Global Perspectives | The Beautiful Journey of Child Life in Taiwan

"Formosa,” meaning “the beautiful island,” is an ancient Portuguese name of Taiwan, now officially named the Republic of China. Taiwan lies within the tropical and sub-tropical climate, surrounded by waters with lush green mountains and diverse species. Neighboring countries include the People’s Republic of China, Japan, Korea, and the Philippines. The 23.43 million population in Taiwan use Mandarin as the official language and traditional Chinese in writing.

Although Taiwan is a small island compared to other Asian countries, the National Health Insurance System in Taiwan is well known internationally. In Taiwan, 99% of the people are covered under the national healthcare insurance. With fairly low co-payments (those with major illnesses, children under 3 years old, and low income families are even waived of the healthcare co-pay), almost everyone has access to high-quality healthcare, medicine, and medical treatments.

While a high standard of medical care has been fairly accessible and affordable in Taiwan, it is only recently and through years of hard work from the mental health pro-fessionals in healthcare that the importance of providing psychosocial support and child-friendly healthcare has started to gain more focus in the field. It was not until the beginning of 2012 that Taiwan added its first Certified Child Life Specialist working in the pediatric cancer unit in Taiwan’s leading children’s hospital, National Taiwan University Children’s Hospital (NTUCH). 

Dr. Lu, always energetic and enthused in promoting child-friendly
healthcare.

Introduction of Child Life to Taiwan

Dr. Frank Leigh Lu, a pediatric intensivist at NTUCH, had a vision that was deeply touched by the concept of child life when it was first introduced to him during his scholar visit to Boston’s Children Hospital from 2003 to 2005. He was inspired by Ms. Myra Fox and her lovely energetic child life team advocating for children’s rights and their support for children facing life challenges. Working hard over several years advocating to the hospital and several nonprofit organizations (NPOs) about the child life concept, his dream of bringing child life practices to children’s medical care in Taiwan finally came true. Child life practices finally started to shed light on this beautiful island of Taiwan in 2012.

Prior to child life practices providing psychosocial support, medical needs and treatments were the main focus when children faced medical care. Psychosocial needs were seldom brought up and support was randomly provided by either caring social workers or nurses who already had heavy case loads, or by volunteers from outside organizations such as religious communities and NPOs. The services were inconsistent and mostly not charted. Play opportunities were not considered a necessity to either medical staff or parents. When a child’s adjustment or psychosocial needs became more challenging issues, they were often referred to the hospital psychiatrists or psychologists that covered hospital-wide units and often had a limited number of visits available for young patients' psychosocial issues.

The Gift Shelf Project started in 2017. This project worked as a meaningful incentive system for  cancer patients of all ages to record their hard work in treatments by collecting points and  selecting gifts from generous donations from the Taiwanese society. The project also brings  medical staff and patients closer through interesting conversations about their choices of gifts.

Expressive therapies, such as art therapy and music therapy, provided therapeutic interventions and mental healthcare support in pediatric cancer units earlier than child life. In Taiwan, expressive therapies were mainly limited to pediatric psychiatry and rehabilitation services in the beginning, and expanded to provide care to the pediatric cancer ward around 2007, funded by NPOs.

Raising Children Medical Foundation (RCMF) was the first nonprofit foundation to financially support Taiwanese students’ child life clinical training in the United States and promote the professional practices of child life in Taiwan. The foundation supported pediatric psychosocial services by collaborating with both expressive therapists and child life.

In the fall of 2011, the first child life trainee (the author) began clinical training in the United States, with assistance from Dr. Lu and international child life advocate Ms. Andy Standish from the Standish Foundation, as well as Thomas Hobson, Director of Child life at Le Bonheur Children’s Hospital. RCMF continued to provide the majority of support for three subsequent child life specialists during their internship training phase in the United States and strived to ensure the value of child life was heard by the government, policy makers, and hospital administrators in Taiwan.

Currently Taiwan has four Certified Child Life Specialists working at three different hospitals. The funding for child life practices comes from hospital or governmental projects in combination with donations by the Taiwanese society and generous foundations like RCMF and many other NPOs.

The pediatric oncology team at NTUCH. The author is fourth from the left in the front row.

Early Challenges

Child life, as a new concept and profession, had a slow introduction into pediatrics in Taiwan in 2012. The first challenge was translation of the term “child life” into Mandarin. In order to introduce the child life specialist role to the medical team, there were many discussions and considerations. Finally, the Chinese terms 兒童醫療輔導 and 兒童 醫療輔導師 were settled, which directly translates to English as “child medical counseling” and “child medical counselor.” These terms were utilized as an easier way to recognize and understand child life in the Taiwanese culture. It was also literal for the medical staff and families to understand the role of child life and the psychosocial services provided without much explanation. Currently Mandarin-speaking regions such as Hong Kong, China, and Singapore have followed Taiwan’s footsteps in using the Mandarin term 兒童醫療輔導 for child life.

During the early stages of developing the child life program, some challenges related to terminologies used when providing child life interventions emerged. One challenge involved translating medical procedures and terms into child-friendly language. This was difficult because some medical procedures have threatening words such as needle (IV), cuts (biopsy), or knife (surgery) in the original Mandarin phrases.

Other challenges included learning how to work with the medical team to promote child life practices to the hospital administration. In the beginning, the pediatric medical professionals were not familiar with new child life team members and were hesitant in allowing child life specialists to be involved in medical procedures or to access patient information or charts. Sometimes staff would mistakenly view child life specialists as volunteers who provide toys or gifts to cheer patients up. For several practical reasons, wearing white medical coats was an unusual but necessary decision for the introduction of child life specialists to help them integrate within the medical team. Many hospital staff in Taiwan, including social workers, dietitians, and case workers, also wear white coats as uniforms.

Growth of Child Life in Taiwan

Happily, after seven years of development in Taiwan, child life services have expanded to many hospital units beyond pediatric cancer units. Over these years, we have been able to work with the medical team to set some examples and have directly supported patients and families in pediatric cancer units, surgery, ICU, radiology, general medicine, hospice care, and more. Although the focus in Taiwan for child life services is still mainly in medical teaching and preparation for medical procedures, despite low manpower and resources, child life is putting more emphasis on family and sibling support, adjustments to the medical environment, and play. Medical staff who have worked with child life specialists have experienced and witnessed the impact of child life on families and understand the benefits of child life’s role in focusing on psychosocial support within the medical team. Referrals for child life services are increasing, sent from residents, fellows, attending physicians, nurses,
social workers, and even psychologists.

Due to low numbers of child life professionals and few resources, child life specialists in Taiwan have to locate more educational resources to learn about providing clinical care and promoting the importance of supporting patients’ and families’ psychosocial needs to the medical field and the general public. During these seven years, there have been over 10 local psychosocial support/child life-related conferences for medical staff in several hospitals in Taiwan, and two national conferences to help build awareness of patient- and family-centered psychosocial care. The first two child life specialists in Taiwan were nominated as ACLP International Scholarship recipients in 2015 and 2017, and attended ACLP’s annual conference in the United States. Attending ACLP conferences with sponsorships was extremely helpful
for child life specialists in Taiwan, not only to advance their own professional skills, but to also to help them bring leading psychosocial concepts back to the medical field and Taiwanese society since we do not have similar platforms in the Eastern part of the world to learn from. The ACLP conferences are also tremendous opportunities for networking  especially with fellow Asian child life specialists, and discussions of important issues, such as program development, resources, and differences or similarities of cultural background continue on long after departing the conference. Taiwanese child life specialists have since connected with other Asian child life specialists in Hong Kong, Singapore, and Japan with the same global goal of developing child life while building and adapting Western models.

The first and second child life specialists in Taiwan: Mei-Chi Fang (right) and Hsin-Ju Hsiao (left).

Child life specialists in Taiwan also work hard on research projects, knowing that research and publications speak loud in the medical and science field; such information also leads to strong evidence for policy makers to take into consideration. Several studies and surveys regarding the impact of providing psychosocial support showed positive results in recognition of child life interventions from the medical staff and patients’ or families’ point of view. The first child life study in pediatric oncology, which showed encouraging results, was published in 2019 in one of Taiwan’s pediatric publications, Pediatrics and Neonatology (Hsiao et al.).

In 2018, NTUCH formally hired two Certified Child Life Specialists to work directly within the hospital system, allowing child life practices to move from an outside resource to hospital-provided care with funding from several foundations.

We are hopeful that one day soon child life services will be considered standard medical care for children and families in Taiwan, and even better, that child life will be included in the National Health Insurance System so that all children and families will have the right to receive psychosocial support. It is our dream that in all parts of Taiwan, from the villages in the mountains to any corner of the city clinics or hospitals, child life will continue to shine brighter and brighter for the children and families in this beautiful island Taiwan!