Child Life Services

Most hospitals specializing in pediatric care have child life programs,¹  and the number of these programs has doubled since 1965. There are now more than 400 child life programs in the United States and Canada.²  A 2001 survey by the National Association of Children’s Hospitals and Related Institutions found that 95% of 118 responding hospitals employed child life specialists (S. Dull, RN, MSN, MBA, National Association of Children’s Hospitals and Related Institutions, verbal communication of unpublished data, June 30, 2005). Child life services are offered in inpatient pediatric health care settings as well as ambulatory clinics, emergency departments, rehabilitation settings, hospice programs, and even some dental and physician offices.^2–4  The provision of such services is a quality benchmark of an integrated child health delivery system and an indicator of excellence in pediatric care.^5,6  Child life programs and the kinds of services they provide are a component of family-centered care.^7,8  Child life services are also recommended for community hospitals with pediatric units.⁹  Some states have identified the importance of child life services through the regulatory process; for example, a 1999 California statute allowed for the reimbursement of bereavement services by a certified child life specialist for someone who experienced trauma.¹⁰  In addition, hospital licensing standards in New Jersey require the services of a child life specialist in PICUs.¹¹ 

A ratio of 1 child life specialist to 15 or 20 inpatients has been used successfully in some institutions; however, the patient’s age and mobility, the patient population on the unit, and the institution’s needs should influence actual staffing allocation.^12,13  An increasing number of child life specialists are employed in outpatient settings. There are no standardized ratios for outpatient areas, but the same factors should be considered as those for inpatient settings, and thought should be given to providing maximal services during peak visit hours (eg, the emergency department may be busier in the afternoon and evening, and the perioperative area may be more active in the early morning). Child life specialists are generally supervised by a child life manager who, in turn, may report to the hospital or division leadership.

The credentials of a certified child life specialist include the minimum of a bachelor’s degree in child life, child development, human development, or a closely related field; the successful accomplishment of a 480- to 600-hour child life internship under the supervision of a certified child life specialist; and the satisfactory completion of the standardized certification examination. The child life specialist should have an understanding of children of all ages and the family, good communication skills, experience with diverse groups of patients, developmental assessment expertise, and collaborative teamwork abilities. Child life specialists often develop specific areas of expertise related to the patient population they serve, such as infants, toddlers, elementary school–aged children, adolescents, oncology patients, critically ill children, radiology patients, technology-dependent children, etc. They recognize the developmental issues specifically related to illness and health care experiences and understand how to mitigate fears, fantasies, and concerns through adaptive role play, education, and behavior-management techniques. Information about the child life profession and certification of child life specialists is available from the Child Life Council (see “Additional Resources”).

An effective child life program provides developmentally appropriate play, offers informative and reassuring psychological preparation before and during procedures, and helps children plan and rehearse coping skills.¹⁴  Child life specialists are part of an interdisciplinary and family-centered model of care, collaborating with the family, physicians, and other members of the health care team to develop a plan of care.^8,15  The child life component of this plan is based on the individual patient’s perception and understanding of the anticipated health care experience with the goal of enhancing coping.^16,17  Child life specialists support these goals by, for example, teaching the child coping strategies for adjusting to a life-changing injury or dealing with impending death, offering nonpharmacologic pain-management techniques, and communicating the child’s developmental and individual needs and perspective to team members.

The therapeutic interventions of child life staff are most effective when delivered in collaboration with the attending physician, primary care physician, and other members of the health care team as part of the medical home^* for the hospitalized child. Child life programs offer services that support the medical home, defined by the American Academy of Pediatrics as care that is “accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.”^18(p184) 

Play is the primary modality of a child life program because it is both familiar and reassuring for children. It helps make the health care experience less intimidating and more comfortable.^19–22  Experts state that play is believed to be “used by children as a means of reducing anxiety produced by stressful conditions.”^17(p213)  Child life programs provide opportunities for play in inpatient medical and surgical areas, ICUs, outpatient clinics, emergency departments, presurgical waiting areas, radiology departments, laboratory waiting rooms, and sibling care centers. Play is adapted to the many age groups in pediatrics. Young children are given opportunities for make-believe play, whereas school-aged children enjoy games with rules.²³  Adolescents will seek to continue their relationships with peers outside the hospital through Internet access and must be provided with opportunities to form new friendships within the hospital. This is particularly important for adolescents with chronic illnesses who may have multiple hospitalizations.^24,25  Activities that promote self-esteem are vital, as is continuation with schooling.

Engaging in developmentally appropriate play, creative or expressive arts (including music therapy, art therapy, drama, video work, and creative writing), and reading activities all help moderate children’s anxiety and decrease the possibility that health care encounters will disrupt their normal development.^3,26–28  Auxiliary programs, such as animal-assisted therapy, therapeutic clowning, or electronic networks for hospitalized children, when used in conjunction with child life services, provide additional supportive activities for all ages of pediatric patients.^29–31 

To help children cope with their feelings, a child life specialist often uses health care play or “medical play.” This child-directed play allows children to be active and exert control over their experiences.^1,12,31–34  These exercises may offer insight into the patients’ concerns and levels of understanding of the health care events. Some examples of child-directed medical play are the exploration of medical equipment, dramatic (or dress-up) play, games or puzzles depicting medical themes, and the creation of artwork using health care materials such as bandage strips, tongue depressors, and syringes.^{1,3,20,34–36}  Such activities allow pediatric patients of all ages to approach a threatening situation with greater familiarity and gain a sense of mastery of the experience, which will help build a basis for future difficult experiences.³⁷ 

Preparing children for hospitalizations, clinic visits, surgeries, and diagnostic/therapeutic procedures is a second important element of a child life program.³⁸  Psychological preparation is a “process of communicating accurate and developmentally appropriate information, identifying potential stressors, as well as planning and practicing coping strategies.”^37(p18)  Many hospitals and other health care facilities have developed preparation programs on the basis of this process that familiarize the children and their families with the circumstances and procedures they will encounter. These developmentally supportive programs help reduce emotional disturbances in hospitalized children.^1,8,39,40  Two studies with children in a perioperative setting indicated that preparation programs before surgery lowered the children’s anxiety and increased their comfort levels.^35,41  Oncology clinics, day surgery units, radiology departments, dialysis units, primary care clinics, emergency departments, eating disorder programs, dental clinics, and other health care settings have used child life specialists to help children anticipate and manage health care experiences.^38,42–55  An emergency department study reported that child life specialists play a major role in calming fears of children, particularly 11- to 14-year-olds requiring sutures, and lead to a higher parent satisfaction rating of the entire care experience.⁵² 

The child life role in children’s perioperative experiences is important. When preparing children and families for procedures, child life specialists not only share accurate descriptions of the experiences children will have but assist children in expressing what they think is going to happen.³⁷  Plain body-outline dolls and other dolls are useful tools of the child life specialist during psychological preparation before procedures occur.^33,56  Misconceptions can be corrected, and a child’s understanding can be clarified. In addition, child life specialists provide opportunities for children to examine equipment and give them developmentally appropriate explanations of their use.^8,20,55  Information and opportunities to handle equipment help make the unpredictable events more manageable, reduce anxiety, and enable the child to plan and rehearse coping strategies.^57,58  Strategies used may include relaxation, visualization, guided imagery, and pain-management techniques. Such observations are shared with the rest of the health care team so that all are better prepared to respond supportively to the individual patient.

A child life specialist who is present with a parent during a procedure also can enhance the parent’s ability to support the child. This can contribute to a patient’s ability to cope more effectively, often resulting in greater cooperation and success during the procedure.⁵⁹  In the absence of parental support, a child life specialist can provide support, enabling staff members to use their time more efficiently.

The third major area of child life services involves education and support of parents and family members, including siblings. 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.⁶⁰  Parents and other family members may be highly anxious about the child’s illness or the various diagnostic and treatment regimens, and such anxiety can be transmitted easily to the patient.^20,39  Child life specialists and other members of the health care team collaborate to facilitate the family’s coping with and adjustment to the child’s illness and health care experience. Child life specialists help family members understand their child’s response to treatment and can help parents maintain their caregiving roles by promoting parent/child play sessions and by sharing strategies for comforting their children during medical procedures, for example. Well siblings can be helped to comprehend a brother’s or sister’s illness via developmentally appropriate teaching sessions and by offering support during visits to ICUs. In collaboration with the primary care physician and other members of the interdisciplinary team, child life services may be integrated within some palliative care teams, hospice services, and home care programs. Specially trained child life specialists can offer grief support activities for siblings in the event of catastrophic injury or death. They also have assisted children during episodes of terrorism.^8,61–64  It is important to protect children and families from prolonged or repeated exposures to situations in which they feel overwhelmed, unable to escape, or unable to have choices. The health care experience can become complicated by these scenarios, and child life specialists can help ameliorate the effects that these adverse experiences have on children and families.

There are almost twice as many hospitalized children in the 0- to 4 year-old age group as there are in the 5- to 14 year-old age range.⁶⁵  In addition, although fewer children are hospitalized, the children who are admitted are more seriously ill and often require longer stays.⁶⁶  Child life programs have had to adapt to younger, less mobile patients who have more complex medical problems. As a result, fewer group interactions are possible, and greater individualization of care is needed. Child life staff members are challenged to meet each child’s emotional, developmental, and educational needs more quickly and efficiently than before and to provide as many normal life experiences as possible. In a continued effort to create “normalcy” for patients, child life specialists often assist parents in arranging for tutoring services for children.⁹ 

The adolescent population must also be considered. The increased survival rate of chronically ill patients has resulted in an expanded need for child life specialists in adolescent care. Teenagers with spina bifida, cystic fibrosis, and other chronic diseases are living longer now.⁶⁷  A new challenge has emerged as more chronically ill adolescents are making the transition to the adult health care system.^67,68  Child life specialists have often played a role with the health care team in helping with that transition.

The expansion of outpatient care has resulted in more demands for ambulatory child life activities as their value and benefits have become recognized. Both direct and indirect interventions are used to support patients and families across the continuum of care. For example, posters may be mounted in treatment areas to educate staff and parents about effective positioning or coping techniques to use with children of different ages. In some cases, a telephone consultation made by a child life specialist can help parents prepare their child for an outpatient procedure.

As health care costs escalate, there is an ongoing effort to justify the cost of child life services. It is clear that more empirical data are needed to explore the value and effectiveness variables of child life services. An experimental evaluation of one child life program model showed that its presence had a significant positive effect on the pediatric patients.³⁹  Specifically, the children in the experimental study had less emotional distress, better overall coping during the hospital stay, a clearer understanding of the procedures, and a more satisfactory posthospital adjustment and physical recovery. The children spent less time on initial pain-management narcotics, the length of stay was slightly reduced, and parents were more satisfied. In another study, child life specialists taught parents in the emergency department how to use distraction and “positioning for comfort” before their child’s venipunctures. The combination of interventions resulted in lower fear and distress scores.⁶⁹ 

Child life services contribute to an organization’s efforts to meet the standards of the Joint Commission on Accreditation of Healthcare Organizations such as developmentally appropriate care, effective communication for patient education, safety issues, age-appropriate environments, and assessment of patients. These specialists assist health care team members to communicate with patients and families on the basis of the child’s developmental and individual needs.⁷⁰  Child life programs can assist in the education of students and professional staff in medical, nursing, and other fields regarding psychosocially sound and developmentally appropriate care.^53,71,72  The role and competence of pediatric unit volunteers are enhanced when they are educated, guided, and supervised as part of a child life program.⁷³ 

Child life specialists are keenly aware of the perspective and concerns of children and the benefits of family-centered care and, thus, are valuable consultants regarding the physical environment of pediatric settings and the effect of these settings on the behavior and adaptation of children. Child life specialists offer a useful perspective on hospital committees such as ethics or bereavement committees.

Child life expertise has applications beyond conventional hospital care. Child life interventions can help children transition back to home, school, and community. Child life specialists can actively help with school reentry and facilitate a variety of support groups for patients and their siblings.^74,75  In addition, child life specialists in pediatric programs located within larger adult-oriented institutions often are called on to work with children of adult patients.⁷⁶  They are able to help children deal with a parent’s illness or impending death. Child life specialists also 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.¹³ 

Child life services make a difference in pediatric care. Although more research is needed, there is some evidence that child life services may help to contain costs by reducing hospital length of stay and decreasing the need for analgesics.^39,59  Observation and consumer satisfaction feedback further confirm the positive effects of child life programs on children, families, and staff. It remains essential for child life specialists to adapt and grow with the changing health care system in support of the emotional well-being of children and families.^77,78 

1. Child life services should be considered an essential component of quality pediatric health care and are integral to family-centered care and best-practice models of health care delivery for children. Child life services should be performed in collaboration with and give support to the child’s medical home.

2. Child life services should be provided directly by or in consultation with qualified child life specialists in pediatric inpatient units, ambulatory areas, emergency departments, and chronic care centers to the extent appropriate for the population served.

3. An appropriate ratio of child life specialists to patients should be developed for inpatient and ambulatory areas. Both inpatient and ambulatory ratios should be adjusted as needed for the severity and acuity of illnesses of the patients served.

4. Child life services should not be withheld for lack of reimbursement. Advocacy for financing of child life services should occur at the facility, local, state, and federal levels.

5. Home health, hospice, and bereavement programs should be encouraged to include child life services.

6. Additional research should be conducted to validate the effect of child life services on patient care outcomes with attention to outcomes of specific interventions as well as cost-effectiveness.

Erin R. Stucky, MD, Chairperson

Jerrold M. Eichner, MD

Sanford M. Melzer, MD, MBA

Jack M. Percelay, MD, MPH

Anthony L. Pearson-Shaver, MD, MHSA

Ted D. Sigrest, MD

Susan Dull, RN, MSN, MBA

National Association of Children’s Hospitals and Related Institutions

Mary T. Perkins, RN, DNSc

American Hospital Association

^*Jerriann M. Wilson, CCLS, MEd

Child Life Council

Timothy E. Corden, MD

Joint Commission on Accreditation of Healthcare Organizations, Hospital Accreditation Professional and Technical Advisory Committee

Brad W. Warner, MD

Section on Surgery

Christina Brown, MS, CCLS

Child Life Council

S. Niccole Alexander, MPP