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Pediatrics,the Right Choice? PDF Print E-mail
 

IS PEDIATRICS RIGHT FOR ME?
By Shannon R. George, MSPT 

Physical Therapy is a dynamic profession in part because of the many options therapists have in providing patient care. As therapists, we can start out working with patients of any age in almost any setting. Some of us serve our patients in hospitals or long term care units. Others work in cardiac rehabilitation or in respiratory care. Therapists can work with sports teams or on the golf course providing preventative and rehabilitative care to athletes. Outpatient orthopedic settings? No problem. It seems that the possibilities are endless, and with a little creativity, a physical therapist can work in almost any environment where patients need our expertise.

In addition to the multitude of environments where patient care is provided, therapists have the ability to help patients of all ages. We can even specialize in the type of patients we work with based on their specific injury or diagnosis. With all of these possibilities, how can we determine what type of environment, patient, or diagnosis is right for us? Where will we be most fulfilled both professionally and personally?

In my case, I have always known that I wanted to work with children. Okay, except for my junior year in high school when I wanted to be an attorney (although I most likely would have worked as an advocate for children!). My mother was a special education teacher, and I was exposed early on to children who were "different" than the children I knew in school. The "least restrictive environment" regulations were just starting to be implemented when I was a child. Most children with moderate to severe disabilities were not educated in the public school system along with their peers. I went along with my mother on home visits and frequently went to the local Intermediate Unit (I.U.) where she was employed. The I.U. had special classrooms for students with a variety of problems (autism, behavior difficulties, those needing medical assistance, cerebral palsy, down syndrome, etc.). I watched my mother talk to these "special" children and teach them. She smiled at them even when they could not respond to her. I watched the other teachers and therapists working with these students. I realized that I had a desire to work with children and to learn how to help them. I felt that pediatrics chose me, rather than the other way around.

What is involved in becoming a pediatric physical therapist? All physical therapists receive a basic education in all areas of physical therapy such that upon graduation, they will have the ability to work with all patient populations. Ideally, new physical therapists will have the opportunity to be mentored by more experienced therapists and to further their education by taking continuing education courses in their specific area of interest.

My own pediatric experience before graduation consisted of two pediatric courses (normal and abnormal development) and two clinical education experiences with pediatric clients. When I started my first job, there were many children in need of physical therapy, but very few physical therapists with pediatric experience. Since I was unable to find a mentor, I enrolled in as many pediatric continuing education courses as I could. I purchased pediatric physical therapy books, and signed up for the pediatric section of the American Physical Therapy Association (APTA). At that time, I lived in Virginia, where there was a shortage of school-based physical therapists. I applied for and received a grant for school-based therapy certification from the state of Virginia. This involved a full year of academic coursework at the Medical College of Virginia as well as an internship with a school-based physical therapist. Slowly, I began to see pediatric clients in an outpatient orthopedic setting. I was fortunate enough to have access to a therapy pool, which I used frequently for my patients. Since there were not many physical therapists willing to treat pediatric patients, my caseload grew quickly. I was able to drive to the University of Virginia frequently to see my patients during their monthly clinic visits. At the clinic appointments, patients would rotate through appointments with the orthopedic surgeons, therapists from all disciplines, rehabilitation equipment experts, and the assistive technology department. After working in an outpatient orthopedic setting for two years, I had a call from another physical therapist asking me if I were interested in early intervention. There was a job opening closer to my home working with infants and toddlers under 3 years of age. I was hired for this part-time position, and continued to work in another outpatient setting with pediatric and adult clients. This experience gave me the ability to continue seeing my patients after they "graduated" from early intervention and started school. As I began to have children of my own, I was eventually able stay home during the day with them while seeing physical therapy clients in the evening and on weekends.

Each of us has a very unique personal journey in discovering what we want to do within the physical therapy profession. Here are some questions you may want to consider if you are interested in pediatrics:

1) Do you have empathy and compassion for children and their families? I think that most people entering the health care field do so because they have a true concern for others. They have a "helper" personality. While all physical therapists should empathize with and have compassion for all of their patients, working with pediatric patients and their families requires a special kind of compassion.

Becoming a parent is a truly rewarding experience, but it can also be a difficult, scary, and challenging one as well. The journey may have involved a difficult pregnancy, undesirable test results, or a medically complicated delivery. Parents who looked forward to welcoming a healthy, happy baby may now be facing the reality that there is something "wrong" with their child. Other parents may have had unremarkable pregnancies with uncomplicated deliveries. For some unknown reason, their children may not be developing like other children their age. Each child and family has a unique story.

As therapists, we need to ask questions and to listen to the parent to get more information about a child. When we are meeting a child for the first time, we are really seeing a "snapshot" of their true abilities. We should use all of the information we have available (prenatal and postnatal history, medical testing, etc.) when evaluating a child. If you work in the early intervention field, you may be one of the first people to tell a parent that their child has developmental delays, atypical muscle tone, or decreased strength. The evaluation process can be stressful for both the child and the family. Our words must be chosen carefully. Therapists must be able to answer questions without using a bunch of therapy jargon. We must be knowledgeable about development, but also show kindness and compassion to patients and their families. Therapists should be a reassuring and supportive presence to families at all stages of providing therapy.

2) Do you like talking to and playing with children? It may seem like an obvious question. Children have a unique ability to quickly sense if an adult is "okay" to be around. Even if you have grown up with many younger siblings or have been a baby sitter, learning how to talk to and interact with children takes practice. No one walks up to a baby and says "BOO" in a loud voice! J It is human nature to lower our voices and speak softly to infants because this cooing and smiling is what they respond to best. Each child is unique. Some children are observers, who like quiet play. Others are motor-oriented, and love to jump, bounce, and spin. As with working with any patient, your first job as a physical therapist is to make some observations before testing, etc. Talk to the child's parents to find out specific information about their child (ie. What games does your child like to play? What is his/her favorite toy? What does your child do when they are upset?). A good pediatric physical therapist will be able to "read" their patients well. The therapist can assess what person the child is most comfortable with, and work with that person during an evaluation of a child. The therapist will probably be able to know the baby/child's signs of distress or fear before the tears start. If your pediatric patients see that you have no idea how to talk to them or what to do with them, you will never be able to actually do any therapy!

3) How do you relate to adults? Why is this question important? Pediatric patients come with parents, guardians, teachers, or other adults. A pediatric therapist must be able to relate to their patients as well as the caregivers of their patients. Further, it is the job of a pediatric therapist to educate the family to carry out the home program between therapy sessions. I think pediatric physical therapists have a responsibility to communicate to the family that they "don’t have magic hands". You are not there to impress families with therapy lingo as you strategically place your hands on their child to encourage age-appropriate development! Caregivers must trust and respect the physical therapist as well as understand what they are doing with their child. It is our responsibility as therapists to communicate well with the caregivers based on their level of knowledge. Therapy activities should be taught to the caregivers, with the caregivers then demonstrating these activities in the presence of the therapist. Caregivers are part of the team and an essential part of successful therapy for the child.

4) Are you a team player? In addition to working with parents and caregivers, pediatric therapists must work with teachers, aides, day care providers, school administrators, service coordinators, occupational therapists, speech therapists, special instructors, doctors, and a variety of other professionals. Depending on the age of the child, pediatric therapists must operate within the guidelines of their state health department or education department. Therapists may work in a team to evaluate a child to determine whether he/she qualifies for early intervention services, and then participate in another team for ongoing therapy providers. Within the school system, therapists working with a child participate in IEP meetings (individualized educational plan) as part of team to establish a plan to meet the educational goals for that child. In short, pediatric therapists do not work in isolation. There are a multitude of personalities and disciplines involved with each pediatric client. Communication, education, and the sharing of professional opinions are challenging and important parts of being a pediatric physical therapist.

5) Are you creative? In physical therapy school, therapists learn to observe the patient, test for various problems, make an assessment, and prescribe a treatment plan. We know exactly what to do with an adult who has weak hip flexors. However, if you have a young pediatric client with weak abdominals, you cannot ask the child to lie supine and perform posterior pelvic tilts or straight leg raises! Treatment of pediatric clients involves several aspects:

  • What is it you want to achieve? As a therapist, you must first identify what specific problems the child is experiencing and what you want to do to correct the problem.
  • How can I communicate with my patient? Again, each child is unique. A child's disability may present challenges with communication, cognitive processing, sensory processing, attentional issues, or social-emotional skills. A therapist must determine the best way to communicate with a particular patient, and be prepared to have alternative ideas. Also, if a therapist is working with infants and young children, he/she will need to figure out how to teach the child an activity without relying on verbal instruction.
  • Is the activity fun? Therapists can develop excellent plans of care for their patients, but be unable to implement them. We can work for hours preparing toys, devising obstacle courses, and developing new ways to use a toy. All of this is meaningless if our patient refuses to participate. Knowing what your patient likes and being ready to follow their lead with an activity are important when working with children. You might arrive with a bag full of toys for your patient, but your patient would rather play with your empty toy bag. Pediatric therapists have to be prepared for the unexpected and be ready (and willing) to modify their therapy session accordingly. Also, figuring out non-traditional ways to play with everyday toys can really make a difference in carrying out your therapy plan. For example, your patient really likes a popper toy, but you want them to work on single leg balance skills. I have often placed the popper on the floor and had the patient push the button with their foot (instead of pushing it with their hands). Pegs in a pegboard can be removed in this position as well (either kicking forward to work on knee extensor strength, or backward to work on hamstring strength). Aside from some strange looks you may get from other people who may not know what you are doing, you have nothing to lose by trying to think of new ways to use toys to make activities fun and meaningful for your particular patient.

6) What does "success" mean to you? I have often heard from therapists who work with adults that they "could never work with children because they want their patients to get better quickly". Yes, it is true that it may be years before your patient learns to walk (some may never be able to walk). Yes, it does take weeks and months before some new skills are acquired. Some children will have severe, lifelong disabilities that may prevent them from achieving independence in any area. There are also children who have regressive disorders (ie. inoperable brain tumors, terminal illness, muscular dystrophy) where skills and functional abilities are lost rather than gained over time. I think each of us has to look inward to answer this question. If you are judging your professional success as a therapist strictly by the functional independence that each patient achieves under your care, pediatrics may not be the best population for you. Although there are indicators that a child is developing "pre-standing" skills, there is not a specific guideline as to when the child will stand, cruise, or walk. We use the developmental milestones as a guide, but these were developed using subjects who were healthy and without disability. The milestones are important, but are not set in stone. With pediatric patients, there is not a specific protocol of rehabilitation that will achieve success. There is no specific timeframe of a certain number of weeks before an activity should be added. Success is measured incrementally. There are the big, long-term goals (example independent walking). More importantly, there are the smaller goals such as making eye contact, being able to hold the head at midline, reaching across the body in order to start rolling, that will help the therapist (and caregiver) know whether or not treatment is successful. You may discharge a patient before they learn to walk, but know that you made a difference to that child when you see them running around the local mall a year later. Success is measured in many ways.

7) Are you able to work in a variety of environments? Pediatric therapists must be able to work with
children in their "natural environments". This means that therapists must go to wherever the child is to provide therapy. Therapists may go out to the child's home, daycare, or school. They may also go to community locations (library, park, children's museum) to meet the child. Therapists may need to provide therapy at a department of social services office because a child has been removed from his/her home and is in foster care. A therapist must be adaptable to go and meet that child to provide care wherever the child is located.

Providing care in a child's home presents challenges for both the therapist and the child's family. Respect for that patient and family are crucial to providing home therapy. Cultural issues and household routines should be considered (example: Does the family remove their shoes at the door? Are you scheduling therapy during a child's mealtime or naptime? Where in the home it is acceptable to play?). Alternately, the family may have concerns about someone coming into their home to provide therapy. Whatever the case, a therapist must consider the needs of each individual patient and the patient's family in providing physical therapy.

Additionally, therapists entering a daycare, library, or school must be aware of the normal routines of that particular center. Does the child receive additional therapies? Are you entering a daycare with a bag of toys just as the day care workers are trying to settle everyone for a nap? Although therapists cannot always avoid schedule conflicts or make accommodations for every person involved in the child's care, we can do our best to consider these factors when providing physical therapy.

8) Can you be an advocate? I have to admit that I am a passionate person in general, and especially with issues involving children. Children are not able to advocate for themselves, and therefore it is our duty as adults to protect their rights. Children have the right to be safe and to not be abused. They have the right to have their basic needs met--food, clothing, shelter, medical care, appropriate hygiene, therapy services, etc. Children with disabilities have the right to be educated in the least restrictive environment with their peers.

Therapists are obligated to report any incidences of neglect and abuse to the local authorities in order to protect the children we serve. Sometimes, we may need to assist families by communicating with their insurance companies to justify physical therapy treatments. Therapists may need to call a school on a child's behalf to explain why they need extra time to walk from one classroom to another due to a physical limitation. We may need to call local agencies to assist a patient to find other services if there is not a social worker/service coordinator available to help them. Our role as pediatric therapists extends beyond providing basic patient care. It is our responsibility to educate parents, doctors, teachers, and other professionals about our goals in physical therapy, but also so that they can best advocate for their child/patient/student. This means that we should be familiar with our own national and state practice guidelines, educational law, signs of child abuse/neglect, and other regulations affecting our care of a child.

9) Can you leave your ego at the door? Anyone who has worked with children knows that the job can be messy. If you desire to wear designer clothing with "dry clean only" labels while working, then this is probably not the job for you! You cannot have long, perfectly manicured fingernails. Therapists probably should not wear their finest jewelry while working. You will need to use "child-friendly" and "parent-friendly" language instead of therapy terms. You will probably have to know all of the words to "Row, Row, Row Your Boat" and be willing to sing it over and over again if that song is your patient's favorite.

Therapists working with children need to work on their level. You will not be seated at a desk in an office cubicle. I can't tell you how many pairs of pants I had to throw away with ripped knees from crawling on the floor after my patients. You will need to explain to other adults that you are not simply playing with the children. Even other physical therapists (usually those that do not work with children) may question what you are doing as you pack bags of toys for your patients. I think it is most helpful to explain to parents and other adults that everything you do has a purpose. You can explain why you are having a child throw balls at a target while standing on one foot (for single leg balance, coordination skills, strengthening of core muscles, etc.). The bottom line is that children's work is play. If it looks like a therapist is merely playing with a child, then that therapist is probably doing a great job!

Whether you are a new graduate or an experienced physical therapist who is interested in working with children, pediatrics is both a rewarding and challenging area of practice. Is pediatrics right for you? If the answer is "yes", my only request is that you be passionate about your work. I cringe when I hear therapists say that they wanted to work in pediatrics because they "like the school schedule with summer vacation". I have to bite my tongue when other therapists say that they wanted to work with children because it is "easier" than lifting adults on a hospital floor. If you really don't enjoy being around children, it will be obvious to your patients and their families. Maybe I am an idealist, but I think anyone who specializes in any area of practice should do so because they are truly fulfilled and enjoy their work. I love cheering on a child as they learn to roll or sit. I have wiped away joyful tears as patients learn to crawl from one end of the room to the other. I have literally jumped up and down when patients take their first steps. There is currently a widespread need for pediatric physical therapists. The children are waiting. Are you willing to cheer them on?