- Email: [email protected]
Theoretical Foundations of a Prepared Sibling Class
Special Section Article
principles and practice Theoretical Foundations of a Prepared Sibling Class NANCY M. JOHNSEN, RN, BS, ACCE, A N D M A R Y ELLEN GASPARD, RN, MA, ACCE Family-centered maternity care is a frequently used phrase, yet children, an integral part of the family, are not always involved in formal preparation for a new infant. Should children be included in the preparation for a new arrival? A formal assessment to answer this question led to the planning and implementation of a Sibling Preparation Class. This article discusses objectives with implementation methods and correlates their direct application to class content. Nursing implications and suggestions for further research are included.
age specific; and those for the Many events in a child’s life parents. create stress and anxiety. The arrival of a new sibling is one Objectives for children a re that of these potentially traumatic events.’ To foster a positive 1) Children’s anxieties will be growth spurt for children resulting lowered regarding th e ir from the birth of a sibling, the mother’s impending hospiPrepared Sibling Class at Overlook talization. Hospital in Summit, New Jersey, 2 ) Children will begin to deprovides children with informavelop realistic expectations tion about babies and a positive of a newborn sibling. experience with the h o ~ p i t a l . ~ , ~ 3) Children will begin to recSince parental attitudes and levels ognize and express their of comfort/discomfort with the feelings regarding their exsituation may set the stage for pected sibling. their childrens’ reactions, the Objectives for parents a re that class also helps adults to become more aware of a child’s need for Parents will begin to formuadditional love, reassurance, and late a strategy for preparing guidance when a sibling is introtheir child(ren) for the exduced into the family.’.4 pected sibling. In the planning stage, two sets Parents will begin to formuof objectives were formulated: late strategies for coping those for the children, which are with a n additional child in the family. Submitted: May 1983. Revised: February 1984. Accepted: February 1984.
May/June 1985 JOGNN
The program is geared toward children between three and 12
years of age because, by the age of three, children begin to have a n interest in conformity, are able to express themselves verbally, have a n interest in playing with other children, and are able to leave their mothers for short periods of time.5 lt was assumed that children over the age of 12 years prefer parental discussions to class work with significantly younger children. CHILDREN’S ANXIETIES ARE LOWERED
Since familiarity with the hospital setting might replace frightening fantasies in children’s minds, the program begins by providing a friendly, concrete experience with the h o ~ p i t a l Chil.~ dren a r e greeted upon arrival, enabling them to meet with the teacher in the security of the parents’ presence. The nurse-teacher dresses in the stereotypical white
237
uniform, and later changes to scrub garb while the children watch. Since children think concretely and are perceptually oriented, the white uniform signifies a nurse, who then dons scrub garb to help the children identify the maternity nurse.6 Next, the children try on hospital dress; pediatric gowns, caps, and masks are provided. The children are told that hospital personnel and fathers wear these clothes when helping mothers give birth, and that the children themselves will wear the gown when they come to the hospital to visit their mother and the newborn. Playing “dress-up” allows the children to use psychomotor skills to help integrate roles and experiences.”’ A tour of the maternity department at the hospital helps to allay the biggest concern of most children-the whereabouts of their mother.’ Actually going into a room like the one their mother will have may forestall children’s fears that their mother is gone forever and that they did something terrible to cause their mother to leave them.2 Before the tour, children are lined up with partners and told the hospital rules (walk slowly, speak quietly, and hold hands) matter-of-factly, because they have no internalized set of rules yet.5 The children are then taken to see and touch the places their mother will be while in the hospital, and to see a naked newborn in the nursery window. Especially important are the telephone, for contact between mother and child, and the mother’s room, where the child may meet with mother daily and hold the newborn with both parents. CHILDREN DEVELOP REALISTIC EXPECTATIONS
Viewing a live, naked newborn in the nursery, stories, dramati-
238
zation, and role-playing a r e some strategies used to help children learn what a newborn is like, which behaviors a r e appropriate, and how a new sibling’s arrival may alter family roles and relationships. Children a r e grouped by age, with preschoolers in one group and children five to 12 years of age in another. This allows the instructor to take advantage of the older child’s ability to problemsolve and think abstractly, while also dealing with the younger child’s concrete thought processes.3.6 Once the younger children are dressed up, the nurse-teacher reads them a story about the arrival of a newborn. During the reading of the story, the children a r e encouraged to comment and leading questions are asked, such as “What did you d o when you were a baby?” “Will you show me?” “How d o you help mommy and daddy?” “Do you dress yourself-feed yourself?” and “Can the new baby d o these things?” Such questions direct the children’s thoughts to home activities related to autonomy and independence, their current life tasks.9 To aid development of correct perception of a typical newborn, children engage in physical activities. While sitting down, they practice holding a doll properly cradled in their arms and rock their “baby” while singing “RockA-Bye-Baby.’’ The children a r e taught that a newborn’s head is quite heavy and that their mother o r father may help them by putting pillows under their elbow. Appropriate behavior with infants is discussed and demonstrated. For example, the children are asked what they can do when the infant cries, and positive behaviors such as singing to the newborn a r e emphasized, while negative behaviors a r e discouraged. Children a r e told alternative behaviors to substitute
for unacceptable actions: “Kick a pillow, not the baby, when angry, and always have a parent help you pick up the baby; never pick up the baby by yourself.” These acceptable actions are modeled by the instructor because children a r e more likely to imitate behaviors they have seen than behaviors they a r e merely told to adopt.3 The older children participate in a separate group and a r e told a story that includes many of the points discussed with the younger children, but in a more mature, discussion-oriented fashion. The instructor again asks leading questions, to bring out the following points: 1) Sometimes children like the
infant, sometimes not; 2) Grown-up activities are often more fun than infant activities; and 3) Although mothers and fathers a r e busy, they will still have special time for the older children, and they love the older children a s much as ever. A discussion of changing family roles includes suggestions about how an older child can help at home. Since the life task of the seven- to 11-year-old is industry, children are often eager to take on additional responsibility so parents will approve and see them as special.’ Older children are also able to problem-solve, allowing discussion of such abstract questions as “How do you think a child feels when people keep bringing only the newborn a present?” or “How do you think you might feel if mom has to say, ‘I can’t help you right now because I’m busy with the baby’?” Because older children have advanced fine-motor skills, their life task is industry, even older boys respond enthusiastically to doll diapering and dressing,
May/June 1985 JOCNN
proper handling of a n infant, and quieting of a crying baby in anticipation of providing significant aid to parents later.
CHILDREN RECOGNIZE THEIR FEELINGS REGARDING THEIR EXPECTED SIBLING Recognition of feelings is begun during previously described activities and discussions. In addition, the children see a film that deals with feelings of jealousy, anger, and being left out, which may help the older child anticipate situations and learn how to seek appropriate help. The younger children often d o not understand all of the situations presented in t h e film; however, the parents also see the film and it is suggested that they use t h e film as a focus for later family discussions. Art is a valuable tool of expression for children. Feelings, awareness of environment and people around them, as well as any changes in their world a r e likely to be reflected in t h e children’s drawing.“’ To help express ideas and feelings in a nonverbal way, the children are asked t o draw, in class, a picture of their family “doing something” after t h e infant comes home. Volunteers, including Candy Stripers, members of the hospital Women’s Auxiliary (and several persons who simply heard about this program and asked to participate) ask each child to tell them about their picture and the picture is labeled accordingly. Both children and parents a r e encouraged t o discuss the drawing at home. In class, instructors survey pictures for obvious content. Noteworthy items include 1) forgetting to draw a family member, frequently t h e newborn, which might signal negative feelings toward that person; 2) omission of self, possibly reflecting feelings of inadequacy o r
May/June 1985 JOGNN
not belonging; 3 ) position and size of family members, with favored persons drawn very large and/or placed nearest to th e child; 4) similarity of color o r closeness between two family members, signifying a wish for a positive relationship; and 5) closeness among all family members who wear smiling faces, indicating perception of close family relationships. Barriers may be placed between family members if a relationship is not perceived Specific characteristics observed in children’s pictures may be pointed out t o their parents a s a basis for future discussion. It must be stressed that th e instructors a r e not art therapists, and conclusions about a child’s thoughts cannot be drawn from o n e picture. An entire series of drawings occurring over a period of time, analyzed by a qualified art therapist taking into account t h e child’s maturation, emotional status, and experiences is necessary before any conclusions can be drawn. In th e class a t Overlook Hospital, pictures a r e used a s another method of initiating dialogue between parents and children.
PARENTS PREPARE THEIR CHILD(REN) FOR THE EXPECTED SIBLING At t h e start of th e children’s activities, th e parents meet separately with another instructor. This separation helps the children to maintain acceptable behavior during class and frees parents to participate fully in the discussion s e ~ s i o nParents .~ receive a tour of the maternity department identical to the o n e their children receive to provide a common basis for communication about the upcoming separation. In a roundtable discussion, many preparation tips a r e discussed. Parents a r e warned that children’s imaginations may
lead to fantasies worse than reality, and a sample of available books is shown and discussed, including a homemade baby book about the older child. This latter type of book is best made by parents and children together. Parents are given a list of tips for preparing their children and a r e reminded that a young child’s central fear is loss of mother. Parents of toddlers are advised that preparation of children under two years of age should include showing the child concrete objects, i.e., crib, bottles, diapers, and real infants, but a r e cautioned that children may assume their new sibling will look exactly like any other real infant they Three- to six-year-olds seem to have the most questions, with the most frequently asked being “How does th e baby get out?” Parents are encouraged to answer simply and honestly. Children aged seven and older may be looking for validation of information they already have. Parents view the same film (“I’m a Little Jealous of that New Baby,” by Kids Korner) a s the children and a r e encouraged to use it as a basis for future communication with their children. In addition, we feel that the film helps parents t o understand their children’s needs for reassurance about their status. Parents a r e made aware of th e variety of normal feelings children may have, especially those that are negative. Nightmares, clinging, anxiety, whining, regression, hostility, and silence are all possible reactions to the birth of a new sibling, along with happiness and loving feeling^.^^'^'^ Such information should enable parents t o discuss with their children the feelings behind the behaviors exhibited. Parents might encourage children to draw a picture of a situation to help shift the focus to a n object other than the child himself, thereby reducing the
239
Table 1.
End-of-Class Questionnaire
1 What did you firid most helpful about this class? 100% found class helpful 61% named parents discussion group as best 35% named tour of hospital as best 2 Is there any part of the class presentation that you did not like? 56% liked everything 44% no response 3 What did you Iike/dislike about the film used? 82% liked it 16% found it too negative, giving children ideas 4 What additional information would y o ~ i like to see presented in the class7 34% no response 47% no additions 19% called for film of newborn, larger bibliography for parents, class for children 18 months to three years
threat of discussing scarey feelings. Parents are informed of the new behaviors (helpfulness and infant care) that their children have learned that morning, so that they may reinforce these behaviors at home. PARENTS LEARN TO COPE WITH AN ADDITIONAL CHILD IN THE FAMILY The parents’ roundtable discussion is guided by the instructor to include potential child-care situations at home. For example, the older child is more likely to be naughty during infant-feeding times when the mother bottlefeeds, so mothers a r e encouraged to provide specific activities for other children during this time. Children of breastfeeding mothers are less likely to behave poorly during feeding times, either because the mother has o n e hand free to help the older child o r because the breastfeeding mother is more likely to provide special
240
activities for the older child at feeding time.8 Also, allowirig the older child t o help bring th e mother and baby home from th e hospital includes the older child as part of the family.8 Since n o two children are the same, parents should be ready to change their parenting techniques for each child, and to acknowledge t h e difference between their children.’.l3 Parents a r e informed that comparing children may cause anger and resentment in th e undervalued child, as well as hostility toward th e valued child and t h e parents. Sibling rivalry is presented as a normal occurrence for which many parents are not fully prepared. Since the intensity of the rivalry may be influenced by events surrounding the birth, parents ar e told to prepare the older child(ren) for th e event, acknowledging feelings honestly, as well a s discussing acceptable/nonacceptable behavior^.'^ At the end of an hour and a half class, parents rejoin their children for a party with juice and cookies. As families leave, the children are presented with a disposable diaper for practice on dolls at home, a coloring book, a graduation certificate, and a “Prepared Big Brother/Sister” button. The children also take home the pictures they colored in class and the paper caps and masks they wore for dress-up. EVALUATION AND DISCUSSION Evaluation of th e program has involved feedback from class participants by several methods. From June 1982 to January 1983, 187 families attended classes, including 226 children. Direct observation by instructors was o n e method used to evaluate achievement of the objectives for children. Dress-up was enjoyed by the ma-
jority of children, although a few chose not to dress up. When the children were observed with dolls, younger children responded to holding and singing, but had motor coordination problems with tasks such as diapering; older children preferred to learn extended caretaking skills. The highlight of the class was the hospital tour, during which questions and comments from children and parents occur almost constantly. The adults responded favorably to th e discussion groups, and it was noted that different group dynamics require a change in teaching strategy. Most groups engaged in much discussion, allowing the instructor to moderate. Objective achievement for the parent division of the class was further evaluated by an End-ofClass Questionnaire (Table 1). Sixty-two questionnaires were returned from th e 187 families. Based on this 33% return response, 100% of the respondents liked the class, with 61% specifying th e parents’ discussion group as most helpful, and 35% saying the hospital tour was the most beneficial portion. Fifty-six percent of respondents stated they enjoyed th e entire class, while five percent left th e question unanswered. The third question showed that 16% of responding parents found the film “too negative,” with some parents expressing concern that their children might have learned new, negative behaviors from the film. However, 82% of parents felt the film portrayed sibling feelings well and provided positive suggestions for dealing with common rivalry situations. Eighty-one percent of the returns indicated the class had provided th e information parents required. Suggestions made for additions to the class included showing a film on normal newborns, supplying a more extensive parents’ bibliography, and begin-
May/June 1985 JOG”
ning a class for children aged 18 months to three years. An After-Birth Questionnaire (Table 2) was aimed a t ascertaining achievement of the children’s section objectives. Only 23 of the 187 questionnaires were returned despite provision of a stamped, self-addressed envelope. In view of such low response, phone-call interviews scheduled for two weeks after delivery were initiated in January, and t h e parents were asked the same questions appearing in t h e After-Birth Questionnaire. The class was wellreceived, evidenced by 100% of respondents stating that their children enjoyed t h e class. The first objective, lowering of children’s anxieties, was apparently accomplished, since 96% of parents reported their children reacted positively to their mothers’ hospital stay, as opposed to frequent misbehavior and tears before establishment of t h e class. Whether children’s improved behavior is a result of lessened fear, parental behavior changes, o r staff attitiidinal changes is unknown and bears further research. Regarding the second objective, helping children develop a n idea of what life is like with a new sibling at home, 96% of parents responding reported n o major upheaval when the newborn came home, and 91% stated the children were able t o participate at home by both fetching things for t h e parents and handling t h e infant. Virtually all parents reported that their children communicate feelings, both positive and negative, about the new sibling-our third objective. Since parents did not share many of their specific strategies for preparing their child(ren) o r for coping with a n additional child, it is difficult to measure t h e achievement of t h e last two objectives. With 100% of returned questionnaires approving
May/June 1985 JOCNN
t h e class content and stating that they found t h e discussion, tours, instructor’s comments, and film beneficial, it is assumed that they gained the information they felt necessary t o plan their strategies. A final method of evaluation includes an ongoing epidemiological survey, showing no increase in inpatient maternal-infant infection rates since t h e introduction of sibling presence in t h e mother’s room and sibling holding of infants. Parents have been cooperative about not bringing a sick child t o the hospital. With positive support of our objectives and program, the original premise seems supported: Children should be included in the family preparation for t h e arrival of a newborn. Sibling preparation has a definite place in family-centered maternity care. As nurses become aware of t h e issues, topics, and availability of programs, they can better guide and counsel parents expecting a subsequent child.
SUMMARY
To assure continuing improvement in prepared siblings programs, nursing- must consider a t least two topics for further research. First, there should be more thorough investigations of children’s behavior in t h e hospital and a t home t o compare children who attended class with those who did not. This would determine the occurrence of a statistically significant change in the behavior of children who attended a class. Second, a n adequate evaluation tool should be created t o measure parents’ ability to manage at home after t h e birth of a subsequent child. This tool could yield information on the presence o r absence of improved parenting as a result of t h e class, as well a s t h e management strategies most often
Table 2.
After-Birth Questionnaire
1. How did your child(ren) react to the class? 100% enjoyed class 2. How did your child(ren) react to your hospital stay? 96% positively 4% no reply 3. Do you feel the Sibling Class helped to ease the introduction of the new baby into your home? 96% yes 4% no; the child has not adjusted well 4. Is (are) your child(ren) participating in baby care? 91% yes 57% fetch for parents 29% handle baby 9% no; child cares for doll or is disinterested 5. Does (do) your child(ren) communicate his/her thoughts and feelings about the new baby? 100% yes 35% negative feelings 61% positive feelings 6. Additional comments: Several parents requested a class for toddlers.
found helpful by parents. This information will allow nurses to meet more closely children’s and parents’ needs during childbearing experiences.
REFERENCES 1. Fassler J. Helping children cope. New York: The Free Press, 1978: 86- 100. 2. Jewett C. Helping children cope with separation and loss. Cam-
bridge: Harvard Common Press, 1981. 3. Hess R, Croft D. Teachers of young children. New York: Houghton Mifflin Co., 1972. 4, Legg c, Shenck I , w,Reaction of preschool children to the birth of a sibling. Child Psychiatry Hum Dev Fall 1974;5:3-29. 5. Gesel1 A. The first five Years Of life. New York: Harper and Brothers, 1940:40-57;252-3. 6. Pulaski MA, Piaget: a n introduction to children’s cog-
nitive development. New York:
24 1
Harper and Row, 1971:24-7;38123. 7. The Threshold Program for Early Learning. Vol. Ill: Fostering growth in language skills and social concepts. New York: Macmillan Publishing Company, Inc., 1970. 8. Weiss JS. Your second child: a guide for parents. New York: Summit Books, 1981:83-111. 9. Erickson E. Identity, youth and crisis. New York: W. W. Norton and Company. Inc., 1968. 10. Solomon S. Knowing your child through his handwriting and
11.
12. 13. 14.
drawing. New York: Ace Books, 1978:l-5. Burns RC, Kaufman SH. Actions, styles and symbols in kinetic family drawings (K-F-D): an interpretive manual. New York: Brunner/ Mazel, 1972:30, 76, 174. DiLeo J. Children’s drawings a s diagnostic aids. New York: Brunner/Mazel, 1973. Anderson SVD, Simken P. Birth through children’s eyes. Seattle: The Penny Press, 1981:l-76. McDermott J. Sibling rivalry. United States: Wideview Books, 1980~3-85.
Address for correspondence: Nancy M. Johnsen, RN, BS, ACCE, Department of Health Education, Overlook Hospital, Summit, NJ 07901.
Nancy M Johnsen is the former director of the Parentcraft Program at Overlook Hospital in Summit, New Jersey Ms Johnsen is also a health educator and certified Lamaze instructor at Overlook Hospital Parentcraft Mary Ellen Gaspard is a prenatal educator at Overlook Hospital in Summit. New Jersey She is also a certified Lamaze instructor
ATTENTION AUTHORS
The JOGNN Editorial Board welcomes the chance to review clinical and research manuscripts on the topics listed below. For author guidelines, send a stamped, self-addressed envelope to J. Serevino, Editor, JOGNN, Suite 200, Washington, DC 20024. Well Newborn Care Nipple Stimulation Used for Augmentation of Labor lntrapartum Birth Options Emergency Delivery Elective Induction of Labor lntrapartum Management
242
Rural Obstetric Care Staffing and Management of Alternative Birth Settings Prenatal Estimation of Gestational Age with Electronic Equipment Induction of Labor with Pitocin I.V.
May/June 1985 JOG”
principles and practice Theoretical Foundations of a Prepared Sibling Class NANCY M. JOHNSEN, RN, BS, ACCE, A N D M A R Y ELLEN GASPARD, RN, MA, ACCE Family-centered maternity care is a frequently used phrase, yet children, an integral part of the family, are not always involved in formal preparation for a new infant. Should children be included in the preparation for a new arrival? A formal assessment to answer this question led to the planning and implementation of a Sibling Preparation Class. This article discusses objectives with implementation methods and correlates their direct application to class content. Nursing implications and suggestions for further research are included.
age specific; and those for the Many events in a child’s life parents. create stress and anxiety. The arrival of a new sibling is one Objectives for children a re that of these potentially traumatic events.’ To foster a positive 1) Children’s anxieties will be growth spurt for children resulting lowered regarding th e ir from the birth of a sibling, the mother’s impending hospiPrepared Sibling Class at Overlook talization. Hospital in Summit, New Jersey, 2 ) Children will begin to deprovides children with informavelop realistic expectations tion about babies and a positive of a newborn sibling. experience with the h o ~ p i t a l . ~ , ~ 3) Children will begin to recSince parental attitudes and levels ognize and express their of comfort/discomfort with the feelings regarding their exsituation may set the stage for pected sibling. their childrens’ reactions, the Objectives for parents a re that class also helps adults to become more aware of a child’s need for Parents will begin to formuadditional love, reassurance, and late a strategy for preparing guidance when a sibling is introtheir child(ren) for the exduced into the family.’.4 pected sibling. In the planning stage, two sets Parents will begin to formuof objectives were formulated: late strategies for coping those for the children, which are with a n additional child in the family. Submitted: May 1983. Revised: February 1984. Accepted: February 1984.
May/June 1985 JOGNN
The program is geared toward children between three and 12
years of age because, by the age of three, children begin to have a n interest in conformity, are able to express themselves verbally, have a n interest in playing with other children, and are able to leave their mothers for short periods of time.5 lt was assumed that children over the age of 12 years prefer parental discussions to class work with significantly younger children. CHILDREN’S ANXIETIES ARE LOWERED
Since familiarity with the hospital setting might replace frightening fantasies in children’s minds, the program begins by providing a friendly, concrete experience with the h o ~ p i t a l Chil.~ dren a r e greeted upon arrival, enabling them to meet with the teacher in the security of the parents’ presence. The nurse-teacher dresses in the stereotypical white
237
uniform, and later changes to scrub garb while the children watch. Since children think concretely and are perceptually oriented, the white uniform signifies a nurse, who then dons scrub garb to help the children identify the maternity nurse.6 Next, the children try on hospital dress; pediatric gowns, caps, and masks are provided. The children are told that hospital personnel and fathers wear these clothes when helping mothers give birth, and that the children themselves will wear the gown when they come to the hospital to visit their mother and the newborn. Playing “dress-up” allows the children to use psychomotor skills to help integrate roles and experiences.”’ A tour of the maternity department at the hospital helps to allay the biggest concern of most children-the whereabouts of their mother.’ Actually going into a room like the one their mother will have may forestall children’s fears that their mother is gone forever and that they did something terrible to cause their mother to leave them.2 Before the tour, children are lined up with partners and told the hospital rules (walk slowly, speak quietly, and hold hands) matter-of-factly, because they have no internalized set of rules yet.5 The children are then taken to see and touch the places their mother will be while in the hospital, and to see a naked newborn in the nursery window. Especially important are the telephone, for contact between mother and child, and the mother’s room, where the child may meet with mother daily and hold the newborn with both parents. CHILDREN DEVELOP REALISTIC EXPECTATIONS
Viewing a live, naked newborn in the nursery, stories, dramati-
238
zation, and role-playing a r e some strategies used to help children learn what a newborn is like, which behaviors a r e appropriate, and how a new sibling’s arrival may alter family roles and relationships. Children a r e grouped by age, with preschoolers in one group and children five to 12 years of age in another. This allows the instructor to take advantage of the older child’s ability to problemsolve and think abstractly, while also dealing with the younger child’s concrete thought processes.3.6 Once the younger children are dressed up, the nurse-teacher reads them a story about the arrival of a newborn. During the reading of the story, the children a r e encouraged to comment and leading questions are asked, such as “What did you d o when you were a baby?” “Will you show me?” “How d o you help mommy and daddy?” “Do you dress yourself-feed yourself?” and “Can the new baby d o these things?” Such questions direct the children’s thoughts to home activities related to autonomy and independence, their current life tasks.9 To aid development of correct perception of a typical newborn, children engage in physical activities. While sitting down, they practice holding a doll properly cradled in their arms and rock their “baby” while singing “RockA-Bye-Baby.’’ The children a r e taught that a newborn’s head is quite heavy and that their mother o r father may help them by putting pillows under their elbow. Appropriate behavior with infants is discussed and demonstrated. For example, the children are asked what they can do when the infant cries, and positive behaviors such as singing to the newborn a r e emphasized, while negative behaviors a r e discouraged. Children a r e told alternative behaviors to substitute
for unacceptable actions: “Kick a pillow, not the baby, when angry, and always have a parent help you pick up the baby; never pick up the baby by yourself.” These acceptable actions are modeled by the instructor because children a r e more likely to imitate behaviors they have seen than behaviors they a r e merely told to adopt.3 The older children participate in a separate group and a r e told a story that includes many of the points discussed with the younger children, but in a more mature, discussion-oriented fashion. The instructor again asks leading questions, to bring out the following points: 1) Sometimes children like the
infant, sometimes not; 2) Grown-up activities are often more fun than infant activities; and 3) Although mothers and fathers a r e busy, they will still have special time for the older children, and they love the older children a s much as ever. A discussion of changing family roles includes suggestions about how an older child can help at home. Since the life task of the seven- to 11-year-old is industry, children are often eager to take on additional responsibility so parents will approve and see them as special.’ Older children are also able to problem-solve, allowing discussion of such abstract questions as “How do you think a child feels when people keep bringing only the newborn a present?” or “How do you think you might feel if mom has to say, ‘I can’t help you right now because I’m busy with the baby’?” Because older children have advanced fine-motor skills, their life task is industry, even older boys respond enthusiastically to doll diapering and dressing,
May/June 1985 JOCNN
proper handling of a n infant, and quieting of a crying baby in anticipation of providing significant aid to parents later.
CHILDREN RECOGNIZE THEIR FEELINGS REGARDING THEIR EXPECTED SIBLING Recognition of feelings is begun during previously described activities and discussions. In addition, the children see a film that deals with feelings of jealousy, anger, and being left out, which may help the older child anticipate situations and learn how to seek appropriate help. The younger children often d o not understand all of the situations presented in t h e film; however, the parents also see the film and it is suggested that they use t h e film as a focus for later family discussions. Art is a valuable tool of expression for children. Feelings, awareness of environment and people around them, as well as any changes in their world a r e likely to be reflected in t h e children’s drawing.“’ To help express ideas and feelings in a nonverbal way, the children are asked t o draw, in class, a picture of their family “doing something” after t h e infant comes home. Volunteers, including Candy Stripers, members of the hospital Women’s Auxiliary (and several persons who simply heard about this program and asked to participate) ask each child to tell them about their picture and the picture is labeled accordingly. Both children and parents a r e encouraged t o discuss the drawing at home. In class, instructors survey pictures for obvious content. Noteworthy items include 1) forgetting to draw a family member, frequently t h e newborn, which might signal negative feelings toward that person; 2) omission of self, possibly reflecting feelings of inadequacy o r
May/June 1985 JOGNN
not belonging; 3 ) position and size of family members, with favored persons drawn very large and/or placed nearest to th e child; 4) similarity of color o r closeness between two family members, signifying a wish for a positive relationship; and 5) closeness among all family members who wear smiling faces, indicating perception of close family relationships. Barriers may be placed between family members if a relationship is not perceived Specific characteristics observed in children’s pictures may be pointed out t o their parents a s a basis for future discussion. It must be stressed that th e instructors a r e not art therapists, and conclusions about a child’s thoughts cannot be drawn from o n e picture. An entire series of drawings occurring over a period of time, analyzed by a qualified art therapist taking into account t h e child’s maturation, emotional status, and experiences is necessary before any conclusions can be drawn. In th e class a t Overlook Hospital, pictures a r e used a s another method of initiating dialogue between parents and children.
PARENTS PREPARE THEIR CHILD(REN) FOR THE EXPECTED SIBLING At t h e start of th e children’s activities, th e parents meet separately with another instructor. This separation helps the children to maintain acceptable behavior during class and frees parents to participate fully in the discussion s e ~ s i o nParents .~ receive a tour of the maternity department identical to the o n e their children receive to provide a common basis for communication about the upcoming separation. In a roundtable discussion, many preparation tips a r e discussed. Parents a r e warned that children’s imaginations may
lead to fantasies worse than reality, and a sample of available books is shown and discussed, including a homemade baby book about the older child. This latter type of book is best made by parents and children together. Parents are given a list of tips for preparing their children and a r e reminded that a young child’s central fear is loss of mother. Parents of toddlers are advised that preparation of children under two years of age should include showing the child concrete objects, i.e., crib, bottles, diapers, and real infants, but a r e cautioned that children may assume their new sibling will look exactly like any other real infant they Three- to six-year-olds seem to have the most questions, with the most frequently asked being “How does th e baby get out?” Parents are encouraged to answer simply and honestly. Children aged seven and older may be looking for validation of information they already have. Parents view the same film (“I’m a Little Jealous of that New Baby,” by Kids Korner) a s the children and a r e encouraged to use it as a basis for future communication with their children. In addition, we feel that the film helps parents t o understand their children’s needs for reassurance about their status. Parents a r e made aware of th e variety of normal feelings children may have, especially those that are negative. Nightmares, clinging, anxiety, whining, regression, hostility, and silence are all possible reactions to the birth of a new sibling, along with happiness and loving feeling^.^^'^'^ Such information should enable parents t o discuss with their children the feelings behind the behaviors exhibited. Parents might encourage children to draw a picture of a situation to help shift the focus to a n object other than the child himself, thereby reducing the
239
Table 1.
End-of-Class Questionnaire
1 What did you firid most helpful about this class? 100% found class helpful 61% named parents discussion group as best 35% named tour of hospital as best 2 Is there any part of the class presentation that you did not like? 56% liked everything 44% no response 3 What did you Iike/dislike about the film used? 82% liked it 16% found it too negative, giving children ideas 4 What additional information would y o ~ i like to see presented in the class7 34% no response 47% no additions 19% called for film of newborn, larger bibliography for parents, class for children 18 months to three years
threat of discussing scarey feelings. Parents are informed of the new behaviors (helpfulness and infant care) that their children have learned that morning, so that they may reinforce these behaviors at home. PARENTS LEARN TO COPE WITH AN ADDITIONAL CHILD IN THE FAMILY The parents’ roundtable discussion is guided by the instructor to include potential child-care situations at home. For example, the older child is more likely to be naughty during infant-feeding times when the mother bottlefeeds, so mothers a r e encouraged to provide specific activities for other children during this time. Children of breastfeeding mothers are less likely to behave poorly during feeding times, either because the mother has o n e hand free to help the older child o r because the breastfeeding mother is more likely to provide special
240
activities for the older child at feeding time.8 Also, allowirig the older child t o help bring th e mother and baby home from th e hospital includes the older child as part of the family.8 Since n o two children are the same, parents should be ready to change their parenting techniques for each child, and to acknowledge t h e difference between their children.’.l3 Parents a r e informed that comparing children may cause anger and resentment in th e undervalued child, as well as hostility toward th e valued child and t h e parents. Sibling rivalry is presented as a normal occurrence for which many parents are not fully prepared. Since the intensity of the rivalry may be influenced by events surrounding the birth, parents ar e told to prepare the older child(ren) for th e event, acknowledging feelings honestly, as well a s discussing acceptable/nonacceptable behavior^.'^ At the end of an hour and a half class, parents rejoin their children for a party with juice and cookies. As families leave, the children are presented with a disposable diaper for practice on dolls at home, a coloring book, a graduation certificate, and a “Prepared Big Brother/Sister” button. The children also take home the pictures they colored in class and the paper caps and masks they wore for dress-up. EVALUATION AND DISCUSSION Evaluation of th e program has involved feedback from class participants by several methods. From June 1982 to January 1983, 187 families attended classes, including 226 children. Direct observation by instructors was o n e method used to evaluate achievement of the objectives for children. Dress-up was enjoyed by the ma-
jority of children, although a few chose not to dress up. When the children were observed with dolls, younger children responded to holding and singing, but had motor coordination problems with tasks such as diapering; older children preferred to learn extended caretaking skills. The highlight of the class was the hospital tour, during which questions and comments from children and parents occur almost constantly. The adults responded favorably to th e discussion groups, and it was noted that different group dynamics require a change in teaching strategy. Most groups engaged in much discussion, allowing the instructor to moderate. Objective achievement for the parent division of the class was further evaluated by an End-ofClass Questionnaire (Table 1). Sixty-two questionnaires were returned from th e 187 families. Based on this 33% return response, 100% of the respondents liked the class, with 61% specifying th e parents’ discussion group as most helpful, and 35% saying the hospital tour was the most beneficial portion. Fifty-six percent of respondents stated they enjoyed th e entire class, while five percent left th e question unanswered. The third question showed that 16% of responding parents found the film “too negative,” with some parents expressing concern that their children might have learned new, negative behaviors from the film. However, 82% of parents felt the film portrayed sibling feelings well and provided positive suggestions for dealing with common rivalry situations. Eighty-one percent of the returns indicated the class had provided th e information parents required. Suggestions made for additions to the class included showing a film on normal newborns, supplying a more extensive parents’ bibliography, and begin-
May/June 1985 JOG”
ning a class for children aged 18 months to three years. An After-Birth Questionnaire (Table 2) was aimed a t ascertaining achievement of the children’s section objectives. Only 23 of the 187 questionnaires were returned despite provision of a stamped, self-addressed envelope. In view of such low response, phone-call interviews scheduled for two weeks after delivery were initiated in January, and t h e parents were asked the same questions appearing in t h e After-Birth Questionnaire. The class was wellreceived, evidenced by 100% of respondents stating that their children enjoyed t h e class. The first objective, lowering of children’s anxieties, was apparently accomplished, since 96% of parents reported their children reacted positively to their mothers’ hospital stay, as opposed to frequent misbehavior and tears before establishment of t h e class. Whether children’s improved behavior is a result of lessened fear, parental behavior changes, o r staff attitiidinal changes is unknown and bears further research. Regarding the second objective, helping children develop a n idea of what life is like with a new sibling at home, 96% of parents responding reported n o major upheaval when the newborn came home, and 91% stated the children were able t o participate at home by both fetching things for t h e parents and handling t h e infant. Virtually all parents reported that their children communicate feelings, both positive and negative, about the new sibling-our third objective. Since parents did not share many of their specific strategies for preparing their child(ren) o r for coping with a n additional child, it is difficult to measure t h e achievement of t h e last two objectives. With 100% of returned questionnaires approving
May/June 1985 JOCNN
t h e class content and stating that they found t h e discussion, tours, instructor’s comments, and film beneficial, it is assumed that they gained the information they felt necessary t o plan their strategies. A final method of evaluation includes an ongoing epidemiological survey, showing no increase in inpatient maternal-infant infection rates since t h e introduction of sibling presence in t h e mother’s room and sibling holding of infants. Parents have been cooperative about not bringing a sick child t o the hospital. With positive support of our objectives and program, the original premise seems supported: Children should be included in the family preparation for t h e arrival of a newborn. Sibling preparation has a definite place in family-centered maternity care. As nurses become aware of t h e issues, topics, and availability of programs, they can better guide and counsel parents expecting a subsequent child.
SUMMARY
To assure continuing improvement in prepared siblings programs, nursing- must consider a t least two topics for further research. First, there should be more thorough investigations of children’s behavior in t h e hospital and a t home t o compare children who attended class with those who did not. This would determine the occurrence of a statistically significant change in the behavior of children who attended a class. Second, a n adequate evaluation tool should be created t o measure parents’ ability to manage at home after t h e birth of a subsequent child. This tool could yield information on the presence o r absence of improved parenting as a result of t h e class, as well a s t h e management strategies most often
Table 2.
After-Birth Questionnaire
1. How did your child(ren) react to the class? 100% enjoyed class 2. How did your child(ren) react to your hospital stay? 96% positively 4% no reply 3. Do you feel the Sibling Class helped to ease the introduction of the new baby into your home? 96% yes 4% no; the child has not adjusted well 4. Is (are) your child(ren) participating in baby care? 91% yes 57% fetch for parents 29% handle baby 9% no; child cares for doll or is disinterested 5. Does (do) your child(ren) communicate his/her thoughts and feelings about the new baby? 100% yes 35% negative feelings 61% positive feelings 6. Additional comments: Several parents requested a class for toddlers.
found helpful by parents. This information will allow nurses to meet more closely children’s and parents’ needs during childbearing experiences.
REFERENCES 1. Fassler J. Helping children cope. New York: The Free Press, 1978: 86- 100. 2. Jewett C. Helping children cope with separation and loss. Cam-
bridge: Harvard Common Press, 1981. 3. Hess R, Croft D. Teachers of young children. New York: Houghton Mifflin Co., 1972. 4, Legg c, Shenck I , w,Reaction of preschool children to the birth of a sibling. Child Psychiatry Hum Dev Fall 1974;5:3-29. 5. Gesel1 A. The first five Years Of life. New York: Harper and Brothers, 1940:40-57;252-3. 6. Pulaski MA, Piaget: a n introduction to children’s cog-
nitive development. New York:
24 1
Harper and Row, 1971:24-7;38123. 7. The Threshold Program for Early Learning. Vol. Ill: Fostering growth in language skills and social concepts. New York: Macmillan Publishing Company, Inc., 1970. 8. Weiss JS. Your second child: a guide for parents. New York: Summit Books, 1981:83-111. 9. Erickson E. Identity, youth and crisis. New York: W. W. Norton and Company. Inc., 1968. 10. Solomon S. Knowing your child through his handwriting and
11.
12. 13. 14.
drawing. New York: Ace Books, 1978:l-5. Burns RC, Kaufman SH. Actions, styles and symbols in kinetic family drawings (K-F-D): an interpretive manual. New York: Brunner/ Mazel, 1972:30, 76, 174. DiLeo J. Children’s drawings a s diagnostic aids. New York: Brunner/Mazel, 1973. Anderson SVD, Simken P. Birth through children’s eyes. Seattle: The Penny Press, 1981:l-76. McDermott J. Sibling rivalry. United States: Wideview Books, 1980~3-85.
Address for correspondence: Nancy M. Johnsen, RN, BS, ACCE, Department of Health Education, Overlook Hospital, Summit, NJ 07901.
Nancy M Johnsen is the former director of the Parentcraft Program at Overlook Hospital in Summit, New Jersey Ms Johnsen is also a health educator and certified Lamaze instructor at Overlook Hospital Parentcraft Mary Ellen Gaspard is a prenatal educator at Overlook Hospital in Summit. New Jersey She is also a certified Lamaze instructor
ATTENTION AUTHORS
The JOGNN Editorial Board welcomes the chance to review clinical and research manuscripts on the topics listed below. For author guidelines, send a stamped, self-addressed envelope to J. Serevino, Editor, JOGNN, Suite 200, Washington, DC 20024. Well Newborn Care Nipple Stimulation Used for Augmentation of Labor lntrapartum Birth Options Emergency Delivery Elective Induction of Labor lntrapartum Management
242
Rural Obstetric Care Staffing and Management of Alternative Birth Settings Prenatal Estimation of Gestational Age with Electronic Equipment Induction of Labor with Pitocin I.V.
May/June 1985 JOG”