pediatric patients

5 Strategies to Help with Your Challenging Pediatric Patients

Got some challenging pediatric patients on your caseload? Never fear! We have your back!

Problem #1: They’re being too silly to listen

Try this: Build in “silly time”

If you know your kiddo likes being silly and has a wiggly body, it’s inevitable – it will happen whether you like it or not. Keep control and stay in charge by building in silly time.

  • “First let’s do 5 more wall clap push ups, then we get 30 seconds of silly time!”
  • Play a high energy song for their silly time break
  • Make up a silly, wiggly body game in which they have to do an exercise you want, while also getting the silly time that they want
  • Play the “Hokey Pokey,” which incorporates music, gross motor movements, motor planning, listening and following directions, and shaking out your body one limb at a time!

The science behind it: If your kiddo likes to move, their body may need need that extra sensory input to help them understand where in space they are. If they’re being silly and you ask them to stop, you may be fighting a losing battle if they’re acting on a basic bodily need. Therefore, by building in that “silly time” for them to get out their wiggles, they’re getting the input they need/want/are seeking and you maintain control over your session.

Child led therapy – they show you what they want – to be silly. You then set up the environment to provide that for them, but on your terms. Win-Win!

Problem #2: They’re looking everywhere…except at you

Try this: Make it big!

How can you show your kiddo the exercises you want them to perform if they won’t look at you? If their eyes are wandering throughout the whole environment, try expanding your desired exercises to fill more of the environmental space you have available!

  • Play “I Spy” throughout the whole gym, then when they find the item you’re thinking of, you can give them a gross motor way to cross the gym to obtain it. Think: animal walks, bunny hops, heel-to-toe walks, running, crawling…
  • Trampoline jumps, jumping around the gym, large-scale hopscotch. Something to catch their attention in a bigger way and to expand the space you’re using so their attention doesn’t have to be focused in such a small, narrow space.

Why this works: You’re meeting the kiddo where they’re at. In OT, we call this the “just right challenge.” This means that if your kiddo’s attention is wide and unfocused on your immediate visual area, then asking them to perform a task right there in that tiny little zoomed-in space may be unrealistic in terms of success.

Instead of just asking them to balance on a wobble board while squatting, try making the exercise part of a bigger picture, like part of a relay or a simple scavenger hunt.

This way the child gets to access more of the space available to you in the therapy gym, and they can potentially show more compliance for your treatment activities. You’ll have to be creative about incorporating the balancing components, but it will be worth the extra effort on your part.

Consider a Simon-Says type game where they run and find an item, balance on one foot, and toss it back to you. Bigger movements and more environmental usage is easier for their brains to handle than working in a tiny little area.

Problem #3: You’re trying to work on their balance, but they think falling to the floor is hilarious…

Try this: Get ahead of the game.

If you already know you’re working on activities that are challenging for your kiddo, try to think ahead and set yourself up for success. Disguise it so it feels less like a difficult task and more like a fun component of a game or activity. Instead of just working on balance you can try to incorporate balance into:

  • An obstacle course challenge
  • A game with a peer
  • Simon Says
  • Follow-the-Leader
  • An interactive story
  • A task or challenge as part of a game
  • Standing on a balance board to rescue and toss stuffed animals to safety, to toss froggies in a pond, throwing the fish back into the sea, etc.
  • Walking across a balance beam without falling in the hot lava! Walking the plank and jumping in the ocean…you get the idea!

Making this a success: Our kiddos are smart. When they know something is difficult for them, they suddenly become the best task avoider you ever did see. Hence the hilarity they find in falling to the floor every time you count backwards from 5 when balancing on one foot.

The child may just be task avoiding by redirecting your attention away from the original point: practicing their static balance.

Problem #4: You’re trying to work on upper body strength, but you can tell they are so over it

Try This: Add some proprioceptive input! Instead of just working on push ups, try varying the routine and the exercises you use.

  • Wheelbarrow walks are a fun way to increase upper body strength, as well as increasing attention, alertness, coordination, visual motor integration, sensory needs, and so much more!
  • Wall clap push-ups are a favorite of mine because even if your kiddo is being silly and not executing this task with ideal form, they can still get so much out of the exercise! Great for upper body strength, visual motor, hand strength, motor planning, bilateral coordination, incorporating fun, and building rapport.
  • Animal walks are a fun, easy, creative way to get your kiddo in different positions (think bear walks for shoulder girdle stability, crab walks for trunk/core strength, snake slithers to promote army crawling). You can find or make some cards with pictures from which they can choose, place animal pictures throughout an obstacle course, or put animal pictures on a large die (dice) and have your kiddo roll to make a selection.
  • Bonus: try these with a partner for some peer-based interventions!

Here’s why this works: Exercises that serve to increase upper body strength often overlap with exercises used to increase proprioceptive input.

Proprioceptive input stimulates the Golgi tendon organs (GTOs – who remembers that from school anyway?!), which then give input to your tendons, sending the signal to the brain to move, and voila! You’re working out the muscles you wanted them to strengthen in no time!

Problem #5: They are all over the place without a sense of personal space!

Try this: Dial it in

This tip is basically the opposite of what we discussed in Problem #2 where we broadened the space and tried to fill it. Here, you can use the following suggestions to help narrow the space for your kiddo who has a difficult time seeing a table as something to avoid or not bump into.

  • Make a schedule
  • Create a list of activities to complete, or a step-by-step for your kiddo to follow
  • Turn your gym into a place that needs a treasure map to navigate!
  • Play a spatial and body awareness-type game, like Simon Says or Twister

This helps because there may be a difficulty with spatial awareness and/or body awareness.

If your kiddo is all over the place constantly running or bumping into other people, things, or furniture, or is always the one knocking things over in the classroom, they may have difficulty with spatial awareness.

Challenging pediatric patients are going to pop up in every PT’s life.

Giving the child a little more structure by following a schedule allows them to better understand the boundaries of your expectations during the session.

About Lauren Elitzak

Lauren Elitzak
Lauren received her Master's in Occupational Therapy in 2012 and her Doctorate in Physical Therapy in 2013 from the University of St. Augustine in San Marcos, CA. Having grown up in the Midwest and on the East Coast, she daily appreciates the unique beauty of the state of California in which she now resides. She enjoys working in pediatrics, and believes that her greatest teachers are the kids and families she gets to work with!

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