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ORIGINAL ARTICLE
Exploring Play Therapy in Pediatric Oncology:A Preliminary Endeavour
Uttara Chari & Uma Hirisave & L. Appaji
Received: 29 March 2012 /Accepted: 24 May 2012 /Published online: 6 July 2012# Dr. K C Chaudhuri Foundation 2012
AbstractObjective To discuss the benefits and feasibility of playtherapy in pediatric oncology.Methods This is highlighted through the use of a case reportof non-directive play therapy with a 4 y- old girl, diagnosedwith Acute Lymphoblastic Leukemia. The outcome of playtherapy was examined using a combination of qualitativeand quantitative assessments.Results The benefits of play therapy with this child weremanifested in better illness adjustment and general mentalwell-being, enhanced coping, and normalization.Conclusions Having illustrated benefits of play therapy inpediatric oncology, this paper discusses its feasibility andproposes avenues for clinical practice and researchendeavours.
Keywords Child . Leukemia . Play-therapy .
Psycho-oncology . Illness adjustment
Introduction
Cancer is a leading non-communicable disease [1].Although childhood cancers are relatively rare, they areamong the major causes of mortality in children [2]. In
India, about 1.6 to 4.8 % of cancers are seen in childrenbelow 15 y of age [3]. Leukemias are the most commonchildhood cancers with Acute Lymphoblastic Leukemia(ALL) amounting for around 60 to 85 % of all reportedcases [3].
Health is considered to be a state of “complete phys-ical, mental, and social well-being” [4]. The uncertaintyassociated with illness prognosis ushers significant men-tal stress and anxiety in families and children withcancer [5, 6, Urvashi 1999 Dissertation, Bharthi 2000,Dissertation], for even as long as 12 y post remission[5]. Nonetheless, psychological adjustment to the illnesshas been found to depend on a composite of factorssuch as illness stage, development and personality ofthe child, family functioning, prior life experiences, andinteraction with the treating team [5–7]. This necessi-tates the need for psychological interventions that facil-itate “coping with cancer and promoting normaldevelopment” [8].
Child-centric psychological interventions are develop-mentally framed with play therapies being preferred foryounger children, as play is a “child’s natural medium ofself-expression” [9]. Play is considered a “lifeline” for chil-dren with cancer [10]; a means through which they expressand make sense of their distress, develop coping resources,and implement coping strategies. Aldiss [7] noted that chil-dren hospitalized with cancer primarily sought toys to playwith, and that play specialists played an important role inpromoting well-being.
Intervention research is scant and “children’s psycholog-ical ordeal with having cancer has not been dealt with assuccessfully” [10]. In India, there are no published reports ofpsychological interventions in pediatric oncology [11].Given this lacuna, a PhD study was designed with the aimof examining the effects of psychological intervention on
U. Chari (*) :U. HirisaveDepartment of Clinical Psychology,National Institute of Mental Health and Neuro Sciences,Hosur Road,Bangalore 560029, Indiae-mail: [email protected]
L. AppajiDepartment of Pediatric Oncology,Kidwai Memorial Institute of Oncology,Bangalore, India
Indian J Pediatr (April 2013) 80(4):303–308DOI 10.1007/s12098-012-0807-8
young children hospitalized for ALL. This study is beingcarried out at the department of Clinical Psychology,National Institute of Mental Health and Neuro Sciences(NIMHANS), Bangalore, by the first author, under the guid-ance of the second and third authors. The sample is beingdrawn from Kidwai Memorial Institute of Oncology(KMIO), Bangalore. The procedure and method of the studyhas been approved by the scientific and ethical reviewboards at both these institutes. The purpose of this paper is
to illustrate the benefit and feasibility of play therapy inpediatric oncology through a case report drawn from theabove mentioned PhD study.
Material and Methods
The procedure followed for this case-report was:
Consent from Paediatric Oncologist
Assent and consent of child and parent respectively
Pre-intervention Assessment
Intervention (10 sessions of play therapy)
Mid-intervention Assessment
Intervention (10 sessions of play therapy)
Post-intervention Assessment
Periodic Assessment of Play
Periodic Assessment of Play
The tools employed were as follows:
1. Semi-structured Interview Schedule (SsI): A semi-structured interview schedule was prepared for the pur-pose of procuring information on the socio-demographicbackground and developmental history of the child.Illness history, parents’ and child’s knowledge of illnesswere also addressed. The semi-structured interviewschedule was administered on the mother prior tointervention.
2. Teddy Bear’s Picnic (TBP) [12]: This tool was used toassess personal constructs of the child regarding self,relationship with family members, and overall adjust-ment. This tool was administered on the child both pre
and post intervention. Using a family of toy bears,narratives were proposed and left unresolved, with thechild being required to complete them. The elicitedthematic material formed the basis of 10 TBP codes.Cross test validity and the applicability of this test in theIndian context has been established [12, Janveja 1999,Dissertation].
3. Illness-specific Adjustment Scale (IsAS) [13]: This is aself-report measure designed to elicit child’s level ofdistress in respect to 10 leukemia-related stressors. Thedistress is rated on a visual scale using five faces rang-ing from smiling face labelled not at all upset (score of1) to a frowning face labelled very, very upset (score of5). Reliability has been found to be robust with internal
304 Indian J Pediatr (April 2013) 80(4):303–308
consistency of 0.83 and test-retest reliability of 0.64. Inthis study, the tool was administered pre, mid, and postintervention.
4. Children’s Play Therapy Instrument (CPTI) [14]: Thistool was used to assess changes in child’s play behav-iours over the course of play sessions. The play sessionswere videotaped and later coded. The longest play seg-ment of a play session was coded for type of playactivities, affect and cognitive components, and socialand developmental level of play. Across studies, inter-rater reliability in coding the play behaviours has rangedfrom 0.49 to 1.00. In this study, inter-rater agreement ofplay behaviors was established by comparing ratings ofthe researcher with the blind ratings of the co-developerof this tool.
The psychological intervention consisted of 20 sessionsof non-directive play therapy [11] with the child, with eachsession being approximately 30 min in duration. Thesesessions were carried out within the hospital ward in adesignated private room. Pioneered by Axline [9], this formof play therapy is based on humanistic principles and ischild-directed, thus facilitating mastery and coping in thechild [9, 15]. The principles of non-directive play therapy[9] provided the framework for sessions. Apart from theprescribed play materials [9], medical toys were alsointroduced.
Seema (name changed to protect identity) was a 4 y-oldgirl from middle socio-economic status. An only child, shecompleted 1 y of formal schooling in nursery. She was ofeasy temperament, with no significant medical or develop-mental history. There was family history of breast cancer inpaternal grandmother and possibly mental retardation inpaternal aunt. Seema was equally attached to both herparents. Two months prior to hospitalization, Seema expe-rienced regular bouts of fever. Subsequent investigationsconfirmed ALL, following which she was hospitalized.When taken up for the study, Seema had been hospitalizedat KMIO for a period of 15 d. She was not aware of herdiagnosis and had been informed that she was admitted forfever. Her mother did not want Seema to know about theillness. She wished that Seema would be “free in her mindand play”, as she had become withdrawn and passive sinceadmission. Mother was found to have adequate awarenessof illness, treatment, and prognosis. This information wasobtained on the semi-structured interview with the mother.
Results
Figures 1 and 2, and Table 1 depict the findings on CPTI[14]. Figures 3 and 4 display the findings on IsAS [13].
Findings on TBP [12] are depicted in Fig. 5.On the CPTI (Figs. 1 and 2, and Table 1), there was a
gradual change in child’s play behaviors across sessions,indexing normalization. Seema’s play activity became moreadvanced (Fig. 1) as she moved from rudimentary play suchas aligning toys (sorting-aligning play) to engaging in re-peated play with medical equipment (traumatic play) toenacting diverse narratives using dolls and other toy materi-als (fantasy play). There was a predominance of adaptivedefences by termination (Fig. 2). Initial isolated/anxietydefences such as constriction (persistent and rigid repetitionof play activities), autistic encapsulation (self-absorbedplay); conflicted defences such as avoidance (evading playwith medical toys) and intellectualization (playing withanxiety provoking stimuli in an unaffected manner); rigid/
Session numbers
Play
cat
egor
ies
arra
nged
in h
iera
rchy
of
mat
urity
F
I
A
T
E
SA
1-5 6-10 11-15 16-20
Fig. 1 Findings on CPTI. SA Sorting-Aligning; E Exploratory; TTraumatic; A Art; I Imitative; F Fantasy
Session numbers
Def
ence
cat
egor
ies
arra
nged
in a
scen
ding
hie
rarc
hy o
f m
atur
ity
A
C
R
I
1-5 6-10 11-15 16-20
Fig. 2 Findings on CPTI: Defences. I Isolated/Anxious; R Rigid/Polarized; C Conflicted; A Adaptive
Indian J Pediatr (April 2013) 80(4):303–308 305
polarized defences such as omnipotent control (dominatingsession activities) and identification with the aggressor(donning the role of doctor in a non-adaptive manner)gradually waxed and waned across sessions. Thus, in thelast block of sessions, only adaptive defences such as adap-tation (making the best use available toys), anticipation(planning and taking steps for forthcoming actions in play),problem-solving (trial and error play with toys), identifica-tion (adaptive enactment of doctor) and affiliation (variousroles enacted during play) were noted. The prominence ofadaptive defences is characteristic of healthy coping. Alsoas depicted in Table 1, her play became more age appropri-
ate (developmental level), she engaged in greater interactionwith therapist and was more verbal in sessions (social leveland verbal expression), and emotional expression and mod-ulation also improved (affect).
On the IsAS (Figs. 3 and 4), by post-intervention as-sessment, most illness related stressors were reported tobe not-upsetting, with the exception of hair loss, bonemarrow aspiration, and intrathecal treatment, which werelittle upsetting, very upsetting, and very very upsettingrespectively.
On TBP (Fig. 5), increase in total positive codes (T+)was characterized by Seema perceiving greater positive
Table 1 Findings on CPTISession No.
Category 1–5 6–10 11–15 16–20
Developmental Level Occasionally immature Age appropriate Age appropriate Age appropriate
Social Level Solitary play Parallel play Reciprocal andCooperative play
Reciprocal andCooperative play
Affect Inhibited and Sober Neutral interest Wide range of affect Overt pleasure andSmooth affectregulation
Role Representation Precursor to role play Solitary roleplay
Complex role play Complex role play
Verbal Expression Few queries andresponses
Described play Voiced roles andAscribed meaning
Voiced roles andAscribed meaning
Fig. 3 Findings on IsAs.0 – Not applicable; 1 – Notupsetting; 2 – Littleupsetting; 3 – Upsetting; 4 –Very upsetting; 4 – Very veryupsetting
Fig. 4 Findings on IsAs.0 – Not applicable; 1 – Notupsetting; 2 – Littleupsetting; 3 – Upsetting; 4 –Very upsetting; 4 – Very veryupsetting
306 Indian J Pediatr (April 2013) 80(4):303–308
affect and resourceful in others (RO+ and PAO+ respec-tively). Decrease in total negative codes (T-) was markedby lesser perception of negative affect in others (NAO-),feelings of uncertainty (E-), and helplessness (H-).
Additionally, a staff nurse voluntarily reported regardingpositive changes in Seema such as increased cooperation formedical procedures, better mood state, and enhanced inter-action with staff and ward-mates. Follow-up 3 mo postintervention indicated that Seema continued to cope wellwith medical procedures, was cheerful, and actively inter-acted with ward-mates and staff.
Discussion
The purpose of this paper was to illustrate the benefits andfeasibility of play-therapy in pediatric oncology. Play ther-apy with Seema facilitated normalization, illness adjust-ment, and mental well-being. The relationship betweenplay and distress is bi-directional such that while distressimpacts play quality, play also simultaneously facilitatesdistress alleviation [10, 15]. Studies have found that evenvicarious exposure to medical settings impacts play suchthat children exhibit either excessive approach or avoidancetowards medical toys [16]. Seema was initially inhibited,avoided medical toys, and engaged in rudimentary play. Heraffect was constricted and interaction with the researcherwas limited. As sessions progressed, she became active andengaged in various types of play. Range of affect widenedand there was cooperative play. Her initial avoidance ofmedical toys followed by repeated enactment of medicalprocedures carried out on her (traumatic play) reflects themechanism of play therapy in facilitating catharsis andmastery through re-enactment of stressful experiences [10,15]. Thus as sessions progressed, Seema’s play becamesimilar to those of healthy children indexing normalization.Specific illness adjustment measures (IsAS) documentedimprovements which are not attributable to habituation[17]. Results on TBP indicated better mental well-being,evident in reduction of feelings of negativity, uncertainty,and helplessness. This reflects enhanced coping, attested by
a nurse’s positive reports of Seema and use of adaptivedefences in play sessions.
In examining the feasibility of play therapy in pediatriconcology, certain conditions are recommended. First, thecooperation of the primary treating team for non-pharmacological interventions is crucial. In this study, thecooperation of the oncology team in providing the opportu-nity and space for carrying out play therapy was greatlybeneficial. Second, flexibility in therapeutic practice is rec-ommended. Cancer treatment is arduous, and there is a needto accommodate to illness variables. Despite session fre-quency being erratic, the outcome of play therapy withSeema was largely positive.
Thus in concluding that play therapy is both beneficialand feasible in pediatric oncology, this paper implicates apertinent need to explore and intervene to address the psy-chological needs of these children. This is likely to enhanceillness adjustment and even facilitate smooth transition tolife without cancer. As with most case-reports, there is aninherent limitation in generalizing these findings. Futurestudies could examine case-control methodologies, compareplay therapy with other psychological interventions, exper-iment with group and individual therapy formats, and com-pare findings with those seen in other cultures.
Conclusions
In this case report of Seema, a 4 y- old girl hospitalized forALL, play therapy facilitated better adjustment to illnessrelated stressors, enhanced mental well-being, and promotednormalization. Thus play therapy is feasible in pediatriconcology, given the cooperation of the treating team andflexibility in therapeutic practice.
Acknowledgements The authors acknowledge the contributions ofDr. Anna Abraham, Clinical Psychologist, KMIO, Bangalore, Indiaand Dr. Saralea Chazan, Clinical Psychologist, USA, for their contri-butions in designing the study and data analysis respectively. Also,much gratitude is indebted to Seema and her family, who willinglycooperated to participate in the study.
12 1213
10
2
4
6
8
10
12
14
Pre-Asst
Post-Asst
T+ T -
Fig. 5 Findings on TBP.Total positive codes (T+),Total negative codes (T-)
Indian J Pediatr (April 2013) 80(4):303–308 307
Contributions UC: Designing study, collecting, analyzing, andinterpreting data, and drafting and finalizing manuscript; UH:Designing study, analyzing and interpreting data, and finalizing man-uscript; LA: Designing study, facilitating data collection, and finalizingmanuscript.
Conflict of Interest None.
Role of Funding Source None.
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