The Value of Certified Child Life Specialists: Direct and Downstream

The Value of Certified Child Life Specialists:

Direct and Downstream Optimization

of Pediatric Patient and Family Outcomes

Jessika Boles, PhD, CCLS

Camille Fraser, MS, CCLS, CIMI

Katherine Bennett, MEd., CCLS

Maile Jones, MEd.(c), CIMI

Jenna Dunbar, MEd.(c), CIMI Ashlie

Woodburn, MEd., CCLS, CIMI Mary

Ann Gill, MEd.(c)

Anne Duplechain, MEd.(c)

Erin K. Munn, MS, CCLS, CIMI Katy

Hoskins, CCLS

Full Report | January 2020

Abstract

____________________________________________________________________________

Today’s value-based healthcare market demands that hospitals, clinics, and medical

professionals provide high quality care at sustainable costs for patients and payers alike. Top-

decile performers systematically target each dimension of the Quadruple Aim, registering

incremental yet cumulative gains (and savings) in safety, timeliness, effectiveness, efficiency

and equity in patient-and-family-centered care. These ambitious objectives require a

multidisciplinary approach, particularly when serving infants, children, adolescents and

emerging adults, and their families. Certified Child Life Specialists, as psychosocial healthcare

professionals with focused training in child development, family systems, and evidence-based

supportive interventions, are indispensable members of high-caliber healthcare teams. In

collaboration with medical and allied health professionals, Certified Child Life Specialists bring a

multifocal lens, individualized to the needs of pediatric patients and their families, grounded in

developmental theory, attuned to the influence of past and present trauma, and aimed at

building resilient family systems. Capitalizing on the power of therapeutic relationships and the

expansive benefits of play-based interventions, Certified Child Life Specialists help children,

youth, and families lay the foundation for lifelong health and wellness. In these ways, child life

professionals significantly reduce the financial, developmental, and psychological costs

associated with the discomfort and distress that persist far beyond each episode of care. By

doing so, Certified Child Life Specialists ensure a cost-effective experience for patients and

families that cultivates well-informed, actively engaged, loyal consumers of healthcare services

throughout the lifespan.

TABLE OF CONTENTS

____________________________________________________________________________

Introduction 2

Value Driver 1: Institutional Savings 7

Preparation 8

Procedural Support 8

Institutional Outcomes of Preparation and Procedural Support 9

Value Driver 2: Psychosocial Outcomes 11

Coping Skills Education 11

Managing Pediatric Pain and Distress 12

Comfort Positioning 14

Value Driver 3: Patient and Family Engagement 14

Communicating with Children 15

Diagnosis Education 16

Adherence-Promoting Interventions 17

Parent Engagement 19

Discharge Education and Health Literacy 20

Value Driver 4: Developmental Impacts 23

Developmental Assessment and Intervention 23

Dimensions of Play 25

School Reentry 28

Transitional Care 29

Value Driver 5: Healthcare Consumership 31

Pediatric Medical Traumatic Stress 31

Infant Mental Health and Attachment 33

Mental Health Outcomes in Childhood and Adolescence 34

Sibling Support 36

Legacy Building 37

Bereavement Support 38

Child Life in Community Settings 40

Cultivating Resilience 41

Conclusion 42

Acknowledgements 43

References 44

Contributors

The Value of Certified Child Life Specialists: Direct and Downstream

Optimization of Pediatric Patient and Family Outcomes

____________________________________________________________________________

In the era of Pay-for-Performance and the

Quadruple Aim, healthcare providers,

payers, and organizations must do more, in

better ways, for less cost. Healthcare-

associated expenses in the United States

have risen at unsustainable rates, creating a

dynamic in which high-quality service

comes with a high price tag for both direct

and indirect stakeholders. Despite

multilevel, multifocal, and multidimensional

efforts, per capita healthcare costs in the

United States are rapidly approaching

double those of other developed nations -

without generating comparable

improvements in population health.

1-3

Pinpointing a singular root cause for the

industry’s transformation is problematic.

Even more challenging is identifying cost-

effective tactics that adequately broach the

“quality chasm”

omnipresent in healthcare

today. Patients and families now enjoy

unprecedented access to performance

ratings, comparative indices, and customer

reviews. When this transparency is coupled

with the sheer number of healthcare service

models available, institutions must

differentiate themselves from the

competition by investing in strategies that

improve care quality, maximize

reimbursement incentives, and instill

consumer loyalty. Emerging techniques and

technologies are quickly being adopted

across the industry; thus, expanding patient-

and-family-centered services is a prime and

promising opportunity to elevate the patient

experience. Certified Child Life Specialists

(CCLSs) - frontline members of

multidisciplinary care teams - create and

maintain an experience and culture within

pediatric healthcare that others cannot.

Prioritizing the coping and developmental

needs of pediatric patients and families,

CCLSs promote and protect emotional

safety in times of healthcare duress. Their

work is predicated on individualized

assessments of patient-and-family strengths

and stressors, alongside the illness and

treatment factors that threaten family

functioning and well-being. As they build

therapeutic relationships with infants,

children, youth, and families of all

circumstances and backgrounds, CCLSs

integrate their knowledge of child

development, family systems, and the

healing properties of play to promote

optimal physical and psychological health in

the face of stress-inducing healthcare

experiences.

In order to become a CCLS, individuals

must fulfill specialized academic

requirements, complete clinical training

hours under qualified supervisors, and

successfully pass a standardized

certification exam. Today’s CCLSs often

complete additional postgraduate work

and/or hold supplemental certifications in

related intervention sets (e.g., grief

counseling, infant massage, and patient

experience) to further refine their expertise

in providing high-quality, cost-effective, and

impactful psychosocial care for children and

their families. Although most prevalent in

the United States, Canada, and Japan,

CCLSs work in children’s hospitals and

healthcare settings across five continents;

2 | ACLP

the Association of Child Life Professionals

(ACLP) and its certifying body, the Child Life

Certification Commission (CLCC), maintains

a membership of more than 6,200 certified

professionals worldwide. Regardless of

geographic location or cultural setting,

CCLSs employ an individualized approach

that honors and serves patients and families

of all backgrounds, experiences, belief

systems, and preferences.

Certified Child Life Specialists are patient-

and-family-centered care professionals who

have established and raised the proverbial

bar for the patient experience movement in

healthcare settings.

Recognized by the

American Academy of Pediatrics,

the Beryl

Institute,

the Canadian Paediatric Society,

the Society of Critical Care Medicine,

The

Walt Disney Company,

and decades of

clinical research,

12-16

CCLSs exemplify a

high-yield investment in patient and family

experience, as well as in the direct and

downstream success of healthcare

institutions.

Certified Child Life Specialists integrate six

evidence-based domains to formulate

interventions that meet infants, children,

youth, and families where they are in their

healthcare experience. Combining 1) an

individualized approach to care, 2) a focus

on cultivating resilience, 3) cognizance of

the developmental contexts in which

children and families live and grow, and 4)

consideration for the impacts of past and

present trauma, CCLSs 5) establish and

develop therapeutic relationships by 6)

capitalizing on the expansive utility of play

(see Figure 1 below).

Figure 1. The Six Domains of Child Life Services.

The Value of Certified Child Life Specialists | 3

It is at the crux of these six domains that

CCLSs promote and optimize patient and

family outcomes throughout their healthcare

journey.

Individualized Approach.

Given the growing call for effective

psychosocial interventions in an

increasingly diverse patient population, a

core component of child life practice is

addressing the individual needs of children

and families to improve their care

experience. Certified Child Life Specialists

develop clinical partnerships with children

and families that make the healthcare

experience more empowering and positive;

they take an other-oriented stance that

reflects advocacy, cultural sensitivity, and

effective communication.

By recognizing

the importance of care that prioritizes and

responds to person-specific needs, CCLSs

integrate themselves into each unique

system to build rapport, cultivate trust, and

provide necessary psychological support

services to help patients and families

identify and achieve their goals. Through

careful and continuous observation of their

distinct characteristics, CCLSs to engage

patients and families in ways that build upon

their strengths and empower them as active

participants in their care. Taking this

collaborative, individualized approach,

CCLSs help patients and families master

their healthcare experience, promoting

improved psychological, physical, and

behavioral health outcomes.

Resilience-Focused.

Certified Child Life Specialists facilitate

psychosocial interventions that build and

fortify resilience in patients and families

facing healthcare challenges. Characterized

by maintaining personal well-being even

when enduring moments of stress,

adversity, and grief,

17,18

resilience is a

phenomenon capable of being both

threatened and enriched by healthcare

encounters. By capitalizing on the individual

and collective strengths of each child and

family, CCLSs reinforce and generate

adaptive coping skills,

positive

appraisals,

health-promoting behaviors,

problem solving skills, and goal setting

behaviors

- all of which are integral

features of resiliency. The patient-and-

family-centered approach CCLSs employ

includes the patient and their identified

family system in partnership with one

another, which achieves optimal trust and

alliance across providers and healthcare

settings.

Certified Child Life Specialists

acknowledge the importance of

relationships to bolster positive outcomes by

prioritizing opportunities for peer

connections,

optimizing family

functioning,

and cultivating therapeutic

clinical relationships with patients of all ages

and their family members.

In collaboration

with patients and families, CCLSs ensure

that healthcare experiences engender

resilience, thereby establishing the

foundation of both psychosocial and

emotional well-being for patients and their

families.

Developmentally Grounded.

Certified Child Life Specialists integrate

seminal and contemporary theories of child

and family development

25-34

to promote

coping and adaptation across the

developmental trajectory. Research has

long demonstrated that infants, children,

youth, and adults interpret and understand

medical information differently, often in

accordance with their evolving cognitive

capabilities and the contexts in which they

live and grow.

35-38

In turn, these individual

appraisals shape the ways in which children

4 | ACLP

and their families respond to and cope with

the stressors of healthcare encounters, and

inform pertinent assessment and

intervention practices.

39,40

Certified Child

Life Specialists, therefore, apply their

calibrated developmental lens and

contextual approach to ensure that

individual needs for education and coping

support are appropriately and sufficiently

met.

41-43

Certified Child Life Specialists also

operationalize their developmental expertise

to help healthcare teams anticipate patient

and family responses to healthcare

experiences, and partner with

multidisciplinary providers to extend the

supports families need for resilience and

recovery.

44-46

Trauma-Informed Care.

The philosophy of trauma-informed care

elucidates the impact of past and present

trauma in the lives of infants, children,

youth, and families - impacts that have far-

reaching consequences for developmental,

psychosocial, and mental health.

47,48

maintaining awareness of their prevalence

and potential manifestations, CCLSs

acknowledge, address, and mitigate the

risks of psychological trauma that are

associated with hospitalization

and other

adverse childhood experiences (ACES).

Existing on a continuum, ACEs involve

events and conditions that inflict or

exacerbate physical, psychological, and

relational distress,

thus encompassing

trauma that spans a multitude of social

environments, such as healthcare settings.

Certified Child Life Specialists have

practiced principles of trauma-informed care

long before the term was coined (e.g.,

understanding and facilitating physical and

emotional safety, establishing trusting

relationships, communicating honestly and

accurately, offering choice and control, and

using a strengths-based approach to care).

As the field has grown, CCLSs continue to

incorporate tools like therapeutic and

medical play, procedural support, and

preparation to decrease manifestations of

traumatic stress during and beyond

healthcare encounters.

43,47,48,51,52

Understanding that 62% of the population

has experienced at least one ACE and that

25% report at least three,

CCLSs assess

and account for ACEs when creating plans

of care. They incorporate approaches true

to the philosophy of trauma-informed care to

allay negative emotional reactions and

maladaptive stress responses (i.e., ACEs),

as well as the ways in which children and

their families interact with new or

unexpected medical events and ongoing

courses of treatment.

52,54

Relationship Oriented.

Defined as “a trusting connection and

rapport established between [clinician] and

[patient] through collaboration,

communication, empathy, and mutual

respect,”

55(p49)

therapeutic relationships

enhance child life interventions, decrease

stress symptoms, and increase positive

developmental and coping outcomes for

infants, children, youth, and their

families.

56,57

Relationships true to these

defining qualities facilitate better

engagement between clinicians, patients,

and families, particularly when formed

through active listening, question-asking,

and sensitive displays to emotional needs.

Through establishing these therapeutic

relationships, CCLSs enhance

communication, teach coping skills, and

build resiliency with and for patients and

families. Strong therapeutic relationships

enhance the quality of communication

between patients, families, and the broader

healthcare team, which not only improves

The Value of Certified Child Life Specialists | 5

the accuracy and deliver

y of

the diagnosis

but also decreases the

frequency of

consumer-generated malpractice

claims.

Play-Based.

Often grossly unde

restimated and

misunderstood, yet

expansively beneficial,

play is among the most

effective tools used

by CCLSs to empower

children

and families

in coping with the

stressors of healthcare

encounters. When indi

vidually and

intentionally constructed

, play

-based

interventions have t

he power to normalize

an otherwise abnormal

healthcare

environment or

experience. Skilled play

partners and opportunities eq

uip children to

regulate their em

otions and manage their

behavioral responses w

hen faced with

painful or distressi

ng procedures, at times

replacing the need

for anesthesia or

sedatives. Thus, play-based psychosocial

care is a functional

, ef

fective means of

alleviating and preventing

trauma among

pediatric patients,

as play provides

distraction, red

uces anxiety, and facilitates

developmentally app

ropriate and effective

communication.

Play is empirically

supported as a signifi

cant opportunit

y for

promoting furthe

r social

-emotional,

cognitive, and langu

age development,

7,59,60

and within the scope of

child life practice,

CCLSs use play to asse

ss the

developmental needs

and potential medical

misconceptions of

pediatric patients and

their families.

Meeting the psycho

social needs of children

and families through i

ndividualized, play

based interventions,

CCLSs form strong

therapeutic rela

tionships that promote

resilience in developm

entally

-appropriate,

trauma-informed ways. I

n addition to the

personally-crafted care exper

ience they

deliver to infants,

children, youth, and

families, more than 40

years of clinical

research and practice de

monstrate that

Certified Child Li

fe Specialists:

1. Drive positive and effec

tive outcomes

for healthcare orga

nizatio

ns by

optimizing the

use of resources and

limiting waste.

2. Generate positive behavioral,

psychological, and physiol

ogical

outcomes through indivi

dualized

interventions wit

h pediatric patients.

3. Empower children and

families to

become informed and

active participants

in their healthcar

e experiences.

4. Promote and sustain opti

mal

developmental and

psychosocial growth

from infancy through

emerging

adulthood.

5. Improve populat

ion health by fostering

long-term patterns

of healthcare

consumership that reduce the risk of

preventable conditions.

Together, these f

ive value drivers produce

substantial outcom

es: significant cost

savings for all he

althcare stakeholders;

improved patient, f

amily, and population

health; enhanced pat

ient experience; and

heightened healthcare quality. (see Figure 2

below).

6 | ACLP

Children are often given sedation or general

anesthesia to complete routine procedures

and radiological scans - burdening

institutions and families with additional costs

and safety risks. When preparation and

procedural support are provided by CCLSs,

sedation and anesthesia use are

diminished, unnecessary expenses are

eliminated, and patient safety is maximized.

The Value of Certified Child Life Specialists | 7

Value Driver 1: Institutional Savings

____________________________________________________________________________

Certified Child Life Specialists drive positive and effective outcomes for healthcare

organizations by optimizing the use of resources and limiting waste. Children who receive

preparation and procedural support require less sedation and anesthesia, demonstrate less

emergence delirium, and consume less narcotic pain medication. As a result, patient safety,

access, and throughput are increased, while staffing costs and post-anesthesia length of stay

are reduced - and significant cost-savings are realized.

Figure 2. The Five Value Drivers of Child Life Services.

Preparation

Preparation, sometimes referred to as

psychological preparation or procedural

preparation, is a fundamental intervention

implemented by CCLSs in which children

and their families are provided with

developmentally appropriate information

about upcoming medical procedures and

experiences.

When equipped with this

accurate and honest information, even very

young patients (such as toddlers and

preschool-age children) and their families

are better able to adjust to and cope with

medical experiences.

Unlike other

multidisciplinary team members, CCLSs

have the education, training, and protected

time to provide high-quality preparation

interventions that align with individual

patient-and-family temperaments, learning

needs, and coping styles.

Certified Child Life Specialists incorporate a

variety of techniques in order to achieve

preparation intervention goals. The specific

method(s) of preparation utilized by a CCLS

vary dependent on an assessment of the

child and family as well as available

resources. Preparation interventions can

include: providing developmentally

appropriate description of the anticipated

sequence of events,

discussing the child’s

questions and concerns using age

appropriate language,

modeling elements

of the procedure,

medical play and

opportunities for the child to manipulate

medical equipment, dolls, and puppets,

66,67

leading coping strategy planning and

rehearsal,

68,69

watching puppet shows

videos,

conducting hospital tours,

reading fiction and/or non-fiction books that

intentionally address relevant stressors,

and providing relevant websites or media

resources for further information.

___________________________________

When preparation and procedural

support are provided by CCLSs,

sedation and anesthesia use are

diminished, unnecessary expenses

are eliminated, and patient safety is

maximized.

___________________________________

Throughout a preparation intervention,

CCLSs rely on observation, interaction, and

return demonstration to assess the child’s

developing understanding, as well as their

ability to cope with the procedure at hand.

When classified as high-quality, preparation

for children undergoing medical procedures

includes teaching through play and

modeling, coping skills training, provision of

procedural and sensory information, and

fostering emotional expression and trust.

A substantial number of studies indicate that

the effectiveness of preparation is highly

dependent on goodness-of-fit between the

specific needs of the child and family and

the teaching modalities utilized by CCLSs.

Thus, across this myriad of strategies, the

central benefit of preparation remains

consistent: patients and families cope more

effectively with what is understood and

expected, rather than what is uncertain and

unpredictable.

Procedural Support

Beyond preparation, CCLSs extend their

support techniques into the procedure room.

With their continued presence, CCLSs can

facilitate a child’s pre-established coping

plan during medical procedures, thereby

minimizing pain perceptions and potential

trauma. Distraction is a highly validated

technique utilized by CCLSs during

8 | ACLP

children’s medical procedures.

73,74

Defined

as a strategic effort to draw a child's

attention away from painful or distressing

stimuli, distraction techniques decrease pain

perceptions

and emotional distress

during invasive medical procedures.

Although distraction is a highly effective

component of procedural support, it is just

one of many tactics that CCLSs use to help

infants, children, and youth manage their

anxiety. For instance, CCLSs assess and

modify the procedural environment before

and throughout the child’s experience by

minimizing unnecessary sensory stimuli,

anticipating developmental stressors (e.g.,

concerns about privacy, needs for

autonomy and control, fears of strangers),

facilitating communication with the

healthcare team, and advocating for

individualized solutions.

Certified Child Life Specialists apply their

developmental assessment skills to identify

the most effective active, passive, or

combinatory distraction techniques for each

child. Active distraction encourages a child’s

engagement with a preferred stimulus

through physical movement or cognitive

processing. Examples include distraction

cards,

virtual reality,

interactive

applications on a computerized tablet,

or a

kaleidoscope.

Conversely, passive

distraction provides stimuli that does not

require the child's active engagement.

Audiovisual resources such as cartoons,

wall projections,

movies,

and music,

are examples of passive procedural support

approaches. When developing coping plans

with children and coaching them through

their identified coping techniques, CCLSs

invoke their developmental training to help

children confront their stressors while

simultaneously incorporating patient

preferences and adapting to procedural

elements.

Multidisciplinary collaboration is

vital in providing quality care during

procedures

84,85

; and when a CCLS is

present in these moments, nurses report

they are more able to tend to the medical

needs of the patient while still feeling

confident that the child’s coping needs are

being met.

When children’s needs are

anticipated and coping plans are enacted,

CCLSs transform potentially traumatic

procedures into empowering experiences

for infants, children, youth, and

parents/caregivers.

Institutional Outcomes of Procedural

Preparation and Support

The overlap of preparation and procedural

support is most profound in procedure-

oriented healthcare settings, such as

radiology and radiation-oncology, where

these interventions significantly lower

sedation rates among infants and children

who would otherwise require sedation to

successfully complete procedures and

scans.

61,87-92

Therefore, beyond the

demonstrated benefits for individual patients

and families, preparation and procedural

support also render gains for the provider

and facility performing the procedures. For

example, preparation programs, often

facilitated by CCLSs, demonstrate lower

rates of sedation and anesthesia, as well as

comparable rates of diagnostic-quality

image acquisition without increasing

procedure time.

68,71,87,93,94

Research

demonstrates that when preparation and

procedural support are provided in

conjunction with one another, patient

outcomes are improved and institutional

efficiency is optimized. Furthermore, when

provided by a CCLS, these interventions

address the individual needs of the patient

and account for their unique stressors and

developmental preferences. This patient-

The Value of Certified Child Life Specialists | 9

specific approa

ch results in children being

significant

ly more likely to complete scans

with diagnost

ic quality images without

requiring

sedation or

general anesthesi

thereby l

essening the need for repeat

procedures, red

ucing costs for the hospital,

and mitigat

ing negative emotional impact on

the child.

63,91,95

,96

Although chil

d life services are an

operational exp

ense, they result in

substantial

turn on inv

estment (ROI)

through the r

eallocation of valuable

anesthesia and staf

fing resources.

90,97-99

radiation oncology

program recorded

savings upwards

of $775,000 per year when

children parti

cipated in a play

-based

procedural prep

aration and suppor

t with

CCLS

; similarly,

a Magnetic Resonance

Imaging (

MRI) program reported an annual

net savings

of $117,870 following the

implementati

on of a mock scanner

preparation inter

vention.

For children

need of intr

-articular joi

nt injections,

preparation and procedu

ral support from a

CCLS gener

ated a 33% cost savings by

reducing the

need for deep sedation

- all

whilst mai

ntaining a 97.5% completion rate

in those cases pe

rformed without

sedation.

Additional

cost savings have

been observed i

n preoperati

ve settings,

with

preparation and p

rocedural support

interventions

yielding a 24% shorter length

of stay, ear

lier post

-procedural extubat

ion,

and a 14% reductio

n in emergence delirium

for those

receiving anesthesia.

69,100-102

These findi

ngs are of great s

ignificance

, as

when anesthesia or sed

ation are used in

infants, children,

and youth, safety

monitoring

and medical management needs

amplify, the

reby constraining institutional

resource reserves

and increasing staffing

costs.

103

When CCLSs a

ctively facilit

ate

preparation and p

rocedural support, larger

numbers are

served at greater efficiency,

improving accessi

bility and throughput for

both individual

s and institutions.

14,96

For

instance, children sche

duled for MRI without

sedation - in conjuncti

on with prep

aration

and procedural

support provided by a CCLS

- demonstrated

an order completion period

of 15 days,

compared to 46 days for those

scheduled wi

th sedation.

Even after

time

and materials

involved in preparation

interventions

are adjusted for, the overa

cost of MRI

remains lower as a function of

the decrea

sed need for sedation and

shorter l

ength of stay (approximately three

hours less per

patient).

104

And, as cos

decrease and re

source use is optimized,

high-quality heal

thcare is actualized.

In addition to red

ucing rates of anesthesia

and sedation duri

ng procedures,

preparation provide

d by CCLSs reduces

unnecessary m

edication use. For example,

preparation has

shown to decrease the

amount of narc

otic pain medications

pediatric pat

ients consume by up to

50%,

thereby r

educing waste, minimizing side

effects, and

helping prevent medication

misuse.

100

When parents

/caregivers partner

with CCLSs i

n providing preparation and

procedural suppor

t, studies have

demonstrated

a 28% reduction in the use of

oral Versed

(midazolam)

in pediatric

surgical patien

- again, wit

hout increasing

length of preoper

ative or induction time.

105

In outpatien

t, non

-surgical setti

ngs,

procedural suppor

t interventions have

shown to be

equal to or more effective than

lidocaine an

d other

topical an

algesics in

aiding pati

ent coping, additionally reducing

care costs whi

le also improving patient and

family experi

ence.

82,101,1

06,107

Thus, when

CCLSs provide

preparation and procedural

support, t

hey decrease the need for

10 | ACLP

anesthesia, sedation, and narcotic pain

medication in pediatric patients, reduce the

risk of medical complications or adverse

events, and produce unparalleled cost

savings for healthcare facilities.

Value Driver 2: Psychosocial Outcomes

____________________________________________________________________________

Certified Child Life Specialists generate positive behavioral, psychological, and

physiological outcomes through individualized interventions with pediatric patients. They

implement an array of play-based, coping-focused techniques shown to ameliorate pain, lower

anxiety, reduce distress, and increase satisfaction with - and loyalty to - institutions of care.

Children demonstrate fewer behavioral disturbances during and beyond medical encounters

when receiving comprehensive preparation, procedural support, and coping skills education, all

of which are associated with accelerated healing.

Healthcare encounters and medical

procedures pose a multitude of threats to a

child’s psychological well-being, such as

disruption of normal routines and

relationships; separation from home, family,

and community; fear and uncertainty; pain;

and loss of control.

108-110

However, by

providing individualized, developmentally

appropriate, and resilience-oriented

interventions, CCLSs facilitate positive

coping, minimize distress, and optimize

patient and family outcomes.

Coping Skills Education

Coping skills education is an aspect of

preparation and procedural support with

benefits that transcend individual stressors,

situations, and settings.

Children’s

responses

to distressing events (e.g.,

illness, injury, or hospitalization) are largely

determined by their individual appraisals of:

1) the stressor at hand, and 2) their

perceived resources and abilities for

managing the stressor. Coping, then, refers

to an individual’s cognitive/behavioral

responses (both verbal/nonverbal and

active/passive) resulting from their

perceptions of stressors and self. Adaptive

(i.e., positive) coping strategies help

children and families manage their emotions

and respond effectively when stressed, but

multiple factors, including developmental

status, previous trauma exposure, and

cognitive or emotional fatigue, can influence

a child’s knowledge and use of coping

strategies.

22,111

When they are unable to

engage in adaptive coping strategies,

children and families experience

psychosocial distress or trauma, which then

jeopardizes illness management and

wellness outcomes.

17,22,112,113

While many possible coping mechanisms

exist, the most prominent - and powerful -

adaptive modality in childhood is

play.

43,114,115

Unfortunately, healthcare

events have been empirically shown to

disrupt children’s access to and ability to

engage in play; this leads to developmental

regression and coping difficulties,

116,117

well as altered levels of the stress

hormones (heightened cortisol and lowered

norepinephrine) associated with adverse

experiences and toxic stress.

118

In stressful

healthcare situations, play is the ideal

coping tool for children because it affords

them a sense of familiarity alongside

opportunities for active engagement,

The Value of Certified Child Life Specialists | 11

control, an

d mastery.

114,115,

119

Engaging i

play is particularly ef

fective when designed

and facilitated

by trained professionals,

such as CCLS

s, boosting positive coping

behaviors and

optimizing outcomes.

119-122

Furthermo

re, CCLSs routinely o

ffer play-

based, family-centered c

oping skills

education t

o address both illness

- and non-

illness-related developm

ental and

psychosocial need

s. For example, CCLSs

construct t

herapeutic, child

-directed play

sessions that

encourage children to express

their emotions mo

re readily,

often util

izing

techniques simi

lar to those implemented

during prepar

ation and procedural support

interventions

Expanding t

he range and variety of coping

resources avail

able to patients and families,

CCLSs provide

additional skil

ls-based

coping interven

tions (e.g., problem solving,

communication

skills, deep breathing,

muscle relaxat

ion, distraction, imagery,

positive thinki

ng).

111,123-125

These

interventions

positively influence children’s

appraisals of t

he intra

- and interper

son

resources they

possess for managing

medical str

essors. Moreover, CCLSs

capitalize on t

he health benefits of social

support - a resource rea

dily available to

most patien

ts and families but at times

unrecognized

and untapped

- by offering

peer support

int

erventions t

o improve

coping, heal

-promoting beha

viors, and

patient sa

tisfaction.

44,126,1

These

interventions

are particularly effective for

adolescents, a pat

ient population for whom

peer interaction

is a primary driver of

socioemotional

development.

126,128

teaching, m

odeling, and facilitating adaptive

coping skill

s, CCLSs catalyze long

-term

benefits f

or children and families that

continue far

beyond the medical moment.

Selecting from

their repertoire of play

- and

skills-based tools

, CCLSs assess

psychosocial and develo

pmental risks and

strengths t

o support patients and families in

creating i

ndividualized coping plans.

125

Collaborative and pe

rsonalized

interventions

like these are linked to long

term imp

rovements in psychosocial well

being, infor

mati

on seeking, i

llness self

efficacy, il

lness knowledge, and treatment

adherence.

123-126,129

Especially be

neficial for

children with au

tism spectrum disorder

(ASD),

individualized coping plans have

been shown t

o improve patient and family

satisfaction and

red

uce procedur

distress.

130-133

Therefore, play-based coping

skills educat

ion is a cornerstone intervention

with which CCLS

s enhance patient

experience, encou

rage health

-promoting

behaviors, and nu

rture resilience.

Managing P

ediatric Pain and Distress

The impact o

f acute or chronic pain and

distress on

children’s psychosocial well

being is un

deniable. Hospitalized children

have been found

to experience an average

of 6.3 painful procedu

res each day,

134

and

without pr

oper pain management and

coping suppor

t, c

hildren can experie

nce

compounding distr

ess and long

-term

psychological seq

uelae such as needle

phobia.

135

This is especi

ally true for infants

as neural structures in

the developing brain

and pain pathways t

hroughout the central

nervous system

can be perma

nently alt

ered

by painful procedu

res, thereby heightening

pain sensations throu

ghout the lifetime.

136

When paired

with frightening or distressing

procedural exper

iences, these factors

understandabl

y influence an individual’s

approach to healthcar

e later in

life.

For example,

in day surgery, children’s peak

anxiety at t

he time of anesthesia induction

and increased di

stress during transitions in

12 | ACLP

care can persist for days and weeks

following the procedure.

108

When left

untreated, prolonged anxiety leads to

increased self-reported pain, behavioral

changes, consumption of more

acetaminophen and codeine following

hospital discharge, and greater risk of

emergence delirium

110

; specifically, higher

salivary cortisol (a physiological indicator of

stress) is connected to greater morphine

consumption.

142

However, children who

receive developmentally appropriate

preparation and procedural support show

significant decreases (upwards of 59%) in

perceived, measured, and observed pain

and distress

13,75,98,144-148

and, in some cases,

accelerated healing.

149

Developmentally appropriate and

individualized preparation and procedural

support provided by a CCLSs has the

capacity to lessen children’s healthcare

anxieties.

67,75,100-102,137-143

Studies

consistently demonstrate that without

preparation and procedural support, many

children not only experience acute distress,

but can also display negative behavioral

and psychological changes such as apathy,

withdrawal, separation anxiety, and sleep

disturbances. And, for nearly 30% of

pediatric patients, these difficulties will

persist for more than 14 postoperative

days.

109

However, when provided with

developmentally appropriate preparation

and procedural support, and guided through

selection and rehearsal of coping

techniques by a CCLS, children

demonstrate fewer problematic emotional

and behavioral changes.

70,143,148

specifically, studies have noted a decrease

in anger, aggressiveness, sleep problems,

concentration, hyperactivity, and impulsivity,

among children following surgery

66,141

with

impacts lasting up to 10 days post-

discharge

150

when these supports are

provided. Additionally, pediatric patients that

receive adequate preparation and

procedural support demonstrate improved

appetite and willingness to eat, and report

feelings of mastery, growth, and joy.

141,151

Preparation and procedural support not only

aid patients but also the entire family

system, including parents, grandparents,

legal guardians, and other caregivers. For

example, parents of children who receive

preparation and procedural support also

experience lower levels of distress and

significant decreases in anxiety over

time.

67,100,139-141,144,150,152-154

This reduction in

parental anxiety positively impacts the

child’s emotional response, given the direct

correlation between parent and child

distress in medical settings.

140

Thus, low

levels of parent and child distress improve

overall psychosocial outcomes at and

beyond the time of hospitalization.

13,76,155,156

___________________________________

However, children who receive

developmentally appropriate

preparation and procedural support

show significant decreases (upwards

of 59%) in perceived, measured, and

observed pain and distress

13,75,98,144-

148

and, in some cases, accelerated

healing.

149

___________________________________

From an experiential standpoint, preparation

and procedural support provided by CCLSs

improves the overall patient and family

experience. The anxiety- and stress-

reducing functions of such interventions

have shown to increase parent/caregiver

satisfaction with the care their child

The Value of Certified Child Life Specialists | 13

received.

13,67,78

,98,101,139,140,143,148,150,157,158

Moreover, fa

milies are more likely to return

to or recommen

d the treating facility to

others when pr

ocedural support was

provided and are, t

hus, a cost

-effective and

organic marketing

mechanism for the

healthcare ins

titutions they serve.

Comfort Pos

itioning

Another w

ay CCLSs support children's

coping and family engag

ement during

procedures is t

hrough comfort positioning.

Comfort posi

tioning refers to the strategic

use of posit

ive parent/child touch to provide

safe, yet suppor

tive, immobilization during

procedures.

159

These positi

oning practices

stand in direct contr

ast to traditional

restraint tech

niques, which have shown to

increase anxiety, decr

ease perceived

feelings of

control, and hinder effective

coping.

160

For example

, the most common

position use

d during pediatric medical

procedures is t

he supin

e position, w

hich

requires the

child to be placed on their back;

however, r

emaining supine throughout such

an experience i

ncreases fear and

tearfulness,

making the child more likely to

become highly di

stressed.

161,162

Comfort posi

tions are an aspect of

procedural suppo

rt planning and

intervention

in which CCLSs purposively

offer paren

ts/caregivers an opportunity to

participat

e in their child’s care, which, in

turn, lessens

parent distress.

163

Children

indicate mor

e positive coping when

procedures occur

whi

le sitting

upright and

comforted by

their parent/caregiver, which,

again, increases pa

rent satisfaction.

162

Certified

Child Life Specialists also

understand

that the implementation of

comfort posi

tioning is dependent on multiple

factors - the child’s

age,

size, and abi

lities,

as well as the

type of procedure

- but that

the practice

itself reaps benefits for all ages.

For example,

even very young infants

placed in a pron

e position rather than a

supine posit

ion for a heel lance, cry less

and experience decreased pain and

distress.

164

Working in co

llaboration with

multidiscipl

inary teams,

CCLSs contr

ibute

an acute aw

areness of individualized,

evidence-based tacti

cs to promote adaptive

coping wit

h medical procedures, thereby

minimizing

distress and

enhancing

satisfaction wi

th care.

Value Driver 3: Patient and Family

Engagement

____________________________________________________________________________

Certified

Child Life Specialists empower children and families to beco

me informed and

active part

icipants in their healthcare experiences.

By providing

timely, individualized

diagnosis, t

reatment, and discharge education for children and families, Certified Child Life

Specialists

promote health literacy and treatment adheren

ce - reducing unne

cessary emergency

department

visits, preventable hospital readmissions, unscheduled clinic visits, and use of

rescue medicatio

ns in chronically ill populations. When education is provided in play

-based,

trauma-informed,

and culturally res

ponsive ways, pa

tient

-family-provider r

elationships and

communication

are strengthened, familial distress is alleviated, and illness self

-management

enhanced.

When healthcar

e providers fail to effectively

communicate wit

h patients and families

about diagnoses, p

rocedures, and

treatment

s, both children and

14 | ACLP

parents/caregivers struggle to cope - often

because of uncertainty and lack of

knowledge; thus, physical and psychological

outcomes are jeopardized. Through ongoing

psychosocial assessment and relationship

building, CCLSs provide educational

interventions that empower children and

families to seek information and become

active participants in their healthcare

experiences.

Communicating with Children

A cornerstone of child life practice, effective

communication with children across all

stages of development is the foundation of

optimal pediatric health outcomes. Children

clearly and consistently report the

importance of receiving honest, accurate

information in healthcare settings,

165-167

and

while physicians also identify honesty as a

priority in healthcare communication,

167

the

medical terminology in which they are

trained is difficult for children and youth to

interpret.

165,168

Ineffective communication

fuels children’s misconceptions and fears

about their illness and treatment.

Conversely, children indicate that receiving

intelligible information about their body,

condition, and care is important in

ameliorating their fears.

165,169

When communication is categorized as

effective, rather than avoidant or ineffective,

children exhibit significantly less distress

(i.e., withdrawal, anxiety, depression) and

fewer social problems.

166

Thus, a pivotal

apex in pediatric healthcare improvement is

individually tailored, developmentally

appropriate communication with children,

and CCLSs advocate for, educate about,

and deliver this intentional communication

with patients of all ages and backgrounds.

Blending cognitive, psychosocial,

information-processing, and sociocultural

perspectives, CCLSs anticipate and assess

for the nuanced understandings that shape

children’s communicative capacities, such

as the development of symbolic thought, the

initiation and resolution of fantastical

thinking, the importance of concrete

exploration and explanations, and the point

at which concerns about the future start to

inform present decision making.

Furthermore, CCLSs are trained in

attending to contextual factors that influence

children’s thoughts and words (even those

that are left unsaid), including cultural

beliefs, family structures, perceived power

dynamics between patients and providers,

and elements of the physical environment

often unnoticed by adults and providers

(e.g., counter heights, seating

arrangements, color schemes, and

accessibility of age appropriate play

materials). Merging their six domains of

practice, CCLSs display and implement a

precisely calibrated skill set for approaching,

involving, and aiding children, youth, and

their families in understanding their care.

Certified Child Life Specialists recognize

that the timing of effective healthcare

communication is an important component

for facilitating patient autonomy in care and

decision-making.

165

As seen with adults,

earlier and more frequent communication is

best. Thus, when communication with

children is conducted using age-appropriate

methods of care planning, patients from

early childhood to emerging adulthood can

better understand illness concepts and

more actively participate in medical

decision-making.

170

By improving

comprehension of their healthcare needs

and eliciting effective communication of their

wishes, age-appropriate and accessible

styles of communication in healthcare

settings facilitate further engagement of

The Value of Certified Child Life Specialists | 15

pediatric patients in their care.

171

Care and

communication that is patient-centered and

collaborative coincides with greater

perceptions of control and competence

amongst patients and parents/caregivers,

resulting in higher self-efficacy and

adherence, especially among older pediatric

patients.

172

Although the need for effective

communication in healthcare settings is

clear, nurses and physicians indicate

considerable barriers when interacting with

children. Nurses identify lengthy, more

involved communication about important

healthcare information as difficult to

prioritize in their busy clinical days, and

physicians note their lack of knowledge

regarding communication with children as a

primary impediment to effective interactions

with pediatric patients.

173

However,

developmentally appropriate communication

facilitated by CCLSs mitigate many of these

barriers noted by nurses and physicians.

Considering that healthcare subject matter

tends to be complex and emotionally

charged, CCLSs apply their education and

training to deliver and reinforce information

that facilitates patient involvement in ways

tailored to their individual needs.

Furthermore, when the subject matter

seems less life-altering, the importance of

therapeutic relationship building - a core

component of child life care - has a salutary

effect on patient and family satisfaction

during treatment.

174-176

The time constraints

often noted by other healthcare

professionals are less applicable to CCLSs

because their profession is largely

dependent upon communication for

education, coping skills training, and

advocacy.

Diagnosis Education

As many as one in four children in the

United States are living with chronic health

conditions - with incidence estimates rapidly

rising - suggesting an important and

expanding need for developmentally

appropriate diagnosis education that begins

early in the illness trajectory.

177

The term

“diagnosis education” describes a multitude

of play-based and developmentally

grounded interventions designed to

increase patient-and-family knowledge and

skills related to medical conditions and their

management.

178,179

Certified Child Life

Specialists employ their distinctive

communication abilities to provide diagnosis

education for patients and families, further

encouraging parental involvement and

continuing to support families with honest

information-sharing.

Diagnosis education is most effective when

it is developmentally appropriate and

incorporates both problem solving and

coping skills training.

180-182

Certified Child

Life Specialists have the distinctive and

dedicated knowledge, focus, resources, and

clinical time to build therapeutic

relationships with children and families,

ensuring that education is individually

tailored, developmentally appropriate, and

coping-focused. In collaboration with

members of multidisciplinary healthcare

teams, CCLSs provide diagnosis education

that improves patient and family experience

in diverse situations, such as inpatient

admissions for ketogenic diet initiation,

perinatally acquired HIV disclosure, burn

rehabilitation, autism support, and

transitional care programs in late

adolescence.

44,45,132,183-187

Research shows that parents/caregivers

struggle with a lack of knowledge and

certainty when communicating medical

16 | ACLP

information to their children, and poor illness

knowledge contributes to increased

psychosocial distress and diminished health

outcomes for children and families.

169,188

fact, clinical and best-practice guidelines

reinforce the importance of combining

pediatric diagnosis education with

psychosocial support. For example, it is

difficult to provide effective diagnosis

education for a patient and family

experiencing healthcare-related emotional

distress

189-191

; thus, combining interventions

that address coping with those targeting

knowledge acquisition creates a space in

which patients and families feel emotionally

and psychologically safe - a space more

conducive to learning and sharing.

Additionally, certain psychosocial risk

factors (e.g., low socioeconomic status,

history of migration experiences, previous

trauma exposures, or childhood mental

illness) are associated with even lower

condition knowledge and higher uncertainty

for child and parent.

192

Certified Child Life

Specialists are adept at communicating with

children in developmentally appropriate

ways to remedy medical misconceptions,

especially through ongoing diagnosis

education. They are aptly positioned within

the multidisciplinary care team to not only

address these issues as they arise but to

also ensure that the mode through which

issues are addressed promotes comfort and

reiterates trust.

By providing diagnosis education, CCLSs

extend benefits to children, families, and

hospitals alike, increasing patient and family

knowledge while also impacting their

behavior in ways that optimize the bottom

line. Children who receive individualized

asthma education, for instance, show

reductions in subsequent emergency

department visits, hospital readmissions,

unscheduled clinic visits, and use of oral

corticosteroids, illustrating a link between

diagnosis education and healthcare

resource utilization.

193-195

Educational

interventions, such as those used by

CCLSs, are associated with long-term

improvements in patient and

parent/caregiver knowledge, psychosocial

well-being, quality of life, and physical

health.

178,195,196

Furthermore,

parents/caregivers who report receiving

more and/or higher quality asthma

education indicate better parent-provider

relationships, highlighting the connection

between quality diagnosis education and

improved patient and family experience.

197

___________________________________

In collaboration with members of

multidisciplinary healthcare teams,

CCLSs provide diagnosis education

that improves patient and family

experience in diverse situations,

such as inpatient admissions for

ketogenic diet initiation, perinatally

acquired HIV disclosure, burn

rehabilitation, autism support, and

transitional care programs in late

adolescence.

44,45,132,183-

187

___________________________________

Adherence-Promoting Interventions

The specialized knowledge and skills that

CCLSs apply in diagnosis education and

coping support closely mirror those they use

to promote treatment adherence in pediatric

patients and their families. Treatment non-

adherence is an increasingly burdensome

exp

ense in healthcare - whether measured

by dollars, population health outcomes, or

resource availability. Across both acute and

The Value of Certified Child Life Specialists | 17

chronic condition

s, non

-adherence to

treatment

plans is seldom without

consequences. Fo

r children with acute

conditions,

poor adherence to antibiotic

medications has been ide

ntified as a barrier

to individual

and public health goals (e.g.,

preventing recurren

t infection, reducing the

growth of ant

ibiotic resistant bacteria)

198

; in

those with chroni

c conditions, substandard

treatment

adherence is correlated with

growing healt

hcare usage and costs.

199

Furthermo

re, non

-adherence can lea

d to

higher risks

of morbidity and mortality, such

as organ rej

ection after transplantation

200

and relapse or

recurrence in those with

cancer.

201

Regardless of t

he diagnosis, and

much like what is

seen in discharge

education r

esearch, combination

interventions

that address multiple

components of ps

ychosocial well

-being

prove most im

pactful,

198,202

aligning w

ith the

multidimen

sional approach and skill set of

CCLSs.

While barriers

to treatm

ent adherence

(e.g.,

difficulty

or inability to swallow pills,

diagnosis and t

reatment intensity, lack of

treatment

knowledge) are many and varied

(and not to be

ignored), they are frequently

overcome through

targeted interventions

within the

scope of chil

d life practi

ce. Such

interventions

have rendered statistically

significant

adherence improvements, while

at the same

time promoting other key health

outcomes, such

as decreased viral load and

improved CD4+ T-cell counts

in children

with HIV.

203,204

Additional adheren

barriers i

n childhood manifest and multiply

when treatm

ent is administered via

injection, incl

uding pain or fear of pain

associated with

needles, lack of knowledge

and understandi

ng regarding the illness

and/or treat

ment, and the quality of

the

relationships betw

een healthcare

professionals and

patients.

205

Certified

Child

Life Specialist

s provide combinatory

interventions

that address illness

-related

knowledge an

d understanding, treatment

comprehension,

and techniques for coping

with needle-related fear

and distress.

Development

al complexities also impact

adherence to

treatment recommendations,

and in the con

text of child life care, they are

essential pieces

of individualized

assessment for

adherence

-targeting

interventions

. For

example, in chi

ldren and

adolescents livi

ng with epilepsy, commonly

endorsed bar

riers reflect the intricacies of

each developmental

stage, such as disliking

the taste of

liquid medication, difficulty

swallowing

pills, forgetfulness on behalf of

the parent

caregiver and/

or patient, overall

medication refusal

, feeling embarrassed

about the

condition and its treatment,

running out

of medicine, and difficulty

accessing a pharm

acy.

206

It can be

seen,

then, that

just as barriers to adherence

change through

out the

child’s devel

opment,

so, too, shoul

d assessment and intervention

techniques for

bolstering adherence

directing extra

attention to the

developmental

periods in which health

outcomes are

typically poorer (i.e.,

adolescence).

206

The importance

implementing freque

nt and individualized

assessment alon

gside ever

-evolving

intervention

rings true across varied and

complex pediatric con

ditions (e.g., organ

transplant,

HIV).

200,207

Thus, by assessi

and addressing conte

xtualized barriers that

can arise for

pat

ients and f

amilies, the

developmental

knowledge of CCLSs is vital

in supporting

adherence (both for patients

and their caregi

vers) across childhood,

adolescence, an

d emerging adulthood.

18 | ACLP

___________________________________

Certified Child Life Specialists

provide combinatory interventions

that address illness-related

knowledge and understanding,

treatment comprehension, and

techniques for coping with needle-

related fear and distress.

___________________________________

Parent Engagement

As shown above, parental involvement is a

key component of both treatment adherence

and adherence-promoting interventions.

Because effective communication and

active engagement are vital in optimizing

both patient and family outcomes,

parents/caregivers need to be intentionally

incorporated into their children’s care. In

pediatric healthcare, parents’/caregivers’

participation in their children’s healthcare

can range from simply being present at the

bedside to intentional interaction and/or

active engagement in communication and

care processes. Research demonstrates

that there are benefits of allowing

parents/caregivers to be present in medical

settings (e.g., during medical procedures,

anesthesia induction, and resuscitation) and

providing them with individualized education

and support.

169

In addition, care that is truly

family-centered leads to increased

satisfaction overall.

208

More specifically, providing

parents/caregivers with guidance on

supporting their child during treatment,

hospitalization, and procedures has

emerged as an essential means for

managing parent/caregiver - and patient -

distress across pediatric healthcare

settings. During their child’s inpatient

hospitalization, parents/caregivers report

significant challenges to their own coping,

such as unfamiliarity with the hospital

environment, ambiguity regarding their role

in the child’s care, a lack of information

about and understanding of procedures,

and uncertainty about the diagnosis and

treatment plan.

140,209-212

Furthermore,

parents/caregivers also experience

healthcare related distress when a child is

hospitalized and/or has a chronic illness

involving repeat healthcare experiences. As

this anxiety rises, so, too, do negative

behavioral and health-related outcomes

such as psychological symptomatology,

disease severity, and healthcare utilization

rates for children and adolescents.

213

day-to-day life, general parenting stress in

those with children diagnosed with a chronic

illness is significantly higher than that of

parents/caregivers of healthy children

213

- a

finding to be expected given the increased

levels of daily care and perceived isolation

for parents/caregivers of chronically ill

children. As multidisciplinary team members

attuned to the dynamic, bidirectional effects

of parent/caregiver and child distress,

CCLSs provide interventions to promote

and support adaptive parental coping with

children’s present and prospective medical

experiences.

An expected component of pediatric

healthcare, parenting stress (like patient

stress), is a modifiable condition.

213

parent’s appraisal, positive or negative, of

an event or situation can largely determine

the psychosocial outcomes of a child’s

healthcare experience. Negative appraisals

can dilute coping efforts and increase

disease-related stress in parents/

caregivers.

213

When parents/caregivers are

given the opportunity to access information

about their child’s treatment and receive

The Value of Certified Child Life Specialists | 19

guidance on ways to best support their

children in the process, parental anxiety is

lessened.

105,169,214

In addition, more

knowledge about and frequent use of

effective coping strategies not only

decreases parent distress but also

heightens parent satisfaction with

healthcare experiences.

215

Additionally,

when parents/caregivers are actively

involved in their child’s care (i.e., included in

decision making and empowered to address

developmental milestones utilizing play and

other skills), they experience less distress,

their children cope more effectively, and

their confidence as parents grows.

105,214,216

Ensuring this active parent/caregiver

engagement in healthcare experiences is a

central tenet of child life care. Interventions

(e.g., preparation, procedural support,

coping skills and diagnosis education) that

reduce negative experiences, increase

understanding and parental engagement

and can reduce distress in parents and their

children alike during future medical

encounters.

162,217-219

For example,

parents/caregivers who are engaged in IV

placements through comfort positioning

report greater satisfaction with catheter

insertion, their level of participation in the

procedure, their ability to provide emotional

support to their child, and the staff’s skill in

managing the child’s pain.

162

In addition,

engaging and involving parents/caregivers

in their children’s care can significantly

lower parent and child distress during

procedures like IV placements without

significantly altering the number of attempts

made or the total time spent on the

procedure, which maximizes both quality of

care and throughput.

148,162,217,218

Often perceived as falling primarily on the

parent/caregiver, responsibility for illness

management in pediatrics is typically shared

between the

child or adolescent, the

parents/caregi

vers, and the healthcare

team. Just

as higher parent/caregiver stress

can intensify ne

gative health outcomes, so,

too, can un

balanced responsibility. Unrest in

health manage

ment responsibilities

between any of

these partners can further

amplify paren

tal distress.

213

Therefore,

cyclical patt

erns of parent, patient, and

family distress are propagat

ed. Through

encouraging

a teamwork approach to

disease managem

ent, CCLSs can: 1)

ascertain a chi

ld’s capacity to begin taking

responsibili

ty for disease management, 2)

work with nursin

g colleagues to assess the

educational

and developmental

needs of t

pediatric pat

ient, and 3) coach

parents/caregi

vers in meeting these needs

all of which le

ad to an increasingly well

balanced approach

to condition

management an

d lowered parent

stress.

175,208,2

13,220,221

Involvement by chil

life professionals aids in preventing

parents/caregi

vers and/or pediatric patients

from assumin

g unsustainable

responsibili

ties for care, and research

demonstrates

that both parents/caregivers

and healthcare

staff find parental support to

be more impa

ctful

- and children to be more

cooperative wi

th care

- when a CCLS

involved.

148,175

,219

Their fine-tuned skill

set

and family-centered t

raining enable CCLSs

to meet t

he needs of parents/caregivers as

they care f

or their ill or hospitalized child,

increasing paren

t satisfa

ction, decr

easing

parent str

ess, and creating a more informed

and engaged generation

of healthcare

consumers.

Discharge Educa

tion and Health Literacy

A prime area f

or improvement in patient

and-family-centered he

althcare

experiences, par

ticularly for inpat

ient

hospitalizations,

is supporting families

20 | ACLP

through hospital-to-home transitions. During

these times of change, much like times of

duress, accurate information and

individualized support are crucial to patient

and family coping and success. In this

sense, the practices and concepts of

discharge education and health literacy are

steadily emerging areas of opportunity, both

for improving patient experience and

population health.

Transitional success in healthcare contexts

is largely a function of health literacy, which

has been defined as, “the degree to which

[patients and/or parents/caregivers] have

the capacity to obtain, process, and

understand basic health information and

services needed to make appropriate health

decisions.”

222

However, according to the

U.S. Department of Education,

223

as many

as 40 million American adults - 1 in 5 - are

considered to have “low English literacy

skills,” or as having below basic functional

reading skills. This means that for this

subset of parents/caregivers, when tasked

with the elevated challenges of reading and

comprehending complex healthcare

information, upwards of 20% of

parents/caregivers are unsuccessful in

achieving the necessary level of health

literacy to serve as proficient partners in

their child’s care. Taking into account the

profound importance of the parent/caregiver

role in effective hospital-to-home transitions

and health outcomes in childhood, providers

must assess and account for health literacy

when formulating and implementing

effective discharge education in healthcare

settings.

Systematic empirical evidence consistently

demonstrates that lower literacy skills in

children lead to poorer personal health

behaviors, and lower parent/caregiver

literacy skills lead to worse child health

outcomes.

224

While much of pediatric health

literacy research focuses on

parents/caregivers, findings demonstrate

these outcomes are also likely to hold true

for children.

225,226

For example, healthcare

literature that is specifically targeted

towards and designed for pediatric patients

has been shown to result in children more

accurately identifying and answering

questions about their health status.

227

This

marks a significant achievement because

children often understand their

hospitalization through their own interpretive

ens – a direct result of their developmental

level, personal knowledge, and

experiences.

228

Certified Child Life

Specialists, by blending their strategies for

effective communication with their robust

developmental knowledge, possess distinct

training allowing them to identify the ways in

which children’s conceptual schemas about

health and illness are developed, revised,

and expanded, especially as children

negotiate the barrage of new information

presented by healthcare encounters. Thus,

CCLSs identify, explain, correct, and

replace these misconceptions through

developmentally appropriate play,

education, and communication,

7,229

strengthening children’s health literacy as it

unfolds.

Across intervention types and modes of

administration, health literacy must be

assessed and adjusted for, ultimately

adjoining into multidisciplinary care

approaches to promote successful

transitions to and from care. Discharge

education and standardized discharge

processes have been identified by both

parents/caregivers and healthcare providers

as indispensable components of pediatric

hospital care

230-233

; furthermore,

The Value of Certified Child Life Specialists | 21

parents

/caregivers and providers

demonstr

ate marked agreement regarding

education

al content and strategies for

effective con

tent delivery.

230,23

1,233,234

-236

Namely, bo

th stakeholder groups prioritize

discharge

education that is: 1) high

quality,

231,23

3,235

2) deliver

ed in standardized

ways,

230,23

1,234

and 3) app

ropriately

timed.

233,23

Relevant l

iterature illuminates vital

consideratio

ns for the delivery of di

scharge

education

, particularly as patients and

families sta

rt their transitions from hospital

to home.

When discharge education is

poorly planned o

r lacking, patients and

families are

more likely to experience

subsequent r

eadmissions.

235,23

It has

been

shown that

when discharge education is

provided all

at once, shortly before

discharge

and/or on the date of discharge,

parents

/caregivers report feeling both

overwhel

med and unprepared,

233,23

compromisi

ng their ability to comprehend

crucial de

tails about t

heir chi

ld’s care. High

quality

discharge education, on the other

hand (as

perceived by the parent/caregiver),

results

in a more positive assessment of

their

discharge readiness by nursing staff,

235

and when di

scharge education is

considered

comprehensive,

reductions

readmission

rates, particularly in children

hospitali

zed for asthma

-related il

lness, can

result.

238

Additi

onally, when in

-home ca

activities are

required after discharge,

simulated t

eaching with parents/caregivers

that ap

propriately addres

ses their

knowledge

and comfort levels bolsters their

self-efficacy

239

- which allays pr

ovider costs

and resour

ces by avoiding preventable

readmissions

or care encounters.

240,24

Beyond t

he institutional benefits rendered

by effective di

scharge education, research

reveals a

host of positive outcomes for

individu

al parent/caregivers and patients

(e.g.,

increased illness

-related know

ledge,

decreased

anxiety, improved coping).

242

addition

, these benefits are magnified when

discharge

education is appropriately

structured

, culturally appropriate, and

individu

alized for the patient and

family.

233,24

Teach-back (a par

ticular

provider-driven

and patient

-reciprocated

education

al strateg

y), for

example, has

proven to be hi

ghly effective in discharge

education

243,24

However,

like many

education

al interventions, its use is

frequen

tly hindered by lack of provider

time

235,24

and staffi

ng.

246

Physicians

likewise id

entify time constraints an

d a lack

of empir

ically supported communication

tools (

e.g., teach

-back) a

s barriers to

promoting

patient and family

comprehension

of discharge information.

247

As effective

communicators, relationship

builder

s, and educators for patients and

families,

7,229,232

CCLSs con

sider, facilitate,

and develop he

alth literacy in children and

families as an

integral part of their dedicated

clinical

time and responsibilities. Their ability

to conduct

individualized assessments

enables chil

d life professionals to design

and implement

structured, educational plans

of care t

hat cater to the unique needs and

experiences o

f each patient and family while

simultan

eously meeting unit

-based and

facilit

-wide di

scharge goals. Certified Child

Life Special

ists possess the distinct,

necessary

multidimensional skills for

ensuring that

discharge education and

hospital-to-home t

ransitions are

opportun

ities carefully constructed and

intentional

ly poised to enhance the health

literacy o

f children, youth, and families.

22 | ACLP

Value Driver 4: Developmental Impacts

____________________________________________________________________________

Certified Child Life Specialists promote and sustain optimal developmental and

psychosocial growth from infancy through emerging adulthood. They facilitate purposeful

play experiences, normative interactions, and transition support for patients, parents/caregivers,

and family members that shape positive coping and development. Targeted, developmentally

appropriate, and family-centered play-based and educational interventions result in increased

weight gain, abated feeding difficulties, and decreased length of stay in infancy, thus enhancing

neurodevelopmental outcomes. In children, adolescents, and emerging adults, these supports

render improved emotion regulation, effective coping behaviors, adaptive peer interactions, and

more appropriate use of healthcare resources.

Chronic illness and prolonged

hospitalization in childhood pose a multitude

of threats to child and family

development.

216

Left unaddressed, these

experiences can damage children’s physical

and psychological health, and quickly

activate traumatic stress responses.

248

providing family-centered, play-based, and

developmentally supportive care, CCLSs

help children and their families access the

tools within themselves and one another

needed to successfully navigate

developmental barriers and transitional

experiences.

Developmental Assessment and

Intervention

Developmentally supportive care is defined

as a comprehensive, collaborative, and

patient-and-family-centered approach to

improving developmental outcomes through

individualized interventions.

249,251

Similarly,

positive patient experiences and outcomes

multiply when the focus is on both the

physical well-being of children and their

developmental and psychosocial needs.

252

Certified Child Life Specialists partner with

patients and families of all abilities and

diagnoses to identify developmental

barriers, needs, and goals during medical

experiences. Depending on the child’s age

(chronological and developmental) and

experiences, these can involve ensuring

parent/caregiver presence during

procedures (especially for infants),

maximizing opportunities for choice and

control for toddlers, correcting

misconceptions of care in preschoolers,

supporting connections to activities and

contexts of daily life (e.g., school,

community, extracurricular activities, and

peer interactions) for older children and

adolescents, and adapting the hospital

environment and care approach to support

the needs of children with complex

healthcare needs, such as autism spectrum

disorder.

253-255

Children understand their medical

experiences, as well as the impacts of these

experiences, based on their cognitive,

social, and emotional development, and an

important component of child life practice is

anticipating potential challenges that can

arise as a result of these perceptions.

Certified Child Life Specialists are

specifically trained to identify children's

interpretations of and reactions to stressful

The Value of Certified Child Life Specialists | 23

events, part

icularly in the context of

healthcare en

vironments.

252

Depending

the child’

s developmental level and

temperament,

factors such as decreased

mobilit

social and physi

cal isolation, use of

life-sustaining med

ical equipment, and

treatmen

t or illness side effects altering

baseline be

havior can provoke

development

al difficulties or delays.

216

Addition

ally, inconsistent parent/caregiver

presence, painful

and

invasive procedu

res,

interrupti

ons of daily routines and

schedules, lack

of opportunities for

exploratory pl

ay, and altered parent

-child

roles and respon

sibilities can jeopardize the

child-parent r

elationship. Furthermore,

disruption

s to parent/caregiver

participa

tion

in the chil

d’s care can jeopardize infant

parent at

tachment and further complicate

the child’

s ability to achieve normative

development

al milestones.

216,248

,249,252

Thus,

CCLSs provide

targeted play

-based,

educational

, and therapeutic soluti

ons to

address medical

misconceptions,

ameliorate t

he consequences of these

misconcepti

ons, and reinforce honest,

accurate, an

d developmentally appropriate

informati

on.

___________________________________

By continually assessing the

individual patient, family,

environment, and situation, CCLS

intervene based not only on

the

child’s developmental needs and

capabilities but also on the influe

nce

of their temperament, previous

medical experiences,

misconceptions, fears, and

responses to stressful events.

257,25

___________________________________

As noted

by the National Association for the

Welfare of

Children in Hospitals,

256

children

need and pr

efer developmentally supportive

care, age approp

riate information about

their di

agnosis and treatment, and

opportunities

to participate in their

healthcare e

xperiences. Without these

elements, i

t is nearly impossible to provide

truly chil

-focused med

ical and

psychosocial care

248

Therefore,

in order to

meet the

unique developmental needs of

children in the

hospit

al (i.e.,

creating and

maintaining

healthy routines, providing

opportuni

ties for play and socialization, and

supporting

children during procedures),

ongoing en

vironmental assessment is

essential, as

a child’s relationship with their

environmen

t is a salien

t source of

exploration,

learning, and development for

children of al

l abilities and conditions.

251

To facili

tate comfort and increase

understandi

ng, CCLSs consider the

environmen

t and its impact on care

interactions w

hen providing ongoing,

individual

ized

support f

or pediatric patients

and their

families

. By co

ntinually assessing

the indi

vidual patient, family, environment,

and situation,

CCLSs intervene based not

only on t

he child’s developmental needs

and capabilit

ies but also on the influence of

their temperament

, previous medical

experiences, m

isconceptions, fears, and

responses t

o stressful events.

257,258

Specifical

ly in infancy, developmentally

supportive

care (e.g., kangaroo care,

purposeful po

sitioning, infant massage, and

age appropriate pa

in manag

ement) resul

in reduced leng

th of stay, earlier transitions

to oral f

eedings, increased weight gain, and

better

neurodevelopmental outcomes for

premature i

nfants.

251

On the

other hand,

environmen

tal stimuli such as harsh lighting

and excessive ambien

t no

ise, inadequ

ate or

24 | ACLP

excessive handling and caregiving, and

repeated exposure to painful procedures

can damage the immature infant brain and,

ultimately, alter their developmental

course.

259

Certified Child Life Specialists,

with their knowledge of child development

and awareness of multisensory

environmental and health-related stressors,

are distinctly prepared to anticipate,

prevent, and combat the potentially harmful

impacts of healthcare encounters for

children and families.

Dimensions of Play

Play is one of the foundational tools that

CCLSs draw upon to assess development

and prevent any emotional or psychological

harm posed by healthcare environments.

Across theoretical perspectives, play is

consistently described as any activity in

which participants are voluntarily engaged,

that is free from the structure and bounds of

reality, and inherently enjoyable.

43,114,122

Play is a therapeutic tool, a conduit for

healing and healthy processing of events

and information, and an essential

intervention in pediatric healthcare

settings.

43,114,115,121,260

Hospitalized children,

in contrast with those in the comforts of

home and family, demonstrate a greater

need to play because of the stress

generated by unfamiliar environments,

unpredictable schedules, painful

experiences, and mobility restrictions due to

illness or treatment.

116,261

When play is

unstructured, child-directed,

developmentally appropriate, contextually

relevant, and easily accessible, play is

replete with therapeutic value and vital for

whole child development. In the safe, low-

stakes atmosphere of play, infants, children,

and youth explore possibilities, rehearse

responses, and process thoughts or

emotions in manners unavailable in other

real-life contexts.

43,120,262

Hospitalization is

one such context that disrupts access to

and activities involving play.

116,117,263

In fact,

consistent and prolonged absence of play in

a child’s environment leads to missed

opportunities for learning, understanding,

and development.

Particularly in hospital settings, children and

adolescents spend less time playing and

use more narrow and repetitive themes,

engaging in less group play with peers than

those in their homes, neighborhoods, and

other community settings.

116

Such changes

in play behaviors stem from anxiety and the

lack of perceived safety and predictability in

the hospital environment.

116

Stress,

therefore, intensely colors children’s

perceptions of medical events,

116,264

and as

a result, hospitalized children are prone to

many months of emotional distress following

discharge.

263

Certified Child Life Specialists

remain cognizant of the detrimental

consequences arising from the absence of

play, thus, intentionally weaving it into most

components of their practice (e.g.,

facilitating self-expression, and providing

preparation, procedural support, diagnosis

teaching and discharge education).

___________________________________

Play is one of the foundational tools

that CCLSs draw upon to assess

development and prevent any

emotional or psychological harm

posed by healthcare environments.

___________________________________

An important piece of facilitating and

protecting play in stressful healthcare

experiences is preparing and preserving

play-conducive spaces

122,260,262,265

- a facet

of care that CCLSs are attuned to across

healthcare situations. The pediatric

The Value of Certified Child Life Specialists | 25

healthcare en

vironment should be designed

to create

as many playful circumstances as

possible, increasi

ng the time and space for

children and adolesce

nts to process and

master the

ir experiences.

7,116,260,2

62,266,267

Certified

Child Life Specialists intentionally

create an

d adapt hospital environments to

promote play

opportunities, improve coping

behaviors and

maximize quality of life in

hospitalized

children and their

families,

51,116,2

and when a safe and

supportive

environment is achieved, play

aids in increased

cooperation and

adherence t

o treatment regime.

114

Often r

eferred to as “pretend play” or

“therapeu

tic unstructured play” in research

literature,

free play prevents or reduces

child anxiety and distr

ess especially when

offered i

n the restrictive bounds of

healthcare en

vironments.

121,143

Addition

ally,

the prese

nce of a knowledgeable,

supportive

adult play partner is necessary in

assisting an

d guiding children in making

sense of thei

r hospital

experiences

through

play.

116

Responsive, em

pathetic, and well

trained adult

s such as CCLSs assess

individual

coping needs of children and

adolescents through

observation that is

supported

by strong, applied knowledge of

child and fami

ly development.

51,114,119,12

And, whe

n they supervise, but do not

necessarily

structure or lead, CCLSs

purposefully

modify play interventions to

reinforce ad

aptive coping behaviors (e.g.,

effective em

otion regulation, appropriate

coping str

ategy usage, and positive peer

interactions) and

abate negative

behaviors.

121,143

Furtherm

ore, parental

presence in a chi

ld’s play environment

directly predi

cts self

-expression an

d positive

coping.

122,26

Along with t

he presence of supportive

caregivers and ski

lled staff such as CCLSs,

the active rol

e of the child in play is

imperative

to building effective coping

strategi

es for managing acute and chronic

(or repeat

ed) healthcare experiences. As

previously est

ablished, in order for positive

coping beha

viors to develop, children need

the ability to f

ree play by selecting their own

play material

s and themes within an

intentionall

-designed,

effectively

supervised environm

ent.

115,116

,268,269

Pretend

play in such en

vironments cultivates

divergent though

t processes and emotion

regulation, w

hich ar

e elements

of problem

solving essentia

l for coping with stress.

121,270

Certified

Child Life Specialists recognize the

ability

of pediatric patients to choose, when

appropriate,

and advocate for opportunities

for the

child to exercise control. Thus, when

play is child-directed, chi

ldren often

perceive the

mselves as in control, gaining

enhanced mast

ery over their experiences

and improved sel

-efficacy r

egarding current

and future

hospitalizations.

117,271

,272

It is

through this

perceived control, and

increased self-efficacy i

n stressful situations

that young

patients are taught to be active

participa

nts in and lifelong consumers of

healthcare.

271

A distinct

form of play unique to child life

practice is

medical play, which gives

children access

to play with med

ical them

and/or medi

cal equipment offered in a

monitored,

and non

-threatening

manner.

This type

of play is further characterized by

three other

essential features: 1) it can be

adult ini

tiated but must be child

-directed and

maintained 2)

it is enjoyable

in nature, of

ten

accompanied

by laughter and relaxation,

and 3) it

offers mastery and control over

frighten

ing medical environments.

272

importan

t component of children’s coping in

26 | ACLP

healthcare settings is this intentional play

with medical equipment (e.g., masks,

gloves, syringes, stethoscopes, and even

needles), and the combination of

recognizable play methods and unfamiliar

medical equipment allows children to

integrate their thoughts and feelings and

achieve a healthy sense of mastery over a

situation.

273,274

For example, research

indicates that children that play with items

related to their stressors (such as those

involved in an IV placement) experience

reduced anxiety and greater ability to

cope.

114

By gradually introducing unfamiliar

medical equipment through play, children

attain greater control over their environment

and begin expressing their feelings and

perceptions, as play is their language and

toys are their words.

266

Because of their extensive education and

training in medical play, CCLSs are model

healthcare professionals for facilitating it for

confused, anxious, and/or stressed pediatric

patients and families. They possess the

developmental knowledge necessary for

ensuring that the medical equipment

involved in play interventions is appropriate

for the social, emotional, and cognitive

abilities of the patient, and they have

clinically completed individualized

assessments to ensure said equipment

meets these developmental requirements.

Certified Child Life Specialists utilize free

play as another form of assessment,

effectively observing children’s behavioral

cues while also screening for accurate

understanding (or misconception) that

indicates need for follow up care.

46,52,131,264

Specifically, medical play can yield insight

into developmental needs, psychological

conflicts, and unexpressed fears

43,51, 52,275

and more directed (or adult- or CCLS-led)

medical play techniques can be used to

prepare children for surgery or other

unpleasant medical procedures, resulting in

decreased anxiety.

61,274

Apart from

alleviating psychological distress, medical

play with the goal of preparation also carries

physiological benefits for the child, such as

decreased cortisol levels and heart rate

both before and during medical

procedures.

115,143

Within the context of well-defined,

therapeutic relationships, CCLSs provide

safe, secure spaces for children and youth

to express feelings that, outside of low-

stakes play contexts, could be construed as

inappropriate and go

unacknowledged.

114,262,264,269

Certified Child

Life Specialists provide opportunities, as

well as physical and temporal space, for

pediatric patients to gain a sense of control

and mastery over healthcare

experiences.

114,116,262,264,269,270

In fact, many

hospitals rely upon CCLS and additional

child life staffing (e.g., child life assistants,

special events coordinators, or volunteer

supervisors) to enhance patient experiences

and normalize the environment through

coordinated hospital events and/or play-

based programming. A visit from a facility

dog, a musical activity in the recording

studio, or a movie night in the hospital

theater are just a few examples of events

that provide therapeutic benefits for patients

and families (e.g., socialization, self-

expression, diversion, a sense of normalcy)

during stressful times while also engaging

the support of community partners and

donors.

4,276-278

As the multidisciplinary team members most

knowledgeable about the powerful effects of

play, CCLSs often demonstrate and teach

coping strategies through play to decrease

stress in healthcare settings and impact

development in the midst of and following

The Value of Certified Child Life Specialists | 27

healthcare en

counters.

119,143

,270

They also

provide ther

apeutic play opportunities that

reduce st

ress before procedures,

ameliorating

negative behaviors and

physiological responses.

143,263

Certified

Child Life Spe

cialists facilitate consistent,

recurring

opportunities for free,

unstructured

, and truly therapeutic play so

as to bolst

er positive, long

-term ef

fects on

pain, adju

stment to illness, and externalizing

behaviors. Notably,

and as expected, the

presence of a

CCLS has been shown to

proliferate

children’s effective and healthy

interactions w

ith play materials in healthcare

settings.

121

Certified

Child Life Specialists

are the pr

ofessionals within multidisciplinary

healthcare

teams specifically trained in the

therapeut

ic value and expansive utility of

play, child develop

ment, and the ideal ways

to apply this

knowledge to identify and

ameliorate st

ress in healthcare settings.

School R

eentry

Medical exp

eriences continu

e to affec

children far

past the point of procedure

completion or di

scharge. When a diagnosis,

treatmen

t, or hospitalization separates them

from t

heir typical social circles for extended

periods of

time, returning to contexts like

home, school

, and peer g

roups can be

additional

source of stress. Research

demonstrate

s that children who are ill or

hospitalized

report disruptions to their daily

activities and soci

al roles as their most

significan

t health

-related str

essors (e.g.,

missing scho

ol days or fall

ing behind

school work,

not doing things they used to

do, feel

ing isolated from their peers).

279,280

Furtherm

ore, work has verified that

prolonged absences

threaten the child’s

peer relationsh

ips and sense of well

-being.

Children often

feel estranged fr

om their

friends,

as school attendance

dwindles

279,28

1,282

and side-effects fr

treatmen

t (e.g., fatigue, nausea, and pain)

not only

prolong separation from school, but

also pose long-term cogni

tive

challenges,

283,28

and attenti

difficult

ies,

285,286

all of which can

have

detrimen

tal and lasting impacts on a child’s

sense of self

and social relationships.

Moreover, ap

proximately 45% of students

with chroni

c health conditions fall behind in

their s

chool work, which, in turn, leads them

to dislike school.

286

An increased

aversion

towards school

and fear of isolation from

classmates can

make returning to school

after a

healthcare encounter that much

more diff

icult. However, play

-based and

educational

school

-reentry p

rograms,

provided by CC

LSs, help ease this

transiti

on for patients, classmates, and

school staf

f. Certified Child Life Specialists

recognize t

he challenges school reentry can

present, assessing

and anticipating the

patient-and-family’

s transitional needs and

providing ind

ividualized, evidence

-based

intervention

s (e.g., coping skills education,

therapeut

ic play, diagnosis and treatment

education)

School ree

ntry programs extend hospital

based child li

fe support into the community

through tar

geted education for the child,

their pe

ers, and school pers

onnel (e

.g.,

teachers,

school counselors and nurses,

classroom aids).

A considerable way in

which CCLSs brid

ge the gap between the

typical devel

opmental context of the

classroom and t

he drastically different

hospital set

ting is by increasing school

personnel’s knowl

edge and comfort with the

child’s condi

tion, and the many ways in

which the s

chool can support the child’s

reentry.

These programs facilitate support

by coordinating

care between the child’s

family, heal

thcare team, and educational

staff, an

d are

individual

ized to reflect the

28 | ACLP

child’s cognitive, physical, and

socioemotional needs both prior to and

since treatment.

287-290

Considering their robust knowledge of child

development and family systems, CCLSs

are distinctly suited to facilitate school

reentry services, liaising between the

patient’s family, multidisciplinary healthcare

team, and school personnel.

291

Certified

Child Life Specialists, through age

appropriate education and play, model ways

to relate to, care for, and engage with the

child to promote connection and reduce

social isolation. They tailor information to

the developmental needs specific to the

patient and their peers, and they possess

the knowledge and communication skills

necessary to explain pertinent medical

information to teachers and classmates

alike. By articulating the developmental

impacts of the child’s condition to educators

and administrators, CCLSs ensure that the

child receives the appropriate instructional

and ancillary support needed to thrive in the

school setting. Educational workshops

provided by CCLSs are particularly

beneficial to peers and classmates because

the provision of accurate and

developmentally appropriate medical

information demystifies misconceptions they

may have prior to the child’s return; if left

unaddressed, classmate fears and fallacies

can evolve into isolating the ill child, further

exacerbating the loneliness they felt during

hospitalization.

282,292

Certified Child Life

Specialists facilitate these support services

to ensure that patients have the

comprehensive academic and psychosocial

resources needed for a successful hospital-

to-school transition.

Transitional Care

Like school reentry, the progression from

pediatric to adult care introduces another

medical and social transition that can

provoke anxiety for adolescents and

emerging adults (AEAs), and their families.

Transitioning toward adult health systems

proves to be a tenuous juncture in the

developmental and medical trajectories of

AEAs

due to their increased vulnerability

to behavioral health risks, emerging or

worsening chronic health conditions, and

diminished healthcare use in this age

group.

293-295

Moreover, age-gradient

patterns of healthcare coverage and access

have been well documented during the AEA

period of development, with rates worsening

as individuals progress through

adolescence and enter into emerging

adulthood

295

- a pattern also evident in

AEAs with special healthcare needs.

296

Poor

planning and/or lack of readiness for

healthcare transition is linked to more

frequent use of emergency rooms and

outpatient clinics, as well as higher

incidence of hospital admissions and

surgical procedures.

297-299

In addition,

transfer to adult care is delayed, medical

appointments are missed, and independent

care management is compromised.

297,298

Taken together, this constellation of effects

can have dire consequences for the delivery

of cost-effective, high-quality healthcare

services and attainment of optimal

population health outcomes.

Developmentally appropriate and

individualized interventions (a core feature

of child life practice) for AEAs improve

transitional healthcare planning and

readiness (e.g., improved patient disease

knowledge and competence, greater patient

self-efficacy, increased patient confidence,

and heightened motivation).

296,300

The

extensive developmental knowledge that

CCLSs routinely employ when working with

patients and families is invaluable in such

The Value of Certified Child Life Specialists | 29

contexts;

these healthcare professionals

ensure that

the interventions and supports

being provi

ded are emotionally, c

ognitivel

and physically

appropriate for each unique

patient

and family system. By tending to the

psychosocial

variables deemed most

import

ant by AEA patients (e.g., unstable

life circumst

ances, competing life demands,

depression,

anxiety, denial of illn

ess, fear

and anxiety as i

t relates to their diagnoses,

changing

social structures, and lack of peer

support/

relation), CCLSs provide the

education

and support this vulnerable

patient

population requires as they

assimilate

into adult healthcare processes

and systems

298,30

The timi

ng by which the transition from

pediatric

to adult care is introduced and

initiated

is another key facet of optimized

AEA he

alth. When unprepared, AEA

patient

s report feeling forced into taking

responsibi

lity for their health man

agement

too soon

- not rea

dy for the tasks upcoming

or at ha

nd.

298

Transitional

care that begins

earlier

in childhood/adolescence and

evolves alongsi

de the pediatric patient and

their

family increases patient disease

knowledge

and self

-management,

298,30

and

by discussing t

his care early in the medical

journeys

of pediatric patients with chronic

condition

s, expectations are set that further

their

confidence, self

-efficacy,

and

independe

nt functioning.

302

Patients who

receive prep

aration for the transition t

o adult

care through st

ructured, purposeful

programming

indicate favorable perceptions

of their

health status, as well as increased

satisfaction

with their providers.

302

Certifi

ed Child Life Specialists, trained in

anticipa

ting and evaluating developmental

changes as t

hey occur, are skilled

therapeu

tic relationship builders; therefore,

they ar

e ideal multidisciplinary team

members f

or incorporating incremental,

purposeful transit

ional education and

training

. Drawing from their expertise in both

family syst

ems and effective

communicat

ion, CCLSs not only recognize

the need

to provide ongoing preparation for

both AEAs

and their parents/caregivers but

are also an i

nvaluable sou

rce of t

his

support.

They understand the particular

import

ance this type of intervention has for

parents

/caregivers because research often

notes str

uggle when tasked with

relinqui

shing control of their adolescent’s

daily i

llness management.

301

Further

more,

in order

to provide all parties with a smooth

transit

ion, CCLSs educate

parents

/caregivers on developmentally

appropriate

strategies to encourage

incremental

ly increased healthcare

responsibi

lity in their AEAs

- strategies

addressing co

mponents such as me

dication

management

, independently engaging with

providers,

and caring for medical equipment

- so as to

facilitate better preparedness and

subsequent care

satisfaction across this

critical

family dyad.

302

Beyond she

er fit of their skillset, CCLSs

demonstrate these

competencies when

designing

and facilitating targeted transition

programs for

AEAs with special healthcare

needs. Fo

r example, when explicitly

employed to imp

rove transition outcomes

for yout

h with chronic conditions, CCLSs

developed

and facilita

ted compr

ehensive

transit

ion programming that was associated

with a t

hree

-year, 40

% increase in AEA

patient

s engaging in treatment, as well as

patient-and-famil

y satisfaction scores

sustained in t

he 90

percent

ile.

Further

more, CCLSs added to healthcare

consumership whi

le concurrently facilitating

improved pat

ient experience by intentionally

30 | ACLP

incorporating leadership development, peer

socialization and mentoring, and

developmentally appropriate treatment and

survivorship education.

AEAs participating

in such programs demonstrated significant

improvements in illness knowledge and a

100% participation rate in routine follow-ups

after transition programming

engagement.

185

While engagement with transition

programming is essential, it cannot happen

without first assessing for the preparedness

of AEAs and their families for such

intervention. Reports of healthcare transition

readiness in this population are notably

impacted by family cohesion, such that the

more unity the patient and family describe,

the more likely patients are to report being

ready for healthcare transitions.

297

healthcare professionals acutely aware of

transitional needs and supports, CCLSs

employ their distinctive developmental

knowledge and training not only to

appropriately begin, but also effectively

maintain and revise purposeful, measured

movement from pediatric to adult health

systems.

Value Driver 5: Healthcare Consumership

____________________________________________________________________________

Certified Child Life Specialists improve population health by fostering long-term patterns

of healthcare consumership that reduce the risk of preventable conditions. By maintaining

and advancing a patient-and-family-centered healthcare environment, Certified Child Life

Specialists mitigate pediatric medical traumatic stress and improve mental health outcomes for

infants, children, youth, and families. They establish the foundation for positive coping and

resilience in the face of medical experiences and attenuate the negative physical and

psychosocial effects of stress, loss, and grief - including stroke, heart attack and high blood

pressure in adulthood - thereby cultivating health-promoting behaviors throughout the lifespan.

A family’s medical experience or

hospitalization has the potential to incur a

host of negative outcomes: pediatric

medical traumatic stress (PMTS), insecure

attachment, psychological maladjustment,

complicated bereavement, escalated risk of

psychopathology, and greater incidence of

life-threatening health conditions throughout

the lifespan. By providing procedural

preparation and support, opportunities for

parental education and involvement, and

therapeutic play interventions, CCLSs equip

patients and families with irreplaceable

adaptive coping strategies - thereby

cultivating resilience and mitigating

iatrogenic effects of healthcare related

stress.

Pediatric Medical Traumatic Stress

Pediatric medical traumatic stress (PMTS)

encompasses a set of psychological and

physiological responses of children to

potentially traumatic events such as pain,

injury, serious illness, medical procedures,

and invasive or frightening treatment

experiences.

303

More than a singular

diagnostic entity, PMTS is a broader

conceptual framework for understanding the

spectrum of possible negative responses to

medical experiences that children may

The Value of Certified Child Life Specialists | 31

exhibit.

Overall

rates of clinical PMTS are

roughly 30

% for children, youth, and

parents/

caregivers.

Symptoms

of PMTS

can include - but are no

t limited to

manifest

ations of posttraumatic stress

disorder (PTSD

) such as arousal, avoidance

of trauma

reminders, dissociation, negative

changes in moo

d or cognition, re

experiencing t

raumatic events, and intrusive

thoughts.

47,48

In fact,

even three to five

months after an

inpatient hospitalization,

more than

55% of children demonstrated

significan

t symptoms of re

-experiencing

trauma,

30.4% exhibited symptoms of

avoidance,

and 32.9% displayed significant

symptoms of

hyperarousal.

304

___________________________________

By providing procedural preparatio

and support, opportunities for

parental education and involveme

nt,

and therapeutic play interventions,

CCLSs equip patients and families

with irreplaceable adaptive c

oping

strategies - thereby cultivating

resilience and mitigating iatrogenic

effects of healthcare related stress.

___________________________________

While acute st

ress reactions are common

initiall

y, they are typically mild to moderate

and short-lived.

305

A notabl

e minority (5

10%) of pe

diatric patients, however, will

develop post

traumatic stress symptoms that

persist l

ong after a healthcare encounter. If

left untr

eated, acute medical distress can

become a cli

nically

-verified PTSD

diagnosis,

inhibiting qua

lity of

life, impairing

day-to-day activi

ties, hindering adherence to

medical t

reatment, and, ultimately, leading

to poorer he

alth and functioning.

48,49

Therefore chil

dren and youth especially

require a

wide range of supports (e.g.,

education

about illness

or inju

ry, preparation

for procedures,

opportunities to play and

regain control

over their new environment)

in order t

o properly address PMTS and its

effects.

Identifying r

isk factors for the development

of PMTS i

s a critical assessment

component for

llaying po

tentially traumatic

healthcare e

xperiences and preventing

persistent

distress. Across illness and injury,

children’s subj

ective interpretations of the

severity

and threat of medical events are

one of the

most salient predictors of

enduring

PMTS,

appraisals whi

ch are

dependent upon their

unique developmental

history - including

ACEs, patterns and strata

of support

from families and communities,

and access to

coping resources. Thus, the

appraisals chil

dren make about their

healthcare en

counters an

d the respon

ses or

efforts

that their thought processes elicit can

be infinit

ely varied. It is imperative that

individual

ized coping interventions are

offered i

n developmentally appropriate

ways, necessit

ating the inclusion of child life

support.

306

Considering ho

w differently each case of

PMTS can

appear, a developmental and

contextual approach

is vital for preventative

intervention

s that support patient and family

post-discharge he

alth outcomes

interrelated

domains which are prioritized in

child life care. Modul

ating distress, providing

emotional sup

port, encouraging positive

coping, an

d explaining typical

development

al recovery processes, CCLSs

buffer

patients and families against the long

term psycho

logical deficits that can result

from ho

spitalizatio

n, alongside

the lingering

trauma t

hat accompanies it.

Certifi

ed Child

Life Speciali

sts are primely positioned to

32 | ACLP

assess for, prevent, and alleviate PMTS

symptoms in infants, children, youth, and

families through play-based, relationship-

reliant, and individualized psychosocial

care.

Infant Mental Health and Attachment

Even when a child is hospitalized in the first

few months of life, stress as a result of

hospitalization can have devastating effects

on health and development. Infant mental

health is an expeditiously emerging topic

within healthcare and psychology that

focuses on the social and emotional

development of children ages birth to five,

particularly as it relates to the child’s

developmental capacity, environment, and

family structure.

307

When an opportunity to

promote physical and social emotional

development is missed during infancy, the

infant will need to compensate for what they

were unable to achieve during that sensitive

peri

od of growth. Therefore, effective

intervention for infant development and

mental health should begin as early in life

as possible and be intensified as necessary

to achieve adaptive outcomes for

hospitalized infants.

308

In the context of their

targeted education and training, CCLSs

implement developmental play, non-

pharmacological pain management, parent

education and engagement, and help to

regulate environmental stimulation based on

the infant’s social emotional cues and

needs.

Optimal infant mental health outcomes

correlate with neurodevelopmental

processes, as well as the infant’s evolving

capacity to cope with stressful experiences,

regulate emotions, and form productive

attachment relationships. Attachment,

specifically, is a relational construct that

describes the child’s understanding of the

world as a trusting and safe environment,

usually a result of consistently positive

experiences with a primary

parent/caregiver.

The quality of the infant-

caregiver relationship, as indicated by the

construct of attachment style, has the

greatest impact on infant mental health

outcomes

307-313

but, separation from or loss

of the primary parent/caregiver, frequent

illness or hospitalizations, pain, and

environmental factors threaten attachment

and subsequent infant mental health

outcomes.

310,314

As practitioners who support the

psychosocial needs of the entire family,

CCLSs empower parents/caregivers to play

active roles in their infant’s daily care

throughout hospitalization, as this

participation directly promotes the formation

of positive and secure attachment.

315,316

Using clear communication and emotional

support to strengthen caregiving roles,

CCLSs help parents/caregivers form or

strengthen these seminal relationships with

their infant amidst the many risks and

stressors presented by healthcare

encounters.

317

For instance, a routine

attachment-promoting intervention

facilitated by CCLSs is touch, and whether a

child is intubated and sedated or has no

medical equipment creating barriers,

parent/caregiver touch provides an active

and constructive caregiving role that

establishes secure attachment.

318,319

Research continually demonstrates that

hospitalization delays the formation of

secure infant attachment,

315,320

and within

the walls of the Neonatal Intensive Care

Unit (NICU) in particular, manifestations of

hospitalization such as presence of medical

staff,

321

infant visual impairment,

319

infant

intellectual disabilities,

322

congenital

anomalies,

323

distance from

The Value of Certified Child Life Specialists | 33

parent/caregi

ver,

316

and materna

l anxiety

and postpartu

m depression

324,325

negatively

impact t

his relationship

. In adultho

od, the

implications of

absent or malformed

attachments

are severe. Insecurely

attached ind

ividuals are 70% more likely to

report ch

ronic, widespread pain and

frequent

routine illnesses.

326,327

Striking

ly,

attachment

ratings

- though prima

rily

discussed in infanc

- are linked to

an array

of adult pa

thology. Avoidant attachment

ratings are linke

d to a broad range of

illnesses and condit

ions characterized by

pain; anxiou

s attachment is associated with

costly, life

threatening, and often

preventable health conditi

ons in adulthood,

including

stroke, heart attack, and high

blood pressure.

Secure attachment,

however,

holds no relationships to health

risks, il

lnesses, or disorders of any kind.

328

Certified

Child Life Specialists promote

positive social, emot

ional, and

development

al outcomes for infants by

providing suppo

rt and education to

parents/

caregivers,

309,312

thus target

ing the

future eff

ects of different attachment styles.

By addressing

infant pain and distress cues

both system

atically and consi

stently,

CCLSs

protect infan

ts' developmental trajectories

and foster

higher quality patient

-and-family-

centered care

experiences for patients,

families, and

institutions

329

- while also

mitigat

ing preventable health conditions in

adulthood.

Mental Health

Outcomes in Childhood

and Adolesce

nce

While the i

nability to form secure

attachments

and trusting relationships

affects deve

lopment beyond infancy,

decreased f

amily functioning, an impact of

chronic illne

ss, is also a contributor to the

recent ri

in mental

illness among children

and adolescents.

330,331

In the gene

ral

population of

the United States, the

prevalence of m

ental health disorders

among children is

16.5% (estimated as 7.7

million

children) with almost half of those

(49.4% na

tionally)

not receiving

counseling

or other

needed treatment from mental

health prof

essionals.

332

Perhaps even mor

alarming are

the recent statistics indicating

that pedi

atric emergency department (ED)

visits fo

r suicide attempt (SA) and/or

suicidal i

deation (SI) have

doubled - with

43% of t

hese being for children between the

ages of 5 and 11

years. Yet at the same

time, t

he number of emergency department

visits fo

r childhood injuries or illnesses has

seen little chang

333

Mental he

alth, also referred to as behavioral

health in pe

diatric settings, is characterized

by an individu

al’s level of psychological

and/or psychosoci

al adjustment. The

symptoms of

mental illness and

psychological

maladjustment are often

categorized into ei

ther internalizing or

externalizing

behavio

rs. Inter

nalizing

behaviors incl

ude depressive symptoms,

withdraw

al, and anxiety, whereas

aggression and

active noncompliance with

behavioral exp

ectations are considered

externalizing

behaviors. In general,

internalizi

ng behaviors impact the individual,

initially,

while externalizing behaviors are

often directed

towards others.

330,331

Mental he

alth is a global epidemic, and

children wit

h chronic medical conditions are

at greate

r risk of mental health disorders,

especially w

hen compared to children

without such conditi

ons.

331,33

-337

While the

survival rat

e of children living with chronic

illness i

s nearly 90%, these conditions and

corresponding

treatments impose significant

stress on

children and families. Living with a

34 | ACLP

chronic illness is empirically associated with

negative psychosocial outcomes,

psychological maladjustment, incidence of

mental illness diagnoses, and symptoms of

anxiety and depression.

112,331,338-340

Moreover, having one mental illness

diagnosis significantly increases a child’s

risk of developing comorbid physical and

mental illness diagnoses that can further

diminish quality-of-life

339

- exemplifying the

bidirectional relationships between physical

and mental health operant throughout the

lifespan. Certified Child Life Specialists are

keenly aware of the impact healthcare

experiences can have on the mental health

of infants, children, and youth. Assessments

by CCLSs give attention to prevention of

misconceptions and the development of

adaptive coping behaviors. For instance,

teaching a child effective coping patterns

near initial diagnosis of a chronic illness can

lead to long-term, healthier patterns of

healthcare experiences for children and

their families.

What is most concerning is that research

reveals a higher prevalence of SI and SA in

children and youth with a history of

hospitalization and chronic illness, with

ideation and attempts directly related to the

reason for hospitalization.

341-343

The highest

risk for SA appear to be in the weeks

immediately following hospital admission,

but the risk appears elevated for five years

following onset of disease, and up to five

years post-discharge.

342,343

specifically, for children with type 1 diabetes

mellitus, the risk of psychiatric morbidity

(including SI) when compared with the

general population, triples for the first six

months after diagnosis, and double between

age of onset and the age of 18.

341

addition, increased risk of psychiatric

diagnoses and SA are proliferated among

individuals with a childhood onset of irritable

bowel disorder (IBD; including diagnoses of

Crohn’s disease, ulcerative colitis, and IBD

unspecified).

342

Moreover, when siblings

and parent/caregiver psychiatric histories

are also considered, there is a significant,

sustained association between childhood

onset of IBD, psychiatric disorders, and SA

for at least five years after diagnosis.

342

To date, studies have revealed that family

functioning and social isolation help to

moderate the relationship between chronic

illness and mental health disorders,

340,344

namely children’s mental health and general

well-being are improved when family

functioning is optimized.

340

However, the

sense of social isolation children and

adolescents experience during

hospitalization further threatens their

mental, behavioral, and emotional

stability.

344

Thus, the quality of survival, or

one’s Health-Related Quality of Life (HR-

QoL),

345

has become a contemporary focus

of research and intervention across the

healthcare sector. Furthermore, given the

prevalence of psychopathological needs

among children living with chronic

conditions, collaborative efforts from all

members of the healthcare team must be

reinforced via thorough screening,

prevention, and early identification.

346

Considering today’s trend of higher survival

rates for children with chronic medical

conditions, yet higher risk of mental health

disorders, simply surviving is no longer a

sufficient end goal. Certified Child Life

Specialists are members of the healthcare

team already working within domains that

optimize developmental trajectories and

prevent negative mental health outcomes

resulting from healthcare experiences.

Using a trauma-informed approach, CCLSs

teach adaptive coping strategies to manage

The Value of Certified Child Life Specialists | 35

the typi

cal stressors involved in growing up,

as well as

the added chal

lenges po

sed by

chronic or acu

te medical conditions.

Certifi

ed Child Life Specialists increase

access to and

effective use of coping

strateg

ies, thereby mediating the effects of

chronic ill

ness on HR

-QoL.

112

The firs

t 12

months

after a medical diagnosis i

considered

a “critical intervention period” in

which children

demonstrate the highest

level of

need for emotional support and

adaptive copi

ng strategies.

338,34

1,342,346

Through

interventions such as therapeutic

and medical

play,

preparation

138,15

and

diagnosis

education,

112

coping

skills

education

124,12

and procedural

support,

75,98,

148,347

CCLSs

positively impact

parent

and child perception of disease, as

well as t

heir adjustment to illness related

limit

ations. Certified Child Life Specialists

facilitate peer

interaction through play,

group activit

ies, and online and

technolog

ically supported platforms of

communicat

ion to decrease social

isolation

330,33

7,344

; such i

nterventions provide

opportun

ities for positive childhood

experiences (

PCEs)

withi

n the context of

healthcar

e (e.g., feelings of control, mastery

of new ski

lls), thereby increasing active

engagemen

t with treatment throughout the

family syst

em and preventing additional

mental

and relational health issues into

adulthood

348

Sibling Support

As evidence

d by the dominant philosophy of

patient-and-famil

-centered

care across

healthcar

e institutions, a pediatric patient’s

medical

needs have resultant

– and often

substanti

– impact

s on all members of

their

identified family system. While

most

research on

PMTS focuses on patients and

parents

/caregivers, siblings, too, face

adverse develop

mental and psychosocial

consequences

as a result of stressful

medical

events, especially when their

unique needs

within the family are not

addressed. When a child is hospi

talized,

their

siblings struggle with separation from

family membe

rs, as well as feelings of

sadness, an

ger, anxiety, confusion,

loneline

ss, and jealousy that can last for

years and

contribute to increased family

conflict

349-351

These siblings m

ay exhibit

symptoms

of PMTS long after the patient’s

hospitali

zation or illness experience is over.

As many

as five years after the completion

of treat

ment, 81% of siblings of childhood

cancer survivors

reported posttraumatic

stress sy

mptoms, includ

ing 32%

exhibiting a

moderate

to severe reaction that predicted a

formal

diagnosis of PTSD.

352

These adverse

developmen

tal and psychosocial impacts

have devastating e

ffects on the sibling’s

immedi

ate and long

-term he

althcare usage

patter

ns, thereby challen

ging popu

lation

health outco

mes even in otherwise healthy

children.

Certifi

ed Child Life Specialists are the only

dedicated psycho

social healthcare

practition

ers who specifically extend their

patient-and-famil

-centered

interventions to

address the

behavio

ral and

psychosocial

health of

siblings. Successful sibling

interventi

ons typically include play,

developmen

tally appropriate health

education

, emotional support, advocating to

parents

/caregivers for siblings’ needs, and

teaching

coping strategies

353-355

- very

similar

to those proven effective in children

hospitali

zed for an illness or injury. For

example,

siblings of hospitalized children

displayed signi

ficant decreases in anxiety

after w

orking individually with a CCLS

356

;

and when pa

rticipating in play g

roups

facilit

ated by a child life professional,

siblings

benefited from medical play

36 | ACLP

interventions used to encourage emotional

expression, enacting themes such as

memories of health events, need for

parental attention, and impact of illness on

the family.

114

In the context of more trying circumstances,

both donor and non-donor siblings of

children undergoing hematopoietic stem cell

transplants highlight the integral role that

CCLSs play in providing therapeutic

interventions for siblings. Such services

were well received by siblings and family

members, in addition to healthcare

providers. For example, 100% of healthcare

providers reported that sibling meetings with

a CCLS were an important component of

the transplant process; in addition, the

sibling participants described child life

interventions as fun, helpful, and an

effective way to talk about their feelings.

357

Furthermore, the availability of child life

services improved both multidisciplinary

collaboration and patient and family

experience during transplant.

357,358

delivering interventions that address the

needs of siblings experiencing healthcare

hardship alongside pediatric patients,

CCLSs offer interventions that protect

against PMTS and encourage long-term

resilience, well-being, and coping that only

serves to benefit family health outcomes

throughout the lifespan.

Legacy Building

As has been seen, healthcare experiences

provoke a wide range of psychological and

developmental responses in infants,

children, adolescents, and their families. To

assist children and families in finding the

individualized sense of meaning needed to

effectively cope with their healthcare

encounters, CCLSs expressly offer legacy-

building interventions as a way to

therapeutically chronicle healthcare

journeys. The term “legacy building,”

distinctively coined and practiced by child

life professionals, describes a variety of

arts- and play-based efforts to help children

and their families reflect on their

experiences and create lasting memories

during illness, treatment, or

hospitalization.

359

While at times referred to

as “legacy making” or “memory making,”

these interventions are grounded in a

conceptual understanding of legacy as

“personal and relational summations of our

unique histories, current activities, and

hopes for the future.”

360(p43)

Children and

families can intentionally and tangibly create

a legacy through mediums like journaling,

scrapbooking, photography, video diaries,

collections, hand prints or molds, writing

letters, storytelling, and songwriting - some

of which are offered at upwards of 97% of

children’s hospitals.

361

Legacy can also be

developed serendipitously, without

forethought, and represented by intangible

items such as character traits, beliefs,

actions, and values. Whether helping a

patient recognize their constantly evolving

legacy or facilitating a targeted, tangible

activity, CCLSs ensure that the avenues

and mediums through which legacy is

explored by patients and families fits and

satisfies their individualized preferences.

Efforts to build memories and make

meaning out of difficult healthcare

experiences for children, adolescents, and

youth through legacy building can create an

important gateway for coping. When offered

by CCLSs, legacy-building interventions

provide patients and families with a chance

to purposefully and collaboratively

document their legacies (both ongoing and

established) through the hopeful framing of

activities, relationships, accomplishments,

and journeys - a technique promoting

The Value of Certified Child Life Specialists | 37

legacies tha

t last beyond hospitalization

and

throughout

a lifetime.

360

Legacy act

ivities

have been fou

nd to promote self

-efficacy

patient

s, empowering them as they work to

create

lasting memories during extended,

signifi

cantly stressful, or end

-of-life

healthcar

e experiences.

362

This

empowerment and con

trol during a time

characteri

zed by uncertainty, fear, and

forced com

placency achieves something

always top-of-mind i

n child life care

- the

provision of

patient

-and-family choi

ce and

control.

For pat

ients nearing the end of life, legacy

building

proves additionally therapeutic, as

patient

s recognize their influence on the

lives of o

thers and develop a sense of

identity by

doing or saying something to be

remember

ed.

363-365

Histor

ically, legacy

building

interventions have encompassed

projects tha

t: 1) assist individuals and

families in

initiating the process of life

review an

d 2) result in a product that can be

enjoyed by

family and friends prior to and

after t

he individual's death.

363

Though t

hey

take man

y forms, children’s hospitals most

commonly

offer legacy

-building

at the end of

life through

mediums such as plaster hand

molds, gi

ving bereaved families an

intentional

and tangible way to remember

the dying

child.

361

However,

it is important to note that the

therapeu

tic value of these acti

vities

comes

not fr

om the objects they produce, but

rather t

he positive experience of connection,

collaborati

on, and control they engender at

the pinn

acle of stress and loss.

360

Certifi

Child Lif

e Specialists recognize that

legacies last

far beyond death

and

keepsakes, an

d champion this awareness in

providers,

patients, and families, making

space and opport

unities for legacies to

manifes

t through self

-expression an

customized

celebration. As a result of

legacy-building

activities and the therapeutic

interactions

they facilitate, CCLSs fill a

compelling

void in health care

psychosocial

support for patients and

families as t

hey navigate personal

difficul

ties facing their family through the

hospitali

zation (or death) of a loved one.

Thus, engagi

ng in lega

cy-building

activities

supports

both patient and family coping in

the cont

ext of illness, promoting familial

engagemen

t and communication from the

day of di

agnosis, to the moment of

discharge,

or the time of death.

359-361

Bereavement

Support

An unfortun

e reali

ty that can generate or

exacerbate P

MTS in siblings and family

members al

ike is the death of a child.

The

grief an

individual experiences when a child

dies is more a

cute and prolonged than for

any other

familial loss.

366

Parents/car

egivers

can experience a

multitude of negative

psychosocial

outcomes as a result of their

child’s de

ath,

367-369

ranging

from clinical

anxiety and

depression

370

to sympt

oms of

posttrau

matic stress, to ultimately a clinical

diagnosis

of PTSD.

371

Negative

physiologi

cal repercussions are also

rampant i

n bereaved parents/caregivers,

resulti

ng in more physician consultations

and subsequent

hospitalizations, increased

pharmacolog

ical treatment, and decreased

productivity i

n the workforce.

372

Striki

ngly,

research ha

s demonstrated that a child’s

death is a

ssociated with increased mortality

in all be

reaved parents/caregivers, though

more sign

ificantly in mothers than fathe

rs.

373

Additi

onal empirical evidence suggests that

maternal

mortality increases by as much as

133%.

374

38 | ACLP

In line with the role and responsibilities of a

CCLS, the most salient predictor of long-

term complicated grief in bereaved

parents/caregivers is access to

psychological support and preparation prior

to the patient’s death.

367

Those with

knowledge of a loved one’s impending

death adapt better than those without

warning,

375

and, likewise, parents/caregivers

who receive psychological support during

the last month of their child’s life are better

equipped to work through grief, reporting

lower levels of persisting grief up to nine

years after their child’s death.

367

What is

more, qualitative reports validate these

findings, as parents/caregivers repeatedly

describe the importance of receiving

anticipatory guidance by psychosocial

professionals working in healthcare settings

to help them understand their child’s end of

life trajectory and cope more adaptively

after their child dies.

369

When asked to

reflect on their experiences, bereaved

parents specifically identified child life

services as “very helpful,” namely for the

developmentally appropriate education and

therapeutic play provided to the dying child

and their siblings; parents further suggested

that child life professionals should be

available across hospital, home, and clinic

settings as a family-centered support.

376

Aptly-timed and ongoing bereavement

support supplied by CCLSs improves

parent/caregiver grief and bereavement

outcome as it facilitates coping and

manages expectations in order to create

meaningful, manageable end-of-life

experiences.

Similar to their parents/caregivers, bereaved

siblings, too, keenly grieve the death of a

family member.

367

They suffer increases in

acute illnesses, hospitalizations, and

medication changes during the first six

months after their sibling’s death, which

have been found to persist for as long as 12

months after the death event.

377

Certified

Child Life Specialists efficaciously and

therapeutically adapt bereavement support

for siblings - which is highly rated by

bereaved parents/caregivers.

376

They

provide anticipatory guidance regarding

what to expect when their sibling dies,

significantly lowering levels of sibling

anxiety two to nine years after the fact.

378

Conversely, research reveals that bereaved

siblings who were dissatisfied with

communication at the end of the patient’s

life had higher distress, as well as greater

likelihood of unresolved grief, compared to

bereaved siblings who received

developmentally appropriate and sensitive

information.

378

___________________________________

When CCLSs provide preparation

specifically for children visiting a

family member in an adult intensive

care unit, as well as age appropriate

information about the illness and its

expected trajectory, children exhibit

fewer and less intense negative

emotional reactions.

381-384

___________________________________

With a strong understanding of how

developmental stages impact perceptions of

death, empathetic communication skills

adapted for individualized needs, and the

ability to establish a therapeutic relationship

with the family, CCLSs maintain unrivaled

positioning within multidisciplinary

healthcare teams to provide the preparation

and psychological support explicitly,

empirically, and anecdotally noted as

beneficial families. Using their scholarly

knowledge of child and family grief

The Value of Certified Child Life Specialists | 39

processes, and de

velopmenta

l framew

orks

for children's

evolving conceptions of death

as final, i

rreversible, and universal, CCLSs

possess the ski

lls to explain such life events

to siblings i

n sensitive, deliberate, and

developmental

ly appropriate language.

Furthermo

re, their experti

se in

psychological prepara

tion is often utilized in

readying and

supporting siblings during

critical care

unit visits as patients near the

end of life,

even when the patient is a

parent, g

randparent, or another adult

relative.

379,380

When CCLSs provi

preparation spe

cifically for children visiting a

family member

in an adult intensive care

unit, as

well as age appropriate information

about the

illness and its expected trajectory,

children exhibit

fewer and less intense

negative emotio

nal reactions.

381-384

Thus, by

providing fam

ilies with honest and timely

information

that is delivered with

compassion and e

mpathy, CCLSs

remediate the

negative psychological and

physiological

consequences associated with

complicated bereave

ment experiences

across famil

y syste

ms.

Child Life

in Community Settings

Certified

Child Life Specialists also extend

their inva

luable psychosocial interventions

and support to

children and families in non

tradition

al, community

-based settings

385,386

outside tho

se considered as healthcare

settings. Th

e basis and rationale for this

expansion is

predicated on the

Child Life

Vision St

atement

387

which explains that

the

“practice of chi

ld life will be applicable to

any healthcar

e setting and transferable to

other communit

y settings or situatio

ns in

which the pot

ential for infants, children and

youth to cope,

learn, and master is placed

at risk.”

387(p1)

Hence, the si

x domains

interwoven in chi

ld life practice (see Figure

1) are comprised

of highly transferable

facets of

care, applicable in any s

etting

where children o

r families may experience

stress. When

CCLSs working in traditional

and non-tradition

al settings (e.g.

rehabilit

ation, private practice, and

community set

tings) were surveyed

about

offering sup

port for non

-illness-related

psychosocial stressors,

they reported

providing freq

uent assistance with other

family challen

ges such as divorce,

substance abuse

, poverty, homelessness,

and parental m

ental illness.

Certified

Child

Life Specialist

s address these stressors

through their

effectively

transferab

le coping

interventions

- those which impr

ove health

outcomes for

children and families across

care settings

Industry suppo

rt for the expansion of child

life services

in community settings amplifies

the aims an

d experiences of CCLS; the

American Academy of

Pediatrics

asserts

that child li

fe services are necessary beyond

the hospital

environment. To date, CCLSs

have already ad

apted the foundational

interventions

of their profession and

documented thei

r impacts in: recreational

and therapeut

ic ca

mps,

388

non-profit

agencies,

229

dentistry practi

ces,

389-391

early

childhood setti

ngs,

392,393

legal system

s and

child advocacy center

394

prenatal

settings,

395

women’s centers,

396

bereavement p

rograms, funeral homes,

hospice and home health,

trauma or cris

teams, an

d behavioral health

clinics.

229,385,

397,398

While it is est

imated that approximately 7%

of all CCLS

s work in these non

-hospital

settings,

229

this proporti

on is growing in

stride wi

th changes in the healthcare

service delivery

model. Because cur

rent

healthcare quali

ty goals are aimed at

reducing acut

e care and extended

40 | ACLP

hospitalizations, many services are now

being provided in outpatient settings,

399

and

in order to best support today’s pediatric

patients and their families, many CCLSs are

developing private practice models and

exploring reimbursable billing schedules to

conti

nue this extension into the community.

Therefore, because the foundational skills

and interventions employed by Certified

Child Life Specialists (e.g., individualized

assessments, cultivation of a therapeutic

environment, coping skills education, and

psychological preparation) can be

implemented in various settings, the

potential for expansion of child life services

into additional service contexts is

innumerable.

Cultivating Resilience

Child life professionals, regardless of

setting, help weave an emotional and

psychological safety net for patients and

families, thus including CCLSs in standard

care protocols cultivates positive

development and, most importantly,

resilience. Resilience is a term used to

describe an individual’s ability to maintain

physical and psychological well-being

during and following times of significant

stress or adversity.

17,18

Resilience

encompasses

the evidence-based

phenomenon in which children and adults

are able to overcome difficulties and adapt

more effectively by capitalizing on the

strengths and abilities they already

possess,

400

all of which are embedded in the

foundations of child life practice. Certified

Child Life Specialists use integrative,

strengths-based approaches that support

patients and families through stressful

experiences, bridging the gaps between an

individual’s coping needs, their unique

strengths, and the task demands of

managing healthcare stress. By affirming

and facilitating positive coping,

17,19,20

problem solving, goal setting,

20,22

family

functioning, social support, and self-efficacy,

CCLSs foster resilience in children and

families facing medical

challenges,

17,22,24,401,402

thus enhancing

health-promoting behaviors and improving

relationships with providers.

19,21,191

It is widely demonstrated that disease-

specific factors can directly challenge

resilience and its associated health

outcomes; more specifically, illnesses that

are longer lasting or more severe are

associated with lower resilience and self-

esteem.

403,404

Findings have highlighted the

importance of interventions that promote

active coping and positive appraisals to

mitigate the negative effects of disease. Not

only do these interventions cultivate

resilience, but they also moderate symptom

severity and enable individuals to engage in

health promoting behaviors.

For example,

creating a disease narrative with patients

affords opportunities for them to make

meaning and exercise benefit-finding, while

also challenging inaccurate appraisals and

adjusting their beliefs about one’s ability to

control their own outcomes.

19,20,401

Moreover, interventions that promote

diagnosis education and problem-solving

behaviors in adolescents increase resilience

and foster self-efficacy and adherence.

Thus, interventions that assist patients and

families in processing their emotions,

thoughts, and experiences - such as those

provided by CCLSs - encourage adherence

and enhance quality-of-life.

191

Certified Child Life Specialists operate

under the premise that resilience can be

clinically cultivated through education, play,

and emotional support for pediatric patients

and their families. Fostering strong

therapeutic relationships, CCLSs recognize

The Value of Certified Child Life Specialists | 41

that infants, children, youth, and

parents/caregivers ar

e capable of exercising

resilience throughout ev

en the most

stressful of exper

iences

- emerging on the

other side with renew

ed awareness of their

own internal coping resources

and

strategies.

405

Certified Child Lif

e Special

ists,

as multidisciplinary he

althcare team

members acutely attune

d to psychosocial

needs, understand t

heir ability to serve as

positive, non-familial allie

s and, while

employing healthy pati

ent

-provider

boundaries, act accordi

ngly. Certified Child

Life Specialists routinely

normalize

experiences and emotions t

hrough

therapeutic conversa

tion and activities, thus

filling a therapeu

tic role that is as comforting

as it is productive.

Strong, supportive

, consistent social

relationships are signif

icant predictors

resilience across age gro

ups and

conditions

401,404

; whether these

relationships

are with famili

es, peers, or non

-familial

adults (such as CCLS

s), the fact remains

that relationships prod

uce the qualities and

abilities individuals

need to engage in thei

care and achieve positi

ve health

outcomes.

17,19,21,402,4

04,406

-408

Grounded in the

therapeutic value o

f relationships, CCLSs

build resilience through t

he individualized,

trauma-informed, and developm

entally

appropriate care they provi

de to children

and families - the effects of which a

re broad

and enduring for physica

l and psychological

health. As the em

pirical links between

resilience and hope, optim

ism, self

-efficacy,

coping, meaning-making, and benef

finding

demonstrate CCLSs i

nstill

transferable skills, strengths,

and beliefs

that pediatric pat

ients and families can draw

upon during and be

yond their healthcare

encounters.

Conclusion

42 | ACLP

____________________________________________________________________________

Certified Child Life Specialists are members of the multidisciplinary care team that affect

positive outcomes for institutions, patients, and families, thus approaching the Quadruple Aim

and improving the healthcare industry in return. Certified Child Life Specialists empower

children and families at all ages and stages to become active, informed, and well-adjusted

consumers throughout their healthcare journey, no matter where it begins or leads. Resultant

reductions in anesthesia, sedation use, repeated tests/procedures due to coping difficulties,

pain medications, readmission rates, and overall length of stay equate to significant savings per

fiscal year scaled upon institutional programs, volumes, and performance. These impacts of

child life services transcend healthcare’s volume- and value-based service descriptors by

increasing throughput, minimizing waste, and improving the patient experience - all without

sacrificing quali

ty or substantially increasing expenditures. Certified Child Life Specialists

optimize resource use in the moment, while also cultivating a new generation of consumers that

will actively seek and sustain a more affordable, accessible, and effective healthcare industry

for all.

The Value of Certified Child Life Specialists | 43

nowl

edgem

ents

____________________________________________________________________________

tho

rs would like to acknowledge Janet Cross, MEd, CCLS, CPXP and Stephanie Van Dyke, CCLS

for the

upport of this project, as well as the many individuals who provided critical feedback on initial

drafts

, i

uding: Stephanie Abbu, MSN,

RN; Marissa A

tti

MD; Michael W. Bishop, MD; Jason Brashier,

hD,

A, MA; Chris Brown, MS, CCLS; Sherwood Burns-Nade

hD, CCLS; Kathryn Cantrell, PhD,

CCLS

;

leen Clark, CCLS; Gary Clark; Sarah Daniels, MS, CCLS; J. Kevin Duplechain, MD, FACS; Ame

nri

Kris

on, PhD; James Gay, MD, MMHC; Megan Greffen, LMSW; Diane

Hart, MA, EDAC; Elise

Hebe

, M

, CCLS; Jim Hollender, MBA; Ellen C. Hollon, MS, CCLS; Yeh Hsueh, PhD; Katy Hudgins;

Jessee, PhD, CCLS; Jennifer A. Jewell, MD, MS, FAAP; Elizabeth McCarroll,

hD, CC

; Amy

k Morse, PsyD, CCLS; Emily Mozena, MA, CCLS; Pamela Norcross, PhD, CCLS;Lori Anne Parker

Danl

, P

hD; C

harles Phelps, PhD; Farya Phillips, PhD, CCLS; Leonard Rappaport, MD, MS; Judy

Rol

ns, PhD, RN; Teresa Schoell, MA, CCLS; Cara Si

, P

hD, CCLS; Jennifer Staab, MS, CCLS; Bindy

wee

tt,

LS; Richard H. Thompson, PhD; Michelle Townsend

-B

ark

le, CCLS; Jessica Turnbull, MD,

;

na Wheelwright, MS, CCLS; Jeremy Willis, MBA; Denise Winsor, PhD; Jason A. Wolf, PhD,

;

Lois Wolgemut

CLS

and the staff and board of directors of the Association of Child Life

ofe

ssionals.

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The Value of Certified Child Life Specialists | 65

Contributors

____________________________________________________________________________

Jessika Boles, PhD, CCLS is a Certified Child Lif

e Specialist and team lead at Monroe

Carell Jr. Children's Hosp

ital at Vanderbilt, and an Adjunct Professor in the Department

of Psychology and Hum

Development at Vanderbilt

University.  In her current

positions and her pr

ior tenure at St. Jude Children's Research Hospital, Dr. Boles has

served infants, children, ad

olescents, and young adults with chronic, life

-threatening, or

terminal illnesses and injuries.  The diversity of

her educational background

- a

bachelor of arts in Religio

us Studies from Rhodes College, a master's of education in

Applied Child Studies

from Vanderbilt University, and a doctorate in Educational

Psychology from the Univ

ersity

of Memphis - shapes her clinical work

and research, both of which aim to

break down the discursive ba

rriers that can limit children's understanding of and participation in their

healthcare experiences.  Her pub

lications and presentations similarly address

topics such as children’s

involvement in healthcare research, thei

r conceptions of abstract constructs such as legacy and loss, and

the ways in which they acc

ess and respond to medical information.  Additionally, Dr. Boles is a former

board member of the Association of Child Li

fe Professionals and

regularly contributes her time t

institutional initia

tives for improving bereavement care, increasing patient mobility, and mitigating trauma

and distress in pediatr

ic critical care environments. 

66 | ACLP

Camille Fraser, MS, CCLS, CIMI is a Child Life Specialist II at Monroe Carell Jr.

Children’s Hospital at Vanderbilt and an Adjunct Professor in the Department of Family

Science at Lipscomb University. In her clinical role, she works in the pediatric

cardiology department providing services to the outpatient cardiology clinic, pediatric

cardiac intensive care unit, and cardiac step-down unit. Camille has helped lead both

unit-specific and institution-wide initiatives to improve bereavement support, facilitate

the formation of infant attachment, and enhance sensory support measures to aid in

long-term coping and regulation. She has held previous child life positions working in

acute care and PRN roles. Her educational background includes a Bachelor of Arts degree in family

relations from Lipscomb University and a Master of Science degree in child life from Bank Street College

of Education.

Katherine Bennett, MEd, CCLS, has worked as a Certified Child Life Specialist at

Monroe Carell, Jr. Children's Hospital since 2001. She has worked with children and

families in the areas of operative surgery, community outreach/education, PICC,

inpatient medicine with all age groups, and in the burn center. Currently, she serves as

the educator for Child Life & Volunteer Services, planning and coordinating the clinical

training experiences for emerging child life professionals, onboarding new employees,

working with the department's clinical advancement program and providing education

about the needs of children in healthcare settings to colleagues both in and outside the Vanderbilt

community. She has written and presented at international conferences and in several published outlets

about such topics as medical play and its impacts, developmental theory applied to hospitalized children,

and teaching child life in the clinical and university settings.

Maile Jones, MEd(c), CIMI is a graduate student pursuing her Master of Education

degree in Applied Child Studies at Vanderbilt University, where her coursework and

clinical experiences have focused on pediatric healthcare. After obtaining her Bachelor

of Science degree in Psychology and Health and Wellness from Tulane University,

Maile spent a year in Australia working for the Starlight Children’s Foundation to

expand her knowledge in international child life practice. The diversity of her

experiences both locally and internationally have shaped her research interests in

understanding how children, adolescents, and caregivers cope with stress and

adversity in their lives. Maile currently works on several research projects including examining the effect

of group medical play interventions on children’s anxiety in the preoperative waiting area, and

investigati

ng the legacy perceptions described by pediatric patients, caregivers, and healthcare

professionals

. Her publications and presentations similarly include the importance of play in healthcare

settings, pediatric patient and caregiver perceptions of legacy, and the ways in which children’s anxiety

level and self-reported fear are influenced by medical play interventions.

The Value of Certified Child Life Specialists | 67

Jenna Dunbar, MEd(c), CIMI is a graduate student in the Applied Child Studies

program at Vanderbilt University’s Peabody College of Education and Human

Development pursuing an emphasis in pediatric healthcare, and a specialization in

poverty and intervention. She will graduate with her M.Ed. in May 2020 and is currently

completing her child life internship at the Children’s Hospital of Philadelphia. Using her

bachelor’s degree in journalism from the University of Missouri, professional experience

at both large and small magazines and in advertising, as well as her present and

evolving experience in pediatric psychosocial care, Jenna incorporates creativity and

effective communication into all aspects of her work. She often employs her nontraditional path to child

lif

e to formulate unique interventions and treatment strategies for pediatric patients and their

families, applying her well-rounded knowledge of the ways in which adversity, poverty, and

marginalization in childhood impact development. Jenna maintains involvement in research and has been

involved in quality improvement initiatives at Monroe Carell Jr. Children’s Hospital at Vanderbilt

that address the influences of child development and early adversity in pediatric healthcare, such as the

study of how legacy and loss are conceptualized by pediatric patients and their families, as well as

improving the treatment of newborns exposed to opioids in utero and procedures for diagnosing neonatal

abstinence syndrome (NAS).

Ashlie Woodburn, MEd, CCLS, CIMI is a Certified Child Life Specialist working at

Monroe Carell Jr. Children’s Hospital at Vanderbilt and serving the pediatric cardiology

population. Ashlie has experience implementing a wide range of child life interventions

that meet the needs of diverse patients and families across outpatient clinic, inpatient

acute and critical care settings. Ashlie is particularly interested in meeting the

devel

opmental needs of infants with chronic medical conditions. Ashlie has completed

certification as an infant massage instructor and has worked to implement programs to

increase the utilization of child life support during infant procedures and encourage developmentally

appropriate sensory support in the Pediatric Cardiac Intensive Care Unit. Her academic training includes

Bachelor of Science degrees in Psychology and Family and Human Development from Arizona State

University and a Master of Education degree in Child Studies from Vanderbilt University.

Mary Ann Gill, MEd(c), is a graduate student at Vanderbilt University, where she is

pursuing a Master of Education in Applied Child Studies with a concentration in

Pediatric Healthcare. While completing a Bachelor of Science in Psychology at St.

Mary's College of Maryland, Mary Ann spent several summers working at the Center

for Courageous Kids, a residential camp for children with serious illnesses. Her diverse

professional experiences there, in the special education field, and at Flying Horse

Farms, another medical specialty camp, have shaped her interests in teaching

emotional literacy, incorporating mindfulness into coping skills education, providing adaptive care for

children with developmental disabilities, and supporting adolescents and emerging adults through

healthcare transitions. Other publications, presentations, and research experiences include projects

related to sibling support, therapeutic camp programs, and behavioral interventions in pediatric

endocrinology. In the spring of 2020, she is completing a child life internship at Riley Hospital for Children

at Indiana Uni

versity Health. 

68 | ACLP

Anne Duplechain, MEd(c), is a graduate student at Vanderbilt University pursuing

her Mas

ter of Education degree in Applied Child Studies, with a concentration in

pediatric healthcare. After completing her Bachelor of Arts degree in elementary

education at Texas Christian University, Annie served children and their families

around the world through humanitarian work in Central America, Africa, and Asia. She

then returned to Texas to teach in a Title I school but felt a continued passion for

providing psychosocial support to children and families in healthcare settings. In her

graduate studies, with aspirations to become a child life specialist in a critical care environment, Annie

has concentrated her coursework, research, and service on best practices for bereavement programs

and the ways in which child life and spiritual care can partner to provide holistic, patient-and-family-

centered care. She has published and presented on this work at national and regional conferences for a

wide range of stakeholder audiences to provide multidisciplinary clinicians with evidence-based

approaches for ameliorating negative psychological sequelae associated with hospitalization and loss.

After completing her internship, Annie will pursue certification and continue to establish her identity as a

child life specialist. 

Erin Munn, MS, CCLS is a Child Life Specialist III at Monroe Carell Jr. Children’s

Hospital at Vanderbilt in Nashville, Tennessee, with twenty-five years of experience as

a Certified Child Life Specialist.  Over her fifteen years at Johns Hopkins Children’s

Medical Center in Baltimore, Maryland and nine years at Vanderbilt, Erin has served

children and families across a wide range of inpatient and outpatient areas -

cardiology, critical care, pre-surgery, burn/trauma, and specialty clinics – as well as

her current role with a quality improvement initiative focused on opioid-exposed

newborns and thei

r mothers. Throughout her career, she has maintained a

commitment to the professional development of child life students and staff, serving as co-chair of the

Internship Task Force for the Association of Child Life Professionals (ACLP) and developing standardized

curriculum modules and a supervisor manual for child life internship programs. In addition to numerous

presentations at conferences in the United States, Erin has been an invited speaker for conferences and

education series in New Zealand, the Philippines, and in the Balkans.  Erin has been an active member of

ACLP since 1995 and is a former President of the organization; most recently, she was named as the

recipient of the Mary Barkey Clinical Excellence Award to acknowledge her exemplary child life care and

high level of clinical skill. 

Katy Hoskins, CCLS is a Certified Child Life Specialist in the Neonatal Intensive Care

Unit at Monroe Carell Jr. Children's Hospital at Vanderbilt in Nashville, TN. Katy's

interests and advocacy centers around infant mental health, non-pharmacological pain

management/procedural support for infants, prenatal psychosocial support for parents

and siblings in Maternal Fetal medicine, preterm developmental needs, and family-

centered end of life care. Katy has been a child life specialist for four years with

previous clinical experience in the emergency department and inpatient neurology.

Katy was instructed and mentored by Dr. Cara Sisk, Ph.D. at Tennessee Tech

University and graduated in 2015 with a Bachelor of Science degree in Human Ecology with a

concentration in Child Life. Katy serves on many hospital committees, including chair of the NICU

Bereavement Committee, and is also an ACLP Bulletin committee member.

www.childlife.org

ACLP Vision

ACLP advances psychosocial care and the emotional safety of children, youth, and families

impacted by healthcare and significant life experiences.

ACLP fosters child life professionals through:

■ Standards and credentialing

■ Connection, collaboration and community

■ Evidence-based practice

■ Professional development

■ Championing the child life profession

ACLP Mission