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

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

3. 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.

4. 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

5. 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.

6. 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

7. 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

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

9. Child Development Focus
Piaget
Erikson
Stress-Coping Model
Parenting Theories

10. 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.

11. 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

12. 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

13. Developmental Care: School Agers
School Agers 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

14. Developmental Care: Adolescents
Adolescents 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

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

16. 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

17. ONE VOICE
Using the ONE VOICE approach, we can create a less-threatening environment for children during medical procedures.
April 2018.ppt
Shift F5 to go to slideshow mode to show video clip

18. 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

19. 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

20. 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

21. 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-

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

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

24. 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

25. 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

26. 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!

27. 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?

28. 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?

29. Prep Materials

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

31. Distraction

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

33. 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

34. 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

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

36. 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: /AJP
Bauchner, H., Waring, C., & Vinci, R. (1991, April). Parental presence during procedures in an emergency room: results from 50 observations. Pediatrics, 87(4), doi:
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)
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: /j 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

37. THANK YOU!