Reper Research Proposal

Running Head: PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE 1

Pediatric Patients and Psycho-Social Adjustment: Do Child Life

Programs make a Difference?

Nicole Reper

University of South Florida

U65968875

PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE2

Abstract

Therapeutic play is associated with improved learning, problem solving, and coping

(Bratton, Ray, & Landreth, 2008). Art therapy has been linked to lowering anxiety in

hospitalized children (Stubbe, 2008). However, few studies have examined the combination of

therapies used in Child Life Programs in association with psycho-social adjustment, while

comparing children that have received the treatment to children that have not. Child Life

Specialists minimize the adverse effects of hospitalization within hospitals (Brown et al., 2014).

Psycho-social research is vital because children’s thoughts about themselves help determine the

presence of depressive symptoms (Steca et al., 2014). I aim to compare coping, self-efficacy,

illness self-concept, and social withdrawal between hospitalized children who have and have not

experienced a program and to examine mean-level differences by gender in the study variables.

The research design is cross-sectional and correlational. Children ages 8 to 15 will be recruited

from a children’s hospital with a program and from two hospital pediatric units without it (target

N = 40). Data will be collected using established measures. I anticipate greater assessment scores

in illness self-concept, self-efficacy, and coping abilities and less social withdrawal among the

Child Life intervention participants. Anticipated findings are expected to increase understanding

of the psycho-social influence of Child Life Programs.


Pediatric Patients and Psycho-Social Adjustment: Do Child Life

Programs make a Difference?

Preoperative anxiety scores of hospitalized children are significantly lower for children

that are prepared for surgery by a Child Life Specialist (Brewer, Gleditsch, Syblik, & Tietjens,

2006). Child Life Specialists that use MRI compatible video goggles with patients before and

during their MRI are found to be highly cost effective based on the fact that this significantly

reduces the number of children that require sedation (Durand, Young, Nagy, Tekes, & Huisman,

2014). As the amount of research regarding the work of Child Life Specialists and Child Life

Programs increases, the number of people that realize how much they are needed in the pediatric

healthcare setting increases. This further justifies the need to install these programs outside of

children’s hospitals alone, while providing additional support for current Child Life Programs.

Research that only assesses individual therapies, rather than all of the therapies combined in

Child Life Programs, is limited. This due to the fact that, if the participants are hospitalized

children, they are more than likely experiencing more than one type of therapy during their time

as an inpatient, which, unless controlled for, could have an impact on research findings. This

calls for research on whole Child Life Programs, rather than individual therapies. However, a

limitation of this study is that it does not provide current Child Life Specialists with new

techniques to improve their existing programs. This study seeks to examine Child Life Programs

in association with coping, illness self-concept, self-efficacy, and social withdrawal, while

comparing children that have received the Child Life treatment to children that have not.

Child Life Programs

Child Life Specialists are nonmedical members of a medical team that focus on children

ranging from newborns to young adults and their loved ones (McDonald, 2001). Their primary


job is to promote coping skills and to simply minimize the adverse effects of hospitalization,

which is done through play therapy and expressive therapies, such as music and art therapy

(Brown et al., 2014). Play therapy and expressive therapies are utilized regularly by the Child

Life team in children’s hospital. Animal-assisted therapy, otherwise known as pet therapy, is also

part of the Child Life intervention program; however, research concerning pet therapy has been

focused particularly on cardiovascular responses, state anxiety, and medical fear in order to make

inferences about coping (Tsai, Friedmann, & Thomas, 2010).

With regards to play therapy and the expressive therapies, a substantial amount of

research concerning various physiological and psychological, and some psycho-social concepts,

has been done on each of the individual treatments. Physiological and psychological effects are

more commonly studied due to the fact that they, particularly heart rate, blood pressure, and

coping, are more readily attached to a quicker healing process, whereas the psycho-social impact

is more important to social development while in the hospital, and sometimes outside of the

hospital. This is because a lower, more normal heart rate and blood pressure have been known to

predict outcomes of chronic wounds and coping with stress has been found to be an influential

factor in wound healing (Sonter, Ho, & Chuter, 2014; Maple et al., 2015). Therapeutic play has

been linked to children learning to express, accept, respect, and take responsibility for

themselves and their feelings, which leads to creative insight, learning, problem solving, and

coping (Bratton et al., 2008). Art therapy has been found to be a coping resource that lowers

anxiety and helps children process the distress of hospitalization (Stubbe, 2008). However, all of

this knowledge is based on the implications of a single therapy per study, rather than the

implications of utilizing a combination of therapies on a daily basis in an all-encompassing Child

Life Program.


Emotional Adjustment

Coping can be defined as the process of contending with life difficulties in an effort to

overcome or work through them (Coping, 2003). The main goal of a Child Life Specialist is to

reduce the stress and anxiety of their patients, while remembering their developmental

background (Brown, 2001). Coping is studied often with regards to Child Life because it is

necessary to achieve their main goal. Coping abilities and strategies are constantly being

examined in order to improve upon the work current Child Life Specialists are doing. However,

coping is rarely studied in comparison to social withdrawal, illness self-concept, and self-

efficacy, which is important because coping has been linked to social adjustment (Marsac,

Donlon, Winston, & Kassam-Adams, 2013). There has been research that indicates that when

parents help their children cope, children are more likely to seek out social support when need be

(Marsac et al., 2013); thus, linking coping abilities with decreased social withdrawal.

Social Adjustment

Social withdrawal is associated with shyness, behavioral inhibition, isolation and

rejection, social reticence, passivity, and peer neglect (Rubin, Coplan, & Bowker, 2009).

Children that are coping better with help from parents have been found to have less of an issue

with social withdrawal (Marsac et al., 2013). The role Child Life Specialists play with regards to

social withdrawal is that they plan events, or therapy sessions, that appear entertaining and fun to

the child while giving them the opportunity to socialize with other pediatric patients. Child Life

Specialists may also involve parents by explaining different methods they can use to socialize

with their child, which could improve coping and, in turn, improve social withdrawal. Research

regarding the effectiveness of current Child Life Programs in relation to social withdrawal is

vital.


Self-efficacy can be defined as people’s judgments of their capabilities to organize and

execute courses of action required to attain designated types of performances (Riggs, Warka,

Babasa, Betancourt, & Hooker, 1994). Or more generally for children, how much they believe in

themselves. Research has found that epileptic children’s attitude toward their illness and self-

concept are positively correlated with self-efficacy, but that no gender differences were found in

the high level of self-efficacy related to managing their epilepsy (Caplin, Austin, Dunn, Shen, &

Perkins, 2002). Hospitalized children face various battles during their time in and out of the

hospital that have the power to impact what and how they believe in themselves. A Child Life

Specialist tries to prevent the hospitalization from having a negative impact through their daily

tasks they do with each child, which gives reason to research self-efficacy in relation to a Child

Life intervention program.

Illness self-concept is the extent to which individuals are consumed by their illness

(Morea, Friend, & Bennett, 2008). This variable is rare among Child Life research, but it is

imperative nonetheless; it is often studied with regards to the common illness self-concept

associated with a certain illness, but it has been found to be a strong predictor of outcomes across

variables such as illness intrusiveness, depression, and life satisfaction (Morea et al., 2008).

Thus, it is important to research factors that may improve illness self-concept, including the

installation and implementation of a Child Life Program.

Present Study

The combination of all therapeutic techniques executed by Child Life Specialists is

infrequently studied. There has been limited research on the Child Life Specialist’s role in the

neonatal intensive care unit (Smith, Desai, Sira, & Engelke, 2014). In the pediatric imaging

department, Child Life Specialists and the role they play are well recognized, but mainly only


anecdotally (Tyson, Bohl, & Blickman, 2014). Research regarding psycho-social concepts, such

as self-efficacy, are important when it concerns children because their thoughts about themselves

can help determine whether or not depressive symptoms will arise at the current time in their life

and/or in their future (Steca et al., 2014). Given the significance of the sense of self in social

development and the lack of knowledge about Child Life Programs, this study seeks to

understand how Child Life intervention programs as a whole can help patients to maintain, or

improve their illness self-concept, self-efficacy, and coping abilities as well as decrease their

feelings of social withdrawal. The mean-level differences among the correlates will be examined

by utilizing a correlational research design.

My hypotheses were as follows: (1) the average illness self-concept score is expected to

be higher for the group that does not experience the Child Life Program relative to the group that

does (a poorer illness self-concept yields a higher score when utilizing the Illness Self Concept

Scale) , (2) the average self-efficacy score is expected to be lower for the group that does not

experience the Child Life intervention program relative to the group that does, (3) it is expected

that coping abilities will be lesser among participants that do not experience the Child Life

Program relative to participants that do, (4) there is expected to be a greater amount of social

withdrawal among participants that do not experience the Child Life intervention program

relative to participants that do, (5) it is anticipated that illness self-concept will be positively

correlated with self-efficacy and coping abilities and negatively correlated with social

withdrawal across both groups, (6) it is expected that self-efficacy will be positively correlated

with coping abilities and negatively correlated with social withdrawal across both groups, (7) it

is expected that coping abilities and social withdrawal to be negatively correlated across both

groups, and (8) there is expected to be significant mean-level differences by gender within the


social withdrawal variable, but not within the coping, self-efficacy, and illness self-concept

variables (Caplin et al., 2002; Marsac et al., 2013; Graves et al.,2014; Luyckx, Rassart, Aujoulat,

Goubert, & Weets, 2014).

Method

Setting and Sample

The total number of participants will be 40; 20 from a local children’s hospital in Pinellas

County, Florida, that have experienced the continuous Child Life intervention program, and 20

from two other regular hospital pediatric units (that do not utilize Child Life Specialists) in either

Hillsborough County or Pinellas County, Florida. The 20 pediatric unit patients may not be

collected evenly from each of the regular hospitals. The reasoning behind utilizing two regular

hospitals, instead of only one, is to ensure ethnic and socioeconomic diversity among the

pediatric unit patients being that children’s hospitals tend be diverse because their specialization

makes them scarce in any state.

The patients experiencing the Child Life intervention program will be hematology

patients, oncology patients, or be from general medical units (children’s hospitals contain many

different units and specialized areas), while patients in the other group will be from a pediatric

unit that naturally varies due to the lack of specialization. The only other patients that spend

enough time in a children’s hospital to possibly experience a good portion of the Child Life

intervention program are intensive care unit (ICU) patients, but the amount of ICU patients that

would be able to experience the whole program would be very few, if any. Patients in both

groups will also have been hospitalized a similar amount of time prior to the assessments,

specifically between 4 and 7 days, to make certain that coping skills will not differ as a product

of time spent with diagnosis and in hospital. The ages will vary from 8 to 15, with 8-10 year olds


receiving extra help in the form of being read the questions when being surveyed to ensure that

they understand. The age range has to include elementary age children, as well as middle and

high school age children, in order to account for that fact that children’s hospitals generally

receive children on the younger end of the spectrum, while regular hospitals generally receive

children on the older end of the spectrum. It is a common opinion that parents of adolescents

think of their children more as young adults rather than actual children, thus it is common for a

parent to take their adolescent to a regular hospital.

Procedures

I would recruit participants from a local children’s hospital that allows for research to be

done by first completing any required research training and submitting my proposal to the

hospital’s IRB. I would recruit participants from local regular hospitals in the same manner as

the children’s hospital, but I would examine ethnic and socioeconomic patient demographics

before establishing which two hospitals I would utilize for this study. While submitting the

proposal to each hospital’s IRB, I would also submit the proposal to the university’s IRB. After

gaining each board’s approval, parental consent would be obtained, as well as participant consent

for participants 11 and older.

The study involves conducting assessments in less than one hour per patient over the

course of two days. The researcher will spend one day visiting patients at the children’s hospital

who have experienced the Child Life intervention program and one visiting patients in two

different local hospital pediatric units that have not experienced any part of the Child Life

intervention program. All patients between the ages of 8 and 10 will be read the various

assessments by the researcher to ensure that they understand and that the questions are not being

asked in a biased or leading manner. Assessments utilized will include parent/guardian


completion (or nursing staff completion if child does not have visitors often) of the Child Social

Preference Scale (Coplan, Prakash, O’Neil, & Armer, 2004) and patient completion of the Illness

Self Concept Scale (Morea, 2006), the Personal Efficacy Beliefs Scale (Riggs et al., 1994), and

the Pediatric Pain Coping Questionnaire (Reid et al., 1994). All of the participants will have their

name put into a drawing to win an iPad Mini that will take place at the end of the day after all the

day two assessments are done in exchange for their participation in the study.

Measures

The Child Social Preference Scale was derived from previous research related to shyness,

sociability, social withdrawal, and social disinterest (Coplan et al., 2004). The person or people

that surround the child answer each item based on how much the child is like that on a scale from

1 to 5, 1 being not at all and 5 being very much so.

The Illness Self Concept Scale will measure the extent to which the child’s illness is

central or peripheral to themselves, while reflect three sub-constructs: directionality,

pervasiveness, and illness self-conscious (Morea et al., 2008). The assessment will consist of

numerous statements that the participant will rate on a scale of 1 to 6, 1 being strongly disagree

and 6 being strongly agree, for central statements. For peripheral statements, strongly agree will

be 1 and strongly disagree will be a 6. All of the individual ratings will be added together to give

each respondent a single score. If the children have a poor illness self-concept they will have a

higher score in that they will rate all of the statements with a higher number.

The Personal Efficacy Beliefs Scale is a questionnaire that involves positively and

negatively worded items that was designed to be consistent with theoretical definitions of

personal efficacy (Riggs et al., 1994). The scale will include an introduction that directs

participants to refer to their own hospital setting when rating each item.


The Pediatric Pain Coping Questionnaire is a self-report instrument consisting of 39

statements that represent eight different subscales, or coping strategies, and are possible

responses to the prompt, “When I am hurting or in pain for a few hours or days, I…” (Reid et al.,

1994). Respondents gave a rating of 1 to 5, 1 being never and 5 being very often, to indicate the

degree to which they experience each statement. All of the individual ratings will be added

together to give each participant a single score; higher scores mean more coping strategy usage

and, thus, better coping abilities.

Data Analysis Plan

The Statistical Package for Social Sciences (IBM Corp., 2011; SPSS version 20.0,

Armonk, NY, USA) will be used during data entry and data analyses. Descriptive statistics will

be utilized to examine mean-level gender differences. Mean-level differences in the study

variables between the Child Life Program group and the no program control group will also be

examined. Correlation coefficients and effect sizes will be observed to establish associations

among coping, social withdrawal, self-efficacy, and illness self-concept.

Discussion

The findings would add valuable knowledge to the psycho-social impact of Child Life

intervention programs being that it is rare to find research done that examines entire Child Life

intervention programs on solely their psycho-social influence. Although, Child Life Specialists

have been around for many years, very few know the difference that Child Life Specialists make,

much less the official title (McDonald, 2001). Thus, any theoretical knowledge is helpful to

support and validate current programs to outside people that do not understand the influence that

Child Life Specialists have. The pediatric health care workers that come in contact with Child

Life Specialists view the specialist’s responsibilities differently (Cole, Diener, Wright, &


Gaynard, 2001). Nurses and other health care team members often consider amusement and

entertainment to be a large responsibility of the specialists, while they view other actual

responsibilities, such as patient and family support, to be hardly responsibilities at all (Cole et al.,

2001). This represents the struggle between Child Life Specialists and their co-workers; they are

salary workers that don’t bring in any money to the hospital, but rather require money and

donations to do their job, and are often misunderstood by their colleagues. Providing health care

workers with a more in-depth look at the psycho-social impact that Child Life Specialists make

could have immense practical implications in that it could give hospital administrators the final

push they need to support the creation of an intervention program in their own hospital being

that, out of the thousands of hospitals in the nation, there are only about 400 Child Life Programs

(“Commonly Asked Questions about the Child Life Program”, 2015). Future research could

encourage this step by administrators by examining Child Life work and attempting to quantify

the value of the work they provide so as to present a cost-benefit analysis to the administrators

(Tyson et al., 2014).

The largest limitation of this study is that it doesn’t provide current Child Life Specialists

with any new techniques or methods they can utilize to improve their existing programs. Another

limitation is that it does not evaluate the psycho-social impact made by individual parts of the

program, such as play therapy, expressive therapies, or pet therapy. Future research examining

this would be different than past research examining a single therapy because the point of it

would be to examine the single therapy as it is used by a Child Life Specialist while controlling

for the other forms of therapy they utilize. This would be ideal for future research in that those

findings could help to improve individual therapeutic parts of the program that are not having a


substantial psycho-social impact, which could lead to further, more specific research on

therapeutic methods utilized by a single therapy.


References

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