LEVEL II ADVANCEMENT

Patient Selection:

• Name: Gianna
• Age:13 years old
• Gender: Female (assigned & identifies)
• Race: Native Hawaiian/Pacific Islander
• Ethnic background: Hispanic Latino
• Socioeconomic Status: Lower SES, support needed and in place.
• Unit: Outpatient Apheresis

Family Makeup:

• Single parent household
• Mother: in a long term engagement
• Biological father: deceased 2017
• 17yo sister & 6yo brother
• Maternal grandparents intermittently live in the home with patient and family

RATIONALE FOR CASE SELECTION: 1

• PERSONAL CHALLENGES: How to provide effective care for a patient that has worked with multiple specialists, with various approaches and techniques regarding continuous behaviors - how can my interventions promote positive change?

RATIONALE FOR CASE SELECTION: 2

• PROFESSIONAL CHALLENGES: Unit dynamics, and team collaboration.
• Lack of continuity in care
• Utilization of Child Life Services

RATIONALE FOR CASE SELECTION: 3

• LEARNING CURVES: Resist reinventing the wheel - reintroduce services through a comprehensive lens.
• Practice information gathering on successful intervention strategies and align them to be developmentally appropriate.
• Team building and collaboration.

MEDICAL BACKGROUND:

• Sickle Cell Disease type SS (SCD-SS)
• Mild Persistent Asthma
• Mild Pulmonary Valve Stenosis
• Acute Chest Syndrome (ACS)
• Treatment: Q3 Apheresis Red Blood Cell Exchange with Hematology
• Prognosis: Chronic Illness, continual maintenance, shortened life expectancy

MEDICAL IMPACT:

• Regular hospitalizations, double port accessing, fever monitoring, medication and treatment compliance
• Q3 Apheresis Red Blood Cell exchanges
• Iron overload due to chronic transfusions
• Acute Chest Syndrome
• SCD pain crisis maintenance

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multidisciplinary collaborations:

• Medical: RN, Primary Physician, Hematology, Oncology, GI, Pulmonary, Surgical and Anesthesia teams
• Comprehensive: Child Life, Social Work, Psychology, Art, Music and Integrative Therapies

stressors, family issues & needs:

• Developmental, cognitive & emotional stages have been disrupted by chronic illness and complex family systems
• Biological father: intermittent incarceration, in and out of halfway housing, unexpected fatal overdose in 2017, suspected abuse/neglect
• Room for improvement with emotional, developmental and behavioral support

PATIENT TIMELINE CONTINUATION:

• 2008: Diagnosed at birth, routine hematology blood transfusions, lab work and daily medication compliance
• 2011: Hydroxyurea Therapy
• 2012: Acute splenic sequestration crisis
• 2012 Splenectomy
• 2013: Temporary relocation: Kentucky
• 2014: Return to New Jersey

PATIENT TIMELINE CONTINUATION:

• 2015: T&A Surgery
• 2016: ACS complications, restart Hydroxyurea, brief CTT intervention
• 2017: Chronic Transfusion Therapy
• Port placement in 2020 to support Apheresis for SCD-SS and ACS to present

child life assessment index score:

• Outpatient score 6-4/3 HR to MR, IP=MR
• Input 1: Mobility and development have not been detrimentally impacted
• Input 2: medical stressors and emotional coping have progressed from a 3 to a 2/1 with continuous care and comprehensive intervention

CHILD LIFE ASSESSMENT INDEX SCORE:

• Family/community support system:
• Father reported of suspected abuse and neglect, struggled with addiction, unexpectedly passed due to overdose
• Mother displays difficulties supporting and validating patient
• Inconsistent community relationships
• Family often physically and emotionally unavilable

PERSONALITY & COPING:

• Personality - bright, engaging, playful, adaptable, appropriate, creative and friendly.
• Coping - ranged from positive to poor, disruptive/dysregulated, "attention seeking", history of reactivity to presently calm, readjusted and healthy.

Developmental Assessment:

• Patient presentation - age appropriate, hygienic/well appearing, good eye contact, effective communication, easy to engage, cognitively clear and oriented, mood and affect appropriate, motor abilities are developmentally on par, mental status is linear

child life assessment:

• Developmental considerations
• Chronic medical impact
• Treatment, prognosis and emergent crises
• Family system dynamics, parental incongruence, sibling relations
• Education disruption, social influence, intersectionality, social/emotional processing and support

CHILD LIFE INTERVENTIONS:

• Diagnosis and procedural re-education and support
• Space-holding, grounding, boundary setting, validation, active listening & positive praise
• Preparation, normalization, promotion of mastery, autonomy & advocacy
• Blackout poetry, Journaling & Art

intervention rationale:

• Patients age, history and development
• Affinity for creative and expressive outlets
• Observed dismissal and downplay of emotional needs, fears, procedural and diagnosis impact
• Heightened benefits of increased autonomy and scaffolding opportunities due to age

DEVELOPMENTAL THEORIES

• Erikson's Psychosocial Development Theory
• Identity vs. Confusion
• Approximately: 12 years to 18 years.
• Challenge boundaries and beliefs. Peer pressure, family stressors, labeling and mislabeling, may leave an adolescent feeling trapped, causing them to rebel or potentially shut down and withdraw.

Piaget's Cognitive Developmental Theory:

• Formal Operational Stage
• Approximately 12 through adulthood
• Conceptualization of abstract, logistical, deductive thoughts and reasoning
• Goal oriented mindsets may emerge in healthy and safe environments
• Explorations of self through problem solving and experience

VYGOTSKY'S SOCIOCULTURAL THEORY

• Seminal Learning Theory
• Emphasis on external impact and influences such as familial makeup, hands-on learning, culture, socioeconomic and social influence
• The belief that learning is inherently social through the zone of proximal development
• Learning through scaffolding

Bandura's Social Learning Theory

• Emphasis on observation and modeling for impactful learning, conditioning and reinforcement
• The critical lens of learning through observation, listening and experience
• Learning through direct interactions with your environment, peers, associations and interactions

Transforming theroy to practice:

• Foremost, the recognition of chronic medical impact while moving through each developmental stage
• Disrupted education and socialization opportunities due to hospitalizations and emergency's impact the first 5 tiers of Erikson's 8 stages of psychosocial development, inevitably carrying over into the final 3 developmental virtues

TRANSFORMING THEORY TO PRACTICE:

• The influence of social learning experiences in Vygotsky's sociocultural Theory becomes impeded by lessened interpersonal interactions and face-to-face schooling, decreasing opportunities for learned social cues, adversity problem solving, bonding, group projects, body language, growth and expression, as well as, solidarity in the human experience

Transforming theroy to practice:

• The Formal Operational Stage allows for both concrete or abstract, evaluative comprehensive conversation and creative opportunities with developmentally appropriate patients
• While Bandura's Social Learning Theory allows for the patient to learn through listening and instruction during times of escalation

outcome and evaluation:

• Patient's needs assessment index score has decreased from a 6 to a 3 with continuous intervention, Child Life Support, boundary setting, creative outlets, encouragement, validation and praise. Patient would benefit from continuity in care and a holistic approach as she moves forward in her treatments.

questions?

references:

• Bellman M, Byrne O, Sege R. Developmental assessment of children. BMJ. 2013;346:e8687. doi:10.1136/bmj.e8687
• Esteban-guitart M. The biosocial foundation of the early Vygotsky: Educational psychology before the zone of proximal development. Hist Psychol. 2018;21(4):384-401. doi:10.1037/hop0000092

REFERENCES:

• Fryling MJ, Johnston C, Hayes LJ. Understanding observational learning: an interbehavioral approach. Anal Verbal Behav. 2011;27(1):191-203.
• Marwaha S, Goswami M, Vashist B. Prevalence of Principles of Piaget's Theory Among 4-7-year-old Children and their Correlation with IQ. J Clin Diagn Res. 2017;11(8):ZC111-ZC115. doi:10.7860/JCDR/2017/28435.10513

references:

• McLeod, S. A. (2018, May 03). Erik Erikson's stages of psychosocial development. Retrieved from https://www.simplypsychology.org/Erik-Erikson.html
• Munley, Patrick H., and Berdie, Ralph F. . “Erik Erikson’s Theory of Psychosocial Development and Vocational Behavior.” Journal of Counseling Psychology 22.4 (1975): 314–319. Web.

Thank you!