Stop Normalizing a Child Crying Through PT Sessions

Dear fellow physical therapists,

I have noticed a disturbing trend in pediatrics for that I wanted to address. There are a few pediatric PTs with large social media profiles who post videos of themselves performing exercises with their patients. Many of the patients in these videos have profound motor challenges and likely global challenges. The exercises look flashy and complicated, but I get stuck on the expression of the child. They are not happy. They are crying. They look terrified. The exercises are so challenging and above the child’s limit, that they are terrified. And the PT continues the exercise.

This seems to be rationalized by saying things like “sometimes you have to do hard things,” or “I don’t like going to the gym either.” But I, as an adult, have the option to choose to put on my gym shoes. I can choose my exercise. I can choose how hard I want to work and push myself if that seems right. I also have full autonomy to stop an exercise. Move to something different. Or just leave. The children in these videos have no autonomy or choice. They cannot stop the exercise. They try to communicate through tears, and they are ignored.

Let’s talk about how the brain works for a bit. When the brain goes into fight or flight, like when you are running from a bear or forced to do a terrifying exercise, you are no longer able to learn. You drop from your mammalian brain to your reptilian brain and learning ceases. Your frontal lobes go offline, and your amygdala takes over. What are you gaining from triggering a trauma response from a child?

Another argument people make is that the child cries to communicate and therefore there is no reason to stop the exercise, they are just communicating. Let’s look at two examples of crying to communicate. First, a child falls down and they start crying. They are communicating with their cry, that they are upset, they didn’t like falling, something might hurt, etc. In this scenario, the adult notices the crying child and responds to the cry with support or comfort. Next, imagine that an adult pushes a child over, causing them to fall and cry. But instead of providing support and repair, they keep pushing the kid down. The adult, the person in a powerful position, ignores the cries for help and rationalize it by thinking, “we all have to do hard things sometimes.” This seems even worse when the child is someone with an intellectual disability, global delays and/or nonverbal.

This line of thinking is in conflict with the APTA code of ethics. Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals (core values: compassion and caring, integrity). Principle #2 Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients and clients (core values: altruism, collaboration, compassion and caring, duty). Principle #3: Physical therapists shall be accountable for making sound professional judgments (core values: collaboration, duty, excellence, integrity).

I have seen these kids in my practice after they have had these intense, negative training regimes. It feels a lot like needing to unravel a trauma response. They are more reactive to being put in challenging physical situations and do not allow any physical assist. It takes work, time and attention to each interaction to rebuild trust or connection. Kids will do amazing things and make huge progress when they are challenged in a way that respect them as people and honor their voice and autonomy.

We need to do better as a profession. There are amazing exercises in the lexicon of pediatric physical therapy that can help with improving motor skills, but not at the expense of the child’s mental health. Could this be a both/and situation? Are there ways to challenge a child motorically and not trigger a fight or flight response. Are there ways to do exercises that improve their motor skills, and they joyfully participate? The answer is yes.