1983 - The fallacy of 'preparing' young healthy children for possible hospitalization

Is there any point in preparing healthy children, in groups, for a possible future hospital visit or hospitalisation? Back in 1983, the English child psychologist Joyce Robertson believed there wasn’t. She argued that hospital-related information is more likely to scare than reassure preschoolers. However, initiatives to inform children in groups are still being launched today, in 2008. This goes to show that Joyce Robertson’s plea to refrain from group-based information efforts has lost little of its relevance.

During the past twenty years there have been increasing attempts throughout the Western world to find ways of softening the experience of being in hospital for young children. Initially the main objective was to obtain unrestricted visiting to all children and to ensure that parents of under-fives could stay in hospital with them in order to help in their care and prevent the dangerous distress commonly seen in young children who go into hospital alone. Refences

In recent years activity has extended beyond the sick child in the hospital ward to healthy children in the community. Attempts are being made to inform all young children about hospitals. The hope is that children thus “prepared” who go into hospital will be better able to cope than if they had not had the benefit of foreknowledge.

Young children from play groups and infant schools have been taken on tours of children’s wards, told what happens there, and shown some of the treatment procedures. Speakers from voluntary organizations visit play groups and infant schools to talk to the children about hospitals, using books, slides, films and toy medical instruments to illustrate blood taking, injections and other procedures. Refence
These well-intentioned projects are misconceived, unnecessary, and potentially harmful. They assume that the children will be reassured by what they are told. But this educational approach neglects the fact that in the early years children are coping with fantasies, labile emotions, and limited comprehension. Talks about hospitals, with their undertones of separation and hurt, may impinge with disturbances for children.

What does “hospital” mean to the young child?

To a young child “hospital” can mean being on a visit to a big building where strange things are seen, smelled and heard. It can mean being ill, perhaps in pain, where there are doctors and nurses who interfere with or hurt one’s body. It can mean being in a strange place away from home and the people one is dependent upon. It can mean feeling frightened, confused and having a limited understanding of what is happening.

Hospital is a subject which cannot be divorced from worrying feelings. Adults and older children can understand the need for hospital and are glad of the help given. But very young children cannot understand why they should be ill or in pain; they are additionally made specially anxious by the threat to their bodies.

Young children are not unaware of illness, pain, and hospitals. In the course of family life they gradually come to know about being ill, getting medicine, hurting themselves, getting a plaster, going to the clinic, seeing the nurse, and having the doctor visit them at home. They see hospital buildings and ambulances and gradually learn their purpose in the haphazard way young children learn. The pace at which the picture is added to will depend upon the children’s ages and personal experiences; the family’s experiences of illness, accidents, birth and death; and what happens to the children’s playmates.

Examples of such learning follow:

  1. Before Sarah was two years old her father injured his back and went to the local hospital. When she was taken to visit she saw that people were in bed and got their dinner there, that doctors and nurses looked after them and made them better. Then they went home, as her father did. That bit of learning was tied to immediate experience. Sarah’s play reflected her anxieties and her limited understanding. Her mother helped her to work through them.

    At three years of age she had an eye infection and was taken twice to outpatients. Her “preparation” was simple. She was told by her mother that she was going to the hospital where a doctor and nurse would look at her eye. The mother explained and comforted as needed. Sarah did not like the eye drops or the patch over her eye and said so. Afterwards there was much play about the visit, putting patches on her teddy bear’s eyes and telling her daddy about it. There was appropriate anxiety to be talked through such as why it had happened, what the doctor had done and how the eye would get better.

    The return visit to the outpatients a week later was unwelcome to Sarah but was accepted as necessary. More play and talk followed, about eyes and only about eyes, the subject of Sarah’s anxiety.

    Her other hospital experience was to visit a maternity ward to see a neighbour’s new baby. This appeared to put no strain on her. Sarah’s knowledge about hospitals had increased but it was still limited to her experiences and was under the control of her parents.

  2. At three years of age Paul, Sarah’s friend next door, visited his mother in the maternity unit, his first experience of hospital. Some months later he saw Sarah’s eye patch and was told about her visit to the hospital where the doctors had made her better. He joined in the play with eye patches. Both mothers were on hand to correct confusions and to cope with anxieties that arose from the children’s play and talk.

    At four years of age Paul cut his head and was taken to outpatients. He complained bitterly as he was held and stitched. Comforting at the time, and play and talk afterwards, increased Paul’s understanding of what hospital is for. His knowledge about hospital is still limited but is realitybased and age-adequate. Unavoidably he is left with some anxiety.

    Sarah and Paul sometimes play at doctors and nurses, but there is much that these two children do not know about hospitals.

    The parents avoid many of the illustrated books on hospitals since these open up anxietymaking issues which they feel their children need not know about yet.

Learning about illness, accident and death, even in the safe setting of the family, inevitably causes anxiety. The parents do not tell the children too much but give as much knowledge as they need to know and can understand.

A person visiting a play group to talk about hospitals will know little or nothing about individual children, the ebb and flow of their inner strengths or their wishes to take in anxietymaking knowledge. The play group leader is unlikely to know about them in detail either, and would be unlikely to anticipate the impact of a talk on any one of the following four children:

  1. Mary, aged four years, has been ill a great deal and has already been to hospital twice, at six months and at eighteen months of age. She does not talk about hospitals and may not remember the last stay. But as a result of illness and the hospital experiences she is more vulnerable to stress than other children in her play group. She gets worried when routines are changed or a strange person comes to the group. A visitor coming to talk about hospitals could not know this. Talk about hospitals and illness is likely to worry this child by reviving forgotten or repressed memories, then leave her to cope with the memories unaided.

  2. Peter, age three years nine months, had an ear operation at two and a half years of age. The experience was upsetting and his mother was not with him. Since then he has been especially anxious about ambulances and about any cut or bruise to his body. He has more minor accidents than most children. Peter was difficult to settle into the play group, stopping and starting twice before he eventually settled three months ago.

    How would Peter react to a talk about hospitals? He has been through an ear operation and now he would be told of other things that might happen to him. Because of the emotional impact of such a talk, he may not listen properly; so to his basic anxiety might be added confusion and further threat. Group “preparation” could add to his problems.

  3. Susan, aged four-and-a-half years, had difficulty in adjusting to play group. She started late but is now making efforts to be big and grown up. Everyone, especially the mother who is pregnant, is relieved that Susan is settled in play group before the birth of the next baby which will take place in hospital.

    The mother is in the process of preparing Susan for the new baby, and for herself being away in hospital. If Susan’s play group is told about hospitals, this already insecure girl could muddle who is going to hospital, she or the mother. It could unsettle her in the play group and thereby add to the family’s problems.

  4. Three year old Stephen is going into hospital shortly to have an abdominal investigation and perhaps an operation. His parents are about to tell him they have not yet told the play group leader.

    If the children in his playgroup get a talk about hospital, Stephen’s parents may be forced to tell him about the impending hospital admission before they or he are ready. If this happens, it is clear that Stephen and his parents would not have been helped.
    The threat of an operation on their child will awaken anxieties in the parents and will affect the way in which they prepare Stephen. It may be thought that the parents should have told the child sooner, or that a visitor to the play group would introduce the subject better because parents get anxious. But families differ in the ways they cope with such situations. Some may need help, while others do not. These differences should be respected.

What of those children in a play group who have not been patients in hospital, who are not especially disturbed, who have the usual smattering of knowledge about hospitals and who play the usual “doctor and nurse” games? Some of these children will not listen to the talk about hospitals, others will not remember what is said. They may not be affected one way or another.

Others will listen to part of what is said. These are the children whose eyes glaze over at story time, and whose thoughts wander off. These children still live a lot of time in their own world, and join adults in theirs only fleetingly and not to order. They will go home with a very confused understanding of what they have been told about hospitals.

Some will sit rooted to the spot, seemingly fascinated by what they are told. The NAWCH Project Report on Preparing Children for Hospital refers with satisfaction to the children being “fascinated,” as if this confirmed the value of what they are being told about hospitals. Reference But this assumption has to be questioned. Children can be fascinated by many a frightening thing which does them no good at all. For example, a child will sit fascinated by a frightening television program until a parent turns it off. Then the child rushes about frantically or sits immobilized, anxiously sucking his thumb.

Play group children can be looked at in another way. There are considerable differences between them in their levels of language, comprehension, memory structure, and concentration. Some will not be able to differentiate between “if” and “when.” For example, one child was reported as asking after a hospital talk, “Can I take my Teddy?” He had probably understood that he was going to hospital.

The under-fives are living through a period of fast psychological growth and they are from time to time troubled by fantasies, anxieties and conflicts. Families know that, without warning, children’s moods change. They may become tense, go off their food, wet the bed, or become aggressive or anxious for some days or weeks.

Parents do not always know why and do not have to know why. They tolerate the inexplicable behaviour, they support, comfort and take their children to the doctor. Usually after a few days or weeks the children return to an even keel. They have worked through some troublesome feelings -- some aspect of psychological growth.

In any group there will be children who are working through something that is troubling them. To be told about hospital with its threat of illness, hurt and leaving home will add further anxieties to those they are already coping with in the course of normal development. This can only be disturbing to these children and their families.

When group talks are illustrated with medical instruments and books the emotional impact will be greatly increased. Children can shut their ears to some extent to protect themselves from what they do not want to hear. But visual material impresses more and is less easy to forget.

Group visits to hospital carry a further danger that the children see not only the planned exhibit but unplanned ones as well, which could confuse and frighten.

The examples in this paper have been of play group children but much that has been said relates also to the five-to seven-year-olds. These infant school children, too, need protection from educational experiments...for experiments they are.

Studies are lacking on the emotional effect of group instruction or group hospital visits upon young children who do not become patients. There is no evidence that young children who go into hospital a month or six months after a group session have been helped by the “preparation.” If children go to hospital how much will be accurately remembered of the “preparation?” And how relevant to the actual experiences will be the information that is retained?

It may be that adequate studies are impossible because of the great number of variables, their subtlety and complexity.

The aim of preparation

It should not be the aim of preparation to make children submit without protest or anxiety to hospital admission or procedures. Submissiveness is not the measure of successful preparation. Anxiety and protest are often appropriate. As Anna Freud said, “When the body submits, the mind retreats.” Reference

The true aim of preparation is to prevent children’s being overwhelmed by anxiety, so that in the longer term they can assimilate the experiences and not be damaged by them. Allowing children to express feelings of anger and sadness, and to play and talk afterwards, are the safest and most effective ways of helping them to cope. These carry no risks and are always helpful. Appropriate books and play materials can aid “working through” the experiences of hospital and the feelings about it.

When young children do go to hospital they need to have their parents to stay, to explain, to support and to comfort. If a parent is not there someone is needed who will take on these functions, ideally a substitute-mother who will stay around the clock. A specially assigned nurse or play person who attends with some consistency can help to a degree. (see earlier refences 3 and 4) References

In addition, preparing children is much more than the giving of information. It is to understand and respond to children’s individual reactions to such preparation, and that means knowing children’s histories. Adults are made anxious by the thought of young children going to hospital. But in contemplating the possibility it is important that we bear the anxiety within ourselves -- as parents, nurses, play group leaders, play specialists -- instead of passing it on to children who are too immature to bear that anxiety.

Joyce Robertson
Child Psychologist Robertson Centre,
London, England.

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