Thoughts from Don | What's different about working with children?

Some orthotists find children to be daunting as patients. They can be difficult to cast and often lack the self-control we see in adults. However, there are lessons to learn from pediatric patients, and I have found that working with children has made me a better adult orthotist.

Children are less jaded (and more vulnerable) than adults. They tend to be sensorially richer and painfully honest. Children respond well to a clinician who is more patient than aggressive, who gradually makes contact, both physically and psychologically. Spending some time connecting with a child can go a long way—but don’t expect instant results. Children often don’t respond immediately. More likely, they may be surprisingly glad to see you on the second visit, having decided that you are trustworthy, rather than warming to you at the first meeting.

If possible, do your casting in the comforting environment of the pediatric therapy room. Physical therapists are generally very skilled at diminishing anxiety. Parents or siblings can also be a calming influence. Most clinics—hospitals, schools, rehab centers—are happy to accommodate your coming to them and will group their patients so that you can spend a full day (or half a day) at the center rather than travelling to each patient’s house.

In the casting process, be gradual. Don’t manipulate bare feet right away; work through the shoes, then the socks, and then move to bare feet. As you rehearse a hold, manipulate for position firmly but not aggressively; ease into the final correction.

Children have limited focus available for casting. Don’t keep rehearsing a handhold, or you will wear them out and use up their ability to relax. Any of these activities increase tone in a high-tone patient, so be watchful and move to “quiet hands” during the wrapping and positioning.

Kiddos like to be involved and I always encourage that, if feasible. They can put on gloves, rub the casting tape as it is setting up or write their name on the cast. Children can also take the fiberglass casting tape out of the package and drop it in the water. Be sure to hold the water container very close to the tape. Kids will really drop the tape, which will cause a splash if the container is not close. Any of these activities can set off tone in a high-tone patient, so be watchful.

During casting, food is a great distractor (but don’t suggest this unless you know the child). Cheerios, as a very popular snack food, give new meaning to the phrase “cereal casting.” (Sorry. I couldn’t resist.) Other distractions include reading books or singing to the child. Verbal children tend to know the words to “The Wheels on the Bus,” “I’m a little Teapot” or “Itsy-bitsy Spider.” One memorable sing-song for me was at Swedish Hospital in Seattle. The child’s mother happened to sing with the Seattle Opera. We were casting in a tile room, and she sang to her child. The resonance was stunningly beautiful. Everyone within hearing range stopped what they were doing to take it in!

Children don’t usually give specific feedback about a process. They are much less direct, so you need to observe behavior carefully. A flinch, a limp or clear discontent are good signs something isn’t working. If you observe that the brace distracts the patient from playing, that’s a useful sign too. Middle-schoolers, though capable of giving feedback, are reluctant to do so. Some are intimidated by adults and may not want to be honest if their honesty is a “negative” comment.

In a clinical situation, the tendency has been to talk to the parents (who, after all, are driving the process) rather than the children. I recommend following the lead I’ve seen from pediatricians: even if the parent asks the question, respond to the child. This is another good way to involve children in the bracing process. Parents can sometimes get in the way. I remember a loving, doting dad with his child. When “Dad” was there, the child cried and cried. As soon as the dad left, though, the child calmed down and we could proceed with casting. When the dad rejoined us, the child began crying again. Many of us have seen this in our own children.

The obstinate behavior of strong-willed children can be even more difficult to work with than, say, bad tone. Try to make casting fun, or at least divert their attention (and will). Littlest children can be challenging: they very much want a sense of control and can often be both strong and wiggly.

Autistic children are the hardest to manage. Typical sensory input doesn’t always make sense to them, and they lack the ability to respond. I recall a session with a boy who was extremely sensitive to external stimuli. The clinical staff had prepared well: the entire wing coordinated to create a calm environment. We were in a secluded corner of a quiet room, and the child had his favorite toy, chair and so on. It was so quiet you could hear a pin drop. What everyone missed, however, was advance notice of the day’s fire drill. With the fire alarm right above our heads, we all got a taste of how traumatic external stimuli could be. We had to take a few deep, calming breaths and reschedule for another day.

Some orthotists find children to be daunting as patients. They can be difficult to cast and often lack the self-control we see in adults. However, there are lessons to learn from pediatric patients, and I have found that working with children has made me a better adult orthotist.

Children are less jaded (and more vulnerable) than adults. They tend to be sensorially richer and painfully honest. Children respond well to a clinician who is more patient than aggressive, who gradually makes contact, both physically and psychologically. Spending some time connecting with a child can go a long way—but don’t expect instant results. Children often don’t respond immediately. More likely, they may be surprisingly glad to see you on the second visit, having decided that you are trustworthy, rather than warming to you at the first meeting.

If possible, do your casting in the comforting environment of the pediatric therapy room. Physical therapists are generally very skilled at diminishing anxiety. Parents or siblings can also be a calming influence. Most clinics—hospitals, schools, rehab centers—are happy to accommodate your coming to them and will group their patients so that you can spend a full day (or half a day) at the center rather than travelling to each patient’s house.

In the casting process, be gradual. Don’t manipulate bare feet right away; work through the shoes, then the socks, and then move to bare feet. As you rehearse a hold, manipulate for position firmly but not aggressively; ease into the final correction.

Children have limited focus available for casting. Don’t keep rehearsing a handhold, or you will wear them out and use up their ability to relax. Any of these activities increase tone in a high-tone patient, so be watchful and move to “quiet hands” during the wrapping and positioning.

Kiddos like to be involved and I always encourage that, if feasible. They can put on gloves, rub the casting tape as it is setting up or write their name on the cast. Children can also take the fiberglass casting tape out of the package and drop it in the water. Be sure to hold the water container very close to the tape. Kids will really drop the tape, which will cause a splash if the container is not close. Any of these activities can set off tone in a high-tone patient, so be watchful.

During casting, food is a great distractor (but don’t suggest this unless you know the child). Cheerios, as a very popular snack food, give new meaning to the phrase “cereal casting.” (Sorry. I couldn’t resist.) Other distractions include reading books or singing to the child. Verbal children tend to know the words to “The Wheels on the Bus,” “I’m a little Teapot” or “Itsy-bitsy Spider.” One memorable sing-song for me was at Swedish Hospital in Seattle. The child’s mother happened to sing with the Seattle Opera. We were casting in a tile room, and she sang to her child. The resonance was stunningly beautiful. Everyone within hearing range stopped what they were doing to take it in!

Children don’t usually give specific feedback about a process. They are much less direct, so you need to observe behavior carefully. A flinch, a limp or clear discontent are good signs something isn’t working. If you observe that the brace distracts the patient from playing, that’s a useful sign too. Middle-schoolers, though capable of giving feedback, are reluctant to do so. Some are intimidated by adults and may not want to be honest if their honesty is a “negative” comment.

In a clinical situation, the tendency has been to talk to the parents (who, after all, are driving the process) rather than the children. I recommend following the lead I’ve seen from pediatricians: even if the parent asks the question, respond to the child. This is another good way to involve children in the bracing process. Parents can sometimes get in the way. I remember a loving, doting dad with his child. When “Dad” was there, the child cried and cried. As soon as the dad left, though, the child calmed down and we could proceed with casting. When the dad rejoined us, the child began crying again. Many of us have seen this in our own children.

The obstinate behavior of strong-willed children can be even more difficult to work with than, say, bad tone. Try to make casting fun, or at least divert their attention (and will). Littlest children can be challenging: they very much want a sense of control and can often be both strong and wiggly.

Autistic children are the hardest to manage. Typical sensory input doesn’t always make sense to them, and they lack the ability to respond. I recall a session with a boy who was extremely sensitive to external stimuli. The clinical staff had prepared well: the entire wing coordinated to create a calm environment. We were in a secluded corner of a quiet room, and the child had his favorite toy, chair and so on. It was so quiet you could hear a pin drop. What everyone missed, however, was advance notice of the day’s fire drill. With the fire alarm right above our heads, we all got a taste of how traumatic external stimuli could be. We had to take a few deep, calming breaths and reschedule for another day.

Children have a pure sense of justice: of what’s “fair.” And they certainly have the right to be treated like human beings. Treasure your interactions with them, no matter how simple. One of the greatest gifts in life is to have a child want to see you—even more meaningful from the more reticent patients. Then the challenge is to feel worthy of their good opinion.

-- Don Buethorn

Don Buethorn, CPO, is founder-owner of Cascade Dafo, Inc., and Cascade Prosthetics and Orthotics