The Impact of Child-Centered Play Therapy on Anxiety Levels in Pre-Neurosurgical Pediatric Patients
AN ABSTRACT OF THE DISSERTATION OF
Julie L. Lerwick for the degree of Doctor of Philosophy in Counseling presented on October 10, 2011.
Title: The Impact of Child-Centered Play Therapy on Anxiety Levels in Pre- Neurosurgical Pediatric Patients
Abstract approved:
______Daniel Stroud
The prevalence of childhood illness requiring hospitalization establishes the need for implementation of an applied intervention to decrease levels of hospitalization- induced anxiety in pediatric patients. In addition to anxiety, levels of perceived trauma have also been linked to pre-operative pediatric patients. Child-Centered Play Therapy
(CCPT) within the medical setting has the potential to reduce anxiety, perceived psychological trauma, and behavioral issues in children preparing for surgery. However, a review of the literature indicates that this need is not currently being met by professionally trained play therapists utilizing specific interventions in the pre-operative departments of hospitals.
The purpose of this dissertation study is to produce two manuscripts related to the use of CCPT in hospital settings. This study investigated the impact of CCPT on levels of anxiety for pre-operative pediatric patients (n = 14) preparing for neurosurgery at
Doernbecher Children’s Hospital in Portland, Oregon. Results indicate that CCPT decreased levels of anxiety for this sample [t(13) = 3.73, p < .01].
© Copyright by Julie L. Lerwick October 10, 2011 All Rights Reserved
The Impact of Child-Centered Play Therapy on Anxiety Levels in Pre-Neurosurgical Pediatric Patients
by Julie L. Lerwick
A DISSERTATION
Submitted to
Oregon State University
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
Presented October 10, 2011 Commencement June 2012
Doctor of Philosophy dissertation of Julie L. Lerwick presented on October 10, 2011.
APPROVED:
Major Professor, representing Counseling
Dean of the College of Education
Dean of the Graduate School
I understand that my dissertation will become part of the permanent collection of Oregon State University libraries. My signature below authorizes release of my dissertation to any reader upon request.
Julie L. Lerwick, Author
ACKNOWLEDGEMENTS
Abraham Lincoln once said, “You can have anything you want, if you want it badly enough. You can be anything you want to be, and do anything you set out to accomplish, if you hold to that desire with singleness of purpose.” If you were alive today, Mr. Lincoln, I would tell you that I read your words every day for the past 3 years of my life. Thank you for inspiring me with a piece of wisdom that became my truth.
While in graduate school earning my masters degree, one special professor addressed me regularly as “Dr. Lerwick.” When asked why, he stated that he could see me as a fellow faculty member one day. The words of Dr. Daniel Sweeney have brought me to this place. Thank you for your belief in me and for seeing something deep within my spirit that I had not even known. I dedicate this dissertation, my field of study, and my future professional journey to you. You hold my utmost respect as honored mentor, colleague, and friend.
I would have given up on this process long ago without the genuine and life- giving support of my peers Michele Eave and Ryan Melton. Thank you for your partnership from day one, “Mama Michele” and “Dr. Significant.” Both of you are held dear to my heart and I am honored to know such skilled professors and practitioners.
Many cold rainy Portland mornings were spent pounding the pavement with my best friend, Kelsey Crawford. Her dedication to my success, unyielding support, and endless availability to process the ups and downs of being a doctoral student, is noteworthy. Thank you, Kelsey. I truly could not have completed my journey through doctoral work without you.
Although too many to name, my heart is filled with deep gratitude for each person that has loved me and supported me throughout my life. My family, friends, colleagues, professors, and supervisors, each of you hold very special and profound pieces of my heart.
A special acknowledgment of thankfulness to Dr. Daniel Guillaume for serving as my Principal Investigator at Doernbecher Children’s Hospital, and equally to the medical staff, parents, and the patients that invited me into their most vulnerable moments preparing for surgery. Thank you.
Friday mornings will always be special to me as I remember sitting at Dr.
Michelle Cox’s dining room table with stacks and stacks of paper as she painstakingly took the time to read every single word of every single draft of my dissertation. Your investment to my success, through mentorship and encouragement, has produced qualities in me that no title ever could. I truly am profoundly humbled by your kindness, expertise, and example. Thank you, Michelle, for believing in me.
Above all, my truest cheerleader and inspiration has been the mercy of my God.
Thank you for never giving up on me and for developing my character and tenacity through this process. You allowed me to prove how much I wanted a doctoral degree, and
I will forever use my education and intellect for Your glory above all things.
CONTRIBUTION OF AUTHORS
Dr. Michelle Cox of Oregon State University contributed to Chapter III by conducting statistical analysis on the data.
TABLE OF CONTENTS
Page
CHAPTER I: Development, Anxiety & Child-Centered Play Therapy...... 1
Dissertation Overview...... 1
Thematic Introduction...... 2
Child-Center Play Therapy, Anxiety, and Trauma...... 4
Anxiety...... 5
Trauma...... 6
Child-Centered Play Therapy...... 6
Rationale...... 7
Glossary of Terms...... 9
CHAPTER II: Pre-Surgical Anxiety in Young Children: A Review of the Literature.....12
Abstract...... 13
Introduction...... 14
Hospitalized Children...... 15
Stages of Development...... 18
Erikson’s Theory of Psychosocial Development...... 18
Summary of Erikson’s Developmental Stages...... 28
Pre-Operative Anxiety...... 29
Child-Centered Play Therapy...... 32
Filial Therapy...... 35
Rationale for Further Research...... 37
TABLE OF CONTENTS (Continued) Page
References...... 39
CHAPTER III: Predictors of Anxiety Reduction in Pre-Neurosurgical Pediatric Patients...... 52
Abstract...... 53
Introduction...... 54
Review of the Literature...... 54
Materials and Methodology...... 54
Informed Consent...... 55
Participants...... 56
Instrument Review and Selection ...... 57
Procedure...... 64
Data Analysis Plan...... 66
Results...... 67
Descriptive Statistics...... 67
Inferential Statistics...... 69
Discussion...... 70
Limitations...... 70
Validity...... 72
Conclusion...... 74
References...... 76
Chapter IV: Child-Centered Play Therapy for the Reduction of Pre-Surgical Anxiety...... 79
TABLE OF CONTENTS (Continued) Page
General Conclusion...... 79
Recommendations for Future Research...... 80
References...... 83
Appendices...... 99
LIST OF FIGURES
Page
Figure 1. Age Range...... 68
Figure 2. Pre-Post Intervention Scores ...... 69
LIST OF APPENDICES
Page
Appendix A. Oregon State University IRB Approval...... 100
Appendix B. Oregon Health & Science University IRB Approval...... 101
Appendix C. Consent Form...... 102
Appendix D. Faces Anxiety Scale...... 107
Appendix E. Lay Language Protocol Summary...... 108
Appendix F. Clinic Appointment Script...... 110
Appendix G. Day of Surgery Script...... 112
Appendix H. Protocol...... 114
Appendix I. Toys Included in Play Kit...... 122
Appendix J. Raw Data...... 123
CHAPTER I: Development, Anxiety & Child-Centered Play Therapy
Dissertation Overview
The purpose of this dissertation study is to demonstrate scholarly work by using the manuscript document dissertation format as outlined by the Oregon State University
Graduate School. In following this format, Chapter I provides explanation as to how two journal-formatted manuscripts, Chapters I and II, are thematically linked and build toward research conclusions pertinent to the field of child and adolescent psychotherapy.
Accordingly, Chapter II is a literature review titled, Pre-Surgical Anxiety in Young
Children: A Review of the Literature, and Chapter III presents quantitative research in a manuscript entitled, Predictors of Anxiety Reduction in Pre-Neurosurgical Pediatric
Patients. Both of these manuscripts focus on the construct of play therapy for the reduction of pre-operative anxiety. Manuscripts thematically converge on the application and competent use of play therapy to reduce anxiety in pediatric patients preparing for surgical procedures and to explore the impact of Child-Centered Play Therapy (CCPT) on anxiety levels in children preparing for neurosurgery.
Mirroring the work of Erik Erikson (1963) and Carl Rogers (1951), Virginia
Axline (1974) applied her understanding of Person-Centered therapy to her work with children creating CCPT (Axline, 1974). Seeing children as valuable people who are capable of positive self-direction (Ray, 2009), CCPT empowers children in a way that allows them to develop emotionally through the natural language of play (Axline, 1974).
Findings from empirical studies point to the importance of psychologically preparing children for surgical procedures and hospitalization in order to decrease levels of anxiety. PRE-OPERATIVE PLAY THERAPY 2
Decreased levels of pre-surgical anxiety may improve developmental outcomes and reduce residual trauma (Brewer, Gleditsch, Syblik, Tietjens, & Vacik, 2006; Edwinson,
Ambjornson, & Ekman, 1988; Ellerton & Mernam, 1993; Kain, Mates, & Carmico, 1996;
Li & Lopez, 2008; Melamed, Dearborn, & Hermeez, 1983; O’Conner-Von, 2000; Price,
1991; Schmidt, 1990; Ziegler & Prior, 1994).
The first manuscript of this dissertation, Chapter II, is a literature review that provides background, definition and theoretical underpinnings of development, anxiety, and CCPT. Chapter II also reviews research regarding the benefits of emotional preparation of children for surgery and hospitalization. The second manuscript, Chapter
III, details the study's methodology: a quantitative investigation of the impact of CCPT on pre-operative pediatric patients (n = 14) preparing for neurosurgery. Chapter IV provides a general conclusion to this dissertation study and offers suggestions for future research.
Thematic Introduction
The purpose of this dissertation study is to explore the impact of Child-Centered
Play Therapy (CCPT) on the reduction of pre-operative anxiety in pediatric patients.
CCPT is a classification of play therapy that allows the child to lead the therapeutic process by nature of relationship with the play therapist. Two important components support the rationale for this study. First, empirical research shows the relationship between surgery and anxiety. Second, current literature suggests that CCPT performed by a skilled practitioner could reduce anxiety in pre-surgical pediatric patients. PRE-OPERATIVE PLAY THERAPY 3
A review of the literature suggested that children have the predisposition to be negatively affected by stressors preceding surgery due to their developing minds and limited coping abilities. Stressors that plague hospitalized children can often lead to heightened anxiety levels, as well as potential psychological trauma if not appropriately treated (Foley, Higdon, & White, 2006). The topic has much personal relevance to the author, who is a child and adolescent play therapist specializing in providing services to hospitalized children and their families. The author is interested in investigating the impact of play therapy in pre-operative contexts because children deserve a voice and an expression of their experience in their most vulnerable moments. Implications of this research extend beyond the realm of counseling. Review of literature and research described in this dissertation are relevant for child and adolescent counseling and psychotherapy, and therefore, have a broad use for those whose professional degrees relate to counselor education, psychology, general medicine, social work, psychiatry, and nursing among other professions that work with ill children. Specifically, the most likely candidate for utilizing the findings of this study are Child Life Specialists who currently work in hospitals with children and their families, yet have not been trained in CCPT protocol.
According to current literature review, there are no studies that address CCPT specifically as a means of reducing anxiety in pre-operative children. However, many articles have been written supporting the efficacy of medical play within the medical setting (Adams, 1976; Alger, Linn, & Beardslee; 1985; Becher & Wan, 1997; Brunskill,
1984; Clatsworthy, 1981; Doverty, 1992; Frankenfield, 1996; Vessey & Mahon, 1990; PRE-OPERATIVE PLAY THERAPY 4
Webb, 1995; Willemsen & Anscombe, 2001; Zahr, 1998). Therapeutic CCPT differs from that of medical play (Le Vieux, 1999; Lingnell & Dunn, 1999) and should be considered in treating children preparing for surgery. Medical play invites the hospitalized child to play out fears and emotions pertaining to hospitalization experiences, specific diagnoses, and treatment concerns (Le Vieux, 1999). CCPT is more concerned about relationship with the child. Therapeutic play is non-directive, allowing children to express emotions not necessarily specific to the hospitalization process
(Landreth, 2002).
The first manuscript, a literature review, examines the potential value of play therapy in a pre-operative setting for children preparing for surgery. Review of the relevant literature in this first document contains information regarding the developmental stages of children, how children respond to anxiety provoking situations, such as preparing for surgery, the history of play therapy, and the use of play therapy in the hospital. The second manuscript highlights the need for empirical research about how to competently provide children with CCPT in a pre-operative hospital setting. In order to explore the impact of CCPT on the reduction of anxiety in children preparing for surgery, a pre-post design using an abbreviated CCPT intervention technique will be applied.
Results will be evaluated using a Repeated-Measures t-test.
Child-Centered Play Therapy, Anxiety, and Trauma
Hospitalized children face unprecedented anxiety as doctors and nurses control their bodies. Lack of control brings about intense fear in many children. Although there is research supporting the use of Cognitive-Behavioral Therapy (CBT) to treat anxiety, this PRE-OPERATIVE PLAY THERAPY 5 approach takes children out of their natural feeling state and into a reasoning (cognitive) state (Deacon & Abramowitz, 2005). As play is a child's natural mode of communication, play can be utilized with both healthy and alimented children (Landreth, 2002). Play in a hospital setting can be a vehicle to introduce familiarity and causation to the myriad of bewildering changes (Le Vieux, 1999; Lingnell & Dunn, 1999).
Defining and exploring the constructs of development, anxiety, and CCPT are important to the central theme of this dissertation. The prevalence of childhood illness and anxiety induced by hospitalization demands the need for preventative, as well as imminent play therapy for children. Medical play therapy has been proven to reduce psychological anxiety, and thus, trauma and behavioral issues in pediatric patients (Li &
Lam, 2003; Lingnell & Dunn, 1999). However, by means of therapeutic play therapy, research indicated that children can be helped emotionally, and therefore, educationally, psychologically, and interpersonally (Foley et al., 2006; Landreth, 2002; Erikson, 1963).
CCPT is about building a relationship with children in such a manner that does not guide their play yet simply allows them to express their own emotions using play
(Landreth, 2002). Children who have experienced trauma often lose a sense of safety and autonomy while receiving treatment. CCPT used to treat any emotional or behavioral issue offers respect, a voice, and a place of safety (Axline, 1974; Landreth, 2002; Li &
Lam, 2003; Lingnell; & Dunn, 1999; O’Conner-Von, 2000). In this way, CCPT promotes the value of children.
Anxiety PRE-OPERATIVE PLAY THERAPY 6
A complex phenomenon, anxiety has been defined as an “Apprehension of danger and dread accompanied with restlessness, tension, tachycardia (fast heartbeat), and dyspnea (shortness of breath) unattached to a clearly identifiable stimulus” (Dirckx,
2001, p. 64). A variety of symptoms manifest depending on circumstance. Freud (1928) believed that anxiety is a psychic reaction to danger and it involves reactivation of an infantile fear situation. Similarly, Erikson (1963) viewed anxiety and fear as a result of direct classical and operant conditioning. Based on this view, it is evident how children can manifest anxiety symptoms and experience trauma as a result of fear and loss of control when hospitalization and surgery are required. Psychological and social factors also contribute to the etiology of anxiety.
Trauma
Trauma, such as that produced from unresolved pre-surgical anxiety experiences, has the potential to adversely affect a child’s physical and emotional development.
Experiences such as surgeries and hospitalizations affect a child's physical growth, personality, and emotional development. In some cases anxiety-based trauma may prejudice the development of behavioral, emotional, or cognitive disorders (Gillis, 1993;
McMahon & Peters, 1985). As a way of helping children plagued by pre-surgical anxiety, the underlying message of CCPT is that children are valuable people who are capable of positive self-direction (Ray, 2009).
Child-Centered Play Therapy
Inspired by Axline's (1974) work, a world-renowned play therapist, Landreth
(2002) presented basic tenets in applying CCPT to children that address their primary PRE-OPERATIVE PLAY THERAPY 7 need to have freedom of expression in a non-verbal world, to be given autonomy in making choices. Play therapy in any setting is a conduit for communication (Landreth,
2002). Play fundamentally satisfies emotional needs by providing feelings of accomplishment and achievement. As an instinctive, voluntary, and spontaneous process, people across the lifespan can benefit as it allows people of any age to develop physically, mentally, emotionally, socially, and spiritually (Landreth, 2002).
Rationale
Hospitalization and surgery can be an emotionally threatening and psychologically traumatizing experience for all people, especially children (Li & Lam,
2003; Lingnell & Dunn, 1999; O’Conner-Von, 2000). When children are hospitalized, there is an increased potential for unresolved anxiety to produce long-term psychological trauma presented as anxiety, aggression, anger, a loss of autonomy and control, fear of mutilation, guilt, pain, rage, and similar expressions of emotion appropriate to their level of development (Adams, 1976; Alger et al., 1985; Clatworthy, 1981; Cooper & Blitz,
1985; Golden, 1983). Within this context, children need a form of age-appropriate control over their healthcare process that is conducive to treatment.
Hospitalized children often lose freedom, which increases the need for emotional containment that can be executed by CCPT in the medical setting (Landreth, 2002;
Lingnell & Dunn, 1999). Literature indicates that medical play therapy reduces behavioral issues because it offers children freedom, control, and autonomy during hospitalization (Lingnell & Dunn, 1999). CCPT is set apart from traditional medical play by creating freedom for undirected play. The child is invited to participate equally in a PRE-OPERATIVE PLAY THERAPY 8 mutual relationship where choices are given as to how play is enacted (Landreth, 2002).
For example, if the child witnessed an argument between the parents the night prior to surgery, the child may be suffering from two sets of anxiety provoking situations: impending surgery and parental distress. By inviting the child to choose what is expressed in the play session, non-directive CCPT allows the child to work out the emotions that feel the most important in that moment.
Current literature helped to determine existing protocols for preparation of surgery including education about the procedure, a tour of the hospital (including the operating room), a review of picture books about the experience, and video introductions.
In addition, medical play with surgical instruments and dolls encourages children to express questions or concerns they have about their upcoming procedure (Brewer et al.,
2006; Edwinson et al., 1988; Ellerton & Mernam, 1993; Kain et al., 1996; Li & Lopez,
2008; Melamed et al., 1983; O’Conner-Von, 2000; Price, 1991; Schmidt, 1990; Ziegler &
Prior, 1994). As yet, however, no studies have investigated the impact of CCPT on anxiety in pre-surgical pediatric patients in hospital settings.
Glossary of Terms PRE-OPERATIVE PLAY THERAPY 9
Anxiety: “Apprehension of danger and dread accompanied with restlessness, tension, tachycardia (fast heartbeat), and dyspnea (shortness of breath) unattached to a clearly identifiable stimulus” (Dirckx, 2001, p. 64). Furthermore, anxiety is a psychic reaction to danger and involvement of reactivation of an infantile fear situation (Freud, 1928).
Child-Centered Medical Play Therapy: A Child-Centered Play Therapy experience within a hospitalized setting.
Child-Centered Play Therapist: A master’s level therapist trained in play therapy whom does not direct or lead the child to a particular topic or activity, but allows the child to lead the way and is content to follow. The therapist does not solve problems for the child, explain behavior, interpret motivation, or question intent, all of which would deprive the children of opportunities for self-discovery. They do not direct or manage the experience, but by being directly and actively involved and genuinely interested in all the child’s feelings, actions, and decisions, the relationship heals the child (Landreth, 2002).
Child-Centered Play Therapy (CCPT): The belief and philosophy that the process of being with a child in an unconditional positive relationship, led by their own needs, opposed to a prescriptive plan by the therapist, creates the process of becoming (Landreth
& Sweeney, 1999). It is the belief of an innate human capacity of the child to strive toward growth and maturity and an attitude of deep and abiding belief in the child’s ability to be constructively self-directing (Sweeney & Landreth, 2003).
Filial Therapy: Parental training in basic Child-Centered Play Therapy principles and skills by a professional play therapist (Landreth, 2002). PRE-OPERATIVE PLAY THERAPY 10
Medical Play: A therapeutic technique used to inform children about the plans and purposes of medical events, to provide children with an expressive outlet, to relieve misconceptions, and to gain insight into children’s coping and understanding. It is the process by which medical items are provided for children to manipulate and to experiment with on an inanimate object, such as a stuffed animal or doll (Lingnell &
Dunn, 1999).
Pediatric Patients: Children aged 0-18 with a medical diagnosis.
Play Therapy:
A dynamic interpersonal relationship between a child (or person of any
age) and a therapist trained in play therapy procedures who provides
selected play materials and facilitates the development of a safe
relationship for the child (or person of any age) to fully express and
explore self (feelings, thoughts, experiences, and behaviors) through play,
the child’s natural medium of communication, for optimal growth and
development. (Landreth, 2002, p. 16)
Pre-Operative Anxiety: Pre-operative anxiety stimulates sympathetic, parasympathetic and endocrine systems leading to an increase in heart rate, blood pressure and cardiac excitability resulting in cardiac arrhythmias (Ramsay, 1972).
Pre-Operative: Physical and psychological care prior to surgery either on the day of, or prior to on an outpatient basis.
PRE-OPERATIVE PLAY THERAPY 11
Psychosocial Crisis: A developmental crisis that arises and demands resolution prior to moving toward subsequent developmental stage (Erikson, 1963).
Psychotherapist: Professional health care provider with an advanced degree who provides psychotherapy.
Surgery: A corrective operative intervention to heal or restore an ailment.
Trauma: According to the DSM-IV-TR (American Psychiatric Association [APA], 2000), a traumatic event is defined as one in which the child “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others” (p. 427), and in which the child’s response involved intense fear, helplessness, horror, or disorganized, agitated behavior (Ronen, 2002).
Virtue: Erikson’s (1963) definition of working through a conflict to a favorable outcome.
PRE-OPERATIVE PLAY THERAPY 12
PRE-SURGICAL ANXIETY IN YOUNG CHILDREN:
A REVIEW OF THE LITERATURE
Julie L. Lerwick
Oregon State University PRE-OPERATIVE PLAY THERAPY 13
Abstract
The prevalence of childhood illness requiring hospitalization demands the need for implementation of an applied intervention to decrease levels of hospitalization- induced anxiety in pediatric patients. Child-Centered Play Therapy (CCPT) within the medical setting has the potential to reduce anxiety in children preparing for surgery, which in turn reduces the potential for long-term effects of trauma. Review of literature indicated this need is not currently being met by professionally-trained play therapists utilizing specific interventions in the pre-operative departments of hospitals. This review of the literature creates a foundation upon anxiety and coping, trauma, childhood development, and CCPT as rationale for studying the impact of CCPT on levels of anxiety for pre-operative pediatric neurosurgery patients. PRE-OPERATIVE PLAY THERAPY 14
CHAPTER II: Pre-Surgical Anxiety in Young Children
Introduction
Hospitalization of any kind has the potential to be an emotionally intimidating and psychologically disturbing encounter for all people, particularly children (Li & Lam,
2003; Lingnell & Dunn, 1999; O’Conner-Von, 2000). Hospitalized children face an increased probability for psychological trauma, presented as anxiety, aggression, anger, a loss of autonomy and control, fear of mutilation, guilt, pain, rage, and similar manifestations of emotionality specific to their developmental level (Adams, 1976; Alger et al., 1985; Clatworthy, 1981; Cooper & Blitz, 1985; Golden, 1983).
The potential for increased levels of fear and anxiety underlines the need for children to be given some form of control in their healthcare process that is age- appropriate and conducive to treatment. For example, when an intravenous line (IV) is inserted, giving the child the choice of a numbing ointment prior to insertion of the needle may be helpful and lend itself to a sense of empowerment for a child. Children in medical settings often lose freedom because of the demands of patient care. Loss of freedom can produce stress and anxiety (Adams, 1976; Alger et al., 1985; Clatworthy,
1981; Cooper & Blitz, 1985; Golden, 1983). Consequently, these stressors increase children’s need for emotional expression, which can be accomplished by Child-Centered
Play Therapy (CCPT: Landreth, 2002; Lingnell & Dunn, 1999).
Research indicated that play therapy with pediatric patients reduced behavioral issues (Lingnell & Dunn, 1999). Specifically, medical play therapy gives the child a place of freedom, control, and autonomy in the process of being hospitalized (Lingnell & PRE-OPERATIVE PLAY THERAPY 15
Dunn, 1999). Play therapy in a hospitalized setting is innovative and concisely accomplishes the task of supporting children emotionally in their time of chaos, fear, and pain. As children progressively learn to see themselves as individuals capable of making choices, not simply being subject to choices made on their behalf, their disruptive behavioral expressions dissipate (Li & Lam, 2003; Lingnell & Dunn, 1999; O’Conner-
Von, 2000).
The prevalence of childhood illness requiring hospitalization suggests the need for implementation of an applied intervention to decrease levels of hospitalization-induced anxiety in young pediatric patients. CCPT within the medical setting has the potential to reduce perceived psychological trauma, anxiety, and behavioral issues in pediatric patients preparing for surgery. By means of therapeutic play therapy, research indicates that children can be helped emotionally, and thereby, changes can occur educationally, psychologically, and socially (Foley et al., 2006). Medically fragile children and children who have experienced trauma have lost a tremendous sense of safety and autonomy.
CCPT in a variety of forms, with an array of issues, restores the balance of valuing children in society by giving them respect, a voice, and a place of safety (Axline, 1974;
Landreth, 2002; Li & Lam, 2003; Lingnell & Dunn, 1999; O’Conner-Von, 2000).
Hospitalized Children
More than 39,000 children are hospitalized each day throughout the United States according to the National Association of Children’s Hospitals and Related Institutions’
(2005) statistical analysis. Some children are brought to the hospital in crisis, whereas others are admitted for routine tests and surgeries; still others are hospitalized due to PRE-OPERATIVE PLAY THERAPY 16 chronic illness. Children may be admitted for a few weeks, whereas others are quarantined for months upon end due to serious medical conditions. When children are brought into the hospital, they are scared, in pain, and, with little explanation and much less preparation, expected to adjust to the new setting and submit to the bewildering array of tests and treatments.
The largest fear is often the unknown (De Pasquale, 1999; Eland & Anderson,
1977). It is crucial that medical and mental health professionals take the time to explain to the child the reason for the treatment. Children need as much control and choice as possible (Doverty, 1992; Ellerton & Merriam, 1994). If this step is not accomplished, anxiety increases. When their anxiety increases, they feel out of control. When they feel out of control, they will not cooperate (Eland & Anderson, 1977). Furthermore, trust is broken once the child feels anxiety-stricken (Burke, 2007). Parents and children alike are psychologically unprepared for the anxiety and emotional strain that a family goes through in a medical crisis.
In 1922, at C. S. Mott Hospital in Ann Arbor, Michigan, after seeing that children tended to get well faster if their psychological needs were taken care of and knowing that mental health is very much related to physical health, the first Child Life program in the nation was established believing that emotional state could aid in healing and help reduce pediatric anxiety (De Pasquale, 1999). Child Life is a popular treatment modality for anxiety and is defined as combining medical play with education of procedures and the hospitalization experience (Burke, 2007). Child Life included more than just play. Child
Life Specialists are professionally trained to provide psychological preparation to young PRE-OPERATIVE PLAY THERAPY 17 patients before they undergo medical procedures and expressive play afterward.
Moreover, the Child Life brand extended beyond the individual patient to encompass the whole family. In a study by De Pasquale (1999) when a young cancer patient was terminally ill, for example, Child Life Specialists worked with siblings and parents—as well as the child—to help them cope with impending death.
Many activities in therapy with anxious children are guided toward expressive outcomes. In the same study (De Pasquale, 1999), one Child Life Specialist had her young patients make a paper chain to hang on their hospital room door. On each strip, they wrote a question or comment they had for their doctor (i.e., “Please let me go to sleep.”) or a concern about being hospitalized. It is therapeutic for children to communicate in ways that makes sense to them. Child-friendly terms such as ‘hospital- pajamas,’ ‘special lights,’ and ‘pokes’ replace scrubs, lasers, and needle insertions in the
Child Life vocabulary and, therefore, reduce anxiety-producing circumstances for children (Burke, 2007; De Pasquale, 1999).
During preparation, the Specialists address all five senses to ensure that a child is not surprised by a smell or sound, and they invest the time to answer all the family’s questions (Burke, 2007). The Child Life Specialists also encourage the children to handle and to speak freely about the various pieces of medical equipment that they would encounter: anesthesia masks, IV lines, catheter bags, or casting material. Additionally, they give the children faceless muslin dolls that come in different skin tones, which allow the children to use markers and yarn to create the doll in whatever image they choose (De PRE-OPERATIVE PLAY THERAPY 18
Pasquale, 1999). Often, the children create miniature versions of themselves and, then, rehearse procedures and tests that they may face (De Pasquale, 1999).
Some young children would not let Child Life Specialists demonstrate on them how the mask, electrocardiogram (EKG) pads, and pulse-oximeter worked, so they would turn to mom, dad, or demonstrate it themselves. Although this act is not a usual form of
Filial Therapy, strength exists in this relationship. As the parents allow themselves to join with the professional staff, the child is comforted and the parent-child relationship is deepened. A large role that Child Life Specialists play is for the parents. Often, the parents have many questions and do not understand what is happening, much less knowing how to explain it to their child. Because everything happens so rapidly in crisis situations, parents feel left in the dark, feeling quite anxious and helpless without a conversation from a Child Life Specialist (Burke, 2007). Medical play can serve to alleviate these fears. CCPT may even be more effective because it allows the child the option to work through any anxiety, not just that related to the hospital setting.
Stages of Development
Erikson’s Theory of Psychosocial Development
Personality patterns and ways of communicating are formed in part by innate inborn traits in addition to the environment in which one is reared. Erik Erikson (1963) believed that a person develops within a system comprised of eight developmental stages, each requiring the resolution of a psychosocial crisis before moving toward the next stage. The eight developmental stages are as follows: 1) Infancy: Trust vs. Mistrust, 2)
Early Childhood: Autonomy vs. Shame and Doubt, 3) Play Age: Initiative vs. Guilt, 4) PRE-OPERATIVE PLAY THERAPY 19
School Age: Industry vs. Inferiority, 5) Adolescence: Identity vs. Role Confusion, 6)
Young Adulthood: Intimacy vs. Isolation, 7) Adulthood: Generativity vs. Stagnation, 8)
Old Age: Ego Integrity vs. Despair.
Erikson’s (1963) theory hinges on the idea that moving through a crisis to a positive outcome allows a person to develop virtues and strong ego qualities necessary for maturity throughout the lifecycle. However, Erikson (1963) purported that people can successfully handle the crisis of any given stage even though they are not completely successful in previous stages (Feist & Feist, 2009). A review of Erikson’s (1963) first four developmental stages establishes a foundation for understanding the emotional needs of young children. Further, it invites the reader to explore the developmental necessity of identifying a valid and reliable method for meeting the emotional needs of children prior to a surgical intervention.
Stage One
Infancy: Trust vs. Mistrust
A myriad of changes are instantly introduced into the life of a couple as a new baby is introduced into a family system. Often, to the parents’ discomfort, the infant is unconsciously concerned with having the needs met with precision and immediacy.
During the first eighteen months of life the primary psychosocial crisis relates to the development of either trust or mistrust (Erikson, 1963). Infants have a strong and innate need to know that their caregivers have heard their needs and that they will be readily attentive and responsive. This normal adjustment period for the infant is demanding and at the forefront of the new parent’s mind. PRE-OPERATIVE PLAY THERAPY 20
For an infant, trust and mistrust are dependent upon the level of attachment and connection with the caregiver and how the caregiver responds to the needs of the infant.
When infants cry, they have a need to know that their primary caregiver is present, attending to them, and listening to their audible requests for resolution of hunger, diaper discomfort, physical pain, etc. If a child is ignored or if the caregiver is incompetent or so consumed with distractions that responsiveness is inconsistent, it is possible that the virtue of hope offered in this stage will not be mastered.
As mistrust is a normal occurrence for a child when interacting with a stranger, it can prove to be emotionally traumatic if the child has cause to mistrust a caregiver, as the foundational attachment is not secure (Ainsworth & Bowlby, 1991). If children's needs are not met quickly or efficiently in a manner that they can depend on, mistrust is introduced, and they may wonder why their caregiver is not attending to their needs.
Mistrust can heighten separation anxiety (Ziegler & Prior, 1994) in a child and therefore result as dissonance in early attachment (Ainsworth & Bowlby, 1991).
Trust and hope are paramount to an infant in order to face and manage future anxiety that will occur as part as normal daily living and development (Erikson, 1963). A child who does not develop sufficient hope during infancy may develop tendencies to withdraw from others, namely the primary caregiver. Working through this foundational developmental stage is especially important to consider within a hospital setting as infants suffer from separation anxiety and stranger anxiety (Ziegler & Prior, 1994). More applicable in terms of the current research study is the impact of resolution at this stage on subsequent stages. If mistrust is developed in infancy, a child hospitalized during a PRE-OPERATIVE PLAY THERAPY 21 later developmental stage may suffer from undue emotional stress related to separation anxiety when in the care of medical staff for the purposes of testing, medical interventions, and the transition from the pre-operative area to the operating room. In the hospitalized setting, infants that have not securely attached (Ainsworth & Bowlby, 1991) with a primary caregiver may question protection and may equally fear harm from medical providers (Li & Lopez, 2008; O’Conner-Von, 2000, Ziegler & Prior, 1994); this is especially true as a child moves to Erikson’s (1963) second stage of psychosocial development.
Stage Two
Early Childhood: Autonomy vs. Shame and Doubt
Learning the power of their own will, toddlers in Erikson’s (1963) second stage of development are working toward the psychosocial crisis of finding autonomy while becoming aware of shame and doubt. Autonomy is attained when a person masters a task alone, thus it is important that young children learn to make mistakes while exploring the process of decision making. Identified predominately as the terrible two’s, the second stage focuses on identity development. Children need to develop a sense of personal control over physical skills and a sense of independence over their interpersonal environment. Independence is key to this sense of control. Thus, children may become threatened by changes in their routine. Children are curious about their surroundings and sensorimotor cognition develops, resulting in a limited ability to communicate, reason, and understand time. At this stage it is common for children to suffer from separation anxiety and stranger anxiety when they lack a familiar environment, routines, and choice. PRE-OPERATIVE PLAY THERAPY 22
Paralleling Freud’s (1928) anal stage that occurs throughout the ages of two and three, Erikson (1963) believed that toddlers not only gain pleasure from mastery of the sphincter muscle, but additionally from mastering other bodily functions including urination, learning to walk, and the ability to throw and catch an object. Children are not only learning to control their bodies during toilet training, but also learning to use their bodies to accomplish tasks—such as running, grasping toys and objects, hugging parents, etc. This mastery invites the child to develop a sense of control over their bodies, as well as their immediate environment. However, if mastery of toileting is unattained, children in stage two face shame and doubt as their autonomy is not confirmed by success, but rather failure.
Accordingly, when young children feel the sense of failure of becoming autonomous, they are likely to display stubborn tendencies and are often inspired by the newfound power of the word “NO!” among other similar words. Toddlers may act out in order to assert their autonomy (Erikson, 1985). If autonomy and independence are not maintained in stage two, children may suffer from shame and doubt that commonly results from the parent over-controlling, over-indulging, or shaming the child. The successful completion of this stage results in children who are able to make choices independently of parents, but within clear boundaries. Success in doing so leads to feelings of autonomy. Paradoxically, failure results in feelings of shame and doubt, which can cause forms of anxiety, as children develop heightened awareness of the negative feelings associated with failure (Erikson, 1985). As children progress toward Erikson’s
(1963) third stage they are given the opportunity to show initiative for achieving new PRE-OPERATIVE PLAY THERAPY 23 goals to overthrow potential failures associated with stage two. Mastery of autonomy influences later development and is key to understanding the needs of children in medical environments.
When children are in medical settings, specifically hospitals, it is not uncommon for toddlers to be bewildered by the rapid changes in environment, change of routines, and the many decisions about which they have no control (Eth & Pynoos, 1995; Foley et al., 2006; Knox, 1983; LaMontange et al., 2000; Peterson, 1989; Tiedeman &
Clatsworthy, 1990; Vogel & Vernberg, 1993). Children in this stage possess a strict conscience that includes feelings of being punished. For this reason, it is possible that children may feel that hospitalization is a punishment for wrongdoing (Wolfer &
Visintainer, 1975) and fear mutilation or bodily injury (Ziegler & Prior, 1994) that they naturally correlate with their negative thoughts or actions. Preschoolers have a high need for emotional soothing within a hospital setting, which could clarify that the intent of the medical procedure is not punishment (Wolfer & Visintainer, 1975).
Stage two emotional needs correlating to the hospitalization process include choice-giving, freedom to inquire about fears, presence of caregivers, awareness of scheduled procedures or interventions, and early explanations of the change of environment. Children would benefit from having a person within their healthcare process specifically attending to their emotional needs, which may increase feelings of autonomy and independence. In order to evaluate the benefit of parents that stay near their child during a medical procedure, research (Visintainer & Wolfer, 1975; Hannallah
& Rosales, 1983; Bauchner et al., 1989;) clearly indicates that parental presence reduces PRE-OPERATIVE PLAY THERAPY 24 both child and parental (Kain et al, 2000) anxiety levels. Paradoxically, randomized controlled trials show that parental presence when anesthesia is being administered is not always beneficial (Kain et al., 1998, 2006).
Stage Three
Play Age: Initiative vs. Guilt
Preschoolers are busy exploring all different components of their environment and their imaginations are budding into understanding of roles, reproduction, growth, the future, as well as death (Erikson, 1968). Being captivated by their own goals and questions, children aged 3 to 5 are busy creating and choosing their own activities and delights, as well as desiring power and control over their environment. The initiative required to achieve also provides a sense of purpose.
However, children who exert too much power experience disapproval, resulting in a sense of guilt. Erikson’s (1963) third stage of development capitalizes on the child’s ability to set and carry out goals. Preschoolers are learning to define right and wrong through moral principles and consequences for immoral choices, including guilt and fear.
They are also developing direction to their action and goals. At this stage children are also busy developing locomotion, language skills, and have curious inquisitive minds and a common captivation with placing their parent at the center of their world.
Freud (1928) placed the Oedipus complex at the center of the phallic phase, whereas Erikson (1968) believed that it was only one piece of many developmental markers during the play age. Erikson (1963) believed the Oedipus complex to be an imaginative way for children to relate to their parents in a way that enhanced normal PRE-OPERATIVE PLAY THERAPY 25 sexual development. This is why children often will pick flowers from the garden to give to their parents or why they want to be married to their parents - trying to please them.
A preschooler’s increased cognitive functioning serves as an opportunity to create elaborate stories in their minds about what it is like to be a grown up. If these fantasies produce guilt, it may contribute to the psychosocial crisis in this stage. With increased mobility and an awakening genital interest, children begin to adopt initiative in their selection and pursuit of goals. The consequence of repressed, delayed, or inhibited goals is guilt, creating a psychosocial crisis of initiative versus guilt. When children strive to achieve something through their own initiative, yet receive disapproval; there is a resulting sense of guilt.
Within the need for approval from their parent, children desire a sense that their parent is near, or if they leave, they want to know when they are returning. Likewise, it is important that when a child is separated from their parent, as is common during hospitalization, the parent be allowed to be nearby. If children at this stage are given age- appropriate responsibility to show ownership of their experience, there is potential for reduced anxiety (Axline, 1974; Landreth, 2002; Li & Lam, 2003; Lingnell; & Dunn,
1999; O’Conner-Von, 2000).
Stage Four
School Age: Industry vs. Inferiority
Children begin to develop their ego identity of competence or incompetence during Erikson’s (1963) fourth stage of psychosocial development. Mirroring Freud’s
(1928) latency stage, children are experiencing their expanded social world, which PRE-OPERATIVE PLAY THERAPY 26 includes peers and adult role models outside of their family. Agreeing with Freud (1928),
Erikson (1963) stated that children in the fourth stage are developing a sense of self through acquiring new skills and viewing themselves as competent or incompetent. How children view themselves can become the origin of the ego identity (Erikson, 1963), which becomes more complete during adolescence.
School-aged children are striving to become competent in the skills required to function within their culture (Erikson, 1963). Within this, children are faced with a conflict between industry and inferiority as they show a willingness to remain busy with something and to finish something that they started. Children learn cooperation and a sense of industry that comes from working hard to complete a task. Erikson (1963) noted that earlier inadequacies, which occurred in the play age, may carry over into the school age.
In stage four, children are active learners with well-developed language skills, concepts of time, and concerns about body image are also introduced. School age is a time of substantial social growth for a child and the psychosocial virtue of competence can be strategically woven into the daily life of a child as they are given tasks to accomplish and offered assistance when needed to complete the task. Self-esteem is formidable at this stage, as is feelings of inadequacy.
Inadequacy can be plaguing to a school-aged child as they are striving to develop their own identity and their ego strength is fragile. If the struggle between industry and inferiority favors inferiority or an overabundance of industry, children are likely to give up and regress to an earlier stage of development (Feist & Feist, 2009). When a child PRE-OPERATIVE PLAY THERAPY 27 fails at achieving the virtue of competence, identity is shaken which leaves the child susceptible to an anxious disposition.
School-aged children that are hospitalized for surgeries or similar healthcare concerns, have the potential to suffer from heightened anxiety levels, as evidenced by their developmental stage of caring what others think of them (i.e. self-image), having no control of the circumstances surrounding their hospitalization, and being unable to create goals or tasks to accomplish (Wennstrom, et al., 2007). These conditions can leave the school-aged child feeling inadequate, inferior, and confused. Further, if children in this stage have not achieved success in prior psychosocial stages, they may have a predisposition to separation anxiety and stranger anxiety (Erikson, 1963; Ziegler & Prior,
1994) when hospitalized.
Current research studies have sought to understand how children perceive, comprehend, and manage hospitalizations (Wennstrom, et al., 2007). Findings have pointed to the fact that school-aged children are inflicted with distress when hospitalized.
Namely, the main stressors are breaking away from daily routines, trying to gain control in an unknown and unfamiliar situation, facing an unknown reality and being introduced to new people (Wennestrom, et. al., 2007). Because school-aged children have limited ability to understand the severity of surgery, researchers (Wennestrom, et al., 2007;
Gedaly-Duff, 1991; Monroe & Kraus, 1996) found that the children were unable to imagine what would happen as part of their hospitalization, thereby magnifying their feelings of anxiety.
PRE-OPERATIVE PLAY THERAPY 28
Summary of Erikson’s Developmental Stages
Proper understanding of Erikson’s stages undergirds developmentally appropriate interaction and intervention for children preparing for surgery. A review of Erikson’s
(1963) first four developmental stages serves as a foundation for understanding the emotional needs of young children, specifically surrounding manifestations of anxiety.
Meeting the emotional needs of children serves as a catalyst to contain the array of emotions displayed as hospitalizations occur.
Encouraging early attachment with infants will establish a secure attachment
(Ainsworth & Bowlby, 1991) that will carry into early childhood as the child is faced with anxieties related to strangers and separation from their caregiver (Ziegler & Prior,
1994). As pre-school aged children feel more secure with choice-giving power, their adjustment to unfamiliar environments will be an easier transition. These transitions in new settings are more easily adjusted to when the primary caregiver can explain the changes to be expected. As developmentally appropriate, Erikson (1963) suggests that school-aged children be given ownership in their environment and an opportunity given for them to express their concerns and questions. Many of these developmental needs can be met with children preparing for surgery with an intervention that caters to the goal of reducing pre-surgical anxiety in pediatric patients.
Pre-Operative Anxiety
Pre-operative anxiety is universal in most patients admitted to the hospital for surgical procedures (McCleane & Cooper, 1990). The age of the child, length of hospitalization, previous hospitalizations, and the level of parental anxiety are highly PRE-OPERATIVE PLAY THERAPY 29 correlated with influencing the anxiety responses in children preparing for surgery
(Berner, 1976; Langford, 1961). “Pre-operative anxiety stimulates sympathetic, parasympathetic and endocrine systems leading to an increase in heart rate, blood pressure and cardiac excitability resulting in cardiac arrhythmias” (Ramsay, 1972, p.
396). Additionally, it increased plasma adrenaline levels by 40% (Fell et al., 1985) and caused electrolyte imbalance (McCleane & Watters, 1990). Research indicated that there is a clear correlation between hospitalization and coping with anxiety for children undergoing medical procedures (Eth & Pynoos, 1995; Foley et al., 2006; Knox, 1983;
LaMontange et al., 2000; Li & Lopez, 2008; Peterson, 1989; Tiedeman & Clatsworthy,
1990; Vogel & Vernberg, 1993).
Children’s cognitive development prohibits their capacity to define the parameters of an event, specific to the duration or intensity (Erikson, 1963; McMurtry, et al., 2010).
They are often inaccurate in their assessment of when an event actually occurred
(McMurtry, et al., 2010). However, Landreth (2002) notes that children’s emotions are played out symbolically in a way that creates emotional distance from the actual event.
That distance creates a safety barrier to protect children from feelings that overwhelm them (Landreth, 2002). This emotional distance allows the child to assimilate and create meaning to their strong feelings (Landreth, 2002).
Child development experts have found that many young children show high levels of emotional discomfort by short-term, highly visually salient, and somewhat painful procedures (Eland & Anderson, 1997; Poster, 1983). Stressors for children undergoing any medical procedure may result from venipuncture, pre-surgical injection, parting from PRE-OPERATIVE PLAY THERAPY 30 the parent prior to surgery, undergoing anesthesia induction, and coping with postoperative discomfort (Wolfer & Visintainer, 1975). Similar to adults, children cope with emotional stress the best they can in the moment. Anxiety in children can be reduced as it serves as a coping mechanism in moments of vulnerability (Landreth, 2002).
Coping in children and adults universally includes three facets, none of which are one-dimensional: (a) active versus passive; (b) internal versus external; and (c) emotionally focused versus problem-focused coping (Peterson, 1989). LaMontagne,
Hepworth, Johnson, and Cohen (1996) found that avoidant coping was used more during the acute phase of hospitalization and active coping was used more often in the recovery phase. In that same study (LaMontagne et al., 1996), results showed that when children preparing for surgery focused their attention on upcoming stressors, coping and recovery was negatively affected. By focusing children’s attention on a specific aspect of hospitalization, they are better equipped to recover faster than children who are avoidant in their experience.
An internal Locus of Control refers to the belief that events or outcomes come as a result of one’s own choices and actions; an external Locus of Control is described as less influenced by one’s own choices and actions and more predisposed by outside influences (LaMontagne, 1993). Choosing an internal Locus of Control correlates positively with active coping approaches, such as seeking information about the illness or surgery and alertness to stressful stimuli (LaMontangne, 1984; 1987). In young children, the internal Locus of Control is associated with the attachment of the primary caregiver.
An external Locus of Control has been shown to be interrelated with avoidant coping PRE-OPERATIVE PLAY THERAPY 31 strategies, such as avoiding information about the event, denying worries, and distancing one’s self from stressful stimuli (LaMontagne, 1984; 1987; Rothbaum, Wolfer, &
Visintainer, 1979). Medical and mental health professionals, including Child Life
Specialists should have awareness and training in how to treat children appropriately based on age style of coping in hopes of decreasing levels of perceived trauma.
Developmentally speaking, common events can offer the presentation and acuity of traumatic experiences in the lives of children, although rates of exposure and severity of exposure vary (Brown, 2002; Fergusson, Lynskey, & Horwood, 1996; Johnson,
Cohen, Kasen, Smailes, & Brook, 2001; Lynskey & Fergusson, 1997; Pine & Cohen,
2002). This emotional trauma can be introduced by unmet needs surrounding anxiety in young children as their sense of mistrust is heightened (Erikson, 1963). Throughout a child’s life, approximately 15% to 20% will encounter some form of relatively severe trauma (Breslau, 2002; Brown, 2002). Trauma in and of itself predisposes children to various forms of psychopathology including anxiety (Yule et al., 2000), major depression
(Brown, Cohen, Johnson, & Smailes, 1999), and behavior problems (Shaw et al., 1995).
Findings from longitudinal studies have delineated three broad sets of factors that predict differential risk in developing psychopathologies (Pine & Cohen, 2002). The factors noted include: (a) children who exhibit high degrees of psychopathology before traumatic exposure; and (b) level of exposure and frequency of exposure to trauma
(Pynoos, Steinberg, & Piacentini, 1999), and finally, social factors emerge as the strongest predictors of risk among traumatized children (Johnson et al., 1999; Lynskey &
Fergusson, 1997; Yule et al., 2000). Many children who have been exposed to acute PRE-OPERATIVE PLAY THERAPY 32 trauma have shown relatively strong outcomes if their social environment has not been severely impaired and if they possess high levels of social support (Pine, 2003).
Additional risk factors include children with limited intellectual ability, sex (female), age
(younger), family life (instability), and intense exposure to frightening events; children with these symptoms may recover at a slower pace and may need professional intervention as noted by Yule et al. (2000).
Child-Centered Play Therapy
Play therapy is a specialized classification of child therapy because it focuses on the person rather than the problem and the present rather than the past (Landreth, 2002).
Feelings are capitalized over thoughts or acts (Landreth, 2002). Understanding matters more than explaination (Landreth, 2002). The play therapy relationship is one of acceptance rather than correction (Axline, 1974). In addition, the child’s direction is more important than the therapist’s instruction; the child’s wisdom is valued more than the therapist’s knowledge (Landreth, 2002).
True play is pleasurable, intrinsically satisfying, and complete (Landreth, 2002). It is voluntary, free from evaluation and judgment, and encourages fantasy and the use of imagination (Landreth, 2002). True play increases interest and involvement, encourages the development of self, and is person-focused, not object-focused (Landreth, 2002). It allows a child to gain insight into his or her lifestyle safely and reduces anxiety as he or she plays out his or her fears (Landreth, 2002). Often, children’s play will reveal what they have experienced, their reactions, what they need in life, and their personal self- concept (Sweeney, 2007). PRE-OPERATIVE PLAY THERAPY 33
CCPT is based on a Person-Centered (Rogers, 1951) theory, which accepts people as they are and promotes the basic principle of trust. Person-Centered therapy (Rogers,
1951) asserts that individuals and groups can set their own goals and monitor their own progress throughout the process of therapy (Raskin & Rogers, 2005). Rogers (1951) designed his work around 19 propositions that show personality should be a naturally evolving process in which a person takes primary responsibility for his or her development. The goal of Person-Centered therapy is clearly presented by Rogers (1942):
It aims directly toward the greater independence and integration of the
individual rather than hoping that such results will accrue if the counselor
assists in solving the problem. The individual, and not the problem, is the
focus. The aim is not to solve one particular problem, but to assist the
individual to grow, so that he can cope with the present problem and with
later problems in a better-integrated fashion. (p. 28)
In CCPT, children are viewed as valuable people who are capable of positive self- direction (Ray, 2009). Landreth (2002) presented 10 basic tenets in applying CCPT to children. They are:
1. Children are not miniature adults. As explained through developmental
theory, children think and act differently from adults.
2. Children are people. They are capable of intense emotions and
complicated thoughts.
3. Children are unique and worthy of respect. Each child possesses an
individual personality and will. PRE-OPERATIVE PLAY THERAPY 34
4. Children are resilient. Although children experience some
unfathomable situations, they are able to preserve beyond adult
understanding.
5. Children have an inherent tendency toward growth and maturity. They
are endowed with the will to strive for self-actualization.
6. Children are capable of positive self-direction. On their own, children
are creative and able to develop ways to work positively in their world.
7. Children’s natural language is play. Play is their safest and most
comfortable way to express themselves.
8. Children have a right to remain silent. Because children operate most
expressively in a non-verbal world, a child-centered counselor does
not force them to communicate in an adult verbal world.
9. Children will take the therapeutic experience to where they need to be.
There is no need for the counselor to direct the experience.
10. Children’s growth cannot be sped up. Children operate on their own
developmental time schedule that cannot be directed by an adult. (p.
54)
Several intensive and short-term play therapy interventions with children suffering from anxiety have been found to have successful outcomes (Oualline, 1975;
Barlow, Landreth & Strother, 1985; Crow, 1990; LeVieux, 1994; Johnson, McLeod, &
Fall, 1997; Webb, 2001). Barlow et al. (1985) found that the most important factor in the therapeutic relationship was the play therapist’s ability to create an environment of PRE-OPERATIVE PLAY THERAPY 35 freedom welcoming all expression of emotions. Ray (2009) noted that optimal time for therapeutic play sessions are from 30 to 45 minutes. However, Landreth, (2002) noted that the relationship between the client and the play therapist is of utmost importance, as the focus is on the relationship and the experience. Notably, Webb (2001) found that after the Oklahoma City bombing in 1995, children benefit from one to three 30-minute play therapy sessions. There is no hard and fast rule to how long a play therapy session should be (Landreth, 2002) as the relationship and experience are more important in play therapy than the content and length of the sessions.
Filial Therapy
Recognizing a shortage of mental health professionals trained to provide mental health services for troubled children, the development of Filial Therapy by Bernard and
Louise Guerney in the early 1960s marked a significant and innovative development to the field of play therapy. The Guerneys (1972) were the first to develop a model for training and supervising parents in Client-Centered Play Therapy methods to use with their own children (L. Guerney, 2000).
Filial Therapy can be simply understood as a therapist teaching the parent to conduct play sessions with their child, looking similar to what a play therapist would do with a child using CCPT. One could speculate that this parent-child relationship would continue to be quite effective as the child transitions home from the hospital environment.
Most parents have a natural bond with their child. This attachment often shows in hospital settings when young children cling to their parent or scream when separated. PRE-OPERATIVE PLAY THERAPY 36
Because of this bonding, it is plausible that a parent may have a stronger therapeutic contribution to their child than a mental health professional.
During Filial Therapy, the therapist intently focuses on encouraging anxious parents to feel understood, cared about, validated, and empowered as they seek to reduce their child’s anxiety (McGuire, 2001). Parents need to believe that it is actually possible to improve the present situation. According to one qualitative study of Filial Therapy, researchers found that parental stress level decreased regarding the situation surrounding the need for therapy, and interestingly, the parent’s stress level increased regarding their effectiveness in carrying out the new skills (Foley, Higdon, & White, 2006).
Parental influence on childhood trauma measures should also be considered.
Often children’s responses to trauma cannot be considered as autonomous responses of their own, because children will take on the emotion displayed by their parents (Janis,
1951; Ronen, 2002; Terr, 1985). Parents tend to underestimate the symptoms of their children when questioned about criteria to diagnose a child with a trauma disorder. This denial may be characteristic of parents’ avoidance of the discomfort from traumatic experience for themselves and their children (Hanford et al., 1986; Pfefferbaum, 1997;
Sack et al., 1994).
Filial Therapy can be beneficial with anxiety stricken hospitalized children, thus the parent is an equally important part of the treatment modality, as the parent is depended upon for commitment to a 30-minute play sessions with their child one time per week. The child feels safer and more at ease when their parent is part of the process; one is led to believe that this alone significantly reduces anxiety. One could speculate that this PRE-OPERATIVE PLAY THERAPY 37 parent-child relationship would continue to be quite effective as the child transitions home from the hospital environment. Research also indicates that group interventions for patients and families with medical issues are effective as it lends support in a psychosocial environment and seems to reduce pediatric anxiety (Sherman, et al., 2004).
Rationale for Further Research
Copious amounts of research emphasize the importance of psychologically preparing children for surgical procedures and hospitalization (Brewer et al., 2006;
Edwinson et al., 1988; Ellerton & Mernam, 1993; Kain et al., 1996; Li & Lopez, 2008;
Melamed et al., 1983; O’Conner-Von, 2000; Price, 1991; Schmidt, 1990; Squires, 1995;
Ziegler & Prior, 1994). Upon review of the literature, research supports the efficacy of medical play within the medical setting (Adams, 1976; Alger et al.; 1985; Becher & Wan,
1997; Brunskill, 1984; Doverty, 1992; Clatsworthy, 1981; Frankenfield, 1996; Vessey &
Mahon, 1990; Webb, 1995; Willemsen & Anscombe, 2001; Zahr, 1998). Medical play invites the hospitalized child to play out fears and emotions pertaining to the hospitalization experiences, specific diagnoses, and treatment concerns (Le Vieux, 1999).
However, therapeutic CCPT in a medical setting differs greatly from that of medical play in that a child is given a wider parameter of choice in object and expression (Le Vieux,
1999; Lingnell & Dunn, 1999) and should be considered in treating children preparing for surgery. The literature indicates a need for further research of the efficacy of CCPT offered to children preparing for surgical procedures as a means of reducing pre-surgical anxiety.
PRE-OPERATIVE PLAY THERAPY 38
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PRE-OPERATIVE PLAY THERAPY 51
PREDICTORS OF ANXIETY REDUCTION IN PRE-NEUROSURGICAL
PEDIATRIC PATIENTS
Julie L. Lerwick
Oregon State University PRE-OPERATIVE PLAY THERAPY 52
CHAPTER III: METHOD
Abstract
Child-Centered Play Therapy (CCPT) within the medical setting has the potential to reduce perceived psychological trauma, anxiety, and behavioral issues in children preparing for surgery. This quantitative, quasi-experimental, repeated measure research study investigated the impact of CCPT on anxiety levels of pre-surgical 4 to 12 year old pediatric patients (n = 14) preparing for neurosurgery at Doernbecher Children’s Hospital in Portland, Oregon. Results indicated a significant reduction of self-reported anxiety immediately after the CCPT intervention.
PRE-OPERATIVE PLAY THERAPY 53
Introduction
Review of the Literature
Hospital visits can be quite stressful for children (Le Vieux, 1999; Lingnell &
Dunn, 1999); however, play has been found to be a natural outlet for expression of emotions such as anxiety, stress, and nervousness (Le Vieux, 1999; Lingnell & Dunn,
1999) among children. Through the interaction promoted by therapeutic play with a qualified clinician, an environment of safety is presented as a context in which hospitalized children express emotion (Le Vieux, 1999; Lingnell & Dunn, 1999).
Heightened levels of anxiety in children preparing for surgery is concerning.
Existing research in the field of childhood counseling identifies the correlation between pre-surgical anxiety and children (O’Conner-Von, 2000), levels of perceived trauma when children are preparing for surgery (Li & Lam, 2003), and the therapeutic benefits of
Child-Centered Play Therapy (Landreth, 2002). Yet the relationship between CCPT and children preparing for surgery, in terms of anxiety reduction and perceived trauma, is unknown. The purpose of this pilot study is to explore the impact of CCPT on the anxiety levels of children preparing for surgery. The hypothesis asserts that a 15-minute CCPT intervention will reduce self-reported anxiety when assessed by the FAS in a pediatric, pre-neurosurgical sample.
Materials and Methodology
Volunteer participants were recruited by a neurosurgeon at Doernbecher
Children's Hospital in Portland, Oregon from a population of neurosurgical patients.
Parents or guardians were told the purpose of the study was to investigate the impact of a PRE-OPERATIVE PLAY THERAPY 54 pre-operative play therapy session on the level of anxiety in pediatric patients. Parents and guardians were assured of equality of medical care regardless of their participation decision.
Informed Consent
Approval for this study was obtained through the Oregon State University
Institutional Review Board (see Appendix A) and the Oregon Health and Sciences
University Institutional Review Board (see Appendix B). The greatest ethical concern related to the withholding of a potentially effective treatment from the pediatric pre- surgery population at Doernbecher, including children receiving care in other departments. Based on this consideration, the Institutional Review Board, as well as the researcher, understood that this design excluded children who could potentially benefit from the treatment intervention.
The population was informed that the experimental research would fulfill doctoral degree requirements for the co-investigator. Parents were informed that the duration of the child’s participation in the study would not exceed 20 minutes. They were told what would occur during that 20-minute period, including asking the child one question prior to the 15-minute CCPT intervention, and one question after the intervention in regard to anxiety level, which would be described as “feeling scared” to the child. Specifically, the parent was told that using a scale of five faces showing a range of anxiety, the child would be asked to point to one face that best shows their fear in the moment.
Full disclosure of the possible risks and discomforts associated with participating in the study included a potential increase in the child’s level of anxiety as a result of a PRE-OPERATIVE PLAY THERAPY 55 non-familiar person in the room with them prior to surgery and latent side effects from study procedures not yet known to the researcher. Parents were informed that if their child did not wish to participate at any time during the session, the student researcher would terminate the session immediately and parents or guardians would have the option of withdrawing the child from the study.
Parents and guardians were also warned that their child may or may not personally benefit from being in the study. However, the Informed Consent noted that by serving as a study participant, the child might help researchers learn how to benefit patients in the future. Parents were given a copy of signed Informed Consent and release forms (see Appendix C). All documentation was secured in a password-protected database and locked file cabinet.
Participants
Participants were recruited from the Pediatric Neurosurgery Clinic of Oregon
Health and Sciences University. The convenience sample (n =14) included English- speaking children, aged 4 to 12 years, who were scheduled to have neurosurgery. During a pre-surgery clinic visit, a surgeon invited children to be part of the research study.
Inclusion criteria required that participants have a diagnosis requiring neurosurgery and be capable of physically and mentally engaging in play therapy. One child was mute, yet was able to fully engage in therapeutic play. Another child was medicated prior to hospital admission with an analgesic and was also cleared to participate by a neurosurgeon. Additionally, participants were limited to those admitted only through the neurosurgery clinic; no Emergency Department admissions were PRE-OPERATIVE PLAY THERAPY 56 accepted. Non-English speaking children were excluded, as the doctoral student co- investigator is monolingual. Children with severe, traumatic brain injury, the presence of intracranial hypertension, or a need for emergency operation, were excluded, as determined by the neurosurgeons who deemed emergent medical care a priority (J.
Chong, Personal Communication, September 2011). Emergent cases require immediate surgical care in order to save the child’s life.
Instrument Review and Selection
Psychometric Anxiety Scales for Children.
Meeting the emotional needs of children, related to anxiety, prior to a surgical procedure demands the need for a developmentally appropriate valid and reliable method for measuring pre-surgical anxiety in children preparing for surgery. Both physical and emotional factors contribute to the experience of pain (Mc Murtry et al., 2010). Because of this correlation of sensory and emotional stimulus, children are frequently asked to report their anxiety and fear, preceding and throughout, painful medical procedures (Mc
Murtry et al., 2010). Thus, both anxiety and pain scales were evaluated to determine appropriateness of use for this research study.
Child Anxiety Sensitivity Index
The Child Anxiety Sensitivity Index (CASI) was developed by Silverman et al.
(1991) to show incremental validity over measures of manifest anxiety in determining relationship between fears and panic symptoms. The CASI is promoted for use with school-aged children 6-17 years because of their ability to read the scale items. Indeed, most studies of childhood anxiety sensitivity measure anxiety levels in children ages 6 to PRE-OPERATIVE PLAY THERAPY 57
10 using self-report measures (Weems et al., 1997, 1998; Calamari et al., 2001). Yet younger children have difficulty reading and understanding a self-report instrument
(Weems et al., 2008). Therefore, when using the CASI with very young children, the items are read aloud. This disruption of suggested method of facilitation brings the validity and reliability into question. Most theorists agree that the CASI is not valid as a self-report in children under the age of 6 or 7 years (Calamari et al., 2001; Chorpita &
Lilienfeld, 1999; Raiban et al., 1999; Weems et al., 1998). The CASI was not chosen as a measure of anxiety in this research study because the sample size includes seven children below age 7.
Revised Children’s Manifest Anxiety Scale
The Revised Children’s Manifest Anxiety Scale (RCMAS: Reynolds &
Richmond, 1978) is a 37-item scale designed to assess the presence or absence of a variety of anxiety related symptoms drawing from three factors: physiological anxiety, worry/over-sensitivity, and concentration (Reynolds & Richmond, 1978). Children are asked to respond to statements such as: "I am nervous," "My hands feel sweaty," and "I get mad easily”. Children affirm or deny the veracity of the statement depending on what is true in the moment. The RCMAS scale was not used because the central purpose of the current study is to measure only manifest anxiety.
State-Trait Anxiety Inventory for Children
Notably, the State-Trait Anxiety Inventory for Children (STAIC) correlates significantly and positively with the RCMAS (Spielberger, 1973). Popularly used as a self-report assessment tool to measure the anxiety level of children during stressful PRE-OPERATIVE PLAY THERAPY 58 medical procedures (Li & Lopez, 2006, 2008), the STAIC evaluates the effectiveness of different interventions for children (Ireland, 1998; Hultcrantz & Ericsson, 2004; Robb &
Ebberts, 2003). The scale does not measure manifest anxiety such as crying, restlessness, agitation, withdrawal, disruptive reaction to medical procedures, or cooperation with medical procedures, which are the emotional behaviors commonly displayed by children when facing stressful situations, such as pre-surgical hospital settings (Li, 2006).
The inventory is 40 questions in length and requires 8-12 minutes to complete.
This limited its usefulness in the context of the current study given the limited time for intervention and assessment as well as the perceived chaos of the environment.
Furthermore, the scale was originally developed to study anxiety levels in children in elementary school (Spielberger et al., 1973). “Younger children who are particularly vulnerable to the stress of medical procedures cannot benefit from this scale” (Li &
Lopez, 2006, p. 224). For these reasons the STAIC was eliminated as an option.
Children’s Emotional Manifestation Scale
The Children’s Emotional Manifestation Scale (CEMS: Li & Lopez, 2006) was developed to measure children’s emotional responses during stressful medical procedures. Five different direct behavior categories are observed: facial expression, vocalization, activity, interaction and level of cooperation. Being that the instrument does not allow the child to self-report anxiety, it was not used for this research study.
The Revised Fear Survey Schedule for Children
The Revised Fear Survey Schedule for Children (FSSC-R) assesses children’s fears, which may manifest from anxiety. Bolby (1973) claimed that fear and anxiety PRE-OPERATIVE PLAY THERAPY 59 evoked the same physiological responses, and conceptualized anxiety as a variant of fear.
Children are asked to rate 80 items on a 5-point Likert scale (1 = not scary at all, 5 = very scary) corresponding to their level of fear about particular items or situations. Items include ghosts and snakes and situations include being punished by their mother. The scale has been shown to be successful in differentiating between normal and phobic children (Ollendick, 1983). Findings indicate that the FSSC-R is specific to measuring psychopathological conditions in children and is not specific to imminent anxiety, as one would have in preparing for surgery, therefore the measure was not used for this research study.
The Child Behavior Checklist
The Child Behavior Checklist (CBCL) is a 130-item parental measure of behavior problems in their children (Achenbach & Edelbrock, 1983). Although the CBCL has well-established psychometric properties and is widely used, it does not measure anxiety specifically. Nor does the CBCL allow for child self-report of anxiety. Therefore it was not selected either.
Faces Pain and Anxiety Scales
Research indicates that children prefer face scales to other scales because of their ease of use (Goodenough et al., 2002). Faces scales are broadly used with children and adults in medical settings. Although most face scales include a smiling face and a tearful face, there has been debate surrounding if the first face in an ordered scale should portray a smiling face, because children were found to be hesitant to pick these scales if they were not smiling (Hicks et al., 2001). Likewise, children were found to be hesitant to pick PRE-OPERATIVE PLAY THERAPY 60 scales depicting tears if they were not crying (Hicks et al., 2001). This suggests that children have a preference for face scales that accurately show their immediate emotional state.
The Wong-Baker Faces Pain Scale
The Wong-Baker Faces Pain Scale (Wong & Baker, 1988) is a commonly used measure of pain in adults and children within medical settings. The scale was validated and originally developed to assess post-operative pain in children of 3 years old and older. A study in 2008 (Wennstrom et al., ) used the scale to gain a description of children’s mood using their own words. The scale was used as a means of connecting with children through verbal dialogue and play. The playing situation was initiated by asking the children to point to the face on the scale that was similar to how thy felt at the time: ‘Which one of these faces do you feel like right now?’ A follow-up question, ‘How does that feel?’ was asked once the child had pointed to the face that was identified.
Because the Wong-Baker Faces Pain Scale is used for both children and adults, the cartoon drawing of the faces allows both age groups to relate to the feelings depicted in the scale ranging from no hurt to hurts worst. In one study (Chambers et al., 1999) children and parents indicated that they preferred the scale due to the fact that it was more attractive, whereas nurses preferred the scale due to its simplicity and ease. Because this scale measures pain, it was not utilized in measuring pre-surgical anxiety in this study.
The Faces Pain Scale-Revised
The Faces Pain Scale-Revised (FPS-R: Hicks, von Baeyer, Spafford, van Korlaar,
& Goodenough, 2001) measures pain intensity using a Likert scale. The FPS-R consists PRE-OPERATIVE PLAY THERAPY 61 of six gender-neutral faces expressing no pain to the most pain possible. Children select a face that represents how much pain is felt and the faces are scored. The FPS-R is the most psychometrically sound self-report measure of pain in children between 4 to 12 years of age (Stinson, Kavanagh, Yamada, Gill, & Stevens, 2006). However, because this scale measures pain, it was not utilized in measuring pre-surgical anxiety in this study.
Children’s Psychometric Anxiety and Pain Scales.
The Children’s Anxiety and Pain Scale.
The Children’s Anxiety and Pain Scale (CAPS: Kuttner & LePage, 1989) consists of five faces representing varying degrees of pain and anxiety. Children are invited to select a face that represents how scared they feel and the ordered faces are scored from 0 to 4. The anxiety scale of the CAPS is intended for use with children between the ages of
4 and 10 years and has shown good evidence of validity (Kuttner & LePage, 1989).
CAPS is often used to measure anxiety and pain in children, however, its acceptability to children and parents is low (Chambers et al., 2005). This scale was not selected as the instrument to measure anxiety in this study due to the fact that it was a dual construct scale that measured both anxiety and pain.
Faces Anxiety Scale.
The data collection instrument for this study was the FAS (McKinley et al.,
2003); it was utilized to measure participants’ self-report of pre-surgical anxiety pre-post intervention. The FAS (see Appendix D), a self-report projective measurement of anxiety, was originally developed to measure anxiety and fear in adult patients being cared for in intensive care units of hospitals. Since it had never been used on children, a PRE-OPERATIVE PLAY THERAPY 62 team of researchers at Dalhousie University in Nova Scotia, Canada, revised the language of the instrument for use with children in a pilot study allowing children to identify their level of “feeling scared” on a one to five ranking scale (McMurtry, Noel, Chambers, &
McGrath, in press). The scale displays five faces ranging from 1, not scared at all to 5, most scared possible. Findings support the use of the FAS (McKinley et al., 2003) with children (McMurtry et al., in press). The research was part of a larger study measuring adult reassurance on children’s report of pain (McMurtry et al., in press).
Summary of Anxiety Scales.
The current literature indicates that faces scales are accurate predictors of pain and anxiety in children (Goodenough et al., 2002; Hicks et al., 2001). However, few existing instruments use faces to measure anxiety in children (McMurtry et al., 2010).
Although research shows that children prefer faces scales as a simple self-report measure, more studies are required to prove the validity and reliability of the limited anxiety scales that currently exist (Kuttner & LePage, 1989). For this reason, mirroring the study by
McMurtry et al. (2010), the Faces Anxiety Scale (McKinley et al., 2003) was used with children preparing for surgery as a means of inviting the patients to self-report anxiety immediately prior to an operation.
Procedure
Once a neurosurgeon obtained verbal consent from a participant's parents or guardians, the student researcher entered the exam room, outlined the experimental nature of the study (see Appendix E), presented possible risks and benefits, answered all questions, received verbal assent from the child (see Appendix F), and obtained consent PRE-OPERATIVE PLAY THERAPY 63 and release signatures as required by the IRB's at both universities. Parents or guardians were provided copies of all signed documents. In some cases, the consent process was completed on the day of surgery. As these children faced urgent rather than emergent medical issues, their status prohibited pre-operative clinic visit but did not limit their participation in the study. In those cases, the student researcher obtained consent from the parent/guardian and assent from the child in the waiting room outside the pre-operative area.
On the day of surgery, participants were greeted in the peri-operative area by the co-investigator to confirm eligibility and willingness to participate in the study by parents or guardians and patients (see Appendix G). Upon completion of required medical preparation by the nurses, the researcher was given permission to enter the curtained area where the child awaited surgery. Family were seated in chairs, and the child, in a hospital gown, was sitting or lying on the gurney awaiting transportation to the operating room.
The researcher, seated approximately two feet away from the child in a chair facing the gurney or on the gurney itself, used the following instructions to guide children through the pre-intervention assessment:
These faces are showing different amounts of being scared. This face
[point to the left- most face] is not scared at all, this face is a little bit more
scared [point to second face from left], a bit more scared (sweep finger
along scale), right up to the most scared possible [point to the last face on
the right]. Have a look at these faces and choose the one that shows how
scared you feel right now. (McMurtry et al., in press) PRE-OPERATIVE PLAY THERAPY 64
Next, the researcher provided a 15-minute play session with the child, following established protocol for CCPT (Ray, 2009; see Appendix H). The 15-minute play session gave children access to 22 toys, including dolls, puppets, toy cars, doctor’s kit, and a magic wand. Appendix I provides a detailed list of available toys. It is important to note that toy choices were not limited to versions of hospital equipment encountered by the child during the hospital stay as CCPT expands on typical medical play that typically limits child choice. Children were not guided in their play by the researcher; however, their behaviors and emotions were verbally tracked aloud as the child played. For example, when one participant chose to place the plastic syringe against the researcher’s arm, the researcher verbally stated, "You chose to put that right there on my arm. Look’s like you have something in mind" (J. Lerwick, Personal Communication, March 2011).
Another child gleefully chose to make circles in the air with a magic wand. The researcher (J. Lerwick, Personal Communication, March 2011) commented, “You are really happy putting that right up there, just the way you want it to be [pointing to magic wand]!”
The child was given a 5-minute and 1-minute time warning about the impending conclusion of the play session. At the completion of the CCPT session the researcher asked the child to select a face on the FAS (McKinley et al., 2003) to represent how
“scared” he or she felt post-intervention using the following verbal script to guide children during the post-intervention analysis:
These faces are showing different amounts of being scared. This face
[point to the left- most face] is not scared at all, this face is a little bit more PRE-OPERATIVE PLAY THERAPY 65
scared [point to second face from left], a bit more scared (sweep finger
along scale), right up to the most scared you can possibly be [point to the
last face on the right]. Which face shows how scared you feel right now?
(J. Lerwick, Personal Communication, March 2011)
The researcher then thanked the child and family for their participation, offered well wishes for the procedure, and recorded the data immediately at the nurse’s station using a secure document on the hospital’s database.
Data Analysis Plan
Power analysis allows researchers to estimate an appropriate sample size when designing a research study. Current reliable and valid research related to the topic of interest and accurate to the study design traditionally provides the researchers with an idea of an appropriate sample size. However, no pre-post studies measuring anxiety in children using the FAS (McKinley et al., 2003) were found in the current literature.
Therefore it was necessary to estimate an appropriate sample size by approximating the mean change in anxiety after the CCPT intervention that could be expected in this population given the context.
Literature indicates that children preparing for surgery would have heightened levels of anxiety. Developmentally, children aged 4 to 12 are struggling with stranger anxiety, autonomy, the need for control, and the desire for choice. Furthermore, young children often take on anxiety demonstrated by their parents. Hospitalization of any kind takes children out of their natural, comfortable environment and creates new situations in which instant adaption is required. PRE-OPERATIVE PLAY THERAPY 66
Based on these developmental considerations the doctoral student co-investigator asserted that a reduction in anxiety was possible and that it would correlate directly with the CCPT intervention. A 1.25 reduction of anxiety on a 5-item Likert scale was chosen in order to determine appropriate sample size. Power analysis was performed using this asserted pre-post intervention change, resulting in the suggestion that 14 participants was a large enough sample size to generalize results with 90% certainty.
Analysis will include a review of descriptive statistics. Correlation between pre- post-intervention anxiety mean and age, sex, family members present, and medical staff present will be assessed. Inferential analysis will consist of a repeated measure t-test statistic used to compare the pre- and post-intervention mean of self-reported anxiety scores based on the FAS.
Results
Descriptive Statistics
Demographics displayed in Figure 1 show the age range. Eight (57%) children in the sample were aged 4 to 7 years and six (43%) were aged 10 to 12 years. As participants were a convenience sample, no children aged 8 to 9 were available for inclusion in the study. PRE-OPERATIVE PLAY THERAPY 67
Figure 1. Age Range
The pre-intervention mean anxiety score was 2.25 (sd = 1.25). The range of pre- intervention anxiety scores was 1 to 5. The scale displays five faces ranging from 1, not scared at all to 5, most scared possible. The post-intervention mean anxiety score was
1.43 (sd = .76) with a range of 1 to 3. The difference between the pre-intervention and post-intervention score was .82. Note that the standard deviation and range decrease from pre-intervention to post-intervention indicates a consistent trend in the sample toward anxiety reduction (see Figure 2 for pre and post intervention scores; see Appendix J for raw data). PRE-OPERATIVE PLAY THERAPY 68
Figure 2. Pre-Post Intervention Scores
Eight (64%) participants were male. Six (36%) were female. Ten participants had two adult family members present. Two participants had three family members present; and two had one family member present. In some cases, the participant was joined in the room by medical staff preparing the child for surgery simultaneous to the CCPT intervention. 43% of the participants had both medical staff and parents or guardians present.
Inferential Statistics
The hypothesis asserted that a 15-minute CCPT intervention would reduce self- reported anxiety when assessed by the FAS in a pediatric, pre-neurosurgery sample. The hypothesis was supported: t(13) = 3.73, p < .01. The null hypothesis was rejected. CCPT intervention significantly reduced pediatric pre-neurosurgical self-reported anxiety in this sample. No correlations existed between mean self-reported anxiety change and age, sex, PRE-OPERATIVE PLAY THERAPY 69 the presence of family members, or the presence of medical staff. These findings lend more credibility to the potential that the CCPT intervention directly resulted in children’s self-reported anxiety reduction.
Discussion
Medical and mental health professionals, as well as parents, should expect children to experience anxiety when preparing for surgery. The negative impact of untreated pediatric pre-neurosurgical anxiety has the potential to interfere with normal development and may produce trauma according to the literature. Using a quasi- experimental repeated-measure design, 14 pediatric patients, aged 4 to 12 years, engaged in a CCPT protocol in order to examine if anxiety scores decreased post-intervention. The hypothesis that stated that a 15-minute CCPT intervention would reduce self-reported anxiety when assessed by the FAS in a pediatric, pre-neurosurgical sample was supported. CCPT intervention decreased anxiety scores in this population.
Limitations
Despite the important contributions that this investigation makes to the understanding of Child-Centered Play Therapy as means of reducing pre-surgical anxiety in pediatric patients preparing for neurosurgery, the study is not without limitations. The sample was composed of young children aged 4 to 12 which introduces participant reliability concerns as the children may or may not be capable of accurate self-report.
However, limited studies have in fact supported the validity of children’s self-report anxiety measures (Calamari et al., 2001; Weems et al., 1997, 1998, 2008). Interventions were given in a busy peri-operative department of a hospital in which results may have PRE-OPERATIVE PLAY THERAPY 70 been skewed due to unpredictability of the environment, as well as time restraints instated by medical personnel of delivering the intervention. One researcher was used to perform the intervention, which limits the expanse of children that could be studied in the defined time period, as well as the risk of researcher bias. To control for these two limitations, each intervention was followed precisely by the protocol in place. A 15-minute play session was a brief time frame to invite a child to express anxiety. For some children it was an appropriate amount of time, yet others could have benefited from extended time.
All children, however, expressed emotion in the intervention that supports the use of the intervention.
As participants were drawn from a convenience sample, the study may not be inclusive as would be desirable for complete objective results. Due to the nature of the convenience sample, pre-surgical neurosurgery patients, the sample size was limited based on how many children fit inclusion criteria and their scheduled surgeries. However, the participants included were selected carefully in order to create generalizable results of the findings. Additionally, power analysis predicted the number of participants necessary to assure results to a 90% certainty.
The measurement tool, FAS, (McKinley et al., 2003) had obvious limitations as well due to the fact that it was originally developed for adults admitted into the Intensive
Care Unit of a hospital to measure the accessibility, meaning ability, of patients to accurately self-report anxiety. Consequently, the FAS (McKinley et al., 2003) had only been used in one other study for children, using modified language. However findings PRE-OPERATIVE PLAY THERAPY 71 from the current study support the use of the FAS (McKinley et al., 2003) with children preparing for surgery.
Validity
Every effort was made to ensure the control for validity; however, in quasi- experimental research, there are often extraneous variables that are outside the scope of controllable outcomes. Ambiguous temporal precedence within internal validity is noteworthy due to the fact that without knowing what component of the therapeutic intervention produced the anxiety reduction, it was difficult to know the exact cause and effect. History, age, developmental stage, and sample selection are important validity issues to consider in this study due to the fact that participants were undergoing surgery for different neurological reasons.
History was not taken into account in this study, including the potential that participants may have had prior clinical experience with a therapist, which could reduce the causal effect. Likewise, participant history with pre-surgical hospitalization was not assessed or analyzed as a potential influential variable. Selection was complicated by the cooperation of the subjects’ parents and availability of children undergoing neurosurgery.
Finally, attrition was recognized as a potential concern and a threat to internal validity, as a parent may agree for the child to be a participant in the study and later withdraw the child from the study. Although the issue of attrition did not occur in this particular study, there were parents who did not consent, stating that their child did not experience anxiety and, therefore, would not benefit from being included the research study. PRE-OPERATIVE PLAY THERAPY 72
Threats to external validity included interaction of the causal relationship over treatment variations. Due to the range in participant ages, the potential for treatment variations to negatively impact the accuracy of the final results existed. Although treatment protocol was implemented with explicit accuracy, the age of the child dictated their desired adaption to the protocol, meaning the older children desired to talk about their emotions in the moment more than the younger children. Likewise, the younger children played with the toys more intently than the older children. Additionally, conducting research at the same hospital for all subjects may have compromised the external validity of the research design, known as context-dependent mediation.
When treatment is not delivered consistently from place-to-place or person-to- person, a possible threat to statistical conclusion validity exists. As noted above in concerns to external validity, it is probable that depending on the child’s diagnosis, age, and sex that the intervention was implemented with slight non-clinically-significant differences. For instance, tracking the play of a non-verbal or developmentally delayed child. Additionally, it was originally considered that females might have responded to play therapy differently than males, and the researcher’s approach may have varied to some degree due to the sex of the child, but this variation was not proven in the resulting data.
Being in a hospital setting, the conditions were subject to change rapidly and without warning, causing an extraneous variance in the experiment setting. Of main concern was that a quiet pre-op might have greater results than a chaotic and emergent pre-op. These conditions could not be pre-determined or remedied, but they are PRE-OPERATIVE PLAY THERAPY 73 recognized as a serious threat to statistical conclusion validity. No statistical difference was noted in the presence of family members or medical staff during the intervention, including if the medical staff was simultaneously performing medical procedures (e.g., starting the IV, shaving the surgical area, etc.).
Threats to construct validity included treatment-sensitive factorial structure.
Due to the nature of working with pediatric patients for this study, it was possible that change may have occurred even in the absence of treatment due to continued contact with the parent in pre-op, the researcher, or the presence of prescription drugs that may decrease anxious symptomology. Of the study participants, only one child had been given prescription drugs to decrease anxiety prior to intervention, and the results indicated that the anxiety levels still decreased post-intervention. It is also possible that reactivity to the experimental situation should be noted, as the subjects of this study were pediatric patients in a hospital setting. Due to the vulnerable nature of the setting itself, it was possible for the subjects to react to the experiment resulting in the skewing of data.
Additionally, the subjects may have reacted to an unfamiliar person (i.e., the researcher) conducting a play session.
Conclusion
Of the 39,000 children that are hospitalized each day throughout the United States
(National Association of Children’s Hospitals and Related Institution, 2005), 14 of those children participated in this quasi-experimental research study supporting the use of
CCPT in pre-op for the reduction of pre-surgical anxiety [t(13) = 3.73, p < .01] A psychometric self-report instrument was recorded pre-post intervention, using the pre- PRE-OPERATIVE PLAY THERAPY 74 intervention report as a baseline. External and internal validity considerations are listed above, and ethical and legal issues are addressed. Presentation of the manualized treatment protocol using CCPT is also incorporated.
Research with children is important and requires careful planning and implementation of intervention. Children and families preparing for surgery are vulnerable and anxiety levels are heightened due to the nature of the unknown. With a pre-surgical intervention of CCPT, decreased levels of anxiety in pediatric neurosurgery patients preparing for surgery occurred in this study.
PRE-OPERATIVE PLAY THERAPY 75
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PRE-OPERATIVE PLAY THERAPY 78
CHAPTER IV: Child-Centered Play Therapy for the Reduction of Pre-Surgical
Anxiety
General Conclusion
Two manuscripts thematically linked in examination of Child-Centered Play
Therapy (CCPT) and hospitalization induced anxiety were included in this dissertation.
Review of the literature asserted that CCPT is an effective treatment intervention and that it has not been investigated in a hospital setting specific to pre-operative pediatric patients. The study presented above provides empirical evidence for the use of CCPT to decrease levels of anxiety for pre-operative pediatric patients.
Due to the fact that pre-surgical anxiety is universal in most patients admitted to the hospital for surgical procedures (McCleane & Cooper, 1990), allocating funding to ensure that a hospital experience is less traumatic for young ones preparing for surgery is recommended. Unsuspectingly, reducing pre-surgical anxiety in hospitalized children is a need not being met by professionally trained play therapists currently. Anxiety levels are at an all time high for children preparing for surgery, and it is possible that there is a predisposition to perceived trauma in these children.
Supporting children and families in the hospitalized setting is important, and pre- surgical play therapy can serve as wrap-around care to compliment services already provided to children and families. When child development is understood and the innate need in children to express their emotions through therapeutic play, a strong case is built for providing CCPT to children preparing for surgery provided by professionally trained play therapists. PRE-OPERATIVE PLAY THERAPY 79
Recommendations for Future Research
Research to further understand the services given to children and families, as well as the efficacy of such, is imperative. Recommendations for future studies pointing to the theme of using CCPT with pediatric patients preparing for surgery include utilizing a larger sample size, employing a random selection of participants, expanding age group to
2- to 18-year olds, and drawing children from all surgical services, not specific to neurosurgery, from multiple hospitals.
With curiosity, the question may be asked if play therapy with pre-surgical children reduces parental anxiety levels, which in turn would result in a greater satisfaction rating of the hospital experience. Furthermore, research could be designed to quantify results of three different interventions offered to pre-surgical children, such as talk therapy, play therapy, and art therapy. Also, a parental measure of child’s anxiety scale versus self-report of pre-surgical anxiety may introduce more information than what current research presents.
Clearly there are costs associated with implementing CCPT in peri-operative units of hospitals. Because Child Life Specialists are currently employed in pediatric hospitals across the country, perhaps they could be trained to implement CCPT to pre-surgical children. And if so, perhaps it could effective as if the intervention were being delivered by a professionally trained play therapist. Finally, a study comparing the effectiveness of
Directive Play Therapy with CCPT with pre-surgical children could be studied.
An effort to address the issue of pre-surgical anxiety in children preparing for surgery was the focus of this quantitative research study. Using a quasi-experimental PRE-OPERATIVE PLAY THERAPY 80 repeated measure design, pediatric patients (n = 14), aged 4 to 12 years, preparing for neurosurgery, from a convenience sample selection process, were introduced to a CCPT protocol to examine if pre-surgical anxiety levels decreased post-intervention. The overall goal of this study was to better understand the impact of play therapy on anxiety levels of pre-neurosurgery pediatric patients. The secondary objective was to understand the relationship between pre-surgical anxiety and play therapy as a means of reducing perceived trauma in children. Resulting from the paired sample t-test to evaluate if there was a decrease in anxiety level from pre-intervention to post-intervention, findings support the use of CCPT in pre-op for the reduction of anxiety in children ages 4 to 12 years old [t(13) = 3.73, p < .01].
Implications of this research extend beyond the realm of counseling. Literature presented in these manuscripts is relevant for counseling and psychotherapy and has a broad use for those whose professional degrees relate to counselor education, psychology, medicine, social work, psychiatry, and nursing among other professions that help vulnerable children. Findings support the use of CCPT as a means of reducing pre- surgical anxiety in children preparing for surgery in a way that is not currently being met by professional play therapists in medical settings, specific to hospitals. Research encompassing the importance of evidence-based practices in working with children was achieved by this study. The more therapists that are trained in CCPT for use in hospitals, the more children can be spared from the seemingly tragic emotional experience, for some, of pre-surgical anxiety. PRE-OPERATIVE PLAY THERAPY 81
As a profession, counselors must stand firm in advocating for the needs of children who have a limited voice in their healthcare and mental health care experience.
CCPT gives a strong voice to the personal emotional world of children who may otherwise have no expression of their vulnerable experience. PRE-OPERATIVE PLAY THERAPY 82
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APPENDICES
PRE-OPERATIVE PLAY THERAPY 99
APPENDIX A
OREGON STATE UNIVERSITY IRB APPROVAL PRE-OPERATIVE PLAY THERAPY 100
PRE-OPERATIVE PLAY THERAPY 101
APPENDIX B
OREGON HEALTH & SCIENCE UNIVERSITY IRB APPROVAL
PRE-OPERATIVE PLAY THERAPY 102
APPENDIX C
CONSENT FORM
Oregon Health & Science University
Consent and Authorization Form
IRB#: 00006641 Protocol Approval Date: 11/17/2010
OREGON HEALTH & SCIENCE UNIVERSITY Consent and Authorization Form
TITLE: Play Therapy in Pre-Op for the Reduction of Anxiety in Pediatric Patients
PRINCIPAL INVESTIGATOR: Daniel Guillaume, MD, MSc (503) 494-4314
CO-INVESTIGATOR: Julie Lerwick, MA, PhD Cand. (503) 334-7374
PURPOSE:
The purpose of this study is to investigate the impact of a play therapy session in pre- op on the reduction of anxiety in young children.
Your child is being invited to take part in this study because he or she is preparing for surgery and fits into the age range that the researcher would like to study. The purpose of this study is to determine if a play therapy session will reduce pre-surgical anxiety in children.
From start to finish, your child’s participation in this study should not exceed 20 minutes. Within this time, your child will be asked 2 questions about his/her anxiety and engage in a 15-minute play session with the student researcher who is a trained play therapist.
Up to 20 children will be invited to take part in this study at OHSU.
PRE-OPERATIVE PLAY THERAPY 103
PROCEDURES:
Hospital visits can be quite stressful for children, however play is natural. Play Therapy allows a child to express his or herself through play. It is believed that a child’s play will reflect his or her emotion and through play, the child will be able to safely express emotions such as anxiety, stress and nervousness. This study’s 15- minute play session gives children access to 15 toys. The toys will not be limited to pretend "hospital" toys such as stethoscopes and thermometers, but will also include toys such as dolls, trucks, and blocks in order to provide your child with a variety of choices. The child is not limited in his or her play, or instructed to play in a certain way, but rather encouraged to play as she or he sees fit.
The study activities include your child being asked one question prior to the intervention and one question after the intervention in regards to their level of anxiety, which will be described as “feeling scared” to your child. Your child will be given a 15-minute therapeutic play session with a professionally trained play therapist to see if his/her pre-surgical anxiety is reduced. These activities are experimental in nature and will be conducted for the purposes of research.
If you have any questions regarding this study now or in the future, contact Dr. Daniel Guillaume (503) 494-4314 or Julie Lerwick (503) 334-7374.
RISKS AND DISCOMFORTS:
The possible risks and discomforts associated with being in this study include: your child’s level of anxiety could increase because of a non-familiar person in the room with them prior to surgery. If your child at any time does not wish to participate in the play session, then the play session will be terminated by the student researcher.
Unforeseeable risks: Your child may experience side effects from the study procedures that are not yet known to the researchers.
BENEFITS:
Your child may or may not personally benefit from being in this study. However, by serving as a subject, your child may help us learn how to benefit patients in the future.
ALTERNATIVES:
You may choose for your child not to be in this study. PRE-OPERATIVE PLAY THERAPY 104
CONFIDENTIALITY AND PRIVACY OF YOUR PROTECTED HEALTH INFORMATION:
We will not use your child’s name or identity for publication or publicity purposes.
If you sign this form, you are agreeing that OHSU may use and disclose protected health information collected and created in this research study. The specific health information and purpose of each use and disclosure are described in the table below:
THE FOLLOWING CHECKED ITEM(S) WILL BE GENERATED/COLLECTED DURING THE COURSE OF THIS STUDY: Questionnaires, interview results, focus group survey, psychology survey, behavioral performance tests (e.g., memory & attention) A Purpose Categories a. To learn more about the condition/disease being studied b. To facilitate treatment, payment, and operations related to the study c. To comply with federal or other governmental agency regulations d. For teaching purposes A. To learn more about the condition/disease being studied
The persons who are authorized to use and disclose this information are all of the investigators listed on page one of this Consent and Authorization Form and the OHSU Institutional Review Board.
The persons who are authorized to receive this information are the Oregon State University Institutional Review Board and the Office for Human Research Protections (OHRP).
We may continue to use and disclose protected health information that we collect from you in this study until the study is completed.
While this study is still in progress, you may not be given access to medical information about you that is related to the study. After the study is completed and the results have been analyzed, you will be permitted access to any medical information collected about you in the study.
You have the right to revoke this authorization and can withdraw your permission for us to use your information for this research by sending a written request to the Principal Investigator listed on page one of the research consent form. If you do send a letter to the Principal Investigator, the use and disclosure of your protected health information will stop as of the date he receives your request. However, the Principal Investigator is allowed to use and disclose information collected before the date of the PRE-OPERATIVE PLAY THERAPY 105
letter or collected in good faith before your letter arrives. Revoking this authorization will not affect your health care or your relationship with OHSU.
The information about you that is used or disclosed in this study may be re-disclosed and no longer protected under federal law.
Under Oregon Law, suspected child or elder abuse must be reported to appropriate authorities.
COSTS:
There are no costs to the subjects related to this study.
LIABILITY:
If you believe your child has been injured or harmed while participating in this research and require immediate treatment, contact Julie Lerwick (503-334-7374).
You have not waived your legal rights by signing this form. If you are harmed by the study procedures, you will be treated. Oregon Health & Science University does not offer to pay for the cost of the treatment. Any claim you make against Oregon Health & Science University may be limited by the Oregon Tort Claims Act (ORS 30.260 through 30.300). If you have questions on this subject, please call the OHSU Research Integrity Office at (503) 494-7887.
PARTICIPATION:
If you have any questions regarding your rights as a research subject, you may contact the OHSU Research Integrity Office at (503) 494-7887.
You do not have to join this or any research study. If you do join, and later change your mind, you may quit at any time. If you refuse to join or withdraw early from the study, there will be no penalty or loss of any benefits to which you are otherwise entitled.
Your health care provider may be one of the investigators of this research study, and as an investigator is interested in both your clinical welfare and in the conduct of this study. Before entering this study or at any time during the research, you may ask for a second opinion about your care from another doctor who is in no way involved in this project. You do not have to be in any research study offered by your physician.
PRE-OPERATIVE PLAY THERAPY 106
You may be removed from the study if the investigator stops the study.
If you wish to be informed of the study’s results, you may contact the investigators once the study is completed.
If you choose to withdraw your child from the study, all intervention will be stopped immediately.
We will give you a copy of this form.
SIGNATURES:
Your signature below indicates that you have read this entire form and that you agree to your child being in this study.
OREGON HEALTH & SCIENCE UNIVERSITY
INSTITUTIONAL REVIEW BOARD
PHONE NUMBER (503) 494-7887 CONSENT/AUTHORIZATION FORM APPROVAL DATE
Nov. 17, 2010
Do not sign this form after the Expiration date of: 11/16/2011
______Signature of parent or guardian Date
______Printed name Relationship to subject
______Signature of Researcher Date
______Printed name PRE-OPERATIVE PLAY THERAPY 107
APPENDIX D
FACES ANXIETY SCALE
PRE-OPERATIVE PLAY THERAPY 108
APPENDIX E
LAY LANGUAGE PROTOCOL SUMMARY
Lay Language Protocol Summary Research Integrity Office Mail code L106-RI 3181 S.W. Sam Jackson Park Road Portland, Oregon 97239-3098 tel: 503 494-7887 | fax: 503 346-6808
Principal Daniel Guillaume, MD, MSc IRB#: 6641 Investigator: Study/Protocol Play Therapy in Pre-Op for the Reduction of Anxiety in Title: Pediatric Patients
Please answer all of the following questions using lay language, similar to the language used in a consent form. Please number your responses.
1. Briefly describe the purpose of this protocol. The purpose of this study is to investigate the impact of a play therapy session in pre-op on pre-surgical anxiety in young children. This research is being completed in order to fulfill the student researcher’s dissertation requirement to earn a doctoral degree.
2. Briefly summarize how participants are recruited. Subjects will be selected from the Pediatric Neurosurgery clinic at OHSU.
3. Briefly describe the procedures subjects will undergo. Hospital visits can be quite stressful for children, however play is natural. Play Therapy allows a child to express his or herself through play. It is believed that a child’s play will reflect his or her emotion and through play, the child will be able to safely express emotions such as anxiety, stress and nervousness. This study’s 15-minute play session gives children access to 15 toys. The toys will not be limited to pretend "hospital" toys such as stethoscopes and thermometers, but will also include toys such as dolls, trucks, and blocks in order to provide your child with a variety of choices. The child is not limited in his or her play, or instructed to play in a certain way, but rather encouraged to play as she or he sees fit.
PRE-OPERATIVE PLAY THERAPY 109
The child will be asked one question prior to the intervention and one question after the intervention in regard to his/her level of anxiety, which is described as “feeling scared” to the child. The child will be given a 15-minute therapeutic play session with a professionally trained play therapist to see if their pre-surgical anxiety is reduced.
4. If applicable, briefly describe survey/interview instruments used. The Faces Anxiety Scale is a self-report instrument that allows the child to identify their level of “feeling scared” on a ranking scale, which is composed of 5 faces ranging from “not scared at all” to “most scared possible.” 5. If this is a clinical trial using an experimental drug or device, or an approved drug or device used for an unapproved purpose, briefly describe the drug or device. N/A
6. Briefly describe how the data will be analyzed to address the purpose of the protocol. The researcher will compare the child’s Faces Anxiety Scale self-report before the play session and after the play session.
PRE-OPERATIVE PLAY THERAPY 110
APPENDIX F
CLINIC APPOINTMENT SCRIPT
Uniform: White lab coat with the writing “Neurosurgical Researcher OHSU” over professional clothes and an OHSU ID badge clearly displayed.
Upon entering the exam room where parent and child were waiting:
Introduction:
Researcher: “Hello, my name is Julie and I am a student researcher who works with Dr. Guillaume and Dr. Selden. I am working towards completing a doctoral degree and am interested in seeing if we can help children, like yours, feel less scared prior to surgery. I want to confirm that the doctors invited you to be part of this study?”
Waited for response from parent.
Researcher: “Before you give consent to your child participating in this study, I want to tell you a little about what I’m interested in studying. Research has shown that children preparing for surgery show exceptional levels of anxiety and we want to develop an intervention to help children emotionally prior to surgery and be able to offer it to all children. And the only way to fund a program like this to help children in this way is to prove that it works—and that is where my research becomes important. May I tell you about my research study?”
Waited for response from parent.
Researcher: “If you choose to allow your child to be considered for this study, I will meet your family outside the pre-op area on the day of surgery to confirm that you are still willing to have your child participate. Upon your consent, after your child is checked in and brought to a pre-op room, I will wait for the medical staff to tell me they are finished with the medical end of things and then come into the room. A that time, I will ask your child a question on a scale of how scared they are feeling, play with your child therapeutically for 15 minutes, and then ask them to tell me how scared they are feeling at the end of our play time together. We are wanting to see how a brief play session with a child influences reported anxiety levels. From start to finish, my time in the room will not exceed 20 minutes, and you are welcome to be present. At this time, we are unsure of any side effects, but we expect them to be rare and minimal. Does this sound like something you would like your child to be part of?”
Waited for response from parent.
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Addressing the child: Researcher: “I know you just heard a lot of talk between your parent and I, but I want to ask your permission for me to spend some time with you at the hospital before you have surgery. I have some toys that I will bring. Does that sound like something you would like?”
Waited for response from child.
Closing
Researcher: “Do either of you (parent or child) have any questions?”
Waited for response and answered questions.
Researcher: “I need your signature on the consent form and it outlines everything we talked about today in more detail. After signing the form, you are not obligated to participate in the study and may withdraw your child at any time.”
Researcher: “I will be in touch with the surgery department and will find out when your child is scheduled for surgery and will meet you at the hospital on the morning of the surgery.”
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APPENDIX G
DAY OF SURGERY SCRIPT
Uniform: Business professional clothing with an OHSU ID badge clearly displayed. No white lab coat.
Upon entering the surgery waiting room where parent and child were waiting:
Introduction:
Researcher: “Good morning, I just wanted to touch base today and see if you still feel good about me coming into the pre-op area to meet with your child in a little while after the medical staff has completed their preparations with your child?”
Waited for response from parent. Consent confirmed.
Once in pre-op area with child:
In a curtained off partitioned room, with two chairs, most often occupied with mom and dad, as child sat on the bed in their hospital gown covered up with blankets, the researcher entered the room with an additional chair in hand, holding a small plastic tub of toys. Often the researcher sat on the chair parallel to the bed facing the child about two feet away, but sometimes the child would invite the researcher to sit on the edge of the bed approximately two feet away from the child.
Researcher: “Hi (child’s name). I brought some toys for you to play with! Before we begin, I have a question to ask you. [Showing Faces Anxiety Scale] These faces show someone just like you. This face shows someone that isn’t scared all (pointing to face #1), this one a little more, a little more, a little more, and this one the most scared you can possibly be (pointing to face #5). Which face best shows how you feel right now?”
Waited for response from child.
Researcher: “We have 15 minutes for our play time and I will tell you when we have about 5 minutes left so you will know. I will also tell you when there is 1 minute left in our play time. You can play with the toys however you wish, with only 2 rules: 1) that you are safe, 2) that I am safe. [Researcher tracked behavior aloud as the child played].”
Gave 5 minute warning Gave 1 minute warning
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Researcher: “Our special play-time has come to an end and you and I can work together to put the toys back in the bucket. Do you remember the question I asked when I first came into your room?”
Waited for response from child.
Researcher: “Now that we have played together for a little while, how scared do you feel now? [Pointing to FAS] Not scared at all? A little bit scared? The most scared you can possibly be?”
Waited for child to point to the appropriate face on the FAS.
Researcher thanked parent for their participation and left the child with well wishes for their upcoming surgery.
Left the room.
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APPENDIX H
PROTOCOL
Title: Play Therapy in Pre-Op for the Reduction of Anxiety in Pediatric Patients
Funding Agency: Non-Funded
Type of Award: Not applicable
Principal Investigator: Daniel J. Guillaume, M.D., M.Sc. Assistant Professor Department of Neurosurgery Oregon Health & Science University 503-494-4176
Co-Investigator: Julie L. Lerwick, M.A., Ph.D. Cand. Doctoral Student Department of Counseling Psychology Oregon State University 503-334-7374
Statistician: Michelle J. Cox, PhD
Final Protocol Date: February 22, 2011
Protocol Revision Dates: June 07, 2011
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1.0 Abstract:
The prevalence of childhood illness and anxiety induced by hospitalization demands the need for preventative, as well as active play therapy for children. Child- Centered Play Therapy within the hospital setting has the potential to reduce psychological trauma, anxiety, and behavioral issues in pediatric patients preparing for surgery. Review of the literature indicates that this need is not currently met by specific interventions in the pre-operative department of hospitals utilizing play therapy by trained play therapists.
Mirroring the work of Carl Rogers (1951), Virginia Axline (1974) applied her understanding of Person-Centered therapy (Rogers, 1951) to her work with children creating Child-Centered Play Therapy. Seeing children as valuable people who are capable of positive self-direction (Ray, 2009), Child-Centered Play Therapy seeks to empower children in a way that allows them to develop naturally through the language of play (Axline, 1974).
Empirical evidence suggests the importance of psychologically preparing children for surgical procedures and hospitalization in order to decrease levels of anxiety and possibly trauma (Kain, Mates & Carmico, 1996; Li & Lopez, 2008; O’Conner-Von, 2000). This prospective study seeks to explore the impact of Child-Centered Play Therapy on anxiety levels of pre-neurosurgery pediatric patients.
Objective: The objective of this study is to determine the impact of a pre-surgical intervention of play therapy in pre-op for the reduction of pre-surgical anxiety in children aged 4-12.
Design: Quasi-experimental repeated measure design of up to 20 patients, aged 4-12, whose anxiety levels will be assessed pre and post play therapy intervention using the Faces Identity Scale.
Setting and Subjects: The study will take place at OHSU Doernbecher Children’s Hospital. Subjects will be children preparing for surgery.
Intervention: Subjects will undergo a 15-minute play therapy session with the researcher, who is a professionally trained play therapist, using established protocol for Child-Centered Play Therapy. Consent will be obtained for the study at the time it is obtained for their surgical procedure.
Analysis: The following data will be collected: demographic details (age and sex), diagnosis, and responses to the Faces Anxiety Scale. All data acquisition and analysis will be performed preoperatively.
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2.0 Background / Rationale:
Hospitalization and surgery can be an emotionally threatening and psychologically traumatizing experience for all people, especially children (Li & Lam, 2003; Lingnell & Dunn, 1999; and O’Conner-Von, 2000). When children are hospitalized, there is an increased potential for psychological trauma presented as anxiety, aggression, anger, a loss of autonomy and control, fear of mutilation, guilt, pain, rage and similar expressions of emotion appropriate to their level of development (Adams, 1976; Alger, Linn, & Beardslee, 1985; Clatworthy, 1981). Within this, there is a need for children to be given some form of control in their healthcare process that is age appropriate and conducive to treatment. Children often lose freedom when they are hospitalized and this increases their need for emotional containment, which can be executed by Child-Centered medical play therapy (Landreth, 2002; Lingnell & Dunn, 1999).
Upon engagement of play therapy with pediatric patients, prior research indicates that medical play therapy reduces behavioral issues and seeks to give the child a place of freedom, control and autonomy in the process of being hospitalized (Lingnell & Dunn, 1999). Play therapy in a hospitalized setting is innovative and beautifully accomplishes the importance of patiently working with children in their season of chaos, fear, and pain as they progressively learn to see themselves as a person who can make choices, not just one that choices are made for (Li & Lam, 2003; Lingnell & Dunn, 1999; O’Conner-Von, 2000).
In review of the literature, it has been found that current protocol for preparation of surgery includes education about the procedure, a tour of the hospital, including the operating room, picture books, and video introductions, in addition to medical play whereby the child is encouraged to play out any questions or concerns they have about their upcoming procedure by playing with surgical instruments and dolls (Brewer, Gleditsch, Syblik, Tietjens, & Vacik, 2006; Kain, Mates, & Carmico, 1996; Li & Lopez, 2008; O’Conner-Von, 2000; Price, 1991; Squires, 1995; Ziegler & Prior, 1994). The purpose of this study is to determine if the introduction of Child-Centered Play Therapy into the pre-surgical and hospitalization process is beneficial.
The central hypothesis driving this study is that a brief play session in pre-op will reduce pre-surgical anxiety in children preparing for neurosurgery. This hypothesis will be tested with the following specific aims:
1. To measure and compare the degree of self-reported anxiety pre- and post intervention.
2. To determine if play therapy aids in the reduction of pre-surgical anxiety.
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The overall goals of this study are to (a) define the true incidence of pre-surgical anxiety in children, (b) better understand the effect of play therapy on anxiety, and (c) evaluate if children have the ability to accurately self-report anxiety.
3.0 Objectives:
Primary Objective. The primary purpose of this study is to explore the impact of Child- Centered Play Therapy on anxiety levels of pre-neurosurgery pediatric patients.
Secondary Objective. To understand the relationship between pre-surgical anxiety and play therapy as a means of reducing perceived trauma in children.
Subgroup hypotheses. Not applicable
4.0 Study Population:
Participants will be limited to 4-12 year old children that speak the English language. Participants will be drawn from a convenience sample from the Pediatric Neurosurgery Clinic at OHSU. During an initial clinic visit, the surgeon will invite the families to be part of the research study. For families indicating a willingness to participate, the student researcher--having completed all HIPPA privacy training--will enter the clinic room during their next pre-op appointment for consent process.
5.0 Inclusion/Exclusion Criteria:
Inclusion Criteria: • Age 4-12 • English speaking • Diagnosis requiring neurosurgery • Child must be capable of Play Therapy • Admitted only through clinic, not Emergency Department • Signed informed consent
Exclusion Criteria: • Non-English speaking • Severe traumatic brain injury • Presence of intracranial hypertension • Need for emergency operation
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6.0 Methodology:
General Plan: Patients aged 4-12 that are scheduled for neurosurgery at Doernbecher Children’s Hospital will be identified by the Pediatric Neurosurgery Clinic. During an initial clinic visit, the surgeon will invite the families to be part of the research study. Upon approval from the parents, during a pre-operative clinic visit, the CI will meet with parents and the child to review the study, answer questions and obtain informed consent. At this time the assent process will be given verbally to the child. If the child chooses not to participate, parental consent will be void.
7.0 Study Procedures:
On the day of surgery, the researcher will meet with parents and confirm eligibility of participant, and the patient’s room prior to surgery. The student researcher will enter the pre-op area of the hospital and ask the child to point to the face on the Faces Anxiety Scale that describes how “scared” they are feeling. The researcher will provide a 15-minute play session with the child, based on established protocol for Child- Centered Play Therapy (Ray, 2009).
Hospital visits can be quite stressful for children, however play is natural. Play Therapy allows a child to express his or herself through play. It is believed that a child’s play will reflect his or her emotion and through play, the child will be able to safely express emotions such as anxiety, stress and nervousness. This study’s 15-minute play session gives children access to 15 toys. The toys will not be limited to pretend "hospital" toys such as stethoscopes and thermometers, but will also include toys such as dolls, trucks, and blocks in order to provide your child with a variety of choices. The child is not limited in his or her play, or instructed to play in a certain way, but rather encouraged to play as she or he sees fit. At the completion of the play session, the researcher will ask the child to again point to the face on the Faces Anxiety Scale that describes how “scared” they are feeling post-intervention.
8.0 Time line and Milestones:
It is expected that all subjects will be enrolled in the study within three months.
9.0 Data Analysis and Interpretation:
Data Analysis: We hypothesize that anxiety will be reduced post-intervention (Null hypothesis, H0 = no difference in anxiety after play therapy intervention). We plan to PRE-OPERATIVE PLAY THERAPY 119 enroll up to 20 subjects in this pilot study. Descriptive statistics will be applied to all variables. Data will be analyzed using a repeated measure t-test statistic with P ≤ 0.05 considered significant.
Risks to Subjects and informed consent: The experimental intervention, play therapy has no known risk. The Co-investigator will obtain informed consent. Full identifiers will be used for research purposes in this study. Personal health information will be kept on a secured folder on the OHSU network during the analysis phase. Only study personnel will have access to this folder. After study completion, all files will be archived to CD- ROM, removed from the network drive, and stored securely by the CI. All working files with information that could potentially link the subject record to protected health information will be deleted at the end of the study. Participation is voluntary. Parents of participants will be given consent documents during the pre-op clinic visit by the CI researcher. Parental consent, for their child participating in this study, will be evidenced by parent signature and a copy of the form with researcher contact information given. Verbal assent will be given by the child after asking if he would like to “play” with the researcher pre-surgery. No script will be used and wording may change to be age appropriate to the child.
Potential Benefits of the Proposed Research to the Subjects and Others: If a brief play therapy session in pre-op leads to the reduction of pre-surgical anxiety in children aged 4- 12, future studies may be formed to create programs in hospitals utilizing this intervention as standardized care. Information gained from this study may lead to institution of routine play therapy sessions for children preparing for surgery.
Limitations: This pilot study is expected to provide data measuring children’s self- reported pre-surgical anxiety pre-and post- operatively. Subjects will not be chosen randomly, due to the convenience sampling of the Pediatric Neurosurgery clinic. This introduces a confounder that will make it difficult to draw conclusions regarding differences between children preparing for neurosurgery compared to other forms of surgery.
10.0 References:
Adams, M. (1976). A hospital play program: Helping children with serious illness.
American Journal of Orthopsychiatry, 45(3), 416-424.
Alger, I., Linn, S., & Beardslee, W. (1985). Puppetry as a therapeutic tool for
hospitalized children. Hospital and Community Psychiatry, 36(2), 129-130.
Axline, V. (1974). Play Therapy. New York, NY: Ballantine Books. PRE-OPERATIVE PLAY THERAPY 120
Clatworthy, S. (1981). Therapeutic play: Effects on hospitalized children. Journal of the
Association for the Care of Children’s Health, 9(4), 108-114.
Kain, Z., Mates, L. C., & Caramico, L. A. (1996). Preoperative preparation in children: a
cross-sectional study. Journal of Clinical Anesthesia, 8(6), 508-514.
doi:10.1016/0952-8180(96)00115-8
Landreth, G. (2002). Play therapy: The art of the relationship (2nd ed.). New York, NY:
Brunner-Routledge.
Li, H. C. W., & Lam, H. Y. A. (2003). Paediatric day surgery: Impact on Hong Kong
Chinese Children and their parents. Journal of Clinical Nursing, 12(6), 882-887.
doi:10.1046/j.1365-2702.2003.00805.x
Li, H. C. W., & Lopez, V. (2008). Effectiveness and appropriateness of therapeutic play
intervention in preparing children for surgery: A randomized controlled trial
study. Journal for Specialists in Pediatric Nursing, 13(2), 63-73.
doi:10.1111/j.1744-6155.2008.00138.x
Lingnell, L., & Dunn, L. (1999). Group play therapy: Wholeness and healing for the
hospitalized child. In D. S. Sweeney & L. E. Homeyer (Eds.), The handbook of
group play therapy: How to do it, how it works, whom it’s best for (pp. 359-374).
San Francisco, CA: Jossey-Bass.
O’Conner-Von, S. (2000). Preparing children for surgery: An integrative research review.
AORN Journal, 71(2), 334-343.
Price, S. (1991). Preparing children for admission to hospitals. Nursing Times, 87(9), 46-
49. PRE-OPERATIVE PLAY THERAPY 121
Ray, D. (2009). Child-centered play therapy treatment manual. San Francisco, CA:
Jossey-Bass.
Rogers, C. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin.
Ziegler, D. M., & Prior, M. M. (1994). Preparation for surgery and adjustment to
hospitalization. The Nursing Clinics of North America, 29(4), 655-669.
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APPENDIX I
TOYS INCLUDED IN PLAY KIT
. Male puppet . Female puppet . Plastic Handcuffs . Baby Doll with bottle . Real stethoscope . Mickey Mouse hat . Plastic syringe . Plastic reflex hammer . Toy ambulance . Toy sports car . Policeman figurine . Plush brain-cell . Plastic axe . Plush Penguin . Plush puppy puppet . Magic wand . Toy truck . Tigger . Eeyore . Black mask . Gorilla . Dart gun
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APPENDIX J
RAW DATA
Pre- Post- Subject # Sex Age Dev. Stage Difference intervention intervention
1 M 7 4 1 1 0 2 M 10 4 2 2 0 3 M 6 4 3 1 -2 4 M 6 4 1 1 0 5 M 4 3 4 3 -1 6 M 5 3 3 1 -2 7 F 11 4 2 1 -1 8 M 5 3 1 1 0 9 M 4 3 1 1 0 10 M 12 5 2.5 1 -1.5 11 F 11 4 2 1 -1 12 F 5 3 1 1 0 13 F 11 4 5 3 -2 14 F 12 5 3 2 -1
Medical Subject Family Staff In Mom Dad Grandpa Grandma Uncle Staff # Present Attendance Present 1 1 Y Y 1 2 1 Y Y 1 3 2 Y Y N 0 4 2 Y Y N 0 5 3 Y Y Y N 0 6 2 Y Y Y 2 7 2 Y Y N 0 8 2 Y Y N 0 9 2 Y Y Y 1 10 2 Y Y N 0 11 2 Y Y N 0 12 3 Y Y Y Y 3 13 2 Y Y N 0 14 2 Y Y Y 3