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A study investigating the themes of children’s play after major heart surgery Ralston, Marjory 1979

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A STUDY  INVESTIGATING THE THEMES OF CHILDREN'S PLAY AFTER MAJOR HEART  SURGERY  by MARJORY B.Sc.N.,  RALSTON  The U n i v e r s i t y o f B r i t i s h  A THESIS SUBMITTED  IN  PARTIAL  THE REQUIREMENTS  Columbia,  FULFILLMENT OF  FOR THE DEGREE OF  MASTER OF SCIENCE IN  NURSING  in THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING  We a c c e p t t h i s  thesis required  as  conforming to  THE UNIVERSITY OF BRITISH  ©  the  standard  October  1973  COLUMBIA  1979  Marjory Ralston, 1979  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements  f o r an advanced degree at the U n i v e r s i t y  of B r i t i s h Columbia, I  agree that the L i b r a r y s h a l l make i t f r e e l y and  study.  a v a i l a b l e f o r reference  I f u r t h e r agree that permission f o r extensive copying of  t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s .  I t i s understood that  copying  or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n  permission.  Department o f The U n i v e r s i t y of B r i t i s h Columbia Vancouver 8, Canada  Date  l*f  •  10  -  7°\  ii  ABSTRACT  This study was designed to gather i n f o r m a t i o n about the nature and content o f p o s t - s u r g i c a l p p l a y behaviour d i s p l a y e d by h o s p i t a l i z e d pre-school c h i l d r e n .  Four questions were e x p l o r e d :  Are common themes  expressed i n the play behaviour o f h o s p i t a l i z e d p r e - s c h o o l c h i l d r e n a f t e r major surgery? behaviour demonstrated  Does the q u a l i t y and i n t e n s i t y o f the p l a y by p r e - s c h o o l c h i l d r e n f o l l o w a s i m i l a r p a t t e r n ?  W i l l p r e - s c h o o l c h i l d r e n use play therapy as a medium through which to express f e a r s and concerns about  t h e i r h o s p i t a l experience?  Do  c h i l d r e n tend to a c t out t h e i r p e r c e p t i o n s o f what has happened to them i n h o s p i t a l ? The p o p u l a t i o n s e l e c t e d f o r the study were four g i r l s and one boy between the ages o f three and f i v e years, who were admitted f o r major surgery on the heart or great v e s s e l s .  During the recovery  p e r i o d a f t e r surgery each c h i l d had the o p p o r t u n i t y to take p a r t i n at l e a s t f i v e play therapy s e s s i o n s l a s t i n g approximately one hour each.  . Play therapy took the form o f s i t u a t i o n a l p l a y u s i n g r e a l or  simulated h o s p i t a l equipment and v a r i o u s d o l l s r e p r e s e n t i n g c h i l d r e n and a d u l t s .  Each c h i l d chose the d i r e c t i o n and content o f p l a y .  i n v e s t i g a t o r took p a r t i n play as d i r e c t e d by the c h i l d . could j o i n i n i f they wished.  The v e r b a l and non-verbal  The  Parents behaviour  d i s p l a y e d by each c h i l d during play therapy was recorded by audio  tape  and by process r e c o r d i n g s . Flour out of f i v e c h i l d r e n i n the study p a r t i c i p a t e d i n p l a y therapy.  actively  In the course o f play they expressed f i v e common  iii  themes:  i n t r u s i v e procedures; re-enactment  of procedures?  testing  r e a l i t y ; autonomy: r e g a i n i n g c o n t r o l ; s e p a r a t i o n from home and f a m i l y ; and n u r t u r i n g a c t i v i t i e s .  The q u a l i t y and i n t e n s i t y of the c h i l d r e n ' s  play behaviour f o l l o w e d a p a t t e r n from i n t e n s e to more r e l a x e d and from aggressive to more gentle p l a y .  During play each c h i l d  some i n d i v i d u a l f e a r s and concerns about h i s h o s p i t a l i z a t i o n .  expressed In-  t r u s i v e procedures were the most frequent t o p i c of play f o r a l l the children.  F i n a l l y , each c h i l d tended to a c t through s p e c i f i c pro-  cedures so that play behaviour became a f a c t u a l account of the c h i l d ' s h o s p i t a l experience.  One c h i l d , the only boy i n the study, d i d not  want to p a r t i c i p a t e i n play therapy.  The reasons f o r t h i s were not  investigated. I t was concluded that play therapy i s a u s e f u l technique which can a s s i s t nurses understand the p r e - s c h o o l c h i l d ' s p e r c e p t i o n of h i s h o s p i t a l experience.  Play therapy a l s o has p o t e n t i a l as a t h e r a p e u t i c  i n t e r v e n t i o n t o help a c h i l d come to terms with the traumatic events of h i s h o s p i t a l i z a t i o n .  iv  TABLE OF CONTENTS CHAPTER I  PAGE INTRODUCTION The Problem Purpose o f the Study Assumptions D e f i n i t i o n o f Terms Limitations  II  REVIEW OF LITERATURE Introduction The S t r e s s f u l E f f e c t s o f H o s p i t a l i z a t i o n on the Pre-School C h i l d Review o f S e l e c t e d Research Studies Investigating Hospitalization of the Pre-Schooler S e l e c t e d Theories of Play T h e r a p e u t i c A p p l i c a t i o n o f Play The C h i l d with C o n g e n i t a l Heart Disease . . . Summary o f L i t e r a t u r e  III  METHODOLOGY Overview Sample S e l e c t i o n C o l l e c t i o n o f Data Implementation  IV  DISCUSSION AND INTERPRETATION OF THE DATA . . . . Introduction The C h i l d r e n i n the Study Overview of Play Therapy Sessions I n t r u s i v e Procedures . Re-enactment o f Procedures: Testing Reality Autonomy: Gaining C o n t r o l Separation from Home and Family Nurturing A c t i v i t i e s The C h i l d Who Didn't Want to Play Hospitals . . P o s t - H o s p i t a l Behaviour D i s c u s s i o n o f Findings L i m i t a t i o n s o f Study  1 5 9 10 10 11 13 13 13 24 29 32 43 48 49 49 51 51 52 53 53 53 55 57 60 62 64 65 65 69 70 75  CHAPTER V  PAGE CONCLUSION AND IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH Conclusion Implications for Nursing P r a c t i c e I n d i c a t i o n s f o r Further Research  78 78 80 82  BIBLIOGRAPHY APPENDIXES: Appendix A Appendix B Appendix C Appendix D  89 91 92 93  ACKNOWLEDGEMENTS  I Ruth E l l i o t t and f o r  all  particularly General  wish  t o e x p r e s s my a p p r e c i a t i o n t o my c o m m i t t e e ,  and M i s s B e t t y B r e g g , t h e many h o u r s grateful  of  and s u p p o r t ,  t i m e and e f f o r t on my b e h a l f .  t o t h e m e d i c a l and n u r s i n g  H o s p i t a l uho made t h i s  t o t h e p a r e n t s uho t o o k p a r t and t o  f o r t h e i r guidance  study  in this  possible. study  t h e c h i l d r e n uho were s u c h a j o y  so  staff I  Mrs.  of  am a l s o  I  am  Vancouver indebted  enthusiastically,  to play  "hospitals"  with.  CHAPTER  I  INTRODUCTION TO THE STUDY  Every year children are  procedures.^  f o r weeks  C h i l d r e n at  characteristics  traumatic  for  There  is  still  to ensure  sistently  used to  this  and may have this  w h i c h makes  body o f theory  that  tours  Over t h e p a s t knowledge  sibling  about  visiting is  nursing  is  one  occur  not  all  is  carried out.  consistently  interventions  trauma o f  in  all  age-  Hospital  conhis in-  the c h i l d .  Much  in  of  practice.  provide  routines.  the  Some  care  hospitals  pre-hospitalization In  some  However t h e s e  instances  interventions  pediatric units.  1975.  do  Furthermore,  determine i f  the p r e - s c h o o l  Morbidity  are  been a s t e a d i l y  improvement  for  British  and a c c e p t  care of  are e v a l u a t e d to  hospitalization  S t a t i s t i c s Canada, 1975, p . 8.  of  a c c e p t e d i n most a r e a s .  hospital  generally  Canada:  into  explaining  not  these  the emotional  A few a r e a s  teaching  the  frightening  especially  interventions  t h e r e has  visiting.  pre-operative  alleviate  and  experience  c h i l d understand  25 y e a r s  c a n be t r a n s l a t e d  and b o o k l e t s  of  children  have many  the h o s p i t a l s  effective age-related  the h o s p i t a l i z e d c h i l d that allow  these  endure p a i n f u l  the h o s p i t a l  much t o be done i n  U n r e s t r i c t e d parent  also  to  Some o f  developmental l e v e l  help the p r e - s c h o o l  hospitalization. creasing  i n Canada.  pre-school  them.  Columbia  of  two h u n d r e d t h o u s a n d  are admitted to h o s p i t a l  in hospital  related  approximately  they  do  child.  Catalogue  82-206,  - 2 The  problem o f p r o v i d i n g c o n s i s t e n t and e f f e c t i v e  emotional  care f o r the p r e - s c h o o l c h i l d i s not p e c u l i a r to B r i t i s h  Columbia.  Azarnoff states that: "The manner i n which c h i l d r e n ' s s t r e s s i s managed by f a m i l i e s and h o s p i t a l s t a f f , i f i t i B d e a l t with at a l l , varies."2 She  a l s o s t a t e s that i n C a l i f o r n i a the most common forms of p r e p a r a t i o n  f o r h o s p i t a l i z a t i o n f o r the p r e - s c h o o l and booklets  about h o s p i t a l routines.''  c h i l d are pre-admission The  r e s u l t s of the  tours  study  c a r r i e d out by Azarnoff et a l . i n d i c a t e that' t h i s form of p r e p a r a t i o n would seem to have l i m i t a t i o n s i n h e l p i n g the c h i l d understand what i s happening to him.  Hardgrove a l s o p o i n t s out t h a t m a t e r i a l s such  as b o o k l e t s , t o u r s and s l i d e tapes may children.  She  be misunderstood by younger  suggests that they should be used with d i s c r e t i o n  i n the presence of an understanding  a d u l t who  could provide  and  guidance  5 and f u r t h e r e x p l a n a t i o n . Although there seems to be a l a c k of d e t a i l e d p r e p a r a t i o n i n many p e d i a t r i c areas there are a l s o some w e l l documented accounts of i n d i v i d u a l i z e d programs e s p e c i a l l y designed c h i l d about h i s h o s p i t a l i z a t i o n .  to teach the  In p a r t i c u l a r , P e t r i l l o  pre-school describes  Pat A z a r n o f f , et a l . The P r e p a r a t i o n of C h i l d r e n f o r Hospitalization. Department of P e d i a t r i c s , U n i v e r s i t y of C a l i f o r n i a , Los Angeles, 1975, p. 1. 3  I b i d . , p.  ^ I b i d . , p.  5  2. 57.  C a r o l Hardgrove, "Emotional I n n o c u l a t i o n : The 3 R ' s of P r e p a r a t i o n " , J o u r n a l of the A s s o c i a t i o n f o r the Care of C h i l d r e n i n H o s p i t a l s , \l (#k Spring 1977) p. 17.  the g u i d e l i n e s  used at  hospitalization. utilized  as  the reasons going  for  his  t o happen t o  ations.  this  teaching  However,  program  aids to  lectual  and t o  for  are  understand  p r e p a r e him f o r what  is  him.^  and H a r d g r o v e  and e m o t i o n a l  thinking  equipment  the p r e - s c h o o l c h i l d  hospitalization,  procedures,  formation.  and h o s p i t a l  s u c h p r e p a r a t i o n p r o g r a m s may a l s o  Tesler  for  Centre to prepare c h i l d r e n  dolls  assist  They must be s k i l l f u l l y  standing. child  In  Cornell Medical  the danger growth  geared point lies  to each c h i l d ' s  out  that,  F u r t h e r m o r e , the p r e - s c h o o l  giving  child's  about  their  under-  the  young  intel-  them t o o much  transductive  what i s  limit-  l e v e l of  in preparing  in overestimating  and c o n s e q u e n t l y  can l e a d t o m i s c o n c e p t i o n s  have some  going  in-  mode  of  t o happen  to  7 him.  They a l s o  p r o g r a m may b e , preparation is situations. in ensuring  point not  not  all  out  that,  no m a t t e r  children w i l l  possible  for  how e f f e c t i v e a  be e x p o s e d t o  c h i l d r e n who a r e  it.  For  admitted i n  P r e p a r a t i o n p r o g r a m s a l o n e may n o t be t o t a l l y that  each c h i l d understands  preparation  and comes t o  example, emergency  effective  terms with  his  hospitalization. Play appropriate  therapy  has  been s u g g e s t e d by s e v e r a l w r i t e r s  i n t e r v e n t i o n w h i c h may f a c i l i t a t e  the c h i l d ' s  M a d e l i n e P e t r i l l o , " P r e p a r i n g C h i l d r e n and P a r e n t s H o s p i t a l i z a t i o n and T r e a t m e n t " , P e d i a t r i c A n n a l s (December  pp.  as  an  understanding  for 1972)  Zk-kl.  7 Mary T e s l e r and C a r o l H a r d g r o v e , " C a r d i a c C a t h e t e r i z a t i o n : P r e p a r i n g t h e C h i l d " , A m e r i c a n J o u r n a l o f N u r s i n g , ( J a n u a r y 1973) p. 8 2 .  - 4 of h i s h o s p i t a l i z a t i o n .  8 9 ID ' '  Play therapy  major procedure such as surgery,  u s u a l l y occurs  after a  has already taken p l a c e .  Using  dolls  and h o s p i t a l equipment the c h i l d i s encouraged to express h i s f e e l i n g s about h o s p i t a l i z a t i o n . a c h i l d may play therapy  I t i s b e l i e v e d that through the medium of p l a y  gain i n s i g h t i n t o the reasons f o r h i s h o s p i t a l i z a t i o n . i s considered  to be an e f f e c t i v e way  f o r the  As  pre-school  c h i l d to communicate h i s f e e l i n g s and b e l i e f s , areas of misunderstanding may  a l s o be r e v e a l e d .  c a t h a r t i c i n nature, same way  E r i k E r i k s o n c o n s i d e r s t h i s type of play to be a l l o w i n g the c h i l d to act out h i s problems i n the  that an a d u l t may  Play therapy  t a l k out h i s problems."'""'"  appears to be a promising  i n t e r v e n t i o n which could  be u t i l i z e d by nurses to help reduce the traumatic i z a t i o n f o r the p r e - s c h o o l c h i l d .  U n l i k e most i n d i v i d u a l l y  p r e p a r a t i o n programs i t i s r e l a t i v e l y simple require a large c a p i t a l outlay.  e f f e c t s of h o s p i t a l -  to conduct and  designed does not  I t a l s o appears to be an i n t e r v e n t i o n  that could be b e n e f i c i a l to a c h i l d , even when a h o s p i t a l does not have a f u l l y  developed p r e p a r a t i o n program.  Although play  also  therapy  should never r e p l a c e p r e p a r a t i o n programs, p r e p a r a t i o n programs which are not f o l l o w e d by play therapy  may  r e s u l t i n a c h i l d r e t u r n i n g home  Madeline P e t r i l l o , "Preventing H o s p i t a l Trauma i n P e d i a t r i c P a t i e n t s " , American J o u r n a l of Nursing, ( J u l y 1968) pp..1469-1473. g Hardgrove, op. c i t . , pp.  17-19.  N a i d a Hyde, "Play Therapy: The Troubled C h i l d ' s S e l f Encounter", American J o u r n a l of Nursing, ( J u l y 1971) pp. 1366-1370. 1 D  " E r i k E r i k s o n , Childhood and S o c i e t y . York: Id. W. Norton Co., 1950) p. 475. 1J  (New  Revised  Edition,  0  - 5 harbouring  dangerous  Because school  child,  surgical of  play  of  fantasies.  the p o s s i b l e  age  of  display  themes?  Would t h e p l a y  questions  surgical  further play  general  r e l a t e d to themes  behaviour  the  literature?  information  about  the  them as  interventions.  child  fear,  of  still  protectors  nursing  of  effects  child is  can no l o n g e r  guilt,  hospital  pre-  post-  clinical  do a l l  is  hospitalized From t h e s e  the  area  play pre-school  experiences?  this  the n a t u r e  the  r e l a t e d to  the o p p o r t u n i t y  If  for  Do  so what a r e  c h i l d r e n be general  these  similar  questions  study  was  and c o n t e n t o f  designed post-  PROBLEM  c h i l d r e n have many  parents  of  an a c u t e  were f o r m u l a t e d and a d e s c r i p t i v e  compound t h e t r a u m a t i c  i n the r o l e  studying  questions  their  of  therapy  behaviour.  Pre-school  perceives  in  in play?  THE  mental stage  group  When g i v e n  similar  described in  gather  this  A number o f  children  to  play  behaviour  c h i l d r e n engage i n p l a y  specific  of  interested in  the h o s p i t a l .  that  benefits  t h e w r i t e r became  t h e r a p y were i d e n t i f i e d :  to  12  very  their  When p a r e n t s  protectors and a n g e r .  op.  hurt.  In  p.  19.  the h o s p i t a l  that  develop-  parents  c h i l d from n e c e s s a r y  and  situation  medical  and  a r e p e r c e i v e d by t h e c h i l d t o  These s t r o n g  cit.,  At t h i s  d e p e n d e n t on h i s  t h e c h i l d may s u f f e r  and c a n l e a d t o p s y c h o l o g i c a l  Hardgrove,  characteristics  hospitalization.  against  protect  age-related  upset  from c o n f l i c t i n g  emotions  may c o n f u s e  which c o u l d continue  fail  emotions  the after  he r e t u r n s h o m e . ' ^ '  '^'^  In some cases such p s y c h o l o g i c a l  upset can i n t e r f e r e with the c h i l d ' s emotional and s o c i a l growth.  1 8  '  1 9  '  2 0  '  2 1  '  2 2  '  2 3  ' ^ 2  An important c o n t r i b u t i n g f a c t o r to the h o s p i t a l i z e d pres c h o o l c h i l d ' s s t r e s s i s h i s l i m i t e d a b i l i t y to understand the reasons f o r h i s h o s p i t a l i z a t i o n , surgery or treatments.  At t h i s  R . B. Aisenberg and P. H. Wolff, " P s y c h o l o g i c a l Impact o f Cardiac C a t h e t e r i z a t i o n " . P e d i a t r i c s , (June 1973) pp. 1051-1059. 13  Ik  John Bouilby, Attachment and Loss: Press, 1973).  Hogarth  Separation.  I I (London:  15 Barbara M. Korch, "Experiences with C h i l d r e n and T h e i r F a m i l i e s During Extended Hemodialysis and Kidney T r a n s p l a n t a t i o n " . P e d i a t r i c C l i n i c s o f North America, (May 1971) pp. 625-637. "^L. M. Linde, et a l . " A t t i t u d i n a l F a c t o r s i n C o n g e n i t a l Heart Disease." P e d i a t r i c s , ( J u l y 1966) pp. 92-101. G . H. Vaughan, " C h i l d r e n i n H o s p i t a l " . 1117-1120. 1 7  pp.  Lancet,  (June 1957)  IB John Bouilby, "Separation A n x i e t y . " P s y c h o a n a l y s i s , (May 1960) pp. 89-113.  I n t e r n a t i o n a l J o u r n a l of  19 Bouilby, op. c i t . , 1973. 20 Anna Freud, "The Role o f B o d i l y I l l n e s s i n the Mental L i f e of C h i l d r e n . " P s y c h o a n a l y t i c Study o f C h i l d r e n , ( J u l y 1952) pp. 69-81. 21 D. M. Levy, "Psychic Trauma o f Operations i n C h i l d r e n . " American J o u r n a l o f Disease i n C h i l d r e n , (January 1945) pp. 7-25. 22 A. Mattsson, "Long Term I l l n e s s i n Childhood: A Challenge to P s y c h o s o c i a l A d a p t a t i o n " . P e d i a t r i c s , (November 1972) pp. 801-809. 23  " P. Orsten and A. Mattsson, " H o s p i t a l i z a t i o n Symptoms i n C h i l d r e n . " Acta P a e d i a c t r i c a , (August 1955) pp. 79-92. * * J . Robertson, Young C h i l d r e n i n H o s p i t a l s . P u b l i c a t i o n s L t d . , 1958. 2  (London:  Tavistock  - 7 developmental stage  the  c h i l d may d e v e l o p m i s c o n c e p t i o n s  and u n -  25 26 27 23 realistic  fears  a b o u t what  common m e d i c a l and n u r s i n g and t e m p e r a t u r e t a k i n g , is  particularly  frequently  states  are o f  that  the p o i n t  view o f  his  of  feelings  development  about the  threats  as  his  it  very  reasoning  as  '  The  child's  injections pre-schooler and  '  language  does  The c h i l d c a n n o t information.^^ for  the c h i l d to  Furthermore, at  capacity  Many  integrity 29 3D  punishment.  difficult  '  surgery,  body  who r e q u i r e s  hospitalization.  child's  to  '  nature.  communication.  a listener  l a n g u a g e makes  him.  such  the p r e - s c h o o l  the f u n c t i o n o f  quality  to  an i n t r u s i v e  such treatments  always s e r v e of  happening  interventions  frightened of  perceives  Piaget  is  this  not assume  This verbalize  stage  is  limited,  and h i s  E r i k E r i k s o n , C h i l d h o o d and S o c i e t y . Id. W. N o r t o n C o . , 1 9 5 0 ) .  (Revised  Edition,  of inter-  25 York:  New  26 Florence Erickson, "Reactions of Experience." N u r s i n g O u t l o o k , (September  C h i l d r e n to H o s p i t a l 1958) p p . 5 0 1 - 5 0 4 .  27 Routledge  J e a n P i a g e t , The C h i l d ' s and Kegan L t d . , 1 9 5 5 ) .  Construction  of  Reality.  (London;  28 Mary T e s l e r and C a r o l H a r d g r o v e , " C a r d i a c C a t h e t e r i z a t i o n : P r e p a r i n g the C h i l d . " A m e r i c a n J o u r n a l o f N u r s i n g , ( J a n u a r y 1973) pp. 80-82. 29 M i l t o n F u j i t a , "The Impact o f I l l n e s s o r S u r g e r y on t h e Body Image o f t h e C h i l d . " Nursing C l i n i c s of North America, VII (December 1972) p p . 6 4 1 - 6 4 9 . ^ I r e n e R i d d l e , " N u r s i n g I n t e r v e n t i o n s t o Promote Body Image Integrity in Children". Nursing C l i n i c s of North America, VII (December 1972) p p . 6 5 1 - 6 6 1 . ^ J e a n P i a g e t , The Language and t h e T h o u g h t (London: R o u t l e d g e and Kegan L t d . , 1 9 2 6 ) .  of  the  Child.  - 8 pretation of  the surrounding  -  environment i s  frequently i l l o g i c a l  and  32 unrealistic. difficult  Both of  for  parents  which a s p e c t s child's  of  these  and f o r  a g e - r e l a t e d c h a r a c t e r i s t i c s make t h e h e a l t h c a r e team t o  h o s p i t a l i z a t i o n c o n t r i b u t e most  psychological  method o f  mental l e v e l Piaget  all  child's  i n t e r p r e t play gaining  The c h i l d c o m m u n i c a t e s of his  play.  Axline  feelings  logically  an  individual  verbalize his  communication a p p r o p r i a t e  s h o u l d be u t i l i z e d .  way o f  understand  upset.  As t h e p r e - s c h o o l e r c a n n o t alternate  to  it  Sigmund F r e u d ,  behaviour of  feelings  just  as  p r e - s c h o o l c h i l d r e n as  the  of his  and e m o t i o n s  an a d u l t  Erik  developand  and M o u s t a k a s b e l i e v e t h a t  and p r o b l e m s  the c h i l d ' s  an  Erikson  better understanding his  for  fears  world.-'3,34,35  through  a child "talks  t h e medium  "plays  out"  his  out" diffi-  36 37 culties.  '  solitary  play  adult  the b e s t  is  Axline, Erik therapy with  Erikson toys,  and M o u s t a k a s a l l  i n the presence o f  way t o u n d e r s t a n d a c h i l d ' s  believe  a  that  sympathetic  problems  and t o h e l p  him  32 J e a n P i a g e t , P l a y s , Dreams and I m i t a t i o n (New Y o r k : W. W. N o r t o n C o . , 1 9 5 1 ) .  Hogarth  "^Sigmund F r e u d , Press, 1955).  Beyond t h e P l e a s u r e  in  Childhood.  Principle.  XVIII  (London:  34 York:  E r i k E r i k s o n , C h i l d h o o d and S o c i e t y . W. U. N o r t o n C o . , 1 9 5 0 ) . 35  Piaget,  op. c i t . ,  (Revised  E d i t i o n , New  1951.  " ^ V i r g i n i a A x l i n e , Play The R i v e r s i d e P r e s s , 1 9 4 7 ) .  Therapy.  (Cambridge,  Massachusetts:  37 C l a r k Moustakas, B a l l a n t i n e Books, 1953).  Children in Play  Therapy.  (New  York:  a d j u s t to new  and overwhelming situations.^B»39,40  In c o n c l u s i o n , a problem e x i s t s i n understanding s c h o o l c h i l d ' s p e r c e p t i o n of h i s h o s p i t a l i z a t i o n . s c h o o l e r ' s n a t u r a l medium f o r s e l f e x p r e s s i o n .  the pre-  Play i s the pre-  In play the c h i l d  can  act out h i s f e e l i n g s and i n doing so can communicate h i s p e r c e p t i o n s of h i s experiences  to a sympathetic  and knowledgable a d u l t .  It there-  f a r e seems to f o l l o w l o g i c a l l y t h a t the h o s p i t a l i z e d c h i l d c o u l d be a s s i s t e d to express h i s f e e l i n g s and to gain understanding h o s p i t a l i z a t i o n through  the medium of play  of h i s  therapy.  PURPOSE OF THE STUDY A study was  designed  to explore v a r i o u s aspects of play  d i s p l a y e d by h o s p i t a l i z e d p r e - s c h o o l e r s a f t e r major s u r g e r y .  behaviour The  study  posed f o u r q u e s t i o n s : 1.  Are common themes expressed  i n the p l a y behaviour  p r e - s c h o o l c h i l d r e n a f t e r major 2.  surgery?  Does the q u a l i t y and i n t e n s i t y of the play behaviour by p r e - s c h o o l c h i l d r e n f o l l o w a s i m i l a r  3.  of h o s p i t a l i z e d  pattern?  W i l l p r e - s c h o o l c h i l d r e n use play therapy which to express f e a r s and  concerns  demonstrated  as a medium  through  about t h e i r h o s p i t a l  perience? 4.  Do c h i l d r e n tend to act out t h e i r p e r c e p t i o n s of what has happened to them i n h o s p i t a l ?  38 A x l i n e , op. c i t . ,  1947.  39 E r i k s o n , op. c i t . , ^ M o u s t a k a s , op. c i t . ,  1950. 1953,  ex-  -  10 -  ASSUMPTIONS Pre-schoolers, particularly ization.  interventions  press  of  age-related  the h o s p i t a l  the g r e a t e r  is  to understand part  of  prone to p s y c h o l o g i c a l  The l o n g e r  Play  because  stay  as  may t h a t  the  pre-schoolers  complexities  and a n x i e t i e s  that  of  are  hospitalthe  upset.  of  t h e i r n o r m a l g r o w t h and d e v e l o p m e n t  feelings  a result  and t h e more t r a u m a t i c  the p s y c h o l o g i c a l  one i m p o r t a n t and m a s t e r  upset  characteristics,  their  normally  environment.  c h i l d r e n use  they cannot  learn  play  to  As ex-  verbalize.  DEFINITION OF TERMS  Psychological reactions of  as:  and p s y c h o l o g i c a l  e x h i b i t e d by a c h i l d i n r e s p o n s e  hospitalization,  hospital  upset  these  crying,  surgical,  adverse  continued resistance  or withdrawal.  apathy  upset  i n d i c a t e d by a c o m p a r a t i v e  i n behavioural responses disturbed sleep more i n f a n t i l e Stress logical  d e f i n e d as  or  adverse experience  interventions.  to procedures,  hospitalization  increase fear of  from b e f o r e  separation  apathy  a state  and of  In such  extreme  psychological hospitalization  from  parents,  regression  to  withdrawal.  physiological  and/or  psycho-  i m b a l a n c e w h i c h o c c u r s when an e x t e r n a l s t i m u l u s o r s t r e s s o r  p e r c e i v e d as ization  the s t r e s s f u l  a g g r e s s i o n towards a u t h o r i t y ,  behaviours, is  Following  such as:  patterns,  to  a r e c o n s i d e r e d t o be b e h a v i o u r s  shyness, is  to  m e d i c a l and n u r s i n g  reactions  screaming,  trauma r e f e r  is Play  threatening.  The t o t a l  impact  c o n s i d e r e d t o be t h e m a j o r therapy r e f e r s  i n the presence of  to  all  aspects  of  hospital-  stressor.  individual  the r e s e a r c h e r .  of  is  play  c a r r i e d o u t by t h e  The e q u i p m e n t  is  either real  child or  - 11 simulated hospital equipment, for example:  stethoscopes, blood  pressure apparatus, syringes, instruments, bandages, catheters, i n t r a venous sets, and oxygen masks. and female d o l l s .  There i s also a collection of male  The c h i l d i s presented with the equipment and i n -  vited to play hospitals. The child chooses the direction of the play and i s allowed to express himself f r e e l y .  The researcher establishes  rapport with the child, recognizes and accepts a l l feelings by the c h i l d and r e f l e c t s them back.  expressed  It i s expected that each c h i l d  w i l l act out his hospital experiences and express i n play personal feelings and perceptions about his t o t a l h o s p i t a l i z a t i o n .  The researcher  may make use of opportunities during play to correct misconceptions expressed by the c h i l d about his hospitalization and to c l a r i f y  reasons  for medical and nursing interventions. The researcher w i l l Use d o l l demonstrations in conjunction with verbal explanations to assist the child to understand  his h o s p i t a l i z a t i o n .  The c h i l d i s considered to have taken part i n play therapy when: a) he acts out at least three events that have occurred in hospital; b) he verbalizes by words, exclamations  or sounds as he acts through  events; c) he expresses emotions as he plays either by words or body language or by both, i . e . aggression, fear, anger; d) he plays the part of an "authority figure" on one occasion, i . e . a doctor, nurse or parent. LIMITATIONS The study w i l l describe the themes and patterns of play carried out by English speaking children only from similar c u l t u r a l backgrounds whD have undergone major surgery Dn the heart or great vessels.  - 12 Play behaviour w i l l be observed only while the c h i l d i s i n hospital. The  sample i s s m a l l t h e r e f o r e not a l l common themes of  s u r g i c a l play may The  be  post-  expressed.  i m p l i c a t i o n s f o r c h i l d r e n who  through play w i l l not be s t u d i e d .  may  not express themselves  - 13 -  CHAPTER  II  REVIEW OF THE LITERATURE  INTRODUCTION  This factors  chapter presents  which a f f e c t  First,  those  ful  the p r e - s c h o o l  to  study  undergo  congenital Studies are  aspects  heart  discussed.  care  is  of  As p l a y  the  as  Discussion of  and s u r g e r y .  ized pre-school  a viable  child.  special  are  reducing  This  stress  aspects  of  explored.  in this  the  the  emotional  reducing  stress  literature  and an e m p i r i c a l b a s i s  study,  application  d e f i n e the problem of review of  of  interventions  i n t e r v e n t i o n used  these  this  implications  family  stress  stress-  children in  a r e r e v i e w e d and t h e t h e r a p e u t i c  a t h e o r e t i c a l framework  therapy  the  various  the h o s p i t a l i z e d c h i l d f u r t h e r  provides  As t h e  t h e c h i l d and h i s  is  to  which are p a r t i c u l a r l y  surgery,  therapy  play  examined.  to h o s p i t a l i z a t i o n  play  for  literature related  the p r e - s c h o o l  c h i l d are r e v i e w e d .  the e f f e c t of  of  the  care of  Df h o s p i t a l i z a t i o n  disease  examining  play  the emotional  corrective heart  selected theories of  a review of  for  intervention for  also  t h e use  the  due  of  hospital-  child.  THE STRESSFUL EFFECTS OF HOSPITALIZATION ON THE PRE-SCHOOL CHILD  Because particularly growth  of  his  developmental l e v e l ,  prone to the t r a u m a t i c  towards  independence i s  just  effects  the p r e - s c h o o l of  beginning  child  is  hospitalization. and he i s  unable  His to  deal  -  with his  -  a new and f e a r f u l e n v i r o n m e n t w i t h o u t significant  yet s u f f i c i e n t take  others.  His  f o r him t o  place; his  social  deal with unfamiliar  separation  growing  fully  not  yet s o p h i s t i c a t e d  p e o p l e and new s t r a n g e the f i r s t  from p a r e n t s  for  o f c o n f i d e n c e and s e c u r i t y .  support  intellectual abilities  of  are  t h e young  not must  enough  about  child. give  the adverse  Edelston young  effects  states  children a  that feeling  Loss o f p a r e n t a l p r o t e c t i o n r e s u l t s  of r e j e c t i o n or fear of  loss of  his  to  routines.  to w r i t e  p r o t e c t i o n and a f f e c t i o n f r o m t h e p a r e n t s  feelings  the constant  u n d e r s t a n d why h o s p i t a l i z a t i o n  competency i s  E d e l s t o n was one o f of  14  mother.^"  Robertson  in and  2 3 Bowlby  e l a b o r a t e on E d e l s t o n ' s  behavioural responses,  ideas.  "protest",  '  Both proposed t h r e e phases  "despair",  and " d e t a c h m e n t " ,  a r e e x p r e s s e d by t h e young c h i l d d u r i n g  separation.  that  o f mourning  The  all  t h r e e phases  "protest"  phase  a r e an e x p r e s s i o n  o f weeping  i n mother's r e t u r n .  phase  loss  with seemingly reproach for  o f hope f o r  Bowlby  a r e u n i o n , and t h e  considers  hypothesized  the  J o h n Bowlby, Psychoanalysis, XLI: 3  4bid.,  p. 9 2 .  "despair"  "detachment"  indicates  an  mother.  behaviour  phase  unconscious  desertion.  that  the s e r i o u s n e s s  of  the c h i l d ' s  ^"H. E d e l s t o n , " S e p a r a t i o n A n x i e t y i n Young C h i l d r e n " . P s y c h o l o g i c a l Monograms, X X V I I I : 1943, p p . 3 - 9 5 . J . Robertson, P u b l i c a t i o n s , 1958).  which  the l o s t  The s a d b e h a v i o u r o f  c a l m and a c c e p t i n g b e h a v i o u r  the mother's  for  and a g g r e s s i o n d e m o n s t r a t e s  t h a t may r e s u l t indicates  Bowlby  of  Young C h i l d r e n i n H o s p i t a l s ,  "Separation Anxiety." 1960, p p . 8 9 - 1 1 3 .  (London:  International  reaction  Genetic  Tavistock  Journal  of  depends  upon w h i c h phase  versible, capacity  but  the  and have  relationships.  is  15  -  reached.  The f i r s t  two p h a s e s a r e  " d e t a c h m e n t " p h a s e may l e a d t o long-term  Bowlby  adverse  considers  effects  that  loss  of  emotional  on t h e a b i l i t y  "detachment"  re-  to  does n o t  form  close  develop  5 for  s e v e r a l months.  separations sense care  of  However,  can have  security  long  lasting  may be s e v e r e l y  and may r e s u l t  in  long-term  Anna F r e u d c o n s i d e r s mother  is  reason  for  son.  especially  that  serious  the adverse  She s u g g e s t s  effect  that  comfort  suggests  psychological  that  effects  and M a t t s s o n l i k e  it  of  body,  difficult  is  the  Anna F r e u d ,  difficult  illness propose  to  v e r y w e l l when s e p a r a t e d  Ibl'd.,  p.  ^Robertson,  of  a  child's  maternal  a c h i l d from  of  her  as  his  need f o r  heightened  and  the  of  illness  from t h e i r p a r e n t s  time.  adverse 7 "  separation.  Orsten  and s e p a r a t i o n  than e i t h e r that as  love,  this  d i f f e r e n t i a t e the  Robert-  rightful  extra at  his  proposed  Bowlby  mother  i n t e r a c t and t h a t t h e c o m b i n e d u p s e t i s g r e a t e r . . , 8 separation alone. A few a u t h o r s , f o r e x a m p l e , S m i t h , s t a t e fare  of  his  from those that  that  loss  However,  from those  is  short-term  behaviour.^  illness.  and t h a t  even  He s u g g e s t s  the s e p a r a t i o n  from her  that  by a b r i e f  a c h i l d considers  affection also  shaken  differs  his  and p h y s i c a l  states  effects.  during  owner and p r o t e c t o r o f  She  Robertson  most long  may  illness  or  children as  they  have  102. op.  cit.  7 Anna F r e u d , "The R o l e o f Children." P s y c h o a n a l y t i c Study 8 P. Children."  Bodily Illness in o f C h i l d r e n , VII:  the Mental L i f e o f 1952, p p . 6 9 - 8 1 .  " O r s t e n and A . M a t t s s o n , " H o s p i t a l i z a t i o n Symptoms A c t a P a e d i a c t r i c a , XLIV ( A u g u s t 1 9 5 5 ) , 7 9 - 9 2 .  in  the  companionship  However,  Smith  of  other  does n o t  16  -  c h i l d r e n and a d i v e r s i o n  distinguish  between a g e ,  such  social  as  television.  background,  g length  of  hospital  separation of  upset  with  as  is  t h e c h i l d who has  1 1  does  c h i l d r e n so  his  Overall, idea that  hospital  statement in  a child  However,  of  the post  contributes  discharge.  Moncrieff,  hospital  unclear  which v a r i a b l e s  a r e most s i g n i f i c a n t .  portant  and t h e r e may be a c u r v i l i n e a r  logical  upset.  study  or  P . E . Rothman, 0.962), p p . 9 9 5 - 9 9 9 . 1 : L  Medical  unlike  are  "detachment"  Robertson  in  these  acceptance  upset  a lack  of  both  Age  does of  Anesthesia (May 1961)  "A Note on H o s p i t a l i s m . "  It  age  to  is  and pp.  South  also im-  psycho-  t o more  Pediatrics,  A . L . M o n c r i e f f , "New A s p e c t s o f C h i l d C a r e . " J o u r n a l , XXXI: (1957), pp. 978-981.  in  seem t o be  by Levy t h e d a t a p o i n t s  of  agreement  a few m o n t h s .  relationship  R. M. S m i t h , " P r e p a r i n g C h i l d r e n f o r American J o u r n a l o f Disease i n C h i l d r e n , CI: 1 Q  i n the  a widespread  lasts  an e a r l y  proof  doubt.  about whether the upset  In  down"  characteristics  behaviour  there is  a few weeks  has  d e s c r i b e d by M o n c r i e f f ,  to p s y c h o l o g i c a l  However,  staff  claim without  a c h i l d who i s  c o u l d be open t o  cause  "settles  the b e h a v i o u r a l  the l i t e r a t u r e t h e r e i s  separation  and a f t e r  that  if  discounts  the major  the h o s p i t a l  and B o w l b y .  describe  Rothman  that  psychologists  from the b e h a v i o u r  not  illness.  contact  s e t t l e d i n , which are  d e s c r i b e d by R o b e r t s o n  and B o w l b y ,  of  He c o n s i d e r s  states  t o be u n h a p p y ,  brooding.  indistinguishable  the  Moncrieff  1 0  appear  the c h i l d i s  phase  trauma.  l i m i t e d and i m p e r s o n a l  the c h i l d r e n .  that  or s e r i o u s n e s s  the cause o f  the  and does n o t  of  stay  upset  Surgery." 650-653. X:  African  -  in  t h e young  quantitative age  child.  12  In  a study  The d a t a  this  age  by P r u g h ,  d i f f e r e n c e i n the upset  g r o u p s w i t h most u p s e t  age.  17—  also  group  displayed  indicates  of  the  data  displayed  by c h i l d r e n u n d e r  an i n c r e a s e  severity  al.  behaviour  on r e t u r n f r o m h o s p i t a l .  Mattsson both c o n s i d e r  et  various  4 years  in regressive  13  by  shows a  of  behaviours  " Anna F r e u d and O r s t e n  illness  to  be an i m p o r t a n t  in  and  contrib-  14 15 uting age,  factor.  '  separation  stress  of  hospitalization. that  the p r e - s c h o o l  may c o n t r i b u t e patterns,  to  pre-schooler  contribute  There are however,  c h i l d has  the upset  of  a poor  other  effects  appear  as  exclusively t o use  a r e f e r e n c e to  from a b o u t  difficulty  concept of  hospitalization.  The c h i l d b e g i n s  has  all  to  suggests  that  increase  the  age-related of  hospitalization  child.  Yesterday,  seems  literature strongly  illness  c h i l d r e n r e f e r almost  tense.  months. that  to  of  the  compound t h e t r a u m a t i c  The p r e - s c h o o l  present  conclusion  and s e v e r i t y  characteristics for  In  the  any  t i m e and t h i s In  early  to t h e i r future  time  36 m o n t h s . ^  in distinguishing  in  speech  existence  tense  at  the p a s t ,  Spayde morning  factor  states from  in  the  about is  a  that  30 concept the  afternoon  12 D. M. L e v y , " P s y c h i c Trauma Df O p e r a t i o n s i n C h i l d r e n . " American J o u r n a l of Disease i n C h i l d r e n , LXIX: ( J a n u a r y 1945) p p . •^D. G. P r u g h , e t . a l . , "A S t u d y o f t h e E m o t i o n a l R e a c t i o n s C h i l d r e n and F a m i l i e s t o H o s p i t a l i z a t i o n and I l l n e s s , " American J o u r n a l o f O r t h o p s y c h i a t r y , XXIII (January 1953), pp. 70-106.  7-25. of  14 Anna F r e u d , 15 Child."  Dp.  cit.  " P. O r s t e n and A . M a t t s s o n , o p . c i t . L . B. Ames, "The Development o f t h e Sense o f Time i n t h e Young J o u r n a l o f G e n e t i c P s y c h o l o g y , LXV/III: (1946) p p . 9 7 - 1 2 5 .  and i n  knowing  and c o n s i d e r s ceptualize  the  days o f  that  future  for  18  t h e week.  t h e young  -  17  Gellert  child  expresses  in hospital,  or past time c l e a r l y ,  hours  this  unable  to  and d a y s d r a g  belief con-  on  in-  terminably. The p r e - s c h o o l and h i s  interpretation of  illogical  the  or  words  images r e f e r .  clearly  in  images o f  This  objects  considers  a period of  During  this  development play  behaviour  which are not  increases  the  of  still  that  stage, or  symbolic when t h e  is  very  the  limited  frequently  between t h e  cognitive  physically  child's  is  environment  and i m a g e s f r o m o b j e c t s  children's  functioning  Piaget  thought.  capacity  surrounding  c h i l d enters  pre-conceptual  differentiate  reasoning  the  and u n r e a l i s t i c .  two and f o u r , as  child's  ages  development  child  events  learns  to  is  seen  c h i l d can c r e a t e  present.  known  to which the  functioning  Although  intellectual ability  his  of  words most  mental symbolic  mode  of  19 thought  is  thought,  still  Piaget  deductive  or  immature. considers  inductive.  from t h e p a r t i c u l a r Transductive where t h e r e haven't  to  reasoning is  none.  had my nap  so  In  the  reasoning In  this  period of to  type  the p a r t i c u l a r finds Piaget it  be of  "transductive" reasoning,  without  a relationship quotes  isn't  pre-conceptual  from h i s  afternoon."  the  touching  As  child on t h e  between two daughter  rather  than  moves general.  concrete  items  Lucienne:  Lucienne u s u a l l y  "I had a  17 P. E . Measurement."  Spayde, " K i n d e r g a r t e n C h i l d r e n ' s F a m i l i a r i t y with E d u c a t i o n a l Research B u l l e t i n , XXXII: 1953), pp.  234-238.  18 E l i z a b e t h G e l l e r t , "Reducing the E m o t i o n a l S t r e s s of H o s p i t a l ization for Children." American J o u r n a l o f O c c u p a t i o n a l Therapy XII: ( M a y - J u n e 1958) p p . 1 2 5 - 1 2 9 . y  19 York:  J e a n P i a g e t , P l a y , Dreams and U. Ul. N o r t o n C o . , 1 9 5 1 ) .  Imitation  in  Childhood.  (New  nap  in  t h e a f t e r n o o n she  saw  19  -  a direct relationship  between t h e  two  20 events  and c o n c l u d e d t h a t  schooler only  one e v e n t  and e v e n t h e e a r l y  because  they occur at  school-age  misconceptions  child  age.  this  understanding cedures.  This  and u n r e a l i s t i c  T e s l e r and H a r d g r o v e  transductive  They  child will  t h e same t i m e .  l i k e l i h o o d of of  d e p e n d e d on t h e o t h e r .  thought  relate  The p r e -  two  can g r e a t l y  fears  emphasize  when p r e p a r i n g  in the the  the  events increase  the  hospitalized  importance child  for  of  pro-  state:  "We make c a u s e and e f f e c t c o n n e c t i o n s f o r t h e c h i l d knowing t h a t h i s i n e x p e r i e n c e m i g h t o t h e r w i s e l e a d him t o f a u l t y and f r i g h t e n i n g conclusions."21 Piaget period point  t o be of  considers  another  "egocentrism!!?  view and i s  c h a r a c t e r i s t i c of  The c h i l d s e e s  unable  to  put  himself  the  pre-conceptual  the world from h i s in  another person's  own situ22  ation.  This  "egocentric"  Piaget believes k t o 6, the  does n o t  c h i l d does  information, quality to  that  of  talks  of  it  op.  cit.,  the  very  of  the c h i l d ' s  especially  function of of  to  himself,  about  in  language. the years  communication.  view o f  difficult  feelings p.  part  language,  himself,  verbalize his  Piaget,  is  assume t h e p o i n t  l a n g u a g e makes  accurately 20  the c h i l d ' s  always serve  not  but  quality  for  the  from  Frequently,  l i s t e n e r who r e q u i r e s 23  and by h i m s e l f . the p r e - s c h o o l  This child  hospitalization.  232.  21 Mary T e s l e r and C a r o l H a r d g r o v e , " C a r d i a c P r e p a r i n g the C h i l d . " American J o u r n a l o f Nursing 1973) p . 8 2 .  Catheterization: LXXIII: (January  22 Routledge  J e a n P i a g e t , The C h i l d ' s and Kegan L t d . , 1 9 5 5 ) .  Construction  of  Reality,  (London:  23 Jean P i a g e t , (London:  Routledge  The Language  and Kegan L t d . ,  and t h e T h o u g h t 1926).  of  the  Child,  The e n t i r e theme o f treatments Erickson  seems  20--  threats  to generate  fear  t o body  integrity  i n the p r e - s c h o o l  and  intrusive  child.  Florence  states:  In a d d i t i o n t o s e p a r a t i o n a n x i e t y , p r e - s c h o o l c h i l d r e n have i n t e n s e f e a r s o f body m u t i l a t i o n . . . V e r y l i t t l e i s known a b o u t c h i l d r e n ' s i n t e r p r e t a t i o n s o f i n t r u s i v e p r o c e d u r e s , and t h a t has been g l e a n e d i n r e t r o s p e c t by a n a l y s t s o r t h r o u g h t h e sympathy o f d o c t o r s and n u r s e s who have o b s e r v e d h o s p i t a l i z e d c h i l d r e n ' s p l a y and e m o t i o n a l r e a c t i o n s . * k Erik as  Erikson  describes  "intrusive".  He  the m o d a l i t y  of  behaviour  i n the p r e - s c h o o l  child  states:  They a r e d o m i n a t e d by t h e i n t r u s i v e mode. They i n t r u d e i n t o o t h e r b o d i e s by p h y s i c a l a t t a c k : into o t h e r p e o p l e s ' e a r s and minds by a g g r e s s i v e t a l k i n g ; i n t o s p a c e by v i g o r o u s l o c o m o t i o n ; i n t o t h e unknown by c o n s u m i n g c u r i o s i t y . 2 5 Fujita  believes  that:  C h i l d r e n are i n t e n s e l y i n t e r e s t e d i n minimal d i f f e r e n c e s between t h e m s e l v e s and o t h e r s . Children ^5 a r e most p e r c e p t i v e o f body i n t e g r i t y and i t s s u r f a c e s . Actual  assaults  casts,  may i n s p i r e  child.  t o body  As t h e s e  by P i a g e t , reflections  fears  integrity  s u c h as  of m u t i l a t i o n  c h i l d r e n are  i n the phase  t h e i r own f e e l i n g s  and,  and even b a n d a g e s  and p u n i s h m e n t  they t e n d to see o t h e r p e o p l e s ' of  scars  of  in  the  "egocentrism"  attitudes  and  pre-school described  and a c t i o n s  t h e r e f o r e , may p e r c e i v e  as  any  24 ence".  F l o r e n c e E r i c k s o n , " R e a c t i o n s o f C h i l d r e n to H o s p i t a l Nursing Outlook, VI: ( S e p t e m b e r 1958) p . 5 0 1 .  Experi-  25 York:  E r i k E r i k s o n , C h i l d h o o d and S o c i e t y Id. Id. N o r t o n C o . , 1950) p p . 1 9 4 - 1 9 5 .  (Revised  Edition,  New  26 M i l t o n F u j i t a , "The Impact o f I l l n e s s o r S u r g e r y on t h e Image o f t h e C h i l d . " Nursing C l i n i c s of North America, VII: (December 1972) p . 6 4 1 .  Body  hospital  21  p r o c e d u r e o r t r e a t m e n t as  when t h e c h i l d ' s  tactile,  in space.  She  a hostile  kinesthetic,  d e c r e a s e d he may be u n a b l e  to  act.  and v i s u a l  define his  Riddle  says  perceptions  body b o u n d a r y  that are  and h i s  location  states:  In many i n s t a n c e s , t h e o n l y e v i d e n c e a c h i l d may have t h a t s o m e t h i n g has happened t o him i s t h e p r e s e n c e o f a bandage a f t e r he wakes f r o m t h e p e r p l e x i n g s l e e p o f a n e s t h e s i a and t h e e x p e r i e n c e o f u n u s u a l , o f t e n p a i n f u l , p e r c e p t i o n s o f a s p e c i f i c body p a r t . . . In a l l i n s t a n c e s , body image d i s t o r t i o n i s most c e r t a i n l y m a g n i f i e d by t h e c h i l d ' s f a n t a s y o f what he d o e s n o t comprehend.27 For  the p r e - s c h o o l e r ,  intertwined.  Erik  Erikson  imagination,  fantasy,  and g u i l t  are  believes:  B e c a u s e o f f a n t a s i e s and i m a g i n i n g s D f an D e d i p a l n a t u r e t h a t t h e c h i l d may engage i n , he may i n c u r a deep s e n s e o f g u i l t . He b e g i n s a u t o m a t i c a l l y t o f e e l g u i l t y e v e n f o r mere t h o u g h t s and deeds nobody has matched. 2 8  This  sense o f  guilt  or misunderstood point  out  that  represents experiences  loss are  Although  may a l l o w  separations  t h e young of  the c h i l d to as  punishment.  c h i l d tends  love because of  a punishment  i n t e r p r e t any  feel  that  wickedness. actively  Jackson  hospitalization  d i s o b e d i e n c e , and t h a t  for his  the p r e - s c h o o l e r i s  to  Woodward and  unexplained  any  unpleasant  29  striving  for  independence  27 Integrity (December 2fl  I r e n e R i d d l e , " N u r s i n g I n t e r v e n t i o n s t o Promote Body Image in Children". Nursing C l i n i c s of North America, VII: 1972) p p . 6 6 5 - 6 5 6 . Erikson,  op.  cit.  p.  195.  29 Woodward and D. J a c k s o n , " E m o t i o n R e a c t i o n s i n B u r n e d Children andttheir Mothers". B r i t i s h Journal of P l a s t i c Surgery, XIII: 1961, p p . 3 1 6 - 3 2 4 .  and s o c i a l  skills,  functions. growing is  he has  He t a k e s  only  pride  independence.  In  in  feels  and J a c k s o n n o t e  he has  suggest  little  that  behaviours gression  the  as  powerful  that  are s t i l l  the parent  Strangers  inflict  strange  and B r a n d t  when h i s  parent  present  when he d i s c o v e r s  cannot  t h e young  protect h i m .  c h i l d cannot  situations.  control his  in hospital  generally  and h i m s e l f .  loss  refusal  to  of  because that  3 1  of  world. the  that  o r by  such  re-  as In  the  the  hospital  s t a n d s by  c h i l d may be  disillusionment whom he f e l t  and J a c k s o n a l s o  that  prestigious,  c h i l d from harm.  the  u n d e r s t a n d why p a r e n t s  The c h i l d may b e l i e v e  c o n t r o l by  talk,  and t h e p a r e n t  the p a r e n t ,  Woodward  They  5 0  protect  indicate  life  child  this  bodily  his  role.  in his  treatments,  and i n  a dependent  to e a t ,  can no l o n g e r  various  into  cope w i t h  authority  O'Connell  ful,  to  environment  behaviours."  lessly.  arising  he has m a s t e r e d  v i e w e d by t h e p r e - s c h o o l e r  and t h e u l t i m a t e  situation  to  control of  ability  back  a young  refusal  infantile  is  his  c o n t r o l over h i s  tantrums,  Parents  the s k i l l s  thrust  child tries  t o more  -  r e c e n t l y gained  hospital,  t a k e n f r o m him and he i s  Woodward  22  can not  because  help-  upset  and  hostility  was  all  power-  point  out  that  control  parents  allow  certain un-  32 pleasant  things  to  happen t o  him t h e y no l o n g e r  The n o r m a l p r e - s c h o o l e r being.  The day  is  Woodward, 3 1  Parents",  is  an e n e r g e t i c  t a k e n up w i t h r u n n i n g ,  Jackson,  dp.  cit.,  p.  love  him.  physically  jumping,  vigorous  and o t h e r  kinetic  323.  E . O ' C o n n e l l and P. B r a n d t , " L i b e r a l V i s i t i n g Hours f o r American J o u r n a l o f N u r s i n g , LX: ( J u n e 1960) p p . 8 1 2 - 8 1 5 .  32  Woodward,  Jackson,  op.  cit.,  p.  323.  activities. mill  Even p r e - s c h o o l  engage i n  allows.  activity  are  In  3  summary,  substantiate for  the  upset.  concept of skills, lively  motor  of  activity. to upset  illness  seem t o  is  There are  developmental  activity  usually  motor  and deny him a  natural  of  is  also  several well  l e v e l which of  of  to  to which s p e c i f i c  unclear,  be i m p o r t a n t that  although variants.  the s t r e s s  of  documented  illness,  to  a poor  communication  body  integrity,  r e c e n t l y gained in  has  been  of  raised  may be b e n e f i c i a l t o  hospitalization  may  in-  con-  and s e r i o u s n e s s  The q u e s t i o n  a  general  characteristics  separation  hospitalization  up-  contribute  limited  and t h r e a t s loss  which  psychologically  seriousness  guilt,  and s t u d i e s  p a r e n t a l p r o t e c t i o n and l i m i t a t i o n s  mastering  capacity  is  on g e n e r a l  theories  capacity,  treatment  and a s e n s e  by V e r n o n and Shulman that  their physical  limitations  a number o f  l i m i t e d reasoning  of  as  physical  hospitalization  The d e g r e e  tribute  these  separation,  intrusive  loss  long  the p r e - s c h o o l e r  t h e r e are  idea that  imagination  as  handicapped  3  These a r e :  fear  children;  for  r e l a t e d to  time,  dependence,  activity  the p r e - s c h o o l e r .  characteristics this  c h i l d r e n who a r e p h y s i c a l l y  that  frustrating  aggressions." "  -  hospitalized his  Vernon s t a t e s  for  setting  type of  When a c h i l d i s  curtailed.  outlet  this  23  some  promote  34 maturity.  There i s  no c l e a r  e v i d e n c e on t h i s  issue  and i n  a  later  D. V e r n o n and A . F o l e y , The P s y c h o l o g i c a l R e s p o n s e s o f C h i l d r e n t o H o s p i t a l i z a t i o n and I l l n e s s , ( S p r i n g f i e l d , Illinois, C h a r l e s C . Thomas, 1965) p . 7 0 . D. V e r n o n and J . S h u l m a n , " H o s p i t a l i z a t i o n as a S o u r c e P s y c h o l o g i c a l B e n e f i t to C h i l d r e n . " P e d i a t r i c s , XXXIV: 1964, pp. 694-696.  of  - 2k study not  by V e r n o n e t  negate  that  the  al.  the b e l i e f  this that  characteristics  have n o t  been f u l l y  investigating  not  substantiated.  hospitalization  of  l e a d to  Some r e s e a r c h has  ways i n w h i c h s p e c i f i c  can be i n s t i g a t e d .  This  35  This  can be b e n e f i c i a l ,  the e x p e r i e n c e which  identified.  various  hospitalization  idea is  -  is  does only  benefit  been c a r r i e d  adverse  effects  discussed  in  out  of  the  following  section.  REVIEW OF SELECTED  RESEARCH STUDIES  INVESTIGATING  THE HOSPITALIZATION OF PRE-SCHOOLERS  In effects  this  section  of h o s p i t a l i z a t i o n  Some i n t e r v e n t i o n s hospitalization An e a r l y children anxiety fied  selected studies  also  study  in hospital as  the problem that  parental  anxiety  care  parents'  warm a c q u a i n t a n c e  anxiety  functions  decrease.  In  in  is  withdrawn.  increases  and when t h e y a r e  parental anxiety  was  of  i d e n t i f i e d the problem  t h e i r mother's  out normal p a r e n t a l  would a l s o  discussed.  trauma  and f r i g h t e n e d and t h a t  carry  anxiety  adverse  be  become a n x i o u s  in hospital  if  child will  the p s y c h o l o g i c a l  c o n d u c t e d by M a h a f f y  alone  that  some  discussed.  child  postulated  the p r e - s c h o o l  w h i c h may a l l e v i a t e  are  increases  for  investigating  unable  their  He a l s o  when t h e y  leave  setting.  study  t h e method u s e d t o  termed " e x p e r i m e n t a l n u r s i n g " ,  between t h e p a r e n t s  D. V e r n o n e t a l . , " C h a n g e s i n Hospitalization." American J o u r n a l of ( J u n e 1966) p p . 5 8 1 - 5 9 3 .  and t h e n u r s e  that  is  their to  Mahaffy  c o u l d be r e d u c e d , t h e n t h e  this  identi-  o r u n c e r t a i n hDw  the h o s p i t a l  that  a  child's decrease sincere  which p e r m i t t e d  C h i l d r e n ' s Behaviour Disease i n C h i l d r e n ,  after III:  them  to  25  -  communicate F r e e l y w i t h e a c h o t h e r .  supports staff  the h y p o t h e s i s  and t h e p a r e n t s  hospital. gressive  However,  behaviours  group  The r e s u l t s  results  i n a decrease in  common t o  reduces the p a r e n t s '  pre-schoolers  It  and t h e  child's  various both  d e m o n s t r a t e d some  anxiety upset  conducted a study  listing  study  nursing  anxiety  revealed that  w o u l d seem t h a t  vent the o c c u r r e n c e of p o s t - h o s p i t a l Vernon e t a l .  Mahaffy's  the c h i l d ' s  questionnaire  and t h e c o n t r o l g r o u p  on r e t u r n home.  of  a warm r e l a t i o n s h i p between t h e  a post-hospital  behaviours  experimental  that  36  in re-  the  regressive  one i n t e r v e n t i o n w h i c h  in hospital  i n the  does n o t  pre-  child.  investigating  and d e f i n i n g  post-  37 hospital  b e h a v i o u r a l change.  questionnaire.consisting in  six  previous  categories ation  of  anxiety;  studies.  upset  of  They d e v e l o p e d a 27 i t e m s  anxiety  d e r i v e d f r o m symptoms m e n t i o n e d  Factor analyses  behaviour: about  general  sleep;  post-hospitalization  of  t h e 27 i t e m s  anxiety  eating  revealed 6  and r e g r e s s i o n ;  disturbances;  separ-  aggression;  and a p a t h y - w i t h d r a w a l . studies  by C a s s e l l  The q u e s t i o n n a i r e has b e e n u s e d i n two o t h e r 38 39 and A z a r n o f f . ' The d a t a c o l l e c t e d d u r i n g t h e  P e r r y R. M a h a f f y , J r . , "The E f f e c t s o f H o s p i t a l i z a t i o n C h i l d r e n A d m i t t e d f o r T o n s i l e c t o m y and A d e n o i d e c t o m y . " Nursing XIV: ( W i n t e r 1965) p p . 1 2 - 1 9 .  on Research  37 D a v i d V e r n o n , e t a l . , "Changes i n C h i l d r e n ' s B e h a v i o u r a f t e r Hospitalization." American J o u r n a l of Disease i n C h i l d r e n , III: ( J u n e 1966) p p . 5 8 1 - 5 9 3 . 38 S. E . C a s s e l , "The E f f e c t o f B r i e f P u p p e t T h e r a p y upon t h e E m o t i o n a l Responses of C h i l d r e n Undergoing C a r d i a c C a t h e t e r i z a t i o n . " Unpublished D o c t o r a l D i s s e r t a t i o n , Northwestern U n i v e r s i t y , Chicago, 1963. 39 P. A z e r n o f f e t a l . , The P r e p a r a t i o n o f C h i l d r e n f o r H o s p i t a l ization. A N a t i o n a l I n s t i t u t e o f M e n t a l H e a l t h G r a n t , #22856, D e p a r t ment o f P e d i a t r i c s , U n i v e r s i t y o f C a l i f o r n i a , L o s A n g e l e s , 1 9 7 5 .  Vernon study years ship upset  -  c o n f i r m e d the h y p o t h e s i s  a r e most l i k e l y was  26  t o be u p s e t  The d a t a  c h i l d r e n f r o m 6 months  following  d e m o n s t r a t e d between l e n g t h  suffered.  that  of  hospitalization.  hospital  stay  4  A relation-  and d e g r e e  d i d not r e v e a l a s i g n i f i c a n t  to  of  difference  in  40 response  r e l a t e d to  Uolfer ating  and V i s i n t a i n e r  the p s y c h o l o g i c a l  f o r minor children for  the sex o f  surgery.  hospitalization  upset  behaviour,  parents with  factor  surgery  in  of  decreasing  reduces  the c h i l d ' s  the c h i l d ' s  study,  were g i v e n  before  other  i n the  child's  that  anxiety, 41  preparing  the p r e - s c h o o l  The age  and s u r g e r y  confirmed the h y p o t h e s i s  upset  is  in  than  agreement  anxiety  preparation  and W o l f e r that  that  pp.  b a s e d on t h e if  is  a  for  range  of  was m i n o r .  the  and  before surgery  and  children in  Play  surgery  results  the c h i l d  t h e r e w o u l d be a g r e a t e r  children for  bp. b i t . ,  less  anxiety.  procedures,  12 y e a r s ,  study  and t h a t  p r e p a r a t i o n and i n f o r m a t i o n  anxiety.  preparation  post-hospital This  and  that  c a r e , w o u l d show  low p a r e n t a l  proposed the hypothesis  stressful  Vernon,  in  by V i s i n t a i n e r  from 3 to  40  and l e s s  investig-  hospitalization  psychological  prepared.  other studies  studies  confirmed the h y p o t h e s i s  and c o n t i n u e d s u p p o r t i v e  and c h i l d r e n who were n o t  the f i r s t  parents  study  who r e c e i v e s y s t e m a t i c  The s e c o n d s t u d y of  c o n d u c t e d two e x t e n s i v e  more c o o p e r a t i o n ,  the f i n d i n g s  child.  p r e p a r a t i o n Df c h i l d r e n f o r  The f i r s t  and p a r e n t s  the  was  decrease  the study  was  used e x t e n s i v e l y  and p r o c e d u r e s .  the c o m b i n a t i o n o f  also  preparation  The for  591-592.  41 John W o l f e r and M a d e l o n V i s i n t a i n e r , " P e d i a t r i c P a t i e n t s ' and P a r e n t s ' S t r e s s R e s p o n s e s and A d j u s t m e n t . " R e s e a r c h XXIV: ( J u l y - A u g u s t 1975) p p . 2 4 4 - 2 5 5 .  Surgical Nursing  in  data  surgery  and p r o c e d u r e s p l u s  consistent  27  -  supportive  c a r e was  superior  in  reducing  42 stress  over c o n s i s t e n t  supportive  care alone.  the e f f e c t i v e n e s s  of  information-giving  and t h e p a r e n t s .  It  also  tool  in  supports  teaching  young  children.  Johnson et  al.  used puppet  an e x p e r i m e n t a l g r o u p The h y p o t h e s i s  that  of  in  This  reducing  the theory  therapy  children for  as  that  study  anxiety play  is  a teaching  hospitalization  puppet t h e r a p y b e f o r e s u r g e r y  emphasizes i n the a  tool  child  useful  to  prepare  and m i n o r  would reduce  surgery. anxiety  43 was  confirmed.  therapy before The age  range  This surgical of  the  Again both s t u d i e s preparation  that  of  is  supports  Cassell's  experiences reduces  other  literature  one way t o r e d u c e a c h i l d ' s 45  useful  t o o l which  school  child. Vredevoe et  and W o l f e r  , support  can f a c i l i t a t e  al.  the  post-hospital  play  responses  was  that  for  that  suggest  to 8  years.  pre-operative  Both s t u d i e s  the concept that of  puppet 44  children.  5 years  anxiety.  transfer  conducted a study  findings  anxiety  c h i l d r e n i n both s t u d i e s  support  Visintainer  aggressive  study  play  information  investigating in hospitalized  the  to  with  is  a  the  degree  pre-  of  pre-schoolers,  42 M a d e l o n V i s i n t a i n e r and John W o l f e r , " P s y c h o l o g i c a l P r e p a r ation for Surgical Pediatric Patients: The E f f e c t on C h i l d r e n ' s and P a r e n t s ' S t r e s s R e s p o n s e s and A d j u s t m e n t . " Pediatrics, LVI: ( A u g u s t 1975) p p . 1 8 7 - 2 0 2 . 43 P a t r i c i a J o h n s o n e t a l . , " E f f e c t s o f P u p p e t T h e r a p y on P a l m e r Sweating of H o s p i t a l i z e d C h i l d r e n . " John Hopkins M e d i c a l J o u r n a l , CXXXVII: ( J u l y 1975) p p . 1 - 5 . 44  Cassell,  bp. c i t . ,  Visintainer  1963.  and W o l f e r ,  bp.  cit.,  pp.  187-202.  age  4 to 5 y e a r s ,  28  -  who had m i n o r s u r g e r y .  46  The p l a y  responses  of  these  c h i l d r e n were compared w i t h h o s p i t a l i z e d c h i l d r e n who d i d n o t  have  surgery  confirm  and w i t h n o n - h o s p i t a l i z e d c h i l d r e n .  the h y p o t h e s i s surgery.  The p l a y  wooden d o l l s telephone  that  pre-schoolers'  The d a t a d i d n o t  p l a y was more a g g r e s s i v e  equipment used d i d not  representing a family,  represent hospital  a cat  and d o g ,  a  Using  this  d e s c r i b e d as  less  play m a t e r i a l the h o s p i t a l i z e d c h i l d r e n s '  play  than f r e e  noted that  M o u s t a k a s has  was  equipment.  wooden b l o c k s ,  and a dump t r u c k were p r e s e n t e d t o e a c h c h i l d .  and s p o n t a n e o u s .  after  play  immediately  47 after  a crisis  tends  t o be s e r i o u s  behaviour that  occurs,  after  surgery,  in  flect  strong  using  and q u i e t e r .  ordinary  toys,  emotions.  It  kind of  would a l s o  A more i n t e r e s t i n g  that  factor  idea that  that  toys  play  to  is  place  the  is  strongly  investigate  the c h i l d ' s  that  i n the p a r e n t s and p u p p e t s  surgical  than normal  the c o n t e n t of  discussed upset  this  supports  after  The s t u d i e s  and t e a c h i n g  and t h e c h i l d .  hospitalization.  seem t o be u s e f u l t o o l s  is  Children in 7.  Play  Therapy  a  support  about  The d a t a  belief  procedures  also  supports  w h i c h can  (New  rethe  facilitate  Donna L . V r e d e v o e e t a l . , " A g g r e s s i v e P o s t - O p e r a t i v e P l a y Responses o f H o s p i t a l i z e d P r e - S c h o o l C h i l d r e n . " Nursing Research R e p o r t , IV: N o . 2, p . 1, p p . 4 - 5 . C l a r k Moustakas, B a l l a n t i n e Books 1953) p .  play  play.  the  reducing parental anxiety  anxiety.  both i n f o r m a t i o n g i v i n g  re-  d i s p l a y e d by p r e - s c h o o l c h i l d r e n .  from p s y c h o l o g i c a l suggests  play  immediately  q u e s t i o n about p o s t  more a g g r e s s i v e  the d a t a from the s t u d i e s  in decreasing  duces a n x i e t y idea  surgical  c h i l d r e n do s u f f e r  The d a t a a l s o  the  post  be i n t e r e s t i n g  Overall,  taking  may be t h a t  a new e n v i r o n m e n t , and w i t h new p e o p l e , w o u l d n o t  p l a y w o u l d seem t o b e , n o t w h e t h e r i t b u t what  It  York:  a child's seems  understanding  to enhance the  of  surgery  29 and h o s p i t a l i z a t i o n .  communication p r o c e s s  Play  also  with pre-school c h i l d r e n .  SELECTED THEORIES OF PLAY  In explain  c e n t u r y a number o f  the u n d e r l y i n g dynamics  analytic of  this  i n t e r p r e t a t i o n of  Sigmund F r e u d and E r i k  cathartic.  That  the  child's  attempt  for  him.  helps  Erikson,  to master  is  believes  that  repetitive play,  closely  the c h i l d a s s i m i l a t e of  the  after  like  feelings  m o t i v a t e d by t h e  because  children  at  With  play.  The  primarily  one p u r p o s e o f  at  first,  of  as  is  reflecting  a r e t o o much  psychological  especially  writings  play  i n t e r p r e t s play that  to  psycho-  i n the  bound up w i t h g r o w t h o f  a situation,  all  that  theory,  thereby gaining  a better  "pleasure  Originally  principle".  the behaviour b r i n g s p l e a s u r e .  play,  is  he d e t e r m i n e d t h a t  more p l e a s i n g  behaviours  o t h e r human b e h a v i o u r s ,  That  is,  children alter  and g r a t i f y i n g  play  and  that  is of  so  that  event.  assumption  did  He b e l i e v e d t h a t  of  all  possible.  organisms t r y  t o keep l e v e l s  He t h e r e f o r e p o s t u l a t e d t h a t  sought  situations  events  than the r e a l this  not  d e t e r m i n e d by  F r e u d wrote  t h e y use o b j e c t s  in play  are  experiences in  peated i n play  under-  dD  From o b s e r v a t i o n  continued observation Freud observed that  low as  He  events,  e x p l a i n why c h i l d r e n f r e q u e n t l y r e p e a t u n p l e a s a n t  as  Piaget  intelligence.  stressful  c h i l d r e n ' s play  and e m o t i o n s .  from t h e i r r e a l w o r l d but t h a t re-enactment  have a t t e m p t e d  event.  by c h a n c e b u t ,  is  that  situations  play  individual's  play  is  the c a t h a r t i c theory  Sigmund F r e u d s u g g e s t s  the  behaviour,  that  standing  occur  children's  From ,the d e v e l o p m e n t a l s c h o o l o f  believes also  is,  play  of  psychologists  nervous  not  play.  tension  c o n f l i c t s were  re-  v  b e c a u s e r e p e t i t i o n r e d u c e s t h e e x c i t e m e n t w h i c h had been  -  aroused. master  He e m p h a s i z e d t h a t  disturbing  events  30  -  by r e p e t i t i o n i n p l a y ,  by a c t i v e l y  taking  part  the  in  child  the event  can instead  48 of  being  has  a passive  participant.  d i r e c t l y influenced various  Freud's forms o f  which u t i l i z e p l a y  b o t h as  identifying  t h a t may t r o u b l e  states  events  Erik  Erikson  that  play  follows  attempts  w i t h i n the s e l f .  a form o f  of  sensual  "autosphere" play  perceptions;  to p r o j e c t i n n e r c o n f l i c t s play  which b r i n g s  adults  and i s  involves  helps  toys  which i s  social  behaviour of  and s o c i a l  processes  the c h i l d a d j u s t  him w i t h t h e  and f i n a l l y  contact with  to  three stages  the i n f a n t ' s  He  the of  exploration the  child's  opportunity  "macrosphere"  other  c h i l d r e n or  the p r e - s c h o o l c h i l d .  This  play  r o l e s and s e e k i n g o u t s o c i a l b e 49 h a v i o u r s a p p r o p r i a t e i n the r e a l w o r l d . E r i k s o n b e l i e v e s t h a t the c h i l d needs s o l i t a r y p l a y w i t h t o y s i n the p r e s e n c e o f a s y m p a t h e t i c adult.  re-enacting various  of  thought.  which i n c l u d e s  and p r o v i d e s  upon p l a y t h i n g s ;  the c h i l d i n t o  t y p i c a l play  t r a i n of  distinguishes  "microsphere" play  i n t e r a c t i o n w i t h manageable  a means  child.  play  Erikson  play  interventions  and as  to s y n c h r o n i z e b o d i l y  He b e l i e v e s t h a t  development:  catharsis a  childrens'  therapeutic  the p s y c h o a n a l y t i c  demands o f e x t e r n a l r e a l i t y . play  view o f  He  social  states:  S o l i t a r y p l a y r e m a i n s an i n d i s p e n s i b l e h a r b o u r f o r the o v e r h a u l i n g o f s h a t t e r e d emotions a f t e r p e r i o d s o f r o u g h g o i n g i n t h e s o c i a l s e a s . . .50  Hogarth  York:  Sigmund F r e u d , Press, 1955).  Beyond t h e P l e a s u r e  P r i n c i p l e , XVIII:  E r i k E r i k s o n , C h i l d h o o d and S o c i e t y , Id. Id. N o r t o n C o . , 1 9 5 0 ) . Ibid.,  p.  194.  (Revised  (London:  E d i t i o n , New  -  He a l s o is  believes  that  31  -  t h e most f a v o u r a b l e  condition for  play  therapy  that: . . . t h e c h i l d has t h e t o y s and t h e a d u l t f o r h i m s e l f , and t h a t s i b l i n g r i v a l r y , p a r e n t a l n a g g i n g , o r any k i n d o f sudden i n t e r r u p t i o n does n o t d i s t u r b t h e u n f o l d i n g p l a y i n t e n t i o n s , w h a t e v e r t h e y may b e . For to " p l a y i t o u t " i s t h e most n a t u r a l s e l f - h e a l i n g measure childhood affords.  Erik  Erikson  emphasizes  and c o n s i d e r s  that  play  the s e l f - c u r a t i v e t r e n d i n spontaneous therapy  can make use o f  this  play  self-curative  provess. Piaget as  symbolic,  process world,  describes  the play  behaviour of  or make-believe p l a y .  c h i l d r e n 2 to 7 years  He p o s t u l a t e s  that  by w h i c h an o r g a n i s m i n t e r n a l i z e s i n f o r m a t i o n and a c c o m m o d a t i o n ,  the r e a l i t y  of  the process  the e x t e r n a l w o r l d ,  He d i s t i n g u i s h e s  symbolic play  assimilation, from t h e  by w h i c h an o r g a n i s m a d j u s t s  are both u t i l i z e d i n  symbolic  f r o m mere i m i t a t i o n :  between p l a y  m a s t e r e d and t h e r e p e t i t i o n o f  as  r e p e t i t i o n of  an e v e n t  an e v e n t  already  i n order to understand  it.  He w r i t e s : A l t h o u g h p l a y sometimes r e p e t i t i o n of p a i n f u l states i n o r d e r t h a t the p a i n s h a l l  ^Erikson,  op.  cit.,  p.  takes the form o f o f m i n d , i t does so n o t be p r e s e r v e d , b u t so  475.  52 Jean P i a g e t , logical  Review,  "Response  LXXIII:  to B r i a n  1966, p .  112.  Sutton  Smith".  Psycho-  to  play.  2  distinguishes  the  outside  If symbolic p l a y uses i m i t a t i o n , i t i s e x c l u s i v e l y as a s y m b o l i c i n s t r u m e n t . T h i s f o l l o w s because t h e r e a r e o n l y two ways t h a t an a b s e n t s i t u a t i o n can be r e p r e s e n t e d ; i t can e i t h e r be d e s c r i b e d by l a n g u a g e o r e v o k e d by i m i t a t i v e g e s t u r e s o r i m a g e s . This in no way means, h o w e v e r , t h a t s y m b o l i c p l a y c a n be r e d u c e d t o i m i t a t i o n s i n c e p l a y i s e x c l u s i v e l y an a s s i m i l a t i o n o f r e a l i t y tD t h e s e l f . - ^ Piaget  old  -  32  -  t h a t i t may become b e a r a b l e , e v e n p l e a s u r a b l e , t h r o u g h a s s i m i l a t i o n t o t h e whole a c t i v i t y o f t h e e g o . 5 3 In  conclusion  Piaget  i n common w i t h Sigmund F r e u d and E r i k  believes  that  means  understanding  of  c h i l d r e n i n the p r e - s c h o o l p e r i o d u t i l i z e p l a y and c o p i n g  THE THERAPEUTIC  There Axline  Erikson,  a r e two c l a s s i c  provides  with  the world  as  i n which they  a live.  APPLICATION OF PLAY  sources  on t h e s u b j e c t  a t h e o r y and m e t h o d o l o g y  for  of  play  "non-directive  therapy. 1 1  play  54 therapy. does  is  Moustakas b e l i e v e s important,  but  that  that  what  how he f e e l s  the p l a y towards  therapist the c h i l d  says  and  determines  55 to  a greater Like  method o f  degree Erik  his  therapeutic  Erikson,  helping  Axline  effectiveness.  suggests  that  c h i l d r e n help themselves.  play  She  therapy  is  a  states:  P l a y t h e r a p y i s b a s e d on t h e f a c t t h a t p l a y i s t h e c h i l d ' s n a t u r a l medium o f s e l f e x p r e s s i o n . I t i s an o p p o r t u n i t y w h i c h i s g i v e n t o t h e c h i l d t o " p l a y o u t h i s f e e l i n g s and p r o b l e m s j u s t a s , i n c e r t a i n t y p e s o f a d u l t t h e r a p y an i n d i v i d u a l "talks out" his d i f f i c u l t i e s . 5 6 Axline  believes  which s t r i v e s  that  there  continuously  is for  a powerful force within  each  complete s e l f - r e a l i z a t i o n .  individual She  states:  53 York:  J e a n P i a g e t , P l a y , Dreams and I m i t a t i o n i i n Ul. Ul. N o r t o n C o . , 1951) p . 1 4 9 .  Childhood,  (New  54 Riverside  Virginia Axline, Press 1947).  C l a r k Moustakas, B a l l a n t i n e Books, 1953. 56  Axline,  op.  cit.,  Play  Therapy.  Children in  p.  9.  (Cambridge,  Play  Therapy,  Massachusetts:  (New  York:  The  -  33  -  N o n - d i r e c t i v e p l a y t h e r a p y i s b a s e d on t h e a s s u m p t i o n t h a t t h e i n d i v i d u a l has w i t h i n h i m s e l f , n o t Dnly t h e a b i l i t y t o s o l v e h i s own p r o b l e m s , b u t a l s o t h i s g r o w t h i m p u l s e t h a t makes mature b e h a v i o u r more s a t i s f y i n g t h a n immature b e h a v i o u r . 5 7 The e i g h t  basic  p r i n c i p l e s of  this  assumption.  with  the c h i l d ;  child  choose  reflecting  They i n c l u d e :  establishing  a c c e p t i n g and r e s p e c t i n g h i s  the s u b j e c t  them back  to  of play, the  Moustakas f o l l o w s the  " n o n - d i r e c t i v e " play  reflect  a warm  relationship  actions;  l e t t i n g thB  and r e c o g n i z i n g  feelings  and  child.  t h e same l i n e  therapeutic process.  therapy  He  of  thought  when he  describes  states:  The t h e r a p e u t i c p r o c e s s does n o t a u t o m a t i c a l l y o c c u r in a play s i t u a t i o n . I t becomes p o s s i b l e i n a t h e r a p e u t i c r e l a t i o n s h i p where t h e t h e r a p i s t r e s p o n d s i n constant s e n s i t i v i t y to the c h i l d j s f e e l i n g s , a c c e p t s t h e c h i l d ' s a t t i t u d e s , and c o n v e y s a c o n s i s t e n t and s i n c e r e b e l i e f i n t h e c h i l d and r e s p e c t f o r h i m . ^ S Moustakas d i f f e r s be t o t a l l y face  non-directive.  crisis  in  aggression, believes  from A x l i n e  life  He s a y s t h a t  is  c o n t r o l l e d or s i t u a t i o n a l  makes take  the  child,  t h e comment f r o m h i s part  play  in situational  the t h e r a p i s t  quickly  Axline,  op.  Moustakas,  from c o n t r o l o f  therapy,  and e x p r e s s  cit., op.  only  that  the  p.  cit.,  their  15. p.  ID.  is  to  confusion,  more e f f e c t i v e  from s p e c i f i c therapist  the a c t u a l p l a y .  c l i n i c a l experience that  play  need not  expressing  therapy  The c o n t r o l r e s u l t s  not  play  For such c h i l d r e n , Moustakas  a p a r t i c u l a r scene or s i t u a t i o n  troubling  that  c h i l d r e n f r e q u e n t l y have  h a t e and a n x i e t y .  than n o n - d i r e c t i v e p l a y . suggesting  he b e l i e v e s  and may r e s p o n d by b e h a v i o u r s  hostility,  that  in that  establish feelings  toys  knows Moustakas  c h i l d r e n , who  a relationship  with  e a r l i e r and more  directly  3k  -  than deeply d i s t u r b e d c h i l d r e n .  much s t r e s s t h e use o f  has  b e e n p l a c e d on r e s p o n d i n g  He a l s o  comments t h a t  skills.  He b e l i e v e s  r e f l e c t i o n a l o n e may be p e r c e i v e d by t h e c h i l d as  too that  a  59 repetitious, It with E r i k  unsympathetic s t a t i c  mould seem t h a t  b o t h M o u s t a k a s and A x l i n e  Erikson  a c h i l d needs  the presence of overwhelming stantiate  in that  a sympathetic  social  the  adult,  situations.  assumptionthat  to reduce p o s t - h o s p i t a l  child.  Through p l a y  beliefs  about  hospitals. for  In  takes  place  ordinary  in  wheel t o y s . and d o u g h .  therapy  articles  s u c h as  Some p r o g r a m s  play  Brooks,  a few h o s p i t a l s  the  his  have s e t  inter-  pre-school  feelings  discussing  i n a group  p r o v i d e d are  games,  up p l a y  procedures.  play  and  provide climbing  These  setting.  dolls  and  authors  and documented c l i n i c a l o b s e r v a t i o n s  after  surgery  or  traumatic  a p r o g r a m where f r e e  cit.,  p p . 1-18,  k5-k£.  play  Play  of  where p l a y  Several  boxes, is  allowed,  used  have of  accidents. is  in  programs  equipment, sand  programs  and p r o c e d u r e s .  play  programs  a variety  art materials,  describe hospital  studies  op.  books,  surgery  behaviour  Moustakas,  in  sub-  have been w r i t t e n on t h e s u b j e c t o f  also  A few a r t i c l e s  to prepare c h i l d r e n f o r  children's  upset  in  t o new and  c o u l d be s u i t a b l e  psychological  a p l a y r o o m and t h e t o y s  d e s c r i b e d case  with toys,  t h r e e v i e w s w o u l d seem t o  c h i l d an o p p o r t u n i t y t o  playthings  agreement  hospitalization.  recent years  o f f e r the  play  in  t o h e l p him a d j u s t  c h i l d r e n a u n d e r g o i n g m e d i c a l and s u r g i c a l  mainly  also  solitary  are  therapy the c h i l d c o u l d express  his  A number o f  All  play  vention  his  response.  says  that  "messy  media" such  as  dough,  t h e c h i l d r e n f r e q u e n t l y use feelings.  Brooks  with  paints  also  says  the  that  form o f  children  that  this  Df p l a y  doctors  is  not  and p a i n t s  these m a t e r i a l s that  as  act  o u t what  or  Erikson's  happens  in  a casual  a c c o u n t o f what  has  fear  pent-up  into  groupsplay.  or  play  most  them.  that  Brooks  It  play.  It  She  takes  that  is  concludes  situation,  happened t o e a c h c h i l d .  She  also  a c h i l d can be  solitary  r e - e n a c t m e n t Df t h e  scrub  often  again demonstrates  observations  because  t h e y may f e e l . ^ ^  happened to  experiences  release  dramatic  This  has  to  are u s e f u l  t h e c h i l d r e n pound dough  and p a t i e n t s .  upsetting  also  clay,  in undirected situations  with Erik  bring  -  can r e d u c e t h e a n g e r  need to  agreement on t o  they  believes  35  in counted  would  that but  appear  this  a  form  factual  states:  O p e r a t i o n s are performed which r e v e a l s u r p r i s i n g knowledge o f m e d i c a l t e c h n i q u e s , c a s t s made o f m a s k i n g t a p e a r e a p p l i e d as a r e b a n d a i d s and gauze dressings,, o f t e n i n t h e same l o c a t i o n where t h e c h i l d has t h e m . However group  play.  there appears  Adams  points  out  c h i l d r e n need t h e o p p o r t u n i t y rage wards  that  t h e y may h a v e .  one a n o t h e r .  This  t o be some d r a w b a c k s that to  pre-school  express  the  and l i m i t a t i o n s  and e a r l y tremendous  They may t h e r e f o r e become v e r y requires  skilled  limit  setting  school  to  age  feelings  of  aggressive by t h e  to-  play 62  therapist  to p r o t e c t themselves  would a l s o group  of  seem t h a t  situations  so  ^Margaret North America S 1  Ibid.,  p.  great that  skill  all  and o t h e r is  c h i l d r e n from i n j u r y .  r e q u i r e d to  t h e c h i l d r e n have  c o n t r o l and  direct  an o p p o r t u n i t y  B r o o k s , "Why P l a y i n H o s p i t a l s . " \l: ( S e p t e m b e r 1970) p . 4 3 5 - 4 3 6 .  Nursing  It  to  vent  Clinics  436.  M a r g a r e t Adams, "A H o s p i t a l P l a y P r o g r a m : Helping Children with Serious I l l n e s s " . American J o u r n a l o f O r t h o p h y c h i a t r y , XLvI: ( J u l y 1976), pp. 416-424.  aggressive that  a group  benefit This of  feelings  play  a socially  situation  vicariously  belief  in  is  helps  discussed  question  here.  It  a c c e p t a b l e manner.  is  child's  catharsis  doubtful i f his  Adams  and f e a r f u l c h i l d :  and does n o t  w o u l d h e l p a c h i l d work t h r o u g h belief  -  the q u i e t  from a n o t h e r  open t o  36  believes ".  i n the  accord u i t h  .  .to  group".^ the  3  theories  a second-hand experience  own f e e l i n g s .  Hyde e x p r e s s e s  the  that: I t i s n o t enough f o r a c h i l d m e r e l y t o e x p r e s s h i s e m o t i o n s t h r o u g h p l a y ; he must a l s o know t h a t h i s e m o t i o n s a r e u n d e r s t o o d and a c c e p t e d and t h a t i t i s good f o r him t o have t h e s e e m o t i o n s . ° *  This  discussion  does n o t n e g a t e  t o many c h i l d r e n , o r t h a t of  play  in hospital.  contact with  an u p s e t  it  the f a c t  is  However,  Butler effects report  et  it  for  assisting  and Knudsen b o t h  t h e c h i l d who i s  c l i n i c a l observations  observed that  of  would appear t h a t  play  use p l a y  with  dolls  can be h e l p f u l  the t o t a l  possibilities.  and  hospital  the c h i l d to u n d e r s t a n d h i s  discuss  the probable  prepared for  surgery  made by o p e r a t i n g  in  op. c i t . ,  p.  surgery.  stress-reducing this  room s t a f f  way.  They  who have  c h i l d r e n who r e c e i v e p r e - o p e r a t i v e i n f o r m a t i o n  ^Adams,  use  a one-to-one  c h i l d c o u l d have more t h e r a p e u t i c  a means o f  al.  group  an e f f e c t i v e p a r t  A few p e d i a t r i c h o s p i t a l s e q u i p m e n t as  that  about  421.  N a i d a Hyde, " P l a y T h e r a p y , the T r o u b l e d C h i l d ' s S e l f Encounter". American J o u r n a l of N u r s i n g , LXXI: ( J u l y 1971) p .  1366.  -  their  surgery  Knudson  lists  seem t o four  demonstrate  types  of  37  -  fewer g e n e r a l i z e d f e a r  concrete information  responses.  a c h i l d needs  before  surgery: 1)  What w i l l  2)  Uhat  3)  T h a t he i s  4)  Where t h e o r g a n  is  happen;  expected of not  him;  t o blame  for  his  illness;  t o be removed o r  repaired is  located, 67  and t h a t Tesler  and H a r d g r o v e  t h e most  is  the  no o t h e r body p a r t s  important  a g r e e w i t h Knudsen  aspects  "what"  of  Tesler  and H a r d g r o v e  standing  the  of  in  preparation  the procedure not  child's  will  also  the  point  transductive  be h a r m e d .  that for  they also  believe  the p r e - s c h o o l 6fl  ^Ada LXXI:  B u t l e r , et a l . (December 1975)  out  mode o f  the importance of  Ibid.,  p.  under-  thinking:  " C h i l d ' s Play p. 3 5 - 3 7 .  is  Therapy".  ^ K a t h l e e n Knudsen, " P l a y T h e r a p y : Preparing for Surgery." N u r s i n g C l i n i c s o f N o r t h A m e r i c a , X: pp. 679-686. 6 7  child  "why".  We make t h e c a u s e and e f f e c t c o n n e c t i o n s f o r t h e t h e c h i l d knowing t h a t h i s e x p e r i e n c e may o t h e r w i s e l e a d him t o f a u l t y and f r i g h t e n i n g conclusions.^ Because the c h i l d ' s thought p r o c e s s e s are p r e - c o n c e p t u a l , i t  Nurse  that  is  Canadian  t h e Young (December  Child 1975)  684.  68 Preparing  Mary T e s l e r and C a r o l H a r d g r o v e , " C a r d i a c C a t h e t e r i z a t i o n : t h e Young C h i l d " . American J o u r n a l of N u r s i n g , LXXIII: Tesler  and H a r d g r o v e ,  op.  cit.,  p.  82.  - 38 difficult to him. have She  t o be s u r e Hardgrove  a play  reality  from  the  in this  helps  school this  the  also  that  c h i l d to p l a y therapy  necessary  to  taken  place.  and r e separate  r e i n f o r c e the  idea that  play  going  that  t o happen t D him and  pre-surgical  children fully  a  facilitates child.  preparation  alone  u n d e r s t a n d and a c c s p t  their  T h e r e seems  a b o u t what has  is  surgery.  between t h e n u r s e - t e a c h e r and t h e  a belief  all  to  be a n e e d f o r  the p r e -  h a p p e n e d t o him i n h o s p i t a l . happened t o  During him  place. have w r i t t e n a b o u t had major s u r g e r y  the process o r has  before play  of  t h e c h i l d r e n were a b l e  to  i n i t i a t e play  to play  sequences without  and c o n c e r n s t h r o u g h Barton  Carol Preparation". Hospitals V:  discusses  the  of  play  suffered a  The c h i l d r e n d e s c r i b e d were d e m o n s t r a t i n g  or withdrawn b e h a v i o u r s  fears  is  given  the c h i l d  f u r t h e r c l a r i f i c a t i o n o f what has  a c h i l d who has  accident.  it  a p r o c e d u r e has  interview helps  c h i l d see what i s  A few a u t h o r s with  this  information  70  and h o s p i t a l i z a t i o n .  can t a k e  of  the  t e a c h and p r e p a r e t h e p r e - s c h o o l c h i l d f o r  there i s  play  because  the p r e c e d i n g a r t i c l e s  does n o t e n s u r e surgery  understands  way c o r r e c t i o n Df m i s c o n c e p t i o n s  communication process  However,  that  This play  fantasy.  u s e f u l way t o Play  believes  can o c c u r .  All  he r e a l l y  i n t e r v i e w with the c h i l d a f t e r  believes that  assurance  that  t h e r a p y was  therapy  traumatic  hostile,  regressive  s t a r t e d . Even s o ,  t h r o u g h what had happened t o d i r e c t i o n ; and t o  express  all  them;  their  play. e f f e c t of  play  t h e r a p y on a c h i l d who  was  Hardgrove, "Emotional I n n o c u l a t i o n : the Three R's o f J o u r n a l o f the A s s o c i a t i o n f o r the Care o f C h i l d r e n i n ( S p r i n g 1977) p . 1 9 .  demonstrating  anxious  catherization.  In  her f i r s t  played spontaneously t o ask  questions  and h o s t i l e  but with  the  She  behaviour therapy  serious  play,  used the s y r i n g e  "mother" d o l l .  aggressive  a f t e r having  session  As p l a y  e v e n t h o u g h she  acting  out  continuously,  sessions  this  concentration.  a b o u t how t h e e q u i p m e n t w o r k e d .  moved on t o v e r y a g g r e s s i v e to h e r .  play  39  a  five  year  She o n l y  aggressively  she  had happened injecting  c o n t i n u e d , her p l a y through  old  spoke  Subsequently,  e x a c t l y what  c o n t i n u e d to p l a y  cardiac  became  hospital  less  pro-  71 cedures.  This  progression  of  play  similar  d e s c r i b e d by M o u s t a k a s as  part  became more r e l a x e d , t h i s  c h i l d became l e s s  ments  although  cedures.  she  Barton  chance but  still  of  is  to  the stages o f 72  the t h e r a p e u t i c p r o c e s s . rigid  t h e change  of  As  play  and f e a r f u l o f  c r i e d and o b j e c t e d when she  believes that  play  treat  had p a i n f u l  b e h a v i o u r was  not  pro-  by  that:  Through p l a y Kathy g a i n e d a c l e a r e r p e r c e p t i o n o f what t o e x p e c t d u r i n g h e r h o s p i t a l e x p e r i e n c e , and had an o p p o r t u n i t y as w e l l t o p l a y o u t h e r f e a r s and hostility.73 Barton  also  states  visual  a i d to  that  clarify  for  Kathy,  play  her p e r c e p t i o n o f  also:  " . . .  s e r v e d as  past  and f u t u r e  an  aud  hospital  „74 experiences."  71 X:  Pauline Barton, "Play 1962) p p . 1 6 2 - 1 6 4 .  (March  as  a Tool of Nursing".  Nursing  72 C l a r k Moustakas, C h i l d r e n i n B a l l a n t i n e B o o k s , 1953) p p . 7 - 9 . 73 74  Barton,  op.  Barton,  loc.  cit., cit.  p.  164.  Play  Therapy.  (New  York:  Outlook  Plank  describes  the play  40  -  behaviour  of  a four  year o l d g i r l  who  75 uas  having  play  therapy  equipment the  difficulty sessions  accepting  the amputation  this  became v e r y  and h e r p l a y  doll's  legs.  girl  consisted  Plank  of  of  her  leg.  interested in  performing multiple  During the  surgery  operations  on  states:  R u t h i e ' s o p e r a t i o n s were a l m o s t e x c l u s i v e l y l e g surgery. In a d d i t i o n t o o t h e r p r o c e d u r e s , a l l p r i m a r i l y on t h e l e g s , she f r e q u e n t l y gave i n j e c t i o n s i n t o t h e s o l e s o f the d o l l ' s f e e t , taped the d o l l ' s l e g s together and s o m e t i m e s h a n d c u f f e d t h e d o l l b e f o r e p e r f o r m i n g the o p e r a t i o n . ^ Again t h i s  little  played through  a c t e d out  her f e a r s  and h o s t i l i t y  what had h a p p e n e d t o h e r i n  Petrillo atised  girl  cites  one f o u r  she  hospital.  year o l d g i r l  and d e m o n s t r a t e d r e g r e s s i v e  while  behaviour  who was after  severely  traum-  experiencing  77 severe burns.  At t h i s  point  and d i d n o t r e s p o n d t o o r first of  encountered t h i s  companionship  through  hospital  the course Petrillo  of  i n t i m e t h e c h i l d was  communicate w i t h  girl  she w o u l d n o t  and s t o r y - t e l l i n g procedures with  this  play  this  very  the n u r s e s . play.  with P e t r i l l o  the d o l l s  c h i l d began t o  However  withdrawn  When  Petrillo  after  a week  she s t a r t e d t o  and h o s p i t a l express  her  play  equipment. feelings  easily.  states:  C a r o l i n e became t h e victim. In a d d i t i o n she  " d o e r " i n s t e a d of the h e l p l e s s i d e n t i f i e d with the r e b e l l i n g  75 Press of 7  Emma N. P l a n k , W o r k i n g w i t h C h i l d r e n i n H o s p i t a l , Case W e s t e r n R e s e r v e U n i v e r s i t y , 1 9 7 1 ) . ^Ibid.,  p.  (The  31.  Madeline P e t r i l l o , "Preventing H o s p i t a l Patients." American J o u r n a l of Nursing, LXVIII: pp. 1469-1473.  In  Trauma i n P e d i a t r i c ( J u l y 1968)  d o l l thereby expressing feelings.^ This out  child, during  play  clarify during  the p r e v i o u s  play,  she was  Petrillo  all  also  also  that  able  paints  to  out  similar  objections  play,  Petrillo  her i n h o s p i t a l .  express  and a n g r y  that  hostile  play  opportunity  to  f r e q u e n t l y answer believes  that:  interject  able  had happened t o  when t h e c h i l d r e n a r e  they  and  two c h i l d r e n d e s c r i b e d , was  therapy  t h e d i f f e r e n c e between f a n t a s y  necessary bad".  like  1*1 -  "This  gives  .  . it  She  says  is  because  the nurse  that  play  and P l a n k ,  therapy  is  like  and M o u s t a k a s  more e f f e c t i v e when t h e r e  and becomes s e c u r e enough  to  that  of  being  an e x c e l l e n t  is  The c h i l d g a i n s  express  his  true  '  a goad a sense  feelings.  82 83 '  '  , believe  relationship of Hott  trust also  believes: When t h e n u r s e p a r t i c i p a t e s i n t h i s make b e l i e v e , she r e a s s u r e s t h e c h i l d t h a t h i s p l a y i s v a l i d and m e a n i n g f u l , g i v e s him s t r e n g t h t o cope w i t h i t , and  7 8  Petrillo,  op.  cit.,  p.  1470.  7 9  Petrillo,  op.  cit.,  p.  1472.  8 0  Petrillo,  op.  cit.,  p.  1470.  8 1  Plank,  op.  cit.,  p.  29.  \ / i r g i n i a A x l i n e , Play The R i v e r s i d e P r e s s , 1 9 4 7 ) . 8 2  83  Moustakas,  op.  cit.,  Therapy.  p.  is  79  Axline  between t h e c h i l d and t h e r a p i s t .  to  procedure  80 S l Petrillo  Through  opportunities  a s k e d why a p a r t i c u l a r ".  act  feelings.  and r e a l i t y .  that:  reality."  provides  to  10.  (Cambridge,  Massachusetts;  - kZ shows him t h a t he has a d u l t a p p r o v a l t o go on f o r mastery i n the p l a y s i t u a t i o n . 8 4 Hott  points  out  that  during play  t h e c h i l d can t a k e  striving  command and c o n t r o l  85 of  situations.  situation child  This  is  in contrast  where t h e c h i l d i s  constantly  becomes a p o w e r f u l p e r s o n .  'procedures' self"/  being  Hardgrove  they occur helps  summary,  that  there i s  directed.  In  believes  hospital play  that:  the c h i l d r e g a i n  c h i l d r e n do want  and need t o p l a y Play  his  the  "Playing  sense  feelings  act  as  and f e a r s .  an a u d i o v i s u a l  and p r o c e d u r e s . tunities  similar  Play  to h e l p the  reality.  The use o f  of  From t h e themes  in  child clarify  case  studies  the course o f  t e n d e d t o be s e r i o u s and f i n a l l y  therapy also  and i n t e n s e  more p o s i t i v e  appears  at  attitudes  learning  aggres-  equipment about  to p r o v i d e n a t u r a l  e a c h c h i l d seems  play.  The p l a y  first,  then a g g r e s s i v e  began  to  described  to e n t e r i n t o  and  appears  surgery oppor-  t h e d i f f e r e n c e between f a n t a s y  discussed his  has  terms w i t h  and h o s p i t a l  a i d which f a c i l i t a t e s  articles  t o be an e f f e c t i v e  and come to  dolls  the  t h r o u g h what  t h e r a p y seems  medium t h r o u g h w h i c h a c h i l d can e x p r e s s  to  his  some c l i n i c a l e v i d e n c e i n  happened t o them i n h o s p i t a l .  sive  of  8 6  In cited  after  to the r e a l i t y  act  and out  also rough,  the p l a y .  These  84 Forum,  Jaqueline IX: (March 8 5  Ibid.,  p.  Hott, 1970)  "Play P.R.N, p. 295.  in  Pediatric Nursing".  Nursing  303.  C a r o l Hardgrove, "Emotional I n n o c u l a t i o n : the Three R's of P r e p a r a t i o n " . J o u r n a l o f the A s s o c i a t i o n f o r the Care o f C h i l d r e n i n H o s p i t a l s V: ( S p r i n g 1977) p . 1 9 .  - U3 stages  are s i m i l a r Overall,  effective what has fact  is  to  play  method o f  those  d e s c r i b e d by  therapy a f t e r surgery  87  w o u l d seem t o be an  h e l p i n g p r e - s c h o o l c h i l d r e n come t o  happened t o them. vital".  Moustakas.  She  Hardgrove  believes that:  terms  "Play  with  after  the  states:  P l a y i s t h e c h i l d ' s avenue t o u n d e r s t a n d i n g and i n t e g r a t i n g t h i n g s t h a t happen t o h i m . As he " p l a y s them o u t " , he makes them h i s own and f e e l s l e s s t h e v i c t i m and more t h e v i c t o r . Such p l a y a l s o r e v e a l s d a n g e r o u s m i s c o n c e p t i o n s and p i n p o i n t s f o r t h e o b s e r v e r where t h e c h i l d n e e d s a b e t t e r p e r s p e c t i v e . S S As H a r d g r o v e  points  out,  vention  and a d i a g n o s t i c  therapy  to  their  act  play  t h e r a p y has  tool.  C h i l d r e n may be a b l e  out  and come t o  own h o s p i t a l  experience.  c h i l d r e n may e x p r e s s each c h i l d ' s  in play,  p o t e n t i a l b o t h as  terms w i t h the t r a u m a t i c Through the hospital  s p e c i f i c n e e d s and  feelings  staff  live  with anxiety  surgery. of  F o r most  disablement  and b e l i e f s  into  between hope f o r  disease  death.  Barnes  frequently  a c u r e and f e a r  reports  that  to  C l a r k Moustakas, C h i l d r e n i n Play B a l l a n t i n e B o o k s , 1953) p p . 7 - 9 . Hardgrove,  op. c i t . ,  p.  19.  Therapy.  of fears  the parents  87  88  that  FAMILY  people a malfunctioning heart gives r i s e  or p o s s i b l e  of  DISEASE  c h i l d r e n with congenital heart  vacillating  events  play  fears.  AND HIS  of  inter-  utilize  may g a i n i n s i g h t  THE CHILD WITH CONGENITAL HEART  The p a r e n t s  to  an  (New  York:  of  - kk a c h i l d with She  heart  disease  -  may e x p e r i e n c e many  conflicting  emotions.  states: O f t e n p a r e n t s have g r e a t d i f f i c u l t y r e a c h i n g a d e c i s i o n to consent to h e a r t s u r g e r y . The s u r g e r y i s v i e w e d as l i f e - t h r e a t e n i n g by t h e p a r e n t , who s t r u g g l e s w i t h the dichotomy o f w i s h i n g to g i v e the c h i l d every c h a n c e t o l i v e a n o r m a l l i f e , and t h e e v e r p r e s e n t f e a r of exposure to trauma. N a t u r a l l y , the p a r e n t ' s greatest f e a r i s that the c h i l d w i l l not s u r v i v e s u r g e r y . 8 9  Barnes  also  states  that  professionals  a r e o f t e n unaware  of  this  They have a t e n d e n c y t o  l a b e l parents  who a r e u n w i l l i n g  to  let  c h i l d undergo child. these  surgery  Professional parents  evidence  that  their  staff  parents of  may n o t they  their  of  care about  comprehend t h a t  tense  the problem  Barnes  also  and f e a r f u l t h a t  they  child.  The c h i l d may be d e n i e d  because  parents  Some p a r e n t s  r i d themselves  who do n o t  c a r e t o o much.  may be so  limitations  becoming w o r s e . cannot  "poor p a r e n t s "  may be t h a t  over-protective within  as  guilt  may a l s o that  are  afraid  of  fear. their  their for  cites become  activities  the  condition  be o v e r - p r o t e c t i v e b e c a u s e  the  child's  anomaly  is,  they  somehow,  90 their  fault.  anxieties during  In  t h e same  a r t i c l e Barnes  points  may w e l l be i n c r e a s e d by c o n f u s i n g  hospitalization  happened t o one  of  the  child.  She  out  that  situations  cites  parental  which  an i n c i d e n t  occur  that  parent:  In t h e f o l l o w i n g y e a r , t h e boy had had t h r e e c a t h e t e r i z a t i o n s p l u s an a d m i s s i o n f a r a f o u r t h , w h i c h was u n s u c c e s s f u l . During that c a t h e t e r i z a t i o n , the m a c h i n e b r o k e down. M r s . M i l l e r was c a l l e d t o t h e l a b o r a t o r y , g o t l o s t , and when q u e s t i o n e d , s a i d , "I t h o u g h t my baby was d e a d " . . . The d o c t o r a p o l o g i z e d  Corinne Barnes, Heart S u r g e r y . " Nursing p. 13. Ibid.,  pp.  "Working with P a r e n t s o f C h i l d r e n Undergoing C l i n i c s of North A m e r i c a , IU: (March 1969)  13-14.  -  45  -  f o r h e r u n n e c e s s a r y F r i g h t and s a i d , "The n u r s e who t o o k t h e message s h o u l d have t o l d you why you were c a l l e d and shown you t h e w a y . " 9 1 This  type of  networks  tends  and team work  parents This  incident  feel  that  certainly  to  are not  demonstrate  to parents  effective.  It  their child is  decreases  not  the p a r e n t s  also  important faith  1  that  tends  communication  t o make  to h o s p i t a l  and t r u s t  the  personnel.  i n the  personnel  92 and,  therefore, further increases Parents  differently  of  c h i l d r e n with  from o t h e r p a r e n t s  life-threatening. reasons They  their  heart  anxiety  disease  probably  who p e r c e i v e t h e i r  Freiberg l i s t e d  for mothers'  anxiety.  child's  t h e most f r e q u e n t l y  during  children's  do n o t  react  illness  as  occurring  hospitalization.  are: lack  of  information  about  diagnosis;  lack  of  information  about  procedures  fears  about  recovery of  fears  about  the  Freiberg about  also  listed  the n u r s i n g not  nurse Freiberg  also  92  They  sarcastic  with  Barnes,  op.  cit.,  p.  15.  Barnes,  op.  cit.,  p.  15.  comments  from  mothers  are: the  to mother o r  i n agreement  illness;  child.93  t h e most f r e q u e n t l y o c c u r r i n g  time spent  states  treatments;  from p r e s e n t  future health of  service.  enough  child  and  patient; 94  child.  with  the  literature:  93 ized. "  K a r e n F r e i b e r g , "How p a r e n t s r e a c t American J o u r n a l of N u r s i n g , LXXII: 9 4  Ibid.,  p.  1271.  when t h e i r c h i l d i s h o s p i t a l ( J u l y 1972) p . 127D.  -  46  -  Young c h i l d r e n a r e s e n s i t i v e t o a n x i e t y t h e i r p a r e n t s and r e a c t t o i t w i t h i n c r e a s e d themselves. These  findings  point  out  reduce p a r e n t a l anxiety dependent o f  i m p a c t on t h e  Linde  cardiac  child.  disability  et  al.  heart  suggest  disease  i n t e r v e n t i o n which child's  disease et  has  an e m o t i o n a l  al.  points  out  as  poor  adjustment  r e l a t e more h i g h l y  well  that  an a n x i e t y - p r o d u c i n g . e f f e c t  that  anxiety  can  in-  behaviour.  Glaser  has  a nursing  o r w h i c h can r e d u c e t h e  the p a r e n t ' s  Congenital  chronic  the need f o r  in fear  a  physical  the e f f e c t on t h e  and a n x i e t y  to m a t e r n a l  as  in  anxiety  of  child.  96  children  than to  a  with degree  97 of  incapacity.  anxiety  A study  by B a r n e s  throughout  the c h i l d ' s  hydroxycortocosteroids  study  concluded that  and a f r a i d b e f o r e m a j o r A study  95  it  Freiberg,  congenital op.  levels  cit.,  of  hospitalization.  is  common f o r  and  gives heart p.  degree  of  hydraxycorto-  High l e v e l s  hospitalization  and a d e c r e a s e t o w a r d s  surgery  by A u e r e t a l .  c h i l d r e n with  a s s e s s e d the  were o b s e r v e d t h r o u g h o u t  an i n c r e a s e b e f o r e p r o c e d u r e s  for  al.  s u f f e r e d by e a c h c h i l d by m e a s u r i n g  costeroids  This  et  hospital  c h i l d r e n t o be 98  of with  discharge.  anxious  procedures. some  indication  disease  to  adjust  that to  it  is  their  difficult physical  1272.  96 H. H. G l a s e r e t a l . , " E m o t i o n a l I m p l i c a t i o n s o f C o n g e n i t a l Heart Disease i n C h i l d r e n . " P e d i a t r i c s XXXIII: (March 1964) pp. 367-379. 97 Heart  L . M. L i n d e e t a l . , " A t t i t u d i n a l F a c t o r s i n C o n g e n i t a l Disease." P e d i a t r i c s X X X I I : ( J u l y 1966) p p . 9 2 - 1 0 1 . 98  Corinne Barnes et a l . , Open H e a r t S u r g e r y " , P e d i a t r i c s  "Measurement o f A n x i e t y i n C h i l d r e n XLIX: ( F e b r u a r y 1972) p p . 2 5 0 - 2 5 9 .  for  c o n d i t i o n and i t  is  relatively  47  -  common f o r  these  c h i l d r e n to  have  99 emotional several had as  problems.  times.  It  is  much i m p a c t  disease.  All quite  This,  plus  the  fact  that  a stay  of  approximately  amount  of  stress  these  few d a y s a f t e r  that  emotional  Most c h i l d r e n h a v i n g  one h o s p i t a l i z a t i o n  children studied  possible  on t h e i r  least  first  the  state  their  open h e a r t two weeks  surgery  the  as  surgery  surgery  is  in hospital,  to  heart  have e x p e r i e n c e d open h e a r t  major  surgery  probably  deal with.  c h i l d has  hospitalizations  congenital  admission for  c h i l d r e n have t o  hospitalized  t h e number o f  open h e a r t  before  had been  at  surgery.  requiring  adds t o  the  Furthermore i n  undergo  painful  the  pro-  cedures. Overall, surgery  c h i l d r e n who a r e  w o u l d seem t o be p a r t i c u l a r l y  emotional upset factors  during  their  come i s  for  frightening Finally,  this:  t h e c h i l d and h i s  possible;  the  prone to  heart  parents;  c h i l d must u n d e r g o  procedures;  the  admitted for  hospitalization.  w h i c h may c o n t r i b u t e t o  plications  length  of  suffer  disease  fear major  hospital  of  have been a b l e  i n even g r e a t e r  to  accept or  anxiety  during  come t o  major  heart  from s t r e s s  There are has  and  a number serious  of im-  an u n s u c c e s s f u l  surgery  and  stay  fairly  t h e c h i l d may have e x p e r i e n c e d p r e v i o u s  he may n o t result  pre-school  is  painful long.  hospitalization  terms w i t h .  hospitalization  for  out-  This heart  which could surgery.  Edward A u e r e t a l . " C o n g e n i t a l H e a r t D i s e a s e and C h i l d h o o d Adjustment." P s y c h i a t r y i n M e d i c i n e , II: ( J a n u a r y 1971) p p . 2 3 - 3 0 .  - ka -  SUMMARY  In that  this  review of  pre-school  reactions viewed, will  is  also  examined.  that  specifically  children,  several  the c h i l d f o r discussed  as  surgery  the  has  use  play  of play  c h i l d r e n cope w i t h the s t r e s s o f out  hospitalization useful their this  stress  reducing  own s p e c i f i c play„  c e p t i o n of  it his  play  therapy.  intervention.  beliefs  literature cardiac well  that  supported.  uses  play hospitalized  the t h e o r i e s cited,  and f e a r s  may be p o s s i b l e  to  hospitalization.  gain  Play  play  give  some  helping Children  events  of  t h e r a p y may t h e r e f o r e be a  Children also during  preparing of  hospitalization.  the t r a u m a t i c  re-  anomalies  a method o f  therapy  upset,  that  c o u l d be an e f f e c t i v e method o f  and come t o t e r m s w i t h  during  is  date  However,  pre-school  act  the  e f f e c t i v e l y as  that  to  fact  emotional  intervention for  indication  appear  of  c h i l d r e n with  reducing  and p r o c e d u r e s .  therapy  light  been f o u n d t o  and t h e c l i n i c a l e x a m p l e s play  from a d v e r s e  emotional problems  a stress  studies  The h i g h p r o b a b i l i t y  pre-school  prone to  no r e s e a r c h s t u d y  In  the  prone to p s y c h o l o g i c a l  may s u f f e r  investigated.  be p a r t i c u l a r l y  therapy  is  c a r d i a c anomalies  the assumption  Although  the evidence s u p p o r t i n g  c h i l d r e n are p a r t i c u l a r l y  due t o h o s p i t a l i z a t i o n , c h i l d r e n with  literature,  play  insight  seem t o  therapy.  into  express By  observing  each c h i l d ' s  per-  -  k9 -  CHAPTER  III  METHODOLOGY  OVERVIEW  A descriptive •f  childrens'  heart  play  surgery.  study  during  was  designed  Simulated  or r e a l  hospital  therapy  and r e p r e s e n t i n g most o f  used  for  c h i l d i n the course  A variety included play  of in  dolls the  equipment  representing  c o l l e c t i o n of is  given  immediately the  study  was  permission letter the  after  consent  t h e c h i l d was  the c h i l d to  w h i c h was  handed t o  form i s  given  child's every with  on a d m i s s i o n  r e t u r n to  consecutive the h o s p i t a l  in  child active  family part  day.  in  day u n t i l  that  major  for  mould be was  figures of  collected. were  the  the  selected for  hospital.  also  complete  in  the s t u d y .  on t h e  The  child's  was  visits  Intensive  t h e c h i l d was  study  to  give  explanatory  admission  and  visited took  the  place  Care U n i t  discharged  by  on  the  and t h e n on  home.  Play  materials  commenced as  s o o n as  each  had r e c o v e r e d from s u r g e r y  sufficiently  to take  an i n t e r e s t  play.  read s t o r i e s  Until  that  time the  or played simple  investigator  games.  of  C.  study  Subsequent  the  The p u r p o s e  and t h e y were a s k e d  A p p e n d i x B and  part  after  suitable  A list  group  a d m i t t e d to  take  themes  A.  t h e ward f r o m t h e  play  the  hospitalization  materials.  the p a r e n t s  Each c h i l d who t o o k investigator  his  c h i l d r e n and a d u l t  play  the  equipment  the equipment  met e a c h f a m i l y  e x p l a i n e d to  for  of  i n Appendix  The i n v e s t i g a t o r  investigate  the recovery p e r i o d i n h o s p i t a l  play  the  to  talked  to  E a c h c h i l d had a t  therapy  individual in  the  child,  least  five  -  play  therapy  forty-five  sessions  minutes  a t e d when t h e Play of  play  using  c h i l d no l o n g e r  therapy  took  the  utilizes  b e l i e v e d t o be s t r e s s f u l that use  in of  this  type of  the p l a y  attitudes.  play  equipment  This  is  not  -  play  materials,  Each p l a y  actively  therapy  strongly  or u p s e t t i n g  the  therapy  the  therapy  is  c u r t a i l e d to m i r r o r i n g  tense  that  statements  the  t o make and  very s i m i l a r  difference is  This  1  form  situation  Moustakas  able  and e x p l o r e  termin-  equipment.  suggests  child.  c h i l d r e n are  express  The m a j o r  to  lasted  s e s s i o n was  played with  equipment u h i c h  to  which  f o r m a d v o c a t e d by M o u s t a k a s .  approach to play  a d v o c a t e d by A x l i n e . child  hospital  t o one h o u r .  therapy  5D  states  immediate insecure  to  that  communication with  and r e f l e c t i n g  the  back  2 feelings. sponses  It  was  considered that  to r e f l e c t i n g the c h i l d ' s for  during  Furthermore, teaching  naturally reflection  during of  form D f p l a y  relationship vestigator  Books,  is  therapy  between t h e  Moustakas, p. 45.  this  to  study,  it  may e a s i l y  and s t a t i c emphasis  and t h e c h i l d .  Play  Therapy  re-  missed  made by t h e  w h i c h may  each c h i l d a f e e l i n g  Children in  in  that  That of  although  be p e r c e i v e d  response.  was  child  occur  Moustakas s t a t e s  technique  investigator convey  statements  unsympathetic  used i n  therapist's  could result  opportunities  be l o s t .  a useful  a repetitious,  attempted to  '''Clark 1974),  confirming  could also  feelings  by t h e c h i l d as the  play  or  the play  statements  opportunities play.  clarifying  limiting  In  3  p l a c e d on is,  the  respect  (New Y o r k :  the in-  for  Ballantine  2 Virginia Riverside Press,  A x l i n e , Play Therapy 1947), p. ID.  ^Moustakas,  op.  cit.,  p.  2.  (Cambridge,  Massachusetts:  The  and a c c e p t a n c e o f each c h i l d chose nature of  was  the h o s p i t a l  suggested.  blood pressures investigator  and e n f o r c e d was  child  and t a l k i n g  All  was  him i n  Because  towards of  play  play of  expression  Procedures such  the stethoscope The o n l y  The i n v e s t i g a t o r used p l a y  as  manner.  of  as  constraint  took  using  c o u l d be  part  a means  consisted  a natural  the  hospital  " n e e d l e s " or other p a i n f u l  V e r b a l communication with  play  accepted.  or p a r e n t s .  t h e use o f  During  play.  forms  and u s i n g  p r o c e d u r e s on p e o p l e .  the c h i l d .  and a t t i t u d e s .  the d i r e c t i o n o f  d i r e c t e d by e a c h c h i l d and a l s o  with  -  t h e d i r e c t i o n and c o n t e n t o f  strongly  p r a c t i c e d on t h e  dangerous  actions  e q u i p m e n t and d o l l s  temperatures,  as  child's  the equipment,  activities  defined  the  51  of  clearly or  i n the  play  communicating  listening  to  each  Li  SAMPLE SELECTION  The p o p u l a t i o n tween t h e surgeon mother  ages o f  for  major  tongue  was  selected for  t h r e e and f i v e surgery  the study  years  on t h e h e a r t  be-  o l d who were a d m i t t e d by  the  and non v e r b a l b e h a v i o u r  their  therapy  o r by p r o c e s s  vessels.  Children  whose  OF DATA  The v e r b a l play  great  E n g l i s h were s e l e c t e d .  COLLECTION  during  children  or  were f i v e  displayed  by e a c h  child  s e s s i o n s were r e c o r d e d e i t h e r by a u d i o  tape  recordings.  John A l l a n , " F a c i l i t a t i n g E m o t i o n a l and S y m b o l i c C o m m u n i c a t i o n i n Young C h i l d r e n : T h e o r y and P r a c t i c e . " Paper p r e s e n t e d at the C o n f e r e n c e o f t h e C a n a d i a n A s s o c i a t i o n f o r Young C h i l d r e n , V a n c o u v e r , B r i t i s h C o l u m b i a , November 1 9 7 6 .  - 52 The i n v e s t i g a t o r each f a m i l y hospital  unit  to  c o l l e c t d a t a Dn t h e c h i l d ' s  discharge.  anxieties  c o n d u c t e d an u n s t r u c t u r e d i n t e r v i e w  Information  was  or b e h a v i o u r a l changes  from h o s p i t a l .  The t o p i c s  also  play  discussed  are  behaviour  g a t h e r e d about  the c h i l d d i s p l a y e d listed  with after  any new  after  fears,  discharge  i n Appendix  D.  IMPLEMENTATION  The i n v e s t i g a t o r Play  sessions  possible taining  in all  took  place either  t h e ward p l a y  i n the c h i l d ' s  room.  The c h i l d was  t h e p l a y m a t e r i a l and was  any way he w i s h e d . asked  to choose  child  throughout  At t h e end o f would v i s i t  v i s i t e d each c h i l d i n h i s  If  another  the play  each s e s s i o n  the next  day.  session.  room.  own room D T when given  the s u i t c a s e  con-  a l l o w e d t o use t h e equipment  a c h i l d d i d n o t want activity.  hospital  to  "play  The i n v e s t i g a t o r Parents  the i n v e s t i g a t o r  hospitals" stayed with  could j o i n in  if  in  he  was  the  they  wished.  t o l d t h e c h i l d when she  - 53 -  CHAPTER  IU  DISCUSSION AND INTERPRETATION OF THE DATA INTRODUCTION  This Are  was  undertaken to  common themes e x p r e s s e d  school of  study  children after  the p l a y  a similar  pattern?  a medium t h r o u g h  experience?  what has  happened t o  t h e r a p y was  one boy w i t h years  took  Will  pre-school express  part  fears  repair.  She has  four  of  were n o t  and o n e - h a l f  an o l d e r b r o t h e r  made f r i e n d s From t h e  able  easily  first  play  always c o n t i n u e d f o r sessions.  intensity follow  therapy about  their perception these  vessels. to  as  their  questions  c h i l d r e n who had  t h r e e and o n e - h a l f  pre-  five  of play  just  Four g i r l s  and  and o n e - q u a r t e r  study.  Her mother and f a t h e r , Moira,  out  To answer  pre-school  THE CHILDREN IN  Moira,  act  and  children  and c o n c e r n s  questions:  hospitalized  c h i l d r e n use p l a y  on t h e h e a r t o r g r e a t  range  i n the  five  of  Does t h e q u a l i t y  them i n h o s p i t a l ?  surgery  an age  behaviour  Do c h i l d r e n t e n d t o  conducted with  undergone major  surgery?  the f o l l o w i n g  d e m o n s t r a t e d by p r e - s c h o o l  which to  hospital  i n the play  major  behaviour  answer  to  although visit  THE STUDY  years  old,  and s i s t e r  each day.  and one y o u n g e r  After  an o u t g o i n g  therapy  session Moira  least  septal  one h o u r .  initial  and q u i t e  shyness,  independent  about Moira  child.  played e n t h u s i a s t i c a l l y Moira  had s i x  play  defect  sister.  t h e y were c o n c e r n e d and a n x i o u s  and was  at  had an a t r i a l  and  therapy  - 54 Shaun, moderately  four  severe  him on a d m i s s i o n mother  of  mission  and o n e - q u a r t e r stenosis  and was  t h e t i m e Shaun was  also  stubbornly  "hospitals".  baby  the  ization  and h e r  Despite  the  fact  Lucy  speech  for  at  after  age  her  Lucy's  Marian,  Marian  at was  she was  going  the  However,  Lucy  half  very  age  outgoing  have  her  her h e a r t  throughout  Care  stiff  Unit  age.  she  play  of  position  as  play  hospital-  stay.  eight  a  days.  and q u i t e  easily  limited speak  language  her play for  She  to r e l i e v e  d i d not  h e r body  and p a s s i v e  and  therapy  most o f  her  sessions.  old, of  her  L u c y had  but  had a s e c o n d p a t c h  aorta.  She  remembered h e r  and gave t h e She  to  He  Tetrology  for  and s o r e  from d u r i n g  years  and f r i e n d l y  for  of  her h o s p i t a l  therapy  and s a i d  of  and p r o c e d u r e s .  a repair  hospital,  a recurrent co-arctation of  of  during  play  and o n e - q u a r t e r  composure to  had f i v e  loud  ad-  session.  daily  withdrawn  step-  displayed  and e n j o y e d a s p e c i a l  Apart  His  like  a  with  Most  He d i d n o t  old,had  to  was  brother.  enthusiastically.  surgery.  was  c h i l d but  Intensive  still  relieve  on S h a u n ' s  and had s e c o n d s u r g e r y  admission  two y e a r s  considerable  in  father  only  old  treatments  visited  course  to  a time each day.  meals.  years  His  hospital  therapy  before  five  very  all  his  "hospitals"  behaviour  to r e l i e v e  surgery  to  first  became e x p r e s s i v e .  hospitalization.  pair  the  she was  played  her  exclamations sessions  for  She was  that  for  came t o  siblings  Her mother  post-operative  tamponade.  all  older  father  cardiac  fatigued,  and o n e - h a l f  had f o u r  valve.  and c o m p l i a n t  i n response  family.  had a r o u g h  visit  had s u r g e r y  He had a new s i x - m o n t h  r e f u s e d most o f  three  She  of  to  Shaun had one p l a y  Lucy,  old,  the a o r t i c  years,  a sweet  resistance  Fallot.  able  one and o n e - h a l f  and d i s c h a r g e .  physical  of  years  told  sSma'de b e t t e r " .  first  re-  had  hospitalization.  appearance  the r e s e a r c h e r Her mother  of that  visited  daily  -  throughout she  her h o s p i t a l i z a t i o n .  enthusiastically Judith, defect  a friendly  quiet,  five  to  Marian  therapy  and t h r e e - q u a r t e r y e a r s  and v e r b a l  child,  Care U n i t and  d i d go  "whiney".  eight  years  t h e new baby therapy  and was  able  old,  play  summary  therapy  played  through  play. to  join  "hospitals"  in  Dn  a period of  home.  septal  brother.  She  return  being  "hospitals"  She  the p l a y  allowed but  J u d i t h ' s m o t h e r had a  visit  travel  had an a t r i a l  and a new baby  J u d i t h every day.  her  Judith  very  baby-sitter Judith  had  sessions.  OVERVIEW OF PLAY THERAPY  In  c o u l d not  Judith played  to  study  sessions.  old,  c o n c e n t r a t i o n u n t i l her d i s c h a r g e who was  the  d e t e r m i n e d and o u t g o i n g .  she  d i r e c t e d the course o f  play  play  child in  and s i s t e r  see h e r .  her f i v e  t e a r f u l , negative  room-mate,  for  the o l d e s t  She had an o l d e r b r o t h e r  Intensive  great  firmly  Columbia  during  four  repair.  from the  with  As  -  seemed t o u n d e r s t a n d why h e r f a t h e r  from c e n t r a l B r i t i s h  was  55  the  four  sessions.  girls  took  Their play  SESSIONS  a very  active  role  tended to  follow  the  in  all  the  patterns  1 2 d e s c r i b e d by M o u s t a k a s and D a v i d . passive.  All  t h e e q u i p m e n t was  The c h i l d r e n were v e r y constantly behaviour.  at  serious  This  was  especially  their  with,  great  approach  true  about  i n Play  to  A Nursing (February  intrusive  Therapy.  play  care  assess her f e e l i n g s  C l a r k Moustakas, C h i l d r e n B a l l a n t i n e B o o k s , 1953) p p . 7 - 9 . Nicole David, "Play: and C h i l d N u r s i n g J o u r n a l I I :  To b e g i n  handled with in  the r e s e a r c h e r to  '  was  and  play about  fairly  respect.  and  looked  their  treatments.  (New  Diagnostic Tool." 1973) p . 5 1 .  play As  York:  Maternal  - 56 the t r u s t  r e l a t i o n s h i p w i t h t h e r e s e a r c h e r d e v e l o p e d and t h e c h i l d r e n  deemed i t  safe  play  still  to express  concentrating mainly  more i m a g i n a t i v e This  play  their  was  as  also  aggressive  t h e y moved on t o more  on n e e d l e p l a y .  they r e - e n a c t e d a l l  that  seemed t o be d i r e c t e d t o w a r d s  demonstrated i n  clearly.  During  watching putting going  Marian  various  one p l a y play.  Marian  today?"  watching  you."  children  also  "No!"  the play  towards  her.  said  in  the study  five  an e x a s p e r a t e d t o n e :  in  Marian,  " y o u have  "I  was  to  play  n e e d by i n v o l v i n g directing talk,  n e e d by g e s t u r e s therapy  and  having  Re-enactment of  III.  Autonomy:  regaining  IU.  Separation  from home and  U.  Nurturing  conversation  her.  you  just  The o t h e r  and  She  in  comments and  also  exclamations. the g i r l s  who t o o k their  procedures. procedures:  activities.  fun  the r e s e a r c h e r  follows:  II.  and  "Aren't  too."  r e c u r r i n g themes were e x p r e s s e d d u r i n g  Intrusive  passively  i n v o l v e d b o t h h e r mother  sessions with  I.  play  the r e s e a r c h e r  them t o h o l d e q u i p m e n t f o r  The themes were d e f i n e d as  the  need v e r y  said  and by c o n t i n u a l l y  the play  involved in  turned to  E v e n Lucy who d i d n o t  demonstrated t h i s  some  relief.  expressed t h i s  The r e s e a r c h e r s a i d :  t h e r e s e a r c h e r by u s i n g  During  Marian  time  finally  demonstrated t h i s  most o f  adult  therapy  s e s s i o n w i t h h e r t h e r e s e a r c h e r was  h e r hands on h e r h i p s  to play  At t h i s  f u n and l i g h t  ways.  t h e n became  As t h e p l a y  were e x p r e s s e d .  The n e e d t o have an u n d e r s t a n d i n g was  The p l a y  aggressive  had h a p p e n e d t o t h e m .  to begin w i t h .  c o n t i n u e d more t e n d e r f e e l i n g s play  feelings  testing  control. family.  reality.  part play.  - 57 The r e m a i n d e r o f  the a n a l y s i s  these  Shaun,  not  headings.  demonstrate  Although so  through p l a y i n g  will  the data w i l l  the f i f t h  the p l a y  he d i d e x p r e s s  of  be d i s c u s s e d  c h i l d who t o o k p a r t  in  under  the study  did  b e h a v i o u r e x p r e s s e d by t h e o t h e r c h i l d r e n . some o f  t h e themes  "hospitals".  t h e r e f o r e be d i s c u s s e d  in  His  i d e n t i f i e d he d i d n o t  i n t e r a c t i o n with  a separate  do  the r e s e a r c h e r  paragraph.  INTRUSIVE PROCEDURES  Intrusive t h e most  p r o c e d u r e s w i t h the emphasis  common theme e x p r e s s e d i n p l a y .  ignored.  M o i r a was  them o n l y  briefly  the o n l y  during  on  " n e e d l e s " was  The p l a y  c h i l d who p l a y e d w i t h  her f i r s t  play  syringes  therapy s e s s i o n .  I  during  had any  fluid  to  her f i r s t  play  " r e a l l y " needles.  therapy session  All  i n j e c t and t h e y a l s o  from a r e a l r u b b e r c a p p e d v i a l . through  accurately;  and p u t t i n g  cleaning  a b a n d - a i d on  eyes.  She  why R a b b i t bunny".  She m a i n l y  the s i t e  session  and i m m e d i a t e l y  the s y r i n g e  by  b e f o r e and a f t e r . t h e  Moira's  used Rabbit  had so many n e e d l e s she  had n e e d l e s .  who  found the  real  asked  if  of  themselves  The i n j e c t i o n p r o c e d u r e was  needle play  and i n j e c t e d h i s  l i k e d to put the n e e d l e r i g h t  days l a t e r s a i d is  fill  played  injection  y o u r m e d i c i n e you know."  head, f e e t  and  When  asked  "he's  been bad -  he's  a bad  said:  a discussion  " y o u have t o  At t h i s  very  the t o y .  M o i r a made no comment a t  t D Raggedy A n n :  was  through  T h i s s t a t e m e n t o p e n e d t h e way f o r  in hospital  Judith,  afterwards.  From t h e s e c o n d p l a y aggressive.  used  t h e c h i l d r e n demanded some k i n d  wanted t o  far  were  them and she  was r e p o r t e d by h e r mother t o be t e r r i f i e d o f n e e d l e s , syringes  by  t i m e she  on why c h i l d r e n  the time but  a few  have a n e e d l e now also  acknowledged  this  that  - 58 needles  hurt  and a c c o m p a n i e d t h e  i n j e c t i o n with  cries  of  pain  from  Raggedy A n n . Lucy,  although  she was  and had d i f f i c u l t y moving from t h e t o y She  case.  gave a l o n g  Lucy  "ah!",  still  very  h e r arms, d i d not  stiff  immediately  talk  took  from  surgery  the r e a l  syringe  b u t made many e x p r e s s i v e  turned the s y r i n g e  carefully  i n h e r hands of  the  and s a i d  The r e s e a r c h e r showed h e r a r e a l n e e d l e and  she  it  to  it.  She  couldn't  her mother.  a needle but  fix  the needle to  Her mother  Lucy  ignored  c o n c e n t r a t i o n she  the  the s y r i n g e  then suggested that  h e r and c h o s e  gave R a b b i t  a needle  Rabbit. in his  she With  leg.  finished  she  looked around s e a r c h i n g  for  band-aid  she  took  satisfaction,  help,  found the  pleted  it  with  a grunt  i n j e c t i o n hole  the t a s k  by d i r e c t i n g  of  and p u t  something.  to  so  she  give  syringe  handed  Raggedy  great  care  When she  Ann  and  had  When o f f e r e d a and w i t h h e r  the band-aid  h e r mother  tip  and  in  grabbed  She t h e n p o i n t e d t o  sounds.  moved t h e b a r r e l "eh!".  and o u t .  and s o r e  on.  mother's  L u c y t h e n com-  draw a " h a p p y - f a c e "  an  the  band-aid. Lucy spent procedures. and a l s o  having  bottle an  opportunity  With  head h e l d down,  despite  was  therapy  sessions  go  the  into  intravenous  the d o l l ' s  drip.  She  of  doing  giving  intrusive injections  equipment.  arm and t h e  Lucy  Her m o t h e r a s k e d h e r why  shook  listened  explained,  her m o t h e r ' s also  but  her head.  impassively. d i d not  confirmation of fascinated  Again  fluid  the  by a l l  elicit  the  from Raggedy  The r e s e a r c h e r  t o e x p l a i n how f o o d and m e d i c i n e g o e s i n t o  also  Lucy was  with  had t o  "I.U.".  this  "needles"  her play  completely mastered the s k i l l  n e e d l e had t o  intravenous  Ann was  of  played constantly  intravenous the  She  most  took  a vein.  The r e a s o n  for  a response  from  Lucy,  statement.  the  tubes  in  the p l a y  kit.  She  - 59 mas  i n the  Intensive  had more i n t r u s i v e drainage for  tubes  confirmation  catheter  for  The b l a d d e r researcher from  placed a l l  the c o r r e c t p l a c e , that  this  was  When she  she s c r e w e d up h e r  c a t h e t e r was  face  to  the  and  and  researcher  used the  nasal  and t u r n e d h e r head  a c c o m p a n i e d by e x c l a m a t i o n s of  children  the c a t h e t e r s  always t u r n i n g  correct.  e x p l a i n e d the purpose  the  squirting  play  last  big  toys.  playing  of p a i n .  away.  The  e a c h c a t h e t e r and r e c e i v e d a  glare  liked  to  .  intense  she  She  "this  discovered syringes  time s i n c e  and t h e n t o  her surgery  a chuckle  .  . this  c l e a n the s k i n .  She  of  the  c h i l d r e n , was  always accompanied  will  do e v e r y t h i n g  is  hurt  now  .  However,  made  Lucy  good  laughed.  and f i n a l l y  gave a  took  to the d o l l with  with  still  On one o c c a s i o n  "Oh d e a r  medication  great  the p l a y  aggressive  . . .  -  should  at  home.  tenderness  she  clean  T h i s was  Again  Marian  it  when  explanations it  y o u r m e d i c i n e t o make you b e t t e r . "  correctly.  said:  least  . you l i e  t h e one c h i l d who gave o r a l m e d i c i n e s .  she r e g u l a r l y  and a g g r e s s i v e .  laugh. the o l d e s t  the d o l l s :  very  sessions  a giggle  "needles".  be f i n i s h e d  generally  For the f i r s t  happy  Marian,  was  two p l a y  s t a r t e d with  great  was  She  than the o t h e r  Lucy.  during  to  much l o n g e r  procedures.  suction  Lucy's  She  in  Care U n i t  will  soon  Marian  forgot  to  first."  possibly  She because  gave t h e m e d i c i n e  and a c c o m p a n i e d t h e m e d i c a t i o n w i t h  explanation. Judith, She in  also the  like  Moira,  was most  played frequently with  doll's  t h e bed and i n  arm w i t h an a n g r y  the  a sharp  jab.  voice,  told  aggressive with  her needle  intravenous  and p u t  She  set  then t i e d the  her to  be s t i l l .  the  doll's At  play.  this  needle  arms point  to  an  - 6D some  discussion  the purpose ations She  p l a c e between J u d i t h and t h e  intravenous  with great  later  can't  of  took  yet."  than b e f o r e .  J u d i t h always  c o n c e n t r a t i o n and f r e q u e n t l y  e x p l a i n e d to  drink  fluids.  the d o l l :  She  During  last  play  therapy  needles  demonstrated her understanding  by s a y i n g :  you d i e  -  "It  is  t h e n you g e t  RE-ENACTMENT  Each o f cedures that  the g i r l s  DF PROCEDURES:  taking  During  this  the r e s e a r c h e r seeking  were d o i n g .  Overall this  than  intrusive  with  total  play  was  on h e r f a c e .  roughly  gently  J u d i t h became much have  the r e s e a r c h e r ' s  . . .  if  explan-  you d o n ' t  have  it  play  and m a j o r  TESTING REALITY  i n the  study  played through  They a c t e d o u t "dressings",  tended to procedures  for  "removing  tubes"  and  constantly  the a c c u r a c y  be s l i g h t l y like  pro-  "operations",  the c h i l d r e n i n t e r a c t e d  confirmation  aggressive  o f what  less  they  aggressive  "operations"  and r o u g h  during  her f i r s t  eye w i t h  a look  of  She  Her r e a s o n was  "this  that  Rabbit's  were  done  and t h a t  they  one come o u t " .  removed R a b b i t ' s  didn't  have  During  the  eye a g a i n .  play  gleeful  oper-  satisfaction  eye was b r o k e n and had  l i s t e n e d when t h e r e s e a r c h e r s a i d  mend b r o k e n e y e s firmly:  play  She removed R a b b i t ' s  come o u t .  down, b u t more  concentration.  Moira ation.  part  "blood pressures",  "temperatures".  you  sick."  had h a p p e n e d t o t h e m .  "anaesthetics",  with  you know  questions.  t h i s 'cause  session,  of  explan-  further  When a s k e d why c h i l d r e n had t o  medicine  very  asked  doll  about  l i s t e n e d to  t o have  the  in  ation  her p l a y .  tie  more g e n t l e she  all  "You have  c o n t i n u e d to  her  researcher  to  that  come o u t .  following  However,  doctors  during  play  could  Moira  said  session  a later  to  play  Moira  - 61 session,  after  she  had t o l d h e r t h a t  had g e n t l y she  was  o p e r a t e d a g a i n on R a b b i t now -  h e r eye mended -  mould l o o k statement  at  L u c y was  not  remove t h e  chest  cries  "ouchy!  with the  of:  better  tube  now h e r  thusiastically t h e same a r e a with  in  doll's  discovery  to  Lucy  accompanied  d i d not  that  Lucy.  for  the  attempt  looked  clothes  at  h e r own.  and t o  that  and now she clear  is as  ready a bell  procedures. She  to  give  liked  p o i n t e d out  in  for  getting  her w r i s t  compared chest this  During  were o u t said: go  she  loud  a reason  the  last  play  accompanied better  d o l l was  "See,  com-  interesting  her  all  in  them  and  The r e s e a r c h e r  to  to  carefully  definitely  Raggedy Ann was  and t h e r e s e a r c h e r  of  procedure with  them she  sutures.  kind  Moira  L u c y would nod e n -  the r e s e a r c h e r .  When t h e s u t u r e s  time;  the  Raggedy Ann&s  She  better  procedures  always covered  discovered  an e x p l a n a t i o n  first  this  "she  This  Raggedy Ann had s u t u r e s  then  wound w i t h  out  about  Raggedy Ann was  When L u c y  She  other  and  Moira  said:  an o p e r a t i o n .  The h o l e was  agreement.  was mended.  had h e r s t i t c h e s  comments  sutures  home,  right?"  t u b e had been t a k e n o u t .  h e r mother  her outdoor  "that  chest  go  She  During  doing  L u c y removed Raggedy A n n ' s  everything  spoke  of  in  and a l w a y s  told  the procedure w i t h  in  and s a y : flow  to  eye b a c k .  home."  The r e s e a r c h e r  chest  pared the  his  going  interested  h e r own w r i s t .  session  she  ouchy!".  but  as  mended and r e a d y  and p u t  a free  tube  a band-aid. chest  all  the r e s e a r c h e r  facilitated  removed Raggedy A n n ' s  now,  dressed  Raggedy Ann  home t o m o r r o w . "  exclaimed:  "Me  has  Lucy  too!  me  too! " Marian  l i k e d to play  operations.  She was  with  Raggedy Ann and a l w a y s o p e r a t e d on t h e  with  the  anaesthetic  confirming  with  always  chest.  the r e s e a r c h e r  She that  very  gentle  took  great  her  care  actions  -  were c o r r e c t . hurt at  eh"?  Researcher:  night".  Marian  here huh?" Ann's  Marian:  to  "Yes,  a special  On one o c c a s i o n  f a c e d and s a i d :  giving  "Oh-oh!  but  to  it  Marian the  have  questions  thing  (blood  your h e a r t  started  scope) good I  working  for?"  it  is  listen  anaesthetic. to  start  practice  chest  wound t o  sistently "Yes,  Judith:  listen  listen  and t e m p e r a t u r e s She  control  of  sessions  they s a i d  however  GAINING  they  Moira  had j u s t  shame-  to  constantly the  actions  and t h e  would spent  doll  pumper  t o make  stetha  thing  your h e a r t  hear  how  Judith:  Judith  "IMo!  to also check  J u d i t h then the  sure  (stetho-  to  your h e a r t ? "  the  con-  researcher:  better."  CONTROL  and c o n t e n t o f  f u r t h e r demonstrated  by s p e c i f i c  figure  how i t  the  and  is  comment as  completely  t h e c h i l d r e n would m a n i p u l a t e  was  "That  healed.  and a l w a y s made t h e same  situations  came t h e a u t h o r i t y  to  was p r o p e r l y  definitely  in  t o mend Raggedy  c a r e f u l l y watched the r e s e a r c h e r it  sleep  medicine  "what  on p e o p l e .  The c h i l d r e n c o n t r o l l e d t h e p a t t e r n sessions;  like  J u d i t h showed a d e f i n i t e p r e f e r e n c e  AUTONOMY:  therapy  not  won't  looked very  Judith:  "Uhat  to  good,  sleep  it  "Special  She  Researcher:  Do you want  confirm that  looks  so  the procedures  to  dressings.  did this  that  all  is  blood pressures  doing  sleep  again."  "That  your h e a r t . "  liked  for?"  right".  Researcher:  beating.  to  cuff)  to  the o p e r a t i o n  a b o u t why t h i n g s were d o n e .  pressure  is  is  go  t h e oxygen mask:  J u d i t h worked h e r way t h r o u g h asked  -  Raggedy Ann has  pointing  heart without  62  during  the  play  t h e i r need to  take  play.  circumstances the h e l p l e s s  so  all  During that  patient.  the  they  play be-  Uhat  be. 20 m i n u t e s  giving  Rabbit  "needles".  It  had  - 63 -  . been a r o u g h  and a g g r e s s i v e  session,  and p l a s t e r e d w i t h b a n d - a i d s . had a l o t she  got  of  needles.  I  at  him:  "I  say  see!"  M o i r a made i t  bet t h a t  Lucy d i r e c t e d p l a y easily  fatigued  equipment. manually  sisted  she was  the  and s o r e  the youngest  dextrous  as  the other c h i l d r e n .  that  h e r hand was  doctor,  she shook  so  hard f o r  the group,  clear.  don't,  shaking  her to,  couldn't  on t h e c l a m p .  She  if  was  she was  not  she was  the  as  she p r e f e r r e d t o  open t h e assist  intravenous but  in-  always chose the  exclamations  When a s k e d  she  her to handle  and body  When h e r mother a s k e d h e r i f  her head.  has  you g o t t o  this  a l l o w e d the r e s e a r c h e r to  also  it  even though  Despite  She  and t h e e q u i p m e n t and w i t h t h e a i d o f made h e r i n t e n t i o n s  was  child in  t h e e q u i p m e n t by h e r s e l f .  "No  to Rabbit  session  it  as  she  said  Moira:  he  nurse.  from the f i r s t  stiff  clamp on h e r own so  hurt."  have t h e n e e d l e s -  Also,  manipulate set  and so  really  water  "Poor o l d R a b b i t ,  Then M o i r a  you g o t t a  clear  mas soggy w i t h  Researcher:  t o have him m e d i c i n e . "  finger  Rabbit  language,  she was  the nurse  doll  the  she  nodded  and s m i l e d . Marian assistant. Marian needles  The d o l l s  was m a i n l y  a bit  the n u r s e . play for  to  the  and u s e d t h e r e s e a r c h e r as  v e r y n i c e t o them b u t was  lie  They a l l  "Now you a r e g o i n g  still  b u t you g o t  watches.  the p l a y  were o r g a n i z e d t h r o u g h o u t  she w o u l d s a y :  now you have hurt  directed a l l  and i t  t o have  insisted  will  it."  always f i r m .  Marian,  . . .  l i k e Moira  the p l a y  to play  session. On  giving  t o have a n o t h e r n e e d l e . .  s o o n be o v e r  on w e a r i n g  Before they s t a r t e d  the p l a y  an  nurse  it  going  and L u c y ,  to was  cap and two  they would d r e s s  formally  part. Judith,  always d i r e c t  o l d r o o m - m a t e , when she  i n h e r comments,  t r i e d to  take  said  to  some e q u i p m e n t :  her e i g h t " y o u go  year away,  .  - Gk this  my t h i n g s .  usually  the nurse  Judith's with she  need f o r  she  ready  them. take  to  do n e e d l e s ,  I  do n e e d l e s . "  b u t when she  did operations  autonomy  very  the s t e t h o s c o p e , felt  take  You c a n ' t  was  strong.  blood pressure  do h e r own v i t a l  One n u r s e  handled t h i s  each o t h e r ' s  vital  cuff  signs  J u d i t h mas  she was  the  A f t e r she  doctor.  had  practiced  and t h e r m o m e t e r , and r e f u s e d t o  w e l l by s u g g e s t i n g  on t h e  let  the  that  dolls,  nurses  Judith  and  signs.  SEPARATION FROM HOME AND FAMILY  This It  was n o t  associated  theme emerged i n voiced strongly with  relationship of  by any o f activities.  themes e x p r e s s e d  Moira's  parents  She  I  think  his  mummy l i v e s  she has  t o work  comment.  L a t e r she  and Daddy  to  Moira's  parents  to R a b b i t will  they w i l l  her all  Lucy all  i n the  This  c o u l d not  i n the came t o  d i d not  day and had a l s o  had many c o m f o r t  during  car  to  play  Rabbit.  with  Moira  a sad  - Bobby  After  Researcher:  come e v e r y  day.  l i s t e n e d but  voice:  to  this  "I  didn't  want my Mummy  discuss  Moira  "Mummy w i l l  and J u l i e  Moira:  come i n . "  the r e s e a r c h e r ,  often.  frequency  isolated  p r o v i d e d an o p p o r t u n i t y visit  and t h e  e x c e p t on  y o u r mummy c a n ' t  evening".  directly  o r Raggedy Ann i n  drive  so  visit  direct  play.  a l o n g way away and c a n ' t  said  come."  visits  time.  frequently  T h e r e seemed t o be a  to  expressed her w o r r i e s  from time to  c h i l d r e n and was  i n each c h i l d ' s  were u n a b l e  "You have been a bad boy t o d a y "Perhaps  the  play  between t h e f r e q u e n c y o f p a r e n t a l  separation  evenings.  nurturing  the c h i l d r e n ' s  why  would  explain  come soon -  and Nancy w i l l  Daddy  come t o o  -  visit."  express  this  been a l l o w e d  articles  theme i n p l a y . to  visit  Lucy  f r o m home i n c l u d i n g  Her m o t h e r was w i t h in  Intensive  pictures  of  her  Care.  her Lucy  brothers  - 65 and s i s t e r s . what  Her mother c o n s t a n t l y  they would a l l Marian  was  do t o g e t h e r  able  and f a t h e r  at  would t e l l  Raggedy A n n :  morning  home.  to  after  to  "You go  home  the r e s e a r c h e r  Her mother v i s i t e d  mother a l s o  anxiety  to her mother, you know,  her about  when t h e y f l e w  speak  sleep  now,  visited  every  day  the f a m i l y  and  again.  about  every day.  to  had a new t h r e e month o l d baby or  to  her  Marian  Mummy w i l l  sister occasionally  come i n  the  breakfast."  Judith's  jealousy  talked  she  she  about said  coming  at  home.  the  J u d i t h d i d not  h e r new b r o t h e r .  t o Raggedy A n n :  back  despite  fact  display  On one o c c a s i o n ,  "she's  only  that  gone  she  any  referring  for  a  smoke,  soon."  NURTURING A C T I V I T I E S  All nurturing as the  the  c h i l d r e n moved on f r o m a g g r e s s i v e  activities  nurturing  during  were p l a y  their  final  behaviours  that  play  play  to  sessions.  demonstrated  occasional Activities  classed  tender concern  for  dolls. Moira  when she  washed  t u c k e d her  game them d r i n k s She washed, during  of  Raggedy Ann t o make h e r i n bed. juice.  demanded t h e  Marian  dolls  therapy  eat  them w e l l more q u i c k l y . them i n  Lucy p a t t e d R a b b i t  f e d and c u d d l e d a l l  her t h i r d p l a y  very  gently  their  the  dinner  t h e most  dolls.  to  She  and p a t t e d  and Raggedy Ann considerate also  telling  them t h a t  started  put  this  and l o v i n g  and  this  play  She  would make  them t o b e d , she  them i n a s o f t  her  nurse.  J u d i t h was more r o u g h .  However when she  and spoke  the o n l y  was  session.  THE CHILD UHO DID Shaun,  comfortable  tucked  way.  NOT UANT TO PLAY HOSPITALS  boy t a k i n g  part  i n the study,  d i d not  express  himself this  through  was  idea.  due t o  Also,  t h e medium o f p l a y sex  difference.  during  four  y e a r o l d boy  this  study. Shaun was  unstable  a previous  demonstrate  -  therapy.  s e r t e d him when he was  It  pilot  study,  his  two y e a r s  one and o n e - h a l f  unlikely  part  first  old.  years  ago  behaviour  in  four  His  that  support  this  the r e s e a r c h e r observed a  t h e same p l a y  during  seems  The l i t e r a t u r e does n o t  t h e one c h i l d t a k i n g  home s i t u a t i o n  relationship  66  as  the study years.  father  the g i r l s  who had  His  an  mother  formed a  in  de-  common-law  and Shaun had a s i x  month  old  step-brother. On f i r s t  m e e t i n g Shaun was  sweet  to hear that  t h e r e s e a r c h e r was  meeting  p l a c e when Shaun r e t u r n e d t o  was  dyspneic  asked of  took  if  his  and l a y  he w o u l d l i k e  own b o o k s  He r e f u s e d a s t o r y cooking  a story  Shaun was about  supper.  his  and s a i d :  " O n l y when Daddy  the  want  to play  and h i s  now.  f u n t h e y had t o g e t h e r .  about  S h a u n ' s r e t u r n home.  negative  and a c t i v e l y  tired,  surgery.  o x y g e n mask o n .  a family  story  he l a u g h e d  madewith  facial  happy  changed to  his about  On  withdrawn. about  a  initiated.  first  time  visit.  a worried  i n a weepy v o i c e t h a t to  talk  The r e s e a r c h e r t o o k  obstructive  the  e q u i p m e n t on t h e t h i r d  away and s a i d  During  one  Mummy."  expression  Shaun was  for  He  LJhen  He c h o s e  a p a t h e t i c and r a t h e r  and c h o s e  shown t h e p l a y  He p o l i t e l y p u s h e d t h e t o y s didn't  t h e ward a f t e r  the funny r e p e t i t i v e p h r a s e s .  cooked supper, is  delighted  The n e x t  C o n v e r s a t i o n a b o u t S h a u n ' s home was  daddy  He o p e n e d t h e c a s e  all  hospitals  if  first  with him.  he s m i l e d and n o d d e d .  still  When a s k e d  Shaun was  to p l a y  i n bed w i t h h i s  and s m i l e d a t  the second v i s i t  "daddy"  quietly  going  and a f f e c t i o n a t e and  about  his  he  father  the o p p o r t u n i t y to  h o s p i t a l i z a t i o n Shaun all  look.  procedures.  He  was loathed  and talk  rectal  temperatures  denied that his  and i n  he had h i s  food although,  behaviour.  Shaun  occasions. the of  c a t h e t e r to catheters On t h e  threatening story  He was  one s i d e .  book.  also  t o u c h so  Shaun  Shaun  with  with  He was  play  still  the  part  tape  of  the s t o r y During  of  aid of  the  Shaun,  a " n e e d l e " and c h o s e  t h e n e e d l e t o be g i v e n this  but  t h e n grew  up a t o y  car  the p l a y  equipment.  not want  to  a game o f friends  talk  balloon  with  visit  to  Shaun  with  handball  was  too  hospital  his  this  use  listen.  equipment  would not  his  more.  again  voice.  Shaun  time r e l a t i n g continue  father's Shaun  "mother" Shaun  it.  r e f u s e d to  the r e s e a r c h e r .  the  t h e n r e f u s e d any  to hear  to  well  the  His  suggested.  encouragement, then asked  doll.  He a s k e d  initially  pushed the h o s p i t a l  and p l a y e d a i m l e s s l y  On t h e n e x t  the  threw  performed.  with  i n the stomach.  anxious,  Shaun  read a  tape,  still  where an o p e r a t i o n was  the next v i s i t  to g i v e  session  the s t o r y  had  several  and r e f u s e d t o  gave a v e r y h a l f - h e a r t e d i n j e c t i o n t o R a b b i t . father  u r i n e on  and  attempted t D e x p l a i n  intrigued  However Shaun  boy.  standing  r e c o r d e r he h e a r d t h e s t o r y  greatly the  refused  a long  found the p l a y  of  to  part  was  therapy  head away  with  book  this  He a l s o  completely  retention post-operatively  then r e p e a t e d the s t o r y the s t o r y  may.  the r e s e a r c h e r d e c i d e d to  l i s t e n e d to  comments.  father,  incontinent  turned his  When he was p l a y i n g his  his  the r e s e a r c h e r  that  The r e s e a r c h e r  fourth v i s i t  to  to  one u n s u c c e s s f u l  b u t Shaun  with  temperature taken  suffered urinary  During  -  conversation  according  to be c a t h e t e r i z e d .  67  toys  Again  Dpen t h e interest  laughed  away  and  was  her to  at  touch  and d i d  aroused only  He t h e n c o n s e n t e d t o  t h e r e s e a r c h e r once more and a s k e d  for  picked  he r e f u s e d t o  suitcase  his  come back  when  be and  - 68 play  the next Shaun  He had j u s t was  c o n s e n t e d to had h i s  immediately  just  like  doll's play  his.  and was  his  able  going his  although  with  about  great  became  the d r e s s i n g  last  visit  home.  time.  then laughed that  versation  in  it  accept  he was  course  of  going  place  it  place  the  go  about then  in  the  looked  outdoor  home.  Shaun  he d i d p i c k  up t h e  sutures  excitement.  just  like  play  The n u r s e  to  way. put  with  He  talked Andy's.  reported still  the r e s e a r c h e r  had t h i s  and knew  Raggedy  t h e p r o c e d u r e , he l a y  "I  out  that,  for  the e x p l a n a t i o n .  was  i n my bum-bum".  The r e s e a r c h e r a thermometer.  somewhat  He t h e n t o o k  t h e t h e r m o m e t e r between t h e  agreed Some  through  this  p r o c e d u r e , he g i g g l e d to  listen  and p u t to  incredulous  Raggedy A n d y ' s  doll's  legs. his  Again  with  con-  b u t he  trousers as  he  hand o v e r h i s  an e x p l a n a t i o n  the  Shaun  on why t e m p e r a t u r e s were t a k e n r e c t a l l y  Shaun's response  now seemed r e a d y  his  was  conversation  and p u t  As Shaun  to  had h i s  home t o o .  embarrassed  a strange  then took  a sigh,  then dressed  contain  t h e r m o m e t e r and s a i d :  a rather  questions  he gave  although  had a l r e a d y  and commented t h a t  the  was  you were s i c k .  Shaun  had c r i e d t h r o u g h o u t  In  the  article.  He c o u l d h a r d l y  dressing  Shaun  needles  in  He  wound  he c o u l d do  involved  c o n c e n t r a t i o n and a s k e d  give  very upset.  He removed Raggedy  Raggedy Andy was  r e f u s e d to  p i c k e d up t h e p l a y  to  the s u g g e s t i o n t h a t  operations.  talk  visit.  Raggedy Andy had a c h e s t  to  He t h e n announced t h a t  Shaun  that  t i m e Shaun  and e x a m i n e d e a c h  On t h e  first  find  For the f i r s t  and s m i l e d .  still  equipment  about  to  still  and t h e r e s e a r c h e r p r o n o u n c e d him r e a d y  however,  he was  Raggedy Andy on t h e e i g h t h  wound c l e a n e d and was  When he had f i n i s h e d  father  clothes  chest  with  He r e s p o n d e d t o  stitches  sutures.  play  intrigued  dressing.  Andy's  at  day.  about  when seemed off  played face.  He  - 69 the reasons more t o his  for  explain  his  hospitalization  this  to S h a u n .  h e a d away and seemed t o  the r e s e a r c h e r endeavoured once  For the  listen  to  first  the  t i m e Shaun d i d n o t  turn  information.  POST HOSPITAL BEHAVIOUR  All  four  "hospitals"  girls  after  theme i n  factory.  In  their  play  c o n t i n u e d to  "Needles"  c o n t i n u e d t o be  syringes  seemed t o be  a f e u ueeks h o s p i t a l  play  diminished  and o t h e r  play an  satissocial  play  over.  Moira  and M a r i a n Marian since  r e p o r t e d t o have  She  Moira i n her  at  uas  up a t  four nightmares  night  to  five  and o n e - q u a r t e r y e a r s and t o  talked  in  have  improved  a happy uay  r e p o r t e d as  active  d a y s she uas independent.  r e p o r t e d as  reluctant  to  active  leave  Her p r e - h o s p i t a l  her v o c a b u l a r y . she r e t u r n e d t o at  She d i d n o t Vancouver  she uas  quite  patient  department  discipline  to  used  in  about  and  like  t o go  child.  t h e home b u t  her f r i e n d s  at  been  performance the  hospital.  dominant  sisters.  past  later  the d o c t o r s .  bed.  r e p o r t e d t o have  aggressive.  For a  the for  uith  an o u t p a t i e n t  the  her daughter  toys  When  visit,  e x p l o r e the  out-  provided.  had c h a n g e d f r o m a  J u d i t h d i d respond  constantly  increased  local hospital.  She u a n t e d t o  play  feu  q u i c k l y became more  s p e e c h p a t t e r n r e t u r n e d and she  on h e r own and t o  an a g g r e s s i v e  in  i n her s c h o l a s t i c  her mother but  seven ueeks  ease u i t h  parents  tuD u e e k s .  disturbances.  uas  and r a t h e r  J u d i t h ' s mother r e p o r t e d t h a t girl  their  the f i r s t  and i n c l i n e d t o be more  i n t e r a c t i o n s u i t h her b r o t h e r s Lucy uas  join  in  u e r e r e p o r t e d t o have no s l e e p  discharge  school.  quiet  the study  play  L u c y and J u d i t h b o t h g o t  at  in  but  Lucy uas  uell  part  t h e y r e t u r n e d home.  important  took  uho t o o k  to  the  t r i e d her mother's  normal patience  - 70 by d o i n g  things  that  mere n o t a l l o w e d .  friendly  and v e r b a l  hospital  J u d i t h announced t h a t :  as e v e r .  "God mended my h e a r t . "  had a c o u p l e o f b e d - u i e t t i n g  f e u temper t a n t r u m s . after  surgery  quietly inch. at  uith  incidents.  f o r a f e u weeks.  His father  some t o y c a r s .  a t ease  i n the d o c t o r ' s  He l o o k e d u e l l  home d i d n o t r e l a t e Shaun shook  friends  instead  eyes u i d e ,  banged  h i s head.  didn't  of having smiled  shou h i s c h e s t  Tarzan,  to h o s p i t a l s .  he?  scar,  i t uith  his  o v e r one  His play  pattern  "Doctor  a l l day u i t h  i n the a f t e r n o o n . "  "Yep".  then pushing  He p l a y e d  When a s k e d uhy he h a d been i n  IMou you c a n p l a y  and s a i d :  months  office.  and h a d g r o u n  The r e s e a r c h e r s a i d :  to s l e e p  He  reported a  When Shaun r e t u r n e d f o r a c h e c k u p f i v e  he seemed q u i t e  mended y o u r h e a r t ,  to  nightmares  Shaun g r e e t e d t h e r e s e a r c h e r as an o l d f r i e n d .  hospital  his  f o u n d J u d i t h as  When a s k e d what h a d happened t o h e r i n  Shaun was r e p o r t e d as h a v i n g also  The r e s e a r c h e r  your  Shaun o p e n e d  He t h e n l i f t e d up h i s  out h i s chest  like  sueater  a miniature  fists.  DISCUSSION OF FINDINGS  Four out o f the f i v e study  uere able  child,  the only  to a c t i v e l y  uith  the p l a y  equipment  children's  play  expressed  They u e r e :  in play  partially  This  During  took  the f i n a l  during  to the f i r s t five  intrusive  their  first  question  common themes procedures;  part  therapy.  during  visit  posed  play  the second  like  therapy  in this  i n the course  this  last  h i s examination  uas r a t h e r play  in  The f i f t h  participated in  place  and t h e t h e r m o m e t e r p l a y  behaviour  In r e l a t i o n clearly  only.  the r e s e a r c h e r .  c h i l d r e n uho t o o k  participate  boy i n t h e s t u d y ,  t h e r a p y on one o c c a s i o n visit  pre-school  the other  session.  study  of play  of  the  girls  therapy.  re-enactment of procedures  and t e s t i n g  -  reality;  autonomy  and f i n a l l y , differing  the  by f a r  activities.  intrusive  during  that  temperature  treatments,  each p l a y  also  these play  such  f r o m home and themes  session.  as  sessions.  giving  "needles"  E a c h c h i l d gave  "needles"  Other  pro-  intravenous  appeared f r e q u e n t l y  family;  recurred uith  therapy  most p a r t i c u l a r l y  behaviour.  therapy  each c h i l d had, taking,  Each of  children's  t h e most f r e q u e n t p l a y  many t i m e s cedures  nurturing  control; separation  f r e q u e n c i e s throughout  All was  and g a i n i n g  -  71  in  intrusive  therapy or that  1  rectal  particular  child's  play. The n e x t most f r e q u e n t c h i l d r e n uas all  played  on t h e head;  the r e - e n a c t m e n t o f  "operations"  chest; Moira  eye.  children  all  sequent  play  therapy  The theme o f  Moira  aggressively also the  and a l u a y s to  take  than  autonomy that  aluays  in  the  chest  tube  Judith  operated  doll's uere  on  and s u t u r e s .  from the second  one p r o c e d u r e d u r i n g  The  play each  sub-  c o n t r o l uas  c h i l d r e n demonstrated  apparent  in  in  play  their  many  and J u d i t h e x p r e s s e d t h e n e e d t o be i n c o n t r o l more the other  expressed  clearly in  and  the o t h e r o p e r a t i o n s  and g a i n i n g  the  tuo  this  c h i l d r e n had any  part  these  session.  and a t t i t u d e s  behaviour.  least  of  Marian  Marian  and once  s t a r t e d re-enacting procedures and i n c l u d e d a t  the p l a y  Moira,  enthusiasm.  Lucy removed Raggedy A n n ' s  session  None o f  great  J u d i t h o p e r a t e d on t h e c h e s t  therapy  children  uith  in  procedures.  o p e r a t e d once on t h e c h e s t ,  Rabbit's  actions  theme e x p r e s s e d  children.  Houever,  need s t r o n g l y  in  difficulty  deciding  in  the o t h e r  the course of uhat  d i r e c t e d the r e s e a r c h e r or parent  the p l a y .  This  theme r a n  through  all  to  tuo  their  piay.  play  next  on hou t h e y  uere  the p l a y  therapy  sessions. The theme o f  separation  appeared l e s s  f r e q u e n t l y t h a n any o f  the  •ther  themes.  theme a t than  any  any o f  sions.  time  the other  the o n l y  pressed  this  The o t h e r  in  expressed way  to  the  theme was  expressed  during  beginning  to  diminish.  chosen  a  later  children's  visits  therapy  with  every  therapy  her  ses-  mother.  day,  ex-  session.  therapy  sessions  doll.  play play  appeared i n  therapy  the  play  sessions only.  when a g g r e s s i v e  activities  injections  the p l a y  a few p l a y  activities,  t e n d e d t o be l e s s for  all  and t o u c h i n g  theme i n  As n u r t u r i n g  needle play  in  this  s t a y e d w i t h h e r more  every play  comfort  children during i n the  part  cuddling  this  seem t o e x p r e s s  h e r mother  have p a r e n t a l  theme, n u r t u r i n g  of  the s i t e s  of  some p o i n t  a positive  behaviour  Also,  and t o o k  c h i l d who d i d n o t  The f i n a l  frequently,  However  enjoyed a l o t  two g i r l s  always  play.  parents  theme a t  -  t h e one c h i l d who d i d n o t  during  Lucy a l s o  Moira,  but  L u c y was  72  play  were e x p r e s s e d  frequent  were s i m i l a r  This  was more  and l e s s  aggressive.  to  used  those  in  reality. In quality  relation  to  and i n t e n s i t y  follow  a pattern.  with.  Play  the second q u e s t i o n of  the  The p l a y  children's was  quiet,  t h e n became a g g r e s s i v e  more i m a g i n a t i v e  as  and more p o s i t i v e  this  also  enter  into  suggest place."''  Books,  play  the play  that That  the is,  play  in  this  behaviour  intense  became l e s s  and i n t r u s i v e .  behaviour.  tender f e e l i n g s intense  This  by moving  C l a r k Moustakas, 1953) p p . 7 - 1 0 .  through  Next,  Children  in  to  play  Play  Therapy.  begin became  were e x p r e s s e d .  play  stages of  to  Aggression  humour  behaviour  d e s c r i b e d by M o u s t a k a s ,  the  the  d i d seem  and o c c a s i o n a l l y  pattern of  therapeutic process,  study;  and s e r i o u s  s e v e r a l p r o c e d u r e s were a c t e d o u t .  then d i m i n i s h e d point  posed  play  (New  the  At would  seems is  to  taking  children,  York:  Ballantine  as  Axline  "talk  postulated,  out" In  first  to  t h e i r major  autonomy;  are:  -  feelings  fears  posed  the c h i l d r e n ' s  and c o n c e r n s  intrusive  and s e p a r a t i o n  in  and p r o b l e m s  about  procedures;  f r o m home and  how d e e p l y  procedure.  Two o f  needle  play  with  ments,  spent  the c h i l d r e n , M o i r a  almost  as  adults  this  play  seem to  their  the  reflect  hospital  experience.  procedures;  and i n t r u s i v e  play  i m p r e s s e d by t h i s  and J u d i t h ,  therapy  doing  of  connect  intrusive  sessions  occured  type  seemed t o  L u c y , who had so many  her e n t i r e play  study,  family.  the c h i l d r e n are  ptlmishment.  in  re-enactment of  The f r e q u e n c y w i t h w h i c h n e e d l e p l a y demonstrates  just  2  the t h i r d q u e s t i o n  themes e x p r e s s e d  themes  out"  difficulties.  relation  four  some o f These  their  "play  73  treat-  intrusive  procedures. E a c h c h i l d seemed t o a better understanding children actions but  constantly  have  a need t o r e - e n a c t p r o c e d u r e s  o f what had happened t o  sought c o n f i r m a t i o n  were c o r r e c t .  continue playing clarification questions,  out  would f r e q u e n t l y g i v e  The theme o f children's  play  behaviour.  The c h i l d  E v e n L u c y who c o u l d n o t  when s h e  and l o s s  of  got  it  " e h ! " as  The their  doing would  she  control entered into  (Cambridge,  of  or  verbalize re-  right.  The c h i l d r e n p l a y e d t h e p a r t  V i r g i n i a A x l i n e , Play Therapy. The R i v e r s i d e P r e s s 1947) p . 9 .  gain  they r e c e i v e d c o n f i r m a t i o n  an i n t e r r o g a t o r y  and nod h a p p i l y autonomy  a b o u t what t h e y were  an e n q u i r y .  the procedure a f t e r  from t h e r e s e a r c h e r .  enacted procedures  as  in hospital.  from the r e s e a r c h e r t h a t  They made comments  t h e comments were o f t e n p h r a s e d  her  to  the  an  Massachusetts:  authority  figure,  usually  by t h e c h i l d r e n ; d o l l s , were t o l d . reflects with  each c h i l d ' s  become t h e  concern with  during play  that  during  rather  was w i t h  than  parents  hospital  about  to  it  appears  express  experience.  an e v e n t ,  from p a r e n t s  some  until  In  agreement  during  t h e more f r e q u e n t l y t h i s  play  to  was  parental  bad c h i l d r e n  express  this  therapy  ex-  visits. cannot their  concern  session  and  bedtime.  e a c h c h i l d who t o o k  the  probably  the need to r e a s s u r e  individual  The g r e a t e r  they  and f a m i l y ,  that,  in every play  that  directed  do what  have r e g u l a r  Lucy d i d not  from b r e a k f a s t  uere  3  to Rabbit  part  had t o  the o p p o r t u n i t y  victim."  would r e t u r n .  adults  control.  and J u d i t h f e l t  Her m o t h e r t o o k  able  of  separation  Marian  conclusion,  t h e r a p y was  the  v o i c e d her b e l i e f  visit.  play  theme e n t e r e d p l a y  of  by M o i r a who d i d n o t  h e r e a c h day  In  his  play  she  play.  loss  e a c h c h i l d made use  "doer"  have p a r e n t s dolls  During  who u e r e t h e p a t i e n t s ,  Sadness because o f  During  the n u r s e .  -  The f r e q u e n c y w i t h w h i c h t h i s  Petrillo,  pressed  74  fears  child's event  part  and c o n c e r n s fear  and  appeared  in  in  play  about  concern the  child's  play. In children  relation  d i d tend to  them i n h o s p i t a l . through  to  specific  account of  In  the f o u r t h act out  each c h i l d ' s  more i n t r u s i v e  so  hospital  procedures  posed i n  their perceptions  the course  procedures,  question  of play  play  study,  experience.  the  o f what had happened  therapy each c h i l d  behaviour  than the o t h e r  this  was  often  a  to  acted factual  Lucy e x p e r i e n c e d many  c h i l d r e n and had t o e n d u r e  M a d e l i n e P e t r i l l o , " P r e v e n t i n g H o s p i t a l Trauma i n P e d i a t r i c Patients." American J o u r n a l of Nursing, LXVIII: ( J u l y 1968) p. 1470.  all  - 75 of  these  procedures  that  the  play  therapy  intravenous  suctioning  Judith  and M a r i a n  play,  She  and a l u a y s  Lucy,  Moira  also  and Shaun d i d not  i n much l o n g e r  very  c l e a r l y when i t  than  have  intravenous  the  foley  their  arm t h r o u g h o u t tubes  the  the o t h e r  taken  the d o l l ' s  chest  tube.  axilla.  She  who t o o k  t h e same m e d i c a t i o n  in  On c h e c k i n g w i t h  c o v e r e d J u d i t h had f o u g h t  against  this  dolls.  Lucy  was chest  remember  o r a l medication  hospital,  the nurses  the  had h e r awn  c h i l d r e n and seemed t o Marian,  doll's  rectally.  J u d i t h a l w a y s t i e d t h e d o l l down when she infusion.  in  each  for  c a t h e t e r between t h e  temperatures  thermometer i n  take  doll's  insisted  put r e c t a l thermometers  was r e m o v e d .  home and c o n t i n u e d t o pills.  into  She  inserted naso-gastric  all  c h i l d who p l a y e d w i t h  tube  dolls  ran  i n s e r t e d the  they p l a c e d the  the o n l y  than the other c h i l d r e n .  infusion  session.  legs.  In  longer  gave  started  the an  the r e s e a r c h e r  p r o c e d u r e and had b o t h  at  dis-  arms  restrained. Shaun,  t h e boy who d i d n o t want  so overwhelmed by h i s was  frightening  trusting to  to  hospitalization  him.  relationship  identify  uith  After eight  to that  "hospitals"  the  play  Nine  t h e u a r d , uhen he kneu he uas  really  finally  able  temperature taken  At t h i s  time t o o ,  ation take  about part  to  his  it  talk  about  having  his  he seemed t o be r e c e p t i v e t o  surgery.  in play  had s u f f e r e d t h e refused to  talk  going  days  t u r n to  At t h i s  therapy. loss  about  u o u l d seem t h a t  his  of his  point  Shaun uas  his  level  of  anxiety  Shaun uas after  home, Shaun  his  From h i s uas  re-  uas  to  an e x p l a n to  c h i l d i n the study tuo  years  old.  behaviour  greater  than  able  rectally.  listening  m o t h e r when he was  step-mother.  equipment  Shaun may have b e e n a b l e  the only  be  when a more  the r e s e a r c h e r ,  chest uound.  seemed t o  therapy  days on t h e w a r d ,  had d e v e l o p e d w i t h  Raggedy A n d y ' s  play  in  that  who  He hospital of  the  -leather his  children in  inability  Winnicott this  to play  states:  destroys  to Shaun's  "There i s  inability  uas  not  for  his  high anxiety  investigated.  a degree of  anxiety  to take  part  in this  that  type of  t o r e a c h any c o n c l u s i o n s  is  unbearable  degree of  post-hospital  play  contributed  behaviour  to the e f f e c t of  psychological  and  therapy.  post-hospital  as  and  Houever,  T h i s may have been a f a c t o r u h i c h  c o l l e c t e d Dn t h e c h i l d r e n ' s  insufficient  t h e r a p y on t h e  The r e a s o n s  hospitals  playing".  The d a t a uas  the s t u d y .  upset  play  s u f f e r e d by  the c h i l d r e n . In  summary  by t h e f o u r intrusive  girls  the data  i n the study  activities.  fears  and c o n c e r n s a b o u t  p e r c e p t i o n o f uhat study,  child's  to  take  to p l a y part  common t h e m e s :  that  play  experience.  c h i l d r e n tended to One c h i l d ,  "hospitals".  in play  D. W. W i n n i c o t t , " P l a y i n g : Clinical Situation." International (1968) p. 598.  separation;  p l a y may  and f r o m  c h i l d r e n did express  had happened t o t h e m .  d i d not uant  refusal  these  expressed  therapy  some  individual behaviours  through  the only  The r e a s o n s are  course  The p l a y act  follou  intense  behaviours noted i n the  their hospital  suggest that  five  suggests  t o more g e n t l e  these  behaviour  p r o c e d u r e s ; autonomy;  also  Some p l a y  therapy suggest that  observed also  the  play  t o more r e l a x e d p l a y .  play  indicate  The d a t a  a p a t t e r n from a g g r e s s i v e  of  does  procedures; re-enactment of  and n u r t u r i n g  play  c o l l e c t e d on t h e p l a y  for  their  boy  in  this  unclear.  It's Theoretical Status in Journal of Psychoanalysis,  the XLIX  - 77 -  LIMITATIONS OF THE STUDY  The r e c o g n i z e d l i m i t a t i o n s The themes having Girls  i d e n t i f i e d i n play  major h e a r t only  in this  One boy o n l y The r e a s o n s  took  may o n l y  study  be common t o c h i l d r e n  part  participated actively  i n the  in play  therapy.  study.  why t h e boy uho t o o k p a r t  sample  uere:  surgery.  want t o p a r t i c i p a t e i n p l a y The t o t a l  of the study  therapy,  o f c h i l d r e n was v e r y  i n the study was n o t small.  d i d not  investigated.  -  78  -  CHAPTER  \1  CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH  CONCLUSIONS  This pressed  common themes  The themes have  descriptive  also  found that  in their  play  i d e n t i f i e d i n the p l a y been d i s c u s s e d  described children's  Hott,  the p r e - s c h o o l  behaviour  behaviour  by v a r i o u s  fear of  described pre-schoolers Petrillo,  study  intrusive  have  all  heart  the c h i l d r e n  this  1  Erik  surgery.  has  Erikson  modality  described children's  ex-  studied  Florence Erickson  procedures.  pre-occupation with  and B a r t o n  a f t e r major  of  writers.  children  of  has  behaviour.  need to  re-  3 4 5 enact procedures hospitalized  and o p e r a t i o n s .  children generally  '  '  feel  Woodward that  and J a c k s o n s t a t e  t h e y have  F l o r e n c e E r i c k s o n , "Reactions-sof C h i l d r e n to Experience". N u r s i n g O u t l o o k , UI: ( S e p t e m b e r 1958)  little  that  control  over  Hospital p. 501.  2 Erik W. W. N o r t o n  E r i k s o n , C h i l d h o o d and S o c i e t y C o . , 1950) p p . 1 9 4 - 1 9 5 .  (Revised  Edition,  New  York:  "^Madeline P e t r i l l o , " P r e v e n t i n g H o s p i t a l Trauma i n P e d i a t r i c Patients." American J o u r n a l of N u r s i n g , LXVIII: ( J u l y 1968) p. 1470.  Forum,  X:  J a q u e l i n e H o t t , "Play P.R.N, IX: (March 1970) p . 2 9 5 .  P a u l i n e B a r t o n , " P l a y as (March 1962) p p . 1 6 2 - 1 6 4 .  in Pediatric Nursing".  a Tool of  Nursing".  Nursing  Nursing  Outlook,  2  - 79 their  environment.^  their  need t o  Children's  The c h i l d r e n i n t h i s  control situations  concern with  in  separation  the  study  course  repeatedly of  their  demonstrated  play.  f r o m home and f a m i l y  has  been  des-  7 8 cribed in  by R o b e r t s o n  the play  day. the  of  During  and B o w l b y .  play  nurturing  demonstrated  therapy in  tenderness  their  behaviours.  process,  takes  pattern.  In  have p a r e n t a l  during  behaviour.  play this  activities,  and i n t e n s i t y  of  the  play  to  is  similar  that  The c h i l d r e n i n their  hospital  this  study  experience.  activities  the  rough  therapeutic  follows  process p o s i t i v e g  every  express  and r e p l a c e d  that  therapy,  a  regular  feelings  which  emerge. the play  tender  d e s c r i b e d by  visiting  These  dolls  behaviour  c h i l d r e n f o l l o w e d a p a t t e r n from i n t e n s e t o more p o s i t i v e  frequently  e a c h c h i l d began t o  Moustakas s u g g e s t s  from a g g r e s s i v e  about  play  stages of  nurturing  The q u a l i t y by t h e  place  the f i n a l  are t y p i c a l o f  theme o c c u r r e d most  sessions  and c o n c e r n f o r  and a g g r e s s i v e which  This  t h e one c h i l d who d i d n o t  later  theme o f  '  demonstrated  t o more r e l a x e d  feelings.  This  pattern  and of  Moustakas.^  did express  some  fears  and  concerns  These f e a r s  and c o n c e r n s were  part  ^Woodward and D. J a c k s o n , " E m o t i o n R e a c t i o n s i n B u r n e d C h i l d r e n and t h e i r M o t h e r s " . B r i t i s h J o u r n a l o f P l a s t i c S u r g e r y , X I I I : (1961)  p p . 316-324. 7  J . Robertson, P u b l i c a t i o n s , 1958).  Young  Children in Hospitals.  (London:  Tavistock  g John B o w l b y , P s y c h o a n a l y s i s , XLI:  "Separation Anxiety." (196Q) p p . 89-113.  International  Journal  g Clark Moustakas, C h i l d r e n B a l l a n t i n e B o o k s , (1953) p. 8. 1 0  Ibid.,  pp.  7-9.  in Play  Therapy.  (New  York:  of  of  the  first  four  themes  80-  identified.  and f e a r s  e x p r e s s e d by h o s p i t a l i z e d  therapy.  She  and t h a t also  states  that  loss  of  children in  injections  children frequently  identifies  Linn describes  focus  autonomy  are  their  similar  the course  concerns  of  puppet  t h e most common p l a y  behaviour  anger  Linn  on  and s e p a r a t i o n  "needles".  as m a j o r  concerns  for  hospitalized children. " " 1  Analysis they  tend to  This  is  in  of  act  1  the c h i l d r e n ' s  out  agreement  specific with  i n which the c h i l d r e n a c t and t r e a t m e n t s . In ation  asked.  this  the n a t u r e  the p r e - s c h o o l  child.  The i n f o r m a t i o n  i n agreement  behaviour  procedures  Petrillo out  that  and P l a n k  d i d demonstrate  have h a p p e n e d t o uho b o t h  t h e i r perception of  cite  their  case  that  them. studies  own  surgery  further  inform-  12 13 '  summary  about  play  descriptive  study  and c o n t e n t o f The d a t a  did gather  post-surgical  play  c o l l e c t e d did support  c o l l e c t e d on p o s t - s u r g i c a l  with other w r i t e r s  on t h e  behaviour  the  play  in  questions  behaviour  is  subject.  IMPLICATIONS FOR NURSING PRACTICE  Play Observation insight out  into  their  t h e r a p y would seem t o be a u s e f u l of  children's  each c h i l d ' s  play  behaviour  fears  p e r c e p t i o n o f what has  tool  during  and c o n c e r n s . happened t o  for  play As  nursing  therapy  them i n h o s p i t a l a  S u s a n L i n n , "Puppet Therapy i n H o s p i t a l s : Helping Cope." J o u r n a l A m e r i c a n M e d i c a l Women's A s s o c i a t i o n X X X I I I 1978) p p . 6 1 - 6 5 .  of  Case  Petrillo,  op. c i t . ,  "^Emma N. P l a n k , Western Reserve  pp.  provides  c h i l d r e n tend to  1 1  1 2  practice,  act  child's  Children (February  1469-1473.  Working w i t h C h i l d r e n i n H o s p i t a l , U n i v e r s i t y , 1971) p . 3 1 .  (The  Press  misconception  of  a situation  t h e r a p y may s e r v e support Play  as  81  -  may be i d e n t i f i e d .  a diagnostic  tool  to  indicate  a c h i l d may need t o h e l p him d e a l w i t h  therapy  and t h e  facilitates  child.  he c a n n o t  express  the nurse  in  In  i n words.  gaining  the  the communication  A pre-school  course  this  his  between t h e  feelings  Again t h i s  of  into  the c h i l d ' s  of  therapy  play or  hospitalization.  process  aspect  way  what i n f o r m a t i o n  c h i l d can e x p r e s s  insight play  In  play  nurse  in play therapy  that assists  needs.  a c h i l d can move t h r o u g h  the  14 stages of as  play  the  therapy  concern f o r  pleasant  continues,  the  may i n d i c a t e  his  therapeutic process  dolls  that  and p a i n f u l  nursing Play  is  In  this  has  been u s e d as  for  teaching  can t a k e  able  terms w i t h  surgery.  However,  place.  in  Previous  through.  By h e l p i n g  is  in  all  the  behaviour  the  un-  course as  is,  tender  This  t h e r a p y may s e r v e  the  feelings  t o be  course  of  of  a thera-  i n the p r e p a r a t i o n  the course surgery yet  of  play  op.  the  and p r o c e d u r e s  to  "why"  therapy  take  place  and  "how"  can be  Also, of  further  can be  happening  anxiety.  of  acted to  him,  when a  a p r o c e d u r e he  co-operative. of  play  and a c c e p t s  Moustakas,  tool  help reduce a c h i l d ' s  some u n d e r s t a n d i n g  much more l i k e l y  child's  bear  each c h i l d u n d e r s t a n d what i s  t h e r a p y may a l s o  During  had t o  a teaching  and p r o c e d u r e s w h i c h have  has  come t o  way p l a y  clarified  child  demonstrate  and a n g e r .  to  That  intervention.  children  play  to  than a g g r e s s i o n  p r o c e d u r e s he has  hospitalization.  peutic  a c h i l d may b e g i n  rather  a child  d e s c r i b e d by M o u s t a k a s .  cit.,  therapy  him as  p.  8.  the nurse  he i s .  Parents  responds  to  the  may t h e n p e r c e i v e  - 82 play  t h e r a p y a s one way i n w h i c h t h e n u r s e  their ship  child's of trust Play  students with  with  T h i s may h e l p p a r e n t s  the n u r s i n g  to l e a r n .  It  patients.  from w h i c h tD b a s e  practice  them f o r m a f r i e n d l y  As n u r s i n g  their skills  From t h e i r o b s e r v a t i o n s  In  establish  a relation-  staff..  could help  t h e y may s h a r p e n  haviour.  concern f o r  t h e r a p y w o u l d a p p e a r t o be a u s e f u l t e c h n i q u e f o r  t h e i r young  therapy  base  welfare.  demonstrates  students  in observing  the students  future nursing  conclusion play and f o r n u r s i n g  therapy  is  take  with nursing  staff.  Nursing  part  in  may e s t a b l i s h  h a s p o t e n t i a l as a  establish  a i d t o h e l p them g a i n more i n f o r m a t i o n  a data  interventions.  It  students  play  children's be-  and c o m m u n i c a t i o n t o o l and as a t h e r a p e u t i c n u r s i n g t h e r a p y may i n d i r e c t l y h e l p p a r e n t s  relationship  a u s e f u l technique f o r  education.  nursing  about  diagnostic  intervention.  a trusting  may f i n d p l a y  nursing  Play  relationship  therapy  a useful  t h e c h i l d r e n under  their  care.  INDICATIONS FOR FURTHER  From t h i s therapy school of  helps child.  upset  in  to reduce the s t r e s s F u r t h e r study  behaviour  who have p l a y Although  d e s c r i p t i v e study  in hospital  play  some i n d i c a t i o n t h a t  of h o s p i t a l i z a t i o n  and o f p o s t h o s p i t a l  study  suggest  hypothesis  d i d not demonstrate  behaviour  that  to g i r l s .  that  play  is  play  f o r the p r e the incidence  upset  in children  t h e r a p y compared t o c h i l d r e n who do n o t have p l a y  the h o s p i t a l i z e d c h i l d t h i s  surgery  there i s  i s needed t o i n v e s t i g a t e  c l i n i c a l observations  This  RESEARCH  therapy reduces  therapy. stress  y e t t o be t e s t e d .  boys e x p r e s s  A f u r t h e r study  similar  w i t h a sample  post-  - 83 population ation  including  a number o f  on t h e p a t t e r n and c o n t e n t o f Finally,  this  study  c h i l d r e n may n o t want t o useful is  boys would p r o v i d e  to  know i f  a reliable  Information  d i d not  take  an i n a b i l i t y  indication  of  them d e a l w i t h  at  risk  their  to  pursue  the  in play act  out  question  therapy. hospital  may h e l p n u r s e s  experience.  It  o f why  some  would be  experiences in  and s t r e s s identify  and who r e q u i r e s p e c i a l  hospital  inform-  play.  extreme a n x i e t y  from such a study  are emotionally  part  their  further  in  a  play  child.  c h i l d r e n who  i n t e r v e n t i o n to  help  -84-  BIBLIOGRAPHY  Books  Axline,  Virginia. Play Therapy. s i d e P r e s s , 1947.  Bouilby,  John. A t t a c h m e n t and L o s s : P r e s s , 1973.  Erikson,  Freud,  Moustakas,  Beyond t h e P l e a s u r e 1955.  Clark. Children in Books, 1953.  Play  Therapy.  of  and I m i t a t i o n 1951.  . The C h i l d ' s C o n s t r u c t i o n o f and Kegan L t d . , 1 9 2 6 . Plank,  London:  The  River-  Hogarth  R e v i s e d E d i t i o n , New Y o r k :  Principle.  Jean. The Language and T h o u g h t and Kegan L t d . , 1 9 2 6 . . P l a y , Dreams Id. Id. N o r t o n C o . ,  Massachusetts:  Separation.  Erik. C h i l d h o o d and S o c i e t y . Id. Id. N o r t o n C o . , 1 9 5 0 .  Sigmund. Press,  Piaget,  Cambridge,  London:  Neui Y o r k :  the C h i l d .  Emma N. Idorking u i i t h C h i l d r e n i n H o s p i t a l . Western Reserve U n i v e r s i t y , 1971.  Ballantine  London:  in Childhood.  Reality.  Hogarth  Neui Y o r k :  London:  The P r e s s  Routledge  of  Case  Robertson,  John. Young C h i l d r e n i n H o s p i t a l s . P u b l i c a t i o n s L t d . , 1958.  Turabian,  Kate. A Manual f o r W r i t e r s o f Term P a p e r s , T h e s e s and Dissertations. 4th E d i t i o n , Chicago: The U n i v e r s i t y o f Chicago P r e s s , 1973.  Vernon,  London:  Routledge  Tavistock  D a v i d and F o l e y , J e a n n e . The P s y c h o l o g i c a l R e s p o n s e o f C h i l d r e n t o H o s p i t a l i z a t i o n and I l l n e s s . Springfield, Illinois: C h a r l e s C . Thomas, 1 9 6 5 .  Articles  Adams,  Margaret. "A H o s p i t a l P l a y P r o g r a m : Helping Children with Serious I l l n e s s . 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" ( J u l y 1966), 92-101.  E. "Attitudinal P e d i a t r i c s , XXXII  Susan. "Puppet Therapy i n H o s p i t a l s : Helping Children Cope." J o u r n a l o f A m e r i c a n Womens' M e d i c a l A s s o c i a t i o n , X X X I I I (February 1978), 61-64.  Mahaffy,  P e r r y R. " T h e E f f e c t s o f H o s p i t a l i z a t i o n on C h i l d r e n A d m i t t e d f o r T o n s i l l e c t o m y and A d e n o i d e c t o m y . " N u r s i n g R e s e a r c h , XIV (Winter 1965), 12-19.  Mattsson A. "Long-Term P h y s i c a l I l l n e s s i n C h i l d h o o d : A Challenge to P s y c h o s o c i a l Adaptation','. P e d i a t r i c s , L (November 1 9 7 2 ) , 801-809. Moncrieff,  A. L. "New A s p e c t s o f C h i l d C a r e . " J o u r n a l , XXXI ( 1 9 5 7 ) 9 7 8 - 9 8 1 .  South  African  Medical  O'Connell,  E l i z a b e t h , A . , and B r a n d t , P . - " L i b e r a l V i s i t i n g Hours f o r Parents." 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"A S t u d y o f t h e E m o t i o n a l R e a c t i o n s o f C h i l d r e n and F a m i l i e s t o H o s p i t a l i z a t i o n a n d I l l n e s s . " American J o u r n a l o f O r t h o p s y c h i a t r y , XXIII (January 1953), 70-106.  Riddle,  Irene. " N u r s i n g I n t e r v e n t i o n t o Promote Body Image I n t e g r i t y in Children." N u r s i n g C l i n i c s o f North America VII (December 1 9 7 2 ) , 6 5 1 - 6 6 1 .  Rothman,  P. E . "A Note on H o s p i t a l i z a t i o n . " 995-999.  Scahill,  Mary. "Preparing Children f o r Procedures N u r s i n g O u t l o o k X V I I (May 1 9 6 9 ) , 3 6 - 3 8 .  Shuler,  Smith,  Review,  Pediatrics  X *(April  1962),  and O p e r a t i o n s " .  Shirley. " C o m m u n i c a t i n g w i t h Young C h i l d r e n : Teaching v i a the Play D i s c u s s i o n . " American J o u r n a l o f N u r s i n g , LXXVII (December 1 9 7 7 ) , 1 9 6 0 - 1 9 6 2 . R. M. " P r e p a r i n g C h i l d r e n f o r A n e s t h e s i a and S u r g e r y . " American J o u r n a l o f D i s e a s e i n C h i l d r e n , CI (May 1 9 6 1 ) , 6 5 0 - 6 5 3 .  Spayde,  P. E . "Kindergarten Childrens F a m i l i a r i t y with Measurement." E d u c a t i o n a l R e s e a r c h B u l l e t i n , XXXII (1953), 234-238.  Tesler,  Mary and H a r d g r o v e , C a r o l . "Cardiac Catheterization: Preparing the C h i l d . " A m e r i c a n J o u r n a l o f N u r s i n g LXX ( J a n u a r y 1 9 7 3 ) , 80-82.  Vaughan,  1  G . H. "Children 1117-1120.  in Hospitals".  L a n c e t CCLXXII  (June  1957),  Vernon,  D. T . A . and S c h u l m a n , J . L . " H o s p i t a l i z a t i o n as a S o u r c e o f P s y c h o l o g i c a l Benefit to C h i l d r e n . " P e d i a t r i c s XXXIV ( A p r i l 1964), 694-696.  Vernon,  D a v i d ; Schulman, Jerome; F o l e y , Jeanne. "Changes i n C h i l d r e n ' s Behaviour a f t e r H o s p i t a l i z a t i o n . " American J o u r n a l o f Disease i n C h i l d r e n , III (June 1966), 5 8 1 - 5 9 3 .  -  88  -  V i s i n t a i n e r , Madelon, A. and U l o l f e r , J o h n A . "Psychological Preparation for Surgical Pediatric Patients: The E f f e c t on Childrens and P a r e n t s ' S t r e s s R e s p o n s e s and A d j u s t m e n t . " P e d i a t r i c s L\7I ( A u g u s t 1 9 7 5 ) , 1 8 7 - 2 0 2 . 1  Vredevoe,  Donna, L . ; C h i n g K i m , A u d r e y ; C a l l , J u s t i n , D. "Aggressive P o s t - O p e r a t i v e P l a y Responses o f H o s p i t a l i z e d P r e - S c h o o l Children." N u r s i n g R e s e a r c h R e p o r t 11/ (Number 2) 1 , 4 - 5 .  LJinnicott,  D. Ul. "Playing: It's T h e o r e t i c a l S t a t u s i n the C l i n i c a l Situation." International Journal of Psychoanalysis, XLIX (1968), 591-599.  Ulolfer,  John A . and V i s i n t a i n e r , M a d e l o n A . "Pediatric Surgical. P a t i e n t s ' and P a r e n t s ' S t r e s s R e s p o n s e s and A d j u s t m e n t . " N u r s i n g R e s e a r c h , XXIV/ ( J u l y - A u g u s t 1 9 7 5 ) , 2 4 4 - 2 5 5 .  Ulooduiard,  J o a n and J a c k s o n , D. " E m o t i o n a l R e a c t i o n s i n Burned C h i l d r e n and t h e i r M o t h e r s . " B r i t i s h Journal of P l a s t i c Surgery XIII (1961), 316-324.  Studies  Azarnoff,  P a t r i c i a et a l . The P r e p a r a t i o n o f C h i l d r e n f o r H o s p i t a l ization. A N a t i o n a l I n s t i t u t e of Mental Health Grant, #22856, D e p a r t m e n t o f P e d i a t r i c s , U n i v e r s i t y o f C a l i f o r n i a , Los A n g e l e s , 1975.  Unpublished  Allan,  Cassel,  Materials  John. F a c i l i t a t i n g E m o t i o n a l and S y m b o l i c C o m m u n i c a t i o n i n Young C h i l d r e n : T h e o r y and P r a c t i c e . Paper p r e s e n t e d at the c o n f e r e n c e o f t h e C a n a d i a n A s s o c i a t i o n f o r Young C h i l d r e n , V a n c o u v e r , B r i t i s h C o l u m b i a , November 1 9 7 6 . S.  E. The E f f e c t o f B r i e f P u p p e t T h e r a p y on t h e E m o t i o n a l Responses o f C h i l d r e n Undergoing C a r d i a c C a t h e t e r i z a t i o n . Unpublished D o c t o r a l D i s s e r t a t i o n , Northwestern U n i v e r s i t y , C h i c a g o , 1963.  Reports  Statistics  Canada. Canada:  Hospital 1975.  Morbidity  1975.  Catalogue  82-206,  -  89  -  APPENDIX A  PLAY THERAPY  EQUIPMENT  DOLLS IS" Raggedy Ann 3  a  ) x x )  y  ,,,, • . „ . 1 6 " Raggedy Andy 18"  4  "Rabbit"  "Barbie"  ., ... . . Both w i t h outdoor h o s p i t a l gowns  , clothes  n  K  type s t u f f e d toy with long dressed i n o v e r a l l s  arms  and l e g s  Stethoscope Blood pressure bottle,  Syringes,  cuff  tubing,  n e e d l e and  ends  capped m e d i c i n e b o t t l e s  Complete d r e s s i n g Lotion bottles Masks,  caps,  Oxygen  mask  Foley  suction  Chest  tube  Medicine Tongue Alcohol  f i l l e d with  set  f i l l e d with  water  gloves  catheter  cups  depressors swabs  Band-aids,  stand  3 c c and 5 c c  Needles with b l u n t Rubber  and  and " K e n " t y p e d o l l s 1 2 " h i g h (The d o l l s were d r e s s e d t o r e p r e s e n t ; a n u r s e , a d o c t o r , a f a t h e r , and a m o t h e r . )  REAL HOSPITAL EQUIPMENT  1.1/,  and  3  dressings,  bandages  water  - 90 -  PLAY HOSPITAL EQUIPMENT Bed and  bedding  Syringes Blood pressure  cuff  Stethoscopes S e l e c t i o n of play instruments? hammers, f o r c e p s , s c i s s o r s s c a l p e l s , p r o b e s , head m i r r o r , d e n t a l m i r r o r Thermometers Receivers, Xray  trays,  machine  Nurse's  cap  Nurse s  watch  1  bottles  -  91  -  APPENDIX B  Address:  School  of  Nursing,  University  of  Vancouver,  British  Columbia,  B.C.  Dear I stand  am t r y i n g  their  parents  hospital  d e v e l o p b e t t e r mays o f experience.  and c h i l d r e n t o  t h e c h i l d and h i s During ask  to  aid in  family  cope w i t h  equipment w i l l  assure  you t h a t  this  o f m e d i c a l and n u r s i n g The d e c i s i o n  to  any  study  t o me w i l l  study  will  care given take  the  best  would l i k e thirty .  games and p l a y i n g  that  from t h i s  you have g i v e n  I  for  information  with  that  c o n f i d e n t i a l and anonymous.  to withdraw  information to  totally  from  help  to  minutes.  Activities toys  and  play  place.  You have my a s s u r a n c e  the r i g h t  in hospital  with  playing take  under-  experience.'  e a c h day  as  stories,  gain information  hospital  tD v i s i t  such  be k e p t  the is  t i m e would be u s e d t o p l a y reading  children  d e t e r m i n i n g w h i c h methods w i l l  This  will  hope t o  the p e r i o d  your p e r m i s s i o n  hospital  I  helping  part  Thank you v e r y much f o r  not  at  any  you g i v e me  You w i l l  time.  also  If  you do s o ,  any  I  would a l s o  like  be d e s t r o y e d . i n t e r f e r e with  the  effectiveness  to in  your  have  . the study  is  entirely  yours.  help.  Yours  sincerely,  Marjory  Ralston,  R.N.,  B.S.N.  - 92 -  APPENDIX C  CONSENT FORM  I  have r e a d and u n d e r s t a n d t h e e n c l o s e d l e t t e r  the proposed study  to help c h i l d r e n b e t t e r understand  explaining their  hospitalization. I myself  hereby give  to take p a r t  my p e r m i s s i o n in this  for  study.  Signed  Relationship  and  - 93 -  APPENDIX D  Interview  uiith p a r e n t s  about the  child's  behaviour  after  hospital  discharge.  The f o r m a t Topics Does  your c h i l d p l a y  unstructured.  every  day?  (a)  What games does he p l a y most  (b)  Does  he p l a y  Doctors  (c)  What  aspects  of  situations  Changes  t h e i n t e r v i e w was  Discussed  in What  of  his  or  often?  Hospitals?  hospital  experience i s  acted  out  the parents  may  play? o r e v e n t s make t h e c h i l d  (a)  Being  left  (b)  Being  away f r o m  (c)  Any new  afraid?  alone? parents?  fears?  i n behaviour or  continued behaviours  such  (a)  temper  (b)  jealousy  (c)  tics  (d)  extreme  (e)  disturbed sleep patterns,  nightmares  (f)  changes  in t o i l e t habits,  bed  (g)  seeking  parents'  or  Any c h a n g e s have n o t e d .  as:  tantrums  mannerisms shyness  wetting  attention  i n the c h i l d ' s  behaviour that  

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