reper research proposal
TRANSCRIPT
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.
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE3
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
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE4
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.
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE5
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.
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE6
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
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE7
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
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE8
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
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE9
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
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE10
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.
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE11
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, &
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE12
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
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE13
substantial psycho-social impact, which could lead to further, more specific research on
therapeutic methods utilized by a single therapy.
PSYCHO-SOCIAL DIFFERENCES AND CHILD LIFE14
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