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Internarea in spital a copilului, efecte emotionale

autor: Daniela Ganciu 26 Noiembrie 2010

Internarea in spital a copilului presupune schimbarea mediului familiar intr-unul care nu este intotdeauna cel mai primitor. Sa stai in spital cu copilul poate fi destul de dificil pentru el la orice varsta. Atat spitalul, cat si boala reprezinta factori de stres puternici pentru micutul tau. El poate interveni in dezvoltarea lui normala si il poate afecta pe termen lung. A interna copilul in spital inseamna practic intreruperea viatii lui obisnuite si schimbarea ambientului confortabil in care era obisnuit pana atunci. Cand sunt in spital copiii resimt lipsa casei, a prietenilor si a altor membrii ai familiei care nu sunt cu el. Pe langa stresul inevitabil care apare la copiii internati, acestia pot dezvolta sentimente de frica sau chiar plictiseala ceea ce ii poate face usor iritabili si agitati. Ei nu inteleg foarte bine de ce anume este acolo si nici ce anume se intampla in incinta unui spital, ceea ce ii poate crea frustrari si temeri.

Ce efecte are spitalul asupra copiilor de diferite varste? Sigur ca exista cativa factori importanti care contribuie la intensitatea efectelor ce pot plana asupra unui copil din cauza internarii in spital: varsta; motivul spitalizarii; temperamentul; persoana care sta internata cu el. Copiii pana la 1 an

pana la un an copiii dezvolta o multime de aptitudini noi; daca ei stau internati o buna parte a timpului in spital pot aparea intarzieri in dezvoltare; pot duce lipsa de stimulare senzoriala care ii ajuta la dezvoltare ca muzica, lumina, pozitii ale corpului, jucarii etc.; daca membrii familiei nu petrec suficient timp cu el la spital, relatiile dintre parinti si copii pot fi afectate. Copiii de la 1 la 2 ani dezvoltarea poate fi intarziata din cauza faptului ca timpul petrecut in spital interfereaza cu activitati care ar fi putut ajuta la stimularea noilor abilitati; pot aparea probleme de somn; dezechilibrele alimentare sunt un efect al schimbarii rutinii de acasa si al stresului; la aceasta varsta copiii se tem foarte tare de straini, iar prezenta asistentelor si doctorilor i-ar putea creste nivelul de anxietate; copiii sunt iritati, frustrati si infricosati pentru ca este greu sa inteleaga la aceasta varsta motivul pentru care sunt in spital. Copiii de 2 la 5 ani principalul impact negativ la copiii de aceste varste este stresul de a fi departe de tot ceea ce le este familiar; pot manifesta o frica de faptul ca procedurile medicale ca injectii, analize etc le poate face rau; pot trai cu impresia ca au facut ceva rau si ca de aceea sunt in spital; ei isi cunosc cat de cat corpul, insa intelegerea modului de functionare a lui este departe de a fi stiuta de ei; acest lucru le poate crea frustrari;

limbajul este dezvoltat intr-o buna masura pana la 5 ani, dar poate exista riscul ca ei sa interpreteze gresit ceea ce aud. Copii de la 5 ani in sus Copiii intre 5-12 ani pot manifesta oricare dintre starile anterior prezentate, plus faptul ca in aceasta perioada ei manifesta obisnuitafrica de doctor, ace sau durere. De asemenea, apare si un disconfort cauzat de invadarea intimitatii, iar pe masura ce cresc incep sa inteleaga ca sufera de o boala grava sau ca ceva rau li se intampla, efectele psihologice fiind mult mai de impact. Cum il poti ajuta sa depaseasca stresul internarii in spital? Pregatirea pentru internare Daca nu este vorba de o urgenta medicala, iar internarea este planificata este recomandat sa il implici pe copil in pregatirea bagajelului si sa vorbesti cu el despre experienta. Daca nu stii cum sa il pregatesti intreaba un medic sau asistentele cum sa faci acest lucru. Retine insa ca tu esti un model pentru el, iar daca iti este frica sau esti mereu trista si suparata, copilul tau va avea tendinta sa preia starile tale. Comunica mereu cu el! Vorbeste-i despre ce va urma si ce se intampla intr-un spital, intr-un vovabular cat mai apropiat varstei lui. Nu incerca sa il minti! Incearca sa raspunzi cat mai eficient la intrebarile pe care ti le adreseaza, iar daca nu stii cum sa o faci la unele dintre ele, nu te panica. Este in regula sa nu stii unele raspunsurile. Spune-i ca medicul ii va raspunde la acele intrebari. Asigura-te ca tot timpul vin in vizita figuri familiare! Familia si prietenii sunt cei care il pot ajuta pe copil sa se simta mai confortabil si in siguranta atunci cand se afla internati in spital. Pe langa faptul ca unul dintre parinti va sta cu el tot timpul, incearca sa planifici vizitele astfel incat

sa acopere o mare parte din zi, pentru ca micutul tau sa fie mai relaxat. Adu-i obiecte familiare de acasa! Pe langa faptul ca spitalul este un mediu necunoscut lui, el este si neprietenos, avand culori terne si reci care cresc nivelul de stres. De aceea este important sa personalizezi rezerva micutului tau cu jucariile preferate si cu alte obiecte aduse de acasa. Incurajeaza-l sa se joace! Atat cat ii este la-ndemana si cat poate din punct de vedere fizic incurajeaza copilul sa se joace pentru a se simti in elementul lui. Joaca ii poate distrage atentia de la boala, durere si anxietate. De asemenea, il ajuta sa se dezvolte corespunzator varstei lui, stimulandu-i creativitateasi alte abilitati.

Atribute de dezvoltare ale copiilor precolari

Exist ase trsturi de dezvoltare ale copiilor precolari care poate afecta pregtirea pentru procedura chirurgical. Precolarii experimenteaz cu lumea din jur n principal prin simuri: ce vd, aud, miros, gust i simt. n a le explica de ce operaia este necesar, prinii i personalul medical pot s utilizeze exemple de cum simptomele vor fi schimbate pozitiv dup operaie. De exemplu, li se poate spune Dup recuperarea de la operaie, vei putea fugi cu prietenii ti fr s mai ai probleme cu respiraia sau s oboseti. Precolarii au o cogniie egocentric: se vd ca centrul universului i sunt convini c toat lumea tie cum se simt. Prin urmare, ar trebui s cerem copiilor s explice propriile simptomele n funcie de experiena lor. De exemplu: Arat-mi sau zi-mi exact unde doare? Pentru a realiza o evaluare corect a durerii, pot fi utilizate scale adaptate copiilor. Precolarii se focuseaz numai pe aspectele evidente ale situaiei lor. n spital ei pot fi uor speriai de maini zgomotoase, mbrcmintea i echipamentul special utilizat de asistente i doctori, iar prinii i personalul medical trebuie s reasigure copilul. Pentru a evita situaii nfricotoare, atenia unui copil poate fi uor distras spre lucruri pozitive precum jucrii moi, muzic sau poze. Copiii precolari nu pot percepe inteniile celorlali. Astfel, nu nelege cum un doctor care i administreaz un tratament dureros i dorete binele. nainte de a ncepe o procedur dureroas i neconfortabil, persoana din echipa medical ar trebui s-i explice bunele intenii. Jocul de rol ar putea fi benefic n aceast situaie. De exemplu, copilul poate fi rugat s explice unei ppui c are nevoie de o injecie i apoi acioneaz n a-i administra ppuii injecia. Ei nu pot gndi n trecut. Prin urmare, procedura creia vor fi supui trebuie explicat secvenial. Adiional, copiii nu au o idee clar asupra timpului. Prinii ar trebui s utilizeze exemple pentru a mbunti nelegerea copilului lor asupra t impului. De exemplu, n loc s i explice copilului c va sta n spital 10 zile, prinii pot s

utilizeze alte repere (ex. dup ce vine bunica n vizit mai stai n spital numai o zi). Precolarii nu neleg diferena dintre cauz i efect. De exemplu, un copil care are un frate mai mare, care a suferit o operaie pe cord, poate considera c este normal ca copiii s fie operai nainte de a ncepe coala. Ali copii pot interpreta operaia ca pe o pedeaps pentru comportamentul reprobabil. Prinii trebuie s discute cu copiii lor pentru a nu corela boala cu comportamente sau atitudini nedorite. Birmingham (Marea Britanie): program de reducere a

anxietii n acest program, un psiholog i un terapeut au lucrat mpreun, utiliznd principii congnitve pentru a reduce anxietate prin de-sensibilizare (i creterea controlului perceput de ctre copil). Durata programului variaz n funcie de vrsta copilului, etapa de dezvoltare, perioada pentru pregtire, experiena, nivelul de anxietate al copilului i al printelui, precum i tipul de intervenie cardiac necesar. Copiii pregtii se prezint mai puin stresai i sunt mai cooperani n timpul procedurilor cardiace, dect cei nepregtii. Prinii i echipa medical par a beneficia de asemenea de pe urma acestei intervenii.

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Medicine > Nursing Medicine > Health care management

An intervention to reduce anxiety/fear in hospitalized Thai school age children


Dissertation Author: Duangrat Kathalae Abstract:

In many Thai hospitals, there is a lack of special psychological preoperative preparation programs for hospitalized Thai children and their families. The purpose of this single-blind, randomized clinical trial was to test the efficacy of a psychological preoperative preparation intervention (PPPI), in the form of a cartoon coloring book, designed to reduce anxiety/fear before surgery in hospitalized Thai school age children 8-11 years old. One hundred and four subjects, hospitalized for surgery, were randomly assigned into either an intervention or control group. Each group received the usual preoperative care given by ward staff. The experimental group received the PPPI given by the investigator. Pre-and posttest anxiety/fear of both groups were measured using the STAIC-R and CMFS-R in Thai versions. Demographic and clinical data, and information on the child's use of meditation were also collected. Descriptive statistics were used to describe demographic and clinical data. A pairedt test demonstrated significant decreases in state anxiety and medical fear means between pre- and postintervention for the experimental group but not for the control group. Hierarchical regression analysis compared

the effect of the PPPI to usual care after controlling for covariate variables. State anxiety at post-intervention was significantly less in the PPPI group than in the usual care group controlling for state- and trait anxiety at preintervention, the child's age, and the child's use of meditation. There was no evidence to support an effect of PPPI on post-intervention medical fear when CMFS and trait anxiety at pre-intervention, the child's age, and the child's use of meditation were controlled. The PPPI appears to be a culturally sensitive intervention for hospitalized Thai school age children. Reading and coloring the cartoon pictures distracted the children from the stressful situations and helped them focus on the content. Age appropriate narrative content in the coloring book may have helped the children assimilate information in a short time period. The possible reasons that could have accounted for the non-significant effect on fear mean scores between groups are the small sample size, the intervention diffusion between groups, and the between-group variation on state anxiety and fear scores. vii TABLE OF CONTENTS Page Dedication ...iii Acknowledgements .iv List of Tables xiii List of Figures......... ..xiv Abstract.......... ....xv Chapter 1 Introduction......................................................................... ............................................1 Research Hypotheses......................................................................... ......................4 Theoretical Framework.......................................................................... ..................5 Definition of

Terms.......... ........5 Overview of Methodology..................... ..........6 Significances...................................................................... ................................10 2 Theoretical Framework and Literature Review.......................................................11 Theoretical Frameworks on Preparing Children for Surgery and Hospitalization.................................................................... .......................11 Cognitive Behavioral Theory (CBT): Stress and Coping Model..........................12 Social Cognitive Theory (SCT)..................................................................... ....13 Lazaruss Anxiety Concept....................................................................... .....15 State-Trait Anxiety Concept.............................................................................. ....17 Transformation of Anxiety into Fear.................................................................18 Relevancy of Stress, Coping, Anxiety, and Fear in the This Study.......................19 viii Page Chapter Piagets Cognitive Development Theory (CDT)...................20 Universal Stage, Childrens Concepts of Physical Illness, and Cross Cultural Variability............................................................................ ......................22 Appropriateness of Theoretical/ Conceptual Frameworks for Preoperative Preparation of Thai School Children.............................22 Anxiety and Fear in School age Children..............................................................25 Childrens Self-report of Anxiety and Fear...........................................................26 Basic Attitudes of Thai Child-rearing Patterns......................................................27 Cultural

Context and Health Care Tradition in Thailand.......................................29 Practicing Meditation among Thai Buddhist Children and Families.....................30 Psychological and Physiological Effects of Hospitalization and Surgery in School age Children.............................................................................. .....32 Importance of Psychological Preoperative Preparation for Pediatric Surgical Patient................................................................................ ........................33 Type and Effectiveness of Psychological Preoperative Interventions...................33 Information and Education Provision....................................................33 Modeling Intervention............................................ ...35 Cognitive Coping................................................................................ .......37 Influencing Factors on the Effectiveness of Psychological Preoperative Preparation Program on School Age Children...............................39 Methodological Constraints of Psychological Preoperative Preparation...............42 ix Page Chapter 3 Methodology... ..................44 Design................................................................................ ................................44 Setting............................................................................. ...................................45 Sample............................................................................ ....................................46 Sampling Frame................................................................................. ........46 Inclusion Criteria.............................. .46 Exclusion Criteria............................................................................ ......46 Sample

Size........................... .....47 Screening and Recruitment........................................................................ 49 Instruments and Measurement...................................................................... .........51 State-Trait Anxiety Inventory for ChildrenRevised (STAIC-R) in Thai Version..........................................................................5 1 Child Medical Fear Scale-Revised (CMFS-R) in Thai Version................52 Psychometric Properties of STAIC-R and CMFS-R in Thai Versions......53 Standard Procedure for Administering the STAIC-R and CMFS-R in Thai Versions............................................................................. 54 Demographic and Clinical Questionnaires................................................56 The Childs Use of Meditation Questionnaire...........................................57 Study Procedures for both the Experimental and Control Groups........................57 Experimental Intervention................... ......62 Psychological Preoperative Preparation Intervention............................................62 x Page Chapter Psychological Preoperative Preparation Intervention (PPPI) Administration..................................................................... ......................63 Benefits of Using the Cartoon Coloring Book as the Modeling Intervention......................................................................... .......................64 Usual Preoperative Care for the Experimental and Control Groups......................66 Data Management and Analysis............................................................................6 6 Data Entry and Verification.......................................................................6 6 Data and Analysis for Research Hypothesis 1 and 2.................67 Data and Analysis for Research

Hypothesis 3...67 Management of Missing Data....................................................................68 Protection of Human Participants......................................................................... .69 4 Results .......71 Sample Descriptive.. ..71 Hypothesis Testing.. ...77 Change in Anxiety/Fear between the Pre-and Post-Intervention Within Groups. ...77 Effectiveness of Cartoon Coloring Book Intervention on Dependent Variables ....79 Summary ....85 5 Discussion .....86 Interpretation and Discussion of Findings.....86 xi Page Change in Anxiety/Fear from Pre-to-PostIntervention by Groups...87 Effectiveness of PPPI Compared to Usual Care88 Comparison of Findings to the Literature......89 Cartoon Coloring Book as a Modeling and Distraction Intervention....89 Influence of Cognitive Ability on the Roles and Expected Behaviors..93 Timing of Preparation.... 94 Possible Reasons for No Group Differences on Fear Variable......95 Small Sample Size.95 Diffusion of Study

Intervention.96 Between-Group Variation on State Anxiety and Fear Scores...97 Cultural Sensitive Intervention..98 Meditation as a Covariate Variable..100 Limitations .......101 Future Research. ..........102 Clinical Implications... .....103 Appendixes Appendix A Potential Subject Screening Sheet ............................................106 Appendix B Informed Consent for Parent or Guardian and Assent for Minor Forms................................................................................. 107 Appendix C Children and Youth Institutional Review Board Approval and Access Letter for Maharat Nakhon Ratchasima Hospital Director............................................................................... .........112 xii Page Appendix D STAIC-R & CMFS-R in English and Thai Languages and Permission Letter.......................................................................116 Appendix E Research Assistant Instructions...................................................127 Appendix F Demographic and Clinical Data Sheet for Subject......................130 Appendix G Demographic and Clinical Data Sheet for Parent or Guardian...132 Appendix H The Childs Use of Meditation....................................................134 Appendix I Cartoon Coloring Book.................................................................135 Appendix J Summary of the Roles and Expected Behaviors in the Cartoon Coloring Book............................................................................148

References............ ...................................151 xiii LIST OF TABLES Table Page 1 Anticipated Time of the PPPI and Measurement........................................................60 2 Number of Pages by Age the Experimental Group Colored on the Cartoon Coloring.. ...65 3 Descriptive Statistics of Demographic and Clinical Characteristics by Study Group ....72 4 Descriptive Statistics of Parent or Guardian Demographic Characteristics by Study Group ...74 5 Number of Days before Surgery and Anxiety Level of Parents or Guardians....76 6 Paired Samples Test within Groups between the Pre-and Post-Intervention..79 7 Regression of PostIntervention S Anxiety on Study Group Controlling for Age, Meditation, and Baseline S-and TAnxiety...81 8 Regression of Post-Intervention CMFS on Study Group Controlling for Age, Meditation, and Baseline CMFS and T-Anxiety...83 9 Frequency of Knowing How to Do Meditation, Regular Practice, and Use after Admission 84 xiv LIST OF FIGURES Figure Page 1 Theoretical and Conceptual Frameworks Application for Designing Intervention....25 2 Study Procedure Flow Chart for Testing the Effectiveness of the Psychological Preoperative Preparation Intervention (PPPI).............................................................61

xv AN INTERVENTION TO REDUCE ANXIETY/FEAR IN HOSPITALIZED THAI SCHOOL AGE CHILDREN Duangrat Kathalae Dr. Mary Ann Jezewski, Dissertation Chair ABSTRACT In many Thai hospitals, there is a lack of special psychological preoperative preparation programs for hospitalized Thai children and their families. The purpose of this single-blind, randomized clinical trial was to test the efficacy of a psychological preoperative preparation intervention (PPPI), in the form of a cartoon coloring book, designed to reduce anxiety/fear before surgery in hospitalized Thai school age children 8- 11 years old. One hundred and four subjects, hospitalized for surgery, were randomly assigned into either an intervention or control group. Each group received the usual preoperative care given by ward staff. The experimental group received the PPPI given by the investigator. Preand posttest anxiety/fear of both groups were measured using the STAIC-R and CMFS-R in Thai versions. Demographic and clinical data, and information on the childs use of meditation were also collected. Descriptive statistics were used to describe demographic and clinical data. A paired-t test demonstrated significant decreases in state anxiety and medical fear means between pre-and post-intervention for the experimental group but not for the control group. Hierarchical regression analysis compared the effect of the PPPI to usual care after xvi controlling for covariate variables. State anxiety at post-intervention was significantly less in the PPPI group than in the usual care group controlling for state-and trait anxiety at pre-intervention, the childs age, and the childs use of meditation. There was no evidence to support an effect of PPPI on post-intervention medical fear when CMFS and trait anxiety at pre-intervention, the childs

age, and the childs use of meditation were controlled. The PPPI appears to be a culturally sensitive intervention for hospitalized Thai school age children. Reading and coloring the cartoon pictures distracted the children from the stressful situations and helped them focus on the content. Age appropriate narrative content in the coloring book may have helped the children assimilate information in a short time period. The possible reasons that could have accounted for the non-significant effect on fear mean scores between groups are the small sample size, the intervention diffusion between groups, and the between-group variation on state anxiety and fear scores. 1 CHAPTER 1 Introduction It is well established that there is a need for psychological preparation of hospitalized children undergoing surgery. Interventions can reduce anxiety and fear producing experiences that could result in short and long term psychological disturbances, emotional and behavior problems in children (Ben-Amitay et al., 2006; Coyne, 2006; Li & Lopez, 2005, 2006; Lumley, Melamed, & Abeles, 1993; Murphy-Taylor, 1999; OConner-Von, 2000; Patel et al., 2006; Strachan, 1993; Tiedeman & Clatworthy, 1990; Vagnoli, Caprilli, Robiglio, & Messeri, 2006; Ziegler & Prior, 1994). Hospitalization can produce stress, anxiety, and fear among pediatric patients irrespective of the reasons for hospitalization. Surgery can be both physically and psychologically threatening for school age children (Bowden, Dickey, & Greenberg, 1998; Wong, 1997). The preoperative period is considered to be a stressful, anxiety-filled time and hospitalized children often experience the highest anxiety prior to surgery which in turn can be a significant factor affecting recovery from surgery (Ellerton & Merriam, 1994; Fortner, 1998). Hospitalized school age children

have to adapt to a new environment and physical changes brought on by hospitalization and surgery (Coyne, 2006; Lizasoain & Polaino, 1995). They also experience separation from their families and peer groups, pain, discomfort, and uncertainty of the outcome (Coyne, 2006; Hart & Bossert, 1994). These stressors could cause emotional and cognitive regression and alter their ability to appraise 2 threat (Lazarus, 1966). A high level of anxiety and fear during hospitalization for surgery could be the end result of these stressors (Ashwill & Droske, 1997). The literature on hospitalized children suggests a consensus among most authors that all school age children need some kind of psychological preparation for the hospital experience, particularly when accompanied by surgery (OConnerVon, 2000). The number of Thai school age children who undergo elective surgery each year has not been officially reported. Although psychological and emotional preparation is an important consideration in Thailand, physiological preparation is the primary concern in many Thai hospitals when Thai school age children are hospitalized for surgery. Each hospital in Thailand appears to have different policies and protocols for hospitalization and preoperative preparation. The variations among these preparation programs are likely a result of unclear and non-empirically based practice. According to the principles of Piagets cognitive developmental theory, the intervention for reducing anxiety and fear in hospitalized school age children before surgery must be designed to be suitable for individual differences in cognitive development (Beckett, 2002). As school age children are developing their cognitive ability in the concrete operational stage (Piaget, 1966), the verbally-based coping techniques such as meditation and the visually-based coping techniques such as distraction, imagery, and modeling depend on

linguistic and visual-spatial skills which are emerging during middle childhood (Cole & Cole, 2001). Not only are school age children better prepared to cope than their younger counterparts, they also respond better to information-based preparation (Kain, et al., 1998; LaMontagne, Hepworth, Cohen, & Salisbury, 2003a). Their reading ability improves from school experiences. If given an 3 appropriately designed intervention within their cognitive ability, school age children are able to read and understand instructions. They are able to readily assimilate and accommodate the new experiences about hospitalization and surgery to adapt by means of their previous experiences (Beckett, 2002; Cole & Cole, 2001). Hospitalized school age children prefer a preparation book for surgery which has pictures and photographs with text (Smith & Callery, 2005). According to social cognitive theory as developed by Bandura (1986a), modeling intervention can benefit school age children by observing the performance of others, especially if the model is similar to their ability, age, gender, and experiences. The cartoon coloring book was used as modeling intervention in this study. The characteristics and the expressions of the children in this cartoon coloring book are a representative model for hospitalized Thai school age children. Observing similar children in the cartoon coloring book performing successfully could raise their capabilities to master comparable activities. Based on the patterns of Thai child rearing, basic attitudes, health care tradition in Thai hospitals, and other cultural contexts such as using meditation as the first choice of a coping strategy among Thai Buddhist families, this cartoon coloring book was a culturally sensitive intervention for hospitalized Thai school age children. This culturally sensitive intervention was used as a psychological preoperative preparation intervention (PPPI) during this

study. The design mainly focused on supporting, guiding, and encouraging hospitalized Thai school age children to use appropriate ways in reducing anxiety and fear before surgery such as asking question, expressing and sharing of how they feel with their families, friends, doctors, or nurses. Coloring the pictures during the 4 waiting period for surgery distracted them from other stressful situations (Wollin, Plummer, Hawkins, Materazzo, & Morrison, 2004). Hospitalization and surgery have many adverse psychological effects on school age children that may be prevented or minimized by psychological preoperative intervention procedures (Gillis, 1990). The major goals of a psychological preoperative preparation intervention are to reduce unknown fear and decrease the unavoidable stresses and anxiety associated with surgery (Ball & Bindler, 1995; Freeland & Munro, 1995). The purpose of this study was to test the efficacy of a psychological preoperative preparation intervention (PPPI) designed to reduce anxiety/fear in hospitalized Thai school age children 8 to 11 years old undergoing elective surgery. The research questions to be addressed were (1) Is there a change in anxiety/fear from pre- to post- intervention for the experimental and control groups? , and (2) What is the effect of PPPI on anxiety/fear at post-intervention as compared to usual care (control group) controlling for the covariate variables: S-anxiety, T-anxiety, and fear from Child Medical Fear Scale (CMFS) at pre-intervention, the childs age, and a childs use of meditation? Research Hypotheses Hypothesis 1 Hospitalized Thai school age children 8 to 11 years old, who receive the PPPI, have significantly less anxiety/fear the evening before surgery (post-intervention) than the first hour after admission (preintervention).

5 Hypothesis 2 Hospitalized Thai school age children 8 to 11 years old, who receive standard preoperative preparation, have the same or greater anxiety/fear the evening before surgery than the first hour after admission. Hypothesis 3 Hospitalized Thai school age children 8 to 11 years old, who receive the PPPI, have significantly less anxiety/fear the evening before surgery (post-intervention) than those in the control group controlling for S-anxiety, T-anxiety, and fear from Child Medical Fear Scale (CMFS) at pre-intervention, the childs age, and the childs use of meditation. Theoretical Framework This study was based on theoretical frameworks comprised of elements of cognitive behavioral theory (CBT), which focuses on a stress and coping model as articulated by Lazarus and colleagues (Lazarus, 1966; Lazarus & Folkman, 1984), social cognitive theory (SCT), which focuses on modeling as developed by Bandura (1986a), the concrete operational stage from Piagets cognitive developmental theory (CDT) (Piaget, 1966), and state-trait conception of anxiety by Spielberger (1973). Definition of Terms Anxiety/Fear An individuals total reaction to perceived threat or danger that involves subjective feelings of apprehension, uneasiness, agitation, uncertainty, and fear, heightened autonomic nervous system activities, and avoidance behavior. In this study, anxiety is defined as synonymous with fear. Anxiety/fear was measured by the Thai 6 Versions of the State-Trait Anxiety Inventory for Children-Revised (STAIC-R) and the Child Medical Fear Scale-Revised (CMFS-R). Thai School age Children Thai children between 8 and 11 years old Psychological Preoperative Preparation Intervention (PPPI) An intervention designed to reduce anxiety/fear by use of a cartoon coloring book developed with considerations for the level of cognitive development of Thai school age

children 8 to 11 years old and of their culture. Elective Surgery Non- emergency surgery that is scheduled at least 24 hours before hospitalization and where the pediatric patients have to stay overnight in hospital. Overview of Methodology The randomized, true experimental, pretest-posttest control group, and singleblind design was used to investigate the effectiveness of the PPPI for reducing anxiety/fear before surgery in hospitalized Thai school age children 8 to 11 years old. The design was a comparison study between an experimental group in which each child received standard preoperative preparation (SPP) from pediatric surgical ward staff and the PPPI from the investigator and a control group where each child received only SPP. The setting was the pediatric surgery ward in a tertiary hospital in the Northeastern part of Thailand, Maharat Nakhon Ratchasima Hospital, located in the metropolitan area of Nakhon Ratchasima province. Sample size predictions employed the use of power analysis for the analysis of covariance (ANCOVA). The following parameters were used (a) probability of a type 7 one error of .05, (b) a power of .80, and (c) a medium effect size of .25. Based on these parameters, a sample size of 64 in each group allowed the detection of postintervention anxiety and fear-mean score differences, if present, due to the PPPI between the experimental and control groups with four covariates (Cohen, 1988; YowWu B. Wu, personal communication, November 1, 2005). A medium effect size has been chosen for the study based on previous studies of Bossert (1994), Hart and Bossert (1994), and Lizasoain and Polaino (1995). By using the SPSS program, the 128 predicted subjects were to be randomly assigned into the experimental or control group by the investigator prior to consent and data collection. The random assignment for allocating subjects into groups was processed and recorded by the

investigator. The results of random assignment were not disclosed to the research assistant who then administered the measurement instruments. The inclusion criteria for selecting Thai school age children who were scheduled to undergo elective surgery were (1) Thai school age children between 8 and 11 years old, (2) anticipated hospital stay of at least 24 hours, (3) admission into the hospital the day before surgery, (4) ability to read and speak the Thai language, (5) normal cognitive ability as determined by age-appropriate grade, (6) the parent or guardian is present during admission, and 7) patient has no previous experience of hospitalization. The exclusion criteria were Thai school age children 8 to 11 years old who (1) have cognitive impairment, (2) have physical or psychological conditions that are not appropriate to participating in the PPPI, such as blindness, deafness, mental retardation, or psychiatric conditions, or (3) have a psychological condition requiring consultation with a specialist or special care. The final sample size of this study was 104 participants. There were 53 subjects in the 8 experimental group and 51 participants in the control group which was lower than expected, based on the power analysis and previous studies (Bossert, 1994; Hart & Bossert, 1994; Lizasoain & Polaino, 1995). The Thai Versions of the State-Trait Anxiety Inventory for ChildrenRevised (STAIC-R) and the Child Medical Fear ScaleRevised (CMFS-R), which were revised, translated, and psychometrically tested by Chaiyawat (2000), were used to measure anxiety/fear pre-and post-intervention. Descriptive statistics were used to describe all demographic and clinical data and the childs use of meditation. To test for the effectiveness of the PPPI, the null hypotheses were rejected at the p < .05 level for all of the hypotheses. The following statistical procedures were used for testing each research hypothesis. Hypothesis 1

The effect of the PPPI on the levels of anxiety/fear of hospitalized Thai school age children 8 to 11 years old undergoing elective surgery was examined within the experimental group. The two-tailed dependent t-test (paired t-test) was used to examine the differences in means from the S-Anxiety scale and CMFS between the pre- intervention (the first hour after admission) and the post-intervention (the evening before surgery) to determine if changes have taken place within the experimental group. Hypothesis 2 The differences of means from the S-Anxiety scale and CMFS between the first hour after admission and the evening before surgery of hospitalized Thai school age children 8 to 11 years old who received standard preoperative preparation were examined 9 by using the two-tailed dependent t-test (paired t-test) to determine if changes have taken place within the control group. Hypothesis 3 The effects of the PPPI on the levels of anxiety/fear of hospitalized Thai school age children 8 to 11 years old undergoing elective surgery were examined between the experimental and control groups at the post-intervention (the evening before surgery). The analysis of covariance (ANCOVA) and the hierarchical multiple linear regression analysis were applied to determine the differences of means from the SAnxiety scale and CMFS between the experimental and control groups at the post-intervention to determine if changes have taken place between groups when Sanxiety, T-anxiety, and fear from Child Medical Fear Scale (CMFS) at pre-intervention, the childs age, and the childs use of meditation were controlled. ANCOVA was used to control for the childs use of meditation since meditation has been reported as a common coping strategy in Thai school age children (Chaiyawat, 2000; Chaiyawat & Jezewski, 2006). The proposed study planned to use the following covariate variables: S-

anxiety, T-anxiety, and fear from Child Medical Fear Scale (CMFS) at pre-intervention, and the childs use of meditation, to determine the effectiveness of cartoon coloring book intervention on the levels of anxiety/fear of hospitalized Thai school age children when conducted ANCOVA. Because the age distributions between and within study groups were not equivalent. The nonequivalence regarding age differences may have had some impact on the analysis results; therefore, age variable was treated as one of the covariate variables. The method of hierarchical multiple linear regression analysis was applied to test the third research hypothesis. Analyses did not 10 differ based on use of ANCOVA or multiple regressions, so only results using multiple regressions are presented in Chapter 4. Significances This study focused on developing and determining the effects of a culturally appropriate intervention for reducing anxiety/fear in hospitalized Thai school age children 8 to 11 years old undergoing elective surgery. Psychological preoperative preparation does not exist for hospitalized Thai school age children undergoing elective surgery. The intervention used in this study was appropriately developed with consideration for the level of cognitive development of Thai school age children 8 to 11 years old and of their culture. This intervention has the potential to be a useful intervention in a variety of health care settings in Thailand that provide elective surgical care for Thai school age children. The intervention was designed to be easy to use and cost effective. The available time for preparing children before elective surgery is very limited. This intervention is very easy to use by any health care provider with a minimum amount of training. Finally, the levels of anxiety/fear were measured by using the State-Trait Anxiety Intervention for Children-Revised (STAIC-R) and Child Medical Fear Scale-Revised

(CMFS-R) in Thai versions. These two instruments possess satisfactory psychometric properties; therefore, they are appropriate instruments to assess anxiety/fear in Thai school age children. 11 CHAPTER 2 Theoretical Framework and Literature Review Psychological preoperative preparation is important for hospitalized Thai school age children because negative impacts of hospitalization and surgery on children can be prevented or minimized. Theoretical and conceptual frameworks, which are related to the psychological preoperative preparation of hospitalized Thai school age children 8 to 11 years old, including the appropriateness of theoretical and conceptual frameworks for Thai school age children were reviewed. The universal stage, childrens concepts of physical illness, and cross cultural variability were discussed. The state and trait anxiety concepts, the transformation of anxiety into fear, childrens self-report of anxiety and fear, the relevancy of stress, coping, anxiety, and fear, including anxiety and fear in school age children, were presented. Cultural context, basic attitude of Thai child-rearing patterns, health care tradition in Thailand, and practicing meditation among Thai Buddhist children and family were also reviewed. Psychological and physiological effects of hospitalization and surgery in school age children, types, effectiveness, and influencing factors on the effectiveness of psychological preoperative preparation including methodological constraints of psychological preoperative preparation to inform the this study design were discussed. Theoretical Frameworks on Preparing Children for Surgery and Hospitalization Three theoretical frameworks, the cognitive behavioral theory (CBT), which focuses on the stress and coping model, the social cognitive theory (SCT), which focuses

12 on modeling, and Piagets cognitive developmental theory (CDT), which focuses on the concrete cognitive developmental stage in school age children including Lazaruss anxiety concept and state-trait anxiety concepts, were used to guide the study. Cognitive Behavioral Theory (CBT): Stress and Coping Model The conceptual framework of stress and coping offered by Lazarus (1966) consists of three processes: primary appraisal, secondary appraisal, and coping process. Primary appraisal is the process of perceiving a threat to oneself. Secondary appraisal is the process of bringing to mind a potential response to the threat. Coping is the process of executing that response. Stressful experiences are construed as person-environment transactions, in which the impact of an external stressor or demand is mediated by the persons appraisal of the stressor and the psychological, social, and cultural resources at his or her disposal. When faced with a stressor, a person evaluates the potential threat (primary appraisal) as well as his or her ability to alter the situation and manage negative emotional reactions (secondary appraisal). A persons perception of mental and physical health is related to the ways he or she evaluates and copes with the stresses of living (Lazarus, 1966; Lazarus & Cohen, 1977; Lazarus & Folkman, 1984). Three broad categories of individual differences in coping variables were described: coping resources, coping styles, and coping strategies or efforts. Coping resources refer to relatively stable characteristics of the individual that influence how individuals cope in specific situations such as temperamental or personality characteristics. Coping styles refer to typical or habitual preferences for ways of approaching problems. Coping efforts or strategies refer to cognitive and behavioral actions in a specific stressful situation which are intended to manage affective arousal or

13 improve the problematic situation. Coping efforts continue overtime and may change in response to the changing demands of the situation (Ayers, Sandler, West, & Roosa, 1996; Carver, Scheier, & Weintraub, 1989; Lazarus & Folkman, 1984; Menaghan, 1983; Sandler, Wolchik, MacKinnon, Ayers, & Roosa, 1997). Avoiding is the most common coping strategy when Thai school age children encounter with fearful situations. Other coping strategies were also reported such as searching for protection and security, being with a companion, talking about their fear, distracting, and controlling their thoughts. Among these coping strategies, meditation was reported as one of the coping strategies that Thai school age children used when they experience fear (Chaiyawat & Jezewski, 2006). The concepts of stress and coping of the cognitive behavioral theory were used to design the Psychological Preoperative Preparation Intervention (PPPI) in this study. The narrative short content in the cartoon coloring book, which was used to conduct the PPPI, presented the roles and expected behaviors which are essential for reducing stress in hospitalized Thai school age children. The narrative short content in the cartoon coloring book also suggested coping strategies which are appropriate in terms of cultural context in reducing anxiety/fear in hospitalized Thai school age children. Social Cognitive Theory (SCT) Social cognitive theory as developed by Bandura (1986a) is largely a cognitive theory but incorporates principles of behaviorism. Behavior is regulated by expectations for similar outcomes on future occasions (Redman, 2001). Much behavior is motivated and regulated by internal standards and self-evaluative reactions to the individuals own actions, including self-incentives and self-efficacy. Judgments of self-efficacy are
Full document contains 181 pages Abstract: In many Thai hospitals, there is a lack of special psychological preoperative preparation programs for hospitalized Thai children and their families. The purpose of this single-blind,

randomized clinical trial was to test the efficacy of a psychological preoperative preparation intervention (PPPI), in the form of a cartoon coloring book, designed to reduce anxiety/fear before surgery in hospitalized Thai school age children 8-11 years old. One hundred and four subjects, hospitalized for surgery, were randomly assigned into either an intervention or control group. Each group received the usual preoperative care given by ward staff. The experimental group received the PPPI given by the investigator. Pre-and posttest anxiety/fear of both groups were measured using the STAIC-R and CMFS-R in Thai versions. Demographic and clinical data, and information on the child's use of meditation were also collected. Descriptive statistics were used to describe demographic and clinical data. A paired-t test demonstrated significant decreases in state anxiety and medical fear means between pre- and post-intervention for the experimental group but not for the control group. Hierarchical regression analysis compared the effect of the PPPI to usual care after controlling for covariate variables. State anxiety at postintervention was significantly less in the PPPI group than in the usual care group controlling for state- and trait anxiety at pre-intervention, the child's age, and the child's use of meditation. There was no evidence to support an effect of PPPI on post-intervention medical fear when CMFS and trait anxiety at pre-intervention, the child's age, and the child's use of meditation were controlled. The PPPI appears to be a culturally sensitive intervention for hospitalized Thai school age children. Reading and coloring the cartoon pictures distracted the children from the stressful situations and helped them focus on the content. Age appropriate narrative content in the coloring book may have helped the children assimilate information in a short time period. The possible reasons that could have accounted for the nonsignificant effect on fear mean scores between groups are the small sample size, the intervention diffusion between groups, and the between-group variation on state anxiety and fear scores.
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Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling. By Melamed, Barbara G.; Siegel, Lawrence J.
Journal of Consulting and Clinical Psychology, Vol 43(4), Aug 1975, 511-521.

Abstract 60 4-12 yr old children about to undergo elective surgery for hernias, tonsillectomies, or urinary-genital tract difficulties were shown on hospital admission either a relevant peer modeling film of a child being hospitalized and receiving surgery or an unrelated control film. Both groups received extensive preparation by the hospital staff. State measures of anxiety, including the Hospital Fears Rating Scale, the Observer Rating Scale of Anxiety, and Palmar Sweat Index, revealed a significant reduction of preoperative (night before) and postoperative (3-4 wk postsurgery examination) fear arousal in the experimental as compared to the control film group. The parents reported a significant posthospital increment in the frequency of behavior problems in the children who

had not seen the modeling film. Trait measures of anxiety (e.g., Children's Manifest Anxiety Scale and the Human Figure Drawing Test) did not reflect the group differences due to the hospital experience. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)

An examination of the anxiety responses of 5to 11-year-old children during and after hospitalization
1988 1988

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Abstract(summary)

This study examined the anxiety responses of 5- to 11-year-old children (N = 52) during and after hospitalization. Change in anxiety over time was examined as was the relationship between children's anxiety and age, gender, length of hospitalization, previous admission, and parental anxiety. Data were collected from the children and their parents at admission, discharge, and 7 to 14 days posthospitalization. Children's anxiety was measured using the Child Drawing Hospital, the Child Rating of Anxiety, and the State Anxiety Inventory for Children (8 to 11 years only), and data were analyzed using repeated measures analyses of variance, stepwise multiple regression, and Pearson r correlations. The children demonstrated a decrease in anxiety from admission to discharge and from admission to posthospitalization. Anxiety remained relatively constant from discharge to posthospitalization. Age, gender, and previous admission were related to the level of children's anxiety with younger children (5 to 7 years), boys, and children not previously admitted being more anxious and not showing a decrease in anxiety overtime. Shorter hospital stays were associated with higher levels of anxiety, and there were positive and negative relationships between parental anxiety and the various measures of children's anxiety. Data indicate that hospitalization is an anxiety-producing experience with anxiety continuing posthospitalization. Also some children are more vulnerable for higher levels of anxiety. These children may need different or more intense nursing intervention.