1. Building Rapport with Children AND Preparing and Assisting the Child and Parent/Caregiver During and After the SANE Exam
Julie Fonferek
Certified Child Life Specialists - Children’s Hospital of Wisconsin, Milwaukee Child Advocacy Center
Office Number:

2. Child Life Services
“Child life specialists are trained professionals with expertise in helping children and their families overcome life’s most challenging events.”
Child Life Council, 2010
We support children and families by promoting positive coping through play, self expression, preparation and education.
Who has heard of CL before?
Ever worked with a child life specialist?

3. Child Life Specialists (Child Life Council, 2010)
Are experts in child development
Promote effective coping through play, preparation, education, and self-expression activities
Provide emotional support for families
Encourage optimum development of children facing a broad range of challenging experiences, particularly those related to healthcare and hospitalization
Provide information, support and guidance to parents, siblings, and other family members
Play a vital role in educating caregivers, administrators, and the general public about the needs of children under stress
Therapeutic Play
Preparation for procedures
Medical play
Procedural support
Sibling support
Family support

4. Child Life Specialist in SANE Exams
Prepares children for physical/sexual abuse exams in an age-appropriate manner and provides support/distraction during exam.
Allows parents and children to ask questions to promote further understanding of their visit or exam.
Provides emotional support to encourage positive coping with CAC visit.
Provides distraction and therapeutic play for patients to help alleviate the stress and anxiety of the visit.
Normalized play

5. Raise your hand if:
You have ever been bullied or known someone who was bullied.
Keep your hand up if you told someone.
Who here has ever been bullied?
Who told?
Why did you tell?
What made you comfortable to disclose that information?
Characteristics of the person you felt comfortable telling?

6. Now think about your most recent sexual experience…
What would it be like to share every detail of that experience?
Could you memory allow you to recall those details?
Why would you tell?
Who would you tell and what would make you comfortable to tell that person?
Now what if that was your first sexual experience?
What if it was a traumatic one?
What would it be like for you to recall those details with those new barriers or would you be reluctant to disclose?

7. Building Rapport with Children
This past weekend a student asked me, how do you build rapport with children so quickly and then jump into the work you do?
Time for my response:
Getting down to their level, taking the time to listen, and conversation can go a long way. It doesn’t always have to be long interactions with a lot of play. Can be the short, meaningful conversation while walking to the exam room.

8. Therapeutic Play
Purpose is to meet the social and emotional needs of children and families
Decreases stress and increases coping and mastery of hospital experiences
Includes: creative activities, diversional play, health care play
Therapeutic play VS Normalization/diversional play
Setting up the environment where the child's wait that is inviting can start to do this without much staff interaction.
Do you have an environment that is welcoming to children?
Have you ever sat on the floor to see the space from a child’s perspective?
What simple things do you have or could you have to make a child feel welcome and more comfortable?
Play is a language of itself and no matter what language spoken, or if the child is verbal or delayed, play is a universal language.

9. Communicating with the Pediatric Patients
Ability to process information may be impaired when in a stressful situation
Cognitive ability and verbal communication skills less well developed than adults
Language should be:
- accurate
- age appropriate
- minimally threatening
Trauma Slide
Reference activity and connect to how it felt to recall information that may have been sensitive to you and imagine that as a child and how blurry that information can be when it is a traumatic event.

10. Communicating with Infants
Erikson’s Trust vs. Mistrust: learning if whether basic needs can be met
Smile
The more comfortable you are the better, children can sense how you are feeling
Overstimulation: Infants are absorbing the world around them be sure not too many senses are being used at once.

11. Communicating with Toddlers
Erikson’s Autonomy vs. Shame and Doubt: learning sense of independence, allowing them to make choices and explore
Smile and get down to their level
Use simple language or ask short questions with choices and give time for a response

12. Infants/Toddlers and Stress
Separation from caregiver can trigger stress
When a toddler feels frightened, stressed or insecure they will respond by:
Turning body away
Crying
Saying “no”
Avoiding eye contact
Kicking and biting
Egocentric world so bringing it back to them and how they can help you may help you find more success.

13. Communicating with Preschool Children
Erikson’s Initiative vs. Guilt: Giving the child spontaneity and opportunity to do on own. If disapproval is given the child will give up and feel guilt.
Learning more concrete thinking and still in Piaget’s Preoperational Phase: magical thinking. Learning the skills of logical reasoning and the idea of symbolism.

14. What do you think of when you hear stool collection?

15. Preschoolers and Stress
Unfamiliar situations may trigger stress
May stall to gain control
“Just wait a minute.”
May cry, groan, whimper and whine
May try to escape or hold themselves absolutely rigid while being treated.
May turn away, kick, flail, bite, scratch, frown, clench their teeth, or shut their eyes.
If bleeding they may become very upset and want to know why and what’s going to happen.
Obviously, you can’t always wait when requested. If you are able to talk the child through what you are doing and continue to move ahead with your intervention do that. Sometimes waiting is just not an option, but if you can work through the situation with them to help them understand what you are doing that is the best option.
Give choices when available to give the child the sense of control

16. Communicating with School Aged Children
Erikson’s Industry vs. Inferiority: Being skillful and approved by those around you vs. not being good enough and not encouraged by those around you.
Seeking approval by the group and creating groups and clubs while becoming a little more competitive

17. School-Age and Stress
May be triggered by loss of control, want to be involved, need honest and accurate information, emotional support, may regress
Kids love to learn new words.
They want to know what a colposcope is all about.
They want to understand special vocabulary.
May attempt to gain control through bargaining or delay tactics, while trying to appear brave.
Will attempt to gather information about the elements of their care.
Will talk more about medical terminology and choosing language later in presentation.

18. School-Age and Stress
Exhibit the same verbal and nonverbal behaviors as younger children
Are able to use specific words to acknowledge pain, and express fear and anger.
Bodily contact important (having hand held, being touched gently, gladly accepts help)
Some kids this age may regress during times of stress
Sucking thumb, biting nails
Doesn’t mean they are babies, just means they are looking for security
Remember the population you are serving though. Important to always ask for permission.

19. School-Age and Stress You can lessen initial fears by:
Maintaining a friendly, reassuring attitude and always remember to be HONEST and ACCURATE when telling the child what you are doing.
You want to make sure to gain their trust!
Often times this age group thinks that their illness or accident is a result of something they did wrong. The most important thing we can do is help them understand that they are not to blame for what has happened.

20. Communicating with Adolescents
Erikson’s Identity and Repudiation vs. Identity Diffusion: learning identity and who they are as individuals.

21. Adolescents and Stress
Talk to them not over them, want their opinions listened to and recognized
May not always be able to abide by their wishes, but important to allow them to express selves and feel heard and have some control over the situation
Include them in conversation if possible
If talking to parents in another area come back and tell teen what was discussed
You don’t need to include everything, but at least acknowledge that you talked to their parents
Teens are at the stage during healthcare experiences where they may feel neglected. Sexual relationships are on their mind and how the circumstances may affect relationships in the future. Self conscious of what peers will think

22. Adolescents and Stress
Teens are especially concerned about self-image
They may want to know whether you can tell if they are still a virgin…be honest!
Modesty is a big factor. If exposed try to cover them up if at all possible.

24. Preparing and Assisting the Child and Parent/Caregiver During and After the SANE Exam

25. Describe what that was like? How did that make you feel?
Activity
Describe what that was like?
How did that make you feel?
Need two volunteers. Have one sit up front the other can come up after.

26. What is Preparation? “The communication of accurate,
developmentally appropriate information in
advance of an experience.”
~Gaynard (1998)

27. Goals of Preparation Reduce fear and anxiety
Promote long term coping and adjustment to future health care challenges
Important to assess patient prior to procedure
Preparation must be individualized
(Child Life Council Evidence-Based Practice Statement Summary: Preparing Children and Adolescents for Medical Procedures, August 2007)

28. What Does the Evidence Tell Us?
“Participation in a preparation program has been shown to reduce significantly the negative psychological sequelae experienced by children both immediately before and after the procedure and for up to a month later.”
Child Life Council Evidence-Based Practice Statement Preparing Children and Adolescents for Medical Procedures –Submitted by: Donna Koller, PhD, Academic and Clinical Specialist in Child Life, Hospital for Sick Children, Toronto, Ontario, Canada
Child Life Council Evidence-Based Practice Statement
Preparing Children and Adolescents for Medical Procedures
Submitted by:
Donna Koller, PhD
Academic and Clinical Specialist in Child Life
Hospital for Sick Children
Toronto, Ontario, Canada

29. Assessment: Key Considerations
Age/developmental level
Personality
Ability to cope with new situations
Prior healthcare experiences
Diagnosis/complexity of the procedure
Family support system
Cultural considerations
Key questions to ask: Have you been to a doctor before? What helps you when you are sad or upset? Who is here with you and how can they be involved?
Create that coping plan up front.

30. Preparation
Preparation provides structured interventions with specific objectives
Tools used in preparation:
- pictures
- dolls
- books
- medical equipment

31. Preparation Give the child a complete scenario during the appointment
What’s going to happen during pre-exam
What the next steps will be
Whether you’re going to move him/her
What’s likely to happen during the exam
If they know what is going to happen they can begin to cope!
Can use stress point preparation as well!

32. Preparation
Provide sensory information to prepare the child about what happens next.
Use phrases like: First we will….. Then we will…..
We are to go to an appointment and while we wait there you can play with the toys and talk to some nice people.
You are going to meet a lot of people today it is important you answer their questions the best you can.
Talk with children about what they will see, feel, hear, smell and taste during their experience.
Be as honest as possible, especially when the child ask

33. Preparation Provide accurate, complete information Use softened words
Avoid using too much detail
Ask the child to describe what they think will happen
Medical terms should match a child’s age/developmental level
Provide children with choices
Encourage the child to play an active role
(Stanford, 1985)

34. Considerations in Choosing Language
Words with dual meanings can be confusing
Check in with the child to assess understanding
Be sensitive to each child and their learning needs
Let the child judge their experience
Can you think of any dual meaning words? IV vs IVY, SWAB vs QTIP, STURIPS vs FOOT HOLDERS,
Asking the child: What do you think will happen?

35. Misconceptions
Ask children what they think is going to happen. Children often misinterpret things they see or overhear.
If their perceptions are inaccurate, gently explain what will actually occur, in terms they can understand.
Determine role of parents/healthcare providers
Create coping plan

36. Techniques -Choices Give choices when choices are available
Would you like to sit on the table or the chair?
Would you like to bring your stuffed animal back with us when you have your check up or leave it here until we are done?
Would you like me to look in your left ear or your right ear first?
We have to go for an appointment and when we get there you get to choose if you want to sit in the chairs by me or play with the toys.
Avoid statements that start with “can you”

37. How would you prepare a child?
What are the steps to the exam?
What words do you use that a child may not know?
What are some things to keep in mind for infants, toddlers, preschoolers, school aged and teens?

38. What I say… Infants Typically nothing.
I do prepare parents if present.
The more calm a caregiver is the better and when under stress simple preparation for them can be helpful.

39. What I say… Toddlers I prepare toddlers in real time
I show the item then the medical staff does uses it

40. What I say… Preschool
Today I will be looking at your skin from your head to your toes, looking at your arms, legs, back, and belly to make sure your skin is healthy.
The last part on your skin I will look at is where you go pee and poop from.
When I do this part of the check up I will have you sit a special way making butter fly legs. You do this by laying down and putting your feet together and letting your knees fall to the outside.  Would you like to try?
Sitting like that helps me to see better. Another tool that helps me see better is this big light. It shines on your skin and makes everything look bigger. This light doesn’t touch you or hurt it will shines on the part of the skin I would like to see better. 
You will feel my hands touching to move the skin around to help me see better.
When I am checking your private parts I will use something that looks like a Q-tip.  The q-tips has a longer handle so that our I don't drop them. I will rub it on the outside of your skin by your private area to make sure there are no germs.  Some kids tell me it may feel a little cold and wet and tickle a little, can you tell me after what it feels like? 
While I am looking what would you like to play with? Look at a book or check out a ball I have?
When I am done looking you can sit up and I will do one last tickle in your throat.  It is real quick.
After the check up I will leave the room to give you privacy to change back into the clothes you came in. 
Education on private parts and what to do if someone touches you.
Qtips not swabs
Big light not colposcope
No germs instead of infection

41. What I say… School Aged
Today I will be looking at your skin from your head to your toes, looking at your arms, legs, back, and belly to make sure your skin is healthy.
The last part on your skin I will look at is the private parts on your body where you go pee and poop (or where your underwear covers).
When I do this part of the check up I will have you sit a special way making butter fly legs. You do this by laying down and putting your feet together and letting your knees fall to the outside. 
Sitting like that helps me to see better. Another tool that helps me see better is the colopscope.  This is a machine that shines on your skin and makes everything look bigger. This light doesn’t touch you or hurt it will shines on the part of the skin I would like to see better. 
You will feel my hands touching to move the skin around to help me see better. Nothing during your check should hurt or feel uncomfortable and if it does tell me and I will stop and readjust. 
When I am checking your private parts I will use something that looks like a Q-tip.  The only difference from the q-tips you have at home is the ones here have a longer handle so that our I don't drop them.  A little water will be put on the Q-tip and then they will rub it on the outside of your skin in your private area to make sure there are no germs or infections.  Some kids tell me it may feel a little cold and wet and tickle a little, can you tell me after what it feels like? 
When I am done looking you can sit up and I will do one last tickle in your throat.  When I am done I will leave the room to give you privacy to change back into the clothes you came in. 
After the check up I will leave the room to give you privacy to change back into the clothes you came in.

42. What I say… Teenager
Today I will be checking your body to make sure it is healthy.
I will look at all the skin on your body including your genitals.
When I do that I will use a colposcope that is a light to magnify the area to help see better. The light doesn’t hurt and won’t touch you.
I will use Qtips and touch the areas by your genitals to check for infections.
Nothing I do should hurt, if it does please tell me so I can stop and readjust as needed.
Embarrassment factor

43. Procedural Support Work with patient to develop coping plan
Provide tools for distraction
Support of child during procedure with encouragement
Stress point preparation throughout

44. Techniques -Directives
Provide positive reinforcement throughout the visit.
I really like how you are using your walking feet, thank you.
You are doing a great job talking to me today.
Thank you for following directions today.
Use positive directives.
You need to use your walking feet so you don’t fall and get hurt.
The ball is rolled inside and we are inside.
Avoid using negative words like don’t, stop, no, I’m sorry
I’m sorry –you didn’t do anything wrong. You need to do the check up. You are helping them.

45. Choosing a Distraction Method
Note age/developmental level
Use parents as information source when choosing tools for distraction
Talk with the patient and offer choices
Distraction helps to give the child something to focus on/control during procedure
Give parents or caregivers a role
Show distraction items

46. How would you distract?
What is already available or could you easily get?
What items on this distraction card you could you have a child find?

47. Positioning for Comfort
Child Sitting Alone
Child feels sense of independence
Child can see distraction item

48. Positioning for Comfort
Parent or caregiver holding
Child being held by someone familiar
Caregiver is mainly touching the child not the medical provider
Child can see distraction item

49. Positioning for Comfort
Other position options
Distraction can still be used
Comfort can be provided as little or as much as the child needs

50. One Voice http://childrensomaha.org/body.cfm?id=210
One voice heard during procedure
Need for parental involvement
Education patient beforehand about what will happen
Validate with words
Offer comfortable, non-threatening position
Individualize plan according to patient’s needs
Choose appropriate distraction
Eliminate unnecessary staff not actively involved in procedure
With all the distraction going on. Important to watch child’s cues and minimize over stimulation.

51. One Voice Sensory Overload Hyper vigilant
Sensory Overload: Think about what you are doing in the room. Is there a RN or MA opening supplies? Is more than one person talking at a time? Are you doing something while explaining or doing what you are explaining at the same time?

52. Resources Child Life Program www.chw.org/childlife
“A Guide For the Caregiver of the Hospitalized Child”
“Helping Kids and Teens Understand Medical Language”
One Voice
Positioning for Comfort
Best Distractions JIT
Comfort Care JIT
About Child Life (Child Life Council)