Child life programs have become the standard in large pediatric settings to address the psychosocial concerns that accompany hospitalization and other health care experiences. Child life programs facilitate coping and the adjustment of children and families in 3 primary service areas: 1) providing play experiences; 2) presenting developmentally appropriate information about events and procedures; and 3) establishing therapeutic relationships with children and parents to support family involvement in each child's care. Although other members of the health care team share these responsibilities for the psychosocial concerns of the child and the family, for the child life specialist, this is the primary role. The child life specialist focuses on the strengths and sense of well-being of children while promoting their optimal development and minimizing the adverse effects of children's experiences in a hospital setting.
CHILD LIFE PROGRAMS
Most hospitals emphasizing pediatric care have child life programs,1 and the number of these programs has doubled since 1965. In a 1988 survey of 396 hospitals (including general and children's hospitals) with pediatric residency programs, 82% of the 286 responding hospitals employed professional child life staff, whereas a 1998 survey of its 152 members by the National Association of Children's Hospitals and Related Institutions found that 97% of 112 responding hospitals employed child life specialists.2,3Child life services could be offered in inpatient pediatric health care settings as well as ambulatory and emergency departments. The National Association of Children's Hospitals and Related Institutions has stated that provision of such services is a quality benchmark of an integrated child health delivery system.4 A number of states have identified the importance of child life services through the regulatory process; for example, in a draft regulation, the state of Florida mandates that child life programs must include preparation services for children and families, training of volunteers, and provision of age-appropriate play and activities.5
Although most child life specialists work on inpatient units, an increasing number are now employed in outpatient settings in response to the general trend toward ambulatory health care. A ratio of 1 child life specialist to 15 or 20 patients has proved to be successful for many institutions for their inpatient areas; however, the patient's age, mobility, and type and acuity of illness and the nature of the population on the unit should influence actual practice.6,7 Ratios for outpatient areas have not been established, but the same factors should be considered. Child life specialists are responsible to a child life manager who typically reports to the Department of Pediatrics through its chairman, administrator, or child/maternal nursing director.
The credentials of a certified child life specialist include at least a bachelor's degree in child development and the completion of a child life internship. Child life specialists often develop specific areas of expertise related to the patient population (eg, infants, oncology patients, critically ill children) that they serve. They are trained to recognize the developmental issues specifically related to health care experiences and to understand how to mitigate fears, fantasies, and concerns. Information about the child life profession and certification of child life specialists is available from the Child Life Council, Inc (see Additional Resources).
An effective child life program provides children and adolescents with developmentally appropriate play, offers informative and reassuring psychological preparation for and during procedures, and provides support to family members.8
Play is the primary modality of a child life program, making the health care experience less intimidating and more comfortable. Child life programs provide opportunities for play in inpatient areas, intensive care units, outpatient clinics, emergency departments, presurgical waiting areas, laboratory waiting rooms, and sibling care centers. Engaging in developmentally appropriate play and reading activities moderates children's anxiety and minimizes the possibility that health care encounters will disrupt normal development.9,10 Child-directed play and guided (or issue-specific) play experiences allow children to be active and exert control over their endeavors.1,7,10,11 Observation of play offers insight into the patient's concerns and level of understanding of the health care events and, thus, affords an opportunity to correct misconceptions. These observations are shared with the rest of the health care team so that all are better prepared to respond appropriately to the individual patient.
To help a child cope with painful treatments and intrusive procedures, a child life specialist often uses “medical play,” involving nondirective exploration of medical equipment, dramatic play in which situations encountered by the child are reenacted, use of games or puzzles depicting medical themes, or the creation of art work using health care materials (eg, bandage strips, tongue depressor, syringes).1,7,10,11 Such activities allow a child to approach a threatening situation with greater familiarity and a sense of mastery.12
Preparing children for hospitalization, clinic visits, or diagnostic and therapeutic procedures is another important element of a child life program. Many hospitals and other health care facilities have developed preparation programs that familiarize the children and their families with the circumstances and procedures they will encounter. These developmentally appropriate programs help reduce emotional disturbances in hospitalized children.9,13,14Oncology clinics, day surgery units, radiology departments, dialysis units, primary care clinics, emergency departments, and other clinics have used child life specialists to help children anticipate and manage health care experiences.15–19
When providing information to children and families, child life specialists share accurate descriptions of the experiences children will have. In addition, they provide opportunities for children to examine equipment and give them developmentally appropriate explanations of their use. The information and opportunities to handle equipment help make the unpredictable more manageable and enable the child to plan and rehearse coping strategies.20 Strategies used may include relaxation, visualization, and pain management techniques. A child life specialist who is present during a procedure can enhance a parent's ability to support the child and contributes to a patient remaining calm and more cooperative during the procedure.21 In the absence of parental support, a child life specialist often provides the support, enabling the staff members to use their time more efficiently.
The third major area of child life services involves education and support of parents and other family members. Because the presence of family members has an important positive effect on a child's adjustment to the health care experience, pediatric health care teams encourage family involvement in patient care.22 Anxiety experienced by parents and siblings also can be transmitted to the children receiving treatment.9,11,13 As agents for the provision of family-centered care services, the frequent contact of child life specialists with family members enables them to develop therapeutic alliances, monitor reactions to events, and provide timely information. Child life staff members help parents understand their child's response to treatment and can assist well siblings to comprehend a brother's or sister's illness. Specially trained child life specialists also may provide grief counseling and sibling support in the event of catastrophic injury or death.
CHILD LIFE SERVICES IN A CHANGING HEALTH CARE ENVIRONMENT
The age distribution of hospitalized children has shifted to an increasing proportion of infants.23–26 In addition, although fewer children are being hospitalized, the children who are admitted are more seriously ill and often require longer stays.27 Child life programs have had to adapt to less mobile patients who have more complex medical problems. As a result, fewer group interactions are possible, and greater individualization of care is needed. Staff members are challenged to meet each child's developmental, emotional, and educational needs more quickly and efficiently than before and to provide as “normal” a life experience as possible. At the same time, the expansion of outpatient care has resulted in more demands for ambulatory child life activities as their value and benefits have become recognized.
Child life services provide important contributions to the organization's efforts to meet the standards of the Joint Commission on Accreditation of Healthcare Organizations (ie, developmentally appropriate care, patient education, and assessment of patients), and they help health care team members communicate issues on the basis of age-specific competencies and individual needs.28 The child life program has become important for students in medical and nursing fields and other human service programs to become educated in child development and understanding behavior. The role and competence of pediatric unit volunteers are enhanced when they are educated, guided, and supervised as part of a child life program.29
Child life specialists are valuable consultants about the physical environment of pediatric settings and the effect of the settings on the behavior and adaptation of children because they are keenly aware of the perspective and concerns of children and their families. Child life specialists offer a useful perspective on hospital committees, such as ethics or bereavement committees.
Child life expertise has application beyond conventional hospital care. Child life skills and interventions can help children make the transition back to home, school, and community and cope with home care experiences. The interventions can facilitate family communication and coping when a parent has a serious illness.30,31 Child life specialists use their skills and training for positions in disease-specific camps, hospice programs, supplemental child care for technology-dependent children, programs for high-risk infants, and courtrooms for pretrial support of juvenile victims.
Child life services make a difference in pediatric care. Research and practice have demonstrated that child life services, such as play and preparation, help to contain costs (ie, reducing the length of stay and decreasing the need for analgesics).14,21 Observation and consumer satisfaction feedback further confirm the positive effects of child life programs on children and families and staff. Yet it remains essential for the child life personnel to adapt and grow with the current health care system as they join forces with other care professionals in support of the emotional well-being of children and families.32
Child life services are important for children and some of these services may be performed by different health care professionals. The services could be offered in pediatric settings including inpatient units, ambulatory units, and emergency departments.
Whenever child life services are provided, an adequate ratio of caregivers to patients needs to be developed. This ratio should be adjusted for the severity and acuity of illness of the patients served.
Child life services should not be withheld regardless of reimbursement.
Home health services may include child life services that help the child and family cope with the child's condition and treatment.
Committee on Hospital Care, 2000–2001
John M. Neff, MD, Chairperson
Henry A. Schaeffer, MD, Immediate Past Chairperson
Jerrold M. Eichner, MD
David R. Hardy, MD
Paul H. Jewett, MD
Jack M. Percelay, MD, MPH
Ted Sigrest, MD
Erin R. Stucky, MD
Susan Dull, RN, MSN, MBA
National Association of Children's Hospitals and Related Institutions
Mary O'Connor, MD, MPH
Hospital Accreditation Professional and Technical Advisory Committee
Elizabeth J. Ostric
American Hospital Association
Sheila Quinn Rucki, RN, PhD
Society of Pediatric Nurses
Eugene Wiener, MD
National Association of Children's Hospitals and Related Institutions
Jerriann M. Wilson, CCLS, MEd
Child Life Council
Robert Wise, MD
Joint Commission on Accreditation of Healthcare Organizations
Michael D. Klein, MD
Section on Surgery
Theodore Striker, MD
Section on Anesthesiology
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
For further information, please contact: Child Life Council Inc (CLC), 11820 Parklawn Dr, Suite 202, Rockville, MD 20852 (Web site:http://www.childlife.org; e-mail: ).
- Thompson RH, Stanford G. Child Life in Hospitals: Theory and Practice. Springfield, IL: Charles C Thomas; 1981
- Roberts MC, Maieron MJ, Collier J. Directory of Psychosocial Policies and Programs. Bethesda, MD: Association for the Care of Children's Health; 1988
- National Association of Children's Hospitals and Related Institutions. 1998 NACHRI Annual Survey: Part II. Alexandria, VA: National Association of Children's Hospitals and Related Institutions; 1998
- National Association of Children's Hospitals and Related Institutions. Pediatric Excellence in Health Delivery Systems. Alexandria, VA: National Association of Children's Hospitals and Related Institutions; 1996:9–10
- Agency for Health Care Administration. Florida's Inpatient Pediatric Standards for Hospitals: Draft 8/13/98. Tallahassee, FL: State of Florida; 1998
- American Academy of Pediatrics, Committee on Hospital Care
- Child Life Council. Brown C, Gaynard L, McCue K, Wilson J, eds. Guidelines for the Development of Child Life Programs. 2nd ed. Rockville, MD: Child Life Council; 1997
- Thompson RH. Psychosocial Research on Pediatric Hospitalization and Health Care: A Review of the Literature. Springfield, IL: Charles C Thomas; 1985
- Thompson RH
- Gaynard L, Wolfer J, Goldberger J, Thompson R, Redburn L, Laidley L. Psychosocial Care of Children in Hospitals: A Clinical Practice Manual. Rockville, MD: Child Life Council; 1998
- Vernon DTA. The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature. Springfield, IL: Charles C Thomas; 1965
- Klein D
- Goldberger J,
- Gaynard L,
- Wolfer J
- Johnson BH, Jeppson ES, Redburn L. Caring for Children and Families. Guidelines for Hospitals. Bethesda, MD: Association for the Care of Children's Health; 1992
- US Bureau of the Census. Statistical Abstract of the United States: 1996. 116th ed. Washington, DC: US Bureau of the Census; 1996
- US Bureau of the Census. Statistical Abstract of the United States: 1994. 114th ed. Washington, DC: US Bureau of the Census; 1994
- US Bureau of the Census. Statistical Abstract of the United States: 1990. 110th ed. Washington, DC: US Bureau of the Census; 1990
- US Bureau of the Census. Statistical Abstract of the United States: 1988. 108th ed. Washington, DC: US Bureau of the Census; 1988
- National Center for Health Statistics. Health, United States, 1995. Hyattsville, MD: Public Health Service; 1996
- Joint Commission for the Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission for the Accreditation of Healthcare Organizations; 1997
- Kiely AB. Volunteers in Child Health: Management, Selection, Training and Supervision. Bethesda, MD: Association for the Care of Children's Health; 1992
- McCue K, Bonn R. How to Help Children Through a Parent's Serious Illness. New York, NY: St Martin's Press; 1994
- Wilson JM,
- Chambers EB
- American Academy of Pediatrics, Committee on Hospital Care
- BU3.Association for the Care of Children's Health. Child Life: An Overview. 2nd ed. Bethesda, MD: Association for the Care of Children's Health; 1986
- BU4.Association for the Care of Children's Health. Position Paper on Ambulatory Care for Children and Families. Bethesda, MD: Association for the Care of Children's Health; 1982
- BU6.Child Life Council. Child Life Position Statement. Rockville, MD: Child Life Council; 1995
- BU7.Child Life Council. Directory of Child Life Programs. Rockville, MD: Child Life Council; 1996
- BU8.Petrillo M, Sanger S. Emotional Care of Hospitalized Children: An Environmental Approach. 2nd ed. Philadelphia, PA: JB Lippincott; 1980
- BU9.Plank EN. Working With Children in Hospitals. Chicago, IL: Year Book Medical Publishers Inc; 1971
- Copyright © 2000 American Academy of Pediatrics