that you mean to do what you have to do and there is no alternative.
The Significance of Age Groups
A newborn child presents the least difficulty. If crying cannot be pacified and adult patients appear irritated, the parent should be asked to take the child to a private room until the doctor can see the patient.
During examination and therapy, your assistance may be necessary to support a small baby to prevent the child from squirming from the doctorís grasp. If the examination or treatment room is drafty or chilly, it may be necessary to wrap the baby in a blanket, exposing only that part necessary for examination or treatment.
When the assistant makes appointments for several children on the same day, many doctors feel that the appointments should be grouped if possible. Children appear more cooperative when they are together and not left entirely in an environment of strange adults. However, siblings of the same sex are often jealous of attention, competitive, and restless.
Childhood, which extends from infancy to adolescence, evolves the child from a state of biologic helplessness to that of mature self-dependence. Between these extremes, many changes are witnessed (some normal and some abnormal) in the childís structural, functional, and emotional development.
About the age of 2 years, the average child begins to understand simple instructions and can often be coaxed into cooperation. Between the ages of 2 and 6, the childís attention span is short, the body is restless, the mind resists discipline, and contrary acts of will are obvious. Equipment must be guarded as the urge to destroy is common. This period between 2 and 6 years is the most difficult age group to deal with, not only because of the child but because a reprimand may bring resentment from a parent.
After the age of 6, reason can be appealed to according to the childís intelligence level. During the period between 6 and 12 years, the child develops reasoning and independence that is not so easily placated by a toy or cute comment. Self-interest evolves to a greater interest in the world about him, and curiosity arouses to a greater degree. By communicating with such a child in a serious manner, avoiding deflating attitudes, and handling him in somewhat of an adult manner, security, relaxation, and cooperation of the patient are achieved. Bright children have a tendency to throw tantrums because they are alert to the effectiveness of the weapon. Such a tantrum is not true hysteria; it is an act that requires the doctorís management.
With the onset of the teen years, both boys and girls often resent having a parent present during consultation, examination, and therapy. The assistant must use great diplomacy in separating child from parent.
Both doctor and assistant must express constant enthusiasm toward the child patient, striving to make the event of the visit a happy occasion rather than a chore. All ethical means should be used to impress the child favorably that he is more than a little person in an adult world. The child must be impressed that you are interested in him as an individual and concerned about his welfare.
Practices handling many children are the least effected by economic trends. The reason for this is that parents want to give their children every possible advantage, even if it takes financial hardship and personal sacrifice. Despite family budget, anything that benefits the childís welfare is a justifiable expense.
Managing the Child-Patientís Parents
Parents are important aspects to consider in the care of children. Not only is a parent part of the situation in the office, the parent is involved in the childís case management, home treatment, and possibly as a factor in the condition under treatment.
Although both parents may accompany a child patient on a visit to the office, it is usually the mother. Either parent can be a great help to the doctor in the childís case management or the mother or father may be possessive, unreasonable, or blinded to the actual situation at hand. Some-times a child is easily managed in the presence of a parent, sometimes not, and at other times it may be better to allow the child to decide.
The Intruding Parent
When a child is asked to do something, a childís reaction time between suggestion and action is longer than in the adult even when the child is willing. Sometimes a parent feels she is helping the doctor when she constantly repeats every directive of the doctor to the child. The parentís constant intrusion at this point of seemingly delayed reaction tends to confuse the child-patient and hinders the doctor-patient relationship.
The parentís repetition intimates that the child is retarded or has a hearing problem. The same is true in the assistant-patient relationship. If you ask the child to "step on the scale to be weighed," the parent may follow with, "Billy, step up on the scale" When you ask, "Bill, turn around and face me," the parent repeats instantly, Turn around dear and face the lady." In such instances, a tactful, "I believe Billy understands" will usually suffice.
The Overly Sympathetic Parent
The too sympathetic parent can be a problem at times. Such a parent constantly reminds the child that she knows just how much the child is hurting or feeling. The result is magnification of the condition in the childís mind. Without such reinforcement, the child might be more cooperative. It is easy for a child to become unmanageable when subjected to this constant excessively sympathetic routine. One must be tactful and firm in requesting the parent not to talk to the patient while the child is being examined or treated unless itís absolutely necessary.
The first time a parent calls to make an appointment for a child is the best time for the assistant to state the officeís policy regarding child care. The doctor may first want to see the parent alone on the first visit unless there is an emergency or the child is in pain. If an assistant is not available to tend to the child during the doctor-parent consultation, the parent should be asked to bring another adult with her during the visit.
By interviewing the parent alone, considerable information can be obtained about the child, and the doctor has an opportunity to explain the reasons behind office policy in child care. This tends to relax the parent, condition the parent of what to expect, and gain cooperation from the parent from the beginning.
Parental Communication During Treatment
When children are under treatment, the assistant should be prepared to handle an increased number of telephone calls. Most of these calls can be handled by the assistant once she becomes acquainted with the parents, childís condition, and treatment plan. It is important for the assistant to discuss this policy with the doctor-employer to determine what questions she should respond and which questions should be referred to the doctor. Frequently, the doctor will prepare a list of questions from which she will question the parent; eg, temperature, pain or distress, breathing difficulty, vomiting, diarrhea, and last meal?
Mothers often like to discuss with the assistant home treatment prescribed by the doctor. They may feel that another womenís viewpoint will help to clear their understanding. If the assistant is familiar with the instructions, she should explain in untechnical terms and/or provide printed instructions approved by the doctor.
History Taking and Its Rationale
If it is the duty of the assistant to take a portion of the history, details should be listed regarding the child-patientís eating habits (including the amount of sweets and soft drinks), sleeping habits, recreation and exercise habits, and general behavior and temperament. Avoid vague and generalized answers.
In recording a childís history, data concerning development and past illnesses and disorders are important. Those conditions having adversely affected normal growth and development constitute the developmental history. Severe vitamin deficiencies (eg, rickets), endocrine disorders (eg, hypo- or hyper-thyroidism), and metabolic disorders may have an effect on skeletal growth and muscular function. The age of occurrence of such disorders is important to record. The age of walking and teething also should be noted.
A record of the childís present and past health status represents the medical history. The parent should be questioned regarding the childís birth, the pregnancy in general, labor abnormalities, and whether instruments were used during delivery. Such childhood diseases as diphtheria, scarlet fever, measles, rheumatic fever, rickets, typhoid, allergies, etc, should be recorded accurately and in detail, along with unusual weight gain or loss. Special concern should be given to any spinal condition, past or present. Questions concerning abnormal shoe wear, irritability, manner of walking, frequency of headaches, general behavior, and "growing pains" are also significant.
Most growth normally occurs in three cycles classified as the infantile period (in utero to 2 years), the juvenile period (from 8 to 11 years), and the adolescent period (from 13 to 17 years). Normal growth within any of these periods may be influenced by under- or over-nutrition, disease, or trauma.
Structural growth, usually measured by standing height and limb measurements, does not occur in an uninterrupted, smooth, even, bilateral manner. Both the body as a whole and its individual parts go through periods characterized by acceleration and retardation.
The doctor may ask the assistant to take several measurements of the child-patient. In general, the length of the extremities from the sole of the foot to the pubis should be approximately three-eights of total body length during normal infancy. This relationship gradually changes with age until the pubis is approximately at the midpoint of the total length of the body. Structural measurements should always be taken bilaterally when extremities are measured. The information gathered is important in disorders of the extremities, especially those involving the epiphyses.
The Initial Examination
After the doctor reviews and enhances the history taken by the assistant, an examination will be scheduled. The examination of a child and that of an adult is similar except for age factors. The doctorís observation faculties must be much greater, however, as the child has more difficulty in expressing subjective feelings or describing an accurate picture of a complaint.
Office Rules and Procedures
Special rules and procedures must be established within the practice if child care is to be incorporated and made pleasant, efficient, and profitable. Several aids are explained below:
Special hours on certain days can be reserved for the treatment of children. They will feel more at home in the presence of other children. From a public relations standpoint, the grouping also educates other parents of the need for chiropractic care for all children of all ages. As children appear to be more cooperative in the morning, the best hours for scheduling younger children are from 9:30 to 11:30 am. Printed excuses can be used to schedule high school students during school hours.
A special attitude is necessary in the care of children from the moment the child enters the reception room to the time of dismissal. The behavior of both assistant and doctor is largely reflected in the childís attitude. Every impression instilled during points of contact is important. Each procedure offered must be carefully limited to the capacity of the childís tolerance.
While almost everybody appreciates and remembers kindness and friendliness, children tend to do so more than adults. Children in the office are little strangers, afraid of a world they never made. By nature, they are apprehensive of changes in routine procedures, thus consistency is important. At the same time, children will usually take to new procedures more rapidly than adults if a change is explained and care is taken to develop their enthusiasm. As with adults, the most important factor before beginning any procedure is to get the patient relaxed and in a receptive frame of mind. Any professional method that attains patient relaxation is well worth the effort.
It is often a good policy to have the assistant spend some time with the child patient before entrance of the doctor. An understanding assistant can do much to ease the childís fear and develop confidence in the doctor to enhance an excellent doctor-patient relationship. If an assistant asks the child about his hobbies, interests, likes and dislikes, answers questions about equipment and procedures, and reassures the child that there is nothing to fear, the child is conditioned to accept the whole procedure as a pleasant experience and will be receptive to the doctor when introduced. Such attention flatters the childís ego and makes him feel as a VlP. He will be more relaxed, more suggestible, and more responsive to the doctorís presence. Confidence and cooperation will be almost assured.
Certain tests must be given to children just as they are to adults. The need for oneís imagination when dealing with children is obvious. As children have a tendency to get excited, it is important to calm them before testing. For this reason, basal metabolism tests on youngsters under 6 years of age are rarely accurate. It is helpful with young children to divert their attention and calm them by telling them a story or make a game of the procedure. The mouthpiece of a BMR instrument, for example, can he likened to the oxygen mask of a space ship.
Home Safety Instruction
It is important that the assistant help the doctor in teaching safety measures when a parent is in the office. All parents should be warned to keep medicine out of the reach of children, flush old medicines down the toilet, and practice good safety habits in the home. Young children should be taught to avoid matches, gas stoves, electric appliances, cleaning fluids, poisons and pesticides, slippery surfaces, and climbing on ladders and trees. The safe use of sharp instruments such as scissors and knives should be taught. Once older children are taught the proper use of such things, they no longer need be hidden.
The assistant must be constantly aware of safety measures so that accident prevention is primary. Cautionary vigilance is imperative. Children should never be left in a room alone. Their imagination can become so overactive that it results in mischief. The doctor should summon the assistant if a child must be left in a room and a parent is not present. One should not be surprised when a child, who is not sufficiently matured, reacts to animal instincts.
When an unsupervised child gives vent to inherited traits, such actions must be understood by the assistant and reacted to with calmness and understanding. With small tots, toys are often important. Avoid toys with sharp edges, small objects that may be swallowed, things that might break easily, or toys that require running or jumping. Building blocks, coloring books, rubber or clean stuffed animals, and animated picture books are common choices.
The doctor of chiropractic may accept many cases of behavior disorders such as retardation, hyperkinesia, severe nervousness, or children with temper tantrums or tics. Thus it is important that waiting time be held at a minimum. This requires alert scheduling. If the patient is late, time from the appointment reservation must be deducted so that the next appointment can be taken on time with a minimum of waiting. Waiting adds to tension. Kindness, special consideration, and efficiency are essential in such case management. To reduce waiting time to a minimum, try to have everything possible in readiness beforehand. If waiting is unavoidable, children love to hear stories. Learn to be a good story teller.
In most practices, children will be scheduled for check-ups before vacations, camps, and supervised sports, and before school opens. Because these appointments will be likely made in June and August, the assistant in charge of scheduling must anticipate time for these children.
The law also protects clinical data of a minor from all but a parent or guardian. Overdoting relatives may telephone and inquire about a childís health. Never release any information without the consent of the parent or guardian. Refer all inquiries to the parent or guardian.
Schools and camps may require certain forms to be completed. The assistant will usually fill these forms out for the doctorís signature. If a vaccination history is required, this must be reported by the parent to a MD or DO.
Building Positive Relationships with Children
When a childís enthusiasm is properly cultivated and stimulated, the child can do much to the indirect education of parents, friends, relatives, and acquaintances to the value of chiropractic services. To develop this state of mind, several factors should be considered. Following are some thoughts to enlist in developing better cooperation of both child patient and parent.
Children love flattery regardless of their age. Boys like to hear that they are brave, have good bodies, and can be an athletic champion if they work at it. Girls like to be complimented on their beauty, form, dress, and potential ability to become wonderful dancers, ballerinas, and attractive to boys. Flattery helps to solidify the office-patient relationship.
Remember that better results are obtained and a closer relationship can be established in many instances if parents of an older child patient are excluded from the examining and treatment rooms. Nothing will yield better dividends in health care than gaining the patientís confidence and satisfaction by minimizing fears and anxieties.
A child should be spoken with at his level of understanding and recognized as a unique individual. Speak to the child as much as possible in an adult manner so that his consciousness will be raised rather than relating to him as a "mere child." At the same time, never exceed the childís level too much. Stoop when you speak so that you are at the same head level, eliminating the image of a very large and overpowering person.
When special instructions are given to the child to execute outside the office, instructions should be given directly to the child (if he can comprehend) in the presence of a parent. This flatters the ego of the child who then feels important and responsible. The presence of the parent offers third party assistance if recall is necessary.
Avoid giving a direct command to a child or using a paternal attitude. It may arouse opposition as the child gets enough of this at home and school. By putting your instructions in the form of a request or suggestion, the child will more happily comply with what you desire.
Both doctor and assistant should choose their words carefully in communicating to children who do not quite understand their meaning. Words such as manipulation, regulate, disciplines, and other technical jargon often stir the imagination to fearful anticipations. Never discuss details of techniques or procedures in front of the child-patient. The doctor will only discuss a childís unfavorable prognosis with a parent in private. Any childís questions should be answered honestly in terms the child can comprehend. While unpleasant details can be minimized, a good relationship will be broken if the child learns he has been lied to or tricked.
High-quality educational material geared to the childís level should be in the reception room, just as it should be for the adult level. The ACA has an excellent coloring book and several pieces of child-oriented literature available.
Special Attention Pays Dividends in Human Relations
Most doctors will not treat a child patient with a chronic condition on the first visit or he will only offer a simple prophylactic therapy. This allows the child time to evaluate the office, staff, and surroundings and arrive at the conclusion there is nothing to worry about. Much can be accomplished during the first visit if nothing more is done but to wean the child from his worries, fears, tensions, and apprehensions. Winning of confidence is the goal. When the child leaves the office smiling, a good relationship is assured.
Special recognition is deeply appreciated by a child. It is good policy to record birth dates and send a card in remembrance. Send children a special valentine from the doctor and staff. Offer companionship to the older child patient showing you appreciate the patientís intelligence and maturity by, within reason, liking things he likes and not liking things he does not like. Show interest in the childís skills and hobbies, and note these in the patientís records as a reminder.
It is policy in many offices that every new young child patient be given some sort of gift when he leaves the office for the first time; eg, a balloon, set of crayons, coloring book, rubber ball, or ice cream cone certificate. This special attention endears the child to the office and increases the desire to return. It is not so much the value of the gift as it is the instilling in the child that you feel he is someone special.
When children are frequent visitors to the office, various gadgets are helpful. For instance, lollipops have proved to be standard equipment in many offices as excellent tranquilizers of younger children. If an assortment is available, let the child choose the flavor. It adds to the pleasure and feeling of self-importance. However, never use such a device as a bribe for good conduct. Rather, use it as a reward for good conduct.
Children take their play very seriously, but sometimes you may have to take the time to point out certain possibilities. Give the child only one toy at a time. Once he tires of it, give him another. A "kiddie korner" equipped with a small table and chairs can be adapted within a 4-ft by 4-ft space in almost every reception room if many children are cared for in the practice. Such space makes small children feel at home, minimizes disciplinary problems, and alerts the casual adult patient that the practice is concerned with the health care of children.
While relationships with child patients should be cordial and friendly, they should not become too familiar. A respectful distance must be maintained or it will stymie respect and require discipline. Be friendly in a reserved manner. Children are not adults, thus they must always be understood and handled as children.