Defusing Children’s Fear of Medical Attention : Pediatric Project Toys Prepare Youngsters for Hospital Stay
When your arm is broken, they cut it off and put a cast on between your shoulder and your hand until a new arm grows back.
The doctor is going to check my heart today. I had heart surgery. He’s going to see if it’s still beating, I think.
My friend had a sore throat and told his mommy. She put him in the hospital and had his throat cut.
Those misunderstandings and others like them, voiced by children between 4 and 6 years old, can lead to misconceptions and neuroses about medicine, said Pat Azarnoff, a child development specialist in Santa Monica.
Special Toy Store
Azarnoff heads a nonprofit corporation called Pediatric Projects, which runs a special toy store. It features stuffed animals with casts and splints, eyeglasses and prosthetic limbs. One doll’s chest unzips to reveal soft sculptures of internal organs that can be removed, examined and replaced. A miniature hospital cart comes complete with a play thermometer, stethoscope, simulated blood sampling equipment and fake eyeglasses to help children play doctor.
Pediatric Projects carries dolls, books and games designed to help children prepare for medical procedures that might otherwise baffle and terrify them.
“All children have natural fears about going to the doctor’s office or the hospital, and it makes sense to deal with those fears when they barise,” explained Azarnoff, whose long career in child care and development includes writing, university teaching and directing the Therapeutic Play Program at UCLA Medical Center.
“One very good way of dealing with those fears with children up to 10 years old, and in some cases through the teen years, is to use dolls,” continued Azarnoff, who has been awarded three fellowships by the World Health Organization to study the emotional development of children in health-care settings. “Dolls let the child pretend what’s going to be happening. That way you can see what he or she is thinking without the child having to put it into words, and it gives you a chance to deal with the situation, to take care of misconceptions and provide information.
“Children are often indirect in both giving and receiving stressful information about themselves, such as information about having to go through medical procedures. Even the simplest procedures like ear or throat examinations can frighten a child. And the more complicated or painful ones can really be terrifying. Taking blood is an example, or some of the high-tech procedures, like being restrained on a metal table with a safety strap and having the table move through a huge machine (CAT scan) or lying still on a cold metal X-ray table and having a camera lowered from above toward your body.”
Experts in using playthings to prepare children for medical procedures agree that a key to success is listening.
Root of Child’s Fear
“I want to see what the child’s needs are and then take care of those needs,” said Carol Dutton, child development specialist at Kaiser Permanente Hospital in Los Angeles.
Too often, Dutton said, adults miss the root of the child’s fear. “Either the adults misinterpret the facts or they don’t listen at all.”
Dottie Passios, director of the Child Life Program at Miller Children’s Hospital in Long Beach, confirmed that without proper preparation, hospital visits can be traumatic. Passios, whose staff includes four child development specialists, said that “if a child comes in unprepared and goes straight to surgery, sometimes without even knowing that he is going to go, the child might lose trust in his parents. His attitude toward any future type of treatment, surgery or visits to the doctor’s office would probably not be very positive, and he would probably have a lot more fears. I say probably because I do not think we can make a general statement.”
Passios, whose program won the Distinguished Service Award from the Assn. for the Care of Children’s Health, an international organization with about 3,800 members, uses dolls to prepare a child and his or her parents for a heart catheterization.
Catheterization Simulation
Heart catheterization requires a doctor to insert a spaghetti-like tube into a blood vessel, usually through a small incision in the leg. The physician moves the tube through the vessel to the patient’s heart and then injects dye into the tube. The dye travels to the heart. Using X-rays, the doctor then can make judgments about how the heart is working on the basis of how the dye is distributed. The test is used to find out if a patient needs heart surgery.
“We have heart catheterization on a little simulator that my staff and I use,” Passios explained. “We have dolls about three or four inches tall for the doctor, patient and nurse. There are a heart catheterization table (scaled to the size of the dolls) and simulated cameras the child can move with his or her fingers. The child can push a button and see a slide of a heart catheterization so he or she can relate to having pictures taken. With the dolls the children tend to do a lot of talking, we do a lot of listening, and are able to focus on any misconceptions or particular problems they may have.
If heart surgery is called for, Passios and her staff can use dolls fitted with intravenous tubes, chest tubes, catheter, heart monitor and proper bandages to work with children and their parents. “It helps them adjust,” Passios said.
Child development professionals warn that misused dolls can have a negative effect, and they emphasize that using dolls is just one means of preparing children for medical procedures.
Getting Kids to Communicate
“The issue is getting children to communicate their feelings,” said Dr. Arthur Parmelee, head of the Division of Child Development at UCLA Medical Center, and an expert on infants and young children. “Younger children--certainly children below 5--often lack the words, and older children may not want to articulate their feelings.
“What you would like to do is set up any kind of situation where there can be some dramatic play. The first thing that comes to mind when you’re setting up a dramatic play situation would be dolls to represent people.
“But my point is that parents aren’t necessarily going to be skillful at interpreting doll play. If the parents are doing it at home they may not (want to) use dolls, they may find it very useful for the children to use books. There are lots of books about children going to the hospital. You have to be careful of too much realism with dolls. A lot of the books are not photographs and realistic descriptions, but are vague . . . if the doll is too threatening the child may discard the doll and look away. You run the risk of opening a (psychological) wound and not being able to heal it.
“I don’t want to make it too rigid,” the doctor said. “Some people can use dolls very successfully at home.”
However, professional observation can be essential to a child’s well being. For example, Parmelee noted, a youngster going to the hospital for eye surgery may be told about waking up with a bandaged eye. Then, Parmelee said, “The child in doll play may be playing out that somebody’s going to cut the eye out of the doll. That may not be very well expressed in words or even demonstrated, but the (child’s) real question may be, ‘Are they going to cut my eye out?’ and the parent may miss the question entirely.
“You’re listening for what the question behind the question is,” the doctor said. “For example, ‘Will I be able to play when I come home?’ might mean, ‘Will I ever be able to play again?’ or something like that.”
Nancy Klein, director of the Department of Child Development, Services at UCLA Medical Center said, “One of the most useful things we do for the parents and the children is to tell children about medical experiences in the children’s terms. Some parents can do that, but most find that they do much better with some guidance from people like us who have had experience.”
Klein illustrated her point with an anecdote about a 3 1/2-year-old girl who came to the hospital for a heart catheterization. “She had heard some talk in her family about her parents trying to have another baby, and she thought she was coming to the hospital to have a baby. Her parents didn’t know what she was thinking. The child told me after playing with a mother doll and a baby doll.”
In another case, Klein said, “I had a a 4-year-old girl who was going to have heart surgery, and she was playing out the theme using a mother doll in the kitchen cooking a meal.
“The mother doll said to the little baby doll, ‘I want you to go upstairs and take a nap,’ so the child had the baby doll go upstairs. But instead of having the doll take a nap, the child had the doll go up to the roof, where the doll fell off and had to come to UCLA for heart surgery.
“The theme of her play was that the little girl was here for heart surgery because she didn’t listen to her mother, and was being punished for it. The child was not conscious of what she was thinking. Throughout her hospitalization I reinforced the idea that she was not here for failing to listen to her mother, and that her parents did love her, and she was here because her heart needed repairing.”
Then Klein described a 5-year-old boy who was in the hospital for a heart catheterization. The boy used dolls to simulate the entire catheterization procedure. Finally, he put the patient doll on the toy table where the heart catheterization had taken place and piled the nurse, doctor, orderly, parent, grandparent dolls and seven or eight other dolls on top of the patient. Then he said, “There, I’m finished.” His mother asked, “What are all those people doing to the little boy?” and the child replied, “They’re squishing him.”
Afraid of the Unknown
Klein discovered that what the boy was trying to say was that he felt a lack of control, vulnerable and afraid of the unknown. He was, in a phrase, feeling “psychologically squished,” Klein said. “The play with dolls, and subsequent play and talk with the boy, alleviated some of his fears,” she added.
Parents strongly support doll play and other therapeutic play to prepare their children for medical procedures.
Cathy May, a Long Beach mother whose daughter Elizabeth, 4, had her heart catheterized at Miller Children’s Hospital, said, “Being able to play took the fear out of it. There was no fear of the unknown because she could play out her anxieties. She would reenact as much as she knew about the catheterization. She did with dolls what she knew would happen to her. It made her feel very good, and it made me and my husband feel really, really good.”
Sometimes, parents say, the therapeutic play has a subtle effect. Deedee Bransky, a Los Angeles housewife and writer, described the reaction of her 3 1/2-year-old son, Max, who played with dolls at Kaiser Permanente Hospital as preparation for a tonsillectomy.
“He was kind of bored,” Bransky said. “He loved playing with the dolls, but he didn’t really relate it to the operation.” But, the mother added, “He felt good in that room (the hospital playroom), and he knows the room is part of the hospital, so it did serve a purpose even though he didn’t relate it to the operation.”
Whether the child’s reaction is general, as with Max Bransky, or more specifically related to a medical procedure, the effect still is beneficial, noted Pat Azarnoff, the child development specialist who runs Pediatric Projects in Santa Monica.
“One of the benefits of playing with dolls and stuffed animals is that children are in charge of it,” Azarnoff said. “They can relate it to the medical experience in many different ways and to the degree that they can stand it. The beauty of properly supervised therapeutic play is that different children get different things from it, but they all seem to get something.”
