Internarea in Spital a Copilului

7/27/2019 Internarea in Spital a Copilului

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Internarea in spital a copilului, efecte

emotionaleautor: Daniela Ganciu

26 Noiembrie 2010

4

Internarea in spital a copilului presupune schimbareamediului familiar intr-unul care nu este intotdeauna cel maiprimitor. Sa stai in spital cu copilul poate fi destul de dificilpentru el la orice varsta. Atat spitalul, cat si boala reprezintafactori de stres puternici pentru micutul tau. El poateinterveni in dezvoltarea lui normala si il poate afecta petermen lung.

A interna copilul in spital inseamna practic intreruperea viatiilui obisnuite si schimbarea ambientului confortabil in careera obisnuit pana atunci. Cand sunt in spital copiii resimtlipsa casei, a prietenilor si a altor membrii ai familiei care nusunt cu el.

Pe langa stresul inevitabil care apare la copiii internati,acestia pot dezvolta sentimente de frica sauchiarplictisealaceea ce ii poate face usor iritabili si agitati.Ei nu inteleg foarte bine de ce anume este acolo si nici ceanume se intampla in incinta unui spital, ceea ce ii poatecrea frustrari si temeri.

Ce efecte are spitalul asupra copiilor de diferite

varste?

Sigur ca exista cativa factori importanti care contribuie laintensitatea efectelor ce pot plana asupra unui copil dincauza internarii in spital:

varsta;

motivul spitalizarii;

temperamentul;

persoana care sta internata cu el.

Copiii pana la 1 an
http://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.htmlhttp://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.htmlhttp://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.htmlhttp://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.html


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pana la un an copiii dezvolta o multime de aptitudininoi; daca ei stau internati o buna parte a timpului inspital pot aparea intarzieri in dezvoltare;

pot duce lipsa de stimulare senzoriala care ii ajuta ladezvoltare ca muzica, lumina, pozitii alecorpului,jucariietc.;

daca membrii familiei nu petrec suficient timp cu el laspital, relatiile dintre parinti si copii pot fi afectate.

Copiii de la 1 la 2 ani

dezvoltarea poate fi intarziata din cauza faptului catimpul petrecut in spital interfereaza cu activitaticare ar fi putut ajuta la stimularea noilor abilitati;

pot aparea probleme de somn;

dezechilibrele alimentare sunt un efect al schimbariirutinii de acasa si al stresului;

la aceasta varsta copiii se tem foarte tare de straini,iar prezenta asistentelor si doctorilor i-ar putea

creste nivelul de anxietate;

copiii sunt iritati, frustrati si infricosati pentru ca estegreu sa inteleaga la aceasta varsta motivul pentrucare sunt in spital.

Copiii de 2 la 5 ani

principalul impact negativ la copiii de aceste varsteeste stresul de a fi departe de tot ceea ce le este

familiar;

pot manifesta o frica de faptul ca procedurilemedicale ca injectii, analize etc le poate face rau;

pot trai cu impresia ca au facut ceva rau si ca deaceea sunt in spital;

ei isi cunosc cat de cat corpul, insa intelegereamodului de functionare a lui este departe de a fi

stiuta de ei; acest lucru le poate crea frustrari;
http://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.htmlhttp://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.htmlhttp://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.htmlhttp://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.html


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limbajul este dezvoltat intr-o buna masura pana la 5ani, dar poate exista riscul ca ei sa interpretezegresit ceea ce aud.

Copii de la 5 ani in sus

Copiii intre 5-12 ani pot manifesta oricare dintre starileanterior prezentate, plus faptul ca in aceasta perioada eimanifesta obisnuitafrica de doctor, ace sau durere.

De asemenea, apare si un disconfort cauzat de invadareaintimitatii, iar pe masura ce cresc incep sa inteleaga casufera de o boala grava sau ca ceva rau li se intampla,efectele psihologice fiind mult mai de impact.

Cum il poti ajuta sa depaseasca stresul internarii in

spital?

Pregatirea pentru internare

Daca nu este vorba de o urgenta medicala, iar internareaeste planificata este recomandat sa il implici pe copil inpregatirea bagajelului si sa vorbesti cu el despre experienta.

Daca nu stii cum sa il pregatesti intreaba un medic sauasistentele cum sa faci acest lucru. Retine insa ca tu esti unmodel pentru el, iar daca iti este frica sau esti mereu tristasi suparata, copilul tau va avea tendinta sa preia starile tale.

Comunica mereu cu el!

Vorbeste-i despre ce va urma si ce se intampla intr-unspital, intr-un vovabular cat mai apropiat varstei lui. Nuincerca sa il minti! Incearca sa raspunzi cat mai eficient la

intrebarile pe care ti le adreseaza, iar daca nu stii cum sa ofaci la unele dintre ele, nu te panica. Este in regula sa nu stiiunele raspunsurile. Spune-i ca medicul ii va raspunde laacele intrebari.

Asigura-te ca tot timpul vin in vizita figuri familiare!

Familia si prietenii sunt cei care il pot ajuta pe copil sa sesimta mai confortabil si in siguranta atunci cand se aflainternati in spital. Pe langa faptul ca unul dintre parinti va

sta cu el tot timpul, incearca sa planifici vizitele astfel incat
http://www.copilul.ro/comunicare-copii/emotiile-copiilor/Frica-de-medic-a2252.htmlhttp://www.copilul.ro/comunicare-copii/emotiile-copiilor/Frica-de-medic-a2252.htmlhttp://www.copilul.ro/comunicare-copii/emotiile-copiilor/Frica-de-medic-a2252.html


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sa acopere o mare parte din zi, pentru ca micutul tau sa fiemai relaxat.

Adu-i obiecte familiare de acasa!

Pe langa faptul ca spitalul este un mediu necunoscut lui, eleste si neprietenos, avand culori terne si reci care crescnivelul de stres. De aceea este important sa personalizezirezerva micutului tau cu jucariile preferate si cu alte obiecteaduse de acasa.

Incurajeaza-l sa se joace!

Atat cat ii este la-ndemana si cat poate din punct de vederefizic incurajeaza copilul sa se joace pentru a se simti inelementul lui. Joaca ii poate distrage atentia de la boala,durere si anxietate. De asemenea, il ajuta sa se dezvoltecorespunzator varstei lui, stimulandu-icreativitateasi alteabilitati.Atribute de dezvoltare ale copiilor precolari

Exist ase trsturi de dezvoltare ale copiilor precolari care poateafecta pregtirea pentru procedura chirurgical.

Precolarii experimenteaz cu lumea din jur n principal prinsimuri: ce vd, aud, miros, gust i simt. n a le explica de ceoperaia este necesar, prinii i personalul medical pot sutilizeze exemple de cum simptomele vor fi schimbate pozitiv dupoperaie. De exemplu, li se poate spune Dup recuperarea de laoperaie, vei putea fugi cu prietenii ti fr s mai ai probleme curespiraia sau s oboseti.

Precolarii au o cogniie egocentric: se vd ca centrul universuluii sunt convini c toat lumea tie cum se simt. Prin urmare, artrebui s cerem copiilor s explice propriile simptomele n funciede experiena lor. De exemplu: Arat-mi sau zi-mi exact undedoare? Pentru a realiza o evaluare corect a durerii, pot fi utilizatescale adaptate copiilor.

Precolarii se focuseaz numai pe aspectele evidente ale situaieilor. n spital ei pot fi uor speriai de maini zgomotoase,mbrcmintea i echipamentul special utilizat de asistente idoctori, iar prinii i personalul medical trebuie s reasigure

copilul. Pentru a evita situaii nfricotoare, atenia unui copilpoate fi uor distras spre lucruri pozitive precum jucrii moi,muzic sau poze.

Copiii precolari nu pot percepe inteniile celorlali. Astfel, nunelege cum un doctor care i administreaz un tratament durerosi dorete binele. nainte de a ncepe o procedur dureroas ineconfortabil, persoana din echipa medical ar trebui s-i explicebunele intenii. Jocul de rol ar putea fi benefic n aceast situaie.De exemplu, copilul poate fi rugat s explice unei ppui c arenevoie de o injecie i apoi acioneaz n a-i administra ppuiiinjecia.

Ei nu pot gndi n trecut. Prin urmare, procedura creia vor fisupui trebuie explicat secvenial. Adiional, copiii nu au o ideeclar asupra timpului. Prinii ar trebui s utilizeze exemple pentrua mbunti nelegerea copilului lor asupra timpului. De exemplu,n loc s i explice copilului c va sta n spital 10 zile, prinii pot s
http://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.htmlhttp://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.htmlhttp://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.htmlhttp://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.html


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utilizeze alte repere (ex. dup ce vine bunica n vizit mai stai nspital numai o zi).

Precolarii nu neleg diferena dintre cauz i efect. De exemplu,un copil care are un frate mai mare, care a suferit o operaie pecord, poate considera c este normal ca copiii s fie operai naintede a ncepe coala. Ali copii pot interpreta operaia ca pe opedeaps pentru comportamentul reprobabil. Prinii trebuie sdiscute cu copiii lor pentru a nu corela boala cu comportamentesau atitudini nedorite.

Birmingham (Marea Britanie): program de reducere a

anxietii n acest program, un psiholog i un terapeut au lucrat

mpreun, utiliznd principii congnitve pentru a reduceanxietate prin de-sensibilizare (i creterea controluluiperceput de ctre copil). Durata programului variaz nfuncie de vrsta copilului, etapa de dezvoltare, perioadapentru pregtire, experiena, nivelul de anxietate alcopilului i al printelui, precum i tipul de intervenie

cardiac necesar. Copiii pregtii se prezint mai puinstresai i sunt mai cooperani n timpul procedurilorcardiace, dect cei nepregtii. Prinii i echipa medicalpar a beneficia de asemenea de pe urma acesteiintervenii.

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An interventio Search

Medicine>Nursing

Medicine>Health care management

An intervention toreduce anxiety/fear inhospitalized Thai

school age childrenDissertation

Author: Duangrat Kathalae

Abstract:

In many Thai hospitals, there is a lack of special

psychological preoperative preparation programs for

hospitalized Thai children and their families. The purpose

of this single-blind, randomized clinical trial was to test

the efficacy of a psychological preoperative preparation

intervention (PPPI), in the form of a cartoon coloring

book, designed to reduce anxiety/fear before surgery in

hospitalized Thai school age children 8-11 years old. One

hundred and four subjects, hospitalized for surgery, were

randomly assigned into either an intervention or control

group. Each group received the usual preoperative care

given by ward staff. The experimental group received the

PPPI given by the investigator. Pre-and posttestanxiety/fear of both groups were measured using the

STAIC-R and CMFS-R in Thai versions. Demographic

and clinical data, and information on the child's use of

meditation were also collected. Descriptive statistics were

used to describe demographic and clinical data. A paired-

t test demonstrated significant decreases in state anxiety

and medical fear means between pre- and post-

intervention for the experimental group but not for thecontrol group. Hierarchical regression analysis compared
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the effect of the PPPI to usual care after controlling for

covariate variables. State anxiety at post-intervention was

significantly less in the PPPI group than in the usual care

group controlling for state- and trait anxiety at pre-

intervention, the child's age, and the child's use of

meditation. There was no evidence to support an effect of

PPPI on post-intervention medical fear when CMFS and

trait anxiety at pre-intervention, the child's age, and the

child's use of meditation were controlled. The PPPI

appears to be a culturally sensitive intervention for

hospitalized Thai school age children. Reading and

coloring the cartoon pictures distracted the children from

the stressful situations and helped them focus on the

content. Age appropriate narrative content in the coloring

book may have helped the children assimilate information

in a short time period. The possible reasons that could

have accounted for the non-significant effect on fear

mean scores between groups are the small sample size,

the intervention diffusion between groups, and the

between-group variation on state anxiety and fear scores.

vii TABLE OF CONTENTS Page

Dedication

...iii

Acknowledgements

.iv List of

Tables

xiii List of

Figures.........

..xiv

Abstract..........

....xv Chapter 1

Introduction.........................................................................

............................................1 Research

Hypotheses.........................................................................

......................4 Theoretical

Framework............................................................................................5 Definition of


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Terms..........

........5 Overview of

Methodology.....................

..........6

Significances......................................................................

................................10 2 Theoretical Framework and

Literature Review.......................................................11

Theoretical Frameworks on Preparing Children for

Surgery and

Hospitalization....................................................................

.......................11 Cognitive Behavioral Theory (CBT):

Stress and Coping Model..........................12 Social

Cognitive Theory

(SCT)..................................................................... ....13

Lazaruss Anxiety

Concept.......................................................................

.....15 State-Trait Anxiety

Concept..............................................................................

....17 Transformation of Anxiety into

Fear.................................................................18Relevancy of Stress, Coping, Anxiety, and Fear in the

This Study.......................19

viii Page Chapter Piagets Cognitive Development Theory

(CDT)...................20 Universal Stage,

Childrens Concepts of Physical Illness, and Cross

Cultural

Variability............................................................................

......................22 Appropriateness of Theoretical/

Conceptual Frameworks for Preoperative Preparation of

Thai School Children.............................22

Anxiety and Fear in School age

Children..............................................................25

Childrens Self-report of Anxiety and

Fear...........................................................26 Basic

Attitudes of Thai Child-rearing

Patterns......................................................27 Cultural


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Context and Health Care Tradition in

Thailand.......................................29 Practicing Meditation

among Thai Buddhist Children and

Families.....................30 Psychological and Physiological

Effects of Hospitalization and Surgery in School age

Children..............................................................................

.....32 Importance of Psychological Preoperative

Preparation for Pediatric Surgical

Patient................................................................................

........................33 Type and Effectiveness of

Psychological Preoperative Interventions...................33

Information and Education

Provision....................................................33 Modeling

Intervention............................................

...35 Cognitive

Coping................................................................................

.......37 Influencing Factors on the Effectiveness of

Psychological Preoperative Preparation Program on

School Age Children...............................39

Methodological Constraints of Psychological PreoperativePreparation...............42

ix Page Chapter 3

Methodology...

..................44

Design................................................................................

................................44

Setting.................................................. ...........................

...................................45

Sample............................................................................

....................................46 Sampling

Frame.................................................................................

........46 Inclusion

Criteria..............................

.46 Exclusion

Criteria............................................................................

......46 Sample


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Size...........................

.....47 Screening and

Recruitment........................................................................

49 Instruments and

Measurement......................................................................

.........51 State-Trait Anxiety Inventory for Children-

Revised (STAIC-R) in Thai

Version..........................................................................5

1 Child Medical Fear Scale-Revised (CMFS-R) in Thai

Version................52 Psychometric Properties of STAIC-R

and CMFS-R in Thai Versions......53 Standard Procedure

for Administering the STAIC-R and CMFS-R in Thai

Versions.............................................................................

54 Demographic and Clinical

Questionnaires................................................56 The

Childs Use of Meditation

Questionnaire...........................................57 Study

Procedures for both the Experimental and Control

Groups........................57 Experimental

Intervention.........................62 Psychological Preoperative Preparation

Intervention............................................62

x Page Chapter Psychological Preoperative Preparation

Intervention (PPPI)

Administration.....................................................................

......................63 Benefits of Using the Cartoon Coloring

Book as the Modeling

Intervention.........................................................................

.......................64 Usual Preoperative Care for the

Experimental and Control Groups......................66 Data

Management and

Analysis............................................................................6

6 Data Entry and

Verification.......................................................................6

6 Data and Analysis for Research Hypothesis 1 and

2.................67 Data and Analysis for Research


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Hypothesis 3...67 Management of

Missing

Data....................................................................68

Protection of Human

Participants.........................................................................

.69 4

Results

.......71 Sample

Descriptive..

..71 Hypothesis

Testing..

...77 Change in Anxiety/Fear between the Pre-and

Post-Intervention Within

Groups.

...77 Effectiveness of Cartoon Coloring Book Intervention

on Dependent

Variables

....79

Summary

....85 5Discussion

.....86 Interpretation and Discussion of

Findings.....86

xi Page Change in Anxiety/Fear from Pre-to-Post-

Intervention by Groups...87 Effectiveness of PPPI

Compared to Usual Care88

Comparison of Findings to the

Literature......89 Cartoon

Coloring Book as a Modeling and Distraction

Intervention....89 Influence of Cognitive Ability on the

Roles and Expected Behaviors..93 Timing of

Preparation....

94 Possible Reasons for No Group Differences on Fear

Variable......95 Small Sample

Size.95

Diffusion of Study


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Intervention.96

Between-Group Variation on State Anxiety and Fear

Scores...97 Cultural Sensitive

Intervention..98

Meditation as a Covariate

Variable..100

Limitations

.......101 Future

Research.

..........102 Clinical

Implications...

.....103 Appendixes Appendix A Potential Subject

Screening Sheet ............................................106

Appendix B Informed Consent for Parent or Guardian and

Assent for Minor

Forms.................................................................................

107 Appendix C Children and Youth Institutional Review

Board Approval and Access Letter for Maharat Nakhon

Ratchasima Hospital

Director........................................................................................112

xii Page Appendix D STAIC-R & CMFS-R in English and

Thai Languages and Permission

Letter.......................................................................116

Appendix E Research Assistant

Instructions...................................................127 Appendix

F Demographic and Clinical Data Sheet for

Subject......................130 Appendix G Demographic and

Clinical Data Sheet for Parent or Guardian...132

Appendix H The Childs Use of

Meditation....................................................134 Appendix

I Cartoon Coloring

Book.................................................................135

Appendix J Summary of the Roles and Expected

Behaviors in the Cartoon Coloring

Book............................................................................148


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References............

...................................151

xiii LIST OF TABLES Table Page 1 Anticipated Time of

the PPPI and

Measurement........................................................60 2

Number of Pages by Age the Experimental Group

Colored on the Cartoon

Coloring..

...65 3 Descriptive Statistics of Demographic and

Clinical Characteristics by Study

Group

....72 4 Descriptive Statistics of Parent or

Guardian Demographic Characteristics by Study

Group

...74 5 Number of Days before Surgery

and Anxiety Level of Parents or Guardians....76 6

Paired Samples Test within Groups between the Pre-and

Post-Intervention..79 7 Regression of Post-

Intervention S Anxiety on Study Group Controlling for

Age, Meditation, and Baseline S-and T-

Anxiety...81

8 Regression of Post-Intervention CMFS on Study Group

Controlling for Age, Meditation, and Baseline CMFS and

T-Anxiety...83

9 Frequency of Knowing How to Do Meditation, Regular

Practice, and Use afterAdmission

84

xiv LIST OF FIGURES Figure Page 1 Theoretical and

Conceptual Frameworks Application for Designing

Intervention....25 2 Study Procedure Flow Chart for

Testing the Effectiveness of the Psychological

Preoperative Preparation Intervention

(PPPI).............................................................61


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xv AN INTERVENTION TO REDUCE ANXIETY/FEAR IN

HOSPITALIZED THAI SCHOOL AGE CHILDREN

Duangrat Kathalae Dr. Mary Ann Jezewski, Dissertation

Chair

ABSTRACT

In many Thai hospitals, there is a lack of special

psychological preoperative preparation programs for

hospitalized Thai children and their families. The purpose

of this single-blind, randomized clinical trial was to test

the efficacy of a psychological preoperative preparation

intervention (PPPI), in the form of a cartoon coloringbook, designed to reduce anxiety/fear before surgery in

hospitalized Thai school age children 8- 11 years old.

One hundred and four subjects, hospitalized for surgery,

were randomly assigned into either an intervention or

control group. Each group received the usual

preoperative care given by ward staff. The experimental

group received the PPPI given by the investigator. Pre-

and posttest anxiety/fear of both groups were measuredusing the STAIC-R and CMFS-R in Thai versions.

Demographic and clinical data, and information on the

childs use of meditation were also collected. Descriptive

statistics were used to describe demographic and clinical

data. A paired-t test demonstrated significant decreases

in state anxiety and medical fear means between pre-and

post-intervention for the experimental group but not for

the control group. Hierarchical regression analysis

compared the effect of the PPPI to usual care after

xvi controlling for covariate variables. State anxiety at

post-intervention was significantly less in the PPPI group

than in the usual care group controlling for state-and trait

anxiety at pre-intervention, the childs age, and the childs

use of meditation. There was no evidence to support an

effect of PPPI on post-intervention medical fear whenCMFS and trait anxiety at pre-intervention, the childs


15/28

age, and the childs use of meditation were controlled.

The PPPI appears to be a culturally sensitive intervention

for hospitalized Thai school age children. Reading and

coloring the cartoon pictures distracted the children from

the stressful situations and helped them focus on the

content. Age appropriate narrative content in the coloring

book may have helped the children assimilate information

in a short time period. The possible reasons that could

have accounted for the non-significant effect on fear

mean scores between groups are the small sample size,

the intervention diffusion between groups, and the


1 CHAPTER 1

Introduction

It is well established that there is a need for psychological

preparation of hospitalized children undergoing surgery.

Interventions can reduce anxiety and fear producing

experiences that could result in short and long term

psychological disturbances, emotional and behavior

problems in children (Ben-Amitay et al., 2006; Coyne,

2006; Li & Lopez, 2005, 2006; Lumley, Melamed, &

Abeles, 1993; Murphy-Taylor, 1999; OConner-Von,

2000; Patel et al., 2006; Strachan, 1993; Tiedeman &

Clatworthy, 1990; Vagnoli, Caprilli, Robiglio, & Messeri,

2006; Ziegler & Prior, 1994). Hospitalization can produce

stress, anxiety, and fear among pediatric patientsirrespective of the reasons for hospitalization. Surgery

can be both physically and psychologically threatening for

school age children (Bowden, Dickey, & Greenberg,

1998; Wong, 1997). The preoperative period is

considered to be a stressful, anxiety-filled time and

hospitalized children often experience the highest anxiety

prior to surgery which in turn can be a significant factor

affecting recovery from surgery (Ellerton & Merriam,1994; Fortner, 1998). Hospitalized school age children


16/28


17/28

linguistic and visual-spatial skills which are emerging

during middle childhood (Cole & Cole, 2001). Not only are

school age children better prepared to cope than their

younger counterparts, they also respond better to

information-based preparation (Kain, et al., 1998;

LaMontagne, Hepworth, Cohen, & Salisbury, 2003a).

Their reading ability improves from school experiences. If

given an

3 appropriately designed intervention within their

cognitive ability, school age children are able to read and

understand instructions. They are able to readily

assimilate and accommodate the new experiences about

hospitalization and surgery to adapt by means of their

previous experiences (Beckett, 2002; Cole & Cole, 2001).

Hospitalized school age children prefer a preparation

book for surgery which has pictures and photographs with

text (Smith & Callery, 2005). According to social cognitive

theory as developed by Bandura (1986a), modeling

intervention can benefit school age children by observing

the performance of others, especially if the model is

similar to their ability, age, gender, and experiences. The

cartoon coloring book was used as modeling intervention

in this study. The characteristics and the expressions of

the children in this cartoon coloring book are a

representative model for hospitalized Thai school age

children. Observing similar children in the cartoon

coloring book performing successfully could raise their

capabilities to master comparable activities. Based on the

patterns of Thai child rearing, basic attitudes, health care

tradition in Thai hospitals, and other cultural contexts

such as using meditation as the first choice of a coping

strategy among Thai Buddhist families, this cartoon

coloring book was a culturally sensitive intervention for

hospitalized Thai school age children. This culturally

sensitive intervention was used as a psychological

preoperative preparation intervention (PPPI) during this


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study. The design mainly focused on supporting, guiding,

and encouraging hospitalized Thai school age children to

use appropriate ways in reducing anxiety and fear before

surgery such as asking question, expressing and sharing

of how they feel with their families, friends, doctors, or

nurses. Coloring the pictures during the

4 waiting period for surgery distracted them from other

stressful situations (Wollin, Plummer, Hawkins,

Materazzo, & Morrison, 2004). Hospitalization and

surgery have many adverse psychological effects on

school age children that may be prevented or minimized

by psychological preoperative intervention procedures

(Gillis, 1990). The major goals of a psychological

preoperative preparation intervention are to reduce

unknown fear and decrease the unavoidable stresses

and anxiety associated with surgery (Ball & Bindler, 1995;

Freeland & Munro, 1995). The purpose of this study was

to test the efficacy of a psychological preoperative

preparation intervention (PPPI) designed to reduce

anxiety/fear in hospitalized Thai school age children 8 to

11 years old undergoing elective surgery. The research

questions to be addressed were (1) Is there a change in

anxiety/fear from pre- to post- intervention for the

experimental and control groups? , and (2) What is the

effect of PPPI on anxiety/fear at post-intervention as

compared to usual care (control group) controlling for the

covariate variables: S-anxiety, T-anxiety, and fear from

Child Medical Fear Scale (CMFS) at pre-intervention, the

childs age, and a childs use of meditation? Research

Hypotheses Hypothesis 1 Hospitalized Thai school age

children 8 to 11 years old, who receive the PPPI, have

significantly less anxiety/fear the evening before surgery

(post-intervention) than the first hour after admission (pre-

intervention).


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5 Hypothesis 2 Hospitalized Thai school age children 8 to

11 years old, who receive standard preoperative

preparation, have the same or greater anxiety/fear the

evening before surgery than the first hour after

admission. Hypothesis 3 Hospitalized Thai school age

children 8 to 11 years old, who receive the PPPI, have

significantly less anxiety/fear the evening before surgery

(post-intervention) than those in the control group

controlling for S-anxiety, T-anxiety, and fear from Child

Medical Fear Scale (CMFS) at pre-intervention, the

childs age, and the childs use of meditation. Theoretical

Framework This study was based on theoretical

frameworks comprised of elements of cognitive

behavioral theory (CBT), which focuses on a stress and

coping model as articulated by Lazarus and colleagues

(Lazarus, 1966; Lazarus & Folkman, 1984), social

cognitive theory (SCT), which focuses on modeling as

developed by Bandura (1986a), the concrete operational

stage from Piagets cognitive developmental theory

(CDT) (Piaget, 1966), and state-trait conception ofanxiety by Spielberger (1973). Definition of Terms

Anxiety/Fear An individuals total reaction to perceived

threat or danger that involves subjective feelings of

apprehension, uneasiness, agitation, uncertainty, and

fear, heightened autonomic nervous system activities,

and avoidance behavior. In this study, anxiety is defined

as synonymous with fear. Anxiety/fear was measured by

the Thai

6 Versions of the State-Trait Anxiety Inventory for

Children-Revised (STAIC-R) and the Child Medical Fear

Scale-Revised (CMFS-R). Thai School age Children Thai

children between 8 and 11 years old Psychological

Preoperative Preparation Intervention (PPPI) An

intervention designed to reduce anxiety/fear by use of a

cartoon coloring book developed with considerations for

the level of cognitive development of Thai school age


20/28

children 8 to 11 years old and of their culture. Elective

Surgery Non- emergency surgery that is scheduled at

least 24 hours before hospitalization and where the

pediatric patients have to stay overnight in hospital.

Overview of Methodology The randomized, true

experimental, pretest-posttest control group, and single-

blind design was used to investigate the effectiveness of

the PPPI for reducing anxiety/fear before surgery in

hospitalized Thai school age children 8 to 11 years old.

The design was a comparison study between an

experimental group in which each child received standard

preoperative preparation (SPP) from pediatric surgical

ward staff and the PPPI from the investigator and a

control group where each child received only SPP. The

setting was the pediatric surgery ward in a tertiary

hospital in the Northeastern part of Thailand, Maharat

Nakhon Ratchasima Hospital, located in the metropolitan

area of Nakhon Ratchasima province. Sample size

predictions employed the use of power analysis for the

analysis of covariance (ANCOVA). The followingparameters were used (a) probability of a type

7 one error of .05, (b) a power of .80, and (c) a medium

effect size of .25. Based on these parameters, a sample

size of 64 in each group allowed the detection of post-

intervention anxiety and fear-mean score differences, if

present, due to the PPPI between the experimental and

control groups with four covariates (Cohen, 1988; Yow-

Wu B. Wu, personal communication, November 1, 2005).

A medium effect size has been chosen for the study

based on previous studies of Bossert (1994), Hart and

Bossert (1994), and Lizasoain and Polaino (1995). By

using the SPSS program, the 128 predicted subjects

were to be randomly assigned into the experimental or

control group by the investigator prior to consent and data

collection. The random assignment for allocating subjects

into groups was processed and recorded by the


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investigator. The results of random assignment were not

disclosed to the research assistant who then

administered the measurement instruments. The

inclusion criteria for selecting Thai school age children

who were scheduled to undergo elective surgery were (1)

Thai school age children between 8 and 11 years old, (2)

anticipated hospital stay of at least 24 hours, (3)

admission into the hospital the day before surgery, (4)

ability to read and speak the Thai language, (5) normal

cognitive ability as determined by age-appropriate grade,

(6) the parent or guardian is present during admission,

and 7) patient has no previous experience of

hospitalization. The exclusion criteria were Thai school

age children 8 to 11 years old who (1) have cognitive

impairment, (2) have physical or psychological conditions

that are not appropriate to participating in the PPPI, such

as blindness, deafness, mental retardation, or psychiatric

conditions, or (3) have a psychological condition requiring

consultation with a specialist or special care. The final

sample size of this study was 104 participants. Therewere 53 subjects in the

8 experimental group and 51 participants in the control

group which was lower than expected, based on the

power analysis and previous studies (Bossert, 1994; Hart

& Bossert, 1994; Lizasoain & Polaino, 1995). The Thai

Versions of the State-Trait Anxiety Inventory for Children-

Revised (STAIC-R) and the Child Medical Fear Scale-

Revised (CMFS-R), which were revised, translated, and

psychometrically tested by Chaiyawat (2000), were used

to measure anxiety/fear pre-and post-intervention.

Descriptive statistics were used to describe all

demographic and clinical data and the childs use of

meditation. To test for the effectiveness of the PPPI, the

null hypotheses were rejected at the p < .05 level for all of

the hypotheses. The following statistical procedures were

used for testing each research hypothesis. Hypothesis 1


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The effect of the PPPI on the levels of anxiety/fear of

hospitalized Thai school age children 8 to 11 years old

undergoing elective surgery was examined within the

experimental group. The two-tailed dependent t-test

(paired t-test) was used to examine the differences in

means from the S-Anxiety scale and CMFS between the

pre- intervention (the first hour after admission) and the

post-intervention (the evening before surgery) to

determine if changes have taken place within the

experimental group. Hypothesis 2 The differences of

means from the S-Anxiety scale and CMFS between the

first hour after admission and the evening before surgery

of hospitalized Thai school age children 8 to 11 years old

who received standard preoperative preparation were

examined

9 by using the two-tailed dependent t-test (paired t-test)

to determine if changes have taken place within the

control group. Hypothesis 3 The effects of the PPPI on

the levels of anxiety/fear of hospitalized Thai school age

children 8 to 11 years old undergoing elective surgery

were examined between the experimental and control

groups at the post-intervention (the evening before

surgery). The analysis of covariance (ANCOVA) and the

hierarchical multiple linear regression analysis were

applied to determine the differences of means from the S-

Anxiety scale and CMFS between the experimental and

control groups at the post-intervention to determine if

changes have taken place between groups when S-

anxiety, T-anxiety, and fear from Child Medical Fear

Scale (CMFS) at pre-intervention, the childs age, and the

childs use of meditation were controlled. ANCOVA was

used to control for the childs use of meditation since

meditation has been reported as a common coping

strategy in Thai school age children (Chaiyawat, 2000;

Chaiyawat & Jezewski, 2006). The proposed study

planned to use the following covariate variables: S-


23/28

anxiety, T-anxiety, and fear from Child Medical Fear

Scale (CMFS) at pre-intervention, and the childs use of

meditation, to determine the effectiveness of cartoon

coloring book intervention on the levels of anxiety/fear of

hospitalized Thai school age children when conducted

ANCOVA. Because the age distributions between and

within study groups were not equivalent. The non-

equivalence regarding age differences may have had

some impact on the analysis results; therefore, age

variable was treated as one of the covariate variables.

The method of hierarchical multiple linear regression

analysis was applied to test the third research hypothesis.

Analyses did not

10 differ based on use of ANCOVA or multiple

regressions, so only results using multiple regressions

are presented in Chapter 4. Significances This study

focused on developing and determining the effects of a

culturally appropriate intervention for reducing

anxiety/fear in hospitalized Thai school age children 8 to

11 years old undergoing elective surgery. Psychological

preoperative preparation does not exist for hospitalized

Thai school age children undergoing elective surgery.

The intervention used in this study was appropriately

developed with consideration for the level of cognitive

development of Thai school age children 8 to 11 years

old and of their culture. This intervention has the potential

to be a useful intervention in a variety of health care

settings in Thailand that provide elective surgical care for

Thai school age children. The intervention was designed

to be easy to use and cost effective. The available time

for preparing children before elective surgery is very

limited. This intervention is very easy to use by any health

care provider with a minimum amount of training. Finally,

the levels of anxiety/fear were measured by using the

State-Trait Anxiety Intervention for Children-Revised

(STAIC-R) and Child Medical Fear Scale-Revised


24/28

(CMFS-R) in Thai versions. These two instruments

possess satisfactory psychometric properties; therefore,

they are appropriate instruments to assess anxiety/fear in

Thai school age children.

11 CHAPTER 2

Theoretical Framework and Literature Review

Psychological preoperative preparation is important for

hospitalized Thai school age children because negative

impacts of hospitalization and surgery on children can be

prevented or minimized. Theoretical and conceptual

frameworks, which are related to the psychological

preoperative preparation of hospitalized Thai school age

children 8 to 11 years old, including the appropriateness

of theoretical and conceptual frameworks for Thai school

age children were reviewed. The universal stage,

childrens concepts of physical illness, and cross cultural

variability were discussed. The state and trait anxiety

concepts, the transformation of anxiety into fear,

childrens self-report of anxiety and fear, the relevancy of

stress, coping, anxiety, and fear, including anxiety and

fear in school age children, were presented. Cultural

context, basic attitude of Thai child-rearing patterns,

health care tradition in Thailand, and practicing

meditation among Thai Buddhist children and family were

also reviewed. Psychological and physiological effects of

hospitalization and surgery in school age children, types,effectiveness, and influencing factors on the effectiveness

of psychological preoperative preparation including

methodological constraints of psychological preoperative

preparation to inform the this study design were

discussed. Theoretical Frameworks on Preparing

Children for Surgery and Hospitalization Three theoretical

frameworks, the cognitive behavioral theory (CBT), which

focuses on the stress and coping model, the socialcognitive theory (SCT), which focuses


25/28

12 on modeling, and Piagets cognitive developmental

theory (CDT), which focuses on the concrete cognitive

developmental stage in school age children including

Lazaruss anxiety concept and state-trait anxiety

concepts, were used to guide the study. Cognitive

Behavioral Theory (CBT): Stress and Coping Model The

conceptual framework of stress and coping offered by

Lazarus (1966) consists of three processes: primary

appraisal, secondary appraisal, and coping process.

Primary appraisal is the process of perceiving a threat to

oneself. Secondary appraisal is the process of bringing to

mind a potential response to the threat. Coping is the

process of executing that response. Stressful

experiences are construed as person-environment

transactions, in which the impact of an external stressor

or demand is mediated by the persons appraisal of the

stressor and the psychological, social, and cultural

resources at his or her disposal. When faced with a

stressor, a person evaluates the potential threat (primary

appraisal) as well as his or her ability to alter the situationand manage negative emotional reactions (secondary

appraisal). A persons perception of mental and physical

health is related to the ways he or she evaluates and

copes with the stresses of living (Lazarus, 1966; Lazarus

& Cohen, 1977; Lazarus & Folkman, 1984). Three broad

categories of individual differences in coping variables

were described: coping resources, coping styles, and

coping strategies or efforts. Coping resources refer torelatively stable characteristics of the individual that

influence how individuals cope in specific situations such

as temperamental or personality characteristics. Coping

styles refer to typical or habitual preferences for ways of

approaching problems. Coping efforts or strategies refer

to cognitive and behavioral actions in a specific stressful

situation which are intended to manage affective arousal

or


26/28

13 improve the problematic situation. Coping efforts

continue overtime and may change in response to the

changing demands of the situation (Ayers, Sandler, West,

& Roosa, 1996; Carver, Scheier, & Weintraub, 1989;

Lazarus & Folkman, 1984; Menaghan, 1983; Sandler,

Wolchik, MacKinnon, Ayers, & Roosa, 1997). Avoiding is

the most common coping strategy when Thai school age

children encounter with fearful situations. Other coping

strategies were also reported such as searching for

protection and security, being with a companion, talking

about their fear, distracting, and controlling their thoughts.

Among these coping strategies, meditation was reported

as one of the coping strategies that Thai school age

children used when they experience fear (Chaiyawat &

Jezewski, 2006). The concepts of stress and coping of

the cognitive behavioral theory were used to design the

Psychological Preoperative Preparation Intervention

(PPPI) in this study. The narrative short content in the

cartoon coloring book, which was used to conduct the

PPPI, presented the roles and expected behaviors whichare essential for reducing stress in hospitalized Thai

school age children. The narrative short content in the

cartoon coloring book also suggested coping strategies

which are appropriate in terms of cultural context in

reducing anxiety/fear in hospitalized Thai school age

children. Social Cognitive Theory (SCT) Social cognitive

theory as developed by Bandura (1986a) is largely a

cognitive theory but incorporates principles ofbehaviorism. Behavior is regulated by expectations for

similar outcomes on future occasions (Redman, 2001).

Much behavior is motivated and regulated by internal

standards and self-evaluative reactions to the individuals

own actions, including self-incentives and self-efficacy.

Judgments of self-efficacy are

Full document contains 181 pages

Abstract: In many Thai hospitals, there is a lack of specialpsychological preoperative preparation programs for hospitalized

Thai children and their families. The purpose of this single-blind,


27/28

randomized clinical trial was to test the efficacy of a psychological

preoperative preparation intervention (PPPI), in the form of a cartoon

coloring book, designed to reduce anxiety/fear before surgery in

hospitalized Thai school age children 8-11 years old. One hundred

and four subjects, hospitalized for surgery, were randomly assigned

into either an intervention or control group. Each group received the

usual preoperative care given by ward staff. The experimental groupreceived the PPPI given by the investigator. Pre-and posttest

anxiety/fear of both groups were measured using the STAIC-R and

CMFS-R in Thai versions. Demographic and clinical data, and

information on the child's use of meditation were also collected.

Descriptive statistics were used to describe demographic and clinical

data. A paired-t test demonstrated significant decreases in state

anxiety and medical fear means between pre- and post-intervention

for the experimental group but not for the control group. Hierarchical

regression analysis compared the effect of the PPPI to usual care

after controlling for covariate variables. State anxiety at post-

intervention was significantly less in the PPPI group than in the usual

care group controlling for state- and trait anxiety at pre-intervention,the child's age, and the child's use of meditation. There was no

evidence to support an effect of PPPI on post-intervention medical

fear when CMFS and trait anxiety at pre-intervention, the child's age,

and the child's use of meditation were controlled. The PPPI appears

to be a culturally sensitive intervention for hospitalized Thai school

age children. Reading and coloring the cartoon pictures distracted

the children from the stressful situations and helped them focus on

the content. Age appropriate narrative content in the coloring book

may have helped the children assimilate information in a short time

period. The possible reasons that could have accounted for the non-

significant effect on fear mean scores between groups are the small

sample size, the intervention diffusion between groups, and the


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Reduction of anxiety in children facinghospitalization and surgery by use of filmedmodeling.By Melamed, Barbara G.; Siegel, Lawrence J.Journal of Consulting and Clinical Psychology, Vol 43(4), Aug 1975, 511-521.

Abstract60 4-12 yr old children about to undergo elective surgery

for hernias, tonsillectomies, or urinary-genital tractdifficulties were shown on hospital admission either arelevant peer modeling film of a child being hospitalizedand receiving surgery or an unrelated control film. Bothgroups received extensive preparation by the hospitalstaff. State measures of anxiety, including the HospitalFears Rating Scale, the Observer Rating Scale ofAnxiety, and Palmar Sweat Index, revealed a significantreduction of preoperative (night before) and postoperative(3-4 wk postsurgery examination) fear arousal in theexperimental as compared to the control film group. The

parents reported a significant posthospital increment inthe frequency of behavior problems in the children who
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28/28

had not seen the modeling film. Trait measures of anxiety(e.g., Children's Manifest Anxiety Scale and the HumanFigure Drawing Test) did not reflect the group differencesdue to the hospital experience. (46 ref) (PsycINFODatabase Record (c) 2012 APA, all rights reserved)

An examination of the anxiety responses of 5-to 11-year-old children during and afterhospitalization

1988 1988

Other formats: Order a copy

Abstract(summary)

This study examined the anxiety responses of 5- to 11-year-oldchildren (N = 52) during and after hospitalization. Change inanxiety over time was examined as was the relationship betweenchildren's anxiety and age, gender, length of hospitalization,previous admission, and parental anxiety. Data were collected fromthe children and their parents at admission, discharge, and 7 to 14days posthospitalization. Children's anxiety was measured usingthe Child Drawing Hospital, the Child Rating of Anxiety, and the

State Anxiety Inventory for Children (8 to 11 years only), and datawere analyzed using repeated measures analyses of variance,stepwise multiple regression, and Pearson r correlations. Thechildren demonstrated a decrease in anxiety from admission todischarge and from admission to posthospitalization. Anxietyremained relatively constant from discharge to posthospitalization.Age, gender, and previous admission were related to the level ofchildren's anxiety with younger children (5 to 7 years), boys, andchildren not previously admitted being more anxious and notshowing a decrease in anxiety overtime. Shorter hospital stayswere associated with higher levels of anxiety, and there werepositive and negative relationships between parental anxiety andthe various measures of children's anxiety. Data indicate thathospitalization is an anxiety-producing experience with anxietycontinuing posthospitalization. Also some children are morevulnerable for higher levels of anxiety. These children may needdifferent or more intense nursing intervention.
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Internarea in Spital a Copilului

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