Child Life Services

POLICY STATEMENT Organizational Principles to Guide and Deﬁne the Child Health Care System and/or Improve the Health of all Children

Child Life Services Barbara Romito, MA, CCLS,a Jennifer Jewell, MD, FAAP,b Meredith Jackson, MD, FAAP,b AAP COMMITTEE ON HOSPITAL CARE; ASSOCIATION OF CHILD LIFE PROFESSIONALS

Child life programs are an important component of pediatric hospital-based abstract care; they address the psychosocial concerns that accompany hospitalization and other health care experiences. Child life specialists focus on the optimal aChild Life Program, The Bristol-Myers Squibb Children’s Hospital at development and well-being of infants, children, adolescents, and young adults Robert Wood Johnson University Hospital, New Brunswick, New Jersey; and bThe Barbara Bush Children’s Hospital at Maine Medical Center, while promoting coping skills and minimizing the adverse effects of Portland, Maine hospitalization, health care encounters, and/or other potentially stressful Ms Romito provided the benchmarking data and the majority of the experiences. In collaboration with the entire health care team and family, child writing; Dr Jewell designed the outline for the policy, noted and life specialists provide interventions that include therapeutic play, expressive updated information that was irrelevant since the last revision, provided assistance with the writing, and presented the content to the modalities, and psychological preparation to facilitate coping and Committee on Hospital Care; Dr Jackson provided technical assistance, draft review, and content expertise for the portions related to medical normalization at times and under circumstances that might otherwise prove education; and all authors approved the final manuscript as overwhelming for the child. Play and developmentally appropriate submitted. communication are used to (1) promote optimal development, (2) educate Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and children and families about health conditions, (3) prepare children and external reviewers. However, policy statements from the American partner with families for medical events or procedures, (4) plan and rehearse Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. useful coping and pain-management strategies with patients and families, (5) The guidance in this statement does not indicate an exclusive course help children work through feelings about past or impending experiences, and of treatment or serve as a standard of medical care. Variations, taking (6) partner with families to establish therapeutic relationships between into account individual circumstances, may be appropriate. patients, siblings, and caregivers. Child life specialists collaborate with the All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, entire interdisciplinary team to promote coping and enhance the overall revised, or retired at or before that time. health care experience for patients and families. DOI: https://doi.org/10.1542/peds.2020-040261

Address correspondence to Barbara Romito, MA, CCLS. E-mail: [email protected] CHILD LIFE INTERVENTIONS: PSYCHOLOGICAL PREPARATION PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). This document is copyrighted and is property of the American Preparing children for hospitalization, clinic visits, surgeries, and Academy of Pediatrics and its Board of Directors. All authors have filed diagnostic and/or therapeutic procedures is essential during a child’s conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process hospitalization and an important element of a child life program. It is approved by the Board of Directors. The American Academy of estimated that 50% to 75% of children develop significant fear and Pediatrics has neither solicited nor accepted any commercial anxiety before surgery; recognized risk factors include age, temperament, involvement in the development of the content of this publication. baseline anxiety, past medical encounters, and caregiver anxiety.1 FINANCIAL DISCLOSURE: The authors have indicated they have no fi Children’s anxiety in the perioperative environment is associated with nancial relationships relevant to this article to disclose. impaired postoperative behavioral and clinical recovery, including increased analgesic requirements and delayed discharge from the To cite: Romito B, Jewell J, Jackson M, AAP COMMITTEE ON recovery room.2,3 Preparation can reduce anxiety and distress before HOSPITAL CARE; ASSOCIATION OF CHILD LIFE PROFESSIONALS. Child Life Services. Pediatrics. 2021;147(1):e2020040261 surgery and/or during mask induction and may also decrease emergence

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 147, number 1, January 2021:e2020040261 FROM THE AMERICAN ACADEMY OF PEDIATRICS – delirium after surgery.4 7 More than stay, a clearer understanding of Child life specialists can effectively 50 years of research and experience procedures, and a more positive provide developmentally appropriate supports 3 key elements of the physical recovery as well as nonpharmacologic pain management preparation process: (1) the provision posthospital adjustment for children and provide coaching and support to of developmentally appropriate enrolled.16 Patients spent less time on patients and caregivers before, information, (2) the encouragement narcotics, the length of stay was during, and after medical of questions and emotional slightly reduced, and caregivers were procedures.40,41 They can also expression, and (3) the formation of more satisﬁed. In other studies, provide valuable education and a trusting relationship with a health researchers have found that child life training to nurses, physicians, care professional.3 A recent interventions play a major role in students, and other personnel, systematic review of preparation calming children’s fears and result in supporting health care team member effectiveness evidence concluded that higher parent satisfaction ratings of competencies in the provision of children who were psychologically the entire care experience.8,17,18 developmentally appropriate, prepared for surgery experienced psychosocially sound care.42,43 fewer negative symptoms than did Multifaceted institution-wide children who did not receive formal CHILD LIFE INTERVENTIONS: protocols, such as the Ouchless Place preparation.3 Findings included PAIN-MANAGEMENT AND COPING and other similar programs, a decrease in posttraumatic stress, STRATEGIES incorporate the standard use of both lower levels of fear and anxiety, When combined with preparation and pharmacologic and increased cooperative behaviors, and appropriate pharmacologic nonpharmacologic techniques, better long-term coping and interventions, nonpharmacologic preparation of the patient and family, adjustment to future medical pain- and distress-management environmental considerations, and challenges. Research also strategies have proven successful in training of all health care team 44,45 demonstrates that preparation and terms of patient and family members. coping facilitation interventions experience, staff experience, and cost- Research has demonstrated that 17,19,20 decrease the need for sedation in effectiveness. Strategies such children are less fearful and procedures such as MRI and as swaddling, oral sucrose, vibratory distressed when positioned for radiotherapy, resulting in lower risks stimulation, breathing techniques, medical procedures in a sitting for the child and cost savings in relaxation, and guided imagery have position rather than supine.46 Child personnel, anesthesia, and been shown to decrease behavioral 8–12 life specialists are often involved in throughput-related expenses. distress and pain experience in facilitating the use of “comfort holds,” Preparation techniques, materials, children during invasive medical techniques for positioning children in 21–25 and language must be adapted to the procedures. a parent or caregiver’s lap or other developmental level, personality, and comforting position. In addition to Distraction strategies have been unique experiences of each child and reducing the child’s distress and highly effective in reducing reported family. Learning is enhanced with gaining cooperation, these techniques and observed pain and distress in hands-on methods versus exclusively generally require fewer staff to be children in inpatient, emergency verbal explanations. Photographs, present in the room, facilitate safe department (ED), and clinic diagrams, tours of surgical or – and effective accomplishment of the settings.26 32 The emergence of treatment areas, actual and pretend medical procedure, decrease parent virtual reality, Internet technology, medical equipment, and various anxiety, and increase parent and electronic and digital devices has 47,48 models (dolls, puppets) are used to satisfaction. With a goal to been found to be an effective means reinforce learning and actively engage – severely limit the use of papoose of distraction in reducing pain.7,33 38 the child.1,13 Caregivers should be boards and eliminate the practice of Child life specialists may also included in the preparation process multiple staff members holding develop comfort kits for use in because this can decrease parental a child down, these techniques treatment areas to include age- anxiety and allow them to provide provide a viable and more humane appropriate distraction items, such essential family-centered alternative in most cases. as bubbles, pop-up and sound books, support.14,15 light-up toys, and other visual or CHILD LIFE INTERVENTIONS: THE An experimental evaluation of one auditory tools.39 Distraction THERAPEUTIC VALUE OF PLAY child life program model revealed techniques have also been shown to that child life interventions resulted be successful in lowering a parent’s Therapeutic play during health care in less emotional distress, better fear and distress during an invasive experiences is essential and a major overall coping during the hospital procedure.27 component of a child life program and

Downloaded from www.aappublications.org/news by guest on September 25, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS of the child life professional’s role. reason video games are so popular is easily transmitted to the patient.64 Play is crucial to a child’s social, with this age group56). Patients in this Child life specialists help facilitate the emotional, and cognitive age group also benefit from activities family’s adjustment to the child’s development and is even more that allow them to maintain illness and health care experience by critical during adversity or stress relationships with peers and establish providing psychosocial support and points in a child’s life.49 In addition to new connections through, for coping strategies for caregivers. They its developmentally supportive example, online networking and the can help family members understand benefits and as a normalizing activity availability of teen-aged activity their child’s response to treatment for children and youth of all ages, play rooms in the hospital setting.57 and support caregiving roles by is particularly valuable for children promoting parent-child play sessions Auxiliary programs, such as animal- who are anxious or struggling to cope and sharing strategies for comforting assisted therapy, infant massage with stressful circumstances of or coaching their children during instruction, therapeutic clowning, hospitalization, illness, or grief.50 Erik performing arts, and artist-in- medical procedures. In addition, child Erikson51 writes, “To play out is the residence programs, often used in life specialists play a pivotal role in most natural auto-therapeutic conjunction with child life services and encouraging and facilitating family measure childhood affords. Whatever ’ incorporated into child life involvement in the patient s care as other roles play may have in the departments, provide additional well as promoting communication child’s development…the child uses it outlets for patients of all ages and between family members, providers, to make up for defeats, sufferings, and – their families.58 60 Live, interactive and the interdisciplinary team. frustrations.” Play in the health care programming using closed-circuit setting is adapted to address unique Siblings of pediatric patients present television systems and studios can be needs on the basis of developmental with their own unique anxieties and a particularly effective way to engage level, self-directed interests, medical psychosocial needs, not often patients restricted to their rooms for condition and physical abilities, assessed or addressed. Siblings, much infection-control or medical reasons. psychosocial vulnerabilities, and like children of adult patients, can be Other interactive technology, such as setting (eg, bedside, playroom, clinic). helped to comprehend a family video conferencing, can help patients Play as a therapeutic modality, member’s illness via therapeutic play engage with people outside the including health care play or “medical and educational interventions or by hospital, including their peers, the play,” has been found to reduce offering support during hospital community, and their schools. The children’s emotional distress and help visits, including diagnoses, critical ability to connect with a child’sschool, them cope with medical care, and end-of-life situations.65,66 community, and home helps normalize experiences.52 Research has revealed Although sibling support is essential the experience by minimizing that physiologic responses, such as in all areas, a critical care disruption of usual routines. palm sweating, excessive body hospitalization in the neonatal or Expressive therapies, such as those movement, tachycardia, and pediatric ICU presents additional provided by distinctly certified play hypertension, can be reduced with stressors for the entire family, and therapists, music therapists, and art therapeutic play interventions.53 child life interventions are often therapists, can be offered to focused on the siblings’ psychosocial Play can be adapted to address the complement child life programs and to needs. Sibling support may include developmental and psychosocial needs provide support for particularly preparing the sibling(s) for an initial of patients in every pediatric age vulnerable patients.26,61,62 visit and providing ongoing emotional group. For example, infants and support throughout the patient’s toddlers benefit from exploratory and CHILD LIFE INTERVENTIONS: hospital stay. Child life specialists are sensorimotor play, and preschoolers PARTNERING WITH FAMILIES TO often involved in providing enjoy fantasy play and creative art PROVIDE SUPPORT bereavement support to patients as activities.54 Opportunities for parents The presence and participation of and well as siblings and other family to engage in play activities with their partnership with family members is members. Grief support and legacy young children are beneficial to both a fundamental component of patient- activities, such as hand molds or the patient and family, alleviating some and family-centered care and has memory boxes for siblings and family feelings of helplessness that can be a significant positive effect on members, are often provided at the common in caregivers and assisting in a child’s adjustment to the health care end of life for both pediatric and adult the child’s adjustment to the hospital.55 experience.63 When parents or other patients throughout the hospital. In School-aged children and adolescents family members are highly anxious conjunction with the interdisciplinary seek play that contributes to feelings about the child’s illness or diagnostic team, child life specialists are critical of mastery and achievement (one and treatment regimens, such anxiety in helping all family members

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 147, number 1, January 2021 3 understand how to support children using the shift length as the The remaining 3 areas, inpatient acute in age-appropriate ways during end- denominator, additional nonpatient care, outpatient ambulatory clinics, of-life events. care responsibilities are accounted for and critical care units, all have similar in the productivity calculation, productivity, with approximately 1 including such things as meetings, patient encounter per hour, or 8 in an RECENT BENCHMARKING DATA committee work, student and staff 8-hour shift. In 2016, the Association of Child Life education, and donor events.67 The productivity data allow Professionals (ACLP) constructed the participating hospitals to clearly Child Life Professional Data Center Figure 1 identifies the total number of identify how their program compares (CLPDC), an online database to house individual patient and family to the national average or similar comprehensive child life program data encounters an individual child life hospitals on the basis of median and metrics, including staffing models, specialist provides in an 8-hour shift scores. The data also serve as a tool to staffing ratios, budget allocation data, in each of the 6 service areas. In support appropriate staffing during and hospital descriptors.67 Using radiology, the median productivity is hospital program growth by offering a systematic and evidence-based 0.74 patient encounters per hour, or a benchmark to adjust staffing approach to measure the impact of approximately 6 encounters in an 8- depending on changes in patient psychosocial services provided to hour day. Of all 6 areas of service, volumes. pediatric patients and families, this radiology encounters trend the longest database has synthesized information because radiologic procedures often Although these ratios establish from more than 160 child life require significant preparation and national benchmarking and staffing programs. In addition, the ACLP support during the procedures, which trends, other factors should influence established a productivity metric may be lengthy. Child life specialists in staffing allocations. Child life services measuring the number of patient and presurgery and the ED have the should be available to meet identified family encounters a child life specialist highest median productivity, with an patient and family needs 7 days per provides in a specified setting within average of 1.2 patient encounters week. Staffing plans should be the hospital during a shift. Currently, every hour, roughly 10 patients seen sufficient to meet fluctuations in more than 50 programs have per 8-hour shift in each of these areas. anticipated and unanticipated staff participated in the productivity data absences, seasonal swings in the collection. The productivity metric is patient census, and nonclinical a numerical indicator of the number of Radiology community activities (such as school patient and family encounters that can Presurgery programming, outreach events, and be expected during the child life increased visits and in-kind donations specialist’s shift. This measure of ED during the holiday season). Child productivity is collected for 6 distinct Inpaent variables (such as age, temperament, areas of service: (1) inpatient acute coping style, and cognitive abilities), Outpaent care units, (2) critical care, (3) family variables (such as caregiver radiology, (4) presurgery, (5) Crical care anxiety, presence, and involvement) outpatient ambulatory care, and (6) and diagnosis and treatment variables the ED. These 6 distinct areas are (acute versus chronic, repeat 10 being used to collect and segment data admissions, number of invasive because the type and length of child 8 procedures) are known to affect life intervention can depend on which psychosocial vulnerability and, thus, medical service is being provided. A 6 influence the child’s particular child patient encounter is defined as a child life needs.68 A combination of life specialist–provided interaction 4 psychosocial risk assessment, medical with a patient, sibling, or caregiver, and/or treatment variables (eg, the and this serves as the numerator of 2 proportion of patients on isolation the productivity metric. The precautions and the volume of patient denominator is the length of the child 0 and family teaching needs), and the life specialist’s shift (eg, 8 hours). The Paent Encounters per 8-Hour time requirements associated with final metric given is the measure of Shi particular interventions directly affect patient and family encounters per operational staff-to-patient ratios in FIGURE 1 hour. These metrics account for both inpatient and outpatient settings Average patient/family encounters per 8-hour nondirect patient care activities and shift for child life specialists in various hospital and could necessitate a lower ratio of direct patient care interventions. By settings. patients to child life specialist.69,70

Downloaded from www.aappublications.org/news by guest on September 25, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS In addition to establishing a CCLS; and passing a standardized The scope of child life programs has a benchmarking standard for child certification examination.71 Ongoing developed beyond pediatric inpatient life specialist and patient encounters, and future requirements for the CCLS acute care settings to include the CLPDC houses multifaceted credential are determined by the Child outpatient and other areas in which information, such as types of Life Certification Commission of child life expertise can be effectively organizations in which child life the ACLP. applied to support children and specialists work, staffing, program families in stressful situations. Child funding, reporting structure, services In some settings, child life services are life specialists provide services to provided, and special services. The augmented by child life assistants (or presurgery and surgical centers, CLPDC should be used as a resource activity coordinators, child life radiology and imaging departments, for programs and hospitals in technicians, etc). Child life assistants dialysis centers, ambulatory clinics, evaluation and continuous are typically required to have core NICUs, urgent care centers, performance improvement of child college coursework, such as an psychiatric units, hospice programs, life programming. associate degree in child development, camps for children with chronic and experience with children in group illness, rehabilitation settings, and settings. They generally focus on the some outpatient dental and physician CHILD LIFE STAFFING AND ROLES normalization of the health care offices.76 Because the majority of experience, providing play activities, children with medical complexities Child life specialists are part of an coordinating special events interdisciplinary, patient- and family- are being treated on an outpatient (community visitors, holiday basis, child life services are centered model of care, collaborating celebrations, etc), and maintaining the with the family, physicians, advanced increasingly common outside the playroom environment. Both child life hospital.77 Increasingly, CCLSs are practice providers, nurses, social specialists and assistants actively workers, and other members of the also part of interdisciplinary health participate in the orientation, training, care teams, including palliative care, health care team to develop and supervision of volunteers, thereby a comprehensive plan of care. Child behavioral health, trauma, and child contributing to volunteer effectiveness, protective services. In cases of life contributions to this plan are satisfaction, and retention. This ’ ’ hospitalized or ill adults, child life based on the patient s and family s collaboration enables the child life psychosocial needs, cultural heritage, specialists may be consulted to work specialist to conduct an assessment with children of adult patients, and responses to the health care and delegate as appropriate, allowing experience. Child life specialists can particularly in end-of-life, trauma, patients with varying degrees of and critical care situations. participate in the care plan by, for psychosocial vulnerability and activity example, teaching a child coping levels to be supported by the team Child life programs continue to evolve strategies for adjusting to a life- member whose skills and knowledge and adapt to meet the changing health changing injury, promoting coping are most closely aligned with patient care needs of patients and families. with examinations for alleged abuse, and family needs. Although volunteers Children with special health care assisting families in talking to their are a valuable supplement, they can needs now represent 18.8% of all children about death, facilitating never be considered an adequate children, up from 12.8% in 2001.78 nonpharmacologic pain-management replacement for CCLSs. Specifically, the increase in patients techniques, preparing and educating with a diagnosis of autism spectrum children about their medical care in disorder presents opportunities for age-appropriate ways, and EVOLUTION OF CHILD LIFE SERVICES child life specialization in supporting communicating the child’s this population in medical developmental and individual needs The provision of child life services is settings.36,79,80 In addition, the and perspective to others. These a quality benchmark of an integrated number of children with mental health interventions are most effective when patient- and family-centered health and developmental disabilities delivered in collaboration with the care system, a recommended conditions is increasing, either alone entire health care team. component of medical education, and an indicator of excellence in pediatric or comorbid with a physical health The credentials of a certified child life care.72–74 There are more than 430 condition.81,82 Hospitals are also specialist (CCLS) currently include the child life programs in operation in admitting children with more complex minimum of a bachelor’s degree in North America75; most are located in medical conditions, with rates child life, child development, or freestanding children’s hospitals, doubling between 1991 and 2005, and acloselyrelatedfield; the successful children’s hospitals within hospitals, may need greater individualization of completion of a 600-hour child life community hospitals with pediatric care from the CCLS.83,84 The numbers internship under the supervision of units, and EDs. of children with disabilities and

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 147, number 1, January 2021 5 medical complexities are increasing, Although evidence supports the value from the hospital to the home setting likely because of the increases in of child life services, financial less disruptive. Child life specialists technology that ensures the survival of pressures in many health care also provide services outside patients with previously lethal settings have threatened the growth hospital-based settings, including conditions.85 Given the increasing and sustainability of child life private practice, community agencies, survival rate of patients with cystic services. In addition to contributions and hospice care, and are becoming fibrosis, cardiac conditions, spina to the patient experience, the increasingly involved in providing bifida, short gut, cancer, and other literature has also demonstrated support to children and families chronic illnesses, more teenagers and financial benefits of child life during catastrophic events. young adults face the challenging interventions, including reduced transition to adult health care.86 sedation-related costs, and increased For hospitals or other health care Acknowledging team goals to compliance during procedures, settings considering the initiation or normalize the transition process and resulting in procedure expansion of child life services, the – address patient and family anxieties or completion.8 12 A child life program ACLP offers a consultation service to questions, child life specialists can improves quality and decreases costs support existing program review and assist in this transition by providing and, therefore, should be included in development, new program startup, the value-added equation and interdisciplinary education, and education and helping patients to 94 communicate their needs, fears, hopes, discussion of health care cost, written practice guidelines. In and expectations.87–89 including with payers. community hospital settings with few pediatric beds and minimal pediatric In recent years, patient experience outpatient or ED visits, the provision ADDITIONAL CONSIDERATIONS and/or patient satisfaction has of full-time child life services may not fi become a key quality and Child life services contribute to an be nancially feasible. In such cases, performance indicator. Although the organization’s efforts to meet the part-time or consultative services of definition of patient experience standards set forth by The Joint a CCLS may be obtained to assist in continues to be explored and honed Commission and other accreditation the ongoing education of staff, by health care leaders, there is agencies, including effective students, and volunteers as well as to common agreement that when communication, patient- and family- advise on a psychosocially sound, evaluating health care quality, patient centered care, age-specific developmentally appropriate patient- satisfaction is an important metric competencies, and cultural and family-centered approach to care. that translates to health care ratings competence.92 Child life specialists’ The advancement of telemedicine and payment.90 Family-centered care psychosocial and developmental also presents an opportunity for child is a core principle for child life expertise and their keen awareness of life specialists to intervene when they specialists; the recent emergence of the benefits of patient- and family- cannot be on-site. Advocating for the patient experience as a key centered care provide a useful child life services as an essential part quality indicator has resulted in child perspective at a systems level. Child of the interdisciplinary team is life specialists often taking the lead in life input is often incorporated into a responsibility of health care family-centered care and patient hospital committees, such as ethics, organizations to ensure it is experience initiatives. Research family-centered care, patient a standard of pediatric care and studies have demonstrated the experience, safety, environmental should occur on local and national positive impact of child life design, bereavement, and strategic levels as well as in regulatory and intervention on patient and parent planning. Child life expertise has accrediting organizations. perception and evaluation of the applications beyond conventional hospital experience, which is hospital care. Interventions can help CONCLUSIONS increasingly important for incentive- children transition back to their based reimbursement, accreditation, homes, schools, communities, and Child life services are associated with marketing, and public reporting of medical homes.11,93 Child life improved quality, outcomes, and outcomes.8,17,34,67,91 Health care specialists often collaborate with patient and family experiences as well professionals and organizations local school districts to arrange as decrease costs in pediatric care. acknowledge the significant impact hospital or homebound education, There is evidence that child life child life specialists have on the and hospital-based teachers may be services help to contain costs by patient experience as well as the role incorporated into child life program reducing the length of stay, child life plays in helping the concept administration. These interventions decreasing the need for sedation and of patient experience continue to help provide continued normalization analgesics, and increasing patient evolve and grow.80 and help make the transition to and satisfaction ratings. Patient

Downloaded from www.aappublications.org/news by guest on September 25, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS experience data and interdisciplinary 4. Child life services staffing must be AAP COMMITTEE ON HOSPITAL CARE, team member feedback further individualized to address the 2018–2019 confirm the positive effects of child needs of specific inpatient and Jennifer Jewell, MD, FAAP, Chairperson life programs on children, families, outpatient areas. The ratio of child Kimberly Ernst, MD, MSMI, FAAP and staff. It remains essential for life specialist to patient should be Vanessa Hill, MD, FAAP Benson Hsu, MD, FAAP – Section on child life services to adapt and grow adjusted to account for the Critical Care ’ with the changing health care patient s medical, psychosocial, Vinh Lam, MD, FAAP delivery system in support of the and developmental complexity and Melissa Mauro-Small, MD, FAAP – Section on highest possible quality of care for vulnerability as well as family Hospital Medicine children and their families. needs and preferences. Child life Charles Vinocur, MD, FAAP services need to continuously RECOMMENDATIONS evolve to meet the changing needs FORMER COMMITTEE ON HOSPITAL CARE in pediatric health care, including MEMBER, 2017–2018 1. Child life collaboration with the the significant increases in entire interdisciplinary team is Daniel A. Rauch, MD, FAAP children with disabilities and essential to meeting the overall medical complexity. health care needs of children and LIAISONS 5. Child life services optimize families. Karen Castleberry – Family Representative pediatric health care and, – Children’s Hospital 2. Child life services are part of an Nancy Hanson therefore, should be included in Association integrated patient- and family- the hospital operating budget; they Kristin Hittle Gigli, PhD, RN, CPNP-AC, CCRN centered model of care and can be cannot solely rely on contingency – National Association of Pediatric Nurse used as a quality measure in the Practitioners or philanthropic funding. delivery of health care services for Michael S. Leonard, MD, MS, FAAP – Representative to The Joint Commission children and families. 6. Legislative advocacy of child life services by pediatricians and other Barbara Romito, MA, CCLS – Association of 3. Child life services, provided directly Child Life Professionals stakeholders is recommended at by CCLSs, are recommended in the state and federal levels. pediatric inpatient units, EDs, STAFF chronic care centers, and other 7. Additional research is needed to diagnostic and treatment areas to further identify the impact of child S. Niccole Alexander, MPP the extent appropriate for the life services on patient care population served. In hospitals outcomes, including patient ABBREVIATIONS with a small number of inpatient or experience, cost-effectiveness, and quality and safety measures. outpatient pediatric visits, ongoing ACLP: Association of Child Life consultation with a CCLS is needed Professionals to educate health care team CCLS: certified child life specialist members and support LEAD AUTHORS CLPDC: Child Life Professional developmentally appropriate Barbara Romito, MA, CCLS Data Center patient- and family-centered Jennifer Jewell, MD, FAAP ED: emergency department practice. Meredith Jackson, MD, FAAP

FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conﬂicts of interest to disclose.

REFERENCES 1. William Li HC, Lopez V, Lee TLI. Effects of Anesthesiol Clin North Am. 2005;23(4): research-ebp/ebp-statements.pdf? preoperative therapeutic play on 597–614, vii sfvrsn=2. Accessed November 5, 2020 outcomes of school-age children 3. Koller D. Child Life Council Evidence- 4. Vantaa Benjaminsson M, Thunberg G, undergoing day surgery. Res Nurs Based Practice Statement: Preparing Nilsson S. Using picture and text Health. 2007;30(3):320–332 Children and Adolescents for Medical schedules to inform children: effects on 2. Kain ZN, Caldwell-Andrews AA. Procedures. Rockville, MD: Child Life distress and pain during needle-related Preoperative psychological preparation Council; 2009. Available at: https://www. procedures in nitrous oxide sedation. of the child for surgery: an update. childlife.org/docs/default-source/ Pain Res Treat. 2015;2015:478503

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 147, number 1, January 2021 7 5. Brewer S, Gleditsch SL, Syblik D, Tietjens procedural anxiety and behavioral 25. Lipsitz JD, Gur M, Albano AM, Sherman ME, Vacik HW. Pediatric anxiety: child life distress. Epilepsy Behav. 2013;27(1): B. A psychological intervention for intervention in day surgery. J Pediatr 169–173 pediatric chest pain: development and Nurs. 2006;21(1):13–22 15. He HG, Zhu L, Chan SWC, Klainin-Yobas P, open trial. J Dev Behav Pediatr. 2011; 32(2):153–157 6. Fortier MA, Bunzli E, Walthall J, et al. Wang W. The effectiveness of therapeutic play intervention in reducing Web-based tailored intervention for 26. Nguyen TN, Nilsson S, Hellström AL, perioperative anxiety, negative preparation of parents and children for Bengtson A. Music therapy to reduce behaviors, and postoperative pain in outpatient surgery (WebTIPS): formative pain and anxiety in children with cancer children undergoing elective surgery: evaluation and randomized controlled undergoing lumbar puncture: trial. Anesth Analg. 2015;120(4):915–922 a systematic review. Pain Manag Nurs. – a randomized clinical trial. J Pediatr 2015;16(3):425 439 – 7. Lan YP, Huang ZH, Finley GA, Zuo YX. Oncol Nurs. 2010;27(3):146 155 Effects of the combination of mask 16. Wolfer J, Gaynard L, Goldberger J, Laidley LN, Thompson R. An experimental 27. Burgess S, Nativio DG, Penrose JE. preconditioning with midazolam evaluation of a model child life program. Quality improvement project to reduce pretreatment on anxiety and mask Child Health Care. 1988;16(4):244–254 pain and distress associated with acceptance during pediatric inhalational immunization visits in pediatric primary induction and postoperative mask fear 17. Gursky B, Kestler LP, Lewis M. care. J Pediatr Nurs. 2015;30(2):294–300 in children. [published correction Psychosocial intervention on procedure- appears in Chin Med J (Engl). 2016; related distress in children being 28. Canbulat N, Inal S, Sönmezer H. Efficacy 129(12):1463]. Chin Med J (Engl). 2012; treated for laceration repair. JDev of distraction methods on procedural 125(11):1908–1914 Behav Pediatr. 2010;31(3):217–222 pain and anxiety by applying distraction cards and kaleidoscope in children. 18. Madhok M, Milner D, Teele M, Finkelstein 8. Törnqvist E, Månsson Å, Hallström I. Asian Nurs Res (Korean Soc Nurs Sci). Children having magnetic resonance M. Child life services and patient 2014;8(1):23–28 imaging: a preparatory storybook and satisfaction in emergency department audio/visual media are preferable to [abstract]. Pediatr Emerg Care. 2007; 29. Hedén L, VON Essen L, Ljungman G. anesthesia or deep sedation. JChild 23(10):764 Randomized interventions for needle – Health Care. 2015;19(3):359 369 19. Cohen LL. Behavioral approaches to procedures in children with cancer. Eur J Cancer Care (Engl). 2009;18(4): 9. Khan JJ, Donnelly LF, Koch BL, Curtwright anxiety and pain management for 358–363 LA, Dickerson JM, Hardin JL. A program pediatric venous access. Pediatrics. to decrease the need for pediatric 2008;122(suppl 3):S134–S139 30. Inal S, Kelleci M. Distracting children sedation for CT and MRI. Appl Radiol. 20. Eldridge C, Kennedy R. during blood draw: looking through – 2007;36(4):30 33 Nonpharmacologic techniques for distraction cards is effective in pain 10. Scott MT, Todd KE, Oakley H, et al. distress reduction during emergency relief of children during blood draw. Int – Reducing anesthesia and health care medical care: a review. Clin Pediatr JNursPract. 2012;18(2):210 219 – cost through utilization of child life Emerg Med. 2010;11(4):244 250 31. Sadeghi T, Mohammadi N, Shamshiri M, specialists in pediatric radiation 21. Srouji R, Ratnapalan S, Schneeweiss S. Bagherzadeh R, Hossinkhani N. Effect of oncology. Int J Radiat Oncol Biol Phys. Pain in children: assessment and distraction on children’spainduring – 2016;96(2):401 405 nonpharmacological management. Int intravenous catheter insertion. JSpec 11. Grissom S, Boles J, Bailey K, et al. Play- J Pediatr. 2010;2010:474838 Pediatr Nurs. 2013;18(2):109–114 based procedural preparation and 22. Uman LS, Chambers CT, McGrath PJ, 32. Ha YO, Kim HS. The effects of audiovisual support intervention for cranial Kisely S. Psychological interventions for distraction on children’spainduring radiation. Support Care Cancer.2016; needle-related procedural pain and laceration repair. Int J Nurs Pract. 2013; – 24(6):2421 2427 distress in children and adolescents. 19(suppl 3):20–27 12. Durand DJ, Young M, Nagy P, Tekes A, Cochrane Database Syst Rev.2006;(4): 33. Brown NJ, Kimble RM, Rodger S, Ware Huisman TAGM. Mandatory child life CD005179 RS, Cuttle L. Play and heal: randomized consultation and its impact on pediatric 23. Baxter AL, Cohen LL, McElvery HL, controlled trial of DittoTM intervention MRI workflow in an academic medical Lawson ML, von Baeyer CL. An efficacy on improving re-epithelialization center. J Am Coll Radiol. 2015;12(6): integration of vibration and cold relieves in pediatric burns. Burns. 2014;40(2): 594–598 venipuncture pain in a pediatric 204–213 13. Goldberger J, Mohl AL, Thompson R. emergency department. Pediatr Emerg 34. Shahid R, Benedict C, Mishra S, Mulye M, Psychological Preparation and Coping. Care. 2011;27(12):1151–1156 Guo R. Using iPads for distraction to In: Thompson RH, ed. The Handbook of 24. Berberich FR, Landman Z. Reducing reduce pain during immunizations. Clin Child Life: A Guide for Pediatric immunization discomfort in 4- to 6-year- Pediatr (Phila). 2015;54(2):145–148 Psychosocial Care, 1st ed. Springfield, IL: old children: a randomized clinical trial. Charles C Thomas; 2009:160–198 Pediatrics. 2009;124(2). Available at: 35. Nilsson S, Renning AC. Pain management 14. Benore E, Enlow T. Improving pediatric www.pediatrics.org/cgi/content/full/124/ during wound dressing in children. Nurs compliance with EEG: decreasing 2/e203 Stand. 2012;26(32):50–55

Downloaded from www.aappublications.org/news by guest on September 25, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS 36. Isong IA, Rao SR, Holiﬁeld C, et al. 47. Stephens BK, Barkey ME, Hall HR. 57. Nicholas DB, Darch J, McNeill T, et al. Addressing dental fear in children with Techniques to comfort children during Perceptions of online support for autism spectrum disorders: stressful procedures. Adv Mind Body hospitalized children and adolescents. a randomized controlled pilot study Med. 1999;15(1):49–60 Soc Work Health Care. 2007;44(3): 205–223 using electronic screen media. Clin 48. Sparks LA, Setlik J, Luhman J. Parental – Pediatr (Phila). 2014;53(3):230 237 holding and positioning to decrease IV 58. Rollins JA. The Arts in Children’s 37. Borges L, Huber D, Lugo S. Harnessing distress in young children: Health-Care Settings. In: Rollins JA, Bolig the power of digital devices. Pediatr a randomized controlled trial. J Pediatr R, Mahan C, eds. Meeting Children’s Nurs. 2011;37(2):88 Nurs. 2007;22(6):440–447 Psychosocial Needs Across the Health-Care Continuum,1sted.Austin, 49. Yogman M, Garner A, Hutchinson J, 38. Nilsson S, Finnström B, Kokinsky E, TX: Pro-Ed; 2005:119–174 Enskär K. The use of virtual reality for Hirsh-Pasek K, Golinkoff RM; Committee needle-related procedural pain and on Psychosocial Aspects of Child and 59. Kaminski M, Pellino T, Wish J. Play and distress in children and adolescents in Family Health; Council on pets: the physical and emotional impact a paediatric oncology unit. Eur J Oncol Communications and Media. The power of child-life and pet therapy on Nurs. 2009;13(2):102–109 of play: a pediatric role in enhancing hospitalized children. Child Health Care. development in young children. 2002;31(4):321–335 39. Blaine S. The where, why and how: Pediatrics. 2018;142(3):e20182058 60. Heilbrunn BR, Wittern RE, Lee JB, Pham coping kits and distraction. Child Life 50. Brown CD. Therapeutic Play and Creative PK, Hamilton AH, Nager AL. Reducing Focus. 1999;1(1):1–6 Arts: Helping Children Cope with Illness, anxiety in the pediatric emergency 40. Bandstra NF, Skinner L, Leblanc C, et al. Death, and Grief. In: Armstrong-Dailey A, department: a comparative trial. The role of child life in pediatric pain Zarbock S, eds. Hospice Care for J Emerg Med. 2014;47(6):623–631 management: a survey of child life Children, 3rd ed. New York, NY: Oxford 61. Avers L, Mathur A, Kamat D. Music specialists. J Pain. 2008;9(4):320–329 University Press; 2009:305–338 therapy in pediatrics. Clin Pediatr 41. Heckler-Medina GA. The importance of 51. Erikson EH. Studies in the interpretation (Phila). 2007;46(7):575–579 of play: clinical observation of play child life and pain management during 62. Councill T. Medical Art Therapy with disruption in young children. Genet vascular access procedures in Children. In: Malchiodi C, ed. Handbook Psychol Monogr. 1940;22:557–671 pediatrics. Journal of the Association of Art Therapy,1sted.NewYork,NY: – for Vascular Access. 2006;11(3):144 151 52. Fereday J, Darbyshire P. Making the wait Guilford Press; 2003:207–219 easier: evaluating the role of supervised 42. Lawes C, Sawyer L, Amos S, Kandiah M, 63. Committee on Hospital Care, American play in a surgical admission area. Pearce L, Symons J. Impact of an Academy of Pediatrics. Family-centered Neonatal, Paediatric and Child Health education programme for staff working care and the pediatrician’srole. Nursing. 2008;11(1):4–9 with children undergoing painful Pediatrics. 2003;112(3, pt 1):691–697 procedures. Paediatr Nurs. 2008;20(2): 53. Koller D. Child Life Council Evidence- 64. Lewindowski L, Baranowski MV. 33–37 Based Practice Statement: Therapeutic Psychological aspects of acute trauma: Play in Pediatric Health Care: The 43. Pederson C. Nonpharmacologic intervening with children and families in Essence of Child Life Practice.Rockville, interventions to manage children’spain: the inpatient setting. Child Adolesc MD: Child Life Council; 2009. Available at: immediate and short-term effects of Psychiatr Clin N Am. 1994;3(3):513–529 https://www.childlife.org/docs/default- a continuing education program. source/research-ebp/ebp-statements. 65. Gursky B. The effect of educational JContinEducNurs. 1996;27(3):131–140 pdf?sfvrsn=2. Accessed November 5, interventions with siblings of 44. Schechter NL. From the ouchless place 2020 hospitalized children. J Dev Behav Pediatr. 2007;28(5):392–398 to comfort central: the evolution of 54. Hughes FP. Children, Play, and a concept. Pediatrics. 2008;122(suppl 3): Development, 4th ed. Thousand Oaks, CA: 66. Prchal A, Graf A, Bergstraesser E, – S154 S160 SAGE Publications, Inc; 2010 Landolt MA. A two-session psychological intervention for siblings of pediatric 45. Leahy S, Kennedy RM, Hesselgrave J, 55. Melnyk BM, Alpert-Gillis L, Feinstein NF, cancer patients: a randomized Gurwitch K, Barkey M, Millar TF. On the et al. Creating opportunities for parent controlled pilot trial. Child Adolesc front lines: lessons learned in empowerment: program effects on the Psychiatry Ment Health. 2012;6(1):3 implementing multidisciplinary mental health/coping outcomes of peripheral venous access pain- critically ill young children and their 67. Association of Child Life Professionals. management programs in pediatric mothers. Pediatrics. 2004;113(6). Child Life Professional Data Center. hospitals. Pediatrics. 2008;122(suppl 3): Available at: www.pediatrics.org/cgi/ Available at: https://www.childlife.org/ S161–S170 content/full/113/6/e597 resources/for-child-life-specialists/childlife-professional-data-center. Accessed 46. Lacey CM, Finkelstein M, Thygeson MV. 56. Olson CK. Children’s motivations for May 1, 2018 The impact of positioning on fear during video game play in the context of normal immunizations: supine versus sitting up. development. Rev Gen Psychol.2010; 68. Koller D. Child Life Council Evidence- J Pediatr Nurs. 2008;23(3):195–200 14(2):180–187 Based Practice Statement: Child Life

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 147, number 1, January 2021 9 Assessment: Variables Associated With Available at: http://community.childlife. approaches. Pediatrics. 2002;110(6, pt aChild’s Ability to Cope with org. Accessed May 1, 2018 2):1315–1321 Hospitalization. Rockville, MD: Child Life 76. Hicks M, ed.. Child Life Beyond the Council; 2009. Available at: https://www. 87. Cooley WC, Sagerman PJ; American Hospital, 1st ed. Rockville, MD: Child Life Academy of Pediatrics; American childlife.org/docs/default-source/ Council; 2008 research-ebp/ebp-statements.pdf? Academy of Family Physicians; American sfvrsn=2. Accessed November 5, 2020 77. Berry JG, Hall M, Neff J, et al. Children College of Physicians; Transitions with medical complexity and Medicaid: Clinical Report Authoring Group. 69. Turner JC, Fralic J. Making explicit the spending and cost savings. Health Aff Supporting the health care transition implicit: child life specialists talk about (Millwood). 2014;33(12):2199–2206 from adolescence to adulthood in the their assessment process. Child Youth medical home. Pediatrics. 2011;128(1): – 78. Centers for Disease Control and Care Forum. 2009;38:39 54 182–200 Prevention. National survey of children 70. Hollon E, Skinner L. Assessment and with special health care needs. Available Documentation in Child Life. In: 88. Transitioning Youth to an Adult Health at: https://www.cdc.gov/nchs/slaits/ Thompson R, ed. TheHandbookofChild Care Clinician. Available at: https:// cshcn.htm. Accessed October, 2018 Life: A Guide for Pediatric Psychosocial gottransition.org/six-core-elements/ Care, 1st ed. Springfield, IL: Charles C 79. Seid M, Sherman M, Seid AB. transitioning-youth-to-adult/. Accessed Thomas; 2009:116–135 Perioperative psychosocial interventions November 5, 2020 for autistic children undergoing ENT 71. Child Life Council, Child Life Certifying 89. Orkoskey N. Transitioning Patients with surgery. Int J Pediatr Otorhinolaryngol. Committee. Child Life Professional Cystic Fibrosis from Pediatric to Adult 1997;40(2–3):107–113 Certification Candidate Manual. Care: A Lifelong Process. Rockville, MD: Rockville, MD: Child Life Council; 2011. 80. The Beryl Institute. What patient Child Life Council; 2009 Available at: https://www.childlife.org/ experience can learn from child life. docs/default-source/certification/ Available at: https://www. 90. Wolf JA, Niederhauser V, Marshburn D, fi candidate-manual.pdf?sfvrsn=10. theberylinstitute.org/store/ViewProduct. LaVela SL. De ning patient experience. – Accessed November 5, 2020 aspx?id=11084124. Accessed May 1, 2018 Patient Exp J. 2014;1(1):7 19 72. National Association of Children’s 81. Perou R, Bitsko RH, Blumberg SJ, et al.; 91. Tyson ME, Bohl DD, Blickman JG. A Hospitals and Related Institutions. Centers for Disease Control and randomized controlled trial: child Pediatric Excellence in Health Delivery Prevention (CDC). Mental health life services in pediatric imaging. Systems. Alexandria, VA: National surveillance among children–United Pediatr Radiol. 2014;44(11):1426– Association of Children’s Hospitals and States, 2005-2011. MMWR Suppl.2013; 1432 Related Institutions; 1996:9–10 62(2):1–35 92. The Joint Commission. Advancing 73. Accreditation Council for Graduate 82. Houtrow AJ, Larson K, Olson LM, Effective Communication, Cultural Medical Education. Program Newacheck PW, Halfon N. Changing Competence, and Patient- and Family- Requirements for Graduate Medical trends of childhood disability, 2001-2011. Centered Care: A Roadmap for Education in Pediatrics.Chicago,IL: Pediatrics. 2014;134(3):530–538 Hospitals. Oakbrook Terrace, IL: The Accreditation Council for Graduate 83. Burns KH, Casey PH, Lyle RE, Bird TM, Joint Commission; 2010. Available at: Medical Education; 2007. Available at: Fussell JJ, Robbins JM. Increasing www.jointcommission.org/Advancing_ https://www.acgme.org/Portals/0/ prevalence of medically complex Effective_Communication/. Accessed PFAssets/ProgramRequirements/320_ children in US hospitals. Pediatrics. May 1, 2018 Pediatrics_2020.pdf?ver=2020-06-29- 2010;126(4):638–646 162726-647. Accessed November 5, 2020 93. Medical Home Initiatives for Children 84. Simon TD, Berry J, Feudtner C, et al. With Special Needs Project Advisory 74. Olmstead MG, Powell R, Murphy J, et al. Children with complex chronic Methodology: US News & World Report Committee, American Academy of conditions in inpatient hospital settings Best Children’s Hospitals 2019–2020. Pediatrics. The medical home. in the United States. Pediatrics. 2010; Research Triangle Park, NC: RTI Pediatrics. 2002;110(1, pt 1): 126(4):647–655 – International; 2019. Available at: https:// 184 186 www.usnews.com/static/documents/ 85. Kuo DZ, Houtrow AJ; Council on Children 94. Association of Child Life Professionals. health/best-hospitals/BCH_ With Disabilities. Recognition and Program review and development Methodology_2019-20.pdf. Accessed management of medical complexity. services. Available at: https://www. Pediatrics. 2016;138(6):e20163021 November 5, 2020 childlife.org/resources/for-child-life- 75. Association of Child Life Professionals. 86. Scal P. Transition for youth with chronic specialists/program-review. Accessed Directory of child life programs. conditions: primary care physicians’ November 5, 2020

Downloaded from www.aappublications.org/news by guest on September 25, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS Child Life Services Barbara Romito, Jennifer Jewell, Meredith Jackson and AAP COMMITTEE ON HOSPITAL CARE; ASSOCIATION OF CHILD LIFE PROFESSIONALS Pediatrics originally published online December 28, 2020;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2020/12/24/peds.2 020-040261 References This article cites 69 articles, 13 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2020/12/24/peds.2 020-040261#BIBL Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 25, 2021 Child Life Services Barbara Romito, Jennifer Jewell, Meredith Jackson and AAP COMMITTEE ON HOSPITAL CARE; ASSOCIATION OF CHILD LIFE PROFESSIONALS Pediatrics originally published online December 28, 2020;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2020/12/24/peds.2020-040261

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 25, 2021