Navigating Difficulties in Pediatric Acupuncture Practice
By Robin Green, MTCM, LAc
Many of you treat children -- at least your own children. You might treat a relative's or neighbor's child too. It's one thing to treat a child you know, but how do you approach and treat a child that's not your own? What do you do when things don't go smoothly? How do you handle children or parents that are non-compliant or difficult to work with? There are plenty of resources available on how to treat the pediatric health conditions, so here are some ideas on how to handle the practical aspects of pediatric acupuncture practice.
There are two general areas where you run into problems when working with kids. The first issue occurs in the treatment room where you need to get the treatment done, handle the chaos of parents and siblings, and answer the parents' questions while managing your time properly. The second set of issues arise outside of the clinic when parents and child are non-compliant in taking herbs or making diet or lifestyle changes.
Children and Needles. What could go wrong?
Without a doubt needle-phobia is the number one issue you will encounter in pediatrics. Fortunately, this can be the easiest problem to deal with. To start with, you can head this problem off by having parents prepare their child before they come to your clinic. You want to develop a relationship based on trust with your pediatric patients, which means you cannot force needles on them. You'll need to resist the idea of trying to trick them. Most children will eventually be ready to try needles. Some may try it after a couple of visits and it may take others a year or two before they are ready. There is absolutely no need to force the issue since you have other tools such as shonishen, microcurrent or laser acupuncture that you can use. In the mean time, show them the needles and share with them how tiny the needles are -- no thicker than a strand of hair. Demonstrate the needles on the parents, on your table, or even on yourself. Make sure they understand that it doesn't hurt. Proceed with the treatment the child is comfortable. If they say the don't want needles, I ask once or twice throughout the session if they are ready to try the needle or "tap," as I call it in my clinic, but once they say "no" a couple of times I drop it and let them know that I'll ask again in the future.
No matter what treatment modality you use, the child will need to hold still for anywhere from 1 - 15 seconds. That doesn't sound like much time, but when you're trying to tap a needle into a wiggling child or apply a microcurrent device to the acupuncture point, movement can make it very hard. Distraction is your best ally in getting the job done. Parents can be very helpful in providing distraction; having plenty of books, toys and puppets can help, too. Many parents use their phones and iPads and have the kids play games or watch movies during the treatment. While it may not be my first choice of distraction, it can work well and I don't see a difference in the effectiveness of the treatment compared to a child distracted by a toy. I have treated kids on the table, in the chair, on their parent's laps or in their arms and on the floor while they play. Sometimes we sing songs during treatment, play little games or count the seconds before the microcurrent is done. Change it up! If you're having difficulty getting the treatment done do a little neck massage, switch from micocurrent to laser, show them how to hold a qi ball or have the child move from the treatment table to mom's lap. Doing something different can help prevent you from getting frustrated and help the child cooperate with the treatment.
Finding Calm Among Chaos
Siblings and parents are often present during your patient's treatment. Having five small kids and two parents crammed into one treatment room is a recipe for chaos. It can get loud and it makes it difficult to have an uninterrupted conversation with the patient and their parent. Once again, make sure to have toys for entertainment, crayons and paper, and other distractions. Remind parents to bring books, movie players, or video games, as well.
If things start to get out of control, remember, it's YOUR office and you set the boundaries. If the parents are not stopping the child from climbing up your bookshelf or doing other dangerous things, then you need to do it. Be gentle, but firm about the behavior you expect when kids are at your office. When the kids are behaving well, use positive reinforcement to help cement the behavior you want. If not, you might say something like, "Jimmy, I need you to be safe so get down from the bookshelf now." Then go and get Jimmy down from the bookshelf and give him a toy to play with.
If the siblings are too distracting, ask their parents to take them outside while you treat the patient (as long as your patient is comfortable with this). Most parents will stop bringing siblings if they are making the treatments too chaotic. If this doesn't happen naturally, you may need to ask the parents to have the children wait in the car with dad while mom brings the patient in, or not bring the siblings at all.
Parents, Fears, Questions
There is so much fear surrounding the health of our children these days, the worst being the child might have an adverse effect if the parents make the wrong medical decision. Many parents have fears about using acupuncture and herbs in addition to conventional medical treatments. They are not sure what to expect from acupuncture. As a result, these fears lead to many questions and it may take a sizable portion of your patient's session to answer them.
To allay some of the fears of the parents you need to educate them about acupuncture. These are the five areas to address:
Be sure to tell them what to expect. If symptoms may get worse before they get better, parents need to know! Make sure you give an assessment on how long the healing process will take, what your recommendations are and how you expect the healing process to go.
Let the parents know that you'll work with the child's medical doctor and that, if at any point they think the child requires medical treatment, follow their instincts. They can use acupuncture and western medicine together without side effects. If the child is on prescription medication, let them know that you'll verify any herbal formulas you'll prescribe to be safe with their medications. If the child is sick, tell them the warning signs that they'll see if the illness requires medical attention.
Remind them that the body was designed to heal itself. Acupuncture stimulates the body's innate healing response. Believing in the body's ability to heal itself shifts the parent's mindset from fear to trust. Once they see their child heal without antibiotics or complications they'll begin to trust in you and their child's ability to heal.
Explain the ailment you are treating in both Western physiological terms and relate it to Chinese medicine. The more you know and the better you can relay it in both terms the more they will trust in your abilities.
Provide a physical examination if it is within your scope of practice in your state. If you can look in ears and throat, listen to lungs and heart, palpate the abdomen, feel the lymphatic chain in the neck it will give you a lot of information on how the body is doing, which you can report to the parents and refer out to for Western medical care if necessary.
The practical aspects of dealing with parent's questions is a practice management issue. To address all the questions parents may have, you may suggest that they bring a list with them. If you cannot adequately address all their questions in the allotted treatment time, schedule extra time at their next session -- you do not have to apologize for charging extra for the additional time. If you find you are fielding many questions over the phone or e-mail you may consider charging for those services. I find as I see more kids I'm getting increasingly more complicated phone and e-mail questions that consume much of my time. Doctors charge for these services and we should, too.
Getting the Child and Parents on Board
Acupuncture is different. We may ask parents to do things that seem strange, like stopping dairy, avoiding cold drinks, or taking yucky tasting herbs. You will likely meet a certain amount of resistance from both the child and the parents when you want them to make changes. Making changes can be especially hard for kids who are picky eaters and for parents who are working full time. Disrupting a seemingly successful routine can prove to be a problem, too.
If you're asking a child to stop eating a certain food, like dairy, make sure to have real world experience with what you're asking them to do. What alternatives for milk do you recommend? Where can they find them? Give them a hand-out on how to make the switch or refer them to a website (or blog) where they can find that information. If you find you make the same dietary or lifestyle recommendations, write about it on your own website or make a handout that you can provide which will make it easier on you and your patients.
Here are some general tips for increasing compliance:
Educate the parents and child on why you want them to do something, the benefits you expect will happen and how they can make the transition you're asking
Make sure both parents are on board and talk to your patient -- get their agreement too.
Don't make too many changes at once. Gradually add herbs or change the diet. Once they get used to those changes then you can do more
If you're trying to get them to take herbs, suggest ways they can take it such as in a small amount of juice, in a frozen fruit juice concentrate or mixed in nutbutter. Start with a small amount and gradually increase the amount as they get used to it.
If you're eliminating foods from the diet, try different food substitutions before taking the food away completely.
If both the parents and the child are willing to make the changes then you're likely to have a positive outcome. However, if one parent is resistant or the child refuses to take herbs or eat the food substitute your impact may be limited. Acupuncture alone is very powerful but, with the increasingly complicated health issues seen in pediatrics today, sometimes it's not enough. All practitioners can do is educate and suggest solutions -- if the patient or their family is unwilling to comply with your suggestions then the outcome will be less than satisfying for the patient, the family and you. We cannot help everyone whose path we cross, but you can rest easier knowing you did all you could for them.
This brief overview of the common problems found in pediatrics only scratches the surface of what you'll face clinically. I hope the suggestions I've made will be helpful to you in your practice.