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Effects of psychological preparation on children hospitalized for dental operations
BEHAVIORAL PEDIATRICS
RichardW. OImsted, Editor
Effects of psychological preparation on children hospitalized for dental operations We studied the effect of preoperative preparation on stress reduction in children hospitalized jor dental surgery under general anesthesia. Participants were 45 children, 3 and 4 years of age, with no previous hospital-surgery experience and no history of medical or psychological conditions requiring special care. Subjects were randomly assigned to one o f three experimental groups." control, receiving no preoperative preparation; unrelated play therapy, receiving a preoperative play session unrelated to hospital or surgical procedures; and related play therapy, receiving a preoperative play session focusing on hospital and surgical procedures. Subjects" behavior was assessed using behavior observation scales for cooperation and upset at seven stress points." admission, nurse's examination, pediatric medical examination, blood test, preoperative injection, transfer to surgery, and induction. The related play therapy group was more cooperative and less upset than either the unrelated play therapy group or the control group across stress points. No significant heart rate differences were found among the three groups. The results suggest that play therapy related to hospital and surgical procedures can alleviate stress and anxiety in 3- and 4-year-old children. (J PED1ATk 102:634, 1983)
Bruce H. Schwartz, D.D.S., M.S., Judith E. Albino, Ph.D., and Lisa A. Tedesco, Ph.D. B a l t i m o r e , M d . , a n d B u f f a l o , N . Y .
HOSPITALIZATION OF CHILDREN for dental extractions and restorations under general anesthesia has proVed to be a useful and necessary approach to treatment in some cases. On the other hand, hospitalization has the disadvantage of producing considerable anxiety for most children. The preponderance of literature in this area reflects hospitalization accompanied by surgery as a stressful, anxiety-producing experience that can lead to either transient or long-term psychological disturbance in a majority of children? 5 The most frequently used method of preparing a child for hospitalization and surgery has been some form of preoperative instruction. 6,7 Although different methods of preparation have been used to inform the child about hospital procedures, they are similar in incorporating attempts to correct any misinformation the child may have concerning these procedures.
From the University of Maryland Dental School and State University of New York at Buffalo. Supported in part by Children's Hospital of Buffalo, N.Y. Reprint requests." Bruce H. Schwartz, D,D.S., Department of Orthodontics, University of Maryland Dental School, 666 West Baltimore St., Baltimore, MD 21201.
634
The Journal of P E D I A T R I C S
Vernon et al? suggest that the major purposes of preoperative preparation are to (1) provide information to the child in an attempt to reduce the unfamiliarity of the hospital setting, (2) encourage the child to express his or her emotions, and (3) establish relationships of trust and confidence with the hospital staff. Melamed and SiegeP used a filmed model in their preparation of children for surgery. Their results indicated that children who observed the film preoperatively demonstrated reduced stress as measured by situational anxiety methods. They also reported that children who did not receive the preoperative preparation showed significantly more behavior problems after hospitalization. In a study by Visintainer and Wolfer, ~~ mothers were included in the preparation procedures. Preparation of the child included information, sensory expectations, role identifications, rehearsals, and support, as related to the specific surgery the child was to undergo. Preparation of the parents mainly dealt with information and support. The results indicated that children receiving preoperative preparation showed a significantly lower degree of upset and more cooperation during hospital procedures than did control children.
Volume 102 Number 4
Psychological preparation for in-hospital dental operations
Cassell ~ showed that children participating in an experimental group undergoing preoperative puppet therapy were significantly less disturbed during catheterization than were control children. Cassell concluded that the puppet therapy relieved the situational anxiety produced by treatment, but had little effect on overall emotional disturbance measured after the hospitalization. The basic rationale of Cassell and other investigators is that play techniques can allow a child emotional expression of fears and concerns related to hospitalization and surgery, clarify preconceptions of events and procedures, and demonstrate the health professional's empathy for the child. It provides an opportunity for the child to approach a conflict situation and "play" through the experience with a manageable amount of fear. We attempted to expand previous findings by testing the effects of preoperative play therapy on very young children hospitalized for dental operations. METHODS Subjects. Forty-five children ranging from 3 to 4 years of age were admitted to the Children's Hospital of Buffalo for dental restorations and extractions under general anesthesia. These children had no previous hospital surgical admissions and no medical or psychological condition requiring special care. Measurement. The effects of preoperative preparation on stress reduction were assessed by systematic observations of behavior and heart rate monitoring. The Manifest Upset Scale and Cooperation Scale were modified for behavioral assessments, and these observation scales utilized the five-point system set forth by Visintainer and Wolfer?: Because of the lack of specific descriptors for scores of 2 and 4, the scales were operationalized to provide concrete observational measurements for these scores as well as to provide greater specificity to scores of 1, 3, and 5. These modifications were based on patient observations prior to this investigation and used descriptors from the behavioral scales developed by Venham. ~3 For both scales, children's behaviors were scored according to the descriptors most closely approximating the behaviors demonstrated for a particular procedure. Two experimentally blind raters provided all the observations. After training, intraclass correlation reliability coefficients for the two raters were 0.93 for the Cooperation Scale and 0.94 for the Manifest Upset Scale. Physiological measurement was accomplished by use of a Mennen-Graetbatch Model 929F Monitor to ascertain the children's heart rate during specific stress points. Procedure. Children were admitted to Buffalo Children's Hospital the day preceding their dental operations. They were randomly assigned to three groups with matching to ensure equivalence in sex composition and size of
635
groups: (1) a control group, which received no preoperative preparation; (2) an unrelated play therapy group, which took part in a preoperative play session unrelated to hospital or surgical procedures; and (3) a related play therapy group, which participated in a preoperative play session focusing on hospital and surgical procedures. The same therapist participated in both the unrelated and related play sessions. On admission the parents or guardians were informed of the nature of the study and asked to sign the consent form. A brief explanation of hospital procedure followed, and a cursory oral inspection was completed, Behavior ratings were then recorded for the admission process. On completing admission procedures, the child and parent were escorted by a therapist from the Child Life Department to a minor-surgical floor. After room assignment the therapist, accompanying the child and parent(s), proceeded to the treatment room for heart monitoring. After careful explanation, three Ag-C1 electrodes were placed on the subject's chest. The monitor leads were attached and baseline heart rate was measured for approximately two minutes. After this, children received treatment as determined by their respective group assignments. A child in the control group received no preoperative therapy and proceeded with the hospital events in the routine manner. A child assigned to the surgically related play therapy group was taken back to the treatment room for the preoperative session. This session concentrated on play therapy techniques that (1) provided information to the child and parent, including descriptions and explanations of hospital procedures, sequencing of events, sensory expectations of procedures and staff duties; and (2) included a role play scheme in which parent and child assumed roles of either a health care provider or patient and carried out actual procedures with hospital toy props. The play therapy protocol developed by the Child Life Staff was age specific for this group of patients and focused on hospital activities corresponding to the stress points used for assessment: nurse's examination, pediatric medical examination, blood test, preoperative injection, transport to surgery, and induction of anesthesia. Each stress point was discussed and role played with a particular emphasis on the actual operation. At this point, discussion focused on nature of the operation, appearance of the operating room, attire of operating room personnel, EKG monitor, the anesthesiologist, the anesthetic mask, and the recovery room. During this preparation both child and parent(s) were encouraged to ask questions and relate their fears and concerns. This session took the form of a dress rehearsal, and the child was encouraged to try out all the equipment and to feel as comfortable with it as possible. The session lasted between 20 and 25 minutes.
636
Schwartz, Albino, and Tedesco
The Journal of Pediatrics April 1983
Control,
4.0
.........
Unrelated
...........
Related Play
Play
3.67
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1.13
I
I
I
Admission
Nurse Exam
Medical Exam
I
I
Blood Injection Test
I
I
Transfer Induction
Fig. 1. Mean cooperation scores.
Children assigned to the surgically unrelated therapy group received a play session with the same therapist for approximately 20 minutes. During this session the therapist interested the child in playing with a toy barn and farm animals. Conversation was limited to the barn and characters, with no mention of surgery. The therapist tried to make this session a pleasant, comfortable experience whereby the child could gain trust and confidence in the hospital staff. After receiving their respective group treatments, children proceeded through six more stress points of hospitalization and surgery. The remaining stress points on the presurgical day were the nurse's examination, the pediatric medical examination, and the blood test performed by venipuncture. On the day of surgery, the stress points were the preoperative injection (3 mg/kg hydroxyzine and 0.3 mg atropine), transport to the operating room, and induction. At each stress point, behavioral measures and heart rate were recorded ~(except for heart rate at surgerytransfer). For purpose of consistency, all nurse's examinations were performed by the head nurse, as were all preoperative
injections. The chief pediatric resident performed all medical examinations, and the same hematology technician accomplished all blood work. Transport to surgery was done by two floor nurses. Patients were induced for general anesthesia by one of six anesthesiologists. RESULTS Univariate analyses of variance on baseline admission assessments of cooperation, upset, and heart rate showed no significant differences by sex or treatment groups. The cooperation means for the three treatment groups at the seven stress points, when subjected to multivariate repeated measures analysis of variance, showed significant treatment effects (F = 3.45, P = 0.04, df = 2, 39) (Fig. 1). The related play group was more cooperative than either the unrelated play therapy group or the control group; the control group was/east cooperative. Uncooperative behavior was higher at induction than at any other stress point, but again, the related play group had the most cooperative behavior when compared to either the unrelated play or control group. Inspection of effects at individual stress points showed significant mean differences only between
Volume 102 Number 4
Psychological preparation for in-hospital dental operations
637
Control U n r e l a t e d Play
4,0
...........
3.87
R e l a t e d Play
3.47
/
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u)
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267. 9 X \\ X
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Nurse
Medical
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Exam
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, I
Blood I n j e c t i o n Test
I
1
Transfer Induction
Fig. 2. Mean upset scores.
the control and related play groups at the following stress points: nurse's examination, blood test, transfer to surgery, and induction. At induction, cooperation means were not only significantly different (P = 0.005) between the control and related play groups, but approaehed significance (P = 0.056) for related play therapy and unrelated play therapy groups. No sex differences were found for cooperation means (F = 0.03, P = 0.86, df = 1, 39). Fig. 2 displays the upset means for the three treatment groups at the seven stress points. A multivariate repeated measures analysis of variance showed significant treatment effects (F = 3.15, P = 0.05, df = 2, 39). The related play group had less upset behavior than in either the unrelated play group or the control group. The control group displayed the most upset behavior. Upset behavior was higher at induction than at any other stress point, but the related play group again showed less upset behavior than either of the other groups, Inspection of the individual effects showed significant mean differences only between the control and related play groups at nurse's examination, preoperative injection, transfer to surgery, and induction9 Upset means at induction were significantly different
(P = 0.002) between the related play and control groups and between the unrelated play and related play groups (P = 0.04). No sex differences were found for upset (F = 0.13, P = 0.71, df = 1, 39). DISCUSSION The data from this study support the hypothesis that systematic preparation in the form of a hosPital-surgery related play therapy session can be beneficial to young children hospitalized for dental operations under general anesthesia. Although the analyses reflected significant differences among the three treatment groups, statistical tests for individual mean differences among treatment groups did not indicate the effectiveness of related play sessions over unrelated play sessions for increasing cooperation and reducing upset behavior, with the exception of one stress point, induction of anesthesia. At this point, the related play group demonstrated significantly less upset behavior than did the unrelated play group, and approached significance for cooperative behavior. The pattern of treatment group differences remained consistent at all stress points for both cooperation and upset; the control group was
6 38
Schwartz, AIbino, and Tedesco
The Journal of Pediatrics April 1983
least cooperative and most upset, followed by the unrelated play group, and finally the related play group. Based on both behavioral and physiological responses, induction of anesthesia appears to be the most stressful procedure the child experiences during hospitalization. Corroborating the observations of Visintainer and Wolfer, ~2this stress may be related to (1) parent separation anxiety, (2) relative loss of control, (3) sequencing of events, with induction being the final potentially threatening procedure, and (4) the ominous appearance of masked personnel and complicated anesthetic and surgical equipment, posing a threat of physical harm or bodily injury. I f a young patient is distressed by these factors, the experience of mask inhalation induction may be terribly frightening. Developmental theories TM~5propose that gradually from age 3 to 6 years a child demonstrates an increasing ability to distinguish fantasy from reality, so that by age 5 or 6 years this distinction is usually accomplished. Younger children of 3 and 4 years do not make this distinction as clearly; therefore, frightening dreams and their characters may become part of the child's reality. Regardless of group assignment, certain children in this study panicked, and physical restraint was required to maintain the mask over the child's face. It is not surprising that some children believe they are being suffocated during inhalation induction. In several postsurgical interviews, children reported the presence of a monster during their operating room visit. One child, when questioned what came out of the inhalation mask, replied, " T h e Hulk did." One possible benefit of preoperative play therapy may be the early identification of those children who react adversely to mask inhalation induction. It is possible that these children may be less distressed by intravenous induction, as implemented by Steward TM and by Kay. ~7 Clearly, further research in this area is indicated. Finally, because of hospital policy, the number of anesthesiologists was a difficult variable to control. Although similar induction techniques were used, it is undeniable that the skills and personalities of the different anesthesiologists could have affected the children's behavior. The results of this study indicate that the information presented in related play therapy sessions, coupled with rehearsal of hospital and surgical procedures, can reduce anxiety and fears and help the young child cope with hospital procedures more effectively, particularly with respect to induction of anesthesia. We thank Terry Knabe, Head Nurse, and Dr. Gene Stanford, Director of the Child Life Program, for their participation and
.
encouragement; Dr. Joe Bernat and Dr. C. W. Snyder for allowing their patients to take part in this study; Dr. Martin Downey, Chief of Anesthesia, and his staff, for their cooperation; and Dr. Lillian Schwartz, Director of Training in Child Psychiatry, Montefiore Hospital, for her advice and suggestions. Barbara Bass and Mary Murphy provided their typing expertise in completing this paper. REFERENCES
1. Prugh DG, Staub EM, Sands HH, Kirshbaum RM, Lenihan EA: A study of the emotional reactions of children and families to hospitalization arid illness. Am J Orthopsychiatry 23:79, 1953. 2. Eckenhoff JE: Relationship of anesthesia to post-operative personality changes in children. Am J Dis Child 86:587, 1953. 3. Jackson K, Winkley R, Faust OA, Germak EG: Behavior changes indicating emotional trauma in tonsillectomized children. Pediatrics 12:25, 1953. 4. James FE: Behavior reactions of normal children to common operations. Practioner 158:339, 1960. 5. Schaffer HR, Callender WW: Psychological effects of hospitalization in infancy. Pediatrics 24:528, 1959. 6. Heller JA: The hospitalized child and his family. Baltimore, 1967, Johns Hopkins Press. 7. Melish RWP: Preparation of a child for hospitalization and surgery. Pediatr Clin North Am 16:243, 1969. 8. Vernon DTS, Gaulin-Kremer E, Munster E, Bengston-Audia D, Cohan J: The psychological responses of children to hospitalization and illness: A review of the literature. Springfield, I11., 1965, Charles C Thomas, p 8. 9. Melamed B, Siegel L: Reduction of anxiety in children facing hospitalization and surgery by use of film modeling. J Consult Clin Psychol 43:511, 1975. 10. Visintainer MA, Wolfer JA: Pediatric surgical patients and parents' stress responses and adjustment. Nurs Res 24:244, 1975. 11. Cassell S: Effect of brief puppet therapy upon the emotional responses of children undergoing cardiac catheterization. J Consult Psychol 29:1, 1965. 12. Visintainer MA, Wolfer JA: Psychological preparations for surgical pediatric patients: The effect on children's and parents' stress responses and adjustment. Pediatrics 56:187, 1975. 13. Venham LL: Internal rating scales for children's dental anxiety and uncooperative behavior. Pediatr Dent 12:195, 1980. 14. Piaget J: The judgment and reasoning in the child. New York, 1928, Harcourt, Brace & World. 15. Murphy L: The widening world of childhood. New York, 1962, Basic Books. 16. Steward DJ: Anesthesia for paediatric out-patients. Can Anaesth Soc J 27:412, 1980. 17. Kay B: Outpatient anesthesia especially for children. Acta Anesthcsiol Scand 25(suppl):421, i966.
RichardW. OImsted, Editor
Effects of psychological preparation on children hospitalized for dental operations We studied the effect of preoperative preparation on stress reduction in children hospitalized jor dental surgery under general anesthesia. Participants were 45 children, 3 and 4 years of age, with no previous hospital-surgery experience and no history of medical or psychological conditions requiring special care. Subjects were randomly assigned to one o f three experimental groups." control, receiving no preoperative preparation; unrelated play therapy, receiving a preoperative play session unrelated to hospital or surgical procedures; and related play therapy, receiving a preoperative play session focusing on hospital and surgical procedures. Subjects" behavior was assessed using behavior observation scales for cooperation and upset at seven stress points." admission, nurse's examination, pediatric medical examination, blood test, preoperative injection, transfer to surgery, and induction. The related play therapy group was more cooperative and less upset than either the unrelated play therapy group or the control group across stress points. No significant heart rate differences were found among the three groups. The results suggest that play therapy related to hospital and surgical procedures can alleviate stress and anxiety in 3- and 4-year-old children. (J PED1ATk 102:634, 1983)
Bruce H. Schwartz, D.D.S., M.S., Judith E. Albino, Ph.D., and Lisa A. Tedesco, Ph.D. B a l t i m o r e , M d . , a n d B u f f a l o , N . Y .
HOSPITALIZATION OF CHILDREN for dental extractions and restorations under general anesthesia has proVed to be a useful and necessary approach to treatment in some cases. On the other hand, hospitalization has the disadvantage of producing considerable anxiety for most children. The preponderance of literature in this area reflects hospitalization accompanied by surgery as a stressful, anxiety-producing experience that can lead to either transient or long-term psychological disturbance in a majority of children? 5 The most frequently used method of preparing a child for hospitalization and surgery has been some form of preoperative instruction. 6,7 Although different methods of preparation have been used to inform the child about hospital procedures, they are similar in incorporating attempts to correct any misinformation the child may have concerning these procedures.
From the University of Maryland Dental School and State University of New York at Buffalo. Supported in part by Children's Hospital of Buffalo, N.Y. Reprint requests." Bruce H. Schwartz, D,D.S., Department of Orthodontics, University of Maryland Dental School, 666 West Baltimore St., Baltimore, MD 21201.
634
The Journal of P E D I A T R I C S
Vernon et al? suggest that the major purposes of preoperative preparation are to (1) provide information to the child in an attempt to reduce the unfamiliarity of the hospital setting, (2) encourage the child to express his or her emotions, and (3) establish relationships of trust and confidence with the hospital staff. Melamed and SiegeP used a filmed model in their preparation of children for surgery. Their results indicated that children who observed the film preoperatively demonstrated reduced stress as measured by situational anxiety methods. They also reported that children who did not receive the preoperative preparation showed significantly more behavior problems after hospitalization. In a study by Visintainer and Wolfer, ~~ mothers were included in the preparation procedures. Preparation of the child included information, sensory expectations, role identifications, rehearsals, and support, as related to the specific surgery the child was to undergo. Preparation of the parents mainly dealt with information and support. The results indicated that children receiving preoperative preparation showed a significantly lower degree of upset and more cooperation during hospital procedures than did control children.
Volume 102 Number 4
Psychological preparation for in-hospital dental operations
Cassell ~ showed that children participating in an experimental group undergoing preoperative puppet therapy were significantly less disturbed during catheterization than were control children. Cassell concluded that the puppet therapy relieved the situational anxiety produced by treatment, but had little effect on overall emotional disturbance measured after the hospitalization. The basic rationale of Cassell and other investigators is that play techniques can allow a child emotional expression of fears and concerns related to hospitalization and surgery, clarify preconceptions of events and procedures, and demonstrate the health professional's empathy for the child. It provides an opportunity for the child to approach a conflict situation and "play" through the experience with a manageable amount of fear. We attempted to expand previous findings by testing the effects of preoperative play therapy on very young children hospitalized for dental operations. METHODS Subjects. Forty-five children ranging from 3 to 4 years of age were admitted to the Children's Hospital of Buffalo for dental restorations and extractions under general anesthesia. These children had no previous hospital surgical admissions and no medical or psychological condition requiring special care. Measurement. The effects of preoperative preparation on stress reduction were assessed by systematic observations of behavior and heart rate monitoring. The Manifest Upset Scale and Cooperation Scale were modified for behavioral assessments, and these observation scales utilized the five-point system set forth by Visintainer and Wolfer?: Because of the lack of specific descriptors for scores of 2 and 4, the scales were operationalized to provide concrete observational measurements for these scores as well as to provide greater specificity to scores of 1, 3, and 5. These modifications were based on patient observations prior to this investigation and used descriptors from the behavioral scales developed by Venham. ~3 For both scales, children's behaviors were scored according to the descriptors most closely approximating the behaviors demonstrated for a particular procedure. Two experimentally blind raters provided all the observations. After training, intraclass correlation reliability coefficients for the two raters were 0.93 for the Cooperation Scale and 0.94 for the Manifest Upset Scale. Physiological measurement was accomplished by use of a Mennen-Graetbatch Model 929F Monitor to ascertain the children's heart rate during specific stress points. Procedure. Children were admitted to Buffalo Children's Hospital the day preceding their dental operations. They were randomly assigned to three groups with matching to ensure equivalence in sex composition and size of
635
groups: (1) a control group, which received no preoperative preparation; (2) an unrelated play therapy group, which took part in a preoperative play session unrelated to hospital or surgical procedures; and (3) a related play therapy group, which participated in a preoperative play session focusing on hospital and surgical procedures. The same therapist participated in both the unrelated and related play sessions. On admission the parents or guardians were informed of the nature of the study and asked to sign the consent form. A brief explanation of hospital procedure followed, and a cursory oral inspection was completed, Behavior ratings were then recorded for the admission process. On completing admission procedures, the child and parent were escorted by a therapist from the Child Life Department to a minor-surgical floor. After room assignment the therapist, accompanying the child and parent(s), proceeded to the treatment room for heart monitoring. After careful explanation, three Ag-C1 electrodes were placed on the subject's chest. The monitor leads were attached and baseline heart rate was measured for approximately two minutes. After this, children received treatment as determined by their respective group assignments. A child in the control group received no preoperative therapy and proceeded with the hospital events in the routine manner. A child assigned to the surgically related play therapy group was taken back to the treatment room for the preoperative session. This session concentrated on play therapy techniques that (1) provided information to the child and parent, including descriptions and explanations of hospital procedures, sequencing of events, sensory expectations of procedures and staff duties; and (2) included a role play scheme in which parent and child assumed roles of either a health care provider or patient and carried out actual procedures with hospital toy props. The play therapy protocol developed by the Child Life Staff was age specific for this group of patients and focused on hospital activities corresponding to the stress points used for assessment: nurse's examination, pediatric medical examination, blood test, preoperative injection, transport to surgery, and induction of anesthesia. Each stress point was discussed and role played with a particular emphasis on the actual operation. At this point, discussion focused on nature of the operation, appearance of the operating room, attire of operating room personnel, EKG monitor, the anesthesiologist, the anesthetic mask, and the recovery room. During this preparation both child and parent(s) were encouraged to ask questions and relate their fears and concerns. This session took the form of a dress rehearsal, and the child was encouraged to try out all the equipment and to feel as comfortable with it as possible. The session lasted between 20 and 25 minutes.
636
Schwartz, Albino, and Tedesco
The Journal of Pediatrics April 1983
Control,
4.0
.........
Unrelated
...........
Related Play
Play
3.67
o o3
3.0
m @ CL 0 0 (J
2.4 O
g
L:.,:u
/
i~
2.4 0 ~
/Ill/'/
~-~ 2.27/ ~
2.20 .
2.0
I
\
1.53,~\\~ -. X ~
~,1.27 '~. 2 0
1.0
i
, ~'~///// ~
1.~ i 1 ~/ ;opj ~'~'---,"
/ /
I
\
/'1 60
\\
/
/ .\ i v 1.40
1.13
I
I
I
Admission
Nurse Exam
Medical Exam
I
I
Blood Injection Test
I
I
Transfer Induction
Fig. 1. Mean cooperation scores.
Children assigned to the surgically unrelated therapy group received a play session with the same therapist for approximately 20 minutes. During this session the therapist interested the child in playing with a toy barn and farm animals. Conversation was limited to the barn and characters, with no mention of surgery. The therapist tried to make this session a pleasant, comfortable experience whereby the child could gain trust and confidence in the hospital staff. After receiving their respective group treatments, children proceeded through six more stress points of hospitalization and surgery. The remaining stress points on the presurgical day were the nurse's examination, the pediatric medical examination, and the blood test performed by venipuncture. On the day of surgery, the stress points were the preoperative injection (3 mg/kg hydroxyzine and 0.3 mg atropine), transport to the operating room, and induction. At each stress point, behavioral measures and heart rate were recorded ~(except for heart rate at surgerytransfer). For purpose of consistency, all nurse's examinations were performed by the head nurse, as were all preoperative
injections. The chief pediatric resident performed all medical examinations, and the same hematology technician accomplished all blood work. Transport to surgery was done by two floor nurses. Patients were induced for general anesthesia by one of six anesthesiologists. RESULTS Univariate analyses of variance on baseline admission assessments of cooperation, upset, and heart rate showed no significant differences by sex or treatment groups. The cooperation means for the three treatment groups at the seven stress points, when subjected to multivariate repeated measures analysis of variance, showed significant treatment effects (F = 3.45, P = 0.04, df = 2, 39) (Fig. 1). The related play group was more cooperative than either the unrelated play therapy group or the control group; the control group was/east cooperative. Uncooperative behavior was higher at induction than at any other stress point, but again, the related play group had the most cooperative behavior when compared to either the unrelated play or control group. Inspection of effects at individual stress points showed significant mean differences only between
Volume 102 Number 4
Psychological preparation for in-hospital dental operations
637
Control U n r e l a t e d Play
4,0
...........
3.87
R e l a t e d Play
3.47
/
3.0 o
u)
/" ."~ \" V / / /..-" \ " , 2 . i 3 / 263-L.,.'~ y-/ 13",2.. ', / / ,;i 2 . 4 7 ~ ',_,.'_ 2.80/
267. 9 X \\ X
2.0
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263
_J /" \1.53 1.53/ ..... 1.40 1.33
i
I
l
Admission
Nurse
Medical
Exam
Exam
1
, I
Blood I n j e c t i o n Test
I
1
Transfer Induction
Fig. 2. Mean upset scores.
the control and related play groups at the following stress points: nurse's examination, blood test, transfer to surgery, and induction. At induction, cooperation means were not only significantly different (P = 0.005) between the control and related play groups, but approaehed significance (P = 0.056) for related play therapy and unrelated play therapy groups. No sex differences were found for cooperation means (F = 0.03, P = 0.86, df = 1, 39). Fig. 2 displays the upset means for the three treatment groups at the seven stress points. A multivariate repeated measures analysis of variance showed significant treatment effects (F = 3.15, P = 0.05, df = 2, 39). The related play group had less upset behavior than in either the unrelated play group or the control group. The control group displayed the most upset behavior. Upset behavior was higher at induction than at any other stress point, but the related play group again showed less upset behavior than either of the other groups, Inspection of the individual effects showed significant mean differences only between the control and related play groups at nurse's examination, preoperative injection, transfer to surgery, and induction9 Upset means at induction were significantly different
(P = 0.002) between the related play and control groups and between the unrelated play and related play groups (P = 0.04). No sex differences were found for upset (F = 0.13, P = 0.71, df = 1, 39). DISCUSSION The data from this study support the hypothesis that systematic preparation in the form of a hosPital-surgery related play therapy session can be beneficial to young children hospitalized for dental operations under general anesthesia. Although the analyses reflected significant differences among the three treatment groups, statistical tests for individual mean differences among treatment groups did not indicate the effectiveness of related play sessions over unrelated play sessions for increasing cooperation and reducing upset behavior, with the exception of one stress point, induction of anesthesia. At this point, the related play group demonstrated significantly less upset behavior than did the unrelated play group, and approached significance for cooperative behavior. The pattern of treatment group differences remained consistent at all stress points for both cooperation and upset; the control group was
6 38
Schwartz, AIbino, and Tedesco
The Journal of Pediatrics April 1983
least cooperative and most upset, followed by the unrelated play group, and finally the related play group. Based on both behavioral and physiological responses, induction of anesthesia appears to be the most stressful procedure the child experiences during hospitalization. Corroborating the observations of Visintainer and Wolfer, ~2this stress may be related to (1) parent separation anxiety, (2) relative loss of control, (3) sequencing of events, with induction being the final potentially threatening procedure, and (4) the ominous appearance of masked personnel and complicated anesthetic and surgical equipment, posing a threat of physical harm or bodily injury. I f a young patient is distressed by these factors, the experience of mask inhalation induction may be terribly frightening. Developmental theories TM~5propose that gradually from age 3 to 6 years a child demonstrates an increasing ability to distinguish fantasy from reality, so that by age 5 or 6 years this distinction is usually accomplished. Younger children of 3 and 4 years do not make this distinction as clearly; therefore, frightening dreams and their characters may become part of the child's reality. Regardless of group assignment, certain children in this study panicked, and physical restraint was required to maintain the mask over the child's face. It is not surprising that some children believe they are being suffocated during inhalation induction. In several postsurgical interviews, children reported the presence of a monster during their operating room visit. One child, when questioned what came out of the inhalation mask, replied, " T h e Hulk did." One possible benefit of preoperative play therapy may be the early identification of those children who react adversely to mask inhalation induction. It is possible that these children may be less distressed by intravenous induction, as implemented by Steward TM and by Kay. ~7 Clearly, further research in this area is indicated. Finally, because of hospital policy, the number of anesthesiologists was a difficult variable to control. Although similar induction techniques were used, it is undeniable that the skills and personalities of the different anesthesiologists could have affected the children's behavior. The results of this study indicate that the information presented in related play therapy sessions, coupled with rehearsal of hospital and surgical procedures, can reduce anxiety and fears and help the young child cope with hospital procedures more effectively, particularly with respect to induction of anesthesia. We thank Terry Knabe, Head Nurse, and Dr. Gene Stanford, Director of the Child Life Program, for their participation and
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encouragement; Dr. Joe Bernat and Dr. C. W. Snyder for allowing their patients to take part in this study; Dr. Martin Downey, Chief of Anesthesia, and his staff, for their cooperation; and Dr. Lillian Schwartz, Director of Training in Child Psychiatry, Montefiore Hospital, for her advice and suggestions. Barbara Bass and Mary Murphy provided their typing expertise in completing this paper. REFERENCES
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