FEATURE | Prescriptions for Joy: Librarians, Collections, and Bibliotherapy in Pediatric Hospital Settings
“Adults who work with hospitalized children look beneath the casts and bandages, behind the conditions of serious illness and disability, to find the child within. Young people in pediatric settings are patients, but they are still children. And wherever children are, books must be there also.”
—Marcella F. Anderson, “Children and Books in Pediatric Hospitals”
When I was three years old, I was hospitalized after I broke my arm in a nasty fall from some baseball bleachers. The fracture was such that my arm needed to be in traction, necessitating a hospital stay that lasted a little over three weeks. I have few memories from the stay— receiving a large teddy bear from my grandfather, feeling lonely one night after my parents had gone home and I couldn’t sleep— but my parents remember all of it. Specifically, they remember how often I wanted to be read to.
As I lay on my small back in that big bed, my arm suspended from a fabric sling strung up above me, my book of choice was The Cat in the Hat by Dr. Seuss (1957). According to my parents, they read me that book hundreds of times during my hospital stay. At one point, according to my mom, I tired of it and requested The Cat in the Hat Comes Back (1958), which the hospital had in the pediatric department playroom. I was a Dr. Seuss–reading machine. When my parents reached the end of each read-aloud, my response was limited to one word: “Again.”
I don’t remember any of these Seuss readings, but aside from that one lonely night, I don’t remember any kind of trauma from what must have felt like an interminable hospital stay either. I have to imagine that the experience of being read to by people who loved me, of hearing Dr. Seuss’s tale of screwball rhymes and feline tomfoolery, entertained, soothed, and distracted me. It conveyed something of home, comfort, and care. I was safe while I listened to Dr. Seuss being read to me by someone I loved.
But many hospitalized children don’t have it so easy. In her article “Creating Bibliotherapeutic Libraries For Pediatric Patients,” Mary Katherine Waibel Duncan writes that “parents’ stress reactions to the diagnosis and treatment of pediatric illness, injury, or victimization as well as their increased involvement in the physical care of young patients may tax their coping resources and impact the quantity and quality of psychosocial support they are able to provide to their children.” Duncan examines the creation of two libraries built to serve pediatric patients and their families in an effort to “support [their] psychological adjustment to their exceptional, and potentially traumatizing, circumstances.” Duncan notes that access to library collections and the read-aloud interactions between parents and children enabled by the presence of collections returns parents and children to “one of the most comforting rituals of childhood and parenting—the shared experience of reading together.” She also argues that “stories and story-related discussions may help children understand that they are not alone and that someone (the story character or a real-life reader/discussant) understands what they are experiencing.” Finally, “the libraries were established to support patients’ and family members’ psychological health and healing by complementing existing child life programs or psychosocial interventions.” It seems that it is not a fluke that the potential trauma of my hospitalization when I was three was alleviated by having my favorite book at hand and people who would read to me.
In 2009, there were nearly 6.4 million hospital stays for children seventeen and under in the United States, “comprising 16 percent of all hospitalizations.” While 72 percent of the 6.4 million recorded hospital stays were for newborns and infants under one year of age, 28 percent of those visits were for children between one and seventeen years old. Within that age range, children between one and four and teens between fourteen and seventeen accounted for the majority of hospital stays.
How many of the millions of children hospitalized each year in the United States have access to book collections during their hospital stays? How many are offered treatment plans that include bibliotherapy? Public libraries have a responsibility to know the answers to these questions pertaining to hospitalized children in their communities and also to serve these young, isolated patients.
The Role of Bibliotherapy in Hospital Library Collection Building
Bibliotherapy can be defined as helping one’s self—or helping others—process and alleviate painful experiences or discomfort through reading. It can be as simple as a warm feeling one might get from holding a beloved book. (To a hospitalized child, a book may ease anxiety by simply being a familiar object in an unfamiliar setting.) It can be as complex as pairing a depressed teen being treated for cancer, which can feel like an unending series of chemotherapy and radiation treatments, with a fictional book like Roland Smith’s Peak (2008), about the youngest boy to climb Mount Everest and live. Bibliotherapy can guide collection development in pediatric settings by connecting material acquisition choices with a deep consideration of pediatric patients and families and their emotional needs.
Books can alleviate anxiety for hospitalized children by providing fun—and the confidence that comes from learning new skills. Elizabeth Weimer, director of early childhood education and director of bibliotherapy at Cleveland (OH) Clinic Children’s Hospital, writes of her experience with a boy named Gilbert who came to the hospital with no exposure to books or English-language skills. During his hospital stay, Gilbert learned how books work, what they are, and that they bring pleasure and fun. Weimer stresses that the work she did reading to Gilbert eased his pain and stress and that it calmed his parents to see their son so positively engaged by reading. Gilbert made cognitive gains during his experiences with Weimer, picking up not only an understanding of books, but an understanding of basic English.
In her 1992 book, Hospitalized Children and Books: A Guide for Librarians, Families, and Caregivers, Marcella F. Anderson writes, “The long-term and frequently hospitalized patient should be a major focus of concern…. A library program that nurtures the child with enriching materials, as he or she moves through developmental stages while hospitalized, supports the ‘fullest possible development and expression of individual potential.’ … In addition to supporting that potential, the library program—with other pediatric therapies—helps to normalize the hospital experience.”
Anderson’s book is an outstanding, sensitively written resource for anyone seeking to build or elevate the quality of hospital book collections. She offers readers a framework for the necessity of the hospital library, finding funding, building the collection, and choosing titles based on the emotional and cognitive needs of patients of different ages. She also provides guidance on successful storytime programming with hospitalized children, bibliotherapy, and working with hospitalized children with special needs like those with severe head injuries or quadriplegia.
Anderson’s book is full of advice for how to manage a hospital library collection, advice that public librarians, working in partnership with local hospital staff, can follow to create or bolster collections for hospitalized kids. For example, she notes the distinction between collection management in public libraries and the same job in hospital libraries, where it is crucial to meaningfully connect with patients in vulnerable circumstances: “Books that do not circulate, do not deserve a place in a hospital collection. Hospital libraries have limited space that can be better used for holding multiple copies of favorite books.” She recommends collecting books in foreign languages based on local language demographics, multi-cultural literature, and special materials like audiobooks, books in braille, adaptive computer software, and tactile books for children with various neurological processing challenges and visual or auditory impairments.
In her book and other articles, Anderson stresses the importance of humor for the hospitalized child: “Studies show that humor helps to reduce stress and to release endorphins, the body’s natural pain blockers that lower pain levels and contribute to a sense of well-being. Also, humor helps patients to relax by the diversion it offers.” She also emphasizes the effectiveness of what she calls “quiet books” for reaching the child’s heart. To Anderson, humorous books and quiet books offer support and solace.
Beyond the criteria of humor and quiet, Anderson usefully separates considerations for collection building into emotional and cognitive needs of patients. She determines emotional and cognitive needs of patients based on different age groups (zero to thirty months; thirty months to five years; six to twelve years) and recommends staff and volunteers building collections do the same. This involves an understanding of child psychology, as well as the psychology of the hospitalized child. Anderson conveys some of the basic needs of hospitalized children in different age groups and models how to think like a collection developer for these children: “Mastery experienced vicariously through a story can carry over to mastering the difficulties of hospitalization—hard feelings, pain, and the medical environment. School age children respond particularly well to these possibilities.” She also recommends books with language “that flows and rhymes,” that provide escape fromboredom, and notes that “it is better to read a book that speaks to the emotion rather than one that mirrors the specific trauma.”
Beyond the building of collections for patients, Anderson writes with authority on how to build a family resource collection:
A Family Resource Collection is based on the premise that family centered care is a desirable goal and that knowledgeable parents are resourceful and supportive partners in the multidisciplinary care of their child.
The general purposes of a Family Resource Collection are:
1. To supplement information provided by the health care staff.
2. To help families develop coping skills with respect to the diagnosis of their child’s illness or disability.
3. To encourage and support the family in participating in the treatment process.
While Anderson’s book could be updated to include information on the use of certain technologies and modern materials such as DVDs, videogames, tablets, and smartphones, her book is an invaluable guide for hospital library collection developers—and anyone who wants to pair books and children together in a hospital setting.
“Underserved communities” are defined by Tonya Badillo, director of the Long Branch (NJ) Free Public Library, as “groups that do not have equal access to programs and services, or have not been identified as a key audience for library services.”
Badillo’s definition of underserved populations would seem to include hospitalized children and their families. Children and families in both short- and long-term hospitalization situations are often confined to the hospital building (let alone confined to beds, incubators, or isolation units) in which medical care is administered. Many parents of hospitalized children rarely want to leave their child’s bedside, preferring to stay nearby and certainly within the building. It is not possible for many pediatric in-patients and their families—members of the public nonetheless—to have equal access to public library programs and services. Nor are these individuals commonly identified as a key audience for library services.
Anderson elaborates further to define hospitalized children as a minority in need of library service:
Chronically ill, frequently hospitalized children can be viewed by themselves and by others as comprising a unique culture group within our larger community. These children can become physically and psychologically separated from family, from friends, from normal growing experiences, from information needed for success in school and job, and from participation in and knowledge of the larger world. Voids in growth and development contribute to a child’s sense of isolation and lowered self-esteem. To encourage, respect, and strengthen these young people is to give them a chance to be an integral part of society. Books can be a powerful tool in accomplishing these goals.
The American Library Association (ALA) states that “diversity is a fundamental value of the association and its members,” and that the association recognizes “the critical need for access to library and information resources, services, and technologies by all people.” Hospitalized children and families are not, however, listed as an underserved population on the ALA’s list of outreach areas.
Because of the specialized care required by hospitalized children and families that makes them unable to access regular library services, outreach to these communities should be a priority of public library service. Children’s outreach librarians could identify local healthcare clinics and hospital pediatric departments where children are regularly treated to establish and tend waiting room collections of books. These books could be culled from library book donations and weeded library items in good condition. Librarians could also partner with child life specialists at local hospitals to create high-quality book collections in family resource centers and play therapy rooms. Reach Out and Read, a national organization that promotes literacy in the context of pediatric care, partners with public libraries to reach children who might otherwise lack access to library services because of illness or physical impairments. Their work includes building collections in waiting rooms serving low-income children, providing story time read-aloud services, and educating parents on promoting literacy at home. Because many long-term pediatric patients require academic support and schooling in the hospital, libraries with “school outreach” librarians can support academic services in pediatric hospitals by providing research instruction and delivering public library books and materials needed to supplement research projects.
Public librarians are in a unique position to bring their professional training and knowledge to bear on book and resource collections in pediatric hospital settings. In doing so, they would satisfy the ALA’s exhortation that we find ways to serve traditionally underserved populations in our community.
Hospitalized children and their families have particular information needs. Through the establishment and management of carefully curated library collections, hospital staff and librarians can partner to provide children and families with invaluable resources and programming to help them cognitively and emotionally. The work of building rich, comprehensive book collections for young hospital patients can help enable read-aloud work and bibliotherapeutic activities that will alleviate anxiety, bolster cognitive functioning, emotionally soothe, and provide moments of grace and joy for young patients and their families.
 Marcella F. Anderson, “Children and Books in Pediatric Hospitals,” Horn Book Magazine 62, no. 6 (Nov. 1986): 788.
 Mary Katherine Waibel Duncan, “Creating Bibliotherapeutic Libraries for Pediatric Patients and Their Families: Potential Contributions of a Cognitive Theory of Traumatic Stress,” Journal of Pediatric Nursing 25, no. 1 (Feb. 2010): 25.
 John T. Pardeck, “Bibliotherapy: An Innovative Approach for Helping Children,” Early Childhood Development and Care 110, no. 1 (1995): 83–88, cited in Duncan, 25.
 Duncan, 25.
 Hao Yu, Lauren M. Wier, and Anne Elixhauser, Hospital Stays for Children, 2009, Healthcare Cost and Utilization Project Statistical Brief #118 (Rockville, MD: Agency for Healthcare Research and Quality, 2011): 1.
 Ibid., 3.
 Elizabeth Weimer, “The Power of Books in a Children’s Hospital: A Success Story,” Children & Libraries 8, no. 1 (2010): 20–21.
 Marcella F. Anderson, Hospitalized Children and Books: A Guide for Librarians, Families, and Caregivers, 2nd ed. (Metuchen, NJ, and London: Scarecrow Press, 1992): xvi.
 Ibid., 7.
 Ibid., 15.
 Ibid., 27.
 Ibid., 67.
 American Library Association, “Outreach and Diversity,” in “The State of America’s Libraries 2014,” special issue, American Libraries (2014): 53.
 Marcella F. Anderson, “Literature in the Pediatric Setting: The Use of Books to Help Meet the Emotional and Cognitive Needs of Chronically Ill Children,” in Anthony L. Manna and Carolyn S. Brodie, eds., Many Faces, Many Voices (Fort Atkinson, WI: Highsmith, 1992): 79–86.
- Bowman, Cynthia Ann, Using Literature to Help Troubled Teenagers Cope with Health Issues (Westport, CT: Greenwood Pr., 2000).
- Calman, Albi, “Are Volunteers Worth the Effort? Maximizing the Value of Volunteers in the Hospital Library,” Journal of Hospital Librarianship 10, no. 4 (Oct. 2010): 395–401.
- Dovey, Ceridwen, “Is Reading the New Therapy?” New Yorker (June 9, 2015).
- Gavigan, Karen, “Caring through Comics—Graphic Novels and Bibliotherapy for Grades 6–12,” Knowledge Quest 40, no. 4 (May/June 2012): 78–80.
- Jones, Jami L., “A Closer Look at Bibliotherapy,” Young Adult Library Services 5, no. 1 (Fall 2006): 24–27.
- Lu, Ya-Ling, “Helping Children Cope: What is Bibliotherapy?” Children & Libraries 6, no. 1 (Spring 2008): 47–49.
- Navsaria, Dipesh, “How Promoting Literacy Is Key To Early Brain and Childhood Development,” filmed Mar. 29. 2015, YouTube video, 59:44, posted Apr. 10, 2014, by Oconomowoc Public Library, https://youtu.be/VG-9BKBcvbo.
- Pierce, Jennifer Burek, ”A Feeling for Books: Therapeutic Connections to Library Practice,” American Libraries (Nov. 22, 2010), accessed Aug. 2, 2016, https://americanlibrariesmagazine.org/2010/11/22/a-feeling-for-books.
- Reach Out and Read (www.reachoutandread.org).
- Texas Children’s Pi Beta Phi Library (www.texaschildrens.org/Plan/Patient-Amenities/Patient-Library).
- Zaccaria, Joseph S., Harold A. Moses, and Jeff S. Hollowell, Bibliotherapy in Rehabilitation, Educational, and Mental Health Settings: Theory, Research, and Practice (Champaign, IL: Stipes, 1978).