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86 Psychological Issues in Paediatric Surgery
Offering Play Therapy was obtained for the USA, where only 58% of the respondents allowed
Some hospitals provide a designated area with toys for children to parents to be present in less than 5% of the cases. This could be a
play with and personnel to oversee this process. Usually, the aim of result of inconclusive evidence concerning the advantages (alleviating
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this is threefold: First, it provides an avenue for a child’s emotional child’s anxiety and gaining cooperation) or disadvantages (making the
expression, thus revealing fears and conceptions that the child may anaesthetist nervous or causing child to be stressed from the parents’
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have that could then be corrected. Second, it provides information in a own response). It could also be that the difference reflects the fear of
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format that would be easy for the child to understand. Last, it creates an litigation or other possible legal proceedings that may exist.
avenue to help build the confidence of the child and establish a trusting In their review of preoperative preparation programmes for children,
relationship between the child and hospital personnel. In preparing the Watson and Visram concluded that these programmes are not
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child for surgery, surgery- or hospital-related props are used. Hence universally helpful in reducing anxiety or postoperative behaviour
play may involve the use of miniature versions of hospital equipment, problems. What we do know is that some programmes have better
such as syringes, masks, surgical implements, toy stethoscopes, dolls, outcomes than others and that they need to be tailored to the individual
intravenous lines, and the like. Play therapy often involves the use of child, taking into account the child’s age, previous hospital experiences,
a specialist, and it offers the chance to evaluate the current level of the and temperament.
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child’s knowledge, misconceptions, and coping level. A gap still exists, however, in transferring the results obtained
Providing Psychological Interventions in clinical research trials to routine clinical settings. Many of these
Psychological intervention involves teaching the child and parents preparation programmes have been evaluated in the controlled
actual techniques that help them to anticipate, recognise, and manage environments of clinical research trials, where factors are manipulated
stress-related surgical experiences. The child is taught actual life- to allow for clearer understanding; in routine clinical settings, these
coping skills in these sessions. Some of the interventions that have factors may not necessarily be the same, thus leading to potentially
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been used include a progressive muscle relaxation technique, positive different results. Bridging this gap is a necessity.
self-instruction, guided imagery, conscious breathing exercises, and Generally speaking, however, in the developed countries such as
refocusing. For the most part, these skills are taught by mental health the United States and in Europe, there is a continuous search for ways
professionals in sessions that last an average of 15–45 minutes, depend- of incorporating these evidence-based findings into routine clinical
ing on the capabilities of the individual or the attention span if it is a settings to improve the lot of both children and parents awaiting
child. Often there is a need for the child or parent to actively rehearse invasive surgical procedures. For paediatric surgeons in the sub-
this procedure after the sessions for maximal mastery and to get the Saharan region, in contrast, the greater challenge and focus are on
desired effect. providing basic health and counselling services for this group.
In the sub-Saharan region, the compounding factor is the acute
Providing Models and Counselling for Children and shortage of paediatric surgeons and other supporting health care
Their Parents professionals. In the more developed settings, where the ratio of children
The modelling and counselling approach is theoretically grounded in to paediatric surgeons is much lower, the inability to adequately prepare
the social learning approach, which points to the ability to learn from a child and parents for invasive procedures is due largely to a lack of
observing others engaging in a particular behaviour. In this light, chil- time. The high volume of ambulatory patients seen in surgical units and
dren awaiting a surgical procedure are exposed to models that have the policy at some institutions to forgo a separate preoperative visit, as
undergone similar procedures and responded positively to it. To be is typical for inpatient surgical procedures, is common. Clinicians who
effective in getting the children to identify and desire to behave in a work with families in the ambulatory setting have an increased burden
similar manner, the models are usually people the children can easily of identifying family needs and providing interventions to parents
identify with by reason of age, gender, race, and other similar charac- and children in a very brief time period. As expected, the situation in
teristics. The children may be exposed to the models through write-ups, sub-Saharan Africa can be considered a lot worse because the child-to-
videos, photographs, or film. This is more effective for children who surgeon ratio is so much larger.
have no previous medical experience. 9,59 In addition to these challenges are specific considerations when
Closely related to this is having the children or parents interact implementing preparatory programmes in sub-Saharan Africa.
either formally or informally with people who are in the same or similar Notably, evidence on the effectiveness of these programmes is from
circumstances or who have previously undergone the experience the industrialised world and may not necessarily be applicable in
that they are awaiting. This could be in the form of group therapy or sub-Saharan practice. Several questions arise that would be worth
sessions, where people come together and are exposed to others facing considering: Do children in sub-Saharan Africa respond to information
similar situations to help them not feel alone. A wider application of in the same way as do children in the more developed societies, or are
this is in more developed societies is getting people involved in online they more dependent on their parents and guardians in determining
or Internet forums to discuss and ask other people who may have had how they respond to new situations? Are the hospitals equipped to
certain experiences what their advice would be. Although interactions offer the preoperative preparatory sessions that are required, and
of this nature have not been tested in all settings and for all conditions, do they have mental health workers or other professionals that can
evidence 60,61 shows that people do welcome online interactions of this facilitate these sessions, or will preoperative preparation be a part of
nature and find them extremely useful.
the paediatricians already overcrowded role? Are there plans in place
Conclusion to confront fundamental societal beliefs and values that may, as in the
It is important to point out that hospitals differ in regard to recom- earlier described case, affect the acceptance of certain procedures that
mended practices in preparing a child for an invasive procedure. Some have been found effective for managing or treating certain conditions?
have formal policies on some of these procedures, whereas others rely A great need exists for research with a focus on finding brief cost-
more on the clinical judgement of the attending health care profes- effective preoperative programmes that are relevant for surgical
sional and what is feasible within that setup. For instance, the United practice in the sub-Saharan region. Raising the bar to a point where
States and United Kingdom vary vastly on the issue of parental pres- every child has access to a well-thought-out preoperative programme
ence (or absence) during anaesthetic induction. Kain et al. found that will continue to be a challenge, but nevertheless one that African
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85% of anaesthetists in the UK allowed parents to be present during nations should strive to overcome.
anaesthetic induction in 75% of the cases, but a much lower percentage