Introduction 1
Milestones 1
Do you like children? The crucial element of authenticity 2
Courtesy 5
The concept of ‘scaffolding’ 6
Building rapport through parents/carers 8
Introduction
Children are not a homogeneous group. In parallel to their physical development, children are simultaneously growing psychosocially. It is very important to recognize this fact when consulting with children, as they are not just scaled down adults. An appreciation of the stages of children’s psychosocial development is both fascinating and necessary if one is to enjoy clinically successful consultations. By this, I mean a consultation which achieves its clinical end, be this assessment or treatment, and one which is a good experience for the child, parent/carer and clinician. To do this is both challenging and gratifying.
Milestones
Just as we have a set of expected milestones for physical development, those of us consulting with children require a similar knowledge of what is expected for ages and stages from a psychosocial perspective. Acknowledging that we are podiatrists, we require what may be termed a working knowledge of paediatric psychology and social science to enhance our clinical encounters with children of all ages. Table 1.1 outlines the main psychosocial stages of development, which it is useful to appreciate (Miller 1993).
| *The development theorist Erik Erikson (a student of Freud) divided the life span into eight basic stages. An awareness of these stages is very useful and the first five apply directly to the paediatric domain. The clinical relevance column is sourced from this author’s experience. | |||
| Stage | Age | Concern | Clinical relevance |
|---|---|---|---|
| 1 | Birth to 1 year | Trust vs mistrust | Mother is usually primary; keep her close and all will be well. Be authentic and consistent with infants |
| 2 | 2–3 years | Autonomy vs shame, doubt | Important for children to ‘succeed’ in the consult; help them to do the right thing by being clear and sensitive |
| 3 | 4–5 years | Initiative vs guilt | Role models are important at this stage; be a good one |
| 4 | 6 years to puberty | Industry vs inferiority | Children are keen to do things well; inform and acknowledge their efforts |
| 5 | Adolescence | Identity and repudiation vs identity diffusion | This is a potent stage – blooming and exciting for some, awkward and uncomfortable for others; be gentle (a grunt can be a socially acceptable whimper) |
| 6 | Young adult | Intimacy and solidarity vs isolation | Relationships are important; expect boyfriends/girlfriends to accompany, so include them |
| 7 | Middle adult | Generativity vs stagnation and self-absorption | Busy careers, often raising their own children; be clear and efficient (and on time) |
| 8 | Late adult | Integrity vs despair | The die is cast – positively or negatively. Be realistic and positive and prepared to listen for some real wisdom |
Do you like children? The crucial element of authenticity
I genuinely like children and enjoy their company. Children are extremely perceptive and can pick out a phony from the start. Such falsity arouses their suspicions that all is not well and induces fear and apprehension. This is quite justifiable and no amount of pandering and hollow words or gestures can fool these astute little people. The consultation will be, at best, an experience the child is pleased to see finish and at worst a frightening, traumatic event.
Some people just are not suited to working with children and it is painfully apparent. The lack of warmth, engagement and basic respect is almost palpable, as is the wariness, doubt and fear of the child, expressed more or less covertly by different children at different ages.
Thoughts as to why children cry
Basically, children cry when they are not happy. This can be for a variety of reasons and while as clinicians (as opposed to the children’s parents/carers) we are not always able to identify the specific cause, we are able to consider the likely factors at play.
Children largely cry when they are:
Key Concepts
• unwell
• tired
• anxious
• hungry
• scared.
Key Concepts
While distressing for everyone, a crying child gives ample opportunity for us to respond. There is nothing subtle about it and no excuse for missing the cue
However, there’s crying and then there’s crying. Personality, socialization, cultural background and fear will all play their part in how and when a child cries. While there are no hard and fast rules, I am often less concerned by a child who cries loudly and obviously as it is impossible to miss their distress and therefore easier to manage it. In general, it is a matter of slowing down and taking time to allay the child’s fears. Children who have recently had their inoculations may not understand that this ‘doctor’ is just going to look at them walking. Play and explain, do not rush the pace (depending upon the age) and things will almost always settle down well. Children do not want to have a bad time any more than you do, but they are usually very honest about it. Respect their honesty, be honest in return and you will have a great time together. So often children are then reluctant to leave, which is a ‘gold star’ for you as a clinician, as is the overheard and unsolicited ‘that was fun’, or ‘I like her’, on the way out.
Children who are not crying may still be frightened
Please look out for these children, the stoic, reserved type who is trembling on the inside. As stated above, the child’s personality, socialization, culture and fear will merge to influence how, where, when and with whom they express their feelings. It is the same for us. Our personality, socialization, culture and fear will influence how we perceive others and relate to them, especially with children.
Sensitivity and the ‘three Fs’
This is a model that is very helpful when working with children, especially in the clinical setting where encounters are fairly brief, often unfamiliar and relatively intrusive.
Using the three Fs (Lally et al 1990) can help to avoid many otherwise likely pitfalls that can result in children being upset and mar the whole consultation. Especially valuable at the initial consultation, screening children’s basic modus operandi (psychosocially) informs and directs aware adults. Recognizing and appreciating a child’s fundamental style takes practice and it is important to realize that each F may be either overt or covert. The main tenets of the three Fs are:
1. Fearful
The child is basically wary and apprehensive, especially of new people, experiences and places. Anxiety is a dominant emotion and feeling. Eye contact with you may be brief or absent.
Overt
The child is obviously crying and clinging to a parent/carer. The pitch of the cry is scared, not angry (these subtle differences are easy to hear after a while).
Covert
The child puts on a brave face and complies. Their body language is ‘louder’ if you ‘listen’, e.g. blank expression, downcast eyes, and a stoop of the shoulders.
It is easy to mistake this quiet child for a flexible child and presume they are coping better than they are. Missing the cues from these ‘easy’ children can result in more overt fear and distress.
2. Flexible
These children are easy-going, cooperative and comfortable (for their age and situation). These children return your smile and maintain eye contact readily – some will stare you down, which can be disquieting until you get used to their genuine interest in you.
Overt
Flexible children will willingly comply with reasonable requests. They are not completely passive, but generally comfortable to work with you.
Covert
Children who hide their fear can be mistaken as being flexible. This is a pity, as too much is then expected from them and it can all come tumbling down.
Flexible children are easy to work with, as long as it is remembered that they are children. It is easy to overlook the needs of children who do not readily protest, which does not necessarily mean they are coping. Check to see if they are all right.
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