Child Life Corner
Child Life 101 – Assessment
By Sarah Davis, MS, CCLS
Child Life Specialist
Deciding whether or not a patient is an appropriate candidate for sedation involves appropriate assessments from multiple members of the health care team. Past medical history, a physical, and family health history are all components that help providers decide what type of sedation (if at all) is needed for the procedure at hand. But did you know that a child life specialist is also integral to the assessment process? Child life specialists are clinically trained to evaluate the child from many different angles, including developmental level, comprehension, coping abilities, anxiety level and compliance. Today let us explore how a child life specialist assesses the patient’s ability to complete a specified procedure with or without the assistance of medication.
Regardless of age, the child life specialist always gathers information directly from the patient. Often this does not look like a typical assessment because the child life specialist can appear to be “just playing” with the child. (This is one reason that child life specialists are still sometimes thought of as the “play lady”). It is important to understand that play is a child’s natural way to comprehend and interact with the world around him or her.
When assessing, play acts as a bridge between the adult and the child where two-way communication can take place. The child life specialist might engage the child in general play to assess the child’s current comfort level and ability to interact with strangers. Medical play is another avenue a child life specialist uses where specific medical equipment is employed to see how the child reacts to the healthcare environment. For an older child or teenager a more direct approach is often taken, asking the patient about past experiences, anxiety level, and expectations of the procedure. All the information gathered from the patient is compiled to create a picture of what he or she can appropriately cope with.
Family members are also a wealth of knowledge when it comes to assessing the patient’s sedation candidacy. They are more than just a source of information regarding the patient’s past experiences. Caregivers generally know the patient very well and are attuned to a patient’s signals regarding stress, pain, and anxiety. Another perspective that only family members can give is the patient’s baseline at home which provides a reference point to measure the patient’s current stress and anxiety, as well as their compliance towards medical staff. Additionally a child life specialist is assessing the family’s past and current reactions to the patient’s medical situation. For example, a parent who is very stressed (regardless of the stressor) can increase the stress of the patient, which impacts the patient’s ability to be compliant. Gathering this additional information provides medical staff with invaluable information that is tailored into a family-centered plan of care.
Last but certainly not least is gathering information from the medical staff. Staff members who have already interacted with the patient and family also have helpful information to the child life specialist. This includes the temperament of the family during registration, how the patient coped with vital signs, and useful information mentioned by the family to any staff member. You might be surprised what a parent says to housekeeping or nutrition that could be relevant information. Furthermore a patient’s chart can often provide a wealth of information about not only his or her past medical experiences but how he or she reacted. Notes from the doctor, nurse, chaplain, social worker, and other child life specialists (to name just a few) gives information about what worked and what did not work during past medical experiences.
Finally a child life specialist needs to know what types of support options are available to the child during the procedure. Can the patient watch a movie or play a game during the test? How much movement will be permissible and how long will it take? What does the equipment look like? Will family members be permitted to stay during the procedure? What will the child feel, hear and/or taste? These are just a few questions that a child life specialist must ask before making their final assessment of the patient.
It is often enlightening to staff regarding how a child life specialist makes an assessment by providing case studies. The following are two different vignettes that put the assessment process into practice. Both cases are fictitious and are meant to demonstrate two contrasting assessments
Jade is an 8-year-old female needing an MRI of the brain without contrast. The child life specialist learns from Jade that she has never had an MRI before and has limited experiences of the hospital. Jade easily engages in conversation with the child life specialist and asks appropriate questions about the MRI. Jade’s mother notes that Jade is developmentally normal, plays everywhere, including small spaces such as tents and play structures. Jade’s mother verbalizes concern about Jade’s pending diagnosis but is calm and collected during the interaction. According to Jade’s chart, she has never been hospitalized but did have a positive experience during her blood draw earlier that week when she was allowed to watch a movie and squeeze her mother’s hand.
Today Jade was compliant with her vital signs and enjoyed talking with the nursing staff about her favorite band. When asked if she could hold still for 20 minutes, Jade enthusiastically demonstrated holding her whole body still and her mother agreed that 20 minutes was feasible for Jade. Jade giggled when she heard the sounds of the MRI machine and said “It sounds silly!” With this information the child life specialist makes the assessment that Jade should be able to hold still for the MRI with appropriate nonpharmacological support such as music to listen to during the MRI and her mom staying with her throughout the scan.
Kris is also an 8-year-old female needing an MRI of the brain without contrast. Kris also has never had an MRI before but according to the records she has had a CT. Kris is quiet during the interaction and declined to make eye-contact with the child life specialist. Kris’s mother reported that while Kris held still for the CT, she told her mother later that it was scary and Kris did not want to come back to the hospital again. When asked about Kris’s developmental level, Kris’s mother reported that Kris does have trouble focusing in school, often not sitting still and sometimes being disruptive. Kris’s mother also noted that Kris is currently being tested for ADHD by the school. Additionally Kris dislikes small spaces, making Kris’s mom wonder if she did not like the CT because of having to go through the hole.
When Kris was brought to the hospital today, the registration staff noted that Kris kept close to her mother and continued to ask when they would leave. During her interaction with the nursing staff Kris was quiet but had trouble holding her arm still for the blood pressure cuff. When the child life specialist showed Kris what the MRI sounded like, Kris put her hands over her ears and said “Make it stop!” Kris’s mother appeared stressed and distracted during the encounter, continually checking her phone and raising her voice at Kris when Kris displayed disruptive behavior. With this information the child life specialist makes the assessment that Kris may have trouble holding still for the MRI and makes the assessment that Kris would probably benefit from a consult with the sedation team.
These two examples show opposite sides of the spectrum when it comes to deciding whether to provide sedation. There are many children that fall between these case studies and sometimes it can be difficult to make a pronouncement on how a child will handle the procedure. Of course this discussion only provides the tip of the iceberg; it does provide a window into a child life assessment.