Preparation books, including those printed, electronic, or on an iPad, can also help to describe the steps of upcoming procedures and encourage dialogue about any concerns or questions that a child may have. Younger children may feel less threatened by illustrated images or photos of a stuffed animal undergoing the procedure, while older children may respond better to photos of a child their own age. To ensure comprehension and to minimize potential misconceptions, it is helpful to ask patients to share their questions, to repeat the steps of the procedure, and to identify their role in the process, for example, to hold their arm as still as a statue. In addition to understanding a child’s learning style, coping strategies must also be assessed and understood as a continuum as a child may respond differently to various stressors over time (Kuttner 1996). See Chap. 5 on coping for details. Children who utilize a problem-oriented coping strategy would be more likely to participate in preparations where they generate their own questions; whereas, children with an emotion-oriented coping style may call upon denial tactics or silence (Salmela et al. 2010; Li et al. 2011a). While research suggests that problem-focused coping tends to be more effective for patients, it is important to utilize interventions that reflect each child’s needs, comfort level, and ability to engage in the intervention.

In addition to creating pleasure and joy, play can assist children as they prepare for and reenact stressful or threatening medical experiences. Children who engaged in a therapeutic play intervention prior to day surgery demonstrated decreased anxiety scores and emotional behaviors both pre- and postoperatively (Li et al. 2011b). Medical play is a powerful tool that can help children process their treatment journey prior to and following procedures. The goal of medical play is to increase communication, self-expression, preparation, familiarization, and reflection in a developmentally appropriate manner. Medical play provides opportunities for children to practice the steps of a procedure on a doll (role rehearsal/role reversal); engage with symbolic, real, or play medical equipment (medical fantasy play); use medically themed games or puzzles (indirect medical play); or manipulate medical supplies through expressive painting, sculpting, or collage (medical art) (Goldberger 1984). By facilitating educational opportunities in a supervised, nonthreatening environment, psychosocial clinicians can help to reduce the child’s fears surrounding their treatment.

Examples of medical play dolls include blank muslin dolls that children can personalize or teaching dolls that are specifically designed for children with cancer. These include Gabe’s Chemo Duck Program™ and Shadow Buddies™ which teach children about ports or central lines. With guided supervision, children can practice port accesses or lab draws on their dolls using play or real medical equipment to increase familiarity and empowerment.

In addition to these medical play materials, Cuzzocrea et al. (2013) found that significant reductions in anxiety can occur following preparation using puppets and storytelling, involving exploratory opportunities with relevant medical equipment, and having a supportive adult present during procedures to remind children of their practiced coping techniques. Preparation, in addition to the use of distraction tools, was most effective in increasing adherence and reducing anxiety compared to distraction alone (Cuzzocrea et al. 2013). Role play and preparation techniques have also been found to increase understanding of what to expect during procedures, reduce fear in younger children, reduce anxiety in older children, and increase overall satisfaction (Hatava et al. 2000).

Providing the opportunity to practice coping strategies through developmentally appropriate procedural education prior to surgery has been shown to minimize the child’s and family’s anxiety as well as increase coping ability (Fein et al. 2012). Such interventions can also foster trust, reduce uncertainty, correct misconceptions, enhance self-efficacy, and decrease distress (DeMaso and Snell 2013) while increasing coping, understanding, medical adherence, and a sense of control for the child and parent (Schechter et al. 2007; Pattillo and Itano 2001). Diagnosis education and procedural preparation tools help psychosocial clinicians collaborate with children and families to develop a coping plan for the procedure and may involve some of the techniques reviewed in the following section.

Creating a calm, child-friendly, engaging environment is essential for anxiety reduction (Fein et al. 2012). Hospital design and its impact on patients exceed the scope of this chapter; however, environmental adjustments can make a tremendous difference. For example, the child’s inpatient hospital room should be maintained as a safe haven as much as possible and treatment rooms should be used for invasive procedures (DeMaso and Snell 2013). Removing excess stimuli can help to create a relaxing environment regardless of the procedure taking place in a treatment, exam, or infusion room. When possible, dimming bright lights (Baxter 2013), playing music of the patient’s choice, speaking softly, and limiting speakers (Pasero and Smith 1997) establish a setting of comfort. Reducing the number of healthcare providers in the room by implementing the ONE VOICE™ approach includes assigning one person to provide verbal instruction to the child during the procedure (Baxter 2013), thus avoiding an otherwise chaotic scene. While limiting the number of clinicians is important, encouraging parental presence once parents have been coached on coping techniques and their role can provide increased security for the child in addition to a comfort item such as a stuffed animal from home (Cramton and Gruchala 2012).

Honesty before and during interventions will help build trust between the clinician and patient (DeMaso and Snell 2013). Telling children “it won’t hurt” does not decrease pain perception and erodes the trust between the patient and clinician if discomfort is felt. Table 7.2 provides communication and language considerations that have been found to both increase and decrease children’s ability to cope with procedures. In general, terms of reassurance, apologies, and criticisms (Cramton and Gruchala 2012) have been shown to increase distress during procedures, while positive encouragement and validation (Leahy et al. 2008) can help to decrease stress. Additionally, humor can facilitate coping as well as physical, emotional, and spiritual healing by reducing tension and stress while supporting the immune system and increasing control, relaxation, and the release of endorphins (Pattillo and Itano 2001).

During a procedure, the experience of fear, lack of control, or a sense of helplessness can be impacted by the child’s physical position. Research supports that the supine position causes greater distress to children and parents. Coached and practiced comfort holding techniques can therefore offer more choice, control, and security for the child (Taddio et al. 2010). “Lying supine is the most vulnerable position for humans, particularly when physically restrained with a papoose board or by adults” (Baxter 2013); whereas, sitting upright, having the opportunity to watch the procedure, and being held by a parent can increase a sense of empowerment and safety. The Comfort Measures model developed by Stephens et al. (1999) starts by welcoming parents to be present during the procedure but not forcing parents to do so if they are not comfortable. To enhance coping, the team involved in a procedure should review procedural positioning choices and each person’s role so that the child and parent have comfortable physical contact, and the clinician has necessary access and room to perform the medical intervention. A study by Sparks et al. (2007) found that seated parental holding decreased anticipatory stress, recovery time, and distress pre-, during, and post-IV placement and increased comfort and parental satisfaction. Additional benefits of this positioning included fewer staff required to safely hold a child still and a reduction in the time it took for IV placement (Sparks et al. 2007). Certainly, considerations of safety for the patient, parent, and clinician must always be taken into account.