J.H.K.C. Psych. (1993) 3, 9-18

SPECIAL TOPIC: CHILD & ADOLESCENT PSYCHIATRY

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INTRODUCTION

The importance of the family as a formative influence on a child's personality growth needs no arguing. Particularly in early childhood, it is the matrix within which the child develops, the area where his strongest emotional ties are formed and the background against which his intense per­ sonal life is enacted. From the moment a child is born, the family governs the early experience that permeates the course of physical and mental development.

Small children, particularly in infancy, need adequate maternal care to avoid the risk of serious maldevelopment of intellect and personality. Maternal care does not neces­ sarily imply the biological parent. More favourable de­ velopments may come from the exclusive maternal care of the infant ('monomotic') in comparison with care shared with extended family or friends ('polymotic').

Mother is normally the source of stimulation to verbal behaviour, play, and the like. She provides for the nutri­ tional, material and security needs of her child (Hill, 1976). The normal growth of children is dependent on the mother's full-time occupation in the role of child-rearing (Baers, 1954). To the extent that such needs can be pro­ vided by other agencies, the impact of separation is dimi­ nished.

EFFECTS OF ACUTE ILLNESS

Any acute illness, with its physical discomfort and emo­ tional stresses, can be quite upsetting to the child and his parents. Even the small child is so organised psychobiologi­ cally that pain or the threat of pain, the loss of a bodily part or the threat of bodily mutilation, an particularly the awareness of the possibility of impending death precipitate a series of defensive reactions initiated by the arousal of anxiety. An impairment of physical strength or a loss of physical control or of the autonomy of behaviour may also result in damage to the child's self-image and self-esteem and thus may lead to feelings of loss of identity and con­ tinuity. While a small child's sense of security may be undermined by some loss of confidence in the omniscience and omnipotence of his parents, a sudden feeling of be­ coming different from his peers may stimulate increased anxiety in the older child.

This anxiety may be complicated by other unpleasant feelings, such as feelings of guilt and anger from the assumption that painful medical or surgical procedures are hostile attacks or that the illness is punishment for past mis­ behaviour. Illness also draws attention to the parts of the body affected, thus making bodily sensations loom up in the child's mind, increasing his sensitivity to bodily sensa­ tions, altering, perhaps, his body and self-image, evoking repressed infantile experiences and fantasies, and suggest­ ing the patterns for the later utilisation of illness for secon­ dary gains.

It is now known that when ill, children may show their anxiety in different ways. Infants and small children usually give vent to their feelings by crying and sometimes by vigorously resisting all medical procedures. Some children regress in their behaviour, becoming overly pliant, apathe­ tic, or withdrawn. Loss of hope may result in loss of in­ terest in the environment, increased self-preoccupation, and sometimes in either depression or a flight into fantan­ sy. The child may defend himself from the intolerableness of acute anxiety by denying his illness. Such children are apt to be uncooperative.

In particular, the diagnosis of a life threatening disease has major psychological, social and economical impacts on the child and family. To the latter, such a diagnosis will in­ troduce feelings of insecurity and the realisation of their mortality. Their expectation of a normal life pattern changes suddenly to one of possible or imminent death of the child. Their realisation of loss of control over their des­ tines and of mortality become the paramount emotions. These feelings can, however, be alleviated by proper pre­ paration for the diagnosis and repeated explanations during the course of the illness.

More often than not, many adjustments must be made by both parents and children following the diagnosis of a child's chronic and possibly fatal illness. After all, a number of factors interact with the course of the illness to deter­ mine the psychological outcome in each individual case and, according to Rutter (1983), such adverse factors are multiplicative rather than additive.

EFFECTS OF ACUTE ILLNESS

Epidemiological studies estimate that prevalence of chro­ nic illness or disability ranges between 5-40% of all chil­ dren, while more serious problems range between 6-10%. For example, Pless and Douglas (1971) have estimated that approximately 111 in 1,000 children below the age of 15 years are undergoing treatment for a wide variety of dis­ eases requiring long-term medical attention.

While children with physical disorders in general are at risk for having emotional or behavioural problems, several studies have reported that children with chronic illnesses in particular are more likely to show a behaviour problem or psychiatric disturbance than normal children. In both the National Survey of Child Health and Development (Pless & Douglas, 1971) and the Rochester survey (Pless & Rogh­ mann, 1971), a consistent although non-significant excess of difficulties in school among chronically sick compared with healthy children was reported. In the Isle of Wright survey (Rutter, Graham & Yule, 1970) it was shown that chronically ill children had a higher rate of specific reading retardation, and a greater frequency of psychiatric disturb­ ance compared with normal children. Further, both the Rochester and National surveys indicated that children with more permanent, and those with more severe, conditions had a higher incidence of maladjustment. Parental reports of such risks were consistent in studies done in the United Kingdom and United States (although somehow teachers' ratings were different, with American teachers reporting more healthy children exhibiting behavioural problems than the ill-children). This has important implications be­ cause the numbers of children suffering from long-term chronic illnesses are increasing and likely to continue to do so. Improvements in medical care have led to survival of children with gross and severe malformations, and the ex­ tension of life for children suffering from diseases that were previously fatal (e.g. leukaemia or spina bifida).

REACTIVE PSYCHOLOG ICAL PROCESSES TO ILLNESS

The presence of an illness may precipitate some or all of these processes in the affected child or adolescent:

1. Psychological conflicts: With the onset of a chronic disorder, old conflicts are re-awakened and may inter­ fere with present conflicts. Thus regression, neurosis and personality problems emerge; these are especially prominent in the
2. Changes in body-image: e. one's mental image or cognitive representation of his/her own body. In a study of children drawing human-figures, children with congenital heart disease were more likely to include a heart in the picture, and those who had chest surgery were more likely to draw rib-bones (Auer et al, 1971).
3. Changes in self-concept: e. one's sense of self ver­ sus non-self (while self-esteem is the positive or nega­ tive value assigned to this self-concept). As discussed above, Wright's (1960) social-psychological theory had been prominent in this field. She further suggested that adjustment to a disability required two changes:
   1. acceptance of the disability and thus expecting others to accept too and
   2. reorganisation of values with emphasis on positive personality values and accomplishments rather than on the physical (health, appearance and competence)
4. Identification and modelling: Psychodynamically, the ill child often goes through an 'identification with the aggressor' by playing 'doctor games' and thus enabling him/her to master anxiety and anger during painful procedures. On the other hand, the child will imitate the parents only selectively (and th us not their inability to prevent pain).
5. Defence and coping mechanisms: Useful coping techniques enhance adjustment to an illness. Among these include defence mechanisms in response to a se­ vere physical disorder, especially isolation and Denial can be very usef ul, thereby allowing the patient to overlook some serious prognosis, at least for a while.

SEPARATION FROM PARENTS

In some circumstances, separation itself can be a disturb­ ing influence. After studying the effects of prolonged separation from parents of 2- and 3-year-olds, Bowlby (1952) proposed three stages in a child's reaction to separation: protest, despair, and detachment. During the first period of protest the child openly displays anger, upset, prolonged crying and demands for mother's return and this would last for up to several days. During the second period of despair, although this open protest gradu­ ally subsides he/she would still seem preoccupied with ex­ pectations of mother's return. The final period of detach­ ment would set in if separation still persists, and the effects on personality development are thought to be more patho­ logical, with the child showing indifference to the mother even if she returns now, say after several days to several weeks. The reactions include hostility in play sessions and after returning home, and decreased activity in their play (as compared with controls).

On one hand, it is recognised that children show most distress at an age just after they are beginning to show attachment to their parents. Separation is probably stressful then just because it is interrupting an important bond at a time when children have difficulty maintaining a rela­ tionship through an absence. On the other hand, it has been contended that the basic variable is not just separa­ tion as such, but rather a disturbance in the mother-infant interaction. Separation from parents and home environ­ ment is the major stress. Other factors tend to amplify this separation anxiety or aggravate the condition. First, infants' distress is a function of the characteristics of both the pre­ separation and the contemporaneous mother-infant rela­ tionship. Second, changes in the mother-infant interaction following reunion largely depend on the mother. Third, in­ fants who have been temporarily removed from their usual living group show less distress on their return than do in­ fants who have remained "at home" but whose mothers have been removed for a period. As a general rule, the rupture of a significant affectional bond or the failure to establish any affective bond can have far-reaching effects upon the individual. There may be a critical period be­ tween the ages of six months and three years in which the failure to form affectional bonds will scar that individual in later life. Because of its long-term consequences a child should be separated from his parents only in exceptional circumstances. However, when separation is not associated with any disturbance in this interaction, then ill-effects are minimal. In contrast, when separation is associated with a disturbed relationship, ill-effects are maximal. In fact, re­ search does show that prolonged separation of a child from his mother (or mother substitute) during the first five years of his life stands foremost among the causes of delinquent character development and persistent misbehaviour.

EFFECTS ON THE CHILD

It is a commonplace phenomenon in a modern society that many children and young adolescents are hospitalised for brief or extended periods because the severity of their illness makes it difficult for community agencies or the chil­ dren's parents to contain them at home. However, hospita­ lisation may produce reactive psychological disturbance of significant magnitude in certain children. As a whole, where children are admitted for much longer periods of time or under emergency conditions and suffering from serious and disabling symptoms, psychological reactions are likely to be much more severe (Hollenbeck et al, 1980; Cataldo, Jacobs & Rogers, 1982).

An important reason is of course maternal deprivation, especially in infants under the age of one or two years. While this reaction may be seen to be in considerable part related to separation from his parents who are his source of emotional satisfaction and security, it is also due to removal from an environment to which he has learned to adjust, as well as a response to the unfamiliar environment in which the child finds himself (with the inevitable inadequate sup­ port from parents, spatial and psychological isolation, unfa­ miliar routines, physical restraint, schedules and proce­ dures, enforced dependency, shame, embarassment, fear, misunderstanding and ignorance, although poor care and perhaps unpleasant experiences at a time when he is already feeling miserable and frightened should also play an important role (Rutter, 1981). It is therefore not surpris­ ing that hospitalisation tends to increase the child's anxiety already present in the face of the illness. None the less, when a mother is not the only source of affectional needs, the presence of siblings will modify the impact of separa­ tion upon a child.

In this context, regression is an almost universal phe­ nomenon among hospitalised children. In its milder form, regression may be reflected in clinging, crying, whimpering, and thumbsucking or more seriously in refusal to eat and the assumption of the foetal position or, in some cases, ex­ cessive motor activity. By putting children in a passive position, the hospital may indeed infantilise them. In a sense, the hospital may be said to take possession of the child's body: according to Anna Freud (1972), it separates the child from the rightful owner of his body at the very moment when this body is threatened by dangers from in­ side as well as from the environment. There may be other evidence of overdependence such as demands for atten­ tion, and sleeplessness may be a problem. Mood changes can have important effects on patients' progress: poor mood often signals longer illness.

Shame is a common reaction, especially among adoles­ cents. It is particularly likely in children who have struggled to master a given developmental task and are suddenly forced to relinguish that mastery. The loss of the ability to perform functions that may have only recently been ac­ quired can lead to feelings of immaturity and consequent shame. Also, children often experience specific fears - of bodily mutilation that will change body image, of helpless­ ness, of loss of control, of pain, and of death.

In the hospital active free play for children physically able to be up and about is rarely provided. As school age children usually drain off a great deal of aggressive energy through movement and activity, it is quite common for chil­ dren whose activity is restricted to become angry, boisterous, incooperative, restless, and verbally aggresive or sar­ castic. Restriction of movement does in fact increase chil­ dren's tensions resulting from hospitalisation and impairs their sense of physical mastery, essential to a sense of com­ petence in the hospital. When the period of restriction is over, such children are often hyper-active for several days or weeks thereafter.

Although invasive procedures can be kept to a minimum, it should be understood that even seemingly in­ nocuous procedures such as collecting urine by a mine bag might involve confrontation between the child and the staff. Several investigators have noted that children report injec­ tions and venepunctures as the most fear-provoking events occurring in the hospital (Eland & Anderson, 1977; Poster, 1983).

CHILD'S VIEW

In this regard, it is clearly valuable for the children's doc­ tors to consider the 'psychodynamic' meaning of hospita­ lisation to the child since this would have an important role in his/her adjustment. The followings are what a child dur­ ing hospitalisation may perceive.

Abandonment: Separation can be so significant be­ cause the child believes that he/she is actually being abandoned and will not have reunion with the parents.
Punishment: Children may see hospitalisation as punishment for past misdeeds (Vernon et al, 1965), and each procedure may also be seen as deliberate acts to give pain.
Fear of castration: This is probably more important for children being hospitalised for surgery.
Fear of death: Older children knows the difference between death and separation and yet may misinter­ pret hospitalisation as a death process and thus am­ plify the threatening experiences.

SHORT-TERM EFFECTS

There is consensus in the literature that at least some of the effects of hospitalisation are damaging to children, lead­ ing to both short-term and long-term problems. Even in early studies it could be demonstrated that up to 90% of child surgery patients may have experienced moderate to severe behaviour problems after hospitalisation (Prugh, Staub, Sands, Kirschbaum & Lenihan, 1953). It was noted that children under four years of age are more prone to psychological trauma after hospitalisation for surgery (Deutsch, 1942), say for tonsillectomy. Rutter (1983) notes that children between the ages of 6 months and 4 years are more vulnerbale to stress from the separation inherent in hospitalisation, partly because at this age relationships are especially difficult to maintain over time in the absence of regular contact with the attachment figure.

Reissland (1983) interviewed a group of 58 children 4 to 13 years old for tonsillectomy or adenoidectomy. The younger children in the group seemed to understand going into the hospital mostly in terms of their family rela- tionships. They indicated that they would have to depend on their parents to help them cope with their fear and pain. The older children in contrast could generally come up with strategies of their own for dealing with their experi­ ences. Indeed, research strongly supports the younger chil­ dren's view that they need their parents to help them cope with hospitalisation (Routh, 1988). In a study of hospital­ ised children aged under 16 years, when parents were asked to report the kids' behavioural problems in the week immediately following hospital discharge after an average stay of 8.8 days, problems related to separation anxiety were especially notable in the age group of older infants and preschoolers (say half to four years of age). In contrast, in another study of children having been admitted for less than 48 hours, hospitalisation was found to have no effect for two weeks after discharge. The classic study of Prugh et al (1953) further confirmed that psychological preparation for medical procedures (along with liberal parental parti­ cipation) significantly lowered these reactions, especially for kids over four years of age.

Therefore, it follows that normally maternal deprivation arises only if an infant is kept in a hospital for many weeks or months without receiving adequate substitute mothering. It can result when an infant (especially under one year old) remains in an emotionally sterile hospital setting for a num­ ber of weeks, during which time it is rarely picked up, cud­ dled or otherwise nurtured and pleasurably stimulated by anybody. It can also arise if a child under the age of two or even three years is kept in a hospital for a number of months without receiving consistent "mothering" from pa­ rents or parent substitutes. These deprivations of mothering care can produce profound and long-lasting disturbances in a child's total development. Among other repercussions, such children may develop major defects in conscience formation, intellectual abilities, and their capacity to relate to other people, as well as chronic depression and failure to thrive.

LONG-TERM EFFECTS

Studies about long-term effects yielded less consistent re­ sults. Some of the best studies were done in the United Kingdom. The first one was based on admissions before major child-centred changes in hospital routine were made, that is, between 1946-1951. In this about 1,000 children with at least one admission before age 6 were studied. Short-terms effects were inferred from mothers' reports, and long-term effects on teachers' reports at ages 13 and 15. The second one, in contrast, comprised 451 children with admissions after child-centred changes were adopted in the 1950's. perhaps the most damning evidence con­ cerning the negative effects of hospitalisation was offered by Douglas (1975), who reported on the long-term follow­ up of more than 1,000 children born in 1946 and admitted to the hospital before age 5. By careful comparison with similar control children who had not experienced child­ hood hospitalisation, he concluded that, in adolescence, multiple problems were observed that were related to early hospital admissions. These problems included reading dif­ ficulties, problematic behaviour outside of class, delinquen­ cy, and an unstable job history. Likewise, Shepherd, Oppenheim & Mitchell (1971) found that the rate of de­ viance among children who have been separated for at least one month was about twice what it was in other youngsters.

All in all, these studies suggested that a single admission spanning less than a week is not, but multiple admissions are, significantly associated with subsequent long-term be­ haviour problems. Studies that have more recently ex­ plored psychologically unprepared children's reactions to hospitalisation continue to report a variety of behaviour disorders due to hospitalisation (Wanschura & Loschenk­ ohl. 1979).

PARENTAL REACTION

It can never be overstated that parents' fears about the hospitalisation of a child are usually quite realistic and to a certain extent also reflect the severity of the child's illness. When apprised of a diagnosis and the need for hospitalisa­ tion, the family typically goes through four phases:

1. Shock or disbelief: The family questions the doctor and may seek a second opinion.
2. Anger: Parents direct their anger either at themselv(::s - in which case it is mixed with guilt - or at the doc­ tors. This anger can delay appropriate treatment.
3. Depression and sadness: Here the family begins to stay with their sadness concerning the illness of the child and mourns the loss of the idealised
4. Adaptation and adjustment: Parents come to view the child and the illness realistically, thereby attemp­ ting to alter the family milieu to deal with it.

In some cases of current or recent trauma, the first three phases, with their varying emotions, may occur all at once. Oftentimes, the parental (usually maternal) anxiety is com­ municated to children by non-verbal and verbal channels, leading to anxiety and nervousness in them, which is likely to make them more distressed and less cooperative during their stay in hospital (Pitts & Phillips, 1991).

Initially at least, parents of a hospitalised child often adopts a defensive behaviour of overprotection. The over­ protective parent, however, does not distinguish between what the child can and cannot do but treats the child as if he or she were totally incapacitated. Such disregard for the child's abilities and areas of competence sooner or later endangers the child's self-esteem.

Since parents often find relief in being able to do some­ thing concrete, they can be very helpful by participating in ward care, especially in feeding and playing with their chil­ dren and settling them for the night. However, parents sometimes become so overinvolved in "doing" for their child that they are unable to give one another the comfort and support both need in a time of stress.

When the family is viewed as a system, the psychic equilibrium of the family can be said to be disturbed by the child's illness, and the sick child then becomes the focus of this disequilibrium. Although family members offer compas­ sion, protection, and help, some of this solicitude repre­ sents an overcompensation for anger and resentment. This is especially likely in cases of chronic illness, when the ill child may at some stage assume the permanent centre of the disequilibrium.

According to Prugh et al (1953), of the several variables that determine the nature and degree of trauma suffered as a result of the hospitalisation experience, the most impor­ tant seems to be the quality of the child's relationship with his or her parents. This relationship is the principal determi­ nant of the capacity of the child's ego to integrate conflict­ ing forces from within and without.

FACTORS AFFECTING THE OUTCOME

1. Parental emotional problems: It has been shown that the depressed parent may be unable to provide consistent caretaking for a child. Other emotional problems would similarly absorb parent's energy
2. Parental coping ability: A parent who can cope well is more likely to have an ill child who copes well.
3. Parental marital satisfaction: When relationship problems drain parents' energies, they are more dif­ficult to cope with the child's illness and thus all family members are more susceptible to adjustment prob­lems.
4. Past personality and temperamental traits: Some personality traits would hinder adjustment to an illness, such as chronic anxiety and fear, shyness and with­ drawal, rebelliousness, dependence and immaturity. Alternatively some temperamental traits may help adjustment. Thus children of low activity level may not be bothered by hospital-imposed restrictions; children who are persistent by nature are better equipped to overcome frustrations after developing a handicap.
5. Illness type and severity: Neurological, and espe­ cially sensory (hearing), illnesses put the child at more risk of maladjustment than other disorders. However, maladjustments are related more to milder than more severe
6. Peers: A chronic illness may severely restrict a child's peer relations, and thus hinder attainment of social skills and self-esteem.
7. Education: No doubt it is in the interest of the sick child to receive his well-deserved share of education for all the hospitalisation. However, most hospitals lack educational facilities to engage children in continued learning, in classroom where possible or at the bed­ side. In this respect the quality of schooling, and when necessary special educational programmes for the handicapped, are also relevant.

CHINESE CHILDREN IN HONG KONG

While literature on the subject abounds in the Western world, no report nor review of such kind is available from the Chinese community. it is therefore deemed worthwhile to summarise the anecdotal evidence gathered in the Hong Kong setting. On the whole Chinese families traditionally ernhasise the need of obedience by the young children. Unlike the West, children are discouraged from being too explorative about the environment, mainly for the sake of protecting them from unnecessary exposure to undue harm. Thus it is expected that children, especially the pre­ schoolers, would be made feel more attached and depen­ dent on the mother than Western children. Separation anxiety would therefore be more prominent.

However, surprisingly enough, in many instances separa­ tion anxiety is seen to be more pronounced on the part of parents than the children. The average Chinese parents seem to be unable to leave the sick children behind in the hospital without feeling guilty for not doing something more in the care of them and helping to speed the recov­ ery from the illness. Hence, the common observation by many children's doctors in Hong Kong is that the parents will try to admit as far as possible their sick children into a private hospital and be willing to pay at a premium simply for the opportunity to stay by the children for most of the hours in the hospital. It is also regularly observed that the emotions and behaviours of the parents are very readily shaped by the recovery process of the children's illness. For this or other reason, they will often make request for potent medications which can bring about immediate and more obvious symptomatic relief, without the usual consid­ eration for the natural history of the illness. Occasionally the event of hospitalisaing the child will precipitate the marital discord of the parents, whereby they blame each other for the cause of their child's illness.

As regards the children's reactions to hospitalisation, they are often polarised. Thus in the vulnerable group of chil­ dren between the ages of six months and four years, one relatively large group would adjust rapidly to the hGspital environment. This group of children usually come from households with many adult family members, and their previous daily care is often shared amongst both parents, grandparents, uncles pnd aunts and even, not infrequently in Hong Kong, the Fiiipino maids. These children, used to 'multiple-mothering', would then be easily soothed by a nurse offering him/her a cookie.

The other pole of reaction pattern is illustrated in a second group who, before hospitalisation, are solely cared for by one of the grandparents, usually the paternal or maternal grandmother; their biological parents are in this case usually 'weekend parents', taking them home on Sa­ turday nights only. These children, upon hospitalisation, would instantly become the focus in the ward because of their loud and incessant crying. Frequently, these children exhibit regressive tendency in their behaviour and become rather dependent in their needs. Even if rooming-in by the grandmother is allowed, they would still effortfully indicate their apprehension at the approach of any stranger, espe­ cially those in uniform. They appear to be ready to upset anything within their reach, and nothing seems able to calm them down except after moderate doses of hypnotics have been prescribed by the children's doctor. This cycle would repeat itself the next morning when the hypnotic effects wear off, while the same picture would often persist for the following half to one week or till their discharge from hospital. In such cases it is often found that the grand­ mother is in fact overprotective, and also she is not confi­ dent in setting limits for the child's behaviour, possibly as a way of avoiding conflict with the parents themsleves. Effects of this nature are usually more accentuated in cases of chronic illnesses.

It looks as if a good analogy to the hospitalisation of chil­ dren is the first few days of admission into the nursery or the play-group where, on one hand, the toddlers find themselve in a totally strange environment, and, on the other hand, they are expected to conform with certain new rules laid down by some unfamiliar persons, yet their pa­ rents can be at a distance, if not far away, from them. The latter are not forthcoming nor close at hand when they feel threatened and are upset by the new order of the environ­ ment.

DISCUSSION

Hospitalisation can be a terrifying experience for a child. Frequently, the younger the child, the less able he or she is to take in what is happening and the more frightened he or she may soon become. Taking this statement further, it is fair to say as a matter of generality that the younger the child and the longer the hospitalisation - the more the child is deprived of its emotional supports, that is the pa­ rents - the more the child is likely to be harmed. Children are more susceptible than adults because they typically have a limited grasp of the phenomenon of illness and its causes, and they are usually not provided with enlightening information (DiMatteo, 1991). At the very least, children and parents could be given better preparation before elec­ tive (non-emergency) hospitalisation. They are rarely talked to clearly and simply before, during or after hospitalisation. Often they do not understand the need to be hospitalised or what procedures will be carried out. In this respect, the hospital should have programmes to provide parents and children with adequate information and preparation for what will be experienced. They should become child-, in­ stead of adult-, centred.

In addition, it is incumbent upon the children's doctor to explain to the child, couched in language that a child can understand and in terms suitable to his age and intelli­ gence, the illness and the treatment, as bedside discussions by staff do not always take into account the child's limited understanding or his tendency to become seriously upset by what he hears. The name of the disease may be used.

Labelling the disease processes should reassure the patient that the doctor knows what is wrong with him and so can do something about it.

On the other hand, the parents should also explain the disease and its treatment to the child. If they are not able to cope with the stress of this, the children' doctor should talk directly to the child in their presence. In either case, the medical team should then begin communicating with the child about the disease and its treatment. Often this is best done by repeating the parents' explanation and using a light-hearted approach and question-and-answer format. The interview with the child should be relaxed, not som­ bre. Early discussions should be kept short, the medical team being sensitive to the child's wish to be alone to think about what he/she has been told.

It has been shown that children are more ready to comp­ ly with treatment regimens when given a chance to partici­ pate in their own care and to have a say in the matter. Also, children do best when they are given the opportunity to verbalise their feelings and to exert some control over what is happening to them (Koocher, 1985).

At the same time, the family's needs for the future can be met only if there is honesty in communicating about the diagnosis, prognosis and treatment of the illness. It is expe­ dient to reassure them that the disease is not the fault of the parents and that other members of the family are not at high risk of contracting it. During the interview, the chil­ dren's doctor should not appear to be distant and unfeel­ ing: he should allow himself to show controlled and digni­ fied emotion, in order to establish non-verbal contact and emotional links with the family which will be necessary in the later phases of the illness. While honesty is essential, discussion of and emphasis on technical points of diagnos­ tic and therapeutic approaches would merely bewilder the family.

RECOMMENDATIONS

Many hospitals in the past did not consider the develop­ mental needs of children in planning for inpatient care. Most hospitals in practice treat children from infancy on as if they were little adults. Therefore, the need for infants and children to be nurtured and sustained by their families dur­ ing hospitalisation has been for a long time rarely recog­ nised or understood as a critical aspect of care, and even more rarely implemented, although it is becoming obvious that children in hospital can be particularly susceptible to adverse environmental influences which can affect their emotional well-being and their recovery (Rainbird, 1991). Hospital administrators should have more insight in these matters when re-organising the structure and personnel for the children's wards, such as the use of play therapy.

Separation is often enforced on the ward, where it may not be possible for every parent, who wishes to do so, to stay overnight near his/her child. The problem is most acute when parents need to sleep next to their child on a multi-bed ward. Rarely are there "rooming-in" units or "liv­ ing-in" facilities for parents with hospitalised children of ages from six months to six years, the developmentally most vulnerable period. The child then would not have to be deprived of family support and care. Older children should be given the opportunity to reduce their separation and loneliness with peer contact.

While formerly the parents are not asked to help and support their children during this difficult period away from home and family in a strange and threatening environment, a gradual involvement of parents in day-to-day care has occurred in parallel with the gradual abandonment of visit­ ing restrictions. There has also been a growing acknow­ ledgement that there are positive benefits such as contribut­ ing to earlier discharge. Involving the parents also fulfils a basic need of the parents themselves and contributes to the well-being of the family unit in hospital (Rainbird, 1991).

Although hospitals exist primarily to treat diseases, the care of children should not be limited to the treatment of their illness. While treatment may at times require pro­ longed immobilisation, total care demands an active social and educational programme to help a child counter bore­ dom, depression and school failure.

It sometimes happens that children are admitted for observation, laboratory investigations, or minor treatments merely out of custom or for the convenience of the doctor or the parents. In deciding whether or not to admit a child, the children's doctors ought to consider and weigh the re­ spective risks and benefits. The benefits are often obvious: close monitoring of the child's progress, rapid availability of test results, and easier modification of the treatment plan. Nevertheless, the risks, such as the physical risks of nosocomial infection, are usually less apparent. The nega­ tive effects on the child as psychological risks are, unfortu­ nately, given very low priority, if not in the oblivion altogether. It is interesting to note that hospital treatment may offer a sense of security that some doctors need more than others (Steinhauer & Rae-Grant, 1983).

It is proposed that if hospitalisation cannot be post­ poned, young children who are highly dependent on their mothers should be treated at home or admitted with their mother, if long-term negative reactions to hospitalisation are to be avoided (Douglas, 1975).

At any rate, doctors caring for children should take second thoughts each time they intend to admit a child for non-urgent procedures or treatment. It pays dividends to realise that hospital staff can inadvertently contribute to a disturbing emotional atmosphere in the hospital. Admis­ sions may ultimately prove to be mandatory, but considera­ tion on preparing the child and the family could make a significant difference. Ideally good ambulatory care could to a great extent eliminate the need for hospital care in the majority of children's illnesses.

REFERENCES

Auer, E.T., Senturia, A.G., Shopper, M., et al (1.971): Congenital heart disease and childhood adjustment. Int. J. Psychiatry Med, 2: 23.

Baers, M. (1954) Women workers ·and house responsibilities. InterLabour Rev, 69: 338-54.

Bowlby, J. (1952). Maternal Care and Mental Health. Geneva: World Health Organization.

Cataldo, M.F., Jacobs, H.E. & Rogers, M.C. (1982) Behavioral/en­ vironmental consideration in pediatric inpatient care, in D.C. Russo & J.W. Varni (Eds.): Behavioural paediatrics Research and practice. New York, Penguin.

Deutsch, H. (1942): Some psychoanalytic observation in surgery. Psychosom Med, 4: 105.

DiMatteo, M.R. (1991) The psychology of health, illness, and medical care. Pacific Grove, Brooks/Cole.

Douglas, J. (1975): Early hospital admissions and later disturb­ ances of behaviour and learning. Dev Med Child Neural, 17: 456.

Eland, J.M. & Anderson, J.E. (1977) The experience of pain in children. In A. Jacox (Ed.): Pain: A source book for nurses and other health professionals. Boston, Little, Brown.

Freud, A. (1972) The role of bodily illness in the mental life of children, in S. Harrison & J.F. McDermott (Eds): Childhood Psychopathology. New York, International Universities Press, p. 572.

Hill, O.W. (1976) Deprivation of parental care, in J. Krause (ed.): Encyclopaedic handbook of medical psychology. London, Routledge.

Hollenbeck, A.R., Susman, E.J., Nannis, E.D., Strope, B.E., Hersh, S.P., Levine, A.S. & Pizzo, P.A. (1980) Children with serious ill­ ness: Behavioural correlation of separation and isloation. Child Psychiatry and Human development, 11: 3-11.

Koocher, G.P. (1985) Promoting coping with illness in childhood, in J.C. Rosen & L.J. Solomon (Eds): Prevention in health psychology. Hanover, University Press of New England.

Pitts, M. & Phillips, K. (1991) The psychology of health. London, Routledge.

Pless, J.B. & Douglas, J.W.B. (1971) Chronic illness in childhood. Pediatrics, 47: 405.

Pless, L B. & Roghmann, K.J. (1971): Chronic illness and its con­ sequences: Observations based on three epidemiological sur­ veys. J Pediatr, 79: 351.

Poster, E.C. (1983) Stress immunization: Techniques to help chil­ dren cope with hositalisation. Maternal-child Nursing Journal, 12: 119-34.

Prugh, D.G., Staub, E.M., Sands, H.H., Kitschbawm, R.M. & Leni­ han, F.A. (1953): A study of the emotional reactions of children and families to hospitalization and illness. Am J Orthopsychiat­ ry, 23: 70.

Rainbird, J. (1991) A quality checklist for children's facilities. Health Services Management, 87 (5): 219-22.

Reissland, N. (1983) Cognitive maturity and the experience of fear and pain in hospital. Soc Sci Med, 17: 1389-95.

Routh, D.K. (1988) Handbook of pediatric psychology. New York, Plenum.

Rutter, M. (1981) Maternal deprivation reassesed. London, Pen­ guin.

Rutter, M. (1983) Helping troubled children. London, Tavistock.

Rutter, M., Graham, P.J. & Yule, W. (1970) A neuropsychiatric study in childhood. London, Heineman Medical Books.

Shepherd, M., Oppenheim, AN. & Mitchell, s. (1966) Child be­ haviour disorders and the child guidance clinic. J Child Psycho[ Psychiat, 7: 39-52.

Steinhauer, P.D. & Rae-Grant, Q. (1983) Psychological problems of the child in the family. New York, Basic Books.

Vernon, D.T.A., Foley, J., Sipowicz, R.R., et al (1965) The psychological responses of children to hospitalization and ill­ ness. Springfield, Charles C Thomas.

Wanschura, T. & Loschenkohl, E. (1979) The child in the hospital. Praxis der Kinderpsychologie und Kinderpsychiatrie, 28: 51-5. Wilkinson, S.R. (1988) The child's world of illness. Cambridge, Cambridge University Press

Wright, B. (1960) Physical disability: A psychosocial approach. New York, Harper and Row.

*Bernard W.K. Lau MBBS, MRCPsych,DPM Psychiatrist in private practice.

Wilson W.C. Tse MBBS, MRCP,DCH Paediatrican in private practice.

*Correspondence: Room 703, Capitol Centre, 5-19 Jardine's Bazaar, Causeway Bay, Hong Kong.