Foreword: Why Pediatrics? When we announced our newest publication, Pediatric Optometry

& Vision Therapy, a loyal reader of High Performance Optometry wrote to express h is concern. "Older patients a r e the largest and fastest- growing segment of the population," h e pointed out. "Why concentrate on pediatrics?"

An excellent question for practitioners, more than for publishing companies! Here are the top 5 reasons you should consider expanding the pediatric portion of your practice:

1. The demographics ARE right. So many "baby boomers" a re having children of their own tha t there's a "mini boom" occurring. They're having fewer children than past generations, but this typically means they have more disposable income for heal th care.

2. Since 80% to 90% of all learning is mediated through the visual system, many children need expert optometric care. For example, in a New York study of 1,634 children, 53% failed a t least one oculomotor, binocular, accommodative, or visual perception test. Other studies show tha t vision dysfunctions a re even more common in the learning disabled, who comprise 11% of all schoolchildren.

3. Adults are more likely to make appointments for chil- dren than for themselves. When i t comes to eye care, most parents take care of their children's needs long before their own. Some reluctant patients even "test" a new doctor by bringing a child in first.

4. Working with children who are learning and growing can be more psychologically rewarding than relieving the symptoms of elderly patients with progressive ocular disease.

5. Children are the lifeblood of a practice. Win a child's friendship now and you're likely to have a n enthusiastic "optometric missionary" for decades.

This booklet will give you pointers about how to win those friend- ships and enhance your reputation for excellence in "family practice." If you have other ideas you'd like to offer for publication in our newsletter, please let u s hear from you!

Will Kuhlmann Publisher

Getting Started in PediatricsNision Therapy

1. To decide whether expanding your pediatric/vision therapy practice is right for you, do some basic research about your office and the community you serve.

a) Comb your patient charts to find out:

a What percentage of your current patients a re children age 12 and under? What percentage are age 13 to 18?

a How many of your adult patients have children who aren't seeing you? If this number is significant, you have built-in growth potential.

b) Consult your local reference librarian or Chamber of Com merce to learn the following:

a How many children in your a rea are age 1 2 and under? How many are age 13 to 18?

a Is the community growingor stable? How many new homes have been built there recently? How many companieshave moved in or out? Are there any new schools?

a What is the income level of the parents in your area? Can they support specialized care for their children?

If you subscribe to a commercial database, such as CompuServe, you can instantly obtain much of this information for minimal cost. I recently conducted such a demographic search for one of my students who was planning to buy a practice in a certain community. For $10 I got a profile of the county's population by age, occupation, race, household income, and other helpful data.

2. The clinical skills necessary for pediatric exams are not all t h a t different from many of the techniques you currently use. However, you'll need to depend more heavily on objective assessment techniques. The advantages include quick assessment of refractive error, oculomo- tor dysfunction, and eye health. Obtaining these clinical skills requires taking courses with workshops tha t allow for hands-on learning and not being timid in applying these newly-learned skills in practice.

3. To supplement hands-on courses, you should consider sub- 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 ofOptometristsinVision Development, 619-425-6191), and the newslet- ter I edit, Pediatric Optometry & Vision Therapy (Anadem Publishing, Inc., 800-633-0055, 614-262-2539). The latter is a "Reader's Digestn newsletter of clinical articles from a broad range of optometry, ophthal- mology, general medicine, and special education and rehabilitation journals. In addition, i t regularly includes tips for marketing and managing the pediatric portion of your practice.

4. Once your academic and clinical skills are in place, send notices to your established patients, announcing that you are now offering specialized services for children.

5. Include information about children's vision and vision ther- apy in your practice newsletter, informational pamphlets, and presen- tations to community groups. The AOA has "news backgrounders" available on these and 10 other topics. They present facts and statistics in jargon-free language, so the information is ideal for sharing with the public. Contact the AOA Order Department, 243 N. Lindbergh Blvd., St. Louis, MO 63141,314-991-4100.

The Best Marketing Technique: Education

1. Thorough, understandable patient education is the #1 way to set yourself apart from retailers. In written handouts and face-to-face, tell parents:

That you can examine a child who is too young to answer questions.

That children should have their first eye exam a t age 6 months to 1 year.

That infants with a family history of a serious visual disorder should be examined even earlier.

That parents should watch children for the following con- ditions:

abnormal appearance of the eyes avoidance of readin~schoolwork

excessive sensitivity to light lack of fixation or following

persistent squinting in one eye poor academic performance

red eyes reluctance to open the eye wandering eye movements watery eyes

2. Keep track of which of your adult patients have young children. On your new patient questionnaire, ask for the names of all other immediate family members, their date of birth, and their year in school. Question parents occasionally (or have your staff question them) about whether their children are exhibiting any of the signs above. This is a practice-builder, but even more importantly, you'll be likely to catch problems while they're still treatable.

3. Once a patient's children have reached school age, ask about their grades and whether they're having any difficulties with reading or studying. Stress tha t 80% of learning is dependent on vision.

4. Here's a n especially persuasive fact. (You may remember this from the AOA News a while ago.) A study a t the Optometric Center of Maryland concluded that vision problems almost certainly contribute to juvenile delinquency. Over 98% of the 132 delinquents studied had learning-related vision problems (inability to perform vision tracking required for reading and writing, inability to copy from a chalkboard, inability to discriminate left-right, lack of eye alignment, a poor near- point of convergence, and a decreasing ability to reachlgrasp).

5. The medical history form for your young patients can do double duty as an educational tool. Include the following items, with explanations about why you're asking:

Child's birth weight. (Explain that low birth weight i s a risk factor in retinopathy, visual-motor problems, visual development, and moderate to high refractive errors.)

Whether there was any difficulty in labor, or whether there was delivery by forceps. (Explain that both are risk factors in extraocular muscle damage.)

Parent's assessment of the child's reading performance. (Explain that poor performance can be related to refractive or binocular problems.)

Parent's assessment of the child's skill in copying text. (Explain that letter reversals beyond age 7% can be related

to perceptual problems.) 6. Train your staff about the importance of ongoing pediatric

vision care, so they can remind parents, too. Your assistants should be able to explain the recommended age for first exams, the difference between your exam and a school vision screening, and the rationale for the tests you perform.

7. When a new patient calls to make an appointment, your front desk assistant should inquire whether any children in the family need appointments, too. I t seems obvious, but you'd be amazed how many practices neglect this.

8. Your personal computer can be used to prepare sophisticated educational materials. Some of the options include distributing free software programs to patients, schools, and rehabilitation centers; putting informational files on a computer "bulletin board"; and prepar- ing your own brochures using desktop publishing. For more informa- tion, see the book I co-edited, Computer Applications in Optometry (Butterworths, 1989).

Putting Children at Ease 1. Get children into the examining room as quickly as possible.

The longer children wait, the more restless they become.

2. Speak to children directly, a t their eye level. For example, a t the first appointment, introduce yourself to the child as well as to the parent. This communicates respect for the child's feelings.

3. Take time to find out what name the child goes by. For example, Michael might prefer Mike or Mikey.

4. If you permit parents in the examining room, have them ask their child whether he or she wants their company.

5. Consider inviting the whole family into the examining room. This helps young children feel even more secure, and observing siblings may give you clues to a child's visual problems. Allow family members to view the stereo fly or other " 3 D tests.

6. If the parents will be present, ask them not to make any comments during the exam unless you direct a question their way. (Do this out ofthe child's earshot.) Of course, you'll want to assure them that you'll answer any questions they have, a t the end.

7. Don't approach children right away, even if you've examined them before. Even infants need time to look around the examining room and get used to your voice. If the parents are present, chat with them for a minute. Childrenhave changeable emotions and won't react to you the same way a t each visit.

8. During the exam, fix 90% of your attention on the child. I position myself so that I'm eye-level with the patient, not towering over him or her. I smile frequently. I'm sincere in the warmth and caring attitude I project, because children can instantly spot a phony!

9. I direct the majority ofmy questions directly to the child; when the parent's confirmation is needed, I turn to him or her after the child answers. This makes children aware that they're the important ones in the examination.

10. Make conversation, just as you would with an adult. Sample conversation starters: "What's your favorite TV program? Do you have 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 Halloween? When's your birthday? Are you going to have a party? What is that you brought with you?"

11. Try to use a soft, non-threatening tone of voice. (If you're not sure how you sound, it's a good idea to tape yourself.) Listen for questions-about having to wear glasses, having an operation, going blind-which may be disguised as casual remarks.

12. Tell and show the child what you plan to do. For example: "I'm going to cover one of your eyes with this paddle, then 1'11 cover the other one."

13. Be truthful: if the eyedrops are going to sting a little, say so. 1'11 usually say somethinglike, "These drops may be cold or stinga little." After I put the drops in, 1'11 ask the child to count to "5" while squeezing my finger. When the child concentrates on counting and squeezing,

, they soon forget the stinging!

14. More tips about eyedrops:

a. Cathy Tibbetts, O.D. of Farmington, NM puts the drop on the end of a fluorescein strip (or another type of filter paper) and dabs the paper on the inside of the lid a few times. "Kids don't mind if you tell them you are just going to touch their lid with a little piece of paper," Dr.

Tibbetts says. "It doesn't even sting." For faster corneal penetration, ask the child to close their eyes for a few moments.

b. If you know in advance that drops will be required and that the child may be fussy, ask parents to administer artificial tears for a week or two a t home. That way you won't have to contend with a squirming youngster, and the childwon't learn to loathe visits to your office.

15. Provide frequent positive reinforcement: "That's very good." But during testing, your goal i s to have the child respond well to the exam, not necessarily provide the "right" answer. Even if a response isn't correct from a visual standpoint, you can say, "Thank you, tha t gives me a lot of information."

16. Ask a n assistant to gently hold a young child's head in place during ophthalmoscopy. Tell the child, "I'm gettingready to look inside your eye . . . Your eye looks really good."

17. When examining a squirmy young patient, touch the child on the shoulder or hand as you talk, to get their attention.

18. If appropriate, report to the parents in the presence of the child. This i s another way to show respect for children. I t also helps insure tha t children will get accurate information about their vision and the importance ofvision care. Never talk about young patients a s if they weren't there.

19. Take advantage of children's honesty. Their actions and facial expressions will generally tell you exactly what they're thinking!

Working with Fearful or Boisterous Children

1. Never force a child to go through a n exam crying if i t can be postponed until another day. Don't let children learn to associate fear with your office.

2. I find that having parents in the examining room is very helpful. There are times I'll ask them to leave, but that's infrequent.

3. In most instances, if a child is acting up I try to '?till them with kindness." Only occasionally will I use sterner methods.

4. A good diversionary tactic is to have the child count, recite ABC's, or name colors of objects in the room.

5. Young children are usually entranced by the wooden toy called "Jacob's Ladder," which clackety-clacks down itself. Keep one in every examining room to distract fussy preschoolers.

6. Human contact i s reassuring-a pat on the back, a hand- shake, a hug.

7. Is there something the child could hold for you? Holding things makes people more comfortable with them and lessens the "Fear of the Unknown." For example, 1'11 let children shine the ophthal- moscope into my eye and view the red reflex.

8. "Before I touch a young patient," says Dr. Max Heeb, "I ask if he can tell me what courage is. The usual answer is something like, 'Courage is not being scared.' That's not my answer. Even if the child says nothing, I volunteer that I used to think that brave people were never afraid, but that I've learned that it's normal and all right to be scared, and that people who are not scared are sometimes just plain nuts. Courage is doing what you need to do even though you're scared. It's amazing how children will settle down and cooperate after you impart this information."

9. Dr. Bruce Hoekstra relaxes fearful children with "magic." "I tell them that if they let me feel their stomachs, I can guess what they've had for breakfast. I always guess cereal, because it's correct about 80 percent of the time. IfI'm wrong, the children are only too happy to blurt out the right answer; ifI'm right, their eyesgrow wide a t my mysterious power. Either way, it makes a potentially difficult examination easy and it's never failed to relax cranky, nervous patients."

Another "magic" trick: Pu t two pieces of Scotch Tape on a balloon so that they form an "X" You'll be able to push a needle right into the balloon without popping it.

, 10. If you're fairly introverted, it's helpful to have a live-wire assistant who talks easily with children. "Children don't like quiet- ness," pedodontist Dr. Marvin Berman says. "Kids often don't relate to reserved people. Kids like craziness, people who repeat things over and over. They love rhyming, they love singing, they love faces, they love action. Ifyou do things too quietly, they don't learn. You need somebody in your ofice who's capable ofkeeping up with the shortness of a child's attention span."

Working with Mentally Handicapped Children

High refractive error, amblyopia, strabismus, poor perceptual skills, and ocular disease are the norm, not the exception, in mentally handicapped children. Early detection and treatment can be vital in helping them get the most from other rehabilitation programs. Some of my articles listed in the bibliography provide an introduction to the mental retardation syndromes most commonly associated with ocular defects: the fragile X syndrome, cerebral palsy, and Down's syndrome.

Developing expertise in working with handicapped children demonstrates just how unique your practice is. Many parents with handicapped children will bring other family members to you if you can work well with their exceptional child. Don't hesitate to seek out other professionals working in this area and offer your assistance.

To assess visual acuity, choose from the tumblingE test, Landholt C or Brokenwheel test, Lighthouse cards, the Catford Visual Acuity Apparatus, the OKN response, visually evoked response, and preferen- tial looking. Oculomotor assessment should include the cover/uncover test, Hirschberg, physiological H test, near point of convergence, saccades, rotations and pursuits (visual tracking).

Assessment of refractive error should include the Placido disk or keratoscope, standard distance retinoscopy, and cycloplegic or dynamic retinoscopy. Binocularity may be determined with such procedures as the Titmus, Frisby, or Randot E stereotest. Accommodative function may be assessed quickly with the monocular estimation method (MEM).

Because mentally handicapped children are prone to ocular pa- thology, a biomicroscopic exam should be performed with either a standard slit lamp or hand-held model. Pupillary actions should be noted as present or absent, and direct or indirect ophthalmoscopy should be completed. You should also attempt to assess visual fields and intraocular pressures.

Examinations of mentally handicapped children will go most smoothly if you:

1. Schedule extra time. You may want to talk casually with the child and parent in your office before proceeding to the exam room. Also, give the child time to get accustomed to the exam room before you begin.

2. Ask the parent to remain present during the exam. They can help you communicate with the child, and if the child becomes upset, they can usually discern the problem. (If the child remains upset, ask the parent whether they'd like to reschedule the appointment.)

3. Modify your exam technique. In particular, avoid sudden movements, and shine the ophthalmoscope into your own palm, directly in front of the patient, to demonstrate i t before you shine i t in their eye. Explaining procedures using an eye model will help patients under- stand you're going to do something for them.

4. Remember to smile. A smile is understood and appreciated by all-even the most severely handicapped.

Building Rapport with Parents 1. Use the child's examination as an opportunity to educate the

parents, ifthey're in the room. For instance, if a child can't see four dots on the Worth Four Dot test (a measure of second degree fusion), I'll place the anaglyph glasses on Mom. When she sees the four dots, she knows her child is not responding appropriately, and has a greater under- standing of how her child's visual system is working. Or I may use the Random Dot Stereo E test. A strabismic child won't be able to see the "E," but Mom or Dad will. (When parents can't, this often prompts them to schedule an exam for themselves!)

2. Take parents' observations seriously. If you can't verify a parent's report, offer an explanation as to why this might be. For example, if a mother reports that she sees her child's eye turn out, but during your examination you don't find strabismus, explain that eye turns can be intermittent. Suggest scheduling a visual efficiency evaluation for further assessment. Never tell parents that they were wrong; instead, let them know that you're simply unable to verify their observations at this time.

3. In discussing a child's visual status, keep in mind that parents often feel embarrassed about not detecting or reporting a problem sooner. Unless we're careful, our comments may be interpreted as criticism or a charge of neglect.

Of course, it's wise to correct misconceptions: "You may have heard that children will grow out of a squint, but this isn't so." Still, the

emphasis should be on what can be done to help the child now. Give all the information and reassurance you can. Praise the parents for bringing the child to you when they did.

Guilt can be particularly pronounced in parents of strabismic children. They may withdraw from the child, unconsciously encourag- ing him or her to discard glasses in an attempt to regain acceptance, or become too authoritarian or solicitous regarding the wearing of glasses.

4. Although far from comprehensive, the following may help you respond to parents' concerns about symptoms:

Diplopia in children is rare, but the complaint of seeing double is common. It's very important to differentiate between blur and diplopia -at times it's difficult for patients to tell the two apart. One excellent method is to patch and eye and see if diplopia is still noted. Monocular diplopia is very rare and is usually due to a pathological etiology which can be ruled out by a good eye health exam.

Pain isn't always a reliable indicator of the seriousness of the disorder. A child with a lacerated globe may barely complain, while a child with a simple corneal abrasion may raise quite a ruckus.

Photophobia and redlwateringleyes often occur in children without obvious cause. In most cases of itchy eyes, we should be able to determine the etiology (allergies are the most common).

Dark-adaptation complaints 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. Ask if other family members have color vision problems.

Complaints of visual phenomena, such a s micropsia (percep- tion of objects a s smaller than they actually are) or macropsia (the opposite) may require additional testing, like an Amsler grid.

Excessive blinking is sometimes due to stress induced by the home or school environment.

A parent's report of protrusion of the globe usually signals true orbital pathology. Lay people rarely pay attention to such a symptom unless it's pronounced.

5. Here are sample answers to common questions from parents:

Will watching TVhurt my kids'eyes? No, but i t may dull their minds! Children should sit on the family couch, not right in front of the TV.

Is it all right ifmy kids lie down while reading, or read in low light? Appropriate posture and lighting is always desirable. However, lying down while reading or usingdim illumination won't hur t the eyes.

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, the eye must constantly refocus to see near objects. This can result in reading difficulties or eyestrain.

Will my child become dependent onglasses? You don't become dependent on glasses-youjust get used to seeingclearly and appreciate the benefits of wearing them!

Won't other children tease my child if he wears glasses? When a child may be teased because of the glasses or other therapies I may prescribe (binasal occlusion, for example), I usually give the child several of my professional cards. I tell the child, "If any of your classmates start to pick on you because of your glasses, you just tell them, 'I see great with my glasses, and if YOU have a problem with it, just call my doctor and he'll explain everything to you!"' This helps the child cope with the "class bully" who picks on other kids.

Dispensing to Youngsters 1. I usually recommend polycarbonate lenses, frames with hinge

temples, and head bands (croakies) for children. The polycarb lenses offer better protection for a n active child, the hinge temples allow the frame to stand up to "punishment" for longer periods of time without breaking, and the croakies keep the glasses on the child's face!

2. Instead offacing children across a table, sitright next to them. This allows for easier and more accurate fitting.

3. To take PD's, I usually have my staff use a pupilometer or use a penlight technique (do a Hirschberg, measure the distance between light reflexes for near PD, and add 2-3 mm for distance PD).

4. Encourage parents to let children choose their own frames. If children don't like their glasses, they may deliberately lose them, break them, or throw them away. This is true even for children as young as 3 or 4.

Another practical reason to minimize parental involvement: i t saves time. Optician Fred Spangler says, "In the 15 minutes to one hour that I spend per patient, I usually have to show the child and parents together some 100 frames. When I'm dealing only with the young patient, that figure drops down to more like 20 or 25."

5. When fitting infants and children with birth defects, it's usually best for you or your assistant to select frames yourself. The best are those with a built-up nasal area and comfortable cable temples.

6. Many children are aware of the fashion aspect of eyeglasses. These days, the most popular frame colorsfor boys are brown, deep blue, and black marble in plastic, and yellow gold and ynmeta l in metallic. Girls prefer navies and greens. Both like bright, solidreds, and logos are particularly popular.

7. If conflicts arise between children and parents, leave the room for a time. That way, the child may find it easier to gracefully yield to the parent's wishes (or vice versa!).

8. When dispensing to a very young child, ask the parent to bring along the child's favorite toy. Then ask the parent to stand back about 6 to 10 feet, hold the toy, and call to the child. Immediately place the corrective lenses on the child's face-the response is gratifying!

9. Instruct both children and parents in proper care of eye- glasses. Explain the importance oftaking the frame on and offwith two hands, folding the temples properly, and placing the spectacles into a case. Also, describe proper cleaning procedures for glass or plastic lenses.

10. Consider displaying, in your reception area, Polaroid photo- graphs of children wearing their new glasses. Let children pin them onto the bulletin board themselves-kids love to feel part of the crowd!

Market Your Practice with Special Services

1. Children don't get much mail, so it means a lot to them. Involve your staff in hand-writing (or hand-printing) a thank-you note after a young patient's first visit. It's a nice touch to use cartoon- illustrated notepaper, but your regular practice letterhead is fine too.

2. If your practice sees many young families, you might want to 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 nearby childcare center. The cost will probably be minimal compared to the patient satisfaction and new referrals you'll have.

3. Consider setting up field trips to your office for young chil- dren. For demonstration purposes I use a real human skull, pickled cow's eyes, X-rays of the human skull, and a bunch of Seymour Safely puppets, stickers, and a movie. I've found that preparing for a talk to first graders requires just as much planning and forethought as prepar- ing a presentation to my optometric colleagues! You have to be ready for the unexpected and be able to respond appropriately.

Using Computers in Pediatric Practice

Your personal computer can be a powerful diagnostic and thera- peutic tool in pediatric practice. Computers perform their testing and training activities consistently and without bias; they never get bored, tired, or ill.

In addition, most children will look forward to coming into your office and "playing with the computer." One of my patients even brought his grandmother so he could show off his newly acquired skills.

The following companies sell programs that are specifically de- signed for optometric diagnosis and therapy:

Computer-Eyes 5887 Hamilton Road Columbus, GA 31909

Frontier Technologies, Inc. 2444 Solomons Iguana Road Annapolis, MD 21401

R.C. Instruments, Inc. 99 W. Jackson St. P.O. Box 109 Cicero, IN 46034

VTC Enterprises 3408 Arcadia Court Bloomington, IN 47401

Other programs are available from commercial software compa- nies, and some are even available free or for a nominal fee ("public domain software"). For detailed information, see the book I co-edited, Computer Applications in Optometry (Butterworths, 1989).

Families of children with visual, physical, cognitive, hearing1 communicative or learning disabilities, and the professionals who work with them, are eligible to join The Committee on Personal Computers and the Handicapped (COPH). This not-for-profit group provides free loans of computer equipment, operates a computer bulletin board, and offers other services to the handicapped. Contact COPH a t The Illinois Children's School, 1950 West Roosevelt Road, Chicago, IL 60608,312- 421-3373 (voice) or 312-286-0608 (modem).

Office Design and Atmosphere 1. Consider doing away with your white lab coat, which might

remind children of a painful visit to a hospital, physician, or dentist. If you do wear a lab coat, you might carry a little stuffed animal in your pocket and let i t peek out.

2. Don't make examining rooms any darker than necessary, especially when examining a very young child.

3. Mirroring a wall seems to make time spent in that room go faster. A mirror can be a good distraction for fussy kids, too.

4. Display frames a t a higher level, to prevent youngsters from snatching them off racks.

5. Be sure to introduce staff members to children. It's friendliest if you use their first names. If your assistants wear name badges, the letters should be big enough for young readers to decipher.

6. To make waiting time fly by, put some of these in your reception room:

A bathroom scale. Kids will weigh themselves over and over!

Pictures your patients have colored. (Be sure to hang them a t child's-eye level.)

A water cooler with paper cups. Kids love to watch the water "glug" out.

An inexpensive computer.

A backless birdhouse or bird feeder, attached to a window so kids can see inside it.

Stained glass suncatchers and rainbow-making prisms in a sunny window.

Cassette tapes and headphones. Some storybooks have companion tapes.

Abigchalkboard and colored chalk. Better yet (because it's cleaner), a white dry-erase board with water-based mark- ing pens.

7. If you know a young patient will be accompanied by restless, 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, fewer of your other patients will be disturbed.

8. As you're saying goodbye:

a. Let the child pick a gift from a loaded "treasure chest." (Let siblings have a gift, too, to thank them for waiting patiently.)

b. An examining glove makes a great balloon. Inflate i t slightly, then tie off the 4 fingers two-by-two. (This makes "hair.") Leave the thumb inflated as a "nose." Give the child a felt marker and invite him or her to draw a face on the balloon.

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 This booklet has given you dozens of suggestions for developing

a n d publicizing your expertise in pediatric optometry. Most are inex- pensive and easy to implement immediately, and all will contribute to increased referrals and a n increase i n the number of patients returning for repeat visits.

We'd like to h e a r other ideas you have, for publication i n Pediatric Optometry & Vision Therapy. Write to Anadem Publishing, Inc., 3620 N. High St., P.O. Box 14385, Columbus, Ohio 43214, USA.

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