doi:10.1111/jpc.

15782

VIEWPOINT

Handshake or high-five: Greeting children

1,2,3,4
John Massie
1
Children’s Bioethics Centre, 2Department of Respiratory and Sleep Medicine, Royal Children’s Hospital, 3Department of Paediatrics, University of
Melbourne and 4Infection, Immunity and Environment Theme, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia

The handshake is a common greeting, parting gesture or deal sealer across the globe. Its origins may go back to pre-history, ancestorial primates
using similar gestures. The handshake is cultural norm, most commonly shared between adults, which children learn as they grow up. There are
many important aspects to the handshake that can promote the clinician–patient relationship, but how clinicians caring for children should use
the handshake has not received attention. This paper explores the origins of the handshake and its closely allied gesture, the high-five, and
considers how they can work to promote the care of children.

I see friends shaking hands, saying ‘How do you do’, they’re
really saying, ‘I love you’
Louis Armstrong, What a Wonderful World
The handshake is a common greeting, leaving and deal-sealing
acknowledgement across the globe. It is an important way that
people acknowledge each other and a social norm that children
learn through observation of their parents and other significant
adults in their lives. There are two important questions for paedi-
atricians: when to start doing it and in what situations is it appro-
priate? One can also bring ethical reflection to the handshake as
ethics (framed along the lines of ‘how should I act’) is in play
whenever people interact. However, the simple gesture of the
handshake is complex, both practically (how to do it) and in
meaning.1 There is little research in the medical literature and
nothing that includes children.2 In this paper, I want to examine
the origins and purpose of the handshake and its closely related
action, the high-five, and to explore how paediatricians should
do this when greeting patients. There is risk involved. Done well,
the handshake ticks a lot of boxes in promoting child-centred
care; done badly, it is a faux pas that can be hard to recover from.
At the outset, I want to acknowledge that I am not speaking for
anyone, other than me, and the ‘rules’ I propose, I do because
they seem to work for me. I am interested in others’ experiences
and interpretations and perhaps the Editor will publish your
replies. I do think it is important for our community of health
professionals who care for children to take time to reflect on all
parts of our interactions, not just the direct medical care. With
this in mind, let us think about the handshake.
The origin of the handshake may well go back further than
you think.3 To human prehistory. I was always taught that the
handshake was a way warriors would greet, as a way of showing
that they were unarmed so that intentions were honourable, but
Correspondence: Professor John Massie, Department of Respiratory
and Sleep Medicine, Royal Children’s Hospital, 50 Flemington Road,
Parkville, Melbourne, Vic. 3052, Australia. Fax: +61 3 9345 9154; email:
john.massie@rch.org.au
Conflict of interest: None declared.
Accepted for publication 29 September 2021.
certainly non-violent; the weapon usually being held in the right
hand that was now empty, and demonstrably so. However,
anthropologists have observed our nearest evolutionary relations,
chimpanzees and bonobo monkeys, overlapping fingers in situa-
tions that resemble the way humans might do, as a greeting and to
make up. This is not all that surprising as higher primates all use
their hands to communicate. It is hypothesised that there may be a
transfer of chemicals (left on the hands or by close proximity), pos-
itive neurotransmitters released through touch or simply that the
body posture associated with presenting the hand is a universal
non-verbal language. This evolutionary model suggests the hand-
shake is hardwired, conveying biological advantage and perhaps
we should respect it deeply. If this origin story is true, it does
explain why handshaking is so common across human cultures.
There are common elements to the handshake, but no univer-
sal prescription. Open palm, hand pushed forward, eye contact
and touch seem to be the common elements, both shakers
mirroring each other.3 The firmness of grasp, degree of shaking,
secondary body movements and addition of the other hand are
all extras which may be cultural, personal or situational. Tradi-
tionally, it seems to have been a male-to-male activity, but
increasingly women shake hands with men and with each other,
particularly in formal or professional situations. There is a lot
more to be considered on this last point about gender, but in this
paper I am considering the role of the handshake with children.
We have all seen the cringeworthy politician’s handshake with
young children. The natural reaction is that it is wrong, it just does
not work. Before I toss this out, though, it is good to explore why
the besuited male politician shaking hands with the young child
invokes this reaction. First, I think that it is insincere with an
incongruity of purpose; the young child usually has no real interest
in the politician and the politician has no real interest in that child
who cannot vote for them. It is purely of instrumental value to the
politician, for the cameras and not of benefit to the child. On this
account, it is actually disrespectful to the child and he automati-
cally loses my vote. But there are other things awry that can make
the adult–child handshake wrong: there is not the sense of equality
a handshake should bring, a size mismatch over-powers the child
(both hand and body) and a grown-up adult bending down loses

226 Journal of Paediatrics and Child Health 58 (2022) 226–227

© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

J Massie
the mirroring body language of a handshake. These negatives are
worth considering in order to avoid them.
Does this mean adults should not shake hands with children?
No, of course not; but the trick is to know which child, when
and how to do it. So here are my ‘rules’ and my approach.
These are situated in 30 years of paediatric practice and mainly
focussed on the hospital outpatient setting, but they usually
work for greetings in the corridor or outside the hospital when
meeting children. You should also know that I am male and
196 cm (60 500 ) if I stand up straight (but rarely seem to do). Boys
are a cinch. From the start of high-school, I make a point of
shaking hands when they come into the room. I can shake
hands with older and taller adolescents standing up (and then
do the same with their parents), but may sit for younger,
shorter patients to be at eye level. For girls my plan is to do the
same, but do not usually in the early high-school years (not
sure why, but think some cultural norm holds me back) and of
course I have to be sensitive to patients from cultures in which
unrelated men do not make physical contact with women of
any age. This reminds me that for all children I am considering
their cues. Some young adolescents seem never to have shaken
hands before, which is telling in all sorts of ways, but reinforces
the value of introducing this social norm to the young person.
The paediatrician’s remit is always beyond the cough
(or whatever brought them to the consultation) and I like this
part of the ‘hidden curriculum’.
The handshake greeting is my chance to centre the consulta-
tion on the young person. The busy clinic slows down, for just
a moment. The handshake levels the power imbalance
between us. Ideally, it relaxes the child and their family and
builds trust from the outset. With the handshake, we acknowl-
edge each other, which is increasingly important in a world
where too many young people come in with faces glued to
their phones all the while leaving the adults to speak. The
mutuality and reciprocity of the handshake is part of its power.
The handshake says, ‘I see you and I will hear you’, ‘this con-
sultation is about you and what happens to you matters to
you, and to me’. The handshake makes physical the first tenet
of our practice as a paediatric health-care worker, respect for
the child as a person.
If I cannot shake hands, I can still do these things with intent,
regarding the child over their parents, placing the child next to
my desk in the clinic, looking at them at eye level and centring
the consultation on them.
On arriving the handshake is a greeting, on leaving a thank
you to both of us for being present, a promise to the patient that
I will maintain confidentiality and keep working hard to fix the
Journal of Paediatrics and Child Health 58 (2022) 226–227
© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).
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Greeting children
problem and hopefully a promise back from the patient to follow
through on our agreed plan.
So, what to do with the primary school aged patient? Hallelu-
jah, the high-five! The original high-five is much more recent
than the handshake.4 There are various origin stories. One is
from the US Fifth Infantry Brigade from The Vietnam War (The
‘Fives’), who greeted each other with hands up and five fingers
spread and as the legend goes, back home, one of their kids
jumping up to smack the hands saying ‘high-five’. Another has
an LA Dodgers baseball player hitting his 30th home run for the
season and holding his hand up to greet his friend running
through to the plate in celebration (October 1977, the first tele-
vised high-five) while another claims a basketball origin at the
University of Louisville in 1978–1979, a player converting the
more regular low-five used commonly by African Americans to a
high-five, the action resonating with the basketballers who are
used to jumping up to dunk baskets. Maybe they are all true and,
like many inventions, have multiple origins. What is common
though is the joyous freedom of a high-five celebration and the
many versions (high, low, side) that can be used. What is com-
mon with the handshake is the touch, the mirrored posture and
action, the human to human encounter and acknowledgement
of the two people. Now even toddlers know a high-five and,
while it may not always be the best greeting, it is a fantastic
good-bye with all the resonance of a handshake.
In the SARS-CoV-2 pandemic, we have probably lost some-
thing in our interactions with children. It will come back, but in
the meantime, we can at least think about what a handshake or
high-five is doing and try to replicate that work in other ways.
So, what do I choose? Handshake or high-five? I choose what
feels right, doing my best to take my cue from the child if possi-
ble. For young children it is a high-five, for older children a
handshake. What is most important is the gesture that best
respects the child.
References
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3 Al-Shamahi E. The Handshake. A Gripping History. London: Profile
Books Ltd; 2021.
4 Mooallem J. The Wild, Mysterious History of Sports’ Most Enduring Ges-
ture: The High Five. 2020. Available from: https://www.espn.com.au/
espn/story/_/page/Mag15historyofthehighfive/who-invented-high-five
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