J-"L"itIMild-III-nm-Ilul - ‘-n WI Q: TOYS AND TONSILS: A STUDY OF THE EFFECTS OF A PLAY PROGRAM ON CHILDREN HOJPITALIZED FOR TONSILLECTOMY AND ADEJOIDECTOHY TOYS AND TONSILS: A STUDY OF THE EFFECTS OF A PLAY PROGRAM ON CHILDREN HOSPITALIZED FOR TONSILLECTOMY AND ADENOIDECTOMY by Judith'P, Oravec Dessalee Overholt .95 . i ‘ .. 3"» ,3 mi n h» 3‘ - ‘ 1:3" 1 r vv~ I .# l 1‘ - 1 ‘ . , . ' un‘ .K' ' I ‘$ ' V 1 ' a . 4 fi 0. a; s : ~ 2%. £3: ‘ I .1 ', u P ' ‘ A‘Q- .fi‘ ; s 3 ' ‘5 L.‘ 1 ' -, . ‘- s . a“ ,§ i «:- I .‘i l," a g " . A y Y ‘4‘.“ 'ng ‘K‘f AN ABSTRACT OF A STUDY In partial fulfillment for the requirements of the degree Master of Social WOrk School of Social Work Michigan State University June, 1967 TH 86m CJ ' I. .““.k; c Ibf‘.r ‘ ABSTRACT TOYS AND TONSILS: A STUDY OF THE EFFECTS OF A PLAY PROGRAM ON CHILDREN HOSPITALIZED FOR TONSILLECTOMY AND ADENOIDECTOMY by Judith P. Oravec Dessalee Overholt This study sought to determine whether the introduction of a play program into the hospital experience of tonsillectomy and adenoidectomy children would help alleviate and/or mitigate stress incurred during hospitalization. Behavioral and physio- logical responses were measured as indicators of stress, Because of the small sample, no statistical significance can be attached to the study, however, findings indicate some support for the belief that a play program is a valuable adjunct for hospitals interested in the total well—being of pediatric patients. TOYS AND TONSILS: A STUDY OF THE EFFECTS OF A PLAY PROGRAM ON CHILDREN HOSPITALIZED FOR TONSILLECTOMY AND ADENOIDECTOMY by Judith P. Oravec Dessalee Overholt A STUDY In partial fulfillment for the requirements of the degree Master of Social Work School of Social WOrk Michigan State University June, 1967 TABLE TABLE OF CONTENTS . . . . LIST OF CHART AND TABLES THE PROBLEM . . . . . . . THE ROLE OF PLAY ACTIVITY THE THEORY . . . . . . . THE SAMPLE . . . . . . . HOSPITAL PROCEDURE . . . THE DESIGN . . . . . . . METHOD OF ANALYSIS . . . RESULTS . . . . . . . . . CONCLUSIONS AND INTERPRETATION APPENDIX A . . . . . . . APPENDIX B . . . . . . . REFERENCES . . . . . . . OF CONTENTS ii Page ii iii ll l3 l3 l4 l7 18 21 22 24 28 LIST OF CHART AND TABLES Table Page BEHAVIORAL RESPONSE CHART . . , , . . , , . . , , , , , , 23 I. COMPARISON OF PRE— AND POST—OPERATIVE BEHAVIORAL RESPONSES . . . . . . . . . . . . . . . . . . . . . 25 II. COMPARISON OF MEAN TEMPERATURES AND PULSE RATES OF EXPERIMENTAL AND CONTROL GROUPS . . , . , , . . . . 26 III. COMPARISON OF MEAN FLUCTUATIONS OF TEMPERATURE AND PULSE RATE FOR EXPERIMENTAL AND CONTROL GROUPS DURING TOTAL HOSPITALIZATION . . . . . . . . . . . 27 iii l The purpose of this experimental study was to investigate the possibility of improving hospital care for children by the introduction of a play program into the routine procedure of a pediatrics ward, The use of a play program to 1) provide a child with a familiar and normal world in the midst of the strangeness of the hospital environment, 2) enable a child to work through some of his stress surrounding hospitalization, and 3) provide an opportunity for a child to continue to grow and develop in a positive direction during hospitalization has been suggested by professionals concerned with the child's total well-being (4). In View of this mounting emphasis, many hospitals have actively begun to initiate such programs, but they have been slower to in— vestigate any relationship between the introduction of the play program and behavioral and/or physiolOgical responses of the chil- dren who participate in the program. THE_PROBLEM Hospitalization is generally a stress-inducing experience. For children this may be especially true because they are in an insecure situation which they do not fully understand; they fear being separated from their parents in strange surroundings which do not meet their needs for love and security; and, they fear bodily harm and mutilation, One of the first threatening situations a child has to face upon admission is that of being transplanted from his familiar 2 world at home to the unfamiliar and usually frightening world of the hospital. Edelston (5) has analyzed a series of cases showing neurotic disturbances of varying degrees of severity related to hospitalization in young children and concludes that an analysis of the hospital experience in terms of the child's need for secur- ity gives the best understanding of the problem. Arsenian (2) has investigated responses of young children to insecure situations and has formulated insecurity as a function of unfamiliarity of the environment in relation to the child's feeling of power in it, Along these lines, a child who has not been prviously admitted to the hospital will lack any cognitive structuring of the situation and thereby experience stress. This may be compounded by the fact that a protective parental figure will not be able to protect the child from the hospital routine to which he must be subjected and is therefore unable to compensate for the child's lack of power, Lack of cognitive structuring may be further complicated by the fact that a child admitted for tonsillectomy and adenoid— ectomy may find himself in a somewhat unique situation in that he has entered the hospital feeling well and is discharged feeling sick and mutilated — the reverse of that which usually transpires. A second source of stress during hospitalization may be due to fears of separation and abandonment, Heinicke and westhei— mer (8) have studied brief separations of children from their parents, The children not only lost significant persons for short 3 periods of time, but were also transferred to a new environment, Although this study deals with two important aspects of hospiti- zation - separation and transference to a new environment, chil— dren in this study were typically separated from their parents for longer durations than children hospitalized for tonsillectomy and adenoidectomy, thus reducing many generalizations regarding adaptive patterns that might otherwise be made, Of particular importance, however, were the manifestations of children's stress over separation, especially during the early stages which may be more easily generalized to the hospital experience of tonsillectomy and adenoidectomy children. Typical behavior included crying, fretting, throwing themselves bodily, refusal to participate in routine, expressions of hostility, sleep disturbance, abandonment of familiar objects, etc. Jessner et_§l, (9) discusses separation anxiety in the child and points out that separation can have many different mean— ings. Among them are loneliness, need for protection, abandonment, and fears surrounding a loss of identity, Although these concepts are useful, it is important to understand that each child will express these unconscious fears individually and that observations made during hospitalization are derivatives of these unconscious forces, A third focus which generates stress in the child is fears of mutilation and castration. Langford (10) calls this "organismic" 4 anxiety, and relates it to an unconscious perception of a threat to the life or integrity of the organism. Anna Freud (7) has also attempted to deal with anxiety as a reaction to illness and pain. She indicates that any surgical interference with a child's body may activate ideas of being over— whelmed, attacked, or castrated, and that the severity of these fears depends not on the seriousness of the surgery, but on the fantasy life of the child. The child may, under the influence of unconscious forces, interpret surgery as a retaliatory attack from the mother, punishment for exhibitionistic desires, or impending death, and will respond to pain with affect appropriate to the content of unconscious fantasies such as anger, rage, revenge, submission, guilt, and depression. Jessner (9) discusses the meaning of narcosis induced by anesthesia which, for many children, can represent a threat of death, a fear of punishment or execution, a murderous or sexual attack, or a fear of loss of control. Again, these are important and useful concepts, especially in helping to understand the severity of a child's reaction, but they fall short of providing us with observational material. The expression of a combined internal and/or external threat may follow many patterns, and one must be sensitive to a child's mani- festation of these conflicts. Because children vary considerably in their c0ping and 5 adaptive abilities, there are a number of adaptational patterns available to the child. Langford (10) has enumerated many of these which include regressive reactions, rebellious reactions, depression, chronic invalid or hypochondriacal reactions, denial, displacement, docility, and persistent dependency reactions; but until recently, very little has been done in helping children to work through or in some measure handle the stress which results in the above patterns, Recently some hospitals have discovered that play, the familiar and normal world of childhood, may be used by children to work through such fears and stress (4). Out of an increased interest in the total well—being of hospitalized children, some hospitals have introduced play programs into their pediatric wards in the hope that play activity will provide the child with an opportunity to mitigate and/or alleviate some of the above men— tioned stresses. The effects of such a program, however, have not been systematically studied, THE ROLE OF PLAY ACTIVITY The play activities of a child, his natural medium for self expression, have increasingly stimulated a great deal of thought, experimentation, and conclusions as to the ways in which play can be used differentially in the treatment of children. (1) Fanny Amster has described play activity as "an activity a child comprehends, and in which 6 he is comfortable, an integral part of his world, his method of communication, his medium of exchange, and his means of testing, partly incorporating and mastering external realities. , , . Provision of play materials means the provision of a medium . . . through which the child's problems may be expressed more readily and the treatment more likely to succeed."(l:12) Although Amster is specifically concerned with the use of play in child psychotherapy, her description of play activity can easily be generalized and differentially applied to the treatment of children in a hospital setting. Margaret Lowenfeld has enumerated several different class- ifications of play and has attempted to discover the meaning those activities bear for the children who engage in them. (11) Out of this classification, four seem to be particularly applicable to the hospital experience of children admitted for tonsillectomy and adenoidectomy, The first of these classifications is play as a repetition of experience. Lowenfeld discusses this in terms of a child's strong inner drive to externalize himself — a wish to reproduce or recreate his experiences in order to be able to assimilate them. She indicates that experience per se benefits the human psyche nothing; that it must first be externalized, meditated upon, re— lated to intimate sequences of facts or experiences already incor- porated in the mind, and finally assimilated and understood before it can have any molding effect upon the personality. She goes on to say that the child's mind spontaneously chooses the nature of 7 it's interests, and that when material is provided with which to work out these interests, the child will explore his experience with deep concentration. In such an exploration, with skilled and sympathetic adult help, the child will find his way toward understanding and assimilating his experiences. This is closely related to what Freud termed the "repeti— tion complusion" ie. the need to re-enact stress producing exper- iences in words or actions in an attempt to master a situation, which in its original form, had been overwhelming. (6) Repetition, in itself, is the vehicle whereby experiences are mastered and assimilated; they take on compulsive characteristics only when a child has encountered an overwhelming experience which he has not been able to master through play activity or verbalization. We have previously pointed out the stresses generated in the child from the time of admission to the hospital through the time of discharge. Transplantation from the familiar world of home to the strange and frightening world of the hospital, lack of cognitive structuring in such a situation, and continual bom— bardment from unfamiliar stimuli, function to alarm the child. The medium of play provides a functional means whereby the child can begin to explore these experiences, and with the help of understanding adults, begin to scale them down to manageable size. The second of these classifications is play as the demon- stration of fantasy. In her discussion of this classification, 8 Lowenfeld points out that every experience leaves some trace upon the total personality and is accompanied in children by rudimentary, intellectual concepts of that experience. Since, however, the small child has no means of testing reality, and no material from which to form correct concepts, the mental picture he creates, no matter how distorted, will appear to him as fact. A complicating factor is that prior to the age of approxi— mately nine, children do not use words to communicate their ideas, but instead develOp a network of fantasy which contains ideas con- cerning themselves, the outside world, their relation to the out- side world, and the relationships between one part and another of that world. "It will be a three—dimensional fantasy in which feeling, experience, imagination, and memory cross each other, layer interweaving with layer, and eXperience with experience. . . . Play expressions of this state of mind . . . can occur only when material which is capable of expressing such ex— perience is present." (11:152—153) She further discusses the fact that through the medium of play, "Children appropriate the materials they find at hand and invest them with imaginative qualities that make them a vehicle for the concepts, wishes, and fantasies that surge within their heads. . Having created the elements they need for their play, they proceed to combine them in ways which enable them to express the underlying ideas they are trying to grasp." (11:156) Once the fantasy has become expressed through play, an effort at 9 clarification and definition has been made which in turn enables the child to ". . . realize the nature of his own preconceived ideas and spontaneous feelings, and by doing so to bring them within reach of comparison with reality." (11:181) We have seen that the hospital experience of children admitted for tonsillectomy and adenoidectomy is conducive to the creation of a wide range of fantasy materials. "Organismic" anxiety, as well as anxiety surrounding unconsciousness induced by the anesthesia, may lead to the production of numerous unreal- istic fears which may be identified and corrected through the child's play activity. The third classification which Lowenfeld discusses is that of play as realization of environment, and she points out that every child, along with exploring his fantasy, is equally engaged in an endeavor to check his experiences with reality and to ex— press realistic emotions. There are occasions when a child will feel frustrated and helpless in his environment, and will long to regain control and power. One of the play techniques utilized by children during such situations is that of imitative activity whereby the child imitates the adults in his world and is tempo— rarily and imaginatively, in possession of the power of his elders. In doing so, he begins to understand the environment, the manner in which one part fits into and affects another, and he is restored to power once more to manipulate the world to his own ends. (11:187) 10 We have discussed the fact that insecurity and stress are related to unfamiliarity of the environment in relation to the child's feeling of power in it which is further compounded by the fact that protective parental figures may not be able to compensate for the child's lack of power in the hospital setting. Lowenfeld suggests that group play activities can offer the child two different types of aids — one of utilizing the knowledge of other children and adults with whom he can discuss such matters, and one of providing an opportunity for such imitative or empathic play wherein the child actually ”becomes" the adult who threatens. A second source of emotional stress for the child hospital— ized for tonsillectomy and adenoidectomy which is closely related to his feelings surrounding power, is that of anger and resentment toward adults. Separation and fears of abandonment induce anger as does the surgery itself which is sometimes perceived by the child as a planned injury. When a child manifests expressions of anger and resentment, however, he is aware that he faces possible retri- bution or retaliation. In view of this fact, most children learn to suppress such feelings of hostility. Even though successful at suppressing their hostile feelings, their impact cannot be en— tirely mitigated and they tend to break out in a variety of other ways. When given the opportunity to do so, children will tend to work the force of these emotions out of their systems by drama— tizing expressions of hatred and bitterness in their play activity. ll (11:206) The last of these classifications is that which Lowenfeld terms play as preparation for life. She states that "The play of children shows that the impulse to grow and develop into specific and definite preconceived patterns exists in the vast majority of them." (11:208) She feels that every child, unless prohibited, tends to spontaneously evolve this sort of play for himself and that it is this type of play activity that bridges the gap between the helplessness of childhood and the possession of power and skill for which he longs. In order that a hospitalized child might continue to grow in a positive direction, it would seem that some provision for constructive, creative play should follow. Without it, children may become deficient in constructive imagin— ation and inhibited in experiences which restrains the natural maturational process. THE THEORY This study was based on the belief that distress in chil- dren admitted for tonsillectomy and adenoidectomy could be reduced by their participation in a pediatrics play program which would allow them to naturally eXpress some of their fears, fantasies, and emotions surrounding hospitalization. For purposes of this study, the play program was defined by the researchers as the hour made available to the children pre- Operatively and post—operatively during which time they could 12 engage in spontaneous play activity with the materials provided. The atmoSphere of the play period was benign and permissive; no attempt was made to structure the activity of the participating children. It was predicted that children participating in the play program during hospitalization would manifest a reduction of be— havioral and physiological distress as measured behaviorally by: a) b) C) d) Negative active responses (dictate, boss, rebel, show off, attack, etc.) Negative passive responses (resist passively, accuse, retreat, distrust, etc.) Positive active responses (support, help, inform, give, direct, etc.) Positive passive responses (cooperate, trust, ask help, obey, depend, etc.) and as measured physiologically by: a) b) C) 61) Temperature Pulse Rate Ability to take oral fluids Post—operative vomiting It was further predicted that an analysis of the above variables, as manifested by the eXperimental and control groups, 'would result in statistically significant differences. 13 THE SAMPLE A sample of five children was randomly selected from a group admitted for tonsillectomy and adenoidectomy during a one month period at Edward G. Sparrow Hospital. All children were between the ages of 4 - 10, and had no previous hospitalization experience. The sample included two experimental patients, and three controls. The fifth child was assigned to the control group, due to the fact that the other two children in this group were brother and sister. Children undergoing tonsillectomy and adenoidectomy can be expected to have similar symptoms and amounts of discomfort. The admission and pre-operative procedures, surgery, and post— operative experiences are also similar; therefore, the experimental and control groups differed only in regard to the play experience. Children were excluded from the sample only if their physicians and/or parents objected to the study. In our exper- ience, no parents objected, however, thirty—six children were ex- cluded from the study due to the objections of two physicians. HOS P ITAL PROCEDURE The general hospital procedure for children included in this sample was routine for tonsillectomy and adenoidectomy patients. They were admitted to the hospital on the afternoon prior to the morning of surgery, at which time a blood sample was taken and children were accompanied to the pediatrics ward. Mea- l4 surements of the child's blood pressure, temperature, and pulse rate were administered and a urine sample was taken. Following this, the child was taken to his room and dressed in pajamas. Parents were allowed and encouraged to remain with their children throughout the entire procedure, since Sparrow Hospital has un- restricted visiting hours for them. After admission, the children were not restricted to their beds, but were allowed to amuse themselves on the ward until the evening meal was served at five o'clock, and again until they went to bed at approximately 8:30 p.m. Beginning at midnight prior to surgery, the children were not allowed to have fluids. And, at 7:30 the following morning, the children were taken to the operating room at half—hour inter- vals. Following surgery, they remained in the recovery room until they awakened and were then returned to their own rooms on the ward. Depending on individual differences, children remained in their rooms or were active until discharge the following morning. THE DESIGN Independent Variable — Play The hospital experience of the experimental group differed from the routine procedure of the control group only by the in- troduction of an organized play hour between 6 and 7 p.m. on the evening of admission and the evening of surgery. This time was selected as being most advantageous for both play periods. By 15 this hour on the day of admission the child had some exposure to the hospital routine and there were less interruptions caused by hospital procedure. On the day of surgery, this hour was late enough post—operatively for the anesthesia to have lost most of its effect. On the evening following admission, the children in the experimental group were taken to the playroom and were allowed to choose freely from a selection of play objects randomly arranged on tables. Included among the play objects were dolls and doll clothes, doctor play equipment (stethoscope, bandages, tongue depressors, swabs, etc.), puppets, water color paints and paper. These objects were selected by the researchers for the children to choose from because it was not feasible to allow children com— plete random choice due to limited supervision, and because it was felt that relatively unstructured play objects such as these would provide children a variety of methods by which they could express their individual feelings. (4) The same choice was pro- vided the evening following surgery, although play was restricted to the child's room. Parents visiting their child during the play hour were encouraged to participate with him, and such par- ticipation or parental absences were noted by the researchers. Following the play hour, the children were unobtrusively observed for a half-hour time sampling between 7 and 8 p.m. The control group, which did not experience organized play, 16 was also unobtrusively observed for a half-hour time sampling be- tween 7 and 8 p.m. on the evenings of admission and surgery. Parental visits were noted for this group as well. Control and experimental data were gathered on separate occasions. Dependent Variables — Patient Stress The patient's stress during hospitalization was measured both behaviorally and physiologically. Behavioral manifestations of stress were measured by means of independent observations of the two researchers. During the 7 - 8 p.m. hour the researchers simultaneously observed and coded behavior exhibited by children in each sample. The behavior (e.g., crying, thumb sucking, etc.) was coded according to a scale adapted from Erika Chance (3) which included positive active, pos— itive passive, negative active and negative passive ratings (see Appendix A). The researchers later compared their observations and any behavior on which there was an observational or coding discrepancy was not included in the study. Physiological manifestations of stress, adapted from a study by Mahaffy (12), were measured by several variables. One of these was elevations and fluctuations of pulse rate and temper- ature. These measures were included since such ". . . Vital signs reliably reflect the child's emotional tension. . . . When they are in a fearful situation, their vital signs reflect the effect of stress. . ." (12:14) Such measures are routinely taken by 17 hospital staff on tonsillectomy and adenoidectomy patients. The ability to take oral fluids was also included as a variable since fluid intake reduces soreness and prevents hemor- rhage in the operative Site. (12:15) Also, it was felt that a child who attempted to take fluids, which was painful to his throat, was making a positive adaptation in spite of his discom- fort. The child's ability to take fluids was recorded by the nurses on a four—point scale of Great Ease, Ease, Difficulty, and Great Difficulty. Post—operative vomiting was the final variable selected because, according to the literature, "Nervous or habit vomiting is . . . incited by emotional disturbances. . ." (13:694) The incidence of this variable was recorded routinely by the nurses from the time the child entered the pediatrics ward until his dis— charge the following morning. In order to insure objectivity, all the physiological variables were measured and charted by medical staff members. METHOD OF ANALYSIS The eXperimental and control groups were compared on the basis of their behavioral and physiological responses. 1. Behavioral responses (negative active, negative passive, positive active and positive passive) were categorized and counted, and ratios were calculated to determine the relationship between negative and positive responses of the experimental and control 18 groups pre—operatively, post—operatively, and totally. A mean ratio of total negative and positive responses was calculated for both control and experimental groups. 2. Mean temperatures and pulse rates for the experimental and control groups were compared. In addition, the mean fluctuations of these measures over time were also compared. The statistical significance of the fluctuations was tested by the Mann—Whitney U Test. 3. Occurence of vomiting in the experimental and control groups was rated on a three point scale and the mean rating of each group was compared using a t test. 4. Ability to take oral fluids was rated on a four point scale and the mean rating of the experimental and control groups was also compared using a t test. RESULTS The distribution of individual behavioral responses pre— operatively, post—operatively, and totally is shown in Table 1. Since individual differences among children's typical behavior were not controlled in this study, the data in Table l are interpreted to show only the direction of behavioral change and frequency of responses observed during hospitalization. Ratios were computed on the basis of this distribution in order to determine the relationship between negative and positive responses, and to standardize the difference in number of observa- l9 tions. Pre—operatively, the mean ratio of positive to negative behavior was 9 for the experimental group and 1.1 for the control group. Post—operatively, the mean ratio of positive to negative behavior changed to 2.2 for the experimental sample and .3 for the control sample. The mean ratio for the total period of hospitali— zation for the experimental group was 10, and for the control group, 7.9, or a mean difference of 2.1. This finding, that there were 2.1 more positive behavioral responses for each negative response among the experimental group supports hypothesis 1. Physiological responses are charted on Tables 2 and 3. Table 2 shows the comparison of mean temperatures and pulse rates between the experimental and control groups at various times during hospitalization. While there were no significant differences of mean temperatures between the groups at admission or discharge, it was seen that the control sample had a much higher temperature post—operatively than pre—operatively. This finding was not appar— ent for the experimental sample, thus supporting hypothesis 2. There were no significant differences between the mean pulse rates of experimental and control groups. The data included in Table 3, a comparison of mean temper— ature and pulse rate fluctuation of experimental and control groups, is interpreted to show that the control group temperatures generally fluctuated more than the experimental group, but these differences were not statistically significant. In terms of pulse rate fluc- 20 tuation, it was apparent that the control group generally fluctuated more than the experimental group, but this fluctuation was minimal, and not statistically significant. The difference of mean temperature fluctuation of experi- mental and control groups between admission and pre—operative mea— sures was not significant (U = 2 p = .800). Between pre-operative and post—operative measures, and between post—operative and dis- charge measures, significance was obtained at p = .200 (U = 0 for both measures). The mean fluctuation over the entire hoSpitaliza— tion was not significant (U = l p = .400). The difference of mean pulse fluctuation of experimental and control groups between admission and pre—operative measures was not significant (U = 3 p = .600), nor was it significant between pre—operative and post—operative measures (U = 2 p = .800), nor between post—operative and discharge measures (U = 2 p = .400). The mean fluctuation over the period of hospitalization was not statistically significant (U = 2 p = .800). A comparison of experimental and control group ability to take oral fluids was rated on a four point scale, and the group mean was computed. The experimental group mean fell within the rating of Great Ease while the control group mean fell within the rating of Difficulty. This finding tends to support hypothesis 2. However, these results also failed to achieve statistical signifi- cance on a t test. 21 The occurence of vomiting was rated for experimental and control groups on a three point scale, and the group mean was again computed. The experimental group had no incidents of vomiting, whereas the control group mean fell between the categories of One and More Than One incident of vomiting. This finding, while it also tends to support the second hypothesis, was not statistically significant on a t test. CONCLUS IONS AND INTERPRETATION It is recognized that the sample in this study was extremely small and does not allow one to generalize from the results. Nevertheless, the results tend to support the hypotheses that be- havioral and physiological stress due to hospitalization is allevi- ated in some measure through play. Although validation of these hypotheses was not statistically significant, it is the feeling of the researchers that the results which were obtained did move in the direction of substantiating the hypotheses, which lends credence to the conclusion that the study merits further attention. The implication of such trends is that hospitals concerned with the total well-being of children should consider initiating play activities for hospitalized children. APPENDIX A BEHAVIORAL RESPONSE CHART Dictate, Dominate, Boss, Rebel, Boast, Show off, Reject, Take away, Compete, Threaten, Mock, Punish, Disapprove, Attack, Condemn NEGATIVE ACTIVE RELATIONSHIPS NEGATIVE PASSIVE RELATIONSHIPS Passively critical, Resentful Unappreciative,Complain,Nag, Resist passively, Distrust, Demand Accuse, Apologetic, Self-critical Retreating, Cowed into obedience, Obeying a feared au— thority, Submitting Direct, Lead, Control kindly, Teach, Inform, Ad— vise, Give, Interpret, Help, Support, Sympathize, Pity, Love, Praise, Approve POSITIVE ACTIVE RELATIONSHIPS POSITIVE PASSIVE RELATIONSHIPS Loves to be praised, Appreci— ates, Loves to be liked, Co— operate, Conciliate, Agree, Trust, Ask help, Depend, Admire, Ask advice, Ask opinion, Conform, Like to do as others do, Obedient APPENDIX B 25 mmmcommmm m>Hmmmm o>Huflmom n mam mmmcommmm m>Hbo< m>fluflmom H Mdm mmmcommwm T>Hmmmm T>Hummmz u mmz mmmcommmm T>Huom 0>Hummmz H mfizsP w Ha H a o I I m m I H HHH mmmo h m w v I m m m m m H HH mmmu n ma H m H b a O OH H I H wmmu Honucoo ma OH I m w m I o o I I HH mmmo OH H I I m I I m a I I H mmmu HmucoEHHmmxm mmm mmm Mmz mdz mmm mflumumm0Iumom T>HumHmQ0Imum mHmEmm mmmzommmm fl¢m0H>¢mmm m>HB¢mmmOIBmOm 92¢ IMMm m0 ZOmHmHumHmmOIumom 0>HumummOImHm coammflfip< QDOHO ucmEmHDmmmz mo mafia >3 mumm mmasm pcm musumuwmfiwa mmbomw QOMBZOU QZ< afifizmszmmxm m0 MMBmm mmqu 92¢ mmmbemmmmzma Z¢m2 m0 ZOmHm¢mZOU HH mam<9 27 mbmm mmHDm n .m.m musumuomeE n ERR mmumxomfln H O T>HumnmmOImum n Olmum m>Hpmummqumom n Olumom COHmmHEpm u ¢R m.ma h.H m.m N.H ma >.N m.mH ¢.H Houusou m.NH m. 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