A PLAY
PROGRAM
AND
ITS FUNCTION
IN A
PEDIATRIC
HOSPITAL
By Veronica B. Tisza, M.D., and Kristine Angoff
Boston Floating Hospital and Departments of Pediatrics and Psychiatry, School of Medicine, Tufts University
ADDRESS: (V.B.T.) 20 Ash Street, Boston 11, Massachusetts.
293
A
FEW years ago the Boston Floating Hospital, a general pediatric hospital, became engaged in a mental health project motivated by the concern for “the total care of the child.” The over-all development of this comprehensive medical approach and its integration into the life of the hospital was described in a recent article.1 The present paper is devoted to a detaileddis-cussion of the Play Program which is an important aspect of the entire project. We
shall describe the organization and
func-tioning of the play activities and record
some general observations concerning its
effect on the children and their parents. The proper operation of the Play Program depends essentially on the co-operation of the various groups in the hospital.
There-fore, we shall include in the discussion the
play group’s relationships and methods of communication with the other members of the “mental health team”-the nurses, doctors, volunteers and the Child Psychiatry Unit.
The Play Program is concerned with every child in the hospital and its activity extends to every inpatient. The play group responsible for the operation of the
pro-gram consists of the teacher-in-charge and her 2 assistants who are all nursery school teachers by training. They are assisted by 1 or 2 part-time student teachers and also
by a student nurse assigned to this duty as part of her training in pediatric nursing.
There are always at beast 2 adults super-vising the playroom activity and there are often 4 or 5 participating.
The headquarters of this group’s activity
is in the playroom, located on the top floor of the hospital building and removed from
the wards. This selection of site, dictated
by
extraneous factors such as the avail-ability of space, makes the playroom re-markably free from the hospital atmosphere. The drawback of such a location is that the nurses on the ward may lose contact with their patients while they are there-a disadvantage which can be remedied effec-tively by good communication between the play group and the nursing staff.Physically the playroom is a many win-dowed room, well equipped with toys and games for all age groups. The room is large enough (44 feet by 16 feet) to permit the spontaneous formation of groups while ab-bowing room for individual activity, and it
is compact enough so that no child is lost from sight. At one end is a small observa-tion room with a one-way vision mirror,
used by doctors, nurses and visitors as well. The activity program of the playroom is similar to that of a nursery school. It is a nursery school in the sense of its offering a place for children to gather, to experiment, create and express themselves with ap-propriate space and play material; while their freedom is limited only by considera-tion of their own and other’s safety and physical handicaps. Beyond these similari-ties it also differs from the typical nursery school in several important aspects. All ages from 2 months to 18 years of age may be represented. The size of the group varies from day to day and from morning to after-noon. An occasional group may have 6 or
22 children, but the usual number would
be 12 to 16. The number of sessions any child may attend will vary within the ex-tremes of from one-half day to 90 or 100
days. The children come and go for
neces-sary medical examinations, laboratory
of any of the children may spend some time in the playroom. All kinds of physical dis-eases with their emotional impact on the child and on the parents may be repre-sented and the great majority of children function under the impact of varying de-grees of grief and anxiety over the separa-tion from the home and the parents.
The play service begins at 8:30 A.M.
every morning except Sundays and holidays, with the teachers and assistants dressed in bright smocks appearing on the wards with loaded toy carts. Their first visit is with the
head nurse of each ward for a brief con-ference. These conferences serve for the exchange of pertinent and necessary in-formation about every child who has re-ceived medical permission to go to the
play-room. The nurse and the teachers discuss all the special medical orders and also the ward and playroom behavior of some of the children who seem to have difficulties in accepting their illness and in adjusting to the hospitalization. These conferences, be-yond their very important informative value, result in a better understanding of the child and a better co-ordinated and more con-sistent handling of his problems. They also serve the very important function of pro-moting understanding and co-operation be-tween the nurses and the teachers.
While one of the teachers consults with the dietician concerning special diets, the others start their morning rounds with the children. They visit with every patient from about 2 months old and up, giving to
each suitable toys and games for the child’s
age, ability and physical limitations. The
children are encouraged to express their wishes, and attempts are made to fulfill specific requests.
Smallest infants are given bright red, lightweight, washable phone raffles. Cradle
gyms or cradle spins are hung on the cribs
of older babies. One-year-old infants are given bright color stacks, squeaky rubber animals, cube blocks or soft plastic nests of boxes. Older infants are given simple
trains, dolls and stuffed animals,
pound-a-ways, large beads, plastic cars, trucks and
planes, balls, etc. Preschool children get large crayons, paper, plastic horses, men and soldiers, books, dolls and dishes, large pegs and peg boards, building blocks, tele-phones, etc. Other children have their choice of trains and tracks that fit together, Tinker Toys, paints, crayons, books, puzzles, games, and Lincoln Logs. The teen-age children enjoy making belts, bracelets and banyards of plastic coated lacings, painting, working at difficult jigsaw puzzles, using the autoharp or phonograph, playing bingo or cards and reading comics and books.
The children handle the offering of toys according to their age, experience and
emo-tional state. It is usual for 1-year-old babies to appear apprehensive and suspici-ous at the teacher’s approach. They watch wide-eyed and often not until she retreats will they look at the toys left for them. Some of the children, belonging roughly to the 1% to 3%-year-old age group, may fear-fully withdraw to the corner of the crib at the teacher’s first appearance and seemingly ignore completely the most attractive toys.
The next day or after, the same child may
greet the teacher with angry looks or loud expressions of anger and revolt and throw the toys on the floor. By the third or fourth day of the hospitalization they usually be-come more accepting and display gradually increasing eagerness by reaching out for toys and even smiling at the teacher. Older children in general show joyful acceptance,
295
vidually to the playroom. They convey by the tone of their voice that this is an invita-tion, not an obligation. The majority of the children are happy to go; however, there are always those who declare that they will not go and this is a situation which has to be handled according to the under-standing of the child’s motivations. Some children need to be persuaded. They have to be reassured repeatedly that they are
really wanted by the teacher. Other
chil-dren, and this occurs again and again espe-cially with those 4 to 6 years old, remain firm in their refusal. The teacher under-stands that they have a need to assert them-selves successfully and accepts the tempo-rary refusal while expressing the hope that
they may change their minds later. It is our
experience that once the teacher’s tolerant attitude gives satisfaction to the child’s de-sire for autonomy the child will become a
willing participant in the play
group-sometimes not later than the afternoon of
the same day.
It has been noted that there are frequent refusals among the severely ill children
(
leukemia, etc.) who seem to seek theSe-curity and protection of the people in white. They prefer the peace of the ward which
is more acceptable to their mood than the
sharply contrasting “operation sunshine” of
the playroom. These children seem to sense their parents’ grief and anxiety in spite of the parents’ determined effort to conceal it, and they are frequently aggrieved and with-drawn beyond what could be explained by their physical condition. The play group and the nursing staff co-ordinates its efforts to reach out for the child until he is able to form relationships devoid of anxiety. Usually one of the teachers spends a regular daily period playing with the child on the ward, and 1 or 2 of the student nurses volunteer to promote a supporting friend-ship with the patient. These relationships form the bridge through which a child is enabled to accept and to enjoy normal childhood activities again.
A similar approach is used with the
oc-casional child who suffers from “invalidism”
SPECIAL ARTICLES
wants, the teachers get a feeling of the
child’s attitude, ability and interests. To the
child the teacher becomes someone who gives nice things and tries to satisfy
de-mands without asking anything in return; and when the times comes that he becomes
ambulatory, he will go with this familiar
person to the playroom.
Permission to go to the playroom is granted by the pediatrician and has to be written into the orderbook together with
the occasional restrictions and specifications
concerning the time spent and the activity allowed there. For example, a child re-covering from rheumatic fever may spend an hour in the playroom sitting in his wheelchair and playing quiet games with
one of the teachers while another child may engage in a full day of unrestricted
activity.
The use of play clothes-short-sleeved
T-shirts and denim overalls and blue
jeans-was quickly instituted in the beginning of
the program when it was found that loose, ill-fitting pajamas were a handicap to free motion and that generally a child felt more
his usual self if dressed in everyday cloth-ing. The play clothes, labeled with the
user’s name, are kept overnight in the
play-room and distributed in the morning to the
children. The majority of the children will
eagerly clamor for their play clothes, but there are always some refusals in accepting them. Children on their first day of hos-pitalization will often refuse play
clothes-they want their own clothes. Also frequent refusers are those children who have had surgery-maybe the loose fitting clothes con-ceal their sometimes bulky dressings better, and it is also more suitable for their less
strenuous moving around. Obese children are frequently embarrassed and anxious if their size is not available. Teen-age
girls often prefer their own frilly lounge
robes, whereas teen-age boys accept blue jeans cheerfully. Many times the patients confined to wheelchairs insist the most on play clothes which seem to make them feel
less different from the other children.
mdi-and who is hampered by this neurotic diffi-culty in dissociating himself from his sick part. These are passive children with deep
feelings of inadequacy who accept all medi-cal procedures without protest. However,
they react to removal from their hospital
bed with intense anxiety and overt re-sistance. Sickness and the confines of the bed seem to symbolize security and protec-tion for them which can be relinquished only when they obtain the support of sus-taming relationships. The pediatric house officer plays an important part in
mobiliz-ing these children through repeated
reas-surances, and by giving the protection of
his personal interest while encouraging and approving of the child’s first strivings for
activity. Doctor, nurse and teacher co-operate to transmit to the child the feeling that he does not have to be sick in order to be loved and accepted.
Age is also an important factor in the ac-ceptance of the play group situation. Many of the older children will be awkward and embarrassed when invited to the “play-room” and yet may often accept with relief and satisfaction the teacher’s request to assist with younger children. However, early adolescent girls, 12 to 14 years old, often prefer the student nurses’ com-pany, and they stay on the ward, watching
their idols, trying to help and declaring that one day they will become student nurses themselves.
Some younger preschool children want to cling to the bed where they were left by their parents. Occasionally, their fears-that if they leave this place their parents will not find them-find verbal expressions, but most of the time it is manifested only
by a refusal to budge. With time and
ex-perience they come to realize that mother can also find them in the playroom.
Patty, a 3-year-old girl, was admitted to the Boston Floating Hospital with a clinically mild nephrotic syndrome. Playroom privileges were
immediately granted and the morning following her admission, the teacher approached her with an invitation to go to the playroom.
First Day: This first morning Patty goes
obediently, clings to the teacher and cries for mother. She goes again in the afternoon, and when mother arrives, she clings to her until mother seeks the teacher’s help in parting.
Second Day: Patty goes to the playroom in th morning, spends the whole time in the same
teacher’s lap, occasionally crying out for mother. She refuses to leave her bed in the afternoon waiting for mother, and then she will not let mother bring her to the playroom.
Third Day: She goes to the playroom in the
morning, occasionally asks for mother, fre-quentby asks to sit in the teacher’s lap. In the afternoon she lets mother take her to the play-room, but at the time of parting, insists that mother take her back to her bed-refusing to return to the playroom after mother leaves.
During the next days, Patty became increas-ingly trusting and active, both in individual and in group play. She continued to join the
teach-ers in the morning and handled the
waiting-separation problems of the afternoon with
in-creasing adequacy.
Fourth Day: She waits for her mother in the
cubicle and mother has to return her to her bed when she is ready to leave, but almost im-mediately Patty comes back to the playroom with a nurse and plays contentedly.
Fifth Day: She comes to the playroom with mother, becomes very sober at parting there, but as soon as mother has left, returns to play.
For the rest of the hospitalization, Patty came to the playroom with the teacher in the afternoon, knew that mother would find her there, and was able to talk of mother’s coming and going without crying.
The fear that the parents will not find
SPECIAL ARTICLES 297
Bobby K., an 8-year-old boy, had many hos-pitalizations and repeated operations because
of congenital malformations of his urinary tract. Generally he was impatient to get to the play-room and was known as an anxious and hyper-active boy. When confined to bed with a high
temperature, he would state, “I don’t want to
get up today.” One morning though he had per-mission to go to the playroom, he preferred to
stay on the ward. He gave no explanation, but
by noontime his motivations were understood.
Another boy, close to Bobby’s age, was having
an operation that morning and Bobby was com-pelbed by his anxiety to wait for his return. When he was brought back from the operating room and Bobby reassured about his condition, his anxiety seemed to be relieved, and in the afternoon he was back in the playroom and his
usual self. Bobby, who had had so many opera-tions, identified himself with the boy who was
operated on that day.
When the group arrives at the playroom;
some children walking, some children in wheelchairs, and the babies carried in arms, there is usually a sudden outburst of ex-cited activity as they rush or clamor for the desired toys and equipment. It takes a little time until they work out the excite-ment accumulated during the long waiting
and preparatory period, and then the
play-room assumes its lively yet relaxed
atmos-phere.
The playroom teacher’s technique is non-directive. With the exception of specffic medical restrictions limitations are imposed
by
the teachers only for the protection andsafety of each child. In this permissive and
accepting atmosphere every child is pro-vided with the opportunity for legitimate play outlets and the patient is helped to maintain his identity as a child. The teach-ers act as mother-substitutes to many. They accept the expression of feelings, such as the fear of needles and procedures, the pain and revolt over the absence of parents, and the anger over the restrictions. They give support by their very presence and by their understanding of the nature and meaning of the child’s feelings.
To give a picture of the activity of the playroom, the following notes were made
on a randomly selected day between 10:00 and 10:10 A.M.
3-month-old colicky baby is held, cuddled and gently fondled by the student nurse who sometimes seems to be enjoying it as much as
the baby.
10-month-old Polly sits on a big playpen mat on floor, protected against falling backward by
a bolster of large stuffed teddy bears to the sides and back of her. She sits contentedly, oc-cupied with chewing a large heel of dark hard bread.
15-month-old Paul rapidly creeps across the
floor pulling himself to standing at the lower big toy drawer where he pulls out and tosses away at random one toy after another, after
first frequently putting the toys to his mouth to sample them.
18-month-old Dottie clutching her “doggie”
wanders about reaching toward the easel-takes out cup of paint and investigatingly turns it upside down, spilling red paint on the floor before the teacher can reach her. She books at the paint on her hand and says, “Fingers?” She
trots out the unguarded door with a backward glance and smile knowing that the teacher will come after her to pick her up.
2-year-old Susan breaks into an anxious cry for mother, but from the security of the teacher’s lap watches other children’s activities with spasmodic interest.
2-year-old Bobby before going to surgery, with a big fireman’s helmet on, vigorously rocks
on rocking horse, smiling at praise from teacher.
4-year-old Judy absorbedly dresses and
ar-ranges dolls, doll bed and carriage and neatly folds blankets, stacks clothes, etc., while 6-year-old Kathy excitedly seeks teacher’s help to pin her into cowgirl shirt.
6-year-old Raymond and 7-year-old Johnny
shoot realistic gun battles while dodging be-hind tables.
7-year-old Linda, newly arrived at the
hos-pital, sits at the table automatically putting pegs into the peg board while looking up now and again to watch the activities of the other chil-dren.
Three 8-year-olds, Steve, Danny and Jimmy, excitedly mess in finger-paints, smearing much paint over paper-then covering arms and hands.
10-year-old Jim builds a complicated block
which is the key foundation block to pull out
and knock it all down.
1 1-year-old Jane quietly stands behind the
painting easel producing colorful, careful bright pictures.
15-year-old Ralph sits weaving a gimp belt,
needing teacher’s help now and again to
un-tangle the strands.
The great majority of the children who come to the playroom have already spent a few days in the hospital. However, the children who are admitted for diagnostic
studies, elective operations, etc., will
proba-bly arrive there on the first day of hospi-talization. In spite of the support the teach-ers give them, most of these newcomers,
especially the younger ones, show many recognizable signs of anxiety and their
ac-tivity could hardly be called play at all. Some appear to be almost completely im-mobilized, remain silent or repetitiously ask the same questions; some break into violent reaction at being left and take out
their helpless revolt on the toys; some dash recklessly and aggressively from one toy and one activity to another. The teachers
give companionship and reassurance and
frequently the child finds relaxation by
sit-ting in a lap or, at least, by some bodily contact with a quietly supportive adult. The older children are better able to handle the
intensity of their feelings, although the signs of these same reactions are recognized
by
observant eyes.At 11 : 15 the toys are put away and the children sit around the higher and lower tables according to their choice. The teach-ers show picture-books and read stories to the younger group while the older ones either chat or look at books. This gives the children a chance to relax from the ex-citement of play; at 11 :30 the hot cart
arrives with dinner. The teachers serve the meal while an older child is given the re-sponsibility of helping. (The children vie for this opportunity.) Servings are mdi-vidual and small, with seconds and even thirds offered. Likes and dislikes are re-spected, and when the teacher feels that a child is struggling with food there comes
the reassurance that it is perfectly all right to leave it. Emphasis is placed in making the mealtime an enjoyable period and no one is scolded for “bad manners” and spills. Little ones who are awkward with the spoon are encouraged to help themselves with their fingers, and the enjoyment of this activity seems to increase their capricious convalescent appetites. Others, who are proud of their newly acquired ability of using utensils, receive help in filling a spoon or holding a cup when needed. Conversa-tion is stimulated and encouraged with the older children. Sitting around the table, watching the others eat seems to be an in-centive to better appetites. It is not rare for a child who has been described as a feeding problem, a finicky eater by the parents, to become a good eater in this atmosphere free from pressure and anxiety concerning food.
When dinner is over, the children return to the ward and change or are changed into their pajamas for naptime. Some return to the nurses happily, but to many of the smaller children the simultaneous separa-tion from the teacher and the return to their crib is a trying period. They cling to the teacher and they cry for their mothers as if reliving again the pain of separation.
Daily visiting hours are from 2:00 to 3:00 P.M., and when the teachers return to
the ward at 2:00 P.M., they invite the chil-dren and the parents as well to join them in the playroom. When some of the expected parents have not arrived as yet, only a few of their children will go to the playroom
trusting that the parents will find them there; but more numerous are the ones who prefer to wait for their visitors while keep-ing close to their cubicles or sitting hope-fully at the elevators. The invitation to the playroom is then extended to the late-comers by the head nurse on the floor. It is interesting to observe how the parent-child groups respond to the invitation. Some leave gladly for the playroom, others p0-litely refuse and seem to want an exclusive relationship with the parents but also would
like to share a new experience with them.
SPECIAL ARTICLES 299
-the child usually shows with pride the
treasures of the playroom; then they return
to the ward. Some parents seem uneasy in
exposing themselves or their child to teach-ers or to other parents while other parents
seize the opportunity to find a listening
ear into which they may pour out their
anxieties. Some parents seem to have a need
for the larger space of the playroom with
its diversions for both child and themselves. At this time the playroom is usually filled to capacity and overflowing with family
groups. Observations made at this time are often helpful in the complete picture of the
family relationships. Spontaneous social
groups often form between parents and
some friendships are established which fre-quently persist bong after discharge from the hospital-especially among families
whose children have similar diagnoses.
Although the end of the visiting hour is announced over the boudspeaking system,
the termination of the actual visit is a
flexi-ble procedure. Some of the parents leave
promptly, others stagger their leavetaking so that the teachers are able to give mdi-vidual help to each parting family unit. Some parents try to “disappear” until they learn that their child will trust them more
if they tell him “goodbye”; many need re-assurance that in spite of the initial tears
of separation, it is best for the child if they do visit every day.
At 4:00 P.M. the children are returned
to the ward and they have their supper served on the tables of each ward. This is a period of great activity. The activity of the playroom is carried over to the ward and is heightened by the increasing anxiety with which children react to the approach-ing evening, the increasing darkness, the coming bedtime in a strange bed and with-out mother to tuck them in. The anxiety becomes increasingly manifest after supper. Some children curl up in bed and turn toward the wall; others, sad and absent minded, manipulate some toys brought from home. Again others become over-active, tear around or fight for adult
com-panionship by tagging after the few nurses
or calling them all the time (at this time the
staff is reduced because of their own meal-time). Television offers some distraction but not enough and especially not for the
younger children. The recognition of the need the children have for supporting
adults, for substitute mother figures, bed to the establishment of the evening volunteer service. At present this group consists of
20 women of varying ages, all of whom
come regularly 1 evening a week (4 or 5 an evening) to visit on the wards from 6:00 to 8:00 P.M. or a little later.
These volunteers generally concentrate their visits with the children from the age of 2 and up, but also a few interested ones
have been given instruction in gown and
diapering technique and are assigned to holding a few upset infants. They attempt to interest the children in listening to stories or participating in quiet games; they join and supervise the groups around the
tele-vision set; they give sympathetic
compan-ionship to the grieving child and do not forget that the silently withdrawn child
may need a bedtime story more than
any-body else.
These volunteers receive their
instruc-tions from both the play group and the nursing staff. The teacher leaves with them
the names of the children who may require
special attention that night and the volun-teers report to the head nurse and check with her requests before beginning their activities on the floor.
Informal meetings occur weekly on vary-ing nights of the week between the volun-teers and the teacher to discuss the general approach to children and to talk about im-mediate problems. Several times a year, the whole volunteer group gets together for
discussions with the various members of
the psychiatric team, and these meetings beyond their educational value help the members of the group get acquainted with one another and to organize themselves to
best advantage.
The doctors of the Boston Floating
activity hastens the child’s convalescence and they use this facility as much as
possi-ble. The houseofficers enjoy dropping in to
play with the children or to watch them while exchanging observations and informa-tion with the play teachers. The medical
students follow the doctors’ bead and are
frequent visitors and participators in the
playroom. This gives them not only the opportunity to help take care of the patient while he is acutely ill but also to observe the same child in a more natural setting of action and play. This double exposure
helps in shaping their medical thinking and
in orienting it toward the care of the “whole child.” The teaching that the patient is not
an “illness,” but a “child with an illness” be-comes a living experience.
The services and responsibilities of the play teachers do overlap and at best
dove-tail with some of the responsibilities of the nursing staff. Absence of good
communica-tion may lead to difficulties and
misunder-standings for both. However, the im-portance of co-operation was recognized
early and through the years these 2 groups
worked out their procedures in the spirit of mutual respect and appreciation. No child
is taken from the ward without the consent
of the head nurse; the teachers observe the rules of gown technique and “special pre-cautions” wherever required; the children’s intake and output is carefully noted in the
playroom and handed over to the nurses for
charting; babies’ toys are washed and sterilized at the end of the day; toys on the wards are sorted and kept in order by the
teachers; etc. The nurses in turn anticipate
the opening of the playroom, make an effort to get their “playroom” children ready
as soon as possible and, once relieved of their ambulatory charges, they can give
more time and attention to the bed-patients. There are always 2 or 3 patients on the wards with whom one of the teachers will
spend a regular daily period, but in general
the play activities on the ward are handled
by the student nurses under the supervision of the graduate staff. Thereby, in a wider
sense, every nurse working in the hospital
becomes a member of the “play group.”
While one cannot overemphasize the gen-eral importance of good communication in a mental health program, the co-ordination of activities between the play group and the nurses is essential for the smooth running of the play program. In addition to the daily conferences, previously described, the staff
nurses meet with the psychiatrist and the
leader of the play group for a weekly
dis-cussion-all measures which help the
co-operation and the development of a unified
approach.
The “playroom” has many meanings to the children and in the following we will men-tion some of its most obvious aspects.
The freedom and activity of the playroom places the emphasis on the healthy part of the child. In this environment the patient is
first of all a child whose capabilities can
be freely expressed and whose handicaps are accepted in a matter-of-fact way. It re-moves the child from the relative isolation of the cubicle and puts him into a social situation, which he may use according to his ability to accept social support and his readiness for interpersonal relations. He
may draw close to the mother figures and
may also play with the other children. Age
is an important factor in group formation and so is sex among the school age children.
Equally important seems to be the child’s
tendency to repeat sibling situations. One
sees older children protecting and caring for younger ones, and little boys tagging after big boys. Children with similar diag-noses seem drawn to each other even when the disease has no visible attributes. Ex-traneous factors may play a part-similar medication or the visit of the same medical consultant-but we are always struck by the empathy which exists between children who suffer from the same “hurt.”
The child is mobilized to the extent his
physical condition permits it, and he is given adequate space and play material with a freedom of choice to use them ac-cording to his needs. From the passive
SPECIAL ARTICLES 301
active agent. He gets the opportunity to gradually master through play activity his
anxiety over illness, bodily injury and separation. The character of this play
ac-tivity was not studied, and we have to
restrict ourselves to a few incidental
ob-servations. For example, during the first day or days of hospitalization, the child’s
spontaneous play activity can be
mo-notonously repetitious. The same
acts-whether it is water play, block building,
painting, etc.-are performed almost
me-chanically, without much affect. Gradually,
the child makes first brief, then longer
“ex-cursions” into other activities and the ease
with which he can handle the diversified
p1’y opportunities seems to be a sign of lessened tension. Also, parents may be
sur-I)risel by the aggressive play of their usually quiet children and the opposite
occurs with e(lual frequency; active
chil-dren may be immobilized by fear at the
on-set of the hospitalization. Both types of ex-treme behavior decrease gradually as the
child succeeds little by little to master the anxieties of the new situation.
The toys can also be used as weapons to
express anger directly. One sees children who ignore their parents and play
through-out the visiting hours; their anxiety breaks through only when the parents are ready to
leave. Others, mainly school age children, may spend a lot of time demonstrating the
delights of this really quite simple playroom
to their visitors. The parents leave with
mixed feelings; they are both pleased and
hurt that while they worry about him at home the child apparently is having a good
time.
We have the feeling that the nondirective
technique employed by the teachers and the wide range of choice in play activities
offered to the children helps them to work
out the anxieties of the hospital experience
in the form of creative activity. It is a
meaningful and sometimes an initially over-whelming event in a child’s life and he will
need some time to assimilate it. Many
par-ents report that when the child returns
home, at first he talks only about the
play-room. It may take days or weeks before the
less pleasant aspects of the hospitalization
are mentioned spontaneously.
Notwithstanding the above mentioned reservations, the parents’ reaction to the
playroom is overwhelmingly positive. It
mitigates their anxiety and guilt about
leav-ing the child in the hospital and the
bitter-ness of the few, who view the playroom
as a competitor, can and will be handled
immediately since the staff is alerted to this possibility. There may be negative feelings
expressed by parents who are taken aback by the permissive atmosphere and consider it a threat to their disciplinary measures. Sometimes observing a more permissive ap-proach bias an educational value, but in
many instances it becomes the teacher’s
task to reassure the parents that the child’s
hyperactivity is due to his anxiety and that
once at home, he will gradually return to his former behavior. “Rooming-in”
par-ents generally regard the playroom as a welcome refuge for themselves as well as
their child. They follow along the usual
program, often serving as parents to other than their own child.
The play teachers belong to the broadly organized Child Psychiatry Unit and are in constant working contact with the other members of this group. The psychiatrist visits the playroom every day. Sometimes it is only to get an impression of the popu-lation and to have a talk with the teacher; at other times observations of specific chil-dren and families are carried out in this
setting. The teacher-in-charge receives supervision from the psychiatrist in the handling of the individual problems pre-sented by the children. The teachers keep
daily brief working notes on each child and
whenever a patient is referred for psychi-atric evaluation as part of a comprehensive medical study, these notes become more detailed and form an important part of the diagnostic work of the Child Psychiatry Unit.
SUMMARY
activities in the service of a comprehensive
approach to pediatrics. The organization
and the functioning of the program are
de-scribed in detail and the necessity of good communication and co-operation among the different groups in the hospital is
empha-sized. Some of the observed reactions of
the patients and their families to various
phases of the program are recorded and
illustrated by short case histories. The
feel-ing is expressed that the non-directive
tech-nique of the playroom teachers and the
wide range of choice in play activities
offered to the children helps them in
gradu-ally mastering anxiety over the illness,
procedures, restrictions and the separation from the parents. It is pointed out that the
“play group” is an integral part of the broadly organized Child Psychiatry Unit of
the Boston Floating Hospital.
REFERENCE
1. Tisza, V. B., and Richardson, M. : The inte-gration of a mental health program and a
