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Play as a Means of Helping Children Cope with Fear of Medical Interventions

Summary:
Like adults, children fear things they don't understand and cannot control. Children need to be told or shown through play what is going to happen and what the results will be. We need to know how children interpret our explanations and to correct misconceptions. Children need to master their fears so that the fears do not cause life-long consequences. Play is a means of addressing these concerns. During play a child controls his/her environment and this bolsters his/her self-confidence.
Japanese

A high-light of my life was working as a Child Life Specialist with Emma N. Plank. (1&2) Plank created the Child Life and Education Program to address the non-medical needs of hospitalized children at MetroHealth Center, Cleveland, Ohio. I learned the importance of addressing children's fears (anxieties) and helping children master their fears. In Vienna Plank received training from Maria Montessori, physician and pioneer teacher, and Anna Freud, daughter of Sigmund Freud who applied his ideas to the psychoanalysis of children. Plank brought an understanding of emotions and stages of child development to our program. The illustrations for this article stem from that experience.


Causes and ramifications of fear - "Children, (and most people) are afraid of things that they cannot understand or control, and strange or new situations or objects."(3) "Young children have more fears and phobias than adults, and experience the emotion of them more intensely." (4) Children have vivid imaginations. "...the heart rate and breathing rate get faster and the person may turn pale, perspire, have an unpleasant feeling in his stomach ('butterflies') or feel shaky." (3) The child may cry, protest, withdraw, lose interest in people and play or may act out. Some fears arise because of direct experiences, such as being bitten by a dog. "Adults also teach children to fear..." (4) For example if their mother shows fear of needles during the child's visit to the doctor, the child is likely to develop this fear. Seeing violence on TV and hearing about dangers can also precipitate fears.

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Terrified child clutches belongings


What children need - Above all children need to feel safe. They need to be informed with words or through play about what is going to happen and what it will be like once the intervention is over. "Knowing helps make children less fearful." (2) The child should be helped through conversations and play to master his fear, and be complimented following each step toward his/her mastery. "Research has shown that failure to identify these early (fears) can lead to a variety of problems later in life." (5) He/she "has to feel the fear in order to shed it," (2) and this can be helped through play. Play can desensitize. During play the child exercises control over his environment, which builds his self confidence, and the confidence extends to other aspects of personality.

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Johnny's play may relieve his homesickness


Play - a means of counteracting the fears around separation and fears of abandonment. Adults separated from loved ones, often talk about those they miss. Talk satisfies an emotional need and makes them feel close. Young children don't have the vocabulary to tell these stories, but they do experience frightening feelings. In the playroom Nancy loved to wash the doll's hair, comb it and then pretend to cook dinner. She relived the comforting feelings when her mother tended to her hair, maybe visualized Mother in the kitchen and thus reassured herself. Ideally her mother or caregiver had told her when she would return, had brought a comfort toy for Nancy to hold, left pictures of the family or some trinket that reminded Nancy of home. And likely the nurse or Child Life Specialist held Nancy or gave her attention. Ideally Nancy was situated to see and play with other children when she felt up to it.

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Nancy reenacts mother's care

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Children help each other


Play - preparing children for new, frightening experiences. Roy, the name I'll call our son, had dietary problems. I listed foods that upset his tummy. When he was two and a half years old, our Pediatrician suggested that Roy might have celiac disease (unable to digest wheat, rye, oats and barley), and the doctor considered scheduling a biopsy of Roy's small intestine. If the intestine showed irregularities, the doctor's supposition was correct. Both the doctor and I were reluctant to put this little fellow through surgery, and so we opted to give him barium and x-ray the results. If the x-ray showed a smooth barium coating of the intestine, it indicated he likely had the celiac condition, and then Roy would be put on a celiac diet to observe his reaction. I planned to prepare him for this procedure. We played that he was the doctor examining me. He remembered our last visit to the doctor and gleefully hammered my knee as the doctor had done to test his reflexes. I told him he would lie on a table so a big machine could take a picture of his tummy. Then I handed him a glass of water. "You have to pretend this is barium. You have to drink all of it. It looks white and it tastes like you are drinking sand from your sandbox. Make a face. Ug. Terrible." He watched me drink a pretend glass of barium. I made a face and said, "Ug. Terrible." Then it was his turn. At the hospital the day of his test, Roy drank three-quarters of the glass of barium without a protest, stopped to take a breath and started to finish the glass-full, but the nurse told him that he'd had enough. She complimented him for his bravery and gave him a hug. I complimented him and gave him a big hug. His smile confirmed that he was proud of himself. The test indicated a celiac condition.


Play - a means of testing a child's understanding. After explaining to children what is going to happen, we need to learn what their understanding is and to correct misconceptions. Tommy, age 7 was in the hospital to have an umbilical hernia repaired. He was painting at the easel, using red paint to sketch the head, torso and appendages of a person. The paint ran down the page. "Tell me about your picture," I said. "He's going to have his navel fixed," Tommy answered. I asked how the doctor could to that, and he replied, "He'll cut my navel off." I explained that the doctor had to make a little cut, then sew it, but that the doctor was not going to cut it off. I relaxed, thinking that my job was done, but added, "What will happen next." Nearly in tears, Tommy said, "Then he'll cut the other one off." The child thought that he was going to be castrated. I explained to him that the doctor wasn't going to do anything to his penis. The operation was only about fixing his navel. It occurred to me that the red paint might mean worry about blood. I explained that his body kept making blood, that he had many pints of blood equal to many jars of the red paint on the easel. Hopefully all of his misconceptions were corrected.


Play - a way for the child to work through his/her feelings after a frightening procedure in order to master the fears. Peter had hemophilia (a strong tendency to bleed) and was frequently in the hospital getting treatment. His favourite activity was to dress up in an operating room gown and pretend he was a doctor. He was meticulous about giving injections to a doll. Make belief "gains a sense of comfort with and mastery over grown-up skills." (6) (Incidentally, Peter became an M.D. specialist in the study of hemophilia.) Anna was a diabetic. At age thirteen her doctor thought that she should be taught to give herself the necessary insulin injections, but she refused to try. In the playroom we asked her to use an orange to show other children how the injection was given. Of course she'd observed and been shown how it was done many times. She proudly demonstrated the procedure to her friends. After this experience, she began to perfect giving herself the shots.

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Peter plays being a doctor

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Child's drawing shows his feelings


Play in preparation for and handling other fearful experiences - Roy, at age two and a half, was going to stay with cousins while my husband and I moved our belongings to a new city. Would he feel abandoned, particularly since our dog was not being "sent away"? He helped pack his suitcase. First item packed was his cozy blanket, which he held close in times of anxiety. Next his toy phone used to reenact conversations with mom and dad. In cartons to be transported to our new home, we packed his remaining toys and clothing, which I marked, "For Roy's New Room." And into my suitcase went his picture, "So you will always be with us." The cousins reported that as they drove away with Roy waving from the back window of their station wagon, our son said, "Mommy and Daddy are really going to miss me." I was reassured that Roy understood that our separation was temporary.


Conclusion - During play a child can control the situation and this builds his/her self-confidence. Play is a means to prepare children for fearful events, to test their understanding of what will happen and explain what the consequences will be. Play is a means by which the child can learn to master his fears and avoid anxiety disorders later in life. Although most of the examples in this article relate to medical procedures, play is a means by which caregivers can prepare children for other fearful separations or interventions and help them master fears.




References:
  • (1) MacDonald, Cinda. "Meet the professional: child life specialists: making the tough times a little easier." 2001. The Exceptional Parent. July, 2001. EP Global Communications. Inc.
  • (2) Plank, Emma N. with the assistance of Marlene A. Ritchie. Working with Children in Hospitals. Third edition, April, 2005. Medical Health Medical Center, Cleveland, Ohio.
  • (3) Women's and Children's Health Network. Parenting and Child Health. "Fears - young children." 2014.
    http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=122&id=1612
  • (4) Anxiety Care UK. "Children's Fears and Phobias." 2014.
    http://www.anxietycare.org.uk/docs/child.asp
  • (5) "Ignoring problem leads to adult difficulties." Feb. 2009. USA Today (Magazine). Society for Advancement of Education.
  • (6) Elkind, David, Ph.D. 2007. the power of play. how spontaneous, imagination activities lead to happier, healthier children. DaCapo Lifelong Books (member of Perseus Books Group) Cambridge, MA, U.S.A.

Note: The three black and white illustrations are from Working with Children in Hospitals by courtesy of the publisher.

Profile

Marlene_Ritchie.jpg Marlene Ritchie
For her writing Marlene Ritchie (née Archer) calls upon her experiences of teaching in the U.S., Japan and China, as a nurse and assisting-founder with Emma N. Plank of the Child Life and Education Program, which addresses the non-medical needs of hospitalized children, as a cofounder of Ritchies, a Toronto auction house, about growing up in a small Ohio town and about being a mother. Currently Marlene is a freelance writer and tutor living in Toronto, Canada. For the past eight years she has contributed to CRN.
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