IMMEDIATE AND LONG-TERM EFFECTS OF INTERVENTIONS EARLY IN PROLONGED HOSPITALIZATION

(1)

(Received July 31; revision accepted October 28, 1967.)

ADDRESS: (HER.) Psychology Division, Department of Pediatrics, The Ohio State University,

Chil-dren’s Hospital, 520 5. 17th Street, Columbus, Ohio 43205.

755

IMMEDIATE

AND

LONG-TERM

EFFECTS

OF

INTERVENTIONS

EARLY IN PROLONGED

HOSPITALIZATION

Herbert E. Rie, Ph.D., Harold Boverman, M.D., Burton J. Grossman, M.D.,

and Natividad Ozoa, M.D.

LaRabida Jackson Park Sanitarium and University of Chicago School of Medicine, Chicago

ABSTRACT. Knowledge about their illness, anxi-ety level, and concern about hospitalization were

studied in hospitalized children with rheumatic

fever, who were either tutored about their illness

or engaged in group psychotherapeutic meetings,

within 3 weeks of hospitalization. Comparisons

fol-lowing these procedures revealed reduced anxiety

in the tutored group, increased knowledge about

rheumatic fever in both groups but not in a control group, and no difference with respect to concern

about hospitalization. Nineteen months after

dis-charge, neither group showed a decreased anxiety

level, both showed far less concern about

hospital-ization, and the children given “psychotherapy”

showed more lasting knowledge about rheumatic

fever.

The potential, ultimate impact of minimal

inter-ventions during crises is noted and the described

procedures constitute relatively economical means

of helping hospitalized children with their distress and to gain knowledge of their illness. Pediatrics,

41:755, 1968, ANXIETY, KNOWLEDGE OF ILLNESS,

REACTION TO HOSPITALIZATION, TUTORING,

PSYCHO-THERAPY, GROUP MEETING.

I

N A recent article’ we reported a pilot

study of two modes of intervention,

edu-cational and psychotherapeutic, early in the hospitalization of children with rheumatic fever. The two procedures appeared to have immediate, differential effects on some aspects of affective and cognitive

function-ing and to yield differences between the children undergoing these experimental procedures and a hospitalized control group. Our discussion and interpretation of

the results obtained with a rather small sample of children were necessarily specu-lative and cautious, and the experimental period was so relatively brief that the ulti-mate significance of the differential effects could not be assessed.

The procedures have 5i1lCC been re-peated, doubling the sample size, and fol-low-up studies were done to determine long-term effects. Confirmation of our ear-lier findings and discovery of long-term

ef-fects are reported in the present paper. They are of relevance because (1) the vari-ables studied are of direct concern to pe-diatricians and others seeking to facilitate

adaptive response to stress, and (2) the

procedures are so relatively brief and eco-nomical.

These studies were initially undertaken because of the general concern regarding the potentially negative effects of illness and hospitalization in a child’s psychologic development and because new experiences, when appropriately mediated by helping adults, can foster new and more flexible ad-aptations, no matter how distressing they may appear on cursory examination. Solnit

has reported on modes of involving mothers in the preparation and cooperative manage-ment of the child relative to his hospital ex-perience and notes that miew mother-child adaptations can be effected. Shore, Geiser, and Wolman’ discuss the potential value of hospitalization in several areas of

function-ing. They note specifically that (1) normal growth patterns can be encouraged when heretofore ummidentified impediments have been identified and their impact can be

re-duced by the “disruptive” hospitalization, (2) parent-child relationships can be in-fluenced as old patterns come under

scru-tiny in a supportive context, (3) hospital-ization may represent a refuge from an

(2)

emotional storm,

(

4

)

new identification

models can become available for both

par-cut and child, and

(

5

)

“emotional educa-tion” can occur as a child is actively helped to explore miew modes of coping and mas-terv.

The increased Potelltial both of negative

effects anti of growth facilitation is evident

ill cases of prolonged illness, prolonged

dis-ruptiomi of IlOrmal patterns of living, and

prolomlged mieed for medical supervision. The following variables were studied: knowledge about 011e’S illness, including the

direction of distortions; level of manifest

anxiety; level of distress apparently occa-sioned by illness alld Ilospitalization;

dis-tantiation from (the converse of

identifica-tiomi with) an ill, hospitalized child.

These variables were chosen for study

because they are believed to be affected by a negative hospital experiellce and because

they appear to be related to potential for

self-help, and hence successful prevention of recurrence. Oumr procedures then were desigmied to explore whether “emotional

ed-ucation could 1)e effected and whether children could usefully be helped to ex-plore problems of separation, physical im-pairment and temporary immobilization, tlleir role-real or fancied-in becoming ill, parent-child relations, peer relations,

mas-tery, depemldence, competence, and so forth.

We wished to know the relations among the level of concern regarding the fore-going, the knowledge about illness, and the level of generalized anxiety. These ques-tions were raised in the cOmltext of recom-mendations in the literature to

communi-cate witil the child-patient at his level and

because of the necessity of obtaining a rea-sonable commitment to post-hospital,

self-help and follow-up.

SElliNG

All cllildrefl in the follow-up group had

rheumatic fever0 and were ilospitalized at

#{176}Uponcompletion of the presnt studs-, early in the period of hospitalization, several children proved

not to have rheumatic fever (four in one

experi-mental group and three in the other). They were

not followed after discharge.

LaRabida Sanitarium, a hospital specializ-ing in rheumatic diseases and associated

connective tissue diseases in children. The program at LaRabida is designed to

pro-vide the optimum care of the “complete child.” Hospital services include school,

so-cial service, occupational therapy, psycho-logic services, and medical and nursing

care. Liberal visiting arrangements exist and the hospital maintains a long-term, fol-low-up program which provides supervision for the pOst-rileumatic fever child to pre-vent recurrence of rheumatic fever.

SUBJECTS

The sample consisted of 52 newly

admit-ted patients believed to have a first attack of rheumatic fever.

(

Of these, one child proved to have a recurrent attack, and other exceptions are noted.0) Twenty-five

patients were assigned to the tutorial (T) group and 27 to the psychotherapy (P) group. The tutorial group included 12 boys

and 13 girls, and the psychotherapy group included 14 boys and 13 girls. Mean ages of

the two groups were 9.83 years and 10.02

years, respectively. (In the follow-up sub-groups the mean ages were 10.01 amid 10.07

years, respectively.) The age range in both

groups was 8 to 11 years and the mean ages

do not differ significantly. Mean I.Q. scores were 104.2 for the T group and 107.9 for the P group, as reported by the children’s schools. These means do not differ signifi-cantly.

As an estimate of socioeconomic status of the families of the subjects, father’s occupa-tions were rated on a seven point scale5 and mean ratings compared for the two groups. No difference was found.f

Subjects were also compared with

re-spect to health status to guard against pos-sible effects of the latter on psychologic sta-tus. The medical director (B.J.G.) rated all

subjects, without knowledge of the results of this study, on three manifestations of

ill-f The mean ratings for both groups were in the

range 4 to 5. A rating of 5 generally represents

skilled labor, while representative occupations at

level 4 would be: bookkeeper, self-employed

(3)

Time of Assessment .4dmission PT Index of Severity’ Polyarihritis 0 2 3 Carditis 0 II mm’ IV VI VII Chorea None Mild Moderate Severe

.lfte, / .1 (or Diseluzrqe

year year.

,‘

0 0 0 0 0 0

17 19 17 11 17 11

0 2 00 0 0

0 4 0 4 0 4 0 0 0 0 0 0

0 0 0 0 0 0

27 1.5 17 15 17 1.5

0 0 0 0 0 0

6 3 10 7 10 3 0 0 0 0 3 16 0 0 4 I I 11 18 3 0 0 0 2 23 0 I 0

* Polyarthritis: I =one joint involvement; 2 =two joint involve-ment; 3=3 to 4 joint involvement; 4=over 4 joint involvement. Carditis: I

=

1 valve, grade II murmur; II 1 valve, grade Iii to IV;

111=2 valves, grade II in 1,oth; 1V=2 valves, grade III to IV of either; V

=

valvular involvement +significant myocardial involve-ment (enlarged heart): vm=valv,ilar involvement with congestive failure; VII

=

valvular involvement with pancarditis. Chorea: mild =few movements; moderate =generalized movements; severe

=cannot speak, cannot feed self.

ARTICLES

ness-polyarthritis, carditis, and chorea.

Ratings were made for time of admission to

tile hospital, time of discharge, first year

follow-up, and second year follow-up.

These data are reported in Table I.

It will be seen that the P and T groups differed so little in health status that it is

reasonable to assume that reactions to

health status did not account for the differ-ential effects following experimental proce-dumres.

Two additional groups of rheumatic

fever patients in the same hospital were

used as controls for certain procedures.

Control Group I consisted of 29 boys and 26 girls, and Control Group II consisted of

11 boys and 17 girls. The age range, mean age, and mean I.Q. scores of these two groups did not differ significantly from those of the two experimental groups.

PROCEDURES

All newly admitted patients meeting the previously described criteria were

evalu-ated by meamis of three psychologic scales within 2 days of admission to the hospital. All patients admitted in a given 1%-week pe-riod were assigned to one of the experimen-tal groups, and all patients admitted in the next 1%-week period were assigned to the

other experimental group. The procedure yielded six sub-groups (three to five pa-tients iiieach sub-group in each of the two

experimental groups) (luring the high

cen-sus (spring) seasons of 2 consecutive years.

No patient was in the hospital for more than 1% weeks before the experimental

procedures were undertaken. Data

collec-tion was terminated in 1)0th years when the

rate of admissions dropped so that no more

than two patients, at most, could be re-cruited in a given 1%-week period. The mean number of (lays between admission and administration of scales was virtually

identical for the two groups.

Each sub-group met three times for pe-riods of 35 to 45 minutes. One of two pedia-tricians (B.J.G. and NO.) met with each of the tumtorial sumb-groups, and a child psy-chiatrist (H.B.) met with each of the psy-chotherapy sub-groups.

Tutorial Method

In the tutorial meetings children were taught facts about rheumatic fever. The onset of the illness, its treatmnemit, amid its follow-up care were described. Routine

hos-pita! procedures were discussed. Children were permitted to ask questions. The pre-sentation and the answers to qumestions were restricted to information about rheummatic

fever. All other matters for discussion were deferred until after the experiment was

over.

Psychotherapy Method

In the psychotherapy meetings children explored the variety of concerns and fanta-sies they might be expected to have about

being hospitalized and ill. There were no restrictions on the range of issimes discussed.

TABLE I

(4)

However, the psychiatrist offered no infor-mation about rheumatic fever. When chil-dremi raised questions about their illness, they were encouraged to voice their own

notions. The psychiatrist initiated the meet-ings by acknowledging that the children were ill and hospitalized and that this could be a worrisome thing. He

acknovl-edged also that he did not know precisely how that worried the group and invited the children to tell him. A child might say: “My mother

(

the doctor, the nurse, etc.

)

didn’t

tell me anything.” The response then might be: “\Vell then, I know you’re curious, but what do you do about it here in a strange

place?” From time to time, the children might be unwilling or unable to initiate dis-cussion and the psychiatrist might then broach an issue himself by saying:

“Chil-dren don’t like to be away from their fami-lies when they’re sick. They get lonely. You are not with your family. What do you do

about your loneliness?” An animated dis-cussion often followed such an inquiry with some tears, some wriggling, and many var-ied examples of adaptive and maladaptive modes of coping. The psychiatrist would

then acknowledge the utility of some of the techniques and opine that it is not particu-larly helpful to pretend that loneliness does not exist. Loneliness is, of course, but one

possible emotional correlate of illness and hospitalization among many. Children were

also concerned, in varying degrees, with culpability in relation to their own illness; with loss of peer group status as a

conse-quence of their enforced withdrawal from interaction and competition; with loss of status in the family and potential loss of their possessions and prerogatives to sib-lings; with parental displeasure occasioned

by the inconvenience and possible expense of hospitalization; with the duration of con-finement; with the danger to their bodies and physical competence; in some

in-stances, with the threat to their lives; and in virtually all cases with the myriad of

often unpredictable events and hospital procedures, as well as hospital routines, which may be painful, frightening,

uncom-fortable, disruptive, or simply distasteful and irritating.

It is often difficult to specify which psy-chotherapeutic techniques

(

or which as-pects of them

)

are actually therapeutic

(

helpful

)

under given circumstances with a given child. The “psychotherapy” method applied in this study is not the prolonged,

one-to-one relation which the term so often implies. It does not demand intimate knowledge of the child’s make-up nor of

psychotherapeutic refinements. It is a brief and relatively simple encounter and its use

is not restricted to mental health workers.

Redhich and Freedmane define psychosocial

therapies as “behavioral methods that influ-ence the total behavior of the patient with the intent of producing well-being and im-prove psychological and social perfor-mance.” More specifically, they define dy-namic psychotherapy as a situation wherein “the therapist helps through economic

in-terpretation of preconscious conflicts and clarification of conscious problems. He, in

effect, teaches the patient to make correct observations and formulations increasing the patient’s awareness and helping him to

differentiate what is real from what is un-real and what can be changed and what cannot.” Thus, the psychotherapy under-taken with our subjects was dynamic group psychotherapy centered on the crisis treat-ment of hospitalization, illness, threat of chronic illness, and separation from home. Like other kinds of psychotherapy, it was sometimes supportive and provided oppor-tunity for discharge and trial solutions. It was also educational, but never specifically educational about rheummatic fever.

Within a day after completion of both

experimental procedures, the children were again evaluated with the scales used at the time of admission.

Scales Used

The self-report Children’s Manifest

Anxi-ety Scaler was used to assess the extent to which the children experienced feelings

(5)

anxi-ARTICLES

ety. The score obtained is regarded as a measure of the child’s general level of

anxi-ety.

THE STORY RECALL SCALE was developed

at LaRabida

(

H.R.

)

specifically for use with childrem#{236} having rheumatic fever. It

was designed to determine the extent to which the child experiences those feelings and comicerns and holds those convictions which have been described in the hitera-ture’#{176} and regarded by us as distressing psychologic consequences or concomitants of hospitalization for rheumatic fever. Prin-cipal among these are the child’s concerns about the precise nature of his illness, his prognosis and ability to maintain his status

in competitive peer relationships, ultimate restrictions omi his level of activity, the sub-sequent danger to his health, amid his status within his family as a consequence of his temporary absence from home. The scale

was also designed to determine the extent to which tile child needs to perceive a

dis-parity between the status of a hospitalized

child amid himself and the extent to which

he is incapable of acknowledging his

cur-remit status. The scores obtained are re-garded as measures of the level of comicern

generated specifically by the child’s illness and of the extent to which the child tends to take psychologic distamice (or distanti-ates himself) from tile status of a

rheu-matic fever patient.

THE RHEUMATIC FEVER TEST was

de-sigmied at LaRabida Sanitarium (HR.) to measure the extent to which patients and their parents understand rheumatic fever and the extent to which they tend to mini-mize or exaggerate the negative implica-tions of the disease. The scores obtained represent the extent to which the subject recognizes correct statements about rheu-matic fever (the C or “correct” score), the extent to which he subscribes to statements which minimize the negative implications

of rheumatic fever (the U or “undercon-cern” score), and the extent to which lie subscribes to statements which exaggerate the negative implications of rheumatic fever (the

0 or

“overconcern” score).

CONTROL GROUPS

Control Group I was used to determine trends, if any, in the total projective score

and distantiation score

(

on the Story Recall Test

)

and the anxiety score

(

on the Cliil-dren’s Manifest Anxiety Scale

)

in the ab-sence of experimental procedures. This

con-trol group, like our experimental groups, responded to the scales during the first week of hospitalization for a first occur-rence of rheumatic fever.

Control Group II was used to determine whether any changes may he anticipated in

scores on the Rheumatic Fever Test in the absence of experimental procedures. Hence, the test was administered to this control group, as it was to our experimental groups, within 2 days of admission to the hospital for a first occurrence of rheumatic fever, and again after slightly longer than 2 weeks of hospitalization. The time between the two test administrations is somewhat

short-er than the nearly 3 weeks that elapsed be-tween the two test administrations to our experimental groups. However, the

differ-ence is probably not great enough to pre-dude an adequate comparison, and addi-tional data were obtained with this control group after 10 weeks of hospitahizatiomi.

No difference exists between the two

ex-perimental groups with respect to duration of hospitalization prior to initiation of the experimental procedures and prior to

re-evaluation following the experimental pro-cedures.

Finally, when the children had been out of the hospital for a period of approxi-mately 19 months in both groimps, the

sev-eral scales were administered once again on the occasion of a routine, follow-up visit to the hospital. Approximately half the

sam-ple was seen about 1 year after discharge and the other half about 2 years after dis-charge. Only one follow-up result is

re-ported in order to maintain adequate sam-ple size. On inspection, there appear to be no differences in mean scores calculated separately for each follow-up period (1 and 2 years).

(6)

Psychotherapy (27)

1st Mean 2nd Mean / P

3.4 ,01

1.9 8.4 6,3

19.3 11 .9

3.6

(‘oncern about illness II.S II .7

I)istant iation 3.4 3._S

-Numbers in parentheses indi(’ate nuunler of children in ea’it group.

14. 1

9.1

5-4

19.3

13.

3.6

i_I

TABLE II

COMPARISONS OF SCORES OF EXPERIMENTAL Gnors B:FOHE AND AF-rER EXPERIMENTAL PROCEDURES

Score Tutorial (2.5)

Group

1st Mean 2nd %fean t P

i.8 13.9 4.4 .001

() 10.0 9.5

U 6.8 .5.9 .98 .01

Auuxietv .4 18.7 3.98 .001

several variables at or shortly after admis-siomi to the hospital, slightly more than 3

weeks later immediately following the ex-perimental procedures, and again between 1 and 2 years after discllarge from the

hos-1)ital.

RESULTS

All relevant in-hospital scores are re-ported in Table II, as well as the probabili-ties associated with the value of t represent-ing

tue

differences between means of the two experimental groups. The results

con-firm the findings previously reported’ with only half the present sample.

1. Both groups obtained significantly higher C scores on the Rheumatic Fever Test after experimental procedures than

be-fore. That is, children in both experimental groups recognized a significantly larger numl)er of correct statements about

rheu-matic fever after the experimental proce-dures than they had before.

2. Children in Control Group II showed no chamige in C score on the Rheumatic Fever Test between first amld second admin-istrations (in the absence of experimental

procedures). Indeed, this group showed no change in C score after 10 weeks of hospi-talization.

3. The tutorial group, but not the

psy-chotherapy group, obtained a significantly lower U score on the Rheimmatic Fever Test

after experimental procedures than before. That is, children in the tutorial group mm-imized the negative implications of the ill-ness less after experimental procedures than

before.

4. The tutorial group, but not the psy-chotherapy group, obtained a significantly lower anxiety score on the Children’s Mani-fest Anxiety Scale after experimental proce-dures than before, indicating reduction of some components of anxiety.

5. All of the fimidings were also obtained for the portions of the sample (in both

ex-perimental groups) which were ultimately followed subsequent to discharge from the hospital. \Ve are therefore reasonably as-sured that the follow-up findings can be ap-propriately generalized to the larger in-hos-pital samples.

\Vith respect to follow-up, the following results, which are represented in Table III, were ol)tained.

1. The psychotherapy group, but not the tutorial group, showed a significant increase in C score on the Rheumatic Fever Test be-tween time of admission and follow-up.

(7)

OF S(’Out:s OF EXI-:ItIM F:NTAL Guoui’s B:t-outt: EXI-RIt IM}:NTAL PUOC:Duuu:s

ANt) AFTF:!t I)ISCI! A IIGE FROM Tii} IIOSPITA L

Score

Group

0

U Anxiety

Tutorial (l5)

lxi Mean P01/on-nj) I P

13.5 14.5

9.1) 7.9 ‘1.46 .05

6.5 4.6

‘11.8 ‘10.1

Concern about illness 1’1() 9.5 ‘1.34 .05 1’1.6

l)istantiation ‘1.1 6.5 .5.46 .001 3.7

Numbers in paraitlueses mdicate number of children in each group.

P

.01 .05 .01

.001

.05

19.4 17.7

-9.1 4.05

5.4 ‘1.13

ARTICLES

significantly larger number of correct state-ments about rheumatic fever than they

were able to recognize at the time of ad-mission to the hospital.

2. The psychotherapy group also showed a significant decrease in both the 0 and U scores on the Rheummatic Fever Test over the same period of time. That is, children in the psychotherapy group ultimately sub-scribed to fewer incorrect statements (of both kinds) aI)out rlleumatic fever. As a group, they exaggerate and minimize the

negative implications of the illness less than the others. This can be viewed as a trend toward greater consistency and clarity in appraising the nature of the illness for

which they had been hospitalized and for

the prevention of which they were being followed.

3. \Vith respect to the (same)

Rheu-matic Fever Test, the tutorial group showed a reduction omily in the 0 score-in the tendency to subscribe to statements which incorrectly exaggerate tile negative implications of rheummatic fever-over the same period of time. In effect, this means, that as an immediate consequence of the experimental procedures, the tutorial group has not been as successful as the

psycho-therapy group in maintaining the gains

each made in knowledge about rheumatic fever.

4. Neither group showed a significant change in the anxiety score between admis-sion and follow-up, though both showed a tendency to decrease. This means that the psychotherapy group has shown no

signifi-cant change in anxiety score throughout the study while the tutorial group, after show-ing a decrease immediately following

ex-perimental procedures, showed no net change either. Its initial amixiety-reduction appears not to be a lasting phenomenon.

5. Both groups showed a significant

de-crease (for tile first time) in the Total Pro-jective Score of the Story Recall Test. That is, both groups showed a reduction, on

fol-low-up, of concern specifically associated with hospitalization and illness even though neither showed a change in this level of

concern immediately following the experi-mental procedures. The change in tile

psy-chotherapy group can more confidently be viewed as a imon-chance occurrence.

6. Control Group I, followed-up approxi-mately 1 year after discharge from the hos-pital, showed mio change in total projective score from time of admission

(

N = 37; mean

change =

-

.54, or essentially nil). In short,

without the noted experimental procedures,

TABLE III

Psychotherapy (21)

1st .1ean P0/lou-nj) /

13.0 14.5 .98

8.5 6.8 .I9

(8)

PROLONGED HOSPITALIZATION

ter would be substantial, as would tue ten-no change in total projective score can be

anticipated on follow-up.

(

Unfortumiately, no follow-up data are available on Control Group II. As noted previously the group showed no increase in knowledge about rheumatic fever even after 10 weeks of

hos-pitahization, a period of time during which our experimental groups showed tile

great-est increase, amid the absence of follow-up data appears less crucial.)

7. Both groups increased imi distamitiation

score

(

omi the Story Recall Test)

,

with the change imi the tutorial group viewed more confidently as a mionchiamice occurremice. This

may i)e viewed as a lesser identification

with an ill, hospitalized child omi follow-up than at time of admiiission. This change ap-pears to be effected by both experimental procedures imi the lomig rumi, even though

there was no immediate effect during the

3-week experimental period. No significamit

chamige imi distantiation score occurred in

Control Group I from time of admission to

follow-up a year after discharge (N = 37;

mean change = .96; P associated with t is

greater than .1).

Imi stmmmary, then, the immediate effect of imicreased knowledge about riieumatic

fever (mioted in both groups) is maintained at a significamit level omily by the psychother-apy group upomi follow-up. Tue psychother-apy group appears, also, to have ami ulti-mately more “realistic” view of the illmiess in

the sense that it subscribes to fewer,

contra-dictory, incorrect statements about the ill-ness. The immediate effect of reduced

gen-eral anxiety (or somne components of it) in

the tutorial group does not endure. Both groups ultimately experience less concern specifically about illness and hospitalization, though neither manifested amiy change in this respect immediately following experi-memital procedures. Both groups also iden-tify less with (distamltiate themselves more from) an ill, hospitalized child upon fol-low-up than they did initially. In contrast, a comitrol group shows no change, either

dur-ing iiospitaiization or upomi follow-ump, with respect to concern about illness and

distan-tiation in the sense used here.

Lastly, it is stressed that where changes

in scores have occurred, either during hos-pitalization or on follow-up, they are intra-group changes and do not necessarily

re-flect sigmiificant absolute differences

be-tween the groups. Thus, while the psycho-therapy group shows a significant increase km knowledge about rheumatic fever from

time of admission to follow-up

(

and the tu-tonal group does not

)

,

the actual ultimate

(lifference betweemi the two groups is not significant.

COMMENT

The different patterns of change among the three groups-tutorial, psychotherapy, and control-the durability of some of the

intra-group changes, and the discovery of

additional long-term effects of the experi-mental procedures bear implications not omily for management of hospitalized

chil-dren but for adaptive functioning under stress generally. Before these effects are ex-1)lOred, two comiditions obtained in tilis

study warrant emphasis.

1. Imi the hospital in which the study was

undertaken, imiformation aboumt rheumatic fever was readily available, not only to the tumtored group btmt also to all other rheu-matic fever patients. The majority of the children in the hospital had the same

ill-ness, the majority of the staff had

consider-able experience with and kmiowledge about rheumatic fever, amid the children had rela-tively free access to each other as well as to the staff. Hence, the source of information for the psychotherapy group is mio mystery. Rather, the issue appears to be the utility of

that informatiomi inasmtmch as a comparable control group failed to “learn” despite the same potential availability of information.

2. Tile learnimig which was facilitated by

tile experimental procedures, and which

(9)

mas-ARTICLES

dencies toward inhibition, regression, and (lenial in the face of illmiess and hospitahiza-tion. Imi short, tile relevance-by-definition of

the information available

(

in one way or

another

)

to all the children can be viewed as one side of an approach-avoidance con-flict while the anxiety-containing

defensive-ness can I)e viewed as the other. If one were able to reduce the “non-learning”

ef-fects of the latter, the motivating effects of the former would presumably lead to

in-creased knowledge.

Teachimig

(

the tutorial approach

)

is a

traditional amid supposedly economic means of conveying information. In this situation, the authority and omnipotence of the teacher was enhanced by virtue of his

sta-tus as physician at a time when a physician

was needed most urgently. Communications were clear, direct, and unambiguous.

How-ever, tiiey were umiilateral and raised no ex-pectations of active, independent striving on the part of the child patients. Indeed, in

the tutorial procedure, the only demands niade on

tue

children were for adherence to the prescribed procedures, essentially a de-mand for compliance. The teaciler-pupil re-lationship is often a familiar dependency fosteritig relationship and may be

condu-cive, at least temporarily, to regressive sub-mission to increased adult ministrations. The childreii had reason to feel that care would be given, that needs would be grati-fied, and that reassurance and support were available. \Ve suspect that the children’s numerous, oftemi vague, amid typically unex-pressed concerns, fearful elaborations of

hospital procedures, and anxious anticipa-tions were stilled through what was clearly a reasurimig amid comforting procedure (to

wit, their general anxiety level dropped

sig-nificantly immediately following the tuto-rial procedure).

But it is our suspicion, with respect to

the tutored group, that precisely because the concerns and anxieties were not formu-lated, evolved, organized, or expressed and,

indeed, were not confronted, the learning that occurred may have lacked the affective investment that might have increased its

durability artd clarity. This hypothesis de-rives not only from the changes observed in the tutorial group but also from those ob-served in the psychotherapy and control groups.

These groups, too, were highly motivated to learn-one did and one did not. Neither was explicitly taught. The enduring gains in accuracy of information about illness in

the psychotherapy group are necessarily a function of the psychotherapeutic

proce-dures or of tile exploration and expression of the concerns and anxieties experienced by the children. Such exploration is not likely to be very reassuring or comforting, at least not in army immediate sense; in fact, the anxiety level of the psychotherapy group remained unchanged. But, these ex-plorations are likely to involve the children

in an active search for resolution. It was, after all, the principal role of the

psychia-trist conducting the psychotherapeutic

procedure to encourage active involvement

in the children in the identification,

expres-sion, and reintegration of the specific con-cerns experienced by them. The increase in

knowledge about rheumatic fever, in the absence of explicit attempts to affect such an increase, attests to the heightened effec-tiveness of the necessarily independent searcii for resolution.

In the postulated approach-avoidance

conflict situation (motivation to learn by virtue of the relevance of the data versus

tendency to avoid by virtue of the anxiety-provoking context), each of the two experi-mental procedures is likely to have affected the components of this conflict in different ways. The tutorial approach, presumably

fostering a reassuring dependency, reduced the anxiety (as demonstrated) and thereby

facilitated “learning.” The psychothera-peutic approach, presumably fostering in-dependent mastery, while not directly

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764

or less high anxiety level manifested

(

ul-timately

)

l)y both groups.

Finally, with respect to the

psychother-apy group, one additional factor may be relevant. The childremi

(

in all groups

)

were between 8 and 11 years of age at the time of hospitahizatiomi. It is a period of

child-1100(1 whemi there is generally increased rehi-ance omi ‘eer relationships for the rewards of imiterpersomial contact which are earlier more consistemitly obtained within the fam-ily. It is a time when competence, mastery, and general self-esteem maintenance are tested amid confirmed to a great extent throumgh iliteraction witil other children. To

be like other childremi of omie’s age becomes extremely importamit amid to he deviamit from tiiem can be devastating. Tue childremi in

our psychotherapy group had the

opportu-nity of determinimig, throughi interaction, that their anxieties were siiared by their

peers. In a sense, they had the opportunity

of redefining their amixieties as “normal” by the standards which are rehevamit to them.

IMPLICATIONS

The implications of our findings are ob-vious. The relatively simple amid economic procedures described offer a means of

help-ing children (at least of the given age)

who are ill to cope with tiieir distress. They are potentially applicable, witll adequate orientation and under proper guidance, by a variety of medical and child-care person-miel. Like most other useful procedures, those employed in this study require some

sensitivity amid some trainimig. We do miot

advocate their indiscriminate use and we

recognize that unsophisticated application of the procedures could have a disruptive rather than constructive effect. Nor do we suggest that one procedure is invariably preferable to the other, or to neither. We can conceive of children being so critically

ill that the initial goal migilt indeed be anx-iety-reduction which has not been atten-dant upon our psychotherapeutic procedure.

We can also comiceive of circumstamices,

though with greater difficulty, in which the nature of the illness, and hence of the

child’s experience, are such that one need have little concern about the psychologic implications and have no special wish to

in-crease the child’s knowledge, be it transient or durable.

We do not know, and it would be worth exploring, whether children at other ages or

children already acclimated to a hospital

setting would react similarly. We are aware that rather minimal imitervention techniques

facilitated remarkably durable alterations in response and we are particularly cogni-zant of the fact that pediatricians have

ac-cess to cllildren at many critical points in a

child’s life and are in a position to facilitate more effective adaptive striving.

REFERENCES

1. Rie, 11. E., Boverman, II., Ozoa, N., and

Grossman, B. J. C. : ‘l’tmtoring and

ventila-tion : A pilot studs’ of reactions of

hospital-ized children. Clii. Pediat., 3:581, 1964.

2. Solnit, A,

J.:

Hospitalization, an aid to physical

and psychological health in childhood. J.

Dis. Child., 99:155, 1960.

3. Shore, M. F., Ceiser, R. L., and Wolman,

H. XV.: Constructive uses of a hospital

ex-perience. Children, 12:3, 1965.

4. \IcCulloch, 11.: A sanitarium for the treatment and study of rheumatic diseases. PEDIATRICS,

15:603, 1955.

5. Warner, \V. L., Meeker, NI., and Eells, K.:

So-cial Class in America. New York: harper and

Row, 1949.

6. Redlich, F., and Freedman, 1). X.: The Theory

and Practice of Psychiatry. New York: Basic

Books, p. 284, 1966.

7. Castaneda, A,, McCandless, B., and Palermo,

D.: The children’s form of the manifest anx-iety scale. Child Develop., 25:317, 1956.

8. Josselvn, I. NI.: Emotional implications of

rheumatic heart disease in children. Amer. J.

Orthopsychiat., 25: 109, 1955.

9. Josselyn, I. NI.: Anxiety in children

convales-cing from rheumatic fever. Amer. J.

Ortho-psychiat., 25:109, 1955.

10. laran, L. M., and hudson, A, E,: Social and

psychological problems associated with

pro-longed institutional care of rheumatic

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1968;41;755

Pediatrics

Herbert E. Rie, Harold Boverman, Burton J. Grossman and Natividad Ozoa

PROLONGED HOSPITALIZATION