Children's Reactions to Hospitalization

The emotional reactions of children to illness and hospitalization depends on the type and quanti ty of the stress or tension produced by the illness, by the hospitalization and by the fantasies--either conscious or unconscious--that the child elaborates around both situations. The final outcome is, in any case, influenced by innumerable other variables as well. For example, his age; his internal balance and level of development; his adaptive capacity; his ability to control-within reason; the fears and anxieties that are provoked by the illness; the type of hospitalization; and accompanying procedures, either medical or surgical; the atti tude and reactions of the parents; the att i tude of the hospital's staff; the environmental conditions of the hospital, etc. All these factors can either facilitate or hinder the child's efforts at adaptation. Thus, we ought to address ourselves first to the effect of the hospitalization and that of the illness itself on the child. Then, we shall identify those influences (social and familial repercussions, etc.) that both events may exercise in the dynamics of the family and in the child's reaction. Let us start considering children under the age of five. For them, Dr. Nagera is Professor of Psychia t ry and Chief of You th Services, D e p a r t m e n t of Psychiatry , Univers i ty of Michigan at A n n Arbor . He is also a training analyst with the Michigan Psychoana ly t i c Ins t i tu te . Child Psychiatry and Human Development, Vol. 9(1), Fall 1978 3 0009-398X/78/1500-0003500.95 9 Human Sciences Press 4 Child Psychiatry and Human Development one of the most vulnerable points in the hospitalization is the separation from the family, and particularly the mother. It results in the sequence described by Robertson [1], Bowlby [2], and others of one first phase of protest followed by one of depression which are, of course, much more easily observable in the young child. In contrast, for the child between the ages of five and ten the significant factor is the psychological and symbolic significance acquired by the hospitalization, the illness, and the treatment. For him, these are the sources of danger, just as the separation from the parents, and particularly the mother, was for the younger child. For the hospitalized child, the fears, anticipations, fantasies, conflicts, and distortions centered around the hospitalization and illness are important, not only as the unavoidable psychological concomitants but because they can directly influence and prolong the illness itself [3]. Consider for example that a highly excited and frightened child before a surgical procedure may well need larger quantities of sedatives and anesthetics with the concomitant danger that such doses imply. Further, present day experience shows that hospitalizations-especially when certain types of precautions are not taken--can precipitate or lead in the here and now to various types of emotional problems in some children. They can influence as well the future emotional development and the personality of the child. Many factors can contribute to this outcome such as the separation from home and parents; surgical procedures; medical procedures of a traumatic, painful nature (especially when they are repeated and the child has not had appropriate preparation for it); chronic illnesses of various types; the immobilization that is required in the case of some illnesses and procedures; the danger of death; the hospital visiting rules; the attitude and education of the hospital staff (M.D.'s, nurses, etc.) in relation to the emotional needs of children of various ages; the age of the child; the specific stage of development of the child in the various areas of his personality at that particular point in time; the resources available to him, for example on the side of the ego, such as the degree or ability that he has reached in terms of comprehension; the previous experiences in the life of the child (to include life in general and other contacts with doctors and hospitals in particular); the type of mother-child relationship; the general health and dynamic state of the family; the general emotional health of the family, etc. This list is really incomplete and not intended to cover all the possible contributory factors, but at least it highlights the complexity of the subject. In any case, what I want to emphasize is the importance of exam-