Case example: Jacob Jacob is a 13-year-old admitted on the weekend with dehydration, 5 days post day surgery fo r tonsillectomy, articulating he was in a lot of pain and could not eat. Jacob was describe d by staff as a \200\230young \200\231 adolescent who was dramatic in his descriptions of his pain, was not eating or drinking well, and was likely going to need to stay for an addi tional night. Nurses reported that his mother was repeatedly voicing her concerns about her son \200\231s level of pain and was frustrated with the lack of pain control and intervent ion from staff . 6. Preparation: child life specialists provide the child and family with developmentally ap propriate information through play and/or discussion; based on anticipated sensory experien ces; explora- tion of stress points, exploration of coping strategies to be used; opportuni ty for rehearsal and development of a coping plan with the team as needed. By its very natu re, this should occur prior to interventions and surgery, be based on the developmental and coping needs, and responses of the child/family. Upon arrival, the child life specialist noted Jacob \200\231s aff ect was blunted; he reluc tantly permitted her to enter the room, made fl eeting eye contact, and initially answered questions quickly and hesitantly. His mother \200\231s posture was rigid and aff ect was ne ither welcoming nor engaging. When asked if he understood the reason for his admission, he stated his throat was bleeding, he couldn \200\231t drink, and the pain was unbearable. He repeatedly stated that the \200\230rotting fl esh \200\231 in his throat gave his mouth an awful taste and he did not want to eat/drink because he did not want it to bleed again or to hurt more. His mother placed herself beside him on the bed, stroking his back, as he was curling into a fetal position. 7. Procedural support: child life specialists support the child and fam- ily during a stres sful encounter/examination, medical interven- tion or procedure. This might include behavio ral or cognitive distraction, breathing exercises, coaching parents, advocating for positio ns of comfort, relaxation techniques, positive reinforce- ment, providing information, visu alization, or guided imagery. 8. Therapeutic dialog: child life specialists encourage the expres- sion of feelings, clari \201 cation of misconceptions; determine cop- ing strategies and work through feelings as sociated with painful or frightening experiences. Assessment Th e child life specialist gathered further information from Jacob in a non-thre atening confi dant manner while indicating there 9. Family support: child life specialists provide information to navi- gate the system of c are, general emotional support; translate SECTION 7 psychosocial interventions 546 were things that can be done to help with his pain. She explored his understanding of the s urgery; the healing process post tonsil- lectomy; his typical coping style and previous suc cessful strate- gies during stressful situations; his informational needs; his pain experie nce and what aspects of his experience were distressing; his personal interests and hobbies as well as expectation for improvement. Mother had been reading stories about going to the hospital and answering Carrie \200\231s questions, as they arose. Parents were plan- ning to be in attendance throughout the admiss ion and reported no other signifi cant stressors. Interventions Carrie and her mother met with the child life specialist and the pre-op nurse 1 week in advance of the surgery to learn what she would see, hear, smell, and experience in developmentally friendly language. Th e child life specialist off ered Carrie a body out line doll for her to color, as she wished, and off ered to explain the medical equipment sh e would see. Carrie was interested in learn- ing more. Th e child life specialist used Carr ie \200\231s new hospital doll to demonstrate anesthetic induction, explain the surgery in sim- ple terms and \200\230perform \200\231 surgery, made a small opening, inserted extern al catheters to demonstrate what she would see upon wak- ing, along with an IV and how the medicine goes through the IV to help her body get water and medicine to help with the \200 \230ouch \200\231. Carrie \200\231s body language and facial expressions were monitored clo sely to ensure the information was appropriate and to clarify any concerns, questions or mi sconceptions. Photographs of the surgical area, the hallways leading to the operating room (OR), the OR space and staff dressed in OR greens were shown aft er she indicated interest in seeing them. Th e family toured the surgical area and the inpatient unit, including the play areas and learned of the fun activities she would be able to do aft er the surgery. Child life interventions Th e child life specialist clarifi ed misconceptions and explained the medical equipment in the room, IV and medication being infused, and the importance of fl uid intake to help the tissue heal. Th e use of thought stopping and cognitive reframing strategies (positive self-talk) were modeled and practiced by Jacob ( \200\230my throat ti ssue is healing and will keep getting better \200\231) while his mother \200\231s negative statements were also reframed and more posi- tive comments were reinforced. Jacob stated he was an actor and loved to perform in plays. He oft en utilized deep breathi ng strategies to support voice pro- jection and also as a calming strategy before he perfor med. His knowledge about deep breathing to assist with his pain and anxi- ety was encourage d. Rehearsal of breathing in slowly through the nose and out through the mouth several time s to permitted his body to develop a rhythm and allow the sensation of relaxation to begin. His mother was eager and willing to be his coach and prompt him to stop his negative think ing and to use the deep breathing method. By the end of the session both mother and child w ere more friendly, physically more relaxed, exuded confi - dence that things would improve, and decided to physically leave the room to explore the unit and the teen lounge which the child life specialist had encouraged. Aft er surgery, the child life specialist followed Carrie \200\231s progress. Th e fi rst d ay post surgery, Carrie was playing contentedly in the bed, enjoying a craft left for her b y the child life specialist. When asked, Carrie had no questions and stated the hardest par t was \200\230it hurts when I move \200\231. Strategies to cope with pain, such as the use of a pillow over the belly when moving, a warm blanket, slow breathing, counting, or using hand-held squeeze toys were dis- cussed and she chose strategies she wanted to try. Daily visits occurred to assess her overall coping with the experience, moni- toring for pain man agement issues, and promoting positive and fun activities in the playroom which motivated h er to get up and walk. Th e child life specialist also provided procedural support for the removal of her catheters, once again preparing Carrie for what she would see, hear and feel as well as choosing distrac- tions that would redirect her attention from the pain, this t ime by using applications on the iPad. Carrie \200\231s response post procedure was that \200\230it wasn \200\231t so bad \200\231. Parents reported she slept well, and adjusted fa r better than anticipated; they felt confi dent and trust- ing of all members of the team g iven the coordinated approach to their daughter \200\231s care and pain management. Case example: Carrie Carrie is a 5-year-old girl referred to child life in anticipation of her upcoming bilatera l ureter re-implantation surgery. Th e nurse recognized that Carrie would benefi t from a c hild life prepara- tion session and tour of the environment given that this was her fi rst surgical experience. Assessment Th e child life specialist contacted the family 2 weeks in advance to plan a pre paration session prior to the surgery and to screen for potential stressors that might impa ct on child/family coping. She was a typically developing child, with a generally easy-goin g tem- perament and who generally likes to know what will happen with enough detail to help her predict the situation. Mother reported Carrie \200\231s only experience with medical i nterventions, other than vaccines, was a cystogram 3 months previously for which she was no t provided advance preparation. Parents reported this proce- dure was anxiety provoking for her and her parents; Carrie cried with pain during the catheter insertion, was able to set tle dur- ing the procedure but was distressed when it was time to release the contrast mate rial from her bladder. When she learned of her upcoming surgery, she was upset and did not want to go back to the hospital for the operation. Mother reported Carrie typically copes w ell when provided with information and a plan of action. Th ese two cases demonstrate the diverse nature of the interven- tions a child life special ist will provide. Building a strong rapport, conveying confi dence and a belief that someth ing can and will be done to decrease the pain are critical (Kuttner, 2010 ). Some of the mo st common interventions child life specialists provide for pain are summarized as follows. Preparing children for procedures Children report pain and discomfort most frequently as on e of the worst aspects of hospitalization (Lindeke et al., 2006 ). Providing clear and accu rate information to children results in fewer negative CHAPTER 52 child life interventions in pediatric pain 547 behaviors, reduces fear and anxiety, and leads to faster recovery postoperatively (Jaaniste et al., 2007 ; Koller, 2007 ). Th e key ele- ments of eff ective preparation include: prov iding developmentally appropriate information, the opportunity to express emotions (fear, a nxiety, and concerns), and the need for a trusting relationship (Koller, 2007 ). Early stud ies of preparatory programs for parents (mothers) of children undergoing surgery using thes e same gen- eral principles showed signifi cant decreases in parental anxiety and child cop ing as well (Mahaff y, 1965 ; Visintainer and Wolfer, 1975 ). Th e information should be ch ild friendly, developmentally appro- priate while using soft language versus words that pro voke anxiety, for example, using the \200\230the doctor will make a small opening \200\231 versus a \200\230cut or incision \200\231. Do not assume or insinuate something will hurt , but rather be honest about managing pain or discomfort should it occur. Balance the need to be honest while avoiding assumptions about how it will be experienced. Be aware of langu age and its dou- ble meaning, for example, for many children being \200\230put to sleep \200\231 reminds them of a pet that has been euthanized and may cause fear they may not awa ken from the surgery, instead state \200\230the doctor will give you sleeping medicine \200\231. Be prepared to address questions and misconceptions. Include not only specifi c a nd accurate infor- mation about the sequence of events (Jaaniste et al., 2007 ; Tak and van Bon, 2006 ), but also the rationale for the procedure (Campbell et al., 1995 ; Koller, 200 7 ; Patterson and Ware, 1988 ) and the sensory information they will see, hear, taste, or s mell (Koller, 2007 ; Suls and Wan, 1989 ). Th e preparation literature also consistently pr omotes the preparation for and modeling of coping strategies to cope with painful experienc es (Jaaniste et al., 2007 ; LaMontagne et al., 2003a , 2003b ; Patterson and Ware, 1988 ; S paff ord et al., 2002 ). music or videogame systems (Cavender et al., 2004 ; Sinha et al., 2006 ). Distraction is of t en used in conjunction with preparation and information sharing. Distraction is more eff ective with mild to moderate pain and can be particularly eff ective for children with chro nic conditions (Kuttner, 2010 ). Parent/sta \200 coaching in the use of distraction A distraction coach (parent or health p rofessional) is an important role during any painful procedure. Child life specialists are trained in this type of intervention, are recommended in the emergency department (ED) lite rature on pain management (Madhok et al., 2011 ; Zempsky and Cravero 2004 ) and can be help ful in training others in these strategies (Cregin et al., 2008 ; Zempsky and Cravero 2004 ). A child \200\231s attention may direct itself to the painful procedure at intensely pain ful moments or with new sensory experiences. With support and education, parents or other h ealth profession- als can become eff ective distraction coaches (Kleiber et al., 2007 ). En gaging parents of children with long-term or chronic illness in this skill development is i mportant in order to minimize depend- ency on health professionals, instill confi dence and decrease paren- tal anxiety caused by feelings of helplessness and guilt. Parents must be provided with information and positive feedback about their skills (Cavender et al., 2004 ; Kleiber et al., 2007 ). In Jacob \200\231s case example, Jacob \200\231s mother did not initially engage with the c hild life specialist, but once she recognized Jacob was receiving concrete and practical in formation and strategies she rec- ognized were useful for both of them, she was able to eng age and accept a role of coach. In Carrie \200\231s case example, notice the key preparatory elements are present. Carrie w as provided specifi c information through play and visual aids, in language she could under stand. She was off ered opportunities for questions; aff ective responses were monitored an d the amount of information provided was guided by her throughout the session. Given her de velopmental level, information regarding anticipated pain was minimal; however, this was ad dressed postop- eratively, with concrete strategies to rehearse and implement post- operati vely as well as during procedures. Breathing Teaching children and parents slow, rhythmic breathing from the diaphragm rather than the chest is a simple and eff ective strategy. Children can be engaged in pretending t o blow out candles, or blowing like the wind to move clouds in the sky, using party blow- e rs, blowing bubbles, pretending to infl ate or defl ate a tire or a bal- loon through inha ling/exhaling. Breathing in through the nose and out through the mouth, imagining the breat h going down to the belly also give the child a visual image. One can also ask the child to imagine all their worries are collected in their belly and to blow them away, until they g et smaller and smaller. Distraction Th e use of distraction during painful procedures is an eff ective strategy in reducing anxiety, distress, and pediatric pain (Uman et al., 2006 ). Distraction is the shi ft ing of attention away from the painful or anxiety provoking stimuli to something more pl easant, interactive, or interesting. Distraction can be used with children as young as 10 m onths of age, can be cognitive in nature, and/or behaviourally focused (Kuttner, 2010 ). So me examples include non-procedural conversation, counting, bubble blowing, playing \200 \230I Spy With my Little Eye \200\231, using pop-up books, the use of stress balls or hand held manipulative, and applications on an iPad. Providing a child with choices about the ki nd of distraction toys or activi- ties provides a sense of control. Oft en children will us e multiple distraction activities during a procedure or stressful experience. Th e distract ion item(s) or activity(ies) must be highly engaging, be easy to use, and match the child \200\231s interest, developmental level, and ability (see Table 52.1 for examples). Younger children tend to need more active distracters and coach involvement whereas older children will oft en choose more passive distracters such as Jacob \200\231s case example demonstrates how using multiple strate- gies, thought stopping , positive self-statements, cognitive refram- ing with the addition of deep breathing can b e very eff ective. Many children require a \200\230tool box \200\231 of skills and strateg ies. Positive reinforcement Positive reinforcement can come in the form of praise or in the form of a tangible reward (sticker/toy). Providing clear and specifi c positive statements is n ecessary. Making a statement \200\230Good job \200\231 will not likely encourage the reocc urrence of the specifi c behavior desired, whereas \200\230You did a great job sitting sti ll like a statue \200 that really helped a lot \200\231 provides a clear understanding of the behavior which was helpful. Th e use of tangible rewards must be clearly defi ned by staff and family. For example, doe s the child receive a sticker for a specifi c, previously determined behavior and does not receive it if the behavior does not occur, or does the child receive the sticker because th e procedure is complete or alternatively as a distracter SECTION 7 psychosocial interventions 548 Table 52.1 Common distraction strategies used by child life specialists: \200\224developmen tally based distraction strategies Age Developmental issues Behavioral/distraction techniques Infant Birth to 2 years 1. Caregiver attachment 2. Basic needs need to be met in a consistent manner 3. Create calm environment, low lighting, low voice tone 4. Encourage touch and parental participation to decrease separation and detachment Create a calm environment Magic Wand Toy Light up toys Singing Music Favorite object Use po sitions of comfort for procedures Toddler 2 \200\2233 years 1. Motor skills and language are developing, understand more than can be expressed verbally 2. Increasing independence 3. Need for routines, consistent caregivers, parental involveme nt and security objects 4. Give positive reinforcement for speci \201 c behaviors 4. Need for mastery and control through play Create a calm environment Magic Wand Toy Light up toys Pop-up picture books Video/DVD Bubbl es Blowing (balloons/imaginary candles) Music, singing, counting Use positions of comfort F avorite object Preschool 4 \200\2235 years 1. Communication skills are more developed. Important to provide information in a simple, c oncrete manner and check for misconceptions 2. Magical thinking and fear of bodily injury a re common 3. Encourage parental participation, verbalization, and social interaction 4. Giv e positive reinforcement for speci \201 c behaviors 5. Clear limits and expectations are i mportant to provide consistent structure Create a calm environment Magic Wand toy Light up toys Pop-up picture books/books I Spy gam es/distraction walls Humor/jokes/joke books Video/DVD Bubbles Blowing (balloons/imaginary c andles) Music, singing, counting Use positions of comfort Stress/squeeze balls Favorite obj ect Guided imagery Wet noodle strategy \200\230Magic Glove \200\231 technique School age 6 \200\22311 years 1. Need to understand why things are happening. Important to provide explanations and prepa ration for upcoming interventions, address misconceptions 2. Th ere is often a fear of body mutilation 3. Encourage parental participation, verbalization, and social interaction 4. G ive positive reinforcement for speci \201 c behaviors 5. Self-image and peer interactions are important at this stage 6. Clear limits and expectations are important to provide consi stent structure 7. More aware and involved in health Create a calm environment Magic Wand toy \200\230Search and \201 nd \200\231 books Distr action walls Humor/jokes/joke books Video/DVD Bubbles Blowing (balloons/imaginary candles) Deep breathing Music Use positions of comfort Stress/squeeze balls Favorite object Guided i magery Wet noodle strategy \200\230Magic Glove \200\231 technique \200\230Pain Switch \200\231 technique CHAPTER 52 child life interventions in pediatric pain 549 Table 52.1 (Continued) Age Developmental issues Behavioral/distraction techniques Adolescence 12 \200\22318 years 1. Respect individual as separate from parents/caregivers 2. Body image, privacy, and peers are critically important 3. Often more active in own health care issues and active in deci sion-making re: treatment 4. Chronic health issues: need for independence con \202 icts wi th dependence eon parents/family for support Humor/jokes/joke books Video/DVD Deep breathing Music Use positions of comfort Stress/squee ze balls Guided imagery \200\230Magic Glove \200\231 technique \200\230Pain Switch \200 \231 technique Developmentally Appropriate Behavioral Distraction Techniques. Adapted and used with permis sion from Boston Children \200\231s Hospital Interdisciplinary Pain Committee, Copyright Boston Children \200\231s Hospital 2013. near the end of procedure? It is important to be clear since one does not wish to reward un wanted behavior. Positioning for comfort Children, especially preschool children, feel more vulnerable and f earful when lying in a supine position and this can be an immedi- ate trigger that evokes a combative and/or uncooperative response (Cavender et al., 2004 ). Diff erent positions can be utilized which allow the child to remain seated on the chair, stretcher, parent \200 \231s lap or between the parent \200\231s legs (Stephens et al., 1999 ) while providing acc ess for procedures and a comforting hold from parents. With the use of positions of comfort , children were observed by health pro- fessionals and parents alike to be less fearful (Ca vender et al., 2004 ) and parents reported greater satisfaction (Sparks et al., 2007 ). Modeling and rehearsal Modeling is the demonstration of positive coping behaviors during a mock procedure by someone else. Child life specialists will oft en model breathing strategi es or a desired behavior for a procedure, such as \200\230keeping your arm still like a st atue \200\231 or the use of physical strat- egies such as squeezing a stress toy. Once mode led, practice and posi- tive reinforcement for the desired behavior will increase its use. In Jacob \200\231s case example, Jacob was shown how to breathe slowly and deeply (modeling ) then was rehearsed with his mother. His mother agreed to be his coach and prompted him to use this breath- ing technique if she noted escalating anxiety or pain. Figure 52.1 Image of a medical play session. Photographer: Copyright Gary Yokoyama, 1999 (December 11). Making a scary world a bit safer. Republished with permission of Th e Hamil ton Spectator . Th erapeutic play Koller \200\231s ( 2008b ) review of therapeutic play in pediatric health care states \200\230therapeutic play refers to specialized activities that are devel- opm entally supportive and facilitate the emotional well-being of a pediatric patient \200\231 and its focus is on the \200\230promotion of continuing \200\230normal development \200 \231 while enabling children to respond more eff ectively to diffi cult situations such as medical experiences \200\231 (p. 3). Th is form of play can take many forms \200\224puppet shows, dramatic play, creative or expressive art or medically focused play. Given that it i s an integral part of a child life specialist \200\231s practice, more research evidence is needed in support of the effi cacy of therapeutic play. play focusing on the re-enactment of interventions with the use of a body outline doll and medical supplies. Th is allows the exploration of the child \200\231s perception of their e xperiences, clarifi cation of mis- conceptions or misunderstandings (Ostrenga 1980 ) and/or rein- forcement of information previously provided during their illness (see Figure 52.1 ) . It also permits the opportunity for the child life specialist to return and continue with this modality to reassess or debrief with the child aft er their experience. Requests for repeated medical play sessions will typically taper off and may resurface at stressful peri ods. Medical play was used during the preparation in Carrie \200\231s case along with the provis ion of developmentally appropriate informa- tion. Th e off er of a body outline doll and an opportunity to explore the medical kit and supplies provided Carrie with a sense of contro l and mastery of the situation. Health care play/medical play Children with serious and/or chronic illnesses, who experienc e many painful procedures, will oft en repeatedly request medical SECTION 7 psychosocial interventions 550 Th ought-stopping/coping self-statements/cognitive reframing Th ought-stopping can be very eff ective when children fi nd their mind repeatedly thinking the same negative statements or images. Children can recognize this and be encouraged to take control of their brain and tell it what to do. Th e child repeats \200\230stop \200\231 or a simi- lar statement dur ing times of distress/pain, to block out negative thoughts. Oft en, child life specialists will then encourage the child to choose a positive thought, strong encouraging statement su ch as, \200\230I can do this \200\231 or \200\230Th is will be over soon \200\231. Th is can be easily taught and reinforced. and skills in pediatric pain management were more likely to use evidence-based non-pharmaco logical pain management strate- gies (Bandstra et al., 2008 ). While child life specialists in this sur- vey reported training in non-pharmacological interventions, they expressed a high degree of interest in receiving additional training in non-pharmacological pain manage ment interventions. Th ere is a growing body of literature supporting the role of child life specialists in imp lementing non-pharmacological interven- tions for children and families experiencing painfu l interventions (Brewer et al., 2006 ; Eldridge and Kennedy 2010 ; Gursky et al., 2010 ; Ma dhok et al., 2011 ; Zempsky and Cravero 2004 ). Th e most signifi cant body of evidence is found in studies of child life inter- ventions in the ED. Gursky and colleagues \200\231 ( 2010 ) study in the ED demonstrates that non-pharmacological interventions such as preparat ion and distraction provided by child life specialists can decrease observed distress behav iors during suturing, that par- ents perceive their child is less distressed and they are m ore satis- fi ed with services provided in the ED. Alcock et al. ( 1985 ) found decreased f ear with child life interventions that included prepara- tion and teaching of coping strate gies and emotional support for suturing while Cavender et al. ( 2004 ) noted decreased fear with preparation, positioning for comfort, and the use of distraction strategies. Interest ingly, the child \200\231s assessment of their pain during these noted procedures has not b een found to be decreased with the interventions. Parent-reported perception of pain distre ss has been found by Sinha et al. ( 2006 ) and Gursky et al. ( 2010 ) to decrease with chil d life intervention of preparation and use of distraction. Th ere is evidence to suggest th at child life interventions impact satisfaction rates in the ED as well (Alcock et al., 198 5 ; Browning and Stroud, 2008 ; Gursky et al., 2010 ). Child life specialists are in a pivo tal role to teach/prepare patients, parents and staff and provide interventions to assist w ith pain management (Cregin et al., 2008 ; Zempsky and Cravero, 2004 ); decrease anxiety an d pain perception (Alcock et al., 1985 ; Gursky et al., 2010 ); and support family partici- pation (Cavender et al., 2004 ; Stephens et al., 1999 ) In reviewing Jacob \200\231s case, the child life specialist used these strategies with Jac ob. Given his vivid imagination about the \200\230rot- ting fl esh \200\231 it was importa nt to use his words and re-phrase the way he perceived the healing process \200\230my thro at tissue is healing and will keep getting better. \200\231 Th is became a mantra he rehear sed and his mother prompted him if he went back to his negative verbalizations. Memory change Aft er a procedure is complete, it is valuable to assess the child and parent s \200\231 perceptions of the experience. Sometimes, children will indicate they did not fe el it went well: \200\230I cried \200\231 or \200\230I wasn \200\231t brave \200\231 or \200\230it hurt a lot \200\231 are common perceptions. Exploring the child \200\231s percep - tions and then helping the child to reframe negative memories of the procedure into posit ive ones, \200\230Lots of boys and girls and even big people cry when something hurts (or is hard work), you stayed so still which really helped make the IV go in easier \200\231; \200\230Being brave means doing something even though it \200\231s scary. You did it ! You let the nurses access your Port-a-Cath \204 even though it was scary and was uncomfortabl e \200\231, \200\230I noticed this time, that you didn \200\231t move your arm when the tu be went in for the IV, you were able to do it, even though it was uncomfortable, I bet next time it won \200\231t bother you as much \200\231. Th e evidence As illustrated in the clinical examples above, child life special- ists frequ ently employ a number of evidence-based non-phar- macological pain management strategies. I n a large scale survey of over 600 child life specialists in North America, Bandstra and co lleagues ( 2008 ) found that over 65% of child life special- ists reported providing pain m anagement interventions for at least 50% of their patients. Th e most commonly reported non - pharmacological pain management strategies used by child life specialists were: providing information/preparation, comforting/ reassurance, positive reinforcement, and behavioral d istraction followed closely by therapeutic play, breathing exercises, and medical play (Ban dstra et al., 2008 ). Consistent with their training and philosophy, child life specialists deliver these interventions in a developmentally appropriate manner, infused with various aspects of play. Th e literature indicates reassurance can increase anxiety and decrease co ping responses to pain (McMurtry et al., 2010 ) thus further study regarding the child life specialists \200\231 use of and/or interpretation of \200\230reassurance \200\231 is warr anted. Of note, child life specialists who were certifi ed, those with greater involvement with children who required assistance with pain management, and those who perceived they ha d a greater level of knowledge Innovative use of technology Children and families access the Internet for health informati on, prior to seeing health professionals, view videos of machinery, and watch YouTube \204 videos of professionals and tests, of other families talking about procedures and what th e experience will be like from an experiential and sensory perspective. Many families arriv e with personal electronic devices and anticipate Internet access during health care visits . Children, youth, and families can utilize these devices to aid with coping; help minimize feelings of isolation and disconnection from family, friends and school; provide diversion from the monotony of long days and provide distraction from inva- sive, distressing, or pa inful interventions. Child life specialists are integrating portable music devices and Wi-Fi tablets into their day-to-day practice. Closed-circuit TV is being utilized for therapeutic goal development w ith children/ youth with the outcome of creating educational and therapeutic videos to educ ate and teach children/youth how to deal with wor- ries, what to do if they have pain, how to talk to health profession- als, and what happens when you have a specifi c test. Tablets are replacing paper copies of preparation photos and books. Th e multitude of appli cations such as I Hear Ewe, Angry CHAPTER 52 child life interventions in pediatric pain 551 Birds, Cookie Doodle as well as audio books, music and YouTube \204 videos can provide a large repertoire of potential distraction activi- ties (McQueen et al., 2012 ). Staff and f amilies report increased suc- cess at maintaining attention for children across the age spe ctrum. Th is one tool in the child life specialists \200\230tool box \200\231 can provide hun- dreds of activities, minimizing the need to anticipate and bring a bagful of activitie s for any given child/youth. of involving child life specialists in pediatric pain care, and for studies to further our understanding of how child life special- ists can provide maximum benefi t to children in p ain and their families. References Alcock , D. S. , Feldman , W. , Goodman , J. T. , McGrath , P. J. , and Park , J . M. ( 1985 ). Evaluation of child life intervention in emergency department suturing . Ped iatr Emerg Care , 1 , 111 \200\223115. Children/youth with chronic physical or mental illness are at risk of social isolation whic h can impact self-esteem, self-perception and overall coping with diagnosis and treatment. Th e advent of Starbright World (< http://www.starbrightworld.org/default_login. aspx?Re turnURL=%2fh ome.aspx >) and American Academy of Pediatrics Child Life Council and Committee on Hospital Care. ( 2006 ). Child life services . Pediatrics , 118 , 1757 \200\2231763. Anonymous . ( 1959 ). Th e we lfare of children in hospital . Br Med J , 1 , 166 \200\223169. Upopolis \204 (< https://www.upopolis.com/webconcepteur/web/ upopolis >) are examples of online Intranet support programs that youth with chronic illness can meet others in similar situations while in a safe, closed system, on the Internet. Both programs con- tain health information written for children and youth in devel- opmentally appropriate language. Stud ies of Starbright World indicate improvements in mood and pain responses in children/ yo uth and nearly signifi cant results for anxiety (Davis et al., 2004 ; Rode et al., 1998 ). Bandstra , N. F. , Skinner , L. , LeBlanc , C. , Chambers , C. T. , Hollon , E. C. , Brenna n , D. , et al . ( 2008 ). Th e role of child life in pediatric pain management: a survey o f child life specialists . J Pain , 9 , 320 \200\223329. Barnes , P. ( 1995 ). Th irty yea rs of play in hospital. Int J Early Child , 48 \200\22353. Blount , R. L. , and Loiselle , K. A. ( 2009 ). Behavioral assessment of pediatric pain . Pain Res Manag , 14 , 47 \200\22352. Bowlby , J. ( 1952 ). Maternal care and mental health . Geneva : World Health Organization . Breiner , S. ( 2003 ). An evidence-based eating disorder program . J Pediatr Nurs , 18 , 75 \200\22380. Th e use of high-defi nition and augmentative reality will likely launch technology to a ne w level of interactive capacity, with grow- ing evidence supporting the effi cacy of these approaches for the management of pain in children (Kipping et al., 2012 ; Miller et al., 20 09 ). Th is may have even more success in distracting children from distressing or painful stimuli. Research into the use of all of these devices has barely begun; however, clinicall y there is a great deal of excitement about the perceived success of such applica- tions in the area of teaching, preparation, procedural support, and expressive activities. Brewer , S. , Gleditsch , S. L. , Syblik , D. , Tietjens , M. E. , and Vacik , H. W. ( 2006 ). Pediatric anxiety: child life intervention in day surgery . J Pediatr Nurs , 21 , 13 \200\22322. Browning , D. and Stroud , M. A. ( 2008 ). Pediatric ED seeks to touch all the bases: advanced courses prepare staff . ED Manage , 20 , 77 \200\22379. Campbell , L. A. , Kirkpatrick , S. E. , Berry , C. C. , and Lamberti , J. J. ( 1995 ). Pre paring children with congenital heart disease for cardiac surgery . J Pediatric Psychol , 2 0 , 313 \200\223328. Cavender , K. , Goff , M. D. , Hollon , E. C. , and Guzzetta , C. E. ( 2004 ). Parents \200 \231 positioning and distracting children during venipuncture: eff ects on children \200 \231s pain, fear, and distress . J Holist Nurs , 22 , 32 \200\22356. Chernoff , R. G. , Ireys , H. T. , DeVet , K. A. , and Kim , Y. J. ( 2002 ). A randomized, controlled trial of a community-based support program for families of children with chronic illness: pediatric outcomes . Arch Pediatr Adolesc Med , 156 , 533 \200\223539. Conclusion Child life specialists play an important role in the assessment and management o f pain in children in a variety of settings through- out the hospital as well as other heal th care settings. Th eir exper- tise and unique relationship with the child and family can provide a rich source of information to the interdisciplinary medical team in order to prom ote eff ective pain assessment and management and to provide the best overall collaborative and eff ective care for children. Child life specialists make major clinical contributions in terms of their delivery of non-pharmacological pain manage- ment strategies, with a foc us on preparation, rehearsal, behav- ioural and cognitive distraction, and physical interve ntions such as positioning for comfort. Despite their considerable involvement in pain asse ssment and management, it has only been in recent years that empirical research on the role of child life specialists in pediatric pain had begun to emerge in the literature. Until f urther research emerges, the use of theoretical frameworks and evidence based literature co ntinues to be the foundation of child life clinical practice. It is critical for the profes sion to continue to question the historical assumptions related to child life interven- tio ns and seek best evidence and research to ensure effi cient and eff ective practice. Child Life Council. ( 2002 ). Offi cial documents of the child life council . Rockville, MD : Child Life Council . Child Life Council. ( 2012 a). Th e child life profession . Available at: < http:// www.chi ldlife.org/Th e%20Child%20Life%20Profession/ > (accessed 17 April 2012). Child Life Council. ( 2012 b). CCLS directory . Available at: < http://ams. childlife.org/members_online/members/CCLS_Directory.asp > (accessed 17 April 2012). Cregin , R. , Rappaport , A. S. , Montagnino , G. , Sabogal , G. , Moreau , H. , and Abular rage , J. J. ( 2008 ). Improving pain management for pediatric patients undergoing nonurgen t painful procedures . Am J Heath Syst Pharm , 65 , 723 \200\223727. Davis , M. A. , Quittner , A. L. , Stack , C. M. , and Yang , M. C. ( 2004 ). Controlled ev aluation of the STARBRIGHT CD-ROM program for children and adolescents with Cystic Fibrosis . J Pediatr Psychol , 29 , 259 \200\223267. Davitt , K. A. , and Munn , E. K. ( 2008 ). Child life in pediatric healthcare . J Pediatr Rehabil Med , 1 , 33 \200\22334. Eldridge , C. and Kennedy , R. ( 2010 ). Nonpharmacologic techniques for distress reduction during emergency medical care: a review . Clin Pediatr Emerg Med , 11 , 244 \200\223250. Gaynard , L. , Goldberger , J. , Th ompson , R. , Redburn , L. & Laidley, L. ( 1990 ). Psyc hosocial care of children in hospitals: a clinical practice manual from the ACCH Child Life Research Project . Bethesda, MD : Association for the Care of Children \200\231s Health . Th ere is a need for interprofessional collaboration, training, and research in the fi eld of pediatric pain in an eff ort to trans- late the knowledge that exists into daily practic e. However, it will also be important for future studies to address the added benefi t Glasrud , P. H. , and Feigal , R. J. ( 1984 ). Child life and children \200\231s dentistry: broadening our scope of concern . Child Health Care , 12 , 143 \200\223147. SECTION 7 psychosocial interventions 552 Plank , E. ( 1962 ). Working with children in hospitals: a guide for the professional Gursky , B. , Kestler , L. P. , and Lewis , M. ( 2010 ). Psychosocial intervention on proce dure-related distress in children being treated for laceration repair . J Dev Behav Pediatr , 31 , 217 \200\223222.