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Physical Healing is Mentally Harming

Uniform: check. Badge: check. Excitement: double check. It was the first day of my five

week internship at John Muir Medical Center Walnut Creek, working in the Womens’ and

Childrens’ department, exactly where I wanted to be as an aspiring pediatric surgeon. I walked

into the Pediatric Intensive Care Unit (PICU), my heart racing as I used my badge to open the

locked doors, feeling like I belonged. I greeted my supervisor with a smile which nowhere near

matched how grateful I was to be there and immediately began to follow her instructions. I had

work to do, but first she let me observe as the various members of the medical team rounded on

the children. I quickly became fascinated by the medical conditions and treatments being

discussed as well as the many professionals which had a role to play. I continued on with my day,

working hard and marveling in the environment I was immersed in. When I walked through the

halls of the hospital I was thoroughly amazed. The science of the medicine was astonishing to

me, as were the numerous conditions present and the equally numerous way of treating those

conditions. I loved being introduced to new medical professions which I did not know existed.

The hospital to me represents a place of healing. A place of innovation. A place of helping others.

However, during rounds one day, it occurred to me that I am an anomaly.

I was observing during rounds, as I had done many times before, when I began to focus on

something different than the medicine. Instead of listening to the medical jargon, which I was

normally quick to write in my notebook and research later, I watched. I watched the parents as

they feared for their child’s life. I watched the children who were scared for their own life. I

noticed, however, there was a difference between the two. The child was not only afraid, but also

confused. They lacked the comprehension ability necessary to understand what they were going

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through. They felt their pain, but they did not understand it. What struck me most was the

chronically ill children. They had been sick for most of their life and would most likely remain

sick for the rest of their childhood. But did they truly understand why they were sick and what

caused it? As I continued to watch the children during their hospital stays, it became evident that

it was not easy for them to cope with their conditions. But, how exactly do they react? What are

they feeling? How does this affect their treatment? These questions all lead me to the final

question which I wish to research: How is the mental health of children ages 3-13 affected by

hospitalization?

Hospitalization is a traumatic event, especially for children. The word trauma is

commonly used and seemly understood by many, however, most do not realize that the

denotation according to adults is different when applied to children. There is a common

misconception that children are less likely to feel and/or be affected by trauma because they are

too young to understand. A child responds to trauma different than an adult but they are no less

likely to feel the effects. According to the National Child Traumatic Stress Network, “Traumatic

experiences can initiate strong emotions and physical reactions... Children may feel terror,

helplessness, or fear, as well as physiological reactions such as heart pounding, vomiting, or loss

of bowel or bladder control” (Peterson). These reactions reflect a change within their mental,

emotional, and physical health. When a child goes through a trauma, hormones related to stress

and fear are released and continue to be released until they are removed from the trauma.

However, a child’s brain is still developing, and subsequently has a high level of plasticity. These

hormones affect the brain development and can lead to changes in “future behavior, emotional

development, mental and physical health” (“Trauma”). There are many different experiences

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which can be classified as trauma, of one which is physical harm. This may mean accidents

resulting in injuries or illness, but the process of hospitalization can also be traumatic and so is

the physical harm of the procedures done in the hospital. Eugene Butler is a Nurse Practitioner

who has spent much of his career working in the emergency department (ED) where he has

treated many kids. As a result of working in the ED, he is able to witness the first signs of trauma

in children and see how it progresses during their hospital stay. He has observed that

hospitalization can be traumatic into adulthood, “I would say most children are traumatized to

some extent. If you ask adults, most can give you amazing details of being in the emergency

room as a child. That kind of detailed memory is only seen with high emotional situations”.

Physical trauma is only one trauma which can be present within hospitalization, and as stated by

Butler there is often an emotional component as well. Children can feel abandoned or neglected,

they can feel alone or uncomfortable, all feelings which lead to emotional trauma. Whether the

child is affected more by the emotional or physical trauma has to do with the myriad of factors

which contribute to the process of hospitalization.

Children are largely affected by everything around them, in both a positive and negative

way. One of the major influences on children is their parents. Pat Frasca, a Child Life Specialist

at John Muir Health Medical Center Walnut Creek works to help children have the most pleasant

hospital experience possible. After working with many children and their families, she states that

it is generally beneficial for the child to have their parents present, however, it all depends on the

type of parent, “There are supportive and not so supportive parents and a parent who advocates

for their child is helpful and one who quietly watches and stands in the corner while their child is

undergoing some type of procedure, is not so helpful”. Parents who are distant from their child

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often cause more emotional trauma for their child, rather than help them, while parents who are

attentive and try their best to help their child eases the child’s anxieties and causes a less

traumatic hospital visit (Maria de Oliveira et al). Along with parents, nurses and other members

of a child’s medical team can have a large impact on the emotional trauma a child experiences. A

kind nurse who takes time to develop a relationship with the child and allows them to feel as if

they can express their concerns and feelings fosters an environment where a child feels safe and

heard (“Pediatric Nurse Career”). This can cause insurmountable positive effects on the healing

process as well as the mental health of children. Nurses who go above and beyond have the best

results. Butler described some of the things which he uses, or has seen involved nurses use:

“Distraction techniques are often used as well as comfort measures such as a warm, soft blanket

or stuffed animal or books”. However, the opposite is also true. If a nurse only enters the child’s

room to do what they need to do and leave, a child may feel ignored and uncomfortable which

will increase the possibility for emotional trauma. The general hospital environment can also

contribute to mental health of a child. Frasca described how children react to the colors of the

room, the shapes, and the pictures on the wall. In the literal sense, everything about the

hospitalization of a child can cause a reaction, both negative and positive, which can alter the

mental health of a child. The level of influence these factors have on a child depends on their

personal characteristics.

There is a common expression which states that children are resilient, however, this term

more adequately defines the characteristics that some children possess rather than the child as a

whole. It is wrong to assume that children will naturally bounce back from a traumatic event

such as hospitalization without much time or help because they are “resilient”. Resiliency is not a

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natural phenomenon. It is built through various factors in a child’s life. According to Katherine

Volk from the Substance Abuse and Mental Health Administration, the main factors which

contribute to the growth of resilience include cognitive development, or problem-solving skills,

self-regulation, and relationships with caring adults. These factors lead children to have a certain

temperament which allows them to be more resilient than others. They exhibit behaviours which

allow them to better react to hardships: “Resilient children are able to make use of a reflective

cognitive style, taking the time to think rather than reacting impulsively” (Blaustein et al 20).

Resiliency should not be expected in a child which does not have the necessary means to build it.

For example, a child who has lost their parents and has never had a stable, reliable adult in their

life may not be as resilient as a child who has two loving parents. This begins a very common

theme when discussing children: it is difficult to categorize children into areas of specific

expectant behaviours. Each child comes from different backgrounds and has different

characteristics and therefore each child will not act the same (Sowden). When it comes to the

mental health of children who are hospitalized, their level of resiliency will have a great deal to

do with how much their mental health is affected. Resilience encompasses the personality and

temperament of a child, and how a child chooses to use their resiliency will depend on their

personal traits. Similar to resilience, each child has their own types of coping mechanisms

depending on their personality and their tastes. The coping mechanisms which a child utilizes

dictates how much hospitalization affects them mentally.

Each child contains their own ways of coping with traumas, and hospitalization is no

exception. The BASIC Ph model constructed by Dr. Mooli Lahad, who is the director of the

Community Stress Prevention Center in Israel, provides six of the most common ways in which

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children cope with stress and trauma (“How Children Cope”). The model stands for belief, affect,

social, imagination, cognitive, and physiological. Belief pertains to reliance on religion or core

principles. The affect section of the model illustrates a child’s possible reliance on emotions or

feelings. They wish to express what they are feeling to those who they are most comfortable

around. Social reflects children who will turn to social interactions as a method of support and

control of their life. Next, imagination, is seen with children who often take their trauma and

recreate the story using various creative outlets. The cognitive section of the model depicts the

children who do not want sugar-coated information. They want honest conversations with the

adults in their lives. The last coping style of the model, physiological, pertains to children who

heal with physical activities, or hands on projects. They benefit most from being up and moving

with something to do constantly. These are all healthy, and common, ways in which children deal

with trauma. If children are able to successfully access these methods of coping during their

hospitalization, the likelihood of developing significant mental health complications decreases.

However, the issue arises when children do not have these healthy coping mechanisms. As stated

in an interview with Frasca there is a difference between adequate coping methods and positive

ones: “There are some positive coping mechanisms and some negative. So they may be adequate

for them but not in a positive way”. The children who have negative coping mechanisms are the

ones who are at risk for developing mental health complications. Although they may be

superficially covering their hospitalization with various unhealthy mechanisms, eventually it will

catch up with them and the child will have to deal with the trauma of hospitalization. When it

comes to coping mechanisms, the theme again arises that all children are different. When

analyzing how coping mechanisms affect the mental health of children in the hospital, it will all

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depend on the child. Generally, if a child has positive coping mechanisms such as the ones in the

BASIC Ph model, then they are at less of a risk of serious mental health complications from

hospital related trauma.

Although factors such as parents, nurses, environment, resiliency, and coping

mechanisms all have a role to play in the mental health effects of hospitalization on a child, there

are some mental illnesses which can be targeted as common due to hospitalization, one of which

being Post-traumatic Stress Disorder (PTSD). In the field of mental health, it was previously

understood that children are not prone to PTSD. However, over the past ten years, it has become

increasingly evident that children are mentally vulnerable after any traumatic event (“Children

and Trauma”). Adult PTSD is different from that in adolescents and children which is one reason

it has been overlooked as a possibility. According to a study on PTSD in children by the National

Institute of Health, symptoms presents them differently in children, “However, the direct

application of adult diagnostic criteria for PTSD can result in the misdiagnosis of post-traumatic

stress reactions in children…” (Kaminer et al). Nonetheless, children are susceptible to obtaining

PTSD from a trauma, and hospitalized children are especially vulnerable. Medical conditions

requiring hospitalization can cause PTSD, as seen in the study conducted to show the possibility

for PTSD in children with congenital heart defects (ConHD) posted by the National Institute of

Health. Authors of this study, Dr. Maya Meentken et al, revealed that children with severe

medical conditions such as those with congenital heart defects are developing PTSD as a result

of treatment and hospitalization for their condition. However, these types of treatments are not

specific to children with ConHD. Later in the study, it states that PTSD can be seen within any

child who has undergone an experience in the hospital:

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From other pediatric populations without ConHD, it is known that the experience of an

injury or illness can lead to traumatic stress reactions in children and adolescents.

Hospitalization, admission to the emergency department, entering intensive care, and

undergoing medical interventions all heighten the risk for psychological problems

alongside the evident physical complaints. (Meentken et al)

This section of the study illustrated that events from hospitalization, or just hospitalization itself,

causes traumatic stress reactions, which are the building blocks for PTSD in the long-term. The

study later asserts that 5-28% of children who were hospitalized in the Pediatric Intensive Care

Unit later developed PTSD. During and after hospitalization, parents and medical professionals

should be cautious and look for signs of PTSD and to start treatment early before it worsens

(Hilton). Albeit PTSD is a possibility for any child entering the hospital, the conditions of

hospitalization also puts them at risk for another mental illness called Situational Depression.

Situational Depression, also known as Adjustment Disorder, is the loss of hope, feelings

of sadness or stress which arise after a large life event (“Adjustment Disorder: MedlinePlus”).

The important thing to remember when discussing Situational Depression is that it is largely

based on the factors of the stressful event which provoked the illness. Hospitalization is a large

life event, and a stressful one as well. Children who enter the hospital frequently are at a larger

risk for developing Situational Depression. Frasca has observed Situational Depression forming

in her patients, “Some have Situational Depression like Cystic Fibrosis patients who have to be

in a room for weeks and can’t interact with other kids…”. This shows how the emotional trauma

of hospitalization affects the mental health of patients. The complete change in daily activities

and environment have a large effect on the child and are markers for Situational Depression. This

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is evident in many other hospital related illnesses, “For example, in children with cancer or renal

failure, prolonged hospitalization and chemotherapy can lead to depression. With the improved

survival of childhood malignancies, the effect of treatment on child's psychosocial well-being

becomes increasingly relevant” (Esmaeeli et al). In the study “Depression in Hospitalized

Pediatric Patients”, they diagnosed 7% as depressed and stated that 38% demonstrated dysphoria,

meaning they showed a general malaise with life. This means that 45% of pediatric patients

exhibit either depression or depression related symptoms. This is a shockingly large percentage

of patients. The long and strenuous treatments given to severely ill patients are helping them live

longer, but it is worsening their mental health and subsequently their quality of life. With the

advancement of physical medicine needs to come advancements for the psychological health of

these patients. Fortunately, there are currently some hospital resources to help children while

they fight through their hospitalization.

There are ways to aid children through the hospitalization process, and diminish the

possibilities for mental illness. It all starts with attentive parents, or caregivers, who take the time

to help children understand what is happening, “While in the hospital kids worry about the pain,

the unknown, separation, and the doctors. If parents help kids understand these things and stay

supportive, they can prevent mental health damages” (Keene). Besides the parents, there are

other ways to aid children. Child Life Specialists can help the child through their hospital stay

and prevent lasting trauma (“Guide to Mental”). They are trained in ways to explain to children

the medical procedures they will go through and give them healthy distractions. These are just

two ways which can significantly help a child from developing mental health issues.

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It is essential to realize what mental health complications can arise from hospitalization,

for both parents and healthcare professionals. Many of the effects from mental health conditions

which develop from hospitalization can be lessened with early treatment and preventative care.

As a result, parents need to be briefed on the possible mental health complications in order for

the child to have the best chance of healing physically without significant mental health damage.

Although each child is different and will react based on the factors such as their coping

mechanisms and parent involvement, it is indispensable to be aware of possible mental illnesses

so that parents and medical professionals can be on the look for changes in behaviours that match

these illnesses. If parents become more aware that their child can develop mental health issues as

a result of hospitalization, they can better help their child through the process (“Preparing Your

Child”). Despite this fact, the idea of mental health being altered is not widely considered within

the event of hospitalization, and this has to do with the stigma surrounding mental health. It has

been overlooked for a long period of time because mental health has a negative connotation.

However, your mental health can be injured just as your physical health can be, and this is

especially true in children. Evidently, is even more critical to notice changes in the mental health

of children before it affects their long term development. Hospitals are supposed to heal a child,

but because children are unable to fully understand their pain and may not have access to proper

emotional outlets, it has long lasting mental and emotional effects. They did not choose to end up

in the hospital and they should not have to pay for it for it through emotional damage. It is time

to consider that the physical healing in hospitals is emotional harming children, and we need to

do something about it.

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Works Cited

“Adjustment Disorder: MedlinePlus Medical Encyclopedia.” MedlinePlus, U.S. National Library

of Medicine, medlineplus.gov/ency/article/000932.htm. Accessed 8 March 2019.

Blaustein, Margaret, and Kristine M. Kinniburgh. Treating Traumatic Stress in Children and

Adolescents: How to Foster Resilience through Attachment, Self-Regulation, and

Competency. The Guilford Press, 2019.

Butler, Eugene. Personal Interview. 6 March 2019.

“Children and Trauma.” American Psychological Association, American

Psychological Association, www.apa.org/pi/families/resources/children-trauma-update.

Accessed 22 Feb. 2019.

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www.sciencedirect.com/science/article/pii/S0002713809607226?via%3Dihub#!

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Esmaeeli, M R, et al. “Screening for Depression in Hospitalized Pediatric Patients.” Current

Neurology and Neuroscience Reports., U.S. National Library of Medicine, 2014,

www.ncbi.nlm.nih.gov/pubmed/24665327. Accessed 25 Feb. 2019.

Frasca, Pat. Phone Interview. 25 February 2019.

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ww.childmind.org/guide/guide-to-mental-health-specialists/. Accessed 3 March 2019.

Hilton, Lisette. "Teaching Kids to Cope with Stress." Contemporary Pediatrics, July 2015, p.

27+.Student Resources In Context,

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5d3f. Accessed 5 Feb. 2019.

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Keene, Nancy. "Preparing Children for Hospitalization." Pediatrics for Parents, Mar.-Apr. 2014,

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Ease Children's Fears and Make Going to the Hospital a Better Experience.”

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