How Primary Care ODs can Profit from Pediatric Practice
Foreword: Why Pediatrics? Getting Started in When we announced our newest publication, Pediatric Optometry PediatricsNision Therapy& Vision Therapy, a loyal reader of High Performance Optometry wrote 1. To decide whether expanding your pediatric/vision therapyto express h i s concern. "Older patients a r e t h e largest a n d fastest- practice is right for you, do some basic research about your office a n d thegrowing segment of the population," h e pointed out. "Why concentrate community you serve.on pediatrics?" a) Comb your patient charts to find out: An excellent question for practitioners, more t h a n for publishingcompanies! Here a r e the top 5 reasons you should consider expanding a What percentage of your current patients a r e children agethe pediatric portion of your practice: 1 2 a n d under? What percentage a r e age 13 to 18? 1. The demographics ARE right. So many "baby boomers" a How many of your adult patients have children who arenta r e having children of their own t h a t theres a "mini boom" occurring. seeing you? If this number is significant, you have built-inTheyre having fewer children than past generations, but this typically growth potential.means they have more disposable income for health care. b) Consult your local reference librarian or Chamber of Com merce to learn the following: 2. Since 80% to 90% of all learning is mediated through thevisual system, many children need expert optometric care. For a How many children i n your a r e a a r e age 1 2 a n d under?example, in a New York study of 1,634 children, 53% failed a t least one How many a r e age 13 to 18?oculomotor, binocular, accommodative, or visual perception test. Other a Is the community growingor stable? How many new homesstudies show t h a t vision dysfunctions a r e even more common in the have been built there recently? How many companieshavelearning disabled, who comprise 11% of all schoolchildren. moved i n or out? Are there any new schools? a W h a t is the income level of the parents i n your area? C a n 3. Adults are more likely to make appointments for chil-dren than for themselves. When it comes to eye care, most parents they support specialized care for their children?take care of their childrens needs long before their own. Some reluctant If you subscribe to a commercial database, such as CompuServe,patients even "test" a new doctor by bringing a child in first. you can instantly obtain much of this information for minimal cost. I 4. Working with children who a r e learning and growing can be recently conducted such a demographic search for one of my studentsmore psychologically rewarding t h a n relieving the symptoms of who was planning to buy a practice in a certain community. For $10 I got a profile of the countys population by age, occupation, race,elderly patients with progressive ocular disease. household income, a n d other helpful data. 5. Children are the lifeblood of a practice. Win a childs 2. The clinical skills necessary for pediatric exams a r e not allfriendship now a n d youre likely to have a n enthusiastic "optometric t h a t different from many of the techniques you currently use. However,missionary" for decades. youll need to depend more heavily on objective assessment techniques. This booklet will give you pointers about how to win those friend- The advantages include quick assessment of refractive error, oculomo-ships a n d enhance your reputation for excellence i n "family practice." tor dysfunction, a n d eye health. Obtaining these clinical skills requiresIf you have other ideas youd like to offer for publication in our taking courses with workshops t h a t allow for hands-on learning a n d notnewsletter, please let u s h e a r from you! being timid i n applying these newly-learned skills i n practice. Will Kuhlmann 3. To supplement hands-on courses, you should consider sub- Publisher scribing to publications which specialize in pediatric optometry: Jour- nal of Behavioral Optometry (Optometric Extension Program Founda-
tion, 714-250-8070),Journal of Optometric Vision Development (College persistent squinting i n one eyeofOptometristsinVision Development, 619-425-6191),and the newslet- poor academic performanceter I edit, Pediatric Optometry & Vision Therapy (Anadem Publishing, red eyesInc., 800-633-0055, 614-262-2539). The latter is a "Readers Digestnnewsletter of clinical articles from a broad range of optometry, ophthal- reluctance to open the eyemology, general medicine, and special education and rehabilitation wandering eye movementsjournals. I n addition, it regularly includes tips for marketing and watery eyesmanaging the pediatric portion of your practice. 2. Keep track of which of your adult patients have young 4. Once your academic and clinical skills are in place, send children. On your new patient questionnaire, ask for the names of allnotices to your established patients, announcing that you are now other immediate family members, their date of birth, a n d their year inoffering specialized services for children. school. Question parents occasionally (or have your staff question them) about whether their children are exhibiting any of the signs above. This 5. Include information about childrens vision and vision ther- is a practice-builder, but even more importantly, youll be likely to catchapy in your practice newsletter, informational pamphlets, and presen- problems while theyre still treatable.tations to community groups. The AOA h a s "news backgrounders"available on these and 10 other topics. They present facts and statistics 3. Once a patients children have reached school age, ask aboutin jargon-free language, so the information is ideal for sharing with the their grades and whether theyre having any difficulties with reading orpublic. Contact the AOA Order Department, 243 N. Lindbergh Blvd., studying. Stress t h a t 80% of learning is dependent on vision.St. Louis, MO 63141,314-991-4100. 4. Heres a n especially persuasive fact. (You may remember this from the AOA News a while ago.) A study a t the Optometric Center of The Best Marketing Technique: Maryland concluded that vision problems almost certainly contribute to juvenile delinquency. Over 98% of the 132 delinquents studied had Education learning-related vision problems (inability to perform vision tracking required for reading and writing, inability to copy from a chalkboard, 1. Thorough, understandable patient education is the #1 way to inability to discriminate left-right, lack of eye alignment, a poor near-set yourself apart from retailers. In written handouts a n d face-to-face, point of convergence, and a decreasing ability to reachlgrasp).tell parents: 5. The medical history form for your young patients can do That you can examine a child who is too young to answer double duty a s a n educational tool. Include the following items, with questions. explanations about why youre asking: That children should have their first eye exam a t age 6 months to 1year. Childs birth weight. (Explain t h a t low birth weight i s a risk factor in retinopathy, visual-motor problems, visual That infants with a family history of a serious visual development, and moderate to high refractive errors.) disorder should be examined even earlier. Whether there was any difficulty in labor, or whether That parents should watch children for the following con- there was delivery by forceps. (Explain that both are risk ditions: factors i n extraocular muscle damage.) abnormal appearance of the eyes Parents assessment of the childs reading performance. avoidance of readin~schoolwork (Explain that poor performance can be related to refractive excessive sensitivity to light or binocular problems.) lack of fixation or following Parents assessment of the childs skill in copying text. (Explain that letter reversals beyond age 7% can be related
to perceptual problems.) 7. Dont approach children right away, even if youve examined 6. Train your staff about the importance of ongoing pediatric them before. Even infants need time to look around the examining roomvision care, so they can remind parents, too. Your assistants should be and get used to your voice. If the parents are present, chat with themable to explain the recommended age for first exams, the difference for a minute. Childrenhave changeable emotions and wont react to youbetween your exam and a school vision screening, and the rationale for the same way a t each visit.the tests you perform. 8. During the exam, fix 90% of your attention on the child. I 7. When a new patient calls to make an appointment, your front position myself so that Im eye-level with the patient, not towering overdesk assistant should inquire whether any children in the family need him or her. I smile frequently. Im sincere in the warmth and caringappointments, too. I t seems obvious, but youd be amazed how many attitude I project, because children can instantly spot a phony!practices neglect this. 9. I direct the majority ofmy questions directly to the child; when 8. Your personal computer can be used to prepare sophisticated the parents confirmation is needed, I turn to him or her after the childeducational materials. Some of the options include distributing free answers. This makes children aware that theyre the important ones insoftware programs to patients, schools, and rehabilitation centers; the examination.putting informational files on a computer "bulletin board"; and prepar-ing your own brochures using desktop publishing. For more informa- 10. Make conversation, just a s you would with a n adult. Sampletion, see the book I co-edited, Computer Applications in Optometry conversation starters: "Whats your favorite TV program? Do you have(Butterworths, 1989). pets? Dolls? Toys? How many children are in your family? Are you the oldest? Have you been on any trips? Did you see the Easter Bunny? Do you have your Valentines ready? What are you going to be on Putting Children at Ease Halloween? Whens your birthday? Are you going to have a party? What is that you brought with you?" 1. Get children into the examining room as quickly as possible.The longer children wait, the more restless they become. 11. Try to use a soft, non-threatening tone of voice. (If youre not sure how you sound, its a good idea to tape yourself.) Listen for 2. Speak to children directly, a t their eye level. For example, a t questions-about having to wear glasses, having a n operation, goingthe first appointment, introduce yourself to the child as well as to the blind-which may be disguised a s casual remarks.parent. This communicates respect for the childs feelings. 12. Tell and show the child what you plan to do. For example: "Im 3. Take time to find out what name the child goes by. For going to cover one of your eyes with this paddle, then 111 cover the otherexample, Michael might prefer Mike or Mikey. one." 4. If you permit parents in the examining room, have them ask 13. Be truthful: if the eyedrops are going to sting a little, say so.their child whether he or she wants their company. 111usually say somethinglike, "These drops may be cold or stinga little." After I put the drops in, 111 ask the child to count to "5" while squeezing 5. Consider inviting the whole family into the examining room. my finger. When the child concentrates on counting and squeezing,This helps young children feel even more secure, and observing siblings , they soon forget the stinging!may give you clues to a childs visual problems. Allow family membersto view the stereo fly or other " 3 D tests. 14. More tips about eyedrops: 6. If the parents will be present, ask them not to make any a. Cathy Tibbetts, O.D. of Farmington, NM puts the drop on thecomments during the exam unless you direct a question their way. (Do end of a fluorescein strip (or another type of filter paper) and dabs thethis out ofthe childs earshot.) Of course, youll want to assure them that paper on the inside of the lid a few times. "Kids dont mind if you tellyoull answer any questions they have, a t the end. them you are just going to touch their lid with a little piece of paper," Dr.
Tibbetts says. "It doesnt even sting." For faster corneal penetration, 4. A good diversionary tactic is to have the child count, reciteask the child to close their eyes for a few moments. ABCs, or name colors of objects in the room. b. If you know in advance t h a t drops will be required and t h a tthe child may be fussy, ask parents to administer artificial tears for a 5. Young children are usually entranced by the wooden toyweek or two a t home. That way you wont have to contend with a called "Jacobs Ladder," which clackety-clacks down itself. Keep one insquirming youngster, and the childwont learn to loathe visits to your every examining room to distract fussy preschoolers.office. 6. Human contact i s reassuring-a p a t on the back, a hand- 15. Provide frequent positive reinforcement: "Thats very good." shake, a hug.But during testing, your goal i s to have the child respond well to the 7. Is there something the child could hold for you? Holdingexam, not necessarily provide the "right" answer. Even if a response things makes people more comfortable with them and lessens the "Fearisnt correct from a visual standpoint, you can say, "Thank you, t h a t of the Unknown." For example, 111 let children shine the ophthal-gives me a lot of information." moscope into my eye and view the red reflex. 16. Ask a n assistant to gently hold a young childs head in place 8. "Before I touch a young patient," says Dr. Max Heeb, "I ask ifduring ophthalmoscopy. Tell the child, "Im gettingready to look inside he can tell me what courage is. The usual answer is something like,your eye . . . Your eye looks really good." Courage is not being scared. Thats not my answer. Even if the child says nothing, I volunteer t h a t I used to think t h a t brave people were 17. When examining a squirmy young patient, touch the child onthe shoulder or hand a s you talk, to get their attention. never afraid, but that Ive learned t h a t its normal and all right to be scared, and t h a t people who are not scared are sometimes just plain 18. If appropriate, report to the parents in the presence of the nuts. Courage i s doing what you need to do even though youre scared.child. This i s another way to show respect for children. I t also helps Its amazing how children will settle down and cooperate after youinsure t h a t children will get accurate information about their vision and impart this information."the importance ofvision care. Never talk about young patients a s if theywerent there. 9. Dr. Bruce Hoekstra relaxes fearful children with "magic." "I tell them that if they let me feel their stomachs, I can guess what theyve 19. Take advantage of childrens honesty. Their actions and had for breakfast. I always guess cereal, because its correct about 8 0facial expressions will generally tell you exactly what theyre thinking! percent of the time. IfIm wrong, the children are only too happy to blurt out the right answer; ifIm right, their eyesgrow wide a t my mysterious power. Either way, it makes a potentially difficult examination easy Working with Fearful and its never failed to relax cranky, nervous patients." or Boisterous Children Another "magic" trick: P u t two pieces of Scotch Tape on a balloon so t h a t they form a n "X" Youll be able to push a needle right into the 1. Never force a child to go through a n exam crying if it can be balloon without popping it.postponed until another day. Dont let children learn to associate fearwith your office. , 10. If youre fairly introverted, its helpful to have a live-wire assistant who talks easily with children. "Children dont like quiet- 2. I find t h a t having parents in the examining room is very ness," pedodontist Dr. Marvin Berman says. "Kids often dont relate tohelpful. There are times Ill ask them to leave, but thats infrequent. reserved people. Kids like craziness, people who repeat things over and over. They love rhyming, they love singing, they love faces, they love 3. In most instances, if a child is acting up I try to ?till them with action. Ifyou do things too quietly, they dont learn. You need somebodykindness." Only occasionally will I use sterner methods. in your ofice whos capable ofkeeping up with the shortness of a childs attention span."
2. Ask the parent to remain present during the exam. Working with They can help you communicate with the child, and if the child becomes Mentally Handicapped Children upset, they can usually discern the problem. (If the child remains upset, ask the parent whether theyd like to reschedule the appointment.) High refractive error, amblyopia, strabismus, poor perceptualskills, and ocular disease are the norm, not the exception, in mentally 3. Modify your exam technique. In particular, avoid suddenhandicapped children. Early detection and treatment can be vital in movements, and shine the ophthalmoscope into your own palm, directlyhelping them get the most from other rehabilitation programs. Some of in front of the patient, to demonstrate it before you shine i t in their eye.my articles listed in the bibliography provide a n introduction to the Explaining procedures using an eye model will help patients under-mental retardation syndromes most commonly associated with ocular stand youre going to do something for them.defects: the fragile X syndrome, cerebral palsy, and Downs syndrome. 4. Remember to smile. A smile is understood and appreciated Developing expertise in working with handicapped children by all-even the most severely handicapped.demonstrates just how unique your practice is. Many parents withhandicapped children will bring other family members to you if you canwork well with their exceptional child. Dont hesitate to seek out other Building Rapport with Parentsprofessionals working in this area and offer your assistance. 1. Use the childs examination a s an opportunity to educate the To assess visual acuity, choose from the tumblingE test, Landholt parents, iftheyre in the room. For instance, if a child cant see four dotsC or Brokenwheel test, Lighthouse cards, the Catford Visual Acuity on the Worth Four Dot test (a measure of second degree fusion), Ill placeApparatus, the OKN response, visually evoked response, and preferen- the anaglyph glasses on Mom. When she sees the four dots, she knowstial looking. Oculomotor assessment should include the cover/uncover her child is not responding appropriately, and has a greater under-test, Hirschberg, physiological H test, near point of convergence, standing of how her childs visual system is working. Or I may use thesaccades, rotations and pursuits (visual tracking). Random Dot Stereo E test. A strabismic child wont be able to see the "E," but Mom or Dad will. (When parents cant, this often prompts them Assessment of refractive error should include the Placido disk or to schedule an exam for themselves!)keratoscope, standard distance retinoscopy, and cycloplegic or dynamicretinoscopy. Binocularity may be determined with such procedures a s 2. Take parents observations seriously. If you cant verify athe Titmus, Frisby, or Randot E stereotest. Accommodative function parents report, offer a n explanation as to why this might be. Formay be assessed quickly with the monocular estimation method (MEM). example, if a mother reports that she sees her childs eye turn out, but during your examination you dont find strabismus, explain that eye Because mentally handicapped children are prone to ocular pa- turns can be intermittent. Suggest scheduling a visual efficiencythology, a biomicroscopic exam should be performed with either a evaluation for further assessment. Never tell parents that they werestandard slit lamp or hand-held model. Pupillary actions should be wrong; instead, let them know that youre simply unable to verify theirnoted as present or absent, and direct or indirect ophthalmoscopy observations at this time.should be completed. You should also attempt to assess visual fields andintraocular pressures. 3. In discussing a childs visual status, keep in mind that parents often feel embarrassed about not detecting or reporting a problem Examinations of mentally handicapped children will go most sooner. Unless were careful, our comments may be interpreted a ssmoothly if you: criticism or a charge of neglect. 1. Schedule extra time. You may want to talk casually with Of course, its wise to correct misconceptions: "You may havethe child and parent in your office before proceeding to the exam room. heard that children will grow out of a squint, but this isnt so." Still, theAlso, give the child time to get accustomed to the exam room before youbegin.
emphasis should be on what can be done to help the child now. Give all 5. Here are sample answers to common questions from parents:the information and reassurance you can. Praise the parents forbringing the child to you when they did. Will watching TVhurt my kidseyes? No, but it may dull their minds! Children should sit on the family couch, not right in front of the Guilt can be particularly pronounced in parents of strabismic TV.children. They may withdraw from the child, unconsciously encourag-ing him or her to discard glasses in an attempt to regain acceptance, or Is it all right ifmykids lie down while reading, or read in lowbecome too authoritarian or solicitous regarding the wearing of glasses. light? Appropriate posture and lighting is always desirable. However, lying down while reading or usingdim illumination wont h u r t the eyes. 4. Although far from comprehensive, the following may help yourespond to parents concerns about symptoms: I f my child sees 20120, why does she need glasses to correct the farsightedness? Although the child can see clearly a t a distance, Diplopia in children is rare, but the complaint of seeing double is the eye must constantly refocus to see near objects. This can result incommon. Its very important to differentiate between blur and diplopia reading difficulties or eyestrain.-at times its difficult for patients to tell the two apart. One excellentmethod is to patch and eye and see if diplopia is still noted. Monocular Will my child become dependent onglasses? You dont becomediplopia is very rare and is usually due to a pathological etiology which dependent on glasses-youjust get used to seeingclearly and appreciatecan be ruled out by a good eye health exam. the benefits of wearing them! Pain isnt always a reliable indicator of the seriousness of the Wont other children tease my child if he wears glasses?disorder. A child with a lacerated globe may barely complain, while a When a child may be teased because of the glasses or other therapies Ichild with a simple corneal abrasion may raise quite a ruckus. may prescribe (binasal occlusion, for example), I usually give t h e child several of my professional cards. I tell the child, "If any of your Photophobia and redlwateringleyes often occur in children classmates start to pick on you because of your glasses, you just tellwithout obvious cause. I n most cases of itchy eyes, we should be able them, I see great with my glasses, and if YOU have a problem with it,to determine the etiology (allergies are the most common). just call my doctor and hell explain everything to you!" This helps the child cope with the "class bully" who picks on other kids. Dark-adaptationcomplaints should be considered a "red light."This symptom is rare in children, so look for pathology. Color-vision defects are also rare. Again, look for pathology. Dispensing to YoungstersAsk if other family members have color vision problems. 1. I usually recommend polycarbonate lenses, frames with hinge temples, and head bands (croakies) for children. The polycarb lenses Complaints of visual phenomena, such a s micropsia (percep- offer better protection for a n active child, the hinge temples allow thetion of objects a s smaller than they actually are) or macropsia (the frame to stand up to "punishment" for longer periods of time withoutopposite) may require additional testing, like a n Amsler grid. breaking, and the croakies keep the glasses on the childs face! Excessive blinking is sometimes due to stress induced by the 2. Instead offacing children across a table, sitright next to them.home or school environment. This allows for easier and more accurate fitting. A parents report of protrusion of the globe usually signals true 3. To take PDs, I usually have my staff use a pupilometer or useorbital pathology. Lay people rarely pay attention to such a symptom a penlight technique (do a Hirschberg, measure the distance betweenunless its pronounced. light reflexes for near PD, and add 2-3 mm for distance PD).
4. Encourage parents to let children choose their own frames. If Market Your Practicechildren dont like their glasses, they may deliberately lose them, breakthem, or throw them away. This is true even for children as young as with Special Services3 or 4. 1. Children dont get much mail, so it means a lot to them. Involve your staff in hand-writing (or hand-printing) a thank-you note Another practical reason to minimize parental involvement: it after a young patients first visit. Its a nice touch to use cartoon-saves time. Optician Fred Spangler says, "In the 15 minutes to one hour illustrated notepaper, but your regular practice letterhead is fine too.that I spend per patient, I usually have to show the child and parentstogether some 100 frames. When Im dealing only with the young 2. If your practice sees many young families, you might want topatient, that figure drops down to more like 20 or 25." offer a "nanny service." Hire a retired adult or high school student to babysit several hours a week, or arrange a "drop-in" service with a 5. When fitting infants and children with birth defects, its nearby childcare center. The cost will probably be minimal comparedusually best for you or your assistant to select frames yourself. The best to the patient satisfaction and new referrals youll have.are those with a built-up nasal area and comfortable cable temples. 3. Consider setting up field trips to your office for young chil- 6. Many children are aware of the fashion aspect of eyeglasses. dren. For demonstration purposes I use a real human skull, pickledThese days, the most popular frame colorsfor boys are brown, deep blue, cows eyes, X-rays of the human skull, and a bunch of Seymour Safelyand black marble in plastic, and yellow gold and y n m e t a l in metallic. puppets, stickers, and a movie. Ive found that preparing for a talk toGirls prefer navies and greens. Both like bright, solidreds, and logos are first graders requires just as much planning and forethought as prepar-particularly popular. ing a presentation to my optometric colleagues! You have to be ready for 7. If conflicts arise between children and parents, leave the room the unexpected and be able to respond appropriately.for a time. That way, the child may find it easier to gracefully yield tothe parents wishes (or vice versa!). Using Computers 8. When dispensing to a very young child, ask the parent to bringalong the childs favorite toy. Then ask the parent to stand back about in Pediatric Practice6 to 10 feet, hold the toy, and call to the child. Immediately place the Your personal computer can be a powerful diagnostic and thera-corrective lenses on the childs face-the response is gratifying! peutic tool in pediatric practice. Computers perform their testing and 9. Instruct both children and parents in proper care of eye- training activities consistently and without bias; they never get bored,glasses. Explain the importance oftaking the frame on and offwith two tired, or ill.hands, folding the temples properly, and placing the spectacles into a In addition, most children will look forward to coming into yourcase. Also, describe proper cleaning procedures for glass or plastic office and "playing with the computer." One of my patients even broughtlenses. his grandmother so he could show off his newly acquired skills. 10. Consider displaying, in your reception area, Polaroid photo- The following companies sell programs that are specifically de-graphs of children wearing their new glasses. Let children pin them signed for optometric diagnosis and therapy:onto the bulletin board themselves-kids love to feel part of the crowd! Computer-Eyes 5887 Hamilton Road Columbus, GA 31909
Frontier Technologies, Inc. 5. Be sure to introduce staff members to children. Its friendliest 2444 Solomons Iguana Road if you use their first names. If your assistants wear name badges, the Annapolis, MD 21401 letters should be big enough for young readers to decipher. R.C. Instruments, Inc. 6. To make waiting time fly by, put some of these in your 99 W. Jackson St. reception room: P.O. Box 109 Cicero, IN 46034 A bathroom scale. Kids will weigh themselves over and over! VTC Enterprises 3408 Arcadia Court Pictures your patients have colored. (Be sure to hang them Bloomington, IN 47401 a t childs-eye level.) A water cooler with paper cups. Kids love to watch the Other programs are available from commercial software compa- water "glug" out.nies, and some are even available free or for a nominal fee ("publicdomain software"). For detailed information, see the book I co-edited, An inexpensive computer.Computer Applications in Optometry (Butterworths, 1989). A backless birdhouse or bird feeder, attached to a window so kids can see inside it. Families of children with visual, physical, cognitive, hearing1communicative or learning disabilities, and the professionals who work Stained glass suncatchers and rainbow-making prisms inwith them, are eligible to join The Committee on Personal Computers a sunny window.and the Handicapped (COPH). This not-for-profit group provides free Cassette tapes and headphones. Some storybooks haveloans of computer equipment, operates a computer bulletin board, and companion tapes.offers other services to the handicapped. Contact COPH a t The IllinoisChildrens School, 1950 West Roosevelt Road, Chicago, IL 60608,312- Abigchalkboard and colored chalk. Better yet (because its421-3373 (voice) or 312-286-0608 (modem). cleaner), a white dry-erase board with water-based mark- ing pens. 7. If you know a young patient will be accompanied by restless, Office Design and Atmosphere disruptive siblings, ask your front desk assistant to schedule the family for the last appointment of the day, or the last before lunch. That way, 1. Consider doing away with your white lab coat, which might fewer of your other patients will be disturbed.remind children of a painful visit to a hospital, physician, or dentist. Ifyou do wear a lab coat, you might carry a little stuffed animal in your 8. As youre saying goodbye:pocket and let i t peek out. a. Let the child pick a gift from a loaded "treasure chest." (Let 2. Dont make examining rooms any darker than necessary, siblings have a gift, too, to thank them for waiting patiently.)especially when examining a very young child. b. An examining glove makes a great balloon. Inflate i t slightly, 3. Mirroring a wall seems to make time spent in that room go then tie off the 4 fingers two-by-two. (This makes "hair.") Leave thefaster. A mirror can be a good distraction for fussy kids, too. thumb inflated a s a "nose." Give the child a felt marker and invite him or her to draw a face on the balloon. 4. Display frames a t a higher level, to prevent youngsters fromsnatching them off racks. c. Dr. Charles Perakis of Pine Point, Maine gives children sand dollars, chestnuts, seashells, minerals, or animal pictures. "They come to appreciate the beauty of the natural world," Dr. Perakis says, "in a society that bombards them with commercialism."
Conclusion McVoy M. How to Build Your Medical Practice by Marketing to Children and Their Mothers. Boulder, CO: Expressions, 1989. This booklet has given you dozens of suggestions for developing Muth E. Selling to tomorrows customer today. Optical Prism 7(5):36, 1989.a n d publicizing your expertise in pediatric optometry. Most are inex- OD makes kids feel like i shots." Professional Enhancement Strategies bg 5(3):8, 1989.pensive a n d e a s y to implement immediately, a n d all will contribute to OD uses special technique on kids. Professional Enhancement Strategiesincreased referrals a n d a n increase i n t h e number of patients r e t u r n i n g 5(6):8, 1989.for r e p e a t visits. Pickwell D. Communication with children. Kansas Optom J 60(6):4, 1987. Problem solving. Dent Teamwork 1(6):218, 1988. Wed like to h e a r other ideas you have, for publication i n Pediatric Rancilio C. Special report: vision problems and the juvenile. AOA NewsOptometry & Vision Therapy. W r i t e to Anadem Publishing, Inc., 3620 27(2):1, 1989. Reidenbach F. Take charge with children: an interview with Marvin H.N. High St., P.O. Box 14385, Columbus, Ohio 43214, USA. Berman, D.D.S. Motivational Dent 1(3):33, 1990. Stein H. Marketing to young patients. Optom Mgt 25(8):116, 1989. Tyner M. Computers well-suited for vision therapy. Professional Enhance- Bibliography ment Strategies 6(5):2, 1990. Zaba J. Catering to the children in your practice. Optom Mgt 25(1):80, 1989.Anderson PE. Proven practice-builders. Dent Econ 78(3):79, 1988.Barnett D. For children only. Eyecare Business 5(7):69, 1990.Bayusik L. Kids a t the centre of attention. Eyecare Business 5(7):77, 1990.Bayusik L. Seeing kids a t eye level. Eyecare Business 5(7):74, 1990.Caring for disabled patients gives ODs rewards. Professional Enhancement Strategies 6(11):8, 1990.Cox TA. Pupillary testing using the direct ophthalmoscope. A m J Ophthalmol 105:427, 1988.Face it: gloves are great gifts. Physicians Mgt 29(11):20, 1989.Gifts au nature]. Physicians Mgt 29(11):18, 1989.Hall DMB and Hall SM. Early detection of visual defects in infancy. Br Med J 296:823, 1988.Heeb MA. What I learned about patients the hard way. Med Econ 65(7):89, 1988.Hiatt RL. The spectrum of child and parent response to eye disease. Ann Ophthalmol 21:325, 1989.Hoekstra BA. A magic question. Cortlandt Forum 1(7/8):36, 1988.Kenitz S. Examination of the younger pediatric patient. Wisc Optom Assoc J 31(2):4, 1987.Maino DM. Applications in pediatrics, binocular vision, and perception. In Maino J H e t al., eds., Computer Applications in Optometry. Boston: Butterworths, 1989.Maino DM. The mentally handicapped patient: a perspective. JArn Optom Assoc 58:14, 1987.Maino DM. Microcomputer mediated visual development and perceptual therapy. JArn Optom Assoc 56:45, 1985.Maino DM. Serving the mentally handicapped patient: a self assessment. J Am Optom Assoc 58:36, 1987.Maino DM and Maino JH. Professional marketing and the microcomputer. In Maino J H e t al., eds., Computer Applications in Optometry. Boston: Butterworths, 1989.Maino DM, Maino JH, and Maino SA. Mental retardation syndromes with associated ocular defects. JArn Optom Assoc 61:707, 1990.Maino D, Schlange D, Maino J , and Caden B. Ocular anomalies in fragile X syndrome. JArn Optom Assoc 61:316, 1990.