June – Pediatrics

[Laura Thornton]

A 12 year old young lady is in her 3rd month of physical therapy and has been progressing well. She is 95% as strong as her unaffected side, is running, and able to cut/jump without impairments or difficulty. Her season is starting in 3 weeks and she is almost ready to return to sport testing.

You notice she has been struggling with her exercises and is not sweating or pushing herself like she did the first 2.5 months of care. She has also cancelled twice and is not wearing her warm up and school colors as she did before.

How would you approach this declining participation with the patient? Who would you include in the conversation?

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[zcanova]

At 3 months into treatment, I would hope that my relationship with this patient is at a level where they feel comfortable speaking with me about these concerns. I would start with bringing up my observations in a nonchalant manner infrequently throughout the treatment session without being too invasive. I think that it is important that the patient does not feel forced to share their feelings/experiences and willingly shares information at a pace that they feel comfortable with. At this point I would hope that I had gathered some information that can be correlated with my observations. With this information I would establish communication with the patient’s parents to inform them of my findings and see if they have noticed similar behaviors. Establishing this relationship with the patients’ parents would hopefully allow for more observers to collaborate as the behavioral changes may not be seen by the parents at this point. It may be beneficial to establish communication between myself, the parents, and even coaches to gather more information.

This can be a difficult situation to deal with depending on a variety of factors. There could be something going on in the patient’s home life that is leading to distress that involves the parents and/or family members. It is also important to think about the social stressors at this age and pressures that are associated with being on a sports team. This could also be more personal to the patient, possibly associated with fear and/or anxiety around confidence and return to sport. Because there are so many different routes this situation can take, it is important that we determine the underlying cause. Depending on the underlying cause of the behavioral change we must also understand where our role stops and where other individuals/professionals begins.

[Kyle Feldman]

Great reflection.
It can be complicated, you want to look at all options, read the patient, the family, and all aspects of what could be going on.

You are a huge person in this patients life during a very vulnerable phase

[Laura Thornton]

Thanks for those insightful thoughts Zack – really great points about communication and connection with parents and coaches. It’s so valuable to think it as a team approach and to gather insight from them (2-way street of communication as opposed to 1-way).

Do you think gender plays a role in this scenario?

Listening is such an important skill here. I think about how sometimes kids don’t have the same capacity as adults to express what they’re feeling. Either they don’t know how to express it or they can’t because of fear, uncertainty, etc. If they are struggling or you notice a change in behavior, it’s important to provide a safe space for them to speak or encourage them to speak with another trusted adult.

[Farisshd]

I like that Zack included the notes about a nonchalant initial questioning and making an effort to draw on the positive rapport already built and avoid being perceived as overly invasive. Sometimes a more indirect approach might be helpful, such as asking how things are going at school, if they are excited about the upcoming return to sport testing, or what they are most excited about with regard to getting back to play without directly pointing out the change in engagement.
I think involving the parent is necessary, and ensuring that the parent is also demonstrating as much engagement and drive as they had been in the past could help build the picture further. The parent might let you know about a loss in the family, trouble at school, or something else that the patient has not been comfortable bringing up to help put things into perspective, and ensure that it is being addressed. At the very least, if the parent had not noticed anything, it would give them the insight needed to recognize there may be an underlying issue to keep an eye on. If necessary a discussion with the parents and coaches together could be beneficial to get to the bottom of the issue and create a game plan.
As for the gender difference, It seems the patient started off doing well and did not seem to have any issues there, but she is entering a challenging age for all of us and may be experiencing different emotional, social, or hormonal stressors that she was at the beginning of the plan of care.
Either way, letting the patient know that you are there for support and that you can assist in finding other resources or connect them with a female therapist if they feel that would be helpful. Just giving options and expressing your caring support is often a big impact.

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