Helping Children Understand and Cope with the Experience of Hospitalization
By Amy Clark, BS, CCLS
Even the most routine hospitalization can be a traumatic and terrifying experience for a child (1). Add the factors of a burn injury to the equation and chances are a child will be fearful of the initial hospital experience. A strange place full of unfamiliar people and big scary things can foster a child’s imagination. Most of the people wear funny clothes and do things that hurt. How do we expect a child to react to these stressors placed upon them?
Many of the fears and misunderstandings can be resolved and addressed once the family has time to meet the members of the burn team treating their child. There are numerous people available to assist families with sorting out the many details involved with having a child hospitalized. One member of the team who will focus on the psychosocial and developmental needs of the child is the Child Life Specialist. This is a person who is available to help ease the stress and anxiety related to hospitalization for children. She will advocate for the developmental, social, and emotional needs of the child. The Child Life Specialist will be known as a “safe” person for the child to interact with and rely on to help cope through difficult or painful situations. Most children possess no coping skills, and frequently elicit responses such as regression, anger, fear, depression and anxiety (2).
Due to the stressful nature of hospitalization and burn injuries, it is important to recognize that children learn, grow, and communicate differently at different stages of development.
HOSPITALIZATION AND THE CHILD
Every child will develop individually at his or her own pace. Parents play the key role in knowing what is average for their child. One thing parents can do while they have a hospitalized child is to note what milestones their child had reached prior to entering the hospital. Also, parents can communicate to staff common coping behaviors of their child. For instance, “the child is usually comforted by a bottle and her blankie when she is scared or upset.” Previous medical experiences and fears that are preexisting may also help staff to custom fit the care your child receives and reduce as much anxiety as possible.
Children will react to hospitalization even if you have taken every possible precaution. One of the most common coping mechanisms for children is regression. Feeling that they are being punished for doing something wrong may move children into a state of regression. Brazelton et al (1953) and Schechter (1961) reported that the longer children were required to stay in hospital the more likely they were to view treatment as punishment (4). The toddler may suddenly want the pacifier or the preschooler may talk baby talk.
Parents can support their child without making regression worse. For instance, if your preschooler is talking baby talk and you start talking back in baby talk or treating him like you did as a toddler, the regression is being encouraged. On the other hand, if your child is talking baby talk you can let him know that you can't understand what he is trying to say and you need to hear words to help him get what he needs. This way you are still supporting the needs of your child without encouraging a behavior that may be harder to break once you leave the hospital. It is also important to remember not to punish your child for regressing. It is a natural coping mechanism for that child at that time and they need support. Most children will return to their previous developmental level shortly after leaving the hospital, although it may vary depending on the length of hospitalization and the developmental support they received.
Parents can support their child’s developmental needs by encouraging normal behavior. Giving children opportunities to play in hospital in full and meaningful ways not only ensures this continuity of development but also helps to bring a feeling of normality to this strange and often frightening environment (5). Often this requires a little creativity to manage the arm that is in a splint or the child who must lay flat on their back, but the extra effort placed on adapting toys will tremendously help a child cope with the hospital experience. Children do not always have the ability to articulate their feelings through words, but they are able to play through what they are experiencing. It would be similar to an adult who relies on a trusted friend to share meaningful conversations about their experiences. A child needs toys just as much to express what they are going through.
THE IMPORTANCE OF PLAY
While playing with children it is always important to observe what they are doing. If significant changes in play or developmental abilities are noticed, it is essential to relay this information to hospital staff. For instance, a toddler who is normally playful and talkative refuses to play. This is a sign to staff that this child is experiencing stress and is unable to communicate her needs. Sometimes playing for a child in a situation such as this provides the emotional outlet needed by the child. Often the child will slowly start to join in the play and may eventually become involved in the activity.
Children will give you clear indications if the stimulus is too much and you need to slow or stop the level of interaction. Look for the infant that no longer makes eye contact and turns away and begins to fuss or the toddler that halts his focus on the activity and turns away or lies down. Notice the preschooler whose interest shifts away or begins to yell or tantrum. It is easy for a child that is quiet or sleeping most of the time to get overlooked. Even the child who is not crying or fussing may have unmet needs. Often a child who has been through a stressful situation and is in an unfamiliar environment may need an adult to initiate play.
Play is also a great way for adults to see what children are understanding about the hospital experience. Child life specialists use medical play to determine a child’s understanding of medical procedures. Allowing children to see, touch and play with commonly used equipment before the hospitalization experience provides children with an opportunity to familiarize themselves with unfamiliar equipment and reinforce teaching (6). Dolls with splints or pressure garments, dressings or tracheotomies, allows a child the experience of playing with real objects and decreasing the fear of them. Staff can help to clear up any misconceptions of medical treatments that may come forth during play.
MAINTAIN ESTABLISHED ROUTINES
Parents often work very hard the first few years of their child's life to establish routines within the family and household. The simple routines of daily life become a great comfort to infants and children and can become a great stressor if they are disrupted. Parents and caregivers need to take every opportunity to maintain a “normal” or regular schedule as much as possible to help prevent any further stress or anxiety for the child. This applies to the hospital environment as well as the home environment. The routine may have to change post-injury, but it is important to establish a new routine as quickly as possible to restore some consistency and comfort to the child's day. This will also help parents to better fulfill their daily tasks if they can have a flexible expectation of what the day will bring. Any parent who has stayed out late with a toddler just to have him wake up at his normal 6:00 AM time the next morning can appreciate how significant routines are in a child’s life.
Limit setting is also a source of comfort for children. Many adults feel guilty setting limits on behavior for a child who is going through such a difficult time. Realistic limits on behavior help teach the child appropriate ways of coping with anger and frustration and also provide a sense of structure that is needed in a child’s life.
Children are resilient people and look to adults for guidance and examples of how to cope with difficult situations. A child that is supported throughout a burn injury can certainly return to life as a child and grow to become a successful adult. Some of the key moments to consider when helping a child cope with such a difficult situation begin while hospitalized. A child that feels safe and secure and able to express himself will learn to accept and adapt to changes in his life. Parents play an important role in establishing the trust and safety a child needs while recovering from a serious injury. Parents and health care providers who keep in mind the many developmental factors a child is facing can better understand and meet the needs of a child in the hospital. A developmental approach helps put many behaviors and interactions into a perspective that is easier to understand. Each small step a child makes in recovery is a major victory and often can be directly related to the love, trust, and developmental support given to that child. When the needs of the whole child are considered during recovery, the whole child can heal.
HOSPITALIZATION ISSUES LISTED BY STAGES OF DEVELOPMENT
Basic Fears: Loss of support, loud noises, strangers; Sudden unexpected and looming object; Separation from parents
Response to Hospital: Unable to communicate verbally Separation distress, irritability Increased crying, decreased play; Schedule is upset; Tactile hypersensitivity; Lethargy
Supportive Care: Swaddle, hold, rock, speak with a soothing voice; Play soothing music and comfort infant when distressed; Verbally label everything you do and talk to child before touching infant when distressed; Approach child slowly, avoid interrupting the infant's schedule whenever possible; Allow toys for expression such as tactile items (soft, rough, bumpy, etc.), rattles or noisy toys that can be handled easily, and visual stimulators such as a mirror
Basic Fears: Loud stimuli, dark rooms; Large objects or machines; Changes in personal environment; Masks
Response to Hospital: May view hospital as punishment Increased crying, decreased play; Decreased appetite; Beginning to verbally communicate pain, irritable; Temper tantrums; Refusal to eat
Supportive Care: Provide toys, play activities; Sing favorite songs; Rocking, stroking; Blow bubbles, read books; Tell stories with puppets; Avoid interrupting regular schedule; Whenever possible allow safe expression of anger with pounding toys, toys that can be squeezed or manipulated
Basic Fears: Separation from parents; Dark rooms, noises; Unfamiliar places; Strangers, “Bad” people; Bodily Harm; Response to
Hospital: May view hospital as punishment; Regression (baby talk, diapers); Aggressive Behavior; Can verbalize pain; Nightmares, misconceptions of treatment
Supportive Care: Deep breathing, bubble blowing; Toys that capture their attention; Glitter wands, view finder, books; Create a pretend place and describe; Needs opportunities for expressive play and mobility; Allow safe expression of anger by providing pounding toys, tactile substances such as playdough or paint, physical activities/outlets, and books describing feelings
Basic Fears: Supernatural beings (ghosts, monsters); Bodily injury; Physical appearance; Thunder, lightening, dark; Sleeping or staying alone; Separation from parents; Death
Response to Hospital: Regression; Aggressive Behavior; Will test authority; May withdraw, deny favorite activities; May verbalize pain, but may not report if anticipates a “shot”; Withdrawal
Supportive Care: Encourage peer interactions; Games: electronic, video, board; Search and find books; Favorite music, computer games; Deep breathing, relaxation tapes; Counting games and pretend stories; Conversation involving their interests; Provide choices when appropriate; Allow safe expression of anger through expressive toys, art activities, physical activities/outlets, writing about feelings, and providing books about feelings.
Basic Fears: Social performance; Sexuality; Loss of independence; Fear of rejection/criticism; Fear internal/external; Body changes or injury
Response to Hospital: Can understand invisible body changes; May withdraw socially and emotionally; May test limits; Body image concerns, sleep disturbance, withdrawal or depression
Supportive Care: Provide Privacy; Allow independence and choices; Encourage peer interactions; Provide activities such as: computers, video/board games; Favorite music; Teach relaxation techniques; Allow safe expression of anger through journal writing, sharing experiences with peers, drawing, and conversation
SUGGESTIONS TO HELP WITH THE TRANSITION HOME:
- Establish a flexible routine that will work for your whole family.
- Include family members as much as possible
- Remember that the injured child isn’t the only child in the home that may have emotional and behavioral changes during the healing process.
- Provide opportunities for the injured child to contribute to the family.
- Seek out the help of friends and family to provide much-needed breaks for caregivers.
- If painful procedures need to be done at home, try to designate one area of the home and do not use an area the where the child sleeps.
- Talk with your mental health professional to know what to expect emotionally so that you can recognize normal trauma responses.
- Practice explaining your child’s situation with other parents or children and help your child develop his definition of how he will talk about his injury. It is helpful to have some answers prepared to prevent a potentially awkward situation.
- Encourage normal behaviors and activities for your child. You may have to help the child modify the way he used to perform an activity.
1, 2 The Challenges of Children: The First 48 Hours, American Burn Association Continuing Education Program.
3, 6 Miron, J., RN, What Children Think About Hospitals, The Canadian Nurse, March 1990, pp. 23-25.
4 Eiser, C., PhD, Children’s Understanding of Medical Procedures, The Practitioner, April 1985 Vol 229 pp. 371-373.
5 Noble, E. Children in Hospital; Why Play? Nursing Times, April 11, 1974, pp. 534-536.
Amy Clark BS, CCLS has been practicing in the field of Child Life since 1997. She became certified in 1999. She works as a Child Life Specialist with DeVos Children's Hospital and the Spectrum Health Regional Burn Center. Amy is a board member of Great Lakes Burn Camp. She also serves as one of the coordinators for the SOAR program at Spectrum. She is involved with the pediatric support group and Firematch, the juvenile firesetters prevention program at Spectrum.