I .vi

 

 

 

A HOSPETAL PLAY PROGRAM.
UNRESTRICTED VISETING,
AND ROOMINGJN:
THEIR EFFECTS ON! CHILDREN‘S
POSTHOSPITAL BEHAVIORAL RESPONSES.
AND PARENTAL 'B-EHAVIOR

The“: {‘09 “W Degree of M. A.
MICHIGAN STATE UNIVERSITY

Jane Ellen BOpp

1967

 

 
    
   

  

LIBRAR Y
Michigan State

University

 

 

 

 

 

 

 

ABSTRACT

A HOSPITAL PLAY PROGRAM, UNRESTRICTED VISITING,
AND ROOMING-IN: THEIR EFFECTS
ON CHILDREN'S POSTHOSPITAL BEHAVIORAL
RESPONSES AND PARENTAL BEHAVIOR

by Jane Ellen Bopp

The effects of illness and short—term hospi-
talization upon children are crucial in relation to
theoretical understanding of children in situations
of stress and to the meaning of the experience for
the individual child. The stresses inherent in hos-
pitalization and illness are met with adaptational
patterns ranging from psychological upset to psycho-
logical benefit. In order to lessen the stress and
provide emotional support for constructive reactions,
new trends in pediatric care emphasize a variety of
ameliorative measures.

The purpose of this study was to investigate
the effects of three ameliorative measures on chil-

dren's posthospital behavioral responses. Hospital I

Jane Ellen Bopp

had unrestricted visiting, provisions for rooming—in,
and a play program. Hospital II had visiting five
hours per day, no play program, and no provisions for
rooming—in.

The Posthospital Behavior Questionnaire, de-
velOped by Vernon, Schulman, and Foley was mailed to
the parents six days following the child's discharge.
An additional Information Sheet, developed by the re-
searcher, was used to collect data pertaining to par—
ticipation in the ameliorative measures. A total of
thirty-seven questionnaires were used in the data anal-
ysis: fifteen medical patients from Hospital I, twenty—
five medical patients from Hospital II and twenty-two
surgical patients from HOSpital I.

It was hypothesized that children from Hospital
I would manifest less General Anxiety and Regression,
Separation Anxiety, Anxiety About Sleep, Eating Disturb-
ance, Aggression Toward Authority, Apathy-Withdrawal,
and total upset than children from Hospital II. Calcu-

lation of the Kruskal-Wallace one-way analysis of

Jane Ellen Bopp

variance showed that there was no significant differ-
ence among the three groups. Thus the hypotheses of
this study were not supported. This finding seemed
to point mainly to problems in research design and
methodology, particularly to the global nature of

the study.

Data from the Additional Information Sheet
seemed to indicate that differences were most appar-
ent in the visiting patterns of mothers and in how
the parents viewed the hospital experience.

This study pointed to the need for education
of the public concerning new trends in pediatric care

and for further definitive research.

A HOSPITAL PLAY PROGRAM, UNRESTRICTED VISITING,
AND ROOMING-IN: THEIR EFFECTS ON CHILDREN'S
POSTHOSPITAL BEHAVIORAL RESPONSES

AND PARENTAL BEHAVIOR

BY

Jane Ellen Bopp

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree Of

MASTER OF ARTS

Department of Home Management and Child Deve10pment

1967

ACKNCIATLEDG EMENTS

Appreciation is expressed to Mr. Robert Lance
for his guidance and direction in planning and conduc-
ting this study. Appreciation is extended to Mrs. Vera
Borosage and Dr. John Garrett, members of the writer's
committee, and to Dr. Sarah Hervey, who assisted with
statistical advice. The writer is also grateful to
Dr. Bernice Borgman for her guidance during develop-
ment of the research problem.

An expression of appreciation is also extended
to Barbara Neumann, Phyllis Jones, Alan Sugawara, and
Fred Hahn for their helpfulness and encouragement.

Although no names can be mentioned, the writer
expresses grateful appreciation to personnel in the
respective hospitals who made this study possible:
administrative personnel, Directors of the Social Ser—
vice Departments, physicians, nursing staff, and persons

in the Medical Records Departments.

ii

TABLE OF CONTENTS

ACKNOWLEDGEMENTS . . . . . . . . .
LIST OF TABLES . . . . . . . . . .

LIST OF APPENDICES . . . . . . . .

Chapter

I INTRODUCTION 0 O O O O O C

General Statement of the Problem. . .
Specific Statement of the Problem . .
Definition of Terms . . . . . . . . .
Research Hypotheses to be Examined. .
Additional Research Questions to be
Investigated . . . . . . . . . . .

II REVIEW OF LITERATURE . . . . . . . . . .
Introduction . . . . . . . . . . . .
Stressful Factors Inherent in Illness

and Hospitalization . . . . . . . .
Adaptational Patterns . . . . . . . .
Ameliorative Measures . . . . . . . .
Summary . . . . . . . . . . . . . . .

III METHODOLOGY . . . . . . . . . . . . . .

Description of the Hospitals . . . .
Permission for the Study . . . . . .
Data Collection . . . . . . . . . . .
Sample . . . . . . . . . . . . . . .
Research Instrument . . . . . . . . .

iii

Page

ii

vi

H

\O\lJ>l-‘

11

12

12

14
23
31
41

42

42
47
49
51
59

Table of Contents (cont'd.)

Chapter Page
IV RESEARCH FINDINGS . . . . . . . . . . . . 67
Statistical Tests of the Hypotheses . . 67
Descriptive Analysis of the Additional
Research Questions . . . . . . . . . 71
Other Findings . . . . . . . . . . . . 87
V DISCUSSION . . . . . . . . . . . . . . . . 93
Summary of Results . . . . . . . . . . 93
Problems Encountered in This Study. . . 97
Limitations of This Study . . . . . . . 99
Implications O O O O O O O O O O O O O 103
Suggestions for Further Research . . . 105

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . 108

APPENDIX 0 O O O O O O O O O O O O O O O O O O O O 115

iv

LIST OF TABLES

Table
1. NUMBER OF QUESTIONNAIRES MAILED, RETURNED, AND
USED; LENGTH OF MAILING TIME . . . . . . . .
2. HOSPITAL I MEDICAL PATIENTS . . . . . . . . .
3. HOSPITAL II MEDICAL PATIENTS . . . . . . . . .
4. HOSPITAL I SURGICAL PATIENTS . . . . . . . . .
5. SUMMARY OF SAMPLE: AGE, SEX, LENGTH OF STAY .
6. REMAINING WITH THE CHILD AT THE TIME OF

ADMISSION . . . . . . . . . . . . . . . . .
7. VISITING PATTERNS . . . . . . . . . . . . . .
8. PARENTS' VIEW OF THE HOSPITAL EXPERIENCE . . .

9. PBQ TOTAL SCORES FOR CHILDREN ADMITTED AT
11:30 P.M. OR LATER . . . . . . . . . . . .

Appendix

10. DISTRIBUTION OF PBQ FACTOR I SCORE . . . . . .
11. DISTRIBUTION OF PBQ FACTOR II SCORE . . . . .
12. DISTRIBUTION OF PBQ FACTOR III SCORE . . . . .
l3. DISTRIBUTION OF PBQ FACTOR IV SCORE . . . . .
14. DISTRIBUTION OF PBQ FACTOR V SCORE . . . . . .
15. DISTRIBUTION OF PBQ FACTOR VI SCORE . . . . .
16. DISTRIBUTION OF PBQ TOTAL SCORE . . . . . . .

V

Page

50
52
54
56

58

74
76

84

91

127
128
129
130
131
132

133

LIST OF APPENDICES

Appendix Page
A POSTHOSPITAL BEHAVIOR QUESTIONNAIRE . . . . . . 115
B ADDITIONAL INFORMATION SHEET . . . . . . . . . 121

C SCORING PROFILE FOR THE POSTHOSPITAL
BEHAVIOR QUESTIONNAIRE . . . . . . . . . . . 125

D POSTHOSPITAL BEHAVIOR QUESTIONNAIRE SCORES. . . 127
E COVER LETTER FOR PARENTS . . . . . . . . . . . 135
F COVER LETTER FOR PHYSICIANS . . . . . . . . . . 136

G PHYSICIAN'S PERMISSION SHEET . . . . . . . . . 137

vi

CHAPTER I
INTRODUCTI ON
General Statement of the Problem

"Hospitalization as a significant psychologic event
in childhood has been a focus of concern, investigation and
action for two decades" (47, p. 406). During this period
a vast quantity of literature dealing with short-term hos-
pitalization has accumulated; the stressful factors inher-
ent in hospitalization and illness, adaptational patterns
of hospitalized children, and ameliorative measures aimed
at lessening the stress and providing psychological support
have been widely discussed.

It is notable that much of the writing, particu-
larly during the 1930's and.l940's, was the result of spec-
ulative and subjective thought based on clinical experience
(3,7,8,18,24,34,41,42). Although evidence from controlled
research (21,22,28,33,37,38,52,61,69,71) has in general
supported the theses of the clinical observers, much of the
research is lacking in scientific adequacy (67, p. 162-4).

1

Unfortunately, the research has not answered many of the
practical questions which arise in daily practice.

There are many aSpects of the illness-hosPital
experience which are potentially stress-producing for the
child. The effects of operative procedures range from
psychological benefit to deep psychological disturbance
(18.34.37.38,51). Children are differentially affected
by immobilization, special dietary regimes, medications,
and the imposition of nursing care (6,8,24,42). The psy-
chological meaning of the stress encountered, along with
the child's intellectual conceptions, are important varia—
bles in determing the child's reactions (7,8,24,28,29,37,
38).

Apart from the illness itself, the unfamiliarity
of the hOSpital setting (19.37.50.66) and separation from
familiar adults may also have significant consequences.
"Separation anxiety" appears to be the most critical for
children of approximately six months to four years of age
(ll,55,56.57.69).

Also affecting how a child reacts to hospitaliza—
tion and illness is his age (37,52,55,57,69), sex (3)

level of personality development, and the quality of

parental relationships (ll,35.37,38,52,7l).

The adaptational patterns of hospitalized children
have been variously observed and classified by clinicians
and researchers (l6,21,36,37,38,43,44,52,69). Generally,
the effects have been viewed in terms of upset, thus ne-
glecting the possibilities for no change in behavior or
for psychological benefit. The possibilities of using hos-
pitalization as a constructive growth eXperience have been
recently emphasized (6,8,37,38,59,63).

Ameliorative measures, designed to minimize the
traumatic elements and provide positive emotional support
for the child have been introduced into hospital care.
Frequently these changes take place at an amazingly slow
pace and amid much skepticism. Unrestricted visiting and
rooming-in are aimed at counteracting the effects of sep-
aration and unfamiliarity by the maintenance of strong
parent-child relationships (2,3,6,14;47,48,56). HOSpital
play programs are established to help the child c0pe with
the eXperience through supervised play activities and ther—
apeutic group interaction (1,9,13,17,30,32;50,71). Revised
admission procedures, changes in physical facilities,

changes in nursing care, and preparation of the child for

stressful events are other important measures (14,26,29,
31,35,38,47,48,49,50).

The most extensive study of the effects of these
measures was carried out by Prugh (52). The results of
this study showed some benefit for those childrefl who were
hospitalized under an experimental program of ward manage-
ment.

The need for more evidence from empirical studies
on the effects of the ameliorative measures on children's
adaptational patterns is critical. The data from such re-
search may aid not only theoretical understanding of chil-
dren in stressful situations, but may also influence clin-
ical practice so that the care of children in hospitals

can be improved.

Specific Statement of the Problem

The purpose of this study was to investigate the
effect of three ameliorative measures on the posthOSpital
behavioral responses of children. Two hOSpitals were se-
lected for study because they differ with regard to pedi-
atric policies which it was hypothesized would affect chil-

dren's posthOSpital behavioral responses. Hospital I

allowed unrestricted visiting, had provisions for rooming-
in with the child, and had a play program under the direc-
tion of a professional worker. HOSpital II had stated
visiting hours of five hours per day, no play program, and
no provisions for rooming-in with the child on the pediat-
ric ward.

Several researchers (21,37,38,44,52,69) have stud—
ied the effects of hospitalization by measuring the change
in behavior which occurred after the child was discharged
from the hosPital. A recently developed questionnaire, the
PosthosPital Behavior Questionnaire (hereafter referred to
as the PBQ), assesses changes in behavior by means of
twentyeeight questions. The parent is asked to compare the
child's typical behavior prior to hospitalization to the
child's behavior following discharge from the hospital.

A c0py of the PBQ is included in Appendix A.

According to the designers of the PBQ, the assump-
tion that mothers can accurately compare the behavior of
their children was supported by several factors. A study
of twins used a modified form of the PBQ. For this study
the authors supported the use of the questionnaire by not-

~ing the mother's general familiarity with the child's

behavior, the fact that psychological sophistication and
training were not needed because of the nature of the ques-
tions, and the fact that the time period between the be-
havior and the mother's judgment was relatively short (59,
p. 229).

Children who had been patients on the pediatric
wards of Hospital I and II were compared on the basis of
scores obtained on the PBQ. Children from ages two to ten
years were included. An Additional Information Sheet
(Appendix B), deve10ped by the researcher, was used to de-
termine the extent of differences in visiting, rooming—in,
staying with the child following admission, being with the
child prior to and following surgery, and the parents' view
of the hospital experience.

The hypotheses to be examined in this study stated
that children from HOSpital I would manifest less upset
than children from HOSpital II. ApprOpriate statistical
measures were used to determine whether the hypotheses were
supported.

A descriptive technique was employed in analyzing
data from the Additional Information Sheet. Other find-

ings that may be suggestive were also reported.

Definition of Terms

Posthospital behavioral re3ponses--reactions as measured

by the Posthospital Behavior Questionnaire.

Surgical group—-those children on whom a surgical pro-

cedure was performed.

Medical group-—those children on whom a surgical pro-

cedure was not performed.

Play program--an activity centered program for hospital-
ized children under the direction of a profes-

sional worker employed by the hospital.

Rooming-in—-provisions made by the hospital for the mother
(or other family member) to stay with the child,

particularly referring to staying overnight.

Restricted visiting--an administrative policy which defines
Specific visiting hours for parents on the pediat-

ric ward, here referring to five hours per day.

Unrestricted (unlimited) visiting--an administrative policy
which defines no specific visiting hours for par-

ents on the pediatric ward.

General Anxiety and Regression--measured by Items 4, 5, 8,
13, 22, and 28 of the Posthospital Behavior Ques-

tionnaire.

Separation Anxiety-~measured by Items 9, l8, l9, and 21

of the Posthospital Behavior Questionnaire.

Anxiety About Sleep--measured by Items 1, 20, and 23 of

the Posthospital Behavior Questionnaire.

Eating Disturbance--measured by Items 2, 3, and 25 of the

Posthospital Behavior Questionnaire.

Aggression Toward Authority--measured by Items 14 and 16

of the Posthospital Behavior Questionnaire.

Apathy - Withdrawal--measured by Items 10, ll, 15, 24, and

27 of the Posthospital Behavior Questionnaire.

Total Score-~the sum of the six factor scores of the

Posthospital Behavior Questionnaire.

Research Hypotheses to be Examined

The hypotheses to be examined in this study are as

follows:
1. Children discharged from Hospital I will manifest
less General Anxiety and Regression than children

discharged from Hospital II.

2. Children discharged from Hospital I will manifest
less Separation Anxiety than children discharged

from Hospital II.

3. Children discharged from Hospital I will manifest
less Anxiety About Sleep than children discharged

from HosPital II.

4. Children discharged from Hospital I will manifest
less Eating Disturbance than children discharged

from Hospital II.

5. Children discharged from HOSpital I will manifest
less Aggression Toward Authority than children

discharged from Hospital II.

10

Children discharged from Hospital I will manifest
less Apathy-Withdrawal than children discharged

from Hospital II.

Children discharged from Hospital I will manifest
less total upset than children discharged from

HOSpital II.

11

Additional Research Questions to be
Investigated

The following questions were asked, in addition,

to determine what differences exist between the two hos-

pitals on the independent variables of the study:

1.

What differences between HoSpital I and II were
apparent in the length of time a parent stayed

with the child following admission?

What differences between Hospital I and II were
apparent in the time Spent with the child prior

to and following surgery?

What differences between Hospital I and II were
apparent in the visiting patterns of parents and

other family members or friends?

What differences between Hospital I and II were
apparent in how parents viewed the hospital ex-

perience?

CHAPTER II
REVIEW OF LITERATURE
Introduction

Clinical observers and, more recently, research
workers, have sought to evaluate the psychological effects
of illness and short—term hospitalization upon children.
Beginning with the exploratory work in the 1930's and
1940's (4,7,18,34,4l,44,49,58), understanding of the hos-
pitalized child and his emotional needs has been increas-
ing. Efforts are now being made to expand theoretical
knowledge and improve clinical practices by researchers and
clinicians in the fields of medicine, psychiatry, social
work, and education. The need for further clarification is.
repeatedly emphasized. As the writers of a recent review
of literature on the psychological responses of children to
hospitalization and illness indicate, at the present time
such a review of literature results in more questions than

answers (67, p. vi).

12

13

The complexity of factors influencing any child's
response affects both research and clinical practice.
Langford (43) lists thirteen factors which determine how
the child handles the stresses of illness and hosPitaliza-
tion: ‘

1. Age and level of personality development.

2. Attitudes of his parents toward him.

3. Past ways of dealing with new situations.

4. Immediate emotional surroundings of the illness.

5. Nature of the illness: its duration, severity,
acuteness and kind of symptoms.

6. Discomfort involved in diagnostic procedures.

7. Nature of the required medical and surgical pro-
cedures, including the type of anesthesia and
its administration.

8. Meaning of illness in general to the child, his
pre—existing feelings regarding health and dis-

ease, his specific fears and fantasies.

9. Attitudes of the parents toward illness and to
this particular illness.

10. Child's relationship with hospital personnel,
their attitudes and feelings toward him.

11. Nature of the hospital setting, its policies
and practices.

12. Ability of the parents to visit.

13. Type of preparation the child has had for the
experience (43, p. 1).

14

The inclusive nature of these factors points to the
necessity for discriminative selection of the literature to
be reviewed; included in this review are only those writ-
ings which appear to be the most respected in the field and
which are most relevant to the present study. This review
of literature falls into three categories: (1) stressful
factors inherent in illness and hospitalization, (2) adap-
tational patterns of hospitalized children, and (3) amelio-

rative measures and their effect on the child.

Stressful Factors Inherent in
Illness and Hospitalization
Certain factors of stress are inherent in illness
and hospitalization. Although the effects of illness and
hospitalization cannot be entirely separated, certain ex-
clusive aspects can be distinguished. As Vernon §E_§1.
noted, the literature has tended to give little emphasis
to aspects of the situation which produce psychological
benefit, but rather the emphasis has been on potential
sources of upset (67, p. 4).
Deutsch has noted that "Operations performed in

childhood leave indelible traces on the psychic life of

15

the individual" (18, p. 107). Assessing the immediate sig-
nificance of an operation, Freud states that it is "common
knowledge among analysts that any surgical interference
with the child's body may serve as a focal point for the
activation, reactivation, grouping, and rationalization of
ideas of being attacked, overwhelmed, and (or) castrated"
(24, p. 74). Conceptions involving mutilation, hostile
acts, or castration have been frequently repOrted (18,22,
34.37.51).

Jessner §E_§l. studied 150 children undergoing ton-
sillectomy and adenoidectomy. The three foci around which
anxiety were manifested were: (1) separation, (2) anesthe-
sia (narcosis), and (3) the operative procedure. To some
children, narcosis produced anxiety because of fear of loss
of control or fear of death. For others, narcosis served
as reassurance that they would not feel anything or for the
gratification of submissive tendencies. The Operation had
a variety of meanings: mutilation or castration, giving
birth, identification with someone who had undergone an

Operation, punishment, or as an initiation rite.

16

The body part involved affects the response. Blom
mentions that "the heart, brain, genitals, and eyes are
all organs which are particularly invested with uncon-
scious as well as realistic significance, and threats to
them represent the threats of death and the integrity of
the body" (8, p. 591).

Less serious procedures can also have significant
meanings to the child. Fear of needles is most commonly
noted (8,22,34,37,38,52). Erickson studied thirty four—
year-old's interpretations of intrusive procedures (medi—
cine, enemas, temperatures, blood tests, intraveneous
fluids). Through individual play interviews she found
that the hypodermic syringe was interpreted as an instru-
ment of violence or punishment. "The data presented clear
evidence that the majority of children studied perceived
no protective intent of the adult behind the intrusive
procedure but rather considered them as hostile in intent
with the exception of procedures in the oral area" (22,
p.66).

The child may be immobilized. Movement restriction
often precipitates a heightening of aggression. The faCt

that "normal emotional discharge through moVement" is blocked

17

presents Special problems (8,24). Vernon §E_al. noted
that "most authors have emphasized that motor restriction
lead to two principal types of response in children—anger
or hyperactivity" (67, p. 73).

Taking medicine orally is influenced not only by
the immediate sensory responses, but by unconscious mean-
ings (8,24). Other sources of upset include: special die-
tary regimes (8,24,42), missing time from school (12,42,
50), and the increased dependency imposed upon the child
(7,24,27,42).

The degree of pain and objective stress theoretic-
ally could be measured by the Severity of the illness and/
or the length of hospitalization. There has been surpris-
ingly little research which considered the variable of ob-
jective stress. Vernon g§_§1, states that Prugh gt_al.
(52), Schaffer and Callender (57), and Woodward (71)
"concluded that the severity and duration of illness are
not important determinants of psychological upset among
children" (67, p. 144). In a recent study using the PBQ
an attempt was made to evaluate the level of objective
stress. Ratings of the degree of pain were made on the
basis of diagnosis, although the rating criteria were

not reported. The results showed no significant

18

differences in degree of upset as related to degree of
pain, although some differences were found when length of
hospitalization was considered (69).

Other authors have suggested that the degree of
pain and stress cannot be measured by strictly objective
criteria; the psychological meaning of pain and illness
must also be investigated (8.24). Freud noted regarding
Operations, "What the experience means in his life, there-
fore, does not depend on the type or seriousness Of the
Operation which has actually been performed, but on the
type and depth Of fantasies aroused by it" (24, p. 74).

The child's intellectual conception of the ex-
perience is another determinant of response. Children
Often deve10p misconceptions (6,26,29). Jessner £5431.
(37,38) found that fantasy notions Often existed simul-
taneously with realistic conceptions in children undergo-
ing tonsillectomy. "Conceptions involving punishment,
mutilation, death, and abandonment predominate" in the
literature (67, p. 77). In a study by Beverly (7), when
asked why children get Sick, 90% Of the children answered,
"Because they are bad." This finding was further supported

by Gips (28) who studied 100 hospitalized children through

19

the use of a projective technique. She concluded:
Teeming through all the results of this study was
found a central concept Of crime and punishment,
guilt and retribution. For the large number Of
children who believed that they themselves were
responsible for the onset of their illness, it fol-
lowed logically that treatment should be painful .
. . The child who believed that others had caused
his illness, for reasons incomprehensible to him,
nevertheless thought he was being punished. The
heavy arm of morality escaped hardly a child
(28, p. 95-6).

Children's intellectual processes may cause other
problems in interpretation. Children Often cannot distin-
guish between the suffering from the illness and suffering
from the treatment (8). They may also be unable to differ-

entiate procedures for diagnosis and those for treatment

(28).

Apart from factors imposed by the nature Of illness,
several determinants of upset are inherent in the hOSPital
situation. Separation is the most frequently discussed var-
iable. Concern over separation was first stimulated by
studies showing the adverse effects Of institutionalization
and prolonged separation experiences. Following these re-
ports, attempts were made to equate all separation exper-
iences. Further refinement of these theories has led to
critical distinctions. This review considers only short—
term separation experiences in which contact with the mother

figure is maintained.

20

Numerous writers (6,7,11,27,34,38,44,51,55,56,69)
have mentioned the importance of separation, especially
for the preschool child. According to Schaffer and
Callender (57), the period from seven months to three
years is the most critical. Robertson stresses the ef-
fects Of separation for the child under five (55,56).
The immediate effects of separation have been best charac-
terized by Bowlby (11) and Robertson (55). In the process
Of "settling in" to the hospital routine the young child
passes through three stages. The "protest" stage is a
period of crying, confusion, fright, and searching for the
mother. Gradually, "despair" sets in, with the child Show-
ing apathy, withdrawal, and monotonous wailing. During the
last stage, "detachment", the child begins to show more in-
terest in his environment. The fact that all is not well
is seen by his relationship with his mother; he remains re-
mote and apathetic, turning away and seeming to have lost
all interest in her. According to Bowlby (ll), if'a child
has reached only one of the first two stages, the psycho—
logical upset can be fairly easily reversed. The farther
along in "detachment" the child has progressed, the more

irreversible are the reactions.

21

A variety of interpretations have been suggested
for the Observed reactions. Bowlby (11) would stress the
child's emotional attachment to his mother. Absence of her
suggests her loss, and for this reason Bowlby believes that
the three phases are manifestations of mourning. Others
have mentioned the child's dependency on the mother for
care, affection, and attention (7,8,37). The infant's
fundamental fear Of being alone or abandoned, his poor
concept of time, and his interpretation Of the experience
as loss of love, rejection, or punishment have also been
suggested (67).

The unfamiliarity of the hOSpital setting may be
stressful to the child. For the child who has never been
away from home, a myriad of new experiences will be en-
countered. "When they come to the hospital, children usu-
ally find their patterns Of living radically disrupted . .
. TO a child, a hospital is like a foreign country to whose
customs, language, and schedule he must learn to adapt"
(27, p. 126).

Critical variables within the child affect his re-
sponses. The concept Of differential susceptibility to

upset for different age groups has been investigated.

22

Most studies have shown the particular vulnerability of
the young child, primarily because of separation anxiety
(52,55,57,69). Prugh gt_§l. (52) found that for children
in the oedipal stage of development, the meaning of illness
and its treatment had more effect than separation. Jessner
gt_gl. (37) observed that anesthesia was more disturbing
to Older than to younger children.

With regard to sex, the evidence fails to suggest
consistent relationships. Jessner §E_§l, (37), Prugh
gg_gl. (52), and Woodward (71) failed to find significant
sex differences. Jackson (34) has suggested that boys are
more susceptible to upset.

The importance of prehospital personality and par-
ent—child relationships have been discussed. In general,
there is agreement that those children who are undisturbed
before hospitalization and who have sound relationships
with their parents show the least amount Of upset (35,37,
38,52,71). A qualification by Bowlby (11) states that the
young child may be upset regardless of the quality Of par—
ental relationship: in fact, a warm relationship with the
mother may make the child especially vulnerable to the im-

mediate effects Of separation.

23

Adaptational Patterns

 

The adaptational patterns of children facing hOS-
pitalization and illness have been studied from several
different perspectives. Because Of the variety of concep-
tual frameworks and methodologies by which hospitalized
children have been studied, it is difficult to gain a uni-
fied concept of the adaptational patterns. The frequent
lack of clear Operational definitions of the reactions
Observed inhibits comparisons between studies. These re-
actions.may be defined in terms Of psychological processes,
observable behavior, or classes Of behavioral symptoms.

The long-term effects of hospitalization and ill—
ness upon the structure of the personality have most fre-
quently been discussed by psychoanalysts as a result of
their analytic experience (11,18,24,37,49). Because Of
the nature of their samples the effects have been discus-
sed mainly in terms of psychological upset. Recollections
Of childhood Operations and the working through of related
conflicts Show some examples of the dire effects Of hos-
pitalization and illness.

Other workers have described the immediate reac-

tions Of children while still hOSpitalized and/Or their

24

posthOSpital responses, usually up to one year later.

Levy (44) studied the post-Operative reactions of 124 chil-
dren who had been referred for psychiatric help because of
behavior problems. The Observed emotional sequalea in-
cluded: (1) night terrors, (2) negativistic reactions,

(3) dependency reactions, (4) regressive symptoms, and

(5) fears.

Eckenhoff (21) used a questionnaire tO study chil-
dren's reSponses two months following a tonsillectomy.
Parents noted if their children had shown increased inci-
dence of: (1) bed-wetting, (2) night terrors, (3) temper
tantrums, (4) fear Of strangers, (5) fear Of having his
face covered, and (6) fear of new odors.

In a study Of 140 children who underwent tonsil-
lectomy, Jackson §t_31. reported that 91%»Of the group
"seemed either benefited by or were scarcely affected by
the eXperience" (36, p. 27). Thirty percent Of the chil—
dren had a mixed reaction, Showing improvement in some
traits and disturbance in others. The evaluated traits
included: (1) appetite and eating habits, (2) dependency,
(3) disposition (overt expression Of retaliatory feelings),

(4) sleep habits, and (5) mannerisms.

25

Jessner gt_§l. classed the behavioral symptoms as:
(1) eating disturbances, (2) sleep disturbances, (3) Speech
disturbances, (4) tics and mannerisms, (5) fears, and (6)
regressive behavior. They found that the majority Of chil-
dren seemed to be able to master and integrate the exper-
ience without any serious emotional consequences. The
majority did, however, have mild reactions for one week to
ten days following the operation (37).

Schaffer and Callender (57) studied infants age
three weeks to fifty-one weeks. By means of interviews
and Observations, data were collected which showed that
psychological upset was less common among children twenty-
eight weeks of age or less than among children twenty-nine
weeks or Older. Upset was measured by: (1) motor and
vocal functioning, (2) responsiveness to the Observer,
mother, or a toy, and (3) somatic functioning.

Chapman §E_§l. (l6) summarized posthospital re-
sponses: (1) eating problems, (2) Sleep disturbances.

(3) enuresis, or fecal soiling, (4) regression, (5) tics,
(6) depresSion, (7) terror of hpspitals, etc., (8) death
fears, (9) withdrawal, (10) hypochondrial body overconcern,

l

and (11) hysterical symptoms.

26

From his clinical experience Langford (43) has
classified children's reactions: (1) regressive reactions,
(2) rebellious reactions, (3) depression, (4) chronic in-
valid reactions, (5) denial, (6) displacement, (7) docil—
ity, (8) persistent dependency reactions, and (9) construc-
tive responses.

A study by Prugh §E_31. (52) investigated the im-
mediate and long-term reactions Of two groups Of 100 chil-
dren each under traditional and improved conditions of ward
management. The groups were differentiated only by inci-
dence of reaction; both groups exhibited the same reaction
patterns. Overall reactions were classified as severe,
moderate, or minimal. The disturbances for which data are
presented include: (1) feeding, (2) sleeping, (3) toilet,
(4) habit disturbances, (5) aggressive, (6) anxious, (7)
somatization, (8) withdrawn, (9) hyperactivity, (lO) irri—
tability, and (11) restlessness.

Although most studies have primarily focused on
psychological upset, it is important to recognize the po-
tentialities for growth and constructive develOpment (6,8,
37,59,68,72). Jessner gt_§1, (37) found that for some

children a tonsillectomy was a constructive experience

27

because it provided atonement for guilt feelings, a chal-
lenge to the ego strength, a gain in prestige, or an im-
provement in general health.

Many children not only show no immediate adverse
reaction, but are able to achieve new heights Of growth
and develOpment. Possible constructive uses Of the hos-
pital experience include the alteration Of parent-child
relationships, the encouragement of normal growth patterns,
the provision of a refuge from emotional storms, and Oppor-
tunities for identification and education (72). Jessner
§E_§1, (37,38) found that those children who are able to
master their emotions and adapt to the environment used
the following means: (1) the ability to transfer positive
feelings to the medical personnel, (2) the capacity to
interact with other children, (3) ability to direct inter-
est away from themselves and into toys, games, etc., and
(4) the freedom to express themselves in direct unsubli-
mated ways.

When blaming hospitalization and illness for neu-
rotic or psychotic effects, one must exercise considerable
caution. "It is true that changes Of this kind may happen

after a period Of hospitalization. But it is equally true

28

that they happen as well where hospitalization does not
take place . . . When considering the effects of bodily“
illness on the life of the child, it is important to note
that hospitalization is not mere than one factor among
several other potentially harmful and upsetting influences"
(24, p. 70).

In constructing the PBQ Vernon §E_al. (69) reviewed
the work of Beller and Neubauer (5), Eckenhoff (21),
Jackson gg_al.(36), Jessner g£_§l. (37). Levy (44), and
Schaffer and Callender (57). Symptoms mentioned in two or
more of the studies were included in the questionnaire.
The authors stress the need for analyzing subgroups of
symptoms and for examining the relationships between symp-
toms. By means Of factor analysis, six dimensions have
been distinguished. On the basis Of high loadings, the
dimensions have been identified. They have been inter-
preted as being related to:. (1) general anxiety and
regression, (2) Separation anxiety, (3) anxiety about
Sleep, (4) eating disturbances, (5) aggressiOn toward
authority, and (6) apathy-Withdrawal.' A total score in-

cluding all the factors is also determined.

29

The factors were analyzed with reSpect to age, sex,
incidence Of prior hOSpitalization, likelihood of pain dur—
ing hospitalization, length of hospitalization, occupa-
tional status of the parents, and birth order. Significant
differences were Obtained for age, duration Of hospitaliza-
tion, and occupational status.

Age differences were greatest for separation anx-
iety. An examination of questionnaire scores revealed
that the preschool children (6 months to 3 years, 11
months) had particularly high (indicating upset) scores
on the factor of separation anxiety (p < .001). Also sig-
nificant (p < .01) in relation to age was aggression, with
children 6 months to 8 years, 11 months showing equal
amounts of increased aggression. Differences on the basis
of total score were found to be significant at the p < .05
level when age was considered.

Another hypothesis stated that the degree of psy-
chological distress varies directly with the length of
hospitalization. Three day intervals were used for the
analysis. Although the groups did not differ significantly
on total score, Sleep Anxiety (p < .01), Aggression

(p < .001), and Apathy-Withdrawal (p < .01), showed

30

significant differences, with children hOSpitalized for
two to three weeks Showing the most upset.

NO hypotheses were formed for occupational status.
On the Anxiety and Regression factor the clinic patients
appeared to have benefited ( < .001). NO significant
differences were found for other factors.

TO evaluate the overall effects of illness on the
full sample, total score and individual factor scores were
analyzed by t-tests. Significant differences indicative
Of increased psychological upset were found for the total
score (p .01 - .001) and for three factor scores Separa-
tion Anxiety (p < .001); SIeep Anxiety (p .05 - .01); and
Aggression (p < .001). These differences were primarily
the result Of preschool children and the children who
were hOSpitalized for a relatively long term (i.e., two
to three weeks or more).

"These findings, which suggest that the illness-
hospitalization combination is4psychologically upsetting
to children in general, agree with the general direction
Of prior research" (69, p. 591). The hypothesis that

hospitalization is a psychologically upsetting experience

31

i
for children in general was supported; it nSults particu-

larly in increased separation anxiety, increased sleep

anxiety, and increased aggression toward authority.

Ameliorative Measures

 

Recognizing the numerous stressful factors and
the traumatic consequences Of hospitalization for some
children, many approaches have been tried to help the
child OOpe more effectively with the experience. The
American Academy of Pediatrics (2) and the British Min-
istry Of Health (48) have made extensive recommendations
regarding the care Of children in hospitals. Many other
writers have also been concerned with the ameliorative
measures (l4,l9,25,37,42,50,72).

Attempts to counteract separation, particularly
of the young child and his mother, have led to policies
Of unrestricted visiting and rooming-in (2,3,6,l4,47,48).
Recognizing the need for the maintenance of a close mother-

child relationship, hospital authorities have encouraged

32

parents to help in the hospital care of their children and
have begun to view parents not as awkward appendages but
as being of fundamental importance for the child's mental
health (56).

The work of Robertson (54,55,56) has shown that
when parents leave the hospital it is not only natural for
the child to cry. but that greater harm is done if parents
are unable to visit and the child is unable to release his
feelings Of grief about separation and anger about being
left. Objections to visiting because of fears of cross-
infection, crowding, interrupting routines, abuse Of rules
by parents, and harm to children are being overcome (47).

Illingworth and Holt (33), Observing children's
reactions to visiting, noted that it was far better for
the child to see his mother every day than to allow the
child to become more certain he had been deserted. He
found that frequently parents expended great amounts Of
time, money, and energy to be able to visit their children.
Woodward (71) followed up seventy-five burned children and
showed that emotional disturbance was significantly
(p < .01) less among children who had been visited two or

three times daily than among children who had been visited

33

one to three times weekly.

Spence (62) has admitted children with mothers for
many years and found it to be advantageous to the child,
the mother, the nurse, and other children on the ward.
Parents who roomed-in with their child were questioned by
MacCarthy g§_§l, (46). When asked about repeating the ex-
perience, generally an emphatic "yes" was given. The up-
sets reported were "rather trivial." Fagin (23) compared
the effects of visiting and rooming-in. By means Of inter-
views it was found that restricted visiting was associated
with psychological upset while rooming—in was associated
with psychological benefit. '

Often unrestricted visiting is available only in
wards which also provide rooming-in accomodations; here
the approach is to encourage the parent to maintain con-
tact in whatever manner is best suitable. As indicated by
parents' letters, when mothers are allowed to live in all
levels Of staff are generally viewed favorably. When re-
strictions Of visiting and physical contact are imposed,
the hospital and its staff are more likely to be viewed

with frustration, apprehension, and criticism (56).

34

Two films by Robertson and Bowlby, A Two—Year Old
Goes tO the Hospita1_(10) and Goingto Hospital with Mother
(54), give an excellent comparison of the hospitalization
Of young children under the restricted and liberal polic-
ies; in the second film the child receives the needed sup-
port by being able to have her mother present at all times.
Recognition Of the fundamental importance of the mother for
the child's happiness and mental health has come slowly;
understanding of the implications for hospital practice
has been even Slower yet (56).

Another important development in the hospital care
Of children has been the inclusion of play programs. The
benefits Of such programs, their organizational structure,
and various aspects Of programming have been frequently
discussed (1,9,13,17,30,32,50,70). Although programs vary
because Of individual hospital setting and because Of a
variety Of professional identifications, four widely sup-
ported goals can be identified.

The literature emphasizes that the play program
gives the child the Opportunity for emotional expression,

particularly for the expression of feelings about illness

35

and the hospital. Children are helped to think through
their feelings instead Of repressing them (17). "In the
warm, non-threatening atmosphere of the group, children
Often play out, or talk out, their anxieties and fears
about the whole experience Of being in the hospital"
(1, p. 218).

The special position of the child care worker
(group worker, teacher, therapist, "playlady", etc.) as a
warm, sympathetic and concerned adult has been emphasized.
"The therapist is not directly connected with the child's
medical care and, as a result, She is more likely to be
associated by the child with the supportive figures from
his normal life" (9, p. 134). For the young child, the
child care worker acts as a mother substitute (1,9,17,32,
65). In an Observational study by Harvey gg_§l, (32) it
was found that children with good play provisions had
more contacts with other hospital personnel (5 contacts
per hour) than those children with poor play provisions
(.76 contacts per hour).

The importance of sharing the experiences with

other children and being able to identify with others

36

has been stressed. Brooks reports that there are “many
examples of how children gain support, comfort, and re-
assurance from their friends, to say nothing of the satis—
faction an Older child may get from caring for one who is
much younger" (13, p. 10). The reassurances children can
give each other are far beyond those that can be given by
an adult, whose help, no matter how well-meaning, Often
appears as a new threat (1).

The play program attempts to alter the child's
View of the hospital; the child's environment is made
more relaxed, accepting, and satisfying (17). The pro-
gram is designed tO help the child realize that even though
unpleasant and painful procedures are Often necessary,
there is something to look forward to, that he can return
to play again with materials which he enjoys using (13).
The importance Of the return to more normal patterns of
life (30,64) and the expression Of the child's initiative
and autonomy (1,17,64,70) are also discussed.

The Harvey SE_§l- study found that where super—
vised play was provided the children occupied themselves

with settled play for an average Of 39.4 minutes; where

37

there was no play leader settled play lasted an average
of 3.8 minutes (32).

Distinct from a play program is the provision for
educational programming. The importance of children con-
tinuing to learn and being able to keep up in school is
generally recognized (12,19,50).

Preparation of the child has been widely advocated.
The basis for preparation is to counteract the stress Of
unfamiliarity. The emphases are: "(a) that vague, unde-
fined threats are more upsetting than threats which are
known and understood, and (b) that unexpected stress is
more upsetting than expected stress" (67, p. 9). Prep-
aration of the child for the hospital may include discus-
sion with the physician, parent, and/Or other workers (6,
l4,26,29,38,47,48). Practical guidelines for determining
what the child should be told before going to the hOSpital
are included in Geist (26). Mason (47) lists several
pamphlets on a child's level which may be used in prepara-
tion. Some hospitals have initiated programs allowing

the child direct contact with the hOSpital (19,25,63).

38

It is considered critical that the child be pre-
pared for surgical or other procedures. Psychological
preparation includes not only explanations Of what will
happen but a recognition and acceptance of the child's
feelings about the procedure (29,31,35,49,50). Haller
reports that it is "no longer enough to say that a surgi-
cal procedure Or Operation was in itself successful . . .
The patient must remain a whole child and be able to look
upon his hospital experience as a new adventure" (31, p.
25).

Revised admission procedures allow the parents to
remain with the child (6,14,26,48,50). The child is al-
lowed time to become used to the hospital with the support
of his parents who are able to accompany him to the floor.
Previously the child and parents were separated upon en-
trance tO the hospital and various routines and procedures
were immediately performed on the child.

Changes in the nursing care have improved the care
of children (2,6,14,19,26,48,50). An important advance is

the development Of home care programs (45). Unique home

39

care programs provide Special medical consultation. They
are designed to bring the child back to health without
imposing on him the stress of hOSpitalization.

The most extensive study of the effects of a spec-
ial care program on children was carried out by Prugh gg_§l.
(52). Two hundred children, one hundred each in control
and experimental group, were selected for study. Those
in the control group were hOSpitalized under traditional
ward procedures. The experimental program included daily
visiting, a special play program, revised admission pro-
cedures, psychological preparation for procedures, early
ambulation, interdisciplinary ward conferences, etc.

From interviews with the parents and Observations Of the
children on the ward, data on the child's reactions were
Obtained. Measurement criteria included degree of reac-
tion, degree of stress encountered, previous adjustment,
nature of the mother—child relationship, the child's ad-
justment to the hospital, and the parent's adjustment to
the hOSpital. Follow-up studies were carried out at three
weeks, three months, and, for some children, up to one

year later.

 

 

40

In the control group 92% of the children showed
moderate or severe immediate reactions in comparison with
68% in the experimental group (p < .01). The experimental
group Showed a significantly lower percentage Of severe
immediate reactions (14%.in experimental group, 36% in
control group) and a higher percentage of minimal reac-
tions (32%.as Opposed to 8%). Children under three years
showed the highest incidence Of severe reactions (50% in
control group, 37% in experimental); children from six to
twelve showed the lowest incidence of severe reactions
(27%.in control, none in experimental).

The long-term effects (three months after dis—
charge) showed that 58% Of the control group and 44%.Of
the experimental group exhibited what were regarded as
disturbing reactions of at least moderate degree. Five
children in the experimental group were considered to
have improved in their adjustment following hospitaliza-
tion.

The authors conclude that the experimental program
"appears to have produced a significant lowering Of the

incidence and severity Of reactions at all age levels,

41

most evident among children over four years of age" (52,
p. 103). The exploratory nature of the study and the need

for further study and clarification were emphasized.

Summary

A review of literature seems to indicate that pro-
found psychological effects may result from a child's hOS-
pitalization and illness. The effect on the child is
determined by many interrelated factors; included are the
stresses and supports as a result Of being ill, of being
in the hOSpital, and Of being influenced by one's previous
development. Reactions to the experience vary from being
able to use the event as a constructive force for further
growth to showing pathological responses which inhibit
further growth. Many forward-looking members Of the medi—
cal community have sought to make hospitalization easier
for the child and have introduced a variety Of measures
to assist the child in coping with the experience.‘ The

need for further research in this area is critical.

CHAPTER III
METHODOLOGY
Description Of the Hospitals

The two hospitals selected for study differed with
respect to administrative policies and provisions effective
on the pediatric wards. The information reported here rep-
resents the stated administrative policy Of each hospital.
Other than information reported on the Additional Informa-
tion Sheet, no attempt was made to evaluate the degree to
which these policies generally were carried out. It was
not possible to determine if there were differences in the
quality of medical care. Data relative to rooming-in,
staying with the child after admission, and being with the
child before and after surgery are provided in Chapter IV
from information on the Additional Information Sheet.

Both hospitals were located in a medium-sized mid—
western community. Neither the names of the hospitals nor
the name Of the community were revealed because of the
nature Of the study.

42

43

Hospital I

Hospital I is a 460 bed general hospital. The
pediatric ward contains forty-eight beds and admits chil-
dren from birth to fourteen years.

A playroom near the end of one hall is Open for
use at any time. Open Shelves and an unlocked cupboard
contain play materials accessible to parents, hospital
staff and children. Materials for the play program are
stored in locked cupboards in the playroom. The play
program is usually held in this room.

In this hospital there are no restrictions on the
hours parents can visit. Unlimited visiting hours were
first put into effect about ten months prior to the col-
lection Of data for this study. Visiting by other family
members or friends is left to the discretion Of the charge
nurse; reasonable requests are usually granted.

Rooming-in parents are accommodated by placing a
cot near the child's bed. There is no charge for this
service; no child is deprived because of his parent's in-
ability to pay. Although rooming-in was available in
another part Of the hospital for several years, it was

not available on the pediatric unit until a move to a new

44

section of the hospital made it feasible in terms of
Space. This occurred approximately two months prior to
the beginning of data collection.

A school teacher, appointed by the Board Of Edu-
cation Of the city, has a full-time assignment at this
hOSpital. She works with students from other floors of
the hospital as well as with those from the pediatric
unit. Teaching is usually on an individual basis.

The play program was established by the Medical
Social Service Department of this hospital approximately
ten months prior to the study. The researcher has been
the Coordinator of this program for seven months prior
to the study. Children Of approximately two years and
Older are included. Children who are not ambulatory are
brought to the program in wheel chairs or beds. Any child
may be automatically included if his physical condition
permits. Decisions about the children's participation
are made jointly by the Coordinator of the program and
the nurse in charge.

The program could be described as a non-directive
approach to working with groups Of children. At present

it Operates from 10:00 to 11:30 each weekday morning.

45

The purposes it serves for the children can be described as
providing for emotional release, for contact with peers,
for satisfying adult-child relationships, and for helping
the child to have a constructive view of the hospital.
The importance of play and activities as a child's way
of learning and expressing himself is central to the pro-
gram. The purpose of the program as stated in the pro—
posal for the pilot project (first six-monthS) is as
follows:
Purpose--The basic purpose will be to minimize
the emotional trauma of hospitalization and to
avoid possible resultant, severe and persevering
emotional disturbances. This purpose may be ac-
complished by Offering a special melieu for the
hospitalized child to continue normal growth and
development in a positive, creative atmosphere
where he can 'play-out,' verbalize and/Or discuss
his anxieties, fears, anger, and other feelings
caused by hospitalization, separation from parents
and necessary medical procedures required to re-
store him to physical health.

A group Of volunteer women have worked on the pedi-
atric ward for many years. At present they work under the
supervision Of the Coordinator Of the play program. They
function with the group or with individual or small groups

Of children who are unable or uninterested in coming to

the group program.

46

Hospital II

Hospital II is a religiously-affiliated hospital
with 335 beds. The pediatric ward has a capacity of forty-
six beds and admits children from birth to fourteen years.

The pediatric visiting hours in this hospital are
from 11 to l and 4 to 7. Special arrangements can be made
for parents who work or have other special problems in
being able to visit during the stated hours. It is hOped
that parents will leave in the evening by 7:30 so that the
children may "settle down." Parents are not asked to
leave at the end Of visiting hours on the child's first
day in the hospital.

There are no provisions for rooming-in on the pedi—
atric ward.

Educational services are provided for individual
cases through the Homebound Teaching Program of the city.
There is no full-time teacher at the hospital.

The playroom is used for pre-and post-surgical
cases and for children with non-infectious diseases.
Children are allowed to be in the play room at any time
during the day except from 3:00 to 3:30 when the nurse's

report is given. Toys and play things are available.

47

Recreational facilities are provided by various
groups. One adult group, a hospital auxiliary, provides
puppets for each child. These are distributed by the aux—
iliary members who come to the ward three times each week.
These women also assist the children with craft projects.

Two volunteer groups Of high school students also
work on the pediatric ward. One group works mainly during
the summer, the other during the school year on weekends
and after school. Both groups are supervised by the charge
nurse. Their activities consist Of entertaining children
in the playroom, taking care Of small children, and help-
ing with cleaning or other ward tasks.

During their pediatric nursing experience, the
student nurses (from the hospital's own nursing school)
Spend part of their time as "playladies." They plan ac-

tivities to be carried out with the children.

Permission for the Study

Permission to collect data in each hOSpital was
Obtained from the respective administrative personnel and

the governing bodies of physicians.

48

Permission to include children in the study was
Obtained from physicians who had patients on the respec-
tive pediatric wards. The physicians received a cover
letter explaining the study (see Appendix F), a c0py of
the PBQ, and a permission sheet to return (See Appendix G).

In Hospital I general practitioners, pediatricians,
and other specialists were included in the original mail-
ing. In Hospital II only general practitioners and pedia-
tricians were included in the original mailing. Other
Specialists were included in a second and third mailing.
Several physicians practiced at both hospitals.

Two weeks following the original mailing approxi-
mately 50% Of the permission forms had been returned. At
this time follow-up was made by telephone and duplicates
Of the material mailed if necessary. This resulted in
additional returns. Data collection began approximately
two weeks after the follow-up. Only those children whose
attending physician had granted permission were included

in the study.

49

Data Collection

The following information was conveyed to the re-
searcher by the Medical Records Department Of each hos-
pital:

Child's name

Sex

Birth date

Date Of admission

Date Of discharge

Admitting diagnosis

Attending physician

Parents' (or guardians') name
Address

kamxlmuluP-wNI—a

The PBQ was mailed to the parents (or guardians)
of all subjects six days following discharge from the hos-
pital. A cover letter (see Appendix E), mimeographed on
stationary of the hospital from which the child was dis—
charged, accompanied the questionnaire. Both were mailed
in hOSpital envelopes. A stamped envelope addressed to
the researcher at her home was provided for return Of the
questionnaire.

The original intent Of this study was to have two
groups Of thirty subjects each, one group from each hOSpi-
tal. For HOSpital I, 60 questionnaires were mailed over
a period Of 37 days, resulting in 37 returned question-

naires. For Hospital II, 48 questionnaires were mailed

50

over a 57 day period. Twenty-seven questionnaires were
returned. Data collection was begun on the same day for
both hospitals; for HOSpital II it extended 20 days longer
than for Hospital I. Table I presents a summary of this

information.

TABLE 1

NUMBER OF QUESTIONNAIRES MAILED, RETURNED,
AND USED: LENGTH OF MAILING TIME

 

Factor Hospital I Hospital II

 

Total number of question-

naires mailed 60 48
Total returned 37 27
% returned 62% 56%
Unuseable returns 0 2

Returns included in
data analysis 37 25

Length of mailing time 37 days 57 days

 

All questionnaires returned from Hospital I were
used in the data analysis. Two questionnaires from Hos-
pital II were not used. One was eliminated because the

child had surgery; no other children from Hospital II had

51

surgery. Another was eliminated because the child was
hospitalized for an extreme length Of time (Six weeks)
and because there was a question as to whether the res—

pondent had a sufficient command Of English.

Sample

Criteria for inclusion in the study included:

(1) the child must have been between the ages Of 2.0 and
9.11 at the time Of discharge. (2) the child must have
been on the pediatric ward for the entire period of hos-
pitalization, (3) the child's attending physician must
have granted permission to study his patients, and (4) no
child was included who was hospitalized solely for the
purpose Of a tonsillectomy and adenoidectomy.

Sixty—two questionnaires were returned from the
two hospitals. The sample was divided into three groups
on the basis of medical diagnosis: 15 medical patients
from Hospital I, 25 medical patients from Hospital II,
and 22 surgical patients from HOSpital I. A surgical
group from Hospital II could not be obtained. Placement

in a medical or surgical group was based on the admission

52

diagnosis and on the parent's answer to question 30 of
the Additional Information Sheet regarding visiting prior
to surgery.

Information concerning the age, sex, length of
hospitalization, PBQ total score, and admitting diagnosis

for the three groups is presented in Tables 2, 3, and 4.

TABLE 2

HOSPITAL I MEDICAL PATIENTS

 

 

Days Of
HOSpital- PBQ Total
Age Sex ization Score Admitting Diagnosis
2.1 F 3 68 Observation-fell from
2nd story window
4.11 F 7 68 fever of undetermined
origin
2.0 M 10 69 Pneumonia
2.6 M 6 69 pneumonia
3.3 F 4 69 inflamation of bowels
4.7 F 9 69 right lobar pneumonia
5.10 M 4 69 swollen knee

8.0 M 2 70 concussion

5.8 M 2 75 cellulitis right calf

53

Table 2, cont'd.

 

 

Days Of
Hospital- PBQ Total
Age Sex ization Score Admitting Diagnosis
5.1 F 4 76 convulsions, cellu—
litis Of forearm,
cerebral palsy
2.2 M 6 77 gastroenteritis,
dehydration
3.9 F 2 81 upper respiratory
infection
2.4 F 5 83 upper respiratory
infection and dif-
ficulty breathing
4.9 M 9 84 infected asthma

6.3 F 5 91 acute rheumatic fever

 

54

TABLE 3

HOSPITAL II--MEDICAL PATIENTS

 

 

 

Days Of
Hospital- PBQ Total

Age Sex ization Score Admitting Diagnosis

6.6 F 12 65 pneumonia

4.10 M 17 66 fever of undeter-
mined origin

5.8 M 12 67 chronic nephritis

5.2 F 8 68 fever of undeter-
mined origin

2.3 F 7 69 diarrhea, vomiting

3.0 M 8 69 pneumonitis

5.3 F 7 69 possible appendix

5.4 F 8 69 upper respiratory
infection

5.11 M 2 69 concussion

7.1 F 8 69 possible meningo-
cOccus septicemia

7.2 M 7 69 bronchial pneumonia

5.10 F 6 70 possible appendicitis

8.2 F 7 7O nephritis

55

Table 3, cont'd.

_ —
L 4—

 

 

Days of
Hospital— PBQ Total
Age Sex ization Score Admitting Diagnosis
8.11 F 10 70 upper respiratory
infection, nephritis
5.6 M 2 71 bronchial asthma
7.6 M 9 71 flu, muscular
dystrOphy*
2.1 M 3 72 laryngo tracheo
bronchitis
2.7 F 15 73 acute gastroenteritis
5.1 F 9 73 acute pharyngitis,
possible pneumonitis
2.8 F 8 V 75 skull fracture
3.8 M 7 77 ingestion gasoline
6.5 F 14 77 tracheal bronchitis
3.5 M 5 78 diarrhea, dehydration
3.6 M 4 78 hives
2.4 M 11 84 pneumonia

 

* from Additional Information Sheet.

56

TABLE 4

HOSPITAL I--SURGICAL PATIENTS

f

 

._—__

 

Days Of
HOspital- PBQ Total
Age Sex ization Score Admitting Diagnosis
3.3 M 8 67 mass left knee
8.4 M 7 67 appendicitis
4.5 F 3 69 strabisms right eye
5.5 M 5 69 cataract left eye
5.9 M 7 69 bilateral tympano-
plasty
5.10 M 1 69 possible torsion
5.11 F 2 69 paracentesis Of tubes
6.2 M 3 69 undescended testicle
right
9.8 M 3 69 otitis media, adenoids
2.1 M 3 70 dermoid cyst upper
left lid
6.0 M 4 70 appendicitis
2.3 F 2 7l strabisms
5.1 M 2 71 umbilical hernia, wart

left third finger

57

 

 

Table 4, cont'd.
Days of
Hospital- PBQ Total
Age Sex ization Score Admitting Diagnosis
6.11 M 6 71 burn scar right
angle mouth
7.2 M 10 71 possible appendicitis,
bilateral otitis media
9.7 M 3 71 urinary tract infec-
tion
4.6 M 4 73 tympanoplasty
4.8 F 3 73 recurrent urinary
tract infection
2.1 M 9 74 right inguinal hernia
3.0 M 2 79 right inguinal hernia
3.4 M 6 80 abdominal pains
4.3 F 5 84 right bronchial cleft,,

tonsillectomy, ade-
noidectomy

 

An analysis Of the total sample shows that both

medical groups had an approximately equal distribution be-

tween the sexes.

Hospital I surgical group, however, con—

sisted of more than three times as many.boys as girls. The

average age ranges Of the three groups were within one year

58

and one month of each other. Hospital I medical patients
were hospitalized for an average of three days less than
Hospital II medical patients. Table 5 presents a summary

of this data.

TABLE 5

SUMMARY OF SAMPLE: SEX, AGE, LENGTH OF STAY

 

 

Hospital I Hospital II HOSpital I

Factor Medical Medical Surgical
Number Of boys 7 12 17
Number Of girls 8 13 5
Age range 2.0-8.0 2.1—8.11 2.1-9.7
Average age 4.2 5.0 5.3
Range Of length
Of stay 2-10 days 2—17 days 1-10 days
Average length
Of stay 5.2 days 8.2 days 4.5 days

 

59
Research Instrument

The PBQ (see appendix) was deve10ped by Vernon,
Schulman, and Foley to assess changes in behavior follow-
ing hospitalization. Items in the questionnaire repre-
sent symptoms mentioned in two or more Of the following
studies dealing with hospitalization and illness: Beller
and Neubauer (5), Eckenhoff (21), Jackson §§_31. (36),
Levy (44), and Schaffer and Callender (57). The twenty—
eight questions assess behavior which would be commonly
Observed by the parents. For each item the parent com-
pares the child's typical behavior before hospitalization
with his behavior during the first week after hospitaliza-
tion. (The five response categories and their numerical
scores are as follows: (a) "much less than before"--scored l,
(b) "less than before"——scored 2, (c) "same as before"--
Scored 3, (d) "more than before"--scored 4, and (e) "much
more than before"--scored 5.

The results of factor analysis showed that the
items fell into six groups. The researchers have made

yinterpretations Of these groups (69).

60

Factor I General Anxiety and Regression
(Items 4,5,6,8,12,13,22,28)

Questions 5 (afraid of leaving the house) and 12
(afraid Of new things) reflect the tendency Of the child
to remain in familiar surroundings and reduce the exposure
to new and presumably threatening experiences. Item 12
(afraid of new things) was not scored, however, because it
also loaded highly on Factor VI. The three habit disturb-
ances (Item 4-—need for a pacifier; Item 8—-nail biting;
Item 28--thumb sucking) may be considered as evidence of
anxiety and regression. A fourth habit disturbance (Item
22--irregular bowel function) may be variously interpreted
as evidence Of anxiety, Of psychosomatic disturbance, or
Of a change in routine. General anxiety or fear of punish-
ment may be reflected in Item 13 (difficulty in arriving
at decisions). Lack Of interest (Item 6) loaded poorly
and was difficult to interpret; it was not included in the
scoring because of its low loading on all factors. In sum-
mary, the following questions were scored for Factor I:

Items 4, 5, 8, 13 22, and 28.

61
Factor II Separation Anxiety
(Items 9,17,18,19,21)

Three items (Item 9--upset when left alone; Item
18--following parent; Item l9-trying to get attention) are
clear expressions Of separation anxiety or the desire to
remain near familiar adults. Bad dreams and night awaken-
ing (Item 21), although commonly evidence of anxiety, may
have reflected a manipulative attempt on the part of the
child for reunion with the parents. Item 17 (upset in re—
lation to mention of the doctor or hospital) suggests fear
Of a traumatic experience in which separation is usually
a prominent feature. Item 17 was not included in the
scoring because of low loadings on all factors. In sum-
mary, items scored for Factor II including Items 9,18,19,
and 21.

Factor III Anxiety About Sleep
(Items 1,20,23)

Items I (fuss about going to bed), 20 (complain-
ing about the dark), and 23 (having trouble getting to
sleep) indicate either fear or reluctance in relation to

going to bed. Items 1,20, and 23 were all scored.

62
Factor IV Eating Disturbance
(Items 2,3,25)

Fuss about eating (Item 2) and poor appetite
(Item 25) were interpreted as being centrally involved
with feeding disturbances.3 Item 3 (doing nothing) is not
directly related, but it was hypothesized that an eating
disturbance tends to be accompanied by a degree of apathy
or lassitude. Items 2, 3, and 25 were all scored.

Factor V Aggression Toward Authority
Items 14, 26)

Both Item 14 (temper tantrums) and Item 26 (tend—
ing to disobey) reflect an active rebelliousness directed
primarily at parents. Reasons for this reaction may be
because Of the reinforcement of discipline relaxed during
illness and because of hostility and resentment toward
the parent for permitting the hospital eXperience to occur.
Both Items 14 and 26 were scored.

Factor VI Apathy-Withdrawal
(Items 7,10,11,15,24,27)

Item 11 (difficult to interest in doing things)
implies apathy or lassitude. Needing help in doing things
(Item 10) and difficulty in getting the child to talk to

the mother (Item 15) may imply regression or apathy.

63

Fear of strangers (Item 24) may reflect reluctance to in—
teract with strangers as a result of apathy. Wetting the
bed (Item 7) had low loadings on all factors and was not

scored. Items used in the scoring for Factor VI included

q

10, 11, 15, 24, and 27.

Total Score (the sum of all Factor scores)
This score indicated the direction of change as

reflected by the scored test items.

Item 16 (fighting with brother and sisters) was
not scored because Of inconsistency with other items.

In summary, 23 of the 28 items were used for the
scoring. The scoring system used for this research was
that used by Vernon 2E_2l- (69). It is included in

Appendix C.

Reliability

The researchers (69) stated that preliminary
studies, although not conclusive in all reSpects, sug-
gested that the total score is stable over a one month
interval. A form of the questionnaire (three response

categories instead of five) was used by Cassell (14) who

64

studied 37 children three to eleven years of age under-
going cardiac catherization. Total scores from the two
administrations Of the questionnaire (three days after
discharge and one month after discharge) were positively

correlated (rdO.9S, P < 0.0001 by two-tailed test).

Validity

The validity of the questionnaire was supported
by comparison Of total scores with independent ratings of
nondirective interviews with parents. The correlation be-
tween total test score and independent ratings Of a child
psychiatrist who briefly interviewed the parents at a
routine examination approximately one week after hospital-
ization was 0.47 (0.05 > P > 0.02 by two—tailed test).
The parents were asked about changes in the child's be-
havior following hospitalization, but particular symptoms
(as those in the PBQ) were not discussed unless brought up
first by the parent. A clinical psychologist's independent
ratings of tape recordings Of the interviews showed high
agreement with the ratings Of the psychiatrist (r-0.95,

P < 0.001).

65

A comparison of questionnaire scores for three
groups of children who underwent tonsillectomy (i.e.,
parent interviewed, parent not interviewed but filled
out the questionnaire in the hospital, and parent not in-
terviewed and mailed the questionnaire) suggested that the
interview and the fact Of filling out the questionnaire in
the hospital did not bias the questionnaire scores in any

fashion.

Additional Information Sheet

In order to determine what differences parents
would report when asked about ameliorative measures, an
Additional Information Sheet was developed. The two forms
(see Appendix B) were identical with the exception of an
additional questiOn for Hospital I which asked whether the
parent and roomed-in with the child and for how many
nights.

The first two sets of questions (remaining with
the child following admission and visiting on the day of
surgery) were asked because they both reflect changes in
pediatric care. Although it did not appear that there

should be differences on the basis of the administrative

66

policy, it seemed necessary to collect this data from
the parents.

A question on visiting was included to determine
how visiting patterns differed as a result of the re-
stricted vs. unrestricted visiting policy.

A question concerning previous hospitalization
was included to determine if this variable had an effect
on the PBQ scores of children from either hOSpital.

Two general questions about how the child reacted
and how the parents felt about having the child in the
hospital were included. Their purpose was to assess how
parents viewed the hospital experience. They were in-
cluded with no expectations as to how the answers would
be categorized but as exploratory questions which would

be analyzed according to the pattern of reSponses.

CHAPTER IV

RESEARCH FINDINGS

The seven hypotheses Of this study were tested by
statistical methods. A descriptive technique was used to
analyze data pertinent to the research questions. Other
findings were also analyzed by means of a descriptive

technique.

Statistical Tests Of the Hypotheses

The Kruskal-Wallace one—way analysis of variance
by ranks was used to test the hypotheses. A nonparametric
statistic was chosen because of the skewed distribution of
the data and because the samples were not distributed with
equal variance. "The Kruskal-Wallace technique tests the
null hypothesis that k samples came from the same popula-
tion or from identical pOpulations with reSpect to aver-
ages" (60, p. 184). TO compute to Kruskal-Wallace test
all scores are replaced by ranks; the value Of H is then

computed. It has a chi square distribution with df = k - l.

67

68

TO be significant at the .05 level Of confidence an H

value of 5.99 with df - 2 was needed.

Hypothesis 1

Children discharged from Hospital I will manifest
less General Anxiety and Regression than children dis-
charged from Hospital II.

Table 10 (see Appendix D) shows the distribution
of scores on Factor I.

Calculation of the Kruskal-Wallace one-way anal-
ysis Of variance resulted in an H value Of 1.45. With
df - 2, this value was not stfinificant at the .05 level.

Hypothesis 1 of this study was not supported.

Hypothesis 2

Children discharged from Hospital I will manifest
less Separation Anxiety than children discharged from
Hospital II.

Table II (See Appendix D) shows the distribution
Of scores of Factor II.

Calculation Of the Kruskal-Wallace one-way anal-
ysis Of variance resulted in an H value Of 3.88. With
df"2, this value was not significant at the .05 level.

Hypothesis 2 of this study was not supported.

69

Hypothesis'3

Children discharged from Hospital I will manifest
less Anxiety About Sleep than children discharged from
Hospital II.

Table 12 (see Appendix D) shows the distribution
of scores on Factor III.

Calculation of the Kruskal-Wallace one-way anal-
ysis Of variance resulted in an H value of 1.28. With
df - 2, this value was not significant at the .05 level.

Hypothesis 3 of this study was not supported.

Hypothesis 4

Children discharged from Hospital I will manifest
less Eating Disturbance than children discharged from
Hospital II.

Table 13 (see Appendix D) shows the distribution
Of scores on Factor IV.

Calculation Of the Kruskal-Wallace one-way anal-
ysis of variance resulted in a H value of 4.06. With
df = 2, this value was not significant at the .05 level.

Hypothesis 4 of this study was not supported.

Hypothesis 5
Children discharged from Hospital I will manifest

less Aggression Toward Authority than children discharged

70
from HOSpital II.
Table 14 (see Appendix D) Shows the distribution
Of scores on Factor V.
Calculation Of the Kruskal-Wallace one-way anal-
ysis of variance resulted in an H value of 1.63. With
df - 2, this value was not significant at the .05 level.

Hypothesis 5 Of this study was not supported.

Hypothesis 6

Children discharged from Hospital I will manifest
less Apathy—Withdrawal than children discharged from
Hospital II.

Table 15 (see Appendix D) shows the distribution
of scores on Factor VI.

Calculation Of the Kruskal—Wallace one-way anal-
ysis of variance resulted in an H value of .88. With
df - 2, this value wasnot significant at the .05 level.

Hypothesis 6 Of this study was not supported.

Hypothesis 7
Children discharged from Hospital I will manifest
less total upset than children discharged from H08pital II.
Table 16 (see Appendix D) shows the distribution
Of scores for the total score.

Calculation of the Kurskal-Wallace one—way analysis

71

of variance resulted in an H value of .51. With df - 2,
this value was not significant at the .05 level. Hypoth—
esis 7 of this study was not supported.

In summary, none Of the hypotheses of this study
were supported. Those children discharged from Hospital I
did not manifest less upset than children discharged from
Hospital II. This finding seemed to be a result mainly Of
the problems and limitations encountered in this study.

These are discussed in Chapter V.

Descriptive Analysis of the Additional
Research Questions

In order to determine what differences existed
between the two hospitals in relation to remaining with
the child following admission, visiting on the day of sur-
gery, daily visiting patterns, and the parents' view Of the
hospital experience, parents were asked to fill out the Ad-
ditional Information Sheet. The following section uses a
descriptive technique to analyze this information which

was collected to answer the research questions.

Research Question 1
What differences between Hospital I and II were
apparent in the length Of time a parent stayed with the

child following admission?

72

Data pertaining to this question were Obtained
from parents' answers to the following set of questions:

What time was your child admitted to the
hospital?

What time did you leave the child on the day
Of admission?

The number of hours a parent remained with the child
was determined from those responses which could be scored
for a specific number of hours. For example, a reSponse
of 1 p.m. for admitting time and 3 p.m. for the parent leav-
ing would be counted as remaining with the child for two
hours. In all groups there were responses which could not
be scored. Included were illogical responses (7 p.m. to
2 p.m.), some Of which indicated that the parent had been
in the hospital overnight but had not roomed-in (the child
was in Hospital II or the parent from Hospital I responded
negatively to the question regarding rooming-in). Hours
from 10:00 A.M. to 11:30 A.M. were frequently mentioned as
the time the parent left. This would be a usual time for
discharge and it is suggested that the parent may have
responded according tO the time the child was discharged.

The mean number of hours as determined from the

scorable responses showed that there was .66 hours

73

difference between the three groups. In order of increas-

ing number of hours, the parents stayed for 2.96 hours

(Hospital I surgical), 3.3 hours (Hospital II medical),

and 3.5 hours (HOSpital I medical).

The parents who indicated that they had remained

the longest were those in Hospital II medical group in

three cases where the child was admitted at 10:00,
and 11:00. These parents remained respectively 9,
8.5 hours. In HOSpital I no child was admitted in
morning before noon.

In some cases the responses indicated that
parent had stayed, even though the specific number
could not be determined. For instance, the parent
the second question with "after he was settled" or

afterward and then returned." In Hospital I, 3 of

10:30,
10, and

the

the

of hours
answered
"shortly

15 medi-

cal parents, and 5 of 22 surgical parents had responses of

this type. In Hospital II, 1 out of 22 parents responded

in this manner. A discussion of the possible meaning of

this type of response is delayed until visiting patterns

are discussed.

A summary of this information is provided in

Table 6.

74

TABLE 6

REMAINING WITH THE CHILD
AT THE TIME OF ADMISSION

 

 

 

m ==========
HOSpital I HOSpital II Hospital I
Medical Medical Surgical
Factor N - 15 N - 25 ‘ N‘- 22
Mean number Of hours
from scorable responses 3.5 3.3 2.96
Time range .25-6.5 .5-10 .5-7.2
hours hours hours
Scorable responses 8 22 14
Unscorable responses 7 3 8
Responses unscorable
numerically but indi-
cating a parent re-
mained with the child 3 l 5

 

Researcthuestion 2

What differences between Hospital I and II were
apparent in the time spent with the child prior to and
following surgery?

Data pertaining to this question were obtained

from parents' answers to the following set of questions:

75

Did your child have surgery?

If yes, were you with the child on that day?

For how long before the surgery?

Were you present when the child returned
from surgery?

If yes, how long did you remain with the child?
What prompted you to leave?

Because no surgical patients from HOSpital II are
included in the sample, no comparison could be made. Anal-
ysis of the data from Hospital I showed that all children
had parents present at some time during the day of surgery.

Twenty of the twenty—two children had a parent (or parents)

present both before and after surgery.

Researchyguestion 3

What differences between HOSpital I and II were
apparent in the visiting patterns of parents and other
family members or friendS?

Data pertaining to this question were obtained
from parents' answers to the following questions:

What hours was the child usually visited:
by the child's mother?

by the child's father?
by other family members or friends?

76

TABLE 7

VISITING PATTERNS

 

Hospital 1 Hospital II Hospital I

 

Medical Medical Surgical

Factor N = 15 N - 25 N = 22
Mean number of hours 6.8 3.7 6.8
visited by the mother
Mean number of hours 3.0 2.4 1.7
visited by the father
Mothers: responses 9 l9 4
scorable for mean number
of hours
Responses not scorable 6 6 16
for mean number of hours
but indicating mother
visited
Mother visited "all day" 4 1 7
"nearly all the time,"
or "constantly"
No indication of mother 0 0 2
visiting
Mother split visiting time 3 15 4
Number of children visited 7 6 10

by friends or other family
members

 

77

The hours visited by the mother were determined by
using those responses which indicated an arrival and de-
parture time. A response of "ll-1, 4-7" would be counted
as 5 hours of visiting time. According to this criteria,
mothers in Hospital II visited a mean of 3.7 hours per day
and mothers of both groups in Hospital I visited a mean of
6.8 hours per day. It would appear the mothers from Hos-
pital I took advantage of the unrestricted visiting hours
and did visit their children for a longer period of time.

Only those responses which indicated an arrival
and departure time were used to determine the mean hours
of visiting. These figures resulted from 19 of 25 (76%)
cases of the Hospital II medical group, 9 of 15 (60%) of
the cases of Hospital I surgical group. The remaining
responses are accounted for by no indication of the mother
visiting (two cases in Hospital I surgical) or by responses
which could not be scored for the exact number of hours.
Included in the unscorable, but visited category were such
responses as "all day," "morning and evening," "at dif-
ferent times," "at night," etc. Included also in this
category were responses which were inapprOpriate or incom-

plete but which seemed to indicate that the mother had been

78

there at some time (2 a.m. to 9 p.m.; 11 in a.m.). In the
unscorable, but visited category were 6 of 15 (40%) of the
cases in Hospital I medical group, 6 of 25 (24%) of the
cases in Hospital II medical group, and 16 of 22 (73%) of
the cases in Hospital I surgical group.

LOOking further at the unscorable category, another
division emerges, those mothers who visited "all day,"
"nearly all the time," "most of the time," or "through the
day." Four of 15 (27%) cases in Hospital I medical group,

1 of 25 (4%) of the cases in Hospital II medical group, and
7 of 22 (32%) of the cases in Hospital I surgical group fell
into this group.

From the unscorable responses, and especially from
those in the "all day" category, we might conclude that the
mean hours of visiting by the mothers in Hospital I was pos-
sibly even greater than was indicated by the numerical data.

A question is raised regarding why a higher percent-
age Of responses were scorable from HOSpital II. Why did
the respondents from HOSPital II have a greater tendency
to write a specific number of hourS? A possible explana-

tion may be related to the fact that in Hospital I there are

79

no stated visiting hours. It may have been easier for
parents from Hospital II to remember the time they visited
because the hours were specifically stated; they would not
have visited at other times except by special permission.
Parents from Hospital II may have been more poignantly
reminded of time because they had to be present during the
stated time in order to visit. It seems possible that par-
ents from Hospital I may have been less concerned with the
specific hours Of the day they visited; they perhaps felt
less regulated by having to see the child during Specific
hours. Instead, they visited "during the morning," "all
day," etc., being only casually aware of the time.

The number of mothers who split their visiting
time revealed differences between the two hOSpitals.
Split visiting time was indicated by specific times ("ll-l,
4-7," "10 a.m.-5, 6:30—10 p.m.") or by unscorable general
responses ("morning and evening," "at lunch time and some-
times in evening"). Three of 15 (20%) of mothers from
Hospital I medical group, 15 of 25 (60%) of mothers from
Hospital II medical group, and 4 of 22 (18%) of mothers

from Hospital I surgical groups reported visiting at more

80

than one time. Although mothers from Hospital II came
more Often, previous data showed that they visited the
child for fewer mean number of hours per day than mothers
from HOSpital I. In other words, mothers from HOSpital I
were more likely to come once and remain longer for that
visit. Since they were free to visit as they desired,

the question was raised as to why they chose this pattern.
It may be suggested that it was more convenient for some
mothers to come once and remain than to make two separate
trips. Also, if either the mother or child was distressed
over separation, the mother may have sought to have only
one such experience per day rather than two.

The parent was asked to indicate visiting by friends
or other family members. Approximately one half of both
groups at Hospital I and approximately one quarter of the
group at Hospital II indicated that a friend or relative
had visited at some time. This included those who visited
only once as well as those who visited more Often. It ap-
peared that a more liberal visiting policy for parents also
resulted in more liberal visiting by other friends and

family members. It could not be determined from these data

81

whether this resulted from fewer refusals from the hos-
pital staff for permission to visit in HOSpital I or
whether parents in Hospital I asked for special permis-
sion more frequently.

Visiting patterns of the fathers showed more simi-
larity between hospitals: Hospital I medical—-9 scorable
responses, mean of 3.0 hours; Hospital II medica1—-l3
scorable responses, mean of 2.4 hours; HOSpital I surgi-
cal--3 scorable responses, mean of 1.7 hours. It might
be expected that fathers would be less affected by visit-
ing hours as most would be able to visit only in the even-
ing unless the child were very seriously ill. In all
groups in this study the majority of fathers visited dur-

ing the evening.

Research Question_4_
What differences were apparent between Hospital I
and II in how parents viewed the hOSpital experience?
Data pertaining to this question were Obtained

from parents' answers to the following questions:

82

In general, how do you feel your child re—
acted to being in the hospital?

How did you feel about having your child
in the hOSpital?

From answers to these two questions an indication
of how the parents viewed the hospital experience was sug-
gested. Those responses which indicated that the parents
tended to regard the hospital in a positive (approving,
helpful) manner seemed to fall into two categories: re—
sponses which referred to the hospital as an institution
in general, and responses which referred to the Specific
hospital in which the child was hospitalized and to the
personal care he received.

Included in the institutional category were the
following types of responses: the child is "better off"
where he can get help; the child will have the "care of
experts" or "professional care"; hospitalization is
"necessary" and "best" for the child; the child was unable
to get the care he needed at home; as long as the child
"needed to be there it was fine"; or the parent is "glad

to have the hospital available even though no one likes

to go there." These comments all appeared to refer to

83

hospitals and medical care as a generality, not to the
specific care their child received within a specific hos-
pital.

Another category Of reSponses seemed to refer to
the specific hospital experience which the family had just
undergone. This category included such responses as: the
child received "good care," "the best care possible," or
was "well taken care of"; the child was treated "very well"
or "real good"; "they" give the "best of care"; the parent
was "satisfied with the treatment given the child"; the
parent was "confident" about the "Doctor and staff nurses"
or "had confidence in the Doctor and the hospital."

Table 8 presents data regarding the number of com-

ments in each category from the three groups.

84

TABLE 8

PARENTS' VIEW OF THE HOSPITAL EXPERIENCE

ll

"" m

Hospital I Hospital II HOSpital I

 

Medical Medical Surgical

Factor N I 15 N I 25 N = 22
Favorable comments:
Referring to hospitals
as institutions 5 12 3
Favorable comments:
Referring to the spe-
cific hOSpital in which
the child was hospital-
ized 7 9 13
Others: not applicable 3 4 6

 

In both Hospital I groups, more parents made favor-
able comments about Hospital I rather than about hospitals
in general. 0n the contrary, in Hospital II more parents
made comments referring to hospitals as institutions rather
than to HOSpital II specifically.

It was suggested that a possible explanation for
this finding may be related to the amount of access parents
are allowed at the two hOSpitals. Robertson states:

"Parental satisfaction is closely correlated with the amount

85

of access that is given" and that this also "holds true
for parents' experience of hospital staff . . . When mOth-
ers live in the hospital or can visit without restriction
their impression of all grades of staff tends to be good;
but the greater the restrictions that are imposed the more
likely are staff to be viewed with frustration, apprehen-
sion and criticism" (56, p. 71). Robertson classified
restricted visiting policies as those policies which allow
visiting two hours or less per day. Hospital II allowed
five hours of visiting per day; consequently, one would not
expect as much criticism as hospitals which allow only two
hours per day. In fact, two to four negative comments
were recorded for all 3 groups. They did not have any
consistent pattern, but rather seemed to represent idio-
syncratic criticisms or complaints of individual parents.
Included were comments about eating, the food served, lax
sleeping hours, uncooperative or harsh nurses, and the
hospital being short of help.

Thus, differences in comments between the two hos-
pitals were not the result of parents from Hospital II

being more critical, but were the result of their tending

86

to view the hospital experience less in terms of the per-
sonal care the child received. As indicated previously by
the hours of visiting, these parents visited their children
less time than parents from Hospital I. Consequently, they
would have had less opportunity to observe how their child
was being cared for. Mothers from Hospital I not only Spent
more time with their child, but could visit the child at any
time if they had concerns about the care their child was
receiving. The idea of being able to see for oneself is
reflected in a comment by a mother from Hospital I who said,
"Through my own observations I felt certain she received
the very best of care."

A difference was also apparent within the HOSpital
I medical group. For the five parents who wrote institu-
tional type comments, the children's PBQ total scores were
75, 76, 81, 83, and 84. The seven parents who wrote favor—
able comments about the specific hospital had children
with PBQ total scores of 68, 69, 69, 69, 70, 77 and 91.
This same pattern of higher PBQ total scores for parents
who viewed the hospital as an institution was not reflected

in the other two groups. In seeking a cause for the finding

87

of the Hospital I medical group, the interactional effects
between parents and children might be questioned. Is the
child's reaction partially a reflection of the parents'
feelings, so that parents who view the hospital less favor-
ably have an affect on the child which leads to more upset?
Or conversely, do the parents regard the care given by the
hospital less personally because their child reacted with
more upset? Because of the small number of cases, these
findings must be regarded as tentative and indicative of

the need for further research.
Other Findings

The variables which it was hypothesized would af-
fect PBQ scores were visiting, rooming—in, and participa-
tion in the play program. In order to evaluate the results
of this study, it was necessary to determine the extent to
which these variables differed between the two hOSpitals.

The differences in visiting patterns between the
hospitals have been discussed with the research questions.

With regard to rooming-in, data from the Additional

Information Sheet (Did you room-in [stay overnight] with

88

your child? If yes, for how many nightS?) revealed that
in only one case in each of the Hospital I groups did
someone room-in with a child. A girl in the surgical
group had a grandmother stay with her. The respondent
to the questionnaire wrote, "We especially appreciated
the playroom and the fact that someone could stay all
night as she did wake up during the night." There was
no indication who had roomed-in with the child from the
medical group. Although rooming-in was one of the amel-
iorative measures available in Hospital I, this factor
cannot be viewed as having been represented in the sample
because of the small number of children who had someone
room-in with them.

Data on the child's participation in the play pro-
gram were kept by the researcher. The child was considered
to have been in the play program for one day of participa-
tion if he remained with the group for at least one-half
hour. Five out Of 15 of the medical patients and 9 Of 22
Of the surgical patients participated in the play program
at some point in their hospital experience. The percentage

of time spent in the play program was determined by

89

dividing the number of days of participation in the play
program by the total days of hospitalization. This re-
vealed that the highest participation record was 50%.
One medical patient participated two out of four days and
one surgical patient participated three out of six days.
The remaining children ranged in their participation re-
cords from 10% to 43%, with the most usual participation
ranging from 20% to 33%,(9 cases). Thus, the children in
both groups had limited participation in the play program.
In examining the cases which showed a high degree/
of upset, the distinguishing feature can be mentioned which
may have been a contributing factor. In the Hospital I
medical group two parents mentioned their child being
"spoiled." One parent wrote, "Being in the hospital was
a real good experience for her. She is spoiled so bad
that it brought her out of it a little." In view Of her
high PBQ total score (81), one wonders what was "good"
about the experience. One questions what other problems
may have been added even though she no longer exhibits the
behavior which caused her to be labeled "spoiled." Another

parent wrote about the child (PBQ total score 91), "I think

she is rather bewildered by the whole idea. She resents

90

the fact that we left her there. She does know that we did
it for her own good. However, she will do things to try
and punish us for leaving her, like being defiant and not
eating her meals, because she knows this bothers us. But
we are trying to get back on a normal routine and not spoil
her by allowing her to have her own way." It may be sug-
gested that the child "knows" why She was left at the hos-
pital but it is questionable if she also "feels" the same
reasons. One might wonder whether the extreme reaction of
this child was not in part precipitated by her parents'
lack of understanding of the needs of a child who has been
hOSpitalized, i.e., by their trying to get her "back to
normal routine" as quickly as possible.

It appeared from the data that a higher prOportion
of those children admitted after 11:30 at night showed a
high degree of upset than those children who were admitted
during the day. The time of admission was obtained from
the first question of the Additional Information Sheet,
although for a more accurate evaluation it is suggested
that admission time be obtained from the hOSpital records.

The following table shows the PBQ total scores of those

91

children who were admitted after 11:30 p.m. This hour

was selected because of differences revealed in the data.

TABLE 9

.PBQ TOTAL SCORES FOR CHILDREN ADMITTED

AT 11:30~p.m. OR LATER

 

 

 

PBQ
Total
Factor Admission Time Score
Hospital I - Medical middle of the night 70
2 in the a.m. 81
2:20 a.m. 83
Hospital II - Medical 11:45 p.m. 69
11:30 p.m. 72
2:30 a.m. 77
2:00 a.m. 78
Hospital I — Surgical 11:30 p.m. 77

 

One can suppose that admission to the hospital dur-

ing the night may have been particularly stressful both for

the parents and for the child. Besides indicating the ser-

ious nature of the child's medical condition, one can imag-

ine that having to come to the hospital in the middle of

92

'the night was upsetting to family routine, particularly
if there were other children in the family. Using two
groups of children with equally serious medical condi-
tions, a study is needed which would compare children
admitted during the day as Opposed to those admitted at

night.

CHAPTER V

DISCUSSION

Summary of Results

The purpose of this study was to investigate the
effects of unlimited visiting, rooming—in, and a play pro-
gram on the posthospital behavioral responses of children
discharged from two selected hospitals. Hospital I allowed
unrestricted visiting, rooming-in, and had a play program.
Hospital II allowed visiting five hours per day, and no
play program, and did not have provisions for rooming—in.
The Posthospital Behavior Questionnaire, deve10ped by
Vernon, Schulman, and Foley was used to collect the data.
An Additional Information Sheet, developed by the re-
searcher, was used to determine the extent to which par-
ticipation in the ameliorative measures varied between
the hospitals. Returns from the two hOSpitals resulted
in three samples: 15 children with a medical diagnosis

from Hospital I, 25 children with a medical diagnosis

93

94

from Hospital II, and 22 children with a surgical diag-
nosis from HoSpital I.

The hypotheses stated that children from Hospital I
would manifest less General Anxiety and Regression, Separa-
tion Anxiety, Anxiety About Sleep, Eating Disturbance, Ag-
gression Toward Authority, Apathy-Withdrawal, and total up—
set than children discharged from HOSpital II. Calculation
of the Kruskal—Wallace‘one-way analysis of variance showed
that there was no significant difference between the three
samples on the total score or any of the factor scores.
Thus, the hypotheses of this study were not supported.

This finding seemed to relate primarily to problems and
limitations of the study.

Data collected from the Additional Information
Sheet suggested some differences between the two hOSpitals.
A minimal difference was reported in the amount of time a
parent remained with the child following admission. A
parent remained for a mean of 3.5 hours in the Hospital I
medical group, 3.3 hours in the HOSPital II medical group,

and 2.96 hours in the Hospital I surgical group.

95

NO comparison was made regarding parents being
with the child on the day of surgery because no surgical
patients from Hospital II were included in the sample.

In Hospital I, however, all children had a parent present
at some time during the day of surgery; 20 of 22 had a
parent present both before and after surgery.

Visiting patterns appeared to differ between the
two hospitals. The mean number of hours visited per day
by the mother was 6.8 hours in HOSpital I and 3.7 hours in
Hospital II. Mothers from Hospital I had a greater tend-
ency to reply that they had visited "all day." There was
a greater tendency for mothers from Hospital II to split
their visiting time, to visit the child at two different
times during the day. Visiting by friends and relatives
showed a greater frequency in HOSpital I than in Hospital
II. There was less difference between the two hospitals
in the mean number of hours visited by the father, with
fathers in all groups visiting mainly in the evening.

A difference was suggested in how parents viewed
their hospital experience. Written comments to the last

two questions of the Additional Information Sheet revealed

96

that parents from HOSpital I had a greater tendency to com-
ment on the personal care their child received in Hospital
I. Parents from Hospital II had a greater tendency to com-
ment on hospitals and medical care in general.

Data on the incidence of rooming-in showed that
only 2 out of 37 children from Hospital I had a member of
the family room—in with them.

In Hospital I 14 of the 37 children had some par—
ticipation in the play program. The highest participation
records were Obtained by two children who were in the play
program for 2 out of 4 and 3 out of 6 days of hospitaliza-
tion. Nine children participated in the play program for
20 to 33% of the days they were hospitalized.

The interactional effects of parent and child upon
each other were brought into question. In the Hospital I
medical group, those children with high PBQ total scores
had parents who tended to view the hOSpital in institu-
tional terms rather than in terms of the personal care
their child received. Reference to the child being
"spoiled" in two different contexts also indicated that

the parents might be affecting the child's reactions.

97

Problems Encountered in This Study

Obtaining the consent of individual physicians to
include patients under their care in the study was a prob-
lem encountered prior to data collection. In order to
obtain a sufficient number Of permissions follow-up was
necessary.

One unanticipated factor was the large number of
physicians who practiced at both hOSpitals. It was not
indicated in the cover letter that individual permissions
were needed for each hospital, even though those who prac-
ticed at both hospitals received two sets of information.
Many of the follow-ups were necessary because a permission
form from only one hospital was returned. Had the neces-
sity for permission for both hospitals been stated, some'
confusion might have been avoided. It might also have
been possible to use a permission form which would have
allowed the physician to give his consent for both hos-
pitals on one form.

An alternative plan, when consent of individual
physicians is needed, might be to send a letter indicat-

ing that a study will be done. All patients would be

98

included in the study unless the physician returned a

form indicating that he preferred his patients not be
included. Unless the form was returned by a stated date
(about two weeks following receipt of the letter), patients
of the physician would automatically be included in the
study. Thus, only the physician who Objects to his pa-
tients being included would need to return a form; receipt
of no communication from the physician would be taken as
permission to study his patients.

Selection of the sample presented methodological
problems. The original design was to have two groups of
thirty subjects each, one group from each hospital. Be-
cause only one surgical case was obtained from HOSpital II,
it was decided that the groups from HOSpital I and II would
be more comparable if surgical patients from Hospital I
were considered separately.

Because of the delay in Obtaining surgeon's per-
missions in Hospital II, no surgical patients were in—
cluded and a longer period of time was needed to draw the

sample from Hospital II than from HOSPital I.

99

The sample in both hospitals was drawn by starting
on a selected day and taking consecutive discharges who met
the sample criteria. It was expected that this would result
in children from Hospital I who differed from children in
Hospital II with respect to the ameliorative measures avail-
able in Hospital I. A study of the returns indicated that
the greatest difference was evident in the visiting patterns
Of mothers. Despite a large number of children under five
in Hospital I, only two had a family member room-in with
them. Participation in the play program was also limited.
This may have been due partially to the time of year the
data was collected. During the winter and early spring
many children with pneumonia and similar disorders are
admitted. These children are put into isolation and are

thus unable to participate in the play program.

Limitations of This Study

The Instrument
The PBQ was fully reported in the literature in
June 1966 (69). Studies of its reliability and validity

and use Of the questionnaire were carried out at Children's

100

Memorial Hospital in Chicago. NO studies have been re—
ported from any other hospital.

Indications of the validity and reliability are
given only for the total score, not for the factor scores
individually.

It may be possible that differences in children's
reSponses under varying hospital conditions cannot be ac-
curately reflected by the use of this instrument. Are
there other, perhaps more subtle, types Of behavior which
are affected by hospital conditionS?

The general limitations Of using mailed question—
naires must also be recognized. There is the possibility
that those children whose parents did not return the ques-
tionnaire show different responses. The results of this
study are dependent upon the adequacy of responses by par—
ents to this instrument. All respondents would not have
viewed the questionnaire or their children's behavior from
the same viewpoint. Definitions of "more than before" and
"much more than before" probably varied between respond-
ents. The orientation a parent had concerning general

expectations of children and perception of their own child

101

would affect responses on the questionnaire. Although we
may feel we can basically rely on a parent's judgment.
some concerns are naturally raised about using question-
naires filled out by the parents as the sole source of
research data.

For this study it was necessary to develop the
Additional Information Sheet. Since no attempts were
made to establish its validity and reliability, findings

from this source can be considered as only suggestive.

Research Design

Some limitations were inherent in the research

design. A basic problem related to the global nature of

the design. Vernon §E_§l. state a weakness of many studies
in this area is a "confounding of theoretical implications."
"In a number of studies, several aspects Of hospitalization
were varied simultaneously and no arrangements were made to
isolate the effects of the different conditions in the anal-
ysis" (67, p. 163). The results of the samples obtained
showed that each sample differed within itself on important

variables. Yet the sample was not large enough to test the

102

significance of these variables within the small group.

The manner in which subjects were selected for
study resulted in groups which proved not to be entirely
comparable. The study would have been more definitive
if the groups could have been more closely matched on
such characteristics as age, sex, diagnosis, length of
hospitalization, etc. Furthermore, the groups needed to
have been more carefully selected so that variables which
it was hypothesized would affect the responses were better
represented.

The hospitals from which the samples were drawn
did not represent extremes on the independent variables.
Although HOSpital II did not have a play program, Some
play was provided by volunteer workers and student nurses.
At the time Of study the play program functioned fOr only
one and a half hours on the week days in Hospital I. The
need for an expanded program to include other hours of the
day has been recognized by hospital staff. Rooming-in was
the newest of the ameliorative measures in this hospital.
It is possible that the few families rooming-in resulted

not from conscious choice, but as a result of not knowing

103

that they could room-in. Hospital II allows visiting five
hours per day, which cannot be considered extremely re-
strictive. It is possible that more definite results
would have been obtained had the researcher been able to

select hospitals which showed more extreme variation.

Implications

The purpose of this study was to investigate the
effects of three ameliorative measures on children's post-
hospital behavioral responses. Analysis of the data showed
that the hypotheses were not supported, that is, that there
was no significant difference between Hospital I and II on
the factors measured by the PBQ. This finding seemed most
importantly to point to problems of research design and
methodology.

Although the results can be considered only sugges-
tive, some of the data did tend to support findings from
other research and from clinical observations. Mothers
did tend to visit their children longer in the hospital

permitting unrestricted visiting. They also had less

104

tendency to split their visiting time. It would appear
that visiting within 5 hours of the day and at 2 times is
not chosen by parents who are allowed to visit at any hour.
The data would lead one to expect that change to unre-
stricted visiting on a pediatric ward would result mainly
in changes in visiting patterns of the mothers, with
fathers still visiting primarily in the evening.

Parents in Hospital I tended to view the hOSpital
more in terms of the personal care their child received
rather than in terms of the hospital as an institution.

One might imagine that these parents would be more inclined
to speak favorably about their hospital experience to
others. Although having the parents gain a favorable per-
sonal impression of the hospital Should not be a primary
goal in instituting some Of the ameliorative measure, it
would not be an unexpected outcome.

Some implication may be made concerning the need
for education of the public regarding new trends in pedia—
tric care. The low incidence of rooming-in, despite a
large number of children under five, may be indicative

that parents are at present unaware that they have this

105

choice. It is notable that in neither hospital did parents
comment about the visiting hours. No parent from Hospital
II expressed the desire to be able to visit more. No par-
ent from Hospital I indicated a recognition of the unique-
ness of having unrestricted visiting. In Hospital I changes
in the pediatric program came, not from parental pressure,

but from a recognition of the needs by hospital staff.

Suggestions for Further Research

Although this research did not establish statisti-
cally significant results on the PBQ, it has led to some
suggestion for further study. Hopefully, the future re-
searcher can seek to avoid some of the problems encountered
in this study. A review of these problems is included in
this chapter.

.It is suggested that future studies focus on a nar-
rower range of variables. Subjects need to be selected
carefully for the extent to which they vary in regard to
the independent variables. A carefully controlled study
of even one of the independent variables would be suffi-

cient. For instance, a study of the effects of a play

106

program alone would be a valuable contribution to the
field.

Controlled studies on the effects of ameliorative
measures are needed. At this point it is possible that
more exploratory type of research is applicable. For
instance, the possibility of conducting semi—structuredf
interviews with parents of children who have been hospital-
ized under varying conditions should be explored. An in-
depth exploration of some of the interactional effects
of parents and children in relation to the ameliorative
measures could be proposed.

Further study of visiting patterns of parents
who are allowed unrestricted visiting as opposed to those
who are allowed fairly liberal visiting but during speci-
fied hours would help to clarify some of the implications
of the research for clinical practice.

Suggestions that those children who are admitted
late at night as well as those whose parents tend to view
the hospital experience in institutional terms show a

higher degree of upset are also worthy of further study.

107

The importance of research in this area is under-
scored not only because of the contributions that can be
made to theoretical understanding, but also because of the
applications that can be made to clinical practice. In the
end, our goal must be to provide supportive care in order
that children may be able to use hospitalization as a con—
structive, growth-producing experience, rather than as an

experience leading to trauma and upset.

10.

BIBLIOGRAPHY

Albee, C. Group work with hospitalized children.
Children 2: 217—221. 1955.

American Academy of Pediatrics, Committee on Child
Care. Care of children in hospitals. Evanston,
Illinois: Author. 1960.

Bakwin, H. The hospital care of infants and children.
Journal of Pediatrics 39: 383-390. 1951.

Barraclough, W. Mental reactions of normal children
to physical illness. American Journal of Psychiatry
93: 865-877. '1937.

Beller, E. and P. Neubauer. Patterning of Symptoms
in Early Childhood. Paper read at American Psychi-
atric Association. Philadelphia. 1959.

Bergmann, T. Children in the hospital. New York:
International Universities Press. 1965.

Beverly, B. The effect of illness upon emotional
development. Journal of Pediatrics 8: 533-543.
1936.

Blom, G. The reactions of hospitalized children to
illness. Pediatrics 22: 590-599. 1958.

Blumgart, E. and B. Korsch. Pediatric recreation;
an approach to meeting the emotional needs of hos-
pitalized children. Pediatrics 34: 133-136. 1964.

Bowlby, J., J. Robertson, and D. Rosenbluth. A two-
year-Old goes to hOSpital. In R. R. Eissler et al.
(Eds.). The psychoanalytic study of the child.
New York: International Universities Press 7:
82-94. 1952.

108

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

109

Bowlby, J. Separation anxiety. International Journal
of Psychoanalysis 41: 89-113. 1960.

Buerke, P. Educational programming for the short—term
hospitalized child. Exceptional Children 32: 559-
563. 1966.

Brooks, M. Constructive play experience for the hOS-
pitalized child. Journal of Nursery Education 7:
7-13. 1957.

Capes, M. The child in the hospital. Mental Hygiene
40: 107-157. 1956.

Cassell, S. The effect of brief puppet therapy upon
the emotional responses of children undergoing car-
diac catherization. Unpublished doctoral disserta—
tion. Northwestern University. 1963.

Chapman, A. H., D. Loeb, and M. Gibbons. Psychiatric
aspects of hospitalizing children. Archives of
Pediatrics 73: 77-88. 1956.

Coyle, G. and R. Fisher. Helping hospitalized chil-
dren through social group work. The Child 16:
114-117, and 126. 1952.

Deutsch, H. Some psychoanalytic Observations in sur—
gery. Psychosomatic Medicine 4: 105-115. 1942.

Dimock, H. The child in hospital. A study of his
emotional and social well-being. Philadelphia:
F. A. Davis. 1960.

Duncombe, M. Visiting children in hospital. Inter-
national Nursing Review 13: 32-36. 1966.

Eckenhoff, J. Relationship of anesthesia to post-
operative personality changes in children. American
Journal of Diseases of Children 86: 589-591. 1951.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

110

Erickson, F. Play interviews for four-year-old hos-
pitalized children. Monograph for Society for Re—
search in Child Development 23: No. 3 (Whole No.69).
1958.

Fagin, C. The case for rooming-in when young children
are hospitalized. Nursing Science 2: 324—333. 1964.

Freud, A. The role of bodily illness in the mental
life of children. In R. S. Eissler et al. (Eds.).
Psychoanalytic study of the child 7: 69-81. New
York: International University Press. 1952.

Geis, D. Home visits help prepare preschoolers for‘
hospital experience. Hospitals 40: 83-87. 1966.

Geist, H. A child goes to the hOSpital. Springfield,
Illinois: Charles C. Thomas. 1965.

Gellert, E. Reducing the emotional stresses of hos-
pitalization for children. American Journal Of
Occupational Therapy 3: 125-129. 1958.

Gips, C. How illness experiences are interpreted by
hospitalized children. Unpublished doctoral disser-
tation. Columbia University. 1956.

Gofman, H., W. Buckman, and G. Schade. The child's
emotional response to hospitalization. American
Journal of Diseases of Children 93: 157-164. 1957.

Gould, E. A playroom helps children adjust to a hos-
pital. Nursing World 12: 14—15, and 26. 1955.

Halier, J. Children and surgery. International
Nursing Review 13: 25-31. 1966.

Harvey, S. et al., United Kingdom Committee for the
World Organization for Early Childhood Education--
Play in hospital. London: E. T. Heron and CO.
1966.

33.

34.

35.

36.

37.

38.

39.

40.

41.

111

Illingworth, R. and K. Holt. Children in hospital:
some Observations on their reactions with special
reference to daily visiting. Lancet 269 (2):
1257-1262. 1955.

Jackson, E. Treatment of the young child in the hos-
pital. American Journal of Orthopsychiatry 12:
56-62. 1942.

Jackson, K., R. Winkley, O. Faust, and E. Cermak.
The problem of emotional trauma in the hospital
treatment of children. Journal of the American
Medical Association 149: 1536-1538. 1952.

Jackson, K., R. Windely, O. Faust, E. Cermak, and M.
Burtt. Behavior changes indicating emotional trauma
in tonsillectomized children. Pediatrics 12: 23-27.
1953.

Jessner, L., G. Blom and S. Waldfogel. Emotional
complications of tonsillectomy and adenoidectomy on
children. In R. S. Eissler et al. (Eds.). The
psycholanalytic study of the child 7: 126—169.

New York: International Universities Press. 1952.

Jessner, L., S. Kaplan. Observations on the emotional
reactions of children to tonsillectomy and adenoid-
ectomy: A preliminary report. In M. Senn (Ed.).
Problems Of infancy and childhood pp. 97-117. New
York: Macy Foundation. 1948.

Katz, G. Mothers help care for sick children in ex-
perimental unit. Hospitals 38: 38. .1964.

Kennell, J. and M. Bergen. Early childhood separa—
tions. Pediatrics 37: 291-298. 1966.

Langford, W. Physical illness and convalescence:
their meaning to the child. Journal of Pediatrics
33: 242-250. 1948.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

112

Langford, W. The child in the pediatric hOSpital:
adaptation to illness and hospitalization; American
Journal of Orthopsychiatry. 31: 667-684. 1961.

Langford, W. Understanding the hospitalized child.‘
Feelings and their medical significance 8: N0. 4.
Columbus, Ohio: Ross Laboratories. 1966.

Levy, D. Psychic trauma of Operations in children.
American Journal of Diseases Of Children 69: 7-25.
1945.

Lightwood, R., F. Brimblecombe, J. Reinhold,
E. Burnard, J. Davis. A London trial of home care
for sick children. Lancet 272 (2): 313-317. 1957.

MacCarthy, D., M. Lindsay and I. Morris. Children in
hospital with mothers. Lancet 282 (2): 603-608.
1962.

Mason, E. The hospitalized child--his emotional needs.
New England Journal of Medicine 272: 406-414.
1965.

Ministry of Health, Central Health Service Council.
The welfare Of children in hospital. London: Her
Majesty's Stationery Office. 1959.

Pearson, G. Effect of Operative procedures on the
emotional life of the child. American Journal of
Diseases of Children 62: 716-729. 1941.

Plank, E. Working with children in hospitals.
Cleveland: Western Reserve University Press. 1962.

Plank, E. Abandonment: deepest fear of hospitalized
children. Hospital topics 43: 93-96. 1965.

Prugh, E., E. Staub, H. Sands, R. Kirschbaum, and E.
Lenihan. A study of the emotional reactions of
children and families to hospitalization and illness.
American Journal of Orthopsychiatry 23: 70-106.
1953.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

113

Richardson, S. and E. Wolff. The organization and
function of play activities in the set-up of a
pediatric department: a report of a three-year“
experiment. Mental Hygiene 24: 229-237. 1940.

Robertson, J. Going to hospital with mother. New
York: New York University Film Library. 1958.

Robertson, J. Young children in hospitals. New York:
Basic Books. 1958.

Robertson, J. (Ed.). Hospitals and children. London:
Victor Gollancz. 1962.

Schaffer, H. and W. Callander. Psychologic effects of
hospitalization in infancy. Pediatrics 24: 528-
539. 1959.

Senn, M. Emotional aspects of convalescence. The
Child 10: 24-28. 1945.

Shore, M., R. Geiser, and H. Wolman. Constructive
uses of a hospital experience. Children 12: 3-8.
1965. '

Siegel, Sidney. Nonparametric statistics for the
behavioral sciences. New York: McGraw-Hill Bodk
Company. 1956.

Sipowicz, R., and D. Vernon. Psychological responses
of children to hOSpitalization: a comparison of
hospitalized and nonhospitalized twins. American
Journal of Diseases of Children 109: 228-231.
1965.

Spence, J. The care of children in hospital. British
Medical Journal 1 (NO. 4490): 125-130. 1947.

Through looking glass. Hospitals 34: 47-49. 1960.

Tisza, V. and K. Angoff. A play program for hos-
pitalized children. Pediatrics 19: 293-302. 1957.

65.

66.

67.

68.

69.

70.

71.

72.

114

Tisza, V. and K. Angoff. A play program for hos—
pitalized children: the role of the playroom
teacher. Pediatrics 28: 841-845. 1961.

Vaughan, G. Children in hospital. Lancet 272 (2):
1117-1120. 1957.

Vernon, D., J. Foley, R. Sipowicz, and J. Schulman.
The psychological responses Of children to hos—
pitalization and illness: A review of the litera-
ture. Springfield, Illinois: Charles C. Thomas.
1965.

Vernon, D. and J. Schulman. Hospitalization as a
source of psychological benefit to children.
Pediatrics 34: 694-696. 1964.

Vernon, D., J. Schulman, and J. Foley. Changes in
children's behavior after hospitalization. Some
dimensions of reSponse and their correlates.
American Journal of Diseases Of Children III:
581-593. 1966.

Woodruff, R. Groups work in a children's hospital.
Social Work 2: 56-61. 1957.

Woodward, J. Emotional disturbances of burned chil-
dren. British Medical Journal 2 (No. 5128):
1009-1013. 1959.

Work, H. Making hospitalization easier for children.
Children 3: 83-86. 1956. '

(PHBQ AD) APPENDIX A
Instruct

POSTHOSPITAL BEHAVIOR QUESTIONNAIRE

Instructions

 

Please answer each of the questions on the following
pages by comparing the way your child has been behaving
in the first week after coming home from the hospital with
the way he (or she) usually behaved before coming to the
hospital.

Mark the gpg_square following each question which best
describes your child's behavior Since his return home. The
headings at the top of the page Show what the different
boxes mean. If your child has shown some change in the be-
havior, even if only a little bit, put a check mark (v’) in
the square that indicates the change most true of your
child. Use a middle square ("same as before") only if your
child has shown no change at all in the area, or if the
question does not apply because your child is either too

young or too Old.

115

Appendix A,

(cont'd.)

PHBQeAD)

Does your child
want a favorite
toy or animal
with him at
bedtime?

Does your child
need help getting
dressed?

116

 

E_Xsr_np_1_s
Much Much
less Less Same More more
than than as than . than”
before before before before before

 

/

 

 

 

 

/

 

 

 

For the first example, the child wanted an animal

at bedtime more than before coming to the hospital so a

check was placed in the fourth square.

For the second example, the child dressed himself

without help for some months before hospitalization and

continued to do this after his return home so the middle

square,

"same as before," was checked.

 

Appendix A. (cont'd.)
(PHBQ-AD) 1
1. Does your child

make a fuss about
going to bed at
night?

117

Hospital

Name

 

 

Much

less

than
before

Less
than
before

Same
as
before

More
than
before

Much
more
than
before

 

 

Does your child
make a fuss about
eating?

 

Does your child
Spend time just
sitting or lying
and doing nothing?

 

Does your child
need a pacifier?

 

Does your child
seem to be afraid
of leaving the
house with you?

 

Is your child un-
interested in
what goes on
around him

a(pr her)?

 

Does your child
wet the bed at
night ?

 

 

 

 

 

 

 

Appendix A. (cont'd.)
(PHBQ-AD) 2
8. Does your child

10.

11.

12.

13.

14.

15.

bite his (or her)
finger nails?

118

 

~Much
less
than

before

Less
than
before

Same
as
efore

More
than
before

Much
more
than
'before

 

 

Does your child get
upset when you
leave him (or her)
alone for a few
minutes:

 

Does your child
need a lot of help
doing thingS?

 

Is it difficult to
get your child in-
terested in doing
things (like play—
ing games, with
toysy and so on?)

 

Does your child

seem to avoid or
be afraid of new
thingS?

 

Does your child
have difficulty
making up his (or
her) mind?

 

Does your child
have temper tan-
trums?

 

Is it difficult to
get your child to
talk to you?

 

 

 

 

 

 

 

Appendix A.

(cont'd.)

(PHBQ-AD) 3

16.

17.

18.

19.

20.

21.

22.

Does your child
quarrel or fight
with brothers or
sisters? (Note:
leave blank if has
no brothers or
sisters.)‘

119

 

Much

less

than
before

Less
than
before

Same
as
before

More
than
before

Much
more
than
before

 

 

Does your child
seem to get upset
when someone men-
tions doctors or
hospitals?

 

Does your child
follow you every-
where around the
house?

 

Does your child
spend time try-
ing to get or
hold your atten-
tion?

 

Is your child
afraid of the
dark?

 

Does your child

have bad dreams

at night or wake
up and cry?

 

Is your child
irregular in his
(or her) bowel
movementS?

 

 

 

 

 

 

 

Appendix A. (cont'd.)
(PHBQ-AD) 4
23. Does your child

24.

25.

26.

27.

28.

have trouble get-
ing to sleep at
night?

120

 

Much

less

than
before

Less
than
'before

Same
as
before

More
than
before

Much
more
than.
before

 

 

Does your child
seem to be shy or
afraid around
strangerS?

 

Does your child
have a poor
appetite?

 

Does your child
tend to disobey

you ?

 

Does your child
break toys or
other ObjectS?

 

Does your child
suck his (or her)
fingers or thumbs?

 

 

 

 

 

 

 

APPENDIX B
ADDITIONAL INFORMATION SHEET

Form for Hoppital I
(PHBQ-last)
We would also like your answers to the following

questions. Fill in the appropriate answers.

29. What time was your child admitted to the hospital?

What time did you leave the

 

child on the day Of admission?

30. Did your child have surgery?

 

If yes, were you with the child on that day?
For how long before the surgery?

Were you present when the child returned from surgery?

 

If yes, how long did you remain with the child?

 

What prompted you to leave?

121

122

Appendix B (cont'd.)
(PHBQ-last)

31.

32.

33.

34.

35.

What hours was the child usually visited:
by the child's mother?
by the child's father?

by other family members or friendS?

Has your child ever been hospitalized before?
If yes, how many times (not including birth)?

At what age?

 

Did you room-in (stay overnight) with your child?

 

If yes, for how many nights?

 

In general, how do you feel your child reacted to

being'in‘the'hospital?

How did you feel about having your child in the

hospital?

123

Appendix B (cont'd.)
(PHBQ-last)

Form for Hospital II

We would also like your answers to the following

questions. Fill in the appr0priate answers.

29. What time was your child admitted to the hospital?

What time did you leave the

 

child on the day of admission?

30. Did your child have surgery?
If yes, were you with the child on that day?
For how long before the surgery?
Were you present when the child returned from
surgery?

If yes, how long did you remain with the child?

 

What prompted you to leave?

31. What hours was the child usually visited:
by the child's mother?
by the child's father

by other family members or friends?

124

Appendix B (cont'd.)
(PHBQ—last)

32. Has your child ever been hospitalized before?

 

If yes, how many times (not including birth)?

 

At what age?

33. In general, how do you feel your child reacted to

being in the hospital?

34. How did you feel about having your child in the

hOSpital?

APPENDIX C

SCORING PROFILE FOR THE POSTHOSPITAL

BEHAVIOR QUESTIONNAIRE

(The scoring system used in this research is the same as

that used by Vernon et a1. [69]).

The responses are scored as follows:

"Much less than before" -- scored 1.
"Less than before" -- scored 2.
"Same as before" -- scored 3.
"More than before" -- scored 4.
"Much more than before" -— scored 5.

Factor I General Anxiety and Regression

Items 4, 5, 8, 13, 22, 28
Mean indicative of no change - 18

Factor II Separation Anxiety

Items 9, l8, 19, 21
Mean indicative of no change - 12

Factor III Anxiety About Sleep

Items 1, 20, 23
'Mean indicative of no change - 9

125

126

Appendix C (cont'd.)

Factor IV Eating Disturbance

Items 2, 3, 25
Mean indicative of no change - 9

Factor V Aggression Toward Authority

Items 14, 26
Mean indicative Of no change - 6

Factor VI Apathy-Withdrawal

Mean indicative of no change - 15

Total Score

Items 1, 2, 3, 4, 5, 8, 9, 10, 11, 13, 14, 15, 18,
19, 20, 21, 22, 23, 24, 25, 26, 27, 28
Items 6, 7, 12, 16, 17 are not scored.

APPENDIX D
POSTHOSPITAL BEHAVIOR QUESTIONNAIRE SCORES

TABLE 10

DISTRIBUTION OF PBQ FACTOR I SCORE

General RegreSSion and Anxiety

 

 

Hospital I Hospital II Hospital I
Score Medical Medical Surgical
Frequency Rank Frequency Rank Frequency Rank

 

l6 1 (1)

17' 1 (2.5) 1 (2.5)
18 11 (27) 20 (27) 16 (27)
19 3 (53) 2 (53)
20 1 (58.5) 2 '(58.5) 3 (58.5)
21 1 (62)

 

127

128

Appendix D. (cont'd.)

TABLE 11

DISTRIBUTION OF FACTOR II SCORES

Separation Anxiety

 

 

Hospital I Hospital II Hospital}?====
Score Medical Medical Surgical
Frequency Rank Frequency Rank Frequency‘ Rank

10 2 (1.5)
11 1 (3)
12 8 (20) 10 (20) 15 (20)
13 3 (39.5) 3 (39.5)
14 2 (47.5) 4 (47.5) 2 (47.5)
15 1 (53) 2 (53) 2 (53)
16 2 (57.5) 2 (57.5)
17 l (60)
18 2 (61.5)

 

129

Appendix D. (cont'd.)

TABLE 12

DISTRIBUTION OF PBQ FACTOR III SCORES

Anxiety About Sleep

 

 

w m —#—_
Hospital I 1 Hospital II Hospital I
Score . Medical Medical Surgical

Frequency Rank Frequency Rank Frequency Rank

 

7 ' 2 (2) 1 (2)

8 1 (4)

9 9 (27) 18 (27) 18 (27)
10 2 (52) 2 (52) 1 (52)
11 1 (55)

12 1 (57.5) 2 (57.5) 1 (57.5)

12 2 (61) 1 (61)

 

130

Appendix D. (cont'd.)

TABLE 13

DISTRIBUTION OF FACTOR IV SCORES

Eating Disturbance

 

—==-: _=: m
Hospital I Hospital II Hospital I
Score Medical Medical . Surgical

Frequency Rank Frequency Rank Frequency 'Rank

 

5 1 (1)

6 1 (2)

7

8 2 (5.5) 3 (5.5) 1 (5.5)
9 7 (26.5) 16 (26.5) 13 (26.5)
10 3 (48) 1 (48) 3 (48)
11 1 (54.5) 2 (54.5) 3 (54.5)
12 1 (59) 2 (59)
13 1 (61)

14 1 (62)

 

131

Appendix D. (cont'd.)

TABLE 14

DISTRIBUTION OF FACTOR V SCORES

Aggression Toward Authority

 

.W
'Hospital I Hospital II HOSpital I

Score Medical Medical Surgical
Frequency Rank Frequency Rank Frequency Rank

 

6 7 (18) 16 (18) 12 (18)

7 1 (41) 2 (41) 8 (41)

8 4 (50) 2 (50) l (50)

9 3 (55.5) 1 (55.5)
10 3 (59.5) 1 (59.5)

11 1 (62)

 

132

Appendix D. (cont'd.)

TABLE 15

DISTRIBUTION OF FACTOR VI SCORES

Apathy—Withdrawal

 

Hospital I Hospital II Hospital I
Score Medical Medical Surgical
Frequency Rank Frequency Rank Frequency"Rank

 

10 1 (1)

11

12

13 2 (3.5) 2 (3.5)
14 1 (8) 2 (8)

15 6 (27.5) 17 (27.5) 15 (27.5)
16 1 (48.5) 3 (48.5)
17 4 (53.5) 2 (53.5)

18 1 (59.5) 3 (59.5) 2 (59.5)

 

Appendix D.

 

(cont'd.)

133

TABLE 16

DISTRIBUTION OF PBQ TOTAL SCORE

 

 

HoEBI::T=I====:* Hospital II 3:7 Hospi::1f?===
Score Medical Medical Surgical
Frequency Rank Frequency Rank Frequency ‘Rank-
65 1 (1)
66 1 (2)
67 1 (4) 2 (4)
68 (7) 1 (7)
69 (18) 7 (18) 7 (18)
70 (30.5) 3 (30.5) 2 (30.5)
71 2 (37) 5 (37)
72 1 (41)
73 2 (43.5) 2 (43.5)
74 1 (46)
75 (47.5) 1 (47.5)
76 (49)
77 (51) 2 ((51)
78 2 (53.5)
79 1 (55)

134

Appendix D. (cont'd.)
Table 16. (cont'd.)

 

w w
Hospital I Hospital II Hospital I
Score Medical Medical Surgical

Frequency Rank Frequency Rank Frequency'*Rank'

 

80 1 (56)
81 1 (57)

82

83 1 (58)

84 l (60) 1 (60) 1 (60)

91 1 (62)

 

APPENDIX E

COVER LETTER FOR PARENTS

(Hospital I) or (Hospital II) Letterhead

Dear

The enclosed questionnaire concerns your child,

who was recently hospitalized at (Hospital 1) or (Hospital II). We would
like to know if the behavior of children changes after they have been in
the hospital. By returning the questionnaire you will help us in under-
standing how being in the hospital affects a child.

The questionnaire is being used in a study by Miss Jane BOpp, a Master's
candidate in Child Development at Michigan State University. Her deep
interest in the hospitalization of children has prompted her to undertake
this study. If you have questions or concerns, Miss Bopp could be reached
at 351-9191.

You may be assured that neither your child's name nor the name of the hos—
pital will be revealed in the study.

A stamped addressed envelOpe is provided in order that you may easily re—
turn the questionnaire.

Since the questionnaire deals with behavior immediately following hospital-
ization, it is important that you promptly fill it out. Please return the
completed form as quickly as possible.

Your cooperation will be greatly appreciated.

Jane Bopp Administrative Official
Graduate Student (Hospital 1) or (Hospital II)
Michigan State University

Robert Lance

Instructor

Department of Home Management
and Child Deve10pment

135

APPENDIX 1“

CovRR LFTTFR FOR PHYSICIANS
MICHIGAN STATE UNIVERSITY EAST LANSING . MICHIGAN 48823

 

COLLEGE OF HOME ECONOMICS 0 DEPARTMENT OF HOME MANAGEMENT AND CHILD DEVELOPMENT

HOME ECONOMICS BUILDING

February 1967

Dear Dr .

A study of children's behavioral responses following hospitalization is
being planned. Using the Posthospital Behavior Questionnaire (American
Journal of Diseases of Children. June 1966), a comparison will be made
between children hospitalized at (Hospital 1) and those hospitalized at
(Hospital II). Variables which it is believed will affect the responses
include differences in visiting privileges, rooming-in provisions, and
the provision of a play program.

Your permission is sought in order to include children under your care
in this study. The enclosed permission sheet is provided for your reply.

The study will be conducted by Miss Jane Bopp, the "World of Childhood"
(Pediatric Play Program) Coordinator at (Hospital 1) and Master's can-
didate in Child Development at Michigan State University.

The questionnaire (enclosed) will be mailed to the child‘s parents six
days following discharge from the hospital. It will be returned by mail.
The sample will consist of seventy-five children from each hospital:
children between the ages of six months and twelve years will be includ-
ed. The comparative nature of the study will not be revealed to the
parents of either group. In the research report neither the names of the
hospitals nor of individual children will be revealed.

If you have further questions or concerns, Miss Bopp can be contacted
each weekday morning (9—12) on the Pediatric Unit of (HOSpital I) or by
phone (351—9191) at other times.

Your prompt return of the permission form is requested in order that data
collection may begin. You are asked to return the form whether or not
your permission is granted to insure that the information has been re-
ceived. Note that you may obtain copies of the returned questionnaire
for your patients if you desire.

Your cooperation will be greatly appreciated.

Robert Lance Jane Bopp
Instructor Graduate Student
Department of Home Management Michigan State University

and Child Development
Michigan State University

Administrative Official Administrative Official
(Hospital 1) (Hospital II)

136

APPENDIX G
PHYSICIAN'S PERMISSION SHEET

A Comparison of Children's Behavioral
Responses Following Discharge

from Two Selected Hospitals

GRANT PERMISSION FOR ANY

 

signature

CHILD UNDER MY CARE TO BE INCLUDED IN THIS STUDY.

I would be interested in knowing
yes no those children under my care who
have been included in this study.

I would be interested in seeing

yes no the returned questionnaire for
those children under my care.

WOULD PREFER THAT THOSE

 

signature
CHILDREN UNDER MY CARE NOT BE INCLUDED IN THIS STUDY.

Reason 3

 

 

137

w .\ 1.1.1.1. I: r... 81:123.: (1.1: n. i-..

 

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