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Internarea in spital a copilului, efecte
emotionaleautor: Daniela Ganciu
26 Noiembrie 2010
4
Internarea in spital a copilului presupune schimbareamediului familiar intr-unul care nu este intotdeauna cel maiprimitor. Sa stai in spital cu copilul poate fi destul de dificilpentru el la orice varsta. Atat spitalul, cat si boala reprezintafactori de stres puternici pentru micutul tau. El poateinterveni in dezvoltarea lui normala si il poate afecta petermen lung.
A interna copilul in spital inseamna practic intreruperea viatiilui obisnuite si schimbarea ambientului confortabil in careera obisnuit pana atunci. Cand sunt in spital copiii resimtlipsa casei, a prietenilor si a altor membrii ai familiei care nusunt cu el.
Pe langa stresul inevitabil care apare la copiii internati,acestia pot dezvolta sentimente de frica sauchiarplictisealaceea ce ii poate face usor iritabili si agitati.Ei nu inteleg foarte bine de ce anume este acolo si nici ceanume se intampla in incinta unui spital, ceea ce ii poatecrea frustrari si temeri.
Ce efecte are spitalul asupra copiilor de diferite
varste?
Sigur ca exista cativa factori importanti care contribuie laintensitatea efectelor ce pot plana asupra unui copil dincauza internarii in spital:
varsta;
motivul spitalizarii;
temperamentul;
persoana care sta internata cu el.
Copiii pana la 1 an
http://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.htmlhttp://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.htmlhttp://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.htmlhttp://www.copilul.ro/copii-1-2-ani/joc-jucarii/Alunga-plictiseala-copilului-tau-Activitati-distractive-a6119.html -
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pana la un an copiii dezvolta o multime de aptitudininoi; daca ei stau internati o buna parte a timpului inspital pot aparea intarzieri in dezvoltare;
pot duce lipsa de stimulare senzoriala care ii ajuta ladezvoltare ca muzica, lumina, pozitii alecorpului,jucariietc.;
daca membrii familiei nu petrec suficient timp cu el laspital, relatiile dintre parinti si copii pot fi afectate.
Copiii de la 1 la 2 ani
dezvoltarea poate fi intarziata din cauza faptului catimpul petrecut in spital interfereaza cu activitaticare ar fi putut ajuta la stimularea noilor abilitati;
pot aparea probleme de somn;
dezechilibrele alimentare sunt un efect al schimbariirutinii 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 estegreu sa inteleaga la aceasta varsta motivul pentrucare sunt in spital.
Copiii de 2 la 5 ani
principalul impact negativ la copiii de aceste varsteeste stresul de a fi departe de tot ceea ce le este
familiar;
pot manifesta o frica de faptul ca procedurilemedicale ca injectii, analize etc le poate face rau;
pot trai cu impresia ca au facut ceva rau si ca deaceea sunt in spital;
ei isi cunosc cat de cat corpul, insa intelegereamodului de functionare a lui este departe de a fi
stiuta de ei; acest lucru le poate crea frustrari;
http://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.htmlhttp://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.htmlhttp://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.htmlhttp://magazin.copilul.ro/catalog/lumea-copiilor/jucarii-jocuri-educative.html -
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limbajul este dezvoltat intr-o buna masura pana la 5ani, dar poate exista riscul ca ei sa interpretezegresit ceea ce aud.
Copii de la 5 ani in sus
Copiii intre 5-12 ani pot manifesta oricare dintre starileanterior prezentate, plus faptul ca in aceasta perioada eimanifesta obisnuitafrica de doctor, ace sau durere.
De asemenea, apare si un disconfort cauzat de invadareaintimitatii, iar pe masura ce cresc incep sa inteleaga casufera 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 internareaeste planificata este recomandat sa il implici pe copil inpregatirea bagajelului si sa vorbesti cu el despre experienta.
Daca nu stii cum sa il pregatesti intreaba un medic sauasistentele cum sa faci acest lucru. Retine insa ca tu esti unmodel pentru el, iar daca iti este frica sau esti mereu tristasi 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-unspital, intr-un vovabular cat mai apropiat varstei lui. Nuincerca sa il minti! Incearca sa raspunzi cat mai eficient la
intrebarile pe care ti le adreseaza, iar daca nu stii cum sa ofaci la unele dintre ele, nu te panica. Este in regula sa nu stiiunele raspunsurile. Spune-i ca medicul ii va raspunde laacele intrebari.
Asigura-te ca tot timpul vin in vizita figuri familiare!
Familia si prietenii sunt cei care il pot ajuta pe copil sa sesimta mai confortabil si in siguranta atunci cand se aflainternati in spital. Pe langa faptul ca unul dintre parinti va
sta cu el tot timpul, incearca sa planifici vizitele astfel incat
http://www.copilul.ro/comunicare-copii/emotiile-copiilor/Frica-de-medic-a2252.htmlhttp://www.copilul.ro/comunicare-copii/emotiile-copiilor/Frica-de-medic-a2252.htmlhttp://www.copilul.ro/comunicare-copii/emotiile-copiilor/Frica-de-medic-a2252.html -
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sa acopere o mare parte din zi, pentru ca micutul tau sa fiemai relaxat.
Adu-i obiecte familiare de acasa!
Pe langa faptul ca spitalul este un mediu necunoscut lui, eleste si neprietenos, avand culori terne si reci care crescnivelul de stres. De aceea este important sa personalizezirezerva micutului tau cu jucariile preferate si cu alte obiecteaduse de acasa.
Incurajeaza-l sa se joace!
Atat cat ii este la-ndemana si cat poate din punct de vederefizic incurajeaza copilul sa se joace pentru a se simti inelementul lui. Joaca ii poate distrage atentia de la boala,durere si anxietate. De asemenea, il ajuta sa se dezvoltecorespunzator varstei lui, stimulandu-icreativitateasi alteabilitati.Atribute de dezvoltare ale copiilor precolari
Exist ase trsturi de dezvoltare ale copiilor precolari care poateafecta pregtirea pentru procedura chirurgical.
Precolarii experimenteaz cu lumea din jur n principal prinsimuri: ce vd, aud, miros, gust i simt. n a le explica de ceoperaia este necesar, prinii i personalul medical pot sutilizeze exemple de cum simptomele vor fi schimbate pozitiv dupoperaie. De exemplu, li se poate spune Dup recuperarea de laoperaie, vei putea fugi cu prietenii ti fr s mai ai probleme curespiraia sau s oboseti.
Precolarii au o cogniie egocentric: se vd ca centrul universuluii sunt convini c toat lumea tie cum se simt. Prin urmare, artrebui s cerem copiilor s explice propriile simptomele n funciede experiena lor. De exemplu: Arat-mi sau zi-mi exact undedoare? Pentru a realiza o evaluare corect a durerii, pot fi utilizatescale adaptate copiilor.
Precolarii se focuseaz numai pe aspectele evidente ale situaieilor. n spital ei pot fi uor speriai de maini zgomotoase,mbrcmintea i echipamentul special utilizat de asistente idoctori, iar prinii i personalul medical trebuie s reasigure
copilul. Pentru a evita situaii nfricotoare, atenia unui copilpoate fi uor distras spre lucruri pozitive precum jucrii moi,muzic sau poze.
Copiii precolari nu pot percepe inteniile celorlali. Astfel, nunelege cum un doctor care i administreaz un tratament durerosi dorete binele. nainte de a ncepe o procedur dureroas ineconfortabil, persoana din echipa medical ar trebui s-i explicebunele intenii. Jocul de rol ar putea fi benefic n aceast situaie.De exemplu, copilul poate fi rugat s explice unei ppui c arenevoie de o injecie i apoi acioneaz n a-i administra ppuiiinjecia.
Ei nu pot gndi n trecut. Prin urmare, procedura creia vor fisupui trebuie explicat secvenial. Adiional, copiii nu au o ideeclar asupra timpului. Prinii ar trebui s utilizeze exemple pentrua mbunti nelegerea copilului lor asupra timpului. De exemplu,n loc s i explice copilului c va sta n spital 10 zile, prinii pot s
http://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.htmlhttp://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.htmlhttp://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.htmlhttp://www.copilul.ro/comunicare-copii/inteligenta-copii/Cum-dezvoltam-creativitatea-copilului-a1923.html -
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utilizeze alte repere (ex. dup ce vine bunica n vizit mai stai nspital 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 pecord, poate considera c este normal ca copiii s fie operai naintede a ncepe coala. Ali copii pot interpreta operaia ca pe opedeaps pentru comportamentul reprobabil. Prinii trebuie sdiscute cu copiii lor pentru a nu corela boala cu comportamentesau 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 reduceanxietate prin de-sensibilizare (i creterea controluluiperceput de ctre copil). Durata programului variaz nfuncie de vrsta copilului, etapa de dezvoltare, perioadapentru pregtire, experiena, nivelul de anxietate alcopilului i al printelui, precum i tipul de intervenie
cardiac necesar. Copiii pregtii se prezint mai puinstresai i sunt mai cooperani n timpul procedurilorcardiace, dect cei nepregtii. Prinii i echipa medicalpar a beneficia de asemenea de pe urma acesteiintervenii.
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An interventio Search
Medicine>Nursing
Medicine>Health care management
An intervention toreduce anxiety/fear inhospitalized Thai
school age childrenDissertation
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 posttestanxiety/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 thecontrol group. Hierarchical regression analysis compared
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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 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 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
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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.................................................................18Relevancy 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
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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 PreoperativePreparation...............42
ix Page Chapter 3
Methodology...
..................44
Design................................................................................
................................44
Setting.................................................. ...........................
...................................45
Sample............................................................................
....................................46 Sampling
Frame.................................................................................
........46 Inclusion
Criteria..............................
.46 Exclusion
Criteria............................................................................
......46 Sample
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Size...........................
.....47 Screening and
Recruitment........................................................................
49 Instruments and
Measurement......................................................................
.........51 State-Trait Anxiety Inventory for Children-
Revised (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
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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 5Discussion
.....86 Interpretation and Discussion of
Findings.....86
xi Page Change in Anxiety/Fear from Pre-to-Post-
Intervention 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
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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
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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 Post-
Intervention S Anxiety on Study Group Controlling for
Age, Meditation, and Baseline S-and T-
Anxiety...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 afterAdmission
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
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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 coloringbook, 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 measuredusing 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 whenCMFS and trait anxiety at pre-intervention, the childs
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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 patientsirrespective 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
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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
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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 (pre-
intervention).
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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 ofanxiety 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
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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 single-
blind 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 followingparameters 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 post-
intervention anxiety and fear-mean score differences, if
present, due to the PPPI between the experimental and
control groups with four covariates (Cohen, 1988; Yow-
Wu 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
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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. Therewere 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 Children-
Revised (STAIC-R) and the Child Medical Fear Scale-
Revised (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
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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 S-
Anxiety scale and CMFS between the experimental and
control groups at the post-intervention to determine if
changes have taken place between groups when S-
anxiety, 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-
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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 non-
equivalence 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
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(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 socialcognitive theory (SCT), which focuses
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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 situationand 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 torelatively 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
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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 whichare 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 ofbehaviorism. 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 specialpsychological preoperative preparation programs for hospitalized
Thai children and their families. The purpose of this single-blind,
-
7/27/2019 Internarea in Spital a Copilului
27/28
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 groupreceived 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 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 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.
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Reduction of anxiety in children facinghospitalization and surgery by use of filmedmodeling.By Melamed, Barbara G.; Siegel, Lawrence J.Journal of Consulting and Clinical Psychology, Vol 43(4), Aug 1975, 511-521.
Abstract60 4-12 yr old children about to undergo elective surgery
for hernias, tonsillectomies, or urinary-genital tractdifficulties were shown on hospital admission either arelevant peer modeling film of a child being hospitalizedand receiving surgery or an unrelated control film. Bothgroups received extensive preparation by the hospitalstaff. State measures of anxiety, including the HospitalFears Rating Scale, the Observer Rating Scale ofAnxiety, and Palmar Sweat Index, revealed a significantreduction of preoperative (night before) and postoperative(3-4 wk postsurgery examination) fear arousal in theexperimental as compared to the control film group. The
parents reported a significant posthospital increment inthe frequency of behavior problems in the children who
http://help.udini.proquest.com/http://udini.proquest.com/about/us/http://udini.proquest.com/about/us/http://proquest.com/go/privacyhttp://proquest.com/go/privacyhttp://udini.proquest.com/about/terms/http://udini.proquest.com/about/terms/http://udini.proquest.com/about/cookies/http://udini.proquest.com/about/cookies/http://udini.proquest.com/about/cookies/http://help.udini.proquest.com/customer/portal/emails/newhttp://help.udini.proquest.com/customer/portal/emails/newhttp://twitter.com/proquest_udinihttp://twitter.com/proquest_udinihttp://twitter.com/proquest_udinihttp://help.udini.proquest.com/customer/portal/emails/newhttp://udini.proquest.com/about/cookies/http://udini.proquest.com/about/cookies/http://udini.proquest.com/about/terms/http://proquest.com/go/privacyhttp://udini.proquest.com/about/us/http://help.udini.proquest.com/ -
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had not seen the modeling film. Trait measures of anxiety(e.g., Children's Manifest Anxiety Scale and the HumanFigure Drawing Test) did not reflect the group differencesdue to the hospital experience. (46 ref) (PsycINFODatabase Record (c) 2012 APA, all rights reserved)
An examination of the anxiety responses of 5-to 11-year-old children during and afterhospitalization
1988 1988
Other formats: Order a copy
Abstract(summary)
This study examined the anxiety responses of 5- to 11-year-oldchildren (N = 52) during and after hospitalization. Change inanxiety over time was examined as was the relationship betweenchildren's anxiety and age, gender, length of hospitalization,previous admission, and parental anxiety. Data were collected fromthe children and their parents at admission, discharge, and 7 to 14days posthospitalization. Children's anxiety was measured usingthe Child Drawing Hospital, the Child Rating of Anxiety, and the
State Anxiety Inventory for Children (8 to 11 years only), and datawere analyzed using repeated measures analyses of variance,stepwise multiple regression, and Pearson r correlations. Thechildren demonstrated a decrease in anxiety from admission todischarge and from admission to posthospitalization. Anxietyremained relatively constant from discharge to posthospitalization.Age, gender, and previous admission were related to the level ofchildren's anxiety with younger children (5 to 7 years), boys, andchildren not previously admitted being more anxious and notshowing a decrease in anxiety overtime. Shorter hospital stayswere associated with higher levels of anxiety, and there werepositive and negative relationships between parental anxiety andthe various measures of children's anxiety. Data indicate thathospitalization is an anxiety-producing experience with anxietycontinuing posthospitalization. Also some children are morevulnerable for higher levels of anxiety. These children may needdifferent or more intense nursing intervention.
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