The Cooperative Pediatric Patient: Child Life Tips, Techniques and Tricks with Kids Erika Croswhite, MA, CCLS Child Life Manager, Denver Health April, 13, 2018

Agenda History of Child Life Denver Health Program Child Development Focus Psychosocial Interventions, strategies Clinical Outcomes/Impact

Objectives Participants will be able to identify 2-3 psychosocial techniques to try with pediatric patients in their setting. Participants will be able to better understand language considerations when speaking with children of various ages when explaining medical procedures. Participants will be able to educate others about how developmentally appropriate interventions enhance care.

A 7-year-old patient offers some rules for the grown-ups who work in hospitals: “Don’t surprise me” “Be honest” “Ask permission before you touch me” “Get down on my level” “Stop saying it’s no big deal” Washington Post, 2002

Our Mission at Denver Health We are a pediatric service who support and empower children and families during stressful experiences. In collaboration with the health care team we promote positive coping through individualized psychological preparation, therapeutic play, and emotional support.

History of Child Life Child Life services were initiated in response to the developmental implications that adverse medical experiences were have on children Child Life services first offered in the 1920s then actualized in 1955 Serve children who are in high risk areas for medical trauma www.childlife.org

Clinical Training Bachelor's or Master’s Degrees, Internship Evidence based practice, research focused Different skill set that enhances the multidisciplinary team Child Development perspective related to supporting children and families in the healthcare/trauma/stressful settings

Psychosocial Interventions Supportive relationships Age appropriate education Psychological preparation Procedural support Family centered care Therapeutic play Emotional processing Validation of feelings Clarifying misconceptions

Child Development Focus Piaget Erikson Stress-Coping Model Parenting Theories

Developmental Care: Infants Infants- 0-1 years Issues: Disruption in normal routine, separation from parents, stranger anxiety, physical response to pain, strong trusting relationships effect coping Focus: Parent support/preparing family for what to expect Strategies: Position of comfort Calm environment I put social and emotional together in this one b/c one is as essential as the other. The socializing helps the emotional as the bond is being formed.

Developmental Care: Toddlers Toddlers- 1-3 years Issues: Stranger anxiety, separation anxiety, desensitizing, small accomplishments, pick your battles wisely Focus: Simple explanations, play, and including parents in procedure Strategies: Position of comfort One Voice Distraction

Developmental Care: Preschoolers Preschoolers- 3-6 years Issues: Separation anxiety, magical thinking, fear of bodily harm, fear of punishment, blaming others for condition/illness Focus: Playful interactions, games, funny names, bring things to life, creativity, concrete explanations, non-threatening language, role play, and parental involvement. Strategies Preparation, distraction, positive affirmations, One Voice Position of Comfort

Developmental Care: School Agers School Agers- 6-12 years Issues: Fear of pain, injury, fear of permanence of condition, school disruption, modesty , regression in cognition Focus: Specific body parts involved in procedure, teaching, participation in preparation, talk through process, address concerns, create openness, non-judgmental attitude, encouraging Strategies: Preparation, distraction, choices, positive affirmations

Developmental Care: Adolescents Adolescents- 12-18 years Issues: Anxiety related to long-term effects of illness, anxiety related to pain, concern for body image, modesty, separation from peers Focus: Independence, choices, using scientific terminology to teach, respectful interactions, not adults, need more information, possibility philosophy vs. fear factor, validation of feelings Strategies Preparation, calming techniques, validation of feelings

Interventions Explained One Voice Positions of Comfort Psychological Preparation Techniques Pain Management Distraction Family Centered Care

What is the ONE VOICE Approach? One voice should be heard during procedure Need parental/support person involvement Educate patient before the procedure about what is going to happen Validate child with words Offer the most comfortable, non-threatening position Individualize your game plan Choose appropriate distraction to be used Eliminate unnecessary people not actively involved with the procedure

ONE VOICE Using the ONE VOICE approach, we can create a less-threatening environment for children during medical procedures. https://www.youtube.com/watch?v=2IdwPFyAuDgRMHP April 2018.ppt Shift F5 to go to slideshow mode to show video clip

Positions of Comfort Successfully immobilizes extremity Secure comforting, hugging hold for child Close physical contact with the parent or caregiver Caregiver participates in positive assistance, not negative restraining Sitting position promotes sense of control Table does not move when child moves Fewer people needed to complete procedure

Guide to Comfort Holds in the DECC Back to Front Can be used for: initial exams, IV starts, blood draws, digital blocks, I&D procedures, etc… infant digital block of toes

Guide to Comfort Holds in the DECC Infant Craddle Can be used for: staple procedures, digital blocks, IM injections, I&D procedures, blood draws, IV starts, etc... Infant Front to Front Can be used for: initial exams, digital blocks, staple procedures, I&D procedures, blood draws, IV starts, etc… Initial assessment positioning, digital blocking, infant staple procedure

Guide to Comfort Holds in the DECC Front to Back Infant Front to Front School Age Front to Back School Age Front to back – leg between parents to minimize kicking; 1st- head lac repairs 2nd- 3rd-

Guide to Comfort Holds in the DECC Straddle School Age Back to Front School Age Side Sitting

Guide to Comfort Holds in the DECC Front to Back School Age Straddle School Age Side Sit School Age

Psychological Preparation Explain sequence of events, slowly Use age appropriate terms Include sensory experiences Show pictures Use a doll with real medical supplies Practice/rehearse coping skills

Don’t forget to S.M.I.L.E. S Seek to understand first (What does the child know?) M Meet the child at his/her level (physically and developmentally) I Introduce yourself and Interact L Loose lips- Watch your language! E Educate, Encourage & Exceed expectations

What you say is not as important as HOW you say it! Say what?! What you say is not as important as HOW you say it!

Language Considerations POTENTIALLY CONFUSING MORE CLEAR IV A small plastic tube that we put in your vein to give you medicine CAT scan Are there cats in there? A bed that moves and takes pictures of the inside of your body. Put you to sleep Like my cat was put to sleep? Give you medicine that will help you go into a very deep sleep. You won’t feel anything until the operation/procedure is done. Move to the floor Why are they moving me to the ground? Unit or ward These are just a few examples. Lots more! “Bee Sting” Not all kids have been stung by bees and if they have it hurt! What if they are allergic?

Language Considerations POTENTIALLY CONFUSING MORE CLEAR Give you Anesthesia Gas Give you medicine that you breathe Cut you open Make a small opening ICU “I see you?” Go to a place in the hospital that takes care of kids who need extra special care from nurses and doctors Do stitches Use small strings to close your skin These are just a few examples. Lots more! “Bee Sting” Not all kids have been stung by bees and if they have it hurt! What if they are allergic?

Prep Materials

Pain Management Position of Comfort Buzzy Lidocaine creams- LMX, EMLA, LET J-Tips Deep breathing Distraction

Distraction

Family Centered Care Institute for Patient- and Family-Centered Care- www.ipfcc.org Parents are the experts on their children Parents as partners Coaching parents Family is defined by the clients

Cognitive & Emotional Impact of Child Life Interventions Activation of positive emotions Promote resiliency Sense of achievement, pride Utilization of stress management techniques Age appropriate understanding leads to a sense of mastery Enhanced emotional regulation More predictability = more trust Opportunities for emotional expression

Expected Outcomes Less aggression Increased cooperation Decrease need for versed (evidenced by studies) Decrease in stress and anxiety Increased trust in medical staff Positive memories associated with health care experiences help future encounters Better patient and family experience Increased patient/parent satisfaction

You can please some of the people some of the time… But you can’t please all of the people all of the time.

References www.childlife.org www.aap.org www.childwelfare.gov Knefley, C. & Peterson, L. (2016). Putting Evidence Based Practice into Practice. Child Life Bulletin, (34), 2. Taddio, A., Shah, V., McMurtry, C. M., MacDonald, N. E., Ipp, M., Riddell, R. P., HELPin Kids & Adults Team (2015). Procedural and physical interventions for vaccine injections: Systematic review of randomized controlled trials and quasi-randomized controlled trials. Clinical Journal of Pain, 31(10S), S20-S37. doi: 10.1097/AJP.0000000000000264 Bauchner, H., Waring, C., & Vinci, R. (1991, April). Parental presence during procedures in an emergency room: results from 50 observations. Pediatrics, 87(4), 544-548. doi:1098-4275 Taddio, A., McMurtry, M., Shah, V., Riddell, R., Chambers, C. T., Noel, M., . . . Bleeker, E. (2015). Reducing pain during vaccine injections: clinical practice guideline. Canadian Medical Association Journal 187 (13) 975-982. McGrath, P., & Huff, N. (2001). “What is it?” Findings on preschooler’s responses to play with medical equipment. Child Care, Health and Development, 27, 451. doi: 10.1046/j.1365-2214.2001.00219.x Evidence based practice statements: PREPARING CHILDREN AND ADOLESCENTS FOR MEDICAL PROCEDURES THERAPEUTIC PLAY IN PEDIATRIC HEALTH CARE: THE ESSENCE OF CHILD LIFE PRACTICE CHILDLIFE ASSESSMENT: VARIABLES ASSOCIATED WITH A CHILD’S ABILITY TO COPE WITH HOSPITALIZATION

THANK YOU!