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( 1976 ). Behavioral methods for chronic pain and illness . St. Louis, MO : Mosby . CHAPTER 51 operant treatment 541 syndromes: an investigation of moderating eff ects on the pathway form pain to disability . J Pediatr Psychol , 30 (8), 698 \200\223707. Fordyce , W. E. , Fowler , R. S. , and DeLateur , B. ( 1968 ). Case histories and shorter c ommunications: an application of behavior modifi cation technique to a problem of chronic p ain . Behav Res Th er , 6 , 105 \200\223107. Fordyce , W. E. , Roberts , A. H. , and Stern bach , R. A. ( 1985 ). Th e behavioral management of chronic pain: a response to critics . Pain , 22 , 113 \200\223125. Fordyce , W. E. , Shelton , J. L. , and Dundore , D. E. ( 198 2 ). Th e modifi cation of Martin-Herz , S. P. , Th urber , C. A. , and Patterson , D. R. ( 2000 ). Psychological prin ciples of burn wound pain in children. II: Treatment applications . J Wound Care Rehabil , 21 , 458 \200\223472. 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W. , Cleghorn , G. , and Woolford , H. ( 1994 ). Th e treat ment of recurrent abdominal pain in children: a controlled comparison of cognitive-behavior al family intervention and standard pediatric care . J Consult Clin Psychol , 62 (2), 306 \200\223314. Linton , S. J. ( 1986 a). A case study of the behavioral treatment of chronic stomach pain in a child . Behav Change , 3 , 70 \200\22373. Sanders , S. H. ( 1985 ). Th e role of learning and chronic pain states . In S. F. Brena , and S. L. Chapman (eds) Clinics in anesthesiology: chronic pain: management principles , pp . 41 \200\22355. Philadelphia, PA : Saunders . Linton , S. J. ( 1986 b). Behavioral remediation of chronic pain: a status report . Pain , 24 , p. 125 . Lipani , T. A. , and Walker , L. S. ( 2006 ). Children \200\231s appraisal and coping with pain: relations to maternal ratings of worry and restriction in family activities . J Pedia tr Psychol , 31 (7), 667 \200\223673. Sanders , S. H. ( 2003 ). Operant therapy with pain patients: evidence for its eff ectiveness . Semin Pain Med , 1 , 90 \200\22398. Sank , L. I. , and Biglan , A. ( 1974 ). Operant treatment of a case of recurrent Logan , D. E. , and Scharff , L. ( 2005 ). Relationships between family and parent characte ristics and functional abilities in children with recurrent pain abdominal pain in a 10-year-old boy . Behav Th er , 5 , 677 \200\223681. SECTION 7 psychosocial interventions 542 Walker , L. S. , Claar , R. L. , and Garber , J. ( 2002 ). Social consequences of children \200\231s pain: when do they encourage symptom maintenance? J Pediatr Psychol , 27 , 689 \200\223698. Schanberg , L. E. , Anthony , K. K. , Gil , K. M. , Lefebvre , J. C. , Kredich , D. W. , an d Macharoni , L. M. ( 2001 ). Family pain history predicts child health status in children with chronic rheumatic disease . Pediatrics , 108 , p. E47 . Scharff , L. , Langan , N. , R otter , N. , Scott-Sutherland , J. , Schenck , C. , Tayor , N. , et al . ( 2005 ). Psycholo gical, behavioral, and family characteristics of pediatric patient with chronic pain . Clin J Pain , 21 (5), 432 \200\223438. Walker , L. S. , Garber , J. , and Greene , J. W. ( 1993 ). Psychosocial correlates of recu rrent childhood pain: a comparison of pediatric patients with recurrent abdominal pain, org anic illness, and psychiatric disorders . J Abnormal Psychol , 102 , 248 \200\223258. Slifer , K. J. , Babbitt , R. L. , and Cataldo , M. D. ( 1995 ). Simulation and countercond itioning as an adjunct to pharmacotherapy for invasive pediatric procedures . J Dev Behav P ediatr , 16 (3), 133 \200\223141. Walker , L.S. , Garber , J. , and Greene , J.W. ( 1994 ). Somatic complaints in pediatric p atients: a prospective study of the role of negative life events, child social and academic competence, and parental somatic symptoms . J Consult Clin Psychol , 62 , 1213 \200\22312 21. Slifer , K. J. , Hankinson , J. C. , Zettler , M. A. , Frutchey , R. A. , Hendricks , M. C. , Ward , C. M. , et al . ( 2011 ). Distraction, exposure therapy, counterconditioning, and topical anesthetic for acute pain management during needle sticks in children with intelle ctual and developmental disabilities . Clin Pediatr , 50 (8), 688 \200\22397. Walker , L. S. , Garber , J. , and Greene , J.W. ( 1991 ). Somatization symptoms in pediatr ic abdominal pain patients: relation to chronicity of abdominal pain and parent somatizatio n . J Abnormal Child Psychol , 19 , 379 \200\223394. Walker , L.S. , Garber , J. , and Van Slyke , D.A. ( 1995 ). Do parents excuse the misbehavior of children with physical or emot ional symptoms? An investigation of the pediatric sick role . J Pediatr Psychol , 20 , 329 \200\223345. Walker , L. S. , Williams , S. E. , Smith , C. A. , Garber , J. , Van Slyke , D. A. , and Lipani , T. A. ( 2006 ). Parent attention versus distraction: Impact on sympto m complaints by children with and without chronic functional abdominal pain . Pain , 122 (1 2), 43 \200\22352. Slifer , K. J. , Tucker , C. L. , and Dahlquist , L. M. ( 2002 ). Helping children and care givers cope with repeated invasive procedures: how are we doing? J Clin Psychol Med Sett 9 (2), 131 \200\223152. Stone , R. T. , and Barbero , G. J. ( 1970 ). Recurrent abdominal pain in childhood . Pediatrics , 45 , 732 \200\223738. Th urber , C. A. , Martin-Herz , S. P. , and Patterson , D. R. ( 2000 ). Psychological prin ciples of burn wound pain in children. I: Th eoretical framework . J Wound Care Rehabil , 2 1 , 376 \200\223387. Walker , L. S. , and Zeman , J. L. ( 1992 ). Parental response to child illness behavior . J Pediatr Psychol , 17 , 49 \200\22371. Van Slyke , D. A. and Walker , L. S. ( 2006 ). Mothers \200\231 responses to adolescent \200\231s Whitehead , W.E. , Crowell , M. D. , Heller , B. R. , Robinson , J. C. , Schuster , M. M. , and Horn , S. ( 1994 ). Modeling and reinforcement of the sick role during childhood predi cts adult illness behavior . Psychosomat Med , 56 , 541 \200\223550. pain . Clin J Pain , 22 (4), 387 \200\223391. Van Tulder , M. W. , Ostelo , R. , Vlaeyen , J. W. , Linton , S. J. , Morley , S. J. , and Assendelft , W. J. ( 2000 ). Behavioral treatment for chronic low back pain . Spine , 25 , 2688 \200\2232699. Zeltzer , L. , Bursch , B. , and Walco , G. ( 1997 ). Pain responsiveness and chronic pain: a psychobiological perspective . J Dev Behav Pediatr , 18 (6), 413 \200\223422. Varni , J. W. , Bessman , C. A. , Russo , D. C. , and Cataldo , M. F. ( 1980 ). Behavioral management of chronic pain in children: a case study . Arch Phys Med Rehabil , 61 , 375 \200\223379. Zeltzer , L. K. , Tsao , J. C. , Bursch , B. , and Myers , C. D. ( 2006 ). Introduction to the special issue on pain: From pain to pain-associated disability syndrome . J Pediatr Psy chol , 31 , 661 \200\223666. Vervoort , T. , Caes , L. , Trost , Z. , Sullivan , M. , Vangronsveld , K. , and Goubert , L. ( 2011 ). Social modulation of facial pain display in high-catastrophizing children: an observational study in schoolchildren and their parents . Pain , 152 , 1591 \200\2231599. CHAPTER 52 Child life interventions in pediatric pain Chantal K. LeBlanc and Christine T. C hambers Introduction Child life specialists, as members of the health care team, are fre- quently i nvolved in the assessment and management of pain in hospitalized children and children in e mergency settings. Child life refers to a non-medical therapeutic service designed to addre ss the developmental, educational, and psychosocial needs of pediatric patients. Child life specialists are professionals who \200\230promote eff ec- tive coping through play, prepa ration, education, and self-expres- sion activities. Th ey provide emotional support for fa milies, and encourage optimum development of children facing a broad range of challenging e xperiences, particularly those related to healthcare and hospitalization \200\231 (Child Li fe Council, 2012a ), including painful procedures and coping with other types of pain (e.g. postoperative pain). Th is chapter provides an overview of the role of a child life specia list, including a historical perspective on the evolution of the fi eld and current child l ife practices. Th e chapter then provides a summary of the specifi c contributions of child life specialists to pain assessment and management, including innovative uses of technolog y oft en facilitated by child life specialists. stimulation and infant deaths (Spitz, 1945 ) and long-term psycho- logical eff ects of hosp italization (Prugh et al., 1953 ). Hospitalized children were frequently withdrawn, quiet, and disengaged, coining the term \200\230hospitalism \200\231 (Spitz, 1945 ). Society at l arge began to develop a more sophisticated appreciation of the importance of cognitive, soc ial, and emotional development during childhood. Th e eff ects of minimal stimulation, sepa ration from family, and the potential trauma of hospitalization led to an appreciation that the experience of hospitalization put children at risk for signifi cant emotional dis- tre ss thereby impacting their overall health (Bowlby, 1952 ; Prugh et al., 1953 ; Spitz, 1945 ). Th is work prompted changes in health care (Th ompson, 1989 ; Wojtasik and White, 2009 ) , including the utili- zation of volunteers and staff , mostly women, to spend time with th e children to engage them in play and learning. Th ese individuals became known as \200 \230play ladies \200\231, \200\230play teachers \200\231, or \200\230play leaders \200 \231 (Rubin, 1992 ; Th ompson, 1989 ). Th e Platt report, released in the UK in 1959 provid ed specifi c recommendations regarding the need for parents to be with their children while in hospital, the importance of spe- cialized education and training of staff working with children, and the need for play and education during pediatric hospitalization (Anonymous, 1959 ). Changes in hospital visitation policies and pro- gramming and the realization of th e need to meet the developmen- tal and emotional needs of children during the provision of medical care (Barnes, 1995 ; Th ompson, 1989 ; Wojtasik and White, 2009 ) provided the foun dation for the child life profession. Historical context Th e child life profession originates from a time when children were lef t at the hospital to be cared for by doctors, nurses, nuns, psychi- atric personnel, and vo lunteers. Many hospitals severely restricted visits, even by parents, limiting these famili ar, and oft en comfort- ing, interactions to only a few hours per week (Th ompson, 1989 ). Th ere was oft en no contact with siblings. Recovery included long stays, immobilization, l ack of stimulation, sterile environments, and no play space or educational support. Little information was shared with children about the reason for their hospital admission, diagnos is, or treatments, let alone preparation for procedures, sur- geries or support for painful experiences (Jun-Tai, 2008 ; McCue and Hicks, 2007 ; Th ompson, 1989 ). Th e lack of famil y visits and information shared was thought to protect patients and families. It was believ ed children would not be able to understand complex information and would become more upset if family members stayed for long periods of time and then left . Play programs were noted as early as 1922 in the US and in 1936 in Canada, with nine identi fi ed programs in North America by 1949. Th e 1960s and 1970s saw the coming together of pr ofessionals to organize associations such as the Association for the Wellbeing of Hospitali zed Children and their Families in the US (later to be renamed the Association for the Care of Children \200\231s Health) and the Hospital Liaison Committee in the UK to lobby for st imulation and play for hospitalized children and specialized training to do this work. Th e re are now over 480 programs listed in the 2012 Child Life Council \200\231s Directory (Chi ld Life Council, 2012b ), in 18 countries around the world. Child life today Th e child life profession is a new profession, stemming from the need for personnel with specifi c training to acknowledge and Th e negative impact of this vacuous psychosocial environment on children \200\231s health became evident including the link between lack of SECTION 7 psychosocial interventions 544 address the developmental and psychosocial needs of hospitalized children. Child life has i ts roots in child development, psychol- ogy, recreation/leisure, education, sociology, and social science. Although there may be some overlap in professional roles with other psychos ocial care providers, Th ompson ( 1989 ) stresses the primary duty of the child life specia list is focusing on the developmental and psychosocial needs of the hospitalized child. In Canada, the US, and Kuwait, the title of \200\230child life specialist \200\231 is well re cognized. In other parts of the world, this role is known as a \200\230hospital play speci alist \200\231, \200\230hospital play staff \200\231, \200\230play leader \200\231, or \200\230child life therapist \200\231, however the philosophy, goals, and interventions are similar. play and/or therapeutic dialog, learn from the child/youth how they perceive and understand what is happening, clarify miscon- ceptions and provide opportunities for questions, fears , or worries to be addressed. Strategies are then developed to assist with coping and adjus tment to the situation, while ensuring a sense of mastery and control throughout the interv entions. Th e child life special- ist explores previous coping strategies and focuses on ea ch fam- ily member \200\231s strengths, assessing the needs within the family (e.g. informa tional needs, emotional, parenting and/or sibling support needs) and partnering with them a nd other members of the team. When children and family members feel respected, engaged, and understood, they share their stories, their fears, worries, and needs, and become partners to make things better. Child life specialists have specialized training, which in North America typically involves a minimum of a bachelor \200\231s degree in child life, child development, psychology or c losely related fi eld that incorporates a variety of coursework, including but not limited to child growth and development, function and development of play behaviors, family systems , behavior management, child coping, psychology, and courses in child life methods. Additio nally, suc- cessful completion of a child life internship, supervised by a certifi ed child life specialist provides the minimum requirements to write the certifi cation exam, off er ed through the Child Life Certifying Committee. Several countries (including Canada, the US , the UK, and New Zealand) off er credentialing processes for child life spe- cialists to e nsure specifi c and continued competencies in working with children in this fi eld (Child L ife Council, 2002 ; Hospital Play Specialist Association of Aotearoal/New Zealand, 2012 ). Child life assessment and interventions Child life specialists fi rst assess the key variab les which are known to impact coping and adjustment to health care experiences in order to develop a child life plan of care and goals for the interprofes- sional plan of care. Th er e are many variables that can impact cop- ing responses to hospitalization and health care interventions. Th is information is gathered from the health record, the child and fam- ily , those involved in the care, as well as through observation. Th e assessment is an ongoing process; it is dynamic, and changes as the information and needs change. Th is in turn inf l uences the child life interventions to be provided. Th e assessment variables associated with a child and family \200\231s ability to cope with hospitalization include (Blount and Loiselle, 2009 ; Gaynard et al., 1990 ; Koller, 2008a ): Family centered care is a philosophy and way of interacting with families that is ingrained and intuitive to the child life specialist. As a result, child life specialists employ a c ollaborative approach to care, believing parents know their children best, should be true p artners in care, and deserve to have information provided in a way they can understand. Cul tural diversity is respected, focusing on the strengths of the family and its individuals, recognizing and respecting diff erent coping styles, and being aware families require the a ppropriate supports to meet their needs (Shelton and Stepanek, 1994 ). Child life specialis ts work closely with all the members of the child \200\231s health care team to provide the best overall experience and outcomes for the child. 1. Child variables: age/developmental level, temperament and cop- ing responses. 2. Family variables: parental anxiety, parental involvement, marital status and education. 3. Medical experiences: number of invasive procedures and mem- ory of these experiences. Th ere are a range of interventions child life specialists will pro- vide. At the core of t he interventions is the use of developmentally appropriate toys/activities and conversation to assist the child and family. Some of the interventions described are provided predom- i nantly by child life specialists such as medical play while others are also commonly utiliz ed by a variety of health professionals, for example cognitive and behavioral distraction. A child life plan of care is developed including one or more of the following interven- tio ns (Skinner and LeBlanc, 2002 ): Th e role of child life specialists fi rst originated in hospital-based pediatric inpatient units. However, many children outside of inpa- tient units experience repeated frightening or invasive procedures. As a result, child life specialists are involved in pediatric care in a number of settings, including: ambulatory clinics, diagnostic imag- ing (McGee, 2003 ), emergency department (Cavender et al., 2004 ; Gursky et al., 2010 ; Stevenson et al., 20 05 ), sedation program, day surgery (Brewer et al., 2006 ), mental health programs (Breiner , 2003 ), neonatal intensive care, pediatric intensive care unit, critical care unit, labor atory medicine, children of adult inpa- tients (Th ompson and Snow, 2009 ). A surgical even t in day surgery or an urgent medical event in the emergency department can be painful and frightening for children and have profound eff ects on future encounters with health care p roviders. Th ere are inequities in child life service delivery for diff erent populations w ithin and among hospitals and this continues to be a challenge. 1. Play: child life specialists use play/activities as their primary tool in assessing and intervening with children and youth regard- less of the reason for involvement. There are m any functions of play for the child life specialist including assessment, teaching, and exp ression of feelings, modeling, preparation, distraction and sheer enjoyment. Play for child ren is universal, how they learn about the world, make sense of the world, develop skills t o socialize, make decisions, and learn how their actions have an impact on themselves and o thers. Play provides freedom and a sense of mastery and control. Play helps children gain t he devel- opmental and psychosocial skills they need for life. It can also be a way to work through stressful experiences and is known to reduce a child \200\231s anxiety (Thompson, 1989 ). The child \200\231s ability to engage in their environment, their understanding of concepts Child life specialists provide valuable information about the child \200\231s perception an d experience of medical events to the medical team. Th ey are in a unique position because their role is typically viewed by the child and family as being non-threatening, non-inva- sive, and oft en \200\230fun \200\231. Th ey are able to quickly build rapport through CHAPTER 52 child life interventions in pediatric pain 545 and experiences, their social skills, their communication and lan- guage skills, their perc eption of the world, their hope for a better day, and their ability to control aspects of t heir world (Jessee and Gaynard, 2009 ) is revealed through their play. medical jargon, liaise with the health care team, support brothers and sisters to cope effe ctively and help parents to recognize their child \200\231s coping style and support parent ing roles. Th ese various interventions are adapted to fi t the context of the work as the role of the child life specialist now extends beyond the hospital walls. Expertise and skills are util ized in rehabilitation cen- tres (Davitt and Munn, 2008 ), dental offi ces (Glasrud and Fei gal, 1984 ), community programs (Chernoff et al., 2002 ), hospice programs, funeral homes, specialized camps, the court system as well as consultation and support services for childr en of adult patients (American Academy of Pediatrics Child Life Council and Committee on Ho spital Care, 2006 ; Hicks, 2008 ). 2. Play programming: child life specialists ensure the child has devel- opmentally appropri ate play materials and supplies to encourage active participation in play, in the room, in play areas or a teen lounge, as appropriate (could be another child life specialist or an a ssistant or volunteer). 3. Health care/medical play: health care play encompasses the use of medical supplies and e quipment, toy medical kits, body outline dolls or demonstration dolls in directive or non-d irective play and even the use of music, photography, or technology applica- tions to expre ss oneself in regard to the health care experience. This play may include expressive or cre ative arts using medical supplies; use of expressive arts to allow children to share their experience, express their feelings through art, puppetry, dramatic play, writing/journaling , photography, video, etc. Medical play typically speci \201 es the use of medical supplie s and equipment to re-enact medical experiences on a \200\230patient \200\231 such as a bo dy outline doll, puppet, or favorite toy. This form of play allows for the expression of fe elings, clari \201 cation of misconceptions; explora- tion of coping strategies and workin g through feelings associated with painful or frightening experiences (Ostrenga, 1980 ). Ve ry young children, even under the age of 2 years, can participate in medical play. The type of medical supplies used and the deci- sion to use real needles in the play is dependent u pon the age/ developmental level of the child, the child \200\231s emotional response to ne edles and the ability to maintain a safe play area. Th e role of child life specialists in pediatric pain During the early years of the child l ife profession, it was recognized that children \200\231s pain responses were greatly infl uenced by distress and anxiety while developmentally appropriate information could infl uen ce coping responses and recovery (Plank, 1962 ). As is sum- marized throughout this volume, research regarding children \200\231s experience of pain and the contributions of various pharmacologi- cal and non-pharmacological interventions to improve pain has advanced our kn owledge signifi cantly since the 1960s. However, there is considerable evidence supporting the fact hospitalized chil- dren experience signifi cant pain and still do not receive opti mal pain management (Stevens et al., 2011 ). Th e following two case examples illustrate some of the varied interventions child life spe cialists provide in the management of children \200\231s pain, followed by a description of some of the most com- monly employed child life interventions when pain is an issue. 4. Developmental support: child life specialists implement individu- alized play program to support the maintenance or progres- sion of developmental and psychosocial skills. 5. Teaching: child life specialists provide simple clear and devel- opmentally appropriate explanations about the reason for admission, the machinery, the diagnosis, the treatment to be undertaken, or a upcoming surgery. 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.