Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Emotional responses of young children to hospital and surgery : a comparative study of procedures and… Holloway, Shirley Kathleen 1958

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1958_A5 H6 E5.pdf [ 4.11MB ]
Metadata
JSON: 831-1.0302587.json
JSON-LD: 831-1.0302587-ld.json
RDF/XML (Pretty): 831-1.0302587-rdf.xml
RDF/JSON: 831-1.0302587-rdf.json
Turtle: 831-1.0302587-turtle.txt
N-Triples: 831-1.0302587-rdf-ntriples.txt
Original Record: 831-1.0302587-source.json
Full Text
831-1.0302587-fulltext.txt
Citation
831-1.0302587.ris

Full Text

EMOTIONAL RESPONSES OF YOUNG CHILDREN TO HOSPITAL AND SURGERY A Comparat ive S tudy of P r o c e d u r e s and F a c i l i t i e s i n the Vancouver G e n e r a l H o s p i t a l , 1953-58 by SHIRLEY KATHLEEN HOLLOWAY T h e s i s Submi t ted i n P a r t i a l F u l f i l m e n t o f the Requi rements f o r the Degree o f MASTER OF SOCIAL WORK i n the S c h o o l o f S o c i a l Work A c c e p t e d as con forming t o the s t a n d a r d r e q u i r e d f o r the degree o f Master o f S o c i a l Work S c h o o l o f S o c i a l Work 1958 The U n i v e r s i t y o f B r i t i s h Columbia - i i i -ABSTRACT The p r e s e n t s tudy c o n s t i t u t e s an at tempt t o observe and measure the e m o t i o n a l r e s p o n s e s of young 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 s u r g e r y . There has been much i n q u i r y and comment f rom p s y c h i a t r i c and m e d i c a l s o u r c e s wh ich s u g g e s t s t h a t t h i s e x p e r i e n c e may be s e r i o u s l y t r a u m a t i c f o r some c h i l d r e n , and s o c i a l workers a r e r i g h t l y c o n c e r n e d about the p o s s i b i l i t i e s of m o d i f y i n g the f r i g h t e n i n g a s p e c t s o f h o s p i t a l r o u t i n e s on the b a s i s o f t h e i r knowledge of c h i l d r e n ' s e m o t i o n a l n e e d s . A sample group of c h i l d r e n (20) r e f e r r e d f o r t o n s i l l e c t o m y and adenoidectomy by the E a r , N o s e , and T h r o a t C l i n i c o f the Vancouver G e n e r a l H o s p i t a l was s t u d i e d . The mother o f each c h i l d was i n t e r v i e w e d , t h r e e months a f t e r the h o s p i t a l i z a t i o n of h e r c h i l d , on the b a s i s of a comprehensive q u e s t i o n n a i r e d e s i g n e d t o de termine the c h i l d ' s b e h a v i o u r b e f o r e and a f t e r s u r g e r y , i n c l u d i n g h i s u s u a l r e a c t i o n s t o punishment and the n a t u r e o f the pun ishment . R e l e v a n t r e f e r e n c e s by m e d i c a l and s o c i a l workers were s t u d i e d , i n c l u d i n g the A l b a n y R e s e a r c h P r o j e c t which was a n o t a b l e example of team r e s e a r c h by a p a e d i a t r i c i a n , an a n a e s t h e t i s t , a p s y c h i a t r i s t , and a s o c i a l w o r k e r , t o e s t a b l i s h p a t t e r n s of c h i l d ' s r e a c t i o n s t o the same o p e r a t i o n i n the A l b a n y H o s p i t a l . S i m i l a r methods of a s s e s s i n g ad justment by measur ing n e u r o -p a t h i c t r a i t s b e f o r e and a f t e r the e x p e r i e n c e were u s e d . In the p r e s e n t s t u d y , s p e c i a l emphasis was l a i d upon a s c e r t a i n i n g the n a t u r e of the m o t h e r - c h i l d r e l a t i o n s h i p and the degree o f a n x i e t y around s e p a r a t i o n . Some f o l l o w - u p was a l s o i n c o r p o r -a t e d . The same wards were o b s e r v e d f i v e y e a r s l a t e r and d i f f e r e n c e s i n s e t t i n g , p o l i c y , and p r o c e d u r e s were n o t e d and e v a l u a t e d i n terms o f the e a r l i e r f i n d i n g s . I t was found t h a t t e n o f the twenty c h i l d r e n s u f f e r e d a severe e m o t i o n a l s e t b a c k as a r e s u l t o f t h e i r i l l n e s s and h o s p i t a l i z a t i o n . I t was a l s o observed t h a t many o f the c h i l d r e n c o n f u s e d s u r g e r y w i t h punishment and many had u n r e a l i s t i c i d e a s about the purpose o f h o s p i t a l i z a t i o n . I t i s suggested t h a t poor p r e p a r a t i o n c o n t r i b u t e d t o t h i s c o n f u s i o n , and t h a t u n i m a g i n a t i v e methods of a p p l y i n g s t a n d a r d h o s p i t a l p r o c e d u r e s to s m a l l p a t i e n t s o f t e n c o n f i r m e d f e a r s and a n x i e t y . Because the c h i l d ' s r e a c t i o n t o h o s p i t a l i z a t i o n i s e s s e n t i a l l y based on the q u a l i t y o f h i s r e l a t i o n s h i p w i t h h i s mother , i t i s c o n c l u d e d t h a t s u r g e r y s h o u l d be p o s t p o n e d , i f p o s s i b l e , u n t i l a f t e r f i v e y e a r s o f age ; o r , where postponement i s i m p o s s i b l e , mothers s h o u l d be a b l e t o accompany young c h i l d r e n t o h o s p i t a l . - i v -Some m o d i f i c a t i o n s i n h o s p i t a l r o u t i n e s a p p l i c a b l e t o c h i l d r e n i n h o s p i t a l a re s u g g e s t e d . The l a t e r o b s e r v a t i o n of Vancouver G e n e r a l H o s p i t a l showed g r e a t changes i n s e t t i n g and p o l i c y , e s p e c i a l l y i n r e g a r d t o v i s i t i n g , but found the two major p r o c e d u r e s o f a d m i t t i n g t o h o s p i t a l and p r e p a r a t i o n f o r a n a e s t h e s i a and s u r g e r y v i r t u a l l y unchanged. - i i -TABLE OF CONTENTS Page Chapter I. The H o s p i t a l i z a t i o n of Young C h i l d r e n C h i l d r e n g o i n g to h o s p i t a l f o r the f i r s t t i m e : some f i n d i n g s of m e d i c a l and s o c i a l r e s e a r c h e r s . I n f a n t i l e trauma and subsequent d i s t u r b a n c e o f menta l e q u i l i b r i u m . P a r t i c u l a r l y s i g n i f i c a n t e x p e r i e n c e s i n h o s p i t a l i z a t i o n and s u r g e r y . The c h i l d ' s approach to f r i g h t e n i n g s i t u a t i o n s 1 Chapter I I . P r o c e d u r e s and F a c i l i t i e s i n the H o s p i t a l S e t t i n g and p r o c e d u r e s f o r s t a f f c a s e s . Method of s tudy and s e l e c t i o n of c a s e s . Problems o f assessment 19 Chapter I I I . The Meaning of H o s p i t a l i z a t i o n I n t e r v i e w s w i t h mothers and c h i l d r e n ; compar ison of r e a c t i o n s i n v a r i o u s s i t u a t i o n s of p a i n , s e p a r a t i o n , e t c e t e r a , w i t h the observed and v e r b a l i z e d r e a c t i o n s to s p e c i f i c h o s p i t a l and s u r g i c a l p r o c e d u r e s . D i s c u s s i o n of n e c e s s i t y o f c e r t a i n p r o c e d u r e s and ways of m o d i f y i n g the d i s t u r b i n g q u a l i t i e s o f t h e s e 30 Chapter IV . Some New Approaches to the Prob lem Vancouver G e n e r a l H o s p i t a l f i v e y e a r s l a t e r . Changes i n (1) s e t t i n g ; (2) p o l i c y ; and (3) p r o c e d u r e s . I n d i c a t i o n s of t r e n d 53 A p p e n d i c e s : Q u e s t i o n n a i r e used as b a s i s f o r i n t e r v i e w s w i t h m o t h e r s . T a b l e showing n e g a t i v e b e h a v i o u r t r a i t s b e f o r e and a f t e r o p e r a t i o n . B i b l i o g r a p h y TABLES IN THE TEXT T a b l e 1. Compar ison of p r e - o p e r a t i v e f e e l i n g s of s e c u r i t y and p o s t - o p e r a t i v e ad jus tment ( I n t e g r a t i o n of the e x p e r i e n c e ) 33 A . B . C . T a b l e 2 . Compar ison of u s u a l method of punishment and m o s t - f e a r e d h o s p i t a l p rocedure . . . . 40 - V -ACKNOWLEDGEMENTS I w i s h t o acknowledge the v a l u a b l e a s s i s t a n c e i n w r i t i n g t h i s t h e s i s g i v e n me by D r . Leonard Marsh and M r s . Mary Tadych of the S c h o o l o f S o c i a l Work o f the U n i v e r s i t y o f B r i t i s h C o l u m b i a , b o t h of whom gave g e n e r o u s l y of t h e i r t ime and knowledge . I w i s h to thank a l s o D r . J . F . McCreary and the s t a f f of the P a e d i a t r i c s Department o f the Vancouver G e n e r a l H o s p i t a l , who gave me every f a c i l i t y i n o b t a i n i n g and e v a l u a t i n g the f a c t u a l m a t e r i a l i n t h i s t h e s i s . M r . Kenneth Weaver and the s t a f f o f the Department o f S o c i a l S e r v i c e o f the same h o s p i t a l a l s o gave i n v a l u a b l e a d v i c e and a s s i s t a n c e , f o r which I am g r a t e f u l . EMOTIONAL RESPONSES OF YOUNG CHILDREN TO HOSPITAL AND SURGERY A Comparative Study of Procedures and F a c i l i t i e s i n the Vancouver General Hospital, 1 9 5 3 - 5 8 CHAPTER I THE HOSPITALIZATION OF YOUNG CHILDREN , When a c h i l d goes t o h o s p i t a l f o r the f i r s t t ime i n h i s l i f e , how does he f e e l about i t ? O b v i o u s l y i t i s a new e x p e r i e n c e f o r h i m , b o t h i n terms o f the p l a c e , which i s d i f f e r e n t f rom o t h e r i n t e r i o r s he has known, and i n terms o f the p e o p l e , who d r e s s d i f f e r e n t l y and a c t d i f f e r e n t l y than mother or f a t h e r or t e a c h e r or the l a d y down the s t r e e t . Sometimes c h i l d r e n go to h o s p i t a l on an emergency b a s i s , because o f an a c c i d e n t a t home or i n the s t r e e t , sometimes they go because they a r e " s i c k 1 ' w i t h pneumonia or p o l i o . Sometimes they have an o p e r a t i o n and sometimes n o t . T h i s s tudy was p l a n n e d to observe the r e a c t i o n s o f c h i l d r e n h o s p i t a l i z e d f o r t o n s i l l e c t o m y o n l y , as t h a t i s a u n i f o r m e x p e r i e n c e common to many c h i l d r e n between the ages o f two and n i n e . I t was begun i n 1953 with, o b s e r v a t i o n o f the c h i l d r e n i n the P a e d i a t r i c wards o f the Vancouver G e n e r a l H o s p i t a l . F i v e years l a t e r , t h o s e w a r d s , now i n a s e p a r a t e b u i l d i n g and w i t h d i f f e r e n t p r o c e d u r e s and r e g u l a t i o n s , were a g a i n o b s e r v e d . D e t a i l s o f s e t t i n g and p r o c e d u r e s w i l l be d i s c u s s e d i n l a t e r c h a p t e r s . Meanwhile what a r e the r e s p o n s e s which one might expect and what a r e the o p i n i o n s o f o t h e r r e s e a r c h e r s on the whole s u b j e c t o f h o s p i t a l i z a t i o n and s u r g e r y f o r young c h i l d r e n ? - 2 « N o r m a l l y t h e s e a r e n o t emergency a d m i s s i o n s , t h a t i s , t h e r e i s a l a p s e of t ime between the making o f the d e c i s i o n t o send the c h i l d t o h o s p i t a l and the a c t u a l t ime of a d m i s s i o n . T h i s f a c t means t h a t t h e r e i s t ime f o r p r e p a r a t i o n , b o t h p h y s i c a l and e m o t i o n a l , f o r the coming e x p e r i e n c e . However, i f t h i s t ime l a p s e i s t o be h e l p f u l t o the p a t i e n t , he must be a b l e t o u n d e r s t a n d f u l l y what i s g o i n g t o happen and why. In the case o f the c h i l d p a t i e n t he may n o t even know t h a t he i s go ing t o h o s p i t a l , and i f he does know he may have l i t t l e u n d e r s t a n d i n g of the p r o c e d u r e s and t h e i r p u r p o s e . In e i t h e r event he w i l l e x p e r i e n c e some f e e l i n g s o f a n x i e t y . Some a u t h o r i t i e s would go f u r t h e r t h a n t h i s , and say t h a t , r e g a r d l e s s of the degree o f u n d e r s t a n d i n g and r e g a r d l e s s o f the age and p r e v i o u s e x p e r i e n c e s o f the p a t i e n t , he w i l l e x p e r i e n c e some i d e n t i f i a b l e a n x i e t y when f a c i n g h o s p i t a l a d m i s s i o n f o r s u r g e r y . He lene D e u t s c h , i n an a r t i c l e on "Some P s y c h o a n a l y t i c O b s e r v a t i o n s i n S u r g e r y , " w r i t e s : "I have o b s e r v e d t h a t even the b e s t - t e m p e r e d and m i l d e s t p e o p l e w i l l have i n c r e a s e d a g g r e s s i v e t e n d e n c i e s i n the p e r i o d p r e c e d i n g an a n t i c i p a t e d o p e r a t i o n . . . " a n d l a t e r : " t h e f a c t o r o f g r e a t e s t impor tance f o r the s u c c e s s f u l conquest o f o p e r a t i o n a n x i e t y and i t s r e s u l t s i s the amount o f p r e - o p e r a t i v e 1 p r e p a r a t i o n . " T h i s p o i n t , t h a t t h e ' p a t i e n t must be p r e p a r e d 1 D e u t s c h , H . "Some P s y c h o a n a l y t i c O b s e r v a t i o n i n S u r g e r y " i n P s y c h o s o m a t i c M e d i c i n e 4:105-15* I n t h i s a r t i c l e a l s o she s t r e s s e s the v a l u e o f t h i s a n x i e t y i n h e l p i n g the p a t i e n t t o b u i l d up h i s i n n e r d e f e n s e s a g a i n s t the t w o - f o l d t h r e a t : the f e a r o f n a r c o s i s , wh ich t o some ( e s p e c i a l l y c h i l d r e n ) i s the f e a r o f d e a t h , and the f e a r o f a t t a c k . as f u l l y as p o s s i b l e f o r the coming e x p e r i e n c e , cannot be s t r e s s e d too much. I t i s emphasized a g a i n and a g a i n by p e d i a t r i c i a n s and p s y c h i a t r i s t s who have observed the r e a c t i o n s o f p a t i e n t s b o t h a d u l t and j u v e n i l e t o h o s p i t a l i z a -t i o n . E x p e r i e n c e h e r e proves t h a t the commonly h e l d n o t i o n t h a t "what you d o n ' t know won ' t h u r t you" i s not t r u e . When a c h i l d does no t unders tand what i s go ing t o happen t o h i m , he makes up an e x p l a n a t i o n w i t h i n the l i m i t s o f h i s own e x p e r i e n c e , r e a l and p s y c h i c . H i s a n x i e t y i s i n c r e a s e d by the i m a g i n a r y e x p l a n a t i o n , and i t becomes more d i f f i c u l t f o r him t o a c c e p t subsequent r e a l i t y . I t becomes more d i f f i c u l t a l s o f o r p a r e n t s and d o c t o r to r e a c h the h i d d e n depths of h i s a n x i e t y w i t h subsequent e x p l a n a t i o n s . T h i s i m a g i n a r y e x p l a n a t i o n i s the source of the o f t e n n o t e d phenomenon o f r e a c t i v a t i o n o f trauma i n the l a t e r l i f e o f n e u r o t i c p a t i e n t s . D r . Rober t L . W o r t h i n g t o n o f f e r s an example o f t h i s i n d i s c u s s i o n o f a c h i l d p a t i e n t who had been t h r e a t e n e d f o r b e d -w e t t i n g and who jumped t o the c o n c l u s i o n t h a t a subsequent 1 t o n s i l l e c t o m y was a punishment f o r the p r o h i b i t e d b e h a v i o u r . 2 D e u t s c h observes the same k i n d o f phenomenon i n d i s c u s s i n g the case o f a boy who underwent a c i r c u m c i s i o n a t the age of t h r e e y e a r s which produced c a s t r a t i o n f e a r s which were r e a c t i v a t e d t w e n t y - f i v e y e a r s l a t e r . She emphasizes t h a t 1 W o r t h i n g t o n , R o b t . L . " P e d i a t r i c s and the C h i l d " i n The  B u l l e t i n o f i h e He lminger C l i n i c , 8:170-7 (Nov. 1944 ) . 2 D e u t s c h , op., c i t . - 4 -" o p e r a t i o n s per formed i n c h i l d h o o d l e a v e i n d e l i b l e t r a c e s on the p s y c h i c l i f e o f the i n d i v i d u a l . " I f the s i t u a t i o n o f a n t i c i p a t i n g s u r g e r y may be a d i s t u r b i n g one f o r most p a t i e n t s , what a r e the component p a r t s o f t h i s e x p e r i e n c e and the p a r t i c u l a r forms of a n x i e t y which each may a c t i v a t e ? The most obv ious f a c t o r i n t h i s e x p e r i e n c e i s the s e p a r a t i o n o f the c h i l d f rom h i s home and f a m i l y , the s e p a r a t i o n f rom h i s mother . A c h i l d ' s g rowth , b o t h p h y s i c a l and e m o t i o n a l , i s i n t i m a t e l y connec ted w i t h the r e l a t i o n s h i p he i s a b l e t o e s t a b l i s h w i t h a t l e a s t one o t h e r human b e i n g , n o r m a l l y h i s mother . T h i s f a c t was shown c l e a r l y 1 i n the work done a t the London C h i l d Guidance C l i n i c and i n the s t u d i e s done d u r i n g the war o f the e f f e c t on c h i l d r e n o f 2 e v a c u a t i o n f rom the bombed a r e a s . E d e l s t o n comments t h a t " the p s y c h o l o g i c a l i n j u r y ^ o f s e p a r a t i o n . 7 can be v e r y s e v e r e indeed a t an e a r l y a g e , even where t h e r e i s no p r e v i o u s s u g g e s t i o n o f i n s t a b i l i t y ©r f a m i l y d i f f i c u l t i e s " and t h a t " i n t h e i r e a r l y y e a r s a t l e a s t c h i l d r e n i n v e s t t h e i r p a r e n t s w i t h complete o m n i s c i e n c e and 3 complete o m n i p o t e n c e . " Thus the c h i l d may assume t h a t m o t h e r ' s a c t i o n i n l e a v i n g him a l o n e a t the h o s p i t a l and a t the mercy o f s t r a n g e r s i s a d e l i b e r a t e and i n t e n t i o n a l 1 E d e l s t o n , H . " 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 : a s tudy of h o s p i t a l c a s e s " i n G e n e t i c S o c i e t y Monographs 28:3-95. 2 F r e u d , A . and D. B u r l i n g h a m : f a r and C h i l d r e n . N . Y . I n t . U . P . , 1943. 3 E d e l s t o n , op., c l t . r e j e c t i o n , an abandonment, or a pun ishment . He may n o t unders tand tha t she has no c h o i c e about l e a v i n g h i m , or t h a t she does so i n h i s i n t e r e s t . The degree t o wh ich he m i s -c o n s t r u e s the s i t u a t i o n o b v i o u s l y depends i n p a r t on h i s a b i l i t y t o unders tand the n a t u r e and purpose of the e x p e r i e n c e . "The younger and more h e l p l e s s the c h i l d the g r e a t e r the s e p a r a t i o n a n x i e t y and the more mass ive the upheava l wh ich i n i n f a n t s may a c t u a l l y produce an e m o t i o n a l r e g r e s s i o n . " The c h i l d ' s i n s e c u r i t y b l o c k s h i s e m o t i o n a l p r o g r e s s and causes him t o r e v e r t t o a " s a f e r " form o f b e h a v i o u r . I t i s o n l y when t h i s i n s e c u r i t y i s d e c r e a s e d by the p h y s i c a l p r e s e n c e o f h i s mother , and he i s a b l e t o express h i s a n x i e t y and h a n d l e i t , t h a t he can b e g i n t o grow a g a i n . The human b e i n g t o whom the c h i l d r e l a t e s need no t be h i s r e a l mother , and i t may be thought t h a t k i n d l y mother and f a t h e r -s u b s t i t u t e s , i n the pe rsons o f n u r s e s and d o c t o r s , may f i l l t h i s n e e d . Such t h i n k i n g i s t o u n d e r e s t i m a t e the c h i l d ' s a b i l i t y t o a p p r e c i a t e d i f f e r e n c e s i n r e l a t i o n s h i p s . He may become v e r y a t t a c h e d to h o s p i t a l p e r s o n n e l d u r i n g h i s s t a y , but he does no t n o r m a l l y c o n f u s e them w i t h h i s own p a r e n t s , w i t h the p e o p l e a t home. Assuming then t h a t he i s v e r y much aware of h i s s e p a r a t i o n f rom h i s mother , i t i s to be expec ted t h a t he would be concerned about the r e a s o n f o r h e r a b s e n c e , and the l e n g t h o f the s e p a r a t i o n . I t has been sugges ted t h a t the c h i l d sees t h i s s e p a r a t i o n v e r y f r e q u e n t l y as an abandonment. C h i l d r e n - 6 -have a v e r y keen s e n s e , as a r u l e , o f t h e i r own s h o r t c o m i n g s , t h e i r e r r o r s o f o m i s s i o n and c o m m i s s i o n , i n d e e d p a r e n t s work v e r y hard t o make sure c h i l d r e n a r e aware o f t h e i r w r o n g d o i n g s , and p a r e n t s p u n i s h c h i l d r e n f o r j u s t t h i s p u r p o s e , t o make them c o n s c i o u s o f t h e i r bad b e h a v i o u r . C h i l d r e n a r e p u n i s h e d i n v a r i o u s ways , but the punishment u s u a l l y f o l l o w s on the h e e l s o f the " c r i m e . " C h i l d r e n sometimes see t h i s s e p a r a t i o n , and the p a i n and a n x i e t y a t t e n d a n t u p o n i t , as punishment f o r w ickedness c o n t e m p l a t e d . As has been n o t e d , p a r e n t s a r e o f t e n thought by the c h i l d t o be v e r y aware o f a c h i l d ' s t h o u g h t s , and i t i s not u n u s u a l i n c a s e s s t u d i e d t o f i n d t h a t c h i l d r e n supposed the s e p a r a t i o n s they s u f f e r e d i n c h i l d h o o d (even upon the d e a t h of a p a r e n t ) t o be the d i r e c t r e s u l t o f t h e i r own naughty t h o u g h t s . In a t t e m p t i n g t o a s s e s s a c h i d ' s r e a c t i o n t o any s i t u a t i o n , i t i s n e c e s s a r y t o remember t h a t h i s t h i n k i n g i s on a p r i m i t i v e l e v e l , t h a t he equates d e a t h w i t h a go ing away, t h a t he sees wickedness as i n e v i t a b l y found out and p u n i s h e d . In the f i n a l a n a l y s i s the c h i l d knows who he i s i n terms o f h i s p a r e n t s , he i s t h e i r c h i l d , t h e i r boy or g i r l . T h i s sense of i d e n t i t y i s a g r a d u a l l y d e v e l o p i n g t h i n g j which s u f f e r s a s e r i o u s se tback as the c h i l d i s removed f rom the environment i n which he knows where he b e l o n g s . From t h i s knowledge o f i d e n t i t y comes a l s o h i s sense o f w o r t h . He f e e l s impor tan t and wor thwhi le i n terms o f the f e e l i n g s of those who c a r e f o r h i m . I f he f e e l s abandoned he w i l l a l s o tend to f e e l w o r t h l e s s , f o r who throws away something - 7 -of value? Increasingly apparent are the dangers to the child's emotional growth which are involved in separating him from his mother, particularly for such a purpose as surgery which is anxiety-producing in i t s e l f . This danger has been recognized by many pediatricians, notably the late Sir James Spence who has long advocated, and in his own hospital i n Newcastle, demanded the admission of the mother with the 1 younger child (under three years). Bowlby, whose United Nations study of the importance of maternal care is based on findings in many countries, adds to this the opinion that: Older children who must be admitted to hospital can be prepared for their stay and accompanied to the hospital by their mothers who w i l l undress them, put them to bed, and see them off to sleep. Nothing is worse than telli n g the child a fairy tale . . .followed by the sudden disappearance of the mother . . . . Regular vi s i t i n g is to be encouraged . . . . It is better to encourage mothers to drop in frequently and casually and stay for relatively brief periods during which they should be allowed to feed and bath their children., 2 There are other disturbing elements in the business of going to hospital for surgery. There i s the element of pain, which takes several forms for this operation: there are the inevitable needles, the enema, and f i n a l l y the operation pain, the sore throat which is i n f l i c t e d during the deep sleep of anaesthesia. What do these different kinds of 1 Spence, J.C. "Care of Children in Hospital" 1:12$ in BMJ (1947). 2 Bowlby, J. "Maternal Care and Mental Health," World  Health Organization Monographs No. 2, 1951> London, HMSO, p. 148 and passim. - 8 -p a i n , t h e s e n e c e s s a r y p r o c e d u r e s mean t o the young c h i l d ? Menninger d e s c r i b e s v e r y g r a p h i c a l l y the e x p e r i e n c e o f s u r g e r y i t s e l f : There i s n o t h i n g i n the p r a c t i c e of m e d i c i n e so barbarous and so f r a u g h t w i t h p s y c h o l o g i c a l danger as the p r e v a l e n t custom o f t a k i n g a c h i l d i n t o a s t r a n g e wh i te room, s u r r o u n d i n g him w i t h w h i t e - g a r b e d s t r a n g e r s , e x h i b i t i n g queer p a r a p h e r n a l i a and g l i t t e r i n g k n i v e s and a t the h e i g h t o f h i s c o n s t e r n a t i o n p r e s s i n g ah e t h e r cone over h i s f a c e and t e l l i n g him t o b rea the d e e p l y . 1 There i t i s , the " b a r b a r o u s c u s t o m . " What does a l l t h i s mean t o the c h i l d p a t i e n t ? The younger the c h i l d the l e s s l i k e l y i s he t o unders tand and r e a l l y a c c e p t the e x p l a n a t i o n s w h i c h have been g i v e n h i m , t h a t t h i s p rocedure i s i n t e n d e d t o make him w e l l . As Deutsch p o i n t s o u t : " i f we remember the i n f a n t i l e c o n c e p t i o n o f dea th as a d i s a p p e a r a n c e and a s t a y i n g away, i t w i l l be c l e a r why the l o s s o f c o n s c i o u s n e s s i n 2 n a r c o s i s i s synonymous w i t h e n t e r i n g d e a t h . " Thus the young c h i l d may view the h o s p i t a l i z a t i o n as a c o n t i n u i n g p r o c e s s o f i n c r e a s i n g d e p r i v a t i o n s : f i r s t the l o s s o f h i s mother and f a m i l i a r s u r r o u n d i n g s , then the l o s s o f h i s own c l o t h e s and o t h e r b e l o n g i n g s , the l a c k o f f o o d p r e - o p e r a t i v e l y , and a t l a s t the l o s s o f c o n s c i o u s n e s s p r e c e d i n g the f i n a l a t t a c k . I t becomes c l e a r how impor tan t i t i s t o break i n t o t h i s p a t t e r n o f t h i n k i n g , by c o n t i n u o u s i n t e r p r e t a t i o n and r e a s s u r a n c e p r e f e r a b l y f rom h i s own mother , 1 M e n n i n g e r , K . A . " P o l y s u r g e r y and P o l y s u r g i c a l A d d i c t i o n " i n P s y c h o a n a l y t i c a l Q u a r t e r l y . 3:173-99. 2 D e u t s c h , op., c i t . - 9 -and by a v o i d i n g a l l the d e p r i v a t i o n s which i t i s p o s s i b l e to a v o i d . L e t him wear h i s own c l o t h e s i n h o s p i t a l , l e t h im b r i n g h i s own teddy b e a r , but most impor tan t o f a l l , l e t him have h i s own mother . By means o f t h e s e t h i n g s , he i s h e l p e d t o remain s t r o n g and t o conquer h i s f e a r s . M o t h e r ' s r e a s s u r i n g p r e s e n c e h e l p s him t o b e l i e v e t h a t what i s heppening to him i s r e a l l y f o r h i s own good and f o r t i f i e s h i s c o n c e p t s o f r e a l i t y . The impor tance t o the c h i l d o f h e r p r e s e n c e i s brought out v e r y c l e a r l y i n J o y c e R o b e r t s o n ' s 1 a r t i c l e i n the N u r s i n g Times i n which she d e s c r i b e s the r e a c t i o n s o f her f o u r - y e a r o l d daughter J e a n t o t o n s i l l e c t o m y . T h i s mother was a b l e to s t a y w i t h h e r c h i l d , and her d i a r y o f events makes ve ry c l e a r t h i s p r o c e s s o f i n f a n t i l e t h i n k i n g and the way i n which the mother was a b l e t o h a n d l e these f e a r s as each a p p e a r e d . Anna F r e u d comments on t h i s d i a r y i n the f o l l o w i n g te rms: J e a n c o n f i r m e d a lmost a l l our t h e o r e t i c a l e x p e c t a t i o n s of what o p e r a t i o n and h o s p i t a l i z a t i o n may mean t o c h i l d r e n o f h e r age . . . . Only the q u i c k u n d e r s t a n d i n g and i n t e r p r e t a t i o n f rom the m o t h e r ' s s i d e . . . p r e v e n t e d symptom f o r m a t i o n and r e n d e r e d the c h i l d amenable t o a r a t i o n a l d i s c u s s i o n o f the danger s i t u a t i o n . 2 I t w i l l be observed t h a t i n the f o r e g o i n g d i s c u s s i o n , the f a c t o r o f age has no t o f t e n been m e n t i o n e d . Ye t o b v i o u s l y the age o f the c h i l d e n t e r s i n t o any q u e s t i o n o f the q u a l i t y o f h i s u n d e r s t a n d i n g . S e v e r a l t h i n g s must be 1 R o b e r t s o n , J . " M o t h e r ' s o b s e r v a t i o n s on the t o n s i l l e c t o m y of her f o u r - y e a r - o l d daughte r" i n N u r s i n g T i m e s , v o . 53> n o . 46:1295-1305. 2 F r e u d , A n n a . "Comments on M o t h e r ' s O b s e r v a t i o n " i n N u r s i n g T i m e s , 53:46:1305-7 (1957). - 10 -c o n s i d e r e d h e r e : f i r s t , the way i n which a c h i l d t h i n k s , and how t h i s d i f f e r s f rom the more o b j e c t i v e approach o f the mature m i n d . As can be s e e n , i t i s a k i n d o f t h i n k i n g r e l a t e d v e r y much to f e e l i n g : i t l o o k s a t t h o s e f a c t s wh ich a r e a v a i l a b l e t o i t and c o n s t r u e s them i n terms of how i t f e e l s . T h i s s o r t o f t h i n k i n g i s not e n t i r e l y f o r e i g n to the a d u l t mind e i t h e r , but w i t h the i n c r e a s i n g e x p e r i e n c e wh ich the a d u l t has g a i n e d , he i s b e t t e r a b l e t o a s s e s s r e a l i t y than the c h i l d i s . There i s no sharp d ichotomy s e p a r a t i n g c h i l d i s h t h i n k i n g f rom a d u l t t h i n k i n g : the one i s a d e v e l o p -ment o f the o t h e r . Hence i t cannot be s a i d t h a t a c h i l d of f o u r w i l l t h i n k i n the terms d e s c r i b e d a b o v e , w h i l e a c h i l d o f s i x w i l l n o t do s o . Indeed as c h i l d r e n do no t d e v e l o p a t even r a t e s i t cannot even be s a i d t h a t every c h i l d o f any age w i l l t h i n k i n t h e s e t e r m s . What i s c e r t a i n i s t h a t t h i n k i n g and f e e l i n g , r a t i o n a l and e m o t i o n a l a t t i t u d e s , must be c o n s i d e r e d i n any d i s c u s s i o n o f the r e a c t i o n s o f s i c k c h i l d r e n . The f a c t t h a t c h i l d r e n i n h o s p i t a l a r e s i c k must a l s o be c o n s i d e r e d i n r e l a t i o n t o t h e i r a b i l i t y t o t h i n k r a t i o n a l l y . S i c k c h i l d r e n a re not r e a s o n a b l e ; the more the p h y s i c a l d i s c o m f o r t , the g r e a t e r the a n x i e t y and the tendency t o p r o j e c t t h a t a n x i e t y on o t h e r p e o p l e . Where these " o t h e r p e o p l e " a r e s t r a n g e r s , p r o j e c t i o n i s much e a s i e r ; hence a s i c k c h i l d i s u s u a l l y an angry c h i l d w i l l i n g t o b e l i e v e the worst about the mot ives o f o t h e r p e o p l e . There i s s t i l l another c o n s i d e r a t i o n wh ich governs the n a t u r e of a c h i l d ' s r e a c t i o n s t o any s i t u a t i o n : t h i s i s - l i -the q u a l i t y o f h i s p r e v i o u s e x p e r i e n c e s . Has he been away f rom home and mother b e f o r e and under what c i r c u m s t a n c e s ? D i d t h i s e x p e r i e n c e r e a s s u r e him about the s a f e t y of s e p a r a -t i o n or n o t ? Is he sure o f h i s p a r e n t s ' l o v e f o r him? Were p r e v i o u s promises kep t? A l l t h e s e q u e s t i o n s can be answered o n l y i n terms o f our knowledge o f the r e l a t i o n s h i p between him and h i s mother as i t was e s t a b l i s h e d p r i o r t o h o s p i t a l -i z a t i o n . O b v i o u s l y the s t r o n g e r t h a t r e l a t i o n s h i p , the g r e a t e r h i s t r u s t i n the w o r l d , and hence the g r e a t e r h i s i n n e r s t r e n g t h t o meet and d e a l w i t h h i s a n x i e t y . A g a i n the importance o f t h a t r e l a t i o n s h i p and the dangers i n i n t e r r u p t -i n g i t become a p p a r e n t . Sometimes however , i t has t o be i n t e r r u p t e d , and how the c h i l d w i l l f a r e depends more than ever on how a c c u r a t e and c l e a r was the p r e p a r a t i o n g i v e n h i m . I f he has been t o l d the t r u t h , t h a t he must s t a y i n the h o s p i t a l o v e r n i g h t w i t h o u t h i s p a r e n t s , t h a t t h e r e w i l l be n e e d l e s , t h a t h i s t h r o a t w i l l be s o r e , t h a t he may vomit b l o o d a f t e r the o p e r a t i o n , but t h a t he w i l l be w e l l and s a f e , and t h a t he w i l l come home as soon as he i s w e l l , he w i l l be e x p e c t i n g a l l these t h i n g s , the good as w e l l as the b a d . Because he needs t o be t o l d these t h i n g s , and t o l d them by someone he t r u s t s , i t i s the r e p o n s i b i l i t y o f the d o c t o r to be sure tha t mother h e r s e l f unders tands and knows the p r o c e d u r e s and what to e x p e c t . I t i s a l s o the d o c t o r ' s r e s p o n s i b i l i t y t o be sure t h a t she unders tands the impor tance of a c c u r a t e p r e p a r a t i o n . - 12 -The p o s s i b i l i t i e s o f s e v e r e t r a u m a t i c e f f e c t s f o l l o w i n g a c h i l d h o o d s u r g e r y have been f u l l y emphas ized . I t i s impor tan t t o c l a r i f y t h i s statement i n terms o f the t o t a l growth p i c t u r e . One trauma does not make a n e u r o s i s . But most p e o p l e s u f f e r many t r a u m a t i c e x p e r i e n c e s i n t h e i r l i v e s and e s p e c i a l l y i n c h i l d h o o d when emot iona l d e f e n s e s a r e weakes t . I f to t h e s e e x p e r i e n c e s i s added the f r i g h t e n i n g one d e s c r i b e d by D r . M e n n i n g e r , some r e s p o n s i b i l i t y f o r the p o s s i b l e c u m u l a t i v e e f f e c t must be a c c e p t e d . Hence i t i s t h a t c h i l d r e n o f t e n d e v e l o p s e r i o u s a n x i e t y symptoms a f t e r some such p r e c i p i t a t i n g e v e n t . D e u t s c h f e e l s t h a t "many p r o l o n g e d c o n v a l e s c e n c e s and many d e p r e s s i o n s a r e connec ted 1 w i t h t h i s s u r r e n d e r t o the p u n i s h i n g f o r c e s " o f which the o p e r a t i o n may be o n l y the f i n a l o n e . Two impor tan t s t u d i e s have been done w i t h i n the l a s t t en y e a r s on the s p e c i f i c emot iona l r e a c t i o n s of c h i l d r e n t o t o n s i l l e c t o m y i n two d i f f e r e n t s e t t i n g s . The f i r s t one was begun by J e s s n e r , Blom and W a l d f o g e l i n 1947 a t the M a s s a c h u s e t t s Eye and E a r I n f i r m a r y . The f i n a l r e p o r t o f 2 t h i s r e s e a r c h was p u b l i s h e d i n 1952 a f t e r 143 c h i l d r e n had been examined by a c h i l d p s y c h i a t r i s t and t h e i r mothers i n t e r v i e w e d by a p s y c h i a t r i c s o c i a l w o r k e r . The c o n c l u s i o n s o f t h i s r e p o r t emphasized a g a i n t h a t t h i s was "an impor tan t and s t r e s s f u l e x p e r i e n c e f o r each c h i l d a c t i v a t i n g c h i l d h o o d 1 D e u t s c h , o p . c i t . , p . 108. 2 J e s s n e r , L u c i e , Gas ton E . B l o m , and Samuel W a l d f o g e l : " E m o t i o n a l i m p l i c a t i o n s of T o n s i l l e c t o m y and Adenoidectomy i n c h i l d r e n " i n P s y c h o a n a l y t i c a l S tudy of the C h i l d , 7:126-68. - 13 -f e a r s of abandonment, m u t i l a t i o n , and d e a t h , " t h a t i t " s t i r r e d up f a n t a s i e s of t r a n s f o r m a t i o n and g e t t i n g a baby (both boys and g i r l s ) . " The a u t h o r s p o i n t out t h a t f o r some c h i l d r e n i n t h e i r group t h i s was a c o n s t r u c t i v e e x p e r i e n c e , e i t h e r as an atonement f o r g u i l t f e e l i n g s or a a c h a l l e n g e t o the ego and a way of g a i n i n g p r e s t i g e . F o r some i t was a d i s r u p t i v e e x p e r i e n c e : these c h i l d r e n had s u f f e r e d a p r e v i o u s t r a u m a t i c e x p e r i e n c e which they had no t i n t e g r a t e d . F o r such c h i l d r e n , p r e p a r a t i o n was not ve ry h e l p f u l , and i t was f e l t t h a t o p e r a t i o n s h o u l d have been postponed i f a t a l l p o s s i b l e . T h i s s tudy observed a l s o t h a t some a n x i o u s mothers d i d a ve ry poor job o f p r e p a r i n g t h e i r c h i l d r e n and t h e i r a t tempts a t p r e p a r a t i o n seemed to s t r e n g t h e n the n o t i o n o f abandonment or pun ishment . Wi th most o f t h e i r cases however , J e s s n e r s t a t e s t h a t the e x p e r i e n c e was n e i t h e r c o n s t r u c t i v e nor d i s r u p t i v e on the who le ; most o f the c h i l d r e n appeared t o i n t e g r a t e t h i s e x p e r i e n c e s u c c e s s f u l l y , but a l l s u f f e r e d a degree of shock and f e a r which needed t o be h a n d l e d . She a l s o sugges ts t h a t some changes i n p r o c e d u r e and a t t i t u d e c o u l d h e l p to m in imize the shock o f t h i s e x p e r i e n c e . I t appeared t h a t i t was good f o r mother t o s t a y w i t h h e r c h i l d u n l e s s she h e r s e l f was o v e r - a n x i o u s . In any event i t seemed impor tan t t o a l l o w the c h i l d to keep a t o y as a t i e w i t h home and a s i g n o f i d e n t i t y , and i t seemed b e s t f o r him t o wear some o f h i s own c l o t h i n g i n the h o s p i t a l . In t h a t s tudy the i n c i d e n c e o f severe r e a c t i o n s , ( d i s t u r b a n c e s i n e a t i n g , s l e e p i n g , and s p e e c h , t i c s and manner isms, f e a r s , and - 14 -r e g r e s s i v e b e h a v i o u r ) was about 20 per c e n t , ^here was l i t t l e d i f f e r e n c e i n terms o f sex or a g e . J e s s n e r c o n c l u d e d t h a t the d e c i s i v e f a c t o r i n ad justment was the a l r e a d y e x i s t i n g r e l a t i o n s h i p between mother and c h i l d . P r e p a r a t i o n , or the l a c k o f i t , was not seen as a d e c i s i v e f a c t o r . The second major s tudy was the A l b a n y R e s e a r c h 1 P r o j e c t r e p o r t e d l a t e r i n the same year (1952). The r e p o r t i n c l u d e s a P i l o t Study done by the team's s o c i a l w o r k e r , who endeavoured t o a s c e r t a i n the normal r e a c t i o n s o f c h i l d r e n t o v a r i o u s s i t u a t i o n s o f s t r e s s o t h e r than h o s p i t a l i z a t i o n or s u r g e r y . T h i s i s f o l l o w e d by t h r e e papers on A n e s t h e s i a , The C a s e w o r k e r ' s P a r t i c i p a t i o n i n P r e p a r a t i o n , and Problems  A r i s i n g out o f M e d i c a l T r e a t m e n t . These t h r e e papers d e s c r i b e the approaches t o the prob lem o f m o d i f y i n g t h i s e x p e r i e n c e f o r those c h i l d r e n i n the " s t u d y " g r o u p . The " c o n t r o l " group had the o r d i n a r y e x p e r i e n c e , i n s o f a r as t h i s remained p o s s i b l e . The f i n a l paper was a r e p o r t o f f i n d i n g s d i s c u s s e d i n terms o f the " B e h a v i o u r Changes I n d i c a t i n g E m o t i o n a l T rauma ." D i s c u s s i o n o f the P i l o t Study t o a s c e r t a i n norms o f b e h a v i o u r and some c r i t e r i a f o r compar ison w i l l be l e f t t o a l a t e r c h a p t e r , as the p r e s e n t s tudy used some o f these f i n d i n g s i n c o n n e c t i o n w i t h our own c a s e s . C o n c l u s i o n s o f the A l b a n y  R e s e a r c h P r o j e c t however , a r e o f i n t e r e s t h e r e . I t was found t h a t the method o f " p s y c h o l o g i c p r e p a r a t i o n " by the 1 Reduc ing E m o t i o n a l Trauma i n H o s p i t a l i z e d C h i l d r e n : a t h r e e year s tudy o f 140 t o n s i l l e c t o m i z e d c h i l d r e n , A l b a n y M e d i c a l C o l l e g e , A l b a n y , N . Y , , 1952. ( H e r e a f t e r r e f e r r e d t o as A l b a n y R e s e a r c h P r o j e c t . ) - 15 -a n e s t h e t i s t , combined w i t h s m a l l amounts of s e d a t i v e p r e -m e d i c a t i o n , was ex t remely h e l p f u l . T h i s method was i n essence the f r i e n d l y meet ing o f the a n e s t h e t i s t and the s m a l l p a t i e n t and h i s mother on the day b e f o r e the o p e r a t i o n . The a n e s t h e t i s t f i n d s out what p r e v i o u s e x p e r i e n c e i f any he has had o f a n e s t h e s i a , e x p l a i n s q u i t e l i t e r a l l y and c a r e f u l l y what w i l l h a p p e n , a l l o w s the c h i l d t o examine the mask, d e s c r i b e s the d i z z y , q u e e r , o r s i n k i n g f e e l i n g t h a t he may have as he goes t o s l e e p . The d e s c r i p t i o n o f the method c o n c l u d e s : "most impor tan t o f a l l , do and say whatever i s n e c e s s a r y t o get him / t h e child7 t o a c c e p t the a n e s t h e t i s t 1 as a p e r s o n whom he w i l l be w i l l i n g t o t r u s t . " D r . J a c k s o n a l s o s t r e s s e s the impor tance o f d o i n g e x a c t l y what the c h i l d was t o l d would be done , and n o t h i n g e l s e . 2 The s o c i a l w o r k e r ' s r e p o r t on h e r p a r t i n p r e p a r i n g c h i l d r e n f o r t o n s i l l e c t o m y emphasizes the v a l u e of a home v i s i t . She f e l t t h a t the m o t h e r - c h i l d r e l a t i o n s h i p emerges more c l e a r l y and more q u i c k l y under t h e s e c i r c u m s t a n c e s . She f e l t a l s o t h a t the v i s i t o f the caseworker p r o v i d e d a c o n c r e t e l i n k f o r the c h i l d between home and h o s p i t a l ; i t a l s o p r o v i d e d an o p p o r t u n i t y t o d i s c u s s p r e p a r a t i o n away f rom the a n x i e t y - p r o d u c i n g atmosphere o f the h o s p i t a l i t s e l f . 1 A l b a n y R e s e a r c h P r o j e c t , p . 34 . 2 W i n k l e y , R u t h : " C a s e w o r k e r ' s p a r t i c i p a t i o n i n P r e p a r a t i o n f o r T o n s i l l e c t o m y i n C h i l d r e n " i n A l b a n y R e s e a r c h P r o j e c t , p p . 44-52. - 16 -The e f f e c t s of m e d i c a l and s u r g i c a l p r o c e d u r e s a re d i s c u s s e d i n the paper on "The Prob lem o f E m o t i o n a l 1 Trauma i n the H o s p i t a l Treatment o f C h i l d r e n . " D i s c u s s i o n i n t h i s paper was around t h r e e main p o i n t s : the c h i l d ' s p r e v i o u s adjustment to l i f e , h i s p r e p a r a t i o n f o r h o s p i t a l , and the m o d i f i c a t i o n o f the h o s p i t a l e x p e r i e n c e i n terms o f the c h i l d ' s a b i l i t y t o endure i t . The impor tance o f the m o t h e r - c h i l d r e l a t i o n s h i p i s s t r e s s e d , and the dep th o f s e p a r a t i o n a n x i e t y , e s p e c i a l l y i n c h i l d r e n under f o u r . C e r t a i n m e d i c a l p r o c e d u r e s can and s h o u l d be m o d i f i e d i n the o p i n i o n o f t h i s r e s e a r c h team. I t i s s a i d , f o r i n s t a n c e , t h a t " h a v i n g a n y t h i n g i n s e r t e d i n t o the a n u s , e s p e c i a l l y by a s t r a n g e r , i s ex t remely o b j e c t i o n a b l e t o most c h i l d r e n and 2 s h o u l d be a v o i d e d whenever p o s s i b l e . " I t was recommended t h a t enemas be o m i t t e d and tempera tures be taken o r a l l y . I t i s sugges ted t h a t the c h i l d ' s mother s h o u l d g i v e u n a v o i d a b l e enemas and take t e m p e r a t u r e s . " N e e d l e s " too were f e l t t o be d i s t u r b i n g and i t was sugges ted t h a t t h e s e be kept t o a minimum, and g i v e n when n e c e s s a r y i n the a rm, r a t h e r than f rom the r e a r i n t o the b u t t o c k s . The paper i n c l u d e s some d i s c u s s i o n o f management of c h i l d r e n on the ward: they s h o u l d not be put t o b e d , e s p e c i a l l y a l o n e , i f they a r e w e l l ; they s h o u l d have some o f t h e i r own b e l o n g i n g s w i t h them. F i n a l l y 1 J a c k s o n , K . ? R. W i n k l e y , 0. F a u s t and E . G . Cermak. "The problem o f e m o t i o n a l trauma i n the h o s p i t a l t rea tment o f c h i l d r e n i n A l b a n y R e s e a r c h P r o j e c t , p p . 54-61. 2 A l b a n y R e s e a r c h P r o j e c t , p . 58. - 17 -I t i s s t r e s s e d , t h a t i f the p a r e n t s cannot be w i t h the c h i l d throughout the h o s p i t a l s t a y , they s h o u l d a t l e a s t be w i t h him when he awakes f rom the a n e s t h e t i c s l e e p . "Under even the b e s t c o n d i t i o n s , he has been t h r o u g h a f r i g h t e n i n g and t h r e a t e n i n g e x p e r i e n c e and needs immediate r e a s s u r a n c e o f the 1 k i n d t h a t o n l y a mother or f a t h e r can p r o v i d e . " The f i n a l paper i n t h i s r e p o r t g i v e s s t a t i s t i c a l and o t h e r f i n d i n g s . The a t tempt to s e p a r a t e the c h i l d r e n i n t o a " s t u d y " group and a " c o n t r o l " group was l a r g e l y u n s u c c e s s f u l , but the compar ison o f o r d i n a r y and p o s t -o p e r a t i v e b e h a v i o u r p a t t e r n s was e n l i g h t e n i n g . " In more than h a l f o f the 140 c h i l d r e n the b e h a v i o u r showed no change or was s l i g h t l y i m p r o v e d . A second g r o u p , about ^0%, showed a mixed r e a c t i o n , w i t h improvement i n some t r a i t s and d i s t u r b a n c e s i n o t h e r s . In a few cases the d i s t u r b a n c e s outweighed any improvement and the c h i l d was c o n s i d e r e d t o have r e a c t e d n e g a t i v e l y to the e x p e r i e n c e . The r e m a i n i n g c h i l d r e n showed 2 c o n s i s t e n t d e t e r i o r a t i o n i n b e h a v i o r . " The c o n s i s t e n t l y d i s t u r b e d c h i l d r e n t o t a l l e d 13 o f the 140 s t u d i e d . I t was n o t e d a l s o t h a t c h i l d r e n t r e a t e d " w i t h c o n s i d e r a t i o n " ( i . e . t h o s e i n the " s t u d y " group) gave l e s s e v i d e n c e o f t rauma; c h i l d r e n who had s u f f e r e d p r e v i o u s e m o t i o n a l d i f f i c u l t i e s r e a c t e d l e s s w e l l t o t h i s e x p e r i e n c e ; and younger c h i l d r e n showed more, but m i l d e r , a d v e r s e b e h a v i o u r c h a n g e s . 1 A l b a n y R e s e a r c h P r e l e c t , p . 60. 2 I b i d . , p . 68. - 18 -In g e n e r a l , t h e n , i t would seem t h a t the f i n d i n g s of t h e s e two s t u d i e s c o n f i r m most o f the t h e o r e t i c a l e x p e c t a t i o n s about c h i l d r e n ' s r e a c t i o n s t o h o s p i t a l i z a t i o n and s u r g e r y . In the f o l l o w i n g c h a p t e r s , d i s c u s s i o n w i l l be c e n t r e d on c h i l d r e n a d m i t t e d t o the Vancouver G e n e r a l H o s p i t a l d u r i n g the f i r s t t h r e e months o f 1953• E x a m i n a t i o n o f t h i s p a r t i c u l a r s e t t i n g w i l l c o n s t i t u t e an at tempt to d i s c o v e r what f a c t o r s i n t h i s e x p e r i e n c e a re most d i s t u r b i n g t o our c h i l d r e n , and c o n s i d e r ways i n wh ich these may be m o d i f i e d , ways i n wh ich the p a e d i a t r i c s o c i a l worker may h e l p c h i l d r e n and t h e i r p a r e n t s to make t h i s a l e s s d i s t u r b i n g e x p e r i e n c e . In the f i n a l c h a p t e r , some o f the changes t h a t have taken p l a c e i n t h i s s e t t i n g i n the f i v e y e a r s f rom 1953 t o 1958 w i l l be n o t e d and d i s c u s s e d . CHAPTER I I PROCEDURES AND FACILIT IES IN THE HOSPITAL The e x p e r i e n c e o f h o s p i t a l i z a t i o n o f c h i l d r e n has been d i s c u s s e d i n g e n e r a l t e r m s , and w i t h s p e c i f i c r e f e r e n c e t o two Amer ican h o s p i t a l s . I t would seem u s e f u l t o examine the s i t u a t i o n and s t u d y the c h i l d r e n a d m i t t e d to the Vancouver G e n e r a l H o s p i t a l . T h i s s t u d y was begun i n 1953? and the case m a t e r i a l used was drawn f rom the c a s e s r e f e r r e d by the E a r , N o s e , and T h r o a t C l i n i c o f the H e a l t h C e n t r e f o r C h i l d r e n , which i s the P a e d i a t r i c O u t - P a t i e n t s Department o f t h i s h o s p i t a l . S i n c e the h o s p i t a l i s p l a n n e d f o r a c u t e and emergency t rea tment o n l y , and s u f f e r s a t a l l t imes f rom a shor tage o f b e d s , p a t i e n t s a r e r e f e r r e d f o r o p e r a t i o n s f rom i t s c l i n i c s on a b a s i s o f s t r i c t m e d i c a l n e c e s s i t y . The u s u a l e x p e r i e n c e of a c h i l d a d m i t t e d a t t h a t t ime (1953) w a s some-t h i n g l i k e the f o l l o w i n g d e s c r i p t i o n : the d o c t o r i n a t tendance a t the r e g u l a r E a r , Nose and T h r o a t C l i n i c examined the c h i l d and t o l d h i s mother t h a t i t would be wise f o r h e r t o a r range f o r the removal o f h i s t o n s i l s or adeno ids or b o t h . The n u r s e made a n o t e o f the c h i l d ' s name and the d o c t o r ' s recommendat ion, and w i t h the consent o f h i s p a r e n t s , she a r ranged h i s a d m i s s i o n t o the h o s p i t a l as a " S t a f f " p a t i e n t . ( T h i s meant t h a t he was a t t e n d e d w i thou t charge by the - 20 -p h y s i c i a n s and surgeons on the s t a f f o f the h o s p i t a l , and would be c a r e d f o r by more than one d o c t o r , and a l l h i s d o c t o r s would be s t r a n g e t o h i m . ) There was u s u a l l y a w a i t i n g p e r i o d o f s e v e r a l weeks b e f o r e a bed was a v a i l a b l e . He p r o b a b l y h e a r d the d o c t o r suggest an o p e r a t i o n but would n o t know when he would e n t e r h o s p i t a l . When a bed was a v a i l a b l e , the c h i l d and h i s mother would have o n l y a few hours n o t i c e . He would then go w i t h h i s mother or f a t h e r t o the H e a l t h C e n t r e (which a t t h a t t ime was i n an o l d wooden b u i l d i n g on the h o s p i t a l grounds) a t 1:00 p .m . o f t h a t d a y . He was t h e r e g i v e n a f u r t h e r m e d i c a l examina t ion t o be sure t h a t he was f r e e o f i n f e c t i o n , and h i s p a r e n t comple ted the n e c e s s a r y forms f o r a d m i s s i o n , i n c l u d i n g the s i g n i n g o f consent t o the o p e r a t i o n . About 3*00 p . m . , they were conducted by a H e a l t h C e n t r e Nurse t o the a s s i g n e d w a r d , wh ich was i n ano ther b u i l d i n g some d i s t a n c e away. T h i s n u r s e then l e f t , and was no t seen a g a i n d u r i n g the s t a y i n h o s p i t a l . 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 Adenoldectomy were g e n e r a l l y a s s i g n e d to one o f t h r e e w a r d s . C h i l d r e n aged two t o s i x o f b o t h sexes went t o Ward U . T h i s was a l a r g e room d i v i d e d by wood and g l a s s p a r t i t i o n s i n t o c u b i c l e s , each c o n t a i n i n g two c r i b s . The c u b i c l e s themselves and the p a s s a g e -way down the c e n t r e o f the ward were f u r n i s h e d w i t h s m a l l t a b l e s and c h a i r s , and t h e r e were many teddy bears and o t h e r toys f o r the c h i l d r e n t o p l a y w i t h . G i r l s f rom s i x t o s i x t e e n were a d m i t t e d t o Ward K. T h i s was a l s o a l a r g e room but was not d i v i d e d i n t o s e c t i o n s , except by c u r t a i n which - 21 -were r a r e l y drawn. Boys f rom s i x t o s i x t e e n were a d m i t t e d to Ward D4, which was i n the new wing o f the h o s p i t a l , and was composed o f a s e r i e s o f s e p a r a t e rooms, each c o n t a i n i n g f o u r b e d s . T o n s i l c a s e s were u s u a l l y a l l a s s i g n e d t o the same room. Games and o t h e r p l a y t h i n g s were a v a i l a b l e f o r the o l d e r c h i l d r e n a l s o . B e f o r e the c h i l d was a d m i t t e d to the w a r d , he was g i v e n a b a t h ( i n c l u d i n g h i s head) by a s t r a n g e n u r s e , and ano ther p h y s i c a l e x a m i n a t i o n by a new d o c t o r . H i s own c l o t h e s were t h e n g i v e n t o h i s mother t o take home and he was s u p p l i e d w i t h the h o s p i t a l o u t f i t . In Ward U t h i s o u t f i t was a b l u e c o t t o n j e r s e y and pants f o r b o y s , and a b l u e c o t t o n d r e s s f o r g i r l s . The o l d e r c h i l d r e n wore pajamas and d r e s s i n g gowns s u p p l i e d by the h o s p i t a l . Whi le the c h i l d was b e i n g bathed and d r e s s e d , h i s mother was b e i n g i n t e r v i e w e d e lsewhere by the i n t e r n e f o r the m e d i c a l h i s t o r y . Meanwhile the c h i l d was t o l d wh ich was h i s bed but was no t r e q u i r e d t o ge t i n t o i t . He p l a y e d w i t h the o t h e r c h i l d r e n u n t i l supper t ime a t 4:*30 p .m . He would p r o b a b l y no t see h i s mother a g a i n u n l e s s she asked p e r m i s s i o n t o say goodbye. The p a t i e n t was p e r m i t t e d to b r i n g one or two o f h i s own t o y s i f these were c l e a n and w a s h a b l e . However, mothers were o f t e n unaware o f t h i s r e g u l a t i o n . Some o f the mothers gave t h e i r c h i l d a new t o y , which was not connected w i t h home and p r o v i d e d no f e e l i n g of c o n t i n u i t y o f e x p e r i e n c e f rom home t o h o s p i t a l . - 22 -Supper was s e r v e d on the ward: the s m a l l e r c h i l d r e n a t e a t the l i t t l e t a b l e s i n Ward U . The o l d e r c h i l d r e n sa t on t h e i r beds or a t a c h a i r b e s i d e the bed and a te f rom a t r a y . There was ano ther s h o r t p e r i o d of p l a y t i m e a f t e r s u p p e r , and a t some t ime d u r i n g the e v e n i n g , the c h i l d was examined by the a n e s t h e t i s t (another s t r a n g e d o c t o r ) who p r e s c r i b e d the a p p r o p r i a t e m e d i c a t i o n f o r the m o r n i n g . T h i s e x a m i n a t i o n i n v o l v e d a f i n g e r - p r i c k f o r the b l o o d t e s t , and the c h e c k i n g of the h e a r t b e a t w i t h the s t e t h e s c o p e . By 7:00 p . m . the s m a l l e r c h i l d r e n were undressed and put t o b e d , and g i v e n an enema by the n u r s e . The o l d e r c h i l d r e n s t a y e d up u n t i l 8:30 p .m. but were a l s o g i v e n an enema. L i g h t s were put out a t bedt ime but the wards were never w h o l l y d a r k , as the l i g h t f rom the o f f i c e or c o r r i d o r c o u l d be seen t h r o u g h the g l a s s i n the d o o r s . Next morning a new n u r s e g r e e t e d the p a t i e n t and a u r i n e specimen was taken by bedpan . The c h i l d r e n s c h e d u l e d f o r t o n s i l l e c t o m y were g i v e n no b r e a k f a s t , nor were they a l l o w e d to have f l u i d s of any k i n d . T h i s d e n i a l o f f o o d was a l e s s t r a u m a t i c e x p e r i e n c e i n D4 than i n the l a r g e r w a r d s , s i n c e the c h i l d c o u l d n o t see o t h e r c h i l d r e n e a t i n g . However, those i n D4 were the o l d e r b o y s , who might be more l i k e l y to unders tand the r e a s o n f o r no t e a t i n g than the younger c h i l d r e n . The o p e r a t i o n was s c h e d u l e d f o r some t ime between 8:00 a . m . and 12:00 n o o n . One hour b e f o r e h i s o p e r a t i o n , the p a t i e n t was g i v e n m e d i c a t i o n by hypodermic n e e d l e . The e f f e c t o f t h i s m e d i c a t i o n was t o make him s l e e p y , - 23 -but not t o put him t o s l e e p , so t h a t he was aware o f b e i n g wheeled t o the o p e r a t i n g room, and b e i n g a n a e s t h e t i z e d by e t h e r mask and i n t r a - e r a n i a l t u b e . The o p e r a t i o n i t s e l f t akes o n l y f i f t e e n or twenty minutes , , and he was then t a k e n t o the r e c o v e r y room where he remained f o r a t l e a s t an h o u r . By t h i s t ime he was once more aware o f h i s s u r r o u n d i n g , and might observe many o t h e r p a t i e n t s r e c o v e r i n g f rom v a r i o u s types o f s u r g e r y . He was then wheeled back t o the ward and put to b e d . U s u a l l y he was hungry and was g i v e n i c e c h i p s . Sometimes he was g i v e n c o o l f l u i d s and o f t e n vomited t h i s , and then dropped o f f i n t o a l o n g sound s l e e p . When he awakened he was g i v e n f o o d and c o o l l i q u i d s . He u s u a l l y f e l t some p a i n a t t h i s p o i n t , s o r e t h r o a t and sometimes an earache f o r which he might be g i v e n ear drops and h a l f an a s p i r i n . Sometimes the p a t i e n t haemorrhaged and might r e q u i r e f u r t h e r s u r g i c a l t rea tment or a l o n g e r s t a y i n h o s p i t a l . N o r m a l l y , however , the c h i l d was d i s c h a r g e d the day a f t e r the o p e r a t i o n , immedia te ly a f t e r l u n c h . Meanwhile f o r the r e s t o f h i s s t a y i n h o s p i t a l the c h i l d remained i n bed and p a r e n t s were a d v i s e d t o keep him i n bed f o r another week a f t e r he went home. A t the end of t h i s t i m e , he was expected t o appear a t the C l i n i c f o r r e - e x a m i n a t i o n . D u r i n g the p e r i o d of t h i s h o s p i t a l i z a t i o n , n o r m a l l y f o r t y - e i g h t h o u r s , the s m a l l p a t i e n t was p e r m i t t e d o n l y one f a i r l y b r i e f v i s i t f rom h i s p a r e n t s on the day o f the o p e r a t i o n . In many c a s e s , p a r e n t s d i d no t a v a i l themselves o f t h i s p r i v i l e g e , e i t h e r t h ro u g h i g n o r a n c e , or because - 24 -v i s i t i n g was a c t u a l l y d i s c o u r a g e d by the n u r s e s . The p r e s e n t s tudy i s based on the e x p e r i e n c e s of twenty c h i l d r e n who were r e f e r r e d from the H e a l t h C e n t r e and had t h e i r t o n s i l s and adeno ids removed d u r i n g the months o f J a n u a r y , F e b r u a r y , and March of 1953 a t Vancouver G e n e r a l H o s p i t a l . The c h i l d r e n ranged i n age f rom two t o n i n e y e a r s . W i t h i n t h i s p e r i o d of t ime and w i t h i n t h i s age g r o u p , some s i x t y c h i l d r e n had t h e s e o p e r a t i o n s . Many of these were f rom o u t s i d e Vancouver or were o t h e r w i s e no t a v a i l a b l e f o r s t u d y . The i n f o r m a t i o n o b t a i n e d f rom the m e d i c a l c h a r t s o f the o t h e r c h i l d r e n does no t suggest much v a r i a t i o n i n h o s p i t a l b e h a v i o u r , i n p r e v i o u s e x p e r i e n c e o f s u r g e r y or h o s p i t a l i z a t i o n , or i n economic b a c k g r o u n d . The c a s e s s t u d i e d t h e r e f o r e , were taken to be a r e a s o n a b l y t y p i c a l g r o u p . I t has been n o t e d t h a t economic background was r e a s o n a b l y s i m i l a r i n a l l c a s e s : t h i s was a s s u r e d by d e r i v i n g the c a s e s f rom the H e a l t h C e n t r e wh ich i s a f r e e examina t ion and c o n s u l t a t i o n s e r v i c e f o r f a m i l i e s whose income f a l l s w i t h i n the e l i g i b i l i t y r e q u i r e m e n t s of the h o s p i t a l f o r s t a f f p a t i e n t s . T h i s means t h a t income i n a l l t h e s e f a m i l i e s was minimum. Most o f the i n f o r m a t i o n f o r t h i s s t u d y was o b t a i n e d through i n t e r v i e w s w i t h the m o t h e r s , and i n a few c a s e s , w i t h the c h i l d r e n t h e m s e l v e s . A l l i n t e r v i e w s were h e l d w i t h i n a p e r i o d o f t h r e e to f o u r months p o s t -o p e r a t i v e l y ; hence b r i e f and temporary d i s t u r b a n c e s c o u l d be a s s e s s e d f o r what they were , and those i n s t a n c e s where - 25 -b e h a v i o u r and a t t i t u d e s were more d e e p l y a f f e c t e d c o u l d be r e c o g n i z e d . The s o c i a l worker h a n d l e d t h e s e i n t e r v i e w s on a casework l e v e l , not a s k i n g d i r e c t q u e s t i o n s , but s e e k i n g t o g a i n i n each c a s e d i r e c t i n f o r m a t i o n about s p e c i f i c a r e a s of 1 b e h a v i o u r and f e e l i n g . Most o f the mothers seen were v e r y w i l l i n g t o d i s c u s s t h e i r c h i l d r e n ' s e x p e r i e n c e and many seemed t o d e r i v e s a t i s f a c t i o n f rom e x p r e s s i n g t h e i r f e e l i n g s and o p i n i o n s about the h o s p i t a l and i t s p r o c e d u r e s . R e a c t i o n s t o the i n t e r v i e w s i t u a t i o n v a r i e d c o n s i d e r a b l y . Some mothers were g r e a t l y concerned w i t h t h e i r c h i l d r e n ' s e m o t i o n a l r e s p o n s e s and wanted h e l p i n h a n d l i n g t h e s e . Others showed l i t t l e c o n c e r n or awareness . I t was n e c e s s a r y t o t ake t h e s e r e a c t i o n s i n t o c o n s i d e r a t i o n a l s o i n e v a l u a t i n g the q u a l i t y o f the f a c t u a l da ta g i v e n i n t h e s e i n t e r v i e w s . In most c a s e s , the worker f e l t t h a t m o t h e r ' s i n t e r e s t i n the s u b j e c t was s t r o n g enough t o ensure r e a s o n a b l y a c c u r a t e r e p o r t i n g o f her c h i l d ' s b e h a v i o u r . In one i n s t a n c e however , t h i s was c l e a r l y not the c a s e . T h i s mother was pregnant and d e l i v e r y was overdue : she was c l e a r l y a n x i o u s about h e r own c o n d i t i o n , and much l e s s concerned about h e r s o n ' s f e e l i n g s and b e h a v i o u r f o u r months b e f o r e , a t the t ime o f h i s o p e r a t i o n . A c c o r d i n g to h e r r e p o r t t h i s boy was t o t a l l y u n a f f e c t e d by the e x p e r i e n c e , and h e r a t t i t u d e toward him seemed one o f 1 The q u e s t i o n n a i r e wh ich i s i n c l u d e d i n Appendix was n o t shown t o the c l i e n t , but was used as a guide by the s o c i a l worker t o a s s u r e coverage of a l l the r e l e v a n t m a t e r i a l . - 26 -complete d i s i n t e r e s t . However, she d i d make a p o i n t o f v i s i t i n g him i n h o s p i t a l , and she made some at tempt t o p r e p a r e him f o r g o i n g . In t h i s c a s e , t h e r e f o r e , no at tempt was made t o e v a l u a t e the degree or k i n d o f ad justment made by the p a t i e n t . The method o f i n t e r v i e w i n g a l s o p r o v i d e d a c r o s s check on the v a l i d i t y of the m a t e r i a l inasmuch as i t was observed t h a t sometimes the mother c o n t r a d i c t e d h e r s e l f i n a d v e r t a n t l y . F o r example , when mothers were t a l k i n g about the u s u a l method o f p u n i s h i n g c h i l d r e n , they sometimes s a i d t h a t they never s p a n k e d , but l a t e r i n the d i s c u s s i o n s t a t e d t h a t the c h i l d s l a p s or b i t e s a f t e r b e i n g s p a n k e d . A g a i n , when the worker spoke of p r e p a r i n g the c h i l d , mother o f t e n i n d i c a t e d t h a t she had t o l d him what t o e x p e c t , ye t l a t e r she would say t h a t he had not known about the e t h e r mask, or s t a y i n g i n b e d , or had no t expec ted h i s t h r o a t t o be s o r e a f t e r w a r d . Thus i t xvas p o s s i b l e to e v a l u a t e more f u l l y what was r e a l l y the n a t u r e o f the p r e p a r a t i o n the c h i l d r e c e i v e d . In a d d i t i o n t o the i n f o r m a t i o n o b t a i n e d f rom the m o t h e r s , the worker a l s o g leaned as much i n f o r m a t i o n as p o s s i b l e f rom the c h i l d ' s m e d i c a l c h a r t . M e d i c a l h i s t o r y and the d o c t o r ' s n o t e s put on the c h a r t a t the t ime of a d m i s s i o n , t o g e t h e r w i t h the sometimes c r y p t i c comments of the n u r s e s c o n c e r n i n g b e h a v i o u r on the w a r d , were used t o round out the p i c t u r e o f each c h i l d ' s m a n i f e s t r e a c t i o n to the immediate s i t u a t i o n . These no tes were sometimes e n l i g h t e n i n g i n r e f e r e n c e t o such mat te rs as the way the c h i l d s l e p t the n i g h t - 27 -b e f o r e the o p e r a t i o n , whether or no t he wet the bed (some c h i l d r e n who a r e c o n s i s t e n t l y e n u r e t i c a t home were d r y b o t h n i g h t s i n h o s p i t a l ) , and whether he was r e a s o n a b l y f r i e n d l y , or w i thdrawn, or over -dependent upon n u r s e s and d o c t o r s . In a v e r y few c a s e s , the worker was a b l e t o i n t e r v i e w the c h i l d h i m s e l f . The amount o f m a t e r i a l g a i n e d i n t h i s way was s l i g h t , as most c h i l d r e n w i l l hot t a l k f r e e l y t o a s t r a n g e r , and i t was not p o s s i b l e f o r the worker to a r range f o r more than one i n t e r v i e w w i t h each c h i l d . F u r t h e r m o r e , some o f the c h i l d r e n were a p p a r e n t l y so t h r e a t e n e d by the whole e x p e r i e n c e , t h a t they would not d i s c u s s i t w i t h someone connected w i t h the h o s p i t a l . Some o f the c h i l d r e n were no t seen a t a l l , e i t h e r because mother " f o r g o t " t h a t the worker had asked f o r the p a t i e n t t o be brought t o the i n t e r v i e w or because she thought he would be too d i s t u r b e d a t b e i n g brought back t o the h o s p i t a l . On the b a s i s o f the m a t e r i a l o b t a i n e d f rom t h e s e s o u r c e s , i t was p o s s i b l e t o observe c e r t a i n g e n e r a l r e a c t i o n s t o the e x p e r i e n c e o f h o s p i t a l i z a t i o n . Some o f the r e a c t i o n s were v e r b a l i z e d , e i t h e r to the mother or to the w o r k e r . Others became apparent i n terms o f b e h a v i o u r c h a n g e s . In o r d e r t o measure the degree o f change c e r t a i n f i x e d c r i t e r i a were a c c e p t e d as normal b e h a v i o u r f o r each c h i l d a c c o r d i n g t o a g e . These c r i t e r i a concerned such mat te rs as a t t i t u d e to s e p a r a t i o n f rom mother and home, e a t i n g and s l e e p i n g h a b i t s , nervous manner isms, temper t a n t r u m s , s e v e r e n i g h t m a r e s , e t c e t e r a and were based t o some ex ten t on the - 28 -norms e s t a b l i s h e d f o r f i v e - , s i x - , and s e v e n - y e a r o l d s i n the 1 A l b a n y R e s e a r c h P r o j e c t . An at tempt was a l s o made to e v a l u a t e the n a t u r e and q u a l i t y of the c h i l d ' s p r e v i o u s a d j u s t m e n t , i n terms o f the m o t h e r - c h i l d r e l a t i o n s h i p , h i s p r e v i o u s l e v e l o f f u n c t i o n i n g a t s c h o o l or w i t h p l a y m a t e s , and h i s p r e v i o u s l y demonst ra ted a b i l i t y to h a n d l e f r u s t r a t i o n . The m a t e r i a l on which t h e s e c o n c l u s i o n s were based was e l i c i t e d by the q u e s t i o n s on h i s t o r y and normal b e h a v i o u r p a t t e r n s f o r e a c h c h i l d i n c l u d i n g the u s u a l methods o f d i s c i p l i n e and h i s r e a c t i o n s t o t h i s , h i s r e a c t i o n s t o s e p a r a t i o n , t o p a i n , e t c e t e r a , and h i s e x p e r i e n c e s w i t h o t h e r c h i l d r e n , i n c l u d i n g h i s own f a m i l y . M o t h e r ' s f e e l i n g s f o r the c h i l d were e v a l u a t e d i n terms of h e r t o t a l r e s p o n s e to the i n q u i r y , and s p e c i f i c a l l y i n terms of h e r r e s p o n s e s to q u e s t i o n s i n the a reas o f mother ing such as p r o t e c t i o n , d i s c i p l i n e , and p e r s o n a l c a r e . The answers t o these q u e s t i o n s were then compared w i t h h e r s t a t e d b e h a v i o u r i n terms o f p r e p a r i n g h e r c h i l d f o r h o s p i t a l , and v i s i t i n g him t h e r e . E a c h mother was a l s o asked t o d e s c r i b e h e r own f e e l i n g s about i l l n e s s , h o s p i t a l i z a t i o n , and s u r g e r y , i n c l u d i n g any p r e v i o u s e x p e r i e n c e she had o f any o f t h e s e . F i n a l l y , each mother was asked about b e h a v i o u r c h a n g e s , temporary or more permanent , wh ich she o b s e r v e d i n h e r c h i l d 1 See Appendix B , The P i l o t Study f o r the A l b a n y R e s e a r c h  P r o j e c t (page 27) was done by the s o c i a l w o r k e r , Ruth W i n k l e y , among c h i l d r e n i n the a r e a who had no t been h o s p i t a l i z e d or s u f f e r e d any r e c e n t t r a u m a t i c e x p e r i e n c e . - 2 9 -following his return home, and was encouraged to r e l a t e these to the s p e c i f i c complaints or comments which her c h i l d had made about the experience of h o s p i t a l i z a t i o n . She t o l d of how he played h o s p i t a l or doctor afterward, of what she heard him say i n explanation to his brothers and s i s t e r s or playmates about his operation. She commented also about the speed or slowness of h i s physical and emotional recovery as she saw i t . The interview with each mother was lengthy and the worker had i n most cases a f a i r l y complete picture of the usual functioning of the c h i l d and the family as well as the variations and changes which followed the operation. After t a l k i n g to the mother, worker chatted b r i e f l y with the c h i l d whenever th i s was possible, and asked the older children f a i r l y d i r e c t l y , how they f e l t about the h o s p i t a l and what part of the experience was most pleasant or unpleasant. Those childr e n who were available and w i l l i n g to talk to the worker spoke quite s p e c i f i c a l l y about the needles, the anaesthetic, and the pain. The next chapter w i l l be devoted to a d e t a i l e d account of some of the more in t e r e s t i n g reactions of s p e c i f i c c h i l d r e n and the general conclusions which were reached concerning the usual effects of t h i s operation as observed here and a comparison of these conclusions with the t h e o r e t i c a l expectations discussed i n Chapter I. CHAPTER III THE MEANING OF HOSPITALIZATION The twenty children studied in the sample group went to the Vancouver General Hospital through the Health Centre for Children to have their tonsils and adenoids removed by the staff surgeons of that hospital. Some of them liked the hospital, enjoyed the attention they received there; and, in spite of the pain, f e l t that they had shown themselves that "there was not so much to be afraid of after a l l . " Some of them did not feel this way at the time or even immediately after, when the throat was s t i l l sore, and the fears s t i l l fresh; but, by the time the social worker was asking questions, three or four months later, this experience had become a f a i r l y positive achievement. It seems clear that this state-ment was true of at least six of these children and three more gave evidence of being in the process of achieving this kind of an integration. Ten of the twenty children, however, were definitely not responding in this fashion: seven of them were showing signs of continued regression and withdrawal as late as four months after the operation; and three children were acting in a way that suggested that the hospitalization and surgery had confirmed an already apparent confusion about identity and sex roles. One case has not been evaluated - 31 -because of the d i f f i c u l t y i n e s t a b l i s h i n g a s t r o n g enough c o n t a c t w i t h mother or son t o c o n f i r m the d a t a o b t a i n e d . I t has been s t a t e d t h a t t h i s group o f twenty c h i l d r e n were chosen f o r t h i s s tudy by v i r t u e o f t h e i r h a v i n g been a d m i t t e d d u r i n g the f i r s t t h r e e months of 1953» and because they were a v a i l a b l e t o t h i s r e s e a r c h e r f o u r months l a t e r . There was no at tempt a t s e l e c t i o n o t h e r than by a g e — no c h i l d was under two years a t the t ime of o p e r a t i o n or over n i n e y e a r s o l d . As i t happened , the group d i v i d e d f a i r l y e v e n l y by s e x : 11 boys and 9 g i r l s . By age the group d i v i d e d i n t o 11 c h i l d r e n (6 boys and 5 g i r l s ) aged f i v e or o l d e r , and 9 c h i l d r e n (5 boys and 4 g i r l s ) under f i v e y e a r s o l d . T h i s p o i n t o f age d i v i s i o n was chosen because s e v e r a l p r e v i o u s r e s e a r c h e r s have sugges ted t h a t c h i l d r e n under f i v e were more d i s t u r b e d by such e x p e r i e n c e s . T h i s c o n c l u s i o n was no t r e a c h e d h e r e . Of the u n d e r - f i v e s i n t h i s s t u d y , f o u r made a good a d j u s t m e n t , f o u r showed c o n t i n u i n g r e g r e s s i o n , and o n l y one was s e r i o u s l y d i s t u r b e d . Of the o v e r - f i v e g r o u p , f i v e c h i l d r e n made a good a d j u s t m e n t , t h r e e showed symptoms o f r e g r e s s i o n , and two were c o n f i r m e d i n t h e i r e m o t i o n a l c o n f u s i o n s . The one c h i l d whose r e a c t i o n s c o u l d not be e v a l u a t e d f e l l i n t o the o l d e r g r o u p . I t would seem t h e r e f o r e , t h a t age i s not the d e c i d i n g f a c t o r . How impor tan t was the e x p e r i e n c e o f p r e v i o u s h o s p i t a l i z a t i o n i n d e t e r m i n i n g the way i n wh ich a c h i l d a d j u s t e d h i s t h i n k i n g about i t ? Of the n i n e c h i l d r e n who - 32 -made a good a d j u s t m e n t , f o u r had had p r e v i o u s e x p e r i e n c e , f i v e had n o t . Is i t p o s s i b l e t h a t a c h i l d ' s p o s i t i o n i n h i s f a m i l y has something t o do w i t h h i s way o f h a n d l i n g such an e x p e r i e n c e ? A g a i n we f i n d t h a t the group o f n i n e w e l l -a d j u s t e d c h i l d r e n b reaks i n t o two e l d e s t c h i l d r e n , two m i d d l e c h i l d r e n , two youngest c h i l d r e n and t h r e e o n l y c h i l d r e n . I t i s e v i d e n t t h a t some more b a s i c f a c t o r u n d e r l i e s the c h i l d ' s a b i l i t y t o a c c e p t f r u s t r a t i o n . I t has been s a i d t h a t t h i s f a c t o r i s the q u a l i t y o f the r e l a t i o n s h i p between the c h i l d and h i s mother . T h i s r e l a t i o n s h i p i s a more d i f f i c u l t t h i n g t o a s s e s s ; however , the m a t e r i a l o b t a i n e d on each o f these c h i l d r e n was c a r e f u l l y examined i n an a t tempt t o d i s c o v e r what was the n a t u r e of the f e e l i n g wh ich e x i s t e d p r i o r t o h o s p i t a l a d m i s s i o n between each c h i l d and h i s mother . T h i s was then compared w i t h the e x t e r n a l f a c t s o f the m o t h e r ' s e x p r e s s e d f e e l i n g s about h e r c h i l d ' s h o s p i t a l i z a t i o n and o p e r a t i o n , h e r a c t u a l per formance i n terms of p r e p a r a t i o n and v i s i t i n g , and the r e p o r t e d r e a c t i o n s o f the c h i l d t o h i s m o t h e r ' s p resence or a b s e n c e . A c o n c l u s i o n was r e a c h e d i n each c a s e : the degree of the c h i l d ' s e m o t i o n a l s e c u r i t y was e v a l u a t e d as good i n t h r e e c a s e s , as c o n t a i n i n g some e lements o f m a t e r n a l r e j e c t i o n i n twe lve c a s e s , and as so c o n f u s e d as t o suggest the need f o r p s y c h i a t r i c a p p r a i s a l i n two c a s e s . Two f u r t h e r cases were c l a s s i f i e d as m e n t a l l y r e t a r d e d c h i l d r e n , and t h e s e t o g e t h e r w i t h the case a l r e a d y ment ioned a b o v e , were n o t e v a l u a t e d i n t h i s way. As w i l l be seen i n T a b l e I, page 33» t h e r e i s no s i m p l e c o r r e l a t i o n between the - 33 -T a b l e I. Compar ison o f P r e - Q p e r a t i v e F e e l i n g s o f S e c u r i t y and P o s t - O p e r a t i v e Ad jus tment ( I n t e g r a t i o n of the B x p e r i e n c e T Degree o f S e c u r i t y i n M o t h e r - C h i l d R e l a t i o n s h i p P r e - O p e r a t i v e l y N o . o f c a s e s Degree o f I n t e g r a t i o n of H o s p i t a l E x p e r i e n c e Good C o n t i n u i n g R e g r e s s i o n I n c r e a s e d C o n f u s i o n Good 3 3 0 0 C h i l d F e l t Some R e j e c t i o n 12 6 5 1 C h i l d F e l t Grea t R e j e c t i o n 2 0 0 2 TOTAL 17 9 5 3 - 34 -degree o f s e c u r i t y i n m o t h e r - c h i l d r e l a t i o n s h i p , and the n a t u r e o f the c h i l d ' s ad justment a f t e r h o s p i t a l i z a t i o n and s u r g e r y . However, the f i n d i n g s a r e s u g g e s t i v e o f a s t r o n g c o n n e c t i o n between the c h i l d ' s f e e l i n g s of s e c u r i t y and h i s a b i l i t y to t o l e r a t e f r u s t r a t i o n s and t r a u m a t i c e x p e r i e n c e s . As was i n d i c a t e d i n Chapter I I , i t was f e l t t h a t the A l b a n y R e s e a r c h P r o j e c t had worked out a c o n v e n i e n t way o f examining the c h i l d ' s b e h a v i o u r b e f o r e and a f t e r s u r g e r y . T h i s method was a p p l i e d t o the twenty c a s e s s t u d i e d here a l s o , and i t i s i n t e r e s t i n g to observe t h a t a d e c r e a s e i n the number o f " N e g a t i v e B e h a v i o u r T r a i t s " d i d not a lways i n d i c a t e a b e t t e r ad justment t o r e a l i t y . I ndeed , a l l but one c h i l d showed e i t h e r no change i n the number o f " N e g a t i v e T r a i t s " or 1 a d e c r e a s e . The case worker would s u s p e c t t h a t the changes which were r e p o r t e d and undoubted ly d i d take p l a c e , were too s u b t l e t o appear on t h i s r a t i n g s c a l e : o f t e n the d i f f e r e n c e s were i n terms o f a t t i t u d e : a c h i l d might s t i l l show nervous symptoms, but be l e s s a f r a i d than f o r m e r l y to approach p e o p l e and s i t u a t i o n s which p r e v i o u s l y f r i g h t e n e d h i m . S i m i l a r l y , some c h i l d r e n changed symptoms, and the change seemed more s i g n i f i c a n t than the t o t a l . These changes can b e s t be seen and e v a l u a t e d by l o o k i n g a t s p e c i f i c c a s e s . F o r i n s t a n c e , many o f the c h i l d r e n e x h i b i t e d more v e r b a l i z e d h o s t i l i t y , becoming l e s s " n e r v o u s " i n the m o t h e r ' s words and more 1 See Appendix B . - 35 -a g g r e s s i v e and demanding. B i l l y , a boy o f f o u r and a h a l f , and the youngest o f f o u r b o y s , has not had a n ightmare s i n c e the o p e r a t i o n , a l t h o u g h he p r e v i o u s l y dreamed o f t e n o f bears and s n a k e s , and wakened t o come i n t o h i s p a r e n t s ' b e d . He a l s o used t o suck h i s thumb and wet h i s b e d . He p l a y e d m o s t l y w i t h h i s s i x - y e a r - o l d b r o t h e r T i m , and was a lways the p a s s i v e f o l l o w e r i n any game. H i s mother says he was l o o k i n g fo rward t o a d m i s s i o n and was d i s a p p o i n t e d when t h i s was p o s t -p o n e d . H i s o l d e r b r o t h e r s had a l l had t h e i r t o n s i l s o u t , and he t r e a t e d h i s s o r e t h r o a t a f t e r w a r d as a mark o f s t a t u s . B i l l y was w e l l p r e p a r e d and s a i d he l i k e d the h o s p i t a l and the n u r s e s . He a l s o s a i d , however , t h a t t h e r e were "no n e e d l e s " which was not t r u e . When h i s mother came f o r h im he t o l d her q u i c k l y t h a t he had been a "good boy" (which he had been) but t h i s statement i s a l s o h i s r e a c t i o n to pun ishment . D i d he see t h i s o p e r a t i o n as a s o r t o f " i n i t i a t i o n r i t e " which i f s u c c e s s f u l l y passed would make h im more a c c e p t a b l e t o h i s p e e r s ? C e r t a i n l y he i s now much more a g g r e s s i v e w i t h o t h e r c h i l d r e n and more demanding o f a t t e n t i o n f rom h i s p a r e n t s . Some c h i l d r e n showed an o p p o s i t e r e a c t i o n : those who had been h o s t i l e and demanding sometimes gave up t h e i r bad h a b i t s and were ex t remely "good" f o r a t i m e . An i n t e r e s t i n g example was the case o f s i x - a n d - a - h a l f - y e a r - o l d R i c k y , the e l d e s t o f t h r e e b o y s . H i s p a r e n t s s e p a r a t e d a year b e f o r e the o p e r a t i o n and h i s mother worked t o suppor t the f a m i l y w h i l e her l a n d l a d y kept an eye on the c h i l d r e n . Mother s a i d t h i s l i t t l e - 36 -boy was l o o k i n g fo rward t o h i s o p e r a t i o n because he b e l i e v e d i t would improve h i s s p e e c h . He was w e l l - p r e p a r e d f o r the e x p e r i e n c e , h i s mother v i s i t e d him t w i c e , and he had brought c o l o u r i n g books and a t r u c k i n t o h o s p i t a l w i t h h i m . However, he came " a l o n e " t o h o s p i t a l a c c o r d i n g t o the m e d i c a l c h a r t . By t h i s was meant t h a t he was not accompanied by a r e l a t i v e ; a V o l u n t e e r Worker p i c k e d him up at home i n h e r c a r , and no one was w i t h him d u r i n g the w a i t i n g f o r e x a m i n a t i o n and a d m i s s i o n . A c c o r d i n g t o the b r i e f n o t e s on the c h a r t he was a model p a t i e n t . N e v e r t h e l e s s , when h i s mother a s k e d him a f t e r -ward about the o p e r a t i o n , and e s p e c i a l l y about the mask he s a i d : "But Mummy, I wanted my t o n s i l s out I" C l e a r l y the a n a e s t h e t i c was u n d e r s t o o d by him as a means o f f o r c i n g him t o do something (as i f he were a bad boy who had t o be f o r c e d ) . Most o f the c h i l d r e n compla ined v e r b a l l y about " n e e d l e s " f rom the l i t t l e g i r l of two who i s t e r r i f i e d of the " p r i c k - b u m " t o the p r e - d e l i n q u e n t boy o f e i g h t who a c t s t o u g h , runs away f rom home t o "ge t a j o b , " and whose own mother says he has had " t o o many l i c k i n g s . " By and l a r g e , however , i t was the younger c h i l d r e n who f e a r e d the n e e d l e m o s t , and the o l d e r ones who were upset by the a n a e s t h e t i c . The r e a c t i o n s of Donna and J o h n , b o t h n i n e y e a r s o l d , were i n t e r e s t i n g . B o t h compla ined t h a t the a n a e s t h e t i c " s m e l t a w f u l " and began t o be f u s s y about e a t i n g a f t e r they r e t u r n e d home. John s a i d he was " s t a r v e d to d e a t h " i n h o s p i t a l , a l t h o u g h he had been t o l d t h a t he would have no b r e a k f a s t the day o f the o p e r a t i o n . - 37 -He remembers t h a t he fought on the o p e r a t i n g t a b l e , but was t i e d down and h e l p l e s s . He s a i d , however , t h a t he l i k e d the n u r s e s , p a r t i c u l a r l y one g i r l who "showed him where the a n a e s t h e t i c was made." T h i s boy was a b l e t o express h i s f e e l i n g s i n t e a r s a t the t ime and v e r b a l l y a f t e r w a r d s . He had a g o o d , warm r e l a t i o n s h i p w i t h h i s mother who h a n d l e d her own f e e l i n g s o f a p p r e h e n s i o n about the o p e r a t i o n v e r y w e l l . She was c h i e f l y concerned about the " c u t t i n g " but d i d n o t d i s c u s s t h i s f e a r w i t h J o h n . Four months a f t e r the o p e r a t i o n he showed no s i g n s o f e mo t io n a l d i s t u r b a n c e . In c o n t r a s t t o t h i s we have the case o f Donna, the n i n e - y e a r - o l d g i r l who wanted h e r mother to s t a y i n h o s p i t a l w i t h h e r . T h i s mother t o l d the worker she would not want to s t a y , and d i d no t i n f a c t v i s i t e i t h e r a l t h o u g h she had promised h e r daughter she w o u l d . Donna 's mother was unmarr ied when t h i s c h i l d was b o r n and o b v i o u s l y p r e t t y unsure o f h e r s e l f . She tended t o be c o n t r o l l i n g w i t h the l i t t l e g i r l and s t r i c t about e a t i n g , s l e e p i n g h a b i t s , e t c e t e r a . Donna had been i n s e v e r a l f o s t e r - h o m e s b e f o r e she was f i v e , and had d e v e l o p e d many symptoms o f e m o t i o n a l n e g l e c t . Her mother d e s c r i b e d h e r as " b o s s y , n e r v o u s , and b a d -t e m p e r e d , " and added t h a t she had f r e q u e n t n ightmares and d i d p o o r l y i n s c h o o l . The h o s p i t a l n o t e s i n d i c a t e d t h a t she was a "poor e a t e r , " and maybe m e n t a l l y r e t a r d e d . Wi th t h i s h i s t o r y , and w i t h her m o t h e r ' s s t a t e d a t t i t u d e , one would wonder i f she were no t " e m o t i o n a l l y r e t a r d e d . " A t the t ime - 38 -of p o s t - o p e r a t i v e i n t e r v i e w , (June 1953) Donna was i n Grade I I I and her t e a c h e r expec ted h e r t o pass i n t o Grade IV the f o l l o w i n g September . Donna saw h o s p i t a l i z a t i o n m a i n l y as another s e p a r a t i o n f rom her mother upon whom her h o l d was tenuous a t b e s t . There was no i n d i c a t i o n i n h e r b e h a v i o u r t h a t t h i s e x p e r i e n c e l e s s e n e d h e r f e a r o f l o s i n g h e r mother . However, h e r improved s c h o o l work and a t t i t u d e toward h e r t e a c h e r might suggest t h a t she found i n h e r s e l f some a b i l i t y t o cope w i t h even v e r y f r i g h t e n i n g s i t u a t i o n s , and hence was l e s s a f r a i d to compete w i t h o t h e r c h i l d r e n . She shows s i g n s o f d i s t u r b a n c e now i n a reas of e a t i n g and b l a d d e r c o n t r o l ( s t i l l a r e a s c l o s e l y r e l a t e d t o m o t h e r ) , but s i n c e the o p e r a t i o n she has had no n i g h t m a r e s , and goes t o bed and ge ts up w i thout p r o t e s t . She may s u s p e c t t h a t i t i s b e t t e r to go t o s l e e p v o l u n t a r i l y than t o be a n a e s t h e t i z e d . T h i s concept o f h o s p i t a l p r o c e d u r e s as a form o f punishment seemed so g e n e r a l among t h e s e c h i l d r e n t h a t an at tempt was made t o f i n d out i f t h e r e were any p o s i t i v e c o r r e l a t i o n between the u s u a l method o f punishment f o r each c h i l d and the k i n d o f p r o c e d u r e which was most u p s e t t i n g to h i m . K i n d s o f punishment were a r r a n g e d under t h r e e h e a d i n g s : E m o t i o n a l I s o l a t i o n , the c u t t i n g o f f o f the c h i l d f rom normal f a m i l y i n t e r c o u r s e and p a r t i c i p a t i o n , b e i n g " s e n t t o o n e ' s room" or " s e n t to C o v e n t r y " ; D e p r i v a t i o n of m a t e r i a l t h i n g s , h a v i n g o n e ' s a l l o w a n c e c o n f i s c a t e d , o n e ' s p r i v i l e g e s c u r t a i l e d , or " t o bed w i thou t s u p p e r " ; and P h y s i c a l A t t a c k , - 3 9 -i . e . s p a n k i n g , s l a p p i n g , e t c e t e r a . R e a c t i o n s t o h o s p i t a l p r o c e d u r e s were then grouped i n t o t h r e e s i m i l a r e x p e r i e n c e s : S e p a r a t i o n , the i s o l a t i o n o f the c h i l d f rom home and f a m i l y ; D e p r i v a t i o n , the l a c k o f f o o d p r e - o p e r a t i v e l y ; and P h y s i c a l P a i n , s u r g e r y , n e e d l e s , the o p e r a t i n g room, the a n a e s t h e t i c , e t c e t e r a . A compar ison was made i n the case of each c h i l d , and as T a b l e I I , page 4 0 , i n d i c a t e s , t h e r e was a p o s i t i v e c o r r e l a t i o n i n twe lve o f the twenty c a s e s . The number o f c a s e s s t u d i e d i s o f c o u r s e too s m a l l f o r t h i s c o n c l u s i o n t o be more than s u g g e s t i v e s t a t i s t i c a l l y . Some o f these c a s e s however , e x h i b i t e d a s t r i k i n g s i m i l a r i t y between f e a r o f punishment and r e a c t i o n t o i t , and the f e a r o f h o s p i t a l p r o c e d u r e s and r e a c t i o n s to them. F o r example B e r t , an e i g h t -a n d - a - h a l f - y e a r - o l d boy who i s p u n i s h e d by spank ing and u s u a l l y c r i e s and s u l k s a f t e r i t , compla ined c h i e f l y o f the p a i n and s a i d t h a t the enema was l a w f u l . ' ' The enema i s l o g i c a l l y a s s o c i a t e d w i t h t o i l e t t r a i n i n g , and i t i s t h e r e f o r e no t s u r p r i s i n g to f i n d t h a t B e r t ' s mother found t r a i n i n g him " v e r y d i f f i c u l t " and t h a t he was s t i l l w e t t i n g h i s pants a t the age of f i v e and a h a l f . She used t o spank him f o r t h i s d a i l y , but she s a i d he was a " c a r e l e s s " l i t t l e boy and would not l e a r n . Mother even sugges ted t o the worker t h a t B e r t seems at t imes t o "ask f o r punishment" and sugges ts t h a t he has been "spanked too much." In t h i s c o n n e c t i o n t o o , i t i s i n t e r e s t i n g t o n o t e t h a t t h i s c h i l d does no t show h i s anger p h y s i c a l l y or v e r b a l l y a g a i n s t o t h e r s , but i n s t e a d , he - 4 0 -T a b l e I I . Compar ison of U s u a l Method o f Punishment  and Most F e a r e d H o s p i t a l P r o c e d u r e s Most F e a r e d H o s p i t a l P r o c e d u r e Kind of Home P u n i s h -ment No . o f cadges S e p a r a t i o n ( I s o l a t i o n ) D e p r i v a t i o n (o f f o o d , c l o t h e s , e t c . ) P h y s i c a l A t t a c k ( P a i n , i n c l . O . R . ) P r o c e d u r e Not S p e c i f i e d Emot iona l I s o l a t i o n 4 2 0 1 1 m a t e r i a l D e p r i v a t i o n 3 0 1 1 1 P h y s i c a l a t t a c k 13 1 0 9 3 TOTAL 20 3 1 11 5 - 41 -d e s t r o y s h i s own f a v o u r i t e t o y s . He has many nervous h a b i t s , i s r e s t l e s s and a poor s l e e p e r . H i s mother showed a g r e a t d e a l of h o s t i l i t y i n t a l k i n g about B e r t and compared h im most u n f a v o u r a b l y w i t h h i s younger s i s t e r , H e l e n . She d e s c r i b e d him as " n o s y " and " c l u m s y . " To t h i s c h i l d , s u r g e r y must have seemed a s e l f - d e s t r u c t i v e p r o c e s s , and the e x p e r i e n c e o f h o s p i t a l i z a t i o n d i d n o t h i n g to s t r e n g t h e n h i s a p p r e c i a t i o n or a c c e p t a n c e o f r e a l i t y . A g a i n , i n the case of the n i n e - y e a r - o l d John d e s c r i b e d a b o v e , who compla ined of b e i n g " s t a r v e d " i n h o s p i t a l , h i s mother s t a t e d t h a t the u s u a l method o f punishment i n h i s home was d e p r i v a t i o n o f m a t e r i a l t h i n g s , u s u a l l y " t o bed w i thou t s u p p e r . " I t i s i n t e r e s t i n g a l s o to n o t e t h a t two o f the c h i l d r e n s t u d i e d compla ined of " s t o m a c h - a c h e " p o s t - o p e r a t i v e l y . B o t h of these were g i r l s , B e t t y aged f i v e - a n d a h a l f and M a d e l e i n e , e i g h t and t h r e e - q u a r t e r s . B o t h o f these g i r l s have been spanked a l o t and showed a good d e a l o f h o s t i l i t y f o r t h e i r m o t h e r s . B o t h c h i l d r e n compla ined a f t e r w a r d s t o mother o f n e e d l e s . N e i t h e r c h i l d was g i v e n adequate p r e p a r a t i o n nor v i s i t e d d u r i n g h o s p i t a l i z a t i o n . One o f the boys s t u d i e d compla ined c h i e f l y o f b e i n g put i n a c r i b . J a c k i e s a i d he was a " b i g b o y , not a b a b y . " T h i s f o u r - a n d - a - h a l f - y e a r - o l d i s the son o f an unmarr ied mother and has been i n th ree f o s t e r homes d u r i n g h i s s h o r t l i f e . He spends weekends w i t h mother and s l e e p s w i t h h e r i n - 42 -a big bed on Friday and Saturday nights. She says she has only to t e l l him: "I don't love you; I ' l l get another boy who'll be good" in order to make him behave. His reaction to this is tears and promises to be good. His mother describes Jackie as sensitive, "touchy," and hard to handle. He was not formally prepared for operation but as his mother works in the hospital, i t was a familiar place, and she visited him briefly but often. One of the girl s who was hospitalized during this period had an extra long stay in hospital. Because of a post-operative fever, six-and-a-half-year old Anne was not discharged until the f i f t h day after her operation. This l i t t l e g i r l had been prepared very inadequately by her mother, but was said to.know what i t was a l l about because the l i t t l e g i r l next door had had the operation and had told Anne a l l about i t . Mother just told Anne that the doctor would "pinch the tonsils out." What Anne expected Heaven knows. Then the l i t t l e g i r l next door told her that the hospital was a horrible place, that doctors and nurses did dreadful things to children. Anne herself told the worker about this conversation afterward and added that the l i t t l e friend had been "wrong" about the hospital, i t was "not that bad," but Anne had been very "scared" a l l the same. One of Anne's chief complaints afterwards was the crib and harness. She f e l t "tied i n , " and apprehensive. The worker's conversa-tion with Anne was interesting in another way too. This - 43 -l i t t l e g i r l d i d not t h i n k i t would be b e t t e r . i f mother had stayed w i t h h e r . E v i d e n t l y she expected no support from t h a t q u a r t e r . However, she would have l i k e d her seven-year-o l d s i s t e r t o be there w i t h h e r . She s a i d t h a t she had d i s l i k e d the enema, and been f r i g h t e n e d by the n e e d l e s . However, the mask had not w o r r i e d her, she s a i d , because the doctor had e x p l a i n e d " a l l about t h a t . " Anne was v i s i t e d twice d u r i n g the s i x days, once by mother and once by f a t h e r . However, she d i d not seem p l e a s e d to see them, and mother f e l t t h a t Anne blamed her f o r p u t t i n g her i n t o h o s p i t a l . She would not t a l k to her mother, and seemed " r e s e n t f u l . " Anne's comments are i n t e r e s t i n g and h e l p f u l f o r they i n d i c a t e how some at l e a s t of the u s u a l h o s p i t a l procedures can be made l e s s alarming t o c h i l d r e n . Which procedures were most d i s t u r b i n g t o these c h i l d r e n ? T h i s q u e s t i o n can o n l y be answered i n terms of the statements of the c h i l d r e n themselves, e i t h e r t o t h e i r mothers or to the worker. Most of the c h i l d r e n commented about s e v e r a l unpleasant aspects of the e x p e r i e n c e , though a few would not t a l k to anyone about any p a r t of i t . Of those c h i l d r e n who d i d t a l k about the experience a f t e r w a r d s , by f a r the l a r g e s t number complained of "needles," t h i s i n s p i t e of the f a c t t h a t a l l had experienced these b e f o r e . I t i s reasonable to wonder i f "needles" i s not a t times an a l l -i n c l u s i v e term, s i g n i f y i n g p a i n , and a t t a c k of v a r i o u s s o r t s . A l a r g e number of c h i l d r e n t a l k e d i n d o u b t f u l terms of the - 44 -operating room. Most had a dim r e c o l l e c t i o n of green walls and being strapped onto a big table. Many seemed vaguely concerned about what happened there a f t e r they went to sleep. Almost as many expressed concern about the actual cutting of t h e i r bodies. I t i s d i f f i c u l t to evaluate the d i f f e r e n t ages of concern because the younger children were na t u r a l l y less able to verbalize. However, some of these chi l d r e n , but probably not the most disturbed ones, played doctor afterwards, and the description of t h e i r play indicated that they know a cutting instrument of some sort was introduced into t h e i r throats. I t seemed, however, that the concern was less where adequate preparation had been given. The q u a l i t y of prepara-t i o n varied a great deal. Some children had been t o l d that they would be away from home overnight, that they would have a big sleep, and that when they awakened they would breathe easier because t h e i r t o n s i l s would be gone. This explanation naturally l e f t a big gap—where would t h e i r t o n s i l s go and by what means? These children were prepared f or ho s p i t a l but not for surgery. Hence, when the anesthetist v i s i t e d them the night before the operation, they did not understand why s t i l l another doctor was involved, and any explanation he might give about the ether mask was not i n t e l l i g i b l e i n terms of what they were expecting. This gap i n preparation also l e f t them wondering why they should be deprived of food before the big sleep. I t i s undoubtedly true that some children could not - 45 -benefit by explanations because they were too frightened to l i s t e n , and this i s p a r t i c u l a r l y so when the explanation was not given u n t i l a f t e r they were admitted to h o s p i t a l . The fact that some children fought and screamed on admission and on the way to the operating room gives an obvious explanation of t h e i r feelings of fear and outrage. It has been shown that many of these children were able to accept t h i s dangerous experience without too deep a sense of f r u s t r a t i o n , and that this a b i l i t y was i n each case related to the degree of security that the c h i l d f e l t i n his own home. Nevertheless, even these children suffered some degree of fear and anger, and these children are the very ones who could p r o f i t most from explanation and the development of some continuing relationships from home to h o s p i t a l . A s to the others, the children already deeply disturbed about themselves and the world, t h i s experience could be, and i n the case of the two children studied here was, a very convincing proof that t h e i r worst fears were indeed true, that l i f e i s a very hazardous thing and perhaps not worth the trouble of f i g h t i n g f o r . What then, can the ho s p i t a l do to modify i n some degree the frightening and p a i n f u l experience which we have seen t h i s minor operation to be? F i r s t of a l l , i t i s necessary for the ho s p i t a l administration to assume r e s p o n s i b i l i t y f or the emotional readiness of children for surgery i n the same degree a s i t assumes r e s p o n s i b i l i t y f or the physical readiness of the patient. A s has been said, - 46 -t h i s i s r a r e l y a n e m e r g e n c y a d m i s s i o n . N o r m a l l y , t h e r e i s t i m e f o r c o n s i d e r a t i o n o f t h i s f a c t o r , a n d t i m e f o r c a r e f u l p l a n n i n g b e t w e e n p h y s i c i a n a n d p a r e n t s s o t h a t t h i s e x p e r i e n c e may be a s m i n i m a l l y d i s t u r b i n g a s p o s s i b l e f o r t h e c h i l d . T h e f i r s t s t e p , t h e r e f o r e , i n t h i s p l a n n i n g s h o u l d t a k e p l a c e i n t h e E a r , N o s e , a n d T h r o a t C l i n i c w h e n t h e d e c i s i o n i s r e a c h e d f o r m e d i c a l r e a s o n s t o a d m i t t h e c h i l d f o r s u r g e r y . O b v i o u s l y i t i s n o t p o s s i b l e f o r t h e p h y s i c i a n t o make a n e x h a u s t i v e i n q u i r y i n t o t h e e m o t i o n a l a n d m e n t a l c o n d i t i o n o f e a c h p a t i e n t , n o r i s i t p o s s i b l e f o r h i m t o r e q u e s t a s o c i a l h i s t o r y f r o m t h e s o c i a l w o r k e r o n e a c h c h i l d . H o w e v e r , i t i s p o s s i b l e f o r h i m t o o b s e r v e c a r e f u l l y t h o s e g r o s s e r symp toms o f m a l a d j u s t m e n t w h i c h w e r e p r e s e n t i n some o f t h e c h i l d r e n s t u d i e d h e r e . I t i s a l s o p o s s i b l e t o d i s c u s s b r i e f l y w i t h e a c h m o t h e r h e r c h i l d ' s p r e v i o u s e x p e r i e n c e o f h o s p i t a l i z a t i o n a n d s e p a r a t i o n . I n d e e d , t h i s i n f o r m a t i o n i s o f t e n a l r e a d y k n o w n t o h i m . A f e w m i n u t e s s p e n t a t t h i s t i m e d i s c u s s i n g w i t h h e r t h e c h i l d ' s p r o b a b l e r e a c t i o n s s h o u l d g i v e h i m some c l u e s t o t h e f e e l i n g s o f b o t h m o t h e r a n d c h i l d . I t i s a l s o a d v i s a b l e f o r t h e d o c t o r t o d i s c u s s w i t h a l l b u t t h e y o u n g e s t c h i l d r e n t h e i r c o n c e p t o f h o s p i t a l a n d s u r g e r y . I f i t i s t h e n h i s o p i n i o n t h a t a c h i l d i s d i s t u r b e d , h e may a s k t h e s o c i a l w o r k e r t o i n v e s t i g a t e f u r t h e r b e f o r e a d m i s s i o n i s d e c i d e d u p o n , o r i n e x t r e m e c a s e s , may a s k f o r c o n s u l t a t i o n w i t h t h e P s y c h i a t r y C l i n i c . A s s u m i n g t h a t t h e d e c i s i o n t o o p e r a t e i s a l w a y s b a s e d u p o n m e d i c a l n e c e s s i t y , i t may be - 47 -d e s i r a b l e to combine the admission w i t h b r i e f psychotherapy. In such gross instances as those represented by two of the c h i l d r e n s t u d i e d , Bert aged eig h t and a h a l f , and David aged e i g h t , where a r e f e r r a l to P s y c h i a t r y had already been suggested, there i s no excuse f o r n e g l e c t i n g t h i s p r e c a u t i o n . Both these boys were extremely m a s o c h i s t i c , and David was already (before the operation) showing strong tendencies to i d e n t i f y h i m s e l f w i t h feminine a c t i v i t i e s and a t t i t u d e s . The confusions i n these c h i l d r e n ' s minds could only be i n t e n s i f i e d by surgery without e x p l a n a t i o n . A second step should a l s o be taken a t t h i s time: parents should be given, p r e f e r a b l y i n w r i t t e n form, f u l l and accurate i n f o r m a t i o n about the h o s p i t a l procedures f o r t h i s o p e r a t i o n . Many parents f a i l t o prepare t h e i r c h i l d r e n adequately and a c c u r a t e l y because they do not themselves know what w i l l happen. This i n f o r m a t i o n should be accompanied by some advice concerning the n e c e s s i t y of g i v i n g t h i s i n f o r m a t i o n t o c h i l d r e n , and the reasons f o r c h i l d r e n ' s f e e l i n g s and r e a c t i o n s to the h o s p i t a l s i t u a t i o n . With t h i s t o o , should go some i n f o r m a t i o n about the h o s p i t a l ' s a t t i t u d e towards v i s i t i n g , and the d e s i r a b i l i t y of v i s i t i n g o l d e r c h i l d r e n , and the d e s i r a b i l i t y of mother s t a y i n g i n h o s p i t a l w i t h young c h i l d r e n . I n l i n e w i t h such a d v i c e , i t i s a l s o necessary t o extend v i s i t i n g hours so tha t parents are able to v i s i t d a i l y , and to r e l a x h o s p i t a l r u l e s s u f f i c i e n t l y that parents may take part i n some of the r o u t i n e s of care f o r - 4 8 younger children. I t i s u t t e r l y incomprehensible to a young c h i l d that his mother should have to s i t by while someone else cares for him. For instance, most children hate to have t h e i r h a i r washed by anyone, even mother, but i f i t has to be done, she i s the least objectionable person to do i t . In the case of older children whose parents are not with them, i t i s desirable that the c h i l d know he can c a l l them by telephone, es p e c i a l l y on the f i r s t night, when he i s not sick or i n bed. I t i s necessary that both he and' his parents be f u l l y aware of whatever p r i v i l e g e s of t h i s sort are available to them. As has been pointed out, the h o s p i t a l has always allowed childr e n to bring a f a m i l i a r toy with them, but as many families were unaware of the f a c t , t h i s p r i v i l e g e was r a r e l y used. Since the importance of accurate preparation can hardly be overestimated, i t would seem most desirable that t h i s s i t u a t i o n should be explored further by the examining physician at the time of admission. A few questions to the c h i l d at the time of the physical examination would be enough to s a t i s f y the doctor that the patient did know what to expect, and that he was not unduly alarmed at the prospect. The s i t u a t i o n which has been described, of children admitted to ho s p i t a l screaming and f i g h t i n g , should never be tolerated. Nor need i t be. With the precautions mentioned above, the extremely disturbed c h i l d should have already been screened out, and the c h i l d who i s frightened because of lack of preparation or because preparation has been badly done, should either be sent home or some time taken to reassure him then - 49 -and there. No exigencies of time or h o s p i t a l beds should take precedence i n such a case. In view of the importance which has been shown to r e l a t e to the q u a l i t y of the mother-child r e l a t i o n s h i p , i t i s no longer possible to accept as good practice any form of admission which does not give the c h i l d every opportunity to form some continuity of experience between home and h o s p i t a l and back again. This f e e l i n g of continuity can be achieved r i n several ways: with younger children i t i s e s s e n t i a l that mother remain with them throughout the experience; with older children, i t i s often enough for contact with home to be maintained through v i s i t i n g and telephone c a l l s ; often too th i s continuity can be helped by the chil d ' s retaining i n h o s p i t a l his own clothes and belongings. There seems to be no good reason why a l l childr e n should be dressed i d e n t i c a l l y i n hospital-provided clothing, and the f e e l i n g of one's own i d e n t i t y i s helped immeasurably by. t h i s simple provision. A further way of helping to promote i n the c h i l d the f e e l i n g that he i s not too i s o l a t e d from a l l he holds dear, i s the simple expedient of giving him one nurse who has met h i s mother or father. This plan holds no p r a c t i c a l d i f f i c u l t i e s i f the parent i s not quickly sent away. The nurse who i s on duty at the time of admission w i l l also be on duty, i n the normal course of events, the following morning when the c h i l d goes to the operating room. She w i l l have been absent, of course, during the evening and night, but her reappearance i n the morning w i l l be a steadying factor at the c r i t i c a l time. - 50 -I t i s , of course, necessary that a l l personnel i n the Paediatrics Department be made aware of the es s e n t i a l elements of children's emotional reactions, and the nature of t h e i r f e a r s . Inasmuch as i t i s standard procedure for the anesthetist to v i s i t and examine the c h i l d the evening before the operation, i t can be planned that t h i s v i s i t be a very meaningful one to the c h i l d . Dr. Katherine Jackson, whose work on a method of "psychologic preparation" for anaesthesia i n the Albany Research Project was described e a r l i e r , 1 summarizes the advantages of the method i n these terms: The p r a c t i c a l advantages of the method are: less anesthetic agent used, quieter inductions, milder excitement stages, lack of physiologic depression from premedication and quieter operating rooms. The advantage to the c h i l d consists i n the fa c t of having an otherwise t e r r i f y i n g experience become a cooperative enterprise between himself and the anesthetist. Conscious of the s i t u a t i o n with which he i s faced, he i s able, with the help of a person he can t r u s t , to accept and to deal with his fears. Here again i s the suggestion that the c h i l d himself be encouraged to take an active part i n the s i t u a t i o n through h i s own understanding of the procedures involved. Thus an other-wise frightening s i t u a t i o n may become a po s i t i v e learning experience for the c h i l d . Post-operatively, the c h i l d i s ine v i t a b l y somewhat unhappy. The great event i s over, tension i s relaxed, and his throat i s sore. Furthermore he i s somewhat groggy and unclear about the passage of time. Some of these children 1 Albany Research Project, p. 40. - 51 -reported they had been i n ho s p i t a l for many days, because they kept dropping off to sleep and waking up again on the post-operative day. Because of the same confusion, one c h i l d thought i t odd that the h o s p i t a l served soup for breakfast 1 This i s the time when the young patient needs to know that mother i s near. New friends are not very h e l p f u l now, and are not very f a m i l i a r e i t h e r . Mother need not be constantly with him, but should be there when he f i r s t awakens from the anaesthetic, and should come back at some time during t h i s day. He may appear not to notice her, but the r e c o l l e c t i o n s of the children studied make i t clear that he did know whether she was i n the h o s p i t a l or not, and her absence at such a time was often taken as clear evidence of re j e c t i o n . The modifications suggested are not such as to upset the routine of a large h o s p i t a l , nor are they based on thinking which i s foreign to most members of the s t a f f . The significance of these modifications i s mostly i n the f a c t that together they constitute a consistent plan to make the c h i l d f e e l that the ho s p i t a l i s a safe place for him to be, that the people there are to be trusted, and that while he w i l l suffer some pain and inconvenience, he w i l l be a l l r i g h t when i t i s over, and he w i l l go safely home again. For the normally well-adjusted c h i l d , t h i s approach w i l l meet his needs. There w i l l be, of course, c e r t a i n cases l i k e the two boys mentioned above, who w i l l need special care, but these cases are i n need of such - 52 -s p e c i a l a t t e n t i o n i n any e v e n t . Of the twenty c h i l d r e n s t u d i e d , i t seems c l e a r tha t a t l e a s t s i x t e e n of them would have responded w e l l t o the e x p e r i e n c e had these m o d i f i c a t i o n s i n h o s p i t a l a t t i t u d e s and p r o c e d u r e s been o b s e r v e d . CHAPTER IV SOME NEW APPROACHES TO THE PROBLEM In the f i v e yea rs f o l l o w i n g the s t u d y of the c a s e s d i s c u s s e d i n the p r e v i o u s c h a p t e r s , many changes have t a k e n p l a c e i n Vancouver G e n e r a l H o s p i t a l . The e n t i r e h o s p i t a l has e n l a r g e d c o n s i d e r a b l y , many new b u i l d i n g s have been a d d e d , and the P a e d i a t r i c s Department has been g i v e n a b u i l d i n g v i r t u a l l y t o i t s e l f . T h i s has meant t h a t the H e a l t h C e n t r e f o r C h i l d r e n ( the name i s now used f o r bo th wards and the o u t -p a t i e n t s d i v i s i o n ) has become a u n i t p lanned and d e s i g n e d f o r c h i l d r e n o n l y . The change i n atmosphere i s immed ia te ly n o t i c e a b l e on e n t e r i n g the b u i l d i n g . F u r n i t u r e , d e c o r a t i o n s , and arrangement a r e p lanned w i t h an eye t o c h i l d r e n ' s i n t e r e s t and c o m f o r t . B r i g h t c o l o u r s a r e used e x t e n s i v e l y , and much of the w h i t e , s t a r c h y , s t e r i l e l o o k i s gone . Nurses and d o c t o r s s t i l l wear c r i s p w h i t e s , but they a r e no l o n g e r the o n l y a d u l t s i n e v i d e n c e . P a r e n t s , o c c u p a t i o n a l t h e r a p i s t s , t e a c h e r s , v o l u n t e e r s and many of the c h i l d p a t i e n t s themselves are met i n the h a l l s . C h i l d r e n a r e out of bed now whenever p o s s i b l e , and a r e f r e e r to wander about v i s i t i n g the new playrooms and t h e i r f r i e n d s i n o ther rooms on the ward . Laughter and the n o i s e of c h i l d i s h games i s h e a r d , and the c h i l d r e n seem b u s i e r ; t h e r e i s l e s s o p p o r t u n i t y f o r moping i n - 54 -lonely i s o l a t i o n i n bed. This much can be seen, and i t indicates a very d i f f e r e n t attitude on the part of h o s p i t a l personnel. C l e a r l y an e f f o r t i s being made to meet the child ' s emotional as well as his medical needs. This concern about his "non-medical needs" i s stressed i n the "Message to Parents" at the beginning of the booklet A V i s i t 1 to the Hospital. Here too i s the advice to parents to t e l l t h e i r children the truth about the h o s p i t a l and to prepare them adequately for t h i s experience. The book i t s e l f i s an excellent idea. The story of "Timothy Dan" who went "to see the doctor man" i s t o l d i n amusing verses and printed i n a colouring book format with i l l u s t r a t i o n s on each page. I t describes graphically the experiences of being washed i n bed, having one's meals on a tray, c a l l i n g for bedpan, and having one's temperature taken r e c t a l l y . I t describes and pictures a l l these things as well as "needles," an X-ray examination, and the journey on the stretcher through the tunnel to the operating room. I t shows pictures of doctors i n gown and mask, and speaks of the anaesthetic mask, but does not show t h i s , nor does i t explain at a l l what an operation i s or may be. It does state that the operation area (throat, tummy, etcetera) w i l l be sore afterward. I t does not indicate what w i l l be the f e e l i n g — d i z z i n e s s , etcetera—which accompanies anaesthesia. It does stress that the h o s p i t a l i s a f r i e n d l y 1 A V i s i t to the Hospital. Health Centre for Children, Vancouver General Hospital, 1957• - 55 -p l a c e , whose p e r s o n n e l a r e i n t e r e s t e d i n c h i l d r e n and i n making them w e l l . And i t does emphasize t h a t the l i t t l e p a t i e n t w i l l go s a f e l y home a g a i n when he i s b e t t e r . However, t h i s b o o k l e t i s no t aimed s p e c i f i c a l l y a t h o s p i t a l -i z a t i o n f o r any one p u r p o s e . Hence i t sugges ts t h a t the c h i l d w i l l be i n h o s p i t a l a good d e a l l o n g e r t h a n the normal t o n s i l l e c t o m y r e q u i r e s . Of c o u r s e , t h i s mat ter can be h a n d l e d by e x p l a n a t i o n f rom p a r e n t s or d o c t o r . In view of p r e v i o u s f i n d i n g s however , one might wonder how o f t e n t h i s i s done . The same doubt o c c u r s when the q u e s t i o n a r i s e s o f f i l l i n g the gaps i n i n f o r m a t i o n around the o p e r a t i o n p r o c e d u r e s , i n c l u d i n g a n a e s t h e s i a . U n f o r t u n a t e l y , t h e r e i s a v e r y human tendency t o assume t h a t " i t ' s a l l i n the b o o k , " and no a d d i t i o n a l i n f o r m a t i o n need be g i v e n . As has been no ted a b o v e , the c h i l d ' s f e a r s and f a n t a s i e s around s u r g e r y i s the a r e a of g r e a t e s t c o n c e r n and a n x i e t y , and i t i s a t t h i s p o i n t t h a t r e a s s u r a n c e i s most i m p o r t a n t . One o f the most e n c o u r a g i n g changes i n h o s p i t a l p o l i c y i s the e x t e n s i o n o f v i s i t i n g h o u r s , and the e n c o u r a g e -ment o f p a r e n t s t o v i s i t t h e i r c h i l d r e n . Not o n l y have f o r m a l v i s i t i n g hours been e x t e n d e d , but where a c h i l d i s a n x i o u s about b e i n g l e f t a l o n e , a p a r e n t may s t a y w i t h him u n t i l he s e t t l e s down. T h i s f l e x i b i l i t y i s now more p o s s i b l e because n u r s i n g u n i t s a re s m a l l e r than they w e r e . I n s t e a d of the b i g , o l d - f a s h i o n e d wards d e s c r i b e d i n Chapter I I , the c h i l d r e n are i n rooms c o n t a i n i n g f o u r or f i v e b e d s . Ages and sexes a r e mixed and an e f f o r t has been made to g i v e a "homel ike - 56 -l atmosphere w i t h the p r e s e n c e o f o l d e r and younger c h i l d r e n . " How h e l p f u l i s t h i s m i x i n g o f ages seems open t o some d o u b t , inasmuch as the c o h e s i v e f o r c e i n a r e a l home i s the p r e s e n c e of the common p a r e n t s . D o c t o r s and n u r s e s may p r o v i d e mother and f a t h e r s u b s t i t u t e s i n a v e r y l i m i t e d way i f c h i l d r e n remain f o r some t ime under t h e i r c a r e . However, f o r the s h o r t term h o s p i t a l i z a t i o n b e i n g d i s c u s s e d h e r e , t h i s p l a n p r o v i d e s l i t t l e i n the way of e m o t i o n a l s e c u r i t y . A g a i n i t seems n e c e s s a r y to s t r e s s t h a t young c h i l d r e n r e a l l y need t h e i r own mothers and u n f o r t u n a t e l y t h e r e i s s t i l l no p r o v i s i o n f o r a p a r e n t t o l i v e i n . S t i l l another change i s q u i c k l y observed as one walks th rough the w a r d s . C h i l d r e n are now d r e s s e d i n p r e t t y c o t t o n p r i n t pa jamas, not a l l o f the same p a t t e r n , and c h i l d r e n who a r e a l l o w e d "up" wear b r i g h t j e r s e y s of d i f f e r e n t c o l o u r s . D o u b t l e s s c h i l d r e n , l i k e o t h e r p e o p l e , f e e l b e t t e r i n p r e t t y c l o t h e s than i n the o l d drab h o s p i t a l b l u e s ; however , these c l o t h e s a re s t i l l not t h e i r own. A l l o f a c h i l d ' s own c l o t h e s a r e s t i l l t a k e n f rom him and g i v e n t o h i s mother t o take home a t the t ime of a d m i s s i o n , and even the p r e t t i e s t and most i n d i v i d u a l cos tume, l i k e the most glamourous h o s p i t a l - o w n e d t o y , g i v e s the c h i l d no r e a s s u r a n c e about h i s own i d e n t i t y and h i s u l t i m a t e r e t u r n t o 1 M c C r e a r y , J . F . " C u r r e n t Trends i n H o s p i t a l i z a t i o n of C h i l d r e n " a b s t r a c t e d f rom an a r t i c l e i n the B u l l e t i n of the Vancouver M e d i c a l A s s o c i a t i o n , O c t o b e r , 1956. - 57 -the f a m i l i a r i t y o f home. C h i l d r e n a re now b e i n g encouraged t o b r i n g t h e i r own f a v o u r i t e t o y , and i n a d d i t i o n t h e r e a re many b e a u t i f u l t o y s p r o v i d e d by the h o s p i t a l , but space i s l i m i t e d f o r a c h i l d t o keep h i s own p e r s o n a l b e l o n g i n g s , i n c l u d i n g h i s c l o t h e s . The changes n o t e d so f a r r e l a t e t o s e t t i n g and p o l i c y . A r e t h e r e s i m i l a r changes i n r e g a r d to p r o c e d u r e s ? Perhaps the most t r a u m a t i c p r o c e d u r e s n o t e d i n t h i s s tudy were those around a d m i s s i o n and s u r g e r y . A d m i t t i n g i s no l o n g e r done th rough the f a m i l i a r o u t - p a t i e n t s department which the c h i l d has a t t e n d e d p r e v i o u s l y . Now when the f a m i l y i s n o t i f i e d t h a t a bed i s a v a i l a b l e , p a r e n t s b r i n g the c h i l d t o ano ther o f f i c e i n the same b u i l d i n g , where he i s examined by a new n u r s e f o r c o l d s or r a s h e s . I f a l l i s w e l l , he and h i s mother a r e t o l d t o wa i t i n the c o r r i d o r u n t i l the ward n u r s e comes f o r them. There i s no l o n g e r the walk t o another b u i l d i n g . They get i n t o the e l e v a t o r and go s t r a i g h t u p s t a i r s . However, t h e r e i s s t i l l q u i t e a l o n g wa i t sometimes q u i t e l o n g enough f o r a s m a l l boy or g i r l t o get w o r r i e d about what i s a h e a d , and to l o s e the courage g a i n e d by m o t h e r ' s c a r e f u l p r e p a r a t i o n . T h i s w a i t i n g i s one of the f e a t u r e s of o u t - p a t i e n t c a r e everywhere , but i t does seem u n f o r t u n a t e t h a t c h i l d r e n s h o u l d have t o wa i t on t h i s o c c a s i o n when they have been c a l l e d i n by a p p o i n t m e n t . However, when they get u p s t a i r s , they a r e shown the c h i l d ' s room and h i s b e d , and he changes i n t o the h o s p i t a l c l o t h e s - 58 -and goes t o the p layroom w h i l e mother i s i n t e r v i e w e d f o r m e d i c a l h i s t o r y . Mother may r e t u r n to him a f t e r t h i s and s t a y f o r a w h i l e u n t i l he s e t t l e s down a l i t t l e . I t w i l l be no ted t h a t the a d m i t t i n g p r o c e d u r e no l o n g e r i n v o l v e s a compulsory b a t h and h a i r - w a s h i n g . T h i s i s done o n l y where the c h i l d i s r e a l l y d i r t y . T h i s i s an improvement f rom the p o i n t o f view o f the c h i l d ' s f i r s t i m p r e s s i o n o f the h o s p i t a l : t h i s i s not a p l a c e where they t r y to make you d i f f e r e n t a t o n c e . Thus i t may be n o t e d t h a t a d m i t t i n g p r o c e d u r e s a re l e s s d i s t u r b i n g on the whole than they w e r e , but t h e r e i s s t i l l no c o n c e r t e d at tempt to examine each c h i l d i n terms o f h i s e m o t i o n a l r e a d i n e s s f o r h o s p i t a l , and t h i s i s a s e r i o u s l i m i t a t i o n . Very a n x i o u s and d i s t u r b e d c h i l d r e n may s t i l l be and a r e s t i l l b e i n g a d m i t t e d t o h o s p i t a l . The c h i l d ' s e m o t i o n a l d i s t u r b a n c e w i l l be r e a d i l y n o t e d i f i t i s the " a c t i n g - o u t " v a r i e t y , and under the p r e s e n t s y s t e m , eve ry e f f o r t w i l l be made to r e a s s u r e h i m ; but the wi thdrawn c h i l d , or the o v e r - c o n t r o l l e d c h i l d w i l l no t be r e c o g n i z e d soon enough. T h i s r e c o g n i t i o n would be made e a s i e r i f mother was c o n s u l t e d on t h i s p o i n t a t the t ime o f a d m i s s i o n , or b e t t e r , a t the t ime h o s p i t a l i z a t i o n was recommended. The o t h e r a r e a of deep c o n c e r n f o r c h i l d r e n and a d u l t s a l i k e i s t h a t o f s u r g e r y and a n a e s t h e s i a . An at tempt was made t o s tudy p r e s e n t p r o c e d u r e s . F i r s t , as n o t e d a b o v e , the p r e p a r a t i o n o f f e r e d to the c h i l d i s n o t a b l y d e f i c i e n t on t h i s s u b j e c t . I t would seem t h a t the a t t i t u d e - 5 9 -i s s t i l l based on the b e l i e f tha t "what c h i l d r e n d o n ' t know, they won ' t worry a b o u t . " Some a u t h o r i t i e s would agree t h a t i t i s unwise t o t e l l c h i l d r e n too soon about f r i g h t e n i n g p r o c e d u r e s , but t h e r e can be no excuse f o r not t e l l i n g them a t a l l . However, t h i s i s s t i l l the u s u a l p r a c t i c e . C h i l d r e n s t i l l u s u a l l y see the a n a e s t h e t i s t the n i g h t b e f o r e the o p e r a t i o n , but he does no t i d e n t i f y h i m s e l f , nor d i s c u s s h i s p a r t i n the coming e v e n t : he i s j u s t ano ther s t r a n g e d o c t o r who examines them, and t h i s tremendous o p p o r t u n i t y t o p r o v i d e f o r the c h i l d an e m o t i o n a l l i n k between the ward' and the o p e r a t i n g room i s l o s t . The o p e r a t i o n looms ahead o f the c h i l d as an unknown and hazardous j o u r n e y , t o be u n d e r t a k e n e n t i r e l y a l o n e . P r e - m e d i c a t i o n nowadays i s u s u a l l y l i g h t e r than i t was , so t h a t c h i l d r e n a r e more than ever aware o f the f r i g h t e n i n g t r i p t h r o u g h the h o s p i t a l ' s underground t u n n e l s t o the o p e r a t i n g room. U n f o r t u n a t e l y , the one t ime when the c h i l d l e a v e s the P a e d i a t r i c Depar tment , where s p e c i a l l y t r a i n e d p e r s o n n e l have some awareness o f c h i l d r e n ' s s p e c i a l s e n s i t i v i t i e s , i s when he has t o have an o p e r a t i o n . F a c i l i t i e s i n the H e a l t h C e n t r e a re s t i l l not s e t up so tha t these o p e r a t i o n s may be per formed t h e r e . However, t h e r e i s some improvement i n the s i t u a t i o n p o s t - o p e r a t i v e l y . S i n c e p r e - m e d i c a t i o n i s l i g h t e r , the c h i l d awakens more q u i c k l y f rom a n a e s t h e s i a , and many c h i l d r e n a r e t aken back a t once t o the ward , thus a v o i d i n g the s o j o u r n i n the Recovery Room which was d e s c r i b e d i n an e a r l i e r c h a p t e r . - 60 -I t i s apparent t h e n , t h a t many m o d i f i c a t i o n s i n h o s p i t a l s e t t i n g , p o l i c i e s , and p r o c e d u r e s have been i n t r o d u c e d , and t h a t t h i s p r o c e s s i s a c o n t i n u i n g o n e . As D r . M c C r e a r y , the P a e d i a t r i c i a n - i n - c h i e f o f the H e a l t h C e n t r e , 1 p o i n t s out i n the a r t i c l e ment ioned a b o v e , " the t r e n d i n r e c e n t y e a r s has been towards a t t e m p t i n g to c r e a t e a s i t u a t i o n i n c h i l d r e n ' s wards where in the c h i l d w i l l be more a t home." In an at tempt to a s s e s s the degree t o wh ich t h i s s i t u a t i o n has been a c h i e v e d , and as p a r t o f the t r a i n i n g o f m e d i c a l s tuden ts i n the h o s p i t a l , a p r o j e c t was i n s t i t u t e d i n wh ich two second year m e d i c a l s t u d e n t s were asked t o examine "2 c a s e s of c h i l d r e n admi t ted t o h o s p i t a l f o r t o n s i l l e c t o m y . I t i s no t p o s s i b l e to compare t h e i r f i n d i n g s s t a t i s t i c a l l y w i t h those of t h i s s t u d y , s i n c e the approach and the q u e s t i o n s asked were d i f f e r e n t . However, some o f the g e n e r a l s u g g e s t i o n s f o r m o d i f y i n g the e x p e r i e n c e were i n t e r e s t i n g . F o r example , i t i s suggested t h a t the day of a d m i s s i o n " s h o u l d be a good day f o r the c h i l d , " i . e . t h a t i t s h o u l d not f o l l o w immed ia te ly upon some e m o t i o n a l l y d i s t u r b i n g event i n the c h i l d ' s l i f e . I t i s a l s o p o i n t e d out t h a t p a r e n t s s h o u l d be encouraged t o s t a y w i t h the c h i l d an hour or so f o l l o w i n g a d m i s s i o n , and t o v i s i t o f t e n ; and the recommendation i s added t h a t " P r o v i s i o n s 1 I b i d . 2 J o h n s o n , M.D. and J . A . C l a r k . "A Study o f the F a c t o r s t h a t may a f f e c t the B e h a v i o u r o f C h i l d r e n F o l l o w i n g T o n s i l -l e c t o m y , " submi t ted to the Department o f P a e d i a t r i c s , F a c u l t y o f M e d i c i n e , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1958. - 61 -s h o u l d be made f o r the ' l i v i n g - i n ' o f the mothers of the 1 young age g r o u p . " In a d d i t i o n t o t h e s e g e n e r a l s u g g e s t i o n s , t h e r e a r e a few recommendations to m e d i c a l p e r s o n n e l i n v o l v e d i n the ca re o f c h i l d r e n ; f o r example , "No d i s c u s s i o n on ward rounds s h o u l d be made t h a t w i l l f r i g h t e n the c h i l d , " and " A f t e r an e x a m i n a t i o n , the c h i l d s h o u l d be r e a s s u r e d as t o h i s p r o g r e s s . " F i n a l l y , i t i s sugges ted t h a t "Any p r o -2 cedures c a r r i e d out s h o u l d be e x p l a i n e d t o the c h i l d . " The tone o f t h i s r e p o r t , as w e l l as the f a c t o f i t s b e i n g d o n e , i s an i n d i c a t i o n o f the i n t e r e s t b e i n g t a k e n c u r r e n t l y by the Department o f P a e d i a t r i c s and the H e a l t h C e n t r e f o r C h i l d r e n i n the e m o t i o n a l needs of s m a l l p a t i e n t s . T h i s s tudy has a t tempted t o examine what a r e some o f these e m o t i o n a l needs and how b e s t they can be met w i t h i n the l i m i t a t i o n s of the m e d i c a l s e t t i n g . I t would seem t h a t the essence o f t h e . p r o b l e m i s how t o e s t a b l i s h a s e r i e s o f e m o t i o n a l l i n k s f rom the f a m i l i a r t o the u n f a m i l i a r i n an e f f o r t t o f o c u s the c h i l d ' s f e a r s on r e a l i s t i c s i t u a t i o n s , and to d i l u t e the i n e v i t a b l e a n x i e t y , so t h a t he can m o b i l i z e h i s i n n e r r e s o u r c e s t o meet and overcome the danger s i t u a t i o n . These l i n k s take the form o f r e l a t i o n a l e x p e r i e n c e s w i t h h o s p i t a l p e r s o n n e l , each of wh ich s h o u l d be p o s i t i v e and e m o t i o n a l l y s a t i s f y i n g . These r e l a t i o n s h i p s a re p a r t i c u l a r l y impor tant a t the d i f f i c u l t t imes of a d m i s s i o n t o h o s p i t a l 1 I b i d . , p . 49. 2 I b i d . - 62 -( the new p l a c e ) and a d m i s s i o n to s u r g e r y ( the new and dangerous e x p e r i e n c e ) . I t i s f o r t h i s r e a s o n t h a t p rocedures i n these a r e a s s h o u l d be examined c r i t i c a l l y f rom the p o i n t o f view of the p a t i e n t ' s e m o t i o n a l n e e d s . Much has been done and i s b e i n g done t o make h o s p i t a l i z a t i o n a p l e a s a n t e r and l e s s f r i g h t e n i n g e x p e r i e n c e f o r the c h i l d . Something more, however , needs to be done t o min imize the a n x i e t y a s s o c i a t e d w i t h the s u r g e r y i t s e l f . I t i s n e c e s s a r y t o p repare the c h i l d f o r n a r c o s i s and s u r g e r y and t o h e l p him f a c e h i s a n x i e t y about the o p e r a t i o n . The p r o v i s i o n o f such h e l p demands an i n t e r - p e r s o n a l r e l a t i o n s h i p between the c h i l d and someone a c t i v e l y a s s o c i a t e d w i t h the o p e r a t i o n . - 63 -APPENDIX A QUESTIONNAIRE USED AS BASIS FOR INTERVIEWS WITH MOTHERS 1. G e n e r a l I n f o r m a t i o n : (a) C o m p o s i t i o n of f a m i l y i n c l u d i n g o t h e r s i n h o u s e h o l d . (b) Economic and s o c i a l s t a t u s o f f a m i l y - - s i z e of home, f a t h e r ' s j o b , unemployment, m o t h e r ' s j o b . (c) C h i l d ' s age and p l a c e i n f a m i l y . (d) P e r s o n a l h i s t o r y of c h i l d — n u r s i n g , wean ing , when walked and t a l k e d , t o i l e t t r a i n i n g , f r i e n d s , s c h o o l , i n t e r e s t s , e t c . (e) U s u a l methods o f pun ishment . ( f ) P r e v i o u s h o s p i t a l i z a t i o n , where , c l i n i c a t t e n d a n c e . (g) P r e v i o u s s e p a r a t i o n f rom mother , when, how, e t c . and r e a c t i o n s . I I . S p e c i f i c i n f o r m a t i o n r e c h i l d ' s b e h a v i o u r b e f o r e and  a f t e r o p e r a t i o n : (a) A b i l i t y and w i l l i n g n e s s t o take c a r e of h i m s e l f . (b) E a t i n g and s l e e p i n g h a b i t s . (c) R e a c t i o n s t o s e p a r a t i o n . (d) R e a c t i o n s t o pun ishment . (e) N i g h t m a r e s . ( f ) Temper t a n t r u m s . (g) Manner isms, s e l f - c o m f o r t i n g h a b i t s , e t c . I I I . O p e r a t i o n i t s e l f : (a) Was c h i l d p r e p a r e d f o r o p e r a t i o n ? (b) How? Was s e p a r a t i o n e x p l a i n e d ? (c) Was he v e r y a p p r e h e n s i v e ? (d) How l o n g d i d they have to wa i t f o r a bed? - 64 -I I I . O p e r a t i o n i t s e l f ( c o n t i n u e d ) (e) P r e v i o u s v i c a r i o u s e x p e r i e n c e o f t h i s h o s p i t a l and t h i s o p e r a t i o n ( e . g . s i b l i n g s , f r i e n d s ) , and i n f o r m a t i o n o b t a i n e d . ( f ) V e r b a l i z a t i o n o f c h i l d a f t e r o p e r a t i o n , t o mother , t o o t h e r s . (g) D i d he p l a y h o s p i t a l or d o c t o r a f t e r ; or n u r s e , or p a t i e n t ? (h) R e a c t i o n s of c h i l d ( v e r b a l l y or i n p l a y ) as n o t e d by mother t o : (1) A n a e s t h e s i a , o p e r a t i n g room. (2) N e e d l e s . (3) Enema. (4) H o s p i t a l , d o c t o r s , n u r s e s , p e o p l e i n w h i t e , f o o d t h e r e , c r i b s , b e i n g t i e d i n b e d , s m e l l s . (5) S e p a r a t i o n : d i d mother v i s i t ? What d i d he say or do when c a l l e d f o r t o go home? How l o n g d i d t h a t r e a c t i o n l a s t ? (6) Changes i n b e h a v i o u r a f t e r h o s p i t a l i z a t i o n : when d i d these appear? How l o n g d i d they l a s t ? What d i d mother t h i n k t h e s e meant? ( i ) F u r t h e r s e p a r a t i o n s s i n c e o p e r a t i o n ? How taken? ( j ) S p e c i a l a t t e n t i o n or toys p o s t - o p e r a t i v e l y ? R e a c t i o n t o t h i s ? (k) Has mother changed h e r a t t i t u d e i n any way s i n c e o p e r a t i o n ? IV . M o t h e r ' s f e e l i n g s and r e a c t i o n s : (a) Was she a p p r e h e n s i v e about o p e r a t i o n ? Own p r e v i o u s e x p e r i e n c e o f h o s p i t a l or s u r g e r y ? What d i d she do about h e r f e e l i n g s ? (b) Yi/hat were f e e l i n g s o f o t h e r s i n f a m i l y ? Were these o b v i o u s ? V e r b a l i z e d ? (c) What were m o t h e r ' s f e e l i n g s about s e p a r a t i o n ? D i d she want to v i s i t ? Would she have s t a y e d w i t h c h i l d i f t h i s had been p o s s i b l e ? - 65 -APPENDIX B TABLE SHOWING NEGATIVE BEHAVIOUR TRAITS BEFORE AND AFTER OPERATION N e g a t i v e T r a i t s S c o r e s by C h i l d r e n B e f o r e o p e r a t i o n A f t e r o p e r a t i o n B o y s : (13) 1. Concern about s e p a r a t i o n f rom mother 8 8 2. G e t t i n g - u p problems 1 1 3. D r e s s i n g problems 4 5 4. E a t i n g problems 3 1 5. V i o l e n t temper 3 1 6. Severe or m u l t i p l e mannerisms 7 7 7. R e b e l l i o u s a t b e d - t i m e 3 3 8. Lapses i n t o i l e t t r a i n i n g 5 5 9. Severe n ightmares 2 l G i r l s : (7) 1. Concern about s e p a r a t i o n f rom mother 6 6 2. G e t t i n g up problems 1 1 3- D r e s s i n g problems 1 1 4. E a t i n g problems 4 3 5. V i o l e n t temper 3 2 6. Severe or m u l t i p l e mannerisms 4 3 7. R e b e l l i o u s a t b e d - t i m e 4 4 8. Lapses i n t o i l e t t r a i n i n g 2 2 9. Severe n ightmares 2 2 - 66 -APPENDIX C BIBLIOGRAPHY 1 . GENERAL REFERENCES (a) B o o k s : J o s s e l y n , I rene M. P s y c h o s o c i a l Development of C h i l d r e n , New Y o r k , F a m i l y S e r v i c e A s s o c i a t i o n , 1948 . K l e i n , M e l a n i e . C o n t r i b u t i o n s to P s y c h o a n a l y s i s 1921-45 , London , H o g a r t h , 1948. Radke , M a r i a n J . R e l a t i o n o f P a r e n t a l A u t h o r i t y t o C h i l d r e n ' s B e h a v i o r and A t t i t u d e s , " M i n n e a p o l i s , U n i v e r s i t y o f M innesota P r e s s , 1946 . S h i r l e y , Ha le F . P s y c h i a t r y f o r the P e d i a t r i c i a n , New Y o r k , Commonwealth P r e s s , 194o . S p e n c e , S i r James C a l v e r t e t a l . A Thousand F a m i l i e s i n Newcast le upon T y n e ; an Approach to the s t u d y of h e a l t h  and i l l n e s s i n c h i l d r e n , London , N u f f i e l d F o u n d a t i o n , Ox ford U n i v e r s i t y P r e s s , 1954 . (b) A r t i c l e s : Chapman, A . H . , M .A . Loeb and M . J . G i b b o n s . " P s y c h i a t r i c a s p e c t s of h o s p i t a l i z i n g c h i l d r e n , " i n A r c h i v e s of  P a e d i a t r i c s , 7 3 ( 3 ) : 7 7 - 8 8 . " C h i l d r e n i n H o s p i t a l " i n The L a n c e t . 2 6 8 ( 6 8 7 4 : 1 1 1 0 - 1 , London , L a n c e t L t d . , 1955» " C h i l d r e n i n H o s p i t a l : c l i n i c a l c o n f e r e n c e " i n J o u r n a l of  P e d i a t r i c s , 4 6 : 4 5 8 - 7 2 , S t . L o u i s , C V . Mosby C o . , 1955 . E l l i s , R . V / . B . "Punishment and the m a l a d j u s t e d c h i l d " i n The  Canad ian M e d i c a l A s s o c i a t i o n J o u r n a l , 6 7 : 2 0 9 - 1 6 , T o r o n t o , Canad ian M e d i c a l A s s o c i a t i o n , 1952 . Faughnan, J . E . "The c h i l d i n h o s p i t a l " i n The Canad ian N u r s e , 5 2 ( 1 2 ) : 9 5 6 - 9 , W i n n i p e g , Canad ian Nurses A s s o c i a t i o n , 195b . F r e u d , A n n a . "The r o l e o f b o d i l y i l l n e s s i n the menta l l i f e of c h i l d r e n , " i n The P s y c h o - a n a l y t i c Study of the C h i l d , 7 : 6 9 - 8 0 , New Y o r k , I n t e r n a t i o n a l U n i v e r s i t i e s P r e s s , 1 9 5 2 . - 67 -Gorman, H., W. Buckman, and G. Schade. "The child' s emotional response to h o s p i t a l i z a t i o n , " i n The A.M.A. Journal of  Diseases of Children, 9 3 ( 2 ) : l 5 7 - 6 4 , Chicago, American Medical Association, 1957 . "The h o s p i t a l i z e d c h i l d : a round table, 1 9 5 4 , " i n The  American Journal of Orthopsychiatry, 2 5 : 2 9 3 - 3 1 8 , Menasha, Wis., Geo. Banta Pub. Co., 1955 . Illingsworth, R.S. and K.S. Holt. "Children i n h o s p i t a l , " i n The Lancet. 2 6 9 ( 6 9 0 3 ) : 1 2 5 7 - 6 2 , London, Lancet Ltd., 1955 . Jackson, E. "Treatment of the young c h i l d i n the h o s p i t a l i n The American Journal of Orthpsychiatry, v. 1 2 , Menasha, Wis., Geo. Banta Pub. Co.", 1 9 4 2 . Levy, D.M. "Child patients may suffer psychic trauma a f t e r surgery," i n Modern Hospital, 6 5 : 5 1 ~ 2 , St. Louis, Modern Hospital Pub. Co., 1945 . MacLennan, B.W. "Non-medical care of ch r o n i c a l l y i l l c h i ldren i n h o s p i t a l , " i n The Lancet, 1 9 4 9 : 2 : 2 0 9 , London, Lancet Ltd., 1949 . Michaels, J . J . "Psychiatric implications of surgery," i n The  Family, vo. 2 3 , New York, The Family Welfare Association, 1 9 4 3 . M i l l e r , M.L. "Traumatic e f f e c t of surgical operations i n childhood on the integrative functions of the ego," i n The Psychoanalytic Quarterly, v. 2 0 , Albany, N.Y., Psychoanalytic Quarterly Press, 1 9 5 1 . Olson, E. "Contribution of psy c h i a t r i c s o c i a l worker to pe d i a t r i c i a n : resident and private p r a c t i t i o n e r , " i n The  American Journal of Orthopsychiatry, 2 0 : 1 1 5 - 2 2 , Menasha, Wis., Geo. Banta Pub. Co., 1950 . Orsten, P. and A. Mattsson. " H o s p i t a l i z a t i o n symptoms i n children," i n Acta Paediatrica, 4 4 : 7 9 - 8 2 , Uppsala, Almquist and Wiks e l l , 1955 . Pearson, G. "E f f e c t of operative procedures on the emotional l i f e of the c h i l d , " i n The A.M.A. Journal of Diseases of Children, v. 6 2 , Chicago: American Medical Association, TJZT. P i c k e r i l l , G.H. and H.P. "The mother as a nurse," i n The  Lancet, 2 6 6 ( 6 3 0 9 ) : 4 4 7 , London, Lancet Ltd., 1954 . - 68 -Potts, W.J. "Pediatric surgery," i n The Journal of the  American Medical Association, 1 5 7 : 6 2 7 - 3 0 , Chicago, American Medical Association, 1955« Prugh, D.G. et a l . "A study of the emotional reactions of children and families to h o s p i t a l i z a t i o n and i l l n e s s , " i n The American Journal of Orthopsychiatry, 23:70-106, Menasha, Wis., Geo. Banta Pub. Co., 1953* "Rooming-in i n p e d i a t r i c s , " i n The American Journal of Nursing, 5 2 : 4 7 , New York, American Journal of Nursing Company, 1952 . Serin, M.J.E. "The contribution of psychiatry to c h i l d health services," i n The American Journal of Ortho-psychiatry, 2 1 : 1 3 8 - 4 7 , Menasha, Wis., Geo. Banta Pub. Co., 19517 Sperling, M e l i t t a . "The r o l e of mother i n psychosomatic disorders i n c h i l d r e n , " i n Psychosomatic Medicine, 1 1 : 3 7 7 - 8 5 , Washington, D.C, Committee on problems of neurotic behavior, D i v i s i o n of Anthropology and Psychology, National Research Council, 194-9. S p i t z , Rene A. "Hospitalism. An inquiry into the genesis of p s y c h i a t r i c conditions i n early childhood," i n The  Psychoanalytic Study of the Chi l d , 1:53? New York, International U n i v e r s i t i e s Press, 1945« Weng, Lorraine. "Group f e e l i n g for h o s p i t a l i z e d children," i n Journal of the American D i e t e t i c Association, 2 5 : 6 2 0 , Baltimore, American D i e t e t i c Association, 1949* Zuger, B. "Growth of the indiv i d u a l ' s concept of s e l f : theory and ped i a t r i c considerations," i n A.M.A. Journal  of Diseases of Children, 8 3 : 7 1 9 - 3 2 , Chicago, American Medical Association, 1952 . 2 . SPECIFIC REFERENCES (a) Books: Bowlby, John. Maternal Care and Mental Health, World Health Organization Monographs # 2 , London, H.M.S.O., 1951* Freud, Anna, and D. Burlingham. War and Children, New York, International U n i v e r s i t i e s Press, 1943* Reducing Emotional Trauma i n Hospitalized Children, a three year study of 140 tonsillectomized children, Albany, N.Y., Albany Medical College, 1 9 5 2 . (The Albany Research Project.) - 69 -A V i s i t to the H o s p i t a l , V a n c o u v e r , B . C . , The H e a l t h C e n t r e f o r C h i l d r e n , Vancouver G e n e r a l H o s p i t a l , 1957• (b) A r t i c l e s : B e l l a m , G . " T o n s i l l e c t o m y w i thou t f e a r , " i n A m e r i c a n J o u r n a l  of N u r s i n g , 51:244-5? New Y o r k , A m e r i c a n J o u r n a l o f N u r s i n g Company, 1951* Bowlby , J o h n , James T o b e r t s o n , and D ina R o s e n b l u t h . "A two-year o l d goes t o h o s p i t a l , " i n The P s y c h o a n a l y t i c  S tudy o f the C h i l d , 7:82-94, New Y o r k , I n t e r n a t i o n a l U n i v e r s i t i e s P r e s s , 1952. D a v i s , B a r b a r a . " C h i l d r e n ' s r e s p o n s e t o t o n s i l l e c t o m i e s , " / a b s t r a c t o f thesis7 i n Smi th C o l l e g e S t u d i e s i n S o c i a l  Work, XX:2 :142 , F e b r u a r y 1950. D e u t s c h , H e l e n e . "Some p s y c h o a n a l y t i c o b s e r v a t i o n s i n s u r g e r y , " i n P s y c h o s o m a t i c M e d i c i n e , 4:105-15? Wash ing ton , D . C , Committee on problems o f n e u r o t i c b e h a v i o r , D i v i s i o n o f A n t h r o p o l o g y and P s y c h o l o g y , N a t i o n a l R e s e a r c h C o u n c i l , 1942. Duncombe, M .A . " D a i l y v i s i t i n g i n c h i l d r e n ' s w a r d s , " i n N u r s i n g T i m e s , 47:587-88, L o n d o n , R o y a l C o l l e g e o f N u r s i n g , 1951. E d e l s t o n , H . " 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 : a s tudy o f h o s p i t a l c a s e s , " i n G e n e t i c P s y c h o l o g y Monographs, 28:3-95? P r o v i n c e t o w n , M a s s . , The J o u r n a l P r e s s , 1941. E r i c k s o n , J . et a l . " H e l l o S u s a n ! ( I n t e r v i e w i n g c h i l d r e n and p a r e n t s f o r a d m i s s i o n t o h o s p i t a l , " i n A m e r i c a n  J o u r n a l o f N u r s i n g , 51:634-5? New Y o r k , A m e r i c a n J o u r n a l o f N u r s i n g Company, 1951• F a u s t , O t t o . "Stop s c a r i n g the c h i l d r e n , " i n Modern H o s p i t a l , 80:5:94, S t . L o u i s , Modern H o s p i t a l P u b l i s h i n g Company, 1953. F r e u d , A n n a . "Comments on ' M o t h e r ' s O b s e r v a t i o n s ' " / b y J . R o b e r t s o n , q.v.7 i n N u r s i n g T i m e s , 53:46:1305-7? L o n d o n , R o y a l C o l l e g e of N u r s i n g , 1957* J a c k s o n , K a t h e r i n e e t a l . "Problems o f e m o t i o n a l trauma i n the h o s p i t a l t rea tment o f c h i l d r e n , " i n J o u r n a l o f the  A m e r i c a n M e d i c a l A s s o c i a t i o n , 149:1536-8, C h i c a g o , A m e r i c a n M e d i c a l A s s o c i a t i o n , 1952. - 70 -Jackson, Katherine et a l . "Behavior changes i n d i c a t i n g emotional trauma i n t o n s i l l e c t o m i z e d c h i l d r e n ; f i n a l r e p o r t , " i n P e d i a t r i c s , 12:23-7, S p r i n g f i e l d , 111., American Academy of P e d i a t r i c s I n c . , 1953• Jessner, L u c i e , Gaston E. Blom, and Samuel Waldfogel. "Emotional i m p l i c a t i o n s of t o n s i l l e c t o m y and adenoid-ectomy i n c h i l d r e n , " i n The Psyc h o a n a l y t i c Study of  the C h i l d , 7:126-68, New York, I n t e r n a t i o n a l U n i v e r s i t i e s P r e s s , 1952. Jessner, L u c i e , and S. Kaplan. "Reaction of c h i l d r e n to t o n s i l l e c t o m y and adenoidectomy—preliminary r e p o r t , " i n Transactions of the Conference on problems of infan c y  and childhood, #3, 97-117, New York, Conference, 1949. Johnson, M.D. and J.A. C l a r k . "A study of the f a c t o r s that may a f f e c t the behaviour of c h i l d r e n f o l l o w i n g t o n s i l -lectomy," submitted to the Department of P a e d i a t r i c s , F a c u l t y of Medicine, U n i v e r s i t y of B r i t i s h Columbia, 1958. Jongkees, L.B.W. "Psychic e f f e c t on c h i l d r e n of h o s p i t a l i z a -t i o n and of operations," t r a n s l a t e d i n Annals of otology, r h i n o l o g y , and laryngology, 63:145-50? S t . L o u i s , M i s s . , Annals P u b l i s h i n g Company, 1954-. Levy, D.M. "Observations of a t t i t u d e s and behavior i n the C h i l d Health Centre; Sample studi e s of maternal f e e l i n g s , dependency, r e s i s t a n t behavior, and i n n o c u l a t i o n f e a r s , " i n American J o u r n a l of P u b l i c H e a l t h , 41:182-90, New York, American P u b l i c Health A s s o c i a t i o n , 1951• McCreary, J.F. "Current trends i n h o s p i t a l i z a t i o n of c h i l d r e n , " i n B u l l e t i n of the Vancouver Med i c a l  A s s o c i a t i o n * Oct. 1956. MacKeith, R. " C h i l d r e n i n h o s p i t a l : p r e p a r a t i o n f o r operation," i n The Lancet, 2:843-5? London, Lancet L t d . , 1953. Menninger, K.A. "Polysurgery and p o l y s u r g i c a l a d d i c t i o n , " i n The Psyc h o a n a l y t i c Q u a r t e r l y , 3:173-99? Albany, N.Y., Quar t e r l y P r e s s , 1934. Modern H o s p i t a l Round Table. "Minor surgery f o r minors," i n Modern H o s p i t a l , 76:82-3, S t . L o u i s , Modern H o s p i t a l P u b l i s h i n g Company, 1951' M o n c r i e f f , A. and A.M. Walton: " V i s i t i n g c h i l d r e n i n h o s p i t a l , " i n B r i t i s h Medical J o u r n a l , 1952:1:43-4, London, B r i t i s h Medical A s s o c i a t i o n , 1952. - 71 -Pillsbury, R.M. "Children can be helped to face surgery," in The Child, vol. 16, Washington, D.C. Children's Bureau, U.S. Department of Labor, 1951. Robertson, Jean. "A mother's observations on the t o n s i l -lectomy of her four-year old daughter," in Nursing  Times, 53:46:1295-1307, London, Royal College of Nursing, 1957. Spence, James C. "The care of children in hospital," in Brit i s h Medical Journal. 1947:1:125, London, B r i t i s h Medical Association, 1947. Veeneklaas, G.M.H. "Avoidable mistakes i n hospitalization of young children," in Nederlandsch ti.jdschrift voor  geneeskunde, 98:1738-41, Amsterdam, Nederlandsche maatschappij tot bevordering der geneeskunst, 1954. Williams, L.A. "Tonsillectomy without tears," in Modern  Hospital, 78:89-91, St. Louis, Modern Hospital Publishing Co., 1952. Winkley, Ruth. "When a child must go to hospital," i n The  Child, 17:34-6, Washington, D.C, Children's Bureau, U..S. Department of Labor, 1952. Worthington, Robert L. "Pediatrics and the child," i n Bulletin of the Menninger Cl i n i c , 8:170-7, Topeka, Kansas, C l i n i c , 1944. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0302587/manifest

Comment

Related Items