Lauren Mednick, PhD - Enhanced Psychological Support as a Tool for Improved Surgical Outcomes

Okay. All right, everybody. We're getting started. So good morning, everyone. Welcome to Grand Rounds. It's my pleasure to introduce Dr. Lauren Mennick. Dr. Mennick received her PhD in Child Clinical Psychology from George Washington University in 2005. After completing her clinical training here at Boston Children's in 2006, she stayed on as faculty in the Department of Psychiatry and in 2013 was promoted to the Director of the Medical Co-oping Clinic and entire Outpatient Psychiatry Service. She has just recently transitioned to the Department of Surgery this one. Her clinical and academic focus is on helping children and families effectively cope with acute and chronic medical conditions. And she is a particular expertise for preparing patients and families for medical interventions. Her time in surgery really split between providing consultation and short-term treatment to patient scene in the colorectal and pelvic malformation center and building a new pre and post-op program for the larger population seen in surgery. She'll be speaking on enhanced psychological support as a tool for improved surgical outcomes. Dr. Mennick, thank you for being here and for sharing your work with us today. And just to make sure everybody mutes themselves and then can unmute themselves at the end of the past questions. Great. Thank you, Hester, for the introduction. And also I wanted to take this moment to thank anyone who is interval in bringing me aboard to surgery, Dr. Kim and Dr. Fishman. And I know there was other folks involved. I'm really excited for this opportunity to bring my skill set to a different department. Hester gave a good overview of my background, but just to add to that, prior to getting my PhD, I was a child life specialist. I've done work over at the STEM Center, helping prepare kids and families for different surgeries. I've done lots of international work, helping prepare kids for different surgeries. So this is really something that's near and dear to my heart. And my time will be split between the colorectal and general surgery. Today you'll see that the majority of my talk is really more about what I do in general surgery. And probably my final goal when I go through my goals is to tell you how to make referrals and who to refer to me, but just probably the most important part of the talk. We'll get to that. My goal today is really just to get you guys to understand the kind of services I can offer and what how to make those referrals to me. So before I get started with the meat of my talk and talking about showing you my goals and my slides, I thought it would be really important if I showed you a video that gave you a good understanding of why psychological services are so important in a children's hospital. So as you'll soon see, it's from a very reputable source. I'm going to share my screen and play this for you. If somebody give me a thumbs up if they can hear it. So here we go. Well, Congress debates how to provide health insurance for America's 9 million uninsured children. A surprising study release today finds the vast majority of children do not want health care. Joining us now is the study's director, Gerald Fisher. Tell us about this study, Mr. Fisher. We surveyed over 2,000 children and found that across the board they were strongly opposed to doctors visits, vaccination programs and essentially every health care service, some politicians, just saying government coverage should provide. Now we're seeing those survey results here. You asked a simple question, would you like to go to the doctor more? The majority of respondents shrieked no. Right. Leave me alone. Don't make me go. They were extremely passionate on the issue. I see. Now why do you think they feel so strongly about this? Well, it's clear these children are worried that increased government funding for health insurance is a slippery slope socialized health care. So you're saying this is a political issue for them? And a moral one. When we ask them if they see universal health care as an unfair burden to certain taxpayers and would they like a lot of the top almost all children said yes. Really? This obviously comes as a blow to politicians who've been calling for universal child health care coverage. So it's got to be. After the results of your study, the majority of senators are backing a bill that will cut all public funding for children's hospitals. It would close approximately 9,000 of the outdated unwanted facilities. Now have you heard any response to this announcement from the children themselves? Absolutely. The kids are thrilled. They're saying, goodie, I want to go home and flood me. I want to go to grandmas or the movies. Basically, they'd rather be anywhere within those hospitals. And it looks like they're going to get their wish. That's great to hear. So as you can see, being in the children's hospitals is not a place that most children want to be. And so my role is to try to make it a little bit easier for them. And I'm hoping that when I publish for some of you guys that the onion isn't the place that we publish, but I think it's a great video anyway. So I'll just share my screen one more time to get you my slides. All right. So here we go. All right. So before I get into the goals of the talk, just wanted to give you a little context of what my role in general surgery is going to be and what I'm trying to do in general surgery. Because I hope to really collaborate with many of you guys on this call and this Zoom meeting. So I want to collaborate with clinicians in surgery and anesthesia, nursing, child life, and develop enhanced ways to enhance psychological support for patients and families. So some of this will be done by referrals to me to see patients for a few different sessions. I might be creating additional educational materials and developing new practices to improve emotional behavioral functioning. And I've already met with so many people over the last few weeks and it's so exciting that everyone is so welcoming and interested in building this program with me. So my goals for the next, let's see, 45 to 50 minutes will be to describe why psychologically informed preparation is important. So why do you want to bring a psychologist to surgery? It seems like you guys can meet your results without me. Explain how evaluation can help predict a child's reaction to a metapolpacidure. I'll review some methods of preparation and common strategies for effective coping and then finally like I said, probably the most important part of the talk I'll get to last, which is how to make a referral and some common reasons to make a referral. So what makes a procedure or visit successful? And I would say the majority of you have this call if I were to ask if we could have a conversation right now, which is what I prefer, but we're doing it this way is completing the visit in a good technical result, right? And that's what you're doing terrifically now. However, I think there's an end and the end is that the child feels safe and secure and is willing to return. So I'll give you a great example from the SIM center work that I've done. We were working with a group of people that wanted to do EEGs with kids with autism. And so, you know, in coming up with these SIM programs, Robby's thinking, what's the outcome we're trying to improve? And so in my mind, they're coming to us because they have this behaviorally dysregulated group and I'm thinking they can't complete EEGs with them. And so they want to do SIM to help them complete EEGs. So I asked them, well, what's your completion right now? How many are you completing? And they said, oh, will we complete 100% of EEGs? So now I'm confused. I'm wondering, well, why are you coming to us? And I say, well, how do you complete 100% of EEGs? And they said, well, we restrain them or pep who's them? And so we're able to complete 100%. And who goes to them for coming to us? Because they clearly realized that part of a successful procedure is that the child feels safe and secure and is willing to return because that was not happening after a child was pep who was from EEG. They were not going to come back again. So why is preparation so important? And expectation is everything. So kids and parents do better when they know what to expect. And I'll give you the simplest example that I see over and over again. And I'll give you with a five year old little boy I was working with and he was having a back surgery and he woke up and he said, doctor, medic, when I woke up, I had this tube in my penis and I thought something happened. And nobody had sort of prepared him for that he would have a catheter because I wasn't part of the surgery per se, but not knowing to expect that was really challenging for him. So we'll talk a little bit more about the kind of information to give kids and what's important to tell them and when, but expectations, everything. And then importantly, Zevcane, which some of you might be familiar with, he's an anesthesiologist and he's done amazing research, looking at the benefits of preparation with families before a procedure. And what he's found is improved medical and psychological outcomes. And so you can see here a list of just some of the things that he's shown in his research. In addition, what we know is that medical experiences as a child impact adults medical interventions. So adults who tend to avoid medical care when you look back, they had traumatic experiences as children. So we can really make a difference now that can go on for years to come. And then in this day and age of surveys and wanting high satisfaction ratings, it's important to remember that we can improve our ratings with lower anxiety has been found to be predictive of overall higher ratings. So second goal is to really talk about, so what am I going to do in my evaluation? What are the things I'm going to look at? They're going to help us predict how a child's going to do and also prepare them to do better. So the goals of a pre-app evaluation with me would be to explore those factors that are going to help us better protect and we're going to go over what those are in a moment. And then also minimize distress through providing more information about what they're going to experience before and after the procedure, providing emotional support, and helping parents and children develop a full effect of coping skills and what I call a coping plan, which is something they can bring with them to use through pre-app, through the whole period of experience. And you know, just so you're aware, my vision here is that I would see a kid who's referred to me for an evaluation. And maybe some kids I would see for one time evaluation get some good information that's going to help you guys work with them best, give them a couple coping skills within that one meeting and move them on. And then look the other kids that I might meet with for two to three additional sessions to really help prepare them for the surgery. There's also the opportunity that we can talk about in a few slides of me seeing them after the surgery too because we know that some kids are going to have difficulty with a hearing to post-op medical measurements and what have you. So it's all short-term work, but it's just going to depend on what the kid needs. So factors that I'll explore and something, you know, this is by far not an exhaustive list, but these are things that I'm always thinking about when I'm thinking about how a kid's going to do in a medical setting. And the important thing to remember is that not one of these bullet pointed items is going to predict how a child is going to do. So let's take age, for example. We've all seen the 15-year-olds who won't leave it if they're parent. And we've also seen the two-year-old that happily takes your hand and walks back with you without their parent to the OR. And so it's hard to say just by looking at one variable, how a child is going to interact. We can say in general, older kids are going to do a little bit better with their anxiety and younger kids will be more anxious and that's developmentally appropriate. But it doesn't tell the whole story. You know, coping styles, something that's really important. So are they an avoidant copar? Are they going to be information seekers? Parental anxiety. So my natural side is all about this because if I were to look at this list and tell you what I think is most influential, I'm going to tell you it's parental anxiety. And you all might have seen this in your own practice. Previous medical experiences. So this could be good and bad, right? I had a girl I was working with who also had a spinal surgery. And she had two spinal surgeries. After the first one, she had a really, really challenging recovery. And so you can imagine that getting ready for her second spinal surgery, she was really a mess. Just had such a challenging time with her anxiety. Needed medications. Needed a lot of support. But that second experience was so positive that when she needed a subsequent surgery, not in her back or something else, she was much less anxious because she had such a good experience. So it just depends what their experience has been. We'll talk a little bit about fear of pain and how fear of pain can impact how a child's going to cope with how anxious they're going to be going into a surgery and how they're going to cope afterwards, relationship with medical providers, obviously. And I wrote type of procedure or impact in the child's functioning because, you know, there's obviously certain procedures that the kid has a surgery in the day or two, they're up on their feet and they're back to their normal self for the most part. And then there's other surgeries where maybe they're in a spike of cast when they wake up. And so that's really, you know, more challenging. So here's what I promised you about the influential role of parents. So over half of the variance for how a child reacts in a medically stressful situation is related to how the parents are reacting. So I used to give a lecture to the Harvard medical students that were rotating through to children's every six weeks. I meet with them. And this was like number one, one of my first take homes. I said, if there's nothing else you can do, help keep the parent calm. And, you know, sounds like an easy recommendation, of course. But what you'll see is that a lot of the preparation that I'm doing for the kid, I'm actually also preparing the parent. So one of the things that we'll talk about in a few minutes is that I prepare a checklist of what a check for a younger kid of like what the steps that they're going to go through. They're going to get in. They're going to check in and say, hi, I'm here. They're going to go into a room and put a gown on. They're going to get a sticker with their name, right? We go through all the steps of what's going to happen. And you see the parent's anxiety visibly reducing as I'm going through these steps because they know what to expect now. So this is huge. Being able to work with the parents to reduce their own anxiety. So I add this slide. So my favorite cartoon is, now is this a procedure invasive or non-invasive? You know, you all have those patients that are kind of chronic patients that they understand what that means. But I put this slide up for a very important reason. This is probably the second amazing take home I have right now, I think, is that we can't make assumptions that we really need to go into these situations with kids when we're exploring what they're anxious about, what they're thinking about, about the surgery. We need to enter these situations with an open mind and not make assumptions. And I'm going to give you two examples of situations that to this day still sort of surprised me of what happened. So I was working with a child from cardiology. They were referred to me. This was a 15-year-old boy who needed a cardiac calf and he was refusing to get the cardiac calf. And I was actually very impressed with the cardiac team because they asked them, do you want a cardiac calf? And he said no. And rather than saying, well, you're getting one anyway, they said, well, you're trying to eat one, why don't you go meet with Dr. Redding and let's explore this? Well, when they made the referral to me, they explained well, the reason he doesn't want a cardiac calf is because he recently had a cousin who died under anesthesia. So I'm thinking, well, of course, I wouldn't want to have a surgery if that's my most recent experience with somebody having a procedure. So I mean with this child and I said to him, he was a younger developmentally delayed. So 15-year-old gone and I said, you know, I know you need this cardiac calf. Can you tell me why? You're saying you don't want it. He looks at me and he says, well, I don't like how that medicine takes that you have to swallow before you go to sleep. He said, okay, well, what if you didn't have to take that medicine and instead you got a poke and your arm, you got an IV or you use a mass to fall asleep? Would you get the cardiac calf? And he said, yeah. And the next thing we know, we work with the team and we say, don't give him a pre-med. That's the cardiac calf. I get asked him then. I said to him, you know, I do wonder, this was during our first meeting. I said, you know, some kids, they worry that something bad might happen to them or maybe they won't wake up or they could die. Does that worry you? And he looked at me like I was crazy. And he said, because had a million cardiac calves, they'd never died. Nothing's ever happened to me. That's not the concern. So really was this very small, equally amenable thing that he didn't want to take the pre-med. The other example I have is a younger child, a fine girl, who wasn't a reader yet. That's the surgery. Never going to happen. There we go. Okay. He was having a neurological study, a Eurodynamics. And I would assume we were kind of lining things up, like which parts are scary, which parts are not scary. And if anyone's familiar with a Eurodynamics study, I would have thought like getting a tube in my bum, getting a wire that like all those things would be the things that scare me. And the thing that he picked out on my list as most scary was putting on a gown. And so what we did is we called down to Eurodynamics and he said, does he have to wear a gown? And they said no. And Sheranah, he did brave with the procedure. So these are sort of simple easy examples. But I think it's important to remember that we never know what the kid is exactly worried about until we ask. All right. So we'll get to our third goal today, which is to review methods of preparation. And this is the kind of things that I will be doing with kids. But I also hope in this section to teach you guys and to inform you guys about some ways you might maybe you're doing some of these things in your practice already, but you might enhance some of the practice that you're already doing with the kids in preparing them. So there's lots of ways to give kids information about what they're going to experience. So there's descriptions of the procedures through words or pictures. I'm going to go over what a visit checklist is. I think something so powerful is meeting with another child. We had a similar procedure. And then we'll talk a little bit about medical play and how that prepares a kid. So who to inform. This is sort of something I always stand up and talk about a lot that all children need to be informed about what to expect before and after a procedure. So it's not, you know, some kids, they're too anxious. We don't tell them. The question is, is what details to include and when? So that's what I'm going to go over with you guys now. So back to kind of what we were talking about before. These are some of the same factors that we talked about. It's an important to remember that these interact. So when I'm making a determination about when to tell a child age and cognitive development is sort of the first thing that comes to my mind. But then I'm sort of looking at these other variables. And particular one thing is like their desire for information. Some kids really are information seekers and getting a lot of details sooner is better. I'm not sure. Other kids having that information soon is only going to increase anxiety. So I try to make a decision based on that. This is a general guideline, but I've said, you know, the caveat here is you want to make sure that you're thinking about those other variables. But in general, younger children I typically have parents or if I'm able to be available to tell them a day or two before. I think about not telling them as they're going to sleep at night because they're never going to want to go to sleep again at night. So maybe the afternoon before I don't I really urge families not to tell the kids on the car ride on the way to the hospital. Even a young kid that they have some understanding in advance. And you know, I would talk to a parent about what to tell a very young child was opposed to what to tell an older kid. School age kid about a week before and teenagers typically do involve, do better when they're involved along the way. Although like I said, there are plenty of teenagers that have said to me, please tell me three days before the surgery, I can't hear anything before them. And sometimes that's fine. They know themselves. So what to tell a child? So you know, that's sort of the when in general based on age guidelines. What to tell a child is the most important thing by far is to use honest information. So you know, it's okay to say to a kid, I don't know. It's okay to tell a kid things that aren't going to be necessarily pleasant because when kids are told something that turns out not to be true, they're going to develop a distrustful relationship with whoever told them that information, whether it be the parent or you know, or the whole medical environment. So it's really important that we are honest with what we say to kids. You know, the prime example that I see in pediatrics all the time is this won't hurt at all. How do we know that since pain is a perception? I see some of the pain folks here. It's hard to say this won't hurt at all. There's other examples. One of my favorites was I was working on the psychiatry consult service probably 15 years ago now. And I was consulted on a three-year-old little boy who was just terrified hiding under the blanket, just post-op. And I asked them on, how did you tell him about coming to the hospital? What did he know before he came here? And she said to me, well, I got him in the car in the morning and I told them we were going to make Donald's for breakfast. And then in the set of going to make Donald's, we ended up at Boston Children's Hospital. And I'm sure you guys have seen stories like this over and over again where a parent does not inform their kids and they just end up there. And I think the thing I try to remind myself all the time is that the intention was good. You know, he was a mom who was trying to reduce anxiety in their kid, get them in the car, get them to the hospital without a big to-do. But the reality is is that the outcome after the surgery is going to be not so good by not preparing that child. So I think it's important to be really honest and not give them information that's not true. And what's challenging about this is sometimes we don't know in medicine, right? Or we think we know in things change. And so I always try to be very flexible in the language I use with the child. So for example, I never would say something like, you'll only sleep over one night. I might say something like, we hope that you'll stay one night in the hospital. Sometimes kids have to stay longer, but we're thinking it'll be one night. So I'm just very careful about how I say things so that the kid doesn't come back and say to me, you told me only one night because that has happened both with my own children and in the work done. And it's really easy. Language is the precision of language can really get us in a lot of trouble. I think it's important that you're honest. I don't know where we're going to go. There's that also. That one needs to meet some of you, right? To tell the child what will happen before during an after-the-manical procedure. So when I'm preparing the kid, I truly start from, you enter the pre-op clinic. And we go through kind of the whole gamut. During the time they're in surgery, for most kids do not want details about what happens when you surgeons are doing your work. And so what I might say to a younger child is when you're in this very special kind of sleep that they end up in the physiology, it's going to help so that you can't even wake up, even if I tickled you, the doctor's going to use their special tools to fix your values or what happened. Most kids will be cool with that explanation and won't want to know details, won't want to hear about the different equipment. So, you know, to that end, I really encourage parents when they're doing a pre-op visit with the surgery team to bring another adult when it's possible to the hospital so that the kids don't have to sit in on that whole conversation. And at the very least, bring some headphones and an iPad and let the kid listen to something when you're having more details conversations about the surgery. And what kids really want to know is what they're going to experience, you know, so again, they're not going to be awake for the surgery for most of these things. So what are they going to hear see, smell feel before and after? I ended here asking for repeat that. I think preparation is such a vital time to also look at misconceptions and change them because often kids think something that's not accurate and actually parents very frequently too. So finding a way to have them tell you what you explain is important. Just to go back to the first point about honesty, I think something that's really important now in my conversations in the last few weeks with both folks on the anesthesia side and surgery side is the biggest change that I've heard about during COVID, at least from my preparation lens, is that parents aren't going back to the going back with the kids until they're under anesthesia. And I think it is really important that we are clear with families that this is not going to be a practice that we're going to do, especially the families who have had multiple surgeries and are used to going back with their kids. The kids are expecting that their parents are going to go back to them. I was just working with a 14-year-old who I've seen for a long time and he was having us to come up coming surgery and I said to him, you know, there's a couple things I'm going to be different and that was one of the things I told him and he was really surprised. And his mom said, I'm not so surprised, I figured. But it's really helpful because that's not what he was expecting. So some important details to include and these are things that I would include in my explanations for things you guys can consider too as you're doing some preparation with kids, is that if a kid's going to wake up with an IV, so I always find out from the docs, I say, all right, do you expect this kid to wake up with one IV, probably two, maybe two, we don't know, and then I always kind of go on the high end of things, I'll say to a kid, you know, it sounds like you might wake up with two tubes in your hands. Maybe you'll only have one, but you might have two. Don't be surprised that there's even a third, you know, so again, being open with that, you know, so there's no surprises, and you know, a tube in your penis. Again, it sounds like, you know, obviously I hope for your logical surgery, we'd remember the kid wouldn't be so surprised about that, but kids are really surprised that the lots of other surgeries you wake up with that, and they, you know, imagine a five-year-old boy all of a sudden thinking something happened to his penis, so it's really important. And I think so often, my sense is we don't share this information with kids, one is because it's not directly about the surgery we're doing, so we're not thinking of the sort of bigger picture thing. But also I think there's this idea that, oh, I don't want to worry that, and again, good intention, I don't want to give, you know, give them all the things that could happen and all the, but there is a balance for, if we know they're going to wake up with a tube in their hand, we should probably let them know. I think for younger kids it's really important to explain that these things will be removed. I truly had little kids think like this is their new normal, they're going to have tubes and their ballet and tubes all over the place. They're going to want to know how they're going to feel immediately after the procedure and through our recovery, and this is an art really. In my next slide, we'll talk a little bit about what to say, sort of when a kid says, is it going to hurt? You know, this is really an art of giving them a balanced perspective of sort of what it will feel like and not being honest, but also not what I'll say is predicting pain and telling them, it's going to be terrible, you're going to feel horrible. They really are going to need to know what it's going to look like, so are they going to have bandages covering them? Will they see stitching? I worked with some kids getting different kinds of surgeries for I'm thinking of a child I got in wet a vascular anomaly in this case and had a surgery. And it was really important to tell this child after the surgery because his intention of getting a surgery was for this vascular army to decrease for him to look what he would consider better. And obviously, bright up the surgery, that was not the case, so kind of telling him, so if he hears what's going to look like it's going to be coffee, it's going to be red, I'll tell kids if they might see some blood on wherever the site is, I think that's important. When I initially did a lot of volunteer work with operations smile, preparing cancer different surgeries and classes and class pallet. And when I initially started working with the group, I didn't realize that when you got a class pallet revision or when you do a class pallet that they tie your tongue to your cheek. So I never told anyone, so I remember being in China, and hearing these kids like wailing and being so upset. And I think they thought something happened to their tongue and it was just a great lesson for me too to be humble and ask, you know, work collaboratively with the team to try to understand all the details of the procedure so I can prepare a kid the best way I can. And then for younger kids, I always try to mention that they're going to go home. Focusing on sort of a future event is just a good psychological thing for anyone, you know, there's an end to this, there's an end to this. But I think young kids actually start to think like this is again the new normal, this is where I'm going to be. So as I said before, one specific concern, I think, I don't know if you guys are asked, I know I'm asked a lot and I think when I've been with kids in Fiji and hopefully live out of your other places, they'll say, is this going to hurt? What is it going to, what is it going to feel like? And the question is always like, I don't know what to say and, you know, as I said earlier, I don't want, I don't think it's helpful to say it won't hurt at all because we don't know how a kid is going to perceive the experience, the sensations they have. So I try not to predict pain but I also am not going to lie to them and say, everything will be rosy and great. So this is an example that I give and again, I try to sort of soften the language a little bit and not use words like hurt and pain. But this is an example I'll frequently give when a kid is going to get a shot or a blood draw, I'll say, you know, some kids feel like, say, it feels like a pinch or a squeeze, some kids say they can barely feel it. So, you know, I'm serving some, there's lots of medicines we give you so that you might not feel it very much at all and you're going to have to let us know how it feels for you. And, you know, I do talk about that, you know, with acute pain or surgery that we would expect that, you know, every day you're going to feel a little bit better and a little bit stronger and kind of again, that future orientation is really helpful. Alright, so here's an example of a checklist that I might use for sort of like before surgery or pre-op visit. And I use checklists for a lot of reasons and I use these with kids probably ten and under. Although sometimes I might use them as an older kid. One, it's a really great way to kind of prepare the kid to go over the steps of what they'll experience. Two, it can be you day of the house to kind of the game where they're checking off the things that are happening and they're ready to be a prize at the end for completing everything. And, you know, when I present this to a kid, I do say things again, keeping that flexible, sinking in mind. I do say things like, you know, I did talk to your doctors and they told me all these steps but maybe they're something we're missing. I don't think so but if there is, you're going to tell me. So, I kind of leave it out there if something else gets out of it in. They're not angry with me. I also talk about, you know, sometimes they do things in a different order than it's here and that's okay. We'll just check it in the order that they do it. So, here's an example of like a pre-op one and then I thought it would be important to show you sort of an after surgery one. So, you'll wake up as you see. This was, I think, a kid getting up that or surgery. So, they'll get two tubes. There'll be two tubes in their belly, one tube in their hand with a bag of medicine and two in their nose. So, I'm telling them all the things they're going to see. And then I kind of talk about what's going to happen to them. So, you know, I found that these checklists are incredibly useful to especially actually for the parents like I said. And often what I'll do is I'll make a checklist like this for a family. If I can't see, let's say an eight-year-old kid who we're going to tell four or five days before the surgery, if I can't meet with them in advance, I'll go over this checklist with the parents and then have them go over with the kids. So, it's sort of a simplified way for them to explain things for the kids too. Another common tool that I use for preparing kids is a child's meeting another child with similar condition or having a similar surgery. Probably this surgery, I've done this the most with is the costumé. It's unbelievable. I've had, I can think of two instances where I had two younger kids that were questioning whether they should get this. They felt they weren't sure if it was the right thing for them. And I had them meet an older patient of mine who had had one. And, I mean, by the time they left the session, the two younger ones were signed up for the surgery. Like I just think it's really empowering to know you're not alone, but also to hear about someone else's experience. And this does take a little bit of financing because there are role models that are two role models. And then there's people that wouldn't be the, you know, you wouldn't want to just throw anyone together if there's, you know, people match for certain reasons. So this is something I tend to do in a clinical setting. But you can also, this video is online and there's things on YouTube. But I also have different videos of patients talking about things. I can watch a video of a kid talking about an experience. And, you know, I always talk about parents as role models, you know, when parents are, I really encourage parents to talk to their kids about their own medical experiences, you know, their own bravery. When they go to get a flu shot, how they were raised, obviously, if a parent has need a phobia, that's probably not the discussion they're going to have with the kid. But for the most part, I can get parents to help their kids more than anything. So the other tool that I'll use in preparing kids is medical playing. And so playing in general allows kids to sort of assimilate reality and resolve conflicts, achieve mastery. But medical play is really special because it aims to familiarize the kids with the medical equipment. Oftentimes when I'm working with kids, I actually use the real medical equipment. I will probably come to some of you guys and I have in the past to some of you guys and say, can I have some masks and can I have some tubes and can I have and we'll do fun things with the equipment. And it promotes active playing rather than being a passive receiver. And it provides them a way to practice some of the coping skills that we'll talk about in a moment. So it's really, it's really a very powerful tool. And many times parents of kids that are really medically complex will say to me, all they play is medical staff. And I actually normalize that for them. And I said, well, that makes sense because a lot of their experience is about being an hospital and medical staff. So they're working through that. So I think it's actually a healthy thing. You know, just thinking about medical exposure and medical play, sometimes we'll take visits to the medical floor and hopefully we'll be able to do that one day again. And the meantime, I have videos and pictures and different things I can share with kids. And then something that I really enjoyed doing and this is sort of from my years as a child life specialist is taking medical equipment and using it in non-traditional ways. So I'll often take anesthesia masks and put them in bubbles and blow bubbles with them. I remember being, I think we were, I was in Thailand and I was working with this anesthesiologist and he comes out after he takes his first patient. He says to me, what did you do with that kid? Because he came back to the OR and he put the mask on his mouth himself. And I was like, oh, well, we probably didn't understand there weren't bubbles in it. But you know, it's really, it's desensitized as it makes it more exciting. I've worked with kids that are scared of ultrasound. We take the jelly, we put it all over the table, we do ultrasound on lots of different things. And catheter art, I put bees on catheters. It's very fun. We might paint with syringes. So again, this is a way of sort of demeticalizing these things but making them last threatening so that when the kid does see them in the medical platform, they're like, why for that? I know what that is. So I'll send the next few minutes talking about some common strategies that I might teach. So that was sort of how I might prepare a kid for what to expect. And hopefully you guys will gain some, gain some information about ways you might prepare a kid for what to expect for a procedure and parents. But now, provide some examples of common strategies that I might use to promote effective coping in a medical setting. So the first thing and probably the most efficacious in the literature, there's a Cochrane review on actually about needle fear. And it talks about the most efficacious type of procedure, type of perceived psychological procedure used to reduce anxiety and subtraction. And so I love this because it's so simple, right? It doesn't take a lot of tools, a lot of training. It's about taking the kid who's in an anxiety-provoking situation and focusing their attention away from the anxiety-provoking parts of the situation onto something less anxiety-provoking. So it's pretty, and so it's not avoidance, it's not leaving the situation, but it's putting your mind on something else. And I'll tell you about a research study that I think is so important to bring home the powerful nature of distractions. So Lindsey Cohen, who's a psychologist, took parents, these were kids that were getting blood draws and put them into three groups. And in the one group, he had the parents due distractions. And he taught them to like show them pop-up bugs, the blow bubbles, to watch a video, you know, whatever it is to keep the kids mind off of the blood draw. To the other group, he had the parents due reassurance. So reassurance is what come naturally to parents. You're going to be okay, this will only take a few minutes, you've done this before, you know, just making reassuring statements. And in the third group, he told the parents to just be a present. Be a present. And what I think is so interesting about, I mean, based on what I'm saying about distraction, you won't be surprised to hear that the kids that did the best that had the least anxiety, least behavioral difficulties were the kids that the parents distracted them. But what I find most interesting about this study is the kids that did the worst, the kids that reported the most anxiety, the most behavioral dysregulation was the reassurance group. And the thinking on that is that when you reassure a kid, what you're doing is you're refocusing their attention on anxiety provoking aspect of the situation. So basically, you're saying, keep thinking about it, it's really hard. I know, this is so scary. So one of the things that I really work with parents about, and I think this is hard because like I said, my natural instinct as a parent is to reassure my child when she falls and when she scrapes her knee when she's having a blood draw. But I think the really important take home here is that to not do excessive reassurance. So a reassuring statement or validating feelings is reasonable. But to continue with the reassurance is only going to make anxiety worse. So what I tend to tell parents is to make a statement like you can do this. You're really brave. All right, let's look over here at whatever it is. A question I frequently get is related to distraction is are there certain tools that are better for certain kids? And I think there's also an interesting research study that looked at a path of distraction as opposed to active distractions. So active distraction would be playing a video game, doing a word search, doing math problems, path of distraction will be watching a movie. And in general, I would say active distraction is going to be more useful because we're going to get the kid involved. I had a little girl that I worked with who would she would whenever she got an IV started, what she wanted to do is math problems. And it really did it like took a lot of requirement of capacity to do those math problems. And so she wasn't as focused on the IV. And you can imagine that path of distraction watching a TV. It's really easy to kind of not really be watching the TV and really your paying attention to the IV. That being said, there's some kids that aren't put on one engage in active distraction. They're going to be like, I'm not doing this with you or maybe you bring a distractor into the situation that the kid's not interested in. You brought a video game, the kid doesn't like video games. The beauty of a path of distractor like a TV is that even if the kid isn't actively involved, probably a little bit of their attention is going back and forth to that TV. So it's not that a path of distractor is a bad thing. In fact, in certain situations when the kid is refusing to engage with an active distractor, a path of can be good. And I've had, when I've given a similar lecture before, talking about the importance of minimizing reassurance and maximizing distraction, I had folks ask me like, well, put, you know, and this is usually medical students and staff like, well, but how do you tell a parent that? It's operating, and I said, well, I really just demonstrate it. And so I start distracting the child and ensuing the parent usually, usually figures out. Obviously, when I'm working with the kid, I'm going to teach the parents this. But in the moment, I'm going to just demonstrate. Relaxation. So we know huge mind body connection. And so, you know, if we can relax the body physiologically, and also there's an element of distraction to relaxation. And we can do sort of deep breathing with younger kids. I might use bubbles or pin meals or party blowers. And with older kids, I might, you know, teach them just teach them how to do diaphragmatic reading without tools, let's say imagery and progressive muscle relaxation is a different kind of relaxation technique. I have some training hypnosis. So for some kids, I might do that. And even for a lot of kids listening to music is really relaxing. So this might be another coping skill that I might put on their coping plan for them. And as a cabinet behavioral therapist, I can't leave out, you know, I, preparation has so much behavioral sides of it. I mean, there's the information that's obviously cognitive, but there's so much about the different distraction and relaxation and medical play that's very behavioral. But I think you can't just count the role that how we think about things affects how we feel and what we do. And so that's really what cognitive behavioral therapy is about is the relationship between thoughts, behaviors and feelings. And so a lot of times what I'm trying to do is try to encourage realistic thinking about situations. Often kids are kind of catastrophizing or, you know, only focusing on the negative aspects of a situation and ignoring the positive, saying things themselves that really aren't helpful and are just increasing their anxiety. So I'll work with kids to think about, you know, so it's one thing to say to yourself, like, this is going to be terrible. It's going to hurt so much. I'm going to have the worst time ever. Why am I getting this? And that's a common refrain you might hear in some kids. And all that's going to lead to is feeling more anxious, having a really hard time. And instead, if we could work with kids to change their thinking to a little bit more realistic. So not the exact off. I always say to kids like, it's not the polyanna. It's not like, let's do the exact opposite. Like, this is great. I can't wait to get a surgery. It's going to feel so good. Like that's just not true. But if they could say to themselves, you know, this is going to be tough. It's going to take a while recover. But I know I'll get better. And I know when this is over, I'll be able to walk better or whatever it is. So, you know, trying to balance their thinking is really, really, really important. So often I have a sheet that I'll use with kids that will write a whole bunch of bravery statements and things they can say to themselves. And I have seen so many kids bring it with them to their procedures and have their parents remind them of those statements or they kind of look at it and remind themselves of those statements. Because in the moment, it's really easy to go down that negative path. And I think another behavioral thing that I often use with kids and I think I get the most resistance, believe it or not, probably from parents for this one. I think there are a frame that I often hear from parents is like, well, why should I reward them? They just need to do this. This is just what they need to do. And I try to talk to parents about, especially younger kids. You know, they don't have the ability cognitively to understand the benefits of, for example, after a surgery to keep cleaning a site or getting up out of bed and walking right away. They're like, well, but it hurts. I'd rather just stay in bed. Like, what, you know, in their mind, they're only in the present and they're thinking, why would I do this? But what we know is that external motivators might help motivate them in the short term until they can gain those internal motivators that like intrinsic motivation to do things. The other thing that I really like about using sort of rewards or behavioral reinforcement is it puts a positive spin on what it couldn't be a very negative experience. So, probably my favorite example in this situation was I was working and used to work a lot with Ellison Felt in the Felt-Telcemia population. And I had these six-year-old twins that I was working with. And they had just been started on transfusions therapy. So every three weeks, they had to get a transfusion in the CACER. And they were having such a hard time, both of them with getting the needle, with sitting there, with everything. And so I was trying to work with them on how we can make this a positive experience. What's something we can do to tell them we're proud of them, they're brave, something to look forward to. And in that conversation, I don't remember how it came up, but what it came up is the mom doesn't allow the kids to have McDonald's. And the kids have always wanted to have McDonald's. And so we had a discussion around coming up with a plan where once a month when they came for their transfusions, could they have McDonald's at the same time. And the mom said, sure, we can try it. And it was like in a snap, it was just such a difference. Now the kids are wanting to come back, because that's when they got McDonald's. And again, I'm giving you examples of times where these things work so beautifully and stuff. But it really does make a difference when there's something positive to look forward to. Often, like I said, on my Netflix, I'll even be screwed at bottom. Get a bravery prize or get a reward. It's a young hit you might see that I'll develop bravery chart with them to use postdocs. And what you define as brave is different for every kid. So it might just say, like, Michael's bravery chart, and you get a sticker for every time you did something brave and every 10 stickers, that's a small reward or something. But it's just a way to motivate kids to put a positive spin on things. And it's unbelievable how powerful this small tool can be. So to get to the last, and like I said, the most important part of this top probably is just to review some common reasons for referrals to me. And also just how you can make a referral. So here's some examples of who to refer. Like I had said earlier, I envision this role. This is a new role. So it's going to be evolving. But what I envision is this is a very short term you know, I'm not doing a psychological therapy that if a kid has depression, that's not what I'm treating them. I'm treating them helping the kid get through a medical procedure with depression. And then I can help find referrals in the community to treat the depression. So I envision this as usually an evaluation filed by maybe one or two appointments. Might be three or four for some kids. And for some kids, it might just be the evaluation and learning some skills in that moment. Kids or parents with significant anxiety are great to refer to me. And you know the difference. Like everyone, you know, some anxiety, I always say to kids, when they'll come to me, when they're kind of resistant to seeing me, and they'll say, you know, I'm not crazy. I don't want to, you know, like why would I come to you? And I talk about that, you know, when I'm talking about things like surgery, I'll say, if you weren't anxious about the surgery, then I would say you need to see a psychologist. So, you know, some amount of anxiety, and as you all know is normal, but you know those families that where the anxiety just seems to really be so palpable and so impacting on so many areas of the child functioning, the parents functioning. Kids who've had a challenge and recovered a hospital course in the past, so it's a great referral. So to see if I can sort of revise how they're thinking about things. Kids who will need to adhere to a complicated medical regimen post-op. So kids that, you know, might need to dilate after a surgery, or what have you, we know that when we talk about and prepare for things before they have to do it, they're going to do better. And those are great kids that I can meet them before the surgery, that I can help post-op, making sure that they remain adherent to whatever that matter for rest of it is. Families who aren't certain about moving forward with the surgery, so maybe it's not a necessary surgery, but it's something that you think would be good for the child. And so there's some ambivalence there, or I will give a shout out to Dr. Lilla Hai who gave me my first referral for a family where the parents wanted the surgery, the parents want the surgery and the kid doesn't. And again, it's not a necessary surgery, but times have really helped the family communicate better with each other and come to sort of a common agreement and decide what are they going to do? How are they going to move forward with things? So I think that's a great referral. And then I think there's some kids where it's probably an assessment of surgery readiness, so it's like, are they from a psychological perspective? Is this the right time to do a certain surgery or should we wait? That's something I can certainly lend my opinion to. And then importantly, how to make a referral. So again, this is an evolving process and potentially we might have a more formalized way. And my hope would be over time we've wrote us into a service with multiple providers, not just me part time. But in the short term, how to make a referral would be to send me an email directly and include in that just a piece whose name and MRNs, right? Who they are, date of surgery or obviously if they're not scheduled for surgery yet, but this is to decide if they're going to have a surgery or they need a surgery, you can kind of give me a little time for you to avoid your thinking. And then the reason for a referral. And I will work my hardest to get them in, especially for kids who are ready scheduled for surgery. At least a week advance notice would be helpful the more time the better, just so if we do need to meet a few times, that's okay. But we can get in an evaluation pretty quickly. And it is most of my services can be built. Most insurances will take billing for me, so it's usually not in a problem of an insurance. I was meeting with Child Life yesterday to talk about my position in BRT, the BRT, the behavioral response team too to talk about sort of what are the cases that I might see as opposed to what they might see. And I've been talking over and over again with lots of folks about the advantage of working with me over Child Life is that I can build so I can see a kid multiple times potentially before surgery as opposed to Child Life is the kind of service. Mostly because of time, you know, they love to see kids multiple times, but I think it's, they have time constraints that they can see them the day off or maybe give one phone call to the family before. But I also, I was realizing it also could be sort of a negative thing. So it's important that the family knows that this is a bill service that this is a cycle lot. They're going to be seeing a psychologist that would be built under psychiat, you know, as a psychological service. I think I'm developing some marketing materials that describe like, why would you see a psychologist for a surgery that tries to make it not seem so threatening, but it is something to just keep in mind. And that is the end. So I'm happy to spend the last minutes if there's anyone that has any questions. Lauren, this is Steve Fishman. I just want to thank you so much for this enlightening talk and actually for pushing us with the proposal to have you join our department. I think all of us who chose to go into the care of children realize that kids are different and that idea of medical intervention or painful procedures or threatening circumstances is really challenged for us. And we like to think that we know how to deal with children different ages and families of different dynamics and we know we're treating the whole family not just the patient. But in fact, we're not all very formally trained for all those circumstances. So we're very much looking forward to learning more from you and having us help our patients directly. As you say, we need to figure out how to how to integrate this into our old habits and learn new ways of doing things. And we're really very excited about this and hope that a year from now or so you will give us an update on all the things that you've done and transforming the way that we care for our patients. So thanks so much for your proactive nature of bringing this to us. Thank you. Lauren, I'd also like to thank you. I guess we've talked briefly about it. What interests me is the idea that we have some 30,000 surgeries going on in a given year. And how do we really figure out which kids will benefit most from this type of intervention? And whether or not you have any ideas about the use of screening tools or other things that could help surgeons, anesthesiologists figure out which kids will be most impacted by intervention as opposed to them trying to figure that out. Yes. Thank you, Dr. Carvero. And yes, that is something. And again, I want to say that I am, even with short-term work, I can only touch a very few patients. And so I think figuring out how we can reach a broader audience, so developing some better educational tools that childlike dogs has some tools and some of them are terrific, but I don't even think families have access, like no kind of access them of like information about how to prepare a kid or whatever. So I think there's ways to sort of reach the broader audience, but to your question about who do I, how do I identify the kids that most need it? Some of this is just going to be, you know, yes, I can think about tools and ways to screen and different questions that, you know, but some of it is going to be over the next few months trying to work together and figure out sort of what is those populations that would need my services the most. Because it's hard to say without being on the ground floor with you guys to kind of look at which other kids that would really, I mean, because I can think of lots of kids that would benefit for lots of different reasons. And so really taking me as a limited resource and thinking about how to use me in the right way. So I think it is something we're going to have to think about together. And, you know, I think that's a great idea about is there any kind of screening tools, screening measure? I don't want to add to the burden of anybody who's seeing their kids, but there might be a simple way for us to kind of say asking for questions of yes, any of them, send them to me at least for a screen. That's great. There's something in the chat. Well, I think that Dr. Gooby's comment in the chat we can all see. And I think we all agree with her. And I see Dr. Bernie clapping. And he sent me a private note, sharing how brilliant idea it was to have you come join us. Because he's worked with you for so many years. So I really look forward to this collaboration to you helping us with our patients and addressing Dr. Vierle's question of how do we figure out who to have you see and help us with. So we'll look forward to that. And I encourage all of the faculty to think about this opportunity and to let Lauren know when you think that she can be helpful and she'll help us learn that together. So thank you so much. And we'll report to you. Thank you all for for attending today. And we'll move out with her with our day. Thank you.