Addressing Social Determinants of Health Through Child Life Practice

ACLP Bulletin  |  Winter 2023  |  Vol. 41, No. 1


  • Kristin Brown, CCLS, Nemours Children’s Hospital, Florida
  • Nicole Gandolfo, MA, CCLS, Child Life Manager, Nemours Children’s Hospital, Delaware
  • Jenna Read, MS, CCLS, Supervisor of Child Life and Creative Arts Therapies, Nemours Children’s Hospital, Florida
  • Jana Teagle, CTRS, CCLS, CBIS, Senior Child Life Specialist, Nemours Children’s Hospital, Delaware
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Photo provided by Katie McGinnis
Photo provided by Katie McGinnis during the 2022 ACLP Bulletin photo contest.

As the topic of social determinants of health (SDoH) is becoming a more widespread discussion in healthcare, and clinicians begin to self-reflect and examine their practice to see how they can best address this need while supporting the whole patient, we must do the same in our field. It is a natural step to see the correlation between the skillset of child life specialists (CLS) and providing support for more widespread family psychosocial issues. SDoH include Adverse Childhood Experiences (ACEs), such as divorce, parental mental illness, bullying, substance abuse, emotional neglect and/or abuse, physical neglect and/or abuse and Health-Related Social Needs (HRSNs), like poverty/financial need, homelessness, unemployment, and hunger or food insecurity (Bottino et al., 2019). As child life specialists, we must first ask ourselves what, if anything, are we currently doing to address these crucial psychosocial issues? And second, how can we use the skills and competencies we pride ourselves on to be of better support in building the healthiest generation of children and teens?

Many of the children and adolescents who receive child life services can be classified as being “at risk” with regards to their physical and emotional health due to previously identified psychosocial stressors, ACEs, and social determinants. Masten and Barnes (2018) noted that singular adversities are rare, as the most severe forms of childhood adversity often reflect chronic, repeated, or combined exposures to traumatic events or hardships. Growing evidence links ACEs and other social determinants to risky health behaviors and other negative outcomes, including chronic health conditions, low life potential, poor learning capacity, and early death (Rollins et al., 2018).

Given the role of CLSs in supporting patients through stressful healthcare experiences, it seemed reasonable to question whether this role extends to family psychosocial issues and SDoH. Bottino et al. (2019) examined the frequency at which CLSs specifically address ACEs and HRSNs and if/how they provide support to patients who experience these. Eighty-five percent of 110 Certified Child Life Specialists (CCLS) surveyed reported addressing these family psychosocial issues at least once a month. CCLS respondents reported providing clinical services to support SDoH including coping strategies, family support, therapeutic play, psychological preparation, and distress management. Most respondents in the study reported that they gave equal or even higher priority to providing SDoH support as they did to medical procedures. One CCLS respondent said “I believe addressing psychosocial issues [SDoH] is an underrated part of the child life scope of field. Many times, the focus is on procedures and coping strategies, but family dynamics can directly affect how a patient does during hospitalization” (Bottino et al., 2019, p 854).

CLSs are astutely aware of how household stressors may impact feelings of shame, anger, worry, or helplessness in children. Additionally, these feelings don’t always derive from the stressor itself but instead come from the internalization of parental stress and worry. When harbored, these feelings can directly affect a child’s hospitalization and ability to cope with medical stressors not only in their present hospitalization, but also in their future. CLSs can facilitate the necessary emotional expression to learn problem-solving skills and identify coping techniques that children and families can transfer to stressors outside of their healthcare experience, such as homelessness, food insecurity, or other psychosocial concerns.

It can be hypothesized that one reason CLSs are readily able to provide support to patients impacted by social determinants of health is due to their status as a non-billable service. It should be noted that Principle 11 in the Child Life Code of Ethics states, “Certified Child Life Specialists recognize that financial gain should never take precedence over the mission, vision, values, and operating principles of the profession” (Association of Child Life Professionals, 2020). Child life programs do not bill for services provided within the hospital and therefore remain an accessible service to all patients and families, regardless of socioeconomic status. Despite the availability of child life support in most pediatric hospitals, it must be acknowledged that these services may not always be available to all pediatric patients. Limitations in staffing and resources may be potential barriers to accessing child life services, which may have greater impact to communities that are already under-resourced.

Children and families impacted by health disparities and adversity may also benefit from child life services outside of the hospital walls. Just as preventative healthcare is essential, preventative education surrounding psychosocial health and well-being is equally vital to children and their families. CLSs remain in the position to utilize community visits as an opportunity to encourage and facilitate understanding of the importance of accessing healthcare, while also promoting protective factors, such as resilience, in a variety of ways. The scope of child life practice ideally positions specialists to support
families in their caregiving roles and build on caregiver knowledge about their child’s health and development. In the primary care setting, CLSs can educate parents on the importance of identifying risk factors and/or stressors in the lives of children and teens, while also nurturing lifelong capacities
for health and well-being by identifying and promoting protective factors such as preferred coping techniques and supportive relationships where youth can seek out mentorship and help.

Together, as a profession, we must think beyond the traditional medical setting and envision how we can support patients, families, and providers in community settings to improve long-term patient health outcomes. CLSs can get involved in community outreach opportunities, such as mobile vaccine clinics, where they can teach easily accessible coping techniques to children and adolescents who can implement these strategies to make future healthcare experiences less scary and more comfortable. Additional activities, such as holding a community-based teddy bear clinic in your local library, can increase health literacy by allowing CLSs to provide preparation and medical play, fostering a positive association with healthcare experiences, reducing fear of the unknown, and likely increasing compliance with preventative care. Another non-traditional point of access to provide support to children and their families would be through educational settings where child life specialists can partner with school nurses, health educators, and school counselors. CLSs already conduct school re-entry programs for many patients, and these visits can present opportunities to teach the class basic health literacy.

Photos provided by Katie McGinnis

Photo provided by Katie McGinnis during the 2022 ACLP Bulletin photo contest.

One example of child life positively impacting SDoH is a grant-funded connection between a hospital child life program and an underserved pediatric primary care population in Wilmington, Delaware. The Children’s Hospital Association, in partnership with the Toy Foundation, awarded $25,000 to child life specialists at Nemours Children’s Hospital, Delaware with the goal of strengthening the social, emotional, physical, and behavioral development of children by making play more accessible. The grant focused on utilizing play-based opportunities to bridge the health equity gap through the lens of health literacy and increasing coping with stressful medical events in a community setting. The CLS collaborated with a community primary care team to assess the specific needs of their patient population. Medical play opportunities were provided for children and families to gain comfort and familiarity with stressful healthcare events. The families received kits that were specific to asthma, dental hygiene, eczema, and/or general coping. Each kit had both real and play medical paraphernalia, coping items, tip sheets for caregivers, and a QR code that linked to additional coping strategies and targeted medical play videos. Funding was used to provide developmentally appropriate bibliotherapy resources for the clinic to provide to continue fostering health literacy. Families were provided with contact information for the CLS and asked to share their feedback via simple survey questions. Families responded positively to the kits, with one parent directly reporting that her child coped more positively with her diagnosis after receiving the materials. Other outcomes included better understand of dental hygiene, pinwheels helping children cope with stressful healthcare events, and improved comfort with stethoscope use due to medical play materials.

The importance of establishing a foundational connection between psychosocial care professionals and healthcare providers is paramount. To accept the World Health Organization’s definition of health as a state of physical, mental, and social well-being leads to the understanding that health literacy and resilience must derive from stronger health care systems; improved population health; and developing capabilities to sustain physically, mentally, and socially healthy individuals and communities (Wulff et al., 2015). With the combined support of healthcare professionals, families, and other social connections, children and adolescents can appropriately overcome stressful situations (Pettoello-Mantovani et al., 2019). In extending our collaboration to include key community partners, such as pediatric primary care, public libraries, and schools, child life specialists incorporate our training, sometimes without noticing, as we work to mitigate some of the disparities in the current healthcare system. The end goal for child life specialists remains to not only be able to recognize the difficulties and barriers that our patients and families face, but to continue educating, advocating, and collaborating to address the need for protective factors and provide services and resources that have lasting impacts outside of the hospital system.
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