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MENKE, Edna Mae, 1941- FACTORS RELATED TO CHILDREN'S PERCEPTION OF STRESS IN THE HOSPITAL.
The Ohio State University, Ph.D., 1972 Education, guidance and counseling
University Microfilms, A XEROX Company, Ann Arbor, Michigan
©Copyright by
Edna Mae Menke
1972
THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED. FACTORS RELATED TO CHILDREN'S PERCEPTION
OF STRESS IN THE HOSPITAL
DISSERTATION
Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate Sehool of the Ohio State University
By
Edna Mae Menke, B.S., M.S.
* * * * *
The Ohio State University 1972
Approved by
Adviser College of Education PLEASE NOTE:
Some pages may have
indistinct print.
Filmed as received.
University Microfilms, A Xerox Education Company ACKNOWLEDGEMENTS
I wish to express my sincere appreciation to my major adviser, Dr. Herman J. Peters, for his guidanee, encouragement, support, and time throughout my doctoral program. Also I want to thank Mrs. Annabelle Peters for her enoouragement during my studies,
I would like to thank the other members of my committee for their assistance during my doctoral program. These include
Dr. Donald J. Tosi, Dr. James V, Wigtil, and Dr. Robert J. Wherry.
I would like to express ny appreciation to Dr, Lillian
Pierce who encouraged me to pursue doctoral work,
I would like to express my gratitude to the children and their parents who made this study possible. Also a word of thanks to the staff at Children's Hospital and at Riverside Methodist
Hospital.
I would also like to express my gratitude to ray friends for their invaluable support and encouragement during my doctoral program. Especially those who shared with me during the "high" and "low" points in my studies.
Above all, I am especially grateful to my parents, for their encouragement, moral support, and financial support, which they provided throughout my studies.
ii Recognition is due for the financial support that the
National Institutes of Health provided for my doctoral studies.
My studies were possible from a special nurse research fellowship
(5FX)4-NU-27,237-03).
iii VITA
September 26, 1941 Born — Cincinnati, Ohio
1963 B.S.N., University of Cincinnati, Cincinnati, Ohio
1963-1964 Assistant Evening Supervisor, St, Luke Hospital, Fort Thomas, Kentucky
1964-1966 Instructor, St, Elisabeth School of Nursing, Covington, Kentucky
1966-1967 Instructor, James Ward Thorne School of Nursing, Chicago, Illinois
1968 M.S., The Ohio State University, Columbus, Ohio
1969 Instructor, School of Nursing, The Ohio State University, Columbus, Ohio
1969-1972 National Institutes of Health Fellow, The Ohio State University, Columbus, Ohio
FIELDS OF STUDY
Major Field» Counseling and Guidance
Studies in Counseling and Guidance. Professors Herman J, Peters and James V. Wigtil
Studies in Quantitative Psychology, Professor Robert J. Wherry
iv TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS ...... 11
VITA ...... lv
LIST OF TA B L E S ...... vii
CHAPTER
I. INTRODUCTION...... 1
The Problem Statement of the Problem Research Hypotheses Definitions Organization of the Study
II. THEORETICAL FRAMEWORK...... 13
Perception Stress Hospitalizationi A Stressful Experience for a Child Model for Studying Children's Perception of Stressful Stimuli in the Hospital
III, METHODOLOGY ...... 80
Research Design Sample Measurement of Stress Statistical Analysis of the Data
v Page
IV. ANALYSIS OF THE D A T A ...... 103
Identification of Stressful Stimuli Test of the Research Hypotheses Summary of Results Discussion of the Results
V. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS...... l6l
Summary Conclusions Recommendations for Future Studies
APPENDIXES
A. STIMULI IN THE G A M E ...... 178
B. INTERVIEW S C H E D U L E ...... 198
C. CONTINGENCY TABLES FOR NON-SIGNIFICANT STIMULI 202
BIBLIOGRAPHY ...... 256
▼i LIST OF TABLES
Table Page
1. Description of the sample 86
2. Judges* rating of the stimuli 94
3. Subjects' responses to each stimuli in the game 104
4. Frequency distribution of subjects' responses 105 to what they dislike in the hospital
5. Frequency distribution of subjects' responses 107 to what bothers them the most about being in the hospital
6 . Frequency distribution of subjects' responses 109 to whom they miss the most
7. Frequency distribution of number of intraper 110 sonal stressors identified by each subject
8 . Frequency distribution of number of interper 111 sonal stressors identified by each subject
9. Frequency distribution of the number of 112 environmental stressors identified by each subject
10, Frequency distribution of the total number 113 of stressors identified by each subject
11, Summary of phi coefficients and ohi-squares 115 for subject's age and stimuli
12, Contingency table for the stimulus, girl, and 116 the subject's age
vll Table Page
13. Contingency table for the stimulus, dog, and 117 the subject's age
14. Summary of phi coefficients and chi-squares for 120 subject's sex and stimuli
15. Contingency table for the stimulus, dog, and 121 subject's sex
16. Contingency table for the stimulus, nurse, 122 and the subject's sex
17. Summary of phi coefficients and chi-squares 126 for subject's diagnosis and stimuli
18. Contingency table for the stimulus, dog, and 127 the subject's diagnosis
19. Contingency table for the stimulus, medications, 128 and the subject's diagnosis
20. Summary of phi coefficients and chi-squares for 131 subject's length of hospitalisation and stimuli
21. Contingency table for the stimulus, girl, and 132 the subject's length of hospitalization
22. Contingency table for the stimulus, dog, and 133 the subject's length of hospitalization
23. Contingency table for the stimulus, nurse, and 134 the subject's length of hospitalization
24. Contingency table for the total number of 135 stressful stimuli and the subject's length of hospitalization
25. Summary of phi coefficients and chi-squares for 139 subject's preparation and stimuli
26. Contingency table for the stimulus, nurse, and 140 the subject's preparation
27. Contingency table for the stimulus, house, and 141 the subject's preparation
viii Table Page
28. Contingency table for the total number of 142 stressful stimuli and the subject's preparation
29. Summary of phi coefficients and chi-squares for 146 subject's experience with separation and stimuli
30. Contingency table for the stimulus, hospital room, 147 and the subject's experience with separation
31. Contingency table for the stimulus, stethoscope, 148 and the subject's experience with separation
32. Canonical weights and canonical factors for the 151 two sets of variables
33. Canonical weights for the first canonical factor 153
34. Contingency table for the stimulus, boy, and the 203 subject's age
35. Contingency table for the stimulus, mother, and 203 the subject's age
36. Contingency table for the stimulus, father, and 204 the subject's age
37. Contingency table for the stimulus, baby, and 204 the subject's age
38. Contingency table for the stimulus, eat, and the 205 subject's age
39. Contingency table for the stimulus, nurse, and 205 the subject's age
40. Contingency table for the stimulus, doctor, and 206 the subject's age
41. Contingency table for the stimulus, hospital 206 gown, and the subject's age
42. Contingency table for the stimulus, hospital 207 room, and the subject's age
43. Contingency table for the stimulus, hospital 207 bed, and the subject's age ix Table Page
44, Contingency table for the stimulus, food, and the 208 subject's age
45, Contingency table for the stimulus, medlolatlons, 208 amd the subject's age
46, Contingency table for the stimulus, toys, and the 209 subject's age
47, Contingency table for the stimulus, thermometer, 209 and the subject's age
48, Contingency table for the stimulus, stethoscope, 210 and the subject's age
49, Contingency table for the stimulus, house, and 210 the subject's age
50, Contingency table for the stimulus, school, and 211 the subject's age
51, Contingency table for the total number of stressful 211 stimuli and the subject's age
52, Contingency table for the stimulus, boy, and the 212 subject's sex
53, Contingencytable for the stimulus, girl, and the 212 subject's sex
54, Contingencytable for the stimulus, mother, and 213 the subject's sex
55, Contingencytable for the stimulus, father, and 213 the subject's sex
56, Contingency table for the stimulus, baby, and 214 the subject's sex
57, Contingency table for the stimulus, cat, and the 214 subject's sex
58, Contingencytable for the stimulus, doctor, and 215 the subject's sex Table Page
59, Contingency table for the stimulus, hospital gown, 215 and the subject's sex
60, Contingency table for the stimulus, hospital room, 216 and the subject's sex
61, Contingency table for the stimulus, hospital bed, 216 and the subject's sex
62, Contingency table for the stimulus, food, and the 217 subject's sex
63 , Contingency table for the stimulus, medications, 217 and the subject's sex
64, Contingency table for the stimulus, toys, and the 218 subject's sex
65, Contingency table for the stimulus, thermometer, 218 and the subject's sex
66, Contingency table for the stimulus, stethoscope, 219 and the subject's sex
67 , Contingency table for the stimulus, house, and 219 the subject's sex
68, Contingency table for the stimulus, school, and 220 the subject's sex
69 , Contingency table for the total number of stressful 220 stimuli and the subject's sex
70, Contingency table for the stimulus, boy, and the 221 subject's diagnosis
71, Contingency table for the stimulus, girl, and 221 the subject's diagnosis
72, Contingency table for the stimulus, mother, and 222 the subject's diagnosis
73, Contingency table for the stimulus, father, and 222 the subject's diagnosis
xi Table Page
74, Contingency table for the stimulus, baby, and the 223 subject's diagnosis
75, Contingency table for the stimulus, cat, and the 223 subject's diagnosis
76, Contingency table for the stimulus, nurse, and 224 the subject's diagnosis
77, Contingency table for the stimulus, doctor, and 224 the subject's diagnosis
78, Contingency table for the stimulus, hospital 225 gown, and the subject's diagnosis
79, Contingency table for the stimulus, hospital 225 room, and the subject's diagnosis
80, Contingency table for the stimulus, hospital 226 bed, and the subject's diagnosis
81, Contingency table for the stimulus, food, and 226 the subject's diagnosis
82, Contingency table for the stimulus, toys, and 227 the subject's diagnosis
83, Contingency table for the stimulus, thermometer, 227 and the subject's diagnosis
84, Contingency table for the stimulus, stethoscope, 228 and the subject's diagnosis
85 , Contingency table for the stimulus, house, and 228 the subject's diagnosis
86, Contingency table for the stimulus, school, and 229 the subject's diagnosis
87 , Contingency table forthe total number of stressful 229 stimuli and the subject's diagnosis
88, Contingency table for the stimulus, boy, and the 230 subject's length of hospitalization
xii Table Page
89. Contingency table for the stimulus, mother, and 230 the subject’s length of hospitalization
90. Contingency table for the stimulus, father, and 231 the subject's length of hospitalization
91. Contingency table for the stimulus, baby, and 231 the subject's length of hospitalization
92. Contingency table for the stimulus, cat, and the 232 subject's length of hospitalization
93. Contingency table for the stimulus, doctor, and 232 the subject's length of hospitalization
9*. Contingency table for the stimulus, hospital gown, 233 and the subject's length of hospitalization
95. Contingency table for the stimulus, hospital room, 233 and the subject's length of hospitalization
96. Contingency table for the stimulus, hospital bed, 23^ and the subject's length of hospitalization
97. Contingency table for the stimulus, food, and the 23 b subject's length of hospitalization
98. Contingency table for the stimulus, medications, 235 and the subject's length of hospitalization
99. Contingency table for the stimulus, toys, and the 235 subject's length of hospitalization
100. Contingency table for the stimulus, thermometer, 236 and the subject's length of hospitalization
101. Contingency table for the stimulus, stethoscope, 236 and the subject's length of hospitalization
102. Contingency table for the stimulus, house, and 237 the subject’s length of hospitalization
103. Contingency table for the stimulus, school, and 237 the subject's length of hospitalization
xiii Table Page
104. Contingency table for the stimulus, boy, and the 238 subject's preparation
105. Contingency table for the stimulus, girl, and the 238 subject's preparation
106. Contingency table for the stimulus, mother, and 239 the subject's preparation
107. Contingency table for the stimulus, father, and 239 the subject's preparation
108. Contingency table for the stimulus, baby, and the 240 subject's preparation
109. Contingency table for the stimulus, dog, and the 240 subject's preparation 110. Contingency table for the stimulus, cat, and the 241 subject's preparation
111. Contingency table for the stimulus, doctor, and 241 the subject'8 preparation 112. Contingency table for the stimulus, hospital 242 gown, and the subject's preparation
113. Contingency table for the stimulus, hospital 242 room, and the subject's preparation
114. Contingency table for the stimulus, hospital 243 bed, and the subject's preparation
115. Contingency table for the stimulus, food, and 243 the subject's preparation
116. Contingency table for the stimulus, medications, 244 and the subject's preparation
117. Contingency table for the stimulus, toys, and 244 the subject's preparation 118. Contingency table for the stimulus, thermometer, 245 and the subject's preparation
xiv Table Page
119. Contingency table for the stimulus, stethoscope, 245 and the subject's preparation
120. Contingency table for the stimulus, school, and 246 the subject's preparation
121. Contingency table for the stimulus, boy, and the 246 subject's experience with separation
122. Contingency table for the stimulus, girl, and the 247 subject's experience with separation
123. Contingency table for the stimulus, mother, and 247 the subject's experience with separation
124. Contingency table for the stimulus, father, and 248 the subject's experience with separation
125. Contingency table for the stimulus, baby, and 248 the subject's experience with separation
126. Contingency table for the stimulus, dog, and the 249 subject's experience with separation
127. Contingency table for the stimulus, cat, and the 249 subject's experience with separation
128. Contingency table for the stimulus, nurse, and 250 the subject's experience with separation
129. Contingency table for the stimulus, doctor, and 250 the subject's experience with separation
130. Contingency table for the stimulus, hospital 251 gown, and the subjeet's experience with separation
131. Contingency table for the stimulus, hospital bed, 251 and the subject's experience with separation
132. Contingency table for the stimulus, food, and the 252 subject's experience with separation
133. Contingency table for the stimulus, medications, 252 and the subjeet's experience with separation
xv Table Page
13**. Contingency table for the stimulus, toys, and the 253 subject's experience with separation
135. Contingency table for the stimulus, thermometer, 253 and the subject's experience with separation
136. Contingency table for the stimulus, house, and the 25** subject's experience with separation
137. Contingency table for the stimulus, school, and the 25** subject's experience with separation 00
• Contingency table for the total number of stressful 255 stimuli and the subject's experience with separation
xvi CHAPTER I
INTRODUCTION
The Problem
Counseling Is a relationship between a counselor and a client or group of clients aimed at assisting each individual in developing his potential and concomitantly learning to handle his environment. The counselor needs to know the client's percep tions since these represent his reality. The way man behaves in any situation tends to be in accordance with how he perceives the situation. The individual's perceptual field is constantly changing as his past perceptual experiences influence his present ones and the result is a new perceptual field that serves as the base for his future perceptions. The individual's percep tions can either help or hinder him in his actions depending upon the degree of resemblance to the real situation.
The perceptual field is the universe of experience in which the individual lives and which he takes to be reality. The
intensity with which events are experienced is a function of differentiation and levels of awareness since the individual is
not aware of all parts of the perceptual field with the same
i degree of clarity at any given moment. Thus, whatever meanings the individual possesses are direct outgrowths of the differen tiations that he has been able to make.^ Perception oan be predicted from behavior or behavior from perception with only a 2 certain probability of correctness. Thus, there is no way of knowing exactly how an individual perceives an event} however, it
is possible to make inferences about it from his actions and his verbal expression.
The counselor dealing with a child has an excellent
opportunity to study his perceptions of new experiences with
fewer confounding variables than when he is dealing with an
adult. The complexity of a child's perception is a function of
his physical, cognitive, and affective development. According to
Mussen, Conger, and Kagan^ the developing child's behavior is
influenced by genetically determined biological variables,
nongenetic biological variables, the child's past learning, his
immediate social psychological environment, and the general social
and cultural milieu in which he develops. If the counselor can
isolate the child's perceptions in a specific context, he has
*Arthur W. Combs and Donald Snygg, Individual Behaviort A Perceptual Approach to Behavior (New York! Harper and Brothers, 1959), pp. 27-32. 2 Daniel J. Weintraub and Edward L. Walker, Perception (Belmont, California! Brook/ Cole Publishing Company, 19^6), p. 8,
•^Paul Mussen, John J. Conger, and Jerome Kagan, Child Development and Personality (3rd ed.i New York! Harper and Row, 1969), p= 33. 3 indicators to describe, explain, and/or predict how the child will behave in a particular situation.
A child experiences "critical periods" which have an impact upon the direction of his social, intellectual, and emotional development. According to the critical period hypo thesis there are certain experiences which are likely to have
a far more profound effect at certain periods than at o t h e r s . 6
An experience which can result in a "critical period" for a 7 child is having to be hospitalized. Blom contends that the hospitalized child may grow emotionally through learning to master the stress he experiences. Likewise, Haller states that:
No event in the.child's life is without effect on the course of his normal growth and development. No ex perience leaves us on the same plateau at which we found ourselves prior to it. A child will be changed one way or the other from his trip to the hospital.
**J. McVickar Hunt, Intelligence and Experience (New Torki The Ronald Press, 1961), p, 270,
5«J. P. Scott, "Critical Periods in Behavioral Development," Science. CXXXVIII (November 30, 1962), pp. 949-958.
^Dorothy Rodgers, Child Psychology (Belmont, California< Brooks/Cole Publishing Company, 1969), pp. 104-106,
^Gaston E. Blom, "The Reactions of Hospitalized Children to Illness," Pediatrics. XXII (September, 1958), p. 596. Q J. Alex Haller, "Preparing a Child for His Operation," in The Hospitalized Child and His Family ed. by J. Alex Haller (Baltimore» John Hopkins Press, 19°7), p. 21. I*
The child in a hospital may perceive the experience as g stressful. According to Belmont, hospitalization ranks high among the stressful experiences which modify and interfere with the child's development. He believes it is necessary to consider what makes a particular experience stressful to a hospitalized child. If the stimuli that are stressful to the child can be identified, the counselor and others, such as physicians and nurses, can use this knowledge as a framework for counseling the child and his parents regarding the child's hospitalization.
Hopefully it would result in maximizing a "critical period" into an experience which would facilitate the child's development in desired ways.
There have been a variety of theories concerning the
psychological effects of hospitalization on the child,10,11,12,13
^Herman S, Belmont, "Hospitalization and Its Effects Upon the Total Child," Clinical Pediatrics. IX (August, 1970), pp. ^72-473.
*°Anna Freud, "The Role of Bodily Illness in the Mental Life of Children," in The Psychoanalytic Study of Children ed, by R. S. Elsser, et al. (New York! International Universities Press, 1952), pp. 69-81.
^John Bowlby, "Separation Anxietyi A Critical Review of the Literature," Journal of Child Psychology and Psychiatry. I (I960), pp. 251-lW .
*^William S, Langford, "The Child in the Pediatric Hospital1 Adaptation to Illness and Hospitalization," American Journal of Orthopsychiatry. XXXI (October, 1961), pp. 667-6&V, 13 David T. A. Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness (Springfield, Illinois 1 Charles C. Thomas, 1965). Some of the variables which have been isolated in these theories include separation from parents, unfamilarity with the setting, interpersonal relationships during hospitalisation, sensory-motor restrictions, parent-child relationship, previous hospitalizations, age of the child, and sex of the child. Even though these theories have resulted in a great deal of research, none of them is conclusive regarding what the child perceives as being stressful in the hospital.
There have been few systematic studies of the emotional 18,19 effects of illness and hospitalization on children. The studies which have been done regarding the hospitalized child
Claire M. Fagin, The Effects of Maternal Attendance During Hospitalization on the Post Hospital Behavior of Young Children* A Comparative Survey (Philadelphia! F. A. Davis Company, 1966),
James K. Skipper and Robert C. Leonard, "Children, Stress, and Hospitalization* A Field Experiment," Journal of Health and Social Behavior. IX (December, 1968), pp. 275-287. 16 Ellamae Bransletter, "The Toting Child's Response to Hospitalization* Separation Anxiety or Laak of Mothering Care?" American Journal of Public Health. LIX (January, 1969), pp. 92-97. 17 Belmont, "Hospitalization and Its Effects Upon the Total Child," pp. 472-483.
^®Sula Wolff, Children Under Stress (London* Allen Lane Penguin Press, 1969), p. 51.
^Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness. 20 21 22 have dealt mainly with one aspect and/or one age group. * * *
23,24,25 Much of the research done pertaining to the hospitalized child in relation to the variable, stress, has been case studies pz! on oft analyzed from a psychoanalytical perspective. ' ’ The other research has focused on a particular variable, such as
^^Bowlby, "Separation Anxietyi A Critical Review of the Literature," pp. 251-269. p1 Florence H. Erickson, "Play Interviews for Four Year Old Hospitalized Children," Monographs of the Society for Research in Child Development. XXIII (1958).
^Fagin, The Effects of Maternal Attendance During Hos pitalization on the Post Hospital Behavior of Young Childrent A Comparative Survey. 23 Dane G. Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness," American Journal of Orthopsychiatry XXIII (January, 1953), pp. 70-10^
.Skipper and Leonard, "Children, Stress, and Hospitali zation! A Field Experiment," pp. 275-287.
^David T. A. Vernon, Jerome L, Schulman, and Jeanne M. Foley, "Changes in Children's Behavior After Hospitalization," American Journal of Diseases of Children. CXI (June, 1966), pp. 581-593.
^^Belmont, "Hospitalization and Its Effects Upon the Total Child," pp. 472-483. 27 Freud, "The Role of Bodily Illness in the Mental Life of Children," pp. 69-81, pQ Langford, "The Child in the Pediatric Hospital! Adapta tion to Illness and Hospitalization," pp. 667-684. 29 10 11 separation, and studied it in relation to stress. 7,J 32 Skipper and Leonard used another type of approach and studied the effects of social interaction on children's responses to hospitalization. They used 3omatic indicators to measure stress accruing from the child’s social environment. The research which has been done regarding hospitalized children's perception of stress has been inconclusive. Thus, there is a need for additional research regarding what children perceive as stressful in the hospital.
Statement of the Problem
The central problem of this study is to identify the
stimuli that children perceive as stressful in the hospital.
Concomitantly, the study is concerned with studying the relation
ship between certain variables and the stimuli that children
perceive as stressful in the hospital.
The problems underlying this study can be understood by
^Bowlby, "Separation Anxietyt A Critical Review of the Literature#M pp. 251-269.
•^Bransletter, "The Young Child's Response to Hospitalize tioni Separation Anxiety or Lack of Mothering Care?" pp. 92-97.
3*Fagin, The Effects of Maternal Attendance During Hos pitalization on the Post Hospital Behavior of Young Childreni A Comparative Survey.
^Skipper and Leonard, "Children, Stress, and Hospitaliza tioni A Field Experiment," pp. 275-287. examining the following questions!
(1) What stimuli are perceived as stressful by children in the
hospital?
(2) Is there a relationship between the age of the children
and the stimuli they perceive as stressful?
(3) Is there a relationship between the sex of the children
and the stimuli they perceive as stressful?
(k) Is there a relationship between the diagnosis of the
children and the stimuli they perceive as stressful?
(5) Is there a relationship between the length of time the
children are hospitalized and the stimuli they perceive
as stressful?
(6) Is there a relationship between the children’s preparation
for hospitalization and the stimuli they perceive as
stressful?
(7) Is there a relationship between the children’s previous
experience with separation from their families and the
stimuli they perceive as stressful?
(8) How do all these variables as a group influence what
stimuli the children perceive as stressful? 9
Research Hypotheses
Hypothesis I . There is a relationship between the stimuli that children perceive as stressful in the hospital and the age of the children. Children between the ages of four and seven perceive different stimuli as stressful in the hospital as compared with children between the ages of seven and twelve.
Hypothesis II. There is a relationship between the stimuli that children perceive as stressful in the hospital and the sex of the children. Male and female children perceive different stimuli as stressful in the hospital.
Hypothesis III. There is a relationship between the stimuli that children perceive as stressful in the hospital and their diagnosis. Children hospitalized for a medical condition perceive different stimuli as stressful compared with children hospitalized for a surgical condition.
Hypothesis IV. There is a relationship between the stimuli that children perceive as stressful in the hospital and the length of time the children are hospitalized. Children hos pitalized for less than five days perceive different stimuli as stressful compared with children hospitalized for more than five days.
Hypothesis V . There is a relationship between the stimuli that children perceive as stressful in the hospital and their preparation for hospitalization. Children Who are prepared for their hospitalization perceive different stimuli as stressful compared with children who are not prepared.
Hypothesis VI. There is a relationship between the stimuli that children perceive as stressful in the hospital and their experience with separation from their families. Children who have been previously separated from their families perceive different stimuli as stressful in the hospital as compared with children who have not been previously separated from their families.
Hypothesis VII. There is a relationship between the stimuli that children perceive as stressful in the hospital and the following group of variables! Children's age, sex, diagnosis, preparation for hospitalization, experience with separation, and the length of hospitalization. 10
Definitions
For the purpose of this study the following definitions
are used!
Child> an individual, between the ages of four and twelve years, who is hospitalized at either Children’s Hospital or River
side Methodist Hospital in Columbus, Ohio,
Stressi a state in which the child perceives that his
well-being or his integrity is endangered and that he must devote
his energies to its protection. It is an intervening variable
between the environment and the individual's behavior which can be
inferred from a situation or condition of the physical or social
environment, and which leads to avoidant, escapist, aggressive,
or problem-solving measures specifically designed to remove or •>3 weaken the condition perceived as threatening.
Stressort any stimulus which may produce stress within
the child.
Environmental stressor! a stimulus in the child's physical
environment perceived as stressful by the child.
Interpersonal stressor! a stimulus which occurs from the
child's interaction with or inability to have an interaction with
33c, N. Cofer and M. H. Appley, Motivation! Theory and Research (New York! John Wiley and Sons, 196*0, P. ^53.
■^Albert Pepitone, "Self, Social Environment, and Stress," in Psychological Stress ed. by Mortimer H. Appley and Richard Trumbull (New Yorki Appleton-Century-Crofts, 1968), p. 182, 11 a hospital personnel.
Intrapersonal stressor« some aspeet of the child's self that is perceived as stressful by the child or stimulus which occurs from the child's interaction with or inability to have an interaction with his family and/or friends and which is perceived as stressful by the child.
Organisation of the Study
Chapter I provides an introduction to the study. It consists of an overview of the problem, statement of the problem, the research hypotheses, and a list of definitions.
Chapter II presents the theoretical framework. The first
two sections deal with the variables of perception and stress.
The third section, pertaining to hospitalisation as a stressful
experience for children, includes a review of related literature
and the derivation of the research hypotheses. The last section
presents a model for studying children's perceptions of stressful
stimuli in the hospital.
Chapter III presents the methodology of the study. It
includes the research design, criteria used for sample selection,
description of the sample, and a description of the game used to
measure stress. Furthermore, there is a discussion of the
statistical techniques used for data analysis.
Chapter IV presents the analysis of the data in relation to the problems underlying this study. The first section is concerned with the identification of stressful stimuli. The second section is concerned with the testing of the research hypotheses. The latter two sections are a summary and discussion of the overall results of the study.
Chapter V provides a summary of the study, conclusions, and recommendations for future studies. CHAPTER II
THEORETICAL FRAMEWORK
The theoretical framework of this study consists of four parts. The first two parts are concerned with the variables, perception and stress. Both, perception and stress, are explored in terms of definitions, status as scientific ooncepts, and theories. The third part of the theoretical framework is con cerned with hospitalization as a stressful experience for children. It consists of a review of the literature and derivation of the research hypotheses. In the last part of the theoretical framework, a model for studying children's perception of stressful stimuli in the hospital is presented.
Perception
An individual's perceptions represent his personal world which may or way not be congruent with reality. The way an
individual behaves with respect to any situation tends to be in
accordance with how he perceives the situation. The perceptual
field is the universe of experience in which the individual lives
13 and that he takes to be reality,* The intensity with which events are experienced is a function of differentiation and levels of awareness since the individual is not aware of all parts of his perceptual field with the same degree of clarity at any given moment. Thus, whatever meanings the individual possesses are direct outgrowths of the differentiations that he has been able to make. The individual's perceptual field is 2 constantly changing.
An individual consciously perceives when he is aware of his perceptions. He evaluates what he perceives and then responds positively or negatively to what he has perceived. The indi vidual's perceptions bias his responses and these bias subsequent perceptions,-^ Thus, the individual's perceptions serve the purpose of providing him with best estimates regarding future happenings.^
*Arthur W. Combs and Donald Snygg, Individual Behaviort A Perceptual Approach to Behavior (New Yorki Harper and Brothers, 1959), p. 21.
2Ibid.. pp. 27-32. q Albert Ellis, "An Operational Reformulation of Some of the Basic Principles of Psychoanalysis," in Minnesota Studies in the Philosophy of Science Vol. I. ed. by Herbert Feigl and Michael Seriven (Minneapolis: University of Minnesota Press, 1956), pp. 137-139.
^Andie L. Knutson, The Individual. Society, and Health Behavior (New Yorki Russell Sage Foundation, 1965), p. 160. 15
Aaeih^ states that!
We act and choose on the basis of what we see, feel and believe| meanings and values are part and parcel of our actions. When we are mistaken about things we aot in terms of our erroneous notions, not in terms of things as they are. To understand human action it is therefore essential to understand the conscious mode in whloh things appear to us.
Thus, an individual’s perceptions can either help or hinder him in his actions depending upon the degree of resemblance to the real situation. The individual seeks to understand and to predict the world so that he may behave in it to his advantage,^
The concept of perception is as old as philosophy itself.
In the seventeenth century, British empiriolsts, such as Berkley,
Hume, and Mills, attempted to explain man's perception of objects, space, and the relation between them. At the end of the nineteenth century, psychologists, such as Titchner and William James, began 7 to develop theories of perception. Even though there are many perceptual theories and concomitantly a great deal of experimentation, how people perceive is still little understood. According to Q Bartley, perception has been conceptualised by many psychologists
^Solomon E. Asch, Social Psychology (Englewood, New Jersey» Prentice Hall, 1952), p.
^Albert Hastorf, David J. Schneider, and Judith Polefka, Person Perception (Reading, Massachusetts! Addison-Wesley Publishing Company, 1970), p. 8.
^Eleanor J. Gibson, Principles of Perceptual Learning and Development (New Yorki Appleton-Century-Crofts, 1969), pp. 19-36.
®S. Howard Bartley, Principles of Perception (New York! Harper and Brothers, 1958), p. 16 as a process by which the organism relates himself to its surroundings. The organism interprets, discriminates, and identifies objects and situations that he experiences as existing in the environment. Perception is an inferred process or an intervening variable which is unobservable except in a phenomenological sense.
There is lack of consensus about defining perception and the operations appropriate to its investigation. Perception is not a precise scientific concept but rather an organising word. The function of the word would be dissipated if its meaning Q were too narrowly delimited.7 There have been a variety of definitions for perception. William James*^ defines perception as the consciousness of particular material things present to the
senses. Murphy and Hoehberg** define perception as a form of continuous adjustment to environmental requirements involving not
only the "sensorium", or seat of cognitive functions, but the 12 whole organism, Gibson defines perception as the process by
which the individual obtains firsthand information about the
^William N. Dember, The Psychology of Perception (New York* Henry Holt and Company, 19oO), p.3.
^Bartley, Principles of Perception, p. 10.
^Gardner Murphy and Julian Hochberg, "Perceptual Develop ment Some Tentative Hypotheses," in Readings in Human Learning ed. by Lester D. Crow and Alice Crow (New York» David McKay Company, 1963), p. 207.
^Gibson, Principles of Perceptual Learning and -Development. p. 3. 17 13 world around him. Mussen, Conger, and Kagan contend that perception refers to the individual’s selection, organization, and initial interpretation of sensory impressions and that an individual's perceptions change as a function of learning, 14 labeling, and experience. According to Bartley, perception may be defined in terms of a general description without necessarily introducing a formal definition or it may be defined in terms of a general definition which does not necessarily place perception in relation to other processes which compose the individual's behavior. Perception may be defined more precisely if an operational definition is employed. However, even as to operational definitions of perception there is lack of consensus among theorists and/or researchers.
Perceptual theories can be categorized in a variety of ways. Perceptual theories can be cognitively-oriented, response-
oriented, or stimulus-oriented.^ Cognitively-oriented theories conceptualize perception as starting with sensory processes whioh
are supplemented by other processes. These theories emphasize
mediating processes, such as inferences, hypotheses, or problem
solving. Some cognitively-oriented perceptual theories are
Paul Mussen, John J. Conger, and Jerome Kagan, Child Development and Personality (3rd ed.f New York» Harper and Row, 1969), p. 287. 14 Bartley, Principles of Perception, p. 12.
^Gibson, Principles of Perceptual Learning and Development. PP. 73-7^. 18 those of Ames, Brunswik, Bruner, and Piaget, ^ Response-oriented theories conceptualize perception as involving sensory processes which are supplemented by responses that involve association. In these theories, perception is considered either to involve a motor copy of objects and events or to involve a discrimination
supplemented by response mediation. Some response-oriented 17 theories are those of J. G. Taylor and Hebb. Stimulus-oriented
theories contend that perception involves the organism’s picking
up information from the stimuli. Perception involves improve
ment in discrimination of information present in the stimulation.
As a result of differentiation, the organism becomes more selective
and specific in his perceptions. An example of a stimulus-oriented
perceptual theory is Gibson’s differentiation theory of perceptual l8 development. Also theories or concepts of perception can be
phenomenologically-oriented or positivlstically-oriented, Simi
larly, theories or concepts can be in terms of a micro level or
a molar level of analysis or in terms of object or social per
ception. It is beyond the scope of this paper to present examples
of each type of perceptual theory or conceptt however, a few are
presented.
^Gibson, Principles of Perceptual Learning and Development, pp. 37-52.
17Ibid.. pp. 53-7**.
l8Ibid,, pp. 75-117. 19
Arne’s theory of perception
Arne's transactional functionalism theory of perception is a molar, cognitively-oriented theory. Perception is determined for the individual by his purposes, his values, and his life history. ^
Emphasis is placed on the effects of past experience and learning.
The individual infers the nature of an object by an unconscious
judgment as to what physioal object would be most likely to produce the present pattern of impingement on the sense organs,^®
The individual is said to "make sense out of intrinsically meaningless sensory impingements by assessing their significance 21 in terms of his assumptive world." Thus, the experience of the
actual properties of the object must be provided by the combined
operation of the object and the pereeiver. There is considered to
be a transaction between the organism and the environment.
Central to this theory is the idea that the individual has
built up certain assumptions about the world in which he lives.
The situation which in the past has been associated most frequently
with the particular cues now presented to the individual's receptors
will be the most probable in the present occasion. In this theory
perception can be considered a process of assessing the probable
19 Gibson, Principles of Perceptual Learning and Development. p. *H. 20 Bartley, Principles of Perception, p. 17. 21 Leo Postman, "Perception and Learning," in Psychology! A Study of Science. Vol. V ed. by Sigmund Koch (New Yorki MeGraw Hill, 1963), p. 46. significance of the cues or stimuli in the situation which serve concomitantly as prognostic directives for action. If a particular assumption yields a false perception regarding the environmental situation, the organism will experience disparity when he tries to act in the situation. The percept will be seen not to fit the case. As a result, adjustive action may take place and lead to a new or revised assumption that will work. The perceptual process is in a constant state of flux since both the individual and the 22 environment are considered dynamic. In essence, the perceptual process represents the individual's transactions with his environ ment and serves as the guide for his behavior. As a result of the transactions with the environment, the individual builds a pattern of unconscious assumptions, and the total of these constitutes the individual's world.
Piaget's concept of perception
Piaget has not developed a theory of perception but a
conceptualization of the perceptual process which is cognitively-
oriented. The individual is assumed to be active in the
perceptual process. Perception depends upon sensory information
which must be structured somehow by the observer and it involves
assimilation of sensory input to a schema. Repetition is essential
^Floyd H. Allport, Theories of Perception and the Concept of Structure (New Yorki John Wiley and Sons, 1955), pp. 278-281, 21 for schema formation because assimilation of similar situations strengthens the schema. Perception is probabilistic and may be 23 distorted. Perception is egocentric as it is strictly personal and uncommunicable except through the mediation of language or of drawings, A key concept is "perceptual activity* which refers to the individual's increasingly active mode of understanding the stimulus world, of attending to relevant aspects of it, and of making comparisons between and interrelating different stimuli.
Initially the individual's perceptions are undifferentiated and are autistically oriented. However, as the individual develops, perception is increasingly directed by the active operation of intelligence. Piaget postulates three processes which underlie the evolution of perceived causality. The first is de-subjectifi- cation of causality which involves a shift of causation from the realm of the pure phenomenological world to specific externally perceived agents. The second is the formation of stable series in time so as to discount sheer contiguity in time as the agent of causation. The third is the progressive reversibility of cause and effect which involves the building up of more abstract
^Gibson, Principles of Perceptual Learning and Development. pp. 47*48, pjt Jean Piaget, The Mechanisms of Perception (New Yorki Basic Books, 1969) t p. 285.
25Ibid.. p. 133. 22 feedback concepts of causation. The third process evolves when 26 the individual is about eight years old.
Solley*s and Murphy*s theory of perception
Solley and Murphy haye a molar theory of perception which emphasizes learning. Perception can be understood if its parameters are defined in terms of learning, of structural components, and of 27 physiological units. ' Perception is regarded as both a process and a product which is unobservable. Perception is a psychological process with parallel physiological events which are isomorphic with
Perception is conceptualized as an instrumental act that
structures stimulation. Perception can be analyzed in terms of the
following stages 1 a preparatory stage, a sensory reception stage,
a trial-and-check stage, and a final structuring stage. In the
preparatory stage the individual's motives, desires, and events
lead to expectations about future perceptions, an aspect of the
preparatory stage known as expectancy. Also in this stage,
26 Charles M, Solley and Gardner Murphy, Development of the Perceptual World (New Yorki Basic Books, 19o0), p, 1^3.
27Ibid.. p. 13.
28Ibid.. p. 18. 23 attending occurs prior to stimulation and continues during stimulation. The next stage is reception, in which the sensory reaction occurs. In the trial-and-check stage, hypotheses are tested, unconcscious assumptions are checked, and materials supplied by the sensory process are articulated with previously
stored memoric traces. New information from proprioceptive and autonomic sources is triggered and fed back into the trial-and-check
stage and into the final structuring stage, in which the conscious
perception occurs. The stages are not isolated units but merge
as a total process. The perceptual act is affected by motivation,
reinforcement, learning, and maturation,^
Perceptual development involves both maturation and learning.
An infant can perceive before any perceptual learning has occurred.
However, the meaning of his perceptions is quite undifferentiated.
Solley and Murphy3^ state thati
Stimuli in the everyday social environment which are at first without speoific significance come in time to have for the child a definite attention-getting, a definite “encouraging," or a definite "threatening" value.
Children between five and eight years of age are more autistic in
their perceptions than older children. Likewise, perception and
cognition are more closely associated with affective processes in
children than in adults. As the child grows older, his perceptions
^Solley and Murphy, Development of the Perceptual World, pp. 18-33.
3°Ibld., p. 19. 2k become more differentiated. However, it cannot be attributed only to maturation nor to learning, but to some combination of 31 both maturation and learning.
Combs* and Snygg*a concept of perception
Combs and Snygg use a phenomenological approach in their conceptualization of perception. Perception is an internal,
individual phenomenon which can be inferred from the individual's behavior. The perceptual field is the universe of experience in which the individual lives and which he takes to be reality,32
It includes all aspects of the individual's awareness, those which
he is capable of describing and those which are at lower levels of
differentiation and which he is incapable of describing. How an
individual behaves at any given moment is always a function of
his total perceptual field in existence at that time. Likewise,
what is perceived by the individual is a function of his needs
operating at that particular time. The individual's perceptions
may or may not be congruent with realityi however, they represent
31 Solley and Murphy, Development of the Perceptual World, pp. 126-139.
32Combs and Snygg, Individual Behaviori A Perceptual Approach to Behavior, p. 21. 25 33 3U his personal meaning of events. Combs and Snygg state thatt
People do not behave according to the facts as others see them. They behave according to the facts as they see them. What governs behavior from the point of view of the individual himself are his unique percep tions of himself and the world in which he lives, the meaning things have for him.
Perception is influenced by the individual's past experiences, learning, and his self perception. New perceptions derive their meaning largely from already existing perceptions in the perceptual field. The perceptual field is continuously being reorganised as a result of new perceptions or differentia tions as long a3 the individual lives. The intensity with which
events are experienced is a function of differentiation and levels
of awareness since the individual is not aware of all parts of
the perceptual field with the same degree of clarity at any given 35 moment. The individual is selective in his perceptions since
he selects only those which are consistent with how he peroeives 36 himself. Therefore, how an individual behaves at any given
point in time is always the consequence of how he perceives a
situation and concomitantly how he perceives himself in relation
33Arthur W. Combs, "Some Basic Concepts in Perceptual Psychology," in The Helping Relationship Souroebook ed, by Donald L, Avila, Arthur W, Combs, and William W. Purkey (Boston! Allyn and Bacon, 1971), p. 118.
3/4, Combs and Snygg, Individual Behavior1 A Perceptual Approach to Behavior, p. 17.
35Ibld.. pp. 27-32. 36 Ibid.. p. 153. 26 to the situation.
Conclusion
Perception is an inferred process which is unobservable except in a phenomenological sense. Perception is not a precise scientific concept but rather an organizing word. There are many theories of perception j however, in the discipline of counseling, counselors are concerned mostly with perceptual theories that are molar, phenomenological, and/or cognitively-oriented. If a counselor can isolate an individual’s perceptions in a specific context, he has indicators to describe, explain, and/or predict how the individual will behave in a particular situation.
Concomitantly, a counselor can utilize this data in assisting the individual to attain greater self-awareness and to learn to handle his environment more effectively.
An individual’s perceptions represent his personal world or perceptual field which may or may not be congruent with reality.
In a specific situation, the individual evaluates what he perceives and then responds positively or negatively to what he has perceived.
His perceptions can be inferred by observing his behavior or by asking him directly how he perceives the situation. The individual's perceptions are influenced by maturation, learning, reinforcement, motives, his past experiences, and his self perception* Thus, the individual's perceptions may be changed through altering any of the factors which influence his perceptual field. 27
Stress
Stress is part of life. It is a natural by-produet of all activites{ there is no more Justification for avoiding stress than for shunning food, exercise, or love. But, in order to express yourself fully, you must first find your optimum stress-level, and then, use your adaptation energy at a rate and in a direction adjusted to the innate structure of your mind and body,3'
The concept of "stress" was introduced into the life og sciences by Hans Selye in 1936. Since then studies have been done concerning the physiological stress and/or psychological
3tress in the behavioral and the biological sciences. In spite of this research, the study of stress, especially the social and psychological aspects of human stress, is still in a fairly primitive state,J Some of the issues include defining stress, operationalizing the concept, and developing it into a useful concept.
Stress conveys the idea that an individual is being
influenced by stimuli that tax the adaptive resources of his
■^Hans Selye, The Stress of Life (New Yorki MeGraw Hill, 1956), pp. 299-300.
3®Mortimer H, Appley and Richard Trumbull, "On the Conoept of Psychological Stress," in Psychological Stress ed. by Mortimer H. Appley and Richard Trumbull (New Yorki Appleton-Century-Crofts, 1967), p. 1.
39jogeph E. McGrath, "Introduction," in Social and Psycho logical Factors in Stress ed, by Josephy E. McGrath (Hew Yorki Holt, Rinehart, and Winston, 1970), p. 3. 28 physiological and/or his psychological system. Stress has been used interchangeably with anxiety, conflict, ego-involvement, frustration, threat, emotionality, tension, and extreme environ- 4o 41 a? mental condition, ' ’ There is a lack of consensus regarding the meaning of stress. Stress can be defined in terms of response,
of situation, or of an organism-environmental interaction,^ A
response-based definition of stress involves the specification
of a class or classes of response which will be taken as evidence
that the organism is under stress. A situation-based definition
of stress involves the specification of a situation with certain
classes of stimulus properties. An organism-environmental inter
action definition of stress involves the specification of a
particular transaction of an organism to environmental events.
According to Pepitone^ there is no single correct definition of
^Appley and Trumbull, "On the Concept of Psychological Stress," p. 1.
^ C . N. Cofer and M. H. Appley, Motivationi Theory and Research (New Yorki John Wiley, 1964), p. 449. ho Richard S. Lazarus, Psychological Stress and the Coping Process (New Yorki MeGraw Hill, 1966), pp. 1-2,
^Joseph E. McGrath, "A Conceptual Formulation for Research on Stress," in Social and Psychological Factors in Stress ed. by Joseph E. McGrath, pp. 11-14.
^Albert Pepitone, "Self, Social Environment, and Stress," in Psychological Stress ed, by Mortimer H, Appley and Richard Trumbull (New Yorki Appleton-Century-Crofts, 1967), p. 182. 29 45 stress. Pepitone states that!
...there is not one correct definition of stress, nor can the research paradigms based on these conceptualisations be evaluated as right or wrong. Evaluations of designs and theoretical formulations can only be in terms of usefulness in producing research, in interpreting research data, and ultimately, in building knowledge.
In this research study, stress is defined as a state of the individual in which he perceives that his well-being or his integrity is endangered and that he must devote his energies to its protection. It is an intervening variable between the environ ment and the individual's behavior which can be inferred from a situation or condition of the physical or social environment and which leads to avoidant, escapist, aggressive, or problem-solving measures specifically designed to remove or weaken the condition 46 47 perceived as threatening. ’
Stress has been operationally defined many ways depending hQ upon the specific purposes with which it is associated, Cohen refers to stress as one of those peculiar terms which is under
stood by everyone when used in a very general context, but
^Pepitone, "Self, Social Environment, and Stress," p. 182. ^Ibid. 4? Cofer and Appley, Motivation! Theory and Research, p. 453.
^Sanford I. Cohen, "Central Nervous System Functioning in Altered Sensory Environment," in Psychological Stress ed. by Mortimer H. Appley and Richard Trumbull (New Yorki Appleton-Century-Crofts, 1967), p. 78. 30 understood by few when an operational definition is desired which is sufficiently specific to enable precise testing of certain relationships. The most widely accepted types of operational definitions for the existence of stress are ohahges in physio- 49 logical indices. Often physiological indices are used even when 50 the interest is in psychological stress, Lazarus^ states thati
Social or personality psychologists frequently employ physiological indicators of stress reaction, but their interest is usually not in the physiological mechanism. The physiological measure is not an end in itself but is rather a sign of a certain psychological state.
The assumption underlying the use of physiological indices is that certain environmental conditions induce not only overt behavioral effects but internal effects as well. Other operational defini tions of stress include the individual's response to a questionnaire, an interview, a scale, or a projective test. The fact that the majority of techniques for measuring stress are crude contributes to the problem of defining stress operationally.
The concept, stress, is criticized as being too unspecific
and thus unscientific. Until more knowledge is obtained through
research, the concept of stress should have openness of meaning.
Lazarus-** contends that stress is a collective term for the whole
ilQ Appley and Trumbull, "On the Concept of Psychological Stress," p. 6,
^Lazarus, Psychological Stress and the Coping Process, p. 48.
51Ibld.. p. 27. 31 area of issues that include the stimuli producing stress reactions, the reactions themselves, and the various intervening processes, 52 Likewise, McGrath contends that stress should be accepted as a general concept with heuristic value. Concomitantly, stress is not a rigorous scientific concept with hypothetic-deductive power.
53 Appley and Trumbull present the conditions which they think are necessary for stress to be developed into a useful concept. They state thati
Its ultimate usefulness as a psychological concept will depend upon the adequacy with which differentiations can be made among stimulus-, organismic-, and response-elements of stress situations, and whether stress researchers can avoid the inviting trap into which many personologists, for example, have fallen, namely that of treating their subject as though it were a unitary, all-or-none phenomenon.
Stress has been conceptualized in a variety of ways. It is beyond the scope of this paper to present all of these conceptualizationst however, a few are presented.
McGrath*8 concept of stress
Kif McGrath has developed a conceptual paradigm for the
^^McGrath, "A Conceptual Formulation for Research on Stress,” p. 11. 51 Appley and Trumbull, "On the Concept of Psychological Stress," p. 2.
5^+McGrath, "A Conceptual Formulation for Research on Stress," pp. 15-17. 32 concept of stress. Stress occurs when there is a substantial imbalance between environmental demand and the response capability of the focal organism. McGrath’s concept is based on propositions which provide a conceptual structure for stress research.
The first proposition is that the focal organism for stress research can be at any of the various system levels— individual humans, groups, or large functional organisations. The focal organism is embedded in a broader physical-social system and always functions within it.55
The second proposition is that stress involves a series of at least four classes of events— objective demand, subjective demand, response, and consequences. The objective demand takes place in the physical-social system in which the focal organism is embedded. The subjective demand is the perception of the objec tive demand by the focal organism. The response refers to the focal organism's responses to the subjective demand at the physiological, psychological, behavioral, and social-interactive levels. The consequences refers to the results of the response both for the focal organism and for the larger system or environ ment in which it is embedded, ^
The other propositions pertain to the four classes of
McGrath, "A Conceptual Formulation for Researoh on Stress," pp. 15-17.
56Ibld. 33 events or the four stage paradigm concerning stress. Properties or attributes of the focal organism come into play at various locations in the paradigm. Stress research should be concerned with tracing the sequence of events which takes place between the environment and the focal organism. Stress involves some relationship between the focal organism and the environment.
Stress research should conceptualize the individual as an active, adaptive, coping organism, rather than as merely a passive or
reactive organism. Stress research needs to consider the temporal dimension in studying the sequence of events in the stress
problem.
Aprpley's and Trumbull's concept of stress
Appley and Trumbull have conceptualized stress on the
basis of their critical review of stress studies. They-*® have
developed the following propositions regarding stresst
1. Stress is probably best conceived as a state of the total organism under extenuating circumstances rather than as an event in the environment.
2, A great variety of different environmental conditions is capable of producing a stress state.
^McGrath, ”A Conceptual Formulation for Research on Stress,” pp. 15-17.
5®Appley and Trumbull, ”0n the Concept of Psychological Stress,” p. 11, 3^ 3. Different individuals respond to the same conditions in different ways. Some enter rapidly into a stress state, others show increased alertness and apparently improved performance, and still others appear to be "immune" to the stress-producing qualities of the environmental conditions.
h-. The same individual may enter into a stress state in response to one presumably stressful condition and not to another,
5. Consistent intra-individual but varied inter-individual psychobiological response patterns occur in stress situa tions. The notion of a common stress reaction needs to be reassessed.
6. The behaviors resulting from operations intended to induce stress may be the same or different, depending on the context of the situation of its induction.
7. The intensity and the extent of the stress state, and the associated behaviors, may not be readily predicted from a knowledge of the stimulus conditions alone, but require an analysis of underlying motivational patterns and of the context in which the stressor is applied.
8. Temporal factors may determine the significance of a given stressor and thus the intensity and extent of the stress state and the optimum measurement of effect.
Appley and Trumbullcontend that the environment seldom produces uni-dimensional stressors. The stressors may be additive, may interact with each other, or may cancel each other. Thus, stress research should involve multi-dimensional stressors in studying organism-environmental interactions.
^Appley and Trumbull, "On the Concept of Psychological Stress," p. 12, 35
Gofer's and Appley13 concept of stress
Cofer and Appley^ contend that there are two stress concepts.
Systemic stress refers primarily to physiological and psychobio- logical changes that occur within an organism in response to a
stressor. Psychological stress refers to the state of an organism
in any situation in which he perceives that his well-being is
endangered, and that he must devote all of his energies to its
protection. Systemic stress and psychological stress are not inde
pendent .
Cofer and Appley have developed these criteria for psycho
logical stress. Stress is considered to be a state of the organism.
It involves an interaction between the individual and the environ
ment. Stress is more extreme than an ordinary motivated state and
may be the same as a state of severe frustration or conflict. A
threat must be present and be perceived by the individual in order
for stress to occur. Likewise, the integrity of the individual
must be involved and a normal adjustive (coping) response must be 6l absent in order for stress to develop within the individual.
Stress is one stage of an arousal continuum, which includes
an instigation threshold, a frustration threshold, a stress thres
hold, and an exhaustion threshold. The instigation threshold
^Cofer and Appley, Motlvation» Theory and Research, pp. 441, 449-450.
6lIbid.. p. 451. occurs when perceived stimuli in the environment necessitate the organism to develop new coping behavior which is task-oriented.
If the situation is perceived to be beyond the capacities of the organism’s readily available cooing ootential, then the frustration threshold occurs. At the frustration threshold there is a shift from exclusively task-oriented, problem solving behavior to the inclusion of ego-oriented, integrity-sustaining behavior. If both the task-oriented and ego-oriented behaviors have persisted without any effective change in the situation, then the stress threshold is reached. At the stress threshold, the organism is exclusively preoccupied with ego protection. If the organism's behavior is
ineffective, he reaches the exhaustion threshold at which he per
ceives himself to be totally helpless. In essence, stress tolerance
is described in terms of available response repertoires and is
considered to be primarily a function of l e a r n i n g . ^
The individual's perception of the situation determines the
stressfulness of an event. Cofer and Appley^3 state that!
Individuals are differentially vulnerable to threat, suggesting a series of stress perception thresholds for different kinds of stressors. Stress response involves emotionality, subjective feelings of distress and defensive behaviors as well as systemic symptoms. The pattern of stress response is one of a temporary inorease in organi zation and quality followed by a deterioration in per formance and a gradual shift from prior goal-oriented to
^Cofer and Appley, Motivation! Theory and Research, pp. **51-453.
63Ibid.. pp. 463-464. 37
ego-defensive behaviors of increasing inappropriateness to the previous goal(s), and perhaps to the environment, culminating in complete withdrawal as a response to the perceived hopelessness of effective responding.
Lazarus * concept of stress
To Lazarus^* the concept of stress is a collective term for the whole area of issues that include the stimuli producing stress reactions, the reactions themselves, and the various inter vening processes. Lazarus distinguishes among three levels of analysis within the field of stress» sociological, psychological, and physiological. Stress should be defined in terms of trans actions between individuals and situations rather than of either
one in isolation. Stress must be considered in terms of the
individual’s developmental level, Lazarus^ states thati
Psychological structure is by no means the same in the infant, young child, and mature adult, and we should expect the important details of psychological-stress production and reduction will be different at these developmental levels, (italics omitted)
Thus, a stimulus which is stressful for a young child may not be
stressful for an adolescent or vice versa.
Psychological stress can be understood through the inter
vening variable of threat. Threat is future oriented and it is
^Lazarus, Psychological Stress and the Coping Process. p. 27.
65Ibid.. p. 22. 38 brought about by cognitive processes involving perception, learning, memory, judgment, and thought. Lazarus^ states thatj
Threat impies a state in which the individual anticipates a confrontation with a harmful condition of some sort. Stimuli resulting in threat or nonthreat reactions are cues that signify to the individual some future condition, harm ful, benign, or beneficial. These and other cues are evaluated by the cognitive process of appraisal. The pro cess of appraisal depends upon two classes of antecedents. The first class consists of factors in the stimulus con figuration . such as the comparative power of the harm- producing condition and the individual's counterharm re sources, the imminence of the harmful confrontation, and degree of ambiguity in the significance of the stimulus cue. The second class of antecedents that determine the appraisal consists of factors within the psychological structure of the individual. including motive strength and pattern, general beliefs about transactions with the environment, intellectual resources, education, and knowledge. Threat exists on a continuum of degree, from complete absence to very intense levels.
When the situation is appraised as threatening, the indivi dual uses coping processes in an effort to reduce the threat.
Secondary appraisal is the cognitive activity underlying the coping processes. Secondary appraisal is concerned with estimating the consequences of any action tendency to cope with the threat, where as primary appraisal is concerned with the nature of the Impending
harm. Factors contributing to secondary appraisal include the
degree of threat, the viability of alternative coping actions, the
location of the agent of harm, situational constraints, motive
strengths and pattern, ego resources, and coping dispositions. The
individual chooses the coping process which he conceives of as
^Lazarus, Psychological Stress and the Coping Process. p. 25. 39 having the best chanee of overcoming the threat and of which he is readily capable. His choice is influenced by his beliefs, expec tations, perceptions, and evaluation. Irrationality in his choice is a reflection of the particular cognitive structure which disposes him to interpret situations in particular ways. In essence, stress exists when the individual anticipates that he will not be able to cope with the threat, or cope with it adequately, or cope with it without endangering other goals. The coping processes used by the 67 individual are his means of dealing with the stressor.
Torrance’s concept of stress
Torranoe's concept of stress is very general. Any stimulus which changes an organism in some significant way for better or worse may be regarded as stressful. Any threat to a fundamental
need is stressful. However, stress is not always noxious depending
upon the effects it has on the individual. Stress may cause the
individual to rise to new heights of performance and achievement.
The effects of stress upon an individual must be considered in
terms of the duration of the stress, the intensity of the stress, 68 and the state of the individual.
67 Lazarus, Psychological Stress and the Coping Process. pp. 152-161.
^Paul E. Torrance, Mental Health and Constructive Behavior» Stress. Personality, and Mental Health (Belmont. California» Wads worth Publishing Company, 1965), pp. 19-21. 40
Stress has a curvilinear effect upon behavior. Behavior improves up to a point and then it deteriorates. A situation may be considered stressful to the extent it causes the individual to lose contact with the environment, anchors in reality, or guides to behavior,^ Torrance7® states thati
Lack of social contacts, monotony, confusion, and over stimulation all help to destroy guides to behavior in the environment. It also seems rather clear that a person responds to continuously increasing stress or sudden pressure first by a lag in response, then by over compensatory response, and finally by collapse) if the stress is unabated.
Conclusion
Stress is a general term with heuristic value. Stress should be defined in terms of organism-environmental interactions rather than of either one in isolation. Concomitantly, stress should be studied in the context of specific situations. The
organism uses his cognitive processes to perceive a situation as stressful and uses coping behaviors in an attempt to reduce the stress.
Any stimulus, given the appropriate circumstances, can be
a stressor. Likewise, few stimuli are stressors to all individuals
^Torrance, Mental Health and Constructive Behaviori Stress. Personality, and Mental Health, pp. 32-33.
7°Ibld.. p. 62. M exposed to them. The kind of situation which is stressful to a particular individual must be related to significant events in that person's life. If familiar stimuli are removed there is an increased probability of the individual perceiving the situation as stressful.
Stress can be characterized as the discrepancy between the demands impinging upon an individual and the way the individual perceives his potential responses to these demands. The effects of stress upon an individual should be considered in terms of the duration of the stress, the intensity of the stress, and the state of the individual. Stress is an individual phenomenon and is dependent upon the particular meaning the individual assigns to
it; but there some stimuli which are perceived as stressful by most individuals exposed to them.
Hospitalizationi A Stressful Experience for a Child
In the course of growing up all children encounter some
stresses. Some possible stresses for a child are the addition
of a sibling, going to school, moving to a different house, having
an accident, and trying to master some developmental task. Illness
is considered to be a universal stress in childhood. Likewise,
hospitalization can be regarded as a stressful experience for a 42 71 72 73 74 child. Hospitalisation ranks high among the stressful experiences which modify and interfere with the child's develop ment,^ Hospitalization may have transitory or lasting effects on the emotional functioning and personality development of the child.^ Hospitalization is a time of stress for a child as well 77 as being possibly an opportunity for learning. The experience
of hospitalization can result in a "critical period" for the
child. According to the critical period hypothesis there are
certain experiences which are likely to have a far more profound
71 Herman S. Belmont, "Hospitalization and Its Effects Upon the Total Child," Clinical Pediatrics. IX (August, 1970), p. 4?2.
^ A . H. Chapman; Dorothy Loeb; and Mary Jane Gibbons, "Psychiatric Aspects of Hospitalizing Children," Archives of Pediatrics. LXXIII (March, 1956), p. 84.
^William S. Langford, "The Child in the Pediatric Hospital* Adaptation to Illness and Hospitalization," American Journal of Orthopsychiatry. XXXI (October, 196l), p. 669.
7^Sula Wolff, Children Under Stress (London* Allen Lane Penguin Press, 1969), p. 51.
^^Belmont, "Hospitalization and Its Effects Upon the Total Child," p. 472.
^Chapman, Loeb, and Gibbons, "Psychiatric Aspects of Hospitalizaing Children," p. 79.
"^Edward A. Mason, "The Hospitalized Child— His Emotional Needs," The New England Journal of Medicine. CCLXXII (February 25, 1965), p. 413. ^3 78 7Q 80 effect at certain periods than at others.' *' * Critical periods have an impact upon the direction of the child*s social, intellectual, and emotional development. The hospitalised child may grow emotionally through learning to master the stress he 8l 82 experiences. Haller states thati
No event in the child’s life is without effect on the oourse of his normal growth and development. No ex perience leaves us on the same plateau at which we found ourselves prior to it. A child will be changed one way or the other from his trip to the hospital.
If the stimuli that are stressful to the child can be identified,
the counselor and others, such as physicians and nurses, oan use
this knowledge as a framework for counseling the child and his
parents regarding the child's hospitalization. It could result in
maximizing a critical period into an experience which would
facilitate the child's development in desired ways.
?8J. MeViekar Hunt, Intelligence and Experience (New Torki The Ronald Press, 1961), p. 270.
p. Scott, "Critical Periods in Behavioral Development," Science. CXXXVIII (November 30, 1962), pp. 9^9-958. 80 , Dorothy Rodgers, Child Psychology (Belmont, California! Brook/Cole Publishing Company, 19^9), pp. 104-106.
®%aston E. Blom, "The Reactions of Hospitalized Children to Illness," Pediatrics. XXII (September, 1958), p. 596. 82 J. Alex Haller, "Preparing a Child for His Operation," in The Hospitalized Child and His Family ed. by J. Alex Haller (Baltimore! John Hopkins Press, 1967), p. 21. 44
Hospitalization presents additional tasks for the child to master when his capacity for coping is interfered with by his illness and separation from his parents, familar surroundings, 83 84 and other security props, J Freud contends that stress occurs since the child is unable to distinguish between the feelings of
suffering caused by the disease inside the body and suffering imposed on him from outside for the sake of curing the disease.
Chapman, Loeb, and Gibbons8-* contend that the stress of hospitali
zation is due in large part to the fact that the hospitalized
ohild is subjected to essentially the same routine and management
as the hospitalized adult. To the child hospitalization may
represent abandonment or rejection by his parents, possibly bodily
harm or mutilation, and/or punishment for wrong he has done, 86 Chapman, Loeb, and Gibbons describe some of the manifestations
of stress in children as follows i
®^Langford, "The Child in the Pediatric Hospitali Adaptation to Illness and Hospitalization," p, 669. pi> Anna Freud, "The Role of Bodily Illness in the Mental Life of Children," in The Psychoanalytic Study of Children ed, by R. 3. Eisser, et al. (New Yorki International Universities Press, 1952), P. 70.
85chapoan, Loeb, and Gibbons, "Psychiatric Aspects of Hospitalizing Children," p. 78.
86Ibid.. p. 84. *5
Among the most common reactions are (a) eating problems, with either refusal to eat or over-eating; (b) sleep disturbances, such as insomnia, nightmares or phobias of the darks (c) enuresis, or fecal soiling! (d) regression to earlier levels of training and social functionings (e) tics; (f) depression, restlessness, anxiety| (g) terror of hospitals, medical personnel, hypodermic needles, eto.s (h) death fearsj (i) mute, autistic regression to uncom municative states, of frightened withdrawal from contact with people; (J) hypochondriacal body, over-concern, or actual delusions about body functions; (k) hysterical symptoms, such as aphonia after tonsillectomy.
There is some consensus about the variables which account for the degree of stress perceived by the hospitalized child, Q r% Wolff contends that the degree of stress that the child experiences during or after an admission to the hospital depends upon his age; his personality and past experiences; and what actually happens 88 to him in the hospital. Langford provides a more comprehensive list of variables related to the child's experience with stress, 89 According to Langford, the variables which are related to stiess in the hospitalized child arei
...the age of the child and the status of his personality development at the time of the illness and hospitalization; his past ways of dealing with new and difficult situations; the immediate emotional surroundings of his illness; the nature of the illness; its acuteness, severity and duration,
Wolff, Children Under Stress, p. 55.
®®Langford, "The Child in the Pediatric Hospitali Adapta tion to Illness and Hospitalization," pp. 669-670. 89Ibid.- the type of symptoms; the degree of discomfort involved in diagnostic procedures; the nature of the required medical and surgical procedures including the type of anesthesia and its administration; the meaning of illness in general to the child, his pre-existing feelings regard ing health and disease, his specific fears and fantasies; the attitudes of his family toward illness in general and the particular illness; the child's relationships with physicians, nurses and other hospital personnel, their attitudes and feelings about children; the nature of the hospital setting, its policies and practices; the ability of the parents to visit; the type of preparation the child has had for the specific experience.
These same variables are either explicitly or Implicitly mentioned by other investigators. Sex is another variable which may con tribute to the degree of stress perceived by the child. Thus some of the variables which may account for the degree of stress per ceived by the hospitalised child are his age, his sex, his diagnosis, the length of his hospitalisation, his preparation for hospitalisa tion, and his experience with previous separation from his family.
These- same variables may make a difference in which stimuli the child perceives as stressful in the hospital.
Age
The child's age is a variable which may influence what stimuli he perceives as stressful in the hospital. The younger the child is, the less differentiated are his perceptions.
Likewise, his perceptions are more autistic and are more closely associated with affective processes. An eight year old child's perceptions are more differentiated and less autistic than are ^7 a five year old child's perceptions.^® As the younger child cannot differentiate as well, he is more likely to distort reality. If he perceives some aspect of a stimulus as stressful, more than likely he will perceive the total stimulus as stressful.
For example, if in his hospital room he has a diagnostic test performed, which he perceives as stressful, probably he will per ceive the hospital room as stressful tooj whereas the older child can differentiate the diagnostic test and the hospital room.
Thus, the older child may perceive the diagnostic test as a stressful stimulus, but not necessarily the hospital room as a stressful stimulus.
The child's cognitive ability is a function of age.
Cognitive ability influences the child's perceptions as it is
an important factor in determining what meaning he assigns to
stimuli. In Piaget’s theory of cognitive development there are
four major phasest sensori-motor, preoperational, concrete
operational, and formal operational. The child between the ages 91 of two and seven years is in the preoperational phase. In
this phase, the child's thoughts and language are egocentricj his
thought is concrete and static j and he attends to only one salient
aspect of a problem which results in a distortion of reasoning.
Solley and Murphy, Development of the Perceptual World, pp. 126, 139.
^Mussen, Conger, and Kagan, Child Development and Personal ity, pp. 302-306. 48
The child between the ages of seven and twelve years is in the 92 concrete operational phase. In this phase, the child has a mental representation of a series of actions, can solve conser vation problems, comprehends relational terms, can reason
simultaneously about part of the whole and the whole, and has
the ability to arrange objects according to some quantified
dimension. Also the child develops a progressive reversibility 93 of cause and effect in this phase at about the age of eight years.
Thus, the child in the preoperational phase should perceive
stimuli differently from the child in the concrete operational
phase.
The child’s past experiences, his ability to communicate,
and his ability to be prepared for hospitalization are all influenced
by his age. In turn all these factors affect how he perceives
stimuli. Usually the younger the child, the less experience he
has had in coping with stressful situations. Hospitalization may
be his first experience in dealing with stress of any duration.
For example, it may be the first time he is separated from his
mother or other significant family members. This in itself can be
a stressful experience for a child, but often he experiences other
stressful stimuli in the hospital when his parents are absent.
92 Mussen, Conger, and Kagan, Child Development and Person ality. pp. 451-453.
■^Solley and Murphy, Development of the Perceptual World. p. 143. However, the older child probably has had more experiences in coping with stress. He may have experienced generation from his family and does not perceive being in an unfamiliar environment as stressful as does the younger child. Since age limits the child’s communication and effective psychological preparation, the younger child is more susceptible to perceiving stimuli as 94 stressful in the hospital. The younger child is less able to assess reality and express himself as accurately as the older
95 child. ^ Thus, the older child may be more able to verbalise what
he perceives as stressful than is the younger child with the
result that the older child spuriously defines more stimuli as
stressful in the hospital.
Considerable attention has been devoted to the possibility
that the stress experienced by the hospitalized child is a function 96 of age, Belmont contends that age is a prime factor in under
standing what meaning hospitalization has for the child. According
to Belmont, the child from three to six years old will perceive
stress in relation to separation from parents and in any possible
^David T. A, Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness (Springfield, Illinois 1 Charles C. Thomas, 19^5), p. 87,
^'’Mas on, "The Hospitalized Child— His Emotional Needs," p. 408.
^Belmont, "Hospitalization and Its Effects Upon the Total Child," pp. 473-4 7 6 . danger to his physical integrity, whether real or Imaginary, In contrast, the school-aged child will perceive stress in situations where he feels a loss of control. He perceives less stress in 97 relation to being separated from his family. Mason contends that the younger child is predisposed to misinterpretations of his surroundings, that his fantasies and fears often lead him far from reality, and that his cognitive ability is not sufficient to help him cope by means available to the older child. Chapman, Loeb, and Gibbons^® contend that the younger the child, the more stress 99 he will experience. Likewise, Vernon et al. contend that the child below the age of five is more susceptible to stress in the hospital than is the older child. Thus, there are two viewpoints regarding the child's age and the stress he perceives in the hospital. One viewpoint is that even though age is related to needs and capacities of children, the sources of stress in hospitalisation may be merely different for children of different ages. The other viewpoint is that there is a decline in vulnerability to stress with increasing agej therefore, school-aged children perceive little 3tress in the hospital in comparison to younger children,
^Mason, "The Hospitalized Child— His Emotional Needs," pv 408.
9®Chapman, Loeb, and Gibbons, "Psychiatric Aspects of Hospitalizing Children," p. 78. 99 Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 86. No reported studies consider the child's age in relation to his perception of stressful stimuli in the hospital. Soma studies regarding children's reaction to hospitalisation have considered the variable of agei however, most of these studies used infants or children under the age of four,*®® In these studies the children experienced a situation which was assumed to be potentially stressful.
In Kassowits's*®* study of children's reaction to Injections, his subjects ranged in age from less than six months to twelve years. Responses before, during, and after injections were rated for all children. His findings were that children under six months displayed no fear prior to injection and that the incidenoe of upset in all phases showed a decline after the age of four years. 102 In Ulingsworth's and Holt's study of children's reactions to daily visiting during hospitalization, their subjects ranged in age from one to fourteen years. The children's behavior was observed before and after visits for fourteen days. Their finding was a decrease in incidence of upset with increasing age. However, their
lOOpor a review of these studies see Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness. pp. 92-102.
101-K. E. Kassowits, "Psychodynamic Reactions of Children to the Use of Hypodermic Needles," American Journal of Diseases of Children. LXIV (1958), PP. 253-257.
*®^R. S. Illingsworth and K. S. Holt, "Children in Hospital! Some Observations on Their Reactions with Special Reference to Daily Visiting," The Lancet. CCLXIX (December 17, 1955), pp. 1257- 1262. finding was based only on percentage distributions. No other kind of statistical analysis was reported. These two studies lend support to the viewpoint that there is a decline in vulnerability to stress with increasing agej therefore, school-aged children perceive little stress in the hospital in comparison to younger children. However, both of these studies consider only one par ticular situation in the hospital as potentially stressful to children, 103 Blom's study lends support to the viewpoint that the sources of stress in hospitalization may be merely different for children of different ages. In Blom*s study of children's emotional reactions to tonsillectomies and short-term hospitalization, his
subjects ranged in age from two to fourteen years. The children were both observed and interviewed. His findings were that the
children assigned fantasy meanings to their operations and that
there was a shift in the main focus of anxiety with age. The foci
of anxiety were hospitalization, operation, needles, and narcosis.
Hospitalization was the most frequently encountered anxiety,
especially in children under five years of age. In the children
between five and seven years of age, hospitalization was the main
focus, with operation the second highest. In the children between
seven and ten years of age, the chief foci of anxiety were operation
and narcosis. In the children over ten years of age, narcosis
*^Blom, "The Reactions of Hospitalized Children to Illness," pp. 594-596. 53 was the chief focus of anxiety, Blom's findings were based on percentage distributions. No other kind of statistical analysis was reported. 10/* Prugh's study lends some support to both viewpoints
regarding the relationship of child's age and the stress he
perceives in the hospital. The purpose of this experimental study was to determine the nature and degree of emotional reactions of
children and families to the experience of short-term hospitalisa
tion for medical illness. The experimental and control groups
were roughly matched for age, sex, length of stay, number of prior
hospitalizations, and diagnosis. Data were obtained on the subjects,
who ranged in age from two to twelve years, through observation of
their behavior and through interviews with their parents. One of
the findings of this study was that all children showed some
reactions to the experience of hospitalization.*®^ The subjects
in the experimental and control groups were categorized as severe,
moderate, or minimal reaction. A statistical analysis, utilizing
a chi-square, showed a significant difference (p<.01) between
the experimental and control groupsj however, the actual statistics 106 were not presented. This finding lends some support to the
Dane G. Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness," American Journal of Orthopsychiatry. XXIII (January, 1953)» PP. 70-103.
105Ibid.. p. 79
106Ibid.. p. 80. viewpoint that the sources of stress may be merely different for children of different ages. However, an analysis of the data according to specific age groups lends support to the viewpoint that there is a decline in vulnerability to stress with increasing age. Children under three years of age showed the highest incidence of severe reaction to hospitalization. In the four to six year old group, severe reactions were less common. In the six to twelve year old group severe reactions were the lowest. The 107 chi-square was not significant, but Prugh contends that con firmatory trends were present. Again, the actual statistics were not presented. The findings of Prugh's study are inconclusive
regarding the relationship between age and children's reaction to
hospitalization.
None of the studies resported is conclusive about the
relationship between age and children's reaction to hospitalization.
Similarly, no reported studies consider the child's age in relation
to hi3 perception of stressful stimuli in the hospital. As there
may be a difference in children's perception of stressful stimuli
in the hospital as a function of age, the following research
hypothesis, is madei
Hypothesis I. There is a relationship between the stimuli that children perceive as stressful in the hospital and the age of the children. Children between the ages of four and seven perceive different stimuli as stressful in the hospital as compared with children between the ages of seven and twelve.
*-®?Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness,'' pp. 79-80. 55
Sex
The sex of the child is a variable whloh may influence what stimuli he perceives as stressful in the hospital. The child's sex determines partially how he perceives himself. This
part of his self-perception is learned through the prooess of 1 nft socialization. Sarason states that, "Beginning with the
earliest days of life boys and girls are differentially responded
to by others to a degree and in ways which result in different
perceptions of self and others." In the process of development,
the child learns behaviors, attributes, and attitudes which are 109 appropriate for his particular sex role. Kagan contends that
the child between the ages of three to seven aoqulres the concept 110 of male and female, Kagan states thati
The child as young as four has dichotomized the world into male and female people and is concerned with boy-girl differences. By the time he is seven he is intensely committed to molding his behavior in con cordance with cultural standards appropriate to his biological sex and he shows uneasiness, anxiety, and even anger when he is in danger of behaving in ways regarded as characteristic of the opposite sex.
!®®Seymour B. Sarason, et al.. Anxiety in Elementary School Children (New York: John Wiley and Sons, i960), p. 260,
Jerome Kagan, "Acquisition and Significance of Sex Typing and Sex Role Identity," in Review of Child Development Research. Vol. I, ed. by Martin L. Hoffman and Lois Wladis Hofftaan (New Yorki Russell Sage Foundation, 196*0, pp. 138-139.
110Ibid.. p. 162. The child’s 3ex influences his experiences which in turn influence his perceptions. As the child grows older, he shows more preference for sex appropriate games in his play. By the age of three, boys become aware of some activities and objects that are regarded as masculine. In contrast, girls show more variability 1 11 up to the age of nine or ten. Often the experiences that the child has are contingent upon his sex. Probably the male is exposed to potentially stressful situations earlier than the female since he is expected to develop aggressive behaviorj whereas the female is expected to be more dependent, passive, and conforming.
Part of sex role behavior is for males to suppress fears and to have a capacity to control expressions of strong emotion in time 112 of stress. In contrast, females are encouraged to express their
fears and emotions, and concomitantly they are supported and are
permitted to depend on others for reassurance and help.**^ Males
are expected to deal more pragmatically, calmly, and effectively 114 with stress situations than are females. Thus, boys in comparison
*^Kagan, "Acquisition and Significance of Sex Typing and Sex Role Identity," p. 141.
112Ibid.. pp. 142-143.
H3sarason, et al.. Anxiety in Elementary School Children. p. 253.
^■^^Mussen, Conger, and Kagan, Child Development and Person ality. p. 505, to girls should perceive different stimuli as stressful. Also girls should verbally admit perceiving more stimuli as stressful.
Although, both boys and girls may perceive the same stimuli as stressful in a new situation, the boys may be reluctant to say that the stimuli are stressful since they think it is not con gruent with their self-perception as males. Boys and girls learn early in life to have different attitudes toward the expression and admission of stress.**^ Boys are more defensive about admitting 116 stress as it is ego-alien to boys and ego-syntonic to girls.
Little attention has been devoted to the possibility that the stress experienced by the hospitalised child is a function of his sex. No studies are reported which consider the child's sex in relation to his perception of stressful stimuli in the hospital.
However, a few studies have considered children's reaction to 117 hospitalization as a function of sex. In Prugh's study of children's reaction to short-term hospitalization, when sex was considered as a variable, there was no significant difference.
**^Sarason, et al.. Anxiety in Elementary School Children. p. 25^.
**^Beeman N. Phillips, An Analysis of Causes of Anxiety Among Children in School (Austin, Texas« University of Texas, 1966), p. 20.
**^Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness,w p. 80. 58 | 40 Similarly, in Blom's study of children's emotional reactions to tonsillectomies and short-term hospitalisation, there was little difference between the responses of males and females.
Thus, these two studies lend some support to the idea that sex does not influence children's reaction to hospitalisation.
In 111ingsworth's ahd Holt's**^ study of children's reactions to daily visiting during hospitalisation, they found some differences between the reactions of males and females.
Males, between the ages of one and four years, appeared to be more upset than females of the samd ages during the hospitalisation period. For children five to six years of age there were no differences in the degree of upset in males and females. For children, between the ages of seven and fourteen years, the females appeared more upset than the males during the hospitalisation 120 period. In Shirley's and Poynts's study of children's reaotlons to various medical examinations in an outpatient clinic, they found some differences in the reactions of males and females. The subjects, who ranged in age from two to six and one-half years, were observed for signs of upset during medical examinations, A
118 Blom, "The Reactions of Hospitalised Children to Illness," pp. 59^-596.
^^Illingsworth and Holt, "Children in Hospitalt Some Observations on Their Reactions with Special Reference to Daily Visiting," pp. 1258-1259.
*2t)Mary M, Shirley and Lillian Poynts, "Children's Emotional Responses to Health Examinations," Child Daveloqnent. XVI (March- June, 19^5). pp. 89-95. 59 child was classified as upset if he cried, verbally protested, actively resisted, attempted withdrawal, or became tense. Their 121 finding was that boys were less often upset than girls. Both of these studies lend some support to sex as an influence on children's reaction to hospitalization or some closely related stressful situation.
The studies reported do not show a consistent relationship between sex and children's reaction to hospitalization. Similarly, no studies were reported which consider the child's sex in relation to his perception of stressful stimuli in the hospital. As there may be a difference in children's perception of stressful stimuli in the hospital as a function of sex, the following research hypothesis is madei
Hypothesis II. There is a relationship between the stimuli that children perceive as stressful in the hospital and the sex of the children. Male and female children perceive different stimuli as stressful in the hospital.
Diagnosis
The child's diagnosis is a variable which may influence what stimuli he perceives as stressful in the hospital. It may
influence the child's perception through the meaning he assigns
to his illness and to his concomitant need for hospitalization,
121 Shirley and Poyntz, "Children's Emotional Responses to Health Examinations," p. 92.
4 60
The child's diagnosis represents emotional stress both in realistic 122 121 i2h- and unconscious meaning, According to Blom, the severity of the illness, the organ involved, the type of treatment, and the degree of suffering all influence the degree of realistic stress, 125 Likewise, Langford contends that the child's stress is influenced by the nature of the illness, its acuteness, severity and duration, the organ involved, and the type of symptoms. However, the child's responses to his illness are not determined solely by these objective criteria, but by the child's own fantasies and inter- 126 pretations of his illness.
The child may see his illness as a form of punishment, of 127 128 mutilation, of death, and/or abandonment. According to Vernon,
^^Langford, "The Child in the Pediatric Hospital: Adaptation to Illness and Hospitalization," p, 672.
*23]31om, "The Reactions of Hospitalized Children to Illness," P. 591.
12W
^•2^Langford, "The Child in the Pediatric Hospital: Adaptation to Illness and Hospitalization," p. 669.
1 Belmont, "Hospitalization and Its Effects Upon the Total Child," p. 1*77.
^■2^Blom, "The Reactions of Hospitalized Children to Illness," P. 591. 1 Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p, 79. the meaning which the child's illness has for him may serve as 129 defenses which prevent or ameliorate upset. Vernon states that
"This implies that the child's ideas, even if they are distorted
or emotionally loaded, may be less upsetting than external reality."
Freud*-^ contends that the child is unable to distinguish between
feelings of suffering caused by the illness and suffering imposed
on him from outside for the sake of curing the illness, Freud
minimizes the possibility that illnesses or treatments objectively
differ from one another with respect to the meaning the child
assigns to them. The meaning an oneration has for the child depends 131 upon the type and depth of the fantasies aroused by it. It is
the same with the psychic meaning or fantasies that the child assigns
to bodily pain. The child in pain may perceive himself being mal
treated, harmed, punished, persecuted, and/or threatened by
annihilation.Thus the child's interpretation of his illness
represents both emotional stress in realistic terms and in fantasy
terms.
129 Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 79.
•*-3®Freud, "The Role of Bodily Illness in the Mental Life of Children," p. 70. 131 Ibid.. p. 74
^ Ibld.. p. 76. The child who has a medical condition probably assigns a different meaning to his illness than does a child who has a
surgical condition. The two children may perceive different
stimuli as stressful in the hospital since they have different 133 experiences. Some of the different experiences may be related
to diagnostic tests, to operations, and to amounts of activity.
Both children experience having their temperatures taken, having
physical examinations, and having some laboratory tests, all of
which are potentially stressful. The child who has a medical
condition may experience some diagnostic tests, such as x-rays
and laboratory tests which require him to be catherised, to have
enemas, and/or to have injections. Any of these experiences is
potentially stressful as they are unfamiliar, may necessitate the
child's going alone to a different part of the hospital, may
produce some discomfort or pain, and/or may be perceived by the
child as a threat to his body's integrity. The child who has a
surgical condition experiences potentially stressful stimuli because
of his operation. Some of these stimuli include having pre-operative
medications, maybe having an enema, having anesthesia, being in
the operating room with the operating personnel and strange equip
ment, waking up in a strange room known as the recovery room,
maybe experiencing discomfort or pain, and maybe having strange
equipment and tubes attached to his body. These stimuli can be
^■Hfolff, Children Under Stress, p. 55. stressful to the child as they may be unfamiliar, may be perceived as a threat to the integrity of his body, and he may experience them without the presence of a family member.
The amount of activity that the child may have is determined largely by his diagnosis. The child who is required to stay in bed more than likely perceives this as stressful because it is ineon- gruent with his routine outside the hospital. Any form of physical restraint or immobilisation inhibits the child’s normal outlets for 134 iqc energy and aggressiveness, ' The child who has a fractured leg or arm that requires traction is confined to bed for at least a week and often several weeks. This situation is potentially very stressful for the child. Anytime a child is required to stay in bed for any period of time, except when he is acutely ill, it is a potentially stressful situation.
Little attention has been given to the influence of the child's diagnosis on his reaction to hospitalieation. Nobody has explicitly taken the position that psychological upset may be
136 a function of objective stress. This might be beoause it is difficult to equate objective stress,
^•^Dermod McCarthy, et al.. "The Handling of the Sick Child," in The Prevention of Damaging Stress in Children ed, by Johathan Gould (Londoni J. and A. Churchill, 1968), p. 3. 135 Harry Bakvin and Ruth Morris Bakwln, Clinical Management of Behavior Disorders in Children (3rd ed.; Philadelphia! W. B. Saunders, 1966), p, 124. 136 Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p, 143. 6k 137 In Prugh's study, the relationship between objective stress and the degree of upset was consideredj however, objective stress was confounded with other variables. The finding was that the objectively verifiable aspects of stress encountered bore little specific relationship to the degree of upset in children in the experimental and control groups. Also Prugh^38 studied the relationship between types of medical illnesses and psycho logical upset. The finding was a relative absence of correlation between severity of upset and the type of illness. Neither the type of statistical analysis nor the data were reported.
There are few studies reported which consider the relation
ship of the child's conception of his illness and his degree of 139 upset in the hospital. In Erickson's J study of the reactions of
four year old, hospitalized children to intrusive procedures, the
children conceptualized intrusive procedures involving the skin
and anus as being hostile acts but those involving the mouth as 140 not being hostile acts. Blom presented a case study which lends
*3?Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness,M p. 82,
138Ibid.
*3^Florence H, Erickson, "Play Interviews for Four Year Old Hospitalized Children," Monographs of the Society for Research in Child Development. XXIII (1958), p. 66,
*^Blom, "The Reactions of Hospitalized Children to Illness," P. 591. support to the idea that the child's fantasies regarding his illness influence the amount of psychological upset he experiences.
However, neither of these studies is conclusive about the relation ship between the child's conception of his illness and his degree of upset.
No studies are reported which consider the child's diagnosis in relation to his perception of stressful stimuli in the hospital.
As there may be a difference in children's perception of stressful stimuli in the hospital as a function of their diagnosis, the following research hypothesis is made!
Hypothesis III. There is a relationship between the stimuli children perceive as stressful in the hospital and their diagnosis. Children hospitalized for a medical condition perceive different stimuli as stressful compared with children hospitalized for a surgical condition.
Length of Hospitalization
The length of time the child is in the hospital is a variable which may influence what stimuli he perceives as stressful in this
situation. The length of time the child has been hospitalized
influences his understanding of different stimuli in the hospital
As the length of time increases, the unfamiliarity of the hospital
should decrease unless the child is exposed to many new situations.
For example, if the child is exposed each day to a different
diagnostic test which requires the use of equipment that is
unfamiliar to him, probably he will continue to perceive many 66 stimuli as stressful. Unfamiliarity plays an important role in 1A1 the hospitalised child being upset. When the child becomes more familiar with his environment some of the stressful stimuli should be eliminated since now he knows what they are and how they affect him. However, even as the length of time in the hospital increases, some stimuli should still be perceived as stressful by the child.
Length of time influences a child's perception of a particular environment, such as a hospital, since he learns to
adapt. Adapting either to intense stress after intense stress or
to prolonged stress is characterized by an overcompensatory
response, maintaining adaptation, lag in performance, or exhaustion
and collapse. The child develops, within his available resources,
a set of coping strategies to manage his environment and to manage 1 ho his feelings aroused by the stress. Coping strategies involve
the use of the child's resources and also new structures and inte
grations developed by the child to master his individual problems 1^3 with the environment. According to Murphy, the coping strategies
that children use to handle stress include! being selective about
Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 22.
l^^Torrance, Mental Health and Constructive Behavior! Stress. Personality, and Mental Health, pp. 59i 192.
*^Lois Barclay Murphy, "Learning How Children Cope with Problems," Children IV (July-August, 1957)» p. 13^. what they attend to in the environment, denying reality, resisting excessive or unwelcome demands, tolerating and understanding, mobilizing extra effort, protecting the self with available grati fications, compensating and embellishing the situation, and redefining or restructuring the situation so it can be mastered,
Murphy^* states thati
The child's management of his relations with the envir onment involves the selection and orchestration of both impersonal and personal stimuli with a view to keeping over-all stimulation at an optiminal level for him, and finding the materials he requires for use of his own equipment and satisfying his own needs.
Thus, if the child develops effective coping strategies, his environment will not be perceived as stressful as it previously had been. If other variables remain constant, there should be a reduction in the quantity and quality of stimuli that the child perceives as stressful the longer he is in a particular environment.
Similarly, if two children are exposed to the same environment,
but the length of time is varied, there should be a difference in
the stimuli perceived as stressful by them.
Some attention has been given to the possibility that the
stress experienced by the hospitalised child is a function of the
length of time he has been in the hospital. No studies are reported
which consider the length of the child's hospitalisation in relation
to his perception of stressful stimuli in the hospital. However,
some studies have considered children's reactions to hospitalization
*****Lois Barclay Murphy, et al.. The Widening World of Childhood (New York* Basic Books, 1962), p, 318. 68 as a function of the length of time they are in the hospital.
There is some evidence that upset decreases as a function of time.
Children appear less upset or even happier as hospitalisation 1*4-5 progresses. 146 In Illingsworth's and Holt's study of children's reaction to daily visiting during hospitalisation, they found some differences in upset as a function of length of hospitalisation.
They studied the incidence of upset displayed by the children during a twelve day period of hospitalisation, which was divided into three successive, four day periods. Illingsworth and Holt found that the overall incidence of upset decreased as a function of time. However, in children under the age of five there was no decrease in upset. In children five years and older, the
incidence of upset rapidly decreased after the first four days
of hospitalization. These findings were based on percentage distributions and proportions. No other statistical analysis
was reported.
In Prugh's^*^ study of children's reactions to short-term
hospitalization, length of hospitalization was considered as a
l^Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 22,
^^Illingsworth and Holt, "Children in Hospitali Some Observations on Their Reactions with Special Reference to Daily Visiting," p. 1260,
*^Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness," pp. 83-84-, variable. He found no correlation between length of hospitaliza tion and degree of reaction or adjustment to the experience,
Prugh reported the same finding even when the period of hospitali zation was considered in relation to age, diagnosis, and integrative capacity. Neither the actual statistics nor statistical method used was presented for any of the findings related to length of hospitalization, 1^8 Vernon et al.. in their review of hospitalization as psychologically upsetting to children, reported some studies which lend support to children being less upset as length of time in the hospital increases. One of these studies, done by Schaffer and
Callender, used infants under one year of age. The finding was a diminution of upset with time, especially for the older infants.
Another study, done by Ylppo et al.. used a group of children hospitalized in Finland, Ylppo studied changes in physiological measures as a function of time in the hospital, Ylppo interpreted the physiological changes as indicating a decrease in stress as length of hospitalization increases.
In general, the studies reported lend support to the con clusion children are less upset as time in the hospital increases.
However, none of these studies reported the use of any correlational
l^*&Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, pp. 41-^3» 51. 70 statistics in analysing the data. Prugh*^ reported the absence of a correlation between upset and length of hospitalization, but he did not report the correlational method used. Similarly, no studies were reported which considered the length of the child*s hospitalization in relation to his perception of stressful stimuli in the hospital. As there may be a difference in children's perception of stressful stimuli, as a function of length of time in the hospital, the following research hypothesis is madei
Hypothesis IV. There is a relationship between the stimuli that children perceive as stressful in the hospital and the length of time the children are hospitalized. Children hospitalized for less than five days perceive different stimuli as stressful compared with children hospitalized for more than five days.
Preparation
The child's preparation for hospitalization is a variable which may influence what stimuli he perceives as stressful in the hospital. The hospitalized child is in an environment with which he has had little or no prior experience. There are many stimuli in the hospital which the child has not encountered previously and which are potentially stressful. Gellert*"^ states« "To a child, a hospital is like a foreign country to whose customs, language,
■^^Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness,” p. 83.
*-^Elizabeth Gellert, "Reducing the Emotional Stresses of Hospitalization for Children,” American Journal of Occupational Therapy. XII (May-June, 1958), p. 126, 71 and schedules he must learn to adapt." The child experiences a great deal of ambiguity in the hospital environment, especially if he has not been prepared for the experience.
Preparation reduces ambiguity which subsequently may reduce the degree of stress perceived by the hospitalized child. Ambiguous stimuli are more upsetting and threatening than stimuli which are understood, Unfamiliarity plays an important role in the hospi- 151 talized child being upset. If the child is prepared prior to his hospitalization, there should be a decrease in the stimuli that he perceives as stressful. However, this is dependent upon the accuracy of the information disseminated to the child, the child's ability and his willingness to understand the information,
and the child's overall understanding of the situation. Vernon 152 et al. J contend that preparation is influenced by age, intelli
gences, type of disability, and personality. The prepared child
has a conceptualization of what to expect in the hospital environ
ment and can begin to develop effective coping strategies. Thus,
of two hospitalized children, if one is prepared and the other is
not, there should be a difference in the stimuli perceived as
stressful by them.
Some attention has been devoted to the possibility that
■^Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 22.
152Ibid.. p. 13. 72 the stress experienced by the hospitalized child is a function of 153 his preparation for the experience. Chapman, Loeb, and Gibbons
contend that hospitalization is a difficult experience for the
prepared child and is a devastating experience for the unprepared 15/4. child. Likewise, Mason contends that children who are unpre
pared or misled have grossly negative reactions to hospitalization.
He attributes these reactions to the child's shaken trust in his 155 parents and to the strangeness of the situation, Belmont and 156 Gellert are of the opinion that prepared children find hospi
talization easier. Thus, there is some consensus that preparation
influences the child's response to hospitalization.
There are no studies reported which consider the child's
preparation in relation to his perception of stressful stimuli in
the hospital. Some studies regarding children's reaction to
hospitalization have considered the variable 1 however, most of
these studies considered post-hospital response. In general, the
findings lend support to the conclusion that preparation is a
153 Chapman, Loeb, and Gibbons, "Psychiatric Aspects of Hospitalizing Childre," p. 80.
^■■^Mason, "The Hospitalized Child — His Emotional Needs," p. **09.
*-^Belmont, "Hospitalization and Its Effects Upon the Total Child," p. 480.
^'^Gellert, "Reducing the Emotional Stresses of Hospitali zation for Children," p. 125. 73
determinant of the level of psychological upset experienced by 1 VP 1 58 children following hospitalization. Prugh's study considered
preparation in relation to immediate hospital reactions. However,
no conclusions can be drawn as preparation was confounded with 159 other variables. Prugh contends that preparation seemed to
reduce psychological upset.
On the basis of the studies reported no conclusions can
be drawn concerning the relationship between children's preparation
and their reactions to hospitalization. Similarly, no studies were
reported which consider the child's preparation in relation to his
perception of stressful stimuli in the hospital. As there may be
a difference in children's perception of stressful stimuli in the
hospital as a function of their preparation, the following research
hypothesis is madei
Hypothesis V. There is a relationship between the stimuli that children perceive as stressful in the hospital and their preparation for hospitalization. Children who are prepared for their hospitalization perceive different stimuli as stressful compared with children who are not prepared,
157 Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 21. 158 * Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness,'' p. 83.
159Ibid.. p. 103. 7b
Separation
The child's experience with separation from his family is a variable which may influence what stimuli he perceives as stressful in the hospital. Hospitalization may be the inital experience the child has with separation of any duration. To the hospitalized child separation may represent loss of trust in and security from his parents, or abandonment, re .lection, and/or 160 punishment. The child's interpretation of his separation influences the way he perceives stimuli in his environment. If he experiences stress from this initial experience of being separated from his family, he probably will perceive many stimuli as stressful in his environment. In contrast, if the child has been previously separated from his family, he may not experience
as much stress and will not perceive as many stimuli as stressful
in his environment. The child may not interpret separation as
loss of trust and security, or abandonment, rejection, and/or
punishment. He may have developed coping mechanisms to handle
separation from his family which he can use in the hospital
environment. Thus, the child with prior experience with separa
tion may not perceive the same stimuli as stressful as the child
who has not had any prior experience.
Separation has been frequently mentioned as a source
160 Vernon, et al.. The Psychological Responses of Children to Hospitalization and Hlne3s. p. 31. 75 of psychological upset in hospitalized children.However, separation considered in terms of children’s experience with it has been rarely mentioned. According to Yarrow,some of the aspects which should be considered in relation to separation are the child’s developmental stage, his experiences prior to separa tion, the nature of the child's relationships with his parents, the degree of concomitant trauma, whether separation is temporary or permanent, whether any contact is maintained with the family, and whether it is the first or one in a series of separations. 16^ Bowlby contends that the child’s reaction results from a primary
anxiety attributed to the rupture of the attachment he has to his mother.
Separation has been considered particularly in reference
to infants and preschool aged children. There is some consensus
that separation is especially traumatic for children of preschool
Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p, 25. 1.62 Leon J. Yarrow, "Separation from Parents During Early Childhood," in Review of Child Development. Vol. I, ed. by Martin L, Hoffman and Lois Wladis Hoffman (New Yorki Russell Sage Foundation, 196*0, p. 91. 1 John Bowlby, "Separation Anxiety: A Critical Review of the Literature," Journal of Child Psychology and Psychiatry. I (I960), p. 253. 76 age and younger. Mason*^ contends that the young child feels deprived of basic trust and security when he is separated from 166 his mother. Gellert contends that the preschool aged child finds separation to be difficult and that the child interprets it as being abandoned forever since his concept of time is on a
"now or never" basis. However, psychological upset due to separation may not be limited only to the preschool aged child. 167 Prugh contends that separation can result in some psychological upset in child through the latency period of development.
Some studies have considered the variable of separation in relation to children's reactions to hospitalisation. The majority of these studies used infants or children under five years of 168 age. There are no studies reported which consider the child's experience with separation from his family in relation to his
164- Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 25.
l65Mason, "The Hospitalised Child — His Emotional Heeds," p. 408, 166 Gellert, "Reducing the Emotional Stresses of Hospi talisation for Children," p. 125.
*^Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalisation and Illness," p. 101, 168 For a review of these studies see Vernon, et al.. The Psychological Responses of Children to Hospitalisation and Illness. pp. 38-4-3. 7? perception of stressful stimuli in the hospital. As there may be a difference in children's perception of stressful stimuli in the hospital as a function of their experience with separation, the following research hypothesis is made:
Hypothesis VI. There is a relationship between the stimuli that children perceive as stressful in the hospital and their experience with separations from their families. Children who have been previously separated from their families perceive different stimuli as stressful in the hospital as compared with children who have not been previously separated from their families.
Model for Studying Children's Perception of
Stressful Stimuli in the Hospital
The investigator developed a model for studying the stimuli
that children perceive as stressful in the hospital environment,
A model is a hypothesis or tentative description of a phenomenon
based more on a hunch than on analysis. The model was educed
essentially from her interpretation of child development, counseling,
stress, perception, and hospitalization of children.
The model is based on three basic assumptions. The first
assumption is that hospitalization can result in "critical periods"
for children. Second, the hospital is a stressful environment for
all organisms that interact within the system. Third, there are
stimuli within the hospital which are stressful to children. These
stimuli influence children's perception and ultimately their behavior.
It follows that if it is possible to identify what children perceive 78 as stressful, then it may be possible to control or eliminate some of the stressors in their environment. The remaining stressors could be utilized to maximize the hospital experience
into a "critical period" which is conducive to children's optiminal development.
Lewin's field theory is the frame of reference for the
child's environment. In this theory the psychological environment
and the behaving self are interdependent components of the life
space. Life space refers to the manifold of coexisting facts
which determine the behavior of an individual at a certain moment.
Behavior is a function of life space which exists at the time
behavior occurs. Life space is a product of the interaction between
the person and his environment. The analysis begins with the
situation as a whole from which are differentiated the component p.rt.,169,170
In the model the child has various stimuli to which he may
attend and ultimately respond as inferred from his behavior. These
stimuli are classified into one of the following categories of
stressors« environmental, interpersonal, and intrapersonal. An
environmental stressor is a stimulus in the child's physical environ
ment which is perceived as stressful by the child. An interpersonal
^^Morton Deutsch, "Field Theory in Social Psychology," in Handbook of Social Psychology. Vol. I, ed, by Gardner Lindzey (Cambridge, Massachusetts! Addison-Wesley, 195*0» PP. 189-191.
l^Calvin S. Hall and Gardner Lindzey, Theories of Person ality (New York! John Wiley and Sons, 1957). pp. 206-256, stressor is a stimulus which occurs from the child's interaction with, or inability to have an interaction with, a hospital personnel.
An intrapersonal stressor is some aspect of the child's self that
is perceived as stressful by the child or stimuli which occur from
the child's interaction or inability to have an interaction with
his family and/or friends which is perceived as stressful by the
child.
The stimuli of which the child is cognizant are the potential
predictors of whether he perceives the stimuli to be stressful or
unstressful. If he perceives the stimuli to be stressful, there
are many possible responses that the child may utilize to cope
with them, depending upon his present stage of development. The
actual response(s) that he selects is considered the predictor(s),
The child’s actual behavior is an indirect measure of what he has
selected from the stimuli. If it were possible to know ahead of
time the predictor, then it would be possible to compare and modify
it with the criterion of desired behavior. The ultimate result
would be the modified desired behavior of the child. CHAPTER III
METHODOLOGY
This chapter presents the methodology or the Justification for the methods used in this study of children's perception of stimuli in the hospital. The methodology chapter consists of the following sections« research design, sample, measurement of stress, and statistical analysis of the data.
Research Design
The purpose of this study is to identify the stimuli that children perceive as stressful in the hospital. Concomitantly, the study is concerned with studying the relationship between certain selected variables and the stimuli that children perceive as stressful in the hospital. Ideally some type of experiment should be conducted in which subjects in a treatment group are exposed to stressful stimuli and subjects in a control group are not exposed to the stimuli (zero level of the treatment) with a comparison of
the responses of each group. However, children's perception of
stress in the hospital environment is a relatively unexplored
area of knowledge. Thus, an exploratory, descriptive design using
80 81 a variety of variables may be more heuristic than an experimental design using two or three variables. In addition, the nature of the study is more amenable to investigation in the natural environment than in the laboratory and to systematic observation of the variables rather than to direct manipulation of the variables.
A descriptive approach can serve as the "reconnaissance” phase in a new area where the intent is to identify variables which are most promising for experimental investigation.*
Descriptive studies do not provide a great deal of information
about the effects of variables as they provide no real evidence
of cause and effect; but they can provide information about 2 concomitants of causation. As the present study is exploratory,
this causality limitation is not of sufficient merit to prevent
using a descriptive approach. Thus an exploratory, descriptive,
cross-sectional design is used in this study.
Sample
The universe of the study consists of all children hos
pitalised during the period of time from April to October of
nineteen hundred, seventy one. The aim in any study is to select
1g. C. Helmstadter, Research Concepts in Human Behavior (New York; Appleton-Century-Crofts, 1970), p. 6 5 .
2Ibid., p. 6 9 . 82 a sample that is representative of the universe. Ideally in the present study, a random sample of hospitalized children would be selected where each child would have an equal probability of being a subject, but the impracticality, cost, and time, and the nature of the study influenced the use of another sampling method, a purposive sample that meets certain criteria. The advantages of purposive sampling are it may reduce cost and time and usually is convenient. The limitations of purposive sampling are that it may not yield a representative sample of the universej it can result in biased estimators of the variables studied} and theore tically generalizations cannot be made unless it can be justified that the sample actually represents the universe.
The population of the study consists of children hospitalized at either Children’s Hospital or Riverside Methodist Hospital in
Columbus, Ohio. It is assumed that the two hospitals are repre sentative of nongovernmental, non-profit institutions that offer short term hospitalization for children. Also it is assumed that
Children's Hospital is representative of hospitals which care only for children and that Riverside Methodist Hospital is representa tive of a general medical-surgical hospital which has a pediatric 3 unit. The American Hospital Association classified both as nongovernmental and non-profit hospitals. Both hospitals are classified as short stay since over fifty percent of all patients
^Hospitals. J.A.H.A. XLV (August 1, 1971), Part 2, p. 166. admitted stay less than thirty days. Children's Hospital serves only children, has a bed capacity of three hundred thirty-eight, and the average daily census is two hundred twenty. Riverside
Methodist Hospital is a general medical and surgical institution which has a bed capacity of seven hundred eighteen. The pediatric unit has a bed capacity of forty-two.
The sample of the study consists of one hundred and four children hospitalized at either Children's Hospital or Riverside
Methodist Hospital. The following criteria are used for selection of the samplei (l) The child is between the ages of four and twelve years of age; (2) This is the first hospitalization for his present illness; (3) The child has not been hospitalized more than three times; (k) The child's condition is not potentially terminal; (5)
The child's participation in the study will not be detrimental to his welfare; (6) Permission of the attending physician can be obtained; (7) Permission of the child can be obtained; and (8)
Written permission of the child's parent can be obtained.
The subjects were selected also in relation to the controlled variables of the study. The controlled or independent variables are age of the child, sex of the child, diagnosis, length of hospitali zation, preparation for hospitalization, and experience with
separation. The rationale underlying the classification of the
controlled variables will be presented. 84
Age
Age is divided into two categories on the basis of Piaget's theory of cognitive development. The child between the ages of four to seven years is in the preoperative phase of cognitive development, whereas, the child between the ages of seven and twelve years is in the concrete operational phase.
Sex
The classification of sex is self-explanatory.
Diagnosis
Diagnosis is divided into two categories— medical and surgical. The child is placed in the medical category if his diagnosis does not require him to have surgery. Examples of medical conditions include abdominal pain, fever of undetermined origin, and urinary infections or problems. The child is placed in the surgical category if he needs surgery. Examples of surgical conditions include appendicitis and compound fractured bones.
Length of Hospitalisation
Length of hospitalization is divided into two categories—
one to five days and six to fifteen days. The classification is
arbitrary. If at the time of participation in the study the child
has been hospitalized five days or less, he is placed in one 85 category. If the child has been in the hospital longer than five days he is placed in the other category.
Preparation
Preparation for hospitalization is divided into two categories— yes and no. The child's parent was interviewed to determine if the child was prepared prior to admission. If the child was prepared, he is placed in the yes categoryi otherwise, he is placed in the no category.
Separation
Experience with separation from the child's family is divided into two categories— yes and no. The child's parent was interviewed to determine if the child was previously separated from his family. Previous experience with separation means that the child was away from his parents at least two days. If the child has experience with separation, he is placed in the yes category?
otherwise, he is placed in the no category.
Description of the Sample
The sample consists of one hundred and four Caucasian
children. Sixty-one of the subjects were hospitalized at Children's
Hospital and the remaining forty-three subjects at Riverside
Methodist Hospital, Table 1 describes the sample according to
certain variables. 8 6
TABLE 1
DESCRIPTION OF THE SAMPLE
Variable
Age
4 - 7 years 44 42 7-12 years 60 58
Sex
Male 58 56 Female 46 44
Diagnosis
Medical 50 48 Surgical 54 52
Length of hospitalization
1 - 5 days 66 63 6-15 days 38 37
Preparation
Yes 5^ 52 No 50 48
Experience with separation
Yes 49 47 No 55 53
Previous hospitalization
Yes 50 48 No 5** 52 87
TABLE 1 — continued
Variable N i
Social class
Middle class 49 47 Working class 44 42 Not ascertained 11 11
Mother's role
At home 76 73 Works outside the home 28 27
Family status
Intact 92 88.5 Broken 12 11.5
Measurement of Stress
The variables in a research study must be capable of being
operationally defined. An operational definition is the means of
linking a concept to the empirical world so that it can be tested.
An operational definition indicates that certain phenomenon
exists and does so by specifying precisely how the phenomenon can 4 be measured, Stress is an intervening variable which can be only
indirectly related to the empirical world. Stress has been
^F. J. McGuigan, Experimental Psychology» A Methodological Approach (2nd ed.; Englewood Cliffs, New Jersey! Prentice-Hall, 1968), pp. 26-27. operationally defined many ways depending upon the specifio purposes with which it is assooiated. The most widely accepted types of operational definitions for the existence of stress are changes in physiological indices.5 Physiological indices are used even when the interest is in psychological stress. The under lying assumption is that certain environmental conditions induce not only overt behavioral effects but internal effeots as well.
Other operational definitions of stress include the individual's
response to a questionnaire, an interview, a scale, or a projective
test. The fact that the majority of techniques for measuring
stress are crude contributes to the problem of defining stress
operationally.
Stress needs to be operationally defined in terms of this
study's purpose. Ideally the investigator should use an operational
definition which has been used by other investigators and should
use two convergent operations. Each researcher's method of measuring
a concept should relate in some reasonable way to the work of other
researchers as well as to the history of that idea.^ However, as
there is no known instrument available that would be appropriate
to measure children's perception of stress in the hospital, an
^Mortimer H. Appley and Richard Trumbull, "On the Concept of Psychological Stress," in Psychological Stress ed. by Mortimer H. Appley and Richard Trumbull (New Yorki Appleton-Century-Crofts, 1967), p. 6.
^Robert Plutchik, Foundations of Experimental Research (New Yorki Harper and Row, 1966), p. 49. 89 instrument must be developed. The investigator developed a game to use as the instrument in this study,
A game is one means of getting a child to express his per ceptions since play is his natural mode of expression. Through play the child learns to master his environment, to come to under stand himself in relation to his environment, to deal with the stresses of daily living, to adapt himself to the demands society makes upon him, and to make satisfactory relations with the people 7 8 around him, Erickson contends that in play the child deals with life experiences which he attempts to repeat, to master, or to negate in order to organize his inner world in relation to his
outer world. Play is the ego's acceptable tool for self-expression
just as dreams afford expression for the id. Many factors influence
what the child does in a structured play situation, such as a game, Q Murphy and Krall7 state that:
,..what the child does in any play situation is influenced by the nature of the situation, the feeling tone and atmo sphere of it, the materials available, the child's feeling as he enters the situation, his expectations and assumptions regarding what he is allowed to do or is free to do, and the interaction between him and the examiner, however covert or open this may be.
^Eva Noble, Play and the Sick Child (London: Faber and Faber, 1967), p. 15.
®Henry W, Maier, Three Theories of Child Development (Revised ed.j New York: Harper and Row, 1969), p. 26. 9 Lois B, Murphy and Vita Krall, "Free Play as a Projective Tool," in Projective Techniques with Children ed. by Albert I, Rabin and Mary R. Haworth (New York: Grune and Stratton, i960), p. 291. 90
A projective technique is a method of obtaining a child's perceptions of a particular situation, and it is an instrument which is considered sensitive to covert aspects of behavior and which encourages a wide variety of responses by the subject. It is multidimensional and elicits a great quantity of data while 10 the subject has minimum awareness of the test's purpose. Some examples of projective-type instruments are doll play, the Rorschach, and the Thematic Apperception Test, Projective techniques have been used widely with children since investigators can obtain 11 12 data which is often otherwise unobtainable, Sigel contends that the child imposes his personal cognitive schema on stimulus materials and concomitantly reveals his inner thoughts, perceptions,
and attitudes about various aspects of his world. Some advantages
of projective techniques include; (l) the investigator can control
the stimulus materials and maintain the research conditions to a
greater degree than in the case of naturalistic observationsj (2)
the subjects cannot depend upon established, stereotyped patterns
of responses as the tasks are quite unstructured; (3) since the
^Gardner Lindsey, Projective Techniques and Cross-Cultural Research (New York; Appleton-Century-Crofts, 1961), p, 4-5,
^Irving Sigel, "The Application of Projective Techniques in Research with Children," in Projective Techniques with Children ed, by Albert I. Rabin and Mary R. Haworth (New York; Grune and Stratton, I960), p, 351. 12 Ibid. 91 subjects are unaware of the true purpose of the test their responses are unbiased; and (4) projective techniques make little 13 14 demands on literacy or academic skills. ' Some disadvantages of projective techniques includej (l) they are often considered
"grossly unscientific"; (2) there is an idioverse dominance; and
(3) it is difficult or impossible to establish either reliability ...... 15,16 or validity.
Interviewing is a more direct method of obtaining a child's perceptions in a particular situation. However, inter viewing depends upon the subject's ability to understand the questions and to verbalize his cognitions. An interview is a
two-person conversation initiated by the investigator for the 17 purpose of obtaining research-relevant information. According 18 to Cannell and Kahn measurement by interviewing involves
13 Sigel, "The Application of Projective Techniques in Research with Children," p. 351.
■^^*Robert L. Thorndike and Elizabeth Hagen, Measurement and Evaluation in Psychology and Education (3rd ed.; New Yorki John Wiley and Sons, 1969), pp. 504-505.
15Ibid.. pp. 506-516.
^Bernard I. Murstein, Theory and Research in Projective Techniques (New Yorki John Wiley and Sons, 1963), pp. 4-5,
^Charles F. Cannell and Robert L. Kahn, "Interviewing," in The Handbook of Social Psychology. Vol. II. ed, by Gardner Lindzey and Eliot Aronson (2nd ed.;Reading, Massachusetts; Addison-Wesley, 1968), p. 527.
l8Ibid.. p. 531. creating or selecting an interview schedule and a set of procedures for its use, conducting the interview, recording these responses, creating a numerical code, and coding the interview responses.
Some advantages of interviews include! (l) it is a method of obtaining an individual's perceptions or attitudes; (2) it is a direct, economical method of obtaining data from subjectsj and
(3) the method can be modified by the investigator when necessary.
Some possible disadvantages of using interviews include! (l) the inability or unwillingness of the subject to communicate; (2) the subject is not providing accurate information; and (3) the 19 investigator's characteristics influencing the subject's response.
However, some of the limitations of interviewing can be overcome through the skills and techniques of the interviewer and through
the interview instrument; and the knowledge of the analyst can
compensate to some degree for the biases, memory failures, and 20 inexpertness of the subjects.
The investigator developed a game to study children's
perceptions of stimuli in the hospital. The rationale underlying
the game is based upon the methodology of projective instruments
and of interviewing. The game consists of plastic cards with
*%elmstadter, Research Concepts in Human Behavior, p. 76.
Charles F, Cannell and Robert L. Kahn, "The Collection of Data by Interviewing,” in Research Methods in the Behavioral Sciences ed. by Leon Festinger and Daniel Katz (New Yorki Holt, Rinehart, and Winston, 1953)» p. 331. colored drawings of different stimuli related to a child's hospitalization. The cards present the following stimuli (each on a separate card): a boy, a girl, a mother, a father, a baby, a dog, a cat, a nurse, a doctor, a hospital gown, a hospital room, a hospital bed, food, medications, toys, a thermometer, a stetho- 21 scope, a house, and a school. These stimuli were selected on the basis of the investigator's theoretical framework. Also a group of five judges was asked to rate the stimuli as stressful or nonstressful for a hospitalized child. The judges were three doctoral students in counseling and child psychology and two registered nurses with experience working in pediatric units.
Approximately half of the stimuli were considered to be stressful by the judges. Table 2 presents the judges' ratings of the stimuli.
21 See Appendix A for the stimuli. TABLE 2
JUDGES' RATINGS OF THE STIMULI
Stimuli Stressful Nonstressful
N * B!
Boy 0 0 5 100
Girl 0 0 5 100
Mother 0 0 5 100
Father 0 0 5 100
Baby 1 20 4 80
Dog 0 0 5 100
Cat 0 0 5 100
Nurse 5 100 0 0
Doctor 5 100 0 0
Hospital gown 5 100 0 0
Hospital room 5 100 0 0
Hospital bed 4 80 1 20
Food 3 60 2 40
Medications 5 100 0 0
Toys 0 0 5 100
Thermometer 5 100 0 0
Stethoscope 3 6o 2 40
House 2 40 3 60
School 2 40 3 6o 95
The investigator talked with each child and one of his parents in order to solicit their cooperation. If they were willing to participate in the study, the investigator interviewed one of 22 the child's parents without the child being present. The purpose of the interview was to obtain some background information and to ask some questions about what the parent thought his child would consider stressful regarding his hospitalization.
The investigator played the game with each child in his hospital room. Usually this was done immediately after the parent's interview. However, sometimes it was necessary to wait until the next day for the game. Although, the same game format was used with each child, the length of time required to play the game varied from approximately an half-hour to an hour. This variation
can be attributed to the number of cards which the child was willing
to play and to the length of the child's responses to a particular
card.
The game format used with each child is as follows! I
am interested in learning how you feel about being in the hospital.
I would like to play a game with you. I have some cards which we
can play with if you are willing to play with me. (The cards are
shown to the child.) Are you willing to play with me? Also I
have this tape recorder which I want to turn on while we are playing|
if that is all right with you? Here are the cards which we can play
22 See Appendix B for Interview Schedule. with while we think about being in the hospital. Choose any card which you want to tell me about. What do you think of when you see the card? (The child responds.) The child selects another card and the same format is followed. If the child does not select all the cards, the investigator asks him if he wants to play with the remaining cards. If the child does not, the omissions are noted. Next the child is asked to answer these four questions!
(l) What do you like about being in the hospital? (2) What don't you like about being in the hospital? (3 ) What has bothered you the most about being in the hospital? and (h) Who have you missed
since being in the hospital?
A content analysis is done of each subject's responses to
the game with the responses being coded as stressful, nonstressful,
or no reaction. Stress is operationally defined as the responses
that the child gives to the stimuli in the game and questions
which connote a "stressful" perception. A child's response is
labelled as a "stressful" perception if any of the following words
are used: annoys, bothers, dislikes, disturbs, feels anxious, hate, 23 hurts, irritates, misses, threatens, uncomfortable, and upset,
A child's response is labelled as "nonstressful" if none of the
words connoting a "stressful" perception was used. A child's
23 'These words were selected to be indicative of stress as they are mentioned in the stress literature. The investigator asked a sample of ten non-hospitalised children what stress meant to them. The majority of these words were used by at least one of the children in their description of stress. response is labelled as Mno reaction" if the child did not play with the card. The subject's responses are labelled also according to the categories of stressors in the model--intrapersonal, inter personal, and environmental. An intrapersonal stressor is some aspect of the child's self that is perceived as stressful by the child or stimulus which occurs from the child's interaction or inability to have an interaction with his family and/or friends and which is perceived as stressful by the child. An interpersonal stressor is a stimulus which occurs from the child's interaction or inability to have an interaction with a hospital personnel and which is perceived as stressful by the child. An environmental stressor is a stimulus in the child's physical environment perceived as stressful by the child.
Statistical Analysis of the Data
The type of statistical analysis used in a research study
is dependent upon how the sample is obtained, how the variables are measured, and how the research hypotheses are stated. In any research
study, the investigator should use both a test of the degree of
relationship between the variables and a test of significance. The
degree of relationship between variables without a test of signi
ficance cannot be trusted, as it provides only a numerical quantity
for expressing the degree of association between the variables.
Likewise, a test of significance by itself is meaningless as it only informs the investigator if he had enough subjects to obtain
significant results.
The variables in this study can be categorized as discrete,
dichotomous variables. The research hypotheses pertaining to
these variables can be analyzed statistically through the use of
phi coefficients. A phi coefficient or a fourfold point correla
tion is a product moment correlational statistic that indicates
the relationship between two dichotomous variables. The assumptions
underlying the use of phi are that the two dichotomous variables
are discrete, the two categories of each variables are amenable to
appropriate representation by two point values, and one of the
variables is measured at either a nominal or an ordinal level. The
range of values for a phi coefficient is minus one to plus one.
The phi coefficient is influenced by the marginal totals in the
fourfold table. If the split in the variables is not almost
equal, the phi coefficient will be spuriously small. The formula
for the phi coefficient is
(^> = ______BC - AD______
(A+B)(C+D)Ca+C)“(B+D)
The phi coefficient is related to the chi-square statistic as
*X2 = Thus, a test of significance is available by using
the relationship of chi-square and phi. If the chi-square is
significant then it follows that the phi coefficient is 99
2 l f . 25 significant also. * The Wherry Test Selection Computer
Program for IBM 360 was used to obtain the phi coefficients in this study.
The relationship between the entire set of controlled variables and the dependent variable stress (the entire set of
stimuli in the game) can be analysed through the use of a canonical
correlation method.^6*27 ^ canonical correlation method uses a
group of variables to predict another group of variables. Canonical
correlation expresses, in a single index, the interrelation be
tween two sets of multiple variables. It is a method which
combines a multiple regression or multiple correlation technique
with a factor analysis technique, Canonical correlation is the
maximum correlation between linear functions of the two sets of
variables. It is based on the underlying concept of the principle
of least squares which minimizes the sum of squares of errors
around the regression line. Each pair of linear functions is
chosen so that the correlation between the new pair of canonical
Andrew R. Baggaley, Intermediate Correlational Methods (New Yorki John Wiley and Sons, 196*0, pp. 24-27.
^Quinn McNemar, Psychological Statistics (hth ed.j New Yorki John Wiley and Sons, 19&9), pp. 225-227.
^Robert J. Wherry, Sr., Unpublished book on Correlational Analysis. (Columbus, Ohiot The Ohio State University).
27william W. Cooley and Paul R. Lohnes, Multivariate Procedures for the Behavioral Sciences (New Yorki John Wiley and Sons, 1962), pp. 35-37. 100 variates is maximized. Each new pair of functions must be independent of previously derived linear combinations. Geome trically, the canonical correlation can be considered as a measure of the extent to which subjects occupy the same relative position in the p-dimensional space as they do in the q-dimensional space. There will be as many factors in canonical correlation as there are variables in the smaller set of variablesj however, not all of them will be statistically significant. The first canonical factor will have the highest eigenvalue and will yield the highest multiple R between the two sets of variables. It yields the maximum multiple R using the principle of least squares criterion.
The first canonical factor yields the best beta weights and con comitantly what the two sets of weighted variables predict best in common. Theother canonical factors will be lower and may or may not be interesting.
The first canonical factor can be tested for significance
through the use of lambda and a chi-square approximation. Lambda
( A) is defined asi
A =^(l -A/t) q < p
q = number of variables in one group
p = number of variables in the other group.
The chi-square approximation is defined asi
*]£ = -(n - .5 (p ♦ q + 1)| logAi df = pq. 101
The chi-square approximation provides a test of the null hypo thesis that the p variables are unrelated to the q variables. It is a test for the maximum correlation that can be obtained for the two groups of variables. If the null hypothesis is rejected, then a test of significance is done for the second canonical factor.
This process is continued until the null hypothesis can no longer be rejected. The formula for the general case of lambda is»
i S ^ (l - where r * number of roots removed.
The chi-square approximation for the general case isi
-|n - ,5 (p + q + 1)] log*' I df * (p - r)(q - r).
In order to use the canonical correlation method one must measure the variables at the interval level and assume linear functions
represent the relationships between the two sets of variables.
The variables in this study cannot be analysed through the
usual canonical correlation method as the two sets of variables
are measured at either the nominal or ordinal level. However, by
creating pseudovariables it is possible to obtain k-coefficients
which are a special case of canonical correlation. When data have
been collected at the nominal or ordinal level of measurement,
pseudovariables can be created. The variable must be capable of
being categorised into one of two classes in a discriminant
function type of framework. When working with pseudovariables, one must omit one variable during the analysis. Pseudovariables were created for the controlled variables and the stimuli in the game. By creating these pseudovariables and contending that a particular class has a mean, it is possible to develop a linear type of relation. The two sets of pseudovariables are analyzed by a canonical correlation method and R. J. Wherry, Jr. k-coefficients are obtained, K-coefficients are similar to regular canonical correlations. The underlying rationale for k-coefficients is the same as that of canonical correlation.
The first canonical factor yields the best canonical weights and concomitantly what the sets of weighted variables predict best in common. The other canonical factors will be lower and may or may not be interesting. The canonical factors can be tested for
significance through the use of lambda and the chi-square
approximation which is used for the canonical correlation method
previously described. Thus, by creating pseudovariables it is
possible to use variables to predict even though they do not look
as though they would be amenable to that type of mathematical
analysis. The CANN computer Program developed by Dr. Robert J.
Wherry, Sr. for the IBM J60 was used to obtain the k-coefficients
in this study. CHAPTER IV
ANALYSIS OF THE DATA
This chapter presents the data analysis. It consists of the following sections! identification of stressful stimuli, test of the research hypotheses, summary of the results, and discussion of the results.
Identification of Stressful Stimuli
The purpose of the study, to identify the stimuli that hospitalised children perceive as stressful, is accomplished by analysing the data collected from the game and the questions asked each subject.
Part of the analysis consists of the subject's responses to the nineteen stimuli in the game. Table 3 presents the subjects' responses to eaoh of the stimuli.
103 104 TABLE 3
SUBJECTS’ RESPONSES TO EACH STIMULI IN THE GAME
Stimuli Total number Total number Total number perceiving perceiving giving no stimuli as stimuli as reaction stressful nonstressful
Boy 26 45 33
Girl 30 41 33
Mother 25 79 0
Father 18 70 16
Baby 3 20 81
Dog 28 33 43
Cat 10 25 69
Nurse 18 86 0
Doctor 16 82 6
Hospital gown 50 44 10
Hospital room 12 90 2
Hospital bed 28 71 5
Food 27 76 1
Medications 86 17 1
Toys 0 100 4
Thermometer 48 52 4
Stethoscope 15 69 20
House 30 67 7
School 17 54 33 105
The stimulus, medications, Is perceived as stressful by the largest number of subjects. The stimulus, hospital gown, is perceived as stressful by the second largest number of subjects.
All the stimuli, except toys, is perceived as stressful by some of the subjects. Thus eighteen of the stimuli in the game are identified as stressful by some of the subjects.
Another part of the analysis consists of the subjects' responses to the questions. One of these questions asked what the subject did not like about being in the hospital. Ninety-nine of the subjects gave a response to the question. The other five subjects stated that they liked everything. Table k presents a frequency distribution of the subjects' responses to what they do not like in the hospital.
TABLE 4
FREQUENCY DISTRIBUTION OF SUBJECTS' RESPONSES TO
WHAT THEY DISLIKE IN THE HOSPITAL
Response (Stressor) Frequency shots, needles, injections **5 pain 10 confinement of staying in bed 9 mother not staying all night if 106
TABLE k — continued
Response (Stressor) Frequency blood tests 3 being in traction 3 having a broken bone 2 being away from home 2 wheelchair 2 doctors performing treatments 2
thermometer 2
bed 2
rest period 2
parents not being present continuously 1
being alone 1
feeling bored 1
not being able to see after surgery 1
not being able to walk 1
not getting better 1
nurses and doctors hurting me
being in the Intensive Care Unit 1
going to the Operating Room 1
being catherized 1
hospital rules 1 107
The most frequent response to what the children do not like about being in the hospital is shots, needles, and/or injeetions.
Experiencing pain and the confinement of staying in bed are the
second and third most frequent responses. In addition to the
stimuli in the game, eighteen different stimuli are identified
as stressful.
One of the questions was what bothered the subjects the most about being in the hospital. One hundred of the subjects
gave a response to the question. The other four subjects stated
that nothing bothered them about being in the hospital. Table
5 presents a frequency distribution of the subjects* responses to
what bothers them the most about being in the hospital,
TABLE 5
FREQUENCY DISTRIBUTION OF THE SUBJECTS* RESPONSES TO WHAT
BOTHERS THEM THE MOST ABOUT BEING IN THE HOSPITAL
Response (Stressor) Frequency
shots, needles, injections 30
confinement of staying in bed 15
pain 12
mother leaving 6 108
TABLE 5 ~ * continued
Response (Stressor) Frequency being away from home 5 sleeping at night 4 bed 4 having a broken bone 3 doctors doing treatments 2 having x-rays done 2 going to the Operating Room 2 suction equipment 2 being catherized 2 parents not being present continuously 1 being away from my friend 1
feeling bored 1
possibility of having surgery 1
missing my cat 1
nurses waking me up 1
having an enema 1
being in traction 1
rest period 1
thermometer 1
food 1 109
The most frequent response to what bothers the children the most about being in the hospital is shots( needles, and/or injections.
The confinement of staying in bed and experiencing pain are the second and third most frequent responses. In addition to the stimuli in the game and the responses to the first question, eight different stimuli are identified as stressful.
The last question is related to whom the subjects miss the most while they are in the hospital, Table 6 presents a frequency distribution of the subjects* responses to whom they miss the most,
TABLE 6
FREQUENCY DISTRIBUTION OF SUBJECTS* RESPONSES
TO WHOM THEY MISS THE MOST
Response (Stressor) Frequency sibling 31 parent 26 family 18
pet 11
friend 11 nobody 7 110
The most frequent response to whom the children miss the most is their siblings. The children's parents is the second most frequent response. Generally it can be concluded that the children miss a specific family member or their entire family whan they are in the hospital.
Another part of the analysis consists of the subjects' responses to both the game and the questions. Each subjects' responses are coded according to the three categories of stressors— intrapersonal, interpersonal, and environmental.
Table 7 presents a frequency distribution for the number of intrapersonal stressors identified by each subject. The mean number of intrapersonal stressors identified by the sample is
2.5^8 or 2.55.
TABLE 7
FREQUENCY DISTRIBUTION OF NUMBER OF INTRAPERSONAL
STRESSORS IDENTIFIED BY EACH SUBJECT
Number of Stimuli Frequency
7 2 6 0 5 11 if 10 3 22 2 29 1 27 0 3 Ill
Table 8 presents a frequency distribution for the number of inter personal stressors identified by each subject. The mean number of interpersonal stressors identified by the sample is sero,
TABLE 8
FREQUENCY DISTRIBUTION OF NUMBER OF INTERPERSONAL
STRESSORS IDENTIFIED BY EACH SUBJECT
Number of Stimuli Frequeney
2 8 1 20 0 76
Table 9 presents a frequency distribution for the number of environmental stressors identified by each subject. The mean number of environmental stressors identified by the sample is
3.1057 or 3.11. 112
TABLE 9
FREQUENCY DISTRIBUTION OF THE NUMBER OF ENVIRONMENTAL
STRESSORS IDENTIFIED BY EACH SUBJECT
Nuaber of Stimuli Frequency
9 1 8 2 7 3 6 5 5 8 i* 18 3 20 2 32 1 11 0 1*
Table 10 presents a frequency distribution for the total number
of stressors identified by each subject. The mean number of
stressors identified by the sample is 5.95. The median number
of stressors is 5.6^, 113 TABLE 10
FREQUENCY DISTRIBUTION OF THE TOTAL NUMBER
OF STRESSORS IDENTIFIED BY EACH SUBJECT
Number of Stimuli Frequency
16 1 14 1 13 1 12 4 10 2 9 6 8 10 7 15 6 14 5 12 4 18 3 13 2 7
In conclusion, forty-four different stimuli are identified as stressful by the sample. The stimuli which are perceived by the largest number of children as stressful include medications, needles, hospital gowns, and thermometers. Stimuli related to the children's family and home are peroeived as stressful by approxi mately a quarter of the sample. Likewise, hospital beds and hospital food are perceived as stressful by approximately a quarter of the sample. In answer to what bothers hospitalized
children the most, needles and injections rank first, followed by
experiencing pain and being confined to bed. The mean number of stressors identified by the sample is 5.95. In relation to the m three categories of stressors, the mean numbers respectively are
3.11 for environmental stressors, 2.55 for intrapersonal stressors, and zero for interpersonal stressors.
Test of the Research Hypotheses
In addition to identifying the stimuli that hospitalized children perceive as stressful, the study is concerned with seven research hypotheses related to the controlled variables used in this study. The ,05 level of significance is used as the criterion to either reject or fail to reject the null hypotheses. The data analysis is presented in terms of the research hypotheses related to the six controlled variables— age, sex, diagnosis, length of hospitalization, preparation, and experience with separation,
Ago
The research hypothesis pertaining to age is«
Hypothesis I. There i3 a relationship between the stimuli that children perceive as stressful in the hospital and the age of the children. Children between the ages of four and seven perceive different stimuli as stressful in the hospital as compared with children between the ages of seven and twelve.
Table 11 enumerates the phi coefficients and chi-squares for
each of the nineteen stimuli in the game and the total number of
stressors perceived by the subjects. Two of the nineteen stimuli 115 TABLE 11
SUMMARY OF PHI COEFFICIENTS AND CHI-SQUARES
FOR SUBJECT'S AGE AND STIMULI
Stimuli Phi Coefficient Chi-square N
Boy -.05835 .2417 71
Girl .26986* 5.1638* 71
Mother .10999 1.2667 104
Father -.05056 .2266 89
Baby .00000 .0000 23
Dog -.37562** 6.9613** 61
Cat .00000 .0000 35
Nurse .01978 .0407 104
Doctor .19487 3.7219 98
Hospital gown -.03221 .0976 94
Hospital room .05059 .2611 102
Hospital bed .05070 .2563 99
Food .06542 .4409 103
Medications -.00511 .0027 103
Toys .00000 .0000 100
Thermometer .03405 .1160 100
Stethoscope .02317 .0451 84
House -.02030 .0402 97
School .00000 .0000 71
Total stressors -.03300 .1130 104
*p< .05 **p<.01 116 have statistically significant phi coefficients and chi-squares.^
The stimulus, girl, has a phi coefficient of .26986 and a chi-square of 5.1638 which are statistically significant at the
.05 level. The phi coefficient of .26976 indicates that there is a low correlation between the age of the child and his perception of the stimulus. Table 12 presents the contingency table for the stimulus, girl, and the subject's age. It can be concluded that there is a relationship between the child's age and his perception of the girl. There is a significant difference regarding how the child perceives the stimulus, girl, as a function of his age. In this sample, a child between the ages of four and seven years is more likely to perceive the stimulus of girl as stressful than is a child between the ages of seven and twelve years.
TABLE 12
CONTINGENCY TABLE FOR THE STIMULUS, GIRL,
AND THE SUBJECT'S AGE
Stressful Nonstressful
4 - 7 years old 16 11
7-12 years old 14 30
Phi = .269861 Chi-square = 5 .1638* p < .05
Only the contingency tables for the significant stimuli are presented in this chapter. The contingency tables for the other stimuli are found in Appendix C. 117
The stimulus, dog, has a phi ooefficient of -.37562 and a chi-square of 6,9613 which are statistically significant at the ,01 level. The phi coefficient of -,37562 indicates that there is a relatively low correlation between the child’s age and his percep tion of the stimulus. Table 13 presents the contingency table for the stimulus, dog, and the subject’s age. It can be concluded that there is a relationship between the child’s age and his perception of the dog. As a function of the child’s age there is a difference in how he perceives the stimulus of dog. In the sample, a child between the ages of seven and twelve is more likely to perceive the stimulus of dog as stressful than is a child between the ages of four and seven years,
TABLE 13
CONTINGENCY TABLE FOR THE STIMULUS, DOG,
AND THE SUBJECT’S AGE
Stressful______Nonstressful
4 - 7 years old 6 18
7-12 years old 22 15
Phi * -.37562; Chi-square = 6,9613; p<,01 118
The overall findings of this part of the study lend support to the idea that the variable, child*s age, does not influence significantly what stimuli he perceives as stressful in the hospital. This conclusion is based on the finding that only two of the nineteen stimuli yielded statistically significant phi coefficients and chi-squares. Similarly, the phi coefficient and chi-square were nonsignificant for the total number of stressors
perceived by the children. In terms of probability theory, the
two significant stimuli could be attributed to chance alone. Thus
the hypothesis that there is a relationship between the stimuli
that children perceive as stressful in the hospital and the age
of the children cannot be accepted. It must be concluded on the
basis of this study that the relationship between the stimuli
that children perceive as stressful in the hospital and the age of
the children does not differ significantly from sero. Children
between the ages of four and seven do not perceive different
stimuli as stressful in the hospital as compared to children
between the ages of seven and twelve. The overall findings of
this part of the study could be due to a true laek of relation
ship between child's age and his perception of stimuli in the
hospital, to confounding variables, or to failure of the measuring
instrument to discriminate between the two age groups.
Some of the findings lend support to the theoretical
viewpoint that the sources of stress in hospitalisation may be
merely different for children of different ages. The two statistically significant stimuli lend support to this viewpoint since the findings for the stimulus, girl, showed more ohildren in the four to seven year old age range perceiving it as stressful than did those in the seven to twelve year old age range. In contrast, the findings for the stimulus, dog, showed more ohildren in the seven to twelve year old age range perceiving it as stressful in comparison to the four to seven year old age range. Also the finding that there was no statistically significant relationship between nor difference in the total number of stressors perceived by the children as a function of age lends support to the view point that the sources of stress in hospitalization are merely different for children of different ages. Thus, these findings regarding children's age and their perception of stimuli in the 2 3 hospital are consistent with the findings of both Blom and Prugh.
Sex
The research hypothesis pertaining to sex is»
Hypothesis II. There is a relationship between the stimuli that children perceive as stressful in the hospital and the sex of the children. Male and female children perceive different stimuli as stressful in the hospital.
Table 14 enumerates the phi coefficients and chi-squares
2 Gaston E, Blom, "The Reactions of Hospitalized Children to Illness," Pediatrics XXII (September, 1958)» pp. 594-596,
*Dane G. Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness," American Journal of Orthopsychiatry XXIII (January, 1953). pp. 70-103. 120 TABLE 14
SUMMARY OP PHI COEFFICIENTS AND CHI-SQUARES
FOR SUBJECT'S SEX AND STIMULI
Stimuli Phi Coefficient Chi-square N
Boy .02899 .0599 71
Girl -.08474 .5099 71
Mother .04472 .2388 104
Father -.00563 .0028 89
Baby .00000 .0000 23
Dog .29099* 5.1652* 61
Cat .07199 .1842 35
Nurse .20272* 4.2743* 104
Doctor .06569 .4230 98
Hospital gown -.00545 .0028 94
Hospital room .01129 .0120 102
Hospital bed .09780 .9471 99
Food .15310 1.8995 103
Medications .02253 .0523 103
Toys .00000 .0000 100
Thermometer .06437 .4144 100
Stethoscope .11152 1.0447 84
House -.09049 .7944 97
School .06335 .2850 71
Total stressors .07302 .55^ 104
*p <.05 121 for each of the nineteen stimuli in the game and the total number of 3tressors perceived by the subjects. Two out of the nine teen stimuli have statistically significant phi coefficients and chi-squares.
The stimulus, dog, has a ohi coefficient of ,29099 *nd a chi-square of 5•1652 which are statistically significant at the
.05 level. The phi coefficient of .29099 indicates that there is a low correlation between the sex of the child and his perception of the stimulus. Table 15 presents the contingency table for the stimulus, dog, and the subject's sex. It can be concluded that there is a relationship between the sex of the child and his per ception of the dog. As a function of his sex, there is a difference
in how the child perceives the stimulus. In this sample, males are more likely to perceive the stimulus of dog as stressful than are
females.
TABLE 15
CONTINGENCY TABLE FOR THE STIMULUS, DOG,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 20 1^
Female 8 19
Phi * .290991 Chi-square = 5.l652» p<,05 122
The stimulus, nurse, has a phi coefficient of .20272 and a chi-square of 4.2?43 which are statistically significant at the
.05 level. The phi coefficient of .20272 lndloates that there is a low correlation between the child's sex and his perception of the stimulus. Table 16 presents the contingency table for the stimulus, nurse, and the sex of the subject. It can be concluded that there is a relationship between the sex of the child and his perception of the nurse. There is a significant difference
regarding how the child peroeives the nurse as a function of his
sex. In this sample, males are more likely to perceive the stimulus
of nurse as stressful than are females,
TABLE 16
CONTINGENCY TABLE FOR THE STIMULUS, NURSE,
AND THE SUBJECT'S SEX
Stressful Nonstressfol
Male 14 44
Female 4 42
Phi * ,20272j Chi-square * 4.2743» p C.05 The overall findings of this part of the study lend
support to the idea that the variable, the sex of the child, does not influence significantly what stimuli he perceives as stressful
in the hospital. This conclusion is based on the finding that only
two of the nineteen stimuli yielded statistically significant phi
coefficients and chi-squares. Concomitantly, the phi coefficient
and chi-square are nonsignificant for the total number of stressors
perceived by the children. In terms of probability theory, the
two significant stimuli could be attributed to chanoe alone. Thus,
the hypothesis that there is a relationship between the stimuli that
children perceive as stressful in the hospital and the sex of the
children cannot be accepted. It must be concluded on the basis of
this study that the relationship between the stimuli that children
perceive as stressful in the hospital and the sex of the children
does not differ significantly from zero. Thus, male and female
children do not perceive different stimuli as stressful in the
hospital. The overall findings of this part of the study could be
due to a true lack of relationship between the variables, to con
founding variables, or to the failure of the measuring instrument
to discriminate between the two groups. The overall findings of
the study of no significant relationship and differences between
male and female children and their perceptions of stimuli in the 124 r hospital a n consistent with the findings of Prugh and Blom.''
The significant findings for the two stimuli, dog and nurse, are inconsistent with the overall findings of this part of the study. The findings for both stimuli are contradictory to the literature, Kagan,^ Sarason,^ and Phillips® predict that more females would perceive the stimuli as stressful. The finding of more males perceiving the stimuli as stressful is contradictory to the findings of Illingsworth's and Holt's^ study and Shirley's and Poyntz's*^ study, Illingsworth's and Holt's study found that
^Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness," p, 80.
'’Blom, "The Reactions of Hospitalized Children to Illness," pp. 594-596.
^Jerome Kagan, "Acquisition and Significance of Sex Typing and Sex Role Identity," in Review of Child Development Research. Vol. I. ed. by Martin L. Hoffman and Lois Wladis Hoffman (New York1 Russell Sage Foundation, 1964), pp. 142-143.
?Seymour B. Sarason, et al.. Anxiety in Elementary School Children (New Yorki John Wiley and Sons, 19^0), p. 254.
®Beeman N. Phillips, An Analysis of Causes of Anxiety Among Children in School (Austin, Texas 1 University of Texas, 1966), p» 20#
% . S. Illingsworth and K. S. Holt, "Children in Hospitalt Some Observations on Their Reactions with Special Reference to Daily Visiting," The Lancet. CCLXIX (December 17, 1955)* pp. 1258- 1259.
l®Kary M. Shirley and Lillian Poyntz, "Children's Emotional Responses to Health Examinations," Child Develoanent. XVI (March- June, 1945), pp. 89-95. 125 for children one to four years old males appeared to be more upset, for children five to six years old there was no difference between males and females, and for children seven to fourteen years old females appeared to be more upset. In Shirley's and
Poyntz's study, the finding was that males were less often upset than females. The findings in the present study that contradict those in Illingsworth's and Holt's study and Shirley's and
Poyntz's 3tudy could be due to the fact that different dependent variables are used, that age groups are classified differently,
that different statistical tests are used, or that a true con
tradiction does exist.
Diagnosis
The research hypothesis pertaining to diagnosis is«
Hypothesis III. There is a relationship between the stimuli that children perceive as stressful in the hospital and their diagnosis. Children hospitalized for a medical condition perceive different stimuli as stressful compared with children hospitalized for a surgical condition.
Table 17 enumerates the phi coefficients and chi-squares
for each of the nineteen stimuli in the game and the total number
of stressors perceived by the subjects. Two of the nineteen
stimuli have statistically significant phi coefficients and
chi-squares. 126 TABLE 17
SUMMARY OF PHI COEFFICIENTS AND CHI-SQUARES
FOR SUBJECT’S DIAGNOSIS AND STIMULI
Stimuli Phi Coefficient Chi-square N
Boy -.02637 .0494 71
Girl .03608 .0929 71
Mother .13424 1.8742 104
Father .11755 1.2299 89
Baby .00000 .0000 23
Dog -,25432* 3.9457* 61
Cat .32645 3.7303 35
Nurse .06847 .4877 104
Doctor .02709 .0719 98
Hospital gown -.03994 .1500 94
Hospital room -.05370 .2942 102
Hospital bed -.12825 1.6279 99
Food -.00474 .0023 103
Medications -.20489* 4.3242* 103
Toys .00000 .0000 100
Thermometer -.15084 3.2754 100
Stethoscope -.12244 1.2590 84
House -.01755 .0299 97
School -.14583 1.5107 71
Total stressors -.07554 .5937 104
*p<.05 12?
The stimulus, dog, has a phi coefficient of -.25432 and a chi-square of 3.9457 which are statistically significant at the
,05 level. The phi coefficient of -.25*02 indicates that there is a low correlation between the child’s diagnosis and his per ception of the stimulus. Table 18 presents the contingency table for the stimulus, dog, and the subject's diagnosis. It can be concluded that there is a relationship between the child's diagnosis and his perception of the dog. As a function of his diagnosis, there is a difference in how the child perceives the stimulus.
In this sample, a child hospitalized with a surgical condition is more likely to perceive the stimulus of dog as stressful than is a child hospitalized with a medical condition.
TABLE 18
CONTINGENCY TABLE FOR THE STIMULUS, DOG,
AND THE SUBJECT'S DIAGNOSIS
Stressful Nonstressful
Medical 9 19
Surgical 19 14
Phi = -.25432» Chi-square = 3.9457» P<.05 The stimulus, medications, has a phi coefficient of
-.20489 and a chi-square of 4.33242 whioh are statistically significant at the .05 level. The phi coefficient of -.20489 indicates that there is a low correlation between the ohild's diagnosis and his perception of the stimulus. Table 19 presents the contingency table for the stimulus, medioations, and the
subject's diagnosis. It can be concluded that there is a relation
ship between the child's diagnosis and his perception of medications.
As a function of his diagnosis, there is a difference in how the child perceives the stimulus. In this sample, a child hospitalised with a surgical condition is more likely to perceive the stimulus
of medications as stressful than is a child hospitalised with a
medical condition.
TABLE 19
CONTINGENCY TABLE FOR THE STIMULUS, MEDICATIONS,
AND THE SUBJECT'S DIAGNOSIS
Stressful______Nonstressful
Medical 37 12
Surgical 49 5
Phi * -,20489i Chi-square = 4,3242% p <.05 129
The overall findings of this part of the study lend support to the idea that the variable, the child's diagnosis, does not influence what stimuli he perceives as stressful ir. the hos pital. This conclusion is based on the finding that only two of the nineteen stimuli yielded statistically significant phi coeffi cients and chi-squares. Likewise, the phi coefficient and chi-square were nonsignificant for the total number of stressors perceived by the children. In terms of probability theory, the two significant stimuli could be attributed to chance alone. Thus, the hypothesis that there is a relationship between the stimuli that children perceive as stressful in the hospital and the diagnosis of the children cannot be accepted. It must be concluded that the
relationship between the stimuli that children perceive as stress
ful in the hospital and the diagnosis of the ohildren does not differ significantly from sero. Children hospitalised for a
medical condition do not perceive different stimuli as stressful
in comparison with children hospitalised for a surgical condition.
The overall findings of this part of the study could be due to a
true lack of relationship between the two variables, to confounding
variables, or to failure of the measuring instrument to discriminate
between the two groups.
The significant findings for the two stimuli, dog and
medications, are contradictory to the overall findings of this
part of the study. The findings for both stimuli are that child
ren with surgical conditions are more likely to perceive the 130 stimuli as stressful than are ohildren with medical conditions.
The lack of other relevant reported studies makes it difficult to draw conclusions about the significant findings. The signifi cant finding for the stimulus, medications, may be attributed to the fact that the children with surgical conditions have experiences different from those of the children with medical conditions. The children with surgical conditions may have received more medications, especially injections, than have the children with medioal conditions.
Length of Hospitalisation
The research hypothesis pertaining to length of hospitalisa
tion is i
Hypothesis IV, There is a relationship between the stimuli that children perceive as stressful in the hospital and the length of time the ohildren are hospitalised. Children hospitalised for less than five days perceive different stimuli as stressful compared with children hospitalised more than five days.
Table 20 enumerates the phi coefficients and chi-squares
for each of the nineteen stimuli in the game and the total number
of stressors perceived by the subjects. Three of the nineteen
stimuli have statistically significant phi coefficients and
chi-squares. Concomitantly, the phi coefficient and chi-square
for the total number of stressors peroelved by the subjeots are
statistically significant. TABLE 20
SUMMARY OF PHI COEFFICIENTS AND CHI-SQUARES FOR SUBJECT'S
LENGTH OF HOSPITALIZATION AND STIMULI
Stimuli Phi Coefficient Chi-square N
Boy -.07486 .3979 71
Girl -.24959* 4.4231* 71
Mother .14647 2.2314 104
Father -.10305 .9186 89
Baby .00000 .0000 23
Dog -.30156* 5.5473* 61
Cat .00000 .0000 35
Nurse -.25397* 5.6683* 104
Doctor -.16885 2.7833 98
Hospital gown -.06360 .3804 94
Hospital room -.04095 .1711 102
Hospital bed -.08470 .7114 99
Food -.00170 .0003 103
Medications -.06746 .4895 103
Toys .00000 .0000 100
Thermometer .04170 .1739 100
Stethoscope .01164 .0114 84
House -.17849 3.0903 97
School -.15504 1.7067 71
Total stressors -.19250* 4.1554* 104
*p <.05 132
The stimulus, girl, has a phi coefficient of -.24959 and a chi-square of 4.4231 which are statistically significant at the
,05 level. The phi coefficient of -.24959 indicates that there is a low correlation between the length of time the child has been hospitalized and his perception of the stimulus. Table 21 presents the contingency table for the subject's length of hospitalisation and the stimulus, girl. It can be concluded that there is a relationship between the length of the child's hospitalization and his perception of the girl. As a function of the length of his hospitalization, there is a difference in how the child perceives the stimulus. In this sample, a child hospitalized for more than
five days is more likely to perceive the stimulus of girl as
stressful than is a child hospitalized for less than five days.
TABLE 21
CONTINGENCY TABLE FOR THE STIMULUS, GIRL, AND THE
SUBJECT'S LENGTH OF HOSPITALIZATION
Stressful Nonstressful
Less than 5 days 13 28
More than 5 days 17 13
Phi * -.249591 Chi-square = 4.4231* p<.05 The stimulus, dog, has a phi eoeffieient of -.30156 and a chi-square of 5.5^73 which are statistically significant at the ,05 level. The phi coefficient of -.30156 indicates that there is a low correlation between the length of tine the child has been hospitalized and his perception of the stimulus. Table 22 presents the contingency table for the subject's length of hospitalization and the stimulus, dog. It canbe concluded that there is a relation ship between the length of the child's hospitalization and his perception of the dog. As a function of the length of his hospital ization, there is a difference in how he perceives the stimulus.
In this sample, a child hospitalized for more than five days is more likely to perceive the stimulus of dog as stressful than is a child hospitalized for less than five days,
TABLE 22
CONTINGENCY TABLE FOR THE STIMULUS, DOG, AND THE
SUBJECT'S LENGTH OF HOSPITALIZATION
Stressful______Nonstresaful
Less than 5 days 13 25
More than 5 days 15 8
Phi = -,30156| Chi-square = 5.5^73* p ^ .05 13*»
The stimulus, nurse, has a phi coefficient of -.25397 end a chi-square of 5.6603 which are statistically significant at the
,05 level. The phi coefficient of -.25397 indicates that there is a low correlation between the length of time the child has been hospitalised and his perception of the stimulus. Table 23 presents the contingency table for the subject's length of hospitalisation and the stimulus, nurse. It can be concluded that there is a relationship between the length of the child's hospitalisation and his perception of the nurse. As a function of the length of his hospitalization, there is a difference in how he perceives the stimulus. In this sample, a child hospitalized for more than five days is more likely to perceive the stimulus of nurse as stressful than is a child hospitalized for less than five days.
TABLE 23
CONTINGENCY TABLE FOR THE STIMULUS, NURSE, AND THE
SUBJECT'S LENGTH OF HOSPITALIZATION
Stressful Nonstressful
Less than 5 days 7 59
More than 5 days 11 27
Phi = -.25397» Chi-square * 5.6683» p < . 0 5 The total number of stressors perceived by each subject
has a phi coefficient of -.1925 and a chi-square of k ,i5 5 kwhich
are statistically significant at the ,05 level. The phi coefficient
of -.1925 indicates that there is a low correlation between the length of time the child has been hospitalised and the total
number of stressors he perceives as stressful in the hospital
environment. Table 2k presents the contingency table for the
subject's length of hospitalisation and his total number of
stressful stimuli. It can be concluded that there is a relationship
between the length of the child's hospitalisation and the total
number of stimuli he perceives as being stressful. As a function
of the length of his hospitalisation, there is a difference in
the total number of stimuli that he perceives as being stressful.
In this sample, a child hospitalised for more than five days is
more likely to perceive more stimuli as stressful than is a child
hospitalized for less than five days.
TABLE 2k
CONTINGENCY TABLE FOR THE TOTAL NUMBER OF STRESSFUL STIMULI
AND THE SUBJECT'S LENGTH OF HOSPITALIZATION
Less than 6 stimuli More than 6 atinml^
Less than 5 days 37 29
More than 5 days 13 25
Phi = -,1925l Chi-square = ^.155^1 p^#05 136
The overall findings of this part of the study lend some support to the idea that the variable, length of hospitalisation, does influence what stimuli the child perceives as stressful in the hospital. This conclusion is based on the finding that three of the nineteen stimuli yielded statistically significant phi coefficients and chi-squares. The phi coefficient and chi-square were significant for the total number of stressors perceived by the children as a function of their length of hospitalisation. In terms of probability theory, the four significant stimuli could not be attributed to chance alone. Thus, the hypothesis that there is a relationship between the stimuli that children perceive as stress ful in the hospital and the length of time the children are hospitalized is accepted. The relationship between the stimuli that children perceive as stressful in the hospital and the length of time the children are hospitalized differs significantly from zero
for some of the stimuli used in this study. The findings for all
four of the significant phi coefficients and chi-squares empirically
showed that children hospitalized for more than five days perceived
the stimuli differently from children hospitalized for less than
five days. Similarly, two of the other stimuli which are statis
tically significant at the ,10 level have the same trend. The
two stimuli are doctor and house. In this sample, children who
have been hospitalized for more than five days are more likely to
perceive stimuli as stressful than are children hospitalized for
less than five days. The findings of this part of the study regarding the relationship of the variable, length of hospitalisation, and the children's perception of stimuli in the hospital environment are inconsistent with those of some other studies. However, in these studies different dependent variables were used, Prugh's** study found no correlation between the length of hospitalization and the degree of reaction or adjustment to the experience. In Illings- 12 worth's and Holt's study, they found that the incident of upset decreases as a function of time. Likewise, Vernon et al.,13 in their review of hospitalization as psychologically upsetting to children, reported some studies which support that children are less upset as length of time in the hospital is increased. The inconsistency of the present study with these studies may be attributed to the fact that different dependent variables are used.
As the length of time increases, the unfamiliarity of the hospital
should decrease and accordingly the number of stressful stimuli
should decrease. However, the children may perceive more stimuli
as stressful as the length of hospitalization increases sinee they
**Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness," pp. 83-8^.
^niingsvorth and Holt, "Children in Hospital! Some Observations on Their Reactions with Special Reference to Daily Visiting," p. 1260,
l^David T. A. Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness (Springfield. Illinois! Charles C. Thomas, 1965), pp. ^l-1^, 51# 138 may have more experiences which are potentially stressful in comparison with children who have been hospitalized less than five days. Similarly, the stimuli of the girl and of the dog may be more likely to be perceived as stressful because a longer period of time has passed for the children to miss their siblings and pets. The stimulus of nurse may be more likely to be perceived as stressful since the longer the children are in the hospital the greater the probability of the children experiencing an inter personal stressor with the nurse. On the other hand, the finding that children who have been hospitalized for more than five days are more likely to perceive stimuli as stressful than are children hospitalized for less than five days may be idiosyncratic to this particular sample.
Preparation
The research hypothesis pertaining to preparation isi
Hypothesis V. There is a relationship between the stimuli that children perceive as stressful in the hospital and their preparation for hospitalization. Children who are prepared for their hospitalization perceive different stimuli as stressful compared with children who are not prepared.
Table 25 enumerates the phi coefficients and chi-squares
for each of the nineteen stimuli in the game and the total number
of stressors perceived by the subjects. Two of the nineteen stimuli
have statistically significant phi coefficients and chi-squares.
Concomitantly, the phi coefficient and chi-square for the total TABLE 25 139
SUMMARY OF PHI COEFFICIENTS AND CHI-SQUARES FOR
SUBJECT'S PREPARATION AND STIMULI
Stimuli Phi Coefficient Chi-square N
Boy .02630 .0494 71
Girl .04498 .1437 71
Mother .00030 .0001 104
Father .01630 .0239 89
Baby .00000 .0000 23
Dog -.17264 1,8181 61
Cat .03652 .0467 35
Nurse -.27196** 7.6922** 104
Doctor -.17469 2.9909 98
Hospital gown .00270 .0007 94
Hospital room -.13614 1.8905 102
Hospital bed -.18577 3.4168 99
Food -.1836? 3.4750 103
Medications .14377 2.1292 103
Toys .00000 .0000 100
Thermometer -.08006 .6410 100
Stethoscope -.09322 .7301 84
House -.25125* 5.1297* 97
School -.07047 .2526 71
Total stressors -.27111** 7.6441** 104
*P<.05 **p<.01 140 number of stressors perceived by the subjects are statistically significant.
The stimulus, nurse, has a phi coefficient of -.27196 and a chi-square of 7.6922 which are statistically significant at the ,01 level. The phi coefficient of -.27196 indicates that there
is a low correlation between the child's preparation for hospitalisa tion and hi3 perception of the stimulus. Table 26 presents the contingency table for the subject's preparation and the stimulus, nurse. It can be conoluded that there is a relationship between
the child's preparation and his perception of the nurse. As a
function of his preparation for hospitalisation, there is a difference in how the child perceives the stimulus. In this
sample, a child who is not prepared for his hospitalisation is more likely to perceive the stimulus of nurse as stressful than
is a child who is prepared,
TABLE 26
CONTINGENCY TABLE FOR THE STIMULUS, NURSE,
AND THE SUBJECT'S PREPARATION
Stressful Nonstressful
Prepared 4 50
Not prepared 14 36
Phi = -,27196} Chi-square = 7.6922} pC.Ol 141
The stimulus, house, has a phi coefficient of -.25126 and a chi-square of 5.1295 which are statistically significant at the
.05 level. The phi coefficient of -.25126 indicates that there is a low correlation between the child's preparation for hospitalisa tion and his perception of the stimulus. Table 27 presents the contingency table for the subject's preparation and the stimulus, house. It can be concluded that there is a relationship between the child's preparation and his perception of the house. As a function of his preparation for hospitalization, there is a difference in how the child perceives the stimulus. In this sample, a child who is not prepared for his hospitalization is more likely to perceive the stimulus of house as stressful than is a child who is prepared.
TABLE 2?
CONTINGENCY TABLE FOR THE STIMULUS, HOUSE,
AND THE SUBJECT'S PREPARATION
Stressful Nonstressful
Prepared 10 39
Not prepared 20 28
Phi = -.25126} Chi-square = 5.1295* P^.05 142
The total number of stressors perceived by each subject has a phi coefficient of -.27111 and a chi-square of 7.6441 which are statistically significant at the .01 level. The phi coefficient of -.27111 indicates that there is a low correlation between the child's preparation for hospitalization and the total number of stressors he perceives as stressful in the hospital environment.
Table 28 presents the contingency table for the subject's prepara tion and the total number of stimuli he perceives as being stressful.
As a function of his preparation for hospitalization, there is a difference in the total number of stimuli that he perceives as being stressful. In this sample, a child who is not prepared for his hospitalization is more likely to perceive more stimuli as stressful than is a child who is prepared.
TABLE 28
CONTINGENCY TABLE FOR THE TOTAL NUMBER OF STRESSFUL STIMULI
AND THE SUBJECT'S PREPARATION
Less than 6 stimuli More than 6 stimuli
Prepared 21 33
Not prepared 33 17
Phi = -.27111} Chi-square = 7.6441} p < . 0 1 1^3
The overall findings of this part of the study lend some support to the idea that the variable, preparation for hospitalisa tion, does influence what stimuli the child perceives as stressful in the hospital. This conclusion is based on the finding that two of the nineteen stimuli yielded statistically significant phi coefficients and chi-squares. Likewise, the phi coefficient and chi-square were significant for the total number of stressors perceived by the children as a function of their preparation for hospitalization. In terms of probability theory, the three
significant stimuli could not be attributed to ohance alone.
Thus, the hypothesis that there is a relationship between the
stimuli that children perceive as stressful in the hospital and
their preparation for hospitalization is accepted. This relation
ship differs significantly from zero for some of the stimuli used
in this study. The findings for all three of the significant phi
coefficients and chi-squares empirically showed that children who
are prepared for their hospitalization perceive the stimuli
differently from children who are not prepared. Similarly, three
of the other stimuli which are statistically significant at the
,10 level have the same trend. The three stimuli are doctor,
hospital bed, and food. In this sample, children who are not
prepared for their hospitalization are more likely to perceive
stimuli as stressful than are children who are prepared.
The findings for this part of the study are consistent
with the notion that the child’s preparation for hospitalization m influences his reaction to the hospital environment. The prepared child should be better able to cope with his hospitalization.
Chapman,^ Mason,^ Belmont,and Gellert*^ are all of the opinion that the prepared child finds hospitalization easier. In the studies which used the variable, child’s preparation, they used the 18 dependent variable of the child's post-hospitalization response,A
The findings of these studies lend support to the idea that pre paration is a determinant of the level of psychological upset experienced by the child, Prugh*^ considered preparation in response to immediate hospital reactions, but the variable was confounded with other ones. However, he contends that preparation 20 appears to reduce psychological upset.
ih A. H. Chapmanj Dorothy Loebi and Mary Jane Gibbons, "Psychiatric Aspects of Hospitalizing Children," Archives of Pediatrics. LXXIII (March, 1956), p.80.
^Edward A. Mason, "The Hospitalized Child— His Emotional Needs," The New England Journal of Medicine. CCLXXII (February 25, 1965), p. 409.
^Herman S. Belmont, "Hospitalization and Its Effects Opon the Total Child," Clinical Pediatrics. IX (August, 19?0), p. 480.
^Elizabeth Gellert, "Reducing the Emotional Stresses of Hospitalization for Children," American Journal of Occupational Therapy. XII (May-June, 1958), p. 125.
*®Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness, p. 21.
^Prugh, et al.. "A Study of the Emotional Reactions of Children and Families to Hospitalization and Illness," p. 83,
20Ibid.. p. 103. 1^5
Separation
The research hypothesis pertaining to separation is«
Hypothesis VI. There is a relationship between the stimuli that children perceive as stressful in the hospital and their experience with separations from their families. Children who have been previously separated from their families perceive different stimuli as stressful in the hospital as compared with children who have not been previously separated from their families.
Table 29 enumerates the phi coefficients and chi-squares for each of the nineteen stimuli in the game and the total number of stressors perceived by the subjects. Two of the nineteen stimuli have statistically significant phi coefficients and chi-squares. TABLE 29
SUMMARY OF PHI COEFFICIENTS AND CHI-SQUARES FOR SUBJECT'S
EXPERIENCE WITH SEPARATION AND STIMULI
Stimuli Phi Coefficient Chi-square N
Boy .07201 .3682 71
Girl -.01*885 .1695 71
Mother .01577 .0259 104
Father -.01033 .0093 89
Baby .00000 .0000 23
Dog -.081*20 .1*329 61
Cat .00000 .0000 35
Nurse .05622 .3288 104
Doctor .11*690 2.1171 98
Hospital gown .16690 2.6219 94
Hospital room .20710* 4.3781* 102
Hospital bed .07301* .5283 99
Food .05730 .3386 103
Medications -.00870 .0079 103
Toys .00000 .0000 100
Thermometer .17001 2.8905 100
Stethoscope .25810* 5.5985* 84
House .02680 .0699 97
School -.11970 1.0178 71
Total stressors .12790 1.7019 104
* P < .05 147
The stimulus, hospital room, has a phi ooeffioient of
.20710 and a chi-square of 4,3781 which are statistically signi ficant at the ,05 level. The phi coefficient of ,20710 indicates that there is a low correlation between the child’s experience with separation and his perception of the stimulus. Table JO presents the contingency table for the subject’s experience with separation and the stimulus, hospital room. It can be concluded that there is a relationship between the child's experience with separation and his perception of the hospital room. As a function of his experience with separation, there is a difference in how the child perceives the stimulus. In this sample, a child who has been previously separated from his family is more likely to perceive the stimulus of hospital room as stressful than is a child who has never been separated from his family,
TABLE 30
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL ROOM, AND THE
SUBJECT’S EXPERIENCE WITH SEPARATION
Stressful Nonstressful
Experience 9 39
No experience 3 51
Phi = ,20710j Chi-square = 4.37811 p ^ . 0 5 The stimulus, stethoscope, has a phi coefficient of ,25810 and a chi-square of 5.5985 which are statistically significant at the ,05 level. The phi coefficient of ,25810 Indicates that there is a low correlation between the child's experience with separation and his perception of the stimulus. Table 31 presents the contin gency table for the subject's experience with separation and the stimulus, stethoscope. It can be concluded that there is a relationship between the child's experience with separation and his perception of the stethoscope. As a function of his experience with separation, there is a difference in how the child perceives the stimulus. In this sample, a child who has been previously separated from his family is more likely to perceive the stimulus of stethoscope as stressful than is a child who has never been separated from his family.
TABLE 31
CONTINGENCY TABLE FOR THE STIMULUS, STETHOSCOPE, AND THE
SUBJECT'S EXPERIENCE WITH SEPARATION
Stressful______Nonstressful
Experience 11 27
No experience 4 42
Phi = ,258101 Chi-square = 5.5085t p<,05 1^9
The overall findings of this part of the study lend support to the idea that the variable, child's experience with separation, does not influence significantly what stimuli he perceives as stressful in the hospital. This conclusion is based on the finding that only two of the nineteen stimuli yielded statistically signi ficant phi coefficients and chi-squares. Concomitantly, the phi coefficient and chi-square are nonsignificant for the total number
of stressors perceived by the children. In terms of probability
theory, the two significant stimuli could be attributed to chance
alone. Thus, the hypothesis that there is a relationship between
the stimuli that children perceive as stressful in the hospital and
their experience with separation from their families cannot be
accepted. It must be concluded on the basis of this study that the
relationship between the stimuli that children perceive as stressful
in the hospital and the children's experience with separation does
not differ significantly from zero. Thus, children who have been
previously separated from their families do not peroeive different
stimuli as stressful in the hospital in comparison with children
who have not been previously separated from their families. The
overall findings of this part of the study could be due to a true
lack of relationship between the variables, to confounding variables,
or to failure of the measuring instrument to discriminate between
the two groups.
The significant findings for the two stimuli, hospital
room and stethoscope, are contradictory to the overall findings of 150 this part of the study. The finding for both stimuli is that children who have been previously separated from their families
are more likely to perceive the stimuli as stressful in comparison
to children who have not been previously separated from their
families. The lack of other reported studies related to children's
experience with separation from their families makes it difficult
to draw any conclusions about the significant findings.
Interrelationship of the Variables
The research hypothesis pertaining to the interrelationship
between all the variables isj
Hypothesis VII. There is a relationship between the stimuli that children perceive as stressful in the hospital and the following group of variables! children's age, sex, diagnosis, preparation for hospitalisation, experience with separation, and the length of hospitalization.
This research hypothesis was tested through the use of a
canonical correlation method which yields k-eoefficients or
canonical weights. Table 32 enumerates the canonical weights and
canonical factors for the two sets of variables. The weights for
the smaller set represent the k-coeffieients for the six controlled
variables and the weights for the larger set represent the canonical
weights for the nineteen stimuli in the game and the total number
of stressors. The first canonical factor is statistically signifi
cant at the ,05 level and yields a multiple correlation coefficient
of .8^75. In other words, the first canonical factor accounts for
seventy-two percent of the total variance between the two groups TABLE 32
CANONICAL WEIGHTS AND CANONICAL FACTORS FOR THE TWO SETS OF VARIABLES
HEIGHTS FOR SMALLER SET
~~0.1609'-0.'3217 " 0.2556"“ D.5689- 0. 6566'-0.2860
~0.60<>k -0.06 07 -0.0257”~0.3207 ~ 0.'1096~"0. 7169 '
-0.5791 0.0356 -0.6271 0.6039 0.1607 0.2898
"-0.26 73 0.9058 0.9956 0.5679 -0.9583‘-0.0709
"-0.2599* 0.3966 0.5111 -0.3023 0. 59 75" 0. 9691
-0.3957 -0.7527 0.3530 -0.0798 -0.2209 ' 0.3093
HEIGHTS FOR LARGER SFT
-0.0805 -0.0582 0. 1665 O.OIOC -0.0835 -0.2788 0.2360 - 0.9063 - 0.2801 - 0.0333 - 0.2065 - 0.2629 - 0. 2277_-0.0257 - 0.16
-0.1233 -0.2117 -0.3018 -0.2926 -0.3933 ______
-0.0135 -0.0690 0.2107 -0.1808 -0.0199 -0.6851 -0.3130 -0.0385 0.2560 0.0996 0.2887_ 0.0812 0.1609 r0.1060 0.09t6_
0.2961 0.2063 -0.0919 -0.6820 0.0626 _ ...... „ ..... 1______
0.0878 -0.6360 -0.1026 -0.0596 -0.2800 0.1620 -0.1695 -0.3715 -0.3008 0.1226 0.0525 -0.0555 -0.0898 _0.2210._0.2867 .
0.2682 0.3600 -0.0198 0.2835 -0.0532 _......
-0.0026 -0.6176 0.3651 0.0263 -0.0261 -0.0625 0.5591 0.2632 -0.1662 -0.1711 -0.0691 0.0365 0.2599 -0.6636 0.2177_
0.0350 0.0578 0.1516 0.0668 -0.0116 •
0.2661 -0.0373 0.0623 0.3010 0.0016 0.1226 0.0335 0.3623 0.0781 0.6575 0.0828 -0.2269 r0.1957 -0.0966_-0.0675_
■0.1117 0.2660 -0.5661 -0.0232 0.0058
-0.1071 0.0516 -0.1880 0.3087 -0.1268 -0.3716 -0.0502 -0.1327 -0.0623 0.3pl5.. «. U21 -0.2683 -0.2522 -0.3692 -0.0696 _
-0.1026 0.0068 0.6963 0.1663 0.1569 ’ '• FACTOR I,CHI SQUARED>219.068» OF* 120,MULTIPLE R*0.8675 " " ...... FACTOR 2,CHI SQUARED-106.626, OF* 95,MULTIPLE R*0.6325 FACTOR 3,CHI SQUARED- 58.182,' OF- 72,MULTIPLE R-0.5659 ’ FACTOR 6,CHI SOUARCO* 26.166. OF- 51.MULTIPLE R-0.3989 ______FACTOR 5,CHI SQUARED- 10.686, OF- 32,MULTIPLE R-0.2102 rZ FACTOR 6,CH1 SQUARED- 6.396, OF- 15,MULTIPLE R-0.2612 H- 152 of variables. The remaining canonical factors are nonsignificant at the ,05 level.
Table 33 enumerates the canonioal weights for the first canonical factor. The canonical weights for the group of controlled variables ranged from .14 to ,65 , The variable, child's prepara tion for hospitalization, has the largest canonical weight of
.65*44. The variable, length of child's hospitalization, yields the second largest canonical weight of .5489. The other variables, in descending order, are the child's sex, child's experience with separation, child's diagnosis, and child's age. The canonical weights for the group of variables pertaining to stressful stimuli ranged from .01 to -.41. The variable, nurse, has the highest canonical weight of -.4063. The variable, total number of stressors, has the second highest canonical weight of -.3933. Other variables which have canonical weights over ,20 are house, school, doctor, dog, hospital bed, cat, food, stethoscope, and hospital room.
The first canonical factor is empirically meaningful in understanding children's perception of stressful stimuli in the hospital environment. In this sample, the two controlled variables,
length of child's hospitalization and child's preparation, influence
the hospitalized child's perception of stimuli the most when the
entire group of controlled variables is considered. The variables
which we have the highest probability of predicting correctly as
being perceived as stressful or nonstressful by the child are the
nurse and the total number of stressors. The controlled variable, TABLE 33
CANONICAL WEIGHTS FOR THE FIRST CANONICAL FACTOR
Smaller Set of Variables* Canonical Weights
Preparation for hospitalization (Yes - No) .6544 Length of hospitalization (Less than 5 days - More than 5 days) .5489 Sex (Male - Female) -.3217 Experience with separation (Yes - No) -.2860 Diagnosis (Medical - Surgical) .2556 Age (4-7 years - 7 - 12 years) .1409
Larger Set of Variables
Nurse -.4063 Total stressors -.3933 House -.3018 School -.2926 Doctor -.2801 Dog -.2788 Hospital bed -.2629 Cat .2360 Food -.2277 Stethoscope -.2117 Hospital room -.2065 Mother .1664 Toys -.1411 Thermometer -.1233 Baby -.0833 Boy -.0805 Girl -.0582 Hospital gown -.0533 Medications -.0257 Father .0100
R = .8475 Chi-square = 219.048; df = 120; p<.05
♦The first category of each variable was given the low weight in coding. Similarly, the nonstress category was given the low weight and the stress category the high weight. 15* child's preparation for hospitalization, would be the best single variable out of the group to use to predict what stimuli the
child would perceive as stressful.
The overall findings of this part of the study lend support
to the idea that there is an interrelationship among all the
variables. One can accept the research hypothesis that there is
a relationship between the stimuli that children perceive as stress
ful in the hospital and the following group of variables* children's
age, sex, diagnosis, preparation for hospitalisation, experience
with separation, and the length of hospitalisation. The relation
ship between these two sets of variables can be expressed in terms
of a significant canonical factor. The canonical factor yields a
multiple R of ,8^75 which is statistically significant at the .05
level. This canonical factor yields the best canonical weights
for the two group of variables and concomitantly what the two groups
of variables predict best in common. In this sample, the two
variables, preparation for hospitalisation and the length of
hospitalization, are the best predictors as they have the largest
canonical weights. It can be predicted that the prepared child who
is in the hospital for a short period of time will probably perceive
fewer stimuli as stressful than will the unprepared child who is
in the hospital for a long period of time. The prepared child who
is in the hospital for a short period of time will probably perceive
few stimuli as stressful. The unprepared child who is in the hospi
tal a long period of time will probably perceive many stimuli as 155 stressful.
Summary of Results
The purpose of the study is to identify the stimuli that hospitalized children perceive as stressful. On the basis of analyzing the data collected from the game and the questions,
forty-four different stimuli are identified as stressful by the
sample. The stimuli which are perceived by the largest number of
children as stressful include medications, needles, hospital gowns,
and thermometers. Stimuli related to the children's family and
home are perceived as stressful by approximately a quarter of the
sample. Similarly, hospital beds and food are perceived as stress
ful by approximately a quarter of the sample. In answer to what
bothers hospitalized children the most, needles and injections rank
first and is followed by experiencing pain and being confined to bed.
The mean number of stressors identified by the sample is 5*95. For
the three categories of stressors, the mean numbers respectively are
3.11 for environmental stressors, 2,55 for intrapersonal stressors,
and zero for interpersonal stressors.
The study is concerned with the relationship between certain
variables and the stimuli that children perceive as stressful. Of
the seven research hypotheses tested, three of the research hypo
theses are accepted at the ,05 level of significance. A summary
of the findings is as follows» There is no relationship between the stimuli that children perceive as stressful in the hospital and the age of the children. Children between the ages of four and seven do not perceive different stimuli as stressful in the hospital compared with children between the ages of seven and twelve.
There is no relationship between the stimuli that children perceive as stressful in the hospital and the sex of the children. Males and females do not perceive different stimuli as stressful in the hospital.
There is no relationship between the stimuli that children perceive as stressful in the hospital and their diagnosis.
Children hospitalized for a medical condition do not perceive different stimuli as stressful compared with children hospitalized for a surgical condition.
There is a relationship between the stimuli that children
perceive as stressful in the hospital and the length of time
the children are hospitalized. Children hospitalized for
less than five days perceive different stimuli as stressful
compared with children hospitalized more than five days.
There is a relationship between the stimuli that children
perceive as stressful in the hospital and their preparation
for hospitalization. Children who are prepared for their
hospitalization perceive different stimuli as stressful
compared with children who are not prepared.
There is no relationship between the stimuli that children 15?
perceive as stressful in the hospital and their experience
with separation from their families. Children who have
been previously separated from their families do not per
ceive different stimuli as stressful compared with children
who have not been previously separated from their families,
7, There is a relationship between the stimuli that children
perceive as stressful in the hospital and the following
group of variablesi children’s age, sex, diagnosis, pre
paration for hospitalization, experience with separation,
and the length of hospitalization.
Discussion of the Results
In a descriptive, cross-sectional, exploratory study only tentative conclusions can be drawn. The finding of forty-four different stressors identified by the sample lends support to the concept that the hospital is a stressful environment for children.
Likewise, the finding that not every stimulus is perceived as
stressful by all the children lends support to the idea that few
stimuli are stressors for all individuals exposed to them. Con
comitantly, the finding lends support to the idea that stress is
an individual phenomenon and is dependent upon the particular
meaning the individual assigns to it. In this sample, the stimuli
of medications, needles, hospital gown, and thermometers are
perceived as stressful by the majority of the children. Thus, there
are some stimuli in the hospital which are perceived as stressful 158 by most children exposed to them.
The stimuli identified by this sampLe of children should be considered in relation to the model developed to study children's perception of stressful stimuli in the hospital. According to the model, the child has various stimuli to which he may attend and ultimately respond and which can be inferred from his behavior.
These stimuli can be classified into one of the following categoriesi environmental, interpersonal, and intrapersonal. The findings of the mean numbers of stimuli identified by the children lend support to two of the three categories— environmental and Intrapersonal,
The category of interpersonal stressors does not appear to be supported as the mean was zero. However, there is an inconsistency in this finding when the two stimuli, nurse and doctor, are con sidered in the game. Both the nurse and doctor are perceived as being stressful by some of the children. Also in terms of the research hypotheses some of the findings are statistically signifi cant for the stimulus of nurse. In the sample, males are more likely to perceive the stimulus of nurse as stressful than are females. A child hospitalized for more than five days is more likely to per ceive the stimulus of nurse as stressful than is a child hospitalized
for less than five days. Likewise, a child who is not prepared for his hospitalization is more likely to perceive the stimulus of
nurse as stressful than is a child who is prepared. Since some
children perceive the nurse and doctor as stressful and three
sub-hypotheses pertaining to the nurse are statistically significant, 159 the conclusion may be drawn that some of the stimuli perceived by hospitalized children can be classified as interpersonal stressors.
Thus, the findings of the study lend some supoort for the three categories of stressors* environmental, intrapersonal, and inter personal.
The findings regarding the relationship between the con trolled variables and the stimuli that children perceive as stress ful merit discussion. When the controlled variables are considered individually, few of the variables yield statistically significant phi coefficients and chi-squares. The variables, length of hospitalization and preparation for hospitalization, are the only ones which are statistically significant.
The overall findings for the variable, length of hospitali zation, is that children hospitalized for more than five days perceive stimuli differently from children hospitalized for less than five days. In this sample, children who have been hospitalized for more than five days are more likely to perceive stimuli as
stressful than are children hospitalized for less than five days.
Thus, it can be concluded that as the child's length of hospitali
zation increases the number of stimuli he may perceive as stressful
increases.
The overall finding for the variable, preparation for hos
pitalization, is that children who are prepared for their hospitali
zation perceive stimuli differently than do those children who are
unprepared. In this sample, children who are unprepared are more 160 likely to perceive stimuli as stressful than are children who are prepared. Thus, it can be concluded that the child's preparation
influences his perception of stimuli in the hospital environment.
Some conclusions can be drawn in respect to the other
controlled variables which are not statistically significant. The
finding that there is no relationship between age and the child's
perception of stimuli lends support to the theoretical viewpoint
that the sources of stress in hospitalisation may be merely
different for children of different ages. The findings for the
variable, sex of the child, lend support to the concept that sex
has little influenoe on the hospitalized child's perception of
stimuli. Also, the findings for diagnosis and experience with
separation lend support to the concept that these variables have
little influence on the hospitalized child's perception of stimuli.
When the six controlled variables are considered as a group
in relation to the group of stimuli in the game, the interrelation
ship between the two groups is statistically significant and
empirically meaningful. It is interesting to note that the variable,
preparation for hospitalization, has the largest k-eoefficient and
that the variable, length of hospitalization, has the second
largest. On the basis of the findings for the individual variables
and the variables as a group, these two variables appear to have
the most influence on the child's perception of stimuli in the
hospital. CHAPTER V
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
This chapter provides a summary of the study, and it includes the major conclusions with their implications and recommendations for future studies.
Summary
Counseling is a relationship between a counselor and a client or group of clients aimed at assisting each individual in developing his potential and concomitantly learning to handle his environment. An important variable in a counseling situation is the client's perceptions. The counselor needs to know the client's perceptions since these represent his reality, A counselor dealing with a child has an excellent opportunity to study his perceptions
of new experiences with fewer confounding variables than when he
is dealing with an adult. If the counselor can Isolate the child's
perceptions in a specific context, he has indicators to describe,
explain, and/or prediot how the child will behave in a particular
situation.
161 162
Stress Is another important variable in a counseling situation. Stress is present in all aspects of life. Stress may be defined as a state in which the child perceives that his well-being or his integrity is endangered and that he must devote his energies to its protection. It is an intervening variable between the environment and the individual's behavior which can be inferred from a situation or condition of the physical or social environment, and which leads to avoidant, escapist, aggressive, or problem-solving measures specifically designed to remove or weaken the condition which is perceived as threatening,
A counselor can assist the child in learning how to cope effectively with a stressful situation or can assist by altering the environment to make it less stressful for the child.
All children in the course of growing up encounter some
stresses. Possible stresses for a child are the addition of a
sibling, going to school, moving to a different house, having an
accident, being sick, and trying to master some developmental task.
Hospitalisation can be regarded as a stressful experience for a
child, but it may also be an opportunity for learning. If the
stressful stimuli can be identified, the counselor and others, such
as physicians and nurses, can use this knowledge as a framework for
counseling the child and his parents regarding the child's hospitali
zation.
The purpose of this study was to study children's perceptions
of stimuli in a specific environment, the hospital. Hopefully it would contribute to the body of knowledge regarding stress and
would provide knowledge for counselors to utilise in working with
children who are experiencing stressful situations, especially
with hospitalized children and their parents. The investigator
developed a model for studying the stimuli that children perceive
as stressful in the hospital environment. The model is based on
three basic assumptions. The first assumption is that hospitaliza
tion can result in "critical periods" for children. Second, the
hospital is a stressful environment for all organisms that interact
within the system. Third, there are stimuli within the hospital
which are stressful to children. These stimuli can be categorized
as environmental, intrapersonal, or interpersonal stressors. These
stimuli influence children's perceptions and ultimately their be
havior, It follows that if it is possible to Identify what children
perceive as stressful, then it may be possible to identify what
children perceive as stressful, then it may be possible to control
or eliminate some of the stressors in their environment. The
remaining stressors could be utilized to maximize the hospital
experience into a "critical period" which is conducive to children's
optiminal development.
The central problem of the study was to identify the stimuli
that children perceive as stressful in the hospital. Concomitantly,
it studied the relationship between certain variables and the stimuli
that children perceive as stressful in the hospital. These variables 16^ included the child's age, sex, diagnosis, length of hospitalization, preparation, and experience with separation from his family.
An exploratory, descriptive, cross-sectional design was used in this study. The sample was obtained via a purposive sampling technique which mat certain criteria. These criteria weret (l) The child is between the ages of four and twelve years of age; (2) This is the first hospitalization for his present illnesst (3) The child has not been hospitalized more than three times; (k) The child's condition is not potentially terminal; (5) The child's participa tion in the study would not be detrimental to his welfare; (6)
Permission of the attending physician is obtained; (7) Permission of the child is obtained; and (8) Written permission of the child's parent is obtained. The sample consisted of one hundred and four children who were hospitalized at either Children's Hospital or
Riverside Methodist Hospital in Columbus, Ohio.
The investigator developed a game to study children's perceptions of stimuli in the hospital. The underlying rationale was based upon the methodology of projective instruments and of interviewing. The game consisted of plastic cards with colored drawings of different stimuli related to a child's hospitalization.
The cards consisted of the following stimuli; a boy, a girl, a mother, a father, a baby, a dog, a cat, a nurse, a doctor, a hospital gown, a hospital room, a hospital bed, food, medications, toys, a thermometer, a stethoscope, a house, and a school. Data were obtained 165 by playing the game with each subject and tape-recording the play
session. The investigator used the same format with each child during the play session in his hospital room,
A content analysis was done of each subject's responses to the game. The subject's responses were coded as stressful, non
stressful, or no reaction. Stress was operationally defined as the responses that the child gave to the stimuli in the game and questions which connoted a "stressful” perception, A child's
response was labelled as a "stressful" perception if any of the
following words was usedi annoys, bothers, dislikes, disturbs,
feels anxious, hates, hurts, irritates, misses, threatens, un
comfortable, and upset, A child's response was labelled as
"nonstressful" if none of the words connoting a "stressful" per
ception was used, A child's response was labelled as "no reaction"
if the child did not play with the card. The child's responses
connoting a "stressful" perception were labelled also as environ
mental, intrapersonal, or interpersonal stressors.
Forty-four different stimuli were identified as stressful
by the sample. The stimuli which were Derceived by the largest
number of children as stressful include medications, needles,
hospital gowns, and thermometers. Stimuli related to the children's
family and home were perceived as stressful by approximately a
quarter of the sample. Similarly, hospital beds and food were
perceived as stressful by approximately a quarter of the sample. 166
In answer to what bothers hospitalized children the most, needles and injections ranked first foiled by experiencing pain and being confined to bed. The mean number of stressors identified by the sample was 5.95. For the three categories of stressors, the mean numbers respectively were 3.11 for environmental stressors, 2.55 for intrapersonal stressors, and zero for interpersonal stressors.
The data were analyzed statistically through the use of phi coefficients, chi-squares, and a canonical correlation technique.
Three of the seven research hypotheses could be accepted at the
.05 level of significance. In this sample, there was a relation ship between the stimuli that the children perceived as stressful in the hospital and the length of time the children were in the hospital. Likewise, there was a relationship between the stimuli that the children perceived as stressful and their preparation for hospitalization. The other research hypothesis which could be accepted had to do with the interrelationship between all the variables. In this sample, there was a relationship between the stimuli that the children perceived as stressful in the hospital and the following group of variablesi children's age, sex, diagnosis, preparation for hospitalization, experience with separation, and the length of hospitalization. The relationship between these two sets
of variables can be expressed in terms of a significant canonical
factor. The canonical factor yielded a multiple R of .8^75. In
other words, the first canonical factor accounted for seventy-two 167 percent of the total variance between the two groups of variables.
This canonical factor yielded the best canonical correlation for the two groups of variables and concomitantly what the two groups of variables predicted best in comnon, In this sample, the two variables, preparation for hospitalization and the length of hospitalization, were the best predictors as they had the largest canonical weights. The other canonical factors were nonsignificant.
Conclusions
The finding of forty-four different stressors identified
by the sample lends support to the concept that the hospital is a
stressful environment for children. The finding that not every
stimulus is perceived as stressful by all the children lends support
to the idea that few stimuli are stressors for all individuals
exposed to them. Moreover, it lends support to the idea that stress
is an individual phenomenon and is dependent upon the particular
meaning the individual assigns to it. In this sample, there were
many stressors which were specific for each child. Thus, there
should be more emphasis placed on identifying the stressful stimuli
for a particular child. This should be done through the cooperative
efforts of the child and the significant others who interact with
the child in the stressful situation. For example, in the hospital
setting it should be done through the cooperation of the child, his
parents, the physicians, the nurses, and the other significant individuals who interact with the child. The stressful stimuli
could be identified by directly asking the child, by observing
his behavior, and by objectively observing his play. The game used in this study could be one medium to encourage the child to verbalize his perceptions of the hospital environment. Other media
which could be used are puppets, dolls, and drawings. When the
stressful stimuli are identified, this information should be
communicated to the significant others who interact with the child.
Concomitantly, these stimuli should be evaluated to determine if
it would be better to help the child learn how to cope effectively
with them or to alter the environment. In either case, conscious
efforts must be taken by those who care for the child to indi
vidualize his hospital experience as much as possible.
There were some stimuli, medications, needles, hospital
gowns, and thermometers, which were perceived as stressful by the
majority of children. Thus, there are some stimuli which are
perceived as stressful by most children exposed to them. These
stimuli may or may not be able to be eliminated from the child's
environment.
Medications and needles were perceived as stressful by
rao3t of the children. Some of the children's responses were "they
hurt", "they make me cry", and "they are given to me as a punish
ment for being bad". The medications and needles may be necessary
for the child to return to a well state and usually the child encounters a needle during part of the routine admission procedure.
Other laboratory tests may require the child to have blood drawn via a needle. The child should be told why the needles and/or medications are necessary and if there will be any pain or dis comfort, If the child perceives Injections as stressful, the physician should reassess the necessity of administering medica tions via that route. Perhaps an alternative route of administra tion would be just as therapeutic or perhaps a different medication which can be adminstered orally could be given to the child. If there is no alternative except to give the medication via an injection, it is important that the person administering the in jections attempt to alleviate some of the stress associated with it. The person should be honest with the child and stay with him after the medication is administered. This provides an opportunity for the child to express how he feels about having had the injection, and concomitantly it may assist the child in learning to cope with
this particular stressor.
The hospital gown was a stimulus perceived as stressful by
many of the children. Some perceived the hospital gowns as stress
ful because they did not like to have their "bottoms" uncovered.
Some boys perceived the gowns as being "sissy" and consequently
did not want to have to wear them. Some boys stated that they were
embarrassed to be seen in the hospital gowns. The stressor of
hospital gowns might be eliminated in most cases by encouraging 170 the parents to bring the child’s own pajamas or night gowns. The hospital might also consider redesigning the hospital gown so they are more modest.
The thermometer was another stimulus perceived as stressful by many of the children. Some responses were "it tastes bad",
"they leave it in my mouth too long", "it makes me have to stay in the hospital", and "I don't like to get woke up to have ray temperature taken". This stressor might be eliminated or reduced by reassessing the procedure used in taking the children's temperatures.
Stimuli related to the children's family and home were perceived as stressful by approximately a quarter of the sample.
If the child perceives being away from his family as stressful, the
child's parents should be encouraged to stay with him. Perhaps the visiting hours need to be liberalized so the child's parents can
be with him for a longer period and so that his siblings might be
able to visit with him also. An effort should be made to make the
hospital as home-like a3 possible for each child.
Many of the children perceived experiencing pain as stress
ful. The experience of pain is a difficult stressor for the child
to cope with as he often is reluctant to admit that he has pain
until it becomes almost overwhelming. He may associate admitting
that he has pain with receiving an injection, or he may believe
that he has pain for having done something bad. The child should 171 be encouraged to verbalize when he has pain. Efforts should be taken to alleviate the pain through the administration of medica tions, changing the child's position, and staying with the child during the experience. Also the child should be informed if he may experience pain during or after a procedure or after an operation.
Many of the children perceived being confined to bed as stressful. Most of these children were confined to bed since they were in traction as part of the treatment for their broken bones.
In such cases this stressor cannot be eliminated but it might be
reduced. The child should be encouraged to do as many of his
usual activities as is physically possible. The child should be
provided with opportunities to play during this period of confine
ment. He should be in a bed which is easily moveable so he can be
taken to the playroom and other significant places. The child
should not be confined to bed any longer than is absolutely
necessary.
The study lends some support to the idea that the variable,
length of hospitalization, influences what stimuli children perceive
as stressful in the hospital. There was a relationship between the
stimuli that the children perceived as stressful and the length of
time the children were in the hospital. In this sample, children
who had been hospitalized for more than five days were more likely
to perceive stimuli as stressful than were children who had been hospitalized for less than five days. Thus, it can be concluded that as the child’s length of hospitalization increases, the number of stimuli he may perceive as stressful increases. This conclu sion is contradictory to those of other studiesj however, different dependent variables were used. Additional studies should be done using the variable, length of hospitalization, in an attempt to understand better the relationship between the variables. An example would be a longitudinal study in an attempt to determine what periods of time the child perceives the most stress during his hospitalization.
The child needs the opportunity to verbalize his percep tions regarding his hospital experiences throughout his stay. This may result in greater self-awareness and ability to cope effectively with the stressful stimuli that he encounters. The child who has been in the hospital for awhile needs Just as much, if not more, emotional support from his parents, hospital personnel, and signi ficant others as the child who has Just been recently admitted.
The child might learn to adapt to some of the stressors in the hospital as time progresses} but concomitantly he might become aware of new stimuli which are perceived as stressful by him.
For instance, he may encounter new stressors as a result of having
to undergo surgery, a diagnostic procedure, or a treatment. Any
of these situations are capable of changing the child’s perception
of the hospital to a stressful environment. The child needs to 173 have somebody to whom he can verbalize how he is perceiving his hospitalization and who can assist him in coping with the situa tion. The child who is experiencing a greal deal of stress may require a more therapeutic environment since verbalization may not be sufficient to reduce his stress. He may benefit from the use of some behavior modification methods such as desensitization.
There is no single way of handling the child's stress. A variety of counseling techniques may help alleviate the stress. The important dimension is that the child's perception of stressful stimuli is not ignored and that efforts are made to assist the child in coping with the stressor or to alter the environment and thus make it less stressful.
The study lends some support to the idea that the variable, preparation for hospitalization, influences the stimuli children
perceive as stressful in the hospital. There was a relationship
between the stimuli that the children perceived as stressful and
their preparation for hospitalization. In this sample, children
who were unprepared were more likely to perceive stimuli as stress
ful than were children who were orepared. Based upon the finding
that preparation has an influence on the child's perception of the
hospital, an effort should be made to preoare every child. If
it is a planned admission the child should be prepared prior to
entering the hospital. There are available books and pamphlets
to assist the parents in preparing him. If it is an emergency 17^ admission the child should be prepared in the Emergency Room or upon his admission to the hospital unit. Preparation of the child can be done by a variety of people including the parents, physicians, nurses, and other hospital personnel. Also, different media can be utilized to prepare the childj for example, play, role playing, puppets or dolls, drawings, and books. The important thing is informing the child what is going to happen so the element of the unknown is reduced. Vernon et al.* state that:
...the child about to be hospitalized (or the child about to experience some upsetting medical procedure) be told what will happen, why it will hapoen, and what he will experience, and that this be done simply, candidly, reassuringly, and at a level appropriate to the child’s general development.
Preparation should be continued throughout the child’s period of hospitalization.
The study lends support to the idea that the two variables, preparation for hosDitalization and length of hospitalization, influence how the children perceive stimuli in the hospital. In this sample, it can be predicted that the child who was prepared
and was in the hospital less than five days would perceive fewer
stimuli as stressful than would the child who was unprepared and
in the hospital for a longer period of time. The other four
David T, A. Vernon, et al.. The Psychological Responses of Children to Hospitalization and Illness (Springfield. Illinois: Charles C. Thomas, 1965), p. 9. 175 2 variables had little influence on the children's perceptions.
The variables which had an influence on the child's perceptions may be altered through counseling and/or learningi whereas the other variables are mainly unchangeable. The variables, prepara tion and length of time, might influence children's perceptions in other potentially stressful situations. In an unfamiliar situation, the child should be prepared as much as is realistically feasible in order to keep any stress he experiences in proportions that the child can handle. Ideally, the stress experienced by the child should be at a level which would encourage him to deal constructively with the situation and stimulate new learning.
In other words, the optiminal level of stress should be determined
for the child. The variable, duration of the stressful situation,
should be considered also in interacting with the child. A mild
or moderate stressor which exists over a long period of time can
affect the child just as much, if not more, than an acute, intense 3 stressor. According to Torrance, there has been undue neglect of
individuals exposed to chronically stressful situations. Torrance
contends that the prolonged stressful situation takes the greatest
toll in personality breakdown. The duration of the stressful
situation can be altered by assisting the child to learn to cope
2 The four variables are age, sex, diagnosis, and experience with separation. 3 Paul E. Torrance, Mental Health and Constructive Behavior: Stress. Personality, and Mental Health (Belmont. Californiat Wadsworth Publishing Company, 1965), p. 28, 1?6 with his environment so he no longer ^receives it as stressful as he did. Also the environment might be altered physically to make it less stressful.
In conclusion, the child may perceive any situation as stressful depending upon the meaning to assigns to the stimuli present in his environment. The child’s preparation and the length of time he is in a situation are two variables which appear to influence his perceptions of the situation. The child should be encouraged to verbalize his perceptions regarding his experiences.
As adults, we should attempt to think, feel, and be like a child when we are trying to understand the child's world. We should try to perceive the world through the eyes of the child. Then we may be better able to comprehend the child's perceptions, assist him in handling stressful stimuli, and facilitate his optiminal development.
Recommendations for Future Studies
This study identified the stimuli that children perceived
as stressful in the hospital. Concomitantly, the study dealt with
the relationships between certain controlled variables and the
stimuli perceived as stressful by hospitalized children. It has
provided a frame of reference for future research of the model
developed by the investigator. On the basis of the data collected, 177 the following recommendations for future studies are made*
1. The study should be replicated in other hospitals.
2. The game used to measure stress should be refined before it
is used in other studies. For example, the number of cards
should be reduced and other measures of stress should be
used along with the game.
3. An experiment should be done using the variables length of
hospitalization and preparation for hospitalization.
4. A longitudinal study should be done using the variable,
length of hospitalization, to determine during what phases
of hospitalization the child perceives the most stress,
5. Additional studies should be done to test other aspects
of the model.
6. Studies of children in other stressful environments should
be done to identify what stimuli are perceived as stressful
and to determine if there is a relationship between these
stressful stimuli and the variables, length of time and
preparation, APPENDIX A
STIMULI IN THE GAME
178 179
0. 180
182 183 181* 185 186
o □ 187 188 189
191 192 193 19^
196 19? APPENDIX B
INTERVIEW SCHEDULE
198 199
INTERVIEW SCHEDULE FOR PARENT
1. What do you think your child likes about being in the hospital?
2. What do you think your child doesn't like about being in the hospital?
3. What do you think has bothered your child the most about being in the hospital? k m Who do you think your child has missed since he has been in the hospital?
5. Did you prepare your child for this hospitalization? When? Did he know why he was being admitted to the hospital? What information did you give him? How did your child respond to this preparation?
6. Have you ever had a child hospitalized before?
7, Has your child been separated from you for any period of time? From your husband or wife? If so, what for? How long?
8, Is there any additional information which you think influences how your child experiences this hospitalization? BACKGROUND DATA
Name ______
Age ______Birth date______
Sex ______
Date of admission______
Diagnosis______
Previous hospitalizations______
Previous illnesses______
Number of siblings Males Females.
Birth order of child______.
Father's occupation______
Mother's occupation______
Father's education______
Mother's education______
Status of family,______
Place of r e s i d e n c e ______201
CONSENT FORM
I consent to ______participating in an investigation entitled: Children's Perception of Stress in the
Hospital. This investigation is to be performed by Edna M.
Menke.
I understand that my child will play a game with the investigator (Edna M. Menke) during his hospitalization which will not interfere in any way with his treatment. I consent to my child being tape recorded while he is playing the game with the investigator. The game will be stopped if ray child becomes tired or shows other evidence of not being able to tolerate it.
I also consent to being interviewed by the investigator.
I understand that my child's identity and my identity will remain anonymous in this investigation. I further under stand that the results of this study may be published, but my child's identity and my identity will not be revealed by any published descriptions.
Signed______(Parent)
Witne s s ______
w'i t ne s s (Investigator) APPENDIX C
CONTINGENCY TABLES FOR NON-SIGNIFICANT STIMULI
202 203
TABLE 3k
CONTINGENCY TABLE FOR THE STIMULUS, BOY,
AND THE SUBJECT'S AGE
Stressful Nonstressful k - 7 years old 10 20
7-12 years old 16 25
Phi = -.0583^; Chi-square = .2A17; p<.90
TABLE 35
CONTINGENCY TABLE FOR THE STIMULUS, MOTHER,
AND THE SUBJECT'S AGE
Stressful______Nonstressful k - 7 years old 13 31
7-12 years old 12 1*8
Phi = .10999; Chi-square = 1.2667} p < ,30 20^
TABLE 36
CONTINGENCY TABLE FOR THE STIMULUS, FATHER,
AND THE SUBJECT'S AGE
Stressful Nonstressful k - 7 years old 6 28
7 - 12 years old 12 k j
Phi = -.050565 Chi-square = .2266} p<,90
TABLE 37
CONTINGENCY TABLE FOR THE STIMULUS, BABY,
AND THE SUBJECT'S AGE
Stressful Nonstressful k - 7 years old 2 10
7 - 12 years old 1 10
Phi = ,0000{ Chi-square = .0000 205
TABLE 38
CONTINGENCY TABLE FOR THE STIMULUS, CAT,
AND THE SUBJECT'S AGE
Stressful______Nonstressful u - 7 years old 3 9
7 - 12 years old 7 16
Phi = .0000; Chi-■square = .0000
TABLE 39
CONTINGENCY TABLE FOR THE STIMULUS, NURSE,
AND THE SUBJECT' S AGE
Stressful Nonstressful
U - 7 years old 8 36
7 - 12 years old 10 50
Phi = .01978; Chi-square = .0^07; p<.90 TABLE 40
CONTINGENCY TABLE FOR THE STIMULUS, DOCTOR,
AND THE SUBJECT’S AGE
Stressful Nonstressful
4 - 7 years old 10 30
7-12 years old 6 52
Phi = .19^7} Chi-square = 3.7219} p<.10
TABLE 41
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL GOWN,
AND THE SUBJECT’S AGE
Stressful Nonstressful
4 - 7 years old 20 19
7-12 years old 30 25
Phi = -.03221} Chi-square = .0976; p <.90 207
TABLE 42
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL ROOM,
AND THE SUBJECT'S AGE
Stressful Nonstressful
4 - 7 years old 6 38
7 - 12 years old 6 52
Phi = .05059; Chi-square = .2611} p <,90
TABLE 43
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL BED,
AND THE SUBJECT'S AGE
Stressful Nonstressful
4 - 7 years old 13 29
7 ~ 12 years old 15 42
Phi = .0507? Chi-square = .2563} p<,90 208
TABLE 44
CONTINGENCY TABLE FOR THE STIMULUS, FOOD,
AND THE SUBJECT'S AGE
Stressful Nonstressful
4 - 7 years old 13 31
7-12 years old 14 **•5
Phi = .06542; Chi-square = ,4409; p <.70
TABLE 45
CONTINGENCY TABLE FOR THE STIMULUS, MEDICATIONS,
AND THE SUBJECT'S AGE
Stressful______Nonstressful
4 - 7 years old 36 7
7-12 years old 50 10
Phi = -.00511; Chi-square = .0027; p<.95 209
TABLE 46
CONTINGENCY TABLE FOR THE STIMULUS, TOYS,
AND THE SUBJECT'S AGE
Stressful______Nonstressful
4 - 7 years old 0 44
7-12 years old 0 56
Phi = .0000} Chi-square = .0000
TABLE 47
CONTINGENCY TABLE FOR THE STIMULUS, THERMOMETER,
AND THE SUBJECT'S AGE
Stressful Nonstressful
4 - 7 years old 21 21
7-12 years old 27 31
Phi = .03405; Phi-square = .Il60j p<,80 210
TABLE 48
CONTINGENCY TABLE FOR THE STIMULUS i , STETHOSCOPE,
AND THE SUBJECT'S AGE
Stressful Nonstressful
4 - 7 years old 5 25
7-12 years old 10 44
Phi = -.02317; Chi-square = .0451; p <.90
TABLE 49
CONTINGENCY TABLE FOR THE STIMULUS, HOUSE,
AND THE SUBJECT’S AGE
Stressful______Nonstressful
4 - 7 years old 11 26
7-12 years old 19
Phi = -.0203; Chi-square = ,0402; p<,90 TABLE 50
CONTINGENCY TABLE FOR THE STIMULUS, SCHOOL,
AND THE SUBJECT’S AGE
Stressful______Non stress ful
^ - 7 years old 1 15
7-12 years old 16 39
Phi = ,0000; Chi-square = .0000
TABLE 51
CONTINGENCY TABLE FOR THE TOTAL NUMBER OF
STRESSFUL STIMULI AND THE SUBJECT’S AGE
Les3 than 6 stimuli More than 6 stimuli
k - 7 years old 22 22
7-12 years old 32 28
Phi = -.0330; Chi-square = ,1130; p<.80 212
TABLE 52
CONTINGENCY TABLE FOR THE STIMULUS, BOY,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 16 29
Female 10 16
Phi = .02899; Chi-square = .0599; p<.90
TABLE 53
CONTINGENCY TABLE FOR THE STIMULUS, GIRL,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 15 27
Female 15 17
Phi = -.0847^; Chi-square = ,5099» p<.50 213
TABLE 54
CONTINGENCY TABLE FOR THE STIMULUS, MOTHER,
AND THE SUBJECT'S SEX
Stressful______Nonstressful
Male 15 43
Female 10 36
Phi = .04422j Chi-square = .2388; p ^ ^ O
TABLE 55
CONTINGENCY TABLE FOR THE STIMULUS, FATHER,
AND THE SUBJECT' S SEX
Stressful Nonstressful
Male 9 36
Female 9 35
Phi = -.00563; Chi-square = .0028; p<.90 TABLE 56
CONTINGENCY TABLE FOR THE STIMULUS, BABY,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 2 9
Female 1 11
Phi = .0000; Chi-square = ,0000
TABLE 57
CONTINGENCY TABLE FOR THE STIMULUS, CAT,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 6 13
Female k 12
Phi = .07199; Chi-square = .1842; p <.70 215
TABLE 58
CONTINGENCY TABLE FOR THE .STIMULUS, DOCTOR,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 10 44
Female 6 38
Phi = .06569; Chi-square = .4230; p<.70
TABLE 59
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL GOWN,
AND THE SUBJECT'S SEX
Stressful______Nonstressful
Male 27 24
Female 23 20
Phi = -.00545; Chi-square = ,0028; p<,98 216
TABLE 60
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL ROOM,
AND THE SUBJECT'S SEX
Stressful______Nonstressful
Male 7 51
Female 5 39
Phi = .01129: Chi-square = ,0120} p<,95
TABLE 61
CONTINGENCY TABLE FOR THE STIMULUS , HOSPITAL BED,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 18 38
Female 10 33
Phi = .09780} Chi-square = . 9 W i p<.50 217
TABLE 62
CONTINGENCY TABLE FOR THE STIMULUS, FOOD,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 18 39
Female 9 37
Phi = .15310; Chi-square = 1.8995; p<.20
TABLE 63
CONTINGENCY TABLE FOR THE STIMULUS, MEDICATIONS,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 48 10
Female 38 7
Phi = .02253? Chi-square = ,0523; p<,90 218
TABLE 64
CONTINGENCY TABLE FOR THE STIMULUS, TOYS,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 0 57
Female 0 43
Phi = .0000; Chi-square = .0000
TABLE 65
CONTINGENCY TABLE FOR THE STIMULUS, THERMOMETER,
AND THE SUBJECT’S SEX
Stressful Nonstressful
Male 28 27
Female 20 25
Phi = .06437; Chi-square = .4144; p<.70 219
TABLE 66
CONTINGENCY TABLE FOR THE STIMULUS, STETHOSCOPE,
AND THE SUBJECT'S SEX
Stressful______Nonstressful
Male 10 36
Female 5 33
Phi = .11152; Chi-square = 1.0447; p<,50
TABLE 67
CONTINGENCY TABLE FOR THE STIMULUS, HOUSE,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 15 40
Female 15 27
Phi = -.09049 ; Chi-square = ,7944; p<,50 220
TABLE 68
CONTINGENCY TABLE FOR THE STIMULUS, SCHOOL,
AND THE SUBJECT'S SEX
Stressful Nonstressful
Male 11 31
Female 6 23
Phi = ,06335s Chi-square = .2850} p <,70
TABLE 69
CONTINGENCY TABLE FOR THE TOTAL NUMBER OF
STRESSFUL STIMULI AND THE SUBJECT'S SEX
Less than 6 stimuli More than 6 stimuli
Male 32 26
Female 22 24
Phi = .07302; Chi-square = .5546} p<,50 221
TABLE 70
CONTINGENCY TABLE FOR THE STIMULUS, BOY,
AND THE SUBJECT'S DIAGNOSIS
Stressful______Nonstress fttl
Medical 12 22
Surgical 23
Phi = -.02637; Chi-square = .0494; p<.90
TABLE 71
CONTINGENCY TABLE FOR THE STIMULUS, GIRL,
AND THE SUBJECT'S DIAGNOSIS
Stressful______Nonstressful
Medical 15 19
Surgical 15 22
Phi = ,03608; Chi-square = .0929; p < .80 TABLE 72
CONTINGENCY TABLE FDR THE STIMULUS, MOTHER,
AND THE SUBJECT'S DIAGNOSIS
Stressful Nonstressful
Medical 15 35
Surgical 10 UU
Phi = ,13h2h» Chi-square = 1.87^2; p ^,20
TABLE 73
CONTINGENCY TABLE FOR THE STIMULUS, FATHER,
AND THE SUBJECT'S DIAGNOSIS
Stressful Nonstressful
Medical 11 33
Surgical 7 38
Phi = .11755; Chi-square = 1.2299; p<.30 223
TABLE 74
CONTINGENCY TABLE FOR THE STIMULUS, BABY,
AND THE SUBJECT’S DIAGNOSIS
Stressful______Nonstressful
Medical 2 12
Surgical 1 8
Phi = .0000? Chi-square = .0000
TABLE 75
CONTINGENCY TABLE FOR THE STIMULUS, CAT,
AND THE SUBJECT'S DIAGNOSIS
Stressful Nonstressful
Medical 8 11
Surgical 2 14
Phi = ,32645? Chi-square = 3.7303? p<.10 TABLE 76
CONTINGENCY TABLE FOR THE STIMULUS, NURSE,
AND THE SUBJECT'S DIAGNOSIS
Stressful Nonstressful
Medical 10 40
Surgical 8 46
Phi = .06847; Chi-square = .4877; p^.50
TABLE 77
CONTINGENCY TABLE FOR THE STIMULUS, DOCTOR,
AND THE SUBJECT'S DIAGNOSIS
Stressful______Non stressful
Medical 8 38
Surgical 8 44
Phi = ,02709; Chi-square = .0719$ p<.80 225
TABLE 78
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL GOWN,
AND THE SUBJECT'S DIAGNOSIS
Stressful______Nonstressful
Medical 23 22
Surgical 27 22
Phi = -.0399^5 Chi-square = .1500; p<«70
TABLE 79
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL ROOM,
AND THE SUBJECT'S DIAGNOSIS
Stressful______Nonstressful
Medical 5 **5
Surgical 7 ^5
Phi = -.05370, Chi-square = .29^2; p<.70 226
TABLE 80
CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL BED,
AND THE SUBJECT'S DIAGNOSIS
Stressful Nonstressful
Medical 11 38
Surgical 17 33
Phi = -.12827; Chi-square = 1.6279} p^.30
TABLE 81
CONTINGENCY TABLE FOR THE STIMULUS, FOOD,
AND THE SUBJECT'S DIAGNOSIS
Stressful Nonstressful
Medical 13 37
Surgical lk 39
Phi = -.0047^; Chi-square = .0023; p TABLE 82 CONTINGENCY TABLE FOR THE STIMULUS, TOYS, AND THE SUBJECT'S DIAGNOSIS Stressful______Nonstressful Medical 0 49 Surgical 0 51 Phi = .0000; Chi-square = .0000 TABLE 83 CONTINGENCY TABLE FOR THE STIMULUS, THERMOMETER, AND THE SUBJECT'S DIAGNOSIS Stressful Nonstressful Medical 19 30 Surgical 29 22 Phi = -.15084; Chi-square = 3.2754; p<,10 228 TABLE 84 CONTINGENCY TABLE FOR THE STIMULUS, STETHOSCOPE, AND THE SUBJECT’S DIAGNOSIS Stressful______Nonstressful Medical 5 3^ Surgical 10 35 Phi = -.12244; Chi-square = 1.2590; p<.30 TABLE 85 CONTINGENCY TABLE FOR THE STIMULUS, HOUSE, AND THE SUBJECT’S DIAGNOSIS Stressful Nonstressful Medical 14 30 Surgical 16 37 Phi = -.0299? Chi-square = .01755? P<.90 229 TABLE 86 CONTINGENCY TABLE FOR THE STIMULUS, SCHOOL, AND THE SUBJECT'S DIAGNOSIS Stressful______Nonstressful Medical 5 25 Surgical 17 29 Phi = -.14583; Chi-square = 1.5107} p TABLE 87 CONTINGENCY TABLE FOR THE TOTAL NUMBER OF STRESSFUL STIMULI AND THE SUBJECT'S DIAGNOSIS Less than 6 stimuli More than 6 stimuli Medical 24 26 Surgical 30 24 Phi = -.07554} Chi-square = .5937} P<.50 230 TABLE 88 CONTINGENCY TABLE FOR THE STIMULUS, BOY, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 16 31 More than 5 days 10 14 Phi = -.07486; Chi-square = ,3979s p < .70 TABLE 89 CONTINGENCY TABLE FOR THE STIMULUS, MOTHER, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful ______Nonstressful. Less than 5 days 19 47 More than 5 days 6 32 Phi = .14647; Chi-square = 2.2314; p<,20 231 TABLE 90 CONTINGENCY TABLE FOR THE STIMULUS, FATHER, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 10 48 More than 5 days 8 23 Phi = -,10305; Chi-square = ,9186; p<,50 TABLE 91 CONTINGENCY TABLE FOR THE STIMULUS, BABY, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful______Nonstressful Less than 5 days 14 1 More than 5 days 6 2 Phi = ,0000; Chi-square = ,0000 232 TABLE 92 CONTINGENCY TABLE FOR THE STIMULUS, CAT, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful______Nonstressful Less than 5 days 8 15 More than 5 days 2 10 Phi = .0000? Chi-square = .0000 TABLE 93 CONTINGENCY TABLE FOR THE STIMULUS, DOCTOR, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 7 5k More than 5 days 9 28 Phi = -.16885? Chi-square = 2.7833? P<.10 233 TABLE 9k CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL GOWN, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 31 31 More than 5 days 19 13 Phi = -,0636; Chi-square = .380^} p C.70 TABLE 95 CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL ROOM, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 7 58 More than 5 days 5 32 Phi = -,0l+095» Chi-square = .1711 j p<.70 I ZJk TABLE 96 CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL BED, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 16 47 More than 5 days 12 2 k Phi = -.0847; Chi-square = .7114; p<.50 TABLE 97 CONTINGENCY TABLE FOR THE STIMULUS, FOOD, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 17 48 More than 5 days 10 28 Phi = -.00170j Chi-square = .0003; p<.99 235 TABLE 98 CONTINGENCY TABLE FOR THE STIMULUS, MEDICATIONS, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful______Nonstressful Less than 5 days 53 12 More than 5 days 33 5 Phi = -,067^6j Chi-square = ,4895? P C.50 TABLE 99 CONTINGENCY TABLE FOR THE STIMULUS, TOYS, AND SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 0 62 More than 5 days 0 38 Phi = ,0000; Chi-square = .0000 TABLE 100 CONTINGENCY TABLE FOR THE STIMULUS, THERMOMETER, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful______Nonstressful Less than 5 days 32 32 More than 5 days 16 20 Phi = .0417} Chi-square = .1739; p^.70 TABLE 101 CONTINGENCY TABLE FOR THE STIMULUS, STETHOSCOPE,, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 10 45 More than 5 days 5 24 Phi = ,01164; Chi-square = .0114; p<,95 237 TABLE 102 CONTINGENCY TABLE FOR THE STIMULUS, HOUSE, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 15 46 More than 5 days 15 21 Phi = -.17849; Chi-square = 3.0903; p^.10 TABLE 103 CONTINGENCY TABLE FOR THE STIMULUS, SCHOOL, AND THE SUBJECT'S LENGTH OF HOSPITALIZATION Stressful Nonstressful Less than 5 days 8 35 More than 5 days 9 19 Phi = -.15504; Chi-square = 1.7067; p<,20 238 TABLE 104 • CONTINGENCY TABLE FOR THE STIMULUS, BOY, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 14 23 Not prepared 12 22 Phi = .0263; Chi-square = .0494; p<,90 TABLE 105 CONTINGENCY TABLE FOR THE STIMULUS, GIRL, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 16 20 Not prepared 14 21 Phi = ,04498; Chi-square = .1437; p<.80 239 TABLE 106 CONTINGENCY TABLE FOR THE STIMULUS, MOTHER, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 13 tu Not prepared 12 38 Phi = .0003; Chi-square = ,0001; p<,97 TABLE 107 CONTINGENCY TABLE FOR THE STIMULUS, FATHER, AND THE SUBJECT'S PREPARATION Stressful______Nonstres3ful Prepared 10 38 Not prepared 8 33 Phi = .01639; Chi-square = .0239; p<.90 240 TABLE 108 CONTINGENCY TABLE FOR THE STIMULUS, BABY, AND THE SUBJECT'S PREPARATION Stressful______Nonstressful Prepared 1 12 Not prepared 2 8 Phi = .0000; Chi-square = .0000 TABLE 109 CONTINGENCY TABLE FOR THE STIMULUS, DOG, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 13 21 Not prepared 15 12 Phi = -.17264; Chi-square = 1,8181; p<,20 TABLE 110 CONTINGENCY TABLE FOR THE STIMULUS, CAT, AND THE SUBJECT'S PREPARATION Stressful______Nonstressful Prepared 6 14 Not prepared 4 11 Phi = .03652} Chi-square = .0467} p <.90 TABLE 111 CONTINGENCY TABLE FOR THE STIMULUS, DOCTOR, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 5 45 Not prepared 11 37 Phi = 17469} Chi-square = 2.9909} p<.10 TABLE 112 CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL GOWN, AND THE SUBJECT'S PREPARATION Stressful______Nonstreasful Prepared 26 23 Not prepared 24 21 Phi = .0027; Chi-square = .0007; p < .98 TABLE 113 CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL ROOM, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 4 49 Not prepared 8 41 Phi = -.13614; Chi-square = 1,8905: p^.20 2 4 3 TABLE 114 CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL BED, AND THE SUBJECT'S PREPARATION Stressful______Nonstressful Prepared 10 40 Not prepared 18 31 Phi = -.18577; Chi-square = 3,4l68; p<,10 TABLE 115 CONTINGENCY TABLE FOR THE STIMULUS, FOOD, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 10 44 Not prepared 17 32 Phi = -,18367; Chi-square = 3,4750; p^,10 244 TABLE 116 CONTINGENCY TABLE FOR THE STIMULUS, MEDICATIONS, AND THE SUBJECT * S PREPARATION Stressful Nonstressful Prepared 47 6 Not prepared 39 11 Phi = .14377; Chi-square = 2,1292} p<,20 TABLE 117 CONTINGENCY TABLE FOR THE STIMULUS, TOYS, AND THE SUBJECT'S PREPARATION Stressful Nonstressful Prepared 0 51 Not prepared 0 49 Phi = .0000; Chi-square = .0000 TABLE 118 CONTINGENCY TABLE FOR THE STIMULUS, THERMOMETER, AND THE SUBJECT’S PREPARATION Stressful Nonstressful Prepared 22 28 Not prepared 26 24 Phi = -,08006; Chi-square = ,6410; p<,50 TABLE 119 CONTINGENCY TABLE FOR THE STIMULUS, STETHOSCOPE, AND THE SUBJECT’S PREPARATION Stressful Nonstressful Prepared 6 36 Not prepared 6 33 Phi = -.09322; Chi-square = .7301; p^.50 TABLE 120 CONTINGENCY TABLE FOR THE STIMULUS, SCHOOL, AND THE SUBJECT'S PREPARATION Stressful______Nonatressful Prepared 7 26 Not prepared 10 28 Phi = -.070^7; Chi-square = .2526; p<.70 TABLE 121 CONTINGENCY TABLE FOR THE STIMULUS, BOY, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 13 20 No experience 12 26 Phi = .07201» Chi-square = .3682j p C.70 2k? TABLE 122 CONTINGENCY TABLE FOR THE STIMULUS, GIRL, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful______Nonstressful Experience 12 19 No experience 17 23 Phi = -,04885s Chi-square = .1695$ p<,70 TABLE 123 CONTINGENCY TABLE FOR THE STIMULUS, MOTHER, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 12 36 No experience 13 43 Phi = ,01577s Chi-square = ,0259s p<,90 TABLE 124 CONTINGENCY TABLE FOR THE STIMULUS, FATHER, AND THE SUBJECT’S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 8 32 No experience 10 39 Phi = -.01033; Chi-square = ,0093} p<.95 TABLE 125 CONTINGENCY TABLE FOR THE STIMULUS, BABY, AND THE SUBJECT’S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 1 6 No experience 2 14 Phi = ,0000} Chi-square = .0000 249 TABLE 126 CONTINGENCY TABLE FOR THE STIMULUS, DOG, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 10 15 No experience 17 19 Phi = -.0842} Chi-square = ,4329} p < .70 TABLE 127 CONTINGENCY TABLE FOR THE STIMULUS, CAT, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 1 11 No experience 8 15 Phi = ,0000} Chi-square = ,0000 250 TABLE 128 CONTINGENCY TABLE FOR THE STIMULUS, NURSE, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful______Nonstressful Experience 9 3 9 No experience 8 4 8 Phi = .05622; Chi-square = .3288; p < .70 TABLE 129 CONTINGENCY TABLE FOR THE STIMULUS, DOCTOR, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful______Nonstressful Experience 10 35 No experience 6 4 7 Phi = ,1469; Chi-square = 2.11711 p<,20 251 TABLE 130 CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL GOWN, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful NonstresBful Experience 2? 16 No experience 23 28 Phi = ,1669} Chi-square = 2,6219} ■pK.ZO TABLE 131 CONTINGENCY TABLE FOR THE STIMULUS, HOSPITAL BED, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 14 31 No experience 13 41 Phi = .07304} Chi-square = .52831 p<«50 252 TABLE 132 CONTINGENCY TABLE FOR THE STIMULUS, FOOD, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION - Stressful Nonstressful Experience 14 3^ No experience 13 42 Phi = ,0573; Chi-square = .3386; p<.70 TABLE 133 CONTINGENCY TABLE FOR THE STIMULUS, MEDICATIONS, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful______Nonstressful Experience 39 8 No experience 46 10 Phi = -.0087; Chi-square = .0079; p<.95 TABLE 134 CONTINGENCY TABLE FOR THE STIMULUS, TOYS, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 0 ^5 No experience 0 55 Phi = ,0000} Chi-square = ,0000 TABLE 135 CONTINGENCY TABLE FOR THE STIMULUS, THERMOMETER, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 27 20 No experience 21 32 Phi = ,17001} Chi-square = 2.8905} p<.10 25^ TABLE 136 CONTINGENCY TABLE FOR THE STIMULUS, HOUSE, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 13 32 No experience 16 36 Phi = ,0268; Chi-square = ,0699} p<.80 TABLE 137 CONTINGENCY TABLE FOR THE STIMULUS, SCHOOL, AND THE SUBJECT'S EXPERIENCE WITH SEPARATION Stressful Nonstressful Experience 6 28 No experience 10 27 Phi = -.1197} Chi-square = 1,0178} p<.50 255 TABLE 138 CONTINGENCY TABLE FOR THE TOTAL NUMBER OF STRESSFUL STIMULI AND THE SUBJECT *S EXPERIENCE WITH SEPARATION Less than 6 stimuli More than 6 stimuli Experience 28 20 No experience 26 30 Phi = ,1279j Chi-square = l.?019i P < .20 BIBLIOGRAPHY 257 BIBLIOGRAPHY Books Allport, Floyd H. 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