Pediatric Annals

Feature Article 

A Systematic Literature Review of Child Life in Ambulatory Settings

Teresa McGinley, MA, CCLS; Stephanie Maskell, MA, CCLS; Kathryn Cantrell, PhD, CCLS

Abstract

This article illustrates the growth and development of the profession of child life within the last 25 years through a literature review of child life services in ambulatory settings. We reviewed all literature chronicling child life services in ambulatory settings published between January 1993 and December 2018 in three major databases, synthesizing common themes across the literature. Over the last 25 years, growth has occurred in the provision of child life interventions in outpatient settings and more publications are being produced. In outpatient settings, procedural support interventions have been written about the most, with much of this literature coming after 2010. [Pediatr Ann. 2020;49(11):e491–e498.]

Abstract

This article illustrates the growth and development of the profession of child life within the last 25 years through a literature review of child life services in ambulatory settings. We reviewed all literature chronicling child life services in ambulatory settings published between January 1993 and December 2018 in three major databases, synthesizing common themes across the literature. Over the last 25 years, growth has occurred in the provision of child life interventions in outpatient settings and more publications are being produced. In outpatient settings, procedural support interventions have been written about the most, with much of this literature coming after 2010. [Pediatr Ann. 2020;49(11):e491–e498.]

Child life is a profession devoted to providing psychosocial care to children and families confronting hospitalization. Certified child life specialists support children's psychosocial development across the health care continuum and design interventions aimed at promoting optimal coping in the face of challenging medical experiences. The role has evolved from its beginnings when child life professionals were referred to as “play ladies” who used play to promote optimal development and reduce distress associated with hospitalization.1 These professionals most often provided play to children bedside in the inpatient setting. Here, child life professionals emphasized individual strengths and provided developmentally appropriate support to allow children to cope with adversity.2 The focus of child life specialists has shifted over the years to also include providing education, pain management, and preparation for medical procedures. Child life specialists have also shifted where they work. Child life specialists have now expanded beyond the inpatient setting and are recognized internationally for helping children cope in ambulatory settings.

The Child Life Council was formed in the United States in 1982 and was later renamed the Association of Child Life Professionals (ACLP). Now, there are more than 400 child life programs in the United States. (Child Life Certification Commission, personal communication, May 1, 2019). The American Academy of Pediatrics published a policy statement in which child life specialists are considered a standard of care in pediatric hospitals, especially in outpatient services.3 The ACLP sets educational and professional standards that must be adhered to in order to practice the profession and maintain certification. Benefits of child life services have been assessed quantitatively and qualitatively, with improvement in medical outcomes and enhanced family satisfaction studied most frequently. Clearly articulating the role of the outpatient child life specialist and the specific interventions used is essential to accurately understanding the support being provided to pediatric patients. However, research chronicling the efficacy of child life practice within ambulatory settings is difficult to find. As a psychosocial profession drawing from developmental, psychological, and family systems approaches, research published on child life assessment, intervention, and evaluation spans multiple fields of inquiry related to child health. Child life researchers publish in a variety of outlets, making it difficult to synthesize our work. As such, this review captured literature chronicling child life services in ambulatory settings published between January 1993 and December 2018 in three major databases. To illustrate the growth and development of the profession of child life within the last 25 years, common themes across the literature were synthesized.

Methods

This systematic literature review followed the steps of Cooper et al.,4 which include (1) problem formulation, (2) collection, (3) data evaluation, (4) analysis and interpretation, and (5) presentation of results. To provide an extensive view of the range of literature describing child life services in ambulatory settings, the authors performed searches of articles published between January 1993 and December 2018. The authors chose to explore all published scholarly articles including observational and experimental studies, position papers, other literature reviews, book chapters, and dissertations.

Search Strategy

This review conducted searches across disciplines in the following bibliographical databases: Google Scholar (Google, January 1993 to December 2018), PubMed (NCBI, January 1993 to December 2018), and PsycInfo (EBSCO, January 1993 to December 2018). To cover all possible terms for child life services in outpatient settings, multiple search terms were used (see Table 1). The authors chose to also search databases for common child life interventions because much of the research does not explicitly label work as “child life” (see Table 2). For each search, all combinations of “Term A + Term B” were used in each of the three databases.

First Search Strategy Employed

Table 1.

First Search Strategy Employed

Second Search Strategy Employed

Table 2.

Second Search Strategy Employed

The three authors, all of whom are a CCLS with graduate degrees, reviewed the list to identify potentially relevant articles. After this, team review and discussion of all abstracted studies ensured consistency.

Study Selection

Our review explored literature covering child life services in outpatient settings. The team of investigators chose to omit publications not published in English as well as entire books, although book chapters specific to outpatient services were included.

Results

More articles resulted from the second search strategy, in which the researchers focused on common interventions performed in outpatient settings. Less fruitful was the first search in which researchers used terms such as “child life” and “child life specialist” to find relevant literature. See Table 3 and Table 4 for a breakdown of numbers across all three databases.

Number of Articles Found in DatabasesNumber of Articles Found in Databases

Table 3.

Number of Articles Found in Databases

Number of Articles Meeting Inclusion CriteriaNumber of Articles Meeting Inclusion Criteria

Table 4.

Number of Articles Meeting Inclusion Criteria

After omission based on inclusion/exclusion criteria, 60 articles discussing child life services in outpatient settings remained and were included in this review. Twenty-nine were original research, 3 were surveys, 1 was a meta-analysis, 16 were commentaries, 2 were policy statements, 5 were book chapters/reviews, and 4 were program evaluations/descriptions. Four were published between 1993 and 1997, 4 were published between 1998 and 2002, 10 were published between 2003 and 2007, 13 were published between 2008 and 2012, and 29 were published between 2013 and 2018.

Common themes across the literature were synthesized. Themes related to the provision of care were most apparent, including procedural support, preparation and education, and psychosocial and bereavement support. Twenty-five articles described procedural support interventions, 22 articles described preparation and education services, and 13 articles described psychosocial support and bereavement interventions.

Discussion

Results from the last 25 years suggest that growth has occurred in the provision of child life interventions in outpatient settings. Results also showed more publications are being produced describing the role of a child life specialist. Three clear themes among the 60 articles emerged from the literature: articles describing (1) advances in procedural support, (2) preparation and education, and (3) psychosocial and bereavement support. Each is described further in the following text.

Procedural Support

Procedural support interventions include multidisciplinary program development for assessing pain, nonpharmacological pain management, and anxiety-reduction techniques including diversion, ONE VOICE, and comfort positions (Table 5). Procedural support interventions are provided in a number of outpatient settings including the emergency department, day surgery, pediatric radiology, and primary care.5–8

Child Life Interventions to Reduce Anxiety and Distress, Including Nonpharmacologic Pain Management

Table 5.

Child Life Interventions to Reduce Anxiety and Distress, Including Nonpharmacologic Pain Management

A foundational message across the literature is the necessity of a multi-disciplinary approach to assessing and intervening during pediatric procedures. When child life specialists are included in the development of these approaches, medical teams report greater ease in working with youth, improved procedural success, and decreased trauma responses.5,9 Researchers argue that age-specific, nonpharmacological interventions used to manage pain in children are most effective when adapted to the developmental level of the child. Because there is significant variance across health care providers' assessments of pediatric pain, child life's multidisciplinary lens can act as a bridge and aid in the assessment process.10

Child life specialists use a variety of interventions to reduce pain and distress in outpatient settings. Most commonly, child life specialists report using distraction, topical anesthesia, positions for comfort, ONE VOICE, information/preparation, comforting/reassurance, and positive reinforcement5–9 (see Table 5 for descriptions of each intervention). These interventions decrease anxiety, reduce pain and distress, improve success rates of procedures (eg, cannulation), and decrease sedation usage in the pediatric emergency department.6,11–14

Patient- and family-centered care with emphasis on parental presence and family choice is another aspect of a child life specialist's role that has been studied. Parental presence aims to reduce distress among youth undergoing procedures. When families are calm and more satisfied, youth experience less distress and are better focused on child life interventions. It was found that families who had the choice in being present for their child's fracture reduction procedure reported increased satisfaction.15

Some studies conducted in the past 25 years have explored whether presence of a child life specialist improves procedural outcomes and decreases health care costs. The presence of a child life specialist during venous cannulations, radiation therapy, and emergency settings results in a higher number of successful procedures16 and less sedation use.17 In the domain of procedural support, the literature has increasingly become more focused on measuring the effect of child life services on pain perception, sedation use, and health care costs.

Preparation and Education

Twenty-five articles describing preparation and education interventions were found in the literature. Preparation and education have been shown to decrease anxiety in children and increase coping behaviors. This, in turn, reduces parent and caregiver anxiety.6 Child life specialists facilitate anxiety reduction through developmentally appropriate conversations and medical play. When these two interventions are provided, children experience less fear and report a better overall experience in the medical setting.18 This positive experience reflects well on hospitals striving to increase satisfaction among patients, families, and staff.18

Some of the literature has looked at educational approaches to preparing families for hospitalization experiences. Child life specialists tailor curriculum to each family's needs so families are educated in a manner that is honest, respectful, and promotes mastery.19,20

Medical play for preparation has also been examined, and it has been found to reduce pain and distress,21 anxiety,19 and sedation use.22 As with the research on procedural support, there has been an increase in examining the effect of child life services on outcomes such as distress and health care costs.

Psychosocial Care

Over the past 25 years, there has been less focus in the research on psychosocial and emotional support in outpatient settings. Thirteen documents explored this domain and the research has shown that in the absence of interventions such as the psychosocial care provided by child life specialists, negative behavior tends to increase significantly in children after discharge.23 Child life specialists aim to reduce this negative effect of hospitalization through psychosocial interventions. In the literature, these interventions can be divided into two separate areas: facilitation of family-centered care and provision of bereavement support.

During the latter half of the 20th century, research emerged indicating negative effects of separating hospitalized children from caregivers and the lack of typical childhood activities made available to them while in the hospital.1 Changes were made in the hospital with groups such as the Association for the Care of Children's Health being founded to support “humanizing health care for children” and promoting the professionalism of child life. Facilitation of family-centered care includes fostering collaborative and clear dialogue between family and medical staff, advocating to include family as an integral part of the health care team and essential to decision-making, validating emotions and support systems present in the family system, assessing coping responses and needs of the family to health care experiences,24 and fostering the developmental needs of children in the family system.25 Additional psychosocial activities and integrative therapies in the hospital setting are shown to increase children's coping and improve their well-being.23,26 A child life specialist supports family-centered care by ensuring continuity of a child's emotional development through provision of play, verbal conversation, reading,25 and facilitating pet therapy visits, which have been shown to improve mood.27

Some of the articles explored the role of a child life specialist in bereavement support. Policy statements indicate the importance of a team-oriented, family-centered approach to providing care to a bereaved family, identifying child life specialists as essential members of the care team.28,29 Best practices include having a child life specialist lead difficult conversations with families, as families found this helpful for their coping.29 Often bereavement support begins as trauma support with the child life specialist supporting the child and family, explaining roles of medical personnel and how the team is supporting the child.24 Child life specialists create legacy or memory items for families to take home as keepsakes, including hand-prints, footprints, locks of hair, hand molds, and memory boxes. Parents have found these mementos helpful in easing the grief process, particularly after a traumatic loss.29 Freyer et al.30 defined child life interventions in the care of a dying adolescent as assessing knowledge and coping style and using child life tools to facilitate knowledge, develop coping skills, and foster a means of self-understanding and self-expression amidst difficult circumstances.30

Implications

The authors noted the lack of articles produced by using search terms of “child life” or “child life specialist” across multiple databases. Rather, we were more successful when searching for interventions completed by child life specialists to find relevant articles. This search strategy presented authors with two distinct types of results. Interventions such as “play” or “normalization” proved to be broad in scope, providing thousands of articles but few referring to the work of child life specialists. Specific interventions, such as “bereavement support,” were too specialized to produce a significant number of articles. This search strategy was further complicated by articles citing other medical professionals as completing interventions commonly used by child life specialists. The difficulty in finding literature attached to the profession's name suggests literature is being published in other domains of inquiry. As child life develops its field of inquiry, it is essential to improve access to research and name recognition. Child life researchers should carefully consider key words when disseminating their work.

Further, the scope of child life interventions presented by current research is misleading. A great deal of attention is provided to procedural preparation and support interventions. These interventions lend themselves well to quantitative measurements, such as anxiety levels before and after a procedure. Other types of interventions that are rarely measured but vital to the child life specialist role are less featured in the literature, such as diagnostic education and normalization through play. Child life specialists increase patient's coping and adjustment effectively through use of these interventions but locating them among the research proves difficult. Likewise, child life interventions in the literature are often presented in a broad, general manner. For example, much of the research cites the use of a child life intervention group resulted in lower anxiety scores or higher satisfaction scores. Although this information reflects positively on the profession, few articles explain interventions in detail. Future research should aim to clearly articulate the intervention being provided and tools used during these interventions.

Although 60 articles were included in this review, the authors are aware of the vast amount of research missing from this review. Since 1999, ACLP has published its own peer-reviewed quarterly publication, The Child Life Focus, which publishes original research. However, this publication is not available to members outside of ACLP and is not indexed, making it impossible for other providers of pediatric care to benefit from the research. Overall, the authors noted a literature review spanning 25 years of research across three databases resulted in only 60 articles meeting inclusion criteria. We would like to note the significance of this issue and use this opportunity as a call for papers to child life professionals. To decrease the silos mentioned above, these publications should be housed in journals across the pediatric continuum, not those reserved for members.

Conclusions

Child life specialists in ambulatory settings help children with education, preparation, developmental play, and support during challenging experiences. Child life interventions help to reduce anxiety, increase coping capacity, and promote optimal development. This results in a reduction in medical-related costs and increased patient and family satisfaction. Although traditionally the child life role has been shown to be efficacious in inpatient settings, it is essential to note its importance for the outpatient environment. More research should be done on the valuable work child life professionals perform in the ambulatory setting to ensure this profession receives more validation as well as increases in resources to complete their work.

References

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  8. Alexander M. Managing patient stress in pediatric radiology. Radiol Technol. 2012;83(6):549–560. PMID:22763832
  9. Leahy S, Kennedy RM, Hesselgrave J, Gurwitch K, Barkey M, Millar TF. On the front lines: lessons learned in implementing multidisciplinary peripheral venous access pain-management programs in pediatric hospitals. Pediatrics. 2008;122(3)(suppl 3):S161–S170. doi:10.1542/peds.2008-1055i [CrossRef] PMID:18978010
  10. Vetter TR, Heiner EJ. Discordance between patient self-reported visual analog scale pain scores and observed pain-related behavior in older children after surgery. J Clin Anesth. 1996;8(5):371–375. doi:10.1016/0952-8180(96)00079-7 [CrossRef] PMID:8832447
  11. Bandstra NF, Skinner L, Leblanc C, et al. The role of child life in pediatric pain management: a survey of child life specialists. J Pain. 2008;9(4):320–329. doi:10.1016/j.jpain.2007.11.004 [CrossRef] PMID:18201933
  12. Gursky B, Kestler LP, Lewis M. Psychosocial intervention on procedure-related distress in children being treated for laceration repair. J Dev Behav Pediatr. 2010;31(3):217–222. doi:10.1097/DBP.0b013e3181d5a33f [CrossRef] PMID:20375734
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  14. Hyland EJ, D'Cruz R, Harvey JG, Moir J, Parkinson C, Holland AJA. An assessment of early Child Life Therapy pain and anxiety management: a prospective randomised controlled trial. Burns. 2015;41(8):1642–1652. doi:10.1016/j.burns.2015.05.017 [CrossRef] PMID:26452308
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  16. Murag S, Suzukawa C, Chang TP. The effects of child life specialists on success rates of intravenous cannulation. J Pediatr Nurs. 2017;36:236–240. doi:10.1016/j.pedn.2017.03.013 [CrossRef] PMID:28377048
  17. Scott MT, Todd KE, Oakley H, et al. Reducing anesthesia and health care cost through utilization of child life specialists in pediatric radiation oncology. Int J Radiat Oncol Biol Phys. 2016;96(2):401–405. doi:10.1016/j.ijrobp.2016.06.001 [CrossRef] PMID:27475669
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  25. Tamiya S. Review of protecting the emotional development of the ill child: the essence of the child life profession. Bull Menninger Clin. 2003;67(4):380–381.
  26. Hall M, Bifano SM, Leibel L, Golding LS, Tsai SL. The elephant in the room: the need for increased integrative therapies in conventional medical settings. Children (Basel). 2018;5(11):154. doi:10.3390/children5110154 [CrossRef] PMID:30453586
  27. Kaminski M, Pellino T, Wish J. Play and pets: the physical and emotional impact of child-life and pet therapy on hospitalized children. Child Health Care. 2002;31(4):321–335. doi:10.1207/S15326888CHC3104_5 [CrossRef]
  28. Levetown MAmerican Academy of Pediatrics Committee on Bioethics. Communicating with children and families: from everyday interactions to skill in conveying distressing information. Pediatrics. 2008;121(5):e1441–e1460. doi:10.1542/peds.2008-0565 [CrossRef] PMID:18450887
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First Search Strategy Employed

Term A Term B
Outpatient Ambulatory Clinic Emergency Child life Psychosocial Child life specialist Child life worker Child life therapist

Second Search Strategy Employed

Term A Term B
Outpatient Ambulatory Clinic Emergency Diagnosis education Diagnostic education Bereavement Bereavement support Play Normalization Procedural support Procedural preparation

Number of Articles Found in Databases

Term A Term B Databases
PubMed PsycInfo Google Scholar
Outpatient Child life 11 9 6,910
Psychosocial 2,452 2,037 157,000
Child life specialist 4 5 1,180
Child life worker 0 0 41
Child life therapist 16 0 83
Diagnostic education 6,935 2 40
Bereavement 82 111 16,500
Bereavement support 5 3 2,370
Play 2,134 809 266,000
Normalization 284 25 34,900
Procedural support 1 1 223
Procedural preparation 30 0 307
Ambulatory Child life 9 5 2,780
Psychosocial 1,369 803 63,800
Child life specialist 2 2 578
Child life worker 0 0 17
Child life therapist 5 0 95
Diagnostic education 4,477 0 26
Bereavement 21 23 7,650
Bereavement support 1 2 755
Play 1,472 245 149,000
Normalization 281 25 25,500
Procedural support 2 0 131
Procedural preparation 801 1 304
Clinic Child life 22 15 14,400
Psychosocial 5,453 4,302 659,000
Child life specialist 2 1 1,560
Child life worker 0 0 62
Child life therapist 21 0 172
Diagnostic education 15,976 5 91
Bereavement 176 341 26,900
Bereavement support 3 6 3,510
Play 10,337 2,659 1,090,000
Normalization 1,238 175 103,000
Procedural support 643 2 356
Procedural preparation 60 0 672
Emergency Child life 45 9 14,100
Psychosocial 5,475 1,217 207,000
Child life specialist 10 3 1,430
Child life worker 0 0 50
Child life therapist 4 0 85
Diagnostic education 10,207 0 1,960
Bereavement 187 112 24,900
Bereavement support 12 6 3,760
Play 4,284 702 1,450,000
Normalization 412 38 67,100
Procedural support 2 0 532
Procedural preparation 2,664 0 311

Number of Articles Meeting Inclusion Criteria

Term A Term B Databases
PubMed PsycInfo Google Scholar
Outpatient Child life 7 8 0
Psychosocial 0 0 0
Child life specialist 4 0 0
Child life worker 0 0 0
Child life therapist 0 0 10
Diagnostic education 0 0 0
Bereavement 3 0 0
Bereavement support 1 0 0
Play 0 0 0
Normalization 1 1 0
Procedural support 0 0 4
Procedural preparation 0 0 0
Ambulatory Child life 3 2 0
Psychosocial 0 0 0
Child life specialist 2 0 0
Child life worker 0 0 0
Child life therapist 0 0 0
Diagnostic education 0 0 0
Bereavement 0 0 0
Bereavement support 0 0 0
Play 0 0 0
Normalization 0 2 0
Procedural support 0 0 2
Procedural preparation 0 0 0
Clinic Child life 5 11 0
Psychosocial 0 0 0
Child life specialist 2 0 0
Child life worker 0 0 0
Child life therapist 0 0 1
Diagnostic education 0 2 0
Bereavement 0 0 0
Bereavement support 0 0 0
Play 0 0 0
Normalization 0 10 0
Procedural support 0 0 3
Procedural preparation 2 0 2
Emergency Child life 25 0 0
Psychosocial 0 0 0
Child life specialist 9 0 0
Child life worker 0 0 0
Child life therapist 0 0 1
Diagnostic education 0 0 0
Bereavement 3 0 0
Bereavement support 0 0 0
Play 0 0 0
Normalization 0 0 0
Procedural support 2 0 3
Procedural preparation 0 0 2

Child Life Interventions to Reduce Anxiety and Distress, Including Nonpharmacologic Pain Management

Intervention Description
Distraction/diversion Engaging child in a play activity or conversation to distract them from the procedure taking place. This can include use of tools like “look and find” books or electronic tablets
Pain reduction and control Advocating for use of lidocaine/prilocaine cream, topical pain relief spray
Positions of comfort Positioning child in nonthreatening manner using caregiver to provide a “comfort hold.” This provides a sense of control to child and avoids the child being held down or restrained
Preparation; education; providing information; medical and therapeutic play Developmentally appropriate conversations regarding procedure, which can include use of individualized education books and photos Providing sequential steps and sensory experiences to be expected Engaging child in medical play with equipment they will see during procedure Therapeutic play to allow expression of emotions or normalization during procedural experience
Comforting; reassurance; coaching Providing active job or role during procedure (ie, deep breathing, holding body still)
Positive reinforcement; coping skill reinforcement Reinforce use of positive and effective coping skills (ie, deep breathing exercises, visualization) Reinforce child is performing their assigned “job” and validate child's emotions
ONE VOICE Acronym used by child life specialist to communicate important messages to team: <list-item>

One voice should be heard during procedure

</list-item><list-item>

Need parental involvement

</list-item><list-item>

Educate patient before the procedure about what is going to happen

</list-item><list-item>

Validate child with words

</list-item><list-item>

Offer the most comfortable, nonthreatening position

</list-item><list-item>

Individualize your game plan

</list-item><list-item>

Choose appropriate distraction to be used

</list-item><list-item>

Eliminate unnecessary people not actively involved with the procedure

</list-item>
Parental presence; caregiver presence; advocating for family choice Family member to remain beside the child during a procedure
Guided imagery; visualization Guiding a child through a mind-body focused relaxation in which the child life specialist helps the child to generate mental images and stimulate the imagination; often includes simulation of sensory experiences
Authors

Teresa McGinley, MA, CCLS, is a Certified Child Life Specialist, Yale New Haven Children's Hospital. Stephanie Maskell, MA, CCLS, is a Certified Child Life Specialist, Joslin Diabetes Center. Kathryn Cantrell, PhD, CCLS, is a Visiting Assistant Professor, Texas Woman's University.

Address correspondence to Teresa McGinley, MA, CCLS, Child Life Program, Yale New Haven Children's Hospital, 20 York Street, SP7-414, New Haven, CT 06510; email: Teresa.McGinley@ynhh.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20201014-03

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