priti desai to receive clc 2013 distinguished service award · pdf filethe walt disney...

VOLUME 31 • NUMBER 2 SpRiNg 2013

INSIDE

Cara Morris, MA, CCLS and Cara Smith, MA, CCLS Children’s Mercy Hospital and Clinics, Kansas City, MO

Hematopoietic stem cell transplant (HSCT) has become the standard therapy for many life-threatening

illnesses in childhood (Packman, Weber, Wallace & Bugescu, 2010). The ideal donor for these transplants matches the recipient at major human leukocyte antigen (HLA) sites. A biological sibling is often the best HLA match for pediatric patients. Sibling donors decrease the risks of transplant-re-lated complications compared to unrelated donors (American Academy of Pediatrics Committee on Bioethics, 2012).

While siblings are often medically the best match for a patient in need of a transplant, there can be psychological ramifications of being a sibling donor, especially when parents make the choice for the sibling (Joffe & Kodish, 2011; Revra & Frangoul, 2011). In 2010, the American Academy of Pediatrics (AAP) released a policy statement to protect sibling donors by recommending a donor advocate meet with minor donors prior to donation.

According to the American Academy of Pediatrics (2010) policy statement on children as hematopoietic stem cell donors,

In 1986, Priti Desai was fresh out of graduate school in India and ready to fight to achieve her dream to advocate for the rights of children in difficult situa-tions, including those in hospitals. After receiving the eagerly awaited letter offering her an opportunity to complete a child life internship at the Johns Hopkins Children’s Center, she began the complex process to obtain a foreign exchange visitor visa. She soon learned that her application was in jeopardy. She faced glitches with bank procedures; her application to exchange Indian Rupees for the U.S. dollars which would be a required step to get her visa approved, was denied.

After negotiating with regional officials, her only remaining recourse was to appeal to a higher authority at the headquarters

of the bank. Armed only with a portfolio she had assembled to help illustrate the work she had done as a volunteer piloting child life services at the Civil Hospital in Ahmedabad, Priti traveled more than 500 miles to Mumbai to meet with the chief executive at the bank, ready to convince him to reverse the decision and approve the currency exchange. “If that meeting had gone differently, my path could have changed dramatically,” she says. Fortu-nately for the Child Life Council and for the child life community at large, the meeting went well. With characteristic de-termination, Priti took the next important step in a unique professional journey that has spanned continents and contributed to the awareness and advancement of child life services around the world.

At next month’s 31st Annual Confer-ence on Professional Issues in Denver, the child life community will celebrate the contributions of an outstanding child life

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2 President’s Perspective

3 From the Executive Director

6 Resiliency in the Hospital

7 8 Reasons to Attend CLC’s 31st Annual Conference

8 Professional Perspective: Disclosing Silence

11 Book Review: What You Think = How You Feel = How You Heal

In Focus:The Effects of Child Life Intervention on Reducing Pediatric Patients’ Anxi-ety and Increasing Cooperation in Perioperative Settings

Child Life AlphabetS iS for Sibling Donor ADvocAcy

continued on page 4

Priti Desai to Receive CLC 2013 Distinguished Service Award

Priti Desai, PhD, MPH, CCLS

Child Life Council Bulletin/FOCUS 11821 Parklawn Drive, Suite 310, Rockville, MD 20852-2539 (800) CLC-4515 • (301) 881-7090 • Fax (301) 881-7092 www.childlife.org • Email: [email protected]

President Executive Editor Associate Editor Executive Director Managing Editor Diane Hart Jaime Bruce Holliman Jessika Boles Dennis Reynolds Cecilia Sepp

Published quarterly in January (Winter issue), April (Spring issue), July (Summer issue), and October (Fall issue). Submission deadlines for each issue are as follows: Winter: November 1; Spring: February 1; Summer: May 1; Fall: August 1. For more information on submitting articles, please see Submission Guidelines in the Bulletin Newsletter section of the CLC Website.

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BULLETIN SPRING 2013

2 A Publication of the Child Life Council

PRESIDENT’S PERSPECTIVE

According to research and expert opinion,

cultivating and developing capable

leaders within a professional association should be a top priority. While some may argue that leadership development is “nice to have,” especially with competing fiscal de-mands, in order to lead during times of rapid change and uncertainty, it is more important than ever to provide leadership training.

One compelling reason for leadership development within a professional associa-tion is to develop future volunteer leaders. The leadership pipeline often begins with volunteers participating on a committee or task force, which may eventually steer them into the role of chair or co-chair. From there, volunteer members may express interest in moving into a position on CLC’s Board of Directors. The question then becomes, what responsibility does an association have in ensuring our future leaders have the skills and competencies necessary to take on a position of responsibility?

That question is not unlike what many of you have, or may experience, in your own organizations. As child life specialists, we

pride ourselves on our exemplary clinical skills. We may spend years honing our assessment skills and providing thoughtful, goal-based therapeutic interventions based on the patient and family’s needs. We may also recognize the importance of representing child life on site-wide committees and pro-viding education and information through workshops and presentations. All of these activities, when done well, may be noticed by the leaders in our organizations. We are often put into leadership positions, whether formally or informally, based on our clinical competence. But does clinical competence translate to being an effective leader?

When you gather together a group of new child life leaders and ask them to discuss their experiences, you often hear how expert they felt in a clinical role, and how ill-prepared they felt when they moved into a leader-ship role. These positions don’t come with “how-to” manuals. We learn how to foster teamwork, manage change, be strategic think-ers and planners and so forth on a trial-by-fire basis. Very few new managers receive formal training in how to be an effective leader before they move into a new position (and if you did, consider yourself one of the lucky ones!).

Given how important leadership

Investing in Tomorrow's LeadersDiane Hart, MA, CCLS, EDAC

development is both for professional associa-tions and within our own organizations, it is very exciting to be looking into the future and seeing leadership development as one of CLC’s key strategic priorities. This initiative will be focused on developing leaders within the child life profession, thereby preparing them for leadership roles not only within CLC but also within their own organizations. We will be moving forward on the explor-atory and planning stages of this initiative in 2013 with the support of a grant awarded by The Walt Disney Company. That exploratory and planning phase will culminate late this year in a roadmap outlining concrete programmatic measures for CLC to pursue in building a program to develop leadership skills throughout the membership.

The Board of Directors recently held a spring meeting in Atlanta, which was in addition to our regular November and May meetings. The extra time together offered a unique opportunity to focus on activities from “10,000 feet,” with an agenda focused on the strategic initiatives and directions of the Child Life Council, and working for the ongoing advancement of the child life profession. The leadership development initiative is one example of how the profes-sion is growing! I look forward to a day in the not-too-distant future when emerging child life leaders supported and encouraged through the leadership development initiative begin to take on positions of responsibility on CLC’s committees and task forces and on the Board. Perhaps even the person writing this president’s column will be a child life special-ist who took part in the program. How exciting to imagine the possibilities!

viSit the chilD life MArketplAce

The Child Life Marketplace provides convenient access to contact information from a growing number of organizations that work with the child life community.

Be sure to visit regularly to check out what’s new at http://marketplace.childlife.org/


A Publication of the Child Life Council 3

From the executive Director

child Life council Board of directors 2012-2013President Diane Hart, MA, CCLS, EDAC

President-Elect Amy Bullock Morse, MSEd, CCLS

Immediate Toni Millar, MS, CCLS Past President

Secretary Suzanne Graca, MS, CCLS

Treasurer Trish Haneman Cox, MSEd, MSW, CCLS

Directors Kimberly Allen, MS, CCLS Carla Oliver, MSW, CCLS Melissa “Missi” Hicks, MS, CCLS, LPC, RPT-S Kate Shamszad, MS, CCLS

CACLL Liaison Cathy Humphreys, CCLS

CLCC Senior Chair Quinn Franklin, MS, CCLS

Executive Director Dennis Reynolds, MA, CAE

To contact a Board member, please visit the CLC Member Directory at http://www.childlife.org/Membership/

MemberDirectory.cfm.

In the last issue of the Bulletin (Winter 2013), we

announced a grant we received from The Walt Disney Company to help us

take important steps toward enacting several long-range, strategic initiatives that have been identified as important to the future of the child life profession. I’d like to take the opportunity to mention some of the things the grant will enable us to do, followed by an update on a number of other initiatives originating from the CLC 2012-2014 strategic plan.

leADerShip DevelopMentIn her column on page 2 in this issue of

the Bulletin, CLC President Diane Hart has described the importance of developing leaders in child life, both so they can take on roles of responsibility within CLC, and more importantly, so they can become effective child life leaders in their own settings. As we work toward developing and expanding leadership-related programming in CLC, we will be focusing on four “levels” of leader-ship: (1) leadership skills for all child life specialists in any role, including those that can be applied in clinical non-managerial positions; (2) leadership and managerial skills that will prepare clinicians to move into managerial roles; (3) advanced leadership and management skills for those already in managerial roles; and (4) skills that will be useful in enabling child life managers/direc-tors to move “up the ladder” in health care administration, as some of our members are starting to do now. We will be commission-ing work later this year to help develop what such a range of programming might look like in terms of conference content, webinars and special advanced training.

internAtionAl outreAchIncreasingly, CLC is contacted by organiza-

tions and individuals outside North America that are exploring the possibility of develop-ing a child life or related profession in their

respective countries. CLC hopes to hold an international summit of delegates from around the world to discuss leading issues in pediatric psychosocial care and possible scenarios for global collaboration. This year, thanks to The Walt Disney Company grant, we will be working to identify countries, organizations and individuals involved in health care initiatives that are consistent with the principles and practices of the child life profession. Through these efforts, we hope to build a network of organizations and indi-viduals with common professional interests, a key initial step before CLC begins planning an international summit in 2014 or 2015.

reSeArchThe focus of The Walt Disney Company

grant is play. The grant includes funding for up to $50,000 to underwrite a rigorous study demonstrating the impact of play interven-tions on outcome measures in a hospital. We have issued a Request for Proposals, and by the time this issue of the Bulletin is published, we will have selected a recipient to conduct a study.

Surveying plAy policieS AnD prActiceS

We often see posts on the CLC forums asking others about their policies or practices regarding some aspect of play, such as who staffs the playrooms, what hours are these rooms open, what policies exist for lending equipment and toys, and so on. We are very pleased that the Disney grant is affording us the opportunity to conduct a comprehensive survey of play practices and policies. This will serve as a seminal benchmark of the role of play in child life, and will hopefully stimulate much conversation, exchange of ideas, and innovation in play as a fundamen-tal tool of child life.

other StrAtegic initiAtiveSAdditional components of The Walt Disney

grant were described in the Winter 2013 issue of the Bulletin, and I will delve into many of these in future columns. We are very thankful for this tremendous support.

Focus on Strategic InitiativesDennis Reynolds, MA, CAE, CLC Executive Director

In addition to embarking on some initiatives with the aid of The Walt Disney Company, there has been quite a bit of activ-ity in other areas related to CLC’s strategic initiatives. Here is just a sampling of that activity:

· We recently completed a major survey of program leaders seeking input on potential studies that can demonstrate the economic value of child life, and we will be putting together a research agenda based on those survey results.

· Our Academic Preparation Task Force (Task Force 2020) is tackling the issues surrounding the charge for the profession to move toward advanced degree prepara-tion of new child life specialists entering the field in the year 2020 and after.

· The Internship Accreditation Task force is building on the work of CLC’s previ-ous Internship Task Force to derive a set of standards for internship programs to ensure that all child life interns will have a basic range and depth of clinical experience to prepare them to enter their first profes-sional child life position.

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leader and educator—and India’s very first Certified Child Life Specialist—with a special presentation of the 2013 Distinguished Service Award to East Carolina University’s Dr. Priti Desai.

Priti is humbled to be the recipient of this year’s award. When asked how she was first introduced to child life, Priti explains that she gravitated toward children and service from an early age. As a child in a family of doctors, Priti grew up in a home where their dining table occasionally became a treatment table during odd hour emergency calls to treat minor eye problems. She observed her father conducting procedures with young children, who were often feisty and put up a good fight. “I began to assist by trying to calm these children” she says. She also started thinking then about developing child friendly medical equipment.

When the time came to choose a career path, psychology and child development seemed a natural fit. After completing her bachelor’s degree in psychology, Priti attended a graduate program in child development at the Maharaja Sayajirao University of Baroda, in Vadodara, India. It was here, under the guidance of Dr. Indira Mallya, that Priti learned more about the child life profession. “I just knew this was going to be it for me,” she recalls. “I am so grateful that my family was so encouraging to let me chase a dream and pursue a path not treaded in India.”

Priti spent a number of enriching months in her internship at Johns Hopkins under the guidance of Jerriann Wilson, Belinda Ledbetter and other child life mentors who helped her to hone her clinical skills. Priti returned to India and used the skills to fine tune her child life volunteer work at the Civil Hospital. She was inspired by the acceptance of these efforts by children, parents, and medical staff. “I was elated that child life worked in India. That means it can work in other developing countries, too,” she says. At the same time, she worked as a child development specialist for CHETNA, a health education organization that works with people in rural, tribal, and urban slum areas of India. “This was community engagement at its best,” she recalls. “I learned to hear the voices of children and community

members who prioritized their concerns, and we worked collaboratively to develop mes-sages and action steps to prevent indigenous health menaces such as malaria or vitamin deficiencies.”

In 1988, Priti travelled once again to the U.S. for advanced child life training and began to cultivate her strengths in the areas of cultural competence. She then worked briefly as a child life specialist at Johns Hopkins and the Kennedy Krieger Institute before moving to Atlanta and joining Scottish Rite Children’s Medical Center, which is now Children’s Healthcare of Atlanta (CHOA). She championed the creation of a diversity

committee to strive for equitable care for patients from different backgrounds. She worked for more than 10 years at the Egleston campus of CHOA, where she earned a reputation as a superior clinician and family advocate, particularly in the area of pediatric cardiology. In her early tenure at Egleston, she collaboratively campaigned to evolve the patient activities service model program to a comprehensive clinical child life program. Priti teamed with parent advocates to develop camping programs and other family support programs, and initiated the child life intern-ship, which has thrived in the years since. During this time, she also earned her second master’s degree in public health (with Inter-national Health) from Emory University, “I did this to improve my credentials to promote children’s psychosocial services worldwide, while making the USA my home.”

Priti credits her colleagues Dr. Peggy Jessee and Dr. Charles Snow with giving her the encouragement she needed to take the leap from a clinical setting into the world of teaching and scholarship. “I’ve always been a bit of a geek. I like to keep learning and wondering,” she says. Adding to the appeal of new intellectual challenge, working in academia offered the exciting opportunity to work with students, as well as a schedule that would give her flexibility during summer to work on her research and continue efforts for the growth of child life in India, while spending quality time with family.

She took a teaching position in the Depart-ment of Child Development and Family Relations at East Carolina University (ECU) in 2002, and quickly got to work in strength-ening the clinical component of the program’s child life course offerings. She is co-advisor for the Child Life Student Association at ECU, and serves on a number of committees, including the ECU chancellor’s diversity lead-ership council. She also took doctoral classes at ECU, and focused on her research and more coursework during summer months to earn her doctorate degree from the Maharaja Sayajirao University of Baroda in 2008. Her dissertation explored Indian pediatricians’ perceptions and practices in identifying young children with special needs.

Priti is beginning to assemble published work, including research and review articles in peer reviewed journals. She co-authored chapters on family-centered care and global perspectives in child life in The Handbook

Priti Desaicontinued from page 1

Priti returned to India and used the skills to fine tune her child life volunteer work at the Civil Hospital. She was inspired by the acceptance of these efforts by children, parents, and medical staff. “I was elated that child life worked in India. That means it can work in other developing countries, too.”

“I learned to hear the voices of children and community members who prioritized their concerns, and we worked collaboratively to develop messages and action steps to prevent indigenous health menaces such as malaria or vitamin deficiencies.”



of Child Life. In addition to teaching her formal academic courses at ECU, Priti has conducted more than 60 presentations and workshops around the world, and partici-pated in the child life diploma program at Kuwait University. Her grant writing efforts have earned hundreds of thousands of dollars for a variety of programs and projects, including Camp WholeHeart, an eastern North Carolina-based camp for children with complex heart defects.

Along with her career and academic achievements, Priti has shared her time generously as a volunteer leader and child life advocate. For nearly 10 years, she has been a member of the Child Life Specialty Council for Operation Smile, participating in numerous missions around the world, as well as developing educational content and presentations for medical teams. Along with Sheila Palm, Priti serves as a child life advisor for The Priyanka Foundation, an organization dedicated to establishing child life programs in other countries. She has collaborated with several other India-based organizations. Among these are KG Patel Children’s Hospital in Vadodara, where she serves as a volunteer child life consultant, and CanKids… KidsCan in New Delhi and KarunaKare Foundation in Ahmedabad, both organizations promoting childhood cancer support.

For the Child Life Council, Priti served as Treasurer of the CLC Board of Direc-tors from 2001-2003, and she chaired the Diversity Committee from 1997-2001. She has been a member of many CLC commit-tees and task forces over the years, including the Conference Planning Committee, Partnership Committee, Practice Analysis Task Force, Child Life Bill of Rights Task Force, Academic Task Force, International Task Force, and, currently, the Research and Scholarship Committee.

As a teacher and lifelong learner, it is no surprise that Priti views rigorous and consis-tent education and training requirements for child life specialists as being critical to the future of the child life profession. “We must unapologetically continue to seek those high standards,” she says, “In the work we do with children, we need to be the best we can be.” Another important endeavor, she urges, will be an ongoing emphasis on cost effectiveness research and creating more awareness of the child life profession. “I have seen that there are more child life graduates than traditional

job openings. Many alumni look outside of child life to find work, which is unfortunate when there are still so many children who would benefit from child life services. En-deavoring to fulfill our mission, we need to better define and promote the child life role in adult and community hospitals, and other settings where children are facing difficult life circumstances.”

Priti believes that the child life com-munity needs to take immediate steps to recruit, retain, and nurture a more diverse workforce; at the same time it continues to define cultural competencies and training for all child life specialists. She is also excited to see support for emerging child life programs around the world.

Looking at the lessons learned in a career of more than 25 years, Priti believes the obstacles have been just as important as the achievements in shaping her as a person and as a professional. “In child life work, one faces resistance at many levels,” she explains. “Being authentic and steadfast is vital, along with partnerships with those in influential roles to create change.” When faced with a barrier, Priti goes back to a favorite piece of Native American wisdom she paraphrased: If it is good for the children, then do it.

“I ask myself that simple question, ‘Is it good for the children?’ And if the answer is yes, then I know I need to be patient and persevere,” she says.

Priti’s dauntless spirit and sense of commit-ment to the wellbeing of children around the world are just two of many inspiring qualities we will be honoring during the Distinguished Service Award presentation on Sunday, May 19 at the Closing General Session of the 31st Annual Conference. We hope you will join us in Denver to celebrate Priti’s distinguished career and contributions to the child life profession.

“I ask myself that simple question, ‘Is it good for the children?’ And if the answer is yes, then I know I need to be patient and persevere.”



“Children and adolescents in the United States face numerous risks on the path to adulthood, including poverty, racial discrimination and injustice, limited opportunities for education and employment, child abuse and neglect, parental conflict and psychopathology, poor parenting and biomedical problems” (Brooks, 2006).

Every day, in the United States and around the world, young children experience significant disadvantages, such as those

noted above, in their environments causing difficulties in their “psychological function-ing and life success” (Harvey & Delfabbro, 2004). Experiencing these risks in bulk is much worse than experiencing just one alone. To understand the ability that children have to become resilient and achieve positive outcomes despite these risks, one must comprehend what the word “resilience” essentially means.

Although the definition for resilience changes and varies across studies, time, and theoretical context, one can come to the conclusion that resilience is the combination of the success in educational achievement, positive behavioral adjustment, enhanced cognitive functioning, and the absence of psychopathology. Resilience is a word that has been defined by researchers, but many have difficulty in differentiating the concept of resilience from coping.

According to one such researcher, resilience is the result of exposure to harmful situations, rather than ignoring or avoiding those risks. Unlike a resilient child, a child who copes with a situation may avoid it all together. Re-silience is an active process, in which a child is able to “manipulate their environment” and guard them from the negative aspects in their life (Harvey & Delfabbro, 2004). Most have a better shot at becoming resilient if they have experienced disadvantages previously in their life and have learned how to overcome them in the past. For example, children who have been hospitalized for a majority of their lives will have an easier time becoming resilient than a child who has only just been hospitalized at ten years old.

Almost everyone is subject to adversity

and stressors, but becoming resilient is an individual factor that needs to be taken into consideration. Not all children are fortunate enough to become resilient as they grow through adolescence and into adulthood. Many succumb to their disadvantages and become too overwhelmed to focus on the positive. Resiliency in children is an impor-tant topic to research and discuss because children are the key to our future. Children who come from less fortunate homes or live in hospitals are being tested everyday, either gaining the ability to become resilient and thrive, or lose the opportunity and

fall behind. Everyone deserves a chance to become all that they can be in life.

Child life specialists have the ability to help hospitalized children become resilient, and make their hospitalization a positive experience. Being hospitalized is, without a doubt, a stressful event, especially to a young child. It can cause diminished abilities and increased stress and anxiety, and sometimes depression. By allowing children to express their fears and concerns using medical equip-ment, art, and blank dolls, they are more likely to understand what is happening to them in the hospital and what each medical supply is, making the hospital experience less scary, less overwhelming, and more conquer-able. Instead of seeing the hospital as a

Resiliency in the HospitalKristyn Santee

5 thingS chilD life SpeciAliStS cAn Do to builD reSilience:Play – A child learns, and sometimes communicates, by playing so let the child play. It is a normalizing

experience, one that will allow the child to explore their environment from the rooms to the medical supplies. Whether it is medical play, imaginative play, or group play, the therapeutic values of play are endless.

Schedule – Children need consistency in their life: people, places, events, etc. When making a schedule, create one with the child to hang on their wall in the hospital room. On the schedule, write any up-coming tests or surgeries, holidays/birthdays, and events happening in the playroom, such as crafts, activities, and organization visitors. This works great for children that have been in the hospital long term, or plan on being there long term. It gives all children a visual, and things to look forward to, as well as a countdown to when scarier things are, giving the child life specialist time to prep the child.

Communicate/Talk It Out – When prompted, most children will tell you how they feel, whether it is through words, play, or art. Listen to the child’s thoughts and be wary of any fears or emotions that arise. To help them talk, ask questions pertaining to their experience, or bring a puppet to life and communicate through the puppet’s experience in the hospital. Child Life Specialists can also create a story, and have the child complete the story. Relate the story to the child’s experience; for example, “the monkey was running really fast, tripped and fell, now he has to have surgery on his knee. The monkey is feeling…” The child will most likely complete the sentence using a word based on how they are feeling.

Create – Many children communicate through artwork, or just enjoy the feeling of the process of creating something and the final product. Creating something, anything, gives children satisfaction and something to be proud of. Using medical supplies is a great way to allow children to take control, while learning what each tool does, moving past fear and on to mastery. Blank dolls are a great way to help the child learn about their illness/disease and feel powerful enough to work through it in a positive manner.

Grow – Children are always asking for a pet when they are younger, but alas, aside from the occasional pet therapy dog, they do not see many pets in the hospital. Instead of an animal, if your hospital allows it, you could start a garden, inside or outside, and have the children grow flowers or plants. Watching something grow gives children confidence and again, something to be proud of, knowing they gave something life. It is a very positive feeling that enables children to feel control.

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VOLUME 31 • NUMBER 2 SPRING 2013

The Effects of Child Life Intervention on Reducing Pediatric Patients’ Anxiety and Increasing Cooperation in Perioperative SettingsMaureen A. Farrell, Floating Hospital for Children at Tufts Medical Center, Boston, MA Katie Parrish, Tufts University, Medford, MA Kristin Ziemer, Tufts University, Medford, MA W. George Scarlett, Tufts University, Medford, MA Sean Parker, Harvard University, Cambridge, MA Keith J. Martin, Tufts University, Medford, MA Mohammed I. Ahmed, Tufts Medical Center, Boston, MA

Acknowledgements: The authors would like to thank Lindsay Cefali, Nicole Joyner, Iwona Bonney, Kaleigh Doherty, and Leanne Rotman for their contributions to this study. In addition, thank you to the nurses and physicians, especially Dr. Olaf Dammann, from Tufts Medical Center, Boston, MA, and Paul Thayer, D. Min., from Wheelock College for their understanding and support.

literAture reviewPediatric patients’ anxiety and non-compliance have been an area of concern that

hospital personnel have been trying to address for many years (Wright, Stewart, Finley, & Buffett-Jerrott, 2007). Of particular importance are children’s anxiety and non-compliance just prior to anesthesia induction (Wright et al., 2007). Children are often timid and anxious in hospital settings, and approximately 60% of all pedi-atric patients suffer from severe anxiety immediately before their anesthesia induc-tion (Dreger & Tremback, 2006). When children experience intimidating medical interventions, such as an anesthesia mask induction, the children who are least cooperative are those who lack preparation for what to expect (Li & Lam, 2003; Brewer, Gleditsch, Syblik, Tietjens, Vancik, 2006). As a result, uncooperativeness can lead to concerns of safety, time, cost efficiency for staff, and psychological stress for both the child and parent (MacLaren & Kain, 2008a). Preoperative anxiety has also been linked to increased incidence of separation anxiety, eating disorders, nightmares and fear of physicians approximately two weeks post-operatively (Kain, Mayes, O’Connor, & Cicchetti, 1996; Golden et al., 2006).

Despite the developmental and psychological theories behind child life inter-ventions, pharmacological methods (e.g. midazolam whose common trade names include Dormicum, Hypnovel, and Versed) have traditionally been used over behavioral methods for managing pediatric patients’ anxiety in the hospital setting (Kain, Caldwell-Andrews, et al., 2004). While many studies have examined the effects of pharmacological intervention in relation to pediatric preoperative anxiety (Kain, Wang, Mayes, Krivutza, & Teague, 2001; Kain et al., 2004), the past decade has produced a number of studies establishing the limitations and risks of relying primarily on premedicating pediatric patients (Wright et al., 2007; Rosenbaum, 2009). Midazolam has been shown to decrease a child’s anxiety upon entering

continued on Focus page 2

ABSTRACTAlthough distraction and other non-pharmacological tech-niques have been shown to reduce children’s anxiety during medical procedures, little is yet known about the effectiveness of comprehensive child life intervention in reducing periopera-tive anxiety. The purpose of this research study was to examine the relationship between child life intervention and children’s anxiety and cooperation levels in the perioperative setting. A total of 63 children, between the ages of two and eight, were randomly assigned to intervention (n = 33) or control (n = 30) groups. Anxiety levels were rated in the holding area, and quantified using the Modified Yale Preoperative Anxiety Scale (m-YPAS). Induction compliance was measured upon anesthe-sia induction using the Induction Compliance Checklist (ICC). Results showed that children who experienced comprehensive child life intervention were statistically and clinically less anxious and more cooperative than those receiving standard of care. Therefore, comprehensive child life intervention appears to be effective in reducing anxiety and increasing compliance in young children undergoing perioperative procedures.

Creating a safe, less threatening perioperative experience is key to promoting a child’s ability to cope with an operating room (OR) setting. Certified child life specialists (CCLS) are profes-sionals specially trained in helping children cope with hospital settings and play an important role in decreasing children’s anxiety and facilitating their ability to cope (Sorenson, Card, Malley, & Strzelecki, 2009; Perry, Hooper & Masiongale, 2012).

A CCLS is knowledgeable about children’s levels of cognitive development in order to prepare children for what to expect during medical experiences. By using developmentally ap-propriate terminology, sensory information, rehearsal, medical play, and other techniques, child life specialists work to help children better understand their medical experience. Addition-ally, play interventions are an effective way to help children cognitively and emotionally appraise medical environments, such as a perioperative area, in a less threatening manner (Lee, Lopez and Li, 2007).

As practitioners, child life specialists improve a child’s healthcare experience and potentially reduce costs by providing non-pharmacological techniques for managing pediatric stress. The problem is few research studies have evaluated the effects of child life interventions on pediatric preoperative anxiety.

FOCUS SPRING 2013


the operating room; however, post opera-tive disadvantages include post operative negative behaviors and frustration due to amnesia (Watson & Visram, 2003; Wright et al., 2007). It also may not be beneficial for children who exhibit high impulsivity (MacLaren & Kain, 2008a) or may increase recovery time in the post anesthesia care unit (PACU) which in turn prolongs recovery times and increases hospital costs (Perry et al., 2012). Therefore, researchers have begun to focus on evaluating non-pharmacological interventions for managing pediatric anxiety in the hospital environment as a means for improving healthcare quality while also managing healthcare costs.

Preparing children for surgical procedures can be complex. Evaluating the child’s prior medical experiences, creating a coping plan

based on the child’s interests, and assessing the desire for information are all key factors in promoting a positive perioperative experi-ence (Jaaniste, Hayes, & von Baeyer, 2007, MacLaren-Chorney & Kain, 2010). Young children are sensory oriented and best able to comprehend what will happen in a periopera-tive setting if the explanations are concretely presented with hands-on materials (LeRoy et al., 2003). Children ages one to five years are the age group most vulnerable to experienc-ing perioperative anxiety (McCann & Kain, 2001). Medical staff rely primarily on verbal explanations to help young patients cope with what will happen during a medical procedure, but a play-based approach to preparation has been found useful in decreas-ing anxiety and increasing cooperation in the perioperative environment (MacLaren & Kain, 2008a). Ultimately, the value of preparation promotes long-term coping skills needed to conquer future medical experiences (Koller, 2007).

Perioperative child life specialists play a key role in decreasing children’s anxiety and facili-tating their ability to cope (Sorenson, Card, Malley, & Strzelecki, 2009). In this role, individualized interventions and consistency of care allows for clinical interventions to be “applicable under real-world conditions” (MacLaren & Kain, 2008b). The expertise of a Certified Child Life Specialist (CCLS) includes a variety of skills and knowledge for reducing anxiety and increasing cooperation among pediatric patients. CCLS, profession-als who are trained in child development, psychosocial care of hospitalized children and, most relevant, how to prepare children and their parents for medical procedures, help explain technical procedures (e.g., anesthesia induction) to young children. Use of “soft” words such as “sleepy air” instead of “gas,” and “medicine water” instead of intravenous fluids (“IV”) are needed to substitute for potentially frightening and confusing “hard” words including “feels like a bee sting”, or “it will burn” (Goldberger, Mohl, & Thompson, 2009).

MacLaren and Kain (2008a) explained how modeling, shaping, and providing more specific interventions (distraction) at the most sensitive time-point can promote cooperative behaviors. Kain et al. (2007) noted the importance of behavioral interven-tions being carried through to the anesthesia induction and not solely in the preoperative holding area. In Lee, Lopez, and Li’s (2007)

study, therapeutic play interventions were found to be an effective way to help children appraise the perioperative environment in a less threatening manner. For instance, hand-held games in the preoperative holding area with continued use right up until anesthesia induction (Patel et al., 2006) or audiovisual distraction have also shown to be an effective stress reduction method in distracting pedi-atric dental patients (Prabahaker, Marwah, & Raju, 2007). Furthermore, practicing with the anesthesia mask and providing distraction in the perioperative holding area significantly lessened children’s preoperative anxiety (For-tier, Blount, Wang, Mayes, & Kain, 2011).

A parent’s presence during the child’s anesthesia induction is another very impor-tant part of how children cope best in an OR setting. Parents who receive adequate coun-seling about their role in the OR during their child’s anesthesia induction were shown to be more helpful in decreasing the child’s anxiety than parents who were not prepared for how to help (Cameron, Bond & Pointer, 1996). In order to promote a child’s successful anesthesia induction, it is essential to provide parents with comprehensive preparation for what to expect (Piira, Sugiura, Champion, Donnelly, & Cole, 2005). According to Kain and colleagues in their 2003 study, more than 80% of parents preferred to be present during the child’s anesthesia induction.

There are presently few research studies evaluating the effects of child life interven-tions on pediatric preoperative anxiety. A recent study by Weber (2010) utilized a play specialist who offered play choices periopera-tively that were compatible with each child’s developmental level. This study demonstrated that pediatric patients who interactively played with a therapeutic play specialist (e.g. equivalent to a child life specialist in Brazil) exhibited less preoperative anxiety than the children who did not receive play opportuni-ties with a specialist. In a similar study of child life intervention during angiocatheter insertion in the pediatric emergency room (ER), investigators found that child life inter-vention reduces stress in children aged four to seven years, particularly during anticipatory and preparatory phases of the ER experience (Stevenson, Bivins, O’Brien, & Gonzalez del Rey, 2005). Another child life research study showed children receiving child life prepara-tion for elective day surgery had less anxiety compared to unprepared children, as assessed by children’s drawings of their OR experience

About the Views Expressed in Focus

It is the expressed intention of Focus to provide a venue for professional sharing on clinical issues, programs, and interven-tions. The views presented in any article are those of the author. All submissions are reviewed for content, relevance, and accuracy prior to publication.

focuS review boArD 2012-2013Brittany Blake, MS, CCLSSiri Bream, MSCD, CCLSKathryn Davitt, MOT, OTR, CCLSNicola Elischer, MACaitlin Koch, MS, CCLSAnne Mohl, PhD, CCLSAllison Riggs, MS, CCLSCara Smith, MA, CCLSDeborah Tellep, MEd, EdS, CCLSJoan Turner, PhD, CCLS

proofreADerS

Desiree Heide, CCLSJanine Zabriskie, MEd, CCLS

continued from Focus page 1

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(Brewer et al., 2006). However, there have been no studies to date that have examined comprehensive child life intervention including assessment, preparation, develop-ment of a coping plan, and distraction in the perioperative area. Therefore, the purpose of this study was to evaluate the effectiveness of child life intervention on children’s anxiety and compliance in the surgical holding area and during anesthesia induction.

MethoDThe study was a randomized, double-

blinded controlled study. It was IRB-approved and took place in an urban medical center serving both children and adults. The hospital site has two separate operating room areas, and the day surgical area consists of eight operating rooms while the main OR has fifteen. Preoperative holding area wait times averaged approximately 34 minutes. Length of procedures was approximately one to two hours. Most study participants were having day surgical procedures including tonsillectomies, eye surgeries, hernia repairs, cystoscopies, hydroceles, endoscopies and colonoscopies.

PARTiCiPAnTS

A total of 70 pediatric patients were approached for participation; of those approached, 63 patients agreed to participate and all 63 completed the study. All patients had a parent present during the study and received general anesthesia. All participants were English speaking, two to eight year old ambulatory children without severe devel-opmental delay (i.e., nonverbal or severely autistic). The mean age of the intervention group was five years old and the control group four years old. No participants attended a preparation program prior to their surgery.

The intervention group included 33 participants who received child life prepara-tion only on the day of surgery, and the control group included 30 participants, who did not receive child life preparation. A parent was present during induction for all but two patients in the control group. In the intervention group, 33 percent of the patients were girls and 67 percent were boys. In the control group, 63 percent were girls and 37 percent were boys. In addition, 27 percent of the total sample had previous surgical experience. The anesthesiologist controlled midazolam delivery, basing the decision on professional judgment and preference. If

an anesthesiologist deemed premedication necessary, oral midazolam was administered 15 minutes before OR entry and intravenous midazolam was administered five minutes before OR entry. Four experimental participants received midazolam (three orally, one I.V), and five control group participants received midazolam (two orally, three I.V.).

PRoCeduRe

Two data collectors alternated observation days. One was a graduate student, the other a graduate student applicant. They did not know the specific hypothesis being explored and medical staff had limited knowledge that a study was being conducted. Parents were informed of data collector’s role including how they would listen and watch from outside the room while documenting the child’s experiences in the holding area and during anesthesia induction. Written consent was obtained from parents, and verbal and written assent were obtained from children seven and eight years old. Participants were assigned to the control and experimental groups using the Research Randomizer (www.randomizer.org). The assignments were handed out on an alternating basis between control and experimental. For identification purposes, a zero (0) was added to control group ID numbers.

inTeRvenTion GRouP

For intervention group participants, the CCLS began by reading the nursing assessment, which provided written parental input regarding a child’s perception of why he or she was in the hospital and information about the child’s medical history. In addition, the perioperative CCLS met families in the waiting room and assessed what has worked well or not in the past. The CCLS advocated for the child by sharing information about a child’s preferences with the multidisciplinary team. Next, the CCLS asked permission from parents to go over basic medical supplies during medical play; all intervention group parents gave permission. The CCLS then introduced the various toy and media options available which included matchbox cars, trains, dolls, bubbles, playdoh as well as portable DVD players and Gameboy DSs. Both the toy or media option were presented to the child based on their developmental level and interests.

In order to increase cooperativeness and decrease anxiety, medical supply prepara-tion was provided by the CCLS. Sensory preparation included sensory exploration of scented chap sticks (which smell similar to the flavored oils the anesthesiologists use for actually scenting the mask), induction masks, EKG leads, (IV) catheter straws and IV fluid bags. Interactive play included modeling of induction mask, EKG lead placement, pulse oximeter light, and taping of IV.

Before entering the OR, children in the intervention group were shown a photo book containing pictures of previous children in the same OR setting. The children in these photos were depicted using the induction mask, engaging in medical play, and utilizing a portable DVD player or handheld video game. The CCLS also conducted parental preparation through verbal and written means (see Appendix A) on what to expect during the child’s anesthesia induction and how to help. The various reactions children can have were described to parents on the parental information sheet in nonthreatening terms such as, “some children’s eyes roll back just prior to the induced sleep.”

The children in the intervention group were coached in the holding area about the option to lie down or sit up during the mask induction. They were also told they could continue watching a favorite DVD


Before entering the OR, children in the intervention group were shown a photo book containing pictures of previous children in the same OR setting. The children in these photos were depicted using the induction mask, engaging in medical play, and utilizing a portable DVD player or handheld video game.

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on the portable DVD player or utilize the Gameboy DS while they were wheeled down the hall on the bed to the OR. Furthermore, the CCLS allowed the experimental group participants to practice the placement of the mask on his or her face to show that they could continue watching the DVD even while the mask is on during the actual anesthesia induction. The CCLS and parent remained with the child until he/she was asleep. Under the guidance of the CCLS, the child employed coping strategies developed in the holding area before entering the OR.

While the child was transported from holding area to OR, the CCLS utilized distraction techniques, which continued to be utilized after entrance to the OR. The CCLS then coached the child and parent to continue their chosen coping method while the OR team prepared for anesthesia induc-tion. All intervention group participants had a parent present during induction, a practice known as Parental Presence during Induction of Anesthesia (PPIA). At the time of induc-tion, the CCLS was focused, not only on the child, but on the wellbeing of the parent, and could cue the anesthesiologist if the experi-ence became too overwhelming for the par-ent. For distraction, all intervention patients chose to watch a favorite DVD or Gameboy DS game. Throughout the induction, the CCLS safely attended to the child to ensure the chosen distraction item did not fall on the child as sleep was induced. Immediately following induction, the CCLS escorted the parent out of the OR and into the waiting room, where they reflected with them on this experience. The CCLS then provided sup-port about recovery room procedures, food and break area options, and where to obtain updates from the surgeon after the child’s procedure has been completed.

ConTRol GRouP

For the control group, the CCLS greeted the patients and their parents and provided patients with a gender-neutral toy (e.g., mag-netic drawing board). Parents and patients then received standard of care with no CCLS present. For this facility, standard of care is defined as basic education for children and parents focused on procedural elements, risks from treatment, and recovery expectations. As part of the hospital’s standard of care, the anesthesia team verbally informed parents

about what his or her child may look like during the anesthesia induction. The control group parents did not receive any written information about how to best support their child during the anesthesia induction. In both the control and intervention groups, one parent was permitted to support his or her child during the anesthesia induction.

MeASuReS

Two data collectors alternated observa-tion days. They were trained in using the Modified Yale Preoperative Anxiety Scale (m-YPAS; Kain et al., 1997) and the Induc-tion Compliance Checklist (ICC) (Kain, Mayes, & Cicchetti, 1995) to assess anxiety and compliance, respectively. As part of their training, they learned to distinguish between the excitement phase of anesthesia (e.g. unconscious movements) versus conscious irritability and distress due to the mask (Zielinska, Holtby, & Wolf, 2011).

Modified Yale PreoPerative anxietY Scale (M-YPaS) (Kain et al., 1997).

The data collectors rated m-YPAS anxiety in five minute intervals. The m-YPAS is a preoperative assessment of pediatric behaviors exhibited prior to anesthesia induction. Observation times ranged from five minutes to ninety minutes depending on the surgical wait time. (Kain et al., 1997). As validated against other behavioral measures, the m-YPAS has good validity (r = 0.64) (MacLaren et al., 2009). The items are labeled “Activity,” “Vocalizations,” “Emotional Expressivity,” “State of Apparent Arousal,” and “Use of Parents.” Ratings on each item are made on a 4-point scale, except for “Vocalizations”, which has a 6-point scale. For example, a

child scoring a 1 in “Emotional Expressivity” is “manifestly happy, smiling, or concen-trating on play”; 2 is “neutral, no visible expression on face”; 3 is “worried (sad) to frightened, sad, worried, or tearful eyes”; and 4 is “distressed, crying, extremely upset, may have wide eyes.” To form an overall measure-ment of the child’s anxiety, the sum of the ratings across is tallied based on the five minute interval observations. Possible total ratings ranged from 23 to 100 with higher numbers indicating higher levels of anxiety. In the current study, the items were internally consistent, yielding a Chronbach’s coefficient alpha of 0.92. There was also high inter-rater agreement of 96% during calibration. To obtain inter-rater reliability, the two data col-lectors simultaneously observed behaviors of four individual patients not included in the present data set. The data collectors then met with the research team to clarify analogous constituents of particular behaviors. In keep-ing with the literature, patients were classified as “clinically anxious” based on the m-YPAS cutoff score of 30 (Kain et al., 1997). The m-YPAS is a dichotomous outcome indicator that is coded 1 for clinically anxious patients and 0 for non-anxious patients.

induCTion CoMPliAnCe CheCkliST (iCC) (Kain et al., 1995).

The ICC is an 11-item checklist of noncompliant behaviors for use during anesthesia induction (Kain et al., 1995). It is a respected scale used in studies to evaluate pediatric patients’ anxiety during anesthesia inductions (Kain, Wang, Mayes, Krivutza, & Teague, 2001; Kain, et al., 2007; MacLaren & Kain, 2008a; Varughese, Nick, Gunter, Wang, & Kurth, 2008). The ICC inter-rater reliability is high with intraclass correlations

continued from Focus page 3 table 1: baSeline characteriSticS of the PatientS

Study Group

Variable Whole Sample interVention Control teSt StatiStiC (n = 63) (n = 33) (n = 30)

Holding Time (minuTes) 34.2 (18.1) 32.6 (18.3) 36.0 (18.3) T(61)=0.75, p=.458

Age (years) 4.8 (1.8) 5.12 (1.7) 4.53 (1.9) t(61) = 1.29, p = .202

Gender (% girls) 48 33 63 x2(1) = 5.67, p = .017

Gender (% boys) 52 66 36 x2(1) = 5.67, p = .017

Premedication (%) 14 12 17 x2(1) = 0.27, p = .607

Previous Surgery (%) 27 33 20 x2(1) = 1.42, p = .234

Note: Data for Holding Time and Age shown as means (standard deviations).

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ranging between 0.995-0.998 (Kain, Mayes, Wang, Caramico, & Hofstadter, 1998). Eleven items measure active noncompliance, for example, “Verbalizes Fear,” “Pushes Away,” “Requires Physical Constraint.” In the current study, the 11 active items were internally consistent, yielding a Chronbach’s coefficient alpha of 0.83. There was also high inter-rater reliability of 100% during calibration. To obtain inter-rater reliability, two data collectors simultaneously observed behaviors of four individual patients, not included in the present data set.

reSultSChi Square and t-test analysis were used to

evaluate intervention and control differences. The statistical software package utilized to conduct our analysis was the Stata Corp. 2005, Stata Statistical Software: Release 9. College Station, TX: Stata Corp LP.

Demographic statistics are shown in table 1. Of the total patient sample, 48% were female and 52% were male. The participants did not statistically differ on the variables of age, pre-sedation, and previous surgery (p > 0.05). Graph 1 exhibits m-YPAS and

ICC comparisons between experimental and control groups. The results showed child life interventions to significantly reduce anxiety and increase cooperation preoperatively and during anesthesia induction.

PReoPeRATive AnxieTy

Child life intervention had a statistically significant anxiolytic effect (x2 (1, N = 63) = 10.0, p = 0.002). In the last five minute m-YPAS observation time in the holding area and upon transition to the anesthesia induc-tion room, only 18% of the intervention patients were clinically anxious, whereas 57% of the control patients were clinically anxious.

induCTion CoMPliAnCe

Child life intervention had a statistically significant effect on increasing induction compliance (x2 (1, N = 63) = 4.6, p = 0.032). We also found a statistically significant relationship between clinical noncompliance and clinical anxiety (x2 (1, N = 63) = 8.2, p = 0.004). During anesthesia induction, only 3% of the intervention patients were clinically noncompliant, whereas 20% of the control patients were clinically noncompli-ant (Graph 1). Of the total 63 participants, it is particularly noteworthy that 76% of experimental group participants scored a 0 (perfectly calm and cooperative) during the anesthesia induction as compared to only 24% of the control group patients (Kain et al., 2001).

DiScuSSionThe purpose of this study was to see if

children who received medical supply prepara-tion, developmentally appropriate distraction activities, and interactive play with a CCLS would exhibit decreased anxiety and increased cooperation during their preoperative experience and during anesthesia induction. The experimental group showed significantly lower anxiety scores than did the control group. Specifically, children in the interven-tion group who received preparation and play opportunities exhibited decreased anxiety and increased cooperation in the holding area and during their anesthesia induction than children in the control group who received standard of care. The researchers believe that the lack of interactive play with a CCLS and the lack of sensory-based preparation rendered the control group participants more anxious than the intervention group participants. Not having comprehensive child life intervention


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may have led the control group children to be more passive and less playful than the children in the intervention group as observed by oth-ers evaluating pediatric anxiety (Collins & Ev-erett, 2010). Perfect anesthesia inductions are not typical, but as this study demonstrated, children may become calm and cooperative during an anesthesia induction when properly prepared, supported, and provided with ap-propriate distractions. Hence, the presence of a CCLS as opposed to one not being present, can reduce anxiety and increased cooperation in this setting (Kain et al., 2007; MacLaren & Kain, 2008a).

What makes the present investigation novel is the decrease in children’s anxiety and increase in cooperation during mask induc-tion after receiving child life preparation and play.

In addition, this is one of a few studies that looked at child life intervention continuing beyond the holding area (preoperatively). Other researchers have noted that prepara-tion programming has been limited to the preoperative holding area and not carried through into the operating room (Kain et al., 2007). In this study, the CCLS intervention began in the waiting room, continued in the holding area, and into the operating room during the child’s anesthesia induction where a portable DVD player, handheld video game, or age appropriate toy encouraged relaxation. It was evident that giving children in the intervention group choices about their means of distraction, and respecting their preferred ways of coping (e.g., starting off anesthesia mask sitting up vs. lying down), as well as parental presence during the anesthe-sia induction were key factors in promoting a positive anesthesia induction.

This study may address a gap in the literature concerning the positive impact of PPIA. Parents’ anxiety strongly affects children’s anxiety (MacLaren-Chorney & Kain, 2010). In some literature, an objec-tion to PPIA is that it may increase parental anxiety (Bevan et al., 1990). However, the authors of this study posit that parents who are given comprehensive preparation through verbal and written guidance along with continuous support and coaching may have a more positive perioperative experience. PPIA is an area of interest in pediatrics that should receive further investigative research.

liMiTATionS And FuTuRe ReSeARCh diReCTionS

Even though the data in this study has demonstrated effectiveness of child life interventions, it is not without limitations. We did not control for socioeconomic family status or for family ethnicity and future stud-ies should explore these areas. A limitation of this study was that the data collectors were aware a study was being conducted, how-ever, they were not informed of the specific hypothesis being explored nor did they know specifically who was in the experimental or in the control groups. The data collectors (on al-ternating days) did see the CCLS interacting with patients in the intervention group for varying time frames and recorded behaviors in a straightforward manner (crying vs. not crying, consciously pulling mask away vs. sitting calmly).

Researchers may argue that the many variables involved in this study make it difficult to replicate. It is difficult to know exactly which component was most effective. Thompson and Snow (2009) have suggested that many studies are one-dimensional and do not consider possible influence of multiple variables, as was seen in this study. For example, holding area waiting times can sometimes go on for more than one hour. As demonstrated by our study, providing children with choices of play at this time can promote a more positive perioperative experience. Furthermore, we noticed that the delivery styles of five different anesthesiolo-gists varied from one another. Some anes-thesiologists let the parent take the coaching lead whereas other anesthesiologists preferred to coach the child themselves. Future studies are needed to see if the interpersonal style of the anesthesiologist significantly influences the behavior and experience of pediatric patients. In a larger scale child life study, it would be helpful to have the CCLS work with one or two anesthesiologists with similar styles in order to better evaluate the procedural support available to children. In addition, as MacLaren and Kain, (2008a) noted in the introduction, behavioral strategies that focus on each child’s specific needs, at the critical anesthesia induction time-point, should be further researched. In future studies, a more detailed analysis should be performed to examine the various aspects of how different aged children cope with the perioperative setting.

iMPliCATionS FoR PRACTiCe

The child life specialist’s role in a pediatric surgical center is unique. It is the one role in which a staff member is able to focus solely on the psychosocial wellbeing of the child and family, not just in the waiting room and holding areas but also in the OR during anesthesia induction and in the recovery room. The nursing and anesthesia staff have many responsibilities in the OR, often necessitating a CCLS to provide the comprehensive psychosocial support needed to prevent patients from becoming clinically anxious and uncooperative (Li et al., 2007). A collaborative relationship between the CCLS and medical staff can keep the peri-operative experience as fluid as possible for the patient, family, and staff (Sorenson et al., 2009). Family-centered care is enhanced by a perioperative CCLS which can help promote open lines of communication between staff, parents, and children (Brewer et al., 2006).

In conclusion, this study demonstrates that child life intervention can have an impact on clinical practice outcomes in the pediatric environment. Evaluating clinical practice and implications is complex, and addi-tional studies similar to this study should be conducted to better understand the impact of psychosocial programs within pediatric care. As mentioned earlier, it’s important for real-world clinical interventions to be made available for pediatric patients (MacLaren & Kain,2008b). The clinical implications of a perioperative CCLS include decreased perioperative anxiety for children through preparation and play, parental coaching and support, and effective communication with the multidisciplinary team. Child life intervention may reduce time spent in the OR, decrease the need for premedication, and increase parent satisfaction, which in turn promotes customer retention. The importance of a thorough understanding of child development, attention to children’s individual needs, and a family-centered approach to healthcare helps to minimize pediatric anxiety in the hospital environment and promote a positive hospital experience for children and families.

referenceSBevan, J. C., Johnston, C., Haig, M. J., Tousignant G., Lucy,

S., Kirnon, V., Assimes, I.K., & Carranza, R. (1990). Preoperative parental anxiety predicts behavioral and emotional responses to induction of anesthesia in children. Can J Anaesthesia, 37, 177-82.

continued from Focus page 5

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Brewer, S., Gleditsch, S. L., Syblik, D., Tietjens, M. E., & Vancik, H. W. (2006). Pediatric anxiety: Child life intervention in day surgery. Pediatric Nursing, 21(1), 13-21.

Cameron, JA., Bond, MJ., & Pointer, SC. (1996). Reduc-ing the anxiety of children undergoing surgery: Parental presence during anaesthetic induction. Journal of Paediatrics and Child Health, 32 (1), 51-56.

Chorney, J. M., & Kain, Z. N. (2010). Family-centered pediatric perioperative care. Anesthesiology, 112(3), 751-755.

Collins, C. E., & Everett, L. L. (2010). Challenges in pediatric ambulatory anesthesia: Kids are diff erent. Anesthesiology Clinics, 28, 315-328.

Dreger, V., & Tremback, T. (2006). Management of pre-operative anxiety in children. AORN, 84(5), 777-804.

Fortier, M. A., Blount, R. L., Wang, S. M., Mayes, L. C., & Kain, Z. N. (2011). Analyzing a family-centered preoperative intervention programme: A dismantling approach. Br. J. Anesth, 106(5), 713-718.

Goldberger, J., Mohl, A. L., & Thompson, R. H. (2009). Psychological preparation and coping. In R. H. Thompson (Ed.). The handbook of child life: A guide for pediatric psychosocial care (pp. 160-198). Springfi eld, IL: Charles Thomas.

Golden, L., Pagala, M., Sukhavasi, S., Nagpal, D., Ahmad, A., & Mahanta, A. (2006). Giving toys to children reduces their anxiety about receiving premedication for surgery. Anesthesia Analgesia, 102, 1070-1072.

Jaaniste, T., Hayes, B., & von Baeyer, C. L. (2007). Eff ects of preparatory information and distraction on children’s cold-pressor pain outcomes: A random-ized trial. Behavior Research and Therapy, 45(11), 2789-2799.

Justus, R., Wyles, D., Wilson, J., Rode, D., Walther, V., & Nanita, L. S. (2006). Preparing children and families for surgery: Mount Sinai’s multidisciplinary perspec-tive. Pediatric Nursing, 32(1), 35-43.

Kain, Z. N., Caldwell-Andrews, A. A., Krivutza, D. M., Weinberg, M. E., Gaal D., Wang, S. M., & Mayes, L. C. (2004). Interactive music therapy as a treatment for preoperative anxiety in children: A random-ized controlled trial. Anesthesia and Analgesia, 98, 1260-1266

Kain, Z. N., Caldwell-Andrews, A. A., Mayes L. C., Wang, S. M., Krivutza, D. M., & LoDolce, M. E. (2003). Physiological eff ects on parents. Anesthesiology, 98, 58-64.

Kain, Z. N., Caldwell-Andrews, A. A., Mayes, L. C., Weinberg, M., Wang, S. M., MacLaren, J., & Blount, R. (2007). Family-centered preparation for surgery improves perioperative outcomes in children.

Anesthesiology, 106, 65-74.

Kain, Z. N., Mayes, L., & Cicchetti, D. (1995). Measure-ment tool for preoperative anxiety in children: The Yale Preoperative Anxiety Scale (YPAS). Child Neuropsych, 1, 203-210.

Kain, Z. N., Mayes, L., Cicchetti, D., Bagnall, A., Finley, J., & Hofstadter, M. (1997). The Yale preoperative anxiety scale: How does it compare with a “gold standard”? Anesthesia & Analgesia, 85, 783-788.

Kain, Z. N., Mayes, L. C., O’Conner, T.Z., &Cicchetti, D. (1996). Preoperative anxiety in children: Predic-tors and outcomes. Arch Pediatr Adolesc Med, 150, 1238-1243.

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AppenDiX A

Parental Presence During Induction of Anesthesia (PPIA)

Once you have received permission from your attending anesthesiologist to escort your child to the operating room (OR), one parent will receive a sterile coverall, which will go over your clothes. You will also put on a hairnet, shoe covers and possibly a mask.

Th e following describes what your child may appear like during the anesthesia induction:

· Some children cope very well and comfortably accept the mask

· Some are agitated with mask over their face

· Some children’s eyes roll back just prior to the induced sleep

· Some make gurgling sounds

· Some have a noticeable “excitement phase.” Th is is when their bodies excitedly move around as they go unconscious

Let the OR staff know if you do not feel comfortable escorting your child into the OR. It is okay to feel this way. Your child will be safe and well attended to.

If you are escorting, try to speak confi dently to your child during the anesthesia induction. For instance say, “You’re okay”. “I’m right here”. “You’re doing a great job”. Or, talk about a special upcoming event. Th e soothing, familiar voice of a parent is key at this time.

Once your child is asleep, you may give a kiss on his/her hand or forehead. Some parents prefer to give a kiss just before the anesthesia process begins.

If you feel emotional after witnessing your child unconscious this is to be expected. But remember, your child is very safe and will be well taken care of. Before the surgery begins, one of the staff will escort you out of the OR.

Th ank you,Th e Operating Room Staff


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LeRoy, S., Elixson, E. M., O’Brien, P., Tong, E., Turpin, S., & Uzark, K. (2003). Recommendations for preparing children and adolescents for invasive procedures. Circulation, 108, 2550-2564.

Li, H.C., Lam, H.Y. (2003). Paediatric day surgery: Impact on Hong Kong Chinese children and their parents. Journal of Clinical Nursing. 12: 882-887.

Li, H. C. W., Lopez,V., & Lee, T. L. (2007). Effects of pre-operative therapeutic play on outcomes of school-age children undergoing day surgery. Research in Nursing & Health, 30, 320-332.

MacLaren, J. E, & Kain, Z. N. (2008). Development of a brief behavioral intervention for children’s anxiety at anesthesia induction. Children’s Health Care, 37, 196-209.

MacLaren, J. E. & Kain, Z. N. (2008). Research to practice in pediatric pain: What are we missing? Pediatrics, 122, 443-444.

MacLaren, J. E., Thompson, C., Weinberg, M., Fortier, M. A., Morrison, D. E., Perret, D., Kain, Z. N. (2009). Prediction of preoperative anxiety in children: Who is most accurate? Anesthesia Analgesia, 108(6), 1777-1782.

McCann, M. E., & Kain, Z. N. (2001). The management of preoperative anxiety in children: An update. Anesthesia Analgesia, 93, 98-105.

Patel, A., Schieble, T., Davidson, M., Tran, M. C., Schoenberg, C., Delphin, E, & Bennett, H. (2006). Distraction with a hand-held video game reduces pediatric preoperative anxiety. Pediatric Anesthesia, 16, 1019-1027.

Perry, JN., Hooper, VD., & Masiongale, J. (2012). Reduction of preoperative anxiety in pediatric surgery patients using age appropriate teaching interventions. Journal of Perianesthesia Nursing, 27 (2), 69-81.

Piira, T., Sugiura, T., Champion, G. D., Donnelly, N., & Cole, A. S. J. (2005). The role of parental presence in the context of children’s medical procedures: A systematic review. Child Care, Health and Develop-ment, 31, 233-243.

Prabhakar, A. R., Marwah, N., & Raju, O. S. (2007). A comparison between audio and audiovisual distrac-tion techniques in managing anxious pediatric den-tal patients. Journal of Indian Society of Pedodontics and Preventive Dentistry, 25(4), 177-182.

Rosenbaum, A., Kain, Z.N., Larsson, P., Lommqvist, P.A., & Wolf, A.R. (2009). The place of premedication in pediatric practice. Pediatric Anesthesia, 19, 817-828.

Sorenson, H. L., Card, C. A., Malley, M. T., & Strzelecki, M. (2009). Using a collaborative child life approach

for continuous surgical preparation. AORN, 90, 557-566.

Stevenson, M. D., Bivins, C. M., O’Brien, K., & Gonzalez del Rey, J. A. (2005). Child life intervention during angiocatheter insertion in the pediatric emergency department. Pediatric Emergency Care, 21(11), 712-718.

Thompson, R. H., & Snow, C. W. (2009). Research in child life. In R. Thompson (Ed.), The handbook of child life: A guide for pediatric psychosocial care (pp. 36-56). Springfield, IL: Charles Thomas.

Varughese, A.M., Nick, T.G., Gunter, J., Wang, Y., & Kurth, C.D. (2008). Factors predictive of poor behavioral compliance during inhaled induction in children. Pediatric Anesthesiology, 107(2), 413- 421.

Watson, A.T. (2003). Children’s preoperative anxiety and postoperative behavior. Paediatric Anaesthesia, 13(3), 188-204.

Weber, F.S. (2010). The influence of playful activities on children’s anxiety during the preoperative period at the outpatient surgical center. Journal de Pediatria, 86, 209-214.

Wright, K., Stewart, S., Finley, G. A., & Buffett-Jerrott, S. (2007). Prevention and intervention strategies to alleviate preoperative anxiety in children: A critical review. Behavior Modification, 31(1), 52-79.

Zielinska, M., Holtby, H., Wolf, A. (2011). Pro-con debate: Intravenous vs. inhalation induction of anesthesia in children. Pediatric Anesthesia 21(2), 159-168.

We as child life specialists find ourselves

working within many teams as we maneuver through

our everyday professional activities; this list may include our child life team, the psycho-social care team, the multidisciplinary team, and our nursing team, just to name a few examples.

Each of these teams may work together differently and at varying levels of engage-ment. I recently had the opportunity to participate in a session on collaborative teamwork during which I was introduced to the work of Arthur Himmelman, who has developed a definition for this variation in teamwork. According to Himmelman, four levels of engagement in teamwork exist on a continuum including networking, coordina-tion, cooperation and, lastly, collaboration, and the level at which your team functions is based on its members ability to overcome the barriers of time, trust and turf.

The overarching message of the presenta-tion was that in order to truly collaborate within a team, members must be willing to commit a substantial amount of time,

develop a high level of trust, and share large areas of common turf. In addition, and perhaps most importantly, members of the collaborative team must be not only willing, but eager, to enhance each other’s knowledge and practice. This continuum and its stair-step components to collaboration remind me of another continuum that you may be familiar with: Parten’s stages of play. Parten’s stages of play behaviors describe the develop-ment of preschoolers’ interactions during play as they become progressively more engaging and require increasingly more shared time, trust and turf as they move from solitary play to cooperative play. Are we as adults and professionals revisiting and honing skills we may have learned as preschoolers? Are we able to take that last important step toward col-laboration by striving to enhance the practice of our peers and colleagues?

On the heels of Child Life Month and as we look forward to coming together for the CLC conference in Denver, I encourage you to consider your own skills in the art of col-laborative teamwork and discover new ways that you can enhance the practice of other members of your various teams.

Keep up the good work!

The Continuum of TeamworkJaime Bruce Holliman, MA, CCLS

FRom THE ExECuTIVE EDIToRcontinued from Focus page 7



CLC invites you to gain New Perspectives from a Mile High at our 31st Annual Conference on Professional Issues taking place on May 16th – 19th at the Sheraton Denver Down-town Hotel in Denver, CO. Here are just a few of the many great reasons to attend:

1. Learn from the leading experts in and outside the fi eld of child life. With over fi fty sessions taught by child life and other health care professionals, you are sure to gain knowledge of a variety of relevant topics.

2. Earn up to 24.5 Professional Develop-ment Hours, with 15.5 PDHs included with basic registration and an optional 3-9 additional PDHs available for at-tending a half or full-day pre-conference intensive and/or attending a half day intensive on Saturday morning (separate registration fees apply).

3. Explore the Exhibit Hall. With the newly extended hours, you can take your time meeting with the exhibitors who off er products and services that support the work of child life specialists.

4. Check out the CLC Bookstore for the latest child life resources and merchandise and save with the special conference discounts and no shipping charges! Th e bookstore will be open during the Exhibit Hall hours.

5. Make lasting connec-tions with fellow child life specialists. With our New Member/First Timer Orientation, Connect 4 Success roundtable discussion, Student Panel, and many more informal networking events, you will have many opportunities to build long-term friendships with those in your fi eld.

6. Bring the conference home by sharing what you’ve learned with everyone else in your department.

7. Enjoy the grandeur of the Rocky Mountains during your stay in the “Mile High City”. Denver boasts some of the

best views in the country, so don’t miss your chance to take in the sights.

8. Experience the power of Profes-sional Community at the largest annual gathering of child life professionals in the world. Th e Annual Conference is truly a unique experience, off ering unparalleled opportunities to meet and learn from your peers.

If you need more encouragement to register for the 31st Annual Conference on Professional Issues, you don’t have to take our word for it! Each year, your peers have great things to say about the Annual Confer-ence. Here are some actual comments from members who attended last year’s conference in Washington, DC:

“Th e professional ‘charge’ you get from being with over 950 child life specialists is priceless. I left feeling really inspired and ready to educate others.”

“I thought this was one of the best, most organized conferences by CLC. I encourage staff to come away with at least one objec-tive/idea from each session. Th ose expectations were exceeded.”

Register now to secure admission to all of your fi rst choice sessions and events. Registrants are encouraged to take advantage of the CLC discounted room rate of $165 per night plus tax (single or double occu-pancy). We are anticipating a sold-out room block, so make your reservations today!

For detailed information and to view the complete conference program, please visit the Annual Conference section of the CLC Web site at http://childlife.org/Annual%20Conference/.

8 Reasons to Attend CLC’s 31st Annual Conference



As a child life specialist in an outpatient facility serving children, adolescents, and young adults with HIV, the issue of

disclosure is a constant clinical discussion. Whether it is determining the appropriate time to tell a child the name of his/her virus or rehearsing partner disclosures with older patients, teaching how, when, and where to say the word “HIV” is an element of my daily routine. These efforts are part of a larger movement to decrease the stigma related to HIV and chronic illness in general—a movement we, as child life specialists, are responsible for fighting.

Despite my role as an advocate for success-ful disclosure, I struggle with my own medi-cal history and my ability to openly share my illness experience. Twenty years ago, I started my journey as a childhood cancer survivor. In December of 1992, I was diagnosed with a liver tumor, underwent a liver resection, and had two years of chemotherapy. Cancer does not hold the negative stigma of HIV and socially, it is largely embraced. Yet, in a professional setting I remain just as silent as my patients about my past diagnosis.

As a college student, I applied to work at a pediatric summer camp facility and was denied a position as a counselor because of my past medical history. I had mentioned it briefly in my cover letter but this decision lost me the position. The candid director was concerned that my time working at the facility was a continuation of my own coping and I would be unable to look beyond my experience to assist others. He relayed stories of previous employees who had, because of their own diagnosis, stolen the spotlight from the campers and engaged in inappro-priate conversations. I had never been told something like this before. And it scared me into silence.

I shared this experience with my professors and they all agreed- revealing my past medi-cal history, even if I felt it was a strength, could jeopardize my chances of obtaining an internship and eventually employment.

My cancer experience is by no means a skill. It pales in comparison to my master’s education, my research experience, and my years of clinical practice. I do, nonetheless,

find it beneficial as it grants a perspective and a sensitivity that I feel is sacred. It has led me to where I am today. Our profession is rapidly growing but many of us do not discover child life in text books; instead, we learn about it because we live it. Some of us are even given our own child life specialists to teach us about this incredible field. Yet, I was advised to omit it from applications, interviews, and conversations with colleagues. Why?

I understand the camp director’s perspec-tive: boundaries are to be protected and honored. And I would be lying if I said that I never felt the urge to tell a family about my own experience- to provide hope, to connect, to simply share- but I have not. I have not because it is not professional, it is not my job, and it is not appropriate. It leads me to question why there is a distrust of this self-regulation and why employers are frightened to expect their staff to make these common-sense decisions. Are we truly more volatile because of our medical history?

When I applied to my current position, I chose to revisit this idea and with a great deal of audacity, decided to include the informa-tion in my application. I summed up my cancer experience in one elusive sentence, neatly tucked away at the bottom of my

cover-letter: Finally, because of a personal pediatric experience, I have an intrinsic desire to give back to the healthcare community and continue to promote the field of child life. This was the first mention of cancer I had made since my summer camp application. And I wasn’t rejected because of it; instead, I was trusted to honor it in a way that also honored our patients. Because that is my job.

I have remained elusive in my current posi-tion, choosing deliberately when to mention

my past experiences to colleagues. But despite my reticence, I have found no outward rejec-tion of my anecdotes when speaking with my child life team. I believe this is because they trust I use my experience appropriately. Nevertheless, I also know others within the field who have had more negative experiences with these disclosures. Some have even felt that it was their greatest flaw.

As our profession grows and we certify hundreds of new specialists a year, I wonder if we will reach a consensus. Will we say, it is ok to share with your team, or will we say, that’s personal, please keep it locked away? I understand both arguments but I challenge our field to trust those who we are teaching, supervising, certifying. If they have made it this far, can they not be trusted with their own medical history?

PRoFeSSionAl PeRSPeCTive

Disclosing Silence



mountain they must climb, instead they can see it as an anthill they can squish.

When given the power and control over any given situation, as well as support, chil-dren can become more resilient. If a child in a hospital does not have a supportive family member or friend, someone they can lean on throughout their hospitalization, the child life specialist has the ability to be that person while in the hospital. By being a supportive individual in a child’s life, one may help build skills such as problem solving, decision making, assertiveness, communicating effec-tively, managing emotions, conflict resolu-tion, resisting peer pressure, and developing personal relationships (Brooks, 2006).

Resilience is an on-going process, one that will not be complete in a day. It is something that takes time and patience. It develops

every day of a child’s life through interactions with family, peers, school, and neighbor-hood. By using the above methods to combat stress in the hospital, a child is more likely to become resilient, and more likely to see their child life specialist as a person that is part of their support system.

referenceSBrooks, J. (2006, April). Strengthening resilience in

children and youths: maximizing opportunities through the schools. Children & Schools, 28(2), 69-76. Retrieved June 7, 2009, from Academic Search Premier database.

Harvey, J., & Delfabbro, P. (2004, March). Psychological resilience in disadvantaged youth: A critical over-view. Australian Psychologist, 39(1), 3-13. Retrieved June 7, 2009, doi:10.1080/00050060410001660281

of events for the day of donation. Sibling donors are encouraged to ask any questions they may have and to express their feelings towards being a donor (Van Walraven, et al., 2010). The advocate communicates to the medical team the donor’s ability to assent for donation and research studies.

As experts in child development and with experience in preparing children for and sup-porting children during stressful events and procedures, child life specialists are a natural fit to fill the role of sibling donor advocate. While the sibling donor advocate is a child life specialist unrelated to the family’s current medical team, the family is often familiar with the role of child life from their experi-ences leading to the bone marrow transplant. This allows the child life specialist to fill the donor advocacy role as a trusted member of the medical team.

Child life specialists, as donor advocates, ensure siblings receive developmentally appropriate education prior to donation, empower siblings to make informed consent, and recognize siblings as autonomous pa-tients. Most importantly, the donor advocacy program gives voice to siblings who may not otherwise be heard.

the role of the sibling donor advocate is to help the donor understand the process and procedures of transplant and to protect and promote the interests and well-being of the donor. The sibling donor advocate should be someone educated in pediatric development, have skills in communicating with children, have a working knowledge of the stem cell transplant and donation process, and be inde-pendent of the recipient’s health care team to alleviate bias.

The donor advocate determines what the sibling already knows about Bone Marrow Transplant (BMT) and his or her role as donor. In a study by Weiner, et al., (2010) donors shared the need for more information about the donation procedure and transplant outcomes. Ninety-three percent of the do-nors interviewed felt being well-informed was very important. The donor advocate clears up any misconceptions the sibling donor may have. The donor advocate provides education about BMT, explanations for why the sibling was chosen to be the donor, and the sequence

S Is for Sibling Donorcontinued from page 1

Resiliency in the Hospitalcontinued from page 6

referenceSAmerican Academy of Pediatrics Committee on Bioeth-

ics. (2010). Children as hematopoietic stem cell donors. Pediatrics, 125, 392-404.

Joffe, S. & Kodish, E. (2011). Protecting the rights and interests of pediatric stem cell donors. Pediatric Blood Cancer, 56, 517-519.

Packman, W., Weber, S., Wallace, J., & Bugescu, N. (2010). Psychological effects of hematopoietic SCT on pediatric patients, siblings and parents: a review. Bone Marrow Transplantation, 45, 1134-1146.

Revera, G. H., Frangoul, H. (2011). A parent’s point of view on the American Academy of Pediatrics policy statement: children as hematopoietic stem cell donors. Pediatric Blood Cancer, 56, 515-516.

Van Walraven, S.M., Nicologoso-de faveri, G., Asdorph-Nygell, U.A.I., Douglas, K.W., Jones, D.A., Lee, S.J., Pulsipher, M., Ritchie, & L., Halter. (2010). Family donor care management: principles and recom-mendations. Bone Marrow Transplantation, 45, 1269-1273.

Wiener, L.S., Steffen-Smith, E., Battles, H.B., Wayne, A., Love, C.P., & Fry, T. (2008). Sibling stem cell donor experiences at a single institution. Psychooncology, 17(3), 304-307.



Call for AbstractschilD life council 32nD AnnuAl conference on

profeSSionAl iSSueS

MAy 22 – 25, 2014hilTon new oRleAnS

RiveRSide new oRleAnS, lA

Abstract submissions for the CLC 32nd Annual Conference will be accepted through the CLC Website beginning May 1 through July 31, 2013.

· The Program Standards Task Force is work-ing to develop multi-tier schemata that will recognize base level and exemplary levels of child life practice and services in child life programs of different sizes.

· The Practicum Task Force has surveyed clinical programs and academic programs about different roles, responsibilities and practices of practicum students. The results of those surveys will be summarized in an article in the summer issue of the Bulletin, and the Task Force is now work-ing on developing an overall statement regarding the philosophy and purpose of practicum programs in child life.

· Several other Task Forces, such as the Di-versity Task Force, the Public Policy Task Force, and the Patient Ratio Task Force are hard at work in identifying initiatives and recommending programs that can further enhance the child life profession and the way we relate to the rest of the health care community and the public.

These particular illustrations are from our task forces. Equally important strategic work is being carried out by our regular standing committees. I encourage you to visit CLC Community and read the blogs of our various committees and task forces to get a detailed view of the enormous range of activities CLC is moving forward with over the next few years.

In talking with colleagues in the associa-tion world and in health care, everyone tells me how ambitious we are to be delving so deeply into such a variety of important initia-tives all at once. But CLC possesses a rare combination that allows us to support this ambition: a very dedicated, forward-looking Board; a hard-working and energetic staff; and consistently hard-working and produc-tive member volunteer groups.

It is that combination that is making so much happen and promises to realize even more in ensuring a very bright future for the profession of child life.

Focus on Strategic Initiatives continued from page 3 SceneS froM the life

Editor’s Note: Every day, child life spe-cialists share special moments with the children they serve and their families. With that in mind, we are pleased to launch a new feature: “Scenes from The Life.” We invite our CLC members to share funny stories, insightful comments, and thoughtful quotes from their days “in the life” – we will share these with our readers in each issue.

To submit your “Scene from The Life,” please send an email to [email protected]

Enjoy our first story below!

After getting a report from mom and calling me for support, the waiting room

paramedic asks the 4 year old patient “why are you here at the hospital?” The patient replied, “Well, I put a googly eye in my ear so I could see what my brain looks like”…. Mom nearly fell on the floor laughing as did all of us!Shared by: Cathleen Johnson, CCLS Child Life Specialist II Pediatric Emergency Department Monroe Carell, Jr. Children’s Hospital at Vanderbilt



A patient arrives in the emergency depart-ment with a laceration. Th e patient is fearful, anxious, and in need of sup-

port. Th e way in which the adults around her respond, the words that she hears, will impact not only the way that she experiences this crisis, but also those to come. Will she continue to experience fear and anxiety, or will she learn to face crises with confi dence and the ability to encourage her own healing? In Verbal First Aid: Help Your Kids Heal from Fear and Pain--and Come Out Strong (Prager & Acosta, 2010), authors Judith Simon Prager, PhD, and Judith Acosta, LISW, CHT, explain the connection between the mind and the body, and how words can promote healing during times of pain and crisis. Intended for parents, this book is also a valuable resource for child life specialists and other health care professionals.

Verbal First Aid is a protocol for com-munication that encourages healing and recovering physically and emotionally from a crisis. It is based on the idea that the specifi c language used when talking about an illness, procedure, or traumatic situation will impact the way that the event is processed by the patient, and in turn, the way the next crisis is approached. When Verbal First Aid is used consistently and eff ectively, the child may be empowered to approach that next crisis with mastery and self-confi dence. With its presentation of theory, anecdotal stories, and scripts for practice, the book is written in an easy-to-read style that is user-friendly and promotes the development of skills. A brief introduction provides an overview of the con-cept of Verbal First Aid as well as guidelines for using the book to best meet the needs of the reader. It can be read from beginning to end, but can also be referenced quickly when the reader desires information that is situation-specifi c.

Part 1 of the book provides the scientifi c foundation behind the concept of Verbal First Aid. Chapter 1 focuses on the mind-body connection. Using scientifi c research as its basis, this chapter explains how the mind and

body work together to interpret a painful event or crisis, and how this interpretation can encourage or discourage healing. In other words, according to the authors, “what you think = how you feel = how you heal” (Prager & Acosta, 2010, p. 8). Chapter 2 reviews basic child development with an emphasis on how Verbal First Aid can be used appropriately with diff erent age groups. For example, infants are soothed by words, such as through singing and rhyming, even when they aren’t cognitively able to understand those words. School-agers may benefi t from the use of role models (“When I had to go to the emergency room…” or “Other kids have told me that…”), and being asked open-ended questions.

Part 2 is the “how to” manual and focuses on the application of Verbal First Aid. Th e third chapter presents the process in three manageable, easy to remember steps that are not unfamiliar to child life practitioners: centering yourself, building rapport, and ground rules (what NOT to say). Chapter 4 is appropriately entitled “What to Say” and provides the reader with many specifi c techniques for putting the steps into action in order to promote healing. For example, the authors discuss the power of suggestion in the promotion of healing. “Th e Yes Set” is based on the idea that when people say “yes” more than twice, they tend to continue saying it. By stating several simple truths, the child may then be willing to agree to other things

such as feeling more comfortable. Anecdotal stories provide examples and bulleted, shaded summary boxes conclude each chapter.

Th e remaining chapters each focus on scripts for implementing Verbal First Aid in a variety of specifi c situations, many of which are a part of daily child life practice, such as cuts, asthma, burns, surgery, illness and death. Similar to the bulleted summary boxes in Chapters 3 and 4, these chapters contain “short-cuts” with bulleted statements that can be used in each situation. Th e book concludes with an examination of the future of Verbal First Aid as knowledge of the brain-body connection continues to grow, and a list of “magic words” that can be referred to quickly and easily.

With a foundation of scientifi c theory, the authors off er new techniques for familiar concepts, enabling those in the fi eld to take their clinical practice to a new level. Verbal First Aid also lends itself well to research opportunities to further substantiate the application of techniques in the hospital setting. Although the premise of this book is not a new concept, child life practitioners wanting to build on the foundation of their practice and implement new techniques for providing services will fi nd this book to be a valuable resource.

book review

What You Think = How You Feel = How You HealA Review oF PRAGeR, J.S. & ACoSTA, J. (2010). VERBAL FIRST AID: HELP YOUR KIDS HEAL FROM FEAR AND PAIN—AND COME OUT STRONG. new yoRk: BeRkley BookS.Leah S. Woodward, MA, CCLS, McLane Children’s Hospital Scott and White, Temple, TX

When Verbal First Aidis used consistently and eff ectively, the child may be empowered to approach that next crisis with mastery and self-confi dence.

VOLUME 31 • NUMBER 2 SPRING 2013

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CLC CalendarApril 1 Deadline for Bulletin and Focus articles for Summer 2013 issue 10 CLC Webinar - Adult Patients and their Children in the Women’s Services Population

MAy 1 Call for Abstracts Opens for 2014 Annual Conference in New Orleans, Louisiana 3 Deadline for written requests to withdraw from the spring administration of the Child Life Professional

Certification Exam 16 Child Life Professional Certification Exam Administration, Denver, Colorado 16-19 CLC 31st Annual Conference on Professional Issues, Denver, Colorado

June 30 Deadline for recertifying by Professional Development Hours 30 Deadline for applications for the August 2013 computer-based Certification Exam Administration

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