FROM THE AMERICAN ACADEMY OF PEDIATRICS

Organizational Principles to Guide and Define the Child

Health Care System and/or Improve the Health of all Children

POLICY STATEMENT

Child Life Services

COMMITTEE ON HOSPITAL CARE and CHILD LIFE COUNCIL
KEY WORDS
abstract
child life, play, patient- and family-centered care, preparation, Child life programs are an important component of pediatric hospital–
psychological preparation, therapeutic play
based care to address the psychosocial concerns that accompany
ABBREVIATIONS
CCLS—certified child life specialist
hospitalization and other health care experiences. Child life special-
ED—emergency department ists focus on the optimal development and well-being of infants,
This document is copyrighted and is property of the American children, adolescents, and young adults while promoting coping skills
Academy of Pediatrics and its Board of Directors. All authors and minimizing the adverse effects of hospitalization, health care,
have filed conflict of interest statements with the American and/or other potentially stressful experiences. Using therapeutic play,
Academy of Pediatrics. Any conflicts have been resolved through
a process approved by the Board of Directors. The American expressive modalities, and psychological preparation as primary
Academy of Pediatrics has neither solicited nor accepted any tools, in collaboration with the entire health care team and family,
commercial involvement in the development of the content of child life interventions facilitate coping and adjustment at times and
this publication.
under circumstances that might otherwise prove overwhelming for
The recommendations in this statement do not indicate an
the child. Play and developmentally appropriate communication are
exclusive course of treatment or serve as a standard of medical
care. Variations, taking into account individual circumstances, used to: (1) promote optimal development; (2) educate children and
may be appropriate. families about health conditions; (3) prepare children and families for
All policy statements from the American Academy of Pediatrics medical events or procedures; (4) plan and rehearse useful coping and
automatically expire 5 years after publication unless reaffirmed, pain management strategies; (5) help children work through feelings
revised, or retired at or before that time.
about past or impending experiences; and (6) establish therapeutic
relationships with patients, siblings, and parents to support family
involvement in each child’s care. Pediatrics 2014;133:e1471–e1478

CHILD LIFE PROGRAMS

During the 1920s and 1930s, early hospital play programs were ini-
tiated at several children’s hospitals, including Mott Children’s Hos-
pital, Babies and Children’s Hospital of Columbia Presbyterian, and
www.pediatrics.org/cgi/doi/10.1542/peds.2014-0556 Montreal Children’s Hospital. In 1955, Emma Plank, under the di-
doi:10.1542/peds.2014-0556 rection of Dr Frederick C. Robbins (Nobel Laureate), developed the
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). first Child Life and Education division at Cleveland City Hospital. Plank
Copyright © 2014 by the American Academy of Pediatrics
is considered a founding “mother” of the profession, and her landmark
publication, Working With Children in Hospitals,1 served to educate
many about the unique needs of children in the health care setting.
Today, hospitals specializing in pediatric care routinely include child
life programs, with more than 400 programs in operation in North
America.2 Child life services are recommended and offered to varying
degrees in community hospitals with pediatric units, ambulatory
clinics, emergency departments (EDs), hospice and palliative care
programs, camps for children with chronic illness, rehabilitation
settings, and some dental and physician offices.3–7 In cases of hos-
pitalized or ill adults, certified child life specialists (CCLSs) may be
consulted to work with children of adult patients, particularly in end-
of-life cases, trauma, and critical care. Child life programs are not

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unique to North America; similar pro- end coverage. In any case, staffing plans are also available, and CCLSs often
grams can be found in other countries should be sufficient to meet fluctua- develop particular areas of expertise
such as the United Kingdom, Japan, tions in anticipated and unanticipated related to the patient populations they
Kuwait, the Philippines, South Africa, staff absences, seasonal swings in serve.
Serbia, New Zealand, and Australia.2 patient census, and nonclinical com- In some settings, child life services are
The provision of child life services is munity activities (eg, increased visits augmented by child life assistants (or
a quality benchmark of an integrated and in-kind donations during the hol- activity coordinators or child life
patient- and family-centered health care iday season, variations in individual technicians). Child life assistants are
system, a recommended component of patient and family needs). typically required to have core college
medical education, and an indicator of Child variables (temperament, coping coursework, such as an associate’s
excellence in pediatric care.8–10 An ex- style, and cognitive abilities), family degree in child development, and ex-
perimental evaluation of 1 child life variables (parental anxiety, presence, perience with children in group set-
program model showed that child life and involvement), and diagnosis/ tings. They generally focus on the
interventions resulted in less emotional treatment variables (the number of “normalization” of the health care
distress, better overall coping during invasive procedures) are known to experience, providing play activities,
the hospital stay, a clearer under- affect psychosocial vulnerability and coordinating special events (eg, com-
standing of procedures, and a more thus influence the child’s particular munity visitors, holiday celebrations),
positive physical recovery as well as child life intervention needs.15 A com- and maintaining the playroom envi-
posthospital adjustment for children bination of psychosocial risk assess- ronment. Both CCLSs and child life
enrolled.11 Patients spent less time on ment, medical/treatment variables assistants actively participate in the
narcotics, the length of stay was slightly (eg, the proportion of patients with orientation, training, and supervision
reduced, and parents were more sat- isolation precautions, the volume of of volunteers, thereby contributing to
isfied. Other studies have found that patient/family teaching needs), and volunteer effectiveness, satisfaction,
child life interventions play a major role the time requirements associated and retention. This collaboration ena-
in calming children’s fears and result with particular interventions directly bles the CCLS to conduct an assess-
in higher parent satisfaction ratings affect operational staff-to-patient ra- ment and delegate as appropriate,
of the entire care experience.12,13 tios in both inpatient and outpatient allowing patients with varying de-
settings.16,17 Table 1 lists variables grees of psychosocial vulnerability
There are a number of variables to
that typically require child life inter- and activity levels to be supported by
consider in identifying adequate child
ventions of greater frequency, dura- the team member whose skills and
life staff–to–patient ratios. Although a
tion, or complexity, thus influencing knowledge are most closely aligned
ratio of 1 full-time CCLS to 15 inpatients14
effective CCLS-to-patient ratios. with patient/family needs. Although
is useful as a guideline, a number of
The credentials of a CCLS currently volunteers are a valuable supplement,
factors should influence specific staf-
include the minimum of a bachelor’s they can never be considered an ad-
fing allocations. Generally speaking, equate replacement for trained/
child life services should be available degree in child life, child development,
to meet identified patient or family needs or a closely related field; the suc- certified professionals.
cessful completion of a 480- to 600- CCLSs are part of an interdisciplinary,
7 days a week. In hospitals with very
hour child life internship under the patient- and family-centered model of
small pediatric units and low out-
supervision of a CCLS; and passing care, collaborating with the family,
patient volume, 1 CCLS may provide
a standardized certification examina- physicians, advance practice pro-
services in both the inpatient and
tion.18,19 Advanced degrees in child life viders, nurses, social workers, and
outpatient areas, including consulta-
tion services to the ED. In hospitals
with high-volume pediatric emergency TABLE 1 Factors Necessitating or Supporting a Lower Ratio of Patients to CCLSs
services, more than 1 CCLS is gener-
• High volume of patient-family teaching needs (eg, surgeries and other medical procedures), especially
ally required to enable 7-day coverage when combined with high patient turnover rate
of the ED. In larger hospitals, 1 or more • High proportion of patients requiring 1-on-1 interventions (eg, isolation rooms, ventilator-dependent
CCLSs are typically assigned to each in- patients, examination/treatment room interventions, critical care units)
• Multiple simultaneous needs (eg, ED during peak hours)
patient unit or outpatient area, including • Frequent time-consuming demands (eg, support during lengthy medical procedures, end-of-life support)
standing and/or rotating schedules to • Significant nonclinical demands, such as supervision of child life students, representing child life on
provide weekday, evening, and week- hospital committees, public relations and marketing activities, and other administrative duties

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 FROM THE AMERICAN ACADEMY OF PEDIATRICS

other members of the health care responses, such as palm sweating, ex- PSYCHOLOGICAL PREPARATION
team to develop a comprehensive plan cessive body movement, tachycardia, Preparing children for hospitalization,
of care. Child life contributions to this and hypertension, can be reduced with clinic visits, surgeries, and diagnostic/
plan are based on the patient’s and therapeutic play interventions.23 therapeutic procedures is another
family’s psychosocial needs, cultural Play can be adapted to address the important element of a child life pro-
heritage, and responses to the health developmental and psychosocial needs gram. It is estimated that 50% to 75%
care experience. For example, child of patients in every pediatric age of children develop significant fear and
life specialists can participate in the group. For example, infants and tod- anxiety before surgery, with recog-
care plan by teaching a child coping dlers benefit from exploratory and nized risk factors such as age, tem-
strategies for adjusting to a life- sensorimotor play, and preschool- perament, baseline anxiety, past medical
changing injury, promoting coping aged children enjoy fantasy play and encounters, and parents’ level of anx-
with examinations for alleged abuse, creative art activities.24 Opportunities iety.32 Children’s anxiety in the peri-
assisting families in talking to their for parents to engage in play activities operative environment is associated
children about death, facilitating with their young children are benefi- with impaired postoperative behav-
nonpharmacologic pain management cial to both patient and family, allevi- ioral and clinical recovery, including
techniques, and communicating the
ating some feelings of helplessness in increased analgesic requirements and
child’s developmental and individual
parents and assisting in the child’s delayed discharge from the recovery
needs and perspective to others.
hospital adjustment.25 School-aged room.33 More than 50 years of re-
These interventions are most effective
children and adolescents seek play search and experience support 3 key
when delivered in collaboration with
that contributes to feelings of mastery elements of the preparation process:
the entire health care team.
and achievement, which is one reason (1) the provision of developmentally ap-
video games are so popular with this propriate information; (2) the encour-
THE THERAPEUTIC VALUE OF PLAY age group.26 Patients in this age group agement of questions and emotional
Play is an essential component of also benefit from activities that allow expression; and (3) the formation of
a child life program and of the child life them to maintain relationships with a trusting relationship with a health
professional’s role. In addition to peers and establish new connections care professional.34 A recent system-
play’s developmentally supportive ben- through, for example, online network- atic review of preparation effective-
efits and as a normalizing activity for ing and the availability of teen activity ness evidence concluded that children
children and youth of all ages, it is rooms in the hospital setting.27 who were psychologically prepared
particularly valuable for children who Auxiliary programs, such as animal- for surgery experienced fewer nega-
are anxious or struggling to cope with assisted therapy, infant massage in- tive symptoms than did children who
stressful circumstances.20 Erikson writes, struction, use of therapeutic clowns, did not receive formal preparation. In
“To play out is the most natural auto- performing arts, and artist-in-residence addition to reducing anxiety and pro-
therapeutic measure childhood affords. programs, often used in conjunction viding a more positive experience for
Whatever other roles play may have in with child life services, provide addi- the patient and family, research de-
the child’s development . . . the child tional outlets for patients of all ages monstrates that preparation and cop-
uses it to make up for defeats, suf- and their families.28,29 Live, interactive ing facilitation interventions decrease
ferings, and frustrations.”21 programming, such as hospital bingo the need for sedation in procedures
Play in the health care setting is ad- or patient-produced videos (broadcast such as MRIs, resulting in lower risks
apted to address unique needs based over a closed-circuit television sys- for the child and cost savings in per-
on developmental level, self-directed tem), can be a particularly effective sonnel, anesthesia, and throughput-
interests, medical condition and phy- way to engage patients restricted to related expenses.35–37
sical abilities, psychosocial vulnera- their rooms for infection control or Preparation techniques, materials,
bilities, and setting (eg, bedside, playroom, medical reasons. Expressive thera- and language must be adapted to the
clinic). Play as a therapeutic modality, pies, such as those provided by dis- developmental level, personality, and
including health care play or “medical tinctly certified play therapists, music unique experiences of the child and his
play,” has been found to reduce chil- therapists, and art therapists, can be or her family. Learning is enhanced
dren’s emotional distress and help offered to complement child life pro- with “hands-on” methods versus ex-
them cope with medical experiences.22 grams and to provide support for clusively verbal explanations. Photo-
Research has shown that physiologic particularly vulnerable patients.30,31 graphs, diagrams, tours of surgical or

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treatment areas, actual and pretend provision of developmentally appro- FAMILY SUPPORT
medical equipment, and various priate, psychosocially sound care.46,47 The presence and participation of
models (eg, dolls, puppets) are used Multifaceted institution-wide protocols family members is a fundamental
to reinforce learning and actively en- such as the “Ouchless Place” and component of patient- and family-
gage the child.32,38 Interpreter ser- other similar programs incorporate centered care and has a significant
vices are used as appropriate to the standard utilization of both phar- positive effect on a child’s adjustment
ensure understanding in patients or macologic and nonpharmacologic tech- to the health care experience.56 When
families who do not speak English or niques, preparation of patient and family, parents or other family members are
for whom English is a second lan- environmental considerations, and train- highly anxious about the child’s illness
guage. Most parents have a strong ing of all health care team members.48,49 or diagnostic and treatment regimens,
desire for comprehensive information Research has demonstrated that such anxiety is easily transmitted to
about their child’s care and should be children are less fearful and dis- the patient.57 CCLSs help facilitate the
included in the preparation process. tressed when positioned for medical family’s adjustment to the child’s ill-
In cases in which children demon- procedures in a sitting position, rather ness and health care experience. They
strate avoidant preferences or when than supine.50 CCLSs are often in- can help family members understand
preparation before the event is not
volved in facilitating the use of “com- their child’s response to treatment and
possible, the CCLS’s focus may change
fort holds”: techniques for positioning support caregiving roles by promoting
from that of imparting information to
children in a parent/caregiver’s lap or parent/child play sessions and sharing
other supportive strategies, such as
other comforting position. In addition strategies for comforting or coaching
teaching behavioral coping skills and
to reducing the child’s distress and the child during medical procedures.
preparing parents to support their
gaining his or her cooperation, these Siblings of pediatric patients present
child during a medical procedure.
techniques generally require fewer with their own unique anxieties and
staff to be present in the room, facil- psychosocial needs, needs that are of-
PAIN MANAGEMENT AND COPING itate safe and effective accomplish- ten not assessed or addressed. Siblings,
STRATEGIES ment of the medical procedure, much like children of adult patients, can
decrease parent anxiety, and increase be helped to comprehend a family
When combined with preparation and
parent satisfaction.51–53 With a goal to member’s illness via therapeutic play
appropriate pharmacologic interven-
limit the use of papoose boards and and educational interventions or by
tions, nonpharmacologic strategies for
alleviate the practice of multiple staff offering support during hospital visits,
pain and distress management have
members holding a child down, these including critical care and end-of-life
proven successful in terms of patient/
techniques provide a viable and more situations.58 CCLSs are often involved
family experience, staff experience, and
cost-effectiveness.13,39–40 Strategies such humane alternative in most cases. in providing grief support or legacy
as swaddling, oral sucrose, vibratory CCLSs may also develop “comfort kits” activities, such as hand molds or
stimulation, breathing techniques, dis- for use in treatment areas to include memory boxes for siblings and other
traction, and visual imagery have been age-appropriate distraction items such family members in the event of the
shown to decrease behavioral distress as bubbles, pop-up and sound books, death of pediatric or adult patients.
and pain experience in children during light-up toys, and other visual or au-
ditory tools.54 There is emerging evi-
RECENT DEVELOPMENTS IN CHILD
invasive medical procedures.41–43 In ad-
LIFE SERVICES
dition to advocating for the appropriate dence that mobile devices can be
use of analgesics, CCLSs are often effective in minimizing patient per- The scope of child life programs has
directly involved in the utilization of ceptions of pain and anxiety during developed beyond pediatric inpatient
nonpharmacologic pain management distressing medical procedures.55 CCLSs medical–surgical settings to include
techniques and coaching or support- can also advocate for a more wel- outpatient and other areas in which
ing patients and families before and/ coming environment in treatment and child life expertise can be effectively
or during distressing medical proce- examination rooms on pediatric units applied to support children and fam-
dures.44,45 They can also provide val- as well as outpatient settings. Their ilies in stressful situations. The pro-
uable education and training to nursing, background and training are helpful vision or expansion of dedicated child
medical, and other personnel and stu- in designing settings that are appro- life programming in areas such as
dents, thus supporting health care priately stimulating, nonthreatening, emergency services, surgery, imaging,
team member competencies in the and interactive. specialty care clinics, dialysis centers,

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 FROM THE AMERICAN ACADEMY OF PEDIATRICS

palliative care, and neonatal intensive based reimbursement and accredita- CCLSs often collaborate with local
care has become more prevalent.59,60 tion standpoint as well as marketing school districts to arrange hospital or
The increase in patients diagnosed and public reporting of outcomes. Child homebound education, and hospital-
with autism spectrum disorders has life and ancillary services, such as based teachers may be incorporated
presented opportunities for child life creative arts therapy, often attract a into child life program administration.
specialization in supporting this pop- segment of the population that may For hospitals or other health care
ulation in the medical setting.61 otherwise not be inclined to provide settings considering the initiation or
Over the past several years, child life philanthropic support to a hospital. expansion of child life services, the
programs have adapted to the great Child life leaders are regularly involved Child Life Council offers a consultation
variety of patients and illnesses seen in community outreach, public relations, service to support existing program
in pediatrics. Younger, less mobile and funding of development activities. review and development, new program
patients who have more complex start-up, interdisciplinary education,
medical conditions may need greater ADDITIONAL CONSIDERATIONS and written standards of care.68 In
individualization of care from the CCLS, Child life services contribute to an community hospital settings with few
for example, when group interaction is organization’s efforts to meet the pediatric beds and minimal pediatric
not possible. Activities that enable standards set forth by The Joint outpatient or ED visits, the provision
social interaction, such as Internet Commission with regard to effective of full-time child life services may not
connectivity and closed-circuit televi- communication, patient- and family- be financially feasible. In such cases,
sion programming, are particularly centered care, age-specific compe- it is recommended that part-time or
helpful for patients who are isolated tencies, and cultural competence.66 consultative services of a CCLS be
for infection control or confined for The CCLSs’ psychosocial and de- obtained to assist in the ongoing ed-
monitoring reasons. Given the in- velopmental expertise and their keen ucation of staff, students, and volun-
creasing survival rate of patients with awareness of the benefits of patient- teers as well as to advise on a
cystic fibrosis, cardiac conditions, and and family-centered care provide psychosocially sound, development-
other chronic illnesses, more teen- a useful perspective at the systems ally appropriate, patient- and family-
agers and young adults face the level. Child life representation is often centered approach to care.
challenging transition to adult health incorporated into hospital commit-
care.62 Acknowledging team goals to tees, such as ethics, patient/family CONCLUSIONS
normalize the transition process and satisfaction, safety, environmental de- Child life services improve quality and
address patient and family anxieties sign, and bereavement. In many cases, outcomes in pediatric care as well as
or questions, CCLSs can assist in this child life professionals provide lead- the patient and family experience. Al-
transition by providing education ership for activities such as patient though more research is needed, there
and helping patients to communicate and/or family advisory councils and is evidence that child life services help
their needs, fears, hopes, and expec- hospital-wide staff education. to contain costs by reducing the length
tations.63–65 Child life expertise has applications of stay and decreasing the need for
Although evidence supports the value beyond conventional hospital care. sedation and analgesics. Patient/family
of child life programs, financial pres- Interventions can help children tran- satisfaction data and interdisciplinary
sures in many health care settings have sition back to their home, school, team member feedback further con-
threatened the growth and sustainability community, and medical home.*,67 firm the positive effects of child life
of this essential service. Recent literature programs on children, families, and
has demonstrated the benefits of child *The American Academy of Pediatrics (AAP) staff. It remains essential for child life
life interventions in reducing sedation- believes that the medical care of infants, children, services to adapt and grow with the
and adolescents ideally should be accessible,
related costs,35 and additional research continuous, comprehensive, family centered, co-
changing health care delivery system in
is underway to further evaluate the cost- ordinated, compassionate, and culturally effective. support of the highest possible quality
effectiveness of child life services. It should be delivered or directed by well-trained of care for children and their families.
physicians who provide primary care and help to
Child life programs are recognized as manage and facilitate essentially all aspects of
contributing to a culture of patient- pediatric care. The physician should be known to RECOMMENDATIONS
and family-centered care as well as to the child and family and should be able to develop 1. Child life services should be deliv-
a partnership of mutual responsibility and trust
customer satisfaction measures, in- with him or her. These characteristics define the ered as part of an integrated pa-
creasingly important from an incentive- “medical home.” tient- and family-centered model of

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 care and included as a quality in- to-patient ratios should be ad- COMMITTEE ON HOSPITAL CARE,
dicator in the delivery of services justed as needed for the medical 2012–2013
Jack M. Percelay, MD, MPH, FAAP, Chairperson
for children and families in health complexity of patients served, in-
James M. Betts, MD, FAAP
care settings. cluding psychosocial and develop- Maribeth B. Chitkara, MD, FAAP
2. Child life services should be pro- mental vulnerability as well as Jennifer A. Jewell, MD, FAAP
vided directly by certified child life family needs and preferences. Claudia K. Preuschoff, MD, FAAP
Daniel A. Rauch, MD, FAAP
specialists in pediatric inpatient units, 4. Child life services should be included Richard A. Salerno, MD, FAAP
emergency departments, chronic in the hospital operating budget as
care centers, and other diagnostic/ an essential part of hospital-based
LIAISONS
treatment areas to the extent appro- pediatric care. Advocacy for financ-
Chris Brown, MS, CCLS – Child Life Council
priate for the population served. In ing of child life services should oc- Charlotte Ipsan, MSN, NNP – American Hospital
hospitals with a small number of cur at the facility, community, state, Association
inpatient or outpatient pediatric and federal levels. Lynne Lostocco, RN, MSN – National Association
of Children’s Hospitals and Related Institutions
visits, ongoing consultation with a 5. Additional research should be con- Charles D. Vinocur, MD, FAAP – Section on
certified child life specialist is rec- ducted to evaluate the effects of child Surgery
ommended to educate health care life services on patient care out-
team members and support devel- comes, including patient and family CONSULTANTS
opmentally appropriate, patient- experience/satisfaction, staffing ratios, Matthew Scanlon, MD, FAAP – Hospital Ac-
and family-centered practice. throughput, and cost-effectiveness. creditation Professional and Technical Advisory
3. Child life services staffing should Committee, The Joint Commission
be individualized to address the LEAD AUTHORS
needs of specific inpatient and out- Chris Brown, MS, CCLS STAFF
patient areas. Child life specialist- Maribeth B. Chitkara, MD, FAAP S. Niccole Alexander, MPP

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
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 Child Life Services
COMMITTEE ON HOSPITAL CARE and CHILD LIFE COUNCIL
Pediatrics 2014;133;e1471; originally published online April 28, 2014;
DOI: 10.1542/peds.2014-0556

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/133/5/e1471.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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