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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
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.
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?
commonly used and seemly understood by many, however, most do not realize that the
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
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
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
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
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
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
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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.
undergoing medical interventions all heighten the risk for psychological problems
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
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
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
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
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Works Cited
Blaustein, Margaret, and Kristine M. Kinniburgh. Treating Traumatic Stress in Children and
www.sciencedirect.com/science/article/pii/S0002713809607226?via%3Dihub#!
“Guide to Mental Health Specialists.” Child Mind Institute, Child Mind Institute,
Hilton, Lisette. "Teaching Kids to Cope with Stress." Contemporary Pediatrics, July 2015, p.
http://link.galegroup.com/apps/doc/A435793220/SUIC?u=wal55317&sid=SUIC&xid=c
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“How Children Cope With Ongoing Threat and Trauma.” Families & Educators,
www.nasponline.org/resources-and-publications/resources/school-safety-and-crisis/trau
Keene, Nancy. "Preparing Children for Hospitalization." Pediatrics for Parents, Mar.-Apr. 2014,
http://link.galegroup.com/apps/doc/A420050319/SUIC?u=wal55317&sid=SUIC&xid=1
Maria de Oliveira Pinheiro de Melo, Elsa, et al. “The Involvement of Parents in the Healthcare
Meentken, Maya G., et al. “Medically Related Post-Traumatic Stress in Children and
March 2019.
March 2019.
Peterson, Sarah. “About Child Trauma.” The National Child Traumatic Stress Network, 5 Nov.
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“Preparing Your Child for Visits to the Doctor (for Parents).” Edited by Steven Dowshen,
Sowden, D. "The Future for Child Healthcare Provision within General Practice; Children’s
http://link.galegroup.com/apps/doc/A113419197/SUIC?u=wal55317&sid=SUIC&xid=f.
2016,www.samhsa.gov/homelessness-programs-resources/hpr-resources/childhood-resil
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Works Consulted
www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilienc
March 2019.
2019.
Hilton, Lisette. "Calming Kids' Hospital Anxieties: Children's Hospitals are Transforming to
Ease Children's Fears and Make Going to the Hospital a Better Experience.”
http://link.galegroup.com/apps/doc/A456573888/SUIC?u=wal55317&sid=SUIC&xid=e
Sesar, Kristina, et al. “Multi-Type Childhood Abuse, Strategies of Coping, and Psychological
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