RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / Mr. Sreekumar. S1st year. M. Sc. Nursing
(Paediatric Nursing)
Smt. Lakshmi Devi College of Nursing
Hoskote, Bangalore
2. / NAME OF THE INSTITUTION / Smt. Lakshmi Devi College of Nursing
Hoskote, Bangalore
3. / COURSE OF STUDY AND SUBJECT / 1st Year, M. Sc. Nursing
Pediatric nursing
4. / DATE OF ADMISSION TO COURSE / 10-06-2011
5. / TITLE OF THE TOPIC / “A study to assess the effectiveness of play activities on the level of anxiety among hospitalized pre-school children in a selected hospital in Bangalore ”
6. BRIEF RESUME OF THE INTENDED WORK
“You can discover more about a person in an hour of play than in a year of conversation.”-Plato
6.1 INTRODUCTION
The child's emotional reaction to hospitalization is determined by personal, interpersonal and environmental factors, the child's predisposition to experience anxiety, namely, trait anxiety. The interpersonal influence was the perceived level of maternal anxiety, and the environmental influence was type of hospitalization--traditional hospital or day clinic. The hospitalized children with high trait anxiety would experience higher anxiety state than children with low trait anxiety; hospitalized children who perceive anxious rather than calm mothers would experience more anxiety; children in a traditional hospital would experience higher anxiety state than children in a day clinic; and the most anxious children would be those who have high trait anxiety, are exposed to anxious mothers and are hospitalized in a traditional hospital. Type of hospitalization did not influence the level of anxiety, but children with high trait anxiety who attributed to their mothers a high level of anxiety reported more anxiety in the day clinic rather than in the hospital. Play is an important part of the childhood development. Through play children learn about shapes, colors, cause and effect, and themselves. Besides cognitive thinking, play helps the child learn social and psychomotor skills. It is a way of communicating joy,fear, sorrow, andanxiety1
Children who are confined to a bed need to have play periods built into their day. The length of play and the toys will depend the individual child's age and physical and emotional states. Short-term school projects appeal to school-age children because these activities help the children feel industrious and think about their future wellness. Parents can help children with their baths; encourage them to drink enough fluids; and prompt them to do deep breathing and muscle strengthening exercises.Play takes different forms for different children, and its definition entails many aspects. Play is the direct opposite of work; it is frivolous. It provides freedom and invites the impulse to engage in foolishness. Yet it provides a means for ego development and a process by which social skills and physical skills develop as well. When a child is ill or traumatized the care plan may include therapeutic play. Unlike normal play in design and intent, therapeutic play is guided by the health professional to meet the physical and psychological needs of the child. Because play is the language of children, children who have difficulty putting their thoughts in words can often speak clearly through play therapy.3
6.2 NEED FOR THE STUDY
In the early 2000s, children of all ages and from every socioeconomic background often prefer television, computers, and battery-operatedtoysto self-directed, imaginative, and creative play. This tendency leaves children developmentally deprived, because imaginative and fantasy play allows children to explore their world and express their innermost thoughts and feelings, hopes and fears, likes and dislikes. Through play, decisions are made without penalty or fear of failure. Play allows children to gain control of their thoughts, feelings, actions, and helps them achieve self-confidence. Spending time in hospital can be very stressful for children and their parents, and distress can affect how children recover from their illness 4
A recent report study based on “The Significance of a Play Program in the Care of Children in a General Hospital” states that It is the fundamental responsibility of the Nurse not only to provide a high quality of medical care but also to serve the needs of each child who is accepted for care, by providing services which are adapted to the characteristics of children - emotional, physical, and otherwise.” This report further states that "Every pediatric unit should have recreational space for children to enjoy group play-.". Out Of 104 cases in India, 41% had anxiety disordersin conjunction with their index depression, which was more likelywith major depressivedisorder (MDD),and dysthymic disorder (DD), than with adjustment disorderwith depressed mood (ADDM). The age-corrected risk of afirst anxiety disorder was 0.47 up to age 18 years. Separation-anxietydisorder was the most frequent disgnosis of anxiety, followedby overanxious disorder of childhood. Among the MDD cases withcomorbidity, the anxiety disorder preceded the depression abouttwo thirds of the time and often persisted after the depressionremitted.4
Based on the theory that hospitalization can be an unnecessary stress to children, only those who cannot successfully be managed on an ambulatory basis are now admitted to the hospital. Three chief fears of the toddler and pre-schooler are fear of unknown, fear of abandonment and separation and fear of mutilation. Children report various types of fear in the context of hospitalization, such as fear of separation from the family, having injections and blood tests, staying in the hospital for a long time, and being told "bad news" about their health.5
6.3 REVIEW OF LITERATURE
Review of literature is a critical summary of research on a topic of interest generally prepared to put a research problem in paper content to identify gaps and weakness on previous studies to justify a new investigation.
A study was conducted on, “The Psychosocial Impact of Play on Hospitalized Children” reveals that Compared the effects of play on the psychosocial adjustment of 46 children hospitalized for acute illness, who were placed in one of four groups: therapeutic play, diversionary play, verbal support, and no treatment. Ratings of psychological adjustment included self-report, as well as nurse and parent ratings. Children in the therapeutic play condition evidenced a significant reduction in self-reported hospital fears. Parent ratings were not affected by therapeutic treatments; rather, parents in all four groups rated their children less anxious from pre- to post testing.7
A study was conducted on “Music therapy to reduce pain andanxietyinchildrenwith cancer undergoing lumbar puncture: a randomized clinical trial” at the National Hospital of Pediatrics, Hanoi, Vietnam. The aim of this study was to evaluate if music medicine influences pain andanxietyin childrenundergoing lumbar punctures. A randomized clinical trial was used in 40children(aged 7-12 years) with leukemia, followed by interviews in 20 of these participants. The participants were randomly assigned to a music group (n = 20) or control group (n = 20). The primary outcome was pain scores and the secondary was heart rate, blood pressure, respiratory rate, and oxygen saturation measured before, during, and after the procedure.Anxietyscores were measured before and after the procedure. Interviews with open-ended questions were conducted in conjunction with the completed procedures. The results showed lower pain scores and heart and respiratory rates in the music group during and after the lumbar puncture. Theanxietyscores were lower in the music group both before and after the procedure. The findings from the interviews confirmed the quantity results through descriptions of a positive experience by thechildren, including less pain and fear.8
A study was conducted on “Anxietyand depression inchildrenand adults: influence of serotonergic and neurotrophic genes?” by Middeldorp CM andSlof-Op 't Landt MC at the Department of Biological Psychology, VU University Amsterdam. This study investigated the effect of 45 single nucleotide polymorphisms (SNPs) in genes encoding for serotonin receptors 1A, 1D, 2A, catechol-O-methyltransferase (COMT), tryptophane hydroxylase type 2 (TPH2), brain derived neurotrophic factor (BDNF), PlexinA2 and regulators of G-protein-coupled signaling (RGS) 2, 4, 16. Anxious depression (A/D) symptoms were assessed five times in 11 years in over 11 000 adults with 1504 subjects genotyped and at age 7, 10, 12 and during adolescence in over 20 000 twins with 1078 subjects genotyped. In both cohorts, a longitudinal model with one latent factor loading on all A/D measures over time was analysed. The genetic association effect modeled at the level of this latent factor was 60% and 70% heritable in thechildrenand adults, respectively, and explained around 50% of the total phenotypic variance. Power analyses showed that the samples contained 80% power to detect an effect explaining between 1.4% and 3.6% of the variance. However, no SNP showed a consistent effect on A/D. To conclude, this longitudinal study inchildrenand adults found no association of SNPs in the serotonergic system or core regulators of neurogenesis with A/D. Overall, there has been no convincing evidence, so far, for a role of genetic variation in these pathways in the development ofanxietyand depression.9
A study was conducted on, “Anxiety and depression in children and adolescents are reviewed, including differential diagnosis, assessment of symptoms, family history data, developmental features, and clinical correlates”. Findings indicate that 15.9% to 61.9% of children identified as anxious or depressed have comorbid anxiety and depressive disorders and that measures of anxiety and depression are highly correlated. Family history data are inconclusive. Differences emerged among children with anxiety, depression, or both disorders. Anxious children were distinguishable from the other 2 groups in that they showed less depressive symptomatology and tended to be younger. The concurrently depressed and anxious group tended to be older and more symptomatic. In this group, the anxiety symptoms tended to predate the depressive symptoms. 10
A study was conducted on“Bidirectional Associations Between Co-parenting Relations and Family MemberAnxiety: A Review and Conceptual Model” at the Research InstituteChildDevelopment and Education, University of Amsterdam. This review discusses the potential mechanisms and empirical findings regarding the bidirectional relations of parent andchildanxietywith coparenting. The majority of studies point to bidirectional associations between greater coparenting difficulties and higher levels ofanxiety. A conceptual model is proposed that integrates the role of parental andchildanxiety, parenting, and co-parenting, to guide future research and the development of clinical interventions. Future research should distinguish between fathers' and mothers' coparenting behaviors, include parentalanxiety, and investigate the coparental relationship longitudinally. Clinicians should be aware of the reciprocal relations between childanxietyand coparenting quality, and families presenting for treatment who reportchild(or parent)anxietyshould be assessed for difficulties in coparenting.11
A study was conducted on“Patterns of dentalanxietyinchildrenafter sequential dental visits”. The aim of the study was To determine whether gradually exposing Brazilianchildrento the dental environment would decrease their levels of dentalanxietyover a 14.5-month period. The study was carried out on 302childrenof both genders, aged 6-7 years old. Dentalanxietywas assessed using the Facial Image Scale (FIS) at five time points: 1) before an epidemiological examination; 2) before the first treatment session; 3) before the second treatment session; 4) before the first evaluation session 5) before the second evaluation session. ANOVA, Student-t tests and ANCOVA were used to analyse the data. There was a statistically significant decrease in levels of dentalanxietybetween time points 1 and 5. Eighty-nine percent of thechildrenwith FIS score 1 or 2 at baseline had the same scores at the last time point, whereas 82% ofchildrenwith FIS score 4 or 5 at baseline had a FIS score of 1 or 2 at the last time point.12
A study was conducted on the “The Efficacy of Play Therapy and Filial Therapy with Children” by Sue Bratton. The aim of this study was to find out the effectiveness of play therapy in children and to compare the efficacy of it when given by a professional and a para-professional. The study included 3263 subjects into three groups as 1) Therapy given by professional,, 2) given by para-professional and 3) control group. A meta-analytical approach was used to conduct the study. The results showed that when the therapy was given by a professional provided most efficacy as compared to a para-professional.13
A study was conducted on ‘Play Therapy: A Case-based Example of a Nondirective Approach”. The study showed the effective use of play therapy in children with different psychiatric diagnoses. Using pre-test, post-test comparison design to evaluate 11 patients in an experimental group and 10 in the control group, Danger, et al., showed a benefit in improving both receptive and expressive language skills in children with speech difficulties. In theory, the safe practice environment of the therapy provided an environment conducive to working on these areas without exacerbating self esteem and social anxiety issues. An exploratory study of nondirective play therapy with an autistic boy using video analysis of 16 sessions suggests both feasibility and effectiveness of play therapy with noted improvements in the child’s autonomy and pretend play, though only mild improvement in decreasing ritualistic behaviors. It was the authors’ opinion in this paper that the therapeutic relationship helped to “enhance and accelerate the emotional/social development of children with severe autism,” as they were able to observe attachment behavior from the child towards the therapist.14
In a case example, play therapy was used to alleviate anxiety, which was contributing to migraine headaches in a 10-year-old child with separation anxiety disorder. In this case, the boy with preexisting migraines began to experience increased anxiety in the wake of the 9/11 attacks as his father took part in the search and rescue efforts at the World Trade Center. The tracked symptom was migraine frequency, which had increased with his anxiety. Through play and art he was able to accomplish a resolution of his fears by bringing them to the surface, directly and indirectly in the content of his play and art projects. As his play and art became less dark and fearful, both his subjective anxiety and migraines decreased.15
A study was conducted on“The Efficacy of Play Therapy on ADHD, Anxiety and Social Maturity in 8 to 12 Years Aged Clientele Children of Ahwaz Metropolitan Counseling Clinics”. The present study was purposed to examine the Efficacy of Play Therapy on Attention Deficit Hyperactivity Disorder (ADHD), Anxiety and Social Maturity in 8-12 years old male and female children. The sample subsumed 80 boys and girls whom were selected randomly via simple sampling procedure from clientele children whom were identified and diagnosed for ADHD and Anxiety in counseling clinics. The subjects randomly allocated to two groups, giving equal chance to every client to be included in each group: the experimental and control group. Experimental group was involved in play therapy for ten sessions; 1 h each. Control group did not. Pre-test and post-test experimental design with control group was processed by administrating Conner's Parent Rating Scale (CPRS), hwaz Children Anxiety Test (ACAT) and Vineland Social Maturity Scale (VSMS). Multivariate Analysis of Variance (MANOVA) as statistical implement revealed that: Play therapy decreased Attention Deficit Hyperactivity Disorder (ADHD) and Anxiety but increased Social Maturity. The results authenticated that play therapy as an effective therapeutic procedure is a conceivable intervention for children experiencing a broad range of problems such as ADHD and anxiety involving no any significant risk.16