STRESS & REACTIONS RELATED TO DEVELOPMENTAL STAGES

& PLAY ACTIVITIES FOR

ILL HOSPITAIZED CHILD

Presented byMiss K Gnana Jyothi

MSc (N)

MEANING OF STRESSThe word stress is derived from the

latin word “stringi” which means, “to be drawn tight”.

Stress is described as a physiological or psychological stimulus that can produce mental tension or physiological reactions that may lead

to illness”.

DEFINITION STRESS :A non-specific response to stressors or

demands made on the body. - SelyeStress is a feeling experienced when a person thinks that “the demands exceed

the personal and social resources the individual is able to mobilize” -Richard.S.Lazarus

STRESSOR :A stressor is any event or stimulus that causes an

individual to experience stress. -Barbara KozierILLNESS:Illness is a highly personal state in which the person’s physical,

emotional,intellectual, social, developmental or spiritual functioning is thought to be diminished. -Barbara Kozier

STRESSORS OF HOSPITALIZATION AND CHILD’S REACTION

Child’s response depends on :• Developmental level and coping mechanism• Parent- child relationships• Cultural and religious influences• Previous experience with hospitalization

STRESSORS OF HOSPITALIZATION

Physical harm or bodily injury

Loss of control

Separation anxiety

SEPARATION

ANXIETY

• Separation anxiety is defined as child’s apprehension associated with separation from a parent or caregiver.

• It is also called as “anaclitic depression”

General manifestations of separation anxiety in young children

Phase of protestPhase of despairPhase of detachment

INFANTS• At 0-5 months of age infant has not attached

much to the care giver• Stress due to change in the enviroment or

change in the care giver can be detected through

Altered sleepingAltered feedingAltered elimination pattern

• STRANGER ANXIETY : 5-7 months shows displeasure at the approach of unfamiliar peopleExpected behaviorCries when approached by nursing staff• SEPARATION ANXIETY :7-9 monthsIs upset when separated from parentsExpected behaviorCries when parents leave, may reject attempts to comfort.

TODDLER {1-3 YEARS}Demonstrates more goal – oriented behaviorExpected behavior• Plead with parents• Tries to keep the parent with them • Try to find parents who have left• Displeasure on parents return or departure by having temper tantrums• Refusing to comply with the usual routines of meal time, bed time, toileting

PRE SCHOOLER {3-6 YEARS}

Normal growth & development• Can tolerate brief periods of separation• Develops substitute trust in other significant

adultsHospitalization • Less able to cope with separation• Develops separation anxiety• Protest behaviors are subtle & passive

EXPECTED BEHAVIOR

• Refusing to eat

• Experiencing difficulty in sleeping

• Crying quietly for their parents

• Withdrawing from others

• Expresses anger indirectly by breaking toys

• Hitting other children

• Refusing to co-operate during self-care activities

SCHOOL CHILDREN{6-12 YEARS}NORMAL GROWTH & DEVELOPMENTIs able to cope up with separationON HOSPITALIZATION• They miss the school routine and worry

that they will not be able to compete or “fit – in” with their class- mates when they return.

• Feelings of Loneliness

isolation

boredom

depression

• Reluctant to seek help , directly fearing that they will appear weak, childish or dependent.

• Cultural expectations “to act like a man” or “to be brave” weigh heavily on these children, especially boys who tend to react to stress with stoicism, withdrawal or passive acceptance.

EXPECTED BEHAVIOR

• Irritability

• Aggression towards parents

• Withdrawal from hospital personnel

• Inability to relate to peers

• Rejection of siblings

• Subsequent behavioral problems at school

ADOLESCENTS{>12 YEARS}• Separation from home and parents may produce

varied emotions.• Loss of peer group contact may pose a severe

emotional threat because of -loss of group status - inability to exert group control or leadership - loss of group acceptance

• On hospitalization temporary separation from the group may benefit from group associations with other hospitalized children.

EXPECTED BEHAVIOR

• Like to be separated from parents for sometime but prolonged separation may produce stress.

• One of the factors influencing the amount of stress imposed by hospitalization is the amount of control that persons perceive themselves as having.

• Lack of control increases the perception of threat & can affect children’s coping skills.

• Many hospital situations decrease the amount of control the child feel.

• Sight, sound, smell of the hospital may overwhelm the child.

• Without insight------type of environment

hospital

Slows development restricts

INFANTS• Develops trust consistent & loving care by nurturing person • In hospital settings, cues may be missed or

misinterpreted and routines may be established to meet the hospital staff’s needs instead of the infants need.

• Inconsistent care and deviations from the infant’s daily routine may lead to mistrust.

EXPECTED BEHAVIOR

• Crying or smiling

TODDLERS

• Strive for autonomy and this can be evident in through their behaviors such as :

motor skills play inter-personal relationships activities of daily living communication

• when their egocentric pleasures meet with obstacles, toddlers react with negativism.

• E.g.,. any restriction or limitation of movement such as simple act of making toddlers lie down, can cause forceful resistance and non-compilance.

ALTERED ROUTINES AND RITUALSEnforced dependency is the chief

characteristic of the sick role and accounts for numerous instances of toddler negativism.

For example :Rigid schedulesDifferent clothesAltered care giving activitiesUnfamiliar surroundingsSeparation from parents medical procedures

• Most toddlers react negatively & aggressively to such dependency, prolonged loss of autonomy may result in :

passive withdrawal from interpersonal relationships and ;

regression in all areas of developmentEXPECTED BEHAVIOURTemper tantrums

PRESCHOOLERS• Suffer from loss of control caused by : physical restriction altered routines enforced dependency• Their specific cognitive ability make them feel

all powerful and also make them feel out of control.

• Their egocentric and magical thinking limits their ability to understand events because they view all experiences from their own self-referenced perspective.

• Without adequate preparation for unfamiliar settings or experiences, preschooler’s fantasy explanations for such events are usually more exaggerated, bizarre and frightening than the facts.

• One typical fantasy to explain the illness or hospitalization is that it represents punishment for real or imagined deeds.

• In response such thinking, the child feels • shame, guilt and fear.

Verbal instructions are inadequate because unable to abstract & synthesize beyond what their senses tell them

• Transductive reasoning implies that pre- schoolers deduct from the particular to particular rather than specific to specific.

• E.g.,. Preschoolers concept of nurse is that they inflict pain & will think that every nurse or every one wearing similar uniform also

• does the same.

EXPECTED BEHAVIOUR• Protests attempts to perform the procedure

SCHOOL AGE CHILDREN• They strive for independence and productivity

vulnerable to events

lessen their feelings of control and power

Factors that result in loss of control includes : altered family roles physical disability fears of death, abandonment or permanent injury loss of peer acceptance lack of productivity inability to cope with stress

• Dependent activities of school age children in hospital are :

enforced bed rest use of bed pan inability to choose a menu lack of privacy help with a bed bath transport by wheel chair or stretcher

• All procedures seem routine and inconsistent but give no freedom to children who want to act “grown up”.

• May help in making their beds, choose their schedule of activities and assist in their own care.

• Boredom is one of the most significant problem seen in school children.

• Physical limitations---depression, frustration.

EXPECTED BEHAVIOR-Depression - Frustration

-hostility

ADOLESCENT• Adolescents search for : independence self- assertion

liberation

• Anything that interfers with this poses a great threat to their sense of identity and results in loss of control.

• Illness forms the major situational crisis.• The parents role fosters Dependency & depersonalizationHence respond to depersonalization with self-

assertion, anger, frustration.

• Peers may visit but they may not be able to offer the kind of support and guidance needed.

• Sick adolescents often voluntarily isolate themselves from age-mates until they feel they can compete on an equal basis and meet group expectations.

EXPECTED BEHAVIOUR• Dependency with rejection• Uncooperativeness• withdrawal

PHYSICAL HARM OR BODILY INJURY

STRESSORS & REACTIONS OF THE FAMILY OF THE HOSPITALIZED CHILD• It includes :Parental reactionsSibling reactionsAltered family roles

PARENTAL REACTIONS

• Crisis of childhood illness and hospitalization affects every member of the family.

SPECIFIC CAUSES OF PARENTAL ANXIETY

• Strange environment in the hospital• Separation from the child• Unknown events & outcome• Suffering of the child• Spread of infections of other members of the

family• Unbearable financial obligations• Society will look upon illness as something wrong

SIBLING REACTIONSSiblings experience • Loneliness• Fear• Worry • Resentment• Jealousy • Guilt

• Craft (1993 ) reported that the following factors regarding siblings are related specifically to the hospital experience and increase the effects on the siblings.

Being younger and experiencing many changes

Being cared for outside the home by care providers who are not relatives.

receiving little information about their ill brother or sister

Perceiving that their parents treat them differently compared with before their sibling’s hospitalization.

• The siblings of a chronically ill child may feel sorrow when told of the diagnosis but they quickly become involved in their own activities of childhood.

• A number of factors increase the risk of negative effects for siblings of ill children, they include:

---------responsibility for care giving---------differential treatment by parents---------limitation in family resources &

recreational time

REACTIONS OF SIBLINGS INCLUDE

• Physical symptoms to those of ill child

• Changes in academic

attendance

• Changes in patterns

of socialization

• Regression

• Attention seeking or anti-social behavior

• Habits related to increased level of anxiety• Eg.,nail biting

Altered family roles• One of the most common reactions of parents

is specialized and intensified attention toward the sick child

• Other siblings may regard this as unfair and interpret the parents attitude

toward them as rejection

• Rivalry between tends to be greatest for the sibling who is nearest in age to the ill child.

• Without an understanding of the inter-personal dynamics between siblings, parents are to blame the well children for anti-social behaviour.

ROLE OF A NURSE AIMS : -To help cope with

stress of illness & hospitalization of

children. - To provide family –

centered care.

In neonates

• Provide continual contact between baby and parents with the active involvement by rooming-in and sensory-motor stimulation as appropriate

In infants• Minimize separation • Basic needs of the infant should be fulfilled• Mother can be allowed during the procedure• Tension and loneliness can be relieved by toys.

In toddlers• Provide rooming-in and un-limited visiting

hours to express child’s feeling• No punishment to the child• Home routine can be continued• Familiar toys and articles can reinforce the the child’s sense of security.• Should provide love and understanding

In pre-school children• Minimize stress of separation by providing

parental presence and participation in care.

• Plan to shorten the hospital stay as possible.

• Help the child to accept the stressful situation with love and concern

• Set limits to the child & provide opportunity to verbalize feelings.

• Careful preparation for all the procedures by privacy and explanation according to the level of understanding.

• Encourage the child to participate in self-care and hygiene as appropriate

• Discourage parents from reinforcing negative feeling’s to the child.

eg. “if you are not listening to me, I

shall leave you here”.

In school children• Help the parent to prepare the child for

elective hospitalization.• Respect the child’s need for privacy and

modesty during examination• Thorough nursing history need to be

obtained to plan the care

• Help the child to identify problems and to ask questions.

• Use treatment room whenever possible to perform the procedure.

• Explain the procedure and its purpose with reassurance

• Encourage the child in self-care, play, school work.

• Encourage parental participation in child care.

In adolescents• Help parents to prepare adolescents for

planned admission.• Assess the impact of illness and

hospitalization and presence of misconceptions

• Obtain thorough history, habits, recreation, personal preferences on self care and food habit

• Hospital staff, hospital routines and facilities available should be explained soon after admission.

• Involve the adult patients in planning of care.

• Explain all procedures • Provide opportunities for recreation, peer-

relationships, and interaction with other adolescent patients and expression of feelings.

PLAY ACTIVITIES FOR ILL

HOSPITALIZED CHILD

DEFINITION OF PLAY “Play is pleasurable and

enjoyable aspect of child’s life & essential to promote growth & development”

-Parul dutta

PLAY THERAPY“Play therapy is based upon the fact that play is

the child’s natural medium of self-expression. It is an opportunity which is given to the child

to “play-out” his feelings and problems just as in certain types of adult therapy, an individual talks out his difficulties.”

PLAY ACTIVITIES OF HOSPITALIZED CHILD

• It includes - diversional activities -toys - expressive activities - creative expression - dramatic play

1.DIVERSIONAL ACTIVITIES

2.TOYS

3.EXPRESSIVE ACTIVITIES

4.CREATIVE EXPRESSION

5. DRAMATIC PLAY

THERAPEUTIC PLAY

• It is the central mechanism in which children cope, communicate, learn, and master a traumatic experience such as hospitalization.

• It is guided by health team members• It can be provided to the convalescent and

immobilized bed-ridden children when they passed over acute illness at hospital or at home.

•

• Play in hospital setting can occur only when children are less threatened.

• When no play is permitted it indicates psychological abuse.

IMPORTANCE OF PLAY FOR HOSPITALIZED CHILDREN

• It helps the childTo enhance coping abilities in hospital environmentTo understand and comprehend the hospital

proceduresTo express fear, anxiety, tension, anger and fantasiesTo communicate with others and to reduce

emotional trauma due to hospital experiences

to continue growth and development in physical, psychological, social, moral and educational aspects

To get rid of boredom due to prolong illness and to release hostile feelings

• It helps the health team members:To gain co-operation and trusting relationship

of the hospitalized children and their family members.

To diagnose the child’s feeling and behaviour and plan for psychological approach during care.

To find out and correct the misconceptions and beliefs regarding hospitalized care.

To reassure the anxious parent & to promote their participation in child care during illness and wellness

TYPES OF PLAY FOR HOSPITALIZED CHILDREN

• It is of three typesEmotional outlet or

dramatic play

Instructional play

Physiological enhancing play

1.EMOTIONAL OUTLET OR DRAMATIC PLAY• It is used to express the child’s anxiety to solve

conflict and as a diagnostic tool to identify child’s concern about the illness and hospitalization.

• Eg.,playing with doll being a nurse and caring sick doll with expression of own feeling, story telling,.etc.

2.INSTRUCTIONAL PLAY

• Instruction is given for therapeutic play to children-according to their past experiences, coping abilities and physiological status.

• Eg,. –use of colour in drawing - drawing in blank paper -learning the instructions on health habit

3.PHYSIOLOGICAL ENHANCING PLAY• It is used to maintain and improve physical

health and body functions• It can be selected to treat pathological

conditions• Eg,. breathing exercises to treat respiratory

problems by blowing bubbles , squeezing the bath sponge or ball to improve neurological

functions.

FILIAL THERAPY• It was developed by Bernard and Louise

guerney• It enhances parent –child relationship by

empowering the parent with new and innovative ways to interact with their child

• It provides an environment where the child receives concentrated attention from the parent, thus lessening the anxiety of the child and allowing them to unlearn behavior patterns that lead to miscommunication.

• Parents are given the skills necessary to practice efffective listening and respond to child’s emotion as well as tools to enhance child’s self-esteem.

FILIAL GROUP THERAPY

• Parents can express their emotions, fears and concerns relating to their parent –child relationship

• Group sessions continue upto 18 months• After necessary training parents may conduct

play sessions at home.

OBJECTIVES AND OUTCOMES OF FILIAL THERAPY

Parents learn to set specific limits and engage the child in consistent and dedicated sessions involving play

The result is that the child begins to feel accepted and learns to express themselves in a socially adaptable and acceptable manner.

PLAY THEARPY• It is of two typesNon-directive playDirective play

1.NON-DIRECTIVE PLAY

• Transitional sand play therapy• Family therapy• Play therapy with the use of toys

2.DIRECTIVE PLAY THERAPY

• Directed sand tray therapy• Cognitive behavioral play therapy

NURSES RESPONSIBILITY IN PLAY• Ensure proper selection of toys• Supervision during play• Maintenance of play articles• Minimize stressors• Minimizing the fear of bodily injury & pain• Participation in play