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Therapeutic touch with HIV-infected children: A pilot study
Therapeutic Touch With HIV-Infected Children: A Pilot Stud'Y Mary Ireland, RN, PhD In this pilot study, 20 HIV-infected children, 6 to 12 years of age, were randomly assigned into therapeutic touch (TT) and mimic TT groups. The effectiveness of TT in reducing anxiety was evaluated. The self-report measure, the A-State Anxiety subscale of the Spielberger State-Trait Anxiety Inventory For Children, was administered before and immediately after interventions. As predicted, the TT intervention resulted in lower overall mean anxiety scores, whereas the mimic TT did not. These findings provide preliminary support for the use of TT in reducing the state anxiety of children with HIV infection. Key words: Therapeutic touch, children, anxiety. D e s p i t e the significant reduction in mother-to-infant transmission of HIV and the improved health status of infants receiving zidovudine (protocol 076)(Connor et al., 1994), a cure for HIV remains elusive, and HIV infection remains a threat to children over the next decade (Gallagher & Klima, 1996). At the other end of the perinatally acquired HIV infection continuum are the infected children who are living longer. Natural history data on perinatal HIV infection indicates that the median survival age has increased from approximately 6 to 9 years (Grubman et al., 1995). Moreover, there is an emerging population of older children with later onset of clinical symptoms and prolonged survival. As HIV-infected children live longer, the stress that they accumulate may put some at risk for severe emotional distress (Lewis, Haiken, & Hoyt, 1994; Pollack & Thompson, 1995). Because HIV infection is accompanied by a pervasive stigma that elicits guilt, shame, anger, and secrecy, it amplifies the impact of
psychosocial stressors. Those children who have had their diagnosis disclosed to them experience the stress of carrying the secret of HIV infection and may feel contaminated. When there has been no disclosure, the infected child often suspects something is wrong because of the cues picked up from family members and the frequency of physician visits and treatments and drugs received. The heightened and prolonged tension experienced under either condition can evolve into a spiral of unrelieved stress that may be manifested in a host of both physical and emotional sequelae. Additional stressors that are unique to pediatric HIV disease, social isolation, multigenerational impact, interactions with previous family problems such as drug addiction, and multiple losses (Lewis et al., 1994) further intensify the child's trauma accommodation. Anxiety evokes a stress response and activates the sympathetic nervous system, which, if sustained, heightens physiologic and emotional reactivity and immunosuppression, and increases infection risk (Caudell, 1996). For these reasons, stress-reduction techniques such as muscle relaxation, imagery, biofeedback, and hypnosis have been increasingly employed to help alleviate the anxiety that accompanies a range of pediatric conditions. An additional and potentially effective techniqfie is the nurse-developed complementary modality called therapeutic touch (TI'). Research and practice literature suggest that through TI', individuals can experience a relaxation response: that is, a deactivation of two classic stress response pathways, the hypothalamic-pituitary Mary Ireland, RN, PhD, is an assistant professor at Rutgers University, College of Nursing.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 9, No. 4, July/August 1998, 68-77 Copyright 9 1998 Association of Nurses in AIDS Care
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 69 adrenal axis (HPA) and the sympatho-adrenalmedullary (SAM)axis (Mulloney & Wells-Federman, 1996). Eliciting the relaxation response, reducing anxiety, and interrupting the stress-symptom cycle enhance the body's natural healing process, facilitate recovery from illness, and prevent further complications. Tr, therefore, seems well suited for the treatment of HIV disease. Indeed, recent findings offer some support that TI" is not only a useful stressreduction intervention but may influence immunosuppression. For example, Garrard (1995) found an increase in both coping skills and lymphocyte subset pattern among HIV-infected males who had been treated with T'I'. Although 22 healthy yet stressed medical and nursing students facing professional board exams showed no significant difference in state anxiety scores following three "lq" treatments compared to a no-treatment group, the "17"group changed in the expected direction and had significantly less decrement in IgA and IgM levels than did controls who had no treatments (Olson et al., 1997). Despite such promising findings with adults, there has been little empirical investigation about the effectiveness of "IT in children, and its potential to comfort and calm the HIV-infected child has yet to be explored.
Background Dolores Krieger (1979), introduced TI" to the nursing community in 1971. Her research questions centered on the idea that healing is a natural human potential that can be taught. She postulates hypothetically that two factors are primary in the practice of TI': the focused intention to heal and a transfer of energy from environment, through the toucher, to and through the subject. To date, this energy field has not been identified and the energy hypotheses not tested directly. TT, then, is an intentionally directed process of energy modulation during which the practitioner uses the hands as a focus to facilitate healing (Mulloney et al., 1996). It is an intervention that is passive in nature; it does not require that the client consciously participate. The technique involves simultaneously centering awareness, directing compassionate intention, and modulating the flow of human energy through the use of the hands. It may include physical contact, but it is
not a requirement for assessment and treatment. Nor is its effectiveness contingent on the patient's belief in the intervention.
TT Research Of direct relevance to this study are the landmark investigations of Heidt (1981) and Quinn (1982) who examined the effect of "IT on anxiety. Although these two investigators used different procedures for administering TT and different control protocols, both found a significant decrease in state anxiety scores on the State-Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch, & Lushene, 1970) in adult hospitalized cardiovascular patients. After administering the STAI, Heidt assigned participants to one of three groups on the basis of matching scores. Group A received TI', Group B casual touch, and Group C no touch. Quinn randomly assigned subjects to two groups after participants completed the STAI. One group was treated with TI' and the other with mimic "IT. Both investigators used rigorous research designs and estimated adequate sample sizes (N = 90 and N = 60, respectively) using power analysis. More recently, investigators have explored the effectiveness of "17"in reducing state anxiety in diverse populations, including the highly stressed Hurricane Hugo survivors (Olson, Sneed, Bonadonna, Ratliff, & Dias, 1992); a healthy sample of adults experiencing an episodic stressful event, that is, students taking examinations (Olson & Sneed, 1994); and adult (Gagne & Toye, 1994) and adolescent psychiatric inpatients (Hughes, Meize-Grochowski, & Harris, 1996). Data gathered in these studies are consistent with that of previous studies, documenting that perceived anxiety seems to decrease following "IT. Of the few extant studies that examined "1"1"as an intervention with children, none have focused exclusively on the school-age child. Kramer (1990) examined the effects of TT on the stress response of 30 hospitalized children 2 weeks to 2 years of age. After she assigned children to one of two groups, "17" or casual touch, baseline pulse, peripheral skin temperature, and galvanic skin response were measured "at the time the child was noted to be in stress" (p. 484). Significant differences in the stress response in the TT group was
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found at 3 minutes and 6 minutes. Had Kramer reported random group assignment, the number of children per group, and what constituted stress behavior, her findings would have been strengthened. In a descriptive study of the healthy child's experience of receiving TF, France (1991) suggested that children respond to "Iq" in ways similar to the adult. Before and after four to six T1~treatments, she asked 11 participating children, (ages 3-9 years) to draw a picture of how they felt and to talk about the drawing. Statements of how they felt after q'q"differed from pretreatment descriptions. Several children said that TF tickled, or was nice. One child stated, "I felt like air. It was like static. I felt like static" (p. 80).
Purpose and Hypothesis The bulk of ~ studies have been directed toward Euro-American adults, with no examination of this intervention with African American and Latino children, the disproportionatley affected and largest group of children who have HIV infection. In addition, although standard treatments such as neuroleptics and group therapy are reported to help these children cope with their distress and relieve anxiety (Pollack & Thompson, 1995), little systematically collected data exists about psychotherapeutic intervention outcomes in this population. The current study responded to these research gaps. The immediate aim of this study was to test the hypothesis that there would be a greater decrease in posttest state anxiety scores immediately following treatment in children treated with q'l" than in children treated with mimic T'I'. Long-term goals are to develop methods by which stress-reduction techniques can be compared and tested for efficacy in immunosuppressed children. Interventions designed to reduce the stress response may affect the physiologic and emotional reactivity of children with HIV disease. By quantifying the stressrelated response called anxiety, the investigator aimed to demonstrate that T'I" is an untapped resource that may help ameliorate or modify the experience of living with a chronic, yet life-threatening illness. If effective, TT could ultimately help these children in their search for normalcy and improve their quality of life.
Methods Participants, Setting, Recruitment, and Sampling Procedure This was a convenience sample of 20 HIV-infected children 6 to 12 years of age--the age range in which A-state anxiety of the State-Trait Anxiety Inventory for Children (STAIC) (Spielberger, 1973) is evaluable--living in a northeastern city that is an epicenter of pediatric HIV disease. Recruitment was conducted at two pediatric ambulatory care centers specializing in HIV disease following institutional review board approval. During clinic sessions, site intermediary nurses at each center informed parents/guardians that the author and two research assistants (RAs) were conducting a study about the use of a nursing intervention called T]" with HIV-infected children. If the parent/guardian and child agreed to talk with the RAs, the RAs showed them sample pictures from the screening tool; the Peabody Picture Vocabulary Test-Revised (PPVT-R) (Dunn & Dunn, 1981); sample STAIC; A-State Anxiety scale questions; and consent, assent, and demographic data forms. The consent form explained that a child would be randomized to either T1~ or a sham treatment called mimic T'l', and briefly described the two treatments. Randomization was described as the flip of a coin; heads up, a child is placed in one treatment; heads down, a child is placed in the other treatment. The RAs advised the parent/guardian that they and their child would be told to which treatment the child had been randomized following treatment. When signed consent was obtained, randomization was initiated. Only children who met the criteria for selection--that is, age 6 to 12 years, English language dominant, no current psychotherapy nor psychotropic or anxiolytic medication, and an age-appropriate score on the PPVT-R--were included in the study.
Training and Orientation of the RAs Prior to data collection, the researcher introduced the RAs to staff in each center, reviewed the issues of disclosure and stigma, reinforced the importance of preserving anonymity and confidentiality, trained
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 71 them in the administration and scoring of the PPVT-R and STAIC, and instructed the mimic T r RA in that technique. The hand and body movements of the mimic qT RA were observed by the TT nurse expert until they were deemed to adequately resemble those used during TI'. A script was developed with the RAs to standardize and keep verbal interaction between the RAs and each child to a minimum at the point of treatment. To establish the fidelity of the interventions, the researcher listened to each RA read the script and then, observed the q~F clinician administer T r to the mimic RA and the mimic RA administer the sham treatment to the q'T clinician. This was done so that the investigator could ensure that, to the naked eye, there would be no observable difference in treatment application. The validity of mimic TI' as a single-blind placebo control for TT was previously established by Quinn (1982). Data Collection Procedures
The two RAs visited the clinics once weekly, January 1997 through September 1997. Once informed consent was obtained, each child received the treatment to which he or she had been randomized, following physician examination and/or treatment. The designated RA (either TF or mimic TF) took the child to a quiet room and established rapport by introducing herself again and reading an assent form with the child. If a child asked that a parent be present, this was permitted. The RA, however, explained that neither the child nor parent could talk during the treatment session. After signed assent was obtained, the PPVT-R was administered. If a child scored in the age-appropriate range on the PPVT-R, the RA asked the child to state how he or she felt and recorded the response, asked the child to read the instructions for the A-State Anxiety scale along with her, and asked the child to fill in the questionnaire. Questions were answered, and the child was allowed to complete the questionnaire at his or her own pace. These tasks accomplished, the RA read the standardized script and administered the treatment. When the treatment was completed, the anxiety scale was readministered and the child was asked to say how he or she felt, and these responses were recorded. Most children completed the scale pre- and posttest in approximately 5 minutes.
At the end of the session, the parent/guardian and child were informed as to which arm of the study the child had been assigned. Children who failed to meet the age-appropriate PPVT-R score were thanked for their participation and returned to the parent/guardian, without either being aware that the child had not met the criteria for participation. TT and Mimic TT Protocol
Quinn and Strelkauskas (1993) suggested that there might be a relationship between the frequent practice of Tl" and its effectiveness. In the current study, a nurse who has practiced TT for more than 9 years, administers it at least once a week in her practice, and has used it with HIV-infected children administered "IT in the manner in which it has been taught by Krieger (1979), and as specified in Quinn and Strelkauskas (1993). Specifically, the nurse systematically (a) centered herself by shifting awareness from an external to an internal focus, becoming relaxed and calm; (b) made the intention mentally to therapeutically assist the child; (c) moved her hands over the body of the child from head to foot, attuning to the condition of the child by becoming aware of changes in sensory cues in her hands; (d) redirected areas of accumulated tension in the child's energy field by movement of her hands; (e) focused attention on the specific direction of energies to the child, using her hands as focal points; and (f) directed energy by placing the hands 4 to 6 inches from the child's body, one just below the waist and one behind the back. Total treatment time lasted from 5 to 7 clocked minutes. Mimic TI" is an intervention designed by Quinn (1982) as a single-blind q'F placebo to control for the fact that a treatment is being offered and, thus, the subject may expect relief. In this study, a TF-na'l've, fourth year baccalaureate nursing student provided mimic q'T. Quinn (1989) suggested that persons not experienced with "IF are the best candidates to administer mimic q'I'. Systematically following this sequence within a clocked 5-minute time frame, the student RA (a) made the intention to imitate the movement ofTF; (b) focused her attention on mentally subtracting from 100 by 7s; (c) moved her hands over the body of the child from head to foot while continuing to subtract from 100 by
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7s; (d) retumed to the child's head and repeated step c; (e) placed her hands 4 to 6 inches from the child's body, one in the area in the solar plexus and the other behind the child's back, and counted backwards from 240; and (f) removed her hands when she had counted down to 0 (Quinn, 1984, 1989). Each treatment was given while a child sat sideways on a chair, so that the back of the chair did not interfere with access to the front and back of the torso and with his or her feet flat on the floor. They were instructed not to talk during the sessions unless discomfort was experienced. The experimental and control condition were administered by separate RAs who administered their intervention to no more than 2 children during a clinic session.
Instruments The PPVT-R, a widely used instrument in evaluating receptive vocabulary in children, was used to determine a child's ability to understand instructions and follow directions. The score reported as a measure of receptive vocabulary is a standard score equivalent, or PPVT-R IQ. An examiner presents a series of plates with four drawings per plate, says a word, and asks a child to point to the picture of the word that he or she has just said, and repeats this process until a child reaches his or her critical range (those items that provide maximum discrimination among persons of similar ability). Administration takes approximately 10 to 15 minutes. .,Split-half reliabilities for the L form that was used in this study range from .67 to .88, test-retest coefficients for raw scores from .73 to .91, and standard scores from .71 to .89 (McCallum, 1985). The PPVT-R has been established as a valid tool for African American and Latino preschool and schoolage children with AIDS (Ireland, 1994; Levenson, Kairam, Bartnett, & Mellins, 1991) and for healthy African American and Latino preschoolers (Ireland, 1994). The STAIC (Spielberger, 1973), which was used to measure state-anxiety pre- and postintervention in each group, is a paper-and-pencil, self-report inventory that is a downward extension of the adult STAI (Spielberger et al., 1970). The A-State scale is composed of 20 "I feel" sentence stems, designed to assess
the child's feelings at a particular moment. Each response receives a weighted score from 1 to 3, with 3 representing the highest level of anxiety. Administration takes 8 to 12 minutes. Spielberger (1973) reported Cronbach alpha coefficients of .78 for males and .81 for females for the A-State scale. Papay and Hedl (1978) reported high A-state internal consistency estimates for Black, inner-city fourth-grade males (.82) and females (.80), and moderately high estimates for the third-grade males (.76) and females (.73). The validity of the A-State scale has been established in children with anxiety disorders, ages 5 to 17 (Strauss, Last, Hersen, & Kazdin, 1988); urban and suburban, low to middle socioeconomic status, bilingual (Spanish and English), and monolingual children 6 to 8 years of age (Murphy, 1990).
Data Analysis Analysis of covariance (ANCOVA) was conducted to test the hypothesis that there would be a greater decrease in state anxiety scores immediately following treatment in children treated with "IT than in children treated with mimic TI'. Correlated t tests were conducted to gain further perspective on these relationships. Each child's open-ended responses before and after treatment were reviewed to obtain a qualitative perspective on the effect of T r versus mimic Tr.
Results Of the 39 children recruited, 19 could not participate for the following reasons: (a) 5 were in foster care, and the agency did not permit the guardian to sign consent; (b) 3 were taking psychotropic medication; (c) 2 failed to score in the age-appropriate range of the PPVT-R; (d) 2 did not wish to participate; (e) 4 could not stay to participate; and (f) 3 parents would not consent for the child to participate. As seen in Table 1, the majority of the 20 participating children were female (65%), African American (50%), and asymptomatic (70%). As noted in Table 2, most of the caretakers who completed the demographic data form were mothers (65%). Of these, 10 were biological, 2 foster, and 1 adoptive. Only 2 caretakers were biological fathers
Ireland / Therapeutic Touch With HIV-Infected Children 73
Table 1.
Child Participant Characteristics (N = 20)
Child Data Age 6to9 10 to 12 Gender Male Female Ethnicity African American Hispanic White Other Asymptomatic Yes No
Table 2.
Number
Percentage
10 10
50 50
07 13
35 65
10 05 03 02
50 25 15 l0
14 06
70 30
Informant Mother Father Other Education High school diploma Yes No Beyond high school Employment status Employed full time Employed part time Unemployed Family income Less than $5000 $5100 to $9000 $10000 to $19000 $20000 to $30000 $31000 to $50000 Greater than $50000 HIV status Positive Negative Seropositive immediate family members None
1 2 3 Religiosity Not at all A little A lot
Pretest and Posttest Anxiety Mean Scores and Standard Deviations By Group Membership
Group
Caretaker Characteristics (N = 20)
Caretaker Data
Table 3.
Number
Percentage
13 02 05
65 10 25
08 11 01
40 55 05
01 02 17
05 10 85
04 03 06 05 02 00
20 15 30 25 10 00
07 13
35 65
05 06 07 02
25 30 35 10
03 10 07
15 50 35
Experimental ('IT) Pretest Posttest Difference Control (mimic TF) Pretest Posttest Difference
Mean
SD
29.20 26.70 2.50
3.04 4.42 2.46
31.20 29.50 1.70
4.51 3.37 3.91
(10%). Of the 25% who comprised the "other" category, 2 were grandmothers, and 3 were aunts. More that one half of the caretakers had not completed high school (55%), and the majority (85%) were unemployed. Although 65% of them indicated that they were not themselves HIV positive, 14 reported that one or more immediate family m e m b e r s were infected. M o s t (85%) reported that they were religious. Pretest and posttest means on state anxiety for both groups are presented in Table 3. A comparison of pretest means between the T r group (M = 29.2, S D = 3.0) and the mimic T r group (M = 31.2, S D = 4.5) detected no statistically significant differences in anxiety, suggesting that randomization resulted in groups comparable in anxiety prior to the intervention. An ANCOVA was conducted, examining the influence of group assignment on postintervention anxiety scores, with pretest scores included as a covariate. The resulting equation was not statistically significant, F(1, 17) = 1.067, p = .32. The inability to detect group effects in this analysis may be due to inadequate power given the low sample size (N = 20). To gain further perspective on this possibility, correlated groups t tests were conducted within the T r and mimic T r groups to assess differences in mean pre- and posttest scores. These analyses revealed a statistically significant decrement in anxiety posttest in the experimental (p < .01) but not the control group (p = .20). Analysis of the verbal responses by the children prior to and after experimental and control conditions demonstrated a variety of feelings and moods as noted in Table 4.
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Analysis of Verbal Responses Before and After Treatment
Group
Before Frequency After Frequency
Experimental (TI') calm happy fine nervous okay
2 4 3 1 1
calm happy fine laughing good no comment
1 2 1 1 4 1
good great happy relaxed fine okay mad
1 1 2 1 3 1 1
good great uncertain dizzy fine okay weird
1 1 1 1 3 2 1
Control (mimic T'F)
Discussion
Recruitment and enrollment of 20 participants took 6 months, reflecting the labor-intensive efforts required in recruiting vulnerable populations with multiple demands on their precious time. Despite the aid of site intermediary nurses, data gathering was slow. Research participation by some parents and children was complicated by facts beyond their control: (a) Some children lived in foster care, necessitating consent procedures that would have further extended the data collection period, (b) other children had HIVrelated cognitive deficits that precluded them from scoring in the age-appropriate range on the PPVT-R, indicating little likelihood that they would be able to follow directions or read the STAIC questions, and (c) several children took psychotropic medications that could have confounded data interpretation. Although we did not probe parents nor children who did not wish to participate, we were sensitive to the fact that this population had participated in other clinical trials, and may have been experiencing fatigue. Others may have had a healthy skepticism about research and its potential to improve the child's quality of life. Among those who did participate, results suggested that "IT may be an effective tool for reducing state anxiety in children with HIV infection. The magnitude
of the mean difference in the experimental group, 2.5, however, was considerably lower than that reported by either Heidt (1981) or Quinn (1984), who found mean decreases in state anxiety in their adult samples of 6.9 and 6.7, respectively. This could be explained by the fact that pre treatment, their subjects were more anxious with mean scores ranging from 36 to 38, whereas, the current sample of children did not have mean scores greater than 32. Examination of verbal responses to the question of how they felt prior to interventions suggests that this was not an especially anxious sample of children. These findings are consistent with those of Bose, Moss, Brouwers, Pizzo, and Lotion (1994) in their study of school-age children with HIV infection. Although they studied primarily transfusion-infected children living in middle-class families, those children saw themselves as less anxious than respective standardization samples. If the stress that HIV-infected children experience is as severe as assumed, then the children in the current sample should have obtained scores reflecting more anxiety than they did. Some explanation is needed to resolve this apparent incongruence. As in the case of childhood cancer, lower than anticipated scores on standardized measures of psychological variables can be interpreted in several ways: (a) Resilience, coping skills, and support may lessen anxiety; (b) symptoms of anxiety may be denied (Kazak & Christakis, 1996); (c) children may act as stoic good soldiers minimizing the severity of their self-report symptoms (Kaplan, Busner, Weinhold, & Lenon, 1987); and (d) methodological difficulties of self-report scales may preclude obtaining accurate data (Kazak & Christakis, 1996). In reference to the first interpretation, anxious symptoms that might be found in this population may be ameliorated by the increased attention and solicitude that parents and health care providers offer them. For many, health care visits provide opportunities for stroking and praise from nurses and physicians very committed to the well-being of their clients. Indeed, the research team was impressed with the depth of the compassionate care delivered by both, the parents/guardians and the health care team, during the data collection period. The level of awareness about having HIV infection is unknown for this sample. However, many infected
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 75 school-age children are aware that they have the HIV virus (Wiener, Moss, Davidson, & Fair, 1992). Despite this knowledge, they tend to seek normalcy. Thus, the only time they may think about their illness and consider that they are sick may be during illness events. Meanwhile, they may make effective use of defenses such as denial, try to live their lives as children, play with friends, go to school, and change and grow in age-appropriate ways. On the other hand, some may minimize the severity of their self-reported anxiety in an effort to reduce complaining. There is a subtle demand expectation in the social environments of some HIV-infected children to minimize complaining. Those children who know their diagnosis, or who are at least suspicious that something is wrong, seriously wrong with them, are aware that talking about their concerns often raises parental/guardian anxiety. Although not explicitly verbalized, those children who live with their biological parents often recognize that illness discussion compounds parental shame over having HIV themselves and that mentioning their illness tends to call this shame to mind, and may even confront parents with their own illness and potential death. When children live in foster or adopted families, they may not easily disclose their anxiety because they understand that the parent does not want to acknowledge that they know about their disease. Some parents equate knowledge as harmful, fearing that knowledge of HIV infection can do physical harm, for example, "If my child knows, he will die." In the current sample of children, anecdotal comments made by children, parents, and RAs following treatment suggest that there was some denial and a covering over of concerns. For example, one child asked whether the treatment could bring a mother back from the dead or could help in communicating with a dead person. Another child was described by the RA as emotionally "shut down," and one parent reported that her child had low self-esteem. Self-report scales have the limitation in that they reveal self-perceptions that are sometimes inflated and inaccurate. It might have been illuminating to have also tested trait anxiety, the more enduring aspect of anxiety, rather than merely assessing state anxiety, a more ephemeral reaction to a transitory event such as a nursing intervention.
Finally, whereas this sample was not staged according to disease severity as determined by C D 4 % - - a marker of disease progression--this was a generally healthy group of children; 70% were reported by the parent/guardian as asymptomatic. Bose et al. (1994) found that low CD4% was one of the variables that contributed to the presence of adjustment problems in HIV-infected children. That is, the lower the CD4 lymphocyte count, the greater the disease severity. The greater the disease severity, the more likely it is that the child is exposed to stressors such as invasive medical procedures, opportunistic infection, and debilitating illness, all of which may effect the child's psychological state.
Implications The current pilot study suggests that there is reason to pursue further research on the relationship between TT and state anxiety among children with HIV infection, and it supports a body of evidence that this technique may help ameliorate or modify the experience of those living with a chronic yet life-threatening illness. TT may be at least as effective as other relaxation therapies as a clinical strategy. However, the current study is merely a beginning to the work that needs to be done in psychosocial research related to care of children with HIV infection. Given that the majority of studies about their emotional needs are not empirical, and that there is a paucity of literature identifying interventions appropriate to those needs, "nurses 'do,' using interventions based on research findings of other chronic childhood illnesses" (Sherwen & Storm, 1996, p. 166). Well-designed intervention research is vital to establishing appropriate care delivery and improving the quality of life for the HIV-infected child. Directions for future research should include the following: . measurement of the effect of stressors on anxiety levels, both state and trait, and other psychological variables, such as mood, with a larger sample; . clinical trials that compare the efficacy of TT with other complementary modalities and nurturing forms of touch, for example, the "nursing back rub"/massage therapy (MT), in modifying anxiety and mood;
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3. longitudinal studies that allow for serial data collection points to extend knowledge about the effects of such interventions on psychological variables beyond a one-time administration or dose; 4 investigations that evaluate the potential of nursing techniques such as TI" and MT to influence immunosuppression as has been done with other forms of stress reduction, for example, progressive muscle relaxation, in HIV-infected adults; and 5. a conceptual approach, for example, psychoneuroimmunology (PNI), that inherently integrates psychological and physiological phenomenon, thereby providing a biobehavioral framework in which to examine the influence of anxiety, depression, pain, and stressful situations on the child's immune system, and the effect of relaxation therapies on these phenomenon. In conclusion, a PNI framework could provide a holistic paradigm in which to launch future research, one that is consistent with the philosophical underpinnings of nursing science and one that could help answer questions that emerge as children with HIV disease live longer. Acknowledgments. This research was supported by the Rutgers College of Nursing Center for Health Promotion Research, Rutgers University Research Council Alpha Tau Chapter, Sigma Theta Tan International. The author thanks the staff, children, and families of Incarnation Children's Center of Catholic Home Bureau and Hew York Hospital-Cornell Medical Center Program for Children With AIDS who participated in this study, and the research assistants, Lousia Porrata, RN, MPH, and Allison McClughan, who assisted with data collection. References Bose, S., Moss, H. A., Brouwers, P., Pizzo, P., & Lotion, R. (1994). Psychologic adjustment of human immunodeficiency virusinfected school-age children. Developmental and Behavioral Pediatrics, 15(Suppl. 3), 26-33. Candell, K. A. (1996). Psychoneuroimmunology and innovative behavioral interventions in patients with leukemia. Oncology Nursing Forum, 23(3), 493-502.
Connor, E., Sperling, R., Gelber, R., Kiselev, E, Scott, G., O'Sullivan, M., VanDyke, R., Mohammed, B., Shearer, W., Jacobson, M. Jemenez, E., O'Neill, E., Bazin, B., Delfraissy, J., Culnane, M., Coombs, R., Elkins, M., Moye, J., Stratton, P., & Balsley, J. (1994). Reduction of maternal-infant transmission of human immunodeficiency virus type I with zidovudine treatment. New England Journal of Medicine, 331(11), 1173-1180. Dunn, L. M., & Dunn, L. M. (1981). Peabody picture vocabulary test-revised. Minnesota: American Guidance Service. France, N. E. (1991). A phenomenological inquiry on the child's lived experience of perceiving the human energy field using therapeutic touch. Dissertation Abstracts International, 53, 3266. (University Microflms No. 92-15-316). Gagne, D., & Toye, R. C. (1994). The effects of therapeutic touch and relaxation therapy in reducing anxiety. Archives of Psychiatric Nursing, 8(3), 184-189. Gallagher, M. A., & Klima, C. (1996). The challenge of maternalinfant transmission of HIV. JANAC, 7(1), 47-48. Garrard, C. T. (1995). The effect of therapeutic touch on stress reduction and immune function in persons with AIDS. Unpublished doctoral dissertation, University of Alabama, Birmingham. Grubman, S., Gross, E., Lerner-Weiss, N., Hernandez, M., McSherry, G. D., Hoyt, L., Boland, M., & Oleske, J. M. (1995). Older children and adolescents living with perinatally acquired human immunodeficiency virus infection. Pediatrics, 95(5), 657-663. Heidt, P. (1981). Effect of therapeutic touch on anxiety level of hospitalized patients. Nursing Research, 30, 32-37. Hughes, P. P., Meize-Grochowski, R., & Harris, E. (1996). Therapeutic touch with adolescent psychiatric patients. Journal of Holistic Nursing, 14(1), 6-23. Ireland, M. (1994). Death anxiety and se.lf-esteem in children four, five and six years of age: A comparison of minority children who have AIDS with minority children who are healthy. Unpublished doctoral dissertation, New York University, New York. Kaplan, S., Busner, J., Weinhold, C., & Lenon, E (1987). Depressive symptoms in children and adolescents with cancer. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 782-787. Kazak, A. E., & Christakis, D. A. (1996). The intense stress of childhood cancer: A systems perspective. In C. R. Pfeffer (Ed.), Severe stress andmental disturbance in children (pp. 277-305). Washington, DC: American Psychiatric Press. Kramer, N. A. (1990). Comparison of therapeutic touch and casual touch in stress reduction of hospitalized children. Pediatric Nursing, 16(5), 483-485. Krieger, D. (1979). The therapeutic touch: How to use your hands to help or to heal. Englewood Cliffs, NJ: Prentice Hall. Levenson, R. L., Kalram, R., B artnett, M., & Mellins, C. A. (1991). Equivalence of Peabody Picture Vocabulary Test-Revised, Forms L and M for children with acquired immunodeficiency syndrome (AIDS). Perceptual and Motor Skills, 72, 99-102. Lewis, S. Y., Haiken, H. J., & Hoyt, L. G. (1994). Living beyond the odds: A psychosocial perspective on long-term survivors of
Ireland / Therapeutic Touch With HIV-Infected Children pediatric human immunodeficiency virus-infected. Developmental and Behavioral Pediatrics, 15(3), S12-S17. McCallum, R. S. (1985). Review of Peabody Picture Vocabulary Test-Revised. In O. K. Buros (Ed.), The ninth mental measurements yearbook: Vol. 2 (pp. 1126-1127). Lincoln, NE: Buros Institute of Mental Measurement. Mulloney, S. S., & Wells-Federman, C. (1996). Therapeutic touch: A healing modality. Journal of Cardiovascular Nursing, 10(3), 27-49. Murphy, D. G. (1990). Comparison of scores of bilingual urban and monolingual suburban elementary school children for two measures of intelligence. Psychological Reports, 67, 1375-1378. Olson, M., Sneed, N. (1994). Anxiety and therapeutic touch. Issues in Mental Health Nursing, 16, 97-108. Olson, M., Sneed, N., Bonadorma, R., Ratliff, J., & Dias, J. (1992). Therapeutic touch and post-Hurricane Hugo stress. Journal of Holistic Nursing, 10(2), 120-136. Olson, M., Sneed, N., LaVia, M, Virella, G., Bonadonna, R., & Michel, Y. (1997). Stress-induced immunosuppression and therapeutic touch. Alternative Therapies, 3(2), 68-74. Papay, J. P., & Hedl, J. J. (1978). Psychometric characteristics and norms for disadvantage third and fourth grade children on state-trait anxiety inventory for children. Journal of Abnormal Psychology, 6(1), 115-120. Pollack, S. W., & Thompson, C. L. (1995). The HIV-infected child in therapy. In N. Boyd-Franklin, G. L. Steiner, & M. G. Boland (Eds.), Children, families, and HIV/AIDS (pp. 127-141), New York: Guilford.
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Quinn, J. F. (1982). An investigation of the effects of therapeutic touch done without physical contact on state anxiety of hospitalized cardiovascular patients (Doctoral dissertation, New York University). Dissertation Abstracts International, 43, 1797-B. Quinn, J. E (1984). Therapeutic touch as energy exchange: Testing the theory. Advances in Nursing Science, 6, 42-49. Quinn, J. E (1989). Therapeutic touch as energy exchange: Replication and extension. Nursing Science Quarterly, 2(2), 79-87. Quinn, J. E & Strelkauskas, A. (1993). Psychoimmunologic effects of therapeutic touch on practitioners and recently bereaved recipients: A pilot study. Advances in Nursing Science, 15, 13-26. Sherwen, L. N., & Storm, D. S. (1996). Looking toward the twenty-first century. Nursing Clinics of North America, 31(I), 155-178. Spielberger, C. (1973). STAICpreliminary manual. Palo Alto, CA: Consulting Psychologists Press. Spielberger, C., Gorsuch, R., & Lushene, R. (1970). Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press. Strauss, C. C., Last, C. G., Hersen, M., & Kazdin, A. E. (1988). Association between anxiety and depression in children and adolescents with anxiety disorders. Journal of Abnormal Child Psychology, 6(1), 57-68. Wiener, L., Moss, H., Davidson, R., & Fair, C. (1992). Pediatrics: The emerging psychosocial challenges of the AIDS epidemic. Child and Adolescent Social Work Journal, 9(5), 381-407.
psychosocial stressors. Those children who have had their diagnosis disclosed to them experience the stress of carrying the secret of HIV infection and may feel contaminated. When there has been no disclosure, the infected child often suspects something is wrong because of the cues picked up from family members and the frequency of physician visits and treatments and drugs received. The heightened and prolonged tension experienced under either condition can evolve into a spiral of unrelieved stress that may be manifested in a host of both physical and emotional sequelae. Additional stressors that are unique to pediatric HIV disease, social isolation, multigenerational impact, interactions with previous family problems such as drug addiction, and multiple losses (Lewis et al., 1994) further intensify the child's trauma accommodation. Anxiety evokes a stress response and activates the sympathetic nervous system, which, if sustained, heightens physiologic and emotional reactivity and immunosuppression, and increases infection risk (Caudell, 1996). For these reasons, stress-reduction techniques such as muscle relaxation, imagery, biofeedback, and hypnosis have been increasingly employed to help alleviate the anxiety that accompanies a range of pediatric conditions. An additional and potentially effective techniqfie is the nurse-developed complementary modality called therapeutic touch (TI'). Research and practice literature suggest that through TI', individuals can experience a relaxation response: that is, a deactivation of two classic stress response pathways, the hypothalamic-pituitary Mary Ireland, RN, PhD, is an assistant professor at Rutgers University, College of Nursing.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 9, No. 4, July/August 1998, 68-77 Copyright 9 1998 Association of Nurses in AIDS Care
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 69 adrenal axis (HPA) and the sympatho-adrenalmedullary (SAM)axis (Mulloney & Wells-Federman, 1996). Eliciting the relaxation response, reducing anxiety, and interrupting the stress-symptom cycle enhance the body's natural healing process, facilitate recovery from illness, and prevent further complications. Tr, therefore, seems well suited for the treatment of HIV disease. Indeed, recent findings offer some support that TI" is not only a useful stressreduction intervention but may influence immunosuppression. For example, Garrard (1995) found an increase in both coping skills and lymphocyte subset pattern among HIV-infected males who had been treated with T'I'. Although 22 healthy yet stressed medical and nursing students facing professional board exams showed no significant difference in state anxiety scores following three "lq" treatments compared to a no-treatment group, the "17"group changed in the expected direction and had significantly less decrement in IgA and IgM levels than did controls who had no treatments (Olson et al., 1997). Despite such promising findings with adults, there has been little empirical investigation about the effectiveness of "IT in children, and its potential to comfort and calm the HIV-infected child has yet to be explored.
Background Dolores Krieger (1979), introduced TI" to the nursing community in 1971. Her research questions centered on the idea that healing is a natural human potential that can be taught. She postulates hypothetically that two factors are primary in the practice of TI': the focused intention to heal and a transfer of energy from environment, through the toucher, to and through the subject. To date, this energy field has not been identified and the energy hypotheses not tested directly. TT, then, is an intentionally directed process of energy modulation during which the practitioner uses the hands as a focus to facilitate healing (Mulloney et al., 1996). It is an intervention that is passive in nature; it does not require that the client consciously participate. The technique involves simultaneously centering awareness, directing compassionate intention, and modulating the flow of human energy through the use of the hands. It may include physical contact, but it is
not a requirement for assessment and treatment. Nor is its effectiveness contingent on the patient's belief in the intervention.
TT Research Of direct relevance to this study are the landmark investigations of Heidt (1981) and Quinn (1982) who examined the effect of "IT on anxiety. Although these two investigators used different procedures for administering TT and different control protocols, both found a significant decrease in state anxiety scores on the State-Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch, & Lushene, 1970) in adult hospitalized cardiovascular patients. After administering the STAI, Heidt assigned participants to one of three groups on the basis of matching scores. Group A received TI', Group B casual touch, and Group C no touch. Quinn randomly assigned subjects to two groups after participants completed the STAI. One group was treated with TI' and the other with mimic "IT. Both investigators used rigorous research designs and estimated adequate sample sizes (N = 90 and N = 60, respectively) using power analysis. More recently, investigators have explored the effectiveness of "17"in reducing state anxiety in diverse populations, including the highly stressed Hurricane Hugo survivors (Olson, Sneed, Bonadonna, Ratliff, & Dias, 1992); a healthy sample of adults experiencing an episodic stressful event, that is, students taking examinations (Olson & Sneed, 1994); and adult (Gagne & Toye, 1994) and adolescent psychiatric inpatients (Hughes, Meize-Grochowski, & Harris, 1996). Data gathered in these studies are consistent with that of previous studies, documenting that perceived anxiety seems to decrease following "IT. Of the few extant studies that examined "1"1"as an intervention with children, none have focused exclusively on the school-age child. Kramer (1990) examined the effects of TT on the stress response of 30 hospitalized children 2 weeks to 2 years of age. After she assigned children to one of two groups, "17" or casual touch, baseline pulse, peripheral skin temperature, and galvanic skin response were measured "at the time the child was noted to be in stress" (p. 484). Significant differences in the stress response in the TT group was
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found at 3 minutes and 6 minutes. Had Kramer reported random group assignment, the number of children per group, and what constituted stress behavior, her findings would have been strengthened. In a descriptive study of the healthy child's experience of receiving TF, France (1991) suggested that children respond to "Iq" in ways similar to the adult. Before and after four to six T1~treatments, she asked 11 participating children, (ages 3-9 years) to draw a picture of how they felt and to talk about the drawing. Statements of how they felt after q'q"differed from pretreatment descriptions. Several children said that TF tickled, or was nice. One child stated, "I felt like air. It was like static. I felt like static" (p. 80).
Purpose and Hypothesis The bulk of ~ studies have been directed toward Euro-American adults, with no examination of this intervention with African American and Latino children, the disproportionatley affected and largest group of children who have HIV infection. In addition, although standard treatments such as neuroleptics and group therapy are reported to help these children cope with their distress and relieve anxiety (Pollack & Thompson, 1995), little systematically collected data exists about psychotherapeutic intervention outcomes in this population. The current study responded to these research gaps. The immediate aim of this study was to test the hypothesis that there would be a greater decrease in posttest state anxiety scores immediately following treatment in children treated with q'l" than in children treated with mimic T'I'. Long-term goals are to develop methods by which stress-reduction techniques can be compared and tested for efficacy in immunosuppressed children. Interventions designed to reduce the stress response may affect the physiologic and emotional reactivity of children with HIV disease. By quantifying the stressrelated response called anxiety, the investigator aimed to demonstrate that T'I" is an untapped resource that may help ameliorate or modify the experience of living with a chronic, yet life-threatening illness. If effective, TT could ultimately help these children in their search for normalcy and improve their quality of life.
Methods Participants, Setting, Recruitment, and Sampling Procedure This was a convenience sample of 20 HIV-infected children 6 to 12 years of age--the age range in which A-state anxiety of the State-Trait Anxiety Inventory for Children (STAIC) (Spielberger, 1973) is evaluable--living in a northeastern city that is an epicenter of pediatric HIV disease. Recruitment was conducted at two pediatric ambulatory care centers specializing in HIV disease following institutional review board approval. During clinic sessions, site intermediary nurses at each center informed parents/guardians that the author and two research assistants (RAs) were conducting a study about the use of a nursing intervention called T]" with HIV-infected children. If the parent/guardian and child agreed to talk with the RAs, the RAs showed them sample pictures from the screening tool; the Peabody Picture Vocabulary Test-Revised (PPVT-R) (Dunn & Dunn, 1981); sample STAIC; A-State Anxiety scale questions; and consent, assent, and demographic data forms. The consent form explained that a child would be randomized to either T1~ or a sham treatment called mimic T'l', and briefly described the two treatments. Randomization was described as the flip of a coin; heads up, a child is placed in one treatment; heads down, a child is placed in the other treatment. The RAs advised the parent/guardian that they and their child would be told to which treatment the child had been randomized following treatment. When signed consent was obtained, randomization was initiated. Only children who met the criteria for selection--that is, age 6 to 12 years, English language dominant, no current psychotherapy nor psychotropic or anxiolytic medication, and an age-appropriate score on the PPVT-R--were included in the study.
Training and Orientation of the RAs Prior to data collection, the researcher introduced the RAs to staff in each center, reviewed the issues of disclosure and stigma, reinforced the importance of preserving anonymity and confidentiality, trained
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 71 them in the administration and scoring of the PPVT-R and STAIC, and instructed the mimic T r RA in that technique. The hand and body movements of the mimic qT RA were observed by the TT nurse expert until they were deemed to adequately resemble those used during TI'. A script was developed with the RAs to standardize and keep verbal interaction between the RAs and each child to a minimum at the point of treatment. To establish the fidelity of the interventions, the researcher listened to each RA read the script and then, observed the q~F clinician administer T r to the mimic RA and the mimic RA administer the sham treatment to the q'T clinician. This was done so that the investigator could ensure that, to the naked eye, there would be no observable difference in treatment application. The validity of mimic TI' as a single-blind placebo control for TT was previously established by Quinn (1982). Data Collection Procedures
The two RAs visited the clinics once weekly, January 1997 through September 1997. Once informed consent was obtained, each child received the treatment to which he or she had been randomized, following physician examination and/or treatment. The designated RA (either TF or mimic TF) took the child to a quiet room and established rapport by introducing herself again and reading an assent form with the child. If a child asked that a parent be present, this was permitted. The RA, however, explained that neither the child nor parent could talk during the treatment session. After signed assent was obtained, the PPVT-R was administered. If a child scored in the age-appropriate range on the PPVT-R, the RA asked the child to state how he or she felt and recorded the response, asked the child to read the instructions for the A-State Anxiety scale along with her, and asked the child to fill in the questionnaire. Questions were answered, and the child was allowed to complete the questionnaire at his or her own pace. These tasks accomplished, the RA read the standardized script and administered the treatment. When the treatment was completed, the anxiety scale was readministered and the child was asked to say how he or she felt, and these responses were recorded. Most children completed the scale pre- and posttest in approximately 5 minutes.
At the end of the session, the parent/guardian and child were informed as to which arm of the study the child had been assigned. Children who failed to meet the age-appropriate PPVT-R score were thanked for their participation and returned to the parent/guardian, without either being aware that the child had not met the criteria for participation. TT and Mimic TT Protocol
Quinn and Strelkauskas (1993) suggested that there might be a relationship between the frequent practice of Tl" and its effectiveness. In the current study, a nurse who has practiced TT for more than 9 years, administers it at least once a week in her practice, and has used it with HIV-infected children administered "IT in the manner in which it has been taught by Krieger (1979), and as specified in Quinn and Strelkauskas (1993). Specifically, the nurse systematically (a) centered herself by shifting awareness from an external to an internal focus, becoming relaxed and calm; (b) made the intention mentally to therapeutically assist the child; (c) moved her hands over the body of the child from head to foot, attuning to the condition of the child by becoming aware of changes in sensory cues in her hands; (d) redirected areas of accumulated tension in the child's energy field by movement of her hands; (e) focused attention on the specific direction of energies to the child, using her hands as focal points; and (f) directed energy by placing the hands 4 to 6 inches from the child's body, one just below the waist and one behind the back. Total treatment time lasted from 5 to 7 clocked minutes. Mimic TI" is an intervention designed by Quinn (1982) as a single-blind q'F placebo to control for the fact that a treatment is being offered and, thus, the subject may expect relief. In this study, a TF-na'l've, fourth year baccalaureate nursing student provided mimic q'T. Quinn (1989) suggested that persons not experienced with "IF are the best candidates to administer mimic q'I'. Systematically following this sequence within a clocked 5-minute time frame, the student RA (a) made the intention to imitate the movement ofTF; (b) focused her attention on mentally subtracting from 100 by 7s; (c) moved her hands over the body of the child from head to foot while continuing to subtract from 100 by
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7s; (d) retumed to the child's head and repeated step c; (e) placed her hands 4 to 6 inches from the child's body, one in the area in the solar plexus and the other behind the child's back, and counted backwards from 240; and (f) removed her hands when she had counted down to 0 (Quinn, 1984, 1989). Each treatment was given while a child sat sideways on a chair, so that the back of the chair did not interfere with access to the front and back of the torso and with his or her feet flat on the floor. They were instructed not to talk during the sessions unless discomfort was experienced. The experimental and control condition were administered by separate RAs who administered their intervention to no more than 2 children during a clinic session.
Instruments The PPVT-R, a widely used instrument in evaluating receptive vocabulary in children, was used to determine a child's ability to understand instructions and follow directions. The score reported as a measure of receptive vocabulary is a standard score equivalent, or PPVT-R IQ. An examiner presents a series of plates with four drawings per plate, says a word, and asks a child to point to the picture of the word that he or she has just said, and repeats this process until a child reaches his or her critical range (those items that provide maximum discrimination among persons of similar ability). Administration takes approximately 10 to 15 minutes. .,Split-half reliabilities for the L form that was used in this study range from .67 to .88, test-retest coefficients for raw scores from .73 to .91, and standard scores from .71 to .89 (McCallum, 1985). The PPVT-R has been established as a valid tool for African American and Latino preschool and schoolage children with AIDS (Ireland, 1994; Levenson, Kairam, Bartnett, & Mellins, 1991) and for healthy African American and Latino preschoolers (Ireland, 1994). The STAIC (Spielberger, 1973), which was used to measure state-anxiety pre- and postintervention in each group, is a paper-and-pencil, self-report inventory that is a downward extension of the adult STAI (Spielberger et al., 1970). The A-State scale is composed of 20 "I feel" sentence stems, designed to assess
the child's feelings at a particular moment. Each response receives a weighted score from 1 to 3, with 3 representing the highest level of anxiety. Administration takes 8 to 12 minutes. Spielberger (1973) reported Cronbach alpha coefficients of .78 for males and .81 for females for the A-State scale. Papay and Hedl (1978) reported high A-state internal consistency estimates for Black, inner-city fourth-grade males (.82) and females (.80), and moderately high estimates for the third-grade males (.76) and females (.73). The validity of the A-State scale has been established in children with anxiety disorders, ages 5 to 17 (Strauss, Last, Hersen, & Kazdin, 1988); urban and suburban, low to middle socioeconomic status, bilingual (Spanish and English), and monolingual children 6 to 8 years of age (Murphy, 1990).
Data Analysis Analysis of covariance (ANCOVA) was conducted to test the hypothesis that there would be a greater decrease in state anxiety scores immediately following treatment in children treated with "IT than in children treated with mimic TI'. Correlated t tests were conducted to gain further perspective on these relationships. Each child's open-ended responses before and after treatment were reviewed to obtain a qualitative perspective on the effect of T r versus mimic Tr.
Results Of the 39 children recruited, 19 could not participate for the following reasons: (a) 5 were in foster care, and the agency did not permit the guardian to sign consent; (b) 3 were taking psychotropic medication; (c) 2 failed to score in the age-appropriate range of the PPVT-R; (d) 2 did not wish to participate; (e) 4 could not stay to participate; and (f) 3 parents would not consent for the child to participate. As seen in Table 1, the majority of the 20 participating children were female (65%), African American (50%), and asymptomatic (70%). As noted in Table 2, most of the caretakers who completed the demographic data form were mothers (65%). Of these, 10 were biological, 2 foster, and 1 adoptive. Only 2 caretakers were biological fathers
Ireland / Therapeutic Touch With HIV-Infected Children 73
Table 1.
Child Participant Characteristics (N = 20)
Child Data Age 6to9 10 to 12 Gender Male Female Ethnicity African American Hispanic White Other Asymptomatic Yes No
Table 2.
Number
Percentage
10 10
50 50
07 13
35 65
10 05 03 02
50 25 15 l0
14 06
70 30
Informant Mother Father Other Education High school diploma Yes No Beyond high school Employment status Employed full time Employed part time Unemployed Family income Less than $5000 $5100 to $9000 $10000 to $19000 $20000 to $30000 $31000 to $50000 Greater than $50000 HIV status Positive Negative Seropositive immediate family members None
1 2 3 Religiosity Not at all A little A lot
Pretest and Posttest Anxiety Mean Scores and Standard Deviations By Group Membership
Group
Caretaker Characteristics (N = 20)
Caretaker Data
Table 3.
Number
Percentage
13 02 05
65 10 25
08 11 01
40 55 05
01 02 17
05 10 85
04 03 06 05 02 00
20 15 30 25 10 00
07 13
35 65
05 06 07 02
25 30 35 10
03 10 07
15 50 35
Experimental ('IT) Pretest Posttest Difference Control (mimic TF) Pretest Posttest Difference
Mean
SD
29.20 26.70 2.50
3.04 4.42 2.46
31.20 29.50 1.70
4.51 3.37 3.91
(10%). Of the 25% who comprised the "other" category, 2 were grandmothers, and 3 were aunts. More that one half of the caretakers had not completed high school (55%), and the majority (85%) were unemployed. Although 65% of them indicated that they were not themselves HIV positive, 14 reported that one or more immediate family m e m b e r s were infected. M o s t (85%) reported that they were religious. Pretest and posttest means on state anxiety for both groups are presented in Table 3. A comparison of pretest means between the T r group (M = 29.2, S D = 3.0) and the mimic T r group (M = 31.2, S D = 4.5) detected no statistically significant differences in anxiety, suggesting that randomization resulted in groups comparable in anxiety prior to the intervention. An ANCOVA was conducted, examining the influence of group assignment on postintervention anxiety scores, with pretest scores included as a covariate. The resulting equation was not statistically significant, F(1, 17) = 1.067, p = .32. The inability to detect group effects in this analysis may be due to inadequate power given the low sample size (N = 20). To gain further perspective on this possibility, correlated groups t tests were conducted within the T r and mimic T r groups to assess differences in mean pre- and posttest scores. These analyses revealed a statistically significant decrement in anxiety posttest in the experimental (p < .01) but not the control group (p = .20). Analysis of the verbal responses by the children prior to and after experimental and control conditions demonstrated a variety of feelings and moods as noted in Table 4.
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Analysis of Verbal Responses Before and After Treatment
Group
Before Frequency After Frequency
Experimental (TI') calm happy fine nervous okay
2 4 3 1 1
calm happy fine laughing good no comment
1 2 1 1 4 1
good great happy relaxed fine okay mad
1 1 2 1 3 1 1
good great uncertain dizzy fine okay weird
1 1 1 1 3 2 1
Control (mimic T'F)
Discussion
Recruitment and enrollment of 20 participants took 6 months, reflecting the labor-intensive efforts required in recruiting vulnerable populations with multiple demands on their precious time. Despite the aid of site intermediary nurses, data gathering was slow. Research participation by some parents and children was complicated by facts beyond their control: (a) Some children lived in foster care, necessitating consent procedures that would have further extended the data collection period, (b) other children had HIVrelated cognitive deficits that precluded them from scoring in the age-appropriate range on the PPVT-R, indicating little likelihood that they would be able to follow directions or read the STAIC questions, and (c) several children took psychotropic medications that could have confounded data interpretation. Although we did not probe parents nor children who did not wish to participate, we were sensitive to the fact that this population had participated in other clinical trials, and may have been experiencing fatigue. Others may have had a healthy skepticism about research and its potential to improve the child's quality of life. Among those who did participate, results suggested that "IT may be an effective tool for reducing state anxiety in children with HIV infection. The magnitude
of the mean difference in the experimental group, 2.5, however, was considerably lower than that reported by either Heidt (1981) or Quinn (1984), who found mean decreases in state anxiety in their adult samples of 6.9 and 6.7, respectively. This could be explained by the fact that pre treatment, their subjects were more anxious with mean scores ranging from 36 to 38, whereas, the current sample of children did not have mean scores greater than 32. Examination of verbal responses to the question of how they felt prior to interventions suggests that this was not an especially anxious sample of children. These findings are consistent with those of Bose, Moss, Brouwers, Pizzo, and Lotion (1994) in their study of school-age children with HIV infection. Although they studied primarily transfusion-infected children living in middle-class families, those children saw themselves as less anxious than respective standardization samples. If the stress that HIV-infected children experience is as severe as assumed, then the children in the current sample should have obtained scores reflecting more anxiety than they did. Some explanation is needed to resolve this apparent incongruence. As in the case of childhood cancer, lower than anticipated scores on standardized measures of psychological variables can be interpreted in several ways: (a) Resilience, coping skills, and support may lessen anxiety; (b) symptoms of anxiety may be denied (Kazak & Christakis, 1996); (c) children may act as stoic good soldiers minimizing the severity of their self-report symptoms (Kaplan, Busner, Weinhold, & Lenon, 1987); and (d) methodological difficulties of self-report scales may preclude obtaining accurate data (Kazak & Christakis, 1996). In reference to the first interpretation, anxious symptoms that might be found in this population may be ameliorated by the increased attention and solicitude that parents and health care providers offer them. For many, health care visits provide opportunities for stroking and praise from nurses and physicians very committed to the well-being of their clients. Indeed, the research team was impressed with the depth of the compassionate care delivered by both, the parents/guardians and the health care team, during the data collection period. The level of awareness about having HIV infection is unknown for this sample. However, many infected
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 75 school-age children are aware that they have the HIV virus (Wiener, Moss, Davidson, & Fair, 1992). Despite this knowledge, they tend to seek normalcy. Thus, the only time they may think about their illness and consider that they are sick may be during illness events. Meanwhile, they may make effective use of defenses such as denial, try to live their lives as children, play with friends, go to school, and change and grow in age-appropriate ways. On the other hand, some may minimize the severity of their self-reported anxiety in an effort to reduce complaining. There is a subtle demand expectation in the social environments of some HIV-infected children to minimize complaining. Those children who know their diagnosis, or who are at least suspicious that something is wrong, seriously wrong with them, are aware that talking about their concerns often raises parental/guardian anxiety. Although not explicitly verbalized, those children who live with their biological parents often recognize that illness discussion compounds parental shame over having HIV themselves and that mentioning their illness tends to call this shame to mind, and may even confront parents with their own illness and potential death. When children live in foster or adopted families, they may not easily disclose their anxiety because they understand that the parent does not want to acknowledge that they know about their disease. Some parents equate knowledge as harmful, fearing that knowledge of HIV infection can do physical harm, for example, "If my child knows, he will die." In the current sample of children, anecdotal comments made by children, parents, and RAs following treatment suggest that there was some denial and a covering over of concerns. For example, one child asked whether the treatment could bring a mother back from the dead or could help in communicating with a dead person. Another child was described by the RA as emotionally "shut down," and one parent reported that her child had low self-esteem. Self-report scales have the limitation in that they reveal self-perceptions that are sometimes inflated and inaccurate. It might have been illuminating to have also tested trait anxiety, the more enduring aspect of anxiety, rather than merely assessing state anxiety, a more ephemeral reaction to a transitory event such as a nursing intervention.
Finally, whereas this sample was not staged according to disease severity as determined by C D 4 % - - a marker of disease progression--this was a generally healthy group of children; 70% were reported by the parent/guardian as asymptomatic. Bose et al. (1994) found that low CD4% was one of the variables that contributed to the presence of adjustment problems in HIV-infected children. That is, the lower the CD4 lymphocyte count, the greater the disease severity. The greater the disease severity, the more likely it is that the child is exposed to stressors such as invasive medical procedures, opportunistic infection, and debilitating illness, all of which may effect the child's psychological state.
Implications The current pilot study suggests that there is reason to pursue further research on the relationship between TT and state anxiety among children with HIV infection, and it supports a body of evidence that this technique may help ameliorate or modify the experience of those living with a chronic yet life-threatening illness. TT may be at least as effective as other relaxation therapies as a clinical strategy. However, the current study is merely a beginning to the work that needs to be done in psychosocial research related to care of children with HIV infection. Given that the majority of studies about their emotional needs are not empirical, and that there is a paucity of literature identifying interventions appropriate to those needs, "nurses 'do,' using interventions based on research findings of other chronic childhood illnesses" (Sherwen & Storm, 1996, p. 166). Well-designed intervention research is vital to establishing appropriate care delivery and improving the quality of life for the HIV-infected child. Directions for future research should include the following: . measurement of the effect of stressors on anxiety levels, both state and trait, and other psychological variables, such as mood, with a larger sample; . clinical trials that compare the efficacy of TT with other complementary modalities and nurturing forms of touch, for example, the "nursing back rub"/massage therapy (MT), in modifying anxiety and mood;
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3. longitudinal studies that allow for serial data collection points to extend knowledge about the effects of such interventions on psychological variables beyond a one-time administration or dose; 4 investigations that evaluate the potential of nursing techniques such as TI" and MT to influence immunosuppression as has been done with other forms of stress reduction, for example, progressive muscle relaxation, in HIV-infected adults; and 5. a conceptual approach, for example, psychoneuroimmunology (PNI), that inherently integrates psychological and physiological phenomenon, thereby providing a biobehavioral framework in which to examine the influence of anxiety, depression, pain, and stressful situations on the child's immune system, and the effect of relaxation therapies on these phenomenon. In conclusion, a PNI framework could provide a holistic paradigm in which to launch future research, one that is consistent with the philosophical underpinnings of nursing science and one that could help answer questions that emerge as children with HIV disease live longer. Acknowledgments. This research was supported by the Rutgers College of Nursing Center for Health Promotion Research, Rutgers University Research Council Alpha Tau Chapter, Sigma Theta Tan International. The author thanks the staff, children, and families of Incarnation Children's Center of Catholic Home Bureau and Hew York Hospital-Cornell Medical Center Program for Children With AIDS who participated in this study, and the research assistants, Lousia Porrata, RN, MPH, and Allison McClughan, who assisted with data collection. References Bose, S., Moss, H. A., Brouwers, P., Pizzo, P., & Lotion, R. (1994). Psychologic adjustment of human immunodeficiency virusinfected school-age children. Developmental and Behavioral Pediatrics, 15(Suppl. 3), 26-33. Candell, K. A. (1996). Psychoneuroimmunology and innovative behavioral interventions in patients with leukemia. Oncology Nursing Forum, 23(3), 493-502.
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