Seven-year-old Michael is scheduled to have a hemangioma removed from his face at the Arkansas Children’s Hospital (ACH) Ambulatory Surgery Center in Little Rock. The morning of surgery, he and his mother meet with child life specialists Cassandra C. James, MS, CCLS, and Camille Dante, MS, CCLS, who show him pictures of the operating room. They let him play with an anesthesia mask and a pulse oximeter, and talk about what to expect when he goes to sleep.
Explore This IssueDecember 2010
The nurse enters the room to start Michael’s IV. He begins to clutch his favorite action hero doll. Wide-eyed, he looks at the nurse and asks, “Are you going to put that needle into my arm now?” Sensing his anxiety, James reaches into her “distraction bag” and pulls out an I Spy book. “Want to read with me?” she asks. Michael nods and his mother picks him up to hold him in what’s called a bear hug comfort position. James settles beside him with the book, and Michael calms down. The nurse is able to place the intravenous line without using any additional sedation.
“Having surgery is really an unusual time for a person. And it’s even scarier for a child,” said Craig W. Senders, MD, FACS, professor and director of the Cleft and Craniofacial Program at University of California Davis Health System. He has observed firsthand the benefits of having child life specialists in the OR environment. “As physicians, we take for granted the bright lights and noises in that environment. It’s a different experience for young children.” Having child life specialists as part of the multidisciplinary team makes the child’s experience go much more smoothly, he said.
Most U.S. hospitals specializing in pediatric care have child life programs in place. Pediatric otolaryngologists who have worked with these professionals note that they can normalize the hospital experience by educating about new diagnoses, teaching pain management and coping skills, preparing children for surgery and working with parents and siblings. Pediatric otolaryngologists point out that their colleagues in community or private practice settings could also boost their care of children by including them in the pediatric care team.
Quality of Care
There are currently over 400 programs documented with the Child Life Council, the professional membership body for the specialty, said Child Life Council past president Ellen Good, MSEd, CCLS, manager of child life at Yale-New Haven Children’s Hospital. Worldwide, there are over 4,000 Child Life Council members. According to the Council, research in the first half of the 20th century showed that long hospitalizations for chronic illness caused children distress, sensory deprivation and loneliness, resulting in a failure to thrive. The Child Life profession began in the 1920s in North America to help mitigate the effects of hospitalization.
Since 1998, the Child Life Council has offered a Child Life Professional Certification Examination. Candidates acquire a bachelor’s or master’s degree with a concentration in human growth and development, psychology and counseling, and complete a 480-hour clinical internship program. After certification, child life specialists continue to acquire professional development hours during a 5-year certification review cycle.
Studies have found that child life specialists contribute to improvements in pain management (J Pain. 2008; 9(4): 320-329), reduced length of stay and increased parental satisfaction (Child Health Care. 1988;16:244-254). In its most recent position paper on child life services (Pediatrics. 2006;118(4):1757-63), the American Academy of Pediatrics (AAP) highlighted the contributions of the profession in meeting the Joint Commission’s standards to deliver developmentally appropriate care.
Working with Specialists
Eric D. Baum, MD, an attending otolaryngologist for Connecticut Pediatric Otolaryngology, attests to both the usefulness and variability of programs. While a resident and fellow at the Children’s Hospital of Philadelphia, he rarely had contact with the child life specialists, who visited and worked with children admitted to the medical floors. “We got only positive feedback from parents about their work, but it was not a collaborative thing,” said Dr. Baum, who is also clinical instructor of surgery and director of the pediatric otolaryngology curriculum at Yale University School of Medicine in New Haven.
When Dr. Baum moved to Yale, one of the first things he noticed was that child life specialists were “right in the mix: they’re there in the morning when I come in to see my pre-op patients [at the Pediatric Surgery Center] and they’re circulating through the recovery room afterwards. So, we just keep bumping into each other and that’s when things get good,” he said.
It’s not unusual for him to meet Alicia Sevilla, MS, CCLS, in the hallway and for them to strategize on the spot about addressing a child’s or parent’s anxiety or refining preoperative instructions. Child life specialists, he said, “have a good understanding of family dynamics and are good at giving me a heads-up if there is an issue.”
Lisa M. Buckmiller, MD, is associate professor of pediatric otolaryngology at the University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, where child life specialists are integral members of the multidisciplinary team approach. “I find child life specialists to be a valuable resource for kids,” she said. “They round out our specialty and you can’t run a children’s hospital without them.”
At ACH, child life specialists are assigned to specific departments. They become conversant with treatment protocol and supply additional patient education after Dr. Buckmiller has met with the family. For chronically ill children or those being treated for cancer, specialists oversee time in the playroom, coordinate with on-site teaching staff and distribute age-appropriate games and gifts. Child life specialists may not round with physicians, but they do chart their observations about a child’s cognitive level or emotional state.
At Yale-New Haven, child life specialists are “always spread thin,” Good said. Realistically, she said, it’s not possible for them to see all children and families. Staff generally cover outpatient clinics in the mornings and inpatient areas in the afternoons. Given the demands on specialists’ time, Good said otolaryngologists should approach their hospital’s child life department to determine their priorities and how best to utilize the expertise of their child life specialists, such as for preparation, distraction, teaching or to support parents. Those in private practice should identify what they would like to add to their practice to make it more family centered, such as incorporating age and language-appropriate educational materials or teaching staff additional skills in relating to children. Inservice education can sometimes be arranged through a local children’s hospital child life department, Good said.
Child life services extend beyond the medical setting. The Yale-New Haven program, for instance, responds to requests from school nurses or principals to help staff transition a child back to the classroom after a serious operation or extended hospital stay.
Child life specialists can be especially valuable for children who have just received a diagnosis, said Morgan Miller, MEd, CCLS, who works at the St. Jude Affiliate Clinic in Baton Rouge, La. “This can be an extremely scary time for children,” she said. “Here they are, coming to a new environment, and all these big words are being thrown around, and they have no idea what is happening. I can help them understand what the tubes and wires and words mean. I choose the right words to describe what’s happening. I even tell kids that I’m like a teacher in the hospital.” (Full disclosure: Morgan is the daughter of Robert Miller, MD, MBA, physician editor of ENT Today.)
Sevilla said she helps parents choose the right words to describe procedures and thus to help dispel any fantasies their child may have about what is going to happen. “The best way to diminish fear is to be honest,” she said. “You can tell the truth without talking about knives and scaring the child.”
Although the AAP has endorsed child life services as essential to patient and family centered care (Pediatrics. 2006;118(4):1757-63), these services are currently non-billable. That may change as more research validates what the pediatric otolaryngologists and the child life specialists interviewed said is a part of assisting families to cope with illness in the hospital setting.
A Routine Service
Dr. Baum’s advice to colleagues is to “figure out a way to work with and parallel to” child life specialists. For example, surgeons can work with child life specialists to ensure that their pre- and post-operative instruction sheets are clear and age-appropriate. Community-based otolaryngologists who treat children can contact the Child Life Council for referrals. Specialists can conduct in-services or develop brochures for the office staff.
“I don’t think there’s any question that these people can be a valuable part of the care of children,” Dr. Baum asserted. “You need to make them part of your daily routine.”