Which stressors are common in hospitalized toddlers?

Being sick and hospitalized is not an easy or a regular occurrence, and may even be terrifying, traumatic, to the child and/or her parents. This article explores this experience from the child’s point of view, in an attempt to highlight -for the medical community and the child’s caregivers - what the child needs while in the hospital.

Key words

 children, sick children, illness, hospitalization, medical staff, caregivers

The modern hospital environment is geared towards providing a safe and healing environment for those afflicted with a variety of illnesses. In the health care system, patients receive the most contemporary care available. They benefit from modern technology in the hands of professional and dedicated doctors and staff with the most updated understanding of the human body and various treatments available [1]. The experience of illness and hospitalisation nonetheless exerts a great deal of psychological distress, one of the most distressful events people might actually experience in their life time [2]. Being admitted to the hospital, there is a serious disruption in one’s life, in her routines, and they must now start to perceive the hospital as their home for as long as they remain there as patients. Additionally, the patients, as well as those individuals who are usually responsible for the health of the patient, often live in a state of constant worry about the patient’s condition, and are forced to instill their complete faith in the medical professionals at the hospital to provide them with appropriate care that will hopefully lead to their healing [3,4]. From the outset, we know that illness is a major stressor in one’s life [5]. Various symptoms of the illness put the body into a state of continuous stress, which may include fatigue, immobility and even loss of bodily functions and control [6]. Being hospitalised, individuals may experience a wide range of short-term as well as long term consequences [7]. It is not only the physical suffering and distress that exerts stress on the body, but also factors that negatively affect the patient’s psychological state [8].

Experience of children in hospitals

As discussed, the experience of being hospitalised is usually an anxiety-provoking and even traumatic experience, especially for children. Children are particularly prone to the adverse effects of being ill, and their hospitalisation is a stressful event with potential untoward consequences for children and their families [9]. In a sense, for children ‘the hospital is like a foreign country to whose customs, language and schedules they must learn to adapt’ [10]. Due to cognitive and emotional limitations and dependence on others, they are particularly vulnerable to stresses involved in adapting to their condition of illness and hospitalisation [11].

Consequently, eliciting hospitalised children’s view and documenting their experiences appears to be an essential task. A considerable body of research on the effects of paediatric hospitalisation has been conducted since the 1950s, and remains a vital area of inquiry to this date [4,12,13]. All those concerned with the welfare of children aim to minimise the social and emotional consequences of childhood hospitalisation [14]. When children are scared, tired or in pain, they are particularly dependent on the safe and stable environment of their home and on the support and love of their family members in order to be able to cope and feel strength and capable [15]. For children, this is not only a subjective need, but also a vital necessity. While growing up, children are greatly dependent on their parents for everyday functioning and well-being, but especially when they become ill, they need their families’ support more than ever, since their limited coping skills and emotional resources are not ‘designed’ to handle the tremendous amount of physical and emotional stress on them during hospitalization [16]. When children’s illness is serious enough to warrant their confinement to hospital, they often report feeling lonely and scared, as they are taken away from the safe and empathetic environment of their home and instead are forced to reside in an unfamiliar, intimidating and uncomfortable environment.

For this reason, the process of treatment and hospitalisation may produce a tremendous amount of stress in addition to that which is precipitated by the illness itself. Young children are particularly affected and are more likely to associate their experienced discomfort of illness and hospitalisation to understandable notions such as being away from home, and being separated from parents [17].

Recent empirical data highlights that adverse effects of hospitalisation on children, have been found to be stronger when parents are not present, or when parents are highly anxious and were not able to calmly respond to them [18]. Illness and hospitalisation are traumatic, anxiety provoking and can lead to transient or long-term behavioural and psychological difficulties in children [19]. Estimates of the incidence of emotional problems resulting from hospital experience have been reported to vary from 10% to 30% for severe psychological distress to as much as 90% for slight emotional upset in hospitalised children [20].

Research indicates that the implications of hospitalization are often present quite strongly immediately after the hospitalisation discharge, which generally subdues soon afterwards [21]. Children, due to their limited maturity and life experience, cannot adequately infer the true causes of their hospitalisation, and might instead interpret their hospitalisation as a punishment for something they have done wrong. It has been argued that hospitalisation can be a life crisis for children, which might further highlight and aggravate their experience of fear, loneliness and frustration. Arguably for some children, this is a crisis that if not mastered properly may result in blocks or distortion in their process of development, and might be exceedingly damaging to their sense of identity and self-esteem [22,23].

While most of us do not enjoy getting injections, research on paediatric hospitalisation has shown that procedures involving needles and injection, or blood tests and transfusions often evoke a very distressing and fearful reaction in young children [16,24,25]. Also, it is often very difficult for children to feel confident and reassured that the treatment they receive is actually for the purpose of helping them and making them feel better in the long run. This fear might then lead to uncooperativeness with medical procedures [19]. One of the most distressing event for children is undergoing a surgical procedure, which they often perceive as assaultive and mutilative, even if it is but a minor and routine procedure [19,26]. Research has shown that for children and adolescent patients, heightened levels of preoperative anxiety increase the possibility of negative psychological consequences throughout their recovery, such as continuing anxiety, separation anxiety, problems with sleep, nightmares, irritability and aggressiveness [8].

The most difficult period of hospitalisation may be near the beginning of the experience, when children, often unexpectedly and unwillingly, have to encounter these fearful and painful procedures and treatments for the first time. It has been observed that hospitalised children are often in a state of waiting and increased vigilance which results in dragging of time [27]. Being confined to bed or being socially restricted can seem like an unending state of imprisonment to children, regardless of the length of stay.

Chronically ill children often suffer from additional anxiety and long-term adjustment problems, as they often fall behind of their normal routines and activities which help them in developing behavioural and emotional competencies further in life. For example, they often express sadness and anxiety over missing out on school, and having limited chance of socialising with their friends and peers, or being involved in their family life and interactions with their parents and siblings [15].

The hospitalised children’s level of physical activities is inherently limited, and thus their means for making sense of the world around them are threatened [28]. As can be seen in any paediatric hospital, hospitalised children tend to engage in less play activity, and when they do engage, their play is characterised by repetitive, solitary themes. This is unfortunate and even damaging since an important coping mechanism for children with a stressful environment such as the hospital is play, which helps in alleviating their anxiety and increasing their adjustment [29]. Worry about the loss of bodily functions and fear of disfigurement are particularly prevalent for children. The experience of feeling different and the anticipation of a distorted body image [in case of having gone through a serious and disfiguring surgery], may further aggregate the anxiety of hospitalised youth while recovering in the hospital, and can even pose a threat to their identity formation and sense of self [19].

To conclude, hospitalized children are commonly confused, frightened, and in need of support, reassurance, explanation of what they will be exposed to [in a manner that fits their level of maturity], and mostly, they need to be recognized as ‘little people’ who are yearning to be treated not just as ‘bodies’ but as humans with emotions, pain, illness, and concerns.

It is suggested that health care professionals, such as physicians, nurses, psychologists and social workers who are affiliated with hospitals must be aware of the psychological and emotional needs of their clients, particularly those of children. In particular, paediatric hospitals must go beyond a narrow focus of the medical aspect of treating children’s illnesses, and improve the implications of the hospitalisation’s distress on children by providing age-appropriate communication, support and empathy of the medical and psychological staff, and devise means of interventions for those children who display marked signs of distress. For instance, the Sick Kids Hospital, in Toronto Canada, created a theatre for hospitalized children, where their fears, and in case of physical effects of the illness or surgery, their concerns of being different  are addressed, and children are taught that different is not a weakness or a negative label, but is an individual difference to be respected [4]. Additionally, children’s hospitals have introduced programs of acquainting the children with the hospitals, its routines, anticipated surgery that the children may need to undergo, and involving their parents in the process [30,31].

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