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Psychological Issues in Paediatric Surgery 85

from the hospital without permission. Thus, even though the children The second issue to take into consideration is the timing of
are valued, this value seems to depend on the child being well and providing information. Intuitively, it would appear that the earlier
conforming to what is expected of a “normal” child. At a certain level, the children and parents are given information and taken through the
children undergoing these various procedures may come to understand preparatory process, the better the outcome. This is not necessarily
the way their condition is viewed by members of the family and so. A review of the evidence shows that for invasive procedures, the
society at large. Where this is not viewed positively, or is associated timing for giving information to the child depends on the child’s age.
with stigma and discrimination, children may grow up feeling guilty For children younger than 6 years of age, it is optimal to start 1–5 days
for bringing this upon the family. They may thus feel responsible for prior to the procedure, but for children who are older than 6 years of
the ridicule and embarrassment and may even misinterpret possible age, the best results are obtained when they are informed a week before
misunderstandings that occur as a natural part of growth for a nuclear the surgery. Information given prior to this time leads to heightened
unit. These feelings of guilt may have long-term implications for a anxiety levels for school-age children. 53,54 It would appear that in
child’s development. situations in which there is a limited time for preparing the child of
Psychological Preparation for Paediatric Surgery school age, a more beneficial approach may be to use distraction and
refocusing techniques.
Over the last four decades, a number of efforts have focused on alle-
Using developmentally appropriate language not only allows the
viating the potential trauma experienced by parents and their children
child to gain a sense of mastery but also facilitates the child’s greater
as they await or undergo an invasive surgical procedure. These efforts understanding of the procedure, correcting any misinformation that
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also aim to maximise the effect of medical treatment. Thus, children
may have existed. In many instances, this would involve working with
(and their parents) are prepared for surgery in an attempt to prevent
parents on how to best communicate with their child regarding the
or decrease the severity of associated distress. These preparatory
upcoming procedure.
interventions range from pharmacological (administration of premedi-
Given that the parents’ high levels of distress can be transmitted to
cation) to psychosocial approaches, the latter of which has been the
the child, which increases the likelihood of multiple negative surgical
focus of this chapter.
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outcomes, it is important that addressing parents’ distress be made a
In looking at the psychological preparation of children for surgery,
primary focus in its own right. 10,56 There is therefore a need to target
various authors have presented slightly different paths. For instance, parents for specific anxiety reduction interventions. Parents should be
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Vernon et al. reviewed existing preparatory programmes and
offered support with more access to the physician to communicate their
highlighted three main themes that were evident in these programmes:
fears and clarify their own understanding of the situation. Many parents
(1) giving information to the child, (2) encouraging emotional
may have an external perception of control of their child’s health—
expression, and (3) establishing a relationship of trust and confidence
which is peculiar to sub-Saharan Africa. These parents should be
with the hospital staff. These three themes were later expanded by assigned a small task, such as monitoring the child’s temperature, from
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Elkins and Roberts to include (4) preparing parents and (5) providing
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the beginning of the child’s hospitalisation. This serves to link the
or teaching coping strategies to parents and children. parents’ perception of internal control and the child’s health condition.
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In a more recent review, Maclaren, and Kain adopted a historical
In giving information to parents, the paediatrician must also
approach, suggesting that preparation programmes moved through
recognise the predominant coping strategy adopted by the parents, which
three different phases: information orientation and design in the 1960s,
affects their response to the given information. In a clinical context,
aimed at facilitating emotional expression and trust between the parties;
for instance, it is easy to identify parents who use a predominantly
modelling and stress-point nursing procedures in the 1970s; and then
information-focused approach because they will manifest a high degree
in the 1980s came the teaching of children skills and the involvement
of information-seeking behaviour. These parents can then be provided
of parents. They concluded that evidence supports the development of
with detailed procedural information. Providing them with accurate
coping skills as being the most effective preoperative preparation. This
information would help reduce the level of anxiety experienced and
is followed by modelling, play therapy, an operation room tour, with the
make them more prepared to offer the needed support to the child. In
least effective being print media.
contrast, parents who predominantly use an emotion-focused approach
In discussing preoperative psychological preparation, we now look
could be given basic information and helped in refocusing while they
briefly at the various programmes with a focus on what is involved and
support their child.
how they attempted to accomplish this.
Giving Information to the Child Using a Variety of Channels in the Provision of
Information
One of the major sources of distress is the child’s lack of information or There are different channels through which information is provided to
unfamiliarity with the hospital and surgical process. It would then be children and their parents. Information could be written with enhanced
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natural to expect that simply providing the child with accurate informa- visual images for a target audience of either the child or parents. This
tion in a format that the child could understand would go a long way in is a facility used by many hospitals, which provide leaflets or send
addressing this. Providing information is not that simple, however, and information out to parents and children prior to their surgical procedure.
does not relate in a direct way to the reduction in the levels of experi- Written information alone, however, has not proven to be very effective
enced distress. One possible explanation for this may be the fact that in preparing the child or parent for surgery.
coping strategy affects the way we respond to the timing of information Other channels for passing information to parents and children
provided. As discussed earlier in the context of adult coping responses, include using multimedia facilities such as videos of hospital procedures
people tend to predominantly respond in two ways; problem-focused or and hospitals in general, giving tours of the hospital, discussion
emotion-focused. This is also applicable to children. For instance, if a with the paediatrician or health care professional, and engaging the
child’s predominant response is emotion-focused, which tends towards children in play sessions or puppet through which the child displays
avoidance, the presentation of information prior to the procedure may emotions and feelings that may expose fears and thus allow them to be
cause more distress than otherwise. In this instance, it may be better addressed. McEwen et al. exposed parents to an 8-minute informative
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to help the child with refocusing (distraction) techniques. If the child video in addition to normal preoperative preparations. They found
copes by using predominantly information-seeking approaches, howev- that those parents who were exposed to the video film showed both a
er, then the provision of medical information in regard to the procedure reduction in the desire for information as well as a greater reduction in
will help alleviate the anxiety experienced by the child.
postoperative anxiety.