Stress Appraisals of Hospitalized School-Age Children

Virtual reality hypnosis for needle-related procedural pain and fear management in children: a non-inferiority randomized trial

Needle-related procedures can cause pain and fear in children and may lead to avoidance of future medical care. The aim of this study is to investigate whether virtual reality hypnosis (VRH) is non-inferior to medical hypnosis (MH) by a trained healthcare provider in reducing pain in children. This non-inferiority randomized trial was conducted at a teaching hospital in the Netherlands. Children aged 6 to 18 years were randomized to treatment with VRH or MH. The primary outcome was self-reported pain, using the Wong-Baker FACES Scale (WBFS) with the non-inferiority margin defined as a difference of 1.5 points. Secondary outcomes included observer-reported pain (Numeric Rating Scale), fear (scored by children and observers with the Children's Fear Scale), blood pressure, heart rate, treatment satisfaction, and adverse effects. We randomized 138 children to VRH or MH treatment and included 114 children in the analyses (VRH n = 60, MH n = 54). We found non-inferiority for VRH compared to MH on patient-reported pain (mean difference =  - 0.17, 95%CI - 1.01;0.66). Secondary outcomes were comparable between VRH and MH groups. Both treatments scored high on patient satisfaction (VRH median = 9.0, MH median = 10.0, p = 0.512).

CONCLUSION

VRH may be an effective and safe treatment option besides MH for reducing patient-reported pain in children during a needle-related procedure. VRH was non-inferior to MH in patient-reported fear and both treatments were comparable in terms of patient-reported fear, observer-reported pain and fear, physical distress, and patient satisfaction.

TRIAL REGISTRATION

ICTRP https://trialsearch.who.int/ , trial ID NL9385; date registered: 03/04/2021.

WHAT IS KNOWN

• Medical hypnosis is effective in reducing procedural distress in children during needle-related procedures. • Virtual reality (VR) is an audiovisual electronic device that guides users into an immersive three-dimensional environment.

WHAT IS NEW

• This study shows that VR hypnosis is non-inferior to medical hypnosis in reducing pain and fear in children undergoing a needle-related procedure. • Both VR hypnosis and medical hypnosis were appreciated highly by children to distract them during needle-related procedures.

Storytelling increases oxytocin and positive emotions and decreases cortisol and pain in hospitalized children

Storytelling is a unique human skill, yet we know little about its physiological and psychological impact. This study provides evidence of the biomarker changes and beneficial effects of storytelling in children admitted to an intensive care unit. We found that, compared with an active control condition, one storytelling session with hospitalized children leads to an increase in oxytocin, a reduction in cortisol and pain, and positive emotional shifts during a free-association task. These multimodal findings support evolutionary theories of storytelling and demonstrate its physiological and psychological effects under naturalistic stress conditions. These important clinical implications affirm storytelling as a low-cost and humanized intervention that can improve the well-being of hospitalized children.

Storytelling is a distinctive human characteristic that may have played a fundamental role in humans’ ability to bond and navigate challenging social settings throughout our evolution. However, the potential impact of storytelling on regulating physiological and psychological functions has received little attention. We investigated whether listening to narratives from a storyteller can provide beneficial effects for children admitted to intensive care units. Biomarkers (oxytocin and cortisol), pain scores, and psycholinguistic associations were collected immediately before and after storytelling and an active control intervention (solving riddles that also involved social interaction but lacked the immersive narrative aspect). Compared with the control group, children in the storytelling group showed a marked increase in oxytocin combined with a decrease in cortisol in saliva after the 30-min intervention. They also reported less pain and used more positive lexical markers when describing their time in hospital. Our findings provide a psychophysiological basis for the short-term benefits of storytelling and suggest that a simple and inexpensive intervention may help alleviate the physical and psychological pain of hospitalized children on the day of the intervention.

Hospitalized Children: Anxiety, Coping Strategies, and Pretend Play

The aim of this paper was to assess strengths and fragilities in children aged 6 to 10 who suffered one or more hospitalizations. State and trait anxiety, coping abilities, and cognitive and affective functioning through play were assessed using a triangulation approach. Fifty hospitalized children aged 6-10 were compared to 50 non-hospitalized children, and children at first admission were compared with children with more than one hospitalization experience. The State-Trait Anxiety Scales Inventory for Children was administered for assessing trait and state anxiety, and the Children's Coping Strategies Checklist (Revision 1) was administered to assess coping dimensions. The Affect in Play Scale - Preschool - Brief (Extended version) was used to assess cognitive and affective dimensions of play. No significant differences were found for trait anxiety between hospitalized vs. non-hospitalized children. Instead, as expected, state anxiety was significantly higher in hospitalized childen than in the non-hospitalized children. Hospitalized children reported higher scores than non-hospitalized children in support-seeking strategies. As for pretend play, hospitalized children showed significantly higher cognitive scores than non-hospitalized children. However, hospitalized children appeared significantly more restricted in their affect expressions. No significant differences were found for play and anxiety scores between children admitted for the first time in the hospital ward and children with more than one admission. However, children at first admission scored higher in coping and positive cognitive restructuring and in avoidance-coping strategies than children with more than one admission. The initial assessment of the interplay of key variables such as anxiety, coping and play can inform healthcare professionals by serving as a guide in order to determine a child's risk for negative psychological outcomes due to hospitalization, to plan appropriate interventions and to provide substantial assistance to hospitalized children in the future.

Stressors of School-age Children With Allergic Diseases: A Qualitative Study

PURPOSE

Most studies of stress in children with chronic diseases have been geared toward parents and caregivers have not considered allergic diseases together. This study aimed to identify the stressors associated with allergic diseases in Japanese school-age children.

DESIGN AND METHODS

Stressors associated with allergic diseases of 11 school-age children (seven boys and four girls; age range: 9-12 years) were investigated using semi-structured interviews.

RESULTS

In the qualitative thematic analysis of stressors about allergic diseases, two themes: allergic disease-specific stressors and common stressors in chronic diseases, and 12 categories were identified. A thematic map was applied to four domains of stressor: physiological factors, psychological factors, social factors, and environmental factors.

CONCLUSIONS

The results showed that school-age children with allergic diseases have a variety of stressors. Future studies should aim to develop an allergic disease-specific stress management program with school-age children.

PRACTICE IMPLICATIONS

In children with allergic diseases, not only is stress management in daily life important, but also stress management for disease-specific matters to control the symptoms and maintain mental health. Stress management should be supported for school-age children with allergic diseases.

Effects of Animal-assisted Activities on Biobehavioral Stress Responses in Hospitalized Children: A Randomized Controlled Study

PURPOSE

This study assessed the effectiveness of animal-assisted activities (AAA) on biobehavioral stress responses (anxiety, positive and negative affect, and salivary cortisol and C-reactive protein [CRP] levels) in hospitalized children.

DESIGN AND METHODS

This was a randomized, controlled study.

METHOD

Forty-eight participants were randomly assigned to receive a 10-minute AAA (n=24) or a control condition (n=24). Anxiety, positive and negative affect, and levels of salivary biomarkers were assessed before and after the intervention.

RESULTS

Although increases in positive affect and decreases in negative affect were larger in the AAA condition, pre- and post-intervention differences between the AAA and control conditions were not significant. In addition, pre- and post-intervention differences between the conditions in salivary cortisol and CRP were not statistically significant. Baseline levels of anxiety, cortisol, and CRP had a significant and large correlation to the corresponding post-intervention measures. Scores on the Pet Attitude Scale were high but were not associated with changes in anxiety, positive affect, negative affect, or stress biomarkers.

CONCLUSIONS

Although changes were in the expected direction, the magnitude of the effect was small. Future randomized controlled trials with larger recruitment are needed to determine the effectiveness of AAAs in reducing biobehavioral stress responses in hospitalized children.

PRACTICE IMPLICATIONS

Nurses are positioned to recommend AAA as a beneficial and safe experience for hospitalized children.

Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials

Children and/or their parents are in fear and anxiety when admitted to hospitals or undergo invasive surgeries or investigations. Clown therapy has been shown as an effective measure in reducing this hospital fear and anxiety. Hence, we carried out a systematic compilation of the existing evidence on the clinical utility of hospital clowns in pediatric population. Electronic databases were searched with an appropriate search strategy, and only randomized controlled trials comparing the effect of clown therapy with standard care in children were included. The key outcome measures were as follows: extent of anxiety and pain felt by children and extent of state and trait parental anxiety. Random effect model was applied when moderate to severe heterogeneity was observed. Forest plot, I(2) statistics and risk of bias were evaluated using RevMan 5.3 software. A total of 19 studies were found eligible to be included in the systematic review and 16 for meta-analysis. The pooled SMD [95 % CI] for child anxiety score was -0.83 [-1.16, -0.51] favoring clown therapy. Similarly, a statistically significant reduction {SMD [95 % CI] -0.46 [-0.7, -0.21]} in the state anxiety was observed amongst parents.

CONCLUSION

We found that hospital clowns play a significant role in reducing stress and anxiety levels in children admitted to hospitals as well as their parents.

WHAT IS KNOWN

• Trials with clown doctors in pediatric population have shown conflicting results in allaying anxiety amongst children undergoing either hospitalization or invasive procedures What is new: • This is the first systematic review and meta-analysis on hospital clowns • We found out that hospital clowns reduce anxiety amongst children before undergoing either hospitalization or invasive procedures.

Assessing pediatric patient's risk of distress during health-care encounters: The psychometric properties of the Psychosocial Risk Assessment in Pediatrics

The aim of this study was to examine the psychometric properties of the Psychosocial Risk Assessment in Pediatrics (PRAP). PRAP is a screening tool designed to assess pediatric patients who are at risk of experiencing elevated distress during health-care encounters. A cross-sectional observational study was conducted with 200 pediatric patients. Patient's distress levels were observed during their health-care encounter using the Children's Emotional Manifestation Scale (CEMS). Health-care staff and parents were asked to rate the patient's level of cooperation and stress. Exploratory factor analysis supported a single latent factor structure of the PRAP tool. Cronbach's α for internal reliability was .83. PRAP score was strongly correlated with CEMS score with r = .82 (p < .0001). The PRAP is a standardized, reliable, and valid method for health-care providers to assess a patient's risk of experiencing significant distress during treatment or testing.

Validation of a clinically useful measure of children's state anxiety before medical procedures

PURPOSE

Assessment of children's anxiety in busy clinic settings is an important step in developing tailored interventions. This article describes the construct validation of the Children's Anxiety Meter-State (CAM-S), a brief measure of state anxiety.

DESIGN AND METHODS

Existing data were used to investigate the associations between child self-reports of anxiety, parent reports of child anxiety, and observed child distress during an intravenous procedure.

RESULTS

Children's (n = 421) CAM-S scores were significantly associated with all parent measures and observed distress ratings.

PRACTICE IMPLICATIONS

Findings support the use of the CAM-S for assessment of child anxiety in clinical settings.

Impact of music therapy interventions (listening, composition, Orff-based) on the physiological and psychosocial behaviors of hospitalized children: a feasibility study

The purpose of this study was to compare three music therapy strategies (music listening, music composition, and Orff-based active engagement) on physiological (heart rate, blood pressure, oxygen saturation, and pain) and psychosocial (anxiety) behaviors of hospitalized children (N=32, 17 females,15 males, ranging in age from 6 to 17). This study was designed and facilitated cooperatively by pediatric nurses and music therapists. Results indicated no clinically significant changes in heart rate, blood pressure, or oxygen saturation (p>.05). Pain and anxiety both decreased significantly (p=.01) but not differentiated among conditions. Videotape analysis determined level of engagement in coping-related behaviors.

Physiological and emotional responses of disabled children to therapeutic clowns: a pilot study

This pilot study examined the effects of Therapeutic Clowning on inpatients in a pediatric rehabilitation hospital. Ten disabled children with varied physical and verbal expressive abilities participated in all or portions of the data collection protocol. Employing a mixed-method, single-subject ABAB study design, measures of physiological arousal, emotion and behavior were obtained from eight children under two conditions-television exposure and therapeutic clown interventions. Four peripheral autonomic nervous system (ANS) signals were recorded as measures of physiological arousal; these signals were analyzed with respect to measures of emotion (verbal self reports of mood) and behavior (facial expressions and vocalizations). Semistructured interviews were completed with verbally expressive children (n = 7) and nurses of participating children (n = 13). Significant differences among children were found in response to the clown intervention relative to television exposure. Physiologically, changes in ANS signals occurred either more frequently or in different patterns. Emotionally, children's (self) and nurses' (observed) reports of mood were elevated positively. Behaviorally, children exhibited more positive and fewer negative facial expressions and vocalizations of emotion during the clown intervention. Content and themes extracted from the interviews corroborated these findings. The results suggest that this popular psychosocial intervention has a direct and positive impact on hospitalized children. This pilot study contributes to the current understanding of the importance of alternative approaches in promoting well-being within healthcare settings.

The voices of children: stories about hospitalization

INTRODUCTION

The study explored children's views of hospitalization through their own voices.

METHOD

In this secondary analysis, 93 children aged 5 to 9 years told stories about hospitalization using a set of drawings of children in the hospital. Children were recruited in the hospital and in the community. Themes were identified through qualitative analysis.

RESULTS

Children's stories focused on being alone and feeling scared, mad, and sad. These children wanted protection. Children in the stories were not always facing scary events. They were simply not at home and feeling bored, lonely, and sad. They wanted companions. Children displayed awareness of both good and bad outcomes. The hospital was a unique environment that could be fun as well as threatening.

DISCUSSION

Children's views of hospitalization were not invariably negative. The themes of hospitalized and never-hospitalized children were different only in degree of detail.

Hospitalized children's mood differences during play and music therapy

BACKGROUND

Paediatric hospitals are concerned with both the physical and social well-being of their young patients. These institutions often provide play and music therapy to enhance the child's sense of normality. The purpose of this study was to test whether children in a hospital were happier during music rather than play therapy.

METHODS

Sixty children were observed either during play or music therapy. Happiness was operationally defined as the frequency of smiles during a 3 minute period.

RESULTS

The results showed that music therapy (M = 12.43, SD = 4.83) led to significantly more smiles than did play therapy (M = 5.83, SD = 3.10).

CONCLUSIONS

Increasing the amount of time hospitals provide music therapy for child patients may be a way to increase positive effect and ultimately to increase mental and physical well-being in hospitalized children.

Revision and psychometric testing of the Barton Hospital Picture Test

The Barton Hospital Picture Test (BHPT) is an instrument designed to elicit self-reports of stress in hospitalized children. This article reports two studies. The results of Study 1 were used to revise the pictures. Study 2 determined the reliability and validity of the revised BHPT. The revised BHPT has construct validity demonstrated by differences in total stress scores in the expected direction between hospitalized and community (well) children. The instrument has acceptable test-retest, interrater, and internal consistency reliability.

Children's experiences of hospitalization

This article reports on children's experiences of hospitalization. Data were collected via semi-structured interviews with 11 children aged between seven and 14 years from four paediatric units in England. The children identified a range of fears and concerns, which included: separation from parents and family; unfamiliar environment; investigations and treatments; and loss of self-determination. The children's loss of self-determination over personal needs exacerbated their fears and concerns. It needs to be recognized that compliance with hospital routines is a variable, which influences children's reaction to hospitalization. The findings clearly indicate that children need adequate information tailored to their needs, that their views are sought in the planning and delivery of their care and that hospital environments need to be made more child-centred. Interventions designed to reduce children's stress during hospitalization are not only likely to decrease their stress at the time, but also likely to influence how future experiences are appraised and managed.

Consultation with children in hospital: children, parents' and nurses' perspectives

AIMS AND OBJECTIVES

To explore children's, parents' and nurses' views on participation in care in the healthcare setting.

BACKGROUND

Children have a right to be consulted and involved in their care.

DESIGN

The grounded theory method was used and data were collected through in-depth interviews, questionnaires and observation. Sample consisted of 11 children, 10 parents and 12 nurses from four paediatric wards in two hospitals in England.

RESULTS

Parents felt that children should be involved in the decision-making process thereby enhancing and promoting children's self-esteem and positive self-regard, which would consequently enhance their overall welfare. Likewise, children expressed the need for consultation and information so that they could understand their illness; be involved in their care, and prepare themselves for procedures. However, children's own opinions and views were underused and they had varying experiences of being consulted about their care and treatment. Nurses appeared to hold varying and discrepant views on the involvement of children in decisions and for some nurses, the child's involvement seemed to be dependent on the child's cognitive maturity and being defined as a rational subject.

CONCLUSION

Health professionals' communication behaviour may reflect recognition of children's cognitive abilities rather than their competence to understand. The fact that children's nurses appeared to make decisions about involving children in decision making in the absence of a reliable framework was a significant finding and highlights a real problem in the current climate.

RELEVANCE TO CLINICAL PRACTICE

Nurses faced with workforce pressures may encounter considerable challenges to facilitating children's involvement in decisions about their care. Hence it is imperative that nurses' examine the basis of their decisions and use more explicit criteria for determining children's involvement.

Chronically ill children coping with repeated hospitalizations: their perceptions and suggested interventions

This qualitative research study used grounded theory methodology to learn from chronically ill children who are repeatedly hospitalized how they cope and how they feel others can assist them to cope with their recurrent hospital experiences. Six hospitalized children, ages 10 to 13 years, with various chronic conditions participated in an audiotaped interview, completed a drawing and kept a journal. The subjects identified their perceived stressors of hospitalization; revealed their use of both cognitive and behavioral coping strategies; described how hospital personnel, family, and friends enhanced their coping; and illustrated the impact of the hospital environment on their coping process. From comparison of the data, it is theorized that chronically ill children who are repeatedly hospitalized become adept at identifying and implementing a repertoire of coping strategies, accessing family and friends as resources in the coping process, developing patterns of coping with their parents, and utilizing the hospital environment to promote coping. Their coping is enhanced by familiarity and knowledge and by the respect and patience of gentle, supportive, and competent health care professionals.

Use of a projective technique to assess young children's appraisal and coping responses to a venipuncture

PURPOSE

To examine the appraisal, emotional and coping responses of young hospitalized children to three phases of a venipuncture procedure.

DESIGN

Exploratory, descriptive.

SETTING

Pediatric unit of a community hospital.

PARTICIPANTS

Four- to 9-year-old hospitalized children (N = 45).

MAIN OUTCOME MEASURES

Data were obtained by means of a projective technique and interview format. Content analysis of the children's responses was guided by the use of four published measures (appraisal, behavioral coping strategies, cognitive coping strategies, and helpful interventions).

RESULTS

The children appraised each phase of the venipuncture as a threat, a benefit, or a threat/benefit. The most frequently identified behavioral coping strategies were self-protective behaviors and returning to normal activities. The most frequently identified cognitive coping behaviors were reality-oriented working through, emotion-regulating cognitions, and diversionary thinking. The children reported the most helpful intervention as providing information about the event.

CONCLUSION

The children were able, through a projective technique, to appraise a venipuncture and spontaneously identify many cognitive and behavioral coping strategies and interventions to help them manage a venipuncture.