Medical practitioners often regard the preschool child as too young to understand medical procedures, too young to cooperate, and certainly too young to fully participate. The traditional approach has been to get the procedure or examination over as quickly as possible, with the goal of minimizing both staff and patient distress. This doesn't necessarily occur. The child's ignored anxiety or pain disrupts and prolongs the medical examination, creating distress for everyone involved. Furthermore, the child becomes rapidly sensitized to further medical interventions.1'2 Jokes, sometimes proposed as a means of harnessing the child's attention, are not necessarily helpful. Interviews with children after hospital treatment indicated that doctors' jokes often were not appreciated, particularly if the doctor was the only one laughing.3
The preschool child is particularly receptive to new situations and quickly absorbs physical details and emotional tone. The accompanying parent often sets or heightens the emotional tone for the very young child and therefore needs to participate in any intervention.4'8 Biobehavioral strategies that encourage the child's participation in treatment, thereby mobilizing coping and recovery skills, are increasingly being recognized as a necessary and potent part of pediatrie clinical practice.8'13
This article discusses a variety of interventions and provides examples to illustrate how receptive and responsive young patients can be. The clinician's intent in using these methods is to enhance the child's coping ability, increasing comfort and minimizing pain, anxiety, and distress. The interventions are strategic and goal-directed. The clinician approaches and talks directly to the child at eye level, suggesting that what was distressing or problematic before can now become more comfortable and manageable. This is achieved by using different techniques to absorb the child's imagination and shift or alter the child's attention.
IMAGINATION AND ATTENTION IN THE PRESCHOOL CHILD
Children under the age of 6 years shift very easily from one cognitive state to another. Children aged 3 to 5 years move fluidly along a continuum of cognitive states from a reality-bound "here-and-now" awareness, to imaginary play involvement in which fantasy and reality blend comfortably together and into a dissociated trance-like, dreamy state.6-14'19 This is particularly noticeable with children aged 3 to 5 years who talk and play with imaginary playmates. A child may adopt different identities, for example, shifting rapidly between Robin Hood and his own self, and become quite incensed if his parents don't know which identity is current and use the wrong name.
The infant and toddler also live entirely in the present. Their attention can very easily be distracted using bubbles, musical boxes, jumping jacks, and other novel toys that shift their attention from pain or absorb their attention so that they will lie still, for example, to allow an ear examination.
It is these blurred boundaries between reality and fantasy that allow the young child to rapidly enter an altered state of consciousness in which sensations, perceptions, and experience can be changed.5'6,8'1749 These changes occur when the child's eyes are wide open. Sometimes the child's focus is slightly more fixed, and sometimes an altered state of consciousness occurs during physical activity, such as being a Ninja Turtle.
It is a moot point whether the trance states of preschool children can be called "hypnosis." Their presentation is different from that of adults - despite the fact that they can achieve significant physiological changes, eg, in peripheral body temperature20 and pain intensity and location,6,8,21 often more easily than adults. The term "imaginative involvement" is applied to this phenomenon in young children,6,8,15,17 as it has been identified as a precursor of hypnotic ability.22 Imagination has the components of imagery, absorption, and dissociation, which are components of the hypnotic process. In contrast to adults, however, altered states for young children are not readily sustained, clearly defined, or easily measured.6'8'17 This has posed research difficulties, and consequently, this age group remains poorly studied.
HOW TO ENGAGE THE YOUNG CHILD
Given the distinct responsiveness of young children's attention process, an actively absorbing and informal participation between clinician and child is necessary for change to occur and be sustained. 5,8,16,19 This applies to a range of different interventions -behavioral, kinesthetic, or imaginai. TKe invitation to the young child to shift away from his or her discomfort or anxiety can be stated as simply as: "Let's pretend that you are cuddling on the couch at home with Mom. Here's Mom, and here's Moms hand [Mom can take the child's hand]. Now, that helps you to feel good while I do. . . "
Unlike the school-aged child who is cognitively more developed, inviting the preschooler to feel more comfortable needs little preamble and works best when stated directly and simply. "Magic," for example, is a concept that many 3 to 5 year olds readily accept. The following is a way of creating glove anesthesia for young children using the concept of magic: "I'm going to put this magic glove over your hand [imaginary glove is put on the child's hand, and the upper part of the hand gently stroked] so that the magic giove can make your hand feel safe and good, and you won't be bothered when we put the medicine into your vein."7
The clinician must be flexible and allow the child to play and move about, with the knowledge that as easily as the child shifts out of one state of consciousness, he or she can readily reenter it or another. Questions about the child's experience help to refocus attention. For example, after the hand was stroked the preschooler could be asked: "Does your hand feel different now?" If the child is uncertain or hesitates, the clinician can provide a variety of ways it could feel different and protected such as, "Your hand may have a tingling nice feeling, or feel like it's going to sleep."
Language needs to be age appropriate. Even the babbling toddler who has few if any clearly articulated words will understand simple words said directly to him or her within certain contexts and may be able to follow directions. The tone of voice, if relaxed, warm, and kindly, will automatically define the context as less threatening.
Absorbing a toddler's or a child's attention requires the clinician to make contact in whatever way the child will allow and to sustain it within those limits. Being at the child's eye level helps the process greatly, as does looking directly into the child's face and eyes. If the child will accept it, touching the child can further the developing sense of comfort before the examination proceeds. This one-on-one relationship focus is necessary for attention to be heightened, narrowed, or absorbed. The parent will often support this by being quiet and allowing the clinician "to take the reins."
Helpful Strategies for Young Children
THE ROLE OF THE PARENTS DURING STRESSFUL INTERVENTIONS
The preschool child is still very dependent on parents, who define the world, explain situations, and shape the child's attitudes and expectations. The child tends to feel secure when accompanied by a parent and often feels tense and anxious when separated from the parent.4,23 "Parentectomies" are counterproductive with the preschool child - unless the parent is being histrionic and clearly not behaving in the best interests of the child. In the great majority of cases, however, the parents will accept guidance on how to best support their child during taxing or distressing medical procedures and will be an important source of information about the child and the coping methods or strategies that were effective in the past.4,8
Giving the parent a role often sets the scene as "everyone helping to get through this distressing but necessary procedure." Parents can be given the role of patting the infant's back, being the "counting coach" for the preschooler, or holding a bubble wand while the child "blows away the scary feelings in the bubbles." The child remains the focus of attention.
"Won't it take too much time?" is the often expressed reservation about the use of biobehavioral strategies. Because most children will return to a doctor's office, one cannot afford not to take a few extra minutes to ensure that the child's medical experience is as positive as possible. The strategies outlined in the Table can be used simultaneously by the physician during physical examinations, or by the team of nurse and parent during invasive procedures. Practice increases success. The rewards are greater cooperation and an enhanced relationship with patients.
Helpful strategies can be classified into three categories that frequently overlap in practice. Combining the strategies can often prolong the therapeutic impact; for example, after absorbing a child's attention with an interesting puppet or book the child becomes even more receptive to hypnotic suggestions for greater comfort, coping better and feeling good at the end of the procedure. Some of the methods in the Table are simple and selfexplanatory such as the application of ice or heat to reduce pain and discomfort. Others, such as telling a favorite story adapted to the present situation,6,19,24 may require a little more preparation.
BEHAVIORAL STRATEGY: SURPRISE
Surprise interrupts the child's attention, momentarily holds it, and allows a different direction to be pursued. The following examples surprise the child and shift him or her away from fear and toward a more detached point of view. The following methods draw on the work of psychiatrist and hypnotherapist Milton Erickson.25
A tearful 4-year-old boy lacerated his hand on broken glass in the park. He seemed more terrified at the sight of his blood than about the lacerations, which were not deep. The admitting nurse (who had recently attended an inservice program on coping with children's pain and anxiety) noted the boy's horror at his own blood and said with authority: "What wonderful red bright blood you have. Look! Isn't it marvelous. It looks very healthy to me. Soon it's going to form a thick strong scab to protect your skin while the skin grows back. Once I've cleaned it up we'll see if we need to put in some stitches. . . but you are very lucky to have such bright red beautiful blood." The boy looked at the nurse in amazement. His sobbing ceased, and he looked at his bloody arm and back at the nurse without saying a word. The nurse swiftly proceeded to clean the wound, inviting the boy to notice how the blood was already turning a bit darker. "That's because it's already getting drier. . . isn't it wonderful that your body knows how to heal itself so quickly. . . what a good job."
Mia, a feisty 3-year-old newly diagnosed leukemia patient, was beginning to have a little more energy after 2 weeks in the hospital. Her energy channeled itself into screaming whenever medical staff approached her. Her treatment had been aggressive since her admission, and her fears were well-founded that something hurtful would happen. She had also been too sick to know that play and fun could be part of her hospital stay. It was decided that everyone involved with her treatment would become more playful with her to reduce her distrust and anger.
Surprise was used in a paradoxical way when she began screaming: "Please, Mia, can you scream louder. . . even louder!" (This was said in a kind pleading manner, and not in a teasing way, which would have upset her more). The child continued to scream, but there was a perceptual weakening of intensity.
"Why don't you give the biggest, loudest, best scream you can make. . . can you do that?" The child stopped screaming and seemed momentarily puzzled. "You are a pretty good screamer. Now that you are getting better and feeling stronger I was wondering if you might also like to hear stories. I've got a story here about Grandma Tiddley who is a very brave lady, as brave as you are. And 1 would like you to hear what things she did that made her brave. . . " Puzzled and maybe a little confused, Mia gave her attention for a short while and thereby began to move to alternative means of coping. She listened to the story, which was quickly personalized and adapted to fit her own situation in order to become a metaphor for courage.
BEHAVIORAL STRATEGY: DISTRACTION
Four-year-old Carrie was brought into the emergency department with a fractured femur and was immediately given an analgesic. Her anxiety, however, remained high. It was suggested to the orthopedic surgeon that setting her fracture in her current state would be difficult and that engaging the child in a pop-up book would distract and refocus her attention. She would also have an opportunity to demonstrate some of her newly learned skills and feel a little less helpless and more competent. Carrie was shown a pop-up counting book26 and was asked: "Do you know how to count?" She said "Yes." "How many fish are there here?" After she pulled the tab, five fish jumped out from the HIy pads- Carrie counted hesitantly and got it right. "Good work!" After a few minutes of establishing that she was a "great counter," she was told, "While the doctor puts the bandage on your leg so that your leg can heal properly, your job is to show your nurse how well you can count all these turtles, butterflies, and fish. She'll be amazed that a 4 year old can count so well, and by the time you get to the end of the counting book, your leg will feel better in the cast, and you won't be so bothered by your leg."
Reading the book absorbed Carrie's attention during the uncomfortable process of setting her leg and helped to relieve her anxiety. It also provided an opportunity for hypnotic suggestions to set a timelimit on the experience of discomfort and to provide pain relief: "By the time you get to the end of the counting book, your leg will feel better in the cast." Her recognition of various animals and insects became an opportunity for encouragement. Instead of feeling overwhelmed by the experience, Carrie came out from the treatment room feeling proud of herself.
Toddlers are the most difficult group to manage. Their verbal skills are limited, and they know how to go limp and wriggle out of one's grasp. Consequently, this age group is most frequently restrained, and many toddlers become highly sensitized to the doctor's office or treatment room. Here is an example of helpful strategies in dealing with a preverbal toddler.
Curious 14-month'old Daniel put his right hand into a 350° oven, sustaining second and third degree bums that required daily a dressing change. Fearing that he wouldn't hold still, his parents decided to set up a fixed routine and to use simple words so that he would learn the procedure and minimize his distress over time.
Preparation included laying out the equipment and dressing before the child was brought into the treatment room. Daniel was then placed securely in his mother's lap. He immediately started wriggling and whimpering. She cuddled him and talked soothingly to him while his dressing was quickly removed and his hand held firmly in a bath for 2 minutes. He initially tried pulling his hand out, at which point his mother began to pat his leg with his other hand and to sing a familiar nursery rhyme (providing a kinesthetic and auditory distraction). After the 2-minute soak, the toddler's hand was removed, dried with gauze, and quickly dressed with ointment and multiple layers of gauze bandage.
By the third day, the parents reported a significant reduction in their toddlers resistance and distress. By the tenth day, Daniel calmly sat in his mother's lap watching the procedure in a curiously detached fashion, which suggested a degree of dissociation from his hand.
The familiarity and regularity of his dressing changes enabled this little boy to leam what to expect and to know how long it would last. Positioning the toddler on the parent's lap and having increased parental involvement in the dressing changes was vital in this instance.
Case 1 : Imaginative Involvement for a Toddler
A squirming 2-and-a-half year old with possible otitis media was told by his playful pediatrician: "Hold very very still so that I can take a close look and find the bunny rabbit that jumped into your ear. . . That's great! Oh! I can see him, he's jumping over the fence. Hold still! Oh! He's gone across to the other ear. . . Quickly, let me look in the other ear. That's it! Ah, I've found him. . . Do you know what he's doing? He's wiggling his nose at me!" The pediatrician rattled this off as he deftly completed the examination. The child sat wide-eyed and strikingly still for the minute that was needed.
The example above is one of many "home-grown" imaginai or biobehavioral techniques that seasoned practitioners have creatively developed to deal with active or anxious young children. These practitioners have commented that having something fun to do with the child often takes the monotony out of these routine procedures. Like children, adults are capable of doing more than one thing at a time.
Case 2: Imaginative Involvement for a Preschooler
Four-year-old Sarah was hospitalized for severe eczema and was not tolerating the applications of dermatological creams over her body. Hospital staff reported that she was kicking, crying, and actively resisting attempts to negotiate anything. In discussion with her about her difficulties she said that creams hurt and stung her skin, and she did not want them. She was then simply asked: "Would you like your skin to feel comfortable and nice?" "Yes," she answered hesitantly. "How about if you were to use your imagination to help your skin feel better?" She seemed attentive, so an imaginative involvement was immediately suggested. "Look at this magic cloud that's here next to your bed. Could I scoop a little up and pack it very gently on your leg?" The "cloud" was scooped up and "packed" just above the child's dry red skin, without touching her skin. "This cloud is a magic cloud and it'll make your skin feel cool, soft, and so good. Can you feel it starting to be better?" The child sat still, watching.
While this active packing procedure was repeated until the imaginary cloud covered her legs, the following was said: "The really good thing about this cloud is that we must put enough of it on your skin so that you won't be bothered by the creams. The cloud does a very good job of protecting your skin so that it feels safe. So you must tell me where you need it." The child then pointed to her elbows, and the packing ritual continued while she, with a little more confidence, indicated her torso, back, and hands. Sarah was then asked how her skin felt, and she said "Good."
"Now that your skin feels safe and good you won't be bothered while the cream goes on. But I want you to blow like this to help the cloud stay on your skin while the cream is gently put on " Sarah's breathing out, ideal for the control of anxiety, was paced slowly, while the cream was applied. Suggestions for comfort and relief ("Your skin is feeling safer and more comfortable with the cloud to protect it") were repeated throughout the procedure. Sarah's blowing out was intense and regular. She seemed intrigued by the process and did not resist the cream application.
The hospital staff used this imaginative involvement technique with continued success throughout Sarah's 5-day hospital stay.
Case 3: Favorite Story
Rachael, an intelligent introverted 5 year old with rheumatoid arthritis, came to the clinic for reevaluation. The team felt that since her medication was not keeping her pain-free, she would benefit from using pain management techniques. Rachael loved books and stories. Using her absorption in a favorite story seemed a natural choice as a means of teaching her to dissociate from her pain and diminish its perception. Her favorite story was Peter Part.
She was invited to make herself comfortable in the chair and asked if she would be interested in learning a fun way of helping her joints to feel better by using her imagination. She nodded her head. A tape recorder was started so that she could take her story home with her and use it whenever she needed to feel more comfortable. She was asked to take a big breath and "... as you blow it out I'm going to tell you a wonderful story that will make you feel so good - it's the story of Peter Pan. Did you know that Peter Pan lost his shadow? He said the dog had stolen it so he came to ask this smart, brave girl named Wendy to help him. He knew she could do lots of things like sew shadows back on, if he wanted it back on again. So, he invited Wendy to come flying with him.
'Fly!' said Wendy, 1I don't know how to fly!' 'It's easy,' said Peter Pan, 'all you have to do is try.' Wendy discovered to her own amazement that all she needed to do was to take a big breath and slowly breath out all the air in her lungs and she became lighter. It was amazing, and she could really fly. The further and further she flew up, the lighter and nicer her body felt. It was as if she was leaving all the heaviness and worries behind her on the ground. You could also join them, Rachael. That would be fun. Would you like to? You'll be amazed to see how cool and comfortable your joints will feel as you drift up easily and gracefully into the sky. . . ."
Rachael had not moved since the story began. She new smiled and said "Yes." For the following 5 minutes, the story of Peter Pan became a tale of how to separate from pain - like a shadow - and fly up where the sun is bright and gives energy. Rachel's familiar story, therefore, became a vehicle for reducing the pain in her joints. By using her good imaginai skills, she experienced a pleasant alternative experience, and she was given the tape of her story to use regularly at home when her joints bothered her. Follow-up, at her request, has consisted of making further tapes, and her parents report that her moodiness and pain complaints are now quite infrequent.
We've come a long way in our management of young children from the days of physically restraining them in order to complete a procedure - or telling them that it's acceptable to cry during pain or discomfort while providing nothing else to shift that expectation or experience. Now an invitation to "blow away your scary feelings" opens the possibility that scary feelings can go away. Similarly, telling an absorbing story captures preschoolers' imaginations, enabling them to cope a little better. The strategies consist of different styles of communicating with children to maximize their comfort and coping skills, altering their current experience into something more positive and manageable.8,10 This in turn empowers young children, indicating that they can control themselves during taxing situations and can alter their perceptions of pain and distress.
Medical intervention with the preschooler is an opportunity for the clinician to be inventive, spontaneous, and playful. Apart from the interpersonal skills of the clinician, the success of these strategies during medical interventions depends on good team work, having the medical equipment prepared, and having a definite plan before the interventions begin. This allows the team's attention to focus on the child and what needs to be accomplished. This child-centered focus increases the likelihood of a successful outcome.
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Helpful Strategies for Young Children