The Eric Hartwell Foundation

Do you remember when you were a child and you woke up on a summer morning with an entire day spread out before you? And do you recall the excitement and joy of letting that day unfold and filling it with play - creative, imaginative, and spontaneous play?

Experts in such things pretty much agree that play is an important part of health and development. And it's not a new idea. Even Plato observed that you can tell more about a person in an hour of play than in a year of conversation.

But what is the value of play when a child is ill, subjected to countless medical procedures, and just doesn't feel like playing? The answer: Combining the two can be an empowering and therapeutic prescription.

Play can provide a healthy outlet for a child's anxiety. Play time, both structured and spontaneous, gives children an opportunity to escape from the constraints of a physically demanding regimen and allow their imaginations to soar. Play also allows the child a sense of mastery and control. While in treatment, the child is often the passive follower. But it is in play that he or she can take control, create the story, and call the shots, literally as well as figuratively.

Sheila Morris, Meg Rescorla, and Jenni Gretzema, have witnessed it time and again. All are Certified Child Life Specialists (CCLS) with the University of Michigan Comprehensive Cancer Center and C.S. Mott Children's Hospital where they work with children and adolescents to ensure healthy development, even during illness and treatment. Their group is comprised of ten Child & Family Life professionals who are members of the Pediatric Hematology & Oncology health care team.

The process begins at diagnosis, often before treatment actually begins. The challenge is to prepare the child and family for treatment and identify coping strategies before difficulties arise. Planning is an integral part of caring for the child. The program goal is for the entire family to come out healthy, recognizing that siblings can also feel confused, isolated, and afraid.

"We're here to help both the child and the family cope by supporting them throughout their medical experiences," Sheila explains. "Our team is very aware that childhood should be a growth-focused, spontaneous, creative, and fun time for children, and we try to preserve as much of that as we can as the children and their families confront the challenges of illness and treatment."

The Child & Family Life Program at C.S. Mott was established in 1922, one of the first such programs in the nation. Over the years, the program has expanded from a hospital school and activities focus to a comprehensive range of Child & Family Life services that includes all pediatric specialties.

"Medical play therapy gives the children opportunities to master their experiences," explains C.S. Mott's Child Life Specialist Jenni Gretzema. "Often these children feel they have no control over what's happening to them, and the play interventions provide many insights and coping techniques."

One of the ways to address the stress and anxiety of treatment is through medical play therapy, with dolls as patients and the child patient taking the role of doctor.

Jenni recalls a six-year old boy who was so terrified of his frequent Neupogen shots that he would build a fortress of his IV poles to hide behind when it was time for the shots.

"He was upset, scared, and angry," recalls Jenni. "So we worked on the shots with the doll and devised a coping plan for him. He became quite receptive and did great. Some time later I was called to his room for a demonstration. And I was overjoyed to see him give himself the shot! He had successfully embraced his own power."

The CCLS role requires seeing the treatment from a child's perspective, clarifying the misconceptions and fears that accompany treatment. An I.V., for example, can conjure up images involving the "eye" in a child's mind. And what would a small child imagine a CAT scan to include but cats!

The medical play box includes dolls complete with various catheters, ports, and lines, and felt bones that zip open to help children understand about bone marrow and where blood cells are made. The kit also includes toy comforts like magic wands, bubbles, and squeeze balls to help the child cope. Games like medical bingo can also help the child better deal with the medical environment.

Child Life Specialists also use deep breathing, guided imagery, and visualization to help lead children through difficult experiences. Images are the language that the mind uses to communicate with the body, and children as young as four or five are able to use this technique to eliminate stress. In younger children, distraction is a valuable tool, whether auditory, as in hearing bells ring; visual, as in watching someone blow bubbles; or tactile as in squeezing a ball or a lump of clay.

The requisite skills of the CCLS are comprehensive when one considers that pediatric patients can range from infancy to young adult, with each young person requiring age-appropriate and individualized techniques and approaches.

Bethany Russell, Certified Child Life Specialist at Children's Hospital of Michigan, has utilized that scope of techniques many times as well. Her job, like that of her colleagues at the University of Michigan, is working with children in a healthcare setting to help children understand their bodies and the procedures they must undergo.

"Medical play therapy helps increase their understanding of the medical procedures they must undergo," explains Bethany, "and that understanding increases their ability to cope."

The Child Life team at Children's Hospital employs a mixture of guided and free play to inform children about their treatments and healthcare related topics. General topics include explanations of medical procedures like ports, catheters, shots, blood draws, and I.V.s. Specific topics might include dealing with adjustments to hair loss or loss of limbs.

"Our approach is very specific, depending on the child's needs," says Bethany. We provide dolls of every combination of physical traits and then allow the child to select one of the dolls to experience what the child will experience. Most of the time, children will select the doll most similar to themselves.

"To overcome fear, for example, we use needle play, allowing the child to actually give the doll a 'shot' of saline and food coloring to see how it's done. By letting them use the needles themselves, we let the child take control and take the lead in a therapeutic manner. It's a powerful tool."

Bethany also uses medical teaching toys accompanied with descriptions that children can relate to, including the felt bones and red and white blood cells that are distinguished by "good guy/bad guy" labels.

And like CLF and the University of Michigan staff, Child Life Specialists at Children's Hospital treat not just the patient but the entire family. Siblings are especially vulnerable in serious medical situations, and the goal of the CCLS is to make the medical environment a safe and comfortable one for the whole family. Additionally, when the family is able to cope, it is beneficial to the patient as well.

The biggest challenge, according to Bethany, is that there are so many variables case-to-case, including the wide age span, all of which require a highly specialized skill set.

"We really have to be able to carefully observe everything," she says. "We need to be able to anticipate their questions and apprehensions and deal with them appropriately. For example, a common fear during transfusions is the possibility of 'popping.' In other words, you're putting all that fluid in and it's not coming out anywhere. Won't I just 'pop?'

"Even the words healthcare professionals use can pose problems. I once heard a medical professional speak in front of a patient about 'yanking' out a catheter. To a child (or even an adult) that can be a terrifying prospect. Our job is to communicate with the patients on their level and to help them understand.

"Children can be incredibly honest, and we don't lie to them. I don't tell them it's not going to hurt, but rather that I'm there to help them through the hurt. Our goal is to provide every child our special attention. Because that's what every child deserves."

According to C.S. Mott's Sheila Morris, the ultimate goal is to make them open up enough to want to "take you along on their adventure" until eventually, the child and their siblings will actually look forward to coming in for medical visits.

"But first you must find that opening that allows you to gain their trust. Once you do that, you open the door to go forward together."

These Child Life Specialists and other professionals are there to preserve the joys of childhood that every child indeed deserves, no matter how daunting the challenges. And the Child Life Specialist's skills and compassion are an important component of the healing process.

Some might say the most important of all.