This document discusses stress and reactions related to developmental stages and play activities for hospitalized children. It begins by defining stress, stressors, and illness. It then discusses the stressors of hospitalization and how a child's reaction depends on their developmental level. Specific stressors include separation from parents, loss of control, and physical harm. The document outlines expected behaviors for infants, toddlers, preschoolers, school-aged children, adolescents, and parents based on their developmental needs. These include crying, temper tantrums, withdrawal, and dependence. The role of nurses is to help children and families cope with stress through minimizing separation, preparation, explanations, and play. Suggested play activities are diversional activities, toys

1. STRESS & REACTIONS RELATED
TO DEVELOPMENTAL STAGES
&
PLAY ACTIVITIES FOR
ILL HOSPITAIZED CHILD
Presented by
Miss K Gnana Jyothi
MSc (N)

2. MEANING OF STRESS
The word stress is derived from the latin word
“stringi” which means, “to be drawn tight”.
Stress is described as a physiological or
psychological stimulus that can produce
mental tension or physiological reactions that
may lead
to illness”.

3. DEFINITION
STRESS :
A non-specific response to stressors or demands
made on the body.
- Selye
Stress is a feeling experienced when a person
thinks that “the demands exceed the
personal and social resources the
individual is able to mobilize”
-Richard.S.Lazarus

4. STRESSOR :
A stressor is any event or stimulus that causes an
individual to experience stress.
-Barbara Kozier
ILLNESS:
Illness is a highly personal state in which the
person’s physical, emotional,intellectual,
social, developmental or spiritual
functioning is thought to be diminished.
-Barbara Kozier

5. STRESSORS OF
HOSPITALIZATION AND CHILD’S
REACTION
Child’s response depends on :
• Developmental level and coping mechanism
• Parent- child relationships
• Cultural and religious influences
• Previous experience with hospitalization

6. STRESSORS OF
HOSPITALIZATION
Physical harm or bodily
injury
Loss of control
Separation
anxiety

8. • Separation anxiety is defined as
child’s apprehension associated
with separation from a parent or
caregiver.
• It is also called as “anaclitic
depression”

9. General manifestations of separation
anxiety in young children
Phase of
protest
Phase of
despair
Phase of
detachment

10. INFANTS
• At 0-5 months of age infant has not attached
much to the care giver
• Stress due to change in the enviroment or
change in the care giver can be detected
through
Altered sleeping
Altered feeding
Altered elimination pattern

11. • STRANGER ANXIETY : 5-7 months
shows displeasure at the approach
of unfamiliar people
Expected behavior
Cries when approached by nursing staff
• SEPARATION ANXIETY :7-9 months
Is upset when separated from parents
Expected behavior
Cries when parents leave, may
reject attempts to comfort.

12. TODDLER {1-3 YEARS}
Demonstrates more goal – oriented behavior
Expected behavior
• Plead with parents
• Tries to keep the parent with
them
• Try to find parents who have left
• Displeasure on parents return or
departure by having temper
tantrums
• Refusing to comply with the usual
routines of meal time, bed time, toileting

13. PRE SCHOOLER {3-6 YEARS}
Normal growth & development
• Can tolerate brief periods of separation
• Develops substitute trust in other significant
adults
Hospitalization
• Less able to cope with separation
• Develops separation anxiety
• Protest behaviors are subtle & passive

14. EXPECTED BEHAVIOR
• Refusing to eat

15. • Experiencing
difficulty in sleeping

16. • Crying quietly for
their parents

17. • Withdrawing from
others

18. • Expresses anger
indirectly by
breaking toys

19. • Hitting other
children

20. • Refusing to co-operate
during self-care
activities

21. SCHOOL CHILDREN{6-12 YEARS}
NORMAL GROWTH & DEVELOPMENT
Is able to cope up with separation
ON HOSPITALIZATION
• They miss the school routine and worry that they will
not be able to compete or “fit – in” with their class-
mates when they return.

22. • Feelings of
Loneliness
isolation
boredom
depression

23. • Reluctant to seek help , directly fearing that they will
appear weak, childish or dependent.
• Cultural expectations “to act like a man” or “to be
brave” weigh heavily on these children, especially
boys who tend to react to stress with stoicism,
withdrawal or passive acceptance.

24. EXPECTED BEHAVIOR
• Irritability

25. • Aggression towards
parents

26. • Withdrawal from
hospital personnel

27. • Inability to relate to
peers

28. • Rejection of siblings

29. • Subsequent
behavioral problems
at school

30. ADOLESCENTS{>12 YEARS}
• Separation from home and parents may produce
varied emotions.
• Loss of peer group contact may pose a severe
emotional threat because of
-loss of group status
- inability to exert group control or
leadership
- loss of group acceptance

31. • On hospitalization temporary separation from
the group may benefit from group associations
with other hospitalized children.

32. EXPECTED BEHAVIOR
• Like to be separated
from parents for
sometime but
prolonged separation
may produce stress.

34. • One of the factors influencing the amount of
stress imposed by hospitalization is the
amount of control that persons perceive
themselves as having.
• Lack of control increases the perception of
threat & can affect children’s coping skills.
• Many hospital situations decrease the amount
of control the child feel.
• Sight, sound, smell of the hospital may
overwhelm the child.

35. • Without insight------type of environment
hospital
Slows development restricts

36. INFANTS
• Develops trust consistent & loving
care by nurturing person
• In hospital settings, cues may be missed or
misinterpreted and routines may be
established to meet the hospital staff’s needs
instead of the infants need.
• Inconsistent care and deviations from the
infant’s daily routine may lead to mistrust.

37. EXPECTED BEHAVIOR
• Crying or smiling

38. TODDLERS
• Strive for autonomy and this can be evident in
through their behaviors such as :
motor skills
play
inter-personal relationships
activities of daily living
communication

39. • when their egocentric pleasures meet with
obstacles, toddlers react with negativism.
• E.g.,. any restriction or limitation of
movement such as simple act of making
toddlers lie down, can cause forceful
resistance and non-compilance.
ALTERED ROUTINES AND RITUALS
Enforced dependency is the chief characteristic of the
sick role and accounts for numerous instances of
toddler negativism.

40. For example :
Rigid schedules
Different clothes
Altered care giving activities
Unfamiliar surroundings
Separation from parents medical procedures

41. • Most toddlers react negatively & aggressively
to such dependency, prolonged loss of
autonomy may result in :
 passive withdrawal from interpersonal
relationships and ;
 regression in all areas of development
EXPECTED BEHAVIOUR
Temper tantrums

42. PRESCHOOLERS
• Suffer from loss of control caused by :
 physical restriction
 altered routines
 enforced dependency
• Their specific cognitive ability make them feel
all powerful and also make them feel out of
control.

43. • Their egocentric and magical thinking limits
their ability to understand events because
they view all experiences from their own self-
referenced perspective.

44. • Without adequate preparation for unfamiliar
settings or experiences, preschooler’s fantasy
explanations for such events are usually more
exaggerated, bizarre and frightening than the
facts.

45. • One typical fantasy to explain the illness or
hospitalization is that it represents
punishment for real or imagined deeds.
• In response such thinking, the child feels
• shame, guilt and fear.

46. Verbal instructions are inadequate
because
unable to abstract & synthesize beyond
what their senses tell them

47. • Transductive reasoning implies that pre-
schoolers deduct from the particular to
particular rather than specific to specific.
• E.g.,. Preschoolers concept of nurse is that
they inflict pain & will think that every nurse
or every one wearing similar uniform also
• does the same.

48. EXPECTED BEHAVIOUR
• Protests attempts to perform the procedure

49. SCHOOL AGE CHILDREN
• They strive for independence and productivity
vulnerable to events
lessen their feelings of control and power

50. Factors that result in loss of control includes :
altered family roles
physical disability
fears of death, abandonment or
permanent injury
loss of peer acceptance
lack of productivity
inability to cope with stress

51. • Dependent activities of school age children in
hospital are :
enforced bed rest
use of bed pan
inability to choose a menu
lack of privacy
help with a bed bath
transport by wheel chair or
stretcher

52. • All procedures seem routine and inconsistent
but give no freedom to children who want to
act “grown up”.
• May help in making their beds, choose their
schedule of activities and assist in their own
care.
• Boredom is one of the most significant
problem seen in school children.
• Physical limitations---depression,
frustration.

53. EXPECTED BEHAVIOR
-Depression - Frustration
-hostility

54. ADOLESCENT
• Adolescents search for :
independence
self- assertion
liberation

55. • Anything that interfers with this poses a great
threat to their sense of identity and results in
loss of control.
• Illness forms the major situational crisis.
• The parents role fosters
Dependency & depersonalization
Hence respond to depersonalization with self-
assertion, anger, frustration.

56. • Peers may visit but they may not be able to
offer the kind of support and guidance
needed.
• Sick adolescents often voluntarily isolate
themselves from age-mates until they feel
they can compete on an equal basis and meet
group expectations.

57. EXPECTED BEHAVIOUR
• Dependency with rejection
• Uncooperativeness
• withdrawal

58. PHYSICAL HARM OR BODILY
INJURY

59. STRESSORS & REACTIONS OF
THE FAMILY OF THE
HOSPITALIZED CHILD
• It includes :
Parental reactions
Sibling reactions
Altered family roles

60. PARENTAL REACTIONS
• Crisis of childhood illness and hospitalization
affects every member of the family.

61. SPECIFIC CAUSES OF PARENTALANXIETY
• Strange environment in the hospital
• Separation from the child
• Unknown events & outcome
• Suffering of the child
• Spread of infections of other members of the
family
• Unbearable financial obligations
• Society will look upon illness as something
wrong

62. SIBLING REACTIONS
Siblings experience
• Loneliness
• Fear
• Worry
• Resentment
• Jealousy
• Guilt

63. • Craft (1993 ) reported that the
following factors regarding siblings are
related specifically to the hospital
experience and increase the effects on
the siblings.
Being younger and experiencing many
changes
Being cared for outside the home by
care providers who are not relatives.

64.  receiving little information about their
ill brother or sister
Perceiving that their parents treat them
differently compared with before their
sibling’s hospitalization.

65. • The siblings of a chronically ill child may
feel sorrow when told of the diagnosis
but they quickly become involved in
their own activities of childhood.
• A number of factors increase the risk of
negative effects for siblings of ill
children, they include:
---------responsibility for care giving
---------differential treatment by parents
---------limitation in family resources &
recreational time

66. REACTIONS OF SIBLINGS INCLUDE
• Physical symptoms
to those of ill child

67. • Changes in
academic attendance

68. • Changes in patterns
of socialization

69. • Regression

70. • Attention seeking or anti-social behavior

71. • Habits related to increased level of anxiety
• Eg.,nail biting

72. Altered family roles
• One of the most common reactions of parents
is specialized and intensified attention toward
the sick child
• Other siblings may regard this as unfair and
interpret the parents attitude
toward them as rejection

73. • Rivalry between tends to be greatest for the
sibling who is nearest in age to the ill child.
• Without an understanding of the inter-
personal dynamics between siblings, parents
are to blame the well children for anti-social
behaviour.

74. ROLE OF A NURSE
AIMS :
-To help cope with stress of
illness
& hospitalization of children.
- To provide family – centered
care.

75. In neonates
• Provide continual contact between baby and
parents with the active involvement by
rooming-in and sensory-motor stimulation as
appropriate

76. In infants
• Minimize separation
• Basic needs of the infant should be fulfilled
• Mother can be allowed during the procedure
• Tension and loneliness can be relieved by toys.

77. In toddlers
• Provide rooming-in and un-limited visiting hours to
express child’s feeling
• No punishment to the child
• Home routine can be continued
• Familiar toys and articles can reinforce the
the child’s sense of security.
• Should provide love and understanding

78. In pre-school children
• Minimize stress of separation by providing parental
presence and participation in care.
• Plan to shorten the hospital stay as possible.
• Help the child to accept the stressful situation with
love and concern
• Set limits to the child & provide opportunity to
verbalize feelings.

79. • Careful preparation for all the procedures by
privacy and explanation according to the level
of understanding.
• Encourage the child to participate in self-care
and hygiene as appropriate
• Discourage parents from reinforcing negative
feeling’s to the child.
eg. “if you are not listening to me, I
shall leave you here”.

80. In school children
• Help the parent to prepare the child for elective
hospitalization.
• Respect the child’s need for privacy and modesty
during examination
• Thorough nursing history need to be obtained to plan
the care

81. • Help the child to identify problems and to ask
questions.
• Use treatment room whenever possible to perform the
procedure.
• Explain the procedure and its purpose with
reassurance
• Encourage the child in self-care, play, school work.
• Encourage parental participation in child care.

82. In adolescents
• Help parents to prepare adolescents for planned
admission.
• Assess the impact of illness and hospitalization and
presence of misconceptions
• Obtain thorough history, habits, recreation, personal
preferences on self care and food habit

83. • Hospital staff, hospital routines and facilities
available should be explained soon after admission.
• Involve the adult patients in planning of care.
• Explain all procedures
• Provide opportunities for recreation, peer-
relationships, and interaction with other adolescent
patients and expression of feelings.

84. PLAY ACTIVITIES
FOR ILL
HOSPITALIZED
CHILD

85. DEFINITION OF
PLAY
“Play is pleasurable and enjoyable
aspect of child’s life & essential to
promote growth & development”
-Parul dutta

86. PLAY THERAPY
“Play therapy is based upon the fact that play is
the child’s natural medium of self-expression.
It is an opportunity which is given to the child
to “play-out” his feelings and problems just as
in certain types of adult therapy, an individual
talks out his difficulties.”

87. PLAY ACTIVITIES OF
HOSPITALIZED CHILD
• It includes
- diversional activities
-toys
- expressive activities
- creative expression
- dramatic play

88. 1.DIVERSIONALACTIVITIES

90. 2.TOYS

91. 3.EXPRESSIVE ACTIVITIES

92. 4.CREATIVE EXPRESSION

93. 5. DRAMATIC PLAY

94. THERAPEUTIC PLAY

95. • It is the central mechanism in which children
cope, communicate, learn, and master a
traumatic experience such as hospitalization.
• It is guided by health team members
• It can be provided to the convalescent and
immobilized bed-ridden children when they
passed over acute illness at hospital or at
home.
•

96. • Play in hospital setting can occur only when
children are less threatened.
• When no play is permitted it indicates
psychological abuse.

97. IMPORTANCE OF PLAY FOR
HOSPITALIZED CHILDREN
• It helps the child
To enhance coping abilities in hospital environment
To understand and comprehend the hospital
procedures
To express fear, anxiety, tension, anger and fantasies
To communicate with others and to reduce
emotional trauma due to hospital experiences

98. to continue growth and development in
physical, psychological, social, moral and
educational aspects
To get rid of boredom due to prolong illness
and to release hostile feelings

99. • It helps the health team members:
To gain co-operation and trusting relationship
of the hospitalized children and their family
members.
To diagnose the child’s feeling and behaviour
and plan for psychological approach during
care.
To find out and correct the misconceptions
and beliefs regarding hospitalized care.

100. To reassure the anxious parent & to promote
their participation in child care during illness
and wellness

101. TYPES OF PLAY FOR HOSPITALIZED
CHILDREN
• It is of three types Emotional outlet
or dramatic play
Instructional play
Physiological
enhancing play

102. 1.EMOTIONAL OUTLET OR DRAMATIC PLAY
• It is used to express the child’s anxiety to solve
conflict and as a diagnostic tool to identify
child’s concern about the illness and
hospitalization.
• Eg.,playing with doll being a nurse and caring
sick doll with expression of own feeling, story
telling,.etc.

103. 2.INSTRUCTIONAL PLAY
• Instruction is given for therapeutic play to
children-according to their past experiences,
coping abilities and physiological status.
• Eg,. –use of colour in drawing
- drawing in blank paper
-learning the instructions on health habit

104. 3.PHYSIOLOGICAL ENHANCING PLAY
• It is used to maintain and improve physical
health and body functions
• It can be selected to treat pathological
conditions
• Eg,. breathing exercises to treat respiratory
problems by blowing bubbles , squeezing the
bath sponge or ball to improve neurological
functions.

105. FILIAL THERAPY
• It was developed by Bernard and Louise
guerney
• It enhances parent –child relationship by
empowering the parent with new and
innovative ways to interact with their child

106. • It provides an environment where the child
receives concentrated attention from the
parent, thus lessening the anxiety of the child
and allowing them to unlearn behavior
patterns that lead to miscommunication.

107. • Parents are given the skills necessary to
practice efffective listening and respond to
child’s emotion as well as tools to enhance
child’s self-esteem.

108. FILIAL GROUP THERAPY
• Parents can express their emotions, fears and
concerns relating to their parent –child
relationship
• Group sessions continue upto 18 months
• After necessary training parents may conduct
play sessions at home.

109. OBJECTIVES AND OUTCOMES OF FILIAL
THERAPY
 Parents learn to set specific limits and engage
the child in consistent and dedicated sessions
involving play
The result is that the child begins to feel
accepted and learns to express themselves in a
socially adaptable and acceptable manner.

110. PLAY THEARPY
• It is of two types
Non-directive play
Directive play

111. 1.NON-DIRECTIVE PLAY
• Transitional sand play therapy
• Family therapy
• Play therapy with the use of toys

112. 2.DIRECTIVE PLAY THERAPY
• Directed sand tray therapy
• Cognitive behavioral play therapy

113. NURSES RESPONSIBILITY IN
PLAY
• Ensure proper selection of toys
• Supervision during play
• Maintenance of play articles
• Minimize stressors
• Minimizing the fear of bodily injury &
pain
• Participation in play