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1989 - Preparation

In 1989, Remedial Educationalist Marguerite Kaptein-de Kock van Leeuwen reported on a literary study into the way in which children experience hospital admissions and the way in which they could best be prepared for such an admission. It related primarily to short-term admissions in relation to tonsillectomies. It was found that a combination of factual information and personal attention works best for parents and children.

Contributions of literature

A great deal of research has been conducted into children’s perceptions of hospital admissions and the possibilities for helping children to cope with these experiences as best as possible. This research not only confirms many of our instincts, but also offers new leads with a view to helping children further on this issue.

Crisis situation

Janis (1958) and Caplan, G. (1958) both describe the possibility of preparing people for a crisis situation. Janis speaks of the process of emotional inoculation, Caplan of the work of worrying. In both cases, the idea is to prepare people for a crisis situation and to enable people to accurately visualise what they would be faced with in such a situation. They will then be better able to recover.


Jessner and co (1952) observed children who had to undergo a tonsillectomy. The research focused on the question of how children experience a short period of hospitalisation and the question of what effects such an operation has on a child. These researchers found that the tonsillectomy incited significant anxiety in all children. The majority of children can control this anxiety and put the event down to experience. A number of children achieve a higher level of emotional adaptation and even benefit from undergoing this experience. For others, it is more the fact that they do not develop any serious emotional disorders as a result that counts. In the case of a small number of children, major behavioural changes are observed, which can last months and even years.

Olwen Harkema

The anxiety that is incited by the hospital experience can be very diffuse. This anxiety can for example be attached to a specific object, for example a thermometer or white coats. Children can also express anxiety in aggressive behaviour such as biting, spitting, hitting, kicking and swearing. Jessner et al. also describe that children of different ages have different anxieties.
Jessner et al. found that preparing for a painful and frightening operation could reduce the traumatic consequences. To this end, children must be given the opportunity to express their feelings, for example during play, but they should also be encouraged to realise that they are capable of coping with risk and pain.

Work of worrying

Caplan (1959, 1961, 1964) referred to the technique of preparing people for a crisis as anticipatory guidance. When a person is threatened with a crisis, the normal balance in emotional functioning is disturbed. The individual is confronted with feelings of displeasure, anxiety, fear, guilt or shame. The body also responds with reactions, such as an adjusted heart rate and a different breathing pattern. Caplan refers to the process that people go through as the work of worrying. From a preventative perspective, Caplan argues in favour of guidance in crisis situations. By helping people to find solutions themselves, emotional problems can be avoided.


Lipton (1962) published an interesting literary study on the significance of tonsillectomies for children. He primarily cites points of view from the psychoanalytical and medical perspective. This author comes to the conclusion that psychologically, the operation is very threatening for children and should therefore only be carried out if there are clear medical grounds for doing so.

Changes in behaviour

Vernon and co (1965, 1966) published an overview of the literature in relation to the significance and the perception of hospital experiences for children. They came to the conclusion that such an experience did not necessarily have to lead to undesirable disruptions in behaviour. They developed a behaviour assessment questionnaire for measuring changes in the behaviour of children after a hospital experience (Post Hospital Behaviour Questionnaire). This questionnaire has since been used by many other researchers.

Intense stress

Skipper and co (1968) observed that in addition to attention for the child, attention must also be paid to the mother because there is an ongoing interaction between the two whereby both spoken and unspoken feelings, anxiety and tensions are transmitted to each other (contagion-hypothesis of Escalona). Children are used to turning to their mothers, particularly in times of stress. They know best how to reassure and comfort them. However, they can only do this if they are not too consumed by worries and anxiety themselves.
The research shows that mothers experience intense stress when their child is in hospital and have to be operated on. This anxiety can be reduced through social interaction with a person who is qualified to provide information and emotional support.


Visintainer and Wolfer (1974, 1975) researched the different possibilities for increasing the level of adjustment of parents and children during the tonsillectomy by means of psychological preparation and supporting care.
They assumed that the systematic provision of information and the teaching of desired behaviours to parents and children, combined with encouraging the expression of emotions, would result in less tension. This is because vague, undifferentiated threats cause greater unrest than threats that are known, understood and expected. Their assumptions were confirmed by their research.
Systematic preparation, combined with supporting care, prevents behavioural problems. By systematic preparation, these authors mean the provision of information on what the child may see, hear, smell and feel, telling the child what is going to happen and how long it will take, and practising desired behaviour, such as muscle relaxation and breathing gently into the anaesthetic mask. They also refer to the importance of repeating information as necessary and checking thoroughly what has been understood by the child.


In 1976-1977, I conducted a study myself in the Sophia Children’s Hospital in Rotterdam into the possibilities for preparing children who had to undergo a tonsillectomy in an outpatients’ clinic.(Kaptein, 1978)
The children were aged between four and six years old. What struck me was that mothers rarely asked for information themselves, in spite of the fact that they needed such information in order to be able to adequately prepare themselves and their children for the procedure. What was also surprising was that almost all mothers indicated afterwards that they were much more shocked than they had expected to be at the pallor and weakness of their children immediately after the operation.


In 1979, Ferguson investigated whether preparation at home achieved different results to showing a modelling film at the hospital. It was found that the mothers who were prepared at home were less anxious during the period of hospitalisation. The children were also found to show fewer negative behavioural problems afterwards.
This researcher indicates that the anxiety that is reflected in a child’s behaviour in the hospital does not exactly reflect the actual level of anxiety of the child. This only manifests itself in the safe, home environment of the child. This finding is of particular importance because the care that a child receives in the hospital is tailored according to the behaviour that the child exhibits at that particular moment.


Wolfer and Visintainer (1979) researched the possibilities for preparing children and parents for a tonsillectomy with printed material. As part of the preparation at home, use was made of leaflets that provided very specific information about this type of surgical procedure and the situation that children and parents would encounter in the hospital concerned. On inquiry, it was found that nineteen percent of parents had not used the leaflets. It also became evident from the research that preparation at home is only effective if it is followed up at the hospital by means of support for the parents at the most stressful moments.


Bush and Cockrell (1987) describe that the level of anxiety of a child in hospital depends largely on the attitude of the mother in respect of her child. Mothers have an influence on the anxiety and coping behaviours (responses to change) of their child. In the case of a young, nervous child, distraction appears to be a successful method of reducing anxiety in the child. In addition, the provision of information forms a basis for exploratory behaviour in terms of the child’s environment. Ignoring the situation or showing signs of agitation does nothing to reassure an anxious child.

Large numbers

In his meta-analytical study, Saile (1988) comes to the conclusion that no economical and practicable methods and techniques have as yet been found for the effective preparation of large numbers of children at the same time.


All in all, the knowledge concerning the effective aspects of psychological preparation of children and parents for a crisis situation (for example a tonsillectomy) is still fairly limited. What is certain is that parents who prepare themselves well are best placed to help their children cope well with the stressful situation with which they are faced.
Good preparation starts with the parent addressing his or her own fears and gathering information. A combination of factual information and personal care and attention boosts confidence in a good outcome and offers the best contribution towards personal growth.

This article has previously been published
in Kind en Ziekenhuis, March
1989, special issue on ‘Amandelen’
[Tonsils], page 19-20 and 32. The
Marguerite Kaptein-de Kock
van Leeuwen
, is a Remedial Educationalist.

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