“I’ve never worked with children before, do you have any suggestions?”
“I really need support with this level II peds fieldwork. Can you help?”
“I don’t know what I’m doing wrong. I can’t seem to connect with this [child/age group].”
I’ve received many questions from you all in private messages about pediatrics; it really is a whole different world of OT! Whether you are working with children formally for the first time or are just looking for extra strategies, this blog is for you!
The goal of this two-part pediatrics series is to help you feel more comfortable working with kids and give you some strategies to maximize your abilities in the field.
Here’s what I’ll cover:
Part 1: Communication and Connection
Part 2: Session Planning and Management
Disclaimer: All of this information comes from my own
personal style. Everyone has their own style and/or approach when working with
children. Additionally, every child is an individual, and responds differently.
Though I can share some scenarios and general strategies, I suggest using your
clinical reasoning in the moment to decide the best approach. Nothing can beat
in-the-moment intuition!
That being said, I have always felt comfortable working with children. As a professional, I’ve held roles in special education, respite/habilitation, as a nanny, and a clinical OT student. I’ve worked with all ages – from infants to late adolescents – and have spent approximately half of my life working with kids of all abilities. Additionally, I’ve observed many other professionals in various roles with children and have picked up some knowledge along the way about what typically works and what doesn’t. I hope that some of what I’ve learned helps you. Thanks for being here, and for choosing to learn more about such an incredible population. <3
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The very first thing that I think everyone should know about children is that they are not scary, or intimidating. I hear it all the time! You don’t know how to interact with them because you’re afraid you’ll “mess up” or “can’t handle” their behaviors and/or emotions. It depends on your mindset and the tools you are equipped with, and I’m here to support you.
Now, I want you to think back to when you were younger. Who were your favorite teachers or adults in your life? What were the qualities they possessed?
My favorite teacher was caring, respectful, and talked to me like a person (never down to me or patronizing). She told me that my ideas were important and that I could make a difference in the world – and she believed it. I could tell. Also, she went out of her way at the end of the year to make an acrostic poem out of our names with all the qualities that we possessed and gifted it to us with our picture as a goodbye. She believed in me, she cared about me.
She was my champion.
According to Rita Pierson, a champion is “an adult who will never give up on them [children], who understands the power of connection, and insists that they become the best they can possibly be.”
The quote above comes from this AMAZING (7 min) TED Talk. Please watch it when you have the chance. It’s life-changing.
Here are some strategies to help you become a child’s champion. This includes the way you communicate and connect with them to form a meaningful therapeutic relationship.
Be Kind and Accepting
“Treat others the way you want to be treated.” That’s the golden rule, and for me, it applies in a more reflective way. I think of how I wanted to be treated as a child, and I follow those guidelines. Of course, every child is different and might not want exactly what I did, but that’s my starting point and I adapt from there. The first thing I think of was I wanted to be treated with kindness and accepted for who I was. Every child, regardless of age or ability, deserves people to be kind to them and accept them for who they are.
Most children you will work with will probably have gone through a fair amount of hardship and/or are facing the world being a little different. Of course, we know now (as adults), what makes you different, makes you great. Uniqueness is valued. However, it’s something that took most of us a long time to learn, and some of us still have a hard time believing that in regards to ourselves. Keep that in mind, and show them through your words and actions that you care about them and support them.
In society, there is this pressure to fit a certain mold, score a certain grade on a test, be able to perform a certain skill etc. Children feel that pressure, too. They know when they don’t fit this unreachable standard. (In reality, no one does.) But it can affect their self-esteem and be hard to deal with, especially around other peers. Build them up. Show them that they are loved, they are valued, and that you support them. That’s the starting point to any meaningful therapeutic relationship.
Be Invested in Their Lives and Interests
When you first meet a client in pediatrics (or on their first treatment session), I suggest taking time to hang back a little bit and get to know them before pushing any intervention. I suggest inquiring about simple things like their favorite color or favorite activities. If it’s in a home-based setting, maybe ask them to show you their room or a favorite toy (if they want to, never push).
Something I do personally, is relate as much as possible through common interests. If I find out that a child really likes Star Wars, for instance, I share with them that I also love Star Wars and connect with them over that. If they talk about things I don’t know, I still inquire and let them share whatever they want. Sometimes, I research characters’ names on a child’s favorite TV show, watch an episode, or learn a theme song later that evening, so I can incorporate what they like into future sessions. (Singing a child’s favorite song during activities or transitions typically is fun and well-received.) As an aside, if children don’t tell you directly, you can often learn about a child’s likes/dislikes, habits, things they respond to etc. from parents and caregivers.
As you start to work with your clients more, you’ll learn more about them and have more opportunity to show you’re invested in them and their lives. You’ll learn about upcoming events, achievements, and more. When you remember something they share, it shows you care. For instance, an early adolescent client that I worked with this summer told me that she was going to be a bridesmaid in a family member’s wedding. I immediately showed excitement and asked if there was anything I could do to help her prepare. Some things we were able to work into her sessions to help her prepare. Then, when I saw her after the wedding, I asked her how it went and she shared pictures with me. In hindsight, that may seem rather small and simple, but the impact that this kind of investment can make is typically significant.
Like any other occupational profile you’d conduct with adult patients, you ask questions to learn about them and their lives. Of course, you’d likely omit things to children about their housing layout, etc. and ask the parent(s) or caregiver(s), but the point is that you want to get to know THEM as a person. Once you know them a bit more, you can incorporate what’s meaningful to them in your conversations with them and in your sessions (more to come on that in part 2).
Grade Your Energy and Communication
As with any other population, it’s really important to use yourself (the clinician) as a tool in therapy. You can show excitement in certain activities you want them to be excited about, you can inquire about their lives and even be positive when they are having a harder time. As mentioned above, it’s important to show your interest and enthusiasm in their lives.
While that’s true, how much outward enthusiasm or expression you portray depends on the situation and child. Every child responds to a different level of energy. Therefore, it’s important to be able to adapt how much you emote, from the intensity of your facial expressions, to the volume of your voice. Typically, younger children respond well to more energy than older children. You want to make therapy session seem fun and inviting, which can be done through your own expressions and excitement for each activity. With older children, I’ve found that if you talk to them as if you were talking to another adult, typically in a more relaxed way, they respond well. Don’t talk down to children, ever. Too many people make the mistake of using their “child voice” which to many children, can feel quite patronizing. Pay attention to their response to your communication, through body language and facial expressions, and adjust accordingly.
Again, every child is different and many factors come into play. Part of our role is to constantly assess the situation and environment (you are part of the child’s social environment) to best fit the child’s needs and help them fully participate in their lives.
Use Specific and Concise Communication (as appropriate)
When working with children, it’s best to be concise and to the point. When children are very young, it’s best to use very short phrases such as “sit please” (point), “your turn”, “put it away” (while modeling behavior). If a young child is looking for more direction, I say something like “first color, then eat” etc. The less verbal communication they have to process, the better. Also, give them processing time. Don’t always feel like you have to fill silence. Often times, silence is helpful in your communication.
Additionally, children may benefit from physical boundaries or visual aids that match your commands. For instance, when doing a basic yoga activity with a 5-year-old, you’re likely not going to explain the position too much verbally. However, you could place laminated feet and hands templates where you want them to be as a physical boundary and cue. You may also have someone model the position you’re looking for. If you’re completing a yoga pose with an adolescent or someone who is cognitively higher-functioning, you likely wouldn’t need that extra visual cue of a foot and hand placement, and could use a model or even explain it through words alone. Make sure that your communication makes sense to who receives it.
Use Open and Non-Intimidating Body Language
This is something that seems simple and has been taught to us since we all started in OT school, I’m sure, but it’s also one of the most important. Children are (often) physically smaller than we are, and are literally looking up to a lot of people in their life. I don’t know about you, but I feel inferior and often times uncomfortable physically looking up to someone to talk to them. To solve this, one simple thing you can do when you’re with children is get down to their level. Sit on the floor with them, squat down, or sit in a chair next to them when interacting with them. It’s an easy fix that makes a huge difference.
Additionally, children can read you like a book. They will be honest with you and they will say the funniest things that will catch you off guard. Always use open body language when working with this population. Including but not limited to, uncrossed arms, sitting up straight, and looking towards them with a smile. If any part of your facial expression or body language makes it appear that you don’t want to be there or are upset in any way, the child will respond to that as if you told them that directly with your words. Be conscious of your own nonverbal communication, and make sure that you are seen as an inviting and fun person that they want to be around.
Provide Clear Expectations and Feedback
Children are curious by nature and always want to know what is expected of them. Some children, like to know the entire routine for the day. If that’s the case, writing it down or making a visual schedule really helps to maintain the child’s attention.
When giving directions, provide a clear expectation or direction. For example, if you want the child to sit back at their desk after you drop them off from OT:
Don’t Say: Please
sit down.
(that’s subjective, some kids may sit right down on the ground in front of you…
it’s happened to me. Haha!)
Do Say: Please sit in your seat.
(still concise, but demonstrates clear expectations by providing a specific
direction. Depending on the child, you may even add “at your desk” to add
clarity.)
When providing feedback, try and avoid only vague phrases like “good job.” Instead include concrete feedback that lets them know what you are talking about like, “Yay! You finished the puzzle!” “You found the green piece.” “Thank you for sitting down the first time I asked.” Feedback is often used a tool to reinforce positive behavior so that it may be repeated again. If a child doesn’t understand what you are reinforcing, it becomes hard for them to repeat. Also, when providing feedback, keep it objective. Never tell a child how “smart” they are, because when they don’t do it right, they may feel “dumb.” I like giving positive feedback about attention, effort, and “good choices.” Why? Those are all things they have control of.
Use Positive Language and Reinforcement
Every action has a natural consequence, and children are often learning what that is as they grow and develop. Though it’s important for us to be a part of that learning, we can do so in a way that is positive. If you are familiar with positive reinforcement, it means that you are actively reinforcing a behavior or event that is desired.
One thing that I’ve noticed over the years is that children typically don’t respond positively to “no.” They often shut down and see it as strictly discipline and may not fully listen to what you said. I make it a rule to avoid telling a child “no” unless it’s a safety concern and something needs to be addressed in that moment, and/or the child needs to understand the severity of that action later. **There are exceptions. One child I worked with in the past used the language “no thank you” at home when they needed to stop doing something. In that case, I honored the typical language the child was used to at home.
One example in practice has to do with physical aggression. If a child is reaching out to hit me, instead of saying “no hitting,” I’d say, “hands are not for hitting” while I calmly pull out of the child’s reach. If they are reaching out to hit another child, I calmly move the child’s hands away from the other child and say the same thing. Then I check in with the other child to see if they are okay (always important for safety and showing concern for all children).
That verbal feedback provided ensures it is still understood that it is not an appropriate behavior, while giving context. Sometimes, that may be too negative, though it depends on your tone (which should be calm and matter of fact). Instead of saying, “hands are not for hitting,” I’d say, “hands are for coloring right now” in that same calm tone, or “please don’t hurt my friend” if they are interacting with another child. That way, that’s a redirection to the activity at hand without giving into their search for negative attention. It’s also okay to give a lesson by explaining why something is not right. There is a difference between education on why something isn’t right and just a disciplining “no.” If you provide the reason, then you can give them explanation to change that behavior in the future, which is often the goal.
As an aside, there is a really good social-emotional program, that is a language-based curriculum to teach choices, consequences of actions, and awareness of feelings. It’s called Social Thinking and there’s a really good article to describe the language of “expected” and unexpected” here, as an alternative to “appropriate/good” and “inappropriate/bad.” I really like it. I’ve seen many OTs use this curriculum as part of social groups, (they also make Superflex – which is fantastic). I also like to use this language consistently with all children.
Another technique I am familiar with and like to use is positive psychology. Essentially, it’s the idea of only focusing on the positive and ignoring the negative. You can read an overview here: http://www.jkp.com/jkpblog/2012/03/interview-jeni-hooper-what-children-need-to-be-happy-confident-and-successful/
Encourage Mistakes and Apologize for Your Own
Children learn through play and making mistakes (among other things). It’s important to set the tone from the beginning that everyone makes mistakes sometimes, and that’s okay. You learn through making mistakes and as long as you put forth your best effort, that’s what matters.
When I work with a child, I want a child to feel comfortable telling me that they need help or don’t understand something. I want a child to feel comfortable saying “oops, try again” instead of “I can’t do this.”
One way of doing this is admitting when you’re wrong. If I say something funny or teach something incorrectly, I say so and ask if I can have another chance. That way, I’m modeling the behavior I’d encourage of them. If I am throwing a ball back and forth and throw it way too far, I say “oh man, I’ll try again.” Doing so shows them that they aren’t expected to be perfect, and that it’s okay to make mistakes.
Respect the Child’s Feelings and Know When to Give Space
Though there are times when you need to push through a
session or behavior (which will be discussed in a future post about behavior
management); however, it’s also very important as part of your relationship to
respect the child’s feelings and give them space as necessary.
If you notice a child is emotional and they look like they are at a point where
they can talk, as them about it and/or what you can do to help. Sometimes, what
I do, if I know a child and have the rapport with them and notice they are
having a hard day, I will say, “I notice you’re having a hard time today” or
what specifically the task is. Sometimes just acknowledging that you notice
really helps them feel supported.
Another way to respect their space and their feelings is by offering a quiet space or sensory corner that the child can go to when they feel overwhelmed or just need a break. I typically set a timer within a reasonable time period, so it isn’t simply used as an avoidance technique, however, children do need a quiet place to recharge from time to time. It’s important to show them, again, that you and your room are safe, and that you can help them get what they need.
Another example about giving space actually is from my personal life. For those who do not know, my youngest brother is 20-years-old, is developmentally delayed, and functions at approximately a six-year-old level. My brother went with my mom the other day to check out a potential day program for him to be enrolled in. My brother was sitting on the couch, somewhat anxious, taking in the new environment when the program leader came up to him enthusiastically, said his name, and sat next to him on the couch. Immediately, he became tense and said, “not, no thank you.”
Instantly, she got up and calmly said that she was happy he was here, from a distance, and that he could take his time. After a few minutes, my brother opened up and actually went up to the same program leader and said hello. He had to be comfortable first to be open to any kind of communication. Because that person noticed that and gave him the space he desired, the interaction was overall positive. Had she not moved, knowing my brother, it could have turned into an escalated situation.
Did the program leader do anything wrong by coming up to welcome my brother originally? No, not at all. She got to his level, was enthusiastic and inviting, all of the things we talked about already. However, this is a good example of how to grade your energy because every child does not respond the same.
What I do want you all to take away from this story is that because the day program leader was able to immediately adapt and give my brother space, she was able to create a positive relationship with her and maintain a positive overall experience.
Employ the Trauma-Informed Approach as a Baseline
Last but not least, I want to share the importance about being trauma-informed. 1 in 4 children (25%) across all demographics are developmentally impacted by trauma, which means their brains and bodies process things differently and have different needs. That is a public health issue! In a typical classroom of 28, approximately 7 of those children will be developmentally impact by trauma by the time they turn 18, which impact their daily occupations and routines.
That’s huge!
Children who have experienced trauma may have difficulty dealing with unexpected situations and certain stimuli, as their brains and bodies may be telling them that they are not safe. With children who have experienced these hardships, it’s extra important to show that YOU are safe through your body language, tone of voice, and inviting language.
If you want to read more about this, please click here for some suggested considerations that I always strive to employ in a pediatric setting. I choose to use this as a baseline because many of these children impacted have not been identified (like other classifications on an IEP, for example) and childhood trauma affects 25% of children by the time they are 18. 25%! Plus, this approach follows a kind and respecting way to approach children regardless.
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I hope that you learned some strategies that you can take with you as a starting point to working with children. One of my favorite quotes and one that I heard at the specialty trauma conference last year is “connection before correction.” To us, that means that before we jump in to gain any control or have the child to participate in an intervention, we have to first connect with them and show them that we care. Above all, we have to show them that we can be their champion.
The next post will focus more on clinical practice, such as planning for sessions in pediatrics and session management. Thank you all for reading and I hope you come back to read part two. 🙂
Please reach out to me if you have any questions.